M. Huelsmann

Hemodynamic effects of a continuous infusion of levosimendan in critically ill patients with cardiogenic shock requiring catecholamines

Background:  Levosimendan, a novel inodilator, has been shown to improve hemodynamic function in patients with decompensated heart failure with preserved arterial blood pressure. Data on its use in patients with cardiogenic shock are rare. The present series describes the 24‐h hemodynamic effects of levosimendan as add‐on therapy in desperately ill patients with cardiogenic shock requiring catecholamines.

Prognostic power of neurohumoral parameters in chronic heart failure depends on clinical stage and observation period

BACKGROUND Endothelin (ET) and natriuretic peptides have prognostic significance in chronic heart failure (CHF). Because stimuli for forming these neurohormones differ, this study investigates whether their prognostic power depends on clinical stage and on length of the observation period. METHODS Plasma big ET, B-type natriuretic peptide (BNP), N-terminal BNP (N-BNP), and N-terminal atrial natriuretic peptide (N-ANP), in addition to 11 clinical and hemodynamic variables, were obtained from 452 patients with left ventricular ejection fraction (LVEF) </=35%. According to their New York Heart Association class and LVEF, patients were stratified into Group A, mild CHF (n = 114); Group B, moderate CHF (n = 210); and Group C, severe CHF (n = 128). To predict the combined end-point of death or urgent heart transplantation, a multivariate analysis was performed after an observation period of up to 1, 2, and 3 years in all patients and in each sub-group. RESULTS Best independents predictors were as follows: All patients: up to 1 year, big ET (p < 0.0001, chi-square = 59); and 2 and 3 years, log N-ANP (p < 0.0001, chi-square = 68; p < 0.0001, chi-square = 89). Group A: up to 2 and 3 years, log N-ANP (p < 0.001, chi-square = 12; p < 0.0001, chi-square = 25). Group B: up to 1 and 3 years, log N-ANP (p < 0.0001, chi-square = 16; p < 0.0001, chi-square = 22); and 2 years, log N-BNP (p < 0.0001, chi-square = 19). Group C: up to 1, 2, and 3 years, big ET (p < 0.0001, chi-square = 23; p < 0.0001, chi-square = 22; p < 0.0001, chi-square = 20). CONCLUSION Big ET was the best independent marker for 1-year prognosis in severe CHF, whereas natriuretic peptides (especially N-ANP) were better markers for 2- and 3-year prognoses in mild and moderate CHF.

Neurohormonal risk stratification for sudden death and death owing to progressive heart failure in chronic heart failure

Background  This study tested various neurohormones for prediction of heart failure death (death owing to progressive deterioration of ventricular function; HFD). Moreover, B‐type natriuretic peptide (BNP) as a predictor of sudden death (SD; as reported previously) and the best predictor of HFD were combined for a simple risk stratification model.

B-type natriuretic peptides (BNP and PRO-BNP) predict longterm survival in patients with advanced heart failure treated with atenolol.

(TX). Methods: The study was designed as a double-blind, randomized, placebo-controlled trial and conducted in 3 German transplant centers. Study duration was 12 months. Patients accepted for TX with advanced left ventricular (LV) systolic dysfunction categorized as NYHA IV at least once since onset of CHF were eligible. The primary endpoint was the absolute change from baseline to latest available LV ejection fraction (EF) measurement determined by radionuclide ventriculography between Carvedilol and placebo. Results: The trial prospectively randomized 118 patients with CHF of ischemic (n544) or non-ischemic (n574) etiology, a mean 6SD [median] age of 53.369.8 [55.5] years, and a mean LVEF at baseline of 19.966.6 [20.1]%. Mean 6SD [median] absolute change of LVEF from baseline was 16.069.3 [13.9]% in the Carvedilol group versus 10.767.1 [0.0]% in the placebo treated patients (p,0.008 [,0.006, Wilcoxon, 2-sided]) in the intention-to-treat population (n574) and 18.2610.3 [16.0]% in Carvedilol versus 11.467.9 [0.0]% on placebo (p,0.011 [,0.013, Wilcoxon, 2-sided]) in the per-protocol population (n552). Serious adverse events were experienced by 33/60 patients (13 deaths) on placebo and 29/58 patients (9 deaths) on Carvedilol. Conclusion: Even in patients with endstage CHF accepted for TX pharmacological therapy may significantly improve cardiac function over a prolonged period of time. Carvedilol appears to be an appropriate and safe drug also in this severely ill patient population. Thus, the EFICAT trial extends the observations made in COPERNICUS.