Munir Janmohamed

Clinical Profile and Predictors of Complications in Peripartum Cardiomyopathy

BACKGROUND Clinical profile and predictors of major adverse events (MAE) associated with peripartum cardiomyopathy (PPCM) have not been characterized. METHODS AND RESULTS A retrospective review and analysis of clinical data of 182 patients with PPCM. Forty-six patients had >or=1 MAE, including death (13), heart transplantation (11), temporary circulatory support (4), cardiopulmonary arrest (6), fulminant pulmonary edema (17), thromboembolic complications (4), and defibrillator or pacemaker implantation (10). Diagnosis of PPCM was delayed >or=1 week in 48% of patients with MAE that preceded the diagnosis in 50% of these patients. Seven (32%) of the surviving patients who had MAE and did not undergo heart transplantation had residual brain damage. Significant predictors of MAE were: left ventricular ejection fraction <or=25% (HR 4.20, CI 2.04-8.64) and non-Caucasian background(HR 2.16, CI 1.17- 3.97). These predictors in addition to diagnosis delay (HR 5.51, CI 1.21-25.04) were also associated with death or heart transplantation. CONCLUSIONS 1. PPCM may be associated with mortality or severe and lasting morbidity. 2. Incidence of MAE is higher in non-Caucasians and in women with left ventricular ejection fraction <or=25%. 3. Diagnosis of PPCM is often delayed and preceded by MAE. 4. Increased awareness of PPCM is required for early diagnosis and aggressive therapy in an attempt to prevent complications.

Renal Vasodilatory Action of Dopamine in Patients With Heart Failure Magnitude of Effect and Site of Action

Background— A “renal dose” of dopamine is often used to increase renal blood flow; however, data on the magnitude of effect and site of action in patients with heart failure are scarce. Methods and Results— Renal effects of intravenous dopamine (1, 2, 3, 5, and 10 &mgr;g · kg−1 · min−1) were evaluated in 13 patients with chronic heart failure. Renal blood flow was calculated from renal artery cross-sectional area measured with intravascular ultrasound and renal blood flow velocity-time integral measured by the intravascular Doppler technique. Cross-sectional area increased and was significantly higher than baseline (0.30±0.04 cm2) at 5 &mgr;g · kg−1 · min−1 (0.36±0.05 cm2) and 10 &mgr;g · kg−1 · min−1 (0.38±0.06 cm2). The velocity-time integral was significantly higher than baseline (22±3 cm) at doses of 3 and 5 &mgr;g · kg−1 · min−1 (both 31±4 cm). Renal blood flow increased, whereas renal vascular resistance decreased, reaching statistical significance at 2 &mgr;g · kg−1 · min−1 through 10 &mgr;g · kg−1 · min−1. Cardiac output gradually increased, reaching statistical significance at doses of 5 and 10 &mgr;g · kg−1 · min−1 (5.5±0.5 and 6.1±0.7 versus 4.5±5.2 L/min at baseline), but the increase in renal blood flow appeared proportionately larger than corresponding increases in cardiac output. Conclusions— Dopamine is associated with an increase in renal blood flow in patients with heart failure. This effect is due to dilation of both the large conductance and small resistance renal blood vessels. Further evaluation of the efficacy and safety of dopamine for improvement of renal function in hospitalized patients with heart failure is warranted.

Vasodilators in the management of acute heart failure.

Recent guidelines by the Heart Failure Society of America have recommended consideration for use of nitroprusside, nitroglycerin, or nesiritide in addition to diuretics to achieve hemodynamic and symptomatic improvement. This article reviews the results of previous studies evaluating the pharmacologic and clinical effects and safety profiles of these drugs in patients with heart failure.

Favorable Outcome of Pregnancy with an Elective Use of Epoprostenol and Sildenafil in Women with Severe Pulmonary Hypertension

Background: Pulmonary hypertension carries significant maternal and fetal risk during pregnancy and the postpartum period. As maternal mortality is high, specific targeted therapy for pulmonary hypertension may be required during pregnancy. Cases: We describe 2 pregnant patients who presented with severe secondary pulmonary arterial hypertension during their last trimester. They were electively treated in the late antepartum and early postpartum periods with sildenafil and intravenous epoprostenol and successfully delivered healthy infants via cesarean section without postpartum complications. Conclusion: Although pulmonary hypertension is associated with a risk of maternal mortality and most women are advised against pregnancy, new therapies may improve the outcome of pregnancy in patients with pulmonary hypertension.

Variable Response of Conductance and Resistance Coronary Arteries to Endothelial Stimulation in Patients With Heart Failure Due to Nonischemic Dilated Cardiomyopathy

Attenuation of endothelial-dependent coronary vasodilation has been reported in idiopathic dilated cardiomyopathy and anatomically normal coronaries; however, data are insufficient for understanding the incidence and extent of this finding. The response of conductance and resistance coronary arteries to endothelial stimulation with acetylcholine was examined in 25 patients. Coronary blood flow had a variable response to acetylcholine and suggested coronary endothelial dysfunction in approximately half of the patients. Abnormal endothelial dysfunction involved the large conductance epicardial coronary arteries and the small resistance vessels. Abnormal endothelial response of coronary blood flow to acetylcholine could not be predicted by demographic and hemodynamic data. Conclusions: Coronary artery endothelial function is heterogeneous in patients with idiopathic dilated cardiomyopathy. Endothelial dysfunction is present in approximately half of the cases and involves both resistance as well as conductance coronary blood vessels. Furthermore, coronary endothelial function cannot be predicted by demographic and hemo-dynamic parameters or left ventricular ejection fraction.

Impact of acute serum creatinine elevation in patients treated with nesiritide.

We assessed the effect of increases in serum creatinine on mortality in nesiritide‐treated versus control subjects with acute decompensated heart failure (ADHF).

Response to Letter Regarding Article, “Renal Vasodilatory Action of Dopamine in Patients With Heart Failure: Magnitude of Effect and Site of Action”

Drs Lema and Canessa point out the important intersubject variability of plasma levels of dopamine, which has been shown in normal volunteers. These differences may also be related …