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A congestive heart failure project with measured improvements in care

EVALUATION & THE HEALTH PROFESSIONS 1998年第4期21卷 472-486页

作者： DeLong, JF Allman, RM Sherrill, RG Schiesz, N [o_1]Alabama Quality Assurance Foundation

This project was designed to improve the in-hospital management of Medicare beneficiaries with congestive heart failure (CHF). Eleven hospitals were studied using two indicators: (a) assessment of left ventricular (LV) function, and (b) use of angiotensin converting enzyme (ACE) inhibitors in patients with systolic dysfunction Baseline performance rates were obtained for 990 cases with the Diagnosis Related Group (DRG) 127 for CHF discharged January 1994 to December 1994. Baseline data feedback presentations in 1995 spurred quality improvement plans with interventions such as physician education, critical care maps, and standing orders. Follow-up abstractions were performed on 612 discharges October 1995 through April 1997 The study demonstrated 12% improvement (53% to 65%, p < .01) in assessing LV function and 20% improvement (54% to 74%. p < .01) in appropriate ACE inhibitor use. Projects emphasizing Health Care Quality Improvement Program (HCQIP) principles can successfully affect health care management for the Medicare population.

关键词：亚拉巴马血管紧张素转换酶抑制药/治疗应用临床方案数据收集 Medicare/标准结果与过程评价(卫生保健) 专业评审组织质量保证卫生保健质量指标卫生保健美国心室功能障碍左/诊断人类

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Aspirin worsens exercise performance and pulmonary gas exchange in patients with heart failure who are taking angiotensin-converting enzyme inhibitors

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AMERICAN HEART JOURNAL 1999年第2期138卷 254-260页

作者： Guazzi, M Pontone, G Agostoni, P Univ Milan Ist Cardiol Ctr Ric Cardiovasc CNRFdn MonzinoIRCCS I-20138 Milan Italy

Background Pulmonary function abnormalities participate in causing exercise disability in patients with congestive heart failure (CHF). impaired pulmonary gas transfer is one of these abnormalities. Angiotensin-converting enzyme (ACE) inhibitors improve diffusion for carbon monoxide and exercise capacity, an effect that is seemingly mediated through prostaglandin activation because it is inhibited by cyclooxygenase blockade with aspirin. This suggests the possibility that aspirin may disturb the pulmonary function and exercise ability in CHF, at least in those patients who are taking ACE inhibitors. This study was aimed at probing this hypothesis. Methods A dose of 325 mg aspirin was given daily for 8 weeks to 26 consecutive patients with primary dilated cardiomyopathy (New York Heart Association class II or III) whose current outpatient antifailure therapy included (group 1, 18 cases) or did not include (group 2, 8 cases) an ACE inhibitor in addition to digoxin and furosemide. During the study ACE inhibition was continued in group 1 by giving enalapril 20 mg daily. Results Tests repeated at 8 weeks proved that aspirin was deleterious in group 1. Compared with run-in, rest carbon dioxide, peak exercise oxygen uptake (peak VO2), and tidal volume levels were diminished in this group;the ratio of exercise minute ventilation to carbon dioxide production (VE/VCO2) was augmented and its variations were inversely related to those of peak VO2. Similar results were not observed in group 2;however, once this part of the study was completed and enalapril was included in the current therapeutic regimen, an inhibitory effect of aspirin on carbon dioxide, peak VO2, peak tidal volume, and VE/VCO2 at 1 I levels become evident and was similar to that observed in group 1. Conclusions Aspirin does not affect ventilation efficiency and peak VO2 in patients with CHF not taking ACE inhibitors, but it worsens the pulmonary diffusion for carbon monoxide, VO2, and the ventilatory response t

关键词：血管紧张素转换酶抑制药/治疗应用阿司匹林/药理学环加氧酶抑制药/药理学药物相互作用依那普利/治疗应用运动耐量/药物作用肺换气/药物作用肺量测定法老年人女(雌)性人类男(雄)性中年人

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EXP3174, the AII antagonist human metabolite of losartan, but not losartan nor the angiotensin-converting enzyme inhibitor captopril, prevents the development of lethal ischemic ventricular arrhythmias in a canine model of recent myocardial infarction

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第3期34卷 876-884页

作者： Lynch, JJ Stump, GL Wallace, AA Painter, CA Thomas, JM Kusma, SE Gould, RJ Grossman, W Merck Res Labs Dept Pharmacol W Point PA 19486 USA Merck Res Labs Dept Safety Assessment W Point PA 19486 USA Merck Res Labs Dept Clin Cardiovasc Res W Point PA 19486 USA

OBJECTIVES The antiarrhythmic efficacies of the competitive angiotensin II (AII) antagonist losartan, losartan's more potent noncompetitive AII antagonist human metabolite EXP3174 and the angiotensin-converting enzyme inhibitor captopril were assessed in a canine model of recent myocardial infarction. BACKGROUND Multiple hemodynamic and electrophysiologic effects of AII may contribute to cardiac electrical instability. In the recent Losartan Heart Failure Study, Evaluation of Losartan in the Elderly (ELITE), a 722-patient trial primarily designed to assess effects on renal function, an unexpected survival benefit was observed with losartan compared with captopril, with the lower mortality using losartan primarily confined to a reduction in sudden cardiac death. METHODS Intravenous losartan (1 mg/kg + 0.03 mg/kg/min), EXP3174 (0.1 mg/kg + 0.01 mg/kg/ min), captopril (1 mg/kg + 0.5 mg/kg/h) or vehicle were infused in anesthetized dogs with recent (8.1 +/- 0.4 days) anterior myocardial infarction. Electrolytic injury of the left circumflex coronary artery to induce thrombotic occlusion and posterolateral ischemia was initiated 1 h after the start of treatment. RESULTS Losartan, EXP3174 and captopril elevated plasma renin activities and comparably and significantly reduced mean arterial pressure. No significant electrocardiographic or cardiac electrophysiologic effects were noted with any treatment. Incidences of acute posterolateral ischemia-induced lethal arrhythmias were: vehicle, 7/9 (77%);losartan, 6/8 (75%);EXP3174, 2/8 (25%;p < 0.05 vs. vehicle control);captopril, 7/10 (70%). There were no among-group differences in time to onset of acute posterolateral ischemia or underlying anterior infarct size. CONCLUSIONS EXP3174, but not losartan nor captopril, reduced the incidence of lethal ischemic ventricular arrhythmia in this preparation. The antiarrhythmic efficacy of EXP3174 may be due to an attenuation of deleterious effects of local cardiac AII formed during acute

关键词：方差分析血管紧张素Ⅱ/拮抗剂和抑制剂血管紧张素转换酶抑制药/治疗应用抗心律失常药/治疗应用心律失常心性/病因学心律失常心性/预防和控制卡托普利/治疗应用疾病模型动物药物评价临床前心室咪唑类/治疗应用洛沙坦/治疗应用心肌梗死/并发症心肌缺血/病因学心肌缺血/预防和控制四唑类/治疗应用时间因素动物狗女(雌)性人类男(雄)性

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Sex differences in the clinical care and outcomes of congestive heart failure in the elderly

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AMERICAN HEART JOURNAL 1999年第5期138卷 835-842页

作者： Vaccarino, V Chen, YT Wang, Y Radford, MJ Krumholz, HM Yale Univ Sch Med Dept Epidemiol & Publ Hlth New Haven CT 06520 USA Yale Univ Sch Med Sect Cardiovasc Med Dept Internal Med New Haven CT USA Yale New Haven Hosp Ctr Outcomes Res & Evaluat CORE New Haven CT 06504 USA Connecticut Peer Review Org Middletown CT USA

Background There is evidence for sex differences in treatment and outcome of ischemic heart disease. However, little and conflicting data exist about sex differences in the care and outcome of elderly patients with heart failure. Methods We compared mortality rate, readmission, and use of selected treatments and procedures between women and men in a database of 2445 patients (1426 women) aged greater than or equal to 65 admitted for heart failure to 18 Connecticut hospitals in 1994 and 1995. Demographic and clinical data were abstracted from the medical records. Results Women were older and more likely to have a history of hypertension whereas men more often had previous coronary heart disease. Women had more preserved left ventricular systolic function and higher systolic blood pressure on presentation than men. Treatments on day 1 (aspirin, angiotensin-converting enzyme [ACE] inhibitors, and diuretics), procedures during admission (assessment of left ventricular function, coronary angiography, and revascularization), and use of ACE inhibitors among ideal candidates at discharge were similar in men and women. Six-month rehospitalization rates were also similar. Although 30-day mortality rate did not differ between men and women, 6-month and 1-year mortality rates were lower in women after age adjustment (relative risk for 6-month death 0.81, 95% confidence interval, 0.68-0.95). In multivariable analysis, sex differences in mortality rate were reduced (relative risk 0.90, 95% confidence intervals, 0.75-1.08). History of hypertension, systolic blood pressure on admission, and left ventricular function mostly explained the observed sex differences in mortality rate. Conclusions Female and male patients hospitalized for heart failure have a similar hospital course, treatment pattern, and readmission rates, but women live longer than men. When baseline differences are accounted for, the mortality risk of women and men becomes very similar.

关键词：血管紧张素转换酶抑制药/治疗应用阿司匹林/治疗应用血压康涅狄格/流行病学冠状血管造影术利尿药/治疗应用药物疗法联合随访研究心脏导管插入术心肌血管重建术病人再入院/统计学和数值数据血小板聚集抑制剂/治疗应用回顾性研究疾病严重程度指数性征每搏输出量存活率治疗结果老年人老年人 80以上女(雌)性人类男(雄)性

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Nonadherence with angiotensin-converting enzyme inhibitor therapy - A comparison of different ways of measuring it in patients with chronic heart failure

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JOURNAL OF THE AMERICAN COLLEGE OF CARDIOLOGY 1999年第7期34卷 2072-2077页

作者： Struthers, AD MacFadyen, R Fraser, C Robson, J Morton, JJ Junot, C Ezan, E Ninewells Hosp Sch Med Dept Clin Pharmacol & Therapeut Dundee DD1 9SY Scotland Ninewells Hosp Sch Med Directorate Biochem Med Dundee DD1 9SY Scotland CEA Serv Pharmacol & Immunol Gif Sur Yvette France Univ Glasgow Western Infirm Dept Med & Therapeut Glasgow G11 6NT Lanark Scotland

OBJECTIVES This study was designed to compare different proposed methods of assessing adherence with angiotensin-converting enzyme (ACE) inhibitor (ACEI) therapy in chronic heart failure. BACKGROUND The use of ACEIs in chronic heart failure gives us a unique opportunity to assess a patient's adherence by measuring whether the expected biochemical effect of an ACEI is present in the patient's bloodstream. In fact, there are several different ways of assessing ACE in vivo: these are serum ACE activity itself, plasma N-acetyl-seryl-aspartyl lysyl-proline (AcSDKP), urine AcSDKP, plasma angiotensin I (AI), plasma angiotensin II (AII), or the AII/AI ratio. METHODS Patients with chronic heart failure (n = 39) were randomized to regimens of ACEI nonadherence for one week, ACEI adherence for one week or two versions of partial adherence for one week, after which the above six tests were performed. RESULTS All six tests significantly distinguished between full nonadherence for one week and full or partial adherence. Only plasma AcSDKP produced a significantly different result between partial adherence and either full adherence or full nonadherence for one week. In terms of their ability to distinguish full nonadherence from full adherence, plasma AcSDKP was 89% sensitive and 100% specific with an area under its ROC of 0.95. Corresponding figures for urine AcSDKP were 92%, 97% and 0.95 and for serum ACE they were 86%, 95% and 0.90. CONCLUSIONS All six tests distinguished full nonadherence from all other forms of adherence. The rank order of performance was plasma AcSDKP, urine AcSDKP, serum ACE, AII/AI ratio and plasma AII followed by plasma AI. (C) 1999 by the American College of Cardiology.

关键词：血管紧张素Ⅰ/血液血管紧张素Ⅱ/血液血管紧张素转换酶抑制药/治疗应用慢性病利尿药/治疗应用药物疗法联合超声心动描记术呋塞米/治疗应用心力衰竭/诊断心力衰竭/药物疗法心力衰竭/代谢赖诺普利/治疗应用寡肽类/血液寡肽类/尿肽基二肽酶A/血液放射性核素心室显像术治疗结果患者拒绝治疗/统计学和数值数据老年人人类

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Underutilization and clinical benefits of angiotensin-converting enzyme inhibitors in patients with asymptomatic left ventricular dysfunction

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AMERICAN JOURNAL OF CARDIOLOGY 2000年第6期86卷 644-648页

作者： Kermani, M Dua, A Gradman, AH Western Penn Hosp Dept Med Pittsburgh PA 15224 USA

Despite evidence of therapeutic benefit of angiotensin-converting enzyme (ACE) inhibitors for congestive heart failure and asymptomatic left ventricular (LV) dysfunction, recent studies suggest that in heart failure patients, rates of ACE inhibitor usage in clinical practice remain low. In this study, the medical records of 107 patients with documented LV dysfunction were investigated for patterns of ACE inhibitor usage;6-month and 1-year outcomes and event rates were evaluated. At index admission, 48% patients did not receive ACE inhibitor treatment, 32% were initiated on treatment, 19% continued on a prior regimen, and 1% were discontinued, Patients seen by a cardiologist were more likely to receive ACE inhibitor treatment (53% vs 35%, p = 0.172), as were patients with histories of hypertension (60% vs 40%, p = 0.044) or myocardial infarction (56% vs 44%, p = 0.221). Significantly shorter hospitalizations (5.9 vs 9.5 days, p = 0.001) were noted for patients with on-going ACE inhibitor treatment compared with those receiving newly initiated treatment or no treatment. At time of hospital discharge, 102 patients were alive. Of 54 patients who received ACE inhibitors, 67% received an insufficient dose. At a 6-month follow-up, of 51 patients on ACE inhibitors, 23% died or were readmitted to hospital compared with 55% of nonusers (p = 0.001). At 1 year, this event rate was 31% amang ACE inhibitor users versus 71% among nonusers (p <0.0001). Bivariate and multivariate analysis revealed absence of ACE inhibitor use as the only significant variable associated with the event rate (p <0.0011). Thus, about half of patients with asymptomatic LV dysfunction received ACE inhibitors;2/3 of these did not receive a sufficient dose. ACE inhibitor usage increased with involvement of a cardiologist, presence of coexistent hypertension, or prior myocardial infarction. Ongoing ACE inhibitor therapy was associated with shorter hospitalizations and fewer hospital readmissions or deaths. (

关键词：血管紧张素转换酶抑制药/治疗应用无病生存药物利用/统计学和数值数据住院时间宾夕法尼亚医师的作用回顾性研究心室功能障碍左/药物疗法成年人老年人老年人 80以上女(雌)性人类男(雄)性中年人

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Platelet activation in patients with congestive heart failure: Do we have enough evidence to consider clopidogrel?

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AMERICAN HEART JOURNAL 2003年第3期145卷 397-403页

作者： Malinin, AI O'Connor, CM Dzhanashvili, AI Sane, DC Serebruany, VL Johns Hopkins Univ Baltimore MD USA Duke Clin Res Inst Durham NC USA Wake Forest Univ Winston Salem NC 27109 USA

Our understanding of the pathogenesis of congestive heart failure (CHF) has improved remarkably in recent years. However, despite better knowledge and novel pharmaceutical strategies, this disease is still one of the most brutal killers in the Western world. The pathophysiology of CHF is complex, and much of our comprehension revolves strictly around the neurohormonal and mechanical. mechanisms involved. It has been suggested that CHF is associated with altered hemostasis, but whether a prothrombotic state contributes to the pathogenesis and progression of the disease is still not well known. The purpose of this review article is to discuss our current knowledge of platelet activation in patients with CHF and the potential role of antiplatelet agents in preventing these hemostatic abnormalities. Clopidogrel is an established medication that reduces the incidence of,stroke, myocardial ischemia, or vascular death. It is currently the drug of choice in the prophylaxis of subacute stent thrombosis and postischemic stroke treatment. Promising results of the most resent trials (Clopidogrel versus Aspirin in Patients at Risk of Ischemic Events [CAPRIE] and Clopidogrel in Unstable angina to prevent Recurrent Events [CURE]) may expand future indications of this ADP receptor antagonist for prevention of thrombotic complications in the CHF population. Currently conducted clinical trials (Warfarin and Antiplatelet Therapy in Chronic Heart Failure [WATCH] and Plavix Use for Treatment of Congestive Heart Failure [PLUTO-CHF] should clarify the, role of clopidogrel in these patients.

关键词：血管紧张素转换酶抑制药/治疗应用阿司匹林/治疗应用临床试验(主题) 药物疗法联合心力衰竭/血液心力衰竭/药物疗法心力衰竭/预防和控制血小板活化/药物作用血小板聚集抑制剂/药理学血小板聚集抑制剂/治疗应用嘌呤能P2受体拮抗剂噻氯匹定/类似物和衍生物噻氯匹定/药理学噻氯匹定/治疗应用治疗结果人类

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Management of heart failure among very old persons living in long-term care: Has the voice of trials spread?

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AMERICAN HEART JOURNAL 2000年第1期139卷 85-93页

作者： Gambassi, G Forman, DE Lapane, KL Mor, V Sgadari, A Lipsitz, LA Bernabei, R Brown Univ Ctr Gerontol & Hlth Care Res Sch Med Providence RI 02912 USA Brown Univ Dept Community Hlth Sch Med Providence RI 02912 USA Univ Cattolica Sacro Cuore Ist Med Interna & Geriatr Rome Italy Miriam Hosp Dept Med Div Cardiol Providence RI 02906 USA Harvard Univ Sch Med Hebrew Rehabil Ctr Aged Boston MA USA

Background increasing prevalence, use of health services, and number of deaths have made congestive heart failure (CHF) a new epidemic in the United States. Yet there are no adequate data to guide treatment of the more typical and complex cases of patients who are very old and frail. Methods Using the SAGE database, we studied the cases of 86,094 patients with CHF admitted to any of the 1492 long-term care facilities of 5 states from 1992 through 1996. We described their clinical and functional characteristics and their pharmacologic treatment to verify agreement with widely approved guidelines. We evaluated age- and sex-related differences, and we determined predictors of receiving an angiotensin-converting enzyme (ACE) inhibitor by developing a multiple logistic regression model. Results The mean age of the population was 84.9 +/- 8 years. Eighty percent of the patients 85 years of age or older were women. More than two thirds of patients underwent frequent hospitalizations related to CHF in the year preceding admission to a long-term care facility. Coronary heart disease and hypertension were the most common causes. Half of the patients received digoxin and 45% a diuretic, regardless of background cardiovascular comorbidities. Only 25% of patients had a prescription for ACE inhibitors. The presence of cardiovascular comorbidity, already being a recipient of a large number of medications, a previous hospitalization for CHF, and admission to the facility in recent years were associated with an increased likelihood of receiving an ACE inhibitor. The presence of severe physical limitation was inversely related to use of ACE inhibitors, as were a series of organizational factors related to the Facilities. Conclusions Patients in long-term care who have CHF little resemble to those enrolled in randomized trials. This circumstance may explain, at least in part, the divergence from pharmacologic management consensus guidelines. Yet the prescription of ACE inhibitors vari

关键词：血管紧张素转换酶抑制药/治疗应用横断面研究地高辛/治疗应用利尿药/治疗应用药物疗法联合老年人保健服务/统计学和数值数据健康状况长期医疗回顾性研究老年人老年人 80以上女(雌)性人类男(雄)性

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Systemic and renal effects of atrial natriuretic peptide in patients with heart failure treated with angiotensin-converting enzyme inhibitor or in acute saline solution loading

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AMERICAN HEART JOURNAL 2001年第3期141卷 422-427页

作者： Tomiyama, H Watanabe, G Abe, M Okazaki, R Yoshida, H Doba, N Teikyo Univ Div Cardiol Ichihara Hosp Chiba 2990111 Japan Teikyo Univ Div Endocrinol Ichihara Hosp Dept Internal Med 3 Chiba 2990111 Japan

Background Our purpose was to study the effects of atrial natriuretic peptide (ANP) on cardiorenal functions when it is used to manage patients with heart failure who are receiving an angiotensin-converting enzyme inhibitor (ACEI) or in acute saline solution loading. Methods seventeen patients with mild to moderate heart failure were entered into protocol 1 or 2. Protocol 1 was ANP (30 ng/kg/min) infused before and after treatment with ACEi (n = 9). Protocol 2 was acute saline loading with or without coadministration of ANP (n = 8). In both protocols cardiorenal hemodynamics and urinary sodium excretion were assessed before and after each intervention. Results Protocol 1: Although ANP infusion significantly increased urinary sodium excretion to a similar extent before and after ACEI treatment, the infusion increased the glomerular filtration rate (75 +/- 16 --> 82 +/- 15 mL/min, P < .05) and renal blood flow (390 +/- 123 --> 438 +/- 140 mL/min, P < .05) only before ACEI treatment. Protocol 2: Acute saline solution loading decreased plasma renin activity (P<.05) but did not affect ANP level. Coadministration of ANP with saline solution load enhanced the increase of urinary sodium excretion (75% +/- 34% increase) compared with the acute saline solution load alone (49% +/- 33% increase) (P.05) but had no affect on renal hemodynamics. Conclusions When ANP is used in patients with mild to moderate heart failure who are on combined ACEi treatment or in acute saline solution loading, the vasodilatory effect of ANP is blunted while the natriuretic effect of ANP is preserved. The renin-angiotensin system seems to modulate the vasodilatory effect of ANP.

关键词：血管紧张素转换酶抑制药/治疗应用心钠素/药理学交叉研究肾小球滤过率/药物作用心脏/药物作用输注静脉内肾/药物作用微循环肾素-血管紧张素系统/药物作用肾素-血管紧张素系统/生理学钠/尿血管舒张/药物作用成年人老年人女(雌)性人类男(雄)性中年人

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Diagnosis and treatment of diastolic heart failure

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HOSPITAL PRACTICE 1999年第3期34卷 115-+页

作者： Weinberger, HD Univ Colorado Hlth Sci Ctr Div Cardiol Denver CO 80262 USA

Up to 40% of patients with heart failure have isolated diastolic dysfunction, With proper management, the prognosis is generally more favorable than in systolic dysfunction, Distinguishing diastolic from systolic dysfuntion is essential since the optimal therapy for one condition may aggravate the other. New echocardiographic methods enable accurate diagnoses.

关键词：血管紧张素转换酶抑制药/治疗应用钙/生理学钙通道阻滞药/治疗应用心舒期/生理学心力衰竭/诊断心力衰竭/药物疗法心力衰竭/病理生理学预后心缩期/生理学成年人老年人女(雌)性人类男(雄)性中年人

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