Displacement of the heart by diaphragm: is this heart alternating?

A-64-year-old man was admitted to the emergency department because of dyspnea. Twelve-lead ECG revealed alternating QRS complexes. In consequence of diagnostic tests, i.e., chest tomography showed eventration of the left diaphragm. In this case, we present an unusual case of electrical alternans due to diaphragmatic eventration.     

Is the prognosis of heart failure improving?

BACKGROUND AND METHODS": Heart failure is common and effective therapy exists but as yet there is little evidence that the overall prognosis is improving in clinical practice. We sought to determine if mortality, re-admission with heart failure and re-admission for any cause, had changed between cohorts of first-time admissions for heart failure identified in 1984, 1988 and 1992 using linked hospital discharge and mortality data from Scotland (population approximately 5 million). FINDINGS: The number of first-time admissions for heart failure increased by 30% between 1984 and 1992, from 9716 to 12640. Their mean age was 74 years and 54% were women. Over the same period 3-year mortality declined in patients < 65 years from 53 to 41% (reduction in risk 12% (95% confidence interval 9-15%. Log-rank 70.0; P<0.001) and for patients > or =65 years from 71% to 66% (reduction in risk 5% (95% confidence interval 3-6%. Log-rank 74.5; P<0.0001). Time to death or first re-admission with heart failure also improved but not time to death or first re-admission for any cause. The total number of re-admissions increased between 1984 and 1992 but bed-days occupancy for heart failure and for any cause, adjusted for days alive, declined due to a reduction in length of stay. INTERPRETATION: These data suggest that the prognosis of patients with a first admission for heart failure is improving. The timing of improvement coincides with the gradual increase in the use of angiotensin converting enzyme inhibitors for heart failure although a causal link cannot be proved from these data.     

Highlights of the physical examination in heart failure

Because decompensated heart failure(HF)patients present primarily with symptoms of congestion,the assessment of volume status is of paramount importance.Despite the addition of new technologies that can predict intracardiac filling pressures,the physical exam(PE)remains the most accessible and cost-effective tool available to clinicians.An elevated jugular venous pressure(JVP) is considered the most sensitive sign of volume overload,although the commonly used‘method of Lewis’has several limitations.A useful cutoff is that if the JVP is greater than 3 cm in vertical distance above the sternal angle,the central venous pressure is elevated.In addition to assessment of volume status,the PE in HF can reveal adverse prognostic signs,namely:elevated JVP,presence of third heart sound,elevated heart rate,low systolic BP,and low proportional pulse pressure(＜25%).This article will review the evidence for the diagnostic and prognostic utility of common PE findings in HF.     

Has the problem of heart failure been solved?

Emphasis on the management of heart failure has shifted from attempts to alter hemodynamics and symptoms to attempts to interfere with the natural history of the disease. This shift in emphasis has been stimulated by the recognition that heart failure progresses despite therapy and that shortened life expectancy makes the disease as lethal as most cancers. Most recent trials have therefore focused on mortality and have evaluated therapies designed to impact on progression of the syndrome. In this article the results of several recent trials are discussed, as well as the future of effective therapy.     

Should statins be part of the treatment of heart failure?

Beyond their lipid lowering properties HMG-CoA reductase inhibitors (statins) have numerous effects in the cardiovascular system. Commonly referred as "pleiotropic properties", these properties could justify the use of statins in the treatment of congestive heart failure. Excluding the beneficial effects of statins related to the prevention of coronary ischemic events, this review focuses on the emerging mechanisms which may explain the therapeutic potential of satins in heart failure, particularly their action on endothelial function, myocardial and renal energetic metabolism, inflammation, thrombosis, oxidative stress, ventricular remodeling and hypertrophy, and renal function.     

Myoblast transplantation for heart repair:A review of the state of the field

Autologous immature myoblasts are obtained from biopsy of thigh muscle. These cells are cultured to a thera peutic dosage at a central Good Manufacture Practic (cGMP) facility. The cells are suspended in a special solu tion which preserves their shelf lif…     

Is heart failure with preserved ejection fraction a ‘dementia’ of the heart?

Heart Failure Reviews - Heart failure with preserved ejection fraction (HFpEF) remains an elusive entity, due to its heterogeneous clinical profile and an arbitrarily defined nosology. Several...     

Neuregulin-1β for the treatment of systolic heart failure

The Neuregulin-1 gene encodes a family of ligands that act through the ErbB family of receptor tyrosine kinases to regulate morphogenesis of many tissues. Work in isolated cardiac cells as well as genetically altered mice demonstrates that neuregulin-1/ErbB signaling is a paracrine signaling system that functions in endocardial-endothelial/cardiomyocyte interactions to regulate tissue organization during development as well as maintain cardiac function throughout life. Treatment of animals with cardiac dysfunction with recombinant neuregulin-1beta improves cardiac function. This has led to ongoing early phase clinical studies examining neuregulin-1beta as a potential novel therapeutic for heart failure. In this review we synthesize the literature behind this rapidly evolving area of translational research. This article is part of a special issue entitled “Key Signaling Molecules in Hypertrophy and Heart Failure.”     

Protection in the aged heart: preventing the heart-break of old age?

The aged heart has a diminished functional and adaptive reserve capacity, an increased susceptibility to incur damage (e.g., as a result of ischemia), and a limited practical ability for repair/regeneration. Thus, there has been considerable interest to harness the heart's endogenous capacity to resist such damage, known as ischemic preconditioning (IPC), as well as other cardioprotective mechanisms. However, the translation of basic research findings into clinical practice has largely been inadequate because there have been few if any successful implementations in terms of viable therapies activating cardioprotection mechanisms to limit infarct size. Here, we provide an overview of the general mechanisms of cardioprotection, changes in the structure and function of the aged heart, and the current knowledge regarding cardioprotection in aged heart. The problems and opportunities for successful bench-to-bedside translation of cardioprotection in the elderly are discussed.     

Rise of the machines: will heart failure become the first cyber-specialty?

Digital healthcare is being introduced to the management of heart failure as a consequence of innovations in information technology. Advancement in technology enables remote symptom and device monitoring, and facilitates early detection and treatment of heart failure exacerbation, potentially improving patient outcomes and quality of life. It also provides the potential to redesign our heart failure healthcare system to one with greater efficacy through resource-sparing, computer-aided decision-making systems. Although promising, there is, as yet, insufficient evidence to support the widespread implementation of digital healthcare. Patient-related barriers include user characteristics and health status; privacy and security concerns; financial costs and lack of accessibility of digital resources. Physician-related barriers include the lack of infrastructure, incentive, knowledge and training. There are also a multitude of technical challenges in maintaining system efficiency and data quality. Furthermore, the lack of regulation and legislation regarding digital healthcare also prevents its large-scale deployment. Further education and support and a comprehensive workable evaluation framework are needed to facilitate confident and widespread use of digital healthcare in managing patients with heart failure.Key words: digital healthcare, heart failure     

Hypertrophy of the heart: a new therapeutic target?

Recent studies call into question the necessity of hypertrophic growth of the heart as a "compensatory" response to hemodynamic stress. These findings, coupled with recent progress in dissecting the molecular bases of hypertrophy, raise the prospect of suppressing hypertrophy without provoking circulatory insufficiency. In this article, we focus on signaling pathways that hold promise as potential targets for therapeutic intervention. We also summarize observations from animal models and clinical trials that suggest benefit from an antihypertrophic strategy.