The American journal of cardiology
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The Can Rapid Risk Stratification of Unstable Angina Patients Suppress Adverse Outcomes with Early Implementation of the American College of Cardiology/American Heart Association Guidelines (CRUSADE) initiative is a prospective, rapid-cycle quality-improvement initiative that focuses on improving both the diagnostic evaluation of patients with non-ST-segment elevation (NSTE) acute coronary syndromes (ACS; defined as ischemic ST-segment changes and/or positive cardiac markers) and the use of treatments recommended by the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines for management of NSTE ACS. The ultimate goal of the CRUSADE initiative is to improve the quality of care among high-risk patients with NSTE ACS. ⋯ Cumulatively, the CRUSADE initiative has collected data from >165,000 patients with NSTE ACS admitted at >400 US hospitals since 2001. This article reviews the major results from the CRUSADE initiative on risk stratification, gaps in guidelines adherence, paradoxical care, and the association of guideline adherence with outcomes.
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Randomized Controlled Trial
Effect of levosimendan on ventricular arrhythmias and prognostic autonomic indexes in patients with decompensated advanced heart failure secondary to ischemic or dilated cardiomyopathy.
Positive inotropes used for the treatment of heart failure have been arrhythmogenic. Levosimendan is a novel calcium sensitizer with vasodilating properties and a complex mechanism of action. Its effect on ventricular arrhythmias and 24-hour Holter electrocardiographically derived prognostic autonomic nervous system-related markers, because it occurs in parallel with changes in cardiac function and neurohormonal response, has not been systematically assessed. ⋯ In conclusion, levosimendan at low doses increases nonsustained ventricular arrhythmias, without affecting Holter-derived, prognostically significant autonomic markers. At the same time, it is associated with improvements in cardiac function and neurohormonal response. These findings may have important clinical and prognostic implications.
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The safety and efficacy of the concomitant use of intravenous diuretics and positive inotropes with nesiritide have not been well studied. There is also a paucity of data examining whether the type of medical therapy before treatment with nesiritide has an effect on outcomes. Data from 167 patients with heart failure and reduced left ventricular ejection fractions (34 +/- 17%) treated with nesiritide were analyzed retrospectively. ⋯ Survival was not worsened in those receiving inotropes (p = 0.51). Also, there were no significant differences in serum creatinine, glomerular filtration rate, or urine output in patients who continued to receive angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, beta blockers, or digoxin therapy during nesiritide infusion. In conclusion, there were no observed adverse affects of baseline medical therapy, intravenous diuretics, or intravenous inotropes on renal functions or mortality when used in conjunction with nesiritide in the treatment of decompensated chronic heart failure.
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Comparative Study
Comparison of the effect of anemia on in-hospital mortality in patients with versus without preserved left ventricular ejection fraction.
Patients with symptomatic heart failure (HF) frequently have preserved left ventricular (LV) ejection fractions (LVEFs). Although anemia is a common finding in this patient population, its prognostic role has not been well studied. This study's aim was to assess if the LVEF interferes in the association between anemia and in-hospital mortality in patients with severe HF. ⋯ On multivariate analysis, anemia was independently associated with in-hospital mortality (odds ratio 2.7, 95% confidence interval 1.43 to 5.04, p = 0.002). There was no interaction between anemia and systolic function (p = 0.08 for interaction). In conclusion, anemia was an independent predictor of in-hospital mortality in symptomatic patients with severe HF, regardless of whether the patients had preserved or impaired LV systolic function.
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Randomized Controlled Trial
Effects of levosimendan on right ventricular function in patients with advanced heart failure.
Right ventricular (RV) dysfunction frequently complicates advanced left ventricular heart failure and contributes to an unfavorable prognosis. Levosimendan is a novel inodilator that beneficially affects hemodynamics and left ventricular systolic and diastolic function in patients with advanced heart failure. However, its effects on RV function have not yet been properly assessed in these patients. ⋯ Systolic pulmonary arterial pressure decreased significantly (54 +/- 11 vs 43 +/- 11 mm Hg, p <0.01) in the levosimendan-treated patients. Levosimendan beneficially modulated neurohormonal and inflammatory status by decreasing B-type natriuretic peptide levels (p <0.05) and by altering the ratio of interleukin-6 to interleukin-10 in favor of the latter (p <0.05). In conclusion, levosimendan could offer further therapeutic advantages in patients with advanced heart failure by improving systolic and diastolic RV function.