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Volume 9, No 3 - Summer 2008

Volume 9, No 3 - Summer 2008

Table of Contents

Nesiritide in Acute Decompensated Heart Failure: Current Status and Future Perspectives Treatment Update
Acute decompensated heart failure (ADHF) is a growing public health problem with high mortality and costs. ADHF often, if not usually, occurs in the setting of cardiovascular and noncardiovascular comorbidities as well as advanced age. New insights provide support for the concept of heart failure as a state of deficiency of and/or resistance to endogenous B-type natriuretic peptide. The primary goals of ADHF therapy are to relieve symptoms and optimize volume status with minimal side effects. Few therapies are proven to effectively do so. Nesiritide is a balanced vasodilator with favorable neurohumoral effects and is superior to placebo in providing rapid symptom relief and to nitroglycerin in reducing filling pressures. Recent trials confirm a lack of renal toxicity at recommended doses. An adequately powered multinational mortality trial is underway. Nesiritide represents a proven therapy for normotensive/hypertensive ADHF patients with severe symptoms at rest. [Rev Cardiovasc Med. 2008;9(3):151-158]
Sleep Apnea and the Heart: Diagnosis and Treatment Management Update
Although sleep apnea is closely associated with cardiovascular disease, it remains underdiagnosed and undertreated. Obstructive sleep apnea elicits a cascade of harmful cardiovascular stimuli, and central sleep apnea is a prognostic factor for heart failure and may exert adverse effects on outcomes. The adverse effects of obstructive sleep apnea can promote the development of atherosclerosis and have also been implicated in the pathogenesis of cardiovascular disease. Sleep apnea characterized by variables of the autonomic nervous system may have a direct association with arrhythmia. Polysomnography with electroencephalography is the gold standard for assessing sleep apnea. Alternative methods of screening for OSA have recently become available. Continuous positive airway pressure for obstructive sleep apnea reduces cardiac risk and cardiovascular disease mortality. Targeting sleep apnea in the primary and/or secondary prevention of cardiovascular disease may lead to better outcomes. [Rev Cardiovasc Med. 2008;9(3):159-167]
Patent Foramen Ovale: Clinical Manifestations and Treatment Management Update
A persistent patent foramen ovale produces an intermittent intra-atrial right-to-left shunt and occurs in approximately 25% of the general population. Although the vast majority of people with patent foramen ovale are asymptomatic, a patent foramen ovale is believed to act as a pathway for chemicals or thrombus that can result in a variety of clinical manifestations, including stroke, migraine headache, decompression sickness, high-altitude pulmonary edema, and platypnea-orthodeoxia syndrome. The optimal management of patients with patent foramen ovale who experience cryptogenic stroke is unclear. Percutaneous closure appears to have a low risk profile and has been considered in high-risk patients who are not candidates for randomized clinical trials. Randomized clinical trials that are underway should help define the best management of patent foramen ovale, as well as the true safety and efficacy of percutaneous closure devices. [Rev Cardiovasc Med. 2008;9(3):168-173]
Cardiac Magnetic Resonance: Physics, Pulse Sequences, and Clinical Applications Technique Review
Cardiac magnetic resonance (CMR) is a new and promising technique for image-based diagnosis in patients with known or suspected diseases of the heart. CMR allows clinicians to obtain relevant information on anatomy, function, perfusion, and viability of the myocardium. This technique offers the advantages of versatility, lack of ionizing radiation, and superior soft tissue contrast. The variety of clinical conditions that can affect the heart and the need to understand the time-varying movement of the heart in 3 dimensions adds challenges to interpretation of CMR above and beyond those present in understanding the imaging modality itself. The image intensities present in CMR scans can vary by orders of magnitude in the same subject depending on parameters set by the individual acquiring the data. These different appearances of images may reflect distinct pathophysiologic states and, therefore, an understanding of image acquisition is fundamental to the clinical diagnosis and assessment of disease. [Rev Cardiovasc Med. 2008;9(3):174-186]
The Relationship Between Erectile Dysfunction and Cardiovascular Disease. Part II: The Role of PDE-5 Inhibition in Sexual Dysfunction and Cardiovascular Disease Treatment Update
Erectile dysfunction (ED) is a sensitive indicator of wider arterial insufficiency and an early correlate for the presence of ischemic heart disease. Among patients with coronary artery disease, prevalence reports of ED range from 42% to 75%. The US Food and Drug Administration has approved 3 phosphodiesterase-5 (PDE-5) inhibitors for treatment of male sexual dysfunction: sildenafil, tadalafil, and vardenafil. PDE-5 inhibitors also have cardiovascular effects. They inhibit PDE-5 enzymes in pulmonary vasculature, which causes vasodilation that decreases pulmonary vascular pressure. Sildenafil is approved for treatment of patients with pulmonary hypertension. PDE-5 inhibition with sildenafil improves cardiac output by balancing pulmonary and systemic vasodilation, and augments and prolongs the hemodynamic effects of inhaled nitric oxide in patients with chronic congestive heart failure and pulmonary hypertension. In vivo and in vitro studies are examining the possible beneficial effects of PDE-5 inhibitors in conditions such as myocardial infarction and endothelial dysfunction. [Rev Cardiovasc Med. 2008;9(3):187-195]
Best of the HRS Scientific Sessions 2008 Meeting Review
Highlights From the Heart Rhythm Society Scientific Sessions May 14-17, 2008 San Francisco, CA [Rev Cardiovasc Med. 2008;9(3):196-199]
Best of the ASH Scientific Sessions 2008 Meeting Review
Highlights From the American Society of Hypertension 2008 Scientific Sessions May 14-17, 2008 New Orleans, LA [Rev Cardiovasc Med. 2008;9(3):200-203]
Inflammatory Aneurysm of the Thoracoabdominal Aorta With Associated Dissection Case Review
The inflammatory variant of aortic aneurysms has 3 unique features: marked thickening of the aneurysm wall, fibrosis of the adjacent retroperitoneum, and rigid adherence of the adjacent structures to the anterior aneurysm wall. Abdominal tenderness with or without a pulsatile abdominal mass is the most common finding, although it is present in only about 33% of patients. Systemic symptoms, such as fever, malaise, and weight loss, are reported in about 20% to 50% of patients. A contrast-enhanced computed tomography scan, magnetic resonance imaging, and a transesophageal echocardiogram are among the best modalities to evaluate for inflammatory thoracoabdominal aneurysm, but a transthoracic echocardiogram can frequently be very suggestive. Medical treatment options include corticosteroids or other anti-inflammatory and immunosuppressive therapies. Surgical intervention usually consists of a transperitoneal approach with infrarenal aortic clamping. This case review describes a 64-year-old woman with a history of hypertension and dyslipidemia who presented with anemia, lower back pain, and a recent 30-pound weight loss. [Rev Cardiovasc Med. 2008;9(3):204-209]