Progress in cardiovascular diseases
-
Subgroup analysis in a clinical trial is the evaluation of the effect of a randomly allocated intervention within only a fraction of the patients in the entire research cohort. This article provides several examples of the use of subgroup analysis, discusses some of the interpretative difficulties that occur during the assessment of the effect of therapy within subgroups, and provides a summary of recent recommendations on reporting subgroup analyses in the literature. Although subgroup analyses can provide new, provocative, and sometimes clinically relevant findings, this group of evaluations must be handled with extreme care.
-
Prog Cardiovasc Dis · Sep 2011
ReviewPulmonary hypertension associated with left heart disease: characteristics, emerging concepts, and treatment strategies.
Left heart disease (LHD) represents the most common causes of pulmonary hypertension (PH). Whether caused by systolic or diastolic dysfunction or valvular heart disease, a hallmark of PH associated with LHD is elevated left atrial pressure. In all cases, the increase in left atrial pressure causes a passive increase in pulmonary pressure. ⋯ Optimizing heart failure regimens and corrective valve surgery represent the cornerstone of the treatment of PH in LHD. Recent studies suggest that sildenafil, a phosphodiesterase-5 inhibitor, is a promising agent in the treatment of PH in LHD. Unloading the left ventricle with circulatory support may also reverse severe PH in patients with end-stage heart failure allowing candidacy to heart transplantation.
-
Advanced heart failure (HF) is a disease process that carries a high burden of symptoms, suffering, and death. Palliative care can complement traditional care to improve symptom amelioration, patient-caregiver communication, emotional support, and medical decision making. ⋯ Review of the literature reveals that although barriers to integrating palliative care are not fully understood, difficult prognostication combined with caregiver inexperience with end-of-life issues specific to advanced HF is likely to contribute. In this review, we have outlined the general need for palliative care in advanced HF, detailed how palliative measures can be integrated into the care of those having this disease, and explored end-of-life issues specific to these patients.
-
Prog Cardiovasc Dis · Sep 2011
ReviewSurgical treatment of advanced heart failure: alternatives to heart transplantation and mechanical circulatory assist devices.
Although orthotopic heart transplantation is the gold standard for definitive surgical treatment of end-stage heart failure, other operative therapies exist for dealing with severe systolic left ventricular dysfunction. The choice of surgical intervention depends on the etiology and functional characteristics of the patient's ventricular dysfunction. In patients with ischemic cardiomyopathy, surgical revascularization improves survival. ⋯ Although surgical ventricular reconstruction is controversial, significant data exist suggesting that it is an effective therapy in a subset of patients with left ventricular dysfunction. Finally, passive restraint devices are effective at halting further ventricular dilation. Although cardiac surgery in patients with severe ventricular dysfunction can be complicated by significant morbidity and mortality, experienced centers have demonstrated acceptable outcomes in carefully selected patients.
-
Valvular heart disease (VHD) carries documented risks for active individuals. At the same time, many individuals with intermediate degrees of valve disease can safely exercise and even participate in competitive athletics. ⋯ Careful physical examination and appropriate imaging studies will identify patients at risk; most will require serial evaluation but can exercise and participate in sports as desired. When symptoms develop, prompt treatment of severe, symptomatic disease and intensive cardiac rehabilitation as well as continued surveillance after surgical treatment will maximize the functional ability of active individuals with VHD.