The syndrome of heart failure: emerging concepts in the understanding of its pathogenesis and treatment

Investigation on the Use of Traditional Chinese Medicine for Polycystic Ovary Syndrome in a Nationwide Prescription Database in Taiwan

Polycystic ovary syndrome (PCOS) is a common condition, affecting 5⁻10% of women of reproductive age worldwide. It has serious reproductive implications and causes mood disorders and metabolic disorders, such as type-2 diabetes. Because PCOS reflects multiple abnormalities, there is no single drug that can treat all its symptoms. Existing pharmaceutical agents, such as oral contraceptives (OCs), are suggested as a first-line therapy for menstrual irregularities; however, OCs are not appropriate for women pursuing pregnancy. Additionally, insulin-sensitizing agents, which appear to decrease insulin levels and hyperandrogenemia in women with PCOS, have been associated with a high incidence of gastrointestinal adverse effects. It is a common practice in Chinese society to receive traditional Chinese medicine (TCM) for treatment of gynecological problems and infertility. Current research demonstrates that several herbs and herbal formulas show beneficial effects in PCOS treatment. In this study, we conducted the first large-scale survey through the Taiwan National Health Insurance Program database to analyze TCM utilization patterns among women with PCOS in Taiwan during 1997⁻2010. The survey results revealed that 89.22% women with newly diagnosed PCOS had received TCM therapy. Jia-Wei-Xiao-Yao-San and Xiang-Fu (Rhizoma Cyperi) were the most commonly used formula and single herb, respectively, in the database. In addition, we found that the top five commonly prescribed single herbs and herbal formulas have shown promise in treating symptoms associated with PCOS.

Anti-apoptotic potential of rosuvastatin pretreatment in murine model of cardiomyopathy

BACKGROUND

Apoptosis is a key pathologic feature in myocardial infarction and heart failure. Recent evidence suggests that statins may have beneficial effects on cardiovascular outcomes in patients with heart failure. The present study was planned to investigate the anti-apoptotic potential of rosuvastatin pretreatment in doxorubicin-induced cardiomyopathy.

METHODS

Sixty male Wistar rats were randomly divided into six groups: Group-I (vehicle control group), Group-II (pathological Control group), Group-III (rosuvastatin 0.5 mg/kg), Group IV (rosuvastatin 2 mg/kg), Group-V (rosuvastatin 2 mg/kg per se), and Group-VI (carvedilol 1mg/kg). Myocardial apoptosis was detected by caspase-3 assay, DNA gel electrophoresis and Na(+)/K(+) ATPase estimation. The animals were evaluated for various biochemical parameters in serum followed by histopathological studies of heart tissue.

RESULTS

Doxorubicin treated rats exhibited cardiac dysfunctions as indicated by an increase in systolic, diastolic, mean BP, heart rate and tail blood flow and volume and increased serum LDH, TC, TGs, LDL-C, VLDL-C levels and atherogenic indexes. A marked induction in caspase-3 and Na(+)-K(+) ATPase levels and DNA laddering as revealed by agarose gel electrophoresis was observed in rat myocardium of pathological group. Pretreatment with the test drug, rosuvastatin significantly reduced the increase in hemodynamic parameters, serum LDH, lipid profile and myocardial caspase-3, Na(+)-K(+) ATPase activity as compared to the pathogenic control group. Further, DNA ladder formation was attenuated by rosuvastatin treatment. Histopathological studies further confirm its myocardial salvaging effects. The results were comparable with carvedilol.

CONCLUSIONS

The study demonstrates the cardioprotective potential of rosuvastatin against doxorubicin-induced myocardial apoptosis.

Long-term effect of atorvastatin on neurohumoral activation and cardiac function in patients with chronic heart failure: a prospective randomized controlled study

BACKGROUND

Statins have pleiotropic effects, such as improvement in endothelial function and antiinflammatory, antiproliferative, and antioxidative effects, that should be beneficial for patients with chronic heart failure (CHF). The aim of this study was to investigate the long-term effect of statins on neurohumoral activation and cardiac function in patients with CHF.

METHODS

We enrolled 38 outpatients with mild to moderate CHF and radionuclide left ventricular ejection fraction (LVEF) <40%. These patients were randomly assigned to receive atorvastatin (10 mg/d) or conventional treatment for heart failure and were prospectively followed up for at least 3 years. At entry, we measured plasma concentrations of brain natriuretic peptides (BNPs) and left ventricular end-diastolic dimension and LVEF by echocardiography; thereafter, these measurements were repeated at least every 6 months. The primary end point was defined as the improvement in cardiac function and BNP.

RESULTS

There were no significant differences in age, sex, New York Heart Association class, left ventricular end-diastolic dimension, LVEF, and serum cholesterol level at entry between patients with (n = 19) and without atorvastatin (control, n = 19). After a follow-up period of 31 +/- 14 months, BNP (median [25th, 75th percentile]) significantly decreased in the atorvastatin group (84 [36, 186] to 55 [37, 91] pg/mL, P = .02) but not in the control group. Left ventricular end-diastolic dimension significantly decreased (67.1 [59.9, 70.8] to 61.1 [58, 63.9] mm, P = .02), and LVEF also significantly increased in the atorvastatin group (33.3% +/- 7.4% to 39.1% +/- 12.1%, P = .01) but not in the control group.

CONCLUSION

Long-term atorvastatin therapy decreases neurohumoral activation and improves cardiac function in patients with mild to moderate CHF.

Effect of High-Dose Atorvastatin on Hospitalizations for Heart Failure

Background— Statins reduce the rate of major cardiovascular events in high-risk patients, but their potential benefit as treatment for heart failure (HF) is less clear.

Methods and Results— Patients (n=10 001) with stable coronary disease were randomized to treatment with atorvastatin 80 or 10 mg/d and followed up for a median of 4.9 years. A history of HF was present in 7.8% of patients. A known ejection fraction <30% and advanced HF were exclusion criteria for the study. A predefined secondary end point of the study was hospitalization for HF. The incidence of hospitalization for HF was 2.4% in the 80-mg arm and 3.3% in the 10-mg arm (hazard ratio, 0.74; 95% confidence interval, 0.59 to 0.94; P =0.0116). The treatment effect of the higher dose was more marked in patients with a history of HF: 17.3% versus 10.6% in the 10- and 80-mg arms, respectively (hazard ratio, 0.59; 95% confidence interval, 0.4 to 0.88; P =0.009). Among patients without a history of HF, the rates of hospitalization for HF were much lower: 1.8% in the 80-mg group and 2.0% in the 10-mg group (hazard ratio, 0.87; 95% confidence interval, 0.64 to 1.16; P =0.34). Only one third of patients hospitalized for HF had evidence of preceding angina or myocardial infarction during the study period. Blood pressure was almost identical during follow-up in the treatment groups.

Conclusions— Compared with a lower dose, intensive treatment with atorvastatin in patients with stable coronary disease significantly reduces hospitalizations for HF. In a post hoc analysis, this benefit was observed only in patients with a history of HF. The mechanism accounting for this benefit is unlikely to be due primarily to a reduction in interim coronary events or differences in blood pressure.

Effects of Statin Therapy on the Development and Progression of Heart Failure: Mechanisms and Clinical Trials

BACKGROUND

Statin therapy has been shown to effectively lower low-density lipoprotein cholesterol levels and reduce cardiovascular events. Statins also appear to exert other favorable effects, including anti-inflammatory actions and improvement in endothelial function. Statin therapy may therefore yield important clinical benefits in patients with heart failure-a physiologic state characterized by systemic inflammation and endothelial dysfunction.

METHODS AND RESULTS

This review summarizes basic and clinical investigations regarding the role of statin therapy in heart failure, focusing on potential mechanisms and preliminary clinical data. There is now extensive evidence suggesting that statins improve endothelial function, inhibit neurohormonal activation, restore autonomic balance, reduce inflammation, and prevent ventricular remodeling. Retrospective and small-scale prospective studies suggest that statins prevent the development of heart failure and reduce mortality in patients with established HF.

CONCLUSION

Preliminary evidence supports a role for statins in improving surrogate markers and clinical outcomes in ischemic and nonischemic heart failure. Large-scale randomized clinical trials are needed to definitively address this important topic.

Impact of blockade of histamine H2 receptors on chronic heart failure revealed by retrospective and prospective randomized studies

OBJECTIVES

The goal of this work was to determine whether the blockade of histamine H2 receptors is beneficial for the pathophysiology of chronic heart failure (CHF).

BACKGROUND

Because CHF is one of the major life-threatening diseases, we need to find a novel effective therapy. Intriguingly, our previous study, which predicts the involvement of histamine in CHF, suggests that we should test this hypothesis in patients with CHF.

METHODS

We selected 159 patients who received famotidine among symptomatic CHF patients for the retrospective study. We blindly selected age- and gender-matched CHF patients receiving drugs for gastritis other than histamine H2 receptor blockers as a control group. For the prospective study, 50 symptomatic CHF patients were randomly divided into 2 groups. One group received famotidine of 30 mg/day for 6 months, and the other group received teprenone.

RESULTS

In the retrospective study, famotidine of 20 to 40 mg decreased both left ventricular end-diastolic and end-systolic lengths (LVDd and LVDs, respectively) and the plasma B-type natriuretic peptide (BNP) levels (182 +/- 21 vs. 259 +/- 25 pg/ml, p < 0.05) with unaltered fractional shortening (FS). In a randomized, open-label study, compared with teprenone, famotidine of 30 mg prospectively decreased both New York Heart Association functional class (p < 0.05) and plasma BNP levels (183 +/- 26 pg/ml vs. 285 +/- 41 pg/ml, p < 0.05); this corresponded to decreasing both LVDd (57 +/- 2 mm vs. 64 +/- 2 mm, p < 0.05) and LVDs (47 +/- 2 mm vs. 55 +/- 2 mm, p < 0.05) with unaltered FS (15 +/- 1% vs. 17 +/- 1%). The frequency of readmission because of worsening of CHF was lower in the famotidine group (4% and 24%, p < 0.05). On the other hand, teprenone had no effects on CHF.

CONCLUSIONS

Famotidine improved both cardiac symptoms and ventricular remodeling associated with CHF. Histamine H2 receptor blockers may have therapeutic benefits for CHF.

Effects of statins beyond lipid lowering: Potential for clinical benefits

BACKGROUND

The role of statin drugs in the reduction of serum lipids has been well documented. More recently, evidence suggesting that statins may positively impact many organ systems and disease states independent of lipid reduction has emerged. The term "pleiotropic effects" has been used to refer to these properties. We reviewed the evidence exploring such potential effects.

METHODS

A search of the MEDLINE database was conducted for articles published between 1985 to 2005 on the pleiotropic and the lipid-lowering independent effects of statin drugs. The search terms "statin", "HMG-CoA reductase inhibitor", "pleiotropic effects", and "inflammation" were used. English language articles were selected for inclusion along with selected cross-references.

RESULTS

Numerous animal and clinical studies support the presence of a spectrum of beneficial effects for statins that are independent of their lipid-lowering properties. These effects are mediated by a variety of mechanisms and they suggest that the therapeutic role of statins may expand.

CONCLUSION

Statins have shown great promise beyond their lipid-lowering effects. Ongoing and future studies will help to further clarify the potential clinical impact of these "pleiotropic effects".

Abnormal Glucose Tolerance Contributes to the Progression of Chronic Heart Failure in Patients with Dilated Cardiomyopathy

Since 1) dilated cardiomyopathy (DCM) causes chronic heart failure (CHF), and 2) augmentation of neurohumoral factors such as angiotensin II impairs glucose metabolism, we examined the rate of abnormal glucose metabolism in patients having both DCM and CHF and whether correction of the impairment of glucose metabolism would improve the pathophysiology of CHF in DCM patients. A 75-g oral glucose tolerance test (OGTT) was performed in 56 patients with DCM-induced CHF and 168 age- and sex-matched control subjects. Among the CHF patients, 26.8% and 50.0% suffered from diabetes mellitus (DM) and impaired glucose tolerance (IGT), respectively, showing that abnormal glucose tolerance was more prevalent in DCM patients than in the control subjects (7.7% and 14.3%, respectively). In the patients with DCM-induced CHF, a correlation was observed between the brain natriuretic peptide (BNP) levels and the difference between the plasma glucose levels at the time of fasting and at 2 h of OGTT. Since neither DM nor IGT are thought to cause DCM, the abnormalities of glucose metabolism may be attributed to the progression of CHF. Furthermore, we tested whether correction of the abnormal glucose tolerance using voglibose (an alpha-glucosidase inhibitor) would improve the severity of CHF in another group of 30 patients with DCM-induced CHF and IGT. The patients treated with voglibose for 24 weeks showed decreases in left ventricular dimension, NYHA functional classification values, and plasma BNP levels, and an improvement in cardiac function. In conclusion, abnormal glucose tolerance was more prevalent among patients with DCM-induced CHF than controls, and the correction of IGT improved the pathophysiology of CHF.

Interaction of implantable defibrillator therapy with angiotensin-converting enzyme deletion/insertion polymorphism

INTRODUCTION

The angiotensin-converting enzyme deletion allele (ACE D) decreases survival in patients with advanced heart failure. Whether the adverse impact on survival reflects an increased risk of pump failure or arrhythmic sudden death remains uncertain. If the ACE D genotype increases the risk of sudden death, implantable cardioverter defibrillator (ICD) therapy should diminish its negative impact. We sought to evaluate the effect of ICD therapy on ACE D genetic risk.

METHODS AND RESULTS

The Genetic Risk Assessment of Cardiac Events (GRACE) study enrolled 479 patients at the University of Pittsburgh between 1996 and 2001. Blood was genotyped for the ACE D/I (deletion/insertion) polymorphism. Of the 479 patients, 82 (77% male, 84% Caucasian, age 56 +/- 11 years, 60% ischemic, left ventricular ejection fraction 0.23 +/- 0.08) received an ICD and were selected for outcomes analysis (mean follow-up 871 +/- 538 days). Transplant-free survival and survival alone were compared in ACE DD patients (n = 24, 29%) versus ACE DI/II patients (n = 58, 71%). Survival was significantly improved in ACE DI/II patients compared to those without an ICD (1 year: 93% vs 87%; 2 year: 89% vs 77%; P = 0.02) but not in ACE DD patients. Transplant-free survival among patients with an ICD was significantly worse in ACE DD versus ACE DI/II (1 year: 67% vs 88%, 2 year: 55% vs 80%, P = 0.03). Analysis of survival as a single endpoint revealed a similar result (1 year = 78% vs 94%; 2 year: 72% vs 88%; P = 0.05). ICD telemetry data showed a nonsignificant trend toward fewer individuals with arrhythmias in the ACE-DD group (46% vs 65%, P = 0.22)

CONCLUSION

ICDs do not diminish the adverse influence of the ACE DD genotype on survival. This finding suggests that mortality in this high-risk genetic subset of patients is due to progression of heart failure rather than arrhythmic sudden death.

Short-term statin therapy improves cardiac function and symptoms in patients with idiopathic dilated cardiomyopathy

BACKGROUND

Chronic heart failure is associated with inflammation and neurohormonal imbalance. The 3-hydroxy-3-methylglutaryl-CoA (HMG-CoA) reductase inhibitors, or statins, exert anti-inflammatory and vascular protective effects. We hypothesized that short-term statin therapy may have beneficial effects in patients with nonischemic heart failure.

METHODS AND RESULTS

Sixty-three patients with symptomatic, nonischemic, dilated cardiomyopathy were randomly divided into 2 groups. One group received simvastatin (n=24), and the other group received placebo (n=27). The initial dose of simvastatin was 5 mg/d, which was increased to 10 mg/d after 4 weeks. After 14 weeks, patients receiving simvastatin exhibited a modest reduction in serum cholesterol level compared with patients receiving placebo (130+/-13 versus 148+/-18, P<0.05). Patients treated with simvastatin had a lower New York Heart Association functional class compared with patients receiving placebo (2.04+/-0.06 versus 2.32+/-0.05, P<0.01). This corresponded to improved left ventricular ejection fraction in the simvastatin group (34+/-3 to 41+/-4%, P<0.05) but not in the placebo group. Furthermore, plasma concentrations of tumor necrosis factor-alpha, interleukin-6, and brain natriuretic peptide were significantly lower in the simvastatin group compared with the placebo group.

CONCLUSIONS

Short-term statin therapy improves cardiac function, neurohormonal imbalance, and symptoms associated with idiopathic dilated cardiomyopathy. These findings suggest that statins may have therapeutic benefits in patients with heart failure irrespective of serum cholesterol levels or atherosclerotic heart disease.

Mitral valve reconstruction in the patient with heart failure

Secondary MR is a complication of end-stage cardiomyopathy and is associated with a poor prognosis and is due to progressive mitral annular dilation and alteration in LV geometry. A vicious cycle of continuing volume overload, ventricular dilation, progression of annular dilation, increased LV wall tension and worsening MR and CHF occur. The mainstay of medical therapy is diuretics and afterload reduction, and is associated with poor long-term survival in these patients with CHF and MR. However, surgical intervention in the form of undersized, 'overcorrecting' mitral valve repair has shown great promise and is an area of ongoing investigation.

Mitral valve repair in heart failure

Mitral regurgitation (MR) is a frequent complication of end-stage heart failure. Historically, these patients were either managed medically or with mitral valve replacement, both associated with poor outcomes. Mitral valve repair via an 'undersized' annuloplasty repair is safe and effectively corrects MR in heart-failure patients. All of the observed changes contribute to reverse remodeling and restoration of the normal left-ventricular geometric relationship. Mitral valve repair offers a new strategy for patients with MR and end-stage heart failure.