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Abstract
BACKGROUND Depression is associated with a substantial utilization of resources in the German healthcare system. A typical symptom in depression is loss of drive, which possibly contributes to non-adherence and increased costs. OBJECTIVE The study is based on routine healthcare data and tested the hypothesis that telephone coaching in cases of depression leads to a reduction in total healthcare costs. MATERIAL AND METHODS Based on approximately 80 covariates and using propensity score matching, a total of 1586 persons who had received telephone coaching for depression and covered by a German statutory health insurance fund were matched to a comparable cohort of patients with depression to whom telephone coaching had not been provided. RESULTS Within the study period of 12 months (3rd quarter 2012-4th quarter 2013) a positive program effect was observed for the intervention group by a significant reduction of total healthcare costs (2332 € vs. 2626 €, p = 0.0015) resulting in total savings to the statutory health insurance fund of 415,532 €. Investment costs amounted to 256,683.42 € leading to a return on investment of 1.62 € (total savings/total investment). The coaching program was well accepted by patients. CONCLUSION Telephone coaching for depression was able to significantly reduce total healthcare expenditure and the intervention was well accepted by patients.
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Affiliation(s)
- W Gerlach-Reinholz
- Praxisgemeinschaft Gerlach-Reinholz/Hadasch, Bahnhofstraße 6, 48619, Heek, Deutschland
- Sanvartis GmbH, Dr.-Alfred-Herrhausen-Allee 9-11, 47228, Duisburg, Deutschland
| | - L Drop
- Sanvartis GmbH, Dr.-Alfred-Herrhausen-Allee 9-11, 47228, Duisburg, Deutschland
| | - E Basic
- Elsevier Health Analytics Germany, Jägerstraße 41, 10117, Berlin, Deutschland
- Health Risk Institute, Spittelmarkt 12, 10117, Berlin, Deutschland
| | - M Rauchhaus
- Klinik mit Schwerpunkt Kardiologie, Campus Virchow Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Deutschland.
- buivm - Beratungsunternehmen Innovatives Versorgungsmanagement, Jägersteig 26, 14482, Potsdam, Deutschland.
| | - J Fritze
- , Asternweg 65, 50259, Pulheim, Deutschland
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Schmidt H, Lotze U, Ghanem A, Anker S, Said S, Braun-Dullaeus R, Oltmanns G, Rose S, Buerke M, Müller-Werdan U, Werdan K, Rauchhaus M. Relation of impaired interorgan communication and parasympathetic activity in chronic heart failure and multiple-organ dysfunction syndrome. J Crit Care 2014; 29:367-73. [DOI: 10.1016/j.jcrc.2013.12.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2013] [Revised: 11/17/2013] [Accepted: 12/22/2013] [Indexed: 11/28/2022]
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Turan RG, Bozdag-T I, Turan CH, Ortak J, Akin I, Kische S, Schneider H, Rauchhaus M, Rehders TC, Kleinfeldt T, Belu C, Amen S, Hermann T, Yokus S, Brehm M, Steiner S, Chatterjee T, Sahin K, Nienaber CA, Ince H. Enhanced mobilization of the bone marrow-derived circulating progenitor cells by intracoronary freshly isolated bone marrow cells transplantation in patients with acute myocardial infarction. J Cell Mol Med 2012; 16:852-64. [PMID: 21707914 PMCID: PMC3822854 DOI: 10.1111/j.1582-4934.2011.01358.x] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Autologous bone marrow cell transplantation (BMCs-Tx) is a promising novel option for treatment of cardiovascular disease. We analysed in a randomized controlled study the influence of the intracoronary autologous freshly isolated BMCs-Tx on the mobilization of bone marrow–derived circulating progenitor cells (BM-CPCs) in patients with acute myocardial infarction (AMI). Sixty-two patients with AMI were randomized to either freshly isolated BMCs-Tx or to a control group without cell therapy. Peripheral blood (PB) concentrations of CD34/45+- and CD133/45+-circulating progenitor cells were measured by flow cytometry in 42 AMI patients with cell therapy as well as in 20 AMI patients without cell therapy as a control group on days 1, 3, 5, 7, 8 and 3, 6 as well as 12 months after AMI. Global ejection fraction (EF) and the size of infarct area were determined by left ventriculography. We observed in patients with freshly isolated BMCs-Tx at 3 and 12 months follow up a significant reduction of infarct size and increase of global EF as well as infarct wall movement velocity. The mobilization of CD34/45+ and CD133/45+ BM-CPCs significantly increased with a peak on day 7 as compared to baseline after AMI in both groups (CD34/45+: P < 0.001, CD133/45+: P < 0.001). Moreover, this significant mobilization of BM-CPCs existed 3, 6 and 12 months after cell therapy compared to day 1 after AMI. In control group, there were no significant differences of CD34/45+ and CD133/45+ BM-CPCs mobilization between day 1 and 3, 6 and 12 months after AMI. Intracoronary transplantation of autologous freshly isolated BMCs by use of point of care system in patients with AMI may enhance and prolong the mobilization of CD34/45+ and CD133/45+ BM-CPCs in PB and this might increase the regenerative potency after AMI.
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Affiliation(s)
- R G Turan
- Division of Cardiology, Department of Internal Medicine, University Hospital Rostock, Rostock, Germany.
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Turan RG, Bozdag-T I, Ortak J, Kische S, Akin I, Schneider H, Turan CH, Rehders TC, Rauchhaus M, Kleinfeldt T, Belu C, Brehm M, Yokus S, Steiner S, Sahin K, Nienaber CA, Ince H. Improved functional activity of bone marrow derived circulating progenitor cells after intra coronary freshly isolated bone marrow cells transplantation in patients with ischemic heart disease. Stem Cell Rev Rep 2011; 7:646-56. [PMID: 21188654 PMCID: PMC3137778 DOI: 10.1007/s12015-010-9220-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Objectives There is growing evidence that intracoronary autologous bone marrow cells transplantation (BMCs-Tx) in patients with chronic myocardial infarction beneficially affects postinfarction remodelling. In this randomized controlled study we analyzed the influence of intracoronary autologous freshly isolated bone marrow cells transplantation by use of point of care system on cardiac function and on the functional activity of bone marrow derived circulating progenitor cells (BM-CPCs) in patients with ischemic heart disease (IHD). Methods 56 patients with IHD were randomized to either received freshly isolated BMC-Tx or a control group that did not receive cell therapy. The functional activity of BM-CPCs in peripheral blood (PB) was measured by migration assay and colony forming unit assay pre- and 3, 6 as well as 12 months after procedure. Global ejection fraction (EF) and infarct size area were determined by left ventriculography. Results Intracoronary transplantation of autologous freshly isolated BMCs led to a significant reduction of infarct size and an increase of global EF as well as infarct wall movement velocity after 3 and 12 months follow-up compared to control group. The colony-forming capacity of BM-CPCs significantly increased 3, 6 and 12 months after cell therapy compared to pre BMCs-Tx and control group (CFU-E: p < 0.001, CFU-GM: p < 0.001). Likewise, we found significant increase of migratory response to stromal cell-derived factor 1 (SDF-1) and vascular endothelial growth factor (VEGF) after cell therapy compared to pre BMCs-Tx (SDF-1: p < 0.001, VEGF: p < 0.001) and to control (SDF-1: p < 0.001, VEGF: p < 0.001). There was no significant difference of migratory- and colony forming capacity between pre- and 3, 6, 12 months after coronary angiography in control group without cell therapy. Conclusions Intracoronary transplantation of autologous freshly isolated BMCs by use of point of care system may lead to improvement of BM-CPCs functional activity in peripheral blood, which might increase the regenerative potency in patients with IHD.
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Affiliation(s)
- R Goekmen Turan
- Department of Internal Medicine, Division of Cardiology, Rostock-University, Ernst Hydemann Str 6, 18055, Rostock, Germany.
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Affiliation(s)
- A Vaz Pérez
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum, Germany
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Metten L, Zucca F, Haver Y, Neukirch B, Rauchhaus M. 22 Oral Effects of intensified care for heart failure patients by telemonitoring. Eur J Cardiovasc Nurs 2011. [DOI: 10.1016/s1474-51511160096-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- L. Metten
- SHL Telemedizin, Dusseldorf, Germany
| | - F. Zucca
- SHL Telemedizin, Dusseldorf, Germany
| | - Y. Haver
- SHL Telemedizin, Dusseldorf, Germany
| | - B. Neukirch
- Hochschule Niederhein, University of Applied Sciences, Krefeld, Germany
| | - M. Rauchhaus
- Charite - Campus Virchow-Klinikum, Department of Cardiology, Berlin, Germany
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von Haehling S, Bode-Böger SM, Martens-Lobenhoffer J, Rauchhaus M, Schefold JC, Genth-Zotz S, Karhausen T, Cicoira M, Anker SD, Doehner W. Elevated levels of asymmetric dimethylarginine in chronic heart failure: a pathophysiologic link between oxygen radical load and impaired vasodilator capacity and the therapeutic effect of allopurinol. Clin Pharmacol Ther 2010; 88:506-12. [PMID: 20827268 DOI: 10.1038/clpt.2010.116] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Asymmetric dimethylarginine (ADMA) is an endogenous inhibitor of nitric oxide-dependent vasodilation. In 113 patients with chronic heart failure (CHF) and 26 controls, ADMA level was studied in relation to peripheral blood flow and vasodilator capacity. Further, the effects of allopurinol on concentrations of reactive oxygen species (ROS) and ADMA and peripheral vasodilator capacity were tested in a double-blind design. ADMA level was found to be elevated in CHF patients as compared with controls and increased in parallel with New York Heart Association (NYHA) class and exercise capacity (all P < 0.0001). The level of ADMA predicted resting blood flow (P < 0.05) and postischemic vasodilator capacity (P < 0.001). Sixty eight patients died during the follow-up period. The level of ADMA predicted survival after multivariable adjustment (P = 0.04). Allopurinol reduced uric acid (UA) concentration (P < 0.001) and decreased ROS concentration (allantoin, P < 0.01). Allopurinol lowered ADMA concentration (P = 0.02); postischemic vasodilation as well as endothelium-dependent vasodilation (both P < 0.05) improved. ADMA may be a pathophysiologic factor that is modulated by ROS accumulation and contributes to impaired vascular regulation in CHF.
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Affiliation(s)
- S von Haehling
- Applied Cachexia Research, Department of Cardiology, Charité Medical School, Campus Virchow-Klinikum, Berlin, Germany
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Akin I, Ince H, Rauchhaus M, Kische S, Rehders TC, Wenzel RR, Nienaber CA, Chatterjee T. [Use of diuretics in acute decompensated heart failure]. Praxis (Bern 1994) 2010; 99:705-714. [PMID: 20533230 DOI: 10.1024/1661-8157/a000159] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/29/2023]
Abstract
Patients with acute heart failure usually present with dyspnoe and edema secondary to elevated intracardiac filling pressure resulting from volume overload. Despite significant progress in understanding heart failure, the treatment strategy for acute heart failure did not change in the same way. Diuretics, especially loop diuretics, are the most common therapy used in this setting. Intravenous diuretics act acutely by exerting a modest vasodilatory response and chronically by reducing circulating blood volume. Despite near universal use of diuretics in patients hospitalized with acute heart failure, nearly half of these patients are discharged from hospital without weight loss. This could be due to inadequate diuresis, overdiuresis with subsequent volume replacement and diuretic resistance. Aggressive diuresis carries a significant risk of electrolyte and volume depletion with subsequent arrythmias, hypotension, and worsening renal function. Actually there were scant data available from randomized clinical trials to guide therapeutic choice with diuretics. Thus, the choice and dosing of diuretic therapy must be individualized based on general knowledge of potency and pharmacokinetic and pharmacodynamic considerations.
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Affiliation(s)
- I Akin
- Kardiologie, Pulmologie, Zentrum für Innere Medizin I, Internistische Intensivmedizin, Universitätsklinikum Rostock AöR, Rostock, Germany
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Lokaj P, Krivan L, Kozak M, Sepsi M, Trcka P, Vlasinova J, Spinar J, Ferraro A, Rordorf R, Belvito C, Vicentini A, Savastano S, Petracci B, Sanzo A, Landolina M, Greenberg S, Goldman D, Deering T, Epstein A, Burke J, Dalal Y, Hurley J, Robinson B, Melton C, Patel M, Saporito J, Charlton S, Sims JJ, Van Casteren L, Heidbuchel H, Rossenbacker T, Gopal R, Vanhaecke J, Van Cleemput J, Droogne W, Willems R, Rocha Costa S, Silva J, Almeida S, Reis Santos K, Cavaco D, Morgado F, Adragao P, Silva A, Kanoupakis EM, Mavrakis HE, Kallergis EM, Koutalas EP, Saloustros IG, Milathianaki M, Manios EG, Vardas PE, Richey M, Malkin RA, Masson SC, Ransbury T, Urtz M, Ideker RE, Sanders WE, Greenberg S, Deering T, Goldman D, Epstein A, Burke J, Dalal Y, Brembilla-Perrot B, Azman B, Terrier De La Chaise A, Blangy H, Sadoul N, Claudon O, Louis P, Selton O, Braunschweig F, Ekman M, Maschio M, Linde C, Cowie MR, Pignalberi C, Lavalle C, Morichelli L, Porfili A, Quarta L, Sassi A, Ricci RP, Santini M, Deering TF, Goldman DS, Greenberg S, Epstein A, Gupta M, Gall SA, Kelland NF, Tynan M, Lord SW, Plummer CJ, Mccomb JM, Treguer F, Mabo P, Tassin A, Prunier F, Furber A, Daubert JC, Leclercq C, Dupuis JM, Bertini M, Ng ACT, Borleffs CJW, Delgado V, Boriani G, Leung DY, Schalij MJ, Bax JJ, Cabrera Bueno F, Alzueta J, Pena-Hernandez J, Molina-Mora MJ, Fernandez-Pastor J, Barrera A, De Teresa E, Stockburger M, Krebs A, Rauchhaus M, Celebi O, Nitardy A, Habedank D, Knaus T, Dietz R, Varma N, Epstein A, Irimpen A, Gibson L, Love C, Hindricks G, Elsner C, Geller J, Kautzner J, Moertel HB, Piorkowski C, Schumacher B, Taborsky M, Vest R, Blanco R, Valadri R, Shukrullah I, London B, Dudley S, Zafari M, Bloom H, Caliskan K, Theuns DF, Hoedemakers YM, Ten Cate FJ, Jordaens L, Szili Torok T, Biscione F, Di Grazia A, Pandolfo L, Porzio A, Deneke T, Lemke B, Horlitz M, Reinecke J, Lawo T, Muegge A, Grewe P, Borleffs CJW, Van Rees JB, Van Welsenes GH, Van Bommel RJ, Van Der Velde ET, Van Erven L, Bax JJ, Schalij MJ, Bhavnani S, Coleman C, Guertin D, White CM, Yarlagadda R, Clyne C, Kluger J. Poster Session 2: Primary prevention. Europace 2009. [DOI: 10.1093/europace/euq203] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Hennen R, Friedrich I, Hoyer D, Nuding S, Rauchhaus M, Schulze M, Schlisske S, Schwesig R, Schlitt A, Buerke M, Müller-Werdan U, Werdan K, Schmidt H. Autonome Dysfunktion und Betablocker beim Multiorgandysfunktionssyndrom. Dtsch Med Wochenschr 2008; 133:2500-4. [DOI: 10.1055/s-0028-1100944] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Heinz C, Mori Y, Karhausen T, Stieler J, Doehner W, Oettle H, Dietz R, Anker S, Rauchhaus M. 3528 POSTER Fatigue in pancreatic cancer: the potential link between exertional dyspnea, exercise limitation, skeletal musculature and neurohormonal activation. EJC Suppl 2007. [DOI: 10.1016/s1359-6349(07)71031-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022] Open
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Rauchhaus M, Schmidt H, Doehner W, Francis D, Davies C, Kemp M, Anker S, Müller-Werdan U, Coats A. Changes in metabolic and cytokine kinetics during strenuous exercise in patients with chronic heart failure. Eur J Heart Fail 2004. [DOI: 10.1016/s1388-9842(00)80243-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
- M. Rauchhaus
- Clinical Cardiology; National Heart and Lung Institute; London United Kingdom
| | - H.B. Schmidt
- Cardiology, Martin Luther University; Halle Germany
| | - W. Doehner
- Clinical Cardiology; National Heart and Lung Institute; London United Kingdom
| | - D.P. Francis
- Clinical Cardiology; National Heart and Lung Institute; London United Kingdom
| | - C. Davies
- Clinical Cardiology; National Heart and Lung Institute; London United Kingdom
| | - M. Kemp
- Clinical Cardiology; National Heart and Lung Institute; London United Kingdom
| | - S.D. Anker
- Clinical Cardiology; National Heart and Lung Institute; London United Kingdom
| | | | - A.J.S. Coats
- Clinical Cardiology; National Heart and Lung Institute; London United Kingdom
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Doehner W, Pflaum CD, Rauchhaus M, Godsland IF, Egerer K, Cicoira M, Florea VG, Sharma R, Bolger AP, Coats AJ, Anker SD, Strasburger CJ. Leptin, insulin sensitivity and growth hormone binding protein in chronic heart failure with and without cardiac cachexia. Eur J Endocrinol 2001; 145:727-35. [PMID: 11720897 DOI: 10.1530/eje.0.1450727] [Citation(s) in RCA: 81] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
OBJECTIVE Regulation of growth hormone (GH) receptor expression and hence tissue GH sensitivity may be important for the conflicting results found in treatment studies with recombinant growth hormone in chronic heart failure (CHF). Growth hormone-binding protein (GHBP) corresponds to the extracellular domain of the GH receptor and is closely related to measures of body composition and, specifically, to size of visceral fat tissue. Leptin, the adipocyte specific (ob) gene product, has been proposed as the signal linking adipose tissue and GHBP/GH-receptor expression. CHF has recently been shown to be a hyperleptinaemic and insulin-resistant state regardless of aetiology. This study aimed to examine the influence of leptin on GHBP in CHF patients with and without cardiac cachexia compared with healthy control subjects. METHODS We studied 47 male patients with CHF (mean age 61+/-2 years, New York Heart Association (NYHA)-class 2.7+/-0.1, left ventricular ejection fraction (LVEF) 28+/-2%, peak oxygen consumption 16.8+/-0.9 ml/kg/min) and 21 male healthy controls of similar age. Of the CHF patients, 19 were cachectic (cCHF; non-oedematous weight loss >7.5% over at least 6 months) and 28 non-cachectic (ncCHF; similar for age and LVEF). Insulin sensitivity was assessed by an intravenous glucose tolerance test using the minimal model approach. RESULTS Compared with healthy controls, patients had elevated levels of leptin (7.6+/-0.7 vs 4.8+/-0.7 ng/ml, P<0.05), insulin (76.2+/-8.9 vs 41.4+/-6.0 pmol/l, P<0.01), and reduced insulin sensitivity (2.43+/-0.2 vs 3.48+/-0.3 min(-1).microU.ml(-1).10(4), P<0.005) but similar GHBP levels (901+/-73 vs 903+/-95 pmol/l). Leptin levels were increased in ncCHF (9.11+/-1.0 ng/ml, P=0.001) but were not different from normal in cCHF (5.32+/-0.7 ng/ml, P>0.5). After correction for total body fat mass, both ncCHF and cCHF were hyperleptinaemic (41.8+/-3.8 and 37.9+/-0.38 vs 24.4+/-2.1 ng/ml/100 g, ANOVA P=0.001). In both patients and controls there was a direct correlation between leptin levels and GHBP (r=0.70 and r=0.71 respectively, both P<0.0001). This relationship was stronger than between GHBP and several parameters of body composition (body mass index (BMI), total and regional body fat mass or % body fat) and held true when sub-groups were tested individually (ncCHF r=0.62, P<0.001; cCHF r=0.79, P<0.0001). In multivariate regression analysis in all CHF patients, serum leptin levels emerged as the strongest predictor of GHBP, independent of age, BMI, total and regional fat mass or % body fat, fasting insulin level and insulin sensitivity. CONCLUSION Fat mass corrected leptin levels are elevated in CHF patients with and without cachexia. Reduced total fat mass may account for lower leptin levels in cachectic CHF patients compared with non cachectic patients. Leptin strongly predicts GHBP levels in CHF regardless of its hyperleptinaemic state or severely altered body composition as in cardiac cachexia. Leptin could be the signalling link between adipose tissue and GHBP/GH receptor expression in CHF.
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Affiliation(s)
- W Doehner
- Department of Clinical Cardiology, NHLI, Imperial College School of Medicine, London, UK.
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Cicoira M, Bolger AP, Doehner W, Rauchhaus M, Davos C, Sharma R, Al-Nasser FO, Coats AJ, Anker SD. High tumour necrosis factor-alpha levels are associated with exercise intolerance and neurohormonal activation in chronic heart failure patients. Cytokine 2001; 15:80-6. [PMID: 11500083 DOI: 10.1006/cyto.2001.0918] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Immune activation plays an important role in the progression of chronic heart failure (CHF). We sought to investigate whether different degrees of tumor necrosis factor-alpha (TNF-alpha) activation are associated with exercise intolerance, neurohormonal activation and alterations in muscle mass and function in patients with CHF without cardiac cachexia. Patients were divided into quartiles according to their TNF levels (first quartile: 0.98-4.90 pg/ml, second quartile: 5.00-6.60 pg/ml; third quartile 6.80-9.00 pg/ml; fourth quartile 9.80-32.00 pg/ml). Patients underwent cardiopulmonary exercise testing, quadriceps muscle strength test, quadriceps fatigue test, and assessment of thigh muscle and fat cross-sectional area (CSA) by computerized tomography scanning. Patients in the highest TNF quartile had the lowest peak oxygen consumption [13.1 (+/-4.1) ml/kg/min vs 18.1 (+/-5.3), 18.8 (+/-4.8) and 18.7 (+/-5.6) ml/kg/min, P<0.01] the greatest relation of ventilation and dioxide production (VE/VCO(2)) slope (P<0.05) and the most elevated catecholamine levels (P<0.05) compared to patients in the first three quartiles. Patients with the lowest TNF levels had preserved thigh muscle size and quadriceps strength. Strength/muscle CSA was similar in the four groups. Muscle strength during fatigue testing was significantly lower in the fourth quartile (P=0.01) compared with the other three groups. In CHF patients only the highest levels of TNF are associated with poor functional status and neurohormonal activation. This group of patients may represent the appropriate target population for TNF antagonism.
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Affiliation(s)
- M Cicoira
- Department of Cardiac Medicine, National Heart & Lung Institute, London, UK.
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Schmidt H, Rauchhaus M. Ideal weight, body composition and lipid levels: an unresolved dilemma? J Am Coll Cardiol 2001; 37:2010-1. [PMID: 11401151 DOI: 10.1016/s0735-1097(01)01262-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Doehner W, Rauchhaus M, Florea VG, Sharma R, Bolger AP, Davos CH, Coats AJ, Anker SD. Uric acid in cachectic and noncachectic patients with chronic heart failure: relationship to leg vascular resistance. Am Heart J 2001; 141:792-9. [PMID: 11320368 DOI: 10.1067/mhj.2001.114367] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Chronic heart failure (CHF) is a hyperuricemic state, and capillary endothelium is the predominant site of xanthine oxidase in the vasculature. Upregulated xanthine oxidase activity (through production of toxic free radicals) may contribute to impaired regulation of vascular tone in CHF. We aimed to study the relationship between serum uric acid levels and leg vascular resistance in patients with CHF with and without cachexia and in healthy control subjects. METHODS In 23 cachectic and 44 noncachectic patients with CHF (age, 62 +/- 1 years, mean +/- SEM) and 10 healthy control subjects (age, 68 +/- 1 years), we assessed leg resting and postischemic peak vascular resistance (calculated from mean blood pressure and leg blood flow by venous occlusion plethysmography). RESULTS Cachectic patients, compared with noncachectic patients and control subjects, had the highest uric acid levels (612 +/- 36 vs 459 +/- 18 and 346 +/- 21 micromol/L, respectively, both P <.0001) and the lowest peak leg blood flow and vascular reactivity (reduction of leg vascular resistance from resting to postischemic conditions: 83% vs 88% and 90%, both P <.005). In all patients, postischemic vascular resistance correlated significantly and independently of age with uric acid (r = 0.61), creatinine (r = 0.47, both P <.0001), peak VO2 (r = 0.34), and New York Heart Association class (r = 0.33, both P <.01). This correlation was not present in healthy control subjects (r = -0.04, P =.9). In multivariate and stepwise regression analyses, serum uric acid emerged as the strongest predictor of peak leg vascular resistance (standardized coefficient = 0.61, P <.0001) independent of age, peak VO2, creatinine, New York Heart Association class, and diuretic dose. CONCLUSIONS Hyperuricemia and postischemic leg vascular resistance are highest in cachectic patients with CHF, and both are directly related independent of diuretic dose and kidney function. The xanthine oxidase metabolic pathway may contribute to impaired vasodilator capacity in CHF.
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Affiliation(s)
- W Doehner
- Clinical Cardiology, National Heart and Lung Institute, Imperial College School of Medicine, London, UK.
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Schmidt HB, Rauchhaus M, Francis DP, Davies CL, Nuding S, Peschel T, Schmidt DS, Coats AJ, Opitz H, Werdan K. Assessment of chemoreflex sensitivity in free breathing young subjects by correction for respiratory influence. Int J Cardiol 2001; 78:157-65. [PMID: 11334660 DOI: 10.1016/s0167-5273(01)00377-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
BACKGROUND The assessment of autonomic function is an important tool for risk stratification in critically ill patients. Peripheral cardiac chemoreflex sensitivity has been considered a marker for increased risk of sudden cardiac death. In normals, the evaluation of peripheral cardiac chemoreflex sensitivity is performed under controlled breathing conditions during inhalation of hypoxic gas. Since this is poorly tolerated by patients, they are commonly studied under hyperoxic conditions, which are not physiological. METHODS We studied 20 healthy volunteers who underwent free and controlled breathing of a hypoxic gas mixture (10% O2 in N2) over 5 min. Values of peripheral cardiac chemoreflex sensitivity, corrected for respiratory influence, were compared with the results obtained experimentally under controlled breathing conditions in the same subjects. RESULTS We found a substantial difference between values obtained during free and controlled breathing (3.64 +/- 0.81 vs. 1.53 +/- 0.32 ms/mmHg, respectively; P < 0.05). After application of a respiratory correction, described and validated in this article, no significant difference was seen for these values (0.89 +/-0.91 vs. 1.53 +/- 0.32 ms/mmHg, P = 0.46). CONCLUSIONS This approach allows the evaluation of peripheral cardiac chemoreflex sensitivity in free breathing subjects. This correction could improve the assessment of cardiac chemoreflex sensitivity in patients with cardiorespiratory disorders, who find it difficult to control their breathing according to an experimental protocol.
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Affiliation(s)
- H B Schmidt
- Department of Internal Medicine III, Martin-Luther-University Halle-Wittenberg, 06097, Halle/Saale, Germany.
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Affiliation(s)
- M Rauchhaus
- Universitätsklinik und Poliklinik für Innere Medizin III, Martin-Luther-Universität Halle-Wittenberg, Ernst-Grube-Strasse 40, 06097 Halle.
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Rauchhaus M, Doehner W, Francis DP, Davos C, Kemp M, Liebenthal C, Niebauer J, Hooper J, Volk HD, Coats AJ, Anker SD. Plasma cytokine parameters and mortality in patients with chronic heart failure. Circulation 2000; 102:3060-7. [PMID: 11120695 DOI: 10.1161/01.cir.102.25.3060] [Citation(s) in RCA: 556] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Inflammatory immune activation is an important feature in chronic heart failure (CHF). Little is known about the prognostic importance of tumor necrosis factor-alpha (TNF-alpha), soluble TNF-receptor 1 and 2 (sTNF-R1/sTNF-R2), interleukin-6 (IL-6), and soluble CD14 receptors (sCD14) in CHF patients. METHODS AND RESULTS In 152 CHF patients (age 61+/-1 years, New York Heart Association [NYHA] class 2.6+/-0.1, peak VO(2) 17.3+/-0.6 mL. kg(-1). min(-1), mean+/-SEM) plasma concentrations of immune variables were prospectively assessed. During a mean follow-up of 34 months (>12 months in all patients), 62 patients (41%) died. Cumulative mortality was 28% at 24 months. In univariate analyses, increased total and trimeric TNF-alpha, sTNF-R1, and sTNF-R2 (all P</=0.0001), sCD14 (P=0.0007), and IL-6 (P=0.005) predicted 24-month mortality. With multivariate analysis and receiver operating characteristics, sTNF-R1 emerged among all cytokine parameters as the strongest and most accurate prognosticator in this CHF population, regardless of follow-up duration and independently of NYHA class, peak VO(2), VE/VCO(2) slope, left ventricular ejection fraction, and wasting (P<0.001). The receiver operating characteristic area under the curve for sTNF-R1 was greater than for sTNF-R2 at 6, 12, and 18 months (all P<0.05). CONCLUSIONS sTNF-R1 was the strongest and most accurate prognosticator, independent of established markers of CHF severity. Assessment of sTNF-R1 may be useful in identifying patients who are at high risk of death and in monitoring patients undergoing anti-TNF-alpha treatment.
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MESH Headings
- Adult
- Aged
- Aged, 80 and over
- Analysis of Variance
- Antigens, CD/blood
- Biomarkers/blood
- Cardiac Output, Low/blood
- Cardiac Output, Low/immunology
- Cardiac Output, Low/mortality
- Chronic Disease
- Cytokines/blood
- Female
- Humans
- Immunoassay
- Interleukin-6/blood
- Lipopolysaccharide Receptors/blood
- Male
- Middle Aged
- Prognosis
- ROC Curve
- Receptors, Tumor Necrosis Factor/blood
- Receptors, Tumor Necrosis Factor, Type I
- Receptors, Tumor Necrosis Factor, Type II
- Solubility
- Survival Analysis
- Tumor Necrosis Factor-alpha/metabolism
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Affiliation(s)
- M Rauchhaus
- Clinical Cardiology, National Heart and Lung Institute, Royal Brompton Hospital, London, UK.
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Rauchhaus M, Koloczek V, Volk H, Kemp M, Niebauer J, Francis DP, Coats AJ, Anker SD. Inflammatory cytokines and the possible immunological role for lipoproteins in chronic heart failure. Int J Cardiol 2000; 76:125-33. [PMID: 11104867 DOI: 10.1016/s0167-5273(00)00224-2] [Citation(s) in RCA: 101] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
AIMS We studied the clinical and immunological importance of fasting cholesterol, HDL, LDL and triglycerides in patients with chronic heart failure in relation to plasma concentrations of tumor necrosis factor-alpha (TNFalpha), soluble TNF receptor-1 and -2 (sTNF-R1 and -R2), and a ratio potentially indicating recent endotoxin bioactivity (soluble [s] CD14/total cholesterol). METHODS AND RESULTS Fifty-eight stable, non-oedematous patients with established heart failure and 19 controls were studied prospectively. Concentrations of sTNF-R1 and sCD14 were higher in patients than in controls (1238+/-96 vs. 632+/-72 pg/ml, P=0.005 and 3401+/-120 vs. 2775+/-139 pg/ml, P=0.007, respectively), whereas those of TNFalpha (9.3+/-1.1 vs. 6.7+/-0.6 pg/ml) and sTNF-R2 (2464+/-145 vs. 1920+/-303 pg/ml) were not. Cholesterol (5.6+/-0.1 vs. 5.5+/-0.2 mmol/l) and LDL (3.5+/-0.1 vs. 3.6+/-0.2 mmol/l) were not different (both P>0.75). Patients had lower HDL (1.10+/-0.04 vs. 1.4+/-0.06 mmol/l, P=0.0004) and higher triglycerides (2.1+/-0.1 vs. 1.1+/-0.1 mmol/l, P=0.0006). Aetiology and the presence of cardiac cachexia did not influence the lipid profile. Correlations in patients: cholesterol vs. TNFalpha (r=-0.40, P=0.003), vs. sTNF-R1 (r=-0.24, P=0.08), vs. sTNF-R2 (r=-0.29, P<0.04); sCD14 vs. TNFalpha (r=0.44, P=0.005), vs. sTNF-R1: (r=0.65, P<0.0001), vs. sTNF-R2 (r=0.59, P<0. 0001). The sCD14/cholesterol ratio related powerfully to TNFalpha (r=0.60), sTNF-R1 (r=0.74), and sTNF-R2 (r=0.65, all P<0.0001). This sCD14/cholesterol ratio emerged as the strongest predictor of TNFalpha, sTNF-R1 and -R2 (all P<0.01), independently of renal and hepatic function, and conventional measures of disease severity. A cholesterol level <5.2 mmol/l (n=18) significantly predicted a poor clinical outcome (P<0.04, RR 3.5, 95% CI 1.1-11.0) independently of peak VO(2) (P=0.07), NYHA class (P=0.08), aetiology (P=0.14), and age, body wasting, sodium, LVEF, heart rate, and blood pressure (all P>0.20, follow-up 12 months, event rate 26%). CONCLUSION Our data supports previous findings that lower, rather than higher cholesterol levels are associated with poor clinical outcome in patients with chronic heart failure. This relationship is unrelated to heart failure aetiology, and suggests that the classic risk profile is not longer relevant in established heart failure. The little-recognised ability of all lipoprotein fractions to bind endotoxin and to serve as natural buffer substances may explain this relationship between lower lipoprotein levels, higher cytokine concentrations and impaired prognosis.
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Affiliation(s)
- M Rauchhaus
- Department of Clinical Cardiology, Imperial College School of Medicine at the National Heart and Lung Institute, London, UK.
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Rauchhaus M, Bolger AP. Seek and thou shalt find: bacterial lipopolysaccharide as a possible link between increased CD14 expression, high CRP, and low HDL. Am J Cardiol 2000; 86:1054-5. [PMID: 11127951 DOI: 10.1016/s0002-9149(00)01301-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rauchhaus M, Sharma R, Bolger A. NSAIDs, intestinal cell integrity, and bacterial translocation in chronic heart failure. Arch Intern Med 2000; 160:3004-5. [PMID: 11041913 DOI: 10.1001/archinte.160.19.3004-b] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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Abstract
The advent of 3-hydroxy-3-methylglutaryl-coenzyme A reductase inhibitors (statins) has revolutionised the treatment of hypercholesterolaemia. Statin treatment, by lowering the atherogenic lipoprotein profile, reduces morbidity and mortality in patients with cardiovascular disease. Treatment with simvastatin causes a reduction of events of new-onset heart failure, but this may be attributable to properties other than its lipid-lowering effects. There is some evidence that lower serum cholesterol concentrations (as a surrogate for the totality of lipoproteins) relate to impaired survival in patients with chronic heart failure (CHF). Inflammation is a feature in patients with CHF and increased lipopolysaccharide may contribute substantially. We postulate that higher concentrations of total cholesterol are beneficial in these patients. This is potentially attributable to the property of lipoproteins to bind lipopolysaccharide, thereby preventing its detrimental effects. We hypothesise there is an optimum lipoprotein concentration below which lipid reduction would, on balance, be detrimental. We also propose that, in patients with CHF, a non-lipid-lowering statin (with ancillary properties such as immune modulatory and anti-inflammatory actions) could be as effective or even more beneficial than a lipid-lowering statin.
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Affiliation(s)
- M Rauchhaus
- Department of Clinical Cardiology, National Heart and Lung Institute, London, UK.
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Sharma R, Rauchhaus M, Ponikowski PP, Varney S, Poole-Wilson PA, Mann DL, Coats AJ, Anker SD. The relationship of the erythrocyte sedimentation rate to inflammatory cytokines and survival in patients with chronic heart failure treated with angiotensin-converting enzyme inhibitors. J Am Coll Cardiol 2000; 36:523-8. [PMID: 10933367 DOI: 10.1016/s0735-1097(00)00745-2] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
OBJECTIVES The object of the study was to assess the relationship between erythrocyte sedimentation rate (ESR) and inflammatory cytokine production in chronic heart failure (CHF). Our findings lead us to re-evaluate the prognostic value of the ESR in assessing patients with CHF. BACKGROUND The search for simple prognostic markers in CHF that can be assessed anywhere at low cost is important. Increases in ESR are related to the acute phase response in states of inflammation and infection. METHODS Initially, we studied ESR in relation to plasma levels of inflammatory cytokines in 58 CHF patients. The findings prompted us to analyze the mortality predictive power of ESR compared with established risk factors in these patients and (retrospectively) in a second group of 101 clinically stable CHF patients who had ESR measured. RESULTS In all 159 CHF patients (age 62+/-2 years, New York Heart Association [NYHA] class 2.7+/-0.1), ESR ranged from 1 to 96 mm/h (median 14 mm/h). The ESR was correlated with tumor necrosis factor (TNF)-alpha (r = 0.31, p<0.05), soluble TNF receptor-1 (r = 0.48, p<0.0005), soluble TNF receptor-2 (r = 0.39, p<0.005) and interleukin 6 (r = 0.45, p<0.005) levels. High ESR levels indicated a poor prognosis (p<0.0001), and this was independent of age, NYHA class, ejection fraction and peak oxygen consumption (p < 0.005). Patients with ESR above median (> or =15 mm/h) compared with patients with ESR <15 mm/h had an impaired survival (hazard ratio 2.62, 95% confidence interval 1.58-4.36, p<0.0001). CONCLUSIONS Our study demonstrates that in CHF a high ESR is an unfavorable prognostic sign, independent of patients' symptomatology and ventricular function. These results are in diametrical contrast to previous results. This may reflect a change in the underlying pathophysiology due to today's treatment with angiotensin-converting enzyme inhibitors.
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Affiliation(s)
- R Sharma
- Department of Cardiac Medicine, National Heart & Lung Institute, Imperial College School of Medicine, London, United Kingdom
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Florea A, Henein M, Rauchhaus M, Ponikowski P, Poole-Wilson P, Coats A, Anker S. Dynamics of left ventricular mass over time in patients with chronic heart failure with and without cardiac cachexia. Eur J Heart Fail 2000. [DOI: 10.1016/s1388-9842(00)80235-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
| | - M.Y. Henein
- Royal Brompton Hospital; London United Kingdom
| | - M. Rauchhaus
- Cardiac Medicine National Heart and Lung Institute; London United Kingdom
| | - P. Ponikowski
- Cardiac Medicine National Heart and Lung Institute; London United Kingdom
| | - P.A. Poole-Wilson
- Cardiac Medicine National Heart and Lung Institute; London United Kingdom
| | - A.J.S. Coats
- Cardiac Medicine National Heart and Lung Institute; London United Kingdom
| | - S.D. Anker
- Cardiac Medicine National Heart and Lung Institute; London United Kingdom
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Davos C, Doehner W, Rauchhaus M, Cicoira M, Francis D, Coats A, Anker S. The impact of obesity on survival in chronic heart failure patients. Eur J Heart Fail 2000. [DOI: 10.1016/s1388-9842(00)80099-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Affiliation(s)
- C.H. Davos
- Dept. of Cardiology; National Heart & Lung Institute; London United Kingdom
| | - W. Doehner
- Cardiac Medicine; National Heart and Lung Institute; London United Kingdom
| | - M. Rauchhaus
- Dept. of Cardiology; National Heart & Lung Institute; London United Kingdom
| | - M. Cicoira
- Cardiac Medicine; National Heart and Lung Institute; London United Kingdom
| | - D. Francis
- Dept. of Cardiology; National Heart & Lung Institute; London United Kingdom
| | - A.J.S. Coats
- Dept. of Cardiology; National Heart & Lung Institute; London United Kingdom
| | - S.D. Anker
- Franz-Volhard-Klinik at MDC; Charité Berlin Germany
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Doehner W, Davos C, Rauchhaus M, Sharma R, Bolger A, Florea V, Anker S. Serum uric acid (UA) in cachectic and non-cachectic chronic heart failure (CHF) patients - Relation to peripheral vascular resistance (PVR). Eur J Heart Fail 2000. [DOI: 10.1016/s1388-9842(00)80234-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Affiliation(s)
- W. Doehner
- Cardiac Medicine; National Heart and Lung Institute; London United Kingdom
| | - C.H. Davos
- Dept. of Cardiology; National Heart & Lung Institute; London United Kingdom
| | - M. Rauchhaus
- Dept. of Cardiology; National Heart & Lung Institute; London United Kingdom
| | - R. Sharma
- Dept. of Cardiology; National Heart & Lung Institute; London United Kingdom
| | - A. Bolger
- Dept. of Cardiology; National Heart & Lung Institute; London United Kingdom
| | - V.G. Florea
- Dept. of Cardiology; National Heart & Lung Institute; London United Kingdom
| | - S.D. Anker
- Franz-Volhard-Klinik at MDC Charité; Berlin Germany
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Rauchhaus M, Doehner W, Koloczek V, Kemp M, Volk HD, Coats A, Anker S. Cytokines and cytokine receptors are predictive for increased mortality in chronic heart failure. Eur J Heart Fail 2000. [DOI: 10.1016/s1388-9842(00)80365-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- M. Rauchhaus
- Clinical Cardiology, National Heart and Lung Institute; London United Kingdom
| | - W. Doehner
- Clinical Cardiology, National Heart and Lung Institute; London United Kingdom
| | - V. Koloczek
- Clinical Cardiology, National Heart and Lung Institute; London United Kingdom
| | - M. Kemp
- Clinical Cardiology, National Heart and Lung Institute; London United Kingdom
| | - H.-D Volk
- Medical Immunology, Charite; Berlin United Kingdom
| | - A.J.S. Coats
- Clinical Cardiology, National Heart and Lung Institute; London United Kingdom
| | - S.D. Anker
- Clinical Cardiology, National Heart and Lung Institute; London United Kingdom
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Rauchhaus M. The HLA system and coronary artery disease in the Japanese population. Int J Cardiol 2000; 73:281-3. [PMID: 10917761 DOI: 10.1016/s0167-5273(00)00239-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
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Leyva F, Rauchhaus M, Anker SD, Proudler AJ, Godsland IF, Stiefel P, Coats AJ, Poole-Wilson PA, Stevenson JC. Non-invasive assessment of vascular function; paradoxical vascular response to intravenous glucose in coronary heart disease. Eur Heart J 2000; 21:39-44. [PMID: 10610742 DOI: 10.1053/euhj.1999.1695] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND In healthy individuals, insulin administration causes an increase in forearm blood flow which is dependent on the effects of insulin on the vascular endothelium. Glucose, administered as an intravenous bolus, produces a transient hyperinsulinaemic response. We hypothesized that the insulin response to an intravenous glucose challenge during the intravenous glucose tolerance test might lead to increases in forearm blood flow in healthy individuals, and that such a response might be altered in patients with coronary heart disease. METHODS AND RESULTS Healthy individuals (n=10, aged 41.6+/-3. 0 years, mean+/-SEM) and patients with angiographically proven coronary heart disease (n=13, aged 65.5+/-2.4 years) underwent an intravenous glucose tolerance test with simultaneous measurement of right forearm blood flow at 28 time points, using mercury-in-silastic venous occlusion plethysmography. In controls, forearm blood flow increased to a mean of 31.7% above baseline values at 7 min and remained above baseline up to 180 min after intravenous glucose. In contrast, patients with coronary heart disease exhibited an opposite response, with forearm blood flow decreasing to a mean of -16.2% below baseline values at 7 min and -25.8% at 180 min. Marked group differences emerged in net changes from baseline in forearm blood flow throughout the intravenous glucose tolerance test, expressed as incremental areas under the forearm blood flow profiles (controls: +351.3+/-121.7; coronary heart disease patients: -244.3+/-72.4 min ml(-1). 100 ml(-1), P=0. 001). CONCLUSIONS We have demonstrated for the first time that in healthy individuals forearm blood flow increases after an intravenous bolus of glucose, and that paradoxically, this response is reduced below baseline forearm blood flow in patients with coronary heart disease. Further studies are needed to determine whether plethysmographic measurement of forearm blood flow after an intravenous bolus of glucose could provide a clinically useful non-invasive test for the diagnosis of occult coronary heart disease.
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Affiliation(s)
- F Leyva
- Department of Cardiac Medicine, Imperial College School of Medicine at the National Heart and Lung Institute, London, U.K.
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Abstract
BACKGROUND Respiratory gas exchange measurements in patients with chronic heart failure (CHF) at rest and during exercise commonly reveal prominent slow oscillations in ventilation (V(E)), measured oxygen uptake (VO(2)), and carbon dioxide production (VCO(2)), whose origin is not clear. Voluntary simulation of periodic breathing (PB) in normals has been reported to generate a different pattern of oscillations in gas exchange from that seen in spontaneous PB. This necessitates hypothesizing that PB is caused by a primary oscillation in tissue metabolism or in cardiac output. METHODS AND RESULTS We developed an automated method by which normal controls could be guided to breathe according to a PB pattern. The resultant metabolic oscillations closely matched those seen in spontaneous PB and had several interesting properties. At low workloads (including rest), the oscillations in VO(2) were as prominent as those in V(E) in both spontaneous PB (alpha(VO2)/alpha(VE)=0.92+/-0.04) and voluntary PB (0.93+/-0.07). However, at increased workload, the oscillations in VO(2) because less prominent than those in V(E) in spontaneous PB (intermediate workload 0.63+/-0.05, high workload 0.57+/-0.04; P<0.001) and voluntary PB (intermediate 0.66+/-0.03, high 0.48+/-0.03; P<0.001). There was no difference in the relative size of metabolic oscillations between voluntary and spontaneous PB at matched workloads (P>0.05 at low, intermediate, and high workloads). Furthermore, VO(2) peaked before V(E) in both spontaneous and voluntary PB. This time delay varied from 6.4+/-0.4 s at low ventilation, to 11.3+/-0.9 s at high ventilation (P<0.0001). CONCLUSIONS The magnitude and phase pattern of oscillations in gas exchange of spontaneous PB can be obtained by adequately matched voluntary PB. Therefore, the gas exchange features of PB are explicable by primary ventilatory oscillation.
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Affiliation(s)
- D P Francis
- National Heart & Lung Institute, Imperial College of Science, Technology and Medicine, London, UK.
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Abstract
Chronic heart failure (CHF) remains an important and increasing public health care problem. Not until recently it has been recognised that CHF is a chronic progressive disorder affecting different physiological and metabolic pathways. Nowadays CHF is reviewed as the consequence of an interplay of haemodynamic, neurohormonal, immunological, and endocrine mechanisms, initially thought to have beneficial adaptive effects for the organism to compensate the heart's inability to pump properly. However, these secondary changes eventually contribute to further deterioration of CHF. This review focuses on metabolic features observed in patients with CHF and discusses immunological and neuroendocrine aspects and their potential contribution to the pathogenesis of CHF. The overall evidence suggests that advanced CHF is a multifactorial metabolic syndrome that can lead to cardiac cachexia and then carries a very poor prognosis. Joint efforts of cardiologists, endocrinologists, and immunologists are required to develop therapeutic strategies able to improve the metabolic status of CHF patients.
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Affiliation(s)
- S D Anker
- Department of Cardiac Medicine, National Heart and Lung Institute, London, UK.
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Niebauer J, Volk HD, Kemp M, Dominguez M, Schumann RR, Rauchhaus M, Poole-Wilson PA, Coats AJ, Anker SD. Endotoxin and immune activation in chronic heart failure: a prospective cohort study. Lancet 1999; 353:1838-42. [PMID: 10359409 DOI: 10.1016/s0140-6736(98)09286-1] [Citation(s) in RCA: 586] [Impact Index Per Article: 23.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/16/2022]
Abstract
BACKGROUND Immune activation in patients with chronic heart failure may be secondary to endotoxin (lipopolysaccharide) action. We investigated the hypothesis that altered gut permeability with bacterial translocation and endotoxaemia would be increased in patients with oedema secondary to congestive heart failure. METHODS We compared 20 patients who had chronic heart failure with recent-onset peripheral oedema (mean age 64 years [SD 10], New York Heart Association [NYHA] class 3.3 [0.7]), 20 stable non-oedematous patients with chronic heart failure (mean age 63 years [19], NYHA class 2.6 [0.7]), and 14 healthy volunteers (mean age 55 years [16]). Biochemical markers of endotoxaemia, inflammation, and immune activation were measured. Ten patients were studied within 1 week of complete resolution of oedema. Five patients survived longer than 6 months and were restudied again after remaining free of oedema for more than 3 months. FINDINGS Mean endotoxin concentrations were higher in oedematous patients with chronic heart failure than in stable patients with chronic heart failure (0.74 [SD 0.45] vs 0.37 EU/mL [0.23], p=0.0009) and controls (0.46 EU/mL [0.21], p=0.02). Oedematous patients had the highest concentrations of several cytokines. After short-term diuretic treatment, endotoxin concentrations decreased from 0.84 EU/mL [0.49] to 0.45 EU/mL [0.21], p<0.05) but cytokines remained raised. After freedom of oedema for more than 3 months after oedema resolved, endotoxin concentrations remained unchanged from the previous visit (0.49 EU/mL [0.06], p=0.45). INTERPRETATION Raised concentrations of endotoxin and cytokines are found in patients with chronic heart failure during acute oedematous exacerbation. Intensified diuretic treatment can normalise endotoxin concentrations. Our preliminary findings suggest that endotoxin may trigger immune activation in patients with chronic heart failure during oedematous episodes.
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Affiliation(s)
- J Niebauer
- Cardiac Medicine, National Heart and Lung Institute, Imperial College School of Medicine, London, UK
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Abstract
Body wasting, i.e, cardiac cachexia, is a complication of chronic heart failure (CHF). The authors have suggested that cardiac cachexia should be diagnosed when nonedematous weight loss of more than 7.5% of the premorbid normal weight occurs over a time period of more than 6 months. In an unselected CHF outpatient population, 16% of patients were found to be cachectic. The cachectic state is predictive of poor survival independently of age, functional class, ejection fraction, and exercise capacity. Patients with cardiac cachexia suffer from a general loss of fat, lean, and bone tissue. Cachectic CHF patients are weaker and fatigue earlier. The pathophysiologic causes of body wasting in patients with CHF remain unclear, but initial studies have suggested that humoral neuroendocrine and immunologic abnormalities may be of importance. Cachectic CHF patients show increased plasma levels of catecholamines, cortisol, and aldosterone. Several studies have shown that cardiac cachexia is linked to increased plasma levels of tumor necrosis factor alpha. The degree of body wasting is strongly correlated with neurohormonal and immune abnormalities. Some investigators have suggested that endotoxin may be important in triggering immune activation in CHF patients. Available studies suggest that cardiac cachexia is a multifactorial neuroendocrine and immunologic disorder that carries a poor prognosis. A complex catabolic-anabolic imbalance in different body systems may cause body wasting in patients with CHF.
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Affiliation(s)
- S D Anker
- Department of Cardiac Medicine, National Heart and Lung Institute, London, UK.
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Anker SD, Ponikowski PP, Clark AL, Leyva F, Rauchhaus M, Kemp M, Teixeira MM, Hellewell PG, Hooper J, Poole-Wilson PA, Coats AJ. Cytokines and neurohormones relating to body composition alterations in the wasting syndrome of chronic heart failure. Eur Heart J 1999; 20:683-93. [PMID: 10208789 DOI: 10.1053/euhj.1998.1446] [Citation(s) in RCA: 286] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Chronic heart failure is one of a number of disorders associated with the development of a wasting syndrome. The precise mechanisms of this remain unknown, but previous studies have suggested a role for immune and neurohormonal factors. METHODS We aimed to investigate in detail the differences in body composition (dual X-ray absorptiometry) and the relationship to candidate biochemical factors of the immune, neurohormonal and metabolic systems in 15 healthy controls, 36 stable non-cachectic and 18 cachectic patients with chronic heart failure. RESULTS Non-cachectic patients showed reduced leg lean tissue (-9.1%, P<0.01) compared to controls. Cachectic patients had significantly reduced lean (-21.0% vs controls, -19.9% vs non-cachectics), fat (-33.0% vs controls, -37. 0% vs non-cachectics) and bone tissue (-17.5% vs controls, -15.9% vs non-cachectics) (all P<0.0001). Cachectic patients showed a significantly increased cortisol/dehydroepiandrosterone ratio (+203% vs controls, P<0.0001; +89% vs non-cachectics, P=0.0011) and increased cytokine levels (TNF-alpha, soluble TNF-receptor 1, interleukin-6). The levels of catabolic hormones and cytokines correlated significantly with reduced muscle and fat tissue content and reduced bone mass. CONCLUSION Peripheral loss of muscle tissue is a general finding in chronic heart failure. The wasting in cardiac cachexia affects all tissue compartments and is significantly related to neurohormonal and immunological abnormalities.
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Affiliation(s)
- S D Anker
- Department of Cardiac Medicine, National Heart and Lung Institute, London, U.K
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Schmidt BH, Opitz H, Rauchhaus M, Werdan K. The cardiac chemoreflex sensitivity (cCRS) and the influence of respiration. Crit Care 1999. [PMCID: PMC3301829 DOI: 10.1186/cc501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
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Rauchhaus M. E-Selectin Genotypes in Patients With Documented Severe Coronary Artery Disease. J Am Coll Cardiol 1998. [DOI: 10.1016/s0735-1097(97)84335-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Niebauer J, Kemp M, Dominguez M, Rauchhaus M, Poole-Wilson P, Coats A, Anker S. Acute peripheral edema in patients with chronic heart failure is associated with endotoxemia and immune activation. J Am Coll Cardiol 1998. [DOI: 10.1016/s0735-1097(98)81317-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rauchhaus M, Anker S, Handschug K, Teichmann W, Glaeser C. E-selectin genotypes in patients with documented severe coronary artery disease. J Am Coll Cardiol 1998. [DOI: 10.1016/s0735-1097(98)81274-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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