Showing papers by "Philip A. Poole-Wilson published in 2001"
TL;DR: In CHF patients with preserved exercise capacity, enhanced ventilatory response to exercise is a simple marker of a widespread derangement of cardiovascular reflex control; it predicts poor prognosis, which peak o2 does not.
Abstract: Background—In patients with chronic heart failure (CHF) and preserved exercise tolerance, the value of cardiopulmonary exercise testing for risk stratification is not known. Elevated slope of ventilatory response to exercise (Ve/Vco2) predicts poor prognosis in advanced CHF. Derangement of cardiopulmonary reflexes may trigger exercise hyperpnea. We assessed the relationship between cardiopulmonary reflexes and Ve/Vco2 and investigated the prognostic value of Ve/Vco2 in CHF patients with preserved exercise tolerance. Methods and Results—Among 344 consecutive CHF patients, we identified 123 with preserved exercise capacity, defined as a peak oxygen consumption (peak Vo2) ≥18 mL · kg−1 · min−1 (age 56 years; left ventricular ejection fraction 28%; peak Vo2 23.5 mL · kg−1 · min−1). Hypoxic and hypercapnic chemosensitivity (n=38), heart rate variability (n=34), baroreflex sensitivity (n=20), and ergoreflex activity (n=20) were also assessed. We identified 40 patients (33%) with high Ve/Vco2 (ie, >34....
395 citations
TL;DR: Coronary artery disease is the cause of 52% (95% CI 43-61%) of incident heart failure in the general population under 75 years and clinical assessment without angiography under-estimates the proportion of patients with coronary artery disease, and fails to identify those patients who may benefit from revascularization.
Abstract: Aims New approaches in the treatment of ischaemic left ventricular dysfunction, including revascularization, make it increasingly important to identify heart failure cases resulting from coronary artery disease. Without angiography these cases may be missed. We investigated the frequency of coronary artery disease in incident cases of heart failure in the population.
Methods and Results We identified all incident cases of heart failure in a population of 292000 in South London, U.K. by monitoring patients admitted to hospital and through a rapid access heart failure clinic. The presence and severity of coronary artery disease was identified by coronary angiography in patients under 75 years. Myocardial perfusion scanning was used to elucidate the aetiological significance of the coronary artery disease and identify hibernating myocardium. Three hundred and thirty-two cases of new heart failure were identified over 15 months. One hundred and thirty-six cases were under 75 years and angiography was undertaken in 99/136 (73%). Coronary artery disease was the aetiology in 71/136 (52%). In 18 of these 71 cases (25%), the aetiology was not recognised to be due to coronary artery disease prior to angiography, including eight cases with hibernating myocardium.
Conclusion Coronary artery disease is the cause of 52% (95% CI 43–61%) of incident heart failure in the general population under 75 years. Clinical assessment without angiography under-estimates the proportion of patients with coronary artery disease, and fails to identify those patients who may benefit from revascularization.
383 citations
TL;DR: The principal predictors of the biochemical features of GH resistance and of the poor biochemical response to short-term and longer-term GH treatment are GH-BP plasma levels.
199 citations
TL;DR: Findings demonstrate that ACE inhibitor therapy in most patients with CHF can be successfully titrated to and maintained at high doses, and that more aggressive use of these agents is warranted.
Abstract: Background Treatment with angiotensin-converting enzyme (ACE) inhibitors reduces mortality and morbidity in patients with chronic heart failure (CHF), but most affected patients are not receiving these agents or are being treated with doses lower than those found to be efficacious in trials, primarily because of concerns about the safety and tolerability of these agents, especially at the recommended doses. The present study examines the safety and tolerability of high- compared with low-dose lisinopril in CHF. Methods The Assessment of Lisinopril and Survival study was a multicenter, randomized, double-blind trial in which patients with or without previous ACE inhibitor treatment were stabilized receiving medium-dose lisinopril (12.5 or 15.0 mg once daily [OD]) for 2 to 4 weeks and then randomized to high- (35.0 or 32.5 mg OD) or low-dose (5.0 or 2.5 mg OD) groups. Patients with New York Heart Association classes II to IV CHF and left ventricular ejection fractions of no greater than 0.30 (n = 3164) were randomized and followed up for a median of 46 months. We examined the occurrence of adverse events and the need for discontinuation and dose reduction during treatment, with a focus on hypotension and renal dysfunction. Results Of 405 patients not previously receiving an ACE inhibitor, doses in only 4.2% could not be titrated to the medium doses required for randomization because of symptoms possibly related to hypotension (2.0%) or because of renal dysfunction or hyperkalemia (2.3%). Doses in more than 90% of randomized patients in the high- and low-dose groups were titrated to their assigned target, and the mean doses of blinded medication in both groups remained similar throughout the study. Withdrawals occurred in 27.1% of the high- and 30.7% of the low-dose groups. Subgroups presumed to be at higher risk for ACE inhibitor intolerance (blood pressure, Conclusions These findings demonstrate that ACE inhibitor therapy in most patients with CHF can be successfully titrated to and maintained at high doses, and that more aggressive use of these agents is warranted.
78 citations
TL;DR: Large drug trials have become very important to determine which drugs should be used in the treatment of patients with chronic heart failure (CHF), and these trials that were conducted in the last 10 years are discussed to provide insight into the pathophysiology and treatment options in CHF.
41 citations
TL;DR: There is a strong case for using drugs that have been shown to be beneficial in the treatment of both hypertension and heart failure, where heart failure is a likely outcome, or where hypertension occurs in the presence of heart failure.
Abstract: There are two major reasons why hypertension is an important risk factor for heart failure. The first is that an elevated blood pressure increases the wall stress in the left ventricle. The second is that hypertension, in a complex manner, contributes to the development of atheromatous vascular disease. Among the more common causes of heart failure are the sequelae of coronary heart disease. The treatment of hypertension modifies the progression to heart failure and the occurrence of coronary events. In patients who have heart failure, hypotension rather than hypertension is a predictor of a poor outcome, likely because low blood pressure is a consequence of damage to the myocardium. The clinical message is that hypertension should be treated aggressively. Where heart failure is a likely outcome, or where hypertension occurs in the presence of heart failure, there is a strong case for using drugs that have been shown to be beneficial in the treatment of both hypertension and heart failure.
6 citations