This study compared the effects of levosimendan, dobutamine, and vasodilator therapy on ongoing myocardial injury in patients with acute decompensated heart failure. The study found that while all treatments were associated with decreases in cardiac troponin I levels and improvements in hemodynamic and functional indicators, levosimendan treatment showed the most pronounced improvements, especially in left ventricular ejection fraction and systolic pulmonary artery pressure. However, none of the treatments significantly reduced cardiac troponin I levels compared to each other. The study demonstrated beneficial effects of short-term use of levosimendan, dobutamine, and nitroglycerin on ongoing myocardial injury in acute decompensated heart failure.
Does Type of Dialysis Affect BNP in Fluid Overload Patients?Premier Publishers
Brain Natriuretic Peptide (BNP) levels are important as predictors of heart failure in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD). Twenty-four HD patients and 35 PD patients were included in the study. Each patient underwent an echocardiographic examination besides the determination of BNP, high-sensitivity C-reactive protein (hs-CRP) and homocysteine (Hcy). BNP, left ventricular mass (LVM), left ventricular mass index (LVMI) and Hcy levels were significantly higher in HD group (p<0.05); hs-CRP levels were significantly higher in PD group (p=0.029). Predialysis BNP was significantly higher than the postdialysis BNP (p=0.003). There was a significant correlation between LVMI and BNP in PD (r=0.527, p=0.009) and predialysis BNP in HD (r=0.417, p=0.043) groups. In conclusion, BNP levels were found to be significantly correlated with LVMI in HD and PD patients. Hemodialysis patients had higher BNP and LVMI levels. This may be due to the hemodynamic changes which occur with the hemodialysis.
Does Type of Dialysis Affect BNP in Fluid Overload Patients?Premier Publishers
Brain Natriuretic Peptide (BNP) levels are important as predictors of heart failure in end-stage renal disease (ESRD) patients undergoing hemodialysis (HD) and continuous ambulatory peritoneal dialysis (PD). Twenty-four HD patients and 35 PD patients were included in the study. Each patient underwent an echocardiographic examination besides the determination of BNP, high-sensitivity C-reactive protein (hs-CRP) and homocysteine (Hcy). BNP, left ventricular mass (LVM), left ventricular mass index (LVMI) and Hcy levels were significantly higher in HD group (p<0.05); hs-CRP levels were significantly higher in PD group (p=0.029). Predialysis BNP was significantly higher than the postdialysis BNP (p=0.003). There was a significant correlation between LVMI and BNP in PD (r=0.527, p=0.009) and predialysis BNP in HD (r=0.417, p=0.043) groups. In conclusion, BNP levels were found to be significantly correlated with LVMI in HD and PD patients. Hemodialysis patients had higher BNP and LVMI levels. This may be due to the hemodynamic changes which occur with the hemodialysis.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Psychopharmacology and Cardiovascular Disease - psycho cardiologymagdy elmasry
Psychopharmacology andCardiovascular Disease.Your Heart And Mind Are Connected.Psychiatric Disorders and Cardiovascular System .Cardiac response to acute stress .Heart disease and depression are closely linkedCardiovascular Side Effects of Psychotropic Drugs
.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
This Journal publishes original research work that contributes significantly to further the scientific knowledge in pharmacy.
Reducing Perioperative Cardiac Risk: Do Beta blockers Help?Terry Shaneyfelt
Review of the effect of beta blockers on perioperative cardiac events including updated recommendations by the ACC/AHA (August 2014. Watch my YouTube video (http://youtu.be/WPLXDm9Nzoc) describing these slides.
John B. Buse, MD, PhD; David Cherney, MD, PhD, FRCP(C); and Mikhail Kosiborod, MD, FACC, FAHA, prepared useful Practice Aids pertaining to SGLT2 inhibitors for this CME activity titled “Complex Cases in Contemporary Practice: Applying New Evidence for SGLT2 Inhibitors in the Management of Patients With Comorbid Cardiometabolic Diseases.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/3dFKZhs. CME credit will be available until July 22, 2021.
Hurdles and new players in the management of chronic heart failure with reduc...Dhritisdiary
Watch the slideshow for a better understanding: https://youtu.be/CsXvS1hA330
1. Learn the standard therapy in HFrEF
2. Learn its challenges
3. Learn the new drugs for HFrEF.
Cardiac Troponin Elevation in Patients Without a Specific DiagnosisShadab Ahmad
Measurement of cardiac troponin (cTn) levels is a cornerstone in the assessment of patients with acute chest pain.
An elevation in the cTn level together with a significant change in the setting of coronary ischemia indicates myocardial infarction (MI).
However, even other cardiac and noncardiac conditions may result in acute cTn increases (e.g., arrhythmias, severe hyper- or hypotension, pulmonary embolism, neurologic events, or endurance efforts).
Acute but subtle increases in cTn levels may also be difficult to distinguish from chronic cTn elevation which is a common finding in the elderly, patients with renal failure, or patients with chronic cardiac conditions.
Inflammation plays a crucial role in the initiation and progression of atherosclerotic disease.
Monocyte chemoattractant protein-1 (MCP-1) is a member of the C-C chemokine family that is produced by monocytes or macrophages, smooth muscle cells, and endothelial cells within atherosclerotic plaques.
In addition to its established role in the pathogenesis of atherosclerotic disease progression and plaque rupture, MCP-1 is also involved in the reparative response, such as arteriolar remodeling and restenosis after an acute coronary event.
Management of CAD in Diabetes the cardiovascular equivalent is challenging.The slides take you from the epidemiology,ADD,and CV benefit and how to manage CAD
E-Mail Marketing & What You Need to KnowPaul Prewitt
Are you interested in starting an Email Marketing program for your school or group? If so then let me take you through the "things you need to know" and then we can work on creating you an email marketing program that will surpass all your wildest expectations.
SGLT2 inhibitors in Heart failure: A prized addition to HF treatment optionsahvc0858
Early Diabetes and Dyslipidaemia Treatment Optimisation.
Presentation by Dr Chan Wan Xian
Cardiologist, Echocardiologist
Heart Failure Intensivist
Asian Heart & Vascular Centre
www.ahvc.com.sg
Psychopharmacology and Cardiovascular Disease - psycho cardiologymagdy elmasry
Psychopharmacology andCardiovascular Disease.Your Heart And Mind Are Connected.Psychiatric Disorders and Cardiovascular System .Cardiac response to acute stress .Heart disease and depression are closely linkedCardiovascular Side Effects of Psychotropic Drugs
.
The IOSR Journal of Pharmacy (IOSRPHR) is an open access online & offline peer reviewed international journal, which publishes innovative research papers, reviews, mini-reviews, short communications and notes dealing with Pharmaceutical Sciences( Pharmaceutical Technology, Pharmaceutics, Biopharmaceutics, Pharmacokinetics, Pharmaceutical/Medicinal Chemistry, Computational Chemistry and Molecular Drug Design, Pharmacognosy & Phytochemistry, Pharmacology, Pharmaceutical Analysis, Pharmacy Practice, Clinical and Hospital Pharmacy, Cell Biology, Genomics and Proteomics, Pharmacogenomics, Bioinformatics and Biotechnology of Pharmaceutical Interest........more details on Aim & Scope).
All manuscripts are subject to rapid peer review. Those of high quality (not previously published and not under consideration for publication in another journal) will be published without delay.
This Journal publishes original research work that contributes significantly to further the scientific knowledge in pharmacy.
Reducing Perioperative Cardiac Risk: Do Beta blockers Help?Terry Shaneyfelt
Review of the effect of beta blockers on perioperative cardiac events including updated recommendations by the ACC/AHA (August 2014. Watch my YouTube video (http://youtu.be/WPLXDm9Nzoc) describing these slides.
John B. Buse, MD, PhD; David Cherney, MD, PhD, FRCP(C); and Mikhail Kosiborod, MD, FACC, FAHA, prepared useful Practice Aids pertaining to SGLT2 inhibitors for this CME activity titled “Complex Cases in Contemporary Practice: Applying New Evidence for SGLT2 Inhibitors in the Management of Patients With Comorbid Cardiometabolic Diseases.” For the full presentation, monograph, complete CME information, and to apply for credit, please visit us at https://bit.ly/3dFKZhs. CME credit will be available until July 22, 2021.
Hurdles and new players in the management of chronic heart failure with reduc...Dhritisdiary
Watch the slideshow for a better understanding: https://youtu.be/CsXvS1hA330
1. Learn the standard therapy in HFrEF
2. Learn its challenges
3. Learn the new drugs for HFrEF.
Cardiac Troponin Elevation in Patients Without a Specific DiagnosisShadab Ahmad
Measurement of cardiac troponin (cTn) levels is a cornerstone in the assessment of patients with acute chest pain.
An elevation in the cTn level together with a significant change in the setting of coronary ischemia indicates myocardial infarction (MI).
However, even other cardiac and noncardiac conditions may result in acute cTn increases (e.g., arrhythmias, severe hyper- or hypotension, pulmonary embolism, neurologic events, or endurance efforts).
Acute but subtle increases in cTn levels may also be difficult to distinguish from chronic cTn elevation which is a common finding in the elderly, patients with renal failure, or patients with chronic cardiac conditions.
Inflammation plays a crucial role in the initiation and progression of atherosclerotic disease.
Monocyte chemoattractant protein-1 (MCP-1) is a member of the C-C chemokine family that is produced by monocytes or macrophages, smooth muscle cells, and endothelial cells within atherosclerotic plaques.
In addition to its established role in the pathogenesis of atherosclerotic disease progression and plaque rupture, MCP-1 is also involved in the reparative response, such as arteriolar remodeling and restenosis after an acute coronary event.
Management of CAD in Diabetes the cardiovascular equivalent is challenging.The slides take you from the epidemiology,ADD,and CV benefit and how to manage CAD
E-Mail Marketing & What You Need to KnowPaul Prewitt
Are you interested in starting an Email Marketing program for your school or group? If so then let me take you through the "things you need to know" and then we can work on creating you an email marketing program that will surpass all your wildest expectations.
Older Drivers - drivingI have been driving for over forty years and believe that I am a very safe driver. I have not received a traffic ticket since 1987. Yes, on the freeway I drive a few miles over the speed limit at times, but I maintain a safe following distance, yield to other drivers and understand that trying to have it my way when driving only leads to frustration.
Wildlife Rehabilitation Centre - Phillip Island, AustraliaPhillipIslandNP
The Penguin Foundation has contributed vital funds for the construction of a new Wildlife Rehabilitation Centre on Phillip Island.
The new Centre cares for sick and injured native wildlife and can rehabilitate up to 1500 little penguins in the event of an oil spill.
Copeptin as a Novel Biomarker in the Diagnosis of Acute Myocardial Infarction...Premier Publishers
To evaluate the diagnostic value of Copeptin as a novel biomarker in early diagnosis of Acute Myocardial Infarction. 56 patients with acute Myocardial Infarction (STEMI) and 25 healthy controls who were admitted to the Cardiology and Clinical Pathology Departments, national heart institute (NHI) from October 2015 to April 2016. The kit used a double-antibody sandwich enzyme-linked immune-sorbent assay (ELISA) to assay the level of Human Copeptin in samples. As regard copeptin, the median range of copeptin level was 242.5pg/ml in patient group and 75pg/ml in control group. The comparative study between the two groups shows a significant difference (p < 0.05) Conclusion: Copeptin is a reliable diagnostic tool in patients with AMI (STEMI) with sensitivity 85.7%, specificity 86.7%, PPV 96% and NPV 61.9%.
Increased Cardiac Troponin T in Patients without Myocardial InfarctionYogeshIJTSRD
According to the World Health Organization, the diagnosis of acute myocardial infarction AMI is based on two of the three main criteria changes in the ECG up to 25 of myocardial infarctions are not reflected in the ECG , anginous pain, and increased markers of myocardial necrosis. In 2000, the European Scientific Society and the American College of Cardiology made a correction to the definition of AMI, according to which the determining factor in the diagnosis of AMI is the detection of an increased level of specific markers of myocardial necrosis — cardiac troponins in the blood. Troponin is a protein that is part of myofibrils. Cardiac troponin contains three subunits T, I, and C. Troponin C is non specific for the myocardium, in contrast to the T and I subunits, whose structure in the contractile fibers of cardiomyocytes differs from similar proteins of other muscle cells. The widespread use of the determination of cardiac troponins in the blood significantly increased the detection of AMI by 30 200 . Until recently, it was believed that troponins enter the blood only as a result of the death of cardiomyocytes. However, in recent years, it has been shown that troponins can penetrate into the interstitial space, and then into the blood, when cardiomyocytes are damaged with an increase in the permeability of their cell membranes, which can be caused not only by AMI, but also by conditions accompanied by hyper production of pro inflammatory cytokines tumor necrosis factor a, interleukin 1, etc. . The aim of this study was to analyze the final diagnoses in patients with increased cardiac troponin T levels without a clinical picture and characteristic ECG changes in AMI. Khusainova Munira Alisherovna "Increased Cardiac Troponin-T in Patients without Myocardial Infarction" Published in International Journal of Trend in Scientific Research and Development (ijtsrd), ISSN: 2456-6470, Special Issue | Innovative Development of Modern Research , April 2021, URL: https://www.ijtsrd.com/papers/ijtsrd40034.pdf Paper URL : https://www.ijtsrd.com/medicine/other/40034/increased-cardiac-troponint-in-patients-without-myocardial-infarction/khusainova-munira-alisherovna
Does Serum Lactate and Central Venous Saturation Predict Perioperative Outcom...crimsonpublishersOJCHD
Off-pump coronary artery bypass grafting (OP-CABG) surgery without the use of cardiopulmonary bypass (CPB) has come into practice for surgical treatment of Coronary artery disease (CAD) to reduce the post-operative systemic inflammatory response and post-operative morbidity. However, manipulation of the beating heart during OP-CABG surgery brings significant fluctuations in the patients haemodynamics leading to occult hypo-perfusion and 'Global tissue hypoxia' (GTH) -a decrease in oxygen utilization associated with anaerobic metabolism.
Bio-Markers of Heart Failure (Dr.LIKHIT T)Likhit T
A brief on bio-markers of Heart failure...First of all, I thank the Authors of all the books from which I picked the points to make this presentation.. This presentation includes classification of bio-markers and explanation according their importance.. Thank you
the 1-year cumulative incidence of a composite end point consisting of cardiovascular death, myocardial infarction, ischemic or hemorrhagic stroke, definite stent thrombosis, and major bleeding was 2.4% in the 1-month DAPT group and 3.7% in the 12-month DAPT group, a difference that met the noninferiority margin of a hazard ratio of 0.5, as well as superiority.
Cardiac biomarkers have evolved over last 20 years. From enzymes like CPK,SGOT,LDH, the focus shifted to CPKMB mass & currently to high sensitive Troponins. Similarly the definition of AMI also evolved and included these markers in guidelines. Natriuretic peptides (BNP & Nt-proBNP) are good markers for heart failure. however, ACS in renal failure continues to have diagnostic challenges.
Did you know that the right kind of salt actually HELPS your heart? How about that blood pressure drugs slow down the heart which decreases oxygen to the brain. Does that sound like a good idea to you? Did you also know that cholesterol is critical for hormone production in the body? It's time for some common sense! You are built to be healthy!
Predictors of Ischaemia and Outcomes in Egyptian Patients with Diabetes Mellitus Referred for Perfusion Imaging. Samir Rafla*, Ahmed Abdel-Aaty, Mohamed Ahmed Sadaka, Aly Ahmed Abo Elhoda and Ahmed Mohamed Shams
Perspective of Cardiac Troponin and Membrane Potential in People Living with ...asclepiuspdfs
Background: Hypertension is an event in which the force of the blood against the artery walls is too high leading to severe health complications and increases the risk of heart disease, stroke, and sometimes death. Aim: This study was carried out to determine the levels of cardiac troponin 1 and membrane potential in hypertensive subjects in Owerri, Imo state. Materials and Methods: A total of 120 subjects within the age 30–70 years were recruited for this study. The study consists of 60 subjects who were diagnosed of hypertension and 60 were apparently healthy individuals who served as controls subjects of the same age bracket. The levels of cardiac troponin 1 and membrane potential were analyzed using enzyme-linked immunosorbent assay technique. Data were assessed using SPSS version 20, the mean value with P ˂ 0.05 was considered statistically significant. Results: The result revealed that the levels of cardiac troponin 1 in hypertension were significantly increased when compared with control subjects while the levels of membrane potential were significantly decreased when compared to control at P < 0.05. Conclusion: The increased serum level of cardiac troponin 1 and decreased membrane potential in hypertensive subjects may contribute some risk factors in patients with hypertension.
Struggling with intense fears that disrupt your life? At Renew Life Hypnosis, we offer specialized hypnosis to overcome fear. Phobias are exaggerated fears, often stemming from past traumas or learned behaviors. Hypnotherapy addresses these deep-seated fears by accessing the subconscious mind, helping you change your reactions to phobic triggers. Our expert therapists guide you into a state of deep relaxation, allowing you to transform your responses and reduce anxiety. Experience increased confidence and freedom from phobias with our personalized approach. Ready to live a fear-free life? Visit us at Renew Life Hypnosis..
Welcome to Secret Tantric, London’s finest VIP Massage agency. Since we first opened our doors, we have provided the ultimate erotic massage experience to innumerable clients, each one searching for the very best sensual massage in London. We come by this reputation honestly with a dynamic team of the city’s most beautiful masseuses.
CHAPTER 1 SEMESTER V PREVENTIVE-PEDIATRICS.pdfSachin Sharma
This content provides an overview of preventive pediatrics. It defines preventive pediatrics as preventing disease and promoting children's physical, mental, and social well-being to achieve positive health. It discusses antenatal, postnatal, and social preventive pediatrics. It also covers various child health programs like immunization, breastfeeding, ICDS, and the roles of organizations like WHO, UNICEF, and nurses in preventive pediatrics.
CHAPTER 1 SEMESTER V - ROLE OF PEADIATRIC NURSE.pdfSachin Sharma
Pediatric nurses play a vital role in the health and well-being of children. Their responsibilities are wide-ranging, and their objectives can be categorized into several key areas:
1. Direct Patient Care:
Objective: Provide comprehensive and compassionate care to infants, children, and adolescents in various healthcare settings (hospitals, clinics, etc.).
This includes tasks like:
Monitoring vital signs and physical condition.
Administering medications and treatments.
Performing procedures as directed by doctors.
Assisting with daily living activities (bathing, feeding).
Providing emotional support and pain management.
2. Health Promotion and Education:
Objective: Promote healthy behaviors and educate children, families, and communities about preventive healthcare.
This includes tasks like:
Administering vaccinations.
Providing education on nutrition, hygiene, and development.
Offering breastfeeding and childbirth support.
Counseling families on safety and injury prevention.
3. Collaboration and Advocacy:
Objective: Collaborate effectively with doctors, social workers, therapists, and other healthcare professionals to ensure coordinated care for children.
Objective: Advocate for the rights and best interests of their patients, especially when children cannot speak for themselves.
This includes tasks like:
Communicating effectively with healthcare teams.
Identifying and addressing potential risks to child welfare.
Educating families about their child's condition and treatment options.
4. Professional Development and Research:
Objective: Stay up-to-date on the latest advancements in pediatric healthcare through continuing education and research.
Objective: Contribute to improving the quality of care for children by participating in research initiatives.
This includes tasks like:
Attending workshops and conferences on pediatric nursing.
Participating in clinical trials related to child health.
Implementing evidence-based practices into their daily routines.
By fulfilling these objectives, pediatric nurses play a crucial role in ensuring the optimal health and well-being of children throughout all stages of their development.
CRISPR-Cas9, a revolutionary gene-editing tool, holds immense potential to reshape medicine, agriculture, and our understanding of life. But like any powerful tool, it comes with ethical considerations.
Unveiling CRISPR: This naturally occurring bacterial defense system (crRNA & Cas9 protein) fights viruses. Scientists repurposed it for precise gene editing (correction, deletion, insertion) by targeting specific DNA sequences.
The Promise: CRISPR offers exciting possibilities:
Gene Therapy: Correcting genetic diseases like cystic fibrosis.
Agriculture: Engineering crops resistant to pests and harsh environments.
Research: Studying gene function to unlock new knowledge.
The Peril: Ethical concerns demand attention:
Off-target Effects: Unintended DNA edits can have unforeseen consequences.
Eugenics: Misusing CRISPR for designer babies raises social and ethical questions.
Equity: High costs could limit access to this potentially life-saving technology.
The Path Forward: Responsible development is crucial:
International Collaboration: Clear guidelines are needed for research and human trials.
Public Education: Open discussions ensure informed decisions about CRISPR.
Prioritize Safety and Ethics: Safety and ethical principles must be paramount.
CRISPR offers a powerful tool for a better future, but responsible development and addressing ethical concerns are essential. By prioritizing safety, fostering open dialogue, and ensuring equitable access, we can harness CRISPR's power for the benefit of all. (2998 characters)
R3 Stem Cells and Kidney Repair A New Horizon in Nephrology.pptxR3 Stem Cell
R3 Stem Cells and Kidney Repair: A New Horizon in Nephrology" explores groundbreaking advancements in the use of R3 stem cells for kidney disease treatment. This insightful piece delves into the potential of these cells to regenerate damaged kidney tissue, offering new hope for patients and reshaping the future of nephrology.
How many patients does case series should have In comparison to case reports.pdfpubrica101
Pubrica’s team of researchers and writers create scientific and medical research articles, which may be important resources for authors and practitioners. Pubrica medical writers assist you in creating and revising the introduction by alerting the reader to gaps in the chosen study subject. Our professionals understand the order in which the hypothesis topic is followed by the broad subject, the issue, and the backdrop.
https://pubrica.com/academy/case-study-or-series/how-many-patients-does-case-series-should-have-in-comparison-to-case-reports/
The dimensions of healthcare quality refer to various attributes or aspects that define the standard of healthcare services. These dimensions are used to evaluate, measure, and improve the quality of care provided to patients. A comprehensive understanding of these dimensions ensures that healthcare systems can address various aspects of patient care effectively and holistically. Dimensions of Healthcare Quality and Performance of care include the following; Appropriateness, Availability, Competence, Continuity, Effectiveness, Efficiency, Efficacy, Prevention, Respect and Care, Safety as well as Timeliness.
1. Article
Comparison of the Effects of Levosimendan
Dobutamine and Vasodilator Therapy
on Ongoing Myocardial Injury in Acute
Decompensated Heart Failure
Erkan Gencer, MD1
, Volkan Dog˘an, MD2
, Mu¨jgan Tek O¨ ztu¨rk, MD3
, Aydın Nadir, MD4
,
Ahmet Musmul, MD5
, and Yu¨ksel Cavus¸og˘lu, MD, FESC6
Abstract
Background: Cardiac troponins (cTn) are reliable and the most sensitive biomarker in the setting of acute decompensated heart
failure (ADHF). Acute decompensated heart failure is usually associated with worsening chronic heart failure, and it may be caused
by ongoing minor myocardial cell damage that may occur without any reported precipitating factors. Methods: We compared
the short-term effect of levosimendan (LEV), dobutamine (DOB), and vasodilator treatment (nitroglycerin [NTG]) on myocardial
injury with hemodynamic, neurohumoral, and inflammatory indicators. One hundred twenty-two patients with a mean age of 66
+ 9 years were treated with LEV (n ¼ 40), DOB (n ¼ 42), and NTG (n ¼ 40) and examined retrospectively. Blood samples (cTnI,
N-terminal probrain natriuretic peptide [NT-proBNP], highly sensitive C-reactive protein [HsCRP], and others), left ventricular
ejection fraction (LVEF), systolic pulmonary artery pressure (sPAP), and 6-minute walk distance (6MWD) were compared before
and after treatment. Results: At admission, detectable levels of cTnI were observed in 53% of patients (!0.05 ng/mL). Serial
changes in the mean cTnI levels were not significantly different between the groups (LEV 0.04 + 0.01 to 0.03 + 0.01 ng/mL; DOB
0.145 + 0.08 to 0.08 + 0.03 ng/mL; NTG 0.1 + 0.03 to 0.09 + 0.02 ng/mL; overall P ¼ .859). Favourable effects on the
NT-proBNP, sPAP values, LVEF, 6MWD, and HsCRP were observed overall, especially in the LEV groups. Conclusion: Beneficial
effects of short-term use of LEV, DOB, and NTG on ongoing myocardial injury were demonstrated. These findings can be
attributed to the anti-ischemic properties as well as the hemodynamic, neurohumoral, and functional benefits from the positive
inotropes, especially LEV, in patients with ADHF.
Keywords
heart failure, levosimendan, dobutamine, troponin
Introduction
There is increasing evidence that cardiac troponins (cTn) are
reliable and sensitive biomarkers for identifying high-risk
patients and good prognostic markers in the setting of acute
decompensated heart failure (ADHF).1-4
Ongoing myocardial
ischemia, inflammation, and apoptosis are associated with
myocyte degeneration in the cardiomyopathic myocardium,
and they may be responsible for worsening heart failure and
cTn release.5
Positive inotropic treatment may be given to patients who
are refractory to optimal medical treatment and intravenous
diuretics or who have evidence of low cardiac output, such as
hypotension or hypoperfusion in patients presenting with
ADHF.
Dobutamine (DOB) is a potent inotropic and weak chrono-
tropic agent that acts on the b1-2 and a1 adrenergic receptors.6
Levosimendan (LEV) is a parenteral inodilatory and so-called
calcium-sensitizing agent used for treating ADHF. In contrast
to DOB, it is suggested that LEV does not change the intracel-
lular calcium levels or oxygen consumption, and it may also
1
Department of Cardiology, Cardiology Clinic, Kilis State Hospital, Kilis, Turkey
2
Department of Cardiology, Department of Cardiology, Mugla Sıtkı Kocman
University, Mugla, Turkey
3
Department of Cardiology, Cardiology Clinic, Kecioren Education and
Research Hospital, Ankara, Turkey
4
Department of Cardiology, Cardiology Clinic, Bozuyuk State Hospital, Bilecik,
Turkey
5
Department of Biostatistics, Faculty of Medicine, Eskisehir Osmangazi
University, Eskisehir, Turkey
6
Department of Cardiology, Faculty of Medicine, Eskisehir Osmangazi
University, Eskisehir, Turkey
Manuscript submitted: March 29, 2016; accepted: May 09, 2016.
Corresponding Author:
Erkan Gencer, Cardiology Clinic, Kilis State Hospital, 79000 Kilis, Turkey.
Email: egencer45@gmail.com
Journal of Cardiovascular
Pharmacology and Therapeutics
1-6
ª The Author(s) 2016
Reprints and permission:
sagepub.com/journalsPermissions.nav
DOI: 10.1177/1074248416657612
cpt.sagepub.com
at University of Sussex Library on July 11, 2016cpt.sagepub.comDownloaded from
2. exhibit protective properties against cardiac ischemia, inflam-
mation, and apoptosis.7-10
On the other hand, positive inotropic
therapy, including LEV and DOB treatment, may have adverse
hemodynamic, intracellular, and arrhythmogenic effects and
they should be used carefully in this patient-group.11-13
This retrospective study was designed to elucidate the
effects of LEV, DOB, and nitroglycerin (NTG) treatment on
ongoing myocardial injury as well as hemodynamic, neurohu-
moral, and inflammatory indicators in patients with ADHF.
Methods
Study Population
The patients who were admitted to the hospital of Osmangazi
University (Eskis¸ehir, Turkey) between June 2008 and May
2010 and those examined retrospectively were included in the
study. A total of 122 patients with ADHF included in the study
with a mean age of 66 + 9 years were treated with LEV, DOB,
or NTG; all patients had received standard heart failure therapy
including optimal oral medication and diuretics and left ven-
tricular ejection fraction (LVEF) of 35% or less as measured by
transthoracic echocardiography. LEV or DOB infusion was
administered to patients who have evidence of low cardiac
output such as peripheral hypoperfusion and hypotension or
who are refractory to optimal medical treatment according to
the clinician’s decision. NTG was administered preferably to
patients who have had hypertension or normotension with pul-
monary and/or peripheral edema in patient with ADHF. In
patients presenting with restrictive or hypertrophic cardiomyo-
pathy, uncorrected valvular disease, cardiogenic shock, sepsis,
severe hepatic impairment, severe renal impairment (glomeru-
lar filtration rate <30 mL/kg/1.73 m2
), chest pain or electro-
cardiogram changes with increased cTn values in serial
measurement, cTnI levels of !5Â cutoff, second- and third-
degree atrioventricular block, coexistence of acute respiratory
distress syndrome, recently with a history of cardiac arrest, and
any positive inotropes received last 4 weeks were excluded.
Study Design and Protocol
In all patients, cTnI, N-terminal probrain natriuretic peptide
(NT-proBNP), highly sensitive C-reactive protein (HsCRP),
echocardiographic estimation of LVEF, systolic pulmonary
artery pressure (sPAP) estimated by Doppler echocardiogra-
phy, 6-minute walk distance (6MWD), and other laboratory
findings were recorded before and after treatment. The mean
time of follow-up postinitiation of treatment was 48 hours. In
the all patients had been received of blood plasma samples
before treatment and postinitiation of 3 days. LEV with a load-
ing dose of 6 to 12 mg/kg over 10 minutes and followed by a
continuous infusion of 0.1 to 0.2 mg/kg/min was administered.
When there were adverse clinical effects, the dose was reduced
to 0.05 mg/kg/min. In the patients who have had received LEV,
5 patients of those had reduced dose of 0.05 mg/kg/min tempo-
rary. Dobutamine was infused at a rate of 10 mg/kg/min for
48 hours. Initial dose of NTG was 25 mg/kg/min and followed
by a continuous infusion up to 100 mg/kg/min when the dosage
adjusted according to blood pressure for 48 hours.
The baseline demographic, clinical, and hemodynamic char-
acteristics were recorded. Noninvasive measurements of the
blood pressure and heart rhythm during treatment were noted.
The results of invasive procedures that were performed at the
coronary care unit or catheterization laboratory were recorded
and compared.
Cardiac Troponin I Analysis
The control group consisted of healthy volunteers who were the
same age and gender in our clinic. Values of multiple cTnI
analyses of patients (Siemens Dimension cTnI Heterogeneous
Immunoassay Module) were recorded. The 99th percentiles of
the cTnI levels were established for optimal precision, and the
cTnI reference ranges were determined.14
Maximum 10%
coefficients of variation were applied to this level; in this way,
the cTnI reference intervals were determined with a lower
limit of detection of 0.05 ng/mL and upper reference limit
of 0.1 ng/mL (cutoff).
Statistical Analysis
The statistical analysis was performed using IBM SPSS Statis-
tics for Windows (version 20). The distribution forms of the
data were tested by Kolmogorov-Smirnov and Shapiro-Wilk
tests. Data for cross-sample comparisons were analyzed by
w2
tests and correlations. Comparison of the average of the data
was examined by t tests, and 1-way analysis of variance and
Tukey or Dunn test were used for post hoc analysis. Mean +
standard error values were used to summarize the data, and
P < .05 was considered as statistically significant.
Results
LEV (n ¼ 40), DOB (n ¼ 42), and NTG (n ¼ 40) groups were
compared in the study. Baseline clinical and demographic char-
acteristics are shown in Table 1. At admission, no significant
differences were observed between the groups in terms of these
characteristics.
Cardiac troponin Levels at Admission
and After Treatment
At admission, 53% of patients were found to exceed the lower
limit of detection of cTnI. The percentages of patients with
increased, decreased, and unchanged cTnI levels after treat-
ment were 36%, 44%, and 20%, respectively. After treatment
in all patients, decreasing trends were observed in the mean
cTnI levels, but statistically significant differences were not
found. After the treatment, no statistically significant effect
was observed with respect to serial changes in the cTnI
between the groups (overall P ¼ .859; Figure 1).
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3. Neurohumoral and Inflammatory Response
Overall, the mean NT-proBNP levels at admission of 9057 +
1052 pg/mL and after treatment of 5930 + 804 pg/mL were
observed (P < .001). In the post hoc analysis, no statistically
significant differences were found between the groups (P ¼
.207). Similarly, no significant differences were found in
terms of the mean change in HsCRP (P ¼ .487) as well as
total white blood cell count and its subtypes (P ¼ .173).
Hemodynamic and Functional Indicators
In each group with more pronounced LEV, statistically signif-
icant increases were found in the LVEF after treatment. In post
hoc analysis, the LVEF increase was significantly higher for
LEV and DOB compared to NTG (LEV DOB NTG,
.001). In each group, the sPAP values were significantly
decreased after treatment. This decrease tended to be greater
in the LEV group. Overall, statistically significant increases
were observed in terms of 6MWD after treatment, but no sta-
tistically significant difference was found between the groups
(P ¼ .087; Table 2). In all patients, statistically significant
increases were observed in the mean heart rate after treatment
(77.5 + 15 vs 84 + 16, P .001), but no statistically signif-
icant differences were found between the groups (P ¼ .124).
Discussion
ADHF is a clinical syndrome with increasing incidence that is
associated with frequent hospitalizations and high morbidity
and mortality. Although many different medications are used
in the effective treatment of acute and chronic heart failure,
inotropes may be required to improve hemodynamic stabiliza-
tion, peripheral perfusion, and cardiac output.15-17
However,
they should be used carefully because of safety concerns, such
as myocardial ischemia, atrial and ventricular tachyarrhyth-
mias, hypotension, and mortality risk.18-23
Many clinical studies on ADHF indicate that LEV improves
myocardial function, reduces the cTn levels, and suppresses
inflammation and apoptotic indicators of both intense myocar-
dial ischemia and stunned myocardium after myocardial infarc-
tion.24-27
In addition, lower levels of cTn release during LEV
administration and improving myocardial performance indica-
tors have been reported.28-30
An association between DOB and myocardial injury has
rarely been studied in patients with ADHF. DOB increases the
myocardial contractility, reducing the peripheral vascular resis-
tance and thus improving the cardiac output without seriously
affecting the blood pressure or sympathetic tone.31
In the pilot
randomized study of nesiritide versus dobutamine in heart fail-
ure (PRESERVED-HF) study, some patients developed cTn
release during hospitalization with DOB treatment.5
In several
studies that used DOB, there was no significant release of cTn
even for patients with a diffuse coronary artery disease or pre-
vious myocardial infarction.32-34
Table 1. Baseline and Clinical Characteristics of Patients at Admission.
Study Population (N ¼ 122) Levosimendan (n ¼ 40) Dobutamine (n ¼ 42) Nitroglycerin (n ¼ 40) P Value
Gender, male (%) 33 27 33 .08
Age, years 67.5 + 9.3 67.3 + 10.4 63.5 + 8.0 .097
Weight, kg 74.3 + 13.5 76.2 + 17.9 77.7 + 15.9 .622
Height, cm 168 + 7.5 167 + 8.5 170 + 6.6 .194
Atrial fibrillation, n (%) 6 (15) 7 (16.7) 12 (30) .189
Diabetes, n (%) 19 (47.5) 21 (50) 16 (40) .284
Hypertension, n (%) 19 (47.5) 26 (61.9) 27 (67.5) .171
Smoking, n (%) 12 (30) 6 (14.3) 14 (35) .083
Hyperlipidemia, n (%) 12 (30) 15 (35.7) 15 (37.5) .482
Heredity, n (%) 6 (15) 10 (23.8) 8 (20) .34
b-Blocker, n (%) 26 (65) 30 (71.4) 23 (57.5) .285
RAAS blocker, n (%) 20 (50) 21 (50) 23 (57.5) .738
Ischemic, n (%) 32 (88.6) 30 (78.4) 28 (73) .248
Single vessel, n 6 6 6 .967
Multivessel, n 26 24 22 .797
Abbreviation: RAAS, renin–angiotensin–aldosterone system.
Figure 1. Mean cTnI levels at admission and after treatment in all
groups. cTnI indicates cardiac troponin I.
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4. At admission, detectable cTnI levels were found in 53% of
our patients. No significant changes were observed with the
mean cTnI levels after positive inotropic therapy or NTG. In
the present study, we observed that high levels of cTnI can
initially be detected regardless of the etiology of cardiomyo-
pathy and they tend to decrease, but did not change signifi-
cantly, after ADHF treatment. In inotropes, but more
pronounced in the LEV group, statistically significant improve-
ments were observed in the LVEF and 6MWD, and the
NT-proBNP and sPAP levels were more effectively decreased.
Overall, no significant differences were observed in the inflam-
mation indicators after treatment.
Recent studies suggest that positive inotropic therapy is not
associated with adverse events if eligible patients are treated.35
This may be associated with different causes, such as anti-
ischemic properties, hemodynamic, neurohumoral, and
functional benefits of positive inotropes, especially LEV.36
Furthermore, in previously reported studies, associations
between adverse events and using positive inotropes have not
inspired widespread use of implantable cardioverter defibrilla-
tors (ICDs) or the fact that the vast majority of mortality depends
on the sudden cardiac death.37
In the vicious cycle of congestive
heart failure and its progressive nature, it is already associated
with adverse outcomes in the absence of optimal medical ther-
apy, complete revascularization, and treatment of comorbidities,
which is exacerbated if an ICD is not implanted per the current
recommendations. Moreover, hospital admission with serious
clinical conditions, such as cardiogenic shock, pulmonary
edema, or end-organ dysfunctions caused by low cardiac output,
can be treated with commonly used positive inotropes, which
may be considered a lifesaving feature of ADHF.38
Conclusion
The present results indicate that beneficial effects were shown
by the short-term infusion of LEV, DOB, and NTG on ongoing
myocardial cell injury, which is considered as the main reason
of worsening heart failure. However, improvement in
hemodynamic, neurohumoral, and functional parameters is
more pronounced with LEV than those with DOB and NTG.
In addition, LEV, DOB, and vasodilator treatment might be
reliable options in the short term with eligible patients having
ADHF are treated. Further studies are needed to support this
conclusion.
Author Contributions
Volkan Dog˘an contributed to conception, design, and analysis.
Mu¨jgan Tek O¨ ztu¨rk, Aydın Nadir, Ahmet Musmul, and Yu¨ksel
Cavus¸og˘lu contributed to conception. Yu¨ksel Cavus¸og˘lu contributed
to design. All authors gave final approval and agree to be accountable
for all aspects of work ensuring integrity and accuracy.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to
the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, author-
ship, and/or publication of this article.
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