Heart Failure and Arrhythmias

Transcription

1

2 1. Brachmann R. Dietz W Kubler (Eds.) Heart Failure and Arrhythmias With 41 Figures and 17 Tables Springer-Verlag Berlin Heidelberg New York London Paris Tokyo Hong Kong Barcelona

3 Priv.-Doz. JOHANNES BRACHMANN, MD Prof. RAINER DIETZ, MD Prof. WOLFGANG KUBLER, MD Department of Internal Medicine III, Cardiology Medizinische UniversiHitsklinik Bergheimer Str Heidelberg, FRG ISBN-13 : e-isbn-13: DOl: / Library of Congress Cataloging-in Publication Data. Heart failure and arrhythmias / 1. Brachmann, R. Dietz, W Kiibler, (eds.). p. cm. Based on an international satellite workshop to the World Congress of Clinical Pharmacology, held in Heidelberg/Mannheim from July 23-29, Includes bibliographical references. Includes index. ISBN-13 : Congestive heart failure-congresses. 2. Heart failure-congresses. 3. Arrhythmia-Congresses. I. Brachmann, 1. II. Dietz, R. (Rainer). III. Kiibler, W IV. World Congress of Clinical Pharmacology (1989: Heidelberg, Germany and Mannheim, Germany) [DNLM: 1. Arrhythmia-drug therapy-congresses. 2. Arrhythmia-physiopathology-congresses. 3. Heart Failure, Congestive-drug therapy-congresses. 4. Heart Failure, Congestive-physiopathology-congresses. WG 370 H ] RC685.C53H '2-dc20 DNLM/DLC for Library of Congress CIP. This work is subject to copyright. All rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in other ways, and storage in data banks. Duplication of this publication or parts thereof is only permitted under the provisions of the German Copyright Law of September 9, 1965, in its current version, and a copyright fee must always be paid. Violations fall under the prosecution act of the German Copyright Law. Springer-Verlag Berlin Heidelberg 1990 Softcover reprint of the hardcover 1st edition 1990 The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. Product Liability: The publishers can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. 2119/ Printed on acid-free paper

4 Preface Heart failure is a clinical entity characterized by a certain combination of symptoms and signs. Although there is neither a definition covering all aspects of it nor any generally accepted criteria for evaluating its severity, it is the endstage of many different heart diseases, in most cases associated with a poor prognosis. Approximately 50% of the patients with advanced heart failure die from pump failure, whereas the other half succumb suddenly and unexpectedly due to ventricular tachyarrhythmias. Although impaired left ventricular function is the main risk factor, sudden death may already occur in less severe cases of heart failure. In certain cardiac diseases, such as dilative cardiomyopathy, the occurrence of ventricular arrhythmias may be related directly to the underlying heart disease, as the frequency and severity (Lown classification) of ventricular ectopics are not related to left ventricular impairment. Treatment of ventricular tachyarrhythmias is still an unsolved problem, especially in patients with heart failure, who need it the most. The vast majority of antiarrhythmic agents are more or less negatively inotropic and may therefore substantially aggravate ventricular impairment. Nonpharmacological approaches - such as the implantation of a defibrillator - still require major surgery with the associated increased risk to the patient in heart failure. No agreement has yet been reached on the criteria for evaluating how effective treatment has been, either for heart failure or for ventricular tachyarrhythmias. In fact, the basic questions when and how to treat have also not been resolved for these two conditions. The symposium "Heart Failure and Arrhythmias" was dedicated to these problems and covered both theoretical topics, such as pathophysiology and pathogenesis, and clinical ones, including prognostic implications. The symposium was designed as an international satellite workshop to the World Congress of Clinical Pharmacology, which took place in HeidelbergjMannheim from July It was organized by J. Brachmann and R. Dietz, who were supported by T. Beyer, M. Haass, K. J. Osterziel, A. Pfeifer, C. Schmitt, W. Waas, and B. Waldecker.

5 VI Preface The symposium has been made possible by an educational grant from ICI-Pharma, Plank stadt, Federal Republic of Germany. We are very grateful to both the organizers and the sponsors. Heidelberg, Mai BRACHMANN R. DIETZ W KUBLER

6 Contents I Pathophysiology Editorial: Heart Failure and Arrhythmias H. lust.... Pathogenesis of Impaired Pump Function in Congestive Heart Failure A.M. KATZ (With 1 Figure) Pathogenesis of Ventricular Arrhythmias in Heart Failure M.I lanse, IM.T. DE BAKKER, and T. OPTHOF (With 2 Figures) 16 Evaluation of the Severity of Heart Failure: Role of Compensatory Mechanisms R. DIETZ, T. FISCHER, M. HAASS, K.I OSTERZIEL, and W W AAS (With 7 Figures) Tissue Renin-Angiotensin Systems in the Pathophysiology of Heart Failure A.T. HIRSCH and Y.I DZAU (With 1 Figure and 1 Table) 33 Evaluation of the Severity of Ventricular Rhythm Disturbances: Value of Electrophysiological Testing and Recording of Late Potentials L. SEIPEL, G. BREITHARDT, and M. BORGGREFE (With 3 Figures and 1 Table) II Approaches to Treatment Hemodynamic Approach Editorial: How to Treat - The Hemodynamic Approach K. KOCHSIEK

7 V III Structural Basis of Left Ventricular Dysfunction: Role of Collagen Network Remodeling and Potential Therapeutic Interventions M.A. SILVER and K.T. WEBER (With 2 Figures) Treatment of Heart Failure by "Afterload" Reduction: Vasodilator or Angiotensin Converting Enzyme Inhibitor? P.A. POOLE-WILSON (With 2 Figures and 3 Tables) Contents Possible Role of Positive Inotropic Drugs in Congestive Heart Failure and in Left Ventricular Dysfunction H. POULEUR (With 1 Table) Prognostic Indices and Prolongation of Life K. SWEDBERG (With 2 Figures) Antiarrhythmic Approach Editorial: Heart Failure and Malignant Ventricular Arrhythmias A.I CAMM.... Heart Failure and Ventricular Arrhythmias - The Antiarrhythmic Approach B. LUDERITZ (With 1 Figure and 1 Table) When to Treat Arrhythmias in Heart Failure? A.P.M. GORGELS, P. BRUGADA, and H.IJ. WELLENS (With 6 Figures and 1 Table) Antiarrhythmic Drugs in Heart Failure I BRACHMANN, C. SCHMITT, T. BEYER, B. WALDECKER, T. HILBEL, M. SCHWEIZER, and W KUBLER (With 3 Figures and 2 Tables) 111 Nonpharmacologic Therapy for Malignant Ventricular Tachyarrhythmias in Patients with Congestive Heart Failure S. SAKSENA (With 4 Figures) Role of Antiarrhythmic Drug Therapy in Patients with Congestive Heart Failure R.L. WOOSLEY (With 4 Figures and 3 Tables)

8 Contents IX III Prognosis Obtaining Reliable Information from Randomized Controlled Trials in Congestive Heart Failure and Left Ventricular Dysfunction S. YUSUF (With 4 Tables) Prognostic Significance of Asymptomatic Ventricular Arrhythmias in Heart Failure: Potential for Mortality Reduction by Pharmacologic Control B.N. SINGH, M.P. SCHOENBAUM, M. ANTIMISIARIS, and C. TAKANAKA (With 3 Figures) SUbject Index

9 List of Contributors ANTIMISIARIS, M., MD Division of Cardiology 691/111 E, VA Medical Center of West Los Angeles Wilshire and Sawtelle Boulevards, Los Angeles, CA 90073, USA BAKKER, IM.T. DE, MD Department of Clinical and Experimental Cardiology and the Interuniversity Cardiology Institute, Academisch Medisch Centrum Meibergdreef 9, 1105 AZ Amsterdam ZO, The Netherlands BEYER, T., MD Department of Internal Medicine III, Medizinische Universitiitsklinik Bergheimer Str. 58, 6900 Heidelberg, FRG BORGGREFE, M., MD Department of Internal Medicine C, Medizinische Universitiitsklinik Albert-Schweitzer-Str., 4400 Munster, FRG BRACHMANN, I, MD Department of Internal Medicine III, Cardiology Medizinische U niversitiitsklinik Bergheimer Str. 58, 6900 Heidelberg, FRG BREITHARDT, G., MD Department of Internal Medicine C, Medizinische Universitiitsklinik Albert-Schweitzer-Str., 4400 Munster, FRG BRUGADA, P., MD Department of Cardiology, University Hospital Maastricht University of Limburg P.O. Box 1918, 6201 BX Maastricht, The Netherlands CAMM, A.I, MD Department of Cardiological Sciences St. George's Hospital Medical School London SW17 ORE, UK

10 XII List of Contributors DIETZ, R., MD Department of Internal Medicine III, Cardiology Medizinische Universitatsklinik DZAU, V.l, MD Cellular Vascular Research Laboratory Brigham and Women's Hospital Harvard Medical School 75 Francis Street, Boston, MA 02115, USA FISCHER, T., MD Department of Internal Medicine III, Medizinische Universitatsklinik OORGELS, A.P.M., MD Department of Cardiology, University Hospital Maastricht University of Limburg P.O. Box 1918, 6201 BX Maastricht, The Netherlands HAASS, M., MD Department of Internal Medicine III, Cardiology Medizinische U niversitatsklinik HILBEL, T., MD, Department of Internal Medicine III, Medizinische Universitatsklinik HIRSCH, A.T., MD Cardiovascular Physiology Laboratory Brigham and Women's Hospital Harvard Medical School 75 Francis Street, Boston, MA 02115, USA JANSE, M.I, MD Department of Clinical and Experimental Cardiology and the Interuniversity Cardiology Institute, Academisch Medisch Centrum Meibergdreef 9, 1105 AZ Amsterdam ZO, The Netherlands JUST, H., MD Department of Internal Medicine III, Cardiology Hugstetter Str. 55, 7800 Freiburg i. Br., FRO KATZ, A.M., MD Cardiology Division, Department of Medicine University of Connecticut Farmington, CT 06032, USA

11 List of Contributors XIII KOCHSIEK, K., MD Department of Internal Medicine, Luitpoldkrankenhaus Josef-Schneider-Str. 2, 8700 Wiirzburg, FRO KUBLER, W, MD Department of Internal Medicine III, Cardiology Medizinische U niversitatsklinik Bergheimer Str. 58,6900 Heidelberg, FRO LUDERITZ, B., MD Department of Internal Medicine, Cardiology Sigmund-Freud-Str. 25, 5300 Bonn, FRO OPTHOF, T., MD Department of Clinical and Experimental Cardiology and the Interuniversity Cardiology Institute, Academisch Medisch Centrum Meibergdreef 9, 1105 AZ Amsterdam ZO, The Netherlands OSTERZIEL, K.J., MD Department of Internal Medicine III, Medizinische Universitatsklinik POOLE-WILSON, P.A., MD Department of Cardiac Medicine, National Heart and Lung Institute Dovehouse Street, London SW3 6LY, UK POULEUR, H., MD Department of Physiology and Division of Cardiology University of Louvain School of Medicine Ave. Hippocrate 55 HEDY/5560, 1200 Brussels, Belgium SAKSENA, S., MD Section of Cardiac Electrophysiology, Division of Cardiology UMDNJ-NJ Medical School, The Eastern Heart Institute Beth Israel Medical Center Newark and Passaic, NJ 07055, USA SCHMITT, C., MD Department of Internal Medicine III, Medizinische Universitatsklinik SCHOENBAUM, M.P., MD Division of Cardiology 691/111 E, VA Medical Center of West Los Angeles Wilshire and Sawtelle Boulevards, Los Angeles, CA 90073, USA SCHWEIZER, M., MD Department of Internal Medicine III, Medizinische Universitatsklinik

12 XIV List of Contributors SEIPEL, L., MD Department of Internal Medicine III, Medizinische Universitiitsklinik Auf dem Schnarrenberg, 7400 Tiibingen, FRG SILVER, M.A., MD Cardiovascular Institute, Michael Reese Hospital University of Chicago, Pritzker School of Medicine Chicago, IL 60616, USA SINGH, B.N., MD Division of Cardiology 691/111 E, VA Medical Center of West Los Angeles Wilshire and Sawtelle Boulevards, Los Angeles, CA 90073, USA SWEDBERG, K., MD Department of Internal Medicine, Gothenburg University Ostra Hospital, Gothenburg, Sweden T AKANAKA, c., MD Division of Cardiology 691/111E, VA Medical Center of West Los Angeles Wilshire and Sawtelle Boulevards, Los Angeles, CA 90073, USA WAAS, W, MD Department of Internal Medicine III, Medizinische Universitiitsklinik Bergheimer Str. 58, 6900 Heidelberg, FRG WALDECKER, B., MD Department of Internal Medicine III, Medizinische Universitiitsklinik Bergheimer Str. 58, 6900 Heidelberg, FRG WEBER, K.T., MD Cardiovascular Institute, Michael Reese Hospital University of Chicago, Pritzker School of Medicine Chicago, IL 60616, USA WELLENS, H.J.J., MD Department of Cardiology, University Hospital Maastricht University of Limburg P.O. Box 1918, 6201 BX Maastricht, The Netherlands WOOSLEY, R.L., MD Department of Pharmacology, Georgetown University School of Medicine, Washington, DC 20007, USA YUSUF, S., MD Clinical Trials Branch, Division of Epidemiology and Clinical Applications, National Heart, Lung and Blood Institute Bethesda, MD 20892, USA