In myocarditis, biventricular dysfunction at diagnosis was the main predictor of death/transplantation. AHA identified immune-mediated myocarditis in the majority of cases. Viral genome was a univariate predictor of adverse prognosis. Our approach of using AHA and positive PCR as aetiopathogenetic markers should help patient selection and recruitment in future studies on aetiological therapy.
The detection of AHA and of AIDA supports the involvement of autoimmunity in the majority of patients with IRAP.
The effects of the acute administration of arterial vasoconstrictors on renal plasma flow (RPF) and urinary sodium excretion (UNaV) in cirrhotic patients with ascites with or without hepatorenal syndrome (HRS) are still controversial. As a consequence, vasoconstrictors are not actually used in the treatment of renal sodium retention or HRS in these patients, regardless of the several lines of evidence suggesting that these renal functional abnormalities are related to a marked arterial vasodilation. The lack of an orally available effective arterial vasoconstrictor probably represents a further reason for this omission. Consequently, the present study was made to evaluate the acute effects of the oral administration of midodrine, an orally available ␣-mimetic drug, on systemic and renal hemodynamics and on UNaV in cirrhotic patients with ascites. Mean arterial pressure (MAP), heart rate (HR), cardiac index ( The improvement in systemic hemodynamics, which was also maintained during the the 3-to 6-hour period after midodrine administration, was accompanied by a significant increase in RPF (541.5 ؎ 43.1 vs. 385.7 ؎ 39.9 mL · min ؊1 ; P F .005), GFR (93.1 ؎ 6.5 vs. 77.0 ؎ 6.7 mL · min ؊1 ; P F .025), and UNaV (92.7 ؎ 16.4 vs. 72.2 ؎ 10.7 Eq · min ؊1 ; P F .025). In addition, a decrease in PRA (5.33 ؎ 1.47 vs. 7.74 ؎ 2.17 ng · mL ؊1 · h; P F .05), ADH (1.4 ؎ 0.2 vs. 1.7 ؎ 0.2 pg · mL ؊1 ; P F .05), and NOx (33.4 ؎ 5.0 vs. 49.3 ؎ 7.3 mol ؊1 ; P F .05) was found. In patients with HRS, the effects of the drug on the systemic hemodynamics was smaller and shorter. Accordingly, regardless of a significant decrease in PRA (15.87 ؎ 3.70 vs. 20.70 ؎ 4.82 ng · mL ؊1 · h; P F .0025) in patients with HRS, no significant improvement was observed in RPF, GFR, or UNaV. In conclusion, the acute oral administration of midodrine is associated with a significant improvement in systemic hemodynamics in nonazotemic cirrhotic patients with ascites. As a result, renal perfusion and UNaV also improve in these patients. By contrast, midodrine only slightly improves systemic hemodynamics in patients with type 2 HRS, with no effect on renal hemodynamics and renal function. (HEPATOLOGY 1998;28:937-943.)It has been hypothesized that a peripheral arterial vasodilation is the main factor in the pathogenesis of the functional renal abnormalities in patients with cirrhosis. 1-3 Arterial vasodilation is thought to be related to an excess of local or systemic vasodilators such as glucagon, prostacyclin, substance P, vasoactive intestinal peptide, bile acids, and nitric oxide. [3][4][5][6][7] The localization of arterial vasodilation as well as its link with renal sodium retention are also debated. Clinical and experimental studies suggest that the reduction of arterial vascular resistance occurs mainly in the splanchnic area, whereas in many other vascular beds, i.e., in the renal vascular bed, arterial resistance is normal or even increased in cirrhosis with ascites. 8,9 The reflex activation of the neurohumoral pressor systems, sympathetic nervous ...
Dilated cardiomyopathy (DCM), a leading cause of heart failure and heart transplantation in younger adults, is characterized by dilatation and impaired contraction of the left or both ventricles; it may be idiopathic, familial/genetic (20-30%), viral, and/or immune. On endomyocardial biopsy there is chronic inflammation in 30-40% of cases. Mutations in genes encoding myocyte structural proteins, cardiotoxic noxae and infectious agents are known causes; due to high aetiologic and genetic heterogeneity, the gene defects identified so far account for a tiny proportion of the familial cases. In at least two thirds of patients, DCM remains idiopathic. Myocarditis may be idiopathic, infectious or autoimmune and may heal or lead to DCM. Circulating heart-reactive autoantibodies are found in myocarditis/DCM patients and symptom-free relatives at higher frequency than in normal or noninflammatory heart disease control groups. These autoantibodies are directed against multiple antigens, some of which are expressed only in the heart (organ-specific); some autoantibodies have functional effects on cardiac myocytes in vitro as well as in animal models. Depletion of nonantigen-specific antibodies by extracorporeal immunoadsorption is associated with improved ventricular function and reduced cardiac symptoms in some DCM patients, suggesting that autoantibodies may also have a functional role in humans. Immunosuppression seems beneficial in patients who are virus-negative and cardiac autoantibody positive. Prospective family studies have shown that cardiac-specific autoantibodies are present in at least 60% of both familial and non familial pedigrees and predict DCM development among asymptomatic relatives, years before clinical and echocardiographic evidence of disease. Animal models have shown that autoimmune myocarditis/DCM can be induced by virus as well as reproduced by immunization with a well-characterized autoantigen, cardiac myosin. Thus, in a substantial proportion of patients, myocarditis and DCM represent different stages of an organ-specific autoimmune disease, that represents the final common pathogenetic pathway of infectious and noninfectious myocardial injuries in genetically predisposed individuals.
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