Comparison of neuroendocrine activation in patients with left ventricular dysfunction with and without congestive heart failure. A substudy of the Studies of Left Ventricular Dysfunction (SOLVD).

Abstract

Neuroendocrine activation is known to occur in patients with congestive heart failure, but there is uncertainty as to whether this occurs before or after the presence of overt symptoms. In the Studies of Left Ventricular Dysfunction (SOLVD), a multicenter study of patients with ejection fractions of 35% or less, we compared baseline plasma norepinephrine, plasma renin activity, plasma atrial natriuretic factor, and plasma arginine vasopressin in 56 control subjects, 151 patients with left ventricular dysfunction (no overt heart failure), and 81 patients with overt heart failure before randomization. Median values for plasma norepinephrine (p=9.0001), plasma atrial natriuretic factor (p<0.0001), plasma arginine vasopressin (p=0.006), and plasma renin activity (p=0.03) were significantly higher in patients with left ventricular dysfunction than in normal control subjects. Neuroendocrine values were highest in patients with overt heart failure. Plasma renin activity was normal in patients with left ventricular dysfunction without heart failure who were not receiving diuretics and was significantly increased (p<0.05) in patients on diuretic therapy. We conclude that neuroendocrine activation occurs in patients with left ventricular dysfunction and no heart failure. Neuroendocrine activation is further increased as overt heart failure ensues and diuretics are added to therapy. (Circulation 1990;82:1724-1729 C ongestive heart failure is a complex clinical syndrome with varying pathophysiology and clinical expression. It is well known that overt heart failure is characterized by activation of several neuroendocrine systems.' Plasma norepinephrine (PNE)2 and plasma atrial natriuretic factor (ANF)3 are increased and known to be prognostic factors in patients with heart failure. Activation of the renin-angiotensin system is common in patients with advanced heart failure. Angiotensin converting enzyme inhibitor therapy improves survival in patients with advanced heart failure,4 suggesting that

Loop Diuretic Therapy in Heart Failure: The Need for Solid Evidence on a Fluid Issue

“…However, PRA was normal in asymptomatic LVD patients not receiving diuretics, but was significantly increased (P < 0.05) in patients on diuretics. 26 This suggests that RAAS activation in moderate HF may occur in response to diuretic treatment rather than the disease process. 27 Diuretic withdrawal in stabilized systolic HF is associated with improvements in renal function parameters and some neurohormonal parameters like PRA.…”

Natriuretic and Neurohormonal Responses to Nesiritide, Furosemide, and Combined Nesiritide and Furosemide in Patients With Stable Systolic Dysfunction

“…This process serves as one of the confounding factors behind relative diuretic resistance in HF. 3,11,16,17 The demonstration that concomitant use of nesiritide with furosemide blocked the aldosterone increase seen with furosemide alone suggests that coadministration of these drugs may preempt the neurohormonal contribution to the blunted diuretic response present during the volume-mobilization stage of acute HF management. Confirmation of this hypothesis will require further studies.…”

Clinical and neurohumoral consequences of diuretic withdrawal in patients with chronic, stabilized heart failure and systolic dysfunction

“…These effects are counteracted by angiotensin converting enzyme inhibitors, which reduce the rise in plasma angiotensin II. With respect to the sympathetic nervous system, loop diuretics reduce the heart failure increase in plasma norepinephrine concentration [4,[17][18][19]. In relation to atrial natriuretic peptide, this neurohormone is released by the atria, atrial stretch being the most direct trigger mechanism.…”