Noninvasive assessment of acute effects of nifedipine on rest and exercise hemodynamics and cardiac function in patients with aortic regurgitation

Shen, Wei Feng; Roubin, Gary S.; Hirasawa, Kunihiko; Uren, Roger F.; Hutton, Brian F.; Harris, Phillip; Fletcher, Peter; Kelly, David T.

doi:10.1016/s0735-1097(84)80049-2

Cited by 43 publications

(8 citation statements)

References 19 publications

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“…9 Reversal of this kind of vascular maladaptation may explain the observations of Bonow and colleagues, 28 who described improvement in LV dysfunction after surgical intervention when surgery was performed in a timely fashion. In addition, the long-term benefit observed with vasodilator therapy 36 in asymptomatic patients with moderate-to-severe aortic regurgitation may be related to optimization of total arterial elastance through a reduction in vascular resistance, 38 which may, in a parallel fashion, prevent or delay maladaptation of the arterial system.…”

Section: Discussionmentioning

confidence: 99%

Impact of Vascular Adaptation to Chronic Aortic Regurgitation on Left Ventricular Performance

et al. 1999

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Background-This investigation was designed to test the hypothesis that vascular adaptation occurs in patients with chronic aortic regurgitation to maintain left ventricular (LV) performance. Methods and Results-Forty-five patients with chronic aortic regurgitation (mean age 50Ϯ14 years) were studied using a micromanometer LV catheter to obtain LV pressures and radionuclide ventriculography to obtain LV volumes during multiple loading conditions and right atrial pacing. .01, respectively), although the slopes of these relationships differed (PϽ0.05). The average LV work was maximal in Group IIa when the left ventricular-arterial coupling ratio was near 1.0 because of a significant decrease in total arterial elastance (PϽ0.01 versus Group I). In contrast, the decrease in the left ventricular-arterial coupling ratio in Group IIb was caused by an increase in total arterial elastance, effectively double loading the LV, contributing to a decrease in LV pump efficiency (PϽ0.01 versus Group IIa and PϽ0.001 versus Group I). Conclusions-Vascular adaptation may be heterogeneous in patients with chronic aortic regurgitation. In some, total arterial elastance decreases to maximize LV work and maintain LV performance, whereas in others, it increases, thereby double loading the LV, contributing to afterload excess and a deterioration in LV performance that is most prominent in those with impaired contractility.

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Section: Discussionmentioning

confidence: 99%

Impact of Vascular Adaptation to Chronic Aortic Regurgitation on Left Ventricular Performance

et al. 1999

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“…Several studies reported a reduction in aortic regurgitant volume with acute therapy [5,[15][16][17][18], but others only showed beneficial effects on LV dimensions, hypertrophy, and function (Table 1) [6][7][8].…”

Section: Aortic Regurgitationmentioning

confidence: 99%

Role of vasodilators in regurgitant valve disease

Evangelista

Tornos²,

Sambola³

et al. 2006

Curr Treat Options Cardio Med

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Vasodilator therapy is designed to reduce regurgitant volume and improve left ventricular function. Acute administration reduces vascular resistance and decreases regurgitant volume and left ventricular filling pressure. These effects may be clinically useful in acute regurgitations, but less consistent results have been reported in long-term therapy. In chronic mitral functional regurgitation, vasodilator therapy has proved to have clinical or prognostic benefit only when heart failure or poor ventricular function is present. The indication of vasodilator treatment in aortic regurgitation has raised significant controversy. Several studies with small series have shown beneficial effects on regurgitant volume, ejection fraction, and mass of the left ventricle. Nevertheless, in the only two randomized long-term follow-up studies, results differed completely. In our experience, both nifedipine and enalapril failed to reduce the need for valvular surgery or show benefits in echocardiographic parameters. Vasodilator therapy would be indicated only in patients with severe aortic regurgitation and systemic hypertension, or when surgery is contraindicated.

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“…It has been known for nearly two decades that vasodilating agents (nitroprusside, hydralazine, nifedipine, and angiotensin-converting enzyme [ACE] inhibitors) are effective in reducing the regurgitant volume in patients with AR and, in doing so, reducing LV volumes and increasing LV ejection fraction [6••, [12][13][14][15][16][17][18][19][20][21]. Until recently, however, it was uncertain if this effect was merely "cosmetic" in nature and whether this afterload reduction might mask the development of irreversible LV dysfunction.…”

Section: Medical Therapymentioning

confidence: 99%

“…In placebo-controlled studies, nifedipine resulted in a reduction in LV dimension, wall stress, and mass and an increase in ejection fraction compared with placebo [15,16,18]. In a randomized longitudinal study comparing nifedipine to digoxin in 143 patients followed 6 years, long-acting nifedipine reduced the need for valve replacement from 34% to 15% …”

Section: Nifedipinementioning

confidence: 99%

Aortic regurgitation

Bonow¹

2000

Curr Treat Options Cardio Med

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Left ventricular (LV) systolic function is an important determinant of long-term prognosis in patients with chronic aortic regurgitation (AR). Impaired LV systolic function identifies a group of patients who are at risk of developing postoperative congestive heart failure and death after aortic valve replacement (AVR). Hence, asymptomatic patients with definite evidence of impaired LV function should undergo operation without waiting for the development of symptoms or more severe LV dysfunction. Among asymptomatic patients with normal LV systolic function (normal ejection fraction), prognosis is excellent, and fewer than 5% per year require surgery because of symptom development or LV dysfunction. Patients likely to require surgery can be identified on the basis of age, severity of LV dilatation, and progressive increase in LV dimensions or decrease in resting ejection fraction during the course of serial follow-up studies. Afterload-reducing therapy in asymptomatic patients with severe AR and normal LV function has beneficial hemodynamic effects; chronic therapy may reduce the likelihood of symptoms or LV systolic dysfunction. Aortic valve replacement should be performed once significant symptoms develop. In the absence of important symptoms, the operation should also be performed in patients with AR who manifest consistent and reproducible evidence of either LV contractile dysfunction at rest or extreme LV dilatation. Noninvasive imaging should play a major role in evaluation. An important clinical decision--such as recommending AVR in the asymptomatic patient--should not be based on a single echocardiographic or radionuclide angiographic measurement. When these data consistently indicate impaired contractile function at rest or extreme LV dilatation on repeat measurement, however, operation is indicated in the asymptomatic patient. This strategy should reduce the likelihood of irreversible LV dysfunction in these patients and enhance long-term postoperative survival.

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Noninvasive assessment of acute effects of nifedipine on rest and exercise hemodynamics and cardiac function in patients with aortic regurgitation

Cited by 43 publications

References 19 publications

Impact of Vascular Adaptation to Chronic Aortic Regurgitation on Left Ventricular Performance

Impact of Vascular Adaptation to Chronic Aortic Regurgitation on Left Ventricular Performance

Role of vasodilators in regurgitant valve disease

Aortic regurgitation

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