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Upward titration of beta-blockers in patients with chronic heart failure(CHF) is often limited by bradycardia. It is, however, controversial whether we should implant a pacemaker solely to achieve higher doses of beta-blockers or to give up the upward titration because conventional ventricular pacing causes asynchronous contraction. Therefore, we studied the prognosis in stable CHF patients treated with beta-blockers and who had bradycardia before or during the upward titration. A total of 20 CHF patients(NYHA class II-III) with bradycardia were retrospectively reviewed and were devided into two groups: In 11 patients, upward titration of beta-blockers was stopped due to bradycardia(B group). In 9 patients, pacemakers were implanted before or during upward titration(P group). All patients had a left ventricular ejection fraction of 40% or less and were followed up for 12-40 months(mean 23months). The baseline characteristics of the patients were similar in the two groups. The final doses of beta-blockers were higher in P group than in B group. The rate of hospitalization for worsening heart failure was significantly higher in P group than in B group although there is no difference in all-cause mortality between two groups.Conclusions:(1) The beneficial effects of beta-blockers may not overcome unfavorable effects of conventional ventricular pacemakers in mild to moderate CHF patients. (2) Cardiac resynchronization therapy may be a good option for CHF patients with bradycardia.

Purpose:Enhanced nocturnal activity of sympathetic nerve characterizes central sleep apnea (CSA) in pts with chronic heart failure (CHF). The aim of this study is to assess the role of heart rate variability (HRV) to diagnose CHF-related CSA.Methods:HRV was analyzed using the maximum-entropy method (MemCalc) in 10 CSA, 6 obstructive sleep apnea and 18 normal breathing pts with stable CHF.Result:Age, left ventricular ejection fraction, left ventricular end-diastolic pressure, brain natriuretic peptide and medications did not differ among 3 groups. Nocturnal ratios of low frequency power to high frequency power (L/H) were 3.4 ± 1.7, 2.6 ± 1.8 and 1.8 ± 0.9, respectively, in the 3 groups (p < 0.01). Nocturnal very low frequency power normalized to total power (VLFn) were 43 ± 17 %, 42 ± 22 % and 28 ± 13 %, respectively (p < 0.01). The other parameters of HRV during either sleep or awakening did not differ among 3 groups. Nocturnal L/H4.0 diagnosed CSA with 40 % of sensitivity and 96 % of specificity, and nocturnal VLFn43 % did with 60 % of sensitivity and 88 % of specificity. The combination of nocturnal L/H4.0 or VLFn43 % improved the diagnostic power to 70% of sensitivity and 88 % of specificity.Conclusions:CSA increased nocturnal cardiac sympathetic activity and VLFn. HRV may provide a useful method to diagnose CHF-related CSA.

Background:Systolic function depends on both the progression of chronic heart failure (CHF) and ventricular load. It is, however, unknown whether the progression of diastolic heart failure (DHF) decreases systolic function and whether transition to systolic heart failure (SHF) affects prognosis of DHF pts. Hence, we tested the time course of systolic function of pts with DHF defined as left-ventricular ejection fraction (EF) =45% and compared the prognosis of pts with and without transition to SHF defined as EF < 45%.Methods:Eighty-five DHF pts were prospectively observed in a mean follow-up duration of 24 months.Results:Reassessment of echocardiography showed transition to SHF in 19 pts (53 ± 8% to 39 ± 4% in EF, p < 0.001) without change in the left ventricle diastolic diameter (LVD, 55mm to 56mm, NS). In the other 66 pts, EF and LVD did not change (59 ± 11% to 62 ± 10%, NS, and 51mm to 50mm, NS, respectively). Kaplan-Meier analysis demonstrated that the combined event-free rate did not differ in DHF pts with and without transition to SHF (88.8% and 89.8% at 1 year and 67.9% and 73.4% at 3 year, respectively).Conclusions:DHF sometimes switches to SHF in an independent manner to LV load, which does not affect prognosis of DHF.

Renal dysfunction(RD) is common in patients with chronic heart failure(CHF). However, its prognostic importance in Japanese CHF patients is still unclear. We sought to clarify characteristics and the prognosis of CHF patients with RD (Serum creatinine 1.0mg/dl) using our CHF registry called the Chronic Heart Failure Analysis and Registry in the Tohoku District. A total of 1,278 CHF patients were enrolled as of April 2004. The study populations were 132 CHF patients with RD and 390 CHF patients without RD from the registry. Patients with creatinine of 4.0 mg/dl were excluded. Following significant differences were observed in CHF patients with RD at the entry compared to CHF patients without RD; older patients(71.3 ± 12.1 vs 64.0 ± 14.5), more prevalent ischemic etiology(24.8% vs 14.9%), higher incidence of anemia(55.9% vs 33.0%), more symptomatic patients(NYHA-III/IV; 27.1% vs 15.0%), more complicated by diabetes(21.8% vs 13.8%), and higher BNP level (339.0 ± 481.0 vs 223.8 ± 290.6 pg/ml). The Kaplan-Meier analysis showed that the all-cause mortality rate and the admission rate due to congestive heart failure were significantly higher in CHF patients with RD (3-year all-cause mortality; 31.9% vs 12.0%). RD had a significant impact on the survival of CHF patients. Further investigations are necessary to improve the prognosis and QOL of CHF patients with RD.