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The expression of cytokines by heart cells other than myocytes in response to myocardial overload in the form of infarction is investigated during the acute, the subacute and the chronic stages of infarction in the rat. Results reveal that the expression of timor necrosis factor, interleukin and transforming growth factors by non-myocytes increased during the acute and subacute phases. This is correlated with the increase in collagen production. The implications of these results on extracellular matrix remodelling after an ischemic episode are discussed.

Amiodarone may not prevent sudden death or prolong life in patients with heart failure and arrythmias. Amiodarone is a drug that causes dilation of blood vessels in the heart and prevents irregular heart beats, or arrythmias. Doctors assigned 336 patients to receive amiodarone and 338 to receive a placebo to determine the effect of the drug on longterm survival. Amiodarone did not have a significant effect on survival. During the study 274 patients died including 131 (39%) patients taking amiodarone and 143 (42%) taking a placebo. Among patients taking amiodarone, 64 (49%) suffered a sudden death compared to 75 (52%) of those patients taking a placebo. Amiodarone did have some beneficial effects. After two weeks of therapy, the patients taking amiodarone had a significantly lower heart rate averaging 70 beats/minute. In addition, the average frequency of irregular heart beats decreased from about 254 per hour to 66 per hour at two weeks to 44 per hour after three months.

Coronary artery bypass grafting (CABG) seems to improve the survival rate and physical functioning of patients with moderate to severe heart failure and chest pain. Researchers reviewed 134 studies that evaluated CABG and 12 studies that evaluated angioplasty for the treatment of moderate to severe heart failure. All studies were published between 1966 and 1993. Results revealed that CABG reduced the three-year death rate in heart-failure patients with chest pain by 30% to 50%. The functional status of heart-failure patients seemed to improve after CABG. During the CABG procedure, the patient death rate ranged from 5% to 30% depending upon patient characteristics, disease severity, and the quality of the medical center. The benefits of CABG in heart failure patients who do not have chest pain remain unclear. The effectiveness of angioplasty as an alternative to CABG or medical management has not been assessed, although the significant patient risks that accompany angioplasty are well-recognized., Objective.--This article reviews the benefits and risks of coronary artery bypass grafting and angioplasty for patients with moderate or severe left ventricular systolic dysfunction and summarizes the recommendations of the expert panel for the Agency for Health Care Policy and Research Heart Failure Guideline. Data Sources.--Data were obtained from studies published in English and referenced in MEDLINE or EMBASE between 1966 and 1993. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with the terms coronary artery bypass grafting and angioplasty. Study Selection.--All cohort studies and case series that provided separate outcomes data on a subgroup of patients with a left ventricular ejection fraction less than 0.40 were reviewed. Data Extraction and Synthesis.--Studies were reviewed for inclusion and exclusion criteria, survival, and functional status measures using a standardized form. Cohort studies were assessed on eight aspects of study quality using a defined list of study flaws. Conclusion.--Coronary artery bypass grafting improves 3-year survival by approximately 30% to 50% and physical functioning by approximately one New York Heart Association class in patients with moderate to severe left ventricular dysfunction and limiting angina. However, the operative mortality ranges from 5% to 30% depending on patients' ejection fractions and comorbidity. It is not clear whether patients whose predominant symptom is heart failure rather than angina benefit from bypass surgery or how much ischemia is required to justify surgical intervention. Clinical outcomes after angioplasty have not been adequately studied to determine the relative risks and benefits compared with bypass grafting. (JAMA. 1994; 272:1528-1534)

Patient education and counseling may help promote the lifestyle changes required in patients with heart failure. Researchers reviewed medical research published between 1966 and 1993 that discussed lifestyle changes and patient education and counseling techniques for people with heart failure due to left ventricular systolic dysfunction. Education and counseling can help patients understand heart failure, recognize the need for medical attention, and adapt psychologically to their condition. Recommended dietary restrictions include limiting salt intake to three grams per day and refraining from alcohol. Exercise offers benefits to most heart failure patients. A walking program is a recommended activity to prevent physical and psychological decline from inactivity. Patient compliance with a treatment regimen can be encouraged through a good patient-provider relationship. Physicians must explain the significance of heart failure to their patients while stressing that the patients can continue to have a good quality of life., Objective.--This article reviews the role of counseling, education, dietary modificatios, and exercise for patients with heart failure due to left ventricular systolic dysfunction. Data Sources.--We reviewed studies published in English between 1966 and 1993 and referenced in MEDLINE or EMBASE. We used the search terms heart failure, congestive; congestive heart failure; heart failure; cardiac failure; and dilated cardiomyopathy in conjunction with terms for the specific areas of interest. Where data were lacking, we relied on opinions of panel members and peer reviewers. Study Selection and Data Synthesis.--Studies were reviewed to determine whether patients had heart failure due to systolic dysfunction (left ventricular ejection fraction, Conclusion.--Counseling and education can improve patient outcomes and decrease unnecessary hospitalizations. Patients with mild to moderate heart failure should be restricted to 3 g/d of sodium initially. Those who are unresponsive to this dosage or who have more severe disease should be advised to consume 2 g/d or less. Patients should be strongly advised to drink no more than 30 mL/d of alcohol or, preferably, to abstain completely. Exercise training is safe and can improve exercise duration and symptoms. Adherence to the treatment plan should be stressed and monitored at each visit. Clinicians should inform patients of the seriousness of their disease and their prognosis, but they should emphasize that patients can continue to remain active and enjoy a reasonable quality of life.

Patient characteristics such as race and age appear to influence the effectiveness of anti-high blood pressure drugs and should be considered when choosing treatment. Of 1283 men with high blood pressure, 188 took hydrochlorothiazide, 176 took atenolol, 188 took captopril, 177 took clonidine, 182 took diltiazem, 186 took prazosin and 186 took a placebo, an inactive substance. Patients who took clonidine and prazosin had significantly more side effects than patients who took the placebo and more often withdrew from treatment than patients who took other drugs. Among white men under age 60, clonidine, atenolol, and diltiazem most effectively reduced blood pressure, and hydrochlorothiazide was the least effective. Among black men under age 60, diltiazem was the most effective and prazosin was the least effective. Diltiazem was the most effective drug among older blacks also, and all drugs were about equally effective in older whites.