Heart disease prognosis

Occasional exercise testing is conducted in order to ascertain disease prognosis or suitability for heart transplant. Even though these tests can demonstrate improvement in heart function and therefore slowed disease progression, patient symptoms may not improve. 

Conduction system abnormalities are common in chronic heart failure, occurring in 15-30% of the population with low left ventricular ejection fraction (LVEF) [1-3]. The prevalence in ischemic heart disease is roughly similar to that seen in other forms of dilated cardiomyopathy. Conduction system disease can occur both at the time of an acute myocardial infarction as well as slowly progressing in chronic ischemic heart disease. Intraventricular conduction delays are associated with a poor prognosis in heart failure, with up to a 70% increase in the risk of death, and are also more prevalent in patients with advanced symptoms [2,4]. In ischemic heart disease, all components of the conduction system are at risk of ischemic injury, from the sinoatrial node to the His-Pukinje system. These conduction system abnormalities have the potential to impair cardiac function by a number of mechanisms. Since conduction abnormalities impair cardiac function, it is logical that pacing therapies to correct or improve these conduction abnormalities may improve cardiac function. 

In clinical practice, nitrates are used on a large scale in the treatment of ischaemic heart disease, in particular stable angina. Although very effective as a symptomatic measure, it remains unclear so far whether the prognosis of patients with stable angina is improved by nitrate treatment. Clinical trials addressing this question are ungoing. 

Richards M, Nicholls MG, Espiner EA, etal. Comparison of B-type natriuretic peptides for assessment of cardiac function and prognosis in stable ischemic heart disease. J Am Coll Cardiol 2006 47 52-60. 

The surface electrocardiography (ECG) in both acute and chronic phase of ischaemic heart disease (IHD) may give crucial information about the coronary artery involved and which is the area of myocardium that is at risk or already infarcted. This information jointly with the ECG-clinical correlation is very important for prognosis and risk stratification, as will be demonstrated in this book. Therefore, we will give in the following pages an overview of the anatomy of the heart, especially the heart walls and coronary tree, and emphasise the best techniques currently used for its study. 

This chapter will not cover the acute coronary syndromes as readers are referred to the accompanying chapter in this text. However, it should be evident that the occurrence of acute plaque rupture and thrombosis has a significant impact on the prognosis of a patient with chronic ischemic heart disease. Cardiogenic shock... 

Not surprisingly then, the effect of smoking cessation on the prognosis of patients with chronic ischemic heart disease is substantial. In one meta-analysis by Critchley and Capewell (113), smoking cessation in patients with established CHD resulted in a crude 36% reduction in crude relative risk of all-cause mortality. The crude risk reduction for nonfatal reinfarction was 32%. 

A review of additional comorbidities that can negatively impact the prognosis of patients with chronic ischemic heart disease is beyond the scope of this chapter. Nonetheless, aggressive management of comorbid conditions such as hypertension, diabetes, atrial fibrillation, renal insufficiency, and peripheral and cerebrovascular disease remain essential to optimizing the treatment of these patients. 

Altered thyroid hormone metabolism and prognosis in heart disease... 

Pyorala K, Pedersen TR, Kjekshus J, et al. Cholesterol lowering with simvastatin improves prognosis of diabetic patients with coronary heart disease. A subgroup analysis of the Scandinavian Simvastatin Survival Study (4S). Diabetes Care. 1997 20 614-620. 

Cardiovascniar In 95 patients with coronary heart disease and depression, who were randomized to sertraline (mean dosage 70 mg/day) or placebo over 20 weeks, sertraline significantly improved flow-dependent, endothelium-mediated dilatation of the brachial artery, while reducing the concentrations of C-reactive protein and interleukin-6 [17 ]. This suggests that sertraline has beneficial effects on the endothehum and immunological system, which could improve the prognosis of patients with depression and coronary heart disease. 

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