Additive beneficial effects of beta-blockers to angiotensin-converting enzyme inhibitors in the Survival and Ventricular Enlargement (SAVE) Study. SAVE Investigators

2025 AHA/ACC Clinical Performance and Quality Measures for Patients With Chronic Coronary Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures

Chronic coronary disease (CCD) is the leading cause of death in the United States. There is an ongoing imperative to disseminate evidence-based and patient-centered care recommendations that further align the management of patients with CCD to updated evidence-based guidelines. The writing committee developed a comprehensive CCD measure set comprising 10 performance measures and 3 quality measures, the focus of which is to include practical steps to specifically advance care in the CCD population. The measure set begins with an assessment of tobacco use and evidence-based cessation interventions. Also included are topics such as antiplatelet therapy, lipid assessment and low-density lipoprotein cholesterol goals, and guideline-directed management and therapy for hypertension and reduced left ventricular dysfunction in patients with CCD. The measure set concludes with an emphasis on the importance of cardiac rehabilitation referral and patient education, including symptom management and lifestyle modification.

2025 AHA/ACC Clinical Performance and Quality Measures for Patients With Chronic Coronary Disease: A Report of the American College of Cardiology/American Heart Association Joint Committee on Performance Measures

Chronic coronary disease (CCD) is the leading cause of death in the United States. There is an ongoing imperative to disseminate evidence-based and patient-centered care recommendations that further align the management of patients with CCD to updated evidence-based guidelines. The writing committee developed a comprehensive CCD measure set comprising 10 performance measures and 3 quality measures, the focus of which is to include practical steps to specifically advance care in the CCD population. The measure set begins with an assessment of tobacco use and evidence-based cessation interventions. Also included are topics such as antiplatelet therapy, lipid assessment and low-density lipoprotein cholesterol goals, and guideline-directed management and therapy for hypertension and reduced left ventricular dysfunction in patients with CCD. The measure set concludes with an emphasis on the importance of cardiac rehabilitation referral and patient education, including symptom management and lifestyle modification.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2025

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

Prevalence of undiagnosed stage B heart failure among emergency department patients

INTRODUCTION

Heart failure (HF) is associated with significant morbidity, mortality, and health care costs. Stage B HF is defined as structural heart disease prior to developing symptomatic HF. If identified early in the disease process, preventative measures may be implemented to slow disease progression to Stage C (symptomatic) or Stage D (refractory) HF. Previous research has focused on outpatient screening for HF in the primary care setting; however, there are limited data on Stage B HF screening in the Emergency Department (ED) setting. The objective of this study was to determine the prevalence of undiagnosed Stage B HF among those with cardiovascular risk factors in the ED setting and identify which risk factors were associated with a greater risk of having Stage B HF.

METHODS

A prospective, observational study was performed in a single, urban academic ED from 07/2023 to 05/2024. Inclusion criteria were age ≥ 45 years with hypertension, diabetes, obesity, coronary heart disease, previous cardiotoxic chemotherapy, or family history of HF. Exclusion criteria included signs or symptoms of HF, known history of HF, valvular disease, current atrial fibrillation, or primary language other than English. A focused cardiac ultrasound was performed and interpreted by ultrasound-fellowship trained emergency physicians. Sonographers assessed systolic function as ejection fraction <50 % using visual assessment in at least two different views. Sonographers assessed diastolic dysfunction as an E/A ratio < 0.8, or if ≥2 of the following were present: septal e' < 7 cm/s or lateral e' < 10 cm/s, E/e' ratio > 14, or left atrial volume > 34 mL/m2. Descriptive statistics were performed, followed by comparative analyses and regression modeling.

RESULTS

209 participants were included in the study, with a mean age of 60 years and 51.7 % women. Of these, 125 (59.8 %) had undiagnosed Stage B HF, with 13 (10.4 %) having systolic dysfunction and 112 (89.6 %) having isolated diastolic dysfunction. Among those with isolated diastolic dysfunction, 44 (39.3 %) were grade I, 66 (58.9 %) were grade II, and 2 (1.8 %) were grade III. Predictors of undiagnosed Stage B HF included age (odds ratio 1.06; 95 % CI 1.02 to 1.10) and BMI (odds ratio 1.06; 95 % CI 1.01 to 1.10).

CONCLUSION

A large majority of ED patients with cardiovascular risk factors had undiagnosed Stage B HF. Age and obesity were associated with a higher risk of Stage B HF. This provides an opportunity for early identification and intervention for patients with undiagnosed Stage B HF to reduce progression to more severe HF.

Comorbidity of patients with noncommunicable diseases in general practice. Eurasian guidelines

Создание руководства поддержано Советом по терапевтическим наукам отделения клинической медицины Российской академии наук.

Cardiovascular-kidney-metabolic syndrome — a new concept of the association of risk factors and metabolic disorders within the cardiovascular and renal continuum. View on the issue

In 2023, the American Heart Association for the first time formally defined cardiovascular-kidney-metabolic (CKM) syndrome as a systemic disease characterized by pathophysiological interactions between metabolic risk factors, chronic kidney disease (CKD), and cardiovascular system, leading to multiple organ dysfunction and a common adverse cardiovascular outcomes. Data are presented based on the pathophysiological mechanisms and clinical manifestations that made it possible to define this syndrome through the interaction between metabolic risk factors, CKD and the cardiovascular system, leading to multiple organ dysfunction and a high level of adverse cardiovascular outcomes. A classification of this syndrome into stages has been determined, for each of which approaches to the diagnosis and management of patients have been defined. CKM syndrome reflects the influence of multisystem pathophysiological relationships embedded in a multi-level socially and clinically determined community of manifestations, the fusion of which specifies clinical outcomes.

10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024

The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.

A Synopsis of the Evidence for the Science and Clinical Management of Cardiovascular-Kidney-Metabolic (CKM) Syndrome: A Scientific Statement From the American Heart Association

A growing appreciation of the pathophysiological interrelatedness of metabolic risk factors such as obesity and diabetes, chronic kidney disease, and cardiovascular disease has led to the conceptualization of cardiovascular-kidney-metabolic syndrome. The confluence of metabolic risk factors and chronic kidney disease within cardiovascular-kidney-metabolic syndrome is strongly linked to risk for adverse cardiovascular and kidney outcomes. In addition, there are unique management considerations for individuals with established cardiovascular disease and coexisting metabolic risk factors, chronic kidney disease, or both. An extensive body of literature supports our scientific understanding of, and approach to, prevention and management for individuals with cardiovascular-kidney-metabolic syndrome. However, there are critical gaps in knowledge related to cardiovascular-kidney-metabolic syndrome in terms of mechanisms of disease development, heterogeneity within clinical phenotypes, interplay between social determinants of health and biological risk factors, and accurate assessments of disease incidence in the context of competing risks. There are also key limitations in the data supporting the clinical care for cardiovascular-kidney-metabolic syndrome, particularly in terms of early-life prevention, screening for risk factors, interdisciplinary care models, optimal strategies for supporting lifestyle modification and weight loss, targeting of emerging cardioprotective and kidney-protective therapies, management of patients with both cardiovascular disease and chronic kidney disease, and the impact of systematically assessing and addressing social determinants of health. This scientific statement uses a crosswalk of major guidelines, in addition to a review of the scientific literature, to summarize the evidence and fundamental gaps related to the science, screening, prevention, and management of cardiovascular-kidney-metabolic syndrome.

The AHA/ACC/HFSA 2022 Heart Failure Guidelines: Changing the Focus to Heart Failure Prevention

The prevalence of heart failure (HF) in the United States (U.S.) is estimated at over 6 million adults, with the incidence continuing to increase. A large proportion of the U.S. population is also at risk of HF due to the high prevalence of established HF risk factors, such as hypertension, diabetes, and obesity. Many individuals have multiple risk factors, placing them at even higher risk. In addition, these risk factors disproportionately impact various racial and ethnic groups. Recognizing the rising health and economic burden of HF in the U.S., the 2022 American Heart Association / American College of Cardiology / Heart Failure Society of America (AHA/ACC/HFSA) Heart Failure Guideline placed a strong emphasis on prevention of HF. The purpose of this review is to highlight the role of both primary and secondary prevention in HF, as outlined by the recent guideline, and address the role of the preventive cardiology community in reducing the prevalence of HF in at-risk individuals.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease: A Report of the American Heart Association/American College of Cardiology Joint Committee on Clinical Practice Guidelines

AIM

The "2023 AHA/ACC/ACCP/ASPC/NLA/PCNA Guideline for the Management of Patients With Chronic Coronary Disease" provides an update to and consolidates new evidence since the "2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease" and the corresponding "2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease."

METHODS

A comprehensive literature search was conducted from September 2021 to May 2022. Clinical studies, systematic reviews and meta-analyses, and other evidence conducted on human participants were identified that were published in English from MEDLINE (through PubMed), EMBASE, the Cochrane Library, Agency for Healthcare Research and Quality, and other selected databases relevant to this guideline.

STRUCTURE

This guideline provides an evidenced-based and patient-centered approach to management of patients with chronic coronary disease, considering social determinants of health and incorporating the principles of shared decision-making and team-based care. Relevant topics include general approaches to treatment decisions, guideline-directed management and therapy to reduce symptoms and future cardiovascular events, decision-making pertaining to revascularization in patients with chronic coronary disease, recommendations for management in special populations, patient follow-up and monitoring, evidence gaps, and areas in need of future research. Where applicable, and based on availability of cost-effectiveness data, cost-value recommendations are also provided for clinicians. Many recommendations from previously published guidelines have been updated with new evidence, and new recommendations have been created when supported by published data.

Comparative Effectiveness of Long-Term Maintenance Beta-Blocker Therapy After Acute Myocardial Infarction in Stable, Optimally Treated Patients Undergoing Percutaneous Coronary Intervention

Background The benefits of long-term maintenance beta-blocker (BB) therapy in patients with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI) have not been well established. Methods and Results Using the Korean nationwide registry, a total of 7159 patients with AMI treated with PCI who received BBs at discharge and were free from death or cardiovascular events for 3 months after PCI were included in the analysis. Patients were divided into 4 groups according to BB maintenance duration: <12 months, 12 to <24 months, 24 to <36 months, and ≥36 months. The primary outcome was the composite of all-cause death, recurrent MI, heart failure, or hospitalization for unstable angina. During a mean 5.0±2.8 years of follow-up, over half of patients with AMI (52.5%) continued BB therapy beyond 3 years following PCI. After propensity score matching and propensity score marginal mean weighting through stratification, a stepwise inverse correlation was noted between BB duration and risk of the primary outcome (<12 months: hazard ratio [HR], 2.19 [95% CI, 1.95-2.46]; 12 to <24 months: HR, 2.10 [95% CI, 1.81-2.43];, and 24 to <36 months: HR, 1.68 [95%CI, 1.45-1.94]; reference: ≥36 months). In a 3-year landmark analysis, BB use for <36 months was associated with an increased risk of the primary outcome (adjusted HR, 1.59 [95% CI, 1.37-1.85]) compared with BB use for ≥36 months. Conclusions Among stabilized patients with AMI following PCI, longer maintenance BB therapy, especially for >36 months, was associated with better clinical outcomes. These findings might imply that a better prognosis can be expected if patients with AMI maintain BB therapy for ≥36 months after PCI. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02806102.

Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for adults with early (stage 1 to 3) non-diabetic chronic kidney disease

BACKGROUND

Chronic kidney disease (CKD) is a long-term condition that occurs as a result of damage to the kidneys. Early recognition of CKD is becoming increasingly common due to widespread laboratory estimated glomerular filtration rate (eGFR) reporting, raised clinical awareness, and international adoption of the Kidney Disease Improving Global Outcomes (KDIGO) classifications. Early recognition and management of CKD affords the opportunity to prepare for progressive kidney impairment and impending kidney replacement therapy and for intervention to reduce the risk of progression and cardiovascular disease. Angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) are two classes of antihypertensive drugs that act on the renin-angiotensin-aldosterone system. Beneficial effects of ACEi and ARB on kidney outcomes and survival in people with a wide range of severity of kidney impairment have been reported; however, their effectiveness in the subgroup of people with early CKD (stage 1 to 3) is less certain. This is an update of a review that was last published in 2011.

OBJECTIVES

To evaluate the benefits and harms of ACEi and ARB or both in the management of people with early (stage 1 to 3) CKD who do not have diabetes mellitus (DM).

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies up to 6 July 2023 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and Embase, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov.

SELECTION CRITERIA

Randomised controlled trials (RCTs) reporting the effect of ACEi or ARB in people with early (stage 1 to 3) CKD who did not have DM were selected for inclusion. Only studies of at least four weeks duration were selected. Authors independently assessed the retrieved titles and abstracts and, where necessary, the full text to determine which satisfied the inclusion criteria.

DATA COLLECTION AND ANALYSIS

Data extraction was carried out by two authors independently, using a standard data extraction form. The methodological quality of included studies was assessed using the Cochrane risk of bias tool. Data entry was carried out by one author and cross-checked by another. When more than one study reported similar outcomes, data were pooled using the random-effects model. Heterogeneity was analysed using a Chi² test and the I² test. Results were expressed as risk ratios (RR) and their 95% confidence intervals (CI) for dichotomous outcomes and mean difference (MD) and 95% CI for continuous outcomes. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach MAIN RESULTS: Six studies randomising 9379 participants with CKD stages 1 to 3 (without DM) met our inclusion criteria. Participants were adults with hypertension; 79% were male from China, Europe, Japan, and the USA. Treatment periods ranged from 12 weeks to three years. Overall, studies were judged to be at unclear or high risk of bias across all domains, and the quality of the evidence was poor, with GRADE rated as low or very low certainty. In low certainty evidence, ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo may make little or no difference to death (any cause) (2 studies, 8873 participants): RR 2.00, 95% CI 0.26 to 15.37; I² = 76%), total cardiovascular events (2 studies, 8873 participants): RR 0.97, 95% CI 0.90 to 1.05; I² = 0%), cardiovascular-related death (2 studies, 8873 participants): RR 1.73, 95% CI 0.26 to 11.66; I² = 54%), stroke (2 studies, 8873 participants): RR 0.76, 95% CI 0.56 to 1.03; I² = 0%), myocardial infarction (2 studies, 8873 participants): RR 1.00, 95% CI 0.84 to 1.20; I² = 0%), and adverse events (2 studies, 8873 participants): RR 1.33, 95% CI 1.26 to 1.41; I² = 0%). It is uncertain whether ACEi (benazepril 10 mg or trandolapril 2 mg) compared to placebo reduces congestive heart failure (1 study, 8290 participants): RR 0.75, 95% CI 0.59 to 0.95) or transient ischaemic attack (1 study, 583 participants): RR 0.94, 95% CI 0.06 to 15.01; I² = 0%) because the certainty of the evidence is very low. It is uncertain whether ARB (losartan 50 mg) compared to placebo (1 study, 226 participants) reduces: death (any-cause) (no events), adverse events (RR 19.34, 95% CI 1.14 to 328.30), eGFR rate of decline (MD 5.00 mL/min/1.73 m2, 95% CI 3.03 to 6.97), presence of proteinuria (MD -0.65 g/24 hours, 95% CI -0.78 to -0.52), systolic blood pressure (MD -0.80 mm Hg, 95% CI -3.89 to 2.29), or diastolic blood pressure (MD -1.10 mm Hg, 95% CI -3.29 to 1.09) because the certainty of the evidence is very low. It is uncertain whether ACEi (enalapril 20 mg, perindopril 2 mg or trandolapril 1 mg) compared to ARB (olmesartan 20 mg, losartan 25 mg or candesartan 4 mg) (1 study, 26 participants) reduces: proteinuria (MD -0.40, 95% CI -0.60 to -0.20), systolic blood pressure (MD -3.00 mm Hg, 95% CI -6.08 to 0.08) or diastolic blood pressure (MD -1.00 mm Hg, 95% CI -3.31 to 1.31) because the certainty of the evidence is very low.

AUTHORS' CONCLUSIONS

There is currently insufficient evidence to determine the effectiveness of ACEi or ARB in patients with stage 1 to 3 CKD who do not have DM. The available evidence is overall of very low certainty and high risk of bias. We have identified an area of large uncertainty for a group of patients who account for most of those diagnosed as having CKD.

Use of point-of-care ultrasound by internists to rapidly diagnose acute decompensated heart failure

Dyspnea is a common presenting complaint seen by hospitalists. The differential is broad, including life-threatening and less urgent etiologies. We report a 43-year-old male presenting to an inpatient medicine service with dyspnea in the setting of asthma, tobacco and occupational exposures, and no prior cardiac history. Use of point-of-care ultrasound (POCUS) immediately confirmed diagnosis of acute decompensated heart failure, allowing prompt decision making and care. Use of POCUS is widespread among emergency physicians and intensivists; however, use among medical students, internal medicine residents, and hospitalists remains variable. Increased use of POCUS by hospitalists may increase speed and accuracy of diagnosis.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021.

STRUCTURE

Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.

Clinical Profile and Prognosis of a Real-World Cohort of Patients With Moderate or Severe Cancer Therapy-Induced Cardiac Dysfunction

Introduction and Objectives: Cancer therapy-related cardiac dysfunction (CTRCD) is a common cause of cancer treatment withdrawal, related to the poor outcomes. The cardiac-specific treatment could recover the left ventricular ejection fraction (LVEF). We analyzed the clinical profile and prognosis of patients with CTRCD in a real-world scenario. Methods: A retrospective study that include all the cancer patients diagnosed with CTRCD, defined as LVEF < 50%. We analyzed the cardiac and oncologic treatments, the predictors of mortality and LVEF recovery, hospital admission, and the causes of mortality (cardiovascular (CV), non-CV, and cancer-related). Results: We included 113 patients (82.3% women, age 49.2 ± 12.1 years). Breast cancer (72.6%) and anthracyclines (72.6%) were the most frequent cancer and treatment. Meantime to CTRCD was 8 months, with mean LVEF of 39.4 ± 9.2%. At diagnosis, 27.4% of the patients were asymptomatic. Cardiac-specific treatment was started in 66.4% of patients, with LVEF recovery-rate of 54.8%. Higher LVEF at the time of CTRCD, shorter time from cancer treatment to diagnosis of CTRCD, and younger age were the predictors of LVEF recovery. The hospitalization rate was 20.4% (8.8% linked to heart failure). Treatment with trastuzumab and lower LVEF at diagnosis of CTRCD were the predictors of mortality. Thirty point nine percent of patients died during the 26 months follow-up. The non-CV causes and cancer-related were more frequent than CV ones. Conclusions: Cardiac-specific treatment achieves LVEF recovery in more than half of the patients. LVEF at the diagnosis of CTRCD, age, and time from the cancer treatment initiation to CTRCD were the predictors of LVEF recovery. The CV-related deaths were less frequent than the non-CV ones. Trastuzumab treatment and LVEF at the time of CTRCD were the predictors of mortality.

Metformin in the era of new antidiabetics

Type II diabetes mellitus is a known cardiovascular risk factor and its prevalence continues to increase. A revolution in the Type II diabetes mellitus treatment has occurred with the arrival of new antidiabetic drugs, which are thought to compromise metformin place. We aim to review the pharmacology, available evidence and clinical aspects of metformin use in the era of new antidiabetics.

Autonomic Modulation for Cardiovascular Disease

Dysfunction of the autonomic nervous system has been implicated in the pathogenesis of cardiovascular disease, including congestive heart failure and cardiac arrhythmias. Despite advances in the medical and surgical management of these entities, progression of disease persists as does the risk for sudden cardiac death. With improved knowledge of the dynamic relationships between the nervous system and heart, neuromodulatory techniques such as cardiac sympathetic denervation and vagal nerve stimulation (VNS) have emerged as possible therapeutic approaches for the management of these disorders. In this review, we present the structure and function of the cardiac nervous system and the remodeling that occurs in disease states, emphasizing the concept of increased sympathoexcitation and reduced parasympathetic tone. We review preclinical evidence for vagal nerve stimulation, and early results of clinical trials in the setting of congestive heart failure. Vagal nerve stimulation, and other neuromodulatory techniques, may improve the management of cardiovascular disorders, and warrant further study.

Heart failure after myocardial infarction: incidence and predictors

Aims

The aim of the present paper was to provide an up‐to‐date view on epidemiology and risk factors of heart failure (HF) development after myocardial infarction.

Methods and results

Based on literature review, several clinical risk factors and biochemical, genetic, and imaging biomarkers were identified to predict the risk of HF development after myocardial infarction.

Conclusions

Heart failure is still a frequent complication of myocardial infarction. Timely identification of subjects at risk for HF development using a multimodality approach, and early initiation of guideline‐directed HF therapy in these patients, can decrease the HF burden.

Point-of-care Echocardiogram as the Key to Rapid Diagnosis of a Unique Presentation of Dyspnea: A Case Report

INTRODUCTION

Dyspnea is commonly evaluated in the emergency department (ED).The differential diagnosis is broad. Due to the large volume of dyspneic patients evaluated, emergency physicians (EP) will encounter uncommon diagnoses. Early, liberal application of point-of-care ultrasound (POCUS) may decrease diagnostic error and improve care for these patients.

CASE REPORT

We report a 48-year-old male presenting to the ED with cough and progressively worsening dyspnea for 11 months after multiple healthcare visits. Using POCUS, the EP was immediately able to diagnose a severe dilated cardiomyopathy (DCM) with left ventricular thrombus.

CONCLUSION

Given that non-ischemic DCM is one of the most common etiologies of heart failure, often presenting with respiratory symptoms, POCUS is key to rapid diagnosis and, along with modalities such as electrocardiography and chest radiograph, should be standard practice in the workup of dyspnea, regardless of age or comorbidities.

Pharmacological interventions for heart failure in people with chronic kidney disease

BACKGROUND

Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD.

OBJECTIVES

This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD.

SEARCH METHODS

We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov.

SELECTION CRITERIA

We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration.

DATA COLLECTION AND ANALYSIS

Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence.

MAIN RESULTS

One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies.

AUTHORS' CONCLUSIONS

The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.

Asymptomatic Left Ventricular Diastolic Dysfunction: Predicting Progression to Symptomatic Heart Failure

Asymptomatic left ventricular diastolic dysfunction (ALVDD) (diastolic abnormalities and normal ejection fraction in the absence of symptoms) is associated with incident heart failure (HF) and decreased survival. Abnormalities of diastolic function might therefore be included in the definition of stage B HF, which denotes individuals at risk for the development of HF. Imaging techniques, especially echocardiography, are necessary for the recognition of preclinical left ventricular (LV) diastolic disturbances, as well as further tracking of pathological changes and responses to treatment. The transition of ALVDD to symptomatic HF is underlain by multiple factors, including both cardiovascular and noncardiovascular determinants. The initiation of management strategies targeting cardiovascular and systemic comorbidities in patients identified as having ALVDD may delay symptomatic progression and improve prognosis.

Predictors of Left Ventricular Remodeling After Myocardial Infarction in Patients With a Patent Infarct Related Coronary Artery After Percutaneous Coronary Intervention (from the Post-Myocardial Infarction Remodeling Prevention Therapy [PRomPT] Trial)

Left ventricular (LV) remodeling after myocardial infarction (MI) is a strong predictor of heart failure and mortality. The predictors of long-term remodeling after MI have been incompletely studied. We therefore examined the correlates of LV remodeling in patients with large ST-segment elevation myocardial infarction and a patent infarct artery after percutaneous 2coronary intervention (PCI) from the randomized Post-Myocardial Infarction Remodeling Prevention Therapy trial. Peri-infarct pacing had a neutral effect on long-term remodeling in patients with large first MI. The present analysis includes 109 patients in whom an open artery was restored after PCI, and in whom LV end-diastolic volume (LVEDV) at baseline and 18 months was assessed by transthoracic echocardiography. Multivariable models were fit to identify the independent predictors of LVEDV at baseline and 18 months. By multivariable analysis, male sex (p = 0.004) and anterior MI location (p = 0.03) were independently associated with baseline LVEDV. The following variables were independent predictors of increased LVEDV at 18 months: younger age (p = 0.01), male sex (p = 0.03), peak creatine phosphokinase (p = 0.03), shorter time from MI to baseline transthoracic echocardiography (p = 0.04), baseline LVEDV (p < 0.0001), and lack of statin use (p = 0.03). In conclusion, patients with large MI and an open infarct artery after PCI, anterior MI location, and male sex were associated with greater baseline LVEDV, but MI location was not associated with 18-month LVEDV. In contrast, younger age, peak creatine phosphokinase, male sex, baseline LVEDV, and lack of statin use were associated with long-term LV remodeling.

The Initial Evaluation and Management of a Patient with Heart Failure

PURPOSE OF REVIEW

The goal of this review is to summarize and discuss a thorough and effective manner in the evaluation of the patient with heart failure.

RECENT FINDINGS

Heart failure is a prevalent disease worldwide and while the diagnosis of heart failure has remained relatively unchanged via a careful history and physical examination, identification of the etiology of the heart failure and treatment has made significant advances. Mechanical circulatory support (MCS), neprilysin inhibitors, and chronic resynchronization therapy (CRT) are just some of the relatively recent therapies afforded to assist heart failure patients. Heart failure is a complicated, multifactorial diagnosis that requires a careful history and physical for diagnosis with the support of laboratory tests. While the prognosis for heart failure patients remains poor in comparison to other cardiovascular disease and even certain cancers, new advancements in therapy have shown survival and quality of life improvement.

Treatment of Heart Failure with Abnormal Left Ventricular Systolic Function in Older Adults

Heart failure (HF) with abnormal left ventricular (LV) ejection fraction should be identified and treated. Treat hypertension with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Treat myocardial ischemia with nitrates and β-blockers. Treat volume overload and HF with diuretics. Treat HF with ACE inhibitors and β-blockers. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in chronic symptomatic HF and abnormal LV ejection fraction. Add isosorbide dinitrate/hydralazine in African Americans with class II to IV HF treated with diuretics, ACE inhibitors, and β-blockers. Exercise training is recommended. Indications for implantable cardioverter-defibrillator and cardiac resynchronization therapy are discussed.

Current treatment of heart failure with reduction of left ventricular ejection fraction

Heart failure is the commonest cause of hospitalization and of rehospitalization This review paper is a comprehensive review of current treatment of heart failure in 2016. The target of this review is all health care professionals who treat patients with heart failure. Areas covered: This article discusses stages of heart failure, treatment of heart failure with general measures, and drug therapy with diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta blockers, aldosterone antagonists, isosorbide dinitrate plus hydralazine, digoxin, other neurohormonal antagonists, sacubitril/valsartan, calcium channel blockers, and ivabradine. This article also discusses treatment of heart failure with use of cardiac resynchronization therapy, implantable cardioverter-defibrillators, and surgical therapy, and management of end-stage heart failure. This paper was written after an extensive Medline search reviewing articles written from 1970 through May, 2016. Expert commentary: Our approach as physicians must emphasize prevention of heart failure as well as treating it. Risk factors for developing heart failure, especially hypertension, must be better controlled starting in childhood. I concur with the current heart failure treatment guidelines (Tables 1 and 2 in this paper).

Update of treatment of heart failure with reduction of left ventricular ejection fraction

Underlying and precipitating causes of heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) should be identified and treated when possible. Hypertension should be treated with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Diuretics are the first-line drugs in the treatment of patients with HFrEF and volume overload. Angiotensin-converting enzyme inhibitors and β-blockers (carvedilol, sustained-release metoprolol succinate, or bisoprolol) should be used in treatment of HFrEF. Use an angiotensin II receptor blocker (ARB) (candesartan or valsartan) if intolerant to ACE inhibitors because of cough or angioneurotic edema. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF class II or III to further reduce morbidity and mortality. Add an aldosterone antagonist (spironolactone or eplerenone) in selected patients with class II-IV HF who can be carefully monitored for renal function and potassium concentration. (Serum creatinine should be ≤ 2.5 mg/dl in men and ≤ 2.0 mg/dl in women. Serum potassium should be < 5.0 mEq/l). Add isosorbide dinitrate plus hydralazine in patients self-described as African Americans with class II-IV HF being treated with diuretics, ACE inhibitors, and β-blockers. Ivabradine can be used in selected patients with HFrEF.

Anthracycline-Induced Cardiomyopathy in Adults

Anthracyclines are one of the most commonly used antineoplastic agent classes, and a core part of the treatment in breast cancers, hematological malignancies, and sarcomas. Their benefit is decreased by their well-recognized cardiotoxicity. The purpose of this review is to outline the presentation, mechanisms, diagnosis, and treatment of anthracyclines-induced cardiotoxicity. Symptomatic heart failure occurs in 2% to 5% of patients treated with anthrayclines and may be higher in older patients or patients with cardiovascular risk factors. The mechanisms involved in anthracycline-induced cardiotoxicity involve myocyte loss by apoptosis in the presence of a limited regenerative capacity. Once symptomatic, anthracycline-induced cardiotoxicity is associated with markedly decreased survival. Left ventricular ejection fraction (LVEF), mostly determined using echocardiography, is used to monitor patients treated with anthracyclines. As more than 1/3 of patients treated with anthracyclines do not recover their baseline LVEF once it is decreased, more sensitive echocardiographic indices of LV function such as myocardial deformation or biomarkers have been studied in patients monitoring. Cardioprotective treatments such as angiotensin-converting enzyme inhibitors, beta-blockers, iron chelators, statins, and metformin are also the topic of research efforts.

Effect of Beta Blockers and Renin-Angiotensin System Inhibitors on Survival in Patients With Acute Myocardial Infarction Undergoing Percutaneous Coronary Intervention

Because it remains uncertain whether β-blockers (BBs) and/or renin-angiotensin system inhibitors benefit a broad population of acute myocardial infarction (AMI) patients, we sought to evaluate the effectiveness of these drugs in improving survival for post-AMI patients who underwent a percutaneous coronary intervention (PCI).From the nationwide data of the South Korea National Health Insurance, 33,390 patients with a diagnosis of AMI who underwent a PCI between 2009 and 2013 and survived at least 30 days were included in this study. We evaluated the risk of all-cause death for patients treated with both BB and angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor antagonist (ARB) (n = 16,280), only BB (n = 3683), and only ACEI/ARB (n = 9849), with the drug-untreated patients (n = 3578) as the reference.Over a median follow-up of 2.4 years, although treated patients displayed a trend toward improved survival, there were no significant differences in the adjusted risk of all-cause death when patients were treated with both drugs (hazard ratio [HR] 0.86, 95% confidence interval [CI] 0.70-1.06, P = 0.154), BB (HR 0.88, 95% CI 0.68-1.14, P = 0.325), or ACEI/ARB (HR 0.84, 95% CI 0.68-1.04, P = 0.111). No additional benefit was found for the combination therapy compared with either isolated BB (HR 0.98, 95% CI 0.80-1.21, P = 0.856) or ACEI/ARB (HR 1.03, 95% CI 0.89-1.19, P = 0.727) therapy.Treatment with BB and/or ACEI/ARB has limited effect on survival in unselected nonfatal AMI patients who undergo PCI.

Gaps and Resemblances in Current Heart Failure Guidelines: A Clinical Perspective

The newly available clinical guidelines in heart failure (HF) from Europe (2012), the United States (2010 and 2013), and Canada (2015) were compared, focusing on the systems for grading the evidence and classifying the recommendations, HF definitions, pharmacologic treatment, and devices used in HF. Some gaps were evident in the methodology for assessing evidence or in HF definitions. Pharmacologic treatments and recommendations for cardiac resynchronization therapy and implantable cardioverter-defibrillators are similar but some differences need to be considered by the practicing clinician. Guideline recommendations regarding new emergent treatments are becoming available.

Clinical outcomes following percutaneous coronary intervention before and after introduction of drug-eluting stent

Drug-eluting stents (DES) have demonstrated safety and efficacy in clinical outcomes, especially reduced rate of revascularization. However, it remains unknown whether clinical outcomes related to mortality improved after the introduction of DES. We sought to examine clinical outcomes including all-cause mortality, cardiovascular and non-cardiovascular death in pre-DES and DES eras. This was a single-center retrospective study including patients who underwent percutaneous coronary intervention (PCI) from August 1997 and June 2011. Study population was divided into two groups according to the time period of PCI (August 1997 to July 2004; pre-DES era, August 2004 to June 2011; DES era). The primary endpoint was all-cause mortality and secondary endpoints were cardiovascular and non-cardiovascular mortality. These endpoints were evaluated 3 years after PCI. A total of consecutive 3361 patients from our PCI cohort were analyzed. Patients in DES era were more likely to have traditional risk factors and angiographic disadvantages. The incidence of the primary endpoint was comparable between the two groups (p = 0.053). Cardiovascular and non-cardiovascular mortality were also similar between the groups (p = 0.1 and p = 0.2, respectively). Importantly, non-cardiovascular mortality accounted for over 60% of all-cause mortality in both eras. DES era was not associated with 3-year all-cause mortality, whereas DES use was associated with a reduction in 3-year cardiovascular mortality (HR 0.16, 95% CI 0.010-0.9, p = 0.035). All-cause mortality, cardiovascular and non-cardiovascular mortality at three years were comparable between pre-DES and DES era, despite the higher risk profiles of patients in DES era.

Role of the Renin-Angiotensin-Aldosterone System and Its Pharmacological Inhibitors in Cardiovascular Diseases: Complex and Critical Issues

Hypertension is one of the major risk factor able to promote development and progression of several cardiovascular diseases, including left ventricular hypertrophy and dysfunction, myocardial infarction, stroke, and congestive heart failure. Also, it is one of the major driven of high cardiovascular risk profile in patients with metabolic complications, including obesity, metabolic syndrome and diabetes, as well as in those with renal disease. Thus, effective control of hypertension is a key factor for any preventing strategy aimed at reducing the burden of hypertension-related cardiovascular diseases in the clinical practice. Among various regulatory and contra-regulatory systems involved in the pathogenesis of cardiovascular and renal diseases, renin-angiotensin system (RAS) plays a major role. However, despite the identification of renin and the availability of various assays for measuring its plasma activity, the specific pathophysiological role of RAS has not yet fully characterized. In the last years, however, several notions on the RAS have been improved by the results of large, randomized clinical trials, performed in different clinical settings and in different populations treated with RAS inhibiting drugs, including angiotensin converting enzyme (ACE) inhibitors and antagonists of the AT1 receptor for angiotensin II (ARBs). These findings suggest that the RAS should be considered to have a central role in the pathogenesis of different cardiovascular diseases, for both therapeutic and preventive purposes, without having to measure its level of activation in each patient. The present document will discuss the most critical issues of the pathogenesis of different cardiovascular diseases with a specific focus on RAS blocking agents, including ACE inhibitors and ARBs, in the light of the most recent evidence supporting the use of these drugs in the clinical management of hypertension and hypertension-related cardiovascular diseases.

Clinical prediction of incident heart failure risk: a systematic review and meta-analysis

BACKGROUND

Early treatment may alter progression to overt heart failure (HF) in asymptomatic individuals with stage B HF (SBHF). However, the identification of patients with SBHF is difficult. This systematic review sought to examine the strength of association of clinical factors with incident HF, with the intention of facilitating selection for HF screening.

METHODS

Electronic databases were systematically searched for studies reporting risk factors for incident HF. Effect sizes, typically HRs, of each risk variable were extracted. Pooled crude and adjusted HRs with 95% CIs were computed for each risk variable using a random-effects model weighted by inverse variance.

RESULTS

Twenty-seven clinical factors were identified to be associated with risk of incident HF in 15 observational studies in unselected community populations which followed 456 850 participants over 4-29 years. The strongest independent associations for incident HF were coronary artery disease (HR=2.94; 95% CI 1.36 to 6.33), diabetes mellitus (HR=2.00; 95% CI 1.68 to 2.38), age (HR (per 10 years)=1.80; 95% CI 1.13 to 2.87) followed by hypertension (HR=1.61; 95% CI 1.33 to 1.96), smoking (HR=1.60; 95% CI 1.45 to 1.77), male gender (HR=1.52; 95% CI 1.24 to 1.87) and body mass index (HR (per 5 kg/m(2))=1.15; 95% CI 1.06 to 1.25). Atrial fibrillation (HR=1.88; 95% CI 1.60 to 2.21), left ventricular hypertrophy (HR=2.46; 95% CI 1.71 to 3.53) and valvular heart disease (HR=1.74; 95% CI 1.07 to 2.84) were also strongly associated with incident HF but were not examined in sufficient papers to provide pooled hazard estimates.

CONCLUSIONS

Prediction of incident HF can be calculated from seven common clinical variables. The risk associated with these may guide strategies for the identification of high-risk people who may benefit from further evaluation and intervention.

Recommendations for cardiomyopathy surveillance for survivors of childhood cancer: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group

Survivors of childhood cancer treated with anthracycline chemotherapy or chest radiation are at an increased risk of developing congestive heart failure. In this population, congestive heart failure is well recognised as a progressive disorder, with a variable period of asymptomatic cardiomyopathy that precedes signs and symptoms. As a result, several clinical practice guidelines have been developed independently to help with detection and treatment of asymptomatic cardiomyopathy. These guidelines differ with regards to definitions of at-risk populations, surveillance modality and frequency, and recommendations for interventions. Differences between these guidelines could hinder the effective implementation of these recommendations. We report on the results of an international collaboration to harmonise existing cardiomyopathy surveillance recommendations using an evidence-based approach that relied on standardised definitions for outcomes of interest and transparent presentation of the quality of the evidence. The resultant recommendations were graded according to the quality of the evidence and the potential benefit gained from early detection and intervention.

Stage B: what is the evidence for treatment of asymptomatic left ventricular dysfunction?

Although patients with American College of Cardiology / American Heart Association (ACC/AHA) Stage B heart failure, or asymptomatic left ventricular dysfunction (ALVD) are at high risk for developing symptomatic heart failure, few management strategies have been shown to slow disease state progression or improve long-term morbidity and mortality. Of the pharmacologic therapies utilized in patients with symptomatic disease, only angiotensin converting enzyme (ACE) inhibitors (and to a lesser extent, angiotensin receptor blockers, or ARBs) have been shown to improve clinical outcomes among patients with ALVD. Although evidence to support the use of beta blockers in this setting has been primarily derived from retrospective studies or subgroup analyses, they are generally recommended in most patients with ALVD, especially those with ischemic etiology. Statins are associated with improvements in both major adverse cardiovascular events and heart failure events among patients with a history of acute myocardial infarction. Finally, in eligible patients, placement of an automatic implantable cardioverter defibrillator (ICD) has been associated with reduced mortality rates among those with ALVD due to ischemic cardiomyopathy, and some subgroups may derive benefit from cardiac resynchronization therapy or biventricular pacing.

Screening for cardiac dysfunction in anthracycline-exposed childhood cancer survivors

PURPOSE

To examine the utility and reliability of obtaining early echocardiographic measurements of left ventricular (LV) remodeling as well as blood biomarkers of cardiac injury in asymptomatic childhood cancer survivors at risk for LV dysfunction and congestive heart failure due to past exposure to anthracycline chemotherapy.

EXPERIMENTAL DESIGN

Using a cross-sectional design, anthracycline-exposed childhood cancer survivors with preserved ejection fraction (EF; ≥50%) were evaluated using early echocardiographic indices and blood biomarkers of LV dysfunction. Survivors treated with ≥300 mg/m(2) anthracyclines [high risk (HR): n = 100] were compared with those treated with <300 mg/m(2) anthracyclines [low risk (LR): n = 50] and matched healthy controls (HC: n = 50). All echocardiograms were interpreted by an institutional cardiologist and a study cardiologist blinded to risk status.

RESULTS

Time from diagnosis was comparable for HR (12.0 years) and LR (13.2 years, P = 0.8) survivors. Echocardiograms: HR had lower LV thickness-dimension ratio (Z-score: HR: -0.62, LR: -0.03, HC: -0.02; P < 0.001), increased LV wall stress (HR: 66.7 g/cm(2), LR: 56.6 g/cm(2), HC: 54.2 g/cm(2); P < 0.01), and higher myocardial performance index (HR: 0.51, LR: 0.46, HC: 0.46; P < 0.01). Interobserver correlation (clinical/blinded reading) for all echocardiographic indices was excellent (range: R = 0.76-0.97, P < 0.001). Blood biomarkers: With the exception of NT-proBNP (r = 0.28, P < 0.01), there was no correlation between blood biomarkers (B-type natriuretic peptide, Troponin-T, ST-2, Galectin-3) and LV dysfunction.

CONCLUSION

Childhood cancer survivors with preserved EF 10+ years from anthracycline exposure had dose-dependent changes in echocardiographic markers of LV dysfunction.

Trends in cause of death after percutaneous coronary intervention

BACKGROUND

The impact of changing demographics on causes of long-term death after percutaneous coronary intervention (PCI) remains incompletely defined.

METHODS AND RESULTS

We evaluated trends in cause-specific long-term mortality after index PCI performed at a single center from 1991 to 2008. Deaths were ascertained by scheduled prospective surveillance. Cause was determined via telephone interviews, medical records, autopsy reports, and death certificates. Competing-risks analysis of cause-specific mortality was performed using 3 time periods of PCI (1991-1996, 1997-2002, and 2003-2008). Final follow-up was December 31, 2012. A total of 19 077 patients survived index PCI hospitalization, of whom 6988 subsequently died (37%, 4.48 per 100 person-years). Cause was determined in 6857 (98.1%). Across 3 time periods, there was a 33% decline in cardiac deaths at 5 years after PCI (incidence: 9.8%, 7.4%, and 6.6%) but a 57% increase in noncardiac deaths (7.1%, 8.5%, and 11.2%). Only 36.8% of deaths in the recent era were cardiac. Similar trends were observed regardless of age, extent of coronary disease, or PCI indication. After adjustment for baseline variables, there was a 50% temporal decline in cardiac mortality but no change in noncardiac mortality. The decline in cardiac mortality was driven by fewer deaths from myocardial infarction/sudden death (P<0.001) but not heart failure (P=0.85). The increase in noncardiac mortality was primarily attributable to cancer and chronic diseases (P<0.001).

CONCLUSIONS

This study found a marked temporal switch from predominantly cardiac to predominantly noncardiac causes of death after PCI over 2 decades. The decline in cardiac mortality was independent of changes in baseline clinical characteristics. These findings have implications for patient care and clinical trial design.

Antihypertensive strategy based on angiotensin II receptor blockers: a new gateway to reduce risk in hypertension

Effective treatment of high blood pressure levels represents a key strategy for reducing global cardiovascular risk. Other factors, beyond blood pressure control, however, appear to be of potential relevance in reducing the risk related to hypertension. Recent clinical trials have demonstrated that those pharmacological agents that counteract the renin-angiotensin system may confer additional clinical benefits across the spectrum of cardiovascular disease, beyond their blood pressure-lowering properties. These studies are largely based on the use of an antihypertensive strategy, based on the association between angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers (ARBs) and low-dose thiazide diuretics or calcium channel blockers. Over the last few decades, clinical trials have also tested the potential effects of combination therapy based on the association between angiotensin-converting enzyme inhibitors or ARBs and other renin-angiotensin system-blocking agents, including mineralocorticoid receptor antagonists and, more recently, renin inhibitors. This review highlights the evidence derived from recent clinical trials, supporting a role for pharmacological strategies based on ARBs in primary and secondary prevention of cardiovascular and renal disease.