Vasodilation by urapidil in the treatment of chronic congestive heart failure in addition to angiotensin-converting enzyme inhibitors is not beneficial: results of a placebo-controlled, double-blind study

Do adrenergic alpha-antagonists increase the risk of poor cardiovascular outcomes? A systematic review and meta-analysis

Due to concerns regarding neurohormonal activation and fluid retention, adrenergic alpha-1 receptor antagonists (A1Bs) are generally avoided in the setting of heart disease, namely, symptomatic heart failure (HF) with reduced ejection fraction (HFrEF). However, this contraindication is mainly supported by ancient studies, having recently been challenged by newer ones. We aim to perform a comprehensive meta-analysis aimed at ascertaining the extent to which A1Bs might influence cardiovascular (CV) outcomes. We systematically searched PubMed, Cochrane Central Register of Controlled Trials and Web of Science for both prospective and retrospective studies, published until 1 December 2020, addressing the impact of A1Bs on both clinical outcomes-namely, acute heart failure (AHF), acute coronary syndrome (ACS), CV and all-cause mortality-and on CV surrogate measures, specifically left ventricular ejection fraction (LVEF) and exercise tolerance, by means of exercise duration. Both randomized controlled trials (RCTs) and studies including only HF patients were further investigated separately. Study-specific odds ratios (ORs) and mean differences (MDs) were pooled using traditional meta-analytic techniques, under a random-effects model. A record was registered in PROSPERO database, with the code number CRD42020181804. Fifteen RCTs, three non-randomized prospective and two retrospective studies, encompassing 32 851, 19 287, and 71 600 patients, respectively, were deemed eligible; 62 256 patients were allocated to A1B, on the basis of multiple clinical indications: chronic HF itself [14 studies, with 72 558 patients, including seven studies with 850 HFrEF or HF with mildly reduced ejection fraction (HFmrEF) patients], arterial hypertension (four studies, with 44 184 patients) and low urinary tract symptoms (two studies, with 6996 patients). There were 25 998 AHF events, 1325 ACS episodes, 955 CV deaths and 33 567 all-cause deaths. When considering only RCTs, A1Bs were, indeed, found to increase AHF risk (OR 1.78, [1.46, 2.16] 95% CI, P < 0.00001, i² 2%), although displaying no significant effect on neither ACS nor CV or all-cause mortality rates (OR 1.02, [0.91, 1.15] 95% CI, i² 0%; OR 0.95, [0.47, 1.91] 95% CI, i² 17%; OR 1.1, [0.84, 1.43] 95% CI, i² 17%, respectively). Besides, when only HF patients were evaluated, A1Bs revealed themselves neutral towards not only ACS, CV, and all-cause mortality events (OR 0.49, [0.1, 2.47] 95% CI, i² 0%; OR 0.7, [0.21, 2.31] 95% CI, i² 21%; OR 1.09, [0.53, 2.23] 95% CI, i² 17%, respectively), but also AHF (OR 1.13, [0.66, 1.92] 95% CI, i² 0%). As for HFrEF and HFmrEF, A1Bs were found to exert a similarly inconsequential effect on AHF rates (OR 1.01, [0.5-2.05] 95% CI, i² 6%). Likewise, LVEF was not significantly influenced by A1Bs (MD 1.66, [-2.18, 5.50] 95% CI, i² 58%). Most strikingly, exercise tolerance was higher in those under this drug class (MD 139.16, [65.52, 212.8] 95% CI, P < 0.001, i² 26%). A1Bs do not seem to exert a negative influence on the prognosis of HF-and even of HFrEF-patients, thus contradicting currently held views. These drugs' impact on other major CV outcomes also appear trivial and they may even increment exercise tolerance.

Quality of life assessment in heart failure interventions: a 10-year (1996–2005) review

The increasing prevalence and poor prognosis associated with heart failure have prompted research to focus on improving quality of life (QoL) for heart failure patients. Research from 1996–2005 was systematically reviewed to identify randomized controlled trials that assessed QoL in heart failure. In 120 studies, 44 were medication trials; 19 surgical/procedural interventions; and 57 patient care/service delivery interventions. Studies were summarized in terms of aim, population, QoL measures used and QoL findings. Studies used 47 different measures of QoL-generic, health-related, condition-specific, domain-specific and utility measures. Most used a single QoL measure. In 87%, a condition specific QoL measure was used, with the Minnesota Living with Heart Failure Questionnaire being the favoured assessment tool. The range of QoL measures in use poses challenges for development of cumulative knowledge. Although comparability across studies is important, this must be informed by the responsiveness of the instrument selected. As carried out in other cardiac groups, comparative evaluations of instrument responsiveness are needed in heart failure. Eur J Cardiovasc Prev Rehabil 14:589-607 © 2007 The European Society of Cardiology

What is the methodological and reporting quality of health related quality of life in chronic heart failure clinical trials?

BACKGROUND

Although the number of clinical trials assessing health related quality of life (HRQoL) in chronic heart failure (CHF) has increased exponentially over the last decade, little is known about the quality of reporting. The purpose of this review was to assess the methodological and reporting rigor of HRQoL in RCTs of pharmacological therapy in CHF.

METHODS

The electronic data bases, Medline and EMBASE were searched from 1990 to 2009 using the key search terms 'heart failure' combined with 'quality of life', 'pharmacological therapy' and 'randomized controlled trials'. A total of 136 articles were identified and evaluated according to the "Minimum Standard Checklist (MSC) for Evaluating HRQoL Outcomes".

RESULTS

According to the MSC criteria, 26 (19.1%) studies were considered 'very limited', 91 (66.9%) were 'limited' and only 19 (14.0%) studies were considered to be of a 'probably robust' in terms of methodological and reporting rigor. In fact, the quality of HRQoL reporting has not improved over time.

CONCLUSION

HRQoL is a critical consideration in CHF management, yet reporting is highly variable. There is a need to develop a standardized method for measuring and reporting HRQoL measures in clinical trials to aid in the interpretation and application of findings.

Health-related quality of life measurement in heart failure: challenges for the new millennium

Health-related quality of life (HRQL), representing a patient-driven end point, has been increasingly emphasized in randomized clinical trials of new heart failure therapies. Measurement of HRQL depends on the use of validated instruments, with attention paid to the timing of administration and analysis of data in the context of conventional morbidity and mortality end points. In a review of HRQL measurement in heart failure drug trials published from 1966 to 1999, we found that important data, such as the number of participating subjects, are often lacking. HRQL is analyzed as a stand-alone end point without consideration of the underlying clinical trajectory of the disease. Improvements in trials methodology are warranted if quality-of-life data are to be meaningful in the determination of drug efficacy in heart failure.