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Tang J, Wang P, Liu C, Peng J, Liu Y, Ma Q. Pharmacotherapy in patients with heart failure with reduced ejection fraction: A systematic review and meta-analysis. Chin Med J (Engl) 2024:00029330-990000000-01087. [PMID: 38811344 DOI: 10.1097/cm9.0000000000003118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2023] [Indexed: 05/31/2024] Open
Abstract
BACKGROUND Angiotensin receptor neprilysin inhibitors (ARNIs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), β-blockers (BBs), and mineralocorticoid receptor antagonists (MRAs) are the cornerstones in treating heart failure with reduced ejection fraction (HFrEF). Sodium-glucose cotransporter 2 inhibitors (SGLT-2is) are included in HFrEF treatment guidelines. However, the effect of SGLT-2i and the five drugs on HFrEF have not yet been systematically evaluated. METHODS PubMed, Embase, and the Cochrane Library were searched for randomized controlled trials (RCTs) from inception dates to September 23, 2022. Additional trials from previous relevant reviews and references were also included. The primary outcomes were changes in left ventricular ejection fraction (LVEF), left ventricular end-diastolic diameter/dimension (LVEDD), left ventricular end-systolic diameter/dimension (LVESD), left ventricular end-diastolic volume (LVEDV), and left ventricular end-systolic volume (LVESV), left ventricular end-systolic volume index (LVESVI), and left ventricular end-diastolic volume index (LVEDVI). Secondary outcomes were New York Heart Association (NYHA) class, 6-min walking distance (6MWD), B-type natriuretic peptide (BNP) level, and N-terminal pro-BNP (NT-proBNP) level. The effect sizes were presented as the mean difference (MD) with 95% confidence interval (CI). RESULTS We included 68 RCTs involving 16,425 patients. Compared with placebo, ARNI + BB + MRA + SGLT-2i was the most effective combination to improve LVEF (15.63%, 95% CI: 9.91% to 21.68%). ARNI + BB + MRA + SGLT-2i (5.83%, 95% CI: 0.53% to 11.14%) and ARNI + BB + MRA (3.83%, 95% CI: 0.72% to 6.90%) were superior to the traditional golden triangle "ACEI + BB + MRA" in improving LVEF. ACEI + BB + MRA + SGLT-2i was better than ACEI + BB + MRA (-8.05 mL/m2, 95% CI: -14.88 to -1.23 mL/m2) and ACEI + BB + SGLT-2i (-18.94 mL/m2, 95% CI: -36.97 to -0.61 mL/m2) in improving LVEDVI. ACEI + BB + MRA + SGLT-2i (-3254.21 pg/mL, 95% CI: -6242.19 to -560.47 pg/mL) was superior to ARB + BB + MRA in reducing NT-proBNP. CONCLUSIONS Adding SGLT-2i to ARNI/ACEI + BB + MRA is beneficial for reversing cardiac remodeling. The new quadruple drug "ARNI + BB + MRA + SGLT-2i" is superior to the golden triangle "ACEI + BB + MRA" in improving LVEF. REGISTRATION PROSPERO; No. CRD42022354792.
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Affiliation(s)
- Jia Tang
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan 410008, China
| | - Ping Wang
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan 410008, China
| | - Chenxi Liu
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan 410008, China
| | - Jia Peng
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan 410008, China
| | - Yubo Liu
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan 410008, China
| | - Qilin Ma
- Department of Cardiovascular Medicine, Xiangya Hospital, Central South University, Changsha, Hunan 410008, China
- National Clinical Research Center for Geriatric Disorders, Xiangya Hospital, Changsha, Hunan 410008, China
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Beavers CJ, Ambrosy AP, Butler J, Davidson BT, Gale SE, Piña IL, Mastoris I, Reza N, Mentz RJ, Lewis GD. Iron Deficiency in Heart Failure: A Scientific Statement from the Heart Failure Society of America. J Card Fail 2023; 29:1059-1077. [PMID: 37137386 DOI: 10.1016/j.cardfail.2023.03.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Revised: 03/10/2023] [Accepted: 03/23/2023] [Indexed: 05/05/2023]
Abstract
Iron deficiency is present in approximately 50% of patients with symptomatic heart failure and is independently associated with worse functional capacity, lower quality of, life and increased mortality. The purpose of this document is to summarize current knowledge of how iron deficiency is defined in heart failure and its epidemiology and pathophysiology, as well as pharmacological considerations for repletion strategies. This document also summarizes the rapidly expanding array of clinical trial evidence informing when, how, and in whom to consider iron repletion.
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Affiliation(s)
- Craig J Beavers
- University of Kentucky College of Pharmacy, Lexington, Kentucky.
| | - Andrew P Ambrosy
- Kaiser Permanente Northern California - Division of Research (DOR), Oakland, CA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; University of Mississippi, Jackson, Mississippi
| | - Beth T Davidson
- Centennial Heart Cardiovascular Consultants, Nashville, Tennessee
| | - Stormi E Gale
- Novant Health Matthews Medical Center, Matthews, North Carolina
| | - Ileana L Piña
- Thomas Jefferson University, Philadelphia, Pennsylvania
| | | | - Nosheen Reza
- Division of Cardiovascular Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert J Mentz
- Duke University School of Medicine, Durham, North Carolina
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Hafkamp FJ, Tio RA, Otterspoor LC, de Greef T, van Steenbergen GJ, van de Ven ART, Smits G, Post H, van Veghel D. Optimal effectiveness of heart failure management - an umbrella review of meta-analyses examining the effectiveness of interventions to reduce (re)hospitalizations in heart failure. Heart Fail Rev 2022; 27:1683-1748. [PMID: 35239106 PMCID: PMC8892116 DOI: 10.1007/s10741-021-10212-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) is a major health concern, which accounts for 1-2% of all hospital admissions. Nevertheless, there remains a knowledge gap concerning which interventions contribute to effective prevention of HF (re)hospitalization. Therefore, this umbrella review aims to systematically review meta-analyses that examined the effectiveness of interventions in reducing HF-related (re)hospitalization in HFrEF patients. An electronic literature search was performed in PubMed, Web of Science, PsycInfo, Cochrane Reviews, CINAHL, and Medline to identify eligible studies published in the English language in the past 10 years. Primarily, to synthesize the meta-analyzed data, a best-evidence synthesis was used in which meta-analyses were classified based on level of validity. Secondarily, all unique RCTS were extracted from the meta-analyses and examined. A total of 44 meta-analyses were included which encompassed 186 unique RCTs. Strong or moderate evidence suggested that catheter ablation, cardiac resynchronization therapy, cardiac rehabilitation, telemonitoring, and RAAS inhibitors could reduce (re)hospitalization. Additionally, limited evidence suggested that multidisciplinary clinic or self-management promotion programs, beta-blockers, statins, and mitral valve therapy could reduce HF hospitalization. No, or conflicting evidence was found for the effects of cell therapy or anticoagulation. This umbrella review highlights different levels of evidence regarding the effectiveness of several interventions in reducing HF-related (re)hospitalization in HFrEF patients. It could guide future guideline development in optimizing care pathways for heart failure patients.
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Affiliation(s)
| | - Rene A. Tio
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | - Luuk C. Otterspoor
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | - Tineke de Greef
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | | | - Arjen R. T. van de Ven
- Netherlands Heart Network, Veldhoven, The Netherlands
- St. Anna Hospital, Geldrop, The Netherlands
| | - Geert Smits
- Netherlands Heart Network, Veldhoven, The Netherlands
- Primary care group Pozob, Veldhoven, The Netherlands
| | - Hans Post
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
| | - Dennis van Veghel
- Netherlands Heart Network, Veldhoven, The Netherlands
- Catharina Hospital, Eindhoven, The Netherlands
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Lewis GD, Docherty KF, Voors AA, Cohen-Solal A, Metra M, Whellan DJ, Ezekowitz JA, Ponikowski P, Böhm M, Teerlink JR, Heitner SB, Kupfer S, Malik FI, Meng L, Felker GM. Developments in Exercise Capacity Assessment in Heart Failure Clinical Trials and the Rationale for the Design of METEORIC-HF. Circ Heart Fail 2022; 15:e008970. [PMID: 35236099 DOI: 10.1161/circheartfailure.121.008970] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is a highly morbid condition for which exercise intolerance is a major manifestation. However, methods to assess exercise capacity in HFrEF vary widely in clinical practice and in trials. We describe advances in exercise capacity assessment in HFrEF and a comparative analysis of how various therapies available for HFrEF impact exercise capacity. Current guideline-directed medical therapy has indirect effects on cardiac performance with minimal impact on measured functional capacity. Omecamtiv mecarbil is a novel selective cardiac myosin activator that directly increases cardiac contractility and in a phase 3 cardiovascular outcomes study significantly reduced the primary composite end point of time to first heart failure event or cardiovascular death in patients with HFrEF. The objective of the METEORIC-HF trial (Multicenter Exercise Tolerance Evaluation of Omecamtiv Mecarbil Related to Increased Contractility in Heart Failure) is to assess the effect of omecamtiv mecarbil versus placebo on multiple components of functional capacity in HFrEF. The primary end point is to test the effect of omecamtiv mecarbil compared with placebo on peak oxygen uptake as measured by cardiopulmonary exercise testing after 20 weeks of treatment. METEORIC-HF will provide state-of-the-art assessment of functional capacity by measuring ventilatory efficiency, circulatory power, ventilatory anaerobic threshold, oxygen uptake recovery kinetics, daily activity, and quality-of-life assessment. Thus, the METEORIC-HF trial will evaluate the potential impact of increased myocardial contractility with omecamtiv mecarbil on multiple important measures of functional capacity in ambulatory patients with symptomatic HFrEF. Registration: URL: https://clinicaltrials.gov; Unique identifier: NCT03759392.
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Affiliation(s)
- Gregory D Lewis
- Division of Cardiology, Massachusetts General Hospital, Boston (G.D.L.)
| | - Kieran F Docherty
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Scotland (K.F.D.)
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, the Netherlands (A.A.V.)
| | - Alain Cohen-Solal
- Paris University, UMR-S 942, Department of Cardiology, Lariboisiere Hospital, Assistance Publique Hopitaux de Paris, France (A.C.-S.)
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy (M.M.)
| | - David J Whellan
- Department of Medicine, Sidney Kimmel Medical College, Thomas Jefferson University Hospital, Philadelphia, PA (D.J.W.)
| | | | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Poland (P.P.)
| | - Michael Böhm
- Department of Internal Medicine, Saarland University, Homburg, Germany. (M.B.).,Department of Cardiology, Saarland University, Homburg, Germany. (M.B.)
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and University of California San Francisco (J.R.T.)
| | - Stephen B Heitner
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Stuart Kupfer
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Fady I Malik
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - Lisa Meng
- Cytokinetics Inc, South San Francisco, CA (S.B.H., S.K., F.I.M., L.M.)
| | - G Michael Felker
- Division of Cardiology, School of Medicine, Duke University Medical Center, Durham, NC (G.M.F.)
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Chen YJ, Chien CS, Chiang CE, Chen CH, Cheng HM. From Genetic Mutations to Molecular Basis of Heart Failure Treatment: An Overview of the Mechanism and Implication of the Novel Modulators for Cardiac Myosin. Int J Mol Sci 2021; 22:6617. [PMID: 34205587 PMCID: PMC8234187 DOI: 10.3390/ijms22126617] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/11/2021] [Accepted: 06/17/2021] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) is a syndrome encompassing several important etiologies that lead to the imbalance between oxygen demand and supply. Despite the usage of guideline-directed medical therapy for HF has shown better outcomes, novel therapeutic strategies are desirable, especially for patients with preserved or mildly reduced left ventricular ejection fraction. In this regard, understanding the molecular basis for cardiomyopathies is expected to fill in the knowledge gap and generate new therapies to improve prognosis for HF. This review discusses an evolutionary mechanism designed to regulate cardiac contraction and relaxation through the most often genetically determined cardiomyopathies associated with HF. In addition, both the myosin inhibitor and myosin activator are promising new treatments for cardiomyopathies. A comprehensive review from genetic mutations to the molecular basis of direct sarcomere modulators will help shed light on future studies for a better characterization of HF etiologies and potential therapeutic targets.
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Affiliation(s)
- Yu-Jen Chen
- Department of Internal Medicine, Division of Cardiovascular Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116081, Taiwan;
- Department of Internal Medicine, Division of Cardiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Chian-Shiu Chien
- Innovative Cellular Therapy Center, Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei 112304, Taiwan
| | - Chen-Huan Chen
- Department of Medical Education, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- College of Medicine, National Yang Ming Chiao Tung University, Taipei 112201, Taiwan
| | - Hao-Min Cheng
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei 112304, Taiwan
- Center for Evidence-Based Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan
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Anthracycline-related cardiotoxicity in older patients with acute myeloid leukemia: a Young SIOG review paper. Blood Adv 2021; 4:762-775. [PMID: 32097461 DOI: 10.1182/bloodadvances.2019000955] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2019] [Accepted: 01/13/2020] [Indexed: 12/16/2022] Open
Abstract
The incidence of acute myeloid leukemia (AML) increases with age. Intensive induction chemotherapy containing cytarabine and an anthracycline has been part of the upfront and salvage treatment of AML for decades. Anthracyclines are associated with a significant risk of cardiotoxicity (especially anthracycline-related left ventricular dysfunction [ARLVD]). In the older adult population, the higher prevalence of cardiac comorbidities and risk factors may further increase the risk of ARLVD. In this article of the Young International Society of Geriatric Oncology group, we review the prevalence of ARLVD in patients with AML and factors predisposing to ARLVD, focusing on older adults when possible. In addition, we review the assessment of cardiac function and management of ARLVD during and after treatment. It is worth noting that only a minority of clinical trials focus on alternative treatment strategies in patients with mildly declined left ventricular ejection fraction or at a high risk for ARLVD. The limited evidence for preventive strategies to ameliorate ARLVD and alternative strategies to anthracycline use in the setting of cardiac comorbidities are discussed. Based on extrapolation of findings from younger adults and nonrandomized trials, we recommend a comprehensive baseline evaluation of cardiac function by imaging, cardiac risk factors, and symptoms to risk stratify for ARLVD. Anthracyclines remain an appropriate choice for induction although careful risk-stratification based on cardiac disease, risk factors, and predicted chemotherapy-response are warranted. In case of declined left ventricular ejection fraction, alternative strategies should be considered.
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Bao J, Kan R, Chen J, Xuan H, Wang C, Li D, Xu T. Combination pharmacotherapies for cardiac reverse remodeling in heart failure patients with reduced ejection fraction: A systematic review and network meta-analysis of randomized clinical trials. Pharmacol Res 2021; 169:105573. [PMID: 33766629 DOI: 10.1016/j.phrs.2021.105573] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/15/2021] [Accepted: 03/18/2021] [Indexed: 12/22/2022]
Abstract
Pharmacotherapies, including angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor II blockers (ARBs), β-blockers (BBs), mineralocorticoid receptor antagonists (MRAs) and angiotensin receptor blocker-neprilysin inhibitor (ARNI), have played a pivotal role in reducing in-hospital and mortality in heart failure patients with reduced ejection fraction (HFrEF). However, effects of the five drug categories used alone or in combination for cardiac reverse remodeling (CRR) in these patients have not been systematically evaluated. A Bayesian network meta-analysis was conducted based on 55 randomized controlled trials published between 1989 and 2019 involving 12,727 patients from PubMed, EMBASE, Cochrane Library, and Clinicaltrials.gov. The study is registered with PROSPERO (CRD42020170457). Our primary outcomes were CRR indicators, including changes of left ventricular ejection fraction (LVEF), left ventricular end-diastolic volume (LVEDV) and end-systolic volume (LVESV), indexed LVEDV (LVEDVI) and LVESV (LVESVI), and left ventricular end-diastolic dimension (LVEDD) and end-systolic dimension (LVESD); Secondary outcomes were functional capacity comprising New York Heart Association (NYHA) class and 6-min walking distance (6MWD); cardiac biomarkers involving B type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP). The effect sizes were presented as the mean difference with 95% credible intervals. According to the results, all dual-combination therapies except ACEI+ARB were significantly more associated with LVEF or NYHA improvement than placebo, ARB+BB and ARNI+BB were the top two effective dual-combinations in LVEF improvement (+7.59% [+4.27, +11.25] and +7.31% [+3.93, +10.97] respectively); ACEI+BB was shown to be superior to ACEI in reducing LVEDVI and LVESVI (-6.88 mL/m2 [-13.18, -1.89] and -10.64 mL/m2 [-18.73, -3.54] respectively); ARNI+BB showed superiority over ACEI+BB in decreasing the level of NT-proBNP (-240.11 pg/mL [-456.57, -6.73]). All tri-combinations were significantly more effective than placebo in LVEF improvement, and ARNI+BB+MRA ranked first (+21.13% [+14.34, +28.13]); ACEI+BB+MRA was significantly more associated with a decrease in LVEDD than ACEI (-6.57 mm [-13.10, -0.84]). A sensitivity analysis ignoring concomitant therapies for LVEF illustrated that all the five drug types except ARB were shown to be superior to placebo, and ARNI ranked first (+4.83% [+1.75, +7.99]). In conclusion, combination therapies exert more benefits on CRR for patients with HFrEF. Among them, ARNI+BB, ARB+BB, ARNI+BB+MRA and ARB+BB+MRA were the top two effective dual and triple combinations in LVEF improvement, respectively; The new "Golden Triangle" of ARNI+BB+MRA was shown to be superior to ACEI+BB+MRA or ARB+BB+MRA in LVEF improvement.
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Affiliation(s)
- Jieli Bao
- The Institute of Cardiovascular Disease Research, Xuzhou Medical University, Xuzhou, Jiangsu, PR China; The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, PR China
| | - Rongsheng Kan
- The Institute of Cardiovascular Disease Research, Xuzhou Medical University, Xuzhou, Jiangsu, PR China
| | - Junhong Chen
- The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, PR China
| | - Haochen Xuan
- The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, PR China
| | - Chaofan Wang
- The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, PR China
| | - Dongye Li
- The Institute of Cardiovascular Disease Research, Xuzhou Medical University, Xuzhou, Jiangsu, PR China; The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, PR China.
| | - Tongda Xu
- The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, PR China
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Effect of Traditional Chinese Medicine Poge Heart-Saving Decoction on Cardiac Function in Heart Failure Rat Model. EVIDENCE-BASED COMPLEMENTARY AND ALTERNATIVE MEDICINE 2021; 2020:8762509. [PMID: 33628294 PMCID: PMC7895586 DOI: 10.1155/2020/8762509] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/23/2020] [Revised: 09/30/2020] [Accepted: 10/24/2020] [Indexed: 12/12/2022]
Abstract
Background Poge heart-saving decoction (PHSD) has been used as a medicine treating heart failure in China for many years. The study aimed to explore the effect of PHSD on cardiac function in heart failure conditions and its underlying mechanism. Methods Adriamycin was used to induce the model of heart failure (HF) in rats. Sixty rats were randomly divided into six groups: blank control group, sham group, 9.33 g/kg group (low-PHSD, test group), 13.995 g/kg group (moderate-PHSD, test group), 18.66 g/kg group (high-PHSD, test group), and fosinopril group (4.67 mg/kg, comparison test group). Cardiac ultrasound was used to evaluate the cardiac function of the rats, and radioimmunoassay was used to measure aldosterone (ALD) and angiotensin II (AngII) levels in the serum. Results Compared with the blank control group, the left ventricular end-diastolic dimension (LVEDd) and left ventricular end-systolic dimension (LVEDs) in the sham group were increased (1.04 ± 0.12 vs. 0.67 ± 0.13 cm; 0.75 ± 0.13 vs. 0.28 ± 0.10 cm; P < 0.05), and the left ventricular ejection fraction was decreased (36.65 ± 5.74 vs. 76.09 ± 4.23%; P < 0.05). The ejection fraction of HF rats was increased in 9.33 g/kg group, 13.995 g/kg group, and 18.66 g/kg group compared with those of the sham group (57.13 ± 1.63, 58.43 ± 1.98, and 59.21 ± 1.37 vs. 36.65 ± 5.74%; P < 0.05). PHSD also improved cardiac function by reducing the LVEDd and LVEDs (0.88 ± 0.11, 0.75 ± 0.13, and 0.72 ± 0.18 vs. 1.04 ± 0.12 cm; 0.62 ± 0.10, 0.63 ± 0.17, and 0.45 ± 0.11 vs. 0.75 ± 0.13 cm; P < 0.05). The levels of ALD and AngII in the serum of rats in the sham group were significantly higher than those in the blank control group (371.58 ± 39.25 vs. 237.12 ± 17.35 μg/L; 232.18 ± 16.33 vs. 159.44 ± 18.42 pg/L; P < 0.05). The ALD and AngII of the rats in all of the three PHSD groups and the fosinopril group were decreased (276.81 ± 25.63, 277.18 ± 21.35, 268.19 ± 19.28, and 271.47 ± 28.96 vs. 371.58 ± 39.25 μg/L; 169.41 ± 27.53, 168.81 ± 19.78, 164.23 ± 21.34, and 174.27 ± 22.84 vs. 232.18 ± 16.33 pg/L; P < 0.05). The histopathological changes of the myocardium in the sham group showed the disorganized fiber, shaded staining, fracture, and zonation. The fracture of the myocardium was relieved in all groups except the sham group and the blank control group. Conclusion Therefore, PHSD could shorten LVEDd and LVEDs of rats and reverse ventricular remodeling. The mechanism might be related to the inhibition of the activation level of renin-angiotensin-aldosterone system (especially ALD and AngII) and decreasing the postload of the heart.
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Benefits and adverse effects of ACE inhibitors in patients with heart failure with reduced ejection fraction: a systematic review and meta-analysis. Eur J Clin Pharmacol 2020; 77:321-329. [PMID: 33070218 DOI: 10.1007/s00228-020-03018-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
PURPOSE Angiotensin-converting enzyme (ACE) inhibitors are part of first-line treatment for reduced ejection fraction heart failure (HFrEF). The aim was to assess the benefits and adverse effects of ACE inhibitors in HFrEF with a focus on important patient outcomes. METHODS A systematic review of double-blind randomized clinical trials (RCTs) and comparison of ACE inhibitors versus placebo, in HFrEF patients published in French or English. Searches were undertaken of Medline, Cochrane Central, and Embase. The primary outcomes were all-cause mortality and adverse events. RESULTS From 636 articles analysed, 11 were included (13,882 patients). For all-cause mortality (5 RCTs, 9277 patients), the number needed to treat (NNT) to avoid one death at 6 months was 50 (33-107). The NNT to prevent one death at 12 months (6 RCTs, 13,016 patients) was 63 (35-314). Under the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, the evidence was of moderate quality. The number needed to harm was 12 (10-15) for cough, 20 (14-31) for hypotension, 23 (17-36) for dizziness, 31 (23-47) for hyperkalaemia, and 49 (30-121) for increased creatinine levels. The quality of evidence was moderate for these criteria except for cough (low quality of evidence). CONCLUSION This review focuses on clinical elements necessary in a shared decision-making process. In practice, general practitioners will be able to use these data to discuss ACE inhibitor treatment with HFrEF patients. This study was registered in the PROSPERO registry under the reference number CRD42018096930.
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McGuinty C, Leong D, Weiss A, MacIver J, Kaya E, Hurlburt L, Billia F, Ross H, Wentlandt K. Heart Failure: A Palliative Medicine Review of Disease, Therapies, and Medications With a Focus on Symptoms, Function, and Quality of Life. J Pain Symptom Manage 2020; 59:1127-1146.e1. [PMID: 31866489 DOI: 10.1016/j.jpainsymman.2019.12.357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022]
Abstract
Despite significant advances in heart failure (HF) treatment, HF remains a progressive, extremely symptomatic, and terminal disease with a median survival of 2.1 years after diagnosis. HF often leads to a constellation of symptoms, including dyspnea, fatigue, depression, anxiety, insomnia, pain, and worsened cognitive function. Palliative care is an approach that improves the quality of life of patients and their caregivers facing the problems associated with life-threatening illness and therefore is well suited to support these patients. However, historically, palliative care has often focused on supporting patients with malignant disease, rather than a progressive chronic disease such as HF. Predicting mortality in patients with HF is challenging. The lack of obvious transition points in disease progression also raises challenges to primary care providers and specialists to know at what point to integrate palliative care during a patient's disease trajectory. Although therapies for HF often result in functional and symptomatic improvements including health-related quality of life (HRQL), some patients with HF do not demonstrate these benefits, including those patients with a preserved ejection fraction. Provision of palliative care for patients with HF requires an understanding of HF pathogenesis and common medications used for these patients, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes HF and current targeted therapies and their effects on symptoms, hospital admission rates, exercise performance, HRQL, and survival. Pharmacological interactions with and precautions related to commonly used palliative care medications are reviewed. The goal of this review is to equip palliative care clinicians with information to make evidence-based decisions while managing the balance between optimal disease management and patient quality of life.
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Affiliation(s)
- Caroline McGuinty
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Derek Leong
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Andrea Weiss
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jane MacIver
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ebru Kaya
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Lindsay Hurlburt
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Filio Billia
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Heather Ross
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
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11
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Tseng AS, Kunze KL, Lee JZ, Amin M, Neville MR, Almader-Douglas D, Killu AM, Madhavan M, Cha YM, Asirvatham SJ, Friedman PA, Gersh BJ, Mulpuru SK. Efficacy of Pharmacologic and Cardiac Implantable Electronic Device Therapies in Patients With Heart Failure and Reduced Ejection Fraction: A Systematic Review and Network Meta-Analysis. Circ Arrhythm Electrophysiol 2019; 12:e006951. [PMID: 31159582 DOI: 10.1161/circep.118.006951] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The treatment of heart failure with reduced ejection fraction has been the subject of numerous randomized controlled trials involving medications and cardiac implantable electronic device therapies. As newer effective pharmacological therapies suggest significant reductions in all-cause mortality, the role of additional device therapy in heart failure with reduced ejection fraction deserves further scrutiny. Methods A systematic review and network meta-analysis on the effect of medication and device therapies in heart failure with reduced ejection fraction on all-cause mortality was performed. Randomized controlled trials published between January 1980 and July 2017 were identified using Medline, EMBASE, and Cochrane Controlled Register of Trials databases. Pcnetmeta package in R was used to calculate treatment arm-based estimated rates, rate ratios, and probability ranks with 95% credible intervals. Results Combination therapy of ACE (angiotensin-converting enzyme) inhibitors or ARBs (angiotensin receptor blockers) with β-blockers (BBs) alone or in addition to implantable cardiac defibrillators or cardiac resynchronization therapy with defibrillators demonstrated a significant reduction of all-cause mortality when compared with placebo. By probability rank, implantable cardiac defibrillator+ACE inhibitor or ARB+BB+mineralocorticoid receptor antagonist, implantable cardiac defibrillator+ACE inhibitor or ARB+BB, and angiotensin receptor-neprilysin inhibitor+BB+mineralocorticoid receptor antagonist combination therapies have the highest probability of being ranked the best treatment. There was no significant difference in the rate of mortality when comparing angiotensin receptor-neprilysin inhibitor+BB+mineralocorticoid receptor antagonist to implantable cardiac defibrillator+optimal pharmacological combination therapy. Conclusions BB and renin-angiotensin system blockers alone or in combination with defibrillator device therapy have robust evidence for a reduction in mortality compared with placebo. The comparative efficacy of pharmacological therapy with angiotensin receptor-neprilysin inhibitors and device therapy deserves further investigation.
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Affiliation(s)
- Andrew S Tseng
- Department of Internal Medicine (A.S.T.), Mayo Clinic Arizona, Phoenix
| | - Katie L Kunze
- Division of Biomedical Statistics and Informatics (K.L.K., M.R.N.), Mayo Clinic Arizona, Phoenix
| | - Justin Z Lee
- Division of Cardiovascular Diseases (J.Z.L., S.K.M.), Mayo Clinic Arizona, Phoenix
| | - Mustapha Amin
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Matthew R Neville
- Division of Biomedical Statistics and Informatics (K.L.K., M.R.N.), Mayo Clinic Arizona, Phoenix
| | | | - Ammar M Killu
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Malini Madhavan
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Yong-Mei Cha
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Samuel J Asirvatham
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Paul A Friedman
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Bernard J Gersh
- Division of Cardiovascular Diseases, Mayo Clinic Rochester, MN (M.A., A.M.K., M.M., Y.-M.C., S.J.A., P.A.F., B.J.G.)
| | - Siva K Mulpuru
- Division of Cardiovascular Diseases (J.Z.L., S.K.M.), Mayo Clinic Arizona, Phoenix
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12
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Tai C, Gan T, Zou L, Sun Y, Zhang Y, Chen W, Li J, Zhang J, Xu Y, Lu H, Xu D. Effect of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers on cardiovascular events in patients with heart failure: a meta-analysis of randomized controlled trials. BMC Cardiovasc Disord 2017; 17:257. [PMID: 28982370 PMCID: PMC5629775 DOI: 10.1186/s12872-017-0686-z] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Accepted: 09/12/2017] [Indexed: 01/14/2023] Open
Abstract
Background Heart failure (HF) remains a significant cause of morbidity and mortality. Multiple trials over the past several years have examined the effects of both angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin II receptor blockers (ARBs) in the treatment of left ventricular dysfunction, both acutely after myocardial infarction and in chronic heart failure. Yet, there is still confusion regarding the relative efficacy of rennin-angiotensin-aldosterone system (RAAS) inhibition. Our study was conducted to assess efficacy of ACEIs and ARBs in reducing all-cause and cardiovascular mortality in heart failure patients. Methods We included randomized clinical trials compared ACEIs and ARBs treatment (any dose or type) with placebo treatment, no treatment, or other anti-HF drugs treatment, reporting cardiovascular or total mortality with an observation period of at least 12 months. Data sources included Pubmed, EMBASE, the Cochrane Central Register of Controlled Trials. Dichotomous outcome data from individual trials were analyzed using the risk ratio measure and its 95%CI with random-effects/ fixed-effects models. We performed meta-regression analyses to identify sources of heterogeneity. All-cause mortality and CV mortality were thought to be the main outcomes. Results A total of 47,662 subjects were included with a mean/median follow-up ranged from 12 weeks to 4.5 years. Of all 38 studies, 32 compared ACEIs with control therapy (included 13 arms that compared ACEIs with placebo, 10 arms in which the comparator was active treatment and 9 arms that compared ACEIs with ARBs), and six studies compared ARBs with placebo. ACEIs treatment in patients with HF reduced all-cause mortality to 11% (risk ratio (RR): 0.89, 95% confidence interval (CI): 0.83–0.96, p = 0.001) and the corresponding value for cardiovascular mortality was 14% (RR: 0.86, 95% CI: 0.78–0.94, p = 0.001). However, ARBs had no beneficial effect on reducing all-cause and cardiovascular mortality. In head-to-head analysis, ACEIs was not superior to ARBs for all-cause mortality and cardiovascular deaths. Conclusions In HF patients, ACEIs, but not ARBs reduced all-cause mortality and cardiovascular deaths. Thus, ACEIs should be considered as first-line therapy to limit excess mortality and morbidity in this population. Electronic supplementary material The online version of this article (10.1186/s12872-017-0686-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Chenhui Tai
- Department of Cardiology, The Second Affiliated Hospital of Nantong University, 6 Northern Haierxiang Road, Nantong, China.,Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China
| | - Tianyi Gan
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liling Zou
- Institute of Clinical Epidemiology and Evidence-based Medicine, Tongji University School of Medicine, 1239 Siping Road, Shanghai, China
| | - Yuxi Sun
- Department of Cardiology, First Hospital of Lanzhou University, Lanzhou, Gansu, China
| | - Yi Zhang
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China
| | - Wei Chen
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China
| | - Jue Li
- Institute of Clinical Epidemiology and Evidence-based Medicine, Tongji University School of Medicine, 1239 Siping Road, Shanghai, China
| | - Jian Zhang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yawei Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China
| | - Huihe Lu
- Department of Cardiology, The Second Affiliated Hospital of Nantong University, 6 Northern Haierxiang Road, Nantong, China.
| | - Dachun Xu
- Department of Cardiology, Shanghai Tenth People's Hospital, Tongji University School of Medicine, 301 Yanchang Road, Shanghai, China.
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13
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Al-Azizi KM, Skelding KA. Renin angiotensin system inhibitors: a panacea for heart disease? J Thorac Dis 2017; 9:1437-1439. [PMID: 28740651 DOI: 10.21037/jtd.2017.05.65] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Karim M Al-Azizi
- Department of Cardiology, Geisinger Health System, Danville, Pennsylvania, USA
| | - Kimberly A Skelding
- Department of Cardiology, Geisinger Health System, Danville, Pennsylvania, USA
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14
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Burnett H, Earley A, Voors AA, Senni M, McMurray JJV, Deschaseaux C, Cope S. Thirty Years of Evidence on the Efficacy of Drug Treatments for Chronic Heart Failure With Reduced Ejection Fraction: A Network Meta-Analysis. Circ Heart Fail 2017; 10:e003529. [PMID: 28087688 PMCID: PMC5265698 DOI: 10.1161/circheartfailure.116.003529] [Citation(s) in RCA: 149] [Impact Index Per Article: 21.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/15/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treatments that reduce mortality and morbidity in patients with heart failure with reduced ejection fraction, including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), β-blockers (BB), mineralocorticoid receptor antagonists (MRA), and angiotensin receptor-neprilysin inhibitors (ARNI), have not been studied in a head-to-head fashion. This network meta-analysis aimed to compare the efficacy of these drugs and their combinations regarding all-cause mortality in patients with heart failure with reduced ejection fraction. METHODS AND RESULTS A systematic literature review identified 57 randomized controlled trials published between 1987 and 2015, which were compared in terms of study and patient characteristics, baseline risk, outcome definitions, and the observed treatment effects. Despite differences identified in terms of study duration, New York Heart Association class, ejection fraction, and use of background digoxin, a network meta-analysis was considered feasible and all trials were analyzed simultaneously. The random-effects network meta-analysis suggested that the combination of ACEI+BB+MRA was associated with a 56% reduction in mortality versus placebo (hazard ratio 0.44, 95% credible interval 0.26-0.66); ARNI+BB+MRA was associated with the greatest reduction in all-cause mortality versus placebo (hazard ratio 0.37, 95% credible interval 0.19-0.65). A sensitivity analysis that did not account for background therapy suggested that ARNI monotherapy is more efficacious than ACEI or ARB monotherapy. CONCLUSIONS The network meta-analysis showed that treatment with ACEI, ARB, BB, MRA, and ARNI and their combinations were better than the treatment with placebo in reducing all-cause mortality, with the exception of ARB monotherapy and ARB plus ACEI. The combination of ARNI+BB+MRA resulted in the greatest mortality reduction.
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Affiliation(s)
- Heather Burnett
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.).
| | - Amy Earley
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Adriaan A Voors
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Michele Senni
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - John J V McMurray
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Celine Deschaseaux
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Shannon Cope
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
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15
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Kumar S, Maurya DR, Chandra M. ACE Inhibition versus Angiotensin-II Antagonism in Heart Failure. Asian Cardiovasc Thorac Ann 2016. [DOI: 10.1177/021849230000800229] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Heart failure is becoming increasingly frequent. Once diagnosed, 5-year survival is less than 50% and a substantial percentage of patients (25% to 50%) die suddenly. Angiotensin-converting enzyme inhibitors are the only agents shown to reduce mortality in heart failure. All angiotensin-converting enzyme inhibitors appear to have similar clinical benefits in heart failure. Therapy should be started with a low dose and titrated up to the target dosage in major trials. Although angiotensin-I receptor antagonists provide more complete inhibition of angiotensin-II effects, they have not been found to be superior to long-acting angiotensin-converting enzyme inhibitors in reducing morbidity and mortality in heart failure. Therefore, in current clinical practice, angiotensin-II antagonists should be used as an alternative to angiotensin-converting enzyme inhibitors when the latter are not tolerated. The combined use of angiotensin-converting enzyme inhibitors and angiotensin-II antagonists is not currently recommended in the treatment of heart failure.
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Affiliation(s)
- Surendra Kumar
- Department of Medicine King George's Medical College Lucknow, Uttar Pradesh, India
| | - Dharm Raj Maurya
- Department of Medicine King George's Medical College Lucknow, Uttar Pradesh, India
| | - Mahesh Chandra
- Department of Medicine King George's Medical College Lucknow, Uttar Pradesh, India
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16
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Vandekerckhove L, Vermeulen Z, Liu ZZ, Boimvaser S, Patzak A, Segers VFM, De Keulenaer GW. Neuregulin-1 attenuates development of nephropathy in a type 1 diabetes mouse model with high cardiovascular risk. Am J Physiol Endocrinol Metab 2016; 310:E495-504. [PMID: 26786778 PMCID: PMC4824141 DOI: 10.1152/ajpendo.00432.2015] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2015] [Accepted: 01/08/2016] [Indexed: 12/19/2022]
Abstract
Neuregulin-1 (NRG-1) is an endothelium-derived growth factor with cardioprotective and antiatherosclerotic properties and is currently being tested in clinical trials as a treatment for systolic heart failure. In clinical practice, heart failure often coexists with renal failure, sharing an overlapping pathophysiological background. In this study, we hypothesized that NRG-1 might protect against cardiomyopathy, atherosclerosis, and nephropathy within one disease process. We tested this hypothesis in a hypercholesterolemic apolipoprotein E-deficient (apoE(-/-)) type 1 diabetes mouse model prone to the development of cardiomyopathy, atherosclerosis, and nephropathy and compared the effects of NRG-1 with insulin. Upon onset of hyperglycemia induced by streptozotocin, apoE(-/-)mice were treated with vehicle, insulin, or recombinant human (rh)NRG-1 for 14 wk and were compared with nondiabetic apoE(-/-)littermates. Vehicle-treated diabetic apoE(-/-)mice developed left ventricular (LV) dilatation and dysfunction, dense atherosclerotic plaques, and signs of nephropathy. Nephropathy was characterized by abnormalities including hyperfiltration, albuminuria, increased urinary neutrophil gelatinase-associated lipocalin (NGAL), upregulation of renal fibrotic markers, and glomerulosclerosis. rhNRG-1 treatment induced systemic activation of ErbB2 and ErbB4 receptors in both heart and kidneys and prevented LV dilatation, improved LV contractile function, and reduced atherosclerotic plaque size. rhNRG-1 also significantly reduced albuminuria, NGALuria, glomerular fibrosis, and expression of fibrotic markers. Regarding the renal effects of rhNRG-1, further analysis showed that rhNRG-1 inhibited collagen synthesis of glomerular mesangial cells in vitro but did not affect AngII-induced vasoconstriction of glomerular arterioles. In conclusion, systemic administration of rhNRG-1 in hypercholesterolemic type 1 diabetic mice simultaneously protects against complications in the heart, arteries and kidneys.
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Affiliation(s)
- Leni Vandekerckhove
- Laboratory of Physiopharmacology, University of Antwerp, Wilrijk, Belgium; and
| | - Zarha Vermeulen
- Laboratory of Physiopharmacology, University of Antwerp, Wilrijk, Belgium; and
| | - Zhi Zhao Liu
- AG Nierengefäßphysiologie, Institut für Vegetative Physiologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Sonia Boimvaser
- Laboratory of Physiopharmacology, University of Antwerp, Wilrijk, Belgium; and
| | - Andreas Patzak
- AG Nierengefäßphysiologie, Institut für Vegetative Physiologie, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Vincent F M Segers
- Laboratory of Physiopharmacology, University of Antwerp, Wilrijk, Belgium; and
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Abstract
Heart failure is a global disease with increasing prevalence due to an aging worldwide population with increasing co-morbidities. Despite several therapeutic options available to treat HFrEF, morbidity and mortality remain high. Importantly, no approved therapies are available to treat HFpEF. This paper will briefly summarize the burden of disease, HF classification and definitions and the landmark clinical trials in both HFrEF and HFpEF. Given the increasing incidence and prevalence of HF and the high morbidity and mortality associated with this disease, continued development efforts are essential to address the unmet needs of these patients.
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18
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Eshtehardi P, Pamerla M, Mojadidi MK, Goodman-Meza D, Hovnanians N, Gupta A, Lupercio F, Mazurek JA, Zolty R. Addition of Angiotensin-Converting Enzyme Inhibitors to Beta-Blockers Has a Distinct Effect on Hispanics Compared With African Americans and Whites With Heart Failure and Reduced Ejection Fraction: A Propensity Score–Matching Study. J Card Fail 2015; 21:448-56. [DOI: 10.1016/j.cardfail.2015.03.010] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 03/16/2015] [Accepted: 03/17/2015] [Indexed: 11/25/2022]
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19
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Joffe SW, Dewolf M, Shih J, McManus DD, Spencer FA, Lessard D, Gore JM, Goldberg RJ. Trends in the medical management of patients with heart failure. J Clin Med Res 2013; 5:194-204. [PMID: 23671545 PMCID: PMC3651070 DOI: 10.4021/jocmr1376w] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/08/2013] [Indexed: 01/16/2023] Open
Abstract
Background Despite the availability of effective therapies, heart failure (HF) remains a highly prevalent disease and the leading cause of hospitalizations in the U.S. Few data are available, however, describing changing trends in the use of various cardiac medications to treat patients with HF and factors associated with treatment. The objectives of this population-based study were to examine decade-long trends (1995 - 2004) in the use of several cardiac medications in patients hospitalized with acute decompensated heart failure (ADHF) and factors associated with evidence-based treatment. Methods We reviewed the medical records of 9,748 residents of the Worcester, MA, metropolitan area who were hospitalized with ADHF at all 11 central Massachusetts medical centers in 1995, 2000, 2002, and 2004. Results Between 1995 and 2004, respectively, the prescription upon hospital discharge of beta-blockers (23%; 67%), angiotensin pathway inhibitors (47%; 55%), statins (5%; 43%), and aspirin (35%; 51%) increased markedly, while the use of digoxin (51%; 29%), nitrates (46%; 24%), and calcium channel blockers (33%; 22%) declined significantly; nearly all patients received diuretics. Patients in the earliest study year, those with a history of obstructive pulmonary disease or anemia, incident HF, non-specific symptoms, and women were less likely to receive beta blockers and angiotensin pathway inhibitors than respective comparison groups. In 2004, 82% of patients were discharged on at least one of these recommended agents; however, only 41% were discharged on medications from both recommended classes. Conclusions Our data suggest that opportunities exist to further improve the use of HF therapeutics.
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Affiliation(s)
- Samuel W Joffe
- Department of Medicine, University of Massachusetts Medical School, Worcester, MA, USA ; Department of Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
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20
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Heart failure and mechanical circulatory support. Best Pract Res Clin Anaesthesiol 2012; 26:91-104. [DOI: 10.1016/j.bpa.2012.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Accepted: 03/14/2012] [Indexed: 11/15/2022]
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21
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The effect of dementia on medication use and adherence among Medicare beneficiaries with chronic heart failure. ACTA ACUST UNITED AC 2012; 10:69-80. [PMID: 22264854 DOI: 10.1016/j.amjopharm.2011.11.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2011] [Revised: 10/28/2011] [Accepted: 11/17/2011] [Indexed: 11/23/2022]
Abstract
BACKGROUND Alzheimer's disease and related disorders (ADRD) are prevalent in older adults, increase the costs of chronic heart failure (CHF) management, and may be associated with undertreatment of cardiovascular disease. OBJECTIVE The purpose of our study was to determine the relationship between comorbid ADRD and CHF medication use and adherence among Medicare beneficiaries with CHF. METHODS This 2-year (1/1/2006-12/31/2007) cross-sectional study used data from the Chronic Condition Data Warehouse of the Centers for Medicare and Medicaid Services. Medicare beneficiaries with evidence of CHF who had systolic dysfunction and Medicare Parts A, B, and D coverage during the entire study period were included. ADRD was identified based on diagnostic codes using the Chronic Condition Data Warehouse algorithm. CHF evidence-based medications (EBMs) were selected based on published guidelines: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, selected β-blockers, aldosterone antagonists, and selected vasodilators. Measures of EBMs included a binary indicator of EBM use and medication possession ratio among users. RESULTS Of 9827 beneficiaries with CHF and systolic dysfunction, 24.2% had a diagnosis of ADRD. Beneficiaries with ADRD were older (80.8 vs 73.6 years; P < 0.0001) and more likely to be female (69.3% vs 58.1%; P < 0.0001). Overall EBM use was lower in patients with CHF and ADRD compared with patients with CHF but no ADRD (85.3% vs 91.2%; P < 0.0001). Lower use among those with ADRD was consistent across all EBM classes except vasodilators. Among beneficiaries receiving EBM, those with ADRD had a slightly higher mean medication possession ratio for EBM compared with those without ADRD (0.86 vs 0.84; P = 0.0001). CONCLUSIONS EBM medication adherence was high in this population, regardless of ADRD status. However, patients with ADRD had lower EBM use compared with those without ADRD. Low use of specific EBM medications such as β-blockers was found in both groups. Therefore, interventions targeting increased treatment with specific EBMs for CHF, even among patients with ADRD, may be of benefit and could help reduce CHF-related hospitalizations.
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Barrios V, Escobar C. Antihypertensive and organ-protective effects of benazepril. Expert Rev Cardiovasc Ther 2011; 8:1653-71. [PMID: 21108548 DOI: 10.1586/erc.10.159] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Benazepril is a nonsulfhydryl ACE inhibitor with favorable pharmacodynamic and pharmacokinetic properties, well-established antihypertensive effects and a good tolerability profile. Recent clinical studies have demonstrated that patients treated with benazepril alone or in combination with hydrochlorothiazide or amlodipine may achieve beneficial renal outcomes that extend beyond blood pressure control. Furthermore, the recent Avoiding Cardiovascular Events Through Combination Therapy in Patients Living with Systolic Hypertension (ACCOMPLISH) trial showed decreased cardiovascular morbidity and mortality with benazepril when administered as a cotreatment. An additional novel therapeutic area for benazepril is atrial fibrillation. Differences between combination therapies have implications for which patients may be best suited to particular interventions, and further studies are required to fully ascertain this potential.
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Affiliation(s)
- Vivencio Barrios
- Department of Cardiology, University Hospital Ramón y Cajal, Madrid, Spain.
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Bangalore S, Kumar S, Messerli FH. Angiotensin-converting enzyme inhibitor associated cough: deceptive information from the Physicians' Desk Reference. Am J Med 2010; 123:1016-30. [PMID: 21035591 DOI: 10.1016/j.amjmed.2010.06.014] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2010] [Revised: 06/03/2010] [Accepted: 06/08/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Dry cough is a common, annoying adverse effect of all angiotensin-converting enzyme (ACE) inhibitors. The present study was designed to compare the rate of coughs reported in the literature with reported rates in the Physicians' Desk Reference (PDR)/drug label. METHODS We searched MEDLINE/EMBASE/CENTRAL for articles published from 1990 to the present about randomized clinical trials (RCTs) of ACE inhibitors with a sample size of at least 100 patients in the ACE inhibitors arm with follow-up for at least 3 months and reporting the incidence or withdrawal rates due to cough. Baseline characteristics, cohort enrolled, metrics used to assess cough, incidence, and withdrawal rates due to cough were abstracted. RESULTS One hundred twenty-five studies that satisfied our inclusion criteria enrolled 198,130 patients. The pooled weighted incidence of cough for enalapril was 11.48% (95% confidence interval [CI], 9.54% to 13.41%), which was ninefold greater compared to the reported rate in the PDR/drug label (1.3%). The pooled weighted withdrawal rate due to cough for enalapril was 2.57% (95% CI, 2.40-2.74), which was 31-fold greater compared to the reported rate in the PDR/drug label (0.1%). The incidence of cough has increased progressively over the last 2 decades with accumulating data, but it has been reported consistently several-fold less in the PDR compared to the RCTs. The results were similar for most other ACE inhibitors. CONCLUSION The incidence of ACE inhibitor-associated cough and the withdrawal rate (the more objective metric) due to cough is significantly greater in the literature than reported in the PDR/drug label and is likely to be even greater in the real world when compared with the data from RCTs. There exists a gap between the data available from the literature and that which is presented to the consumers (prescribing physicians and patients).
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Affiliation(s)
- Sripal Bangalore
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Ma TKW, Kam KKH, Yan BP, Lam YY. Renin-angiotensin-aldosterone system blockade for cardiovascular diseases: current status. Br J Pharmacol 2010; 160:1273-92. [PMID: 20590619 DOI: 10.1111/j.1476-5381.2010.00750.x] [Citation(s) in RCA: 229] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Activation of the renin-angiotensin-aldosterone system (RAAS) results in vasoconstriction, muscular (vascular and cardiac) hypertrophy and fibrosis. Established arterial stiffness and cardiac dysfunction are key factors contributing to subsequent cardiovascular and renal complications. Blockade of RAAS has been shown to be beneficial in patients with hypertension, acute myocardial infarction, chronic systolic heart failure, stroke and diabetic renal disease. An aggressive approach for more extensive RAAS blockade with combination of two commonly used RAAS blockers [ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs)] yielded conflicting results in different patient populations. Combination therapy is also associated with more side effects, in particular hypotension, hyperkalaemia and renal impairment. Recently published ONTARGET study showed ACEI/ARB combination therapy was associated with more adverse effects without any increase in benefit. The Canadian Hypertension Education Program responded with a new warning: 'Do not use ACEI and ARB in combination'. However, the European Society of Cardiology in their updated heart failure treatment guidelines still recommended ACEI/ARB combo as a viable option. This apparent inconsistency among guidelines generates debate as to which approach of RAAS inhibition is the best. The current paper reviews the latest evidence of isolated ACEI or ARB use and their combination in cardiovascular diseases, and makes recommendations for their prescriptions in specific patient populations.
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Affiliation(s)
- Terry K W Ma
- Department of Medicine & Therapeutics, Chinese University of Hong Kong, Hong Kong
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Johnson MJ, Oxberry SG, Cleland JG, Clark AL. Measurement of breathlessness in clinical trials in patients with chronic heart failure: the need for a standardized approach: a systematic review. Eur J Heart Fail 2010; 12:137-47. [DOI: 10.1093/eurjhf/hfp194] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Miriam J. Johnson
- Hull York Medical School and St Catherine's Hospice; Scarborough North Yorkshire YO12 5RE UK
- Department of Academic Cardiology; Hull York Medical School, Castle Hill Hospital; Hull East Yorkshire UK
| | - Stephen G. Oxberry
- Department of Academic Cardiology; Hull York Medical School, Castle Hill Hospital; Hull East Yorkshire UK
| | - John G.F. Cleland
- Department of Academic Cardiology; Hull York Medical School, Castle Hill Hospital; Hull East Yorkshire UK
| | - Andrew L. Clark
- Department of Academic Cardiology; Hull York Medical School, Castle Hill Hospital; Hull East Yorkshire UK
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Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines Developed in Collaboration With the International Society for Heart and Lung Transplantation. J Am Coll Cardiol 2009; 53:e1-e90. [PMID: 19358937 DOI: 10.1016/j.jacc.2008.11.013] [Citation(s) in RCA: 1183] [Impact Index Per Article: 78.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG, Konstam MA, Mancini DM, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 Focused Update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults. Circulation 2009; 119:1977-2016. [PMID: 19324967 DOI: 10.1161/circulationaha.109.192064] [Citation(s) in RCA: 1059] [Impact Index Per Article: 70.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW. 2009 focused update incorporated into the ACC/AHA 2005 Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 2009; 119:e391-479. [PMID: 19324966 DOI: 10.1161/circulationaha.109.192065] [Citation(s) in RCA: 1080] [Impact Index Per Article: 72.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Coberley C, Morrow G, McGinnis M, Wells A, Coberley S, Orr P, Shurney D. Increased Adherence to Cardiac Standards of Care during Participation in Cardiac Disease Management Programs. ACTA ACUST UNITED AC 2008; 11:111-8. [DOI: 10.1089/dis.2008.112725] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Affiliation(s)
| | | | | | | | | | - Patty Orr
- Healthways, Inc., Nashville, Tennessee
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Abdulla J, Pogue J, Abildstrøm SZ, Køber L, Christensen E, Pfeffer MA, Yusuf S, Torp-Pedersen C. Effect of angiotensin-converting enzyme inhibition on functional class in patients with left ventricular systolic dysfunction-a meta-analysis. Eur J Heart Fail 2005; 8:90-6. [PMID: 16054435 DOI: 10.1016/j.ejheart.2005.03.006] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2004] [Accepted: 03/03/2005] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND The effect of angiotensin converting enzyme (ACE) inhibitors on symptoms in patients with left ventricular systolic dysfunction (LVSD) is controversial. AIMS To perform a meta-analysis of studies evaluating effect of ACE inhibitors on New York Heart Association (NYHA) class in patients with LVSD. METHODS Individual data from 10389 patients in NYHA classes I-IV from four large long-term studies (2-4-year follow-up) and summary data from 2302 patients in NYHA classes II-IV from 16 short-term studies (3 months follow-up) were meta-analysed to assess changes in NYHA class. RESULTS The large long-term studies showed a significant improvement in the worst NYHA classes (classes II-IV compared to class I) in the ACE inhibitor arm versus placebo, odds ratio (OR) = 0.875 (0.811-0.943) p = 0.0005. This effect was only present in studies which included patients with chronic heart failure and was particularly pronounced on deterioration to the worst NYHA class IV, OR = 0.66 (0.52-0.84) p = 0.001. There was no effect in the studies which included patients after myocardial infarction. The short-term chronic heart failure studies showed a significant improvement in NYHA class; OR for improvement of at least one NYHA class was 2.11 (1.48-2.98, 95% CI) p < 0.0001. CONCLUSION ACE inhibition significantly improves symptomatic status measured as NYHA classification in patients with chronic heart failure.
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Affiliation(s)
- Jawdat Abdulla
- Department of Cardiology P, Gentofte University Hospital, Copenhagen, Denmark.
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Hunt SA. ACC/AHA 2005 guideline update for the diagnosis and management of chronic heart failure in the adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure). J Am Coll Cardiol 2005; 46:e1-82. [PMID: 16168273 DOI: 10.1016/j.jacc.2005.08.022] [Citation(s) in RCA: 1123] [Impact Index Per Article: 59.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation 2005. [PMID: 16160202 DOI: 10.1161/circulationaha.105.167587] [Citation(s) in RCA: 294] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
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ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult—Summary Article. J Am Coll Cardiol 2005. [DOI: 10.1016/j.jacc.2005.08.023] [Citation(s) in RCA: 293] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Belgeri MT. Long-Acting Angiotensin-Converting Enzyme Inhibitors in Congestive Heart Failure: Does Multiple-Daily Dosing Provide Additional Benefit over Once-Daily Dosing? J Pharm Technol 2005. [DOI: 10.1177/875512250502100404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objective: To determine if there is clinical evidence supporting the use of twice-daily long-acting angiotensin-converting enzyme (ACE) inhibitors in congestive heart failure (CHF). Data Sources: Articles were identified through searches of MEDLINE and PubMed (1966–June 2005). Search terms included angiotensin-converting enzyme inhibitors, congestive heart failure, dosing, dosing schedules, captopril, enalapril, fosinopril, lisinopril, quinapril, ramipril, and trandolapril. Only articles published in English were included. Additionally, bibliographies of articles cited were used to identify additional articles. Study Selection and Data Extraction: All available articles identified by the data sources were reviewed and those deemed relevant to the review were included. Data Synthesis: Data have suggested that long-acting ACE inhibitors are more effective than short-acting ACE inhibitors for the treatment of CHF. A few ACE inhibitors approved for the treatment of CHF have twice-daily dosing schedules; these same ACE inhibitors have once-daily dosing schedules when used in the treatment of hypertension. Recent data propose greater adrenergic blockage, and, thus, decreased stimulation of the renin–angiotensin–aldosterone system, with the twice-daily dosing schedule of the long-acting ACE inhibitors. This controversy has led some providers to prescribe all long-acting ACE inhibitors twice daily in the setting of CHF, which, when unnecessary, can lead to decreased compliance, increased morbidity, and decreased quality of life. Conclusions: The available clinical studies comparing dosing schedules of long-acting ACE inhibitors have many limitations. Until a well-designed, randomized, double-blind trial of appropriate duration evaluating clinical outcomes is conducted, multiple-daily dosing schedules do not provide additional benefit over once-daily dosing schedules of long-acting ACE inhibitors in the treatment of CHF.
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Affiliation(s)
- Myra T Belgeri
- MYRA T BELGERI PharmD CGP BCPS, Assistant Professor of Pharmacy Practice, St. Louis College of Pharmacy, St. Louis, MO 63110-1088, fax 314/446-8500
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Abdulla J, Abildstrom SZ, Christensen E, Kober L, Torp-Pedersen C. A meta-analysis of the effect of angiotensin-converting enzyme inhibitors on functional capacity in patients with symptomatic left ventricular systolic dysfunction. Eur J Heart Fail 2005; 6:927-35. [PMID: 15556055 DOI: 10.1016/j.ejheart.2004.02.002] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2003] [Revised: 11/07/2003] [Accepted: 02/05/2004] [Indexed: 11/18/2022] Open
Abstract
AIM To determine by meta-analysis whether angiotensin-converting enzyme (ACE) inhibitors improve exercise tolerance in patients with symptomatic left ventricular systolic dysfunction (LVSD). METHODS AND RESULTS After literature search 13 multi-centre double blind parallel group trials that evaluated the effect of ACE inhibitors vs. placebo on exercise duration were selected. Ninety-four percent of patients were in New York Heart Association class II-IV. The studies were combined using the Cochrane meta-analysis program (Review manager version 4.1). Analyses according to treatment period, exercise protocols and publication periods were performed. Treatment with ACE inhibitor over 4-12 weeks resulted in a beneficial effect on exercise duration (P=0.003 and P=0.0008 for 4- and 12-weeks treatment, respectively), but the magnitude of improvements did not exceed 30 s corresponding to only 5% compared with placebo. CONCLUSION In addition to the pronounced effect on mortality and morbidity in patients with symptomatic LVSD, ACE inhibitors have improving effect on functional capacity measured as exercise tolerance time.
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Affiliation(s)
- Jawdat Abdulla
- Department of Cardiology P, Gentofte University Hospital, Niels Andersensvej 65, DK-2990 Hellerup, Denmark.
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Masoudi FA, Rumsfeld JS, Havranek EP, House JA, Peterson ED, Krumholz HM, Spertus JA. Age, functional capacity, and health-related quality of life in patients with heart failure. J Card Fail 2004; 10:368-73. [PMID: 15470645 DOI: 10.1016/j.cardfail.2004.01.009] [Citation(s) in RCA: 166] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although heart failure disproportionately affects older persons and is associated with significant physical disability, existing data on physical limitations and health-related quality of life (HRQL) derive largely from studies of younger subjects. We compared the relationship between functional limitation and HRQL between older and younger patients with heart failure. METHODS AND RESULTS We evaluated 546 outpatients with heart failure enrolled in a multicenter prospective cohort study. At baseline and 6 +/- 2 weeks later, functional status was assessed by New York Heart Association (NYHA) classification and 6-minute walk testing. HRQL was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ). Comparing older (age >65 years, n = 218) and younger patients (n = 328), we assessed baseline HRQL across strata of functional status. In the 484 patients who completed follow-up (194 older and 290 younger patients), we also assessed the changes in HRQL associated with changes in functional status over time. At baseline, older patients had better HRQL than younger patients (mean KCCQ score 60 +/- 25 versus 54 +/- 28, P = .005) in spite of worse NYHA class (mean 2.54 versus 2.35, P < .001) and lower 6-minute walk distances (824 +/- 378 versus 1064 +/- 371 feet, P < .001). After multivariable adjustment including baseline NYHA class, older age was independently correlated with better HRQL (beta = +7.9 points, P < .001). At follow-up, older patients with a deterioration in NYHA class experienced marked declines in HRQL compared with younger patients (mean HRQL change of -14.4 points versus +0.3 points, respectively, P < .001). Analyses using 6-minute walk distance as the functional measure yielded similar results. CONCLUSIONS Although older patients with heart failure have relatively good HRQL in spite of significant functional limitations, they are at risk for worsening HRQL with further decline in functional status. These results underscore the importance of treatments aimed at maintaining functional status in older persons with heart failure, including those with significant baseline functional limitations.
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Agustí A, Bonet S, Arnau JM, Vidal X, Laporte JR. Adverse effects of ACE inhibitors in patients with chronic heart failure and/or ventricular dysfunction : meta-analysis of randomised clinical trials. Drug Saf 2004; 26:895-908. [PMID: 12959631 DOI: 10.2165/00002018-200326120-00004] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
BACKGROUND The evidence-based benefit/risk evaluation of therapeutic interventions in randomised clinical trials should include both the assessment of the benefits and of the adverse outcomes. There is ample evidence that ACE inhibitors improve the symptoms and prognosis of chronic heart failure (CHF) and ventricular dysfunction. However, there is little systematic information on the tolerability and adverse effects associated with their use in these conditions. OBJECTIVE To estimate the adverse events related to ACE inhibitor use in the treatment of CHF and ventricular dysfunction. DESIGN AND METHODS Description of adverse events in reports of randomised clinical trials of ACE inhibitors in CHF or ventricular dysfunction was examined, and a meta-analysis was performed. Trials were included if they were placebo- or standard treatment-controlled, and if the treatment duration was at least 8 weeks. Relative risks and their 95% CIs were estimated with a random effects model. RESULTS Only 22 (43%) of 51 original reports contained information on the number of withdrawals and their causes. Missing information from the remaining 29 trials was obtained from the authors. The weighted mean duration of treatment was 100.2 weeks. After excluding administrative reasons, heart failure, myocardial infarction and hypertension, the withdrawal rates attributed to adverse events were 13.8% and 9.4% for the ACE inhibitor and control groups, respectively (RR = 1.54 [95% CI 1.30-1.83]; weighted difference = 3.1 per 100 treated patients [95% CI 1.8-4.4]). Cough, hypotension, renal dysfunction, dizziness, hyperkalaemia, and impotence were all significantly more prevalent among patients treated with ACE inhibitors than among those in the control groups. CONCLUSIONS Among patients with CHF or ventricular dysfunction enrolled in randomised clinical trials, treatment with an ACE inhibitor for an average of 2 years leads to an additional 3% of treatment withdrawals. In a significant proportion of the reports on these randomised clinical trials, information on adverse events leading to treatment withdrawal was inadequate. Proper evidence-based evaluation of the benefit/risk of therapeutic interventions needs a more systematic approach to reporting of adverse events experiences recorded in clinical trials.
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Affiliation(s)
- Antònia Agustí
- Fundació Institut Català de Farmacologia; Servei de Farmacologia Clínica, Hospital Universitari Vall d'Hebron, and Department of Pharmacology, Therapeutics and Toxicology, Universitat Autònoma de Barcelona, Barcelona, Spain
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Kittleson M, Hurwitz S, Shah MR, Nohria A, Lewis E, Givertz M, Fang J, Jarcho J, Mudge G, Stevenson LW. Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality. J Am Coll Cardiol 2003; 41:2029-35. [PMID: 12798577 DOI: 10.1016/s0735-1097(03)00417-0] [Citation(s) in RCA: 174] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study examined the hypothesis that patients who develop angiotensin-converting enzyme inhibitor intolerance attributable to circulatory-renal limitations (CRLimit) have more severe underlying disease and worse outcome. BACKGROUND Although the renin-angiotensin system contributes to the progression of heart failure (HF), it also supports the failing circulation. Patients with the most severe disease may not tolerate inhibition of this system. METHODS Consecutive inpatient admissions to the cardiomyopathy service of the Brigham and Women's Hospital between 2000 and 2002 were reviewed retrospectively for initial profiles, discharge medications, and documented reasons for discontinuation of angiotensin-converting enzyme inhibitors. Outcomes of death and transplantation were determined. RESULTS Of the 259 patients, 86 were not on an angiotensin-converting enzyme inhibitor at discharge. Circulatory-renal limitations of symptomatic hypotension, progressive renal dysfunction, or hyperkalemia were documented in 60 patients (23%); other adverse effects, including cough, in 24 patients; and absent reasons in 2 patients. Compared with patients on angiotensin-converting enzyme inhibitors, patients with CRLimit were older (60 vs. 55 years; p = 0.006), with longer history of HF (5 vs. 2 years; p = 0.009), lower systolic blood pressure (104 vs. 110 mm Hg; p = 0.05), lower sodium (135 vs. 138 mEql/l; p = 0.002), and higher initial creatinine (2.5 vs. 1.2 mg/dl; p = 0.0001). Mortality was 57% in patients with CRLimit and 22% in the patients on angiotensin-converting enzyme inhibitors during a median 8.5-month follow-up (p = 0.0001). CONCLUSIONS Development of CRLimit to angiotensin-converting enzyme inhibitor intolerance identifies patients with severe disease who are likely to die during the next year. New treatment strategies should be targeted to this population.
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Affiliation(s)
- Michelle Kittleson
- Departments of Medicine and Cardiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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Khalil ME, Basher AW, Brown EJ, Alhaddad IA. A remarkable medical story: benefits of angiotensin-converting enzyme inhibitors in cardiac patients. J Am Coll Cardiol 2001; 37:1757-64. [PMID: 11401108 DOI: 10.1016/s0735-1097(01)01229-3] [Citation(s) in RCA: 55] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The development of angiotensin-converting enzyme inhibitors (ACE inhibitors) has been one of the most remarkable stories in the treatment of cardiovascular diseases. Angiotensin converting enzyme inhibitors have several acute and sustained hemodynamic effects that are beneficial in the presence of left ventricular (LV) dysfunction. They increase cardiac output and stroke volume and reduce systemic vascular resistance as well as pulmonary capillary wedge pressure. The hemodynamic benefits are associated with improvement in the signs and symptoms of congestive heart failure (CHF) as well as decreased mortality, regardless of the severity of CHF. In patients with asymptomatic LV dysfunction, therapy with ACE inhibitors prevented the development of CHF and reduced hospitalization and cardiovascular death. They also increase survival when administered early after an acute myocardial infarction (MI). Most recently, ACE inhibition was associated with improved clinical outcomes in a broad spectrum of high-risk patients with preserved LV function. The mechanism of ACE inhibitors benefits is multifactorial and includes prevention of progressive LV remodeling, prevention of sudden death and arrhythmogenicity and structural stability of the atherosclerotic process. Evidence suggests that ACE inhibitors are underutilized in patients with cardiovascular diseases. Efforts should be directed to prescribe ACE inhibitors to appropriate patients in target doses. It is reasonable to believe that ACE inhibitors have a class effect in the management of LV dysfunction with or without CHF and acute MI. Whether the same is true for ACE inhibitors in the prevention of ischemic events is not known yet.
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Affiliation(s)
- M E Khalil
- Department of Medicine, Bronx-Lebanon Hospital Center, Albert Einstein College of Medicine, New York, USA
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Agustí Escasany A, Durán Dalmau M, Arnau De Bolós JM, Rodríguez Cumplido D, Diogène Fadini E, Casas Rodríguez J, Galve Basilio E, Manito Lorite N. [Evidence based medical treatment of heart failure]. Rev Esp Cardiol 2001; 54:715-34. [PMID: 11412778 DOI: 10.1016/s0300-8932(01)76387-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION AND OBJECTIVES Recommendations for the treatment of heart failure were carried out by a systematic review of the available evidence of the different pharmacologic treatments. MATERIAL AND METHODS The review focused on the treatment of chronic and systolic heart failure. All the studies published in english about the pharmacologic treatment of heart failure where identified. The evidence of every pharmacologic treatment was classified according to: a) efficacy variables (reduction of mortality and hospitalizations, improvement of functional class, ejection fraction and exercise tolerance), and b) the level of quality of the evidence according to an evaluation scale. The evidence was also reviewed for the comparisons and the combinations of the pharmacologic treatments, as well as for the toxicity and costs of treatments. RESULTS The recommendations were defined according to the NYHA functional class and were classified in the A, B and C categories according to the level of quality of the available evidence. The evidence on mortality was considered the most important. First line drugs, the alternatives and other possible treatments were take into account. CONCLUSIONS There is enough evidence based on information about some variables such as reduction of mortality or hospitalizations to carry out treatment recommendations in all stages of heart failure. This point out the interest ant the priority of used them in the evaluation and improvement of the results of heart failure.
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Affiliation(s)
- A Agustí Escasany
- Fundación Institut Català de Farmacologia. Servicios de Farmacología Clínica, Barcelona.
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Galatius S, Wroblewski H, Sørensen V, Haunsø S, Nørgaard T, Kastrup J. Reversal of peripheral microvascular dysfunction during long-term treatment with the angiotensin-converting enzyme inhibitor fosinopril in congestive heart failure. J Card Fail 1999; 5:17-24. [PMID: 10194656 DOI: 10.1016/s1071-9164(99)90020-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
BACKGROUND Treatment with angiotensin-converting enzyme (ACE) inhibitors in congestive heart failure (CHF) improves cardiac and peripheral hemodynamic function and exercise performance. However, studies on the effects of long-term treatment with an ACE inhibitor on the neurogenic and nonneurogenic regulation and structural microangiopathy of the peripheral microvasculature in CHF are lacking. METHODS AND RESULTS We investigated the effect of 12 weeks of treatment with the ACE inhibitor fosinopril on peripheral microvascular function in a double-blind, placebo-controlled study of 12 patients treated with fosinopril and 10 patients treated with placebo. All had moderate CHF. Microvascular blood flow and resistance were calculated after application of the local isotope washout method in relaxed and nonrelaxed calf vascular beds in the supine position and during head-up tilt. Skeletal muscle vascular resistance was reduced in the fosinopril group (46 +/- 6 to 30 +/- 1 mm Hg.mL-1.100 g.min +/- standard error; P < .05) and differed compared with the effect of placebo (P < .05) where no change was seen (37 +/- 11 to 55 +/- 13 mm Hg.mL-1.100 g.min; not significant [NS]). Also, skin minimal vascular resistance was reduced during fosinopril treatment (13 +/- 0.6 to 11 +/- 0.7 mm Hg.mL-1.100 g.min; P < .05) and differed compared with the effect of placebo (P < .05) with absence of change (12 +/- 1.6 to 14 +/- 1.4 mm Hg.mL-1.100 g.min; NS). CONCLUSIONS These results suggest that long-term ACE inhibitor treatment with fosinopril in patients with CHF improves hemodynamic status to as far as the peripheral microvascular level in both the relaxed and nonrelaxed microcirculation of the lower leg.
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Affiliation(s)
- S Galatius
- Heart Center, Rigshospital, University of Copenhagen, Denmark
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Sica DA, Gehr TWB, Kelleher N, Blumenthal M. Fosinopril: Emerging Considerations and Implications for Angiotensin-Converting Enzyme Inhibitor Therapy. ACTA ACUST UNITED AC 1998. [DOI: 10.1111/j.1527-3466.1998.tb00362.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Zannad F, Chati Z, Guest M, Plat F. Differential effects of fosinopril and enalapril in patients with mild to moderate chronic heart failure. Fosinopril in Heart Failure Study Investigators. Am Heart J 1998; 136:672-80. [PMID: 9778071 DOI: 10.1016/s0002-8703(98)70015-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
OBJECTIVES To investigate the efficacy and safety of fosinopril in the treatment of chronic heart failure (CHF), patients with mild to moderate CHF and left ventricular ejection fractions <40% were randomly assigned in a double-blind manner to receive fosinopril 5 to 20 mg every day (n = 122) or enalapril 5 to 20 mg every day (n = 132) for 1 year. RESULTS The event-free survival time was longer (1.6 vs 1.0 months, P= .032) and the total rate of hospitalizations plus deaths was smaller with fosinopril than with enalapril (19.7% vs 25.0%, P= .028). There was consistently better symptom improvement with fosinopril (P< .05). The incidence of orthostatic hypotension was lower in the fosinopril group (1.6% vs 7.6%, P< .05). CONCLUSIONS Fosinopril 5 to 20 mg every day was more effective in improving symptoms and delaying events related to worsening of CHF and produced less orthostatic hypotension than enalapril 5 to 20 mg every day.
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Affiliation(s)
- F Zannad
- Department of Cardiology, Centre d'Investigation Clinique INSERM-CHU, University Henri Poincaré, Nancy, France.
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Waeber B. The place of ACE inhibition in the modern therapeutic era: beyond blood pressure control. Introduction. J Cardiovasc Pharmacol 1998; 32 Suppl 2:v-vi. [PMID: 9736434 DOI: 10.1097/00005344-199800004-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
The use of angiotensin-converting enzyme (ACE) inhibitors has been generally beneficial in the treatment of many clinical conditions characterized by a significant degree of cardiovascular and renal involvement. Most of the available data on the benefits of ACE inhibitors have come from well-conducted large clinical trials that have provided much information supporting the use of ACE inhibitors, in agreement with the basic principles of evidence-based medicine. In particular, ACE inhibitors improve blood pressure control in patients with hypertension and have proved to be beneficial in patients with left ventricular (LV) systolic dysfunction and chronic congestive heart failure (CHF). Improved survival rates after the use of ACE inhibitors have been also demonstrated in patients with acute myocardial infarction (MI), whether or not the condition is complicated by acute CHF. More recently, some studies have demonstrated the ability of ACE inhibitors (particularly fosinopril) to prevent the long-term development of CHF in patients treated acutely during MI and without baseline LV dysfunction. ACE inhibitors appear to improve the long-term prognosis of patients with coronary artery disease (CAD) and to reduce the occurrence of re-infarction, as demonstrated in the Studies of Left Ventricular Dysfunction (SOLVD) trial and the Survival and Ventricular Enlargement study (SAVE). Finally, a protective role for ACE inhibitors has been reported even in diabetic hypertensive patients, in whom such agents can significantly reduce the occurrence of major cardiovascular events (CAD and stroke) with a pattern that is largely independent of blood pressure control and is not observed with the use of calcium antagonists. These data confirm the strong involvement of the renin-angiotensin system in the pathophysiology of vascular diseases and strongly support the role of ACE inhibitors as drugs for present and future therapy.
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Affiliation(s)
- C Borghi
- Department of Internal Medicine, University of Bologna, Italy
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Introduction. J Cardiovasc Pharmacol 1998. [DOI: 10.1097/00005344-199806322-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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