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Quality of Life following Coronary Artery Bypass Graft Surgery versus Guideline-based Medical Therapy in Ischemic Cardiomyopathy  

14 Oct, 14 | by Alistair Lindsay

It remains uncertain if surgical revascularization improves patient outcomes in the setting of coronary artery disease with reduced systolic function. This is particularly true in light of the STICH trial, a contemporary randomized control trial of coronary artery bypass graft surgery (CABG) with optimal medical therapy compared to optimal medical therapy alone in patients with ischemic left ventricular dysfunction. The primary results of the STICH trial demonstrated no overall mortality benefit to CABG with medical therapy compared to medical therapy alone. In this study, the trial authors report quality of life outcomes from the STICH trial. The trial randomized 1212 patients with an ejection fraction ≤35% with coronary anatomy suitable for surgical revascularization to either CABG with medical therapy or medical therapy alone. more…

Beta-blockers in heart failure – what is the impact of concurrent atrial fibrillation?            

14 Oct, 14 | by Alistair Lindsay

Beta-blockers form an essential cornerstone of therapy for heart failure with reduced ejection fraction. However, the benefits of beta-blockade for heart failure in patients with concurrent atrial fibrillation are less certain. In this meta-analysis of individual-patient data from 10 randomized control trials comparing beta-blockers to placebo for systolic heart failure, investigators assessed the impact of beta-blockade by the presence of sinus rhythm or atrial fibrillation at baseline. Of the 18,254 patients assessed, 76% were in sinus rhythm and 17% were in atrial fibrillation at baseline. Over 1.5 years of mean follow-up, beta-blocker therapy was associated with a significant mortality benefit in sinus rhythm patients (HR 0.73, 0.67-0.80; p<0.001) but not in patients with atrial fibrillation (HR 0.97, 0.83-1.14; p=0.73). Results did not vary by subgroup of patients with atrial fibrillation or for secondary outcomes which included cardiovascular death, cardiovascular hospital admission, and non-fatal stroke. more…

A new PARADIGM in heart failure treatment?

14 Oct, 14 | by Alistair Lindsay

Natriuretic peptides are released in response to cardiac-wall stress and other stimuli of heart failure. These potent natriuretic and vasodilatory peptides also inhibit the renin-angiotensin system and sympathetic drive. The neutral endopeptidase neprilysin is responsible for the degradation of several of these natriuretic peptides. Inhibition of neprilysin increases the level of these natriuretic peptides, thus potentially enhancing the beneficial effects of standard therapies to suppress the renin angiotensin system. In the PARADIGM-HF randomized controlled trial, the ACE inhibitor enalapril at a dose of 10mg twice a day was compared with the experimental drug LCZ696, which was a combination of the ARB valsartan and the neprilysin inhibitor sacubitril. This combination was chosen in response to prior studies that demonstrated combining a neprilysin inhibitor with an ARB reduced the risk of angioedema. more…

Spironolactone for heart failure with preserved ejection fraction

8 Jun, 14 | by Alistair Lindsay

Nearly half of all patients presenting with heart failure have normal or near normal left ventricular systolic function.  Optimal treatment strategies for this large patient group remain unclear.  Small mechanistic studies have suggested diastolic function may be improved by mineralocorticoid-receptor antagonists.  Whether this mechanistic benefit translates into better patient outcomes is not known.  In the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trial, 3445 patients with heart failure and an ejection fraction of 45% or more were randomised in a double-blind fashion to either spironolactone (15 to 45 mg daily) or placebo.  The primary outcome was a composite of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for the management of heart failure with patients.  Over a mean follow-up period of 3.3 years, the primary outcome occurred in 18.6% of the spironolactone group and 20.4% of the placebo group (HR, 0.89; 95% CI, 0.77 to 1.04; P=0.14).  Compared with placebo, spironolactone resulted in a statistically significant reduction in hospitalizations for heart failure (206 patients vs. 245 patients, HR, 0.83; 95% CI, 0.69 to 0.99, P=0.04).  Use of spironolactone came at a cost of increased rates of hyperkaliemia (18.7%, vs. 9.1%), but no differences in serious adverse events. more…

No Benefit from Cardiac Resynchronization Therapy in Patients with a Narrow QRS Complex

28 Nov, 13 | by Alistair Lindsay

Cardiac-resynchronization therapy (CRT) has known benefits in patients with severe left ventricular systolic dysfunction and prolonged QRS duration (>120 ms).  However, up to half of patients with systolic dysfunction appear to have left ventricular dyssynchrony by echocardiographic measures, despite a QRS duration of less than 120 ms.  As a result, CRT is often used for patients with echocardiographic evidence of dyssynchrony and a narrow QRS complex, despite a lack of clear benefit to this approach.  The Echocardiography Guided Cardiac Resynchronization Therapy (EchoCRT) study sought to determine the effect of CRT on patient outcomes in the setting of symptomatic heart failure, echocardiographic findings of dyssynchrony, and QRS duration <120 ms. more…

BNP-based screening for heart failure

3 Jul, 13 | by Alistair Lindsay

The increasing prevalence of heart failure emphasises the need for effective prevention strategies; brain-type natriuretic peptide (BNP) has been found to identify those at highest risk of cardiovascular events and heart failure.  Therefore the purpose of this study was to determine whether using BNP and collaborative care could reduced newly diagnosed heart failure cases and the prevalence of significant left ventricular systolic and/or diastolic dysfunction (LV). more…

CELLWAVE: bone marrow cells improve ventricular function

21 Apr, 13 | by Alistair Lindsay

In patients with chronic postinfarction heart failure, bone marrow-derived mononuclear cell (BMC) therapy has demonstrated mixed results to date.  One possible reason for this is that cell retention by the heart is more difficult in the stable setting in comparison to therapies given following acute myocardial infarction, however a recent discovery found that extracorporeal application of focused low-energy shock waves can upregulate chemokine expression and improve homing and attachment of cell therapies.  The purpose of this study was to determine whether this new technique could improve left ventricular ejection fraction (LVEF) in patients with chronic heart failure. more…

Erythropoietin fails to improve outcomes in heart failure

3 Apr, 13 | by Alistair Lindsay

Anaemia is common in patients with systolic heart failure and is associated with lower functional capacity, worse quality of life, and higher rates of hospitalization and death. The cause of anaemia in these patients is often unclear but may be related to an absolute or relative deficiency of, or resistance to, erythropoietin. In this study Swedberg et al. evaluated the effects of erythropoietin replacement with darbepoetin alfa on clinical outcomes in patients with systolic heart failure and anaemia. more…

Sildenafil shows no benefit in HFPEF

3 Apr, 13 | by Alistair Lindsay

Heart failure with preserved ejection fraction (HFPEF) is now felt to be the most common form of heart failure in the community, and is associated with significant morbidity and mortality. Currently, effective therapies are needed as trials of traditional renin-angiotensin antagonists have failed to show an improvement in outcomes or clinical status. Experimental work has suggested that phosphodiesterase-5 inhibitors may be able to enhance cardiovascular function and this exercise capacity in HFPEF. more…

Berlin heart beats ECMO for childhood heart failure

20 Oct, 12 | by Alistair Lindsay

Heart failure is uncommon in children but carries a poor prognosis with 46% of children with severe systolic dysfunction dying or undergoing transplantation within five years. Survival among children after heart transplantation is 83% at 3 years, but the limited availability of donor hearts prolongs the waiting period, resulting in a high rate of death whilst on waiting lists.  Options for mechanical circulatory support have been limited in children, with one choice being extracorporeal membrane oxygenation (ECMO); however, this is only capable of providing shot term support at best. More recently, the Excor Paediatric pulsatile-flow ventricular assist device (Berlin Heart) has become available in a wide range of sizes. more…

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