A review of Perindopril in the reduction of cardiovascular events

BACKGROUND

Angiotensin-converting enzyme inhibitors (ACEI) have a well-established role in the prevention of cardiovascular events in hypertension, left ventricular dysfunction, and heart failure. More recently, ACEI have been shown to prevent cardiovascular events in individuals with increased cardiovascular risk, where hypertension, left ventricular dysfunction, or heart failure was not the primary indication for ACEI therapy.

OBJECTIVE

To review studies of the effects of the ACEI perindopril on cardiovascular events.

METHOD

The EUROPA (European Trial on Reduction of Cardiac Events with Perindopril in Patients with Stable Coronary Artery Disease Study), PROGRESS (Perindopril Protection Against Recurrent Stroke Study), and ASCOT-BPLA (Anglo-Scandinavian Cardiac Outcomes Trial--Blood Pressure Lowering Arm) trials are reviewed.

RESULTS

Perindopril alone reduced cardiovascular events in subjects with stable coronary heart disease. Perindopril in combination with indapamide reduced cardiovascular events in subjects with cerebrovascular disease. Perindopril in combination with amlodipine reduced cardiovascular events in subjects with hypertension.

CONCLUSION

Perindopril reduced cardiovascular events. The reduction of cardiovascular events by perindopril was in large part associated with reduction of blood pressure, and greater reduction in cardiovascular events was associated with greater reduction of blood pressure. Perindopril may need to be combined with other antihypertensive agents to maximize reduction of cardiovascular events.

LF/(LF+HF) index in ventricular repolarization variability correlated and uncorrelated with heart rate variability

The purpose of this study, was to asses whether LF/(LF+HF) obtained from ventricular repolarization variability (VRV) reflects the state of sympathovagal balance. The VRV time series and heart rate variability (HRV) time series from seventy two electrocardiogram (ECG) records in four different autonomic nervous system (ANS) profiles (athletes, cardiac transplant patient, heart failure patients and normal subjects) were extracted. A dynamic linear parametric model was applied to separate the VRV in two parts, VRV correlated with HRV (VRV(r)) and VRV uncorrelated with HRV (VRV(u)). Spectral indices were obtained from HRV, VRV, VRV(u) and VRV(u) time series. Changes of these indicators from rest to tilt position were analyzed. Results showed that: i) only LF/(LF+HF) from HRV time series increases significantly from rest to tilt in all ANS profiles, this information could not be retrieved in the other three series (VRV, VRV (u) and VRV(u)) ii) LF/(LF+HF) index in HRV series are significantly different between normal subjects and heart failure patients, while cardiac transplant patients show a low coherence between HRV and VRV power spectra and iii) HF rhythm in VRV series seem to be related to the mechanical effect of respiration.

Candesartan in heart failure

Candesartan cilexetil is a nonpeptide selective blocker of the angiotensin II receptor sub-type 1. It is a prodrug that is converted to its active metabolite during its variable absorption. It is highly protein bound with a small volume of distribution and a nine-hour half-life. Candesartan is one of two angiotensin receptor blockers approved for use in heart failure. MEDLINE was searched using OVID and PubMed to evaluate the evidence for using candesartan in patients with heart failure. Pharmacologic and pharmacokinetic evaluations, as well as clinical trials, were selected and are presented in this review. Clinical evidence supports the indication for use in systolic heart failure. Results for use in patients with diastolic heart failure were non-significant. Candesartan was well tolerated in the trials, with hyperkalemia, renal dysfunction, and hypotension being the most common adverse events. Use of angiotensin receptor blockers with angiotensin-converting enzyme inhibitors needs further study; however, candesartan appears to provide added benefit in this setting. Candesartan is a safe and effective option for patients with systolic heart failure. Data regarding other angiotensin receptor blockers is underway.

Isosorbide dinitrate-hydralazine combination therapy in African Americans with heart failure

Despite significant improvement in therapy and management, heart failure remains a worrisome disease state that is especially problematic in special populations. African Americans suffer a disproportionately higher prevalence of heart failure when compared to other populations. It has been recently demonstrated that vasodilator therapy using the combination of isosorbide dinitrate (ISDN) and hydralazine (HYD) as an adjunct to background evidence-based therapy appears to display the strongest signal of benefit in reducing mortality and morbidity in the African American population. Through review of the retrospective and more recent prospective data, we will focus on the benefit of ISDN-HYD as adjunctive therapy for use in African Americans with systolic heart failure on concomitant appropriate evidence based therapy. This review also closely examines some of the potential contributions to endothelial dysfunction in African Americans, and the relationship of vascular homeostasis and nitric oxide. The role of oxidative stress in left ventricular dysfunction will also be explored as a reduction of oxidative stress offers particular promise in the management of heart failure. Although neurohormonal blockade has been responsible for notable event reductions in patients with systolic heart failure, the addition of ISDN-HYD, vasodilator therapy that enhances nitric oxide and reduces oxidative stress, further improves quality of life and survival in African American patients with heart failure. These findings strongly imply that nitric oxide enhancement and/or oxidative stress reduction may be important new therapeutic directions in the management of heart failure.

Selection of patients for cardiac resynchronisation therapy (CRT) in an unselected heart failure population

BACKGROUND

In patients with chronic heart failure (CHF), the presence of conduction delay across the myocardium is a well-known feature. During recent years an increasing number of CHF patients have been treated with cardiac resynchronisation therapy (CRT). So far in many protocols patients have been selected using the criteria of left ventricular ejection fraction (LVEF) ≤35% concomitant with signs of widening of the QRS on the surface electrocardiogram, either with or without left bundle branch block (LBBB) morphology.

METHODS

In this article we discuss which of the patients admitted with CHF to a regular cardiology practice could be candidates for this therapy. Data were obtained from January 2000 to December 2004 on a total of 861 CHF patients, of whom 309 had an LVEF ≤35%. Of these patients, 123 patients showed a QRS width >120 msec, while 81 patient had a QRS width >140 msec. In total, 89 patients had an LBBB morphology on the electrocardiogram, while 21 patients had univentricular pacing devices in situ. In those patients with an LVEF >35%, QRS width was 108±27msec.

CONCLUSION

A substantial number of patients presenting with CHF in a regular cardiology practice are suitable candidates for CRT therapy according to currently used criteria of QRS width and LVEF. This number could be increased even more if recent information concerning intraventricular conduction delay in CHF patients with less widening of the QRS complex were to be applied, as judged by echocardiographic techniques.

Digoxin and reduction in mortality and hospitalization in heart failure: a comprehensive post hoc analysis of the DIG trial

AIMS

To determine the effects of digoxin on all-cause mortality and heart failure (HF) hospitalizations, regardless of ejection fraction, accounting for serum digoxin concentration (SDC).

METHODS AND RESULTS

This comprehensive post-hoc analysis of the randomized controlled Digitalis Investigation Group trial (n=7788) focuses on 5548 patients: 1687 with SDC, drawn randomly at 1 month, and 3861 placebo patients, alive at 1 month. Overall, 33% died and 31% had HF hospitalizations during a 40-month median follow-up. Compared with placebo, SDC 0.5-0.9 ng/mL was associated with lower mortality [29 vs. 33% placebo; adjusted hazard ratio (AHR), 0.77; 95% confidence interval (CI), 0.67-0.89], all-cause hospitalizations (64 vs. 67% placebo; AHR, 0.85; 95% CI, 0.78-0.92) and HF hospitalizations (23 vs. 33% placebo; AHR, 0.62; 95% CI, 0.54-0.72). SDC> or =1.0 ng/mL was associated with lower HF hospitalizations (29 vs. 33% placebo; AHR, 0.68; 95% CI, 0.59-0.79), without any effect on mortality. SDC 0.5-0.9 reduced mortality in a wide spectrum of HF patients and had no interaction with ejection fraction >45% (P=0.834) or sex (P=0.917).

CONCLUSIONS

Digoxin at SDC 0.5-0.9 ng/mL reduces mortality and hospitalizations in all HF patients, including those with preserved systolic function. At higher SDC, digoxin reduces HF hospitalization but has no effect on mortality or all-cause hospitalizations.

Left ventricular pacing in patients with congestive heart failure

Cardiac resynchronisation therapy (CRT) using biventricular (BIV) pacing has proved its effectiveness to correct myocardial asynchrony and improve clinical status of patients with severe congestive heart failure (CHF) and widened QRS. Despite a different effect on left ventricular electrical dispersion, left univentricular (LV) pacing is able to achieve the same mechanical synchronisation as BIV pacing in experimental studies and in humans. This results in clinical benefits of LV pacing at mid-term follow-up, with significant improvement in functional class, quality of life and exercise tolerance at the same extent as those observed with BIV stimulation in non randomised studies. Furthermore these benefits are obtained at lesser costs and with conventional dual-chamber devices. However, LV pacing has to be compared to BIV pacing in randomised trials before being definitely considered as a cost-effective alternative to BIV pacing.

Serum cystatin C levels to predict serum concentration of digoxin in Japanese patients

Cystatin C (Cys-C) has been recently paid great attention as a better endogenous marker of the glomerular filtration rate than creatinine (Cr). In this study, the usefulness of Cys-C was compared with Cr in terms of the estimation of the steady-state serum trough concentrations of digoxin in Japanese patients. Forty patients treated with digoxin and 56 healthy elderly subjects were participated in this study. The serum levels of Cys-C and Cr in the patients were higher than those in the healthy elderly subjects, but the increase of Cys-C was more predominant in the patients. Their levels were well-correlated for both of the healthy elderly subjects (r=0.691) and patients (r=0.774), but the serum concentrations of digoxin were better correlated with those of the reciprocal values of Cr (r=0.667) than those of Cys-C (r=0.383), presumably due to the fact that digoxin and Cr were excreted via both glomerular filtration and tubular secretion. Cys-C is useful for the substratification of the patients diagnosed to have normal renal function with Cr of < 1.3 mg/dL into those with normal and pseudo-normal renal function, resulting in the corresponding serum concentrations of digoxin.

Cost-effectiveness of eplerenone plus standard treatment compared with standard treatment in patients with myocardial infarction complicated by left ventricular systolic dysfunction and heart failure in the Netherlands

AIMS

Following the results of the EPHESUS study in patients with heart failure after myocardial infarction, a cost-effectiveness analysis was undertaken from a Dutch societal perspective to evaluate the lifetime benefits and costs of eplerenone as add-on to standard treatment.

METHODS

Life-years gained in the eplerenone arm during the trial period were extrapolated to lifetime life-years gained using three sources of life expectancy data (Framingham Heart Study, Saskatchewan Health Database and Worcester Heart Attack Registry). Resource use measured included direct medical costs of hospitalisation, medications including eplerenone, outpatient diagnostic tests and procedures, and emergency room visits. Incremental cost-effectiveness ratios were calculated for life-years gained and quality-adjusted life-years gained.

RESULTS

Eplerenone prolonged lifetime survival by five weeks at an additional cost of €803. The incremental cost-effectiveness ratio was about €8000 per life-year gained, well below the only published Dutch benchmark for cost-effectiveness of €18,000. Probabilistic sensitivity analyses showed the results to be robust when varying the discount rate applied to benefits and costs, the hospitalisation costs, and the source of life expectancy data used.

CONCLUSION

Treatment with adjunctive eplerenone is effective in preventing deaths and prolonging life.

Measuring quality of life in heart failure: one versus multiple items

BACKGROUND

Symptoms of heart failure and consequences of treatment can have a great impact on patients' lives. Improving quality of life is generally recognised as one of the major goals of treatment. The purpose of this study was to determine the relationship between a one-item quality-of-life measure (Ladder of Life) and the Minnesota Living with Heart Failure Questionnaire and possible equality.

METHOD

231 patients who were admitted with symptoms of chronic heart failure to a cardiology ward in a general hospital (53% male, age 75±11, LVEF 40±16) completed the Minnesota Living with Heart Failure Questionnaire (MLwHFQ) and were asked to rate their sense of well-being on the Ladder of Life (10= best possible life, 0= worst possible life). Demographic and clinical data were obtained by chart review.

RESULTS

The overall well-being score on the Ladder of Life correlated significantly with the total MLwHFQ (r=-0.36, p<0.001). However, there is a large variation in MLwHFQ scores (12-83) in patients who score a relatively high overall well-being (>6, relatively good Q0L). A large variation in MLwHFQ scores (10-105) also exists in patients with a relatively low score on the Ladder of Life (<1, low QOL).

CONCLUSION

Assessment of quality of life with a simple and practical tool using the one-item Ladder of Life can give clinicians and researchers important information on the quality of life of patients. Whether such a single-item question is responsive enough to detect changes in treatment and predict readmission needs to be studied in more detail.

Relationship of the implantable cardioverter defibrillator and chronic resynchronization therapy: the perfect marriage?

BACKGROUND

The two major modes of death in the patient with a reduced ejection fraction (EF) are death due to heart failure and death due to lethal arrhythmia, essentially the two sides of the same coin. Over the last 20 years, two therapies-cardiac resynchronization therapy (CRT) and the implantable cardioverter defibrillator (ICD)-have been developed and tested in clinical trials. They are now, in conjunction with appropriate medical therapy, the mainstays of therapy for these two commonly encountered clinical problems.

METHOD AND RESULTS

Both of these therapies were conceived and patented by two Baltimore cardiologists, Michel Mirowski and Morton Mower (Table I). The path to everyday acceptance of both therapies was remarkably similar. The concept and early success of both devices was accomplished but the proof of concept depended on a series of carefully designed randomized clinical trials that showed that both the CRT and ICD devices saved lives in the low EF population, especially when used together. These trials overcame substantial skepticism on behalf of elements of the cardiology and electrophysiology establishment.

CONCLUSION

We are now at a crossroads in the further extension of either therapy. The majority of the indications for either device alone or in combination are established. In the next few years, assuming the continued commitment on the part of regulatory agencies to fully embrace evidence-based medicine, we will see indications extended but only by the careful clinical trials that became the bedrock of their initial acceptance.

Cardiac amyloidosis

Systemic amyloidosis commonly affects the heart. Indeed, cardiac symptoms may be the first clinical indicator of underlying amyloid deposition. Using two case studies, this article reviews the latest evidence regarding cardiac amyloidosis. The diagnosis of cardiac involvement can be established through imaging with echocardiography and magnetic resonance. Supportive evidence may be gained from biochemical markers such as serum N-terminal probrain natriuretic peptide (NT-proBNP). The main clinical consequences of amyloid deposition are cardiac failure and rhythm disturbances. Attempts to cure the underlying disease process with chemotherapy and/or cardiac and/or liver transplantation have had variable results. Stem-cell transplantation is associated with significant mortality in the context of cardiac involvement. Although newer therapeutic agents are emerging, the overall outlook at this time remains poor.

Pharmaceutical care of patients with heart failure

AIM

The aim of this study was to investigate the impact of a pharmacist-led pharmaceutical care programme, involving optimization of drug treatment and intensive education and self-monitoring of patients with heart failure (HF) within the United Arab Emirates (UAE), on a range of clinical and humanistic outcome measures.

METHODS

The study was a randomized, controlled, longitudinal, prospective clinical trial at Al-Ain Hospital, Al-Ain, UAE. Patients were recruited from the general medical wards and from cardiology and medical outpatient clinics. HF patients who fulfilled the entrance criteria, and had no exclusion criteria present, were identified for inclusion in the study. After recruitment, patients were randomly assigned to one of two groups: intervention group or control group. Intervention patients received a structured pharmaceutical care service while control patients received traditional services. Patient follow-up took place when patients attended scheduled outpatient clinics (every 3 months). A total of 104 patients in each group completed the trial (12 months). The patients were generally suffering from mild to moderate HF (NYHA Class 1, 29.5%; Class 2, 50.5%; Class 3, 16%; and Class 4, 4%).

RESULTS

Over the study period, intervention patients showed significant (P < 0.05) improvements in a range of summary outcome measures [AUC (95% confidence limits)] including exercise tolerance [2-min walk test: 1607.2 (1474.9, 1739.5) m.month in intervention patients vs. 1403.3 (1256.5, 1549.8) in control patients], forced vital capacity [31.6 (30.8, 32.4) l.month in the intervention patients vs. 27.8 (26.8, 28.9) in control patients], health-related quality of life, as measured by the Minnesota living with heart failure questionnaire [463.5 (433.2, 493.9) unit.month in intervention patients vs. 637.5 (597.2, 677.7) in control patients; a lower score in this measure indicates better health-related quality of life]. The number of individual patients who reported adherence to prescribed medications was higher (P < 0.05) in the intervention group (85 vs. 35), as was adherence to lifestyle advice (75 vs. 29) at the final assessment (12 months). There was a tendency to have a higher incidence of casualty department visits by intervention patients, but a lower rate of hospitalization.

CONCLUSIONS

The research provides clear evidence that the delivery of pharmaceutical care to patients with HF can lead to significant clinical and humanistic benefits.

Heart failure with preserved left ventricular systolic function: a hospital cohort study

OBJECTIVE

To investigate how patients with heart failure with preserved left ventricular systolic function (LVSF) compare with patients with reduced LVSF.

DESIGN

Cohort study.

SETTING

Urban university hospital.

PATIENTS

528 index emergency admissions with heart failure during the year 2000. Information on LVSF and follow up was available for 445 (84%) of these patients.

RESULTS

130 (29%) patients had preserved LVSF (defined as an ejection fraction > 40%). The median follow up was 814 days (range 632-978 days). The average (SD) age was 72 (13) years. Women accounted for 62% and 45% of patients with preserved and reduced LVSF, respectively (p = 0.001). Patients with preserved LVSF (compared with those with reduced LVSF) had a higher prevalence of left ventricular hypertrophy (56% v 29%) and aortic valve disease (mean gradient > 20 mm Hg; 31% v 9%). Fewer patients with preserved LVSF received an angiotensin converting enzyme inhibitor (65% v 78%, p = 0.008) or spironolactone (12% v 21%, p = 0.027). Anaemia tended to occur more often in patients with preserved LVSF than in those with reduced LVSF (43% v 33% for women, p = 0.12; 59% v 49% for men, p = 0.22). There was a similarly high prevalence of significant renal dysfunction in both groups (estimated glomerular filtration rate < 60 ml/min/1.73 m2 in 68% with preserved and 64% with reduced LVSF, p = 0.40). Mortality was similar in both groups (preserved versus reduced 51 (39%) v 132 (42%), p = 0.51). Compared with patients with reduced LVSF, patients with preserved LVSF tended to have a lower risk of death or hospital admission for heart failure (56 (42%) v 165 (53%), p = 0.072) but a similar rate of death or readmission for any reason.

CONCLUSION

Patients with preserved LVSF had more co-morbid problems than those with reduced LVSF; however, prognosis was similar for both groups.

Systematic review of multidisciplinary interventions in heart failure

OBJECTIVE

To determine the impact of multidisciplinary interventions on hospital admission and mortality in heart failure.

DESIGN

Systematic review. Thirteen databases were searched and reference lists from included trials and related reviews were checked. Trial authors were contacted if further information was required.

SETTING

Randomised controlled trials conducted in both hospital and community settings.

PATIENTS

Trials were included if all, or a defined subgroup of patients, had a diagnosis of heart failure.

INTERVENTIONS

Multidisciplinary interventions were defined as those in which heart failure management was the responsibility of a multidisciplinary team including medical input plus one or more of the following: specialist nurse, pharmacist, dietician, or social worker. Interventions were separated into four mutually exclusive groups: provision of home visits; home physiological monitoring or televideo link; telephone follow up but no home visits; and hospital or clinic interventions alone. Pharmaceutical and exercise based interventions were excluded.

MAIN OUTCOME MEASURES

All cause hospital admission, all cause mortality, and heart failure hospital admission.

RESULTS

74 trials were identified, of which 30 contained relevant data for inclusion in meta-analyses. Multidisciplinary interventions reduced all cause admission (relative risk (RR) 0.87, 95% confidence interval (CI) 0.79 to 0.95, p = 0.002), although significant heterogeneity was found (p = 0.002). All cause mortality was also reduced (RR 0.79, 95% CI 0.69 to 0.92, p = 0.002) as was heart failure admission (RR 0.70, 95% CI 0.61 to 0.81, p < 0.001). These results varied little with sensitivity analyses.

CONCLUSION

Multidisciplinary interventions for heart failure reduce both hospital admission and all cause mortality. The most effective interventions were delivered at least partly in the home.

Cardiac KATP channels in health and disease

ATP-sensitive potassium (K(ATP)) channels are evolutionarily conserved plasma-membrane protein complexes, widely represented in tissue beds with high metabolic activity. There, they are formed through physical association of the inwardly rectifying potassium channel pore, most typically Kir6.2, and the regulatory sulfonylurea receptor subunit, an ATP-binding cassette protein. Energetic signals, received via tight integration with cellular metabolic pathways, are processed by the sulfonylurea receptor subunit that in turn gates the nucleotide sensitivity of the channel pore thereby controlling membrane potential dependent cellular functions. Recent findings, elicited from genetic disruption of channel proteins, have established in vivo the requirement of intact K(ATP) channels in the proper function of cardiac muscle under stress. In the heart, where K(ATP) channels were originally discovered, channel ablation compromises cardioprotection under ischemic insult. New data implicate the requirement of intact K(ATP) channels for the cardiac adaptive response to acute stress. K(ATP) channels have been further implicated in the adaptive cardiac response to chronic (patho)physiologic hemodynamic load, with K(ATP) channel deficiency affecting structural remodeling, rendering the heart vulnerable to calcium-dependent maladaptation and predisposing to heart failure. These findings are underscored by the identification in humans that defective K(ATP) channels induced by mutations in ABCC9, the gene encoding the cardiac sulfonylurea receptor subunit, confer susceptibility to dilated cardiomyopathy. Thus, in parallel with the developed understanding of the molecular identity and mode of action of K(ATP) channels since their discovery, there is now an expanded understanding of their critical significance in the cardiac stress response in health and disease.

Acute pulmonary congestion in patients with systolic heart failure versus diastolic heart failure: experience of a heart emergency unit

BACKGROUND

Acute pulmonary congestion can be caused by systolic and diastolic heart failure. Whether this distinction is reflected in clinical outcome is unknown.

AIM

To compare outcome after an episode of acute pulmonary congestion in patients with systolic heart failure and diastolic heart failure.

METHODS

A retrospective, descriptive study was conducted on consecutive patients who presented with acute pulmonary congestion. Clinical outcome was evaluated based on mortality, number of hospital re-admissions, visits to the cardiology outpatient clinic and cardiovascular events.

RESULTS

Altogether 86 patients were enrolled in this study: 59 patients (68%) had systolic dysfunction and 27 (32%) had diastolic dysfunction. Mean age was 75.6±11.0 in the systolic heart failure group and 80.1±9.4 years in the diastolic heart failure group. Mean follow-up was 427 days. Men and women were equally distributed between both patient groups. Re-admission and mortality rates were comparable between both groups. When combining cardiovascular events and mortality, patients with diastolic heart failure had more favourable outcome after acute pulmonary congestion than patients with systolic heart failure (37 vs. 70%, p=0.03).

CONCLUSION

The proportions of patients presenting with acute pulmonary congestion due to diastolic heart failure were comparable with those found in literature. Patients were mainly elderly and as often male as female. Readmission and mortality rates were comparable between both patient groups. However, patients with diastolic heart failure had a more favourable prognosis when combining cardiovascular events and mortality.

Xanthine oxidase inhibition for chronic heart failure: is allopurinol the next therapeutic advance in heart failure?

A substantial body of evidence has accumulated to suggest a role for the xanthine oxidase metabolic pathway in the pathophysiology of chronic heart failure and other cardiovascular diseases.