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Givertz MM, Cohn JN. Pharmacologic Management of Heart Failure in the Ambulatory Setting. Cardiovasc Ther 2007. [DOI: 10.1016/b978-1-4160-3358-5.50020-6] [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: 10/20/2022] Open
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Abstract
Unlike heart failure with a low ejection fraction, there is no evidence-based treatment for heart failure with preserved ejection fraction which improves clinical outcomes. Indeed, the only evidence for any treatment effect comes from small studies with verapamil where this drug increased exercise capacity and reduced a heart failure score. Large trials are presently underway which are examining the effect of treatment with an ACE inhibitor, ARB and aldosterone antagonist in patients with heart failure and preserved ejection fraction.
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Affiliation(s)
- Karen Hogg
- Department of Cardiology, Clinical Research Initiative in Heart Failure, University of Glasgow Western Infirmary, Glasgow, G11 6NT, United Kingdom
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Witte KKA, Nikitin NP, Cleland JGF, Clark AL. Excessive breathlessness in patients with diastolic heart failure. Heart 2006; 92:1425-9. [PMID: 16621875 PMCID: PMC1861064 DOI: 10.1136/hrt.2005.081521] [Citation(s) in RCA: 34] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2006] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To establish the prevalence of preserved left ventricular (LV) systolic function (PSF) in 435 consecutive symptomatic patients referred to a heart failure clinic and to examine their ventilatory response to exercise when compared with 134 control volunteers. METHODS 216 (50%) patients had systolic heart failure (SHF) (ejection fraction < 45%). 51 (11%) had an immediately apparent alternative causes of breathlessness and 168 (39%), with no obvious other cause of breathlessness, were divided into those with PSF and diastolic dysfunction (DD) (PSF(DD); n = 113 or 26% of referrals) and those without DD (PSF(N); n = 55 or 13% of referrals). The controls were divided into those with (C(DD); n = 32) and those without (C(N); n = 102) echocardiographic evidence of DD. RESULTS Patients with SHF had lower peak oxygen consumption (pVo(2)), steeper slope of minute ventilation (Ve) to carbon dioxide production, lower exercise time and shorter 6 min walk test than PSF patients and controls. PSF(DD) patients had lower pVo(2), exercise time and 6 min walk test than C(DD), although their echocardiograms were not different. Exercise capacity did not differ between PSF(DD) and PSF(N) patients. The slope relating Ve to symptoms (Borg/Ve slope) was less steep in those with SHF than in PSF(DD) (0.17 (0.04) v 0.20 (0.08), p < 0.05) and in PSF(N) (0.19 (0.10), p < 0.05), implying greater symptoms of breathlessness for a given level of Ve. Both PSF groups had a steeper slope than C(DD) (0.14 (0.09), p < 0.05 for both comparisons). CONCLUSIONS Patients with PSF have exercise tolerance intermediate between that of patients with SHF and controls. Exercise tolerance is similar in PSF(DD) and PSF(N). Both groups have worse exercise tolerance than C(DD). PSF(DD) and PSF(N) patients seem to experience a greater awareness of Ve than C(DD) and patients with SHF.
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Affiliation(s)
- K K A Witte
- Department of Academic Cardiology, Castle Hill Hospital, Kingston upon Hull, UK.
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54
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Mangoni AA, Jackson SHD. The implications of a growing evidence base for drug use in elderly patients Part 2. ACE inhibitors and angiotensin receptor blockers in heart failure and high cardiovascular risk patients. Br J Clin Pharmacol 2006; 61:502-12. [PMID: 16669842 PMCID: PMC1885051 DOI: 10.1111/j.1365-2125.2006.02610.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
Traditionally, angiotensin converting enzyme (ACE) inhibitors have been used for the management of patients with congestive cardiac failure. Studies performed over the last decade have demonstrated that (1) angiotensin receptor blockers (ARBs) are as effective as ACE inhibitors in reducing morbidity and mortality in cardiac failure; and (2) inhibition of the renin-angiotensin system provides beneficial effects in patients at high cardiovascular risk without cardiac failure. This review focuses on the applicability of the results of the main trials with ACE inhibitors and ARBs to the elderly population.
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Affiliation(s)
- A A Mangoni
- Department of Clinical Pharmacology and Centre for Neuroscience, Flinders University, Adelaide, Australia.
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55
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Abstract
PURPOSE OF REVIEW beta-Blockers, angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists, and digoxin are the most common drug classes used to treat chronic heart failure. We examine current clinical trial evidence concerning heart-failure management in the elderly. RECENT FINDINGS beta-Blockers provide significant mortality benefit to elderly heart-failure patients and are remarkably well tolerated. Angiotensin-converting-enzyme inhibitors improve mortality and morbidity in systolic heart failure. However, the risk/benefit relationship of angiotensin-converting-enzyme therapy in the elderly has not been adequately determined. Angiotensin II receptor blockers improve morbidity in elderly and non-elderly chronic heart-failure patients; however, data are limited regarding mortality in these patients. Aldosterone receptor antagonists provide significant mortality benefit to elderly chronic heart-failure patients. Digoxin is beneficial as an additive therapy in the treatment of systolic heart failure regardless of advanced age. SUMMARY Agents that provide substantive clinical benefit overall also appear to do so in the elderly, based on subgroup analysis of major trials. There have been very few prospective, placebo-controlled trials specifically in elderly heart-failure patients. Elderly heart-failure patients generally tolerate standard chronic heart-failure therapies well. Standard chronic heart-failure therapies should not be withheld from elderly patients based on concerns regarding efficacy or fear of medication intolerance.
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Affiliation(s)
- Brian R Dulin
- NHMRC Centre of Clinical Research Excellence in Therapeutics, Department of Epidemiology, Monash University and Alfred Hospital, Melbourne, Australia
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Grigorian Shamagian L, Roman AV, Ramos PM, Veloso PR, Bandin Dieguez MA, Gonzalez-Juanatey JR. Angiotensin-Converting Enzyme Inhibitors Prescription Is Associated With Longer Survival Among Patients Hospitalized for Congestive Heart Failure Who Have Preserved Systolic Function: A Long-Term Follow-Up Study. J Card Fail 2006; 12:128-33. [PMID: 16520261 DOI: 10.1016/j.cardfail.2005.09.001] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2005] [Revised: 08/30/2005] [Accepted: 09/02/2005] [Indexed: 01/14/2023]
Abstract
BACKGROUND The use of inhibitors of angiotensin-converting enzyme (ACE) is strongly indicated by a diagnosis of congestive heart failure (CHF) with deteriorated systolic function (SF), but their effects on patients with CHF but no systolic deterioration have not been clarified. We focused this study on the evaluation of the influence of ACE inhibitors on survival among CHF patients with preserved SF, but also determined the effect of these drugs on the prognosis of our patients with deteriorated SF. METHOD AND RESULTS We studied 416 patients, aged 72.7 +/- 10.2 years, who between January 1, 1991, and December 31, 2001, were admitted to the cardiology service of a tertiary hospital for CHF and who fulfilled the requirements that left ventricular SF that had been evaluated echocardiographically during hospitalization was preserved and that data were available on medication at the time of their release from hospital. Two hundred four patients (49.0%) were men, 250 (60.8%) were hypertensive, and, in 171 (41.1%) cases, ischemic cardiopathy was the primary cause of the CHF. ACE inhibitors were prescribed to 210 patients (50.5%) on hospital release. Kaplan-Meier survival curve analysis showed that, among patients with preserved SF, a longer survival was associated with ACE inhibitors use (mean survival 6.14 years as compared with 4.57 years in the control group, P < .001; adjusted hazard ratio = 0.63, P = .012). Similar results were obtained in CHF patients with deteriorated SF in whom those taking ACE inhibitors had significantly longer life with mean survival 6.42 years compared with 5.03 years in the control group (P < .001; adjusted hazard ratio = 0.62, P = .001). CONCLUSION ACE inhibitors prescription is associated with a better prognosis of patients with CHF and preserved SF.
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Affiliation(s)
- Lilian Grigorian Shamagian
- Servicio de Cardiologia, Hospital Clinico de Santiago de Compostela, Departmento de Medicina, Facultad de Medicina de Santiago de Compostela, Spain
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Shibata MC, Soneff CM, Tsuyuki RT. Utilization of evidence-based therapies for heart failure in the institutionalized elderly. Eur J Heart Fail 2005; 7:1122-5. [PMID: 16043409 DOI: 10.1016/j.ejheart.2005.03.005] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2004] [Accepted: 03/03/2005] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES Heart failure (HF) is a major source of morbidity and mortality in elderly populations. A significant proportion of the elderly with HF are living in long-term care facilities. Little is known about their management. The aim of this study was to evaluate the use of evidence-based therapies in institutionalized elderly patients with HF. DESIGN, SETTING AND PARTICIPANTS Retrospective chart review conducted at 15 long-term care facilities in the Capital Health Region (Edmonton, Alberta). Residents > or =65 years of age with HF were identified using a pharmacy database. RESULTS Overall prevalence of HF was 15% (313/2062 residents). Mean age was 87 years, median duration of residence was 1.8 years. Utilization of ACE-inhibitors, beta-blockers and spironolactone was 51%, 16% and 10%, respectively. Use of these medications was not significantly different between subgroups of those with and without contraindications to the therapies, different advance directive levels, gender or age. Sodium and fluid restricted diets were prescribed in only 11.0% and 3.8% of residents. Weight was not regularly monitored. Influenza and pneumococcal vaccination were administered to 60.4% and 81.2% of the residents. CONCLUSION The use of evidence-based therapies in institutionalized elderly patients with HF is low, and unexplained by contraindications or advance directives. Efforts to increase the utilization of evidence-based therapies and improve monitoring are warranted.
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Affiliation(s)
- Marcelo C Shibata
- EPICORE Centre, Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Canada
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58
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Wu EB, Yu CM. Management of diastolic heart failure--a practical review of pathophysiology and treatment trial data. Int J Clin Pract 2005; 59:1239-46. [PMID: 16178994 DOI: 10.1111/j.1368-5031.2005.00642.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
The lack of large randomised controlled trials to guide therapy in diastolic heart failure causes some difficulties for evidence-based medicine practising clinicians. Traditionally, treatments for systolic heart failure have been highjacked for diastolic heart failure without much proof of benefit. However, recent studies have began to provide some evidence base for our practice. Betablockers and angiotensin receptor antagonists have recently been shown to reduce hospitalisation in large randomised controlled trials. Diuretic based antihypertensive regimes have been shown to reduce heart failure by 50%. Left ventricular hypertrophy regression is likely to be a good surrogate endpoint for diastolic heart failure, although definitive proof for this is not yet available. Angiotensin receptor antagonists, ACEI, calcium channel blockers, diuretics and aldosterone blockers have all been shown to cause left ventricular hypertrophy regression. We recommend these drugs to achieve strict blood pressure control together with dietary and lifestyle modification for the treatment of diastolic heart failure. We emphasise the importance of rate control, as diastolic heart-failure patients tolerate tachycardia poorly. We further argue that the pathophysiology of diastolic heart failure is part of systolic heart failure and the two should not be thought of as separate entities. Therefore, our traditional practice of using systolic heart failure treatments for diastolic heart failure is theoretically sound and should not cause us undue anxiety.
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Affiliation(s)
- E B Wu
- Division of Cardiology, Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University Hong Kong, Shatin, Hong Kong.
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Hori M, Kitabatake A, Tsutsui H, Okamoto H, Shirato K, Nagai R, Izumi T, Yokoyama H, Yasumura Y, Ishida Y, Matsuzaki M, Oki T, Sekiya M. Rationale and Design of a Randomized Trial to Assess the Effects of β-blocker in Diastolic Heart Failure; Japanese Diastolic Heart Failure Study (J-DHF). J Card Fail 2005; 11:542-7. [PMID: 16198251 DOI: 10.1016/j.cardfail.2005.04.003] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2004] [Revised: 03/31/2005] [Accepted: 04/07/2005] [Indexed: 11/28/2022]
Abstract
BACKGROUND Heart failure consists of two phenotypes: systolic heart failure and diastolic heart failure (DHF). A growing body of evidence demonstrated benefits of beta-blocker, angiotensin-converting enzyme inhibitor, and angiotensin II receptor blocker in systolic heart failure; however, evidence leading to therapeutic strategy of DHF is lacking. METHODS AND RESULTS The Japanese Diastolic Heart Failure Study (J-DHF) is a multicenter, prospective, randomized trial designed to assess effects of beta-blocker in patients with DHF. A total of 800 patients (400 patients in each group) will be enrolled. The primary outcome is a composite of cardiovascular death and unplanned admission to hospital for congestive heart failure. Other outcomes include all-cause mortality, worsening of the symptoms of heart failure, or a need for modification of the treatment for heart failure. Serial assessment of echocardiographic and neurohumoral parameters and cost analysis of the treatment regimen will be conducted. The follow-up period is a minimum of 2 years. CONCLUSION This study will provide important evidences for the treatment of DHF.
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Affiliation(s)
- Masatsugu Hori
- Department of Internal Medicine and Therapeutics, Osaka University Graduate School of Medicine, Yamadaoka, Suita, Japan
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Rosolova H, Cech J, Simon J, Spinar J, Jandova R, Widimský sen J, Holubec L, Topolcan O. Short to long term mortality of patients hospitalised with heart failure in the Czech Republic-a report from the EuroHeart Failure Survey. Eur J Heart Fail 2005; 7:780-3. [PMID: 16051521 DOI: 10.1016/j.ejheart.2005.03.009] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2004] [Accepted: 03/03/2005] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND AND AIM The European Society of Cardiology initiated the EuroHeart Failure Survey to obtain more data about the quality of care in patients hospitalised with suspected heart failure (HF). The Czech Republic was 1 of the 24 European Society countries included in the survey. The aim of this report is to extend the original follow-up period of 12 weeks out to 4 years to assess mortality. METHODS All admitted patients were screened according to the EuroHeart Survey Protocol, over a 6-week period in six hospitals in Pilsen, Prague and Brno in the year 2000. Annual mortality and cause of death were obtained from the Prague Institute for Health Statistical Information (UZIS Praha). RESULTS A total of 2365 patients were screened and about 25% of all admitted patients fulfilled the criteria for HF. About 14% of patients died between admission and the 12-week follow-up, 36% of male and 42% of female patients died during the 4-year follow-up (2000-2003). Cardiovascular diseases were the main causes of death (92%). Deceased patients were significantly older, had lower haemoglobin and total plasma cholesterol level, and had renal insufficiency and higher levels of big endothelin and BNP than the survivors. Mortality risk was increased independently by positive history of previous myocardial infarction OR=2.39 (1.59-3.59), by age OR=1.03 (1.01-1.05) and by plasma creatinine level OR=1.04 (1.01-1.07). Treatment with diuretics and digoxin was associated with a higher risk of death; by contrast, a protective effect of beta-blockers and statins was found in these HF patients. CONCLUSION Patients with HF were older and had a poor prognosis; approximately one third of the patients will die within 3 years.
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Affiliation(s)
- Hana Rosolova
- Centre of Preventive Cardiology of the 2nd Medical Department University Hospital, E. Benese 13, 305 99 Pilsen, Czech Republic.
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Gottdiener JS, Bednarz J, Devereux R, Gardin J, Klein A, Manning WJ, Morehead A, Kitzman D, Oh J, Quinones M, Schiller NB, Stein JH, Weissman NJ. American Society of Echocardiography recommendations for use of echocardiography in clinical trials. J Am Soc Echocardiogr 2005; 17:1086-119. [PMID: 15452478 DOI: 10.1016/j.echo.2004.07.013] [Citation(s) in RCA: 329] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
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Wisniacki N, Taylor W, Lye M, Wilding JPH. Insulin resistance and inflammatory activation in older patients with systolic and diastolic heart failure. Heart 2005; 91:32-7. [PMID: 15604330 PMCID: PMC1768659 DOI: 10.1136/hrt.2003.029652] [Citation(s) in RCA: 50] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE To evaluate insulin resistance and systemic inflammation in older patients with systolic (SHF) or diastolic heart failure (DHF). PATIENTS 52 non-diabetic patients (> 70 and < 90 years old) with chronic heart failure (CHF) and hospitalised within the previous six months for heart failure were studied, together with a control group of older healthy volunteers (n = 26). On the basis of Doppler echocardiographic criteria patients were classed as having SHF (n = 27) or DHF (n = 25). MAIN OUTCOME MEASURES Fasting glucose, insulin, C reactive protein, interleukin 6, and tumour necrosis factor alpha soluble receptor II (TNF-alphaSRII) concentrations were determined. Insulin resistance was estimated by the homeostasis model assessment (HOMA). RESULTS HOMA index (median, interquartile range) was higher in patients with DHF (1.77, 1.06-2.26) than in patients with SHF (0.97, 0.81-1.85) or healthy volunteers (1.04, 0.76-1.44; p = 0.01). After adjustment for body mass index, age, and use of angiotensin converting enzyme inhibitors, both groups of patients with CHF were more insulin resistant than were healthy volunteers (p = 0.02). C reactive protein, interleukin 6, and TNF-alphaSRII were all significantly (p < 0.001) higher in patients with DHF and SHF than in healthy volunteers. All markers of systemic inflammation were independently associated with the presence of clinical CHF. CONCLUSION Insulin resistance and inflammatory activation are present in older patients with SHF and DHF.
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Affiliation(s)
- N Wisniacki
- Diabetes and Endocrinology Research Group, Department of Medicine, University of Liverpool, Liverpool, UK.
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Ceia F, Fonseca C, Mota T, Morais H, Matias F, Costa C, Oliveira AG. Aetiology, comorbidity and drug therapy of chronic heart failure in the real world: the EPICA substudy. Eur J Heart Fail 2004; 6:801-6. [PMID: 15542420 DOI: 10.1016/j.ejheart.2004.09.003] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2004] [Accepted: 09/08/2004] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Chronic heart failure (CHF) is common and is frequently managed by primary care physicians (PCPs). Despite the European Society of Cardiology (ESC) Guidelines, standard treatments for CHF are frequently underutilised, particularly in primary care. AIM To evaluate current drug therapy for CHF in adults with HF diagnosed according to ESC guidelines in the context of the EPICA study. Aetiological features and therapy relevant comorbidities were also analysed. METHODS EPICA was a community-based epidemiological study conducted in mainland Portugal. The study involved 365 primary care physicians, who evaluated 6300 primary care attendees aged over 25 years. CHF was diagnosed by clinical and echocardiography criteria according to ESC guidelines. RESULTS Total of 551 cases of CHF were identified, with a mean age of 65+/-9 years. The estimated overall prevalence of CHF in the Portuguese population was 4.4%; 1.3% with and 1.7% without left ventricular systolic dysfunction (LVSD). There are 6,280,792 people aged >25 years in Portugal, which extrapolates to 261,400 cases of heart failure. About 80% of patients had a history of hypertension, 39% had a history of coronary artery disease and 15% had atrial fibrillation. Only 58% of patients were on angiotensin-converting enzyme (ACE) inhibitors and 7% on beta-blockers. The type of ventricular dysfunction, age and presence of renal failure had little effect on prescription rates. Diuretics were prescribed in 78%. Thiazides were used more frequently in those with preserved systolic function and frusemide in those with left ventricular systolic dysfunction. Digoxin was prescribed more often to patients with than without left ventricular systolic dysfunction (34% vs. 17%; p=0.02). Long-acting nitrates were prescribed to 20% and amiodarone to 8% of patients. CONCLUSION The EPICA study, as in other studies in primary care in Europe, particularly the IMPROVEMENT study, suggests that greater efforts are required to improve training of primary care teams in the management of CHF.
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Affiliation(s)
- Fátima Ceia
- Department of Medical Therapeutics, Medical Sciences School, New University of Lisbon, Portugal.
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Thomas MD, Fox KF, Coats AJS, Sutton GC. The epidemiological enigma of heart failure with preserved systolic function. Eur J Heart Fail 2004; 6:125-36. [PMID: 14984719 DOI: 10.1016/j.ejheart.2003.11.002] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2002] [Revised: 09/16/2003] [Accepted: 11/13/2003] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Current epidemiological evidence suggests that the prevalence of preserved systolic function in patients with heart failure varies widely from 13 to 74%. This inconsistency suggests a lack of consensus as to what this condition really is and how it has been characterised for epidemiological studies. AIMS In this review, we summarise and discuss the current understanding of the epidemiology of heart failure with preserved systolic function and the challenges that this raises. METHODS Studies were identified from Medline and Embase Literature Database searches using the subject headings heart failure, diastolic heart failure, epidemiology, incidence, prevalence, diagnosis, prognosis and mortality. RESULTS Sixty-one studies of congestive heart failure with preserved systolic function were reviewed. There is great diversity in the criteria used to determine whether heart failure is present, the patient population, the setting of the study and methods of evaluating left ventricular function. This makes epidemiological studies of prevalence, morbidity and mortality impossible to compare. CONCLUSIONS The diagnosis of this syndrome might be better defined in terms of symptoms, elevated neuro hormones and impaired cardiac workload. This would allow accurate identification of cases so that further research could be conducted to measure outcome and assess therapeutic benefit.
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Affiliation(s)
- Martin D Thomas
- Cardiovascular Medicine, National Heart and Lung Institute, Imperial College, Charing Cross Campus, Fulham Palace Road, London SW3 6LY, UK.
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Zile M, Gaasch W, Little W, Francis G, Tavazzi L, Cleland J, Davies M. A phase II, double-blind, randomized, placebo-controlled, dose comparative study of the efficacy, tolerability, and safety of MCC-135 in subjects with chronic heart failure, NYHA class II/III (MCC-135-GO1 study): rationale and design. J Card Fail 2004; 10:193-9. [PMID: 15190528 DOI: 10.1016/j.cardfail.2003.10.004] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Chronic heart failure (CHF) can be caused either by a predominant abnormality in systolic function (systolic heart failure) or a predominant abnormality in diastolic function (diastolic heart failure). Randomized clinical trials have identified a number of pharmaceutical agents that can reduce morbidity and mortality in patients with systolic heart failure. Despite significant therapeutic advances, systolic heart failure continues to result in high rates of morbidity and mortality. In contrast to systolic heart failure, no randomized clinical trials have been performed in patients with diastolic heart failure. Common to the mechanisms causing both systolic and diastolic heart failure are abnormalities in calcium homeostasis. Mitsubishi Pharma Corporation has developed a compound (MCC-135, INN; caldaret) whose mechanism of action is proposed to be modulation of calcium homeostasis at the sarcoplasmic reticulum and cellular membrane. The purpose of this study was to test the safety, tolerability, and efficacy of MCC-135 in patients with mild to moderate heart failure. METHODS This was a phase II, multicenter, randomized, double-blind study of parallel group design comparing 3 oral dose regimens of MCC-135 (5 mg, 25 mg, 50 mg, twice daily) with a placebo control. The treatment period was 24 weeks. A total of 511 patients were recruited from 69 centers in the United States and Europe. One hundred and twenty-five patients were recruited in each of the 4 treatment groups. Patients in each treatment group were divided into 2 cohorts: those with an ejection fraction < or = 40%, and those with an ejection fraction >40% as determined by core laboratory analysis of echocardiographic studies. CONCLUSION Patient recruitment was completed in September 2002. Patient follow-up was completed by February 2003; the results will be available for release in 2004.
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Affiliation(s)
- Michael Zile
- Cardiology Division, Department of Medicine, Gazes Cardiac Research Institute, Medical University of South Carolina, and the Ralph H. Johnson, Department of Veterans Affairs Medical Center, Charleston, 29425, USA
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Abstract
Heart failure with normal systolic function has been equated to diastolic heart failure (DHF). DHF appears to be quite common in the elderly, especially in elderly women with hypertension. Recent epidemiologic studies suggest that 30%-50% of patients with heart failure may have DHF. Morbidity for DHF is considerable and comparable to that of heart failure with left ventricular systolic dysfunction. Both groups of patients have similar rates of recurrent hospitalization and cost of care. Long-term mortality also appears to be similar in the two groups of patients. With the aging of the population, the numbers of patients with DHF will continue to rise and are likely to contribute significantly to the burden of disease caused by heart failure. Unfortunately, as yet, no reliable definition has been found for DHF. Currently the diagnosis of DHF is often made by exclusion, and treatment is empirical and unsatisfactory because of the lack of large-scale, randomized, controlled trials in this area; however, several large and other smaller trials are currently in progress that will hopefully provide some answers.
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Affiliation(s)
- Prithwish Banerjee
- Department of Cardiology, University of Hull, Castle Hill Hospital, Cottingham, Kingston upon Hull, HU16 5JQ, United Kingdom.
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Lapu-Bula R, Ofili E. Diastolic heart failure: The forgotten manifestation of hypertensive heart disease. Curr Hypertens Rep 2004; 6:164-70. [PMID: 15128466 DOI: 10.1007/s11906-004-0064-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Heart failure (HF) is a progressively debilitating disorder characterized by frequent hospital admissions and high annual mortality rates. Coronary artery disease (CAD), hypertension, and aging are major risk factors for the development/progression of HF. For years, most of the attention has been focused on HF caused by reduced left ventricular (LV) systolic function, largely attributable to CAD. It is now generally accepted that nearly 50% of elderly patients with HF might have normal or preserved LV systolic function. This condition is commonly referred to as a distinct type of HF caused by LV diastolic dysfunction, and it often accompanies hypertensive heart disease. Isolated diastolic HF is increasingly recognized as the dominant cause of symptoms and hospitalizations from HF in a large proportion of individuals aged 65 and older. However, the clinicians caring for patients with diastolic HF do not fully understand its cause, how it progresses, or how it could be appropriately diagnosed and treated. Because varying degrees of systolic and diastolic dysfunction might coexist in any individual patient, and given the limitation of current diagnostic tools, the overall impact of isolated diastolic HF continues to evolve. Ongoing clinical trials are testing new strategies for treatment of diastolic HF.
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Affiliation(s)
- Rigobert Lapu-Bula
- Division of Cardiology, Department of Medicine, Morehouse School of Medicine, 720 Westview Drive SW, Atlanta, GA 30310, USA
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Witte KKA, Desilva R, Chattopadhyay S, Ghosh J, Cleland JGF, Clark AL. Are hematinic deficiencies the cause of anemia in chronic heart failure? Am Heart J 2004; 147:924-30. [PMID: 15131553 DOI: 10.1016/j.ahj.2003.11.007] [Citation(s) in RCA: 89] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Anemia in chronic heart failure (CHF) is common, varying in prevalence between 14.4% and 55%, and is more frequent in patients with more severe heart failure. Patients with CHF who have anemia have a poorer quality of life, higher hospital admission rates, and reduced exercise tolerance. We explored the relation between hematinic levels and hemoglobin (Hb) levels and exercise tolerance in a group of patients with CHF. METHODS We analyzed data from 173 patients with left ventricular systolic dysfunction (LVSD), 123 patients with symptoms of heart failure, but preserved left ventricular (LV) systolic function ("diastolic dysfunction"), and 58 control subjects of similar age. Each underwent echocardiography, a 6-minute walk test, and blood tests for renal function and Hb and hematinic levels (vitamin B12, iron, and folate). We classified patients as having no anemia (Hb level >12.5 g/dL), mild anemia (Hb level from 11.5-12.5 g/dL), or moderate anemia (Hb level <11.5 g/dL). RESULTS Of patients with LVSD, 16% had moderate anemia and 19% had mild anemia. Of patients with preserved LV function, 16% had moderate anemia and 17% had mild anemia. Four control subjects had a Hb level <12.5 g/dL. Of all patients, 6% were vitamin B12 deficient, 13% were iron deficient, and 8% were folate deficient. There was no difference between patients with LVSD and the diastolic dysfunction group. In patients with LVSDS, the average Hb level was lower in New York Heart Association class III than classes II and I. The distance walked in 6 minutes correlated with Hb level in both groups of patients with CHF (r = 0.29; P <.0001). Patients with anemia achieved a lower pVO2 (15.0 [2.3] vs 19.5 [4.4], P <.05). Peak oxygen consumption correlated with Hb level (r = 0.21, P <.05) in the patients, but not in the control subjects. In patients with anemia, the mean creatinine level was higher than in patients with a Hb level >12.5 g/dL, but there was no clear relationship with simple regression. Hematocrit level and mean corpuscular volume were not different in the patients with diastolic dysfunction, patients with LV dysfunction, or the control subjects. Hematocrit levels were not influenced by diuretic dose. Patients with anemia were not more likely to be hematinic deficient than patients without anemia. CONCLUSIONS Patients with symptoms and signs of CHF have a high prevalence of anemia (34%) whether they have LV dysfunction or diastolic dysfunction, but few patients have hematinic deficiency. Hemoglobin levels correlate with subjective and objective measures of severity and renal function.
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Affiliation(s)
- Klaus K A Witte
- Division of Academic Cardiology, Castle Hill Hospital, Cottingham, United Kingdom.
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Hogg K, Swedberg K, McMurray J. Heart failure with preserved left ventricular systolic function; epidemiology, clinical characteristics, and prognosis. J Am Coll Cardiol 2004; 43:317-27. [PMID: 15013109 DOI: 10.1016/j.jacc.2003.07.046] [Citation(s) in RCA: 553] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2003] [Revised: 06/26/2003] [Accepted: 07/21/2003] [Indexed: 11/30/2022]
Abstract
Recent cross-sectional, population-based echocardiographic studies show that about half of all patients with heart failure have preserved left ventricular systolic function (HF-PSF). Cohort studies of hospitalized patients show a smaller proportion of HF-PSF. Compared to those with reduced systolic function, patients with HF-PSF are more often female, older, less likely to have coronary artery disease, and more likely to have hypertension. Patients with HF-PSF are less symptomatic and receive different pharmacologic therapy than patients with reduced systolic function. Morbidity and mortality rates in patients with HF-PSF are high but not quite as high as in patients with reduced systolic function. Though much has recently been learned about the syndrome of HF-PSF, many questions remain to be answered, not least how it should be treated.
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Affiliation(s)
- Karen Hogg
- Department of Cardiology, Western Infirmary, Glasgow G12 8QQ, Scotland, United Kingdom
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71
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Klapholz M, Maurer M, Lowe AM, Messineo F, Meisner JS, Mitchell J, Kalman J, Phillips RA, Steingart R, Brown EJ, Berkowitz R, Moskowitz R, Soni A, Mancini D, Bijou R, Sehhat K, Varshneya N, Kukin M, Katz SD, Sleeper LA, Le Jemtel TH. Hospitalization for heart failure in the presence of a normal left ventricular ejection fraction. J Am Coll Cardiol 2004; 43:1432-8. [PMID: 15093880 DOI: 10.1016/j.jacc.2003.11.040] [Citation(s) in RCA: 299] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2003] [Revised: 11/08/2003] [Accepted: 11/17/2003] [Indexed: 11/24/2022]
Abstract
OBJECTIVES We conducted a prospective multicenter registry in a large metropolitan area to define the clinical characteristics, hospital course, treatment, and factors precipitating decompensation in patients hospitalized for heart failure with a normal ejection fraction (HFNEF). BACKGROUND The clinical profile of patients hospitalized for HFNEF has been characterized by retrospective analyses of hospital records and state data banks, with few prospective single-center studies. METHODS Patients hospitalized for heart failure (HF) at 24 medical centers in the New York metropolitan area and found to have a left ventricular (LV) ejection fraction of > or 50% within seven days of admission were included in this registry. Patient demographics, signs and symptoms of HF, coexisting and exacerbating cardiovascular and medical conditions, treatment, laboratory tests, procedures, and hospital outcomes data were collected. Analysis by gender and race was prespecified. RESULTS Of 619 patients, 73% were women, who were on average four years older than men (72.8 +/- 14.1 years vs. 68.6 +/- 13.8 years, p < 0.001). Black non-Hispanic patients comprised 30% of the study population. They were eight years younger than other patients (66.0 +/- 14.2 years vs. 74 +/- 13.5 years p < 0.001). Co-morbid conditions and their prevalence were: hypertension, 78%; increased LV mass, 82%; diabetes, 46%; and obesity, 46%. Before clinical decompensation that precipitated hospitalization, 86% of patients had chronic symptoms compatible with New York Heart Association functional classes II to IV. Factors precipitating clinical decompensation were identified in 53% of patients. In-hospital mortality was 4.2%. CONCLUSIONS Patients hospitalized for HFNEF are most often chronically incapacitated elderly women with a history of hypertension and increased LV mass. Reasons for clinical decompensation are identified in only one-half of patients.
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Affiliation(s)
- Marc Klapholz
- Saint Vincent Catholic Medical Centers, New York, New York, USA
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Shinozaki T, Watanabe J, Kikuchi J, Tamaki K, Hoshi N, Hayashi M, Onodera Y, Hiramoto T, Ikeda J, Sakuma M, Fukuchi M, Sugi M, Kagaya Y, Shirato K. Rationale, Design, and Organization of the Diastolic Heart Failure Assessment Study in Tohoku District (DIAST). Circ J 2004; 68:660-4. [PMID: 15226632 DOI: 10.1253/circj.68.660] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND High mortality and a high readmission rate characterize diastolic heart failure (DHF), but evidence-based therapeutic strategies have not been established for DHF. METHODS The aim of a multicenter, randomized open trial (the Diastolic Heart Failure Assessment Study in Tohoku District, DIAST) is to evaluate the safety and prognostic efficacy of the multiple action non-selective beta-blocker carvedilol in 160 patients with DHF (left-ventricular ejection fraction > or =50%). The target dose of carvedilol is 10 mg twice a day and the mean follow-up is estimated to be 2 years. The primary endpoints are to evaluate (1) all-cause mortality or hospitalization, (2) cardiovascular mortality or hospitalization and (3) worsening heart failure. The secondary endpoints are to assess (1) cardiovascular events, (2) the individual components of the above combined endpoints, (3) the duration of hospitalization, (4) the functional class and exercise capacity and (5) the safety and tolerability. All patients' data are processed using an original registration system on an internet homepage. Several substudies to assess neurohumoral factors, heart rate variability, oxidative stress and sleep apnea will clarify the pathophysiology of DHF. CONCLUSIONS The DIAST will contribute to establish therapeutic guidelines for DHF.
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73
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Lamb RE, King D. Left ventricular diastolic dysfunction: risks, identification, and treatment. PROGRESS IN CARDIOVASCULAR NURSING 2004; 19:31-6. [PMID: 15017155 DOI: 10.1111/j.0889-7204.2004.02893.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/29/2023]
Abstract
Risk factors of cardiovascular disease, such as hypertension, diabetes, and myocardial infarction, if left untreated, will increase the risk of the development of chronic heart failure. Much is known about the pathophysiology and effective treatments of chronic heart failure from left ventricular systolic dysfunction; however, little clinical trial evidence exists concerning benefits of treating patients with chronic heart failure and preserved systolic function, also known as left ventricular diastolic dysfunction. Rather, an understanding of the pathophysiology and patient signs and symptoms has usually dictated choice of treatments. With the results of ongoing trials, as well as the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM)-Preserved and the Digitalis Investigation Group (DIG) trials, clinical evidence is accumulating to support effective treatments in patients with left ventricular diastolic dysfunction. The focus of this review is to discuss the risks of, identification of, and rationale for therapeutic choices being employed for treating left ventricular diastolic dysfunction and implications from studies that may support these choices.
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Affiliation(s)
- Robert E Lamb
- Medical Affairs, AstraZeneca LP, 1800 Concord Pike, Wilmington, DE 19850, USA.
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74
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Tamargo J, López-Sendón J. Bases y evidencias clínicas de los efectos de los nuevos tratamientos farmacológicos en la insuficiencia cardíaca. Rev Esp Cardiol 2004. [DOI: 10.1016/s0300-8932(04)77129-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
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Coletta AP, Cleland JGF, Freemantle N, Loh H, Memon A, Clark AL. Clinical trials update from the European Society of Cardiology: CHARM, BASEL, EUROPA and ESTEEM. Eur J Heart Fail 2003; 5:697-704. [PMID: 14607210 DOI: 10.1016/s1388-9842(03)00161-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
This article contains a series of reports on recent research developments in the field of heart failure. Reports of key presentations made at the European Society of Cardiology meeting, held in Vienna, Austria, between 30 August and 3 September 2003 are reported. In the CHARM study, candesartan reduced cardiovascular deaths and hospital admissions for heart failure, both in patients who were already taking an ACE-inhibitor and in those who were ACE intolerant. However, results in patients with preserved left ventricular function were less conclusive. The BASEL study supports the use of B-type natriuretic peptide testing to confirm the diagnosis of heart failure in patients presenting with acute dyspnoea. In EUROPA, the largest ever study of secondary prevention of coronary artery disease, long-term treatment with perindopril reduced the incidence of cardiovascular death, myocardial infarction (MI) and cardiac arrest. The ESTEEM study showed that the oral thrombin inhibitor ximelagatran plus aspirin was more effective than aspirin alone in the prophylaxis of major cardiovascular events following MI.
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Affiliation(s)
- Alison P Coletta
- Department of Cardiology, University of Hull, Castle Hill Hospital, Cottingham, Kingston-upon-Hull HU15 5JQ, UK.
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Abstract
Chronic heart failure is an increasingly common cause of premature death and poor quality of life. Community-based epidemiological studies have provided much-needed information on the demography of chronic heart failure, providing insight into its influence on public health. In most patients, chronic heart failure is accompanied by a range of concomitant disorders that both contribute to the cause of the disease and have a key role in its progression and response to treatment. Information on the most common comorbidities in chronic heart failure--ischaemic heart disease, hypertension, and diabetes mellitus--is presented for prespecified subgroups in the reports of many large-scale, multicentre trials; despite their limitations, these subanalyses provide guidance in therapeutic decision-making. Similarly, because chronic heart failure is commonly an endpoint in intervention trials of both hypertension and diabetes, such studies afford important information on the prevention of chronic heart failure in these common diseases.
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78
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Krishnan P, Ventura HO, Uber PA, Arcement LM, Mehra MR. Treatment of hypertension for patients with diastolic dysfunction. Curr Opin Cardiol 2003; 18:272-7. [PMID: 12858125 DOI: 10.1097/00001573-200307000-00006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Diastolic dysfunction is a poorly understood pathophysiological entity; its importance is magnified by the increasing prevalence of diastolic heart failure. Forty-six million people in the US are experiencing heart failure and 550000 new cases are diagnosed annually. A large percentage of these patients with heart failure have a normal or nearly normal left-ventricular ejection fraction. Isolated diastolic dysfunction may be associated with an increased mortality. One of the major causes of diastolic dysfunction is hypertension. Advances in diagnosis and treatment strategies may improve the clinical outcome for patients with diastolic dysfunction.
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79
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Krum H, Liew D. New developments in the pharmacological treatment of chronic heart failure. Expert Opin Investig Drugs 2003; 12:751-7. [PMID: 12720487 DOI: 10.1517/13543784.12.5.751] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
In recent years, rapid growth in the understanding of the pathophysiology of chronic heart failure has allowed for insights into many potential new therapeutic strategies. Yet until now, despite sound biological basis for efficacy and success in early-Phase studies, novel agents have not stood up to the scrutiny of late-Phase clinical trials. Indeed, remarkably negative results have been observed for vasopeptidase inhibitors, endothelin receptor antagonists and agents which block immune activation. However, efficacy data from other novel agents are still awaited, including the selective aldosterone receptor antagonist eplerenone, arginine vasopressin inhibitors, erythropoietin and hydroxy-methyl-glutaryl coenzyme A reductase inhibitors. Other classes of drugs which may enter clinical development include cardiac metabolic agents, matrix metalloproteinase inhibitors and advanced glycation end product antagonists. That the mortality and morbidity of patients with chronic heart failure remain unacceptably high makes the ongoing commitment to exploration of new drug therapies for the condition critical.
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Affiliation(s)
- Henry Krum
- Department of Medicine, Monash University Central and Eastern Clinical School, Alfred Hospital, Melbourne, Victoria 3004, Australia.
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80
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Utilidad del perindopril en insuficiencia cardíaca leve-moderada en la práctica clínica diaria. Estudio MÉTRICA. Rev Clin Esp 2003. [DOI: 10.1016/s0014-2565(03)71184-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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81
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Cleland JGF, Cohen-Solal A, Aguilar JC, Dietz R, Eastaugh J, Follath F, Freemantle N, Gavazzi A, van Gilst WH, Hobbs FDR, Korewicki J, Madeira HC, Preda I, Swedberg K, Widimsky J. Management of heart failure in primary care (the IMPROVEMENT of Heart Failure Programme): an international survey. Lancet 2002; 360:1631-9. [PMID: 12457785 DOI: 10.1016/s0140-6736(02)11601-1] [Citation(s) in RCA: 380] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Heart failure is a prevalent condition that is generally treated in primary care. The aim of this study was to assess how primary-care physicians think that heart failure should be managed, how they implement their knowledge, and whether differences exist in practice between countries. METHODS The survey was undertaken in 15 countries that had membership of the European Society of Cardiology (ESC) between Sept 1, 1999, and May 31, 2000. Primary-care physicians' knowledge and perceptions about the management of heart failure were assessed with a perception survey and how a representative sample of patients was managed with an actual practice survey. FINDINGS 1363 physicians provided data for 11062 patients, of whom 54% were older than 70 years and 45% were women. 82% of patients had had an echocardiogram but only 51% of these showed left ventricular systolic dysfunction. Ischaemic heart disease, hypertension, diabetes mellitus, atrial fibrillation, and major valve disease were all common. Physicians gave roughly equal priority to improvement of symptoms and prognosis. Most were aware of the benefits of ACE inhibitors and beta blockers. 60% of patients were prescribed ACE inhibitors, 34% beta blockers but only 20% received these drugs in combination. Doses given were about 50% of targets suggested in the ESC guidelines. If systolic dysfunction was documented, ACE inhibitors were more likely and beta blockers less likely to be prescribed than when there was no evidence of systolic dysfunction. INTERPRETATION Results from this survey suggest that most patients with heart failure are appropriately investigated, although this finding might be as a result of high rates of hospital admissions. However, treatment seems to be less than optimum, and there are substantial variations in practice between countries. The inconsistencies between physicians' knowledge and the treatment that they deliver suggests that improved organisation of care for heart failure is required.
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Affiliation(s)
- J G F Cleland
- Department of Cardiology, University of Hull, Castle Hill Hospital, Kingston-upon-Hull, UK.
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Hutcheon SD, Gillespie ND, Crombie IK, Struthers AD, McMurdo MET. Perindopril improves six minute walking distance in older patients with left ventricular systolic dysfunction: a randomised double blind placebo controlled trial. Heart 2002; 88:373-7. [PMID: 12231595 PMCID: PMC1767356 DOI: 10.1136/heart.88.4.373] [Citation(s) in RCA: 74] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To evaluate the effects of the angiotensin converting enzyme inhibitor perindopril on six minute walking distance and quality of life in very old patients with left ventricular systolic dysfunction. DESIGN Prospective, double blind placebo controlled trial. SETTING Medicine for the elderly day hospital. PATIENTS 66 patients (average age 81) with left ventricular systolic dysfunction identified by echocardiography. INTERVENTIONS 10 weeks of treatment with titrated doses of perindopril or placebo. MAIN OUTCOME MEASURES Six minute walking distance 10 weeks following treatment, quality of life measurements including the Minnesota living with heart failure questionnaire and the 36 item short form health survey. RESULTS In patients with left ventricular systolic dysfunction, six minute walking distance was significantly increased in the treatment group (37.1 m) compared with the placebo group (-0.3 m, p < 0.001). The medication was well tolerated and there were no significant adverse events. CONCLUSIONS Six minute walking distance is improved considerably by treatment with perindopril in older patients with heart failure caused by left ventricular systolic dysfunction.
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Affiliation(s)
- S D Hutcheon
- Section of Ageing & Health, Department of Medicine, University of Dundee, Ninewells Hospital, Dundee, UK
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83
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van Kraaij DJW, van Pol PEJ, Ruiters AW, de Swart JBRM, Lips DJ, Lencer N, Doevendans PAFM. Diagnosing diastolic heart failure. Eur J Heart Fail 2002; 4:419-30. [PMID: 12167379 DOI: 10.1016/s1388-9842(02)00020-x] [Citation(s) in RCA: 38] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND increasing evidence supports the existence of left ventricular diastolic dysfunction as an important cause of congestive heart failure, present in up to 40% of heart failure patients. AIM to review the pathophysiology of LV diastolic dysfunction and diastolic heart failure and the currently available methods to diagnose these disorders. RESULTS for diagnosing LV diastolic dysfunction, invasive hemodynamic measurements are the gold standard. Additional exercise testing with assessment of LV volumes and pressures may be of help in detecting exercise-induced elevation of filling pressures because of diastolic dysfunction. However, echocardiography is obtained more easily, and will remain the most often used method for diagnosing diastolic heart failure in the coming years. MRI may provide noninvasive determination of LV three-dimensional motion during diastole, but data on correlation of MRI data with clinical findings are scant, and possibilities for widespread application are limited at this moment. CONCLUSIONS in the forthcoming years, optimal diagnostic and therapeutic strategies for patients with primary diastolic heart failure have to be developed. Therefore, future heart failure trials should incorporate patients with diastolic heart failure, describing precise details of LV systolic and diastolic function in their study populations.
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Affiliation(s)
- D J W van Kraaij
- Department of Cardiology, Academic Medical Hospital Maastricht, P.O. Box 5800, 6262 AZ, The Netherlands.
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84
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Affiliation(s)
- John McMurray
- Clinical Research Initiative in Heart Failure, University of Glasgow, Scotland.
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85
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Mehra MR, Uber PA, Potluri S, Ventura HO. Is heart failure with preserved systolic function an overlooked enigma? Curr Cardiol Rep 2002; 4:187-93. [PMID: 11960586 DOI: 10.1007/s11886-002-0049-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Heart failure with preserved systolic function, or diastolic heart failure, represents the neglected other half of the pandemic of heart failure. Unlike previously held beliefs, diastolic heart failure carries with it the same connotation of morbidity and mortality as systolic heart failure, particularly in the elderly. Due to lack of standards in application of the diagnosis of diastolic heart failure, studies are difficult to interpret due to heterogeneity in the clinical criteria applied to the patient enrollment. It is imperative that preventive efforts be implemented in high-risk groups, and screening measures with newer biomarkers be considered for identifying underlying structural heart disease in order to employ preventive therapy early in the course of illness. No evidence-based therapeutic strategy to reduce morbidity and mortality has been established, even after the diagnosis of diastolic heart failure is manifest. Current therapy targets lusitropic abnormalities in the realm of impaired relaxation, abnormal diastolic compliance, avoidance of tachycardia, and restoration of atrial booster pump function. Outcomes-based placebo-controlled clinical trials are currently underway to define appropriate therapeutic strategies in diastolic heart failure.
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Affiliation(s)
- Mandeep R Mehra
- The Ochsner Cardiomyopathy and Heart Transplantation Center, Ochsner Clinic Foundation, 1514 Jefferson Highway, New Orleans, LA 70121, USA.
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86
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Polypharmacy in chronic heart failure: practical issues regarding the use of angiotensin-converting enzyme inhibitors, beta-blockers and other drugs. Eur Heart J Suppl 2002. [DOI: 10.1093/ehjsupp/4.suppl_d.d111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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88
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Abstract
Recent epidemiological studies suggest that 30% to 50% of patients with heart failure (HF) have preserved left ventricular (LV) systolic function. These patients, often presumed to have diastolic heart failure (DHF), appear to have lower short-term but similar long-term mortality when compared to patients with HF and LV systolic dysfunction. Rates of recurrent hospitalization and costs of care appear similar in the two groups of patients. Therefore, DHF may contribute significantly to the burden of disease caused by HF. Exertional breathlessness, the principal symptom of HF, has many causes, including obesity, pulmonary disease and myocardial ischemia. A diagnosis of DHF by exclusion, based on symptoms in the absence of important LV systolic dysfunction or major valve disease, is unsatisfactory. Unfortunately, as yet, no reliable definition with which to make a positive diagnosis of DHF has been agreed on, frequently rendering this diagnosis uncertain. Echocardiography has several limitations, whereas hemodynamic confirmation of DHF by cardiac catheterization is potentially complex and not practically feasible for many patients. Treatment of DHF remains empirical and unsatisfactory because of the lack of large-scale randomized controlled trials in this area. Currently, three large outcome studies on DHF are in progress along with other smaller trials. These should start to provide some of the answers we need to diagnose and effectively treat DHF.
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Affiliation(s)
- Prithwish Banerjee
- Department of Cardiology, University of Hull, Castle Hill Hospital, Kingston upon Hull, United Kingdom.
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89
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Taylor J, Stott DJ. Chronic heart failure and cognitive impairment: co-existence of conditions or true association? Eur J Heart Fail 2002; 4:7-9. [PMID: 11812660 DOI: 10.1016/s1388-9842(01)00182-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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Petrie MC, Caruana L, Berry C, McMurray JJV. "Diastolic heart failure" or heart failure caused by subtle left ventricular systolic dysfunction? Heart 2002; 87:29-31. [PMID: 11751660 PMCID: PMC1766950 DOI: 10.1136/heart.87.1.29] [Citation(s) in RCA: 125] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES To determine whether patients with suspected heart failure but preserved systolic function, as determined by conventional echocardiographic measures (often said to have "diastolic heart failure), might have subtle left ventricular systolic dysfunction detectable by a new measure of left ventricular systolic function-left ventricular systolic atrioventricular plane displacement. DESIGN Observational study. SETTING Direct access echocardiography. PATIENTS 147 patients with suspected heart failure referred by general practitioners. MEASUREMENTS Echocardiographic assessment of conventional measures of left ventricular systolic function (fractional shortening, ejection fraction (by Simpson's biplane method) and "eyeball" assessment) and measurement of left ventricular systolic atrioventricular plane displacement. RESULTS Between 21% and 33% of patients with "normal" left ventricular systolic function by conventional methods were found to have abnormal left ventricular systolic atrioventricular plane displacement. CONCLUSIONS Approximately one quarter of patients with suspected heart failure but preserved systolic function by conventional methods have abnormal atrioventricular plane displacement. These patients with suspected heart failure but preserved systolic function by conventional echocardiographic measures may have heart failure caused by subtle systolic dysfunction rather than isolated "diastolic heart failure".
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Affiliation(s)
- M C Petrie
- Department of Cardiology, Western Infirmary of Glasgow, Glasgow, UK
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91
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Cleland JG. ACE inhibitors for 'diastolic' heart failure? reasons not to jump to premature conclusions about the efficacy of ACE inhibitors among older patients with heart failure. Eur J Heart Fail 2001; 3:637-9. [PMID: 11738214 DOI: 10.1016/s1388-9842(01)00211-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Abstract
The angiotensin-converting enzyme inhibitor, perindopril erbumine, has been approved for use in the United States only recently but has been studied extensively worldwide over the last decade. Placebo-controlled trials in a wide range of patients with hypertension, including the elderly, those with isolated systolic hypertension, and those with concomitant diseases such as hyperlipidemia, diabetes, cardiac arrhythmia, peripheral arterial occlusive disease, nephropathy with proteinuria, and chronic obstructive pulmonary disease, have shown that perindopril is highly effective in lowering both systolic and diastolic blood pressure (BP). Studies in which BP has been monitored for 24-hour intervals show that perindopril (1) has a gradual onset of action, (2) provides smooth BP control over its once-daily dosing interval, (3) has a trough-peak ratio of about 1, and (4) maintains its antihypertensive efficacy despite missed doses. Perindopril increases arterial compliance and reverses left ventricular hypertrophy in hypertensive patients. Both of these effects are at least partly independent of its ability to lower BP. Perindopril is safe and well tolerated in patients with hypertension. Rates of adverse events and discontinuation because of such events are low.
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Affiliation(s)
- S Oparil
- Vascular Biology and Hypertension Program of the Division of Cardiovascular Disease, University of Alabama School of Medicine, Birmingham, Alabama 35294, USA.
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Affiliation(s)
- Christopher G. Jones
- Cardio.net Editorial Office; SK10 1AA First Floor, Sovereign Court, King Edward Street Macclesfield Cheshire UK
| | - John G.F. Cleland
- Cardio.net Editorial Office; SK10 1AA First Floor, Sovereign Court, King Edward Street Macclesfield Cheshire UK
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Dauterman KW, Go AS, Rowell R, Gebretsadik T, Gettner S, Massie BM. Congestive heart failure with preserved systolic function in a statewide sample of community hospitals. J Card Fail 2001; 7:221-8. [PMID: 11561221 DOI: 10.1054/jcaf.2001.26896] [Citation(s) in RCA: 65] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND The importance of congestive heart failure (CHF) in patients with preserved left ventricular systolic function is increasingly recognized, but most studies have been conducted at a single, usually academic, medical center. The aim of this study was to determine the prognosis, readmission rate, and effect of ACE inhibitor therapy in a Medicare cohort with CHF and preserved systolic function. METHODS AND RESULTS We examined a statewide, random sample of 1,720 California Medicare patients hospitalized with an ICD-9 diagnosis of CHF confirmed by a decreased left ventricular ejection fraction (EF) or chest radiograph from July 1993 to June 1994 and January 1996 to June 1996. Among the 782 patients with confirmed CHF and an in-hospital left ventricular EF measurement, 45% had reduced systolic function (ReSF) (EF < 40%) and 55% had preserved systolic function (PrSF) (EF > 40%). The PrSF group had a lower 1-year mortality rate but similar hospital readmission rates for both CHF and all causes. In patients with ReSF, ACE inhibitor treatment was associated with a lower mortality rate (P =.04) and a trend toward a lower CHF readmission rate (P =.13). In contrast, ACE inhibition therapy was associated with neither a lower rate of mortality nor CHF readmission in PrSF patients (P =.61 and.12, respectively). In multivariate analyses treatment with ACE inhibitors in PrSF patients was not associated with either a reduction in mortality (hazard ratio, 1.15; 95% CI, 0.79-1.67) or CHF readmission (hazard ratio, 1.21; 95% CI, 0.92-1.58). CONCLUSIONS CHF with PrSF seems to be associated with high mortality and morbidity rates, but ACE inhibitors may not produce comparable benefit in this group as in patients with ReSF.
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Affiliation(s)
- K W Dauterman
- Department of Medicine, University of California, San Francisco, CA 94121, USA
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Affiliation(s)
- M Petrie
- Clinical Research Initiative in Heart Failure, University of Glasgow, G12 8QQ, Glasgow, UK
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McDonald K, Ledwidge M, Cahill J, Kelly J, Quigley P, Maurer B, Begley F, Ryder M, Travers B, Timmons L, Burke T. Elimination of early rehospitalization in a randomized, controlled trial of multidisciplinary care in a high-risk, elderly heart failure population: the potential contributions of specialist care, clinical stability and optimal angiotensin-converting enzyme inhibitor dose at discharge. Eur J Heart Fail 2001; 3:209-15. [PMID: 11246059 DOI: 10.1016/s1388-9842(00)00134-3] [Citation(s) in RCA: 68] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Despite a growing body of data demonstrating the benefits of multidisciplinary care in heart failure, persistently high rates of readmission, especially within the first month of discharge, continue to be documented. AIMS As part of an ongoing randomized study on the value of multidisciplinary care in a high risk (NYHA Class IV), elderly (mean age 69 years) heart failure population, we examined the effects of this intervention on previously high (20%) 1-month readmission rates. METHODS Unlike previous studies of this approach, both multidisciplinary (MC) and routine care (RC) populations were cared for by the cardiology service, complied with adherence to clinical stability criteria prior to discharge (100% of patients) and received at least target dose angiotensin-converting enzyme (ACE) inhibition with perindopril prior to discharge (94% of indicated patients). We analysed death and unplanned readmission for heart failure at 1 month. RESULTS This early report from the first 70 patients (67% male, 71% systolic dysfunction with a mean ejection fraction of 31.0+/-6.7%) enrolled in this study demonstrates elimination of 1-month hospital readmission in both RC and MC groups. This unexpected result represents a dramatic improvement both for this patient cohort (20% 30-day readmission rate prior to enrollment reduced to 0% following the index admission in both care groups) and in comparison with available data. CONCLUSIONS Critical contributors to this improvement appear to be specialist cardiology care, adherence to clinical stability criteria prior to discharge and routine use of target or high-dose ACE inhibitor therapy prior to discharge. Widespread application of this approach may have a dramatic improvement in morbidity of CHF while limiting the escalating costs of this condition.
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Affiliation(s)
- K McDonald
- St. Vincent's University Hospital Cardiomyopathy Research Group, Elm Park, Dublin 4, Ireland
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Affiliation(s)
- A Khand
- Department of Cardiology, Castle Hill Hospital, University of Hull, Kingston-Upon-Hull, United Kingdom
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100
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Cleland JG, Clark A, Caplin JL. Taking heart failure seriously. BMJ (CLINICAL RESEARCH ED.) 2000; 321:1095-6. [PMID: 11061720 PMCID: PMC1118887 DOI: 10.1136/bmj.321.7269.1095] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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