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Allen LA, Stevenson LW, Grady KL, Goldstein NE, Matlock DD, Arnold RM, Cook NR, Felker GM, Francis GS, Hauptman PJ, Havranek EP, Krumholz HM, Mancini D, Riegel B, Spertus JA. Decision making in advanced heart failure: a scientific statement from the American Heart Association. Circulation 2012; 125:1928-52. [PMID: 22392529 PMCID: PMC3893703 DOI: 10.1161/cir.0b013e31824f2173] [Citation(s) in RCA: 601] [Impact Index Per Article: 50.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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Abstract
Acute decompensated heart failure (ADHF) is a major public health problem throughout the world and its importance is continuing to grow. This article reviews the epidemiology of ADHF and the profile of patients suffering from this condition. It describes factors used in assessing prognosis and presents treatment options. Although no currently available treatments have been shown to favorably affect long-term outcomes, there are a variety of strategies and approaches to management that are expected to reduce morbidity and mortality following discharge after ADHF hospitalization. In particular, the clinician is alerted to the need to identify factors that trigger decompensation as well as to optimize treatments for chronic heart failure. The importance of the transition from hospital to the outpatient setting is described. Particular attention should be focused on providing health education to the patient and their family at an appropriate level of medical literacy as well as ensuring early follow-up evaluation after hospital discharge.
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Affiliation(s)
- Barry Greenberg
- Advanced Heart Failure Treatment Program, Division of Cardiovascular Medicine, Sulpizio Cardiovascular Center, University of California at San Diego, CA 92093, USA.
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253
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Trochu JN, Leprince P, Bielefeld-Gomez M, Bastien O, Beauvais F, Gueffet JP, Logeart D, Isnard R, Iliou MC, Leclercq C, Girard C. Left ventricle assist device: when and which patients should we refer? Arch Cardiovasc Dis 2012; 105:114-21. [PMID: 22424329 DOI: 10.1016/j.acvd.2011.11.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Revised: 11/06/2011] [Accepted: 11/08/2011] [Indexed: 11/17/2022]
Abstract
Progress in the medical treatment of patients with heart failure with systolic dysfunction, cardiac resynchronization therapy, internal cardiac defibrillators and multidisciplinary management programmes has resulted in dramatic improvements in survival and quality of life; however, this progress has led to an increase in the prevalence of advanced heart failure. In the context of organ shortage for cardiac transplantation, the technological developments in left ventricular assist devices, shown in recent positive clinical studies, provide real hope for patients with advanced heart failure. This article summarizes the most recent clinical studies concerning left ventricular assist devices and discusses for whom and when a left ventricular assist device should be proposed.
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Affiliation(s)
- Jean-Noël Trochu
- Inserm, UMR, université de Nantes, l'institut du thorax, CHU de Nantes, France.
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Rutten FH, Heddema WS, Daggelders GJA, Hoes AW. Primary care patients with heart failure in the last year of their life. Fam Pract 2012; 29:36-42. [PMID: 21810902 DOI: 10.1093/fampra/cmr047] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Quantitative information about the management of patients with advanced heart failure (HF) is scarce. OBJECTIVE To assess the management of primary care patients with HF in their last year of life. METHODS A retrospective observational study performed in 23 general practices in the Netherlands. The medical records of 399 patients with a diagnosis of HF and who died between 2001 and 2006 were scrutinized to review treatment and care in the year preceding death. RESULTS The mean age at death was 82.3 (SD 8.8) years, and the median time between diagnosis and death was 48 months (range 3-285 months). In total, 55.9% died at home or home for the elderly, 32.6% in hospital and 11.5% in a nursing home or hospice. The mode of death was in 28% sudden death, in 23% progressive HF and in 49% others. During the last year of life, patients on average visited 0.4 times the cardiology outpatient clinic and needed on average 12.1 (range 0-53) home visits of the GP. At the end of life, 35% of all the patients received opioids, 7% haloperidol, 7% oxygen and 5% diuretics intravenously. Patients co-treated by a cardiologist received similar care, however, they used more HF drugs than patients managed solely by the GP. CONCLUSIONS A minority of patients with advanced HF have a terminal phase and died of progressive HF. In the last year of life, the GP is the main provider of care.
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Affiliation(s)
- Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht.
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Sokolski M, Rydlewska A, Krakowiak B, Biegus J, Zymlinski R, Banasiak W, Jankowska EA, Ponikowski P. Comparison of invasive and non-invasive measurements of haemodynamic parameters in patients with advanced heart failure. J Cardiovasc Med (Hagerstown) 2011; 12:773-8. [DOI: 10.2459/jcm.0b013e32834cfebb] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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256
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Metra M, Bettari L, Carubelli V, Cas LD. Old and new intravenous inotropic agents in the treatment of advanced heart failure. Prog Cardiovasc Dis 2011; 54:97-106. [PMID: 21875509 DOI: 10.1016/j.pcad.2011.03.011] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Inotropic agents are administered to improve cardiac output and peripheral perfusion in patients with systolic dysfunction and low cardiac output. However, there is evidence of increased mortality and adverse effects associated with current inotropic agents. These adverse outcomes may be ascribed to patient selection, increased myocardial energy expenditure and oxygen consumption, or to specific mechanisms of action. Both sympathomimetic amines and type III phosphodiesterase inhibitors act through an increase in intracellular cyclic adenosine monophoshate and free calcium concentrations, mechanisms that increase oxygen consumption and favor arrhythmias. Concomitant peripheral vasodilation with some agents (phosphodiesterase inhibitors and levosimendan) may also lower coronary perfusion pressure and favor myocardial damage. New agents with different mechanisms of action might have a better benefit to risk ratio and allow an improvement in tissue and end-organ perfusion with less untoward effects. We have summarized the characteristics of the main inotropic agents for heart failure treatment, the data from randomized controlled trials, and future perspectives for this class of drugs.
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Affiliation(s)
- Marco Metra
- Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Civil Hospital of Brescia, Italy.
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257
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Malfatto G, Blengino S, Perego GB, Branzi G, Villani A, Facchini M, Parati G. Transthoracic Impedance Accurately Estimates Pulmonary Wedge Pressure in Patients With Decompensated Chronic Heart Failure. ACTA ACUST UNITED AC 2011; 18:25-31. [DOI: 10.1111/j.1751-7133.2011.00248.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Ezekowitz JA, Thai V, Hodnefield TS, Sanderson L, Cujec B. The correlation of standard heart failure assessment and palliative care questionnaires in a multidisciplinary heart failure clinic. J Pain Symptom Manage 2011; 42:379-87. [PMID: 21444186 DOI: 10.1016/j.jpainsymman.2010.11.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 11/27/2010] [Accepted: 12/03/2010] [Indexed: 11/20/2022]
Abstract
CONTEXT Heart failure (HF) is a leading cause of death and disability, and despite optimal care, patients may eventually require palliative care. Little is known about how palliative care questionnaires (the Edmonton Symptom Assessment Scale [ESAS] and the Palliative Performance Scale [PPS]) perform compared with HF assessment using the New York Heart Association (NYHA) functional class and the Kansas City Cardiomyopathy Questionnaire (KCCQ). OBJECTIVES To assess the utility of a palliative care questionnaire in patients with HF. METHODS One hundred and five patients (mean age=65 years, 76% male, mean ejection fraction=28%) followed in an HF clinic were surveyed with the NYHA, PPS, ESAS, and KCCQ. RESULTS The PPS and ESAS were each correlated to the NYHA class (P<0.0001 for both) and the KCCQ score (PPS: R(2)=0.57; ESAS: R(2)=-0.72; both P<0.0001). There were 33 patients who either died (10 deaths) or were hospitalized (26 patients) for more than one year. In addition to age and gender, a higher (worse) ESAS score trended toward significance (P=0.07) and a lower (worse) PPS was a significant (P=0.04) predictor of all-cause hospitalization or death. CONCLUSION In a cohort of HF patients, we found a modest correlation with NYHA class and KCCQ assessment with the PPS and ESAS, two standard palliative care questionnaires. Given the difficulty in identifying patients with HF eligible for palliative or hospice care, these tools may be of use in clinical practice.
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Affiliation(s)
- Justin A Ezekowitz
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta.
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259
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260
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Kamouh A, Francis GS. Contemporary management and research directions in advanced heart failure: where are we going? ACTA ACUST UNITED AC 2011; 17:241-7. [PMID: 21906249 DOI: 10.1111/j.1751-7133.2011.00243.x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Advanced heart failure (AHF) is not a uniform disorder, but is rather a heterogeneous group of patients with varying clinical presentations and definitions. It is growing in magnitude and represents a major public health problem. Herein we describe contemporary care of the patient with AHF, novel medical therapies, and mechanical circulatory assist devices. We speculate where progress has been made and where the major gaps in knowledge remain. Clearly, there is ample opportunity for research and discovery to further advance the care of these very sick patients.
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Affiliation(s)
- Abdallah Kamouh
- Heart Failure and Transplantation Section, Department of Cardiology, University of Minnesota Medical Center, Minneapolis, MN, USA
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261
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Abouezzeddine OF, Redfield MM. Who has advanced heart failure?: definition and epidemiology. ACTA ACUST UNITED AC 2011; 17:160-8. [PMID: 21790965 DOI: 10.1111/j.1751-7133.2011.00246.x] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Summarizing current guidelines and advanced heart failure (AHF) clinical trials/registries, this review focuses on the current definition of AHF and emphasizes the secular trends in this definition over the last two decades. Further, clinical, imaging, hemodynamic, functional capacity and biomarker parameters that may aid clinicians to better recognize patients with AHF are reviewed. Finally, we review the limited data concerning the epidemiology of AHF which to date has been poorly characterized.
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Affiliation(s)
- Omar F Abouezzeddine
- Division of Cardiovascular Diseases and Internal Medicine Mayo Clinic, Rochester, MN, USA
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262
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Abstract
Despite recent advances with neurohormonal antagonists and devices, the prognosis of patients with advanced heart failure (HF) remains grave. Renal dysfunction is a common comorbid condition in HF and is associated with adverse outcomes. Current evidence indicates that intrinsic renal disease and inflammation in HF makes the kidney susceptible to hemodynamic compromise and congestion and contributes to a great extent to the development of renal dysfunction. Relief of congestion requires combination treatment with diuretics, neurohormonal antagonists, and occasionally vasodilators as well as inotropes. However, high doses of diuretics may accelerate the development of renal dysfunction by increasing neurohumoral activity and inducing renal structural and functional changes. Ultrafiltration should be reserved for patients with true diuretic resistance. Finally, early identification of the "patient at risk" remains a challenging issue and is limited by the currently used conventional parameters of renal function. However, novel biomarkers of acute kidney ischemia and/or injury are emerging and promise to become a diagnostic option for this patient population.
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Nagarajan V, Wilson Tang WH. Biomarkers in Advanced Heart Failure: Diagnostic and Therapeutic Insights. ACTA ACUST UNITED AC 2011; 17:169-74. [DOI: 10.1111/j.1751-7133.2011.00244.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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264
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Metra M, Bettari L, Carubelli V, Bugatti S, Dei Cas A, Del Magro F, Lazzarini V, Lombardi C, Dei Cas L. Use of inotropic agents in patients with advanced heart failure: lessons from recent trials and hopes for new agents. Drugs 2011; 71:515-25. [PMID: 21443277 DOI: 10.2165/11585480-000000000-00000] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Abnormalities of cardiac function, with high intraventricular filling pressure and low cardiac output, play a central role in patients with heart failure. Agents with inotropic properties are potentially useful to correct these abnormalities. However, with the exception of digoxin, no inotropic agent has been associated with favourable effects on outcomes. This is likely related to the mechanism of action of current agents, which is based on an increase in intracellular cyclic adenosine monophosphate and calcium concentrations. Novel agents acting through different mechanisms, such as sarcoplasmic reticulum calcium uptake, cardiac myosin and myocardial metabolism, have the potential to improve myocardial efficiency and lower myocardial oxygen consumption. These characteristics might allow a haemodynamic improvement in the absence of untoward effects on the clinical course and prognosis of the patients.
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Affiliation(s)
- Marco Metra
- Institute of Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy.
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265
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Marik PE, Flemmer M. Narrative review: the management of acute decompensated heart failure. J Intensive Care Med 2011; 27:343-53. [PMID: 21616957 DOI: 10.1177/0885066611403260] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Acute decompensated heart failure (ADHF) is the most common reason for hospitalization in Western nations. The prognosis of patients admitted to hospital with ADHF is poor, with up to 64% being readmitted within the first 90 days after discharge and with a 1-year mortality approximating 20%. Epidemiological studies suggest that the majority of patients hospitalized with ADHF receive treatment that is inadequate and which is not based on scientific evidence. Furthermore, emerging data suggest that the "conventional" therapeutic interventions for ADHF including morphine, high-dose diuretics, and inotropic agents may be harmful. The goal of this review is to provide evidence-based recommendations for the diagnosis and management of ADHF.
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Affiliation(s)
- Paul E Marik
- Department of Medicine, Eastern Virginia Medial School, Norfolk, VA 23507, USA.
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266
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Favorable effects of left ventricular reconstruction in patients excluded from the Surgical Treatments for Ischemic Heart Failure (STICH) trial. J Thorac Cardiovasc Surg 2011; 141:905-16, 916.e1-4. [DOI: 10.1016/j.jtcvs.2010.10.026] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 10/11/2010] [Accepted: 10/16/2010] [Indexed: 11/21/2022]
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267
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Pérez-Calvo JI, Montero-Pérez-Barquero M, Camafort-Babkowski M, Conthe-Gutiérrez P, Formiga F, Aramburu-Bodas O, Romero-Requena JM. Influence of admission blood pressure on mortality in patients with acute decompensated heart failure. QJM 2011; 104:325-33. [PMID: 21068084 DOI: 10.1093/qjmed/hcq202] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To determine the relationship between admission blood pressure (BP) and prognosis in patients hospitalized for acute decompensated heart failure (HF). BACKGROUND The relationship between BP admission blood pressure and outcomes in decompensated HF is controversial. It has been suggested that this presentation may be a specific disorder, but their mechanisms and clinical relationships are poorly defined. METHODS We evaluated the association between initial BP (systolic, diastolic and mean BP) with readmission and mortality, as well as potential interactions with age, clinical characteristics, renal function, left ventricular dysfunction, comorbidities and treatment. By using Cox regression models the association between each outcome and BP was tested. RESULTS A total of 581 patients (77.5-years-old, range 51-100) were included. At admission, mean BP in quartiles was 77.09 mm Hg (53.3-85.0) (Q1); 91.46 mm Hg (85.0-96.7) (Q2); 103.41 mm Hg (96.7-109.9) (Q3) and 124.79 mm Hg (109.9-209.0) (Q4). Median duration of follow-up was 8 months [95% confidence interval (CI) 5.2-11.1]. Mortality was 15.5% (Q1), 9.2% (Q2), 12.6% (Q3) and 7.3% (Q4). Interquartile hazard ratio (95% CIs) for mortality was 0.40 (0.19-0.85) P=0.017. Body mass index (BMI) was higher in Q4 29.59 k/m2 than in Q1 28.25 k/m2 (P=0.018). There were no differences in age, clinical antecedents, renal function, comorbidities or severity of HF between groups. CONCLUSION Higher mean BP at admission is associated with significantly lower mortality during follow-up, in patients hospitalized for HF. With the exception of BMI, positively correlated with blood pressure, this relationship is independent of other clinical factors and medications.
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Affiliation(s)
- J I Pérez-Calvo
- Department of Internal Medicine, Hospital Clínico Universitario Lozano Blesa, Avda. San Juan Bosco n° 15, 50009 Zaragoza, Spain.
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268
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Metra M, O'Connor CM, Davison BA, Cleland JGF, Ponikowski P, Teerlink JR, Voors AA, Givertz MM, Mansoor GA, Bloomfield DM, Jia G, DeLucca P, Massie B, Dittrich H, Cotter G. Early dyspnoea relief in acute heart failure: prevalence, association with mortality, and effect of rolofylline in the PROTECT Study. Eur Heart J 2011; 32:1519-34. [PMID: 21388992 DOI: 10.1093/eurheartj/ehr042] [Citation(s) in RCA: 80] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
AIMS Dyspnoea and pulmonary and/or peripheral congestion are the most frequent manifestations of acute heart failure (AHF) and are important targets for therapy. We have assessed changes in dyspnoea, their relationship with mortality, and the effects of the adenosine A1 receptor antagonist rolofylline on these endpoints in patients enrolled in the PROTECT trial. METHODS AND RESULTS PROTECT was a prospective, double-blind, placebo-controlled study assessing the effect of rolofylline in patients hospitalized for AHF with dyspnoea, fluid overload, increased plasma natriuretic peptides, and mild-to-moderate renal dysfunction. Early dyspnoea relief, prospectively defined as moderately or markedly better dyspnoea at both 24 and 48 h after the start of study drug administration, occurred in 49.8% of the patients. Early dyspnoea relief was associated with greater weight loss and with reduced mortality at Days 14 and 30 [hazard ratio (HR) 0.28, 95% confidence interval (CI): 0.15, 0.50; and 0.35, 95% CI: 0.22, 0.55, respectively]. Rolofylline administration was associated with an increase in the proportion of patients showing early dyspnoea relief (HR 1.30; 95% CI: 1.08, 1.57) and with a numerically lower mortality at 14 and 30 days, largely driven by the mortality due to HF [at 30 days, HR (95% CI, P-value): 0.65 (0.38-1.10, P= 0.107)]. Rolofylline did not reduce episodes of in-hospital worsening HF or post-discharge re-admissions, nor did it improve survival at 60 or 180 days. CONCLUSION The present analysis from PROTECT demonstrated that more weight loss was associated with early dyspnoea relief and reduced short-term mortality.
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Affiliation(s)
- Marco Metra
- Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
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Shimizu Y, Yamada S, Miyake F, Izumi T. The effects of depression on the course of functional limitations in patients with chronic heart failure. J Card Fail 2011; 17:503-10. [PMID: 21624739 DOI: 10.1016/j.cardfail.2011.01.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2010] [Revised: 01/10/2011] [Accepted: 01/18/2011] [Indexed: 12/25/2022]
Abstract
BACKGROUND This study examined whether depressive symptoms are associated with persistent functional limitations and severity classified according to the course of functional limitations in chronic heart failure (CHF) patients after discharge. METHODS AND RESULTS The Performance Measure for Activities of Daily Living 8 (PMADL-8) was used to measure the course of functional limitations at 1, 3, and 5 months after discharge in a cohort of 148 patients. Depressive symptoms were assessed using the Hospital Anxiety and Depression Scale at 1 month after discharge. Repeated-measures logistic regression adjusting for potential confounders demonstrated that the depression groups had different persistent functional limitations (PMADL-8 scores ≥20 at 1, 3, and 5 months after discharge [χ(2) = 5.3; P < .05]). Using cluster analysis, we identified 4 distinctive courses of functional limitations, and there was a graded relationship between the severity of the course and depressive symptoms (χ(2) = 26.1; P < .001). CONCLUSIONS In this prospective study, depression was associated with poorer functional limitations in CHF patients after discharge. The findings of this study suggest that depression may be a treatment target for improving functional limitations in CHF patients during the recovery phase.
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Affiliation(s)
- Yuko Shimizu
- Program in Physical and Occupational Therapy, Graduate School of Medicine, Nagoya, Japan
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270
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Metra M, Bugatti S, Bettari L, Carubelli V, Danesi R, Lazzarini V, Lombardi C, Cas LD. Can we improve the treatment of congestion in heart failure? Expert Opin Pharmacother 2011; 12:1369-79. [PMID: 21342081 DOI: 10.1517/14656566.2011.557069] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
INTRODUCTION Dyspnoea and peripheral oedema, caused by fluid redistribution to the lungs and/or by fluid overload, are the main causes of hospitalization in patients with heart failure and are associated with poor outcomes. Treatment of fluid overload should relieve symptoms and have a neutral or favorable effect on outcomes. AREAS COVERED We first consider the results obtained with furosemide administration, which is still the mainstay of treatment of congestion in patients with heart failure. We then discuss important shortcomings of furosemide treatment, including the development of resistance and side effects (electrolyte abnormalities, neurohormonal activation, worsening renal function), as well as the relationship of furosemide - and its doses - with patient prognosis. Finally, the results obtained with potential alternatives to furosemide treatment, including different modalities of loop diuretic administration, combined diuretic therapy, dopamine, inotropic agents, ultrafiltration, natriuretic peptides, vasopressin and adenosine antagonists, are discussed. EXPERT OPINION Relief of congestion is a major objective of heart failure treatment but therapy remains based on the administration of furosemide, an agent that is often not effective and is associated with poor outcomes. The results of the few controlled studies aimed at the assessment of new treatments to overcome resistance to furosemide and/or to protect the kidney from its untoward effects have been mostly neutral. Better treatment of congestion in heart failure remains a major unmet need.
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Affiliation(s)
- Marco Metra
- University of Brescia, Cardiology, Department of Experimental and Applied Medicine Spedali Civili , Piazzale Spedali Civili, Italy.
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271
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Metra M, Zacà V, Parati G, Agostoni P, Bonadies M, Ciccone M, Cas AD, Iacoviello M, Lagioia R, Lombardi C, Maio R, Magrì D, Musca G, Padeletti M, Perticone F, Pezzali N, Piepoli M, Sciacqua A, Zanolla L, Nodari S, Filardi PP, Dei Cas L. Cardiovascular and noncardiovascular comorbidities in patients with chronic heart failure. J Cardiovasc Med (Hagerstown) 2011; 12:76-84. [DOI: 10.2459/jcm.0b013e32834058d1] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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272
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Metra M, Eichhorn E, Abraham WT, Linseman J, Böhm M, Corbalan R, DeMets D, De Marco T, Elkayam U, Gerber M, Komajda M, Liu P, Mareev V, Perrone SV, Poole-Wilson P, Roecker E, Stewart J, Swedberg K, Tendera M, Wiens B, Bristow MR. Effects of low-dose oral enoximone administration on mortality, morbidity, and exercise capacity in patients with advanced heart failure: the randomized, double-blind, placebo-controlled, parallel group ESSENTIAL trials. Eur Heart J 2011; 30:3015-26. [PMID: 19700774 PMCID: PMC2792716 DOI: 10.1093/eurheartj/ehp338] [Citation(s) in RCA: 100] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Aims Use of inotropic agents in patients with heart failure (HF) has been limited by adverse effects on outcomes. However, administration of positive inotropes at lower doses and concomitant treatment with beta-blockers might increase benefit–risk ratio. We investigated the effects of low doses of the positive inotrope enoximone on symptoms, exercise capacity, and major clinical outcomes in patients with advanced HF who were also treated with beta-blockers and other guideline-recommended background therapy. Methods and results The Studies of Oral Enoximone Therapy in Advanced HF (ESSENTIAL) programme consisted of two identical, randomized, double-blind, placebo-controlled trials that differed only by geographic location (North and South America: ESSENTIAL-I; Europe: ESSENTIAL-II). Patients with New York Heart Association class III–IV HF symptoms, left ventricular ejection fraction ≤30%, and one hospitalization or two ambulatory visits for worsening HF in the previous year were eligible for participation in the trials. The trials had three co-primary endpoints: (i) the composite of time to all-cause mortality or cardiovascular hospitalization, analysed in the two ESSENTIAL trials combined; (ii) the 6 month change from baseline in the 6 min walk test distance (6MWTD); and (iii) the Patient Global Assessment (PGA) at 6 months, both analysed in each trial separately. ESSENTIAL-I and -II randomized 1854 subjects at 211 sites in 16 countries. In the combined trials, all-cause mortality and the composite, first co-primary endpoint did not differ between the two treatment groups [hazard ratio (HR) 0.97; 95% confidence interval (CI) 0.80–1.17; and HR 0.98; 95% CI 0.86–1.12, respectively, for enoximone vs. placebo]. The two other co-primary endpoints were analysed separately in the two ESSENTIAL trials, as prospectively designed in the protocol. The 6MWTD increased with enoximone, compared with placebo, in ESSENTIAL-I (P = 0.025, not reaching, however, the pre-specified criterion for statistical significance of P < 0.020), but not in ESSENTIAL-II. No difference in PGA was observed in either trial. Conclusion Although low-dose enoximone appears to be safe in patients with advanced HF, major clinical outcomes are not improved.
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Affiliation(s)
- Marco Metra
- Cardiology, Department of Experimental and Applied Medicine, c/o Spedali Civili, University of Brescia, P.zza Spedali Civili, 25100 Brescia, Italy.
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La insuficiencia cardíaca en el paciente anciano. Rev Clin Esp 2011; 211:26-35. [DOI: 10.1016/j.rce.2010.09.005] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2009] [Revised: 08/24/2010] [Accepted: 09/02/2010] [Indexed: 10/18/2022]
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274
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Quality of life and symptoms of depression in advanced heart failure patients and their partners. Curr Opin Support Palliat Care 2010; 4:233-7. [PMID: 20966757 DOI: 10.1097/spc.0b013e328340744d] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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275
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Frea S, Franco E, Najd K, Panella S, Pinneri F. Refractory acute decompensated heart failure: an observational study on a noninvasive hemodynamic monitoring system aimed at improving the therapeutic approach. J Cardiovasc Med (Hagerstown) 2010; 11:655-61. [PMID: 20308915 DOI: 10.2459/jcm.0b013e3283383293] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Inotropic agents should only be administered in acute decompensated heart failure (ADHF) refractory to vasodilators at optimal doses because they are associated with adverse outcome. In this setting a noninvasive hemodynamic monitoring system (NHMS) could be useful for optimizing treatment. METHODS INCLUSION CRITERIA advanced chronic heart failure, ejection fraction 30% or less, admission for ADHF with systolic blood pressure 115 mmHg or less and inadequate response at 48 h of therapy. Patients were evaluated with a NHMS: with vascular systemic resistance (VSR) greater than 1500 dyne x s/cm we used vasodilators at increasing doses, with VSR less than 1500 and cardiac index (CI) less than 2.4 l/min per m inotropic agents were used. RESULTS The study population consisted of 20 patients (mean age 67 + or - 12 years) with ejection fraction 20 + or - 7%. After 48 h of clinical-guided therapy, none of the patients achieved VSR 1500 or less, and 12 patients had a CI less than 2.4 l/min per m. After hemodynamic-guided therapeutic optimization there was a significant reduction of dyspnea at rest (7.7 + or - 1.25 versus 2.44 + or - 1.33 on the 10-point Likert scale, P < 0.001) and 'cold' presentation (12 patients before and 1 patient after, P = 0.0004). Daily urinary volume was higher (1217 + or - 369 versus 2260 + or - 797 ml, P = 0.001) without renal function deterioration (creatinine 1.56 + or - 0.52 versus 1.34 + or - 0.61 mg/dl, P = 0.012).The nitroprusside dosing was increased after NHMS (0.13 + or - 0.19 versus 0.4 + or - 0.310 microg/kg per min, P = 0.044), whereas doses of inotropic agents, diuretics and beta-blockers did not change significantly. CONCLUSIONS In refractory ADHF a NHMS improves significantly symptoms and renal function, with a better use of vasodilators.
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Affiliation(s)
- Simone Frea
- S.C. Cardiologia, O. Civico di Chivasso (TO), Corso Galileo Ferraris, Chivasso, Torino.
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276
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Metra M, Gheorghiade M, Bonow RO, Dei Cas L. Postdischarge Assessment After a Heart Failure Hospitalization. Circulation 2010; 122:1782-5. [DOI: 10.1161/circulationaha.110.982207] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Affiliation(s)
- Marco Metra
- From Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy (M.M., L.D.C.), and Division of Cardiology and Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Ill (M.G., R.O.B.)
| | - Mihai Gheorghiade
- From Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy (M.M., L.D.C.), and Division of Cardiology and Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Ill (M.G., R.O.B.)
| | - Robert O. Bonow
- From Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy (M.M., L.D.C.), and Division of Cardiology and Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Ill (M.G., R.O.B.)
| | - Livio Dei Cas
- From Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy (M.M., L.D.C.), and Division of Cardiology and Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Ill (M.G., R.O.B.)
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Branzi G, Malfatto G, Villani A, Ciambellotti F, Revera M, Giglio A, Rosa FD, Facchini M, Parati G. Acute effects of levosimendan on mitral regurgitation and diastolic function in patients with advanced chronic heart failure. J Cardiovasc Med (Hagerstown) 2010; 11:662-8. [DOI: 10.2459/jcm.0b013e32833832f6] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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278
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Maggioni AP, Dahlström U, Filippatos G, Chioncel O, Leiro MC, Drozdz J, Fruhwald F, Gullestad L, Logeart D, Metra M, Parissis J, Persson H, Ponikowski P, Rauchhaus M, Voors A, Nielsen OW, Zannad F, Tavazzi L. EURObservational Research Programme: the Heart Failure Pilot Survey (ESC-HF Pilot). Eur J Heart Fail 2010; 12:1076-84. [PMID: 20805094 DOI: 10.1093/eurjhf/hfq154] [Citation(s) in RCA: 296] [Impact Index Per Article: 21.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
AIMS The primary objective of the new ESC-HF Pilot Survey was to describe the clinical epidemiology of outpatients and inpatients with heart failure (HF) and the diagnostic/therapeutic processes applied across 12 participating European countries. This pilot study was specifically aimed at validating the structure, performance, and quality of the data set, for continuing the survey into a permanent registry. METHODS AND RESULTS The ESC-HF Pilot study is a prospective, multicentre, observational survey conducted in 136 cardiology centres from 12 European countries selected to represent the different health systems and care attitudes across Europe. All outpatients with HF and patients admitted for acute HF were included during the enrolment period (1 day per week for 8 consecutive months). From October 2009 to May 2010, 5118 patients were included in this pilot survey, of which 1892 (37%) were admitted for acute HF and 3226 (63%) for chronic HF. Ischaemic aetiology was reported in about half of the patients. In patients admitted for acute HF, the most frequent clinical profile was decompensated HF (75% of cases), whereas pulmonary oedema and cardiogenic shock were reported, respectively, in 13.3 and 2.3% of the cases. The total in-hospital mortality rate was 3.8% and was cardiovascular in 90.1% of the cases. Lowest and highest mortality rates were observed in hypertensive HF and in cardiogenic shock, respectively. More than 80% of patients with chronic HF were treated with renin-angiotensin-aldosterone system blockers and β-adrenergic blockers. However, target doses of such drugs were reached in one-third to one-fourth of the patients only. CONCLUSION The ESC-HF Pilot Survey is an example of the possibility of utilizing an observational methodology to get insights into the current clinical practice in Europe, whose picture will be completed by the 1-year follow-up. Moreover, this study offered the opportunity to refine the organizational structure of a long-term, extended European network.
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279
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Metra M, Teerlink JR, Felker GM, Greenberg BH, Filippatos G, Ponikowski P, Teichman SL, Unemori E, Voors AA, Weatherley BD, Cotter G. Dyspnoea and worsening heart failure in patients with acute heart failure: results from the Pre-RELAX-AHF study. Eur J Heart Fail 2010; 12:1130-9. [PMID: 20732868 PMCID: PMC2944016 DOI: 10.1093/eurjhf/hfq132] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Aims Although dyspnoea is the most common cause of admission for acute heart failure (AHF), more needs to be known about its clinical course and prognostic significance. Methods and results The Pre-RELAX-AHF study randomized 232 subjects with AHF to placebo or four doses of relaxin and evaluated early (6–24 h Likert scale) and persistent [change in visual analogue scale area under the curve (VAS AUC) through Day 5] dyspnoea relief. Worsening heart failure (WHF) was defined as worsening AHF signs and symptoms requiring additional therapy. Patients were followed until Day 180. Early dyspnoea relief was observed in only 25% of all patients, and VAS AUC at 5 days was 45% over baseline values in all patients (32% placebo; 50% all relaxin-treated patients). Worsening heart failure to Day 5 was observed in 16% of all patients (21% placebo; 14% relaxin). Lack of persistent dyspnoea relief and WHF were associated with a longer length of initial hospital stay and worse 60-day outcomes. Conclusion Dyspnoea relief in patients admitted with AHF is often incomplete, and many may show WHF after the initial stabilization. Both lack of persistent dyspnoea relief and in-hospital WHF predict a longer length of stay and worse outcome.
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Affiliation(s)
- Marco Metra
- Cardiology, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy.
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280
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Malfatto G, Branzi G, Giglio A, Villani A, Facchini C, Ciambellotti F, Facchini M, Parati G. Transthoracic bioimpedance and brain natriuretic peptide levels accurately indicate additional diastolic dysfunction in patients with chronic advanced systolic heart failure. Eur J Heart Fail 2010; 12:928-35. [PMID: 20562427 DOI: 10.1093/eurjhf/hfq089] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Diastolic dysfunction in patients with heart failure has prognostic relevance, possibly because of its relationship with worsening haemodynamic status. In the quest for simpler indexes of haemodynamic status in patients, brain natriuretic peptide (BNP) levels have been proposed as a surrogate of diastolic function. To date, the value of combining BNP levels with non-invasive haemodynamic monitoring by transthoracic electric bioimpedance (TEB) for the prediction of diastolic function has not been evaluated. METHODS AND RESULTS We compared left ventricular diastolic function measured by tissue Doppler imaging (TDI) with TEB results and BNP levels in 120 patients with chronic advanced systolic heart failure on optimal treatment (70 +/- 9 years, NYHA 2.4 +/- 0.8, ejection fraction 31 +/- 5%). Of the TEB variables measured, we only considered thoracic fluid content (TFC). To describe diastolic function, we used the TDI of the velocity of displacement of the mitral annulus (E') and the ratio E/E'. In all patients, E/E' was significantly related to TFC and to BNP levels (P < 0.001). Moreover, the combination of BNP > or = 350 pg/mL and TFC > or = 35/kOmega identified patients with diastolic dysfunction (defined as E/E' > or = 15) with high sensitivity and specificity (95 and 94%, respectively). CONCLUSION The combination of transthoracic bioimpedance monitoring and BNP measurement accurately indicated the presence of diastolic dysfunction in most patients. These user-friendly and operator-independent tools may be useful as a screening assessment for diastolic dysfunction, and consequently abnormal central haemodynamic status, either in ambulatory patients or when an adequate echocardiographic evaluation is not readily available.
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Affiliation(s)
- Gabriella Malfatto
- Divisione di Cardiologia, Istituto Scientifico Ospedale San Luca, Istituto Auxologico Italiano IRCCS via Spagnoletto, 3, 20149 Milano, Italy.
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Abstract
Despite advances in both drug and device treatment of chronic heart failure (CHF) over the last 20 years, many patients still progress to a stage of advanced CHF, characterized by increasing symptoms and declining functional status. Future drug management of such patients presents many challenges. This review focuses on the issue of optimizing standard medical therapy in advanced CHF, the treatment of diuretic resistance and hyponatremia. As well as prescribing drugs in this phase of the disease, the system of care used to deliver therapy is crucial. On its own, multiprofessional heart failure care can improve outcomes for these patients. Finally, this review also addresses the drugs and model of care used to deliver palliative care in the end stage of advanced CHF.
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282
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Dyspnoea in patients with acute heart failure: an analysis of its clinical course, determinants, and relationship to 60-day outcomes in the PROTECT pilot study. Eur J Heart Fail 2010; 12:499-507. [DOI: 10.1093/eurjhf/hfq021] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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283
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Altenberger J, Parissis JT, Ulmer H, Poelzl G. Rationale and design of the multicentre randomized trial investigating the efficacy and safety of pulsed infusions of levosimendan in outpatients with advanced heart failure (LevoRep study). Eur J Heart Fail 2010; 12:186-92. [DOI: 10.1093/eurjhf/hfp189] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Johann Altenberger
- Department of Cardiology; Paracelsus Medical Private University (PMU); Salzburg Landeskliniken, Muellner Hauptstrasse 48 Salzburg 5020 Austria
| | - John T. Parissis
- Second Cardiology Department and Heart Failure Unit; University of Athens Medical School, Attikon University Hospital; Athens Greece
| | - Hanno Ulmer
- Department of Medical Statistics, Informatics and Health Economics; Innsbruck Medical University; Innsbruck Austria
| | - Gerhard Poelzl
- Department of Cardiology; Innsbruck Medical University; Innsbruck Austria
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284
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Kamp O, Metra M, De Keulenaer GW, Pieske B, Conraads V, Zamorano J, Huysse L, Vardas PE, Böhm M, Cas LD. Effect of the long-term administration of nebivolol on clinical symptoms, exercise capacity and left ventricular function in patients with heart failure and preserved left ventricular ejection fraction: background, aims and design of the ELANDD study. Clin Res Cardiol 2009; 99:75-82. [DOI: 10.1007/s00392-009-0098-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2009] [Accepted: 12/08/2009] [Indexed: 11/25/2022]
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285
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Zemljic G, Bunc M, Vrtovec B. Trimetazidine Shortens QTc Interval in Patients With Ischemic Heart Failure. J Cardiovasc Pharmacol Ther 2009; 15:31-6. [DOI: 10.1177/1074248409354601] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: Trimetazidine improves functional class and left ventricular function in patients with heart failure; however, its potential impact on QTc interval remains undefined. We analyzed the effects of trimetazidine on QTc interval in patients with ischemic heart failure. Methods: A prospective trial included 42 patients with ischemic heart failure (New York Heart Association [NYHA] 2 or 3) and reduced left ventricular ejection fraction (<55%), who were randomly allocated to conventional therapy plus trimetazidine in a modulated release formulation (35 mg twice daily; 22 patients) or conventional therapy alone (20 patients; controls). We measured QTc interval at baseline and after 1 month. Results: At baseline, QTc interval duration was similar in both groups (443 ± 41 milliseconds in trimetazidine group vs 446 ± 27 milliseconds in controls, P = .62). After 1 month, QTc interval decreased in the trimetazidine group (404 ± 36 milliseconds, P = .0002) but not in controls (452 ± 25 milliseconds, P = .74). QTc interval shortening with trimetazidine was more pronounced in patients with prolonged (>440 milliseconds) baseline QTc interval (—45 ± 38 milliseconds) than in patients with normal QTc interval (—19 ± 19 milliseconds P = .04). Significant QTc interval shortening (>20 milliseconds) was present in 14 of 22 patients (64%) in trimetazidine group compared to 3 of 20 (15%) patients in control group (P = .002). Conclusions: Trimetazidine therapy is associated with QTc interval shortening in patients with ischemic heart failure.
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Affiliation(s)
- Gregor Zemljic
- Advanced Heart Failure and Transplantation Center, Division of Cardiology, Ljubljana University Medical Center, Ljubljana, Slovenia,
| | - Matjaz Bunc
- Advanced Heart Failure and Transplantation Center, Division of Cardiology, Ljubljana University Medical Center, Ljubljana, Slovenia
| | - Bojan Vrtovec
- Advanced Heart Failure and Transplantation Center, Division of Cardiology, Ljubljana University Medical Center, Ljubljana, Slovenia
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286
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Teerlink JR, Metra M, Zacà V, Sabbah HN, Cotter G, Gheorghiade M, Cas LD. Agents with inotropic properties for the management of acute heart failure syndromes. Traditional agents and beyond. Heart Fail Rev 2009; 14:243-53. [PMID: 19876734 PMCID: PMC2772951 DOI: 10.1007/s10741-009-9153-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/05/2022]
Abstract
Treatment with inotropic agents is one of the most controversial topics in heart failure. Initial enthusiasm, based on strong pathophysiological rationale and apparent empirical efficacy, has been progressively limited by results of controlled trials and registries showing poorer outcomes of the patients on inotropic therapy. The use of these agents remains, however, potentially indicated in a significant proportion of patients with low cardiac output, peripheral hypoperfusion and end-organ dysfunction caused by heart failure. Limitations of inotropic therapy seem to be mainly related to their mechanisms of action entailing arrhythmogenesis, peripheral vasodilation, myocardial ischemia and damage, and possibly due to their use in patients without a clear indication, rather than to the general principle of inotropic therapy itself. This review will discuss the characteristics of the patients with a potential indication for inotropic therapy, the main data from registries and controlled trials, the mechanism of the untoward effects of these agents on outcomes and, lastly, perspectives with new agents with novel mechanisms of action.
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Affiliation(s)
- John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, University of California, San Francisco, San Francisco, CA USA
| | - Marco Metra
- Cardiology, Department of Experimental and Applied Medicine, University of Brescia, c/o Spedali Civili di Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy
| | - Valerio Zacà
- Division of Cardiology, Cardiovascular and Thoracic Department, Santa Maria alle Scotte Hospital, Siena, Italy
| | - Hani N. Sabbah
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Heart & Vascular Institute, Detroit, MI USA
| | | | - Mihai Gheorghiade
- Feinberg School of Medicine, Northwestern University, Chicago, IL USA
| | - Livio Dei Cas
- Cardiology, Department of Experimental and Applied Medicine, University of Brescia, c/o Spedali Civili di Brescia, Piazza Spedali Civili 1, 25123 Brescia, Italy
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287
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A Pilot Evaluation of the Long-term Effect of Combined Therapy With Intravenous Iron Sucrose and Erythropoietin in Elderly Patients With Advanced Chronic Heart Failure and Cardio-Renal Anemia Syndrome: Influence on Neurohormonal Activation and Clinical Outcomes. J Card Fail 2009; 15:727-35. [DOI: 10.1016/j.cardfail.2009.05.010] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2008] [Revised: 05/04/2009] [Accepted: 05/12/2009] [Indexed: 11/21/2022]
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288
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Goldraich L, Beck-da-Silva L, Clausell N. Are scores useful in advanced heart failure? Expert Rev Cardiovasc Ther 2009; 7:985-97. [PMID: 19673676 DOI: 10.1586/erc.09.68] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Advanced heart failure (HF) is becoming an increasingly challenging problem as more patients with this disease are living longer, yet experiencing its inexorable progression. Adding to this complex matter, there are different views on how to define advanced HF, whereby an acute decompensation episode does not necessarily indicate advanced disease. Several scores have been described aiming at a better prognostic performance across the HF spectrum. These include the Heart Failure Survival Score, the Seattle Heart Failure Model, the Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients With Heart Failure predictive schemes, the Acute Decompensated Heart Failure National Registry regression tree discrimination, among others. Most scoring systems have been built based on outpatient populations or recently hospitalized HF subjects. The setting of advanced HF has not gained much attention as far as prognostication is concerned, and yet there lies potentially challenging decision-making situations where issues, such as heart transplantation, use of costly devices and end-of-life questions, are raised.
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Affiliation(s)
- Livia Goldraich
- Heart Failure and Cardiac Transplantation Unit, Division of Cardiology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul Medical School, Porto Alegre, Brazil
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289
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Lamirault G, Meur NL, Roussel JC, Cunff MFL, Baron D, Bihouée A, Guisle I, Raharijaona M, Ramstein G, Teusan R, Chevalier C, Gueffet JP, Trochu JN, Léger JJ, Houlgatte R, Steenman M. Molecular risk stratification in advanced heart failure patients. J Cell Mol Med 2009; 14:1443-52. [PMID: 19793385 PMCID: PMC3829011 DOI: 10.1111/j.1582-4934.2009.00913.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Risk stratification in advanced heart failure (HF) is crucial for the individualization of therapeutic strategy, in particular for heart transplantation and ventricular assist device implantation. We tested the hypothesis that cardiac gene expression profiling can distinguish between HF patients with different disease severity. We obtained tissue samples from both left (LV) and right (RV) ventricle of explanted hearts of 44 patients undergoing cardiac transplantation or ventricular assist device placement. Gene expression profiles were obtained using an in-house microarray containing 4217 muscular organ-relevant genes. Based on their clinical status, patients were classified into three HF-severity groups: deteriorating (n= 12), intermediate (n= 19) and stable (n= 13). Two-class statistical analysis of gene expression profiles of deteriorating and stable patients identified a 170-gene and a 129-gene predictor for LV and RV samples, respectively. The LV molecular predictor identified patients with stable and deteriorating status with a sensitivity of 88% and 92%, and a specificity of 100% and 96%, respectively. The RV molecular predictor identified patients with stable and deteriorating status with a sensitivity of 100% and 96%, and a specificity of 100% and 100%, respectively. The molecular prediction was reproducible across biological replicates in LV and RV samples. Gene expression profiling has the potential to reproducibly detect HF patients with highest HF severity with high sensitivity and specificity. In addition, not only LV but also RV samples could be used for molecular risk stratification with similar predictive power.
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290
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Vizzardi E, Chiari E, Faggiano P, D'Aloia A, Bordonali T, Metra M, Cas LD. Measurement of the myocardial performance index in ambulatory patients with heart failure: correlation with other clinical and echocardiographic parameters and independent prognostic value. Echocardiography 2009; 27:123-9. [PMID: 19765064 DOI: 10.1111/j.1540-8175.2009.00986.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Many echocardiographic parameters have been proposed for the assessment of the patients with heart failure (HF). Recently, the myocardial performance index (MPI) has been shown to be an accurate index of myocardial function. We assessed the correlation with other clinical and echocardiographic measurements and the prognostic value of MPI in patients with HF. METHODS AND RESULTS The MPI was assessed in 112 consecutive patients with persistent symptoms of HF (II-III NYHA class), sinus rhythm, LV systolic dysfunction (defined by an ejection fraction <or= 45%). At multivariable analysis, only NYHA class and ejection fraction were independently related to MPI. The severity of mitral regurgitation and MPI were the only parameters independently related to the incidence of death or cardiovascular hospitalizations. A MPI > 0.55 (median value) and medium to severe mitral regurgitation were associated with a relative risk of cardiovascular events of 18.7 (95% confidence interval [CI], 16.6-20.7; P < 0.005) and of 3.03 (95% CI, 2-4.1; P = 0.035), respectively. CONCLUSIONS In our patients with HF, MPI was the best predictor of cardiovascular events. Mitral regurgitation was the only other variable which had an additive prognostic value at multivariate analysis.
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Affiliation(s)
- Enrico Vizzardi
- Department of Experimental and Applied Medicine, Section of Cardiovascular Diseases, University of Brescia, Brescia, Italy.
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291
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292
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Gogas BD, Parissis JT, Filippatos GS, Iliodromitis EK, Soultanis KC, Kostopanagiotou GG, Theodoropoulos SP, Kremastinos DT, Yacoub MH. Severe anaemia and subcapital femur fracture in a patient with Left Ventricular Assist Device Heart Mate II: the cardiologist's management of this rare patient. Eur J Heart Fail 2009; 11:806-8. [DOI: 10.1093/eurjhf/hfp090] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Bill D. Gogas
- Second Department of Cardiology, Heart Failure Unit; Attikon University Hospital; 1 Rimini Street Athens Greece
| | - John T. Parissis
- Second Department of Cardiology, Heart Failure Unit; Attikon University Hospital; 1 Rimini Street Athens Greece
| | - Gerasimos S. Filippatos
- Second Department of Cardiology, Heart Failure Unit; Attikon University Hospital; 1 Rimini Street Athens Greece
| | - Efstathios K. Iliodromitis
- Second Department of Cardiology, Heart Failure Unit; Attikon University Hospital; 1 Rimini Street Athens Greece
| | | | | | | | - Dimitrios T. Kremastinos
- Second Department of Cardiology, Heart Failure Unit; Attikon University Hospital; 1 Rimini Street Athens Greece
| | - Magdi H. Yacoub
- Heart Science Centre; Royal Brompton and Harefield Hospital; Harefield UK
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293
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Jaarsma T, Beattie JM, Ryder M, Rutten FH, McDonagh T, Mohacsi P, Murray SA, Grodzicki T, Bergh I, Metra M, Ekman I, Angermann C, Leventhal M, Pitsis A, Anker SD, Gavazzi A, Ponikowski P, Dickstein K, Delacretaz E, Blue L, Strasser F, McMurray J. Palliative care in heart failure: a position statement from the palliative care workshop of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2009; 11:433-43. [PMID: 19386813 DOI: 10.1093/eurjhf/hfp041] [Citation(s) in RCA: 362] [Impact Index Per Article: 24.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Heart failure is a serious condition and equivalent to malignant disease in terms of symptom burden and mortality. At this moment only a comparatively small number of heart failure patients receive specialist palliative care. Heart failure patients may have generic palliative care needs, such as refractory multifaceted symptoms, communication and decision making issues and the requirement for family support. The Advanced Heart Failure Study Group of the Heart Failure Association of the European Society of Cardiology organized a workshop to address the issue of palliative care in heart failure to increase awareness of the need for palliative care. Additional objectives included improving the accessibility and quality of palliative care for heart failure patients and promoting the development of heart failure-orientated palliative care services across Europe. This document represents a synthesis of the presentations and discussion during the workshop and describes recommendations in the area of delivery of quality care to patients and families, education, treatment coordination, research and policy.
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Affiliation(s)
- Tiny Jaarsma
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands.
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Lourenço P, Araújo JP, Azevedo A, Ferreira A, Bettencourt P. The cyclic guanosine monophosphate/B-type natriuretic peptide ratio and mortality in advanced heart failure. Eur J Heart Fail 2009; 11:185-90. [PMID: 19168517 DOI: 10.1093/eurjhf/hfn037] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
AIMS Attenuation of the effects of natriuretic peptides has been demonstrated in animal models but studies in humans are scarce, particularly concerning renal attenuation. We investigated the attenuation of B-type natriuretic peptide (BNP) in chronic advanced heart failure (HF). METHODS AND RESULTS We included 62 outpatients with HF and severe left ventricular systolic dysfunction. Cases had at least one hospital admission or emergency department visit for acute HF in the previous year and were in NYHA class III/IV despite optimized therapy. The individual age- and sex-matched controls were symptomatically controlled (NYHA I and II). We collected 24 h urine and a blood sample from all patients. Plasma BNP and plasma (pcGMP) and urine cyclic guanosine monophosphate (ucGMP) were measured. Patients were followed for 3 months for hospital admission or all-cause death. ucGMP to plasma BNP (ucGMP/BNP) ratio was attenuated in cases vs. controls [median (IQR): 8354 (4293-16,456) vs. 12,693 (6896-22,851)]. There were no differences in pcGMP to BNP (pcGMP/BNP) ratio or urine cGMP excretion. Patients with worse outcome had lower pcGMP/BNP [260 (86-344) vs. 381 (244-728) in patients without adverse outcome events] and lower ucGMP/BNP [4146 (2207-9363) vs. 10,922 (7495-19,971)]. CONCLUSION Renal NP's second messenger production is attenuated in advanced HF. Patients with worse outcome have lower ucGMP/BNP and pcGMP/BNP ratios.
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Affiliation(s)
- Patrícia Lourenço
- Serviço de Medicina Interna, Hospital S. João, Faculdade de Medicina da Universidade do Porto, Unidade I&D Cardiovascular do Porto, 4202-451 Porto, Portugal.
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295
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Gheorghiade M, Pang PS. Acute Heart Failure Syndromes. J Am Coll Cardiol 2009; 53:557-573. [PMID: 19215829 DOI: 10.1016/j.jacc.2008.10.041] [Citation(s) in RCA: 403] [Impact Index Per Article: 26.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/02/2008] [Revised: 10/21/2008] [Accepted: 10/26/2008] [Indexed: 01/08/2023]
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296
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Lourenço P, Azevedo A, Araújo JP, Bettencourt P. Natriuretic peptide system is not exhausted in severe heart failure. J Cardiovasc Med (Hagerstown) 2009; 10:39-43. [DOI: 10.2459/jcm.0b013e328319679f] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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297
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Abstract
PURPOSE OF REVIEW Mechanical circulatory support has a progressively increasing impact in the treatment of heart failure. The results of mechanical circulatory support are limited not only by the severity of the disease, which necessitated initiation of support, but also by the serious device-related adverse events. Optimized patient selection, improved patient management, and advanced device technology are interdependent key factors that contributed to the recently improved outcomes. The aim of this article is to summarize the current experience in application of mechanical circulatory support, focusing on the ICU management. RECENT FINDINGS Management should aim to prevent rather than treat serious complications and adverse events. Timing of intervention, optimization of the preimplantation patient status, patient and device management to ensure optimal hemodynamics, infection prevention, nutritional support, careful anticoagulation, and vigilance for early recognition and prompt treatment of 'minor' events before progression into major complications are essential elements of successful treatment. SUMMARY Critical patient care is a valuable adjunct to successful application of mechanical circulatory support, but it cannot counterbalance a late intervention, neither can it be fruitful in treating irreversible organ damage. Current management includes careful application of treatment protocols adjusted to recent experience, and also individualized care by a specialized team.
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298
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Metra M, Brutsaert D, Dickstein K, Fraser AG, Bergh CH, Böhm M, Gavazzi A, Jaarsma T, Ponikowski P, Komajda M. Treatment of advanced chronic heart failure with normal left ventricular ejection fraction. Response to the letter by Dr. Martinez-Selles. Eur J Heart Fail 2008. [DOI: 10.1016/j.ejheart.2007.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Affiliation(s)
- Marco Metra
- Section of Cardiovascular Diseases, Department of Experimental and Applied Medicine; University of Brescia; Italy
| | - Dirk Brutsaert
- Department of Cardiology, A.Z. Middellheim Hospital; Univ. of Antwerp; Antwerp Belgium
| | - Kenneth Dickstein
- Cardiology Division; University of Bergen, Stavanger University Hospital; Stavanger Norway
| | - Alan G. Fraser
- Department of Cardiology, Wales Heart Research Institute; University of Wales College of Medicine; Cardiff UK
| | - Claes-Hakan Bergh
- Department of Cardiology; Sahlgrenska University Hospital/Sahlgrenska; Göteborg Sweden
| | - Michael Böhm
- Innere Medizin III; Universitätskliniken des Saarlandes; Homburg/Saar Germany
| | - Antonello Gavazzi
- Department of Cardiology; Ospedali Riuniti di Bergamo; Bergamo Italy
| | - Tiny Jaarsma
- Department of Cardiology, Programme Coördinator COACH; University Hospital Groningen; Groningen The Netherlands
| | | | - Michel Komajda
- Département de Cardiologie, Pitié; Salpêtrière Hospital; Paris Cedex 13 France
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299
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Guía de práctica clínica de la Sociedad Europea de Cardiología (ESC) para el diagnóstico y tratamiento de la insuficiencia cardiaca aguda y crónica (2008). Rev Esp Cardiol 2008. [DOI: 10.1016/s0300-8932(08)75740-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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300
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Goodlin SJ. Why should palliative care clinicians learn about heart failure? PROGRESS IN PALLIATIVE CARE 2008. [DOI: 10.1179/096992608x346224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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