Use of angiotensin-converting enzyme inhibitors in heart failure with preserved left ventricular systolic function

Study the relationship between left atrial (LA) volume and left ventricular (LV) diastolic dysfunction and LV hypertrophy: Correlate LA volume with cardiovascular risk factors

Heart failure (HF) with normal ejection fraction - the isolated diastolic heart failure, depicts increasing prevalence and health care burden in recent times. Having less mortality rate compared to systolic heart failure but high morbidity, it is evolving as a major cardiac concern. With increasing clinical use of Left atrial volume (LAV) quantitation in clinical settings, LAV has emerged as an important independent predictor of cardiovascular outcome in HF with normal ejection fraction. This article is intended to review the diastolic and systolic heart failure, their association with left atrial volume, in depth study of Left atrial function dynamics with determinants of various functional and structural changes.

Angiotensin converting enzyme inhibitors and angiotensin II receptor blockers and outcomes in patients with acute decompensated heart failure: a systematic review and meta-analysis

BACKGROUND

Angiotensin-converting enzyme inhibitor (ACEi) and angiotensin-receptor blocker (ARB) are cornerstones in the treatment of heart failure with reduced ejection (HFrEF). However, there are limited data on their risk-benefit profile in patients with acute heart failure requiring hospitalizations.

METHODS

We did a meta-analysis pooling data from all studies examining the use of ACEi/ARB in patients hospitalized for heart failure compared to patients without ACEi/ARB use. We calculated pooled hazard ratios (HR) and their 95% confidence intervals (CI) using a random-effects model.

RESULTS

Twenty-five studies were included in the meta-analysis. Continued use of ACEi/ARBs in hospitalized patients with HFrEF was associated with lower 1-year mortality risk (pooled HR 0.68 [0.60-0.77] p < 0.001) and with lower 1-6-year mortality risk in those with heart failure preserved ejection fraction (HFpEF) (pooled HR 0.86 [0.78-0.94] p = 0.002). There were significant reductions in 1-year HF readmissions among hospitalized HFrEF patients (pooled HR 0.83 [0.73-0.95] p = 0.005).

CONCLUSION

Maintaining or initiating patients with HFrEF hospitalized for acute decompensated heart failure (ADHF) on ACEi/ARB is associated with a reduce risk of mortality and 1-year admissions, but the effect size is lower among those with HFpEF with more heterogeneous outcomes.

Treatment with renin-angiotensin system inhibitors and prognosis of heart failure with preserved ejection fraction: A propensity-matched study in the community

AIMS

There is currently no consensus on the effect of treatment with angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs), on the prognosis of patients with heart failure and preserved ejection fraction (HFpEF). Therefore, we have analysed the relationship of commencing treatment with ACEIs or ARBs and the prognosis of patients with incident HFpEF.

METHODS

Retrospective study over 15 years on 3864 patients with HFpEF (GAMIC cohort). Main outcomes were mortality (all-cause and cardiovascular) and hospitalisations for HF. The independent relationship between CT-RASIs and the prognosis, stratifying patients for cardiovascular comorbidity after propensity score-matching was analysed.

RESULTS

During a median follow-up of 7.94 years, 2960 died (76.6%) and 3138 were hospitalised (81.2%). Therapy with RASIs was associated with a lower mortality, all-cause (RR [95% CI] for ACEIs: 0.76 [0.66-0.86], and RR for ARBs: 0.88 [0.80-0.96]; P < 0.001 in both cases), and cardiovascular (RR for ACEIs: 0.72 [0.66-0.78], and RR for ARBs: 0.87 [0.80-0.94]; P < 0.001), a lower hospitalisation rate (RR for ACEIs: 0.82 [0.74-0.90], and RR for ARBs: 0.90 [0.82-0.98]; P < 0.001), and a lower 30-day readmission rate (RR for ACEIs: 0.66 [0.60-0.73], and RR for ARBs: 0.86 [0.75-0.97]; P < 0.001), after adjustment for the propensity to take RASIs or other medications, comorbidities and other potential confounders. Results on the effect of ARBs are compromised by the small number of patients. Analyses of recurrent hospitalisations gave larger treatment benefits than time-to-first-event analyses.

CONCLUSION

In this propensity-matched study, commencing treatment with ACEIs is associated with an improved prognosis of patients newly diagnosed with incident HFpEF.

Association is not causation: treatment effects cannot be estimated from observational data in heart failure

Aims

Treatment 'effects' are often inferred from non-randomized and observational studies. These studies have inherent biases and limitations, which may make therapeutic inferences based on their results unreliable. We compared the conflicting findings of these studies to those of prospective randomized controlled trials (RCTs) in relation to pharmacological treatments for heart failure (HF).

Methods and results

We searched Medline and Embase to identify studies of the association between non-randomized drug therapy and all-cause mortality in patients with HF until 31 December 2017. The treatments of interest were: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists (MRAs), statins, and digoxin. We compared the findings of these observational studies with those of relevant RCTs. We identified 92 publications, reporting 94 non-randomized studies, describing 158 estimates of the 'effect' of the six treatments of interest on all-cause mortality, i.e. some studies examined more than one treatment and/or HF phenotype. These six treatments had been tested in 25 RCTs. For example, two pivotal RCTs showed that MRAs reduced mortality in patients with HF with reduced ejection fraction. However, only one of 12 non-randomized studies found that MRAs were of benefit, with 10 finding a neutral effect, and one a harmful effect.

Conclusion

This comprehensive comparison of studies of non-randomized data with the findings of RCTs in HF shows that it is not possible to make reliable therapeutic inferences from observational associations. While trials undoubtedly leave gaps in evidence and enrol selected participants, they clearly remain the best guide to the treatment of patients.

Effect of renin-angiotensin system inhibitors on mortality in heart failure with preserved ejection fraction: a meta-analysis of observational cohort and randomized controlled studies

Despite the high mortality rate, there is no therapy to improve survival in heart failure with preserved ejection fraction (HFpEF). Large randomized controlled trials (RCTs) did not show clear mortality benefit of renin-angiotensin system (RAS) inhibitors (angiotensin-converting enzyme inhibitors or angiotensin receptor blockers) in HFpEF. However, because of the strict enrollment criteria, the patients who participated in these trials might represent a selected group of patients that is poorly representative of patients treated in routine clinical practice. In contrast, clinical characteristics of real-world patients are similar to those of patients enrolled in observational cohort studies (OCSs). Although many OCSs have examined the prognostic effect of RAS inhibitors in HFpEF, the results are inconsistent due to limited power with small sample sizes and/or inadequate adjustment for known prognostic factors. We aimed to conduct a meta-analysis of OCSs with and those without propensity score (PS) analysis and RCTs on the effect of RAS inhibitors on mortality in HFpEF patients. The search of electronic databases identified 4 OCSs with PS analysis (10,164 patients), 8 OCSs without PS analysis (16,393 patients), and 3 RCTs (8001 patients). Use of RAS inhibitors was associated with reduced mortality in the pooled analysis of OCSs with PS analysis (RR [95% CI] = 0.90 [0.81-1.00]) and in that of OCSs without PS analysis (0.81 [0.68-0.96]) but not in that of RCTs (0.99 [0.87-1.12]). In conclusion, the present meta-analysis suggests the potential mortality benefit of RAS inhibitors in HFpEF, emphasizing the importance of conducting new well-designed RCTs.

Renin-angiotensin blockade in heart failure with preserved ejection fraction: a systematic review and meta-analysis

Studies with angiotensin-converting enzyme inhibitors (ACE-Is) and angiotensin receptor blockers (ARBs) in patients with heart failure with preserved ejection fraction (HFpEF) have yielded inconsistent results. To conduct a systematic review and meta-analysis of all evidence for ACE-I and ARBs in patients with HFpEF, we searched PubMed, Ovid SP, Embase, and Cochrane database to identify randomized trials and observational studies that compared ACE-I or ARBs against placebo or standard therapy in HFpEF patients. Random-effect models were used to pool the data, and I² testing was performed to assess the heterogeneity of the included studies. A total of 13 studies (treatment arm = 8676 and control arm = 8608) were analysed. Pooled analysis of randomized trials for ACE-I and ARBs (n = 6) did not show any effect on all-cause mortality [relative risk (RR) = 1.02, 95% confidence interval (CI) = 0.93-1.11, P = 0.68, I²  = 0%], while results from observational studies showed a significant improvement (RR = 0.91, 95% CI = 0.87-0.95, P = 0.005, I²  = 81.5%). In pooled analyses of all studies, ACE-I showed a reduction of all-cause mortality (RR = 0.91, 95% CI = 0.87-0.95, P = 0.01). There was no reduction in cardiovascular mortality seen, but in pooled analysis of randomized trials, there was a trend towards reduced HF hospitalization risk (RR = 0.91, 95% CI = 0.83-1.01, I²  = 0%, P = 0.074). These data suggest that ACE-I and ARBs may have a role in improving outcomes of patients with HFpEF, underscoring the need for future research with careful patient selection, and trial design and conduct.

Meta-Analysis of Renin-Angiotensin-Aldosterone Blockade for Heart Failure in Presence of Preserved Left Ventricular Function

Background: Heart failure (HF) with a preserved left ventricular (LV) ejection fraction (EF) is the leading cause of hospitalization after 65 years of age. Individual randomized trials have not shown benefits conferred by angiotensin-converting enzyme (ACE) inhibitors or angiotensin-II receptor blockers (ARB) in these patients. To overcome this limitation, we performed a meta-analysis of the randomized trials of ACE inhibitors or ARB in patients with HF and preserved LVEF. Methods: Our search identified 4 randomized trials, comprising a total of 8152 patients, that investigated the effects of ACE inhibitors (n = 1), ARB (n = 2), or both treatments (n = 1). Risk ratios (RR) and 95% confidence intervals (CI) were calculated using a fixed-effect estimate method in the randomised trials. Results: Compared with placebo or no treatment, treatment with ACE inhibition or ARB was associated with lower rates of hospitalization for HF (RR 0.90; 95% CI 0.81-0.99, P = .032), though not cardiovascular mortality (RR 1.01; 95% CI 0.90-1.13, P = 0.858). In 3 studies where these endpoints were combined, the 1-year incidence of cardiovascular death or hospitalization for HF was lowered by ACE inhibition or ARB (RR 0.74; 95% CI 0.58-0.94, P = .014). Conclusion: Compared with placebo, ACE inhibition or ARB significantly lowered risks of (a) hospitalization for HF and (b) the combined endpoint of cardiovascular mortality and hospitalization for HF at 1 year, in patients with HF and preserved LVEF. However, they have no significant effect on mortality during more prolonged follow-up; the width of the 95% confidence limits is compatible with a benefit as big as 10% or a hazard as large as 13%.

Are angiotensin-converting enzyme inhibitors or angiotensin 2 receptor antagonists effective in heart failure with preserved ejection fraction?

Angiotensin-converting enzyme inhibitors (ACEI) and angiotensin receptor blockers (ARB) constitute first line treatment for patients with heart failure with reduced ejection fraction. However, their role in patients with preserved ejection fraction remains controversial. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified five systematic reviews including five randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded ACEI and ARB do not decrease mortality or hospitalization risk in this group of patients.

Effects of renin-angiotensin system blockade on mortality and hospitalization in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HF-PEF) is a well-recognized complication of long-standing hypertension. However, beyond the control of the traditional cardiovascular risk factors, there are few other recommendations for its management. To examine the potential benefit of renin-angiotensin system (RAS) inhibition in HF-PEF, we performed a systematic review of the published medical literature. MEDLINE, EMBASE, and COCHRANE databases were searched from 1966 to 2011 for longitudinal studies examining HF-PEF patients receiving treatment with RAS inhibitors, either ACE inhibitors (ACE-I) or angiotensin receptor blockers (ARB) in addition to their standard treatment compared to those receiving standard treatment alone. We examined the all-cause mortality, cardiovascular mortality, and hospitalizations for heart failure. A total of 12 studies with 11,259 participants were included in the analysis. Among the randomized clinical trials, with the use of RAS inhibitors over standard treatment, there was no improvement in all-cause mortality (RR: 0.99; 95% CI: 0.88-1.12; p = 0.88), while there was a trend toward lowered rates of hospitalization (RR: 0.93; 95% CI: 0.86-1.01; p = 0.08). There were no major differences in the outcomes between the ACE-I or ARB. However, among the observational studies with the use of RAS inhibitors, there was a significant benefit in all-cause mortality (RR: 0.76; 95% CI: 0.62-0.93; p = 0.009), with no significant impact on the hospitalization rates. RAS inhibition in HF-PEF was not associated with significant reduction in all-cause or cardiovascular mortality, but randomized control trials appear to demonstrate a trend toward reduction in the risk for subsequent hospitalization. Further prospective randomized trials are warranted to confirm the effects of RAS inhibition on mortality and hospitalization.

Efficacy of ACE inhibitors in chronic heart failure with preserved ejection fraction--a meta analysis of 7 prospective clinical studies

BACKGROUND

The effect of ACE inhibitors on the prognosis of chronic heart failure patients with preserved left ventricular ejection fraction remains controversial.

AIMS

To assess the impact of ACE inhibitors on the prognosis of chronic heart failure patients with preserved left ventricular ejection fraction.

METHODS AND RESULTS

Seven prospective studies evaluating the effect of ACE inhibitors compared to placebo or other classes of drugs, such as monotherapy or first-line therapy, on the prognosis of chronic heart failure patients with preserved left ventricular ejection fraction were included. A total of 2554 patients (mean age: 75.1 years, female: 58%) were recruited with an average follow up of 20.9 months. The primary etiology of heart failure with preserved ejection fraction was ischemic heart disease (33.7%), hypertension (69.1%) and diabetes mellitus (25.8%). Our results demonstrated that ACE inhibitors significantly reduced all-cause mortality (odds ratio, OR = 0.52; 95% Confidence Interval (CI), 0.41 to 0.64; P<0.01). Furthermore, ACE inhibitors were able to reduce heart failure related rehospitalization or treatment over 20.9 months (p<0.05) in a subgroup of patients aged over 75 years. However, death due to worsening of heart failure, heart failure related rehospitalization and any-cause readmission were not affected (OR = 0.88; 95% CI: 0.66 to 1.17; P = 0.37 for death due to worsening of heart failure; OR = 0.81; 95% CI: 0.63 to 1.05; P = 0.11 for heart failure related rehospitalization and OR = 0.88; 95% CI: 0.68 to 1.14; P = 0.33 for any-cause readmission, respectively).

CONCLUSIONS

In patients with chronic heart failure with preserved ejection fraction, ACE inhibitors reduced all-cause mortality without affecting mortality due to heart failure and any-cause rehospitalization.

Demonstrating the pharmacogenetic effects of angiotensin-converting enzyme inhibitors on long-term prognosis of diastolic heart failure

The objective of this study was to evaluate the effects of angiotensin-converting enzyme (ACE) inhibitors and pharmacogenetic interaction on the survival of the patients with diastolic heart failure (DHF). A total of 285 subjects with DHF confirmed by echocardiography were recruited in the period between 1995 and 2003. Baseline characteristics (age, sex, prior history, medication, and echocardiographic findings) and genetic polymorphisms (ACE gene insertion/deletion (I/D) polymorphism; T174M, M235T, G-6A, A-20C, G-152A, and G-217A polymorphisms of the angiotensinogen (AGT) gene; and A1166C polymorphisms of the angiotensin II type I receptor (AT1R)) were collected and matched (by propensity score) in those who received and those who did not receive ACE inhibitors. The patients were followed up to 10 years. Kaplan-Meier curves and Cox regression models were used to demonstrate the survival trend. The 85 patients who received ACE inhibitors and the other 85 patients who did not were found to have comparable baseline characteristics and polymorphism distribution. Prescription of ACE inhibitors was associated with a significant decrease in overall mortality (hazard ratio (HR), 0.45; 95% confidence interval (CI), 0.24-0.83; P=0.01), and a lower rate of cardiovascular events at 4000 days (HR, 0.53; 95% CI, 0.32-0.90; P=0.02). In addition, ACE I/D gene D allele was associated with higher overall mortality as compared with the I allele (HR, 2.04; P=0.003). This effect was diminished in those who received ACE inhibitors. The use of ACE inhibitor was associated with a significant decrease in long-term mortality and cardiovascular events in the patients with DHF. Genetic variants in the renin-angiotensin system genes were also associated, but their effects could be modified by the use of ACE inhibitors.

Heart failure with preserved ejection fraction in older adults

Age-associated physiologic changes predispose older adults to develop heart failure, even when left ventricular ejection fraction is normal or near normal. Heart failure with a preserved ejection fraction is particularly common in older hypertensive women, and hypertension plays a key role in its pathophysiology. In contrast with heart failure with a reduced ejection fraction, the treatment of heart failure with a preserved ejection fraction has a limited empiric basis, although some basic principles are useful. Ongoing studies provide hope of improving care of these patients.

Prognostic impact of angiotensin-converting enzyme inhibitor therapy in diastolic heart failure

The angiotensin-converting enzyme (ACE) inhibitor has a well defined place in the treatment of systolic heart failure (HF). Evidence for routine prescription of an ACE inhibitor in patients with diastolic HF (DHF) is inconsistent. Therefore, our aim was to evaluate the prognostic impact of ACE inhibitor in patients with DHF. The present prospective study included patients with normal or slightly impaired ejection fraction (> or =50%) surviving a first hospitalization for HF. We assessed the long-term prognosis of these patients according to prescription of an ACE inhibitor at discharge. ACE inhibitor therapy prescribed at discharge in 46% (n = 165) of the 358 included patients was associated with a 30% relative decrease in the risk of 5-year mortality (hazard ratio 0.70, 95% confidence interval 0.53 to 0.93, p = 0.013). On multivariable Cox analysis, the relation between ACE inhibitor prescription and mortality remained significant (hazard ratio 0.73, 95% confidence interval 0.54 to 0.99, p = 0.045). Using propensity score analysis, 120 patients receiving an ACE inhibitor were matched with 120 patients not receiving this medication. In the postmatch group, prescription of ACE inhibitor was associated with a significant decrease in the risk of 5-year mortality (hazard ratio 0.61, 95% confidence interval 0.43 to 0.87, p = 0.006). Five-year relative survival (observed/expected survival) of the ACE inhibitor group was better than that of the no-ACE inhibitor group (65% vs 57%). In conclusion, we demonstrate that in this cohort of patients with DHF, prescription of ACE inhibitor was associated with a significant decrease in long-term mortality.

Effect of statins, angiotensin-converting enzyme inhibitors, and beta blockers on survival in patients >or=65 years of age with heart failure and preserved left ventricular systolic function

About half of all patients with heart failure (HF) have preserved left ventricular systolic function. Statins, angiotensin-converting enzyme inhibitors, and beta blockers have been shown to improve survival in patients with HF and low ejection fraction. However, no large national study has investigated these agents in patients with HF and preserved left ventricular ejection fraction. We evaluated a nationwide sample of 13,533 eligible Medicare beneficiaries aged >or=65 years who were hospitalized with a primary discharge diagnosis of HF and had chart documentation of preserved left ventricular ejection fraction between April 1998 and March 1999 or between July 2000 and June 2001. In Cox proportional hazard model accounting for demographic profile, clinical characteristics, treatments, physician specialty, and hospital characteristics, discharge statin therapy was associated with significant improvements in 1- and 3-year mortality (RR 0.69, 95% confidence interval [CI] 0.61 to 0.78; RR 0.73, 95% CI 0.68 to 0.79, respectively). Irrespective of total cholesterol level or coronary artery disease status, diabetes, hypertension, and age, statin therapy was associated with significant differences in mortality rates. Similarly, angiotensin-converting enzyme inhibitors were associated with better survival at 1 year (RR 0.88, 95% CI 0.82 to 0.95) and 3 years (RR 0.93, 95% CI 0.89 to 0.98). Beta-blocker therapy was associated with a nonsignificant trend at 1 year (RR 0.93, 95% CI 0.87 to 1.10) and significant survival benefits at 3 years (RR 0.92%, 95% CI 0.87 to 0.97). In conclusion, our data demonstrate that statins, angiotensin-converting enzyme inhibitors, and beta blockers are associated with better short- and long-term survival in patients >or=65 years with HF and preserved left ventricular ejection fraction.

Economic burden of heart failure in the elderly

Heart failure (HF) ranks among the most costly chronic diseases in developed countries. At present these countries devote 1-2% of all healthcare expenditures towards HF. In the US, these costs are estimated at $US30.2 billion for 2007. The burden of HF is greatest among the elderly, with 80% of HF hospitalizations and 90% of HF-related deaths in this cohort. As a result, approximately three-quarters of the resources for HF care are consumed by elderly patients. As demographic shifts increase the number of elderly individuals in both developed and developing nations, the resources devoted to HF care will likely further increase. Hospitalization accounts for roughly two-thirds of HF costs, but procedures, outpatient visits and medications also consume significant financial resources. HF also adversely impacts patient quality of life, and these relevant effects may not be captured in pure cost analyses. The cost effectiveness of several pharmacological interventions has been explored. In general, neurohormonal antagonists used for outpatient treatment of chronic HF are relatively cost effective, in part by reducing hospitalizations. Because HF poses such an enormous financial burden, efficient resource allocation for its management is a major societal and governmental challenge. In order to make informed decisions and allocate resources for HF care rationally, detailed data regarding costs and resource use will be essential. Further studies are needed to examine the impact of pharmacological and non-pharmacological interventions on costs and resource use in elderly individuals with HF.

Long-term trends of angiotensin-converting enzyme inhibitor and angiotensin-receptor blocker use after heart failure hospitalization in community-dwelling seniors

BACKGROUND

Despite multiple trials demonstrating the benefit of angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin-receptor blockers (ARBs) for heart failure (HF) patients with systolic dysfunction, studies have reported underuse of these drugs. Little is known about recent trends in the use of ACEI/ARB in community-dwelling seniors.

METHODS

Using administrative data from pharmacy assistance programs and Medicare in two states, we identified all patients hospitalized for HF between 1995 and 2004 who survived >or=90 days after discharge. The study outcomes were filled prescriptions for an ACEI or ARB within 90 days after discharge. We assessed age, gender, race, and comorbidities. Multivariate modified Poisson regression was used to analyze temporal trends.

RESULTS

Of 54,453 patients identified, 26,166 (48%) filled prescriptions for ACEIs/ARBs within 90 days after discharge from HF, but utilization of these drugs did not increase during the decade studied. Among those who were on ACEI/ARB before the index hospitalization, 74% filled at least one ACEI/ARB prescription within 90 days after the hospitalization. These results were similar among the subgroup of HF patients with prior MI.

CONCLUSIONS

Use of ACEI/ARB after discharge from HF hospitalization in seniors did not increase over the decade of observation and may still be inadequate.

Diastolic Heart Failure in the Elderly

Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.

The contribution of observational studies to the knowledge of drug effectiveness in heart failure

AIMS

Randomized controlled trials (RCTs) are the golden standard for the assessment of drug efficacy. Little is known about the add-on value of observational studies in heart failure (HF). We aimed to assess the contribution of observational studies to actual knowledge regarding the effectiveness of angiotensin-converting enzyme inhibitors (ACEI), and beta-blockers (BB) in HF.

METHODS

Observational studies that assessed the effectiveness of ACEI and BB in HF were identified by searching Medline, Embase, Cochrane Database (1990-2005) and the bibliographies of published articles. Cohort, case-control and time-series analysis studies were considered for inclusion. Studies with <100 patients and those who did not perform a multivariate analysis were excluded.

RESULTS

A total of 23 cohort studies met the inclusion criteria. Studies of ACEI and BB showed a decrease in mortality with drug use in elderly patients with a broad range of ejection fraction (EF), and in those with depressed EF. Additionally, they showed a decrease in mortality in patients with renal insufficiency. The effect of ACEI and BB in HF with preserved EF was not clear, although last evidence suggests a potential benefit. Low-dose ACEI and BB may have beneficial effects. Target doses of ACEI seemed superior to low doses, but there was no clear dose-response relationship.

CONCLUSIONS

Observational studies in HF validate the effectiveness of ACEI and BB in populations underrepresented or excluded from RCTs. Observational studies of drug effectiveness provide relevant additional information for clinical practice.

Treatment practices in heart failure with preserved left ventricular ejection fraction: A prospective observational study

BACKGROUND

Current guidelines for treatment of patients with heart failure (HF) and preserved left ventricular ejection fraction (LVEF) are empirical. One of the objectives of the ETICS study was to evaluate medical treatment at discharge and after 1 year in patients hospitalised for a first episode of HF in 2000. We report the results concerning treatment of patients with preserved LVEF at discharge and at 1 year.

METHODS

Two hundred and sixty three consecutive patients (75+/-10 years, 47 males) with LVEF >50% hospitalised for a first episode of HF were prospectively included. Mean LVEF was 63+/-8%. The main aetiology was hypertension (61%) followed by ischaemic heart disease (29%). Atrial fibrillation and diabetes were present in 34% and 27% of cases, respectively. Medical treatment records were complete at discharge and at 1 year after discharge.

RESULTS

At discharge, as at 1 year after discharge, diuretics were the drugs most commonly prescribed (81% and 78%), followed by ACE inhibitors (49% and 46%), amiodarone (32% and 28%), beta-blockers (27% and 29%), nitrates (28% and 27%), calcium channel blockers (27% and 26%), spironolactone (21% and 25%), cardiac glycosides (19% and 24%), and angiotensin II receptor antagonists (4% and 6%). Once prescribed at hospital discharge, drug prescription rates and daily doses did not change significantly over time. Age did not influence drug prescription rates at discharge or at 1 year, except for the spironolactone prescription rate, which decreased at 1 year in patients > or =75 years of age. At discharge, ACE inhibitor and beta-blocker daily doses were lower in older patients, while, at 1 year, no differences in daily doses of these drugs were observed between patients above and below the age of 75 years.

CONCLUSION

Loops diuretics are largely prescribed in HF with preserved LVEF, followed by ACE inhibitors. Future large multicentre trials are required to define the background standard treatment in addition to treatment of aetiological factors.

Diastolic heart failure in the elderly

Most elderly patients, particularly women, who have heart failure have a normal ejection fraction. Patients who have this syndrome have severe symptoms of exercise intolerance, frequent hospitalizations, and increased mortality. The pathophysiology and treatment are not well defined. Control of systemic hypertension may be a key to prevention and treatment. Several large trials of specific agents are currently underway.

Long-term costs and resource use in elderly participants with congestive heart failure in the Cardiovascular Health Study

BACKGROUND

Although heart failure (HF) afflicts nearly 5 million Americans, the long-term cost of HF care has not been described previously. In a prospective, longitudinal cohort of community-dwelling elderly from 4 regions, we examined the long-term costs and resource use of elderly patients with HF.

METHODS

We linked 4860 elderly participants in the National Heart, Lung, and Blood Institute Cardiovascular Health Study to Medicare part A and part B claims from 1992 to 2003. Costs were calculated from Medicare payments and discounted at 3% annually. We applied nonparametric estimators to calculate mean costs and resource use per patient for a 10-year period. To describe the relationship between patient characteristics and long-term costs, we constructed censoring-adjusted regression models.

RESULTS

There were 343 participants (84.8% white; 50.1% men; mean age, 78.2 years) with prevalent HF and 4517 participants without HF at study entry. Mean follow-up was 6.7 years (median, 6.4 years). The 10-year survival rates were 33% and 63% for the prevalent HF and nonprevalent HF groups (P < .001), respectively. The mean 10-year medical costs were significantly higher for the prevalent HF cohort (54,704 dollars vs 41 dollars,780, P < .001). The higher costs associated with HF were also reflected in greater resource use with more hospitalizations (P < .05) and more intensive care unit days (P < .05). Participants with HF had more physician visits (P < .05), with most of these encounters involving noncardiology physicians. However, in multivariate models, prevalent HF was not an independent predictor of higher costs.

CONCLUSION

Patients with HF consume substantially more health care resources than their elderly peers, and these higher costs persist through 10 years of follow-up. Many of these costs may be related to other comorbid conditions.

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

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.

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)

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.

Diabetic cardiomyopathy: mechanisms, diagnosis and treatment

Independent of the severity of coronary artery disease, diabetic patients have an increased risk of developing heart failure. This clinical entity has been considered to be a distinct disease process referred to as 'diabetic cardiomyopathy'. Experimental studies suggest that extensive metabolic perturbations may underlie both functional and structural alterations of the diabetic myocardium. Translational studies are, however, limited and only partly explain why diabetic patients are at increased risk of cardiomyopathy and heart failure. Although a range of diagnostic methods may help to characterize alterations in cardiac function in general, none are specific for the alterations in diabetes. Treatment paradigms are very much limited to interpretation and translation from the results of interventions in non-diabetic patients with heart failure. This suggests that there is an urgent need to conduct pathogenetic, diagnostic and therapeutic studies specifically in diabetic patients with cardiomyopathy to better understand the factors which initiate and progress diabetic cardiomyopathy and to develop more effective treatments.

Anesthesiology: perioperative medicine or "when the anesthetic is a diuretic"

Two patients are reported, each with heart failure, who were treated with digoxin (case 1) and furosemide (case 2). Indications for medical treatment of patients with heart failure, the role of various drugs, and exercise therapy, are reviewed. At a time when the population of people over 65 years of age is increasing, it is important for physicians to recognize the symptoms of heart failure and to know the most up-to-date treatment for this disorder. These cases demonstrate the significance of the anesthesiologist as a perioperative physician.

Hospitalization for heart failure in the presence of a normal left ventricular ejection fraction

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.

Demographics, Treatment Regimens and the Use of Angiotensin-Receptor Blockers in Heart Failure: Findings from the Valsartan Heart Failure Trial

Heart failure is the only major cardiovascular disease with an incidence and prevalence that continue to increase in the developed world. Early identification and correct treatment of the condition are of paramount importance. In recent years, there has been growing interest in identifying the differences between patients in terms of their risk of heart failure and response to treatment. Differences between men and women, different age groups, patients with varying aetiologies or co-morbidities and differences between ethnic groups are only some of the factors that have been identified. This review surveys the available data on differences in responses to treatment, and discusses the use of angiotensin-receptor blockers in heart failure in light of the recent Valsartan Heart Failure Trial (Val-HeFT).

Conclusion: Heart failure is a complex syndrome, a fact that is reflected in the wide spectrum of patient characteristics and breadth of treatments available to physicians. Recommendations will keep evolving as we learn more about the changing aetiology and manifestations of the disease, and as new data become available on old and emerging treatments. The recent addition of ARBs (or at least valsartan) to the list of drugs of benefit in HF is a welcome development. Perhaps the most important message from Val-HeFT is that valsartan significantly reduced the risk of a first morbid event, irrespective of most underlying physiological and demographic parameters. This implies that valsartan will be beneficial in most patients, whether they are old or young, male or female and whatever the aetiology of their HF. As polypharmacy will continue to be the therapy of choice in HF and as no wonder-drug seems to be on the horizon to make the concept obsolete, further blocking the RAS by adding a well-tolerated agent would seem a very welcome expansion of our current treatment options.

Diastolic heart failure demystified

The mystery of diastolic heart failure (DHF), described by authorities as a "puzzle" and a "clinical paradox," stems from the following misperception: (1) that the normal ejection fraction implies normal cardiac output (CO), (2) that therefore low CO is not operative (it is rarely mentioned in relation to the pathophysiology of DHF), and (3) the congestive phenomena are due to the stiff left ventricle. In fact, a normal ejection fraction is not a reliable indicator of normal CO; low CO is the fundamental pathophysiologic abnormality of all heart failure (HF), whether systolic and/or diastolic (or, indeed, "high output"); and increased ventricular stiffness is not the principal cause of congestion in DHF. Pathophysiologic explorations supporting these understandings further reveal the following: (1) the premise that a clinical event as dramatic as acute pulmonary edema (systolic and/or diastolic) would be contingent on similarly dramatic acute hypertensive or ischemic ventricular dysfunction, while intuitive, is unsubstantiated, and there is an alternate explanation satisfying both theoretical and clinical observations; (2) contrary to general perception, DHF is no more vulnerable to diuretic-induced hypotension than systolic HF; (3) heart rate reduction should not yet be considered an established therapeutic goal in DHF; (4) since HF is HF whether systolic and/or diastolic, studies are likely to show that therapeutic similarities outweigh differences except as the various agents might modify the underlying structural and/or functional pathology; (5) although long evident that HF occurs by only two mechanisms (systolic dysfunction and/or diastolic dysfunction), it has only recently been acknowledged that the mere exclusion of one is diagnostic of the other; and (6) the definition of HF currently in widespread use is unnecessarily confounded by neglect of the fundamental distinction between ventricular dysfunction and failure.

Heart failure as a cause for hospitalization in chronic dialysis patients

BACKGROUND

Risk factors for heart failure (HF) have not been reported previously in a nationally representative sample of dialysis patients.

METHODS

We conducted a historic cohort study of 1,995 patients enrolled in the US Renal Data System Dialysis Morbidity and Mortality Study Wave 2 who were Medicare eligible at the study start and were followed up until December 31, 1999, or receipt of a renal transplant. Cox regression analysis was used to model associations with time to first hospitalization for both recurrent and de novo HF (International Classification of Diseases, Ninth Revision code 428.x), defined as patients with and without a history of HF, respectively.

RESULTS

The incidence density of HF was 71/1,000 person-years. Angiotensin-converting enzyme inhibitors and beta-blockers were each used in less than 25% of patients with a known history of HF. A history of coronary heart disease was associated with an increased total risk for HF, as were hemodialysis (versus peritoneal dialysis), aspirin use, and a history of diabetes. However, hemodialysis and aspirin use were the only factors associated with both de novo and recurrent HF. Widened pulse pressure was associated with de novo HF. The mortality rate after HF was 83% at 3 years (adjusted hazard ratio for mortality, 2.10; 95% confidence interval, 1.80 to 2.45; P < 0.0001).

CONCLUSION

In chronic dialysis patients, hemodialysis and aspirin use were associated with increased risk for both total and de novo HF. Hospitalized HF was associated with a significantly increased risk for death.

Improving outcomes in diastolic heart failure. Techniques to evaluate underlying causes and target therapy

Abnormal diastolic function is a common cause of clinical heart failure, particularly among elderly patients. Through early diagnosis and careful management of diastolic dysfunction, these patients can expect improved functional capacity and, in some cases, a favorable long-term outcome. In this article, Drs Torosoff and Philbin discuss how to confirm the diagnosis of diastolic heart failure through objective testing. Current approaches to the treatment of symptoms, including reduction of intravascular volume, heart rate control, and elimination of precipitating factors, are also presented.

Heart failure mortality among older Medicare beneficiaries: association with left ventricular function evaluation and angiotensin-converting enzyme inhibitor use

BACKGROUND

Left ventricular function evaluation and angiotensin-converting enzyme (ACE) inhibitor use are the two basic indicators of heart failure quality of care. In this retrospective follow-up study, we analyzed the association between these two quality indicators and mortality in elderly hospitalized heart failure patients.

METHODS

The patients in our study were older Alabama Medicare beneficiaries discharged with a diagnosis of heart failure in 1994. Cox regression analyses, adjusted for various patient and care characteristics, were performed to estimate the overall mortality rate.

RESULTS

The mean age of the 1,090 patients in our study was 79+/-7.5 years. Both left ventricular function evaluation (hazard ratio, 0.83; 95% confidence interval, 0.705-0.976) and ACE inhibitor use (hazard ratio, 0.77; 95% confidence interval, 0.655-0.905) were associated with a lower 3-year mortality rate. Adjustment for various patient and care characteristics did not alter these associations.

CONCLUSION

Left ventricular function evaluation and ACE inhibitor use were each associated with increased survival time in older Medicare beneficiaries with heart failure.

Can treatment with angiotensin-converting enzyme inhibitors in elderly patients with moderate to severe chronic heart failure be improved by a nurse-monitored structured care program? A randomized controlled trial

OBJECTIVE

The purpose of this study was to examine whether a nurse-monitored structured care program resulted in a more effective use of angiotensin-converting enzyme (ACE) inhibitors in elderly patients compared with standard care in patients with chronic heart failure (CHF).

METHODS

Hospitalized patients were screened to identify individuals with CHF, age more than 65 years, New York Heart Association classification III to IV, and no contraindications to ACE inhibitor treatment. One hundred forty-five patients were randomized to a nurse-monitored structured care program that included uptitration of enalapril to a target dose of 10 mg twice a day or to standard care. Six-month follow-up data were collected.

RESULTS

The mean age of the randomized patients was 81 years. Although the proportion of patients treated with an ACE inhibitor did not differ between structured care (70%) and standard care (64%), the number of patients with the target ACE inhibitor dose was significantly higher in the structured care group (26% versus 11% in the standard care group; P <.018). Treatment had to be discontinued in 26% of the patients because of adverse effects.

CONCLUSION

The patients in this study were older than in previous intervention studies and had considerable comorbidity and reduced tolerance for ACE inhibitors. ACE inhibitor treatment was underused but improved with the structured care program, although achieved treatment levels were below those in the large intervention trials in patients with CHF.

Elderly hospitalized patients with diastolic heart failure: lack of gender and ethnic differences in 18-month mortality rates

BACKGROUND

Racial and gender differences in mortality rates have been reported for patients with systolic heart failure. Relatively little is known regarding diastolic heart failure prognosis.

METHODS

Our sample consisted of 1058 patients 65 years of age or older who were admitted to 30 hospitals in Northeastern Ohio with a principal diagnosis of heart failure and a left ventricular ejection fraction of >/=50% by echocardiogram.

RESULTS

Of the 1058 patients with diastolic heart failure (13% African American and 87% white), African Americans and whites were comparable with respect to history of angina, stroke, being on dialysis, and alcohol use; the proportion of male patients was also comparable. The African American to white adjusted odds ratio for 18-month mortality (all cause) was 1.03 (0.66-1.59). For men versus women (30% vs 70%), the above-mentioned comorbidities were comparable, except women were more likely to have a do not resuscitate status (16% vs 7.3%; p =.000) and to be older (79.5 +/- 8 vs 77 +/- 7; p =.000). Men were more likely to have a history of tobacco use (30% vs 14%; p =.000) and alcohol use (36% vs 15%; p =.000), and a higher serum creatinine level (1.7 +/- 1.2 vs 1.4 +/- 1.1; p =.001). The men to women adjusted odds ratio for 18-month mortality (all cause) was 1.06 (0.76-1.46).

CONCLUSION

In this cohort of elderly patients admitted with diastolic heart failure, there were no ethnic or gender differences in 18-month mortality rates.

Correlates and outcomes of preserved left ventricular systolic function among older adults hospitalized with heart failure

BACKGROUND

Heart failure (HF) in older adults is often associated with preserved left ventricular systolic function (LVSF). The objective of this retrospective follow-up study was to determine the correlates and outcomes of preserved LVSF among older adults hospitalized with HF.

METHODS

We studied older Medicare beneficiaries hospitalized with HF (n = 1091) who had documented LVSF evaluation (n = 438). LVSF was defined as preserved if left ventricular ejection fraction was > or =40%. The Fisher exact test and the Student t test were used to compare baseline characteristics between patients with preserved versus those with impaired LVSF. Multivariate logistic regression analysis was used to determine the correlates of preserved LVSF. Cox proportional hazards analyses were used to determine the associations between LVSF and both 4-year mortality rates and 6-month readmission rates and the associations between angiotensin-converting enzyme (ACE) inhibitor use and 4-year mortality rates, separately, in patients with preserved and impaired LVSF.

RESULTS

Of the 438 patients, 200 (46%) had preserved LVSF. Women were more likely to have preserved LVSF (odds ratio [OR] = 2.44, 95% CI 1.57-3.81) than men. Preserved LVSF was associated with lower 4-year mortality rates (adjusted hazards ratio [HR] = 0.67, 95% CI 0.52-0.86) but not with 6-month readmission rates (adjusted HR = 0.66, 95% CI 0.41-1.09). The use of ACE inhibitors was associated with lower 4-year mortality rates in patients with impaired LVSF (adjusted HR = 0.61, 95% CI 0.43-0.86) but not in those with preserved LVSF (HR = 0.96, 95% CI 0.65-1.42).

CONCLUSIONS

Among older adults hospitalized with HF, preserved LVSF was common among women and was associated with significantly higher morbidity and mortality rates, which were unaffected by treatment with ACE inhibitors.

Interaction between aspirin and angiotensin-converting enzyme inhibitors: should they be used together in older adults with heart failure?

PURPOSE

To determine whether the prostacyclin-inhibiting properties of aspirin counteracts the bradykinin-induced prostacyclin-stimulating effects of angiotensin-converting enzyme (ACE) inhibitors, thereby attenuating the beneficial effects of ACE inhibitors in heart failure patients.

BACKGROUND

Most heart failure patients are older adults. Heart failure is the number one hospital discharge diagnosis of older Americans. The renin-angiotensin system plays a major role in the pathophysiology of heart failure, and ACE inhibitors play a pivotal role in the management of heart failure. Large-scale double-blind randomized trials have demonstrated the survival benefits of using ACE inhibitors in patients with heart failure associated with left ventricular systolic dysfunction. In addition to inhibiting the conversion of angiotensin I to angiotensin II, ACE inhibitors also decrease the breakdown of bradykinin. Bradykinin, a potent vasodilator, acts by stimulating formation of vasodilatory prostaglandins such as prostacyclin, whereas aspirin or acetyl salicylic acid inhibits the enzyme cyclooxygenase, which in turn decreases the production of the prostaglandins. Coronary artery disease and hypertension are the two major underlying causes of heart failure. Most heart failure patients are also on aspirin. There is evidence that aspirin at a daily dose of 80 to 100 mg prevents the synthesis of thromboxane A2 by platelets while relatively sparing the synthesis of prostacyclin in the vascular endothelium. Aspirin at a daily dose of 325 mg has significant inhibitory effects on the vasodilatory prostacyclin synthesis. Studies have demonstrated that, in heart failure patients, low-dose aspirin has no adverse effect on hemodynamic, neurohumoral, or renal functions. Whether the prostacyclin-inhibiting effects of aspirin attenuate some of the beneficial effects of ACE inhibitors mediated by prostacyclin stimulation in heart failure patients is currently unknown.

METHODS

Data from large clinical trials investigating the interaction between aspirin and ACE inhibitors were analyzed to determine the effect of aspirin on the vasodilatory actions of ACE inhibitors in heart failure patients, and the results were analyzed on the basis of theoretical and laboratory findings. The studies included are the Studies of Left Ventricular Dysfunction (SOLVD) (N=6,797), the Cooperative New Scandinavian Enalapril Survival Study II (CONSENSUS II) (N=6,090), the Captopril and Thrombolysis Study (CATS) (N=296), and another study involving 317 subjects. The data from these clinical trials investigating the interaction between aspirin and ACE inhibitors included 13,470 subjects. Most of the subjects received aspirin. In the SOLVD study, subjects received aspirin or dipyridamole. Subjects were followed up for an average of about 6 years.

RESULTS

In the SOLVD study, subjects were followed up for 41.1 months in the treatment trial and 37.4 months in the prevention trial. Patients who received aspirin or dipyridamole at baseline did not receive the survival benefits of enalapril, whereas patients who received enalapril did not receive the survival benefits of aspirin. In a rather small study of 317 subjects with left ventricular systolic dysfunction (ejection fraction <35%) who were followed up for a relatively longer period of time (5.7 years), the favorable long-term prognosis of patients receiving aspirin was independent of receipt of an ACE inhibitor. A retrospective subgroup analysis of data from the CONSENSUS II study demonstrated that the 6-month mortality rate of patients with acute myocardial infarction (MI) who received enalapril and aspirin was higher than the combined mortality rates of patients receiving enalapril or aspirin alone. This strong interaction between aspirin and the ACE inhibitor enalapril suggests that the survival benefit of enalapril was significantly lower in patients also taking aspirin than in those taking enalapril alone. This interaction was not associated with other nonfatal major events. In the CATS study, use of low-dose aspirin (80 or 100 mg) did not attenuate beneficial effects of captopril (immediate and 1-year follow up) after acute MI.

CONCLUSION

There is a theoretical possibility that the negative interaction between ACE inhibitors and aspirin may reduce the beneficial effects of ACE inhibitors in patients with heart failure, but the information obtained from the existing databases is limited by the retrospective nature of the analyses and does not establish the association definitively. Double-blind randomized controlled trials should be conducted to determine whether such a negative interaction indeed exists.

Is heart failure with preserved systolic function an overlooked enigma?

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.

Heart failure with preserved systolic function. A different natural history?

Three well-controlled epidemiology studies in the U.S. have reported that 40% of incident congestive heart failure (CHF) cases and 50% to 60% of prevalent CHF cases occur in the setting of preserved systolic function. This condition has been termed "diastolic heart failure" (DHF). Despite minor differences in the types of populations examined, these community-based studies have established DHF as a major health problem in the U.S., particularly among the elderly. Although extensive data are available concerning the natural history of CHF associated with reduced systolic dysfunction (systolic heart failure; SHF), the natural history of DHF is not well-characterized. Indeed, it remains unclear whether patients with DHF share the grim prognosis described for patients with SHF. In this review we examine the available studies comparing survival observed in patients with DHF to that observed in patients with SHF. Although there are insufficient data at present to make definitive conclusions, careful examination of the available studies raises the possibility that the natural history of patients with DHF may not be different from that observed in patients with CHF and reduced systolic function.

Congestive heart failure with preserved systolic function in a statewide sample of community hospitals

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.

Systolic versus diastolic heart failure in community practice: clinical features, outcomes, and the use of angiotensin-converting enzyme inhibitors

BACKGROUND

Among patients with heart failure, there is controversy about whether there are clinical features and laboratory tests that can differentiate patients who have low ejection fractions from those with normal ejection fractions. The usefulness of angiotensin-converting enzyme (ACE) inhibitors among heart failure patients who have normal left ventricular ejection fractions is also not known.

METHODS

From a registry of 2,906 unselected consecutive patients with heart failure who were admitted to 10 acute-care community hospitals during 1995 and 1997, we identified 1291 who had a quantitative measurement of their left ventricular ejection fraction. Patients were separated into three groups based on ejection fraction: < or =0.39 (n = 741, 57%), 0.40 to 0.49 (n = 238, 18%), and > or =0.50 (n = 312, 24%). In-hospital mortality, prescription of ACE inhibitors at discharge, subsequent rehospitalization, quality of life, and survival were measured; survivors were observed for at least 6 months after hospitalization.

RESULTS

The mean (+/- SD) age of the sample was 75+/-11 years; the majority (55%) of patients were women. In multivariate models, age >75 years, female sex, weight >72.7 kg, and a valvular etiology for heart failure were associated with an increased probability of having an ejection fraction > or =0.50; a prior history of heart failure, an ischemic or idiopathic cause of heart failure, and radiographic cardiomegaly were associated with a lower probability of having an ejection fraction > or =0.50. Total mortality was lower in patients with an ejection fraction > or =0.50 than in those with an ejection fraction < or =0.39 (odds ratio [OR] = 0.69, 95% confidence interval [CI 0.49 to 0.98, P = 0.04). Among hospital survivors with an ejection fraction of 0.40 to 0.49, the 65% who were prescribed ACE inhibitors at discharge had better mean adjusted quality-of-life scores (7.0 versus 6.2, P = 0.02), and lower adjusted mortality (OR = 0.34, 95% CI: 0.17 to 0.70, P = 0.01) during follow-up than those who were not prescribed ACE inhibitors. Among hospital survivors with an ejection fraction > or =0.50, the 45% who were prescribed ACE inhibitors at discharge had better (lower) adjusted New York Heart Association (NYHA) functional class (2.1 versus 2.4, P = 0.04) although there was no significant improvement in survival.

CONCLUSIONS

Among patients treated for heart failure in community hospitals, 42% of those whose ejection fraction was measured had a relatively normal systolic function (ejection fraction > or 0.40). The clinical characteristics and mortality of these patients differed from those in patients with low ejection fractions. Among the patients with ejection fractions > or =0.40, the prescription of ACE inhibitors at discharge was associated favorable effects.

Heart failure complicating acute myocardial infarction

Older people with congestive heart failure associated with acute myocardial infarction should be treated with loop diuretic therapy. Class I indications for the use of early intravenous beta blockade in patients with acute myocardial infarction are patients without a contraindication to beta blockers who can be treated within 12 hours of onset of myocardial infarction; patients with continuing or recurrent ischemic pain; and patients with tachyarrythmias, such as atrial fibrillation with a rapid ventricular rate. Class I indications for the use of angiotensin-converting enzyme inhibitors during acute myocardial infarction are (1) patients within the first 24 hours of onset of a suspected acute myocardial infarction with ST segment elevation in two or more anterior precordial leads or with clinical heart failure in the absence of significant hypotension or contraindications to the use of angiotensin-converting enzyme inhibitors, (2) patients with myocardial infarction and a left ventricular ejection fraction of less then 40%, (3) and patients with clinical heart failure on the basis of systolic pump dysfunction during and after convalescence from acute myocardial infarction. No class I indications exist for using calcium channel blockers or magnesium during acute myocardial infarction.

Determinants of angiotensin-converting enzyme inhibitor prescription in severe heart failure with left ventricular systolic dysfunction: the EPICAL study

BACKGROUND

Angiotensin-converting enzyme (ACE) inhibitors have been demonstrated to reduce morbidity and mortality rates in patients with heart failure with left ventricular systolic dysfunction. Nevertheless, these drugs are underutilized in current practice and prescribed at doses below those usually recommended. The aim of this work was to identify the social, demographic, laboratory, clinical, and therapeutic factors associated with nonprescription of ACE inhibitors and/or their prescription at doses below those recommended in the treatment of severe long-term congestive heart failure (CHF).

METHODS AND RESULTS

An epidemiologic observational study, EPICAL (EPidémiologie de l'Insuffisance Cardiaque Avancée en Lorraine), studied 417 patients with severe CHF surviving after the index hospitalization. Multivariate logistic regression determined the factors associated with ACE inhibitor nonprescription and with their prescription at lower-than-recommended doses. ACE inhibitors were taken by 75% of the patients but 38% took lower-than-recommended doses. Factors shown to be associated with nonprescription included patients >65 years of age with renal impairment (odds ratio 19.5, confidence interval [CI] 7.9-48.0), nonsinus cardiac rhythm (odds ratio 2.0, CI 1.2-3.2), and prescription of potassium-sparing diuretics (odds ratio 2.4, CI 1. 2-4.7). Renal impairment was the single most important factor associated with prescription of lower-than-recommended doses, particularly in elderly patients.

CONCLUSIONS

Our results underline the need for optimal and better use of ACE inhibitor therapy. CHF treatment guidelines must be more uniformly applied by all physicians caring for patients with heart failure.