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Fukuta H, Goto T, Kamiya T. Effects of calcium channel blockers in patients with heart failure with preserved and mildly reduced ejection fraction: A systematic review and meta-analysis. IJC HEART & VASCULATURE 2024; 55:101515. [PMID: 39346950 PMCID: PMC11437750 DOI: 10.1016/j.ijcha.2024.101515] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2024] [Revised: 08/27/2024] [Accepted: 09/15/2024] [Indexed: 10/01/2024]
Abstract
In contrast to beta-blockers and renin-angiotensin system inhibitors, the role of calcium channel blockers (CCBs) in patients with heart failure with preserved ejection fraction (HFpEF) remains uncertain. Despite several randomized controlled trials (RCTs) and cohort studies exploring the effects of CCBs on prognosis and exercise capacity in HFpEF patients, the findings have been inconsistent, likely due to limited statistical power and/or variations in study design. We aimed to conduct a systematic review and meta-analysis of studies on the effects of CCBs in HFpEF patients. The search of electronic databases identified 2 RCTs including 35 patients and 4 cohort studies including 25,078 patients. In cases of significant heterogeneity (I2 > 50 %), data were pooled using a random-effects model; otherwise, a fixed-effects model was used. In pooled analysis of the cohort studies, use of CCBs was not associated with the risk of all-cause death (hazard ratio [95 % CI] = 0.913 [0.732, 1.139], P random = 0.420) or hospitalization for heart failure (1.050 [0.970, 1.137], P fix = 0.230). Separate analyses for dihydropyridine and non-dihydropyridine CCBs revealed similar results. In pooled analysis of the RCTs, verapamil increased exercise time (weighted mean difference [95 % CI] = 0.953 [0.109, 1.797] min; P fix = 0.027) and decreased the congestive heart failure score (2.019 [1.673, 2.365] points; P fix < 0.001) compared with placebo. In conclusion, in HFpEF patients, verapamil may improve exercise capacity and symptoms but use of CCBs, regardless of subclass, may not be associated with better prognosis. Our meta-analysis is limited by the inclusion of only several studies for each outcome and further research is necessary to confirm our findings.
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Affiliation(s)
- Hidekatsu Fukuta
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toshihiko Goto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takeshi Kamiya
- Department of Medical Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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2
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Fukuta H, Goto T, Kamiya T. Effects of calcium channel blockers in patients with heart failure with preserved ejection fraction: A protocol for systematic review and meta-analysis. PLoS One 2024; 19:e0307258. [PMID: 39159218 PMCID: PMC11332996 DOI: 10.1371/journal.pone.0307258] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Accepted: 07/01/2024] [Indexed: 08/21/2024] Open
Abstract
BACKGROUND Nearly half of patients with heart failure (HF) have preserved ejection fraction (EF) and the mortality and morbidity of patients with HF with preserved EF (HFpEF) are high. Patients with HFpEF are often elderly and their primary chronic symptom is severe exercise intolerance. Due to the frequent coexistence of hypertension in HFpEF patients, the use of anti-hypertensive medications is common in their treatment. While many cohort studies and several randomized controlled trials (RCTs) have examined the effectiveness of various anti-hypertensive drugs such as beta-blockers and renin-angiotensin system inhibitors in HFpEF, the role of calcium channel blockers (CCBs) remains uncertain. Despite several RCTs and cohort studies exploring the effects of CCBs on prognosis and exercise capacity in HFpEF patients, the findings have been inconsistent, likely due to limited statistical power and/or variations in study design. Therefore, our aim is to conduct a systematic review and meta-analysis of studies on the effects of CCBs in these patients. METHODS This meta-analysis will include RCTs and cohort studies on the effect of CCBs in HFpEF patients. Information of studies will be collected from PubMed, Web of Science, and Scopus. The primary outcome of interest will be prognosis. The secondary outcome of interest will be exercise capacity. DISCUSSION Synthesizing our meta-analytical results with expert consensus could contribute to the formulation of updated clinical guidelines. Our systematic review and meta-analysis will provide directions for future research on the use of CCBs in HFpEF patients. SYSTEMATIC REVIEW REGISTRATION INPLASY202430097.
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Affiliation(s)
- Hidekatsu Fukuta
- Core Laboratory, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Toshihiko Goto
- Department of Cardiology, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
| | - Takeshi Kamiya
- Department of Medical Innovation, Nagoya City University Graduate School of Medical Sciences, Nagoya, Japan
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3
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Triska J, Uretsky BF, Pitt B, Birnbaum Y. Closing the Digitalis Divide: Back to the Basics of Randomized Controlled Trials. Cardiovasc Drugs Ther 2023; 37:807-813. [PMID: 34748147 DOI: 10.1007/s10557-021-07287-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/01/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Publishe d decades after several randomized controlled trials (RCT) demonstrating decreased hospitalizations and no effect on all-cause mortality with digoxin use, a series of meta-analyses linking digoxin treatment and mortality have contributed to a narrower application of this medication for the management of heart failure (HF) and atrial fibrillation (AF). Given the conflicting data from the earlier RCTs and more recent meta-analyses, there is a growing polarization among providers for and against the use of digoxin in managing these conditions. METHODS To help close this divide, we provide a perspective on the literature with special attention to the quality of both older and more recent studies on this subject. RESULTS The data from the highest quality studies we have, RCTs, suggest that digoxin use in patients with HF and/or AF is associated with improvement in several areas of outcomes including functional capacity, symptom management, reduced hospitalizations, fewer deaths due to HF, and treatment of refractory chronic heart failure with rEF, and may even have overall mortality benefit when serum digoxin concentrations are within therapeutic range. These effects are more pronounced in patients with EF < 25% and NYHA Class II-IV and at highest risk for hospitalization. CONCLUSION As the risk of confounding factors was minimized by the study design, the likelihood that positive outcomes were identified with digoxin use increased. Clinicians and researchers need further adequately designed and powered RCTs exploring the connection between digoxin therapy and mortality, hospitalizations, and symptom management.
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Affiliation(s)
- J Triska
- Internal Medicine Residency, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA.
| | - B F Uretsky
- University of Arkansas for Medical Sciences, Central Arkansas Veterans Health System, Little Rock, AR, 72205, USA
| | - B Pitt
- University of Michigan School of Medicine, Ann Arbor, MI, 48109, USA
| | - Y Birnbaum
- John S. Dunn Chair in Cardiology Research and Education, The Department of Medicine, Section of Cardiology, Baylor College of Medicine, One Baylor Plaza, Houston, TX, 77030, USA
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McGuinty C, Leong D, Weiss A, MacIver J, Kaya E, Hurlburt L, Billia F, Ross H, Wentlandt K. Heart Failure: A Palliative Medicine Review of Disease, Therapies, and Medications With a Focus on Symptoms, Function, and Quality of Life. J Pain Symptom Manage 2020; 59:1127-1146.e1. [PMID: 31866489 DOI: 10.1016/j.jpainsymman.2019.12.357] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2019] [Revised: 12/09/2019] [Accepted: 12/11/2019] [Indexed: 12/11/2022]
Abstract
Despite significant advances in heart failure (HF) treatment, HF remains a progressive, extremely symptomatic, and terminal disease with a median survival of 2.1 years after diagnosis. HF often leads to a constellation of symptoms, including dyspnea, fatigue, depression, anxiety, insomnia, pain, and worsened cognitive function. Palliative care is an approach that improves the quality of life of patients and their caregivers facing the problems associated with life-threatening illness and therefore is well suited to support these patients. However, historically, palliative care has often focused on supporting patients with malignant disease, rather than a progressive chronic disease such as HF. Predicting mortality in patients with HF is challenging. The lack of obvious transition points in disease progression also raises challenges to primary care providers and specialists to know at what point to integrate palliative care during a patient's disease trajectory. Although therapies for HF often result in functional and symptomatic improvements including health-related quality of life (HRQL), some patients with HF do not demonstrate these benefits, including those patients with a preserved ejection fraction. Provision of palliative care for patients with HF requires an understanding of HF pathogenesis and common medications used for these patients, as well as an approach to balancing life-prolonging and HRQL care strategies. This review describes HF and current targeted therapies and their effects on symptoms, hospital admission rates, exercise performance, HRQL, and survival. Pharmacological interactions with and precautions related to commonly used palliative care medications are reviewed. The goal of this review is to equip palliative care clinicians with information to make evidence-based decisions while managing the balance between optimal disease management and patient quality of life.
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Affiliation(s)
- Caroline McGuinty
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Derek Leong
- Department of Pharmacy, University Health Network, Toronto, Ontario, Canada
| | - Andrea Weiss
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Jane MacIver
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Ebru Kaya
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada
| | - Lindsay Hurlburt
- Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Department of Anesthesia, University of Toronto, Toronto, Ontario, Canada
| | - Filio Billia
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Heather Ross
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Kirsten Wentlandt
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Supportive Care, University Health Network, Toronto, Ontario, Canada; Division of Palliative Care, Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada.
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5
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Zhou J, Cao J, Jin X, Zhou J, Chen Z, Xu D, Yang X, Dong W, Li L, Fan Y, Chen L, Zhong Q, Fu M, Hu K, Ge J. Digoxin is associated with worse outcomes in patients with heart failure with reduced ejection fraction. ESC Heart Fail 2020; 7:138-146. [PMID: 31994361 PMCID: PMC7083440 DOI: 10.1002/ehf2.12539] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Revised: 09/02/2019] [Accepted: 09/17/2019] [Indexed: 11/10/2022] Open
Abstract
AIMS The aim of this study was to investigate the impact of digoxin use on the outcomes of patients with heart failure with reduced ejection fraction (HFrEF) and its possible interaction with atrial fibrillation or use of currently guideline-recommended treatments in the real world in China. METHODS AND RESULTS Patients hospitalized with HFrEF from 45 hospitals participating in the China National Heart Failure Registration Study (CN-HF) were enrolled to assess the all-cause mortality, HF mortality, all-cause re-hospitalization, and HF re-hospitalization associated with digoxin use. Eight hundred eighty-two eligible HFrEF patients in the CN-HF registry were included: 372 patients with digoxin and 510 patients without digoxin. Among them, 794 (90.0%) patients were followed up for the endpoint events, with a median follow-up of 28.6 months. Kaplan-Meier survival analysis showed that the all-cause mortality (P < 0.001) and all-cause re-hospitalization (P = 0.020) were significantly higher in digoxin group than non-digoxin group, while HF mortality (P = 0.232) and HF re-hospitalization (P = 0.098) were similar between the two groups. The adjusted Cox proportional-hazards regression analysis demonstrated that digoxin use remained as an independent risk factor for increased all-cause mortality [hazard ratio (HR) 1.76; 95% confidence interval (CI) 1.27-2.44; P = 0.001] and all-cause re-hospitalization (HR 1.27; 95% CI 1.03-1.57; P = 0.029) in HFrEF patients and the predictive value of digoxin for all-cause mortality irrespective of rhythm or in combination with other guideline-recommended therapies. CONCLUSIONS Digoxin use is independently associated with increased risk of all-cause mortality and all-cause re-hospitalization in HFrEF patients.
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Affiliation(s)
- Jingmin Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Shanghai, 200032, China
| | - Juan Cao
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Shanghai, 200032, China.,North Sichuan Medical College, Department of Cardiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Xuejuan Jin
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Shanghai, 200032, China
| | - Jun Zhou
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Shanghai, 200032, China
| | - Zhenyue Chen
- Department of Cardiology, Ruijin Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Dingli Xu
- Department of Cardiology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Xinchun Yang
- Heart Center, Beijing Chaoyang Hospital affiliated to Capital Medical University, Beijing, China
| | - Wei Dong
- Department of Cardiology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Liwen Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong General Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yuyuan Fan
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Shanghai, 200032, China.,North Sichuan Medical College, Department of Cardiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Li Chen
- North Sichuan Medical College, Department of Cardiology, The Affiliated Hospital of North Sichuan Medical College, Nanchong, Sichuan, China
| | - Qiaoqing Zhong
- Department of Cardiology, First People's Hospital of Chenzhou, Chenzhou, China
| | - Micheal Fu
- Section of Cardiology, Department of Medicine, Sahlgrenska University Hospital/Östra Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Kai Hu
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Shanghai, 200032, China
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Fudan University, Shanghai Institute of Cardiovascular Diseases, 180 Fenglin Road, Shanghai, 200032, China
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Tkacheva ON, Ostroumova OD, Kotovskaya YV, Kochetkov AI, Pereverzev AP, Krasnov GS. [Treatment of chronic heart failure: is deprescribing possible?]. ACTA ACUST UNITED AC 2020; 60:126-136. [PMID: 32375625 DOI: 10.18087/cardio.2020.3.n779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/17/2019] [Accepted: 10/18/2019] [Indexed: 11/18/2022]
Abstract
Deprescribing is a scheduled withdrawal, dose reduction, or replacement of a medicine with a safer one. Several groups of medicinal products (MPs) are used simultaneously in the treatment of chronic heart failure. This increases the risk of adverse drug reactions, particularly in elderly and senile patients. A systematic search for literature allowed evaluating possibilities of deprescribing for the following pharmaceutic groups: 1) MPs influencing the renin-angiotensin-aldosterone system; 2) beta-blockers; 3) digoxin; and 4) diuretics. Three systematic reviews and several studies were analyzed to determine the most feasible and potentially optimal regimens of deprescribing in CHF. It was established that in CHF, deprescribing has a very limited potential for use due to the documented, obvious effect of some MP groups on prediction and severity of clinical symptoms in CHF patients.
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Affiliation(s)
- O N Tkacheva
- Russian Clinical and Research Center of Gerontology, N.I. Pirogov Russian National Research Medical University
| | - O D Ostroumova
- Russian Clinical and Research Center of Gerontology, N.I. Pirogov Russian National Research Medical University
| | - Yu V Kotovskaya
- Russian Clinical and Research Center of Gerontology, N.I. Pirogov Russian National Research Medical University
| | - A I Kochetkov
- Russian Clinical and Research Center of Gerontology, N.I. Pirogov Russian National Research Medical University
| | - A P Pereverzev
- Russian Clinical and Research Center of Gerontology, N.I. Pirogov Russian National Research Medical University
| | - G S Krasnov
- Russian Clinical and Research Center of Gerontology, N.I. Pirogov Russian National Research Medical University
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Abstract
Heart failure (HF) affects 2.4% of the adult population in the United States and is associated with high health care costs. Medical and device therapy delay disease progression and improve survival in HF with reduced ejection fraction. Stage D HF is characterized by significant functional limitation, frequent HF hospitalization for decompensation, intolerance of medical therapy, use of inotropes, and high diuretic requirement. Advanced therapies with left ventricular assist devices and cardiac transplantation reduce mortality and improve quality of life, and early referral to specialized centers is imperative for patient selection and success with these therapies.
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Affiliation(s)
- Maya H Barghash
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA.
| | - Sean P Pinney
- Department of Medicine, Division of Cardiology, Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, One Gustave L. Levy Place, Box 1030, New York, NY 10029, USA
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8
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Wang J, Yang R, Zhang F, Jia C, Wang P, Liu J, Gao K, Xie H, Wang J, Zhao H, Chen J, Wang W. The Effect of Chinese Herbal Medicine on Quality of Life and Exercise Tolerance in Heart Failure With Preserved Ejection Fraction: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Front Physiol 2018; 9:1420. [PMID: 30416450 PMCID: PMC6212585 DOI: 10.3389/fphys.2018.01420] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2018] [Accepted: 09/18/2018] [Indexed: 11/23/2022] Open
Abstract
Background: Chinese herbal medicine (CHM) has a good effect of alleviating symptoms and improving quality of life and exercise tolerance in patients with heart failure with preserved ejection fraction (HFpEF), but it wasn't sufficiently valued and promoted because of the lack of evidence-based medical evidence. Aim: To systematically review the effect of CHM on quality of life and exercise tolerance in patients with HFpEF. Methods: We conducted a systematic literature search for Chinese and English studies in PubMed, EMBASE, Cochrane Central Register of Controlled Trials, Chinese Biomedical Literature Database, China Knowledge Resource Integrated Database, Wanfang Data, and China Science and Technology Journal Database. Databases were searched using terms relating to or describing CHM, HFpEF and randomized controlled trials, without any exclusion criteria for other types of diseases or disorders. Literature retrieval, data extraction, and risk of bias assessments were performed independently by two investigators. Differences were resolved by consensus. RevMan 5.3.0 was used for data analysis. Quantitative synthesis was used when the included studies were sufficiently homogeneous and subgroup analyses were performed for studies with different sample sizes and blind methods. GRADEpro was used to grade the available evidence to minimize bias in our findings. Results: Seventeen studies with 2,724 patients were enrolled in this review. ROB assessments showed a relatively high selection and performance bias. Meta-analyses showed that compared with conventional western medicine, combined CHM and conventional western medicine could significantly improve 6-min walk distance (MD = 52.13, 95% CI [46.91, 57.34], P < 0.00001), and it seemed to be more effective as compared with combined placebo and conventional western medicine. Similar results were observed for quality of life and the results were better in a larger sample. The GRADEpro showed a very low to moderate level of the available evidence. Conclusion: Combined CHM and conventional western medicine might be effective to improve exercise tolerance and quality of life in HFpEF patients, but new well-designed studies with larger sample size, strict randomization, and clear description about detection and reporting processes are needed to further strengthen this evidence.
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Affiliation(s)
- Jinping Wang
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Ran Yang
- Guanganmen Hospital, China Academy of Chinese Medical Sciences, Beijing, China
| | - Feilong Zhang
- Beijing University of Chinese Medicine, Beijing, China
| | - Caixia Jia
- Beijing University of Chinese Medicine, Beijing, China
| | - Peipei Wang
- Beijing University of Chinese Medicine, Beijing, China
| | - Junjie Liu
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Kuo Gao
- Beijing University of Chinese Medicine, Beijing, China
| | - Hua Xie
- Beijing University of Chinese Medicine, Beijing, China
| | - Juan Wang
- Beijing University of Chinese Medicine, Beijing, China
| | - Huihui Zhao
- Beijing University of Chinese Medicine, Beijing, China
| | - Jianxin Chen
- Beijing University of Chinese Medicine, Beijing, China
| | - Wei Wang
- Beijing University of Chinese Medicine, Beijing, China
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9
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Alkhawam H, Abo-Salem E, Zaiem F, Ampadu J, Rahman A, Sulaiman S, Zaitoun A, Helmy T, Vittorio TJ. Effect of digitalis level on readmission and mortality rate among heart failure reduced ejection fraction patients. Heart Lung 2018; 48:22-27. [PMID: 30172414 DOI: 10.1016/j.hrtlng.2018.07.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2018] [Revised: 07/06/2018] [Accepted: 07/11/2018] [Indexed: 12/28/2022]
Abstract
INTRODUCTION Digitalis has been used for over 200 years to treat patients with heart failure, and evidence supports its use to improve clinical symptoms and quality of life, but not survival. The objective of this retrospective study was to evaluate the effects of digitalis on readmission and mortality in patients with heart failure with reduced ejection fraction (HFrEF) who were receiving current guideline recommended medical therapy. METHODS We reviewed medical record data from a retrospective cohort study of 1047 patients admitted to the hospital from 2005 to 2014 with decompensated HFrEF. 244 received digitalis, at some point during patient trajectory, and 803 never received digitalis. The primary outcomes of interest were the length of stay in hospital, readmission rates after discharge at 1, 6, 12, and 24 months and the overall mortality rate, at the same time points. RESULTS We studied the effects of digitalis after adjusting for age, sex, race, potentially confounding comorbidities, and prescription medications. Digitalis treatment is associated with decreases in EF in patients with HFrEF (OR = -2.83, P < 0.001) and was associated with an increased readmission rate for any reason after discharge from the hospital at 6, 12, and 24 months, 53%, 34%, and 35%, respectively. No statistically significant difference was found between patients who received digitalis and those who did not (referent group) for the length of hospital stay and overall mortality rate. CONCLUSION Digitalis use is associated with increased re-admission rates for any reason following discharge from the hospital at 6, 12, and 24 months.
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Affiliation(s)
- Hassan Alkhawam
- Center for Comprehensive Cardiovascular Care, St Louis University, St Louis, MO, United States; Department of Medicine, Icahn School of Medicine at Mount Sinai (Elmhurst), Elmhurst, NY, United States.
| | - Elsayed Abo-Salem
- Center for Comprehensive Cardiovascular Care, St Louis University, St Louis, MO, United States
| | - Feras Zaiem
- Department of Pathology, Karmanos Cancer Institute, Wayne State University School of Medicine, Detroit, MI, United States
| | - James Ampadu
- Center for Comprehensive Cardiovascular Care, St Louis University, St Louis, MO, United States
| | - Aleef Rahman
- School of Medicine, St. George's University, St. George's, Grenada
| | - Samian Sulaiman
- Department of Medicine, Medical College of Wisconsin, Milwaukee, WI, United States
| | - Anwar Zaitoun
- Division of Cardiology, Saint John Hospital and Medical Center, Detroit, MI, United States
| | - Tarek Helmy
- Center for Comprehensive Cardiovascular Care, St Louis University, St Louis, MO, United States
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10
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Upshaw JN, van Klaveren D, Konstam MA, Kent DM. Digoxin Benefit Varies by Risk of Heart Failure Hospitalization: Applying the Tufts MC HF Risk Model. Am J Med 2018; 131:676-683.e2. [PMID: 29284111 PMCID: PMC7643562 DOI: 10.1016/j.amjmed.2017.12.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2017] [Accepted: 12/04/2017] [Indexed: 11/27/2022]
Abstract
BACKGROUND Digoxin has been shown to reduce heart failure hospitalizations with a neutral effect on mortality. It is unknown whether there is heterogeneity of treatment effect for digitalis therapy according to predicted risk of heart failure hospitalization. METHODS AND RESULTS We conducted a post hoc analysis of the Digitalis Investigator Group (DIG) studies, randomized controlled trials of digoxin vs placebo in participants with heart failure and left ventricular ejection fraction ≤45% (main DIG study, n = 6800) or >45% (ancillary DIG study, n = 988). Using a previously derived multistate model to risk-stratify DIG study participants, we determined the differential treatment effect on hospitalization and mortality outcomes. There was a 13% absolute reduction in the risk of any heart failure hospitalizations (39% vs 52%; odds ratio 0.58; 95% confidence interval 0.47-0.71) in the digoxin vs placebo arms in the highest-risk quartile, compared with a 3% absolute risk reduction for any heart failure hospitalization (17% vs 20%; odds ratio 0.84; 95% confidence interval, 0.66-1.08) in the lowest-risk quartile. There were 12 fewer total all-cause hospitalizations per 100 person-years in the highest-risk quartile compared with an increase of 8 hospitalizations per 100 person-years in the lowest-risk quartile. There was neutral effect of digoxin on mortality in all risk quartiles and no interaction between baseline risk and the effect of digoxin on mortality (P = .94). CONCLUSIONS Participants in the DIG study at higher risk of hospitalization as identified by a multistate model were considerably more likely to benefit from digoxin therapy to reduce heart failure hospitalization.
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Affiliation(s)
- Jenica N Upshaw
- The CardioVascular Center, Tufts Medical Center, Boston, Mass.
| | - David van Klaveren
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass; The Medical Statistics Department, Leiden University Medical Center, The Netherlands
| | | | - David M Kent
- The Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass
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11
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Abstract
Digoxin remains one of the oldest therapies for heart failure; however, its safety and efficacy have been controversial since its initial use. Questions that remain include the clinical efficacy of digoxin when added to contemporary medical therapy, when and if it should be added, and how to minimize adverse effects. In this review, we will summarize recent data on the use of digoxin in systolic heart failure and address some of the controversies regarding the role of digoxin in the modern era of heart failure treatment.
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Affiliation(s)
- Chonyang L Albert
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Forum Kamdar
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA
| | - Mazen Hanna
- Department of Cardiovascular Medicine, Cleveland Clinic Foundation, 9500 Euclid Ave, Cleveland, OH, 44195, USA.
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12
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Kim MS, Lee JH, Kim EJ, Park DG, Park SJ, Park JJ, Shin MS, Yoo BS, Youn JC, Lee SE, Ihm SH, Jang SY, Jo SH, Cho JY, Cho HJ, Choi S, Choi JO, Han SW, Hwang KK, Jeon ES, Cho MC, Chae SC, Choi DJ. Korean Guidelines for Diagnosis and Management of Chronic Heart Failure. Korean Circ J 2017; 47:555-643. [PMID: 28955381 PMCID: PMC5614939 DOI: 10.4070/kcj.2017.0009] [Citation(s) in RCA: 54] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2017] [Revised: 06/19/2017] [Accepted: 06/23/2017] [Indexed: 11/11/2022] Open
Abstract
The prevalence of heart failure (HF) is skyrocketing worldwide, and is closely associated with serious morbidity and mortality. In particular, HF is one of the main causes for the hospitalization and mortality in elderly individuals. Korea also has these epidemiological problems, and HF is responsible for huge socioeconomic burden. However, there has been no clinical guideline for HF management in Korea.
The present guideline provides the first set of practical guidelines for the management of HF in Korea and was developed using the guideline adaptation process while including as many data from Korean studies as possible. The scope of the present guideline includes the definition, diagnosis, and treatment of chronic HF with reduced/preserved ejection fraction of various etiologies.
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Affiliation(s)
- Min-Seok Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ju-Hee Lee
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Eung Ju Kim
- Department of Cardiology, Cardiovascular Center, Korea University Guro Hospital, Seoul, Korea
| | - Dae-Gyun Park
- Division of Cardiology, Hallym University Kangdong Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Sung-Ji Park
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Jin Joo Park
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Mi-Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gachon University Gil Medical Center, Incheon, Korea
| | - Byung Su Yoo
- Division of Cardiology, Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Sang Eun Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Sang Hyun Ihm
- Department of Cardiology, Bucheon St. Mary's Hospital, The Catholic University of Korea, Bucheon, Korea
| | - Se Yong Jang
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Sang-Ho Jo
- Division of Cardiology, Hallym University Pyeongchon Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Hyun-Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
| | - Seonghoon Choi
- Division of Cardiology, Hallym University Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Seong Woo Han
- Division of Cardiology, Hallym University Dongtan Sacred Heart Hospital, Hallym University College of Medicine, Hwaseong, Korea
| | - Kyung Kuk Hwang
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Eun Seok Jeon
- Division of Cardiology, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Korea
| | - Myeong-Chan Cho
- Division of Cardiology, Department of Internal Medicine, Chungbuk National University Hospital, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Shung Chull Chae
- Division of Cardiology, Department of Internal Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Dong-Ju Choi
- Department of Internal Medicine, Cardiovascular Center, Seoul National University Bundang Hospital, Seongnam, Korea
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Madelaire C, Schou M, Nelveg-Kristensen KE, Schmiegelow M, Torp-Pedersen C, Gustafsson F, Køber L, Gislason G. Use of digoxin and risk of death or readmission for heart failure and sinus rhythm: A nationwide propensity score matched study. Int J Cardiol 2016; 221:944-50. [DOI: 10.1016/j.ijcard.2016.07.111] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2016] [Revised: 07/04/2016] [Accepted: 07/07/2016] [Indexed: 10/21/2022]
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Biteker M, Başaran Ö, Dogan V, Beton O, Tekinalp M, Çağrı Aykan A, Kalaycıoğlu E, Bolat I, TaŞar O, Şafak Ö, Kalçık M, Yaman M, Kırma C. Real-life use of digoxin in patients with non-valvular atrial fibrillation: data from the RAMSES study. J Clin Pharm Ther 2016; 41:711-717. [PMID: 27671101 DOI: 10.1111/jcpt.12460] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2016] [Accepted: 09/04/2016] [Indexed: 02/05/2023]
Affiliation(s)
- M. Biteker
- Department of Cardiology; Faculty of Medicine; Mugla Sitki Kocman University; Muğla Turkey
| | - Ö. Başaran
- Department of Cardiology; Faculty of Medicine; Mugla Sitki Kocman University; Muğla Turkey
| | - V. Dogan
- Department of Cardiology; Faculty of Medicine; Mugla Sitki Kocman University; Muğla Turkey
| | - O. Beton
- Department of Cardiology; Faculty of Medicine; Sivas Cumhuriyet University; Sivas Turkey
| | - M. Tekinalp
- Department of Cardiology; Kahramanmaraş Necip Fazıl State Hospital; Kahramanmaraş Turkey
| | - A. Çağrı Aykan
- Department of Cardiology; Trabzon Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital; Trabzon Turkey
| | - E. Kalaycıoğlu
- Department of Cardiology; Trabzon Ahi Evren Chest Cardiovascular Surgery Education and Research Hospital; Trabzon Turkey
| | - I. Bolat
- Department of Cardiology; Fethiye State Hospital; Muğla Turkey
| | - O. TaŞar
- Department of Cardiology; Elazığ Education and Research Hospital; Elazig Turkey
| | - Ö. Şafak
- Department of Cardiology; Burdur State Hospital; Burdur Turkey
| | - M. Kalçık
- Department of Cardiology; İskilip Atıf Hoca State Hospital; İskilip Turkey
| | - M. Yaman
- Department of Cardiology; Samsun Education and Research Hospital; Samsun Turkey
| | - C. Kırma
- Kartal Kosuyolu Heart Education and Research Hospital; Istanbul Turkey
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Abstract
Standard drug therapy of systolic heart failure has been evaluated in large-scale randomized clinical trials and includes angiotensin-converting enzyme (ACE) inhibi tors, which should be used as first-line therapy, diuret ics for the management of extracellular fluid volume excess, and digoxin. In combination with ACE inhibitors and diuretics, with or without digoxin, some β-adrener gic receptor blockers attenuate disease progression and improve outcome in mild-to-moderate systolic heart failure. The pharmacologic management of chronic dia stolic heart failure is largely empirical and directed at reducing symptoms. Symptoms caused by increased ventricular filling pressures may be diminished by diuret ics and nitrovasodilators. Some calcium channel antago nists and most β-blockers prolong diastolic filling time by slowing heart rate, thereby improving the symptoms of diastolic heart failure.
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Affiliation(s)
- William T. Abraham
- Section of Heart Failure and Cardiac Transplantation, University of Cincinnati College of Medicine, Cincinnati, OH
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Konstantinou DM, Karvounis H, Giannakoulas G. Digoxin in Heart Failure with a Reduced Ejection Fraction: A Risk Factor or a Risk Marker? Cardiology 2016; 134:311-9. [DOI: 10.1159/000444078] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Accepted: 01/17/2016] [Indexed: 11/19/2022]
Abstract
Digoxin is one of the oldest compounds used in cardiovascular medicine. Nevertheless, its mechanism of action and most importantly its clinical utility have been the subject of an endless dispute. Positive inotropic and neurohormonal modulation properties are attributed to digoxin, and it was the mainstay of heart failure therapeutics for decades. However, since the institution of β-blockers and aldosterone antagonists as part of modern heart failure medical therapy, digoxin prescription rates have been in free fall. The fact that digoxin is still listed as a valid therapeutic option in both American and European heart failure guidelines has not altered clinicians' attitude towards the drug. Since the publication of original Digitalis Investigation Group trial data, a series of reports based predominately on observational studies and post hoc analyses have raised concerns about the clinical efficacy and long-term safety of digoxin. In the present review, we will attempt a critical appraisal of the available clinical evidence regarding the efficacy and safety of digoxin in heart failure patients with a reduced ejection fraction. The methodological issues, strengths, and limitations of individual studies will be highlighted.
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Rain C, Rada G. Is there a role for digitalis in chronic heart failure?--First update. Medwave 2015; 15 Suppl 1:e6148. [PMID: 25919287 DOI: 10.5867/medwave.2015.6149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
This Living FRISBEE (Living FRIendly Summary of the Body of Evidence using Epistemonikos) is an update of the summary published in April 2015, based on a new systematic review published in May 2015. The main clinical guidelines recommend the use of digitalis for chronic heart failure when moderate to severe symptoms persist after standard therapy, even though there is controversy about its efficacy and security. Searching in Epistemonikos database, which is maintained by screening 30 databases, we identified four systematic reviews including 13 randomized trials. We combined the evidence using meta-analysis and generated a summary of findings table following the GRADE approach. We concluded the use of digitalis for chronic heart failure probably leads to little or no decrease in mortality, but they might reduce hospitalizations and clinical deterioration. However, the certainty of the evidence is low.
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Affiliation(s)
- Carmen Rain
- Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile. Address: Facultad de Medicina, Pontificia Universidad Católica de Chile, Lira 63, Santiago Centro, Chile.
| | - Gabriel Rada
- Programa de Salud Basada en Evidencia, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Departamento de Medicina Interna, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; GRADE working group; The Cochrane Collaboration; Fundación Epistemonikos
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Rain C, Rada G. ¿Tienen un rol los digitálicos en la insuficiencia cardíaca crónica? Medwave 2015. [DOI: 10.5867/medwave.2015.03.6129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Abstract
ACC Stage C heart failure includes those patients with prior or current symptoms of heart failure in the context of an underlying structural heart problem who are primarily managed with medical therapy. Although there is guideline-based medical therapy for those with heart failure with reduced ejection fraction (HFrEF), therapies in heart failure with preserved ejection fraction (HFpEF) have thus far proven elusive. Emerging therapies such as serelaxin are currently under investigation and may prove beneficial. The role of advanced surgical therapies, such as mechanical circulatory support, in this population is not well defined. Further investigation is warranted for these therapies in patients with Stage C heart failure.
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Affiliation(s)
- Sasikanth Adigopula
- Mechanical Circulatory Support & Heart Transplantation Program, Ahmanson-UCLA Cardiomyopathy Center, David Geffen School of Medicine, University of California, Los Angeles, 100 UCLA Medical Plaza, Suite 630 East, Los Angeles, CA 90095, USA
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Hood, Jr. WB, Dans AL, Guyatt GH, Jaeschke R, McMurray JJV. Digitalis for treatment of heart failure in patients in sinus rhythm. Cochrane Database Syst Rev 2014; 2014:CD002901. [PMID: 24771511 PMCID: PMC7138042 DOI: 10.1002/14651858.cd002901.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND Digitalis glycosides have been in clinical use for the treatment of heart failure (HF) for longer than 200 years. In recent years, several trials have been conducted to address concerns about their efficacy and toxicity. OBJECTIVES To examine the effectiveness of digitalis glycosides in treating HF in patients with normal sinus rhythm. To examine the effects of digitalis in patients taking diuretics and angiotensin-converting enzyme inhibitors; in patients with varying severity and duration of disease; in patients with prior exposure to digitalis versus no prior exposure; and in patients with "HF due to systolic dysfunction" versus "HF with preserved ejection fraction." SEARCH METHODS Searches on the following databases were updated in May 2013: The Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, and Dissertation Abstracts. Annual meeting abstracts of the American Heart Association, the American College of Cardiology, and the European Society of Cardiology were searched from 1996 to March 2013. In addition, reference lists provided by the pharmaceutical industry (GlaxoSmithKline and Covis Pharma) were searched. SELECTION CRITERIA Included were randomized placebo-controlled trials of 20 or more adult participants of either sex with symptomatic HF who were studied for seven weeks or longer. Excluded were trials in which the prevalence of atrial fibrillation was 2% or greater, or in which any arrhythmia that might compromise cardiac function or any potentially reversible cause of HF such as acute ischemic heart disease or myocarditis was present. DATA COLLECTION AND ANALYSIS Articles selected from the searches described above were evaluated in a joint effort of the review authors. The staff of the Cochrane Heart Group ran searches on the Cochrane Central Register of Controlled Trials, MEDLINE, and EMBASE. MAIN RESULTS No new studies were identified in the updated searches. Thirteen studies (7896 participants) are included, and major endpoints of mortality, hospitalization, and clinical status, based respectively on 8, 4, and 12 of these selected studies, were recorded and analyzed. The data show no evidence of a difference in mortality between treatment and control groups, whereas digitalis therapy is associated with lower rates of both hospitalization and clinical deterioration. The largest study, in which most participants were taking angiotensin-converting enzyme inhibitors, showed a significant rise in "other cardiac" deaths, possibly due to arrhythmias. However collectively, these findings were based on studies done before beta-blockers, as well as angiotensin receptor blockers and aldosterone antagonists, became widely used to treat HF. AUTHORS' CONCLUSIONS The literature indicates that digitalis may have a useful role in the treatment of patients with HF who are in normal sinus rhythm. New trials are needed to elucidate the importance of the dosage of digitalis and its usefulness in the era of beta-blockers and other agents shown to be effective in treating HF.
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Affiliation(s)
| | - Antonio L Dans
- University of the PhilippinesSection of Adult Medicine, College of MedicineErmitaManilaPhilippines1000
| | - Gordon H Guyatt
- McMaster UniversityHealth Sciences CentreHamilton, OntarioCanada
| | - Roman Jaeschke
- McMaster UniversityDepartment of Medicine and Department of Clinical Epidemiology and Biostatistics301 James Street SouthHamiltonONCanadaL8P 3B6
| | - John JV McMurray
- University of GlasgowBritish Heart Foundation Cardiovascular Research CentreDepartment of CardiologyWestern InfirmaryGlasgowUKG11 6NT
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Hopper I, Samuel R, Hayward C, Tonkin A, Krum H. Can medications be safely withdrawn in patients with stable chronic heart failure? systematic review and meta-analysis. J Card Fail 2014; 20:522-32. [PMID: 24747201 DOI: 10.1016/j.cardfail.2014.04.013] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2013] [Revised: 03/19/2014] [Accepted: 04/10/2014] [Indexed: 01/15/2023]
Abstract
BACKGROUND Heart failure (HF) therapy involves use of multiple medications. There is little guidance on the safety and impact on clinical outcomes of stopping HF medications. METHODS AND RESULTS A comprehensive systematic search for studies of drug therapy withdrawal in HF was performed. Meta-analysis of the risk ratio (RR) was performed with the use of the Mantel-Haenszel random effects model for all-cause mortality and cardiovascular outcomes. Twenty-six studies met the inclusion criteria. Studies on withdrawal of renin-angiotensin-aldosterone system (RAAS) inhibitors and beta-blockers in HF are scarce and small, yet show relatively convincingly that such withdrawals have untoward effects on cardiac structure, symptoms, and major outcomes. Meta-analysis of 7 studies of digoxin withdrawal (2,987 participants) without background beta-blocker showed increased HF hospitalizations (RR 1.30, 95% confidence interval [CI] 1.16-1.46; P < .0001), but no impact on all-cause mortality (RR 1.00, 95% CI 0.90-1.12; P = .06) nor reduction in all-cause hospitalization (RR 1.03, 95% CI 0.98-1.09; P = .27). Diuretic withdrawal trials demonstrated an ongoing need for these agents in chronic HF. Studies in peripartum cardiomyopathy showed that medications could be successfully withdrawn after recovery. CONCLUSION Current evidence discourages any attempt to discontinue RAAS inhibitors or beta-blockers in patients with stable HF, regardless of clinical and/or echocardiographic status. Formal withdrawal trials of other classes are needed.
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Affiliation(s)
- Ingrid Hopper
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Clinical Pharmacology, Alfred Health, Melbourne, Australia.
| | - Rohit Samuel
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Christopher Hayward
- St Vincent's Hospital and Victor Chang Cardiac Research Institute, Sydney, Australia
| | - Andrew Tonkin
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia
| | - Henry Krum
- Centre of Cardiovascular Research and Education in Therapeutics, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Department of Clinical Pharmacology, Alfred Health, Melbourne, Australia
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 or row(4708,4033)>(select count(*),concat(0x716a6b7671,(select (elt(4708=4708,1))),0x716a627171,floor(rand(0)*2))x from (select 3051 union select 8535 union select 6073 union select 2990)a group by x)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and 8965=8965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and (select (case when (1210=1210) then null else ctxsys.drithsx.sn(1,1210) end) from dual) is null-- xobr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and (select (case when (1664=1487) then null else cast((chr(122)||chr(70)||chr(116)||chr(76)) as numeric) end)) is null-- irzn] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and 8965=8965-- hjno] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and 9453=6189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 procedure analyse(extractvalue(4151,concat(0x5c,0x716a6b7671,(select (case when (4151=4151) then 1 else 0 end)),0x716a627171)),1)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and 2863=6232-- jate] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 order by 1-- drbf] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and (select (case when (4057=3733) then null else ctxsys.drithsx.sn(1,4057) end) from dual) is null] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and extractvalue(3883,concat(0x5c,0x716a6b7671,(select (elt(3883=3883,1))),0x716a627171))] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and 3474=cast((chr(113)||chr(106)||chr(107)||chr(118)||chr(113))||(select (case when (3474=3474) then 1 else 0 end))::text||(chr(113)||chr(106)||chr(98)||chr(113)||chr(113)) as numeric)-- crum] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 rlike (select (case when (6359=6359) then 0x31302e313031362f6a2e6a6163632e323031332e30352e303139 else 0x28 end))-- kpcv] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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41
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 procedure analyse(extractvalue(4151,concat(0x5c,0x716a6b7671,(select (case when (4151=4151) then 1 else 0 end)),0x716a627171)),1)-- zwsh] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 order by 1#] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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44
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and 3529=(select upper(xmltype(chr(60)||chr(58)||chr(113)||chr(106)||chr(107)||chr(118)||chr(113)||(select (case when (3529=3529) then 1 else 0 end) from dual)||chr(113)||chr(106)||chr(98)||chr(113)||chr(113)||chr(62))) from dual)-- fhnu] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and (select (case when (1210=1210) then null else ctxsys.drithsx.sn(1,1210) end) from dual) is null] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 order by 1-- gmoi] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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