The document discusses trials evaluating new drug and device therapies for heart failure, including the EMPHASIS-HF trial which found that the aldosterone antagonist eplerenone reduced cardiovascular mortality and hospitalization for worseness heart failure in patients with mild heart failure and reduced ejection fraction. It also summarizes the SHIFT trial which found that the If inhibitor ivabradine reduced the primary composite outcome of cardiovascular death or hospitalization for worsening heart failure compared to placebo in patients with chronic heart failure, left ventricular systolic dysfunction, and heart rate ≥70 bpm.
Patti G. Vecchi e nuovi anticoagulanti orali a confronto. ASMaD 2013Gianfranco Tammaro
This document summarizes the results of several clinical trials comparing new oral anticoagulants to warfarin for preventing stroke in atrial fibrillation patients. The RELY trial found that dabigatran 150mg reduced stroke risk compared to warfarin, with similar major bleeding rates. Rivaroxaban in ROCKET-AF reduced stroke risk similarly to warfarin with similar bleeding rates. Apixaban in ARISTOTLE reduced stroke and major bleeding compared to warfarin. Overall, the new oral anticoagulants were found to be non-inferior or superior to warfarin for stroke prevention with similar or better safety profiles.
The document reviews a new oral direct thrombin inhibitor called dabigatran that is as effective as warfarin for preventing stroke in atrial fibrillation patients based on the RE-LY trial. The RE-LY trial found that dabigatran 150mg twice daily was superior to warfarin in reducing strokes and similar in major bleeding, while the 110mg dose was non-inferior and associated with less bleeding than warfarin. Dabigatran provides an alternative to warfarin for stroke prevention in atrial fibrillation that has more predictable dosing and fewer drug and food interactions than warfarin.
1. Perindopril 10 mg po daily is the recommended initial treatment. It is an ACE inhibitor which is recommended as first line treatment for hypertension in patients with diabetes according to guidelines.
2. The patient should be followed up with basic screening including potassium and creatinine levels within one week of starting treatment, then every 3 months to monitor for side effects of the ACE inhibitor such as hyperkalemia and worsening renal function.
3. Additional monitoring of renal function and potassium is needed due to the patient's risk factors of obesity and diabetes which increase
This document summarizes several studies on the use of ACE inhibitors and angiotensin receptor blockers (ARBs) in treating heart failure and reducing cardiovascular risk. The HOPE trial showed that the ACE inhibitor ramipril reduced cardiovascular events in high-risk patients. The CHARM trial found that the ARB candesartan reduced cardiovascular outcomes in heart failure patients, both alone and in combination with ACE inhibitors. The ONTARGET trial aimed to compare the ARB telmisartan to ramipril, and their combination, to determine if telmisartan was non-inferior to ramipril and if their combination provided additional benefit.
This document summarizes the PARADIGM-HF clinical trial which compared the angiotensin receptor-neprilysin inhibitor LCZ696 to the ACE inhibitor enalapril in patients with heart failure and reduced ejection fraction. The trial found that LCZ696 was superior to enalapril in reducing cardiovascular death and hospitalization for heart failure. Specifically, LCZ696 reduced the risk of the primary composite outcome of death from cardiovascular causes or hospitalization for heart failure by 16% compared to enalapril. LCZ696 also reduced deaths from any cause by 16% compared to enalapril.
This document summarizes the key points about renal denervation for treatment of resistant hypertension. It discusses:
1) How renal sympathetic nerves connect the kidney to the brain and how stimulating or blocking these nerves can raise or lower blood pressure.
2) How surgical renal denervation was previously used but had high risks, so was abandoned when safer drug therapies emerged.
3) How catheter-based renal denervation uses radiofrequency energy to ablate the renal sympathetic nerves, providing a minimally invasive alternative.
4) Results from the first human trial (Symplicity HTN-1) showing significant and sustained reductions in both systolic and diastolic blood pressure out to 3 years with
The document provides information on the diagnosis and management of heart failure with preserved ejection fraction (HFpEF) according to ESC guidelines. It notes that HFpEF has a different epidemiological profile than heart failure with reduced ejection fraction (HFrEF), with older, female, obese, and hypertensive patients who are less likely to have coronary heart disease. The diagnosis of HFpEF is more difficult than HFrEF as other potential causes must be ruled out first. No treatments have convincingly reduced morbidity and mortality for HFpEF, though diuretics are used to control symptoms and treatment of comorbidities is important. The guidelines recommend controlling blood pressure and provide limited guidance for HFpEF management in
Patti G. Vecchi e nuovi anticoagulanti orali a confronto. ASMaD 2013Gianfranco Tammaro
This document summarizes the results of several clinical trials comparing new oral anticoagulants to warfarin for preventing stroke in atrial fibrillation patients. The RELY trial found that dabigatran 150mg reduced stroke risk compared to warfarin, with similar major bleeding rates. Rivaroxaban in ROCKET-AF reduced stroke risk similarly to warfarin with similar bleeding rates. Apixaban in ARISTOTLE reduced stroke and major bleeding compared to warfarin. Overall, the new oral anticoagulants were found to be non-inferior or superior to warfarin for stroke prevention with similar or better safety profiles.
The document reviews a new oral direct thrombin inhibitor called dabigatran that is as effective as warfarin for preventing stroke in atrial fibrillation patients based on the RE-LY trial. The RE-LY trial found that dabigatran 150mg twice daily was superior to warfarin in reducing strokes and similar in major bleeding, while the 110mg dose was non-inferior and associated with less bleeding than warfarin. Dabigatran provides an alternative to warfarin for stroke prevention in atrial fibrillation that has more predictable dosing and fewer drug and food interactions than warfarin.
1. Perindopril 10 mg po daily is the recommended initial treatment. It is an ACE inhibitor which is recommended as first line treatment for hypertension in patients with diabetes according to guidelines.
2. The patient should be followed up with basic screening including potassium and creatinine levels within one week of starting treatment, then every 3 months to monitor for side effects of the ACE inhibitor such as hyperkalemia and worsening renal function.
3. Additional monitoring of renal function and potassium is needed due to the patient's risk factors of obesity and diabetes which increase
This document summarizes several studies on the use of ACE inhibitors and angiotensin receptor blockers (ARBs) in treating heart failure and reducing cardiovascular risk. The HOPE trial showed that the ACE inhibitor ramipril reduced cardiovascular events in high-risk patients. The CHARM trial found that the ARB candesartan reduced cardiovascular outcomes in heart failure patients, both alone and in combination with ACE inhibitors. The ONTARGET trial aimed to compare the ARB telmisartan to ramipril, and their combination, to determine if telmisartan was non-inferior to ramipril and if their combination provided additional benefit.
This document summarizes the PARADIGM-HF clinical trial which compared the angiotensin receptor-neprilysin inhibitor LCZ696 to the ACE inhibitor enalapril in patients with heart failure and reduced ejection fraction. The trial found that LCZ696 was superior to enalapril in reducing cardiovascular death and hospitalization for heart failure. Specifically, LCZ696 reduced the risk of the primary composite outcome of death from cardiovascular causes or hospitalization for heart failure by 16% compared to enalapril. LCZ696 also reduced deaths from any cause by 16% compared to enalapril.
This document summarizes the key points about renal denervation for treatment of resistant hypertension. It discusses:
1) How renal sympathetic nerves connect the kidney to the brain and how stimulating or blocking these nerves can raise or lower blood pressure.
2) How surgical renal denervation was previously used but had high risks, so was abandoned when safer drug therapies emerged.
3) How catheter-based renal denervation uses radiofrequency energy to ablate the renal sympathetic nerves, providing a minimally invasive alternative.
4) Results from the first human trial (Symplicity HTN-1) showing significant and sustained reductions in both systolic and diastolic blood pressure out to 3 years with
The document provides information on the diagnosis and management of heart failure with preserved ejection fraction (HFpEF) according to ESC guidelines. It notes that HFpEF has a different epidemiological profile than heart failure with reduced ejection fraction (HFrEF), with older, female, obese, and hypertensive patients who are less likely to have coronary heart disease. The diagnosis of HFpEF is more difficult than HFrEF as other potential causes must be ruled out first. No treatments have convincingly reduced morbidity and mortality for HFpEF, though diuretics are used to control symptoms and treatment of comorbidities is important. The guidelines recommend controlling blood pressure and provide limited guidance for HFpEF management in
Eplerenone, a selective aldosterone blocker, inSalman Ahmed
This document summarizes a clinical trial that evaluated the effect of the selective aldosterone blocker eplerenone in patients with left ventricular dysfunction after myocardial infarction. The trial involved over 6,600 patients who received either eplerenone or a placebo in addition to optimal medical therapy. The results showed that eplerenone reduced all-cause mortality by 14.4% compared to 16.7% for placebo and reduced cardiovascular mortality and hospitalization. However, there was an increased risk of serious hyperkalemia with eplerenone. The study concluded that eplerenone improves outcomes for patients with left ventricular dysfunction after a myocardial infarction when added to maximal medical therapy.
CARDIOTalks: La IC vuelve a escena
22/05/2015 17:45h - 19:30h
Hotel Sevilla Center. Sala Giralda I, Sevilla (XII Reunión Anual de la Sección de Insuficiencia Cardiaca y Trasplante de la SEC)
http://cardiotalks.secardiologia.es
Top 3 Hits en Insuficiencia cardiaca en 2014
Dr. Nicolás Manito, Barcelona
The PARADIGM-HF trial compared the new drug LCZ696, which inhibits the angiotensin receptor and neprilysin, to enalapril in over 8,000 patients with heart failure. LCZ696 reduced the primary composite outcome of cardiovascular death or heart failure hospitalization more than enalapril. Specifically, LCZ696 reduced cardiovascular death alone by 20% compared to only a 15% reduction with enalapril. The benefits of LCZ696 were seen across all subgroups and it had a better side effect and tolerability profile. The results provide sufficient evidence to replace ACE inhibitors and ARBs with LCZ696 as first-line treatment for heart failure.
Estudio PARADIGM-HF: LCZ696 en Insuficiencia CardiacaCardioTeca
LCZ696, which inhibits both neprilysin and the angiotensin receptor, was compared to enalapril in the PARADIGM-HF trial involving over 8,000 patients with chronic heart failure and reduced ejection fraction. The trial found that LCZ696 reduced the primary composite endpoint of cardiovascular death or heart failure hospitalization by 20% compared to enalapril (HR 0.80, p=0.0000002). LCZ696 also reduced cardiovascular death alone by 20% compared to enalapril (HR 0.80, p=0.00004) and was generally well-tolerated with less cough and renal dysfunction, though there was more symptomatic hypotension with L
ACE ACE inhibitors and ARBs in Heart Failure -What Does the evidence say?Syed Raza
This document discusses evidence from landmark clinical trials regarding the use of ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in the treatment of heart failure. It summarizes that ACEIs such as enalapril have been shown to reduce mortality and hospitalizations in heart failure patients based on the SOLVD trial. ARBs such as candesartan were also shown to reduce cardiovascular outcomes compared to placebo in trials like CHARM. However, while ACEIs/ARBs may improve symptoms in heart failure with preserved ejection fraction, none have demonstrated a reduction in mortality for this subgroup according to trials such as PEP-CHF.
Secondary Prevention after ACS: Focused on Anticoagulant TherapyPERKI Pekanbaru
Dr. Nathania Marliani Kristanti, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 25th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
The document discusses congestive heart failure (CHF) in children. It defines CHF as a state of systemic and pulmonary congestion due to failure of the heart pump to meet the metabolic needs of the body. Causes of CHF include ventricular dysfunction, preserved ventricular function with volume or pressure overload. Symptoms vary with age from tachypnea and diaphoresis with feeding in infants to exercise intolerance and dyspnea in older children. Treatment involves controlling congestion through diuretics, afterload reduction with ACE inhibitors, and ionotropes like digoxin. Management of underlying cardiac lesions and advanced support with ECMO or VADs may also be required. Nutritional management is important for improving
The document provides guidelines from the 2013 ACCF/AHA/ESC/HFA for the diagnosis and management of heart failure. It outlines recommendations for initial evaluation of HF patients including history, physical exam, diagnostic tests, biomarkers, and noninvasive cardiac imaging. Invasive hemodynamic monitoring is recommended to guide therapy for patients with respiratory distress or impaired perfusion when intracardiac pressures cannot be determined clinically. The guidelines also cover treatment strategies for stages A through D of heart failure and management of hospitalized patients.
Leveraging Healthcare Analytics to Reduce Heart Failure Readmission Rates Health Catalyst
Heart failure patients are adding an enormous strain to the US healthcare system. In addition, readmission rates for these diseases are adding to the burden. Healthcare analytics can play a key role. By following these 4 steps, all of which include data analytics, health systems can begin to reduce readmission rates: 1) Understand your true admission rates. 2) Establish reliable baseline measures. 3) Be aware of balance measures. 4) Establish an EDW.
Healthcare Analytics Adoption Model -- UpdatedHealth Catalyst
The Healthcare Analytics Adoption Model is the result of a collaboration of healthcare industry veterans over the last 15 years. The model borrows lessons learned from the HIMSS EMR Adoption Model, and describes an analogous approach for assessing the adoption of analytics in healthcare.
The Healthcare Analytics Adoption Model provides:
1) A framework for evaluating the industry’s adoption of analytics
2) A roadmap for organizations to measure their own progress toward analytic adoption
3) A framework for evaluating vendor products
This Analytics Adoption Model will enable healthcare organizations to fully understand and leverage the capabilities of analytics and so achieve the ultimate goal that has eluded most provider organizations – that of improving the quality of care while lowering costs and enhancing clinician and patient satisfaction.
Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs. It has many potential causes, but is often due to problems with the heart muscle itself or valves. Treatment focuses on managing symptoms with diuretics, and slowing progression with ACE inhibitors, beta-blockers, and aldosterone antagonists. Other therapies aim to improve heart function or treat underlying causes. Prognosis depends on severity but ranges from 5-50% annual mortality.
Heart failure is a common condition where the heart is unable to pump enough blood to meet the body's needs. It can result from structural or functional disorders of the heart. The document provides details on the definition, causes, risk factors, pathophysiology, symptoms, diagnostic evaluation, classification systems, and treatment of heart failure. It emphasizes the importance of controlling risk factors, using medications such as ACE inhibitors and diuretics to manage symptoms, and making lifestyle changes like following a low-sodium diet and exercising regularly.
4 Best Practices for Analyzing Healthcare DataHealth Catalyst
Meaningful healthcare analytics today generally need data from multiple source systems to help address the triple aim cost, quality, and patient satisfaction. Once appropriate data has been captured, pulled into a single place, and tied together, then data analysis can begin. In this article I share 4 ways to enable your analyst including providing them with
1) a data warehouse
2) a sandbox
3) a set of discovery tools
4) the right kind of direction.
This document summarizes guidelines for managing chronic heart failure. It discusses evaluating patients, lifestyle modifications including diet and exercise, and pharmacological treatments. Key drugs discussed are ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and digoxin. Several clinical trials are summarized that demonstrate the mortality benefits of these drug classes in heart failure.
- The EPHESUS trial randomized over 6,000 patients who had a myocardial infarction with reduced left ventricular ejection fraction (<40%) within 3-14 days to eplerenone or placebo in addition to standard therapy.
- At 16 months follow up, eplerenone reduced the risk of death from any cause by 15% and death from cardiovascular causes by 13% compared to placebo.
- Eplerenone was generally well tolerated but increased the risk of hyperkalemia compared to placebo.
1) Several early trials evaluated lipid lowering drugs such as mevastatin and lovastatin, which were isolated from fungi and shown to inhibit HMG CoA reductase. However, mevastatin was not marketed due to toxicity in dogs. Lovastatin was first marketed as Mevacor in 1987.
2) Large primary prevention trials such as WOSCOPS, AFCAPS/TexCAPS, CARDS and JUPITER demonstrated significant reductions in cardiovascular events with statin therapy compared to placebo in various populations with and without known heart disease.
3) Secondary prevention trials in patients with stable CAD such as 4S, CARE, LIPID and TNT showed that statin therapy reduces
This document summarizes information on two newer drugs for cardiovascular conditions - ivabradine and aliskiren. Ivabradine is a drug that reduces heart rate by binding to "funny channels" and is used to treat chronic stable angina and heart failure. Clinical trials have shown it reduces cardiovascular events when added to standard treatments. Aliskiren is a direct renin inhibitor used for hypertension by blocking renin from converting angiotensinogen to angiotensin I. It provides renin inhibition as an alternative to blocking downstream effects of the renin-angiotensin-aldosterone system. The document reviews the mechanisms, pharmacokinetics, clinical uses, trials and guidelines for use of these two
ACE inhibitors were originally synthesized from compounds found in pit viper venom. They work by blocking the conversion of angiotensin I to angiotensin II, lowering blood pressure. Major clinical trials have shown that ACE inhibitors reduce mortality and hospitalization in patients with heart failure, myocardial infarction, diabetes, and vascular disease. Landmark trials such as HOPE and EUROPA demonstrated that ACE inhibitors provide cardiovascular protection beyond blood pressure lowering alone in patients at high risk of cardiovascular events.
Triple antithrombotic treatment with aspirin, clopidogrel and dabigatran etex...MerqurioEditore_redazione
This document summarizes a case report of a 29-year-old man with a combined deficiency of protein C and protein S who suffered an anterior myocardial infarction. He was treated with aspirin, clopidogrel, and PTCA with stenting. Due to his thrombophilia, he was initially treated with low molecular weight heparin, then switched to the oral anticoagulant dabigatran etexilate. Laboratory tests showed therapeutic dabigatran levels without significant effects on other clotting parameters. This is reported to be the first case describing myocardial infarction in a young patient with combined protein C and protein S deficiency treated long-term with aspirin, clopidogrel, and d
The REACH Registry study found that beta-blockers do not reduce the risk of cardiovascular events like death, heart attack, or stroke in stable outpatients with or without coronary artery disease. However, beta-blockers were found to lower the risk of secondary outcomes in patients who had a heart attack within the past year. The study followed over 45,000 patients for 4 years on average and compared outcomes in patients taking beta-blockers to those not taking them.
The success of neurohormonal blockade: looking back – looking forward: Beta-b...drucsamal
- The document summarizes the history of beta-blocker treatment for heart failure, from early studies in the 1970s showing potential benefits to large randomized controlled trials in the 1990s and 2000s firmly establishing mortality reduction.
- Key trials included MDC (1993) showing reduced mortality and heart transplantation, CIBIS-II (1999) showing reduced mortality with bisoprolol, MERIT-HF (1999) showing reduced mortality with metoprolol CR/XL, and COPERNICUS (2001) showing reduced mortality, hospitalizations, and worsening heart failure with carvedilol.
- Meta-analyses demonstrated a consistent mortality reduction of approximately 35% associated with beta-blocker use in
Eplerenone, a selective aldosterone blocker, inSalman Ahmed
This document summarizes a clinical trial that evaluated the effect of the selective aldosterone blocker eplerenone in patients with left ventricular dysfunction after myocardial infarction. The trial involved over 6,600 patients who received either eplerenone or a placebo in addition to optimal medical therapy. The results showed that eplerenone reduced all-cause mortality by 14.4% compared to 16.7% for placebo and reduced cardiovascular mortality and hospitalization. However, there was an increased risk of serious hyperkalemia with eplerenone. The study concluded that eplerenone improves outcomes for patients with left ventricular dysfunction after a myocardial infarction when added to maximal medical therapy.
CARDIOTalks: La IC vuelve a escena
22/05/2015 17:45h - 19:30h
Hotel Sevilla Center. Sala Giralda I, Sevilla (XII Reunión Anual de la Sección de Insuficiencia Cardiaca y Trasplante de la SEC)
http://cardiotalks.secardiologia.es
Top 3 Hits en Insuficiencia cardiaca en 2014
Dr. Nicolás Manito, Barcelona
The PARADIGM-HF trial compared the new drug LCZ696, which inhibits the angiotensin receptor and neprilysin, to enalapril in over 8,000 patients with heart failure. LCZ696 reduced the primary composite outcome of cardiovascular death or heart failure hospitalization more than enalapril. Specifically, LCZ696 reduced cardiovascular death alone by 20% compared to only a 15% reduction with enalapril. The benefits of LCZ696 were seen across all subgroups and it had a better side effect and tolerability profile. The results provide sufficient evidence to replace ACE inhibitors and ARBs with LCZ696 as first-line treatment for heart failure.
Estudio PARADIGM-HF: LCZ696 en Insuficiencia CardiacaCardioTeca
LCZ696, which inhibits both neprilysin and the angiotensin receptor, was compared to enalapril in the PARADIGM-HF trial involving over 8,000 patients with chronic heart failure and reduced ejection fraction. The trial found that LCZ696 reduced the primary composite endpoint of cardiovascular death or heart failure hospitalization by 20% compared to enalapril (HR 0.80, p=0.0000002). LCZ696 also reduced cardiovascular death alone by 20% compared to enalapril (HR 0.80, p=0.00004) and was generally well-tolerated with less cough and renal dysfunction, though there was more symptomatic hypotension with L
ACE ACE inhibitors and ARBs in Heart Failure -What Does the evidence say?Syed Raza
This document discusses evidence from landmark clinical trials regarding the use of ACE inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) in the treatment of heart failure. It summarizes that ACEIs such as enalapril have been shown to reduce mortality and hospitalizations in heart failure patients based on the SOLVD trial. ARBs such as candesartan were also shown to reduce cardiovascular outcomes compared to placebo in trials like CHARM. However, while ACEIs/ARBs may improve symptoms in heart failure with preserved ejection fraction, none have demonstrated a reduction in mortality for this subgroup according to trials such as PEP-CHF.
Secondary Prevention after ACS: Focused on Anticoagulant TherapyPERKI Pekanbaru
Dr. Nathania Marliani Kristanti, SpJP, FIHA. 3rd Pekanbaru Cardiology Update, August 25th 2013. Pangeran Hotel Pekanbaru. Learn more at PerkiPekanbaru.com
The document discusses congestive heart failure (CHF) in children. It defines CHF as a state of systemic and pulmonary congestion due to failure of the heart pump to meet the metabolic needs of the body. Causes of CHF include ventricular dysfunction, preserved ventricular function with volume or pressure overload. Symptoms vary with age from tachypnea and diaphoresis with feeding in infants to exercise intolerance and dyspnea in older children. Treatment involves controlling congestion through diuretics, afterload reduction with ACE inhibitors, and ionotropes like digoxin. Management of underlying cardiac lesions and advanced support with ECMO or VADs may also be required. Nutritional management is important for improving
The document provides guidelines from the 2013 ACCF/AHA/ESC/HFA for the diagnosis and management of heart failure. It outlines recommendations for initial evaluation of HF patients including history, physical exam, diagnostic tests, biomarkers, and noninvasive cardiac imaging. Invasive hemodynamic monitoring is recommended to guide therapy for patients with respiratory distress or impaired perfusion when intracardiac pressures cannot be determined clinically. The guidelines also cover treatment strategies for stages A through D of heart failure and management of hospitalized patients.
Leveraging Healthcare Analytics to Reduce Heart Failure Readmission Rates Health Catalyst
Heart failure patients are adding an enormous strain to the US healthcare system. In addition, readmission rates for these diseases are adding to the burden. Healthcare analytics can play a key role. By following these 4 steps, all of which include data analytics, health systems can begin to reduce readmission rates: 1) Understand your true admission rates. 2) Establish reliable baseline measures. 3) Be aware of balance measures. 4) Establish an EDW.
Healthcare Analytics Adoption Model -- UpdatedHealth Catalyst
The Healthcare Analytics Adoption Model is the result of a collaboration of healthcare industry veterans over the last 15 years. The model borrows lessons learned from the HIMSS EMR Adoption Model, and describes an analogous approach for assessing the adoption of analytics in healthcare.
The Healthcare Analytics Adoption Model provides:
1) A framework for evaluating the industry’s adoption of analytics
2) A roadmap for organizations to measure their own progress toward analytic adoption
3) A framework for evaluating vendor products
This Analytics Adoption Model will enable healthcare organizations to fully understand and leverage the capabilities of analytics and so achieve the ultimate goal that has eluded most provider organizations – that of improving the quality of care while lowering costs and enhancing clinician and patient satisfaction.
Heart failure is a condition where the heart cannot pump enough blood to meet the body's needs. It has many potential causes, but is often due to problems with the heart muscle itself or valves. Treatment focuses on managing symptoms with diuretics, and slowing progression with ACE inhibitors, beta-blockers, and aldosterone antagonists. Other therapies aim to improve heart function or treat underlying causes. Prognosis depends on severity but ranges from 5-50% annual mortality.
Heart failure is a common condition where the heart is unable to pump enough blood to meet the body's needs. It can result from structural or functional disorders of the heart. The document provides details on the definition, causes, risk factors, pathophysiology, symptoms, diagnostic evaluation, classification systems, and treatment of heart failure. It emphasizes the importance of controlling risk factors, using medications such as ACE inhibitors and diuretics to manage symptoms, and making lifestyle changes like following a low-sodium diet and exercising regularly.
4 Best Practices for Analyzing Healthcare DataHealth Catalyst
Meaningful healthcare analytics today generally need data from multiple source systems to help address the triple aim cost, quality, and patient satisfaction. Once appropriate data has been captured, pulled into a single place, and tied together, then data analysis can begin. In this article I share 4 ways to enable your analyst including providing them with
1) a data warehouse
2) a sandbox
3) a set of discovery tools
4) the right kind of direction.
This document summarizes guidelines for managing chronic heart failure. It discusses evaluating patients, lifestyle modifications including diet and exercise, and pharmacological treatments. Key drugs discussed are ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and digoxin. Several clinical trials are summarized that demonstrate the mortality benefits of these drug classes in heart failure.
- The EPHESUS trial randomized over 6,000 patients who had a myocardial infarction with reduced left ventricular ejection fraction (<40%) within 3-14 days to eplerenone or placebo in addition to standard therapy.
- At 16 months follow up, eplerenone reduced the risk of death from any cause by 15% and death from cardiovascular causes by 13% compared to placebo.
- Eplerenone was generally well tolerated but increased the risk of hyperkalemia compared to placebo.
1) Several early trials evaluated lipid lowering drugs such as mevastatin and lovastatin, which were isolated from fungi and shown to inhibit HMG CoA reductase. However, mevastatin was not marketed due to toxicity in dogs. Lovastatin was first marketed as Mevacor in 1987.
2) Large primary prevention trials such as WOSCOPS, AFCAPS/TexCAPS, CARDS and JUPITER demonstrated significant reductions in cardiovascular events with statin therapy compared to placebo in various populations with and without known heart disease.
3) Secondary prevention trials in patients with stable CAD such as 4S, CARE, LIPID and TNT showed that statin therapy reduces
This document summarizes information on two newer drugs for cardiovascular conditions - ivabradine and aliskiren. Ivabradine is a drug that reduces heart rate by binding to "funny channels" and is used to treat chronic stable angina and heart failure. Clinical trials have shown it reduces cardiovascular events when added to standard treatments. Aliskiren is a direct renin inhibitor used for hypertension by blocking renin from converting angiotensinogen to angiotensin I. It provides renin inhibition as an alternative to blocking downstream effects of the renin-angiotensin-aldosterone system. The document reviews the mechanisms, pharmacokinetics, clinical uses, trials and guidelines for use of these two
ACE inhibitors were originally synthesized from compounds found in pit viper venom. They work by blocking the conversion of angiotensin I to angiotensin II, lowering blood pressure. Major clinical trials have shown that ACE inhibitors reduce mortality and hospitalization in patients with heart failure, myocardial infarction, diabetes, and vascular disease. Landmark trials such as HOPE and EUROPA demonstrated that ACE inhibitors provide cardiovascular protection beyond blood pressure lowering alone in patients at high risk of cardiovascular events.
Triple antithrombotic treatment with aspirin, clopidogrel and dabigatran etex...MerqurioEditore_redazione
This document summarizes a case report of a 29-year-old man with a combined deficiency of protein C and protein S who suffered an anterior myocardial infarction. He was treated with aspirin, clopidogrel, and PTCA with stenting. Due to his thrombophilia, he was initially treated with low molecular weight heparin, then switched to the oral anticoagulant dabigatran etexilate. Laboratory tests showed therapeutic dabigatran levels without significant effects on other clotting parameters. This is reported to be the first case describing myocardial infarction in a young patient with combined protein C and protein S deficiency treated long-term with aspirin, clopidogrel, and d
The REACH Registry study found that beta-blockers do not reduce the risk of cardiovascular events like death, heart attack, or stroke in stable outpatients with or without coronary artery disease. However, beta-blockers were found to lower the risk of secondary outcomes in patients who had a heart attack within the past year. The study followed over 45,000 patients for 4 years on average and compared outcomes in patients taking beta-blockers to those not taking them.
The success of neurohormonal blockade: looking back – looking forward: Beta-b...drucsamal
- The document summarizes the history of beta-blocker treatment for heart failure, from early studies in the 1970s showing potential benefits to large randomized controlled trials in the 1990s and 2000s firmly establishing mortality reduction.
- Key trials included MDC (1993) showing reduced mortality and heart transplantation, CIBIS-II (1999) showing reduced mortality with bisoprolol, MERIT-HF (1999) showing reduced mortality with metoprolol CR/XL, and COPERNICUS (2001) showing reduced mortality, hospitalizations, and worsening heart failure with carvedilol.
- Meta-analyses demonstrated a consistent mortality reduction of approximately 35% associated with beta-blocker use in
This document discusses the treatment of various cardiac arrhythmias. It begins by describing common drug classes used to treat arrhythmias and then discusses the treatment of specific arrhythmias including supraventricular arrhythmias like atrial fibrillation and flutter, AV nodal reentrant tachycardia, preexcitation syndrome, AV block, PVCs, ventricular tachycardia, and ventricular fibrillation. For each arrhythmia, it outlines recommended treatment approaches including drugs, cardioversion, ablation, and pacemaker implantation. It provides pricing information for various antiarrhythmic drugs available in Iran.
This study investigated the effects of adding eplerenone to evidence-based heart failure therapies in patients with mild systolic heart failure symptoms. The study randomized 2,737 patients to receive either eplerenone or placebo. The primary outcome of death from cardiovascular causes or hospitalization for heart failure occurred in 18.3% of the eplerenone group compared to 25.9% of the placebo group, demonstrating that eplerenone reduced risks. The trial was stopped early due to these benefits after a median follow up of 21 months. Eplerenone was found to provide cardiovascular protection in patients with heart failure compared to placebo.
Trial to assess chelation therapy (tact) slidesMarilyn Mann
The Trial to Assess Chelation Therapy (TACT) was a randomized controlled trial that compared chelation therapy (disodium EDTA injections) to placebo injections in 1708 patients with prior heart attacks. The primary goal was to see if chelation therapy reduced cardiovascular events like death, heart attack, stroke, and hospitalization. The trial found that chelation therapy reduced the primary composite endpoint compared to placebo with a hazard ratio of 0.82 and p-value of 0.035. A pre-specified subgroup analysis found the benefit was greater in patients with diabetes, with a hazard ratio of 0.61 and p-value of 0.002 for chelation therapy versus placebo in reducing cardiovascular events. The trial provides evidence that che
Prehospital Ketamine – Is there anything it can’t do?SMACC Conference
PHARM Physician, Per Bredmose, provides an indepth look at Ketamine in the prehospital setting. Per discusses the uses, benefits and potential complications of Ketamine, providing tips and tricks from his wealth of experience.
Active treatment of isolated systolic hypertension in elderly patients using indapamide with or without perindopril resulted in significant reductions in mortality, stroke, and heart failure compared to placebo. Systolic blood pressure was reduced by 15 mmHg in the active treatment group. The benefits of treatment were seen early with number needed to treat of 94 for stroke and 40 for mortality reduction over 2 years. Treatment was also found to be safe with no significant differences in adverse lab values between groups.
- Early initiation of high-intensity statin therapy in acute coronary syndrome patients significantly reduces mortality and morbidity rates compared to later initiation or lower-intensity statins. Clinical trials found a 16-36% reduction in major coronary events with early high-dose statin use.
- Guidelines recommend high-intensity statins like atorvastatin 80mg or simvastatin 80mg for acute coronary syndrome patients, though risks like side effects must be considered. Long-term statin therapy is also generally advised after acute coronary syndrome.
The document provides health tips on living longer and stronger through preventive measures like certain drugs. It discusses [1] secondary prevention to reduce risks after events like heart attacks, [2] primary prevention for high-risk patients through drugs like aspirin and statins to prevent adverse events, and [3] primordial prevention by adopting a healthy lifestyle before being deemed high-risk. It outlines studies showing reduced cardiovascular risks from aspirin, ACE inhibitors, and statins in both primary and secondary prevention settings.
AF in ACS patients: what is the evidence of managementAmit Badgal
- 5-15% of atrial fibrillation (AF) patients undergoing percutaneous coronary intervention (PCI) are at risk of thromboembolism from AF and stent thrombosis from dual antiplatelet therapy (DAPT).
- Clinical trials have evaluated different anticoagulation and antiplatelet regimens to reduce these risks, finding dual therapy with novel oral anticoagulants and a P2Y12 inhibitor reduced bleeding vs. warfarin triple therapy without increasing thromboembolic risk.
- Ongoing trials are further exploring dual or triple therapy options for AF patients requiring PCI or with acute coronary syndrome.
Eplerenone in Patients with Systolic Heart Failure and Mild Symptoms.
Presented at AHA by: Faiez Zannad, M.D., Ph.D., John J.V. McMurray, M.D., Henry Krum, M.B., PhD., Dirk J. van Veldhuisen, M.D.,Ph.D., Karl Swedberg, M.D., Ph.D, Harry Shi, M.S., John Vincent, M.B., PhD., Stuart J Pocock, Ph.D. and Bertram Pitt, M.D. for the EMPHASIS-HF Study Group * Eplerenone in Mild Patients Hospitalization And SurvIval Study in Heart Failure
Courtesy of http://www.cardiovascularbusiness.com
- The EMPHASIS-HF trial studied the effects of adding eplerenone versus placebo to evidence-based heart failure therapy in 2737 patients with systolic heart failure and mild symptoms.
- Patients taking eplerenone experienced a 37% reduced risk of the primary composite endpoint of cardiovascular death or heart failure hospitalization compared to placebo.
- Eplerenone treatment was also associated with reduced risk of all-cause mortality compared to placebo.
- The trial was stopped early based on a recommendation from the data safety monitoring board due to clear benefits of eplerenone beyond prespecified stopping boundaries.
Similar to Cowie Inverness Nov 2011 New Solutions in HF (20)
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1. New solutions in heart failure:
Drugs and Devices
Martin R Cowie
Professor of Cardiology
Imperial College London (Royal Brompton Hospital)
m.cowie@imperial.ac.uk
2. NICE 2010
Low Ejection Fraction
HF with normal
Ejection Fraction
7. Aldosterone antagonist therapy for heart failure
due to LVSD
Probability
of Survival
• The Randomised Aldactone Evaluation
1.00 Study (RALES)
0.95
0.90
• 1663 patients with NYHA III or IV heart
RRR=0.30 (0.18-0.40) failure and ejection fraction ≤35% who
0.85
RRR = 30% were already treated with ACE inhibitor,
0.80 P<0.001 diuretic digoxin
0.75
Spironolactone
0.70 • Spironolactone 25mg od vs placebo,
0.65 with patients followed for an average of
0.60
2 years
Placebo
0.55
P < 0.001 • 30% reduction in the risk of death
0.50 (p<0.001) and 35% reduction in risk of
0.45 hospitalisation (p<0.001) among
0.00 patients randomised to spironolactone
0 3 6 9 12 15 18 21 24 27 30 33 36
Months
Pitt et al, N Engl J Med, 1999
8. Aldosterone antagonist therapy for
heart failure after MI
EPHESUS trial
• 3313 patients were randomised to eplerenone
Cumulative
Incidence (%) 25 mg/day and 3319 to placebo (in addition to
‘standard’ medical therapy).
40
35 p=0.008 • Mean follow-up of 16-months. Among those
30 RRR=0.15 taking eplerenone there was:
25 Placebo – 15% relative risk reduction in all-cause death
20 (p=0.008)
15 Eplerenone – 13% relative risk reduction in cardiovascular
10 death or hospitalisation (p=0.002)
5 – 21% relative risk reduction in sudden cardiac
0 death ( p=0.03)
0 3 6 9 121518212427303336
Months since Randomization • Compared with spironolactone, eplerenone was
No. at Risk
Placebo 3313 3064
3319 3125
2983 2830 2418 1801 1213 709 323 99 2 0 0 less likely to cause gynaecomastia or breast
Eplerenone 3044 2896 2463 1857 1260 728 336 110 0 0 0
tenderness, but K+ monitoring was still
essential.
Pitt et al, N Engl J Med, 2003
16. EMPHASIS-HF Study
SAFETY ADVERSE EVENTS
Patients with an adverse event (AE)*
Outcome Eplerenone Placebo (N=1373) P Value
(N=1360)
All 979 (72) 1007 (73.6) 0.37
Hyperkalemia – n (%) 109 (8) 50 (3.7) <0.001
Hypokalemia – n (%) 16 (1.2) 30 (2.2) 0.05
Renal failure – n (%) 38 (2.8) 41 (3.0) 0.82
Hypotension – n (%) 46 (3.4) 37 (2.7) 0.32
Gynecomastia and other 10 (0.7) 14 (1.0) 0.54
breast disorders – n (%)
*Investigator reported adverse events
17. EMPHASIS-HF Study
SAFETY: DRUG DISCONTINUATIONS DUE TO AE
Patients with an adverse event* leading to
drug withdrawal — no. (%)
Outcome Eplerenone Placebo P Value
(N=1360) (N=1373)
All 188 (13.8) 222 (16.2) 0.09
Hyperkalemia – n (%) 15 (1.1) 12 (0.9) 0.57
Hypokalemia – n (%) 0 3 (0.2) 0.25
Renal failure – n (%) 4 (0.3) 6 (0.4) 0.75
Hypotension – n (%) 0 3 (0.2) 0.25
Gynecomastia and other 2 (0.1) 2 (0.1) 1.00
breast disorders – n (%)
*Investigator reported adverse events
18. EMPHASIS-HF Study
SAFETY: PRESPECIFIED ADJUDICATED EVENTS
Eplerenone Placebo Hazard Ratio P
Outcome
(N=1364) (N=1373) (95% CI) Value
Hospitalization for
worsening renal 9 (0.7) 8 (0.6) 0.97 (0.37, 2.58) 0.95
failure*
Hospitalization for
4 (0.3) 3 (0.2) 1.15 (0.25, 5.31) 0.85
hyperkalemia*
EMPHASIS HF study results presentation. Presented at AHA congress 2010.
http://click.heartemail.org/?qs=c809010216325f9c50c94e221d4e3fd62e92e966356857c348c68a0675e1e1a3. Accessed November 21, 2010
19. Important addition to therapy....
For mild HF with low EF
NNT
• To prevent one patient
experiencing the primary
endpoint, per year of
follow up, is 19
• To postpone one death, per
year of follow up, is 51
NB Eplerenone not yet licensed for treatment of EMPHASIS population
25. Primary objective
To evaluate whether the If inhibitor ivabradine
improves cardiovascular outcomes in patients with:
1. Moderate to severe chronic heart failure
2. Left ventricular ejection fraction 35%
3. Heart rate 70 bpm in sinus rhythm
4. Best recommended therapy
Ivabradine 5mg bd or placebo, titrated to
7.5mg/5mg/2.5mg according to tolerability
26. Study end points
Primary composite end point
Cardiovascular death
Hospitalization for worsening heart failure
Other end points
All-cause / CV / HF death
All-cause / CV / hospitalization for heart failure
Composite of CV death, hospitalization for HF or nonfatal MI
NYHA class / Patient & Physician Global Assessment
Median study duration 22.9 months, maximum 41.7 months
Swedberg K, et al. Eur J Heart Fail. 2010;12:75-81.
27. Baseline characteristics
Ivabradine Placebo
3241 3264
Mean age (y) 60.7 60.1
Male (%) 76 77
Ischemic etiology (%) 68 67
NYHA II (%) 49 49
NYHA III/IV (%) 51 51
Previous MI (%) 56 56
Diabetes (%) 30 31
Hypertension (%) 67 66
Swedberg K, et al. Lancet. 2010;376:875-885.
28. Baseline characteristics
Ivabradine Placebo
3241 3264
Mean heart rate (bpm) 80 80
Mean LVEF (%) 29 29
Mean SBP (mm Hg) 122 121
Mean DBP (mm Hg) 76 76
eGFR (mL/min/1.73 m2) 75 75
Swedberg K, et al. Lancet. 2010;376:875-885.
30. Background beta-blocker
treatment
Patients (%)
100 Ivabradine
89 89
Placebo
80
60 56 56
40
26 26
20
0
Beta-blockers at At least 50% target daily Target daily dose
randomization dose
Swedberg K, et al. Lancet. 2010;376:875-885.
31. Heart rate is a predictor of CV death and/or
hospitalizations for HF
Patients with primary composite end point in the placebo group (%)
50 ≥87 bpm
P<0.001
40
80 to <87 bpm
75 to <80 bpm
30
72 to <75 bpm
70 to <72 bpm
20
10
0 Months
0 6 12 18 24 30
Risk increases by 3% per 1 bpm increase, and by 16% per 5 bpm increase
Böhm M, et al. Lancet. 2010;376:886-894.
33. Primary composite end point
(CV death or hospital admission for worsening HF)
Cumulative frequency (%)
40
HR = 0.82 (0.75–0.90)
P < 0.0001 Placebo
30 18% RRR
Ivabradine
20
10
0
Months
0 6 12 18 24 30
Swedberg K, et al. Lancet. 2010;376:875-885.
34. Hospitalization
for worsening heart failure
Cumulative frequency (%)
30
HR = 0.74 (0.66–0.83)
P < 0.0001 Placebo
26% RRR
20
Ivabradine
10
0
0 6 12 18 24 30 Months
Swedberg K, et al. Lancet. 2010;376:875-885.
35. Cardiovascular death
Cumulative frequency (%)
30
HR = 0.91 (0.80–1.03)
P = 0.128
9% RRR (P=0.12) Placebo
20
Ivabradine
10
0
0 6 12 18 24 30 Months
Swedberg K, et al. Lancet. 2010;376:875-885.
36. Death from heart failure
Cumulative frequency (%)
10
HR = 0.74 (0.58–0.94)
P = 0.014
26% RRR Placebo
5
Ivabradine
0
0 6 12 18 24 30 Months
Swedberg K, et al. Lancet. 2010;376:875-885.
37. Effect of ivabradine in
prespecified subgroups
Test for interaction
Age
<65 years
≥65 years
Sex
Male
Female
Beta-blockers
No
Yes
Etiology of heart failure
Nonischemic
Ischemic
NYHA class
NYHA class II
NYHA class III or IV
Diabetes
No
Yes
Hypertension
No
Yes
Baseline heart rate
<77 bpm P = 0.029
≥77 bpm
0.5 1.0 1.5
Hazard ratio
Favors ivabradine Favors placebo
Swedberg K, et al. Lancet. 2010;376:875-885.
38. Incidence of selected
adverse events
Patients with an event
n= 6492
Ivabradine Placebo
P value
n=3232, n (%) n=3260, n (%)
All serious adverse events 1450 (45%) 1553 (48%) 0.025
All adverse events 2439 (75%) 2423 (74%) 0.303
Symptomatic bradycardia 150 (5%) 32 (1%) <0.0001
Asymptomatic bradycardia 184 (6%) 48 (1%) <0.0001
Atrial fibrillation 306 (9%) 251 (8%) 0.012
Phosphenes 89 (3%) 17 (1%) <0.0001
Blurred vision 17 (1%) 7 (<1%) 0.042
Swedberg K, et al. Lancet. 2010;376:875-885.
39. Treatment discontinuation
Patients with an adverse event,
leading to withdrawal
Ivabradine Placebo
P value
n=3232, n (%) n=3260, n (%)
All adverse events 467 (14%) 416 (13%) 0.051
Symptomatic bradycardia 20 (1%) 5 (<1%) 0.002
Asymptomatic bradycardia 28 (1%) 5 (<1%) <0.0001
Atrial fibrillation 135 (4%) 113 (3%) 0.137
Phosphenes 7 (<1%) 3 (<1%) 0.224
Blurred vision 1 (<1%) 1 (<1%) 1.000
Swedberg K, et al. Lancet. 2010;376:875-885.
40. Important addition to therapy....
For those in sinus rhythm with HR > 70bpm and low EF
NNT
• To prevent one patient
experiencing the primary
endpoint, per year of follow
up, is 26
• To postpone one
hospitalisation for HF, per year
of follow up, is 27
NB Ivabradine not yet licensed for treatment of SHIFT population
52. So – how should this affect practice for those
with low EF HF?
• Life-saving therapy should include:
– ACEI (or ARB),
– Β-blocker, and
– aldosterone antagonist (eplerenone) or good reason for not!
• Once β-blockade maximised, if in sinus rhythm and HR >
70bpm, ivabradine should be added
• For patients with severe LV systolic dysfunction, mild-
moderate HF, LBBB and optimal drug therapy, increasingly
likely that CRT-D (rather than CRT-P or ICD alone) will be
recommended
• NICE will issue new guidance in 2012/13 for device therapy.
• Good monitoring always required!!
These statements are a personal opinion - NOT official recommendations!
Editor's Notes
1 For more information on drug treatment see appendix D of the NICE guideline and ‘Chronic kidney disease’ (NICE clinical guideline 73).2 Consider an ICD in line with ‘Implantable cardiovascular defibrillators for arrhythmias’ (NICE technology appraisal guidance 95).3 NYHA class III–IV.4 Not all ARBs are licensed for use in heart failure in combination with ACE inhibitors.5 NYHA class II–III.6 This does not include mixed race. For more information see the full guideline at www.nice.org.uk/guidance/CG1087 Consider CRT in line with ‘Cardiac resynchronisation therapy for the treatment of heart failure’ (NICE technology appraisal guidance 120).Additional informationThere is evidence of improved outcome for patients with heart failure due to left ventricular systolic dysfunction who are offered ACE inhibitors and beta-blockers for first-line treatment. There is also evidence that beta-blockers can be safely used by all patients.Those who remain symptomatic despite optimal first-line treatment will have several choices of second-line treatments: aldosterone antagonists, angiotensin II receptor antagonists (ARBs) or hydralazine in combination with nitrate. This recommendation is based on evidence for better outcomes for particular second-line treatments in certain subgroups.There was no clear evidence of benefit for drug treatment in heart failure with preserved ejection fraction (HFPEF), but advice on drug treatments for comorbid conditions is stressed.