The management of secondary mitral regurgitation in patients with heart failure: a joint position statement from the Heart Failure Association (HFA), European Association of Cardiovascular Imaging (EACVI), European Heart Rhythm Association (EHRA), and European Association of Percutaneous Cardiova...more
Secondary (or functional) mitral regurgitation (SMR) occurs frequently in chronic heart failure (HF) with reduced left ventricular (LV) ejection fraction, resulting from LV remodelling that prevents coaptation of the valve leaflets.... more
Secondary (or functional) mitral regurgitation (SMR) occurs frequently in chronic heart failure (HF) with reduced left ventricular (LV) ejection fraction, resulting from LV remodelling that prevents coaptation of the valve leaflets. Secondary mitral regurgitation contributes to progression of the symptoms and signs of HF and confers worse prognosis. The management of HF patients with SMR is complex and requires timely referral to a multidisciplinary Heart Team. Optimization of pharmacological and device therapy according to guideline recommendations is crucial. Further management requires careful clinical and imaging assessment, addressing the anatomical and functional features of the mitral valve and left ventricle, overall HF status, and relevant comorbidities. Evidence concerning surgical correction of SMR is sparse and it is doubtful whether this approach improves prognosis. Transcatheter repair has emerged as a promising alternative, but the conflicting results of current rando...
Heart Failure (HF) is a multi-faceted and life-threatening syndrome characterized by significant morbidity and mortality, poor functional capacity and quality of life, and high costs. HF affects more than 64 million people worldwide.... more
Heart Failure (HF) is a multi-faceted and life-threatening syndrome characterized by significant morbidity and mortality, poor functional capacity and quality of life, and high costs. HF affects more than 64 million people worldwide. Therefore, attempts to decrease its social and economic burden have become a major global public health priority. While the incidence of HF has stabilized and seems to be declining in industrialized countries, the prevalence is increasing due to the ageing of the population, improved treatment of and survival with ischaemic heart disease, and the availability of effective evidence-based therapies prolonging life in patients with HF. There are geographical variations in HF epidemiology. There is substantial lack of data from developing countries, where HF exhibits different features compared with that observed in the Western world. In this review, we provide a contemporary overview on the global burden of HF, providing updated estimates on prevalence, in...
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There is evidence demonstrating that heart failure (HF) occurs in 1–2% of the global population and is often accompanied by comorbidities which contribute to increasing the prevalence of the disease, the rate of hospitalization and the... more
There is evidence demonstrating that heart failure (HF) occurs in 1–2% of the global population and is often accompanied by comorbidities which contribute to increasing the prevalence of the disease, the rate of hospitalization and the mortality. Although recent advances in both pharmacological and non-pharmacological approaches have led to a significant improvement in clinical outcomes in patients affected by HF, residual unmet needs remain, mostly related to the occurrence of poorly defined strategies in the early stages of myocardial dysfunction. Nutritional support in patients developing HF and nutraceutical supplementation have recently been shown to possibly contribute to protection of the failing myocardium, although their place in the treatment of HF requires further assessment, in order to find better therapeutic solutions. In this context, the Optimal Nutraceutical Supplementation in Heart Failure (ONUS-HF) working group aimed to assess the optimal nutraceutical approach t...
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The VICTORIA trial showed Vericiguat once daily (titrated up to 10 mg) significantly reduced its primary end-point, the composite of death from cardiovascular causes or first hospitalization for heart failure, in 5050 class II-IV HFrEF... more
The VICTORIA trial showed Vericiguat once daily (titrated up to 10 mg) significantly reduced its primary end-point, the composite of death from cardiovascular causes or first hospitalization for heart failure, in 5050 class II-IV HFrEF patients (LVEF<45%). This a land-mark trial, one of the largest we have seen in heart failure, and it had some very important novel features; it only recruited patients with a recent (within 6 months) worsening of their heart failure, a group known to be at increased risk of subsequent events, and it included more severe heart failure than most recent trials with NTproBNP levels nearly twice that of Paradigm-HF or DAPA-HF. VICTORIA had substantially higher mortality rate but an apparently less impressive hazard ratio (HR) 0.90 (0.82 – 0.98) compared to Paradigm’s 0.80 (0.73 – 0.87) and DAPA’s 0.74 (0.65 –0.85). This must be considered against a healthy absolute risk reduction at 4.2% compared to Paradigm’s 2.7% and DAPA’s 4.0%, due to the highe...
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Heart failure (HF) is a complex clinical syndrome resulting from structural or functional cardiac disorders. In the developed world, HF is primarily a disorder of the elderly. It is one that is accompanied by many non-cardiac... more
Heart failure (HF) is a complex clinical syndrome resulting from structural or functional cardiac disorders. In the developed world, HF is primarily a disorder of the elderly. It is one that is accompanied by many non-cardiac comorbidities that affect treatments given, the patient’s response and treatment tolerance and outcomes. Even the pathophysiological mechanisms of HF change as we look at older patient populations. Younger HF patients typically have ischaemic heart disease and HF with reduced ejection fraction (HFrEF), whereas older patients have more hypertension HF with preserved ejection fraction (HFpEF). The prevalence of HF has progressively increased for many years and rises even more steeply with age. The outcomes of older especially HFpEF patients have not progressed as much younger HFrEF cohorts. We need more studies specifically recruiting older HF patients with more comorbidities, to guide real-world practice, and we need more assessment of patient-reported outcomes ...
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Heart failure is associated with altered cardiac metabolism, in part, due to maladaptive mechanisms, in part secondary to comorbidities such as diabetes and ischaemic heart disease. The metabolic derangements taking place in heart failure... more
Heart failure is associated with altered cardiac metabolism, in part, due to maladaptive mechanisms, in part secondary to comorbidities such as diabetes and ischaemic heart disease. The metabolic derangements taking place in heart failure are not limited to the cardiac myocytes, but extend to skeletal muscles and the vasculature causing changes that contribute to the worsening of exercise capacity. Modulation of cardiac metabolism with partial inhibition of free fatty acid oxidation has been shown to be beneficial in patients with heart failure. At the present, the bulk of evidence for this class of drugs comes from Trimetazidine. Newer compounds partially inhibiting free fatty acid oxidation or facilitating the electron transport on the mitochondrial cristae are in early phase of their clinical development.
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Cardiac Cachexia - A Window to the Wasting DisordersCardiac cachexia: perspectives for prevention and treatmentSkeletal muscle aging: influence of oxidative stress and physical exerciseCancer-induced muscle wasting: latest findings in prevention and treatmentCancer-induced cardiac cachexia: patho...more
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Renin angiotensin aldosterone system inhibitors/antagonists/blockers (RAASi) are a cornerstone in treatment of patients with cardiovascular diseases especially in those with heart failure (HF) due to their proven effect on surrogate and... more
Renin angiotensin aldosterone system inhibitors/antagonists/blockers (RAASi) are a cornerstone in treatment of patients with cardiovascular diseases especially in those with heart failure (HF) due to their proven effect on surrogate and hard endpoints. Renin angiotensin aldosterone system inhibitors are also the basis in treatment of arterial hypertension, and they are furthermore indicated to reduce events and target organ damage in patients with diabetes and chronic kidney disease, where they have specific indication because of the evidence of benefit. Renin angiotensin aldosterone system inhibitor therapy, however, is associated with an increased risk of hyperkalaemia. Patients with chronic kidney disease and HF are at increased risk of hyperkalaemia and ∼50% of these patients experience two or more yearly recurrences. A substantial proportion of patients receiving RAASi therapy have their therapy down-titrated or more often discontinued even after a single episode of elevated po...
Research Interests: Cardiology, Biomarkers, Chronic kidney disease, Arterial hypertension, Medicine, and 15 moreHeart Failure, Humans, Internal Medicine, Diabetes mellitus, Consensus, Renin Angiotensin Aldosterone System, Potassium, Recurrence, Pharmacotherapy, Kidney Disease, Cardiovascular Diseases, Angiotensin Converting Enzyme Inhibitors, Hyperkalemia, Mineralocorticoid Receptor Antagonists, and Angiotensin Receptor Antagonists
The 2016 ESC/HFA HF guidelines list the very many drug and device therapies that are proven to be beneficial in terms of life prolongation and hospitalisation prevention for HFrEF. The list of recommended therapies or devices for HFpEF... more
The 2016 ESC/HFA HF guidelines list the very many drug and device therapies that are proven to be beneficial in terms of life prolongation and hospitalisation prevention for HFrEF. The list of recommended therapies or devices for HFpEF and HFmrEF is limited to diuretics and the management of comorbidities and so far there is no clinical evidence for an electrical or mechanical device for HFpEF. The Cardiac Contractility Modulation (CCM) device that may have a role in selected HFrEF and HFmrEF patients has been reviewed in another paper in this issue but here we survey the results so far of a novel device for patients with HFpEF. Despite lagging many years behind HFrEF, HFpEF patients are now being targeted with novel devices with the potential to improve symptoms, improve quality of life, reduce hospitalization and delay progression of the syndrome. The front-runner is a novel inter-atrial left atrial pressure decompression device the Corvia IASD, which currently enrolling patients ...
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Anaemia has been found to be a common complication of chronic heart failure. It is associated with exercise intolerance and a poor prognosis, independent of conventional markers of heart failure severity and markers of renal dysfunction.... more
Anaemia has been found to be a common complication of chronic heart failure. It is associated with exercise intolerance and a poor prognosis, independent of conventional markers of heart failure severity and markers of renal dysfunction. Although the cause of anaemia complicating heart failure is not known, it is likely to be multi-factorial in many patients. Anaemia, when present, reduces oxygen delivery to the periphery. Correcting this may improve capacity. Erythropoietin therapy has a long history in the management of renal failure with complicating anaemia, and the first reports of the use of erythropoietin in heart failure are now coming through. This article will review what is known of the aetiology of anaemia in chronic heart failure and what may be possible for erythropoietic therapy to achieve in chronic heart failure.
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1. Heart rate variability can be used to evaluate autonomic balance, but it is unclear how inotropic therapy may affect the findings. The aim of the study was to assess whether heart rate variability can differentiate between sympathetic... more
1. Heart rate variability can be used to evaluate autonomic balance, but it is unclear how inotropic therapy may affect the findings. The aim of the study was to assess whether heart rate variability can differentiate between sympathetic stimulation induced by inotrope infusion or by physical exercise. 2. Ten patients with chronic heart failure (64.3 ± 5.4 years of age) underwent four dobutamine infusions (8-min steps of 5 μg min−1 kg−1) and four supine bicycle exercise tests (5-min steps of 25 W). Plasma noradrenaline was evaluated, as well as the SD of R—R intervals, together with low-frequency (0.03–0.14 Hz) and high-frequency (0.15–0.4 Hz) components of heart rate variability using autoregressive spectral analysis. 3. Exercise and inotrope infusion produced similar changes in heart rate variability. An exercise load of 50 W and a dobutamine infusion of 15 μg min−1 kg−1 gave the following results respectively: heart rate, 120.3 ± 3.0 beats/min versus 110.2 ± 3.0 beats/min; SD, 16...
Research Interests: Cardiology, Medicine, Heart rate variability, Heart Failure, Humans, and 15 moreInternal Medicine, Blood Pressure, Chronic Disease, Exploration, Heart rate, Exercise, Aged, Middle Aged, Reproducibility of Results, Physical Exercise, Sympathetic Nervous System, Exercise Test, inotrope, Medical and Health Sciences, and supine position
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Research Interests: Cardiology, Medicine, Heart Failure, Insulin Resistance, Humans, and 12 moreInternal Medicine, Heart, Aged, Middle Aged, Anaerobic Exercise, Analysis of Variance, Ejection Fraction, Glucose Tolerance Test, Exercise Test, Case Control Studies, Anaerobic Threshold, and Cardiovascular medicine and haematology
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Research Interests: Medicine, Humans, Cholesterol, Postgraduate medical education, Female, and 12 moreMale, Hypercholesterolemia, Risk factors, Aged, Middle Aged, Adult, Coronary heart disease, Dietary fiber, Risk Factors, Coronary Artery Disease, Guidance and Counseling Intervention Programs, and Medical and Health Sciences
Research Interests: Endocrinology, Cytokines, Medicine, Heart Failure, Humans, and 15 moreInternal Medicine, Chronic Disease, Female, Male, Exercise, Aged, Middle Aged, Adult, Chronic Heart Failure, Ejection Fraction, Exercise Test, Exercise Tolerance, Fas Ligand, Cardiorespiratory Fitness, and Cardiovascular medicine and haematology
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Chronic heart failure is a well-recognized syndrome in which left ventricular impairment produces a constellation of secondary changes in other organ symptoms leading to symptoms such as muscular fatigue and dyspnoea and objective... more
Chronic heart failure is a well-recognized syndrome in which left ventricular impairment produces a constellation of secondary changes in other organ symptoms leading to symptoms such as muscular fatigue and dyspnoea and objective limitation to exercise tolerance. With modern drug therapy of diuretics and ACE inhibitors, the majority of patients have minimal if any signs of congestion, and yet severe symptomatic limitation remains. This limitation bears little relationship to conventional measures of either left ventricular function or the haemodynamic profile of the patient. The symptoms limiting exercise are predominantly fatigue or dyspnoea, and yet the classical pathophysiological explanations for their genesis now seem inadequate. Recent investigations, as demonstrated, in part, by the research presented in this symposium, attest to the importance of abnormalities in peripheral blood flow and in skeletal muscle in producing both objective limitation to exercise and in explaining the generation of the exercise-limiting symptoms of the syndrome of stable optimally treated chronic heart failure. In addition it is now evident that these muscle changes may in addition have pathophysiological significance for the maintenance of sympatho-excitation during exercise and potentially therefore in the progression of left ventricular remodelling and in the susceptibility to ventricular arrhythmias. This paper presents some of the background evidence which leads to the hypothesis that a feedback loop links changes in skeletal muscle to abnormal reflex cardiopulmonary control which may both limit exercise and be harmful in the progression of the syndrome.
Research Interests: Cardiology, Skeletal muscle biology, Medicine, Pathophysiology, Heart Failure, and 13 moreHumans, Internal Medicine, Chronic Disease, Exercise, Skeletal Muscle, Chronic Heart Failure, Drug Therapy, Feedback loop, Left Ventricular Function, Left Ventricular, Cardiovascular medicine and haematology, physical exertion, and Peripheral blood
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The beta-blocker/vasodilator carvedilol is found to have beneficial effects in patients with chronic heart failure. However, the safety and efficacy of this agent in the presence of concomitant amiodarone therapy has not been previously... more
The beta-blocker/vasodilator carvedilol is found to have beneficial effects in patients with chronic heart failure. However, the safety and efficacy of this agent in the presence of concomitant amiodarone therapy has not been previously determined. We retrospectively analyzed the Australia/New Zealand Carvedilol Heart Failure Research Collaborative Group study of 415 patients with mild to moderate ischemic heart failure where amiodarone was administered as part of the treatment therapy (in 52 patients). After the open-label carvedilol run-in, patients received carvedilol (target dose 25 mg twice daily) or placebo for an average of 19 months. The main adverse events during this double-blind period were worsened heart failure, hypotension/dizziness, bradycardia/atrioventricular block, and aggravation of angina. By Chi square analysis, carvedilol and amiodarone together were not associated with a greater overall incidence of adverse effects than either drug alone. The beneficial effects of carvedilol on left ventricular ejection that were observed in the main trial were preserved in the presence of amiodarone. Carvedilol is a useful additional therapy for patients with chronic heart failure already receiving amiodarone. Carvedilol can be added to amiodarone in these patients without expectation of increased adverse effects or loss of clinical efficacy.
Research Interests: Cardiology, Drug interactions, Medicine, Heart Failure, Humans, and 15 moreInternal Medicine, Hemodynamics, Female, Male, Clinical Sciences, Aged, Chronic Heart Failure, Retrospective Studies, Cardiac failure, Amiodarone, Bradycardia, Randomized Controlled Trials as Topic, Adverse effect, carvedilol, and Cardiovascular medicine and haematology
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In a press conference on Nov. 20, 2001 it was announced that the Multi-center Autonomic Defibrillator Implantation Trial II (MADIT II) was stopped early because of a 30% reduction in mortality in patients randomised to receive an... more
In a press conference on Nov. 20, 2001 it was announced that the Multi-center Autonomic Defibrillator Implantation Trial II (MADIT II) was stopped early because of a 30% reduction in mortality in patients randomised to receive an implantable defibrillator device. The 4 year multi-centre trial of 1200 patients was terminated early after an independent board observed that the post-MI patients with impaired left ventricular function receiving the implantable defibrillator had improved survival rates compared to those receiving conventional treatment. The MADIT II trial&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;#39;s aim was to test whether an AICD will reduce mortality in high-risk patients with coronary artery disease and left ventricular dysfunction with no arrhythmia entry criteria. The intention was to recruit 1200 patients aged 21-85 years with left ventricular ejection fraction (EF) &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt;or=0.30. Exclusion criteria included myocardial infarction within 1 month, coronary artery bypass graft or percutaneous transluminal coronary angioplasty within 2 months, and any patient already satisfying criteria for receiving an AICD by satisfying the entry criteria for the first MADIT trial. The primary end-point was all-cause mortality. Pre-specified secondary outcomes included non-cardiovascular mortality, sudden death, non-fatal myocardial infarction, fatal myocardial infarction, non-fatal cardiac arrest, fatal cardiac arrest, quality of life, and an economic evaluation. A positive outcome for this trial would be a major step forward both in delineating the indication for AICD therapy but also in guiding routine therapy for patients with impaired left ventricular function as defined by a reduced LVEF. This is not the first positive trial for the AICD approach to preventing sudden deaths due to ventricular tachyarrhythmias. Previous trials (MADIT, MUSST and AVID) have demonstrated that implantable defibrillators improve survival in other patient populations. Under current U.S. Food and Drug Administration (FDA) guidelines restricting the use of AICD therapy to defined patient criteria, 300,000 patients each year in the United States are estimated to be eligible to receive an implantable defibrillator. Guidant was quoted as saying that once the complete study findings of MADIT II are published it plans to submit an application to the FDA that, if approved, could double the population of patients eligible for the implanted devices in the USA, clearly having a major impact on care and its costs for the heart failure and post-MI populations.
Research Interests: Cardiology, Medicine, Humans, Internal Medicine, Left Ventricular Dysfunction, and 12 moreAged, Middle Aged, Myocardial Infarction, Adult, Survival Rate, Sudden Cardiac Death, Implantable defibrillators-cardioverters, Coronary Artery Disease, Ejection Fraction, Multicenter Studies as Topic, Randomized Controlled Trials as Topic, and Cardiovascular medicine and haematology
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We have previously commented on the difference between citations and requests for downloads of full text articles. We analyzed the download and citation statistics for articles in the first volume in 2005 (volume 98), giving sufficient... more
We have previously commented on the difference between citations and requests for downloads of full text articles. We analyzed the download and citation statistics for articles in the first volume in 2005 (volume 98), giving sufficient time for the value of articles to be appreciated. We might have expected some similarity between the most downloaded and the most cited articles.