Background and Methods Aldosterone is important in the pathophysiology of heart failure. In a double-blind study, we enrolled 1663 patients who had severe heart failure and a left ventricular ejection fraction of no more than 35 percent and who were being treated with an angiotensin-converting–enzyme inhibitor, a loop diuretic, and in most cases digoxin. A total of 822 patients were randomly assigned to receive 25 mg of spironolactone daily, and 841 to receive placebo. The primary end point was death from all causes. Results The trial was discontinued early, after a mean follow-up period of 24 months, because an interim analysis determined that spironolactone was efficacious. There were 386 deaths in the placebo group (46 percent) and 284 in the spironolactone group (35 percent; relative risk of death, 0.70; 95 percent confidence interval, 0.60 to 0.82; P<0.001). This 30 percent reduction in the risk of death among patients in the spironolactone group was attributed to a lower risk of both death from prog...

https://www.nejm.org/doi/pdf/10.1056/NEJM199909023411001

The effect of spironolactone on morbidity and mortality in patients with severe heart failure. Randomized Aldactone Evaluation Study Investigators.

Preamble and Transition to ACC/AHA Guidelines to Reduce Cardiovascular Risk S2

The goals of the …

/pdf/2013-acc-aha-guideline-on-the-treatment-of-blood-cholesterol-pvngcav7fq.pdf

2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

ACC/AHA
: American College of Cardiology/American Heart Association
ACCF/AHA
: American College of Cardiology Foundation/American Heart Association
ACE
: angiotensin-converting enzyme
ACEI
: angiotensin-converting enzyme inhibitor
ACS
: acute coronary syndrome
AF
: atrial fibrillation

/pdf/2016-esc-guidelines-for-the-diagnosis-and-treatment-of-acute-53v7yllhiz.pdf

2016 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure

Efficacy and safety of cholesterol-lowering treatment: prospective meta-analysis of data from 90,056 participants in 14 randomised trials of statins.

ALAT
: alanine aminotransferase
ASAT
: aspartate aminotransferase
APAH
: associated pulmonary arterial hypertension
BAS
: balloon atrial septostomy
BMPR2
: bone morphogenetic protein receptor 2
BNP
: brain natriuretic peptide
BPA
: balloon pulmonary angioplasty
BREATHE
: Bosentan

/pdf/2015-esc-ers-guidelines-for-the-diagnosis-and-treatment-of-y26yabnnom.pdf

2015 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: The Joint Task Force for the Diagnosis and Treatment of Pulmonary Hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS): Endorsed by: Association for European Paediatric and Congenital Cardiology (AEPC), International Society for Heart and Lung Transplantation (ISHLT).

Cardiac resynchronization therapy is an additional therapeutic option for heart failure patients that has became available in recent years and aroused great interest among both electrophysiologists and clinical cardiologists managing heart failure patients. The prevalence of conduction disturbances (QRS interval ≥120 ms) among patients with left ventricular dysfunction or overt heart failure has been found to range between 27% and 53% [1–3]. Upon analyzing subjects with varying degrees of functional impairment according to New York Heart Association (NYHA) functional class, wider mean QRS intervals were found in subjects with a higher degree of functional impairment [4]. In subjects with dilated cardiomyopathy the QRS interval was widened in elec- trograms recorded shortly before death as compared to recordings made a mean of 35 months before the terminal event [5]. In unselected patients, left bundle branch block was associated with increased risk of both total mortality and sudden death at 1 year [2]. In another study [6] a QRS duration >110 ms was associated with increased mortality independently of left ventricular ejection fraction. It is a matter for investigation to assess whether left bundle branch block with left QRS axis deviation is most closely related to left ventricular enlargement and left ventricular dysfunction or whether it carries additional prognostic implications [7]. In a recent paper [8], a widening of the QRS interval in patients with heart failure who were followed by a heart failure clinic was a definite and independent predictor of mortality. According to these data, analysis of the QRS interval may provide additional information as a basis for selecting candidates for nonpharmacological treatments.

Cardiac Resynchronization Therapy: The Low Voltage Road or the High Voltage Road?

Atrial fibrillation (AF) and heart failure are two common cardiac diseases, affecting 1%-2% of the population [1, 2] with a prevalence that rises steeply with age. AF and heart failure are conditioned by common risk factors and fre­ quently coexist [3]; indeed, the prevalence of left ventricular dysfunction and/or congestive heart failure among patients with AF may be as high as 40% [4], and in the Framingham Study the presence of congestive heart failure implied a 6.6-fold increased risk of developing AF in a 2-year period. On the other side, the strong association between AF and congestive heart failure is further attested by the high prevalence of AF found in major heart failure trials dealing with patients in more advanced NYHA functional classes [3]. In clinical practice the relationship between AF and heart failure, or left ven­ tricular dysfunction, is intriguing. AF may indeed cause congestive heart fail­ ure, particularly when there is a fast uncontrolled ventricular response. This form of heart failure may be reversible after rhythm or rate control [5]. At first observation of a patient it may be quite difficult to distinguish this condition from the most common phenomenon of AF facilitated by the mechanical, elec­ trophysiological, and neurohormonal derangements caused by heart failure in a substrate characterized by primary ventricular dilation and hypokinesia.

http://link.springer.com/content/pdf/10.1007%2F978-88-470-2087-0_9.pdf

Atrial Fibrillation and Heart Failure: Epidemiologic and Clinical Connections

Electrical cardioversion may restore sinus rhythm in approximately 90% of patients with chronic atrial fibrillation [1]. The most relevant clinical problem after successful cardioversion is represented by the risk of recurrence which may occur either in a very early phase (first minutes after electrical shock), in an early phase (first 24 hours), in the days following the procedure or several weeks or months later.

Antiarrhythmic Drug Administration before Electrical Cardioversion of Atrial Fibrillation: Is It Useful to Prevent Early Arrhythmia Recurrence?

Background. Patients withchronic coronaryartery disease exhibit adysfunctioning endothelium, which may beresponsible forexercise-induced platelet activation andexpression ofa procoagulant moiety. In thisstudy, we evaluated thetherapeutic efficacy ofa lowmolecular weight heparin (Parnaparin) in patients withstable angina pectoris. Methods andResults. According toadouble-blind, randomized, placebo-controlled trial, 29patients with stable exercise-induced angina pectoris andangiographically provencoronaryartery disease received a single daily subcutaneous injection ofParnaparin or placebo on topofaspirin andconventional antianginal medication over3months. Patients randomized toParnaparin showed a significant decrease inthefibrinogen level (P=.035) andan improvement inboththetimeto1-mmSTsegmentdepression (P=.008) andthepeakSTsegment depression (P=.015). TheCanadian Cardiovascular Society class for anginapectoris was alsoimproved byParnaparin (P=.016). Parnaparin didnotaffect ADP and collagen-induced platelet aggregation, whereas thrombin-induced aggregation was reduced (P=.0001). Thebleeding timewas slightly prolonged, butthis was notassociated withanysignificant bleeding. Conclsions. Patients withstable angina pectoris may betreated withParnaparin inaddition toaspirin andconventional antianginal medication. Sideeffects are negligible, andcompliance isexcellent. (Circulation. 1993;88:2517-2523.)

Benefit ofAddingLowMolecular Weight Heparin totheConventional Treatment of Stable AnginaPectoris A Double-Blind, Randomized, Placebo-Controlled Trial

that electrophysiologists are more likely to implement CRT-D devices irrespective of the appropriateness of the procedure. The issue of off-label use of CRT-D in the ICD Registry is the focus of an ongoing analysis by other investigators, and we look forward to seeing the results. Nevertheless, it is important to keep in mind that the absolute differences across physician categories in off-label use were small (range, 11.4%-13.3%) compared with the observed variation in onlabel use (range, 57.8%-83.1%). Given the known benefits of CRT-D therapy, it is arguable that the consequences of nonelectrophysiologists failing to implant a CRT-D device in many patients who do meet criteria are greater than those of electrophysiologists implanting a smaller number of CRT-D devices in patients in whom the expectation of benefit is less clear.

Angelo Branzi

Papers

Cardiac Resynchronization Therapy: The Low Voltage Road or the High Voltage Road?

Atrial Fibrillation and Heart Failure: Epidemiologic and Clinical Connections

Antiarrhythmic Drug Administration before Electrical Cardioversion of Atrial Fibrillation: Is It Useful to Prevent Early Arrhythmia Recurrence?

Benefit ofAddingLowMolecular Weight Heparin totheConventional Treatment of Stable AnginaPectoris A Double-Blind, Randomized, Placebo-Controlled Trial

Prognostic importance of ventricular arrhythmia in patients treated with percutaneous coronary intervention.