BackgroundAngina pectoris (AP) is associated with worse outcomes in heart failure (HF) patients, but less is known about implications on health related quality of life (HRQoL) and functional ...capacity.MethodsWe assessed HRQoL, functional capacity and outcomes in chronic HF patients with reduced EF in the HF-ACTION trial of usual care +/- exercise training based on whether patients had AP. AP was patient-reported based on recent symptoms or development during exercise testing. We assessed all-cause mortality/hospitalization in patients with AP vs. no AP using multivariable Cox proportional hazards regression. We assessed for an interaction between AP status and exercise training with respect to outcomes and the change in quality of life and functional capacity from baseline to 3 months.ResultsIn HF-ACTION, 406 (17%) patients had AP at baseline with 44% of these reporting ≥ class II symptoms. Patients with AP more often had ischemic etiology, but had similar EF, NT-proBNP and beta-blocker use. Baseline 6-minute walk distance and peak VO2were similar in both groups, but patients with AP had worse depressive symptoms and HRQoL. After risk adjustment, AP was associated with a 22% greater risk of all-cause mortality/hospitalization (Figure). There was evidence of an interaction between baseline AP and exercise training on change in peak VO2 (P=0.019), but not for HRQoL or clinical outcomes. The median change in peak VO2 with exercise training was 0.8 mL/kg/min with AP vs. 0.6 mL/kg/min without AP.ConclusionAP was associated with worse HRQoL and more depressive symptoms. Despite a greater improvement in peak VO2 with exercise training, patients with AP experienced more adverse events. Clinicians should consider routine assessment and management of AP in HF patients as well as the associated symptoms related to depression and implications on quality of life.
Milrinone is a phosphodiesterase inhibitor that has been shown to improve hemodynamic parameters in patients with class III to IV heart failure when administered intravenously for ≤48 hours. This ...study examines the tolerability of long-term intravenous milrinone therapy and assesses its utility in allowing upward titration of oral vasodilator agents. A retrospective review of hospital records identified 63 patients who underwent hemodynamic monitoring and received intravenous milrinone for >24 hours in a critical care setting. Hemodynamics and medications were recorded before and after 24 hours of milrinone therapy. Additional medications, as well as any adverse events, were recorded throughout milrinone therapy. The mean dose of milrinone was 0.43 ± 0.10 μg/kg/min, with a mean duration of 12 ± 15 days (range 1 to 70). Therapy was continued for >48 hours in 89% of patients. After 24 hours of milrinone therapy, patients exhibited significant improvements in pulmonary artery pressures, pulmonary capillary wedge pressures, and cardiac index. When compared with baseline, significantly more patients received angiotensin-converting enzyme (ACE) inhibitors after 24 hours of milrinone and at the end of milrinone therapy (67% vs 86%, p <0.01). Likewise, significantly more patients also received oral hydralazine and/or nitrates at the end of milrinone therapy (38% vs 65%, p <0.01) when compared with baseline. The mean doses of most oral medications at the 3 time periods were similar. The ACE inhibitor dose was significantly higher at the end of milrinone therapy when compared with baseline, and hydralazine dose was significantly higher at the end of therapy when compared with 24 hours. Few adverse effects were noted, with only 10% of patients experiencing symptomatic ventricular tachycardia and 2 patients with significant hypotension requiring discontinuation of the drug. The adverse events were similar in the group of patients who received milrinone for ≥7 days compared with the entire cohort. Milrinone was well tolerated over the long term in a controlled inpatient setting, and allowed uptitration of oral vasodilator therapy.
IntroductionStudies have shown sex-specific differences regarding CAD and heart failure with left ventricular (LV) dysfunction. Whether these differences impact the benefit of CABG in patients with ...ischemic LV dysfunction has not been studied prospectively. Female sex is conventionally considered a risk factor for open-heart surgery, and has been included as a poor prognostic factor in multiple cardiac operative risk evaluation scores. We investigated the impact of sex on the long-term benefit of CABG in patients enrolled in the prospective Surgical Treatment for Ischemic Heart Failure Study (STICH) trial.MethodThe STICH trial randomized 1212 patients 148 (12%) women and 1064 (88%) men with CAD and EF≤ 35% to medical therapy alone (MED) versus MED plus CABG. Long-term (10-year) outcomes with each treatment were compared according to sex.ResultsAt baseline, women were older with higher BMI and more CAD risk factors (e.g. diabetes) except for smoking, and had lower rates of prior CABG than men (all p<0.05). Moreover, women had higher NYHA class, lower 6-min walk capacity and lower Kansas City Cardiomyopathy Questionnaire scores (all p<0.05). At 10-year follow up, the all-cause mortality rate (HR 0.70, CI 0.55-0.89, adjusted p=0.002) and CV mortality rate (HR 0.64, CI 0.48-0.86, adjusted p=0.006) were significantly lower in women than men. Furthermore, with randomization to CABG vs. MED treatment, there was no significant interaction between sex and treatment group in all-cause mortality, CV mortality, mortality or CV hospitalization (all p>0.05, Figure 1). In addition, surgical deaths were similar for both sexes among patients randomized to CABG.ConclusionSex does not impact the effect of CABG on all-cause mortality, CV mortality, CV hospitalization or surgical deaths in patients with ischemic LV dysfunction. Thus, sex should not influence treatment decisions regarding CABG in these patients.
The purpose of this study was to determine whether exercise training is associated with an increased risk of implantable cardioverter-defibrillator (ICD) therapy in patients with heart failure (HF).
...Few data are available regarding the safety of exercise training in patients with ICDs and HF.
HF-ACTION (Heart Failure and A Controlled Trial Investigating Outcomes of Exercise TraiNing) randomized 2,331 outpatients with HF and an ejection fraction (EF) ≤35% to exercise training or usual care. Cox proportional hazards modeling was used to examine the relationship between exercise training and ICD shocks.
We identified 1,053 patients (45%) with an ICD at baseline who were randomized to exercise training (n = 546) or usual care (n = 507). Median age was 61 years old, and median EF was 24%. Over a median of 2.2 years of follow-up, 20% (n = 108) of the exercise patients had a shock versus 22% (n = 113) of the control patients. A history of sustained ventricular tachycardia/fibrillation (hazard ratio HR: 1.93 95% confidence interval (CI): 1.47 to 2.54), previous atrial fibrillation/flutter (HR: 1.63 95% CI: 1.22 to 2.18), exercise-induced dysrhythmia (HR: 1.67 95% CI: 1.23 to 2.26), lower diastolic blood pressure (HR for 5-mm Hg decrease <60: 1.35 95% CI: 1.12 to 1.61), and nonwhite race (HR: 1.50 95% CI: 1.13 to 2.00) were associated with an increased risk of ICD shocks. Exercise training was not associated with the occurrence of ICD shocks (HR: 0.90 95% CI: 0.69 to 1.18, p = 0.45). The presence of an ICD was not associated with the primary efficacy composite endpoint of death or hospitalization (HR: 0.99 95% CI: 0.86 to 1.14, p = 0.90).
We found no evidence of increased ICD shocks in patients with HF and reduced left ventricular function who underwent exercise training. Exercise therapy should not be prohibited in ICD recipients with HF. (Exercise Training Program to Improve Clinical Outcomes in Individuals With Congestive Heart Failure; NCT00047437)
This study sought to better understand the discrepant results of 2 trials of serelaxin on acute heart failure (AHF) and short-term mortality after AHF by analyzing causes of death of patients in the ...RELAX-AHF-2 (Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF-2) trial.
Patients with AHF continue to suffer significant short-term mortality, but limited systematic analyses of causes of death in this patient population are available.
Adjudicated cause of death of patients in RELAX-AHF-2, a randomized, double-blind, placebo-controlled trial of serelaxin in patients with AHF across the spectrum of ejection fraction (EF), was analyzed.
By 180 days of follow-up, 11.5% of patients in RELAX-AHF-2 died, primarily due to heart failure (HF) (38% of all deaths). Unlike RELAX-AHF, there was no apparent effect of treatment with serelaxin on any category of cause of death. Older patients (≥75 years) had higher rates of mortality (14.2% vs. 8.8%) and noncardiovascular (CV) death (27% vs. 19%) compared to younger patients. Patients with preserved EF (≥50%) had lower rates of HF-related mortality (30% vs. 40%) but higher non-CV mortality (36% vs. 20%) compared to patients with reduced EF.
Despite previous data suggesting benefit of serelaxin in AHF, treatment with serelaxin was not found to improve overall mortality or have an effect on any category of cause of death in RELAX-AHF-2. Careful adjudication of events in the serelaxin trials showed that older patients and those with preserved EF had fewer deaths from HF or sudden death and more deaths from other CV causes and from noncardiac causes. (Efficacy, Safety and Tolerability of Serelaxin When Added to Standard Therapy in AHF RELAX-AHF-2; NCT01870778)
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...it will attempt to measure change in quality of life for patients participating in the exercise program with sufficient power to comment on quality-of-life changes and cost to the health care ...system. ...the study will attempt to validate the putative surrogate markers that have been used in small-scale studies such as peak Vo2, exercise duration, 6-minute walk test changes, and quality-of-life indices.
...significant judgment by clinicians is required to adapt these guidelines to the care of individual patients, and these guidelines can be generated with varying degrees of confidence based upon ...available evidence. While the focus of the performance measures writing committees is to develop measures for internal quality improvement, it is appreciated that other organizations may use these measures for external reporting of provider performance. ...it is within the scope of the writing committee's task to comment on the strengths and limitations of externally reporting potential performance measures. Daichii Proctor & Gamble Dr. Frederick Kushner Content Reviewer-ACC/AHA STEMI Guideline Writing Committee Aginamoto Co. Andrx Labs Atherogenics, Inc. Boehringer-Ingelheim Medtronic Novartis Rorer Schering-Plough Bristol-Myers Squibb Merck Pfizer Reliant Abbott Labs Baxter Guidant Medtronic Merck Pfizer * Millennium, Inc. Dr. Joseph Ornato Content Reviewer-ACC/AHA STEMI Guideline Writing Committee Genentech Meridian Medical Corp. Wyeth None None Bristol-Myers-Squibb Genentech HP/Agilent Medtronic Meridian Medical Corp. Philips PhysioControl Scios Revivant Corp. Wyeth Dr. Eugene Braunwald Content Reviewer-Chair, ACC/AHA UA/NSTEMI Guideline Writing Committee None None None None Dr. Thomas Levin Content Reviewer-ACC/AHA UA/NSTEMI Guideline Writing Committee None None None None Dr. Earl Smith III Content Reviewer-ACC/AHA UA/NSTEMI Guideline Writing Committee None None None None Dr. Pierre Theroux Content Reviewer-ACC/AHA UA/NSTEMI Guideline Writing Committee None None Astra Zeneca Aventis Proctor & Gamble None Dr. Rohit Arora Content Reviewer-ACCF Cardiac Catheterization and Intervention Committee None Aventis None None Dr. Carlos Ruiz Content Reviewer-ACCF Cardiac Catheterization and Intervention Committee Cook Cardiology None None None Dr. Karl B. Kern Content Reviewer-ACCF EmergencyCardiac Care Committee None None None ERS Medtronic Revivant Corp. Dr. Mary Ann Peberdy Content Reviewer-ACCF EmergencyCardiac Care Committee None None None None Dr. Michael Rosenberg Content Reviewer-ACCF EmergencyCardiac Care Committee None None None None Dr. David Faxon Content Reviewer-AHA Quality of Care and Outcomes Steering Committee None None None None Dr. William Weintraub Content Reviewer-AHA Quality of Care and Outcomes Steering Committee None None None None Dr. Bojan Cercek Content Reviewer-AHA Committee on Acute Cardiac Care None None None None Dr. James De Lemos Content Reviewer-AHA Committee on Acute Cardiac Care Aventis BMS/Sanofi Merck None None None Dr. Jose Lopez-Sendon Content Reviewer-AHA Committee on Acute Cardiac Care Aventis BMS TIMI None None None * This table represents the relationships of peer reviewers with industry that were disclosed at the time of peer review of this guideline.
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