Clinical Status In Heart Failure Research Articles

Abstract 16838: Relation of Clinical Status in Heart Failure to Cardiac Lysophosphatidylethanolamine Accumulation in Hypertrophic Cardiomyopathy

Background: Patients with hypertrophic cardiomyopathy (HCM) represents diverse symptoms, morphology, and cardiovascular events. Although myocardium metabolism in patients with HCM has been studied, it is not well elucidated. In this study, we assessed the association between biomarkers, heart failure-related findings, genetic mutations, and myocardium lipid metabolism in HCM patients using imaging mass spectrometry. Method: We prospectively enrolled patients with HCM in Hamamatsu University hospital from July 2020 to October 2022. All patients underwent endomyocardial biopsy and genetic analysis. Obtained myocardial specimens were analyzed using a desorption electrospray ionization source attached to a mass spectrometer. Differences among groups were statistically evaluated with the Fisher’s exact test and Mann-Whitney U test. Correlations between the two values were analyzed using Spearman’s correlation coefficient values. Results: A total of 31 Japanese patients were enrolled in this study. These patients included 18 (58.0%) women, and the mean age was 67.6 ± 10.6 years. Genetic analysis revealed that six (19.4%) patients had pathogenic or likely pathogenic variant. (Frequency of causal genes was as follows: MYBPC3 2 [6.5%], TNNI3 2 [6.5%], MYH7 1 [3.2%], and MYOZ2 1 [3.2%].) We divided the patients into two groups according to their median intensity of candidate molecule to reveal between group differences. The group of high lysophosphatidylethanolamine (LPE) showed lower N-terminal pro-brain natriuretic peptide (NT-proBNP) levels (330.0 [147.0-614.0] pg/mL vs. 933.0 [699.5-2576.5] pg/mL, P = 0.001). A correlation was observed between the intensity of LPE and the NT-proBNP levels (r = -0.455, P = 0.012). There was no association between the presence of genetic mutations and New York Heart Association class and LPE intensity. Conclusion: HCM patients with the high intensity of LPE in myocardial tissue had relatively low NT-proBNP levels.

Seismocardiography Feature Selection For Prediction Of Heart Failure Readmission

<h3>Introduction</h3> Seismocardiography (SCG) is a potential tool to assess the clinical status of heart failure (HF) patients. Preliminary data suggests that certain features extracted from SCG signal may be utilized to predict HF readmission, which in turn may help identify patients requiring more intensive therapy or monitoring. Machine learning may be utilized for identification of potential SCG features to optimize readmission predictive value. <h3>Objective</h3> The objective of this study was to utilize machine learning to identify SCG features that correlate with HF readmission prediction. <h3>Methods</h3> SCG recordings were longitudinally collected from 40 HFrEF patients, among them 9 were readmitted during the 12 m study period. One hundred and three features were extracted from SCG waveforms including waveform variability, amplitude, spectro-temporal and heart rate variability parameters. Some of the features involved separating SCG waveforms into clusters that correlated with breathing phases. Four machine learning methods (information gain, random forest, ANOVA and "ReliefF") were used to select optimum features. <h3>Results</h3> Features identified by various machine learning methods as most predictive of HF readmission are shown in Table 1 with the performance measure for each feature shown in parenthesis. The listed features are: IF_rms,avg=mean of the root mean square (RMS) of instantaneous frequency of the 2 "cluster medoids." WV_bC=variability of SCG waveform before clustering. WV_iC and WV_IC=intra and inter cluster waveform variability. SCG2_{amp(0.5-50),avg},SCG2_{amp(20-50),avg}=mean RMS amplitude (normalized to SCG peak-to-peak) around SCG2 in 0.5-50 & 20-50 Hz bands, respectively. PEP=pre ejection period. SCG1_{amp(0.5-50),avg}=mean RMS amplitude around SCG1 in 0.5-50 Hz. MF_diff=mean frequency difference between clusters. <h3>Conclusions</h3> SCG instantaneous frequency, waveform variability, pre-ejection period, and SCG amplitudes were the most predictive of HF readmission in this initial analysis. More data are needed to confirm consistency of these results. If successful, the proposed approach may have utility for management of HF patients.

Association of Cancer With Outcomes in Patients Hospitalized for Heart Failure.

The complex clinical status of heart failure (HF) patients with concomitant cancer is gaining clinical interest. This study sought to explore the prevalence of cancer in patients with HF and its effect on outcomes using a nationwide inpatient database.Methods and Results:In total, 447,818 HF patients who were admitted and discharged between January 2010 and March 2018 were studied and included in the Diagnosis Procedure Combination (DPC) database. The median age was 81 years; 238,192 patients (53.2%) were men and 25,951 (5.8%) had concomitant cancer. The prevalence of cancer peaked in patients aged in their 70 s and 80 s and increased with time. Patients with cancer were older and more likely to be male. Cigarette smoking was more common in patients with cancer. Patients with cancer more frequently had infectious complications during hospitalization. Advanced medical procedures were less frequently performed for patients with cancer. In-hospital mortality was higher in patients with cancer than those without (10.0% vs. 6.7%, P<0.001). Among patients with cancer, in-hospital mortality was higher in patients with metastasis than those without (18.9% vs. 9.4%, P<0.001). Multivariable logistic regression analysis, fitted with a generalized estimating equation, indicated cancer is associated with higher in-hospital mortality (odds ratio 1.51, 95% confidential interval 1.43-1.59, P<0.001). Cancer was frequently observed in patients hospitalized for worsened HF, and its prevalence increased with time. The presence of cancer increased the risk of in-hospital death. Further studies are warranted to establish the optimal management strategy for HF patients with cancer in the field of cardio-oncology.

Immature surfactant protein-B impairs the antioxidant capacity of HDL

Circulating immature surfactant protein B (proSP-B) forms emerged as the most reliable lung-specific circulating marker for alveolar-capillary membrane (ACM) dysfunction and for the overall clinical status of heart failure (HF). Notably, in terms of HF hospitalization, immature SP-B overwhelms the prognostic role of other most frequently used clinical parameters such as those related to lung dysfunction. The strong prognostic value of circulating proSP-B in HF suggests more widespread and possible systemic effects. Thus, we assessed the plasma distribution of proSP-B evaluating whether it exists in a lipoprotein-bound form and its impact on lipoprotein structure and function.ProSP-B forms were detectable in high-density lipoprotein (HDL) only. To assess the impact of proSP-B on HDL, HDL from healthy subjects were enriched with proSP-B produced by a stably transfected CHO cell line that specifically expresses and releases the human proSP-B. After enrichment, HDL size and lipoprotein electrophoretic mobility, and protein composition did not show apparent differences. HDL antioxidant capacity (HOI), assessed as their ability to inhibit air-induced LDL oxidation, was impaired after proSP-B enrichment. HOI was also higher in HF patients with respect to age-matched control healthy subjects (p = 0.013).Circulating proSP-B, besides its potential role as a specific marker for ACM dysfunction in HF patients with diagnostic and prognostic value, binds to human HDL impairing their antioxidant capacity. These findings shed light on proSP-B as a molecule that contributes to the reduction of the defense against oxidative stress, a key mediator in the pathogenesis of HF.

Ablation for Atrial Fibrillation in Heart Failure with Reduced Ejection Fraction.

AF and heart failure with reduced ejection fraction (HFrEF) frequently coexist. Catheter ablation is an increasingly utilised treatment strategy for patients with AF and can be safely performed and is effective in achieving sinus rhythm for patients with HFrEF. Successful ablation may result in improved LV function, clinical heart failure status, quality of life and possibly even mortality. This review summarises the literature analysing efficacy, safety and outcomes of AF ablation for patients with HFrEF.

Iron deficiency and anemia in heart failure.

Heart failure is an important community health problem. Prevalence and incidence of heart failure have continued to rise over the years. Despite recent advances in heart failure therapy, prognosis is still poor, rehospitalization rate is very high, and quality of life is worse. Co-morbidities in heart failure have negative impact on clinical course of the disease, further impair prognosis, and add difficulties to treatment of clinical picture. Therefore, successful management of co-morbidities is strongly recommended in addition to conventional therapy for heart failure. One of the most common co-morbidities in heart failure is presence of iron deficiency and anemia. Current evidence suggests that iron deficiency and anemia are more prevalent in patients with heart failure and reduced ejection fraction, as well as those with heart failure and preserved ejection fraction. Moreover, iron deficiency and anemia are referred to as independent predictors for poor prognosis in heart failure. There is strong relationship between iron deficiency or anemia and severity of clinical status of heart failure. Over the last two decades, many clinical investigations have been conducted on clinical effectiveness of treatment of iron deficiency or anemia with oral iron, intravenous iron, and erythropoietin therapies. Studies with oral iron and erythropoietin therapies did not provide any clinical benefit and, in fact, these therapies have been shown to be associated with increase in adverse clinical outcomes. However, clinical trials in patients with iron deficiency in the presence or absence of anemia have demonstrated considerable clinical benefits of intravenous iron therapy, and based on these positive outcomes, iron deficiency has become target of therapy in management of heart failure. The present report assesses current approaches to iron deficiency and anemia in heart failure in light of recent evidence.

Relation of Longitudinal Changes in Quality of Life Assessments to Changes in Functional Capacity in Patients With Heart Failure With and Without Anemia

Clinical status in heart failure is conventionally assessed by the physician's evaluation, patients' own perception of their symptoms, quality of life (QoL) tools, and a measure of functional capacity. These aspects can be measured with tools such as the New York Heart Association functional class, QoL tools such as the EuropeanQoL-5 dimension, the Kansas City Cardiomyopathy Questionnaire, patient global assessment (PGA), and by 6-minute walk test (6MWT), respectively. The ferric carboxymaltose in patients with heart failure and iron deficiency (FAIR-HF) trial demonstrated that treatment with intravenous ferric carboxymaltose in iron-deficient patients with symptomatic heart failure with reduced left ventricular function, significantly improved all 5 outcome measures. This analysis assessed the correlations between the longitudinal changes in the measures of clinical status, as measured by QoL tools and the changes in the measures of functional capacity as measured by the 6MWT. This analysis used the database from the FAIR-HF trial, which randomized 459 patients with chronic heart failure (reduced left ventricular ejection fraction) and iron deficiency, with or without anemia to ferrous carboxymaltose or placebo. The degree of correlation between QoL tools and the 6MWT was assessed at 4, 12, and 24 weeks. The data demonstrate highly significant correlations between QoL and functional capacity, as measured by the 6MWT, at all time points (p <0.001). Changes in PGA, Kansas City Cardiomyopathy Questionnaire, and EuroQoL-5D correlated increasingly over time with changes in 6MWT performance. Interestingly, the strongest correlation at 24 weeks is for the PGA, which is a simple numerical scale (r = -0.57, p <0.001). This analysis provides evidence that QoL assessment show a significant correlation with functional capacity, as measured by the 6MWT. The strength of these correlations increased over time.

Device monitoring of heart failure in cardiac resynchronization therapy device recipients

We investigated the performance of a new intrathoracic multivector impedance monitoring system for the prediction of heart failure events in consecutive device-implanted patients. Eighty heart failure patients implanted with biventricular defibrillators with multivector impedance monitoring capability were prospectively enrolled. Clinical heart failure status and impedance data were assessed during follow-up and if patients presented with an alert or heart failure deterioration. During follow-up (8.0 ± 4.4 months), 56 events of device alert for fluid index increase were identified in 29 patients, and a total of 39 heart failure events (defined by worsening of heart failure signs and symptoms) occurred in 23 patients. The sensitivity and positive predictive value (PPV) for heart failure deterioration was 61.5 and 42.9%, respectively. False-positive alerts occurred in 23 of 80 patients (28.8%), for an episode rate of 0.60 a year. Among all clinical heart failure events, decompensation caused hospitalization in 13 cases (33.3%), seven of them were preceded by an alert condition (53.8%) resulting in a sensitivity of 53.8% and a PPV of 17.9%. The present study confirms the feasibility and clinical usefulness of this novel multivector impedance monitoring system. It would be worthwhile to perform larger studies to assess its actual clinical value in heart failure patients.

Effect of Phosphodiesterase-5 Inhibition on Exercise Capacity and Clinical Status in Heart Failure With Preserved Ejection Fraction

Studies in experimental and human heart failure suggest that phosphodiesterase-5 inhibitors may enhance cardiovascular function and thus exercise capacity in heart failure with preserved ejection fraction (HFPEF). To determine the effect of the phosphodiesterase-5 inhibitor sildenafil compared with placebo on exercise capacity and clinical status in HFPEF. Multicenter, double-blind, placebo-controlled, parallel-group, randomized clinical trial of 216 stable outpatients with HF, ejection fraction ≥50%, elevated N-terminal brain-type natriuretic peptide or elevated invasively measured filling pressures, and reduced exercise capacity. Participants were randomized from October 2008 through February 2012 at 26 centers in North America. Follow-up was through August 30, 2012. Sildenafil (n = 113) or placebo (n = 103) administered orally at 20 mg, 3 times daily for 12 weeks, followed by 60 mg, 3 times daily for 12 weeks. Primary end point was change in peak oxygen consumption after 24 weeks of therapy. Secondary end points included change in 6-minute walk distance and a hierarchical composite clinical status score (range, 1-n, a higher value indicates better status; expected value with no treatment effect, 95) based on time to death, time to cardiovascular or cardiorenal hospitalization, and change in quality of life for participants without cardiovascular or cardiorenal hospitalization at 24 weeks. Median age was 69 years, and 48% of patients were women. At baseline, median peak oxygen consumption (11.7 mL/kg/min) and 6-minute walk distance (308 m) were reduced. The median E/e' (16), left atrial volume index (44 mL/m2), and pulmonary artery systolic pressure (41 mm Hg) were consistent with chronically elevated left ventricular filling pressures. At 24 weeks, median (IQR) changes in peak oxygen consumption (mL/kg/min) in patients who received placebo (-0.20 [IQR, -0.70 to 1.00]) or sildenafil (-0.20 [IQR, -1.70 to 1.11]) were not significantly different (P = .90) in analyses in which patients with missing week-24 data were excluded, and in sensitivity analysis based on intention to treat with multiple imputation for missing values (mean between-group difference, 0.01 mL/kg/min, [95% CI, -0.60 to 0.61]). The mean clinical status rank score was not significantly different at 24 weeks between placebo (95.8) and sildenafil (94.2) (P = .85). Changes in 6-minute walk distance at 24 weeks in patients who received placebo (15.0 m [IQR, -26.0 to 45.0]) or sildenafil (5.0 m [IQR, -37.0 to 55.0]; P = .92) were also not significantly different. Adverse events occurred in 78 placebo patients (76%) and 90 sildenafil patients (80%). Serious adverse events occurred in 16 placebo patients (16%) and 25 sildenafil patients (22%). Among patients with HFPEF, phosphodiesterase-5 inhibition with administration of sildenafil for 24 weeks, compared with placebo, did not result in significant improvement in exercise capacity or clinical status. clinicaltrials.gov Identifier: NCT00763867.

Autonomic nervous system in heart failure: an endless area of research/ The preserved autonomic functions may provide the asymptomatic clinical status in heart failure despite advanced left ventricular systolic dysfunction

Autonomic nervous system in heart failure: an endless area of research/ The preserved autonomic functions may provide the asymptomatic clinical status in heart failure despite advanced left ventricular systolic dysfunction

The preserved autonomic functions may provide the asymptomatic clinical status in heart failure despite advanced left ventricular systolic dysfunction

Autonomic dysfunction is an important marker of prognosis in congestive heart failure (CHF) and may determine the symptoms and progression of CHF. The aim of our study was to investigate whether preserved autonomic function assessed by heart rate variability (HRV) analyses is related to absence of CHF symptoms despite prominently reduced systolic function. The study had a cross-sectional observational design. Fifty patients with left ventricular ejection fraction (EF) below 40% were enrolled. The patients were divided into two groups according to their CHF symptomatic status as Group 1 (NYHA functional class I, asymptomatic group) and Group 2 (NYHA functional class ≥ II, symptomatic group). Plasma C-reactive protein (CRP), N-terminal proB-type natriuretic peptide (NT-proBNP) levels, echocardiographic parameters and HRV indices were measured while the patients were clinically stable in each group. Possible factors associated with the development of CHF symptoms were assessed by using multiple regression analysis. Baseline clinical characteristics and left ventricular EF were similar in the two groups. Serum CRP (15 ± 21 vs 7 ± 18 mg/L, p=0.011) and NT-proBNP levels (1935 ± 1088 vs 1249 ± 1083 pg/mL, p=0.020) were significantly higher in symptomatic group. The HRV parameters (SDNN: 78 ± 57 vs 122 ± 42 ms, p=0.001; SDANN: 65 ± 55 vs 84 ± 38 ms, p=0.024; SDNNi: 36 ± 41 vs 70 ± 46 ms, p<0.001; triangular index [Ti]: 17 ± 12 vs 32 ± 14, p<0.001) were also significantly depressed in symptomatic group. When multiple regression analysis was performed, only HRV indices of autonomic function were significantly associated with the asymptomatic status (SDNN, OR: 1.016, 95%CI: 1.002-1.031, p=0.028; SDNNi, OR: 1.030, 95%CI: 1.008-1.052, p=0.006; TI, OR: 1.088, 95%CI: 1.019-1.161, p=0.011). Preserved autonomic functions were shown to be associated with absence of CHF symptoms independently of angiotensin converting enzyme inhibitor/angiotensin receptor blocker's treatment and BNP levels and may be protective against the development of CHF symptoms despite advanced left ventricular systolic dysfunction.

Clinical utility of intrathoracic impedance monitoring to alert patients with an implanted device of deteriorating chronic heart failure

To evaluate the utility of intrathoracic impedance monitoring for detecting heart failure (HF) deterioration in patients with an implanted cardiac resynchronization/defibrillation device. Patients enrolled in the European InSync Sentry Observational Study were audibly alerted by a device algorithm if a decrease in intrathoracic impedance suggested fluid accumulation. Clinical HF status and device data were assessed at enrolment, during regular follow-up, and if patients presented with an alert or HF deterioration. Data from 373 subjects were analysed. Fifty-three alert events and a total of 53 clinical events (HF deterioration defined by worsening of HF signs and symptoms) were reported during a median of 4.2 months. Adjusted for multiple events per patient, the alert detected clinical HF deterioration with 60% sensitivity (95% CI 46-73) and with a positive predictive value of 60% (95% CI 46-73). Higher NYHA class at baseline was predictive for adequate alert events during follow-up (P < 0.05). In 11 of 20 HF deteriorations without preceding alert, an upstroke of the fluid index occurred without reaching the programmed alert threshold. A device-based algorithm that alerts patients in case of decreasing intrathoracic impedance facilitates the detection of HF deterioration. Future randomized, controlled trials are needed to test whether the tailored use of intrathoracic impedance monitoring can improve the ambulatory management of patients with chronic HF and an implanted device.

B-type natriuretic peptides as powerful markers in cardiac diseases – analytical and clinical aspects / B-Typ natriuretische Peptide als aussagekräftige Marker bei kardialen Erkrankungen – analytische und klinische Aspekte

Abstract Among all natriuretic peptides and neurohormones, B-type natriuretic peptide (BNP) and its N-terminal prohormone fragment (NT-proBNP) have been shown to be the best and most powerful markers to identify patients with acute and chronic heart failure (HF). The fully automated BNP and NT-proBNP assays require only 15–20 min to achieve a test result so that a turn-around time of less than 60 min is possible, as requested by the guidelines of the cardiological societies. The in-vitro stabilities of BNP and NT-proBNP are sufficient for routine use. Most of the commercially available assays, except if they are sublicensed, use different antibodies. This may explain that in general, BNP and NT-proBNP assays show close correlations, but do not agree in absolute values. The assays have not been standardized so far and the application of various calibration materials may contribute to different results. Thus, reference ranges are dependent on the assay used, and reference ranges have to be determined for each assay separately. The increasing values with age may be related to the increasing frequency of subclinical renal or cardiac dysfunction in the elderly. Estrogens stimulate the natriuretic peptide production in females, and reference ranges depend on sex from adolescence to menopause. Immediately after birth, BNP and NT-proBNP levels are substantially higher in neonates than in their mothers. The high biological variation of natriuretic peptides must be considered when interpreting serial BNP and NT-proBNP results. Therefore, only marked BNP or NT-proBNP changes during follow-up are related to changes in the clinical HF status. A conclusion of all major studies is that in patients with chronic HF BNP and NT-proBNP are rather rule-out than rule-in markers because of limited cardiac specificities. Patients with acute HF usually show higher BNP and NT-proBNP levels than patients with chronic HF. The greatest efficiency of BNP and NT-proBNP testing was demonstrated in patients presenting to the emergency department with acute dyspnoea or in outpatients with symptoms suggesting chronic HF. Many studies indicate that short- and long-term prognosis in HF can be assessed by BNP or NT-proBNP determination. These hormones are independent predictors of death or HF hospitalizations. Natriuretic peptides are increased in all diseases affecting the cardiac or renal function and fluid balance. BNP and NT-proBNP are markers of cardiac dysfunction in patients with renal failure as well, but higher decision limits have to be used. Decreased BNP and NT-proBNP concentrations in obesity are not fully understood and controversial reports are found in the literature. In summary, BNP or NT-proBNP determination is a powerful test for ruling out HF. Furthermore, these markers are a useful addition to the standard clinical investigations of patients with suspected ventricular dysfunction.

B-type natriuretic peptides as powerful markers in cardiac diseases: Analytical and clinical aspects

Among all natriuretic peptides and neurohormones, B-type natriuretic peptide (BNP) and its Nterminal prohormone fragment (NT-proBNP) have been shown to be the best and most powerful markers to identify patients with acute and chronic heart failure (HF). The fully automated BNP and NT-proBNP assays require only 15-20 min to achieve a test result so that a turn-around time of less than 60 min is possible, as requested by the guidelines of the cardiological societies. The in-vitro stabilities of BNP and NT-proBNP are sufficient for routine use. Most of the commercially available assays, except if they are sublicensed, use different antibodies. This may explain that in general, BNP and NT-proBNP assays show close correlations, but do not agree in absolute values. The assays have not been standardized so far and the application of various calibration materials may contribute to different results. Thus, reference ranges are dependent on the assay used, and reference ranges have to be determined for each assay separately. The increasing values with age may be related to the increasing frequency of subclinical renal or cardiac dysfunction in the elderly. Estrogens stimulate the natriuretic peptide production in females, and reference ranges depend on sex from adolescence to menopause. Immediately after birth, BNP and NTproBNP levels are substantially higher in neonates than in their mothers. The high biological variation of natriuretic peptides must be considered when interpreting serial BNP and NT-proBNP results. Therefore, only marked BNP or NT-proBNP changes during follow-up are related to changes in the clinical HF status. A conclusion of all major studies is that in patients with chronic HF BNP and NT-proBNP are rather rule-out than rule-in markers because of limited cardiac specificities. Patients with acute HF usually show higher BNP and NT-proBNP levels than patients with chronic HF. The greatest efficiency of BNP and NT-proBNP testing was demonstrated in patients presenting to the emergency department with acute dyspnoea or in outpatients with symptoms suggesting chronic HF. Many studies indicate that short- and long-term prognosis in HF can be assessed by BNP or NT-proBNP determination. These hormones are independent predictors of death or HF hospitalizations. Natriuretic peptides are increased in all diseases affecting the cardiac or renal function and fluid balance. BNP and NT-proBNP are markers of cardiac dysfunction in patients with renal failure as well, but higher decision limits have to be used. Decreased BNP and NT-proBNP concentrations in obesity are not fully understood and controversial reports are found in the literature. In summary, BNP or NT-proBNP determination is a powerful test for ruling out HF. Furthermore, these markers are a useful addition to the standard clinical investigations of patients with suspected ventricular dysfunction.

Current status of TNF blocking therapy in heart failure

Recent experimental studies have shown that tumor necrosis factor alpha (TNF-alpha) has deleterious cardiovascular effects. Tumor necrosis factor alpha antagonists bind to TNF-a and functionally inactivate this cytokine and thereby reverse some of these effects. Various clinical studies of TNF-alpha antagonists have reported conflicting results. The present review analyses all reported clinical trials of TNF-alpha antagonists in congestive heart failure (CHF). The effect of these agents on clinical composite score, CHF hospitalizations, and mortality were compared. Early clinical studies of blocking TNF in patients with heart failure demonstrated promising results. However, recent large-scale, placebo-controlled trials have failed to show any improvement in the clinical status of heart failure. There have in fact, been some reports of worsening of heart failure with these agents. It may be concluded that TNF-alpha antagonists could adversely affect the clinical condition of patients with moderate to severe heart failure.

Digitalis may reduce hospitalisation and improve clinical status in heart failure, but has no effect on mortalityAbstracted from: Hood WB Jr, Dans AL, Guyatt GH, et al. Digitalis for treatment of congestive heart failure in patients in sinus rhythm: a systematic review and meta-analysis. J Cardiac Failure 2004; 10(2): 155–64.

Digitalis may reduce hospitalisation and improve clinical status in heart failure, but has no effect on mortalityAbstracted from: Hood WB Jr, Dans AL, Guyatt GH, et al. Digitalis for treatment of congestive heart failure in patients in sinus rhythm: a systematic review and meta-analysis. J Cardiac Failure 2004; 10(2): 155–64.