Conventional Heart Failure Treatment Research Articles

Modern heart failure treatment is superior to conventional treatment across the left ventricular ejection spectrum: Real-life data from the Swedish Heart Failure Registry 2013-2020

Abstract Background Heart failure (HF) is a clinical syndrome characterized by high mortality and morbidity. In 2016, Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), was recommended as a new treatment option for HF in patients with HFrEF. In the 2021 European Society of Cardiology guidelines for treatment of HFrEF patients Sodium-glucose cotransporter 2 inhibitors (SGLT2i) were introduced because they demonstrated significantly reduced HF events or cardiovascular (CV) mortality. Since ARNI and SGLT2i were introduced to treat HF, its therapeutic regimen has modernized from previous treatment with beta-blocker (BB) and angiotensin-converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB) with mineralocorticoid receptor antagonist (MRA) as added-on in HF with reduced ejection fraction (HFrEF). Purpose This study is aimed to compare effectiveness of modern therapy including ARNI and SGLT2i with conventional heart failure treatment. Conventional HF treatment includes (BB, ACEi/ARB, with or without MRA) and modern heart failure treatment (BB, ACEi/ARB, MRA, SGLT2i or BB, ARNI, MRA with/without SGLT2i) in real-world. Methods This observational study (2013-2020), using the Swedish HF Registry, involved 20,849 HF patients. Patients received either conventional (BB, ACEi/ARB, with/without MRA, n=20,140) or modern (BB, ACEi/ARB, MRA, SGLT2i or BB, ARNI, MRA with/without SGLT2i, n=709) treatment at the index visit. The endpoints were all-cause and cardiovascular (CV) mortality. Results Modern HF therapy was associated with a significant 28% reduction in all-cause mortality compared to conventional HF treatment (adjusted HR [aHR]: 0.72 (95% CI 0.54 - 0.96), p=0.024), and had 33% reduced all-cause mortality (aHR: 0.67 (95% CI 0.48 - 0.94), p=0.019) within 2 years of index registration. Similarly, modern HF therapy was associated with a significant 62% reduction in CV mortality compared to conventional HF treatment (aHR: 0.38 (95% CI 0.21 - 0.68), p=0.0013). In addition, we found a 58% reduced CV mortality (aHR 0.42 (95% CI 0.22 - 0.79), p=0.0067) within 2 years of index registration. In the propensity score 1:1 matched cohort in which ARNI was included in the matching procedure, i.e., no ARNI was used in any of the two treatment groups and the effect of SGLT2i was the target assessment. The results were associated with a statistically significant risk reduction of 42% in all-cause mortality in the modern HF treatment group compared to the conventional treatment group (aHR: 0.58 (95% CI 0.36 - 0.94), p=0.028), and a 49% (aHR: 0.51 (95% CI 0.29 - 0.89), p=0.018) risk reduction within 2 years of index registration. Conclusion This study demonstrates that modern HF therapy in a real-world Swedish HF population is associated with a statistically significant risk reduction in all-cause and CV mortality, regardless of EF, sex, age, eGFR, and etiology of HF compared to conventional HF therapy.Central Illustration

Modern heart failure treatment is superior to conventional treatment across the left ventricular ejection spectrum: real-life data from the Swedish Heart Failure Registry 2013–2020

ObjectivesThis study is aimed to compare the effectiveness of modern therapy including angiotensin receptor-neprilysin inhibitor (ARNI) and sodium-glucose cotransporter 2 inhibitors (SGLT2i) with conventional heart failure treatment in the real world.BackgroundSince ARNI and SGLT2i were introduced to treat heart failure (HF), its therapeutic regimen has modernized from previous treatment with beta-blocker (BB) and angiotensin-converting enzyme inhibitor (ACEi)/angiotensin II receptor blocker (ARB) with mineralocorticoid receptor antagonist (MRA) as added-on in HF with reduced ejection fraction (HFrEF). However, a comparison between conventional and modern treatment strategies with drugs in combination has not been performed.MethodsThis observational study (2013–2020), using the Swedish HF Registry, involved 20,849 HF patients. Patients received either conventional (BB, ACEi/ARB, with/without MRA, n = 20,140) or modern (BB, ACEi/ARB, MRA, SGLT2i or BB, ARNI, MRA with/without SGLT2i, n = 709) treatment at the index visit. The endpoints were all-cause and cardiovascular (CV) mortality.ResultsModern HF therapy was associated with a significant 28% reduction in all-cause mortality (adjusted HR [aHR], 0.72 (0.54–0.96); p = 0.024) and a significant 62% reduction in CV mortality (aHR, 0.38 (0.21–0.68); p = 0.0013) compared to conventional HF treatment. Similar results emerged in a sensitivity analysis using propensity score matching. The interaction analyses did not reveal any trends for EF (< 40% and ≥ 40%), sex, age (< 70 and ≥ 70 years), eGFR (< 60 and ≥ 60 ml/min/1.73 m2), and etiology of HF subgroups.ConclusionIn this nationwide study, modern HF therapy was associated with significantly reduced all-cause and CV mortality, regardless of EF, sex, age, eGFR, and etiology of HF.Graphical abstract

A case report on Transthyretin Cardiac Amyloidosis

Introduction : Cardiac amyloidosis is due to the extracellular accumulation of insoluble fibrillar proteins which progressively alter the function of the myocardium. The prognosis depends on the severity of the cardiac involvement. Transthyretin cardiac amyloidosis (TTR) is the most common. It can be wild-type (ATTRwt), hereditary (ATTRv) or senile (wild TTR). The diagnosis of cardiac amyloidosis has greatly improved in the last decade and is based on multimodal imaging, mainly echocardiography and bone scintigraphy. Case Report: We report the case of a male patient hospitalized for heart failure due to transthyretin cardiac amyloidosis. Conclusion: Recognition of this pathology is essential because cardiological management is specific and conventional treatments for heart failure can be harmful. Only specific treatments can slow down or stop the infiltration process.

Melatonin enhances captopril mediated cardioprotective effects and improves mitochondrial dynamics in male Wistar rats with chronic heart failure

Mitochondrial dysfunction is a recent emerging research scope that proved to be involved in many cardiovascular diseases culminating in chronic heart failure (CHF), which remains one of the primary causes of morbidity and mortality. This study investigated the added cardio-protective effects of exogenous melatonin administration to conventional captopril therapy in isoproterenol (ISO) exposed rats with CHF. Five groups of Wistar rats were recruited; (I): Control group, (II): (ISO group), (III): (ISO + captopril group), (IV): (ISO + melatonin group) and (V): (ISO + melatonin/captopril group). Cardiac function parameters and some oxidant, inflammatory and fibrotic markers were investigated. Moreover; mRNA expression of mitochondrial mitophagy [parkin & PTEN induced kinase 1 (PINK1)], biogenesis [Peroxisome proliferator-activated receptor gamma coactivator 1-alpha (PGC-1α)], fusion [mitofusin 2 (Mfn2)] and fission [dynamin-related protein 1 (DRP-1)] parameters in rat’s myocardium were evaluated. Rats’ myocardium was histo-pathologically and immunohistochemically evaluated for Beclin1 and Sirt3 expression. The present study revealed that captopril and melatonin ameliorated cardiac injury, oxidative stress biomarkers, and pro-inflammatory cytokines in ISO-exposed rats. These protective effects could be attributed to mitochondrial dynamic proteins control (i.e. enhanced the mRNA expression of parkin, PINK1, PGC-1α and Mfn2, while reduced DRP-1 mRNA expression). Also, Beclin1 and Sirt3 cardiac immunoreactivity were improved. Combined captopril and melatonin therapy showed a better response than either agent alone. Melatonin enhanced myocardial mitochondrial dynamics and Sirt3 expression in CHF rats and may represent a promising upcoming therapy added to conventional heart failure treatment.

Outcomes with sacubitril/valsartan in outpatients with heart failure and reduced ejection fraction: The ARIADNE registry.

ARIADNE aimed to assess the association between effects of sacubitril/valsartan and no sacubitril/valsartan treatment and clinical characteristics, functional capacity, and clinical outcomes (cause-specific mortality and hospitalizations) in outpatients with heart failure (HF) with reduced ejection fraction (HFrEF). ARIADNE was a prospective European registry of 9069 patients with HFrEF treated by office-based cardiologists or selected primary care physicians. Of the 8787 eligible for analysis, 4173 patients were on conventional HF treatment (non-S/V group), whereas 4614 patients were either on sacubitril/valsartan treatment at enrolment or started sacubitril/valsartan within 1month of enrolment (S/V group). We also generated a restricted analysis set (rS/V) including only those 2108 patients who started sacubitril/valsartan treatment within the month prior to or after enrolment. At the baseline, average age of patients enrolled in the study was 68years, and 23.9% (2099/8787) were female. At the baseline, the proportions of patients with New York Heart Association (NYHA) Class III symptoms were 30.9 (1288/4173), 42.8 (1974/4614), and 48.2% (1015/2108), in non-S/V, S/V, and rS/V groups, respectively. After 12months of treatment, the proportion of patients with NYHA Class III at baseline who improved to Class II was 32.0% (290/907) in the non-S/V group vs. 46.3% (648/1399) in S/V group and 48.7% (349/717) in rS/V group. The overall mortality rate was 5.0 per 100 patient-years. Rates of HF hospitalizations were high (20.9, 20.3, and 21.2 per 100 patient-years in the non-S/V, S/V, and rS/V groups, respectively). Emergency room visits without hospitalization occurred in 3.9, 3.2, and 3.9% of patients in the non-S/V, S/V, and rS/V groups, respectively. This large HFrEF European registry provides a contemporary outcome profile of outpatients with HFrEF treated with or without sacubitril/valsartan. In a real-world setting, sacubitril/valsartan was associated with an improvement of symptoms in patients with HFrEF compared with the conventional HFrEF treatment.

Myocardite à COVID-19 : « à propos d'une série monocentrique de 33 cas »

IntroductionThe world is experiencing a pandemic linked to the respiratory spread of SARS-CoV2 which can affect the heart with elevated troponins, ECG abnormalities and kinetic disturbances in echocardiography, of ischemic or non-ischemic origin (most often fulminant myocarditis). ObjectiveTo describe the evolutionary modalities of post-COVID-19 myocarditis and to identify factors of poor ejection fraction (EF) recovery under treatment of heart failure. MethodMonocentric observational study including patients with post-COVID-19 non-fulminant myocarditis confirmed by cardiac MRI. These patients were divided into 2 groups according to the evolution of their EF at 3 months (EF > 50% vs EF < 50%). Results33 patients (19♂/14♀) aged from 30 to 61 were included, all of whom had repolarization disorder; mean EF at baseline was 44.3% (30–52%) with a troponin level 480 times normal (20–2100). Conventional treatment for heart failure was initiated in all patients with clinical, electrical and echocardiographic monitoring at 1 and 3 months. A significant improvement (EF > 50%) was observed in 29 patients. Gender, congestive signs, electrical and angiographic abnormalities do not seem to influence the evolution of EF (P > 0.10). Age > 60 years, troponins > 1200 times normal, pericardial effusion and a combined criterion of the three seem to be associated with poor evolution of EF (P at 0.07, 0.02, 0.035 and 0.01 respectively). DiscussionNon-fulminant post-COVID-19 myocarditis have a good prognosis (EF recovery in 87.88%). Factors of poor recovery are age > 60 years, elevated troponins, appearance of pericardial effusion and the combined criterion of the three. ConclusionNon-fulminant post-COVID-19 myocarditis seems to have a favorable course. Patients presenting factors of poor evolution had to have a longer follow-up.

Heart Failure Associated with Rheumatoid Arthritis

Rheumatoid arthritis (RA) is a chronic inflammatory disease of the joints. Extra-articular features are very common. We report a case of RA first diagnosed after an episode of congestive heart failure (CHF) and the evolution of left ventricular function after conventional treatment of CHF and immunosuppressive drugs. The patient, a 52-year-old man, with history of epilepsy and a stroke 6 years before, presented to the emergency department with increasing dyspnea. He had polyarthralgia 2 months before. The lower extremities had mild pitting edema. The musculoskeletal examination revealed synovial thickening of the metacarpophalangeal and proximal interphalangeal&#x0D; joints, but there was no joint tenderness. The patient’s alanine aminotransferase, troponin levels and CRP were slightly elevated. His renal function was preserved. The electrocardiogram (EKG) was normal. An echocardiogram performed in showed a global hypokinetic dilated cardiomyopathy with an ejection fraction of 15–20%, with apical thrombus. The patient was diagnosed with exacerbation&#x0D; of congestive heart failure (CHF) and was treated with intravenous diuretics. This led to symptomatic improvement. He got a conventional heart failure treatment with vit K antagonists. Coronarography was normal. Viral serologies were negative. The martial, phosphocalcic and thyroid markers were normal. However, the immunologic tests showed positive rheumatoid factor and anti-CCP. The diagnosis of dilated cardiomyopathy due to rheumatoid arthritis was retained. The patient was treated by corticosteroids and immunosuppressive agents. Patient was seen during routine follow-up after 6 months. Interestingly, echocardiographic findings were totally normal with left ventricular ejection fraction &gt;50% and normal LV size.

Ischemic Stroke Revealing Infective Endocarditis in a Young Subject: About a Clinical Case

Introduction: Neurological complications are possible during infective endocarditis. They are often life-threatening and can be a source of sequelae. Case Presentation: We report the case of an 11-year-old patient admitted to the cardiology department of the CHU-ME “LUXEMBOURG” in Bamako for functional impotence of the left hemibody, accompanied by fever and NYHA stage II dyspnea. The clinical examination on admission shows the poor general condition, normal consciousness, and sensory-motor deficit of the pyramidal type of the left hemibody. The cardiovascular examination notes a systolic murmur at the mitral focus, hepato-jugular reflux, hepatomegaly, and slight edema in the lower limbs. Brain CT showed localized hypodensity in favor of an ischemic stroke. The electrocardiogram shows a sinus rhythm. Transthoracic Doppler echocardiography revealed mitral insufficiency with vegetation of 17 × 14 mm on the anterior mitral valve, with left ventricular ejection fraction estimated at 75%. Dual antibiotic therapy associated with conventional treatment for heart failure was initiated. The clinical evolution was marked by the persistence of the deficit of the left upper limb, the cardiac Doppler echography of control after 6 weeks of treatment found the same vegetation. A discussion with the heart team with a view to a surgical cure has been initiated for the rest of the treatment. Conclusion: A motor deficit associated with fever related to an ischemic vascular accident should lead to a search for infective endocarditis on cardiac Doppler ultrasound.

A Systematic Review of the Utility of Bromocriptine in Acute Peripartum Cardiomyopathy.

In formerly healthy females, acute heart failure (HF) of an unknown cause that develops during the last weeks of gestation or in the first months after childbirth is known as peripartum cardiomyopathy (PPCM). This study aimed to establish the therapeutic value of combining bromocriptine with conventional HF treatment on left ventricular ejection fraction (LVEF), death, thromboembolic events, left ventricular (LV) dysfunction recurrence in subsequent pregnancies in PPCM women, and newborn children's outcomes. We conducted a systematic review to find clinical studies that described the utility of bromocriptine in addition to conventional HF treatment compared to conventional HF treatment only in the management of acute PPCM. Four databases comprising records from July 10, 2001, to July 10, 2021, were analyzed, including PubMed (MEDLINE), Google Scholar, Scopus, and the Cochrane Library. We discovered 4,717 potentially eligible records across all the databases. According to our eligibility criteria, we included six studies consisting of 263 patients in this review. Bromocriptine combined with conventional HF therapy led to an 11.37% increase in LVEF (mean difference: 11.37; 95% confidence interval [CI]: 9.55-13.19; p-value = 0.001) after six months compared to conventional HF treatment only. Notably, bromocriptine combined with conventional HF treatment reduced mortality associated with PPCM, and no thromboembolism events were recorded in the 263 patients. PPCM is a severe condition affecting women globally. In this study, the combination of bromocriptine with conventional HF treatment enhanced the LVEF of women with acute PPCM and their clinical outcomes.

Clinical Value of Echocardiographic Parameters in Patients with Chronic Heart Failure

Chronic heart failure (CHF) is a major disease that affects the safety of human life. The traditional diagnosis method of chronic heart failure is mainly blood test. At the same time, the conventional treatment of heart failure is not only limited to improve the clinical symptoms of patients, but also can prevent the deterioration of chronic diseases. Systemic adjuvant treatment of heart failure also includes improving the quality of life and regulating the mood of patients. However, the traditional diagnostic methods of chronic heart failure have the disadvantages of incomplete and unreliable diagnostic parameters. Therefore, in view of this situation, this paper will carefully analyze and study the application of ultrasound diagnosis technology in the diagnosis of chronic heart failure, and compare the corresponding diagnostic parameters with conventional blood detection parameters, including ventricular septal thickness, ventricular septal thickness, ventricular septal thickness, end diastolic ventricular posterior wall thickness, ejection dispersion and maximum blood flow velocity. In the experimental part, 50 related patients in a hospital were diagnosed and compared. The experimental results show that the ultrasonic diagnosis technology can reflect the heart function of patients with heart failure more comprehensively and reliably.

Does the volume overload exaggerate the severity of mitral regurgitation in patients with decompensated heart failure?

Background/aimDiagnosing and managing functional mitral regurgitation (MR) is often challenging and requires an integrated approach including a comprehensive echocardiographic examination. However, the effects of volume overload on the echocardiographic assessment of MR severity are uncertain. The purpose of this study was to weigh the effects of volume overload in the echocardiographic assessment of MR severity among patients with heart failure (HF).Materials and methodsTwenty-nine patients with decompensated HF, who had moderate or severe MR, were included in the present study. The volume status and the N-terminal pro-B-type natriuretic peptide (proBNP) levels were recorded and the echocardiographic parameters were assessed. After the conventional treatment for HF, the proBNP levels and the echocardiographic parameters were assessed again.ResultsThe mean age of the patients was 72 ± 9 years and the average hospitalization time was 10.9 ± 5.9 days. Between the beginning and the end of the treatment, there were significant reductions in the effective regurgitant orifice area (EROA) (0.36 ± 0.09 cm2 to 0.29 ± 0.09 cm2, P < 0.001), vena contracta (VC) (P < 0.001), the regurgitant volume (RV) (P < 0.001), and systolic pulmonary artery pressure (sPAP) (P < 0.001). ConclusionThis is the first study to investigate the relationship of changes in severity of MR with volume-load by monitoring the proBNP levels among patients with HF. The present results demonstrated that volume reduction, as evidenced by a decline in the proBNP levels, was accompanied by a marked reduction in the EROA, VC, and the RV among patients with left ventricular dysfunction.

Effect of Short-Term L-Thyroxine Therapy on Left Ventricular Mechanics in Idiopathic Dilated Cardiomyopathy

Previous experimental studies have provided evidence of notable changes in thyroid hormone signaling that corresponds to alterations in myocardial function in animal models of heart failure (HF). The present study further explores whether oral thyroid hormone treatment can change left ventricular (LV) mechanics and functional status in patients with idiopathic dilated cardiomyopathy (IDCM) or not. Sixty IDCM patients who were receiving conventional HF treatment were randomized to oral L-thyroxine (n=40) or placebo (n=20) for 3months. Fifty-two (86.7%) of all IDCM patients were symptomatic, their mean age was 41±12years, and their ejection fraction was 32%±7%. At baseline, the two groups were comparable in clinical and echocardiographic variables. Vector velocity imaging was utilized to assess LV mechanics. Myocardial longitudinal peak systolic strain, systolic strain rate, early and late diastolic strain rate, circumferential strain, LV dyssynchrony, plasma tri-iodothyronine, thyroxine, and thyroid stimulating hormonelevels were measured at baseline and 3months after treatment. All patients receiving L-thyroxine significantly improved in functional status (New York Heart Association class; P<.001) and echocardiographic parameters including end-diastolic diameter (P<.001), end-systolic diameter (P<.001), mitral regurgitation severity reduction (P<.001), and increased ejection fraction (P<.001). Left ventricular mechanics showed marked improvement at segmental and global levels of both longitudinal and circumferential myocardial strain (P<.005) when compared with placebo group. Short-term L-thyroxine therapy is well tolerated in IDCM patients. It improves cardiac mechanics and functional status, which might support the potential role of synthetic thyroid hormones in HF treatment.

Reversible Toxic Myocarditis with Intraventricular Thrombus Associated with Aluminium Phosphide Poisoning Treated with Trimetazidine: A Case Report

Objectives: To report atypical aspects of cardiovascular manifestations related to phostoxin poisoning and to propose a therapeutic approach in the case of myocarditis induced by intoxication. Patient and method: We report the medical observation of an atypical case of a patient admitted to the medical intensive care unit then to cardiology department in university hospital Ibn Rochd of Casablanca for aluminum phosphide poisoning. Case report: A 30 -year-old man initially admitted to the emergency department resuscitation room and then to the cardiology department, presenting with ventricular dysfunction at 30% ejection fraction following myocarditis due to aluminum phosphide voluntary poisoning with left ventricular apical thrombus. Under treatment of heart failure, associated with the administration of trimetazidine and anticoagulation, the patient recovered to 50% of LVEF after fifteen days of treatment with thrombus dissolution. From a case reported in the literature on the impact of trimetazidine in the evolution of myocarditis in phostoxin intoxication, we discussed the particular effect of trimetazidine in the favorable evolution in our patient. Conclusion: No specific drug has been established as an antidote for the phostoxin poisoning, Hence treatment strategy is mainly supportive until the myocardial injury induced by the active metabolite (phosphine) subsides. Our use of Trimetazidine for this patient with encouraging results needs further validation by others, as it may be a useful adjunct to aggressive supportive care when needed alongside with other conventional treatments for heart failure.

New treatment strategy for severe heart failure: combination of ventricular assist device and regenerative therapy.

Heart transplantation and ventricular assist device for the patients with end-stage heart failure are limited by availability and durability due to limited donor or device-related complication. Thus, complementation or a new alternative is needed for the treatment of severe heart failure. Based on the results of basic experiments, we applied skeletal myoblast cell sheet transplantation in a clinical setting using cell-sheet methods with temperature-responsive dish for the treatment of heart failure patient from 2007. After confirming the safety of this treatment, we started a clinical trial of myoblast cell sheet transplantation as sole therapy. According to these results, in 2015, myoblast cell sheet transplantation with ischemic cardiomyopathy was approved by the Japanese government and now this treatment was covered by Japanese health insurance. Here we report our approach and future perspective of cardiac regenerative therapy using this new treatment method for severe heart failure including new strategy incorporating regenerative therapy in the conventional treatment of heart failure including VAD and heart transplantation.

Physical activity and exercise training in heart failure with preserved ejection fraction: gathering evidence from clinical and pre-clinical studies.

Conventional treatments for heart failure have failed to improve survival in heart failure with preserved ejection fraction (HFpEF). The current therapy recommendations highlight the importance of symptom management and improvement of patient's well-being or other health-related outcomes. Physical activity/exercise training might be an adjuvant treatment option, since several studies in HFpEF patients reported beneficial effects on exercise intolerance, which is the main symptom associated with this disease. In addition, exercise training was shown to improve quality of life and, in some studies, to improve cardiac function. However, the mechanisms behind these effects are not completely known. The objective of this narrative review is to summarize the main clinical findings regarding the role of physical activity/exercise training in several outcomes, such as hospitalization and mortality, exercise capacity, quality of life, and cardiac function and remodeling. In addition, we will briefly discuss the findings provided by pre-clinical studies. In conclusion, while the impact of physical activity/exercise training on exercise intolerance and quality of life is already well known, its effect on mortality and hospitalization is not well documented, and whether it benefits diastolic function needs further investigation. Some clinical studies showed that exercise training can improve diastolic function, and evidences from pre-clinical studies suggest that this effect is mediated through reduced myocardial stiffness.

Chinese Herbal Medicines and Conventional Chronic Heart Failure Treatment for the Management of Chronic Heart Failure Complicated with Depression: A Systematic Review and Meta-Analysis.

Background Combination therapy with Chinese herbal medicines (CHMs) and conventional medical treatment (CMT) was proposed as a therapeutic strategy for chronic heart failure (CHF) patients complicated with depression. Therefore, we performed a systematic review and meta-analysis of randomized controlled trials (RCTs) to assess effects of this combination therapy on CHF complicated with depression. Methods RCTs comparing the combination of CHMs and CMT to CMT were retrieved in seven electrical databases till March 30, 2019. The effective rate of cardiac function and Hamilton depression scale (HAMD) were marked as the primary outcomes. Left ventricular ejection fraction (LVEF) and Minnesota Living with Heart Failure Questionnaire (MLHFQ) were marked as the secondary outcomes. The methodological quality of eligible RCTs used the Cochrane bias risk assessment tool. Stata 13.0 and Review Manager 5.3 were preferred for synthesizing the results if the results were appropriate. Results Thirteen RCTs enrolling 1022 subjects met the inclusion criteria. The majority of the retrieved RCTs were evaluated to be of low methodological quality. The pooled results of the meta-analysis showed that CHMs plus CMT group created better outcomes compared to CMT alone therapy, as evidenced by the fact that the overall effects of combination therapy strategy were significantly greater than the control group in increasing effective rate of cardiac function (risk ratio (RR) = 1.28; 95% CI: 1.16 to 1.42), in improving depressive symptoms (HAMD) (standard mean difference (SMD) = −1.31; 95% CI: −1.68 to −0.95) and quality of life (MLHFQ) (weighted mean difference (WMD) = −8.42; 95% CI: −10.08 to −6.76), in increasing LVEF scores (WMD = 5.33; 95% CI: 4.30 to 6.35). Conclusion The combination of CHMs and CMT increased the effective rate of cardiac function and LVEF scores and reduced HAMD and MLHFQ scale scores, which was a potential therapeutic strategy that improved the management of CHF patients complicated with depression. Future trials were needed to verify the above results since abnormal heterogeneity and poor quality of literature have existed in the included studies.

Peritoneal Ultrafiltration for Heart Failure: Lessons from a Randomized Controlled Trial.

Peritoneal ultrafiltration (PuF) has been employed for severe heart failure (HF), but evidence for its benefit is lacking. The Peritoneal Dialysis for Heart Failure (PDHF) study was a multicenter prospective randomized controlled trial which aimed to investigate this issue. The trial stopped early due to inadequate recruitment. We describe methods, trial activity, and lessons learned.The trial aimed to recruit 130 participants with severe diuretic-resistant HF (New York Heart Association [NYHA] 3/4) and chronic kidney disease (CKD) stage 3/4 on optimal medical treatment for ≥ 4 weeks from 6 UK centers. Participants were randomized to either continuation of conventional HF treatment or to additionally receiving PuF (1 overnight exchange using Icodextrin dialysate). Primary outcome was change in 6-minute walk test (6MWT) between baseline and 28 weeks (end of trial). Secondary outcomes were changes in patient reported quality of life as assessed by the Kansas City Cardiomyopathy Questionnaire, short form 36 (SF 36) health survey results, hospitalization, and mortality.Over a 2-year period, 290 patients were screened from which only 20 met inclusion criteria and 10 were recruited. Reasons for ineligibility were fluctuating estimated glomerular filtration rate (eGFR), suboptimal HF treatment, frailty, and patients being too unwell for randomization. Barriers to recruitment included patient frailty, with some participants considered only when they were at end of life, unwillingness to engage in an invasive therapy, and suboptimal coordination between cardiology and renal services. This is a challenging patient group in which to perform research, and lessons learned from the peritoneal dialysis (PD)-HF trial will be helpful in the planning of future studies in this area.

Yixinshu capsule combined with conventional treatment for chronic heart failure: Protocol for a systematic review and trial sequential analysis.

Background:Yixinshu Capsule is widely utilized in Asia for the treatment of chronic heart failure (CHF) as a conventional drug, but a comprehensive conclusion is lacking. Here, we will provide a protocol to perform a meta-analysis and trial sequential analysis to evaluate the efficacy of Yixinshu Capsule combined with conventional treatment for chronic heart failure.Methods:We will conduct a thorough search in six databases, PubMed, EMBASE, Cochrane Library Database, Chinese National Knowledge Infrastructure (CNKI), Chinese Science Journal Database (VIP), and Chinese Biomedical and Medical Database (CBM). Inclusion criteria will be randomized control trials (RCTs) with one group receiving Yixinshu Capsule based on conventional treatment and another group receiving conventional treatment alone. Modified Jadad scale and Cochrane's risk of bias assessment will be used to assess methodological quality. Only studies with modified Jadad scale score ≥3 will be included in meta-analysis for efficacy, which will be defined as moderate methodological quality. The total effective rate will be considered as the primary outcome and the secondary outcome will include mortality, rehospitalized rate, left ventricular ejection fraction (LVEF), 6-minute walking distance, E/A, left ventricular end-diastolic diameter (LVEDD), BNP, and NT-proBNP. We will conduct trial sequential analysis to evaluate the reliability of the primary outcome.Results:This study will provide a rational synthesis of current evidences for Yixinshu Capsule on chronic heart failure.Conclusion:The conclusion of this study will provide evidence for judging the efficacy of Yixinshu Capsule on chronic heart failure.Registration:PROS-PERO CRD42019119612.

Improvement of the outcome in patients with infantile dilated cardiomyopathy over three decades – The usefulness of long-term gradually medical supportive care

BackgroundThe treatment of heart failure has changed with the use of angiotensin-converting enzyme inhibitors (ACEIs) and beta-blockers since the middle of the 1990s. However, the outcome in infantile dilated cardiomyopathy (DCM) when treated with them remains poorly understood. MethodsWe reviewed the medical records of infants with DCM within 24 months old in our hospital between 1979 and 2012, and compared the outcome in the later group (1997–2012) with that in the early group (1979–1996). The survival and cardiac event (CE)-free survival rates were calculated by the Kaplan–Meier method. ResultsThere were 20 patients in the early group and 24 patients in the later group. The median left ventricular fractional shortening at the onset of disease in the early and later groups were 11% (range 4–17%) and 12% (range 4–25%), respectively. In the later group, ACEIs and beta-blockers were administered in 22 and 21 patients, respectively. An usual low-dose induction of carvedilol therapy (0.01–0.02mg/kg/day) sometimes worsened the heart failure in 9 patients (43%) after the successful initial conventional treatment for acute heart failure. Nineteen patients died and 25 survived. The CEs were as follows: heart transplantation 4, mitral valvuloplasty 1, Batista operation with mitral valve replacement 1, and cardiac resynchronization therapy in the late period 1. The 20-year survival rate in the early and later groups were 5% (95% CI 0.7–28) and 100%, respectively (p<0.001). The 2-year CE-free survival rate in the early and later groups were 5% (95% CI 0.7–28) and 83% (95% CI 59–91), respectively (p<0.001). ConclusionsThe outcome in patients with infantile DCM has significantly improved with careful acute and chronic treatments using ACEIs and beta-blockers since the 2000s. Adopting a long-term supportive treatment during a period of low ventricular function and the use of beta-blockers corresponding to each patient's condition were key to survival.

Oktojenaryen Bir Hastada Apiksaban Tedavisi Altında Gelişen Hemorajik Plevral Efüzyonun Yönetimi

After verification of the relevant trial data with real-world registries, it is now a widely accepted fact that Non-Vitamin K oral anticoagulants (NOACs) offer at least equal efficacy about stroke risk reduction with less bleeding events in comparison to Vitamin K antagonists. Spontaneous serous bleeding (pericardial or pleural) is a quite rare complication of NOAC treatment which had just been previously reported in a few cases with dabigatran, rivaroxaban, and apixaban. Here we present a 72-year-old patient receiving apixaban, who was diagnosed to have a massive right pleural hemorrhagic effusion during conventional heart failure treatment. Effusion was drained immediately. Reversal of anticoagulation or blood transfusion was not required.