Doses Of Beta-blockers Research Articles

Guideline-directed medical therapy is similarly effective in heart failure with mildly reduced ejection fraction

AimsCurrent guidelines recommend that disease-modifying pharmacological therapies may be considered for patients who have heart failure with mildly reduced ejection fraction (HFmrEF). We aimed to describe the characteristics, outcomes, provision of pharmacological therapies and dose-related associations with mortality risk in HFmrEF.Methods and resultsWe explored data from two prospective observational studies, which permitted the examination of the effects of pharmacological therapies across a broad spectrum of left ventricular ejection fraction (LVEF). The combined dataset consisted of 2388 unique patients, with a mean age of 73.7 ± 13.2 years of whom 1525 (63.9%) were male. LVEF ranged from 5 to 71% (mean 37.2 ± 12.8%) and 1504 (63.0%) were categorised as having reduced ejection fraction (HFrEF), 421 (17.6%) as HFmrEF and 463 (19.4%) as preserved ejection fraction (HFpEF). Patients with HFmrEF more closely resembled HFrEF than HFpEF. Adjusted all-cause mortality risk was lower in HFmrEF (hazard ratio [HR] 0.86 (95% confidence interval [CI] 0.74–0.99); p = 0.040) and in HFpEF (HR 0.61 (95% CI 0.52–0.71); p < 0.001) compared to HFrEF. Adjusted all-cause mortality risk was lower in patients with HFrEF and HFmrEF who received the highest doses of beta-blockers or renin-angiotensin inhibitors. These associations were not evident in HFpEF. Once adjusted for relevant confounders, each mg equivalent of bisoprolol (HR 0.95 [95% CI 0.91–1.00]; p = 0.047) and ramipril (HR 0.95 [95%CI 0.90–1.00]; p = 0.044) was associated with incremental reductions in mortality risk in patients with HFmrEF.ConclusionsPharmacological therapies were associated with lower mortality risk in HFmrEF, supporting guideline recommendations which extend the indications of these agents to all patients with LVEF < 50%.Graphic abstractHFmrEF more closely resembles HFrEF in terms of clinical characteristics and outcomes. Pharmacological therapies are associated with lower mortality risk in HFmrEF and HFrEF, but not in HFpEF.

Nurse and general practioner-led up-titration strategy: a real world experience in a heart failure unit in colombia

Abstract Funding Acknowledgements Type of funding sources: None. Background Despite improvement of heart failure (HF) prescription rates, doses prescribed in clinical practice are lower than those achieved in randomized clinical trials. Nurse-led up-titration strategy has been widely used in Europe with promising results. Nevertheless, there is no evidence of this approach in Latin America. Methods A prospective cohort study was conducted in 50 patients with reduced ejection fraction to evaluate efficacy and safety of nurse and general practioner(GP)-led up-titration protocol, based on problem solving from the European Society of Cardiology HF guidelines. Patients were admitted in our HF unit from January 2017 to December 2019. After discharge our clinical pathway provides 3 types of visits : Cardiologist visits, educational visits and titration visits with GP and registered nurse. Along intervention the registered nurse lead flexible diuretic titration and structured phone monitoring calls. Results Baseline characteristics are showed in Table 1. Mean age was 72.5 years, 50% of patients were women, 66% had ischemic cardiomiopathy, mean N-terminal pro-B-type natiuretic peptide was 3285pg/dl, and 58% of patients were NYHA class III. At 97 days with an average of 4 up-titration visits disease-modifying drugs titration was completed. At the beginning 98% of patients had Beta Blockers (BB) , 98% had Mineralocorticoid Receptor Antagonist (MRA), and all of them had Angiotensin Converting Enzyme Inhibitors, angiotensin receptor blockers or Angiotensin Receptor Neprilysin Inhibitor (ARNI). According to the guidelines Angiotensin Converting Enzyme Inhibitors and angiotensin receptor blockers were replaced by ARNI in symptomatic patients. At the end of titration, BB target dose was achieved for 44% of patients, intermediate dose for 46% and final low dose for only 10% of patients. Ivabradine was added for 22% of patients. MRA intermediate and high doses were achieved for 82,5% of patients. Target dose of ARNI was achieved for 62% of patients, intermediate dose for 22% and only 20% of patients remained in starting dose. On average ARNI target dose was completed at 56 days. According to our protocol three patients stopped MRA due to hyperkalemia and symptomatic hypotension was the main cause for stopping up-titration. There was a relationship between patient´s caregiver and higher doses of ARNI( p=0.624) and BB (p=0.421). Conclusion A nurse and GP directed up-titration protocol is an encouraging strategy in HF units to achieve the recommended doses of disease-modifying drugs according to the guidelines.

The challenges of ascites management: An Indian perspective.

Content available: Author Interview and Audio Recording.

Physicians' adherence to the guidelines on the chronic heart failure diagnosis and treatment

Aim To evaluate the physician's knowledge of basic provisions of clinical guidelines for diagnosis and treatment of chronic heart failure (CHF) and to determine how the actions of physicians in their everyday clinical practice comply with these provisions.Materials and methods The study analyzed anonymous questionnaires of 185 physicians (127 cardiologists, 40 internists and general practitioners, 18 other specialists) who were trained in advanced training programs during the 2020/2021 academic year. The main part of the questionnaire included 15 questions related to the classification, diagnosis, pharmacotherapy, and the use of implantable devices in the treatment of patients with CHF.Results The results showed that internists were less than cardiologists aware of major provisions of clinical guidelines for diagnosis and treatment of CHF. However, the knowledge of cardiologists could not be considered sufficient either. 57.5% of internists and 30% of cardiologists incorrectly indicated the main echocardiographic criterion for diagnosis of CHF with reduced left ventricular ejection fraction (CHFrEF). More than 40% of internists did not consider fluid retention with development of the congestion syndrome as a mandatory condition for administration of a loop diuretic to a patient with CHFrEF. 34.6% of cardiologists and 25% of internists correctly determined the indication for the administration of mineralocorticoid receptor antagonists. 37.6% of internists and 21.1% of cardiologists incorrectly indicated the dose of spironolactone recommended for achieving the neuromodulation effect. In determining doses of angiotensin-converting enzyme (ACE) inhibitors and beta-blockers, after arriving at which it is necessary to stop their up-titration, most of the physicians preferred to be based on systolic blood pressure (SBP) rather than on symptoms of hypotension. However, among therapists there were doctors for whom the patient's well-being and clinical symptoms, and not the level of SBP, were priority factors for choosing the tactics of the treatment with ACE inhibitors and beta-blockers. Physicians of both specialties were poorly familiar with indications for cardioverter defibrillator implantation; only 14.2% of cardiologists and 5% of internists chose the correct wording of indications.Conclusion The insufficient knowledge should be considered the basis for the low adherence of doctors to guidelines for diagnosis and treatment of CHF. When developing programs for advanced training of physicians in CHF, special attention should be paid to the use of renin-angiotensin-aldosterone system inhibitors and beta-blockers with detailed discussion of the dosing principles as well as of indications for implantation and results of using cardioverter defibrillators.

Incidental arrhythmias during atrial fibrillation screening in a hospital-based patient population

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Screening for atrial fibrillation may reveal other, incidental arrhythmias of relevance. We sought to describe such incidental arrhythmias in the prospective STARFIB cohort study, which screened for silent atrial fibrillation in hospitalized patients aged 65-84 years. Method Patients included in the STARFIB cohort study had up to three 7-day Holter ECGs, performed in two-month intervals. We analysed all the 7-day Holter ECGs of study participants for the presence of one of the following incidental arrhythmias: 1) sick-sinus-syndrome (SSS), defined as sinus arrest of ≥3 seconds duration; 2) second or higher degree atrioventricular block (AVB); 3) sustained atrial tachycardia of ≥30 seconds duration (AT); and 4) sustained ventricular tachycardia of ≥30 seconds duration (VT). Results A total of 2’077 Holter ECGs were performed in 794 patients (mean age 74.7 years; 49% females), resulting in a mean cumulative duration of an analyzable ECG signal of 414±136 hours per patient. We found incidental arrhythmias in 94 patients (11.8%). Among these were SSS in 14 patients (1.8%), AVB in 41 (5.2%), AT in 41 (5.2%), and VT in two (0.3%). The median pause duration in SSS was 4 seconds and SSS resulted in pacemaker implantation in one patient with a pause of 9 seconds duration. The most severe type of AVB found per patient was second degree AVB type Wenkebach in 23 patients (2.9%), second degree AVB type Mobitz or 2:1 AV conduction in 10 patients (1.3%) and complete AVB in 8 (1%; maximum pause 18 seconds). AVB led to pacemaker implantation in 9 patients (1.1%). The median duration and heart rate of AT was 2.2 minutes and 144 bpm, respectively. Initiation of betablocker therapy was recommended in 3 patients (0.4%) due to symptomatic AT. The duration and heart rate of VT was 3 minutes at 216 bpm in one patient and 38 seconds at 150 bpm in another. The former patient with VT experienced syncope and an ICD was implanted, whereas in the latter the betablocker dose was increased. One patient died from a non-cardiac cause during a Holter ECG, which showed progressive bradycardia and finally asystole. Conclusion Incidental arrhythmias were frequently discovered during screening for atrial fibrillation and resulted in device therapy in 1.4% of our cohort patients.

Factors associated with excess female mortality in obstructive hypertrophic cardiomyopathy.

Several studies have reported excess female mortality in patients with hypertrophic cardiomyopathy, but the cause is unknown. To compare risk-factors for disease-related death in both sexes in a geographical cohort of patients with obstructive hypertrophic cardiomyopathy (oHCM). Data-bases in all ten hospitals within West Götaland Region yielded 250 oHCM-patients (123 females, 127 males). Mean follow-up was 18.1 y. Risk-factors for disease-related death were evaluated by Cox-hazard regression and Kaplan-Meier survival-curves, with sex-comparisons of distribution of risk-factors and therapy in total and age-matched (n = 166) groups. At diagnosis females were older, median 62 y vs. 51 y, (P < 0.001), but not different in outflow-gradients and median NYHA-class. However, septal hypertrophy was more advanced: 10.6 [IQR = 3.2] vs. 9.6 [2.5] mm/m2 BSA; P = 0.002. Females had higher disease-related mortality than males (P = <0.001), with annual mortality 2.9% vs. 1.5% in age-matched groups (P = 0.010 log-rank). For each risk-category identified (NYHA-class ≥ III, outflow-gradient ≥50 mmHg), a higher proportion of females died (P = 0.0004; P = 0.001). Calcium-blocker therapy was a risk-factor (P = 0.005) and was used more frequently in females (P = 0.034). A beta-blocker dose above cohort-median reduced risk for disease-related death in both males (HR = 0.32; P = 0.0040) and in females (HR = 0.49; P = 0.020). Excess female deaths occurred in chronic heart-failure (P = 0.001) and acute myocardial infarctions (P = 0.015). Fewer females received beta-blocker therapy after diagnosis (64% vs. 78%, P = 0.018), in a smaller dose (P = 0.007), and less frequently combined with disopyramide (7% vs. 16%, P = 0.048). Addressing sex-disparities in the timing of diagnosis and pharmacological therapy has the potential to improve the care of females with oHCM.

Application of a risk-guided strategy to secondary prevention of coronary heart disease: analysis from a state-wide data linkage in Queensland, Australia

ObjectiveThis study sought whether higher risk patients with coronary heart disease (CHD) benefit more from intensive disease management.DesignLongitudinal cohort study.SettingState-wide public hospitals (Queensland, Australia).ParticipantsThis longitudinal study included 20 426 patients...

Maternal beta‐blocker dose and risk of small‐for gestational‐age in women with heart disease

Beta-blockers are prescribed for many pregnant women with heart disease, but whether there is a dose-dependent effect on fetal growth remains to be examined. We aimed to investigate if antenatal beta-blocker use and dose were associated with delivering a small-for-gestational-age infant among women with heart disease. Our cohort included women with heart disease who delivered at Oslo University Hospital between 2006 and 2015. Maternal heart disease was classified into modified WHO risk scores. Women with beta-blocker treatment were dichotomized into whether they had been treated with a low or high dose based on clinical factors. We compared the risk of delivering a small-for-gestational-age infant in women exposed to high doses, low doses, or with no exposure to antenatal beta-blockers while adjusting for severity of maternal heart disease in logistic regression models. Of a total of 540 pregnancies among women with heart disease, 163 (30.2%) were exposed to beta-blocker treatment. The majority were treated with metoprolol (86.5%). Almost twice as many babies in the beta-blocker group were small-for-gestational-age, compared with the non-exposed group (19.8 vs 9.5%, P < 0.001). Women using a high-dose beta-blocker had a five-fold increased risk of delivering a small-for-gestational-age infant compared with non-exposure (adjusted odds ratio [aOR] 4.89, 95% confidence interval [CI] 2.22-10.78, P < 0.001). Women using a low dose of beta-blocker had a two-fold increased risk of delivering a small-for-gestational-age infant; however, the confidence interval included the null (aOR 1.75, 95% CI 0.83-3.72, P=0.143). Results when restricting the analyses to metoprolol showed the same pattern, but with attenuation of risks. We found a five-fold increased risk of delivering a small-for-gestational-age infant in women with heart disease treated with a high dose of beta-blocker, and a two-fold increased risk among those treated with a low dose, showing an apparent dose-response relation. Close monitoring of fetal growth is warranted among women with heart disease treated with beta-blockers. As drug therapy in pregnancy concerns both mother and fetus, an optimum balance for both should be the goal.

Dose Response Relationship of RAS Blockers and Beta-Blockers in Patients with Acute Heart Failure Syndrome: A Nationwide Prospective Cohort Study, on Behalf of KorAHF Investigators

<h3>Purpose</h3> It remains unclear if patients with acute heart failure syndrome (AHFS) need to reach the maximally tolerated doses of renin-angiotensin system blockers (RASBs) or beta-blockers (BBs) to obtain a survival benefit. This study evaluated the dose-response relationship between RASBs or BBs and survival in AHFS patients. <h3>Methods</h3> In total, 5,331 patients in the Korean Acute Heart Failure registry were analyzed based on the doses of RASBs and BBs at discharge. Also, an additional analysis of 4,613 patients with dosage information at the first post-discharge follow-up visit was done. Survival curves were constructed using the Kaplan-Meier method and compared using the log-rank test, and independent predictors of mortality were identified with the multivariable Cox proportional hazards model. <h3>Results</h3> In patients hospitalized with AHFS, RASB use at discharge was associated with a significant reduction in the risk of all-cause mortality. This effect was dose dependent for heart failure with reduced ejection fraction (HFrEF) but did not attain statistical significance for heart failure with preserved ejection fraction (HFpEF). BB use at discharge was associated with a reduction in all-cause mortality in HFrEF but not for HFpEF patients, although this was not dose dependent. At the first post-discharge follow-up visit, a significantly higher risk of all-cause mortality was associated with the maintenance or withdrawal of RASBs compared to up-titration of dose in HFrEF patients. <h3>Conclusion</h3> Using RASBs or BBs at discharge was associated with improved survival. A dose-response relationship between RASB and all-cause mortality was evident in AHFS patients with a reduced ejection fraction but not BBs. It is important to initiate and up-titrate RASBs to the maximally tolerated dose in AHFS patients during the transition period, especially for patients with a reduced ejection fraction.

The Association Of Resting Heart Rate With Beta Blocker Uptitration In Patients With Heart Failure And Reduced Ejection Fraction: A Single Center Experience From The Middle East

<h3>Introduction</h3> Beta-blocker (BB) therapy is an essential component of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF). Use of guideline specified target dose or the maximum tolerable BB dose is associated with beneficial effects that might extend beyond those related to heart rate (HR) reduction and is, therefore, strongly recommended. We aim to explore BB utilization patterns, predictors of BB dose uptitration, and its association with resting HR in a newly established heart failure program in the Middle East. <h3>Methods</h3> HFrEF patients seen in our outpatient clinic and treated with a BB (n=152) were identified using retrospective chart review. Data on patient characteristics and medication use at baseline and 12-month follow-up were collected and compared between patients who did and those who did not achieve BB target dose using appropriate tests. Predictors of receiving guideline-specified target dose of BB were determined using multivariable logistic regression. <h3>Results</h3> A total of 152 HFrEF patients received a BB at 12-month follow-up, most commonly with bisoprolol (63.1%), followed by carvedilol (24.3%) and metoprolol (12.5%). More patients achieved BB target dose from baseline to follow-up (32% to 54.6%, p<0.01). However, proportion of patients achieving resting HR<70 bpm did not change significantly over time (35.5% vs. 34.9%, p=0.9). Patients receiving BB target dose at follow-up (n=83) were younger and more likely to be diabetic (Table 1). Age, baseline systolic blood pressure, and diabetes mellites were independent predictors of achieving BB target dose at follow-up, but baseline resting HR was not (Table 2). In addition, being treated with an ACEI, ARB, or ARNI at baseline was associated with more likelihood of achieving BB target dose at 1-year follow-up. <h3>Conclusion</h3> In our young program, nearly half of HFrEF patients did not achieve BB target dose over a year of follow-up, with the majority of them having inadequately controlled resting HR. Identifying other patient-related factors that prevent escalation of GDMT may help efforts to achieve recommended target doses.

Multimorbidity And Guideline-Directed Medical Therapy Intensification In Heart Failure: Findings From The EPIC-HF Trial

<h3>Background</h3> Despite proven benefits of guideline directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), multiple studies have shown that rates of GDMT prescribing are suboptimal worldwide. An important potential contributor to suboptimal GDMT is the high burden of multimorbidity in the HFrEF population, with estimates showing at least 50% of patients having 5+ co-occurring chronic conditions and taking 10+ medications daily. Large registries examining GDMT prescribing demonstrate associations between individual co-morbidities and GDMT, but data is lacking on the cumulative effect of multimorbidity on GDMT prescription. <h3>Methods</h3> The recently completed 3-site EPIC-HF trial tested the effect of a pre-clinic patient activation tool on GDMT prescribing made following a visit with a cardiology provider and then over the subsequent 6 months. Using this data, we examined the effect of multimorbidity on both baseline GDMT prescription and GDMT initiation and dose intensification (the primary outcome of the EPIC-HF trial). Presence of the following 9 co-morbidities was collected: COPD or other pulmonary disease, liver disease, diabetes, cancer (excluding non-melanoma skin cancer), depression, anxiety or other psychiatric disease, atrial fibrillation or flutter, hypertension, CKD (eGFR <= 60), and obesity (BMI>=30). <h3>Results</h3> Of the 292 patients, 35.6% had 3 or more non-HFrEF comorbidities and 34.6% had 1 or fewer additional comorbidities. The most commonly occurring comorbidities were hypertension (51.7%), obesity (41.4%), CKD (32.9%), diabetes (25%) and atrial fibrillation or flutter (28.1%). Increasing burden of multimorbidity was not associated with less total prescription of GDMT at baseline, and was, in fact, associated with the prescription of higher doses of beta-blocker (median 50% target dose with 3+ additional comorbidities vs 25% with no comorbidities, p=<0.01). When controlling for study arm in the original EPIC-HF trial, the presence of additional comorbidities was associated with decreased likelihood of GDMT intensification (1 comorbidity v. 0: RR 0.61, 95% CI 0.4-0.95; 2 v. 0: RR 0.88 95% CI 0.61-1.27; 3+ v. 0: RR 0.56, 95% CI 0.36-0.86). Individual comorbidities associated with decreased likelihood of GDMT intensification were diabetes (p=0.02), hypertension (p=0.003), and CKD (p=0.047). <h3>Conclusions</h3> Increasing burden of multimorbidity was not associated with less total GDMT prescription at baseline but was associated with decreased up-titration or initiation of GDMT at the study visit.

The Impact Of Race And Ethnicity On Clinical Outcomes In Patients With Heart Failure(On Behalf Of The Guide-IT Steering Committee)

Introduction Black and Hispanic patients (pts) with heart failure (HF) are under-represented in clinical trials. Thus, it has been challenging to understand the impact of race and/or ethnicity on clinical outcomes and responsiveness to treatment in pts with HF. Hypothesis The data in the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker-Intensified Treatment in HF) trial was used to explore racial and ethnic differences in clinical outcomes. Pts were included who were event-free at 90 days and had data on attainment of guideline-directed triple therapy (GDMT, defined as greater than 50% target dose of beta-blocker, ACEI or ARB, and any MRA dose) or target NT-proBNP ≤ 1000 pg/mL. We postulated that Black pts would have worse clinical outcomes than non-Black pts, and that Hispanic pts would have worse outcomes than non-Hispanic pts. Methods Cox proportional hazards models were used to estimate the impact of race and ethnicity on mortality and HF hospitalization. These models accounted for 3-month achievement of GDMT or target NT-proBNP, as well as previously identified prognostic characteristics. Results Of the 733 patients included, 35% were Black and 6% were Hispanic. Black pts were younger, had more co-morbidities, lower EF, and higher NYHA class vs. non-Black pts. After accounting for GDMT attainment, Black pts were at a higher risk than non-Black pts for HF hospitalization (HR=1.97, 95% CI = 1.41-2.77, p < 0.0001), but not mortality (HR = 0.70, 95% CI = 0.39-1.26, p = 0.23) (Figures 1A-1B). Hispanic pts trended towards a higher risk than non-Hispanic pts for HF hospitalization (HR=1.83, 95% CI = 0.82-4.08, p = 0.14), but not for death (HR = 0.61, 95% CI = 0.18-2.09, p = 0.43) (Figures 1C-1D). Similar patterns were observed when accounting for target NT-proBNP. Estimated effects on mortality were limited by the low mortality rate (14%). Conclusion After adjusting for GDMT or target NT-proBNP attainment, as well as prognostic characteristics, Black HF pts had a higher risk of HF hospitalization than non-Black pts. There was also a trend for higher HF hospitalization risk for Hispanic pts compared to non-Hispanic pts . Mortality results were indeterminate, but point estimates did not support an excess mortality risk for Black or Hispanic pts. Black and Hispanic patients (pts) with heart failure (HF) are under-represented in clinical trials. Thus, it has been challenging to understand the impact of race and/or ethnicity on clinical outcomes and responsiveness to treatment in pts with HF. The data in the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker-Intensified Treatment in HF) trial was used to explore racial and ethnic differences in clinical outcomes. Pts were included who were event-free at 90 days and had data on attainment of guideline-directed triple therapy (GDMT, defined as greater than 50% target dose of beta-blocker, ACEI or ARB, and any MRA dose) or target NT-proBNP ≤ 1000 pg/mL. We postulated that Black pts would have worse clinical outcomes than non-Black pts, and that Hispanic pts would have worse outcomes than non-Hispanic pts. Cox proportional hazards models were used to estimate the impact of race and ethnicity on mortality and HF hospitalization. These models accounted for 3-month achievement of GDMT or target NT-proBNP, as well as previously identified prognostic characteristics. Of the 733 patients included, 35% were Black and 6% were Hispanic. Black pts were younger, had more co-morbidities, lower EF, and higher NYHA class vs. non-Black pts. After accounting for GDMT attainment, Black pts were at a higher risk than non-Black pts for HF hospitalization (HR=1.97, 95% CI = 1.41-2.77, p < 0.0001), but not mortality (HR = 0.70, 95% CI = 0.39-1.26, p = 0.23) (Figures 1A-1B). Hispanic pts trended towards a higher risk than non-Hispanic pts for HF hospitalization (HR=1.83, 95% CI = 0.82-4.08, p = 0.14), but not for death (HR = 0.61, 95% CI = 0.18-2.09, p = 0.43) (Figures 1C-1D). Similar patterns were observed when accounting for target NT-proBNP. Estimated effects on mortality were limited by the low mortality rate (14%). After adjusting for GDMT or target NT-proBNP attainment, as well as prognostic characteristics, Black HF pts had a higher risk of HF hospitalization than non-Black pts. There was also a trend for higher HF hospitalization risk for Hispanic pts compared to non-Hispanic pts . Mortality results were indeterminate, but point estimates did not support an excess mortality risk for Black or Hispanic pts.

Effectiveness of Beta Blockers against Hypertrophic Cardiomyopathy

Aim: To evaluate the effectiveness of beta blockers against hypertrophic cardiomyopathy. Study design: Retrospective study Place and duration of study: Department of Medicine, Islam Medical College, Sialkot from 01-10-2020 30-01-09-2021. Methodology: One hundred and thirty six confirmed hypertrophic cardiomyopathy cases within the age of 3-75 years were enrolled. Different types of beta blocker used and its efficacy result and side effects were documented. The average efficacy was assessed for each beta blocker uptil 5 years’ survival rate. Results: High doses of beta blocker were indicated for hypertrophic cardiomyopathy patients in majority of the cases. The efficacy of various beta blockers shows that cardio-selective blocker is much better in efficacy. Left ventricle outflow tract (LVOT) with a value greater or equal to 50 mmHg was observed in patients at or greater than 70 years. Conclusion: Beta blockers are effective in hypertrophy cardiomyopathy cases depending upon the left ventricle out flow tract for better outcome. Key words: Beta blockers, Cardiomyopathy, Efficacy, Therapeutic interventions

Diferencias de género en la titulación de fármacos de pacientes con insuficiencia cardiaca y fracción de eyección reducida del ensayo ETIFIC

Introduction and objectivesOptimal medical therapy decreases mortality and heart failure (HF) hospitalizations in HF patients with reduced left ventricular ejection fraction. Women have been underrepresented in clinical trials and not specifically evaluated. This study aimed to compare the safety and effectiveness of drug titration in women vs men. MethodsThis post hoc gender study of the ETIFIC multicenter randomized trial included hospitalized patients with new-onset HF with reduced ejection fraction and New York Heart Association II-III and no contraindications to beta-blockers. A structured 4-month titration process was implemented in HF clinics. The primary endpoint was the mean relative dose (% of target dose) of beta-blockers achieved by women vs men. Secondary endpoints included the mean relative doses of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, and mineralocorticoid receptor antagonists, adverse events, and other clinical outcomes at 6 months. ResultsA total of 320 patients were included, 83 (25.93%) women and 237 (74.06%) men (76 vs 213 analyzed). The mean±standard deviation of the relative doses achieved by women vs men were as follows: beta-blockers 62.08%±30.72% vs 64.4%±32.77%, with a difference of−2.32% (95%CI,−10.58-5.94), P = .580; and mineralocorticoid receptor antagonists 79.85%±27.72% vs 67.29%±31.43%, P =.003. No other differences in drug dosage were found. Multivariate analysis showed nonsignificant differences. CV mortality was 1 (1.20%) vs 3 (1.26%), P=1, and HF hospitalizations 0 (0.00%) vs 10 (4.22%), P=.125. ConclusionsIn a post hoc analysis from the HF-titration ETIFIC trial, we found nonsignificant gender differences in drug dosage, cardiovascular mortality, and HF hospitalizations.Trial registry number: NCT02546856.

Sleeve Gastrectomy Reduces BMI and Pill Count in Patients With LVAD.

Sleeve Gastrectomy Reduces BMI and Pill Count in Patients With LVAD.

A dose-response relationship of renin-angiotensin system blockers and beta-blockers in patients with acute heart failure syndrome: a nationwide prospective cohort study.

It remains unclear if patients with acute heart failure syndrome (AHFS) need to reach the maximally tolerated doses of renin-angiotensin system blockers (RASBs) or beta-blockers (BBs) to obtain a survival benefit. This study evaluated the dose-response relationship between RASBs or BBs and survival in AHFS patients. In total, 5331 patients in the Korean Acute Heart Failure registry were analysed based on the doses of RASBs and BBs at discharge. In AHFS patients, RASB use at discharge was associated with a significant reduction in all-cause mortality risk. This effect was dose-dependent for heart failure with reduced ejection fraction (HFrEF) but did not attain statistical significance for heart failure with preserved ejection fraction (HFpEF). BB use at discharge was associated with reduced all-cause mortality in HFrEF patients but not in HFpEF patients. In an additional analysis of 4613 patients with dosage information at the first post-discharge follow-up visit, a significantly higher mortality risk was associated with the maintenance or withdrawal of RASBs compared with up-titrating the dose in HFrEF patients. Using RASBs or BBs at discharge was associated with improved survival. A dose-response relationship between RASBs and all-cause mortality was evident in AHFS patients with a reduced ejection fraction but not BBs. It is important to initiate and up-titrate RASBs to the maximally tolerated dose in AHFS patients during the transition period, especially for patients with a reduced ejection fraction.

Prognostic value of beta-blocker doses in patients with ventricular tachyarrhythmias

The study investigates the prognostic significance of beta-blocker (BB) dose in patients with ventricular tachyarrhythmias. Limited data regarding the prognostic impact of BB dose in ventricular tachyarrhythmias is available. A large retrospective registry was used including consecutive patients on BB treatment with episodes of ventricular tachycardia (VT) or fibrillation (VF) from 2002 to 2015. Discharge BB doses were grouped as > 0–12.5%, > 12.5–25%, > 25–50%, and > 50% according to doses used in randomized trials. The primary endpoint was all-cause mortality at three years. Secondary endpoints comprised of a composite arrhythmic endpoint (i.e., recurrences of ventricular tachyarrhythmias and appropriate ICD therapies) and cardiac rehospitalization. Kaplan–Meier survival curves and multivariable Cox regression analyses were applied for statistics. A total of 1313 patients with BB were included; most patients were discharged with > 25–50% of BB target dose (59%). At three years, > 12.5–25% of BB target dose was associated with improved long-term mortality as compared to the > 0–12.5% group (HR = 0.489; 95% CI 0.297–0.806; p = 0.005), whereas higher BB doses did not improve survival (> 25–50%: HR = 0.849; p = 0.434; > 50%: HR = 0.735; p = 0.285). In contrast, the composite endpoint and risk of rehospitalization were not affected by BB target dose. In conclusion, > 12.5–25% of BB target dose is associated with best long-term survival among patients with ventricular tachyarrhythmias. In contrast, risk of the composite arrhythmic endpoint and risk of cardiac rehospitalization were not affected by BB dose.

Efficacy of Empagliflozin in the EMPEROR-Reduced Trial According to Dose and Combination of Baseline Heart Failure Therapies

In the EMPEROR-Reduced Trial, empagliflozin was demonstrated to reduce cardiorenal outcomes and improve quality of life in patients with HFrEF. We examined whether the benefit of empagliflozin was consistent across the doses and combinations of baseline heart failure therapies. The primary outcome of time to cardiovascular (CV) death or hospitalization for heart failure (HHF) was examined in patients receiving ACEi or ARB (RAASi), MRA or beta-blockers (BB) at ≥ 50% or < 50% of target dose. Furthermore, the primary outcome was examined in patients receiving baseline combination therapy: RAASi + BB; RAASi + BB + MRA; and ARNI + BB + MRA. At baseline, of the 3730 patients randomized, 26.8%, 61.5%, and 48.9% were treated with ≥50% of target doses of RAASi, MRA or BB respectively. Additionally, 66.7%, 17.5%, 48.4%, 13.8%, 84.1%, 61.1%, and 13.4% were treated with combination of either RAASi + BB, RAASi + BB (≥50%), RAASi + BB + MRA, RAASi + BB (≥ 50%) + MRA, RAASi or ARNI + BB, RAASi or ARNI + BB + MRA or ARNI + BB + MRA. Across all sub-groups, the hazard ratio for the primary outcome was consistent with the overall estimate of 0.75 (0.65 to 0.86; P < 0.001) in empagliflozin vs. placebo treated patients with no heterogeneity by subgroup interaction (Fig. 1). KCCQ-CSS improved across all subgroups. Tolerability was similar between groups. Empagliflozin's beneficial effects in HFrEF are observed consistently regardless of the doses and combinations of other foundational drugs for heart failure.

Subaortic stenosis and Wolff-Parkinson-White syndrome: Clinical case and literature review

The association of a subaortic stenosis with a WPW syndrome is very rare yet so challenging due to the difficulty of the treatment. In order to describe this association, we report the case of a young man. A 39 yo Moroccan man with a history of recurrent sore throat, was referred to our care after a heart murmur was discovered during a pre-employment medical checkup. He beneficed from a physical examination, an EKG and a transthoracic cardiac ultrasound. The patient did not have any symptoms: no dyspnea or palpitations or fatigue or syncope. There was no family history of cardiac disease or murmur. Physical examination found a well-developed male in no distress, blood pressure at 140/80 mmHg, heart rate at 91 bpm, BMI = 21 kg/m 2 . Cardiac auscultation revealed a systolic murmur in the aortic area increased by the Valsalva maneuver. With no sign of heart failure. The results of the remaining physical examination were within normal ranges. The electrocardiogram revealed an intermittent WPW. Echocardiography was performed while the patient was in ventricular pre-excitation conduction revealed a subaortic stenosis diaphragm with an average gradient of 51 mmHg, a hypertrophic left ventricular wall, with good systolic function with an ejection fraction of 68%, the LV filling pressures were highs. A left atrium surface of 18.3 cm 2 , the aortic valve was tricuspide with a small regurgitation, the ascending aorta was dilated. Mitral valve was thin with normal opening. Right cavities were not dilated with normal function, we noted a small tricuspide regurgitation with systolic pulmomanary artery pression at 44 mmHg. Inferior vena cava was thin, and no pericardium effusion was found. Labs results came normal. The patient was put under small dose of beta-blockers and diuretics and a surgical treatment was discussed. The necessity to explore the WPW patients before treatment.

HEPATIC VASCULAR TUMORS IN CHILDREN: POTENTIAL RISKS, OPTIMAL IMAGING AND THE ROLE OF SURGICAL INTERVENTION.

The aim: To revise the case-series of hepatic vascular tumors (HVT), particularly to identify optimal visualization, management and role of surgical intervention. Materials and methods: Out of 96 children with hepatic tumors who hospitalized in a single center from 2011 to 2020, 20 (20,8%) were diagnosed HVT. Hepatic Hemangiomas (HHs) were presented in 19 patients and Kaposiform hemangioendotelioma (KHE) in one case. To determine the type of HH we used radiological classification. For visualisation contrast-enhanced MRI (n=7, 30%) and cCT (n=15,70%) were used. Follow-up period was 14-77 months. Results: All HVT were revealed by sonogram at the age of 0-5 m, with 4 (20%) diagnosed prenatally. Male to female ratio was 3:2. Beta-blockers were prescribed to 12 patients with HHs. Treatment duration was from 6 to 24 month. Steroid therapy was initial in cases when it was impossible to prescribe the curative dose of beta-blockers. Complications of propranolol treatment were transitory bradycardia (n=7) and transitory hypoglycemia (n=2). After vincristine chemotherapy decreases the tumor size by 54%, that allowed a safe liver resection. 4 (20%) patients - two multifocal HHs, one diffuse HH and in patient with KHE manifested congestive heart failure and pulmonary hypertension Mortality rate is 5% (n=1), this patient died against progressive cardiovascular failure. Conclusions: life-threatening complication of HVT was congestive heart failure. Early treatment is beneficial for complications prevention. Surgical treatment is optional for KHE when can be removed safely.