Best of heart failure

12 clear reasons, and they are stem. Recently, the advent inhibitor (ARNI) sacubi- rmacologic approach that al endopeptidase enzyme concomitantly blocks the ith valsartan). of ARNI with ACEI to rtality and Morbidity in tudy [ 31 ], a double-blind, patients with Class II–IV tion of 40% or less were itril/valsartan (at a dose of ectively) or enalapril (at a rimary outcome of death rt failure rehospitalization ARNI arm (21.8%) com- 01). Cardiovascular death % CI, 0.71; 0.89)) and risk n by 21% (HR 0.79 (95% lity was reduced by 16% HR 0.84 (95% CI, 0.76; y stopped because of the en compared to ACEI. ere reported in more than study, and these included gh, dizziness, and renal dema was also higher in pared to enalapril (0.5% in the black population). be encountered more fre- double-blind period of by a single-blind run-in ed if they could not toler- I. en tested in CHF patients . These include endothelin agents, and growth hor- terventions that modulate he neprilysin enzyme (in only proven treatment to patients with congestive t in treating patients with bradine, an HCN channel n normal sinus rhythm and or on maximum tolerable was tested in The Systolic inhibitor ivabradine Trial 505 patients with chronic bradine versus placebo on t. Patients had to be in rt rate of more or equal ss or equal 35%, and have N. W. Shammas 452 Patients with left ventricular diastolic dysfunction need to be treated with aggressive blood pressure control with the use f diuretics, beta blockers, or non-dihydropyridine cal- cium channel blockers (diltiazem or verapamil) [ 48 ]. The ACC/AHA 2005 Guidelines recommend blood pressure con- trol as a Class I level A in patients with HFNEF [ 49 ]. ACE inhibitors or angiotensin receptor blockers (ARBs) can have long-term value in reducing left ventricular hyper- tr phy and theoretically may improve left ventricular com- pliance [ 50 ] and improve diastolic function in contrast to hydralazin and hydrochlorothiazide [ 51 ]. In the Hong Kong Di stolic Heart Failure Study [ 52 ], diuretics in combination with an ACEI (ramipril) or ARB (irbesartan) marginally i prove LV systolic and diastolic function and lowered BNP t 1 year. Aldosterone antagonist appears to have a beneficial effect on diastolic function particularly in the elderly, possibly by reducing myocardial fibrosis [ 53 ]. Losartan and amlodipine were compared in the effect of losartan and amlodipine on left ventricular diastolic function in patients with mild-to- moderate hypertension (J-ELAN) to determine their role in improving diastolic function [ 54 , 55 ]. Fifty-seven patients were randomized to losartan or amlodipine and were fol- lowed up for 18 months. Despite similar blood pressure in both regim ns, there was no statistical difference between the two drugs in shortening the transmitral E-wave decelera- ti n time or reducing LV mass index; However, mean carotid intima-media thickness (mean IMT) and plaque score sig- nificantly increased in the amlodipine group (pre, 1.05 ± 0.26 mm; follow-up, 1.23 ± 0.33 mm, p = 0.0015), but not in the losartan group indicating that losartan may reduce agai st progression of atherosclerosis in these patients. Diastolic dysfunction also has been described in diabetic patients with impaired glucose tolerance and insulin resis- tance [ 56 ] and is associated with endothelial dysfunction and abn rmalities on stress myocardial single-photon emission computed tomography [ 57 ]. Glycemic control shows an improvement in diastolic parameters that was inversely cor- related with percent changes in glycated hemoglobin [ 58 ]. In th Euro Heart Failure Survey I, preserved systolic function is also seen in elderly patients with HF [ 59 ]. These atie ts typically have a high mortality. Measurements of EF and lifes ving therapies are quite often underutilized in this group of patients with multiple comorbidities. The use of beta blockers and ACEI was associated with a better out- com in these patients. In conclusion, ACEI and ARB are important therapies in reducing left ventricular hypertrophy and improving left ventri ular diastolic function. The role of beta blockers and c lcium cha nel blockers remains unclear but of concern is the likelihood of progression of atherosclerosis in patients on amlodipine when compared to ARB. Diuretics reduce left ventricular filling pressures and improve symptoms. Risk factor modification is also important including treatment of hypertension, diabetes, sleep apnea, elevated triglycerides, coronary artery disease, and valvular disease. 24.4.2 Asymptomatic Left Ventricular Systolic Dysfunction Asymptomatic left ventricular dysfunction (Stage B, ACC/ AHA classification) is prevalent and typically identified by echocardiography [ 60 ]. Asymptomatic left ventricular sys- tolic dysfunction (ejection fraction ≤ 50%) was reported in 6.0% of men and 0.8% of women with a hazard ratio for CHF of 4.7 on 12 years follow-up [ 61 ]. Neurohormonal acti- vation is present in patients with asymptomatic left ventricu- lar dysfunction and leads to worsening left ventricular function and progression to symptomatic failure [ 62 ]. Risk factors modification is also important in these patients including treatment of hypertension, diabetes, sleep apnea, elevated triglycerides, coronary artery disease [ 63 ], valvular disease, smoking cessation, reducing alcohol intake or illicit drug use, and routine exercise. Tachycardia-induced cardiomyopathy needs to be recognized and treated. Anemia has been associated with asymptomatic left ventricular dys- function and progression to heart failure particularly when the hematocrit is ≤ 40% [ 64 ]. Beta blockers and ACEI are important therapies in Stage B CHF including the post-myocardial infarction patients [ 64 , 65 ] and have been shown to improve left ventricular EF [ 66 ] and reduce progression to heart failure [ 67 ]. In the SOLVD trial [ 68 ], asymptomatic patients with reduced left ventricu- lar function (EF < 35%) were randomized to enalapril ( n = 2117) versus placebo ( n = 2111) and followed for an average of 37.4 months. The reduction in cardiovascular mortality was larger in the enalapril group than placebo (risk reduction of 12%, p = 0.12). Also, the combined endpoint of death and heart failure was 36% lower in the enalapril group ( p < 0.001). ARBs are a reasonable alternative to ACEI [ 69 ]. The role of calcium channel blockers or digoxin in Stage B CHF is unclear. Endothelin A/B receptor antagonists (enrasentan) increases resting cardiac index but was associated with more serious adverse events (16.7% and 2.8%, respectively, p = 0.02) than enalapril [ 70 ]. As per ACC/AHA Guideline Update 2005 , patients with asymptomatic left ventricular dysfunction post-myocar- dial infarction and an EF of ≤ 30% despite optimal medical therapy for at least 40 days post-MI need to be considered for an implantable defibrillator (ICD) without requiring screening for ventricular arrhythmias, whether occurring spontaneously or induced by electrophysiologic testing [ 71 – 73 ]. ICD therapy in this population yielded a 31% N. W. Shammas