血清基质金属蛋白酶-9与冠心病相关性的临床研究

目的　观察冠心病患者基质金属蛋白酶 - 9(MMP- 9)血清水平以及与冠状动脉内径狭窄程度的关系。探讨MMP- 9在冠心病发病中所起的作用。方法　行冠状动脉造影术诊断为冠心病者 32例 ,另选 30例正常人为对照组 ,用 EL ISA法测定两组之间血清 MMP- 9水平 ,并探讨 MMP- 9与冠状动脉内径狭窄程度的关系。结果　冠心病组血清 MMP- 9水平高于正常对照组 (P<0 .0 1) ,冠状动脉内径狭窄程度与基质金属蛋白酶浓度值呈正相关 (r=0 .6 0 1,P<0 .0 1)。结论　 MMP- 9可能参与了冠心病的发生发展过程     

Levosimendan Use Reduces Matrix Metalloproteinase-2 in Patients with Decompensated Heart Failure

Summary Background: Extracellular matrix metabolism (ECM) has an important role in left ventricular (LV) remodeling in chronic heart failure (CHF). Matrix metalloproteinases (MMPs) are involved in the regulation of extracellular matrix (ECM) metabolism. We investigated the effect of levosimendan, a novel calcium sensitizer, on serum levels of MMP-2. Methods: Our study population consisted of 60 consecutive patients with advanced heart failure who were admitted to hospital with an acute decompensation of their CHF. Patients were randomized to levosimendan (n = 30; 18 men, aged 65 ± 3 years) or placebo (n = 30; 15 men, aged 67 ± 4 years). Serum MMP-2 levels were assessed before and after treatment with levosimendan or placebo, using a commercially available ELISA. Results: Serum levels of MMP-2 were reduced from 427 ng/ml 95%CI 372–484 to 371 ng/ml 95%CI 329–413 in the levosimendan treated group and from 433 ng/ml 95%CI 422–444 to 425 ng/ml 95%CI 414–436 in the placebo group. Repeated measurements ANOVA showed that treatment with levosimendan significantly affected levels of MMP-2 (p = 0.019). Conclusions: The present study showed that levosimendan may beneficially affect ECM remodeling in patients with acutely decompensated CHF. Whether these effects translate into added clinical benefits, as suggested by an improved ejection fraction in the levosimendan group, deserves further investigation.     

Atrial Fibrillation in Decompensated Heart Failure: Associated Factors and In-Hospital Outcome

Background

Studies on atrial fibrillation (AF) in decompensated heart failure (DHF) are scarce in Brazil.

Objectives

To determine AF prevalence, its types and associated factors in patients hospitalized due to DHF; to assess their thromboembolic risk profile and anticoagulation rate; and to assess the impact of AF on in-hospital mortality and hospital length of stay.

Methods

Retrospective, observational, cross-sectional study of incident cases including 659 consecutive hospitalizations due to DHF, from 01/01/2006 to 12/31/2011. The thromboembolic risk was assessed by using CHADSVASc score. On univariate analysis, the chi-square, Student t and Mann Whitney tests were used. On multivariate analysis, logistic regression was used.

Results

The prevalence of AF was 40%, and the permanent type predominated (73.5%). On multivariate model, AF associated with advanced age (p < 0.0001), non-ischemic etiology (p = 0.02), right ventricular dysfunction (p = 0.03), lower systolic blood pressure (SBP) (p = 0.02), higher ejection fraction (EF) (p < 0.0001) and enlarged left atrium (LA) (p < 0.0001). The median CHADSVASc score was 4, and 90% of the cases had it ≥ 2. The anticoagulation rate was 52.8% on admission and 66.8% on discharge, being lower for higher scores. The group with AF had higher in-hospital mortality (11.0% versus 8.1%, p = 0.21) and longer hospital length of stay (20.5 ± 16 versus 16.3 ± 12, p = 0.001).

Conclusions

Atrial fibrillation is frequent in DHF, the most prevalent type being permanent AF. Atrial fibrillation is associated with more advanced age, non-ischemic etiology, right ventricular dysfunction, lower SBP, higher EF and enlarged LA. Despite the high thromboembolic risk profile, anticoagulation is underutilized. The presence of AF is associated with longer hospital length of stay and high mortality.     

冠状动脉支架植入对冠心病患者血清基质金属蛋白酶2表达的影响

目的研究冠心病患者血清基质金属蛋白酶2浓度与冠状动脉病变程度的关系及冠状动脉支架植入对血清基质金属蛋白酶2浓度的影响。方法将50例冠心病患者分为冠状动脉支架植入组和非冠状动脉支架植入组,统计冠状动脉造影结果,于术前1d,术后1d、10d及30d取静脉血,应用双抗体夹心酶联免疫法检测血清基质金属蛋白酶2浓度的变化。结果非冠状动脉支架植入组手术前后各时间点血清基质金属蛋白酶2浓度差异无显著性(P>0.05);冠状动脉支架植入组手术后基质金属蛋白酶2浓度持续升高(P<0.05)。与术前1d比较,双支病变组基质金属蛋白酶2浓度较单支病变组高,三支病变组比双支病变组高(P<0.05);B型病变组基质金属蛋白酶2浓度比A型病变组高,C型病变组比B型病变组高(P<0.05)。结论冠心病患者冠状动脉病变程度越重血清基质金属蛋白酶2浓度越高,冠状动脉支架植入后30d内基质金属蛋白酶2浓度持续升高。     

血浆基质金属蛋白酶2和组织型基质金属蛋白酶抑制剂2水平变化与急性冠状动脉综合征的关系

目的 探讨不同类型冠心病患者基质金属蛋白酶2、组织型基质金属蛋白酶抑制剂2水平及其比值变化,分析其在急性冠状动脉综合征中的临床意义.方法 经冠状动脉造影的118例心内科住院患者,依据其临床表现和冠状动脉造影结果分组:急性冠状动脉综合征患者49例,其中包括不稳定型心绞痛患者30例、急性心肌梗死患者19例;非急性冠状动脉综合征冠心病患者44例,包括稳定型心绞痛患者23例、冠状动脉慢性完全闭塞患者21例;25例冠状动脉正常患者为对照组.采用夹心酶联免疫吸附法检测动脉血浆基质金属蛋白酶2和组织型基质金属蛋白酶抑制剂2水平.结果 急性冠状动脉综合征和非急性冠状动脉综合征患者血浆基质金属蛋白酶2、组织型基质金属蛋白酶抑制剂2水平均明显高于对照组(P<0.05),且基质金属蛋白酶2/组织型基质金属蛋白酶抑制剂2比值均显著高于对照组(P<0.01);与非急性冠状动脉综合征患者比较,急性冠状动脉综合征患者基质金属蛋白酶2、组织型基质金属蛋白酶抑制剂2水平及基质金属蛋白酶2/组织型基质金属蛋白酶抑制剂2比值均显著增高(P<0.05和P<0.01);与对照组比较,不稳定型心绞痛组、急性心肌梗死组和冠状动脉慢性完全闭塞组基质金属蛋白酶2水平明显增高(P<0.05和P<0.01),不稳定型心绞痛组、稳定型心绞痛组和冠状动脉慢性完全闭塞组组织型基质金属蛋白酶抑制剂2显著增高(P<0.05和P<0.01).结论 动脉粥样硬化斑块的演变与血基质金属蛋白酶2、组织型基质金属蛋白酶抑制剂2水平及基质金属蛋白酶2/组织型基质金属蛋白酶抑制剂2比值变化和失衡密切相关,基质金属蛋白酶2水平和基质金属蛋白酶2/组织型基质金属蛋白酶抑制剂2比值显著升高提示动脉粥样硬化斑块的不稳定性,有可能作为急性冠状动脉综合征病情严重程度的有效预测指标之一.     

Meta-Analysis of Ultrafiltration versus Diuretics Treatment Option for Overload Volume Reduction in Patients with Acute Decompensated Heart Failure

Introduction

Although diuretics are mainly used for the treatment of acute decompensated heart failure (ADHF), inadequate responses and complications have led to the use of extracorporeal ultrafiltration (UF) as an alternative strategy for reducing volume overloads in patients with ADHF.

Objective

The aim of our study is to perform meta-analysis of the results obtained from studies on extracorporeal venous ultrafiltration and compare them with those of standard diuretic treatment for overload volume reduction in acute decompensated heart failure.

Methods

MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials databases were systematically searched using a pre‑specified criterion. Pooled estimates of outcomes after 48 h (weight change, serum creatinine level, and all-cause mortality) were computed using random effect models. Pooled weighted mean differences were calculated for weight loss and change in creatinine level, whereas a pooled risk ratio was used for the analysis of binary all-cause mortality outcome.

Results

A total of nine studies, involving 613 patients, met the eligibility criteria. The mean weight loss in patients who underwent UF therapy was 1.78 kg [95% Confidence Interval (CI): −2.65 to −0.91 kg; p < 0.001) more than those who received standard diuretic therapy. The post-intervention creatinine level, however, was not significantly different (mean change = −0.25 mg/dL; 95% CI: −0.56 to 0.06 mg/dL; p = 0.112). The risk of all-cause mortality persisted in patients treated with UF compared with patients treated with standard diuretics (Pooled RR = 1.00; 95% CI: 0.64–1.56; p = 0.993).

Conclusion

Compared with standard diuretic therapy, UF treatment for overload volume reduction in individuals suffering from ADHF, resulted in significant reduction of body weight within 48 h. However, no significant decrease of serum creatinine level or reduction of all-cause mortality was observed.     

脂多糖对胎儿主动脉平滑肌细胞合成基质金属蛋白酶1和基质金属蛋白酶抑制物1的影响

为探讨脂多糖是否通过影响基质金属蛋白酶 1和基质金属蛋白酶抑制物 1的平衡对动脉粥样硬化的进程起作用 ,应用体外培养的胎儿主动脉平滑肌细胞 ,加入不同浓度的脂多糖孵育 72h ,收集细胞上清液 ,用蛋白质印迹分析方法检测细胞上清液中基质金属蛋白酶 1和基质金属蛋白酶抑制物 1的含量。结果发现 ,脂多糖组与对照组相比 ,基质金属蛋白酶 1的含量明显减少 (P <0 .0 5 ) ,基质金属蛋白酶抑制物 1的含量没有显著差别。以上提示 ,脂多糖能抑制胎儿主动脉平滑肌细胞合成基质金属蛋白酶 1 ,但对基质金属蛋白酶抑制物 1的合成没有影响     

Neutrophil-to-Lymphocyte Ratio and Platelet-to-Lymphocyte Ratio are Predictors of Heart Failure

Background

Neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) are inflammatory markers used as prognostic factors in various diseases. The aims of this study were to compare the PLR and the NLR of heart failure (HF) patients with those of age-sex matched controls, to evaluate the predictive value of those markers in detecting HF, and to demonstrate the effect of NLR and PLR on mortality in HF patients during follow-up.

Methods

This study included 56 HF patients and 40 controls without HF. All subjects underwent transthoracic echocardiography to evaluate cardiac functions. The NLR and the PLR were calculated as the ratio of neutrophil count to lymphocyte count and as the ratio of platelet count to lymphocyte count, respectively. All HF patients were followed after their discharge from the hospital to evaluate mortality, cerebrovascular events, and re-hospitalization.

Results

The NLR and the PLR of HF patients were significantly higher compared to those of the controls (p < 0.01). There was an inverse correlation between the NLR and the left ventricular ejection fraction of the study population (r: -0.409, p < 0.001). The best cut-off value of NLR to predict HF was 3.0, with 86.3% sensitivity and 77.5% specificity, and the best cut-off value of PLR to predict HF was 137.3, with 70% sensitivity and 60% specificity. Only NLR was an independent predictor of mortality in HF patients. A cut-off value of 5.1 for NLR can predict death in HF patients with 75% sensitivity and 62% specificity during a 12.8-month follow-up period on average.

Conclusion

NLR and PLR were higher in HF patients than in age-sex matched controls. However, NLR and PLR were not sufficient to establish a diagnosis of HF. NLR can be used to predict mortality during the follow-up of HF patients.     

Mortality by Heart Failure and Ischemic Heart Disease in Brazil from 1996 to 2011

Background

Circulatory system diseases are the first cause of death in Brazil.

Objective

To analyze the evolution of mortality caused by heart failure, by ischemic heart diseases and by ill-defined causes, as well as their possible relations, in Brazil and in the geoeconomic regions of the country (North, Northeast, Center-West, South and Southeast), from 1996 to 2011.

Methods

Data were obtained from DATASUS and death declaration records with codes I20 and I24 for acute ischemic diseases, I25 for chronic ischemic diseases, and I50 for heart failure, and codes in chapter XIII for ill-defined causes, according to geoeconomic regions of Brazil, from 1996 to 2011.

Results

Mortality rates due to heart failure declined in Brazil and its regions, except for the North and the Northeast. Mortality rates due to acute ischemic heart diseases increased in the North and Northeast regions, especially from 2005 on; they remained stable in the Center-West region; and decreased in the South and in the Southeast. Mortality due to chronic ischemic heart diseases decreased in Brazil and in the Center-West, South and Southeast regions, and had little variation in the North and in the Northeast. The highest mortality rates due to ill-defined causes occurred in the Northeast until 2005.

Conclusions

Mortality due to heart failure is decreasing in Brazil and in all of its geoeconomic regions. The temporal evolution of mortality caused by ischemic heart diseases was similar to that of heart failure. The decreasing number of deaths due to ill-defined causes may represent the improvement in the quality of information about mortality in Brazil. The evolution of acute ischemic heart diseases ranged according to regions, being possibly confused with the differential evolution of ill-defined causes.     

Effects of PDE type 5 inhibitors on Left Ventricular Diastolic Dysfunction in Resistant Hypertension

Resistant hypertension (RHTN) is a multifactorial disease characterized by bloodpressure (BP) levels above goal (140/90 mmHg) in spite of the concurrent use of threeor more antihypertensive drugs of different classes. Moreover, it is well known thatRHTN subjects have high prevalence of left ventricular diastolic dysfunction (LVDD),which leads to increased risk of heart failure progression. This review gathers datafrom studies evaluating the effects of phosphodiesterase-5 (PDE-5) inhibitors(administration of acute sildenafil and short-term tadalafil) on diastolic function,biochemical and hemodynamic parameters in patients with RHTN. Acute study withsildenafil treatment found that inhibition of PDE-5 improved hemodynamic parametersand diastolic relaxation. In addition, short-term study with the use of tadalafildemonstrated improvement of LVDD, cGMP and BNP-32 levels, regardless of BP reduction.No endothelial function changes were observed in the studies. The findings of acuteand short-term studies revealed potential therapeutic effects of IPDE-5 drugs on LVDDin RHTN patients.     

Soluble ST2 Testing: A Promising Biomarker in the Management of Heart Failure

ST2 is a member of the interleukin-1 receptor family biomarker andcirculating soluble ST2 concentrations are believed to reflectcardiovascular stress and fibrosis. Recent studies have demonstratedsoluble ST2 to be a strong predictor of cardiovascular outcomes in bothchronic and acute heart failure. It is a new biomarker that meets allrequired criteria for a useful biomarker. Of note, it adds information tonatriuretic peptides (NPs) and some studies have shown it is even superiorin terms of risk stratification. Since the introduction of NPs, this hasbeen the most promising biomarker in the field of heart failure and mightbe particularly useful as therapy guide.     

Atrial Fibrillation and Non-cardiovascular Diseases: A Systematic Review

Atrial fibrillation (AF) is the most common cardiac arrhythmia and is associated withan unfavorable prognosis, increasing the risk of stroke and death. Althoughtraditionally associated with cardiovascular diseases, there is increasing evidenceof high incidence of AF in patients with highly prevalent noncardiovascular diseases,such as cancer, sepsis, chronic obstructive pulmonary disease, obstructive sleepapnea and chronic kidney disease. Therefore, considerable number of patients has beenaffected by these comorbidities, leading to an increased risk of adverseoutcomes.The authors performed a systematic review of the literature aiming to betterelucidate the interaction between these conditions.Several mechanisms seem to contribute to the concomitant presence of AF andnoncardiovascular diseases. Comorbidities, advanced age, autonomic dysfunction,electrolyte disturbance and inflammation are common to these conditions and maypredispose to AF.The treatment of AF in these patients represents a clinical challenge, especially interms of antithrombotic therapy, since the scores for stratification ofthromboembolic risk, such as the CHADS₂ andCHA₂DS₂VASc scores, and the scores for hemorrhagic risk, likethe HAS-BLED score have limitations when applied in these conditions.The evidence in this area is still scarce and further investigations to elucidateaspects like epidemiology, pathogenesis, prevention and treatment of AF innoncardiovascular diseases are still needed.     

Association between Functional Variables and Heart Failure after Myocardial Infarction in Rats

Background

Heart failure prediction after acute myocardial infarction may have important clinical implications.

Objective

To analyze the functional echocardiographic variables associated with heart failure in an infarction model in rats.

Methods

The animals were divided into two groups: control and infarction. Subsequently, the infarcted animals were divided into groups: with and without heart failure. The predictive values were assessed by logistic regression. The cutoff values predictive of heart failure were determined using ROC curves.

Results

Six months after surgery, 88 infarcted animals and 43 control animals were included in the study. Myocardial infarction increased left cavity diameters and the mass and wall thickness of the left ventricle. Additionally, myocardial infarction resulted in systolic and diastolic dysfunction, characterized by lower area variation fraction values, posterior wall shortening velocity, E-wave deceleration time, associated with higher values of E / A ratio and isovolumic relaxation time adjusted by heart rate. Among the infarcted animals, 54 (61%) developed heart failure. Rats with heart failure have higher left cavity mass index and diameter, associated with worsening of functional variables. The area variation fraction, the E/A ratio, E-wave deceleration time and isovolumic relaxation time adjusted by heart rate were functional variables predictors of heart failure. The cutoff values of functional variables associated with heart failure were: area variation fraction < 31.18%; E / A > 3.077; E-wave deceleration time < 42.11 and isovolumic relaxation time adjusted by heart rate < 69.08.

Conclusion

In rats followed for 6 months after myocardial infarction, the area variation fraction, E/A ratio, E-wave deceleration time and isovolumic relaxation time adjusted by heart rate are predictors of heart failure onset.     

Optimized Treatment and Heart Rate Reduction in Chronic Heart Failure

Background

Heart failure (HF) is a syndrome that leads to poor outcome in advanced forms. The neurohormonal blockade modifies this natural history; however, it is often suboptimal.

Objective

The aim of this study is to assess at what percentage cardiologists used to treating HF can prescribe target doses of drugs of proven efficacy.

Methods

A total of 104 outpatients with systolic dysfunction were consecutively enrolled, all under stabilized treatment. Demographic and treatment data were evaluated and the doses achieved were verified. The findings are shown as percentages and correlations are made between different variables.

Results

The mean age of patients was 64.1 ± 14.2 years, with SBP =115.4 ± 15.3, HR = 67.8 ± 9.4 bpm, weight = 76.0 ± 17.0 kg and sinus rhythm (90.4%). As for treatment, 93.3% received a RAS blocker (ACEI 52.9%), all received beta-blockers (BB), the most often prescribed being carvedilol (92.3%). As for the doses: 97.1% of those receiving an ARB were below the optimal dose and of those who received ACEI, 52.7% received an optimized dose. As for the BB, target doses were prescribed to 76.0% of them. In this group of patients, most with BB target dose, it can be seen that 36.5% had HR ≥ 70 bpm in sinus rhythm.

Conclusion

Cardiologists used to treating HF can prescribe target doses of ACEI and BB to most patients. Even though they receive the recommended doses, about one third of patients persists with HR > 70 bpm and should have their treatment optimized.     

Testosterone Deficiency Increases Hospital Readmission and Mortality Rates in Male Patients with Heart Failure

Background

Testosterone deficiency in patients with heart failure (HF) is associated with decreased exercise capacity and mortality; however, its impact on hospital readmission rate is uncertain. Furthermore, the relationship between testosterone deficiency and sympathetic activation is unknown.

Objective

We investigated the role of testosterone level on hospital readmission and mortality rates as well as sympathetic nerve activity in patients with HF.

Methods

Total testosterone (TT) and free testosterone (FT) were measured in 110 hospitalized male patients with a left ventricular ejection fraction < 45% and New York Heart Association classification IV. The patients were placed into low testosterone (LT; n = 66) and normal testosterone (NT; n = 44) groups. Hypogonadism was defined as TT < 300 ng/dL and FT < 131 pmol/L. Muscle sympathetic nerve activity (MSNA) was recorded by microneurography in a subpopulation of 27 patients.

Results

Length of hospital stay was longer in the LT group compared to in the NT group (37 ± 4 vs. 25 ± 4 days; p = 0.008). Similarly, the cumulative hazard of readmission within 1 year was greater in the LT group compared to in the NT group (44% vs. 22%, p = 0.001). In the single-predictor analysis, TT (hazard ratio [HR], 2.77; 95% confidence interval [CI], 1.58–4.85; p = 0.02) predicted hospital readmission within 90 days. In addition, TT (HR, 4.65; 95% CI, 2.67–8.10; p = 0.009) and readmission within 90 days (HR, 3.27; 95% CI, 1.23–8.69; p = 0.02) predicted increased mortality. Neurohumoral activation, as estimated by MSNA, was significantly higher in the LT group compared to in the NT group (65 ± 3 vs. 51 ± 4 bursts/100 heart beats; p < 0.001).

Conclusion

These results support the concept that LT is an independent risk factor for hospital readmission within 90 days and increased mortality in patients with HF. Furthermore, increased MSNA was observed in patients with LT.     

Ivabradine Improves Heart Rate Variability in Patients with Nonischemic Dilated Cardiomyopathy

Background

Ivabradine is a novel specific heart rate (HR)-lowering agent that improves event-free survival in patients with heart failure (HF).

Objectives

We aimed to evaluate the effect of ivabradine on time domain indices of heart rate variability (HRV) in patients with HF.

Methods

Forty-eight patients with compensated HF of nonischemic origin were included. Ivabradine treatment was initiated according to the latest HF guidelines. For HRV analysis, 24-h Holter recording was obtained from each patient before and after 8 weeks of treatment with ivabradine.

Results

The mean RR interval, standard deviation of all normal to normal RR intervals (SDNN), the standard deviation of 5-min mean RR intervals (SDANN), the mean of the standard deviation of all normal-to-normal RR intervals for all 5-min segments (SDNN index), the percentage of successive normal RR intervals exceeding 50 ms (pNN50), and the square root of the mean of the squares of the differences between successive normal to normal RR intervals (RMSSD) were low at baseline before treatment with ivabradine. After 8 weeks of treatment with ivabradine, the mean HR (83.6 ± 8.0 and 64.6 ± 5.8, p < 0.0001), mean RR interval (713 ± 74 and 943 ± 101 ms, p < 0.0001), SDNN (56.2 ± 15.7 and 87.9 ± 19.4 ms, p < 0.0001), SDANN (49.5 ± 14.7 and 76.4 ± 19.5 ms, p < 0.0001), SDNN index (24.7 ± 8.8 and 38.3 ± 13.1 ms, p < 0.0001), pNN50 (2.4 ± 1.6 and 3.2 ± 2.2 %, p < 0.0001), and RMSSD (13.5 ± 4.6 and 17.8 ± 5.4 ms, p < 0.0001) substantially improved, which sustained during both when awake and while asleep.

Conclusion

Our findings suggest that treatment with ivabradine improves HRV in nonischemic patients with HF.     

Effects of Yoga in Patients with Chronic Heart Failure: A Meta-Analysis

The use of yoga as an effective cardiac rehabilitation in patients with chronic heartfailure (CHF) remains controversial.We performed a meta-analysis to examine the effects of yoga on exercise capacity andhealth-related quality of life (HRQOL) in patients with CHF. Methods: We searchedMEDLINE, Cochrane Central Register of Controlled Trials, Excerpta Medica database,LILACS, Physiotherapy Evidence Database, The Scientific Electronic Library Online,and Cumulative Index to Nursing and Allied Health (from the earliest date availableto December 2013) for randomized controlled trials (RCTs) examining the effects ofyoga versus exercise and/or of yoga versus control on exercise capacity (peakVO2) andquality-of-life (HRQOL) in CHF. Two reviewers selected studies independently.Weighted mean differences (WMDs) and 95% confidence intervals (CIs) were calculated,and heterogeneity was assessed using the I² test.Two studies met the selection criteria (total: 30 yoga and 29 control patients). Theresults suggested that yoga compared with control had a positive impact on peakVO₂ and HRQOL. Peak VO₂, WMD (3.87 95% CI: 1.95 to 5.80),and global HRQOL standardized mean differences (-12.46 95% CI: -22.49 to -2.43)improved in the yoga group compared to the control group.Yoga enhances peak VO₂ and HRQOL in patients with CHF and could beconsidered for inclusion in cardiac rehabilitation programs. Larger RCTs are requiredto further investigate the effects of yoga in patients with CHF.