Critical Appraisal of Costly Therapy Modalities for Heart Failure in a Developing Country

Contemporaneous challenges in heart failure management include strategies to rationally use health economic resources and relative donor shortage to adequately offer electric devices (cardiac resynchronization therapy [CRT] and implantable cardioverter defibrillators [ICD]), ventricular assist devices (VADs) and heart transplant, respectively. These issues are particularly important in countries with middle-income rates and limited structured heart transplant centers, such as Brazil. Use of CRT and ICDs need to follow strict guidelines, further customized to public financial health conditions. Experience with VADs in is the early days in Brazil and will require extreme caution to allocate health public resources to develop VAD programs in highly selected centers. Chagas’ disease is epidemiologically important in Brazil; outcomes of patients with Chagas’ on electric devices are unclear while these patients fare better post-transplant than non-Chagas’ patients. Thus, heart transplant remains an attractive option regarding both favorable outcomes and resource allocation for advanced heart failure patients in Brazil.     

Does Limiting Salt Intake Prevent Heart Failure? A Critical Appraisal

Reducing the incidence of heart failure (HF) and its associated morbidity is a major goal for public health authorities. In this review, we evaluate the evidence supporting sodium restriction as a means to prevent HF. High dietary sodium intake is associated with several factors that promote the development of HF including systemic hypertension, ventricular hypertrophy, diastolic dysfunction, vascular stiffness, and endothelial dysfunction. Some argue that sodium restriction actually may contribute to the development of HF through increased neurohormonal activation. The effect of sodium intake on HF risk may depend on an individual’s “salt-sensitivity.” Due in part to methodological limitations, currently available cohort studies have not fully clarified the links between sodium intake and incident HF. Future research is needed to determine accurate and reproducible methods of measuring sodium intake and to identify factors which may make specific individuals more vulnerable to developing HF in the setting of high sodium intake.     

Ivabradine,Coronary Heart Disease,and Heart Failure: Time for Reappraisal

Ivabradine is generally considered to be a safe drug with well-established and substantial benefits. Nevertheless, recently published results from the SIGNIFY trial suggest that ivabradine has rather inconsistent effects on cardiovascular outcomes. In addition, careful examination of all available data from ivabradine trials reveals signals of harm that have not yet been appropriately addressed, including a markedly increased incidence of atrial fibrillation and increased risk of cardiovascular events in patients with heart rates below 70 bpm. These concerns warrant consideration, since they could have implications for the future use of ivabradine.     

A Critical Appraisal of Short-Term End Points in Acute Heart Failure Clinical Trials

The prevalence of heart failure continues to grow, and this is accompanied by an increase in hospitalization for acute heart failure. Hospitalization for heart failure results in a trajectory shift of the syndrome and is associated with worsening outcomes, increased mortality risk, and high costs. Numerous clinical trials over the past 2 decades have had limited success, with no single agent shown to improve mortality risk. The lack of success is multifactorial and in part related to inadequate targets and end points selected for intervention, underscoring the need to better understand and define the pathophysiology of acute heart failure. To better inform future drug development, this review critically explores the short-term end points and outcomes that previous phase III acute heart failure trials have examined.     

Implication of Ivabradine in Up-titrating Beta-blocker in a Patient with Advanced Heart Failure

Titration of beta-blockers is a gold-standard therapy in patients with heart failure and a reduced ejection fraction but is sometimes challenging to administer, given symptomatic hypotension. Ivabradine is a recently introduced selective I_f channel inhibitor that purely reduces the heart rate. We encountered a patient with advanced heart failure in whom a beta-blocker could not be up-titrated given his symptomatic hypotension. Following the initiation of ivabradine, an increase in blood pressure due to heart rate optimization, probably via an improvement in the cardiac output, allowed for the further up-titration of carvedilol, followed by a successful clinical course. Ivabradine might be a novel therapeutic tool to facilitate the up-titration of beta-blockers in patients with heart failure and hypotension.     

Ivabradine in Cardiovascular Disease Management Revisited: a Review

Cardiovascular Drugs and Therapy - Ivabradine is a unique agent that is distinct from beta-blockers and calcium channel blockers as it reduces heart rate without affecting myocardial contractility...     

Acute Liver Failure: A Critical Appraisal of Available Animal Models

The availability of adequate experimental models of acute liver failure (ALF) is of prime importance to provide a better understanding of this condition and allow the development and testing of new therapeutic approaches for patients with ALF. However, the numerous etiologies and complications of ALF contribute to the complexity of this condition and render the development of an ideal experimental model of ALF more difficult than expected. Instead, a number of different models that may be used for the study of specific aspects of ALF have been developed. The most common approaches used to induce ALFin experimental animals are surgical procedures, toxic liver injury,or a combination of both. Despite the high prevalence of viral hepatitis worldwide, very few satisfactory viral models of ALF are available. Established and newly developed models of ALF are reviewed.     

Outpatient Management of Heart Failure

With the increasing prevalence of heart failure, the greater spectrum of proven therapies, the broader spectrum of cardiac dysfunction qualifying for treatment and the recognition that heart failure is difficult to diagnose, the need for an indicator of both the diagnosis and the efficacy of treatment in this condition is clear. Plasma concentrations of the B-type natriuretic peptides are related to cardiac function and cardiovascular prognosis. They parallel hemodynamic indicators of cardiac dysfunction and may therefore act as indicators of the adequacy of therapy. In the one published trial of outpatient treatment of heart failure guided by plasma BNP, 69 patients (LVEF <40%, NYHA II–IV) were randomised to treatment according to plasma peptide levels or a clinical score. The primary end point of total cardiovascular events was reduced in BNP-guided patients (19 versus 54 events) with p < 0.001 in a multivariate analysis. The natriuretic peptides and particularly plasma BNP and aminoterminal proBNP promised to provide an objective guide for optimising treatment in heart failure.     

Rhythm Management in Pediatric Heart Failure

There are several options now available for the management of arrhythmias and ventricular dysfunction in pediatric patients with heart failure. A hybrid approach that combines the expertise of heart failure and electrophysiology specialists may be well suited for the optimal management of these complex patients. Medical and device therapies may be synergistic in decreasing the morbidity and mortality in pediatric heart failure. Pediatric electrophysiology can now potentially offer therapies that can help prevent both arrhythmic and pump failure deaths, as well as improve functional capacity and quality of life. These therapies and the available supporting data relevant to pediatrics will be the focus of this review.