慢性心衰猝死患者QT离散度的变化

本文观察研究慢性心衰(观察组),和无心脏病病人(对照组)各60例的QT离散度。发现观察组的QT离散度较对照组大。而观察组中心衰猝死者(11例)的QT离散度明显大于观察组心衰存活组(30例)、心衰进展死亡组(19例)的QT离散度(P<0.001)。并发现心衰猝死组QT离散度的增大与心功能分级、电解质的血清浓度无相关性。慢性心衰猝死组QTd均值为96.81ms.提示QT离散度的明显增大,是慢性心衰发生猝死的一项具有警告性的重要标志。     

心率减速力及 QT 离散度对慢性心力衰竭患者心源性猝死的预测价值

目的：探讨心率减速力（deceleration capacity,DC）及 QT 离散度（QT dispersion,QTd）对慢性心力衰竭（chronic heart failure,CHF）患者心源性猝死的预测价值。方法随机选择慢性心力衰竭患者100例（心衰组）,随访一年,根据有无室性心律失常分为室性心律失常组（43例）和非室性心律失常组（57例）;根据有无心源性猝死分为猝死组（18例）和生存组（82例）。同期100例在本院体检健康者作为对照组。测定各组患者早期 DC 值和 QTd 值,进行统计分析。结果心衰组、室性心律失常组及猝死组患者的 DC 和 QTd 值分别和对照组、非室性心律失常组及生存组比较,差异均有统计学意义（P ＜0．05）。慢性心力衰竭患者的 QTd 与 DC 呈负性相关。结论慢性心力衰竭患者的 DC 和 QTd 值与病情严重程度有关,可作为预测慢性心力衰竭患者发生心源性猝死的敏感指标。     

QT interval dispersion as a predictor of arrhythmic events in congestive heart failure: Importance of aetiology

Aims Identification of patients with congestive heart failure atrisk of sudden death remains problematic and few data are availableon the prognostic implications of QT dispersion. We sought toassess the predictive value of QT dispersion for arrhythmicevents in heart failure secondary to dilated cardiomyopathyor ischaemic heart disease. Methods and Results Twelve-lead ECGs calculated for QT dispersion, 24h Holter ECGsand signal-averaged ECGs were prospectively recorded in 205heart failure patients in sinus rhythm. The 86 patients withischaemic heart disease and the 119 with dilated cardiomyopathywere not significantly different as regards NYHA grades (51vs 49% in grades III–IV), cardiothoracic ratio (57±7vs 57±6%) and ejection fraction (28±8 vs 29±9%).The mean QT dispersion (66±29 vs 65±27ms), thefrequency of non-sustained ventricular tachycardia (37 vs 38%)and ventricular late potentials (41 vs 40%) were not significantlydifferent in patients with ischaemic or dilated cardiomyop-athy.QT dispersion was not significantly related to other arrhythmogenicmarkers. During follow-up (24±16 months), 66 patientsdied, 22 of them died suddenly and seven presented a spontaneoussustained ventricular tachycardia. In patients with dilatedcardiomyopathy, in multivariate analysis, only a QT dispersion>80ms was an independent predictor of sudden death (RR: 4·9,95% CI 1·4–16·8,P<0·02) and arrhythmicevents (RR: 4·5, 95% CI 1·5–13·5,P<0·01).In patients with ischaemic heart disease, no studied parameterwas found significantly related to sudden death or arrhythmicevents. Conclusion: In congestive heart failure, abnormal QT dispersion can identifypatients with dilated cardiomyopathy who are at high risk ofarrhythmic events.     

安体舒通对慢性充血性心力衰竭患者QT离散度的影响

目的观察安体舒通对慢性充血性心力衰竭患者QT离散度(QTd)的影响,探讨其临床应用价值。方法采用随机、对照方法,设立安体舒通干预组及常规治疗组,测定两组用药前及用药1月后的QTd、校正QT离散度(QTcd)、血钾、血镁、血钠和肌酐。同时测定正常对照者的QTd及QTcd。结果心力衰竭组QTd、QTcd较对照组明显延长,差异有显著性(p<0.01);安体舒通干预组治疗后QTd、QTcd较治疗前显著下降(p<0.01):安体舒通干预组血清钾、镁治疗后较治疗前明显升高(p<0.01),肌酐轻度减低但差异无显著性(p>0.05)。结论安体舒通可降低心衰患者的QTd、QTcd。     

The effects of chronic carvedilol therapy on QT dispersion in patients with congestive heart failure.

BACKGROUND: Carvedilol therapy reduces mortality from sudden cardiac death and progressive pump failure in congestive heart failure (CHF). However, the effect(s) of carvedilol on ventricular repolarization characteristics is unclear. AIM: The aim of the study was to investigate the effects of chronic carvedilol therapy on ventricular repolarization characteristics as assessed by QT dispersion (QTd) in patients with CHF. METHOD: Nineteen patients (age 53+/-12 years; 16 male, three female) with CHF (eight ischemic, 11 non-ischemic dilated cardiomyopathy) were prospectively included in the study. Carvedilol was administered in addition to standard therapy for CHF at a dose of 3.125 mg bid and uptitrated biweekly to the maximum tolerated dose. From standard 12-lead electrocardiograms the maximum and minimum QT intervals (QTmax, QTmin), QTd, corrected QT intervals (QTcmax, QTcmin) and corrected QTd (QTcd) values were calculated at baseline, after the 2nd and the 16th month of carvedilol therapy. RESULTS: A significant reduction was noted in the QTd and QTcd values with carvedilol therapy after the 16th month (QTd: 81+/-22 ms vs. 40+/-4.3 ms P<0.001; QTcd: 91+/-25 ms vs. 51+/-7 ms P<0.001), but not after the 2nd month (P>0.05). The resting heart rate was also significantly reduced after a 16-month course of carvedilol therapy (78+/-13 bpm vs. 66+/-15 bpm, P<0.05). Carvedilol therapy did not alter QTmax and QTcmax intervals (P>0.05), however, QT min and QTcmin significantly increased with carvedilol at the 16th month (P<0.001 and P<0.01, respectively). CONCLUSION: Long-term carvedilol therapy was associated with a reduction in QTd, an effect that might contribute to the favorable effects of carvedilol in reducing sudden cardiac death in CHF.     

Right lateral decubitus position reduces QT dispersion in patients with chronic heart failure

A greater QT dispersion in patients with chronic heart failure (CHF) appears to be a non-invasive marker of susceptibility to malignant ventricular arrhythmias. We evaluated whether QT dispersion in CHF patients is modified by the patients' recumbent position. In 12 CHF patients, and age and sex-matched 12 normal subjects, a single 12-lead surface ECG was recorded in each postural position [left lateral decubitus position (L), supine position (S), and right lateral decubitus position (R)]. In normal subjects, the QT dispersion was comparable in the three recumbent positions [L: 47+/-15 (SD) ms, S: 40+/-9 ms, R: 38+/-14 ms, P=NS]. In contrast, in CHF patients, QT dispersion was significantly shorter in R than those in L and S (L: 93+/-42 ms*, S: 81+/-29 ms*, R: 63+/-24 ms, *P <.05 vs. R). In conclusion, reclining in R reduces the prolonged QT dispersion in CHF patients.     

慢性心衰并低钾血症QT离散度与室性心律失常的关系

目的：了解心衰并低血钾时校正QT离散度（QTcd)与室性心律失常的关系。方法：分别测量健康对照组。单纯心衰组、心衰并低血钾组及其血钾纠正后的QTcd，并进行比较，同时对各组室性心律失常发生率进行比较。结果：心衰并低血钾组QTcd及室性心律失常发生率明显高于血钾纠正后及单纯心衰组的（P＜0．05－0．01）。结论：QTcd可作为监测心衰并低血钾时室性心律失常危险性的指标。     

充血性心力衰竭QT离散度变化及美托洛尔对其影响

目的 :测定充血性心力衰竭 （CHF）患者的 QT离散度 （QTd）及美托洛尔对 QTd的影响。方法 :110例 CHF患者和 5 0例健康人同时作 QTd测量 ,CHF患者中 38例进行美托洛尔治疗 ,与未使用美托洛尔的 78例作比较。结果 :CHF患者的 QTd明显高于健康人 （P<0 .0 1） ;QTd与心功能受损的程度呈正相关 ;CHF伴室性心律失常者QTd大于不伴室性心律失常者 （P<0 .0 5 ） ;予美托洛尔治疗后 CHF患者 QTd明显缩短 （P<0 .0 5 ）。结论 :CHF患者 QTd明显增大。美托洛尔可使 QTd缩小 ,对防治严重心律失常和猝死有重要意义     

QT离散度对慢性充血性心力衰竭的临床意义

本文分析６６例ＮＹＨＡ分级法心功能Ⅲ－Ⅳ级的慢性充血性心力衰竭患者治疗前后ＱＴ离散度，并与正常组对照，结果表明：１．ＣＨＦ组较正常对照组ＱＴｄ显著延长，不同病因组间无差异；２．住院观察期间，ＱＴｄ在非持续性室速组及死于慢性心衰的病人组无显著延长，１例心性猝死者ＱＴｄ显著处长；３．治疗好转后ＱＴｄ呈下降趋势，治疗无效，恶化者ＱＴｄ进一步延长。     

Repolarization dispersion and sudden cardiac death in patients with impaired left ventricular function

AIMS: Prolongation of repolarization dispersion measured from the12-lead surface ECG has been associated with sudden cardiacdeath and ventricular tachyarrhythmia in a variety of heartdisorders. This study tested the hypothesis that increased repolarizationdispersion is of prognostic value in identifying chronic heartfailure patients at high risk of sudden cardiac death and ventriculartachyarrhythmia. RESULTS: In 163 patients, ischaemic (n=126) and idiopathic dilated (n=37)cardiomyopathy with a left ventricular ejection fraction 40%were diagnosed by left ventricular angiography. During follow-up(26±15 months) 24 patients died suddenly, 10 experiencedventricular tachyarrhythmia, 19 died from pump failure, sixdied from acute myocardial infarction, and 97 survived. Bazett'sformula rate-corrected JT-interval dispersion (JTc-d) was foundto be 109±23 ms in sudden cardiac death/ventricular tachyarrhythmiapatients, 57±20 ms in survivors, and 55+20 ms in patientswho died from pump failure or acute myocardial infarction. Bothunivariate and multivariate analyses showed JTc-d to be themost important independent predictor of sudden cardiac death/ventriculartachyarrhythmia. A cut-off value of 85 ms for JTc-d had a 74%positive and a 98% negative predictive accuracy in identifyingpatients at risk for sudden cardiac death/ventricular tachyarrhythmia. CONCLUSION: Analysis of repolarization dispersion from the 12-lead surfaceECG seems to be a useful screening method for identifying chronicheart failure patients at high risk for sudden cardiac death/ventriculartachyarrhythmia.     

Effect of dofetilide on QT dispersion and the prognostic implications of changes in QT dispersion for patients with congestive heart failure

AIMS: Drug-induced changes in QT dispersion may be a way of detecting harmful repolarisation abnormalities for patients receiving antiarrhythmic drugs affecting ventricular repolarisation. METHODS AND RESULTS: In 463 congestive heart failure (CHF) patients enrolled in the Danish Investigations Of Arrhythmia and Mortality On Dofetilide-CHF (DIAMOND-CHF) study, both pre-treatment and on-treatment day 2-6 QT dispersion was available from standard 12-lead ECGs. Patients were randomised in a double-blind manner to receive either placebo or dofetilide, a new class III antiarrhythmic drug. During a median follow-up of 19 months (minimum 1 year), 179 patients (39%) died (135 patients from cardiac causes). Changes in QT dispersion did not predict all-cause or cardiac mortality for patients treated with dofetilide in multivariate survival analysis (Risk ratio: 1.02, 95% confidence interval: 0.97-1.08, P>0.4). This finding was independent of pre-treatment QT dispersion. Dofetilide caused a small QT dispersion increment of 8 ms, not different from the changes seen in the placebo group (3 ms). CONCLUSION: For patients with CHF and reduced left ventricular systolic function, changes in QT dispersion following treatment with dofetilide do not predict all-cause or cardiac mortality. The dofetilide-induced QT dispersion changes are small and comparable to those seen in placebo treated patients.     

β-受体阻滞剂在心力衰竭治疗中的应用

β-受体阻滞剂可以分为非选择性、选择性和具有血管扩张作用的β-受体阻滞剂3类。这类药物可以通过β信号系统上调、逆转重构、改善收缩和舒张功能、抗心律失常以及抗缺血等作用改善心力衰竭患者预后。随机对照临床研究已经证实其可以降低心力衰竭患者病死率、提高生存质量。各种指南也推荐其应用于心力衰竭的治疗。应用该类药物应该注意用药的时机、剂量、时程和禁忌证。     

QT dispersion as a predictor of long-term mortality in patients with acute myocardial infarction and clinical evidence of heart failure.

BACKGROUND: QT interval dispersion is a marker of inhomogeneous ventricular repolarization, and therefore has the potential to predict re-entry arrhythmias. Following acute myocardial infarction, increased QT dispersion has been associated with a higher risk of ventricular arrhythmias. However, whether or not QT dispersion predicts prognosis post-acute myocardial infarction is not clear. We addressed this issue by analysing the AIREX study registry. METHODS: AIREX was a follow-up study of 603 post-acute myocardial infarction patients who exhibited clinical signs of heart failure and were randomly allocated to ramipril or placebo. An interpretable 12-lead ECG obtained between day 0 and day 9 after the index infarction (median time 2 days) was available in 501 patients. We examined whether QT dispersion was a predictor of all-cause mortality in the AIREX study registry (mean follow-up 6 years). RESULTS: QT dispersion measurements were significantly increased in patients who subsequently died (QT dispersion: 92.0 +/- 38.5 ms vs 82.7 +/- 34.3 ins. P=0.005; rate corrected QT dispersion: 105.7 +/- 42.7 ms vs 93.1 +/- 35.9 ms, P<0.001). Univariate analysis showed that QT dispersion as a predictor of all-cause mortality risk (QT dispersion: hazard ratio per l0 ms 1.05, [95% CI 1.02 to 1.09]. P= 0.004; rate corrected QT dispersion: 1-07 [1.03 to 1.10], P<0.001): an increase of 10 ms added a 5-7%, relative risk of death. QT dispersion remained an independent predictor of all-cause mortality risk on multivariate analysis (QT dispersion: 1.05 [1.01 to 1.09], P=0.027; rate corrected QT dispersion: 1.05 [1.01 to 1.09]. P=0.022). CONCLUSION: QT dispersion. measured from Li routine 12-lead ECG following acute myocardial infarction complicated by heart failure provides independent information regarding the probability of long-term survival. However. the low sensitivity of this electrocardiographic marker limits its usefulness for risk stratification if used in isolation.     

The relationship between QT intervals and mortality in ambulant patients with chronic heart failure. The united kingdom heart failure evaluation and assessment of risk trial (UK-HEART)

Aims: Mortality in patients with heart failure remains high and is difficult to predict. QT interval parameters on a 12-lead ECG have been shown to predict arrhythmic events in patients with a variety of myocardial diseases. There is some, but not consistent, evidence that QT interval parameters may act as predictors of mortality, in particular sudden death, in patients with heart failure. In an adequately powered prospective study we have studied QT interval parameters in patients with stable chronic heart failure in order to determine whether they are predictive of all-cause mortality or mode of death. Methods and Results: Five hundred and fifty-four ambulant outpatients with chronic heart failure were recruited. A 12-lead ECG, chest radiograph, echocardiogram, 24 h ambulatory electrocardiogram and serum for biochemical analysis were obtained at baseline. Patients were followed for 471+/-168 days. QT intervals were measured in all leads blinded to patient's characteristics and outcome, were corrected for heart rate, and the maximum QT intervals, and QT dispersion (range of QT intervals) were determined. The same parameters were determined for JT intervals. The primary end-point was all-cause mortality, secondary end-points were sudden cardiac death and death due to progressive heart failure. Multivariate analysis with the Cox's proportional hazards model was used to determine which variables were independently related to outcome.Four hundred and ninety-five patients had analysable ECGs at study entry and of these 71 died during follow-up. The heart rate corrected QT dispersion and maximum QT interval were significant univariate predictors of all-cause mortality (P=0.026 and <0.0001 respectively), and also of sudden death and progressive heart failure death, but were not related to outcome in the multivariate analysis. The independent predictors of all-cause mortality were cardiothoracic ratio (P=0.0003), creatinine (P=0.0009), heart rate (P=0.007), echocardiographically derived left ventricular end-diastolic dimension (P=0.007) and ventricular couplets on 24 h electrocardiographic monitoring (P=0.015).Conclusion: In an adequately powered prospective study none of the QT or JT parameters were shown to be independent predictors of outcome in patients with mild to moderate congestive heart failure. These variables do not therefore add to the prognostic information which can be gained from simple radiographic, biochemical, echocardiographic and Holter data in this group of patients.     

Evaluation of QT dispersion in beta thalassaemia major patients

Cardiac complications are considered to be the primary cause of death in patients with beta thalassaemia major. QT dispersion is a marker variability of ventricular repolarization and is elevated in various high risk groups of patients. This study was carried out in patients with beta thalassaemia major to evaluate QT dispersion and to investigate the relationship between QT dispersion and body iron load. Sixty-two beta thalassaemia major patients were enrolled into the study. The average serum ferritin levels and liver iron concentration was assessed. For each patient, QT-QTc intervals and QT-QTc dispersions were calculated and V1S and V5R were measured. All the subjects underwent two-dimensional M mode echocardiogram and Doppler study. LVMI was found higher in thalassaemia major patients compared to control group. beta thalassaemia major patients showed significantly higher mean QT, QTc, QTd, and QTcd values compared to the control group. The mean V5R and V1S amplitudes were also higher in beta thalassaemia major patients. There was a positive correlation between LVMI and QTc, QTd and QTcd. However, there was no significant correlation between QT dispersion and serum ferritin and liver iron concentration. Prospective longitudinal studies are needed to assess the prognostic significance of these findings.     

Prognostic value of QT/RR slope in predicting mortality in patients with congestive heart failure

Introduction: Repolarization dynamics, reflecting adaptation of QT to changing heart rate, is considered a marker of unfavorable prognosis in patients with heart diseases. We aimed to evaluate the prognostic value of QT/RR slope in predicting total mortality (TM) and sudden death (SD) in patients with congestive heart failure (CHF). Methods and Results: In 651 sinus rhythm patients with CHF in NYHA class II–III enrolled in the MUSIC study, 24‐hour Holter monitoring was performed at enrollment to assess slope of the QTa/RR (QT apex) and QTe/RR (QTend) during the entire 24‐hour Holter recording and separately during day and night periods. Patients were followed for a median of 44 months, with the primary endpoint defined as TM and the secondary as SD. Analysis of repolarization dynamics was feasible in 542 patients (407M), mean age 63 years, 83% in NYHA class II, 49% with ischemic cardiomyopathy, with mean LVEF 37%. Mean value of QTa/RR slope was 0.172 and QTe/RR was 0.193. During the 44‐month follow‐up there were 119 deaths including 47 SD. Nonsurvivors were characterized by steeper QT/RR slopes. Increased QT/RR slopes during the daytime (>0.20 for QTa and >0.22 for QTe) were independently associated with increased TM in multivariate analysis after adjustment for clinical covariates with respective hazard ratios 1.57 and 1.58, P = 0.002. None of the dynamic repolarization parameters was associated with increased risk of SD in the entire population. Conclusions: Abnormal repolarization dynamics reflected as increased daytime QT/RR slopes is an independent risk stratifier of all‐cause mortality in patients with chronic heart failure     

β Blockade in congestive heart failure: persistent adverse haemodynamic effects during chronic treatment with subsequent doses

Objective—To determine whether the acute adverse haemodynamic effects of β blockade in patients with congestive heart failure persist during chronic treatment.
Design—Sequential haemodynamic evaluation of heart failure patients at baseline and after three months of continuous treatment with the β₁ selective antagonist metoprolol.
Setting—Cardiac care unit in university hospital.
Patients—26 patients with moderate to severe congestive heart failure (New York Heart Association grade II to IV) and background treatment with digoxin, diuretics, and angiotensin converting enzyme inhibitors, and with a left ventricular ejection fraction < 25%.
Methods—Baseline variables included a six minute walk, maximum oxygen consumption, and right heart catheterisation. All patients received metoprolol 6.25 mg orally twice daily initially and the dose was gradually increased to a target of 50 mg twice daily. Haemodynamic measurements were repeated after three months of treatment, both before (trough) and after drug readministration.
Results—Long term metoprolol had functional, exercise, and haemodynamic benefits. It produced decreases in heart rate, pulmonary capillary wedge pressure, and systemic vascular resistance, and increases in cardiac index, stroke volume index, and stroke work index. However, when full dose metoprolol was readministered during chronic treatment, there was a reduction in cardiac index (from 2.8 (SD 0.46) to 2.3 (0.38) l/min/m², p << 0.001) and stroke work index (from 31.4 (11.1) to 26.6 (10.0) g.m/m², p < 0.001) and an increase in systemic vascular resistance (from 943 (192) to 1160 (219) dyn.s.cm⁻⁵, p << 0.001).
Conclusions—Adverse haemodynamic effects of β blockers in heart failure persist during chronic treatment, as shown by worsening haemodynamic indices with subsequent doses.

Keywords: heart failure;  β blockers;  adverse effects     

Effect of carvedilol and metoprolol on the mode of death in patients with heart failure

BACKGROUND: In the COMET study, carvedilol improved survival compared to metoprolol tartrate in 3029 patients with NYHA II-IV heart failure and EF <35%, followed for an average of 58 months. AIMS: To evaluate whether the effect on overall mortality was specific for a particular mode of death. This may help to identify the mechanism of the observed difference. METHODS: Of the 1112 total deaths, 972 were adjudicated as cardiovascular, including 480 sudden, 365 circulatory failure (CF) and 51 stroke deaths. For each mode of death, the effect of pre-specified baseline variables was assessed, including sex, age, NYHA class, aetiology, heart rate, systolic blood pressure, EF, atrial fibrillation, previous myocardial infarction or hypertension, renal function, concomitant medication, and study treatment allocation. RESULTS: In multivariate Cox regression analyses, compared to metoprolol, carvedilol reduced cardiovascular (RR 0.80, CI 0.7-0.91, p=0.0009), sudden (RR 0.77, CI 0.64-0.93, p=0.0073) and stroke deaths (RR 0.37, CI 0.19-0.71, p=0.0027) with a non-significant trend for CF death (RR 0.83, CI 0.66-1.04, p=0.07). Treatment benefit with carvedilol did not differ between modes of death, except for a greater reduction in stroke death with carvedilol (competing risk analysis, p=0.0071 vs CF death). There were no interactions between treatment allocation and baseline characteristics. CONCLUSION: Mortality reduction with carvedilol compared to metoprolol appears relatively non-specific and could be consistent with a superior effect of carvedilol on cardiac function, arrhythmias or, in view of the greater reduction in stroke deaths, on vascular events.     

QT及JT离散度对心性猝死预测价值的探讨

测定３２例心性猝死和３０例非猝死性心性死亡病人入院后的首次心电图ＱＴ离散度（ＱＴｄ）和ＪＴ离散度（ＪＴｄ），产以３０例存活病人作对照，结果显示：（１）心性猝死组ＱＴｄ，ＪＴｄ较存活组和非猝死性心性死亡组显著增大（前者Ｐ均〈０．０１，后者Ｐ均〈０．０５，而非猝死性心性死亡组与存活组ＱＴｄ，ＪＴｄ比较差异均无统计学意义。（２）在心性猝死病人中，死亡直接原因为快速室性心律失常组（２３例）的ＱＴｄ，ＪＴｄ     

Beta blockers in heart failure

The rationale for beta blockade in heart failure is now well established. Heart failure mortality, which is predicted by neurohormonal activation, remains high despite modern treatment, including angiotensin-converting enzyme (ACE) inhibition, and additional neurohormonal blockade has further therapeutic potential. Previous clinical trial experience in heart failure, most of which has been in patients with idiopathic cardiomyopathy, indicates consistent improvement in ventricular function, although variable changes in symptoms and exercise performance. However, the major burden of heart failure occurs in patients with ischemic heart disease, and in this respect it is notable that beta blockade following myocardial infarction confers a significant mortality benefit in subgroups with heart failure. An overview of all currently available randomized clinical trials of beta blockade in heart failure, which includes more than 1600 patients, indicates a mortality risk reduction of approximately 20%, but with wide confidence intervals. A large scale trial with several thousand patients is required to confirm reliably a plausible 20% mortality reduction with beta blockade in heart failure. The dissociation of clinical and mortality effects demonstrated with other heart failure treatments indicates the necessity for an appropriately powered mortality study that could define a major improvement in heart failure therapy for the future. The response to beta blockade will vary according to heart failure severity. A cautious dosetitration approach is required in all cases. In severe heart failure, symptomatic improvement may result, but for the large group of patients with moderate and stable heart failure, the principal aim of treatment is improved longevity.