PubMed Health⌕ Search

Biomedical subjects

Cristina Opasich

Publications and source records attributed to Cristina Opasich.

At least 19 recordsLinked to original sources
PubMed2006

Does atrial fibrillation in very elderly patients with chronic systolic heart failure limit the use of carvedilol?

BACKGROUND AND AIMS: It is well known that beta-blockers are useful in patients with chronic heart failure (CHF). These favourable effects have recently been observed even in elderly CHF patients. Objectives of the present study were to evaluate the feasibility, tolerability and safety of carvedilol therapy in a cohort of patients > 70 years of age with CHF and left ventricular ejection fraction < 40% with chronic atrial fibrillation. For this purpose, we designed an observational, 12-month prospective study. RESULTS: Among 240 patients who were referred to our centers and met inclusion criteria, 64 had chronic atrial fibrillation (27%). Thirty-nine out of these 64 subjects (61%) were treated with carvedilol, while 25 patients (39%) had contraindications to such treatment. In the cohort of 176 patients with stable sinus rhythm (control group), carvedilol could be administered in 121 patients (69%), while it was not given in 55 (31%, p=ns). Airways disease was the main reason for exclusion from carvedilol in this setting of patients. No difference in 1-year tolerability of study drug was observed among patients with chronic atrial fibrillation (29 of 33 patients=87.9%) and stable sinus rhythm (95 of 102=93.1%). Adverse events leading to the discontinuation of carvedilol in these two populations were rare and never resulted in any disability, death or were life-threatening. CONCLUSION: In over-70 patients with systolic CHF, chronic atrial fibrillation does not limit the possibility of testing beta-blocker therapy. Carvedilol was equally tolerated and safe in patients with atrial fibrillation and sinus rhythm.

Adrenergic beta-Antagonists↗
PubMed2006

Programme to improve the use of beta-blockers for heart failure in the elderly and in those with severe symptoms: results of the BRING-UP 2 Study.

BACKGROUND: Beta-blockers are underused in HF patients, thus strategies to implement their use are needed. OBJECTIVES: To improve beta-blocker use in elderly and/or patients with severe heart failure (HF) and to evaluate safety and outcome. METHODS: Patients with symptomatic HF and age>/=70 years or left ventricular EF<25% and symptoms at rest were enrolled, including those already on beta-blocker treatment. Patients who were not receiving a beta-blocker were considered for carvedilol treatment. All patients were followed up for 1-year. RESULTS: Of the 1518 elderly patients, 505 were already on beta-blockers, and carvedilol was newly prescribed in 419 patients. At 1-year, patients treated with carvedilol had a lower incidence of death [10.8% vs. 18.0% in already treated (adjusted RR 0.68; 95%CI 0.49-0.96) and 11.2% in newly treated patients (adjusted RR 0.68; 95%CI 0.48-0.97)]. Of the 709 patients with severe HF, 38.4% were already on beta-blockers, and carvedilol was newly prescribed in 189 patients. Patients not treated with carvedilol showed the worst clinical outcome. Total rate of discontinuation (including adverse reaction and non-compliance) was 14% and 9%, respectively, in elderly and severe patients. CONCLUSIONS: In a real world setting, beta-blocker treatment was not associated with an increased risk of adverse events in elderly and severe HF patients.

Adrenergic beta-Antagonists↗
PubMed2005

Anemia and change in hemoglobin over time related to mortality and morbidity in patients with chronic heart failure: results from Val-HeFT.

BACKGROUND: Anemia is known to be a prognostic marker for patients with heart failure. However, little is known about the prognostic value of changes in hemoglobin (Hgb) over time or about the causes of anemia. METHODS AND RESULTS: Retrospective analysis of Valsartan Heart Failure Trial data indicated that the quartile of patients with the biggest average decrease in Hgb over 12 months (from 14.2 to 12.6 g/dL) had significantly (P< or =0.01) increased risk of subsequent hospitalization (hazard ratio [HR], 1.47), morbid events (HR, 1.41), and death (HR, 1.6) compared with the quartile that exhibited little change in Hgb over 12 months (from 13.7 to 13.8 g/dL). Increasing Hgb was significantly associated with lower mortality in patients with (HR, 0.78) and without (HR, 0.79) anemia at baseline. Anemia at baseline and the changes in Hgb were independently associated with serum albumin, blood pressure, glomerular filtration rate, B-type natriuretic peptide, and C-reactive protein. Lack of anemia at baseline and increases in Hgb over 12 months were not associated with smaller left ventricular diameters or higher ejection fractions. CONCLUSIONS: Changes in Hgb over 12 months were inversely associated with subsequent risk of mortality and morbidity, independently of the effects of baseline anemia and other important predictors. Several factors were independently related to anemia at baseline and changes in Hgb, suggesting multiple causes of anemia in patients with heart failure. These findings raise important questions about the optimal level of Hgb in patients with moderate to severe heart failure and how to achieve them.

Aged↗
PubMed2005

Blunted erythropoietin production and defective iron supply for erythropoiesis as major causes of anaemia in patients with chronic heart failure.

AIMS: Anaemia is often observed in patients with chronic heart failure (CHF), and it may be associated with a worse prognosis. Aim of this study was to identify the individual mechanisms of anaemia in CHF patients. METHODS AND RESULTS: One hundred and forty-eight consecutive patients with haemoglobin concentration <13 g/dL (if males) or <12 g/dL (if females) were enrolled. Factors responsible for anaemia were investigated by evaluating endogenous erythropoietin (Epo) production, serum cytokines levels, body iron status, and iron supply for erythropoiesis. Most patients (57%) presented anaemia of chronic disease and among them, 92% showed evidence of a defective endogenous Epo production. This was indicated by an observed/predicted log(serum Epo) ratio less than 0.8 and/or a defective iron supply for erythropoiesis diagnosed by low transferrin saturation and/or increased value of soluble transferrin receptor. According to regression analysis sex, renal failure, and serum Epo were correlated with anaemia. CONCLUSION: According to our study, about half of anaemic CHF patients showed anaemia of chronic disease with blunted endogenous Epo production and/or a defective iron supply for erythropoiesis. Determination of the individual mechanisms of anaemia in CHF could justify a rational therapeutic approach to anaemia.

Anemia↗
PubMed2005

Anemia in patients with heart failure: prevalence and prognostic role in a controlled trial and in clinical practice.

BACKGROUND: Aims of the present study were (1) to confirm the prognostic role of anemia in patients with heart failure (HF) and (2) to analyze this aspect in relatively unselected patients with HF monitored prospectively in a community setting (IN-CHF), and in patients selected for enrollment into the Valsartan Heart Failure Trial (Val-HeFT). METHODS AND RESULTS: In both Val-HeFT and IN-CHF Registry, anemia was defined as a hemoglobin (Hb) level < or = 11 g/dL in women and < or = 12 g/dL in men. Of the 2411 patients of the IN-CHF Registry, 15.5% had anemia, whereas in the 5010 patients of the Val-HeFT trial, the prevalence was 9.9%. In the IN-CHF registry, 1-year all-cause mortality was significantly higher in anemic patients (25.9%) than in patients without anemia (13.2%) (P < .0001). The association of anemia with mortality was confirmed by the multivariable analysis (hazard ratio [HR] 1.54, 95% confidence interval [CI] 1.20-1.97). The risk of death decreased by 9.7% for each gram of Hb. The Val-HeFT trial showed an all-cause mortality rate for anemic patients of 29.6% over a mean follow-up period of 22.4 months versus 18.5% (P < .0001) in patients without anemia. After adjustment, anemia retained its negative independent prognostic role (HR 1.26, 95% CI 1.04-1.52). When Hb was considered as a continuous variable, the risk of death decreased by 7.8% for each gram of Hb. CONCLUSIONS: Anemia was confirmed to be an independent negative prognostic factor in patients with HF. This finding is consistent in 2 different clinical contexts, a controlled trial and a registry in clinical practice, in which patient characteristics and outcome are largely different.

Aged↗
PubMed2005

Effect of valsartan on quality of life when added to usual therapy for heart failure: results from the Valsartan Heart Failure Trial.

BACKGROUND: The effect on quality of life (QOL) of valsartan administered in addition to prescribed background heart failure therapy was assessed as a secondary endpoint in the Valsartan Heart Failure Trial (Val-HeFT). METHODS AND RESULTS: QOL was assessed in 3010 patients receiving either valsartan (160 mg twice daily) or placebo in addition to prescribed background therapy (beta-blockers or angiotensin-converting enzyme inhibitors), using the Minnesota Living with Heart Failure (MLWHF) questionnaire. Treatment differences were compared at intervals to 36 months after randomization and at endpoint (last observation) using analysis of covariance and repeated measures mixed-effects, and at endpoint using a Mantel-Haenszel chi-squared test. Scores lower than baseline were indicative of improved QOL. Valsartan had a significant beneficial effect on the least-square mean change in overall MLWHF score from baseline to study endpoint (+/- standard error) (average followup 23.0 months) compared with placebo (0.19 +/- 0.47 versus 1.94 +/- 0.48; P = .005 respectively). The placebo group was characterized by a deterioration in QOL as the trial progressed. More patients on valsartan reported a clinically meaningful improvement in MLWHF score (a decrease of > or =5 points) than on placebo (34.0% versus 30.2%). CONCLUSION: Valsartan compared to placebo added to prescribed therapy slows progressive worsening of QOL in patients with heart failure.

Adrenergic beta-Antagonists↗
PubMed2005

Pharmacological left ventricular reverse remodeling in elderly patients receiving optimal therapy for chronic heart failure.

BACKGROUND AND AIMS: In recent years, reversal of established left ventricular (LV) dilatation has been increasingly recognized in middle-aged patients with dilated cardiomyopathy receiving angiotensin-converting enzyme (ACE) inhibitors and/or beta-blockers. We performed this prospective study to evaluate whether optimized therapy for heart failure also induces LV reverse remodeling in older patients. METHODS: One hundred and twenty-four patients aged >70 years with LV ejection fraction <40% underwent clinical and echocardiographic evaluation at baseline and after 1 year. During the early stage of follow-up, pharmacological therapy was optimized. LV reverse remodeling was defined as a reduction in LV end-diastolic volume >25% from baseline to final evaluation. RESULTS: LV reverse remodeling was recognized in 32 patients (26%). Compared to the subjects who did not improve LV geometry, those with reverse remodeling had, at baseline, higher arterial blood pressure, lower serum creatinine levels, shorter duration of symptoms of heart failure, more frequently received beta-blocker therapy and had predominantly nonischemic aetiology. The variables associated with the development of reverse remodeling in the multivariate analysis were shorter duration of symptoms of heart failure (Odds ratio: 7.7; CI: 2.5-23.3, p=0.0001) and beta-blocker therapy (Odds ratio: 6.0; CI: 1.6-23.3, p=0.01). CONCLUSIONS: LV reverse remodeling takes place in elderly as well as in younger heart failure patients. A significant proportion of elderly patients undergoes this favourable process which occurs prevalently in patients receiving beta-blocker therapy with a short history of cardiac disease.

Adrenergic beta-Antagonists↗
PubMed2005

Functional mitral regurgitation predicts 1-year mortality in elderly patients with systolic chronic heart failure.

BACKGROUND AND AIM: Mitral regurgitation (MR) has been demonstrated to be a powerful predictor of adverse outcome in middle-aged patients with chronic heart failure (CHF). In this study, we sought to define the prognostic impact of functional mitral regurgitation in a population of elderly patients with systolic CHF. METHODS: One hundred seventy-five outpatients aged >70 years with validated CHF and left ventricular ejection fraction <40% underwent clinical and echocardiographic evaluations at baseline. Mitral regurgitation was diagnosed by Color Doppler and quantified in 5 categorical values using a 0-4+ grading system. Outcome measures included 1-year mortality and hospitalization for worsening CHF. RESULTS: The distribution of patients according to the 5 different degrees of MR detected at baseline was: absent=11%, 1+=31%, 2+=38%, 3+=16%, 4+=4%. The relationship between MR and mortality was direct and approximately linear (r=0.39, p=0.00001). The prevalence of death in the 5 subgroups was 0%, 7%, 15%, 45%, 57%, respectively. Multivariate logistic regression analysis showed that MR was the strongest predictor of death (OR 4.47, 95% CI 1.50-13.0), independently of the presence of diabetes mellitus, older age and larger left ventricular end-diastolic volume. No association was found between MR and hospitalization for worsening CHF (r=0.08, p=0.41). CONCLUSIONS: This study establishes the direct and independent relationship between MR severity and one-year mortality among elders with systolic CHF. Conversely, MR does not provide useful information regarding the risk of subsequent hospitalization for worsening CHF.

Aged↗
PubMed2005

Scar detection by contrast-enhanced magnetic resonance imaging in chronic coronary artery disease: a comparison with nuclear imaging and echocardiography.

We compared contrast-enhanced MRI (CeMRI) with the most widely used imaging techniques for myocardial infarct (MI) diagnosis, SPECT and Echo, in unselected patients with chronic coronary artery disease (CAD). Two blinded operators assessed scars on MRI, SPECT and Echo images using a 16-segments LV model. We studied 105 consecutive patients: 50 had Q-wave MI (Q-MI), 19 non Q-wave MI or rest angina (nonQ-MI/RA) and 36 effort angina (EA) history. CeMRI was positive, respectively, in 96%, 37%, and 6%, SPECT in 90%, 53%, and 44%, and Echo in 84%, 32%, and 28% of patients (within Q-MI: CeMRI vs. SPECT p < 0.03, vs. Echo p < 0.001; within EA CeMRI vs. SPECT and ECHO p < 0.001; all trends p < 0.001, pseudo r-square: 0.56-0.75 for CeMRI, 0.18-0.28 for SPECT and 0.23-0.37 for Echo). CeMRI and SPECT agreed in 83 patients (79%); negative SPECT with 1 +/- 0 segments subendocardial delayed enhancement (DE) was found in 4 (4%); negative CeMRI with 4 +/- 3 segments perfusion defects in 18 (17%), 16 of whom were obese or showed LBB or sub-occlusion of related coronary. CeMRI and Echo agreed in 78 patients (75%); negative Echo with 2 +/- 1 segments subendocardial DE was found in 13 (12%) and negative CeMRI with 11 +/- 7 segments kinetic abnormalities in 14 (13%), in 10 confirmed by Cine-MRI. In Q-MI, CeMRI detects DE more frequently than perfusion defects and, especially, kinetic abnormalities are found by SPECT and Echo, respectively. CeMRI identifies small areas of DE also in some patients with nonQ-MI or RA but usually not in patients with EA. This biologically plausible decreasing trend is shown by CeMRI more clearly than by SPECT and Echo. Disagreement between CeMRI and SPECT or Echo may be reduced, but perhaps not fully eluded, performing dobutamine Echo and SPECT after maximal epicardial coronary dilatation.

Aged↗
PubMed2005

Contrast-enhanced magnetic resonance imaging assessment of scar size in patients with chronic myocardial infarction.

BACKGROUND: In the assessment of myocardial infarction (MI) mass, contrast-enhanced magnetic resonance imaging (CE-MRI) is comparable to single-photon emission computed tomography (SPECT). The aim of the present study was to determine whether the MI area, as assessed at CE-MRI and SPECT, is comparable to mass evaluation. We also compared CE-MRI and SPECT estimates of the MI area with functional evaluations made at echocardiography and kinetic MRI (cine-MRI). METHODS: We used a 1.0 Tesla MRI scanner and an inversion-recovery turboFLASH sequence, a tomographic gamma-camera and second-harmonic ultrasound systems. Two blinded operators assessed the extent of scarring, expressed as a percentage of the whole left ventricle (LV), using a 16-segment model. We studied 55 consecutive patients with a clinically stable healed MI (50 Q wave, 5 non-Q wave). RESULTS: The scar mass was 19+/-23% of the LV at CE-MRI and 21+/-25% at SPECT; the scar area was 29+/-23% of the LV at CE-MRI, 41+/-28% at SPECT, 29+/-31% at cine-MRI, and 32+/-29% at echocardiography. The Bland-Altman bias between CE-MRI and SPECT mass estimations was -2% of the LV with a+/-23% limit of agreement (LOA), while the bias between the area assessments was -12% with a+/-42% LOA. Bias between CE-MRI and functional evaluation by cine-MRI and echocardiography was 0% with a+/-39% LOA and -3% with a+/-36% LOA respectively. Comparing SPECT with cine-MRI and echocardiography the bias was 12% with a+/-52% LOA and 9% with a+/-56% LOA respectively. CONCLUSIONS: CE-MRI has proved to be comparable to SPECT in the assessment of the healed MI mass. Conversely, a high systematic error (high bias and LOA) renders CE-MRI and SPECT assessments of the MI area incomparable. Similarly (high bias and/or LOA) CE-MRI and SPECT estimations of the MI area cannot be compared with functional evaluation by echocardiography or cine-MRI.

Aged↗
PubMed2005

Does atrial fibrillation in elderly patients with chronic heart failure limit the efficacy of carvedilol? Suggestions from an observational study.

BACKGROUND: No clinical investigation provided any information about a possible influence of atrial fibrillation on the response to beta-blocker therapy in elderly patients with chronic heart failure (CHF). The aim of this study was to observe carvedilol effects in a cohort of patients > 70 years of age with CHF due to left ventricular dysfunction and with chronic atrial fibrillation. METHODS: An observational, 12-month prospective clinical and echocardiographic study was carried out on 240 patients > 70 years of age with heart failure due to systolic dysfunction, 64 of whom with atrial fibrillation. RESULTS: After 1 year of beta-blocker treatment, patients with atrial fibrillation and those in sinus rhythm showed similar benefits, in terms of symptomatic improvement (deltaNYHA -0.44 if atrial fibrillation vs -0.57 if sinus rhythm, p = NS), reduction of events (death + hospitalizations -38 vs -15%), recovery of cardiac function (left ventricular ejection fraction delta +8.8 vs +9.4%, p = NS; left ventricular end-diastolic volume delta -17.2 vs -12.5 ml, p = NS), and reduction in mitral regurgitation (delta -042 vs -0.57, p = NS). No difference was found between the two study groups regarding left ventricular end-diastolic volume reduction (12% in atrial fibrillation patients and 18% in sinus rhythm patients, p = NS) and prevalence of the "reverse remodeling" phenomenon (22 and 21%, respectively, p = NS). CONCLUSIONS: In CHF patients > 70 years of age, beta-adrenergic blockade was shown to be equally effective in improving symptoms and left ventricular geometry and function in patients with atrial fibrillation or in sinus rhythm, without any adjunctive sign of long-term clinical deterioration.

Adrenergic beta-Antagonists↗
PubMed2005

Functional evaluation of patients with chronic pulmonary hypertension.

The importance of studying the pathophysiological bases and clinical correlates of exercise limitation in patients with pulmonary arterial hypertension (PAH) is well established. Two modes of exercise testing, the 6-min walk test (6MWT) and the cardiopulmonary exercise test (CPET), are currently proposed for diagnostic, therapeutic and prognostic finalities. The 6MWT is inexpensive, feasible and is thought to better reproduce daily life activities and to reliably detect therapeutic benefits. CPET requires the patient's maximal effort and does not provide a reliable quality of life measure. It is, however, highly reproducible and provides remarkable insights into the pathophysiological mechanisms that lead to exercise intolerance. Due to the limited experience accumulated, CPET is not actually advised for the routine assessment and for the overall clinical decision making of PAH patients. In this review we critically address the knowledge currently acquired on these techniques.

Exercise Test↗
PubMed2004

Inadequate nutritional intake for daily life activity of clinically stable patients with chronic heart failure.

We investigated the nutritional adequacy and energy availability in 57 normal-weight patients with chronic heart failure (HF) and 49 matched healthy sedentary subjects. We found that the chronic HF patients had a higher total energy expenditure (1,700 +/- 53 vs 1,950 +/- 43 kcal/day; p <0.01), a negative calorie balance (104 +/- 35 vs -186 +/- 40 kcal/day; p <0.01), a negative nitrogen balance (2.2 +/- 0.5 vs -1.7 +/- 0.4 g/day; p <0.01), and a hypercatabolic hormonal status (cortisol/insulin ratio 32 +/- 1.7 vs 65 +/- 5.1; p <0.01). We conclude that patients with chronic HF had an inadequate calorie intake to support energetic needs for daily activities, with consequent important protein breakdown that causes muscular wasting.

Cachexia↗
PubMed2004

Chronic left ventricular failure in the community: Prevalence, prognosis, and predictors of the complete clinical recovery with return of cardiac size and function to normal in patients undergoing optimal therapy.

BACKGROUND: Chronic heart failure (CHF) is a progressive process requiring complex therapeutic interventions. Recently, several trials documented the clinical improvement and regression of left ventricular (LV) remodeling and function in patients on optimized CHF treatment. Furthermore, some authors reported isolated cases of patients who apparently "healed" from CHF. The aim of the present study was to characterize the phenomenon of the normalization in clinical status and LV size and function in CHF patients. METHODS AND RESULTS: We monitored the clinical and echocardiographic parameters of a large cohort of patients with CHF and LV ejection fraction <40% every 6 months for a mean period of 17 +/- 9 months. Twenty of 110 study patients (18%) normalized clinical status and LV size and ejection fraction at any time (mean time 13 +/- 6 months) during the follow up. Such condition, however, was subsequently lost in 11 patients. The normalization was predicted by the nonischemic etiology of CHF, arterial hypertension, absence of diabetes mellitus, carvedilol therapy, and the dose of carvedilol. CONCLUSIONS: The normalization in clinical status and LV size and function is not infrequently observed in patients on optimal CHF therapy. It is predicted by a set of clinical variables and favored by beta-blocker therapy. At medium term, this condition fades in a significant portion of patients.

Adrenergic beta-Antagonists↗
PubMed2004

Dilated versus nondilated cardiomyopathy in the elderly population treated with guideline-based medical therapy for systolic chronic heart failure.

BACKGROUND: Although the process by which the left ventricular (LV) remodels in response to an injury generally leads to dilatation, in patients with heart failure (HF) the recognition of a small or mildly dilated left ventricle is not uncommon. We investigated the prevalence and the characteristics of elderly patients with traditional dilated and nondilated cardiomyopathy (CMP). We also assessed the response to the guideline-based medical therapy and the prognosis based on LV dilatation in this population. METHODS AND RESULTS: We selected 243 patients >70 years of age with HF and LV ejection fraction <40% who underwent clinical and echocardiographic evaluations at baseline and after 12 months. They were subdivided into 2 groups according to baseline LV end-diastolic volume (LVEDV) (values < or =78 mL/m(2) identified nondilated CMP). Nondilated CMP was recognized in 64 patients (26%) who showed at baseline better clinical status, less severe mitral regurgitation, and higher LV ejection fraction than those with dilated CMP. At the final evaluation, favorable changes in clinical and echocardiographic parameters could be detected in both groups. The magnitude of these variations did not differ between the groups. The risk of hospitalization for worsening HF was 2.4-fold higher in patients with nondilated than dilated CMP. Mortality was 11% and 20%, respectively (P = .06). Statistical analysis revealed a direct, approximately linear relationship between LVEDV and outcomes in this population. CONCLUSIONS: A total of 1 of 4 elderly patients with systolic HF had a nondilated left ventricle. These patients had a better clinical presentation than did counterparts with dilated left ventricles. After HF therapy is optimized, the likelihood of improvement is independent of LV size in this population, whereas the risk of death or worsening HF linearly increases with LV dilatation.

Aged↗
PubMed2004

Distance walked in the 6-minute test soon after cardiac surgery: toward an efficient use in the individual patient.

STUDY OBJECTIVES: To describe the results of the 6-min walking test performed on admission to an intensive rehabilitation program after cardiac surgery and to develop, through an algorithm based on a few clinical indicators, reference tables in order to apply distance walked values more efficiently in the individual patient at his/her entry into a cardiac rehabilitation program. SETTING: Intensive cardiac rehabilitation units. PATIENTS AND INTERVENTION: A total of 2,555 consecutive patients admitted between January 2001 and December 2002 to the Cardiac Rehabilitation Department of the S. Maugeri Foundation early after cardiac surgery performed a 6-min walking test within the fourth day of hospital admission. RESULTS: The mean walked distance was 296 +/- 111 m (+/- SD). At multiple regression analysis, age, sex, and comorbidity were independent predictors of walking test performance. The left ventricular ejection fraction only influenced the walked distance in men. Starting from these variables, we propose an algorithm and specific reference tables. CONCLUSIONS: Reference values for gender-, age-, comorbidity-, and systolic function-related test performance in patients after cardiac surgery at the beginning of the rehabilitative phase are provided. Once a new patient has been categorized through simple parameters, the actual distance walked could be compared with the matched reference value, thus making the interpretation of the result more efficient. The walked distance might be used to define different levels of disability and to personalize therapeutic exercise prescriptions.

Aged↗
PubMed2004

Pre-discharge initiation of beta-blocker therapy in elderly patients hospitalized for acute decompensation of chronic heart failure: an effective strategy for the implementation of beta-blockade in heart failure.

BACKGROUND: Current guidelines recommend beta-blockers in patients with heart failure and left ventricular systolic dysfunction. These agents, however, are largely underused in elderly patients because of the perception of up-titration complexity and the fear of side effects. METHODS: We prospectively assessed the feasibility, safety, tolerability, and 1-year outcome of the in-hospital initiation of carvedilol in elderly patients admitted for worsening heart failure. RESULTS: Among 164 eligible subjects (age > 70 years, left ventricular ejection fraction < 40% and no sign of congestion), 120 (73%) received carvedilol, on average 4.5 days after admission. The drug was permanently withdrawn in 10 out of 116 survivors (9%) at 60 days: 5 did not tolerate the starting dose because of worsening heart failure (n = 1), bradycardia (n = 1), and bronchospasm (n = 3). Two discontinued carvedilol during the in-hospital dose titration phase because of increasing premature ventricular beats and transient second degree atrioventricular block. The remaining 3 dropouts (fatigue in 2 and symptomatic bradycardia in 1 case) occurred after discharge. During the period between 60 days and 12 months, carvedilol was discontinued in 2 patients because of a depressive syndrome and symptomatic bradycardia. In no case these adverse events lead to death or were life-threatening, required hospitalization or resulted in any disability. The 1-year tolerability was 89%, the mortality was 17.5%, the frequency of hospitalization for worsening heart failure was 21%. CONCLUSIONS: Thus, our results show that the in-hospital initiation of carvedilol is feasible and well-tolerated in elderly patients with recent worsening heart failure, and allows rapid identification of the most intolerant patients. The proportion of subjects taking carvedilol after 1 year from discharge was very high. This unconventional approach could significantly modify the use of beta-blockers in clinical practice.

Adrenergic beta-Antagonists↗