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Questions and Answers
What is the recommended approach to initiating medications for HFrEF?
What is the recommended approach to initiating medications for HFrEF?
What is the benefit of reducing heart rate in patients with HF, as demonstrated by the SHIFT trial?
What is the benefit of reducing heart rate in patients with HF, as demonstrated by the SHIFT trial?
What is the effect of digoxin on mortality in patients with HF, according to the large-scale RCT?
What is the effect of digoxin on mortality in patients with HF, according to the large-scale RCT?
What is the typical dose of digoxin maintained in patients with HF?
What is the typical dose of digoxin maintained in patients with HF?
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What is the effect of beta blockers on LVEF in patients with HFrEF?
What is the effect of beta blockers on LVEF in patients with HFrEF?
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What is the effect of ACEi and ARBs on cardiovascular death and HF hospitalization in patients with HFrEF?
What is the effect of ACEi and ARBs on cardiovascular death and HF hospitalization in patients with HFrEF?
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What is the risk of worsening HF associated with the use of NSAIDs in patients with heart failure?
What is the risk of worsening HF associated with the use of NSAIDs in patients with heart failure?
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What is the current uncertainty regarding the use of DPP-4 inhibitors in patients with heart failure?
What is the current uncertainty regarding the use of DPP-4 inhibitors in patients with heart failure?
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What is the benefit of using beta blockers in patients with HFrEF?
What is the benefit of using beta blockers in patients with HFrEF?
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What percentage of patients were on optimal doses of beta-blocker therapy in the SHIFT trial?
What percentage of patients were on optimal doses of beta-blocker therapy in the SHIFT trial?
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Study Notes
Heart Failure Treatment
- Two RCTs (V-HeFT I and A-HeFT) demonstrated the benefit of hydralazine-isosorbide dinitrate in self-identified African Americans with heart failure.
- However, uptake of this regimen has been modest due to complexity and drug-related adverse effects.
Omega-3 PUFA Supplementation
- Omega-3 PUFA supplementation can reduce cardiovascular events in patients with heart failure.
- The GISSI-HF trial showed that 1g of omega-3 PUFA reduced death among post-MI patients and significantly reduced death or admission to hospital for a cardiovascular event.
- Omega-3 PUFA therapy has been well tolerated, but may have a dose-related risk of AF in patients with cardiovascular risk.
Renin-Angiotensin System Inhibition
- Inhibition of the renin-angiotensin system is recommended to reduce morbidity and mortality in patients with HFrEF.
- An ARNi, ACEi, or ARB are recommended as first-line therapy.
- ARNi may be used as de novo treatment in patients with symptomatic chronic HFrEF to simplify management.
ACEi and ARB Therapy
- ACEi reduce morbidity and mortality in patients with HFrEF.
- ACEi should be started at low doses and titrated upward to doses shown to reduce the risk of cardiovascular events in clinical trials.
- ARB reduce mortality and hospitalizations in patients with HFrEF in large RCTs.
Dosing and Titration of Medications
- Clinical trials of ACEi, ARB, ARNi, beta blockers, and most other HFrEF medications started patients at low dose and increased the dose over time to a specified target dose.
- The highest tolerated dose is recommended if the target dose cannot be achieved.
Beta Blockers
- Beta blockers provide dose-dependent improvements in LVEF, reduction in HF hospitalizations, and reduction in all-cause mortality.
Heart Rate and Cardiovascular Outcomes
- Heart rate is a strong predictor of cardiovascular outcomes in patients with CVD, including HF.
- The SHIFT trial demonstrated that reducing heart rate improves cardiovascular outcomes.
Digoxin Therapy
- To date, there has been only 1 large-scale, RCT of digoxin in patients with HF.
- The trial showed no effect on mortality but modestly reduced the combined risk of death and hospitalization.
- Digoxin has also shown improvement in symptoms and exercise tolerance in mild to moderate HF.
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Description
This quiz covers the benefits and limitations of using hydralazine-isosorbide dinitrate in treating heart failure in African Americans, as established by RCTs V-HeFT I and A-HeFT.
