New 2012 heart failure guidelines

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1.      Compared with the ESC’s 2008 guidelines, the new guidelines call for a more liberal use of mineralocorticoid-receptor antagonists (MRAs) i.e. aldosterone antagonists in heart failure. They are recommended for most patients who remain symptomatic despite treatment with both ACE inhibitors and beta-blockers.  It can now be given to NYHA class 2 patients with an LVEF <35%.
2.       The new guidelines also give new weight to reduction of heart rate (HR) as a specific treatment target by adding ivabradine if the rate remains 70 bpm or higher despite triple-drug therapy: optimized
beta blockers, ACE inhibitors, and MRAs (SHIFT trial).
3.      Drugs that should not be given specifically for heart failure include statins and oral anticoagulants, except in patients with atrial fibrillation.
4.      Drugs that may actually be harmful in heart failure include thiazolidinediones and calcium-channel blockers that are negatively inotropic i.e. most of them.
5.       In AF it is possible of course to use the new anticoagulants [oral direct thrombin inhibitors and oral factor Xa inhibitors]. But these drugs are contraindicated in severe renal impairment–and a lot of
patients with heart failure, as we know, have this condition.
6.       Patients expected to survive with good functional status for more than one year should receive CRT if they are in sinus rhythm, their LVEF is low (<30%), and QRS duration is markedly prolonged
irrespective of symptom severity.
7.       Application to NYHA class 2 heart failure is what’s new based on the MADIT-CRT and RAFT trials, in addition to reduced certainty that CRT will benefit patients with a right-bundle-branch-block QRS morphology or atrial fibrillation.
8.      CRT should be done in patients with NYHA class 2 with a QRS duration >130 ms with a left bundle branch block (LBBB) morphology and LVEF <30%.
9.      For non-LBBB morphology, look for a QRS width of >150 ms, and that gets a class IIa ['should be considered'] recommendation.
10.     In considering CRT in NYHA class 2 patients within the QRS-duration window of 120-150 ms take a clinical decision. “Do you see strong convincing evidence of mechanical dyssynchrony with an
imaging technique? Is there left ventricular dilatation? Is there LBBB? Has the patient recently been more symptomatic?”
11.      Recommendations for use of CABG in heart failure have broadened as a result of the STICH trial, which saw benefits from the surgery in patients with systolic heart failure but only mild angina.
12.     As a result of the PARTNER trials, transcatheter aortic valve implantation (TAVI) enters the guidelines. It should be considered in patients with aortic stenosis who are not appropriate candidates for
conventional surgery.
13.     Left ventricular assist devices (LVADs) are now “recommended” in patients who are also candidates for transplantation and have “should-be-considered” status for destination therapy.
14.     LVADs may be increasingly used in selected patients with less severe disease than end stage, “before right-ventricular or multiorgan failure develops.
15.      The ventricular assist devices may ultimately become a more general alternative therapy to transplantation, because the current 2-3 year survival rates with continuous-flow devices seem superior not only to medical therapy but also to pulsatile flow devices.
16.     In the new guidelines there is a smaller presence of recommendations relating to lifestyle changes. With only two exceptions, you will not see in the new guidelines any recommendation in relation to lifestyle. The exceptions, both class IA recommendations: “Regular aerobic exercise is encouraged in patients with heart failure to improve functional capacity and symptoms,” and patients are advised to enroll in a “multidisciplinary-care management program” to lower the risk of heart-failure hospitalization. [www.escardio.org/guidelines ]

Calcium pills may raise risk of heart attack

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People taking calcium supplements had nearly double the risk of heart attack as individuals not taking any dietary supplements. Among 23,980 participants in the European Prospective Investigation into Cancer and Nutrition (EPIC-Heidelberg) study, the hazard ratio for MI in those using calcium supplements, compared with nonusers of supplements, was 1.86 (95% CI 1.17 to 2.96), according to Sabine Rohrmann, MD, of the University of Zurich in Switzerland, and colleagues.

The study, published online in the journal Heart, also suggested that calcium intake from food, previously considered to be beneficial for cardiovascular health, may not make much of a difference after all.

This study suggests that increasing dietary calcium intake from diet might not confer significant cardiovascular benefits, while calcium supplements, which might raise MI risk, should be taken with caution. The increased risk of MI in users of calcium supplements was especially prominent in participants who took only such supplements, not other minerals or vitamins.