Congestive Heart Failure Survival Trial

Deedwania PC, Singh BN, Ellenbogen K, Fisher S, Fletcher R, Singh SN. Spontaneous conversion and maintenance of sinus rhythm by amiodarone in patients with heart failure and atrial fibrillation observations from the veterans affairs congestive heart failure survival trial of antiarrhythmic therapy (CHF-STAT). The Department of Veterans Affairs CHF-STAT Investigators. Circulation 1998 98 2574-9. 

Chymostatin-sensitive Il-generating enzyme Carvedilol Post-Infarct Survival Control in Left Ventricular Dysfunction Trial Collaborative Study Captopril Trial ( The Effect of Angiotensin-Converting Enzyme Inhibition on Diabetic Nephropathy ) calcium channel blocking agents Candesartan in Heart Failure Assessment of Reduction in Morbidity and Mortality Trial congestive heart failure, but the latest recommendations use HF for heart failure chronic kidney disease cardiac output... 

CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 1987 316 1429-1435. 

Abbreviations-. BEST, beta-blocker evaluation survival trial CAPRICORN, caiveclilol postinfarct suivival control in left ventricular dysfunction C1B1S II, Cardiac Insufficiency Bisoprolol Study II COMET, Carvedilol or Metoprolol European Trial COPERNICUS, carvedilol prospective randomized cumulative survival HF, heart failure LVEF, left ventricular ejection fraction MDC, metoprolol in dilated cardiomyopathy MERIT-HF, metoprolol controlled-release randomized intervention trial in congestive heart failure fJYHA, New York Heart Association. 

Adverse effects Amiodarone shows a variety of toxic effects. After long-term use, more than one half of the patients receiving the drug show side effects sufficiently severe to prompt its discontinuation. Some of the more common effects include interstitial pulmonary fibrosis, gastrointestinal tract intolerance, tremor, ataxia, dizziness, hyper- or hypothyroidism, liver toxicity, photosensitivity, neuropathy, muscle weakness, and blue skin discoloration caused by iodine accumulation in the skin. As noted earlier (see p. 166) recent clinical trials have shown that amiodarone did not reduce incidence of sudden death or prolong survival in patient with congestive heart failure (CHF). 

STEMI (17). This landmark trial revealed that the use of early beta-blocker therapy in STEMI reduces the risks of reinfarction and ventricular fibrillation. However, there was a small increase in frequency of cardiogenic shock in patients randomized to the beta-blocker group. Therefore, beta-blockers should be contraindicated in patients presenting with a cardiogenic shock or decompensated congestive heart failure (CHF). Other relative contraindications to beta-blockers include advanced heart block, bradyarrythmias, and active asthma. Unless these contraindications are present, the (ACC/AHA) guidelines list oral beta-blocker therapy within 24 hours as a class I indication in patients with ACS (18). In patients presenting with left ventricular dysfunction after MI as defined by an ejection fraction <40%, carvedilol has been shown to reduce reinfarction rate and mortality in the Carvedilol Post Infarction Survival Control in Left Ventricular Dysfunction (CAPRICORN) trial when compared with placebo (19). 

Cardiac resynchronization therapy (CRT) for systolic congestive heart failure (CHF) represents a new paradigm in cardiology the use of an electrical therapy (cardiac pacing) to treat a mechanical problem. Multiple randomized clinical trials have proven that resynchronization therapy improves symptoms and functional status, increases quality of life, reduces hospitalizations, and prolongs survival in appropriately selected patients. As a result, this therapy has been quickly established as a standard treatment for patients with severe left ventricular dysfunction, moderate-to-severely symptomatic CHF despite optimal medical therapy, and prolonged QRS duration (1,2). 

Califf R, Adams KF, McKenna WJ, et al. A randomized controlled trial of epoprostenol therapy for severe congestive heart failure The Flolan International Randomized Survival Trial (FIRST). Am Heart] 1997 134 44-54. 

SCD-HeFT was a prospective, randomized trial that enrolled patients with left ventricular ejection fraction < 0.35 and New York Heart Association Functional Class II-III congestive heart failure to evaluate whether amiodarone or an ICD improved survival compared to a placebo pill. The primary end point of the trial was death from any cause. Amiodarone therapy did not affect outcomes compared to placebo (54). A few studies and one meta-analysis of several large studies have shown reduction in SCD using amiodarone for LV dysfunction due to prior myocardial infarction and nonischemic dilated cardiomyopathy (117,136). Any long-term survival benefit from amiodarone is doubtful. 

Singh, S.N., et al., Amiodarone in patients with congestive heart failure and asymptomatic ventricular arrhythmia. Survival Trial of Antiarrhythmic Therapy in Congestive Heart Failure. New Engl J Med, 1995. 333(2) p. 77-82. 

Inhibitors of a heart-specific subtype (type III) phosphodiesterase, which are positive inotropics, may be used in the short-term treatment of severe congestive cardiac failure, e.g. amrinone, enoximone and milrinone. However, developments of oral formulations of drugs of this type have been halted by the results of the PROMISE trial (Prospective Randomised Milrinone Survival Evaluation trial) which documented a paradoxical increase in mortality in class IV heart failure patients randomised to receive milrinone. However, some benzimidazole derivatives with class III phosphodiesterase inhibitor actions seem to be beneficial in heart failure. The agent vesnarinone is an orally active compound that may act as a class III phosphodiesterase inhibitor but appears to be a vasodilator with multiple mechanisms. See HEART FAUURE TREATMENT INOTROPIC AGENTS. 

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