Mortality hospital standardized

The combination of nitrates and hydralazine improves the composite endpoint of mortality, hospitalizations for HF, and quality of life in African Americans who receive standard therapy. A fixed-dose combination product is available that contains ISDN 20 mg and hydralazine 37.5 mg (BiDil). Practice guidelines recommend adding ISDN and hydralazine as part of standard therapy in African Americans with moderately severe to severe HF. The combination may also be reasonable for patients of other ethnicities with persistent symptoms despite optimized therapy with an ACE inhibitor (or ARB) and /Tblocker. The combination is also appropriate as first-line therapy in patients unable to tolerate ACE inhibitors or ARBs because of renal insufficiency, hyperkalemia, or possibly hypotension. 

OPTIME-CHF (5) was a randomized, placebo-controlled study in which 951 patients (mean age 65 years 92% with baseUne NYHA class III or IV mean left ventricular ejection fraction 23%) with acute exacerbations of chronic heart failure in 78 community and tertiary care hospitals in the USA were randomly assigned to a 48-hour infusion of either milrinone (0.5 micrograms/kg/minute initially for 24 hours) or saline (6). The median number of days in hospital for cardiovascular causes within 60 days after randomization did not differ significantly between patients given milrinone (6 days) or placebo (7 days). Sustained hypotension requiring intervention (11 versus 3.2%) and new atrial dysrhythmias (4.6 versus 1.5%) were more common in the patients who received milrinone. There was no difference in hospital mortality (3.8 versus 2.3%), 60-day mortality (10 versus 8.9%), or the composite incidence of death or readmission (35 versus 35%). The authors concluded that these results do not support the routine use of intravenous milrinone as an adjunct to standard therapy in patients with an exacerbation of chronic heart failure. 

With evidence that monitoring BNP can be helpful in stratifying disease severity, whether treatments that lower BNP result in decreased morbidity and mortality has to be considered, and multicenter studies are imderway to address this question. The initial data from smaller trials and pilot studies look promising. A pilot study examined BNP in patients admitted with decompensated CHF and treated with the current standard of care. BNP was monitored regularly during hospitalization (hut bhnded to physicians) and correlated with the following endpoints mortality in hospital. 

In summary, the data provide clear evidence that /S-blockers slow the progression of heart failure, evidenced by reductions in mortality and hospitalizations. Many patients also will have improvements in quality of life associated with /S-blocker therapy, although this is not a universal finding. Based on these data, /S-blockers are recommended as standard therapy for all patients with systolic dysfunction, irrespective of the severity of their symptoms. 

Initial studies indicate that ARBs and ACE inhibitors produce similar hemodynamic effects and that combination therapy improves exercise capacity, ventricular function, quality of life, and neurohormones in heart failure patients. The ELITE II trial was the first to compare the effects of an ARB (losartan) with those of an ACE inhibitor (captopril) on all-cause mortality in patients with NYHA class II-IV heart failure. No significant difference in mortahty between the two groups was observed, although losartan was better tolerated than captopril. The Val-HeFT trial evaluated whether the addition of valsartan to standard background heart failure therapy (which included an ACE inhibitor in 93% and a /3-blocker in 35% of patients) improved survival. The addition of valsartan had no effect on all-cause mortality but produced a 13% reduction in morbidity and mortality (principally due to reductions in heart failure hospitalizations). Subgroup analysis showed that the benefits were greatest in... 

CARVEDILOL Carvedilol (coreg) is a nonselective fi receptor antagonist and j-selective antagonist that is FDA-approved for the management of mild-to-severe heart failure. Carvedilol, in combination with standard therapy, is associated with significant reductions in all-cause mortality and hospitalization for heart failure exacerbation. 

Casanova et al., in a one-year study (145), randomized 52 COPD patients to standard care or standard care plus NIV with outcomes that included rate of acute exacerbations, hospital admissions, need for intubation and mortality at three, six, and 12 months. Bi-level positive pressure in spontaneous mode was implemented at an expiratory positive airway pressure of 4 cmH20 and an inspiratory positive airway pressure level of 12 cmH20, adjusted to decrease dyspnea and accessory muscle use. Five of the NIV group (total n = 26) did not tolerate it and the remainder used it for 6.2 hours per 24 hours, with only a few using it for less than 3 hr/day. One-year survival was similar between groups, as was the number of exacerbations. The breathlessness scores decreased in the NIV group, but only one psychomotor test improved. There was no evidence that the results were better in more hypercapnic patients (Paco2 > 7.3 kPa) or in those who used NIV for >5 hours per 24 hours. 

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