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Commencing Volume 19, Issue 1, MedReviews has ceased the publication of this journal. Reviews in Cardiovascular Medicine will continue to be published by IMRPress, Ltd. (www.imrpress.org)

Volume 5, Supplement 1, 2004

Volume 5, Supplement 1, 2004

Table of Contents

Management of Chronic Heart Failure: What Do Recent Clinical Trials Teach Us?
Though understanding and development of new therapies for heart failure (HF) have increased dramatically in recent years, the condition still takes a huge toll in terms of both morbidity and mortality and it is essential to continue with the quest for more effective HF treatments. Clinical trials provide the most precise scientific data regarding efficacy of HF therapies. Over the past 2 decades, about 100 large-scale clinical trials have significantly impacted treatment practices with respect to HF patients. The latest have shown benefit in the use of certain ß-blockers, aldosterone-receptor blockers, and the implantation of biventricular pacing-cardioverter defibrillator devices, generally in conjunction with an aggressive medical therapy regimen. This information should be integrated into existing guidelines for HF patient treatment as the search for greater efficacy in controlling and reversing this disease state continues. [Rev Cardiovasc Med. 2004; 5(suppl 1):S3-S9]
Nonselective Versus Selective Beta-Blockers in the Management of Chronic Heart Failure: Clinical Implications of the Carvedilol or Metoprolol European Trial
The abundance of evidence supporting ß-blocker therapy has resulted in the widespread acceptance of these drugs in the treatment of heart-failure patients. However, ß-blockers are not a homogeneous class of drugs, and important differences in efficacy have been noted between different members of the class. Thus, practicing physicians are faced with a choice when selecting a particular ß-blocker for treating heart failure. One of the considerations is whether to choose a selective or a nonselective ß-blocker. The results of the Carvedilol or Metoprolol European Trial indicate that carvedilol, a third-generation, nonselective ß-blocker with additional -blocking, antioxidant, and other properties, is clearly superior to a ß1-blocking drug, metoprolol tartrate. The choice between these drugs is therefore unambiguously in favor of carvedilol. [Rev Cardiovasc Med. 2004; 5(suppl 1):S10-S17]
Carvedilol: Beta-Blockade and Beyond
Carvedilol is an adrenergic antagonist with nonselective ß- and a1-receptor blocking properties that has demonstrated significant clinical benefit in the management of patients with heart failure and in the post-myocardial infarction setting. It also possesses unique ancillary properties that may account for positive results in a number of clinical trials. It appears to offer particular advantages in the treatment of comorbid conditions, including coronary artery disease, stroke, hypertension, renal failure, diabetes, and atrial fibrillation, that can independently contribute to the progression of heart failure. [Rev Cardiovasc Med. 2004; 5(suppl 1):S18-S27]
Heart Failure Therapy in Special Populations: The Same or Different?
Traditional clinical trials of heart failure therapy have focused on fairly homogenous patient populations. Therefore, a pressing question is raised regarding whether it is appropriate to extrapolate findings from these trials to other groups, such as the elderly, women, and African Americans. Based on current knowledge, the differences among these groups should be acknowledged as subtle and represent a need for heightened clinical awareness and more vigorous investigation. These special populations, however, should receive medical therapy for heart failure that is consistent with the results from the major trials and is in accordance with published heart failure guidelines. [Rev Cardiovasc Med. 2004;5(suppl 1):S28-S35]
Practical Considerations for Switching Beta-Blockers in Heart Failure Patients
The use of ß-blocker therapy has proven extremely useful in a variety of clinical settings, including the management of hypertension, acute- and post-myocardial infarction, and in congestive heart failure (HF). However, there are noticeable differences among individual ß-blockers in regard to efficacy of treatment and clinical outcomes in many of these conditions. These differences are particularly apparent in the treatment of HF, where effects on reverse remodeling and interactions on the periphery are potential factors that can differentiate between the efficacy of one drug versus another. In fact, ß-blockers are not a singular, homogeneous group, but rather a class made up of a number of agents with individual differences in pharmacology, receptor biology, hemodynamic effects, and tolerability. In the event of ongoing disease progression, the onus of choosing the most appropriate ß-blocker falls on the clinician’s shoulders. Given the baseline differences among medications of this class, the rationale and manner for transitioning to a different ß-blocker should take into account the specific receptor-blockade subtype of any given agent, as well as any other intrinsic effects attributed to a specific drug. This article includes 2 protocols for switching between carvedilol, a third generation non-selective agent with vasodilatory properties through a1-blockade, and a ß1-selective agent (e.g., metoprolol, atenolol). The aim is to simplify and maximize the safety and tolerability of performing this exchange. With the increasing amount of clinical evidence supporting the use of one ß-blocker over another in the treatment of HF, it behooves physicians treating this patient population to utilize the adrenergic blocking agent that provides optimal therapy with minimal side effects and intolerability. [Rev Cardiovasc Med. 2004;5(suppl. 1):S36-S44]
Strategies to Improve the Use of Evidence-Based Heart Failure Therapies: OPTIMIZE-HF
Patients with heart failure face a very high risk of hospitalizations and mortality. Despite the compelling scientific evidence that angiotensin-converting enzyme inhibitors, ß-blockers, and aldosterone antagonists reduce hospitalizations and mortality in patients with heart failure, these life-saving therapies continue to be underutilized. A number of studies in a variety of clinical settings have documented that a significant proportion of patients with heart failure are not receiving treatment with these guideline-recommended, evidence-based therapies when guided by conventional care. Treatment gaps in providing other components of heart failure patient care, including patient education, have also been documented. The demonstration that initiation of cardiovascular protective medications prior to hospital discharge results in a marked increase in treatment rates, improved long-term patient compliance, and better clinical outcomes has led to the revision of national guidelines to endorse this approach as the standard of care. Recent studies demonstrated that ß-blocker therapy can be safely and effectively initiated in heart failure patients prior to hospital discharge, resulting in improved treatment rates and clinical outcomes. The Organized Program to Initiate Lifesaving Treatment in Hospitalized Patients with Heart Failure (OPTIMIZE-HF) is a national collaborative designed to improve medical care and education of hospitalized heart failure patients and to accelerate initiation of evidence- based heart failure guideline-recommended therapies by administering them before hospital discharge. A registry focusing on hospital admission to discharge and 60–90 day follow-up is designed to evaluate the demographic, pathophysiologic, clinical, treatment, and outcome characteristics of patients hospitalized with heart failure. The aim of this program is to improve the standard of heart failure care in the hospital and outpatient settings and to increase the use of evidence-based therapeutic strategies to prolong life in the large number of heart failure patients hospitalized each year. [Rev Cardiovasc Med. 2004;5(suppl 1):S45-S54]