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xmlns=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022 id=\u0022content-block-markup\u0022 xmlns:xhtml=\u0022http:\/\/www.w3.org\/1999\/xhtml\u0022\u003E\u003Cdiv class=\u0022article fulltext-view \u0022\u003E\u003Cspan class=\u0022highwire-journal-article-marker-start\u0022\u003E\u003C\/span\u003E\u003Cdiv class=\u0022section abstract\u0022 id=\u0022abstract-1\u0022\u003E\u003Ch2\u003ESummary\u003C\/h2\u003E\n            \u003Cp id=\u0022p-1\u0022\u003EThis article reviews data from four heart failure studies and discussed changes in the 2013 American College of Cardiology Foundation\/American Heart Association Heart Failure Guidelines [Yancy CW et al. \u003Cem\u003EJ Am Coll Cardiol\u003C\/em\u003E 2013; \u003Cem\u003ECirculation\u003C\/em\u003E 2013].\u003C\/p\u003E\n         \u003C\/div\u003E\u003Cul class=\u0022kwd-group\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003EAnemias\u003C\/li\u003E\u003Cli class=\u0022kwd\u0022\u003EHeart Failure\u003C\/li\u003E\u003C\/ul\u003E\u003Cul class=\u0022kwd-group clinical-trial\u0022\u003E\u003Cli class=\u0022kwd\u0022\u003ECardiology \u0026amp; Cardiovascular Medicine\u003C\/li\u003E\u003C\/ul\u003E\u003Cp id=\u0022p-2\u0022\u003EDipti Itchhaporia, MD, Hoag Heart and Vascular Institute, Newport Beach, California, USA, reviewed data from four heart failure studies and discussed changes in the 2013 American College of Cardiology Foundation (ACCF)\/American Heart Association (AHA) Heart Failure Guidelines [Yancy CW et al. \u003Cem\u003EJ Am Coll Cardiol 2013; Circulation\u003C\/em\u003E 2013].\u003C\/p\u003E\u003Cp id=\u0022p-3\u0022\u003EThe primary change is the expanded definition of heart failure (HF) to HF with reduced ejection fraction (EF \u226440%; HF\u003Cem\u003Er\u003C\/em\u003EEF or systolic HF) and heart failure with preserved ejection fraction (EF \u226550%; HF\u003Cem\u003Ep\u003C\/em\u003EEF or diastolic HF). Two subcategories of HF\u003Cem\u003Ep\u003C\/em\u003EEF have also been defined: HF\u003Cem\u003Ep\u003C\/em\u003EEF Borderline (EF 41% to 49%) and HF\u003Cem\u003Ep\u003C\/em\u003EEF Improved (patients previously diagnosed with HF\u003Cem\u003Er\u003C\/em\u003EEF whose EF is now \u0026gt;40%).\u003C\/p\u003E\u003Cp id=\u0022p-4\u0022\u003EGreater emphasis has been placed on adherence to performance and quality measures, reducing readmissions, patient self-care, and team-based care. The guidelines call for a more thorough analysis of HF\u003Cem\u003Ep\u003C\/em\u003EEF, a continued assessment of risk factors, genetic testing, and avoidance of anticoagulation in patients with chronic reduced EF and no risk factors. For the first time, the guidelines include recommendations for optimal guideline-directed medical therapy (GDMT).\u003C\/p\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-1\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003ERED-HF: ADDRESSING ANEMIA\u003C\/h2\u003E\n         \u003Cp id=\u0022p-5\u0022\u003EStudies have shown that anemia in HF patients is associated with worse functional capacity and poor survival. Increasing hemoglobin using an erythropoiesis-stimulating agent has been suggested to have clinical benefit. Darbepoetin alfa is a glycoprotein that stimulates erythropoietin, a hormone released from the kidney that develops red blood cells and produces hemoglobin.\u003C\/p\u003E\n         \u003Cp id=\u0022p-6\u0022\u003EThe Reduction of Events With Darbepoetin Alfa in Heart Failure study [RED-HF; Swedberg K et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2013] assessed its effects on clinical outcomes in 2778 HF patients with HF\u003Cem\u003Er\u003C\/em\u003EEF and mild-to-moderate anemia. Although darbepoetin alfa significantly increased hemoglobin levels, the increase did not reduce the risk of the primary composite outcome of death or hospitalization for HF. Scores on the Kansas City Cardiomyopathy Questionnaire indicated a small, but statistically significant improvement in quality of life (QoL; p=0.005) after 6 months in patients treated with darbepoetin alfa. The risk of thromboembolic events was significantly higher in darbepoetin alfa-treated patients (13.5% vs 10% with placebo). These findings suggested that hemoglobin is simply a marker of poor prognosis in HF rather than a therapeutic target.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cdiv class=\u0022section\u0022 id=\u0022sec-2\u0022\u003E\n         \u003Ch2 class=\u0022\u0022\u003EASTRONAUT: TESTING ALISKIREN, A NEW DIRECT RENIN INHIBITOR\u003C\/h2\u003E\n         \u003Cp id=\u0022p-7\u0022\u003EThe ASTRONAUT trial [Gheorghiade M et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2013] was an international, randomized, controlled trial designed to evaluate the effect of inhospital initiation of the direct renin inhibitor aliskiren on postdischarge morbidity and mortality among patients with HF. The study population was comprised of patients hospitalized with HF who were hemodynamically stable with HF\u003Cem\u003Er\u003C\/em\u003EEF, elevated natriuretic peptides (brain natriuretic peptide [BNP] \u2265400 pg\/mL or N-terminal pro-BNP [NT-proBNP] \u22651600 pg\/mL), and signs and symptoms of fluid overload. Patients were recruited from 316 sites across North and South America, Europe, and Asia between May 2009 and December 2011. The follow-up period ended in July 2012. Patients were randomized to aliskiren (starting dose 150 mg, titrated to 300 mg as tolerated; n=808) or placebo (n=807), on top of standard therapy. The primary outcome of cardiovascular (CV) death or hospitalization for heart failure at 6 months occurred in 24.9% of the aliskiren group versus 26.5% of the placebo group (p=0.41).\u003C\/p\u003E\n         \u003Cp id=\u0022p-8\u0022\u003EThe ASTRONAUT trial did not support routine administration of aliskiren in patients recently hospitalized for worsening chronic heart failure (\u003Ca id=\u0022xref-fig-1-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F1\u0022\u003EFigure 1\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cp id=\u0022p-9\u0022\u003EData from observational studies and small trials have suggested that sildenafil, a phosphodiesterase-5 (PDE-5) inhibitor, might improve exercise capacity and clinical outcomes in HF patients compared with placebo. The Effect of Phosphodiesterase-5 Inhibition on Exercise Capacity and Clinical Status in Heart Failure With Preserved Ejection Fraction trial [RELAX; Redfield MM et al. \u003Cem\u003EJAMA\u003C\/em\u003E 2013] was a randomized, controlled study that enrolled 216 patients with NYHA Class II to IV HF\u003Cem\u003Ep\u003C\/em\u003EEF at 26 North American centers between October 2008 through February 2012. Follow-up was through August 30, 2012. Participants were randomized to sildenafil (n=113) or placebo (n=103) administered orally at 20 mg TID for 12 weeks, followed by 60 mg TID for 12 weeks. The primary endpoint was change in peak oxygen consumption after 24 weeks of therapy. A key secondary endpoint was the composite clinical status rank score, based on time to death, time to CV or cardiorenal hospitalization, and change in QoL for participants without CV or cardiorenal hospitalization at 24 weeks.\u003C\/p\u003E\n         \u003Cdiv id=\u0022F1\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/14\/F1.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022CV Death or HF Rehospitalization Following Aliskiren Treatment\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2045275063\u0022 data-figure-caption=\u0022CV Death or HF Rehospitalization Following Aliskiren Treatment\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 1.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/14\/F1.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/14\/F1.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 1.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/14\/F1.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13467\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 1.\u003C\/span\u003E \n               \u003Cp id=\u0022p-10\u0022 class=\u0022first-child\u0022\u003ECV Death or HF Rehospitalization Following Aliskiren Treatment\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-1\u0022\u003EReproduced from Gheorghiade M et al. Effect of aliskiren on postdischarge mortality and heart failure readmissions among patients hospitalized for heart failure: The ASTRONAUT randomized trial. \u003Cem\u003EJAMA\u003C\/em\u003E 2013;309(11):1125\u20131135. With permission from the American Medical Association.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-11\u0022\u003EAt Week 24 in RELAX, the change in peak oxygen consumption was not significantly different between the two groups, and there was no significant difference in mean clinical status rank scores (\u003Ca id=\u0022xref-fig-2-1\u0022 class=\u0022xref-fig\u0022 href=\u0022#F2\u0022\u003EFigure 2\u003C\/a\u003E).\u003C\/p\u003E\n         \u003Cdiv id=\u0022F2\u0022 class=\u0022fig pos-float  odd\u0022\u003E\u003Cdiv class=\u0022highwire-figure\u0022\u003E\u003Cdiv class=\u0022fig-inline-img-wrapper\u0022\u003E\u003Cdiv class=\u0022fig-inline-img\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/14\/F2.large.jpg?width=800\u0026amp;height=600\u0026amp;carousel=1\u0022 title=\u0022Effects of Sildenfil on Exercise Capacity and Clinical Outcome\u0022 class=\u0022fragment-images colorbox-load\u0022 rel=\u0022gallery-fragment-images-2045275063\u0022 data-figure-caption=\u0022Effects of Sildenfil on Exercise Capacity and Clinical Outcome\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003E\u003Cimg class=\u0022fragment-image\u0022 alt=\u0022Figure 2.\u0022 src=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/14\/F2.medium.gif\u0022\/\u003E\u003C\/a\u003E\u003C\/div\u003E\u003C\/div\u003E\u003Cul class=\u0022highwire-figure-links inline\u0022\u003E\u003Cli class=\u00220 first\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/14\/F2.large.jpg?download=true\u0022 class=\u0022highwire-figure-link highwire-figure-link-download\u0022 title=\u0022Download Figure 2.\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload figure\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00221\u0022\u003E\u003Ca href=\u0022http:\/\/d282kpwvnogo5m.cloudfront.net\/content\/spmdc\/13\/7\/14\/F2.large.jpg\u0022 class=\u0022highwire-figure-link highwire-figure-link-newtab\u0022 target=\u0022_blank\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EOpen in new tab\u003C\/a\u003E\u003C\/li\u003E\u003Cli class=\u00222 last\u0022\u003E\u003Ca href=\u0022\/highwire\/powerpoint\/13468\u0022 class=\u0022highwire-figure-link highwire-figure-link-ppt\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EDownload powerpoint\u003C\/a\u003E\u003C\/li\u003E\u003C\/ul\u003E\u003C\/div\u003E\u003Cdiv class=\u0022fig-caption attrib\u0022\u003E\u003Cspan class=\u0022fig-label\u0022\u003EFigure 2.\u003C\/span\u003E \n               \u003Cp id=\u0022p-12\u0022 class=\u0022first-child\u0022\u003EEffects of Sildenfil on Exercise Capacity and Clinical Outcome\u003C\/p\u003E\n            \u003Cq class=\u0022attrib\u0022 id=\u0022attrib-2\u0022\u003EReproduced from Redfield MM et al. Effect of Phosphodiesterase-5 Inhibition on Exercise Capacity and Clinical Status in Heart Failure With Preserved Ejection Fraction: A Randomized Clinical Trial: Effect of PDE-5 on Exercise and Clinical Status in HFPEF. \u003Cem\u003EJAMA\u003C\/em\u003E 2013;309(12):1268. With permission from the American Medical Association.\u003C\/q\u003E\u003Cdiv class=\u0022sb-div caption-clear\u0022\u003E\u003C\/div\u003E\u003C\/div\u003E\u003C\/div\u003E\n         \u003Cp id=\u0022p-13\u0022\u003EEven though HF remains a leading cause of hospital admission and readmission [Jencks SF et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 2009] the use of digoxin has been declining, in part due to its lack of effect on mortality and a downgrade in guideline recommendations. Older trials had shown benefit with digoxin, a drug discovered more than 2 centuries ago. The DIG trial [Digitalis Investigation Group. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 1997] showed that digoxin improved HF symptoms and reduced the risk of hospital admission both overall and for worsening heart failure. But, digoxin did not reduce overall mortality (Figure 4). In the RADIANCE trial [Packer M et al. \u003Cem\u003EN Engl J Med\u003C\/em\u003E 1993] digoxin improved exercise tolerance and endurance, and patients switched from digoxin to placebo had lower QoL scores (p=0.04), decreased EF (p=0.001), and increases in heart rate (p=0.001) and body weight (p\u0026lt;0.001).\u003C\/p\u003E\n         \u003Cp id=\u0022p-14\u0022\u003EA recent post hoc analysis of the 3405 patients aged \u0026gt;65 years in the DIG trial showed that digoxin reduced the rate of all-cause hospital admission through 30 days (5.4% vs 8.1% with placebo) in ambulatory older patients with chronic HF\u003Cem\u003Er\u003C\/em\u003EEF treated with ACE inhibitors and diuretics [Bourge RC et al. \u003Cem\u003EAm J Med\u003C\/em\u003E 2013]. The absolute and relative risk for all-cause hospital admission were reduced by 2.7% and 34%, respectively, 30 days after randomization in patients randomized to digoxin. Digoxin reduced the risk of hospital admission due to CV causes by 47% (p\u0026lt;0.001) and worsening HF by 60% (p\u0026lt;0.001) during this same period.\u003C\/p\u003E\n         \u003Cp id=\u0022p-15\u0022\u003EThese results are limited by their post hoc nature and other generalizability concerns. However, if they can be replicated in contemporary older HF patients discharged from the hospital after acute decompensation, digoxin may provide an inexpensive tool to reduce 30-day all-cause hospital readmission, the study authors stated.\u003C\/p\u003E\n         \u003Cp id=\u0022p-16\u0022\u003EEvidence-based, guideline-directed diagnosis, evaluation, and therapy should be the mainstay for all patients with HF, concluded Dr. Itchhaporia. Effective implementation of guideline-directed best quality care reduces mortality, improves QoL, and preserves healthcare resources. More research is needed to answer questions pertaining to prevention, nonpharmacologic therapy of HF (including dietary adjustments), treatment of HF\u003Cem\u003Ep\u003C\/em\u003EEF, management of hospitalized HF, effective reduction in HF readmissions, more precise use of device-based therapy, and cell-based regenerative therapy.\u003C\/p\u003E\n      \u003C\/div\u003E\u003Cul class=\u0022copyright-statement\u0022\u003E\u003Cli class=\u0022fn\u0022 id=\u0022copyright-statement-1\u0022\u003E\u00a9 2013 MD Conference Express\u00ae\u003C\/li\u003E\u003C\/ul\u003E\u003Cspan class=\u0022highwire-journal-article-marker-end\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Cspan id=\u0022related-urls\u0022\u003E\u003C\/span\u003E\u003C\/div\u003E\u003Ca href=\u0022http:\/\/mdc.sagepub.com\/content\/13\/7\/14.abstract\u0022 class=\u0022hw-link hw-link-article-abstract\u0022 data-icon-position=\u0022\u0022 data-hide-link-title=\u00220\u0022\u003EView Summary\u003C\/a\u003E\u003C\/div\u003E  \u003C\/div\u003E\n\n  \n  \u003C\/div\u003E\n\u003C\/div\u003E\n  \u003C\/div\u003E\n\u003C\/div\u003E\n\u003C\/div\u003E\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_figures.js?nznta1\u0022\u003E\u003C\/script\u003E\n\u003Cscript type=\u0022text\/javascript\u0022 src=\u0022http:\/\/mdc.sagepub.com\/sites\/all\/modules\/highwire\/highwire\/plugins\/highwire_markup_process\/js\/highwire_openurl.js?nznta1\u0022\u003E\u003C\/script\u003E\n\u003C\/body\u003E\u003C\/html\u003E"}