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Aims: Patients with heart failure (HF) remain often undertreated for multiple reasons, including treatment inertia, contraindications, and intolerance. The OPTIimal PHARMacological therapy for patients with Heart Failure (OPTIPHARM‐HF) registry is designed to evaluate the prevalence of evidence‐based medical treatment prescription and titration, as well as the causes of its underuse, in a broad real‐world population of consecutive patients with HF across the whole ejection fraction spectrum and among different clinical phenotypes. Methods: The OPTIPHARM‐HF registry (NCT06192524) is a prospective, multicenter, observational, national study of adult patients with symptomatic HF, as defined by current international guidelines, regardless of ejection fraction. Both outpatients and inpatients with chronic and acute decompensated HF will be recruited. The study will enroll up to 2500 patients with chronic HF at approximately 35 Italian HF centres. Patients will be followed for a maximum duration of 24 months. The primary objective of the OPTIPHARM‐HF registry is to assess prescription and adherence to evidence‐based guideline‐directed medical therapy (GDMT) in patients with HF. The primary outcome is to describe the prevalence of GDMT use according to target guideline recommendation. Secondary objectives include implementation of comorbidity treatment, evaluation of sequence of treatment introduction and up‐titration, description of GDMT implementation in the specific HF population, main causes of GDMT underuse, and assessment of cumulative rate of cardiovascular events. Conclusion: The OPTIPHARM‐HF registry will provide important implications for improving patient care and adoption of recommended medical therapy into clinical practice among HF patients. [ABSTRACT FROM AUTHOR]

Background: The impact of atrial fibrillation catheter ablation (AFCA) on hard clinical endpoints remains controversial. Objective: Our aim was to conduct a random‐effect model meta‐analysis on efficacy data from high‐quality large matched database/registry studies and randomized clinical trials. We compared long‐term all‐cause mortality, stroke, and hospitalization for heart failure in patients undergoing AFCA vs patients treated with medical therapy alone (rhythm and/or rate control medications) in a general AF population. Methods and Results: PubMed/MEDLINE and Embase databases were screened and a total of nine studies were selected (one randomized clinical trial—CABANA—and eight large matched population studies). A total of 241 372 patients (27 711 in the ablation group, 213 661 in the nonablation group) were included. After a median follow‐up of 3.5 years, AFCA decreased the risk of mortality (hazard ratio [HR], 0.62; 95% confidence interval [CI], 0.54‐0.72; I2 = 54%; number needed to treat [NNT] = 28), stroke (HR, 0.63; 95% CI, 0.56‐0.70; I2 = 23%; NNT = 59) and hospitalization for heart failure (HR, 0.64; 95% CI, 0.51‐0.80; I2 = 28%; NNT = 33) compared with AF patients treated with medical therapy alone. Conclusion: Based on the currently available efficacy and effectiveness evidence, AFCA significantly reduces the risk of death, stroke, and hospitalization compared with medical therapy alone. [ABSTRACT FROM AUTHOR]

Cardiac resynchronization therapy is beneficial in heart failure patients with LVEF ≤35% and electrical dyssynchrony. However, its effects among patients with less severe LV dysfunction have not been established. Recent post-hoc analyses of landmark CRT trials suggest that CRT benefit may be present in patients with LVEF >35% and is associated with improvement in cardiac reverse remodelling, all-cause mortality, and need for heart failure hospitalizations. This review summarizes the currently available literature regarding the potential impact of CRT in patients with more modest reductions in LVEF. [ABSTRACT FROM AUTHOR]

Aims Increased sympathetic activation and reduced parasympathetic tone are important pathophysiological contributors to the progression of heart failure, and are associated with poor outcome in patients. The aim of this study is to determine if vagal nerve stimulation ( VNS) is a promising approach to modulate autonomic function and slow cardiac remodelling and the progression of heart failure. Methods The NECTAR-HF ( NEural Cardiac TherApy foR Heart Failure) trial is designed to evaluate whether the Boston Scientific VNS device is safe and may attenuate cardiac remodelling, improve cardiac function and increase exercise capacity, in symptomatic heart failure patients (New York Heart Association Class II-III) with left ventricular systolic dysfunction (ejection fraction ≤35%) and receiving optimal medical therapy. Patients will be randomized in a 2:1 ratio to receive standard optimal medical treatment plus VNS system in an active mode vs. optimal medical treatment plus VNS system in an inactive mode, for a 6 month period. After the 6 month control period, inactive VNS systems will be activated and all patients will receive VNS. The study is powered to detect differences in the primary efficacy endpoint of change in left ventricular end systolic diameter. Secondary endpoints include ejection fraction, left ventricular volumes, quality of life scores, functional capacity, and changes in biomarkers. Conclusion This Phase II, randomized clinical trial conducted with vagal stimulation for heart failure will provide important new information on the potential of this novel and promising technique. [ABSTRACT FROM AUTHOR]

In patients with advanced heart failure with reduced ejection fraction (HFrEF), RFCA-related potential need for advanced haemodynamic support and periprocedural mortality represent major limiting factors.1 Stereotactic arrhythmia radioablation (STAR) is an emerging non-invasive approach potentially overcoming some of the limitations of RFCA. (C) Computed tomography-based treatment plan showing the proton impinging beam dose distribution. Radiofrequency catheter ablation (RFCA) is the gold standard therapy for recurrent scar-related ventricular tachycardia (VT), but its efficacy is suboptimal. [Extracted from the article]

Dronedarone versus Amiodarone in Patients with AF. Introduction: We compared the efficacy and safety of amiodarone and dronedarone in patients with persistent atrial fibrillation (AF). Methods: Five hundred and four amiodarone-naïve patients were randomized to receive dronedarone 400 mg bid (n = 249) or amiodarone 600 mg qd for 28 days then 200 mg qd (n = 255) for at least 6 months. Primary composite endpoint was recurrence of AF (including unsuccessful electrical cardioversion, no spontaneous conversion and no electrical cardioversion) or premature study discontinuation. Main safety endpoint (MSE) was occurrence of thyroid-, hepatic-, pulmonary-, neurologic-, skin-, eye-, or gastrointestinal-specific events, or premature study drug discontinuation following an adverse event. Results: Median treatment duration was 7 months. The primary composite endpoint was 75.1 and 58.8% with dronedarone and amiodarone, respectively, at 12 months (hazard ratio [HR] 1.59; 95% confidence interval [CI] 1.28–1.98; P < 0.0001), mainly driven by AF recurrence with dronedarone compared with amiodarone (63.5 vs 42.0%). AF recurrence after successful cardioversion was 36.5 and 24.3% with dronedarone and amiodarone, respectively. Premature drug discontinuation tended to be less frequent with dronedarone (10.4 vs 13.3%). MSE was 39.3 and 44.5% with dronedarone and amiodarone, respectively, at 12 months (HR = 0.80; 95% CI 0.60–1.07; P = 0.129), and mainly driven by fewer thyroid, neurologic, skin, and ocular events in the dronedarone group. Conclusion: In this short-term study, dronedarone was less effective than amiodarone in decreasing AF recurrence, but had a better safety profile, specifically with regard to thyroid and neurologic events and a lack of interaction with oral anticoagulants. (J Cardiovasc Electrophysiol, Vol. 21, pp. 597-605, June 2010) [ABSTRACT FROM AUTHOR]

Background: Several studies have searched for predictors of clinical outcome in patients with heart failure (HF). However, since they were collected in clinical trials, most data were subject to selection biases and do not specifically apply to patients with nonischemic heart disease. This study examined the impact of several variables on combined all-cause mortality and hospitalization for cardiac causes, in consecutive ambulatory patients with HF included in the ALPHA registry. Methods and Results: This analysis included 446 patients with HF and nonischemic heart disease, in New York Heart Association functional class II or III, and a left ventricular (LV) ejection fraction below 40%. In 126 patients (73%) the disease was idiopathic dilated cardiomyopathy, in 72 (16%) hypertensive, in nine (2%) valvular, and in 39 (9%) of other etiologies. The median age was 61 years (range 51–69 years) and 349 (78%) patients were men. Over a median follow-up of 31 months (range 23–40), 82 patients (18%) died or were hospitalized for cardiac causes. In a proportional hazard (Cox) regression model, maximal oxygen consumption (HR 0.9, P = 0.001), LV end-diastolic diameter (HR 1.07, P < 0.001), resting systolic blood pressure (HR 0.97, P < 0.005), and hemoglobin (HR 0.86, P < 0.05) were independent predictors of the combined study endpoint. Conclusions: In an unselected population of patients with HF and nonischemic heart disease, a reduced exercise capacity, large LV end-diastolic diameter, low systolic blood pressure, and hemoglobin were correlated with long-term all-cause mortality or hospitalization for cardiac causes. These observations may help stratifying and tailoring the treatment of patients with HF and nonischemic heart disease. [ABSTRACT FROM AUTHOR]

Abstract: Background: Experimentally, vagal stimulation (VS) is protective in chronic heart failure (HF). In man, VS is used in refractory epilepsy but has never been used in cardiovascular diseases. Increased sympathetic and reduced vagal activity predict increased mortality in HF. Aims: This pilot study assessed feasibility and safety and tested possible efficacy of chronic VS in HF patients. Methods: We studied 8 patients (mean age 54 years). CardioFit (BioControl Medical), a VS implantable system delivering pulses synchronous with heart beats through a multiple contact bipolar cuff electrode, was used. VS was started 2–4 weeks after implant, slowly raising intensity; patients were followed 1, 3 and 6 months thereafter. Results: All procedures were successful: as sole surgical side effect, one patient had transient hoarseness. VS was well tolerated, with only mild side effects (cough and sensation of electrical stimulation). There was a significant improvement in NYHA class, Minnesota quality of life® (from 52±14 to 31±18, p <0.001), left ventricular end-systolic volume (from 208±71 to 190±83 ml, p =0.03), and a favourable trend toward reduction in end-diastolic volume. Conclusions: This novel approach to the treatment of patients with HF is feasible, and appears safe and tolerable. The preliminary efficacy results appear promising. These findings suggest the opportunity to proceed with a larger multicentre study. [Copyright &y& Elsevier]

Abstract: Background: Heart rate (HR) reduction may be useful in treatment of patients with heart failure (HF). There are no data on the haemodynamic effects of ivabradine (a selective I f current inhibitor) in advanced HF patients. Aims: To assess the haemodynamic effects of ivabradine in patients with advanced HF and markedly depressed left ventricular (LV) function. Methods and results: Ten NYHA class III patients (50±12 years, LV ejection fraction 21±7%) underwent 24-h haemodynamic monitoring. Ivabradine 0.1 mg/kg was infused over 90′, followed by 0.05–0.075 mg/kg in the subsequent 90′. Baseline HR was 93±8 bpm, cardiac index (CI) 2.2±0.6 l/min⁎m2; LV stroke volume 44±11 ml and systolic work 39±13 g. Ivabradine significantly reduced HR, by a maximum of 27% (to 68±9 bpm) at 4 h, without decreasing CI. Ivabradine increased stroke volume and LV systolic work by a maximum of 51% (to 66±17 ml) and 53% (to 58±20 g) at 4 h. No serious adverse events occurred. Conclusion: In patients with advanced HF and markedly depressed LV function, the acute administration of ivabradine is well tolerated, effectively reduces HR, markedly increases stroke volume and preserves cardiac output. Ivabradine appears a promising approach for the treatment of patients with moderate and advanced heart failure. [Copyright &y& Elsevier]

Abstract: Background: Estimates of the prevalence of atrial fibrillation (AF) in heart failure (HF) originate from patients enrolled in clinical trials. Aims: To assess the prevalence and clinical correlates of AF among HF patients in everyday clinical practice from HF patients screened for the T-wave ALternans in Patients with Heart fAilure (ALPHA) study; to investigate the correlation between AF and functional status. Methods and results: Consecutive patients (N =3513) seen at nine Heart Failure Clinics were studied; 21.4% were in AF. AF prevalence was greater with increasing age (OR 1.04/year, p <0.001) in non-ischaemic cardiomyopathy (OR 2.34, p <0.001) and with increasing NYHA class (p <0.0001). Multiple logistic regression predictors of AF were age >70 years (OR 2.35), NYHA class II III or IV vs class I (OR 1.8, 4.4 and 3.1) and non-ischaemic cardiomyopathy (OR 3.2). A logistic model indicated that AF was associated with a 2.5 OR of being in NYHA class III–IV vs I–II while accounting for age, gender, left ventricular ejection fraction (LVEF), and aetiology of HF. Conclusions: The prevalence of AF in HF patients exceeds 20%, and increases with age and functional class. The presence of AF leads to a more severe NYHA class, indicating that AF contributes to the severity of heart failure. [Copyright &y& Elsevier]

Donor-to-Recipient Decremental Conduction of AK We describe the unique case of a heart transplant patient with type I atrial fibrillation that arose in the donor atrium during a late acute rejection episode and conducted to the recipient atrium with second-degree type I local block. After internal cardio-version, programmed stimulation showed bidirectional decremental conduction across the suture line with nearly equal atrioatrial interval, whereas the recipient atrium showed progressively delayed intra-atrial conduction. These findings strongly suggest that the mechanism of atrioatrial conduction may he electrical propagation along viable myocardium bridging the surgical scar and that the electrophysiologic characteristics of the recipient atrium are involved in decremental conduction across the suture line. [ABSTRACT FROM AUTHOR]

Introduction: Conduction abnormalities associated with long QT syndrome (I.QTS) have been reported as ‘pseudo 2:1 AV block’ due to sinus intervals shorter than ventricular refractoriness. Method and Results: We report the electrophysiologic characteristics of a patient suffering from congenital LQTS with episodes of true 2:1 AV block. Induction of 2:1 infra-Hisian blocks and return to 1:1 conduction were observed using single atrial and ventricular extrastimuli. The block was located in the Purkinje network but not in the myocardium. Conclusion: The His-Purkinje system of our LQTS patient displayed dynamic properties with a strong increase in refractoriness for short-long sequences and a decrease for long-short sequences that triggered intermittent 2:1 AV blocks. [ABSTRACT FROM AUTHOR]