Eduardo Benchimol Saad
Sixth year medical student - The Federal University of Rio de Janeiro
ß-Blockers are increasingly recognized as effective in Heart Failure due to systolic dysfunction. The Carvedilol US trials were presented. 1094 patients with NYHA class II, III and IV Heart Failure with a mean ejection fraction of 35 % and taking standard medications ( digoxin, diuretics and ACE inhibitors ) were randomized to receive Carvedilol ( target dose = 25 mg bid ) or placebo.
They were further stratified by a 6 min. walking test, where they were divided in 4 groups, accorging to functional capacity. The primary end point was the combination of Heart Failure deaths, hospitalizations and increases in medications. It showed that this end point was reduced in all patients, irrespective of NYHA class or functional capacity, the only exceptions being the most severe patients ( NYHA class IV ), in which the 95 % confidence interval achieved a worse effect.This trial concluded that Carvedilol reduced progression of Heart Failure of mild to moderate severity ( NYHA class III ). Class IV patients should be brought to class III before starting the drug, altough more information is needed to indicate it to high risk group.
The ELITE trial, publishe in Lancet in march this year, randomized class II, III and IV Heart Failure patients older than 65 years taking digoxin and diuretics and ACE inhibitors naive to receive either Captopril in a target dose of 150 mg / day or Losartan ( and Angiotensin II receptor inhibitor ) in a target dose of 50 mg once a day. The primary end point was an increase in the serum creatinin of 0.3 mg/dl; so, it was a safety trial.
Its results were surprising in that the Losartan group had a 46 % total mortality reduction ( relative risk = 0.54 ), an effect due mainly to sudden death reduction. The primary end point showed no difference between the two groups, with about 10 % in each reaching it. There were no differences in hospitalizations and in the incidence of hypotension (24 % in both groups), although the incidence of cough was significantly reduced in the Losartan group. This trial encouraged the ongoing ELITE II trial, in which the primary end point is total mortality. This trial is highly awaited, as its results could change not only managment of patients with Heart Failure but also some pathophysiological concepts.
2 ) Unstable Angina / Non Q wave AMI
5 ) Atrial Fibrilation and Atrial Flutter
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