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B-blockers are regarded as beneficial pharmacologic agents in cardiac care, but their role in the acute setting remains ambiguous. Increasing evidence supports the important role of landiolol in critical care, a highly cardioselective intravenous b-blocker with rapid onset of action and short elimination time. Among its most valuable properties, which may aid to overcome special reservations related to b-blocker therapy in the acute setting, landiolol has a potent negative chronotropic effect while at the same time it exhibits a mild negative inotropic effect. This expert opinion review aims to present basic pharmacologic aspects of landiolol and provide current clinical research focused on its efficacy and safety. Landiolol is a valuable and safe pharmacologic agent in acute cardiac care. Japanese and European guidelines have incorporated its use for the management of atrial tachyarrhythmia in patients with cardiac dysfunction. Although emerging clinical trials have experimented its use in patients with sustained ventricular tachycardia/fibrillation, acute myocardial infarction undergoing primary percutaneous intervention and in patients with septic cardiomyopathy, more studies are needed in order to establish its value in such cardiac conditions. [ABSTRACT FROM AUTHOR]

Aim: Evidence on healthcare resource utilization (HCRU) for hospitalized patients with heart failure (HF) and reduced (HFrEF), mildly reduced (HFmrEF) and preserved (HFpEF) ejection fraction is limited. Methods and results: We analysed HCRU in relation to left ventricular ejection fraction (LVEF) phenotypes, clinical features and in‐hospital and 12‐month outcomes in 16 943 patients hospitalized for HF in a worldwide registry. HFrEF was more prevalent (53%) than HFmrEF (17%) or HFpEF (30%). Patients with HFmrEF and HFpEF were older, more often women, with milder symptoms and more comorbidities, but differences were not pronounced. HCRU was high in all three groups; two or more in‐ and out‐of‐hospital services were required by 51%, 49% and 52% of patients with HFrEF, HFmrEF and HFpEF, respectively, and intensive care unit by 41%, 41% and 37%, respectively. Hospitalization length was similar (median, 8 days). Discharge prescription of neurohormonal inhibitors was <80% for each agent in HFrEF and only slightly lower in HFmrEF and HFpEF (74% and 67%, respectively, for beta‐blockers). Compared to HFrEF, 12‐month all‐cause and cardiovascular mortality were lower for HFmrEF (adjusted hazard ratios 0.78 [95% confidence interval 0.59–0.71] and 0.80 [0.70–0.92]) and HFpEF (0.64 [0.59–0.87] and 0.63 [0.56–0.71]); 12‐month HF hospitalization was also lower for HFpEF and HFmrEF (21% and 20% vs. 25% for HFrEF). In‐hospital mortality, 12‐month non‐cardiovascular mortality and 12‐month all‐cause hospitalization were similar among groups. Conclusions: In patients hospitalized for HF, overall HCRU was similarly high across LVEF spectrum, reflecting the subtle clinical differences among LVEF phenotypes during hospitalization. Discharge prescription of neurohormonal inhibitors was suboptimal in HFrEF and lower but significant in patients with HFpEF and HFmrEF, who had better long‐term cardiovascular outcomes than HFrEF, but similar risk for non‐cardiovascular events. [ABSTRACT FROM AUTHOR]

Background: The role of neurohormonal inhibition in chronic heart failure (HF) is well established. There are limited data on the effect of up‐titration of renin–angiotensin inhibitors (RASi) and beta‐blockers (BBs) on clinical outcomes of patients with worsening HF across the left ventricular ejection fraction (LVEF) spectrum. Methods and results: We analysed data from 2345 patients from BIOSTAT‐CHF (80.9% LVEF <40%), who completed a 3‐month up‐titration period after recent worsening of HF. Patients were classified by achieved dose (% of recommended): ≥100%, 50–99%, 1–49%, and none. Recurrent event analysis using joint and shared frailty models was used to examine the association between RASi/BB dose and all‐cause and HF hospitalizations. In the 21 months following up‐titration, 512 patients died and 879 (37.5%) had ≥1 hospitalization. RASi up‐titration was associated, incrementally, with reduced risk of all‐cause hospitalization at all achieved dose levels compared to no treatment [hazard ratio (95% confidence interval): ≥100%: 0.60 (0.49–0.74), P < 0.001; 50–99%: 0.56 (0.46–0.68), P < 0.001; 1–49%: 0.71 (0.59–0.86), P < 0.001]. This association was consistent up to an LVEF of 49% (P < 0.001), and when considering only HF hospitalizations. Up‐titration of BBs was associated with fewer all‐cause hospitalizations only when LVEF was <40% (overall P < 0.001), but with more HF hospitalizations when LVEF was ≥50%. Up‐titration of both RASi/BBs was associated with lower mortality in LVEF up to 49%. Conclusion: After recent worsening of HF, up‐titration of RASi and BBs was associated with a better prognosis in patients with LVEF ≤49%. Up‐titration of BBs was associated with a greater risk of HF hospitalization when LVEF was ≥50%. [ABSTRACT FROM AUTHOR]

Aims: Oral sucrosomial iron (SI) combines enhanced bioavailability and tolerance compared to conventional oral iron along with similar efficacy compared to intravenous iron in several conditions associated with iron deficiency (ID).Methods and Results: In this non-randomized, open-label study, we sought to evaluate prospectively the effects of SI on clinical parameters, exercise capacity and quality of life in 25 patients with heart failure (HF) with reduced ejection fraction (HFrEF) and ID, treated with SI 28 mg daily for 3 months, in comparison to 25 matched HFrEF controls. All patients were on optimal stable HF therapy. Patients were followed for 6 months for death or worsening HF episodes. There were no differences in baseline characteristics between groups. At 3 months, SI was associated with a significant increase in haemoglobin, serum iron and serum ferritin levels (all P ≤ 0.001) along with a significant improvement in 6-min walked distance and Kansas City Cardiomyopathy Questionnaire (all P < 0.01), even after adjustment for baseline parameters; these differences persisted at 6 months. Over the study period, there were no deaths, while 10 patients (20%) in total (four in the SI group and six in the control group), experienced worsening HF (odds ratio 0.51, 95% confidence interval 0.41-6.79, P = 0.482). Drug-associated diarrhoea was reported by one patient in the SI group and led to drug discontinuation; no other adverse events were reported.Conclusions: In this proof-of-concept study, SI was well tolerated and improved exercise capacity and quality of life in HFrEF patients with ID. Randomized studies are required to further investigate the effects of this therapy. [ABSTRACT FROM AUTHOR]

Advanced neuroimaging is one of the most important means that we have in the attempt to overcome time constraints and expand the use of intravenous thrombolysis (IVT). We assessed whether, and how, the prior use of advanced neuroimaging (AN), and more specifically CT/MR perfusion post-processed with RAPID software, regardless of time from symptoms onset, affected the outcomes of acute ischemic stroke (AIS) patients who received IVT. Methods. We retrospectively evaluated consecutive AIS patients who received intravenous thrombolysis monotherapy (without endovascular reperfusion) during a six-year period. The study population was divided into two groups according to the neuroimaging protocol used prior to IVT administration in AIS patients (AN+ vs. AN−). Safety outcomes included any intracranial hemorrhage (ICH) and 3-month mortality. Effectiveness outcomes included door-to-needle time, neurological status (NIHSS-score) on discharge, and functional status at three months assessed by the modified Rankin Scale (mRS). Results. The rate of IVT monotherapy increased from ten patients per year (n = 29) in the AN− to fifteen patients per year (n = 47) in the AN+ group. Although the onset-to-treatment time was longer in the AN+ cohort, the two groups did not differ in door-to-needle time, discharge NIHSS-score, symptomatic ICH, any ICH, 3-month favorable functional outcome (mRS-scores of 0–1), 3-month functional independence (mRS-scores of 0–2), distribution of 3-month mRS-scores, or 3-month mortality. Conclusion. Our pilot observational study showed that the incorporation of advanced neuroimaging in the acute stroke chain pathway in AIS patients increases the yield of IVT administration without affecting the effectiveness and safety of the treatment. [ABSTRACT FROM AUTHOR]

Background: Fagerstrom score is a validated marker of nicotine addiction in smokers., Methods: In a prospective study, we investigated a) the predictive value of Fagerstrom score for the smoking status in patients early after acute myocardial infarction (AMI) and b) the effectiveness of medically assisted smoking cessation programs in the prevention of relapsing to smoking post discharge. In 103 smokers (58 ± 12 years, 79.6% males), we assessed Fagerstrom score during hospitalization for AMI. Patients filled a dedicated questionnaire including data on family, marital and educational status, habits related to smoking and were followed-up at 3 and 6 months after discharge., Results: Twenty-eight patients (27.2%) did not quit smoking throughout the 6-months follow-up period (Fagerstrom score:8.1 ± 1.6), 39 patients (37.8%) ceased smoking at 3 months but relapsed to smoking at 6 months (score:6.8 ± 2.1), and only 34 patients (33%) had ceased smoking for 6 consecutive months (score:5.2 ± 2 p < 0.05 for all comparisons between subgroups). By multivariate analysis, Fagerstrom score remained a significant predictor of smoking cessation at 6 months (OR: 0.72, 95%CI: 0.60--0.86, p < 0.001). Out of 73 patients who abstained from smoking for the first 3 months post-AMI, those who participated in a smoking cessation program displayed lower rate of relapsing to smoking compared with those who opted to cease smoking without any support (33.3% vs 61.8% p = 0.012)., Conclusion: Fagerstrom score is a useful predictor of smoking cessation 6 months post-AMI. Patients participating in a smoking cessation program display lower relapse rates post-discharge suggesting the need of well-organized smoking cessation clinics for secondary prevention of heart disease., (Copyright © 2022 Hellenic Society of Cardiology. Published by Elsevier B.V. All rights reserved.)

Atrial tachyarrhythmias and worsening heart failure frequently coexist and potentially progress to a life threatening condition. Therapeutic approach requires simultaneous management of rapid ventricular response and heart failure symptom relief in order to improve haemodynamic stability and cardiac function. Landiolol is an ultra-short-acting b-adrenergic receptor blocker with high b1 selectivity incorporated in 2020 European Society of Cardiology guidelines for the management of atrial fibrillation. We provide a report of two cases with atrial fibrillation treated with landiolol in the acute setting of pulmonary oedema and cardiogenic shock, respectively. Additionally, we searched the international database PUBMED (MEDLINE, PubMed Central) to retrieve scientific evidence regarding its implementation in the treatment of atrial tachyarrhythmias in patients with cardiac dysfunction. Recent studies support the use of landiolol in patients with acute heart failure and atrial tachyarrhythmias. Compared to digoxin, landiolol proved to be more effective in controlling heart rate, with minimal adverse effects. Moreover, landiolol may be helpful in the conversion of atrial tachyarrhythmia to sinus rhythm. A more potent effect has been reported in patients with heart failure with preserved or mildly reduced ejection fraction, small left ventricular volume and high blood pressure. Likewise, administration of low doses of landiolol in patients with cardiogenic shock and atrial tachyarrhythmias reduced heart rate and pulmonary capillary wedge pressure and improved cardiac contractility without reducing blood pressure. Landiolol seems to be an attractive alternative in the acute management of patients with atrial tachyarrhythmias and cardiac dysfunction, though further clinical trials are needed to establish its role., (© The Author(s) 2022. Published by Oxford University Press on behalf of European Society of Cardiology.)

Cognitive impairment (CI) represents a common but often veiled comorbidity in patients with acute heart failure (AHF) that deserves more clinical attention. In the AHF setting, it manifests as varying degrees of deficits in one or more cognitive domains across a wide spectrum ranging from mild CI to severe global neurocognitive disorder. On the basis of the significant negative implications of CI on quality of life and its overwhelming association with poor outcomes, there is a compelling need for establishment of detailed consensus guidelines on cognitive screening methods to be systematically implemented in the population of patients with heart failure (HF). Since limited attention has been drawn exclusively on the field of CI in AHF thus far, the present narrative review aims to shed further light on the topic. The underlying pathophysiological mechanisms of CI in AHF remain poorly understood and seem to be multifactorial. Different pathophysiological pathways may come into play, depending on the clinical phenotype of AHF. There is some evidence that cognitive decline closely follows the perturbations incurred across the long-term disease trajectory of HF, both along the time course of stable chronic HF as well as during episodes of HF exacerbation. CI in AHF remains a rather under recognized scientific field that poses many challenges, since there are still many unresolved issues regarding cognitive changes in patients hospitalized with AHF that need to be thoroughly addressed.

In the acute cardiac care setting, undifferentiated clinical presentations such as dyspnea, chest pain, shock, and cardiac arrest are common diagnostic challenges for the clinician. Lung ultrasonography is a well-established diagnostic tool which can be integrated in simplified decision making algorithms during the initial approach of the patient, in order to differentiate accurately cardiac from non-cardiac causes and improve the management of time-sensitive cardiovascular emergencies.

Background and Aims: Increased sodium intake is associated with increased risk of decompensation in patients with heart failure. This non-randomized, open-label, controlled study aimed to examine the feasibility, preliminary safety and efficacy of a low sodium-potassium enriched salt substitute compared to regular table salt in patients with heart failure with reduced ejection fraction (HFREF)., Methods: Fifty patients (68% male, NYHA I/II/III 6%/68%/26%, mean age 70 ± 9 years, LVEF 31 ± 5%, median BNP 112 pg/ml) were included. Of these, 30 patients received the salt substitute (maximum consumption of 2 g daily), who were prospectively compared to a control group of 20 age/sex/NYHA class-matched HFREF patients who consumed regular salt (maximum consumption of 2 g daily). Consumption of regular salt was prohibited in the salt substitution group. All patients were followed for 12 weeks., Results: Patient groups did not differ by sex, age, LVEF, NYHA class, 6MWD, and BNP at baseline. In primary safety analysis, no significant differences were detected between groups regarding SBP (p = 0.052), DBP (p = 0.159), HR (p = 0.246), serum potassium (p = 0.579), serum sodium (p = 0.125), and eGFR (p = 0.710) throughout the 12 weeks. Secondary efficacy analysis revealed a statistically significant difference in 6MWD at 12 weeks between the salt substitute and regular salt groups after adjustment for baseline 6MWD (mean difference±SEM, 4.7 ± 2.1 m, F = 4.92, p = 0.031)., Conclusions: In this pilot study, a low sodium-potassium enriched salt substitute was found to be safe compared to regular salt in HFREF patients, while it resulted in a small albeit significant improvement in exercise capacity, possibly justifying further investigation with randomized clinical studies., (Copyright © 2019 European Society for Clinical Nutrition and Metabolism. Published by Elsevier Ltd. All rights reserved.)

Inotropes aim at increasing cardiac output by enhancing cardiac contractility. They constitute the third pharmacological pillar in the treatment of patients with decompensated heart failure, the other two being diuretics and vasodilators. Three classes of parenterally administered inotropes are currently indicated for decompensated heart failure, (i) the beta adrenergic agonists, including dopamine and dobutamine and also the catecholamines epinephrine and norepinephrine, (ii) the phosphodiesterase III inhibitor milrinone and (iii) the calcium sensitizer levosimendan. These three families of drugs share some pharmacologic traits, but differ profoundly in many of their pleiotropic effects. Identifying the patients in need of inotropic support and selecting the proper inotrope in each case remain challenging. The present consensus, derived by a panel meeting of experts from 21 countries, aims at addressing this very issue in the setting of both acute and advanced heart failure., (Copyright © 2019 The Authors. Published by Elsevier B.V. All rights reserved.)

Inotropes are pharmacological agents that are indicated for the treatment of patients presenting with acute heart failure (AHF) with concomitant hypoperfusion due to decreased cardiac output. They are usually administered for a short period during the initial management of AHF until haemodynamic stabilisation and restoration of peripheral perfusion occur. They can be used for longer periods to support patients as a bridge to a more definite treatment, such as transplant of left ventricular assist devices, or as part of a palliative care regimen. The currently available inotropic agents in clinical practice fall into three main categories: beta-agonists, phosphodiesterase III inhibitors and calcium sensitisers. However, due to the well-documented potential for adverse events and their association with increased long-term mortality, physicians should be aware of the indications and dosing strategies suitable for different types of patients. Novel inotropes that use alternative intracellular pathways are under investigation, in an effort to minimise the drawbacks that conventional inotropes exhibit., Competing Interests: Disclosure: JP has received honoraria for lectures and advisory meetings from Orion Pharma and Roche Diagnostics. All other authors have no conflicts of interest to declare., (Copyright © 2019, Radcliffe Cardiology.)