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Background: No clinical investigation provided any information about a possible influence of atrial fibrillation on the response to beta-blocker therapy in elderly patients with chronic heart failure (CHF). The aim of this study was to observe carvedilol effects in a cohort of patients > 70 years of age with CHF due to left ventricular dysfunction and with chronic atrial fibrillation., Methods: An observational, 12-month prospective clinical and echocardiographic study was carried out on 240 patients > 70 years of age with heart failure due to systolic dysfunction, 64 of whom with atrial fibrillation., Results: After 1 year of beta-blocker treatment, patients with atrial fibrillation and those in sinus rhythm showed similar benefits, in terms of symptomatic improvement (deltaNYHA -0.44 if atrial fibrillation vs -0.57 if sinus rhythm, p = NS), reduction of events (death + hospitalizations -38 vs -15%), recovery of cardiac function (left ventricular ejection fraction delta +8.8 vs +9.4%, p = NS; left ventricular end-diastolic volume delta -17.2 vs -12.5 ml, p = NS), and reduction in mitral regurgitation (delta -042 vs -0.57, p = NS). No difference was found between the two study groups regarding left ventricular end-diastolic volume reduction (12% in atrial fibrillation patients and 18% in sinus rhythm patients, p = NS) and prevalence of the "reverse remodeling" phenomenon (22 and 21%, respectively, p = NS)., Conclusions: In CHF patients > 70 years of age, beta-adrenergic blockade was shown to be equally effective in improving symptoms and left ventricular geometry and function in patients with atrial fibrillation or in sinus rhythm, without any adjunctive sign of long-term clinical deterioration.

Background: Current guidelines recommend beta-blockers in patients with heart failure and left ventricular systolic dysfunction. These agents, however, are largely underused in elderly patients because of the perception of up-titration complexity and the fear of side effects., Methods: We prospectively assessed the feasibility, safety, tolerability, and 1-year outcome of the in-hospital initiation of carvedilol in elderly patients admitted for worsening heart failure., Results: Among 164 eligible subjects (age > 70 years, left ventricular ejection fraction < 40% and no sign of congestion), 120 (73%) received carvedilol, on average 4.5 days after admission. The drug was permanently withdrawn in 10 out of 116 survivors (9%) at 60 days: 5 did not tolerate the starting dose because of worsening heart failure (n = 1), bradycardia (n = 1), and bronchospasm (n = 3). Two discontinued carvedilol during the in-hospital dose titration phase because of increasing premature ventricular beats and transient second degree atrioventricular block. The remaining 3 dropouts (fatigue in 2 and symptomatic bradycardia in 1 case) occurred after discharge. During the period between 60 days and 12 months, carvedilol was discontinued in 2 patients because of a depressive syndrome and symptomatic bradycardia. In no case these adverse events lead to death or were life-threatening, required hospitalization or resulted in any disability. The 1-year tolerability was 89%, the mortality was 17.5%, the frequency of hospitalization for worsening heart failure was 21%., Conclusions: Thus, our results show that the in-hospital initiation of carvedilol is feasible and well-tolerated in elderly patients with recent worsening heart failure, and allows rapid identification of the most intolerant patients. The proportion of subjects taking carvedilol after 1 year from discharge was very high. This unconventional approach could significantly modify the use of beta-blockers in clinical practice.

Background: Little is known about the clinical profile, use of resources, management and outcome of a large population of diabetic patients with heart failure managed in a community setting., Methods: A prospective cross-sectional survey in the setting of acute hospital admissions for heart failure to 167 cardiology and 250 internal medicine departments between February 14 and 25, 2000., Results: Among the 2127 consecutively admitted patients, 603 (28.4%) had a history of diabetes; they were significantly younger, had a lower rate of atrial fibrillation, and a more frequent ischemic etiology than non-diabetics. Just as non-diabetic patients, diabetics underwent invasive and non-invasive procedures in a low percentage of cases, even though slightly more frequently when managed by cardiologists. Diabetic patients were less frequently prescribed amiodarone and anticoagulants, and more frequently prescribed nitrates and antiplatelets. The all-cause in-hospital mortality rate was similar among diabetics and non-diabetics (5.3 vs 5.7%, p = NS). Adjusted analysis confirmed that diabetes is not independently associated with a worse outcome., Conclusions: In a community setting diabetes per se has only a slight impact on the management and outcome of patients with heart failure.

Recent studies have suggested some gender-related differences in the incidence, quality of care, response to therapy, and outcome in heart failure patients. The majority of studies have proposed a better survival for women compared to men. However, the under-representation of women in clinical trials leads to some uncertainty regarding the survival benefit. Some data suggest the possibility that ACE-inhibitors may be less beneficial in women as compared to men. Beta-blockers seem to be effective both in women and men. Further studies are needed to clarify whether these differences may have a pathophysiological basis.

Although improved, the prognosis of chronic heart failure is still malignant, the survival rate being similar to that of cancer. Due to the relevant epidemiology of this disease, the terminal care of heart failure has a significant impact, searching for the best quality of cure and care.

Significant differences between sexes may influence the prevalence, incidence and severity of the heart failure syndrome. These differences may also interfere with treatment and management. In this review sex differences and similarities have been analyzed focusing on epidemiology, drug therapy and psychological implications. Pathophysiological differences but also a selection bias are evident; such differences bear an influence on clinical management. Gender differences exist even in the health-related quality of life, depression and coping ability. No studies have been specifically designed to investigate gender differences and the exclusion of elderly persons (mainly women) from large trials may compromise the quality of their care.

In the progressive understanding of the heart failure syndrome different models have followed. Current pathophysiology model suggests that heart failure is a neurohormonal disorder: an abnormality in cardiac function and a disturbance in myocardial contractile force is the initiating event in heart failure, and the clinical expression and progression of the disease occurs as a result of subsequent extracardiac alterations. Treatment with drugs capable of antagonizing the effects of neuroendocrine activation, such as angiotensin-converting enzyme inhibitors, beta-blockers and antialdosterone agents have induced a significant reduction in morbidity and mortality in heart failure patients. The progressive understanding of the circulating homeostasis mechanisms moved from the systemic to the paracrine aspects of the neurohormonal systems and contributed to the development of new drugs. Moreover, the analysis of a drug's development can be an important step in the medical knowledge advancement. In this sense, aldosterone and spironolactone became an interesting "case", which is analyzed in this paper, going through the steps that have promoted the spironolactone from a weak diuretic to a neurohormonal drug and, finally, to a "central" drug.

In this part, the risks and complications of pregnancy in women with active or corrected, congenital or acquired heart disease are reviewed, in order to allow individual counseling on a possible pregnancy or treatment recommendations on contraception.