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AimsTo examine associations of below-target and target dose of enalapril, an angiotensin-converting enzyme (ACE) inhibitor, with outcomes in patients with heart failure and reduced ejection fraction (HFrEF) in the Studies of Left Ventricular Dysfunction (SOLVD) Treatment trial.Methods and resultsTwo thousand five hundred and sixty-nine patients with HFrEF (ejection fraction ≤35%) were randomized to below-target (5-10 mg/day) dose placebo (n = 1284) or enalapril (n = 1285). One month post-randomization, blind up-titration to target (20 mg/day) dose was attempted for both study drugs in 2458 patients. Among the 1444 patients who achieved dose up-titration (placebo, n = 748; enalapril, n = 696; mean dose for both groups, 20.0 mg/day), target dose enalapril (vs. target dose placebo) was associated with a 9% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality [adjusted hazard ratio (HR) 0.70; 95% confidence interval (CI) 0.60-0.81; P < 0.001] during 4 years of follow-up. Among the 1014 patients who could not achieve target dose (placebo, n = 486; enalapril, n = 528; mean dose for both groups, 8.8 mg/day), below-target dose enalapril (vs. below-target dose placebo) was associated with a 12% absolute lower risk of the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 0.68; 95% CI 0.57-0.81; P < 0.001). Among the 1224 patients receiving enalapril, target (vs. below-target) dose had no association with the combined endpoint of heart failure hospitalization or all-cause mortality (adjusted HR 1.04; 95% CI 0.87-1.23; P = 0.695).ConclusionIn patients with HFrEF, the clinical benefits of ACE inhibitors appear to be similar at both below-target and target doses.

Myocardial wall rupture should be considered in patients presenting with hypotension and STEMI especially of delayed onset. Diagnosing this entity in the COVID‐19 era can be challenging—handheld echocardiography may aid toward this end. [ABSTRACT FROM AUTHOR]

Abstract: Background: Reduced right ventricular ejection fraction (RVEF) is associated with poor outcomes in patients with chronic systolic heart failure (HF). Although most HF patients are older adults, little is known about the relationship between low RVEF and outcomes in older adults with systolic HF. Methods: Of the 2008 Beta-Blocker Evaluation of Survival Trial (BEST) participants with systolic HF (left ventricular ejection fraction ≤35%) 822 were ≥65years and had data on baseline RVEF estimated by gated-equilibrium radionuclide ventriculography. Using RVEF ≥40% (n=308) as reference, we examined association of RVEF 30–39% (n=214), 20–29% (n=206) and <20% (n=94) with outcomes using Cox regression models. Results: All-cause mortality occurred in 36%, 40%, 39% and 56% of patients with RVEF ≥40%, 30–39%, 20–29% and <20% respectively. Compared with RVEF ≥40%, unadjusted hazard ratios (HR) and 95% confidence intervals (CI) for all-cause mortality associated with RVEF 30–39%, 20–29% and <20% were 1.19 (0.90–1.57; P=0.220), 1.13 (0.84–1.51; P=0.423) and 1.97 (1.43–2.73; P<0.001) respectively. Respective multivariable-adjusted HR''s (95% CI''s) for all-cause mortality were 1.19 (0.88–1.60; P=0.261), 1.00 (0.73–1.39; P=0.982) and 1.70 (1.14–2.53; P=0.009). Adjusted HR''s (95% CI''s) associated with RVEF <20% (versus ≥40%) for cardiovascular mortality and HF mortality were 1.79 (1.17–2.76; P=0.008) and 1.97 (1.02–3.83; P=0.045) respectively. RVEF had no independent association with sudden cardiac death, all-cause or HF hospitalization. Conclusions: Abnormally low RVEF is a significant independent predictor of mortality, but not of HF hospitalization, in older adults with systolic HF. [Copyright &y& Elsevier]

Incidence and prevalence of abdominal obesity (AO) are growing exponentially. Subjects with AO are at higher risk of developing heart failure. The purpose of the study was to investigate early changes in cardiac and arterial structure and function and extracellular matrix biomarkers in normotensive healthy subjects with AO. Subjects with AO and age- and sex-matched controls underwent echocardiography, MRI (cardiac remodeling index), carotid intima-media thickness, pulse wave velocity, and blood fibrosis biomarkers measurements. We enrolled 87 subjects with AO and 53 controls. Although normotensive, subjects with AO had higher systolic blood pressure (BP; 122±11 versus 116±11 mm Hg; P=0.003), left ventricular mass (94±24 versus 84±21 g; P=0.034), and cardiac remodeling index (0.67±0.16 versus 0.60±0.10 g/mL; P=0.026) but unchanged carotid intima-media thickness and pulse wave velocity. Diastolic dysfunction (E' <10 cm/s) could be detected in 38% of subjects with AO (4% in controls). Left ventricular remodeling, as assessed by cardiac remodeling index, was positively and independently associated with higher BP (systolic BP and mean arterial pressure but not diastolic BP) and AO. Higher BP, AO, and procollagen-III-N-terminal peptide (≥2.4 ng/mL) concentrations (odds ratio, 4.15 [1.42-12.2]; P=0.01) were positively associated with diastolic dysfunction. Early cardiac structural remodeling, fibrosis, and diastolic dysfunction were detectable in healthy subjects with AO. Higher BP, procollagen-III-N-terminal peptide, and AO were independently associated with early cardiac structural and functional changes. It is to be investigated whether in subjects with AO, an early BP reduction, even if normotensive, combined with weight loss may avoid adverse cardiac remodeling and protect against progression to heart failure.

Hypertension in the elderly, especially systolic hypertension, has been recognized as a major cardiovascular risk factor. Several international studies, using primarily diuretics and/or beta-blockers, have shown the benefits of antihypertensive treatment in elderly patients in terms of cardiovascular morbidity and mortality reduction. However, because the risk of side-effects is a major concern when treating the elderly, the use of low-dose combination treatments may be of particular interest. A randomized, multicentre, double-blind, parallel group study was conducted to compare the efficacy and safety of bisoprolol 2.5 mg/hydrochlorothiazide 6.25 mg (biso 2.5/HCTZ 6.25) (n = 84) versus amlodipine 5 mg (n = 80) in subjects over 60years of age with isolated systolic hypertension. The effects of these two treatment strategies on patients' quality of life were also assessed. After a two- to four-week placebo washout period, both drugs were administered once daily and taken for 12 weeks. Blood pressure was measured 24 h after treatment administration. Systolic blood pressure/diastolic blood pressure changes from baseline to week 12 were similar for both biso 2.5/HCTZ6.25 and amlodipine (-20.0/-4.5 mmHg and -19.6/-2.4 mmHg, respectively). Overall adverse events for biso 2.5/HCTZ 6.25 and amlodipine were 39% and 40%, respectively. Both treatments improved quality of life scores in the same way. This study demonstrates comparable efficacy and tolerability of biso 2.5/HCTZ 6.25 and amlodipine. Low-dose combination of bisoprolol and hydrochlorothiazide may be an appropriate alternative for elderly patients with systolic hypertension.