Search

BACKGROUND Drug concentration in blood or urine is an acknowledged method to detect nonadherence. Observational studies suggest that informing patients about low or absent serum drug levels improves blood pressure (BP). We performed a multicenter randomized clinical trial to test the hypothesis that therapeutic drug monitoring (TDM) could improve drug adherence and BP in patients with uncontrolled hypertension (HT). METHODS Patients were ≥18 years on stable treatment with at least 2 antihypertensive agents. We planned to randomize 80 nonadherent patients with a systolic daytime ambulatory BP ≥135 mm Hg to TDM intervention or not. The control group and the study personnel who measured BP remained uninformed about serum drug measurements throughout. All patients and physicians were blinded for BPs. Lifestyle advice and detailed information on the disease process and the importance of BP treatment were given to both groups. RESULTS From 2017 to 2022, we randomized 46 diagnosed nonadherent from a total of 606 patients with uncontrolled HT. The TDM group had a 6.7 (±14.5) mm Hg reduction from 147.9 (±10.3) to 141.1 (±14.1) mm Hg, and the control group experienced a 7.3 (±13.2) mm Hg reduction from 147.1 (±9.2) to 139.1 (±17.4) mm Hg, P  = 0.9 between groups. Adherence improved in both groups, 73% in the TDM group and 59% in the control group became adherent at 3 months, P  = 0.51. CONCLUSIONS In our prospective multicenter clinical trial of uncontrolled and nonadherent hypertensive patients, we found no additional effect of TDM on BP and drug adherence compared with standard care. CLINICAL TRIALS REGISTRATION Trial Number NCT03209154 , www.clinicaltrials.gov. [ABSTRACT FROM AUTHOR]

Available data of event-based clinical outcomes trials show that little evidence supports the guidelines recommendations to lower blood pressure (BP) to <130/80 mmHg in middle-aged and elderly people with type 2 diabetes mellitus and hypertension. We addressed this issue by post-hoc analysing the risk of cardiovascular (CV) events in mostly elderly high-risk hypertensive patients with type 2 diabetes mellitus participating in the Valsartan Antihypertensive Long-term Use Evaluation (VALUE) trial. Patients (n = 5250) were divided into 4 groups according to the proportion of on-treatment visits before the occurrence of an event (<25% to ≥ 75%) in which BP was reduced to <140/90 or <130/80 mmHg. After adjustment for baseline demographic differences between groups, a reduction in the proportion of visits in which BP achieved <140/90 mmHg accompanied a progressive increase in the risk of CV mortality and morbidity as well as of cause-specific events such as stroke, myocardial infarction and heart failure. A progressive reduction in the proportion of visits in which BP was reduced <130/80 mmHg did not have any effect on CV risks. In mostly elderly high-risk hypertensive patients with type 2 diabetes mellitus participating in the VALUE trial, achieving more frequently BP <140/90 mmHg showed a marked protective effect on overall and all cause-specific cardiovascular outcomes. This was not the case for a more frequent achievement of the more intensive BP target, i.e. <130/80 mmHg. [ABSTRACT FROM AUTHOR]

Abstract: Purpose: Cardiac rehabilitation participation rates are low despite strong recommendations, and many chronic heart failure patients remain physically inactive. Rural living, long travel distance, costs, age, and frailty might be factors explaining this. To increase cardiac rehabilitation uptake, we designed an exercise-based randomized controlled telerehabilitation trial enabling chronic heart failure patients unable or unwilling to participate in outpatient cardiac rehabilitation to exercise at home. Aim was to evaluate the long-term effects of telerehabilitation on physical activity levels.Methods and results: CHF patients (n = 61) with reduced (≤40%), mildly reduced (41-49%), or preserved ejection fraction (≥50%) were randomized (1:1) to telerehabilitation (n = 31) with an initial 3-month group-based high-intensity exercise telerehabilitation program or control (n = 30), with regular follow-up visits over a 2-year period. All participants attended a "Living with heart failure" course. Outcomes were measures of physical activity, peak oxygen uptake, 6-minute walk test distance, quality of life, morbidity, and mortality. We found no significant differences between groups for long-term changes in moderate to vigorous activity (MVPA) or peak oxygen uptake from baseline to the 2-year follow-up. Nor quality of life differed between groups, but both groups had significant within-group improvements in score on the Minnesota living with heart failure questionnaire (p = 0.000) and improvement in EQ-5D VAS score was significant (p = 0.05) in the telerehabilitation group.Conclusions: Telerehabilitation performed as home-based real-time high-intensity exercise sessions provided by videoconferencing for participants unable or unwilling to participate in standard outpatient cardiac rehabilitation did not affect long-term physical activity levels or physical capacity as expected. Still, a positive effect on health-related quality of life was seen in both groups., Competing Interests: Conflict of Interest and Funding Source: The work was supported by funds from the Liaison Committee of Central Norway Regional Health Authority and the Norwegian University of Science and Technology and the National Association for Heart and Lung Diseases. The authors declare no conflicts of interest., (Copyright © 2024 by the American College of Sports Medicine.)

Background: Immunotherapy is used to treat several cancer types. As it is a relatively new type of treatment, knowledge of optimal handling of rare side effects is sparse., Case Presentation: A woman in her early eighties with inoperable metastases from malignant melanoma was given immunotherapy. Five weeks after the first dose of nivolumab 480 mg she was admitted to the hospital with symptoms of coronary artery disease. On suspicion of side effects from nivolumab, she was given prednisolone 80 mg daily. MRI of the heart showed findings highly suggestive of myocarditis. Her condition initially improved, but 9 days after leaving the hospital she developed muscular weakness and ptosis. Neurography and electromyography revealed acute axonal polyneuropathy and she was treated with mycophenolate mofetil. In the days that followed she had increasing paresis, apnoea and pain in the right shoulder. Echocardiography showed reduced systolic function. The patient died 11 days after the second hospitalisation., Interpretation: The patient developed hepatitis, myocarditis and neuropathy after only one course of immunotherapy. Those are known to be rare side effects with a high mortality rate. The patient was given high dose prednisolone and mycophenolate mofetil. Intravenous immunoglobulins and/or plasmapheresis could have been alternative treatments.

Congestive heart failure is a major health problem in the western world and the prevalence of patients with this diagnosis increases. About 2% of the adult population are affected; the majority are elderly, which represents a challenge when it comes to assessment and treatment. This article concerns the aetiology and diagnosis of congestive heart failure and provides a suggestion for guidelines. The proposed guidelines are aimed at primary, secondary and third line health care providers in Norway, and are based on previously published Norwegian guidelines and international guidelines. Hypertension and coronary artery disease account for 75-80% of known cases of congestive heart failure. The patient's history and risk factors must be investigated. Laboratory tests emphasising organ functions are important, and these should include measurement of B-type natriuretic peptide (BNP). Electrocardiograms and chest X-rays should be taken as well. All patients with suspected impaired left ventricular ejection fraction should undergo an echocardiographic examination. Invasive tests, and non-invasive imaging should be used for selected groups of patients only.

The Working Group on Heart Failure of the Norwegian Society of Cardiology here presents a revised programme for the treatment of congestive heart failure. Possible surgical and percutaneous interventions should be considered, and non- pharmacological measures taken as indicated for each patient. ACE-inhibitors are the first-line pharmacological therapy in heart failure with reduced left ventricular ejection fraction (< 40%). Possible adverse effects on blood pressure, renal function and electrolytes necessitate close monitoring of these variables. Beta-blockers should be considered in patients with symptomatic heart failure. If ACE-inhibitors are not tolerated, an angiotensin- II-blocker can be the added. Diuretics should only be used as adjunctive therapy to ACE-inhibitors. Aldosterone antagonists have a proven effect on survival, but close monitoring of potassium levels is imperative. Especially in the elderly, the renal function and level of electrolytes must be monitored closely. Device therapy, such ac cardiac resynchronization therapy and implantable cardioverter defibrillators, are only indicated for selected patients. ACE-inhibitors, diuretics and beta-blockers are the drugs-of-choice for patients with congestive heart failure with preserved systolic function. Health care for patients with congestive heart failure must be well organized on different levels of care and with multidisciplinary teams involved. The goal is to reduce morbidity and mortality in the heart failure population. This programme is meant for primary, secondary and third line health care providers in Norway.

Hypertension commonly leads to heart disease, in particular left ventricular hypertrophy, heart failure and coronary artery disease. Left ventricular hypertrophy and coronary artery disease are both often subclinical diseases in hypertensives. Symptomatic coronary artery disease in hypertension may be due to atherosclerosis in epicardial arteries, microvascular dysfunction, reduced fibrinolytic capacity, or left ventricular hypertrophy; the latter is present in 20-50% of patients with mild to moderate and in up to 90% of patients with severe hypertension. Left ventricular hypertrophy in hypertension is associated with a twofold increase in risk of myocardial infarction, sudden death and stroke, and a fourfold increase in risk of heart failure. While coronary artery disease is the most common cause of heart failure in men, hypertension and in particular untreated isolated systolic hypertension is the most common cause in women. Heart failure symptoms may be subtle in hypertension, like tiredness or reduced physical capacity. Echocardiography can reveal subclinical heart disease as well as serve as a guide to correct diagnosis and treatment.