Efficacy of ivabradine in four patients with inappropriate sinus tachycardia: A three month-long experience based on electrocardiographic, Holter monitoring, exercise tolerance and quality of life assessments

Background: Inappropriate sinus tachycardia (IST) is an uncommon disorder characterized by an exaggerated heart rate (HR). It is mostly treated with b-blockers or verapamil leaving the sinus node modulation for refractory cases. Ivabradine, a pure HR lowering agent, has proven anti-anginal efficiency linked to the If current inhibition. We conducted a small prospective experience investigating its efficacy in IST. Methods: Four women exhibiting sinus rhythm with a resting HR ≥ 100 bpm and an average HR ≥ 90 bpm (Holter monitoring) were followed for three months. Structural heart disease and other causes of tachycardia were discarded. Electrocardiographic, Holter monitoring, exercise tolerance and quality of life determinations were performed. Ivabradine was initiated at 5 mg (bid) and increased to 7.5 mg (bid) after one week. Results: All patients (mean age 33.7 years) presented a typical history of effort intolerance, palpitations and tachycardia. Resting HR (bpm) was decreased: 106.5 ± 3 to 88.5 ± 2 (week 1), to 77.0 ± 3 (week 2) and to 73.7 ± 13 (month 3). Reductions (Holter monitoring) of the maximum, average and minimum HR (beats) were: 152.0 ± 19 to 128.5 ± 18; 96.0 ± 1.4 to 73 ± 3.2 and 63.2 ± 6 to 48.2 ± 3. Total exercise time was amplified (555 ± 99 to 679 ± 90 s) and quality of life improved. Conclusions: IST causes an elevated HR and its control is the treatment objective. If future data confirm our results, ivabradine could be used for this purpose. More information is necessary in order to define its role: initial option, second step (β-blockers non-responders or intolerants) or combined (refractory cases). (Cardiol J 2010; 17, 2: 166-171

Emerging concepts in heart failure management and treatment: focus on SGLT2 inhibitors in heart failure with preserved ejection fraction

Dapagliflozin; Empagliflozin; Heart failureDapagliflozina; Empagliflozina; Atac de corDapagliflozina; Empagliflozina; Insuficiencia cardiacaThe role of sodium-glucose cotransporter 2 inhibitors (SLTG2i), developed initially as glucose-lowering agents, has represented a novelty in patients with heart failure (HF) and reduced ejection fraction (HFrEF) since dapagliflozin (DAPA-HF study) and empagliflozin (EMPEROR-Reduced study) were able to reduce morbidity and mortality in this setting regardless of the presence or absence of diabetes. In previous large clinical trials (EMPA-REG OUTCOME study, CANVAS, DECLARE-TIMI 58), SGLT2i have been shown to attenuate HF progression expressed by reducing the risk of HF hospitalizations in patients with type 2 diabetes mellitus mostly without HF at baseline. This benefit was then corroborated with positive results in HF outcomes (cardiovascular mortality and HF hospitalizations) in patients with HF with preserved ejection fraction (HFpEF) in the EMPEROR-Preserved (empagliflozin) and DELIVER (dapagliflozin) trials. Several biological mechanisms apart from the glycosuria are attributed to these agents in this last context, including anti-inflammatory effects, reduction of fibrosis and apoptosis, improvement of myocardial metabolism, mitochondrial function optimization, and oxidative stress protection. Moreover, SGLT2i can also improve ventricular loading conditions by forcing diuresis and natriuresis, and by enhancing vascular and renal function. In addition, SGLT2i can reduce myocardial passive stiffness (diastolic function) by enforcing the phosphorylation of myofilament modulatory proteins. This article provided an overview of the main pathophysiological characteristics of HFpEF and of the diverse mechanisms of action of SGLT2i in this setting. The supporting clinical evidence of SGLT2i in HFpEF (EMPEROR-Preserved and DELIVER trials) is also reviewed. This article is part of the Emerging concepts in heart failure management and treatment Special Issue: https://www.drugsincontext.com/special_issues/emerging-concepts-in-heart-failure-management-and-treatment

Dengue Myocarditis: A Case Report and Major Review

Dengue is a viral disease transmitted by the bite of a female arthropod, prevalent primarily in tropical and subtropical regions. Its manifestations include asymptomatic infections, dengue fever, and a severe form called hemorrhagic dengue or dengue shock syndrome. Atypical manifestations can also occur, called expanded dengue syndrome. We describe the case of a 43-year-old man with an unusual presentation of dengue, demonstrating a workup suggestive of myocardial and pericardial damage. Symptoms and markers indicative of cardiac compromise improved after five days on anti-inflammatory treatment. Dengue myocarditis is considered an uncommon complication of dengue, although its reported incidence is likely an underestimation. In general, most cases of dengue myocarditis are self-limited, with only a minority at risk of progressing to heart failure. In order to improve recognition and prevent progression, healthcare providers should maintain a high degree of suspicion regarding potential cardiac complications in patients with dengue

Cardiac myosin activators for heart failure therapy: focus on omecamtiv mecarbil

Heart failure continues to be a major global health problem with a pronounced impact on morbidity and mortality and very limited drug treatment options especially with regard to inotropic therapy. Omecamtiv mecarbil is a first-in-class cardiac myosin activator, which increases the proportion of myosin heads that are tightly bound to actin and creates a force-producing state that is not associated with cytosolic calcium accumulation. Phase I and phase II studies have shown that it is safe and well tolerated. It produces dose-dependent increases in systolic ejection time (SET), stroke volume (SV), left ventricular ejection fraction (LVEF), and fractional shortening. In the ATOMIC-AHF trial, intravenous (IV) omecamtiv mecarbil did not improve dyspnoea overall but may have improved it in a high-dose group of acute heart failure patients. It did, however, increase SET, decrease left ventricular end-systolic diameter, and was well tolerated. The COSMIC-HF trial showed that a pharmacokinetic-based dose-titration strategy of oral omecamtiv mecarbil improved cardiac function and reduced ventricular diameters compared to placebo and had a similar safety profile. It also significantly reduced plasma N-terminalpro B-type natriuretic peptide compared with placebo. The GALACTIC-HF trial is now underway and will compare omecamtiv mecarbil with placebo when added to current heart failure standard treatment in patients with chronic heart failure and reduced LVEF. It is expected to be completed in January 2021. The ongoing range of preclinical and clinical research on omecamtiv mecarbil will further elucidate its full range of pharmacological effects and its clinical usefulness in heart failure

Trasplante cardíaco: nuevos retos para el siglo XXI

Desde el primer trasplante cardíaco (TC) realizado en 1967, este procedimiento quirúrgico ha sufrido grandes avatares. A los difíciles inicios que acompañan a cualquier actividad pionera de la medicina, se asociaron unos resultados considerados como inaceptables para muchos cardiólogos y cirujanos cardíacos de aquel momento. En los primeros 82 pacientes del grupo de Stanford, la supervivencia era del 48 y del 25% a los 12 y 36 meses, respectivamente1 . La elevada mortalidad por rechazo era la causa de este descrédito en todo el mundo, y comentarios como: «el trasplante cardíaco: esa gran especulación del futuro» eran habituales en los foros médicos. La introducción de la ciclosporina como tratamiento inmunodepresor en los años ochenta hizo posible el aumento del número de trasplantes cardíacos hasta límites impensables en los años setenta. Por último, la gran especulación se había convertido en una realidad que aportaba supervivencias muy superiores a las previas, y actualmente es del 82% al año y del 68% a los 5 años2 . El TC era, por tanto, la única salida para los enfermos con insuficiencia cardíaca (IC) avanzada y en muchos casos resistente a todo tipo de tratamientos, y esta afirmación no era cuestionada. Por otro lado, los profundos conocimientos de la hiperactividad neurohormonal como base de la fisiopatología y del pronóstico de los pacientes con IC, así como el papel de la terapia dirigida a controlar y modular esta actividad, han modificado de forma sustancial las expectativas en los pacientes con IC avanzada

Emerging concepts in heart failure management and treatment: focus on point-of-care ultrasound in cardiogenic shock

Abstract: Point-of-care ultrasound (POCUS) plays a strategic role in the diagnostic and therapeutic evaluation of critically ill patients and, especially, in those who are haemodynamically unstable. In this context, POCUS allows a more precise identification of the cause, its differential diagnosis, the eventual coexistence with another entity and, finally, guiding of the therapeutic approach. It implies a portable use of ultrasound in acute settings covering different specified protocols, such as echocardiography, vascular, lung or abdominal ultrasound. This article reviews POCUS application in the emergency department or the intensive care unit, focused on severely compromised patients with cardiogenic shock with an emergent bedside assessment. Considering the high mortality rate of this entity, POCUS provides the intensivist/clinician with an appropriate tool for accurate diagnoses and a timely management plan. The authors propose practical algorithms for the diagnosis of patients using POCUS in these settings