Pharmacotherapy of heart failure A.D. 2023. Expert opinion of Working Group on Cardiovascular Pharmacotherapy, Polish Cardiac Society.

Heart failure (HF) remains one of the most common causes of hospitalization and mortality among Polish patients. The position of the Section of Cardiovascular Pharmacotherapy presents the currently applicable options for pharmacological treatment of HF based on the latest European and American guidelines from 2021-2022 in relation to Polish healthcare conditions. Treatment of HF varies depending on its clinical presentation (acute/chronic) or left ventricular ejection fraction. Initial treatment of symptomatic patients with features of volume overload is based on diuretics, especially loop drugs. Treatment aimed at reducing mortality and hospitalization should include drugs blocking the renin-angiotensin-aldosterone system, preferably angiotensin receptor antagonist/neprilysin inhibitor, i.e. sacubitril/valsartan, selected beta-blockers (no class effect - options include bisoprolol, metoprolol succinate, or vasodilatory beta-blockers - carvedilol and nebivolol), mineralocorticoid receptor antagonist, and sodium-glucose cotransporter type 2 inhibitor (flozin), constituting the 4 pillars of pharmacotherapy. Their effectiveness has been confirmed in numerous prospective randomized trials. The current HF treatment strategy is based on the fastest possible implementation of all four mentioned classes of drugs due to their independent additive action. It is also important to individualize therapy according to comorbidities, blood pressure, resting heart rate, or the presence of arrhythmias. This article emphasizes the cardio- and nephroprotective role of flozins in HF therapy, regardless of ejection fraction value. We propose practical guidelines for the use of medicines, profile of adverse reactions, drug interactions, as well as pharmacoeconomic aspects. The principles of treatment with ivabradine, digoxin, vericiguat, iron supplementation, or antiplatelet and anticoagulant therapy are also discussed, along with recent novel drugs including omecamtiv mecarbil, tolvaptan, or coenzyme Q10 as well as progress in the prevention and treatment of hyperkalemia. Based on the latest recommendations, treatment regimens for different types of HF are discussed.

Rationale and design of the AFFIRM-AHF trial: a randomised, double-blind, placebo-controlled trial comparing the effect of intravenous ferric carboxymaltose on hospitalisations and mortality in iron-deficient patients admitted for acute heart failure.

AIMS: Iron deficiency (ID) is a common co-morbidity in heart failure (HF), associated with impaired functional capacity, poor quality of life and increased morbidity and mortality. Treatment with intravenous (i.v.) ferric carboxymaltose (FCM) has shown improvements in functional capacity, symptoms and quality of life in stable HF patients with reduced ejection fraction. The effect of i.v. iron supplementation on morbidity and mortality in patients hospitalised for acute HF (AHF) and who have ID has yet to be established. The objective of the present article is to present the rationale and design of the AFFIRM-AHF trial (ClinicalTrials.gov NCT02937454) which will investigate the effect of i.v. FCM (vs. placebo) on recurrent HF hospitalisations and cardiovascular (CV) mortality in iron-deficient patients hospitalised for AHF. METHODS: AFFIRM-AHF is a multicentre, randomised (1:1), double-blind, placebo-controlled trial which recruited 1100 patients hospitalised for AHF and who had iron deficiency ID defined as serum ferritin <100 ng/mL or 100-299 ng/mL if transferrin saturation <20%. Eligible patients were randomised (1:1) to either i.v. FCM or placebo and received the first dose of study treatment just prior to discharge for the index hospitalisation. Patients will be followed for 52 weeks. The primary outcome is the composite of recurrent HF hospitalisations and CV mortality. The main secondary outcomes include the composite of recurrent CV hospitalisations and CV mortality, recurrent HF hospitalisations and safety-related outcomes. CONCLUSION: The AFFIRM-AHF trial will evaluate, compared to placebo, the effect of i.v. FCM on morbidity and mortality in iron-deficient patients hospitalised for AHF.

Laser biostimulation in end-stage multivessel coronary artery disease--a preliminary observational study.

BACKGROUND: Low-energy laser radiation through its direct influence on tissue repair processes without heating effect may have vital importance in the therapy of patients with advanced coronary artery disease (CAD). AIM: The introductory assessment of the effects of laser biostimulation applied to patients with advanced multivessel CAD. METHODS: 39 patients with advanced CAD were assigned (mean age 64.8+/-9.6, male gender 64%, CCS class 2.5+/-0.5, EF=46+/-11%, 69% with a history of acute myocardial infarction), to undergo two sessions of irradiation of low-energy laser light on skin in the chest area from helium-neon B1 lasers. The time of irradiation was 15 minutes while operations were performed 6 days a week for one month. Before including the patients in the experimental group a full clinical evaluation, basic biochemical tests, ECG, 24h Holter recordings, 6-minute walk test, treadmill test using Bruce protocol and full echocardiographic examination were performed. After the first and second period of laser therapy with a one-month break between them analogical parameters with the initial examination were measured. RESULTS: No side effects associated with the laser biostimulation or performed clinical tests were noted. Lower CCS class (2.5+/-0.5 --> 2.2+/-0.4 --> 2.0+/-0.4, p<0.001), higher exercise capacity (5.1+/-2.2 --> 5.8+/-2.2 --> 6.6+/-2.5 [METS], p=0.023), longer exercise time (257+/-126 --> 286+/-127 --> 325+/-156 [s], p=0.06), less frequent angina symptoms during the treadmill test (65% --> 44% --> 38%, p=0.02), longer distance of 6-minute walk test (341+/-93 --> 405+/-113 --> 450+/-109 [m], p <0.001), lower systolic blood pressure values (SP 130+/-14 --> 125+/-12 --> 124+/-14 [mmHg], p=0.05) and trend towards less frequent 1 mm ST depression lasting 1 min during Holter recordings were noted. CONCLUSIONS: An improvement of functional capacity and less frequent angina symptoms during exercise tests without a significant change in the left ventricular function were observed. Laser biostimulation in short-term observation was a very safe method. These encouraging results should be confirmed in a larger, placebo-controlled study.