24 agosto 2014

CIRCULATION. AHA Policy Statement. Electronic Cigarettes. A Policy Statement From the American Heart Association

Aruni Bhatnagar, PhD, FAHA, Chair; Laurie P. Whitsel, PhD; Kurt M. Ribisl, PhD; Chris Bullen, MBChB, PhD; Frank Chaloupka, PhD; Mariann R. Piano, PhD; Rose Marie Robertson, MD, FAHA; Timothy McAuley, PhD; David Goff, MD, PhD, FAHA; Neal Benowitz, MD; on behalf of the American Heart Association Advocacy Coordinating Committee, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research

For decades, advocacy for tobacco control has been a priority of the American Heart Association (AHA). In partnership with major public health organizations, the association has made major strides in tobacco use prevention and cessation by prioritizing evidence-based strategies such as increasing excise taxes; passing comprehensive smoke-free air laws; facilitating US Food and Drug Administration (FDA) authority to regulate tobacco, including comprehensive tobacco cessation treatment within healthcare plans; and supporting adequate funding of comprehensive tobacco control programs in different states. These tobacco control efforts have cut in half the youth smoking rate from 1997 to 2007 and have saved >8 million lives in the past 50 years.1 However, the work is far from done and has stalled, especially for people living below the poverty line, those with mental illnesses,2 and those with low educational attainment.3 Unless current trends reverse, ≈5.6 million children alive today in the United States will die prematurely of smoking-related diseases.1 Even now, cigarette smoking kills nearly half a million Americans each year, and an additional 16 million individuals suffer from smoking-related illness, which costs the United States $289 billion dollars annually in direct medical care and other economic costs.1

29 septiembre 2014

CIRCULATION. AHA Scientific Statement. Approaches to Enhancing Radiation Safety in Cardiovascular Imaging. A Scientific Statement From the American Heart Association

Reza Fazel, MD, MSc, FAHA, Chair; Thomas C. Gerber, MD, PhD, FAHA, Co-Chair; Stephen Balter, PhD; David J. Brenner, DSc; J. Jeffrey Carr, MD, MSCE; Manuel D. Cerqueira, MD; Jersey Chen, MD, MPH; Andrew J. Einstein, MD, PhD, FAHA; Harlan M. Krumholz, MD, SM, FAHA; Mahadevappa Mahesh, MS, PhD; Cynthia H. McCollough, PhD; James K. Min, MD; Richard L. Morin, PhD; Brahmajee K. Nallamothu, MD, MPH, FAHA; Khurram Nasir, MD, MPH; Rita F. Redberg, MD, MSc, FAHA; Leslee J. Shaw, PhD; on behalf of the American Heart Association Council on Quality of Care and Outcomes Research, Council on Clinical Cardiology, and Council on Cardiovascular Radiology and Intervention

Cardiac imaging is an invaluable tool in the diagnosis and management of heart disease. As a consequence of new capabilities and widespread availability, the use of medical imaging has increased dramatically in the United States, as has radiation exposure related to imaging. The National Council on Radiation Protection & Measurements reports that the total radiation exposure to the US population from medical imaging has increased 6-fold since 1980, even though the radiation doses from individual examinations have stayed approximately constant or decreased. Nearly 40% of this medical radiation exposure to the US population (excluding radiotherapy) is related to cardiovascular imaging and intervention.1

28 julio 2014

CIRCULATION. ACC/AHA/AATS/PCNA/SCAI/STS Focused Update. 2014 ACC/AHA/AATS/PCNA/SCAI/STS Focused Update of the Guideline for the Diagnosis and Management of Patients With Stable Ischemic Heart Disease. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines, and the American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons

Stephan D. Fihn, MD, MPH, Chair†; James C. Blankenship, MD, MHCM, MACC, FAHA, Vice Chair*†; Karen P. Alexander, MD, FACC, FAHA*†; John A. Bittl, MD, FACC*†; John G. Byrne, MD, FACC‡; Barbara J. Fletcher, RN, MN, FAHA§; Gregg C. Fonarow, MD, FACC, FAHA*‖; Richard A. Lange, MD, FACC, FAHA†; Glenn N. Levine, MD, FACC, FAHA†; Thomas M. Maddox, MD, MSc, FACC, FAHA†; Srihari S. Naidu, MD, FACC, FAHA, FSCAI¶; E. Magnus Ohman, MD, FACC*#; Peter K. Smith, MD, FACC**

Preamble: Keeping pace with emerging evidence is an ongoing challenge to timely development of clinical practice guidelines. In an effort to respond promptly to new evidence, the American College of Cardiology (ACC)/American Heart Association (AHA) Task Force on Practice Guidelines (Task Force) has created a “focused update” process to revise the existing guideline recommendations that are affected by evolving data or opinion. New evidence is reviewed in an ongoing manner to respond quickly to important scientific and treatment trends that could have a major impact on patient outcomes and quality of care. Evidence is reviewed at least twice a year, and updates are initiated on an as-needed basis and completed as quickly as possible while maintaining the rigorous methodology that the ACC and AHA have developed during their partnership of >20 years.

1 2010

CIRCULATION. AHA/ACC/HHS Clinical Practice Guideline. AHA/ACC/HHS Strategies to Enhance Application of Clinical Practice Guidelines in Patients With Cardiovascular Disease and Comorbid Conditions. From the American Heart Association, American College of Cardiology, and US Department of Health and Human Services

Donna K. Arnett, MSPH, PhD; Richard A. Goodman, MD, MPH*; Jonathan L. Halperin, MD; Jeffrey L. Anderson, MD; Anand K. Parekh, MD, MPH; William A. Zoghbi, MD

Background: Cardiovascular disease, the leading cause of death in the United States and worldwide, accounts for substantial suffering and healthcare-related expenditures.1–3 For more than 30 years, the American Heart Association (AHA) and the American College of Cardiology (ACC) have partnered with other organizations to translate the best available scientific evidence into clinical practice guidelines (CPGs) for cardiovascular conditions. These efforts reflect a shared vision and responsibility for using scientific evidence and the expert clinical opinion of leaders in the field to develop recommendations for healthcare providers. These CPGs, based on systematic methods to evaluate and classify evidence, have provided the cornerstones for delivering quality cardiovascular care.

27 mayo 2014

CANADIAN JOURNAL OF CARDIOLOGY. Canadian Cardiovascular Society Guidelines for the Diagnosis and Management of Stable Ischemic Heart Disease

G.B. John Mancini, MD ((Co-Chair)), Gilbert Gosselin, MD ((Co-Chair)), Benjamin Chow, MD, William Kostuk, MD, James Stone, MD, PhD, Kenneth J. Yvorchuk, MD, CM, Beth L. Abramson, MD, MSc, Raymond Cartier, MD, Victor Huckell, MD, Jean-Claude Tardif, MD, Kim Connelly, MD, John Ducas, MD, Michael E. Farkouh, MD, MSc, Milan Gupta, MD, Martin Juneau, MD, Blair O’Neill, MD, Paolo Raggi, MD, Koon Teo, MBBCh, PhD, Subodh Verma, MD, Rodney Zimmermann, MD

Abstract: This overview provides a guideline for the management of stable ischemic heart disease. It represents the work of a primary and secondary panel of participants from across Canada who achieved consensus on behalf of the Canadian Cardiovascular Society. The suggestions and recommendations are intended to be of relevance to primary care and specialist physicians with an emphasis on rational deployment of diagnostic tests, expedited implementation of long- and short-term medical therapy, timely consideration of revascularization, and practical follow-up measures.

01 septiembre 2014

JACC. The Evolution and Future of ACC/AHA Clinical Practice Guidelines: A 30-Year Journey

Alice K. Jacobs, MD, FACC, FAHA; Jeffrey L. Anderson, MD, FACC, FAHA; Jonathan L. Halperin, MD, FACC, FAHA

In 2014, we mark the 30th anniversary of the first publication of an American College of Cardiology (ACC) and American Heart Association (AHA) clinical practice guideline (CPG). This joint effort was undertaken in response to the U.S. government’s request to review the evidence concerning cardiac pacemakers and develop CPGs to mitigate potential overuse. Since then, fueled by a shared sense of responsibility to translate available evidence into clinical practice to guide cardiovascular clinicians, the ACC and AHA have developed 23 CPGs across the spectrum of cardiovascular diseases and procedures.

10 julio 2014

CANADIAN JOURNAL OF CARDIOLOGY. Canadian Heart Rhythm Society and Canadian Association of Radiologists Consensus Statement on Magnetic Resonance Imaging With Cardiac Implantable Electronic Devices

Atul Verma, MD, Andrew C.T. Ha, MD, Carole Dennie, MD, Vidal Essebag, MD, PhD, Derek V. Exner, MD, MPH, Naeem Khan, MD, Chris Lane, MD, Jonathan Leipsic, MD, Francois Philippon, MD, Marcos Sampaio, MD, Nicola Schieda, MD, Colette Seifer, MD, Alain Berthiaume, MRT, Debra Campbell, RN, Santanu Chakraborty, MD

Abstract: Magnetic resonance imaging (MRI) has historically been considered contraindicated for individuals with cardiac implantable electronic devices (CIEDs) such as pacemakers and implantable defibrillators. Magnetic resonance scanners produce magnetic fields that can interact negatively with the metallic components of CIEDs. However, as CIED technology has advanced, newer MRI conditional devices have been developed that are now in clinical use and these systems have had demonstrated safety in the MRI environment. Despite the supportive data of such CIED systems, physicians remain reluctant to perform MRI scanning of conditional devices. This joint statement by the Canadian Heart Rhythm Society and the Canadian Association of Radiologists describes a collaborative process by which CIED specialists and clinics can work with radiology departments and specialists to safely perform MRI in patients with MRI conditional CIED systems. The steps required for patient and scanning preparation and the roles and responsibilities of the CIED and radiology departments are outlined. We also briefly outline the risks and a process by which patients with nonconditional CIEDs might also receive MRI in highly specialized centres. This document supports MRI in patients with MRI conditional CIEDs and offers recommendations on how this can be implemented safely and effectively.

01 noviembre 2013

CIRCULATION. ACC/AHA Prevention Guideline. 2013 ACC/AHA Guideline on the Treatment of Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Neil J. Stone, MD, MACP, FAHA, FACC, Chair; Jennifer G. Robinson, MD, MPH, FAHA, Vice Chair; Alice H. Lichtenstein, DSc, FAHA, Vice Chair; C. Noel Bairey Merz, MD, FAHA, FACC; Conrad B. Blum, MD, FAHA; Robert H. Eckel, MD, FAHA; Anne C. Goldberg, MD, FACP, FAHA; David Gordon, MD; Daniel Levy, MD*; Donald M. Lloyd-Jones, MD, SCM, FACC, FAHA; Patrick McBride, MD, MPH, FAHA; J. Sanford Schwartz, MD; Susan T. Shero, MS, RN*; Sidney C. Smith Jr, MD, FACC, FAHA; Karol Watson, MD, PhD, FACC, FAHA; Peter W. F. Wilson, MD, FAHA

The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases; improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults.

01 noviembre 2013

CIRCULATION. ACC/AHA Prevention Guideline. 2013 ACC/AHA Guideline on the Assessment of Cardiovascular Risk. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

David C. Goff Jr, MD, PhD, FACP, FAHA, Co-Chair; Donald M. Lloyd-Jones, MD, ScM, FACC, FAHA, Co-Chair; Glen Bennett, MPH*; Sean Coady, MS*; Ralph B. D’Agostino, Sr, PhD, FAHA; Raymond Gibbons, MD, FACC, FAHA; Philip Greenland, MD, FACC, FAHA; Daniel T. Lackland, DrPH, FAHA; Daniel Levy, MD*; Christopher J. O’Donnell, MD, MPH*; Jennifer G. Robinson, MD, MPH, FAHA; J. Sanford Schwartz, MD; Susan T. Shero, MS, RN*; Sidney C. Smith Jr, MD, FACC, FAHA; Paul Sorlie, PhD*; Neil J. Stone, MD, FACC, FAHA; Peter W. F. Wilson, MD, FAHA

The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases (CVD); improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults.

01 noviembre 2013

CIRCULATION. AHA/ACC Prevention Guideline. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce Cardiovascular Risk. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines

Robert H. Eckel, MD, FAHA, Co-Chair; John M. Jakicic, PhD, Co-Chair; Jamy D. Ard, MD; Janet M. de Jesus, MS, RD*; Nancy Houston Miller, RN, BSN, FAHA; Van S. Hubbard, MD, PhD*; I-Min Lee, MD, ScD; Alice H. Lichtenstein, DSc, FAHA; Catherine M. Loria, PhD, FAHA*; Barbara E. Millen, DrPH, RD, FADA; Cathy A. Nonas, MS, RD; Frank M. Sacks, MD, FAHA; Sidney C. Smith Jr, MD, FACC, FAHA; Laura P. Svetkey, MD, MHS; Thomas A. Wadden, PhD; Susan Z. Yanovski,

The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases (CVDs); improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults.

01 junio 2013

JACC. 2012 ACCF/AHA Focused Update Incorporated Into the ACCF/AHA 2007 Guidelines for the Management of Patients With Unstable Angina/Non–ST-Elevation Myocardial Infarction. A Report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines

Jeffrey L. Anderson, MD, FACC, FAHA; Cynthia D. Adams, RN, PhD, FAHA; Elliott M. Antman, MD, FACC, FAHA; Charles R. Bridges, MD, ScD, FACC, FAHA; Robert M. Califf, MD, MACC; Donald E. Casey, MD, MPH, MBA, FACP, FAHA; William E. Chavey, MD, MS; Francis M. Fesmire, MD, FACEP; Judith S. Hochman, MD, FACC, FAHA; Thomas N. Levin, MD, FACC, FSCAI; A. Michael Lincoff, MD, FACC; Eric D. Peterson, MD, MPH, FACC, FAHA; Pierre Theroux, MD, FACC, FAHA; Nanette K. Wenger, MD; R. Scott Wright, MD, FACC, FAHA

It is important that the medical profession play a significant role in critically evaluating the use of diagnostic procedures and therapies as they are introduced and tested in the detection, management, or prevention of disease states. Rigorous and expert analysis of the available data documenting absolute and relative benefits and risks of those procedures and therapies can produce helpful guidelines that improve the effectiveness of care, optimize patient outcomes, and favorably affect the overall cost of care by focusing resources on the most effective strategies.

01 julio 2013

JACC. ACCF/AHA/SCAI 2013 Update of the Clinical Competence Statement on Coronary Artery Interventional Procedures. A Report of the American College of Cardiology Foundation/American Heart Association/American College of Physicians Task Force on Clinical Competence and Training (Writing Committee to Revise the 2007 Clinical Competence Statement on Cardiac Interventional Procedures)

John G. Harold, MD, MACC, FAHA; Theodore A. Bass, MD, FACC, FSCAI; Thomas M. Bashore, MD, FACC, FAHA, FSCAI; Ralph G. Brindis, MD, MPH, MACC, FSCAI; John E. Brush, MD, FACC; James A. Burke, MD, PhD, FACC; Gregory J. Dehmer, MD, FACC, FAHA, FSCAI; Yuri A. Deychak, MD, FACC; Hani Jneid, MD, FACC, FAHA, FSCAI; James G. Jollis, MD, FACC; Joel S. Landzberg, MD, FACC; Glenn N. Levine, MD, FACC, FAHA; James B. McClurken, MD, FACC; John C. Messenger, MD, FACC, FSCAI; Issam D. Moussa, MD, FACC, FAHA, FSCAI; J. Brent Muhlestein, MD, FACC; Richard M. Pomerantz, MD, FACC, FSCAI; Timothy A. Sanborn, MD, FACC, FAHA; Chittur A. Sivaram, MBBS, FACC; Christopher J. White, MD, FACC, FAHA, FSCAI; Eric S. Williams, MD, FACC

Granting clinical staff privileges to physicians is the primary mechanism institutions use to uphold quality care. The Joint Commission requires that medical staff privileges be based on professional criteria specified in medical staff bylaws. Physicians themselves are charged with defining the criteria that constitute professional competence and with evaluating their peers accordingly. The process of evaluating physicians´ knowledge and competence has become more complex as various subspecialties have evolved over time.

25 abril 2013

EUROPEAN HEART JOURNAL. Expert consensus document from the European Society of Cardiology on catheter-based renal denervation†

Felix Mahfoud1,*, Thomas Felix Lüscher2, Bert Andersson3, Iris Baumgartner4, Renata Cifkova5, Carlo DiMario6, Pieter Doevendans7, Robert Fagard8, Jean Fajadet9, Michel Komajda10, Thierry LeFèvre11, Chaim Lotan12, Horst Sievert13, Massimo Volpe14,15, Petr Widimsky16, William Wijns17, Bryan Williams18, Stephan Windecker19, Adam Witkowski20, Thomas Zeller21 and Michael Böhm1

Introduction: Hypertension is highly prevalent and one of the most frequent chronic diseases worldwide.1 It has been suggested that over the next two decades up to 50% of the adult population will be diagnosed with hypertension, according to the standard guideline definitions.1 Despite the availability of many safe and effective antihypertensive drugs, control rates to target blood pressure remain low.2 Approximately 5–10% of all patients with high blood pressure are resistant to drug treatment defined as blood pressure >140/90 mmHg, >130–139/80–85 mmHg in diabetes mellitus or >130/80 mmHg in chronic kidney disease in the presence of three or more antihypertensives of different classes, including a diuretic, at maximal or the highest tolerated dose.3 Resistant hypertension is associated with an increased risk of cardiovascular events.4 Current non-invasive therapeutic strategies are mainly based on lifestyle interventions and pharmacological treatment, including mineralocorticoid receptor antagonists.3 Up until recently treatment options for patients with resistant hypertension were limited. Nowadays catheter-based renal denervation offers a new approach targeting the renal sympathetic nerves. Indeed, the technique has been shown to reduce sympathetic nerve activity,5 norepinephrine spillover6 as well as blood pressure7–9 in patients with resistant hypertension. Several national10–13 and international14 consensus documents from different societies have recently been published, with different degrees of involvement of interventionalists. This expert consensus document summarizes the view of an expert panel of the European Society of Cardiology and the European Association of Percutaneous Cardiovascular Interventions to provide guidance regarding appropriate patient selection, efficacy, safety, limitations, and potential new indications of renal denervation for referring physicians, interventionalists, and healthcare providers.

01 noviembre 2013

CIRCULATION. AHA/ACC/TOS Prevention Guideline. 2013 AHA/ACC/TOS Guideline for the Management of Overweight and Obesity in Adults. A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines and The Obesity Society

Michael D. Jensen, MD, Co-Chair; Donna H. Ryan, MD, Co-Chair; Caroline M. Apovian, MD, FACP; Jamy D. Ard, MD; Anthony G. Comuzzie, PhD; Karen A. Donato, SM*; Frank B. Hu, MD, PhD, FAHA; Van S. Hubbard, MD, PhD*; John M. Jakicic, PhD; Robert F. Kushner, MD; Catherine M. Loria, PhD, FAHA*; Barbara E. Millen, DrPH, RD; Cathy A. Nonas, MS, RD; F. Xavier Pi-Sunyer, MD, MPH; June Stevens, PhD; Victor J. Stevens, PhD; Thomas A. Wadden, PhD; Bruce M. Wolfe, MD; Susan Z. Yanovski, MD*

The goals of the American College of Cardiology (ACC) and the American Heart Association (AHA) are to prevent cardiovascular diseases (CVD); improve the management of people who have these diseases through professional education and research; and develop guidelines, standards, and policies that promote optimal patient care and cardiovascular health. Toward these objectives, the ACC and AHA have collaborated with the National Heart, Lung, and Blood Institute (NHLBI) and stakeholder and professional organizations to develop clinical practice guidelines for assessment of cardiovascular risk, lifestyle modifications to reduce cardiovascular risk, management of blood cholesterol in adults, and management of overweight and obesity in adults.

01 marzo 2014

CANADIAN JOURNAL OF CARDIOLOGY. The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update: Focus on Rehabilitation and Exercise and Surgical Coronary Revascularization

Primary Panel:, Gordon W. Moe, MD, MSc, FRCPC ((Chair)), Justin A. Ezekowitz, MB, BCh, MSc, FRCPC ((Co-Chair)), Eileen O´Meara, MD, FRCPC, Jonathan G. Howlett, MD, FRCPC, Steve E. Fremes, MD, FRCPC, Abdul Al-Hesayen, MD, FRCPC, George A. Heckman, MD, MSc, FRCPC, Anique Ducharme, MD, FRCPC, Estrellita Estrella-Holder, RN, BN, MScA, CCN(C), Adam Grzeslo, MD, CCFP, FCFP, Karen Harkness, RN, BScN, CCNC, PhD, Serge Lepage, MD, FRCPC, Michael McDonald, MD, FRCPC, Robert S. McKelvie, MD, FRCPC, Anil Nigam, MD, MSc, FRCPC, Miroslaw Rajda, MD, FRCPC, Vivek Rao, MD, PhD, FRCPS, Elizabeth Swiggum, MD, FRCPC, Sean Virani, MD, FRCPC, Vy Van Le, MD, FRCPC, Shelley Zieroth, MD, FRCPC, Secondary Panel:, J. Malcolm O. Arnold, MD, FRCPC, Tom Ashton, MD, FRCPC, Michel D´Astous, MD, FRCPC, Paul Dorian, MD, FRCPC, Nadia Giannetti, MD, FRCPC, Haissam Haddad, MD, FRCPC, Debra L. Isaac, MD, FRCPC, Simon Kouz, MD, FRCPC, FACC, Marie-Hélène Leblanc, MD, FRCPC, Peter Liu, MD, FRCPC, Heather J. Ross, MD, FRCPC, Bruce Sussex, MD, FRCPC, Michel White, MD, FRCPC

Abstract : The 2013 Canadian Cardiovascular Society Heart Failure Management Guidelines Update provides focused discussions on the management recommendations on 2 topics: (1) exercise and rehabilitation; and (2) surgical coronary revascularization in patients with heart failure. First, all patients with stable New York Heart Association class I-III symptoms should be considered for enrollment in a tailored exercise training program, to improve exercise tolerance and quality of life. Second, selected patients with suitable coronary anatomy should be considered for bypass graft surgery. As in previous updates, the topics were chosen in response to stakeholder feedback. The 2013 Update also includes recommendations, values and preferences, and practical tips to assist the clinicians and health care workers manage their patients with heart failure.