Current cardiology reports
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The renin-angiotensin-aldosterone system (RAAS) plays an important role in blood pressure control and volume homeostasis. Inappropriate activation of the RAAS has been implicated in the pathogenesis of hypertension and related cardiovascular disease. Several classes of agents that block RAAS signaling have been shown to be effective antihypertensives and to have cardioprotective and renoprotective properties. Because blockade of the RAAS is incomplete with any of the currently available monotherapies, combinations of these agents have been tested and shown to provide additional clinical benefit in patients with hypertension and various forms of cardiovascular and renal disease.
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Stroke prevention is the primary goal in atrial fibrillation (AF) given its clinical and socioeconomic impact. With AF, the prevalence of thromboembolic stroke continues to rise and there is an urgent need to develop better strategies of stroke prevention. Warfarin, although effective when used appropriately, is burdened by underutilization, narrow therapeutic windows, and life-threatening bleeding complications. ⋯ Because most thromboemboli arise from the left atrial appendage (LAA), surgical exclusion of the LAA is often used in AF patients undergoing cardiac surgery. Percutaneous device LAA closure has now been developed as an adjunct and as an alternative to pharmacotherapy in patients with AF. Promising randomized data are available with the WATCHMAN device, while several other devices are in various stages of clinical and preclinical development.
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Despite recent advances in treating cardiovascular disease, many of the predisposing risk factors for heart disease are increasing in prevalence, raising concern that heart disease rates may rise in the years to come. When faced with the range of risk factors such as obesity, smoking, hypertension, hyperlipidemia, and diabetes, the clinician needs to address all components. ⋯ Key elements of lifestyle changes are individualized treatment plans and frequent follow-up, whereas approaches to improve medical therapy include using structured programs to increase awareness and implementation of risk-reducing medications. Improving risk factor modification requires a global approach, not only in addressing the spectrum of risk factors, but also in using the full range of strategies available to clinicians.
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The clinical syndrome of heart failure is increasing in prevalence, as is the number of elderly persons with heart failure. Increasing frailty and progression of heart failure in large numbers of patients means clinicians are increasingly challenged to provide end-of-life care for heart failure patients. End-of-life care has been little studied, but management can be understood from early clinical trials of advanced heart failure. ⋯ Patients also should have ongoing meticulous management of fluid status to maximize quality of life. End-of-life care should be planned with the patient and family and should incorporate comprehensive symptom management, bereavement support, and spiritual support. Ongoing communication with patients and families about prognosis can ease the planning of care when the end of life nears.
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Clinical practice guidelines recommend cardiac resynchronization therapy (CRT) for ambulatory New York Heart Association (NYHA) class IV patients with a QRS duration >or= 120 ms and a left ventricular ejection fraction