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Figure 3a. Moreover, unstable clinical conditions and hypotension, as well as bradycardia and AV block, typically represent a challenge in implementing betablocker therapy. Clinical trials on beta-blockers have shown that inhibition of the beta-adrenergic system increases survival and quality of life in patients with HF [, 5]. Reaching the optimal dose of carvedilol is one of the goals of medical therapy for HF.

The MOCHA study demonstrated that the carvedilol-induced increase in LVEF is dose-dependent and is associated to better survival [22]; for this reason, its use at the target dose is strongly recommended by the international HF guidelines [23].

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There is evidence that lack to achieve optimal medical therapy in HF is a major factor of hospitalization for worsening HF. The importance of achieving the optimal beta- antagonist dose is also suggested by the results of the two largest HF carvedilol studies: the Australia New Zealand Heart Failure Study [25] and the US Carvedilol Study [5].

Only one study regarding the effect of CRT on beta-blocker therapy has been published [27]; in this retrospective analysis of 52 HF patients, Aranda et al.

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The use of an alternative therapy, such as CRT, to improve LV performance might facilitate pharmacological compliance with beta-blockers. In patients Figure 4.

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The favorable clinical effects are probably due to a synergistic effect of CRT and carvedilol. Study limitations As this study began inwhen the clinical use of biventricular devices had just been started, a limited number of patients were enrolled in the CRT group.

In knowledge of dyssynchrony criteria was limited and few studies involving tissue Doppler analysis had been published; for this reason, we assessed cardiac dyssynchrony according to the criteria proposed by the CARE-HF trial [14].

There was no statistical difference in heart rate HR between the 2 groups at the end of the study; but HR at rest is not wrinkle focus syn ake cremă efector spot good an index of beta-adrenergic antagonism as exercise HR, which is considered more appropriate.

Stiinte medicale 1_ 2013

Natriuretic peptides plasma levels are related with heart failure severity and in the CARE- HF after CRT implantation were decreased, but their determination was not routinely available when the present study began.

If dyssynchrony criteria are present, CRT may create favorable conditions, which allow the doses of beta-blockers to be increased, thereby improving the clinical status and outcome.

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Bisetti, T. De Santo, A. De Luca are employees of Medtronic, Italy. Investigators and Committees.

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The 1. Lancet, ; Effect of metoprolol 2.

Waagstein, F. Camerini F. Circulation, ; Packer M. R, Cohn J. Colucci W. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med, ; Colucci, W. Gilbert E. Carvedilol inhibits clinical progression in patients with mild symptoms of heart failure.

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Bristow, M. Adams K. Carvedilol produces dose-related improvements in left ventricular function and survival in subjects with chronic heart failure. Wilstrand J. Goldstein S. J Am Coll Cardiol, ; Masca de intinerire a liniei de frumusete, S.