Congestive heart failure calcium channel blockers: Difference between revisions

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(/* ACC/AHA Guidelines- Calcium channel blockers Recommendation Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC...)
(/* ACC/AHA Guidelines- Calcium channel blockers Recommendation Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC...)
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| bgcolor="LightGreen"|'''1.''' Drugs known to adversely affect the clinical status of patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]) should be avoided or withdrawn whenever possible (e.g., [[NSAID|nonsteroidal anti-inflammatory drugs]], most [[Antiarrhythmic agent|antiarrhythmic drugs]], and most [[Calcium channel blocker|calcium channel blocking drugs]].<ref name="pmid9605782">{{cite journal |author=Heerdink ER, Leufkens HG, Herings RM, Ottervanger JP, Stricker BH, Bakker A |title=NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics |journal=[[Archives of Internal Medicine]] |volume=158 |issue=10 |pages=1108–12 |year=1998 |month=May |pmid=9605782 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=9605782 |accessdate=2012-04-05}}</ref><ref name="pmid2703968">{{cite journal |author=Herchuelz A, Derenne F, Deger F, Juvent M, Van Ganse E, Staroukine M, Verniory A, Boeynaems JM, Douchamps J |title=Interaction between nonsteroidal anti-inflammatory drugs and loop diuretics: modulation by sodium balance |journal=[[The Journal of Pharmacology and Experimental Therapeutics]] |volume=248 |issue=3 |pages=1175–81 |year=1989 |month=March |pmid=2703968 |doi= |url=http://jpet.aspetjournals.org/cgi/pmidlookup?view=long&pmid=2703968 |accessdate=2012-04-05}}</ref><ref name="pmid1529943">{{cite journal |author=Gottlieb SS, Robinson S, Krichten CM, Fisher ML |title=Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy |journal=[[The American Journal of Cardiology]] |volume=70 |issue=9 |pages=890–3 |year=1992 |month=October |pmid=1529943 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-9149(92)90733-F |accessdate=2012-04-05}}</ref><ref name="pmid1655327">{{cite journal |author=Bank AJ, Kubo SH, Rector TS, Heifetz SM, Williams RE |title=Local forearm vasodilation with intra-arterial administration of enalaprilat in humans |journal=[[Clinical Pharmacology and Therapeutics]] |volume=50 |issue=3 |pages=314–21 |year=1991 |month=September |pmid=1655327 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid2473403">{{cite journal |author= |title=Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators |journal=[[The New England Journal of Medicine]] |volume=321 |issue=6 |pages=406–12 |year=1989 |month=August |pmid=2473403 |doi=10.1056/NEJM198908103210629 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198908103210629?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-05}}</ref><ref name="pmid1377359">{{cite journal |author= |title=Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. The Cardiac Arrhythmia Suppression Trial II Investigators |journal=[[The New England Journal of Medicine]] |volume=327 |issue=4 |pages=227–33 |year=1992 |month=July |pmid=1377359 |doi=10.1056/NEJM199207233270403 |url=http://dx.doi.org/10.1056/NEJM199207233270403 |accessdate=2012-04-05}}</ref><ref name="pmid2476016">{{cite journal |author=Pratt CM, Eaton T, Francis M, Woolbert S, Mahmarian J, Roberts R, Young JB |title=The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-benefit ratio |journal=[[American Heart Journal]] |volume=118 |issue=3 |pages=433–40 |year=1989 |month=September |pmid=2476016 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-8703(89)90254-8 |accessdate=2012-04-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
| bgcolor="LightGreen"|'''1.''' Drugs known to adversely affect the clinical status of patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]) should be avoided or withdrawn whenever possible (e.g., [[NSAID|nonsteroidal anti-inflammatory drugs]], most [[Antiarrhythmic agent|antiarrhythmic drugs]], and most [[Calcium channel blocker|calcium channel blocking drugs]].<ref name="pmid9605782">{{cite journal |author=Heerdink ER, Leufkens HG, Herings RM, Ottervanger JP, Stricker BH, Bakker A |title=NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics |journal=[[Archives of Internal Medicine]] |volume=158 |issue=10 |pages=1108–12 |year=1998 |month=May |pmid=9605782 |doi= |url=http://archinte.ama-assn.org/cgi/pmidlookup?view=long&pmid=9605782 |accessdate=2012-04-05}}</ref><ref name="pmid2703968">{{cite journal |author=Herchuelz A, Derenne F, Deger F, Juvent M, Van Ganse E, Staroukine M, Verniory A, Boeynaems JM, Douchamps J |title=Interaction between nonsteroidal anti-inflammatory drugs and loop diuretics: modulation by sodium balance |journal=[[The Journal of Pharmacology and Experimental Therapeutics]] |volume=248 |issue=3 |pages=1175–81 |year=1989 |month=March |pmid=2703968 |doi= |url=http://jpet.aspetjournals.org/cgi/pmidlookup?view=long&pmid=2703968 |accessdate=2012-04-05}}</ref><ref name="pmid1529943">{{cite journal |author=Gottlieb SS, Robinson S, Krichten CM, Fisher ML |title=Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy |journal=[[The American Journal of Cardiology]] |volume=70 |issue=9 |pages=890–3 |year=1992 |month=October |pmid=1529943 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-9149(92)90733-F |accessdate=2012-04-05}}</ref><ref name="pmid1655327">{{cite journal |author=Bank AJ, Kubo SH, Rector TS, Heifetz SM, Williams RE |title=Local forearm vasodilation with intra-arterial administration of enalaprilat in humans |journal=[[Clinical Pharmacology and Therapeutics]] |volume=50 |issue=3 |pages=314–21 |year=1991 |month=September |pmid=1655327 |doi= |url= |accessdate=2012-04-05}}</ref><ref name="pmid2473403">{{cite journal |author= |title=Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators |journal=[[The New England Journal of Medicine]] |volume=321 |issue=6 |pages=406–12 |year=1989 |month=August |pmid=2473403 |doi=10.1056/NEJM198908103210629 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198908103210629?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-05}}</ref><ref name="pmid1377359">{{cite journal |author= |title=Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. The Cardiac Arrhythmia Suppression Trial II Investigators |journal=[[The New England Journal of Medicine]] |volume=327 |issue=4 |pages=227–33 |year=1992 |month=July |pmid=1377359 |doi=10.1056/NEJM199207233270403 |url=http://dx.doi.org/10.1056/NEJM199207233270403 |accessdate=2012-04-05}}</ref><ref name="pmid2476016">{{cite journal |author=Pratt CM, Eaton T, Francis M, Woolbert S, Mahmarian J, Roberts R, Young JB |title=The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-benefit ratio |journal=[[American Heart Journal]] |volume=118 |issue=3 |pages=433–40 |year=1989 |month=September |pmid=2476016 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-8703(89)90254-8 |accessdate=2012-04-05}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: B]])''
|}
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{|class="wikitable"
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|colspan="1" style="text-align:center; background:LightCoral"| [[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]] (No Benefit)
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|bgcolor="LightCoral"|'''1.''' [[CCB|Calcium channel blocking drugs]] are not indicated as routine treatment for [[heart failure]] in patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]). <ref name="pmid2899840">{{cite journal |author= |title=The effect of diltiazem on mortality and reinfarction after myocardial infarction. The Multicenter Diltiazem Postinfarction Trial Research Group |journal=[[The New England Journal of Medicine]] |volume=319 |issue=7 |pages=385–92 |year=1988 |month=August |pmid=2899840 |doi=10.1056/NEJM198808183190701 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198808183190701?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-06}}</ref><ref name="pmid15215801">{{cite journal |author=Reed SD, Friedman JY, Velazquez EJ, Gnanasakthy A, Califf RM, Schulman KA |title=Multinational economic evaluation of valsartan in patients with chronic heart failure: results from the Valsartan Heart Failure Trial (Val-HeFT) |journal=[[American Heart Journal]] |volume=148 |issue=1 |pages=122–8 |year=2004 |month=July |pmid=15215801 |doi=10.1016/j.ahj.2003.12.040 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002870304001000 |accessdate=2012-04-06}}</ref><ref name="pmid2220622">{{cite journal |author=Setaro JF, Zaret BL, Schulman DS, Black HR, Soufer R |title=Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diastolic filling and normal left ventricular systolic performance |journal=[[The American Journal of Cardiology]] |volume=66 |issue=12 |pages=981–6 |year=1990 |month=October |pmid=2220622 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-9149(90)90937-V |accessdate=2012-04-06}}</ref><ref name="pmid8813041">{{cite journal |author=Packer M, O'Connor CM, Ghali JK, Pressler ML, Carson PE, Belkin RN, Miller AB, Neuberg GW, Frid D, Wertheimer JH, Cropp AB, DeMets DL |title=Effect of amlodipine on morbidity and mortality in severe chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation Study Group |journal=[[The New England Journal of Medicine]] |volume=335 |issue=15 |pages=1107–14 |year=1996 |month=October |pmid=8813041 |doi=10.1056/NEJM199610103351504 |url=http://dx.doi.org/10.1056/NEJM199610103351504 |accessdate=2012-04-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''|


===[[ACC AHA guidelines classification scheme#Classification of Recommendations|Class III]]===
}
'''1.''' [[CCB|Calcium channel blocking drugs]] are not indicated as routine treatment for [[heart failure]] in patients with current or prior symptoms of [[heart failure]] and reduced [[left ventricular ejection fraction]] ([[LVEF]]). <ref name="pmid2899840">{{cite journal |author= |title=The effect of diltiazem on mortality and reinfarction after myocardial infarction. The Multicenter Diltiazem Postinfarction Trial Research Group |journal=[[The New England Journal of Medicine]] |volume=319 |issue=7 |pages=385–92 |year=1988 |month=August |pmid=2899840 |doi=10.1056/NEJM198808183190701 |url=http://www.nejm.org/doi/abs/10.1056/NEJM198808183190701?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%3dpubmed |accessdate=2012-04-06}}</ref><ref name="pmid15215801">{{cite journal |author=Reed SD, Friedman JY, Velazquez EJ, Gnanasakthy A, Califf RM, Schulman KA |title=Multinational economic evaluation of valsartan in patients with chronic heart failure: results from the Valsartan Heart Failure Trial (Val-HeFT) |journal=[[American Heart Journal]] |volume=148 |issue=1 |pages=122–8 |year=2004 |month=July |pmid=15215801 |doi=10.1016/j.ahj.2003.12.040 |url=http://linkinghub.elsevier.com/retrieve/pii/S0002870304001000 |accessdate=2012-04-06}}</ref><ref name="pmid2220622">{{cite journal |author=Setaro JF, Zaret BL, Schulman DS, Black HR, Soufer R |title=Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diastolic filling and normal left ventricular systolic performance |journal=[[The American Journal of Cardiology]] |volume=66 |issue=12 |pages=981–6 |year=1990 |month=October |pmid=2220622 |doi= |url=http://linkinghub.elsevier.com/retrieve/pii/0002-9149(90)90937-V |accessdate=2012-04-06}}</ref><ref name="pmid8813041">{{cite journal |author=Packer M, O'Connor CM, Ghali JK, Pressler ML, Carson PE, Belkin RN, Miller AB, Neuberg GW, Frid D, Wertheimer JH, Cropp AB, DeMets DL |title=Effect of amlodipine on morbidity and mortality in severe chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation Study Group |journal=[[The New England Journal of Medicine]] |volume=335 |issue=15 |pages=1107–14 |year=1996 |month=October |pmid=8813041 |doi=10.1056/NEJM199610103351504 |url=http://dx.doi.org/10.1056/NEJM199610103351504 |accessdate=2012-04-06}}</ref> ''([[ACC AHA guidelines classification scheme#Level of Evidence|Level of Evidence: A]])''}}


==Vote on and Suggest Revisions to the Current Guidelines==
==Vote on and Suggest Revisions to the Current Guidelines==

Revision as of 14:19, 5 October 2012

Congestive Heart Failure Microchapters

Home

Patient Information

Overview

Historical Perspective

Classification

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Systolic Dysfunction
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Differentiating Congestive heart failure from other Diseases

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Summary
Acute Pharmacotherapy
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Chronic Pharmacotherapy in HFrEF
Diuretics
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Angiotensin receptor blockers
Aldosterone Antagonists
Beta Blockers
Ca Channel Blockers
Nitrates
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Associated conditions

Exercise Training

Surgical Therapy:

Biventricular Pacing or Cardiac Resynchronization Therapy (CRT)
Implantation of Intracardiac Defibrillator
Ultrafiltration
Cardiac Surgery
Left Ventricular Assist Devices (LVADs)
Cardiac Transplantation

ACC/AHA Guideline Recommendations

Initial and Serial Evaluation of the HF Patient
Hospitalized Patient
Patients With a Prior MI
Sudden Cardiac Death Prevention
Surgical/Percutaneous/Transcather Interventional Treatments of HF
Patients at high risk for developing heart failure (Stage A)
Patients with cardiac structural abnormalities or remodeling who have not developed heart failure symptoms (Stage B)
Patients with current or prior symptoms of heart failure (Stage C)
Patients with refractory end-stage heart failure (Stage D)
Coordinating Care for Patients With Chronic HF
Quality Metrics/Performance Measures

Implementation of Practice Guidelines

Congestive heart failure end-of-life considerations

Specific Groups:

Special Populations
Patients who have concomitant disorders
Obstructive Sleep Apnea in the Patient with CHF
NSTEMI with Heart Failure and Cardiogenic Shock

Congestive heart failure calcium channel blockers On the Web

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Directions to Hospitals Treating Congestive heart failure calcium channel blockers

Risk calculators and risk factors for Congestive heart failure calcium channel blockers

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-In-Chief: Lakshmi Gopalakrishnan, M.B.B.S. [2]

Overview

Although calcium channel blockers cause vasodilation and may reduce afterload in the setting of heart failure, their overall benefit in heart failure is minimized by the fact that they have a negative inotropic effect and by the reflex activation of the sympathetic nervous system. These agents are therefore not recommended as vasodilators in patients with systolic dysfunction,however they may be useful as antihypertensive agents in patients with diastolic dysfunction.

ACC/AHA Guidelines- Calcium channel blockers Recommendation [1][2]

Class I
1. Drugs known to adversely affect the clinical status of patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF) should be avoided or withdrawn whenever possible (e.g., nonsteroidal anti-inflammatory drugs, most antiarrhythmic drugs, and most calcium channel blocking drugs.[3][4][5][6][7][8][9] (Level of Evidence: B)
Class III (No Benefit)
1. Calcium channel blocking drugs are not indicated as routine treatment for heart failure in patients with current or prior symptoms of heart failure and reduced left ventricular ejection fraction (LVEF). [10][11][12][13] (Level of Evidence: A)|

}

Vote on and Suggest Revisions to the Current Guidelines

Guidelines Resources

References

  1. ↑ 1.0 1.1 Hunt SA, Abraham WT, Chin MH, Feldman AM, Francis GS, Ganiats TG, Jessup M, Konstam MA, Mancini DM, Michl K, Oates JA, Rahko PS, Silver MA, Stevenson LW, Yancy CW, Antman EM, Smith SC Jr, Adams CD, Anderson JL, Faxon DP, Fuster V, Halperin JL, Hiratzka LF, Jacobs AK, Nishimura R, Ornato JP, Page RL, Riegel B; American College of Cardiology; American Heart Association Task Force on Practice Guidelines; American College of Chest Physicians; International Society for Heart and Lung Transplantation; Heart Rhythm Society. ACC/AHA 2005 Guideline Update for the Diagnosis and Management of Chronic Heart Failure in the Adult: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Update the 2001 Guidelines for the Evaluation and Management of Heart Failure): developed in collaboration with the American College of Chest Physicians and the International Society for Heart and Lung Transplantation: endorsed by the Heart Rhythm Society. Circulation. 2005 Sep 20; 112(12): e154-235. Epub 2005 Sep 13. PMID 16160202
  2. ↑ 2.0 2.1 Jessup M, Abraham WT, Casey DE, Feldman AM, Francis GS, Ganiats TG et al. (2009) 2009 focused update: ACCF/AHA Guidelines for the Diagnosis and Management of Heart Failure in Adults: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines: developed in collaboration with the International Society for Heart and Lung Transplantation. Circulation 119 (14):1977-2016. DOI:10.1161/CIRCULATIONAHA.109.192064 PMID: 19324967
  3. ↑ Heerdink ER, Leufkens HG, Herings RM, Ottervanger JP, Stricker BH, Bakker A (1998). "NSAIDs associated with increased risk of congestive heart failure in elderly patients taking diuretics". Archives of Internal Medicine. 158 (10): 1108–12. PMID 9605782. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  4. ↑ Herchuelz A, Derenne F, Deger F, Juvent M, Van Ganse E, Staroukine M, Verniory A, Boeynaems JM, Douchamps J (1989). "Interaction between nonsteroidal anti-inflammatory drugs and loop diuretics: modulation by sodium balance". The Journal of Pharmacology and Experimental Therapeutics. 248 (3): 1175–81. PMID 2703968. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  5. ↑ Gottlieb SS, Robinson S, Krichten CM, Fisher ML (1992). "Renal response to indomethacin in congestive heart failure secondary to ischemic or idiopathic dilated cardiomyopathy". The American Journal of Cardiology. 70 (9): 890–3. PMID 1529943. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  6. ↑ Bank AJ, Kubo SH, Rector TS, Heifetz SM, Williams RE (1991). "Local forearm vasodilation with intra-arterial administration of enalaprilat in humans". Clinical Pharmacology and Therapeutics. 50 (3): 314–21. PMID 1655327. Unknown parameter |month= ignored (help); |access-date= requires |url= (help)
  7. ↑ "Preliminary report: effect of encainide and flecainide on mortality in a randomized trial of arrhythmia suppression after myocardial infarction. The Cardiac Arrhythmia Suppression Trial (CAST) Investigators". The New England Journal of Medicine. 321 (6): 406–12. 1989. doi:10.1056/NEJM198908103210629. PMID 2473403. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  8. ↑ "Effect of the antiarrhythmic agent moricizine on survival after myocardial infarction. The Cardiac Arrhythmia Suppression Trial II Investigators". The New England Journal of Medicine. 327 (4): 227–33. 1992. doi:10.1056/NEJM199207233270403. PMID 1377359. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  9. ↑ Pratt CM, Eaton T, Francis M, Woolbert S, Mahmarian J, Roberts R, Young JB (1989). "The inverse relationship between baseline left ventricular ejection fraction and outcome of antiarrhythmic therapy: a dangerous imbalance in the risk-benefit ratio". American Heart Journal. 118 (3): 433–40. PMID 2476016. Retrieved 2012-04-05. Unknown parameter |month= ignored (help)
  10. ↑ "The effect of diltiazem on mortality and reinfarction after myocardial infarction. The Multicenter Diltiazem Postinfarction Trial Research Group". The New England Journal of Medicine. 319 (7): 385–92. 1988. doi:10.1056/NEJM198808183190701. PMID 2899840. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  11. ↑ Reed SD, Friedman JY, Velazquez EJ, Gnanasakthy A, Califf RM, Schulman KA (2004). "Multinational economic evaluation of valsartan in patients with chronic heart failure: results from the Valsartan Heart Failure Trial (Val-HeFT)". American Heart Journal. 148 (1): 122–8. doi:10.1016/j.ahj.2003.12.040. PMID 15215801. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  12. ↑ Setaro JF, Zaret BL, Schulman DS, Black HR, Soufer R (1990). "Usefulness of verapamil for congestive heart failure associated with abnormal left ventricular diastolic filling and normal left ventricular systolic performance". The American Journal of Cardiology. 66 (12): 981–6. PMID 2220622. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)
  13. ↑ Packer M, O'Connor CM, Ghali JK, Pressler ML, Carson PE, Belkin RN, Miller AB, Neuberg GW, Frid D, Wertheimer JH, Cropp AB, DeMets DL (1996). "Effect of amlodipine on morbidity and mortality in severe chronic heart failure. Prospective Randomized Amlodipine Survival Evaluation Study Group". The New England Journal of Medicine. 335 (15): 1107–14. doi:10.1056/NEJM199610103351504. PMID 8813041. Retrieved 2012-04-06. Unknown parameter |month= ignored (help)


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