This group will receive conventional evidence-based medications with up-titration to maximal tolerable dose. The evidence-based medications include angiotensin converting enzyme inhibitor/angiotensin receptor blocker, beta-blocker, mineralocorticoid receptor antagonist, ivabradine and entresto. Which evidence-based medications will be started first depends on the decision of in-charge doctors without strict regulation. However, all evidence-based medications should be up-titrated to maximal tolerable dose. (Excuse me! Up-titration of evidence-based medications in heart failure isn't multiple intervention. Those medications should be prescribed in each heart failure case if no contraindication was noted.)

another group will receive low-dose hydralazine initially with rapid up-titration, if no adverse effect including hypotension with worsening low cardiac output sign, skin rash and joint pain occurred. Since the half-life of hydralazine is around 4-6 hours and 3-5 half-life achieves the steady blood concentration, up-titration of hydralazine will be done per 1-2 days. For example, initial dose of hydralazine would be 25 mg tid and the dose would be 50 mg bid next day if no adverse effect occurred. Following this rule, one week is enough to reach high-dose hydralazine with daily dose of 300-400 mg.

Systolic Heart Failure Stage D (Disorder)

Mitral Regurgitation

randomized in 1 to 1 fashion After discharge, high-dose hydralazine is maintained except any adverse effect and up-titration of other evidence-based medications to maximal tolerable dose will be done. The dose of medications is adjusted by clinical signs, especially peripheral perfusion, not only simply by blood pressure. If participant had low blood pressure (for example, systolic blood pressure less than 90 mmHg) but no sign of postural hypotension, or low cardiac output (cold limbs, decreased urine output, dizzy), the investigators will keep up-titration of medications.

evidence-based medications vs. high-dose hydralazine + evidence-based medications

E-Da hospital

The Prognostic Impact of Using High-dose Hydralazine in Severe Systolic Heart Failure With Hemodynamically Significant Mitral Regurgitation

Hospitalization for HF is defined as a hospital stay of at least 1 night for treatment of a clinical syndrome with at least two of the following symptoms: paroxysmal nocturnal dyspnea, orthopnea, elevated jugular venous pressure, pulmonary rales, a third heart sound, cardiomegaly on chest radiography, or pulmonary edema on chest radiography.

The certification of death is based on death records, death certificates, and hospital medical records

Shih-Hung Hsiao

Staff of Cardiology, Principal Investigator, Clinical Associate Professor

Kaohsiung Veterans General Hospital.

E-DA Hospital

This prospective study will recruit 400 patients aged 18 years or older, and hospitalization to E-Da Hospital for acute decompensated heart failure due to severe left ventricular systolic dysfunction combined with hemodynamically significant mitral regurgitation. Severe systolic dysfunction and hemodynamically significant mitral regurgitation are defined as left ventricular ejection fraction less than 35% and mitral regurgitant volume more than 45 ml (more than moderate degree), respectively. All participants will be randomly divided into two groups according to 1 to 1 fashion. One group will receive conventional evidence-based medication with up-titration to maximal tolerable dose and another group will receive low-dose hydralazine initially with rapid up-titration, if no adverse effect including hypotension with worsening low cardiac output sign, skin rash and joint pain occurred.

Chagas Cardiomyopathy

Chronic Heart Failure

Bisoprolol

Fundación Cardiovascular de Colombia

Chagas Cardiomyopathy Bisoprolol Intervention Study: Charity

A Randomized Double-blind Placebo Force-titration Controlled Study With Bisoprolol in Patients With Chronic Heart Failure Secondary to Chagas´ Cardiomyopathy.

aortic valve insufficiency/edema

The Prognostic Impact of Using High-dose Hydralazine in Severe Systolic Heart Failure With Hemodynamically Significant Mitral Regurgitation

Chagas Cardiomyopathy Bisoprolol Intervention Study: Charity

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