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Cocianni D, Perotto M, Barbisan D, Contessi S, Rizzi JG, Savonitto G, Zocca E, Brollo E, Soranzo E, De Luca A, Fabris E, Merlo M, Sinagra G, Stolfo D. In-hospital evolution of secondary mitral regurgitation in acutely decompensated heart failure. J Cardiovasc Med (Hagerstown) 2024; 25:789-798. [PMID: 39347727 DOI: 10.2459/jcm.0000000000001667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 08/26/2024] [Indexed: 10/01/2024]
Abstract
AIMS Secondary mitral regurgitation (MR) negatively affects prognosis in acutely decompensated heart failure (ADHF), but can be rapidly sensitive to changes in volume status and medical interventions. We sought to assess the evolution of secondary MR in patients hospitalized for ADHF and its prognostic implications. METHODS We retrospectively enrolled 782 patients admitted for ADHF with at least two in-hospital echocardiographic evaluations of MR. We classified MR severity as none-mild or moderate-severe. Based on MR evolution, patients were divided into 'persistent moderate-severe MR', 'improved MR' (from moderate-severe to none-mild) and 'persistent none-mild MR'. RESULTS Four hundred and forty patients (56%) had moderate-severe MR at first evaluation, of whom 144 (33% of patients with baseline moderate-severe MR) had 'improved MR', while 296 (67%) had 'persistent moderate-severe MR'. Patients with improved MR had better clinical, laboratory and echocardiographic parameters of decongestion at discharge compared with those with persistent moderate-severe MR and showed a higher up-titration of recommended therapies. Left ventricular volume, ejection fraction and serum urea were the predictors of improved MR at multivariable analysis. After adjustment, no differences in 5-years survival (primary outcome) were observed according to baseline MR severity. When patients were stratified according to the in-hospital changes in MR severity, improved MR was associated with lower risk of 5-years mortality, compared with both persistent none-mild MR [hazard ratio (HR) = 0.505, P = 0.032] and persistent moderate-severe MR (HR = 0.556, P = 0.040). CONCLUSIONS The severity of MR frequently improved during hospitalization for ADHF; the extent and the changes in MR severity during the in-hospital stay identified distinct patient phenotypes, and seemed to portend different long-term outcomes, with higher 5-years survival associated with improvement in MR.
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Affiliation(s)
- Daniele Cocianni
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Maria Perotto
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Davide Barbisan
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Stefano Contessi
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Jacopo Giulio Rizzi
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Giulio Savonitto
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Eugenio Zocca
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Enrico Brollo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Elisa Soranzo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Antonio De Luca
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Enrico Fabris
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Marco Merlo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Davide Stolfo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Cuevas Pérez J, Moro Quesada D, Alonso Fernández V, Prieto-Díaz MÁ, Prieto García B, Herrero Puente P, Chiminazzo V, Ludeña Martín-Tesorero R, de la Hera Galarza JM. [Primary care and natriuretic peptides: design of a care process as a pathway to improve the diagnosis of heart failure]. Semergen 2024; 50:102224. [PMID: 38554677 DOI: 10.1016/j.semerg.2024.102224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2023] [Revised: 01/25/2024] [Accepted: 02/16/2024] [Indexed: 04/02/2024]
Abstract
INTRODUCTION There are few data about the optimal use of natriuretic peptides (NP) in the Primary Care (PC) setting. The aim to assess how, through a common coordinated PC-hospital care pathway, the use of NPs in patients with suspected heart failure (HF) is improved. MATERIAL AND METHODS Analytical, experimental, prospective, non-randomized study. An intervention group composed of 22 PC physicians from 2 health centers is provided with face-to-face training and a consensual protocol is attached with a cut-off point of NT-proBNP> 300 pg/mL as pathological. The control group is made up of the rest of PC physicians in the healthcare area. The aim is to compare the use and results of PN in both groups. Propensity analysis is performed so thar the patient populations with requested PN are comparable. RESULTS From June 2021 to March 2022, NP was requested in 103 and 105 patients in the intervention/control groups. Both populations were similar, with equal HF risk. Symptomatology was present in 100% of intervention vs 41% of asymptomatic patients in the control group (p <0.001). ECG was performed in 100% vs 33.3%, p <0.001. Optimal NP indication in 76.7% vs 29.5%, p <0.001. In the intervention group more patients with NT-proBNP> 300 pg/mL are referred to cardiology consultations (76.6% vs 27.2%, p 0.001). CONCLUSION The optimal indication for NP and its interpretation as a diagnostic tool for HF, in the PC setting seems not to be appropriate, but improvable with a coordinated and multidisciplinary intervention approach.
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Affiliation(s)
- J Cuevas Pérez
- Servicio de Cardiología, Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, España
| | | | - V Alonso Fernández
- Servicio de Cardiología, Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, España; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | | | - B Prieto García
- Bioquímica Clínica, Área de gestión Clínica Laboratorio de Medicina, Hospital Universitario Central de Asturias Oviedo, España; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - P Herrero Puente
- Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España; Servicio de Urgencias, Hospital Universitario Central de Asturias, Oviedo, España
| | - V Chiminazzo
- Plataforma de Bioestadística y Epidemiología, Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España
| | - R Ludeña Martín-Tesorero
- Servicio de Cardiología, Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, España
| | - J M de la Hera Galarza
- Servicio de Cardiología, Área del Corazón, Hospital Universitario Central de Asturias, Oviedo, España; Instituto de Investigación Sanitaria del Principado de Asturias (ISPA), Oviedo, España.
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Contreras J, Tinuoye EO, Folch A, Aguilar J, Free K, Ilonze O, Mazimba S, Rao R, Breathett K. Heart Failure with Reduced Ejection Fraction and COVID-19, when the Sick Get Sicker: Unmasking Racial and Ethnic Inequities During a Pandemic. Heart Fail Clin 2024; 20:353-361. [PMID: 39216921 DOI: 10.1016/j.hfc.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Minoritized racial and ethnic groups have the highest incidence, prevalence, and hospitalization rate for heart failure. Despite improvement in medical therapies and overall survival, the morbidity and mortality of these groups remain elevated. The reasons for this disparity are multifactorial, including social determinant of health (SDOH) such as access to care, bias, and structural racism. These same factors contributed to higher rates of COVID-19 infection among minoritized racial and ethnic groups. In this review, we aim to explore the lessons learned from the COVID-19 pandemic and its interconnection between heart failure and SDOH. The pandemic presents a window of opportunity for achieving greater equity in the health care of all vulnerable populations.
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Affiliation(s)
- Johanna Contreras
- Division of Cardiovascular Medicine, The Mount Sinai Health System, 1190 5th Avenue, 1st Floor, New York, NY 10029, USA
| | - Elizabeth O Tinuoye
- Division of Cardiovascular Medicine, The Mount Sinai Health System, 1190 5th Avenue, 1st Floor, New York, NY 10029, USA
| | - Alejandro Folch
- Division of Cardiovascular Medicine, The Mount Sinai Health System, 1190 5th Avenue, 1st Floor, New York, NY 10029, USA
| | - Jose Aguilar
- Division of Cardiovascular Medicine, The Mount Sinai Health System, 1190 5th Avenue, 1st Floor, New York, NY 10029, USA
| | - Kendall Free
- Department of Biofunction Research, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Onyedika Ilonze
- Division of Cardiovascular Medicine, Indiana University, 1800 North Capitol Avenue, Indianapolis, IN 46202, USA
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia, 1215 Lee Street, Charlottesville, VA 22908-0158, USA
| | - Roopa Rao
- Division of Cardiovascular Medicine, Indiana University, 1800 North Capitol Avenue, Indianapolis, IN 46202, USA
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Indiana University, 1800 North Capitol Avenue, Indianapolis, IN 46202, USA.
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Pitt B, Anker SD, Lund LH, Coats AJS, Filippatos G, Rossignol P, Weir MR, Friede T, Kosiborod MN, Metra M, Böhm M, Ezekowitz JA, Bayes-Genis A, Mentz RJ, Ponikowski P, Senni M, Piña IL, Pinto FJ, van der Meer P, Bahit C, Belohlavek J, Brugts JJ, Perrin A, Waechter S, Budden J, Butler J. Patiromer Facilitates Angiotensin Inhibitor and Mineralocorticoid Antagonist Therapies in Patients With Heart Failure and Hyperkalemia. J Am Coll Cardiol 2024; 84:1295-1308. [PMID: 39322323 DOI: 10.1016/j.jacc.2024.05.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/24/2024] [Accepted: 05/29/2024] [Indexed: 09/27/2024]
Abstract
BACKGROUND Hyperkalemia (HK) is associated with suboptimal renin-angiotensin system (RAS) inhibitor and mineralocorticoid receptor antagonist (MRA) use in heart failure with reduced ejection fraction (HFrEF). OBJECTIVES This study sought to assess characteristics and RAS inhibitor/MRA use in patients receiving patiromer during the DIAMOND (Patiromer for the Management of Hyperkalemia in Subjects Receiving RAASi Medications for the Treatment of Heart Failure) run-in phase. METHODS Patients with HFrEF and HK or past HK entered a run-in phase of ≤12 weeks with patiromer-facilitated RAS inhibitor/MRA optimization to achieve ≥50% recommended RAS inhibitor dose, 50 mg/d MRA, and normokalemia. Patients achieving these criteria (randomized group) were compared with the run-in failure group (patients not meeting the randomization criteria). RESULTS Of 1,038 patients completing the run-in, 878 (84.6%) were randomized and 160 (15.4%) were run-in failures. Overall, 422 (40.7%) had HK entering run-in with a similar frequency in the randomized and run-in failure groups (40.3% vs 42.5%; P = 0.605). From start to the end of run-in, in the randomized group, an increase was observed in target RAS inhibitor and MRA use in patients with HK (RAS inhibitor: 76.8% to 98.6%; MRA: 35.9% to 98.6%) and past HK (RAS inhibitor: 60.5% to 98.1%; MRA: 15.6% to 98.7%). Despite not meeting the randomization criteria, an increase after run-in was observed in the run-in failure group in target RAS inhibitor (52.5% to 70.6%) and MRA use (15.0% to 48.1%). This increase was observed in patients with HK (RAS inhibitor: 51.5% to 64.7%; MRA: 19.1% to 39.7%) and past HK (RAS inhibitor: 53.3% to 75.0%; MRA: 12.0% to 54.3%). CONCLUSIONS In patients with HFrEF and HK or past HK receiving suboptimal RAS inhibitor/MRA therapy, RAS inhibitor/MRA optimization increased during patiromer-facilitated run-in.
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Affiliation(s)
- Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA.
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Lars H Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Solna, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Patrick Rossignol
- Medical Specialties and Nephrology Departments, Princess Grace Hospital, and Monaco Private Hemodialysis Centre, Monaco; Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, Nancy, France, and F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Tim Friede
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
| | - Mikhail N Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili and University, Brescia, Italy
| | - Michael Böhm
- Klinik für Innere Medizin III, Saarland University, Homburg/Saar, Germany
| | - Justin A Ezekowitz
- Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Antoni Bayes-Genis
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, CIBERCV, Barcelona, Spain
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Michele Senni
- University of Milano - Bicocca, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ileana L Piña
- Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA
| | - Fausto J Pinto
- Santa Maria University Hospital, CAML, CCUL, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Cecilia Bahit
- INECO Neurociencias Oroño, Rosario, Santa Fe, Argentina
| | - Jan Belohlavek
- Clinic of Cardiology and Angiology, General University Hospital Prague, Prague, Czech Republic
| | - Jasper J Brugts
- Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | | | | | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
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Myhre PL, Tromp J, Ouwerkerk W, Ting DSW, Docherty KF, Gibson CM, Lam CSP. Digital tools in heart failure: addressing unmet needs. Lancet Digit Health 2024; 6:e755-e766. [PMID: 39214764 DOI: 10.1016/s2589-7500(24)00158-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 07/03/2024] [Accepted: 07/11/2024] [Indexed: 09/04/2024]
Abstract
This Series paper provides an overview of digital tools in heart failure care, encompassing screening, early diagnosis, treatment initiation and optimisation, and monitoring, and the implications these tools could have for research. The current medical environment favours the implementation of digital tools in heart failure due to rapid advancements in technology and computing power, unprecedented global connectivity, and the paradigm shift towards digitisation. Despite available effective therapies for heart failure, substantial inadequacies in managing the condition have hindered improvements in patient outcomes, particularly in low-income and middle-income countries. As digital health tools continue to evolve and exert a growing influence on both clinical care and research, establishing clinical frameworks and supportive ecosystems that enable their effective use on a global scale is crucial.
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Affiliation(s)
- Peder L Myhre
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway; KG Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
| | - Jasper Tromp
- National Heart Centre Singapore, Singapore; Duke-National University of Singapore, Singapore; Saw Swee Hock School of Public Health, National University of Singapore, Singapore
| | | | | | - Kieran F Docherty
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - C Michael Gibson
- Harvard Medical School, Boston, MA, USA; Baim Institute for Clinical Research, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore; Duke-National University of Singapore, Singapore; Baim Institute for Clinical Research, Boston, MA, USA.
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Burgos LM, Ballari FN, Spaccavento A, Ricciardi B, Suárez LL, Baro Vila RC, De Bortoli MA, Conde D, Diez M. In-hospital initiation of sodium-glucose cotransporter-2 inhibitors in patients with heart failure and reduced ejection fraction: 90-day prescription patterns and clinical implications. Curr Probl Cardiol 2024; 49:102779. [PMID: 39089410 DOI: 10.1016/j.cpcardiol.2024.102779] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Safety and early clinical benefit make sodium-glucose cotransporter-2 inhibitor (SGLT2-i) therapy suitable for in-hospital initiation in patients with heart failure and reduced ejection fraction (HFrEF). Despite randomized controlled trials and guideline recommendations, they are underused, and clinical inertia may play a role. OBJECTIVES PRIMARY To assess the impact of initiating SGLT-2i at discharge on 90-day prescription rates in patients with HFrEF during hospitalization for acute heart failure (AHF). Secondary: To evaluate the presence of independent factors associated with prescription, and to explore clinical outcomes at 90 days. METHODS Retrospective analysis of a consecutive prospective single-center cohort. Adult patients hospitalized between January 2021 and September 2022 with a primary diagnosis of AHF and left ventricular ejection fraction (LVEF) <40% were included. The primary outcome was SGLT2-i prescription rate at 90 days, and the exploratory secondary endpoints was the composite of hospitalization or urgent visit for AHF or all-cause mortality at 90 days. RESULTS 237 patients were included. Mean age was 76±11 years, and mean LVEF was 29±7%. In patients without contraindications, SGLT2 inhibitors (SGLT2-i) were prescribed during hospitalization in 52.3%. At 90 days, the SGLT2-i prescription rate was 94.2% in those with in-hospital initiation and 14.4% in those without. (p<0.001). Independent factor associated with inpatient prescription was lower LVEF, 0.83 (95% CI: 0.77-0.89) for each point. Patients with in-hospital SGLT2-i initiation showed a lower rate of the combined endpoint of all-cause death, HF rehospitalization, or unplanned HF visit at 90 days (44.4% versus 23.9%, p=0.005). CONCLUSIONS In-hospital initiation of SGLT-2-i was associated with significantly higher prescription rates and lower prevalence in the secondary combined endpoint at 90 days. This study reflects the presence of medical inertia, particularly in patients with higher LVEF, and highlights the hospitalization period as an optimal time to start SGLT2-i.
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Affiliation(s)
- Lucrecia María Burgos
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina.
| | - Franco Nicolás Ballari
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina
| | - Ana Spaccavento
- Clinical Cardiology Department. Instituto Cardiovascular de Buenos Aires. Argentina
| | - Bianca Ricciardi
- Clinical Cardiology Department. Instituto Cardiovascular de Buenos Aires. Argentina
| | | | - Rocío Consuelo Baro Vila
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina
| | - María Antonella De Bortoli
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina
| | - Diego Conde
- Clinical Cardiology Department. Instituto Cardiovascular de Buenos Aires. Argentina
| | - Mirta Diez
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina
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Rossing P. Experimental Designs for Multicomponent Interventions in Kidney and Cardiometabolic Diseases. J Am Soc Nephrol 2024; 35:1438-1441. [PMID: 39078403 DOI: 10.1681/asn.0000000000000449] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024] Open
Affiliation(s)
- Peter Rossing
- Steno Diabetes Center Copenhagen, Herlev, Denmark; and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Hu JR, Schwann AN, Tan JW, Nuqali A, Riello RJ, Beasley MH. Sequencing Quadruple Therapy for Heart Failure with Reduced Ejection Fraction: Does It Really Matter? Heart Fail Clin 2024; 20:373-386. [PMID: 39216923 DOI: 10.1016/j.hfc.2024.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
The conventional sequence of guideline-directed medical therapy (GDMT) initiation in heart failure with reduced ejection fraction (HFrEF) assumes that the effectiveness and tolerability of GDMT agents mirror their order of discovery, which is not true. In this review, the authors discuss flexible GDMT sequencing that should be permitted in special populations, such as patients with bradycardia, chronic kidney disease, or atrial fibrillation. Moreover, the initiation of certain GDMT medications may enable tolerance of other GDMT medications. Most importantly, the achievement of partial doses of all four pillars of GDMT is better than achievement of target dosing of only a couple.
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Affiliation(s)
- Jiun-Ruey Hu
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/ruey_hu
| | - Alexandra N Schwann
- Department of Internal Medicine, Yale New Haven Hospital, P.O. Box 208030, New Haven, CT, 06520-8030, USA. https://twitter.com/aschwann212
| | - Jia Wei Tan
- Division of Nephrology, Stanford University School of Medicine, 780 Welch Road, Palo Alto, CA 94304, USA. https://twitter.com/jiiiiawei
| | - Abdulelah Nuqali
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/AbdulelahNuqali
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA. https://twitter.com/ralphadelta
| | - Michael H Beasley
- Clinical and Translational Research Accelerator, Yale School of Medicine, New Haven, CT 06520, USA.
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9
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Mastoris I, Gupta K, Sauer AJ. The War Against Heart Failure Hospitalizations: Remote Monitoring and the Case for Expanding Criteria. Heart Fail Clin 2024; 20:419-436. [PMID: 39216927 DOI: 10.1016/j.hfc.2024.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
Successful remote patient monitoring depends on bidirectional interaction between patients and multidisciplinary clinical teams. Invasive pulmonary artery pressure monitoring has been shown to reduce heart failure (HF) hospitalizations, facilitate guideline-directed medical therapy optimization, and improve quality of life. Cardiac implantable electronic device-based multiparameter monitoring has shown encouraging results in predicting future HF-related events. Potential expanded indications for remote monitoring include guideline-directed medical therapy optimization, application to specific populations, and subclinical detection of HF. Voice analysis, inferior vena cava diameter monitoring, and artificial intelligence-based remote electrocardiogram show potential to gain some merit in remote patient monitoring in HF.
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Affiliation(s)
- Ioannis Mastoris
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Kashvi Gupta
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO 64111, USA
| | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO 64111, USA.
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10
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Schwann AN, Jaffe LM, Givertz MM, Wood KL, Engelman DT. Early Initiation of Guideline-Directed Medical Therapy for Heart Failure After Cardiac Surgery. Ann Thorac Surg 2024; 118:792-800. [PMID: 38878947 DOI: 10.1016/j.athoracsur.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Revised: 05/21/2024] [Accepted: 05/28/2024] [Indexed: 07/04/2024]
Abstract
There is an evolving role for guideline-directed medical therapy (GDMT) in managing heart failure with reduced ejection fraction after cardiac surgery. GDMT is based on the use of pharmacologic agents from each of 4 distinct drug classes, also known as the 4 pillars of heart failure therapy: β-blockers, renin-angiotensin system inhibitors, often paired with neprilysin inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. Despite the demonstrated benefits of GDMT in reducing mortality and hospitalization rates in the nonsurgical literature, there is conspicuous underuse of GDMT after cardiac surgery. The lack of published literature and practical challenges surrounding the timing for initiation of GDMT in the immediate postoperative period has limited standardized implementation strategies. A multidisciplinary approach will be necessary to assist in initiating, titrating, and monitoring the response to these therapies in patients with heart failure with reduced ejection fraction after cardiac surgery.
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Affiliation(s)
- Alexandra N Schwann
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Leeor M Jaffe
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Katherine L Wood
- Division of Cardiac Surgery, University of Rochester Medical Center, Rochester, New York
| | - Daniel T Engelman
- Heart & Vascular Program, Baystate Health, University of Massachusetts Chan Medical School-Baystate, Springfield, Massachusetts.
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11
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Pogge E, Sibicky S. Heart Failure in Older People Part 2: Guideline-Directed Medical Therapy. Sr Care Pharm 2024; 39:360-372. [PMID: 39358876 DOI: 10.4140/tcp.n.2024.360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/04/2024]
Abstract
Heart failure is a common cardiovascular disease that affects older people and has a high rate of mortality. Treatment for heart failure has evolved in the past 10 years to include novel evidence-based agents as well as changes in how medications are initiated and up-titrated. Despite evidence of the importance of using four guideline-directed medications, older people are often undertreated with these lifesaving therapies. Senior care pharmacists play an important role in heart failure management among older people by providing therapeutic recommendations; monitoring therapeutic interventions; and educating patients, caregivers, and/ or providers.
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Affiliation(s)
- Elizabeth Pogge
- 1 Midwestern University College of Pharmacy-Glendale, Glendale, Arizona
| | - Stephanie Sibicky
- 2 Northeastern University School of Pharmacy and Pharmaceutical Sciences, Boston, Massachusetts
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12
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Odajima S, Fujimoto W, Takegami M, Nishimura K, Iwasaki M, Okuda M, Konishi A, Shinohara M, Nagao M, Toh R, Hirata KI, Tanaka H. BEEAF 2 Score: A New Risk Stratification Score for Patients With Stage B Heart Failure From the KUNIUMI Registry Chronic Cohort. J Am Heart Assoc 2024; 13:e034793. [PMID: 39344672 DOI: 10.1161/jaha.124.034793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2024] [Accepted: 05/16/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Stage B heart failure (HF) refers to structural heart disease without signs or symptoms of HF, so that early intervention may delay or prevent the onset of overt HF. However, stage B HF is a very broad concept, and risk stratification of such patients can be challenging. METHODS AND RESULTS We conducted a prospective study of data for 1646 consecutive patients with HF from the KUNIUMI (Kobe University Heart Failure Registry in Awaji Medical Center) registry chronic cohort. The definition of HF stages was based on current guidelines for classification of 29 patients as stage A HF, 761 as stage B HF, 827 as stage C HF, and 29 patients as stage D HF. The primary end point was the time-to-first-event defined as cardiovascular death or HF hospitalization within 2.0 years of follow-up. A maximum of 6 adjustment factor points was assigned based on Cox proportional hazards analysis findings for the hazard ratio (HR) of independent risk factors for the primary end point: 1 point for anemia, estimated glomerular filtration rate <45 mL/min per 1.73 m2, brain natriuretic peptide ≥150 pg/mL, and average ratio of early transmitral flow velocity to early diastolic mitral annular velocity >14, and 2 points for clinical frailty scale >3. Patients with stage B HF were stratified into 3 groups, low risk (0-1 points), moderate risk (2-3 points), and high risk (4-6 points). Based on this scoring system (BEEAF2 [brain natriuretic peptide, estimated glomerular filtration rate, ratio of early transmitral flow velocity to early diastolic mitral annular velocity, anemia, and frailty]), the outcome was found to become worse in accordance with risk level. High-risk patients with stage B HF and patients with stage C HF showed similar outcomes. CONCLUSIONS Our scoring system offers an easy-to-use evaluation of risk stratification for patients with stage B HF.
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Affiliation(s)
- Susumu Odajima
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Japan
| | - Wataru Fujimoto
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Japan
- Department of Cardiology Hyogo Prefectural Awaji Medical Center Sumoto Japan
| | - Misa Takegami
- Department of Preventive Medicine and Epidemiology National Cerebral and Cardiovascular Center Suita Japan
- Department of Public Health and Health Policy, Graduate School of Medicine The University of Tokyo Japan
| | - Kunihiro Nishimura
- Department of Preventive Medicine and Epidemiology National Cerebral and Cardiovascular Center Suita Japan
| | - Masamichi Iwasaki
- Department of Cardiology Hyogo Prefectural Awaji Medical Center Sumoto Japan
| | - Masanori Okuda
- Department of Cardiology Hyogo Prefectural Awaji Medical Center Sumoto Japan
| | - Akihide Konishi
- Clinical and Translational Research Center Kobe University Hospital Kobe Japan
| | - Masakazu Shinohara
- Division of Epidemiology Kobe University Graduate School of Medicine Kobe Japan
| | - Manabu Nagao
- Division of Evidence-Based Laboratory Medicine Kobe University Graduate School of Medicine Kobe Japan
| | - Ryuji Toh
- Division of Evidence-Based Laboratory Medicine Kobe University Graduate School of Medicine Kobe Japan
| | - Ken-Ichi Hirata
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Japan
- Division of Evidence-Based Laboratory Medicine Kobe University Graduate School of Medicine Kobe Japan
| | - Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine Kobe University Graduate School of Medicine Kobe Japan
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13
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Polsinelli VB, Sun JL, Greene SJ, Chiswell K, Grunwald GK, Allen LA, Peterson P, Pandey A, Fonarow GC, Heidenreich P, Ho PM, Hess PL. Hospital Heart Failure Medical Therapy Score and Associated Clinical Outcomes and Costs. JAMA Cardiol 2024:2824184. [PMID: 39320905 PMCID: PMC11425195 DOI: 10.1001/jamacardio.2024.2969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/26/2024]
Abstract
Importance A composite score for guideline-directed medical therapy (GDMT) for patients with heart failure (HF) is associated with increased survival. Whether hospital performance according to a GDMT score is associated with a broader array of clinical outcomes at lower costs is unknown. Objectives To evaluate hospital variability in GDMT score at discharge, 90-day risk-standardized clinical outcomes and costs, and associations between hospital GDMT score and clinical outcomes and costs. Design, Setting, and Participants This was a retrospective cohort study conducted from January 2015 to September 2019. Included for analysis were patients hospitalized for HF with reduced ejection fraction (HFrEF) in the Get With the Guidelines-Heart Failure Registry, a national hospital-based quality improvement registry. Study data were analyzed from July 2022 to April 2023. Exposures GDMT score at discharge. Main Outcomes and Measures Hospital variability in GDMT score, a weighted index from 0 to 1 of GDMT prescribed divided by the number of medications eligible, at discharge was evaluated using a generalized linear mixed model using the hospital as a random effect and quantified with the adjusted median odds ratio (AMOR). Parallel analyses centering on 90-day mortality, HF rehospitalization, mortality or HF rehospitalization, home time, and costs were performed. Costs were assessed from the perspective of the Centers of Medicare & Medicaid Services. Associations between hospital GDMT score and clinical outcomes and costs were evaluated using Spearman coefficients. Results Among 41 161 patients (median [IQR] age, 78 [71-85] years; 25 546 male [62.1%]) across 360 hospitals, there was significant hospital variability in GDMT score at discharge (AMOR, 1.23; 95% CI, 1.21-1.26), clinical outcomes (mortality AMOR, 1.17; 95% CI, 1.14-1.24; HF rehospitalization AMOR, 1.22; 95% CI, 1.18-1.27; mortality or HF rehospitalization AMOR, 1.21; 95% CI, 1.18-1.26; home time AMOR, 1.07; 95% CI, 1.06-1.10) and costs (AMOR, 1.23; 95% CI, 1.21-1.26). Higher hospital GDMT score was associated with lower hospital mortality (Spearman ρ, -0.22; 95% CI, -0.32 to -0.12; P < .001), lower mortality or HF rehospitalization (Spearman ρ, -0.17; 95% CI, -0.26 to -0.06; P = .002), more home time (Spearman ρ, 0.14; 95% CI, 0.03-0.24; P = .01), and lower cost (Spearman ρ, -0.11; 95% CI, -0.21 to 0; P = .047) but not with HF rehospitalization (Spearman ρ, -0.10; 95% CI, -0.20 to 0; P = .06). Conclusions and Relevance Results of this cohort study reveal that hospital variability in GDMT score, clinical outcomes, and costs was significant. Higher GDMT score at discharge was associated with lower mortality, lower mortality or hospitalization, more home time, and lower cost. Efforts to increase health care value should include GDMT optimization.
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Affiliation(s)
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Larry A Allen
- University of Colorado, Anschutz Medical Campus, Aurora
| | | | | | | | | | - P Michael Ho
- University of Colorado, Anschutz Medical Campus, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
| | - Paul L Hess
- University of Colorado, Anschutz Medical Campus, Aurora
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado
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14
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Aissaoui H, Pichard S, Gaulupeau V, Gautron E, Wajchert T, Assayag F, Gilles F, Duvillier P, Georges JL, Gibault-Genty G. [Preliminary evaluation of the interest of a therapeutic optimization cell on the titration of treatments for heart failure with reduced left ventricular ejection fraction and the quality of life of patients]. Ann Cardiol Angeiol (Paris) 2024; 73:101802. [PMID: 39317082 DOI: 10.1016/j.ancard.2024.101802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2024] [Accepted: 08/20/2024] [Indexed: 09/26/2024]
Abstract
INTRODUCTION A multidisciplinary therapeutic optimization unit (COT) was created in January 2023 at Versailles Hospital, aimed at therapeutic optimisation of patients with chronic heart failure with reduced left ventricular ejection fraction. The objective of the study was to assess the impact of the first year of COT activity on the sequential implementation and titration of heart failure treatments, the clinical evolution, and improvement of patients' quality of life. METHODS This prospective study included consecutive patients treated by the COT after hospitalisation for acute heart failure, from January to December 2023. Clinical, biological, titration, and tolerance data were analysed. Quality of life was assessed at baseline and at the end of the follow-up by COT, using standardized SF-12 and EQ-5D questionnaires. RESULTS We included 90 patients (men 73%, mean age 67 years). The mean left ventricular ejection fraction was 34 ± 10 %. At final visit (median number of visits 4 ; median follow-up duration 156 days), 76.7% of patients achieved optimisation with respect to maximum individually tolerated doses, but only 13.3% with respect to theoretical maximum doses for the four therapeutic classes. At 1-year follow up, total mortality was 4.4% (4/90), and 9 patients (10%) were rehospitalised unplanned for acute heart failure. COT monitoring was associated with significant improvement in NYHA class, left ventricular ejection fraction, and SF-12 and EQ-5D-5L quality of life scores. CONCLUSION Although titration of heart failure treatments remained suboptimal, significant improvement was observed for NYHA class, left ventricular ejection fraction, and patient quality of life parameters.
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Affiliation(s)
- Hanane Aissaoui
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Stéphane Pichard
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Violaine Gaulupeau
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Elodie Gautron
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Thibault Wajchert
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Franck Assayag
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Floriane Gilles
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Paul Duvillier
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Jean-Louis Georges
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
| | - Géraldine Gibault-Genty
- Service de cardiologie, Centre hospitalier de Versailles, Hôpital André Mignot, 78150 Le Chesnay, France.
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15
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Biegus J, Cotter G, Davison BA, Freund Y, Voors AA, Edwards C, Novosadova M, Takagi K, Hayrapetyan H, Mshetsyan A, Mayranush D, Cohen-Solal A, Maaten JMT, Filippatos G, Chioncel O, Sadoune M, Pagnesi M, Simon T, Metra M, Mann DL, Mebazaa A, Ponikowski P. The effects of burst steroid therapy on short-term decongestion in acute heart failure patients with pro-inflammatory activation: a post-hoc analysis of the CORTAHF randomized, open-label, pilot trial. J Card Fail 2024:S1071-9164(24)00376-2. [PMID: 39353506 DOI: 10.1016/j.cardfail.2024.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2024] [Revised: 09/10/2024] [Accepted: 09/10/2024] [Indexed: 10/04/2024]
Abstract
BACKGROUND The effect of steroids on congestion in patients with acute heart failure (AHF) is not known. METHODS AND RESULTS Patients with AHF, NT-proBNP>1500 pg/mL, and high-sensitivity C-reactive protein (hsCRP)>20 mg/L were randomized to once daily oral 40 mg prednisone for 7 days or usual care. In this post-hoc analysis, congestion score was calculated from orthopnea, edema, and rales (0 reflecting lack of congestion, and 9 maximal congestion) at each time point. Among 100 eligible patients randomized, those assigned to prednisone had a greater improvement in congestion score at day 31 (win odds for the prednisone group compared to usual care at day 31 was 1.77 (95% CI 1.17-2.84; p = 0.0066) in all patients and 2.41 (95% CI 1.37- 5.05; p = 0.0016) in patients with IL-6>13 pg/mL at baseline. In patients with congestion score ≥7 at baseline, the effects of prednisone therapy on EQ-5D visual analog scale score were 4.30 (95% CI 0.77-7.83) points at day 7 and 5.40 (0.51-10.29) points at day 31, accompanied by lower heart rate and respiratory rate, and higher oxygen saturation compared to usual care. CONCLUSIONS In patients with AHF and inflammatory activation, 7-day steroid therapy was associated with reduction in signs of congestion up to day 31. These results need confirmation in larger studies examining potential effects of steroids on congestion, diuresis, fluid redistribution and vascular permeability as well as clinical effects in AHF.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Poland
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), France; Heart Initiative, Durham, NC, USA; Momentum Research Inc, Durham, NC, USA
| | - Beth A Davison
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), France; Heart Initiative, Durham, NC, USA; Momentum Research Inc, Durham, NC, USA
| | - Yonathan Freund
- Sorbonne Université, IMProving Emergency Care FHU, Paris, France; Emergency Department and Service Mobile d'Urgence et de Réanimation (SMUR), Hôpital Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris (AP-HP), Paris, France
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | | | | | | | | | - Andranik Mshetsyan
- "Mikaelyan" Surgery Institute CJSC, Ezras Hasratyan st., 0093, Yerevan, Armenia
| | | | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), France; Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Greece
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C.Iliescu," University of Medicine "Carol Davila," Bucharest, Romania
| | - Malha Sadoune
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), France
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Tabassome Simon
- Sorbonne Université, IMProving Emergency Care FHU, Paris, France
| | - Marco Metra
- Department of Clinical Pharmacology and Clinical Research Platform Paris-East (URCEST-CRC-CRB), St Antoine Hospital, APHP, Paris, France
| | - Douglas L Mann
- Cardiovascular Division, Department of Medicine, Center for Cardiovascular Research, Washington University School of Medicine, St. Louis, MO, USA
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Poland.
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16
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Paton MF, Gierula J, Jamil HA, Straw S, Lowry JE, Byrom R, Slater TA, Fellows AM, Gillott RG, Chumun H, Smith P, Cubbon RM, Stocken DD, Kearney MT, Witte KK. Echocardiographic screening for heart failure and optimization of the care pathway for individuals with pacemakers: a randomized controlled trial. Nat Med 2024:10.1038/s41591-024-03265-3. [PMID: 39300290 DOI: 10.1038/s41591-024-03265-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 08/22/2024] [Indexed: 09/22/2024]
Abstract
Individuals with pacemakers are at increased risk of left ventricular systolic dysfunction (LVSD). Whether screening for and optimizing the medical management of LVSD in these individuals can improve clinical outcomes is unknown. In the present study, in a multicenter controlled trial (OPT-PACE), we randomized 1,201 patients (717 men) with a pacemaker to echocardiography screening or usual care. In the screening arm, LVSD was detected in 201 of 600 (34%) patients, who then received management in either primary care or a specialist heart failure (HF) and devices clinic. The primary outcome of the trial was the difference in a composite of time to first HF hospitalization or death. Over 31 months (interquartile range = 30-40 months), the primary outcome occurred in 106 of 600 (18%) patients receiving echocardiography screening, which was not significantly different compared with the occurrence of the primary outcome in 115 of 601 (19%) patients receiving the usual care (hazard ratio = 0.89; 95% confidence interval = 0.69, 1.17). In a prespecified, nonrandomized, exploratory analysis, patients with LVSD managed by the specialist clinic experienced the primary outcome event less frequently than those managed in primary care. The results of this trial indicate that echocardiography screening commonly identifies LVSD in individuals with pacemakers but alone does not alter outcomes. ClinicalTrials.gov registration: NCT01819662 .
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Affiliation(s)
- Maria F Paton
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK
| | - John Gierula
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Haqeel A Jamil
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Sam Straw
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Judith E Lowry
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Rowena Byrom
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Thomas A Slater
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Alasdair M Fellows
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Richard G Gillott
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK
| | - Hemant Chumun
- Leeds Teaching Hospitals NHS Trust, Department of Cardiology, Leeds, UK
| | - Paul Smith
- Department of Cardiology, Bradford Teaching Hospitals NHS Trust, Bradford, UK
| | - Richard M Cubbon
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Deborah D Stocken
- Leeds Institute of Clinical Trials Research, University of Leeds, Leeds, UK
| | - Mark T Kearney
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Klaus K Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.
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17
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Fortuni F, Tavazzi L, Ciliberti G. Digital health in heart failure: Empowering physicians to enhance patient care. Int J Cardiol 2024; 411:132261. [PMID: 38885795 DOI: 10.1016/j.ijcard.2024.132261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2024] [Accepted: 06/12/2024] [Indexed: 06/20/2024]
Affiliation(s)
- Federico Fortuni
- Department of Cardiology, San Giovanni Battista Hospital, Foligno, Italy; Cardiology Department, Leiden University Medical Center, Leiden, The Netherlands
| | - Lugi Tavazzi
- Maria Cecilia Hospital GVM Care & Research, Cotignola, RA, Italy
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18
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Nguyen DV, Nguyen SV, Pham AL, Nguyen BT, Hoang SV. Prognostic value of NT-proBNP in the new era of heart failure treatment. PLoS One 2024; 19:e0309948. [PMID: 39269956 PMCID: PMC11398679 DOI: 10.1371/journal.pone.0309948] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Accepted: 08/21/2024] [Indexed: 09/15/2024] Open
Abstract
BACKGROUND Heart failure is one of the leading causes of mortality and hospitalization in cardiovascular patients. Guideline-directed medical treatment (GDMT) in the current era includes novel medications such as ARNI and SGLT2 inhibitors, as well as an approach to treatment based on clinical phenotypes. To assess prognostic factors for mortality and hospital readmissions plays a crucial role in patient care. OBJECTIVES This study aimed to determine the rate of 90-day post-discharge events in patients having heart failure with reduced ejection fraction (HFrEF) and investigate the associated clinical factors. METHOD A prospective study was conducted on 110 HFrEF patients at the cardiology department of Cho Ray Hospital. The 90-day events included all-cause mortality and rehospitalization due to heart failure. RESULTS The rate of 90-day events was 45.6%. After multivariable Cox regression analysis, NT-proBNP level ≥ 1858 pg/mL was identified as an independent factor associated with the 90-day events. CONCLUSION NT-proBNP cut-off ≥ 1858 pg/mL can be used for the prognosis of 90-day events in HFrEF.
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Affiliation(s)
- Dat Vu Nguyen
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Nguyen Tri Phuong Hospital, Ho Chi Minh City, Vietnam
| | - Si Van Nguyen
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - An Le Pham
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Bay Thi Nguyen
- School of Medicine, Vietnam National University Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Sy Van Hoang
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
- Cho Ray Hospital, Ho Chi Minh City, Vietnam
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19
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Čelutkienė J, Čerlinskaitė-Bajorė K, Cotter G, Edwards C, Adamo M, Arrigo M, Barros M, Biegus J, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Léopold V, Deniau B, Metra M, Novosadova M, Pagnesi M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Ter Maaten JM, Tomasoni D, Lam CSP, Voors AA, Mebazaa A, Davison B. Insights on prevalence and incidence of anemia and rapid up-titration of oral heart failure treatment from the STRONG-HF study. Clin Res Cardiol 2024:10.1007/s00392-024-02518-y. [PMID: 39259364 DOI: 10.1007/s00392-024-02518-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Accepted: 08/05/2024] [Indexed: 09/13/2024]
Abstract
BACKGROUND Anemia is one of the most frequent comorbidities in patients with heart failure (HF), which potentially can interfere with the effect of guideline-recommended HF medical therapy and can be associated with the use of neurohormonal blockers. AIM The aim of this analysis was to determine the prevalence and changes of anemia status in the STRONG-HF study, its association with clinical endpoints, and possible interaction of the presence of anemia with the efficacy and safety of high-intensity HF treatment. METHODS The design and main results of the study have been previously described. Patients were randomized within 2 days prior to anticipated hospital discharge after HF worsening in a 1:1 fashion to either high-intensity care (HIC) or usual care (UC). Baseline characteristics, clinical and safety outcomes, and treatment effect of HIC vs. UC on the primary and secondary outcomes were compared in groups based on baseline anemia. In addition, dynamics of hemoglobin during the study follow-up and predictors of incident anemia at 90 days were investigated. RESULTS The proportion of anemia in 1077 STRONG-HF patients at enrollment was 27.2%, while at 90 days, it changed to 32.1%. The primary composite outcome occurred in 18.2% of patients without baseline anemia, and 22.5% of patients with baseline anemia (unadjusted HR 1.27; 95% CI 0.90-1.80), a difference that did not reach statistical significance. However, patients with baseline anemia had significantly less improvement of EQ-VAS questionnaire values from baseline to day 90 (adjusted LS-Mean difference -2.34 (-4.37, -0.31), P = 0.02). During the study, anemia developed in 19.4 and 14.6% in HIC and UC groups, respectively. The opposite phenomenon-recovery of anemia-occurred in 27.6 and 28.8% in HIC and UC groups (P = 0.1379). The predictors of incident anemia at 90 days were male sex, geographical region other than Europe, ischemic etiology, higher glucose, and elevated uric acid at baseline. The percentages of optimal doses of renin-angiotensin system inhibitors, beta-blockers, and mineralocorticoid receptor antagonists were not different between anemic and non-anemic patients. High-intensity care strategy did not increase rate of incident anemia at 90 days and reduced the rate of primary and secondary endpoints regardless of baseline hemoglobin. CONCLUSION Hemoglobin level and status of anemia have a dynamic nature in the acute HF patients in the post-discharge period dependent on multiple factors. High-intensity HF treatment is safe and beneficial regardless of baseline hemoglobin level and presence of anemia. The improvement of quality of life is significantly lower in anemic HF patients implying specific attention to correction of this condition.
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Affiliation(s)
- Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Heart Initiative, Durham, NC, USA
- Momentum Research Inc, Durham, NC, USA
| | | | - Marianna Adamo
- Cardiology, Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C.Iliescu", University of Medicine "Carol Davila", Bucharest, Romania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Antoine Kimmoun
- Université de Lorraine, Nancy; INSERM, Défaillance Circulatoire Aigue Et Chronique; Service de Médecine Intensive Et Réanimation Brabois, CHRU de Nancy, 54511, Vandœuvre-Lès-Nancy, France
| | - Valentine Léopold
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Benjamin Deniau
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Marco Metra
- Cardiology, Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Matteo Pagnesi
- Cardiology, Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital / Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | | | | | - Daniela Tomasoni
- Cardiology, Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
- Baim Institute for Clinical Research, Boston, MA, USA
- University Medical Centre Groningen, Groningen, The Netherlands
| | - Adriaan A Voors
- Department of Cardiology, Medical Centre Groningen, Groningen, Netherlands
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Heart Initiative, Durham, NC, USA
- Momentum Research Inc, Durham, NC, USA
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20
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Devoldere J, Droogmans S, Heggermont WA, Van Craenenbroeck E. Implementation of guideline-directed medical therapy for heart failure patients with reduced ejection fraction in Belgium: a Delphi panel approach. Acta Cardiol 2024:1-12. [PMID: 39254605 DOI: 10.1080/00015385.2024.2396767] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/17/2024] [Accepted: 08/21/2024] [Indexed: 09/11/2024]
Abstract
BACKGROUND The 2021 European Society of Cardiology (ESC) guidelines recommended a shift from a traditional hierarchical treatment for heart failure with reduced ejection fraction (HFrEF) to a four-pillar medical therapy strategy intended for near-simultaneous initiation. However, practical guidance for implementation in clinical practice is lacking. To address this, a Delphi Panel of 12 Belgian heart failure experts aimed to obtain consensus on integrating guideline-directed medical therapy (GDMT) in HFrEF patients in Belgian clinical practice, considering local specificities, including reimbursement criteria. METHODS A geographically representative sample of 12 Belgian cardiologists engaged in a three-round Delphi process, evolving from 20 open-ended questions to 39 statements. A qualitative analysis after the first round resulted in expert statements for the subsequent questionnaire, categorised into treatment for newly diagnosed and chronic HFrEF patients. RESULTS The Delphi consensus revealed four key findings: (i) Agreement on initiating the four medical cornerstones within 7-14 days of HFrEF diagnosis, prioritising initiation over individual class up-titration; (ii) Lack of consensus on a fixed sequence for initiation due to patient variability and national reimbursement criteria; (iii) Emphasis on treatment adjustment based on the patient's clinical presentation and comorbidities; (iv) Recognition of the crucial role of regular follow-up visits, allowing optimisation of medical therapy where appropriate. CONCLUSION This national Delphi consensus addresses clinical implementation of GDMT in HFrEF patients for Belgian cardiologists. The consensus highlights the importance of swift implementation of the four cornerstone medical therapies in newly diagnosed HFrEF patients, individualising treatment sequencing, and ensuring regular follow-up to optimise therapy.
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Affiliation(s)
- Joke Devoldere
- Medical Affairs, BioPharmaceuticals, AstraZeneca, Groot-Bijgaarden, Belgium
| | - Steven Droogmans
- Department of Cardiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZB), Centrum voor Hart- en Vaatziekten (CHVZ), Brussels, Belgium
| | - Ward A Heggermont
- Cardiovascular Research Center, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Emeline Van Craenenbroeck
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
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21
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Kuwayama T, Okumura T, Kondo T, Oishi H, Kimura Y, Kazama S, Araki T, Hiraiwa H, Morimoto R, Kanashiro M, Asano H, Kawaguchi K, Yoshida Y, Tanaka N, Morishima I, Murohara T. Characteristics, Treatment, and Prognosis in Octogenarian and Older Patients With Acute Heart Failure in Japan - Prospective Observational Study on Acute Pharmacotherapy and Prognosis in Management of Acute Heart Failure (POPEYE-AHF Registry). Circ J 2024:CJ-24-0299. [PMID: 39245574 DOI: 10.1253/circj.cj-24-0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
BACKGROUND The number of older people in Japan is increasing more quickly than in other countries; with this aging of society, the number of elderly patients hospitalized for acute heart failure (HF) is also increasing. The treatment and prognosis of acute HF may be changing, but there are insufficient recent data, especially for octogenarian and older patients. METHODS AND RESULTS This study investigated the characteristics and treatment of acute HF patients in Japan. From 2018 to 2020, 1,146 patients from 7 Tokai area hospitals were followed for at least 1 year. The mean age was 78 years. Compared with patients aged <80 years, those aged ≥80 years were more likely to be female (57.4% vs. 34.2%), have a lower body mass index (22.2 vs. 24.9 kg/m2), and have HF with preserved ejection fraction (43.1% vs. 21.4%), and less likely to have HF with reduced ejection fraction (38.9% vs. 61.7%). During hospitalization, 6.5% died. After discharge, patients faced high risks of rehospitalization for HF and death (27.6 and 14.2 per 100 patient-years, respectively). Notably, prescription rates of HF medications have declined over time for all patients, but especially for those aged ≥80 years. CONCLUSIONS Guideline-directed medical therapy should be provided based on a thorough understanding of an individual's background rather than withheld simply because of clinical inertia due to a patient's advanced age.
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Affiliation(s)
- Tasuku Kuwayama
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hideo Oishi
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Yuki Kimura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Shingo Kazama
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takashi Araki
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | | | | | - Yukihiko Yoshida
- Department of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital
| | | | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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22
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Kinoshita H, Sugino H, Fujita K, Sumimoto Y, Masada K, Shimonaga T, Suga A, Toko M, Taniyasu K, Ushirozako S, Katayama Y, Hirahara C, Takada M. Examination of the Suitability of Vericiguat in Non-Heart Failure with Preserved Ejection Fraction Patients with Improved Ejection Fraction. J Clin Med 2024; 13:5264. [PMID: 39274476 PMCID: PMC11396383 DOI: 10.3390/jcm13175264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2024] [Revised: 08/26/2024] [Accepted: 09/03/2024] [Indexed: 09/16/2024] Open
Abstract
Background/Objectives: Vericiguat has been shown to reduce cardiovascular mortality and hospitalisation for heart failure in patients with reduced ejection fraction. While Vericiguat is considered one of the standard treatments for heart failure, it is unclear under which conditions Vericiguat would be most effective. With a focus on the prognosis and improved EF of heart failure, we aimed to investigate in which cases Vericiguat is suitable for use in addition to standard cardioprotective drugs. Methods: We prospectively compared echocardiograms taken before and after the administration of Vericiguat in 46 patients with non-dialysis and without heart failure with preserved ejection fraction (non-HFpEF) (left ventricle ejection fraction [LVEF] < 50%) who were able to continue Vericiguat in addition to other standard heart failure drugs (the "Fantastic Four") for more than 6 months at our hospital. Patients who showed an improvement of 10 points or more in LVEF were defined as improved EF+. Results: LVEF improved significantly from 38 [33-45]% at the time of administration to 46 [35-54.5]% at 6 months (p < 0.001). When comparing patients with and without improved EF, a significant difference was observed in the Hb (OR = 1.66, 95%CI = 1.12-2.83, p = 0.028), early introduction (OR = 12.5, 95%CI = 1.58-149, p = 0.025), and initiation of Vericiguat after the administration of the Fantastic Four (OR = 9.79, 95%CI = 1.71-100.2, p = 0.022). Conclusions: In this study, the early administration of Vericiguat, haemoglobin value, and initiation of Vericiguat after the introduction of the Fantastic Four were identified as independent factors for eligibility in non-dialysis, non-HFpEF patients who were able to continue GDMT treatment for more than 6 months after adding Vericiguat.
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Affiliation(s)
| | - Hiroshi Sugino
- Department of Cardiology, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Kento Fujita
- Department of Cardiology, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Yoji Sumimoto
- Department of Cardiology, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Kenji Masada
- Department of Cardiology, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Takashi Shimonaga
- Department of Cardiology, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Akiyo Suga
- The Ultrasound Team, Physiological Examination Department, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Mayumi Toko
- The Ultrasound Team, Physiological Examination Department, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Kaori Taniyasu
- The Ultrasound Team, Physiological Examination Department, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Saki Ushirozako
- The Ultrasound Team, Physiological Examination Department, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Yumiko Katayama
- The Ultrasound Team, Physiological Examination Department, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Chiemi Hirahara
- The Ultrasound Team, Physiological Examination Department, NHO Kure Medical Center, Kure 737-0023, Japan
| | - Masahiro Takada
- Department of Pharmacy, NHO Kure Medical Center, Kure 737-0023, Japan
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23
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Deaton C. Understanding medication adherence in patients with heart failure: commentary. Eur J Cardiovasc Nurs 2024; 23:e104-e105. [PMID: 38441965 DOI: 10.1093/eurjcn/zvae029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Accepted: 02/20/2024] [Indexed: 03/07/2024]
Affiliation(s)
- Christi Deaton
- Primary Care Unit, Department of Primary Care and Public Health, University of Cambridge School of Clinical Medicine, East Forvie Building, Cambridge Biomedical Campus, Robinson Way, Cambridge CB2 0SR, UK
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24
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Iwasaki E, Kohyama N, Inamoto M, Nagao M, Sunaga T, Suzuki H, Ebato M, Kogo M. Factors Associated With Sacubitril/Valsartan Continuation and the Methods of Combining Heart Failure Medications in Patients With Heart Failure. Ann Pharmacother 2024:10600280241277354. [PMID: 39229914 DOI: 10.1177/10600280241277354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/05/2024] Open
Abstract
BACKGROUND Sacubitril/valsartan (SV) is recommended for patients with heart failure (HF). In addition, a combination of 4 HF medications, including SV, is recommended in patients with HF with reduced ejection fraction (HFrEF). However, evidence on the characteristics of patients who could continue SV and its initiation methods is limited. OBJECTIVE To investigate the factors associated with SV continuation and methods of combining HF medications. METHODS This retrospective cohort study included HF patients who initiated with SV at our institution. The endpoint was SV continuation for 6 months after its initiation. Multivariate analysis was used to extract factors associated with SV continuation. The relationship between the methods of combining HF medications (renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, or sodium-glucose cotransporter 2 inhibitors), including the number of HF medications, their combination patterns, and the timing of their initiation, and SV continuation was examined in patients with HFrEF. RESULTS Of 186 eligible patients, 68.8% had HFrEF, and 79.0% continued SV for 6 months. Significant factors associated with SV continuation were albumin ≥ 3.5 g/dL (odds ratio, 4.81; 95% confidence interval, 2.19-10.59), body mass index (BMI) ≥ 18.5 kg/m2 (4.17; 1.10-15.85), and systolic blood pressure (SBP) ≥ 110 mmHg (2.66; 1.12-6.28). In patients with HFrEF, the proportion of HF medications not initiated simultaneously with SV was significantly higher in the continuation group than in the discontinuation group (67.3% vs 33.3%, P = 0.002). The number of HF medications and their combination patterns were not significantly associated with SV continuation. CONCLUSION AND RELEVANCE Albumin, BMI, and SBP are useful indicators for selecting patients who are likely to continue SV. In addition, initiating only SV without simultaneously initiating other HF medications in patients with HFrEF may lead to SV continuation.
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Affiliation(s)
- Erika Iwasaki
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy, Tokyo, Japan
| | - Noriko Kohyama
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy, Tokyo, Japan
| | - Mayumi Inamoto
- Department of Pharmacy, Showa University Fujigaoka Hospital, Kanagawa, Japan
- Department of Hospital Pharmaceutics, Showa University, Tokyo, Japan
| | - Michiru Nagao
- Department of Pharmacy, Showa University Fujigaoka Hospital, Kanagawa, Japan
- Department of Hospital Pharmaceutics, Showa University, Tokyo, Japan
| | - Tomiko Sunaga
- Department of Hospital Pharmaceutics, Showa University, Tokyo, Japan
- Department of Pharmacy, Showa University Dental Hospital, Tokyo, Japan
| | - Hiroshi Suzuki
- Department of Cardiovascular Medicine, Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Mio Ebato
- Department of Cardiovascular Medicine, Showa University Fujigaoka Hospital, Kanagawa, Japan
| | - Mari Kogo
- Division of Pharmacotherapeutics, Department of Clinical Pharmacy, Showa University School of Pharmacy, Tokyo, Japan
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25
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Shoji S, Mentz RJ. Beyond quadruple therapy: the potential roles for ivabradine, vericiguat, and omecamtiv mecarbil in the therapeutic armamentarium. Heart Fail Rev 2024; 29:949-955. [PMID: 38951303 DOI: 10.1007/s10741-024-10412-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/17/2024] [Indexed: 07/03/2024]
Abstract
Quadruple therapy is effective for patients with heart failure with reduced ejection fraction, providing significant clinical benefits, including reduced mortality. Clinicians are now in an era focused on how to initiate and titrate quadrable therapy in the early phase of the disease trajectory, including during heart failure hospitalization. However, patients with heart failure with reduced ejection fraction still face a significant "residual risk" of mortality and heart failure hospitalization. Despite the effective implementation of quadruple therapy, high mortality and rehospitalization rates persist in heart failure with reduced ejection fraction, and many patients cannot maximize therapy due to side effects such as hypotension and renal dysfunction. In this context, ivabradine, vericiguat, and omecamtiv mecarbil may have adjunct roles in addition to quadruple therapy (note that omecamtiv mecarbil is not currently approved for clinical use). However, the contemporary use of ivabradine and vericiguat is relatively low globally, likely due in part to the under-recognition of the role of these therapies as well as costs. This review offers clinicians a straightforward guide for bedside evaluation of potential candidates for these medications. Quadruple therapy, with strong evidence to reduce mortality, should always be prioritized for implementation. As second-line therapies, ivabradine could be considered for patients who cannot achieve optimal heart rate control (≥ 70 bpm at rest) despite maximally tolerated beta-blocker dosing. Vericiguat could be considered for high-risk patients who have recently experienced worsening heart failure events despite being on quadrable therapy, but they should not have N-terminal pro-B-type natriuretic peptide levels exceeding 8000 pg/mL. In the future, omecamtiv mecarbil may be considered for severe heart failure (New York Heart Association class III to IV, ejection fraction ≤ 30%, and heart failure hospitalization within 6 months) when current quadrable therapy is limited, although this is still hypothesis-generating and requires further investigation before its approval.
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Affiliation(s)
- Satoshi Shoji
- Duke Clinical Research Institute, 300 W Morgan St, Durham, NC, 27701, USA.
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan.
| | - Robert J Mentz
- Duke Clinical Research Institute, 300 W Morgan St, Durham, NC, 27701, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
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26
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Thibodeau JT, Givertz MM. Rapid Uptitration of Guideline-Directed Medical Therapy Regardless of Risk: It's Not MAGGIC, It's Science. JACC. HEART FAILURE 2024; 12:1583-1585. [PMID: 39023492 DOI: 10.1016/j.jchf.2024.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/20/2024] [Accepted: 05/22/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Jennifer T Thibodeau
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Michael M Givertz
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/GivertzMichael
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27
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Teng LE, Lammoza N, Aung AK, Thayaparan A, Vasudevan S, Edwards G, Hormiz M, Gibbs H, Hopper I. General physicians' perspectives on SGLT2 inhibitors for heart failure. Intern Med J 2024; 54:1483-1489. [PMID: 38957943 DOI: 10.1111/imj.16440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 05/17/2024] [Indexed: 07/04/2024]
Abstract
BACKGROUND Sodium-glucose cotransporter-2 inhibitors (SGLT2is) are novel agents for heart failure (HF) and are now recommended in guidelines. Understanding general physicians' perspectives can help to optimise utilisation of this new medication. AIM To understand the clinical concerns and barriers from general physicians about prescribing SGLT2is in a general medicine cohort. METHODS A questionnaire exploring clinicians' experience, comfort level and barriers to prescribing SGLT2is in patients with HF, incorporating two clinical scenarios, was disseminated to Internal Medicine Society of Australia and New Zealand members over a 2-month period. RESULTS Ninety-eight participants responded to the questionnaire (10.8% response rate). Most respondents (66.3%) were senior medical staff. Most participants worked in metropolitan settings (64.3%) and in public hospital settings (83.7%). For HF with reduced ejection fraction, 23.5% of participants reported prescribing SGLT2is frequently (defined as prescribing SGLT2is frequently over 75% of occasions). For HF with preserved ejection fraction, 57.1% of participants reported prescribing SGLT2is less than 25% of the time. Almost half of the participants (44%) expressed a high level of familiarity with therapeutic knowledge of SGLT2is, while 47% indicated high familiarity with potential side effects. Patient complexity, cost of medications and discontinuity of care were identified as important barriers. Euglycemic diabetic ketoacidosis was the side effect that caused the most hesitancy to prescribe SGLT2is in 48% of the respondents. CONCLUSION General physicians in Australia and Aotearoa New Zealand are familiar with the therapeutic knowledge and side effects of SGLT2is. Patient complexity, medication cost and discontinuity of care were significant barriers to the use of SGLT2is for HF among general physicians.
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Affiliation(s)
- Lung E Teng
- General Medicine Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Noor Lammoza
- General Medicine Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Ar K Aung
- General Medicine Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Archana Thayaparan
- General Medicine Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Swetha Vasudevan
- General Medicine Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Gail Edwards
- General Medicine Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
- Department of Pharmacy, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Maria Hormiz
- General Medicine Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
| | - Harry Gibbs
- General Medicine Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
- Central Clinical School, Faculty of Medicine, Nursing and Health Sciences, Monash University, Melbourne, Victoria, Australia
| | - Ingrid Hopper
- General Medicine Unit, Alfred Health, Monash University, Melbourne, Victoria, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
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28
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Romanò M. New Disease Trajectories of Heart Failure: Challenges in Determining the Ideal Timing of Palliative Care Implementation. J Palliat Med 2024; 27:1118-1124. [PMID: 38973549 DOI: 10.1089/jpm.2023.0681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Abstract
Background: The disease trajectory of heart failure (HF), along with other organ failures, is still being elucidated. The trajectory is represented as a descending saw-tooth curve, indicating the frequent exacerbations and hospitalizations and slow progression to death. However, the clinical pattern of HF is no longer unique because of the definition of three distinct phenotypes, according to different values of ejection fraction (EF): HF with reduced EF (HFrEF), mildly reduced EF (HFmEF), and preserved EF (HFpEF). Patients with HFrEF have access to pharmacological and nonpharmacological treatments that have been shown to reduce mortality, unlike the other two classes for which no effective therapies are present. Therefore, their disease trajectories are markedly different. Methods: In this study, multiple new disease trajectories of HFrEF are being proposed, ranging from a complete and persistent recovery to rapid clinical deterioration and premature death. These new trajectories pose challenges to early implementation of palliative care (PC), as indicated in the guidelines. Results: From these considerations, we discuss how the improved prognosis of HFrEF because of effective treatment could paradoxically delay the initiation of early PC, especially with the insufficient palliative knowledge and training of cardiologists, who usually believe that PC is required only at the end of life. Conclusions: The novel therapeutic approaches for HF discussed in this study highlight the clinical specificity and peculiar needs of patients with HF. The changing model of disease trajectories of patients with HF will provide new opportunities for the early implementation of PC.
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Affiliation(s)
- Massimo Romanò
- Organizing Committee Master in Palliative Care. University of Milan, Milano, Italy
- Hospice of Abbiategrasso, Milan, Italy
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29
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Buttar C, Alai H, Matanes FN, Cassidy MM, Stencel J, Le Jemtel TH. Full decongestion in acute heart failure therapy. Am J Med Sci 2024; 368:182-189. [PMID: 38880301 DOI: 10.1016/j.amjms.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2024] [Revised: 06/07/2024] [Accepted: 06/07/2024] [Indexed: 06/18/2024]
Abstract
Incomplete decongestion is the main cause of readmission in the early post-discharge period of a hospitalization for acute heart failure. Recent heart failure guidelines have highlighted initiation and rapid up-titration of quadruple therapy with angiotensin receptor neprilysin inhibitor, beta adrenergic receptor blocker, mineralocorticoid receptor antagonist, and sodium glucose cotransporter 2 inhibitor to prevent hospitalizations for heart failure with reduced ejection fraction. However, full decongestion remains the foremost therapeutic goal of hospitalization for heart failure. While early addition of sodium glucose cotransporter 2 inhibitors and mineralocorticoid receptor antagonists may be helpful, the value of the other therapeutics comes after decongestion is complete.
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Affiliation(s)
- Chandan Buttar
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Hamid Alai
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Faris N Matanes
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Mark M Cassidy
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Jason Stencel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA
| | - Thierry H Le Jemtel
- Department of Cardiology, Tulane University Medical Center, 1415 Tulane Ave, New Orleans, LA 70112, USA; Southeast Louisiana Veterans Healthcare System, 2400 Canal Street, New Orleans, LA 70119, USA.
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Ambrosy AP, Chang AJ, Davison B, Voors A, Cohen-Solal A, Damasceno A, Kimmoun A, Lam CSP, Edwards C, Tomasoni D, Gayat E, Filippatos G, Saidu H, Biegus J, Celutkiene J, Ter Maaten JM, Čerlinskaitė-Bajorė K, Sliwa K, Takagi K, Metra M, Novosadova M, Barros M, Adamo M, Pagnesi M, Arrigo M, Chioncel O, Diaz R, Pang PS, Ponikowski P, Cotter G, Mebazaa A. Titration of Medications After Acute Heart Failure Is Safe, Tolerated, and Effective Regardless of Risk. JACC. HEART FAILURE 2024; 12:1566-1582. [PMID: 38739123 DOI: 10.1016/j.jchf.2024.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 04/26/2024] [Accepted: 04/26/2024] [Indexed: 05/14/2024]
Abstract
BACKGROUND Guideline-directed medical therapy (GDMT) decisions may be less affected by single patient variables such as blood pressure or kidney function and more by overall risk profile. In STRONG-HF (Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure), high-intensity care (HIC) in the form of rapid uptitration of heart failure (HF) GDMT was effective overall, but the safety, tolerability and efficacy of HIC across the spectrum of HF severity is unknown. Evaluating this with a simple risk-based framework offers an alternative and more clinically translatable approach than traditional subgroup analyses. OBJECTIVES The authors sought to assess safety, tolerability, and efficacy of HIC according to the simple, powerful, and clinically translatable MAGGIC (Meta-Analysis Global Group in Chronic) HF risk score. METHODS In STRONG-HF, 1,078 patients with acute HF were randomized to HIC (uptitration of treatments to 100% of recommended doses within 2 weeks of discharge and 4 scheduled outpatient visits over the 2 months after discharge) vs usual care (UC). The primary endpoint was the composite of all-cause death or first HF rehospitalization at day 180. Baseline HF risk profile was determined by the previously validated MAGGIC risk score. Treatment effect was stratified according to MAGGIC risk score both as a categorical and continuous variable. RESULTS Among 1,062 patients (98.5%) with complete data for whom a MAGGIC score could be calculated at baseline, GDMT use at baseline was similar across MAGGIC tertiles. Overall GDMT prescriptions achieved for individual medication classes were higher in the HIC vs UC group and did not differ by MAGGIC risk score tertiles (interaction nonsignificant). The incidence of all-cause death or HF readmission at day 180 was, respectively, 16.3%, 18.9%, and 23.2% for MAGGIC risk score tertiles 1, 2, and 3. The HIC arm was at lower risk of all-cause death or HF readmission at day 180 (HR: 0.66; 95% CI: 0.50-0.86) and this finding was robust across MAGGIC risk score modeled as a categorical (HR: 0.51; 95% CI: 0.62-0.68 in tertiles 1, 2, and 3; interaction nonsignificant) for all comparisons and continuous (interaction nonsignificant) variable. The rate of adverse events was higher in the HIC group, but this observation did not differ based on MAGGIC risk score tertile (interaction nonsignificant). CONCLUSIONS HIC led to better use of GDMT and lower HF-related morbidity and mortality compared with UC, regardless of the underlying HF risk profile. (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP testinG, of Heart Failure Therapies [STRONG-HF]; NCT03412201).
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Affiliation(s)
- Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.
| | - Alex J Chang
- Department of Medicine, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina, USA; Heart Initiative, Durham, North Carolina, USA
| | - Adriaan Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | | | - Antoine Kimmoun
- Université de Lorraine, Nancy, INSERM, Défaillance Circulatoire Aigue et Chronique, Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandoeuvre-lès-Nancy, France
| | - Carolyn S P Lam
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands; National Heart Centre Singapore and Duke-National University of Singapore
| | | | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital/Bayero University Kano, Kano, Nigeria
| | - Jan Biegus
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Kamilė Čerlinskaitė-Bajorė
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Karen Sliwa
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | - Koji Takagi
- Momentum Research Inc, Durham, North Carolina, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | | | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Arrigo
- Emergency Institute for Cardiovascular Diseases "Prof. C.C.Iliescu," University of Medicine "Carol Davila," Bucharest, Romania
| | - Ovidiu Chioncel
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Rafael Diaz
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina, USA; Heart Initiative, Durham, North Carolina, USA
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
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Yan CL, Snipelisky D, Velez M, Baran D, Estep JD, Bauerlein EJ, Thakkar Rivera N. Protocol-driven approach to guideline-directed medical therapy optimization for heart failure: A real-world application to recovery. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 45:100438. [PMID: 39220718 PMCID: PMC11362780 DOI: 10.1016/j.ahjo.2024.100438] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 05/30/2024] [Accepted: 07/31/2024] [Indexed: 09/04/2024]
Abstract
The objective of our study was to evaluate the real-world effects of an aggressive, personalized protocol for guideline-directed medical therapy (GDMT) titration in patients with heart failure (HF) with reduced ejection fraction (HFrEF). We conducted a two-center retrospective cohort study. Patients with HFrEF who presented to a HF clinic from January 2020 to December 2022 were placed on a GDMT protocol. 180 patients were included in the study. Mean GDMT score significantly increased from 4.7 to 5.9 (p < 0.001) between initial and final visits. Mean left ventricular ejection fraction (LVEF) significantly increased from 28 % to 33 % (+5 %, p < 0.001). 27 (15.7 %) of the 172 patients with complete New York Heart Association (NYHA) classification data had improvement by at least 1 class, while 2 (1.2 %) patients had worsening NYHA classification. 140 (77.8 %) patients had no unplanned hospitalizations between visits. 21 (11.7 %) patients had an unplanned hospitalization for acute HF during the study period with a mean time from first clinic visit to hospitalization of 183 days (range: 13-821 days). 2 (1.1 %) patients were hospitalized due to GDMT-associated adverse drug events (i.e. hypotension, hyperkalemia). 7 (3.9 %) patients died during the study period, which was lower than the predicted 1-year death rate for our cohort (12.3 %) using the MAGGIC score. In conclusion, an aggressive, personalized protocol for GDMT titration in patients with HFrEF led to significant improvements in LVEF, NYHA classification, hospitalization, and mortality in a real-world setting. This protocol may help serve as a road map to lessen the gap between clinical knowledge and practice surrounding optimization of GDMT and move HFrEF patients toward a path to recovery.
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Affiliation(s)
- Crystal Lihong Yan
- Divison of Internal Medicine, University of Miami Health System, Miami, FL, USA
| | - David Snipelisky
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Mauricio Velez
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - David Baran
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Florida, Weston, FL, USA
| | - Jerry D. Estep
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Florida, Weston, FL, USA
| | | | - Nina Thakkar Rivera
- Heart, Vascular & Thoracic Institute, Cleveland Clinic Florida, Weston, FL, USA
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Onyebeke C, Zhang D, Musse M, Unlu O, Nahid M, Ambrosy AP, Levitan EB, Safford MM, Goyal P. Polypharmacy and Guideline-Directed Medical Therapy Initiation Among Adults Hospitalized With Heart Failure. JACC. ADVANCES 2024; 3:101126. [PMID: 39210913 PMCID: PMC11357976 DOI: 10.1016/j.jacadv.2024.101126] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Revised: 05/13/2024] [Accepted: 05/21/2024] [Indexed: 09/04/2024]
Abstract
Background Underprescribing of guideline-directed medical therapy (GDMT) for heart failure (HF) persists. Objectives The purpose of this study was to assess polypharmacy as a barrier to GDMT. Methods We examined participants hospitalized for HF with reduced ejection fraction and HF with mildly reduced ejection fraction between 2003 and 2017 from the Reasons for Geographic and Racial Differences in Stroke study. Participants were stratified by admission medication count-0 to 4, 5 to 9, and ≥10 medications. We examined GDMT use at admission, GDMT contraindications, and initiation of eligible indicated GDMT by medication count. We conducted a multivariable Poisson regression with robust standard errors to examine the association between medication count and GDMT initiation. GDMT included agents for HF with reduced ejection fraction/HF with mildly reduced ejection fraction, antiplatelet agents and statins for coronary artery disease, and anticoagulants for atrial fibrillation. Results Among 545 participants with HF, 34% were not taking a beta-blocker, 39% were not taking an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, or hydralazine-isosorbide dinitrate, and 90% were not taking a mineralocorticoid receptor antagonist at admission; among participants with coronary artery disease, 36% were not taking an antiplatelet agent, and 38% were not taking a statin; and among participants with atrial fibrillation, 49% were not taking an anticoagulant. Polypharmacy was inversely associated with initiation of at least one indicated medication (5-9 medications: relative risk [RR]: 0.67; 95% CI: 0.56-0.82; P < 0.001; ≥10 medications: RR: 0.50; 95% CI: 0.39-0.64; P < 0.001) and initiation of at least half of indicated medications (5-9 medications: RR: 0.64; 95% CI: 0.51-0.81; P < 0.001; ≥10 medications: RR: 0.50; 95% CI: 0.38-0.67; P < 0.001). Conclusions Polypharmacy is an important barrier to GDMT.
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Affiliation(s)
- Chukwuma Onyebeke
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - David Zhang
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Mahad Musse
- Program for the Care and Study of the Aging Heart, Weill Cornell Medicine, New York, New York, USA
| | - Ozan Unlu
- Division of Cardiovascular Medicine, Brigham and Women‘s Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Musarrat Nahid
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Andrew P. Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, Alabama, USA
| | - Monika M. Safford
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
- Program for the Care and Study of the Aging Heart, Weill Cornell Medicine, New York, New York, USA
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Biegus J, Pagnesi M, Davison B, Ponikowski P, Mebazaa A, Cotter G. High-intensity care for GDMT titration. Heart Fail Rev 2024; 29:1065-1077. [PMID: 39037564 PMCID: PMC11306642 DOI: 10.1007/s10741-024-10419-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2024] [Indexed: 07/23/2024]
Abstract
Heart failure (HF) is a systemic disease associated with a high risk of morbidity, mortality, increased risk of hospitalizations, and low quality of life. Therefore, effective, systemic treatment strategies are necessary to mitigate these risks. In this manuscript, we emphasize the concept of high-intensity care to optimize guideline-directed medical therapy (GDMT) in HF patients. The document highlights the importance of achieving optimal recommended doses of GDMT medications, including beta-blockers, renin-angiotensin-aldosterone inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter inhibitors to improve patient outcomes, achieve effective, sustainable decongestion, and improve patient quality of life. The document also discusses potential obstacles to GDMT optimization, such as clinical inertia, physiological limitations, comorbidities, non-adherence, and frailty. Lastly, it also attempts to provide possible future scenarios of high-intensive care that could improve patient outcomes.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Borowska 213, Poland.
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Beth Davison
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Borowska 213, Poland
| | - Alexander Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Gadi Cotter
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
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Driscoll A, Meagher S, Kennedy R, Currey J. Effect of Intensive Nurse-Led Optimization of Heart Failure Medications in Patients With Heart Failure: A Meta-analysis of Randomized Controlled Trials. J Cardiovasc Nurs 2024; 39:417-426. [PMID: 38227630 DOI: 10.1097/jcn.0000000000001068] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2024]
Abstract
BACKGROUND Prescribing of recommended medications for heart failure (HF) is suboptimal, leaving patients at a high risk of death or rehospitalization post discharge. Nurse-led titration (NLT) clinics are one strategy that could potentially improve the prescription of these medications. OBJECTIVE The aim of this article was to determine the effect of NLT clinics on all-cause mortality, all-cause or HF rehospitalizations, and adverse effects in patients with HF. METHODS We searched MEDLINE, EMBASE, Cochrane CENTRAL, International Clinical Trials Registry Platform, and ClinicalTrials.gov to identify randomized controlled trials comparing NLT of β-blocking agents, angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors, and/or angiotensin receptor blockers to optimization by another health professional in patients with HF. We used the fixed-effects Mantel-Haenszel method or meta-analyses. We assessed heterogeneity between studies using χ 2 and I2 . RESULTS Eight studies with 2025 participants were included. Participants in the NLT group experienced a lower rate of all-cause rehospitalizations (relative risk, 0.76, 95% confidence interval, 0.68-0.85; moderate quality of evidence) and less HF-related rehospitalizations (relative risk, 0.47; 95% confidence interval, 0.33-0.66; high quality of evidence) compared with the usual care group. All-cause mortality was lower in the NLT group (relative risk, 0.67; 95% confidence interval, 0.48-0.92; moderate quality of evidence) compared with the usual care group. Authors of one study reported no adverse events, and another study found one adverse event. CONCLUSION This meta-analysis indicates that NLT clinics may improve optimization of guideline-recommended medications with the potential to reduce rehospitalization and improve survival in a cohort of patients known for their poor outcomes.
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Severino P, D'Amato A, Prosperi S, Mariani MV, Myftari V, Labbro Francia A, Cestiè C, Tomarelli E, Manzi G, Birtolo LI, Marek-Iannucci S, Maestrini V, Mancone M, Badagliacca R, Fedele F, Vizza CD. Strategy for an early simultaneous introduction of four-pillars of heart failure therapy: results from a single center experience. Am J Cardiovasc Drugs 2024; 24:663-671. [PMID: 38909334 PMCID: PMC11344711 DOI: 10.1007/s40256-024-00660-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/02/2024] [Indexed: 06/24/2024]
Abstract
INTRODUCTION The 2021 European Society of Cardiology (ESC) Guidelines recommend the use of four different classes of drugs for heart failure with reduced ejection fraction (HFrEF): beta blockers (BB), sodium-glucose cotransporter-2 inhibitors (SGLT2i), angiotensin receptor/neprilysin inhibitor (ARNI), and mineralocorticoid receptor antagonists (MRAs). Moreover, the 2023 ESC updated Guidelines suggest an intensive strategy of initiation and rapid up-titration of evidence-based treatment before discharge, based on trials not using the four-pillars. We hypothesized that an early concomitantly administration and up-titration of four-pillars, compared with a conventional stepwise approach, may impact the vulnerable phase after hospitalization owing to HF. METHODS This prospective, single center, observational study included consecutive in-hospital patients with HFrEF. After performing propensity score matching, they were divided according to treatment strategy into group 1 (G1), with predischarge start of all four-pillars, with their up-titration within 1 month, and group 2 (G2) with the pre Guidelines update stepwise four-pillars introduction. HF hospitalization, cardiovascular (CV) death, and the composite of both were evaluated between the two groups at 6-month follow-up. RESULTS The study included a total of 278 patients who completed 6-month follow-up (139 for both groups). There were no differences in terms of baseline features between the two groups. At survival analysis, HF hospitalization risk was significantly lower in G1 compared with G2 (p < 0.001), while no significant differences were observed regarding CV death (p = 0.642) or the composite of CV death and HF hospitalization (p = 0.135). CONCLUSIONS In our real-world population, patients with HF treated with a predischarge and simultaneous use of four-pillars showed a reduced risk of HF hospitalization during the vulnerable phase after discharge, compared with a conventional stepwise approach.
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Affiliation(s)
- Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy.
| | - Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Aurora Labbro Francia
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Claudia Cestiè
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Elisa Tomarelli
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Giovanna Manzi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Stefanie Marek-Iannucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161, Rome, Italy
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Oskouie S, Pandey A, Sauer AJ, Greene SJ, Mullens W, Khan MS, Quinn KL, Ho JE, Albert NM, Van Spall HGC. From Hospital to Home: Evidence-Based Care for Worsening Heart Failure. JACC. ADVANCES 2024; 3:101131. [PMID: 39184855 PMCID: PMC11342447 DOI: 10.1016/j.jacadv.2024.101131] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Revised: 05/02/2024] [Accepted: 06/10/2024] [Indexed: 08/27/2024]
Abstract
Heart failure (HF) is a leading cause of hospitalization in older adults. Patients are at high risk of readmission and death following hospitalization for HF. There is no standard approach of health care delivery during the hospital-to-home transition period, leaving missed opportunities in care optimization. In this review, we discuss contemporary randomized clinical trials that tested decongestion strategies, disease-modifying therapies, and health care services that inform the care of patients with worsening HF. We provide evidence-informed recommendations for optimizing therapies and improving outcomes during and following hospitalization for HF. These include adequate decongestion with loop diuretics and select sequential nephron blockade strategies based on early evaluation of diuretic response; initiation of disease-modifying pharmacotherapies prior to hospital discharge with close follow-up and optimization after discharge; cardiac rehabilitation; and transitional or palliative care referral post-hospitalization. Evidence-based implementation strategies to facilitate broad uptake include digital health tools and algorithm-driven optimization of pharmacotherapies.
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Affiliation(s)
- Suzanne Oskouie
- Division of Cardiology, University of Arizona Sarver Heart Center, Tucson, Arizona, USA
| | - Ambarish Pandey
- Division of Cardiology, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew J. Sauer
- Department of Cardiology, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA
| | - Stephen J. Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Kieran L. Quinn
- Department of Medicine, Sinai Health System, University of Toronto, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
- Tammy Latner Centre for Palliative Care, Toronto, Ontario, Canada
| | - Jennifer E. Ho
- Division of Cardiology, Department of Medicine, Cardiovascular Institute, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Nancy M. Albert
- Research and Innovation- Nursing Institute and Kaufman Center for Heart Failure- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Harriette GC. Van Spall
- Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
- Baim Institute for Clinical Research, Boston, Massachusetts, USA
- Research Institute of St. Joseph’s Hospital Hamilton, Ontario, Canada
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Newman E, Kamanu C, Gibson G, Brailovsky Y. How to Optimize Goal-Directed Medical Therapy (GDMT) in Patients with Heart Failure. Curr Cardiol Rep 2024; 26:995-1003. [PMID: 39093374 PMCID: PMC11379751 DOI: 10.1007/s11886-024-02101-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/11/2024] [Indexed: 08/04/2024]
Abstract
PURPOSE OF REVIEW Heart failure is a clinical syndrome with signs and symptoms from underlying cardiac abnormality and evidence of pulmonary or systemic congestion on laboratory testing or other objective findings (Bozkurt et al. in Eur J Heart Fail 23:352-380, 2021). Heart failure with reduced ejection fraction (HFrEF), when heart failure is due to underlying reduction in ejection fraction to ≤ 40. The goal of this review is to briefly describe the mechanisms and benefits of the various pharmacological interventions described in the 2022 AHA/ACC/HFSA Guidelines focusing on Stage C: Symptomatic Heart Failure HFrEF, while providing basic guidance on safe use of these medications. RECENT FINDINGS Use of medications from each class as recommended in the 2022 Guidelines can provide significant morbidity and mortality benefits for our patients. Despite advances in therapeutics for patients with HFrEF, patients are frequently under treated and more research is needed to help optimize management of these complicated patients.
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Affiliation(s)
- Emily Newman
- Division of Cardiology, Thomas Jefferson University Hospital, 833 Chestnut Street, Suite 630, Philadelphia, PA, 19107, USA
| | - Chukwuemezie Kamanu
- Department of Medicine, Thomas Jefferson University Hospital, 833 Chestnut Street, Suite 630, Philadelphia, PA, 19107, USA
| | - Gregory Gibson
- Division of Cardiology, Thomas Jefferson University Hospital, 833 Chestnut Street, Suite 630, Philadelphia, PA, 19107, USA
| | - Yevgeniy Brailovsky
- Division of Cardiology, Thomas Jefferson University Hospital, 833 Chestnut Street, Suite 630, Philadelphia, PA, 19107, USA.
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Tanaka A, Kida K, Matsue Y, Imai T, Suwa S, Taguchi I, Hisauchi I, Teragawa H, Yazaki Y, Moroi M, Ohashi K, Nagatomo D, Kubota T, Ijichi T, Ikari Y, Yonezu K, Takahashi N, Toyoda S, Toshida T, Suzuki H, Minamino T, Nogi K, Shiina K, Horiuchi Y, Tanabe K, Hachinohe D, Kiuchi S, Kusunose K, Shimabukuro M, Node K. In-hospital initiation of angiotensin receptor-neprilysin inhibition in acute heart failure: the PREMIER trial. Eur Heart J 2024:ehae561. [PMID: 39215531 DOI: 10.1093/eurheartj/ehae561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2024] [Revised: 08/05/2024] [Accepted: 08/15/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND AND AIMS The efficacy and safety of early sacubitril/valsartan (Sac/Val) initiation after acute heart failure (AHF) has not been demonstrated outside North America. The present study aimed to evaluate the effect of in-hospital Sac/Val therapy initiation after an AHF episode on N-terminal pro-B-type natriuretic peptide (NT-proBNP) level in Japanese patients. METHODS This was an investigator-initiated, multicentre, prospective, randomized, open-label, blinded-endpoint pragmatic trial. After haemodynamic stabilization within 7 days after hospitalization, eligible inpatients were allocated to switch from angiotensin-converting enzyme inhibitor or angiotensin receptor blocker to Sac/Val (Sac/Val group) or to continue angiotensin-converting enzyme inhibitor or angiotensin receptor blocker (control group). The primary efficacy endpoint was the 8-week proportional change in geometric means of NT-proBNP levels. RESULTS A total of 400 patients were equally randomized, and 376 (median age 75 years, 31.9% women, de novo heart failure rate 55.6%, and median left ventricular ejection fraction 37%) were analysed. The per cent changes in NT-proBNP level geometric means at Weeks 4/8 were -35%/-45% (Sac/Val group) and -18%/-32% (control group), and their group ratio (Sac/Val vs. control) was 0.80 (95% confidence interval 0.68-0.94; P = .008) at Week 4 and 0.81 (95% confidence interval 0.68-0.95; P = .012) at Week 8, respectively. In the pre-specified subgroup analyses, the effects of Sac/Val were confined to patients with a left ventricular ejection fraction < 40% and were more evident in those in sinus rhythm and taking mineralocorticoid receptor antagonists. No adverse safety signal was evident. CONCLUSIONS In-hospital Sac/Val therapy initiation in addition to contemporary recommended therapy triggered a greater NT-proBNP level reduction in Japanese patients hospitalized for AHF. These findings may expand the evidence on Sac/Val therapy in this clinical situation outside North America. CLINICAL TRIAL REGISTRATION ClinicalTrial.gov (NCT05164653) and Japan Registry of Clinical Trials (jRCTs021210046).
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Affiliation(s)
- Atsushi Tanaka
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
| | - Keisuke Kida
- Department of Pharmacology, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takumi Imai
- Clinical Research Division, Organization for Clinical Medicine Promotion, Tokyo, Japan
- Clinical and Translational Research Center, Kobe University Hospital, Kobe, Japan
| | - Satoru Suwa
- Department of Cardiology, Juntendo University Shizuoka Hospital, Shizuoka, Japan
| | - Isao Taguchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Itaru Hisauchi
- Department of Cardiology, Dokkyo Medical University Saitama Medical Center, Koshigaya, Japan
| | - Hiroki Teragawa
- Department of Cardiovascular Medicine, JR Hiroshima Hospital, Hiroshima, Japan
| | - Yoshiyuki Yazaki
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Masao Moroi
- Division of Cardiovascular Medicine, Toho University Ohashi Medical Center, Tokyo, Japan
| | - Koichi Ohashi
- Department of Cardiology, Tokyo Metropolitan Bokutoh Hospital, Tokyo, Japan
| | - Daisuke Nagatomo
- Division of Cardiology, Cardiovascular and Aortic Center, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Toru Kubota
- Division of Cardiology, Cardiovascular and Aortic Center, Saiseikai Fukuoka General Hospital, Fukuoka, Japan
| | - Takeshi Ijichi
- Department of Cardiology, Tokai University, Isehara, Japan
| | - Yuji Ikari
- Department of Cardiology, Tokai University, Isehara, Japan
| | - Keisuke Yonezu
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Japan
| | - Naohiko Takahashi
- Department of Cardiology and Clinical Examination, Faculty of Medicine, Oita University, Yufu, Japan
| | - Shigeru Toyoda
- Department of Cardiovascular Medicine, Dokkyo Medical University, Mibu, Japan
| | - Tsutomu Toshida
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiroshi Suzuki
- Division of Cardiology, Department of Internal Medicine, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Kazutaka Nogi
- Department of Cardiovascular Medicine, Nara Medical University, Kashihara, Japan
| | - Kazuki Shiina
- Department of Cardiology, Tokyo Medical University, Tokyo, Japan
| | - Yu Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Kengo Tanabe
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Daisuke Hachinohe
- Department of Cardiology, Sapporo Heart Center, Sapporo Cardio Vascular Clinic, Sapporo, Japan
| | - Shunsuke Kiuchi
- Department of Cardiovascular Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Kenya Kusunose
- Department of Cardiovascular Medicine, Nephrology, and Neurology, Graduate School of Medicine, University of the Ryukyus, Okinawa, Japan
| | - Michio Shimabukuro
- Department of Diabetes, Endocrinology, and Metabolism, Fukushima Medical University School of Medicine, Fukushima, Japan
| | - Koichi Node
- Department of Cardiovascular Medicine, Saga University, 5-1-1 Nabeshima, Saga 849-8501, Japan
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Man JP, Koole MAC, Meregalli PG, Handoko ML, Stienen S, de Lange FJ, Winter MM, Schijven MP, Kok WEM, Kuipers DI, van der Harst P, Asselbergs FW, Zwinderman AH, Dijkgraaf MGW, Chamuleau SAJ, Schuuring MJ. Digital consults in heart failure care: a randomized controlled trial. Nat Med 2024:10.1038/s41591-024-03238-6. [PMID: 39217271 DOI: 10.1038/s41591-024-03238-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 08/07/2024] [Indexed: 09/04/2024]
Abstract
Guideline-directed medical therapy (GDMT) has clear benefits on morbidity and mortality in patients with heart failure; however, GDMT use remains low. In the multicenter, open-label, investigator-initiated ADMINISTER trial, patients (n = 150) diagnosed with heart failure and reduced ejection fraction (HFrEF) were randomized (1:1) to receive usual care or a strategy using digital consults (DCs). DCs contained (1) digital data sharing from patient to clinician (pharmacotherapy use, home-measured vital signs and Kansas City Cardiomyopathy Questionnaires); (2) patient education via a text-based e-learning; and (3) guideline recommendations to all treating clinicians. All remotely gathered information was processed into a digital summary that was available to clinicians in the electronic health record before every consult. All patient interactions were standardly conducted remotely. The primary endpoint was change in GDMT score over 12 weeks (ΔGDMT); this GDMT score directly incorporated all non-conditional class 1 indications for HFrEF therapy with equal weights. The ADMINISTER trial met its primary outcome of achieving a higher GDMT in the DC group after a follow-up of 12 weeks (ΔGDMT score in the DC group: median 1.19, interquartile range (0.25, 2.3) arbitrary units versus 0.08 (0.00, 1.00) in usual care; P < 0.001). To our knowledge, this is the first multicenter randomized controlled trial that proves a DC strategy is effective to achieve GDMT optimization. ClinicalTrials.gov registration: NCT05413447 .
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Affiliation(s)
- Jelle P Man
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
- Amsterdam Cardiovascular Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten A C Koole
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Cardiology Center of the Netherlands, Utrecht, The Netherlands
- Department of Cardiology, Red Cross Hospital, Beverwijk, The Netherlands
| | - Paola G Meregalli
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Science, University of Amsterdam, Amsterdam, The Netherlands
| | - M Louis Handoko
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Science, University of Amsterdam, Amsterdam, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Susan Stienen
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Frederik J de Lange
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Michiel M Winter
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Science, University of Amsterdam, Amsterdam, The Netherlands
- Cardiology Center of the Netherlands, Utrecht, The Netherlands
| | | | - Wouter E M Kok
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Dorianne I Kuipers
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Pim van der Harst
- Department of Cardiology, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Institute of Health Informatics, University College London, London, UK
- National Institute for Health Research, University College London Hospitals, Biomedical Research Centre, University College London, London, UK
| | - Aeilko H Zwinderman
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam, The Netherlands
- Methodology, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam UMC, Amsterdam, The Netherlands
- Methodology, Amsterdam Public Health, Amsterdam, The Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam UMC, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
- Amsterdam Cardiovascular Science, University of Amsterdam, Amsterdam, The Netherlands
| | - Mark J Schuuring
- Department of Cardiology, Medical Spectrum Twente, Enschede, The Netherlands.
- Department of Biomedical Signals and Systems, University of Twente, Enschede, The Netherlands.
- Cardiovascular Health Research Pillar, University of Twente, Enschede, The Netherlands.
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Nardone M, Sridhar VS, Yau K, Odutayo A, Cherney DZI. Proximal versus distal diuretics in congestive heart failure. Nephrol Dial Transplant 2024; 39:1392-1403. [PMID: 38425090 PMCID: PMC11361814 DOI: 10.1093/ndt/gfae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Indexed: 03/02/2024] Open
Abstract
Volume overload represents a hallmark clinical feature linked to the development and progression of heart failure (HF). Alleviating signs and symptoms of volume overload represents a foundational HF treatment target that is achieved using loop diuretics in the acute and chronic setting. Recent work has provided evidence to support guideline-directed medical therapies, such as sodium glucose cotransporter 2 (SGLT2) inhibitors and mineralocorticoid receptor (MR) antagonists, as important adjunct diuretics that may act synergistically when used with background loop diuretics in people with chronic HF. Furthermore, there is growing interest in understanding the role of SGLT2 inhibitors, carbonic anhydrase inhibitors, thiazide diuretics, and MR antagonists in treating volume overload in patients hospitalized for acute HF, particularly in the setting of loop diuretic resistance. Thus, the current review demonstrates that: (i) SGLT2 inhibitors and MR antagonists confer long-term cardioprotection in chronic HF patients but it is unclear whether natriuresis or diuresis represents the primary mechanisms for this benefit, (ii) SGLT2 inhibitors, carbonic anhydrase inhibitors, and thiazide diuretics increase natriuresis in the acute HF setting, but implications on long-term outcomes remain unclear and warrants further investigation, and (iii) a multi-nephron segment approach, using agents that act on distinct segments of the nephron, potentiate diuresis to alleviate signs and symptoms of volume overload in acute HF.
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Affiliation(s)
- Massimo Nardone
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Vikas S Sridhar
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Kevin Yau
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Ayodele Odutayo
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
| | - David Z I Cherney
- University Health Network, Division of Nephrology, Department of Medicine, University of Toronto, Ontario, Canada
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41
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Zheng J, Sandhu AT, Bhatt AS, Collins SP, Flint KM, Fonarow GC, Fudim M, Greene SJ, Heidenreich PA, Lala A, Testani JM, Varshney AS, Wi RSK, Ambrosy AP. Inpatient Use of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations Among Community-Based Health Systems. JACC. HEART FAILURE 2024:S2213-1779(24)00603-6. [PMID: 39269395 DOI: 10.1016/j.jchf.2024.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/18/2024] [Revised: 07/30/2024] [Accepted: 08/06/2024] [Indexed: 09/15/2024]
Abstract
BACKGROUND Guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains underused. Acute heart failure (HF) hospitalization represents a critical opportunity for rapid initiation of evidence-based medications. However, data on GDMT use at discharge are mostly derived from national quality improvement registries. OBJECTIVES This study aimed to describe contemporary GDMT use patterns across HF hospitalizations at community-based health systems. METHODS The authors identified HF hospitalizations from 2016 to 2022 in a U.S. database aggregating deidentified electronic health record data from more than 30 health systems. In-hospital and discharge rates of GDMT use were reported for eligible HFrEF patients. Factors associated with inpatient GDMT use and predischarge discontinuation were evaluated with the use of multivariable models. RESULTS A total of 20,387 HF hospitalizations among 13,729 HFrEF patients were identified. Renin-angiotensin system inhibitors, beta-blockers, and mineralocorticoid receptor antagonists were administered during 70%, 86%, and 37% of eligible hospitalizations, respectively. Angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter 2 inhibitors were used in 17% and 8% of eligible hospitalizations, respectively. Discharge GDMT rates were low. Triple/quadruple therapy was administered in 26% of hospitalizations, falling to 14% on discharge. Predischarge GDMT discontinuations were associated with inpatient hypotension, hyperkalemia, and worsening renal function, but 43%-57% had no medical contraindications. In adjusted analyses, use of 3 or more GDMT classes was associated with fewer 90-day all-cause deaths and HF readmissions compared with less comprehensive GDMT. CONCLUSIONS Inpatient GDMT use in a national analysis of HF hospitalizations was lower than reported in quality improvement registries. High discontinuation rates emphasize an unmet need for inpatient and postdischarge strategies to optimize GDMT use.
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Affiliation(s)
- Jimmy Zheng
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Ankeet S Bhatt
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA; Geriatric Research, Education, and Clinical Center, VA Tennessee Valley Healthcare System, Nashville, Tennessee, USA
| | - Kelsey M Flint
- Rocky Mountain Regional VA Medical Center, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, California, USA
| | - Marat Fudim
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA
| | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Mount Sinai, New York, New York, USA; Department of Population Health Science and Policy, Mount Sinai, New York, New York, USA
| | - Jeffrey M Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA
| | - Ryan S K Wi
- Department of Medicine, Albany Medical College, Albany, New York, USA
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA.
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Maron BA, Bortman G, De Marco T, Huston JH, Lang IM, Rosenkranz SH, Vachiéry JL, Tedford RJ. Pulmonary hypertension associated with left heart disease. Eur Respir J 2024:2401344. [PMID: 39209478 DOI: 10.1183/13993003.01344-2024] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2024] [Accepted: 07/11/2024] [Indexed: 09/04/2024]
Abstract
Left heart disease (LHD) is the most common cause of pulmonary hypertension (PH), which may be classified further as isolated post-capillary (ipcPH) or combined post- and pre-capillary PH (cpcPH). The 7th World Symposium on Pulmonary Hypertension PH-LHD task force reviewed newly reported randomised clinical trials and contemplated novel opportunities for improving outcome. Results from major randomised clinical trials reinforced prior recommendations against the use of pulmonary arterial hypertension therapy in PH-LHD outside of clinical trials, and suggested possible harm. Greater focus on phenotyping was viewed as one general strategy by which to ultimately improve clinical outcomes. This is potentially achievable by individualising ipcPH versus cpcPH diagnosis for patients with pulmonary arterial wedge pressure within a diagnostic grey zone (12-18 mmHg), and through a newly developed PH-LHD staging system. In this model, PH accompanies LHD across four stages (A=at risk, B=structural heart disease, C=symptomatic heart disease, D=advanced), with each stage characterised by progression in clinical characteristics, haemodynamics and potential therapeutic strategies. Along these lines, the task force proposed disaggregating PH-LHD to emphasise specific subtypes for which PH prevalence, pathophysiology and treatment are unique. This includes re-interpreting mitral and aortic valve stenosis through a contemporary lens, and focusing on PH within the hypertrophic cardiomyopathy and amyloid cardiomyopathy clinical spectra. Furthermore, appreciating LHD in the profile of PH patients with chronic lung disease and chronic thromboembolic pulmonary disease is essential. However, engaging LHD patients in clinical research more broadly is likely to require novel methodologies such as pragmatic trials and may benefit from next-generation analytics to interpret results.
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Affiliation(s)
- Bradley A Maron
- Department of Medicine, University of Maryland School of Medicine, Baltimore, MD, USA
- The University of Maryland - Institute for Health Computing, Bethesda, MD, USA
| | - Guillermo Bortman
- Transplant Unit, Heart Failure and PH Program, Sanatorio Trinidad Mitre and Sanatorio Trinidad Palermo, Buenos Aires, Argentina
| | - Teresa De Marco
- Division of Cardiology, Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | | | - Irene M Lang
- Medical University of Vienna AUSTRIA Center of Cardiovascular Medicine, Vienna, Austria
| | - Stephan H Rosenkranz
- Department of Cardiology and Cologne Cardiovascular Research Center (CCRC), Faculty of Medicine and University Hospital Cologne, University of Cologne, Cologne, Germany
| | - Jean-Luc Vachiéry
- HUB (Hopital Universitaire de Bruxelles) Erasme, Free University of Brussels, Brussels, Belgium
| | - Ryan J Tedford
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
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43
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Anderson LJ. STRONG-HF: It's the Quickstep, Whatever the Rhythm. JACC. HEART FAILURE 2024:S2213-1779(24)00567-5. [PMID: 39243244 DOI: 10.1016/j.jchf.2024.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 07/15/2024] [Indexed: 09/09/2024]
Affiliation(s)
- Lisa J Anderson
- Cardiovascular Clinical Academic Group, St. George's, University of London, London, United Kingdom.
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Matsukawa R, Kabu K, Koga E, Hara A, Kisanuki H, Sada M, Okabe K, Okahara A, Tokutome M, Kawai S, Ogawa K, Matsuura H, Mukai Y. Optimizing Guideline-Directed Medical Therapy During Hospitalization Improves Prognosis in Patients With Worsening Heart Failure Requiring Readmissions. Circ J 2024; 88:1416-1424. [PMID: 39034132 DOI: 10.1253/circj.cj-24-0265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 07/23/2024]
Abstract
BACKGROUND We previously demonstrated that higher simple guideline-directed medical therapy (GDMT) scores (comprising renin-angiotensin system inhibitors, β-blockers, mineralocorticoid antagonists, and sodium-glucose cotransporter 2 inhibitors) at discharge were correlated with improved prognosis in heart failure (HF) patients. HF readmissions are linked to adverse outcomes, emphasizing the need for enhanced optimization of GDMT. METHODS AND RESULTS Using the simple GDMT score, we evaluated the effect of revising and modifying in-hospital GDMT on the prognosis of patients with HF readmissions. In this retrospective analysis of 2,100 HF patients, we concentrated on 1,222 patients with HF with reduced ejection/moderately reduced ejection fraction, excluding patients with HF with preserved ejection fraction, on dialysis, or who died in hospital. A higher current GDMT score was associated with better HF prognosis. Of the 1,222 patients in the study, we analyzed 372 cases of rehospitalization, calculating the simple GDMT scores at admission and discharge. Patients were divided into groups according to score improvement. Multivariate analysis showed a significant association between improved in-hospital simple GDMT score and the composite outcome (HF readmission+all-cause mortality; hazard ratio 0.459; 95% confidence interval 0.257-0.820; P=0.008). Even after propensity score matching to adjust for background, among rehospitalized patients, those with an improved in-hospital simple GDMT score had a better prognosis. CONCLUSIONS Our results highlight the potential of robust interventions and score elevation during hospitalization leading to improved outcomes.
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Affiliation(s)
| | - Keisuke Kabu
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | - Eiichi Koga
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | - Ayano Hara
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | | | - Masashi Sada
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | - Kousuke Okabe
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | - Arihide Okahara
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | - Masaki Tokutome
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | - Shunsuke Kawai
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | - Kiyohiro Ogawa
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
| | | | - Yasushi Mukai
- Department of Cardiology, Japanese Red Cross Fukuoka Hospital
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Geavlete O, Chioncel O. Prognostic impact of heart failure pharmacotherapies in acute heart failure: strong association in mildly reduced ejection fraction. Eur J Prev Cardiol 2024; 31:1361-1362. [PMID: 38711389 DOI: 10.1093/eurjpc/zwae162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 05/02/2024] [Indexed: 05/08/2024]
Affiliation(s)
- Oliviana Geavlete
- Cardiology 1st Department, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Sos Fundeni No. 258, Sector 2, 22328 Bucharest, Romania
- University of Medicine Carol Davila, Bulevardul Eroilor Sanitari 88, Sector 5, 050474 Bucharest, Romania
| | - Ovidiu Chioncel
- Cardiology 1st Department, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Sos Fundeni No. 258, Sector 2, 22328 Bucharest, Romania
- University of Medicine Carol Davila, Bulevardul Eroilor Sanitari 88, Sector 5, 050474 Bucharest, Romania
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Weir MR, Rossignol P, Pitt B, Lund LH, Coats AJS, Filippatos G, Perrin A, Waechter S, Budden J, Kosiborod M, Metra M, Boehm M, Ezekowitz JA, Bayes-Genis A, Mentz RJ, Ponikowski P, Senni M, Castro-Montes E, Nicolau JC, Parkhomenko A, Seferovic P, Cohen-Solal A, Anker SD, Butler J. Patiromer-Facilitated Renin-Angiotensin-Aldosterone System Inhibitor Utilization in Patients with Heart Failure with or without Comorbid Chronic Kidney Disease: Subgroup Analysis of DIAMOND Randomized Trial. Am J Nephrol 2024:1-18. [PMID: 39159624 DOI: 10.1159/000540453] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2024] [Accepted: 07/03/2024] [Indexed: 08/21/2024]
Abstract
INTRODUCTION Renin-angiotensin-aldosterone system inhibitor (RAASi; including mineralocorticoid receptor antagonists [MRAs]) benefits are greatest in patients with heart failure with reduced ejection fraction (HFrEF) and chronic kidney disease (CKD); however, the risk of hyperkalemia (HK) is high. METHODS The DIAMOND trial (NCT03888066) assessed the ability of patiromer to control serum potassium (sK+) in patients with HFrEF with/without CKD. Prior to randomization (double-blind withdrawal, 1:1), patients on patiromer had to achieve ≥50% recommended doses of RAASi and 50 mg/day of MRA with normokalemia during a run-in period. The present analysis assessed the effect of baseline estimated glomerular filtration rate (eGFR) in subgroups of ≥/<60, ≥/<45 (prespecified), and ≥/<30 mL/min/1.73 m2 (added post hoc). RESULTS In total, 81.3, 78.9, and 81.1% of patients with eGFR <60, <45, and <30 mL/min/1.73 m2 at screening achieved RAASi/MRA targets. A greater efficacy of patiromer versus placebo to control sK+ in patients with more advanced CKD was reported (p-interaction ≤ 0.027 for all eGFR subgroups). Greater effects on secondary endpoints were observed with patiromer versus placebo in patients with eGFR <60 and <45 mL/min/1.73 m2. Adverse effects were similar between patiromer and placebo across subgroups. CONCLUSION Patiromer enabled use of RAASi, controlled sK+, and minimized HK risk in patients with HFrEF, with greater effect sizes for most endpoints noted in patient subgroups with lower eGFR. Patiromer was well tolerated by patients in all eGFR subgroups.
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Affiliation(s)
- Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Patrick Rossignol
- INSERM CIC-P 1433, CHRU de Nancy, INSERM U1116, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
- Department of Medical Specialties and Nephrology-Hemodialysis, Princess Grace Hospital, Centre d'Hémodialyse Privé de Monaco, Monaco, Monaco
| | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Lars H Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Solna, Sweden
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gerasimos Filippatos
- School of Medicine, Athens University Hospital Attikon, National and Kapodistrian University of Athens, Haidari, Greece
| | | | | | | | - Mikhail Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili and University, Brescia, Italy
| | - Michael Boehm
- Klinik für Innere Medizin III, Saarland University, Homburg, Germany
| | - Justin A Ezekowitz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Antoni Bayes-Genis
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, CIBERCV, Barcelona, Spain
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII Hospital, University of Milano - Bicocca, Bergamo, Italy
| | - Eliodoro Castro-Montes
- Instituto de Corazon de Queretaro (ICQ), Faculty of Medicine Universidad Autonoma de Queretaro, Santiago de Queretaro, Mexico
| | - Jose Carlos Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
| | | | - Petar Seferovic
- University of Belgrade - Faculty of Medicine, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Alain Cohen-Solal
- Université de Paris, INSERM U942, APHP, Hospital Lariboisiere, Paris, France
| | - Stefan D Anker
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Department of Cardiology (CVK), German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Center for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Javed Butler
- Division of Cardiology, University of Michigan, Ann Arbor, Michigan, USA
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Barnes C, Sharma H, Gamble J, Dawkins S. Management of secondary mitral regurgitation: from drugs to devices. Heart 2024; 110:1099-1106. [PMID: 37607812 PMCID: PMC11347202 DOI: 10.1136/heartjnl-2022-322001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/24/2023] Open
Abstract
Severe secondary mitral regurgitation carries a poor prognosis with one in five patients dying within 12 months of diagnosis. Fortunately, there are now a number of safe and effective therapies available to improve outcomes. Here, we summarise the most up-to-date treatments. Optimal guideline-directed medical therapy is the mainstay therapy and has been shown to reduce the severity of mitral regurgitation in 40-45% of patients. Rapid medication titration protocols reduce heart failure hospitalisation and facilitate earlier referral for device therapy. The pursuit of sinus rhythm in patients with atrial fibrillation has been shown to significantly reduce mitral regurgitation severity, as has the use of cardiac resynchronisation devices in patients who meet guideline-directed criteria. Finally, we highlight the key role of mitral valve intervention, particularly transcatheter edge-to-edge repair (TEER) for management of moderate-severe mitral regurgitation in carefully selected patients with poor left ventricular systolic function, with a number needed to treat of 3.1 to reduce heart failure hospitalisation and 5.9 to reduce all-cause death. To slow the rapid accumulation of morbidity and mortality, we advocate a proactive approach with accelerated medical optimisation, followed by management of atrial fibrillation and cardiac resynchronisation therapy if indicated, then, rapid referral to the Heart Team for consideration of mitral valve intervention in patients with ongoing symptoms and at least moderate-severe mitral regurgitation. Mitral TEER has been shown to be 'reasonably cost-effective' (but not cost-saving) in the UK in selected patients, although TEER remains underused with only 6.5 procedures per million population (pmp) compared with Germany (77 pmp), Switzerland (44 pmp) and the USA (32 pmp).
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Affiliation(s)
- Cara Barnes
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Harish Sharma
- Cardiology, University Hospitals Birmingham NHS Foundation Trust, Birmingham, UK
| | - James Gamble
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
| | - Sam Dawkins
- Oxford Heart Centre, Oxford University Hospitals NHS Foundation Trust, Oxford, UK
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Veltmann C, Duncker D, Doering M, Gummadi S, Robertson M, Wittlinger T, Colley BJ, Perings C, Jonsson O, Bauersachs J, Sanchez R, Maier LS. Therapy duration and improvement of ventricular function in de novo heart failure: the Heart Failure Optimization study. Eur Heart J 2024; 45:2771-2781. [PMID: 38864173 PMCID: PMC11313580 DOI: 10.1093/eurheartj/ehae334] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Revised: 04/30/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND AND AIMS In patients with de novo heart failure with reduced ejection fraction (HFrEF), improvement of left ventricular ejection fraction (LVEF) is expected to occur when started on guideline-recommended medical therapy. However, improvement may not be completed within 90 days. METHODS Patients with HFrEF and LVEF ≤ 35% prescribed a wearable cardioverter-defibrillator between 2017 and 2022 from 68 sites were enrolled, starting with a registry phase for 3 months and followed by a study phase up to 1 year. The primary endpoints were LVEF improvement > 35% between Days 90 and 180 following guideline-recommended medical therapy initiation and the percentage of target dose reached at Days 90 and 180. RESULTS A total of 598 patients with de novo HFrEF [59 years (interquartile range 51-68), 27% female] entered the study phase. During the first 180 days, a significant increase in dosage of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists was observed (P < .001). At Day 90, 46% [95% confidence interval (CI) 41%-50%] of study phase patients had LVEF improvement > 35%; 46% (95% CI 40%-52%) of those with persistently low LVEF at Day 90 had LVEF improvement > 35% by Day 180, increasing the total rate of improvement > 35% to 68% (95% CI 63%-72%). In 392 patients followed for 360 days, improvement > 35% was observed in 77% (95% CI 72%-81%) of the patients. Until Day 90, sustained ventricular tachyarrhythmias were observed in 24 wearable cardioverter-defibrillator carriers (1.8%). After 90 days, no sustained ventricular tachyarrhythmia occurred in wearable cardioverter-defibrillator carriers. CONCLUSIONS Continuous optimization of guideline-recommended medical therapy for at least 180 days in HFrEF is associated with additional LVEF improvement > 35%, allowing for better decision-making regarding preventive implantable cardioverter-defibrillator therapy.
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Affiliation(s)
- Christian Veltmann
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
- Heart Center Bremen, Electrophysiology Bremen, Senator-Wessling-Str. 1, 28277 Bremen, Germany
| | - David Duncker
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Michael Doering
- Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Siva Gummadi
- Department of Cardiology, CVI of Central Florida, Ocala, FL, USA
| | | | - Thomas Wittlinger
- Department of Cardiology, Asklepios Harzklinik Goslar, Goslar, Germany
| | - Byron J Colley
- Department of Cardiology, Jackson Heart Clinic, Jackson, MS, USA
| | - Christian Perings
- Department of Cardiology, Katholisches Klinikum Luenen, Luenen, Germany
| | - Orvar Jonsson
- Department of Cardiology, Sanford Cardiovascular Institute, Sioux Falls, SD, USA
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Robert Sanchez
- Department of Cardiology, HCA Florida Heart Institute, St. Petersburg, FL, USA
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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49
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Greene SJ, Butler J, Fonarow GC. Rapid and Intensive Guideline-Directed Medical Therapy for Heart Failure: 5 Core Principles. Circulation 2024; 150:422-424. [PMID: 39102475 DOI: 10.1161/circulationaha.124.070228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/07/2024]
Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi, Jackson (J.B.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles (G.C.F.)
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50
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Farmakis D, Davison B, Fountoulaki K, Liori S, Chioncel O, Metra M, Celutkiene J, Cohen-Solal A, Damasceno A, Diaz R, Edwards C, Gayat E, Novosadova M, Bistola V, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Voors AA, Mebazaa A, Cotter G, Filippatos G. Rapid Uptitration of Guideline-Directed Medical Therapies in Acute Heart Failure With and Without Atrial Fibrillation. JACC. HEART FAILURE 2024:S2213-1779(24)00510-9. [PMID: 39152986 DOI: 10.1016/j.jchf.2024.06.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Revised: 06/13/2024] [Accepted: 06/18/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Rapid uptitration of guideline-directed medical therapy (GDMT) before and after discharge in hospitalized heart failure (HF) patients is feasible, is safe, and improves outcomes; whether this is also true in patients with coexistent atrial fibrillation/flutter (AF/AFL) is not known. OBJECTIVES This study sought to investigate whether rapid GDMT uptitration before and after discharge for HF is feasible, safe and beneficial in patients with and without AF/AFL. METHODS In this secondary analysis of the STRONG-HF (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies) trial, GDMT uptitration and patient outcomes were analyzed by AF/AFL status and type (permanent, persistent, paroxysmal). RESULTS Among 1,078 patients enrolled in STRONG-HF, 496 (46%) had a history of AF, including 238 assigned to high-intensity care (HIC) and 258 to usual care (UC), and 581 did not have a history of AF/AFL, including 304 assigned to HIC and 277 to UC. By day 90, the average percent optimal dose of neurohormonal inhibitors achieved in the HIC arm was similar in patients with and without AF/AFL, reaching approximately 80% of the optimal dose (average absolute difference between AF/AFL and non-AF/AFL groups: -0.81%; 95% CI: -3.51 to 1.89). All-cause death or HF readmission by day 180 occurred less frequently in the HIC than the UC arm, both in patients with and without AF (adjusted HR: 0.75 [95% CI: 0.48-1.19] in AF vs adjusted HR: 0.50 [95% CI: 0.31-0.79] in non-AF/AFL patients; P for interaction = 0.2107). Adverse event rates were similar in patients with and without AF/AFL. AF/AFL type did not affect either uptitration or patient outcomes. CONCLUSIONS Nearly half of acute HF patients have AF/AFL history. Rapid GDMT uptitration before and early after discharge is feasible, is safe, and may improve outcomes regardless of AF presence or type. (Safety, Tolerability, and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies [STRONG-HF]; NCT03412201).
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Affiliation(s)
- Dimitrios Farmakis
- Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens Medical School, Athens, Greece; Physiology Lab, University of Cyprus Medical School, Nicosia, Cyprus
| | - Beth Davison
- Heart Initiative, Durham, North Carolina, USA; Momentum Research Inc, Durham, North Carolina, USA; Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
| | - Katerina Fountoulaki
- Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens Medical School, Athens, Greece; Physiology Lab, University of Cyprus Medical School, Nicosia, Cyprus
| | - Sotiria Liori
- Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens Medical School, Athens, Greece; Physiology Lab, University of Cyprus Medical School, Nicosia, Cyprus
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C. Iliescu," University of Medicine "Carol Davila," Bucharest, Romania
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Alain Cohen-Solal
- Paris Cite University, INSERM U946, AP-HP, Lariboisiere Hospital, Paris, France
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | | | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942(MASCOT [Cardiovascular MArkers in Stressed COndiTions]), Paris, France
| | | | - Vasiliki Bistola
- Department of Cardiology, Athens University Hospital Attikon, National and Kapodistrian University of Athens Medical School, Athens, Greece; Physiology Lab, University of Cyprus Medical School, Nicosia, Cyprus
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital, Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Koji Takagi
- Momentum Research Inc, Durham, North Carolina, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, University Hospital Federation PROMICE (PRecision medicine for cOMprehensIve care of Critically ill patieEnts), Departments Medico-Universitaires Parabol, Assistance Public - Hopitaux de Paris, Paris, France
| | - Gad Cotter
- Heart Initiative, Durham, North Carolina, USA; Momentum Research Inc, Durham, North Carolina, USA; Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
| | - Gerasimos Filippatos
- Emergency Institute for Cardiovascular Diseases "Prof. C.C. Iliescu," University of Medicine "Carol Davila," Bucharest, Romania.
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