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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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102
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Alkhatib NS, Ramos K, Slack M, Erstad B, Gharaibeh M, Klimecki W, Karnes JH, Sweitzer NK, Abraham I. Ex ante economic evaluation of genetic testing for the ARG389 beta1-adrenergic receptor polymorphism to support bucindolol treatment decisions in Stage III/IV heart failure. EXPERT REVIEW OF PRECISION MEDICINE AND DRUG DEVELOPMENT 2018. [DOI: 10.1080/23808993.2018.1526079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Affiliation(s)
- Nimer S. Alkhatib
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Kenneth Ramos
- Center for Applied Genetics and Genomic Medicine, University of Arizona, Tucson, AZ, USA
- College of Medicine, University of Arizona, Tucson, AZ, USA
| | - Marion Slack
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Brian Erstad
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Mahdi Gharaibeh
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Walter Klimecki
- Department of Pharmacology and Toxicology, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Jason H Karnes
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
| | - Nancy K. Sweitzer
- College of Medicine, University of Arizona, Tucson, AZ, USA
- Sarver Heart Center, University of Arizona College of Medicine, Tucson, AZ, USA
| | - Ivo Abraham
- Center for Health Outcomes and PharmacoEconomic Research, College of Pharmacy, University of Arizona, Tucson, AZ, USA
- Center for Applied Genetics and Genomic Medicine, University of Arizona, Tucson, AZ, USA
- College of Medicine, University of Arizona, Tucson, AZ, USA
- Department of Pharmacy Practice and Science, College of Pharmacy, University of Arizona, Tucson, AZ, USA
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Luzum JA, Peterson E, Li J, She R, Gui H, Liu B, Spertus JA, Pinto YM, Williams LK, Sabbah HN, Lanfear DE. Race and Beta-Blocker Survival Benefit in Patients With Heart Failure: An Investigation of Self-Reported Race and Proportion of African Genetic Ancestry. J Am Heart Assoc 2018; 7:JAHA.117.007956. [PMID: 29739794 PMCID: PMC6015313 DOI: 10.1161/jaha.117.007956] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background It remains unclear whether beta‐blockade is similarly effective in black patients with heart failure and reduced ejection fraction as in white patients, but self‐reported race is a complex social construct with both biological and environmental components. The objective of this study was to compare the reduction in mortality associated with beta‐blocker exposure in heart failure and reduced ejection fraction patients by both self‐reported race and by proportion African genetic ancestry. Methods and Results Insured patients with heart failure and reduced ejection fraction (n=1122) were included in a prospective registry at Henry Ford Health System. This included 575 self‐reported blacks (129 deaths, 22%) and 547 self‐reported whites (126 deaths, 23%) followed for a median 3.0 years. Beta‐blocker exposure (BBexp) was calculated from pharmacy claims, and the proportion of African genetic ancestry was determined from genome‐wide array data. Time‐dependent Cox proportional hazards regression was used to separately test the association of BBexp with all‐cause mortality by self‐reported race or by proportion of African genetic ancestry. Both sets of models were evaluated unadjusted and then adjusted for baseline risk factors and beta‐blocker propensity score. BBexp effect estimates were protective and of similar magnitude both by self‐reported race and by African genetic ancestry (adjusted hazard ratio=0.56 in blacks and adjusted hazard ratio=0.48 in whites). The tests for interactions with BBexp for both self‐reported race and for African genetic ancestry were not statistically significant in any model (P>0.1 for all). Conclusions Among black and white patients with heart failure and reduced ejection fraction, reduction in all‐cause mortality associated with BBexp was similar, regardless of self‐reported race or proportion African genetic ancestry.
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Affiliation(s)
- Jasmine A Luzum
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI
| | - Edward Peterson
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Jia Li
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Ruicong She
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - Hongsheng Gui
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI
| | - Bin Liu
- Department of Public Health Sciences, Henry Ford Health System, Detroit, MI
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/UMKC, Kansas City, MO
| | - Yigal M Pinto
- Department of Cardiology, University of Amsterdam, Amsterdam, The Netherlands
| | - L Keoki Williams
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI
- Department of Internal Medicine, Henry Ford Health System, Detroit, MI
| | - Hani N Sabbah
- Heart and Vascular Institute, Henry Ford Health System, Detroit, MI
| | - David E Lanfear
- Center for Health Policy and Health Services Research, Henry Ford Health System, Detroit, MI
- Heart and Vascular Institute, Henry Ford Health System, Detroit, MI
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104
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Shen L, Jhund PS, Mogensen UM, Køber L, Claggett B, Rogers JK, McMurray JJV. Re-Examination of the BEST Trial Using Composite Outcomes, Including Emergency Department Visits. JACC-HEART FAILURE 2018; 5:591-599. [PMID: 28774394 DOI: 10.1016/j.jchf.2017.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The influence of choice of endpoint on trial size, duration, and interpretation of results was examined in patients with heart failure who were enrolled in BEST (Beta-blocker Evaluation of Survival Trial). BACKGROUND The choice of endpoints in heart failure trials has evolved over the past 3 decades. METHODS In the BEST trial, we used Cox regression analysis to examine the effect of bucindolol on the current standard composite of cardiovascular death or heart failure hospitalization (CVD/HFH) compared with the original primary mortality endpoint and the expanded composite that included emergency department (ED) visits. We also undertook an analysis of recurrent events primarily using the Lin, Wei, Ying, and Yang model. RESULTS Overall, 448 (33%) patients on placebo and 411 (30%) patients on bucindolol died (hazard ratio [HR]: 0.90; 95% confidence interval [CI]: 0.78 to 1.02; p = 0.11). A total of 730 (54%) patients experienced CVD/HFH on placebo and 624 (46%) on bucindolol (HR: 0.80; 95% CI: 0.72 to 0.89; p < 0.001). Adding ED visits increased these numbers to 768 (57%) and 668 (49%), respectively (HR: 0.81; 95% CI: 0.73 to 0.90; p < 0.001). A total of 568 (42%) patients on placebo experienced HFH compared with 476 (35%) patients on bucindolol (HR: 0.78; 95% CI: 0.69 to 0.89; p < 0.001), with a total of 1,333 and 1,124 admissions, respectively. With the same statistical assumptions, using the composite endpoint instead of all-cause mortality would have reduced the trial size by 40% and follow-up duration by 69%. The rate ratio for recurrent events (CVD/HFH) was 0.83 (95% CI: 0.73 to 0.94; p = 0.003). CONCLUSIONS Choice of endpoint has major implications for trial size and duration, as well as interpretation of results. The value of broader composite endpoints and inclusion of recurrent events needs further investigation. (Beta Blocker Evaluation in Survival Trial [BEST]; NCT00000560).
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Affiliation(s)
- Li Shen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Ulrik M Mogensen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
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105
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Kristensen SL, Rørth R, Jhund PS, Shen L, Lee MMY, Petrie MC, Køber L, McMurray JJV. Microvascular complications in diabetes patients with heart failure and reduced ejection fraction-insights from the Beta-blocker Evaluation of Survival Trial. Eur J Heart Fail 2018; 20:1549-1556. [PMID: 29727039 DOI: 10.1002/ejhf.1201] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2018] [Revised: 03/11/2018] [Accepted: 03/26/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS The role of microvascular complications in the risk conferred by diabetes in heart failure with reduced ejection fraction (HFrEF) is unknown. METHODS AND RESULTS We studied 2707 HFrEF patients in the Beta-blocker Evaluation of Survival Trial (BEST), stratified into three groups: no diabetes and diabetes without or with microvascular complications (neuropathy, nephropathy, or retinopathy). The risks of the composite of cardiovascular death or heart failure hospitalization, and all-cause death, were studied using Cox regression analyses adjusted for other prognostic variables. Overall, 964 (36%) patients had diabetes, of which 313 (32%) had microvascular complications. Patients with microvascular complications had more severe symptoms (New York Heart Association class IV 12% vs. 9% diabetes with no complications and 7% no diabetes), and worse quality of life (Minnesota Living with Heart Failure median score 60 vs. 54 and 51 points). In patients with diabetes and complications, the rate of the composite outcome was 50 per 100 person-years of follow-up (compared with 34 and 29 in those with diabetes and no microvascular complications and participants without diabetes, respectively). Compared to patients without diabetes, the adjusted hazard ratio (HR) for the composite outcome was 1.44 [95% confidence interval (CI) 1.22-1.70] and 1.18 (95% CI 1.03-1.35) for patients with diabetes with and without complications, respectively. The risk of all-cause mortality was similarly elevated: adjusted HR 1.42 (95% CI 1.16-1.74) and 1.20 (95% CI 1.01-1.42), respectively. CONCLUSION In HFrEF, diabetes with microvascular complications is associated with worse symptoms and outcomes than diabetes without microvascular complications. Prevention of microvascular complications has the potential to improve HFrEF outcomes.
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Affiliation(s)
- Søren L Kristensen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Rasmus Rørth
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Li Shen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Matthew M Y Lee
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Køber
- Department of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Piccini JP, Connolly SJ, Abraham WT, Healey JS, Steinberg BA, Al-Khalidi HR, Dignacco P, van Veldhuisen DJ, Sauer WH, White M, Wilton SB, Anand IS, Dufton C, Marshall DA, Aleong RG, Davis GW, Clark RL, Emery LL, Bristow MR. A genotype-directed comparative effectiveness trial of Bucindolol and metoprolol succinate for prevention of symptomatic atrial fibrillation/atrial flutter in patients with heart failure: Rationale and design of the GENETIC-AF trial. Am Heart J 2018; 199:51-58. [PMID: 29754666 DOI: 10.1016/j.ahj.2017.12.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2017] [Accepted: 12/01/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Few therapies are available for the safe and effective treatment of atrial fibrillation (AF) in patients with heart failure. Bucindolol is a non-selective beta-blocker with mild vasodilator activity previously found to have accentuated antiarrhythmic effects and increased efficacy for preventing heart failure events in patients homozygous for the major allele of the ADRB1 Arg389Gly polymorphism (ADRB1 Arg389Arg genotype). The safety and efficacy of bucindolol for the prevention of AF or atrial flutter (AFL) in these patients has not been proven in randomized trials. METHODS/DESIGN The Genotype-Directed Comparative Effectiveness Trial of Bucindolol and Metoprolol Succinate for Prevention of Symptomatic Atrial Fibrillation/Atrial Flutter in Patients with Heart Failure (GENETIC-AF) trial is a multicenter, randomized, double-blinded "seamless" phase 2B/3 trial of bucindolol hydrochloride versus metoprolol succinate, for the prevention of symptomatic AF/AFL in patients with reduced ejection fraction heart failure (HFrEF). Patients with pre-existing HFrEF and recent history of symptomatic AF are eligible for enrollment and genotype screening, and if they are ADRB1 Arg389Arg, eligible for randomization. A total of approximately 200 patients will comprise the phase 2B component and if pre-trial assumptions are met, 620 patients will be randomized at approximately 135 sites to form the Phase 3 population. The primary endpoint is the time to recurrence of symptomatic AF/AFL or mortality over a 24-week follow-up period, and the trial will continue until 330 primary endpoints have occurred. CONCLUSIONS GENETIC-AF is the first randomized trial of pharmacogenetic guided rhythm control, and will test the safety and efficacy of bucindolol compared with metoprolol succinate for the prevention of recurrent symptomatic AF/AFL in patients with HFrEF and an ADRB1 Arg389Arg genotype. (ClinicalTrials.govNCT01970501).
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107
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Avila MS, Ayub-Ferreira SM, de Barros Wanderley MR, das Dores Cruz F, Gonçalves Brandão SM, Rigaud VOC, Higuchi-Dos-Santos MH, Hajjar LA, Kalil Filho R, Hoff PM, Sahade M, Ferrari MSM, de Paula Costa RL, Mano MS, Bittencourt Viana Cruz CB, Abduch MC, Lofrano Alves MS, Guimaraes GV, Issa VS, Bittencourt MS, Bocchi EA. Carvedilol for Prevention of Chemotherapy-Related Cardiotoxicity: The CECCY Trial. J Am Coll Cardiol 2018. [PMID: 29540327 DOI: 10.1016/j.jacc.2018.02.049] [Citation(s) in RCA: 300] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Anthracycline (ANT) chemotherapy is associated with cardiotoxicity. Prevention with β-blockers remains controversial. OBJECTIVES This prospective, randomized, double-blind, placebo-controlled study sought to evaluate the role of carvedilol in preventing ANT cardiotoxicity. METHODS The authors randomized 200 patients with HER2-negative breast cancer tumor status and normal left ventricular ejection fraction (LVEF) referred for ANT (240 mg/m2) to receive carvedilol or placebo until chemotherapy completion. The primary endpoint was prevention of a ≥10% reduction in LVEF at 6 months. Secondary outcomes were effects of carvedilol on troponin I, B-type natriuretic peptide, and diastolic dysfunction. RESULTS Primary endpoint occurred in 14 patients (14.5%) in the carvedilol group and 13 patients (13.5%) in the placebo group (p = 1.0). No differences in changes of LVEF or B-type natriuretic peptide were noted between groups. A significant difference existed between groups in troponin I levels over time, with lower levels in the carvedilol group (p = 0.003). Additionally, a lower incidence of diastolic dysfunction was noted in the carvedilol group (p = 0.039). A nonsignificant trend toward a less-pronounced increase in LV end-diastolic diameter during the follow-up was noted in the carvedilol group (44.1 ± 3.64 mm to 45.2 ± 3.2 mm vs. 44.9 ± 3.6 mm to 46.4 ± 4.0 mm; p = 0.057). CONCLUSIONS In this largest clinical trial of β-blockers for prevention of cardiotoxicity under contemporary ANT dosage, the authors noted a 13.5% to 14.5% incidence of cardiotoxicity. In this scenario, carvedilol had no impact on the incidence of early onset of LVEF reduction. However, the use of carvedilol resulted in a significant reduction in troponin levels and diastolic dysfunction. (Carvedilol Effect in Preventing Chemotherapy-Induced Cardiotoxicity [CECCY]; NCT01724450).
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Affiliation(s)
- Mônica Samuel Avila
- Heart Failure Department, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Silvia Moreira Ayub-Ferreira
- Heart Failure Department, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Mauro Rogerio de Barros Wanderley
- Heart Failure Department, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Fatima das Dores Cruz
- Heart Failure Department, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Sara Michelly Gonçalves Brandão
- Heart Failure Department, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vagner Oliveira Carvalho Rigaud
- Heart Failure Department, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | | | - Ludhmila Abrahão Hajjar
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo-Universidade de São Paulo, São Paulo, Brazil
| | - Roberto Kalil Filho
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo-Universidade de São Paulo, São Paulo, Brazil
| | - Paulo Marcelo Hoff
- Instituto do Câncer do Estado de São Paulo-Universidade de São Paulo, São Paulo, Brazil
| | - Marina Sahade
- Instituto do Câncer do Estado de São Paulo-Universidade de São Paulo, São Paulo, Brazil
| | - Marcela S M Ferrari
- Instituto do Câncer do Estado de São Paulo-Universidade de São Paulo, São Paulo, Brazil
| | | | - Max Senna Mano
- Instituto do Câncer do Estado de São Paulo-Universidade de São Paulo, São Paulo, Brazil
| | - Cecilia Beatriz Bittencourt Viana Cruz
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo-Universidade de São Paulo, São Paulo, Brazil
| | - Maria Cristina Abduch
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marco Stephan Lofrano Alves
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Guilherme Veiga Guimaraes
- Heart Failure Department, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Victor Sarli Issa
- Heart Failure Department, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Marcio Sommer Bittencourt
- Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil; Instituto do Câncer do Estado de São Paulo-Universidade de São Paulo, São Paulo, Brazil; Center for Clinical and Epidemiological Research, University Hospital, University of São Paulo, São Paulo, Brazil
| | - Edimar Alcides Bocchi
- Heart Failure Department, Heart Institute (InCor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil.
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108
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Sullivan LT, Randolph T, Merrill P, Jackson LR, Egwim C, Starks MA, Thomas KL. Representation of black patients in randomized clinical trials of heart failure with reduced ejection fraction. Am Heart J 2018; 197:43-52. [PMID: 29447783 DOI: 10.1016/j.ahj.2017.10.025] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2017] [Accepted: 10/30/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Black individuals have a disproportionately higher burden of heart failure with reduced ejection fraction (HFrEF) relative to other racial and ethnic populations. We conducted a systematic review to determine the representation, enrollment trends, and outcomes of black patients in historic and contemporary randomized clinical trials (RCTs) for HFrEF. METHODS We searched PubMed and Embase for RCTs of patients with chronic HFrEF that evaluated therapies that significantly improved clinical outcomes. We extracted trial characteristics and compared them by trial type. Linear regression was used to assess trends in enrollment among HFrEF RCTs over time. RESULTS A total of 25 RCTs, 19 for pharmacotherapies and 6 (n=9,501) for implantable cardioverter defibrillators, were included in this analysis. Among these studies, there were 78,816 patients, 4,640 black (5.9%), and the median black participation per trial was 162 patients. Black race was reported in the manuscript of 14 (56.0%) trials, and outcomes by race were available for 12 (48.0%) trials. Implantable cardiac defibrillator trials enrolled a greater percentage of black patients than pharmacotherapy trials (7.1% vs 5.7%). Overall, patient enrollment among the 25 RCTs increased over time (P = .075); however, the percentage of black patients has decreased (P = .001). Outcomes varied significantly between black and white patients in 6 studies. CONCLUSIONS Black patients are modestly represented among pivotal RCTs of individuals with HFrEF for both pharmacotherapies and implantable cardioverter defibrillators. The current trend for decreasing black representation in trials of HF therapeutics is concerning and must improve to ensure the generalizability for this vulnerable population.
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109
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Choi DJ, Park CS, Park JJ, Lee HY, Kang SM, Yoo BS, Jeon ES, Hong SK, Shin JH, Kim MA, Park DG, Kim EJ, Hong SJ, Kim SY, Kim JJ. Assessment of clinical effect and treatment quality of immediate-release carvedilol-IR versus SLOW release carvedilol-SR in Heart Failure patients (SLOW-HF): study protocol for a randomized controlled trial. Trials 2018; 19:103. [PMID: 29433525 PMCID: PMC5809818 DOI: 10.1186/s13063-018-2470-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Accepted: 01/13/2018] [Indexed: 11/30/2022] Open
Abstract
Background Carvedilol is a non-selective, third-generation beta-blocker and is one of the cornerstones for treatment for patients with heart failure and reduced ejection fraction (HFrEF). However, due to its short half-life, immediate-release carvedilol (IR) needs to be prescribed twice a day. Recently, slow-release carvedilol (SR) has been developed. The aim of this study is to evaluate whether carvedilol-SR is non-inferior to standard carvedilol-IR in terms of its clinical efficacy in patients with HFrEF. Methods/design Patients with stable HFrEF will be randomly assigned in a 1:1 ratio to the carvedilol-SR group (160 patients) and the carvedilol-IR group (160 patients). Patients aged ≥ 20 years, with a left ventricular ejection fraction ≤ 40%, N-terminal pro B-natriuretic peptide (NT-proBNP) ≥ 125 pg/ml or BNP ≥ 35 pg/ml, who are clinically stable and have no evidence of congestion or volume retention, will be eligible. After randomization, patients will be followed up for 6 months. The primary endpoint is the change in NT-proBNP level from baseline to the study end. The secondary endpoints include the proportion of patients with NT-proBNP increment > 10% from baseline, composite of all-cause mortality and readmission, mortality rate, readmission rate, changes in blood pressure, quality of life, and drug compliance. Discussions The SLOW-HF trial is a prospective, randomized, open-label, phase-IV, multicenter study to evaluate the therapeutic efficacy of carvedilol-SR compared to carvedilol-IR in HFrEF patients. If carvedilol-SR proves to be non-inferior to carvedilol-IR, a once-daily prescription of carvedilol may be recommended for patients with HFrEF. Trial registration ClinicalTrials.gov, ID: NCT03209180. Registered on 6 July 2017. Electronic supplementary material The online version of this article (10.1186/s13063-018-2470-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dong-Ju Choi
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Chan Soon Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jin Joo Park
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, South Korea. .,Cardiovascular Center and Division of Cardiology, Department of Internal Medicine, Seoul National University Bundang Hospital, 82 Gumi-ro 173 Beon-gil, Bundang-gu, Gyeonggi-do, 13620, South Korea.
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Hospital, Seoul, South Korea
| | - Seok-Min Kang
- Division of Cardiology, Yonsei University Severance Hospital, Seoul, South Korea
| | - Byung-Su Yoo
- Division of Cardiology, Yonsei University Wonju Severance Christian Hospital, Wonju, South Korea
| | - Eun-Seok Jeon
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Samsung Medical Center, Seoul, South Korea
| | - Seok Keun Hong
- Division or Cardiology, Sejong General Hospital, Bucheon, Gyeonggi-do, South Korea
| | - Joon-Han Shin
- Division of Cardiology, Ajou University Hospital, Suwon, Gyeonggi-do, South Korea
| | - Myung-A Kim
- Department of Internal Medicine, Seoul National University College of Medicine, Seoul National University Boramae Medical Center, Seoul, South Korea
| | - Dae-Gyun Park
- Cardiovascular Center, Hallym University Medical Center, Seoul, South Korea
| | - Eung-Ju Kim
- Division of Cardiology, Korea University Guro Hospital, Seoul, South Korea
| | - Soon-Jun Hong
- Division of Cardiology, Korea University Anam Hospital, Seoul, South Korea
| | - Seok Yeon Kim
- Department of Internal Medicine, Seoul Medical center, Seoul, South Korea
| | - Jae-Joong Kim
- Department of Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, South Korea
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Ayesta A, Martínez-Sellés H, Bayés de Luna A, Martínez-Sellés M. Prediction of sudden death in elderly patients with heart failure. J Geriatr Cardiol 2018; 15:185-192. [PMID: 29662512 PMCID: PMC5895958 DOI: 10.11909/j.issn.1671-5411.2018.02.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2018] [Revised: 02/25/2018] [Accepted: 02/27/2018] [Indexed: 02/06/2023] Open
Abstract
Most heart failure (HF) related mortality is due to sudden cardiac death (SCD) and worsening HF, particularly in the case of reduced ejection fraction. Predicting and preventing SCD is an important goal but most works include no or few patients with advanced age, and the prevention of SCD in elderly patients with HF is still controversial. A recent reduction in the annual rate of SCD has been recently described but it is not clear if this is also true in advanced age patients. Age is associated with SCD, although physicians frequently have the perception that elderly patients with HF die mainly of pump failure, underestimating the importance of SCD. Other clinical variables that have been associated to SCD are symptoms, New York Heart Association functional class, ischemic cause, and comorbidities (chronic obstructive pulmonary disease, renal dysfunction and diabetes). Some test results that should also be considered are left ventricular ejection fraction and diameters, natriuretic peptides, non-sustained ventricular tachycardias and autonomic abnormalities. The combination of all these markers is probably the best option to predict SCD. Different risk scores have been described and, although there are no specific ones for elderly populations, most include age as a risk predictor and some were developed in populations with mean age > 65 years. Finally, it is important to stress that these scores should be able to predict any type of SCD as, although most are due to tachyarrhythmias, bradyarrhythmias also play a role, particularly in the case of the elderly.
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Affiliation(s)
- Ana Ayesta
- Cardiology Department, Hospital Universitario del Sureste, Arganda del Rey, Madrid, Spain
| | | | | | - Manuel Martínez-Sellés
- Universidad Complutense, Madrid, Spain
- Cardiology Department, Hospital General Universitario Gregorio Marañón, CIVERCV, Universidad Europea, Madrid, Spain
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111
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Chanchai R, Kanjanavanit R, Leemasawat K, Amarittakomol A, Topaiboon P, Phrommintikul A. Clinical tolerability of generic versus brand beta blockers in heart failure with reduced left ventricular ejection fraction: a retrospective cohort from heart failure clinic. J Drug Assess 2018; 7:8-13. [PMID: 29379674 PMCID: PMC5769774 DOI: 10.1080/21556660.2018.1423988] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Accepted: 12/23/2017] [Indexed: 12/21/2022] Open
Abstract
Background: Beta-blockers have been shown to decrease mortality and morbidity in heart failure with reduced ejection fraction (HFrEF) patients. However, the side effects are also dose-related, leading to the underdosing. Cost constraint may be one of the limitations of appropriate beta-blocker use; this can be improved with generic drugs. However, the effects in real life practice have not been investigated. Methods and results: This study aimed to compare the efficacy and safety of generic and brand beta-blockers in HFrEF patients. We performed a retrospective cohort analysis in HFrEF patients who received either generic or brand beta-blocker in Chiang Mai Heart Failure Clinic. The primary endpoint was the proportion of patients who received at least 50% target dose of beta-blocker between generic and brand beta-blockers. Adverse events were secondary endpoints. 217 patients (119 and 98 patients received generic and brand beta-blocker, respectively) were enrolled. There were no differences between groups regarding age, gender, etiology of heart failure, New York Heart Association (NYHA) functional class, left ventricular ejection fraction (LVEF), rate of receiving angiotensin converting enzyme inhibitor (ACEI), angiotensin recepter blocker (ARB), or spironolactone. Patients receiving brand beta-blockers had lower resting heart rate at baseline (74.9 and 84.2 bpm, p = .001). Rate of achieved 50% target dose and target daily dose did not differ between groups (40.4 versus 44.5% and 48.0 versus 55.0%, p > .05, respectively). Rate of side effects was not different between groups (32.3 versus 29.5%, p > .05) and the most common side effect was hypotension. Conclusion: This study demonstrated that beta-blocker tolerability was comparable between brand and generic formulations. Generic or brand beta-blockers should be prescribed to HFrEF patients who have no contraindications.
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Affiliation(s)
- Rattanachai Chanchai
- Northern Cardiac Center, Faculty of Medicine, Chiang Mai UniversityChiang MaiThailand
| | - Rungsrit Kanjanavanit
- Northern Cardiac Center, Faculty of Medicine, Chiang Mai UniversityChiang MaiThailand.,Department of Internal Medicine, Faculty of Medicine, Chiang Mai UniversityChiang MaiThailand
| | - Krit Leemasawat
- Northern Cardiac Center, Faculty of Medicine, Chiang Mai UniversityChiang MaiThailand
| | - Anong Amarittakomol
- Northern Cardiac Center, Faculty of Medicine, Chiang Mai UniversityChiang MaiThailand
| | - Paleerat Topaiboon
- Northern Cardiac Center, Faculty of Medicine, Chiang Mai UniversityChiang MaiThailand
| | - Arintaya Phrommintikul
- Northern Cardiac Center, Faculty of Medicine, Chiang Mai UniversityChiang MaiThailand.,Department of Internal Medicine, Faculty of Medicine, Chiang Mai UniversityChiang MaiThailand
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112
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Cleland JGF, Bunting KV, Flather MD, Altman DG, Holmes J, Coats AJS, Manzano L, McMurray JJV, Ruschitzka F, van Veldhuisen DJ, von Lueder TG, Böhm M, Andersson B, Kjekshus J, Packer M, Rigby AS, Rosano G, Wedel H, Hjalmarson Å, Wikstrand J, Kotecha D. Beta-blockers for heart failure with reduced, mid-range, and preserved ejection fraction: an individual patient-level analysis of double-blind randomized trials. Eur Heart J 2018; 39:26-35. [PMID: 29040525 PMCID: PMC5837435 DOI: 10.1093/eurheartj/ehx564] [Citation(s) in RCA: 406] [Impact Index Per Article: 67.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2017] [Revised: 08/17/2017] [Accepted: 09/17/2017] [Indexed: 12/15/2022] Open
Abstract
Aims Recent guidelines recommend that patients with heart failure and left ventricular ejection fraction (LVEF) 40-49% should be managed similar to LVEF ≥ 50%. We investigated the effect of beta-blockers according to LVEF in double-blind, randomized, placebo-controlled trials. Methods and results Individual patient data meta-analysis of 11 trials, stratified by baseline LVEF and heart rhythm (Clinicaltrials.gov: NCT0083244; PROSPERO: CRD42014010012). Primary outcomes were all-cause mortality and cardiovascular death over 1.3 years median follow-up, with an intention-to-treat analysis. For 14 262 patients in sinus rhythm, median LVEF was 27% (interquartile range 21-33%), including 575 patients with LVEF 40-49% and 244 ≥ 50%. Beta-blockers reduced all-cause and cardiovascular mortality compared to placebo in sinus rhythm, an effect that was consistent across LVEF strata, except for those in the small subgroup with LVEF ≥ 50%. For LVEF 40-49%, death occurred in 21/292 [7.2%] randomized to beta-blockers compared to 35/283 [12.4%] with placebo; adjusted hazard ratio (HR) 0.59 [95% confidence interval (CI) 0.34-1.03]. Cardiovascular death occurred in 13/292 [4.5%] with beta-blockers and 26/283 [9.2%] with placebo; adjusted HR 0.48 (95% CI 0.24-0.97). Over a median of 1.0 years following randomization (n = 4601), LVEF increased with beta-blockers in all groups in sinus rhythm except LVEF ≥50%. For patients in atrial fibrillation at baseline (n = 3050), beta-blockers increased LVEF when < 50% at baseline, but did not improve prognosis. Conclusion Beta-blockers improve LVEF and prognosis for patients with heart failure in sinus rhythm with a reduced LVEF. The data are most robust for LVEF < 40%, but similar benefit was observed in the subgroup of patients with LVEF 40-49%.
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Affiliation(s)
- John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Karina V Bunting
- Institute of Cardiovascular Sciences, University of Birmingham, Vincent Drive, Birmingham B15 2TT, UK
| | - Marcus D Flather
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Norwich NR4 7TJ, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX1 2JD, UK
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford OX1 2JD, UK
| | - Andrew J S Coats
- San Raffaele Pisana Scientific Institute, Via della Pisana, 235, 00163 Rome, Italy
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá (IRYCIS), Plaza de San Diego, 28801 Alcalá de Henares, Madrid, Spain
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Frank Ruschitzka
- Klinik für Kardiologie, UniversitätsSpital Zürich, Universitätstrasse 8, 8006 Zürich, Switzerland
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, PO box 30.001 9700 RB Groningen, The Netherlands
| | - Thomas G von Lueder
- Department of Cardiology, Oslo University Hospital, PO Box 4950 Nydalen N-0424 Oslo, Norway
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Michael Böhm
- Kardiologie, Angiologie und internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrberger Str. 100, 66421 Homburg/Saar, Germany
| | - Bert Andersson
- Department of Cardiology, Sahlgrenska University Hospital and Gothenburg University, Blå stråket 5, 413 45 Gothenburg, Sweden
| | - John Kjekshus
- Rikshospitalet University Hospital and Faculty of Medicine, University of Oslo, Problemveien 7, 0315 Oslo, Norway
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, 621 Hall St, Dallas TX 75226, USA
| | - Alan S Rigby
- Hull York Medical School, Faculty of Health Sciences, University of Hull, Kingston-upon-Hull, HU6 7RX, UK
| | - Giuseppe Rosano
- Cardiovascular and Cell Science Institute, St George’s University of London, SW17 0RE, UK
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Roma, Italy
| | - Hans Wedel
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Box 100, S-405 30 Gothenburg, Sweden
| | - Åke Hjalmarson
- Department of Cardiology, Sahlgrenska University Hospital and Gothenburg University, Blå stråket 5, 413 45 Gothenburg, Sweden
| | - John Wikstrand
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Bruna Stråket 16, 413 45 Gothenburg, Sweden
| | - Dipak Kotecha
- Institute of Cardiovascular Sciences, University of Birmingham, Vincent Drive, Birmingham B15 2TT, UK
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, 99 Commercial Road, Melbourne, Victoria 3004, Australia
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113
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Leitao Filho FS, Alotaibi NM, Yamasaki K, Ngan DA, Sin DD. The role of beta-blockers in the management of chronic obstructive pulmonary disease. Expert Rev Respir Med 2017; 12:125-135. [DOI: 10.1080/17476348.2018.1419869] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Fernando Sergio Leitao Filho
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Nawaf M. Alotaibi
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
- Division of Pulmonary Medicine, Department of Medicine, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Kei Yamasaki
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - David A. Ngan
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Don D. Sin
- Centre for Heart Lung Innovation, St. Paul´s Hospital, & Department of Medicine, University of British Columbia, Vancouver, BC, Canada
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114
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Abstract
The Centers for Diseases Control and Prevention estimates that 5.7 million adults in the United States suffer from heart failure and 1 in 9 deaths in 2009 cited heart failure as a contributing cause. Almost 50% of patients who are diagnosed with heart failure die within 5 years of diagnosis. Cardiovascular disease is a public health burden. The prognosis of patients with heart failure has improved significantly. However, the risk for death remains high. Managing sudden death risk and intervening appropriately with primary or secondary prevention strategies are of paramount importance.
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Affiliation(s)
- Basil Saour
- Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, 420 E Superior Street, Chicago, IL 60611, USA
| | - Bryan Smith
- Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, 420 E Superior Street, Chicago, IL 60611, USA
| | - Clyde W Yancy
- Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, 420 E Superior Street, Chicago, IL 60611, USA.
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115
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Carnethon MR, Pu J, Howard G, Albert MA, Anderson CAM, Bertoni AG, Mujahid MS, Palaniappan L, Taylor HA, Willis M, Yancy CW. Cardiovascular Health in African Americans: A Scientific Statement From the American Heart Association. Circulation 2017; 136:e393-e423. [PMID: 29061565 DOI: 10.1161/cir.0000000000000534] [Citation(s) in RCA: 691] [Impact Index Per Article: 98.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE Population-wide reductions in cardiovascular disease incidence and mortality have not been shared equally by African Americans. The burden of cardiovascular disease in the African American community remains high and is a primary cause of disparities in life expectancy between African Americans and whites. The objectives of the present scientific statement are to describe cardiovascular health in African Americans and to highlight unique considerations for disease prevention and management. METHOD The primary sources of information were identified with PubMed/Medline and online sources from the Centers for Disease Control and Prevention. RESULTS The higher prevalence of traditional cardiovascular risk factors (eg, hypertension, diabetes mellitus, obesity, and atherosclerotic cardiovascular risk) underlies the relatively earlier age of onset of cardiovascular diseases among African Americans. Hypertension in particular is highly prevalent among African Americans and contributes directly to the notable disparities in stroke, heart failure, and peripheral artery disease among African Americans. Despite the availability of effective pharmacotherapies and indications for some tailored pharmacotherapies for African Americans (eg, heart failure medications), disease management is less effective among African Americans, yielding higher mortality. Explanations for these persistent disparities in cardiovascular disease are multifactorial and span from the individual level to the social environment. CONCLUSIONS The strategies needed to promote equity in the cardiovascular health of African Americans require input from a broad set of stakeholders, including clinicians and researchers from across multiple disciplines.
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116
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Gender and racial differences in surgical outcomes among adult patients with acute heart failure. Heart Lung 2017; 47:47-53. [PMID: 29066115 DOI: 10.1016/j.hrtlng.2017.09.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2017] [Revised: 09/23/2017] [Accepted: 09/27/2017] [Indexed: 12/24/2022]
Abstract
BACKGROUND Approximately three million U.S. adult women have heart failure (HF), increasing their risk of adverse perioperative outcomes. While gender and racial differences are reported in surgical outcomes, less is known about 30-day perioperative outcomes in HF patients. OBJECTIVES To characterize and compare gender and racial differences in 30-day perioperative outcomes in adults with new or acute/worsening HF. METHODS The 2012-2013 American College of Surgeons National Surgical Quality Improvement Program database of surgical patients (n = 9458) with HF was analyzed. Logistic regression was used to adjust for gender and racial differences in baseline covariates. RESULTS No gender difference in mortality (odds ratio = 0.922, 95% confidence interval = 0.0792-1.073, p = 0.294) was noted. Whites were more likely than Blacks to die 30 days after surgery (14% vs 9%, p < 0.001); after adjustment, Blacks were more likely to experience complications and be readmitted compared to Whites. CONCLUSIONS There was no gender difference in mortality. White patients with HF were more likely to die after surgery than Black patients.
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117
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Abstract
PURPOSE OF REVIEW We explore the pharmacogenomics of the beta-blocker bucindolol by discussing relevant beta-1 adrenergic receptor (ADRB1) polymorphisms and recent beta-blocker studies. Through this, we will understand how bucindolol may help patients with atrial fibrillation and heart failure with reduced ejection fraction (AF-HFrEF), which carries poor prognosis. RECENT FINDINGS Retrospective study of the Heart Failure: A Controlled Trial Investigating Outcomes of Exercise Training trial revealed the interaction between the optimal beta-blocker dose and the ADRB1 Arg389 genotype for HFrEF clinical outcomes. Further, a combinatorial genotype analysis in the Beta-Blocker Evaluation of Survival Trial showed that the Arg389Arg genotype, but not the Gly carrier, was associated with 40% lower mortality risk with bucindolol. Finally, the AF-HFrEF subgroup with the ADRB1 Arg389Arg genotype had greater heart rate reduction and suggestion for mortality benefit. Therapeutic response to beta-blockers varies by beta-blocker mechanism, ADRB1 Arg389 genotype, and clinical setting (AF, HFrEF, AF-HFrEF). The ongoing trial A Genotype-Directed Comparative Effectiveness Trial of Bucindolol and Toprol-XL for Prevention of Symptomatic Atrial Fibrillation/Atrial Flutter in Patients with Heart Failure prospectively identifies AF-HFrEF patients with favorable genotype for bucindolol to prevent AF recurrence.
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Affiliation(s)
- Kishan S Parikh
- Duke Clinical Research Institute, Durham, NC, USA. .,Duke University Medical Center, DUMC 3428, Durham, NC, 27710, USA.
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118
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Docherty KF, Campbell RT, Jhund PS, Petrie MC, McMurray JJV. How robust are clinical trials in heart failure? Eur Heart J 2017; 38:338-345. [PMID: 27742808 DOI: 10.1093/eurheartj/ehw427] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2016] [Accepted: 06/25/2016] [Indexed: 11/14/2022] Open
Abstract
Aims Guidelines for the management of chronic heart failure (CHF) cite the results of randomized controlled trials (RCTs) to support treatment recommendations. The significance of an observed treatment-effect relies on the use of a boundary P-value, most commonly P < 0.05. There is concern about relying on arbitrary threshold P-values to report results as 'statistically significant'. The 'fragility index' (FI) has been proposed as an additional measure of the robustness of trial findings. FI is the minimum number of events needing to change from a non-event to an event in order to render a significant result non-significant. We calculated the FI to examine the robustness of statistically significant RCTs in CHF. Methods and results Two reviewers extracted data from RCTs supporting treatment recommendations in CHF guidelines. Twenty-five eligible trials were identified with a median sample size of 2331 patients (range 129-8399) and a median number of primary endpoints of 688.5 (range 88-2031). For the primary endpoint (analysed for 20 trials), the median FI was 26 (range 0-118). The FI was ≤10 in 7 (35%) of these 20 trials, and in 4 (20%) trials the number of patients lost to follow-up in the treatment group exceeded the FI. Conclusion The results of some large RCTs in CHF hinge on a small number of events. The FI offers an additional, easy to understand metric, which augments the standard reporting of boundary P-values for statistical significance. The FI helps in the interpretation of the robustness of the results of RCTs.
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Affiliation(s)
| | - Ross T Campbell
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - Pardeep S Jhund
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - Mark C Petrie
- Golden Jubilee National Hospital, Glasgow G81 4DY, UK
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
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119
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The Initial Evaluation and Management of a Patient with Heart Failure. Curr Cardiol Rep 2017; 19:103. [PMID: 28879633 DOI: 10.1007/s11886-017-0900-8] [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: 10/18/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to summarize and discuss a thorough and effective manner in the evaluation of the patient with heart failure. RECENT FINDINGS Heart failure is a prevalent disease worldwide and while the diagnosis of heart failure has remained relatively unchanged via a careful history and physical examination, identification of the etiology of the heart failure and treatment has made significant advances. Mechanical circulatory support (MCS), neprilysin inhibitors, and chronic resynchronization therapy (CRT) are just some of the relatively recent therapies afforded to assist heart failure patients. Heart failure is a complicated, multifactorial diagnosis that requires a careful history and physical for diagnosis with the support of laboratory tests. While the prognosis for heart failure patients remains poor in comparison to other cardiovascular disease and even certain cancers, new advancements in therapy have shown survival and quality of life improvement.
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120
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Griffin EA, Wonderling D, Ludman AJ, Al-Mohammad A, Cowie MR, Hardman SMC, McMurray JJV, Kendall J, Mitchell P, Shote A, Dworzynski K, Mant J. Cost-Effectiveness Analysis of Natriuretic Peptide Testing and Specialist Management in Patients with Suspected Acute Heart Failure. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2017; 20:1025-1033. [PMID: 28964433 DOI: 10.1016/j.jval.2017.05.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/04/2015] [Revised: 02/16/2017] [Accepted: 05/11/2017] [Indexed: 06/07/2023]
Abstract
OBJECTIVES To determine the cost-effectiveness of natriuretic peptide (NP) testing and specialist outreach in patients with acute heart failure (AHF) residing off the cardiology ward. METHODS We used a Markov model to estimate costs and quality-adjusted life-years (QALYs) for patients presenting to hospital with suspected AHF. We examined diagnostic workup with and without the NP test in suspected new cases, and we examined the impact of specialist heart failure outreach in all suspected cases. Inputs for the model were derived from systematic reviews, the UK national heart failure audit, randomized controlled trials, expert consensus from a National Institute for Health and Care Excellence guideline development group, and a national online survey. The main benefit from specialist care (cardiology ward and specialist outreach) was the increased likelihood of discharge on disease-modifying drugs for people with left ventricular systolic dysfunction, which improve mortality and reduce re-admissions due to worsened heart failure (associated with lower utility). Costs included diagnostic investigations, admissions, pharmacological therapy, and follow-up heart failure care. RESULTS NP testing and specialist outreach are both higher cost, higher QALY, cost-effective strategies (incremental cost-effectiveness ratios of £11,656 and £2,883 per QALY gained, respectively). Combining NP and specialist outreach is the most cost-effective strategy. This result was robust to both univariate deterministic and probabilistic sensitivity analyses. CONCLUSIONS NP testing for the diagnostic workup of new suspected AHF is cost-effective. The use of specialist heart failure outreach for inpatients with AHF residing off the cardiology ward is cost-effective. Both interventions will help improve outcomes for this high-risk group.
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Affiliation(s)
- Edward A Griffin
- National Clinical Guideline Centre, Royal College of Physicians, London, UK.
| | - David Wonderling
- National Clinical Guideline Centre, Royal College of Physicians, London, UK
| | | | | | - Martin R Cowie
- Imperial College Healthcare NHS Foundation Trust (Royal Brompton Hospital), London, UK
| | | | - John J V McMurray
- Institute of Cardiovascular Medical Sciences, British Heart Foundation Glasgow Cardiovascular Research Centre, Glasgow, UK
| | - Jason Kendall
- Emergency Department, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Polly Mitchell
- National Institute for Cardiovascular Outcomes Research, UCL Institute of Cardiovascular Science, London, UK
| | - Aminat Shote
- National Institute for Cardiovascular Outcomes Research, UCL Institute of Cardiovascular Science, London, UK
| | | | - Jonathan Mant
- Primary Care Unit, Department of Public Health and Primary Care, University of Cambridge, Cambridge, UK
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121
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Mechanisms contributing to cardiac remodelling. Clin Sci (Lond) 2017; 131:2319-2345. [PMID: 28842527 DOI: 10.1042/cs20171167] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2017] [Revised: 07/26/2017] [Accepted: 07/31/2017] [Indexed: 12/14/2022]
Abstract
Cardiac remodelling is classified as physiological (in response to growth, exercise and pregnancy) or pathological (in response to inflammation, ischaemia, ischaemia/reperfusion (I/R) injury, biomechanical stress, excess neurohormonal activation and excess afterload). Physiological remodelling of the heart is characterized by a fine-tuned and orchestrated process of beneficial adaptations. Pathological cardiac remodelling is the process of structural and functional changes in the left ventricle (LV) in response to internal or external cardiovascular damage or influence by pathogenic risk factors, and is a precursor of clinical heart failure (HF). Pathological remodelling is associated with fibrosis, inflammation and cellular dysfunction (e.g. abnormal cardiomyocyte/non-cardiomyocyte interactions, oxidative stress, endoplasmic reticulum (ER) stress, autophagy alterations, impairment of metabolism and signalling pathways), leading to HF. This review describes the key molecular and cellular responses involved in pathological cardiac remodelling.
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122
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Achieving a Maximally Tolerated β-Blocker Dose in Heart Failure Patients: Is There Room for Improvement? J Am Coll Cardiol 2017; 69:2542-2550. [PMID: 28521892 DOI: 10.1016/j.jacc.2017.03.563] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2017] [Revised: 03/07/2017] [Accepted: 03/10/2017] [Indexed: 02/07/2023]
Abstract
Heart failure (HF) is associated with significant morbidity and mortality. Although initially thought to be harmful in HF, beta-adrenergic blockers (β-blockers) have consistently been shown to reduce mortality and HF hospitalization in chronic HF with reduced ejection fraction. Proposed mechanisms include neurohormonal blockade and heart rate reduction. A new therapeutic agent now exists to target further heart rate lowering in patients who have been stable on a "maximally tolerated β-blocker dose," but this definition and how to achieve it are incompletely understood. In this review, the authors summarize published reports on the mechanisms by which β-blockers improve clinical outcomes. The authors describe differences in doses achieved in landmark clinical trials and those observed in routine clinical practice. They further discuss reasons for intolerance and the evidence behind using β-blocker dose and heart rate as therapeutic targets. Finally, the authors offer recommendations for clinicians actively initiating and up-titrating β-blockers that may aid in achieving maximally tolerated doses.
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123
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Shen L, Jhund PS, Petrie MC, Claggett BL, Barlera S, Cleland JGF, Dargie HJ, Granger CB, Kjekshus J, Køber L, Latini R, Maggioni AP, Packer M, Pitt B, Solomon SD, Swedberg K, Tavazzi L, Wikstrand J, Zannad F, Zile MR, McMurray JJV. Declining Risk of Sudden Death in Heart Failure. N Engl J Med 2017; 377:41-51. [PMID: 28679089 DOI: 10.1056/nejmoa1609758] [Citation(s) in RCA: 341] [Impact Index Per Article: 48.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND The risk of sudden death has changed over time among patients with symptomatic heart failure and reduced ejection fraction with the sequential introduction of medications including angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers, beta-blockers, and mineralocorticoid-receptor antagonists. We sought to examine this trend in detail. METHODS We analyzed data from 40,195 patients who had heart failure with reduced ejection fraction and were enrolled in any of 12 clinical trials spanning the period from 1995 through 2014. Patients who had an implantable cardioverter-defibrillator at the time of trial enrollment were excluded. Weighted multivariable regression was used to examine trends in rates of sudden death over time. Adjusted hazard ratios for sudden death in each trial group were calculated with the use of Cox regression models. The cumulative incidence rates of sudden death were assessed at different time points after randomization and according to the length of time between the diagnosis of heart failure and randomization. RESULTS Sudden death was reported in 3583 patients. Such patients were older and were more often male, with an ischemic cause of heart failure and worse cardiac function, than those in whom sudden death did not occur. There was a 44% decline in the rate of sudden death across the trials (P=0.03). The cumulative incidence of sudden death at 90 days after randomization was 2.4% in the earliest trial and 1.0% in the most recent trial. The rate of sudden death was not higher among patients with a recent diagnosis of heart failure than among those with a longer-standing diagnosis. CONCLUSIONS Rates of sudden death declined substantially over time among ambulatory patients with heart failure with reduced ejection fraction who were enrolled in clinical trials, a finding that is consistent with a cumulative benefit of evidence-based medications on this cause of death. (Funded by the China Scholarship Council and the University of Glasgow.).
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Affiliation(s)
- Li Shen
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Pardeep S Jhund
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Mark C Petrie
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Brian L Claggett
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Simona Barlera
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - John G F Cleland
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Henry J Dargie
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Christopher B Granger
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - John Kjekshus
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Lars Køber
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Roberto Latini
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Aldo P Maggioni
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Milton Packer
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Bertram Pitt
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Scott D Solomon
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Karl Swedberg
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Luigi Tavazzi
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - John Wikstrand
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Faiez Zannad
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - Michael R Zile
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
| | - John J V McMurray
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences (L.S., P.S.J., M.C.P., J.J.V.M.), and Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.G.F.C.), University of Glasgow, the Department of Cardiology, Golden Jubilee National Hospital (M.C.P.), and the Cardiology Department, Glasgow Royal Infirmary (H.J.D.), Glasgow, and the National Heart and Lung Institute, Imperial College London, London (J.G.F.C.) - all in the United Kingdom; the Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston (B.L.C., S.D.S.); the Department of Cardiovascular Research, Istituto di Ricovero e Cura a Carattere Scientifico-Istituto di Ricerche Farmacologiche Mario Negri, Milan (S.B., R.L.), Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence (A.P.M.), and Maria Cecilia Hospital, Gruppo Villa Maria Care and Research, Ettore Sansavini Health Science Foundation, Cotignola (L.T.) - all in Italy; Duke Clinical Research Institute, Duke University, Durham, NC (C.B.G.); Rikshospitalet University Hospital, Oslo (J.K.); the Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen (L.K.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas (M.P.); the Department of Medicine, University of Michigan, Ann Arbor (B.P.); the Center for Person-Centered Care (K.S.) and Sahlgrenska Academy (J.W.), University of Gothenburg, Gothenburg, Sweden; INSERM Centre d'Investigation Clinique 1433, Université de Lorraine and Centre Hospitalier Universitaire, Nancy, France (F.Z.); and the Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston (M.R.Z.)
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Campbell RT, Willox GP, Jhund PS, Hawkins NM, Huang F, Petrie MC, McMurray JJV. Reporting of Lost to Follow-Up and Treatment Discontinuation in Pharmacotherapy and Device Trials in Chronic Heart Failure: A Systematic Review. Circ Heart Fail 2017; 9:CIRCHEARTFAILURE.115.002842. [PMID: 27162229 DOI: 10.1161/circheartfailure.115.002842] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2015] [Accepted: 03/18/2016] [Indexed: 12/21/2022]
Abstract
BACKGROUND Premature treatment discontinuation and loss to follow-up (LTFU) with unknown outcomes leave uncertainty about the true efficacy and safety of a treatment and a lack of confidence in the results of any trial. We reviewed the extent of (and trends over time in) reporting LTFU and treatment discontinuation in large studies in chronic heart failure published since 1990. METHODS AND RESULTS Online databases were systematically reviewed to identify randomized controlled clinical trials (RCTs) in chronic heart failure with >400 participants and utilizing all-cause mortality as a component of the primary or secondary end point. Assessments were made of documentation of treatment discontinuation, LTFU, inclusion of and completeness of a Consolidated Standards Of Reporting Trials (CONSORT) diagram, and whether LTFU was differentiated from withdrawal of consent. Sixty-eight trials were identified, with >154 000 participants. Reasons for treatment discontinuation in pharmacotherapy trials were infrequently reported (35%), particularly in a CONSORT diagram (20%). Eighty-three percent of trials reported LTFU, although only 34% of these differentiated LTFU for vital status from withdrawal of consent. Use of a CONSORT diagram increased over time, although reporting of LTFU in the CONSORT diagram remained low overall at 35%. CONCLUSIONS Participant flow through RCTs in chronic heart failure has not been uniformly reported, and the use of a complete CONSORT diagram has been low, although it seems to be improving. All study participants should be accounted for within a CONSORT diagram in any RCT to enable the practicing cardiologist to interpret how the results should influence his/her clinical practice.
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Affiliation(s)
- Ross T Campbell
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (R.T.C., G.P.W., P.S.J., M.C.P., J.J.V.M.); and Division of Cardiology (N.M.H.) and Facutly of Medicine (F.H.), University of British Columbia, Vancouver, Canada
| | - Gage P Willox
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (R.T.C., G.P.W., P.S.J., M.C.P., J.J.V.M.); and Division of Cardiology (N.M.H.) and Facutly of Medicine (F.H.), University of British Columbia, Vancouver, Canada
| | - Pardeep S Jhund
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (R.T.C., G.P.W., P.S.J., M.C.P., J.J.V.M.); and Division of Cardiology (N.M.H.) and Facutly of Medicine (F.H.), University of British Columbia, Vancouver, Canada
| | - Nathaniel M Hawkins
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (R.T.C., G.P.W., P.S.J., M.C.P., J.J.V.M.); and Division of Cardiology (N.M.H.) and Facutly of Medicine (F.H.), University of British Columbia, Vancouver, Canada
| | - Flora Huang
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (R.T.C., G.P.W., P.S.J., M.C.P., J.J.V.M.); and Division of Cardiology (N.M.H.) and Facutly of Medicine (F.H.), University of British Columbia, Vancouver, Canada
| | - Mark C Petrie
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (R.T.C., G.P.W., P.S.J., M.C.P., J.J.V.M.); and Division of Cardiology (N.M.H.) and Facutly of Medicine (F.H.), University of British Columbia, Vancouver, Canada
| | - John J V McMurray
- From the British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom (R.T.C., G.P.W., P.S.J., M.C.P., J.J.V.M.); and Division of Cardiology (N.M.H.) and Facutly of Medicine (F.H.), University of British Columbia, Vancouver, Canada.
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Kotecha D, Flather MD, Altman DG, Holmes J, Rosano G, Wikstrand J, Packer M, Coats AJS, Manzano L, Böhm M, van Veldhuisen DJ, Andersson B, Wedel H, von Lueder TG, Rigby AS, Hjalmarson Å, Kjekshus J, Cleland JGF. Heart Rate and Rhythm and the Benefit of Beta-Blockers in Patients With Heart Failure. J Am Coll Cardiol 2017; 69:2885-2896. [PMID: 28467883 DOI: 10.1016/j.jacc.2017.04.001] [Citation(s) in RCA: 179] [Impact Index Per Article: 25.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 03/31/2017] [Accepted: 04/02/2017] [Indexed: 01/08/2023]
Abstract
BACKGROUND The relationship between mortality and heart rate remains unclear for patients with heart failure with reduced ejection fraction in either sinus rhythm or atrial fibrillation (AF). OBJECTIVES This analysis explored the prognostic importance of heart rate in patients with heart failure with reduced ejection fraction in randomized controlled trials comparing beta-blockers and placebo. METHODS The Beta-Blockers in Heart Failure Collaborative Group performed a meta-analysis of harmonized individual patient data from 11 double-blind randomized controlled trials. The primary outcome was all-cause mortality, analyzed with Cox proportional hazard ratios (HR) modeling heart rate measured at baseline and approximately 6 months post-randomization. RESULTS A higher heart rate at baseline was associated with greater all-cause mortality for patients in sinus rhythm (n = 14,166; adjusted HR: 1.11 per 10 beats/min; 95% confidence interval [CI]: 1.07 to 1.15; p < 0.0001) but not in AF (n = 3,034; HR: 1.03 per 10 beats/min; 95% CI: 0.97 to 1.08; p = 0.38). Beta-blockers reduced ventricular rate by 12 beats/min in both sinus rhythm and AF. Mortality was lower for patients in sinus rhythm randomized to beta-blockers (HR: 0.73 vs. placebo; 95% CI: 0.67 to 0.79; p < 0.001), regardless of baseline heart rate (interaction p = 0.35). Beta-blockers had no effect on mortality in patients with AF (HR: 0.96, 95% CI: 0.81 to 1.12; p = 0.58) at any heart rate (interaction p = 0.48). A lower achieved resting heart rate, irrespective of treatment, was associated with better prognosis only for patients in sinus rhythm (HR: 1.16 per 10 beats/min increase, 95% CI: 1.11 to 1.22; p < 0.0001). CONCLUSIONS Regardless of pre-treatment heart rate, beta-blockers reduce mortality in patients with heart failure with reduced ejection fraction in sinus rhythm. Achieving a lower heart rate is associated with better prognosis, but only for those in sinus rhythm.
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Affiliation(s)
- Dipak Kotecha
- University of Birmingham Institute of Cardiovascular Sciences, Birmingham, United Kingdom; Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia
| | - Marcus D Flather
- Norwich Medical School, University of East Anglia, Norwich, United Kingdom
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Jane Holmes
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology and Musculoskeletal Sciences, University of Oxford, Oxford, United Kingdom
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele Pisana, Rome, Italy; Cardiovascular and Cell Science Institute, St. George's University of London, London, United Kingdom
| | - John Wikstrand
- Wallenberg Laboratory for Cardiovascular Research, Sahlgrenska Academy, Gothenburg University, Gothenburg, Sweden
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Andrew J S Coats
- Monash University, Melbourne, Victoria, Australia; University of Warwick, Warwick, United Kingdom
| | - Luis Manzano
- Internal Medicine Department, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, Madrid, Spain
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Homburg/Saar, Germany
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | - Bert Andersson
- Department of Cardiology, Sahlgrenska University Hospital and Gothenburg University, Gothenburg, Sweden
| | - Hans Wedel
- Health Metrics, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Thomas G von Lueder
- Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Victoria, Australia; Department of Cardiology, Oslo University Hospital, Oslo, Norway
| | - Alan S Rigby
- Academic Cardiology, Castle Hill Hospital, Kingston upon Hull, United Kingdom
| | - Åke Hjalmarson
- Department of Cardiology, Sahlgrenska University Hospital and Gothenburg University, Gothenburg, Sweden
| | - John Kjekshus
- Rikshospitalet University Hospital and Faculty of Medicine, University of Oslo, Oslo, Norway
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, United Kingdom.
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Abstract
INTRODUCTION A dysregulated sympathetic nervous system is a major factor in the development and progression of cardiovascular disease; thus, understanding the mechanism and function of the sympathetic nervous system and appropriately regulating sympathetic activity to treat various cardiovascular diseases are crucial. Areas covered: This review focused on previous studies in managing hypertension, atrial fibrillation, coronary artery disease, heart failure, and perioperative management with sympathetic blockade. We reviewed both pharmacological and non-pharmacological management. Expert commentary: Chronic sympathetic nervous system activation is related to several cardiovascular diseases mediated by various pathways. Advancement in measuring sympathetic activity makes visualizing noninvasively and evaluating the activation level even in single fibers possible. Evidence suggests that sympathetic blockade still has a role in managing hypertension and controlling the heart rate in atrial fibrillation. For ischemic heart disease, beta-adrenergic receptor antagonists have been considered a milestone drug to control symptoms and prevent long-term adverse effects, although its clinical implication has become less potent in the era of successful revascularization. Owing to pathologic involvement of sympathetic nervous system activation in heart failure progression, sympathetic blockade has proved its value in improving the clinical course of patients with heart failure.
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Affiliation(s)
- Chan Soon Park
- a Department of Internal Medicine , Seoul National University College of Medicine, Seoul National University Hospital , Seoul , Korea
| | - Hae-Young Lee
- a Department of Internal Medicine , Seoul National University College of Medicine, Seoul National University Hospital , Seoul , Korea
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Sun Y, Huang CY, Wang MC. Nonparametric Benefit-Risk Assessment Using Marker Process in the Presence of a Terminal Event. J Am Stat Assoc 2017; 112:826-836. [PMID: 29731529 DOI: 10.1080/01621459.2016.1180988] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Benefit-risk assessment is a crucial step in medical decision process. In many biomedical studies, both longitudinal marker measurements and time to a terminal event serve as important endpoints for benefit-risk assessment. The effect of an intervention or a treatment on the longitudinal marker process, however, can be in conflict with its effect on the time to the terminal event. Thus, questions arise on how to evaluate treatment effects based on the two endpoints, for the purpose of deciding on which treatment is most likely to benefit the patients. In this article, we present a unified framework for benefit-risk assessment using the observed longitudinal markers and time to event data. We propose a cumulative weighted marker process to synthesize information from the two endpoints, and use its mean function at a prespecified time point as a benefit-risk summary measure. We consider nonparametric estimation of the summary measure under two scenarios: (i) the longitudinal marker is measured intermittently during the study period, and (ii) the value of the longitudinal marker is observed throughout the entire follow-up period. The large-sample properties of the estimators are derived and compared. Simulation studies and data examples exhibit that the proposed methods are easy to implement and reliable for practical use. Supplemental materials for this article are available online.
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Affiliation(s)
- Yifei Sun
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
| | - Chiung-Yu Huang
- Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University, Baltimore, MD
| | - Mei-Cheng Wang
- Department of Biostatistics, Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD
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128
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Baker JG, Gardiner SM, Woolard J, Fromont C, Jadhav GP, Mistry SN, Thompson KSJ, Kellam B, Hill SJ, Fischer PM. Novel selective β 1-adrenoceptor antagonists for concomitant cardiovascular and respiratory disease. FASEB J 2017; 31:3150-3166. [PMID: 28400472 PMCID: PMC5471521 DOI: 10.1096/fj.201601305r] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 03/20/2017] [Indexed: 11/12/2022]
Abstract
β-Blockers reduce mortality and improve symptoms in people with heart disease; however, current clinically available β-blockers have poor selectivity for the cardiac β1-adrenoceptor (AR) over the lung β2-AR. Unwanted β2-blockade risks causing life-threatening bronchospasm and reduced efficacy of β2-agonist emergency rescue therapy. Thus, current life-prolonging β-blockers are contraindicated in patients with both heart disease and asthma. Here, we describe NDD-713 and -825, novel highly β1-selective neutral antagonists with good pharmaceutical properties that can potentially overcome this limitation. Radioligand binding studies and functional assays that use human receptors expressed in Chinese hamster ovary cells demonstrate that NDD-713 and -825 have nanomolar β1-AR affinity >500-fold β1-AR vs. β2-AR selectivity and no agonism. Studies in conscious rats demonstrate that these antagonists are orally bioavailable and cause pronounced β1-mediated reduction of heart rate while showing no effect on β2-mediated hindquarters vasodilatation. These compounds also have good disposition properties and show no adverse toxicologic effects. They potentially offer a truly cardioselective β-blocker therapy for the large number of patients with heart and respiratory or peripheral vascular comorbidities.—Baker, J. G., Gardiner, S. M., Woolard, J., Fromont, C., Jadhav, G. P., Mistry, S. N., Thompson, K. S. J., Kellam, B., Hill, S. J., Fischer, P. M. Novel selective β1-adrenoceptor antagonists for concomitant cardiovascular and respiratory disease.
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Affiliation(s)
- Jillian G Baker
- Cell Signalling Research Group, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom;
| | - Sheila M Gardiner
- Cell Signalling Research Group, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Jeanette Woolard
- Cell Signalling Research Group, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Christophe Fromont
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom.,Centre for Biomolecular Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Gopal P Jadhav
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom.,Centre for Biomolecular Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Shailesh N Mistry
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom.,Centre for Biomolecular Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Kevin S J Thompson
- Cell Signalling Research Group, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Barrie Kellam
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom.,Centre for Biomolecular Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Stephen J Hill
- Cell Signalling Research Group, School of Life Sciences, University of Nottingham, Nottingham, United Kingdom
| | - Peter M Fischer
- School of Pharmacy, University of Nottingham, Nottingham, United Kingdom; .,Centre for Biomolecular Sciences, University of Nottingham, Nottingham, United Kingdom
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Olchanski N, Cohen JT, Neumann PJ, Wong JB, Kent DM. Understanding the Value of Individualized Information: The Impact of Poor Calibration or Discrimination in Outcome Prediction Models. Med Decis Making 2017; 37:790-801. [PMID: 28399375 DOI: 10.1177/0272989x17704855] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Risk prediction models allow for the incorporation of individualized risk and clinical effectiveness information to identify patients for whom therapy is most appropriate and cost-effective. This approach has the potential to identify inefficient (or harmful) care in subgroups at different risks, even when the overall results appear favorable. Here, we explore the value of personalized risk information and the factors that influence it. METHODS Using an expected value of individualized care (EVIC) framework, which monetizes the value of customizing care, we developed a general approach to calculate individualized incremental cost effectiveness ratios (ICERs) as a function of individual outcome risk. For a case study (tPA v. streptokinase to treat possible myocardial infarction), we used a simulation to explore how an EVIC is influenced by population outcome prevalence, model discrimination (c-statistic) and calibration, and willingness-to-pay (WTP) thresholds. RESULTS In our simulations, for well-calibrated models, which do not over- or underestimate predicted v. observed event risk, the EVIC ranged from $0 to $700 per person, with better discrimination (higher c-statistic values) yielding progressively higher EVIC values. For miscalibrated models, the EVIC ranged from -$600 to $600 in different simulated scenarios. The EVIC values decreased as discrimination improved from a c-statistic of 0.5 to 0.6, before becoming positive as the c-statistic reached values of ~0.8. CONCLUSIONS Individualizing treatment decisions using risk may produce substantial value but also has the potential for net harm. Good model calibration ensures a non-negative EVIC. Improvements in discrimination generally increase the EVIC; however, when models are miscalibrated, greater discriminating power can paradoxically reduce the EVIC under some circumstances.
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Affiliation(s)
- Natalia Olchanski
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK)
| | - Joshua T Cohen
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK)
| | - Peter J Neumann
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK)
| | - John B Wong
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK).,Division of Clinical Decision Making, Tufts Medical Center, Boston, MA (JBW)
| | - David M Kent
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA (NO, JTC, PJN, JBW, DMK)
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130
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Krzysztofik J, Ponikowski P. Current and emerging pharmacologic options for the management of patients with chronic and acute decompensated heart failure. Expert Rev Clin Pharmacol 2017; 10:517-534. [PMID: 28358228 DOI: 10.1080/17512433.2017.1299574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
INTRODUCTION For many years heart failure (HF) was known as a fatal disease with an ominous prognosis. In the last decades better understanding of the pathophysiological mechanisms underlying HF has resulted in major breakthrough in the management and improvement in the natural history of this clinical syndrome. Areas covered: The review is focused on current and upcoming pharmacological therapies in patients with chronic and acute HF, starting with brief overview of drugs which improve the outcomes in patients with chronic HF with reduced ejection fraction (EF) including neurohormonal antagonists, angiotensin receptor neprilysin inhibitor and If- channel inhibitor, then presenting the summary of symptomatic treatment, the pharmacotherapy in chronic HF with preserved and mid-range EF and in acute HF. Finally, we report the emerging pharmacologic options and ongoing clinical trials and future directions in pharmacotherapy. Expert commentary: The guidelines-recommended therapies in HF with reduced EF need to be widely implemented into the everyday clinical practice. Better clinical characterization of HF with preserved, mid-range EF and acute HF, with better understanding of the underlying pathophysiological mechanisms may ultimately result in a development of effective strategies improving ominous outcomes in these patients.
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Affiliation(s)
- Justyna Krzysztofik
- a Department of Heart Diseases , Wroclaw Medical University , Wroclaw , Poland.,b 4th Military Hospital, Cardiology Department , Centre for Heart Diseases , Wroclaw , Poland
| | - Piotr Ponikowski
- a Department of Heart Diseases , Wroclaw Medical University , Wroclaw , Poland.,b 4th Military Hospital, Cardiology Department , Centre for Heart Diseases , Wroclaw , Poland
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131
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Gambahaya ET, Hakim J, Kao D, Munyandu N, Matenga J. Peripartum cardiomyopathy among cardiovascular patients referred for echocardiography at Parirenyatwa Teaching Hospital, Harare, Zimbabwe. Cardiovasc J Afr 2017; 28:8-13. [PMID: 28262909 PMCID: PMC5423423 DOI: 10.5830/cvja-2016-043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2015] [Accepted: 04/03/2016] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVES The main aim was to evaluate the outcome of patients with peripartum cardiomyopathy (PPCM) within six months of diagnosis. The secondary aim was to describe demographic and clinical characteristics of patients with PPCM in Harare, Zimbabwe. METHODS This was a prospective cohort study in which patients recruited into a detailed PPCM registry were followed up for six months. Echocardiograms were performed at enrolment, and three and six months after diagnosis, to determine left ventricular function. RESULTS From 1 August 2012 to 31 July 2013, 43 patients with a new diagnosis of PPCM were recruited at Parirenyatwa Hospital in Harare. At six months, mean ejection fraction improved from 29.7 ± 9.8 to 44.9 ± 14.9%, p < 0.001 and New York Heart Association (NYHA) functional class improved significantly (p < 0.0001). Five (11.6%) patients died. CONCLUSIONS Left ventricular function improved in a substantial number of patients (42.9%) in this Zimbabwean cohort compared to other African cohorts. However the mortality rate remained high.
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Affiliation(s)
| | - James Hakim
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - David Kao
- Division of Cardiology, Department of Medicine, University of Colorado Denver School of Medicine, Colorado, USA
| | - Noleen Munyandu
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
| | - Jonathan Matenga
- College of Health Sciences, University of Zimbabwe, Harare, Zimbabwe
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132
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Rosa GM, Meliota G, Brunelli C, Ferrero S. Pharmacokinetic drug evaluation of bucindolol for the treatment of atrial fibrillation in heart failure patients. Expert Opin Drug Metab Toxicol 2017; 13:473-481. [DOI: 10.1080/17425255.2017.1291631] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- Gian Marco Rosa
- Department of Internal Medicine, Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Giovanni Meliota
- Department of Internal Medicine, Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Claudio Brunelli
- Department of Internal Medicine, Cardiology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
| | - Simone Ferrero
- Department of Obstetrics and Gynaecology, IRCCS AOU San Martino – IST, University of Genoa, Genova, Italy
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134
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Burnett H, Earley A, Voors AA, Senni M, McMurray JJV, Deschaseaux C, Cope S. Thirty Years of Evidence on the Efficacy of Drug Treatments for Chronic Heart Failure With Reduced Ejection Fraction: A Network Meta-Analysis. Circ Heart Fail 2017; 10:e003529. [PMID: 28087688 PMCID: PMC5265698 DOI: 10.1161/circheartfailure.116.003529] [Citation(s) in RCA: 151] [Impact Index Per Article: 21.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/15/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND Treatments that reduce mortality and morbidity in patients with heart failure with reduced ejection fraction, including angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB), β-blockers (BB), mineralocorticoid receptor antagonists (MRA), and angiotensin receptor-neprilysin inhibitors (ARNI), have not been studied in a head-to-head fashion. This network meta-analysis aimed to compare the efficacy of these drugs and their combinations regarding all-cause mortality in patients with heart failure with reduced ejection fraction. METHODS AND RESULTS A systematic literature review identified 57 randomized controlled trials published between 1987 and 2015, which were compared in terms of study and patient characteristics, baseline risk, outcome definitions, and the observed treatment effects. Despite differences identified in terms of study duration, New York Heart Association class, ejection fraction, and use of background digoxin, a network meta-analysis was considered feasible and all trials were analyzed simultaneously. The random-effects network meta-analysis suggested that the combination of ACEI+BB+MRA was associated with a 56% reduction in mortality versus placebo (hazard ratio 0.44, 95% credible interval 0.26-0.66); ARNI+BB+MRA was associated with the greatest reduction in all-cause mortality versus placebo (hazard ratio 0.37, 95% credible interval 0.19-0.65). A sensitivity analysis that did not account for background therapy suggested that ARNI monotherapy is more efficacious than ACEI or ARB monotherapy. CONCLUSIONS The network meta-analysis showed that treatment with ACEI, ARB, BB, MRA, and ARNI and their combinations were better than the treatment with placebo in reducing all-cause mortality, with the exception of ARB monotherapy and ARB plus ACEI. The combination of ARNI+BB+MRA resulted in the greatest mortality reduction.
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Affiliation(s)
- Heather Burnett
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.).
| | - Amy Earley
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Adriaan A Voors
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Michele Senni
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - John J V McMurray
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Celine Deschaseaux
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
| | - Shannon Cope
- From the Mapi, Health Economics and Outcomes Research, Dundas, Canada (H.B.); Mapi, Health Economics and Outcomes Research, Boston, MA (A.E.); Department of Cardiology, University of Groningen, The Netherlands (A.A.V.); Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.); British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.); Global Patient Access, Novartis Pharma AG, Postfach, CH-4002 Basel, Switzerland (C.D.); and Mapi, Health Economics and Outcomes Research, Toronto, Canada (S.C.)
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135
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Song F, Bachmann MO. Cumulative subgroup analysis to reduce waste in clinical research for individualised medicine. BMC Med 2016; 14:197. [PMID: 27974045 PMCID: PMC5157082 DOI: 10.1186/s12916-016-0744-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 11/09/2016] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Although subgroup analyses in clinical trials may provide evidence for individualised medicine, their conduct and interpretation remain controversial. METHODS Subgroup effect can be defined as the difference in treatment effect across patient subgroups. Cumulative subgroup analysis refers to a series of repeated pooling of subgroup effects after adding data from each of related trials chronologically, to investigate the accumulating evidence for subgroup effects. We illustrated the clinical relevance of cumulative subgroup analysis in two case studies using data from published individual patient data (IPD) meta-analyses. Computer simulations were also conducted to examine the statistical properties of cumulative subgroup analysis. RESULTS In case study 1, an IPD meta-analysis of 10 randomised trials (RCTs) on beta blockers for heart failure reported significant interaction of treatment effects with baseline rhythm. Cumulative subgroup analysis could have detected the subgroup effect 15 years earlier, with five fewer trials and 71% less patients, than the IPD meta-analysis which first reported it. Case study 2 involved an IPD meta-analysis of 11 RCTs on treatments for pulmonary arterial hypertension that reported significant subgroup effect by aetiology. Cumulative subgroup analysis could have detected the subgroup effect 6 years earlier, with three fewer trials and 40% less patients than the IPD meta-analysis. Computer simulations have indicated that cumulative subgroup analysis increases the statistical power and is not associated with inflated false positives. CONCLUSIONS To reduce waste of research data, subgroup analyses in clinical trials should be more widely conducted and adequately reported so that cumulative subgroup analyses could be timely performed to inform clinical practice and further research.
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Affiliation(s)
- Fujian Song
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Research Park, Norwich, Norfolk NR4 7TJ UK
| | - Max O. Bachmann
- Norwich Medical School, Faculty of Medicine and Health Science, University of East Anglia, Research Park, Norwich, Norfolk NR4 7TJ UK
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136
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Baker JG, Wilcox RG. β-Blockers, heart disease and COPD: current controversies and uncertainties. Thorax 2016; 72:271-276. [PMID: 27927840 DOI: 10.1136/thoraxjnl-2016-208412] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 10/14/2016] [Accepted: 10/21/2016] [Indexed: 11/03/2022]
Abstract
Treating people with cardiovascular disease and COPD causes significant clinician anxiety. β-Blockers save lives in people with heart disease, specifically postinfarction and heart failure. COPD and heart disease frequently coexist and people with both disorders have particularly high cardiovascular mortality. There are concerns about giving β-blockers to people with concomitant COPD that include reduced basal lung function, diminished effectiveness of emergency β-agonist treatments, reduced benefit of long-acting β-agonist treatment and difficulty in discriminating between asthma and COPD. β-Blockers appear to reduce lung function in both the general population and those with COPD because they are poorly selective for cardiac β1-adrenoceptors over respiratory β2-adrenoceptors, and studies have shown that higher β-agonist doses are required to overcome the β-blockade. COPD and cardiovascular disease share similar environmental risks and both disease states have high adrenergic and inflammatory activation. β-Blockers may therefore be particularly helpful in reducing cardiovascular events in this high-risk group. They may reduce the background inflammatory state, and inhibit the tachycardia and hypertension associated with both the endogenous adrenaline and high-dose β-agonist treatment associated with acute exacerbations of COPD. Some studies have suggested no increased and, at times, reduced mortality in patients with COPD taking β-blockers for heart disease. However, these are all observational studies and there are no randomised controlled trials. Potential ways to improve this dilemma include the development of highly β1-selective β-blockers or the use of non-β-blocking heart rate reducing agents, such as ivabridine, if these are proven to be beneficial in randomised controlled trials.
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Affiliation(s)
- Jillian G Baker
- Respiratory Medicine, Cell Signalling, School of Life Sciences, University of Nottingham, Nottingham, UK
| | - Robert G Wilcox
- Department of Clinical Neurosciences, Queen's Medical Centre, University of Nottingham, Nottingham, UK
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137
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Kent DM, Nelson J, Dahabreh IJ, Rothwell PM, Altman DG, Hayward RA. Risk and treatment effect heterogeneity: re-analysis of individual participant data from 32 large clinical trials. Int J Epidemiol 2016; 45:2075-2088. [PMID: 27375287 PMCID: PMC5841614 DOI: 10.1093/ije/dyw118] [Citation(s) in RCA: 53] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/18/2016] [Indexed: 01/21/2023] Open
Abstract
Background Risk of the outcome is a mathematical determinant of the absolute treatment benefit of an intervention, yet this can vary substantially within a trial population, complicating the interpretation of trial results. Methods We developed risk models using Cox or logistic regression on a set of large publicly available randomized controlled trials (RCTs). We evaluated risk heterogeneity using the extreme quartile risk ratio (EQRR, the ratio of outcome rates in the lowest risk quartile to that in the highest) and skewness using the median to mean risk ratio (MMRR, the ratio of risk in the median risk patient to the average). We also examined heterogeneity of treatment effects (HTE) across risk strata. Results We describe 39 analyses using data from 32 large trials, with event rates across studies ranging from 3% to 63% (median = 15%, 25th-75th percentile = 9-29%). C-statistics of risk models ranged from 0.59 to 0.89 (median = 0.70, 25th-75th percentile = 0.65-0.71). The EQRR ranged from 1.8 to 50.7 (median = 4.3, 25th-75th percentile = 3.0-6.1). The MMRR ranged from 0.4 to 1.0 (median = 0.86, 25th-75th percentile = 0.80-0.92). EQRRs were predictably higher and MMRRs predictably lower as the c-statistic increased or the overall outcome incidence decreased. Among 18 comparisons with a significant overall treatment effect, there was a significant interaction between treatment and baseline risk on the proportional scale in only one. The difference in the absolute risk reduction between extreme risk quartiles ranged from -3.2 to 28.3% (median = 5.1%; 25th-75th percentile = 0.3-10.9). Conclusions There is typically substantial variation in outcome risk in clinical trials, commonly leading to clinically significant differences in absolute treatment effects Most patients have outcome risks lower than the trial average reflected in the summary result. Risk-stratified trial analyses are feasible and may be clinically informative, particularly when the outcome is predictable and uncommon.
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Affiliation(s)
- David M Kent
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, MA, USA
| | - Jason Nelson
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, MA, USA
| | - Issa J Dahabreh
- Predictive Analytics and Comparative Effectiveness Center, Tufts Medical Center/Tufts University School of Medicine, Boston, MA, USA
- Center for Evidence-Based Medicine
- Department of Health Services, Policy & Practice
- Department of Epidemiology, Brown University, Providence, RI, USA
| | - Peter M Rothwell
- Stroke Prevention Research Unit, Nuffield Department of Clinical Neuroscience, University of Oxford, Oxford, UK
| | - Douglas G Altman
- Centre for Statistics in Medicine, Nuffield Department of Orthopaedics, Rheumatology & Musculoskeletal Sciences, University of Oxford, Oxford, UK
| | - Rodney A Hayward
- Department of Internal Medicine and Department of Health Management and Policy, University of Michigan, Ann Arbor, MI, USA
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138
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Reiffel JA. Drug and Drug-Device Therapy in Heart Failure Patients in the Post-COMET and SCD-HeFT Era. J Cardiovasc Pharmacol Ther 2016; 10 Suppl 1:S45-58. [PMID: 15965572 DOI: 10.1177/10742484050100i406] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Reduced left ventricular ejection fraction and heart failure are the most important risk factors for sudden cardiac death. Recent trials have contributed to the knowledge base of critical therapies for the treatment of left ventricular systolic dysfunction and heart failure as it relates to arrhythmic and sudden cardiac death. Both pharmacologic and device therapies can reduce sudden cardiac death. The trials discussed in this paper have identified the pharmacologic and device interventions that are likely to improve the length and quality of life of the patient with left ventricular dysfunction and reduce the risk of sudden cardiac death. The mortality and anti-arrhythmic effects of angiotensin-converting enzyme inhibitors and β-blockers have been confirmed in large-scale controlled clinical heart failure trials. Recent trials have evaluated which agents are most effective and which patients will derive the most benefit from device therapy in terms of the reduction in the risk of sudden cardiac death and in the amelioration of heart failure. The recent data from the Carvedilol or Metoprolol European Trial (COMET) and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) are discussed as the latest in the series of landmark studies that have shaped the current approaches to treating patients with heart failure and that have altered the heart failure treatment paradigm.
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Affiliation(s)
- James A Reiffel
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA.
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139
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Singh BN. β-Adrenergic Blockers as Antiarrhythmic and Antifibrillatory Compounds: An Overview. J Cardiovasc Pharmacol Ther 2016; 10 Suppl 1:S3-S14. [PMID: 15965570 DOI: 10.1177/10742484050100i402] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
β-Adrenergic blockers have a wide spectrum of action for controlling cardiac arrhythmias that is larger than initially thought. Data from the past several decades indicate that, as an antiarrhythmic class, β-blockers remain among the very few pharmacologic agents that reduce the incidence of sudden cardiac death, prolong survival, and ameliorate symptoms caused by arrhythmias in patients with cardiac disease. As a class of compounds, β-blockers have a fundamental pharmacologic property that attenuates the effects of competitive adrenergic receptors. However, the net clinical effects of the different β-receptor blockers may vary quantitatively because of variations in associated intrinsic sympathomimetic agonism and in their intrinsic potency for binding to β-receptors. These individual compounds also differ in their selectivity for β1- and β2-receptors. Metoprolol is a β1-selective blocker, whereas carvedilol is a nonselective β1- and β2-blocker, an antioxidant, and has a propensity to inhibit α1-receptors and endothelin. Evolving data from controlled and uncontrolled clinical trials suggest that there are clinically significant differences among this class of drugs. Recent evidence also suggests that the antiarrhythmic actions of certain β-receptor blockers such as carvedilol and metoprolol extend beyond the ventricular tissue to encompass atrial cells and help maintain sinus rhythm in patients with atrial fibrillation, especially in combination with potent antifibrillatory agents such as amiodarone. This introduction provides a current perspective on these newer developments in the understanding of the antiarrhythmic and antifibrillatory actions of β-blockers.
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Affiliation(s)
- Bramah N Singh
- Department of Cardiology, VA Medical Center, West Los Angeles, David Geffen School of Medicine at UCLA, Los Angeles 90073, USA.
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140
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Mottet F, Vardeny O, de Denus S. Pharmacogenomics of heart failure: a systematic review. Pharmacogenomics 2016; 17:1817-1858. [PMID: 27813451 DOI: 10.2217/pgs-2016-0118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Heart failure (HF) and multiple HF-related phenotypes are heritable. Genes implicated in the HF pathophysiology would be expected to influence the response to treatment. METHODS We conducted a series of systematic literature searches on the pharmacogenetics of HF therapy to assess the current knowledge on this field. RESULTS Existing data related to HF pharmacogenomics are still limited. The ADRB1 gene is a likely candidate to predict response to β-blockers. Moreover, the cytochrome P450 2D6 coding gene (CYP2D6) clearly affects the pharmacokinetics of metoprolol, although the clinical impact of this association remains to be established. CONCLUSION Given the rising prevalence of HF and related costs, a more personalized use of HF drugs could have a remarkable benefit for patients, caregivers and healthcare systems.
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Affiliation(s)
- Fannie Mottet
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada.,Montreal Heart Institute, Montreal, Canada
| | - Orly Vardeny
- Associate Professor of Pharmacy & Medicine, University of Wisconsin-Madison, Madison, WI 53705, USA
| | - Simon de Denus
- Faculty of Pharmacy, Université de Montréal, Montreal, Canada.,Montreal Heart Institute, Montreal, Canada
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141
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A New Overall-Subgroup Simultaneous Test for Optimal Inference in Biomarker-Targeted Confirmatory Trials. STATISTICS IN BIOSCIENCES 2016. [DOI: 10.1007/s12561-016-9174-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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143
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Iyngkaran P, Toukhsati SR, Thomas MC, Jelinek MV, Hare DL, Horowitz JD. A Review of the External Validity of Clinical Trials with Beta-Blockers in Heart Failure. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:163-171. [PMID: 27773994 PMCID: PMC5063839 DOI: 10.4137/cmc.s38444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/03/2016] [Accepted: 07/16/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Beta-blockers (BBs) are the mainstay prognostic medication for all stages of chronic heart failure (CHF). There are many classes of BBs, each of which has varying levels of evidence to support its efficacy in CHF. However, most CHF patients have one or more comorbid conditions such as diabetes, renal impairment, and/or atrial fibrillation. Patient enrollment to randomized controlled trials (RCTs) often excludes those with certain comorbidities, particularly if the symptoms are severe. Consequently, the extent to which evidence drawn from RCTs is generalizable to CHF patients has not been well described. Clinical guidelines also underrepresent this point by providing generic advice for all patients. The aim of this review is to examine the evidence to support the use of BBs in CHF patients with common comorbid conditions. METHODS We searched MEDLINE, PubMed, and the reference lists of reviews for RCTs, post hoc analyses, systematic reviews, and meta-analyses that report on use of BBs in CHF along with patient demographics and comorbidities. RESULTS In total, 38 studies from 28 RCTs were identified, which provided data on six BBs against placebo or head to head with another BB agent in ischemic and nonischemic cardiomyopathies. Several studies explored BBs in older patients. Female patients and non-Caucasian race were underrepresented in trials. End points were cardiovascular hospitalization and mortality. Comorbid diabetes, renal impairment, or atrial fibrillation was detailed; however, no reference to disease spectrum or management goals as a focus could be seen in any of the studies. In this sense, enrollment may have limited more severe grades of these comorbidities. CONCLUSIONS RCTs provide authoritative information for a spectrum of CHF presentations that support guidelines. RCTs may provide inadequate information for more heterogeneous CHF patient cohorts. Greater Phase IV research may be needed to fill this gap and inform guidelines for a more global patient population.
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Affiliation(s)
- Pupalan Iyngkaran
- Cardiologist and Senior Lecturer, Northern Territory School of Medicine, Flinders University, Bedford Park, South Australia
| | - Samia R Toukhsati
- Department of Cardiology, Austin Health, Heidelberg, Victoria, Australia
| | - Merlin C Thomas
- Professor, NHMRC Senior Research Fellow, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Michael V Jelinek
- Professor, Department of Cardiology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - David L Hare
- Professor, Coordinator, Cardiovascular Research, University of Melbourne; Director of Heart Failure Services, Austin Health, Melbourne, Victoria, Australia
| | - John D Horowitz
- Professor of Cardiology, Director, Cardiology Unit, Discipline of Medicine, Cardiology Research Laboratory, The Basil Hetzel Institute, Woodville South, South Australia, Australia
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144
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Breathett K, Allen LA, Udelson J, Davis G, Bristow M. Changes in Left Ventricular Ejection Fraction Predict Survival and Hospitalization in Heart Failure With Reduced Ejection Fraction. Circ Heart Fail 2016; 9:CIRCHEARTFAILURE.115.002962. [PMID: 27656000 DOI: 10.1161/circheartfailure.115.002962] [Citation(s) in RCA: 65] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Accepted: 09/07/2016] [Indexed: 01/06/2023]
Abstract
BACKGROUND Left ventricular remodeling, as commonly measured by left ventricular ejection fraction (LVEF), is associated with clinical outcomes. Although change in LVEF over time should reflect response to therapy and clinical course, serial measurement of LVEF is inconsistently performed in observational settings, and the incremental prognostic value of change in LVEF has not been well characterized. METHODS AND RESULTS The β-Blocker Evaluation of Survival Trial measured LVEF by radionuclide ventriculography at baseline and at 3 and 12 months after randomization. We built a series of multivariable models with 16 clinical parameters plus change in LVEF for predicting 4 major clinical end points, including the trial's primary end point of all-cause mortality. Among 2484 patients with at least 1 follow-up LVEF, change in LVEF was the second most significant predictor (behind baseline creatinine) of all-cause mortality (adjusted hazard ratio for improvement in LVEF by ≥5 U responder versus nonresponder [95% confidence intervals] for all-cause mortality=0.62 [0.52-0.73]). Other end points, including heart failure hospitalization or the composite of all-cause mortality and heart failure hospitalization, yielded similar results. LVEF change ≥5 U was associated with a modest increase in discrimination when added to traditional predictors and was predictive of outcomes in both the bucindolol and placebo treatment groups. LVEF change as a predictor of outcomes was affected by sex and race, with evidence that LVEF improvement is associated with less survival benefit in African Americans and women. CONCLUSIONS Serial evaluation for LVEF change predicts both survival and heart failure hospitalization and provides a dynamic/real-time measure of prognosis in heart failure with reduced LVEF. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00000560.
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Affiliation(s)
- Khadijah Breathett
- From the Division of Cardiology, University of Colorado, Aurora (K.B., L.A.A., M.B.); Division of Cardiology, Tufts Medical Center, Boston, MA (J.U.); and ARCA Biopharma, Westminster, CO (G.D., M.B.).
| | - Larry A Allen
- From the Division of Cardiology, University of Colorado, Aurora (K.B., L.A.A., M.B.); Division of Cardiology, Tufts Medical Center, Boston, MA (J.U.); and ARCA Biopharma, Westminster, CO (G.D., M.B.)
| | - James Udelson
- From the Division of Cardiology, University of Colorado, Aurora (K.B., L.A.A., M.B.); Division of Cardiology, Tufts Medical Center, Boston, MA (J.U.); and ARCA Biopharma, Westminster, CO (G.D., M.B.)
| | - Gordon Davis
- From the Division of Cardiology, University of Colorado, Aurora (K.B., L.A.A., M.B.); Division of Cardiology, Tufts Medical Center, Boston, MA (J.U.); and ARCA Biopharma, Westminster, CO (G.D., M.B.)
| | - Michael Bristow
- From the Division of Cardiology, University of Colorado, Aurora (K.B., L.A.A., M.B.); Division of Cardiology, Tufts Medical Center, Boston, MA (J.U.); and ARCA Biopharma, Westminster, CO (G.D., M.B.)
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145
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Zhang X, Shen C, Zhai S, Liu Y, Yue WW, Han L. A meta-analysis of the effects of β-adrenergic blockers in chronic heart failure. Exp Ther Med 2016; 12:2489-2496. [PMID: 27703506 PMCID: PMC5038900 DOI: 10.3892/etm.2016.3657] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2016] [Accepted: 07/20/2016] [Indexed: 11/18/2022] Open
Abstract
Adrenergic β-blockers are drugs that bind to, but do not activate β-adrenergic receptors. Instead they block the actions of β-adrenergic agonists and are used for the treatment of various diseases such as cardiac arrhythmias, angina pectoris, myocardial infarction, hypertension, headache, migraines, stress, anxiety, prostate cancer, and heart failure. Several meta-analysis studies have shown that β-blockers improve the heart function and reduce the risks of cardiovascular events, rate of mortality, and sudden death through chronic heart failure (CHF) of patients. The present study identified results from recent meta-analyses of β-adrenergic blockers and their usefulness in CHF. Databases including Medline/Embase/Cochrane Central Register of Controlled Trials (CENTRAL), and PubMed were searched for the periods May, 1985 to March, 2011 and June, 2013 to August, 2015, and a number of studies identified. Results of those studies showed that use of β-blockers was associated with decreased sudden cardiac death in patients with heart failure. However, contradictory results have also been reported. The present meta-analysis aimed to determine the efficacy of β-blockers on mortality and morbidity in patients with heart failure. The results showed that mortality was significantly reduced by β-blocker treatment prior to the surgery of heart failure patients. The results from the meta-analysis studies showed that β-blocker treatment in heart failure patients correlated with a significant decrease in long-term mortality, even in patients that meet one or more exclusion criteria of the MERIT-HF study. In summary, the findings of the current meta-analysis revealed beneficial effects different β-blockers have on patients with heart failure or related heart disease.
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Affiliation(s)
- Xiaojian Zhang
- Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan, Shandong 250021, P.R. China
| | - Chengwu Shen
- Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan, Shandong 250021, P.R. China
| | - Shujun Zhai
- Shandong Provincial Hospital Affiliated to Shandong University, Ji'nan, Shandong 250021, P.R. China
| | - Yukun Liu
- Laiwu Health School, Laiwu, Shandong 271100, P.R. China
| | - Wen-Wei Yue
- The Fourth People's Hospital of Ji'nan, Ji'nan, Shandong 250021, P.R. China
| | - Li Han
- The Fourth People's Hospital of Ji'nan, Ji'nan, Shandong 250021, P.R. China
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146
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Alexander KM, Falk RH. V122I TTR Cardiac Amyloidosis in Patients of African Descent. Circ Heart Fail 2016; 9:CIRCHEARTFAILURE.116.003489. [DOI: 10.1161/circheartfailure.116.003489] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Kevin M. Alexander
- From the Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Heart & Vascular Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Rodney H. Falk
- From the Cardiac Amyloidosis Program, Division of Cardiology, Department of Medicine, Heart & Vascular Center, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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147
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Krittanawong C, Namath A, Lanfear DE, Tang WHW. Practical Pharmacogenomic Approaches to Heart Failure Therapeutics. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2016; 18:60. [PMID: 27566707 DOI: 10.1007/s11936-016-0483-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OPINION STATEMENT The major challenge in applying pharmacogenomics to everyday clinical practice in heart failure (HF) is based on (1) a lack of robust clinical evidence for the differential utilization of neurohormonal antagonists in the management of HF in different subgroups, (2) inconsistent results regarding appropriate subgroups that may potentially benefit from an alternative strategy based on pharmacogenomic analyses, and (3) a lack of clinical trials that focused on testing gene-guided treatment in HF. To date, all pharmacogenomic analyses in HF have been conducted as post hoc retrospective analyses of clinical trial data or of observational patient series studies. This is in direct contrast with the guideline-directed HF therapies that have demonstrated their safety and efficacy in the absence of pharmacogenomic guidance. Therefore, the future of clinical applications of pharmacogenomic testing will largely depend on our ability to incorporate gene-drug interactions into the prescribing process, requiring that preemptive and cost-effective testing be paired with decision-support tools in a value-based care approach.
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Affiliation(s)
- Chayakrit Krittanawong
- Department of Cardiovascular Medicine, Heart and Vascular Institute, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, 44195, USA
| | - Amalia Namath
- Center for Clinical Genomics, Cleveland Clinic, Cleveland, OH, USA
| | - David E Lanfear
- Advanced Heart Failure and Cardiac Transplantation, Research Scientist, Center for Health Services Research, Henry Ford Hospital, Detroit, MI, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, 44195, USA. .,Center for Clinical Genomics, Cleveland Clinic, Cleveland, OH, USA.
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148
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Liu SX, Xiang R, Lagor C, Liu N, Sullivan K. Economic Modeling of Heart Failure Telehealth Programs: When Do They Become Cost Saving? Int J Telemed Appl 2016; 2016:3289628. [PMID: 27528868 PMCID: PMC4977384 DOI: 10.1155/2016/3289628] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2015] [Accepted: 04/18/2016] [Indexed: 11/18/2022] Open
Abstract
Telehealth programs for congestive heart failure have been shown to be clinically effective. This study assesses clinical and economic consequences of providing telehealth programs for CHF patients. A Markov model was developed and presented in the context of a home-based telehealth program on CHF. Incremental life expectancy, hospital admissions, and total healthcare costs were examined at periods ranging up to five years. One-way and two-way sensitivity analyses were also conducted on clinical performance parameters. The base case analysis yielded cost savings ranging from $2832 to $5499 and 0.03 to 0.04 life year gain per patient over a 1-year period. Applying telehealth solution to a low-risk cohort with no prior admission history would result in $2502 cost increase per person over the 1-year time frame with 0.01 life year gain. Sensitivity analyses demonstrated that the cost savings were most sensitive to patient risk, baseline cost of hospital admission, and the length-of-stay reduction ratio affected by the telehealth programs. In sum, telehealth programs can be cost saving for intermediate and high risk patients over a 1- to 5-year window. The results suggested the economic viability of telehealth programs for managing CHF patients and illustrated the importance of risk stratification in such programs.
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Affiliation(s)
- Sheena Xin Liu
- Philips Research North American, Briarcliff Manor, NY 10510, USA
| | - Rui Xiang
- Columbia University, New York, NY 10027, USA
| | - Charles Lagor
- Philips Home Health Services, Framingham, MA 01702, USA
| | - Nan Liu
- Columbia University, New York, NY 10027, USA
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149
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Abstract
Although the landscape of heart failure continues to rapidly evolve, and the widespread use of evidence-based pharmaceutical and device therapies has improved overall survival rates, mortality rates in heart failure patients remain high. Understanding the mode of death in heart failure is particularly important if we are to improve survival. This study reviews the evaluation of modes of death from heart failure and discusses the therapies, both pharmaceutical and device, that are useful in preventing these sequelae.
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Affiliation(s)
- Jigar Patel
- Department of Cardiology, Scripps Clinic, La Jolla, California 92037, USA
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150
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Rush CJ, Campbell RT, Jhund PS, Connolly EC, Preiss D, Gardner RS, Petrie MC, McMurray JJV. Falling Cardiovascular Mortality in Heart Failure With Reduced Ejection Fraction and Implications for Clinical Trials. JACC-HEART FAILURE 2016; 3:603-14. [PMID: 26251086 DOI: 10.1016/j.jchf.2015.03.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2015] [Revised: 03/11/2015] [Accepted: 03/13/2015] [Indexed: 12/25/2022]
Abstract
OBJECTIVES This study examined the trends in the relative contributions of cardiovascular and noncardiovascular mortality to total mortality according to use of beta-blockers in clinical trials of patients with heart failure with reduced ejection fraction (HF-REF). BACKGROUND With the increasingly widespread use of disease-modifying therapies, particularly beta-blockers, in HF-REF, the proportion of patients dying from cardiovascular causes is likely to be decreasing. METHODS In a systematic review, 2 investigators independently searched online databases to identify clinical trials including >400 patients with chronic heart failure published between 1986 and 2014 and that adjudicated cause of death. Trials were divided into 3 groups on the basis of the proportion of patients treated with a beta-blocker (<33% [low], 33% to 66% [medium], and >66% [high]). Percentages of total deaths adjudicated as cardiovascular or noncardiovascular were calculated by weighted means and weighted standard deviations. Weighted Student t tests were used to compare results between groups. RESULTS Sixty-six trials met the inclusion criteria with a total of 136,182 patients and 32,140 deaths. There was a sequential increase in the percentage of noncardiovascular deaths with increasing beta-blocker use from 11.4% of all deaths in trials with low beta-blocker use to 19.1% in those with high beta-blocker use (p < 0.001). CONCLUSIONS In trials of patients with HF-REF, the proportion of deaths adjudicated as cardiovascular has decreased. Cardiovascular mortality, and not all-cause mortality, should be used as an endpoint for trials of new treatments for HF-REF.
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Affiliation(s)
| | - Ross T Campbell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Eugene C Connolly
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - David Preiss
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Roy S Gardner
- Golden Jubilee National Hospital, Glasgow, Scotland, United Kingdom
| | - Mark C Petrie
- Golden Jubilee National Hospital, Glasgow, Scotland, United Kingdom
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom.
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