101
|
Rohde LE, Vaduganathan M, Claggett BL, Polanczyk CA, Dorbala P, Packer M, Desai AS, Zile M, Rouleau J, Swedberg K, Lefkowitz M, Shi V, McMurray JJV, Solomon SD. Dynamic changes in cardiovascular and systemic parameters prior to sudden cardiac death in heart failure with reduced ejection fraction: a PARADIGM-HF analysis. Eur J Heart Fail 2021; 23:1346-1356. [PMID: 33565237 DOI: 10.1002/ejhf.2120] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Revised: 01/02/2021] [Accepted: 02/02/2021] [Indexed: 12/16/2022] Open
Abstract
AIMS Prognostic models of sudden cardiac death (SCD) typically incorporate data at only a single time-point. We investigated independent predictors of SCD addressing the impact of integrating time-varying covariates to improve prediction assessment. METHODS AND RESULTS We studied 8399 patients enrolled in the PARADIGM-HF trial and identified independent predictors of SCD (n = 561, 36% of total deaths) using time-updated multivariable-adjusted Cox models, classification and regression tree (CART), and logistic regression analysis. Compared with patients who were alive or died from non-sudden cardiovascular deaths, patients who suffered a SCD displayed a distinct temporal profile of New York Heart Association (NYHA) class, heart rate and levels of three biomarkers (albumin, uric acid and total bilirubin), with significant differences observed more than 1 year prior to the event (Pinteraction < 0.001). In multivariable models adjusted for baseline covariates, seven time-updated variables independently contributed to SCD risk (incremental likelihood chi-square = 46.2). CART analysis identified that baseline variables (implantable cardioverter-defibrillator use and N-terminal prohormone of B-type natriuretic peptide levels) and time-updated covariates (NYHA class, total bilirubin, and total cholesterol) improved risk stratification. CART-defined subgroup of highest risk had nearly an eightfold increment in SCD hazard (hazard ratio 7.7, 95% confidence interval 3.6-16.5; P < 0.001). Finally, changes over time in heart rate, NYHA class, blood urea nitrogen and albumin levels were associated with differential risk of sudden vs. non-sudden cardiovascular deaths (P < 0.05). CONCLUSIONS Beyond single time-point assessments, distinct changes in multiple cardiac-specific and systemic variables improved SCD risk prediction and were helpful in differentiating mode of death in chronic heart failure.
Collapse
Affiliation(s)
- Luis E Rohde
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, MA, USA.,Hospital de Clínicas de Porto Alegre and UFRGS Medical School, Porto Alegre, Brazil
| | | | - Brian L Claggett
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, MA, USA
| | - Carisi A Polanczyk
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, MA, USA.,Hospital de Clínicas de Porto Alegre and UFRGS Medical School, Porto Alegre, Brazil
| | - Pranav Dorbala
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Akshay S Desai
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | - Jean Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Canada
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden, London, UK
| | | | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
102
|
Wong JA, Roberts JD, Healey JS. The Optimal Timing of Primary Prevention Implantable Cardioverter-Defibrillator Referral in the Rapidly Changing Medical Landscape. Can J Cardiol 2021; 37:644-654. [PMID: 33549824 DOI: 10.1016/j.cjca.2021.01.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Revised: 01/28/2021] [Accepted: 01/28/2021] [Indexed: 12/28/2022] Open
Abstract
The use of implantable cardioverter-defibrillators (ICDs) significantly reduces the risk of mortality in patients with heart failure with reduced ejection fraction (HFrEF). Current guidelines, which are based on seminal clinical trials published nearly 2 decades ago, recommend that patients be on optimal medical therapy for HF for a minimum of 3 months before referral for prophylactic ICD. This waiting period allows for left ventricular reverse remodelling and improvement in HF symptoms, which may render primary prevention ICD implantation unnecessary. However, medical therapy for HFrEF has significantly evolved since the publication of these landmark trials. Given the plethora of medical therapy options now available for HFrEF, it is appropriate to reassess the duration of this waiting period. In the present review, we examine the landmark randomised trials in primary prevention of sudden cardiac death in patients with HFrEF, summarise the novel medical therapies (sacubitril-valsartan, sodium-glucose cotransporter 2 inhibitors, ivabradine, vericiguat, and omecamtiv mecarbil) that have emerged since the publication of those trials, discuss the optimal timing of ICD referral, and review subtypes of nonischemic cardiomyopathy where timing of ICD insertion is guided by alternative criteria. With the steps now needed to optimise medical therapy for HFrEF, in terms of both classes of drugs and doses of each agent, it can easily take up to 6 months to achieve optimisation. Following that, waiting periods of 3 months for ischemic cardiomyopathy and 6 months for nonischemic cardiomyopathy may be required to allow adequate reverse remodelling before reevaluating for ICD implantation.
Collapse
Affiliation(s)
- Jorge A Wong
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jason D Roberts
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Jeff S Healey
- Population Health Research Institute, Hamilton, Ontario, Canada; Department of Medicine, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| |
Collapse
|
103
|
Pathadka S, Yan VKC, Li X, Tse G, Wan EYF, Lau H, Lau WCY, Siu DCW, Chan EW, Wong ICK. Hospitalization and Mortality in Patients With Heart Failure Treated With Sacubitril/Valsartan vs. Enalapril: A Real-World, Population-Based Study. Front Cardiovasc Med 2021; 7:602363. [PMID: 33553256 PMCID: PMC7855850 DOI: 10.3389/fcvm.2020.602363] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/21/2020] [Indexed: 12/11/2022] Open
Abstract
Background: The effect of sacubitril/valsartan on survival and hospitalization risk in older patients with heart failure has not been explored. We aimed to investigate the risk of hospitalization and mortality with the use of sacubitril/valsartan vs. enalapril in patients with heart failure. Methods: This was a population-based cohort study using the Hong Kong-wide electronic healthcare database. Patients diagnosed with heart failure and newly prescribed sacubitril/valsartan or enalapril between July 2016 and June 2019 were included. The risk of primary composite outcome of cardiovascular mortality or heart failure-related hospitalization, all-cause hospitalization, heart failure-related hospitalization, cardiovascular mortality and all-cause mortality were compared using Cox regression with inverse probability treatment weighting. Additional analysis was conducted by age stratification. Results: Of the 44,503 patients who received sacubitril/valsartan or enalapril, 3,237 new users (sacubitril/valsartan, n = 1,056; enalapril, n = 2,181) with a diagnosis of heart failure were identified. Compared with enalapril, sacubitril/valsartan users were associated with a lower risk of primary composite outcome [hazard ratio (HR) 0.58; 95% confidence interval (CI), 0.45–0.75], heart failure-related hospitalization (HR 0.59; 95% CI, 0.45–0.77), all-cause mortality (HR 0.51; 95% CI, 0.36–0.74) and borderline non-significant reductions in all-cause hospitalization (HR 0.85; 95% CI, 0.70–1.04) and cardiovascular mortality (HR 0.63; 95% CI, 0.39–1.02). The treatment effect of sacubitril/valsartan remains unaltered in the patient subgroup age ≥ 65 years (73%). Conclusions: In real-world settings, sacubitril/valsartan was associated with improved survival and reduced heart failure-related hospitalization compared to enalapril in Asian patients with heart failure. The effectiveness remains consistent in the older population.
Collapse
Affiliation(s)
- Swathi Pathadka
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China
| | - Vincent K C Yan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China
| | - Xue Li
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China.,Department of Social Work and Social Administration, Faculty of Social Science, University of Hong Kong, Hong Kong, China
| | - Gary Tse
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
| | - Eric Y F Wan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Hayden Lau
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Department of Accident & Emergency, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Wallis C Y Lau
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Research Department of Practice and Policy, University College of London School of Pharmacy, London, United Kingdom
| | - David C W Siu
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Research Department of Practice and Policy, University College of London School of Pharmacy, London, United Kingdom
| |
Collapse
|
104
|
Miller RJH, Howlett JG, Fine NM. A Novel Approach to Medical Management of Heart Failure With Reduced Ejection Fraction. Can J Cardiol 2021; 37:632-643. [PMID: 33453357 DOI: 10.1016/j.cjca.2020.12.028] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2020] [Revised: 12/29/2020] [Accepted: 12/29/2020] [Indexed: 01/05/2023] Open
Abstract
The advent of newly available medical therapies for heart failure with reduced ejection fraction (HFrEF) has resulted in many potential therapeutic combinations, increasing treatment complexity. Publication of expert consensus guidelines and initiatives aimed to improve implementation of treatment has emphasized sequential stepwise initiation and titration of medical therapy, which is labour intensive. Data taken from heart failure registries show suboptimal use of medications, prolonged titration times, and consequently little change in dose intensity, all of which indicate therapeutic inertia. Recently published evidence indicates that 4 medication classes-renin-angiotensin-neprilysin inhibitors, β-blockers, mineralocorticoid antagonists, and sodium-glucose cotransporter inhibitors-which we refer to as Foundational Therapy, confer rapid and robust reduction in both morbidity and mortality in most patients with HFrEF and that they work in additive fashion. Additional morbidity and mortality may be observed following addition of several personalized therapies in specific subgroups of patients. In this review, we discuss mechanisms of action of these therapies and propose a framework for their implementation, based on several principles. These include the critical importance of rapid initiation of all 4 Foundational Therapies followed by their titration to target doses, emphasis on multiple simultaneous drug changes with each patient encounter, attention to patient-specific factors in choice of medication class, leveraging inpatient care, use of the entire health care team, and alternative (ie, virtual visits) modes of care. We have incorporated these principles into a Cluster Scheme designed to facilitate timely and optimal medical treatment for patients with HFrEF.
Collapse
Affiliation(s)
- Robert J H Miller
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan G Howlett
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Nowell M Fine
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
105
|
Hadwiger M, Frielitz FS, Eisemann N, Elsner C, Dagres N, Hindricks G, Katalinic A. Cardiac Resynchronisation Therapy in Patients with Moderate to Severe Heart Failure in Germany: A Cost-Utility Analysis of the Additional Defibrillator. APPLIED HEALTH ECONOMICS AND HEALTH POLICY 2021; 19:57-68. [PMID: 32215877 PMCID: PMC7790776 DOI: 10.1007/s40258-020-00571-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
BACKGROUND Cardiac resynchronisation therapy (CRT) is a well-established form of treatment for patients with heart failure and cardiac dyssynchrony. There are two different types of CRT devices: the biventricular pacemaker (CRT-P) and the biventricular defibrillator (CRT-D). The latter is more complex but also more expensive. For the majority of patients who are eligible for CRT, both devices are appropriate according to current guidelines. The purpose of this study was to conduct a cost-utility analysis for CRT-D compared to CRT-P from a German payer's perspective. METHODS A cohort Markov-model was developed to assess average costs and quality-adjusted life-years (QALY) for CRT-D and CRT-P. The model consisted of six stages: one for the device implementation, one for the absorbing state death, and two stages ("Stable" and "Hospital") for either a CRT device or medical therapy. The time horizon was 20 years. Deterministic and probabilistic sensitivity analyses and scenario analyses were conducted. RESULTS The incremental cost-effectiveness ratio (ICER) of CRT-D compared with CRT-P was €24,659 per additional QALY gained. In deterministic sensitivity analysis, the survival advantage of CRT-D to CRT-P was the most influential input parameter. In the probabilistic sensitivity analysis 96% of the simulated cases were more effective but also more costly. CONCLUSIONS Therapy with CRT-D compared to CRT-P resulted in an additional gain of QALYs, but was more expensive. In addition, the ICER was subject to uncertainty, especially due to the uncertainty in the survival benefit. A randomised controlled trial and subgroup analyses would be desirable to further inform decision making.
Collapse
Affiliation(s)
- Moritz Hadwiger
- Institute of Social Medicine and Epidemiology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany.
| | - Fabian-Simon Frielitz
- Institute of Social Medicine and Epidemiology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Nora Eisemann
- Institute of Social Medicine and Epidemiology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Christian Elsner
- Institute of Social Medicine and Epidemiology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| | - Nikolaos Dagres
- Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Gerhard Hindricks
- Heart Center Leipzig, University of Leipzig, Strümpellstr. 39, 04289, Leipzig, Germany
| | - Alexander Katalinic
- Institute of Social Medicine and Epidemiology, University of Lübeck, Ratzeburger Allee 160, 23538, Lübeck, Germany
| |
Collapse
|
106
|
Judge PK, Haynes R. TaleNeprilysin and Neprilysin inhibition in chronic kidney disease. Curr Opin Nephrol Hypertens 2021; 30:123-130. [PMID: 33148948 DOI: 10.1097/mnh.0000000000000659] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
PURPOSE OF REVIEW Chronic kidney disease (CKD) is associated with increased risk of progression to end-stage kidney disease and cardiovascular events. There is limited evidence that available treatments have beneficial effects on cardiorenal outcomes in all people with nondiabetic CKD. Neprilysin inhibition (NEPi) is a new therapeutic strategy with potential to improve outcomes for patients with CKD. RECENT FINDINGS NEPi enhances the activity of the natriuretic peptide system producing natriuresis, diuresis and inhibition of the renin-angiotensin system and sympathetic nervous system. Sacubitril/valsartan is the first Angiotensin receptor-neprilysin inhibitor (ARNI) to be produced and has been shown to substantially improve cardiovascular outcomes in heart failure and delay progression of kidney disease in this population. Although ARNIs have not shown similar effects on kidney function in the short-to-medium term in people with CKD, they are associated with substantial reductions in cardiac biomarkers and blood pressure in CKD. SUMMARY These data suggest that NEPi with an ARNI could benefit patients with CKD by reducing the risk of cardiovascular disease and have the possibility of retarding the progression of CKD (hence delaying the need for renal replacement therapy).
Collapse
Affiliation(s)
| | - Richard Haynes
- Medical Research Council Population Health Research Unit, Nuffield Department of Population Health, Richard Doll Building, Old Road Campus, Oxford, UK
| |
Collapse
|
107
|
Bunsawat K, Ratchford SM, Alpenglow JK, Park SH, Jarrett CL, Stehlik J, Smith AS, Richardson RS, Wray DW. Sacubitril-valsartan improves conduit vessel function and functional capacity and reduces inflammation in heart failure with reduced ejection fraction. J Appl Physiol (1985) 2021; 130:256-268. [PMID: 33211601 PMCID: PMC7944927 DOI: 10.1152/japplphysiol.00454.2020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2020] [Revised: 11/11/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
The Prospective comparison of ARNI with angiotensin-converting enzyme inhibitor to Determine Impact on Global Mortality and morbidity in Heart Failure trial identified a marked reduction in the risk of death and hospitalization for heart failure in patients with heart failure with reduced ejection fraction (HFrEF) treated with sacubitril-valsartan (trade name Entresto), but the physiological processes underpinning these improvements are unclear. We tested the hypothesis that treatment with sacubitril-valsartan improves peripheral vascular function, functional capacity, and inflammation in patients with HFrEF. We prospectively studied patients with HFrEF (n = 11, 10 M/1 F, left ventricular ejection fraction = 27 ± 8%) on optimal, guideline-directed medical treatment who were subsequently prescribed sacubitril-valsartan (open-label, uncontrolled, and unblinded). Peripheral vascular function [brachial artery flow-mediated dilation (FMD, conduit vessel function) and reactive hyperemia (RH, microvascular function)], functional capacity [six-minute walk test (6MWT) distance], and the proinflammatory biomarkers tumor necrosis factor-α (TNF-α) and interleukin-18 (IL-18) were obtained at baseline and at 1, 2, and 3 mo of treatment. %FMD improved after 1 mo of treatment, and this favorable response persisted for months 2 and 3 (baseline: 3.25 ± 1.75%; 1 mo: 5.23 ± 2.36%; 2 mo: 5.81 ± 1.79%; 3 mo: 6.35 ± 2.77%), whereas RH remained unchanged. 6MWT distance increased at months 2 and 3 (baseline: 420 ± 92 m; 1 mo: 436 ± 98 m; 2 mo: 465 ± 115 m; 3 mo: 460 ± 110 m), and there was a sustained reduction in TNF-α (baseline: 2.38 ± 1.35 pg/mL; 1 mo: 2.06 ± 1.52 pg/mL; 2 mo: 1.95 ± 1.34 pg/mL; 3 mo: 1.92 ± 1.37 pg/mL) and a reduction in IL-18 at month 3 (baseline: 654 ± 150 pg/mL; 1 mo: 595 ± 140 pg/mL; 2 mo: 601 ± 176 pg/mL; 3 mo: 571 ± 127 pg/mL). This study provides new evidence for the potential of this new drug class to improve conduit vessel function, functional capacity, and inflammation in patients with HFrEF.NEW & NOTEWORTHY We observed an approximately twofold improvement in conduit vessel function (brachial artery FMD), increased functional capacity (6MWT distance), and a reduction in inflammation (TNF-α and IL-18) following 3 mo of sacubitril-valsartan therapy. These findings provide important new information concerning the physiological mechanisms by which this new drug class provokes favorable changes in HFrEF pathophysiology.
Collapse
Affiliation(s)
- Kanokwan Bunsawat
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Stephen M Ratchford
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Department of Health & Exercise Science, Appalachian State University, Boone, North Carolina
| | - Jeremy K Alpenglow
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah
| | - Soung Hun Park
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah
| | - Catherine L Jarrett
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
| | - Josef Stehlik
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
| | - Adam S Smith
- Department of Pharmacy Services, University of Utah, Salt Lake City, Utah
| | - Russell S Richardson
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah
| | - D Walter Wray
- Division of Geriatrics, Department of Internal Medicine, University of Utah, Salt Lake City, Utah
- Geriatric Research, Education, and Clinical Center, George E. Wahlen Department of Veterans Affairs Medical Center, Salt Lake City, Utah
- Department of Nutrition and Integrative Physiology, University of Utah, Salt Lake City, Utah
| |
Collapse
|
108
|
Expect the Unexpected in the Medical Treatment of Heart Failure with Reduced Ejection Fraction: between Scientific Evidence and Clinical Wisdom. INTERNATIONAL JOURNAL OF HEART FAILURE 2021; 3:205-218. [PMID: 36262556 PMCID: PMC9536688 DOI: 10.36628/ijhf.2021.0013] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2021] [Revised: 05/13/2021] [Accepted: 05/13/2021] [Indexed: 11/20/2022]
Abstract
Over the past three decades, pharmacological treatment of heart failure (HF) with reduced ejection fraction (HFrEF) has witnessed a significant progress with the introduction of multiple disease-modifying therapies with a proven benefit on morbidity, mortality and quality of life. Recently, several novel medications (sacubitril/valsartan, sodium-glucose contransporter-2 [SGLT2] inhibitors, vericiguat and omecamtiv mecarbil) have shown to provide further improvement in outcomes in patients already receiving standard therapy for HFrEF. Available evidence suggests that sacubitril/valsartan and SGLT2 inhibitors (dapagliflozin and empagliflozin) are beneficial and well-tolerated in the majority inpatients and could be the mainstay treatment of HFrEF. Another group of medications (vericiguat and omecamtiv mecarbil) has shown promising results in reducing the risk of the composite of HF hospitalisation or cardiovascular mortality in patients with the more severe or advanced HF requiring recent hospitalisation. Therefore, these medications may be considered for the treatment of select group of patients with HFrEF with persisting or worsening symptoms despite optimal treatment. In addition, advances in pharmacological management of comorbidities frequently seen in HFrEF patients (diabetes, iron deficiency/anaemia, hyperkalaemia) provide further opportunities to improve outcomes. Given the increasing complexity of evidence-based therapies for HFrEF, there is a growing need to provide a practical perspective to their use. The purpose of this review is to summarise scientific evidence on the efficacy and safety of new and emerging medical therapies in HFrEF, with a focus on the clinical perspective of their use.
Collapse
|
109
|
Seferović PM, Polovina M. An ounce of prevention is worth a pound of cure: drugs and devices to prevent sudden cardiac death in heart failure. Eur J Prev Cardiol 2020; 28:107-109. [PMID: 33624022 DOI: 10.1093/eurjpc/zwaa061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Affiliation(s)
- Petar M Seferović
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Serbian Academy of Science and Arts, Heart Failure Society of Serbia, 8 Koste Todorovića, 11000 Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Department of Cardiology, Clinical Centre of Serbia, 11000 Belgrade, Serbia
| |
Collapse
|
110
|
Boriani G, De Ponti R, Guerra F, Palmisano P, Zanotto G, D'Onofrio A, Ricci RP. Sinergy between drugs and devices in the fight against sudden cardiac death and heart failure. Eur J Prev Cardiol 2020; 28:110-123. [PMID: 33624080 DOI: 10.1093/eurjpc/zwaa015] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 06/28/2020] [Accepted: 07/17/2020] [Indexed: 01/02/2023]
Abstract
The impact of sudden cardiac death (SCD) in heart failure (HF) patients is important and prevention of SCD is a reasonable and clinically justified endpoint if associated with a reduction in all-cause mortality. According to literature, in HF with reduced ejection fraction, only three classes of agents were found effective in reducing SCD and all-cause mortality: beta-blockers, mineralcorticoid receptor antagonists and, more recently, angiotensin-receptor neprilysin-inhibitors. In the PARADIGM trial that tested sacubitril/valsartan vs. enalapril, the 20% relative risk reduction in cardiovascular deaths obtained with sacubitril/valsartan was attributable to reductions in the incidence of both SCD and death due to HF worsening and this effect can be added to the known positive effect of implantable cardioverter-defibrillators in appropriately selected patients. In order to maximize the implementation of all the available treatments, patients with HF should be included in virtuous networks with a dialogue between all the physician involved, with commitment by all these physicians for appropriate decision-making on application of pharmacological and device treatments according to available evidence, as well as commitment for drug titration before and after device implant, taking advantage from remote monitoring, and with the safety of back up device therapy when indicated. There are potential synergistic effects of drug therapy, with all the therapies acting on neuro-hormonal and sympathetic activation, but specifically with sacubitril/valsartan, and device therapy, in particular cardiac resynchronization therapy, with added incremental benefits on positive cardiac remodelling, prevention of HF progression, and prevention of ventricular tachyarrhythmias.
Collapse
Affiliation(s)
- Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Largo del Pozzo 71, 41121 Modena, Italy
| | - Roberto De Ponti
- Cardiovascular Department, Circolo Hospital, Università degli Studi dell'Insubria, Via Ravasi, 2, 21100 Varese, Italy
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital 'Ospedali Riuniti', Via Lodovico Menicucci, 6, 60121 Ancona, Italy
| | - Pietro Palmisano
- Cardiology Unit, 'Card. G. Panico' Hospital, Via Papa Pio X, 4, 73039 Tricase, Italy
| | - Gabriele Zanotto
- UFS Cardiologia Interventistica - Cardiologia Ospedale Mater Salutis, Via Carlo Gianella, 1, 37045 Legnago, Italy
| | - Antonio D'Onofrio
- Unità Operativa di Elettrofisiologia, Studio e Terapia delle Aritmie, Azienda Ospedaliera dei Colli - Monaldi, Via Leonardo Bianchi, 80131, Naples, Italy
| | | |
Collapse
|
111
|
Sabbah HN, Zhang K, Gupta RC, Xu J, Singh-Gupta V. Effects of Angiotensin-Neprilysin Inhibition in Canines with Experimentally Induced Cardiorenal Syndrome. J Card Fail 2020; 26:987-997. [PMID: 32841710 PMCID: PMC7704862 DOI: 10.1016/j.cardfail.2020.08.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 08/12/2020] [Accepted: 08/17/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND Sacubitril/valsartan (Sac/Val), a combined angiotensin-II receptor blocker (Val) and neprilysin inhibitor (Sac) in a 1:1 molar ratio, was shown to decrease the risk of cardiovascular death or heart failure (HF) hospitalization in patients with HF and reduced left ventricular (LV) ejection fraction. This study examined the effects of Sac/Val on LV structure, function, and bioenergetics, and on biomarkers of kidney injury and kidney function in dogs with experimental cardiorenal syndrome. METHODS AND RESULTS Fourteen dogs with cardiorenal syndrome (coronary microembolization-induced HF and renal dysfunction) were randomized to 3 months Sac/Val therapy (100 mg once daily, n = 7) or no therapy (control, n = 7). LV ejection fraction and troponin-I, as well as biomarkers of kidney injury/function including serum creatinine and urinary kidney injury molecule-1 were measured before and at end of therapy and the change (treatment effect change) calculated. Mitochondrial function measures, including the maximum rate of adenosine triphosphate synthesis, were measured in isolated cardiomyocytes at end of therapy. In Sac/Val dogs, the change in ejection fraction increased compared with controls, 6.9 ± 1.4 vs 0.7 ± 0.6%, P < .002, whereas change in troponin I decreased, -0.16 ± 0.03 vs -0.03 ± 0.02 ng/mL, P < .001. Urinary change in kidney injury molecule 1 decreased in Sac/Val-treated dogs compared with controls, -17.2 ± 7.9 vs 7.7 ± 3.0 mg/mL, P < .007, whereas the change in serum creatinine was not significantly different. Treatment with Sac/Val increased adenosine triphosphate synthesis compared with controls, 3240 ± 121 vs 986 ± 84 RLU/µg protein, P < .05. CONCLUSIONS In dogs with cardiorenal syndrome, Sac/Val improves LV systolic function, improves mitochondrial function and decreases biomarkers of heart and kidney injury. The results offer mechanistic insights into the benefits of Sac/Val in HF with compromised renal function.
Collapse
Affiliation(s)
- Hani N Sabbah
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan.
| | - Kefei Zhang
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Ramesh C Gupta
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Jiang Xu
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| | - Vinita Singh-Gupta
- Department of Medicine, Division of Cardiovascular Medicine, Henry Ford Hospital, Detroit, Michigan
| |
Collapse
|
112
|
Abstract
In situ ATR-FTIR spectroscopy and imaging and image analysis were applied to the study of the multicomponent co-crystallization process involving S-valsartan and sacubitril in which LCZ696 crystals were formed. LCZ696 is a combination drug for use in heart failure that was approved by the FDA in 2015 following development by Novartis Pharmaceuticals. Though much work was reported on LCZ696 about its pharmacokinetic and pharmacodynamic effects in the evaluation and clinical testing, less attention was paid to study on the co-crystallization process. LCZ696 crystals have shown difficulties in filtration mainly due to the small particle size. In this work, LCZ696 crystals were prepared successfully by S-valsartan and sacubitril, and characterized by SEM, XRPD, TG-DSC and ATR-FTIR. ATR-FTIR and imaging and image analysis were used to monitoring solution concentration and investigating the co-crystallization mechanism. It revealed that the nucleation process was very slow compared with the transformation process, which is indication that the co-crystallization was controlled by nucleation. LCZ696 crystals are composed of very thin hexagonal plates, which seems indicating that LCZ696 crystals grow mainly in two size dimensions. Stirrer speed and crystal seeds were found to have noticeable effect on the induction time, transformation time and crystal size distribution. The Johnson-Mehl-Avrami equation was found to be able to describe the co-crystallization process.
Collapse
|
113
|
Docherty KF, Vaduganathan M, Solomon SD, McMurray JJV. Sacubitril/Valsartan: Neprilysin Inhibition 5 Years After PARADIGM-HF. JACC. HEART FAILURE 2020; 8:800-810. [PMID: 33004114 PMCID: PMC8837825 DOI: 10.1016/j.jchf.2020.06.020] [Citation(s) in RCA: 60] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 12/22/2022]
Abstract
Sacubitril/valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), has been shown to reduce the risk of cardiovascular death or heart failure hospitalization and improve symptoms among patients with chronic heart failure with reduced ejection fraction compared to enalapril, the gold standard angiotensin-converting enzyme inhibitor. In the 5 years since the publication of the results of PARADIGM-HF, further insight has been gained into integrating a neprilysin inhibitor into a comprehensive multidrug regimen, including a renin-angiotensin aldosterone system (RAS) blocker. This paper reviews the current understanding of the effects of sacubitril/valsartan and highlights expected developments over the next 5 years, including potential new indications for use. Additionally, a practical, evidence-based approach is provided to the clinical integration of sacubitril/valsartan among patients with heart failure with reduced ejection fraction.
Collapse
Affiliation(s)
- Kieran F Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - Scott D Solomon
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, Massachusetts
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom.
| |
Collapse
|
114
|
Sacubitril/Valsartan and Sudden Cardiac Death According to Implantable Cardioverter-Defibrillator Use and Heart Failure Cause. JACC-HEART FAILURE 2020; 8:844-855. [DOI: 10.1016/j.jchf.2020.06.015] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/28/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 11/18/2022]
|
115
|
Packer M, Metra M. Guideline-directed medical therapy for heart failure does not exist: a non-judgmental framework for describing the level of adherence to evidence-based drug treatments for patients with a reduced ejection fraction. Eur J Heart Fail 2020; 22:1759-1767. [PMID: 32432391 PMCID: PMC7687274 DOI: 10.1002/ejhf.1857] [Citation(s) in RCA: 33] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 04/09/2020] [Accepted: 04/21/2020] [Indexed: 12/11/2022] Open
Abstract
Numerous guideline documents have issued recommendations to clinicians concerning the treatment of chronic heart failure and a reduced ejection fraction. However, guidelines do not describe what constitutes an acceptable standard of care, and thus, practitioners who adhere to only a small fraction of the recommendations might claim that they are treating patients 'in accordance with the guidelines'. As a result, <1% of patients with heart failure are receiving all life-prolonging treatments at trial-proven doses. A major impediment to the widespread adoption of trial-based treatments is a lack of any existing framework that would allow physicians to describe the adequacy of care. To address this deficiency, we propose a novel simple approach that would ask practitioners if a patient had been treated using the dosing algorithm that had been shown to be effective for each drug class. The proposed framework recognizes that all landmark survival trials in heart failure were 'strategy trials', i.e. the studies mandated a standardized forced-titration treatment plan that required timely uptitration to specified target dose unless patients experienced clinically meaningful, intolerable or serious adverse events, which persisted or recurred despite adjustment of other medications. Adherence to trial-proven regimens might be improved if physicians were asked to describe the degree to which a patient's treatment adhered to or deviated from the strategies that had been used to demonstrate the survival benefits of neurohormonal antagonists. The proposed framework should also promote practitioner self-awareness about the lack of evidence supporting the current widespread use of subtarget doses that are non-adherent with trial-proven forced-titration strategies.
Collapse
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical CenterDallasTXUSA
- Imperial CollegeLondonUK
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| |
Collapse
|
116
|
LCZ696 Ameliorates Oxidative Stress and Pressure Overload-Induced Pathological Cardiac Remodeling by Regulating the Sirt3/MnSOD Pathway. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:9815039. [PMID: 33014281 PMCID: PMC7519988 DOI: 10.1155/2020/9815039] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2020] [Revised: 08/10/2020] [Accepted: 08/22/2020] [Indexed: 12/11/2022]
Abstract
Aims We aimed to investigate whether LCZ696 protects against pathological cardiac hypertrophy by regulating the Sirt3/MnSOD pathway. Methods In vivo, we established a transverse aortic constriction animal model to establish pressure overload-induced heart failure. Subsequently, the mice were given LCZ696 by oral gavage for 4 weeks. After that, the mice underwent transthoracic echocardiography before they were sacrificed. In vitro, we introduced phenylephrine to prime neonatal rat cardiomyocytes and small-interfering RNA to knock down Sirt3 expression. Results Pathological hypertrophic stimuli caused cardiac hypertrophy and fibrosis and reduced the expression levels of Sirt3 and MnSOD. LCZ696 alleviated the accumulation of oxidative reactive oxygen species (ROS) and cardiomyocyte apoptosis. Furthermore, Sirt3 deficiency abolished the protective effect of LCZ696 on cardiomyocyte hypertrophy, indicating that LCZ696 induced the upregulation of MnSOD and phosphorylation of AMPK through a Sirt3-dependent pathway. Conclusions LCZ696 may mitigate myocardium oxidative stress and apoptosis in pressure overload-induced heart failure by regulating the Sirt3/MnSOD pathway.
Collapse
|
117
|
Tini G, Bertero E, Signori A, Sormani MP, Maack C, De Boer RA, Canepa M, Ameri P. Cancer Mortality in Trials of Heart Failure With Reduced Ejection Fraction: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e016309. [PMID: 32862764 PMCID: PMC7726990 DOI: 10.1161/jaha.119.016309] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 05/27/2020] [Indexed: 12/11/2022]
Abstract
Background The burden of cancer in heart failure with reduced ejection fraction is apparently growing. Randomized controlled trials (RCTs) may help understanding this observation, since they span decades of heart failure treatment. Methods and Results We assessed cancer, cardiovascular, and total mortality in phase 3 heart failure RCTs involving ≥90% individuals with left ventricular ejection fraction <45%, who were not acutely decompensated and did not represent specific patient subsets. The pooled odds ratios (ORs) of each type of death for the control and treatment arms were calculated using a random-effects model. Temporal trends and the impact of patient and RCT characteristics on mortality outcomes were evaluated by meta-regression analysis. Cancer mortality was reported for 15 (25%) of 61 RCTs, including 33 709 subjects, and accounted for 6% to 14% of all deaths and 17% to 67% of noncardiovascular deaths. Cancer mortality rate was 0.58 (95% CI, 0.46-0.71) per 100 patient-years without temporal trend (P=0.35). Cardiovascular (P=0.001) and total (P=0.001) mortality rates instead decreased over time. Moreover, cancer mortality was not influenced by treatment (OR, 1.08; 95% CI, 0.92-1.28), unlike cardiovascular (OR, 0.88; 95% CI, 0.79-0.98) and all-cause (OR, 0.91; 95% CI, 0.84-0.99) mortality. Meta-regression did not reveal significant sources of heterogeneity. Possible reasons for excluding patients with malignancy overlapped among RCTs with and without published cancer mortality, and malignancy was an exclusion criterion only for 4 (8.7%) of the RCTs not reporting cancer mortality. Conclusions Cancer is a major, yet overlooked cause of noncardiovascular death in heart failure with reduced ejection fraction, which has become more prominent with cardiovascular mortality decline.
Collapse
Affiliation(s)
- Giacomo Tini
- Cardiovascular Disease UnitIRCCS Ospedale Policlinico San MartinoIRCCS Italian Cardiovascular NetworkGenovaItaly
- Department of Internal MedicineUniversity of GenovaItaly
| | - Edoardo Bertero
- Comprehensive Heart Failure Center (CHFC)University Clinic WürzburgWürzburgGermany
| | - Alessio Signori
- Department of Health SciencesSection of BiostatisticsUniversity of GenovaItaly
| | - Maria Pia Sormani
- Department of Health SciencesSection of BiostatisticsUniversity of GenovaItaly
| | - Christoph Maack
- Comprehensive Heart Failure Center (CHFC)University Clinic WürzburgWürzburgGermany
| | - Rudolf A. De Boer
- Department of CardiologyUniversity of GroningenUniversity Medical Center GroningenGroningenThe Netherlands
| | - Marco Canepa
- Cardiovascular Disease UnitIRCCS Ospedale Policlinico San MartinoIRCCS Italian Cardiovascular NetworkGenovaItaly
- Department of Internal MedicineUniversity of GenovaItaly
| | - Pietro Ameri
- Cardiovascular Disease UnitIRCCS Ospedale Policlinico San MartinoIRCCS Italian Cardiovascular NetworkGenovaItaly
- Department of Internal MedicineUniversity of GenovaItaly
| |
Collapse
|
118
|
Chatterjee NA, Rea TD. Secondary prevention of sudden cardiac death. Heart Rhythm O2 2020; 1:297-310. [PMID: 34113884 PMCID: PMC8183887 DOI: 10.1016/j.hroo.2020.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/05/2022] Open
Abstract
The prevention and treatment of sudden cardiac death (SCD) remains a significant public health challenge. For patients with a history of sudden death attributable to ventricular arrhythmia, implantable cardioverter-defibrillator (ICD) therapy is a mainstay of treatment, although these patients remain at high risk for recurrent ventricular arrhythmia and defibrillator therapies. In this review, we summarize landmark clinical trials evaluating the efficacy of ICD therapy in secondary prevention patients, review clinical outcomes including mode of death in survivors of SCD, and highlight the role for systematic diagnostic evaluation. We additionally discuss the invasive electrophysiological management of these patients, including ICD selection and programming as well as the role and timing of antiarrhythmic drug therapy and catheter ablation. Finally, we frame future challenges and needs to advance the care for secondary prevention patients.
Collapse
Affiliation(s)
- Neal A Chatterjee
- Electrophysiology Section, Cardiology Division, University of Washington, Seattle, Washington
| | - Thomas D Rea
- Division of General Internal Medicine, University of Washington, Seattle, Washington
| |
Collapse
|
119
|
Yenerçağ M, Arslan U, Dereli S, Çoksevim M, Doğduş M, Kaya A. Effects of angiotensin receptor neprilysin inhibition on pulmonary arterial stiffness in heart failure with reduced ejection fraction. Int J Cardiovasc Imaging 2020; 37:165-173. [PMID: 32815051 DOI: 10.1007/s10554-020-01973-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Accepted: 08/14/2020] [Indexed: 11/25/2022]
Abstract
The sacubitril/valsartan combination is an important agent used in the treatment of heart failure with reduced ejection fraction (HFrEF). Pulmonary artery stiffness (PAS) is an index developed to evaluate the pulmonary vascular bed. Changes in pulmonary vascular structures in HFrEF patients can affect PAS. In this study, we aimed to investigate the effect of sacubitril/valsartan on PAS in HFrEF patients. One hundred fifty HFrEF patients, who received sacubitril/valsartan therapy and continued for at least 6 months without interruption, were examined retrospectively. N-terminal pro-B-type natriuretic peptide levels (NT-proBNP), NYHA classes, Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores, New York Heart Association (NYHA) functional classes and echocardiograpic parameters such as left ventricular ejection fraction (LVEF), mean pulmonary artery pressure (mPAP), right ventricle myocardial performance index (RV-MPI), Tricuspid annular plane systolic excursion (TAPSE), right ventricular fractional area change (RV-FAC) and PAS changes were evaluated before and 6 months after sacubitril/valsartan treatment. PAS was calculated by using the maximal frequency shift and acceleration time of the pulmonary artery flow trace measured in the echocardiogram. PAS values were significantly reduced (23.8 ± 2.8 vs 19.1 ± 3.1 kHz/ms, p < 0.001) after the sacubitril/valsartan treatment. Sacubitril/valsartan treatment was associated with significant improvements in NYHA class and MLWHFQ scores; significant reductions in the NT-proBNP levels, mPAP, and RV-MPI, and significant increases in LVEF, TAPSE, and RV-FAC (p < 0.05). The significant reduction in the PAS value was significantly correlated with the improvements in the MLWFQ scores, NT-proBNP levels, mPAP, RV-MPI, TAPSE and RV-FAC. In HFrEF patients, switching from angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker therapy to sacubitril/valsartan may result in reduction in PAS.
Collapse
Affiliation(s)
- Mustafa Yenerçağ
- Department of Cardiology, University of Health Sciences Samsun Training and Research Hospital, Baris Bulvari, No: 199, 55400, Samsun, Turkey
| | - Uğur Arslan
- Department of Cardiology, University of Health Sciences Samsun Training and Research Hospital, Baris Bulvari, No: 199, 55400, Samsun, Turkey.
| | - Seçkin Dereli
- Deparment of Cardiology, Ordu University Faculty of Medicine, Ordu, Turkey
| | - Metin Çoksevim
- Deparment of Cardiology, Ondokuz Mayis University Faculty of Medicine, Samsun, Turkey
| | - Mustafa Doğduş
- Department of Cardiology, University of Usak Training and Research Hospital, Usak, Turkey
| | - Ahmet Kaya
- Deparment of Cardiology, Ordu University Faculty of Medicine, Ordu, Turkey
| |
Collapse
|
120
|
Cuthbert JJ, Pellicori P, Clark AL. Cardiovascular Outcomes with Sacubitril-Valsartan in Heart Failure: Emerging Clinical Data. Ther Clin Risk Manag 2020; 16:715-726. [PMID: 32848403 PMCID: PMC7425097 DOI: 10.2147/tcrm.s234772] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022] Open
Abstract
One of the defining features of heart failure (HF) is neurohormonal activation. The renin-angiotensin-aldosterone-system (RAAS) and sympathetic nervous system (SNS) cause vasoconstriction and fluid retention and, in response, the secretion of natriuretic peptides (NPs) from volume and pressure-overloaded myocardium promotes vasodilation and diuresis. Inhibition of the RAAS with either angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) has been the cornerstone of medical treatment for HF with a reduced ejection fraction (HFrEF) but, until recently, it was unclear how the beneficial effects of NPs may be augmented in patients with HF. Neprilysin, a metalloproteinase widely distributed throughout the body, plays a role in degrading the gross excess of circulating NPs in patients with HF. Early studies of neprilysin inhibition suggested possible physiological benefits. In 2014, the PARADIGM-HF trial found that sacubitril-valsartan, a combination of the ARB valsartan, and the neprilysin inhibitor sacubitril, was superior to enalapril in patients with HFrEF, reducing the relative risk of cardiovascular (CV) death or first hospitalisation with HF by 20%. Almost half of the patients with HF symptoms have a “preserved” ejection fraction (HFpEF); however, the PARAGON-HF study found that sacubitril-valsartan in patients with LVEF ≥45% had no effect on CV death or first and recurrent hospitalisations with HF compared to valsartan. Guidelines across the world have changed to include sacubitril-valsartan for patients with HFrEF yet, nearly 6 years after PARADIGM-HF, there is still uncertainty as to when and in whom sacubitril-valsartan should be started. Furthermore, there may yet be subsets of patients with HFpEF who might benefit from treatment with sacubitril-valsartan. This review will describe the mechanisms behind the outcome benefit of sacubitril-valsartan in patients with HFrEF and to consider its future role in the management of patients with HF.
Collapse
Affiliation(s)
- Joseph J Cuthbert
- Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Kingston upon Hull HU16 5JQ, UK
| | - Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Kingston upon Hull HU16 5JQ, UK
| |
Collapse
|
121
|
Akbar S, Kabra N, Aronow WS. Impact of Sacubitril/Valsartan on Patient Outcomes in Heart Failure: Evidence to Date. Ther Clin Risk Manag 2020; 16:681-688. [PMID: 32801725 PMCID: PMC7405908 DOI: 10.2147/tcrm.s224772] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Accepted: 07/14/2020] [Indexed: 12/11/2022] Open
Abstract
With an estimated 6.2 million adults affected in the USA, heart failure remains a leading cause of morbidity, mortality, and health-care costs, despite the use of guideline-based medical therapies. The search for a more efficient therapy was rekindled when findings from the Prospective Comparison of Angiotensin Receptor–Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial demonstrated evidence for cardiovascular and mortality benefit of sacubitril/valsartan, a dual angiotensin receptor blocker and neprilysin inhibitor (ARNI), over enalapril (an angiotensin-converting enzyme inhibitor) in patients with heart failure and reduced rjection fraction (HFrEF). Following the trial’s compelling results, recommendations for the use of sacubitril/valsartan as a replacement for an angiotensin-converting enzyme inhibitor and/or angiotensin receptor blocker were incorporated into the 2016 American College of Cardiology (ACC), the American Heart Association (AHA), and the Heart Failure Society of America recommended (HFSA) guidelines for the management of heart failure. This review aims to gain insight into the benefits as well as limitations associated with the use of sacubitril/valsartan in the treatment of heart failure (HF) through exploration of various subgroup analyses of the PARADIGM-HF trial, subsequent retrospective analyses, and randomized controlled trials that followed this landmark trial.
Collapse
Affiliation(s)
- Sara Akbar
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA.,Department of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Nitin Kabra
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA.,Department of Medicine, New York Medical College, Valhalla, NY 10595, USA
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center, Valhalla, NY 10595, USA.,Department of Medicine, New York Medical College, Valhalla, NY 10595, USA
| |
Collapse
|
122
|
Chang PC, Wang CL, Hsiao FC, Wen MS, Huang CY, Chou CC, Chu PH. Sacubitril/valsartan vs. angiotensin receptor inhibition in heart failure: a real-world study in Taiwan. ESC Heart Fail 2020; 7:3003-3012. [PMID: 32720478 PMCID: PMC7524065 DOI: 10.1002/ehf2.12924] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/08/2020] [Accepted: 07/13/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS This study aimed to compare the efficacy of angiotensin receptor-neprilysin inhibitor (ARNI) therapy with angiotensin receptor blocker (ARB) therapy for cardiovascular outcomes in patients with heart failure (HF) with reduced ejection fraction. METHODS AND RESULTS Data were obtained from the Chang Gung Research Database. The cohort entry date of the ARB group was assigned as that of the ARNI group to avoid immortal time bias. Additionally, 1:1 propensity score matching based on age, sex, and baseline left ventricular ejection fraction was conducted. The expectation-maximization imputation method with inverse probability of treatment weighting was used to compare outcomes between the two groups. The primary outcome was a composite of cardiovascular death and hospitalization for worsening HF. Patients who received ARNI therapy had a significantly lower risk of the primary composite outcome occurring than patients who received ARBs (hazard ratio, 0.74; 95% confidence interval, 0.57-0.96). The reduction of hospitalization for worsening HF contributed most to the primary outcome benefits. In addition to the primary outcome, the ARNI group had a significantly lower risk of non-fatal myocardial infarction. The improvement of ejection fraction was not significantly different between the groups. The medication doses of ARNI were lower than in clinical trials. CONCLUSIONS In patients with HF with reduced ejection fraction, sacubitril/valsartan was superior to ARB therapy in reducing the occurrence of the primary outcome endpoint of hospitalization for worsening HF and cardiovascular death.
Collapse
Affiliation(s)
- Po-Cheng Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Medical School, 5 Fu-Xing Street, Guishan District, Taoyuan, 33305, Taiwan
| | - Chun-Li Wang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Medical School, 5 Fu-Xing Street, Guishan District, Taoyuan, 33305, Taiwan
| | - Fu-Chih Hsiao
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Medical School, 5 Fu-Xing Street, Guishan District, Taoyuan, 33305, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Medical School, 5 Fu-Xing Street, Guishan District, Taoyuan, 33305, Taiwan
| | - Chien-Ying Huang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Medical School, 5 Fu-Xing Street, Guishan District, Taoyuan, 33305, Taiwan
| | - Chung-Chuan Chou
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Medical School, 5 Fu-Xing Street, Guishan District, Taoyuan, 33305, Taiwan
| | - Pao-Hsien Chu
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou and Chang Gung University, Medical School, 5 Fu-Xing Street, Guishan District, Taoyuan, 33305, Taiwan
| |
Collapse
|
123
|
Dereli S, Bayramoğlu A, Kaya A. Effects of sacubutril/valsartan on nutritional status in heart failure with reduced ejection fraction. J Cardiovasc Med (Hagerstown) 2020; 21:13-20. [PMID: 31714330 DOI: 10.2459/jcm.0000000000000895] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Malnutrition commonly occurs in patients with heart failure with reduced ejection fraction (HFrEF). Sacubitril/valsartan, which is an AT1 neprilysin inhibitor, has been shown to reduce mortality and hospitalization in patients with HFrEF. However, its effects on nutritional status remain unclear. METHODS Sacubitril/valsartan was initiated in 164 symptomatic patients with HFrEF receiving an optimal medical treatment with angiotensin inhibition (mean age: 63 ± 20 years; 120 males, 60% ischemic cause). The New York Heart Association (NYHA) functional class and nutritional statuses of the patients were evaluated at the switching to AT1 neprilysin inhibitor and at the 6th-month follow-up of the maximum sacubitril/valsartan dose using the geriatric nutritional risk index (GNRI), controlling nutritional status (CONUT) score, prognostic nutritional index (PNI), and prealbumin. RESULTS After the sacubutril/valsartan treatment, a significant reduction in the number (%) of malnourished patients was observed according to CONUT (before 47% vs. after 7%, P < 0.001), GNRI (before 39% vs. after 19%, P < 0.001), PNI scores (before 36% vs. after 12%, P = 0.002), and prealbumin (before 41% vs. after 12%, P < 0.001). Also significant changes were observed at the baseline and follow-up in the mean scores of the three different nutritional indexes and prealbumin levels [CONUT: 2.68 ± 2.5, 1.02 ± 1.0 (P < 0.001); GNRI: 97.1 ± 9.7, 101.2 ± 5.9 (P < 0.001); PNI: 38.8 ± 4.8, 41.6 ± 3.7 (P < 0.001); prealbumin: 14.6 ± 6.9 mg/dl, 17.1 ± 5.2 mg/dl (P < 0.001)]. Overall, the patients exhibited a significant functional improvement following the initiation of sacubitril/valsartan: 23% of the patients improved by two NYHA classes, 48% improved by one NYHA class, and 39% remained stable. CONCLUSION In patients with HFrEF, the switch from angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker therapy to sacubitril/valsartan resulted in a significant improvement in both nutritional and functional statuses.
Collapse
Affiliation(s)
| | - Adil Bayramoğlu
- Deparment of Cardiology, Ordu University Faculty of Medicine, Ordu, Turkey
| | - Ahmet Kaya
- Deparment of Cardiology, Ordu University Faculty of Medicine, Ordu, Turkey
| |
Collapse
|
124
|
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas.,Imperial College, London, United Kingdom
| |
Collapse
|
125
|
Cambio en la causa de muerte e influencia de la mejora terapéutica con el tiempo en pacientes con insuficiencia cardiaca y fracción de eyección reducida. Rev Esp Cardiol 2020. [DOI: 10.1016/j.recesp.2019.09.012] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
126
|
Abumayyaleh M, El-Battrawy I, Behnes M, Borggrefe M, Akin I. Current evidence of sacubitril/valsartan in the treatment of heart failure with reduced ejection fraction. Future Cardiol 2020; 16:227-236. [DOI: 10.2217/fca-2020-0002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Heart failure (HF) is one of the most common reasons for hospital admission in western countries. The measurement of the left ventricular ejection fraction is essential for the classification of HF and deciding on HF treatment. The treatment of HF has been improved in both diagnostic and therapeutic fields over the past two decades. The angiotensin receptor-neprilysin inhibitor decreased the cardiovascular mortality in patients with chronic HF with reduced ejection fraction. Sacubitril/valsartan (LCZ696) improves the imbalance between the renin-angiotensin-aldosterone and natriuretic peptide systems. We present the clinical efficacy, real-world experience, safety and tolerability, the relevance of etiology of cardiomyopathy, and gender differences and regulatory affairs of LCZ696 in the treatment of patients with HF with reduced ejection fraction.
Collapse
Affiliation(s)
- Mohammad Abumayyaleh
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| |
Collapse
|
127
|
Fernández-Vázquez D, Ferrero-Gregori A, Álvarez-García J, Gómez-Otero I, Vázquez R, Delgado Jiménez J, Worner Diz F, Bardají A, García-Pavía P, Bayés-Genís A, González-Juanatey JR, Cinca J, Pascual Figal DA. Changes in causes of death and influence of therapeutic improvement over time in patients with heart failure and reduced ejection fraction. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2020; 73:561-568. [PMID: 31974070 DOI: 10.1016/j.rec.2019.09.030] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Accepted: 09/13/2019] [Indexed: 06/10/2023]
Abstract
INTRODUCTION AND OBJECTIVES In patients with heart failure and reduced ejection fraction (HFrEF), several therapies have been proven to reduce mortality in clinical trials. However, there are few data on the effect of the use of evidence-based therapies on causes of death in clinical practice. METHODS This study included 2351 outpatients with HFrEF (< 40%) from 2 multicenter prospective registries: MUSIC (n=641, period: 2003-2004) and REDINSCOR I (n=1710, period: 2007-2011). Variables were recorded at inclusion and all patients were followed-up for 4 years. Causes of death were validated by an independent committee. RESULTS Patients in REDINSCOR I more frequently received beta-blockers (85% vs 71%; P <.001), mineralocorticoid antagonists (64% vs 44%; P <.001), implantable cardioverter-defibrillators (19% vs 2%; P <.001), and resynchronization therapy (7.2% vs 4.8%; P=.04). In these patients, sudden cardiac death was less frequent than in those in MUSIC (6.8% vs 11.4%; P <.001). After propensity score matching, we obtained 2 comparable populations differing only in treatments (575 vs 575 patients). In patients in REDINSCOR I, we found a lower risk of total mortality (HR, 0.70; 95%CI, 0.57-0.87; P=.001) and sudden cardiac death (sHR, 0.46; 95%CI, 0.30-0.70; P <.001), and a trend toward lower mortality due to end-stage HF (sHR, 0.73; 95%CI, 0.53-1.01; P=.059), without differences in other causes of death (sHR, 1.17; 95%CI, 0.78-1.75; P=.445), regardless of functional class. CONCLUSIONS In ambulatory patients with HFrEF, implementation of evidence-based therapies was associated with a lower risk of death, mainly due to a significant reduction in sudden cardiac death.
Collapse
Affiliation(s)
- David Fernández-Vázquez
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, IMIB-Arrixaca, El Palmar, Murcia, Spain
| | - Andreu Ferrero-Gregori
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Jesús Álvarez-García
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Inés Gómez-Otero
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain; Servicio de Cardiología, Hospital Universitario de Santiago de Compostela, IDIS, Santiago de Compostela, A Coruña, Spain
| | - Rafael Vázquez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain; Servicio de Cardiología, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | - Juan Delgado Jiménez
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain; Servicio de Cardiología, Hospital Universitario 12 de Octubre, Facultad de Medicina UCM, Madrid, Spain
| | - Fernando Worner Diz
- Servicio de Cardiología, Hospital Universitari Arnau de Vilanova, IRBLleida, Lleida, Spain
| | - Alfredo Bardají
- Servicio de Cardiología, Hospital Universitario Joan XXIII, Tarragona, Spain
| | - Pablo García-Pavía
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain; Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda, Majadahonda, Madrid, Spain; Facultad de Medicina, Universidad Francisco de Vitoria (UFV), Pozuelo de Alarcón, Madrid, Spain
| | - Antoni Bayés-Genís
- Servicio de Cardiología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - José R González-Juanatey
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain; Servicio de Cardiología, Hospital Universitario de Santiago de Compostela, IDIS, Santiago de Compostela, A Coruña, Spain
| | - Juan Cinca
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, Universidad Autónoma de Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain
| | - Domingo A Pascual Figal
- Servicio de Cardiología, Hospital Clínico Universitario Virgen de la Arrixaca, Universidad de Murcia, IMIB-Arrixaca, El Palmar, Murcia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares, Madrid, Spain; Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.
| |
Collapse
|
128
|
Sun J, Xu W, Hua H, Xiao Y, Chen X, Gao Z, Li S, Jing X, Du F, Sun G. Pharmacodynamic and pharmacokinetic effects of S086, a novel angiotensin receptor neprilysin inhibitor. Biomed Pharmacother 2020; 129:110410. [PMID: 32570118 DOI: 10.1016/j.biopha.2020.110410] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Revised: 06/09/2020] [Accepted: 06/13/2020] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND AND PURPOSE Angiotensin receptor-NEP inhibitor (ARNi), which includes an angiotensin receptor blocker (ARB) and a neprilysin inhibitor (NEPi), has been proven safe and effective for treating heart failure with reduced ejection fraction (HF-REF). S086 is a novel single-molecule ARNi that includes the molecular moieties of EXP3174 (the active metabolite of the ARB losartan) and sacubitril (a NEP inhibitor prodrug) in a 1:1 M ratio. We performed preclinical animal model studies to evaluate the efficacy of S086 in treating HF. EXPERIMENTAL APPROACH Rat and dog models of myocardial ischemia-induced chronic heart failure were used in this research. PRINCIPAL RESULTS The oral administration of S086 dose-dependently lowered the heart weight index, attenuated cardiac fibrosis, and improved left ventricular ejection fraction, shortening fraction, and cardiac output, without effects on hemodynamics in animal models of myocardial ischemia-induced chronic heart failure. A comparable protective effect to LCZ696 was observed for S086 at an equal molar dose in dog models. In addition, S086 was superior to LCZ696 since it significantly reversed the decrease in left ventricular posterior wall end-systolic thickness. CONCLUSION This animal study suggests that S086 is effective in treating myocardial ischemia-induced chronic heart failure.
Collapse
Affiliation(s)
- Jingchao Sun
- Shenzhen Salubris Pharmaceutical Co., Ltd., Shenzhen, Guangdong, China.
| | - Wenjie Xu
- Shenzhen Salubris Pharmaceutical Co., Ltd., Shenzhen, Guangdong, China
| | - Huaijie Hua
- Shenzhen Salubris Pharmaceutical Co., Ltd., Shenzhen, Guangdong, China
| | - Ying Xiao
- Shenzhen Salubris Pharmaceutical Co., Ltd., Shenzhen, Guangdong, China
| | - Xiaoyan Chen
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Zhiwei Gao
- Shanghai Institute of Materia Medica, Chinese Academy of Sciences, Shanghai, China
| | - Song Li
- Shenzhen Salubris Pharmaceutical Co., Ltd., Shenzhen, Guangdong, China
| | - Xiaolong Jing
- Shenzhen Salubris Pharmaceutical Co., Ltd., Shenzhen, Guangdong, China
| | - Frank Du
- WuXi AppTec (Shanghai) Co., Ltd., Shanghai, China
| | - Guofeng Sun
- WuXi AppTec (Shanghai) Co., Ltd., Shanghai, China
| |
Collapse
|
129
|
Vecchi AL, Abete R, Marazzato J, Iacovoni A, Mortara A, De Ponti R, Senni M. Ventricular arrhythmias and ARNI: is it time to reappraise their management in the light of new evidence? Heart Fail Rev 2020; 27:103-110. [PMID: 32556671 DOI: 10.1007/s10741-020-09991-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The remarkable scientific progress in the treatment of patients with heart failure (HF) and reduced ejection fraction (HFrEF) has more than halved the risk of sudden cardiac death (SCD) in this setting. However, SCD remains one of the major causes of death in this patient population. Beyond the acknowledged role of beta blockers and inhibitors of the renin-angiotensin-aldosterone system (RAAS), a new class of drugs, the angiotensin receptor neprilysin inhibitors (ARNI), proved to reduce the overall cardiovascular mortality and, more specifically, the risk of SCD in HFrEF patients. The mechanism by which ARNI may reduce the mortality connected with harmful ventricular arrhythmias is not utterly clear. A variety of direct and indirect mechanisms have been suggested, but a favorable left ventricular reverse remodeling seems to play a key role in this setting. Furthermore, the well-known protective effect of implantable cardioverter-defibrillator (ICD) has been debated in HFrEF patients with non-ischemic cardiomyopathy (NICM) arguing against the role of primary prevention ICD in this setting, particularly when ARNI therapy is considered. The purpose of this review was to provide insights into the SCD mechanisms involved in HFrEF patients together with the current role of electrical therapies and new drug agents in this setting. Graphical abstract.
Collapse
Affiliation(s)
- Andrea Lorenzo Vecchi
- Department of Heart and Vessels, Ospedale di Circolo and Macchi Foundation, University of Insubria, Varese, Italy.
| | - Raffaele Abete
- Department of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Jacopo Marazzato
- Department of Heart and Vessels, Ospedale di Circolo and Macchi Foundation, University of Insubria, Varese, Italy
| | - Attilio Iacovoni
- Cardiovascular Department & Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| | - Andrea Mortara
- Department of Cardiology, Policlinico di Monza, Monza, Italy
| | - Roberto De Ponti
- Department of Heart and Vessels, Ospedale di Circolo and Macchi Foundation, University of Insubria, Varese, Italy
| | - Michele Senni
- Cardiovascular Department & Cardiology Unit, Papa Giovanni XXIII Hospital-Bergamo, Bergamo, Italy
| |
Collapse
|
130
|
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) represents half of HF patients, who are more likely older, women, and hypertensive. Mortality rates in HFpEF are higher compared with age- and comorbidity-matched non-HF controls and lower than in HF with reduced ejection fraction (HFrEF); the majority (50-70%) are cardiovascular (CV) deaths. Among CV deaths, sudden death (SD) (~ 35%) and HF-death (~ 20%) are the leading cardiac modes of death; however, proportionally, CV deaths, SD, and HF-deaths are lower in HFpEF, while non-CV deaths constitute a higher proportion of deaths in HFpEF (30-40%) than in HFrEF (~ 15%). Importantly, the underlying mechanism of SD has not been clearly elucidated and non-arrhythmic SD may be more prominent in HFpEF than in HFrEF. Furthermore, there is no specific strategy for identifying high-risk patients, probably due to wide heterogeneity in presentation and pathophysiology of HFpEF and a plethora of comorbidities in this population. Thus, the management of HFpEF remains problematic due to paucity of data on the clinical benefits of current therapies, which focus on symptom relief and reduction of HF-hospitalization by controlling fluid retention and managing risk-factors and comorbidities. Matching a specific pathophysiology or mode of death with available and novel therapies may improve outcomes in HFpEF. However, this still remains an elusive target, as we need more information on determinants of SD. Implantable cardioverter-defibrillators (ICDs) have changed the landscape of SD prevention in HFrEF; if ICDs are to be applied to HFpEF, there must be a coordinated effort to identify and select high-risk patients.
Collapse
|
131
|
Choi HM, Shin MS. Angiotensin receptor-neprilysin inhibitor for the treatment of heart failure: a review of recent evidence. Korean J Intern Med 2020; 35:498-513. [PMID: 32392658 PMCID: PMC7214374 DOI: 10.3904/kjim.2020.105] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 04/22/2020] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is a growing health concern in aging societies worldwide. Sacubitril/valsartan is changing the real-world treatment in the whole spectrum of HF. The beginning was the PARADIGM-HF trial published in 2014, which demonstrated the beneficial effects of inhibiting natriuretic peptide breakdown in combination with hindering the renin-angiotensin system in HF patients with a reduced ejection fraction. Subsequent large-scale randomized trials have evaluated angiotensin receptor-neprilysin inhibitor in HF patients with acute decompensation or with preserved ejection fraction. The post hoc analyses are being conducted as well. This review summarizes the recent evidence of sacubitril/ valsartan regarding patient-centered outcomes, based on randomized controlled trials and their associated studies.
Collapse
Affiliation(s)
- Hong-Mi Choi
- Division of Cardiology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea
| | - Mi-Seung Shin
- Division of Cardiology, Department of Internal Medicine, Gil Medical Center, Gachon University College of Medicine, Incheon, Korea
| |
Collapse
|
132
|
Kuchulakanti PK. ARNI in cardiovascular disease: current evidence and future perspectives. Future Cardiol 2020; 16:505-515. [PMID: 32319309 DOI: 10.2217/fca-2019-0089] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers are the mainstay of therapy for cardiovascular disease and heart failure (HF). The angiotensin receptor II blocker - neprilysin inhibitor (ARNI), sacubitril-valsartan has an established role in treatment of patients with HF with reduced ejection fraction (HFrEF) based on the results of PARADIGM-HF trial. This trial has provided a strong evidence base for treatment of HFrEF in various subsets of patients. Several studies are done using ARNI in various indications such as HFrEF, HFrEF, patients hospitalized with acute decompensated HF, HF with preserved EF, AMI with LVEF <40%, hypertension, chronic kidney disease, pulmonary hypertension, obstructive sleep apnea, so on and so forth. This review provides an update of current literature and future perspective on ARNI in various cardiovascular disorders.
Collapse
|
133
|
Gama F, Ferreira J, Carmo J, Costa FM, Carvalho S, Carmo P, Cavaco D, Morgado FB, Adragão P, Mendes M. Implantable Cardioverter-Defibrillators in Trials of Drug Therapy for Heart Failure: A Systematic Review and Meta-Analysis. J Am Heart Assoc 2020; 9:e015177. [PMID: 32290732 PMCID: PMC7428541 DOI: 10.1161/jaha.119.015177] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Medical therapy for heart failure with reduced ejection fraction evolved since trials validated the use of implantable cardioverter-defibrillators (ICDs). We sought to evaluate the performance of ICDs in reducing mortality in the era of modern medical therapy by means of a systematic review and meta-analysis of contemporary randomized clinical trials of drug therapy for heart failure with reduced ejection fraction. METHODS AND RESULTS We systematically identified randomized clinical trials that evaluated drug therapy in patients with heart failure with reduced ejection fraction that reported mortality. Studies that enrolled <1000 patients, patients with left ventricular ejection fraction >40%, or patients in the acute phase of heart failure and study treatment with devices were excluded. We identified 8 randomized clinical trials, including 31 701 patients of whom 3631 (11.5%) had an ICD. ICDs were associated with a lower risk of all-cause mortality (relative risk [RR], 0.85; 95% CI, 0.78-0.94) and sudden cardiac death (RR, 0.49; 95% CI, 0.40-0.61). Results were consistent among studies published before and after 2010. In meta-regression analysis, the proportion of nonischemic etiology did not affect the associated benefit of ICD. CONCLUSIONS In our meta-analysis of contemporary randomized trials of drug therapy for heart failure with reduced ejection fraction, the rate of ICD use was low and associated with a decreased risk in both all-cause mortality and sudden cardiac death. This benefit was still present in trials with new medical therapy.
Collapse
Affiliation(s)
- Francisco Gama
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
| | - Jorge Ferreira
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
| | - João Carmo
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
- Hospital da LuzLisbonPortugal
| | - Francisco Moscoso Costa
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
- Hospital da LuzLisbonPortugal
| | - Salomé Carvalho
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
- Hospital da LuzLisbonPortugal
| | - Pedro Carmo
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
- Hospital da LuzLisbonPortugal
| | - Diogo Cavaco
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
- Hospital da LuzLisbonPortugal
| | - Francisco Belo Morgado
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
- Hospital LusíadasLisbonPortugal
| | - Pedro Adragão
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
- Hospital da LuzLisbonPortugal
| | - Miguel Mendes
- Hospital Santa CruzCentro Hospitalar Lisboa OcidentalNova Medical SchoolFaculdade de Ciências MédicasLisbonPortugal
| |
Collapse
|
134
|
Gatti M, Antonazzo IC, Diemberger I, De Ponti F, Raschi E. Adverse events with sacubitril/valsartan in the real world: emerging signals to target preventive strategies from the FDA adverse event reporting system. Eur J Prev Cardiol 2020; 28:983-989. [DOI: 10.1177/2047487320915663] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2019] [Accepted: 03/08/2020] [Indexed: 12/28/2022]
Abstract
Abstract
Aims
The aim of this study was to characterise clinical priority of adverse events with sacubitril/valsartan for targeting preventive measures.
Methods
We used the US Food and Drug Administration adverse event reporting system (worldwide pharmacovigilance database) to compare adverse events recording sacubitril/valsartan as suspect with other cardiovascular drugs. Disproportionality analyses were performed by calculating the reporting odds ratios, deemed significant when the lower limit of the 95% confidence interval was greater than 1. Clinical priority was assigned to adverse events with significant disproportionality by scoring (range 0–10 points) five features (number of events, magnitude of the lower limit of the 95% confidence interval, mortality frequency, important/designated medical event, biological plausibility).
Results
Sacubitril/valsartan was recorded in 20,021 reports, with 178 adverse events associated with significant disproportionality: 71.9%, 25.9% and 2.2% were classified as weak, moderate and strong clinical priorities, respectively. Increased reporting emerged for several cardiovascular adverse events, including ‘renal failure’ (N = 388; lower limit of the 95% confidence interval 2.26), ‘hyperkalaemia’ (314; 2.42) and ‘angioedema’ (309; 1.56). Sudden cardiac death (priority score 9 points) was the only designated medical event with strong clinical priority. Notably, sudden cardiac death occurred early after sacubitril/valsartan administration (average onset 124 days), with concomitant drugs known for pro-arrhythmic potential (e.g. amiodarone, escitalopram, mirtazapine, loop diuretics) in 26.2% of records.
Conclusion
The increased cardiovascular reporting of sacubitril/valsartan in the real world was largely predictable from pre-approval evidence, underlying disease and likely patients’ comorbidities. The unexpected reporting of sudden cardiac death occurred well before the complete development of positive electrical remodelling induced by sacubitril/valsartan, and calls for stringent clinical monitoring (to reduce the pro-arrhythmic burden related to co-medications), and further investigation on appropriate combination with other preventive measures.
Collapse
Affiliation(s)
- Milo Gatti
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | | | - Igor Diemberger
- Department of Experimental, Diagnostic and Specialty Medicine, University of Bologna, Italy
| | - Fabrizio De Ponti
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Emanuel Raschi
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| |
Collapse
|
135
|
Chang PC, Wo HT, Lee HL, Lin SF, Chu Y, Wen MS, Chou CC. Sacubitril/Valsartan Therapy Ameliorates Ventricular Tachyarrhythmia Inducibility in a Rabbit Myocardial Infarction Model. J Card Fail 2020; 26:527-537. [PMID: 32209390 DOI: 10.1016/j.cardfail.2020.03.007] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND Coronary artery disease is the most common cause of heart failure (HF) in developed countries. The aim of this study was to elucidate the mechanisms of reduction of arrhythmias after sacubitril/valsartan (LCZ696) therapy in a myocardial infarction (MI)-HF rabbit model. METHODS AND RESULTS Chronic MI in rabbits with HF were divided into 3 groups: placebo control, valsartan 30 mg/day and LCZ696 60 mg/day. After 4 weeks of therapy, an electrophysiologic study and a dual voltage-calcium optical mapping study were performed. The LCZ696 group had significantly better left ventricular ejection fraction and lower ventricular tachyarrhythmia inducibility than the valsartan and placebo groups. The most common ventricular tachyarrhythmia pattern was 1 or 2 ectopic beats originating from the peri-infarct areas, followed by re-entrant beats surrounding phase singularity points. Compared to the valsartan and placebo groups, the LCZ696 group had significantly shorter action-potential duration, shorter intracellular calcium tau constant, faster conduction velocity, and shorter pacing cycle length to induce arrhythmogenic alternans. LCZ696 therapy reduced the phosphorylated calmodulin-dependent protein kinase II (CaMKII-p) expression. CONCLUSIONS In a rabbit model with chronic MI and HF, LCZ696 therapy ameliorated postinfarct heart function impairment and electrophysiologic remodeling and altered CaMKII-p expression, leading to reduced ventricular tachyarrhythmia inducibility.
Collapse
Affiliation(s)
- Po-Cheng Chang
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan
| | - Hung-Ta Wo
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou
| | - Hui-Ling Lee
- Department of Anesthesia, Chang Gung Memorial Hospital, Taipei
| | - Shien-Fong Lin
- Institute of Biomedical Engineering, National Chiao Tung University, Hsin Chu, Taiwan
| | - Yen Chu
- Division of Thoracic Surgery, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan
| | - Ming-Shien Wen
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan
| | - Chung-Chuan Chou
- Division of Cardiology, Department of Internal Medicine, Chang Gung Memorial Hospital, Linkou; Chang Gung University College of Medicine, Taoyuan.
| |
Collapse
|
136
|
Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GF, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
Collapse
Affiliation(s)
- Meaghan Lunney
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Marinella Ruospo
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Patrizia Natale
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Robert R Quinn
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Paul E Ronksley
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical Center, Department of Medicine, 3459 Fifth Avenue, Pittsburgh, PA, USA, 15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of Otago, Department of Medicine, Nephrologist, Christchurch, New Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Giovanni Fm Strippoli
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
- The Children's Hospital at Westmead, Cochrane Kidney and Transplant, Centre for Kidney Research, Westmead, NSW, Australia, 2145
| | - Pietro Ravani
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| |
Collapse
|
137
|
Abstract
New therapeutic strategies aimed to tackle the rising socio-economic burden of heart failure (HF) have become an impelling priority. The new pharmacological class of angiotensin (Ang) receptor-neprilysin inhibitors (ARNI) prompted a real conceptual change in the treatment of HF moving from only the inhibition of the renin-Ang-aldosterone system and sympathetic nervous system to a strategy based on the concomitant pharmacological enhancement of endogenous natriuretic peptides. Sacubitril/valsartan, a first-in-class ARNI, has reduced the primary composite endpoint of cardiovascular death or HF hospitalisation, sudden cardiac death, disease progression and improved quality of life, compared with enalapril, in patients on evidence-based contemporary medical therapy. Our review underlines the increasing body of evidence supporting the efficacy of sacubitril/valsartan, which may be considered a new disease-modifying therapy and, after about 30 years of research, a real step forward in HF pharmacological therapy.
Collapse
|
138
|
Okutucu S, Sabanoglu C, Yetis Sayin B, Aksoy H, Bursa N, Oto A. Switching from ramipril to sacubitril/valsartan favorably alters electrocardiographic indices of ventricular repolarization in heart failure with reduced ejection fraction. Acta Cardiol 2020; 75:20-25. [PMID: 30513267 DOI: 10.1080/00015385.2018.1535818] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Angiotensin receptor neprilysin inhibitor (ARNI, sacubitril/valsartan) reduces sudden death in heart failure with reduced ejection fraction (HFrEF). Corrected QT (QTc), T-wave peak to T-wave end interval (Tp-e) and Tp-e/QTc are electrocardiographic indices of ventricular repolarization heterogeneity. We aimed to assess the effects of switching from ramipril to ARNI on electrocardiographic indices of ventricular repolarization.Methods: A total of 48 patients with HFrEF (mean age: 63.3 ± 11.7 years; 36 males, 77.1% ischaemic etiology) were enrolled. All patients had New York Heart Association functional class II-III, left ventricular ejection fraction ≤35% and previously switched from ramipril to ARNI treatment. The standard 12-lead electrocardiograms on ramipril treatment and 1 month after ARNI treatment were analysed; heart rate, QTc, Tp-e and Tp-e/QTc were calculated. Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores and N-terminal pro-BNP (NT-proBNP) values were recorded.Results: QTc (415.2 ± 19.7 ms vs. 408.5 ± 20.8 ms, p = 0.022), Tp-e (100.7 ± 13.8 ms vs. 92.9 ± 12.1 ms, p < 0.001), Tp-e/QTc (0.242 ± 0.028 vs. 0.227 ± 0.029, p = 0.003) and heart rate (73.2 ± 4.7 bpm vs. 71.1 ± 4.9 bpm, p = 0.027) were reduced after ARNI. ARNI switch associated with improvement in MLWHFQ scores (32.4 ± 7.1 ms vs. 22.6 ± 7.0 ms, p < 0.001) and reduction of NT-proBNP (2457 ± 1879 pg/ml to 1377 ± 874 pg/ml, p < 0.001). Pearson's correlation analysis revealed moderate correlations of MLWHFQ score with Tp-e (r = 0.543, p = 0.001) and Tp-e/QTc (r = 0.556, p = 0.001).Conclusions: Switching from ramipril to ARNI favourably alters QTc, Tp-e and Tp-e/QTc in HFREF. ARNI reduces symptoms of HFREF assessed by MLWHFQ and lowers NT-proBNP levels. Reduction in Tp-e and Tp-e/QTc correlate with clinical improvement in patients with HFrEF.
Collapse
Affiliation(s)
- Sercan Okutucu
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| | - Cengiz Sabanoglu
- Department of Cardiology, High Speciality Hospital, Kirikkale, Turkey
| | | | - Hakan Aksoy
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| | - Nurbanu Bursa
- Department of Statistics, Hacettepe University, Ankara, Turkey
| | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| |
Collapse
|
139
|
Sokos GG, Raina A. Understanding the early mortality benefit observed in the PARADIGM-HF trial: considerations for the management of heart failure with sacubitril/valsartan. Vasc Health Risk Manag 2020; 16:41-51. [PMID: 32021227 PMCID: PMC6972579 DOI: 10.2147/vhrm.s197291] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 08/02/2019] [Indexed: 12/11/2022] Open
Abstract
This review aims to elucidate the optimal dosing of angiotensin receptor-neprilysin inhibitor (ARNI) therapy in the heart failure (HF) treatment paradigm through examination of the trial population characteristics and the mortality benefit observed in the Prospective Comparison of ARNI with angiotensin-converting enzyme inhibitor (ACEI) to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF; NCT01035255) trial. Considerations regarding the initiation and titration of sacubitril/valsartan, a first-in-class ARNI, will also be addressed. The approval of sacubitril/valsartan heralded the first novel pharmacological class in over a decade for the treatment of heart failure with reduced ejection fraction (HFrEF). The PARADIGM-HF trial showed that treatment with valsartan/valsartan reduced the risk of first occurrence of either cardiovascular death or HF-related hospitalization (composite primary endpoint) by 20% compared with enalapril in patients with HFrEF. The incremental benefits of treatment with valsartan/valsartan over enalapril demonstrated in the PARADIGM-HF trial led to strong recommendations for its use over ACEIs or angiotensin receptor blockers to further reduce morbidity and mortality in the 2016 and 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America updates to the guidelines for the management of HF. Although the optimal timing for the initiation of valsartan/valsartan has yet to be determined, its early use is likely to have a positive impact on patient outcomes.
Collapse
Affiliation(s)
- George G Sokos
- Department of Medicine, Division of Cardiology, West Virginia School of Medicine, Morgantown, WV, USA
| | - Amresh Raina
- Pulmonary Hypertension Program, Section of Heart Failure/Transplant/MCS & Pulmonary Hypertension, Allegheny General Hospital, AGH McGinnis Cardiovascular Institute, Pittsburgh, PA, USA
| |
Collapse
|
140
|
Docherty KF, Ferreira JP, Sharma A, Girerd N, Gregson J, Duarte K, Petrie MC, Jhund PS, Dickstein K, Pfeffer MA, Pitt B, Rossignol P, Zannad F, McMurray JJV. Predictors of sudden cardiac death in high-risk patients following a myocardial infarction. Eur J Heart Fail 2020; 22:848-855. [PMID: 31944496 DOI: 10.1002/ejhf.1694] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2019] [Revised: 10/25/2019] [Accepted: 10/30/2019] [Indexed: 12/21/2022] Open
Abstract
AIMS To develop a risk model for sudden cardiac death (SCD) in high-risk acute myocardial infarction (AMI) survivors. METHODS AND RESULTS Data from the Effect of Carvedilol on Outcome After Myocardial Infarction in Patients With Left Ventricular Dysfunction trial (CAPRICORN) and the Valsartan in Acute Myocardial Infarction Trial (VALIANT) were used to create a SCD risk model (with non-SCD as a competing risk) in 13 202 patients. The risk model was validated in the Eplerenone Post-AMI Heart Failure Efficacy and Survival Study (EPHESUS). The rate of SCD was 3.3 (95% confidence interval 3.0-3.5) per 100 person-years over a median follow-up of 2.0 years. Independent predictors of SCD included age > 70 years; heart rate ≥ 70 bpm; smoking; Killip class III/IV; left ventricular ejection fraction ≤30%; atrial fibrillation; history of prior myocardial infarction, heart failure or diabetes; estimated glomerular filtration rate < 60 mL/min/1.73 m2 ; and no coronary reperfusion or revascularisation therapy for index AMI. The model was well calibrated and showed good discrimination (C-statistic = 0.72), including in the early period after AMI. The observed 2-year event rates increased steeply with each quintile of risk score (1.9%, 3.6%, 6.2%, 9.0%, 13.4%, respectively). CONCLUSION An easy to use SCD risk score developed from routinely collected clinical variables in patients with heart failure, left ventricular systolic dysfunction or both, early after AMI was superior to left ventricular ejection fraction. This score might be useful in identifying patients for future trials testing treatments to prevent SCD early after AMI.
Collapse
Affiliation(s)
- Kieran F Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - João Pedro Ferreira
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France.,Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, Montreal, Canada
| | - Nicolas Girerd
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, UK
| | - Kevin Duarte
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Kenneth Dickstein
- Department of Cardiology, University of Bergan, Stavanger University Hospital, Stavanger, Norway
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, MI, USA
| | - Patrick Rossignol
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Faiez Zannad
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| |
Collapse
|
141
|
Hernandez AV, Pasupuleti V, Banach M, Bielecka-Dabrowa AM. LCZ696 (sacubitril/valsartan) for patients with heart failure. Hippokratia 2020. [DOI: 10.1002/14651858.cd013517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
| | - Vinay Pasupuleti
- ProEd Communications Inc; Department of Scientific Services; Cleveland USA
| | - Maciej Banach
- Medical University of Lodz, Polish Mother’s Memorial Hospital Research Institute; Department of Hypertension and Department of Cardiology and Congenital Diseases of Adults; Lodz Poland
| | - Agata M Bielecka-Dabrowa
- Medical University of Lodz, Polish Mother’s Memorial Hospital Research Institute; Department of Cardiology and Congenital Diseases of Adults and Department of Hypertension; Lodz Poland
| |
Collapse
|
142
|
The risk and prevention of sudden death in patients with heart failure with reduced ejection fraction. Curr Opin Cardiol 2020; 35:138-144. [PMID: 31895241 DOI: 10.1097/hco.0000000000000710] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
PURPOSE OF REVIEW Patients with heart failure are at increased risk of sudden cardiac death. The methods to predict patients at high risk of sudden cardiac death in heart failure are neither sensitive nor specific; both overestimating risk in those with ejection fractions less than 35% and not identifying those at risk with ejection fractions greater than 35%. RECENT FINDINGS The absolute risk of sudden cardiac death in patients with heart failure have decreased over the past 20 years. New novel tools are being developed and tested to identify those at higher risk of sudden cardiac death. Reduction in the risk of sudden cardiac death has been achieved with the use of beta-blockers, spironolactone, sacubitril-valsartan, cardiac resynchronization and implantable cardioverter defibrillators. SUMMARY The use of contemporary treatments for patients with heart failure can reduce the risk of sudden cardiac death, but research is required to identify those at highest risk.
Collapse
|
143
|
The impact of discontinuation of sacubitril-valsartan and shifting to angiotensin-converting enzyme inhibitor or angiotensin receptor blocker in patients with heart failure with reduced ejection fraction. Anatol J Cardiol 2020; 25:163-169. [PMID: 33690130 DOI: 10.14744/anatoljcardiol.2020.39267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE Many trials confirmed the role of sacubitril-valsartan in the treatment of patients with heart failure with reduced ejection fraction (HFrEF). However, there is no sufficient data to register the effect of compulsory discontinuation of sacubitril-valsartan, either because of finan-cial shortage or adverse effects, and shifting to the standard therapy, including angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB). METHODS The patients with HFrEF (LVEF ≤35%) were included in the study. They received treatment with sacubitril-valsartan as a replacement for an ACEI or ARB. The patients were divided into two groups: the compliant group (n=111). The non-compliant group (n=82), whose members discontinued sacubitril-valsartan after ≥5 months but <6 months since their enrollment in the study. RESULTS Initially, 199 patients with HFrEF were included in the study. All the patients were started treatment with sacubitril-valsartan in addition to the evidence-based standard therapy of heart failure. Six patients were excluded at the first follow-up visit (at 6 months). The remaining 193 patients showed initial improvement of the New York Heart Association (NYHA) class, the end-diastolic volume (EDV), and the left ventricular ejection fraction (LVEF). Five patients were excluded at the 12 months' follow-up visit. The other 188 patients were divided into two groups: Group I (n=108) patients were compliant on sacubitril-valsartan for 12 months; Group II (n=80) patients were compliant on sacubitril-valsartan for ≥5 months, but stopped it at <6 months, and were shifted to ACEI or evidence-based ARB. Group II (n=80) patients showed worsening of their NYHA class, compared to the 6 months' follow-up visit (p=0.001). LVEF and EDV were also shown to be worsened in these patients when we compared them to the values of the 6 months' follow-up appointment with p=0.001 for both parameters. CONCLUSION The discontinuation of sacubitril-valsartan in patients with HFrEF leads to deterioration of the LVEF as well as worsening of the functional class. The decline in LVEF and NYHA functional class occurs despite being compliant with the optimal conventional therapy with ACEI or evidence-based ARB.
Collapse
|
144
|
Heart Failure with Reduced Ejection Fraction (HFrEF) and Preserved Ejection Fraction (HFpEF): The Diagnostic Value of Circulating MicroRNAs. Cells 2019; 8:cells8121651. [PMID: 31888288 PMCID: PMC6952981 DOI: 10.3390/cells8121651] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 12/10/2019] [Accepted: 12/13/2019] [Indexed: 12/28/2022] Open
Abstract
Circulating microRNAs offer attractive potential as epigenetic disease biomarkers by virtue of their biological stability and ready accessibility in liquid biopsies. Numerous clinical cohort studies have revealed unique microRNA profiles in different disease settings, suggesting utility as markers with diagnostic and prognostic applications. Given the complex network of microRNA functions in modulating gene expression and post-transcriptional modifications, the circulating microRNA landscape in disease may reflect pathophysiological status, providing valuable information for delineating distinct subtypes and/or stages of complex diseases. Heart failure (HF) is an increasingly significant global health challenge, imposing major economic liability and health care burden due to high hospitalization, morbidity, and mortality rates. Although HF is defined as a syndrome characterized by symptoms and findings on physical examination, it may be further differentiated based on left ventricular ejection fraction (LVEF) and categorized as HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). The presenting clinical syndromes in HFpEF and HFrEF are similar but mortality differs, being somewhat lower in HFpEF than in HFrEF. However, while HFrEF is responsive to an array of therapies, none has been shown to improve survival in HFpEF. Herein, we review recent HF cohort studies focusing on the distinct microRNA profiles associated with HF subtypes to reveal new insights to underlying mechanisms and explore the possibility of exploiting these differences for diagnostic/prognostic applications.
Collapse
|
145
|
Giblin EM, Adams KF, Hill L, Fonarow GC, Williams FB, Sharma PP, Albert NM, Butler J, DeVore AD, Duffy CI, Hernandez AF, McCague K, Spertus JA, Thomas L, Patterson JH. Comparison of Hydralazine/Nitrate and Angiotensin Receptor Neprilysin Inhibitor Use Among Black Versus Nonblack Americans With Heart Failure and Reduced Ejection Fraction (from CHAMP-HF). Am J Cardiol 2019; 124:1900-1906. [PMID: 31679641 DOI: 10.1016/j.amjcard.2019.09.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 12/21/2022]
Abstract
Underuse of hydralazine/nitrate (HYD/NIT) in black patients with heart failure and reduced ejection fraction (HFrEF) has been previously described, but whether this important treatment gap persists in contemporary practice is unknown. Sacubitril/valsartan has become a part of guideline-directed medical therapy for HFrEF but data on utilization of this therapy in black patients is lacking. This study addressed these issues by assessing the frequency of HYD/NIT and sacubitril/valsartan use in black patients with HFrEF in the Change the Management of Patients with Heart Failure Registry, a multicenter cohort study. The association of race with utilization rates of these agents was also evaluated. Clinical and medication data at baseline and during 12 months of follow-up from black and nonblack registry patients without documented contraindications or intolerance to the medications of interest were analyzed. Data were available from December 2015 to October 2017, in 4,848 HFrEF patients, of whom 853 were black (18%) and 3995 were nonblack. Black patients were younger, more likely to be female, and had lower ejection fractions compared with nonblacks. Only 11% of black patients were receiving HYD/NIT therapy at baseline and 13% at 1 year. The percentage of black patients treated at baseline with sacubitril/valsartan was also low at 18% and remained unchanged at 1 year. After adjustment for covariates, race was independently associated with HYD/NIT use (odds ratio 8.32; 95% confidence interval 6.12 to 11.3; p < 0.0001), but not for sacubitril/valsartan. In conclusion, study findings demonstrate a marked persistent treatment gap for HYD/NIT and similar poor utilization of sacubitril/valsartan in black patients with HFrEF despite current guideline recommendations.
Collapse
Affiliation(s)
- Erika M Giblin
- Department of Pharmacy, Vidant Medical Center, Greenville, North Carolina; Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, North Carolina
| | - Kirkwood F Adams
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Larry Hill
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C Fonarow
- Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | | | | | - Nancy M Albert
- Office of Nursing Research and Innovation, Cleveland Clinic Health System, Cleveland, Ohio
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Adam D DeVore
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Adrian F Hernandez
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - John A Spertus
- Department of Medicine, Washington School of Medicine in St. Louis, St. Louis, Missouri
| | - Laine Thomas
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - J Herbert Patterson
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina.
| |
Collapse
|
146
|
Okutucu S, Fatihoglu SG, Sabanoglu C, Bursa N, Sayin BY, Aksoy H, Oto A. Effects of angiotensin receptor neprilysin inhibition on P-wave dispersion in heart failure with reduced ejection fraction. Herz 2019; 46:69-74. [PMID: 31796977 DOI: 10.1007/s00059-019-04872-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/23/2019] [Accepted: 11/12/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Angiotensin receptor neprilysin inhibitors (ARNI; sacubitril/valsartan combination) decrease morbidity and mortality in heart failure with reduced ejection fraction (HFrEF). Increased P‑wave duration and P‑wave dispersion (Pd) reflect prolongation of atrial conduction and correlate with atrial fibrillation. Here, we aimed to assess the effects of switching from valsartan to ARNI treatment on the basis of P‑wave indices. METHODS A total of 28 patients with HFrEF (mean age, 64.8 ± 10.6 years; 18 males, 78.6% ischemic etiology) were included. All patients had New York Heart Association functional class II-III, left ventricular ejection fraction ≤35%, and had been switched from valsartan to ARNI treatment. Standard 12-lead electrocardiograms from patients on valsartan treatment and electrocardiograms 1 month after ARNI treatment were analyzed; heart rate, maximum P‑wave duration (Pmax), minimum P‑wave duration (Pmin), and Pd were calculated. Minnesota Living with Heart Failure Questionnaire (MLWHFQ) scores and N‑terminal pro-brain natriuretic peptide (NT-proBNP) values were recorded. RESULTS The Pmax (135.6 ± 32.1 ms vs. 116.1 ± 14.1 ms, p = 0.041) and Pd (33.6 ± 7.9 vs. 28.6 ± 5.3, p = 0.006) values were significantly reduced after ARNI treatment. Furthermore, ARNI treatment was associated with an improvement in MLWHFQ scores (31.2 ± 6.2 ms vs. 23.2 ± 7.0 ms, p < 0.001) and with a reduction in NT-proBNP values (1827.3 ± 1287.3 pg/ml vs. 1074.4 ± 692.3 pg/ml, p < 0.001). There were moderately positive correlations between the reduction in Pd and the improvement in MLWHFQ scores (r = 0.408, p = 0.031) and the reduction in NT-proBNP values (r = 0.499, p = 0.007) CONCLUSION: Switching to ARNI treatment alters Pd and Pmax favorably in patients with HFrEF. The reduction in atrial inhomogeneous conduction assessed by Pd was correlated with clinical improvement and reduced NT-proBNP levels in patients with HFrEF.
Collapse
Affiliation(s)
- Sercan Okutucu
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| | | | - Cengiz Sabanoglu
- Department of Cardiology, High Speciality Hospital, Kirikkale, Turkey
| | - Nurbanu Bursa
- Department of Statistics, Hacettepe University, Ankara, Turkey
| | | | - Hakan Aksoy
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| | - Ali Oto
- Department of Cardiology, Memorial Ankara Hospital, Ankara, Turkey
| |
Collapse
|
147
|
Boehmer AA, Ehrlich JR. Sacubitril/valsartan in HFrEF - Should the aces up our sleeves be played earlier? IJC HEART & VASCULATURE 2019; 25:100428. [PMID: 31890858 PMCID: PMC6933444 DOI: 10.1016/j.ijcha.2019.100428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2019] [Revised: 09/21/2019] [Accepted: 09/24/2019] [Indexed: 10/30/2022]
Affiliation(s)
- Andreas A Boehmer
- Division of Cardiology, St Josefs-Hospital, Wiesbaden, Germany
- Division of Cardiology, St Josefs-Hospital, Wiesbaden, Germany
- Division of Cardiology, Goethe-University, Frankfurt, Germany
| | - Joachim R Ehrlich
- Division of Cardiology, St Josefs-Hospital, Wiesbaden, Germany
- Division of Cardiology, Goethe-University, Frankfurt, Germany
| |
Collapse
|
148
|
Fu S, Chang Z, Luo L, Deng J. Therapeutic Progress and Knowledge Basis on the Natriuretic Peptide System in Heart Failure. Curr Top Med Chem 2019; 19:1850-1866. [PMID: 31448711 DOI: 10.2174/1568026619666190826163536] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 06/25/2019] [Accepted: 07/25/2019] [Indexed: 01/26/2023]
Abstract
Notwithstanding substantial improvements in diagnosis and treatment, Heart Failure (HF) remains a major disease burden with high prevalence and poor outcomes worldwide. Natriuretic Peptides (NPs) modulate whole cardiovascular system and exhibit multiple cardio-protective effects, including the counteraction of the Renin-Angiotensin-Aldosterone System (RAAS) and Sympathetic Nervous System (SNS), promotion of vasodilatation and natriuresis, and inhibition of hypertrophy and fibrosis. Novel pharmacological therapies based on NPs may achieve a valuable shift in managing patients with HF from inhibiting RAAS and SNS to a reversal of neurohormonal imbalance. Enhancing NP bioavailability through exogenous NP administration and inhibiting Neutral Endopeptidase (NEP) denotes valuable therapeutic strategies for HF. On the one hand, NEP-resistant NPs may be more specific as therapeutic choices in patients with HF. On the other hand, NEP Inhibitors (NEPIs) combined with RAAS inhibitors have proved to exert beneficial effects and reduce adverse events in patients with HF. Highly effective and potentially safe Angiotensin Receptor Blocker Neprilysin Inhibitors (ARNIs) have been developed after the failure of NEPIs and Vasopeptidase Inhibitors (VPIs) due to lacking efficacy and safety. Therapeutic progress and knowledge basis on the NP system in HF are summarized in the current review.
Collapse
Affiliation(s)
- Shihui Fu
- Department of Geriatric Cardiology, National Clinical Research Center of Geriatrics Disease, Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Chinese People's Liberation Army General Hospital, Beijing, China.,Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Beijing, China
| | - Zhenyu Chang
- Department of Hepatobiliary and Pancreatic Surgical Oncology, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Leiming Luo
- Department of Geriatric Cardiology, National Clinical Research Center of Geriatrics Disease, Beijing Key Laboratory of Precision Medicine for Chronic Heart Failure, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Juelin Deng
- Department of Cardiology, Hainan Hospital of Chinese People's Liberation Army General Hospital, Beijing, China
| |
Collapse
|
149
|
Alvarez CK, Cronin E, Baker WL, Kluger J. Heart failure as a substrate and trigger for ventricular tachycardia. J Interv Card Electrophysiol 2019; 56:229-247. [PMID: 31598875 DOI: 10.1007/s10840-019-00623-x] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2019] [Accepted: 09/06/2019] [Indexed: 02/06/2023]
Abstract
Heart failure (HF) is a major cause of morbidity and mortality with more than 5.1 million individuals affected in the USA. Ventricular tachyarrhythmias (VAs) including ventricular tachycardia and ventricular fibrillation are common in patients with heart failure. The pathophysiology of these mechanisms as well as the contribution of heart failure to the genesis of these arrhythmias is complex and multifaceted. Myocardial hypertrophy and stretch with increased preload and afterload lead to shortening of the action potential at early repolarization and lengthening of the action potential at final repolarization which can result in re-entrant ventricular tachycardia. Myocardial fibrosis and scar can create the substrate for re-entrant ventricular tachycardia. Altered calcium handling in the failing heart can lead to the development of proarrhythmic early and delayed after depolarizations. Various medications used in the treatment of HF such as loop diuretics and angiotensin converting enzyme inhibitors have not demonstrated a reduction in sudden cardiac death (SCD); however, beta-blockers (BB) are effective in reducing mortality and SCD. Amongst patients who have HF with reduced ejection fraction, the angiotensin receptor-neprilysin inhibitor (sacubitril/valsartan) has been shown to reduce cardiovascular mortality, specifically by reducing SCD, as well as death due to worsening HF. Implantable cardioverter-defibrillator (ICD) implantation in HF patients reduces the risk of SCD; however, subsequent mortality is increased in those who receive ICD shocks. Prophylactic ICD implantation reduces death from arrhythmia but does not reduce overall mortality during the acute post-myocardial infarction (MI) period (less than 40 days), for those with reduced ejection fraction and impaired autonomic dysfunction. Furthermore, although death from arrhythmias is reduced, this is offset by an increase in the mortality from non-arrhythmic causes. This article provides a review of the aforementioned mechanisms of arrhythmogenesis in heart failure; the role and impact of HF therapy such as cardiac resynchronization therapy (CRT), including the role, if any, of CRT-P and CRT-D in preventing VAs; the utility of both non-invasive parameters as well as multiple implant-based parameters for telemonitoring in HF; and the effect of left ventricular assist device implantation on VAs.
Collapse
Affiliation(s)
- Chikezie K Alvarez
- Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th Street, Bronx, NY, 10467, USA.
| | - Edmond Cronin
- University of Connecticut School of Medicine, Farmington, CT, USA
| | - William L Baker
- University of Connecticut School of Pharmacy, Storrs, CT, USA
| | - Jeffrey Kluger
- Hartford Healthcare Heart and Vascular Institute, Hartford Hospital, Hartford, CT, USA
| |
Collapse
|
150
|
Kim JJ, Youn JC. Eligibility and Usage of Sacubitril/Valsartan in Korea. INTERNATIONAL JOURNAL OF HEART FAILURE 2019; 1:69-71. [PMID: 36262742 PMCID: PMC9536666 DOI: 10.36628/ijhf.2019.0008] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 10/21/2019] [Accepted: 10/21/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Jin-Jin Kim
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| |
Collapse
|