201
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Dai Z, Asano T, Takahashi O, Komiyama N, Ohde S. The minimal informative monitoring interval of N-terminal pro-B-type natriuretic peptide in patients with stable heart failure. BMC Cardiovasc Disord 2020; 20:262. [PMID: 32487160 PMCID: PMC7268659 DOI: 10.1186/s12872-020-01537-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Accepted: 05/17/2020] [Indexed: 11/10/2022] Open
Abstract
Background N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a potential biomarker for monitoring the status of heart failure. However, the optimal monitoring interval of NT-proBNP is unknown. This study sought to investigate the minimal informative monitoring interval of NT-proBNP in patients with stable chronic heart failure. Methods This retrospective cohort study included patients who were admitted due to heart failure and subsequently followed with serial NT-proBNP measurements in a tertiary hospital. We analyzed NT-proBNP measured between six months after discharge and the earliest timepoint of: an alteration of medication regimen, readmission due to worsening of heart failure, or all-cause death. To distinguish progression of the disease from biological variability and measurement error, the signal-to-noise ratio method was applied with a random-effects model. Results In the 368 patients included, NT-proBNP was measured for a median 6 times. In the random-effects model, signal (progression of disease) exceeded noise (biological variability and measurement error) at 7.9 months (95% confidence interval [CI]: 5.1–9.6), while noise corresponded to a 61% increase from baseline. In stratified analysis using the AHEAD risk score, the minimal informative monitoring interval shortened as the risk score increased (0–1 point: 12.2 months [95%CI: 10.3–14.4]; 2–3 points: 8.0 months [95%CI: 6.8–9.7]; 4–5 points: 3.3 months [95%CI: 3.0–3.8]). Conclusions In patients with stable chronic heart failure, the minimal informative monitoring interval of NT-proBNP measurement was 7.9 months in the current population, which varied with underlying risks. The optimal monitoring interval could be lengthened for patients at lower risks.
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Affiliation(s)
- Zhehao Dai
- Department of Cardiology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-0045, Japan.,Graduate School of Public Health, St. Luke's International University, 3-6-2 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Taku Asano
- Department of Cardiology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-0045, Japan.
| | - Osamu Takahashi
- Graduate School of Public Health, St. Luke's International University, 3-6-2 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
| | - Nobuyuki Komiyama
- Department of Cardiology, St. Luke's International Hospital, 9-1 Akashi-cho, Chuo-ku, Tokyo, 104-0045, Japan
| | - Sachiko Ohde
- Graduate School of Public Health, St. Luke's International University, 3-6-2 Tsukiji, Chuo-ku, Tokyo, 104-0045, Japan
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202
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Verhestraeten C, Heggermont WA, Maris M. Clinical inertia in the treatment of heart failure: a major issue to tackle. Heart Fail Rev 2020; 26:1359-1370. [PMID: 32474794 PMCID: PMC8510913 DOI: 10.1007/s10741-020-09979-z] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Despite an enormous improvement in heart failure management during the last decades, the hospitalization and mortality rate of heart failure patients still remain very high. Clinical inertia, defined as the lack of treatment intensification in a patient not at evidence-based goals for care, is an important underlying cause. Clinical inertia is extensively described in hypertension and type 2 diabetes mellitus, but increasingly recognized in heart failure as well. Given the well-established guidelines for the management of heart failure, these are still not being reflected in clinical practice. While the absolute majority of patients were treated by guideline-directed heart failure drugs, only a small percentage of these patients reached the correct guideline-recommended target dose of angiotensin-converting enzyme inhibitors, angiotensin II receptor blockers, beta-blockers, mineralocorticoid receptor antagonists, and angiotensin receptor-neprilysin inhibitors. This considerable under-treatment leads to a large number of avoidable hospitalizations and deaths. This review discusses clinical inertia in heart failure and explains its major contributing factors (i.e., physician, patient, and system) and touches upon some recommendations to prevent clinical inertia and ameliorate heart failure treatment.
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Affiliation(s)
| | - Ward A Heggermont
- Cardiovascular Center OLV Aalst, Moorselbaan 164, 9300, Aalst, Belgium.,Cardiovascular Research Center Maastricht, Universiteitssingel 50, 6202, Maastricht, The Netherlands
| | - Michael Maris
- Novartis Pharma nv-sa, Medialaan 40, 1800, Vilvoorde, Belgium.
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203
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Hitzeman TC, Xie Y, Zadikany RH, Nikolova AP, Baum R, Caldaruse AM, Agvanian S, Melmed GY, McGovern DPB, Geft DR, Chang DH, Moriguchi JD, Hage A, Azarbal B, Czer LS, Kittleson MM, Patel JK, Wu AHB, Kobashigawa JA, Hamilton M, Hong T, Shaw RM. cBIN1 Score (CS) Identifies Ambulatory HFrEF Patients and Predicts Cardiovascular Events. Front Physiol 2020; 11:503. [PMID: 32670075 PMCID: PMC7326053 DOI: 10.3389/fphys.2020.00503] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2020] [Accepted: 04/24/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Cardiac Bridging Integrator 1 (cBIN1) is a membrane deformation protein that generates calcium microdomains at cardiomyocyte t-tubules, whose transcription is reduced in heart failure, and is released into blood. cBIN1 score (CS), an inverse index of plasma cBIN1, measures cellular myocardial remodeling. In patients with heart failure with preserved ejection fraction (HFpEF), CS diagnoses ambulatory heart failure and prognosticates hospitalization. The performance of CS has not been tested in patients with heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS CS was determined from plasma of patients recruited in a prospective study. Two comparative cohorts consisted of 158 ambulatory HFrEF patients (left ventricular ejection fraction (LVEF) ≤ 40%, 57 ± 10 years, 80% men) and 115 age and sex matched volunteers with no known history of HF. N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations were also analyzed for comparison. CS follows a normal distribution with a median of 0 in the controls, which increases to a median of 1.9 (p < 0.0001) in HFrEF patients. CS correlates with clinically assessed New York Heart Association Class (p = 0.007). During 1-year follow-up, a high CS (≥ 1.9) in patients predicts increased cardiovascular events (43% vs. 26%, p = 0.01, hazard ratio 1.9). Compared to a model with demographics, clinical risk factors, and NT-proBNP, adding CS to the model improved the overall continuous net reclassification improvement (NRI 0.64; 95% CI 0.18-1.10; p = 0.006). Although performance for diagnosis and prognosis was similar to CS, NT-proBNP did not prognosticate between patients whose NT-proBNP values were > 400 pg/ml. CONCLUSION CS, which is mechanistically distinct from NT-proBNP, successfully differentiates myocardial health between patients with HFrEF and matched controls. A high CS reflects advanced NYHA stage, pathologic cardiac muscle remodeling, and predicts 1-year risk of cardiovascular events in ambulatory HFrEF patients. CS is a marker of myocardial remodeling in HFrEF patients, independent of volume status.
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Affiliation(s)
- Tara C. Hitzeman
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, United States
| | - Yu Xie
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Ronit H. Zadikany
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Andriana P. Nikolova
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Rachel Baum
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, United States
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Ana-Maria Caldaruse
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Sosse Agvanian
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Gil Y. Melmed
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Dermot P. B. McGovern
- Division of Gastroenterology, Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, United States
| | - Dael R. Geft
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - David H. Chang
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Jaime D. Moriguchi
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Antoine Hage
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Babak Azarbal
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Lawrence S. Czer
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Michelle M. Kittleson
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Jignesh K. Patel
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Alan H. B. Wu
- Department of Laboratory Medicine, University of California, San Francisco, San Francisco, CA, United States
| | - Jon A. Kobashigawa
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Michele Hamilton
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - TingTing Hong
- Department of Medicine, Cedars-Sinai Medical Center, Cedars-Sinai Smidt Heart Institute, Los Angeles, CA, United States
| | - Robin M. Shaw
- Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah, Salt Lake City, UT, United States
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204
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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] [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.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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205
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Schuurman AS, Tomer A, Akkerhuis KM, Brugts JJ, Constantinescu AA, Ramshorst JV, Umans VA, Boersma E, Rizopoulos D, Kardys I. Personalized screening intervals for measurement of N-terminal pro-B-type natriuretic peptide improve efficiency of prognostication in patients with chronic heart failure. Eur J Prev Cardiol 2020; 28:e11-e14. [PMID: 33611526 DOI: 10.1177/2047487320922639] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Anne-Sophie Schuurman
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Cardiovascular Research School COEUR, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Anirudh Tomer
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - K Martijn Akkerhuis
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Cardiovascular Research School COEUR, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | | | - Victor A Umans
- Department of Cardiology, Northwest Clinics, Alkmaar, Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Cardiovascular Research School COEUR, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Dimitris Rizopoulos
- Department of Biostatistics, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Isabella Kardys
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Cardiovascular Research School COEUR, Erasmus MC University Medical Center, Rotterdam, Netherlands
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206
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Vinnakota S, Chen HH. The Importance of Natriuretic Peptides in Cardiometabolic Diseases. J Endocr Soc 2020; 4:bvaa052. [PMID: 32537542 PMCID: PMC7278279 DOI: 10.1210/jendso/bvaa052] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022] Open
Abstract
The natriuretic peptide (NP) system is composed of 3 distinct peptides (atrial natriuretic peptide or ANP, B-type natriuretic peptide or BNP, and C-type natriuretic peptide or CNP) and 3 receptors (natriuretic peptide receptor-A or NPR-A or particulate guanynyl cyclase-A natriuretic peptide receptor-B or NPR-B or particulate guanynyl cyclase-B, and natriuretic peptide receptor-C or NPR-C or clearance receptor). ANP and BNP function as defense mechanisms against ventricular stress and the deleterious effects of volume and pressure overload on the heart. Although the role of NPs in cardiovascular homeostasis has been extensively studied and well established, much remains uncertain about the signaling pathways in pathological states like heart failure, a state of impaired natriuretic peptide function. Elevated levels of ANP and BNP in heart failure correlate with disease severity and have a prognostic value. Synthetic ANP and BNP have been studied for their therapeutic role in hypertension and heart failure, and promising trials are under way. In recent years, the expression of ANP and BNP in human adipocytes has come to light. Through their role in promotion of adipocyte browning, lipolysis, lipid oxidation, and modulation of adipokine secretion, they have emerged as key regulators of energy consumption and metabolism. NPR-A signaling in skeletal muscles and adipocytes is emerging as pivotal to the maintenance of long-term insulin sensitivity, which is disrupted in obesity and reduced glucose-tolerance states. Genetic variants in the genes encoding for ANP and BNP have been associated with a favorable cardiometabolic profile. In this review, we discuss several pathways that have been proposed to explain the role of NPs as endocrine networkers. There is much to be explored about the therapeutic role of NPs in improving metabolic milieu.
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Affiliation(s)
- Shravya Vinnakota
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
| | - Horng H Chen
- Department of Cardiovascular Diseases, Mayo Clinic, Rochester, Minnesota
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207
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Congestion in heart failure: a contemporary look at physiology, diagnosis and treatment. Nat Rev Cardiol 2020; 17:641-655. [DOI: 10.1038/s41569-020-0379-7] [Citation(s) in RCA: 74] [Impact Index Per Article: 18.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/02/2020] [Indexed: 12/14/2022]
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208
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Sarhene M, Wang Y, Wei J, Huang Y, Li M, Li L, Acheampong E, Zhengcan Z, Xiaoyan Q, Yunsheng X, Jingyuan M, Xiumei G, Guanwei F. Biomarkers in heart failure: the past, current and future. Heart Fail Rev 2020; 24:867-903. [PMID: 31183637 DOI: 10.1007/s10741-019-09807-z] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Despite the enhanced knowledge of the pathophysiology of heart failure (HF), it still remains a serious syndrome with substantial morbidity, mortality, and frequent hospitalizations. These are due to the current improvements in other cardiovascular diseases (like myocardial infarction), the aging population, and growing prevalence of comorbidities. Biomarker-guided management has brought a new dimension in prognostication, diagnosis, and therapy options. Following the recommendation of natriuretic peptides (B-type natriuretic peptide and N-terminal-proBNP), many other biomarkers have been thoroughly studied to reflect different pathophysiological processes (such as fibrosis, inflammation, myocardial injury, and remodeling) in HF and some of them (like cardiac troponins, soluble suppression of tumorigenesis-2, and galectin 3) have subsequently been recommended to aid in the diagnosis and prognostication in HF. Consequently, multi-marker approach has also been approved owing to the varied nature of HF syndrome. In this review, we discussed the guidelines available for HF biomarkers, procedures for evaluating novel markers, and the utilities of both emerging and established biomarkers for risk stratification, diagnosis, and management of HF in the clinics. We later looked at how the rapidly emerging field-OMICs, can help transform HF biomarkers discoveries and establishment.
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Affiliation(s)
- Michael Sarhene
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China.,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, 300193, China
| | - Yili Wang
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China.,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, 300193, China
| | - Jing Wei
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China.,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, 300193, China
| | - Yuting Huang
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China.,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, 300193, China
| | - Min Li
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China.,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, 300193, China
| | - Lan Li
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China.,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.,Tianjin Laboratory of Translational Research of TCM Prescription and Syndrome, Tianjin, 300193, China
| | - Enoch Acheampong
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Zhou Zhengcan
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China.,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Qin Xiaoyan
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China.,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Xu Yunsheng
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China.,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Mao Jingyuan
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China
| | - Gao Xiumei
- State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Fan Guanwei
- First teaching hospital of Tianjin University of Traditional Chinese Medicine, Number 314 Anshanxi Road, Nankai District, Tianjin, China. .,State Key Laboratory of Modern Chinese Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China.
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209
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Januzzi JL, Ahmad T, Mulder H, Coles A, Anstrom KJ, Adams KF, Ezekowitz JA, Fiuzat M, Houston-Miller N, Mark DB, Piña IL, Passmore G, Whellan DJ, Cooper LS, Leifer ES, Desvigne-Nickens P, Felker GM, O'Connor CM. Natriuretic Peptide Response and Outcomes in Chronic Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2020; 74:1205-1217. [PMID: 31466618 DOI: 10.1016/j.jacc.2019.06.055] [Citation(s) in RCA: 51] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2019] [Revised: 06/12/2019] [Accepted: 06/17/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND The GUIDE-IT (GUIDing Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure) trial demonstrated that a strategy to "guide" application of guideline-directed medical therapy (GDMT) by reducing amino-terminal pro-B-type natriuretic peptide (NT-proBNP) was not superior to GDMT alone. OBJECTIVES The purpose of this study was to examine the prognostic meaning of NT-proBNP changes following heart failure (HF) therapy intensification relative to the goal NT-proBNP value of 1,000 pg/ml explored in the GUIDE-IT trial. METHODS A total of 638 study participants were included who were alive and had available NT-proBNP results 90 days after randomization. Rates of subsequent cardiovascular (CV) death/HF hospitalization or all-cause mortality during follow-up and Kansas City Cardiomyopathy Questionnaire (KCCQ) overall scores were analyzed. RESULTS A total of 198 (31.0%) subjects had an NT-proBNP ≤1,000 pg/ml at 90 days with no difference in achievement of NT-proBNP goal between the biomarker-guided and usual care arms. NT-proBNP ≤1,000 pg/ml by 90 days was associated with longer freedom from CV/HF hospitalization or all-cause mortality (p < 0.001 for both) and lower adjusted hazard of subsequent HF hospitalization/CV death (hazard ratio: 0.26; 95% confidence interval: 0.15 to 0.46; p < 0.001) and all-cause mortality (hazard ratio: 0.34; 95% confidence interval: 0.15 to 0.77; p = 0.009). Regardless of elevated baseline concentration, an NT-proBNP ≤1,000 pg/ml at 90 days was associated with better outcomes and significantly better KCCQ overall scores (p = 0.02). CONCLUSIONS Patients with heart failure with reduced ejection fraction whose NT-proBNP levels decreased to ≤1,000 pg/ml during GDMT had better outcomes. These findings may help to understand the results of the GUIDE-IT trial. (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment [GUIDE-IT]; NCT01685840).
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Affiliation(s)
- James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Baim Institute for Clinical Research, Boston, Massachusetts.
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University Medical Center, New Haven, Connecticut
| | - Hillary Mulder
- Duke Clinical Research Institute, Durham, North Carolina
| | - Adrian Coles
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, California
| | - Mona Fiuzat
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Daniel B Mark
- Duke Clinical Research Institute, Durham, North Carolina
| | - Ileana L Piña
- Albert Einstein College of Medicine, Bronx, New York
| | - Gayle Passmore
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Lawton S Cooper
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Eric S Leifer
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
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210
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Abstract
Heart failure (HF) is a clinical syndrome caused by a decline in cardiac systolic or diastolic function, which leaves the heart unable to pump enough blood to meet the normal physiological requirements of the human body. It is a serious disease burden worldwide affecting nearly 23 million patients. The concept that heart failure is "an engine out of fuel" has been generally accepted and metabolic remodeling has been recognized as an important aspect of this condition; it is characterized by defects in energy production and changes in metabolic pathways involved in the regulation of essential cellular functions such as the process of substrate utilization, the tricarboxylic acid cycle, oxidative phosphorylation, and high-energy phosphate metabolism. Advances in second-generation sequencing, proteomics, and metabolomics have made it possible to perform comprehensive tests on genes and metabolites that are crucial in the process of HF, thereby providing a clearer and comprehensive understanding of metabolic remodeling during HF. In recent years, new metabolic changes such as ketone bodies and branched-chain amino acids were demonstrated as alternative substrates in end-stage HF. This systematic review focuses on changes in metabolic substrate utilization during the progression of HF and the underlying regulatory mechanisms. Accordingly, the conventional concepts of metabolic remodeling characteristics are reviewed, and the latest developments, particularly multi-omics studies, are compiled.
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Affiliation(s)
- Liang Chen
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital; National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), 167A Beilishi Road, Xi Cheng District, Beijing, 100037, People's Republic of China
| | - Jiangping Song
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital; National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), 167A Beilishi Road, Xi Cheng District, Beijing, 100037, People's Republic of China.
| | - Shengshou Hu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital; National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences (CAMS) and Peking Union Medical College (PUMC), 167A Beilishi Road, Xi Cheng District, Beijing, 100037, People's Republic of China
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211
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van der Meer P, Gaggin HK, Dec GW. ACC/AHA Versus ESC Guidelines on Heart Failure: JACC Guideline Comparison. J Am Coll Cardiol 2020; 73:2756-2768. [PMID: 31146820 DOI: 10.1016/j.jacc.2019.03.478] [Citation(s) in RCA: 141] [Impact Index Per Article: 35.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2018] [Revised: 02/06/2019] [Accepted: 03/07/2019] [Indexed: 01/03/2023]
Abstract
The 2013 (with updates in 2016 and 2017) American College of Cardiology/American Heart Association and 2016 European Society of Cardiology guidelines provide practical evidence-based clinical guidelines for the diagnosis and treatment of both acute and chronic heart failure (HF). Both guidelines address noninvasive and invasive testing to establish the diagnosis of HF with reduced ejection fraction and HF with preserved ejection fraction. Extensive trial evidence supports the use of guideline-directed medical therapy and device-based therapies for the optimal management of patients with HF with reduced ejection fraction. Specific recommendations are also provided for HF with preserved ejection fraction although the evidence is substantially weaker. Management of medical comorbidities is now addressed in both guidelines. Acute HF and end-stage disease requiring advanced therapies are also discussed. This review compares specific recommendations across the spectrum of HF phenotypes and disease severity, highlights areas where differences exist, and lists consequential studies published since the latest guidelines.
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Affiliation(s)
- Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, the Netherlands
| | - Hanna K Gaggin
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts. https://twitter.com/HannaGaggin
| | - G William Dec
- Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts.
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212
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Haarman MG, Douwes JM, Ploegstra MJ, Roofthooft MTR, Vissia-Kazemier TR, Hillege HL, Berger RMF. The Clinical Value of Proposed Risk Stratification Tools in Pediatric Pulmonary Arterial Hypertension. Am J Respir Crit Care Med 2020; 200:1312-1315. [PMID: 31298925 DOI: 10.1164/rccm.201902-0266le] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
| | | | | | | | | | - Hans L Hillege
- University Medical Center GroningenGroningen, the Netherlands
| | - Rolf M F Berger
- University Medical Center GroningenGroningen, the Netherlands
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213
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Caprnda M, Zulli A, Shiwani HA, Kubatka P, Filipova S, Valentova V, Gazdikova K, Mozos I, Berukstis A, Laucevicius A, Rihacek I, Dragasek J, Prosecky R, Egom EE, Staffa R, Kruzliak P, Krasnik V. The therapeutic effect of B-type natriuretic peptides in acute decompensated heart failure. Clin Exp Pharmacol Physiol 2020; 47:1120-1133. [PMID: 32083749 DOI: 10.1111/1440-1681.13290] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 02/03/2020] [Accepted: 02/19/2020] [Indexed: 12/23/2022]
Abstract
B-type natriuretic peptide (BNP) exhibits roles in natriuresis and diuresis, making it an ideal drug that may aid in diuresing a fluid-overloaded patient with poor or worsening renal function. Several randomized clinical trials have tested the hypothesis that infusions of pharmacological doses of BNP to acute heart failure (HF) patients may enhance decongestion and preserve renal function in this clinical setting. Unfortunately, none of these have demonstrated beneficial outcomes. The current challenge for BNP research in acute HF lies in addressing a failure of concept and a reluctance to abandon an ineffective research model. Future success will necessitate a detailed understanding of the mechanism of action of BNP, as well as better integration of basic and clinical science.
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Affiliation(s)
- Martin Caprnda
- First Department of Internal Medicine, Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovakia
| | - Anthony Zulli
- Institute for Health and Sport, Victoria University, Melbourne, VIC, Australia
| | - Haaris A Shiwani
- Royal Lancaster Infirmary, University Hospitals of Morecambe Bay NHS Trust, Lancaster, UK
| | - Peter Kubatka
- Department of Medical Biology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia.,Division of Oncology, Department of Experimental Carcinogenesis, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Slavomira Filipova
- Department of Cardiology, National Institute of Cardiovascular Diseases and Slovak Medical University, Bratislava, Slovakia
| | - Vanda Valentova
- Division of Oncology, Department of Experimental Carcinogenesis, Biomedical Center Martin, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia.,Independent Researcher, Mosjøen, Norway
| | - Katarina Gazdikova
- Department of Nutrition, Faculty of Nursing and Professional Health Studies, Slovak Medical University, Bratislava, Slovakia.,Department of General Medicine, Faculty of Medicine, Slovak Medical University, Bratislava, Slovakia
| | - Ioana Mozos
- Department of Functional Sciences, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania.,Center for Translational Research and Systems Medicine, "Victor Babes" University of Medicine and Pharmacy, Timisoara, Romania
| | - Andrius Berukstis
- Clinic of Heart and Vessel Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Aleksandras Laucevicius
- Clinic of Heart and Vessel Diseases, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ivan Rihacek
- Second Department of Internal Medicine, Faculty of Medicine, Masaryk University and St, Anne´s University Hospital, Brno, Czech Republic
| | - Jozef Dragasek
- First Department of Psychiatry, Faculty of Medicine, Luis Pasteur University Hospital, Pavol Jozef Safarik University, Kosice, Slovakia
| | - Robert Prosecky
- Department of Internal Medicine, Brothers of Mercy Hospital, Brno, Czech Republic
| | - Emmanuel E Egom
- Egom Clinical & Translational Research Services Ltd, Dartmouth, NS, Canada.,Jewish General Hospital and Lady Davis Research Institute, Montreal, QC, Canada
| | - Robert Staffa
- Second Department of Surgery, Faculty of Medicine, St. Anne´s University Hospital, Masaryk University, Brno, Czech Republic
| | - Peter Kruzliak
- Department of Internal Medicine, Brothers of Mercy Hospital, Brno, Czech Republic.,Second Department of Surgery, Faculty of Medicine, St. Anne´s University Hospital, Masaryk University, Brno, Czech Republic
| | - Vladimir Krasnik
- Department of Ophthalmology, Faculty of Medicine, Comenius University and University Hospital, Bratislava, Slovakia
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Abstract
PURPOSE OF REVIEW Heart failure represents a major growing health problem in developed world. This article aims to review recent heart failure trials that have significantly impacted the management of heart failure. RECENT FINDINGS Despite advances in heart failure, mortality and morbidity remains elevated amongst patients. Recent clinical trials demonstrate promising treatment strategies that likely impact clinical practice; including heart failure prevention with the use of SGLT2-inhibitors in patients with diabetes and cardiovascular risk, new treatments that may abrogate disease progression in cardiac amyloidosis, intravenous iron therapy in iron deficiency anemia in chronic systolic heart failure, predischarge treatment with angiotensin receptor blocker with neprilysin inhibition (ARNi) in patients hospitalized for acute decompensated heart failure, and newer continuous flow left ventricular assist device with increased durability and efficacy in patients with Stage D heart failure. SUMMARY Recent clinical trials with SGLT2 inhibitors, therapies targeting transthyretin cardiac amyloidosis, iron, angiotensin receptor blocker with neprilysin inhibition and newer mechanical circulatory support devices are very promising as practice changing new treatment strategies in prevention and treatment of heart failure. This article presents a summary of important trials and should be of practical value to both clinicians and researchers.
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215
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Santas E, Palau P, Bayés-Ge A, Núñez J. The emerging role of carbohydrate antigen 125 in heart failure. Biomark Med 2020; 14:249-252. [DOI: 10.2217/bmm-2019-0470] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Patricia Palau
- Servicio de Cardiología, Hospital General Universitario de Castellón, Universitat Jaume I, Castellón, Spain
| | - Antoni Bayés-Ge
- CIBER Cardiovascular, Spain
- Servicio de Cardiología, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, INCLIVA, Universitat de Valencia, Valencia, Spain
- CIBER Cardiovascular, Spain
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216
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Alphonsus CS, Govender P, Rodseth RN, Biccard BM. Natriuretic peptide-directed medical therapy: a systematic review. Perioper Med (Lond) 2020; 9:5. [PMID: 32095234 PMCID: PMC7027249 DOI: 10.1186/s13741-019-0134-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2019] [Accepted: 12/16/2019] [Indexed: 12/29/2022] Open
Abstract
Natriuretic peptides (NP) are strongly associated with perioperative cardiovascular events. However, in patients with raised NP, it remains unknown whether treatment to reduce NP levels prior to surgery results in better perioperative outcomes. In this systematic review and meta-analysis, we investigate NP-directed medical therapy in non-surgical patients to provide guidance for NP-directed medical therapy in surgical patients. The protocol was registered with PROSPERO (CRD42017051468). The database search included MEDLINE (PubMed), CINAHL (EBSCO host), EMBASE (EBSCO host), ProQuest, Web of Science, and Cochrane database. The primary outcome was to determine whether NP-directed medical therapy is effective in reducing NP levels within 6 months, compared to standard of care. The secondary outcome was to determine whether reducing NP levels is associated with decreased mortality. Full texts of 18 trials were reviewed. NP-directed medical therapy showed no significant difference compared to standard care in decreasing NP levels (standardized mean difference − 0.04 (− 0.16, 0.07)), but was associated with a 6-month (relative risk (RR) 0.82 (95% confidence interval (CI) 0.68–0.99)) reduction in mortality.
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Affiliation(s)
| | | | - Reitze N Rodseth
- 3Consultant Anaesthesiologist, University of KwaZulu-Natal, KwaZulu-Natal, South Africa
| | - Bruce M Biccard
- 1Consultant Anaesthesiologist, University of Cape Town, Western Cape, South Africa
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217
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Seoudy H, Frank J, Neu M, Güßefeld N, Klaus Y, Freitag-Wolf S, Lambers M, Lutter G, Dempfle A, Rangrez AY, Kuhn C, Frey N, Frank D. Periprocedural Changes of NT-proBNP Are Associated With Survival After Transcatheter Aortic Valve Implantation. J Am Heart Assoc 2020; 8:e010876. [PMID: 30686097 PMCID: PMC6405592 DOI: 10.1161/jaha.118.010876] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Cardiovascular biomarkers constitute promising tools for improved risk stratification and prediction of outcome in patients undergoing transcatheter aortic valve implantation. We examined the association of periprocedural changes of NT‐proBNP (N‐terminal pro–B‐type natriuretic peptide) with survival after transcatheter aortic valve implantation. Methods and Results NT‐proBNP levels were measured in 704 patients before transcatheter aortic valve implantation and at discharge. Patients were grouped as responders and nonresponders depending on an NT‐proBNP–based ratio (postprocedural NT‐proBNP at discharge/preprocedural NT‐proBNP). Overall, 376 of 704 patients showed a postprocedural decrease in NT‐proBNP levels (NT‐proBNP ratio <1). Responders and nonresponders differed significantly regarding median preprocedural (2822 versus 1187 pg/mL, P<0.001) and postprocedural (1258 versus 3009 pg/mL, P<0.001) NT‐proBNP levels. Patients in the nonresponder group showed higher prevalence of atrial fibrillation (47.0% versus 39.4%, P=0.042), arterial hypertension (94.2% versus 87.5%, P=0.002), renal impairment (77.4% versus 69.1%, P=0.013), and peripheral artery disease (24.4% versus 14.6%, P=0.001). In contrast, patients in the responder group had higher prevalence of moderately reduced left ventricular ejection fraction (17.3% versus 11.0%, P=0.017), lower calculated aortic valve area (0.7 versus 0.8 cm2, P<0.001), and higher mean pressure gradient (41 versus 35 mm Hg, P<0.001). Median follow‐up was 22.6 months. Kaplan–Meier analysis showed a highly significant survival benefit for the responder group compared with the nonresponder group (log‐rank test, P<0.001). Conclusions A ratio based on periprocedural changes of NT‐proBNP is a simple tool for better risk stratification and is associated with survival in patients after transcatheter aortic valve implantation.
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Affiliation(s)
- Hatim Seoudy
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany
| | - Johanne Frank
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany
| | - Markus Neu
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany
| | - Nathalie Güßefeld
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany
| | - Yannic Klaus
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany
| | - Sandra Freitag-Wolf
- 2 Institute of Medical Informatics and Statistics Kiel University University Hospital Schleswig-Holstein Kiel Germany
| | - Moritz Lambers
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany.,3 Department of Cardiology and Angiology Contilia Heart and Vascular Centre Elisabeth-Krankenhaus Essen Germany
| | - Georg Lutter
- 4 Department of Cardiovascular Surgery University Hospital Schleswig-Holstein Kiel Germany.,5 DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
| | - Astrid Dempfle
- 2 Institute of Medical Informatics and Statistics Kiel University University Hospital Schleswig-Holstein Kiel Germany
| | - Ashraf Yusuf Rangrez
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany.,5 DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
| | - Christian Kuhn
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany.,5 DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
| | - Norbert Frey
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany.,5 DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
| | - Derk Frank
- 1 Department of Internal Medicine III, Cardiology and Angiology University Hospital Schleswig-Holstein Kiel Germany.,5 DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Lübeck Kiel Germany
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218
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Abstract
PURPOSE OF REVIEW Biomarkers play a fundamental role in the management of heart failure. Both new and old biomarkers are evaluated every year with new information gained for their use in heart failure. Major advancements have been made in the past 2 years in key biomarkers that will surely become part of standard clinical management of heart failure. This review will focus on major developments since 2016. RECENT FINDINGS Soluble suppression of tumorigenicity 2 has had multiple breakthrough studies solidifying its prognostic use in both acute and chronic heart failure and with multiple studies showing a strong benefit with serial monitoring. High-sensitivity troponin has also recently been demonstrated to be a powerful prognostic biomarker in heart failure. Additionally, it may serve as a novel screening tool to identify patients at high risk for incident heart failure. Natriuretic peptides continue to show their resilience as the main prognostic biomarker in heart failure. Recent studies suggest natriuretic peptides may help identify certain patient populations that benefit from specific therapies and they can predict prognosis beyond in diseases other than heart failure. SUMMARY Although natriuretic peptides are well-established biomarkers in heart failure, the weight of evidence for soluble suppression of tumorigenicity 2 and high-sensitivity troponin has significantly grown since 2016 that these two biomarkers should be incorporated into regular practice and management of heart failure patients.
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219
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McLellan J, Bankhead CR, Oke JL, Hobbs FDR, Taylor CJ, Perera R. Natriuretic peptide-guided treatment for heart failure: a systematic review and meta-analysis. BMJ Evid Based Med 2020; 25:33-37. [PMID: 31326896 PMCID: PMC7029248 DOI: 10.1136/bmjebm-2019-111208] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND GUIDE-IT, the largest trial to date, published in August 2017, evaluating the effectiveness of natriuretic peptide (NP)-guided treatment of heart failure (HF), was stopped early for futility on a composite outcome. However, the reported effect sizes on individual outcomes of all-cause mortality and HF admissions are potentially clinically relevant. OBJECTIVE This systematic review and meta-analysis aims to combine all available trial level evidence to determine if NP-guided treatment of HF reduces all-cause mortality and HF admissions in patients with HF. STUDY SELECTION Eight databases, no language restrictions, up to November 2017 were searched for all randomised controlled trials comparing NP-guided treatment versus clinical assessment alone in adult patients with HF. No language restrictions were applied. Publications were independently double screened and extracted. Fixed-effect meta-analyses were conducted. FINDINGS 89 papers were included, reporting 19 trials (4554 participants), average ages 62-80 years. Pooled risk ratio estimates for all-cause mortality (16 trials, 4063 participants) were 0.87, 95% CI 0.77 to 0.99 and 0.80, 95% CI 0.72 to 0.89 for HF admissions (11 trials, 2822 participants). Sensitivity analyses, restricted to low risk of bias, produced similar estimates, but were no longer statistically significant. CONCLUSIONS Considering all the evidence to date, the pooled effects suggest that NP-guided treatment is beneficial in reducing HF admissions and all-cause mortality. However, there is still insufficient high-quality evidence to make definitive recommendations on the use of NP-guided treatment in clinical practice. TRIAL REGISTRATION NUMBER Systematic Review Cochrane Database Number: CD008966.
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Affiliation(s)
- Julie McLellan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare R Bankhead
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jason L Oke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - F D Richard Hobbs
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Clare J Taylor
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Rafael Perera
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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220
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Fudim M, Kelly JP, Jones AD, AbouEzzeddine OF, Ambrosy AP, Greene SJ, Reddy YN, Anstrom KJ, Alhanti B, Lewis GD, Hernandez AF, Felker GM. Are existing and emerging biomarkers associated with cardiorespiratory fitness in patients with chronic heart failure? Am Heart J 2020; 220:97-107. [PMID: 31805424 DOI: 10.1016/j.ahj.2019.11.006] [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] [Received: 11/12/2019] [Accepted: 11/12/2019] [Indexed: 01/28/2023]
Abstract
BACKGROUND Cardiorespiratory fitness (CRF) is closely linked to health status and clinical outcomes in heart failure (HF) patients. We aimed to test whether biomarkers can reflect CRF and its change over time. METHODS This post hoc analysis used data from ambulatory cohorts of heart failure with reduced ejection fraction (HFrEF) (IRONOUT) and heart failure with preserved ejection fraction (HFpEF) (RELAX). Cardiopulmonary exercise testing, 6-minute walk distance (6MWD), and serum biomarkers were measured at baseline and 16- or 24-week follow-up (for IRONOUT and RELAX respectively). Biomarkers included N-terminal pro-B-type natriuretic peptide (NT-proBNP), soluble ST2, growth differentiation factor-15, and Galectin-3. RESULTS Analysis included 225 patients with HFrEF and 216 with HFpEF. Baseline peak VO2, VE/VCO2 slope, and 6MWD showed a mild correlation with the doubling of all 4 tested biomarkers in HFrEF and HFpEF. Following multivariable adjustment (including all biomarkers), the only significant association between change in biomarker and functional parameter in HFrEF was change in NT-proBNP and change in VE/VCO2 slope (3.596% increase per doubling, 95% CI 0.779-6.492, P = .012). In HFpEF, a decrease in peak VO2 was associated with an increase in NT-proBNP (-0.726 mL/min/kg per doubling, 95% CI -1.100 to -0.353, P < .001), and a decrease in 6MWD was associated with an increase in growth differentiation factor-15 (-31.606 m per doubling, 95% CI -61.404 to -1.809, P = .038). CONCLUSIONS In these ambulatory trial cohorts, NT-proBNP was associated with baseline and change in CRF in HFrEF and HFpEF. In contrast, novel biomarkers do not appear suitable as a reliable surrogate for serial assessment of exercise capacity in HF patients given lack of consistent independent association with CRF beyond traditional risk factors and NT-proBNP.
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221
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Heneghan C, Aronson JK. Why reports of clinical trials should include updated meta-analyses. BMJ Evid Based Med 2020; 25:1-2. [PMID: 31473599 DOI: 10.1136/bmjebm-2019-111243] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/19/2019] [Indexed: 12/19/2022]
Affiliation(s)
- Carl Heneghan
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Centre for Evidence-Based Medicine, Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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222
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Bayes-Genis A, Emdin M, Núñez J. Biomarker-guided management in acute heart failure: is there light at the end of the tunnel? Eur J Heart Fail 2020; 22:276-278. [PMID: 31833167 DOI: 10.1002/ejhf.1690] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 10/26/2019] [Indexed: 11/08/2022] Open
Affiliation(s)
- Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain.,Department of Medicine, CIBERCV, Autonomous University of Barcelona, Barcelona, Spain
| | - Michele Emdin
- Institute of Life Sciences, Scuola Superiore Sant'Anna, Pisa, Italy.,Fondazione Toscana G. Monasterio, Pisa, Italy
| | - Julio Núñez
- Cardiology Department, Hospital Clínico Universitario, CIBERCV, INCLIVA. Universitat de València, València, Spain
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223
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Evaluating risk prediction models for adults with heart failure: A systematic literature review. PLoS One 2020; 15:e0224135. [PMID: 31940350 PMCID: PMC6961879 DOI: 10.1371/journal.pone.0224135] [Citation(s) in RCA: 50] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2019] [Accepted: 09/24/2019] [Indexed: 12/25/2022] Open
Abstract
Background The ability to predict risk allows healthcare providers to propose which patients might benefit most from certain therapies, and is relevant to payers’ demands to justify clinical and economic value. To understand the robustness of risk prediction models for heart failure (HF), we conducted a systematic literature review to (1) identify HF risk-prediction models, (2) assess statistical approach and extent of validation, (3) identify common variables, and (4) assess risk of bias (ROB). Methods Literature databases were searched from March 2013 to May 2018 to identify risk prediction models conducted in an out-of-hospital setting in adults with HF. Distinct risk prediction variables were ranked according to outcomes assessed and incorporation into the studies. ROB was assessed using Prediction model Risk Of Bias ASsessment Tool (PROBAST). Results Of 4720 non-duplicated citations, 40 risk-prediction publications were deemed relevant. Within the 40 publications, 58 models assessed 55 (co)primary outcomes, including all-cause mortality (n = 17), cardiovascular death (n = 9), HF hospitalizations (n = 15), and composite endpoints (n = 14). Few publications reported detail on handling missing data (n = 11; 28%). The discriminatory ability for predicting all-cause mortality, cardiovascular death, and composite endpoints was generally better than for HF hospitalization. 105 distinct predictor variables were identified. Predictors included in >5 publications were: N-terminal prohormone brain-natriuretic peptide, creatinine, blood urea nitrogen, systolic blood pressure, sodium, NYHA class, left ventricular ejection fraction, heart rate, and characteristics including male sex, diabetes, age, and BMI. Only 11/58 (19%) models had overall low ROB, based on our application of PROBAST. In total, 26/58 (45%) models discussed internal validation, and 14/58 (24%) external validation. Conclusions The majority of the 58 identified risk-prediction models for HF present particular concerns according to ROB assessment, mainly due to lack of validation and calibration. The potential utility of novel approaches such as machine learning tools is yet to be determined. Registration number The SLR was registered in Prospero (ID: CRD42018100709).
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224
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Brooksbank JA, Greene SJ, DeWald TA, Mentz RJ. Body surface area and medication dosing in patients with heart failure with reduced ejection fraction. Trends Cardiovasc Med 2020; 31:111-116. [PMID: 32008834 DOI: 10.1016/j.tcm.2019.12.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Revised: 12/09/2019] [Accepted: 12/31/2019] [Indexed: 11/26/2022]
Abstract
Multiple medications are proven to reduce morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF), but data regarding personalized approaches to optimize medication dosing remain limited. Current treatment guidelines recommend up-titration to target or maximally tolerated doses of these medications, yet use and dosing remain suboptimal in clinical practice. Body surface area (BSA) is a readily available clinical metric, used for dosing many medications, closely associated with blood pressure, renal function, and vascular congestion, and may influence efficacy, safety, and tolerability of HFrEF medications. In this review, we examine the rationale, strengths/weaknesses, and potential utility of BSA as a means of optimizing HFrEF medication use and dosing.
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Affiliation(s)
- Jeremy A Brooksbank
- Department of Medicine, Duke University Medical Center (DUMC), Box 3182, Durham, NC 27710, United States.
| | - Stephen J Greene
- Department of Medicine, Duke University Medical Center (DUMC), Box 3182, Durham, NC 27710, United States; Division of Cardiology, Duke University Medicial Center, Durham, NC 27710, United States; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, United States
| | - Tracy A DeWald
- Department of Medicine, Duke University Medical Center (DUMC), Box 3182, Durham, NC 27710, United States; Division of Pharmacology, Duke University Medical Center, Durham, NC 27710, United States
| | - Robert J Mentz
- Department of Medicine, Duke University Medical Center (DUMC), Box 3182, Durham, NC 27710, United States; Division of Cardiology, Duke University Medicial Center, Durham, NC 27710, United States; Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC 27701, United States
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225
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A Novel In-hospital Congestion Score to Risk Stratify Patients Admitted for Worsening Heart Failure (from ASCEND-HF). J Cardiovasc Transl Res 2020; 13:540-548. [DOI: 10.1007/s12265-020-09954-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/02/2020] [Indexed: 12/01/2022]
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226
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McCallum W, Tighiouart H, Kiernan MS, Huggins GS, Sarnak MJ. Relation of Kidney Function Decline and NT-proBNP With Risk of Mortality and Readmission in Acute Decompensated Heart Failure. Am J Med 2020; 133:115-122.e2. [PMID: 31247182 PMCID: PMC7373496 DOI: 10.1016/j.amjmed.2019.05.047] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2019] [Revised: 05/21/2019] [Accepted: 05/23/2019] [Indexed: 01/17/2023]
Abstract
BACKGROUND Acute declines in kidney function occur in approximately 20%-30% of patients with acute decompensated heart failure, but its significance is unclear, and the importance of its context is not known. This study aimed to determine the prognostic value of a decline in kidney function in the context of decongestion among patients admitted with acute decompensated heart failure. METHODS Using data from patients enrolled in the Ultrafiltration in Decompensated Heart Failure with Cardiorenal Syndrome Study (CARRESS) and Diuretic Optimization Strategies Evaluation (DOSE) trials, we used multivariable Cox regression models to evaluate the association between decline in estimated glomerular filtration rate (eGFR) and change in N-terminal pro-b-type natriuretic peptide (NT-proBNP) with a composite outcome of death and rehospitalization, as well as testing for an interaction between the two. RESULTS Among 435 patients, in-hospital decline in eGFR was not significantly associated with death and rehospitalization (hazard ratio [HR] = 0.89 per 30% decline, 95% confidence interval [CI] 0.74, 1.07), whereas decline in NT-proBNP was associated with lower risk (HR = 0.69 per halving, 95% CI 0.58, 0.83). There was a significant interaction (P = 0.002 unadjusted; P = 0.03 adjusted) between decline in eGFR and change in NT-proBNP where a decline in eGFR was associated with better outcomes when NT-proBNP declined (HR = 0.78 per 30% decline in eGFR, 95% CI 0.61, 0.99), but not when NT-proBNP increased (HR = 0.99, 95% CI 0.76, 1.30). CONCLUSIONS Decline in kidney function during therapy for acute decompensated heart failure is associated with improved outcomes as long as NT-proBNP levels are decreasing as well, suggesting that incorporation of congestion biomarkers may aid clinical interpretation of eGFR declines.
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Affiliation(s)
- Wendy McCallum
- Division of Nephrology, Tufts Medical Center, Boston, Mass
| | - Hocine Tighiouart
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, Mass; Tufts Clinical and Translational Science Institute, Tufts University, Boston, Mass
| | | | | | - Mark J Sarnak
- Division of Nephrology, Tufts Medical Center, Boston, Mass.
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227
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Litwin SE, Zile MR. Should We Test for Diastolic Dysfunction? How and How Often? JACC Cardiovasc Imaging 2020; 13:297-309. [DOI: 10.1016/j.jcmg.2019.02.029] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2018] [Revised: 02/14/2019] [Accepted: 02/20/2019] [Indexed: 01/24/2023]
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228
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Abstract
The role of biomarkers is increasingly recognized in heart failure (HF) management, for diagnosis, prognostication, and screening of high-risk patients. Beyond natriuretic peptides and troponins, the utility of novel, emerging biomarkers is less established. This document reflects the key points of a Heart Failure Association of the European Society of Cardiology (ESC) consensus meeting on biomarker monitoring in HF.
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Affiliation(s)
- Ilaria Spoletini
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Rome, Italy
| | - Andrew J S Coats
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Rome, Italy
| | - Michele Senni
- Azienda Ospedaliera Papa Giovanni XXIII, Bergamo, Italy
| | - Giuseppe M C Rosano
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Via della Pisana, 235, 00163 Rome, Italy
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229
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Abstract
After more than a decade of relatively modest advancements, heart failure therapeutic development has accelerated, with the PARADIGM-HF trial and the SHIFT trial demonstrated significant reductions in cardiovascular death and heart failure hospitalization for sacubitril-valsartan and in heart failure hospitalization alone for ivabradine. Several heart failure therapies have since received or stand on the verge of market approval and promise substantive advances in the treatment of chronic heart failure. Some of these improve clinical outcomes, whereas others improve functional or patient-reported outcomes. In light of these rapid advances in the care of adults living with chronic heart failure, in this review we seek to update the general practitioner on novel heart failure therapies. Specifically, we will review recent data on the implementation of sacubitril-valsartan, treatment of functional mitral regurgitation, sodium-glucose co-transporter-2 (SGLT-2) inhibitor therapy, agents for transthyretin amyloid cardiomyopathy, treatment of iron deficiency in heart failure, and the use of biomarkers or remote hemodynamic monitoring to guide heart failure therapy.
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Affiliation(s)
- Leo F Buckley
- Department of Pharmacy, Brigham and Women's Hospital, Boston, USA
| | - Amil M Shah
- Department of Pharmacy, Brigham and Women's Hospital, Boston, USA.,Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, USA
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230
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Zhao J, Xu T, Zhou Y, Zhou Y, Xia Y, Li D. B-type natriuretic peptide and its role in altering Ca 2+-regulatory proteins in heart failure-mechanistic insights. Heart Fail Rev 2019; 25:861-871. [PMID: 31820203 DOI: 10.1007/s10741-019-09883-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Heart failure (HF) is a worldwide disease with high levels of morbidity and mortality. The pathogenesis of HF is complicated and involves imbalances in hormone and electrolyte. B-type natriuretic peptide (BNP) has served as a biomarker of HF severity, and in recent years, it has been used to treat the disease, thanks to its cardio-protective effects, such as diuresis, natriuresis, and vasodilatation. In stage C/D HF, symptoms are severe despite elevated BNP. Disturbances in Ca2+ homeostasis are often a dominating feature of the disease, causing Ca2+-regulatory protein dysfunction, including reduced expression and activity of sarcoplasmic reticulum Ca2+-ATPase2a (SERCA2a), impaired ryanodine receptors (RYRs) function, intensive Na+-Ca2+ exchanger (NCX), and downregulation of S100A1. The relationship between natriuretic peptides (NPs) and Ca2+-regulatory proteins has been widely studied and represents important mechanisms in the etiology of HF. In this review, we present evidence that BNP may regulate Ca2+-regulatory proteins, in particular, suppressing SERCA2a and S100A1 expression. However, relationships between BNP and other Ca2+-regulatory proteins remain vague.
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Affiliation(s)
- Jiaqi Zhao
- Institute of Cardiovascular Disease Research, Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China
| | - Tongda Xu
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China
| | - Yao Zhou
- Institute of Cardiovascular Disease Research, Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China
| | - You Zhou
- Institute of Cardiovascular Disease Research, Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China
| | - Yong Xia
- Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China.
| | - Dongye Li
- Institute of Cardiovascular Disease Research, Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China. .,Department of Cardiology, The Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, People's Republic of China.
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231
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Jackson AM, Jhund PS. The price of a failing heart. Eur J Heart Fail 2019; 21:1532-1533. [PMID: 31815336 DOI: 10.1002/ejhf.1605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 07/27/2019] [Accepted: 08/14/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Alice M Jackson
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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232
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Maurer MS. Call for New Therapies in Heart Failure. JACC CardioOncol 2019; 1:305-306. [PMID: 34396196 PMCID: PMC8352019 DOI: 10.1016/j.jaccao.2019.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Affiliation(s)
- Mathew S. Maurer
- Address for correspondence: Dr. Mathew S. Maurer, Cardiac Amyloidosis Program, Center for Advanced Cardiac Care, Columbia University Irving Medical Center, New York Presbyterian Hospital, 622 West 168th Street, PH12 Stem Room 134, New York, New York 10032, USA. @MathewMaurer
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233
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Caraballo C, Desai NR, Mulder H, Alhanti B, Wilson FP, Fiuzat M, Felker GM, Piña IL, O'Connor CM, Lindenfeld J, Januzzi JL, Cohen LS, Ahmad T. Clinical Implications of the New York Heart Association Classification. J Am Heart Assoc 2019; 8:e014240. [PMID: 31771438 PMCID: PMC6912957 DOI: 10.1161/jaha.119.014240] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background The New York Heart Association (NYHA) classification has served as a fundamental tool for risk stratification of heart failure (HF) and determines clinical trial eligibility and candidacy for drugs and devices. However, its ability to adequately stratify risk is unclear. Methods and Results To compare NYHA class with objective assessments and survival in patients with HF, we performed secondary analyses of 4 multicenter National Institutes of Health–funded HF clinical trials that included patients classified as NYHA class II or III: TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist), DIG (The Effect of Digoxin on Mortality and Morbidity in Patients With Heart Failure), HF‐ACTION (Efficacy and Safety of Exercise Training in Patients With Chronic Heart Failure), and GUIDE‐IT (Guiding Evidence‐Based Therapy Using Biomarker Intensified Treatment in Heart Failure). Twenty‐month cumulative survival was compared between classes using Kaplan–Meier curves and the log rank test. NT‐proBNP (N‐terminal pro–B‐type natriuretic peptide), Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, 6‐minute walk distances, left ventricular ejection fraction, and cardiopulmonary test parameters were compared using Wilcoxon rank sum tests and percentage overlap using kernel density estimations. Cumulative mortality varied significantly across NYHA classes and HF clinical trials (likelihood ratio, P<0.001). Mortality at 20 months for NYHA class II ranged from 7% for patients in HF‐ACTION to 15% in GUIDE‐IT, whereas mortality for NYHA class III ranged from 12% in TOPCAT to 26% in GUIDE‐IT. There was substantial percentage overlap in values for NT‐proBNP levels (79% and 69%), KCCQ scores (63% and 54%), 6‐minute walk distances (63% and 54%), and left ventricular ejection fraction (88% and 83%). Similarly, there was substantial overall in values for minute ventilation–carbon dioxide production relationship (71%), maximal oxygen uptake (54%), and exercise duration (53%). Conclusions The NYHA system poorly discriminates HF patients across the spectrum of functional impairment. These findings raise important questions about the need for improved phenotyping of these patients to facilitate risk stratification and response to interventions.
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Affiliation(s)
- César Caraballo
- Section of Cardiovascular Medicine Center for Outcomes Research Evaluation (CORE) Yale University School of Medicine New Haven CT
| | - Nihar R Desai
- Section of Cardiovascular Medicine Center for Outcomes Research Evaluation (CORE) Yale University School of Medicine New Haven CT
| | | | | | - F Perry Wilson
- Program of Applied Translational Research Yale University School of Medicine New Haven CT
| | | | | | | | | | | | - James L Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research Boston MA
| | - Lawrence S Cohen
- Program of Applied Translational Research Yale University School of Medicine New Haven CT
| | - Tariq Ahmad
- Section of Cardiovascular Medicine Center for Outcomes Research Evaluation (CORE) Yale University School of Medicine New Haven CT
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234
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McAlister FA, Ezekowitz JA, Armstrong PW. Heart failure treatment and the art of medical decision making. Eur J Heart Fail 2019; 21:1510-1514. [PMID: 31769152 DOI: 10.1002/ejhf.1655] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023] Open
Affiliation(s)
- Finlay A McAlister
- Division of General Internal Medicine, University of Alberta, Edmonton, Alberta, Canada.,Faculty of Medicine and Dentistry, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Justin A Ezekowitz
- Faculty of Medicine and Dentistry, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta, Canada
| | - Paul W Armstrong
- Faculty of Medicine and Dentistry, Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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235
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Logan JK, Mentz RJ. Targeting Natriuretic Peptide Levels in Heart Failure with Therapy: Does "X" Really Mark the Spot? Curr Heart Fail Rep 2019; 16:250-256. [PMID: 31741230 DOI: 10.1007/s11897-019-00441-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE OF REVIEW Explore controversial biomarker-guided management of patients with heart failure (HF) with reduced ejection fraction. RECENT FINDINGS Natriuretic peptides (e.g., BNP, NT-proBNP) are elevated in HF as a result of end-diastolic stress and are used in the diagnosis and prognosis of heart failure. Natriuretic peptide levels decrease with guideline-directed medical therapy (GDMT). Multiple small studies examined whether the use of biomarker-guided therapy would be beneficial to guide HF care and potentially improve outcomes. Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment in Heart Failure (GUIDE-IT), the largest randomized control study seeking to answer that question, did not find biomarker guided therapy to be more effective than usual care in improving the primary endpoints of HF hospitalization or cardiovascular mortality in HF patients. Natriuretic peptides are important for diagnosis and prognosis in HF. GUIDE-IT showed that patients with HF and reduced ejection did not benefit from biomarker-guided strategy in terms of clinical outcomes. Future studies could focus on additional routine clinical care settings and take into account other HF phenotypes including preserved ejection fraction.
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Affiliation(s)
- Juliette K Logan
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA. .,Duke Clinical Research Institute, PO Box 17969, Durham, NC, 27715, USA.
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236
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Roxana ME, Georgică TÃ, Ionuț D, Gianina M, Cristina F. Atrial and Brain Natriuretic Peptides- Benefits and Limits of their use in Cardiovascular Diseases. Curr Cardiol Rev 2019; 15:283-290. [PMID: 30914031 PMCID: PMC8142359 DOI: 10.2174/1573403x15666190326150550] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/14/2019] [Accepted: 03/19/2019] [Indexed: 02/07/2023] Open
Abstract
Natriuretic peptides, produced by cardiac myocytes, are regulators of the intravascular volume and blood pressure, and also exhibit neuroendocrine, metabolic and growth controlling effects. In heart failure, their synthesis increases exponentially as part of the neuroendocrine activation, but their beneficial effects are diminished. The paper reviews relevant data about their role as diagnosis and prognosis markers in heart failure, the hemodynamic and clinical benefits of their use as therapy in heart failure, together with the main adverse effects. Peptides non-specifically increase in extracardiac pathology and the literature reveals the mechanisms of increase, significance and threshold values to exclude cardiac dysfunction.
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Affiliation(s)
- Mustafa Edme Roxana
- Department of Internal Medicine-Cardiology, Craiova University of Medicine and Pharmacy, Craiova 200349, Romania
| | - TÃrtea Georgică
- Department of Physiology, Craiova University of Medicine and Pharmacy, Craiova 200349, Romania
| | - Donoiu Ionuț
- Department of Internal Medicine-Cardiology, Craiova University of Medicine and Pharmacy, Craiova 200349, Romania
| | - Moise Gianina
- County Clinical Emergency Hospital of Craiova, Craiova 200349, Romania
| | - Florescu Cristina
- Department of Internal Medicine-Cardiology, Craiova University of Medicine and Pharmacy, Craiova 200349, Romania
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237
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Platz E, Solomon SD, McMurray JJV. Lung ultrasound: monitoring congestion in patients with heart failure. Eur J Heart Fail 2019; 21:1614-1615. [PMID: 31702095 DOI: 10.1002/ejhf.1636] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2019] [Accepted: 09/13/2019] [Indexed: 02/06/2023] Open
Affiliation(s)
- Elke Platz
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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238
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Considerations for Clinical Trials Targeting the Myocardial Interstitium. JACC Cardiovasc Imaging 2019; 12:2319-2331. [DOI: 10.1016/j.jcmg.2019.03.034] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2018] [Revised: 02/26/2019] [Accepted: 03/07/2019] [Indexed: 01/23/2023]
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239
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Rivas‐Lasarte M, Álvarez‐García J, Fernández‐Martínez J, Maestro A, López‐López L, Solé‐González E, Pirla MJ, Mesado N, Mirabet S, Fluvià P, Brossa V, Sionis A, Roig E, Cinca J. Lung ultrasound‐guided treatment in ambulatory patients with heart failure: a randomized controlled clinical trial (LUS‐HF study). Eur J Heart Fail 2019; 21:1605-1613. [DOI: 10.1002/ejhf.1604] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/07/2019] [Accepted: 08/08/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
- Mercedes Rivas‐Lasarte
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Jesús Álvarez‐García
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Juan Fernández‐Martínez
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Alba Maestro
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Laura López‐López
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Eduard Solé‐González
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Maria J. Pirla
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Nuria Mesado
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Sonia Mirabet
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Paula Fluvià
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Vicens Brossa
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Alessandro Sionis
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Eulàlia Roig
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
| | - Juan Cinca
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIb‐SantPau, CIBERCVUniversitat Autónoma de Barcelona Barcelona Spain
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240
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Bossuyt PM. Laboratory Measurement's Contribution to the Replication and Application Crisis in Clinical Research. Clin Chem 2019; 65:1479-1480. [PMID: 31672850 DOI: 10.1373/clinchem.2019.311605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2019] [Accepted: 09/24/2019] [Indexed: 11/06/2022]
Affiliation(s)
- Patrick M Bossuyt
- Department of Clinical Epidemiology, Biostatistics and Bioinformatics, Amsterdam University Medical Centers, Amsterdam the Netherlands.
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241
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Weinmann K, Werner J, Koenig W, Rottbauer W, Walcher D, Keßler M. Use of Cardiac Biomarkers for Monitoring Improvement of Left Ventricular Function by Immunoadsorption Treatment in Dilated Cardiomyopathy. Biomolecules 2019; 9:biom9110654. [PMID: 31731547 PMCID: PMC6920763 DOI: 10.3390/biom9110654] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/22/2019] [Accepted: 10/22/2019] [Indexed: 01/03/2023] Open
Abstract
Immunoadsorption and subsequent administration of intravenous immunoglobulin (IVIG) have shown beneficial effects on cardiac function and symptoms in patients with dilated cardiomyopathy. Biomarkers play an emerging role in disease monitoring and outcome prediction of heart failure (HF) patients. We aimed to analyze cardiac biomarkers as predictor for improvement of left ventricular (LV) function after immunoadsorption treatment in dilated cardiomyopathy (DCM). Thirty-one patients with dilated cardiomyopathy on optimized HF pharmacotherapy received a single cycle of immunoadsorption for five days followed by IVIG administration. Left ventricular ejection fraction (LVEF) and heart failure biomarkers (hs troponin T, hs troponin I, NT-proBNP and sST2) were evaluated before treatment, after the last cycle of immunoadsorption and during a median follow-up of 30.5 months. We correlated HF biomarkers before immunoadsorption and acute changes of HF biomarkers by immunoadsorption with LV improvement during the long-term follow-up. LV function improved significantly after immunoadsorption from 28.0 to 42.0% during the long-term follow-up (p < 0.0001). Evaluation of biomarker levels showed a significant decrease for hs troponin I (from 9.2 to 5.5 ng/L, p < 0.05) and NT-proBNP (from 789.6 to 281.2 pg/mL, p < 0.005). Correlation of biomarker levels before immunoadsorption and LVEF at the long-term follow-up show good results for hs troponin T (r = −0.40, r2 = 0.16, p < 0.05), hs troponin I (r = −0.41, r2 = 0.17, p < 0.05) and sST2 (r = −0.46, r2 = 0.19, p < 0.05). Correlation of biomarker levels before immunoadsorption and the individual increase in LV function was significant for hs troponin T (r = −0.52, r2 = 0.27, p < 0.005) and hs troponin I (r = −0.53, r2 = 0.29, p < 0.005). To imply a tool for monitoring outcome immediately after immunoadsorption treatment, we investigated the correlation of acute changes of biomarker levels by immunoadsorption treatment and individual increase in LV function. A drop in hs troponin T (r = −0.41, r2 = 0.17, p < 0.05) and hs troponin I (r = −0.53, r2 = 0.28, p < 0.005) levels demonstrate a good correlation to improvement in LVEF during the long-term follow-up. Conclusion: Hs troponin T and I levels correlate with LV function improvement during long-term follow-up. Acute decrease of troponins by immunoadsorption treatment is paralleled by individual improvement of LVEF at the long-term follow-up. Thus, troponins could serve as a monitoring tool for the improvement of LV function after immunoadsorption treatment in dilated cardiomyopathy.
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Affiliation(s)
| | | | | | | | | | - Mirjam Keßler
- Correspondence: ; Tel.: +49-731-500-45064; Fax: +49-731-500-45005
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242
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Kavsak PA. The Evidence for Laboratory Test-Based Computer Clinical Decision Support Tools on Medication Errors and Adverse Drug Events. J Appl Lab Med 2019; 3:922-924. [PMID: 31639683 DOI: 10.1373/jalm.2018.028951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/31/2019] [Indexed: 11/06/2022]
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243
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Selvaraj S, Claggett B, Pozzi A, McMurray JJ, Jhund PS, Packer M, Desai AS, Lewis EF, Vaduganathan M, Lefkowitz MP, Rouleau JL, Shi VC, Zile MR, Swedberg K, Solomon SD. Prognostic Implications of Congestion on Physical Examination Among Contemporary Patients With Heart Failure and Reduced Ejection Fraction. Circulation 2019; 140:1369-1379. [DOI: 10.1161/circulationaha.119.039920] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The contemporary prognostic value of the physical examination— beyond traditional risk factors including natriuretic peptides, risk scores, and symptoms—in heart failure (HF) with reduced ejection fraction is unknown. We aimed to determine the association between physical signs of congestion at baseline and during study follow-up with quality of life and clinical outcomes and to assess the treatment effects of sacubitril/valsartan on congestion.
Methods:
We analyzed participants from PARADIGM-HF (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in HF) with an available physical examination at baseline. We examined the association of the number of signs of congestion (jugular venous distention, edema, rales, and third heart sound) with the primary outcome (cardiovascular death or HF hospitalization), its individual components, and all-cause mortality using time-updated, multivariable-adjusted Cox regression. We further evaluated whether sacubitril/valsartan reduced congestion during follow-up and whether improvement in congestion is related to changes in clinical outcomes and quality of life, assessed by Kansas City Cardiomyopathy Questionnaire overall summary scores.
Results:
Among 8380 participants, 0, 1, 2, and 3+ signs of congestion were present in 70%, 21%, 7%, and 2% of patients, respectively. Patients with baseline congestion were older, more often female, had higher MAGGIC risk scores (Meta-Analysis Global Group in Chronic Heart Failure) and lower Kansas City Cardiomyopathy Questionnaire overall summary scores (
P
<0.05). After adjusting for baseline natriuretic peptides, time-updated Meta-Analysis Global Group in Chronic Heart Failure score, and time-updated New York Heart Association class, increasing time-updated congestion was associated with all outcomes (
P
<0.001). Sacubitril/valsartan reduced the risk of the primary outcome irrespective of clinical signs of congestion at baseline (
P
=0.16 for interaction), and treatment with the drug improved congestion to a greater extent than did enalapril (
P
=0.011). Each 1-sign reduction was independently associated with a 5.1 (95% CI, 4.7–5.5) point improvement in Kansas City Cardiomyopathy Questionnaire overall summary scores. Change in congestion strongly predicted outcomes even after adjusting for baseline congestion (
P
<0.001).
Conclusions:
In HF with reduced ejection fraction, the physical exam continues to provide significant independent prognostic value even beyond symptoms, natriuretic peptides, and Meta-Analysis Global Group in Chronic Heart Failure risk score. Sacubitril/valsartan improved congestion to a greater extent than did enalapril. Reducing congestion in the outpatient setting is independently associated with improved quality of life and reduced cardiovascular events, including mortality.
Clinical Trial Registration:
https://www.clinicaltrials.gov
. Unique identifier: NCT01035255.
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Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (S.S.)
| | - Brian Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | - Andrea Pozzi
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (A.P., J.J.V.M., P.S.J.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (A.P., J.J.V.M., P.S.J.)
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (A.P., J.J.V.M., P.S.J.)
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, United Kingdom (M.P.)
| | - Akshay S. Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | - Eldrin F. Lewis
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | | | - Jean L. Rouleau
- Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.)
| | | | - Michael R. Zile
- Medical University of South Carolina and Ralph H. Johnson Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.)
- National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.)
| | - Scott D. Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
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244
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Abstract
Procalcitonin is a biomarker that is generally elevated in bacterial infections. This review describes a conceptual framework for biomarkers using lessons from the history of troponin, applies this framework to procalcitonin with a review of observational studies and randomized trials in and out of the intensive care unit, and concludes with clinical recommendations and thoughts on how to test a test.
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245
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Palazzuoli A, Ruocco G, Paolillo S, Perrone Filardi P. The use of diuretics in heart failure with congestion: we can't judge a book by its cover. ESC Heart Fail 2019; 6:1222-1225. [PMID: 31617332 PMCID: PMC6989299 DOI: 10.1002/ehf2.12515] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2019] [Revised: 06/22/2019] [Accepted: 08/16/2019] [Indexed: 12/28/2022] Open
Abstract
Although congestion assessment is one of the major challenges in the management of acute heart failure (AHF), no specific Gguidelines have been previously published on this topic. A recent position paper from ESC HF society, focused attention on targeting therapy in relation to clinical congestion. However, in our opinion, the scarce correlation existing between wedge pressure with and traditional clinical signs is the fundamental concern in congestion detection. The two main characteristics of congestion are redistribution of blood volume from the systemic to the pulmonary district and intravascular fluid retention, and both of these are often employed with different significance. Another weakness could come from the varied congestion appearance in relation to the clinical scenario: the different pattern could vary in relation to prevalent cardiac dysfunction ([i.e. heart failure with reduced ejection fraction [(HFrEF]) vs. heart failure with preserved ejection fraction [(HFpEF)]), the Stevenson picture, and the history of recurrent or de novo HF. Thus, it could be worth distinguishing between central and peripheral congestion, in relation to the involved sites and organ damage. Our advice for a more effective diuretic dose is to obtain a better assessment of congestion by an integration between the clinical examination and a diagnostic algorithm taking into account echo and laboratory parameters. Consequently, the use of intravenous diuretics needs to be tailored in relation to the severity of congestion, the oral administration amount, and the different HF profiles.
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Affiliation(s)
- Alberto Palazzuoli
- Department of Internal Medicine, Cardiovascular Diseases Unit, Le Scotte Hospital, University of Siena, Viale Bracci n. 16, 53100, Siena, Italy
| | - Gaetano Ruocco
- Department of Internal Medicine, Cardiovascular Diseases Unit, Le Scotte Hospital, University of Siena, Viale Bracci n. 16, 53100, Siena, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
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246
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Sweeney C, Ryan F, Ledwidge M, Ryan C, McDonald K, Watson C, Pharithi RB, Gallagher J. Natriuretic peptide-guided treatment for the prevention of cardiovascular events in patients without heart failure. Cochrane Database Syst Rev 2019; 10:CD013015. [PMID: 31613983 PMCID: PMC6953366 DOI: 10.1002/14651858.cd013015.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cardiovascular disease (CVD) is the leading cause of morbidity and mortality globally. Early intervention for those with high cardiovascular risk is crucial in improving patient outcomes. Traditional prevention strategies for CVD have focused on conventional risk factors, such as overweight, dyslipidaemia, diabetes, and hypertension, which may reflect the potential for cardiovascular insult. Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro B-type natriuretic peptide (NT-proBNP), are well-established biomarkers for the detection and diagnostic evaluation of heart failure. They are of interest for CVD prevention because they are secreted by the heart as a protective response to cardiovascular stress, strain, and damage. Therefore, measuring NP levels in patients without heart failure may be valuable for risk stratification, to identify those at highest risk of CVD who would benefit most from intensive risk reduction measures. OBJECTIVES To assess the effects of natriuretic peptide (NP)-guided treatment for people with cardiovascular risk factors and without heart failure. SEARCH METHODS Searches of the following bibliographic databases were conducted up to 9 July 2019: CENTRAL, MEDLINE, Embase, and Web of Science. Three clinical trial registries were also searched in July 2019. SELECTION CRITERIA We included randomised controlled trials enrolling adults with one or more cardiovascular risk factors and without heart failure, which compared NP-based screening and subsequent NP-guided treatment versus standard care in all settings (i.e. community, hospital). DATA COLLECTION AND ANALYSIS Two review authors independently screened titles and abstracts and selected studies for inclusion, extracted data, and evaluated risk of bias. Risk ratios (RRs) were calculated for dichotomous data, and mean differences (MDs) with 95% confidence intervals (CIs) were calculated for continuous data. We contacted trial authors to obtain missing data and to verify crucial study characteristics. Using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach, two review authors independently assessed the quality of the evidence and GRADE profiler (GRADEPRO) was used to import data from Review Manager to create a 'Summary of findings' table. MAIN RESULTS We included two randomised controlled trials (three reports) with 1674 participants, with mean age between 64.1 and 67.8 years. Follow-up ranged from 2 years to mean 4.3 years.For primary outcome measures, effect estimates from a single study showed uncertainty for the effect of NP-guided treatment on cardiovascular mortality in patients with cardiovascular risk factors and without heart failure (RR 0.33, 95% CI 0.04 to 3.17; 1 study; 300 participants; low-quality evidence). Pooled analysis demonstrated that in comparison to standard care, NP-guided treatment probably reduces the risk of cardiovascular hospitalisation (RR 0.52, 95% CI 0.40 to 0.68; 2 studies; 1674 participants; moderate-quality evidence). This corresponds to a risk of 163 per 1000 in the control group and 85 (95% CI 65 to 111) per 1000 in the NP-guided treatment group.When secondary outcome measures were evaluated, evidence from a pooled analysis showed uncertainty for the effect of NP-guided treatment on all-cause mortality (RR 0.90, 95% CI 0.60 to 1.35; 2 studies; 1354 participants; low-quality evidence). Pooled analysis indicates that NP-guided treatment probably reduces the risk of all-cause hospitalisation (RR 0.83, 95% CI 0.75 to 0.92; 2 studies; 1354 participants; moderate-quality evidence). This corresponds to a risk of 601 per 1000 in the control group and 499 (95% CI 457 to 553) per 1000 in the NP-guided treatment group. The effect estimate from a single study indicates that NP-guided treatment reduced the risk of ventricular dysfunction (RR 0.61, 95% CI 0.41 to 0.91; 1374 participants; high-quality evidence). The risk in this study's control group was 87 per 1000, compared with 53 (95% CI 36 to 79) per 1000 with NP-guided treatment. Results from the same study show that NP-guided treatment does not affect change in NP level at the end of follow-up, relative to standard care (MD -4.06 pg/mL, 95% CI -15.07 to 6.95; 1 study; 1374 participants; moderate-quality evidence). AUTHORS' CONCLUSIONS This review shows that NP-guided treatment is likely to reduce ventricular dysfunction and cardiovascular and all-cause hospitalisation for patients who have cardiovascular risk factors and who do not have heart failure. Effects on mortality and natriuretic peptide levels are less certain. Neither of the included studies were powered to evaluate mortality. Available evidence shows uncertainty regarding the effects of NP-guided treatment on both cardiovascular mortality and all-cause mortality; very low event numbers resulted in a high degree of imprecision in these effect estimates. Evidence also shows that NP-guided treatment may not affect NP level at the end of follow-up.As both trials included in our review were pragmatic studies, non-blinding of patients and practices may have biased results towards a finding of equivalence. Further studies with more adequately powered sample sizes and longer duration of follow-up are required to evaluate the effect of NP-guided treatment on mortality. As two trials are ongoing, one of which is a large multi-centre trial, it is hoped that future iterations of this review will benefit from larger sample sizes across a wider geographical area.
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Affiliation(s)
- Claire Sweeney
- The Heartbeat TrustDublinIreland
- Trinity College DublinSchool of Pharmacy and Pharmaceutical SciencesDublinIreland
| | | | - Mark Ledwidge
- The Heartbeat TrustDublinIreland
- University College DublinSchool of Medicine and Medical ScienceDublinIreland
| | - Cristin Ryan
- Trinity College DublinSchool of Pharmacy and Pharmaceutical SciencesDublinIreland
| | - Ken McDonald
- The Heartbeat TrustDublinIreland
- University College DublinSchool of Medicine and Medical ScienceDublinIreland
| | - Chris Watson
- Queen's University BelfastWellcome‐Wolfson Institute for Experimental MedicineBelfastUK
| | | | - Joe Gallagher
- Irish College of General PractitionersLincoln PlaceDublinIreland
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247
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Dhir S, Dhir A. Cardiovascular Risk Assessment for Noncardiac Surgery: Are We Ready for Biomarkers? J Cardiothorac Vasc Anesth 2019; 34:1914-1924. [PMID: 31866221 DOI: 10.1053/j.jvca.2019.10.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2019] [Revised: 09/07/2019] [Accepted: 10/04/2019] [Indexed: 02/07/2023]
Abstract
Biomarkers aided perioperative cardiac assessment is a relatively new concept. Cardiac biomarkers with historical significance (aspartate transaminase, dehydrogenase, creatinine kinase and myoglobin) have paved the way for traditional biomarkers (cardiac troponin, C-reactive protein, lipoprotein). Contemporary biomarkers like natriuretic peptides (BNP and ProBNP) are validated risk markers in both acute and chronic cardiac diseases and are showing remarkable promise in predicting serious cardiovascular complications after non-cardiac surgery. This review is intended to provide a critical overview of traditional and contemporary biomarkers for perioperative cardiovascular assessment and management. This review also discusses the potential utility of newer biomarkers like galectin-3, sST-2, GDF-15, TNF-alpha, MiRNAs and many others that can predict inflammation, cardiac remodeling, injury and endogenous stress and need further investigations to establish their clinical utility. Though promising, biomarker led perioperative care is still in infancy and it has not been determined that it can improve clinical outcomes.
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Affiliation(s)
- Shalini Dhir
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada.
| | - Achal Dhir
- Department of Anesthesia and Perioperative Medicine, Western University, London, Ontario, Canada
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248
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Grodin JL, Drazner MH. Lung Ultrasound: Our New "Sixth Sense"? JACC-HEART FAILURE 2019; 7:859-861. [PMID: 31582108 DOI: 10.1016/j.jchf.2019.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/23/2019] [Accepted: 08/26/2019] [Indexed: 11/15/2022]
Affiliation(s)
- Justin L Grodin
- University of Texas Southwestern Medical Center, Dallas, Texas.
| | - Mark H Drazner
- University of Texas Southwestern Medical Center, Dallas, Texas
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249
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Kavsak PA, Lam CSP, Saenger AK, Jaffe AS, Collinson P, Pulkki K, Omland T, Lefèvre G, Body R, Ordonez-Llanos J, Apple FS. Educational Recommendations on Selected Analytical and Clinical Aspects of Natriuretic Peptides with a Focus on Heart Failure: A Report from the IFCC Committee on Clinical Applications of Cardiac Bio-Markers. Clin Chem 2019; 65:1221-1227. [DOI: 10.1373/clinchem.2019.306621] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 07/12/2019] [Indexed: 12/23/2022]
Abstract
Abstract
The IFCC Committee on Clinical Applications of Cardiac Bio-Markers (C-CB) has directives and initiatives focused on providing evidence-based educational resources to aid and improve understanding around key analytical and clinical aspects of cardiac biomarkers used in clinical practice and the research setting. As a task force, we have previously published position statements and recommendations focused on use and analytical aspects of high-sensitivity cardiac troponin assays. The current educational document is the first from the C-CB highlighting important biochemical, analytical, and clinical aspects as they relate to the natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro–B-type natriuretic peptide (NT-proBNP), with a focus on heart failure.
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Affiliation(s)
- Peter A Kavsak
- Department of Pathology and Molecular Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Carolyn S P Lam
- National Heart Centre and Duke-National University of Singapore, Singapore, Singapore
| | - Amy K Saenger
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
| | - Allan S Jaffe
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
- Department of Cardiology, Mayo Clinic, Rochester, MN
| | - Paul Collinson
- Department of Clinical Blood Sciences and Cardiology, St George's University Hospitals NHS Foundation Trust and St George's University of London, London, UK
| | - Kari Pulkki
- Department of Clinical Chemistry, University of Turku and Turku University Hospital, Turku, Finland
| | - Tobjørn Omland
- Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- Center for Heart Failure Research, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Guillaume Lefèvre
- Department of Biochemistry and Hormonology, Hospital Tenon, Sorbonne Universités GRC-14 BIOSFAST, AP-HP, Paris, France
| | - Richard Body
- Emergency Department, Central Manchester University Hospitals NHS Foundation Trust, Manchester Academic Health Science Centre, Manchester, UK
- Cardiovascular Sciences Research Group, Core Technology Facility, Manchester, UK
- Healthcare Sciences Department, Manchester Metropolitan University, Manchester, UK
| | - Jordi Ordonez-Llanos
- Servicio de Bioquímica Clínica, Institut d'Investigacions Biomèdiques Sant Pau, Barcelona, Spain
- Departamento de Bioquímica y Biología Molecular, Universidad Autònoma de Barcelona, Barcelona, Spain
| | - Fred S Apple
- Department of Laboratory Medicine and Pathology, Hennepin Healthcare/HCMC, Minneapolis, MN
- Department of Laboratory Medicine and Pathology, University of Minnesota, Minneapolis, MN, USA
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250
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Cresci S, Pereira NL, Ahmad F, Byku M, de las Fuentes L, Lanfear DE, Reilly CM, Owens AT, Wolf MJ. Heart Failure in the Era of Precision Medicine: A Scientific Statement From the American Heart Association. CIRCULATION-GENOMIC AND PRECISION MEDICINE 2019; 12:458-485. [DOI: 10.1161/hcg.0000000000000058] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
One of 5 people will develop heart failure over his or her lifetime. Early diagnosis and better understanding of the pathophysiology of this disease are critical to optimal treatment. The “omics”—genomics, pharmacogenomics, epigenomics, proteomics, metabolomics, and microbiomics— of heart failure represent rapidly expanding fields of science that have, to date, not been integrated into a single body of work. The goals of this statement are to provide a comprehensive overview of the current state of these omics as they relate to the development and progression of heart failure and to consider the current and potential future applications of these data for precision medicine with respect to prevention, diagnosis, and therapy.
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