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Mohanty AF, Levitan EB, Dodson JA, Vardeny O, King JB, LaFleur J, He T, Patterson OV, Alba PR, Russo PA, Choi ME, Bress AP. Characteristics and Healthcare Utilization Among Veterans Treated for Heart Failure With Reduced Ejection Fraction Who Switched to Sacubitril/Valsartan. Circ Heart Fail 2019; 12:e005691. [DOI: 10.1161/circheartfailure.118.005691] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background:
US guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF), who tolerate an ACEI (angiotensin-converting enzyme inhibitor) or ARB (angiotensin II receptor blocker), be switched to sacubitril/valsartan to reduce morbidity and mortality. We compared characteristics and healthcare utilization between Veterans with HFrEF who were switched to sacubitril/valsartan versus maintained on an ACEI or ARB.
Methods:
retrospective cohort study of treated HFrEF (July 2015–June 2017) using Veterans Affairs data. The index date was the first fill for sacubitril/valsartan and if none, for an ACEI or ARB. Treated HFrEF was defined by (1) left ventricular ejection fraction ≤40%, (2) ≥1 in/outpatient HF encounter, and (3) ≥1 ACEI or ARB fill, all within 1-year preindex. Poisson regression models were used to compare baseline characteristics and 1:1 propensity score-matched adjusted 4-month follow-up healthcare utilization between sacubitril/valsartan switchers and ACEI or ARB maintainers.
Results:
Switchers (1612; 4.2%) were less likely than maintainers (37 065; 95.8%) to have a history of myocardial infarction or hypertension, and more likely to be black, have a lower left ventricular ejection fraction, and higher preindex healthcare utilization. Switchers were less likely to experience follow-up all-cause hospitalizations (11.2% versus 14.0%; risk ratio 0.80 [95% CI, 0.65–0.98],
P
value 0.035).
Conclusions:
Few Veterans with treated HFrEF were switched to sacubitril/valsartan within the first 2 years of Food and Drug Administration approval. Sacubitril/valsartan use was associated with a lower risk for all-cause hospitalizations at 4 months follow-up. Reasons for lack of guideline-recommended sacubitril/valsartan initiation warrant investigation and may reveal opportunities for HFrEF care optimization.
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Affiliation(s)
- April F. Mohanty
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
| | - Emily B. Levitan
- Department of Epidemiology, University of Alabama at Birmingham School of Public Health, Birmingham, Alabama. (E.B.L.)
| | - John A. Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY (J.A.D.)
| | - Orly Vardeny
- University of Minnesota Medical School and Minneapolis Veterans Affairs Center for Chronic Disease Outcomes Research, Minneapolis, Minnesota (O.V.)
| | - Jordan B. King
- Department of Population Health Sciences (J.B.K., A.P.B.), University of Utah School of Medicine, Salt Lake City, UT
| | - Joanne LaFleur
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
- Department of Pharmacotherapy, University of UT College of Pharmacy, Salt Lake City, UT (J.L.)
| | - Tao He
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
| | - Olga V. Patterson
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
| | - Patrick R. Alba
- Department of Internal Medicine, Division of Epidemiology (A.F.M., T.H., O.V.P., P.R.A.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
| | - Patricia A. Russo
- US Health Economics & Outcomes Research, Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.A.R.)
| | | | - Adam P. Bress
- Department of Population Health Sciences (J.B.K., A.P.B.), University of Utah School of Medicine, Salt Lake City, UT
- Veterans Affairs Salt Lake City Health Care System, Salt Lake City, UT (A.F.M., J.L., O.V.P., P.R.A., A.P.B.)
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Herron R, Nanjundappa A, Annie FH, Wood M, Embrey S, Heatherly C, Tager A. Our Experience with Transcatheter Aortic Valve Replacement Medication Outcomes from 2013 to 2016. Cureus 2019; 11:e6030. [PMID: 31824797 PMCID: PMC6886647 DOI: 10.7759/cureus.6030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Accepted: 10/29/2019] [Indexed: 11/05/2022] Open
Abstract
Background Aortic stenosis is classified as stenosis that can be caused by a congenital disability in infants and children but is more commonly produced by a degenerative process of calcification and scarring of the valve in the later decades of life. High systemic pressure and hemodynamic disturbances characteristic of this area of the cardiovascular system makes the aortic valve susceptible to plaque and cholesterol buildup over time, similarly to atherosclerosis, contributing to the pathology of aortic stenosis. Thus, this study aims to assess the short and long-term clinical outcomes of risk factor reduction, post transcatheter aortic valve replacement (post-TAVR), and results of tested medication outcomes. Methods Data were obtained from Charleston Area Medical Center, which is a tertiary care 800-bed community teaching facility and was examined using STATA 11.4 (StataCorp LLC, College Station, Texas, USA), a Cox proportional hazards model to test for clinical significance. This study examined the medications aspirin, clopidogrel, beta-blockers, and angiotensin-converting enzyme (ACE) inhibitors. Additional medications analyzed included statin, anticoagulant, aspirin with clopidogrel, and beta-blocker with ACE inhibitor and statin following the procedure of transcatheter aortic valve replacement (TAVR) and the overall risk of a hazard event of mortality. Results Results suggest that clopidogrel by itself had the lower rate of mortality at one year with hazards of 0.6906, a p-value of 0.221 and a 95% confidence interval of 0.3677 - 1.259; and at three years with hazards of 0.4845, a p-value of 0.027 and a 95% confidence interval of 0.2552 - 0.9201. Statins had the second-lowest rate at one year with hazards of 0.7299 and a p-value 0.215 and a 95% confidence interval of 0.4438 - 1.200; and at three years with hazard of 0.8529 and a p-value of 0.530 and a 95% confidence interval of 0.5192 - 1.401. Both of these medications had a consistent lower hazard and/or risk of death compared to other standard medication regiments. Within our center's data, clopidogrel had the best clinical outcome. Conclusions This study showed that therapy with aspirin and clopidogrel alone did not demonstrate a significant increase in mortality versus alternative anticoagulation therapy in patients post aortic valve replacement. Clopidogrel and statin usage post-aortic valve revascularization may have a trend towards a reduction in mortality.
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Affiliation(s)
- Robert Herron
- Surgery, Charleston Area Medical Center, Charleston, USA
| | | | - Frank H Annie
- Cardiology, Charleston Area Medical Center, Charleston, USA
| | - Megan Wood
- Heart and Vascular Center, Charleston Area Medical Center, Charleston, USA
| | - Sarah Embrey
- Pharmacy, University of Charleston School of Pharmacy, Charleston, USA
| | - Carly Heatherly
- Osteopathic Medicine, West Virginia School of Osteopathic Medicine, Buckhannon, USA
| | - Alfred Tager
- Emergency Medicine, Charleston Area Medical Center, Charleston, USA
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203
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Han J, Chung F, Nguyen QL, Mody FV, Jackevicius CA. Evaluation of Patients with Heart Failure to Determine Eligibility for Treatment with Sacubitril/Valsartan: Insights from a Veterans Administration Healthcare System. Pharmacotherapy 2019; 39:1053-1059. [DOI: 10.1002/phar.2328] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Jamie Han
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Francisco Chung
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Quyen L. Nguyen
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Freny Vaghaiwalla Mody
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
- Division of Cardiology University of California, Los Angeles Los Angeles California
- David Geffen School of Medicine University of California, Los Angeles Los Angeles California
| | - Cynthia A. Jackevicius
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
- Department of Pharmacy Practice and Administration Western University of Health Sciences Pomona California
- Institute for Clinical Evaluative Sciences University of Toronto Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation University of Toronto Toronto Ontario Canada
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204
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Ibrahim NE, Song Y, Cannon CP, Doros G, Russo P, Ponirakis A, Alexanian C, Januzzi JL. Alteration of medical therapy in patients with heart failure relative to change in symptom severity. ESC Heart Fail 2019; 6:1085-1087. [PMID: 31268222 PMCID: PMC6816058 DOI: 10.1002/ehf2.12480] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 04/30/2019] [Accepted: 05/30/2019] [Indexed: 01/14/2023] Open
Abstract
In this observational analysis from the Practice Innovation and Clinical Excellence Registry®, we examined changes in guideline-directed medical therapies relative to changes in symptom severity in ambulatory patients with heart failure with reduced ejection fraction, finding change in medication more often occurring when patients were changing their New York Heart Association symptom severity, rather than during periods of stable symptoms. Additionally, despite being available for a year during the time of our analysis, the use of sacubitril/valsartan was extremely low, and most often added in the context of worsening symptoms, not how this drug was studied and not how the guidelines articulate its use.
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Affiliation(s)
- Nasrien E. Ibrahim
- Cardiology DivisionMassachusetts General Hospital55 Fruit Street, GRB‐800BostonMA02114USA
| | - Yang Song
- Baim Institute for Clinical ResearchBrooklineMAUSA
| | | | - Gheorghe Doros
- Baim Institute for Clinical ResearchBrooklineMAUSA
- Boston UniversityBostonMAUSA
| | | | | | | | - James L. Januzzi
- Cardiology DivisionMassachusetts General Hospital55 Fruit Street, GRB‐800BostonMA02114USA
- Baim Institute for Clinical ResearchBrooklineMAUSA
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205
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Geng Q, Li S, Wang Z, Ren Y. Efficacy and safety of combined neprilysin and RAS inhibition in heart failure: A meta-analysis of randomized controlled trials. Int J Cardiol 2019; 293:159-164. [DOI: 10.1016/j.ijcard.2019.05.048] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2019] [Revised: 05/19/2019] [Accepted: 05/21/2019] [Indexed: 12/28/2022]
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206
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Arendse LB, Danser AHJ, Poglitsch M, Touyz RM, Burnett JC, Llorens-Cortes C, Ehlers MR, Sturrock ED. Novel Therapeutic Approaches Targeting the Renin-Angiotensin System and Associated Peptides in Hypertension and Heart Failure. Pharmacol Rev 2019; 71:539-570. [PMID: 31537750 PMCID: PMC6782023 DOI: 10.1124/pr.118.017129] [Citation(s) in RCA: 204] [Impact Index Per Article: 40.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Despite the success of renin-angiotensin system (RAS) blockade by angiotensin-converting enzyme (ACE) inhibitors and angiotensin II type 1 receptor (AT1R) blockers, current therapies for hypertension and related cardiovascular diseases are still inadequate. Identification of additional components of the RAS and associated vasoactive pathways, as well as new structural and functional insights into established targets, have led to novel therapeutic approaches with the potential to provide improved cardiovascular protection and better blood pressure control and/or reduced adverse side effects. The simultaneous modulation of several neurohumoral mediators in key interconnected blood pressure-regulating pathways has been an attractive approach to improve treatment efficacy, and several novel approaches involve combination therapy or dual-acting agents. In addition, increased understanding of the complexity of the RAS has led to novel approaches aimed at upregulating the ACE2/angiotensin-(1-7)/Mas axis to counter-regulate the harmful effects of the ACE/angiotensin II/angiotensin III/AT1R axis. These advances have opened new avenues for the development of novel drugs targeting the RAS to better treat hypertension and heart failure. Here we focus on new therapies in preclinical and early clinical stages of development, including novel small molecule inhibitors and receptor agonists/antagonists, less conventional strategies such as gene therapy to suppress angiotensinogen at the RNA level, recombinant ACE2 protein, and novel bispecific designer peptides.
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Affiliation(s)
- Lauren B Arendse
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - A H Jan Danser
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Marko Poglitsch
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Rhian M Touyz
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - John C Burnett
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Catherine Llorens-Cortes
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Mario R Ehlers
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
| | - Edward D Sturrock
- Department of Integrative Biomedical Sciences, Institute of Infectious Disease and Molecular Medicine, University of Cape Town, South Africa (L.B.A., E.D.S.); Division of Pharmacology, Department of Internal Medicine, Erasmus Medical Center, Rotterdam, The Netherlands (A.H.J.D.); Attoquant Diagnostics, Vienna, Austria (M.P.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (R.M.T.); Department of Cardiovascular Medicine, Mayo Clinic, Rochester, Minnesota (J.C.B.); Institut National de la Santé et de la Recherche Médicale, Paris, France (C.L.-C.); and Clinical Trials Group, Immune Tolerance Network, San Francisco, California (M.R.E.)
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207
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Edelmann F, Knosalla C, Mörike K, Muth C, Prien P, Störk S. Chronic Heart Failure. DEUTSCHES ARZTEBLATT INTERNATIONAL 2019. [PMID: 29526184 DOI: 10.3238/arztebl.2018.0124] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Chronic heart failure (CHF) is the most common reason for hospital admissions in Germany. For the National Disease Management Guideline (NDMG) on CHF, a multidisciplinary expert panel revised the chapters on drug therapy, invasive therapy, and care coordination, following the methods of evidence-based medicine. METHODS Recommendations are based on international guideline adaptations or systematic literature search. They were developed by a multidisciplinary expert panel, approved in a formal consensus procedure, and tested in open consultation, as specified by the requirements for S3 guidelines. RESULTS The pharmacological treatment is based on ACE inhibitors, beta-blockers and mineralocorticoid receptor antagonists as well as diuretics to treat fluid retention, if present. Sacubitril/Valsartan and ivabradine showed positive effects on mortality in large but methodologically limited RCT. They are recommended if established combination therapy is not sufficient for symptom control, or if drugs are not tolerated/contraindicated. The indications for pacemakers or defibrillators have been confined to patient subgroups in which clinical trials have shown a clear benefit. Moreover, the goals of treatment and the patient's expectations should be aligned with each other. Structured care programs, specialized nurses, remote, or telephone monitoring showed moderate effects on patient related outcomes in RCT. CONCLUSION All patients with heart failure are suggested to be enrolled in a structured program (e.g., a disease management program) including coordinated multidisciplinary care and continuous educational interventions. In patients with a poor prognosis, more intensive care is recommended, e.g. specialized nurses, or telephone support.
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Affiliation(s)
- Frank Edelmann
- Medical Department, Division of Cardiology and Angiology, Charité Universitätsmedizin Berlin, Campus Virchow Klinikum; Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, German Centre for Cardiovascular Research; Universitätsklinikum Tübingen, Department of Experimental and Clinical Pharmacology and Toxicology; Institute of General Practice, J.W. Goethe University, Frankfurt/Main; German Agency for Quality in Medicine (ÄZQ), Berlin; Comprehensive Heart Failure Center & Deptartment of Internal Medicine I, University and University Hospital Würzburg
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208
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Abstract
Heart failure (HF) is a clinical syndrome of diverse etiologies and can be associated with preserved, reduced, or mid-range ejection fraction (EF). In the community, heart failure with preserved ejection fraction (HFpEF) is emerging as the most common form of HF. There remains considerable uncertainty regarding its pathogenesis, diagnosis, and optimal therapeutic approach. Hypotheses have been advanced to explain the underlying pathophysiology responsible for HFpEF, but to date, no specific therapy based on these hypotheses has been proven to improve outcomes in HFpEF. We provide a clinically focused review of the epidemiology, clinical presentation, diagnostic approach, pathophysiology, and treatment of HFpEF.
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Affiliation(s)
- James D Gladden
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota 55905; , ,
| | - Antoine H Chaanine
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota 55905; , ,
| | - Margaret M Redfield
- Department of Cardiovascular Disease, Division of Circulatory Failure, Mayo Clinic, Rochester, Minnesota 55905; , ,
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209
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Hollenberg SM, Warner Stevenson L, Ahmad T, Amin VJ, Bozkurt B, Butler J, Davis LL, Drazner MH, Kirkpatrick JN, Peterson PN, Reed BN, Roy CL, Storrow AB. 2019 ACC Expert Consensus Decision Pathway on Risk Assessment, Management, and Clinical Trajectory of Patients Hospitalized With Heart Failure: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2019; 74:1966-2011. [PMID: 31526538 DOI: 10.1016/j.jacc.2019.08.001] [Citation(s) in RCA: 199] [Impact Index Per Article: 39.8] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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210
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Khariton Y, Fonarow GC, Arnold SV, Hellkamp A, Nassif ME, Sharma PP, Butler J, Thomas L, Duffy CI, DeVore AD, Albert NM, Patterson JH, Williams FB, McCague K, Spertus JA. Association Between Sacubitril/Valsartan Initiation and Health Status Outcomes in Heart Failure With Reduced Ejection Fraction. JACC-HEART FAILURE 2019; 7:933-941. [PMID: 31521679 DOI: 10.1016/j.jchf.2019.05.016] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study sought to describe the short-term health status benefits of angiotensin-neprilysin inhibitor (ARNI) therapy in patients with heart failure and reduced ejection fraction (HFrEF). BACKGROUND Although therapy with sacubitril/valsartan, a neprilysin inhibitor, improved patients' health status (compared with enalapril) at 8 months in the PARADIGM-HF (Prospective Comparison of ARNI with ACE inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) study, the early impact of ARNI on patients' symptoms, functions, and quality of life is unknown. METHODS Health status was assessed by using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ) in 3,918 outpatients with HFrEF and left ventricular ejection fraction ≤40% across 140 U.S. centers in the CHAMP-HF (Change the Management of Patients with Heart Failure) registry. ARNI therapy was initiated in 508 patients who were matched 1:2 to 1,016 patients who were not initiated on ARNI (no-ARNI), using a nonparsimonious time-dependent propensity score (6 sociodemographic factors, 23 clinical characteristics), prior KCCQ overall summary (KCCQ-OS) score, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker status. RESULTS Multivariate linear regression demonstrated a greater mean improvement in KCCQ-OS in patients initiated on ARNI therapy (5.3 ± 19 vs. 2.5 ± 17.4, respectively; p < 0.001) over a median (interquartile range [IQR]) of 57 (32 to 104) days. The proportions of ARNI versus no-ARNI groups with ≥10-point (large) and ≥20-point (very large) improvements in KCCQ-OS were 32.7% versus 26.9%, respectively, and 20.5% versus 12.1%, respectively, consistent with numbers needed to treat of 18 and 12, respectively. CONCLUSIONS In routine clinical care, ARNI therapy was associated with early improvements in health status, with 20% experiencing a very large health status benefit compared with 12% who were not started on ARNI therapy. These findings support the use of ARNI to improve patients' symptoms, functions, and quality of life.
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Affiliation(s)
- Yevgeniy Khariton
- Departments of Cardiology and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri.
| | - Gregg C Fonarow
- Department of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan University of California Los Angeles Medical Center, Los Angeles, California
| | - Suzanne V Arnold
- Departments of Cardiology and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Ann Hellkamp
- Duke Clinical Research Institute, Durham, North Carolina
| | - Michael E Nassif
- Department of Cardiology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri
| | - Puza P Sharma
- Novartis Pharmaceuticals Corp, East Hanover, New Jersey
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina
| | - Carol I Duffy
- Novartis Pharmaceuticals Corp, East Hanover, New Jersey
| | - Adam D DeVore
- Division of Cardiology, Department of Medicine, and the Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | | | - Kevin McCague
- Novartis Pharmaceuticals Corp, East Hanover, New Jersey
| | - John A Spertus
- Departments of Cardiology and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
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211
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Darden D, Drazner MH, Mullens W, Dupont M, Tang WHW, Grodin JL. Implications of renin-angiotensin-system blocker discontinuation in acute decompensated heart failure with systolic dysfunction. Clin Cardiol 2019; 42:1010-1018. [PMID: 31498919 PMCID: PMC6788475 DOI: 10.1002/clc.23260] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2019] [Revised: 08/16/2019] [Accepted: 08/26/2019] [Indexed: 01/14/2023] Open
Abstract
Background Renin‐angiotensin‐system blockers (RASB) improve clinical outcomes in patients with chronic heart failure with reduced fraction; however, there remains ambiguity whether RASB therapy should be continued during the treatment of acute decompensated heart failure (ADHF). Hypothesis In comparison to patients with RASB use, RASB discontinuation in ADHF will be associated with worsening renal function, hypotension, and adverse long‐term clinical outcomes. Methods Patients in the Evaluation Study of Congestive Heart Failure and Pulmonary Artery Catheterization (ESCAPE) trial were separated into four groups based on RASB use at baseline and discharge: continuation (n = 316), discontinuation (n = 21), initiation (n = 42), and nonuse (n = 23). Post‐discharge outcomes were validated in an independent ADHF cohort admitted to the Cleveland Clinic (n = 253). Results RASB discontinuation and nonuse were associated with higher serial creatinine and blood urea nitrogen levels than RASB continuation or initiation (P < .001 for both), but not with serial potassium and systolic blood pressure measurements. No other clinical parameter changes were significant. In comparison to RASB continuation, RASB discontinuation and nonuse was associated with ~75% increased risk of a 180‐day composite of death, transplant, or rehospitalization (HR 1.87, 95% CI 1.09‐3.20, P = 0.02 and HR 1.72, CI 1.04‐2.82, P = .03, respectively). Post‐discharge outcomes were similar in the validation cohort. Conclusion Compared to RASB continuation, RASB discontinuation and nonuse were associated with higher baseline and serial creatinine levels during treatment for ADHF, but not with changes in SBP and potassium levels. Furthermore, RASB discontinuation and nonuse in ADHF were associated with an increased risk of adverse clinical outcomes.
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Affiliation(s)
- Douglas Darden
- Division of Cardiology, Department of Internal Medicine, University of California, San Diego, California
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
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212
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Ferreira JP, Rossello X, Pitt B, Rossignol P, Zannad F. Eplerenone in patients with myocardial infarction and "mid-range" ejection fraction: An analysis from the EPHESUS trial. Clin Cardiol 2019; 42:1106-1112. [PMID: 31482613 PMCID: PMC6837025 DOI: 10.1002/clc.23261] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Accepted: 08/26/2019] [Indexed: 12/28/2022] Open
Abstract
Background Trials using mineralocorticoid receptor antagonists (MRAs) in myocardial infraction (MI) without heart failure (HF) or systolic impairment have been underpowered to assess morbidity‐mortality benefit. In EPHESUS 6632 patients were included, of whom 11% had an ejection fraction (EF) of 40% and HF or diabetes. We aim to assess the potential benefit of MRAs in MI with EF of 40%. Methods Cox models with interaction term for EF. The primary outcome was a composite of cardiovascular death or hospitalization for cardiovascular reasons. Hypothesis Patients with an EF of 40% benefit similarly from MRA therapy to those with an EF <40%. Results In EPHESUS, 753 patients had an EF = 40% and 5864 an EF < 40%. Patients with an EF = 40% were younger (63 vs 64 years), had lower heart rate (73 vs 75 bpm), less atrial fibrillation (10% vs 14%), previous MI (21% vs 28%), HF hospitalization (5% vs 8%), and had more often reperfusion therapy and/or revascularization (55% vs 44%). The mean EF was 40.0 ± 0.3% in those with EF = 40% vs 32.2 ± 5.9% in those with EF < 40%. The primary outcome occurred in 13.3% (10 events per 100 py) of the patients with EF = 40% vs 22.9% (19 events per 100 py) in those with EF < 40%; adjusted HR for EF = 40% vs <40% = 0.65 (0.53‐0.81). Eplerenone reduced the event‐rate homogenously regardless of EF (interactionp EF = 40% vs EF < 40% = 0.21). Similar findings were observed for cardiovascular and all‐cause death. Conclusion Eplerenone reduces hospitalizations and mortality in patients with MI and EF = 40% similarly to patients with EF < 40%. These findings suggest that MI patients with EF in the “mid‐range zone” may also benefit from MRA therapy which might help clinicians in their treatment decisions.
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Affiliation(s)
- João Pedro Ferreira
- Université de Lorraine, Centre d'Investigation Clinique- Plurithématique Inserm CIC-P 1433, Nancy, France.,Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Xavier Rossello
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain.,Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Bertram Pitt
- Department of Medicine, University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Patrick Rossignol
- Université de Lorraine, Centre d'Investigation Clinique- Plurithématique Inserm CIC-P 1433, Nancy, France.,Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigation Clinique- Plurithématique Inserm CIC-P 1433, Nancy, France.,Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
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213
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Abstract
Diabetes is strongly associated with development of cardiovascular disease and poor cardiovascular outcomes. Management of hypertension reduces cardiovascular outcomes among patients with diabetes. Many studies have examined the benefits of various classes of antihypertensives among patients with diabetes. Based on these, the American Diabetes Association has advised that all patients (particularly those with microalbuminuria) be treated first with an angiotensin-converting enzyme inhibitor or an aldosterone receptor blocker followed by a calcium channel blocker or diuretic. Recently, sodium glucose transporter 2 inhibitors have been identified for their benefit in blood pressure control and cardiovascular risk reduction in patients with diabetes.
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214
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Pimenov OY, Galimova MH, Evdokimovskii EV, Averin AS, Nakipova OV, Reyes S, Alekseev AE. Myocardial α2-Adrenoceptors as Therapeutic Targets to Prevent Cardiac Hypertrophy and Heart Failure. Biophysics (Nagoya-shi) 2019. [DOI: 10.1134/s000635091905021x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
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215
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Bartko PE, Arfsten H, Heitzinger G, Pavo N, Strunk G, Gwechenberger M, Hengstenberg C, Binder T, Hülsmann M, Goliasch G. Papillary Muscle Dyssynchrony-Mediated Functional Mitral Regurgitation. JACC Cardiovasc Imaging 2019; 12:1728-1737. [DOI: 10.1016/j.jcmg.2018.06.013] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2018] [Revised: 06/01/2018] [Accepted: 06/13/2018] [Indexed: 01/14/2023]
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216
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Abstract
PURPOSE OF REVIEW Heart failure clinical practice guidelines are fundamental and serve as framework for providers to deliver evidence-based care that correlates with enhanced patient outcomes. However, adherence, particularly to guideline-directed medical therapy, remains suboptimal for a multitude of reasons. RECENT FINDINGS Despite robust clinical trials, updated guidelines and an expert consensus statement from American Heart Association, American College of Cardiology, and Heart Failure Society of America registry data signal that heart failure patients do not receive appropriate pharmacotherapy and may receive an intracardiac device without prior initiation or optimization of medical therapy. Strategies to improve provider adherence to heart failure guidelines include multidisciplinary models and appropriate referral and care standardization. These approaches can improve morbidity, mortality, and quality of life in HF patients.
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217
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Normalizing Plasma Renin Activity in Experimental Dilated Cardiomyopathy: Effects on Edema, Cachexia, and Survival. Int J Mol Sci 2019; 20:ijms20163886. [PMID: 31404946 PMCID: PMC6720926 DOI: 10.3390/ijms20163886] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2019] [Revised: 08/04/2019] [Accepted: 08/06/2019] [Indexed: 12/18/2022] Open
Abstract
Heart failure (HF) patients frequently have elevated plasma renin activity. We examined the significance of elevated plasma renin activity in a translationally-relevant model of dilated cardiomyopathy (DCM), which replicates the progressive stages (A–D) of human HF. Female mice with DCM and elevated plasma renin activity concentrations were treated with a direct renin inhibitor (aliskiren) in a randomized, blinded fashion beginning at Stage B HF. By comparison to controls, aliskiren treatment normalized pathologically elevated plasma renin activity (p < 0.001) and neprilysin levels (p < 0.001), but did not significantly alter pathological changes in plasma aldosterone, angiotensin II, atrial natriuretic peptide, or corin levels. Aliskiren improved cardiac systolic function (ejection fraction, p < 0.05; cardiac output, p < 0.01) and significantly reduced the longitudinal development of edema (extracellular water, p < 0.0001), retarding the transition from Stage B to Stage C HF. The normalization of elevated plasma renin activity reduced the loss of body fat and lean mass (cachexia/sarcopenia), p < 0.001) and prolonged survival (p < 0.05). In summary, the normalization of plasma renin activity retards the progression of experimental HF by improving cardiac systolic function, reducing the development of systemic edema, cachexia/sarcopenia, and mortality. These data suggest that targeting pathologically elevated plasma renin activity may be beneficial in appropriately selected HF patients.
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218
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Rehman ZU, Siddiqui AK, Karim M, Majeed H, Hashim M. Medication Non-Adherence among Patients with Heart Failure. Cureus 2019; 11:e5346. [PMID: 31602351 PMCID: PMC6779150 DOI: 10.7759/cureus.5346] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Introduction Poor adherence or non-adherence to the prescribed medications among heart failure (HF) patients is a common problem. This leads to hospital admission due to increased HF exacerbations, reduced physical function, and even death. The study was conducted to assess the heart failure medication adherence level, using Morisky Medication Adherence Scale (MMAS-8), among heart failure patients visiting the adult cardiology department of a tertiary care cardiac center in Karachi. Methods This cross-sectional study included patients diagnosed with heart failure visiting for the follow-up to both inpatient and outpatient departments of a tertiary care cardiac center of Karachi, Pakistan. Medication adherence level was assessed using a validated Morisky Medication Adherence Scale (MMAS-8). The total MMAS-8 score was calculated by adding all of the 8 individual question scores and patients with a score of eight were classified as adherent, otherwise non-adherent. Results A total of 200 patients were included in this study, out of which 61.5% (123) were male and 38.5% (77) were female. More than half, 54% (108), of the patients were rural residents and majority were Urdu (39.5%) speaking followed by Sindhi (19.5%) and Pashto (19.0%) speaking. Almost all, 99.5% (199) were married and 52% (104) patients were uneducated. Overall 76.5% (153) were adherent to the prescribed medication. And reaming 23.5% (47) were moderately adherent with MMAS-8 score of seven and six. Non-adherence to the prescribed medication is more common among rural residents and uneducated patients. Conclusion Non-adherence to the prescribed medication was observed in a significant number of heart failure patients (23.5%) in our population, and it was more common observation for the patients with rural residence and uneducated. It is important to counsel the patients about the importance of medication adherence to marginalize the re-hospitalization and complications these patients.
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Affiliation(s)
- Zahid U Rehman
- Miscellaneous, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Arsalan K Siddiqui
- Miscellaneous, Aga Khan University Medical College, Aga Khan University Hospital, Karachi, PAK
| | - Musa Karim
- Miscellaneous, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Haris Majeed
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
| | - Muhammad Hashim
- Cardiology, National Institute of Cardiovascular Diseases, Karachi, PAK
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219
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay. J Am Coll Cardiol 2019; 74:e51-e156. [DOI: 10.1016/j.jacc.2018.10.044] [Citation(s) in RCA: 151] [Impact Index Per Article: 30.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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220
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Smets M, Smeets M, Van den Bulck S, Janssens S, Aertgeerts B, Vaes B. Defining quality indicators for heart failure in general practice. Acta Cardiol 2019; 74:291-298. [PMID: 30261830 DOI: 10.1080/00015385.2018.1492659] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background: Quality indicators (QIs) are used to measure and evaluate quality of care. However, QIs to evaluate care for HF patients in general practice in Belgium are lacking. Therefore, this study aimed to determine which QIs, rooted in the electronic health record (EHR), are useful to monitor quality of care for patients with HF in general practice. Methods: The RAND/UCLA appropriateness method (a modified Delphi method) was used to define these assigned QIs. First, a literature review was performed to generate a list of possible QIs for HF. Second, by applying the SMART principle, 25 QIs were withheld. Third, an expert panel of health care providers experienced in HF (cardiologists, general practitioners and HF nurses) was convened. Finally, the panellists rated the QIs for appropriateness in three rounds. Results: The withheld QIs highlighted diverse aspects of HF care. In round 1, 20 of the 25 QIs were considered appropriate, and five were considered uncertain. In round 2, 19 QIs were rated appropriate, four inappropriate, and two uncertain. In round 3, the final 19 appropriate QIs were ranked to form a top 10. The top three began with the identification of the aetiology of HF, continued with the differentiation between HF with preserved and reduced ejection fraction, and concluded with the treatment of HF with an ACE-I and a β-blocker in third place. Conclusion: In this study, 19 QIs for HF in general practice, extractable from the EHR, were identified. These QIs should enable the qualitative monitoring of HF care.
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Affiliation(s)
- Marie Smets
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Miek Smeets
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | | | - Stefan Janssens
- Department of Cardiovascular Diseases, Universitair Ziekenhuis Gasthuisberg, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Bert Aertgeerts
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Bert Vaes
- Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
- Institute of Health and Society, Université Catholique de Louvain, Brussels, Belgium
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221
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Kusumoto FM, Schoenfeld MH, Barrett C, Edgerton JR, Ellenbogen KA, Gold MR, Goldschlager NF, Hamilton RM, Joglar JA, Kim RJ, Lee R, Marine JE, McLeod CJ, Oken KR, Patton KK, Pellegrini CN, Selzman KA, Thompson A, Varosy PD. 2018 ACC/AHA/HRS Guideline on the Evaluation and Management of Patients With Bradycardia and Cardiac Conduction Delay: Executive Summary. J Am Coll Cardiol 2019; 74:932-987. [DOI: 10.1016/j.jacc.2018.10.043] [Citation(s) in RCA: 144] [Impact Index Per Article: 28.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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222
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Hägglund E, Strömberg A, Hagerman I, Lyngå P. Theory Testing of Patient Perspectives Using a Mobile Health Technology System in Heart Failure Self-care. J Cardiovasc Nurs 2019; 34:448-453. [DOI: 10.1097/jcn.0000000000000595] [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] [Indexed: 12/28/2022]
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223
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Abstract
BACKGROUND Heart failure prevalence continues to rise in the United States causing significant morbidity and mortality and costing billions in healthcare expenditures. Consensus guidelines updated in 2016 recommend an angiotensin receptor-neprilysin inhibitor (ARNi) as a therapeutic option in lieu of an angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for the management of stage C heart failure with reduced ejection fraction (HFrEF). For chronic HFrEF patients with New York Heart Association class II or III symptoms tolerating an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, a change in therapy to an ARNi is recommended to further reduce morbidity and mortality. PURPOSE We present a brief case series of 2 patients initiated on ARNi therapy for treatment of HFrEF and evaluate their fluid status and diuretic needs before and after ARNi dose optimization. CONCLUSIONS After titration to target-dose ARNi therapy, both patients demonstrated improved fluid and electrolyte balance, as well as a reduction in diuretic therapy requirements, suggesting a mechanism of diuresis attributable to ARNi therapy. CLINICAL IMPLICATIONS Angiotensin receptor-neprilysin inhibitor therapy seems to promote a clinically relevant diuresis in heart failure patients because of increased levels of functioning natriuretic peptides. Awareness of this diuretic potential may allow for optimization of heart failure regimens with pharmacologic agents demonstrated to improve morbidity and mortality, while preventing adverse effects that may occur with overdiuresis.
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224
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Abstract
The prevalence of heart failure increases with age. Changes in the age distribution and growing life expectancy will lead to a further rise. However, data concerning drug treatment of heart failure especially in the elderly are scarce. Subgroup analyses of the heart failure trials suggest that drug therapy in older patients should follow the recommendations in the current guidelines. In doing so, several common comorbidities in these patients (e. g., impaired renal function) have to be considered and may have an influence on the therapy (e. g., drug dose, choice of active pharmaceutical ingredient, etc.). Especially in old, multimorbid patients, possible interaction of drugs might play a substantial role. In many cases the main goal of the therapy, especially in the very elderly, is to improve symptoms and quality of life.
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225
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Park JH. Two-dimensional Echocardiographic Assessment of Myocardial Strain: Important Echocardiographic Parameter Readily Useful in Clinical Field. Korean Circ J 2019; 49:908-931. [PMID: 31456367 PMCID: PMC6753023 DOI: 10.4070/kcj.2019.0200] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2019] [Accepted: 07/03/2019] [Indexed: 01/14/2023] Open
Abstract
Echocardiography is the first and is the most-available imaging modality for many cardiovascular diseases, and echocardiographic parameters can give much important information for diagnosis, treatment, and prognostic evaluations. Left ventricular ejection fraction (LVEF) is the most commonly used echocardiographic parameter for left ventricular (LV) systolic function. Although LVEF is used routinely in daily practice, it is calculated from volumetric change without representing true myocardial properties. Recently, strain echocardiography has been used to objectively measure myocardial deformation. Myocardial strain can give accurate information about intrinsic myocardial function, and it can be used to detect early-stage cardiovascular diseases, monitor myocardial changes with specific therapies, differentiate cardiomyopathies, and predict the prognosis of several cardiovascular diseases. Although strain echocardiography has been applied to measure the right ventricle and left atrium, in addition to analyzing the LV, many cardiologists who are not imaging specialists are unaware of its clinical use and importance. Therefore, this review describes the measurement and clinical utility of 2-dimensional strain analysis in various cardiovascular diseases.
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Affiliation(s)
- Jae Hyeong Park
- Department of Cardiology in Internal Medicine, Chungnam National University Hospital, Chungnam National University College of Medicine, Daejeon, Korea.
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226
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Ambrosy AP, Fudim M, Chioncel O. Should providers prescribe sacubitril/valsartan based on trial eligibility, approval indication, or guideline recommendations? Eur J Heart Fail 2019; 21:1398-1401. [PMID: 31332924 DOI: 10.1002/ejhf.1555] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2019] [Revised: 06/19/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
- Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases 'Professor C.C. Iliescu', University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania
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227
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Meng L, Tseng CH, Shivkumar K, Ajijola O. Efficacy of Stellate Ganglion Blockade in Managing Electrical Storm: A Systematic Review. JACC Clin Electrophysiol 2019; 3:942-949. [PMID: 29270467 DOI: 10.1016/j.jacep.2017.06.006] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
BACKGROUND The efficacy of percutaneous stellate ganglion block (SGB) for managing electrical storm (ES) is not well understood. OBJECTIVE To characterize the efficacy of SGB as a treatment for ES. METHODS We conducted literature searches using PubMed/Medline and Google Scholar, for mixed combinations of terms including "stellate ganglion block", *ganglion block (ade)", "sympathetic block (ade)" and "arrhythmia", "ventricular arrhythmia (VA)" or "tachycardia" (VT), "ventricular fibrillation" (VF), "electrical storm". Inclusion criteria were presentation with guideline-defined ES and treatment with SGB. Exclusion criteria: presentation with any supraventricular arrhythmia, VA without ES, or surgical sympathectomy. Studies lacking basic demographic data, arrhythmia description, and outcomes were excluded. RESULTS Of 3,374 publications reviewed, 38 patients from 23 studies met study criteria (52 ± 19.1 years, 11 F, 17 with ischemic cardiomyopathy). Anti-arrhythmics were used in all patients. Mean Left ventricular ejection fraction was 31 ± 10%. ES was triggered by acute myocardial infarction in 15 patients and QT prolongation in 7 patients. The most common local anesthetic used for SGB was bupivacaine (0.25-0.5%). SGB resulted in a significant decrease in VA burden (12.4±8.8 vs. 1.04±2.12 episodes/day, p< 0.001) and number of external and ICD shocks (10.0±9.1 vs. 0.05±0.22 shocks/day, p< 0.01). Following SGB, 80.6% of patients survived to discharge. CONCLUSION SGB is an effective acute treatment for ES. However, larger prospective randomized studies are needed to better understand the role of SGB in ES and other VAs.
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Affiliation(s)
- Lingjin Meng
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, University of California, Los Angeles, CA
| | - Chi-Hong Tseng
- Division of General Internal Medicine and Health Services Research, University of California, Los Angeles, CA
| | - Kalyanam Shivkumar
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, University of California, Los Angeles, CA
| | - Olujimi Ajijola
- UCLA Cardiac Arrhythmia Center and Neurocardiology Research Center of Excellence, University of California, Los Angeles, CA
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228
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Ibrahim NE, Song Y, Cannon CP, Doros G, Russo P, Ponirakis A, Alexanian C, Januzzi JL. Heart failure with mid-range ejection fraction: characterization of patients from the PINNACLE Registry®. ESC Heart Fail 2019; 6:784-792. [PMID: 31268631 PMCID: PMC6676450 DOI: 10.1002/ehf2.12455] [Citation(s) in RCA: 42] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 03/27/2019] [Accepted: 04/28/2019] [Indexed: 01/08/2023] Open
Abstract
AIMS Guidelines for management of patients with heart failure with mid-range ejection fraction [HFmrEF; left ventricular EF (LVEF) 41-49%] do not exist. Disagreement exists whether HFmrEF should be considered a distinct group. The aim of this study is to examine characteristics of patients with HFmrEF with HF with reduced EF (HFrEF; LVEF ≤ 40%) or preserved EF (HFpEF; LVEF ≥ 50%). METHODS AND RESULTS We examined data collected in the American College of Cardiology's National Cardiovascular Data Registry (NCDR) Practice Innovation and Clinical Excellence (PINNACLE) Registry® for first HF patient visits between 1 May 2008 and 30 June 2016. Analysis was performed using ANOVA F-tests (or Kruskal-Wallis tests for non-normally distributed variables) for continuous parameters and χ2 tests for nominal covariates at the first diagnosed HF visit. Given the NCDR PINNACLE Registry® is a US-based registry, we opted to define HFmrEF as per the US guidelines, which define HFmrEF as LVEF 41-49% in contrast to European guidelines, which define HFmrEF as LVEF 40-49%. Among 1 103 386 patients with available data, 36.1% (N = 398 228) had HFrEF, 7.5% (N = 82 292) had HFmrEF, and 56.5% (N = 622 866) had HFpEF. Compared with patients with HFrEF or HFpEF, patients with HFmrEF had more prevalent coronary and peripheral artery disease and more history of myocardial infarction, percutaneous coronary intervention, or coronary artery bypass surgery (all P < 0.001). Patients with HFmrEF were also more likely to have atrial fibrillation/flutter, diabetes, and chronic kidney disease and to have a history of tobacco use (both P < 0.001). Among those with EF assessment prior to this analysis, only 4.8% (N = 1032) previously had HFrEF that improved to HFmrEF; 32.9% (N = 7072) had HFpEF previously and progressed to HFmrEF. Those patients who transitioned from HFpEF to HFmrEF had considerably more complex profiles and were less aggressively managed compared with those who remained with HFmrEF (all P < 0.001). CONCLUSIONS In this large descriptive analysis, patients with HFmrEF had an atherothrombotic phenotype distinct from other forms of HF. Interventions aimed at treating coronary ischaemia and addressing prevalent risk factors may play a particularly important role in the management of patients with HFmrEF.
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Affiliation(s)
- Nasrien E Ibrahim
- Cardiology Division, Massachusetts General Hospital, 32 Fruit Street, Yawkey 5984, Boston, MA, 02114, USA
| | - Yang Song
- Baim Institute for Clinical Research, Boston, MA, USA
| | | | - Gheorghe Doros
- Baim Institute for Clinical Research, Boston, MA, USA.,Boston University, Boston, MA, USA
| | | | | | | | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, 32 Fruit Street, Yawkey 5984, Boston, MA, 02114, USA.,Baim Institute for Clinical Research, Boston, MA, USA
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Wen J, Zou W, Wang R, Liu H, Yang Y, Li H, Wei S, Li R, Cai H, Wang J, Zhao Y. Cardioprotective effects of Aconiti Lateralis Radix Praeparata combined with Zingiberis Rhizoma on doxorubicin-induced chronic heart failure in rats and potential mechanisms. JOURNAL OF ETHNOPHARMACOLOGY 2019; 238:111880. [PMID: 31004728 DOI: 10.1016/j.jep.2019.111880] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 03/22/2019] [Accepted: 04/11/2019] [Indexed: 06/09/2023]
Abstract
BACKGROUND The combined use of Aconiti Lateralis Radix Praeparata (ALRP) and Zingiberis Rhizoma (ZR) are classic compatibilities in China for the treatment of cardiovascular diseases such as increasing myocardial contractility, anti-arrhythmia, reducing myocardial oxygen consumption, and dilating organ blood vessels, etc, thereby exerting anti-heart failure (HF) effects in traditional Chinese herbal medicine. However, comprehensive approaches for understanding the therapeutic effects and mechanisms underlying chronic heart failure (CHF) from the perspective of energy metabolism have not been pursued. AIM This research was aimed to investigate the effectiveness and potential mechanism of ALRP combined with ZR (1:1) on doxorubicin (DOX)-induced CHF in rats based on an integrated approach that combines network pharmacology analyses and molecular biology. MATERIAL AND METHODS CHF model was established by the intraperitoneal injection of DOX. ALRP and ZR were intragastrically administrated for three weeks. The detection indices including hemodynamic measurements, myocardial injury marker, and myocardial pathological changes were measured. Network pharmacology analysis was used to illustrate the pathways and network of ALRP and ZR against HF. Mitochondrial energy metabolism pathway associated gene and protein levels of PPARα, PGC-1α and Sirt3 in myocardial tissue were detected by real-time PCR and western blotting, respectively. RESULTS The results indicated that ALRP-ZR herbal couple significantly improved the left ventricular function and cardiac enzyme activities in comparison with their single use. Network pharmacology analysis results showed that the pharmacological mechanisms of ALRP-ZR may be related to PPAR energy metabolism pathway. Besides, the outcomes of western-blot and real-time PCR analysis showed that ALRP-ZR significantly upregulates the protein and gene level of PPARα, PGC-1α, and Sirt3. CONCLUSIONS Network pharmacology analysis would be an effective network analyze workflow which was feasible for evaluating the pharmacological effect of a multi-drug complex system. The Chinese herbal couple ALRP-ZR had a better therapeutic effect than their single-use against DOX-induced CHF, which may be related to enhancing left ventricular function by activating the PPARα/PGC-1α/Sirt3 pathway.
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Affiliation(s)
- Jianxia Wen
- Provincial and State Key Laboratory Breeding Base of System Research, Development and Utilization of Chinese Herbal Medicine Resources, College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China; Department of Pharmacy, Fifth Medical Center, 302 Military Hospital of China, Beijing, 100039, China
| | - Wenjun Zou
- Provincial and State Key Laboratory Breeding Base of System Research, Development and Utilization of Chinese Herbal Medicine Resources, College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China
| | - Ruilin Wang
- Department of Traditional Chinese Medicine, Fifth Medical Center, 302 Military Hospital of China, Beijing, 100039, China
| | - Honghong Liu
- Integrative Medical Center, Fifth Medical Center, 302 Military Hospital of China, Beijing, 100039, China
| | - Yuxue Yang
- Provincial and State Key Laboratory Breeding Base of System Research, Development and Utilization of Chinese Herbal Medicine Resources, College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China; Department of Pharmacy, Fifth Medical Center, 302 Military Hospital of China, Beijing, 100039, China
| | - Haotian Li
- Department of Pharmacy, Fifth Medical Center, 302 Military Hospital of China, Beijing, 100039, China
| | - Shizhang Wei
- Provincial and State Key Laboratory Breeding Base of System Research, Development and Utilization of Chinese Herbal Medicine Resources, College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China; Department of Pharmacy, Fifth Medical Center, 302 Military Hospital of China, Beijing, 100039, China
| | - Ruisheng Li
- Research Center for Clinical and Translational Medicine, Fifth Medical Center, General Hospital of Chinese PLA, Beijing, 100039, China
| | - Huadan Cai
- Department of Pharmacy, Fifth Medical Center, 302 Military Hospital of China, Beijing, 100039, China
| | - Jian Wang
- Provincial and State Key Laboratory Breeding Base of System Research, Development and Utilization of Chinese Herbal Medicine Resources, College of Pharmacy, Chengdu University of Traditional Chinese Medicine, Chengdu, 611137, China.
| | - Yanling Zhao
- Department of Pharmacy, Fifth Medical Center, 302 Military Hospital of China, Beijing, 100039, China.
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231
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Abstract
Heart failure is a progressive condition that continues to increase in both incidence and prevalence despite pharmacologic treatment. The high rate of morbidity and mortality associated with advanced heart failure has led to exploration of additional treatments, which include surgical interventions to improve outcomes. Heart transplant remains the gold standard but, because of the persistent donor shortage and increasing number of patients with advanced heart failure, mechanical circulatory support is gaining acceptance and can be used as a bridge to heart transplant for those eligible or as destination therapy.
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Affiliation(s)
- Candice Falls
- Internal Medicine-Cardiology, University of Kentucky, 1000 South Limestone Pavilion A 08.176, Lexington, KY, USA.
| | - Andrew R Kolodziej
- Gill Heart Institute, University of Kentucky, 900 South Limestone, CTW 320, Lexington, KY 40536, USA
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232
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Ambrosy AP, DeVore AD, Velazquez EJ. In-hospital initiation of sacubitril/valsartan in acute decompensated heart failure: being in the right place at the right time. Eur J Heart Fail 2019; 21:1008-1011. [PMID: 31218805 DOI: 10.1002/ejhf.1540] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Accepted: 05/24/2019] [Indexed: 12/28/2022] Open
Affiliation(s)
- Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA.,Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
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233
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Daley C, Al-Abdulmunem M, Holden RJ. Knowledge among patients with heart failure: A narrative synthesis of qualitative research. Heart Lung 2019; 48:477-485. [PMID: 31227224 DOI: 10.1016/j.hrtlng.2019.05.012] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2018] [Revised: 04/15/2019] [Accepted: 05/18/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients' knowledge of heart failure (HF) is integral to improved outcomes. However, the HF literature has not adequately explored the nature of patients' knowledge of HF as part of their lived experience. OBJECTIVES We aimed to characterize the nature of patients' knowledge of HF, in the context of living with the disease. METHODS We conducted a narrative synthesis of qualitative studies that addressed patients' knowledge of HF. Studies were systematically searched and retrieved from MEDLINE, CINAHL, PsycINFO and PsycARTICLES databases. Findings were synthesized using an iterative coding process carried out by multiple analysts and reported following Enhancing Transparency in the Reporting of Qualitative Health Research (ENTREQ) criteria. RESULTS Analysis of 73 eligible articles produced five themes: the content that comprises HF knowledge; development of HF knowledge over time; application of HF knowledge for decision making; communication of information between clinicians and patients; and patients' experience of knowledge. CONCLUSION The nature of patients' knowledge of HF is both explicit and implicit, dynamic, and personal. This multidimensional model of knowledge-in-context calls for equally multidimensional research and intervention design.
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Affiliation(s)
- Carly Daley
- Department of BioHealth Informatics, IUPUI, Indianapolis, IN, USA; Parkview Mirro Center for Research and Innovation, Parkview Health, Fort Wayne, IN, USA.
| | | | - Richard J Holden
- Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA; Indiana University Center for Aging Research, Regenstrief Institute, Inc., Indianapolis, IN, USA.
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234
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Abstract
Objective, noninvasive, clinical assessment of patients with heart failure can be made using biomarker measurements, including natriuretic peptides, cardiac troponins, soluble suppression of tumorigenicity 2, and galectin-3. The aim of this review is to provide clinicians with guidance on the use of heart failure biomarkers in clinical practice. The authors provide a didactic narrative based on current literature, an exemplary case study, and their clinical experience.
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235
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Park SK, Hong SH, Kim H, Kim S, Lee EK. Cost-Utility Analysis of Sacubitril/Valsartan Use Compared With Standard Care in Chronic Heart Failure Patients With Reduced Ejection Fraction in South Korea. Clin Ther 2019; 41:1066-1079. [DOI: 10.1016/j.clinthera.2019.04.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2018] [Revised: 04/10/2019] [Accepted: 04/17/2019] [Indexed: 01/14/2023]
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236
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Heart failure guideline update: a guide for general practice. Br J Gen Pract 2019; 69:313-314. [DOI: 10.3399/bjgp19x704069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 12/04/2018] [Indexed: 10/31/2022] Open
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237
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Clague-Baker N, Robinson T, Hagenberg A, Drewry S, Gillies C, Singh S. The validity and reliability of the Incremental Shuttle Walk Test and Six-minute Walk Test compared to an Incremental Cycle Test for people who have had a mild-to-moderate stroke. Physiotherapy 2019; 105:275-282. [DOI: 10.1016/j.physio.2018.12.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2018] [Accepted: 12/17/2018] [Indexed: 01/14/2023]
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238
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Yancy CW. Acute Heart Failure: Searching for a New Evident Truth. J Am Coll Cardiol 2019; 69:1420-1423. [PMID: 28302293 DOI: 10.1016/j.jacc.2017.01.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2017] [Accepted: 01/02/2017] [Indexed: 01/14/2023]
Affiliation(s)
- Clyde W Yancy
- Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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239
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Abstract
Although cardiogenic shock is uncommon in the emergency department, it is associated with high mortality. Most cardiogenic shock is caused by ischemia, but nonischemic etiologies are essential to recognize. Clinicians should optimize preload, contractility, and afterload. Volume-responsive patients should be resuscitated in small aliquots, although some patients may require diuresis to improve cardiac output. Vasopressors are important to restore end-organ perfusion, and inotropes improve contractility. Intubation and positive pressure ventilation impact hemodynamics, which, depending on volume status, may be beneficial or deleterious. Knowing indications for mechanical circulatory support is important for timely consultation or transfer as indicated.
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Affiliation(s)
- Susan R Wilcox
- Division of Critical Care, Department of Emergency Medicine, Massachusetts General Hospital, Zero Emerson Place, Suite 3B, Boston, MA 02114, USA.
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240
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Affiliation(s)
- Edimar Alcides Bocchi
- Heart Failure Team, Heart Institute (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Vera Maria Cury Salemi
- Heart Failure Team, Heart Institute (Incor) do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
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241
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Dittrich S, Graf E, Trollmann R, Neudorf U, Schara U, Heilmann A, von der Hagen M, Stiller B, Kirschner J, Pozza RD, Müller-Felber W, Weiss K, von Au K, Khalil M, Motz R, Korenke C, Lange M, Wilichowski E, Pattathu J, Ebinger F, Wiechmann N, Schröder R. Effect and safety of treatment with ACE-inhibitor Enalapril and β-blocker metoprolol on the onset of left ventricular dysfunction in Duchenne muscular dystrophy - a randomized, double-blind, placebo-controlled trial. Orphanet J Rare Dis 2019; 14:105. [PMID: 31077250 PMCID: PMC6509833 DOI: 10.1186/s13023-019-1066-9] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Accepted: 04/17/2019] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND X-linked Duchenne muscular dystrophy (DMD), the most frequent human hereditary skeletal muscle myopathy, inevitably leads to progressive dilated cardiomyopathy. We assessed the effect and safety of a combined treatment with the ACE-inhibitor enalapril and the β-blocker metoprolol in a German cohort of infantile and juvenile DMD patients with preserved left ventricular function. METHODS TRIAL DESIGN Sixteen weeks single-arm open run-in therapy with enalapril and metoprolol followed by a two-arm 1:1 randomized double-blind placebo-controlled treatment in a multicenter setting. INCLUSION CRITERIA DMD boys aged 10-14 years with left ventricular fractional shortening [LV-FS] ≥ 30% in echocardiography. Primary endpoint: time from randomization to first occurrence of LV-FS < 28%. Secondary: changes of a) LV-FS from baseline, b) blood pressure, c), heart rate and autonomic function in ECG and Holter-ECG, e) cardiac biomarkers and neurohumeral serum parameters, f) quality of life, and g) adverse events. RESULTS From 3/2010 to 12/2013, 38 patients from 10 sites were centrally randomized after run-in, with 21 patients continuing enalapril and metoprolol medication and 17 patients receiving placebo. Until end of study 12/2015, LV-FS < 28% was reached in 6/21 versus 7/17 patients. Cox regression adjusted for LV-FS after run-in showed a statistically non-significant benefit for medication over placebo (hazard ratio: 0.38; 95% confidence interval: 0.12 to 1.22; p = 0.10). Analysis of secondary outcome measures revealed a time-dependent deterioration of LV-FS with no statistically significant differences between the two study arms. Blood pressure, maximal heart rate and mean-NN values were significantly lower at the end of open run-in treatment compared to baseline. Outcome analysis 19 months after randomization displayed significantly lower maximum heart rate and higher noradrenalin and renin values in the intervention group. No difference between treatments was seen for quality of life. As a single, yet important adverse event, the reversible deterioration of walking abilities of one DMD patient during the run-in period was observed. CONCLUSIONS Our analysis of enalapril and metoprolol treatment in DMD patients with preserved left ventricular function is suggestive to delay the progression of the intrinsic cardiomyopathy to left ventricular failure, but did not reach statistical significance, probably due to insufficient sample size. CLINICAL TRIAL REGISTRATION DRKS-number 00000115, EudraCT-number 2009-009871-36.
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Affiliation(s)
- Sven Dittrich
- Department Pediatric Cardiology, Erlangen University Hospital, Friedrich-Alexander Universität Erlangen-Nürnberg, Loschgestraße 15, 91054, Erlangen, Germany. .,German Competence Network for Congenital Heart Defects partner site, Berlin, Germany.
| | - Erika Graf
- Institute of Medical Biometry and Statistics, Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Regina Trollmann
- Department of Pediatrics, Division of Pediatric Neurology, Erlangen University Hospital, Friedrich-Alexander Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Ulrich Neudorf
- Clinic for Pediatrics III, University Hospital Essen, Essen, Germany
| | - Ulrike Schara
- Department of Neuropediatrics, University Hospital Essen, Essen, Germany
| | - Antje Heilmann
- Department of Pediatrics, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Maja von der Hagen
- Department of Neurological Surgery, University Hospital Carl-Gustav-Carus, Technical University of Dresden, Dresden, Germany
| | - Brigitte Stiller
- Department of Congenital Heart Disease and Pediatric Cardiology, University Heart Center Freiburg, Bad Krozingen, Freiburg, Germany
| | - Janbernd Kirschner
- Department of Neuropediatrics and Muscle Disorders, University Medical Center, Freiburg, Germany
| | - Robert Dalla Pozza
- Department of Pediatric Cardiology, Ludwig Maximilians-University of Munich, Munich, Germany
| | - Wolfgang Müller-Felber
- Department of Pediatric Neurology and Developmental Medicine, Ludwig-Maximilians- University of Munich, Munich, Germany
| | - Katja Weiss
- Pediatric Cardiology and Congenital Heart Disease, University Hospital Charité, Berlin, Germany
| | - Katja von Au
- Department of Pediatrics, Division of Neurology, University Hospital Charité, Berlin, Germany
| | - Markus Khalil
- Division of Pediatric Heart Surgery, Pediatric Heart Center, University Hospital UKGM, Justus-Liebig University, Giessen, Germany
| | - Reinald Motz
- Department of Pediatric Cardiology, Elisabeth Children's Hospital, Oldenburg, Germany
| | | | - Martina Lange
- Department of Pediatric Cardiology and Intensive Care Medicine, Heart Center, University Medical Center Göttingen, Göttingen, Germany
| | - Ekkehard Wilichowski
- Department of Pediatrics and Adolescent Medicine, Division of Pediatric Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Joseph Pattathu
- Department of Pediatric Cardiology, University of Heidelberg, Heidelberg, Germany
| | | | - Nicola Wiechmann
- Clinical Trials Unit of the Medical Center, University of Freiburg, Freiburg, Germany
| | - Rolf Schröder
- Institute of Neuropathology, Erlangen University Hospital, Erlangen, Germany
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242
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Towbin JA, McKenna WJ, Abrams DJ, Ackerman MJ, Calkins H, Darrieux FCC, Daubert JP, de Chillou C, DePasquale EC, Desai MY, Estes NAM, Hua W, Indik JH, Ingles J, James CA, John RM, Judge DP, Keegan R, Krahn AD, Link MS, Marcus FI, McLeod CJ, Mestroni L, Priori SG, Saffitz JE, Sanatani S, Shimizu W, van Tintelen JP, Wilde AAM, Zareba W. 2019 HRS expert consensus statement on evaluation, risk stratification, and management of arrhythmogenic cardiomyopathy. Heart Rhythm 2019; 16:e301-e372. [PMID: 31078652 DOI: 10.1016/j.hrthm.2019.05.007] [Citation(s) in RCA: 436] [Impact Index Per Article: 87.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Indexed: 02/08/2023]
Abstract
Arrhythmogenic cardiomyopathy (ACM) is an arrhythmogenic disorder of the myocardium not secondary to ischemic, hypertensive, or valvular heart disease. ACM incorporates a broad spectrum of genetic, systemic, infectious, and inflammatory disorders. This designation includes, but is not limited to, arrhythmogenic right/left ventricular cardiomyopathy, cardiac amyloidosis, sarcoidosis, Chagas disease, and left ventricular noncompaction. The ACM phenotype overlaps with other cardiomyopathies, particularly dilated cardiomyopathy with arrhythmia presentation that may be associated with ventricular dilatation and/or impaired systolic function. This expert consensus statement provides the clinician with guidance on evaluation and management of ACM and includes clinically relevant information on genetics and disease mechanisms. PICO questions were utilized to evaluate contemporary evidence and provide clinical guidance related to exercise in arrhythmogenic right ventricular cardiomyopathy. Recommendations were developed and approved by an expert writing group, after a systematic literature search with evidence tables, and discussion of their own clinical experience, to present the current knowledge in the field. Each recommendation is presented using the Class of Recommendation and Level of Evidence system formulated by the American College of Cardiology and the American Heart Association and is accompanied by references and explanatory text to provide essential context. The ongoing recognition of the genetic basis of ACM provides the opportunity to examine the diverse triggers and potential common pathway for the development of disease and arrhythmia.
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Affiliation(s)
- Jeffrey A Towbin
- Le Bonheur Children's Hospital, Memphis, Tennessee; University of Tennessee Health Science Center, Memphis, Tennessee
| | - William J McKenna
- University College London, Institute of Cardiovascular Science, London, United Kingdom
| | | | | | | | | | | | | | | | | | - N A Mark Estes
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Wei Hua
- Fu Wai Hospital, Beijing, China
| | - Julia H Indik
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | - Jodie Ingles
- Agnes Ginges Centre for Molecular Cardiology at Centenary Institute, The University of Sydney, Sydney, Australia
| | | | - Roy M John
- Vanderbilt University Medical Center, Nashville, Tennessee
| | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina
| | - Roberto Keegan
- Hospital Privado Del Sur, Buenos Aires, Argentina; Hospital Español, Bahia Blanca, Argentina
| | | | - Mark S Link
- UT Southwestern Medical Center, Dallas, Texas
| | - Frank I Marcus
- University of Arizona, Sarver Heart Center, Tucson, Arizona
| | | | - Luisa Mestroni
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Silvia G Priori
- University of Pavia, Pavia, Italy; European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); ICS Maugeri, IRCCS, Pavia, Italy
| | | | | | - Wataru Shimizu
- Department of Cardiovascular Medicine, Nippon Medical School, Tokyo, Japan
| | - J Peter van Tintelen
- University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Utrecht University Medical Center Utrecht, University of Utrecht, Department of Genetics, Utrecht, the Netherlands
| | - Arthur A M Wilde
- European Reference Network for Rare and Low Prevalence Complex Diseases of the Heart (ERN GUARD-Heart); University of Amsterdam, Academic Medical Center, Amsterdam, the Netherlands; Department of Medicine, Columbia University Irving Medical Center, New York, New York
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243
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Yuan T, Chen Y, Zhou X, Lin X, Zhang Q. Effectiveness and safety of Danshen injection on heart failure: Protocol for a systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e15636. [PMID: 31145280 PMCID: PMC6709174 DOI: 10.1097/md.0000000000015636] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2019] [Accepted: 04/18/2019] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND Danshen injection (DSI) is a traditional Chinese medicine preparation extracted from Danshen (Salvia miltiorrhiza), which has the functions of promoting blood circulation and removing blood stasis. Heart failure (HF) is a complex cardiovascular disease, always leading to frequent onset and hospitalization, decreased quality of life, increased mortality, etc. Many clinical studies demonstrate that DSI has a good treatment on HF. We will provide a protocol to evaluate the effectiveness and safety of DSI for HF. METHODS We will systematically search 3 English databases (PubMed, Excerpta Medica database [EMBASE], the Cochrane Central Register of Controlled Trials [Cochrane Library]) and 4 Chinese databases (Chinese National Knowledge Infrastructure [CNKI], Chinese VIP Information, Wanfang Database, and Chinese Biomedical Literature Database [CBM]) for randomised controlled trials (RCT) of DSI for HF. Left ventricular ejection fraction (LVEF), ejection fraction, left ventricular end diastolic dimension (LVEDD), and six-minute walk distance (SWD) will be set as the primary outcome measures. The secondary outcome measures will include NT-pro BNP, quality of life and adverse reaction. All data will be analysed by using Stata 14.0 software and TSA v0.9 software. We will use I test statistics to assess the heterogeneity of included studies, and Begg's funnel plots and Egger's test to assess publication bias. Methodological quality will be assessed through a Cochrane risk of bias tool for randomized controlled trials (RCTs). RESULT This study will provide a high quality evidence for DSI on HF. CONCLUSION This protocol will provide a reliable evidence to evaluate the effectiveness and safety of DSI on HF. REGISTRATION PROS-PERO CRD42019125274.
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Affiliation(s)
- Tianhui Yuan
- The First Affiliated Hospital of Guangzhou University of Chinese Medicine
| | - Yi Chen
- Guangzhou University of Chinese Medicine, Guangzhou
| | - Xiaoqi Zhou
- Guangzhou University of Chinese Medicine, Guangzhou
| | - Xueying Lin
- Guangzhou University of Chinese Medicine, Guangzhou
| | - Qingsong Zhang
- Shenzhen Baoan Traditional Chinese Medicine Hospital Group, Guangdong Sheng, China
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244
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Sacubitril/valsartan: A practical guide. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2018.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
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245
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Affiliation(s)
- N Javaud
- AP-HP, Urgences, Centre de référence sur les angiœdèmes à kinines (CRéAk), Hôpital Louis Mourier, Université Paris 7, Colombes, France
| | - O Fain
- AP-HP, Médecine Interne, DHUi2B, Centre de Référence associé sur les angiœdèmes à kinines (CRéAk), Hôpital Saint-Antoine, Université Paris 6, Paris, France
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246
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Silva-Cardoso J, Brás D, Canário-Almeida F, Andrade A, Oliveira L, Pádua F, Fonseca C, Bragança N, Carvalho S, Soares R, Santos JF. Neurohormonal modulation: The new paradigm of pharmacological treatment of heart failure. Rev Port Cardiol 2019; 38:175-185. [PMID: 31029493 DOI: 10.1016/j.repc.2018.10.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 07/30/2018] [Accepted: 10/29/2018] [Indexed: 12/15/2022] Open
Abstract
The current paradigm of medical therapy for heart failure with reduced ejection fraction (HFrEF) is triple neurohormonal blockade with an angiotensin-converting enzyme inhibitor (ACEI), a beta-blocker (BB) and a mineralocorticoid receptor antagonist (MRA). However, three-year mortality remains over 30%. Stimulation of counter-regulatory systems in addition to neurohormonal blockade constitutes a new paradigm, termed neurohormonal modulation. Sacubitril/valsartan is the first element of this new strategy. PARADIGM-HF was the largest randomized clinical trial conducted in HFrEF. It included 8442 patients and compared the efficacy and safety of sacubitril/valsartan versus enalapril. The primary endpoint was the composite of cardiovascular mortality and hospitalization due to HF, which occurred in 914 (21.8%) patients receiving sacubitril/valsartan and in 1117 (26.5%) patients receiving enalapril (HR 0.8, 95% CI 0.73-0.87, p=0.0000002; NNT 21). Sacubitril/valsartan reduced both primary endpoint components, as well as sudden cardiac death, death due to worsening HF, and death from all causes. Patients on sacubitril/valsartan reported less frequent deterioration of HF and of quality of life, and discontinued study medication less frequently because of an adverse event. PARADIGM-HF demonstrated the superiority of sacubitril/valsartan over enalapril, with a 20% greater impact on cardiovascular mortality compared to ACEIs. Accordingly, in 2016, the European (ESC) and American (ACC/AHA/HFSA) cardiology societies simultaneously issued a class I recommendation for the replacement of ACEIs by sacubitril/valsartan in patients resembling PARADIGM-HF trial participants.
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Affiliation(s)
- J Silva-Cardoso
- Unidade de Doenças Cardiovasculares, Faculdade de Medicina da Universidade do Porto, Portugal; Centro de Pesquisa em Tecnologias e Serviços de Saúde, Universidade do Porto, Portugal; Clínica de Insuficiência Cardíaca e Transplante do Serviço de Cardiologia do Centro Hospitalar de S. João, Porto, Portugal.
| | - D Brás
- Medical Advisor, Departamento Médico, Novartis Farma-Produtos Farmacêuticos S.A., Lisboa, Portugal
| | - F Canário-Almeida
- Serviço de Cardiologia do Hospital Senhora da Oliveira, Guimarães, Portugal
| | - A Andrade
- Clínica de Insuficiência Cardíaca, Serviço de Cardiologia do Centro Hospitalar do Tâmega e Sousa, Penafiel, Portugal
| | - L Oliveira
- Serviço de Cardiologia do Centro Hospitalar Cova da Beira, Covilhã, Portugal
| | - F Pádua
- Hospital Dr. José Maria Grande (Unidade Local de Saúde do Norte Alentejano), Portalegre, Portugal
| | - C Fonseca
- Unidade de Insuficiência Cardíaca, Serviço de Medicina III e Hospital Dia, Hospital São Francisco Xavier - Centro Hospitalar de Lisboa Ocidental, Lisboa, Portugal; NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisboa, Portugal
| | - N Bragança
- Serviço de Medicina III, Hospital Prof. Doutor Fernando Fonseca, Amadora, Portugal
| | - S Carvalho
- Serviço de Cardiologia do Centro Hospitalar de Trás-os-Montes e Alto Douro, Vila Real, Portugal
| | - R Soares
- Serviço de Cardiologia do Hospital de Santa Marta, Lisboa, Portugal
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247
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Katsurahgi S, Kamiya C, Yamanaka K, Neki R, Miyoshi T, Iwanaga N, Horiuchi C, Tanaka H, Yoshimatsu J, Niwa K, Takagi Y, Ogo T, Nakanishi N, Ikeda T. Maternal and fetal outcomes in pregnancy complicated with Eisenmenger syndrome. Taiwan J Obstet Gynecol 2019; 58:183-187. [PMID: 30910135 DOI: 10.1016/j.tjog.2019.01.002] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2018] [Indexed: 01/14/2023] Open
Abstract
OBJECTIVE The goal of the study was to clarify the risk factors for pregnancy complicated with Eisenmenger syndrome (ES). MATERIALS AND METHODS A retrospective study was performed in 15 patients with ES who were managed throughout pregnancy at one institution from 1982 to 2013. Cases associated with congenital heart diseases other than atrial septal defect (ASD), ventricular septal defect (VSD), and patent ductus arteriosus (PDA) were excluded. RESULTS The congenital heart diseases in ES included ASD (n = 3), VSD (n = 9), and PDA (n = 3). Ten women chose termination and 5 continued with their pregnancies. In the 5 continuation cases (PDA 1, VSD 4), worsening of cyanosis, exertional fatigue and dyspnea appeared between 25 and 30 weeks gestation and cesarean section was performed at 30 (28-33) weeks. LVEF, PaO2, and SpO2 decreased and heart rate increased significantly from before pregnancy to 25-30 weeks gestation. From before to during the pregnancy, there were no significant changes in mean PABP or pulmonary vascular resistance (PVR) in four cases with data (582-592, 885 to 868, 1280 to 1291, 1476-1522 dyn × s/cm2). PVR at conception had a negative relationship with delivery weeks. NYHA classes before, during and 1 year after pregnancy were II, III and II. In one recent case, epoprostenol and tadalafil were administered during pregnancy. CONCLUSIONS Pregnancy with ES has a high risk due to hypooxygenation, cyanosis, and cardiac failure, which can appear as common complications as early as the 2nd trimester. Early interventions with meticulous care are required for these complications during pregnancy and delivery.
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Affiliation(s)
- Shinji Katsurahgi
- Department of Obstetrics and Gynecology, Sakakibara Heart Institute, Japan; Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan.
| | - Chizuko Kamiya
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Kaoru Yamanaka
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Reiko Neki
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Takekazu Miyoshi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Naoko Iwanaga
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Chinami Horiuchi
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Hiroaki Tanaka
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Jun Yoshimatsu
- Department of Perinatology and Gynecology, National Cerebral and Cardiovascular Center, Japan
| | - Koichiro Niwa
- Department of Cardiology, St. Luke's International Hospital, Japan
| | - Yaemi Takagi
- Department of Cardiovascular Medicine, Pulmonary Circulation Group, National Cerebral and Cardiovascular Center, Japan
| | - Takeshi Ogo
- Department of Cardiovascular Medicine, Pulmonary Circulation Group, National Cerebral and Cardiovascular Center, Japan
| | - Norifumi Nakanishi
- Department of Cardiovascular Medicine, Pulmonary Circulation Group, National Cerebral and Cardiovascular Center, Japan
| | - Tomoaki Ikeda
- Department of Obstetrics and Gynecology, Mie University, Japan
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248
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Pfau D, Thorn SL, Zhang J, Mikush N, Renaud JM, Klein R, deKemp RA, Wu X, Hu X, Sinusas AJ, Young LH, Tirziu D. Angiotensin Receptor Neprilysin Inhibitor Attenuates Myocardial Remodeling and Improves Infarct Perfusion in Experimental Heart Failure. Sci Rep 2019; 9:5791. [PMID: 30962467 PMCID: PMC6453892 DOI: 10.1038/s41598-019-42113-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/19/2019] [Indexed: 12/11/2022] Open
Abstract
Angiotensin receptor blocker-neprilysin inhibitor (ARNi) therapy improves the prognosis of heart failure patients. However, the mechanisms remain unclear. This study investigated the biological effects of ARNi with neprilysin inhibitor sacubitril and angiotensin receptor blocker valsartan on myocardial remodeling and cardiac perfusion in experimental heart failure (HF) after myocardial infarction (MI). Male Lewis rats (10-weeks old) with confirmed HF were randomized one-week post-MI to treatment with vehicle (water), sacubitril/valsartan or valsartan, as comparator group, for either 1 or 5 weeks. Sacubitril/valsartan for 1-week limited LV contractile dysfunction vs. vehicle and both sacubitril/valsartan and valsartan attenuated progressive LV dilation after 1 and 5 weeks treatment. After 5 weeks, both sacubitril/valsartan and valsartan reduced CTGF expression in the remote myocardium, although only sacubitril/valsartan prevented interstitial fibrosis. In the border zone, sacubitril/valsartan and valsartan reduced hypertrophic markers, but only sacubitril/valsartan reduced cardiomyocyte size and increased VEGFA expression. In the infarct, sacubitril/valsartan induced an early uptake of 99mTc-NC100692 (a radiotracer of angiogenesis) and improved perfusion, as determined by 201Tl microSPECT/CT imaging. In conclusion, ARNi improved global LV function, limited remodeling in the remote and border zones, and increased perfusion to the infarct. Sacubitril/valsartan had more consistent effects than valsartan on LV remodeling in experimental HF.
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Affiliation(s)
- Daniel Pfau
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephanie L Thorn
- Yale Translational Research Imaging Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jiasheng Zhang
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Nicole Mikush
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Ran Klein
- Division of Nuclear Medicine, Department of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Robert A deKemp
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Xiaohong Wu
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Xiaoyue Hu
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Albert J Sinusas
- Yale Translational Research Imaging Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, CT, USA
| | - Lawrence H Young
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Daniela Tirziu
- Yale Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
- Yale Cardiovascular Research Group, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA.
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249
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Komajda M, Schöpe J, Wagenpfeil S, Tavazzi L, Böhm M, Ponikowski P, Anker SD, Filippatos GS, Cowie MR. Physicians' guideline adherence is associated with long-term heart failure mortality in outpatients with heart failure with reduced ejection fraction: the QUALIFY international registry. Eur J Heart Fail 2019; 21:921-929. [PMID: 30933403 DOI: 10.1002/ejhf.1459] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2018] [Revised: 02/05/2019] [Accepted: 02/20/2019] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Physicians' adherence to guideline-recommended therapy is associated with short-term clinical outcomes in heart failure (HF) with reduced ejection fraction (HFrEF). However, its impact on longer-term outcomes is poorly documented. Here, we present results from the 18-month follow-up of the QUALIFY registry. METHODS AND RESULTS Data at 18 months were available for 6118 ambulatory HFrEF patients from this international prospective observational survey. Adherence was measured as a continuous variable, ranging from 0 to 1, and was assessed for five classes of recommended HF medications and dosages. Most deaths were cardiovascular (CV) (228/394) and HF-related (191/394) and the same was true for unplanned hospitalizations (1175 CV and 861 HF-related hospitalizations, out of a total of 1541). According to univariable analysis, CV and HF deaths were significantly associated with physician adherence to guidelines. In multivariable analysis, HF death was associated with adherence level [subdistribution hazard ratio (SHR) 0.93, 95% confidence interval (CI) 0.87-0.99 per 0.1 unit adherence level increase; P = 0.034] as was composite of HF hospitalization or CV death (SHR 0.97, 95% CI 0.94-0.99 per 0.1 unit adherence level increase; P = 0.043), whereas unplanned all-cause, CV or HF hospitalizations were not (all-cause: SHR 0.99, 95% CI 0.9-1.02; CV: SHR 0.98, 95% CI 0.96-1.01; and HF: SHR 0.99, 95% CI 0.96-1.02 per 0.1 unit change in adherence score; P = 0.52, P = 0.2, and P = 0.4, respectively). CONCLUSION These results suggest that physicians' adherence to guideline-recommended HF therapies is associated with improved outcomes in HFrEF. Practical strategies should be established to improve physicians' adherence to guidelines.
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Affiliation(s)
- Michel Komajda
- Department of Cardiology, Groupe Hospitalier, Paris Saint Joseph, Paris, France
| | - Jakob Schöpe
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg, Germany
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research, Ettore Sansavini Health Science Foundation, Cotignola, Italy
| | - Michael Böhm
- Internal Medicine Clinic III, Saarland University Clinic, Saarland University, Homburg, Germany
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Faculty of Public Health, Wroclaw, Poland
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany.,Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Göttingen, Germany
| | - Gerasimos S Filippatos
- Department of Cardiology, National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Martin R Cowie
- National Heart and Lung Institute, Imperial College London (Royal Brompton Hospital), London, UK
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250
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AlTurki A, Proietti R, Russo V, Dhanjal T, Banerjee P, Essebag V. Anti-arrhythmic drug therapy in implantable cardioverter-defibrillator recipients. Pharmacol Res 2019; 143:133-142. [PMID: 30914300 DOI: 10.1016/j.phrs.2019.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 01/14/2023]
Abstract
Implantable cardioverter-defibrillators (ICDs) have revolutionized the primary and secondary prevention of patients with ventricular arrhythmias. However, the adverse effects of appropriate or inappropriate shocks may require the adjunctive use of anti-arrhythmic drugs (AADs). Beta blockers are the cornerstone of pharmacological primary and secondary prevention of ventricular arrhythmias. In addition to their established efficacy at reducing the incidence of ventricular arrhythmias, beta-blockers are safe with few side effects. Amiodarone is superior to beta blockers and sotalol for the prevention of ventricular arrhythmia recurrence. However, long-term amiodarone use is associated with significant side effects that limit its utility. Sotalol and mexiletine are the main alternatives to amiodarone with a better side effect profile though they are less efficacious at preventing ventricular arrhythmia recurrence. Dofetilide, azimilide and ranolazine are emerging as therapeutic options for secondary prevention; more studies are needed to assess efficacy and safety in comparison to currently used agents. Beta blockers and amiodarone are the mainstay of therapy in patients experiencing electrical storm; their use reduces the frequency of ventricular arrhythmias and ICD intervention as well as affording time until catheter ablation can be considered.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Quebec, Canada.
| | - Riccardo Proietti
- Department of Cardiac, Thoracic, and Vascular Sciences, Padua, Italy
| | - Vincenzo Russo
- Chair of Cardiology, University of Campania, Ospedale Monaldi, Naples, Italy
| | - Tarvinder Dhanjal
- Cardiology Department, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Prithwish Banerjee
- Cardiology Department, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Quebec, Canada; Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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