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Myhre PL, Berge K, Ørn S. Reply to the letter regarding the article 'Changes in 6-min walk test is an independent predictor of death in chronic heart failure with reduced ejection fraction'. Eur J Heart Fail 2024. [PMID: 39221640 DOI: 10.1002/ejhf.3448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2024] [Accepted: 08/19/2024] [Indexed: 09/04/2024] Open
Affiliation(s)
- Peder L Myhre
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristian Berge
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Stein Ørn
- Department of Cardiology, Stavanger University Hospital, Stavanger, Norway
- Department of Electrical Engineering and Computer Science, University of Stavanger, Stavanger, Norway
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Gruson D, Hammerer-Lercher A, Collinson P, Duff C, Baum H, Pulkki K, Suvisaari J, Stankovic S, Laitinen P, Bayes-Genis A. The multidimensional value of natriuretic peptides in heart failure, integrating laboratory and clinical aspects. Crit Rev Clin Lab Sci 2024; 61:458-472. [PMID: 38523480 DOI: 10.1080/10408363.2024.2319578] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Revised: 01/15/2024] [Accepted: 02/13/2024] [Indexed: 03/26/2024]
Abstract
Natriuretic peptides (NP) play an essential role in heart failure (HF) regulation, and their measurement has improved diagnostic and prognostic accuracy. Clinical symptoms and objective measurements, such as NP levels, should be included in the HF definition to render it more reliable and consistent among observers, hospitals, and healthcare systems. BNP and NT-proBNP are reasonable surrogates for cardiac disease, and their measurement is critical to early diagnosis and risk stratification of HF patients. NPs should be measured in all patients presenting with dyspnea or other symptoms suggestive of HF to facilitate early diagnosis and risk stratification. Both BNP and NT-proBNP are currently used for guided HF management and display comparable diagnostic and prognostic accuracy. Standardized cutoffs for each NP assay are essential for data comparison. The value of NP testing is recognized at various levels, including patient empowerment and education, analytical and operational issues, clinical HF management, and cost-effectiveness.
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Affiliation(s)
- Damien Gruson
- Pôle de recherche en Endocrinologie, Diabète et Nutrition, Institut de Recherche Expérimentale et Clinique, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
- Department of Clinical Biochemistry, Cliniques Universitaires St-Luc and Université Catholique de Louvain, Brussels, Belgium
| | | | - Paul Collinson
- Department of Clinical Blood Science Chemical Pathology and Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Christopher Duff
- Department of Clinical Biochemistry, University Hospitals of North Midlands, Stoke-on-Trent, UK
| | - Hannsjörg Baum
- Department Laboratory Medicine, Regionale Kliniken Holding RKH, Ludwigsburg, Germany
| | - Kari Pulkki
- Clinical Chemistry and Hematology, Diagnostic Center, Helsinki University Hospital and the University of Helsinki, Helsinki, Finland
| | - Janne Suvisaari
- Clinical Chemistry and Hematology, Diagnostic Center, Helsinki University Hospital and the University of Helsinki, Helsinki, Finland
| | - Sanja Stankovic
- Center for Medical Biochemistry, University Clinical Center of Serbia, Belgrade, Serbia
- Department of Medical Sciences, University of Kragujevac, Kragujevac, Serbia
| | - Paivi Laitinen
- Center for Medical Biochemistry, University Clinical Center of Serbia, Belgrade, Serbia
| | - Antoni Bayes-Genis
- Germans Trias Heart Institute (iCor), Pujol, Universitat Autònoma de Barcelona; CIBERCV, Barcelona, Spain
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Budweg J, Ahmed MM, Vilaro JR, Al-Ani MA, Aranda JM, Guo Y, Li A, Patel S, Parker AM. Combination diuretic therapies in heart failure: Insights from GUIDE-IT. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2024; 45:100436. [PMID: 39220719 PMCID: PMC11362771 DOI: 10.1016/j.ahjo.2024.100436] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/16/2024] [Accepted: 07/22/2024] [Indexed: 09/04/2024]
Abstract
Introduction Diuretics are the mainstay of maintaining and restoring euvolemia in the management of heart failure. Loop diuretics are often preferred, however, combination diuretic therapy (CDT) with a thiazide diuretic is often used to overcome diuretic resistance and increase diuretic effect. We performed an analysis of the GUIDE-IT study to assess all-cause mortality and time to first hospitalizations in patients necessitating CDT. Methods Patients from the GUIDE-IT dataset were stratified by their requirement for CDT with a thiazide to achieve euvolemia. A total of 894 patients were analyzed, 733 of which were treated with loop diuretics alone vs 161 used either chlorothiazide or metolazone in addition to loop diuretics. Kaplan-Meir curves were derived with log-rank p-values to evaluate for differences between the groups. Results There was no significant difference in all-cause mortality regardless of CDT utilization status (mean survival of 612.704 days vs 603.326 days, p = 0.083). On subgroup analysis, there was no significant difference in all-cause mortality amongst those using loop diuretics compared to CDT in the BNP-guided therapy group, (mean survival time 576.385 days vs 620.585 days, p = 0.0523), nor the control group (614.1 days vs 588.9 days; p = 0.5728). Time to first hospitalization was reduced in all using CDT compared to loop diuretics alone (280.5 days vs 407.2 days, p < 0.0001). On subgroup analysis, both the BNP-guided group as well as the control group had reduced time to first hospitalization in the CDT group compared to those who did not require CDT (BNP group: 287.503 days vs 402.475 days, p ≤0.0001; control group 248.698 days vs 399.035 days, p = 0.0009). Conclusion Use of CDT is associated with earlier time to hospitalization, though no association was identified with increased all-cause mortality. Further prospective studies are likely needed to determine the true risk and benefits of combination diuretic therapy.
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Affiliation(s)
- Jeffery Budweg
- Department of Medicine, Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - Mustafa M. Ahmed
- Department of Medicine, Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - Juan R. Vilaro
- Department of Medicine, Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - Mohammad A. Al-Ani
- Department of Medicine, Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - Juan M. Aranda
- Department of Medicine, Division of Cardiology, University of Florida, Gainesville, FL, USA
| | - Yi Guo
- Department of Medicine, Division of Cardiology, Statistics, University of Florida, Gainesville, FL, USA
| | - Ang Li
- Department of Medicine, Division of Cardiology, Statistics, University of Florida, Gainesville, FL, USA
| | - Sandip Patel
- Department of Internal Medicine, Division of Cardiology, Orlando Health, Orlando, FL, USA
| | - Alex M. Parker
- Department of Medicine, Division of Cardiology, University of Florida, Gainesville, FL, USA
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4
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Larsen AI. Tools for timing in heart failure: what-when-how?-the prognostic value of the Metabolic Exercise test data combined with Cardiac and Kidney Indexes score confirmed. Eur J Prev Cardiol 2024; 31:1430-1433. [PMID: 37652028 DOI: 10.1093/eurjpc/zwad281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 08/25/2023] [Accepted: 08/27/2023] [Indexed: 09/02/2023]
Affiliation(s)
- Alf Inge Larsen
- Department of Cardiology, Stavanger University Hospital, Gerd-Ragna Bloch Thorsens Gate 8, 4011 Stavanger, Norway
- Department of Clinical Science, University of Bergen, Jonas Lies vei 65, 5021 Bergen, Norway
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5
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Landolfo M, Spannella F, Giulietti F, Ortensi B, Stella L, Carlucci MA, Galeazzi R, Turchi F, Luconi MP, Zampa R, Cecchi S, Tortato E, Petrelli M, Sarzani R. Detecting heart stress using NT-proBNP in patients with type 2 diabetes mellitus and hypertension or high-normal blood pressure: a cross-sectional multicentric study. Cardiovasc Diabetol 2024; 23:297. [PMID: 39135091 PMCID: PMC11321074 DOI: 10.1186/s12933-024-02391-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2024] [Accepted: 08/05/2024] [Indexed: 08/15/2024] Open
Abstract
BACKGROUND We evaluated the prevalence of "heart stress" (HS) based on NT-proBNP cut-points proposed by the 2023 Consensus of the Heart Failure Association (HFA) of the European Society of Cardiology (ESC) in asymptomatic patients with T2DM and hypertension or high-normal blood pressure (BP) eligible for SGLT2 inhibitors (SGLT2i) and/or GLP-1 receptor agonists (GLP1-RA), drugs with proven benefits on reducing the incidence of HF, hospitalizations, cardiovascular events and mortality. METHODS A cross-sectional multicentric study was conducted on 192 consecutive outpatients, aged ≥ 55 years, with hypertension or high-normal BP, referred to three diabetology units. NT-proBNP was collected before starting new anti-diabetic therapy. Patients with known HF were excluded, and participants were classified based on the age-adjusted NT-proBNP cut-points. RESULTS Mean age: 70.3 ± 7.8 years (67.5% males). Patients with obesity (BMI ≥ 30 Kg/m2): 63.8%. Median NT-proBNP: 96.0 (38.8-213.0) pg/mL. Prevalence of chronic kidney disease (CKD, eGFR < 60 mL/min/1.73m2): 32.1%. Mean arterial BP: 138.5/77.0 ± 15.8/9.9 mmHg. The NT-proBNP values, according to the proposed age-adjusted cut-points, classified 28.6% of patients as "HS likely" (organize elective echocardiography and specialist evaluation), 43.2% as "HS not likely" (a grey area, repeat NT-proBNP at six months) and 28.2% as "very unlikely HS" (repeat NT-proBNP at one year). The presence of CKD and the number of anti-hypertensive drugs, but not glycemic parameters, were independently associated with HS. CONCLUSIONS According to NT-proBNP, over a quarter of T2DM patients with hypertension/high-normal BP, among those eligible for SGLT2i and/or GLP1-RA, were already at risk of cardiac damage, even subclinical. Most would receive an indication to echocardiogram and be referred to a specialist, allowing the early implementation of effective strategies to prevent or delay the progression to advanced stages of cardiac disease and overt HF.
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Affiliation(s)
- Matteo Landolfo
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, Politecnica delle Marche University, Ancona, Italy
| | - Francesco Spannella
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy.
- Department of Clinical and Molecular Sciences, Politecnica delle Marche University, Ancona, Italy.
| | | | - Beatrice Ortensi
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, Politecnica delle Marche University, Ancona, Italy
| | - Lucia Stella
- Department of Clinical and Molecular Sciences, Politecnica delle Marche University, Ancona, Italy
| | - Maria A Carlucci
- Unit of Diabetology- Endocrinology and Metabolic Diseases, AST Pesaro-Urbino, Urbino, Italy
| | - Roberta Galeazzi
- Clinic of Laboratory and Precision Medicine, IRCCS INRCA, Ancona, Italy
| | - Federica Turchi
- Metabolic Diseases and Diabetology, IRCCS INRCA, Ancona, Italy
| | - Maria P Luconi
- Metabolic Diseases and Diabetology, IRCCS INRCA, Ancona, Italy
| | - Roberto Zampa
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, Politecnica delle Marche University, Ancona, Italy
| | - Sofia Cecchi
- Department of Clinical and Molecular Sciences, Politecnica delle Marche University, Ancona, Italy
| | - Elena Tortato
- Metabolic Diseases and Diabetology, IRCCS INRCA, Ancona, Italy
| | - Massimiliano Petrelli
- Clinic of Endocrinology and Metabolic Diseases, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Riccardo Sarzani
- Internal Medicine and Geriatrics, IRCCS INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, Politecnica delle Marche University, Ancona, Italy
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López B, Ravassa S, San José G, Latasa I, Losada-Fuentenebro B, Tapia L, Díez J, Bayés-Genís A, González A. Circulating biomarkers of myocardial remodelling: current developments and clinical applications. Heart 2024:heartjnl-2024-323865. [PMID: 39117384 DOI: 10.1136/heartjnl-2024-323865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2024] [Accepted: 06/21/2024] [Indexed: 08/10/2024] Open
Abstract
Myocardial remodelling, entailing cellular and molecular changes in the different components of the cardiac tissue in response to damage, underlies the morphological and structural changes leading to cardiac remodelling, which in turn contributes to cardiac dysfunction and disease progression. Since cardiac tissue is not available for histomolecular diagnosis, surrogate markers are needed for evaluating myocardial remodelling as part of the clinical management of patients with cardiac disease. In this setting, circulating biomarkers, a component of the liquid biopsy, provide a promising approach for the fast, affordable and scalable screening of large numbers of patients, allowing the detection of different pathological features related to myocardial remodelling, aiding in risk stratification and therapy monitoring. However, despite the advances in the field and the identification of numerous potential candidates, their implementation in clinical practice beyond natriuretic peptides and troponins is mostly lacking. In this review, we will discuss some biomarkers related to alterations in the main cardiac tissue compartments (cardiomyocytes, extracellular matrix, endothelium and immune cells) which have shown potential for the assessment of cardiovascular risk, cardiac remodelling and therapy effects. The hurdles and challenges for their translation into clinical practice will also be addressed.
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Affiliation(s)
- Begoña López
- Program of Cardiovascular Disease, CIMA Universidad de Navarra, Pamplona, Spain
- IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Susana Ravassa
- Program of Cardiovascular Disease, CIMA Universidad de Navarra, Pamplona, Spain
- IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Gorka San José
- Program of Cardiovascular Disease, CIMA Universidad de Navarra, Pamplona, Spain
- IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Iñigo Latasa
- Program of Cardiovascular Disease, CIMA Universidad de Navarra, Pamplona, Spain
- IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Blanca Losada-Fuentenebro
- Program of Cardiovascular Disease, CIMA Universidad de Navarra, Pamplona, Spain
- IdiSNA, Pamplona, Spain
| | - Leire Tapia
- Program of Cardiovascular Disease, CIMA Universidad de Navarra, Pamplona, Spain
- IdiSNA, Pamplona, Spain
| | - Javier Díez
- Program of Cardiovascular Disease, CIMA Universidad de Navarra, Pamplona, Spain
- CIBERCV, Madrid, Spain
| | - Antoni Bayés-Genís
- CIBERCV, Madrid, Spain
- University Hospital Germans Trias i Pujol and Universitat Autònoma de Barcelona, Badalona, Spain
| | - Arantxa González
- Program of Cardiovascular Disease, CIMA Universidad de Navarra, Pamplona, Spain
- IdiSNA, Pamplona, Spain
- CIBERCV, Madrid, Spain
- Department of Cardiology, Clínica Univarsidad de Navarra, Pamplona, Spain
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7
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Hollenberg SM, Stevenson LW, Ahmad T, Bozkurt B, Butler J, Davis LL, Drazner MH, Kirkpatrick JN, Morris AA, Page RL, Siddiqi HK, Storrow AB, Teerlink JR. 2024 ACC Expert Consensus Decision Pathway on Clinical Assessment, Management, and Trajectory of Patients Hospitalized With Heart Failure Focused Update: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024:S0735-1097(24)07449-7. [PMID: 39127954 DOI: 10.1016/j.jacc.2024.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
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8
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Allach Y, Barry-Loncq de Jong M, Clephas PRD, van Gent MWF, Brunner-La Rocca HP, Szymanski MK, van Halm VP, Handoko ML, Kok WEM, Asselbergs FW, van Kimmenade RRJ, Manintveld OC, van Mieghem NMDA, Beeres SLMA, Rienstra M, Post MC, van Heerebeek L, Borleffs CJW, Tukkie R, Mosterd A, Linssen GCM, Spee RF, Emans ME, Smilde TDJ, van Ramshorst J, Kirchhof CJHJ, Feenema-Aardema MW, da Fonseca CA, van den Heuvel M, Hazeleger R, van Eck JWM, Boersma E, Kardys I, de Boer RA, Brugts JJ. Serial cardiac biomarkers, pulmonary artery pressures and traditional parameters of fluid status in relation to prognosis in patients with chronic heart failure: Design and rationale of the BioMEMS study. Eur J Heart Fail 2024; 26:1736-1744. [PMID: 38825743 DOI: 10.1002/ejhf.3303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2024] [Revised: 04/03/2024] [Accepted: 05/13/2024] [Indexed: 06/04/2024] Open
Abstract
AIMS Heart failure (HF), a global pandemic affecting millions of individuals, calls for adequate predictive guidance for improved therapy. Congestion, a key factor in HF-related hospitalizations, further underscores the need for timely interventions. Proactive monitoring of intracardiac pressures, guided by pulmonary artery (PA) pressure, offers opportunities for efficient early-stage intervention, since haemodynamic congestion precedes clinical symptoms. METHODS The BioMEMS study, a substudy of the MONITOR-HF trial, proposes a multifaceted approach integrating blood biobank data with traditional and novel HF parameters. Two additional blood samples from 340 active participants in the MONITOR-HF trial were collected at baseline, 3-, 6-, and 12-month visits and stored for the BioMEMS biobank. The main aims are to identify the relationship between temporal biomarker patterns and PA pressures derived from the CardioMEMS-HF system, and to identify the biomarker profile(s) associated with the risk of HF events and cardiovascular death. CONCLUSION Since the prognostic value of single baseline measurements of biomarkers like N-terminal pro-B-type natriuretic peptide is limited, with the BioMEMS study we advocate a dynamic, serial approach to better capture HF progression. We will substantiate this by relating repeated biomarker measurements to PA pressures. This design rationale presents a comprehensive review on cardiac biomarkers in HF, and aims to contribute valuable insights into personalized HF therapy and patient risk assessment, advancing our ability to address the evolving nature of HF effectively.
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Affiliation(s)
- Youssra Allach
- Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Mylene Barry-Loncq de Jong
- Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Pascal R D Clephas
- Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Marco W F van Gent
- Department of Cardiology, Albert Schweitzer Hospital, Dordrecht, The Netherlands
| | | | - Mariusz K Szymanski
- Department of Cardiology, Utrecht University Medical Centre, Utrecht, The Netherlands
| | - Vokko P van Halm
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M Louis Handoko
- Department of Cardiology, Utrecht University Medical Centre, Utrecht, The Netherlands
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Wouter E M Kok
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Olivier C Manintveld
- Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Nicolas M D A van Mieghem
- Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Saskia L M A Beeres
- Department of Cardiology, Leiden University Medical Centre, Leiden, The Netherlands
| | - Michiel Rienstra
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Marco C Post
- Department of Cardiology, Utrecht University Medical Centre, Utrecht, The Netherlands
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | | | | | - Raymond Tukkie
- Department of Cardiology, Spaarne Hospital, Haarlem, The Netherlands
| | - Arend Mosterd
- Department of Cardiology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Gerard C M Linssen
- Department of Cardiology, Hospital Group Twente, Almelo, The Netherlands
| | - Ruud F Spee
- Department of Cardiology, Maxima Medical Centre, Eindhoven, The Netherlands
| | - Mireille E Emans
- Department of Cardiology, Ikazia hospital, Rotterdam, The Netherlands
| | - Tom D J Smilde
- Department of Cardiology, Scheeper Hospital Treant, Emmen, The Netherlands
| | - Jan van Ramshorst
- Department of Cardiology, Noordwest Hospital Group, Alkmaar, The Netherlands
| | | | | | - Carlos A da Fonseca
- Department of Cardiology, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
| | | | - Ronald Hazeleger
- Department of Cardiology, Vie Curi Hospital, Venlo, The Netherlands
| | - J W Martijn van Eck
- Department of Cardiology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - Eric Boersma
- Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Isabella Kardys
- Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Cardiovascular Institute, Erasmus University Medical Center, Rotterdam, The Netherlands
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Pintalhao M, Vasques-Nóvoa F, Barros AS, Lourenço P, Couto-Viana B, Leite-Moreira A, Bettencourt P, Castro-Chaves P. Prognostic association of circulating relaxin-2 in acute heart failure. Int J Cardiol 2024; 413:132358. [PMID: 39002802 DOI: 10.1016/j.ijcard.2024.132358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Revised: 05/29/2024] [Accepted: 07/10/2024] [Indexed: 07/15/2024]
Abstract
BACKGROUND Despite the increasing interest in the study of the endogenous relaxin system in heart failure (HF), its role as a prognostic marker in acute HF remains unclear. We aimed to evaluate the association of relaxin-2 circulating levels with 6 months' mortality in acute HF. METHODS We evaluated relaxin-2 serum levels at admission in a cohort of patients with acute HF (n = 202) using an enzyme immunoassay. The ability of relaxin-2 to predict all-cause death (primary outcome) and HF-specific death (secondary outcome) at 6 months was assessed using Cox-regression analysis. RESULTS The median age was 79 (70-85) years old, 44% of the patients were male, and 43% had preserved ejection fraction (≥50%). Median serum relaxin-2 level was 25 pg/mL. Patients with higher relaxin-2 levels had more peripheral oedemas, higher sodium retention score, higher pulmonary artery pressures, higher prevalence of right ventricle dysfunction and lower inferior vena cava collapse at inspiration. Conversely, there was no association with left chambers parameters or with B-type natriuretic peptide (BNP). Higher relaxin-2 concentrations were associated with a higher risk of all-cause death [HR 1.15; 95%CI 1.01,1.30; P = 0.030] and HF-specific death [HR 1.21; 95% CI 1.03-1.42; P = 0.018], after adjustment for classical prognostic factors such as age, sex and BNP. CONCLUSIONS In our acute HF population, relaxin-2 circulating levels were associated with clinical and echocardiographic markers of systemic congestion and with 6-months' mortality, independently of BNP. These results lay the groundwork for future investigations on the potential of relaxin-2 as an auxiliary biomarker in HF.
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Affiliation(s)
- Mariana Pintalhao
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Internal Medicine Department, Unidade Local de Saúde de São João, Porto, Portugal.
| | - Francisco Vasques-Nóvoa
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Internal Medicine Department, Unidade Local de Saúde de São João, Porto, Portugal
| | - António S Barros
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Patrícia Lourenço
- Cardiovascular R&D Centre - UnIC@RISE, Department of Medicine, Faculty of Medicine of the University of Porto, Internal Medicine Department, Unidade Local de Saúde de São João, Porto, Portugal
| | - Benedita Couto-Viana
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Adelino Leite-Moreira
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Paulo Bettencourt
- Cardiovascular R&D Centre - UnIC@RISE, Department of Medicine, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Paulo Castro-Chaves
- Cardiovascular R&D Centre - UnIC@RISE, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Internal Medicine Department, Unidade Local de Saúde de São João, Porto, Portugal
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10
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Sun J, Xie Z, Ye M, Xu H, Dong Y, Liu C, Zhu W. S 2I 2N 0-3 score predicts short- and long-term mortality and morbidity in HFrEF: a post-hoc analysis of the GUIDE-IT trial. ESC Heart Fail 2024; 11:1422-1434. [PMID: 38327133 PMCID: PMC11098633 DOI: 10.1002/ehf2.14689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/11/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
AIMS This study investigated the S2I2N0-3 score, a simple tool comprising stroke history, insulin-treated diabetes, and N-terminal pro-brain natriuretic peptide, for forecasting mortality and morbidity in heart failure (HF) with reduced ejection fraction (HFrEF). METHODS AND RESULTS Analysing 890 GUIDE-IT HFrEF trial participants, we stratified them by baseline S2I2N0-3 risk score into three risk groups. We examined the score's association with five adverse outcomes over short (90 days) and extended periods (median follow-up of 15 months) using Cox and competing risk models. Our analysis revealed significant positive associations between the S2I2N0-3 strata and adverse outcomes. When analysed as a continuous variable, each point increment of the S2I2N0-3 score was associated with a higher risk of short- and long-term cardiovascular death [short term: hazard ratio (HR) 1.43, 95% confidence interval (CI) 1.03-1.98; long term: HR 1.18, 95% CI 1.02-1.38], all-cause death (HR 1.52, 95% CI 1.12-2.07; HR 1.18, 95% CI 1.03-1.36), HF hospitalization (HR 1.39, 95% CI 1.20-1.62; HR 1.18, 95% CI 1.06-1.31), any hospitalization (HR 1.19, 95% CI 1.06-1.34; HR 1.09, 95% CI 1.00-1.19), and the composite outcome of cardiovascular death and HF hospitalization (HR 1.39, 95% CI 1.21-1.60; HR 1.17, 95% CI 1.06-1.30). The S2I2N0-3 demonstrated reliable prognostic value, with C-indices ranging from 0.619 to 0.753 across outcomes and time points. When compared with the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score using Z-statistics, net reclassification index, and integrated discrimination improvement, the S2I2N0-3 showed comparable predictive power for all outcomes during both short- and long-term follow-ups. CONCLUSIONS The S2I2N0-3 risk score had modest predictive values for both short- and long-term clinical outcomes in HFrEF patients, offering equivalent performance to the established MAGGIC score.
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Affiliation(s)
- Junyi Sun
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Zhengshuo Xie
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Min Ye
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- Department of Medical Ultrasound, Institute of Diagnostic and Interventional UltrasoundThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - He Xu
- Center of Translational MedicineThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yugang Dong
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Chen Liu
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Wengen Zhu
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
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11
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Kodur N, Tang WHW. Myocardial Recovery and Relapse in Heart Failure With Improved Ejection Fraction. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2024; 26:139-160. [PMID: 38993352 PMCID: PMC11238717 DOI: 10.1007/s11936-024-01038-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/18/2024] [Indexed: 07/13/2024]
Abstract
Purpose of review The purpose of this review is to discuss myocardial recovery in heart failure with reduced ejection fraction (HFrEF) and to summarize the contemporary insights regarding heart failure with improved ejection fraction (HFimpEF). Recent findings Improvement in left ventricular ejection fraction (LVEF ≥ 40%) with improved prognosis can be achieved in one out of three (10-40%) patients with HFrEF treated with guideline-directed medical therapy. Clinical predictors include non-ischemic etiology of HFrEF, less abnormal blood or imaging biomarkers, and lack of specific pathogenic genetic variants. However, a subset of patients may ultimately relapse, suggesting that many patients are merely in remission rather than having fully recovered. Summary Patients with HFimpEF have improved prognosis but nonetheless remain at risk of relapse and long-term adverse events. Future studies will hopefully chart the natural history of HFimpEF and identify clinical predictors such as blood or novel imaging biomarkers that distinguish subgroups of patients based on differential trajectory and prognosis.
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Affiliation(s)
- Nandan Kodur
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, US
| | - W. H. Wilson Tang
- Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, 9500 Euclid Avenue, Desk J3-4, Cleveland, OH, US
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, US
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12
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Di Fiore V, Cappelli F, Del Punta L, De Biase N, Armenia S, Maremmani D, Lomonaco T, Biagini D, Lenzi A, Mazzola M, Tricò D, Masi S, Mengozzi A, Pugliese NR. Novel Techniques, Biomarkers and Molecular Targets to Address Cardiometabolic Diseases. J Clin Med 2024; 13:2883. [PMID: 38792427 PMCID: PMC11122330 DOI: 10.3390/jcm13102883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2024] [Revised: 05/01/2024] [Accepted: 05/11/2024] [Indexed: 05/26/2024] Open
Abstract
Cardiometabolic diseases (CMDs) are interrelated and multifactorial conditions, including arterial hypertension, type 2 diabetes, heart failure, coronary artery disease, and stroke. Due to the burden of cardiovascular morbidity and mortality associated with CMDs' increasing prevalence, there is a critical need for novel diagnostic and therapeutic strategies in their management. In clinical practice, innovative methods such as epicardial adipose tissue evaluation, ventricular-arterial coupling, and exercise tolerance studies could help to elucidate the multifaceted mechanisms associated with CMDs. Similarly, epigenetic changes involving noncoding RNAs, chromatin modulation, and cellular senescence could represent both novel biomarkers and targets for CMDs. Despite the promising data available, significant challenges remain in translating basic research findings into clinical practice, highlighting the need for further investigation into the complex pathophysiology underlying CMDs.
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Affiliation(s)
- Valerio Di Fiore
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Federica Cappelli
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Lavinia Del Punta
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Nicolò De Biase
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Silvia Armenia
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Davide Maremmani
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Tommaso Lomonaco
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via Giuseppe Moruzzi 13, 56124 Pisa, Italy; (T.L.)
| | - Denise Biagini
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via Giuseppe Moruzzi 13, 56124 Pisa, Italy; (T.L.)
| | - Alessio Lenzi
- Department of Chemistry and Industrial Chemistry, University of Pisa, Via Giuseppe Moruzzi 13, 56124 Pisa, Italy; (T.L.)
| | - Matteo Mazzola
- Department of Surgical, Medical and Molecular Pathology and Critical Care Medicine, University of Pisa, Via Paradisa 2, 56124 Pisa, Italy
| | - Domenico Tricò
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Stefano Masi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Alessandro Mengozzi
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
| | - Nicola Riccardo Pugliese
- Department of Clinical and Experimental Medicine, University of Pisa, Via Roma 67, 56124 Pisa, Italy (F.C.)
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13
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Cordwin DJ, Guidi J, Alhashimi L, Hummel SL, Koelling TM, Dorsch MP. Differences in provider approach to initiating and titrating guideline directed medical therapy in heart failure with reduced ejection fraction. BMC Cardiovasc Disord 2024; 24:247. [PMID: 38730379 PMCID: PMC11087241 DOI: 10.1186/s12872-024-03911-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Despite the strong evidence supporting guideline-directed medical therapy (GDMT) in patients with heart failure with reduced ejection fraction (HFrEF), prescription rates in clinical practice are still lacking. METHODS A survey containing 20 clinical vignettes of patients with HFrEF was answered by a national sample of 127 cardiologists and 68 internal/family medicine physicians. Each vignette had 4-5 options for adjusting GDMT and the option to make no medication changes. Survey respondents could only select one option. For analysis, responses were dichotomized to the answer of interest. RESULTS Cardiologists were more likely to make GDMT changes than general medicine physicians (91.8% vs. 82.0%; OR 1.84 [1.07-3.19]; p = 0.020). Cardiologists were more likely to initiate beta-blockers (46.3% vs. 32.0%; OR 2.38 [1.18-4.81], p = 0.016), angiotensin receptor blocker/neprilysin inhibitor (ARNI) (63.8% vs. 48.1%; OR 1.76 [1.01-3.09], p = 0.047), and hydralazine and isosorbide dinitrate (HYD/ISDN) (38.2% vs. 23.7%; OR 2.47 [1.48-4.12], p < 0.001) compared to general medicine physicians. No differences were found in initiating angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARBs), initiating mineralocorticoid receptor antagonist (MRA), sodium-glucose transporter protein 2 (SGLT2) inhibitors, digoxin, or ivabradine. CONCLUSIONS Our results demonstrate cardiologists were more likely to adjust GDMT than general medicine physicians. Future focus on improving GDMT prescribing should target providers other than cardiologists to improve care in patients with HFrEF.
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Affiliation(s)
- David J Cordwin
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Jessica Guidi
- Medical School, University of Michigan, Ann Arbor, MI, USA
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Lana Alhashimi
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA
| | - Scott L Hummel
- Medical School, University of Michigan, Ann Arbor, MI, USA
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
- VA Ann Arbor Health System, Ann Arbor, MI, USA
| | - Todd M Koelling
- Medical School, University of Michigan, Ann Arbor, MI, USA
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA
| | - Michael P Dorsch
- College of Pharmacy, University of Michigan, Ann Arbor, MI, USA.
- Frankel Cardiovascular Center, University of Michigan, Ann Arbor, MI, USA.
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14
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Eltayeb M, Squire I, Sze S. Biomarkers in heart failure: a focus on natriuretic peptides. Heart 2024; 110:809-818. [PMID: 37673654 DOI: 10.1136/heartjnl-2020-318553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/08/2023] Open
Abstract
While progress has been made in the management of most aspects of cardiovascular disease, the incidence and prevalence of heart failure (HF) remains high. HF affects around a million people in the UK and has a worse prognosis than most cancers. Patients with HF are often elderly with complex comorbidities, making accurate assessment of HF challenging. A timely diagnosis and initiation of evidence-based treatments are key to prevent hospitalisation and improve outcomes in this population. Biomarkers have dramatically impacted the way patients with HF are evaluated and managed. The most studied biomarkers in HF are natriuretic peptides (NPs). Since their discovery in the 1980s, there has been an explosion of work in the field of NPs and they have become an important clinical tool used in everyday practice to guide diagnosis and prognostic assessment of patients with HF. In this article, we will review the physiology of NPs and study their biological effects. Then, we will discuss the role of NPs in the diagnosis, management and prognostication of patients with HF. We will also explore the role of NPs as a potential therapeutic agent.
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Affiliation(s)
- Mohamed Eltayeb
- Department of Cardiovascular Sciences and NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Iain Squire
- Department of Cardiovascular Sciences and NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
| | - Shirley Sze
- Department of Cardiovascular Sciences and NIHR Biomedical Research Centre, University of Leicester, Leicester, UK
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15
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Javed N, El-Far M, Vittorio TJ. Clinical markers in heart failure: a narrative review. J Int Med Res 2024; 52:3000605241254330. [PMID: 38779976 PMCID: PMC11119339 DOI: 10.1177/03000605241254330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
Heart failure is a complex clinical syndrome that is one of the causes of high mortality worldwide. Additionally, healthcare systems around the world are also being burdened by the aging population and subsequently, increasing estimates of patients with heart failure. As a result, it is crucial to determine novel ways to reduce the healthcare costs, rate of hospitalizations and mortality. In this regard, clinical biomarkers play a very important role in stratifying risk, determining prognosis or diagnosis and monitoring patient responses to therapy. This narrative review discusses the wide spectrum of clinical biomarkers, novel inventions of new techniques, their advantages and limitations as well as applications. As heart failure rates increase, cost-effective diagnostic tools such as B-type natriuretic peptide and N-terminal pro b-type natriuretic peptide are crucial, with emerging markers like neprilysin and cardiac imaging showing promise, though larger studies are needed to confirm their effectiveness compared with traditional markers.
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Affiliation(s)
- Nismat Javed
- Department of Medicine, BronxCare Health System/BronxCare Hospital Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Markos El-Far
- American University of the Caribbean, Department of Medicine, Sint Maarten, West Indies
| | - Timothy J. Vittorio
- Department of Medicine, BronxCare Health System/BronxCare Hospital Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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16
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Gouda P, Rathwell S, Colin-Ramirez E, Felker GM, Ross H, Escobedo J, Macdonald P, Troughton RW, O'Connor CM, Ezekowitz JA. Utilizing Quality of Life Adjusted Days Alive and Out of Hospital in Heart Failure Clinical Trials. Circ Cardiovasc Qual Outcomes 2024; 17:e010560. [PMID: 38567506 DOI: 10.1161/circoutcomes.123.010560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 02/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND In heart failure (HF) trials, there has been an emphasis on utilizing more patient-centered outcomes, including quality of life (QoL) and days alive and out of hospital. We aimed to explore the impact of QoL adjusted days alive and out of hospital as an outcome in 2 HF clinical trials. METHODS Using data from 2 trials in HF (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure [GUIDE-IT] and Study of Dietary Intervention under 100 mmol in Heart Failure [SODIUM-HF]), we determined treatment differences using percentage days alive and out of hospital (%DAOH) adjusted for QoL at 18 months as the primary outcome. For each participant, %DAOH was calculated as a ratio between days alive and out of hospital/total follow-up. Using a regression model, %DAOH was subsequently adjusted for QoL measured by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score. RESULTS In the GUIDE-IT trial, 847 participants had a median baseline Kansas City Cardiomyopathy Questionnaire Overall Summary Score of 59.0 (interquartile range, 40.8-74.3), which did not change over 18 months. %DAOH was 90.76%±22.09% in the biomarker-guided arm and 88.56%±25.27% in the usual care arm. No significant difference in QoL adjusted %DAOH was observed (1.09% [95% CI, -1.57% to 3.97%]). In the SODIUM-HF trial, 796 participants had a median baseline Kansas City Cardiomyopathy Questionnaire Overall Summary Score of 69.8 (interquartile range, 49.3-84.3), which did not change over 18 months. %DAOH was 95.69%±16.31% in the low-sodium arm and 95.95%±14.76% in the usual care arm. No significant difference was observed (1.91% [95% CI, -0.85% to 4.77%]). CONCLUSIONS In 2 large HF clinical trials, adjusting %DAOH for QoL was feasible and may provide complementary information on treatment effects in clinical trials.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Edmonton, Canada (P.G., J.A.E.)
| | - Sarah Rathwell
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.R., J.A.E.)
| | - Eloisa Colin-Ramirez
- Universidad Anáhuac México, Huixquilucan, Estado de México, Naucalpan, Mexico (E.C.-R.)
| | | | | | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City, Mexico (J.E.)
| | - Peter Macdonald
- St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia (P.M.)
| | - Richard W Troughton
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand (R.W.T.)
| | - Christopher M O'Connor
- Duke Clinical Research Institute, Durham, NC (G.M.F., C.M.O.)
- Inova Heart and Vascular Center, Falls Church, VA (C.M.O.)
| | - Justin A Ezekowitz
- University of Alberta, Edmonton, Canada (P.G., J.A.E.)
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.R., J.A.E.)
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17
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Mocan D, Lala RI, Puschita M, Pilat L, Darabantiu DA, Pop-Moldovan A. The Congestion "Pandemic" in Acute Heart Failure Patients. Biomedicines 2024; 12:951. [PMID: 38790913 PMCID: PMC11117769 DOI: 10.3390/biomedicines12050951] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/07/2024] [Accepted: 04/22/2024] [Indexed: 05/26/2024] Open
Abstract
Congestion not only represents a cardinal sign of heart failure (HF) but is also now recognized as the primary cause of hospital admissions, rehospitalization, and mortality among patients with acute heart failure (AHF). Congestion can manifest through various HF phenotypes in acute settings: volume overload, volume redistribution, or both. Recognizing the congestion phenotype is paramount, as it implies different therapeutic strategies for decongestion. Among patients with AHF, achieving complete decongestion is challenging, as more than half still experience residual congestion at discharge. Residual congestion is one of the strongest predictors of future cardiovascular events and poor outcomes. Through this review, we try to provide a better understanding of the congestion phenomenon among patients with AHF by highlighting insights into the pathophysiological mechanisms behind congestion and new diagnostic and management tools to achieve and maintain efficient decongestion.
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Affiliation(s)
- Daniela Mocan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Radu Ioan Lala
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
| | - Maria Puschita
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | - Luminita Pilat
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
| | | | - Adina Pop-Moldovan
- Multidisciplinary Doctoral School, Vasile Goldis Western University of Arad, 310025 Arad, Romania; (D.M.)
- Cardiology Department, Arad County Clinical Emergency Hospital, 310037 Arad, Romania
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18
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Maddox TM, Januzzi JL, Allen LA, Breathett K, Brouse S, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024; 83:1444-1488. [PMID: 38466244 DOI: 10.1016/j.jacc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
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19
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Ferrannini G, Benson L, Lautsch D, Dahlström U, Lund LH, Savarese G, Carrero JJ. N-terminal pro-B-type natriuretic peptide concentrations, testing and associations with worsening heart failure events. ESC Heart Fail 2024; 11:759-771. [PMID: 38115625 DOI: 10.1002/ehf2.14613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/23/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
AIMS In patients with heart failure (HF), we aimed to assess (i) the time trends in N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing; (ii) patient characteristics associated with NT-proBNP testing; (iii) distribution of NT-proBNP levels, focusing on the subgroups with (WHFE) vs. without (NWHFE) a worsening HF event, defined as an HF hospitalization; and (iv) changes of NT-proBNP levels over time. METHODS AND RESULTS NT-proBNP testing and levels were investigated in HF patients enrolled in the Swedish Heart Failure Registry (SwedeHF) linked with the Stockholm CREAtinine Measurements project from January 2011 to December 2018. Index date was the first registration in SwedeHF. Patterns of change in NT-proBNP levels before (in the previous 6 ± 3 months) and after (in the following 6 ± 3 months) the index date were categorized as follows: (i) <3000 ng/L at both measurements = stable low; (ii) <3000 ng/L at the first measurement and ≥3000 ng/L at the second measurement = increased; (iii) ≥3000 ng/L at the first measurement and <3000 ng/L at the second measurement = decreased; and (iv) ≥3000 ng/L at both measurements = stable high. Univariable and multivariable logistic regression models, expressed as odds ratios (ORs) and 95% confidence intervals (95% CIs), were performed to assess the associations between (i) clinical characteristics and NT-proBNP testing and (ii) changes in NT-proBNP from 6 months prior to the index date and the index date and a WHFE. Consistency analyses were performed in HF with reduced ejection fraction (HFrEF) alone. A total of 4424 HF patients were included (median age 74 years, women 34%, HFrEF 53%), 33% with a WHFE. NT-proBNP testing increased over time, up to 55% in 2018, and was almost two-fold as frequent, and time to testing was less than half, in patients with WHFE vs. NWHFE. Independent predictors of testing were WHFE, higher heart rate, diuretic use, and preserved ejection fraction. Median NT-proBNP was 3070 ng/L (Q1-Q3: 1220-7395), approximately three-fold higher in WHFE vs. NWHFE. Compared with stable low NT-proBNP levels, increased (OR 4.27, 95% CI 2.47-7.37) and stable high levels (OR 2.48, 95% CI 1.58-3.88) were independently associated with a higher risk of WHFE. Results were consistent in the HFrEF population. CONCLUSIONS NT-proBNP testing increased over time but still was only performed in half of the patients. Testing was associated with a WHFE, with features of more severe HF and for differential diagnosis purposes. Increased and stable high levels were associated with a WHFE. Overall, our data highlight the potential benefits of carrying further implementation of NT-proBNP testing in clinical practice.
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Affiliation(s)
- Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Norrbacka S1:02, SE-17176, Stockholm, Sweden
- Internal Medicine Unit, Södertälje Hospital, Södertälje, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Norrbacka S1:02, SE-17176, Stockholm, Sweden
| | | | - Ulf Dahlström
- Division of Cardiology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Norrbacka S1:02, SE-17176, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Norrbacka S1:02, SE-17176, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Pagnesi M, Adamo M, Metra M. Is it NICE to measure natriuretic peptides after a hospitalization for heart failure? Eur J Heart Fail 2024; 26:785-787. [PMID: 38654473 DOI: 10.1002/ejhf.3257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024] Open
Affiliation(s)
- Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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21
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Girerd N, Monzo L. Tackling the ReD(S) Flag of Congestion in Heart Failure. JACC. HEART FAILURE 2024; 12:707-710. [PMID: 38569824 DOI: 10.1016/j.jchf.2024.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Accepted: 02/02/2024] [Indexed: 04/05/2024]
Affiliation(s)
- Nicolas Girerd
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU Nancy, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.
| | - Luca Monzo
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU Nancy, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
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22
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Pascual-Figal DA, Hernández-Vicente A, Pastor-Pérez F, Martínez-Sellés M, Solé-González E, Alvarez-García J, García-Pavía P, Varela-Román A, Sánchez PL, Delgado JF, Noguera-Velasco JA, Bayes-Genis A. N-terminal pro-B-type natriuretic peptide post-discharge monitoring in the management of patients with heart failure and preserved ejection fraction - a randomized trial: The NICE study. Eur J Heart Fail 2024; 26:776-784. [PMID: 38606524 DOI: 10.1002/ejhf.3222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2023] [Revised: 02/26/2024] [Accepted: 03/17/2024] [Indexed: 04/13/2024] Open
Abstract
AIMS There is a lack of specific studies assessing the impact of natriuretic peptide monitoring in the post-discharge management of patients with heart failure (HF) and preserved ejection fraction (HFpEF), throughout the vulnerable phase following acute HF hospitalization. The NICE study aims to assess the clinical benefit of incorporating N-terminal pro-B-type natriuretic peptide (NT-proBNP) into the post-discharge management of HFpEF patients. METHODS AND RESULTS Individuals admitted with HFpEF (left ventricular ejection fraction >50%) were included in a multicentre randomized controlled study employing an open-label design with event blinding (NCT02807168). Upon discharge, 157 patients were randomly allocated to either NT-proBNP monitoring (n = 79) or no access to NT-proBNP (control group, n = 78) during pre-scheduled visits at 2, 4 and 12 weeks. Clinical endpoints were evaluated at 6 months. The primary endpoint of HF rehospitalizations occurred in 12.1% patients, without significant differences observed between the NT-proBNP monitoring group (12.8%) and the control group (11.4%) (hazard ratio [HR] 1.15, 95% confidence interval [CI] 0.47-2.81, p = 0.760). Regarding secondary endpoints, the NT-proBNP monitoring group demonstrated a significantly lower risk of death (1.3% vs. 10.1%; HR 0.12, 95% CI 0.02-0.98; p = 0.048), whereas non-HF hospitalizations (12.8% vs. 19.0%, p = 0.171) and any adverse clinical event (26.9% vs. 36.7%, p = 0.17) did not reach statistical significance [Correction added on 29 April 2024, after first online publication: In the preceding sentence, "95% CI 0.02 - 0.09" has been corrected to "95% CI 0.02 - 0.98; p = 0.048" in this version.]. Awareness of NT-proBNP levels were associated with higher doses of diuretics and renin-angiotensin system inhibitors (angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers) in the NT-proBNP monitoring group. CONCLUSIONS Post-discharge monitoring of NT-proBNP in HFpEF patients did not exhibit an association with reduced rates of HF hospitalization in this study. Nonetheless, it appears to enhance global clinical management by optimizing medical therapies and contributing to improved overall survival.
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Affiliation(s)
- Domingo A Pascual-Figal
- Hospital Virgen de la Arrixaca, Universidad de Murcia, IMIB-Pascual Parrilla, Murcia, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- CIBERCV, Madrid, Spain
| | | | - Francisco Pastor-Pérez
- Hospital Virgen de la Arrixaca, Universidad de Murcia, IMIB-Pascual Parrilla, Murcia, Spain
- CIBERCV, Madrid, Spain
| | - Manuel Martínez-Sellés
- CIBERCV, Madrid, Spain
- Hospital Gregorio Marañón, Universidad Europea, Universidad Complutense, Madrid, Spain
| | | | | | - Pablo García-Pavía
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
- CIBERCV, Madrid, Spain
- Hospital Universitario Puerta de Hierro Majadahonda, IDIPHISA, Madrid, Spain
| | - Alfonso Varela-Román
- CIBERCV, Madrid, Spain
- Hospital Clínico Universitario de Santiago, A Coruña, Spain
| | - Pedro Luis Sánchez
- CIBERCV, Madrid, Spain
- Hospital Clinico de Salamanca-IBSAL, Universidad de Salamanca, Salamanca, Spain
| | - Juan F Delgado
- CIBERCV, Madrid, Spain
- Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Jose A Noguera-Velasco
- Hospital Virgen de la Arrixaca, Universidad de Murcia, IMIB-Pascual Parrilla, Murcia, Spain
| | - Antoni Bayes-Genis
- CIBERCV, Madrid, Spain
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
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23
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Provencher S, Arsenault BJ, Bonnet S. Mendelian Randomization in Pulmonary Arterial Hypertension: Unveiling Early Insights With Promise for Future Discoveries. J Am Heart Assoc 2024; 13:e033446. [PMID: 38456451 PMCID: PMC11010037 DOI: 10.1161/jaha.123.033446] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/09/2024]
Affiliation(s)
- Steeve Provencher
- Pulmonary Hypertension Research GroupInstitut Universitaire de Cardiologie et de Pneumologie de Québec Research CentreQuébecCanada
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Benoit J. Arsenault
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of MedicineUniversité LavalQuébec CityQuébecCanada
| | - Sebastien Bonnet
- Pulmonary Hypertension Research GroupInstitut Universitaire de Cardiologie et de Pneumologie de Québec Research CentreQuébecCanada
- Centre de Recherche de l’Institut Universitaire de Cardiologie et de Pneumologie de QuébecQuébec CityQuébecCanada
- Department of MedicineUniversité LavalQuébec CityQuébecCanada
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24
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Khan MS, Greene SJ, DeVore AD. Serial NT-proBNP Measurements and Implementation of Guideline-Directed Medical Therapy. JACC. HEART FAILURE 2024; 12:488-491. [PMID: 38448150 DOI: 10.1016/j.jchf.2024.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/26/2023] [Accepted: 01/02/2024] [Indexed: 03/08/2024]
Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA.
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam D DeVore
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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25
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Fuery MA, Leifer ES, Samsky MD, Sen S, O'Connor CM, Fiuzat M, Ezekowitz J, Piña I, Whellan D, Mark D, Felker GM, Desai NR, Januzzi JL, Ahmad T. Prognostic Impact of Repeated NT-proBNP Measurements in Patients With Heart Failure With Reduced Ejection Fraction. JACC. HEART FAILURE 2024; 12:479-487. [PMID: 38127049 DOI: 10.1016/j.jchf.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 10/10/2023] [Accepted: 11/04/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Although clinical studies have demonstrated the association between a single N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement and clinical outcomes in chronic heart failure, the biomarker is frequently measured serially in clinical practice. OBJECTIVES The aim of this study was to determine the added prognostic value of repeated NT-proBNP measurements compared with single measurements alone for chronic heart failure patients. METHODS In the GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure) study, 894 study participants with chronic heart failure with reduced ejection fraction were enrolled at 45 outpatient sites in the United States and Canada. Repeated NT-proBNP levels were measured over a 2-year study period. Associations between repeated NT-proBNP measurements and trial endpoints were assessed using a joint longitudinal and survival model. RESULTS After adjustment for baseline covariates, each doubling of the baseline NT-proBNP level was associated with a HR of 1.17 (95% CI: 1.08-1.28; P = 0.0003) for the primary trial endpoint of cardiovascular death or heart failure hospitalization. Serial measurements increased the adjusted HR for the primary trial endpoint to 1.66 (95% CI: 1.50-1.84; P < 0.0001), and a similar increased risk was observed across secondary trial endpoints. In joint modeling, an increase in NT-proBNP occurred weeks before the onset of adjudicated events. CONCLUSIONS Repeated NT-proBNP measurements are a strong predictor of outcomes in heart failure with reduced ejection fraction with an increase in concentration occurring well before event onset. These results may support routine NT-proBNP monitoring to assist in clinical decision making. (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure [GUIDE-IT]; NCT01685840).
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Affiliation(s)
- Michael A Fuery
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Eric S Leifer
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Marc D Samsky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Mona Fiuzat
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Ileana Piña
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Whellan
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Mark
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - G Michael Felker
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Heart Failure and Biomarker Trials, Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, Connecticut, USA.
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26
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Ezekowitz J, Alemayehu W, Edelmann F, Ponikowski P, Lam CSP, O'Connor CM, Butler J, Corda S, McMullan CJ, Westerhout CM, Voors AA, Mentz RJ, Armstrong PW. Diuretic use and outcomes in patients with heart failure with reduced ejection fraction: Insights from the VICTORIA trial. Eur J Heart Fail 2024; 26:628-637. [PMID: 38450878 DOI: 10.1002/ejhf.3179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/08/2024] [Accepted: 02/11/2024] [Indexed: 03/08/2024] Open
Abstract
AIMS In VICTORIA, vericiguat compared with placebo reduced the risk of cardiovascular death (CVD) and heart failure hospitalization (HFH) in patients enrolled after a worsening heart failure (WHF) event. We examined clinical outcomes and efficacy of vericiguat as it relates to background use of loop diuretics in patients with WHF. METHODS AND RESULTS We calculated the total daily loop diuretic dose equivalent to furosemide dosing at randomization and categorized these as: no loop diuretic, 1-39, 41-80, 40, and >80 mg total daily dose (TDD). The primary composite outcome of CVD/HFH and its components were evaluated based on TDD loop diuretic and expressed as adjusted hazard ratios with 95% confidence intervals. Post-randomization rates of change in TDD were also examined. Of 4974 patients (98% of the trial) with diuretic dose information available at randomization, 540 (10.8%) were on no loop diuretic, 647 (13.0%) were on 1-39, 1633 (32.8%) were on 40, 1185 (23.8%) were on 41-80, and 969 (19.4%) were on >80 mg TDD. Patients with higher TDD had a higher rate of primary and secondary clinical outcomes. There were no significant interactions with TDD at randomization and efficacy of vericiguat versus placebo for any outcome (all pinteraction > 0.5). Post-randomization diuretic dose changes for vericiguat and placebo showed similar rates of up-titration (19.6 and 20.2/100 person-years), down-titration (16.8 and 18.1/100 person-years), and stopping diuretics (22.9 and 24.2/100 person-years). CONCLUSIONS Loop diuretic TDD at randomization was independently associated with worse outcomes in this high-risk population. The efficacy of vericiguat was consistent across the range of diuretic doses.
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Affiliation(s)
- Justin Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | | | - Frank Edelmann
- Charité University Medicine, German Heart Center, Berlin, Germany
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University Poland and Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | | | - Javed Butler
- Baylor University Medical Center, Dallas, TX, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | | | | | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center of Groningen, Groningen, The Netherlands
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
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27
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Badrish N, Sheifer S, Rosner CM. Systems of care for ambulatory management of decompensated heart failure. Front Cardiovasc Med 2024; 11:1350846. [PMID: 38455722 PMCID: PMC10918851 DOI: 10.3389/fcvm.2024.1350846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/25/2024] [Indexed: 03/09/2024] Open
Abstract
Heart failure (HF) represents a worldwide health burden and the annual per patient cost to treat HF in the US is estimated at $24,383, with most of this expense driven by HF related hospitalizations. Decompensated HF is a leading cause for hospital admissions and is associated with an increased risk of subsequent morbidity and mortality. Many hospital admissions for decompensated HF are considered preventable with timely recognition and effective intervention.Systems of care that include interventions to facilitate early recognition, timely and appropriate intervention, intensification of care, and optimization to prevent recurrence can help successfully manage decompensated HF in the ambulatory setting and avoid hospitalization.
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Affiliation(s)
- Narotham Badrish
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
| | - Stuart Sheifer
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
- Department of Cardiology, Virginia Heart, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
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28
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Palazzuoli A, Cartocci A, Pirrotta F, Tavera MC, Morrone F, Vannuccini F, Campora A, Ruocco G. Usefulness of Combined Ultrasound Assessment of E/e' Ratio, Pulmonary Pressure, and Cava Vein Status in Patients With Acute Heart Failure. Am J Cardiol 2024; 213:36-44. [PMID: 38104754 DOI: 10.1016/j.amjcard.2023.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 11/15/2023] [Accepted: 12/01/2023] [Indexed: 12/19/2023]
Abstract
Congestion is poorly investigated by ultrasound scans during acute heart failure (AHF) and systematic studies evaluating ultrasound indexes of cardiac pulmonary and systemic congestion during early hospital admission are lacking. We aimed to investigate the prevalence of ultrasound cardiac pulmonary and systemic congestion in a consecutive cohort of hospitalized patients with AHF, analyzing the relevance of each ultrasound congestion component (cardiac, pulmonary, and systemic) in predicting the risk of death and rehospitalization. This is a prospective research study of a single center that evaluates patients with an AHF diagnosis who are divided according to the left ventricular ejection fraction in patients with heart failure with preserved ejection fraction or reduced ejection fraction. We performed a complete bedside echocardiography and lung ultrasound analyses within the first 24 hours of hospital admission. The ultrasound congestion score was preliminarily established by measuring the following parameters: cardiac congestion, which was defined as the contemporary presence of E/e' >15 and pulmonary systolic pressure >35 mm Hg and the pulmonary congestion, defined as the total B-line number >25 at the lung ultrasound performed in 8 chest sites; moreover, the systemic congestion was defined if the inferior vena cava (IVC) was >21 mm and if it was associated with a reduced inspiratory collapse >50%. We thoroughly assessed 230 patients and evaluated their results. Of these patients, 135 had heart failure with reduced ejection fraction and there were 95 patients with heart failure with preserved ejection fraction; 122 patients experienced adverse events during the 180-day follow-up. The receiver operating characteristic curve analysis showed that the tricuspid annular peak systolic excursion (TAPSE) (area under the curve [AUC] 0.34 [0.26 to 0.41], p <0.001), E/e' (AUC 0.62 [0.54 to 0.69], p = 0.003), and IVC (AUC 0.70 [0.63 to 0.77], p <0.001) were all significantly related to poor prognosis detection. The univariate Cox regression analysis revealed that cardiac congestion in terms of E/e' and pulmonary systolic pressure (hazard ratio [HR] 1.49 [1.02 to 2.17], p = 0.037), TAPSE (HR 0.90 [0.85 to 0.94], p <0.001), and systemic congestion (HR 2.64 [1.53 to 4.56], p <0.001) were all significantly related to the 180-day outcome. After adjustment for potential confounders, only TAPSE (HR 0.92 [0.88 to 0.98], p = 0.005) and IVC (HR 1.92 [1.07 to 3.46], p = 0.029) confirmed their prognostic role. The multivariable analysis of multiple congestion levels in terms of systemic plus cardiac (HR 1.54 [1.05 to 2.25], p = 0.03), systemic plus pulmonary (HR 2.26 [1.47 to 3.47], p <0.001), and all 3 congestion features (HR 1.53 [1.06 to 2.23], p = 0.02) revealed an incremental prognostic role for each additional determinant. In conclusion, among the ultrasound indexes of congestion, IVC and TAPSE are related to adverse prognosis, and the addition of pulmonary and cardiac congestion indexes increases the risk prediction accuracy. Our data confirmed that right ventricular dysfunction and systemic congestion are the most powerful predictive factors in AHF.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-thoracic and Vascular Department Le Scotte Hospital, University of Siena, Siena, Italy.
| | - Alessandra Cartocci
- Department of Medical Biotechnology, and Postgraduate School of Cardiology, University of Siena, Siena, Italy
| | - Filippo Pirrotta
- Cardiovascular Diseases Unit, Cardio-thoracic and Vascular Department Le Scotte Hospital, University of Siena, Siena, Italy
| | - Maria Cristina Tavera
- Cardiovascular Diseases Unit, Cardio-thoracic and Vascular Department Le Scotte Hospital, University of Siena, Siena, Italy
| | - Francesco Morrone
- Postgraduate School of Cardiology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Francesca Vannuccini
- Postgraduate School of Cardiology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Alessandro Campora
- Postgraduate School of Cardiology, Department of Medical Biotechnology, University of Siena, Siena, Italy
| | - Gaetano Ruocco
- Cardiology Unit, "Buon Consiglio Hospital" Fatebenefratelli, Naples, Italy
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29
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Kayani M, Fatima N, Yarra PC, Almansouri NE, K D, Balasubramanian A, Parvathaneni N, Mowo-Wale AG, Valdez JA, Nazir Z. Novel Biomarkers in Early Detection of Heart Failure: A Narrative Review. Cureus 2024; 16:e53445. [PMID: 38435138 PMCID: PMC10909379 DOI: 10.7759/cureus.53445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/02/2024] [Indexed: 03/05/2024] Open
Abstract
Heart failure (HF) represents a significant global health challenge, characterized by a variety of symptoms resulting from cardiac dysfunction. This dysfunction often leads to systemic and pulmonary congestion. The pathophysiology of HF is complex, involving stimulation of the sympathetic nervous system, which is insufficiently balanced by the release of natriuretic peptide. This imbalance leads to progressive hypertrophy and dilatation of the heart's chambers, impairing its pumping efficiency and increasing the risk of arrhythmias and conduction disorders. The prevalence of HF is exceptionally high in industrialized nations and is expected to increase owing to an aging population and advancements in diagnostic methods. This study emphasizes the critical role of early diagnosis in reducing morbidity and mortality associated with HF, focusing specifically on the evolving importance of biomarkers in managing this condition. Biomarkers have played a key role in transforming the diagnosis and treatment of HF. Traditional biomarkers such as b-type natriuretic peptide and N-terminal pro-b-type natriuretic peptide have been widely adopted for their cost-effectiveness and ease of access. However, the rise of novel biomarkers such as growth differentiation factor 15 and adrenomedullin has shown promising results, offering superior sensitivity and specificity. These new biomarkers enhance diagnostic accuracy, risk stratification, and prognostic evaluation in HF patients. Despite these advancements, challenges remain, such as limited availability, high costs, and the need for further validation in diverse patient populations. Through a comprehensive literature review across databases such as PubMed, Google Scholar, and the Cochrane Library, this study compiles and analyzes data from 18 relevant studies, offering a detailed understanding of the current state of HF biomarkers. The study examines both traditional and emerging biomarkers such as galectin-3 and soluble suppression of tumorigenicity 2 in HF, exploring their clinical roles and impact on patient outcomes.
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Affiliation(s)
- Maryam Kayani
- Cardiology, Shifa Tameer-e-Millat University Shifa College of Medicine, Islamabad, PAK
| | - Neha Fatima
- Internal Medicine, Lisie Hospital, Kochi, IND
| | | | - Naiela E Almansouri
- Internal Medicine, California Institute of Behavioral Neurosciences & Psychology, Fairfield, USA
- Internal Medicine, University of Tripoli, Tripoli, LBY
| | - Deepshikha K
- Cardiology, Pondicherry Institute of Medical Sciences, Pondicherry, IND
| | | | | | | | - Josue A Valdez
- General Practice, Universidad Autónoma de Durango, Los Mochis, MEX
| | - Zahra Nazir
- Internal Medicine, Combined Military Hospital, Quetta, PAK
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30
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Spatz ES, Ginsburg GS, Rumsfeld JS, Turakhia MP. Wearable Digital Health Technologies for Monitoring in Cardiovascular Medicine. N Engl J Med 2024; 390:346-356. [PMID: 38265646 DOI: 10.1056/nejmra2301903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Erica S Spatz
- From the Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); the National Institutes of Health, Bethesda, MD (G.S.G.); the University of Colorado School of Medicine, Aurora (J.S.R.); and Meta Platforms, Menlo Park (J.S.R.), the Stanford Center for Digital Health, Stanford University School of Medicine, Stanford (M.P.T.), and iRhythm Technologies, San Francisco (M.P.T.) - all in California
| | - Geoffrey S Ginsburg
- From the Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); the National Institutes of Health, Bethesda, MD (G.S.G.); the University of Colorado School of Medicine, Aurora (J.S.R.); and Meta Platforms, Menlo Park (J.S.R.), the Stanford Center for Digital Health, Stanford University School of Medicine, Stanford (M.P.T.), and iRhythm Technologies, San Francisco (M.P.T.) - all in California
| | - John S Rumsfeld
- From the Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); the National Institutes of Health, Bethesda, MD (G.S.G.); the University of Colorado School of Medicine, Aurora (J.S.R.); and Meta Platforms, Menlo Park (J.S.R.), the Stanford Center for Digital Health, Stanford University School of Medicine, Stanford (M.P.T.), and iRhythm Technologies, San Francisco (M.P.T.) - all in California
| | - Mintu P Turakhia
- From the Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.S.S.); the National Institutes of Health, Bethesda, MD (G.S.G.); the University of Colorado School of Medicine, Aurora (J.S.R.); and Meta Platforms, Menlo Park (J.S.R.), the Stanford Center for Digital Health, Stanford University School of Medicine, Stanford (M.P.T.), and iRhythm Technologies, San Francisco (M.P.T.) - all in California
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31
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Kryczka KE, Demkow M, Dzielińska Z. Biomarkers in Peripartum Cardiomyopathy-What We Know and What Is Still to Be Found. Biomolecules 2024; 14:103. [PMID: 38254703 PMCID: PMC10813209 DOI: 10.3390/biom14010103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/20/2023] [Accepted: 01/04/2024] [Indexed: 01/24/2024] Open
Abstract
Peripartum cardiomyopathy (PPCM) is a form of heart failure, often severe, that occurs in previously healthy women at the end of their pregnancy or in the first few months after delivery. In PPCM, the recovery of heart function reaches 45-50%. However, the all-cause mortality in long-term observation remains high, reaching 20% irrespective of recovery status. The incidence of PPCM is increasing globally; therefore, effort is required to clarify the pathophysiological background of the disease, as well as to discover specific diagnostic and prognostic biomarkers. The etiology of the disease remains unclear, including oxidative stress; inflammation; hormonal disturbances; endothelial, microcirculatory, cardiomyocyte and extracellular matrix dysfunction; fibrosis; and genetic mutations. Currently, antiangiogenic 16-kDa prolactin (PRL), cleaved from standard 23-kDa PRL in the case of unbalanced oxidative stress, is recognized as the main trigger of the disease. In addition, 16-kDa PRL causes damage to cardiomyocytes, acting via microRNA-146a secreted from endothelial cells as a cause of the NF-κβ pathway. Bromocriptine, which inhibits the secretion of PRL from the pituitary gland, is now the only specific treatment for PPCM. Many different phenotypes of the disease, as well as cases of non-responders to bromocriptine treatment, indicate other pathophysiological pathways that need further investigation. Biomarkers in PPCM are not well established. There is a deficiency in specific diagnostic biomarkers. Pro-brain-type natriuretic peptide (BNP) and N-terminal BNP are the best, however unspecific, diagnostic biomarkers of heart failure at the moment. Therefore, more efforts should be engaged in investigating more specific biomolecules of a diagnostic and prognostic manner such as 16-kDa PRL, galectin-3, myeloperoxidase, or soluble Fms-like tyrosine kinase-1/placental growth factor ratio. In this review, we present the current state of knowledge and future directions of exploring PPCM pathophysiology, including microRNA and heat shock proteins, which may improve diagnosis, treatment monitoring, and the development of specific treatment strategies, and consequently improve patients' prognosis and outcome.
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Affiliation(s)
- Karolina E. Kryczka
- Department of Coronary and Structural Heart Diseases, National Institute of Cardiology, 04-628 Warsaw, Poland
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Jaeger BC, Welden S, Lenoir K, Speiser JL, Segar MW, Pandey A, Pajewski NM. Accelerated and Interpretable Oblique Random Survival Forests. J Comput Graph Stat 2024; 33:192-207. [PMID: 39184344 PMCID: PMC11343578 DOI: 10.1080/10618600.2023.2231048] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2022] [Accepted: 06/12/2023] [Indexed: 08/27/2024]
Abstract
The oblique random survival forest (RSF) is an ensemble supervised learning method for right-censored outcomes. Trees in the oblique RSF are grown using linear combinations of predictors, whereas in the standard RSF, a single predictor is used. Oblique RSF ensembles have high prediction accuracy, but assessing many linear combinations of predictors induces high computational overhead. In addition, few methods have been developed for estimation of variable importance (VI) with oblique RSFs. We introduce a method to increase computational efficiency of the oblique RSF and a method to estimate VI with the oblique RSF. Our computational approach uses Newton-Raphson scoring in each non-leaf node, We estimate VI by negating each coefficient used for a given predictor in linear combinations, and then computing the reduction in out-of-bag accuracy. In benchmarking experiments, we find our implementation of the oblique RSF is hundreds of times faster, with equivalent prediction accuracy, compared to existing software for oblique RSFs. We find in simulation studies that "negation VI" discriminates between relevant and irrelevant numeric predictors more accurately than permutation VI, Shapley VI, and a technique to measure VI using analysis of variance. All oblique RSF methods in the current study are available in the aorsf R package, and additional supplemental materials are available online.
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Affiliation(s)
- Byron C Jaeger
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Sawyer Welden
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Kristin Lenoir
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Jaime L Speiser
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
| | - Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, TX
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Wake Forest University School of Medicine, Winston-Salem, NC
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Kong MG, Moon I, Seo HS, Suh J, Choi JY, Na JO, Kim EJ. Home Bioelectrical Impedance Analysis Management System in Patients With Heart Failure: Rationale and Study Design. INTERNATIONAL JOURNAL OF HEART FAILURE 2024; 6:22-27. [PMID: 38303915 PMCID: PMC10827698 DOI: 10.36628/ijhf.2023.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/25/2023] [Accepted: 08/11/2023] [Indexed: 02/03/2024]
Abstract
Body fluid monitoring and management are essential to control dyspnea and prevent re-hospitalization in patients with chronic heart failure (HF). There are several methods to estimate and monitor patient's volume status, such as symptoms, signs, body weight, and implantable devices. However, these methods might be difficult to use for reasons that are slow to reflect body water change, inaccurate in specific patients' condition, or invasive. Bioelectrical impedance analysis (BIA) is a novel method for body water monitoring in patients with HF, and the value in prognosis has been proven in previous studies. We aim to determine the efficacy and safety of home BIA body water monitoring-guided HF treatment in patients with chronic HF. This multi-center, open-label, randomized control trial will enroll patients with HF who are taking loop diuretics. The home BIA group patients will be monitored for body water using a home BIA device and receive messages regarding their edema status and direction of additional diuretics usage or behavioral changes through the linked application system once weekly. The control group patients will receive the usual HF management. The primary endpoint is the change in N-terminal prohormone of brain natriuretic peptide levels from baseline after 12 weeks. This trial will provide crucial evidence for patient management with a novel home BIA body water monitoring system in patients with HF.
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Affiliation(s)
- Min Gyu Kong
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Inki Moon
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hye-Sun Seo
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jon Suh
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jah Yeon Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jin Oh Na
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Eung Ju Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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Dong B, Chen C, Zheng Y, Dong Y, Liu C, Xue R, Chen C. Clinical Implication of N-Terminal Pro-Brain Natriuretic Peptide Burden in Heart Failure With Reduced Ejection Fraction: From the GUIDE-IT. Am J Cardiol 2024; 210:188-194. [PMID: 37875234 DOI: 10.1016/j.amjcard.2023.10.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/22/2023] [Accepted: 10/13/2023] [Indexed: 10/26/2023]
Abstract
This study aimed to explore the prognostic implication of N-terminal pro-brain natriuretic peptide (NT-proBNP) burden on heart failure (HF) with reduced ejection fraction (HFrEF). We performed a post hoc analysis of the GUIDing Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure (GUIDE-IT) trial. NT-proBNP burden was defined as the proportion of days with increased NT-proBNP (≥1,800 pg/ml) to the whole observation time. A Cox proportional hazards regression model was used to evaluate the association with NT-proBNP burden and prognosis. A total of 815 patients with HFrEF were analyzed in our study. Patients were categorized into 4 groups according to the degree of NT-proBNP burden. In the multivariate Cox analysis, NT-proBNP burden was significantly associated with all-cause mortality, cardiovascular mortality, and HF hospitalization. Compared with patients without NT-proBNP burden, the risk for the composite outcome increased by 210% (hazard ratio [HR] 3.10, 95% confidence interval [CI] 1.72 to 5.58, p <0.001) in NT-proBNP burden 1 (mild) group, 432% (HR 5.32, 95% CI 2.93 to 9.67, p <0.001) in NT-proBNP burden 2 (moderate) group, and over 12 times (HR 13.15, 95% CI 7.42 to 23.33, p <0.001) in NT-proBNP burden 3 (severe) group. The sensitivity analyses stratified by age and renal function yielded similar results. A higher NT-proBNP burden was associated with a significant increase in risks of all-cause mortality, cardiovascular mortality, HF hospitalization, and composite outcome. The results suggested that NT-proBNP burden could be an important predictor of the prognosis of patients with HFrEF.
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Affiliation(s)
- Bin Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China; NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, PR China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, PR China
| | - Chen Chen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China; NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, PR China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, PR China
| | - Yuanqi Zheng
- Department of Cardiology, The Affiliated Sanming First Hospital of Fujian Medical University, Sanming, PR China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China; NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, PR China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, PR China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China; NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, PR China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, PR China; Department of Cardiology, The Affiliated Sanming First Hospital of Fujian Medical University, Sanming, PR China
| | - Ruicong Xue
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China; NHC Key Laboratory of Assisted Circulation (Sun Yat-Sen University), Guangzhou, PR China; National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, PR China.
| | - Cong Chen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-Sen University, Guangzhou, PR China; Department of Cardiology, The University of Hong Kong-Shenzhen Hospital, Shenzhen, PR China.
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Kittleson MM. Management of Heart Failure in Hospitalized Patients. Ann Intern Med 2023; 176:ITC177-ITC192. [PMID: 38079639 DOI: 10.7326/aitc202312190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
Heart failure affects more than 6 million people in the United States, and hospitalizations for decompensated heart failure confer a heavy toll in morbidity, mortality, and health care costs. Clinical trials have demonstrated effective interventions; however, hospitalization and mortality rates remain high. Key components of effective hospital care include appropriate diagnostic evaluation, triage and risk stratification, early implementation of guideline-directed medical therapy, adequate diuresis, and appropriate discharge planning.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California (M.M.K.)
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Chaikijurajai T, Rincon-Choles H, Tang WHW. Natriuretic peptide testing strategies in heart failure: A 2023 update. Adv Clin Chem 2023; 118:155-203. [PMID: 38280805 DOI: 10.1016/bs.acc.2023.11.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2024]
Abstract
Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP), have been recommended as standard biomarkers for diagnosing heart failure (HF), and one of the strongest risk predictors for mortality and HF hospitalization regardless of ejection fraction (EF) and etiology of HF. BNP is an active neurohormone opposing renin-angiotensin-aldosterone and sympathetic nervous system overactivated in HF, whereas NT-proBNP is an inactive prohormone released from cardiomyocytes in response to wall stress. Despite substantial advances in the development of guideline-directed medical therapy (GDMT) for HF with reduced EF, studies demonstrating direct benefits of NP-guided chronic HF therapy on mortality, HF hospitalization, and GDMT optimization have yielded conflicting results. However, accumulating evidence shows that achieving prespecified BNP or NT-proBNP target over time is significantly associated with favorable outcomes, suggesting that benefits of serially measured NPs may be limited to particular groups of HF patients, such as those with extreme levels of baseline BNP or NT-proBNP, which could represent severe phenotypes of HF associated with natriuretic peptide resistance or cardiorenal syndrome. Over the past decade, clinical utilization of BNP and NT-proBNP has been expanded, especially using serial NP measurements for guiding HF therapy, optimizing GDMT and identifying at-risk patients with HF phenotypes who may be minimally symptomatic or asymptomatic.
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Affiliation(s)
- Thanat Chaikijurajai
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States; Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Hernan Rincon-Choles
- Department of Nephrology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, United States
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States.
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Riccardi M, Myhre PL, Zelniker TA, Metra M, Januzzi JL, Inciardi RM. Soluble ST2 in Heart Failure: A Clinical Role beyond B-Type Natriuretic Peptide. J Cardiovasc Dev Dis 2023; 10:468. [PMID: 37998526 PMCID: PMC10672197 DOI: 10.3390/jcdd10110468] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023] Open
Abstract
Soluble (s)ST2 has been proposed as a useful biomarker for heart failure (HF) patient management. Myocardial damage or mechanical stress stimulate sST2 release. ST2 competes with a membrane bound receptor (ST2 ligand, or ST2L) for interleukin-33 (IL-33) binding, inhibiting the effects induced by the ST2L/IL-33 interaction so that excessive sST2 may contribute to myocardial fibrosis and ventricular remodeling. Compared to natriuretic peptides (NPs), sST2 concentration is not substantially affected by age, sex, body mass index, kidney function, atrial fibrillation, anemia, or HF etiology, and has low intra-individual variation. Its prognostic role as an independent marker is well reported in the literature. However, there is a gap on its use in combination with NPs, currently the only biomarkers recommended by European and American guidelines for HF management. Reflecting the activation of two distinct biological systems, a benefit from the use of sST2 and NP in combination is advocated. The aim of this review is to report the current scientific knowledge on sST2 in the acute and chronic HF settings with a particular attention to its additive role to natriuretic peptides (NPs).
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Affiliation(s)
- Mauro Riccardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, 25121 Brescia, Italy; (M.R.); (M.M.)
| | - Peder L. Myhre
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, 1478 Nordbyhagen, Norway;
- K.G. Jebsen Center for Cardiac Biomarkers, Institute of Clinical Medicine, University of Oslo, 0313 Oslo, Norway
| | - Thomas A. Zelniker
- Department of Internal Medicine II, Division of Cardiology, Center of Cardiovascular Medicine, Medical University of Vienna, 1090 Vienna, Austria;
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, 25121 Brescia, Italy; (M.R.); (M.M.)
| | - James L. Januzzi
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, and Baim Institute for Clinical Research, Boston, MA 02215, USA;
| | - Riccardo M. Inciardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, 25121 Brescia, Italy; (M.R.); (M.M.)
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Bhatia MS, Attri R, Sharda SC, Swarup P, Garg A. Natriuretic Peptides and Need for Reliable Tool to Assess Pulmonary Congestion for Treatment Monitoring in Heart Failure. J Community Hosp Intern Med Perspect 2023; 13:120-125. [PMID: 38596554 PMCID: PMC11000840 DOI: 10.55729/2000-9666.1260] [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: 06/13/2023] [Revised: 08/08/2023] [Accepted: 08/10/2023] [Indexed: 04/11/2024] Open
Abstract
Natriuretic peptides (NPs) play a significant role in the pathophysiology of heart failure (HF) and are considered reliable diagnostic and prognostic indicators of congestive HF. Pulmonary congestion in HF patients leads to clinical deterioration and hospitalizations. It remains an important aspect to address the management and treatment tailoring in HF patients. However, the role of NP-guided therapy remains debatable due to contrasting reports in the literature. Current guidelines do not recommend the use of NP-guided therapy in the treatment monitoring of HF. Therefore, there is an urgent need to identify reliable markers for treatment monitoring in congestive HF. For early detection of congestion, a technology-based approach to monitor pulmonary hemodynamics and absolute lung fluid measurement is found to be effective in guiding treatment. Remote dielectric sensing technology is one such non-invasive approach that measures pulmonary fluid levels in the lungs which results in reduced hospitalization and re-admission rate in HF patients. In this review, we summarized the role of natriuretic peptides and the need for a reliable tool to assess pulmonary congestion for treatment monitoring in HF.
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Affiliation(s)
- Mandip S. Bhatia
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh,
India
| | - Ritu Attri
- Department of General Medicine, Dr.BR. Ambedkar State Institute of Medical Sciences, Mohali, Punjab,
India
| | - Saurabh C. Sharda
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh,
India
| | - Pulkit Swarup
- Medical & Clinical Affairs, Terumo India Pvt. Ltd.,
India
| | - Amit Garg
- Medical & Clinical Affairs, Terumo India Pvt. Ltd.,
India
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Kula AJ, Bansal N. Brain Natriuretic Peptide Monitoring in CKD: Ready for Prime Time? Am J Kidney Dis 2023; 82:515-517. [PMID: 37737747 DOI: 10.1053/j.ajkd.2023.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 06/14/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Alexander J Kula
- Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, Illinois; Department of Pediatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
| | - Nisha Bansal
- Kidney Research Institute, Seattle, Washington; Department of Nephrology, University of Washington School of Medicine, Seattle, Washington
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Georges G, Fudim M, Burkhoff D, Leon MB, Généreux P. Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 2. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101059. [PMID: 39131062 PMCID: PMC11307977 DOI: 10.1016/j.jscai.2023.101059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/13/2024]
Abstract
Congestion is the most common manifestation of acute decompensated heart failure (ADHF). Residual congestion despite initial medical therapy is common and is recognized to be associated with worse outcomes; however, there are currently no standardized definition regarding decongestion end point. In the second part of this 2-part review, we provide a critical appraisal of decongestion definitions previously used in ADHF studies, review alternative metrics to define severity of volume overload, and propose a more granular 4-class congestion grading scheme and decongestion end point definitions that could potentially be included in future ADHF trials and consensus definitions.
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Affiliation(s)
- Gabriel Georges
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Martin B. Leon
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
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Khan MS, Singh S, Segar MW, Usman MS, Keshvani N, Ambrosy AP, Fiuzat M, Van Spall HGC, Fonarow GC, Zannad F, Felker GM, Januzzi JL, O'Connor C, Butler J, Pandey A. Polypharmacy and Optimization of Guideline-Directed Medical Therapy in Heart Failure: The GUIDE-IT Trial. JACC. HEART FAILURE 2023; 11:1507-1517. [PMID: 37115133 DOI: 10.1016/j.jchf.2023.03.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/03/2023] [Accepted: 03/16/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Polypharmacy is common among patients with heart failure with reduced ejection fraction (HFrEF). However, its impact on the use of optimal guideline-directed medical therapy (GDMT) is not well established. OBJECTIVES This study sought to evaluate the association between polypharmacy and odds of receiving optimal GDMT over time among patients with HFrEF. METHODS The authors conducted a post hoc analysis of the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment) trial. Polypharmacy was defined as receiving ≥5 medications (excluding HFrEF GDMT) at baseline. The outcome of interest was optimal triple therapy GDMT (concurrent administration of a renin-angiotensin-aldosterone blocker and beta-blocker at 50% of the target dose and a mineralocorticoid receptor antagonist at any dose) achieved over the 12-month follow-up. Multivariable adjusted mixed-effect logistic regression models with multiplicative interaction terms (time × polypharmacy) were constructed to evaluate how polypharmacy at baseline modified the odds of achieving optimal GDMT on follow-up. RESULTS The study included 891 participants with HFrEF. The median number of non-GDMT medications at baseline was 4 (IQR: 3-6), with 414 (46.5%) prescribed ≥5 and identified as being on polypharmacy. The proportion of participants who achieved optimal GDMT at the end of the 12-month follow-up was lower with vs without polypharmacy at baseline (15% vs 19%, respectively). In adjusted mixed models, the odds of achieving optimal GDMT over time were modified by baseline polypharmacy status (P for interaction < 0.001). Patients without polypharmacy at baseline had increased odds of achieving GDMT (OR: 1.16 [95% CI: 1.12-1.21] per 1-month increase; P < 0.001) but not patients with polypharmacy (OR: 1.01 [95% CI: 0.96-1.06)] per 1-month increase). CONCLUSIONS Patients with HFrEF who are on non-GDMT polypharmacy have lower odds of achieving optimal GDMT on follow-up.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sumitabh Singh
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | - Muhammad Shariq Usman
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Neil Keshvani
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Harriette G C Van Spall
- Department of Medicine, Population Health Research Institute, Research Institute of St. Joseph's, McMaster University, Hamilton, Ontario, Canada
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm Centre d'Investigation, Centre Hospitalier Régional Universitaire, Université de Lorraine, Nancy, France
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - James L Januzzi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Ambarish Pandey
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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42
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Georges G, Fudim M, Burkhoff D, Leon MB, Généreux P. Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 1. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101060. [PMID: 39131061 PMCID: PMC11307876 DOI: 10.1016/j.jscai.2023.101060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/13/2024]
Abstract
Despite recent advances in the treatment of patients with chronic heart failure, acute decompensated heart failure remains associated with significant mortality and morbidity because many novel therapies have failed to demonstrate meaningful benefit. Persistent congestion in the setting of escalating diuretic therapy has been repeatedly shown to be a marker of poor prognosis and is currently being targeted by various emerging device-based therapies. Because these therapies inherently carry procedural risk, patient selection is key in the future trial design. However, it remains unclear which patients are at a higher risk of residual congestion or adverse outcomes despite maximally tolerated decongestive therapy. In the first part of this 2-part review, we aimed to outline patient risk factors and summarize current evidence for early recognition of high-risk profile for residual congestion and adverse outcomes. These factors are classified as relating to the following: (1) previous clinical course, (2) severity of congestion, (3) diuretic response, and (4) degree of renal impairment. We also aimed to provide an overview of key inclusion criteria in recent acute decompensated heart failure trials and investigational device studies and propose potential criteria for selection of high-risk patients in future trials.
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Affiliation(s)
- Gabriel Georges
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Martin B. Leon
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
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Maeda D, Kanzaki Y, Sakane K, Tsuda K, Akamatsu K, Hourai R, Okuno T, Tokura D, Hasegawa HT, Morita H, Ito T, Hoshiga M. Prognostic impact of a reduction in the fibrosis-4 index among patients hospitalized with acute heart failure. Heart Vessels 2023; 38:1235-1243. [PMID: 37277568 DOI: 10.1007/s00380-023-02273-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 05/19/2023] [Indexed: 06/07/2023]
Abstract
Although the fibrosis-4 index (FIB-4) is associated with right atrial pressure or prognosis in acute heart failure (AHF), the prognostic impact of its reduction during hospitalization remains uncertain. We included 877 patients (age, 74.9 ± 12.0 years; 58% male) hospitalized with AHF. The reduction in FIB-4 was defined as: (FIB-4 on admission-FIB-4 at discharge)/FIB-4 on admission × 100. Patients were divided into low (< 1.0%, n = 293), middle (1.0-27.4%, n = 292), and high (> 27.4%, n = 292) FIB-4 reduction groups. The primary outcome was a composite of all-cause death or heart failure rehospitalization within 180 days. The median FIB-4 reduction was 14.7% (interquartile range - 7.8-34.9%). The primary outcome was observed in 79 (27.0%), 63 (21.6%), and 41 (14.0%) patients in the low, middle, and high FIB-4 reduction groups, respectively (P = 0.001). Adjusted Cox proportional-hazards analysis revealed that the middle and low FIB-4 reduction groups were associated with the primary outcome, independent of the pre-existing risk model including baseline FIB-4 ([high vs. middle] hazard ratio [HR]: 1.70, 95% confidence interval [CI]: 1.10-2,63, P = 0.017; [high vs. low] HR: 2.16, 95% CI 1.41-3.32, P < 0.001). FIB-4 reduction provided additional prognostic value to the baseline model, including well-known prognostic factors ([continuous net reclassification improvement] 0.304; 95% CI 0.139-0.464; P < 0.001; [integrated discrimination improvement] 0.011; 95% CI 0.004-0.017; P = 0.001). Additionally, the combination of the reduction in FIB-4 and brain natriuretic peptide was useful for risk stratification. In conclusion, among patients hospitalized with AHF, a greater FIB-4 reduction during hospitalization was associated with better prognoses.
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Affiliation(s)
- Daichi Maeda
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan.
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
| | - Yumiko Kanzaki
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
| | - Kazushi Sakane
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
| | - Kosuke Tsuda
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
- Department of Cardiology, Hokusetsu General Hospital, Osaka, Japan
| | - Kanako Akamatsu
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
| | - Ryoto Hourai
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
| | - Takahiro Okuno
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
| | - Daisuke Tokura
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
| | - Hitomi T Hasegawa
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
| | - Hideaki Morita
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
| | - Takahide Ito
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
| | - Masaaki Hoshiga
- Department of Cardiology, Osaka Medical and Pharmaceutical University, 2-7 Daigaku-machi, Takatsuki, Osaka, 5698686, Japan
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Lam CSP, Docherty KF, Ho JE, McMurray JJV, Myhre PL, Omland T. Recent successes in heart failure treatment. Nat Med 2023; 29:2424-2437. [PMID: 37814060 DOI: 10.1038/s41591-023-02567-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 08/25/2023] [Indexed: 10/11/2023]
Abstract
Remarkable recent advances have revolutionized the field of heart failure. Survival has improved among individuals with heart failure and a reduced ejection fraction and for the first time, new therapies have been shown to improve outcomes across the entire ejection fraction spectrum of heart failure. Great strides have been taken in the treatment of specific cardiomyopathies such as cardiac amyloidosis and hypertrophic cardiomyopathy, whereby conditions once considered incurable can now be effectively managed with novel genetic and molecular approaches. Yet there remain substantial residual unmet needs in heart failure. The translation of successful clinical trials to improved patient outcomes is limited by large gaps in implementation of care, widespread lack of disease awareness and poor understanding of the socioeconomic determinants of outcomes and how to address disparities. Ongoing clinical trials, advances in phenotype segmentation for precision medicine and the rise in technology solutions all offer hope for the future.
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Affiliation(s)
- Carolyn S P Lam
- Duke-NUS Medical School, Singapore, Singapore.
- National Heart Centre Singapore, Singapore, Singapore.
- University Medical Center Groningen, Groningen, the Netherlands.
| | - Kieran F Docherty
- University of Glasgow, School of Cardiovascular and Metabolic Health, Glasgow, UK
| | - Jennifer E Ho
- CardioVascular Institute and Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - John J V McMurray
- University of Glasgow, School of Cardiovascular and Metabolic Health, Glasgow, UK
| | - Peder L Myhre
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
| | - Torbjørn Omland
- Department of Cardiology, Akershus University Hospital, Lørenskog, Norway
- K.G. Jebsen Center for Cardiac Biomarkers, University of Oslo, Oslo, Norway
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Talha KM, Pandey A, Fudim M, Butler J, Anker SD, Khan MS. Frailty and heart failure: State-of-the-art review. J Cachexia Sarcopenia Muscle 2023; 14:1959-1972. [PMID: 37586848 PMCID: PMC10570089 DOI: 10.1002/jcsm.13306] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/16/2023] [Accepted: 07/11/2023] [Indexed: 08/18/2023] Open
Abstract
At least half of all patients with heart failure (HF) are affected by frailty, a syndrome that limits an individual ability to recover from acute stressors. While frailty affects up to 90% of patients with HF with preserved ejection fraction, it is also seen in ~30-60% of patients with HF with reduced ejection fraction, with ~26% higher prevalence in women compared with men. The relationship between frailty and HF is bidirectional, with both conditions exacerbating the other. Frailty is further complicated by a higher prevalence of sarcopenia (by ~20%) in HF patients compared with patients without HF, which negatively affects outcomes. Several frailty assessment methods have been employed historically including the Fried frailty phenotype and Rockwood Clinical Frailty Scale to classify HF patients based on the severity of frailty; however, a validated HF-specific frailty assessment tool does not currently exist. Frailty in HF is associated with a poor prognosis with a 1.5-fold to 2-fold higher risk of all-cause death and hospitalizations compared to non-frail patients. Frailty is also highly prevalent in patients with worsening HF, affecting >50% of patients hospitalized for HF. Such patients with multiple readmissions for decompensated HF have markedly poor outcomes compared to younger, non-frail cohorts, and it is hypothesized that it may be due to major physical and functional limitations that limit recovery from an acute episode of worsening HF, a care aspect that has not been addressed in HF guidelines. Frail patients are thought to confer less benefit from therapeutic interventions due to an increased risk of perceived harm, resulting in lower adherence to HF interventions, which may worsen outcomes. Multiple studies report that <40% of frail patients are on guideline-directed medical therapy for HF, of which most are on suboptimal doses of these medications. There is a lack of evidence generated from randomized trials in this incredibly vulnerable population, and most current practice is governed by post hoc analyses of trials, observational registry-based data and providers' clinical judgement. The current body of evidence suggests that the treatment effect of most guideline-based interventions, including medications, cardiac rehabilitation and device therapy, is consistent across all age groups and frailty subgroups and, in some cases, may be amplified in the older, more frail population. In this review, we discuss the characteristics, assessment tools, impact on prognosis and impact on therapeutic interventions of frailty in patients with HF.
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Affiliation(s)
- Khawaja M. Talha
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - Ambarish Pandey
- Division of CardiologyUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Marat Fudim
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | - Javed Butler
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
- Baylor Scott and White Research InstituteDallasTXUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK) of German Heart Center CharitéInstitute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité UniversitätsmedizinBerlinGermany
- Institute of Heart DiseasesWroclaw Medical UniversityWroclawPoland
| | - Muhammad Shahzeb Khan
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
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Dong C, Feng S, Ma H, Lei Y, Guo L, Sun Z. Predictive value of serum human epididymis protein 4 for heart failure in patients with chronic kidney disease. Am J Transl Res 2023; 15:5664-5673. [PMID: 37854237 PMCID: PMC10579016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 08/28/2023] [Indexed: 10/20/2023]
Abstract
AIM To investigate the predictive value of human epididymis protein 4 (HE4) for heart failure in patients with chronic kidney disease (CKD). METHODS This study retrospectively analyzed the data of 241 patients with CKD admitted to Zhangjiakou First Hospital from January 2019 to January 2021. The subjects were divided into a heart failure (HF) group (n=117) and a non-HF group (n=124) according to whether heart failure occurred. The baseline data and laboratory hematologic indicators (complete set of HE4, blood routine and biochemistry) were collected and analyzed by univariate analysis. Subsequently, the variables that were significant in the correlation analysis were included in a multi-factor logistic regression analysis. RESULTS The HF group exhibited higher serum creatinine, HE4, hemoglobin, total cholesterol, triglycerides (TG), high-density lipoprotein (P<0.05), as well as higher B-type natriuretic peptide (BNP), creatine kinase, and creatine kinase-MB than the non-HF group, with significant differences (P<0.05). Spearman's rank correlation analysis revealed that age, HE4, calcium, TG, BNP and left ventricle ejection fraction were associated with the occurrence of heart failure (P<0.05). Multivariate analysis demonstrated that HE4 was a significant factor that could predict the development of heart failure in CKD patients (P<0.01), and the risk of heart failure was higher when HE4>27.2368 pmol/L. CONCLUSIONS HE4 is an important factor for predicting the occurrence of heart failure in CKD patients. A higher HE4 level predicts greater possibility of heart failure.
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Affiliation(s)
- Cunyuan Dong
- Department of Nuclear Medicine, Zhangjiakou First HospitalZhangjiakou 075000, Hebei, China
| | - Shujuan Feng
- Department of Laboratory, Zhangjiakou First HospitalZhangjiakou 075000, Hebei, China
| | - Haiqian Ma
- Department of Laboratory, Zhangjiakou First HospitalZhangjiakou 075000, Hebei, China
| | - Yan Lei
- Department of Laboratory, Zhangjiakou First HospitalZhangjiakou 075000, Hebei, China
| | - Lianhong Guo
- Department of Nuclear Medicine, Zhangjiakou First HospitalZhangjiakou 075000, Hebei, China
| | - Zhigang Sun
- Department of Nephrology, Zhangjiakou First HospitalZhangjiakou 075000, Hebei, China
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Zoccali C, Mallamaci F, Adamczak M, de Oliveira RB, Massy ZA, Sarafidis P, Agarwal R, Mark PB, Kotanko P, Ferro CJ, Wanner C, Burnier M, Vanholder R, Wiecek A. Cardiovascular complications in chronic kidney disease: a review from the European Renal and Cardiovascular Medicine Working Group of the European Renal Association. Cardiovasc Res 2023; 119:2017-2032. [PMID: 37249051 PMCID: PMC10478756 DOI: 10.1093/cvr/cvad083] [Citation(s) in RCA: 23] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/07/2022] [Revised: 12/29/2022] [Accepted: 01/09/2023] [Indexed: 05/31/2023] Open
Abstract
Chronic kidney disease (CKD) is classified into five stages with kidney failure being the most severe stage (stage G5). CKD conveys a high risk for coronary artery disease, heart failure, arrhythmias, and sudden cardiac death. Cardiovascular complications are the most common causes of death in patients with kidney failure (stage G5) who are maintained on regular dialysis treatment. Because of the high death rate attributable to cardiovascular (CV) disease, most patients with progressive CKD die before reaching kidney failure. Classical risk factors implicated in CV disease are involved in the early stages of CKD. In intermediate and late stages, non-traditional risk factors, including iso-osmotic and non-osmotic sodium retention, volume expansion, anaemia, inflammation, malnutrition, sympathetic overactivity, mineral bone disorders, accumulation of a class of endogenous compounds called 'uremic toxins', and a variety of hormonal disorders are the main factors that accelerate the progression of CV disease in these patients. Arterial disease in CKD patients is characterized by an almost unique propensity to calcification and vascular stiffness. Left ventricular hypertrophy, a major risk factor for heart failure, occurs early in CKD and reaches a prevalence of 70-80% in patients with kidney failure. Recent clinical trials have shown the potential benefits of hypoxia-inducible factor prolyl hydroxylase inhibitors, especially as an oral agent in CKD patients. Likewise, the value of proactively administered intravenous iron for safely treating anaemia in dialysis patients has been shown. Sodium/glucose cotransporter-2 inhibitors are now fully emerged as a class of drugs that substantially reduces the risk for CV complications in patients who are already being treated with adequate doses of inhibitors of the renin-angiotensin system. Concerted efforts are being made by major scientific societies to advance basic and clinical research on CV disease in patients with CKD, a research area that remains insufficiently explored.
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Affiliation(s)
- Carmine Zoccali
- Renal Research Institute, 315 E, 62nd St., New York, NY 10065, USA
- Associazione Ipertensione Nefrologia e Trapianto Renale (IPNET) c/o Nefrologia e CNR, Grande Ospedale Metropolitano, Contrada Camporeale, 83031 Ariano Irpino Avellino, Italy
| | - Francesca Mallamaci
- Nephrology and Transplantation Unit, Grande Ospedale Metropolitano Reggio Cal and CNR-IFC, Via Giuseppe Melacrino 21, 89124 Reggio Calabria, Italy
| | - Marcin Adamczak
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Francuska 20-24 St. 40-027 Katowice, Poland
| | - Rodrigo Bueno de Oliveira
- Department of Internal Medicine (Nephrology), School of Medical Sciences, University of Campinas (Unicamp), Campinas, Brazil
| | - Ziad A Massy
- Ambroise Paré University Hospital, APHP, Boulogne Billancourt/Paris, and INSERM U-1018, Centre de recherche en épidémiologie et santé des populations (CESP), Equipe 5, Paris-Saclay University (PSU) and University of Paris Ouest-Versailles-Saint-Quentin-en-Yvelines (UVSQ), FCRIN INI-CRCT, Villejuif, France
| | - Pantelis Sarafidis
- Department of Nephrology, Hippokration Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Rajiv Agarwal
- Indiana University School of Medicine and Richard L. Roudebush VA Medical Center, 1481 W 10th St, Indianapolis, IN 46202, USA
| | - Patrick B Mark
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Peter Kotanko
- Renal Research Institute, LLC Icahn School of Medicine at Mount Sinai, 315 East 62nd Street, 3rd Floor, New York, NY 10065, USA
| | - Charles J Ferro
- Department of Renal Medicine, University Hospitals Birmingham, Birmingham, UK
| | - Christoph Wanner
- Division of Nephrology, University Hospital of Würzburg, Würzburg, Germany
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Raymond Vanholder
- Nephrology Section, Department of Internal Medicine and Pediatrics, University Hospital, Ghent, Belgium
| | - Andrzej Wiecek
- Department of Nephrology, Transplantation and Internal Medicine, Medical University of Silesia in Katowice, Francuska 20-24 St. 40-027 Katowice, Poland
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Nassif ME, Nguyen D, Spertus JA, Gosch KL, Tang F, Windsor SL, Jones P, Khariton Y, Sauer AJ, Kosiborod MN. Association Between Change in Ambulatory Pulmonary Artery Pressures and Natriuretic Peptides in Patients with Heart Failure: Results From the EMBRACE-HF Trial. J Card Fail 2023; 29:1324-1328. [PMID: 37230315 DOI: 10.1016/j.cardfail.2023.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2022] [Revised: 04/06/2023] [Accepted: 05/07/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Remote monitoring of pulmonary artery (PA) pressures and serial N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurements guide heart failure (HF) treatment, but their association has yet to be described. METHODS AND RESULTS In the Empagliflozin Evaluation by Measuring the Impact on Hemodynamics in Patients with Heart Failure (EMBRACE-HF) trial, patients with HF and a remote PA pressure monitoring device were randomized to empagliflozin vs placebo. PA diastolic pressures (PADP) and NT-proBNP levels were obtained at baseline and 6 and 12 weeks. We used linear mixed models to examine the association between change in PADP and change in NT-proBNP, adjusting for baseline covariates. Of 62 patients, the mean patient age was 66.2 years, and 63% were male. The mean baseline PADP was 21.8 ± 6.4 mm Hg, and the mean NT-proBNP was 1844.6 ± 2767.7 pg/mL. The mean change between baseline and averaged 6- and 12-week PADP was -0.4 ± 3.1 mm Hg, and the mean change between baseline and averaged 6- and 12-week NT-proBNP was -81.5 ± 878.6 pg/mL. In adjusted analyses, every 2-mm Hg decrease in PADP was associated with an NT-proBNP reduction of 108.9 pg/mL (95% confidence interval -4.3 to 222.0, P = .06). CONCLUSIONS We observed that short-term decreases in ambulatory PADP seem to be associated with decreases in NT-proBNP. This finding may provide additional clinical context when tailoring treatment for patients with HF.
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Affiliation(s)
- Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Dan Nguyen
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Kensey L Gosch
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Fengming Tang
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | | | - Philip Jones
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | | | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri; University of Missouri-Kansas City, Kansas City, Missouri.
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Ezekowitz JA, McMullan CJ, Westerhout CM, Piña IL, Lopez-Sendon J, Anstrom KJ, Hernandez AF, Lam CSP, O'Connor CM, Pieske B, Ponikowski P, Roessig L, Voors AA, Koglin J, Armstrong PW, Butler J. Background Medical Therapy and Clinical Outcomes From the VICTORIA Trial. Circ Heart Fail 2023; 16:e010599. [PMID: 37417824 DOI: 10.1161/circheartfailure.123.010599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/18/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND We examined whether the primary composite outcome (cardiovascular death or heart failure hospitalization) was related to differences in background use and dosing of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction enrolled in VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction), a randomized trial of vericiguat versus placebo. METHODS We evaluated the adherence to guideline use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists. We assessed basic adherence; indication-corrected adherence accounting for guideline indications and contraindications; and dose-corrected adherence (indication-corrected adherence+≥50% of drug dose target). Associations between study treatment and the primary composite outcome according to the adherence to guidelines were assessed using multivariable adjustment; adjusted hazard ratios with 95% CIs and Pinteraction are reported. RESULTS Of 5050 patients, 5040 (99.8%) had medication data at baseline. For angiotensin-converting enzyme inhibitor, angiotensin-receptor blockers, and angiotensin receptor-neprilysin inhibitors, basic adherence to guidelines was 87.4%, indication-corrected was 95.7%, and dose-corrected was 50.9%. For beta-blockers, basic adherence was 93.1%, indication-corrected was 96.2%, and dose-corrected was 45.4%. For mineralocorticoid receptor antagonists, basic adherence was 70.3%, indication-corrected was 87.1%, and dose-corrected was 82.2%. For triple therapy (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, or angiotensin receptor-neprilysin inhibitors+beta-blocker+mineralocorticoid receptor antagonist), basic adherence was 59.7%, indication-corrected was 83.3%, and dose-corrected was 25.5%. Using basic or dose-corrected adherence, the treatment effect of vericiguat was consistent across adherence to guidelines groups, with or without multivariable adjustment with no treatment heterogeneity. CONCLUSIONS Patients in VICTORIA were well treated with heart failure with reduced ejection fraction medications. The efficacy of vericiguat was consistent across background therapy with very high adherence to guidelines accounting for patient-level indications, contraindications, and tolerance. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02861534.
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Affiliation(s)
- Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (J.A.E., C.M.W., P.W.A.)
| | | | - Cynthia M Westerhout
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (J.A.E., C.M.W., P.W.A.)
| | - Ileana L Piña
- Central Michigan University, Mount Pleasant (I.L.P.)
| | - Jose Lopez-Sendon
- IdiPaz Research Institute, Hospital Universitario La Paz, Universidad Autonoma de Madrid, Spain (J.L.-S.)
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University, Durham, NC (K.J.A., A.F.H.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, NC (K.J.A., A.F.H.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | | | - Burkert Pieske
- Charité University Medicine German Heart Center, Berlin, Germany (B.P.)
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Poland (P.P.)
| | | | - Adriaan A Voors
- University Medical Center Groningen, University of Groningen, the Netherlands (A.A.V.)
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (J.A.E., C.M.W., P.W.A.)
| | - Javed Butler
- Baylor University Medical Center, Dallas, TX (J.B.)
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50
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Bayes-Genis A, Pascual-Figal D. Making STRONGer the transition phase: personalized GDMT through NT-proBNP monitoring. Eur Heart J 2023; 44:2963-2965. [PMID: 37220888 DOI: 10.1093/eurheartj/ehad356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 05/25/2023] Open
Affiliation(s)
- Antoni Bayes-Genis
- Heart Institute, University Hospital Germans Trias i Pujol, Crta. Canyet s/n, 08916 Badalona, Spain
- Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Domingo Pascual-Figal
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, University of Murcia, Murcia, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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