GDMT for heart failure and the clinician's conundrum

ARNI or ARB Treats Residual Left Ventricular Remodelling after Surgery for Valvular Regurgitation: ReReRe study protocol

AIMS

Patients with persistent or de novo left ventricular (LV) dilation and/or reduced ejection fraction (EF) after correction for primary aortic (AR) or mitral (MR) regurgitation (i.e. residual LV remodelling) have not been well studied with regard to guideline-directed medical therapy after successful aetiology-reversing surgery. We aim to (i) compare the effectiveness of sacubitril/valsartan vs. valsartan in promoting LV reverse remodelling and (ii) explore the safety of medication withdrawal after LV recovery.

METHODS AND RESULTS

The ReReRe study is a multicentre, randomized, open-label, parallel trial that consists of two consecutive parts. A total of 371 patients with an LV end-diastolic diameter (LVEDD) > 60 mm or LVEF < 50%, assessed by transthoracic echocardiography (TTE) 7-14 days after valve surgery for significant AR or primary MR will be enrolled. The 1st randomization into the sacubitril/valsartan or valsartan groups and structured follow-up (1, 3, 6, 9, and 12 months after randomization) will be conducted to observe the primary objective as the rate of complete recovery of LV remodelling (i.e. LVEDD < 55 mm and LVEF ≥ 60% by TTE at two consecutive visits). Those who have complete recovery of LV remodelling will be enrolled in Study Part 2; consequently, they will receive the 2nd randomization into the medication withdrawal or maintenance group and 6-monthly visits for the observation of the primary objective as the rate of LV remodelling relapse (LVEDD > 60 mm or LVEF < 50%). The secondary objectives include the rate of composite clinical outcomes and the degree of change in 6-min walk distance and Kansas City Cardiomyopathy Questionnaire scores.

CONCLUSIONS

The ReReRe study will provide new evidence for the treatment of patients with residual LV remodelling after curable unloaded surgery, as well as the duration of treatment. The study results will fill the gap in identifying an appropriate medical therapy regimen for this group of patients and perhaps for those with reversible aetiologies of heart failure.

Relation of Cardiorenal Syndrome to Mitral and Tricuspid Regurgitation in Acute Decompensated Heart Failure

This study aimed to investigate the role of secondary mitral regurgitation (MR) and tricuspid regurgitation (TR) in the pathogenesis of cardiorenal syndrome (CRS). Worsening renal function in patients with acute decompensated heart failure receiving diuretic therapy is defined as CRS and is related to central venous congestion. The role of secondary MR and TR is not well studied. We retrospectively reviewed the electronic medical records of 80 consecutive patients hospitalized with acute decompensated heart failure. Patients were divided into 2 groups: group 1 (CRS) if creatinine increased >0.3 mg/dl from baseline and group 2 (no CRS) if creatinine remained stable or improved with diuretic therapy. Admission creatinine was higher in group 1 compared with group 2 (1.5 vs 1.2 mg/dl, p = 0.033). The magnitude of MR and TR were higher by both visual assessment (moderate to severe [3+] or severe [4+] MR in 68% of patients in group 1 vs 3% in group 2, p <0.0001; 3+ or 4+ TR in 48% of patients in group 1 vs 10% in group 2, p = 0.0004) and by vena contracta (MR 0.6 ± 0.2 cm in group 1 vs 0.4 ± 0.1 cm in group 2, p <0.0001; TR 0.5 ± 0.2 cm in group 1 vs 0.4 ± 0.2 cm in group 2, p = 0.0013). By using receiver operating characteristic curves, MR and TR were the most sensitive parameters in predicting CRS. In conclusion, renal function on admission and moderate to severe or severe MR and TR are highly predictive of the risk of developing CRS.

Out with the Old and In with the New: Primary Care Management of Heart Failure with Preserved Ejection Fraction

Primary care plays an integral role in the management of complex, chronic disease states such as heart failure. However, there is a disconnect between the characteristics of those recruited into clinical trials and those managed in the real world, which means the contribution and consideration of primary care in current guidelines is suboptimal. In this article, the authors explore key issues in the diagnosis and management of heart failure that need to be addressed from a primary care perspective. This article focuses on the issue of heart failure with preserved ejection fraction and the integration of new clinical epidemiology and trial evidence into clinical practice. In response, the authors advocate for dedicated guidelines for the primary care management of heart failure, the development of strategies to facilitate communications between health professionals in acute and community care and a renewed focus on researching optimal models of heart failure care in the community.

Contemporary economic burden in a real-world heart failure population with Commercial and Medicare supplemental plans

BACKGROUND

Limited real-world data exist on healthcare resource utilization (HCRU) and associated costs of patients with heart failure (HF) with reduced ejection fraction (HFrEF) and preserved EF (HFpEF), including urgent HF visits, which are assumed to be less burdensome than HF hospitalizations (hHFs) HYPOTHESIS: This study aimed to quantify the economic burden of HFrEF and HFpEF, via a retrospective, longitudinal cohort study, using IBM® linked claims/electronic health records (Commercial and Medicare Supplemental data only).

METHODS

Adult patients, indexed on HF diagnosis (ICD-10-CM: I50.x) from July 2012 through June 2018, with 6-month minimum baseline period and varying follow-up, were classified as HFrEF (I50.2x) or HFpEF (I50.3x) according to last-observed EF-specific diagnosis. HCRU/costs were assessed during follow-up.

RESULTS

About 109 721 HF patients (22% HFrEF, 31% HFpEF, 47% unclassified EF; median 18 months' follow-up) were identified. There were 3.2 all-cause outpatient visits per patient-month (HFrEF, 3.3; HFpEF, 3.6); 69% of patients required inpatient stays (HFrEF, 80%; HFpEF, 78%). Overall, 11% of patients experienced hHFs (HFrEF, 23%; HFpEF, 16%), 9% experienced urgent HF visits (HFrEF, 15%; HFpEF, 12%); 26% were hospitalized less than 30 days after first urgent HF visit versus 11% after first hHF. Mean monthly total direct healthcare cost per patient was $9290 (HFrEF, $11 053; HFpEF, $7482).

CONCLUSIONS

HF-related HCRU is substantial among contemporary real-world HF patients in US Commercial or Medicare supplemental health plans. Patients managed in urgent HF settings were over twice as likely to be hospitalized within 30 days versus those initially hospitalized, suggesting urgent HF visits are important clinical events and quality improvement targets.

GDMT for heart failure and the clinician's conundrum

Therapeutic advances in management of CHF have decreased mortality and have impacted progression in patients with mild to moderate heart failure. Aggressive campaigns by cardiology societies aimed at increasing implementation of these measures in routine practices have almost generalized the treatment of heart failure irrespective of individual variations of clinical status of patients and stages of heart failure. This explains why morbidity compression and quality of life improvement have not been realized fully particularly in patients with advanced disease. To examine whether GDMT for CHF is backed by unambiguous evidence of clinical efficacy for its global implementation in every patient at all stages of the syndrome. ACC/AHA, ESC Guidelines for CHF, and their updates were reviewed. Clinical trial cited in the guideline documents and other pertaining published literatures were analyzed.

Findings

Many of the recommended GDMT for CHF lack unequivocal evidence of clinical efficacy in patients with diverge etiology of heart failure and concomitant comorbid conditions Some of the recommendations which are useful in early stages, lack evidence of efficacy in more advanced stages of heart failure. Application of results of research trials in patients beyond their inclusion and exclusion criteria, appears mere extrapolation, Clinicians are faced with the conundrum of implementing the recommendations without indubitable evidence of their efficacy in every patient of their practice.

Conclusion

A reappraisal of Guidelines is needed to address outstanding questions pertaining to the efficacy of recommendations and plug the knowledge gaps without assumption and extrapolation of results of RCTs beyond their inclusion and exclusion criteria.