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Zhang X, Wang Z, Zhang L, Zhao X, Han Y. Comparative Effectiveness and Safety of Intermittent, Repeated, or Continuous Use of Levosimendan, Milrinone, or Dobutamine in Patients With Advanced Heart Failure: A Network and Single-Arm Meta-analysis. J Cardiovasc Pharmacol 2024; 84:92-100. [PMID: 38547524 DOI: 10.1097/fjc.0000000000001561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Accepted: 02/19/2024] [Indexed: 07/07/2024]
Abstract
ABSTRACT The aim of this study was to synthesize the available evidence regarding differences in the long-term safety and efficacy of intermittent, repeated, or continuous palliative inotropic therapy among patients with advanced heart failure. We systematically searched the PubMed, Embase, and Cochrane Library electronic databases, with a cutoff date of November 23, 2023, for studies reporting outcomes in adult patients with advanced heart failure treated with intermittent, repeated, or continuous levosimendan, milrinone, or dobutamine. Forty-one studies (18 randomized controlled trials and 23 cohort studies) comprising 5137 patients met the inclusion criteria. The results of the network meta-analysis of randomized controlled trials showed that levosimendan had significant advantages over milrinone or dobutamine in reducing mortality and improving left ventricular ejection fraction. A single-arm meta-analysis also indicated that levosimendan had the lowest mortality and significantly improved B-type brain natriuretic peptide and left ventricular ejection fraction. Regarding safety, hypotension events were observed more frequently in the levosimendan and milrinone groups. However, the current evidence is limited by the heterogeneity and relatively small sample size of the studies.
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Affiliation(s)
- Xue Zhang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People's Republic of China ; and
| | - Zhongsu Wang
- Department of Cardiology, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Medicine and Health Key Laboratory of Cardiac Electrophysiology and Arrhythmia, Jinan, Shandong Province, People's Republic of China
| | - Le Zhang
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People's Republic of China ; and
| | - Xia Zhao
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People's Republic of China ; and
| | - Yi Han
- Department of Clinical Pharmacy, The First Affiliated Hospital of Shandong First Medical University & Shandong Provincial Qianfoshan Hospital, Shandong Engineering and Technology Research Center for Pediatric Drug Development, Shandong Medicine and Health Key Laboratory of Clinical Pharmacy, Jinan, Shandong Province, People's Republic of China ; and
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2
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Ahmad T, Manohar SA, Stencel JD, Le Jemtel TH. Dobutamine in the Management of Advanced Heart Failure. J Clin Med 2024; 13:3782. [PMID: 38999346 PMCID: PMC11242841 DOI: 10.3390/jcm13133782] [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: 05/14/2024] [Revised: 06/16/2024] [Accepted: 06/20/2024] [Indexed: 07/14/2024] Open
Abstract
Background: The potential harm and clinical benefits of inotropic therapy in patients with decompensated heart failure with reduced ejection fraction or advanced heart failure were debated for three decades. Nonetheless, confronted with a dismal quality of life in the last months to years of life, continuous home inotropic therapy has recently gained traction for palliative therapy in patients who are not candidates for left ventricular mechanical circulatory support or heart transplantation. Methods: As continuous inotropic therapy is only considered for patients who experience symptomatic relief and display objective evidence of improvement, clinical equipoise is no longer present, and randomized controlled trials are hard to conduct. Results: We first outline the transient use of inotropic therapy in patients with decompensated heart failure with reduced ejection fraction and emphasize the hemodynamic requisite for inotropic therapy, which is a demonstration of a low cardiac output through a low mixed venous oxygen saturation. Lastly, we review the current experience with the use of home inotropic therapy in patients who are not candidates or are awaiting mechanical circulatory support or heart transplantation. Conclusions: Evidence-based clinical data are needed to guide inotropic therapy for refractory decompensated heart failure with reduced ejection fraction in patients who are ineligible or awaiting mechanical circulatory support or heart transplantation.
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Affiliation(s)
- Tanjeev Ahmad
- John W. Deming Department of Medicine Tulane University, 131 S., New Orleans, LA 70112, USA
| | - Shamitha A Manohar
- John W. Deming Department of Medicine Tulane University, 131 S., New Orleans, LA 70112, USA
| | - Jason D Stencel
- John W. Deming Department of Medicine Tulane University, 131 S., New Orleans, LA 70112, USA
| | - Thierry H Le Jemtel
- John W. Deming Department of Medicine Tulane University, 131 S., New Orleans, LA 70112, USA
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Gentile P, Masciocco G, Palazzini M, Tedeschi A, Ruzzenenti G, Conti N, D'Angelo L, Foti G, Perna E, Verde A, Ammirati E, Sinagra G, Oliva F, Garascia A. Intravenous continuous home inotropic therapy in advanced heart failure: Insights from an observational retrospective study. Eur J Intern Med 2023; 116:65-71. [PMID: 37393183 DOI: 10.1016/j.ejim.2023.06.010] [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: 02/28/2023] [Revised: 05/23/2023] [Accepted: 06/12/2023] [Indexed: 07/03/2023]
Abstract
INTRODUCTION Intravenous inotropic support represents an important therapeutic option in advanced heart failure (HF) as bridge to heart transplantation, bridge to mechanical circulatory support, bridge to candidacy or as palliative therapy. Nevertheless, evidence regarding risks and benefits of its use is lacking. METHODS we conducted a retrospective single center study, analysing the effect of inotropic therapies in an outpatient cohort, evaluating the burden of hospitalizations, the improvement in quality of life, the incidence of adverse events and the evolution of organ damage. RESULTS twenty-seven patients with advanced HF were treated in our Day Hospital service from 2014 to 2021. Nine patients were treated as bridge to heart transplant while eighteen as palliation. Comparing data regarding the year before and after the beginning of inotropic infusion, we observed a reduction of hospitalization (46 vs 25, p<0,001), an improvement of natriuretic peptides, renal and hepatic function since the first month (p<0,001) and a better quality of life in 53% of the population treated. Two hospitalizations for arrhythmias and seven hospitalizations for catheter-related complications were registered. CONCLUSIONS in a selected population of advanced HF patients, continuous home inotropic infusion were able to reduce hospitalizations, improving end organ damage and quality of life. We provide a practical guidance on starting and maintaining home inotropic infusion while monitoring a challenging group of patients.
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Affiliation(s)
- Piero Gentile
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Gabriella Masciocco
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy.
| | - Matteo Palazzini
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Andrea Tedeschi
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Giacomo Ruzzenenti
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy; Department of Health Sciences, University of Milano-Bicocca, Monza, Italy
| | - Nicolina Conti
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Luciana D'Angelo
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Grazia Foti
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Enrico Perna
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Alessandro Verde
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Enrico Ammirati
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Gianfranco Sinagra
- Center for Diagnosis and Treatment of Cardiomyopathies, Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano-Isontina (ASUGI) and University of Trieste, Trieste, Italy
| | - Fabrizio Oliva
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
| | - Andrea Garascia
- De Gasperis Cardio Center and Transplant Center, Niguarda Hospital, Milan, Italy
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4
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Abdi A, Doulatyari PK, Mahmodi M, Torabi Y. Relationship of spiritual wellbeing with life expectancy and quality of life for patients living with heart failure. Int J Palliat Nurs 2022; 28:262-269. [PMID: 35727830 DOI: 10.12968/ijpn.2022.28.6.262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Aim: Spirituality is a crucial dimension in human health. However, it is often overlooked in patients with heart failure (HF) in Iran. Thus, the purpose of this study was to determine the relationship between spiritual wellbeing, life expectancy and quality-of-life (QOL) in patients with HF. Methods: This cross-sectional study was performed with 150 HF patients, who were enrolled through convenience sampling. Data were collected using a questionnaire comprising four parts: the Minnesota Living with Heart Failure Questionnaire, Schneider's life expectancy instrument, Ellison's and Paulotzin's (1982) Spiritual Well-Being Scale, and a demographic checklist. SPSS software was used for data analysis. Results: In this study, mean and standard deviation of QOL, life expectancy and spiritual wellbeing were 41.82±19.17, 30.20±4.58 and 87.80±5.28 respectively. There was a significant relationship between spiritual wellbeing and quality of life (r=-0.633, P<0.001) and also life expectancy (r=0.544, P<0.001). Quality of life and life expectancy were significantly higher in men than in women. Linear regression tests showed that the existential and religious dimensions of spirituality could influence 44.9% of the QOL variance (F=54.54, P<0.001) and increased values of existential spirituality would improve QOL by an average of 3.45 units. Improving life expectancy also raised QOL by 14.0% (F=21.26, P<0.001). This study also demonstrated that life expectancy is impacted by spiritual health, with a variance of 34.2%, in which the role of existential-spiritual health is of particular significance (t=7.10, P<0.001). Conclusion: The results revealed that spiritual wellbeing, especially the existential type, enhances life expectancy and quality-of-life among HF patients. Therefore, it is recommended that healthcare professionals design a comprehensive and supportive care model for the promotion of spiritual wellbeing in HF patients.
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Affiliation(s)
- Alireza Abdi
- Associate Professor of Nursing, Kermanshah University of Medical Sciences, Iran
| | | | - Milad Mahmodi
- Nursing Student, Kermanshah University of Medical Sciences, Iran
| | - Yousef Torabi
- Nursing Student, Kermanshah University of Medical Sciences, Iran
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5
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Tomasoni D, Vishram-Nielsen JKK, Pagnesi M, Adamo M, Lombardi CM, Gustafsson F, Metra M. Advanced heart failure: guideline-directed medical therapy, diuretics, inotropes, and palliative care. ESC Heart Fail 2022; 9:1507-1523. [PMID: 35352499 PMCID: PMC9065830 DOI: 10.1002/ehf2.13859] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 01/16/2022] [Accepted: 02/09/2022] [Indexed: 01/10/2023] Open
Abstract
Heart failure (HF) is a major cause of mortality, hospitalizations, and reduced quality of life and a major burden for the healthcare system. The number of patients that progress to an advanced stage of HF is growing. Only a limited proportion of these patients can undergo heart transplantation or mechanical circulatory support. The purpose of this review is to summarize medical management of patients with advanced HF. First, evidence-based oral treatment must be implemented although it is often not tolerated. New therapeutic options may soon become possible for these patients. The second goal is to lessen the symptomatic burden through both decongestion and haemodynamic improvement. Some new treatments acting on cardiac function may fulfil both these needs. Inotropic agents acting through an increase in intracellular calcium have often increased risk of death. However, in the recent Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) trial, omecamtiv mecarbil was safe and effective in the reduction of the primary outcome of cardiovascular death or HF event compared with placebo (hazard ratio, 0.92; 95% confidence interval, 0.86-0.99; P = 0.03) and its effects were larger in those patients with more severe left ventricular dysfunction. Patients with severe HF who received omecamtiv mecarbil experienced a significant treatment benefit, whereas patients without severe HF did not (P = 0.005 for interaction). Lastly, clinicians should take care of the end of life with an appropriate multidisciplinary approach. Medical treatment of advanced HF therefore remains a major challenge and a wide open area for further research.
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Affiliation(s)
- Daniela Tomasoni
- Cardiology, Cardio-thoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Matteo Pagnesi
- Cardiology, Cardio-thoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology, Cardio-thoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Carlo Mario Lombardi
- Cardiology, Cardio-thoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Marco Metra
- Cardiology, Cardio-thoracic Department, Civil Hospitals and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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6
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Liu E, Lampert BC. Heart Failure in Older Adults: Medical Management and Advanced Therapies. Geriatrics (Basel) 2022; 7:geriatrics7020036. [PMID: 35447839 PMCID: PMC9029870 DOI: 10.3390/geriatrics7020036] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/10/2022] [Accepted: 03/15/2022] [Indexed: 12/04/2022] Open
Abstract
As the population ages and the prevalence of heart failure increases, cardiologists and geriatricians can expect to see more elderly patients with heart failure in their everyday practice. With the advancement of medical care and technology, the options for heart failure management have expanded, though current guidelines are based on studies of younger populations, and the evidence in older populations is not as robust. Pharmacologic therapy remains the cornerstone of heart failure management and has improved long-term mortality. Prevention of sudden cardiac death with implantable devices is being more readily utilized in older patients. Advanced therapies have provided more options for end-stage heart failure, though its use is still limited in older patients. In this review, we discuss the current guidelines for medical management of heart failure in older adults, as well as the expanding literature on advanced therapies, such as heart transplantation in older patients with end-stage heart failure. We also discuss the importance of a multidisciplinary care approach including consideration of non-medical co-morbidities such as frailty and cognitive decline.
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7
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McPherson A, Nguyen C, Groninger H, Anderson KM, Henderson P, Rao A. Continuous Intravenous Inotropic Support for Advanced Heart Failure: Palliative Considerations. J Pain Palliat Care Pharmacother 2022; 36:59-67. [PMID: 35319327 DOI: 10.1080/15360288.2022.2050456] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
The global prevalence of heart failure (HF) is increasing. Advancements in guideline-directed medical and device therapy have resulted in improved survival. Thus, there are more patients living - and living longer - with advanced HF. Only a small proportion of these patients are deemed appropriate for advanced surgical intervention (mechanical circulatory support or heart transplantation), and even if offered, some may decline such interventions if not aligned with their overall goals and values. Therefore, a growing number of patients with advanced HF receive chronic intravenous inotropic support (CIIS) for palliation of symptoms. Despite increased use, clinical evidence supporting use of palliative inotropes remains limited. However, available data suggest improvements in functional class, health-related quality of life (HRQoL) indicators, symptom burden, hemodynamic parameters, and possibly rehospitalization. While initial concerns regarding increased mortality have been assuaged in the modern era of guideline-directed medical therapy, palliative inotropes are certainly not without burden. Risks of infection and medication-related adverse effects, need for routine laboratory monitoring, frequent dressing changes, and presence of a reliable caregiver must be carefully considered prior to initiation. This review addresses pharmacology, guideline recommendations, benefits and burdens, considerations related to hospice and end-of-life care, and future directions of CIIS in advanced HF care.
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8
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Abstract
The introduction of multiple new pharmacological agents over the past three decades in the field of heart failure with reduced ejection fraction (HFrEF) has led to reduced rates of mortality and hospitalizations, and consequently the prevalence of HFrEF has increased, and up to 10% of patients progress to more advanced stages, characterized by high rates of mortality, hospitalizations, and poor quality of life. Advanced HFrEF patients often show persistent or progressive signs of severe HF symptoms corresponding to New York Heart Association class III or IV despite being on optimal medical, surgical, and device therapies. However, a subpopulation of patients with advanced HF, those with the most advanced stages of disease, were often insufficiently represented in the major trials demonstrating efficacy and tolerability of the drugs used in HFrEF due to exclusion criteria such as low BP and kidney dysfunction. Consequently, the results of many landmark trials cannot necessarily be transferred to patients with the most advanced stages of HFrEF. Thus, the efficacy and tolerability of guideline-directed medical therapies in patients with the most advanced stages of HFrEF often remain unsettled, and this knowledge is of crucial importance in the planning and timing of consideration for referral for advanced therapies. This review discusses the evidence regarding the use of contemporary drugs in the advanced HFrEF population, covering components such as guideline HFrEF drugs, diuretics, inotropes, and the use of HFrEF drugs in LVAD recipients, and provides suggestions on how to manage guideline-directed therapy in this patient group.
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9
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van Ramshorst J, Duffels M, de Boer SPM, Bos-Schaap A, Drexhage O, Walburg S, de Beij J, van der Stoop D, Umans VAWM. Connected care for endocarditis and heart failure patients: a hospital-at-home programme. Neth Heart J 2021; 30:319-327. [PMID: 34524621 PMCID: PMC9123121 DOI: 10.1007/s12471-021-01614-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 11/26/2022] Open
Abstract
Background Healthcare expenditure in the Netherlands is increasing at such a rate that currently 1 in 7 employees are working in healthcare/curative care. Future increases in healthcare spending will be restricted, given that 10% of the country’s gross domestic product is spent on healthcare and the fact that there is a workforce shortage. Dutch healthcare consists of a curative sector (mostly hospitals) and nursing care at home. The two entities have separate national budgets (€25 bn + €20 bn respectively) Aim In a proof of concept, we explored a new hospital-at-home model combining hospital cure and nursing home care budgets. This study tests the feasibility of (1) providing hospital care at home, (2) combining financial budgets, (3) increasing workforces by combining teams and (4) improving perspectives and increasing patient and staff satisfaction. Results We tested the feasibility of combining the budgets of a teaching hospital and home care group for cardiology. The budgets were sufficient to hire three nurse practitioners who were trained to work together with 12 home care cardiovascular nurses to provide care in a hospital-at-home setting, including intravenous treatment. Subsequently, the hospital-at-home programme for endocarditis and heart failure treatment was developed and a virtual ward was built within the e‑patient record. Conclusion The current model demonstrates a proof of concept for a hospital-at-home programme providing hospital-level curative care at home by merging hospital and home care nursing staff and budgets. From the clinical perspective, ambulatory intravenous antibiotic and diuretic treatment at home was effective in safely achieving a reduced length of stay of 847 days in endocarditis patients and 201 days in heart-failure-at-home patients. We call for further studies to facilitate combined home care and hospital cure budgets in cardiology to confirm this concept.
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Affiliation(s)
- J van Ramshorst
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - M Duffels
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - S P M de Boer
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - A Bos-Schaap
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - O Drexhage
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | | | | | - D van der Stoop
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands
| | - V A W M Umans
- Department of Cardiology, Noordwest Ziekenhuisgroep, Alkmaar, The Netherlands.
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10
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Nielsen JC, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care. Europace 2021; 23:1324-1342. [PMID: 34037728 DOI: 10.1093/europace/euaa411] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium
- University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
- Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands
- Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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11
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Outcome Predictors and Safety of Home Dobutamine Intravenous Infusion in End Stage Heart Failure Patients. J Clin Med 2021; 10:jcm10122571. [PMID: 34200733 PMCID: PMC8229659 DOI: 10.3390/jcm10122571] [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: 04/12/2021] [Revised: 05/28/2021] [Accepted: 06/07/2021] [Indexed: 11/23/2022] Open
Abstract
Patients in end-stage heart failure can experiment cardiogenic shock and may not be weanable from dobutamine. The fate of these patients is a challenge for doctors, patients, family, and the institution. Dobutamine use at home can be a solution. The aim of the present study was to assess the outcome, biological predictors, and safety of dobutamine use at home in dobutamine-dependent patients. All consecutive dobutamine-dependent patients discharged with continuous home intravenous dobutamine, from a single tertiary center between February 2014 and November 2019, were retrospectively analyzed. A total of 19 patients (age 65 ± 10 years) were followed for one year. At one-year, the survival rate was 32%, (6/19). Five (26%) patients had an adverse event related to the intravenous catheter. In a multivariate logistic regression analysis, the combination of a glomerular filtration rate >60 mL/min and a brain natriuretic peptide level <1000 ng/L, were highly predictive of one-year survival (HR = 10.87, IC95% (5.78–36.44), p < 0.001). Management of dobutamine-unweanable patients after cardiogenic shock may involve dobutamine at home to permit a home return. This strategy allows a significant survival and few readmissions, and, if eligible, access to surgical strategies, such as heart transplantation. Simple biological markers at discharge can identify severe patients to refer to palliative care and good responders.
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Cosedis Nielsen J, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology. Eur J Heart Fail 2021; 22:2349-2369. [PMID: 33136300 DOI: 10.1002/ejhf.2046] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Affiliation(s)
- Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Angelo Auricchio
- Division of Cardiology, Cardiocentro Ticino, Lugano, Switzerland
| | - Pieter Martens
- Ziekenhuis Oost Limburg, Genk, Belgium.,University Hasselt, Hasselt, Belgium
| | - Klaus Witte
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK
| | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Victoria Delgado
- Department of Cardiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - Cecilia Linde
- Heart and Vascular Theme, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden
| | - Kevin Vernooy
- Department of Cardiology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands.,Department of Cardiology, Radboud University Medical Center (Radboudumc), Nijmegen, The Netherlands
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Carsten W Israel
- Department of Medicine - Cardiology, Diabetology and Nephrology, Bethel-Clinic, Bielefeld, Germany
| | - Lars H Lund
- Department of Medicine Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Erwan Donal
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena, Italy
| | - Tiny Jaarsma
- Julius Center, University Medical Center Utrecht, Utrecht, The Netherlands.,Department of Health, Medicine and Caring Science, Linköping University, Linköping, Sweden
| | | | - Vassil Traykov
- Department of Cardiology, Acibadem City Clinic Tokuda Hospital, Sofia, Bulgaria
| | - Zaheer Yousef
- Department of Cardiology, University Hospital of Wales & Cardiff University, Cardiff, UK
| | - Zbigniew Kalarus
- Department of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | - Jan Steffel
- UniversitätsSpital Zürich, Zürich, Switzerland
| | - Panos Vardas
- Heart Sector, Hygeia Hospitals Group, Athens, Greece
| | | | - Petar Seferovic
- Faculty of Medicine, Serbian Academy of Science and Arts, Belgrade University, Belgrade, Serbia
| | - Thor Edvardsen
- Department of Cardiology, Oslo University Hospital, Rikshospitalet, and University of Oslo, Oslo, Norway
| | - Hein Heidbuchel
- Antwerp University and Antwerp University Hospital, Antwerp, Belgium
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | - Christophe Leclercq
- Cardiologie, CHU Rennes - LTSI Inserm UMR 1099, Université Rennes-1, Rennes, France
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Martens P, Verluyten L, Van de Broek H, Somers F, Dauw J, Dupont M, Mullens W. Determinants of maximal dose titration of sacubitril/valsartan in clinical practice. Acta Cardiol 2021; 76:20-29. [PMID: 31697901 DOI: 10.1080/00015385.2019.1686226] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Little information is available about the tolerability of uptitration to the maximal dose of sacubitril/valsartan and the predictors and clinical correlates of achieving such a dose. METHODS All consecutive heart failure patients with reduced ejection fraction (HFrEF) who received sacubitril/valsartan for a class-IB indication in a tertiary heart failure clinic were retrospectively analysed. Predictors of maximal uptitration including associated changes in clinical parameters were assessed in patients with at least 1 follow-up. RESULTS A total of 401 HFrEF-patients received sacubitril/valsartan. Uptitration was possible in 41% and up to 32% of patients tolerated the maximal dose of sacubitril/valsartan. Younger age (HR = 0.862; CI = 0.751-0.989), higher systolic-blood-pressure (HR = 1.077; CI = 1.014-1.137), lower serum creatinine (HR = 0.064; CI = 0.005-0.822), and higher previous dose of renin-angiotensin-system-inhibitors (RASi [HR = 1.065; CI = 1.016-1.115]) independently predicted a higher odds of tolerating a maximal dose of sacubitril/valsartan. Patients who were seen more frequently in a structured heart failure clinic were also more likely to receive a maximal dose (p = .038). Patient assigned to the maximal dose, were more often able to reduce their loop diuretic dose (p = .001) and more often had an increase in serum creatinine (p = .011), without a higher risk for hyperkalemia (p = .524). An improvement in New York Heart Association class and the rate of heart failure hospitalisations was observed in all patients, independent of the sacubitril/valsartan dose. CONCLUSION Uptitration to the maximal dose of sacubitril/valsartan is possible in up to 32% of real-world HFrEF-patients in our cohort, which relates to both patient characteristics' as well as heart failure care-related factors.
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Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Lina Verluyten
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | | | - Frauke Somers
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Jeroen Dauw
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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Sierpiński R, Sokolska JM, Suchocki T, Koń B, Urbański F, Kruk M, Sokolski M, Ponikowski P, Jankowska EA. 10 year trends in hospitalization rates due to heart failure and related in-hospital mortality in Poland (2010-2019). ESC Heart Fail 2020; 7:3365-3373. [PMID: 33089965 PMCID: PMC7754958 DOI: 10.1002/ehf2.13060] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 09/16/2020] [Accepted: 09/29/2020] [Indexed: 01/14/2023] Open
Abstract
AIMS Heart failure (HF) remains a major public health challenge worldwide. Contemporary epidemiological data on HF hospitalization rates and related in-hospital mortality are scarce also in Poland. The aim of the study was to determine the trends in hospitalization rates due to HF and related in-hospital mortality in Poland in the recent decade. METHODS AND RESULTS Data on HF hospitalizations and in-hospital mortality in patients aged >17 years in Poland between 2010 and 2019 were obtained from the central database of the Polish National Health Fund. Hospitalizations with either primary or secondary diagnosis of HF were identified using the 10th revision of the International Statistical Classification of Diseases and Related Health Problems codes (I50, I42, J81 with extensions, and R57.0). There were 4 259 698 HF hospitalizations and 608 577 in-hospital deaths (14% in-hospital mortality) reported during 2010-2019 in Poland. During this period, there was a steady increase in the number of HF hospitalizations per 1000 inhabitants in subsequent years, being more pronounced in men than in women (in 2019: 16 and 13 HF hospitalizations per 1000 inhabitants in men and women, respectively). The relative risk of HF hospitalization was higher in men than in women, and this gender-related difference steadily increased from 9% in 2010 to 25% in 2019. During 2010-2019, there was an increase in the number of HF hospitalizations per 1000 inhabitants in subsequent age groups, with a trend being more pronounced in men than in women (129 and 99 HF hospitalizations per 1000 inhabitants in men and women aged ≥80 years, respectively). During this period, there was a slight increase in in-hospital mortality during HF hospitalization in subsequent years, being more pronounced in women than in men (in 2019: 16% and 14% of in-hospital mortality in women and men, respectively). The relative risk of in-hospital mortality during HF hospitalization was higher in women than in men, and this gender-related difference steadily increased from 8% in 2010 to 18% in 2019. During this period, in-hospital mortality during HF hospitalization was ~12% for women and men aged 18-29 years, whereas the highest values of in-hospital mortality reached ~19% for patients aged ≥80 years. CONCLUSIONS We have observed steady growing trends in HF hospitalization rates and related in-hospital mortality in Poland over the last decade. Both age and gender have differentiated the reported epidemiological patterns.
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Affiliation(s)
- Radosław Sierpiński
- Medical Research AgencyWarsawPoland
- University of Cardinal Wyszynski in WarsawWarsawPoland
| | - Justyna M. Sokolska
- Department of Heart DiseasesWrocław Medical UniversityWroclawPoland
- Department of Cardiology, University Heart CenterUniversity Hospital ZurichZurichSwitzerland
| | - Tomasz Suchocki
- Biostatistics Group, Department of GeneticsWroclaw University of Environmental and Life SciencesWroclawPoland
| | | | | | | | - Mateusz Sokolski
- Department of Heart DiseasesWrocław Medical UniversityWroclawPoland
- Centre for Heart DiseasesUniversity HospitalWroclawPoland
| | - Piotr Ponikowski
- Department of Heart DiseasesWrocław Medical UniversityWroclawPoland
- Centre for Heart DiseasesUniversity HospitalWroclawPoland
| | - Ewa A. Jankowska
- Department of Heart DiseasesWrocław Medical UniversityWroclawPoland
- Centre for Heart DiseasesUniversity HospitalWroclawPoland
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Severino P, Mather PJ, Pucci M, D'Amato A, Mariani MV, Infusino F, Birtolo LI, Maestrini V, Mancone M, Fedele F. Advanced Heart Failure and End-Stage Heart Failure: Does a Difference Exist. Diagnostics (Basel) 2019; 9:diagnostics9040170. [PMID: 31683887 PMCID: PMC6963179 DOI: 10.3390/diagnostics9040170] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 10/28/2019] [Accepted: 10/29/2019] [Indexed: 12/16/2022] Open
Abstract
Advanced heart failure (AdHF) represents a challenging aspect of heart failure patients. Because of worsening clinical symptoms, high rates of re-hospitalization and mortality, AdHF represents an unstable condition where standard treatments are inadequate and additional interventions must be applied. A heart transplant is considered the optimal therapy for AdHF, but the great problem linked to the scarcity of organs and long waiting lists have led to the use of mechanical circulatory support with ventricular-assist device (VAD) as a destination therapy. VAD placement improves the prognosis, functional status, and quality of life of AdHF patients, with high rates of survival at 1 year, similar to transplant. However, the key element is to select the right patient at the right moment. The complete assessment must include a careful clinical evaluation, but also take into account psychosocial factors that are of crucial importance in the out-of-hospital management. It is important to distinguish between AdHF and end-stage HF, for which advanced therapy interventions would be unreasonable due to severe and irreversible organ damage and, instead, palliative care should be preferred to improve quality of life and relief of suffering. The correct selection of patients represents a great issue to solve, both ethically and economically.
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Affiliation(s)
- Paolo Severino
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Paul J Mather
- Department of Medicine, Division of Cardiology University of Pennsylvania, Perelman School of Medicine, 3400 Civic Center Blvd, Philadelphia, PA 19104, USA.
| | - Mariateresa Pucci
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Andrea D'Amato
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Marco Valerio Mariani
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Fabio Infusino
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Lucia Ilaria Birtolo
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Viviana Maestrini
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Massimo Mancone
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
| | - Francesco Fedele
- Department of Cardiovascular, Respiratory, Nephrology, Anesthesiology and Geriatric Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy.
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Belletti A, Landoni G, Lomivorotov VV, Oriani A, Ajello S. Adrenergic Downregulation in Critical Care: Molecular Mechanisms and Therapeutic Evidence. J Cardiothorac Vasc Anesth 2019; 34:1023-1041. [PMID: 31839459 DOI: 10.1053/j.jvca.2019.10.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2019] [Revised: 09/09/2019] [Accepted: 10/10/2019] [Indexed: 02/08/2023]
Abstract
Catecholamines remain the mainstay of therapy for acute cardiovascular dysfunction. However, adrenergic receptors quickly undergo desensitization and downregulation after prolonged stimulation. Moreover, prolonged exposure to high circulating catecholamines levels is associated with several adverse effects on different organ systems. Unfortunately, in critically ill patients, adrenergic downregulation translates into progressive reduction of cardiovascular response to exogenous catecholamine administration, leading to refractory shock. Accordingly, there has been a growing interest in recent years toward use of noncatecholaminergic inotropes and vasopressors. Several studies investigating a wide variety of catecholamine-sparing strategies (eg, levosimendan, vasopressin, β-blockers, steroids, and use of mechanical circulatory support) have been published recently. Use of these agents was associated with improvement in hemodynamics and decreased catecholamine use but without a clear beneficial effect on major clinical outcomes. Accordingly, additional research is needed to define the optimal management of catecholamine-resistant shock.
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Affiliation(s)
- Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy.
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy; Vita-Salute San Raffaele University, Milan, Italy
| | - Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk, Russia; Novosibirsk State University, Novosibirsk, Russia
| | - Alessandro Oriani
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Silvia Ajello
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
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18
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Lau CW, Martens P, Lambeets S, Dupont M, Mullens W. Effects of sacubitril/valsartan on functional status and exercise capacity in real-world patients. Acta Cardiol 2019; 74:405-412. [PMID: 30474478 DOI: 10.1080/00015385.2018.1521054] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Sacubitril/valsartan significantly reduced heart failure(HF) hospitalisations and mortality in the PARADIGM-HF-trial. However real-world data on symptomatic and functional improvement are lacking. Methods: Between December 2016 and January 2018, we retrospectively collected baseline and follow-up data including New York Heart Association (NYHA)-functional class and Cardio-pulmonary exercise data(CPET) in all HF-patients receiving sacubitril/valsartan. Additionally, in patients with an implantable electric cardiovascular device (IECD) enrolled in remote telemonitoring, we quantified patient level activity before and after initiation. Results: A total of 201 patients (82% males) were identified. NYHA-functional class was reassessed after an average of 221 ± 114 days. Overall, 3.3% of patients improved 2 NYHA classes, 28.7% improved 1 NYHA class, 64% remained stable and 4% deteriorated 1 NYHA class. Patients with symptomatic improvement exhibited a larger reduction in Left Ventricular End Systolic Volume(LVESV) and a larger increase in Left Ventricular Ejection Fraction(LVEF[p-value both <.05]). In total, 110 patients (55%) were equipped with an IECD capable of quantifying outpatient activity-level. On an average of 364 days before sacubitril/valsartan, an activity expressed as %-of-the-day was 13 ± 2%, vs. 18 ± 3% the 364 days following sacubitril/valsartan initiation. Signifying a 38% improvement in the out-patient activity level. CPET-data was obtained in paired-fashion in 45 patients (22%). VO2max at baseline (14.7 ± 3.8 mL/kg/min) did not significantly change at follow-up (14.1 ± 4.7 mL/min/kg; p = .237). Conclusion: Real-world patients exhibit significant symptomatic and functional improvement following the initiation of sacubitril/valsartan. However, larger prospective studies are necessary to assess the impact of sacubitril/valsartan on indices of maximal exercise performance measured during CPET.
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Affiliation(s)
- Chirik Wah Lau
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Seppe Lambeets
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
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Martens P, Lambeets S, Lau CW, Dupont M, Mullens W. Impact of sacubitril/valsartan on heart failure admissions: insights from real-world patient prescriptions. Acta Cardiol 2019; 74:115-122. [PMID: 29909743 DOI: 10.1080/00015385.2018.1473825] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Sacubitril/valsartan reduced heart failure (HF)-admissions and cardiovascular mortality in the PARADIGM-HF-trial. However, real-world patients are often frailer and less able to tolerate high doses of sacubitril/valsartan. METHODS We performed a retrospective analysis of consecutive patients prescribed sacubitril/valsartan in a single tertiary HF-clinic between December 2016 and January 2018. HF-admissions were assessed in a paired fashion, comparing the amount of antecedent HF-episodes with incident HF-episodes after the initiation. Baseline risk for adverse events was assessed by the EMPHASIS-HF-risk-score. RESULTS A total of 201-HF-patients were retrospectively identified (age = 68 ± 11 years, ejection fraction = 29 ± 8%). Real world patients were older, had higher serum creatinine and a higher New-York Heart-Association (NYHA)-class (p < .05 for all) than in the PARADIGM-HF trial. Over a mean duration of 221 ± 114 days after initiation of sacubitril/valsartan a total of 23-individual patients experienced at least one HF-episodes. Over the same time period preceding initiation of sacubitril/valsartan, 51 individual patients experienced a HF-episodes (p < .001). Sacubitril/valsartan significantly reduced the rate of incident vs. antecedent HF-admissions, in patients with low or high baseline NYHA-class (II vs. III and IV; p value = 0.019 respectively p = .004) or patients with an EMPHASIS-HF risk score below or above the mean (p = .002 respectively p = .016). Patients older than 75-years exhibited a trend towards HF-reduction. Higher doses of sacubitril/valsartan were associated with more reduction in incident versus antecedent HF-episodes. CONCLUSION Despite being frailer and older, real-world patients exhibit a significant and early reduction in incident HF-hospitalisations following initiation of sacubitril/valsartan. Higher doses might be associated with more reduction in HF-admissions, underscoring the importance of dose uptitration.
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Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Seppe Lambeets
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Chirik Wah Lau
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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Martens P, Vercammen J, Ceyssens W, Jacobs L, Luwel E, Van Aerde H, Potargent P, Renaers M, Dupont M, Mullens W. Effects of intravenous home dobutamine in palliative end-stage heart failure on quality of life, heart failure hospitalization, and cost expenditure. ESC Heart Fail 2018; 5:562-569. [PMID: 29341466 PMCID: PMC6073033 DOI: 10.1002/ehf2.12248] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2017] [Revised: 10/06/2017] [Accepted: 11/27/2017] [Indexed: 01/06/2023] Open
Abstract
Aims In patients with palliative end‐stage heart failure, interventions that could provide symptomatic relief and prevent hospital admissions are important. Ambulatory continuous intravenous inotropes have been advocated by guidelines for such a purpose. We sought to determine the effect of intravenous dobutamine on symptomatic status, hospital stay, mortality, and cost expenditure. Methods and results All consecutive end‐stage heart failure patients not amenable for advanced therapies and discharged with continuous intravenous home dobutamine from a single tertiary centre between April 2011 and January 2017 were retrospectively analysed. Dobutamine (fixed dose) was infused through a single‐lumen central venous catheter with a small pump that was refilled by a nurse on a daily basis. Symptomatic status was longitudinally assessed as the change in New York Heart Association class and patient global assessment scale. Antecedent and incident heart failure hospitalizations were determined in a paired fashion, and cost impact was assessed. A total of 21 patients (age 77 ± 9 years) were followed up for 869 ± 647 days. At first follow‐up (6 ± 1 weeks) after the initiation of dobutamine, patients had a significant improvement in New York Heart Association class (−1.29 ± 0.64; P < 0.001), global assessment scale (<0.001), and N‐terminal pro‐brain natriuretic peptide (6247 vs. 2543 pg/mL; P = 0.033). Incident heart failure hospitalizations assessed at 3, 6, and 12 months were significantly reduced (P < 0.001 for all) in comparison with antecedent heart failure hospitalizations over the same time period. Cost expenditure was significantly lower at 3 (P < 0.001), 6 (P = 0.005), and 12 months (P = 0.001) after initiation of dobutamine. Mortality rate at 1 year was 48% with 9/12 (75%) patients dying at home, most often from progressive pump failure. Conclusions Continuous intravenous home dobutamine in patients with palliative end‐stage heart failure is feasible and associated with improved symptomatic status, heart failure hospitalizations, and health‐care‐related costs. Nevertheless, results should be interpreted in the context of the small and retrospective design. Larger studies are necessary to evaluate the effect of dobutamine in palliative end‐stage heart failure.
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Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.,Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Jan Vercammen
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Wendy Ceyssens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Linda Jacobs
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Evert Luwel
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | | | | | - Monique Renaers
- Clinic Care Pathway Home-Dobutamine, Wit-Geel Kruis, Limburg, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Schiepse Bos 6, 3600, Genk, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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