1
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Parikh RV, Go AS, Bhatt AS, Tan TC, Allen AR, Feng KY, Hamilton SA, Tai AS, Fitzpatrick JK, Lee KK, Adatya S, Avula HR, Sax DR, Shen X, Cristino J, Sandhu AT, Heidenreich PA, Ambrosy AP. Developing Clinical Risk Prediction Models for Worsening Heart Failure Events and Death by Left Ventricular Ejection Fraction. J Am Heart Assoc 2023; 12:e029736. [PMID: 37776209 PMCID: PMC10727243 DOI: 10.1161/jaha.122.029736] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/24/2023] [Indexed: 10/02/2023]
Abstract
Background There is a need to develop electronic health record-based predictive models for worsening heart failure (WHF) events across clinical settings and across the spectrum of left ventricular ejection fraction (LVEF). Methods and Results We studied adults with heart failure (HF) from 2011 to 2019 within an integrated health care delivery system. WHF encounters were ascertained using natural language processing and structured data. We conducted boosted decision tree ensemble models to predict 1-year hospitalizations, emergency department visits/observation stays, and outpatient encounters for WHF and all-cause death within each LVEF category: HF with reduced ejection fraction (EF) (LVEF <40%), HF with mildly reduced EF (LVEF 40%-49%), and HF with preserved EF (LVEF ≥50%). Model discrimination was evaluated using area under the curve and calibration using mean squared error. We identified 338 426 adults with HF: 61 045 (18.0%) had HF with reduced EF, 49 618 (14.7%) had HF with mildly reduced EF, and 227 763 (67.3%) had HF with preserved EF. The 1-year risks of any WHF event and death were, respectively, 22.3% and 13.0% for HF with reduced EF, 17.0% and 10.1% for HF with mildly reduced EF, and 16.3% and 10.3% for HF with preserved EF. The WHF model displayed an area under the curve of 0.76 and mean squared error of 0.13, whereas the model for death displayed an area under the curve of 0.83 and mean squared error of 0.076. Performance and predictors were similar across WHF encounter types and LVEF categories. Conclusions We developed risk prediction models for 1-year WHF events and death across the LVEF spectrum using structured and unstructured electronic health record data and observed no substantial differences in model performance or predictors except for death, despite differences in underlying HF cause.
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Affiliation(s)
- Rishi V. Parikh
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of Epidemiology and Population HealthStanford UniversityPalo AltoCAUSA
| | - Alan S. Go
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of Health Systems ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCAUSA
- Departments of Epidemiology, Biostatistics and MedicineUniversity of California, San FranciscoSan FranciscoCAUSA
- Department of MedicineStanford UniversityPalo AltoCAUSA
| | - Ankeet S. Bhatt
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Thida C. Tan
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Amanda R. Allen
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Kent Y. Feng
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Steven A. Hamilton
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Andrew S. Tai
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Jesse K. Fitzpatrick
- Department of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCAUSA
| | - Keane K. Lee
- Department of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCAUSA
| | - Sirtaz Adatya
- Department of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCAUSA
| | - Harshith R. Avula
- Department of CardiologyKaiser Permanente Walnut Creek Medical CenterWalnut CreekCAUSA
| | - Dana R. Sax
- Department of Emergency MedicineKaiser Permanente Oakland Medical CenterOaklandCAUSA
| | - Xian Shen
- Novartis Pharmaceuticals CorporationEast HanoverNJUSA
| | | | - Alexander T. Sandhu
- Division of Cardiovascular Medicine, Department of MedicineStanford UniversityStanfordCAUSA
- Medical Service, VA Palo Alto Health Care SystemPalo AltoCAUSA
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Department of MedicineStanford UniversityStanfordCAUSA
- Medical Service, VA Palo Alto Health Care SystemPalo AltoCAUSA
| | - Andrew P. Ambrosy
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of Health Systems ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCAUSA
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
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2
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Patolia H, Khan MS, Fonarow GC, Butler J, Greene SJ. Implementing Guideline-Directed Medical Therapy for Heart Failure: JACC Focus Seminar 1/3. J Am Coll Cardiol 2023; 82:529-543. [PMID: 37532424 DOI: 10.1016/j.jacc.2023.03.430] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 08/04/2023]
Abstract
Despite the availability of lifesaving guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), there remain major gaps in utilization of these therapies among eligible patients. Simultaneous with these gaps in quality of care, HFrEF continues as a leading cause of death and hospitalization with associated clinical risk far exceeding most other cardiovascular and noncardiovascular conditions. In the context of this urgent need to improve provision of appropriate therapy, multiple lines of evidence support various implementation strategies. Such strategies include in-hospital initiation of GDMT, simultaneous or rapid sequence initiation of GDMT, participation in quality improvement registries to assess site performance and provide feedback, multidisciplinary titration clinics, virtual consult teams, reduction of cost-sharing, remote algorithm-based medication optimization, electronic health record-based interventions, and direct-to-patient educational initiatives. This review describes and contextualizes the evidence surrounding each of these potential avenues for improving use of foundational GDMTs for patients with HFrEF.
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Affiliation(s)
- Harsh Patolia
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
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3
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Worsening Heart Failure: Nomenclature, Epidemiology, and Future Directions: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:413-424. [PMID: 36697141 DOI: 10.1016/j.jacc.2022.11.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 01/25/2023]
Abstract
Heart failure (HF) is a progressive disease characterized by variable durations of symptomatic stability often punctuated by episodes of worsening despite continued therapy. These periods of clinical worsening are increasingly recognized as a distinct phase in the history of HF, termed worsening HF (WHF). The definition of WHF continues to evolve from a historical focus solely on hospitalization to now include nonhospitalization events (eg, need for intravenous diuretic therapy in the emergency or outpatient setting). Most HF clinical trials to date have had HF hospitalization and death as primary endpoints, and only recently, some studies have included other WHF events regardless of location of care. This article reviews the evolution of the WHF definition, highlights the importance of considering the onset of WHF as an event that marks a new phase of HF, summarizes the latest clinical trials investigating novel therapies, and outlines unmet needs regarding identification and treatment of WHF.
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4
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Ambrosy AP, Parikh RV, Sung SH, Tan TC, Narayanan A, Masson R, Lam PQ, Kheder K, Iwahashi A, Hardwick AB, Fitzpatrick JK, Avula HR, Selby VN, Ku IA, Shen X, Sanghera N, Cristino J, Go AS. Analysis of Worsening Heart Failure Events in an Integrated Health Care System. J Am Coll Cardiol 2022; 80:111-122. [DOI: 10.1016/j.jacc.2022.04.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Revised: 03/30/2022] [Accepted: 04/12/2022] [Indexed: 12/12/2022]
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5
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Khan MS, Greene SJ, Hellkamp AS, DeVore AD, Shen X, Albert NM, Patterson JH, Spertus JA, Thomas LE, Williams FB, Hernandez AF, Fonarow GC, Butler J. Diuretic Changes, Health Care Resource Utilization, and Clinical Outcomes for Heart Failure With Reduced Ejection Fraction: From the Change the Management of Patients With Heart Failure Registry. Circ Heart Fail 2021; 14:e008351. [PMID: 34674536 DOI: 10.1161/circheartfailure.121.008351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diuretics are a mainstay therapy for the symptomatic treatment of heart failure. However, in contemporary US outpatient practice, the degree to which diuretic dosing changes over time and the associations with clinical outcomes and health care resource utilization are unknown. METHODS Among 3426 US outpatients with chronic heart failure with reduced ejection fraction in the Change the Management of Patients with Heart Failure registry with complete medication data and who were prescribed a loop diuretic, diuretic dose increase was defined as: (1) change to a total daily dose higher than their previous total daily dose, (2) addition of metolazone to the regimen, (3) change from furosemide to either bumetanide or torsemide, and the change persists for at least 7 days. Adjusted hazard ratios or rate ratios along with 95% CIs were reported for clinical outcomes among patients with an increase in oral diuretic dose versus no increase in diuretic dose. RESULTS Overall, 796 (23%) had a diuretic dose increase (18 episodes per 100 patient-years). The proportion of patients with dyspnea at rest (38% versus 26%), dyspnea at exertion (79% versus 67%), orthopnea (32% versus 21%), edema (60% versus 43%), and weight gain (40% versus 23%) were significantly (all P <0.001) higher in the diuretic increase group. Baseline angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (hazard ratio, 0.75 [95% CI, 0.65-0.87]) use were associated with lower likelihood of diuretic increase over time. Patients with a diuretic dose increase had a significantly higher number of heart failure hospitalizations (rate ratio, 2.53 [95% CI, 2.10-3.05]), emergency department visits (rate ratio, 1.84 [95% CI, 1.56-2.17]), and home health visits (rate ratio, 1.88 [95% CI, 1.39-2.54]), but not all-cause mortality (hazard ratio, 1.10 [95% CI, 0.89-1.36]). Similarly, greater furosemide dose equivalent increases were associated with greater resource utilization but not with mortality, compared with smaller increases. CONCLUSIONS In this contemporary US registry, 1 in 4 patients with heart failure with reduced ejection fraction had outpatient escalation of diuretic therapy over longitudinal follow-up, and these patients were more likely to have sign/symptoms of congestion. Outpatient diuretic dose escalation of any magnitude was associated with heart failure hospitalizations and resource utilization, but not all-cause mortality.
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Affiliation(s)
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.).,Department of Biostatistics and Bioinformatics (A.S.H., L.E.T.), Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (X.S.)
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, OH (N.M.A.)
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City (J.A.S.)
| | - Laine E Thomas
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.).,Department of Biostatistics and Bioinformatics (A.S.H., L.E.T.), Duke University School of Medicine, Durham, NC
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson (J.B.)
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6
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Arulmurugananthavadivel A, Holt A, Parveen S, Lamberts M, Gislason GH, Torp-Pedersen C, Madelaire C, Andersson C, Zahir D, Butt JH, Petrie MC, McMurray J, Fosbol EL, Kober L, Schou M. Importance of diagnostic setting in determining mortality in patients with new-onset heart failure: temporal trends in Denmark 1997-2017. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2021; 8:750-760. [PMID: 34625809 PMCID: PMC9603536 DOI: 10.1093/ehjqcco/qcab073] [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: 08/16/2021] [Revised: 09/30/2021] [Accepted: 10/06/2021] [Indexed: 11/21/2022]
Abstract
Aim To investigate temporal trends in inpatient vs. outpatient diagnosis of new-onset heart failure (HF) and the subsequent risk of death and hospitalization. Methods and results Using nationwide registers, 192 581 patients with a first diagnosis of HF (1997–2017) were included. We computed incidences of HF, age-standardized mortality rates, and absolute risks (ARs) of death and hospitalization (accounting for competing risk of death) to understand the importance of the diagnosis setting in relation to subsequent mortality and hospitalization. The overall incidence of HF was approximately the same (170/100 000 persons) every year during 1997–2017. However, in 1997, 77% of all first diagnoses of HF were made during a hospitalization, whereas the proportion was 39% in 2017. As inpatient diagnoses decreased, outpatient diagnoses increased from 23% to 61%. Outpatients had lower mortality and hospitalization rates than inpatients throughout the study period, although the 1-year age-standardized mortality rate decreased for each inpatient (24 to 14/100-person) and outpatient (11 to 7/100-person). One-year and five-year AR of death decreased by 11.1% and 17.0%, respectively, for all HF patients, while the risk of hospitalization for HF did not decrease significantly (1.13% and 0.96%, respectively). Conclusion Between 1997 and 2017, HF changed from being primarily diagnosed during hospitalization to being mostly diagnosed in the outpatient setting. Outpatients had much lower mortality rates than inpatients throughout the study period. Despite a significant decrease in mortality risk for all HF patients, neither inpatients nor outpatients experienced a reduction in the risk of an HF hospitalization.
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Affiliation(s)
| | - Anders Holt
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Saaima Parveen
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Morten Lamberts
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Gunnar H Gislason
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark.,Danish Heart Foundation
| | - Christian Torp-Pedersen
- Department of Cardiology, Aalborg University Hospital, Aalborg.,Department of Cardiology, Nordsjællands Hospital, Hillerød.,Department of Biostatistics, University of Copenhagen, Denmark
| | - Christian Madelaire
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Charlotte Andersson
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark.,Section of Cardiovascular Medicine, Boston Medical Center, Boston University, MA, USA
| | - Deewa Zahir
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mark C Petrie
- Department of Cardiology, Glasgow Royal Infirmary, Glasgow, United Kingdom.,British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - John McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Emil L Fosbol
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Kober
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
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7
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D'Onofrio A, Solimene F, Calò L, Calvi V, Viscusi M, Melissano D, Russo V, Rapacciuolo A, Campana A, Caravati F, Bonfanti P, Zanotto G, Gronda E, Vado A, Calzolari V, Botto GL, Zecchin M, Bontempi L, Giacopelli D, Gargaro A, Padeletti L. Combining Home Monitoring temporal trends from implanted defibrillators and baseline patient risk profile to predict heart failure hospitalizations: results from the SELENE HF study. Europace 2021; 24:234-244. [PMID: 34392336 PMCID: PMC8824514 DOI: 10.1093/europace/euab170] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 06/18/2021] [Indexed: 11/15/2022] Open
Abstract
AIMS We developed and validated an algorithm for prediction of heart failure (HF) hospitalizations using remote monitoring (RM) data transmitted by implanted defibrillators. METHODS AND RESULTS The SELENE HF study enrolled 918 patients (median age 69 years, 81% men, median ejection fraction 30%) with cardiac resynchronization therapy (44%), dual-chamber (38%), or single-chamber defibrillators with atrial diagnostics (18%). To develop a predictive algorithm, temporal trends of diurnal and nocturnal heart rates, ventricular extrasystoles, atrial tachyarrhythmia burden, heart rate variability, physical activity, and thoracic impedance obtained by daily automatic RM were combined with a baseline risk-stratifier (Seattle HF Model) into one index. The primary endpoint was the first post-implant adjudicated HF hospitalization. After a median follow-up of 22.5 months since enrolment, patients were randomly allocated to the algorithm derivation group (n = 457; 31 endpoints) or algorithm validation group (n = 461; 29 endpoints). In the derivation group, the index showed a C-statistics of 0.89 [95% confidence interval (CI): 0.83-0.95] with 2.73 odds ratio (CI 1.98-3.78) for first HF hospitalization per unitary increase of index value (P < 0.001). In the validation group, sensitivity of predicting primary endpoint was 65.5% (CI 45.7-82.1%), median alerting time 42 days (interquartile range 21-89), and false (or unexplained) alert rate 0.69 (CI 0.64-0.74) [or 0.63 (CI 0.58-0.68)] per patient-year. Without the baseline risk-stratifier, the sensitivity remained 65.5% and the false/unexplained alert rates increased by ≈10% to 0.76/0.71 per patient-year. CONCLUSION With the developed algorithm, two-thirds of first post-implant HF hospitalizations could be predicted timely with only 0.7 false alerts per patient-year.
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Affiliation(s)
- Antonio D'Onofrio
- Cardiology Department - Electrophysiology and Cardiac Pacing Unit A.O.R.N. V. Monaldi, Via L. Bianchi, Naples, Italy
| | - Francesco Solimene
- Electrophysiology, Montevergine Clinic, Viale S. Modestino 8, 83013 Mercogliano, Italy
| | - Leonardo Calò
- Cardiology Division, Policlinico Casilino, Via Casilina 1049, 00169 Rome, Italy
| | - Valeria Calvi
- Cardiology Department, Policlinico G. Rodolico, AOU Policlinico V. Emanuele, Via S. Sofia 78, 95125 Catania, Italy
| | - Miguel Viscusi
- Cardiology Division, Sant'Anna and San Sebastiano Hospital, Via F. Palasciano, 81100 Caserta, Italy
| | - Donato Melissano
- Cardiology Division, F. Ferrari Hospital, Viale F. Ferrari 1, 73042 Casarano (LE), Italy
| | - Vitantonio Russo
- Cardiology Division, SS. Annunziata Hospital, Via F. Bruno 1, 74121 Taranto, Italy
| | - Antonio Rapacciuolo
- Cardiology Department of Advanced Biomedical Sciences, Corso Umberto I 40, 80138 Federico II University of Naples, Italy
| | - Andrea Campana
- Cardiology Division, A.O.U. San Giovanni di Dio e Ruggi D'Aragona, Via San Leonardo 1, 84131 Salerno, Italy
| | - Fabrizio Caravati
- Division of Cardiology, ASST Settelaghi, Di Circolo Hospital, Via L. Borri 57, 21100 Varese, Italy
| | - Paolo Bonfanti
- Cardiology Division, Rho Civil Hospital, Corso Europa 250, 20017 Rho (MI), Italy
| | - Gabriele Zanotto
- Cardiology Division, Mater Salutis Hospital, Via C. Gianella 1, 37045 Legnago, Italy
| | - Edoardo Gronda
- Department of Medicine and Medical Specialties, I.R.C.C.S. Foundation Ca' Granda, Via M. Fanti 6, 20122 Milano, Italy
| | - Antonello Vado
- Cardiology Division, S. Croce e Carle Hospital, Via M. Coppino 26, 12100 Cuneo, Italy
| | - Vittorio Calzolari
- Cardiology Division, Santa Maria di Ca' Foncello Hospital, Piazzale dell'Ospedale 1, 31100 Treviso, Italy
| | - Giovanni Luca Botto
- Cardiology Division, Rho Civil Hospital, Corso Europa 250, 20017 Rho (MI), Italy
| | - Massimo Zecchin
- Cardiology Department, Cattinara University Hospital, Strada di Fiume 447, 34149 Trieste, Italy
| | - Luca Bontempi
- Cardiology Division, Spedali Civili , Piazzale Spedali Civili 1, 25123 Brescia, Italy
| | | | - Alessio Gargaro
- BIOTRONIK Italia, Via delle Industrie 11, 20090 Vimodrone (MI), Italy
| | - Luigi Padeletti
- Cardiology Department, I.R.C.C.S. MultiMedica, Via Milanese 300, 20099 Sesto San Giovanni, Milano, Italy
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8
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Uemura Y, Shibata R, Ishikawa S, Takemoto K, Murohara T, Watarai M. Initiation and long-term use of tolvaptan for patients with worsening heart failure through hospital and clinic cooperation. NAGOYA JOURNAL OF MEDICAL SCIENCE 2021; 83:431-441. [PMID: 34552281 PMCID: PMC8438006 DOI: 10.18999/nagjms.83.3.431] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/19/2020] [Indexed: 11/30/2022]
Abstract
Worsening heart failure (WHF) has a negative impact on the prognosis of patients with heart failure. Adequate management of non-hospitalized episodes of WHF, regarded as "outpatient WHF", may reduce the frequency of emergent/urgent hospitalization for acute heart failure; thus, the patients' cardiac parameters return to their clinical baseline. This study aimed to investigate the efficacy of tolvaptan initiation during planned hospitalization of patients with "outpatient WHF" through hospital and clinic cooperation. The data from 28 patients with outpatient WHF referred by general practitioners to hospital were assessed. Tolvaptan administration was initiated during planned hospitalization and continued in the clinics. Patients were followed-up for 12 months. None of the patients required withdrawal of tolvaptan due to adverse effects. During the follow-up period, the loop diuretic dosage significantly decreased. There were significant favorable changes in the levels of serum creatinine, estimated glomerular filtration rate, natriuretic peptide and body weight. Kaplan-Meier survival analysis revealed that the cardiac death- and HF-related hospitalization-free survival rates were significantly higher among the patients who were administered tolvaptan for the outpatient WHF than the propensity score-matched patients who were administered tolvaptan for acute heart failure requiring emergent/urgent hospitalization. In conclusion, tolvaptan may be safe and effective for the long-term management of outpatient WHF through hospital and clinic cooperation.
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Affiliation(s)
- Yusuke Uemura
- Cardiovascular Center, Anjo Kosei Hospital, Anjo, Japan
| | - Rei Shibata
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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9
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Blumer V, Mentz RJ, Sun JL, Butler J, Metra M, Voors AA, Hernandez AF, O'Connor CM, Greene SJ. Prognostic Role of Prior Heart Failure Hospitalization Among Patients Hospitalized for Worsening Chronic Heart Failure. Circ Heart Fail 2021; 14:e007871. [PMID: 33775110 PMCID: PMC9990499 DOI: 10.1161/circheartfailure.120.007871] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospitalization for heart failure (HF) is associated with increased risk of death among patients with chronic HF. The degree to which hospitalization for HF is a distinct biologic entity with independent prognostic value versus a marker of higher risk chronic HF patients is unclear. METHODS After excluding patients with new-onset HF, the ASCEND-HF trial (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) included 4205 patients hospitalized for worsening chronic HF with reduced or preserved ejection fraction. The present analysis compared patients by presence or absence of prior HF hospitalization within 12 months and by timing of prior HF hospitalization relative to index hospitalization. Associations with 180-day all-cause mortality were assessed, including adjustment for 27 prespecified clinical factors. RESULTS Overall, 2241 (53.3%) patients had a HF hospitalization within the prior 12 months and 1964 (46.7%) did not. Mortality rates at 180 days were 15.5% and 11.9%, respectively. In unadjusted analyses, prior HF hospitalization was associated with increased risk of 180-day mortality (HR, 1.35 [95% CI, 1.14-1.59]; P<0.01). After adjustment, the point estimate was attenuated and the association not statistically significant (HR, 1.18 [95% CI, 0.99-1.40]; P=0.064). Similarly, after adjustment, compared with patients without prior hospitalization, prior HF hospitalization was not associated with mortality, irrespective of timing (0-4 months: HR, 1.10 [95% CI, 0.87-1.39], P=0.41; 4-8 months: HR, 0.95 [95% CI, 0.70-1.27]; P=0.72; 8-12 months: HR, 1.06 [95% CI, 0.74-1.51], P=0.77; >12 months: HR, 0.81 [95% CI, 0.63-1.06], P=0.12). CONCLUSIONS In this cohort of patients hospitalized for worsening HF, prior HF hospitalization was not associated with 180-day mortality after comprehensively accounting for patient characteristics measured during the index patient visit. Clinical confounders measured at the point-of-care may explain previously observed associations between prior HF hospitalization and mortality, and these clinical factors may be a more direct means of predicting patient survival. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00475852.
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Affiliation(s)
- Vanessa Blumer
- Division of Cardiology, Duke University School of Medicine, Durham, NC (V.B., R.J.M., A.F.H., S.J.G.)
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, NC (V.B., R.J.M., A.F.H., S.J.G.).,Duke Clinical Research Institute, Durham, NC (R.J.M., J.-L.S., A.F.H., S.J.G.)
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, NC (R.J.M., J.-L.S., A.F.H., S.J.G.)
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS (J.B.)
| | - Marco Metra
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy (M.M.)
| | | | - Adrian F Hernandez
- Division of Cardiology, Duke University School of Medicine, Durham, NC (V.B., R.J.M., A.F.H., S.J.G.).,Duke Clinical Research Institute, Durham, NC (R.J.M., J.-L.S., A.F.H., S.J.G.)
| | | | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC (V.B., R.J.M., A.F.H., S.J.G.).,Duke Clinical Research Institute, Durham, NC (R.J.M., J.-L.S., A.F.H., S.J.G.)
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10
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Tomasoni D, Adamo M, Anker MS, von Haehling S, Coats AJS, Metra M. Heart failure in the last year: progress and perspective. ESC Heart Fail 2020; 7:3505-3530. [PMID: 33277825 PMCID: PMC7754751 DOI: 10.1002/ehf2.13124] [Citation(s) in RCA: 43] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 11/11/2020] [Indexed: 12/11/2022] Open
Abstract
Research about heart failure (HF) has made major progress in the last years. We give here an update on the most recent findings. Landmark trials have established new treatments for HF with reduced ejection fraction. Sacubitril/valsartan was superior to enalapril in PARADIGM-HF trial, and its initiation during hospitalization for acute HF or early after discharge can now be considered. More recently, new therapeutic pathways have been developed. In the DAPA-HF and EMPEROR-Reduced trials, dapagliflozin and empagliflozin reduced the risk of the primary composite endpoint, compared with placebo [hazard ratio (HR) 0.74; 95% confidence interval (CI) 0.65-0.85; P < 0.001 and HR 0.75; 95% CI 0.65-0.86; P < 0.001, respectively]. Second, vericiguat, an oral soluble guanylate cyclase stimulator, reduced the composite endpoint of cardiovascular death or HF hospitalization vs. placebo (HR 0.90; 95% CI 0.82-0.98; P = 0.02). On the other hand, both the diagnosis and treatment of HF with preserved ejection fraction, as well as management of advanced HF and acute HF, remain challenging. A better phenotyping of patients with HF would be helpful for prognostic stratification and treatment selection. Further aspects, such as the use of devices, treatment of arrhythmias, and percutaneous treatment of valvular heart disease in patients with HF, are also discussed and reviewed in this article.
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Affiliation(s)
- Daniela Tomasoni
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
- Cardiology and Cardiac Catheterization Laboratory, Cardio‐thoracic DepartmentCivil HospitalsBresciaItaly
| | - Marianna Adamo
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
- Cardiology and Cardiac Catheterization Laboratory, Cardio‐thoracic DepartmentCivil HospitalsBresciaItaly
| | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK)Charité–University Medicine BerlinBerlinGermany
- Berlin Institute of Health Center for Regenerative Therapies (BCRT)BerlinGermany
- German Centre for Cardiovascular Research (DZHK), partner site BerlinBerlinGermany
- Department of Cardiology (CBF)Charité–University Medicine BerlinBerlinGermany
| | - Stephan von Haehling
- Department of Cardiology and PneumologyUniversity of Göttingen Medical CenterGöttingenGermany
- German Centre for Cardiovascular Research (DZHK), partner site GöttingenGöttingenGermany
| | - Andrew J. S. Coats
- Centre for Clinical and Basic Research, Department of Medical SciencesIRCCS San Raffaele PisanaRomeItaly
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
- Cardiology and Cardiac Catheterization Laboratory, Cardio‐thoracic DepartmentCivil HospitalsBresciaItaly
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11
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Mann DL, Greene SJ, Givertz MM, Vader JM, Starling RC, Ambrosy AP, Shah P, McNulty SE, Mahr C, Gupta D, Redfield MM, Lala A, Lewis GD, Mohammed SF, Gilotra NA, DeVore AD, Gorodeski EZ, Desvigne-Nickens P, Hernandez AF, Braunwald E. Sacubitril/Valsartan in Advanced Heart Failure With Reduced Ejection Fraction: Rationale and Design of the LIFE Trial. JACC. HEART FAILURE 2020; 8:789-799. [PMID: 32641226 PMCID: PMC7286640 DOI: 10.1016/j.jchf.2020.05.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022]
Abstract
The PARADIGM-HF (Prospective Comparison of Angiotensin II Receptor Blocker Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial reported that sacubitril/valsartan (S/V), an angiotensin receptor-neprilysin inhibitor, significantly reduced mortality and heart failure (HF) hospitalization in HF patients with a reduced ejection fraction (HFrEF). However, fewer than 1% of patients in the PARADIGM-HF study had New York Heart Association (NYHA) functional class IV symptoms. Accordingly, data that informed the use of S/V among patients with advanced HF were limited. The LIFE (LCZ696 in Hospitalized Advanced Heart Failure) study was a 24-week prospective, multicenter, double-blinded, double-dummy, active comparator trial that compared the safety, efficacy, and tolerability of S/V with those of valsartan in patients with advanced HFrEF. The trial planned to randomize 400 patients ≥18 years of age with advanced HF, defined as an EF ≤35%, New York Heart Association functional class IV symptoms, elevated natriuretic peptide concentration (B-type natriuretic peptide [BNP] ≥250 pg/ml or N-terminal pro-B-type natriuretic peptide [NT-proBNP] ≥800 pg/ml), and ≥1 objective finding of advanced HF. Following a 3- to 7-day open label run-in period with S/V (24 mg/26 mg twice daily), patients were randomized 1:1 to S/V titrated to 97 mg/103 mg twice daily versus 160 mg of V twice daily. The primary endpoint was the proportional change from baseline in the area under the curve for NT-proBNP levels measured through week 24. Secondary and tertiary endpoints included clinical outcomes and safety and tolerability. Because of the COVID-19 pandemic, enrollment in the LIFE trial was stopped prematurely to ensure patient safety and data integrity. The primary analysis consists of the first 335 randomized patients whose clinical follow-up examination results were not severely impacted by COVID-19. (Entresto [LCZ696] in Advanced Heart Failure [LIFE STUDY] [HFN-LIFE]; NCT02816736).
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Affiliation(s)
- Douglas L Mann
- Department of Medicine, Washington University, St. Louis, Missouri.
| | - Stephen J Greene
- Department of Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Michael M Givertz
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Justin M Vader
- Department of Medicine, Washington University, St. Louis, Missouri
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Steven E McNulty
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Claudius Mahr
- Department of Medicine, University of Washington, Seattle, Washington
| | - Divya Gupta
- Department of Medicine, Emory University, Atlanta, Georgia
| | | | - Anuradha Lala
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregory D Lewis
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Nisha A Gilotra
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam D DeVore
- Department of Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Eiran Z Gorodeski
- Department of Medicine, Harrington Heart and Vascular Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Baltimore, Maryland
| | - Adrian F Hernandez
- Department of Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Eugene Braunwald
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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12
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Affiliation(s)
| | - Javed Butler
- Department of Medicine University of Mississippi Jackson MS
| | - Stephen J Greene
- Division of Cardiology Duke University School of Medicine Durham NC.,Duke Clinical Research Institute Durham NC
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13
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Butler J, Packer M, Greene SJ, Fiuzat M, Anker SD, Anstrom KJ, Carson PE, Cooper LB, Fonarow GC, Hernandez AF, Januzzi JL, Jessup M, Kalyani RR, Kaul S, Kosiborod M, Lindenfeld J, McGuire DK, Sabatine MS, Solomon SD, Teerlink JR, Vaduganathan M, Yancy CW, Stockbridge N, O'Connor CM. Heart Failure End Points in Cardiovascular Outcome Trials of Sodium Glucose Cotransporter 2 Inhibitors in Patients With Type 2 Diabetes Mellitus: A Critical Evaluation of Clinical and Regulatory Issues. Circulation 2019; 140:2108-2118. [PMID: 31841369 PMCID: PMC7027964 DOI: 10.1161/circulationaha.119.042155] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Following regulatory guidance set forth in 2008 by the US Food and Drug Administration for new drugs for type 2 diabetes mellitus, many large randomized, controlled trials have been conducted with the primary goal of assessing the safety of antihyperglycemic medications on the primary end point of major adverse cardiovascular events, defined as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. Heart failure (HF) was not specifically mentioned in the US Food and Drug Administration guidance and therefore it was not a focus of these studies when planned. Several trials subsequently showed the impact of antihyperglycemic drugs on HF outcomes, which were not originally specified as the primary end point of the trials. The most impressive finding has been the substantial and consistent risk reduction in HF hospitalization seen across 4 trials of sodium glucose cotransporter 2 inhibitors. However, to date, these results have not led to regulatory approval of any of these drugs for a HF indication or a recommendation for use by US HF guidelines. It is therefore important to explore to what extent persuasive treatment effects on nonprimary end points can be used to support regulatory claims and guideline recommendations. This topic was discussed by researchers, clinicians, industry sponsors, regulators, and representatives from professional societies, who convened on the US Food and Drug Administration campus on March 6, 2019. This report summarizes these discussions and the key takeaway messages from this meeting.
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Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson (J.B.)
| | | | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., A.F.H.)
| | - Mona Fiuzat
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
| | - Stefan D Anker
- Berlin-Brandenburg Center for Regenerative Therapies, Germany (S.D.A.)
- Department of Cardiology, German Center for Cardiovascular Research partner site Berlin, Charite Universitatsmedizin Berlin (S.D.A.)
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
| | - Peter E Carson
- Cardiovascular Division, Department of Cardiology, Washington Veterans Affairs Medical Center (P.E.C.)
| | - Lauren B Cooper
- Inova Heart and Vascular Institute, Falls Church, VA (L.B.C., C.M.O.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles (G.C.F.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., A.F.H.)
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Baim Institute for Clinical Research, Boston (J.L.J.)
| | | | - Rita R Kalyani
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD (R.R.K.)
| | - Sanjay Kaul
- Cedars-Sinai Medical Center, Los Angeles, CA (S.K.)
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (M.K.)
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.K.)
| | | | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Marc S Sabatine
- TIMI Study Group (M.S.S.), Brigham and Women's Hospital, Boston, MA
- Division of Cardiovascular Medicine (M.S.S., S.D.S., M.V.), Brigham and Women's Hospital, Boston, MA
| | - Scott D Solomon
- Division of Cardiovascular Medicine (M.S.S., S.D.S., M.V.), Brigham and Women's Hospital, Boston, MA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, CA (J.R.T.)
- School of Medicine, University of California, San Francisco (J.R.T.)
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine (M.S.S., S.D.S., M.V.), Brigham and Women's Hospital, Boston, MA
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.)
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.)
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