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Kresoja K, Adamo M, Rommel K, Stolz L, Karam N, Giannini C, Melica B, von Bardeleben RS, Butter C, Horn P, Praz F, Kalbacher D, Iliadis C, Thiele H, Hausleiter J, Metra M, Lurz P. Guideline-directed medical therapy assessment in heart failure patients undergoing percutaneous mitral valve repair. ESC Heart Fail 2024; 11:1802-1807. [PMID: 38351672 PMCID: PMC11098622 DOI: 10.1002/ehf2.14705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 11/27/2023] [Accepted: 01/13/2024] [Indexed: 05/18/2024] Open
Abstract
AIMS Achieving optimized guideline-directed medical therapy (GDMT) is recommended prior to transcatheter mitral valve edge-to-edge repair (M-TEER) for secondary mitral regurgitation (SMR). We aimed to propose and validate an easy-to-use score for assessing the quality of GDMT in patients with heart failure with reduced ejection fraction (HFrEF) undergoing M-TEER. METHODS AND RESULTS Among the 1641 EuroSMR patients enrolled in the EuroSMR Registry who underwent M-TEER, a total of 1072 patients [median age 74, interquartile range (IQR) 67-79 years, 29% female] had complete data on GDMT and a left ventricular ejection fraction ≤ 40% and were included in the current study. We proposed a GDMT score that considers the dosage levels of three medication classes (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists), with a maximum score of 12 points indicating optimal GDMT. The primary outcome was all-cause mortality. The median GDMT score was 4 points (IQR 3-6). All three domains of the scoring system were associated with all-cause mortality (P < 0.05 for all). The overall GDMT score was associated with all-cause mortality (hazard ratio 0.90, 95% confidence interval 0.86-0.95 for each 1-point increase in the GDMT score). This association remained significant after adjusting for renal function and co-morbidities. CONCLUSIONS This study demonstrates the utility of a simple GDMT scoring system for assessing the adequacy of GDMT in HFrEF patients with relevant SMR undergoing M-TEER. The GDMT score has potential applications in guiding the design of future clinical trials and aiding clinical decision-making processes.
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Affiliation(s)
- Karl‐Patrik Kresoja
- Department of CardiologyUniversity Medical Center of MainzMainzGermany
- Department of Internal Medicine/CardiologyHeart Center Leipzig at University of Leipzig and Leipzig Heart ScienceStrümpellstraße 39Leipzig04289Germany
| | - Marianna Adamo
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Karl‐Phillipp Rommel
- Department of CardiologyUniversity Medical Center of MainzMainzGermany
- Department of Internal Medicine/CardiologyHeart Center Leipzig at University of Leipzig and Leipzig Heart ScienceStrümpellstraße 39Leipzig04289Germany
| | - Lukas Stolz
- Medizinische Klinik und Poliklinik IKlinikum der Universität MünchenMunichGermany
| | - Nicole Karam
- Department of CardiologyEuropean Hospital Georges Pompidou and Paris Cardiovascular Research Center, INSERM U970ParisFrance
| | - Cristina Giannini
- Cardiothoracic and Vascular DepartmentAzienda Ospedaliero‐Universitaria PisanaPisaItaly
| | - Bruno Melica
- Centro Hospitalar Vila Nova de GaiaEspinhoPortugal
| | | | - Christian Butter
- Department of Cardiology, Immanuel Heart Center BernauBrandenburg Medical School Theodor FontaneBernauGermany
| | - Patrick Horn
- Department of Cardiology, Heart CenterUniversity Hospital of DüsseldorfDüsseldorfGermany
| | - Fabien Praz
- Universitätsklinik für Kardiologie, Inselspital BernBernSwitzerland
| | - Daniel Kalbacher
- Department of CardiologyUniversity Heart and Vascular Center HamburgHamburgGermany
- German Center for Cardiovascular Research (DZHK), partner site Hamburg/Kiel/LübeckHamburgGermany
| | - Christos Iliadis
- Department of Cardiology, Heart CenterUniversity Hospital of CologneCologneGermany
| | - Holger Thiele
- Department of CardiologyUniversity Medical Center of MainzMainzGermany
- Department of Internal Medicine/CardiologyHeart Center Leipzig at University of Leipzig and Leipzig Heart ScienceStrümpellstraße 39Leipzig04289Germany
| | - Jörg Hausleiter
- Medizinische Klinik und Poliklinik IKlinikum der Universität MünchenMunichGermany
| | - Marco Metra
- Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Philipp Lurz
- Department of CardiologyUniversity Medical Center of MainzMainzGermany
- Department of Internal Medicine/CardiologyHeart Center Leipzig at University of Leipzig and Leipzig Heart ScienceStrümpellstraße 39Leipzig04289Germany
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Ferrannini G, Biber ME, Abdi S, Ståhlberg M, Lund LH, Savarese G. The management of heart failure in Sweden-the physician's perspective: a survey. Front Cardiovasc Med 2024; 11:1385281. [PMID: 38807949 PMCID: PMC11130511 DOI: 10.3389/fcvm.2024.1385281] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 04/17/2024] [Indexed: 05/30/2024] Open
Abstract
Aims To assess the barriers to guideline-directed medical therapy (GDMT) use in heart failure (HF), diagnostic workup and general knowledge about HF among physicians in Sweden. Methods A survey about the management of HF was sent to 828 Swedish physicians including general practitioners (GPs) and specialists during 2021-2022. Answers were reported as percentages and comparisons were made by specialty (GPs vs. specialists). Results One hundred sixty-eight physicians participated in the survey (40% females, median age 43 years; 41% GPs and 59% specialists). Electrocardiography and New York Heart Association class evaluations are mostly performed once a year by GPs (46%) and at every outpatient visit by specialists (40%). Echocardiography is mostly requested if there is clinical deterioration (60%). One-third of participants screen for iron deficiency only if there is anemia. Major obstacles to implementation of different drug classes in HF with reduced ejection fraction are related to side effects, with no significant differences between specialties. Device implantation is deemed appropriate regardless of aetiology (69%) and patient age (86%). Specialists answered correctly to knowledge questions more often than GPs. Eighty-six percent of participants think that GDMT should be implemented as much as possible. Most participants (57%) believe that regular patient assessment in nurse-led HF clinics improve adherence to GDMT. Conclusion Obstacles to GDMT implementation according to physicians in Sweden mainly relate to potential side effects, lack of specialist knowledge and organizational aspects. Further efforts should be placed in educational activities and structuring of nurse-led clinics.
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Affiliation(s)
- Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Internal Medicine Unit, Södertälje Hospital, Södertälje, Sweden
| | - Mattia Emanuele Biber
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Studies, University of Trieste School of Medicine, Trieste, Italy
| | - Sam Abdi
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Internal Medicine, Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Ståhlberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H. Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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Tomasoni D, Pagnesi M, Colombo G, Chiarito M, Stolfo D, Baldetti L, Lombardi CM, Adamo M, Maggi G, Inciardi RM, Loiacono F, Maccallini M, Villaschi A, Gasparini G, Montella M, Contessi S, Cocianni D, Perotto M, Barone G, Merlo M, Cappelletti AM, Rosano G, Sinagra G, Pini D, Savarese G, Metra M. Guideline-directed medical therapy in severe heart failure with reduced ejection fraction: An analysis from the HELP-HF registry. Eur J Heart Fail 2024; 26:327-337. [PMID: 37933210 DOI: 10.1002/ejhf.3081] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/08/2023] Open
Abstract
AIM Persistent symptoms despite guideline-directed medical therapy (GDMT) and poor tolerance of GDMT are hallmarks of patients with advanced heart failure (HF) with reduced ejection fraction (HFrEF). However, real-world data on GDMT use, dose, and prognostic implications are lacking. METHODS AND RESULTS We included 699 consecutive patients with HFrEF and at least one 'I NEED HELP' marker for advanced HF enrolled in a multicentre registry. Beta-blockers (BB) were administered to 574 (82%) patients, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors (ACEi/ARB/ARNI) were administered to 381 (55%) patients and 416 (60%) received mineralocorticoid receptor antagonists (MRA). Overall, ≥50% of target doses were reached in 41%, 22%, and 56% of the patients on BB, ACEi/ARB/ARNI and MRA, respectively. Hypotension, bradycardia, kidney dysfunction and hyperkalaemia were the main causes of underprescription and/or underdosing, but up to a half of the patients did not receive target doses for unknown causes (51%, 41%, and 55% for BB, ACEi/ARB/ARNI and MRA, respectively). The proportions of patients receiving BB and ACEi/ARB/ARNI were lower among those fulfilling the 2018 HFA-ESC criteria for advanced HF. Treatment with BB and ACEi/ARB/ARNI were associated with a lower risk of death or HF hospitalizations (adjusted hazard ratio [HR] 0.63, 95% confidence interval [CI] 0.48-0.84, and HR 0.74, 95% CI 0.58-0.95, respectively). CONCLUSIONS In a large, real-world, contemporary cohort of patients with severe HFrEF, with at least one marker for advanced HF, prescription and uptitration of GDMT remained limited. A significant proportion of patients were undertreated due to unknown reasons suggesting a potential role of clinical inertia either by the prescribing healthcare professional or by the patient. Treatment with BB and ACEi/ARB/ARNI was associated with lower mortality/morbidity.
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Affiliation(s)
- Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giada Colombo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Mauro Chiarito
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Maggi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Maria Inciardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Marta Maccallini
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alessandro Villaschi
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Gaia Gasparini
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Marco Montella
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Stefano Contessi
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniele Cocianni
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Maria Perotto
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Giuseppe Barone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Merlo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | | | - Giuseppe Rosano
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniela Pini
- Humanitas Research Hospital IRCCS, Rozzano, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Chen X, Kang Y, Dahlström U, Fu M. Impact of adherence to guideline-directed therapy on risk of death in HF patients across an ejection fraction spectrum. ESC Heart Fail 2023; 10:3656-3666. [PMID: 37803813 PMCID: PMC10682881 DOI: 10.1002/ehf2.14358] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 02/26/2023] [Accepted: 03/05/2023] [Indexed: 10/08/2023] Open
Abstract
AIMS How different degrees of adherence to guideline-directed medical therapy (GDMT) affect mortality risk in patients with heart failure (HF) in a real-world clinical setting is poorly understood. This study sought to investigate how different levels of adherence to GDMT were associated with the risk of all-cause mortality in patients with HF across a spectrum of left ventricular ejection fractions (LVEFs) in a real-world clinical setting. METHODS AND RESULTS A total of 64 610 HF patients with no missing value of LVEF from the Swedish Heart Failure Registry were included in the study. Patients were divided according to different LVEFs (<30%, 30-39%, 40-49%, and≥50%) and stratified by an adherence score (good, moderate, or poor) according to the triple, double, and single one usage of GDMT: angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists. The outcome is time to all-cause mortality. The mean age of the whole cohort was 73.9 ± 12.1 years, and the proportion of patients in LVEF < 30%, 30-39%, 40-49%, and≥50% groups was 27.6%, 26.9%, 22.1%, and 23.3%, respectively. Patients with LVEF < 30% had the highest mortality rate, almost 20% higher than those with LVEF ≥ 50% {hazard ratio [HR] [95% confidence interval (CI)]: 0.80 [0.71-0.90], P < 0.001}. After treatment of GDMT with good adherence, patients with LVEF < 30% had similar mortality to those with LVEF ≥ 50% [HR (95% CI): 0.97 (0.86-1.10), P = 0.664]. However, the percentage of moderate or poor GDMT was alarmingly high, with good adherence only in 20% of the patients. CONCLUSIONS Good adherence to GDMT works best in patients with LVEF < 50%, whereas moderate adherence to GDMT varies in efficacy depending on the components of the drug combinations.
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Affiliation(s)
- Xiaojing Chen
- Department of CardiologyWest China Hospital, Sichuan UniversityChengduSichuanChina
- Department of Molecular and Clinical Medicine, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
| | - Yu Kang
- Department of CardiologyWest China Hospital, Sichuan UniversityChengduSichuanChina
| | - Ulf Dahlström
- Department of CardiologyLinköping UniversityLinköpingSweden
- Department of Health, Medicine and Caring SciencesLinköping UniversityLinköpingSweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of MedicineSahlgrenska Academy, University of GothenburgGothenburgSweden
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Jarjour M, Ducharme A. Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines? Drugs Context 2023; 12:2023-5-6. [PMID: 38021409 PMCID: PMC10664772 DOI: 10.7573/dic.2023-5-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Heart failure is a growing epidemic with high mortality rates and recurrent hospital admissions that creates a burden on affected individuals, their caregivers and the whole healthcare system. Throughout the years, many randomized trials have established the effectiveness of several pharmacological therapies and electrophysiological devices to reduce hospitalizations and improve quality of life and survival, mostly for patients with heart failure with reduced ejection fraction (HFrEF). These studies led to the publication of national societies' recommendations to guide clinicians in the management of HFrEF. Yet, many reports have shown significant care gaps in adherence to these recommendations in clinical practice, highlighting suboptimal use and/or dosing of evidence-based therapies. Adherence to guidelines has been shown to be associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events; however, it remains unclear whether this association is causal or merely a marker of more advanced disease. Furthermore, individual characteristics may limit the possibility of reaching the targeted dosage of specific agents. Herein, we provide a comprehensive overview of clinicians' adherence to heart failure guidelines in a specialized real-life setting, particularly regarding use and optimization of guideline-derived medical therapies, as well as the implementation of more recent agents such as sacubitril/valsartan and SGLT2 inhibitors. We seek potential explanations for suboptimal treatment and its impact on patient outcomes.
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Affiliation(s)
- Marilyne Jarjour
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
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Memenga F, Rybczynski M, Magnussen C, Goßling A, Kondziella C, Becher N, Becher PM, Bernadyn J, Berisha F, Bremer W, Sinning C, Blankenberg S, Kirchhof P, Knappe D. Heart Rate Reduction and Outcomes in Heart Failure Outpatients. J Clin Med 2023; 12:6779. [PMID: 37959246 PMCID: PMC10648474 DOI: 10.3390/jcm12216779] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 10/09/2023] [Accepted: 10/24/2023] [Indexed: 11/15/2023] Open
Abstract
Aim. Pharmacologic reduction in heart rate with beta-blockers (BB) or ivabradine is associated with improved survival in heart failure (HF) with sinus rhythm. We analyzed the association of different heart rate-reducing drug treatments on outcomes in HF outpatients. Methods. Consecutive patients with HF in sinus rhythm referred to a specialized tertiary service were prospectively enrolled from August 2015 until March 2018. Clinical characteristics were assessed at baseline. We performed Cox regression analyses to examine the effect of the resting heart rate and different heart rate-reducing drug regimens on all-cause mortality and a composite endpoint of "all-cause mortality or heart transplantation" over a mean follow-up of 3.1 years. Results. Of the 278 patients included, 213 (76.6%) were male, the median age was 57.0 years (IQR 49.0-66.1), and 185 (73.7%) had an ejection fraction <40%. Most patients received BB in submaximal [n = 118] or maximum dose [n = 136]. Patients on BB in maximum dose plus ivabradine [n = 24] were younger (53.0 vs. 58.0 years) and had a lower EF (25 vs. 31%). Higher resting heart rate was associated with an increased risk of death or transplantation (HR 1.03 [1.01, 1.06], p = 0.0072), even after adjusting for age and sex. There were no differences between the groups concerning all-cause mortality or the composite endpoint. Conclusion. Our prospective study confirms the association between low heart rate and survival in HF patients receiving various heart rate-reducing medications. We could not identify a specific effect of either regimen.
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Affiliation(s)
- Felix Memenga
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
| | - Meike Rybczynski
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
| | - Christina Magnussen
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck
| | - Alina Goßling
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
| | - Christoph Kondziella
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
| | - Nina Becher
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck
| | - Peter Moritz Becher
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck
| | - Julia Bernadyn
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
| | - Filip Berisha
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck
| | - Wiebke Bremer
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
| | - Christoph Sinning
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck
| | - Paulus Kirchhof
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Luebeck
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham B152TT, UK
| | - Dorit Knappe
- Department of Cardiology, University Heart & Vascular Center Hamburg, 20246 Hamburg, Germany; (M.R.); (C.M.); (A.G.); (C.K.); (N.B.); (P.M.B.); (J.B.); (F.B.); (S.B.); (P.K.); (D.K.)
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Van der Linden L, Hias J, Walgraeve K, Petrovic M, Tournoy J, Vandenbriele C, Van Aelst L. Guideline-Directed Medical Therapies for Heart Failure with a Reduced Ejection Fraction in Older Adults: A Narrative Review on Efficacy, Safety and Timeliness. Drugs Aging 2023; 40:691-702. [PMID: 37452262 DOI: 10.1007/s40266-023-01046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
Heart failure is a prevalent syndrome among older adults, with a major impact on morbidity and mortality. Higher age is correlated with underuse of guideline-directed medical therapies which, in turn, has been linked to worse clinical outcomes. Importantly, most evidence so far has been collected in adults who were younger, less multi-morbid and polymedicated compared with those who are commonly treated in daily clinical practice. Hence, we aimed to assess and describe the evidence base for pharmacotherapy in older adults with heart failure with a reduced ejection. First, a narrative review was undertaken using Medline, from inception to January 2023. Four foundational therapies were selected based on the latest European Society of Cardiology clinical practice guideline: angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors. Post hoc analyses from landmark heart failure drug trials were searched and included if they contained data on the impact of age on efficacy, safety and/or timeliness of therapies in the management of heart failure with a reduced ejection fraction. Second, a proposal was developed to support and promote the use of evidence-based heart failure pharmacotherapy in complex, older adults. In total, 11 articles were selected: 4 meta-analyses, 6 post hoc analyses and 1 review paper. No attenuation of efficacy for any of the foundational agents was found in older adults. Regarding safety, dedicated analyses showed that beta blockers, mineraloid receptor antagonists, sacubitril-valsartan, dapagliflozin and empagliflozin retained their overall benefit-risk profile regardless of age. Time to benefit was short and occurred generally within 1 month. Consensus was achieved on a five-step proposal to manage complex medication regimens in older adults suffering from heart failure. In conclusion, older adults suffering from heart failure with a reduced ejection fraction should not be denied treatment based on their age.
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Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karolien Walgraeve
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary care, KU Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Adult intensive Care, Royal Brompton Hospital, Guy's & St. Thomas' NHS Foundations Trust, London, UK
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
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8
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Orszulak M, Baasansuren S, Balwierz M, Cempa M, Halfar A, Zimoląg A, Męcka K, Wybraniec MT, Mizia-Stec K. Evaluation of the pharmacotherapeutic impact on contractility recovery in patients with newly diagnosed, acute onset dilated cardiomyopathy. Medicine (Baltimore) 2023; 102:e33761. [PMID: 37327277 PMCID: PMC10270493 DOI: 10.1097/md.0000000000033761] [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: 12/22/2022] [Accepted: 04/21/2023] [Indexed: 06/18/2023] Open
Abstract
In patients with acute onset dilated cardiomyopathy (DCM) an improvement of left ventricular ejection fraction (LVEF) can occur as an effect of complex therapy. The aim of the study was to evaluate a pharmacotherapeutic impact on LVEF recovery in newly diagnosed DCM heart failure (HF) patients. A total of 2436 patients hospitalized due to acute decompensated HF were retrospectively analyzed. Finally, 24 patients with newly diagnosed DCM (51.4 ± 16.3 years, New York Heart Association 2.3 ± 0.7, LVEF 25 ± 10%) were observed (13.4 ± 16.0 months) in terms of the result of complex therapy. Patients were divided according to LVEF improvement on follow-up echocardiography: "recovery group" (LVEF improvement > 5%; n = 13) and "nonrecovery group" (∆LVEF ≤ 5%; n = 11). Evaluation of baseline parameters showed lower LVEF (19 ± 6 vs 31 ± 10%; P = .0048) and lower incidence of arterial hypertension (27% vs 73%; P = .043) in "recovery" group. After follow-up period LVEF was similar in both groups; however, significant LVEF improvement was demonstrated only in the "recovery group" (19 ± 6% to 34 ± 8%; P < .001). Only the "recovery group" showed significant HF symptoms reduction (New York Heart Association class: 2.5 ± 0.7 to 1.6 ± 0.6; P = .003). The "recovery group" had prescribed higher doses of loop diuretic (equivalent dose of furosemidum: 80 ± 38 mg vs 43 ± 24 mg; P = .025). Despite optimal therapy, significant LVEF improvement is observed only in the half of the patients with newly diagnosed DCM with HF with reduced EF. Prescription of higher doses of loop diuretics may have positive effect on the reduction of symptoms in newly diagnosed DCM HF patients. Lack of other risk factors such as arterial hypertension may increase the chance of LVEF recovery.
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Affiliation(s)
- Michal Orszulak
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Sugarmaa Baasansuren
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Magdalena Balwierz
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Miłosz Cempa
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Andrzej Halfar
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Aneta Zimoląg
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Klaudia Męcka
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Maciej T. Wybraniec
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Mizia-Stec
- First Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
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9
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Cappelletto C, Stolfo D, Orsini N, Benson L, Rodolico D, Rosano GMC, Dahlström U, Sinagra G, Lund LH, Savarese G. Use of and association between heart failure pharmacological treatments and outcomes in obese versus non-obese patients with heart failure with reduced ejection fraction: data from the Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:698-710. [PMID: 36781199 DOI: 10.1002/ejhf.2795] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2022] [Revised: 01/21/2023] [Accepted: 02/02/2023] [Indexed: 02/15/2023] Open
Abstract
AIMS To investigate the use of guideline-directed medical therapies (GDMT) and associated outcomes in obese (body mass index ≥30 kg/m2 ) versus non-obese patients with heart failure (HF) with reduced ejection fraction (HFrEF). METHODS AND RESULTS Patients with HFrEF from the Swedish HF Registry were included. Of 16 116 patients, 24% were obese. In obese versus non-obese patients, use of treatments was 91% versus 86% for renin-angiotensin system inhibitors (RASi)/angiotensin receptor-neprilysin inhibitors (ARNi), 94% versus 91% for beta-blockers, 53% versus 43% for mineralocorticoid receptor antagonists. Obesity was shown to be independently associated with more likely use of each treatment, triple combination therapy, and the achievement of target dose by multivariable logistic regressions. Multivariable Cox regressions showed use of RASi/ARNi and beta-blockers being independently associated with lower risk of all-cause/cardiovascular death regardless of obesity, although, when considering competing risks, a lower risk of cardiovascular death with RASi/ARNi in obese versus non-obese patients was observed. RASi/ARNi were associated with lower risk of HF hospitalization in obese but not in non-obese patients, whereas beta-blockers were not associated with the risk of HF hospitalization regardless of obesity. At the competing risk analysis, RASi/ARNi use was associated with higher risk of HF hospitalization regardless of obesity. CONCLUSION Obese patients were more likely to receive optimal treatments after adjustment for factors affecting tolerability, suggesting that perceived beyond actual tolerance issues limit GDMT implementation. RASi/ARNi and beta-blockers were associated with lower mortality regardless of obesity, with a greater association between RASi/ARNi and lower cardiovascular death in obese versus non-obese patients when considering competing risk.
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Affiliation(s)
- Chiara Cappelletto
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Cardiology, Cardiothoracovascular Department, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano Isontina and University of Trieste, Trieste, Italy
| | - Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Cardiology, Cardiothoracovascular Department, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano Isontina and University of Trieste, Trieste, Italy
| | - Nicola Orsini
- Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Daniele Rodolico
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiovascular and Pulmonary Sciences, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Giuseppe M C Rosano
- Cardiology Clinical Academic Group, Molecular and Clinical Sciences Research Institute, St Georges, University of London, London, UK
- IRCCS San Raffaele Pisana, Rome, Italy
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Gianfranco Sinagra
- Division of Cardiology, Cardiothoracovascular Department, Cattinara Hospital, Azienda Sanitaria Universitaria Giuliano Isontina and University of Trieste, Trieste, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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10
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Patel HC, Kaye DM. Sodium-glucose cotransporter 2 inhibitors: efficacious and safe in elderly patients with heart failure. Eur J Heart Fail 2022; 24:2305-2306. [PMID: 36394526 DOI: 10.1002/ejhf.2744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Hitesh C Patel
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
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11
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Nakai M, Iwanaga Y, Kanaoka K, Sumita Y, Nishioka Y, Myojin T, Kubo S, Okada K, Soeda T, Noda T, Sakata Y, Imamura T, Saito Y, Yasuda S, Miyamoto Y. Age-dependent association of discharge heart-failure medications with clinical outcomes in a super-aged society. Biomed Pharmacother 2022; 155:113761. [DOI: 10.1016/j.biopha.2022.113761] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 09/20/2022] [Accepted: 09/26/2022] [Indexed: 11/30/2022] Open
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12
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Already low drug dose antagonism of the renin-angiotensin aldosterone system decreases 1-year mortality and rehospitalization in old heart failure patients. Biomed Pharmacother 2022; 154:113615. [DOI: 10.1016/j.biopha.2022.113615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 08/24/2022] [Accepted: 08/25/2022] [Indexed: 11/24/2022] Open
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13
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Milinković I, Polovina M, Coats AJS, Rosano GMC, Seferović PM. Medical Treatment of Heart Failure with Reduced Ejection Fraction in the Elderly. Card Fail Rev 2022; 8:e17. [PMID: 35601008 PMCID: PMC9115638 DOI: 10.15420/cfr.2021.14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Accepted: 11/26/2021] [Indexed: 11/24/2022] Open
Abstract
The aging population, higher burden of predisposing conditions and comorbidities along with improvements in therapy all contribute to the growing prevalence of heart failure (HF). Although the majority of trials have not demonstrated age-dependent heterogeneity in the efficacy or safety of medical treatment for HF, the latest trials demonstrate that older participants are less likely to receive established drug therapies for HF with reduced ejection fraction. There remains reluctance in real-world clinical practice to prescribe and up-titrate these medications in older people, possibly because of (mis)understanding about lower tolerance and greater propensity for developing adverse drug reactions. This is compounded by difficulties in the management of multiple medications, patient preferences and other non-medical considerations. Future research should provide a more granular analysis on how to approach medical and device therapies in elderly patients, with consideration of biological differences, difficulties in care delivery and issues relevant to patients’ values and perspectives. A variety of approaches are needed, with the central principle being to ‘add years to life – and life to years’. These include broader representation of elderly HF patients in clinical trials, improved education of healthcare professionals, wider provision of specialised centres for multidisciplinary HF management and stronger implementation of HF medical treatment in vulnerable patient groups.
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Affiliation(s)
- Ivan Milinković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | | | | | - Petar M Seferović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia; Serbian Academy of Sciences and Arts, Belgrade, Serbia
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14
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Stolfo D, Sinagra G, Savarese G. Evidence-based Therapy in Older Patients with Heart Failure with Reduced Ejection Fraction. Card Fail Rev 2022; 8:e16. [PMID: 35541287 PMCID: PMC9069263 DOI: 10.15420/cfr.2021.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/15/2022] [Indexed: 11/06/2022] Open
Abstract
Older patients are becoming prevalent among people with heart failure (HF) as the overall population ages. However, older patients are largely under-represented, or even excluded, from randomised controlled trials on HF with reduced ejection fraction, limiting the generalisability of trial results in the real world and leading to weaker evidence supporting the use and titration of guideline-directed medical therapy (GDMT) in older patients with HF with reduced ejection fraction. This, in combination with other factors limiting the application of guideline recommendations, including a fear of poor tolerability or adverse effects, the heavy burden of comorbidities and the need for multiple therapies, classically leads to lower adherence to GDMT in older patients. Although there are no data supporting the under-use and under-dosing of HF medications in older patients, large registry-based studies have confirmed age as one of the major obstacles to treatment optimisation. In this review, the authors provide an overview of the contemporary state of implementation of GDMT in older groups and the reasons for the lower use of treatments, and discuss some measures that may help improve adherence to evidence-based recommendations in older age groups.
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Affiliation(s)
- Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina and University Hospital of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina and University Hospital of Trieste, Trieste, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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15
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Stolfo D, Lund LH, Becher PM, Orsini N, Thorvaldsen T, Benson L, Hage C, Dahlström U, Sinagra G, Savarese G. Use of evidence‐based therapy in heart failure with reduced ejection fraction across age strata. Eur J Heart Fail 2022; 24:1047-1062. [PMID: 35278267 PMCID: PMC9546348 DOI: 10.1002/ejhf.2483] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/05/2022] [Accepted: 03/10/2022] [Indexed: 11/05/2022] Open
Affiliation(s)
- Davide Stolfo
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Cardiothoracovascular Department and University of Trieste Trieste Italy
| | - Lars H Lund
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - Peter Moritz Becher
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center of Cardiovascular Research (DZHK) Partner Site Hamburg/Kiel/Lübeck Germany
| | - Nicola Orsini
- Department of Global Public Health Karolinska Institutet Stockholm Sweden
| | - Tonje Thorvaldsen
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
| | - Lina Benson
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
| | - Camilla Hage
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences Linköping University Linköping Sweden
| | - Gianfranco Sinagra
- Cardiothoracovascular Department and University of Trieste Trieste Italy
| | - Gianluigi Savarese
- Department of Medicine, Division of Cardiology Karolinska Institutet Stockholm Sweden
- Heart and Vascular Theme Karolinska University Hospital Stockholm Sweden
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16
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Rosano GM, Vitale C, Adamo M, Metra M. Roadmap for the management of heart failure patients during the vulnerable phase after heart failure hospitalizations: how to implement excellence in clinical practice. J Cardiovasc Med (Hagerstown) 2022; 23:149-156. [PMID: 34937849 PMCID: PMC10484190 DOI: 10.2459/jcm.0000000000001221] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2021] [Revised: 05/08/2021] [Accepted: 05/27/2021] [Indexed: 11/05/2022]
Abstract
Patients discharged after an episode of acute heart failure have an increased risk of hospitalizations and deaths within the subsequent 3 months. This phase is commonly called the 'vulnerable period' and it represents a window of opportunity of intervention in order to improve longer term outcomes. Prompt identification of signs of residual haemodynamic congestion is a priority in planning for the out-of-hospital management strategies. Patients will also need to be screened for frailty and have a prioritization of the management of their comorbidities. Life-saving medications should be started together or in a short time and up-titrated (when needed) according to blood pressure, heart rate and concomitant comorbidities. Ideally, patients should be assessed by their general practitioner within 1 week of discharge and have a hospital/clinic follow-up within 4 weeks of discharge. Patients should progressively resume physical activities and adhere to an educational programme with appropriate lifestyle adjustments best implemented during a cardiac rehabilitation programme.
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Affiliation(s)
- Giuseppe M.C. Rosano
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome
| | - Cristiana Vitale
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome
| | - Marianna Adamo
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Bresica, Italy
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Bresica, Italy
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17
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Hias J, Hellemans L, Walgraeve K, Tournoy J, Van der Linden L. SGLT2 Inhibitors in Older Adults with Heart Failure with Preserved Ejection Fraction. Drugs Aging 2022; 39:185-190. [PMID: 35118602 DOI: 10.1007/s40266-022-00920-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2022] [Indexed: 11/03/2022]
Abstract
Heart failure is an important medical condition that is prevalent in older adults. Multiple therapies have been identified that improve clinical outcome in heart failure with a reduced ejection fraction. Conversely, this has not been the case in heart failure with preserved ejection fraction (HFpEF). Until now, empagliflozin is the first therapy that has convincingly been shown to improve clinical outcome in HFpEF. Importantly, some key points should be considered to better understand the impact of empagliflozin on the patient trajectory, particularly in older adults with HFpEF. In this current opinion article, we have therefore provided more information on how to translate the findings of the EMPEROR-Preserved trial to the setting of older adults, with a focus on the impact of empagliflozin on hospitalizations, both heart failure-related and all-cause. To better understand the importance of EMPEROR-Preserved findings, we compared these findings with previous relevant HFpEF and heart failure with reduced ejection fraction (HFrEF) trials and provided information on ongoing trials in the HFpEF setting.
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Affiliation(s)
- Julie Hias
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Laura Hellemans
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | | | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Geriatrics and Gerontology, Department of Public Health and Primary Care, KU Leuven, Leuven, Belgium
| | - Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Leuven, Belgium. .,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
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18
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Pagnesi M, Adamo M, Metra M. March 2021 at a glance: focus on epidemiology, prevention and COVID-19. Eur J Heart Fail 2021; 23:347-349. [PMID: 33915003 PMCID: PMC8207108 DOI: 10.1002/ejhf.1878] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Affiliation(s)
- Matteo Pagnesi
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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19
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Ferreira JP, Konstam MA, McMurray JJV, Butler J, Girerd N, Rossignol P, Sharma A, Voors AA, Lam CSP, Packer M, Zannad F. Dosing of losartan in men versus women with heart failure with reduced ejection fraction: the HEAAL trial. Eur J Heart Fail 2021; 23:1477-1484. [PMID: 34050594 DOI: 10.1002/ejhf.2255] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 05/25/2021] [Accepted: 05/25/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS In heart failure with reduced ejection fraction (HFrEF), guidelines recommend up-titration of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptors blockers (ARBs) to the maximum tolerated dose. However, some studies suggest that women might need lower doses of ACEi/ARBs than men to achieve similar treatment benefit. METHODS AND RESULTS The HEAAL trial compared low vs. high dose of losartan. We reassessed the efficacy and safety of high- vs. low-dose in men vs. women using Cox models and machine learning algorithms. The mean age was 66 years and 30% of patients were women. Men appeared to have benefited more from high-dose than from low-dose losartan, whereas women appeared to have responded similarly to low and high doses [hazard ratio (95% confidence interval) comparing high- vs. low-dose losartan for the composite outcome of all-cause death or all-cause hospitalization: 0.89 (0.81-0.98) in men and 1.10 (0.95-1.28) in women; interaction P = 0.018]. Female sex clustered along with older age, ischaemic heart failure, New York Heart Association class III/IV, and estimated glomerular filtration rate <60 mL/min. Patients with these features had a poorer response to high-dose losartan. Subgroup analyses supported no benefit from high-dose losartan in patients with poorer kidney function and severe heart failure symptoms. CONCLUSIONS Compared with men, women might need lower doses of losartan to achieve similar treatment benefit. However, beyond sex, other factors (e.g. kidney function, age, and symptoms) may influence the response to high-dose losartan, suggesting that sex-based subgroup findings may be biased by other confounders.
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Affiliation(s)
- João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, CHRU de Nancy, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Marvin A Konstam
- The CardioVascular Center of Tufts Medical Center, Boston, MA, USA
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, CHRU de Nancy, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Patrick Rossignol
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, CHRU de Nancy, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Abhinav Sharma
- Division of Cardiology, McGill University Health Centre, McGill University, Montreal, Canada
| | - Adriaan A Voors
- University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carolyn S P Lam
- National Heart Center Singapore, and Duke National University of Singapore, Singapore
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, UMR 1116, CHRU de Nancy, F-CRIN INI-CRCT Cardiovascular and Renal Clinical Trialists, Nancy, France
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