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Romiti GF, Nabrdalik K, Corica B, Bucci T, Proietti M, Qian M, Chen Y, Thompson JLP, Homma S, Lip GYH. Diabetes mellitus in patients with heart failure and reduced ejection fraction: a post hoc analysis from the WARCEF trial. Intern Emerg Med 2024; 19:931-939. [PMID: 38393500 DOI: 10.1007/s11739-024-03544-4] [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: 11/16/2023] [Accepted: 01/16/2024] [Indexed: 02/25/2024]
Abstract
Patients with heart failure with reduced ejection fraction (HFrEF) and diabetes mellitus (DM) have an increased risk of adverse events, including thromboembolism. In this analysis, we aimed to explore the association between DM and HFrEF using data from the "Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction" (WARCEF) trial. We analyzed factors associated with DM using multiple logistic regression models and evaluated the effect of DM on long-term prognosis, through adjusted Cox regressions. The primary outcome was the composite of all-cause death, ischemic stroke, or intracerebral hemorrhage; we explored individual components as the secondary outcomes and the interaction between treatment (warfarin or aspirin) and DM on the risk of the primary outcome, stratified by relevant characteristics. Of 2294 patients (mean age 60.8 (SD 11.3) years, 19.9% females) included in this analysis, 722 (31.5%) had DM. On logistic regression, cardiovascular comorbidities, symptoms and ethnicity were associated with DM at baseline, while age and body mass index showed a nonlinear association. Patients with DM had a higher risk of the primary composite outcome (Hazard Ratio [HR] and 95% Confidence Intervals [CI]: 1.48 [1.24-1.77]), as well as all-cause death (HR [95%CI]: 1.52 [1.25-1.84]). As in prior analyses, no statistically significant interaction was observed between DM and effect of Warfarin on the risk of the primary outcome, in any of the subgroups explored. In conclusion, we found that DM is common in HFrEF patients, and is associated with other cardiovascular comorbidities and risk factors, and with a worse prognosis.
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Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Katarzyna Nabrdalik
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Bernadette Corica
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Min Qian
- Mailman School of Public Health, Columbia University, New York, USA
| | - Yineng Chen
- Center for Preventive Ophthalmology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Shunichi Homma
- Cardiology Division, Columbia University Medical Center, New York, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Mentias A, Keshvani N, Sumarsono A, Desai R, Khan MS, Menon V, Hsich E, Bress AP, Jacobs J, Vasan RS, Fonarow GC, Pandey A. Patterns, Prognostic Implications, and Rural-Urban Disparities in Optimal GDMT Following HFrEF Diagnosis Among Medicare Beneficiaries. JACC. HEART FAILURE 2024; 12:1044-1055. [PMID: 37943222 DOI: 10.1016/j.jchf.2023.08.027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 08/28/2023] [Accepted: 08/30/2023] [Indexed: 11/10/2023]
Abstract
BACKGROUND Patterns and disparities in guideline-directed medical therapy (GDMT) uptake for heart failure with reduced ejection fraction (HFrEF) across rural vs urban regions are not well described. OBJECTIVES This study aims to evaluate patterns, prognostic implications, and rural-urban differences in GDMT use among Medicare beneficiaries following new-onset HFrEF. METHODS Patients with a diagnosis of new-onset HFrEF in a 5% Medicare sample with available data for Part D medication use were identified from January 2015 through December 2020. The primary exposure was residence in rural vs urban zip codes. Optimal triple GDMT was defined as ≥50% of the target daily dose of beta-blockers, ≥50% of the target daily dose of angiotensin-converting enzyme inhibitors/angiotensin receptor blocker or any dose of sacubitril/valsartan, and any dose of mineralocorticoid receptor antagonist. The association between the achievement of optimal GDMT over time following new-onset HFrEF diagnosis and risk of all-cause mortality and subsequent HF hospitalization was also evaluated using adjusted Cox models. The association between living in rural vs urban location and time to optimal GDMT achievement over a 12-month follow-up was assessed using cumulative incidence curves and adjusted Fine-Gray subdistribution hazard models. RESULTS A total of 41,296 patients (age: 76.7 years; 15.0% Black; 27.6% rural) were included. Optimal GDMT use over the 12-month follow-up was low, with 22.5% initiated on any dose of triple GDMT and 9.1% on optimal GDMT doses. Optimal GDMT on follow-up was significantly associated with a lower risk of death (HR: 0.89 [95% CI: 0.85-0.94]; P < 0.001) and subsequent HF hospitalization (HR: 0.93 [95% CI: 0.87-0.98]; P = 0.02). Optimal GDMT use at 12 months was significantly lower among patients living in rural (vs urban) areas (8.4% vs 9.3%; P = 0.02). In adjusted analysis, living in rural (vs urban) locations was associated with a significantly lower probability of achieving optimal GDMT (HR: 0.92 [95% CI: 0.86-0.98]; P = 0.01 Differences in optimal GDMT use following HFrEF diagnosis accounted for 16% of excess mortality risk among patients living in rural (vs urban) areas. CONCLUSIONS Use of optimal GDMT following new-onset HFrEF diagnosis is low, with substantially lower use noted among patients living in rural vs urban locations. Suboptimal GDMT use following new-onset HFrEF was associated with an increased risk of mortality and subsequent HF hospitalization.
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Affiliation(s)
- Amgad Mentias
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew Sumarsono
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | | | | | - Venu Menon
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eileen Hsich
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio, USA
| | - Adam P Bress
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Joshua Jacobs
- Department of Population Health Sciences, Spencer Fox Eccles School of Medicine, University of Utah, Salt Lake City, Utah, USA
| | - Ramachandran S Vasan
- School of Public Health, Department of Population Health, and Division of Cardiology, Long School of Medicine, University of Texas San Antonio, San Antonio, Texas, USA
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Los Angeles, California, USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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Villaschi A, Chiarito M, Pagnesi M, Stolfo D, Baldetti L, Lombardi CM, Adamo M, Loiacono F, Sammartino AM, Colombo G, Tomasoni D, Inciardi RM, Maccallini M, Gasparini G, Montella M, Contessi S, Cocianni D, Perotto M, Barone G, Merlo M, Vitale C, Rosano GMC, Cappelletti AM, Sinagra G, Metra M, Pini D. Frailty according to the 2019 HFA-ESC definition in patients at risk for advanced heart failure: Insights from the HELP-HF registry. Eur J Heart Fail 2024. [PMID: 38741569 DOI: 10.1002/ejhf.3234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 03/05/2024] [Accepted: 03/27/2024] [Indexed: 05/16/2024] Open
Abstract
AIMS Frailty is highly prevalent in patients with heart failure (HF), but a concordant definition of this condition is lacking. The Heart Failure Association of the European Society of Cardiology (HFA-ESC) proposed in 2019 a new multi-domain definition of frailty, but it has never been validated. METHODS AND RESULTS Patients from the HELP-HF registry were stratified according to the number of HFA-ESC frailty domains fulfilled and to the cumulative deficits frailty index (FI) quintiles. Prevalence of frailty and of each domain was reported, as well as the rate of the composite of all-cause death and HF hospitalization, its single components, and cardiovascular death in each group and quintile. Among 854 included patients, 37 (4.3%), 206 (24.1%), 365 (42.8%), 217 (25.4%), and 29 (3.4%) patients fulfilled zero, one, two, three, or four domains, respectively, while 179 patients had a FI < 0.21 and were considered not frail. The 1-year risk of adverse events increased proportionally to the number of domains fulfilled (for each criterion increase, all-cause death or HF hospitalization: hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.27-1.62; all-cause death: HR 1.72, 95% CI 1.46-2.02, HF hospitalizations: subHR 1.21, 95% CI 1.04-1.31; cardiovascular death: HR 1.77, 95% CI 1.45-2.15). Consistent results were found stratifying the cohort for FI quintiles. The FI as a continuous variable demonstrated higher discriminative ability than the number of domains fulfilled (area under the curve = 0.68 vs. 0.64, p = 0.004). CONCLUSION Frailty in patients at risk for advanced HF, assessed via a multi-domain approach and the FI, is highly prevalent and identifies those at increased risk of adverse events. The FI was found to be slightly more effective in identifying patients at increased risk of mortality.
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Affiliation(s)
- Alessandro Villaschi
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Mauro Chiarito
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, 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
| | | | - Antonio Maria Sammartino
- 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
| | - Daniela Tomasoni
- 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, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Gaia Gasparini
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Marco Montella
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, 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
| | - Cristiana Vitale
- 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
| | - 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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Zahir Anjum D, Strange JE, Fosbøl E, Garred CH, Elmegaard M, Andersson C, Jhund PS, McMurray JJV, Petrie MC, Kober L, Schou M. Use of medical therapy and risk of clinical events according to frailty in heart failure patients - A real-life cohort study. Eur J Heart Fail 2024. [PMID: 38700461 DOI: 10.1002/ejhf.3249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 03/21/2024] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
AIMS Although recent randomized clinical trials have demonstrated the advantages of heart failure (HF) therapy in both frail and not frail patients, there is insufficient information on the use of HF therapy based on frailty status in a real-world setting. The aim was to examine how frailty status in HF patients associates with use of HF therapy and with clinical outcomes. METHODS AND RESULTS Patients with new-onset HF between 2014 and 2021 were identified using the nationwide Danish registers. Patients across the entire range of ejection fraction were included. The associations between frailty status (using the Hospital Frailty Risk Score) and use of HF therapy and clinical outcomes (all-cause mortality, HF hospitalization, and non-HF hospitalization) were evaluated using multivariable-adjusted Cox models adjusting for age, sex, diagnostic setting, calendar year, comorbidities, pharmacotherapy, and socioeconomic status. Of 35 999 participants (mean age 69.1 years), 68% were not frail, 26% were moderately frail, and 6% were severely frail. The use of HF therapy was significantly lower in frailer patients. The hazard ratio (HR) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker initiation was 0.74 (95% confidence interval 0.70-0.77) and 0.48 (0.43-0.53) for moderate frailty and severe frailty, respectively. For beta-blockers, the corresponding HRs were 0.74 (0.71-0.78) and 0.51 (0.46-0.56), respectively, and for mineralocorticoid receptor antagonists, 0.83 (0.80-0.87) and 0.58 (0.53-0.64), respectively. The prevalence of death and non-HF hospitalization increased with frailty status. The HR for death was 1.55 (1.47-1.63) and 2.32 (2.16-2.49) for moderate and severe frailty, respectively, and the HR for non-HF hospitalization was 1.37 (1.32-1.41) and 1.82 (1.72-1.92), respectively. The association between frailty status and HF hospitalization was not significant (HR 1.08 [1.02-1.14] and 1.08 [0.97-1.20], respectively). CONCLUSION In real-world HF patients, frailty was associated with lower HF therapy use and with a higher incidence of clinical outcomes including mortality and non-HF hospitalization.
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Affiliation(s)
- Deewa Zahir Anjum
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Jarl E Strange
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Mariam Elmegaard
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Charlotte Andersson
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Kober
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Chuzi S, Manning K. Integration of palliative care across the spectrum of heart failure care and therapies: considerations, contemporary data, and challenges. Curr Opin Cardiol 2024; 39:218-225. [PMID: 38567949 DOI: 10.1097/hco.0000000000001120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2024]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is characterized by significant symptoms, compromised quality of life, frequent hospital admissions, and high mortality, and is therefore well suited to palliative care (PC) intervention. This review elaborates the current PC needs of patients with HF across the spectrum of disease, including patients who undergo advanced HF surgical therapies, and reviews the current data and future directions for PC integration in HF care. RECENT FINDINGS Patients with chronic HF, as well as those who are being evaluated for or who have undergone advanced HF surgical therapies such as left ventricular assist device or heart transplantation, have a number of PC needs, including decision-making, symptoms and quality of life, caregiver support, and end-of-life care. Available data primarily supports the use of PC interventions in chronic HF to improve quality of life and symptoms. PC skills and teams may also help address preparedness planning, adverse events, and psychosocial barriers in patients who have had HF surgeries, but more data are needed to determine association with outcomes. SUMMARY Patients with HF have tremendous PC needs across the spectrum of disease. Despite this, more data are needed to determine the optimal timing and structure of PC interventions in patients with chronic HF, left ventricular assist device, and heart transplantation. Future steps must be taken in clinical, research, and policy domains in order to optimize care.
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Affiliation(s)
- Sarah Chuzi
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Katharine Manning
- Heart and Vascular Center, Dartmouth-Hitchcock Medical Center
- Section of Palliative Medicine, Department of Internal Medicine, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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6
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Maeda D, Fujimoto Y, Nakade T, Abe T, Ishihara S, Jujo K, Matsue Y. Frailty, Sarcopenia, Cachexia, and Malnutrition in Heart Failure. Korean Circ J 2024; 54:54.e51. [PMID: 38767446 DOI: 10.4070/kcj.2024.0089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Accepted: 04/10/2024] [Indexed: 05/22/2024] Open
Abstract
With global aging, the number of patients with heart failure has increased markedly. Heart failure is a complex condition intricately associated with aging, organ damage, frailty, and cognitive decline, resulting in a poor prognosis. The relationship among frailty, sarcopenia, cachexia, malnutrition, and heart failure has recently received considerable attention. Although these conditions are distinct, they often exhibit a remarkably close relationship. Overlapping diagnostic criteria have been observed in the recently proposed guidelines and position statements, suggesting that several of these conditions may coexist in patients with heart failure. Therefore, a comprehensive understanding of these conditions is essential, and interventions must not only target these conditions individually, but also provide comprehensive management strategies. This review article provides an overview of the epidemiology, diagnostic methods, overlap, and prognosis of frailty, sarcopenia, cachexia, and malnutrition in patients with heart failure, incorporating insights from the FRAGILE-HF study data. Additionally, based on existing literature, this article discusses the impact of these conditions on the effectiveness of guideline-directed medical therapy for patients with heart failure. While recognizing these conditions early and promptly implementing interventions may be advantageous, further data, particularly from well-powered, large-scale, randomized controlled trials, are necessary to refine personalized treatment strategies for patients with heart failure.
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Affiliation(s)
- Daichi Maeda
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yudai Fujimoto
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Taisuke Nakade
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takuro Abe
- Department of Cardiology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Shiro Ishihara
- Department of Cardiology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Kentaro Jujo
- Department of Cardiology, Saitama Medical Center, Saitama Medical University, Saitama, Japan
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan.
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Yuguchi T, Nakajima K, Takaoka H, Shimokawa T. Usefulness of Clinical Frailty Scale for Comprehensive Geriatric Assessment of Older Heart Failure Patients. Circ Rep 2024; 6:127-133. [PMID: 38606420 PMCID: PMC11004034 DOI: 10.1253/circrep.cr-24-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Accepted: 02/08/2024] [Indexed: 04/13/2024] Open
Abstract
Background: Comprehensive geriatric assessment (CGA) is a multidisciplinary diagnostic process to identify the physical, psychological, and social functions of patients with frailty. The Clinical Frailty Scale (CFS) might aid in effectively identifying older patients with heart failure (HF) and frailty who would then reap maximum benefits from the CGA. Methods and Results: A single-centre prospective cohort study that enrolled consecutive hospitalised patients (age ≥75 years) with HF was conducted. The Barthel index (BI), Mini Mental State Examination (MMSE), the Charlson comorbidity index (CCI), and the COntrolling NUTritional (CONUT) for CGA was used. Among 190 enrolled patients (mean age, 85.4 years; 47.9% male), all-cause mortality (primary endpoint) occurred in 45 patients and HF-related rehospitalization (secondary endpoint) in 59 patients within 1 year. The cumulative incidence of all-cause mortality was significantly higher in the high CFS group (low 6.3%, high 30.5%, P<0.001). However, the cumulative incidence of HF-related rehospitalization was not significantly different (low 26.3%, high 32.0%, P=0.304). The multivariable analysis revealed that the CFS group was independently associated with the risk of all-cause mortality. CFS showed a strong correlation with the BI and moderate correlation with the MMSE. Conclusions: The CFS was associated with all-cause mortality within 1 year and was correlated with frailty domains of CGA.
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Affiliation(s)
- Tadashi Yuguchi
- Department of Intensive Care Medicine, Nara Prefecture General Medical Center Nara Japan
- Department of Internal Medicine, Division of Cardiovascular Medicine, Aijinkai Takatsuki General Hospital Takatsuki Japan
| | - Kenji Nakajima
- Department of Internal Medicine, Division of Cardiovascular Medicine, Aijinkai Takatsuki General Hospital Takatsuki Japan
| | - Hideyuki Takaoka
- Department of Internal Medicine, Division of Cardiovascular Medicine, Aijinkai Takatsuki General Hospital Takatsuki Japan
| | - Toshio Shimokawa
- Clinical Study Support Center, Wakayama Medical University Wakayama Japan
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Heckman GA, Barnard K, McKelvie RS. Yes, Frailty Matters: Time for Action. Can J Cardiol 2024; 40:685-687. [PMID: 38181973 DOI: 10.1016/j.cjca.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Revised: 12/31/2023] [Accepted: 01/01/2024] [Indexed: 01/07/2024] Open
Affiliation(s)
- George A Heckman
- School of Public Health Sciences, University of Waterloo, Waterloo, Ontario, Canada.
| | - Kari Barnard
- St. Joseph's Health Care London and Western University, London, Ontario, Canada
| | - Robert S McKelvie
- St. Joseph's Health Care London and Western University, London, Ontario, Canada
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9
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Aguilar-Iglesias L, Perez-Asensio A, Vilches-Miguel L, Jimenez-Mendez C, Diez-Villanueva P, Perez-Rivera JA. Impact of Frailty on Heart Failure Prognosis: Is Sex Relevant? Curr Heart Fail Rep 2024; 21:131-138. [PMID: 38363515 DOI: 10.1007/s11897-024-00650-4] [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] [Accepted: 01/31/2024] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is one of the most frequent causes of hospital admission in elderly patients, especially in women, who present a high prevalence of geriatric syndromes like frailty. Studies have suggested that frailty and its impact may also differ between males and females. Understanding how frailty may differently affect HF patients depending on sex is therefore imperative for providing personalized care. The aim of this review is to summarize the role of sex in the prognostic impact of frailty in HF patients. RECENT FINDINGS Numerous studies have identified frailty as a significant predictor of all-cause mortality and hospital readmissions. A recent study of elderly HF out-patients demonstrated that while women had a higher prevalence of frailty, it was an independent predictor of mortality and readmission only in men. Moreover, another study revealed that physical frailty was associated with time to first clinical event among men but not among women. These results raise the question about why frailty affects differently HF prognosis in men and women. Women with HF present a higher prevalence of frailty, especially when it is considered as physical decline. Nevertheless, frailty affects differently HF prognosis in men and women. Women with HF present lower mortality than men and frailty is related with prognosis only in men. The different severity of HF between men and women and other hormonal, psychosocial, and clinical factors might be involved in this fact.
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Affiliation(s)
- Lara Aguilar-Iglesias
- Department of Cardiology, Hospital Universitario de Burgos, Avda. Islas Baleares, 3. 09005, Burgos, Spain
| | - Ana Perez-Asensio
- Department of Cardiology, Hospital Universitario Puerta del Mar, Cádiz, Spain
| | | | | | | | - Jose-Angel Perez-Rivera
- Department of Cardiology, Hospital Universitario de Burgos, Avda. Islas Baleares, 3. 09005, Burgos, Spain.
- Facultad de Ciencias de La Salud, Universidad Isabel I, Burgos, Spain.
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10
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Lai H, Huang S, Anker SD, von Haehling S, Akishita M, Arai H, Chen L, Hsiao F. The burden of frailty in heart failure: Prevalence, impacts on clinical outcomes and the role of heart failure medications. J Cachexia Sarcopenia Muscle 2024; 15:660-670. [PMID: 38291000 PMCID: PMC10995260 DOI: 10.1002/jcsm.13412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Revised: 10/20/2023] [Accepted: 11/20/2023] [Indexed: 02/01/2024] Open
Abstract
BACKGROUND Frailty often coexists with heart failure (HF), which significantly aggravates the clinical outcomes of older adults. However, studies investigating the interplay between frailty and HF in older adults are scarce. We aimed to assess the prevalence of frailty using the cumulative deficit approach and evaluate the impacts of frailty on health utilization, use of HF-related medications and adverse clinical outcomes (all-cause mortality, all-cause readmissions and HF readmissions) among older HF patients. METHODS A total of 38 843 newly admitted HF patients were identified from Taiwan's National Health Insurance Research Database and categorized into three frailty subgroups (fit, mild frailty and severe frailty) based on the multimorbidity frailty index. Cox regression models and Fine and Gray subdistribution hazard models were used to estimate the impacts of frailty on clinical outcomes at 1 and 2 years of follow-up. Generalized estimating equation models were further conducted to evaluate the associations between longitudinal and time-varying use of HF-related medications and clinical outcomes among distinct frailty subgroups. RESULTS Of 38 843 older HF patients (mean age 80.4 ± 8.5 years, 52.3% females) identified, 68.3% were categorized as frail (47.5% of mild frailty and 20.8% of severe frailty). The median number of readmissions (fit: 1 [inter-quartile range-IQR 2], mild frailty: 1 [IQR 2] and severe frailty: 2 [IQR 3]) increased with the severity of frailty. Only 27.3% of HF patients died of cardiovascular diseases regardless of their frailty status. Compared with the fit group, the severe frailty group was associated with increased risk of all-cause mortality (adjusted hazard ratio 1.16, 95% confidence interval [CI] 1.11-1.21), all-cause readmissions (subdistributional hazard ratio (sHR) 1.21, 95% CI 1.16-1.25) and HF-related readmissions (sHR 1.14, 95% CI 1.09-1.20) at 2 years of follow-up. Those who used triple or more HF-related medications were at lower risk for all-cause readmissions (adjusted odds ratio [aOR] 0.49, 95% CI 0.44-0.54) and HF-related readmissions (aOR 0.42, 95% CI 0.37-0.47) at 2 years of follow-up even in the severe frailty group. CONCLUSIONS Frailty is highly prevalent and associated with increased risk of all-cause mortality, all-cause readmissions and HF readmissions among older HF patients. Those who were using triple or more HF-related medications were at lower risk of adverse clinical outcomes across distinct frailty subgroups. Further studies are needed to optimize the treatment strategies for older HF patients with distinct frailty status.
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Affiliation(s)
- Hsi‐Yu Lai
- Graduate Institute of Clinical Pharmacy, College of MedicineNational Taiwan UniversityTaipeiTaiwan
| | - Shih‐Tsung Huang
- Center for Healthy Longevity and Aging SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Stefan D. Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site BerlinCharité Universitätsmedizin BerlinBerlinGermany
| | - Stephan von Haehling
- Department of Cardiology and PneumologyUniversity of Göttingen Medical CenterGöttingenGermany
- German Centre for Cardiovascular Research (DZHK)partner site Göttingen, GöttingenGöttingenGermany
| | | | - Hidenori Arai
- National Center for Geriatrics and GerontologyObuJapan
| | - Liang‐Kung Chen
- Center for Healthy Longevity and Aging SciencesNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
- Center for Geriatrics and GerontologyTaipei Veterans General HospitalTaipeiTaiwan
- Taipei Municipal Gan‐Dau Hospital (Managed by Taipei Veterans General Hospital)TaipeiTaiwan
| | - Fei‐Yuan Hsiao
- Graduate Institute of Clinical Pharmacy, College of MedicineNational Taiwan UniversityTaipeiTaiwan
- School of PharmacyCollege of Medicine, National Taiwan UniversityTaipeiTaiwan
- Department of PharmacyNational Taiwan University HospitalTaipeiTaiwan
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11
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Kuthi LK, Schwertner WR, Veres B, Merkel ED, Masszi R, Behon A, Kovács A, Osztheimer I, Zima E, Molnár L, Gellér L, Kosztin A, Merkely B. The prevalence of frailty and its effect on the outcome in cardiac resynchronization therapy patients. GeroScience 2024; 46:2671-2679. [PMID: 38127223 PMCID: PMC10828248 DOI: 10.1007/s11357-023-01023-w] [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: 09/14/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023] Open
Abstract
Frailty is a complex clinical syndrome associated with aging and comorbidities, which correlates with unfavorable outcomes. However, in heart failure patients, frailty is very common, data is scarce about those, who are eligible for Cardiac Resynchronization Therapy (CRT) implantation. We investigated the incidence of frailty and the association of Frailty Index (FI) with the outcome. Thirty baseline clinical parameters were used by the Rockwood cumulative deficit method to determine patients' FI in our single-center cohort. Based on previous studies, patients with FI ≤ 0.210 were considered as non-frail, those with FI 0.10-0.210 were classified in Frail-1, with FI > 0.10 in Frail-2 groups, respectively. Echocardiographic response after 12 months and all-cause mortality were investigated by frailty groups. Among 1004 included patients, 75 (7%) were considered Non-frail, 271 (27%) grouped in Frail-1, and 658 (66%) in Frail-2 with a median FI of 0.36 (0.28-0.43). Patients in Frail-2 group were older, with more comorbidities compared with non-frail patients or those in Group Frail-1. During the median follow-up time of 4.8 years, 29 (39%) patients died in the Non-frail, 140 (52%) in Frail-1, and 471 (72%) in the Frail-2 groups (log-rank p < 0.001). Group Frail-2 showed an unfavorable outcome compared to the non-frail (HR 2.49, 95%CI 1.92-3.22; p < 0.001) and the Frail-1 group (1.83, 95%CI 1.55-2.16; p < 0.001). In our HFrEF patients eligible for CRT implantation, patients were exceedingly vulnerable with a high prevalence of frailty. The calculated frailty index was associated with outcome and proved to be prevalent in individual risk stratification.
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Affiliation(s)
- Luca Katalin Kuthi
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | | | - Boglárka Veres
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Eperke Dóra Merkel
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Richard Masszi
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Anett Behon
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - István Osztheimer
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Levente Molnár
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Annamária Kosztin
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary.
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12
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Bisset ES, Howlett SE. Sex-specific effects of frailty on cardiac structure and function: insights from preclinical models. Can J Physiol Pharmacol 2024. [PMID: 38489788 DOI: 10.1139/cjpp-2024-0009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024]
Abstract
Advanced age is an independent risk factor for cardiovascular diseases in both sexes. This is thought to be due, in part, to age-dependent cellular, structural, and functional changes in the heart, a process known as cardiac aging. An emerging view is that cardiac aging leads to the accumulation of cellular and subcellular deficits that increase susceptibility to cardiovascular diseases. Still, people age at different rates, with those aging rapidly considered frail. Evidence suggests that frailty, rather than simply age, is a major risk factor for cardiovascular disease and predicts adverse outcomes in those affected. Recent studies in mouse models of frailty show that many adverse changes associated with cardiac aging are more prominent in mice with a high degree of frailty. This suggests that frailty sets the stage for late life cardiovascular diseases to flourish and raises the possibility that treating frailty may treat cardiovascular diseases. These studies show that ventricular dysfunction increases with frailty in males only, whereas atrial dysfunction increases with frailty in both sexes. These results may shed light on the reasons that men and women can be susceptible to different cardiovascular diseases as they age, and why frail individuals are especially vulnerable to these disorders.
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Affiliation(s)
- Elise S Bisset
- Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
| | - Susan E Howlett
- Department of Pharmacology, Dalhousie University, Halifax, NS B3H 4R2, Canada
- Department of Medicine (Geriatric Medicine), Dalhousie University, Halifax, NS B3H 4R2, Canada
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13
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Rose RA, Howlett SE. Preclinical Studies on the Effects of Frailty in the Aging Heart. Can J Cardiol 2024:S0828-282X(24)00200-9. [PMID: 38460611 DOI: 10.1016/j.cjca.2024.03.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2023] [Revised: 02/20/2024] [Accepted: 03/04/2024] [Indexed: 03/11/2024] Open
Abstract
Age is a major risk factor for the development of cardiovascular diseases in men and in women. However, not all people age at the same rate and those who are aging rapidly are considered frail, compared with their fit counterparts. Frailty is an important clinical challenge because those who are frail are more likely to develop and die from illnesses, including cardiovascular diseases, than fit people of the same age. This increase in susceptibility to cardiovascular diseases in older individuals might occur as the cellular and molecular mechanisms involved in the aging process facilitate structural and functional damage in the heart. Consistent with this, recent studies in murine frailty models have provided strong evidence that maladaptive cardiac remodelling in older mice is the most pronounced in mice with a high level of frailty. For example, there is evidence that ventricular hypertrophy and contractile dysfunction increase as frailty increases in aging mice. Additionally, fibrosis and slowing of conduction in the sinoatrial node and atria are proportional to the level of frailty. These modifications could predispose frail older adults to diseases like heart failure and atrial fibrillation. This preclinical work also raises the possibility that emerging interventions designed to "treat frailty" might also treat or prevent cardiovascular diseases. These findings might help to explain why frail older people are most likely to develop these disorders as they age.
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Affiliation(s)
- Robert A Rose
- Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada; Department of Physiology and Pharmacology, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.
| | - Susan E Howlett
- Department of Pharmacology, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada; Department of Medicine (Geriatric Medicine), Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada.
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14
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Prokopidis K, Ishiguchi H, Jordan C, Irlik K, Nabrdalik K, Formiga F, Sankaranarayanan R, Lip GYH, Isanejad M. Association between natriuretic peptides and C-reactive protein with frailty in heart failure: a systematic review and meta-analysis. Aging Clin Exp Res 2024; 36:57. [PMID: 38446241 PMCID: PMC10917829 DOI: 10.1007/s40520-024-02713-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 01/24/2024] [Indexed: 03/07/2024]
Abstract
BACKGROUND Heart failure (HF) and frailty are accompanied by a bidirectional relationship, sharing common risk factors including elevated levels of natriuretic peptides and inflammation. The aim of this study was to compare biomarkers associated with poor clinical outcomes, that is, plasma brain natriuretic peptide (BNP), N-terminal-pro B-type natriuretic peptide (NT-proBNP), and C-reactive protein (CRP) in patients with HF and frailty vs. patients with HF without frailty. METHODS From inception until July 2023, PubMed, Scopus, Web of Science, and Cochrane Library a systematic literature search was conducted. To evaluate whether frailty is linked with greater levels of BNP, NT-proBNP, and CRP, a meta-analysis using a random-effects model was used to calculate the pooled effects (CRD42023446607). RESULTS Fifty-three studies were included in this systematic review and meta-analysis. Patients with HF and frailty displayed significantly higher levels of BNP (k = 11; SMD: 0.53, 95%CI 0.30-0.76, I2 = 86%, P < 0.01), NT-proBNP (k = 23; SMD: 0.33, 95%CI 0.25-0.40, I2 = 72%, P < 0.01), and CRP (k = 8; SMD: 0.30, 95%CI 0.12-0.48, I2 = 62%, P < 0.01) vs. patients with HF without frailty. Using meta-regression, body mass index (BMI) and age were deemed potential moderators of these findings. CONCLUSIONS Frailty in HF is linked to increased concentrations of BNP, NT-proBNP, and CRP, which have been epidemiologically associated with adverse outcomes. The increased risk of NYHA III/IV classification further emphasizes the clinical impact of frailty in this population.
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Affiliation(s)
- Konstantinos Prokopidis
- Department of Musculoskeletal Ageing and Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK.
| | - Hironori Ishiguchi
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Division of Cardiology, Department of Medicine and Clinical Science, Yamaguchi University Graduate School of Medicine, Ube, Japan
| | - Cara Jordan
- School of Health and Life Sciences, Teesside University, Middlesbrough, UK
| | - Krzysztof Irlik
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Faculty of Medical Sciences in Zabrze, Students' Scientific Association By the Department of Internal Medicine, Diabetology and Nephrology in Zabrze, Medical University of Silesia, Katowice, Poland
- Doctoral School, Faculty of Medical Sciences in Zabrze, Department of Internal Medicine, Diabetology and Nephrology, Medical University of Silesia, Katowice, Poland
| | - Katarzyna Nabrdalik
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Faculty of Medical Sciences in Zabrze, Department of Internal Medicine, Diabetology and Nephrology, Medical University of Silesia, Katowice, Poland
| | - Francesc Formiga
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, Spain
| | - Rajiv Sankaranarayanan
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
- National Institute for Health and Care Research, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart and Chest Hospital, Liverpool, UK
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Masoud Isanejad
- Department of Musculoskeletal Ageing and Science, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK
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15
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Vart P, Butt JH, Jongs N, Schechter M, Chertow GM, Wheeler DC, Pecoits-Filho R, Langkilde AM, Correa-Rotter R, Rossing P, McMurray JJV, Heerspink HJL. Efficacy and Safety of Dapagliflozin in Patients With Chronic Kidney Disease Across the Spectrum of Frailty. J Gerontol A Biol Sci Med Sci 2024; 79:glad181. [PMID: 37527836 PMCID: PMC10809037 DOI: 10.1093/gerona/glad181] [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: 05/05/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND A sizeable proportion of patients with chronic kidney disease (CKD) are reported to be frail. Here we examined the safety and efficacy of dapagliflozin in patients with CKD by frailty level. METHODS Adults with CKD, with/without type 2 diabetes, with an estimated glomerular filtration rate (eGFR) of 25-75 mL/min/1.73 m2, and urinary albumin-to-creatinine ratio 200-5 000 mg/g were randomized to dapagliflozin (10 mg/day) or placebo. The primary endpoint was a composite of sustained ≥50% eGFR decline, end-stage kidney disease (ESKD), or death from kidney or cardiovascular (CV) causes. RESULTS Frailty index (FI), assessed by Rockwood cumulative deficit approach, was calculable in 4 303/4 304 (99.9%) patients: 1 162 (27.0%) in not-to-mildly frail (FI ≤0.210), 1 642 (38.2%) in moderately frail (FI 0.211-0.310), and 1 499 (34.8%) in severely frail categories (FI >0.311). Dapagliflozin reduced the risk of the primary composite endpoint across all FI categories (hazard ratios [95% confidence interval {CI}]: 0.50 [0.33-0.76], 0.62 [0.45-0.85], and 0.64 [0.49--0.83], respectively; p-interaction = 0.67). Results were similar for secondary outcomes including kidney composite outcome (sustained ≥50% eGFR decline, ESKD or death from kidney cause; p-interaction = 0.44), CV endpoint (heart failure hospitalization or CV death; p-interaction = 0.63), and all-cause mortality (p-interaction p = .42). Results were consistent when using FI as a continuous variable. Occurrence of serious adverse events was numerically lower in patients receiving dapagliflozin versus placebo in all FI categories (16.9% vs 20.1%, 26.3% vs 30.7%, and 42.9% vs 47.8%, in not-to-mildly, moderately, and severely frail categories, respectively). CONCLUSIONS The relative benefit of dapagliflozin for all outcomes was consistent across all frailty categories, with no difference in associated safety.
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Affiliation(s)
- Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jawad H Butt
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Meir Schechter
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | | | - Ricardo Correa-Rotter
- The National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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16
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Coats AJS, Butler J, Tsutsui H, Doehner W, Filippatos G, Ferreira JP, Böhm M, Chopra VK, Verma S, Nordaby M, Iwata T, Nitta D, Ponikowski P, Zannad F, Packer M, Anker SD. Efficacy of empagliflozin in heart failure with preserved ejection fraction according to frailty status in EMPEROR-Preserved. J Cachexia Sarcopenia Muscle 2024; 15:412-424. [PMID: 38158636 PMCID: PMC10834334 DOI: 10.1002/jcsm.13393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/22/2023] [Accepted: 11/06/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Frailty is a severe, common co-morbidity associated with heart failure (HF) with preserved ejection fraction (HFpEF). The impact of frailty on HFpEF outcomes may affect treatment choices in HFpEF. The impact of frailty on HFpEF patients and any impact on the clinical benefits of sodium glucose co-transporter 2 (SGLT2) inhibition in HFpEF have been described in only a limited number of trials. Whether the SGLT2 inhibitor empagliflozin would improve or worsen frailty status when given to HFpEF patients is also not known. The aims of this study were, therefore, to evaluate, in HFpEF patients enrolled in the EMPEROR-Preserved trial (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction), the impact of frailty on clinical outcomes, and on the effects of empagliflozin, as well as the effect of empagliflozin on frailty status during treatment period. METHODS We calculated a cumulative deficit-derived frailty index (FI) using 44 variables including clinical, laboratory and quality of life parameters recorded in EMPEROR-Preserved. Patients were classified into four groups: non-frail (FI < 0.21), mild frailty (0.21 to <0.30), moderate frailty (0.30 to <0.40) and severe frailty (≥0.40). Clinical outcomes and health-related quality of life were evaluated according to baseline FI along with the effect of empagliflozin on chronological changes in FI (at 12, 32 and 52 weeks). RESULTS The patient distribution was 1514 (25.3%), 2100 (35.1%), 1501 (25.1%) and 873 (14.6%) in non-frail, mild frailty, moderate frailty and severe frailty, respectively. Severe frailty patients tended to be female and have low Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, more co-morbidities and more polypharmacy. Incidence rates of the primary outcome of cardiovascular death or HF hospitalization increased as frailty worsened (hazard ratio [HR] of each FI category compared with the non-frail group: 1.10 [95% confidence interval, CI, 0.89-1.35], 2.00 [1.63-2.47] and 2.61 [2.08-3.27] in the mild frailty, moderate frailty and severe frailty groups, respectively; P trend < 0.001). Compared with placebo, empagliflozin reduced the risk for the primary outcome across the four FI categories, HR: 0.59 [95% CI 0.42-0.83], 0.79 [0.61-1.01], 0.77 [0.61-0.96] and 0.90 [0.69-1.16] in non-frail to severe frailty categories, respectively (P value for trend = 0.097). Empagliflozin also improved other clinical outcomes and KCCQ score across frailty categories. Compared with placebo, empagliflozin-treated patients had a higher likelihood of being in a lower FI category at Weeks 12, 32 and 52 (P < 0.05), odds ratio: 1.12 [95% CI 1.01-1.24] at Week 12, 1.21 [1.09-1.34] at Week 32 and 1.20 [1.09-1.33] at Week 52. CONCLUSIONS Empagliflozin improved key efficacy outcomes with a possible diminution of effect in very frail patients. Empagliflozin also improved frailty status during follow-up.
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Affiliation(s)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Hiroyuki Tsutsui
- School of Medicine and Graduate School, International University of Health and Welfare, Okawa, Japan
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiology (Campus Virchow), Charité Universitätsmedizin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - João Pedro Ferreira
- Cardiovascular R&D Centre-UnIC@RISE, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Internal Medicine, Heart Failure Clinic, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Michael Böhm
- Department of Internal Medicine III, University Hospital Saarland, Saarland University, Homburg, Germany
| | | | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - Daisuke Nitta
- Medicine Division, Nippon Boehringer Ingelheim Co. Ltd, Tokyo, Japan
| | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Wrocław, Poland
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
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17
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Naito A, Nagatomo Y, Kawai A, Yukino-Iwashita M, Nakazawa R, Taruoka A, Takefuji A, Yasuda R, Toya T, Ikegami Y, Masaki N, Ido Y, Adachi T. The Safety and Efficacy of Sodium-Glucose Cotransporter-2 Inhibitors for Patients with Sarcopenia or Frailty: Double Edged Sword? J Pers Med 2024; 14:141. [PMID: 38392575 PMCID: PMC10890336 DOI: 10.3390/jpm14020141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) show cardiovascular protective effects, regardless of the patient's history of diabetes mellitus (DM). SGLT2is suppressed cardiovascular adverse events in patients with type 2 DM, and furthermore, SGLT-2is reduced the risk of worsening heart failure (HF) events or cardiovascular death in patients with HF. Along with these research findings, SGLT-2is are recommended for patients with HF in the latest guidelines. Despite these benefits, the concern surrounding the increasing risk of body weight loss and other adverse events has not yet been resolved, especially for patients with sarcopenia or frailty. The DAPA-HF and DELIVER trials consistently showed the efficacy and safety of SGLT-2i for HF patients with frailty. However, the Rockwood frailty index that derived from a cumulative deficit model was employed for frailty assessment in these trials, which might not be suitable for the evaluation of physical frailty or sarcopenia alone. There is no fixed consensus on which evaluation tool to use or its cutoff value for the diagnosis and assessment of frailty in HF patients, or which patients can receive SGLT-2i safely. In this review, we summarize the methodology of frailty assessment and discuss the efficacy and safety of SGLT-2i for HF patients with sarcopenia or frailty.
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Affiliation(s)
- Ayami Naito
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Akane Kawai
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | | | - Ryota Nakazawa
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Akira Taruoka
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Asako Takefuji
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Risako Yasuda
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yukinori Ikegami
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Nobuyuki Masaki
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yasuo Ido
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
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Li T, Jiang YL, Kang J, Song S, Du QF, Yi XD. Prevalence and risk factors of frailty in older patients with chronic heart failure: a systematic review and meta-analysis. Aging Clin Exp Res 2023; 35:2861-2871. [PMID: 37864762 DOI: 10.1007/s40520-023-02587-5] [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: 08/03/2023] [Accepted: 09/30/2023] [Indexed: 10/23/2023]
Abstract
AIM To provide a summary of the available evidence concerning prevalence and risk factors of frailty in elderly patients with CHF. METHODS PubMed, Embase, Web of Science, CINAHL, The Cochrane Library, China National Knowledge Infrastructure Database (CNKI), Chinese Biomedical Database (Sinomed), Weipu Database (VIP), and Wanfang database were searched from inception to July 2023. This study strictly followed the PRISMA guidelines. The quality of the included studies was rated by the Agency for Healthcare and Research and Quality and the Newcastle-Ottawa Scale. RESULTS A total of 21 original studies were included, involving 4,797 patients. Meta-analysis results showed that the prevalence of frailty in older patients with heart failure was 38% (95%CI: 0.32-0.44). Age, cardiac function grading, left atrial diameter, left ventricular ejection fraction, hemoglobin, polypharmacy, BNP, nutritional risk, and hospitalization day are the influential factors of frailty in older patients with CHF. CONCLUSION The prevalence of frailty in older patients with CHF is high, and clinical medical personnel should identify and intervene early to reduce or delay the frailty in older patients with CHF as much as possible.
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Affiliation(s)
- Tao Li
- Department of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Yun-Lan Jiang
- Affiliated Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610075, China.
| | - Jing Kang
- Department of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Shuang Song
- Department of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Qiu-Feng Du
- Department of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
| | - Xiao-Dong Yi
- Department of Nursing, Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, China
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Talha KM, Greene SJ, Butler J, Khan MS. Frailty and Its Implications in Heart Failure with Reduced Ejection Fraction: Impact on Prognosis and Treatment. Cardiol Clin 2023; 41:525-536. [PMID: 37743075 DOI: 10.1016/j.ccl.2023.06.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Abstract
Frailty affects half of all patients with heart failure with reduced ejection fraction (HFrEF) and carries a ∼2-fold increased risk of mortality. The relationship between frailty and HFrEF is bidirectional, with one condition exacerbating the other. Paradoxical to their higher clinical risk, frail patients with HFrEF are more often under-treated due to concerns over medication-related adverse clinical events. However, current evidence suggests consistent safety of HF medical therapies among older frail patients with HFrEF. A multidisciplinary effort is necessary for the appropriate management of these high-risk patients which focuses on the optimization of known beneficial therapies with a goal-directed effort toward improving quality of life.
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Affiliation(s)
- Khawaja M Talha
- Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA
| | - Stephen J Greene
- Division of Cardiology, Department of Medicine, Duke University Hospital, 2301 Erwin Road, Durham, NC 27710, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 North State Street, Jackson, MS 39216, USA; Baylor Scott & White Research Institute, 3434 Live Oak Street Suite 501, Dallas, TX 75204, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Department of Medicine, Duke University Hospital, 2301 Erwin Road, Durham, NC 27710, USA.
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Pinsino A, Carey MR, Husain S, Mohan S, Radhakrishnan J, Jennings DL, Nguonly AS, Ladanyi A, Braghieri L, Takeda K, Faillace RT, Sayer GT, Uriel N, Colombo PC, Yuzefpolskaya M. The Difference Between Cystatin C- and Creatinine-Based Estimated GFR in Heart Failure With Reduced Ejection Fraction: Insights From PARADIGM-HF. Am J Kidney Dis 2023; 82:521-533. [PMID: 37086965 DOI: 10.1053/j.ajkd.2023.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2022] [Accepted: 03/02/2023] [Indexed: 04/24/2023]
Abstract
RATIONALE & OBJECTIVE The clinical implications of the discrepancy between cystatin C (cysC)- and serum creatinine (Scr)-estimated glomerular filtration rate (eGFR) in patients with heart failure (HF) and reduced ejection fraction (HFrEF) are unknown. STUDY DESIGN Post-hoc analysis of randomized trial data. SETTING & PARTICIPANTS 1,970 patients with HFrEF enrolled in PARADIGM-HF with available baseline cysC and Scr measurements. EXPOSURE Intraindividual differences between eGFR based on cysC (eGFRcysC) and Scr (eGFRScr; eGFRdiffcysC-Scr). OUTCOMES Clinical outcomes included the PARADIGM-HF primary end point (composite of cardiovascular [CV] mortality or HF hospitalization), CV mortality, all-cause mortality, and worsening kidney function. We also examined poor health-related quality of life (HRQoL), frailty, and worsening HF (WHF), defined as HF hospitalization, emergency department visit, or outpatient intensification of therapy between baseline and 8-month follow-up. ANALYTICAL APPROACH Fine-Gray subdistribution hazard models and Cox proportional hazards models were used to regress clinical outcomes on baseline eGFRdiffcysC-Scr. Logistic regression was used to investigate the association of baseline eGFRdiffcysC-Scr with poor HRQoL and frailty. Linear regression models were used to assess the association of WHF with eGFRcysC, eGFRScr, and eGFRdiffcysC-Scr at 8-month follow-up. RESULTS Baseline eGFRdiffcysC-Scr was higher than +10 and lower than-10mL/min/1.73m2 in 13.0% and 35.7% of patients, respectively. More negative values of eGFRdiffcysC-Scr were associated with worse outcomes ([sub]hazard ratio per standard deviation: PARADIGM-HF primary end point, 1.18; P=0.008; CV mortality, 1.34; P=0.001; all-cause mortality, 1.39; P<0.001; worsening kidney function, 1.31; P=0.05). For a 1-standard-deviation decrease in eGFRdiffcysC-Scr, the prevalences of poor HRQoL and frailty increased by 29% and 17%, respectively (P≤0.008). WHF was associated with a more pronounced decrease in eGFRcysC than in eGFRScr, resulting in a change in 8-month eGFRdiffcysC-Scr of-4.67mL/min/1.73m2 (P<0.001). LIMITATIONS Lack of gold-standard assessment of kidney function. CONCLUSIONS In patients with HFrEF, discrepancies between eGFRcysC and eGFRScr are common and are associated with clinical outcomes, HRQoL, and frailty. The decline in kidney function associated with WHF is more marked when assessed with eGFRcysC than with eGFRScr. PLAIN-LANGUAGE SUMMARY Kidney function assessment traditionally relies on serum creatinine (Scr) to establish an estimated glomerular filtration rate (eGFR). However, this has been challenged with the introduction of an alternative marker, cystatin C (cysC). Muscle mass and nutritional status have differential effects on eGFR based on cysC (eGFRcysC) and Scr (eGFRScr). Among ambulatory patients with heart failure enrolled in PARADIGM-HF, we investigated the clinical significance of the difference between eGFRcysC and eGFRScr. More negative values (ie, eGFRScr>eGFRcysC) were associated with worse clinical outcomes (including mortality), poor quality of life, and frailty. In patients with progressive heart failure, which is characterized by muscle loss and poor nutritional status, the decline in kidney function was more pronounced when eGFR was estimated using cysC rather than Scr.
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Affiliation(s)
- Alberto Pinsino
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center; Division of Critical Care Medicine, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY.
| | - Matthew R Carey
- Department of Medicine, Columbia University Irving Medical Center
| | - Syed Husain
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center
| | - Sumit Mohan
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center; Department of Epidemiology, Mailman School of Public Health, Columbia University Irving Medical Center
| | - Jai Radhakrishnan
- Department of Medicine, Division of Nephrology, Columbia University Irving Medical Center
| | - Douglas L Jennings
- Department of Pharmacy, Columbia University Irving Medical Center; Department of Pharmacy Practice, Long Island University College of Pharmacy, New York
| | - Austin S Nguonly
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center
| | - Annamaria Ladanyi
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center
| | - Lorenzo Braghieri
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center; Department of Medicine, Cleveland Clinic, Cleveland, OH
| | - Koji Takeda
- Department of Surgery, Division of Cardiac Surgery, Columbia University Irving Medical Center
| | | | - Gabriel T Sayer
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center
| | - Nir Uriel
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center
| | - Melana Yuzefpolskaya
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center
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Lee YC, Lin JK, Ko D, Cheng S, Patorno E, Glynn RJ, Tsacogianis T, Kim DH. Frailty and uptake of angiotensin receptor neprilysin inhibitor for heart failure with reduced ejection fraction. J Am Geriatr Soc 2023; 71:3110-3121. [PMID: 37345734 PMCID: PMC10592538 DOI: 10.1111/jgs.18481] [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: 01/24/2023] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Frail older adults may be less likely to receive guideline-directed medical therapy (GDMT)-renin-angiotensin blockers, beta-blockers, and mineralocorticoid receptor antagonists-for heart failure with reduced ejection fraction (HFrEF). We aimed to examine the uptake of angiotensin receptor neprilysin inhibitor (ARNI) and GDMT in frail older adults with HFrEF. METHODS Using 2015-2019 Medicare data, we estimated the proportion of beneficiaries with HFrEF receiving ARNI and GDMT each year by frailty status, defined by a claims-based frailty index. Logistic regression was used to identify clinical characteristics associated with ARNI initiation. Cox proportional hazards regression was used to examine the association of GDMT use in 2015 and death or heart failure hospitalization in 2016-2019. RESULTS Among 147,506-180,386 beneficiaries with HFrEF (mean age: 77 years; 27% women; 42.6-49.1% frail) in 2015-2019, the proportion of patients receiving ARNI increased in both non-frail (0.4%-16.4%) and frail (0.3%-13.7%) patients (p for yearly-trend-by-frailty = 0.970). Among those not receiving a renin-angiotensin system blocker, patients with age ≥ 85 years (odds ratio [95% CI], 0.89 [0.80-0.99]), dementia (0.88 [0.81-0.96]), and frailty (0.87 [0.81-0.94]) were less likely to initiate ARNI. The proportion of patients receiving all 3 GDMT classes increased in non-frail patients (22.0%-27.0%) but changed minimally in frail patients (19.6%-21.8%). Regardless of frailty status, treatment with at least 1 class of GDMT was associated with lower death or heart failure hospitalization than no GDMT medications (hazard ratio [95% CI], 0.94 [0.91-0.97], 0.92 [0.89-0.94], 0.94 [0.91-0.97] for 1, 2, and 3 classes, respectively). CONCLUSIONS Our results suggest an evidence-practice gap in the use of ARNI and GDMT in Medicare beneficiaries with HFrEF, particularly those with frailty. Efforts to narrow this gap are needed to reduce the burden of HFrEF in older adults.
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Affiliation(s)
- Yu-Chien Lee
- Harvard T.H. Chan School of Public Health, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Family Medicine, Chang Gung Memorial Hospital, Linko Branch, Taiwan
| | - Joshua K. Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, MA
| | - Susan Cheng
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Robert J. Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Theodore Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Talha KM, Pandey A, Fudim M, Butler J, Anker SD, Khan MS. Frailty and heart failure: State-of-the-art review. J Cachexia Sarcopenia Muscle 2023; 14:1959-1972. [PMID: 37586848 PMCID: PMC10570089 DOI: 10.1002/jcsm.13306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/16/2023] [Accepted: 07/11/2023] [Indexed: 08/18/2023] Open
Abstract
At least half of all patients with heart failure (HF) are affected by frailty, a syndrome that limits an individual ability to recover from acute stressors. While frailty affects up to 90% of patients with HF with preserved ejection fraction, it is also seen in ~30-60% of patients with HF with reduced ejection fraction, with ~26% higher prevalence in women compared with men. The relationship between frailty and HF is bidirectional, with both conditions exacerbating the other. Frailty is further complicated by a higher prevalence of sarcopenia (by ~20%) in HF patients compared with patients without HF, which negatively affects outcomes. Several frailty assessment methods have been employed historically including the Fried frailty phenotype and Rockwood Clinical Frailty Scale to classify HF patients based on the severity of frailty; however, a validated HF-specific frailty assessment tool does not currently exist. Frailty in HF is associated with a poor prognosis with a 1.5-fold to 2-fold higher risk of all-cause death and hospitalizations compared to non-frail patients. Frailty is also highly prevalent in patients with worsening HF, affecting >50% of patients hospitalized for HF. Such patients with multiple readmissions for decompensated HF have markedly poor outcomes compared to younger, non-frail cohorts, and it is hypothesized that it may be due to major physical and functional limitations that limit recovery from an acute episode of worsening HF, a care aspect that has not been addressed in HF guidelines. Frail patients are thought to confer less benefit from therapeutic interventions due to an increased risk of perceived harm, resulting in lower adherence to HF interventions, which may worsen outcomes. Multiple studies report that <40% of frail patients are on guideline-directed medical therapy for HF, of which most are on suboptimal doses of these medications. There is a lack of evidence generated from randomized trials in this incredibly vulnerable population, and most current practice is governed by post hoc analyses of trials, observational registry-based data and providers' clinical judgement. The current body of evidence suggests that the treatment effect of most guideline-based interventions, including medications, cardiac rehabilitation and device therapy, is consistent across all age groups and frailty subgroups and, in some cases, may be amplified in the older, more frail population. In this review, we discuss the characteristics, assessment tools, impact on prognosis and impact on therapeutic interventions of frailty in patients with HF.
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Affiliation(s)
- Khawaja M. Talha
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - Ambarish Pandey
- Division of CardiologyUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Marat Fudim
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | - Javed Butler
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
- Baylor Scott and White Research InstituteDallasTXUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK) of German Heart Center CharitéInstitute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité UniversitätsmedizinBerlinGermany
- Institute of Heart DiseasesWroclaw Medical UniversityWroclawPoland
| | - Muhammad Shahzeb Khan
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
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23
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Wang Z, Du X, Hua C, Li W, Zhang H, Liu X, Wang Y, Jiang C, Guo J, Lv Q, Anderson CS, Dong J, Ma C. The Effect of Frailty on the Efficacy and Safety of Intensive Blood Pressure Control: A Post Hoc Analysis of the SPRINT Trial. Circulation 2023; 148:565-574. [PMID: 37401465 DOI: 10.1161/circulationaha.123.064003] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Accepted: 06/01/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Frailty is associated with an increased risk of all-cause death and cardiovascular events. However, it is uncertain whether frailty modifies the efficacy and safety of intensive blood pressure control. METHODS Data from SPRINT (Systolic Blood Pressure Intervention Trial) were used to construct a frailty index. Subgroup differences in intensive blood pressure control treatment effects and safety outcomes were measured on a relative and an absolute scale in patients with and without frailty (defined as a frailty index >0.21) using Cox proportional hazard models and generalized linear models, respectively. The primary outcome was a composite of myocardial infarction, acute coronary syndrome without myocardial infarction, stroke, heart failure, and cardiovascular death. RESULTS A total of 9306 patients (mean age, 67.9±9.4 years), 2560 (26.7%) of whom had frailty, were included in our study. Over a median follow-up of 3.22 years, 561 primary outcomes were observed. Patients with frailty had a significantly higher risk of primary outcome in both the intensive and standard blood pressure control arms (adjusted hazard ratio, 2.10 [95% CI, 1.59-2.77] and 1.85 [95% CI, 1.46-2.35], respectively). Intensive treatment effects on primary and secondary outcomes were not significantly different on a relative scale (except for cardiovascular death [hazard ratio in patients with and without frailty, 0.91 (95% CI, 0.52-1.60) versus 0.30 (95% CI, 0.16-0.59), respectively; Pinteraction=0.01]) or absolute scale. There was no significant interaction between frailty and risks for serious adverse events with intensive treatment. CONCLUSIONS Frailty status was a marker of high cardiovascular risk. Patients with frailty benefit similarly to other patients from intensive blood pressure control without an increased risk of serious adverse events.
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Affiliation(s)
- Zhiyan Wang
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
| | - Xin Du
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
- Heart Health Research Center, Beijing, China (X.D., J.G., C.S.A.)
- The George Institute for Global Health (Australia), The University of New South Wales, Sydney, Australia (X.D., C.S.A.)
| | - Chang Hua
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
| | - Wenjie Li
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
| | - Hao Zhang
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
| | - Xinru Liu
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
| | - Yufeng Wang
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
| | - Chao Jiang
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
| | - Jiakun Guo
- Heart Health Research Center, Beijing, China (X.D., J.G., C.S.A.)
| | - Qiang Lv
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
| | - Craig S Anderson
- Heart Health Research Center, Beijing, China (X.D., J.G., C.S.A.)
- The George Institute for Global Health (Australia), The University of New South Wales, Sydney, Australia (X.D., C.S.A.)
| | - Jianzeng Dong
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
- Department of Cardiology, the First Affiliated Hospital of Zhengzhou University, Henan Province, China (J.D.)
| | - Changsheng Ma
- Department of Cardiology, Anzhen Hospital, Beijing, China (Z.W., X.D., C.H., W.L., H.Z., X.L., Y.W., C.J., Q.L., J.D., C.M.)
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Schnabel RB, Ameri P, Siller-Matula JM, Diemberger I, Gwechenberger M, Pecen L, Manu MC, Souza J, De Caterina R, Kirchhof P. Outcomes of patients with atrial fibrillation on oral anticoagulation with and without heart failure: the ETNA-AF-Europe registry. Europace 2023; 25:euad280. [PMID: 37713182 PMCID: PMC10540669 DOI: 10.1093/europace/euad280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2023] [Revised: 09/07/2023] [Accepted: 09/09/2023] [Indexed: 09/16/2023] Open
Abstract
AIMS Heart failure (HF) is a risk factor for major adverse events in atrial fibrillation (AF). Whether this risk persists on non-vitamin K antagonist oral anticoagulants (NOACs) and varies according to left ventricular ejection fraction (LVEF) is debated. METHODS AND RESULTS We investigated the relation of HF in the ETNA-AF-Europe registry, a prospective, multicentre, observational study with an overall 4-year follow-up of edoxaban-treated AF patients. We report 2-year follow-up for ischaemic stroke/transient ischaemic attack (TIA)/systemic embolic events (SEE), major bleeding, and mortality. Of the 13 133 patients, 1854 (14.1%) had HF. Left ventricular ejection fraction was available for 82.4% of HF patients and was <40% in 671 (43.9%) and ≥40% in 857 (56.1%). Patients with HF were older, more often men, and had more comorbidities. Annualized event rates (AnERs) of any stroke/SEE were 0.86%/year and 0.67%/year in patients with and without HF. Compared with patients without HF, those with HF also had higher AnERs for major bleeding (1.73%/year vs. 0.86%/year) and all-cause death (8.30%/year vs. 3.17%/year). Multivariate Cox proportional models confirmed HF as a significant predictor of major bleeding [hazard ratio (HR) 1.65, 95% confidence interval (CI): 1.20-2.26] and all-cause death [HF with LVEF <40% (HR 2.42, 95% CI: 1.95-3.00) and HF with LVEF ≥40% (HR 1.80, 95% CI: 1.45-2.23)] but not of ischaemic stroke/TIA/SEE. CONCLUSION Anticoagulated patients with HF at baseline featured higher rates of major bleeding and all-cause death, requiring optimized management and novel preventive strategies. NOAC treatment was similarly effective in reducing risk of ischaemic events in patients with or without concomitant HF.
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Affiliation(s)
- Renate B Schnabel
- Department of Cardiology, University Clinic Hamburg-Eppendorf, University Heart and Vascular Centre Hamburg-Eppendorf, Buildung O50, Martinistrasse 52, 20246 Hamburg, Germany
- DZHK (German Centre for Cardiovascular Research), partner site Hamburg/Kiel/Luebeck, Potsdamer Str, 5810785 Berlin, Germany
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, Genova, Italy
- Cardiac, Thoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | - Igor Diemberger
- Department of Medical and Surgical Sciences, University of Bologna, 40138 Bologna, Italy
- Unit of Cardiology, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | | | - Ladislav Pecen
- Czech Academy of Science, Institute of Computer Sciences, Prague, Czech Republic
- Department of Immunochemistry Diagnostics, University Hospital Pilsen, Pilsen, Czech Republic
| | | | - José Souza
- Daiichi Sankyo Europe GmbH, Munich, Germany
| | - Raffaele De Caterina
- Cardiology Division, Pisa University Hospital, Pisa, Italy
- Fondazione Villa Serena per la Ricerca, Pescara, Italy
| | - Paulus Kirchhof
- Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
- Department of Cardiology, University Heart and Vascular Centre Hamburg, University Medical Centre Hamburg Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Sciences (DZHK), partner site Hamburg/Kiel/Lübeck, Germany
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25
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Metze C, Iliadis C, Körber MI, von Stein J, Halbach M, Baldus S, Pfister R. Disentangling Heart Failure and Physical Frailty: Prospective Study of Patients Undergoing Percutaneous Mitral Valve Repair. JACC. HEART FAILURE 2023; 11:972-982. [PMID: 37227390 DOI: 10.1016/j.jchf.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/27/2023] [Revised: 03/27/2023] [Accepted: 04/04/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Frailty and heart failure share pathophysiology and clinical characteristics. OBJECTIVES The aim of this study was to analyze the contribution of heart failure to the physical frailty phenotype by examining patients with heart failure before and after percutaneous mitral valve repair (PMVR). METHODS Frailty according to the Fried criteria (weight loss, weakness, exhaustion, slowness, and low activity) was assessed in consecutive patients before and 6 weeks after PMVR. RESULTS A total of 118 of 258 patients (45.7%) (mean age: 78 ± 9 years, 42% female, 55% with secondary mitral regurgitation) were frail at baseline, which significantly decreased to 74 patients (28.7 %) at follow-up (P < 0.001). The frequency of frailty domains slowness, exhaustion, and inactivity significantly decreased, whereas weakness remained unchanged. Baseline frailty was significantly associated with comorbidities, N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and functional capacity, whereas frailty after PMVR was not associated with NT-proBNP levels. Predictors of postprocedural reversibility of frailty were NYHA functional class CONCLUSIONS Treatment of mitral regurgitation in patients with heart failure is associated with almost a halved burden of physical frailty, particularly in patients with a less advanced phenotype. Considering the prognostic relevance of frailty dynamics, this data warrants further evaluation of the concept of frailty as a primary treatment target.
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Affiliation(s)
- Clemens Metze
- Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Christos Iliadis
- Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Maria I Körber
- Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Jennifer von Stein
- Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Marcel Halbach
- Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Stephan Baldus
- Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany
| | - Roman Pfister
- Faculty of Medicine, University of Cologne, and Department III of Internal Medicine, University Hospital Cologne, Cologne, Germany.
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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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27
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Kondo T, Adachi T, Kobayashi K, Okumura T, Izawa H, Murohara T, McMurray JJV, Yamada S. Physical Frailty and Use of Guideline-Recommended Drugs in Patients With Heart Failure and Reduced Ejection Fraction. J Am Heart Assoc 2023; 12:e026844. [PMID: 37301739 PMCID: PMC10356033 DOI: 10.1161/jaha.122.026844] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/19/2022] [Indexed: 06/12/2023]
Abstract
BACKGROUND Guideline-recommended therapies that improve prognosis remain underused in clinical practice. Physical frailty may lead to underprescription of life-saving therapy. We aimed to investigate the association between physical frailty and the use of evidence-based pharmacological therapy for heart failure with reduced ejection fraction and the impact of this on prognosis. METHODS AND RESULTS The FLAGSHIP (Multicentre Prospective Cohort Study to Develop Frailty-Based Prognostic Criteria for Heart Failure Patients) included patients hospitalized for acute heart failure, and data on physical frailty were collected prospectively. We analyzed 1041 patients with heart failure with reduced ejection fraction (aged 70 years; 73% male) and divided them by physical frailty categories using grip strength, walking speed, Self-Efficacy for Walking-7 score, and Performance Measures for Activities of Daily Living-8 score: categories I (n=371; least frail), II (n=275), III (n=224), and IV (n=171). Overall prescription rates of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, and mineralocorticoid receptor antagonists were 69.7%, 87.8%, and 51.9%, respectively. The proportion of patients receiving all 3 drugs decreased as physical frailty increased (in category I patients, 40.2%; IV patients, 23.4%; P for trend<0.001). In adjusted analyses, the severity of physical frailty was an independent predictor for nonuse of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (odds ratio [OR], 1.23 [95% CI, 1.05-1.43] per 1 category increase) and β-blockers (OR, 1.32 [95% CI, 1.06-1.64]), but not mineralocorticoid receptor antagonists (OR, 0.97 [95% CI, 0.84-1.12]). Patients receiving 0 to 1 drug had a higher risk of the composite outcome of all-cause death or heart failure rehospitalization than those treated with 3 drugs in physical frailty categories I and II (hazard ratio [HR], 1.80 [95% CI, 1.08-2.98]) and III and IV (HR, 1.53 [95% CI, 1.01-2.32]) in the multivariate Cox proportional hazard model. CONCLUSIONS Prescription of guideline-recommended therapy decreased as severity of physical frailty increased in heart failure with reduced ejection fraction. Underprescription of guideline-recommended therapy may contribute to the poor prognosis associated with physical frailty.
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Affiliation(s)
- Toru Kondo
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowUK
| | - Takuji Adachi
- Department of Integrated Health SciencesNagoya University Graduate School of MedicineNagoyaJapan
| | | | - Takahiro Okumura
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Hideo Izawa
- Department of CardiologyFujita Health UniversityToyoakeJapan
| | - Toyoaki Murohara
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - John J. V. McMurray
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowUK
| | - Sumio Yamada
- Department of Integrated Health SciencesNagoya University Graduate School of MedicineNagoyaJapan
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28
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Wong EKC, Demers C. Letter by Wong and Demers Regarding Article, "Efficacy and Safety of Dapagliflozin According to Frailty in Patients With Heart Failure: A Prespecified Analysis of the DELIVER Trial". Circulation 2023; 147:1118. [PMID: 37011074 DOI: 10.1161/circulationaha.122.062440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/05/2023]
Affiliation(s)
- Eric K C Wong
- Division of Geriatric Medicine, Department of Medicine, University of Toronto, Canada (E.K.C.W.)
| | - Catherine Demers
- Division of Cardiology, Department of Medicine, Department of Health Research Methods, Evidence, and Impact, and Division of Cardiology, Department of Medicine, McMaster University, Canada (C.D.)
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Ko D, Bostrom JA, Qazi S, Kramer DB, Kim DH, Orkaby AR. Frailty and Cardiovascular Mortality: A Narrative Review. Curr Cardiol Rep 2023; 25:249-259. [PMID: 36795307 PMCID: PMC10130976 DOI: 10.1007/s11886-023-01847-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/06/2023] [Indexed: 02/17/2023]
Abstract
PURPOSE OF REVIEW The goal of the narrative review is to provide an overview of the epidemiology of frailty in cardiovascular disease and cardiovascular mortality and discuss applications of frailty in cardiovascular care of older adults. RECENT FINDINGS Frailty is highly prevalent in older adults with cardiovascular disease and is a robust, independent predictor of cardiovascular death. There is a growing interest in using frailty to inform management of cardiovascular disease either through pre- or post-treatment prognostication or by delineating treatment heterogeneity in which frailty serves to distinguish patients with differential harms or benefits from a given therapy. Frailty can enable more individualized treatment in older adults with cardiovascular disease. Future studies are needed to standardize frailty assessment across cardiovascular trials and enable implementation of frailty assessment in cardiovascular clinical practice.
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Affiliation(s)
- Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - John A Bostrom
- Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, USA
| | - Saadia Qazi
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Daniel B Kramer
- Richart A. and Susan F. Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Division of Gerontology, Beth Israel Deaconess Medical Center, Harvard University, Boston, MA, USA
| | - Ariela R Orkaby
- Department of Medicine, VA Boston Healthcare System, Boston, MA, USA.
- Division of Aging, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA.
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, 150 South Huntington, 02130, Boston, MA, USA.
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30
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Pandey A, Kitzman DW. Role of a Novel Self-Reported Questionnaire for Frailty Assessment in HFpEF. JACC. HEART FAILURE 2023; 11:404-406. [PMID: 37019556 PMCID: PMC10283081 DOI: 10.1016/j.jchf.2023.01.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Accepted: 01/17/2023] [Indexed: 04/05/2023]
Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
| | - Dalane W Kitzman
- Section on Cardiovascular Medicine and Geriatrics, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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31
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Villarreal D, Ramírez H, Sierra V, Amarís JS, Lopez-Salazar AM, González-Robledo G. Sodium-Glucose Cotransporter 2 Inhibitors in Frail Patients with Heart Failure: Clinical Experience of a Heart Failure Unit. Drugs Aging 2023; 40:293-299. [PMID: 36811172 DOI: 10.1007/s40266-022-01004-2] [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: 12/23/2022] [Indexed: 02/23/2023]
Abstract
OBJECTIVE The objective of this study was to determine the difference in tolerance for sodium glucose cotransporter 2 inhibitors between patients with heart failure classified as frail according to the FRAIL questionnaire, compared to those with heart failure without frailty. METHODS A prospective cohort study was performed between 2021 and 2022 that included patients with heart failure at a heart failure unit in Bogotá who were being treated with a sodium glucose cotransporter 2 inhibitor. Clinical and laboratory data were collected during an initial visit and 12-48 weeks after that. The FRAIL questionnaire was applied to all participants through a phone call or during the follow-up visit. The primary outcome was the adverse effect rate and as a secondary outcome we compared the estimated glomerular filtration rate change between frail and non-frail patients. RESULTS One hundred and twelve patients were included in the final analysis. Frail patients had a more than twice increased risk of having adverse effects (95% confidence interval 1.5-3.9). Age was also a risk factor for the appearance of these. The estimated glomerular filtration rate decrease was inversely correlated with the age, left ventricular ejection fraction, and renal function before the use of sodium glucose cotransporter 2 inhibitors. CONCLUSIONS When prescribing in heart failure, it is important to remember that frail patients are more likely to have adverse effects with the use of sodium glucose cotransporter 2 inhibitors, of which the most common are those related to osmotic diuresis. Nonetheless, these do not appear to increase the risk of discontinuation or abandonment of therapy in this population.
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Affiliation(s)
- Daniel Villarreal
- School of Medicine, Universidad de los Andes, Cra. 7 #116-5, 110121, Bogotá, Colombia.
| | - Hernán Ramírez
- Heart Failure Unit, Internal Medicine Department, University Hospital Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | | | - Juan S Amarís
- School of Medicine, Universidad de los Andes, Bogotá, Colombia
| | - Ana M Lopez-Salazar
- Geriatrics Team and Palliative Care Unit, Internal Medicine Department, University Hospital Fundación Santa Fe de Bogotá, Bogotá, Colombia
| | - Gina González-Robledo
- Heart Failure Unit, Internal Medicine Department, University Hospital Fundación Santa Fe de Bogotá, Bogotá, Colombia
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Nakamaru R, Shiraishi Y, Niimi N, Kohno T, Nagatomo Y, Takei M, Ikoma T, Nishikawa K, Sakamoto M, Nakano S, Kohsaka S, Yoshikawa T. Phenotyping of Elderly Patients With Heart Failure Focused on Noncardiac Conditions: A Latent Class Analysis From a Multicenter Registry of Patients Hospitalized With Heart Failure. J Am Heart Assoc 2023; 12:e027689. [PMID: 36695300 PMCID: PMC9973643 DOI: 10.1161/jaha.122.027689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 12/19/2022] [Indexed: 01/26/2023]
Abstract
Background The burden of noncardiovascular conditions is becoming increasingly prevalent in patients with heart failure (HF). We aimed to identify novel phenogroups incorporating noncardiovascular conditions to facilitate understanding and risk stratification in elderly patients with HF. Methods and Results Data from a total of 1881 (61.2%) patients aged ≥65 years were extracted from a prospective multicenter registry of patients hospitalized for acute HF (N=3072). We constructed subgroups of patients with HF with preserved ejection fraction (HFpEF; N=826, 43.9%) and those with non-HFpEF (N=1055, 56.1%). Latent class analysis was performed in each subgroup using 17 variables focused on noncardiovascular conditions (including comorbidities, Clinical Frailty Scale, and Geriatric Nutritional Risk Index). The latent class analysis revealed 3 distinct clinical phenogroups in both HFpEF and non-HFpEF subgroups: (1) robust physical and nutritional status (Group 1: HFpEF, 41.2%; non-HFpEF, 46.0%); (2) multimorbid patients with renal impairment (Group 2: HFpEF, 40.8%; non-HFpEF, 41.9%); and (3) malnourished patients (Group 3: HFpEF, 18.0%; non-HFpEF, 12.1%). After multivariable adjustment, compared with Group 1, patients in Groups 2 and 3 had a higher risk for all-cause death over the 1-year postdischarge period (hazard ratio [HR], 2.79 [95% CI, 1.64-4.81] and HR, 2.73 [95% CI, 1.39-5.35] in HFpEF; HR, 1.96 [95% CI, 1.22-3.14] and HR, 2.97 [95% CI, 1.64-5.38] in non-HFpEF; respectively). Conclusions In elderly patients with HF, the phenomapping focused on incorporating noncardiovascular conditions identified 3 phenogroups, each representing distinct clinical outcomes, and the discrimination pattern was similar for both patients with HFpEF and non-HFpEF. This classification provides novel risk stratification and may aid in clinical decision making.
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Affiliation(s)
- Ryo Nakamaru
- Department of CardiologyKeio University School of MedicineTokyoJapan
- Department of Healthcare Quality AssessmentThe University of TokyoTokyoJapan
| | | | - Nozomi Niimi
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Takashi Kohno
- Department of Cardiovascular MedicineKyorin University Faculty of MedicineTokyoJapan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical CollegeTokorozawaJapan
| | - Makoto Takei
- Department of CardiologySaiseikai Central HospitalTokyoJapan
| | - Takenori Ikoma
- Division of Cardiology, Internal Medicine IIIHamamatsu University School of MedicineHamamatsuJapan
| | - Kei Nishikawa
- Department of CardiologySakakibara Heart InstituteTokyoJapan
| | - Munehisa Sakamoto
- Department of CardiologyNational Hospital Organization Tokyo Medical CenterTokyoJapan
| | - Shintaro Nakano
- Department of CardiologySaitama Medical University, International Medical CenterHidakaJapan
| | - Shun Kohsaka
- Department of CardiologyKeio University School of MedicineTokyoJapan
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Nguyen DD, Arnold SV. Impact of frailty on disease-specific health status in cardiovascular disease. Heart 2023:heartjnl-2022-321631. [PMID: 36604164 DOI: 10.1136/heartjnl-2022-321631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Accepted: 12/20/2022] [Indexed: 01/07/2023] Open
Abstract
Frailty is a syndrome of older age that reflects an impaired physiological reserve and decreased ability to recover from medical stressors. While the impact of frailty on mortality in cardiovascular disease has been well described, its impact on cardiovascular disease-specific health status-cardiac symptoms, physical functioning and quality of life-has been less well studied. In this review, we summarise the impact of frailty on health status outcomes across different cardiovascular conditions. In heart failure, frail patients have markedly impaired disease-specific health status and are at risk for subsequent health status deteriorations. However, frail patients have similar or even greater health status improvements with interventions for heart failure, such as cardiac rehabilitation or guideline-directed medical therapy. In valvular heart disease, the impact of frailty on disease-specific health status is of even greater concern since management involves physiologically taxing procedures that can worsen health status. Frailty increases the risk of poor health status outcomes after transcatheter aortic valve intervention or surgical aortic valve replacement for aortic stenosis, but there is no evidence that frail patients benefit more from one procedure versus another. In both heart failure and valvular heart disease, health status improvements may reverse frailty, highlighting the overlap between cardiovascular disease and frailty and emphasising that treatment should typically not be withheld based on the presence of frailty alone. Meanwhile, data are limited on the impact of frailty on health status outcomes in the treatment of coronary artery disease, peripheral artery disease and atrial fibrillation, and requires further research.
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Affiliation(s)
- Dan D Nguyen
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA.,Department of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
| | - Suzanne V Arnold
- Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute, Kansas City, Missouri, USA .,Department of Medicine, University of Missouri Kansas City, Kansas City, Missouri, USA
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Kaul P, Rathwell S, Lam CSP, Westerhout CM, Spertus JA, Anstrom KJ, Blaustein RO, Ezekowitz JA, Pieske B, Roessig L, Butler J, Armstrong PW. Patient-Reported Frailty and Functional Status in Heart Failure With Preserved Ejection Fraction: Insights From VITALITY-HFpEF. JACC. HEART FAILURE 2023; 11:392-403. [PMID: 36881394 DOI: 10.1016/j.jchf.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Revised: 10/28/2022] [Accepted: 11/23/2022] [Indexed: 02/04/2023]
Abstract
BACKGROUND The association between frailty and health status in patients with heart failure with preserved ejection fraction (HFpEF) is not well known. OBJECTIVES The authors examined the association between: 1) patient-reported frailty, measured by the Fried frailty phenotype, Kansas City Cardiomyopathy Questionnaire physical limitation score (KCCQ-PLS), 6-minute walking distance (6MWD), and other baseline characteristics; 2) baseline frailty compared with KCCQ-PLS and 24-week 6MWD; 3) frailty and changes in KCCQ-PLS and 6MWD; and 4) vericiguat and frailty at 24 weeks. METHODS In a post hoc analysis, patients in the VITALITY-HFpEF (Patient-reported Outcomes in Vericiguat-treated Patients With HFpEF) trial were categorized as not frail (0 symptoms), prefrail (1-2 symptoms), and frail (≥3 symptoms) according to patient-reported number of frailty symptoms. Correlations and linear regression models were used to examine the association between frailty and other measures, and between frailty and KCCQ-PLS at baseline with 24-week 6MWD. RESULTS Among 739 patients, 27.3% were not frail, 37.6% were prefrail, and 35.0% were frail at baseline. Frail patients were older, more likely to be women, and less likely to be from Asia. Baseline KCCQ-PLS and 6MWD (mean ± SD) among not frail, prefrail, and frail patients was 68.2 ± 23.2, 61.7 ± 22.6, and 48.4 ± 23.8 and 328.5 ± 117.1 m, 310.8 ± 98.9 m, and 250.7 ± 104.3 m (P < 0.01 for both). After accounting for baseline 6MWD, frailty status at baseline, but not KCCQ-PLS, was significantly associated with 6MWD at 24 weeks. By 24 weeks, 47.5% of patients had no change in frailty, 45.5% had become less frail, and 7.0% had become more frail. Treatment with vericiguat did not alter frailty status at 24 weeks. CONCLUSIONS Patient-reported frailty is modestly correlated with both the KCCQ-PLS and 6MWD but offers prognostic insight into 6MWD at 24 weeks. (Patient-reported Outcomes in Vericiguat-treated Patients With HFpEF [VITALITY-HFpEF]; NCT03547583).
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Affiliation(s)
- Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| | - Sarah Rathwell
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Burkert Pieske
- Charité University Medicine, German Heart Center, Berlin, Germany
| | | | - Javed Butler
- Baylor University Medical Center, Dallas, Texas, USA
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
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Seo EJ, Won MH, Son YJ. Association of sleep duration and physical frailty with cognitive function in older patients with coexisting atrial fibrillation and heart failure. Nurs Open 2022; 10:3201-3209. [PMID: 36560851 PMCID: PMC10077387 DOI: 10.1002/nop2.1570] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 11/15/2022] [Accepted: 12/10/2022] [Indexed: 12/24/2022] Open
Abstract
AIM To investigate the associations of sleep duration and physical frailty with cognitive function in older patients with both atrial fibrillation and heart failure. DESIGN This study used a cross-sectional, secondary data analysis design. METHOD We included outpatients aged ≥ 65 years with coexisting atrial fibrillation and heart failure in South Korea. We used a sample of 176 patients (men = 100) with HF among 277 data from the parent study. The data were collected through a self-report, structured questionnaire and electronic medical record. RESULTS Our main finding showed that long sleep duration and physically frail status were significant predictors of cognitive impairment in older adults with both atrial fibrillation and heart failure. Healthcare providers should be aware of the importance of assessing sleep duration and physical activity in older adults with both atrial fibrillation and heart failure to prevent or delay cognitive impairment.
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Affiliation(s)
- Eun Ji Seo
- Ajou University College of Nursing and Research Institute of Nursing Science, Suwon, Korea
| | - Mi Hwa Won
- Wonkwang University, Department of Nursing 460 Iksandaero, Iksan, Korea
| | - Youn-Jung Son
- Red Cross College of Nursing, Chung-Ang University, Seoul, Korea
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Zhang H, Hao M, Hu Z, Li Y, Hu X, Jiang X, Liu Z, Sun X, Wang X. Causal Association of Cardiac Function by Magnetic Resonance Imaging with Frailty Index: A Mendelian Randomization Study. PHENOMICS (CHAM, SWITZERLAND) 2022; 2:430-437. [PMID: 36939795 PMCID: PMC9712899 DOI: 10.1007/s43657-022-00072-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 07/31/2022] [Accepted: 08/04/2022] [Indexed: 11/30/2022]
Abstract
Owing to the susceptibility of conventional observational studies to confounding factors and reverse causation, the causal association between cardiac function and frailty is unclear. We aimed to investigate whether cardiac function has causal effects on frailty. In this study, a two-sample Mendelian randomization (MR) study was conducted using genetic variants associated with cardiac function assessed by magnetic resonance imaging phenotypes as instrumental variables. Genetic variants associated with cardiac function by magnetic resonance imaging (including seven cardiac function phenotypes) and the frailty index (FI) were obtained from two large genome-wide association studies. MR estimates from each genetic instrument were combined using inverse variance weighted (IVW), weighted median, and MR‒Egger regression methods. We found that the increase in genetically determined stroke volume (beta - 0.13, 95% CI - 0.16 to - 0.10, p = 1.39E-6), rather than other cardiac phenotypes, was associated with lower FI in MR analysis of IVW after Bonferroni correction. Sensitivity analyses examining potential bias caused by pleiotropy or reverse causality revealed similar findings (e.g., intercept [SE], - 0.008 [0.011], p = 0.47 by MR‒Egger intercept test). The leave-one-out analysis indicated that the association was not driven by single nucleotide polymorphisms. No evidence of heterogeneity was found among the genetic variants (e.g., MR‒Egger: Q statistic = 14.4, p = 0.156). In conclusion, we provided evidence that improved cardiac function could contribute to reducing FI. These findings support the hypothesis that enhancing cardiac function could be an effective prevention strategy for frailty. Supplementary Information The online version contains supplementary material available at 10.1007/s43657-022-00072-z.
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Affiliation(s)
- Hui Zhang
- Human Phenome Institute, Zhangjiang Fudan International Innovation Center, Fudan University, Shanghai, 200433 China
- Fudan University-the People’s Hospital of Rugao Joint Research Institute of Longevity and Ageing, Rugao, 226599 Jiangsu China
| | - Meng Hao
- Human Phenome Institute, Zhangjiang Fudan International Innovation Center, Fudan University, Shanghai, 200433 China
| | - Zixin Hu
- Human Phenome Institute, Zhangjiang Fudan International Innovation Center, Fudan University, Shanghai, 200433 China
| | - Yi Li
- Human Phenome Institute, Zhangjiang Fudan International Innovation Center, Fudan University, Shanghai, 200433 China
| | - Xiaoxi Hu
- Human Phenome Institute, Zhangjiang Fudan International Innovation Center, Fudan University, Shanghai, 200433 China
| | - Xiaoyan Jiang
- Key Laboratory of Arrhythmias of the Ministry of Education of China, Tongji University School of Medicine, Shanghai, 200092 China
| | - Zuyun Liu
- Center for Clinical Big Data and Analytics, Second Affiliated Hospital and Department of Big Data in Health Science, School of Public Health, Zhejiang University School of Medicine, Hangzhou, 310030 Zhejiang China
| | - Xuehui Sun
- Human Phenome Institute, Zhangjiang Fudan International Innovation Center, Fudan University, Shanghai, 200433 China
- Fudan University-the People’s Hospital of Rugao Joint Research Institute of Longevity and Ageing, Rugao, 226599 Jiangsu China
| | - Xiaofeng Wang
- Human Phenome Institute, Zhangjiang Fudan International Innovation Center, Fudan University, Shanghai, 200433 China
- Fudan University-the People’s Hospital of Rugao Joint Research Institute of Longevity and Ageing, Rugao, 226599 Jiangsu China
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Riccardi M, Sammartino AM, Piepoli M, Adamo M, Pagnesi M, Rosano G, Metra M, von Haehling S, Tomasoni D. Heart failure: an update from the last years and a look at the near future. ESC Heart Fail 2022; 9:3667-3693. [PMID: 36546712 PMCID: PMC9773737 DOI: 10.1002/ehf2.14257] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
In the last years, major progress occurred in heart failure (HF) management. Quadruple therapy is now mandatory for all the patients with HF with reduced ejection fraction. Whilst verciguat is becoming available across several countries, omecamtiv mecarbil is waiting to be released for clinical use. Concurrent use of potassium-lowering agents may counteract hyperkalaemia and facilitate renin-angiotensin-aldosterone system inhibitor implementations. The results of the EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trial were confirmed by the Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER) trial, and we now have, for the first time, evidence for treatment of also patients with HF with preserved ejection fraction. In a pre-specified meta-analysis of major randomized controlled trials, sodium-glucose co-transporter-2 inhibitors reduced all-cause mortality, cardiovascular (CV) mortality, and HF hospitalization in the patients with HF regardless of left ventricular ejection fraction. Other steps forward have occurred in the treatment of decompensated HF. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload (ADVOR) trial showed that the addition of intravenous acetazolamide to loop diuretics leads to greater decongestion vs. placebo. The addition of hydrochlorothiazide to loop diuretics was evaluated in the CLOROTIC trial. Torasemide did not change outcomes, compared with furosemide, in TRANSFORM-HF. Ferric derisomaltose had an effect on the primary outcome of CV mortality or HF rehospitalizations in IRONMAN (rate ratio 0.82; 95% confidence interval 0.66-1.02; P = 0.070). Further options for the treatment of HF, including device therapies, cardiac contractility modulation, and percutaneous treatment of valvulopathies, are summarized in this article.
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Affiliation(s)
- Mauro Riccardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San DonatoUniversity of MilanMilanItaly
- Department of Preventive CardiologyUniversity of WrocławWrocławPoland
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | | | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Stephan von Haehling
- Department of Cardiology and PneumologyUniversity of Goettingen Medical CenterGottingenGermany
- German Center for Cardiovascular Research (DZHK), Partner Site GöttingenGottingenGermany
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
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Quach J, Theou O, Godin J, Rockwood K, Kehler DS. The impact of cardiovascular health and frailty on mortality for males and females across the life course. BMC Med 2022; 20:394. [PMID: 36357932 PMCID: PMC9650802 DOI: 10.1186/s12916-022-02593-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Accepted: 10/03/2022] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND The effect of frailty and poor cardiovascular health on mortality for males and females is not fully elucidated. We investigated whether the combined burden of frailty and poor cardiovascular health is associated with all-cause and cardiovascular disease (CVD) mortality by sex and age. METHODS We analyzed data of 35,207 non-institutionalized US residents aged 20-85 years old (mean age [standard deviation]: 46.6 [16.7 years], 51.4% female, 70.8% White, 10.3% Black, 13.2% Hispanic) from the National Health and Nutrition Examination Survey (1999-2015). Cardiovascular health was measured with the American Heart Association's Life's Simple 7 score (LS7). A 33-item frailty index (FI) was constructed to exclude cardiovascular health deficits. We grouped the FI into 0.1 increments (non-frail: FI < 0.10, very mildly frail: 0.1 ≤ FI < 0.20, mildly frail: 0.20 ≤ FI < 0.30, and moderately/severely frail: FI ≥ 0.30) and LS7 into tertiles (T1[poor] = 0-7, T2[intermediate] = 8-9, T3[ideal] = 10-14). All-cause and CVD mortality data were analyzed up to 16 years. All regression models were stratified by sex. RESULTS The average FI was 0.09 (SD 0.10); 29.6% were at least very mildly frail, and the average LS7 was 7.9 (2.3). Mortality from all-causes and CVD were 8.5% (4228/35,207) and 6.1% (2917/35,207), respectively. The median length of follow-up was 8.1 years. The combined burden of frailty and poor cardiovascular health on mortality risk varied according to age in males (FI*age interaction p = 0.01; LS7*age interaction p < 0.001) but not in females. In females, poor FI and LS7 combined to predict all-cause and CVD mortality in a dose-response manner. All-cause and CVD mortality risk was greater for older males (60 and 70 years old) who were at least mildly frail and had intermediate cardiovascular health or worse (hazard ratio [lower/higher confidence interval ranges] range: all-cause mortality = 2.02-5.30 [1.20-4.04, 3.15-6.94]; CVD-related mortality = 2.22-7.16 [1.03-4.46, 4.49-11.50]) but not for younger males (30, 40, and 50 years old). CONCLUSIONS The combined burden of frailty and LS7 on mortality is similar across all ages in females. In males, this burden is greater among older people. Adding frailty to assessments of overall cardiovascular health may identify more individuals at risk for mortality and better inform decisions to implement preventative or treatment approaches.
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Affiliation(s)
- Jack Quach
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada.,Geriatric Medicine, Dalhousie University and Nova Scotia Health, NS, Halifax, Canada
| | - Olga Theou
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada.,Geriatric Medicine, Dalhousie University and Nova Scotia Health, NS, Halifax, Canada
| | - Judith Godin
- Geriatric Medicine, Dalhousie University and Nova Scotia Health, NS, Halifax, Canada
| | - Kenneth Rockwood
- Geriatric Medicine, Dalhousie University and Nova Scotia Health, NS, Halifax, Canada.
| | - Dustin Scott Kehler
- School of Physiotherapy, Dalhousie University, Halifax, NS, Canada.,Geriatric Medicine, Dalhousie University and Nova Scotia Health, NS, Halifax, Canada
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Sato R, Vatic M, da Fonseca GWP, von Haehling S. Sarcopenia and Frailty in Heart Failure: Is There a Biomarker Signature? Curr Heart Fail Rep 2022; 19:400-411. [PMID: 36261756 DOI: 10.1007/s11897-022-00575-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/10/2022] [Indexed: 10/24/2022]
Abstract
PURPOSE OF REVIEW Sarcopenia and frailty are common in patients with heart failure (HF) and are strongly associated with prognosis. This review aims to examine promising biomarkers that can guide physicians in identifying sarcopenia and frailty in HF. RECENT FINDINGS Traditional biomarkers including C-reactive protein, aminotransaminase, myostatin, and urinary creatinine as well as novel biomarkers including microRNAs, suppression of tumorigenicity 2 (ST2), galectin-3, and procollagen type III N-terminal peptide may help in predicting the development of sarcopenia and frailty in HF patients. Among those biomarkers, aminotransferase, urinary creatinine, and ST2 predicted the prognosis in HF patients with sarcopenia and frailty. This review outlines the current knowledge of biomarkers that are considered promising for diagnosing sarcopenia and frailty in HF. The listed biomarkers might support the diagnosis, prognosis, and therapeutic decisions for sarcopenia and frailty in HF patients.
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Affiliation(s)
- Ryosuke Sato
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37075, Gottingen, Germany
| | - Mirela Vatic
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Str. 40, 37075, Gottingen, Germany
| | | | - Stephan von Haehling
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Gottingen, Germany.
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Butt JH, Jhund PS, Belohlávek J, de Boer RA, Chiang CE, Desai AS, Drożdż J, Hernandez AF, Inzucchi SE, Katova T, Kitakaze M, Kosiborod MN, Lam CS, Maria Langkilde A, Lindholm D, Bachus E, Martinez F, Merkely B, Petersson M, Saraiva JFK, Shah SJ, Vaduganathan M, Vardeny O, Wilderäng U, Claggett BL, Solomon SD, McMurray JJ. Efficacy and Safety of Dapagliflozin According to Frailty in Patients With Heart Failure: A Prespecified Analysis of the DELIVER Trial. Circulation 2022; 146:1210-1224. [PMID: 36029465 PMCID: PMC9815819 DOI: 10.1161/circulationaha.122.061754] [Citation(s) in RCA: 53] [Impact Index Per Article: 26.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Accepted: 08/21/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Frailty is increasing in prevalence. Because patients with frailty are often perceived to have a less favorable risk/benefit profile, they may be less likely to receive new pharmacologic treatments. We investigated the efficacy and tolerability of dapagliflozin according to frailty status in patients with heart failure with mildly reduced or preserved ejection fraction randomized in DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure). METHODS Frailty was measured using the Rockwood cumulative deficit approach. The primary end point was time to a first worsening heart failure event or cardiovascular death. RESULTS Of the 6263 patients randomized, a frailty index (FI) was calculable in 6258. In total, 2354 (37.6%) patients had class 1 frailty (FI ≤0.210; ie, not frail), 2413 (38.6%) had class 2 frailty (FI 0.211-0.310; ie, more frail), and 1491 (23.8%) had class 3 frailty (FI ≥0.311; ie, most frail). Greater frailty was associated with a higher rate of the primary end point (per 100 person-years): FI class 1, 6.3 (95% CI 5.7-7.1); class 2, 8.3 (7.5-9.1); and class 3, 13.4 (12.1-14.7; P<0.001). The effect of dapagliflozin (as a hazard ratio) on the primary end point from FI class 1 to 3 was 0.85 (95% CI, 0.68-1.06), 0.89 (0.74-1.08), and 0.74 (0.61-0.91), respectively (Pinteraction=0.40). Although patients with a greater degree of frailty had worse Kansas City Cardiomyopathy Questionnaire scores at baseline, their improvement with dapagliflozin was greater than it was in patients with less frailty: placebo-corrected improvement in Kansas City Cardiomyopathy Questionnaire Overall Summary Score at 4 months in FI class 1 was 0.3 (95% CI, -0.9 to 1.4); in class 2, 1.5 (0.3-2.7); and in class 3, 3.4 (1.7-5.1; Pinteraction=0.021). Adverse reactions and treatment discontinuation, although more frequent in patients with a greater degree of frailty, were not more common with dapagliflozin than with placebo irrespective of frailty class. CONCLUSIONS In DELIVER, frailty was common and associated with worse outcomes. The benefit of dapagliflozin was consistent across the range of frailty studied. The improvement in health-related quality of life with dapagliflozin occurred early and was greater in patients with a higher level of frailty. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03619213.
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Affiliation(s)
- Jawad H. Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.H.B., P.S.J., J.J.V.M.)
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Denmark (J.H.B.)
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.H.B., P.S.J., J.J.V.M.)
| | - Jan Belohlávek
- Second Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital, First Faculty of Medicine, Charles University, Prague, Czech Republic (J.B.)
| | | | - Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taiwan (C.-E.C.)
| | - Akshai S. Desai
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (A.S.D.)
| | - Jarosław Drożdż
- Department of Cardiology, Medical University of Lodz, Poland (J.D.)
| | | | | | - Tzvetana Katova
- Department of Noninvasive Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.)
| | - Masafumi Kitakaze
- Cardiovascular Division of Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (M.K.)
| | | | - Carolyn S.P. Lam
- National Heart Centre Singapore and Duke National University of Singapore (C.S.P.L.)
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., E.B., M.P., U.W.)
| | - Daniel Lindholm
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., E.B., M.P., U.W.)
| | - Erasmus Bachus
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., E.B., M.P., U.W.)
| | | | - Béla Merkely
- Heart and Vascular Centre, Semmelweis University, Budapest, Hungary (B.M.)
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., E.B., M.P., U.W.)
| | - Jose F. Kerr Saraiva
- Cardiovascular Division, Instituto de Pesquisa Clínica de Campinas, Brazil (J.F.K.S.)
| | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V., B.L.C., S.D.S.)
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota (O.V.)
| | - Ulrica Wilderäng
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (A.M.L., D.L., E.B., M.P., U.W.)
| | - Brian L. Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V., B.L.C., S.D.S.)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.V., B.L.C., S.D.S.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.H.B., P.S.J., J.J.V.M.)
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Clinical phenotypes of delirium in patients admitted to the cardiac intensive care unit. PLoS One 2022; 17:e0273965. [PMID: 36054128 PMCID: PMC9439246 DOI: 10.1371/journal.pone.0273965] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022] Open
Abstract
Background Limited data are available on clinical phenotype for delirium that occurs frequently among patients admitted to the cardiac intensive care unit (CICU). The objective of this study was to investigate the clinical pictures of delirium, and their association with clinical outcomes in CICU patients. Methods A total of 4,261 patients who were admitted to the CICU between September 1 2012 to December 31 2018 were retrospectively registered. Patients were excluded if they were admitted to the CICU for less than 24 hours or had missed data. Ultimately, 2,783 patients were included in the analysis. A day of delirium was defined as any day during which at least one CAM-ICU assessment was positive. The clinical risk factors of delirium were classified by the delirium phenotype, as follows; hypoxic, septic, sedative-associated, and metabolic delirium. Results The incidence of delirium was 24.4% at the index hospitalization in all CICU patients, and 22.6% within 7 days after CICU admission. The most common delirium phenotype was septic delirium (17.2%), followed by hypoxic delirium (16.8%). Multiple phenotypes were observed during most delirium days. Delirium most frequently occurred in patients with heart failure. Of all patients affected by delirium within 7 days, both ICU and hospital mortality significantly increased according to the combined number of delirium phenotypes. Conclusions Delirium occurred in a quarter of patients admitted to the modern CICU and was associated with increased in-hospital mortality. Therefore, more efforts are needed to reduce the clinical risk factors of delirium, and to prevent it in order to improve clinical outcomes in the CICU.
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Boureau A, Annweiler C, Belmin J, Bouleti C, Chacornac M, Chuzeville M, David J, Jourdain P, Krolak‐Salmon P, Lamblin N, Paccalin M, Sebbag L, Hanon O. Practical management of frailty in older patients with heart failure: Statement from a panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology. ESC Heart Fail 2022; 9:4053-4063. [PMID: 36039817 PMCID: PMC9773761 DOI: 10.1002/ehf2.14040] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2022] [Revised: 05/02/2022] [Accepted: 06/09/2022] [Indexed: 01/19/2023] Open
Abstract
AIMS The heart failure (HF) prognosis in older patients remains poor with a high 5-years mortality rate more frequently attributed to noncardiovascular causes. The complex interplay between frailty and heart failure contribute to poor health outcomes of older adults with HF independently of ejection fraction. The aim of this position paper is to propose a practical management of frailty in older patients with heart failure. METHODS A panel of multidisciplinary experts on behalf the Heart Failure Working Group of the French Society of Cardiology and on behalf French Society of Geriatrics and Gerontology conducted a systematic literature search on the interlink between frailty and HF, met to propose an early frailty screening by non-geriatricians and to propose ways to implement management plan of frailty. Statements were agreed by expert consensus. RESULTS Clinically relevant aspects of interlink between frailty and HF have been reported to identify the population eligible for screening and the most suitable screening test(s). The frailty screening program proposed focuses on frailty model defined by an accumulation of deficits including geriatric syndromes, comorbidities, for older patients with HF in different settings of care. The management plan of frailty includes optimization of HF pharmacological treatments and non-surgical device treatment as well as optimization of a global patient-centred biopsychosocial blended collaborative care pathway. CONCLUSION The current manuscript provides practical recommendations on how to screen and optimize frailty management in older patients with heart failure.
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Affiliation(s)
- Anne‐Sophie Boureau
- Department of Geriatrics, University Hospital, Nantes, France; Institut du ThoraxUniversity HospitalNantesFrance
| | - Cédric Annweiler
- Department of Geriatric Medicine and Memory Clinic, Research Center on Autonomy and Longevity, University Hospital, Angers; UPRES EA 4638, University of Angers; Gérontopôle Autonomie Longévité des Pays de la Loire; Robarts Research Institute, Department of Medical Biophysics, Schulich School of Medicine and DentistryUniversity of Western OntarioLondonONCanada
| | - Joël Belmin
- Hôpital Charles Foix et Sorbonne UniversitéIvry‐sur‐SeineFrance
| | - Claire Bouleti
- Cardiology, University of Poitiers, Clinical Investigation Center (CIC) INSERM 1402Poitiers University HospitalPoitiersFrance
| | | | - Michel Chuzeville
- Geriatric Cardiology Department, Edouard Herriot HospitalHospices Civils de LyonLyonFrance
| | - Jean‐Philippe David
- INSERM‐ U955, IMRB, CEpiA team, Department of Geriatric Medicine, AP‐HP, Hôpitaux Henri‐MondorUniv Paris Est CreteilCreteilFrance
| | - Patrick Jourdain
- DMU COREVE, GHU Paris Saclay, APHP, Paris, France; INSERM UMR S 999IHU TORINO (thorax Innovation)TurinItaly
| | - Pierre Krolak‐Salmon
- Clinical and Research Memory Center of Lyon, Lyon Institute For Elderly, Hospices Civils de Lyon, Villeurbanne, France; University of Lyon, Lyon, France; Neuroscience Research Centre of Lyon, INSERM 1048CNRSLyonFrance
| | - Nicolas Lamblin
- Institut Cœur Poumon, CHU de Lille, Inserm U1167, Institut Pasteur de LilleUniversité de LilleLilleFrance
| | - Marc Paccalin
- Department of GeriatricsCHU La Milétrie, CIC‐1402PoitiersFrance
| | - Laurent Sebbag
- Service Insuffisance Cardiaque et Transplantation Hospices Civils de Lyon Hôpital Louis PradelBronFrance
| | - Olivier Hanon
- Department of GeriatricsUniversité de Paris, EA 4468, APHP, Hôpital BrocaParisFrance
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Andrew MK, Matthews S, Kim JH, Riley ME, Curran D. An Easy-to-Implement Clinical-Trial Frailty Index Based on Accumulation of Deficits: Validation in Zoster Vaccine Clinical Trials. Clin Interv Aging 2022; 17:1261-1274. [PMID: 36017192 PMCID: PMC9397533 DOI: 10.2147/cia.s364997] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 07/02/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Despite being among those most in need of protection, frail older adults are often not well represented in clinical trials. Although frailty likely influences responses to treatments and vaccines, frailty may not be explicitly considered in trials even when frail participants are enrolled due to the perception that frailty is difficult to measure effectively and efficiently without adding to participant or data collection burden. We developed an easy-to-implement frailty index, the Clinical Trial-Frailty Index (CT-FI), based on baseline medical history and standard patient-reported outcomes using data from clinical trials of recombinant Zoster vaccine (the ZOE-50 and ZOE-70 studies). Our objective was to demonstrate that the CT-FI is a robust measure that may be used retrospectively or prospectively in clinical trials where sufficient patient data have been collected. Methods The CT-FI was based on baseline medical history and Quality of Life questionnaires (SF-36 and EQ-5D). Items meeting criteria for inclusion were scored from 0 to 1, then summed for each participant and divided by the total number of deficits considered. Validation analyses included descriptive verification of distribution and age- and sex-associations in relation to usual patterns of the frailty index, regressions in relation to outcomes hypothesized to be related to frailty, and resampling methods within the index. Results The CT-FI distribution was well represented by a gamma distribution with a range of 0–0.70. Deficit accumulation increased with chronological age and was higher for females. Multivariate Cox regression survival analysis showed that the CT-FI, age, and sex were significant predictors of mortality. Jackknife and Bootstrap resampling methods highlighted the robustness of the CT-FI, which was not sensitive to inclusion/exclusion of specific individual or groups of variables. Conclusion We have developed a reliable, robust and easy-to-implement CT-FI with potential retrospective or prospective application in other clinical trials. ![]()
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Affiliation(s)
- Melissa K Andrew
- Department of Medicine (Division of Geriatric Medicine), Dalhousie University, Halifax, Nova Scotia, Canada
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Butt JH, Dewan P, Jhund PS, Anand IS, Atar D, Ge J, Desai AS, Echeverria LE, Køber L, Lam CSP, Maggioni AP, Martinez F, Packer M, Rouleau JL, Sim D, Van Veldhuisen DJ, Vrtovec B, Zannad F, Zile MR, Gong J, Lefkowitz MP, Rizkala AR, Solomon SD, McMurray JJV. Sacubitril/Valsartan and Frailty in Patients With Heart Failure and Preserved Ejection Fraction. J Am Coll Cardiol 2022; 80:1130-1143. [PMID: 36050227 DOI: 10.1016/j.jacc.2022.06.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Frailty is an increasingly common problem, and frail patients are less likely to receive new pharmacologic therapies because the risk-benefit profile is perceived to be less favorable than in nonfrail patients. OBJECTIVES This study investigated the efficacy of sacubitril/valsartan according to frailty status in 4,796 patients with heart failure with preserved ejection fraction randomized in the PARAGON-HF (Prospective Comparison of ARNI With ARB Global Outcomes in Heart Failure With Preserved Ejection Fraction) trial. METHODS Frailty was measured by using the Rockwood cumulative deficit approach. The primary endpoint was total heart failure hospitalizations or cardiovascular death. RESULTS A frailty index (FI) was calculable in 4,795 patients. In total, 45.2% had class 1 frailty (FI ≤0.210, not frail), 43.5% had class 2 frailty (FI 0.211-0.310, more frail), and 11.4% had class 3 frailty (FI ≥0.311, most frail). There was a graded relationship between FI class and the primary endpoint, with a significantly higher risk associated with greater frailty (class 1: reference; class 2 rate ratio: 2.19 [95% CI: 1.85-2.60]; class 3 rate ratio: 3.29 [95% CI: 2.65-4.09]). The effect of sacubitril/valsartan vs valsartan on the primary endpoint from lowest to highest FI class (as a rate ratio) was: 0.98 [95% CI: 0.76-1.27], 0.92 [95% CI: 0.76-1.12], and 0.69 [95% CI: 0.51-0.95]), respectively (Pinteraction = 0.23). When FI was examined as a continuous variable, the interaction with treatment was significant for the primary outcome (Pinteraction = 0.002) and total heart failure hospitalizations (Pinteraction < 0.001), with those most frail deriving greater benefit. CONCLUSIONS Frailty was common in heart failure with preserved ejection fraction and associated with worse outcomes. Compared with valsartan, sacubitril/valsartan seemed to show a greater reduction in the primary endpoint with increasing frailty, although this was not significant when FI was examined as a categorical variable. (Prospective Comparison of ARNI With ARB Global Outcomes in Heart Failure With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
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Affiliation(s)
- Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Pooja Dewan
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Inder S Anand
- Department of Medicine, VA Medical Center, Minneapolis, Minnesota, USA; University of Minnesota Medical Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Luis E Echeverria
- Heart Failure Unit and Cardiac Transplant Program, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri, Florence, Italy
| | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - David Sim
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Dirk J Van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Faiez Zannad
- Inserm CIC 1433 and Université de Lorraine, Centre Hospitalier Régional Universitaire, Nancy, France
| | - Michael R Zile
- Medical University of South Carolina, Charleston, South Carolina, USA; Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina, USA
| | - Jianjian Gong
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Adel R Rizkala
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
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Wilkinson C, Rockwood K. Frailty assessment in the management of cardiovascular disease. BRITISH HEART JOURNAL 2022; 108:1991-1995. [PMID: 36007935 DOI: 10.1136/heartjnl-2022-321265] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Affiliation(s)
- Chris Wilkinson
- Population Health Sciences Institute, Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, Tyne and Wear, UK .,Hull York Medical School, University of York, York, North Yorkshire, UK.,Academic Cardiovascular Unit, South Tees NHS Foundation Trust, Middlesbrough, UK
| | - Kenneth Rockwood
- Geriatric Medicine, Dalhousie University, Halifax, Nova Scotia, Canada
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Peterson LR, Coggan AR. Heart Failure With Reduced Ejection Fraction: “The Importance of Being Frail”. Circulation 2022; 146:91-93. [DOI: 10.1161/circulationaha.122.060467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Linda R. Peterson
- Washington University School of Medicine in Saint Louis, MO (L.R.P.)
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Employing the Multivariate Edmonton Scale in the Assessment of Frailty Syndrome in Heart Failure. J Clin Med 2022; 11:jcm11144022. [PMID: 35887785 PMCID: PMC9318958 DOI: 10.3390/jcm11144022] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 07/09/2022] [Accepted: 07/11/2022] [Indexed: 11/29/2022] Open
Abstract
Background: Frailty syndrome (FS) is a syndrome characterized by a reduction in the body’s physiological reserves as a result of the accumulation of reduced efficiency of many organs and systems. Experts of the Heart Failure Association of the European Society of Cardiology (ECS) emphasize the need to assess frailty in all patients with heart failure (HF). There is no specific scale dedicated to this group of patients. The aim of the study was to assess the occurrence of the frailty syndrome in heart failure using the multidimensional Edmonton Frailty Scale (EFS). Methods: The study included 106 patients diagnosed with heart failure with reduced left ventricular ejection fraction (LVEF < 40%). The average age was 62.6 ± 9.7 years. Most of the patients (84%) studied were men. In 70 people (66%), the cause of heart failure was coronary artery disease. The study group included patients admitted to hospital on a scheduled basis and with exacerbation of heart failure. Frailty was measured using the EFS before discharge from the hospital. Demographic, sociodemographic and clinical data were obtained. A 12-month follow-up period was included in the project. The number of readmissions after 6 and 12 months was assessed. Results: A correlation was observed between the New York Heart Association (NYHA) functional class and the occurrence of frailty—this applies to the assessment at the beginning and at the end of hospitalization. When analyzing the age of the patients in relation to frailty, a statistically significant difference was obtained. The youngest group in terms of age were non-frail patients. Hospitalization of people prone to development of the frailty syndrome and diagnosed with the FS was significantly more often associated with the occurrence of complications during hospital stays. Rehospitalizations for exacerbation of heart failure were much more frequent in patients with frailty. Conclusions: Assessment and monitoring of the state of increased sensitivity to the development of frailty or FS in patients with heart failure should influence the differentiation of clinical management. The Edmonton Questionnaire may be a helpful tool for the assessment of frailty in hospitalized patients with HF.
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Yang Y, Liu Y, Zhang Z, Mao J. Frailty and predictive factors in Chinese hospitalized patients with chronic heart failure: A Structural Equation Model Analysis. Eur J Cardiovasc Nurs 2022; 22:400-411. [PMID: 35816040 DOI: 10.1093/eurjcn/zvac063] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2022] [Revised: 07/05/2022] [Accepted: 07/07/2022] [Indexed: 11/14/2022]
Abstract
AIMS Frailty is closely related to the prognosis and quality of life of patients with heart failure (HF). However, the predictors of it are still unclear. Our study aimed to describe the frailty status of Chinese hospitalized patients with heart failure and explore predictive factors guided by Theory of Unpleasant Symptoms. METHODS AND RESULTS In this cross-sectional descriptive study, questionnaire-based survey was conducted among 323 patients hospitalized with heart failure in three tertiary hospitals in Wuhan, China. Frailty was measured by the Tilburg Frailty Indicator (TFI) in this study. The model based on Theory of Unpleasant Symptoms fits the sample well (root mean square error of approximation = 0.063, goodness of fit index = 0.977, normed fit index = 0.901, comparative fit index = 0.940). Frailty among Chinese patients hospitalized with heart failure was at high level (TFI = 6.57 ± 3.05). General demographic characteristics (older age, female gender, lower education level, and medical payment method), physical factors (higher New York Heart Association cardiac function class), psychological factors (more severe depression), and social factors (poorer social support) were significant predictors of more severe frailty (p < 0.05). Depression played an important mediating role in this study. CONCLUSIONS Theory of Unpleasant Symptoms can be used to guide the research on the frailty of heart failure patients. It is suggested to strengthen emotional support and health education for heart failure patients in China. In addition, more attention should be paid to the less educated population by providing more personalized health guidance.
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Affiliation(s)
- Yang Yang
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Yifang Liu
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
| | - Zeyu Zhang
- Institute for Hospital Management of Tsinghua University, Haidian District, Beijing, China
| | - Jing Mao
- School of Nursing, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei Province, China
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Duong MH, Gnjidic D, McLachlan AJ, Sakiris MA, Goyal P, Hilmer SN. The Prevalence of Adverse Drug Reactions and Adverse Drug Events from Heart Failure Medications in Frail Older Adults: A Systematic Review. Drugs Aging 2022; 39:631-643. [PMID: 35761118 PMCID: PMC9355931 DOI: 10.1007/s40266-022-00957-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/02/2022] [Indexed: 12/14/2022]
Abstract
Introduction Frailty is highly prevalent in heart failure populations and a major risk factor for adverse drug reactions (ADRs) and adverse drug events (ADEs). This review aimed to describe the prevalence, causality and severity of ADRs or ADEs from heart failure medications among frail compared with non-frail older adults. Methods A systematic search of CENTRAL, MEDLINE, Embase, Ageline, CINAHL, International Pharmaceutical Abstracts, PsychInfo, Scopus, registries and citations prior to 18 May 2021 was conducted according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 checklist. Risk of bias and quality of evidence were assessed. Eligible studies included randomised controlled trials (RCTs) and observational studies of people diagnosed with heart failure, aged ≥ 65 years, with frailty defined by an objective measurement, and reported ADRs/ADEs from/with heart failure medications. Results Two reviewers screened 2419 articles; interrater reliability kappa = 0.88. Three observational studies (n = 2596), a secondary analysis of two RCTs (n = 2098) and two cohort studies (n = 498) were included in a narrative synthesis. Frail patients in randomised trials of sacubitril/valsartan, aliskiren, or enalapril had twice the risk of mortality (hazard ratio [HR] 2.09, 1.62–2.71) and hospitalisations (HR 1.82, 1.37–2.41) compared with robust patients, which may reflect responsiveness to medications and/or factors unrelated to medication use. Hospitalisations from falls, tiredness and nausea were probably attributable to digoxin and possibly preventable according to the Naranjo and Hallas scales, respectively. Conclusion The potential harms from heart failure medications in frail older people are poorly studied and understood. Clinical trials and pharmacovigilance studies should include frailty as a covariate to inform medication optimisation for this vulnerable and growing population. Registration Prospero registration number: CRD 42021253762. Graphical Abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s40266-022-00957-8.
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Affiliation(s)
- Mai H Duong
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia. .,Department of Clinical Pharmacology and Aged Care, Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia.
| | - Danijela Gnjidic
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, NSW, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Andrew J McLachlan
- Faculty of Medicine and Health, Sydney Pharmacy School, The University of Sydney, Sydney, NSW, Australia.,Charles Perkins Centre, The University of Sydney, Sydney, NSW, Australia
| | - Marissa A Sakiris
- Department of Pharmacy, Royal North Shore Hospital, Sydney, NSW, Australia
| | | | - Sarah N Hilmer
- Faculty of Medicine and Health, Northern Clinical School, The University of Sydney, Sydney, NSW, Australia.,Department of Clinical Pharmacology and Aged Care, Kolling Institute, Royal North Shore Hospital, Sydney, NSW, Australia
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Abstract
BACKGROUND Heart failure prevalence will double in the next 40 years and affects more than 10% of persons over the age of 70 years in an age-dependent manner. Frailty is an age-associated clinical syndrome defined as a decrease in physiological reserve in situations of stress, such as operations, infections and acute illness based on a state of higher vulnerability. The prevalence is up to 74% in older individuals over the age of 80 years or those over 70 years old with a high burden of comorbidities and chronic diseases. This geriatric syndrome is associated with a worse clinical outcome and higher morbidity and mortality in acute and chronic disease than in age-matched cohorts without this syndrome. METHODS In this brief review, the scientific evidence of appropriate tools for diagnosis of frailty in heart failure patients is addressed. Heart failure management in this special group of patients requires a holistic care planning presented here in accordance with pathophysiologic particularities. A literature search in PubMed using the terms "heart failure" and "frailty" was carried out and a further search in the references based on the findings. CONCLUSION The diagnosis of frailty should influence the intensity of further diagnostic investigations and medical treatment based on the personal wishes of the patient, reduced organ reserves and general prognosis. The prognosis of heart failure patients remains poor, partially due to the intertwining with frailty. A clear statement for the use of an appropriate diagnostic tool for frailty and heart failure and specific therapeutic recommendations are presented based on clinical evidence.
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Affiliation(s)
- Peter Dovjak
- Department of Acute Geriatrics, Salzkammergut Klinik Gmunden, Miller von Aichholzstr. 49, 4810, Gmunden, Austria.
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