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Prediction of Angina Pectoris Events in Middle-Aged and Elderly People Using RR Interval Time Series in the Resting State: A Cohort Study Based on SHHS. INT J COMPUT INT SYS 2023. [DOI: 10.1007/s44196-023-00182-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023] Open
Abstract
AbstractAngina pectoris is associated with adverse cardiovascular events. In this study, a Bi-directional Long Short-Term Memory (Bi-LSTM) prediction model with the Attention layer was established to explore the predictive value of the resting-state RR interval time series on the occurrence of angina pectoris. The data of this cohort study were from the Sleep Heart Health Study database, 2,977 people were included with the follow-up of 15 years. We used the RR interval time series of electrocardiogram signals in the resting state. The outcome variables were any angina events during the follow-up. We randomly divided 2,977 participants into training (n = 2680) and testing sets (n = 297) with a partition ratio of 9:1. The prediction model of Bi-LSTM with Attention layer was developed and the predictive performance was assessed. 1,236 had angina pectoris and 1,741 patients did not have angina pectoris during the follow-up period. The predictive performance of the Bi-LSTM model was great with the value of accuracy = 0.913, area under the curve (AUC) = 0.922, precision = 0.913 in the testing set. RR intervals may be the potential predictors of angina events. It is more and more convenient to obtain heart rate with the development of wearable devices; the Bi-LSTM prediction model established in this study is expected to provide support for the intelligent prediction of angina pectoris events.
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Martin N, Manoharan K, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2021; 5:CD012721. [PMID: 34022072 PMCID: PMC8140651 DOI: 10.1002/14651858.cd012721.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF. SEARCH METHODS We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.
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Affiliation(s)
- Nicole Martin
- Institute of Health Informatics Research, University College London, London, UK
| | | | - Ceri Davies
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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Freitas C, Wang X, Ge Y, Ross HJ, Austin PC, Pang PS, Ko DT, Farkouh ME, Stukel TA, McMurray JJ, Lee DS. Comparison of Troponin Elevation, Prior Myocardial Infarction, and Chest Pain in Acute Ischemic Heart Failure. CJC Open 2020; 2:135-144. [PMID: 32462127 PMCID: PMC7242506 DOI: 10.1016/j.cjco.2020.02.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/19/2020] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Patients with heart failure (HF) with concomitant ischemic heart disease (IHD) have not been well characterized. We examined survival of patients with ischemic HF syndrome (IHFS), defined as presentation with acute HF and concomitant features suggestive of IHD. METHODS Patients were included if they presented with acute HF to hospitals in Ontario, Canada. IHD was defined by any of the following criteria: angina/chest pain, prior myocardial infarction (MI), or troponin elevation that was above the upper limit of normal (mild) or suggestive of cardiac injury. Deaths were determined after hospital presentation. RESULTS Of 5353 patients presenting with acute HF, 4088 (76.4%) exhibited features of IHFS. Patients with IHFS demonstrated a higher rate of 30-day (hazard ratio [HR], 1.89; 95% confidence interval [CI], 1.33-2.68) and 1-year death (HR, 1.16, 95% CI, 1.00-1.35) compared with those with nonischemic HF. Troponin elevation demonstrated the strongest association with mortality. Mildly elevated troponin was associated with increased hazard over 30-day (HR, 1.77; 95% CI, 1.12-2.81) and 1-year (HR, 1.63; 95% CI, 1.38-1.93) mortality. Troponins indicative of cardiac injury were associated with increased hazard of death over 30 days (HR, 2.33; 95% CI, 1.63-3.33) and 1 year (HR, 1.40; 95% CI, 1.21-1.61). The association between elevated troponin and higher mortality at 30 days was similar in left ventricular ejection fraction subcategories of HF with reduced ejection fraction, HF with mildly reduced ejection fraction, or HF with preserved ejection fraction (P interaction = 0.588). After multivariable adjustment, prior MI and angina were not associated with higher mortality risk. CONCLUSIONS In acute HF, elevated troponin, but not prior MI or angina, was associated with a higher risk of 30-day and 1-year mortality irrespective of left ventricular ejection fraction.
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Affiliation(s)
- Cassandra Freitas
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | | | - Yin Ge
- University of Toronto, Toronto, Ontario, Canada
| | - Heather J. Ross
- University Health Network, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, Toronto, Ontario, Canada
- Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
| | - Peter C. Austin
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - Peter S. Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Dennis T. Ko
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Michael E. Farkouh
- University Health Network, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, Toronto, Ontario, Canada
- Heart & Stroke Richard Lewar Centre of Excellence in Cardiovascular Research, Toronto, Ontario, Canada
| | - Therese A. Stukel
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Douglas S. Lee
- University Health Network, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Peter Munk Cardiac Centre, Toronto, Ontario, Canada
- Ted Rogers Centre for Heart Research, Toronto, Ontario, Canada
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Seferovic JP, Solomon SD, Seely EW. Potential mechanisms of beneficial effect of sacubitril/valsartan on glycemic control. Ther Adv Endocrinol Metab 2020; 11:2042018820970444. [PMID: 33489085 PMCID: PMC7768573 DOI: 10.1177/2042018820970444] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Accepted: 10/12/2020] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) and diabetes mellitus (DM) frequently coexist, with a prevalence of DM of 35-40% in patients with HF, independent of the level of impairment of the ejection fraction (EF). Furthermore, DM is considered a strong independent risk factor for the progression of HF with either preserved or reduced EF and is associated with poor prognosis. The ability of neprilysin inhibitors to elevate levels of biologically active natriuretic peptides has made them a potential therapeutic approach in HF. In the Prospective comparison of ARNi with ACEi to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM-HF) trial, a dual-acting angiotensin-receptor-neprilysin inhibitor, sacubitril/valsartan was superior to enalapril in reducing the risks of death and HF hospitalization in patients with HF with reduced EF. In addition, in a post-hoc analysis of this trial, among patients with DM, treatment with sacubitril/valsartan resulted in improved glycemic control compared with enalapril. Also, there are additional studies suggesting beneficial metabolic effects of this class of drugs. In this review we discuss potential mechanisms of sacubitril/valsartan effect on glycemic control. Sacubitril/valsartan concomitantly blocks the renin-angiotensin system and inhibits neprilysin, a ubiquitous enzyme responsible for the breakdown of more than 50 vasoactive peptides, including the biologically active natriuretic peptides, bradykinin, angiotensin I and II, endothelin 1, glucagon, glucagon-like peptide-1, insulin-B chain, and others. There are a number of potential mechanisms by which inhibition of neprilysin may lead to improvement in glycemic control, with most evidence suggesting modulation of neprilysin circulating substrates. Although there is some evidence suggesting the improvement of glucose metabolism by renin-angiotensin system inhibition, this effect is most likely modest. As these mechanisms are not fully understood, detailed mechanistic studies, as well as large randomized clinical trials in patients with DM, are needed to further clarify beneficial metabolic properties of sacubitril/valsartan.
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Affiliation(s)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s
Hospital, Harvard Medical School, Boston, MA, USA
| | - Ellen W. Seely
- Endocrinology, Diabetes, and Hypertension
Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,
USA
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Martin N, Manoharan K, Thomas J, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2018; 6:CD012721. [PMID: 29952095 PMCID: PMC6513293 DOI: 10.1002/14651858.cd012721.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction. There is uncertainty whether these treatments are beneficial for people with heart failure with preserved ejection fraction and a comprehensive review of the evidence is required. OBJECTIVES To assess the effects of beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with heart failure with preserved ejection fraction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trial registries on 25 July 2017 to identify eligible studies. Reference lists from primary studies and review articles were checked for additional studies. There were no language or date restrictions. SELECTION CRITERIA We included randomised controlled trials with a parallel group design enrolling adult participants with heart failure with preserved ejection fraction, defined by a left ventricular ejection fraction of greater than 40 percent. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion and extracted data. The outcomes assessed included cardiovascular mortality, heart failure hospitalisation, hyperkalaemia, all-cause mortality and quality of life. Risk ratios (RR) and, where possible, hazard ratios (HR) were calculated for dichotomous outcomes. For continuous data, mean difference (MD) or standardised mean difference (SMD) were calculated. We contacted trialists where neccessary to obtain missing data. MAIN RESULTS 37 randomised controlled trials (207 reports) were included across all comparisons with a total of 18,311 participants.Ten studies (3087 participants) investigating beta-blockers (BB) were included. A pooled analysis indicated a reduction in cardiovascular mortality (15% of participants in the intervention arm versus 19% in the control arm; RR 0.78; 95% confidence interval (CI) 0.62 to 0.99; number needed to treat to benefit (NNTB) 25; 1046 participants; 3 studies). However, the quality of evidence was low and no effect on cardiovascular mortality was observed when the analysis was limited to studies with a low risk of bias (RR 0.81; 95% CI 0.50 to 1.29; 643 participants; 1 study). There was no effect on all-cause mortality, heart failure hospitalisation or quality of life measures, however there is uncertainty about these effects given the limited evidence available.12 studies (4408 participants) investigating mineralocorticoid receptor antagonists (MRA) were included with the quality of evidence assessed as moderate. MRA treatment reduced heart failure hospitalisation (11% of participants in the intervention arm versus 14% in the control arm; RR 0.82; 95% CI 0.69 to 0.98; NNTB 41; 3714 participants; 3 studies; moderate-quality evidence) however, little or no effect on all-cause and cardiovascular mortality and quality of life measures was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% of participants in the intervention group versus 8% in the control group; RR 2.11; 95% CI 1.77 to 2.51; 4291 participants; 6 studies; high-quality evidence).Eight studies (2061 participants) investigating angiotensin converting enzyme inhibitors (ACEI) were included with the overall quality of evidence assessed as moderate. The evidence suggested that ACEI treatment likely has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. Data for the effect of ACEI on hyperkalaemia were only available from one of the included studies.Eight studies (8755 participants) investigating angiotensin receptor blockers (ARB) were included with the overall quality of evidence assessed as high. The evidence suggested that treatment with ARB has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% of participants in the intervention group versus 0.5% in the control group; RR 1.88; 95% CI 1.07 to 3.33; 7148 participants; 2 studies; high-quality evidence).We identified a single ongoing placebo-controlled study investigating the effect of angiotensin receptor neprilysin inhibitors (ARNI) in people with heart failure with preserved ejection fraction. AUTHORS' CONCLUSIONS There is evidence that MRA treatment reduces heart failure hospitalisation in heart failure with preserverd ejection fraction, however the effects on mortality related outcomes and quality of life remain unclear. The available evidence for beta-blockers, ACEI, ARB and ARNI is limited and it remains uncertain whether these treatments have a role in the treatment of HFpEF in the absence of an alternative indication for their use. This comprehensive review highlights a persistent gap in the evidence that is currently being addressed through several large ongoing clinical trials.
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Affiliation(s)
- Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Karthick Manoharan
- John Radcliffe HospitalEmergency Department3 Sherwood AvenueLondonMiddlesexUKUb6 0pg
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of EducationLondonUK
| | - Ceri Davies
- Barts Heart Centre, St Bartholomew's HospitalDepartment of CardiologyWest SmithfieldLondonUKEC1A 7BE
| | - R Thomas Lumbers
- University College LondonInstitute of Health InformaticsLondonUK
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7
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Vedin O, Lam CSP, Koh AS, Benson L, Teng THK, Tay WT, Braun OÖ, Savarese G, Dahlström U, Lund LH. Significance of Ischemic Heart Disease in Patients With Heart Failure and Preserved, Midrange, and Reduced Ejection Fraction: A Nationwide Cohort Study. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.117.003875. [PMID: 28615366 DOI: 10.1161/circheartfailure.117.003875] [Citation(s) in RCA: 180] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 05/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND The pathogenic role of ischemic heart disease (IHD) in heart failure (HF) with reduced ejection fraction (HFrEF; EF <40%) is well established, but its pathogenic and prognostic significance in HF with midrange (HFmrEF; EF 40%-50%) and preserved EF (HFpEF; EF ≥50%) has been much less explored. METHODS AND RESULTS We evaluated 42 987 patients from the Swedish Heart Failure Registry with respect to baseline IHD, outcomes (IHD, HF, cardiovascular events, and all-cause death), and EF change during a median follow-up of 2.2 years. Overall, 23% had HFpEF (52% IHD), 21% had HFmrEF (61% IHD), and 55% had HFrEF (60% IHD). After multivariable adjustment, associations with baseline IHD were similar for HFmrEF and HFrEF and lower in HFpEF (risk ratio, 0.91 [0.89-0.93] versus HFmrEF and risk ratio, 0.90 [0.88-0.92] versus HFrEF). The adjusted risk of IHD events was similar for HFmrEF versus HFrEF and lower in HFpEF (hazard ratio, 0.89 [0.84-0.95] versus HFmrEF and hazard ratio, 0.84 [0.80-0.90] versus HFrEF). After adjustment, prevalent IHD was associated with increased risk of IHD events and all other outcomes in all EF categories except all-cause mortality in HFpEF. Those with IHD, particularly new IHD events, were also more likely to change to a lower EF category and less likely to change to a higher EF category over time. CONCLUSIONS HFmrEF resembled HFrEF rather than HFpEF with regard to both a higher prevalence of IHD and a greater risk of new IHD events. Established IHD was an important prognostic factor across all HF types.
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Affiliation(s)
- Ola Vedin
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden.
| | - Carolyn S P Lam
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Angela S Koh
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Lina Benson
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Tiew Hwa Katherine Teng
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Wan Ting Tay
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Oscar Ö Braun
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Gianluigi Savarese
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Ulf Dahlström
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
| | - Lars H Lund
- From the Department of Medical Sciences, Uppsala University and Uppsala Clinical Research Center, Sweden (O.V.); National Heart Centre Singapore (C.S.P.L., A.S.K., T.H.K.T., W.T.T.); Duke-NUS Medical School, Singapore (C.S.P.L., A.S.K.); Regional Cancer Centre Stockholm Gotland, Sweden (L.B.); School of Population Health, University of Western Australia, Perth (T.H.K.T.); Department of Cardiology, Skåne University Hospital, Lund University, Sweden (O.Ö.B.); Department of Medicine, Karolinska Institutet, Stockholm, Sweden (G.S., L.H.L.); Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden (G.S., L.H.L.); and Department of Cardiology (U.D.) and Department of Medical and Health Sciences (U.D.), Linkoping University, Sweden
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8
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Seferovic JP, Claggett B, Seidelmann SB, Seely EW, Packer M, Zile MR, Rouleau JL, Swedberg K, Lefkowitz M, Shi VC, Desai AS, McMurray JJV, Solomon SD. Effect of sacubitril/valsartan versus enalapril on glycaemic control in patients with heart failure and diabetes: a post-hoc analysis from the PARADIGM-HF trial. Lancet Diabetes Endocrinol 2017; 5:333-340. [PMID: 28330649 PMCID: PMC5534167 DOI: 10.1016/s2213-8587(17)30087-6] [Citation(s) in RCA: 234] [Impact Index Per Article: 33.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Revised: 01/31/2017] [Accepted: 02/01/2017] [Indexed: 12/26/2022]
Abstract
BACKGROUND Diabetes is an independent risk factor for heart failure progression. Sacubitril/valsartan, a combination angiotensin receptor-neprilysin inhibitor, improves morbidity and mortality in patients with heart failure with reduced ejection fraction (HFrEF), compared with the angiotensin-converting enzyme inhibitor enalapril, and improves peripheral insulin sensitivity in obese hypertensive patients. We aimed to investigate the effect of sacubitril/valsartan versus enalapril on HbA1c and time to first-time initiation of insulin or oral antihyperglycaemic drugs in patients with diabetes and HFrEF. METHODS In a post-hoc analysis of the PARADIGM-HF trial, we included 3778 patients with known diabetes or an HbA1c ≥6·5% at screening out of 8399 patients with HFrEF who were randomly assigned to treatment with sacubitril/valsartan or enalapril. Of these patients, most (98%) had type 2 diabetes. We assessed changes in HbA1c, triglycerides, HDL cholesterol and BMI in a mixed effects longitudinal analysis model. Time to initiation of oral antihyperglycaemic drugs or insulin in subjects previously not treated with these agents were compared between treatment groups. FINDINGS There were no significant differences in HbA1c concentrations between randomised groups at screening. During the first year of follow-up, HbA1c concentrations decreased by 0·16% (SD 1·40) in the enalapril group and 0·26% (SD 1·25) in the sacubitril/valsartan group (between-group reduction 0·13%, 95% CI 0·05-0·22, p=0·0023). HbA1c concentrations were persistently lower in the sacubitril/valsartan group than in the enalapril group over the 3-year follow-up (between-group reduction 0·14%, 95% CI 0·06-0·23, p=0·0055). New use of insulin was 29% lower in patients receiving sacubitril/valsartan (114 [7%] patients) compared with patients receiving enalapril (153 [10%]; hazard ratio 0·71, 95% CI 0·56-0·90, p=0·0052). Similarly, fewer patients were started on oral antihyperglycaemic therapy (0·77, 0·58-1·02, p=0·073) in the sacubitril/valsartan group. INTERPRETATION Patients with diabetes and HFrEF enrolled in PARADIGM-HF who received sacubitril/valsartan had a greater long-term reduction in HbA1c than those receiving enalapril. These data suggest that sacubitril/valsartan might enhance glycaemic control in patients with diabetes and HFrEF. FUNDING Novartis.
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Affiliation(s)
- Jelena P Seferovic
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sara B Seidelmann
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Ellen W Seely
- Endocrinology, Diabetes, and Hypertension Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Michael R Zile
- The Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC, USA
| | - Jean L Rouleau
- Université de Montréal, Institut de Cardiologie, Montréal, QC, Canada
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital, Göteborg, Sweden
| | | | - Victor C Shi
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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9
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End points in heart failure-are we doing it right? Eur J Clin Pharmacol 2017; 73:651-659. [PMID: 28280889 DOI: 10.1007/s00228-017-2228-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2016] [Accepted: 02/27/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE Heart Failure (HF) continues to be associated with high mortality and morbidity. We attempted to identify the most common end points used in phase 3 clinical trials of heart failure and discuss their merits and demerits. METHODS Literature evaluation was done using the databases PubMed and Clinicaltrials.gov from January 2010 to December 2016 to identify randomised clinical trials (RCTs) evaluating the effect of therapeutic drugs on heart failure. Following the literature search, the data on the primary end points were extracted from each of the selected trials. The most recurrent and important end points of Phase III clinical trials for HF over the last six years were identified for further discussion. RESULTS From our search, it was observed that the most common end points used in trials with acute heart failure (AHF) were composite end point, dyspnea, CV death and most common end points used in trials with chronic heart failure (CHF) were composite end point, 6 minute walk test (6MWT), CV death or HFH, Vo2 max, all cause mortality, left ventricular ejection fraction (LVEF), and dyspnea. CONCLUSION Choosing the appropriate end points is a critical step in the study design that could turn the tide in the beleaguered drug development pipeline of HF, resulting in the right molecule reaching the HF community.
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10
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Abstract
Angina pectoris is defined as substernal chest pain, pressure, or discomfort that is typically exacerbated by exertion and/or emotional stress, lasts greater than 30 to 60 seconds, and is relieved by rest and nitroglycerin. There are approximately 10 million people in the United States who have angina, and there are over 500 000 cases diagnosed per year. Several studies now show that angina itself is a predictor of major adverse cardiac events. In addition, angina is a serious morbidity that impedes quality of life and should be treated. In the United States, pharmacologic therapy for angina includes β-blockers, nitrates, calcium channel blockers, and the late sodium current blocker ranolazine. In other countries, additional pharmacologic agents include trimetazidine, ivabradine, nicorandil, fasudil, and others. Revascularization is indicated in certain high-risk individuals and also has been shown to improve angina. However, even after revascularization, a substantial percentage of patients return with recurrent or continued angina, requiring newer and better therapies. Treatment for refractory angina not amenable to usual pharmacologic therapies or revascularization procedures, includes enhanced external counterpulsation, transmyocardial revascularization, and stem cell therapy. Angina continues to be a significant cause of morbidity. Therapy should be geared not only to treating the risk factors for atherosclerotic disease and improving survival but should also be aimed at eliminating or reducing the occurrence of angina and improving the ability of patients to be active.
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Affiliation(s)
- Robert A. Kloner
- Huntington Medical Research Institutes, Pasadena, CA, USA
- Keck School of Medicine at the University of Southern California, Los Angeles, CA, USA
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11
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Metra M, Carubelli V, Ravera A, Stewart Coats AJ. Heart failure 2016: still more questions than answers. Int J Cardiol 2016; 227:766-777. [PMID: 27838123 DOI: 10.1016/j.ijcard.2016.10.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/23/2016] [Accepted: 10/23/2016] [Indexed: 12/21/2022]
Abstract
Heart failure has reached epidemic proportions given the ageing of populations and is associated with high mortality and re-hospitalization rates. This article reviews and summarizes recent advances in the diagnosis, assessment and treatment of the patients with heart failure. Data are discussed based also on the most recent guidelines indications. Open issues and unmet needs are highlighted.
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Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy.
| | - Valentina Carubelli
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Alice Ravera
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
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12
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Triposkiadis F, Giamouzis G, Parissis J, Starling RC, Boudoulas H, Skoularigis J, Butler J, Filippatos G. Reframing the association and significance of co-morbidities in heart failure. Eur J Heart Fail 2016; 18:744-58. [DOI: 10.1002/ejhf.600] [Citation(s) in RCA: 146] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2015] [Revised: 03/18/2016] [Accepted: 03/20/2016] [Indexed: 01/09/2023] Open
Affiliation(s)
| | - Gregory Giamouzis
- Department of Cardiology; Larissa University Hospital; Larissa Greece
| | - John Parissis
- Department of Cardiology; Athens University Hospital Attikon; Athens Greece
| | - Randall C. Starling
- Kaufman Center for Heart Failure; Cleveland Clinic and the Cleveland Clinic Lerner College of Medicine; Cleveland OH USA
| | - Harisios Boudoulas
- The Ohio State University, Columbus, OH, USA; Biomedical Research Foundation Academy of Athens, Athens, and; Aristotelian University of Thessaloniki; Thessaloniki Greece
| | - John Skoularigis
- Department of Cardiology; Larissa University Hospital; Larissa Greece
| | - Javed Butler
- Cardiology Division, School of Medicine; Stony Brook University; Stony Brook NY USA
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13
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Badar AA, Perez-Moreno AC, Hawkins NM, Jhund PS, Brunton AP, Anand IS, McKelvie RS, Komajda M, Zile MR, Carson PE, Gardner RS, Petrie MC, McMurray JJ. Clinical Characteristics and Outcomes of Patients With Coronary Artery Disease and Angina. Circ Heart Fail 2015; 8:717-24. [DOI: 10.1161/circheartfailure.114.002024] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2014] [Accepted: 06/01/2015] [Indexed: 01/09/2023]
Abstract
Background—
The aim of our study was to investigate the relationship between coronary artery disease (CAD), angina, and clinical outcomes in patients with heart failure and preserved ejection fraction enrolled in the irbesartan in patients with heart failure and preserved systolic function (I-Preserve) trial.
Methods and Results—
The mean follow-up period for the 4128 patients enrolled in I-Preserve was 49.5 months. Patients were divided into 4 mutually exclusive groups according to history of CAD and angina: patients with no history of CAD or angina (n=2008), patients with no history of CAD but a history of angina (n=649), patients with a history of CAD but no angina (n=468), and patients with a history of CAD and angina (n=1003); patients with no known CAD or angina were the reference group. After adjustment for other prognostic variables using Cox proportional-hazard models, patients with CAD but no angina were found to be at higher risk of all-cause mortality (hazard ratio [HR], 1.58 [1.22–2.04];
P
<0.01) and sudden death (HR, 2.12 [1.33–3.39];
P
<0.01), compared with patients with no CAD or angina. Patients with CAD and angina were also at higher risk of all-cause mortality (HR, 1.29 [1.05–1.59];
P
=0.02) and sudden death (HR, 1.83 [1.24–2.69];
P
<0.01) compared with the same reference group and had the highest risk of unstable angina or myocardial infarction (HR, 5.84 [3.43–9.95];
P
<0.01).
Conclusions—
Patients with heart failure and preserved ejection fraction and CAD are at higher risk of all-cause mortality and sudden death when compared with those without CAD.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00095238.
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Affiliation(s)
- Athar A. Badar
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Ana Cristina Perez-Moreno
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Nathaniel M. Hawkins
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Pardeep S. Jhund
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Alan P.T. Brunton
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Inder S. Anand
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Robert S. McKelvie
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Michel Komajda
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Michael R. Zile
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Peter E. Carson
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Roy S. Gardner
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - Mark C. Petrie
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
| | - John J.V. McMurray
- From the BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.A.B., A.C.P.-M., P.S.J., A.P.T.B., R.S.G., M.C.P., J.J.V.M.); Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow, United Kingdom (A.A.B., R.S.G., M.C.P.); Division of Cardiology, University of British Columbia, Vancouver, Canada (N.M.H.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A
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