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Chan DZL, Doughty RN, Poppe KK, Harwood M, Lee MAW, Kerr AJ. Short, Medium and Long-Term Cause-Specific Mortality Following First-Ever Heart Failure Hospitalisation in New Zealand. Heart Lung Circ 2024; 33:1475-1483. [PMID: 38981830 DOI: 10.1016/j.hlc.2024.05.009] [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: 01/31/2024] [Revised: 04/15/2024] [Accepted: 05/18/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Heart failure (HF) is associated with high mortality, but there are limited reports on the underlying cause of death. This study reports short-, medium- and long-term cause-specific mortality following first-ever HF hospitalisation in New Zealand. METHOD First-ever HF hospitalisations were identified from hospital discharge coding between 2010 and 2013. Mortality outcomes were obtained via anonymised linkage to national datasets. Short (0-30 days), medium (31-364 days), and long-term (1-5 years) mortality rates were identified. Cause of death was identified from death certification coding and classified as cardiovascular and non-cardiovascular. Cox regression analysis was performed to adjust for confounding variables. RESULTS A cohort of 34,264 individuals with first-ever HF hospitalisation were identified. Mean age was 75.8±13 years and 50.5% were male. A total of 21,637 (63.1%) died within 5 years of hospitalisation; 4,122 (12.0%) within the first 30 days, 6,358 (18.6%) between 31-364 days, and 11,157 (32.6%) between 1 and 5 years. Older age, male gender, Māori ethnicity, higher socioeconomic deprivation and increased comorbidity were independent factors associated with higher all-cause mortality. Cardiovascular causes accounted for 51% of total deaths. Cardiovascular mortality was 6.0%, 9.5%, and 16.7% at 30 days, 31-364 days, and 1-5 years, respectively. The most common causes of non-cardiovascular mortality were neoplasms, chronic respiratory diseases and infections, accounting for 14.6%, 11.0%, and 5.5% of total deaths respectively. Comorbidity was associated with higher non-cardiovascular mortality (hazard ratio [HR] 3.35; 95% confidence interval [CI] 3.16-3.55) but not cardiovascular mortality (HR 0.79; 95% CI 0.72-0.86). CONCLUSIONS In New Zealand, mortality following first-ever HF hospitalisation is high. Non-cardiovascular death is common and there are ethnic inequities.
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Affiliation(s)
- Daniel Z L Chan
- Department of Cardiology, Te Whatu Ora Health New Zealand Te Tai Tokerau. Whangarei, New Zealand.
| | - Rob N Doughty
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Greenlane Cardiovascular Service, Te Whatu Ora Health New Zealand Te Toka Tumai, Auckland Hospital, Auckland, New Zealand
| | - Katrina K Poppe
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Matire Harwood
- Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
| | - Mildred Ai Wei Lee
- Department of Cardiology, Te Whatu Ora Health New Zealand Counties Manukau, Auckland, New Zealand
| | - Andrew J Kerr
- Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand; Section of Epidemiology and Biostatistics, School of Population Health, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand
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2
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Burgos LM, Ballari FN, Spaccavento A, Ricciardi B, Suárez LL, Baro Vila RC, De Bortoli MA, Conde D, Diez M. In-hospital initiation of sodium-glucose cotransporter-2 inhibitors in patients with heart failure and reduced ejection fraction: 90-day prescription patterns and clinical implications. Curr Probl Cardiol 2024; 49:102779. [PMID: 39089410 DOI: 10.1016/j.cpcardiol.2024.102779] [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: 07/26/2024] [Accepted: 07/29/2024] [Indexed: 08/04/2024]
Abstract
INTRODUCTION Safety and early clinical benefit make sodium-glucose cotransporter-2 inhibitor (SGLT2-i) therapy suitable for in-hospital initiation in patients with heart failure and reduced ejection fraction (HFrEF). Despite randomized controlled trials and guideline recommendations, they are underused, and clinical inertia may play a role. OBJECTIVES PRIMARY To assess the impact of initiating SGLT-2i at discharge on 90-day prescription rates in patients with HFrEF during hospitalization for acute heart failure (AHF). Secondary: To evaluate the presence of independent factors associated with prescription, and to explore clinical outcomes at 90 days. METHODS Retrospective analysis of a consecutive prospective single-center cohort. Adult patients hospitalized between January 2021 and September 2022 with a primary diagnosis of AHF and left ventricular ejection fraction (LVEF) <40% were included. The primary outcome was SGLT2-i prescription rate at 90 days, and the exploratory secondary endpoints was the composite of hospitalization or urgent visit for AHF or all-cause mortality at 90 days. RESULTS 237 patients were included. Mean age was 76±11 years, and mean LVEF was 29±7%. In patients without contraindications, SGLT2 inhibitors (SGLT2-i) were prescribed during hospitalization in 52.3%. At 90 days, the SGLT2-i prescription rate was 94.2% in those with in-hospital initiation and 14.4% in those without. (p<0.001). Independent factor associated with inpatient prescription was lower LVEF, 0.83 (95% CI: 0.77-0.89) for each point. Patients with in-hospital SGLT2-i initiation showed a lower rate of the combined endpoint of all-cause death, HF rehospitalization, or unplanned HF visit at 90 days (44.4% versus 23.9%, p=0.005). CONCLUSIONS In-hospital initiation of SGLT-2-i was associated with significantly higher prescription rates and lower prevalence in the secondary combined endpoint at 90 days. This study reflects the presence of medical inertia, particularly in patients with higher LVEF, and highlights the hospitalization period as an optimal time to start SGLT2-i.
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Affiliation(s)
- Lucrecia María Burgos
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina.
| | - Franco Nicolás Ballari
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina
| | - Ana Spaccavento
- Clinical Cardiology Department. Instituto Cardiovascular de Buenos Aires. Argentina
| | - Bianca Ricciardi
- Clinical Cardiology Department. Instituto Cardiovascular de Buenos Aires. Argentina
| | | | - Rocío Consuelo Baro Vila
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina
| | - María Antonella De Bortoli
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina
| | - Diego Conde
- Clinical Cardiology Department. Instituto Cardiovascular de Buenos Aires. Argentina
| | - Mirta Diez
- Heart Failure, Pulmonary Hypertension and Heart Transplant Division. Instituto Cardiovascular de Buenos Aires Argentina
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3
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Devoldere J, Droogmans S, Heggermont WA, Van Craenenbroeck E. Implementation of guideline-directed medical therapy for heart failure patients with reduced ejection fraction in Belgium: a Delphi panel approach. Acta Cardiol 2024:1-12. [PMID: 39254605 DOI: 10.1080/00015385.2024.2396767] [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: 02/26/2024] [Revised: 05/17/2024] [Accepted: 08/21/2024] [Indexed: 09/11/2024]
Abstract
BACKGROUND The 2021 European Society of Cardiology (ESC) guidelines recommended a shift from a traditional hierarchical treatment for heart failure with reduced ejection fraction (HFrEF) to a four-pillar medical therapy strategy intended for near-simultaneous initiation. However, practical guidance for implementation in clinical practice is lacking. To address this, a Delphi Panel of 12 Belgian heart failure experts aimed to obtain consensus on integrating guideline-directed medical therapy (GDMT) in HFrEF patients in Belgian clinical practice, considering local specificities, including reimbursement criteria. METHODS A geographically representative sample of 12 Belgian cardiologists engaged in a three-round Delphi process, evolving from 20 open-ended questions to 39 statements. A qualitative analysis after the first round resulted in expert statements for the subsequent questionnaire, categorised into treatment for newly diagnosed and chronic HFrEF patients. RESULTS The Delphi consensus revealed four key findings: (i) Agreement on initiating the four medical cornerstones within 7-14 days of HFrEF diagnosis, prioritising initiation over individual class up-titration; (ii) Lack of consensus on a fixed sequence for initiation due to patient variability and national reimbursement criteria; (iii) Emphasis on treatment adjustment based on the patient's clinical presentation and comorbidities; (iv) Recognition of the crucial role of regular follow-up visits, allowing optimisation of medical therapy where appropriate. CONCLUSION This national Delphi consensus addresses clinical implementation of GDMT in HFrEF patients for Belgian cardiologists. The consensus highlights the importance of swift implementation of the four cornerstone medical therapies in newly diagnosed HFrEF patients, individualising treatment sequencing, and ensuring regular follow-up to optimise therapy.
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Affiliation(s)
- Joke Devoldere
- Medical Affairs, BioPharmaceuticals, AstraZeneca, Groot-Bijgaarden, Belgium
| | - Steven Droogmans
- Department of Cardiology, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel (UZB), Centrum voor Hart- en Vaatziekten (CHVZ), Brussels, Belgium
| | - Ward A Heggermont
- Cardiovascular Research Center, Hartcentrum OLV Aalst, Aalst, Belgium
| | - Emeline Van Craenenbroeck
- Research Group Cardiovascular Diseases, University of Antwerp, Antwerp, Belgium
- Department of Cardiology, Antwerp University Hospital (UZA), Edegem, Belgium
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4
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Kuwayama T, Okumura T, Kondo T, Oishi H, Kimura Y, Kazama S, Araki T, Hiraiwa H, Morimoto R, Kanashiro M, Asano H, Kawaguchi K, Yoshida Y, Tanaka N, Morishima I, Murohara T. Characteristics, Treatment, and Prognosis in Octogenarian and Older Patients With Acute Heart Failure in Japan - Prospective Observational Study on Acute Pharmacotherapy and Prognosis in Management of Acute Heart Failure (POPEYE-AHF Registry). Circ J 2024:CJ-24-0299. [PMID: 39245574 DOI: 10.1253/circj.cj-24-0299] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/10/2024]
Abstract
BACKGROUND The number of older people in Japan is increasing more quickly than in other countries; with this aging of society, the number of elderly patients hospitalized for acute heart failure (HF) is also increasing. The treatment and prognosis of acute HF may be changing, but there are insufficient recent data, especially for octogenarian and older patients. METHODS AND RESULTS This study investigated the characteristics and treatment of acute HF patients in Japan. From 2018 to 2020, 1,146 patients from 7 Tokai area hospitals were followed for at least 1 year. The mean age was 78 years. Compared with patients aged <80 years, those aged ≥80 years were more likely to be female (57.4% vs. 34.2%), have a lower body mass index (22.2 vs. 24.9 kg/m2), and have HF with preserved ejection fraction (43.1% vs. 21.4%), and less likely to have HF with reduced ejection fraction (38.9% vs. 61.7%). During hospitalization, 6.5% died. After discharge, patients faced high risks of rehospitalization for HF and death (27.6 and 14.2 per 100 patient-years, respectively). Notably, prescription rates of HF medications have declined over time for all patients, but especially for those aged ≥80 years. CONCLUSIONS Guideline-directed medical therapy should be provided based on a thorough understanding of an individual's background rather than withheld simply because of clinical inertia due to a patient's advanced age.
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Affiliation(s)
- Tasuku Kuwayama
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takahiro Okumura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Toru Kondo
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hideo Oishi
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Yuki Kimura
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Shingo Kazama
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takashi Araki
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Hiroaki Hiraiwa
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Ryota Morimoto
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | | | | | - Yukihiko Yoshida
- Department of Cardiology, Japanese Red Cross Aichi Medical Center Nagoya Daini Hospital
| | | | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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5
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Biegus J, Pagnesi M, Davison B, Ponikowski P, Mebazaa A, Cotter G. High-intensity care for GDMT titration. Heart Fail Rev 2024; 29:1065-1077. [PMID: 39037564 PMCID: PMC11306642 DOI: 10.1007/s10741-024-10419-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/07/2024] [Indexed: 07/23/2024]
Abstract
Heart failure (HF) is a systemic disease associated with a high risk of morbidity, mortality, increased risk of hospitalizations, and low quality of life. Therefore, effective, systemic treatment strategies are necessary to mitigate these risks. In this manuscript, we emphasize the concept of high-intensity care to optimize guideline-directed medical therapy (GDMT) in HF patients. The document highlights the importance of achieving optimal recommended doses of GDMT medications, including beta-blockers, renin-angiotensin-aldosterone inhibitors, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter inhibitors to improve patient outcomes, achieve effective, sustainable decongestion, and improve patient quality of life. The document also discusses potential obstacles to GDMT optimization, such as clinical inertia, physiological limitations, comorbidities, non-adherence, and frailty. Lastly, it also attempts to provide possible future scenarios of high-intensive care that could improve patient outcomes.
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Affiliation(s)
- Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Borowska 213, Poland.
| | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Beth Davison
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, 50-556 Wroclaw, Borowska 213, Poland
| | - Alexander Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Gadi Cotter
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
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Inciardi RM, Vaduganathan M, Lombardi CM, Gussago C, Agostoni P, Ameri P, Aspromonte N, Calò L, Cameli M, Carluccio E, Carugo S, Cipriani M, De Caterina R, De Ferrari GM, Emdin M, Fornaro A, Guazzi M, Iacoviello M, Imazio M, La Rovere MT, Leonardi S, Maccallini M, Masarone D, Moschini L, Palazzuoli A, Patti G, Pedretti RFE, Perrone Filardi P, Piepoli MF, Potena L, Salzano A, Sciacqua A, Senni M, Sinagra G, Specchia C, Taddei S, Vizza D, Savarese G, Rosano G, Volterrani M, Metra M. OPTImal PHARMacological therapy for patients with heart failure: Rationale and design of the OPTIPHARM-HF registry. Eur J Heart Fail 2024; 26:1707-1714. [PMID: 38923140 DOI: 10.1002/ejhf.3260] [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: 03/02/2024] [Revised: 03/30/2024] [Accepted: 04/15/2024] [Indexed: 06/28/2024] Open
Abstract
AIMS Patients with heart failure (HF) remain often undertreated for multiple reasons, including treatment inertia, contraindications, and intolerance. The OPTIimal PHARMacological therapy for patients with Heart Failure (OPTIPHARM-HF) registry is designed to evaluate the prevalence of evidence-based medical treatment prescription and titration, as well as the causes of its underuse, in a broad real-world population of consecutive patients with HF across the whole ejection fraction spectrum and among different clinical phenotypes. METHODS The OPTIPHARM-HF registry (NCT06192524) is a prospective, multicenter, observational, national study of adult patients with symptomatic HF, as defined by current international guidelines, regardless of ejection fraction. Both outpatients and inpatients with chronic and acute decompensated HF will be recruited. The study will enroll up to 2500 patients with chronic HF at approximately 35 Italian HF centres. Patients will be followed for a maximum duration of 24 months. The primary objective of the OPTIPHARM-HF registry is to assess prescription and adherence to evidence-based guideline-directed medical therapy (GDMT) in patients with HF. The primary outcome is to describe the prevalence of GDMT use according to target guideline recommendation. Secondary objectives include implementation of comorbidity treatment, evaluation of sequence of treatment introduction and up-titration, description of GDMT implementation in the specific HF population, main causes of GDMT underuse, and assessment of cumulative rate of cardiovascular events. CONCLUSION The OPTIPHARM-HF registry will provide important implications for improving patient care and adoption of recommended medical therapy into clinical practice among HF patients.
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Affiliation(s)
- Riccardo M Inciardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Carlo M Lombardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Cristina Gussago
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Pietro Ameri
- Cardiology Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
- Department of Internal Medicine, University of Genoa, Genoa, Italy
| | - Nadia Aspromonte
- Department of Cardiovascular ad Thoracic Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Leonardo Calò
- Division of Cardiology, Policlinico Casilino, Rome, Italy
| | - Matteo Cameli
- Department of Medical Biotechnologies, Division of Cardiology, University of Siena, Siena, Italy
| | - Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, Santa Maria della Misericordia Hospital, University of Perugia, Perugia, Italy
| | - Stefano Carugo
- Department of Cardio-Thoracic-Vascular Diseases, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico and Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
| | - Manlio Cipriani
- Clinical Cardiology and Heart Failure Unit, Mediterranean Institute for Transplantation and Advanced Specialized Therapies ISMETT, Palermo, Italy
| | - Raffaele De Caterina
- Cardiology Division, Cardiothoracic and Vascular Department, Pisa University Hospital, Pisa, Italy
- Department of Surgical, Medical and Molecular Pathology and of Critical Sciences, University of Pisa, Pisa, Italy
| | - Gaetano M De Ferrari
- Division of Cardiology, Cardiovascular and Thoracic Department, Città della Salute e della Scienza Hospital, Turin, Italy
- Department of Medical Sciences, University of Turin, Turin, Italy
| | - Michele Emdin
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
- Interdisciplinary Center for Health Sciences, Scuola Superiore Sant'Anna, Pisa, Italy
| | | | - Marco Guazzi
- Cardiology Division, San Paolo Hospital, Milan, Italy
- Department of Biological Sciences, University of Milan School of Medicine, Milan, Italy
| | - Massimo Iacoviello
- Cardiology Unit, University Hospital Policlinico Riuniti, Foggia, Italy
- Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Massimo Imazio
- Department of Medicine (DMED), University of Udine, and Cardiothoracic Department, University Hospital Santa Maria della Misericordia, ASUFC, Udine, Italy
| | | | - Sergio Leonardi
- Division of Cardiology, Fondazione IRCCS Policlinico San Matteo, Pavia, Italy
- Department of Molecular Medicine, University of Pavia, Pavia, Italy
| | - Marta Maccallini
- Humanitas Clinical and Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, Naples, Italy
| | - Luigi Moschini
- Division of Cardiology, Ospedale Oglio Po, ASST Cremona, Cremona, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardiothoracic and Vascular Department, Le Scotte Hospital, University of Siena, Siena, Italy
| | - Giuseppe Patti
- Division of Cardiology, AOU Maggiore della Carità, Novara, Italy
- Department of Translational Medicine, Università del Piemonte Orientale, Novara, Italy
| | - Roberto F E Pedretti
- Unit of Cardiology, Cardiovascular Department, IRCCS MultiMedica, Sesto San Giovanni, Milan, Italy
- University of Milano - Bicocca, School of Medicine and Surgery, Milan, Italy
| | | | - Massimo F Piepoli
- Clinical Cardiology, IRCCS Policlinicco San Donato, San Donato Milanese, Milan, Italy
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Luciano Potena
- Heart Failure and Transplant Unit, IRCCS Azienda Ospedaliero Universitaria di Bologna, Bologna, Italy
| | | | - Angela Sciacqua
- Geriatrics Division. AOU R.Dulbecco, Department of Medical and Surgical Sciences, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Michele Senni
- Cardiology Unit, Cardiovascular Department, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina, University of Trieste, Trieste, Italy
| | - Claudia Specchia
- Department of Molecular and Translational Medicine, University of Brescia, Brescia, Italy
| | - Stefano Taddei
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | - Dario Vizza
- Department of Clinical Internal, Anesthesiological and Cardiovascular Sciences, Sapienza University of Rome, Policlinico Umberto I, Rome, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Giuseppe Rosano
- Chair of Pharmacology, University San Raffaele, Rome, Italy
- Cardiology, San Raffaele Cassino Hospital, Cassino, Italy
- Cardiovascular CAG, St George's University Hospital, London, UK
| | - Maurizio Volterrani
- Department of Exercise Science and Medicine, San Raffaele Open University of Rome, Italy
- Cardiopulmonary Department, IRCCS San Raffaele Roma, Rome, 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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7
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Qin H, Dewan P, Santema BT, ter Maaten JM, Swedberg K, McMurray JJV, Voors AA. Achieved dose and treatment discontinuation of candesartan in men and women with chronic heart failure: data from CHARM. ESC Heart Fail 2024; 11:1880-1887. [PMID: 38581132 PMCID: PMC11287367 DOI: 10.1002/ehf2.14715] [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: 10/05/2023] [Revised: 01/11/2024] [Accepted: 01/18/2024] [Indexed: 04/08/2024] Open
Abstract
AIMS Angiotensin receptor blockers have been shown to reduce heart failure hospitalization and cardiovascular mortality in men and women with heart failure with reduced ejection fraction (HFrEF). It is unknown whether there are differences between men and women in achieved dose and treatment discontinuation due to adverse events of candesartan. METHODS AND RESULTS We conducted a post hoc analysis of the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) programme. A total of 3172 men and 1106 women with HFrEF [left ventricular ejection fraction (LVEF) ≤ 40%] in New York Heart Association class II-IV were randomized to candesartan or placebo. Every 2 weeks, patients were up-titrated from 4 or 8, to16, to 32 mg once daily, unless a higher dose was contraindicated or not tolerated. Women were older (66 vs. 64 years), had a higher LVEF (29.9% vs. 28.6%), and had more hypertension (54% vs. 47%) than men. The mean achieved dose of candesartan was 21.5 ± 12.6 mg in men and 20.7 ± 12.9 mg in women (P = 0.19). In both the candesartan and placebo groups, cardiovascular death and heart failure hospitalizations were higher in men and women who achieved lower dose levels. Event rates for achieved dose levels of 0, 4 or 8, 16, and 32 mg candesartan were 20.8, 17.2, 14.0, and 10.1 per 100 person-years in men, respectively, and 23.6, 13.7, 14.0, and 9.1 per 100 person-years in women, respectively. In each of the achieved dose levels, there was no sex difference in the proportion of patients with an event, neither in the candesartan group nor in the placebo group (P-value for all > 0.05). There was no significant interaction between sex and treatment-related discontinuation for hypotension (P = 0.520), an increase in creatinine (P = 0.102), and hyperkalaemia (P = 0.905). CONCLUSIONS In a randomized clinical trial in patients with HFrEF, men and women achieved similar doses of candesartan. Primary event rates and treatment-related discontinuation due to adverse events were also similar between men and women.
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Affiliation(s)
- Hailun Qin
- Department of CardiologyUniversity Medical Center Groningen, University of GroningenHanzeplein 19713 GZGroningenThe Netherlands
| | - Pooja Dewan
- British Heart Foundation Cardiovascular Research Centre, University of GlasgowGlasgowUK
| | - Bernadet T. Santema
- Department of CardiologyUniversity Medical Center Groningen, University of GroningenHanzeplein 19713 GZGroningenThe Netherlands
| | - Jozine M. ter Maaten
- Department of CardiologyUniversity Medical Center Groningen, University of GroningenHanzeplein 19713 GZGroningenThe Netherlands
| | - Karl Swedberg
- Department of Molecular and Clinical MedicineUniversity of GothenburgGothenburgSweden
| | - John J. V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of GlasgowGlasgowUK
| | - Adriaan A. Voors
- Department of CardiologyUniversity Medical Center Groningen, University of GroningenHanzeplein 19713 GZGroningenThe Netherlands
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8
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Svensson MK, Tangri N, Bodegård J, Adamsson Eryd S, Thuresson M, Sofue T. Dapagliflozin treatment of patients with chronic kidney disease without diabetes across different albuminuria levels (OPTIMISE-CKD). Clin Kidney J 2024; 17:sfae100. [PMID: 39165293 PMCID: PMC11333959 DOI: 10.1093/ckj/sfae100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Indexed: 08/22/2024] Open
Abstract
Background We compared kidney and cardiorenal protection in patients without type 2 diabetes across urine albumin-creatinine ratio (UACR) levels after initiation on dapagliflozin for the treatment of chronic kidney disease (CKD). Methods OPTIMISE-CKD is an observational study describing dapagliflozin treatment for CKD. Adult patients with CKD without type 2 diabetes were included in the primary analysis. Baseline UACR was grouped as normal/mildly elevated (0-29 mg/g), low (30-200 mg/g) and high (>200 mg/g). Outcomes were estimated glomerular filtration rate (eGFR) trajectories/slopes, cardiorenal complications and all-cause mortality. Results In total, 1480 patients had low (n = 796) and high (n = 684) UACR. The two groups were similar at baseline, aged 75 and 74 years, and 42% and 39% female, respectively. After dapagliflozin initiation, an acute eGFR dip of 3 mL/min/1.73 m2 was observed, followed by a flat development in both groups. The eGFR slope [95% confidence interval (CI)] for patients with low UACR was 0.79 mL/min/1.73 m2 per year (-0.59, 2.56), and similar to patients with high UACR [0.40 mL/min/1.73 m2 per year (-0.46, 1.38)]. Risks of cardiorenal complications and all-cause mortality were similar, with adjusted hazard ratios of 0.89 (95% CI 0.66, 1.19) and 1.10 (95% CI 0.63, 1.92), respectively. Analogous results were found in those with normal/mildly elevated UACR. Conclusions Dapagliflozin in patients without type 2 diabetes for the treatment of CKD demonstrated similar kidney protection, cardiorenal and all-cause mortality risk across UACR levels. This suggests that the efficacy of dapagliflozin found in clinical trials expands to real-world patients with CKD, regardless of albuminuria levels.
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Affiliation(s)
- Maria K Svensson
- Department of Medical Sciences, Renal Medicine, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Centre, Uppsala, Sweden
| | - Navdeep Tangri
- University of Manitoba Max Rady College of Medicine, Winnipeg, MB, Canada
| | - Johan Bodegård
- Cardiovascular, Renal and Metabolism Evidence, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Samuel Adamsson Eryd
- Cardiovascular, Renal and Metabolism Evidence, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | | | - Tadashi Sofue
- Department of Cardiorenal and Cerebrovascular Medicine, Kagawa University, Takamatsu, Kagawa, Japan
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9
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Pabon MA, Vaduganathan M, Lam CSP. Is the optimal dose of heart failure medical therapy different in women and men? Eur J Heart Fail 2024; 26:1699-1702. [PMID: 38800983 DOI: 10.1002/ejhf.3320] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Accepted: 05/19/2024] [Indexed: 05/29/2024] Open
Affiliation(s)
- Maria A Pabon
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muthiah Vaduganathan
- Cardiovascular Medicine Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore, Singapore
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10
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Sax DR, Mark DG, Rana JS, Huang J, Casey SD, Norris RP, Tillage V, Reed ME. Pilot trial of an electronic decision support to improve care for emergency department patients with acute heart failure. ESC Heart Fail 2024. [PMID: 39054726 DOI: 10.1002/ehf2.14989] [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: 03/06/2024] [Revised: 06/28/2024] [Accepted: 07/08/2024] [Indexed: 07/27/2024] Open
Abstract
AIMS Emergency department (ED) providers play an important role in the management of patients with acute heart failure (AHF). We present findings from a pilot study of an electronic decision support that includes personalized risk estimates using the STRIDE-HF risk tool and tailored recommendations for initiating guideline directed medical therapy (GDMT) among appropriate patients. METHODS Among ED patients treated for AHF who were discharged from the ED or the ED-based observation unit in two EDs from 1 January 2023 to 31 July 2023, we assess prescriptions to the four classes of GDMT at two intervals: (1) ED arrival and (2) ED discharge. Specifically, we report active prescriptions for beta-blockers (BBs), renin-angiotensin receptor system inhibitors (RASis), sodium-glucose transport protein 2 inhibitors (SGLT2is) and mineralocorticoid receptor antagonists (MRA) among patients with reduced ejection fraction (HFrEF) and mildly reduced (HFmrEF). Second, we describe rates of 30-day serious adverse events (SAE) (death, cardiopulmonary resuscitation, balloon-pump insertion, intubation, new dialysis, myocardial infarction or coronary revascularization) among patients predicted to be very low risk by STRIDE-HF and discharged home. RESULTS Among 234 discharged patients, 55% were female and 76% were non-White. We found 51 (21.8%), 21 (9.0%) and 126 (53.8%) had HFrEF, HFmEF and HFpEF, respectively, while 36 (15.4%) were missing EF, and 51 (22%) were very low risk, 82 (35%) were low risk, 60 (26%) were medium risk and 41 (18%) were high risk. Among HFrEF patients, 68.6%, 66.7%, 25.5% and 19.6% were on a RASi, BB, SGLT2i and MRA, respectively, at ED arrival, while 42.9%, 66.7%, 14.3% and 4.8% of HFmrEF patients were on a RASi, BB, SGLT2i and MRA, respectively. Among patients with HFpEF, only 6 (4.8%) were on an SGLT2i at ED arrival. The most prescribed new medication at ED discharge was an SGLT2i, with a nearly 10% increase in the proportion of patients with an active prescription for SGLT2i at ED discharge among HFrEF and HFmEF patients. We observed no 30-day SAE among the 51 patients predicted to be very low risk and discharged home. CONCLUSIONS Ongoing treatment with GDMT at ED arrival was sub-optimal. Initiation among appropriate patients at discharge may be feasible and safe.
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Affiliation(s)
- Dana R Sax
- The Permanente Medical Group, Oakland, California, USA
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
| | - Dustin G Mark
- The Permanente Medical Group, Oakland, California, USA
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
| | - Jamal S Rana
- The Permanente Medical Group, Oakland, California, USA
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
| | - Jie Huang
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
| | - Scott D Casey
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
- The Permanente Medical Group, Vallejo, California, USA
| | | | - Viliami Tillage
- Drexel University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Mary E Reed
- Kaiser Permanente Northern California Division of Research, Pleasanton, California, USA
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11
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Ju C, Lau WCY, Manisty C, Chambers P, Brauer R, Forster MD, Mackenzie IS, Wei L. Use of heart failure medical therapy before and after a cancer diagnosis: A longitudinal study. ESC Heart Fail 2024. [PMID: 39041459 DOI: 10.1002/ehf2.14981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Revised: 05/13/2024] [Accepted: 07/01/2024] [Indexed: 07/24/2024] Open
Abstract
AIMS We aim to evaluate change in the use of prognostic guideline-directed medical therapies (GDMTs) for heart failure (HF) before and after a cancer diagnosis as well as the matched non-cancer controls, including renin-angiotensin-system inhibitors (RASIs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs). METHODS AND RESULTS We conducted a longitudinal study in patients with HF in the UK Clinical Practice Research Datalink between 2005 and 2021. We selected patients with probable HF with reduced ejection fraction (HFrEF) based on diagnostic and prescription records. We described the longitudinal trends in the use and dosing of GDMTs before and after receiving an incident cancer diagnosis. HF patients with cancer were matched with a 1:1 ratio to HF patients without cancer to investigate the association between cancer diagnosis and treatment adherence, persistence, initiation, and dose titration as odds ratios (ORs) with 95% confidence intervals (CIs) using multivariable logistic regression models. Of 8504 eligible HFrEF patients with incident cancer, 4890 were matched to controls without cancer. The mean age was 75.7 (±8.4) years and 73.9% were male. In the 12 months following a cancer diagnosis, patients experienced reductions in the use and dosing of GDMT. Compared with the non-cancer controls, patients with cancer had higher risks for poor adherence for all three medication classes (RASIs: OR = 1.51, 95% CI = 1.35-1.68; beta-blockers: OR = 1.22, 95% CI = 1.08-1.37; MRAs: OR = 1.31, 95% CI = 1.08-1.59) and poor persistence (RASIs: OR = 2.04, 95% CI = 1.75-2.37; beta-blockers: OR = 1.35, 95% CI = 1.12-1.63; MRAs: OR = 1.49, 95% CI = 1.16-1.93), and higher risks for dose down-titration for RASIs (OR = 1.69, 95% CI = 1.40-2.04) and beta-blockers (OR = 1.31, 95% CI = 1.05-1.62). Cancer diagnosis was not associated with treatment initiation or dose up-titration. Event rates for HF hospitalization and mortality were higher in patients with poor adherence or persistence to GDMTs. CONCLUSIONS Following a cancer diagnosis, patients with HFrEF were more likely to have reduced use of GDMTs for HF.
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Affiliation(s)
- Chengsheng Ju
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
| | - Wallis C Y Lau
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, SAR, China
- Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, SAR, China
| | - Charlotte Manisty
- Institute of Cardiovascular Science, University College London, London, UK
- Department of Cardiology, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
| | - Pinkie Chambers
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | - Ruth Brauer
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
| | | | - Isla S Mackenzie
- MEMO Research, Division of Molecular and Clinical Medicine, University of Dundee, Dundee, UK
| | - Li Wei
- Research Department of Practice and Policy, School of Pharmacy, University College London, London, UK
- Centre for Medicines Optimisation Research and Education, University College London Hospitals NHS Foundation Trust, London, UK
- Laboratory of Data Discovery for Health (D24H), Hong Kong Science Park, Hong Kong, SAR, China
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12
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Carigi S, Gentile P, Gori M, Tinti D, De Gennaro L, Leonardi G, Orso F, Felici AR, Catalano MR, Floresta M, Rizzello V, Lucci D, Gonzini L, De Maria R, Marini M. Clinical characteristics, treatment, trajectories and outcome of patients with dilated cardiomyopathy in a national heart failure registry. Int J Cardiol 2024; 407:131986. [PMID: 38513737 DOI: 10.1016/j.ijcard.2024.131986] [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: 01/02/2024] [Revised: 02/23/2024] [Accepted: 03/17/2024] [Indexed: 03/23/2024]
Abstract
BACKGROUND Available data on the clinical characteristics and prognosis of patients with heart failure (HF) due to dilated cardiomyopathy (DCM) derive mainly from tertiary care centres for cardiomyopathies or from drug trial sub-studies, which may entail a referral bias. METHODS From 2008 to 2021, we enrolled in a nationwide HF Registry 1886 DCM patients and 3899 with ischemic heart disease (IHD). RESULTS Patients with DCM were younger, more often female, had more commonly recent onset HF, left bundle branch block, and showed higher LV end-diastolic volume and lower LVEF than IHD. With respect to IHD, DCM patients received more often mineralocorticoid receptor antagonists, renin angiotensin system inhibitors and betablockers, the latter more commonly at doses ≥50% of target, and triple guideline-directed medical therapy (GDMT) (adjusted OR 1.411, 95% CI 1.247-1.595, p < .0001). During one-year follow-up, 819 patients (14.2%) died or were hospitalized for HF [187 (9.9%) DCM, 632 (16.2%) IHD]; DCM was associated with lower risk of the combined end-point (adjusted HR 0.745, 95% CI 0.625- 0.888, p = .0011). Among the 1954 patients with 1-year echocardiograms available, 1483 had LVEF≤40% at baseline; of these,166 (30.6%) DCM and 165 (17.5%) IHD improved their LVEF to >40% (p < .0001). DCM aetiology was associated with higher likelihood of LVEF improvement (adjusted OR 1.722, 95% CI 1.328 -2.233, p < .0001). CONCLUSIONS DCM patients have a different clinical profile, greater uptake of GDMT and better outcomes than IHD subjects. A comprehensive management approach is needed to further address the risk of unfavorable outcomes in DCM.
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Affiliation(s)
- Samuela Carigi
- Heart Failure Working Group, Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy; Cardiology Unit, Infermi Hospital, Rimini, Italy
| | - Piero Gentile
- Heart Failure Working Group, Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy; De Gasperis Cardio ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mauro Gori
- Heart Failure Working Group, Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy; Cardiology Division, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Denitza Tinti
- Heart Failure Working Group, Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy; Unit of Cardiology, San Camillo Hospital, Rome, Italy
| | - Luisa De Gennaro
- Heart Failure Working Group, Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy; Cardiology Department, San Paolo Hospital, Bari, Italy
| | - Giuseppe Leonardi
- Heart Failure Working Group, Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy; SSD Severe Heart Failure, PO "G. Rodolico", Catania, Italy
| | - Francesco Orso
- Heart Failure Working Group, Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy; Heart Failure Unit, Division of Geriatric Medicine and Intensive Care Unit, Department of Medicine and Geriatrics, Careggi University Hospital, Florence, Italy
| | - Anna Rita Felici
- UOC di Cardiologia e UTIC, Ospedale dei Castelli, Ariccia, Italy
| | | | - Marina Floresta
- UOC Cardiologia e UTIC Villa Sofia, AOR Villa Sofia-Cervello, Palermo, Italy
| | - Vittoria Rizzello
- UOC Cardiologia d'urgenza e UTIC, AO San Giovanni Addolorata, Roma, Italy
| | - Donata Lucci
- ANMCO Research Centre, Heart Care Foundation, Florence, Italy
| | - Lucio Gonzini
- ANMCO Research Centre, Heart Care Foundation, Florence, Italy
| | - Renata De Maria
- Heart Failure Working Group, Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy.
| | - Marco Marini
- Heart Failure Working Group, Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy; Department of Cardiovascular Sciences Cardiology, Ospedali Riuniti, Ancona, Italy
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13
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Hamo CE, Mukhopadhyay A, Li X, Zheng Y, Kronish IM, Chunara R, Dodson J, Adhikari S, Blecker S. Association between visit frequency, continuity of care, and pharmacy fill adherence in heart failure patients. Am Heart J 2024; 273:53-60. [PMID: 38621576 PMCID: PMC11162924 DOI: 10.1016/j.ahj.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Despite advances in medical therapy for heart failure with reduced ejection fraction (HFrEF), major gaps in medication adherence to guideline-directed medical therapies (GDMT) remain. Greater continuity of care may impact medication adherence and reduced hospitalizations. METHODS We conducted a cross-sectional study of adults with a diagnosis of HF and EF ≤40% with ≥2 outpatient encounters between January 1, 2017 and January 10, 2021, prescribed ≥1 of the following GDMT: 1) Beta Blocker, 2) Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker/Angiotensin Receptor Neprilysin Inhibitor, 3) Mineralocorticoid Receptor Antagonist, 4) Sodium Glucose Cotransporter-2 Inhibitor. Continuity of care was calculated using the Bice-Boxerman Continuity of Care Index (COC) and the Usual Provider of Care (UPC) index, categorized by quantile. The primary outcome was adherence to GDMT, defined as average proportion of days covered ≥80% over 1 year. Secondary outcomes included all-cause and HF hospitalization at 1-year. We performed multivariable logistic regression analyses adjusted for demographics, insurance status, comorbidity index, number of visits and neighborhood SES index. RESULTS Overall, 3,971 individuals were included (mean age 72 years (SD 14), 71% male, 66% White race). In adjusted analyses, compared to individuals in the highest COC quartile, individuals in the third COC quartile had higher odds of GDMT adherence (OR 1.26, 95% CI 1.03-1.53, P = .024). UPC tertile was not associated with adherence (all P > .05). Compared to the highest quantiles, the lowest UPC and COC quantiles had higher odds of all-cause (UPC: OR 1.53, 95%CI 1.23-1.91; COC: OR 2.54, 95%CI 1.94-3.34) and HF (UPC: OR 1.81, 95%CI 1.23-2.67; COC: OR 1.77, 95%CI 1.09-2.95) hospitalizations. CONCLUSIONS Continuity of care was not associated with GDMT adherence among patients with HFrEF but lower continuity of care was associated with increased all-cause and HF-hospitalizations.
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Affiliation(s)
- Carine E Hamo
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY.
| | - Amrita Mukhopadhyay
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Xiyue Li
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Yaguang Zheng
- New York University Rory Meyers College of Nursing, New York, NY
| | - Ian M Kronish
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, NY
| | - Rumi Chunara
- Department of Biostatistics, NYU School of Global Public Health, New York, NY
| | - John Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Samrachana Adhikari
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Saul Blecker
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
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14
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Huang W, Ahmed MM, Morris EJ, Yang L, O'Neal L, Hernandez I, Bian J, Kimmel SE, Smith S, Guo J. Trajectories of Sacubitril/Valsartan Adherence Among Medicare Beneficiaries With Heart Failure. JACC. ADVANCES 2024; 3:100958. [PMID: 39129974 PMCID: PMC11312759 DOI: 10.1016/j.jacadv.2024.100958] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/19/2024] [Accepted: 02/13/2024] [Indexed: 08/13/2024]
Abstract
Background Sacubitril/valsartan, an angiotensin receptor/neprilysin inhibitor (ARNi), improves heart failure (HF) outcomes, yet real-world adherence patterns are not well understood. Objectives The purpose of this study was to analyze longitudinal patterns of adherence to ARNis in patients with HF and to identify factors associated with adherence patterns. Methods Using Medicare beneficiaries from 2015 to 2018, we included patients diagnosed with HF who initiated an ARNi. A group-based trajectory model was constructed to identify adherence patterns during follow-up. We used multivariable logistic regression to investigate factors associated with membership in each adherence trajectory group. Results Among 9,475 eligible beneficiaries (age 77 ± 7 years, 34% female), we identified 5 distinct ARNi adherence trajectories, characterized as: immediate discontinuers, who discontinued treatment within the first 3 months (12%); early discontinuers, who discontinued treatment in months 4 to 7 (10%); late discontinuers, who discontinued treatment in months 7 to 10 (12%); intermittently adherent patients (12%); and consistently adherent patients (54%). The first 4 groups were collectively categorized as nonconsistent adherents. Living in a socioeconomically disadvantaged area, ie, a county with the top 20% of Area Deprivation Index (adjusted OR [aOR]: 1.12 [95% CI: 1.00-1.24]) and Black race (aOR: 1.36, [95% CI: 1.18-1.56]) were associated with a higher likelihood of being nonconsistently adherent. Receiving prescriptions from a cardiologist (aOR: 0.64 [95% CI: 0.57-0.73]) was associated with a lower likelihood of suboptimal ARNi adherence. Conclusions Half of ARNi users were not consistently adherent to the drug in the first year after treatment initiation. There exist significant racial and socioeconomic inequities in longitudinal adherence to ARNi.
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Affiliation(s)
- Wenxi Huang
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Mustafa M. Ahmed
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Earl J. Morris
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Lanting Yang
- Department of Pharmacy and Therapeutics, School of Pharmacy, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Latoya O'Neal
- Department of Family, Youth and Community Sciences, Institute of Food and Agricultural Sciences, College of Agricultural and Life Sciences, University of Florida, Gainesville, Florida, USA
| | - Inmaculada Hernandez
- Division of Clinical Pharmacy, Skaggs School of Pharmacy and Pharmaceutical Sciences, University of California-San Diego, La Jolla, California, USA
| | - Jiang Bian
- Department of Health Outcomes and Biomedical Informatics, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Stephen E. Kimmel
- Department of Epidemiology, College of Public Health and Health Professions, and College of Medicine, University of Florida, Gainesville, Florida, USA
| | - Steven Smith
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, University of Florida College of Pharmacy, Gainesville, Florida, USA
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Shi H, Yu Y, Li D, Zhu K, Cheng X, Ma T, Tao Z, Hong Y, Liu Z, Zhou S, Zhang J, Chen Y, Zhang XJ, Zhang P, Li H. TNIP3 protects against pathological cardiac hypertrophy by stabilizing STAT1. Cell Death Dis 2024; 15:450. [PMID: 38926347 PMCID: PMC11208599 DOI: 10.1038/s41419-024-06805-4] [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: 12/29/2023] [Revised: 05/26/2024] [Accepted: 06/03/2024] [Indexed: 06/28/2024]
Abstract
Pathological cardiac hypertrophy is one of the major risk factors of heart failure and other cardiovascular diseases. However, the mechanisms underlying pathological cardiac hypertrophy remain largely unknown. Here, we identified the first evidence that TNFAIP3 interacting protein 3 (TNIP3) was a negative regulator of pathological cardiac hypertrophy. We observed a significant upregulation of TNIP3 in mouse hearts subjected to transverse aortic constriction (TAC) surgery and in primary neonatal rat cardiomyocytes stimulated by phenylephrine (PE). In Tnip3-deficient mice, cardiac hypertrophy was aggravated after TAC surgery. Conversely, cardiac-specific Tnip3 transgenic (TG) mice showed a notable reversal of the same phenotype. Accordingly, TNIP3 alleviated PE-induced cardiomyocyte enlargement in vitro. Mechanistically, RNA-sequencing and interactome analysis were combined to identify the signal transducer and activator of transcription 1 (STAT1) as a potential target to clarify the molecular mechanism of TNIP3 in pathological cardiac hypertrophy. Via immunoprecipitation and Glutathione S-transferase assay, we found that TNIP3 could interact with STAT1 directly and suppress its degradation by suppressing K48-type ubiquitination in response to hypertrophic stimulation. Remarkably, preservation effect of TNIP3 on cardiac hypertrophy was blocked by STAT1 inhibitor Fludaradbine or STAT1 knockdown. Our study found that TNIP3 serves as a novel suppressor of pathological cardiac hypertrophy by promoting STAT1 stability, which suggests that TNIP3 could be a promising therapeutic target of pathological cardiac hypertrophy and heart failure.
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Affiliation(s)
- Hongjie Shi
- Taikang Medical School (School of Basic Medical Sciences), Wuhan University, 430000, Wuhan, China
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China
| | - Yongjie Yu
- Taikang Medical School (School of Basic Medical Sciences), Wuhan University, 430000, Wuhan, China
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China
| | - Dajun Li
- Taikang Medical School (School of Basic Medical Sciences), Wuhan University, 430000, Wuhan, China
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China
| | - Kun Zhu
- Taikang Medical School (School of Basic Medical Sciences), Wuhan University, 430000, Wuhan, China
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China
| | - Xu Cheng
- Gannan Innovation and Translational Medicine Research Institute, Gannan Medical University, 341000, Ganzhou, China
- State Key Laboratory of New Drug Discovery and Development for Major Diseases, Gannan Innovation and Translational Medicine Research Institute, 341000, Ganzhou, China
| | - Tengfei Ma
- Department of Neurosurgery, Huanggang Central Hospital, 438000, Huanggang, China
- Huanggang Institute of Translational Medicine, 438000, Huanggang, China
| | - Zhangqian Tao
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China
| | - Ying Hong
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China
| | - Zhen Liu
- Department of Cardiology, Renmin Hospital of Wuhan University, 430000, Wuhan, China
| | - Siyi Zhou
- Taikang Medical School (School of Basic Medical Sciences), Wuhan University, 430000, Wuhan, China
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China
| | - Jianqing Zhang
- Department of Cardiology, Renmin Hospital of Wuhan University, 430000, Wuhan, China
| | - Yun Chen
- Clinical trial centers, Huanggang Central Hospital, 438000, Huanggang, China
| | - Xiao-Jing Zhang
- Taikang Medical School (School of Basic Medical Sciences), Wuhan University, 430000, Wuhan, China
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China
| | - Peng Zhang
- Taikang Medical School (School of Basic Medical Sciences), Wuhan University, 430000, Wuhan, China.
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China.
| | - Hongliang Li
- Taikang Medical School (School of Basic Medical Sciences), Wuhan University, 430000, Wuhan, China.
- Institute of Model Animal, Wuhan University, 430000, Wuhan, China.
- Gannan Innovation and Translational Medicine Research Institute, Gannan Medical University, 341000, Ganzhou, China.
- State Key Laboratory of New Drug Discovery and Development for Major Diseases, Gannan Innovation and Translational Medicine Research Institute, 341000, Ganzhou, China.
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Savarese G, Lindberg F, Christodorescu RM, Ferrini M, Kumler T, Toutoutzas K, Dattilo G, Bayes-Genis A, Moura B, Amir O, Petrie MC, Seferovic P, Chioncel O, Metra M, Coats AJS, Rosano GMC. Physician perceptions, attitudes, and strategies towards implementing guideline-directed medical therapy in heart failure with reduced ejection fraction. A survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice. Eur J Heart Fail 2024; 26:1408-1418. [PMID: 38515385 DOI: 10.1002/ejhf.3214] [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: 01/13/2024] [Revised: 02/14/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024] Open
Abstract
AIMS Recent guidelines recommend four core drug classes (renin-angiotensin system inhibitor/angiotensin receptor-neprilysin inhibitor [RASi/ARNi], beta-blocker, mineralocorticoid receptor antagonist [MRA], and sodium-glucose cotransporter 2 inhibitor [SGLT2i]) for the pharmacological management of heart failure (HF) with reduced ejection fraction (HFrEF). We assessed physicians' perceived (i) comfort with implementing the recent HFrEF guideline recommendations; (ii) status of guideline-directed medical therapy (GDMT) implementation; (iii) use of different GDMT sequencing strategies; and (iv) barriers and strategies for achieving implementation. METHODS AND RESULTS A 26-question survey was disseminated via bulletin, e-mail and social channels directed to physicians with an interest in HF. Of 432 respondents representing 91 countries, 36% were female, 52% were aged <50 years, and 90% mainly practiced in cardiology (30% HF). Overall comfort with implementing quadruple therapy was high (87%). Only 12% estimated that >90% of patients with HFrEF without contraindications received quadruple therapy. The time required to initiate quadruple therapy was estimated at 1-2 weeks by 34% of respondents, 1 month by 36%, 3 months by 24%, and ≥6 months by 6%. The average respondent favoured traditional drug sequencing strategies (RASi/ARNi with/followed by beta-blocker, and then MRA with/followed by SGLT2i) over simultaneous initiation or SGLT2i-first sequences. The most frequently perceived clinical barriers to implementation were hypotension (70%), creatinine increase (47%), hyperkalaemia (45%) and patient adherence (42%). CONCLUSIONS Although comfort with implementing all four core drug classes in patients with HFrEF was high among physicians, a majority estimated implementation of GDMT in HFrEF to be low. We identified several important perceived clinical and non-clinical barriers that can be targeted to improve implementation.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ruxandra M Christodorescu
- Department V Internal Medicine, University of Medicine and Pharmacy V. Babes Timisoara, Institute of Cardiology Research Center, Timișoara, Romania
| | - Marc Ferrini
- Department of Cardiology and Vascular Pathology, CH Saint Joseph and Saint Luc, Lyon, France
| | - Thomas Kumler
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Denmark
| | - Konstantinos Toutoutzas
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, 'Hippokration' General Hospital of Athens, Athens, Greece
| | - Giuseppe Dattilo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Antoni Bayes-Genis
- Institut del Cor, Hospital Universitari Germans Trias I Pujol, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV; Departamento de Medicina, Universitat Autònoma de Barcelona), Barcelona, Spain
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Offer Amir
- Heart Institute, Hadassah Medical Center & Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, The University Court of the University of Glasgow, Glasgow, UK
| | - Petar Seferovic
- University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe M C Rosano
- Cardiovascular Clinical Academic Group, St George's University Hospital, London, UK
- Cardiology, IRCCS San Raffaele, Rome, Italy
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17
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Savarese G, Lindberg F, Cannata A, Chioncel O, Stolfo D, Musella F, Tomasoni D, Abdelhamid M, Banerjee D, Bayes-Genis A, Berthelot E, Braunschweig F, Coats AJS, Girerd N, Jankowska EA, Hill L, Lainscak M, Lopatin Y, Lund LH, Maggioni AP, Moura B, Rakisheva A, Ray R, Seferovic PM, Skouri H, Vitale C, Volterrani M, Metra M, Rosano GMC. How to tackle therapeutic inertia in heart failure with reduced ejection fraction. A scientific statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024; 26:1278-1297. [PMID: 38778738 DOI: 10.1002/ejhf.3295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
Guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF) reduces morbidity and mortality, but its implementation is often poor in daily clinical practice. Barriers to implementation include clinical and organizational factors that might contribute to clinical inertia, i.e. avoidance/delay of recommended treatment initiation/optimization. The spectrum of strategies that might be applied to foster GDMT implementation is wide, and involves the organizational set-up of heart failure care pathways, tailored drug initiation/optimization strategies increasing the chance of successful implementation, digital tools/telehealth interventions, educational activities and strategies targeting patient/physician awareness, and use of quality registries. This scientific statement by the Heart Failure Association of the ESC provides an overview of the current state of GDMT implementation in HFrEF, clinical and organizational barriers to implementation, and aims at suggesting a comprehensive framework on how to overcome clinical inertia and ultimately improve implementation of GDMT in HFrEF based on up-to-date evidence.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Antonio Cannata
- School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', and University of Medicine Carol Davila, Bucharest, Romania
| | - Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | - Daniela Tomasoni
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Magdy Abdelhamid
- Faculty of Medicine, Kasr Al Ainy, Department of Cardiology, Cairo University, Cairo, Egypt
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, Cardiovascular and Genetics Research Institute, St George's University, London, UK
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias I Pujol, CIBERCV, Badalona, Spain
| | | | - Frieder Braunschweig
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | | | - Nicolas Girerd
- Centre d'Investigation Clinique Plurithémathique Pierre Drouin & Département de Cardiologie Institut Lorrain du Cœur et des Vaisseaux, Université de Lorraine, CHRU-Nancy, Vandœuvre-lès-Nancy, France
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University and Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Mitja Lainscak
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yury Lopatin
- Volgograd State Medical University, Regional Cardiology Centre, Volgograd, Russia
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Amina Rakisheva
- City Cardiology Center, Konaev City Hospital, Almaty Region, Kazakhstan
| | - Robin Ray
- Department of Cardiology, St George's University Hospital, London, UK
| | - Petar M Seferovic
- University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Hadi Skouri
- Cardiology Division, Internal Medicine Department, Balamand University School of Medicine, Beirut, Lebanon
| | - Cristiana Vitale
- Department of Cardiology, St George's University Hospital, London, UK
| | - Maurizio Volterrani
- Department of Exercise Science and Medicine, San Raffaele Open University of Rome, Rome, Italy
- Cardiopulmonary Department, IRCCS San Raffaele Roma, Rome, Italy
| | - Marco Metra
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe M C Rosano
- Department of Cardiology, St George's University Hospital, London, UK
- Cardiology, San Raffaele Hospital, Cassino, Italy
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18
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Okami S, Ohlmeier C, Takeichi M, Aguila M, Holl K, Michel A, Lecomte C, Ide T. Vericiguat Use in Patients with Heart Failure in Real-World Settings during the First Year after the Drug Authorization in Japan. J Clin Med 2024; 13:3222. [PMID: 38892932 PMCID: PMC11172519 DOI: 10.3390/jcm13113222] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 04/08/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Background: Vericiguat was developed to treat patients with heart failure (HF). Currently, limited data are available to characterize vericiguat-treated patients in real-world clinical settings. Methods: This retrospective cohort study was done using a Japanese hospital administrative database to describe the use of vericiguat in patients with HF in real-world settings. Adult patients diagnosed with HF prescribed vericiguat between 1 July 2021 and 30 September 2022 were included. Patient characteristics at the initiation of vericiguat treatment, patterns of HF medication use, and vericiguat dose titrations were assessed within the first 90 days of treatment. Results: The study included 829 patients who were initiated on vericiguat therapy. The mean age was 75.5 years and 69.0% were male. Hypertension, coronary artery disease, and diabetes mellitus were present in 91.7, 71.3, and 60.1% of patients, respectively. Most patients had previously received HF medications, with high percentages using angiotensin-receptor blocker neprilysin inhibitors (ARNI; 43.9%) and sodium-glucose cotransporter-2 inhibitors (54.4%). During the first 90 days of vericiguat treatment, 65.8% of the patients were uptitrated from their starting dose, and 32.3% had reached the maximal daily dose. The median time to reach the maximal daily dose was 34 days. The multivariable model identified that initiating vericiguat treatment in an outpatient setting and using ARNI before initiating vericiguat treatment were factors significantly associated with reaching the maximal daily dose of vericiguat at any given time, whereas older age, chronic kidney disease, hyperkalemia, and anemia were not associated. Conclusions: These findings provide early insights into the use of vericiguat, which aid in optimizing the combinations and/or sequences of HF treatment incorporating vericiguat therapy.
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Affiliation(s)
- Suguru Okami
- Medical Affairs & Pharmacovigilance, Bayer Yakuhin Ltd., Breeze Tower, 2-4-9 Umeda, Kita-ku, Osaka 530-0001, Japan
| | - Christoph Ohlmeier
- Integrated Evidence Generation & Business Innovation, Bayer AG, 13342 Berlin, Germany
| | - Makiko Takeichi
- Medical Affairs & Pharmacovigilance, Bayer Yakuhin Ltd., Breeze Tower, 2-4-9 Umeda, Kita-ku, Osaka 530-0001, Japan
| | | | - Katsiaryna Holl
- Integrated Evidence Generation & Business Innovation, Bayer AG, 13342 Berlin, Germany
| | - Alexander Michel
- Integrated Evidence Generation & Business Innovation, Bayer Consumer Care AG, Peter Merian Straße 84, CH-4052 Basel, Switzerland
| | | | - Tomomi Ide
- Department of Cardiovascular Medicine, Faculty of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka 812-8582, Japan
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Sarullo FM, Nugara C, Sarullo S, Iacoviello M, Di Gesaro G, Miani D, Driussi M, Correale M, Bilato C, Passantino A, Carluccio E, Villani A, Degli Esposti L, D’Agostino C, Peruzzi E, Poli S, Di Lenarda A. Effects of sacubitril/valsartan on the functional capacity of real-world patients in Italy: the REAL.IT study on heart failure with reduced ejection fraction. Front Cardiovasc Med 2024; 11:1347908. [PMID: 38798920 PMCID: PMC11116782 DOI: 10.3389/fcvm.2024.1347908] [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: 12/01/2023] [Accepted: 04/12/2024] [Indexed: 05/29/2024] Open
Abstract
Background Heart failure (HF) significantly affects the morbidity, mortality, and quality of life of patients. New therapeutic strategies aim to improve the functional capacity and quality of life of patients while controlling HF-related risks. Real-world data on both the functional and cardiopulmonary exercise capacities of patients with HF with reduced ejection fraction upon sacubitril/valsartan use are lacking. Methods A multicenter, retrospective, cohort study, called REAL.IT, was performed based on the data collected from the electronic medical records of nine specialized HF centers in Italy. Cardiopulmonary exercise testing was performed at baseline and after 12 months of sacubitril/valsartan therapy, monitoring carbon dioxide production (VCO2) and oxygen consumption (VO2). Results The functional capacities of 170 patients were evaluated. The most common comorbidities were hypertension and diabetes (i.e., 53.5 and 32.4%, respectively). At follow-up, both the VO2 peak (from 15.1 ± 3.7 ml/kg/min at baseline to 17.6 ± 4.7 ml/kg/min at follow-up, p < 0.0001) and the predicted % VO2 peak (from 55.5 ± 14.1 to 65.5 ± 16.9, p < 0.0001) significantly increased from baseline. The VO2 at the anaerobic threshold (AT-VO2) increased from 11.5 ± 2.6 to 12.5 ± 3.3 ml/kg/min (p = 0.021), and the rate ratio between the oxygen uptake and the change in work (ΔVO2/Δwork slope) improved from 9.1 ± 1.5 to 9.9 ± 1.6 ml/min/W (p < 0.0001). Conclusions Sacubitril/valsartan improves the cardiopulmonary capacity of patients with HFrEF in daily clinical practice in Italy.
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Affiliation(s)
- Filippo Maria Sarullo
- U.O.S.D. di Riabilitazione Cardiovascolare Ospedale Buccheri La Ferla Fatebenefratelli, Palermo, Italy
| | - Cinzia Nugara
- U.O.S.D. di Riabilitazione Cardiovascolare Ospedale Buccheri La Ferla Fatebenefratelli, Palermo, Italy
| | - Silvia Sarullo
- School of Sport Medicine and Physical Exercise Medicine, Department of Biomedicine, Neurosciences and Advances Diagnostic, University of Palermo, Palermo, Italy
| | - Massimo Iacoviello
- Department of Surgical and Medical Sciences, University of Foggia, Foggia, Italy
| | | | - Daniela Miani
- SOC Cardiologia, Dipartimento Cardiotoracico, Azienda Sanitaria Universitaria Friuli Centrale Ospedale S. Maria della Misericordia, Udine, Italy
| | - Mauro Driussi
- SOC Cardiologia, Dipartimento Cardiotoracico, Azienda Sanitaria Universitaria Friuli Centrale Ospedale S. Maria della Misericordia, Udine, Italy
| | - Michele Correale
- SC Universitaria di Cardiologia AOU “Ospedali Riuniti”, Foggia, Italy
| | - Claudio Bilato
- U.O.C. Cardiologia Azienda ULSS 8 Berica—Ospedali dell’Ovest Vicentino, Arzignano, Italy
| | - Andrea Passantino
- Istituti Clinici Scientifici Maugeri IRCCS, Cardiac Rehabilitation Unit of Bari Institute, Bari, Italy
| | - Erberto Carluccio
- Cardiologia e Fisiopatologia Cardiovascolare, Azienda Ospedaliera Universitaria “Santa Maria della Misericordia”, Perugia, Italy
| | - Alessandra Villani
- UO Cardiologia, Dipartimento di Scienze Cardiovascolari, Neurologiche, Metaboliche, Istituto Auxologico Italiano IRCCS, Milano, Italy
| | | | | | | | | | - Andrea Di Lenarda
- Cardiovascular Center, University Hospital and Health Services of Trieste, Trieste, Italy
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20
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Zhang Z, Wang C, Tu T, Lin Q, Zhou J, Huang Y, Wu K, Zhang Z, Zuo W, Liu N, Xiao Y, Liu Q. Advancing Guideline-Directed Medical Therapy in Heart Failure: Overcoming Challenges and Maximizing Benefits. Am J Cardiovasc Drugs 2024; 24:329-342. [PMID: 38568400 PMCID: PMC11093832 DOI: 10.1007/s40256-024-00646-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 05/15/2024]
Abstract
The delayed titration of guideline-directed drug therapy (GDMT) is a complex event influenced by multiple factors that often result in poor prognosis for patients with heart failure (HF). Individualized adjustments in GDMT titration may be necessary based on patient characteristics, and every clinician is responsible for promptly initiating GDMT and titrating it appropriately within the patient's tolerance range. This review examines the current challenges in GDMT implementation and scrutinizes titration considerations within distinct subsets of HF patients, with the overarching goal of enhancing the adoption and effectiveness of GDMT. The authors also underscore the significance of establishing a novel management strategy that integrates cardiologists, nurse practitioners, pharmacists, and patients as a unified team that can contribute to the improved promotion and implementation of GDMT.
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Affiliation(s)
- Zixi Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Cancan Wang
- Department of Metabolic Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Tao Tu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Qiuzhen Lin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Jiabao Zhou
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yunying Huang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Keke Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Zeying Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Wanyun Zuo
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Na Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
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Michel A, Lecomte C, Ohlmeier C, Raad H, Basedow F, Haeckl D, Beier D, Evers T. Treatment Patterns, Outcomes, and Persistence to Newly Started Heart Failure Medications in Patients with Worsening Heart Failure: A Cohort Study from the United States and Germany. Am J Cardiovasc Drugs 2024; 24:409-418. [PMID: 38573461 DOI: 10.1007/s40256-024-00643-7] [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] [Accepted: 03/19/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Data are limited regarding guideline-directed medical therapy (GDMT) treatment patterns in patients with worsening heart failure (HF). METHODS We used administrative claims databases in Germany and the USA to conduct a retrospective cohort study of patients with worsening HF. Two cohorts of patients with prevalent HF and a HF hospitalization (HFH) from 2016 to 2019, alive at discharge (N = 75,140 USA; N = 47,003 Germany) were identified. Index date was the first HFH during the study period. One-year HF rehospitalization and mortality rates were calculated and a composite endpoint of both outcomes assessed using Kaplan-Meier estimation. We evaluated HF medication patterns in the 6 months before and after the index date. New users of a HF medication (at discharge/after index HFH) were followed for 1 year to evaluate persistence (no treatment gaps > 2 months) RESULTS: One-year HF rehospitalization rates were 36.2% (USA) and 47.7% (Germany). One year mortality rates were 30.0% (USA) and 23.0% (Germany), and the composite endpoint (mortality/HF rehospitalization) was reached in 55.1 % (USA) and 56.6% (Germany). Kaplan-Meier plots showed the risk for the composite endpoint was high in the early post discharge period. Comparison of patterns pre- and postindex HFH showed some increase in use of mineralocorticoid receptor antagonists (MRAs), angiotensin receptor-neprilysin inhibitor (ARNI), and triple therapy; use of angiotensin-converting enzyme (ACE) inhibitor/ angiotensin receptor blocker (ARB) plus beta-blockers remained constant/slightly declined; < 20% patients received triple therapy (ACE inhibitor/ARB plus beta-blocker plus MRA). A third of patients were new users; 1 year persistence rates were often low. CONCLUSIONS Morbidity, mortality, and rehospitalization risk is high among patients with worsening HF; uptake and continuation of GDMT is suboptimal.
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Affiliation(s)
- Alexander Michel
- Bayer Consumer Care AG, Pharmaceuticals, Peter Merian Straße 84, 4052, Basel, Switzerland.
| | | | | | | | - Frederike Basedow
- InGef-Institute for Applied Health Research, Berlin GmbH, Berlin, Germany
| | | | - Dominik Beier
- InGef-Institute for Applied Health Research, Berlin GmbH, Berlin, Germany
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22
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Okami S, Lecomte C, Raad H, Aguila M, Mohrova Z, Takeichi M, Tsuchiya T, Ohlmeier C, Evers T, Michel A. Initiation and continuation of pharmacological therapies in patients hospitalized for heart failure in Japan. Sci Rep 2024; 14:9095. [PMID: 38643208 PMCID: PMC11032365 DOI: 10.1038/s41598-024-60011-y] [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: 12/26/2023] [Accepted: 04/17/2024] [Indexed: 04/22/2024] Open
Abstract
Currently, the utilization patterns of medications for heart failure (HF) after worsening HF events remain unelucidated in Japan. Here, we conducted a retrospective cohort study evaluating the changes in HF drug utilization patterns in 6 months before and after hospitalizations for HF. The adherence to newly initiated HF medications was evaluated based on the proportion of days covered (PDC) and persistence as continuous treatment episodes among new users. The study included 9091 patients hospitalized for HF between January 2016 and September 2019, including 2735 (30.1%) patients who were newly prescribed at least one HF medication after hospitalization. Despite increases in the use of foundational HF therapy (beta-blockers, angiotensin-converting-enzyme inhibitors/angiotensin receptor blockers, or mineralocorticoid receptor antagonists), 35.6% and 7.6% of patients were treated with the HF foundational monotherapy or diuretics alone after hospitalization, respectively. The mean PDC of newly initiated HF medications ranged from 0.57 for thiazide diuretics to 0.77 for sodium-glucose cotransporter-2 inhibitors. Continuous use of HF medications during the first year after initiation was observed in 30-60% of patients. The mean PDC and one-year continuous HF medication use were consistently lower in patients aged ≥ 75 years and in patients with a history of HF hospitalization for all HF medication classes except for tolvaptan and digoxin. Despite the guideline recommendations of HF pharmacotherapy, both treatment and adherence were suboptimal after HF hospitalization, especially in vulnerable populations such as older patients and those with prior HF hospitalizations.
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Affiliation(s)
- Suguru Okami
- Medical Affairs & Pharmacovigilance, Bayer Yakuhin Ltd., Breeze Tower, 2-4-9 Umeda, Kita-Ku, Osaka, 530-0001, Japan.
| | | | | | | | | | - Makiko Takeichi
- Medical Affairs & Pharmacovigilance, Bayer Yakuhin Ltd., Breeze Tower, 2-4-9 Umeda, Kita-Ku, Osaka, 530-0001, Japan
| | - Takanori Tsuchiya
- Market Access & Public Affairs, Bayer Yakuhin, Ltd, 2-4-9 Umeda, Kita-Ku, Osaka, Japan
| | - Christoph Ohlmeier
- Integrated Evidence Generation & Business Innovation, Bayer AG, 13342, Berlin, Germany
| | - Thomas Evers
- Integrated Evidence Generation & Business Innovation, Bayer AG, 42096, Wuppertal, Germany
| | - Alexander Michel
- Integrated Evidence Generation & Business Innovation, Bayer Consumer Care AG, Peter Merian Straße 84, 4052, Basel, Switzerland
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23
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Pagnesi M, Adamo M, Metra M. Is it NICE to measure natriuretic peptides after a hospitalization for heart failure? Eur J Heart Fail 2024; 26:785-787. [PMID: 38654473 DOI: 10.1002/ejhf.3257] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Accepted: 04/10/2024] [Indexed: 04/26/2024] Open
Affiliation(s)
- Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Tomasoni D, Davison B, Adamo M, Pagnesi M, Mebazaa A, Edwards C, Arrigo M, Barros M, Biegus J, Čelutkienė J, Čerlinskaitė-Bajorė K, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Lam CSP, Novosadova M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Maaten JMT, Voors A, Cotter G, Metra M. Safety Indicators in Patients Receiving High-intensity Care After Hospital Admission for Acute Heart Failure: The STRONG-HF Trial. J Card Fail 2024; 30:525-537. [PMID: 37820896 DOI: 10.1016/j.cardfail.2023.09.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies (STRONG-HF) demonstrated the safety and efficacy of rapid up-titration of guideline-directed medical therapy (GDMT) with high-intensity care (HIC) compared with usual care in patients hospitalized for acute heart failure (HF). In the HIC group, the following safety indicators were used to guide up-titration: estimated glomerular filtration rate of <30 mL/min/1.73 m2, serum potassium of >5.0 mmol/L, systolic blood pressure (SBP) of <95 mmHg, heart rate of <55 bpm, and N-terminal pro-B-type natriuretic peptide concentration of >10% higher than predischarge values. METHODS AND RESULTS We examined the impact of protocol-specified safety indicators on achieved dose of GDMT and clinical outcomes. Three hundred thirteen of the 542 patients in the HIC arm (57.7%) met ≥1 safety indicator at any follow-up visit 1-6 weeks after discharge. As compared with those without, patients meeting ≥1 safety indicator had more severe HF symptoms, lower SBP, and higher heart rate at baseline and achieved a lower average percentage of GDMT optimal doses (mean difference vs the HIC arm patients not reaching any safety indicator, -11.0% [95% confidence interval [CI] -13.6 to -8.4%], P < .001). The primary end point of 180-day all-cause death or HF readmission occurred in 15.0% of patients with any safety indicator vs 14.2% of those without (adjusted hazard ratio 0.84, 95% CI 0.48-1.46, P = .540). None of each of the safety indicators, considered alone, was significantly associated with the primary end point, but an SBP of <95 mm Hg was associated with a trend toward increased 180-day all-cause mortality (adjusted hazard ratio 2.68, 95% CI 0.94-7.64, P = .065) and estimated glomerular filtration rate decreased to <30 mL/min/1.73 m2 with more HF readmissions (adjusted hazard ratio 3.60, 95% CI 1.22-10.60, P = .0203). The occurrence of a safety indicator was associated with a smaller 90-day improvement in the EURO-QoL 5-Dimension visual analog scale (adjusted mean difference -3.32 points, 95% CI -5.97 to -0.66, P = .015). CONCLUSIONS Among patients with acute HF enrolled in STRONG-HF in the HIC arm, the occurrence of any safety indicator was associated with the administration of slightly lower GDMT doses and less improvement in quality of life, but with no significant increase in the primary outcome of 180-day HF readmission or death when appropriately addressed according to the study protocol.
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Affiliation(s)
- Daniela Tomasoni
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina; Heart Initiative, Durham, North Carolina
| | - Marianna Adamo
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | | | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof. C.C. Iliescu", University of Medicine "Carol Davila", Bucharest, Romania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; AP-HP Nord, Department of Cardiology, Lariboisière University Hospital, Paris, France
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Antoine Kimmoun
- Université de Lorraine, Nancy; INSERM, Défaillance Circulatoire Aigue et Chronique; Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, Francel
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore; Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | | | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital, Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Koji Takagi
- Momentum Research Inc, Durham, North Carolina
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Adriaan Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina; Heart Initiative, Durham, North Carolina
| | - Marco Metra
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
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Tangri N, Svensson MK, Bodegård J, Adamsson Eryd S, Thuresson M, Gustafsson S, Sofue T. Mortality, Health Care Burden, and Treatment of CKD: A Multinational, Observational Study (OPTIMISE-CKD). KIDNEY360 2024; 5:352-362. [PMID: 38297439 PMCID: PMC11000732 DOI: 10.34067/kid.0000000000000374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/17/2024] [Indexed: 02/02/2024]
Abstract
Key Points Newly detected, moderately progressed CKD is associated with high clinical risks and health care costs. Most patients with moderately progressed CKD do not have diabetes and are at the same clinical risk as those with diabetes. Substantial inertia with kidney-protective treatment is observed when moderately progressed CKD is detected. Background Kidney-protective treatments (renin–angiotensin system inhibitors and sodium–glucose cotransporter-2 inhibitors [SGLT-2is]) can delay CKD progression, cardiovascular events, and death. Methods This observational cohort study used electronic health records and claims data from Japan, Sweden, and the United States to assess 1-year mortality/hospitalization event rates per 100 patient-years (PYs), cumulative hospital health care costs per patient, and kidney-protective treatment use before/after SGLT-2i (dapagliflozin) approval for CKD (2021) for patients with CKD stage 3–4 with/without type 2 diabetes (T2D). Results Among 449,232 patients (across-country median age range 74–81 years), 79% did not have T2D. Prevalence ranges for atherosclerotic cardiovascular disease and heart failure were 20%–36% and 17%–31%, respectively. Baseline kidney-protective treatment (renin–angiotensin system inhibitor and/or SGLT-2i) use was limited, especially among patients without T2D. Event rates were high for CKD (11.4–44.4/100 PYs) and heart failure (7.4–22.3/100 PYs). Up to 14.6% of patients had died within 1 year. Hospital costs were higher for CKD and heart failure than for atherosclerotic cardiovascular disease. After incident CKD, kidney-protective treatment initiation was low (8%–20%) and discontinuation was high (16%–27%), especially among patients without T2D. Conclusions Incident CKD was associated with substantial morbidity, mortality, costs, and undertreatment, especially in patients without T2D, who represented the majority of patients. This highlights an urgent need for early CKD detection and better kidney-protective treatment use in moderate CKD.
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Affiliation(s)
- Navdeep Tangri
- University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Maria K. Svensson
- Department of Medical Sciences, Renal Medicine, Uppsala University, Uppsala, Sweden
- Uppsala Clinical Research Centre, Uppsala, Sweden
| | - Johan Bodegård
- Cardiovascular, Renal and Metabolism Evidence, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - Samuel Adamsson Eryd
- Cardiovascular, Renal and Metabolism Evidence, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | | | | | - Tadashi Sofue
- Department of Cardiorenal and Cerebrovascular Medicine, Kagawa University, Kagawa, Japan
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26
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Pagnesi M, Vilamajó OAG, Meiriño A, Dumont CA, Mebazaa A, Davison B, Adamo M, Arrigo M, Barros M, Biegus J, Celutkiene J, Čerlinskaitė-Bajorė K, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Edwards C, Filippatos G, Gayat E, Kimmoun A, Lam CSP, Novosadova M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Ter Maaten JM, Tomasoni D, Voors AA, Cotter G, Metra M. Blood pressure and intensive treatment up-titration after acute heart failure hospitalization: Insights from the STRONG-HF trial. Eur J Heart Fail 2024; 26:638-651. [PMID: 38444216 DOI: 10.1002/ejhf.3174] [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: 09/17/2023] [Revised: 02/04/2024] [Accepted: 02/12/2024] [Indexed: 03/07/2024] Open
Abstract
AIMS A high-intensity care (HIC) strategy with rapid guideline-directed medical therapy (GDMT) up-titration and close follow-up visits improved outcomes, compared to usual care (UC), in patients recently hospitalized for acute heart failure (AHF). Hypotension is a major limitation to GDMT implementation. We aimed to assess the impact of baseline systolic blood pressure (SBP) on the effects of HIC versus UC and the role of early SBP changes in STRONG-HF. METHODS AND RESULTS A total of 1075 patients hospitalized for AHF with SBP ≥100 mmHg were included in STRONG-HF. For the purpose of this post-hoc analysis, patients were stratified by tertiles of baseline SBP (<118, 118-128, and ≥129 mmHg) and, in the HIC arm, by tertiles of changes in SBP from the values measured before discharge to those measured at 1 week after discharge (≥2 mmHg increase, ≤7 mmHg decrease to <2 mmHg increase, and ≥8 mmHg decrease). The primary endpoint was 180-day heart failure rehospitalization or death. The effect of HIC versus UC on the primary endpoint was independent of baseline SBP evaluated as tertiles (pinteraction = 0.77) or as a continuous variable (pinteraction = 0.91). In the HIC arm, patients with increased, stable and decreased SBP at 1 week reached 83.5%, 76.2% and 75.3% of target doses of GDMT at day 90. The risk of the primary endpoint was not significantly different between patients with different SBP changes at 1 week (adjusted p = 0.46). CONCLUSIONS In STRONG-HF, the benefits of HIC versus UC were independent of baseline SBP. Rapid GDMT up-titration was performed also in patients with an early SBP drop, resulting in similar 180-day outcome as compared to patients with stable or increased SBP.
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Affiliation(s)
- Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | | | | | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine 'Carol Davila', Bucharest, Romania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Department of Cardiology, Lariboisière University Hospital, APHP Nord, Paris, France
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP.Nord, Paris, France
| | - Antoine Kimmoun
- Université de Lorraine, Nancy, France
- INSERM, Défaillance Circulatoire Aigue et Chronique, Nancy, France
- Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | | | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital/Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | | | - Jozine M Ter Maaten
- Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Adriaan A Voors
- Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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27
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De Nicola L, Ferraro PM, Montagnani A, Pontremoli R, Dentali F, Sesti G. Recommendations for the management of hyperkalemia in patients receiving renin-angiotensin-aldosterone system inhibitors. Intern Emerg Med 2024; 19:295-306. [PMID: 37775712 PMCID: PMC10954964 DOI: 10.1007/s11739-023-03427-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 09/04/2023] [Indexed: 10/01/2023]
Abstract
Hyperkalemia is common in clinical practice and can be caused by medications used to treat cardiovascular diseases, particularly renin-angiotensin-aldosterone system inhibitors (RAASis). This narrative review discusses the epidemiology, etiology, and consequences of hyperkalemia, and recommends strategies for the prevention and management of hyperkalemia, mainly focusing on guideline recommendations, while recognizing the gaps or differences between the guidelines. Available evidence emphasizes the importance of healthcare professionals (HCPs) taking a proactive approach to hyperkalemia management by prioritizing patient identification and acknowledging that hyperkalemia is often a long-term condition requiring ongoing treatment. Given the risk of hyperkalemia during RAASi treatment, it is advisable to monitor serum potassium levels prior to initiating these treatments, and then regularly throughout treatment. If RAASi therapy is indicated in patients with cardiorenal disease, HCPs should first treat chronic hyperkalemia before reducing the dose or discontinuing RAASis, as reduction or interruption of RAASi treatment can increase the risk of adverse cardiovascular and renal outcomes or death. Moreover, management of hyperkalemia should involve the use of newer potassium binders, such as sodium zirconium cyclosilicate or patiromer, as these agents can effectively enable optimal RAASi treatment. Finally, patients should receive education regarding hyperkalemia, the risks of discontinuing their current treatments, and need to avoid excessive dietary potassium intake.
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Affiliation(s)
- Luca De Nicola
- Nephrology Unit, Advanced Medical and Surgical Sciences Department, University of Campania "Luigi Vanvitelli", Naples, Italy
| | - Pietro Manuel Ferraro
- U.O.S. Terapia Conservativa della Malattia Renale Cronica, Dipartimento di Scienze Mediche e Chirurgiche, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
- Dipartimento Universitario di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, Rome, Italy.
- Section of Nephrology, Department of Medicine, Università degli Studi di Verona, Verona, Italy.
| | - Andrea Montagnani
- Department of Internal Medicine, Hospital Misericordia, Grosseto, Italy
| | - Roberto Pontremoli
- Department of Internal Medicine, University of Genoa, Genoa, Italy
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Francesco Dentali
- Department of Medicine and Surgery, Insubria University, Varese, Italy
| | - Giorgio Sesti
- Department of Clinical and Molecular Medicine, University of Rome-Sapienza, Rome, Italy
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28
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Fukino K, Ueshima D, Yamaguchi T, Mizuno A, Tobita K, Suzuki K, Murata N, Jujo K, Kodama T, Nakamura F, Higashitani M. Prognostic Impact of Reduced Left Ventricular Ejection Fraction After Endovascular Therapy for Lower Extremities. Circ J 2024; 88:341-350. [PMID: 37813602 DOI: 10.1253/circj.cj-23-0215] [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: 10/11/2023]
Abstract
BACKGROUND The mechanism underlying a poor prognosis in patients with lower-extremity artery disease (LEAD) with heart failure is unknown. We examined the prognostic impact of the left ventricular ejection fraction (LVEF) in patients with LEAD who underwent endovascular therapy (EVT). METHODS AND RESULTS From August 2014 to August 2016, 2,180 patients with LEAD (mean age, 73.2 years; male, 71.9%) underwent EVT and were stratified into low-LVEF (LVEF <40%; n=234, 10.7%) and not-low LVEF groups. In the low- vs. not-low LVEF groups, there was a higher prevalence of heart failure (i.e., history of heart failure hospitalization or New York Heart Association functional class III or IV symptoms) (44.0% vs. 8.3%, respectively), diabetes mellitus, chronic kidney disease, below-the-knee lesion, critical limb ischemia, and incidence of major cardiovascular and cerebrovascular events (MACCEs) and major adverse limb events (MALEs) (P<0.001, all). Low LVEF independently predicted MACCEs (hazard ratio: 2.23, 95% confidence interval: 1.63-3.03; P<0.001) and MALEs (hazard ratio: 1.85, 95% confidence interval: 1.15-2.96; P=0.011), regardless of heart failure (P value for interaction: MACCEs: 0.27; MALEs: 0.52). CONCLUSIONS Low LVEF, but not symptomatic heart failure, increased the incidence of MACCEs and MALEs. Intensive cardiac dysfunction management may improve LEAD prognosis after EVT.
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Affiliation(s)
- Keiko Fukino
- The Third Department of Internal Medicine, Teikyo University Chiba Medical Center
| | | | | | - Atsushi Mizuno
- Department of Cardiology, St. Luke's International Hospital
| | - Kazuki Tobita
- Department of Cardiology, Shonan Kamakura General Hospital
| | - Kenji Suzuki
- Department of Cardiology, Tokyo Saiseikai Central Hospital
| | | | - Kentaro Jujo
- Department of Cardiology, Saitama Medical Center
| | | | - Fumitaka Nakamura
- The Third Department of Internal Medicine, Teikyo University Chiba Medical Center
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29
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Abuelazm M, Badr A, Turkmani M, Amin MA, Amin AM, Aboutaleb A, Gowaily I, Soliman Y, Abdelazeem B. The efficacy and safety of new potassium binders on renin-angiotensin-aldosterone system inhibitor optimization in heart failure patients: a systematic review and meta-analysis. ESC Heart Fail 2024; 11:28-43. [PMID: 38012095 PMCID: PMC10804144 DOI: 10.1002/ehf2.14588] [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: 07/12/2023] [Revised: 10/08/2023] [Accepted: 10/29/2023] [Indexed: 11/29/2023] Open
Abstract
Guideline-directed medical therapy (GDMT) has improved outcomes in patients with heart failure, including the use of renin-angiotensin-aldosterone system inhibitors, which can hinder the excretion of potassium, resulting in hyperkalaemia. New potassium binders (NPBs) can prevent this adverse effect; however, the efficacy and safety of NPB for this indication have not been fully established. We conducted a systematic review and meta-analysis synthesizing randomized controlled trials (RCTs), which were retrieved by systematically searching PubMed, Web of Science, Scopus, and Cochrane through 26 April 2023. The risk of bias assessment was conducted, following Cochrane's updated Risk of Bias 2 assessment tool. We used the fixed-effects model to pool dichotomous data using risk ratio (RR) and continuous data using mean difference (MD), with a 95% confidence interval (CI) (PROSPERO ID: CRD42023426113). We included six RCTs with a total of 1432 patients. NPB was significantly associated with successful mineralocorticoid receptor antagonist (MRA) optimization [RR: 1.13 with 95% CI (1.02-1.25), P = 0.02], decreased patients with MRA at less than the target dose [RR: 0.72 with 95% CI (0.57-0.90), P = 0.004], and decreased hyperkalaemic episodes [RR: 0.42 with 95% CI (0.24-0.72), P = 0.002]. However, there was no difference between NPB and placebo regarding angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB)/angiotensin receptor/neprilysin inhibitor (ANRi) optimization [RR: 1.02 with 95% CI (0.89-1.17), P = 0.76] and serum potassium change [MD: -0.31 with 95% CI (-0.61 to 0.00), P = 0.05], with an acceptable safety profile except for the increased incidence of hypokalaemia with NPB [RR: 1.57 with 95% CI (1.12-2.21), P = 0.009]. NPB has been shown to improve GDMT outcomes by enhancing MRA optimization and reducing hyperkalaemic episodes. However, there are limited data on the effects of NPB on ACEi/ARB/ANRi optimization. Future RCTs should investigate ACEi/ARB/ANRi optimization and conduct head-to-head comparisons of NPB (patiromer and sodium zirconium cyclosilicate).
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Affiliation(s)
| | - Amr Badr
- Department of CardiologyBanha Teaching HospitalBanhaEgypt
| | - Mustafa Turkmani
- Department of Internal MedicineMcLaren Health CareOaklandMIUSA
- Department of Internal MedicineMichigan State UniversityEast LansingMIUSA
| | | | | | | | | | | | - Basel Abdelazeem
- Department of Internal MedicineMichigan State UniversityEast LansingMIUSA
- Department of CardiologyWest Virginia UniversityMorgantownWVUSA
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30
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Pol T, Karlström P, Lund LH. Heart failure registries - Future directions. J Cardiol 2024; 83:84-90. [PMID: 37844799 DOI: 10.1016/j.jjcc.2023.10.006] [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: 06/27/2023] [Revised: 09/13/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023]
Abstract
Heart failure (HF) is a growing, global public health issue. Despite advances in HF care, many challenges remain and HF outcomes are poor. Some of the major reasons for this are the lack of understanding and treatment for certain HF sub-types as well as the lack of implementation of treatment in areas where effective treatment exists. HF registries provide the opportunity to transform clinical research and patient care. Recently the registry-based randomized clinical trial has emerged as a pragmatic and inexpensive alternative to the gold standard in clinical trial design, the randomized controlled trial. Registries may also provide platforms for strategy trials, implementation trials, and screening. Using examples from the Swedish Heart Failure Registry and others, the present review provides insights into how registry-based research can address many of the unmet needs in HF.
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Affiliation(s)
- Tymon Pol
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.
| | - Patric Karlström
- Department of Internal Medicine, Ryhov County Hospital, Region Jönköping County, Jönköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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Tomasoni D, Pagnesi M, Colombo G, Chiarito M, Stolfo D, Baldetti L, Lombardi CM, Adamo M, Maggi G, Inciardi RM, Loiacono F, Maccallini M, Villaschi A, Gasparini G, Montella M, Contessi S, Cocianni D, Perotto M, Barone G, Merlo M, Cappelletti AM, Rosano G, Sinagra G, Pini D, Savarese G, Metra M. Guideline-directed medical therapy in severe heart failure with reduced ejection fraction: An analysis from the HELP-HF registry. Eur J Heart Fail 2024; 26:327-337. [PMID: 37933210 DOI: 10.1002/ejhf.3081] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/08/2023] Open
Abstract
AIM Persistent symptoms despite guideline-directed medical therapy (GDMT) and poor tolerance of GDMT are hallmarks of patients with advanced heart failure (HF) with reduced ejection fraction (HFrEF). However, real-world data on GDMT use, dose, and prognostic implications are lacking. METHODS AND RESULTS We included 699 consecutive patients with HFrEF and at least one 'I NEED HELP' marker for advanced HF enrolled in a multicentre registry. Beta-blockers (BB) were administered to 574 (82%) patients, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors (ACEi/ARB/ARNI) were administered to 381 (55%) patients and 416 (60%) received mineralocorticoid receptor antagonists (MRA). Overall, ≥50% of target doses were reached in 41%, 22%, and 56% of the patients on BB, ACEi/ARB/ARNI and MRA, respectively. Hypotension, bradycardia, kidney dysfunction and hyperkalaemia were the main causes of underprescription and/or underdosing, but up to a half of the patients did not receive target doses for unknown causes (51%, 41%, and 55% for BB, ACEi/ARB/ARNI and MRA, respectively). The proportions of patients receiving BB and ACEi/ARB/ARNI were lower among those fulfilling the 2018 HFA-ESC criteria for advanced HF. Treatment with BB and ACEi/ARB/ARNI were associated with a lower risk of death or HF hospitalizations (adjusted hazard ratio [HR] 0.63, 95% confidence interval [CI] 0.48-0.84, and HR 0.74, 95% CI 0.58-0.95, respectively). CONCLUSIONS In a large, real-world, contemporary cohort of patients with severe HFrEF, with at least one marker for advanced HF, prescription and uptitration of GDMT remained limited. A significant proportion of patients were undertreated due to unknown reasons suggesting a potential role of clinical inertia either by the prescribing healthcare professional or by the patient. Treatment with BB and ACEi/ARB/ARNI was associated with lower mortality/morbidity.
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Affiliation(s)
- Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giada Colombo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Mauro Chiarito
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Maggi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Maria Inciardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Marta Maccallini
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alessandro Villaschi
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Gaia Gasparini
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Marco Montella
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Stefano Contessi
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniele Cocianni
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Maria Perotto
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Giuseppe Barone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Merlo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | | | - Giuseppe Rosano
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniela Pini
- Humanitas Research Hospital IRCCS, Rozzano, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Markousis-Mavrogenis G, Baumhove L, Al-Mubarak AA, Aboumsallem JP, Bomer N, Voors AA, van der Meer P. Immunomodulation and immunopharmacology in heart failure. Nat Rev Cardiol 2024; 21:119-149. [PMID: 37709934 DOI: 10.1038/s41569-023-00919-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/03/2023] [Indexed: 09/16/2023]
Abstract
The immune system is intimately involved in the pathophysiology of heart failure. However, it is currently underused as a therapeutic target in the clinical setting. Moreover, the development of novel immunomodulatory therapies and their investigation for the treatment of patients with heart failure are hampered by the fact that currently used, evidence-based treatments for heart failure exert multiple immunomodulatory effects. In this Review, we discuss current knowledge on how evidence-based treatments for heart failure affect the immune system in addition to their primary mechanism of action, both to inform practising physicians about these pleiotropic actions and to create a framework for the development and application of future immunomodulatory therapies. We also delineate which subpopulations of patients with heart failure might benefit from immunomodulatory treatments. Furthermore, we summarize completed and ongoing clinical trials that assess immunomodulatory treatments in heart failure and present several therapeutic targets that could be investigated in the future. Lastly, we provide future directions to leverage the immunomodulatory potential of existing treatments and to foster the investigation of novel immunomodulatory therapeutics.
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Affiliation(s)
- George Markousis-Mavrogenis
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Lukas Baumhove
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ali A Al-Mubarak
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Joseph Pierre Aboumsallem
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
- Department of Cardiology, Erasmus Medical Center, Rotterdam, Netherlands
| | - Nils Bomer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands.
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Iacoviello M, Di Gesaro G, Sarullo FM, Miani D, Driussi M, Correale M, Bilato C, Passantino A, Carluccio E, Villani A, degli Esposti L, d'Agostino C, Peruzzi E, Poli S, di Lenarda A. Pharmacoutilization and adherence to sacubitril/valsartan in real world: the REAL.IT study in HFrEF. ESC Heart Fail 2024; 11:456-465. [PMID: 38041517 PMCID: PMC10804148 DOI: 10.1002/ehf2.14600] [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: 03/08/2023] [Revised: 07/17/2023] [Accepted: 10/31/2023] [Indexed: 12/03/2023] Open
Abstract
AIMS The current European Society of Cardiology (ESC) guidelines provide clear indications for the treatment of acute and chronic heart failure (HF). Nevertheless, there is a constant need for real-world evidence regarding the effectiveness, adherence, and persistence of drug therapy. We investigated the use of sacubitril/valsartan for the treatment of HF with reduced ejection fraction in real-world clinical practice in Italy. METHODS AND RESULTS An observational, retrospective, non-interventional cohort study based on electronic medical records from nine specialized hospital HF centres in Italy was carried out on patients with prescription of sacubitril/valsartan. Overall, 948 patients had a prescription of sacubitril/valsartan, with 924 characterized over 6 months and followed up for 12 months. Pharmacoutilization data at 1 year of follow-up were available for 225 patients {mean age 69.7 years [standard deviation (SD) = 10.8], 81.8% male}. Of those, 398 (45.2%) reached the target dose of sacubitril/valsartan of 97/103 mg in a mean time of 6.9 (SD = 6.2) weeks. Blood pressure and hypotension in 61 patients (65%) and worsening of chronic kidney disease in 10 patients (10.6%) were the main reasons for not reaching the target dose. Approximatively 50% of patients had a change in sacubitril/valsartan dose during follow-up, and 158 (70.2%) were persistent with the treatment during the last 3 months of follow-up. A sensitivity analysis (persistence during the last 4 months of follow-up) showed persistence for 162 patients (72.0%). Adherence data, available for 387 patients, showed full adherence for 205 (53%). Discontinuation (102/717 patients, 14.2%) was mainly due to hypotension and occurred after a mean time of 34.3 (SD = 28.7) weeks. During follow-up, out of 606 patients with available data, 434 patients (71.6%) had an HF add-on drug or drugs concomitant with sacubitril/valsartan. HF-related hospitalization during follow-up was numerically higher in non-persistent (16/67 patients, 23.9%) vs. patients persistent to sacubitril/valsartan (30/158, 19%) (P = 0.405). CONCLUSIONS Real-world data on the use of sacubitril/valsartan in clinical practice in Italy show a rapid titration to the target dose, high therapeutic adherence enabling a good level of therapeutic management in line with ESC guidelines for patients with reduced ejection fraction.
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Affiliation(s)
| | | | - Filippo Maria Sarullo
- U.O.S. Di Riabilitazione Cardiovascolare Ospedale Buccheri La Ferla FatebenefratelliPalermoItaly
| | - Daniela Miani
- SOC Cardiologia, Dipartimento CardiotoracicoAzienda Sanitaria Universitaria Friuli Centrale, Ospedale S. Maria della MisericordiaUdineItaly
| | - Mauro Driussi
- SOC Cardiologia, Dipartimento CardiotoracicoAzienda Sanitaria Universitaria Friuli Centrale, Ospedale S. Maria della MisericordiaUdineItaly
| | - Michele Correale
- SC Universitaria di Cardiologia AOU ‘Ospedali Riuniti’ FoggiaFoggiaItaly
| | - Claudio Bilato
- U.O.C. Cardiologia Azienda ULSS 8 Berica ‐ Ospedali dell'Ovest VicentinoArzignanoItaly
| | - Andrea Passantino
- Division of Cardiology and Cardiac RehabilitationU.O. Cardiologia ICS Maugeri SpA SB Bari, IRCCS Istituto di BariBariItaly
| | - Erberto Carluccio
- Cardiologia e Fisiopatologia CardiovascolareAzienda Ospedaliera Universitaria ‘Santa Maria della Misericordia’PerugiaItaly
| | - Alessandra Villani
- UO Cardiologia, Istituto AuxologicoItaliano IRCCS, Dipartimento di Scienze Cardiovascolari, Neurologiche, MetabolicheMilanItaly
| | | | | | | | | | - Andrea di Lenarda
- Cardiovascular CenterUniversity Hospital and Health Services of TriesteTriesteItaly
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Lynch A, Jeewa A, Minn S, Arathoon K, Honjo O, Floh A, Hassan A, Jean-St-Michel E. Outcomes of Children With Hypoplastic Left Heart Syndrome and Heart Failure on Medical Therapy. JACC. ADVANCES 2024; 3:100811. [PMID: 38939382 PMCID: PMC11198231 DOI: 10.1016/j.jacadv.2023.100811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 09/05/2023] [Accepted: 11/09/2023] [Indexed: 06/29/2024]
Abstract
Background Systemic right ventricle (RV) dysfunction is associated with lower transplant-free survival (TFS) in hypoplastic left heart syndrome (HLHS), but the likelihood of functional improvement and utility of heart failure (HF) medications is not understood. Objectives The authors aimed to describe TFS, HF medication use, and surgical interventions in HLHS patients with RV dysfunction with and without subsequent improvement in function. Methods The SickKids HF Database is a retrospective cohort that includes all pediatric HLHS patients with RV dysfunction lasting >30 days. We compared TFS, HF medications, and surgical interventions in HLHS patients with and without functional normalization. Results Of 99 patients with HLHS and RV dysfunction, 52% had normalized function for ≥30 days. TFS at 2 years after dysfunction onset was lower in those without normalization (14% vs 78%, P < 0.001). Patients without normalization were less likely to reach target dosing (TD) of HF medications (27% vs 47% on 1 medication at TD, P < 0.001) and undergo Fontan completion (7% vs 53%, P < 0.001). Clinical factors associated with improved TFS were normalization of function for ≥30 days, onset of dysfunction after bidirectional Glenn, and exposure to ACE inhibition. Conclusions Our cohort of HLHS patients with systemic RV dysfunction demonstrated a novel finding of improved TFS in those with functional normalization for ≥30 days. Achieving TD of HF medications was associated with improved outcomes. This may reflect patient stability and tolerance for HF medication more than its therapeutic effect, but it can help inform decisions to proceed with surgical palliation or list for transplant.
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Affiliation(s)
- Aine Lynch
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Aamir Jeewa
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Sunghoon Minn
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Katelyn Arathoon
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Osami Honjo
- University of Toronto, Toronto, Ontario, Canada
- Division of Cardiovascular Surgery, The Labatt Family Heart Centre, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Alejandro Floh
- University of Toronto, Toronto, Ontario, Canada
- Division of Critical Care Medicine, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Ahmed Hassan
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
| | - Emilie Jean-St-Michel
- Division of Cardiology, The Hospital for Sick Children, Toronto, Ontario, Canada
- University of Toronto, Toronto, Ontario, Canada
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Clephas PRD, Malgie J, Schaap J, Koudstaal S, Emans M, Linssen GCM, de Boer GA, van Heerebeek L, Borleffs CJW, Manintveld OC, van Empel V, van Wijk S, van den Heuvel M, da Fonseca C, Damman K, van Ramshorst J, van Kimmenade R, van de Ven ART, Tio RA, van Veghel D, Asselbergs FW, de Boer RA, van der Meer P, Greene SJ, Brunner‐La Rocca H, Brugts JJ. Guideline implementation, drug sequencing, and quality of care in heart failure: design and rationale of TITRATE-HF. ESC Heart Fail 2024; 11:550-559. [PMID: 38064176 PMCID: PMC10804201 DOI: 10.1002/ehf2.14604] [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: 05/01/2023] [Revised: 09/19/2023] [Accepted: 11/03/2023] [Indexed: 01/03/2024] Open
Abstract
AIMS Current heart failure (HF) guidelines recommend to prescribe four drug classes in patients with HF with reduced ejection fraction (HFrEF). A clear challenge exists to adequately implement guideline-directed medical therapy (GDMT) regarding the sequencing of drugs and timely reaching target dose. It is largely unknown how the paradigm shift from a serial and sequential approach for drug therapy to early parallel application of the four drug classes will be executed in daily clinical practice, as well as the reason clinicians may not adhere to new guidelines. We present the design and rationale for the real-world TITRATE-HF study, which aims to assess sequencing strategies for GDMT initiation, dose titration patterns (order and speed), intolerance for GDMT, barriers for implementation, and long-term outcomes in patients with de novo, chronic, and worsening HF. METHODS AND RESULTS A total of 4000 patients with HFrEF, HF with mildly reduced ejection fraction, and HF with improved ejection fraction will be enrolled in >40 Dutch centres with a follow-up of at least 3 years. Data collection will include demographics, physical examination and vital parameters, electrocardiogram, laboratory measurements, echocardiogram, medication, and quality of life. Detailed information on titration steps will be collected for the four GDMT drug classes. Information will include date, primary reason for change, and potential intolerances. The primary clinical endpoints are HF-related hospitalizations, HF-related urgent visits with a need for intravenous diuretics, all-cause mortality, and cardiovascular mortality. CONCLUSIONS TITRATE-HF is a real-world multicentre longitudinal registry that will provide unique information on contemporary GDMT implementation, sequencing strategies (order and speed), and prognosis in de novo, worsening, and chronic HF patients.
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Affiliation(s)
- Pascal R. D. Clephas
- Department of CardiologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Jishnu Malgie
- Department of CardiologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Jeroen Schaap
- Department of CardiologyAmphia ZiekenhuisBredaThe Netherlands
| | - Stefan Koudstaal
- Department of CardiologyGroene Hart ZiekenhuisGoudaThe Netherlands
| | - Mireille Emans
- Department of CardiologyIkazia ZiekenhuisRotterdamThe Netherlands
| | | | | | | | | | - Olivier C. Manintveld
- Department of CardiologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Vanessa van Empel
- Department of CardiologyMaastricht University Medical CentreMaastrichtThe Netherlands
| | - Sandra van Wijk
- Department of CardiologyZuyderland HospitalSittardThe Netherlands
| | | | - Carlos da Fonseca
- Department of CardiologyMedisch Centrum LeeuwardenLeeuwardenThe Netherlands
| | - Kevin Damman
- Department of CardiologyUniversity Medical Centre Groningen, University of GroningenGroningenThe Netherlands
| | - Jan van Ramshorst
- Department of CardiologyNoordwest Hospital GroupAlkmaarThe Netherlands
| | - Roland van Kimmenade
- Department of CardiologyRadboud University Medical CenterNijmegenThe Netherlands
| | | | - René A. Tio
- Department of CardiologyCatharina HospitalEindhovenThe Netherlands
| | | | | | - Rudolf A. de Boer
- Department of CardiologyErasmus MC University Medical CenterRotterdamThe Netherlands
| | - Peter van der Meer
- Department of CardiologyUniversity Medical Centre Groningen, University of GroningenGroningenThe Netherlands
| | - Stephen J. Greene
- Duke Clinical Research InstituteDurhamNCUSA
- Division of CardiologyDuke University School of MedicineDurhamNCUSA
| | | | - Jasper J. Brugts
- Department of CardiologyErasmus MC University Medical CenterRotterdamThe Netherlands
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Li W, Zhu Y, Wang W, He D, Feng L, Li Z. Src tyrosine kinase promotes cardiac remodeling induced by chronic sympathetic activation. Biosci Rep 2023; 43:BSR20231097. [PMID: 37650260 PMCID: PMC10611920 DOI: 10.1042/bsr20231097] [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: 06/14/2023] [Revised: 08/08/2023] [Accepted: 08/22/2023] [Indexed: 09/01/2023] Open
Abstract
Cardiac remodeling serves as the underlying pathological basis for numerous cardiovascular diseases and represents a pivotal stage for intervention. The excessive activation of β-adrenergic receptors (β-ARs) assumes a crucial role in cardiac remodeling. Nonetheless, the underlying molecular mechanisms governing β-AR-induced cardiac remodeling remain largely unresolved. In the present study, we identified Src tyrosine kinase as a key player in the cardiac remodeling triggered by excessive β-AR activation. Our findings demonstrated that Src mediates isoproterenol (ISO)-induced cardiac hypertrophy, fibrosis, and inflammation in vivo. Furthermore, Src facilitates β-AR-mediated proliferation and transdifferentiation of cardiac fibroblasts, and hypertrophy and cardiomyocytes in vitro. Subsequent investigations have substantiated that Src mediates β-AR induced the extracellular signal-regulated protein kinase (ERK1/2) signaling pathway activated by β-AR. Our research presents compelling evidence that Src promotes β-AR-induced cardiac remodeling in both in vivo and in vitro settings. It establishes the promoting effect of the β-AR/Src/ERK signaling pathway on overall cardiac remodeling in cardiac fibroblasts and underscores the potential of Src as a therapeutic target for cardiac remodeling.
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Affiliation(s)
- Wenqi Li
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Yuzhong Zhu
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Wenjing Wang
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; Beijing Key Laboratory of Cardiovascular Receptors Research; State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University; NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Peking University; Research Unit of Medical Science Research Management/Basic and Clinical Research of Metabolic Cardiovascular Diseases, Chinese Academy of Medical Sciences. Beijing 100191, China
| | - Dan He
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; Beijing Key Laboratory of Cardiovascular Receptors Research; State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University; NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Peking University; Research Unit of Medical Science Research Management/Basic and Clinical Research of Metabolic Cardiovascular Diseases, Chinese Academy of Medical Sciences. Beijing 100191, China
| | - Lei Feng
- Wuxi School of Medicine, Jiangnan University, Wuxi, China
| | - Zijian Li
- Department of Cardiology and Institute of Vascular Medicine, Peking University Third Hospital; Beijing Key Laboratory of Cardiovascular Receptors Research; State Key Laboratory of Vascular Homeostasis and Remodeling, Peking University; NHC Key Laboratory of Cardiovascular Molecular Biology and Regulatory Peptides, Peking University; Research Unit of Medical Science Research Management/Basic and Clinical Research of Metabolic Cardiovascular Diseases, Chinese Academy of Medical Sciences. Beijing 100191, China
- Department of Pharmacy, Peking University Third Hospital, Beijing, China
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Bozkurt B, Savarese G, Adamsson Eryd S, Bodegård J, Cleland JGF, Khordoc C, Kishi T, Thuresson M, Vardeny O, Zhang R, Lund LH. Mortality, Outcomes, Costs, and Use of Medicines Following a First Heart Failure Hospitalization: EVOLUTION HF. JACC. HEART FAILURE 2023; 11:1320-1332. [PMID: 37354145 DOI: 10.1016/j.jchf.2023.04.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND There are few contemporary data on outcomes, costs, and treatment following a hospitalization for heart failure (hHF) in epidemiologically representative cohorts. OBJECTIVES This study sought to describe rehospitalizations, hospitalization costs, use of guideline-directed medical therapy (GDMT) (renin-angiotensin system inhibitors, sacubitril/valsartan, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors), and mortality after hHF. METHODS EVOLUTION HF (Utilization of Dapagliflozin and Other Guideline Directed Medical Therapies in Heart Failure Patients: A Multinational Observational Study Based on Secondary Data) is an observational, longitudinal cohort study using data from electronic health records or claims data sources in Japan, Sweden, the United Kingdom, and the United States. Adults with a first hHF discharge between 2018 and 2022 were included. The 1-year event rates per 100 patient-years (ERs) for death and rehospitalizations (with a primary diagnosis of heart failure (HF), chronic kidney disease [CKD], myocardial infarction, stroke, or peripheral artery disease) were calculated. Hospital health care costs were cumulatively summarized. Cumulative GDMT use was assessed using Kaplan-Meier estimates. RESULTS Of 263,525 patients, 28% died within the first year post-hHF (ER: 28.4 [95% CI: 27.0-29.9]). Rehospitalizations were mainly driven by HF (ER: 13.6 [95% CI: 9.8-17.4]) and CKD (ER: 4.5 [95% CI: 3.6-5.3]), whereas the ERs for myocardial infarction, stroke, and peripheral artery disease were lower. Health care costs were predominantly driven by HF and CKD. Between 2020 and 2022, use of renin-angiotensin system inhibitors, sacubitril/valsartan, beta-blockers, and mineralocorticoid receptor antagonists changed little, whereas uptake of sodium-glucose cotransporter-2 inhibitors increased 2- to 7-fold. CONCLUSIONS Incident post-hHF rehospitalization risks and costs were high, and GDMT use changed little in the year following discharge, highlighting the need to consider earlier and greater implementation of GDMT to manage risks and reduce costs.
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Affiliation(s)
- Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA
| | - Gianluigi Savarese
- Cardiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.
| | | | - Johan Bodegård
- CVRM Evidence, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Cindy Khordoc
- Global Medical Affairs, BioPharmaceuticals Medical, AstraZeneca, Wilmington, Delaware, USA
| | - Takuya Kishi
- Department of Graduate School of Medicine (Cardiology), International University of Health and Welfare, Okawa, Japan
| | | | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ruiqi Zhang
- Medical and Scientific Affairs, BioPharmaceuticals Medical, AstraZeneca, London, United Kingdom
| | - Lars H Lund
- Cardiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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Valladales-Restrepo LF, Sánchez-Ramírez N, Usma-Valencia AF, Velásquez-Quirama S, Henao-Martínez M, Castro-Rodriguez JA, Gaviria-Mendoza A, Machado-Duque ME, Machado-Alba JE. Use of sacubitril/valsartan in patients with heart failure: evidence from the real world. Expert Opin Pharmacother 2023; 24:2211-2219. [PMID: 38051633 DOI: 10.1080/14656566.2023.2287667] [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: 09/27/2023] [Accepted: 11/21/2023] [Indexed: 12/07/2023]
Abstract
BACKGROUND To characterize the use of sacubitril/valsartan in a group of patients with heart failure in Colombia. RESEARCH DESIGN AND METHODS Follow-up study of patients with heart failure who started sacubitril/valsartan and were affiliated with the Colombian health system between 2019 and 2021. Sociodemographic, clinical, and pharmacological variables and adherence and persistence of use were identified. RESULTS A total of 514 patients were identified, with a mean age of 65.7 years, 73.7% of whom started sacubitril/valsartan at low doses, and only 12.5% reached the maximum dose. Adherence was 78.2% and persistence was 56.8% at 1 year of follow-up. The increase in systolic blood pressure (odds ratio (OR): 1.01; 95% CI: 1.00-1.03) and the use of β-blockers (OR: 2.63; 95% CI: 1.42-4.85) were correlated with a greater persistence, while receiving furosemide (OR: 0.59; 95% CI: 0.39-0.89) and not having received renin - angiotensin - aldosterone system inhibitors in the 3 months before starting sacubitril/valsartan (OR: 0.48; 95% CI: 0.31-0.76) were associated with lower persistence. CONCLUSIONS The persistence of treatment 1 year after starting sacubitril/valsartan was not high, and a small proportion of patients reached the target dose of the drug. Nontitration of the drug dose was common.
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Affiliation(s)
- Luis Fernando Valladales-Restrepo
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
- Semillero de Investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Nicolás Sánchez-Ramírez
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
| | - Andrés Felipe Usma-Valencia
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
| | - Santiago Velásquez-Quirama
- Semillero de Investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Manuela Henao-Martínez
- Semillero de Investigación en Farmacología Geriátrica, Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Risaralda, Colombia
| | - Jorge Alejandro Castro-Rodriguez
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
| | - Andrés Gaviria-Mendoza
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Manuel Enrique Machado-Duque
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
- Grupo de Investigación Biomedicina, Facultad de Medicina, Fundación Universitaria Autónoma de las Américas, Pereira, Colombia
| | - Jorge Enrique Machado-Alba
- Grupo de Investigación en Farmacoepidemiología y Farmacovigilancia, Universidad Tecnológica de Pereira-Audifarma S.A, Pereira, Risaralda, Colombia
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Stolfo D, Lund LH, Benson L, Lindberg F, Ferrannini G, Dahlström U, Sinagra G, Rosano GMC, Savarese G. Real-world use of sodium-glucose cotransporter 2 inhibitors in patients with heart failure and reduced ejection fraction: Data from the Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:1648-1658. [PMID: 37419495 DOI: 10.1002/ejhf.2971] [Citation(s) in RCA: 18] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/09/2023] Open
Abstract
AIMS Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce mortality/morbidity in heart failure (HF). We explored the implementation of SGLT2i over time, and patient characteristics associated with their use, in a large, nationwide population with HF with reduced ejection fraction (HFrEF). METHODS AND RESULTS Patients with HFrEF (ejection fraction <40%), no type 1 diabetes, estimated glomerular filtration rate (eGFR) <20 ml/min/1.73 m2 and/or on dialysis, registered in the Swedish HF Registry between 1 November 2020 and 5 August 2022 were included. Independent predictors of use were investigated by multivariable logistic regressions. Of 8192 patients, 37% received SGLT2i. Use increased overall from 20.5% to 59.0% over time, from 46.2% and 12.5% to 69.8% and 55.4% in patients with and without type 2 diabetes, from 14.7% and 22.3% to 58.0% and 59.8% in eGFR <60 versus ≥60 ml/min/1.73 m2 , from 21.0% and 18.9% to 61.6% and 52.0% in males versus females, from 24.2% and 18.0% to 60.8% and 57.7% in patients with versus without recent HF hospitalization, from 26.1% and 19.8% to 54.7% and 59.6% in inpatients versus outpatients, and from 20.2% and 21.2% to 59.2% and 58.7% in those with HF duration <6 versus ≥6 months, respectively. Important characteristics associated with SGLT2i use were male sex, recent HF hospitalization, specialized HF follow-up, lower ejection fraction, type 2 diabetes, higher education level, use of other HF/cardiovascular interventions. Older age, higher blood pressure, atrial fibrillation and anaemia were associated with less use. Discontinuation rate at 6 and 12 months was 13.1% and 20.0%, respectively. CONCLUSIONS Use of SGLT2i increased three-fold over 2 years. Although this indicates a more rapid translation of trial results and guidelines into clinical practice compared to previous HF drugs, further efforts are advocated to complete the implementation process while avoiding inequities across different patient subgroups and discontinuations.
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Affiliation(s)
- Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | | | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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Malgie J, Clephas PRD, Brunner-La Rocca HP, de Boer RA, Brugts JJ. Guideline-directed medical therapy for HFrEF: sequencing strategies and barriers for life-saving drug therapy. Heart Fail Rev 2023; 28:1221-1234. [PMID: 37311917 PMCID: PMC10403394 DOI: 10.1007/s10741-023-10325-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
Multiple landmark trials have helped to advance the treatment of heart failure with reduced ejection fraction (HFrEF) significantly over the past decade. These trials have led to the introduction of four main drug classes into the 2021 ESC guideline, namely angiotensin-receptor neprilysin inhibitors/angiotensin-converting-enzyme inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. The life-saving effect of these therapies has been shown to be additive and becomes apparent within weeks, which is why maximally tolerated or target doses of all drug classes should be strived for as quickly as possible. Recent evidence, such as the STRONG-HF trial, demonstrated that rapid drug implementation and up-titration is superior to the traditional and more gradual step-by-step approach where valuable time is lost to up-titration. Accordingly, multiple rapid drug implementation and sequencing strategies have been proposed to significantly reduce the time needed for the titration process. Such strategies are urgently needed since previous large-scale registries have shown that guideline-directed medical therapy (GDMT) implementation is a challenge. This challenge is reflected by generally low adherence rates, which can be attributed to factors considering the patient, health care system, and local hospital/health care provider. This review of the four medication classes used to treat HFrEF seeks to present a thorough overview of the data supporting current GDMT, discuss the obstacles to GDMT implementation and up-titration, and identify multiple sequencing strategies that could improve GDMT adherence. Sequencing strategies for GDMT implementation. GDMT: guideline-directed medical therapy; ACEi: angiotensin-converting enzyme inhibitor; ARB: Angiotensin II receptor blocker; ARNi: angiotensin receptor-neprilysin inhibitor; BB: beta-blocker; MRA: mineralocorticoid receptor antagonist; SGLT2i: sodium-glucose co-transporter 2 inhibitor.
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Affiliation(s)
- Jishnu Malgie
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Pascal R D Clephas
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Rudolf A de Boer
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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Musella F, Rosano GMC, Hage C, Benson L, Guidetti F, Moura B, Sibilio G, Boccalatte M, Dahlström U, Coats AJS, Lund LH, Savarese G. Patient profiles in heart failure with reduced ejection fraction: Prevalence, characteristics, treatments and outcomes in a real-world heart failure population. Eur J Heart Fail 2023; 25:1246-1253. [PMID: 37210605 DOI: 10.1002/ejhf.2892] [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: 03/23/2023] [Revised: 05/03/2023] [Accepted: 05/03/2023] [Indexed: 05/22/2023] Open
Abstract
AIMS The Heart Failure Association of the European Society of Cardiology has recently proposed to optimize guideline-directed medical treatments according to patient's profiles. The aim of this analysis was to investigate prevalence/characteristics/treatments/outcomes for individual profiles. METHODS AND RESULTS Patients with heart failure (HF) with reduced ejection fraction (HFrEF) enrolled in the Swedish Heart Failure Registry (SwedeHF) between 2013 and 2021 were considered. Among 108 profiles generated by combining different strata of renal function (by estimated glomerular filtration rate [eGFR]), systolic blood pressure (sBP), heart rate, atrial fibrillation (AF) status and presence of hyperkalaemia, 93 were identified in our cohort. Event rates for a composite of cardiovascular (CV) mortality or first HF hospitalization were calculated for each profile. The nine most frequent profiles accounting for 70.5% of the population had eGFR 30-60 or ≥60 ml/min/1.73 m2 , sBP 90-140 mmHg and no hyperkalaemia. Heart rate and AF were evenly distributed. The highest risk of CV mortality/first HF hospitalization was observed in those with concomitant eGFR 30-60 ml/min/1.73 m2 and AF. We also identified nine profiles with the highest event rates, representing only 5% of the study population, characterized by no hyperkalaemia, even distribution among the sBP strata, predominance of eGFR <30 ml/min/1.73 m2 and AF. The three profiles with eGFR 30-60 ml/min/1.73 m2 also showed sBP <90 mmHg. CONCLUSIONS In a real-world cohort, most patients fit in a few easily identifiable profiles; the nine profiles at highest risk of mortality/morbidity accounted for only 5% of the population. Our data might contribute to identifying profile-tailored approaches to guide drug implementation and follow-up.
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Affiliation(s)
- Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | | | - Camilla Hage
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Federica Guidetti
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Brenda Moura
- Armed Forces Hospital, Porto, Portugal, CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
| | - Gerolamo Sibilio
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | - Marco Boccalatte
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences Linkoping University, Linkoping, Sweden
| | | | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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Schrage B, Lund LH, Benson L, Braunschweig F, Ferreira JP, Dahlström U, Metra M, Rosano GMC, Savarese G. Association between a hospitalization for heart failure and the initiation/discontinuation of guideline-recommended treatments: An analysis from the Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:1132-1144. [PMID: 37317585 DOI: 10.1002/ejhf.2928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/25/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023] Open
Abstract
AIMS To investigate whether a heart failure (HF) hospitalization is associated with initiation/discontinuation of guideline-directed medical HF therapy (GDMT) and consequent outcomes. METHODS AND RESULTS Among patients in the Swedish HF registry with an ejection fraction <50% enrolled in 2009-2018, initiation/discontinuation of GDMT was investigated by assessing dispensations of GDMT in those with versus without a HF hospitalization. Of 14 737 patients, 6893 (47%) were enrolled when hospitalized for HF. Initiation of GDMT was more likely than discontinuation following a HF hospitalization compared to a control group of patients without a HF hospitalization (odds ratio range 2.1-4.0 vs. 1.4-1.6 for the individual medications), although the proportion of patients not on GDMT was still high (8.1-44.0%). Key patient characteristics triggering less use of GDMT (i.e. less initiation or more discontinuation) were older age and worse renal function. Following a HF hospitalization, initiation of renin-angiotensin system inhibitors/angiotensin receptor-neprilysin inhibitors or beta-blockers was associated with lower and their discontinuation with higher mortality risk, but no association with mortality was observed for initiation/discontinuation of mineralocorticoid receptor antagonists. CONCLUSIONS Following a HF hospitalization, initiation of GDMT was more likely than discontinuation, although still limited. Perceived or actual low tolerance were barriers to GDMT implementation. Early re-/initiation of GDMT was associated with better survival. Our findings represent a call for further implementing the current guideline recommendation for an early re-/initiation of GDMT following a HF hospitalization.
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Affiliation(s)
- Benedikt Schrage
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- University Heart and Vascular Centre Hamburg, Department of Cardiology and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Frieder Braunschweig
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Marco Metra
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe M C Rosano
- Centre for Clinical and Basic Research, IRCCS San Raffaele Roma, Rome, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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Zheng J, Mednick T, Heidenreich PA, Sandhu AT. Pharmacist- and Nurse-Led Medical Optimization in Heart Failure: A Systematic Review and Meta-Analysis. J Card Fail 2023; 29:1000-1013. [PMID: 37004867 PMCID: PMC10524094 DOI: 10.1016/j.cardfail.2023.03.012] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Traditional approaches to guideline-directed medical therapy (GDMT) management often lead to delayed initiation and titration of therapies in patients with heart failure. This study sought to characterize alternative models of care involving nonphysician provider-led GDMT interventions and their associations with therapy use and clinical outcomes. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing nonphysician provider-led GDMT initiation and/or uptitration interventions vs usual physician care (PROSPERO ID: CRD42022334661). We queried PubMed, Embase, the Cochrane Library, and the World Health Organization International Clinical Trial Registry Platform for peer-reviewed studies from database inception to July 31, 2022. In the meta-analysis, we used RCT data only and leveraged random-effects models to estimate pooled outcomes. Primary outcomes were GDMT initiation and titration to target dosages by therapeutic class. Secondary outcomes included all-cause mortality and HF hospitalizations. RESULTS We reviewed 33 studies, of which 17 (52%) were randomized controlled trials with median follow-ups of 6 months; 14 (82%) trials evaluated nurse interventions, and the remainder assessed pharmacists' interventions. The primary analysis pooled data from 16 RCTs, which enrolled 5268 patients. Pooled risk ratios (RR) for renin-angiotensin system inhibitor (RASI) and beta-blocker initiation were 2.09 (95% CI 1.05-4.16; I2 = 68%) and 1.91 (95% CI1.35-2.70; I2 = 37%), respectively. Outcomes were similar for uptitration of RASI (RR 1.99, 95% CI 1.24-3.20; I2 = 77%) and beta-blocker (RR 2.22, 95% CI 1.29-3.83; I2 = 66%). No association was found with mineralocorticoid receptor antagonist initiation (RR 1.01, 95% CI 0.47-2.19). There were lower rates of mortality (RR 0.82, 95% CI 0.67-1.04; I2 = 12%) and hospitalization due to HF (RR 0.80, 95% CI 0.63-1.01; I2 = 25%) across intervention arms, but these differences were small and not statistically significant. Prediction intervals were wide due to moderate-to-high heterogeneity across trial populations and interventions. Subgroup analyses by provider type did not show significant effect modification. CONCLUSIONS Pharmacist- and nurse-led interventions for GDMT initiation and/or uptitration improved guideline concordance. Further research evaluating newer therapies and titration strategies integrated with pharmacist- and/or nurse-based care may be valuable.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, CA.
| | - Thomas Mednick
- Sutter Health, California Pacific Medical Center, San Francisco, CA
| | - Paul A Heidenreich
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
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Gregg LP, Navaneethan SD. Steroidal or non-steroidal MRAs: should we still enable RAASi use through K binders? Nephrol Dial Transplant 2023; 38:1355-1365. [PMID: 36264349 PMCID: PMC10229268 DOI: 10.1093/ndt/gfac284] [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: 07/12/2022] [Indexed: 01/31/2023] Open
Abstract
Renin-angiotensin-aldosterone system inhibitors (RAASi) and mineralocorticoid receptor antagonists (MRAs) are important interventions to improve outcomes in patients with chronic kidney disease and heart failure, but their use is limited in some patients by the development of hyperkalemia. The risk of hyperkalemia may differ between agents, with one trial showing lower risk of hyperkalemia with the novel non-steroidal MRA finerenone compared with steroidal MRA spironolactone. Novel potassium binders, including patiromer and sodium zirconium cyclosilicate, are available interventions to manage hyperkalemia and enable continuation of RAASi and MRAs in patients who could benefit from these treatments. These agents bind free potassium ions in the lumen of the gastrointestinal tract to prevent the absorption of dietary potassium and increase potassium secretion. Several studies showed that potassium binders are effective compared with placebo for preventing hyperkalemia or steroidal MRA discontinuation, but none has evaluated whether this strategy impacts clinically important endpoints such as cardiovascular events. Due to this and other limitations related to cost, clinical availability, pill burden and patient selection, alternative potential strategies to mitigate hyperkalemia may be more practical. Conservative strategies include increased monitoring and use of loop or thiazide diuretics to increase urinary potassium excretion. Non-steroidal MRAs may have a lower risk of hyperkalemia than steroidal MRAs and have stronger anti-inflammatory and anti-fibrotic effects with resultant reduced risk of kidney disease progression. Sodium-glucose cotransporter-2 inhibitors also decrease hyperkalemia risk in patients on MRAs and decrease cardiovascular events and kidney disease progression. These may be better first-line interventions to obviate the need for potassium binders and offer additional benefits.
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Affiliation(s)
- L Parker Gregg
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Nephrology, Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA
| | - Sankar D Navaneethan
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
- Section of Nephrology, Medical Care Line, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
- Veterans Affairs Health Services Research and Development Center for Innovations in Quality, Effectiveness and Safety, Houston, TX, USA
- Institute of Clinical and Translational Research, Baylor College of Medicine, Houston, TX, USA
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Jankowska EA, Andersson T, Kaiser-Albers C, Bozkurt B, Chioncel O, Coats AJS, Hill L, Koehler F, Lund LH, McDonagh T, Metra M, Mittmann C, Mullens W, Siebert U, Solomon SD, Volterrani M, McMurray JJV. Optimizing outcomes in heart failure: 2022 and beyond. ESC Heart Fail 2023. [PMID: 37060168 PMCID: PMC10375115 DOI: 10.1002/ehf2.14363] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 01/04/2023] [Accepted: 03/13/2023] [Indexed: 04/16/2023] Open
Abstract
Although the development of therapies and tools for the improved management of heart failure (HF) continues apace, day-to-day management in clinical practice is often far from ideal. A Cardiovascular Round Table workshop was convened by the European Society of Cardiology (ESC) to identify barriers to the optimal implementation of therapies and guidelines and to consider mitigation strategies to improve patient outcomes in the future. Key challenges identified included the complexity of HF itself and its treatment, financial constraints and the perception of HF treatments as costly, failure to meet the needs of patients, suboptimal outpatient management, and the fragmented nature of healthcare systems. It was discussed that ongoing initiatives may help to address some of these barriers, such as changes incorporated into the 2021 ESC HF guideline, ESC Heart Failure Association quality indicators, quality improvement registries (e.g. EuroHeart), new ESC guidelines for patients, and the universal definition of HF. Additional priority action points discussed to promote further improvements included revised definitions of HF 'phenotypes' based on trial data, the development of implementation strategies, improved affordability, greater regulator/payer involvement, increased patient education, further development of patient-reported outcomes, better incorporation of guidelines into primary care systems, and targeted education for primary care practitioners. Finally, it was concluded that overarching changes are needed to improve current HF care models, such as the development of a standardized pathway, with a common adaptable digital backbone, decision-making support, and data integration, to ensure that the model 'learns' as the management of HF continues to evolve.
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Affiliation(s)
- Ewa A Jankowska
- Institute of Heart Diseases, Wrocław Medical University and University Hospital, Wrocław, Poland
| | | | | | - Biykem Bozkurt
- Section of Cardiology, Winters Center for Heart Failure, Baylor College of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu' Bucharest, University of Medicine Carol Davila, Bucharest, Romania
| | | | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Belfast, UK
| | - Friedrich Koehler
- Division of Cardiology and Angiology, Medical Department, Campus Charité Mitte, Centre for Cardiovascular Telemedicine, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Centre for Cardiovascular Telemedicine, Berlin, Germany
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
| | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Wilfried Mullens
- Ziekenhuis Oost Limburg, Genk and University Hasselt, Genk, Belgium
| | - Uwe Siebert
- Department of Public Health, Health Services Research and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics and Technology, Hall in Tirol, Austria
- Departments of Epidemiology and Health Policy & Management, Institute for Technology Assessment, Massachusetts General Hospital, Harvard Medical School, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Savage HO, Dimarco AD, Li B, Langley S, Hardy-Wallace A, Barbagallo R, Dungu JN. Sequencing of medical therapy in heart failure with a reduced ejection fraction. Heart 2023; 109:511-518. [PMID: 36368882 DOI: 10.1136/heartjnl-2022-321497] [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: 08/02/2022] [Accepted: 10/17/2022] [Indexed: 11/13/2022] Open
Abstract
The management of heart failure with a reduced ejection fraction is a true success story of modern medicine. Evidence from randomised clinical trials provides the basis for an extensive catalogue of disease-modifying drug treatments that improve both symptoms and survival. These treatments have undergone rigorous scrutiny by licensing and guideline development bodies to make them eligible for clinical use. With an increasing number of drug therapies however, it has become a complex management challenge to ensure patients receive these treatments in a timely fashion and at recommended doses. The tragedy is that, for a condition with many life-prolonging drug therapies, there remains a potentially avoidable mortality risk associated with delayed treatment. Heart failure therapeutic agents have conventionally been administered to patients in the chronological order they were tested in clinical trials, in line with the aggregate benefit observed when added to existing background treatment. We review the evidence for simultaneous expedited initiation of these disease-modifying drug therapies and how these strategies may focus the heart failure clinician on a time-defined smart goal of drug titration, while catering for patient individuality. We highlight the need for adequate staffing levels, especially heart failure nurse specialists and pharmacists, in a structure to provide the capacity to deliver this care. Finally, we propose a heart failure clinic titration schedule and novel practical treatment score which, if applied at each heart failure patient contact, could tackle treatment inertia by a constant assessment of attainment of optimal medical therapy.
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Affiliation(s)
- Henry Oluwasefunmi Savage
- Cardiology, Essex Cardiothoracic Centre, Basildon, UK .,Department of Circulatory Health, Anglia Ruskin University Faculty of Health Education Medicine & Social Care, Chelmsford, UK
| | | | - Brian Li
- Cardiology, Essex Cardiothoracic Centre, Basildon, UK.,Department of Circulatory Health, Anglia Ruskin University Faculty of Health Education Medicine & Social Care, Chelmsford, UK
| | | | | | | | - Jason N Dungu
- Cardiology, Essex Cardiothoracic Centre, Basildon, UK.,Department of Circulatory Health, Anglia Ruskin University Faculty of Health Education Medicine & Social Care, Chelmsford, UK
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Norhammar A, Bodegard J, Vanderheyden M, Tangri N, Karasik A, Maggioni AP, Sveen KA, Taveira-Gomes T, Botana M, Hunziker L, Thuresson M, Banerjee A, Sundström J, Bollmann A. Prevalence, outcomes and costs of a contemporary, multinational population with heart failure. Heart 2023; 109:548-556. [PMID: 36781285 PMCID: PMC10086499 DOI: 10.1136/heartjnl-2022-321702] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 10/20/2022] [Indexed: 02/15/2023] Open
Abstract
OBJECTIVE Digital healthcare systems could provide insights into the global prevalence of heart failure (HF). We designed the CardioRenal and Metabolic disease (CaReMe) HF study to estimate the prevalence, key clinical adverse outcomes and costs of HF across 11 countries. METHODS Individual level data from a contemporary cohort of 6 29 624 patients with diagnosed HF was obtained from digital healthcare systems in participating countries using a prespecified, common study plan, and summarised using a random effects meta-analysis. A broad definition of HF (any registered HF diagnosis) and a strict definition (history of hospitalisation for HF) were used. Event rates were reported per 100 patient years. Cumulative hospital care costs per patient were calculated for a period of up to 5 years. RESULTS The prevalence of HF was 2.01% (95% CI 1.65 to 2.36) and 1.05% (0.85 to 1.25) according to the broad and strict definitions, respectively. In patients with HF (broad definition), mean age was 75.2 years (95% CI 74.0 to 76.4), 48.8% (40.9-56.8%) had ischaemic heart disease and 34.5% (29.4-39.6%) had diabetes. In 51 442 patients with a recorded ejection fraction (EF), 39.1% (30.3-47.8%) had a reduced, 18.8% (13.5-24.0%) had a mildly reduced and 42.1% (31.5-52.8%) had a preserved left ventricular EF. In 1 69 518 patients with recorded estimated glomerular filtration rate, 49% had chronic kidney disease (CKD) stages III-V. Event rates were highest for cardiorenal disease (HF or CKD) and all cause mortality (19.3 (95% CI 11.3 to 27.1) and 13.1 (11.1 to 15.1), respectively), and lower for myocardial infarction, stroke and peripheral artery disease. Hospital care costs were highest for cardiorenal diseases. CONCLUSIONS We estimate that 1-2% of the contemporary adult population has HF. These individuals are at significant risk of adverse outcomes and associated costs, predominantly driven by hospitalisations for HF or CKD. There is considerable public health potential in understanding the contemporary burden of HF and the importance of optimising its management.
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Affiliation(s)
- Anna Norhammar
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Johan Bodegard
- CVRM Evidence, BioPharmaceuticals Medical, AstraZeneca, Oslo, Norway
| | | | - Navdeep Tangri
- Department of Medicine and Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Avraham Karasik
- Maccabi Institute for Research and Innovation, Maccabi Healthcare Services, Tel Aviv, Israel
| | - Aldo Pietro Maggioni
- Fondazione ReS Ricerca e Salute, Bologna, Italy
- ANMCO Research Center, Florence, Italy
| | - Kari Anne Sveen
- Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Tiago Taveira-Gomes
- Department of Community Medicine, Information and Decision in Health, University of Porto, Porto, Portugal
| | | | - Lukas Hunziker
- Department of Cardiology, Inselspital University Hospital Bern, Bern, Switzerland
| | | | - Amitava Banerjee
- Institute of Health Informatics, University College London, London, UK
- Department of Cardiology, University College London Hospitals NHS Foundation Trust, London, UK
| | - Johan Sundström
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
- The George Institute for Global Health, Newtown, New South Wales, Australia
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48
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Radhoe SP, Clephas PRD, Linssen GCM, Oortman RM, Smeele FJ, Van Drimmelen AA, Schaafsma HJ, Westendorp PH, Brunner-La Rocca HP, Brugts JJ. Phenotypic patient profiling for improved implementation of guideline-directed medical therapy: An exploratory analysis in a large real-world chronic heart failure cohort. Front Pharmacol 2023; 14:1081579. [PMID: 36969869 PMCID: PMC10033992 DOI: 10.3389/fphar.2023.1081579] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 02/08/2023] [Indexed: 03/12/2023] Open
Abstract
Aims: Implementation of guideline-recommended pharmacological treatment in heart failure (HF) patients remains challenging. In 2021, the European Heart Failure Association (HFA) published a consensus document in which patient profiles were created based on readily available patient characteristics and suggested that treatment adjusted to patient profile may result in better individualized treatment and improved guideline adherence. This study aimed to assess the distribution of these patient profiles and their treatment in a large real-world chronic HF cohort. Methods and results: The HFA combined categories of heart rate, blood pressure, presence of atrial fibrillation, chronic kidney disease, and hyperkalemia into eleven phenotypic patient profiles. A total of 4,455 patients with chronic HF and a left ventricular ejection fraction ≤40% with complete information on all characteristics were distributed over these profiles. In total, 1,640 patients (36.8%) could be classified into one of the HFA profiles. Three of these each comprised >5% of the population and consisted of patients with a heart rate >60 beats per minute with normal blood pressure (>90/60 mmHg) and no hyperkalemia. Conclusion: Nearly forty percent of a real-world chronic HF population could be distributed over the eleven patient profiles as suggested by the HFA. Phenotype-specific treatment recommendations are clinically relevant and important to further improve guideline implementation.
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Affiliation(s)
- Sumant P. Radhoe
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Pascal R. D. Clephas
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Remko M. Oortman
- Department of Cardiology, Bravis Hospital, Bergen op Zoom, Netherlands
| | - Frank J. Smeele
- Department of Cardiology, Slingeland Hospital, Doetinchem, Netherlands
| | | | | | - Paul H. Westendorp
- Department of Cardiology, Rivas Beatrix Hospital, Gorinchem, Netherlands
| | | | - Jasper J. Brugts
- Department of Cardiology, Thorax Center, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
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Abstract
The notion that the risk of sudden cardiac death (SCD) in patients with heart failure (HF) is declining seems to be gaining traction. Numerous editorials and commentaries have suggested that SCD, specifically arrhythmic SCD, is no longer a significant risk for patients with HF on guideline-directed medical therapy. In this review, we question whether the risk of SCD has indeed declined in HF trials and in the real world. We also explore whether, despite relative risk reductions, the residual SCD risk after guideline-directed medical therapy still suggests a need for implantable cardioverter defibrillator therapy. Among our arguments is that SCD has not decreased in HF trials, nor in the real world. Moreover, we argue that data from HF trials, which have not adhered to guideline-directed device therapy, do not obviate or justify delays to implantable cardioverter defibrillator therapy. In this context, we underline the challenges of translating the findings of HF randomized, controlled trials of guideline-directed medical therapy to the real world. We also make the case for HF trials that adhere to current guideline-directed device therapy so that we can better understand the role of implantable cardioverter defibrillators in chronic HF.
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Affiliation(s)
- Francisco Leyva
- Aston Medical School, Aston University, Birmingham, United Kingdom (F.L.)
| | - Carsten W Israel
- Bethel-Clinic, University of East-Westphalia, Bielefeld, Germany (C.W.I.)
| | - Jagmeet Singh
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston (J.S.)
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50
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Krittanawong C, Rodriguez M, Lui M, Misra A, Tang WHW, Bozkurt B, Yancy CW. Misconceptions and Facts about Heart Failure with Reduced Ejection Fraction. Am J Med 2023; 136:422-431. [PMID: 36740210 DOI: 10.1016/j.amjmed.2023.01.024] [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: 12/27/2022] [Revised: 01/11/2023] [Accepted: 01/11/2023] [Indexed: 02/05/2023]
Abstract
Heart failure with reduced ejection fraction is a significant driver of morbidity and mortality. There are common misconceptions regarding the disease processes underlying heart failure and best practices for therapy. The terms heart failure with reduced ejection fraction and left ventricular systolic dysfunction are not interchangeable terms. Key therapies for heart failure with reduced ejection fraction target the underlying disease processes, not the left ventricular ejection fraction alone. The absence of congestion does not rule out heart failure. Patients with cardiac amyloidosis can also present with heart failure with reduced ejection fraction. A rise in serum creatinine in acute heart failure exacerbation is not associated with tubular injury. Guideline directed medical therapy should be continued during acute exacerbations of heart failure with reduced ejection fraction and should be started in the same hospitalization in new diagnoses. Marginal blood pressure is not a relative contraindication to optimal guideline directed medical therapy. Guideline directed medical therapy should be continued even if ejection fraction improves. There are other therapies that provide significant benefit besides the four key medications in guideline directed medical therapy.
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Affiliation(s)
| | - Mario Rodriguez
- John T Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital/Washington University in St. Louis School of Medicine, Mo
| | - Matthew Lui
- John T Milliken Department of Medicine, Division of Cardiovascular Disease, Section of Advanced Heart Failure and Transplant, Barnes-Jewish Hospital/Washington University in St. Louis School of Medicine, Mo
| | - Arunima Misra
- Section of Cardiology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Ohio
| | - Biykem Bozkurt
- Winters Center for Heart Failure Research, Cardiovascular Research Institute, Baylor College of Medicine, DeBakey VA Medical Center, Houston, Texas
| | - Clyde W Yancy
- Chief, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Ill
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