Head-to-head comparison between recommendations by the ESC and ACC/AHA/HFSA heart failure guidelines

Outcome reporting in studies on pregnant women with cardiac disease: a systematic review: Outcomes in studies on pregnancy and heart disease

BACKGROUND

Although considerable variation in the reporting and definition of outcomes in cardio-obstetric studies is known, the extent of this variation has not been documented. The primary objective of this systematic review was to highlight this variation and inform the development of a Core Outcome Set for studies on Cardiac disease in Pregnancy (COSCarP).

METHODS

Medline, Embase, Web of Science and Cochrane Central databases were searched from 1980 to 2018 to identify all English-language publications on pregnancy and heart disease. Title/abstract screening and data extraction which included details on the study, patient population, and all reported outcomes, was performed in duplicate by two reviewers. As the aim of the review was to identify variation in outcome reporting, risk-of-bias assessment was not performed. The study protocol was registered on PROSPERO (CRD42016038218).

RESULTS

The final analysis included 422 cardio-obstetric studies. Maternal mortality or survival were reported in 232/422 studies, with inconsistency in terms of cause of death [all-cause (n=65), cardiac (n=55) or obstetric (n=10)] or timeframe (ranging from in-hospital mortality (n=11) to mortality 5 years following pregnancy). In 95/232 studies (41%), the cause and timeframe were not specified. Similar inconsistencies in reporting and definitions were noted for outcomes such as heart failure (n=298), perinatal loss (n=296), fetal growth (n=221), bleeding (n=205), arrhythmias (n=202), preterm birth (n=191), thromboembolism (n=153) and hypertensive disorders (n=122). Functioning / life-impact and adverse effects of treatment were sparingly reported in cardio-obstetric studies.

CONCLUSIONS

This systematic review hopes to create awareness among cardio-obstetric teams about the inconsistencies in reporting and defining outcomes which makes it difficult to compare studies and perform meta-analyses. COSCarP which is being developed through international consensus between patients and care-providers will provide cardio-obstetrics teams with a minimal set of outcomes to be reported in future cardio-obstetric studies.

Comparison of American and European Guideline Recommendations for Diagnostic Workup and Secondary Prevention of Ischemic Stroke and Transient Ischemic Attack

Guidelines help to facilitate treatment decisions based on available evidence, and also to provide recommendations in areas of uncertainty. In this paper, we compare the recommendations for stroke workup and secondary prevention of ischemic stroke and transient ischemic attack of the American Heart Association (AHA)/American Stroke Association (ASA) with the European Stroke Organization (ESO) guidelines. The primary aim of this paper is to offer clinicians guidance by identifying areas where there is consensus and where consensus is lacking, in the absence or presence of high-level evidence. We compared AHA/ASA with the ESO guideline recommendations for 7 different topics related to diagnostic stroke workup and secondary prevention. We categorized the recommendations based on class and level of evidence to determine whether there were relevant differences in the ratings of evidence that the guidelines used for its recommendations. Finally, we summarized major topics of agreement and disagreement, while also prominent knowledge gaps were identified. In total, we found 63 ESO and 82 AHA/ASA recommendations, of which 38 were on the same subject. Most recommendations are largely similar, but not all are based on high-level evidence. For many recommendations, AHA/ASA and ESO assigned different levels of evidence. For the 10 recommendations with Level A evidence (high quality) in AHA/ASA, ESO only labeled 4 of these as high quality. There are many remaining issues with either no or insufficient evidence, and some topics that are not covered by both guidelines. Most ESO and AHA/ASA Guideline recommendations for stroke workup and secondary prevention were similar. However not all were based on high-level evidence and the appointed level of evidence often differed. Clinicians should not blindly follow all guideline recommendations; the accompanying level of evidence informs which recommendations are based on robust evidence. Topics with lower levels of evidence, or those with recommendations that disagree or are missing, may be an incentive for further clinical research.

Performance of sodium-glucose cotransporter 2 inhibitors in cardiovascular disease

AIMS

The use of sodium-glucose cotransporter 2 inhibitors (SGLT2i) as a new class of drug in treating type 2 diabetes has expanded beyond its original framework. Positive results have been achieved in reducing symptoms in patients with cardiovascular disease (CVD). The aim of this article is to present an in-depth review of the basic principles of this class of medications and how it has brought benefits to patients affected particularly by heart failure.

METHODS

Following a thorough PubMed search, this review includes 62 studies published between 2015 and 2023. Keywords searched included 'sodium-glucose cotransporter 2 inhibitors', 'cardiovascular disease', 'heart failure', 'chronic kidney disease', and 'type 2 diabetes'. The most recent and comprehensive data were used.

RESULTS

Positive results have been achieved in reducing symptoms in patients with CVD. SGLT2 inhibitors have also been shown to be useful in other contexts such as nonalcoholic fatty liver disease (NAFLD) by reducing liver fat accumulation, kidney benefits by improving body weight and vascular endothelium, improving eGFR, and reducing progression to end stage kidney disease (ESKD). SGLT2 inhibitors are also effective in reducing the need for heart failure hospitalizations and the risk of serious cardiac adverse events, including cardiovascular and all-cause mortality, in patients with reduced or preserved left ventricular (LV) ejection fraction and in acute or decompensated settings.

CONCLUSION

SGLT2 inhibitors have evolved into metabolic drugs because of their multisystem action and are indicated for the treatment of all spectrums of heart failure, type 2 diabetes, and chronic kidney disease.

Sodium glucose co-transporter 2 inhibitors and quality of life in patients with heart failure: a comprehensive systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Sodium glucose co-transporter 2 inhibitors (SGLT2i) are one of the cornerstones of heart failure (HF) therapy. While benefits in terms of HF hospitalizations and death are well established, their impact on quality-of-life (QoL) has not been systematically investigated.

OBJECTIVE

This systematic review and meta-analysis aims to evaluate the impact of SGLT2i treatment on QoL in patients with HF, by analysing data from randomized clinical trials (RCTs).

METHODS

We identified a total of 23 RCTs that investigated the role of SGLT2i on quality of life in patients with HF, irrespective of their left ventricular ejection fraction (LVEF). RCTs that used Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OSS) to assess QoL and had a minimum follow-up of 3 months were included. The difference in mean change of the KCCQ-OSS between the SGLT2i group and the standard of care (SOC) group at 3 and 6 months from baseline was considered as the outcome measure.

FINDINGS

Fourteen RCTs (21 737 patients) were included in the analysis. A significant improvement in KCCQ-OSS over time (p < 0.001) was observed in both patients receiving SOC and those receiving SGLT2i in addition. The pooled estimate showed a significant improvement of 1.94 points [95% confidence interval (CI), 1.41-2.46] in KCCQ-OSS mean change at 3 months and of 2.18 points (95% CI, 1.13-3.24) at 6 months from baseline, with SGLT2i compared to SOC alone, irrespective of LVEF. A greater improvement in KCCQ-OSS was observed among patients with a recent episode of worsening HF compared to those with chronic stable HF.

CONCLUSIONS

Among patients with HF, irrespective of their LVEF and clinical status, the addition of SGLT2i to SOC demonstrated a significant improvement in quality of life as early as at 3-month follow-up.

Heart Failure Nurses within the Primary Care Setting

Cardiology services within primary care often focus on disease prevention, early identification of illness and prompt referral for diagnosis and specialist treatment. Due to advances in pharmaceuticals, implantable cardiac devices and surgical interventions, individuals with heart failure are living longer, which can place a significant strain on global healthcare resources. Heart failure nurses in a primary care setting offer a wealth of clinical knowledge and expertise across all phases of the heart failure trajectory and are able to support patients, family members and other community services, including general practitioners. This review examines the recently published evidence on the current and potential future practice of heart failure nurses within primary care.

Asymptomatic vs. symptomatic atrial fibrillation: Clinical outcomes in heart failure patients

BACKGROUND

The outcome implications of asymptomatic vs. symptomatic atrial fibrillation (AF) in specific groups of patients according to clinical heart failure (HF) and left ventricular ejection fraction (LVEF) need to be clarified.

METHODS

In a prospective observational study, patients were categorized according to overt HF with LVEF≤40 %, or with LVEF>40 %, or without overt HF with LVEF40 %≤ or > 40 %, as well as according to the presence of asymptomatic or symptomatic AF.

RESULTS

A total of 8096 patients, divided into 8 groups according to HF and LVEF, were included with similar proportions of asymptomatic AF (ranging from 43 to 48 %). After a median follow-up of 730 [699 -748] days, the composite outcome (all-cause death and MACE) was significantly worse for patients with asymptomatic AF associated with HF and reduced LVEF vs. symptomatic AF patients of the same group (p = 0.004). On adjusted Cox regression analysis, asymptomatic AF patients with HF and reduced LVEF were independently associated with a higher risk for the composite outcome (aHR 1.32, 95 % CI 1.04-1.69) and all-cause death (aHR 1.33, 95 % CI 1.02-1.73) compared to symptomatic AF patients with HF and reduced LVEF. Kaplan-Meier curves showed that HF-LVEF≤40 % asymptomatic patients had the highest cumulative incidence of all-cause death and MACE (p < 0.001 for both).

CONCLUSIONS

In a large European cohort of AF patients, the risk of the composite outcome at 2 years was not different between asymptomatic and symptomatic AF in the whole cohort but adverse implications for poor outcomes were found for asymptomatic AF in HF with LVEF≤40 %.

Temporal trends in evidence supporting therapeutic interventions in heart failure and other European Society of Cardiology guidelines

AIMS

This study aimed to determine whether any change occurred over time in level of evidence (LoE) of therapeutic interventions supporting heart failure (HF) and other European Society of Cardiology guideline recommendations.

METHODS AND RESULTS

We selected topics with at least three documents released between 2008 and April 2022. Classes of recommendations (CoR) and supporting LoE related to therapeutic interventions within each document were collected and compared over time. A total of 1822 recommendations from 18 documents on 6 topics [median number per document = 112, 867 (48%) CoR I] were included in the analysis. There was a trend towards a reduction over time in the percentage of CoR I in HF (46-36-34%), non-ST elevation myocardial infarction (NSTEMI; 78-58-54%), and pulmonary embolism (PE; 65-50-39%) guidelines, with a decrease in the total number of recommendations for HF only. Percentage of CoR I was stable over time around 40% for valvular heart disease (VHD) and atrial fibrillation (AF), and around 60% for cardiovascular prevention (CVP), with an increase in the total number of recommendations for VHD and CVP and a decrease for AF. Among CoR I, 319 (37%) were supported by LoE A, with a decrease over time for HF (56-46-42%), an increase for NSTEMI (29-38-48%) and AF (28-31-36%), a bimodal distribution for PE and CVP, and a lack for VHD.

CONCLUSIONS

LoE supporting therapeutic recommendations in contemporary European guidelines is generally low. Physicians should be aware of these limitations, and scientific societies promote a greater understanding of their significance and drive future research directions.

Heart Failure Management in 2023: A Pharmacotherapy- and Lifestyle-Focused Comparison of Current International Guidelines

This review examines the pharmacotherapy and lifestyle recommendations of the most recent iterations of the Canadian Cardiovascular Society (CCS) / Canadian Heart Failure Society (CHFS), the European Society of Cardiology (ESC), and the American Heart Association (AHA) / American College of Cardiology (ACC) / Heart Failure Society of America (HFSA) heart failure (HF) guidelines, which all have been updated in response to therapeutic developments across the spectrum of left ventricular ejection fraction. Identified areas of unanimity across these guidelines include the following: recommending quadruple therapy for patients with HF with reduced ejection fraction (HFrEF; although no guideline proposed an ideal sequence of initiation); intravenous iron administration for patients with HFrEF and iron deficiency; and sodium restriction for patients with HF. Recent evidence regarding the harms of HFrEF medication withdrawal in patients with HF with improved ejection fraction has prompted subsequent guidelines to recommend against withdrawal. Due to the lower quality of evidence, there are disagreements regarding management of HF with preserved ejection fraction and uncertainty regarding management of HF with mildly reduced ejection fraction. Practical guidance is provided to clinicians navigating these challenging areas. In addition to these clinically focused comparisons, we describe opportunities for guideline improvement and harmonization. Specifically, these include opportunities regarding HFrEF sequencing, the need for timely updates, shared decision-making, Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework adoption, and the creation of recommendations where high-quality evidence is lacking. Although these guidelines have broad agreement, key areas of controversy remain that may be addressed by emerging evidence and changes in guideline methodology.

Renal Oxygen Demand and Nephron Function: Is Glucose a Friend or Foe?

The kidneys and heart work together to balance the body's circulation, and although their physiology is based on strict inter dependence, their performance fulfills different aims. While the heart can rapidly increase its own oxygen consumption to comply with the wide changes in metabolic demand linked to body function, the kidneys physiology are primarily designed to maintain a stable metabolic rate and have a limited capacity to cope with any steep increase in renal metabolism. In the kidneys, glomerular population filters a large amount of blood and the tubular system has been programmed to reabsorb 99% of filtrate by reabsorbing sodium together with other filtered substances, including all glucose molecules. Glucose reabsorption involves the sodium-glucose cotransporters SGLT2 and SGLT1 on the apical membrane in the proximal tubular section; it also enhances bicarbonate formation so as to preserve the acid-base balance. The complex work of reabsorption in the kidney is the main factor in renal oxygen consumption; analysis of the renal glucose transport in disease states provides a better understanding of the renal physiology changes that occur when clinical conditions alter the neurohormonal response leading to an increase in glomerular filtration pressure. In this circumstance, glomerular hyperfiltration occurs, imposing a higher metabolic demand on kidney physiology and causing progressive renal impairment. Albumin urination is the warning signal of renal engagement over exertion and most frequently heralds heart failure development, regardless of disease etiology. The review analyzes the mechanisms linked to renal oxygen consumption, focusing on sodium-glucose management.

Pathophysiological Rationale and Clinical Evidence for Neurohormonal Modulation in Heart Failure with Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous syndrome resulting from the interaction between cardiac diseases, comorbidities and ageing. HFpEF is characterised by the activation of neurohormonal axes, namely of the renin-angiotensin-aldosterone system and the sympathetic nervous system, although to a lesser extent compared with heart failure with reduced ejection fraction. This provides a rationale for neurohormonal modulation as a therapeutic approach for HFpEF. Nonetheless, randomised clinical trials have failed to demonstrate a prognostic benefit from neurohormonal modulation therapies in HFpEF, with the sole exception of patients with left ventricular ejection fraction in the lower range of normality, for whom the American guidelines suggest that such therapies may be considered. In this review, the pathophysiological rationale for neurohormonal modulation in HFpEF is summarised and the clinical evidence on pharmacological and nonpharmacological approaches backing current recommendations discussed.

Aiming at harmony. Comparing and contrasting International HFrEF Guidelines

Large randomized controlled trials (RCTs) have led to major changes in the treatment of patients with heart failure and reduced left ventricular ejection fraction (HFrEF) and these advances are included in the recent European Society of Cardiology (ESC) and the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) guidelines issued in 2021 and 2022, respectively. According to both guidelines, treatment of patients with HFrEF is based on the administration of four classes of drugs that reduce the primary endpoint of cardiovascular death and HF hospitalizations in RCTs: angiotensin-converting enzyme or angiotensin receptor neprilysin inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose co-transporter 2 inhibitors. Specific sequences of treatment are not recommended but emphasis is given to reaching treatment with all four drugs as early as possible. Further treatments are considered in selected patients including ivabradine, hydralazine nitrates, digoxin, and the new agent vericiguat. Specific treatments, mostly new, for cardiovascular and non-cardiovascular comorbidities are also given. The aim of this article is to compare the two recent guidelines issued by the ESC and ACC/AHA/HFSA and show the few differences and the many consistent recommendations, now more numerous given the evidence available for many new treatments.