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von Haehling S, Assmus B, Bekfani T, Dworatzek E, Edelmann F, Hashemi D, Hellenkamp K, Kempf T, Raake P, Schütt KA, Wachter R, Schulze PC, Hasenfuss G, Böhm M, Bauersachs J. Heart failure with preserved ejection fraction: diagnosis, risk assessment, and treatment. Clin Res Cardiol 2024:10.1007/s00392-024-02396-4. [PMID: 38602566 DOI: 10.1007/s00392-024-02396-4] [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: 12/05/2023] [Accepted: 02/02/2024] [Indexed: 04/12/2024]
Abstract
The aetiology of heart failure with preserved ejection fraction (HFpEF) is heterogenous and overlaps with that of several comorbidities like atrial fibrillation, diabetes mellitus, chronic kidney disease, valvular heart disease, iron deficiency, or sarcopenia. The diagnosis of HFpEF involves evaluating cardiac dysfunction through imaging techniques and assessing increased left ventricular filling pressure, which can be measured directly or estimated through various proxies including natriuretic peptides. To better narrow down the differential diagnosis of HFpEF, European and American heart failure guidelines advocate the use of different algorithms including comorbidities that require diagnosis and rigorous treatment during the evaluation process. Therapeutic recommendations differ between guidelines. Whilst sodium glucose transporter 2 inhibitors have a solid evidence base, the recommendations differ with regard to the use of inhibitors of the renin-angiotensin-aldosterone axis. Unless indicated for specific comorbidities, the use of beta-blockers should be discouraged in HFpEF. The aim of this article is to provide an overview of the current state of the art in HFpEF diagnosis, clinical evaluation, and treatment.
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Affiliation(s)
- Stephan von Haehling
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany.
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany.
| | - Birgit Assmus
- Department of Cardiology and Angiology, Universitätsklinikum Gießen und Marburg, Giessen, Germany
| | - Tarek Bekfani
- Department of Cardiology and Angiology, Universitätsklinikum Magdeburg, Magdeburg, Germany
| | - Elke Dworatzek
- Institute of Gender in Medicine, Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Frank Edelmann
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Djawid Hashemi
- Charité - Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité - Medical Heart Center of Charité and German Heart Institute Berlin, Campus Virchow-Klinikum, Berlin, Germany
- DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
- Berlin Institute of Health at Charité - Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, BIH Charité Digital Clinician Scientist Program, Berlin, Germany
| | - Kristian Hellenkamp
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
| | - Tibor Kempf
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Philipp Raake
- I. Medical Department, Cardiology, Pneumology, Endocrinology and Intensive Care Medicine, University Hospital Augsburg, University of Augsburg, Augsburg, Germany
| | - Katharina A Schütt
- Department of Internal Medicine I, University Hospital RWTH Aachen, Aachen, Germany
| | - Rolf Wachter
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
- Klinik und Poliklinik für Kardiologie, Universitätsklinikum Leipzig, Leipzig, Germany
| | - Paul Christian Schulze
- Department of Internal Medicine I, Division of Cardiology, University Hospital Jena, FSU, Jena, Germany
| | - Gerd Hasenfuss
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Robert-Koch-Strasse 40, 37075, Göttingen, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Göttingen, Göttingen, Germany
| | - Michael Böhm
- Kardiologie, Angiologie und Internistische Intensivmedizin, Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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Rist A, Sevre K, Wachtell K, Devereux RB, Aurigemma GP, Smiseth OA, Kjeldsen SE, Julius S, Pitt B, Burnier M, Kreutz R, Oparil S, Mancia G, Zannad F. The current best drug treatment for hypertensive heart failure with preserved ejection fraction. Eur J Intern Med 2024; 120:3-10. [PMID: 37865559 DOI: 10.1016/j.ejim.2023.10.008] [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: 08/03/2023] [Revised: 09/15/2023] [Accepted: 10/09/2023] [Indexed: 10/23/2023]
Abstract
More than 90 % of patients developing heart failure (HF) have hypertension. The most frequent concomitant conditions are type-2 diabetes mellitus, obesity, atrial fibrillation, and coronary disease. HF outcome research focuses on decreasing mortality and preventing hospitalization for worsening HF syndrome. All drugs that decrease these HF endpoints lower blood pressure. Current drug treatments for HF are (i) angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor neprilysin inhibitors, (ii) selected beta-blockers, (iii) steroidal and non-steroidal mineralocorticoid receptor antagonists, and (iv) sodium-glucose cotransporter 2 inhibitors. For various reasons, these drug treatments were first studied in HF patients with a reduced ejection fraction (HFrEF). Subsequently, they have been investigated in HF patients with a preserved left ventricular ejection fraction (LVEF, HFpEF) of mostly hypertensive etiology, and with modest benefits largely assessed on top of background treatment with the drugs already proven effective in HFrEF. Additionally, diuretics are given on symptomatic indications. Patients with HFpEF may have diastolic dysfunction but also systolic dysfunction visualized by lack of longitudinal shortening. Considering the totality of evidence and the overall need for antihypertensive treatment and/or treatment of hypertensive complications in almost all HF patients, the principal drug treatment of HF appears to be the same regardless of LVEF. Rather than LVEF-guided treatment of HF, treatment of HF should be directed by symptoms (related to the level of fluid retention), signs (tachycardia), severity (NYHA functional class), and concomitant diseases and conditions. All HF patients should be given all the drug classes mentioned above if well tolerated.
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Affiliation(s)
- Aurora Rist
- Medical School and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kaja Sevre
- Medical School and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Kristian Wachtell
- Weill-Cornell Medicine, Division of Cardiology, New York City, NY, USA
| | | | - Gerard P Aurigemma
- Division of Cardiovascular Medicine, Department of Medicine, UMass Chan School of Medicine, Worcester, MA, USA
| | - Otto A Smiseth
- Institute for Surgical Research and Department of Cardiology, University of Oslo, Rikshospitalet, Oslo, Norway
| | - Sverre E Kjeldsen
- Medical School and Institute of Clinical Medicine, University of Oslo, Oslo, Norway; Department of Cardiology, Ullevaal Hospital, Oslo, Norway; Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Stevo Julius
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Bertram Pitt
- Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michel Burnier
- Centre Hospitalier Universitaire Vaudois, Service of Nephrology and Hypertension, Lausanne, Switzerland
| | - Reinhold Kreutz
- Charité - Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Suzanne Oparil
- Vascular Biology and Hypertension Program, Department of Medicine, University of Alabama at Birmingham, AL, USA
| | | | - Faiez Zannad
- Inserm, Centre d'Investigations Cliniques-1433 and F-CRIN INI CRCT, Universite de Lorraine, Nancy, France
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Sevre K, Rist A, Wachtell K, Devereux RB, Aurigemma GP, Smiseth OA, Kjeldsen SE, Julius S, Pitt B, Burnier M, Kreutz R, Oparil S, Mancia G, Zannad F. What Is the Current Best Drug Treatment for Hypertensive Heart Failure With Preserved Ejection Fraction? Review of the Totality of Evidence. Am J Hypertens 2024; 37:1-14. [PMID: 37551929 PMCID: PMC10724525 DOI: 10.1093/ajh/hpad073] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 08/07/2023] [Indexed: 08/09/2023] Open
Abstract
BACKGROUND More than 90% of patients developing heart failure (HF) have an epidemiological background of hypertension. The most frequent concomitant conditions are type 2 diabetes mellitus, obesity, atrial fibrillation, and coronary disease, all disorders/diseases closely related to hypertension. METHODS HF outcome research focuses on decreasing mortality and preventing hospitalization for worsening HF syndrome. All drugs that decrease these HF endpoints lower blood pressure. Current drug treatments for HF are (i) angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor neprilysin inhibitors, (ii) selected beta-blockers, (iii) steroidal and nonsteroidal mineralocorticoid receptor antagonists, and (iv) sodium-glucose cotransporter 2 inhibitors. RESULTS For various reasons, these drug treatments were first studied in HF patients with a reduced ejection fraction (HFrEF). However, subsequently, they have been investigated and, as we see it, documented as beneficial in HF patients with a preserved left ventricular ejection fraction (LVEF, HFpEF) and mostly hypertensive etiology, with effect estimates assessed partly on top of background treatment with the drugs already proven effective in HFrEF. Additionally, diuretics are given on symptomatic indications. CONCLUSIONS Considering the totality of evidence and the overall need for antihypertensive treatment and/or treatment of hypertensive complications in almost all HF patients, the principal drug treatment of HF appears to be the same regardless of LVEF. Rather than LVEF-guided treatment of HF, treatment of HF should be directed by symptoms (related to the level of fluid retention), signs (tachycardia), severity (NYHA functional class), and concomitant diseases and conditions. All HF patients should be given all the drug classes mentioned above if well tolerated.
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Affiliation(s)
- Kaja Sevre
- University of Oslo, Medical School and Institute of Clinical Medicine, Oslo, Norway
| | - Aurora Rist
- University of Oslo, Medical School and Institute of Clinical Medicine, Oslo, Norway
| | - Kristian Wachtell
- Weill-Cornell Medicine, Division of Cardiology, New York City, New York, USA
| | - Richard B Devereux
- Weill-Cornell Medicine, Division of Cardiology, New York City, New York, USA
| | - Gerard P Aurigemma
- Division of Cardiovascular Medicine, Department of Medicine, UMassChan School of Medicine, Worcester, Massachusetts, USA
| | - Otto A Smiseth
- University of Oslo, Institute for Surgical Research and Department of Cardiology, Rikshospitalet, Oslo, Norway
| | - Sverre E Kjeldsen
- University of Oslo, Medical School and Institute of Clinical Medicine, Oslo, Norway
- Departments of Cardiology and Nephrology, Ullevaal Hospital, Oslo, Norway
- University of Michigan, Division of Cardiovascular Medicine, Ann Arbor, Michigan, USA
| | - Stevo Julius
- University of Michigan, Division of Cardiovascular Medicine, Ann Arbor, Michigan, USA
| | - Bertram Pitt
- University of Michigan, Division of Cardiovascular Medicine, Ann Arbor, Michigan, USA
| | - Michel Burnier
- Faculty of Biology and Medicine, University of Lausanne, Lausanne, Switzerland
| | - Reinhold Kreutz
- Charité – Universitätsmedizin Berlin, Institute of Clinical Pharmacology and Toxicology, Berlin, Germany
| | - Suzanne Oparil
- University of Alabama at Birmingham, Vascular Biology and Hypertension Program, Department of Medicine, Birmingham, Alabama, USA
| | | | - Faiez Zannad
- Universite de Lorraine, Inserm, Centre d’Investigations Cliniques-1433 and F-CRIN INI CRCT, Nancy, France
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Kintscher U, Edelmann F. The non-steroidal mineralocorticoid receptor antagonist finerenone and heart failure with preserved ejection fraction. Cardiovasc Diabetol 2023; 22:162. [PMID: 37386461 PMCID: PMC10311906 DOI: 10.1186/s12933-023-01899-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/22/2023] [Indexed: 07/01/2023] Open
Abstract
Finerenone is a novel non-steroidal mineralocorticoid receptor (MR) antagonist (MRA) with high binding affinity, high MR selectivity and a short plasma half-life. In two major endpoint-driven clinical trials in patients with chronic kidney disease and type 2 diabetes mellitus (FIDELIO-DKD and FIGARO-DKD), finerenone induced significant cardiorenal protective actions, and has been recently approved for treatment of these patients. Heart failure with preserved ejection fraction (HFpEF) is a devastating clinical syndrome with increasing prevalence and poor prognosis. Pharmacological therapy of HFpEF is very limited and new therapeutic options are urgently needed. Finerenone has been shown to improve multiple pathophysiological parameters of HFpEF in preclinical models. In consonance, pre-specified subgroup analyses of FIDELIO-DKD and FIGARO-DKD suggested a potential beneficial effect of finerenone in HFpEF. This review will discuss the pharmacodynamic and -kinetic profile of finerenone. We will provide a general overview over the complex pathophysiology of HFpEF and data from pre-clinical studies, focusing on how finerenone improves multiple components of this pathophysiology. Finally, we will discuss current and future clinical trials with finerenone in heart failure patients focusing on HFpEF.
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Affiliation(s)
- Ulrich Kintscher
- Institute of Pharmacology, Charite - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt- Universität zu Berlin, Max Rubner Center for Cardiovascular Metabolic Renal Research, Hessische Str. 3-4, 10115, Berlin, Germany.
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.
| | - Frank Edelmann
- DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Campus Virchow-Klinikum, 13353, Berlin, Germany
- Berlin Institute of Health, 13353, Berlin, Germany
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Correia ETDO, Mesquita ET. Novidades e Reflexões sobre o Tratamento Farmacológico da Insuficiência Cardíaca com Fração de Ejeção Preservada. Arq Bras Cardiol 2022; 119:627-630. [PMID: 36102421 PMCID: PMC9563882 DOI: 10.36660/abc.20210753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 03/09/2022] [Indexed: 11/21/2022] Open
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6
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Targeting Myocardial Fibrosis—A Magic Pill in Cardiovascular Medicine? Pharmaceutics 2022; 14:pharmaceutics14081599. [PMID: 36015225 PMCID: PMC9414721 DOI: 10.3390/pharmaceutics14081599] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/27/2022] [Accepted: 07/28/2022] [Indexed: 11/16/2022] Open
Abstract
Fibrosis, characterized by an excessive accumulation of extracellular matrix, has long been seen as an adaptive process that contributes to tissue healing and regeneration. More recently, however, cardiac fibrosis has been shown to be a central element in many cardiovascular diseases (CVDs), contributing to the alteration of cardiac electrical and mechanical functions in a wide range of clinical settings. This paper aims to provide a comprehensive review of cardiac fibrosis, with a focus on the main pathophysiological pathways involved in its onset and progression, its role in various cardiovascular conditions, and on the potential of currently available and emerging therapeutic strategies to counteract the development and/or progression of fibrosis in CVDs. We also emphasize a number of questions that remain to be answered, and we identify hotspots for future research.
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Girerd N, Mewton N, Tartière JM, Guijarro D, Jourdain P, Damy T, Lamblin N, Bayes-Génis A, Pellicori P, Januzzi J, Rossignol P, Roubille F. Practical outpatient management of worsening chronic heart failure. Eur J Heart Fail 2022; 24:750-761. [PMID: 35417093 PMCID: PMC9325366 DOI: 10.1002/ejhf.2503] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Revised: 04/04/2022] [Accepted: 04/10/2022] [Indexed: 11/12/2022] Open
Abstract
Management of worsening heart failure (WHF) has traditionally been hospital‐based, but with the rising burden of heart failure (HF), the pressure on healthcare systems exerted by this disease necessitates a different strategy than long (and costly) hospital stays. A strategy for outpatient intravenous (IV) diuretic treatment of WHF has been developed in certain American centres in the past 10 years, whereas European centres have been mostly favouring ‘classic’ in‐hospital management of WHF. Embracing novel, outpatient approaches for treating WHF could substantially reduce the burden on healthcare systems while improving patient's satisfaction and quality of life. The present article is intended to provide essential knowledge and practical guidelines aimed at helping clinicians implement these new ambulatory approaches using day hospital and/or at‐home hospitalization. The topics addressed by our group of HF experts include the pathophysiological background of diuretic therapy, the most suitable profile of WHF that may be managed in an ambulatory setting, the pharmacological protocols that can be used, as well as a detailed description of healthcare structures that can be proposed to deliver these ambulatory care interventions. The practical aspects of day hospital and hospital‐at‐home IV diuretic administration are specifically emphasized. The algorithm provided along with the practical IV diuretic protocols should assist HF clinicians in implementing this new approach in their local clinical setting.
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Affiliation(s)
- Nicolas Girerd
- Université de Lorraine, Centre d'Investigation Clinique- Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Nathan Mewton
- Hôpital Cardiovasculaire Louis Pradel Hospices Civils de Lyon Heart Failure Department Clinical Investigation Center Inserm 1407 CarMeN Inserm 1060, University Claude Bernard Lyon 1 28 Avenue Doyen Lépine 69500, Bron
| | | | - Damien Guijarro
- Université de Nantes, CHU Nantes, CNRS, INSERM, l'institut du thorax, Nantes, F-44000, France
| | - Patrick Jourdain
- Covidom regional telemedicine platform, Assistance Publique-Hôpitaux de Paris, Paris, France; Cardiology Department, University Hospital of Bicêtre, Assistance Publique-Hôpitaux de Paris, Kremlin Bicêtre, France
| | - Thibaud Damy
- Réseau cardiogen, Department of Cardiology, centre français de référence de l'amylose cardiaque (CRAC), CHU d'Henri-Mondor, AP-HP, 94000, Créteil, France
| | - Nicolas Lamblin
- Department of Cardiology, Université de Lille, 59000, Lille, France
| | - Antoni Bayes-Génis
- CIBERCV; Servicio de Cardiología. Hospital Germans Trias i Pujol. Universitat Autònoma de Barcelona. Barcelona., Spain
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - James Januzzi
- Cardiology Division, Massachusetts General Hospital, Baim Institute for Clinical Research, Harvard Medical School, Boston, MA, USA
| | - Patrick Rossignol
- Université de Lorraine, Centre d'Investigation Clinique- Plurithématique Inserm CIC-P 1433, Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - François Roubille
- PhyMedExp, Université de Montpellier, INSERM, CNRS, Cardiology Department, CHU de Montpellier, France
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Pabón MA, Cunningham JW, Claggett BL, Packer M, Zile M, Pfeffer MA, Lefkowitz M, Shi V, Rizkala A, McMurray JJV, Solomon SD, Vaduganathan M. Natriuretic Peptide-Based Inclusion Criteria in Heart Failure with Preserved Ejection Fraction Clinical Trials: Insights from PARAGON-HF. Eur J Heart Fail 2022; 24:672-677. [PMID: 35080787 DOI: 10.1002/ejhf.2439] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/14/2022] [Accepted: 01/21/2022] [Indexed: 11/09/2022] Open
Abstract
AIM Natriuretic peptides (NPs) are now routinely incorporated as key inclusion criteria in clinical trials of heart failure with preserved ejection fraction (HFpEF) as objective measures of risk. An early amendment in PARAGON-HF required all participants to have elevated NP concentrations, but some were enrolled pre-amendment, providing a unique opportunity to understand the influence of enrollment pathway in HFpEF clinical trials. METHODS AND RESULTS Among 4,796 participants in PARAGON-HF, 193 (4.0%) did not meet the final NP-based enrollment criteria (NT-proBNP >300 pg/ml for patients in sinus rhythm or >900 pg/ml for patients in atrial fibrillation/flutter). These patients had lower rates of the primary endpoint of total HF hospitalizations and cardiovascular death as compared with patients meeting final enrollment criteria (8.6 [6.7-11.2] events per 100py vs. 14.0 [13.4-14.7] events per 100py P=0.01). The rate ratio for the treatment effect comparing sacubitril/valsartan with valsartan was 0.85 [95% CI 0.74-0.99]; P=0.035 in those who met final criteria. CONCLUSIONS NPs are an important tool in HFpEF clinical trials to objectively affirm diagnoses and enrich clinical event rates.
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Affiliation(s)
- Maria A Pabón
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jonathan W Cunningham
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Michael Zile
- RHJ Department of Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, South Carolina
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - John J V McMurray
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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9
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Savarese G, Stolfo D, Sinagra G, Lund LH. Heart failure with mid-range or mildly reduced ejection fraction. Nat Rev Cardiol 2022; 19:100-116. [PMID: 34489589 PMCID: PMC8420965 DOI: 10.1038/s41569-021-00605-5] [Citation(s) in RCA: 135] [Impact Index Per Article: 67.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/19/2021] [Indexed: 02/08/2023]
Abstract
Left ventricular ejection fraction (EF) remains the major parameter for diagnosis, phenotyping, prognosis and treatment decisions in heart failure. The 2016 ESC heart failure guidelines introduced a third EF category for an EF of 40-49%, defined as heart failure with mid-range EF (HFmrEF). This category has been largely unexplored compared with heart failure with reduced EF (HFrEF; defined as EF <40% in this Review) and heart failure with preserved EF (HFpEF; defined as EF ≥50%). The prevalence of HFmrEF within the overall population of patients with HF is 10-25%. HFmrEF seems to be an intermediate clinical entity between HFrEF and HFpEF in some respects, but more similar to HFrEF in others, in particular with regard to the high prevalence of ischaemic heart disease in these patients. HFmrEF is milder than HFrEF, and the risk of cardiovascular events is lower in patients with HFmrEF or HFpEF than in those with HFrEF. By contrast, the risk of non-cardiovascular adverse events is similar or greater in patients with HFmrEF or HFpEF than in those with HFrEF. Evidence from post hoc and subgroup analyses of randomized clinical trials and a trial of an SGLT1-SGLT2 inhibitor suggests that drugs that are effective in patients with HFrEF might also be effective in patients with HFmrEF. Although the EF is a continuous measure with considerable variability, in this comprehensive Review we suggest that HFmrEF is a useful categorization of patients with HF and shares the most important clinical features with HFrEF, which supports the renaming of HFmrEF to HF with mildly reduced EF.
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Affiliation(s)
- Gianluigi Savarese
- grid.4714.60000 0004 1937 0626Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Davide Stolfo
- grid.4714.60000 0004 1937 0626Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden ,Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Lars H. Lund
- grid.4714.60000 0004 1937 0626Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden ,grid.24381.3c0000 0000 9241 5705Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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10
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Zannad F, Cotter G, Alonso Garcia A, George S, Davison B, Figtree G, Prasad K, Rockhold F, Schilsky RL, Stockbridge N, Pitt B, Butler J. What can heart failure trialists learn from oncology trialists? Eur Heart J 2021; 42:2373-2383. [PMID: 34076243 DOI: 10.1093/eurheartj/ehab236] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 02/24/2021] [Accepted: 04/30/2021] [Indexed: 12/27/2022] Open
Abstract
Globally, there has been little change in mortality rates from cardiovascular (CV) diseases or cancers over the past two decades (1997-2018). This is especially true for heart failure (HF) where 5-year mortality rates remain as high as 45-55%. In the same timeframe, the proportion of drug revenue, and regulatory drug approvals for cancer drugs, far out paces those for CV drugs. In 2018, while cancer drugs made 27% of Food and Drug Administration drug approvals, only 1% of drug approvals was for a CV drug, and over this entire 20 year span, only four drugs were approved for HF in the USA. Cardiovascular trialists need to reassess the design, execution, and purpose of CV clinical trials. In the area of oncology research, trials are much smaller, follow-up is shorter, and targeted therapies are common. Cardiovascular diseases and cancer are the two most common causes of death globally, and although they differ substantially, this review evaluates whether some elements of oncology research may be applicable in the CV arena. As one of the most underserved CV diseases, the review focuses on aspects of cancer research that may be applicable to HF research with the aim of streamlining the clinical trial process and decreasing the time and cost required to bring safe, effective, treatments to patients who need them. The paper is based on discussions among clinical trialists, industry representatives, regulatory authorities, and patients, which took place at the Cardiovascular Clinical Trialists Workshop in Washington, DC, on 8 December 2019 (https://www.globalcvctforum.com/2019 (14 September 2020)).
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Affiliation(s)
- Faiez Zannad
- Université de Lorraine, Inserm Clinical Investigation Center 1439 at Institut Lorrain du Coeur et des Vaisseaux, CHU 54500, University Hospital of Nancy, Nancy, France
| | - Gad Cotter
- 2Momentum Research, Inc., 3100 Tower Blvd, Durham, NC, 27707, USA, Inserm, Paris, 942 Mascot, France
| | - Angeles Alonso Garcia
- Medicines and Healthcare products Regulatory Agency (MHRA), 10 South Colonnade, London, E14 4PU, UK
| | - Suzanne George
- Sarcoma Center, Dana-Farber Cancer Center, 450 Brookline Ave, Boston, MA, 02215, USA
| | - Beth Davison
- 2Momentum Research, Inc., 3100 Tower Blvd, Durham, NC, 27707, USA, Inserm, Paris, 942 Mascot, France
| | - Gemma Figtree
- Northern Clinical School, Kolling Institute of Medical Research, University of Sydney, Sydney, Australia, Reserve Road, St Leonards, NSW 2065
| | - Krishna Prasad
- Medicines and Healthcare products Regulatory Agency (MHRA), 10 South Colonnade, London, E14 4PU, UK
| | - Frank Rockhold
- Department of Biostatistics & Bioinformatics, Duke University Medical Center, 2424 Erwin Rd, Durham, NC, 27710, USA
| | | | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, FDA Center for Drug Evaluation and Research (CDER), 10903 New Hampshire Ave, Silver Spring, MD, 20993, USA
| | - Bertram Pitt
- Division of Cardiology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, 2500 North State St, Jackson, MS, 39216, USA
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11
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Hypertension and heart failure with preserved ejection fraction: position paper by the European Society of Hypertension. J Hypertens 2021; 39:1522-1545. [PMID: 34102660 DOI: 10.1097/hjh.0000000000002910] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Hypertension constitutes a major risk factor for heart failure with preserved ejection fraction (HFpEF). HFpEF is a prevalent clinical syndrome with increased cardiovascular morbidity and mortality. Specific guideline-directed medical therapy (GDMT) for HFpEF is not established due to lack of positive outcome data from randomized controlled trials (RCTs) and limitations of available studies. Although available evidence is limited, control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF. Thus, in current guidelines including the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines, blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers provides the backbone of BP-lowering therapy in hypertensive patients. Although superiority of RAS blockers has not been clearly shown in dedicated RCTs designed for HFpEF, we propose that this core drug treatment strategy is also applicable for hypertensive patients with HFpEF with the addition of some modifications. The latter apply to the use of spironolactone apart from the treatment of resistant hypertension and the use of the angiotensin receptor neprilysin inhibitor. In addition, novel agents such as sodium-glucose co-transporter-2 inhibitors, currently already indicated for high-risk patients with diabetes to reduce heart failure hospitalizations, and finerenone represent promising therapies and results from ongoing RCTs are eagerly awaited. The development of an effective and practical classification of HFpEF phenotypes and GDMT through dedicated high-quality RCTs are major unmet needs in hypertension research and calls for action.
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12
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Martin N, Manoharan K, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2021; 5:CD012721. [PMID: 34022072 PMCID: PMC8140651 DOI: 10.1002/14651858.cd012721.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF. SEARCH METHODS We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.
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Affiliation(s)
- Nicole Martin
- Institute of Health Informatics Research, University College London, London, UK
| | | | - Ceri Davies
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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13
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Ferreira JP, Claggett BL, Liu J, Desai AS, Pfeffer MA, Anand IS, van Veldhuisen DJ, Kober L, Cleland JGF, Rouleau JL, Packer M, Zile MR, Shi VC, Lefkowitz MP, Shah SJ, Vardeny O, Zannad F, Solomon SD, McMurray JJV. Serum potassium and outcomes in heart failure with preserved ejection fraction: a post-hoc analysis of the PARAGON-HF trial. Eur J Heart Fail 2021; 23:776-784. [PMID: 33609066 DOI: 10.1002/ejhf.2134] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Revised: 02/08/2021] [Accepted: 02/18/2021] [Indexed: 12/13/2022] Open
Abstract
AIMS The relationship between serum potassium concentration and outcomes in patients with heart failure and preserved ejection fraction (HFpEF) is not well-established. The aim of this study was to explore the association between serum potassium and clinical outcomes in the PARAGON-HF trial in which 4822 patients with HFpEF were randomised to treatment with sacubitril/valsartan or valsartan. METHODS AND RESULTS The relationship between serum potassium concentrations and the primary study composite outcome of total (first and recurrent) heart failure hospitalisations and cardiovascular death was analysed. Hypo-, normo-, and hyperkalaemia were defined as serum potassium <4 mmol/L, 4-5 mmol/L and >5 mmol/L, respectively. Both screening and time-updated potassium (categorical and continuous spline-transformed) were studied. Patient mean age was 73 years and 52% were women. Patients with higher baseline potassium more often had an ischaemic aetiology and diabetes and mineralocorticoid receptor antagonist treatment. Compared with normokalaemia, both time-updated (but not screening) hypo- and hyperkalaemia were associated with a higher risk of the primary outcome [adjusted hazard ratio (HR) for hypokalaemia 1.55, 95% confidence interval (CI) 1.30-1.85; P < 0.001, and for hyperkalaemia HR 1.21, 95% CI 1.02-1.44; P = 0.025]. Hypokalaemia had a stronger association with a higher risk of all-cause, cardiovascular and non-cardiovascular death than hyperkalaemia. The association of hypokalaemia with increased risk of all-cause and cardiovascular death was most marked in participants with impaired kidney function (interaction P < 0.05). Serum potassium did not significantly differ between sacubitril/valsartan and valsartan throughout the follow-up. CONCLUSIONS Both hypo- and hyperkalaemia were associated with heart failure hospitalisation but only hypokalaemia was associated with mortality, especially in the context of renal impairment. Hypokalaemia was as strongly associated with death from non-cardiovascular causes as with cardiovascular death. Collectively, these findings suggest that potassium disturbances are a more of a marker of HFpEF severity rather than a direct cause of death.
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Affiliation(s)
- João Pedro Ferreira
- National Institute of Health and Medical Research, Center for Clinical Multidisciplinary Research, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France.,British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Inder S Anand
- Department of Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Lars Kober
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Jean L Rouleau
- Montreal Institute of Cardiology, University of Montreal, Montreal, Canada
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
| | - Michael R Zile
- Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC, USA
| | | | | | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, MN, USA
| | - Faiez Zannad
- National Institute of Health and Medical Research, Center for Clinical Multidisciplinary Research, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and 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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14
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Sweeney M, Corden B, Cook SA. Targeting cardiac fibrosis in heart failure with preserved ejection fraction: mirage or miracle? EMBO Mol Med 2020; 12:e10865. [PMID: 32955172 PMCID: PMC7539225 DOI: 10.15252/emmm.201910865] [Citation(s) in RCA: 86] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2020] [Revised: 07/30/2020] [Accepted: 08/14/2020] [Indexed: 12/11/2022] Open
Abstract
Cardiac fibrosis is central to the pathology of heart failure, particularly heart failure with preserved ejection fraction (HFpEF). Irrespective of the underlying profibrotic condition (e.g. ageing, diabetes, hypertension), maladaptive cardiac fibrosis is defined by the transformation of resident fibroblasts to matrix-secreting myofibroblasts. Numerous profibrotic factors have been identified at the molecular level (e.g. TGFβ, IL11, AngII), which activate gene expression programs for myofibroblast activation. A number of existing HF therapies indirectly target fibrotic pathways; however, despite multiple clinical trials in HFpEF, a specific clinically effective antifibrotic therapy remains elusive. Therapeutic inhibition of TGFβ, the master-regulator of fibrosis, has unfortunately proven toxic and ineffective in clinical trials to date, and new approaches are needed. In this review, we discuss the pathophysiology and clinical implications of interstitial fibrosis in HFpEF. We provide an overview of trials targeting fibrosis in HFpEF to date and discuss the promise of potential new therapeutic approaches and targets in the context of underlying molecular mechanisms.
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Affiliation(s)
- Mark Sweeney
- MRC‐London Institute of Medical SciencesHammersmith Hospital CampusLondonUK
- Wellcome Trust 4i/NIHR Clinical Research FellowImperial CollegeLondonUK
| | - Ben Corden
- MRC‐London Institute of Medical SciencesHammersmith Hospital CampusLondonUK
- National Heart Research Institute SingaporeNational Heart Centre SingaporeSingaporeSingapore
- Cardiovascular and Metabolic Disorders ProgramDuke‐National University of Singapore Medical SchoolSingaporeSingapore
- National Heart and Lung InstituteImperial College LondonLondonUK
| | - Stuart A Cook
- MRC‐London Institute of Medical SciencesHammersmith Hospital CampusLondonUK
- National Heart Research Institute SingaporeNational Heart Centre SingaporeSingaporeSingapore
- Cardiovascular and Metabolic Disorders ProgramDuke‐National University of Singapore Medical SchoolSingaporeSingapore
- National Heart and Lung InstituteImperial College LondonLondonUK
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15
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Chirinos JA, Zhao L, Jia Y, Frej C, Adamo L, Mann D, Shewale SV, Millar JS, Rader DJ, French B, Brandimarto J, Margulies KB, Parks JS, Wang Z, Seiffert DA, Fang J, Sweitzer N, Chistoffersen C, Dahlbäck B, Car BD, Gordon DA, Cappola TP, Javaheri A. Reduced Apolipoprotein M and Adverse Outcomes Across the Spectrum of Human Heart Failure. Circulation 2020; 141:1463-1476. [PMID: 32237898 PMCID: PMC7200273 DOI: 10.1161/circulationaha.119.045323] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Apo (apolipoprotein) M mediates the physical interaction between high-density lipoprotein (HDL) particles and sphingosine-1-phosphate (S1P). Apo M exerts anti-inflammatory and cardioprotective effects in animal models. METHODS In a subset of PHFS (Penn Heart Failure Study) participants (n=297), we measured apo M by Enzyme-Linked ImmunoSorbent Assay (ELISA). We also measured total S1P by liquid chromatography-mass spectrometry and isolated HDL particles to test the association between apo M and HDL-associated S1P. We confirmed the relationship between apo M and outcomes using modified aptamer-based apo M measurements among 2170 adults in the PHFS and 2 independent cohorts: the Washington University Heart Failure Registry (n=173) and a subset of TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial; n=218). Last, we examined the relationship between apo M and ≈5000 other proteins (SomaScan assay) to identify biological pathways associated with apo M in heart failure. RESULTS In the PHFS, apo M was inversely associated with the risk of death (standardized hazard ratio, 0.56 [95% CI, 0.51-0.61]; P<0.0001) and the composite of death/ventricular assist device implantation/heart transplantation (standardized hazard ratio, 0.62 [95% CI, 0.58-0.67]; P<0.0001). This relationship was independent of HDL cholesterol or apo AI levels. Apo M remained associated with death (hazard ratio, 0.78 [95% CI, 0.69-0.88]; P<0.0001) and the composite of death/ventricular assist device/heart transplantation (hazard ratio, 0.85 [95% CI, 0.76-0.94]; P=0.001) in models that adjusted for multiple confounders. This association was present in both heart failure with reduced and preserved ejection fraction and was replicated in the Washington University cohort and a cohort with heart failure with preserved ejection fraction only (TOPCAT). The S1P and apo M content of isolated HDL particles strongly correlated (R=0.81, P<0.0001). The top canonical pathways associated with apo M were inflammation (negative association), the coagulation system (negative association), and liver X receptor/retinoid X receptor activation (positive association). The relationship with inflammation was validated with multiple inflammatory markers measured with independent assays. CONCLUSIONS Reduced circulating apo M is independently associated with adverse outcomes across the spectrum of human heart failure. Further research is needed to assess whether the apo M/S1P axis is a suitable therapeutic target in heart failure.
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Affiliation(s)
- Julio A. Chirinos
- Perelman School of Medicine. University of Pennsylvania School of Medicine/Hospital of the University of Pennsylvania. Philadelphia, PA
| | - Lei Zhao
- Bristol-Myers Squibb Company, Lawrenceville, NJ
| | - Yi Jia
- SomaLogic Inc., Boulder, CO
| | | | - Luigi Adamo
- Washington University School of Medicine, St. Louis, MO
| | - Douglas Mann
- Washington University School of Medicine, St. Louis, MO
| | - Swapnil V. Shewale
- Perelman School of Medicine. University of Pennsylvania School of Medicine/Hospital of the University of Pennsylvania. Philadelphia, PA
| | - John S. Millar
- Perelman School of Medicine. University of Pennsylvania School of Medicine/Hospital of the University of Pennsylvania. Philadelphia, PA
| | - Daniel J. Rader
- Perelman School of Medicine. University of Pennsylvania School of Medicine/Hospital of the University of Pennsylvania. Philadelphia, PA
| | - Benjamin French
- Perelman School of Medicine. University of Pennsylvania School of Medicine/Hospital of the University of Pennsylvania. Philadelphia, PA
| | - Jeff Brandimarto
- Perelman School of Medicine. University of Pennsylvania School of Medicine/Hospital of the University of Pennsylvania. Philadelphia, PA
| | - Kenneth B. Margulies
- Perelman School of Medicine. University of Pennsylvania School of Medicine/Hospital of the University of Pennsylvania. Philadelphia, PA
| | - John S. Parks
- Dept. of Internal Medicine-Molecular Medicine, Wake Forest School of Medicine, Winston Salem, NC
| | | | | | - James Fang
- University of Utah. Salt Lake City, Utah
| | - Nancy Sweitzer
- Sarver Heart Institute, University of Arizona, Tuscon, AZ
| | - Christina Chistoffersen
- Dept. of Clinical Biochemistry, Rigshospitalet and Dept. of Biomedical Sciences, Copenhagen, Denmark
| | | | | | | | - Thomas P. Cappola
- Perelman School of Medicine. University of Pennsylvania School of Medicine/Hospital of the University of Pennsylvania. Philadelphia, PA
| | - Ali Javaheri
- Washington University School of Medicine, St. Louis, MO
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16
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Ferrari R, Fucili A, Rapezzi C. Understanding the results of the PARAGON-HF trial. Eur J Heart Fail 2020; 22:1531-1535. [PMID: 32212295 DOI: 10.1002/ejhf.1797] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2019] [Revised: 02/18/2020] [Accepted: 02/29/2020] [Indexed: 12/16/2022] Open
Affiliation(s)
- Roberto Ferrari
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy
- GVM Care & Research, Maria Cecilia Hospital, Cotignola (RA), Italy
| | - Alessandro Fucili
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy
| | - Claudio Rapezzi
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy
- GVM Care & Research, Maria Cecilia Hospital, Cotignola (RA), Italy
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17
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Ferreira JP, Dewan P, Jhund PS, Lorenzo-Almorós A, Duarte K, Petrie MC, Carson PE, McKelvie R, Komajda M, Zile M, Zannad F, McMurray JJV. Covariate adjusted reanalysis of the I-Preserve trial. Clin Res Cardiol 2020; 109:1358-1365. [DOI: 10.1007/s00392-020-01632-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2020] [Accepted: 03/11/2020] [Indexed: 11/24/2022]
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18
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Enzan N, Matsushima S, Ide T, Kaku H, Higo T, Tsuchihashi‐Makaya M, Tsutsui H. Spironolactone use is associated with improved outcomes in heart failure with mid-range ejection fraction. ESC Heart Fail 2020; 7:339-347. [PMID: 31951680 PMCID: PMC7083406 DOI: 10.1002/ehf2.12571] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Revised: 10/22/2019] [Accepted: 11/11/2019] [Indexed: 12/28/2022] Open
Abstract
AIMS Spironolactone has been shown to improve outcomes in patients with heart failure (HF) with reduced ejection fraction (EF). We investigated whether the discharge use of spironolactone could be associated with better long-term outcomes among patients with HF with mid-range EF (HFmrEF). METHODS AND RESULTS We analysed HFmrEF (left ventricular EF 40-49%) patients enrolled in the Japanese Cardiac Registry of Heart Failure in Cardiology, which prospectively studied the clinical characteristics, treatments, and long-term outcomes of patients hospitalized due to HF. Patients were divided into two groups according to the use of spironolactone at discharge. The primary outcome was a composite of all-cause death or HF rehospitalization. A total of 457 patients had HFmrEF. The mean age was 69.3 years and 286 (62.6%) were male. Among them, spironolactone was prescribed at discharge in 158 patients (34.6%). Chronic kidney disease (7.6% vs. 16.8%, P = 0.007) was less prevalent and loop diuretics (89.2% vs. 70.2%, P < 0.001) were more often prescribed in patients with spironolactone. During a mean follow-up of 2.2 years, patients with spironolactone had a lower incidence rate of the primary outcome than those without it (171.5 vs. 278.8 primary outcome per 1000 patient-years, incidence rate ratio 0.61, 95% confidence interval 0.44-0.86; P = 0.004). After multivariable adjustment, spironolactone use at discharge was associated with a significant reduction in the composite of all-cause death or HF rehospitalization (adjusted hazard ratio 0.63, 95% confidence interval 0.44-0.90, P = 0.010). CONCLUSIONS Among patients with HF hospitalized for HFmrEF, spironolactone use at discharge was associated with better long-term outcomes.
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Affiliation(s)
- Nobuyuki Enzan
- Department of Cardiovascular Medicine, Faculty of Medical SciencesKyushu UniversityFukuokaJapan
| | - Shouji Matsushima
- Department of Cardiovascular MedicineKyushu University HospitalMaidashi 3‐1‐1, Higashi‐kuFukuoka812‐8582Japan
| | - Tomomi Ide
- Department of Experimental and Clinical Cardiovascular Medicine, Graduate School of Medical SciencesKyushu UniversityFukuokaJapan
| | - Hidetaka Kaku
- Department of Cardiovascular Medicine, Faculty of Medical SciencesKyushu UniversityFukuokaJapan
| | - Taiki Higo
- Department of Cardiovascular Medicine, Faculty of Medical SciencesKyushu UniversityFukuokaJapan
| | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Faculty of Medical SciencesKyushu UniversityFukuokaJapan
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19
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Kjeldsen SE, von Lueder TG, Smiseth OA, Wachtell K, Mistry N, Westheim AS, Hopper I, Julius S, Pitt B, Reid CM, Devereux RB, Zannad F. Medical Therapies for Heart Failure With Preserved Ejection Fraction. Hypertension 2019; 75:23-32. [PMID: 31786973 DOI: 10.1161/hypertensionaha.119.14057] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Current cardiovascular pharmacotherapy targets maladaptive overactivation of the renin-angiotensin-aldosterone system (RAAS), which occurs throughout the continuum of cardiovascular disease spanning from hypertension to heart failure with reduced ejection fraction. Over the past 16 years, 4 prospective, randomized, placebo-controlled clinical trials using candesartan, perindopril, irbesartan, and spironolactone in patients with heart failure with preserved ejection fraction (HFpEF) failed to demonstrate increased efficacy of RAAS blockade added to guideline-directed medical therapy. We reappraise these trials and their weaknesses, which precluded statistically significant findings. Recently, dual-acting RAAS blockade with sacubitril-valsartan relative to stand-alone valsartan failed to improve outcome in the PARAGON-HF trial (Efficacy and Safety of LCZ696 Compared with Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction). The majority of patients with HFpEF experience hypertension, frequently with subclinical left ventricular dysfunction, contributed to by comorbidities such as coronary disease, diabetes mellitus, overweight, and atrial fibrillation. Contrasting the findings in HFpEF, trials evaluating RAAS blockade on either side of HFpEF on the cardiovascular continuum in patients with high-risk hypertension and heart failure with reduced ejection fraction, respectively, showed positive outcomes. We do not have a biologically plausible explanation for such divergent efficacy of RAAS blockade. Based on considerations of well-established clinical efficacy in hypertension and heart failure with reduced ejection fraction and the shortcomings of aforementioned clinical trials in HFpEF, we argue that RAAS blockers including MRAs (mineralocorticoid receptor antagonists; aldosterone antagonists) should be used in the treatment of patients with HFpEF.
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Affiliation(s)
- Sverre E Kjeldsen
- From the Department of Cardiology, Oslo University Hospital, Norway (S.E.K., T.G.v.L., O.A.S., K.W., N.M., A.S.W.).,Institute of Clinical Medicine, University of Oslo, Norway (S.E.K., O.A.S.).,Division of Cardiology, University of Michigan, Ann Arbor (S.E.K., S.J., B.P.)
| | - Thomas G von Lueder
- From the Department of Cardiology, Oslo University Hospital, Norway (S.E.K., T.G.v.L., O.A.S., K.W., N.M., A.S.W.)
| | - Otto A Smiseth
- From the Department of Cardiology, Oslo University Hospital, Norway (S.E.K., T.G.v.L., O.A.S., K.W., N.M., A.S.W.).,Institute of Clinical Medicine, University of Oslo, Norway (S.E.K., O.A.S.)
| | - Kristian Wachtell
- From the Department of Cardiology, Oslo University Hospital, Norway (S.E.K., T.G.v.L., O.A.S., K.W., N.M., A.S.W.)
| | - Nisha Mistry
- From the Department of Cardiology, Oslo University Hospital, Norway (S.E.K., T.G.v.L., O.A.S., K.W., N.M., A.S.W.)
| | - Arne S Westheim
- From the Department of Cardiology, Oslo University Hospital, Norway (S.E.K., T.G.v.L., O.A.S., K.W., N.M., A.S.W.)
| | - Ingrid Hopper
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (I.H., C.M.R.)
| | - Stevo Julius
- Division of Cardiology, University of Michigan, Ann Arbor (S.E.K., S.J., B.P.)
| | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor (S.E.K., S.J., B.P.)
| | - Christopher M Reid
- Department of Epidemiology and Preventive Medicine, Centre of Cardiovascular Research and Education in Therapeutics, Monash University, Melbourne, Australia (I.H., C.M.R.).,School of Public Health, Curtin University, Perth, Australia (C.M.R.)
| | | | - Faiez Zannad
- Universite de Lorraine, Inserm, Centre d'Investigations Cliniques-1433 and F-CRIN INI CRCT, Nancy, France (F.Z.)
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20
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Abstract
The annual "heart report" published by the German Heart Foundation (Deutsche Herzstiftung) in December 2017 indicates that heart failure (ICD I50) remains the number one diagnosis of in-hospital-treated patients throughout Germany. For some time, the clinical diagnosis of heart failure has been verified by echocardiographic parameters as well as cardiac biomarkers that assist the clinician to rule in or rule out the presence of a failing heart, when used wisely. By introducing the term "heart failure with mid-range ejection fraction" (HFmrEF), the 2016 European Society of Cardiology (ESC) heart failure guidelines established a third heart failure entity, which was not necessarily seen as an improvement by the heart failure community. Nevertheless, half of all patients suffering from heart failure are now classified as having HFmrEF or heart failure with preserved ejection fraction (HFpEF), but the etiology and treatment options differ substantially. To elucidate this issue, the current review aims to highlight the key findings published to date. This should minimize the confusion that may have been generated by the new term "HFmrEF".
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21
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Barrera-Chimal J, Girerd S, Jaisser F. Mineralocorticoid receptor antagonists and kidney diseases: pathophysiological basis. Kidney Int 2019; 96:302-319. [PMID: 31133455 DOI: 10.1016/j.kint.2019.02.030] [Citation(s) in RCA: 118] [Impact Index Per Article: 23.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 02/04/2019] [Accepted: 02/20/2019] [Indexed: 12/13/2022]
Abstract
Chronic kidney disease (CKD) represents a global health concern, and its prevalence is increasing. The ultimate therapeutic option for CKD is kidney transplantation. However, the use of drugs that target specific pathways to delay or halt CKD progression, such as angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and sodium-glucose co-transporter-2 (SGLT-2) inhibitors is limited in clinical practice. Mineralocorticoid receptor activation in nonclassical tissues, such as the endothelium, smooth muscle cells, inflammatory cells, podocytes, and fibroblasts may have deleterious effects on kidney structure and function. Several preclinical studies have shown that mineralocorticoid receptor antagonists (MRAs) ameliorate or cure kidney injury and dysfunction in different models of kidney disease. In this review, we present the preclinical evidence showing a benefit of MRAs in acute kidney injury, the transition from acute kidney injury to CKD, hypertensive and diabetic nephropathy, glomerulonephritis, and kidney toxicity induced by calcineurin inhibitors. We also discuss the molecular mechanisms responsible for renoprotection related to MRAs that lead to reduced oxidative stress, inflammation, fibrosis, and hemodynamic alterations. The available clinical data support a benefit of MRA in reducing proteinuria in diabetic kidney disease and improving cardiovascular outcomes in CKD patients. Moreover, a benefit of MRAs in kidney transplantation has also been observed. The past and present clinical trials describing the effect of MRAs on kidney injury are presented, and the risk of hyperkalemia and use of other options, such as potassium binding agents or nonsteroidal MRAs, are also addressed. Altogether, the available preclinical and clinical data support a benefit of using MRAs in CKD, an approach that should be further explored in future clinical trials.
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Affiliation(s)
- Jonatan Barrera-Chimal
- Laboratorio de Fisiología Cardiovascular y Trasplante Renal, Unidad de Medicina Traslacional, Instituto de Investigaciones Biomédicas, Universidad Nacional Autónoma de México and Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
| | - Sophie Girerd
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France; Institut national de la santé et de la recherche médicale U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France; Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, French-Clinical Research Infrastructure Network, Nancy, France
| | - Frederic Jaisser
- Institut national de la santé et de la recherche médicale U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France; Investigation Network Initiative - Cardiovascular and Renal Clinical Trialists, French-Clinical Research Infrastructure Network, Nancy, France; Institut national de la santé et de la recherche médicale, UMRS 1138, Team 1, Centre de Recherche des Cordeliers, Sorbonne University, Paris Descartes University, Paris, France.
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22
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Martin N, Manoharan K, Thomas J, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2018; 6:CD012721. [PMID: 29952095 PMCID: PMC6513293 DOI: 10.1002/14651858.cd012721.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction. There is uncertainty whether these treatments are beneficial for people with heart failure with preserved ejection fraction and a comprehensive review of the evidence is required. OBJECTIVES To assess the effects of beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with heart failure with preserved ejection fraction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trial registries on 25 July 2017 to identify eligible studies. Reference lists from primary studies and review articles were checked for additional studies. There were no language or date restrictions. SELECTION CRITERIA We included randomised controlled trials with a parallel group design enrolling adult participants with heart failure with preserved ejection fraction, defined by a left ventricular ejection fraction of greater than 40 percent. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion and extracted data. The outcomes assessed included cardiovascular mortality, heart failure hospitalisation, hyperkalaemia, all-cause mortality and quality of life. Risk ratios (RR) and, where possible, hazard ratios (HR) were calculated for dichotomous outcomes. For continuous data, mean difference (MD) or standardised mean difference (SMD) were calculated. We contacted trialists where neccessary to obtain missing data. MAIN RESULTS 37 randomised controlled trials (207 reports) were included across all comparisons with a total of 18,311 participants.Ten studies (3087 participants) investigating beta-blockers (BB) were included. A pooled analysis indicated a reduction in cardiovascular mortality (15% of participants in the intervention arm versus 19% in the control arm; RR 0.78; 95% confidence interval (CI) 0.62 to 0.99; number needed to treat to benefit (NNTB) 25; 1046 participants; 3 studies). However, the quality of evidence was low and no effect on cardiovascular mortality was observed when the analysis was limited to studies with a low risk of bias (RR 0.81; 95% CI 0.50 to 1.29; 643 participants; 1 study). There was no effect on all-cause mortality, heart failure hospitalisation or quality of life measures, however there is uncertainty about these effects given the limited evidence available.12 studies (4408 participants) investigating mineralocorticoid receptor antagonists (MRA) were included with the quality of evidence assessed as moderate. MRA treatment reduced heart failure hospitalisation (11% of participants in the intervention arm versus 14% in the control arm; RR 0.82; 95% CI 0.69 to 0.98; NNTB 41; 3714 participants; 3 studies; moderate-quality evidence) however, little or no effect on all-cause and cardiovascular mortality and quality of life measures was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% of participants in the intervention group versus 8% in the control group; RR 2.11; 95% CI 1.77 to 2.51; 4291 participants; 6 studies; high-quality evidence).Eight studies (2061 participants) investigating angiotensin converting enzyme inhibitors (ACEI) were included with the overall quality of evidence assessed as moderate. The evidence suggested that ACEI treatment likely has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. Data for the effect of ACEI on hyperkalaemia were only available from one of the included studies.Eight studies (8755 participants) investigating angiotensin receptor blockers (ARB) were included with the overall quality of evidence assessed as high. The evidence suggested that treatment with ARB has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% of participants in the intervention group versus 0.5% in the control group; RR 1.88; 95% CI 1.07 to 3.33; 7148 participants; 2 studies; high-quality evidence).We identified a single ongoing placebo-controlled study investigating the effect of angiotensin receptor neprilysin inhibitors (ARNI) in people with heart failure with preserved ejection fraction. AUTHORS' CONCLUSIONS There is evidence that MRA treatment reduces heart failure hospitalisation in heart failure with preserverd ejection fraction, however the effects on mortality related outcomes and quality of life remain unclear. The available evidence for beta-blockers, ACEI, ARB and ARNI is limited and it remains uncertain whether these treatments have a role in the treatment of HFpEF in the absence of an alternative indication for their use. This comprehensive review highlights a persistent gap in the evidence that is currently being addressed through several large ongoing clinical trials.
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Affiliation(s)
- Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Karthick Manoharan
- John Radcliffe HospitalEmergency Department3 Sherwood AvenueLondonMiddlesexUKUb6 0pg
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of EducationLondonUK
| | - Ceri Davies
- Barts Heart Centre, St Bartholomew's HospitalDepartment of CardiologyWest SmithfieldLondonUKEC1A 7BE
| | - R Thomas Lumbers
- University College LondonInstitute of Health InformaticsLondonUK
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23
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Grodin JL, Testani JM, Pandey A, Sambandam K, Drazner MH, Fang JC, Tang WW. Perturbations in serum chloride homeostasis in heart failure with preserved ejection fraction: insights from TOPCAT. Eur J Heart Fail 2018; 20:1436-1443. [DOI: 10.1002/ejhf.1229] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/05/2018] [Revised: 04/21/2018] [Accepted: 05/08/2018] [Indexed: 01/17/2023] Open
Affiliation(s)
- Justin L. Grodin
- Division of Cardiology, Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Jeffrey M. Testani
- Section of Cardiovascular Medicine; Yale University School of Medicine; New Haven CT USA
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Kamalanathan Sambandam
- Division of Nephrology, Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - Mark H. Drazner
- Division of Cardiology, Department of Internal Medicine; University of Texas Southwestern Medical Center; Dallas TX USA
| | - James C. Fang
- Division of Cardiovascular Medicine; University of Utah Health Sciences Center; Salt Lake City UT USA
| | - W.H. Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic; Cleveland OH USA
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24
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Rossignol P, Ferreira JP, Zannad F. Fibrosis mechanistic phenotyping and antifibrotic response determination with biomarkers in heart failure: one single biomarker may not fit all settings. Eur J Heart Fail 2018; 20:1300-1302. [PMID: 29851257 DOI: 10.1002/ejhf.1214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Patrick Rossignol
- Université de Lorraine, Inserm, Centre, d'Investigations Cliniques-Plurithématique 14-33, and Inserm U1116, Nancy CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre, d'Investigations Cliniques-Plurithématique 14-33, and Inserm U1116, Nancy CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre, d'Investigations Cliniques-Plurithématique 14-33, and Inserm U1116, Nancy CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
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25
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Girerd S, Jaisser F. Mineralocorticoid receptor antagonists in kidney transplantation: time to consider? Nephrol Dial Transplant 2018; 33:2080-2091. [DOI: 10.1093/ndt/gfy065] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2017] [Accepted: 02/27/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Sophie Girerd
- Transplant Unit, Nephrology Department, Nancy University Hospital, Lorraine University, Vandoeuvre-lès-Nancy, France
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
| | - Frédéric Jaisser
- INSERM U1116, Clinical Investigation Centre, Lorraine University, Vandoeuvre-lès-Nancy, France
- INI-CRCT (Cardiovascular and Renal Clinical Trialists) F-CRIN Network, Nancy, France
- INSERM, UMRS 1138, Team 1, Centre de Recherche des Cordeliers, Pierre et Marie Curie University, Paris Descartes University, Paris, France
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26
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Anand IS, Claggett B, Liu J, Shah AM, Rector TS, Shah SJ, Desai AS, O'Meara E, Fleg JL, Pfeffer MA, Pitt B, Solomon SD. Interaction Between Spironolactone and Natriuretic Peptides in Patients With Heart Failure and Preserved Ejection Fraction: From the TOPCAT Trial. JACC-HEART FAILURE 2018; 5:241-252. [PMID: 28359411 DOI: 10.1016/j.jchf.2016.11.015] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 11/23/2016] [Accepted: 11/28/2016] [Indexed: 01/09/2023]
Abstract
OBJECTIVES The aims of this study were to explore the relationship of baseline levels of natriuretic peptides (NPs) with outcomes and to test for an interaction between baseline levels of NPs and the effects spironolactone. BACKGROUND Plasma NPs are considered to be helpful in the diagnosis of heart failure (HF) with preserved ejection fraction (HFpEF), and elevated levels are associated with adverse outcomes. Levels of NPs higher than certain cutoffs are often used as inclusion criteria in clinical trials of HFpEF to increase the likelihood that patients have HF and to select patients at higher risk for events. Whether treatments have a differential effect on outcomes across the spectrum of NP levels is unclear. METHODS The TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial) trial randomized patients with HFpEF and either prior hospitalization for HF or elevated natriuretic peptide levels (B-type NP [BNP] ≥100 pg/ml or N-terminal proBNP ≥360 pg/ml) to spironolactone or placebo. Baseline BNP (n = 430) or N-terminal proBNP (n = 257) levels were available in 687 patients enrolled from the Americas in the elevated-NP stratum of TOPCAT. RESULTS Higher levels of NPs were independently associated with an increased risk for TOPCAT's primary endpoint of cardiovascular mortality, aborted cardiac arrest, or hospitalization for HF when analyzed either continuously or grouped by terciles, adjusting for region of enrollment, age, sex, atrial fibrillation, diabetes, renal function, body mass index, and heart rate. There was a significant interaction between the effect of spironolactone and baseline NP terciles for the primary outcome (p = 0.017), with greater benefit of the drug in the lower compared with higher NP terciles. CONCLUSIONS Similar to the effects of irbesartan in the I-PRESERVE (Irbesartan in Heart Failure With Preserved Ejection Fraction) trial, a greater benefit of spironolactone was observed in the group with lower levels of NPs and overall risk in TOPCAT. Elevated NPs in HFpEF identify patients at higher risk for events but who may be less responsive to treatment. The mechanism of this apparent interaction between disease severity and response to therapy requires further exploration. (Aldosterone Antagonist Therapy for Adults With Heart Failure and Preserved Systolic Function [TOPCAT]; NCT00094302).
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Affiliation(s)
- Inder S Anand
- VA Medical Center and University of Minnesota, Minneapolis, Minnesota.
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Amil M Shah
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Thomas S Rector
- VA Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - Sanjiv J Shah
- Cardiology Division, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | | | - Jerome L Fleg
- National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
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27
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Lund LH, Køber L, Swedberg K, Ruschitzka F. The year in cardiology 2017: heart failure. Eur Heart J 2018; 39:832-839. [DOI: 10.1093/eurheartj/ehx782] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Accepted: 12/18/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- Lars H Lund
- FoU Tema Hjärta Kärl, Norrbacka, S1: 02, 17176 Stockholm, Sweden
- Department of Medicine, Karolinska Institutet, Heart and Vascular Theme, Karolinska University Hospital, Stockholm, 171776 Stockholm, Sweden
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, University of Copenhagen, København Ø, Denmark
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, 405 30 Gothenburg, Sweden
- National Heart and Lung Institute, Imperial College, London SW7 2AZ, UK
| | - Frank Ruschitzka
- University Heart Centre Zurich, Rämistrasse 100, 8091 Zürich, Switzerland
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28
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Metra M. August 2017 at a glance: tailored treatment, acute heart failure and cardiac resynchronization. Eur J Heart Fail 2017; 19:969-970. [DOI: 10.1002/ejhf.936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Revised: 06/05/2017] [Accepted: 06/08/2017] [Indexed: 12/15/2022] Open
Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health; University of Brescia; Italy
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29
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Ferreira JP, Mentz RJ, Pizard A, Pitt B, Zannad F. Tailoring mineralocorticoid receptor antagonist therapy in heart failure patients: are we moving towards a personalized approach? Eur J Heart Fail 2017; 19:974-986. [DOI: 10.1002/ejhf.814] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/02/2016] [Revised: 12/30/2016] [Accepted: 02/21/2017] [Indexed: 12/28/2022] Open
Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116; University of Lorraine; Nancy France
- Department of Physiology and Cardiothoracic Surgery; Cardiovascular Research and Development Unit, Faculty of Medicine, University of Porto; Porto Portugal
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Department of Medicine; Duke University Medical Center; Durham NC USA
| | - Anne Pizard
- Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116; University of Lorraine; Nancy France
| | - Bertram Pitt
- Department of Cardiology; University of Michigan School of Medicine; Ann Arbor MI USA
| | - Faiez Zannad
- Centre d'Investigation Clinique Plurithématique 1433, INSERM U1116; University of Lorraine; Nancy France
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30
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Zannad F. Monitoring renal safety in mineralocorticoid receptor antagonist trials. Eur J Heart Fail 2017; 19:466-468. [PMID: 28371142 DOI: 10.1002/ejhf.764] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2016] [Accepted: 12/31/2016] [Indexed: 11/05/2022] Open
Affiliation(s)
- Faiez Zannad
- Inserm, Clinical Investigation Centre 1433, University of Lorraine and CHRU, Nancy, France
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