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Sze S, Pellicori P, Zhang J, Weston J, Clark AL. Which frailty tool best predicts morbidity and mortality in ambulatory patients with heart failure? A prospective study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:731-739. [PMID: 36385564 DOI: 10.1093/ehjqcco/qcac073] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Revised: 11/04/2022] [Accepted: 11/15/2022] [Indexed: 11/08/2023]
Abstract
BACKGROUND Frailty is common in patients with heart failure (HF) and is associated with adverse outcome, but it is uncertain how frailty should best be measured. OBJECTIVES To compare the prognostic value of commonly-used frailty tools in ambulatory patients with HF. METHODS AND RESULTS We assessed, simultaneously, three screening tools [clinical frailty scale (CFS); Derby frailty index (DFI); acute frailty network (AFN) frailty criteria), three assessment tools (Fried criteria; Edmonton frailty score (EFS); deficit index (DI)) and three physical tests (handgrip strength, timed get-up-and-go test (TUGT), 5-metre walk test (5MWT)] in consecutive patients with HF attending a routine follow-up visit. 467 patients (67% male, median age = 76 years, median NT-proBNP = 1156 ng/L) were enrolled. During a median follow-up of 554 days, 82 (18%) patients died and 201 (43%) patients were either hospitalised or died. In models corrected for age, Charlson score, haemoglobin, renal function, sodium, NYHA, atrial fibrillation (AF), and body mass index, only log[NT-proBNP] and frailty were independently associated with all-cause death. A base model for predicting mortality at 1 year including NYHA, log[NT-proBNP], sodium and AF, had a C-statistic = 0.75. Amongst screening tools: CFS (C-statistic = 0.84); amongst assessment tools: DI (C-statistic = 0.83) and amongst physical test: 5MWT (C-statistic = 0.80), increased model performance most compared with base model (P <0.05 for all). CONCLUSION Frailty is strongly associated with adverse outcomes in ambulatory patients with HF. When added to a base model for predicting mortality at 1 year including NYHA, NT-proBNP, sodium, and AF, CFS provides comparable prognostic information with assessment tools taking longer to perform.
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Affiliation(s)
- Shirley Sze
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, HU16 5JQ, UK
- Cardiovascular Research Centre, University of Leicester, Glenfield Hospital, Groby Road, Leicester, LE3 9QP, UK
| | - Pierpaolo Pellicori
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, HU16 5JQ, UK
- Robertson Centre for Biostatistics & Clinical Trials, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Jufen Zhang
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, HU16 5JQ, UK
- Faculty of Medical Science, Anglia Ruskin University, Cambridge, CB1 1PT, UK
| | - Joan Weston
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, HU16 5JQ, UK
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, HU16 5JQ, UK
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Jain A, Meyur S, Wadhwa L, Singh K, Sharma R, Panchal I, Varrassi G. Effects of Angiotensin Receptor-Neprilysin Inhibitors Versus Enalapril or Valsartan on Patients With Heart Failure: A Systematic Review and Meta-Analysis. Cureus 2023; 15:e41566. [PMID: 37554618 PMCID: PMC10405977 DOI: 10.7759/cureus.41566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 07/07/2023] [Indexed: 08/10/2023] Open
Abstract
Recent studies have focused on treating heart failure, primarily mitigating symptoms and reducing the risk of mortality and other cardiovascular complications. A promising new treatment approach involves using LCZ696, an angiotensin receptor-neprilysin inhibitor (ARNI) comprising sacubitril and valsartan. This treatment is superior to the conventional drugs enalapril or valsartan in patients diagnosed with heart failure. A systematic search was conducted on PubMed, the Cochrane Library, and Elsevier's ScienceDirect databases to identify studies comparing sacubitril/valsartan with other drugs in heart failure patients with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). The analyses were conducted using the random-effects model. The study's primary outcomes included all-cause mortality, death from cardiovascular causes, first hospitalization for heart failure, congestive heart failure, and changes in the Kansas City Cardiomyopathy Questionnaire (KCCQ) clinical score. The pooled analysis showed that treatment with the sacubitril/valsartan combination was associated with a significantly decreased rate of first hospitalization for heart failure (RR: 0.86; 95% CI: 0.79, 0.98, p: 0.03; I2: 57%) and significantly increased KCCQ clinical score (WMD: 2.20; 95% CI: 0.33, 4.06, p: 0.02; I2: 100%). However, the two groups had no significant difference in all-cause mortality (RR: 0.90; 95% CI: 0.80, 1.01, p: 0.08; I2: 20%), death from cardiovascular causes (RR: 0.96; 95% CI: 0.87, 1.05, p: 0.34; I2: 0%), or congestive heart failure (RR: 0.97; 95% CI: 0.75, 1.25, p: 0.19; I2: 38%). The research findings suggest that sacubitril/valsartan (LCZ696) reduces hospitalizations due to heart failure and improves KCCQ clinical scores. This treatment also reduces the decline in renal function and side effects associated with enalapril or valsartan. Nonetheless, further high-quality randomized controlled trials with large sample sizes are needed to assess other impacts of this therapy on heart failure patients. Overall, the use of LCZ696 represents a promising new approach to the treatment of heart failure.
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Affiliation(s)
- Arpit Jain
- Emergency Medicine, All India Institute of Medical Sciences, New Delhi, New Delhi, IND
| | - Shourya Meyur
- Medicine, AMA School of Medicine, Makati, PHL
- Internal Medicine, Sambhunath Pandit Hospital, Kolkata, IND
| | | | - Kamaldeep Singh
- Cardiology, Government Medical College & Hospital, Chandigarh, IND
- Internal Medicine, Jawaharlal Nehru Medical College, Chandigarh, IND
| | - Rishi Sharma
- Medicine, D. Y. Patil Medical College, D. Y. Patil Education Society Deemed University, Kolhapur, IND
| | - Ishita Panchal
- Internal Medicine, Jawaharlal Nehru Medical College, Belagavi, IND
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Alcidi G, Goffredo G, Correale M, Brunetti ND, Iacoviello M. Brain Natriuretic Peptide Biomarkers in Current Clinical and Therapeutic Scenarios of Heart Failure. J Clin Med 2022; 11:jcm11113192. [PMID: 35683578 PMCID: PMC9181765 DOI: 10.3390/jcm11113192] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Revised: 05/23/2022] [Accepted: 06/01/2022] [Indexed: 01/25/2023] Open
Abstract
Brain natriuretic peptide (BNP) and its inactive N-terminal fragment, NT-proBNP, are serum biomarkers with key roles in the management of heart failure (HF). An increase in the serum levels of these peptides is closely associated with the pathophysiological mechanisms underlying HF such as the presence of structural and functional cardiac abnormalities, myocardial stretch associated with a high filling pressure and neuro-hormonal activation. As BNP and NT-proBNP measurements are possible, several studies have investigated their clinical utility in the diagnosis, prognostic stratification, monitoring and guiding therapy of patients with HF. BNP and NT-proBNP have also been used as criteria for enrollment in randomized trials evaluating the efficacy of new therapeutic strategies for HF. Nevertheless, the use of natriuretic peptides is still limited in clinical practice due to the controversial aspect of their use in different clinical settings. The purpose of this review is to discuss the main issues associated with using BNP and NT-proBNP serum levels in the management of patients with HF under current clinical and therapeutic scenarios.
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Affiliation(s)
- Gianmarco Alcidi
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Giovanni Goffredo
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
- Correspondence: (G.G.); (M.I.)
| | - Michele Correale
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Natale Daniele Brunetti
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
| | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, University of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy; (G.A.); (M.C.); (N.D.B.)
- Cardiology Unit, Polyclinic University Hospital Riuniti of Foggia, Viale Luigi Pinto 1, 71122 Foggia, Italy
- Correspondence: (G.G.); (M.I.)
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4
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Pellicori P, Cleland JGF. Heart failure: age is no excuse for complacency. Eur J Heart Fail 2022; 24:1063-1065. [PMID: 35481861 DOI: 10.1002/ejhf.2517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - John G F Cleland
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
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Girerd N, Von Hunolstein J, Pellicori P, Bayés‐Genís A, Jaarsma T, Lund LH, Bilbault P, Boivin J, Chouihed T, Costa J, Eicher J, Fall E, Kenizou D, Maillier B, Nazeyrollas P, Roul G, Zannad N, Rossignol P, Seronde M. Therapeutic inertia in the pharmacological management of heart failure with reduced ejection fraction. ESC Heart Fail 2022; 9:2063-2069. [PMID: 35429120 PMCID: PMC9288781 DOI: 10.1002/ehf2.13929] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 03/28/2022] [Indexed: 12/24/2022] Open
Affiliation(s)
- Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques‐Plurithématique 1433, CHRU Nancy, and INSERM U1116, CHRU F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists) 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy France
| | | | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing University of Glasgow Glasgow UK
| | - Antoni Bayés‐Genís
- CIBERCV, Servicio de Cardiología, Hospital Germans Trias i Pujol Universitat Autònoma de Barcelona Barcelona Spain
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Linköping University Linköping Sweden
| | - Lars H. Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology Karolinska University Hospital Stockholm Sweden
| | - Pascal Bilbault
- Emergency Department Hôpitaux Universitaires de Strasbourg Strasbourg France
- INSERM (French National Institute of Health and Medical Research), UMR 1260, Regenerative NanoMedicine (RNM), Fédération de Médecine Translationnelle (FMTS) University of Strasbourg Strasbourg France
| | - Jean‐Marc Boivin
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques‐Plurithématique 1433, CHRU Nancy, and INSERM U1116, CHRU F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists) 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy France
- Université de Lorraine, APEMAC, équipe MICS Nancy France
| | - Tahar Chouihed
- Emergency Department University Hospital of Nancy Nancy France
- INSERM, UMRS 1116 University Hospital of Nancy Nancy France
| | - Jérôme Costa
- Pôle vasculaire, service de cardiologie, centre hospitalo‐universitaire de Reims Reims France
| | | | | | - David Kenizou
- Department of Cardiology Hôpital Emile Muller Mulhouse France
| | - Bruno Maillier
- Service de cardiologie Centre hospitalier de Troyes Troyes France
| | - Pierre Nazeyrollas
- Pôle vasculaire, service de cardiologie, centre hospitalo‐universitaire de Reims Reims France
| | - Gérald Roul
- Unité Fonctionnelle Dédiée à L'insuffisance Cardiaque, Pôle Médical et Chirurgical des Maladies Cardio‐vasculaires Hôpitaux Universitaires de Strasbourg Strasbourg France
| | - Noura Zannad
- Department of Cardiology Regional Hospital, Mercy Hospital Metz France
| | - Patrick Rossignol
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques‐Plurithématique 1433, CHRU Nancy, and INSERM U1116, CHRU F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists) 4 Rue du Morvan, 54500 Vandoeuvre lès Nancy France
| | - Marie‐France Seronde
- Department of Cardiology University Hospital Besançon Besançon France
- EA3920 University of Burgundy Franche‐Comté Besançon Besançon France
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Radhoe SP, Veenis JF, Linssen GC, van der Lee C, Eurlings LW, Kragten H, Al‐Windy NY, van der Spank A, Koudstaal S, Brunner‐La Rocca H, Brugts JJ. Diabetes and treatment of chronic heart failure in a large real-world heart failure population. ESC Heart Fail 2022; 9:353-362. [PMID: 34862765 PMCID: PMC8788034 DOI: 10.1002/ehf2.13743] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 11/06/2021] [Accepted: 11/17/2021] [Indexed: 12/11/2022] Open
Abstract
AIMS Although diabetes mellitus (DM) is a common co-morbidity in chronic heart failure (HF) patients, European data on concurrent HF and DM treatment are lacking. Therefore, we have studied the HF treatment of patients with and without DM. Additionally, with the recent breakthrough of sodium-glucose cotransporter 2 (SGLT2) inhibitors in the field of HF, we studied the potential impact of this new drug in a large cohort of HF patients. METHODS AND RESULTS A total of 7488 patients with chronic HF with a left ventricular ejection fraction <50% from 34 Dutch outpatient HF clinics between 2013 and 2016 were analysed on diabetic status and background HF therapy. Average age of the total population was 72.8 years (±11.7 years), and 64% of the patients were male. Diabetes was present in 29% of the patients (N = 2174). Diabetics had a worse renal function (mean estimated glomerular filtration rate 56 vs. 61 mL/min/1.73 m2 , P < 0.001). Renin-angiotensin system inhibitors were less often prescribed in diabetics compared with non-diabetics (79% vs. 82%, P = 0.001), while no significant differences regarding other guideline-recommended HF drugs were found. Target doses of beta-blockers (23% vs. 16%, P < 0.001), renin-angiotensin system inhibitors (47% vs. 43%, P = 0.009), and mineralocorticoid receptor antagonists (57% vs. 51%, P = 0.005) were more often prescribed in diabetics than non-diabetics. Based on the latest trials on SGLT2 inhibitors, 31-64% of all HF patients would fulfil the eligibility or enrichment criteria (with vs. without N-terminal prohormone BNP criterion). CONCLUSIONS In this large real-world HF registry, a high prevalence of DM was observed and diabetics more often received guideline-recommended target doses. Based on current evidence, the majority of patients would fulfil the enrichment criteria of SGLT2 trials in HF and the impact of this new drug class will be large.
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Affiliation(s)
- Sumant P. Radhoe
- Department of Cardiology, Thorax CenterErasmus MC, University Medical Center RotterdamDr. Molewaterplein 40Rotterdam3015GDThe Netherlands
| | - Jesse F. Veenis
- Department of Cardiology, Thorax CenterErasmus MC, University Medical Center RotterdamDr. Molewaterplein 40Rotterdam3015GDThe Netherlands
| | - Gerard C.M. Linssen
- Department of CardiologyHospital Group TwenteAlmelo and HengeloThe Netherlands
| | - Chris van der Lee
- Department of CardiologyStreekziekenhuis Koningin BeatrixWinterswijkThe Netherlands
| | | | - Hans Kragten
- Department of CardiologyZuyderland Medisch CentrumHeerlenThe Netherlands
| | | | | | - Stefan Koudstaal
- Department of CardiologyUniversity Medical Center Utrecht and Utrecht UniversityUtrechtThe Netherlands
| | | | - Jasper J. Brugts
- Department of Cardiology, Thorax CenterErasmus MC, University Medical Center RotterdamDr. Molewaterplein 40Rotterdam3015GDThe Netherlands
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7
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Cabral J, Vasconcelos H, Maia-Araújo P, Moreira E, Campelo M, Amorim S, Sousa A, Moura B, Pinto R, Dias C, Silva-Cardoso J. Sacubitril/valsartan in everyday clinical practice: an observational study based on the experience of a heart failure clinic. Cardiovasc Diagn Ther 2021; 11:1217-1227. [PMID: 35070791 PMCID: PMC8748480 DOI: 10.21037/cdt-21-312] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2021] [Accepted: 09/29/2021] [Indexed: 12/10/2023]
Abstract
BACKGROUND Heart failure (HF) is a growing public health problem. Sacubitril/valsartan is now recommended to be used in persistently symptomatic patients with left ventricular ejection fraction (LVEF) <40%, replacing angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs). In the present study, we aimed to characterise the challenges of sacubitril/valsartan use in everyday clinical practice. METHODS We assessed the medical records of patients with HF and reduced ejection fraction eligible for sacubitril/valsartan attending a HF clinic at a Portuguese University Hospital during 2018 (n=152). The number of eligible patients receiving the drug and the reasons for not prescribing sacubitril/valsartan were evaluated. Additionally, we assessed the tolerability of maximal doses of sacubitril/valsartan. New York Heart Association functional class (NYHA class) and LVEF before and after up-titration to maximal tolerated sacubitril/valsartan dose were compared. Median follow-up was 41 months. RESULTS Of the 152 included patients, 75 (49%) were prescribed the drug. The two main reasons for non-prescription were patient financial barriers (31%) and hypotension (27%). Only 33% of patients on sacubitril/valsartan did reach maximal dose. Hypotension was the main limiting factor for dose optimisation. Duration of sacubitril/valsartan treatment showed a positive association with LVEF improvement during follow-up (6.6% absolute LVEF increase/year). NYHA functional class improved significantly from baseline through the end of follow-up. CONCLUSIONS In every-day clinical practice, although sacubitril/valsartan was associated with a marked improvement in NYHA class and in LVEF, important financial and clinical barriers to the implementation of this therapy were identified.
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Affiliation(s)
- Joana Cabral
- Faculty of Medicine, University of Porto, Porto, Portugal
- CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
| | - Henrique Vasconcelos
- Faculty of Medicine, University of Porto, Porto, Portugal
- CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
| | - Paulo Maia-Araújo
- CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Emília Moreira
- CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Manuel Campelo
- CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Sandra Amorim
- CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Alexandra Sousa
- CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Cardiology, Hospital Santa Maria Maior, Barcelos, Portugal
| | - Brenda Moura
- CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Cardiology, Hospital das Forças Armadas, Polo do Porto, Porto, Portugal
| | - Roberto Pinto
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Biomedicine, Faculty of Medicine, University of Porto, Porto, Portugal
| | - Camila Dias
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
- Department of Community Medicine, Information and Health Decision Sciences, Faculty of Medicine, University of Porto, Porto, Portugal
| | - José Silva-Cardoso
- CINTESIS-Center for Health Technology and Services Research, Porto, Portugal
- Department of Cardiology, Centro Hospitalar Universitário de São João, Porto, Portugal
- Department of Medicine, Faculty of Medicine, University of Porto, Porto, Portugal
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8
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Abel AAI, Clark AL. Long-Term Pharmacological Management of Reduced Ejection Fraction Following Acute Myocardial Infarction: Current Status and Future Prospects. Int J Gen Med 2021; 14:7797-7805. [PMID: 34795500 PMCID: PMC8593493 DOI: 10.2147/ijgm.s294896] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2021] [Accepted: 10/26/2021] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) with reduced ejection fraction is common following acute myocardial infarction (MI), and active medical management can have a profound impact on prognosis. Reviewing relevant clinical trials, we focus on the pharmacological management of left ventricular systolic dysfunction (LVSD) following an acute MI, although there is overlap with the pharmacological management of chronic HF due to reduced ejection fraction. Angiotensin converting enzyme (ACE) inhibitors, beta-blockers, and mineralocorticoid receptor antagonists are the mainstay of medical management in patients with LVSD post MI; there may also be a role for anticoagulation. Sacubitril-valsartan (angiotensin receptor neprilysin inhibitor) has not yet been shown to be superior to an ACE inhibitor in reducing cardiovascular mortality and HF events in patients with LVSD post MI. Large randomised trials evaluating sodium glucose transporter 2 (SGLT-2) inhibitors in LVSD post MI are ongoing.
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Affiliation(s)
- Alexandra A I Abel
- Department of Academic Cardiology, Castle Hill Hospital, Kingston Upon Hull, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Castle Hill Hospital, Kingston Upon Hull, UK
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9
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Sodium-glucose co-transporter-2 inhibitors eligibility in patients with heart failure with reduced ejection fraction. Int J Cardiol 2021; 341:56-59. [PMID: 34454968 DOI: 10.1016/j.ijcard.2021.08.035] [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: 07/15/2021] [Revised: 08/17/2021] [Accepted: 08/23/2021] [Indexed: 12/21/2022]
Abstract
BACKGROUND The sodium-glucose co-transporter-2 (SGLT2) inhibitors dapagliflozin and empagliflozin have been demonstrated to reduce adverse cardiovascular outcomes in patients with heart failure with reduced ejection fraction (HFrEF). Limited data are available characterizing the generalizability of SGLT2 inhibitors treatment in the clinical practice. The aim of the study was to evaluate the proportion of outpatients with HFrEF that would be eligible for SGLT2 inhibitors in a contemporary real-world population. METHODS We retrospectively evaluated patients with chronic stable HFrEF followed-up at the HF outpatient clinic of our institution. Patients' eligibility was assessed according to the entry criteria of DAPA-HF (dapagliflozin) and EMPEROR-Reduced (empagliflozin) trials and to US Food and Drug Administration (FDA) label criteria (only dapagliflozin). RESULTS A total of 441 HFrEF patients was enrolled. According to the major inclusion and exclusion criteria from DAPA-HF and EMPEROR-Reduced trials, 198 (45%) patients would be candidates for initiation of both dapagliflozin and empagliflozin, 61 (14%) would be eligible only to dapagliflozin and 23 (5%) only to empagliflozin, without significant differences between diabetic and non-diabetic patients (p = 0.23). Among patients not suitable for gliflozins treatment (159 patients; 36%), the major determinant of ineligibility was the failure to achieve the predefined NT-proBNP inclusion threshold. Excluding NTproBNP as per FDA label criteria, dapagliflozin eligibility increased to 86%. CONCLUSIONS In our real-world analysis a large proportion of HFrEF patients would be candidates for initiation of SGLT2 inhibitors, supporting its broad generalizability in clinical practice. This would be expected to reduce morbidity and mortality in eligible patients.
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Giovinazzo S, Carmisciano L, Toma M, Benenati S, Tomasoni D, Sormani MP, Porto I, Canepa M, Senni M, Metra M, Ameri P. Sacubitril/valsartan in real-life European patients with heart failure and reduced ejection fraction: a systematic review and meta-analysis. ESC Heart Fail 2021; 8:3547-3556. [PMID: 34338429 PMCID: PMC8497227 DOI: 10.1002/ehf2.13547] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 06/22/2021] [Accepted: 07/16/2021] [Indexed: 01/13/2023] Open
Abstract
AIMS We systematically reviewed the European real-world evidence (RWE) about sacubitril-valsartan for heart failure with reduced ejection fraction. METHODS AND RESULTS Twenty-one articles, including 16 952 subjects, were identified until 31 October 2020. Taking as reference the PARADIGM-HF cohort, few baseline characteristics were presented in >80% of these studies, most often with high heterogeneity. In random-effects model meta-analysis, age was higher (mean difference +3.84, 95% CI 1.92-5.76), ischaemic aetiology (OR 0.76, 95% CI 0.64-0.91), hypertension (OR 0.55, 95% CI 0.37-0.82), and diabetes (OR 0.77, 95% CI 0.64-0.92) were less common, and the use of mineralocorticoid receptor antagonists was more frequent (OR 3.54, 95% CI 2.27-5.53) in real-life than in PARADIGM-HF. Other clinical and medical features were presented in 19-76% of the selected publications and suggested more severe heart failure with reduced ejection fraction. Sacubitril-valsartan was titrated to 97/103 mg b.i.d. in 35% (95% CI 23-47) and discontinued in 12.8% (95% CI 7.4-18.3) patients. When reported, the incidence of hyperkalaemia (six studies, no. 1076), all-cause mortality (five studies, no. 684), and any hospitalization (three studies, no. 390) was 12 (95% CI 5-19)/100 person-year, 8 (95% CI 4-12)/100 person-year, and 24 (95% CI 5-42)/100 person-year, respectively. Knowledge contribution, a metric measuring the proportion of RWE provided by each article based on the number of reported variables and the sample size, was 58.8% and 13.6% for the two biggest investigations (12 082 and 2037 patients), and <5% for all others (most with <100 subjects). CONCLUSIONS Limited-quality RWE indicates that there are important differences between European patients prescribed sacubitril-valsartan and the PARADIGM-HF population, including the frequency of target dose achievement.
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Affiliation(s)
- Stefano Giovinazzo
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genoa, Italy
| | - Luca Carmisciano
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Matteo Toma
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genoa, Italy
| | - Stefano Benenati
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genoa, Italy.,Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Daniela Tomasoni
- Cardiology Unit, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Maria Pia Sormani
- Department of Health Sciences, Section of Biostatistics, University of Genova, Genoa, Italy
| | - Italo Porto
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genoa, Italy.,Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Marco Canepa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genoa, Italy.,Department of Internal Medicine, University of Genova, Genoa, Italy
| | - Michele Senni
- Cardiology Division, Cardiovascular Department, Ospedale Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Metra
- Cardiology Unit, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Pietro Ameri
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, IRCCS Italian Cardiology Network, Genoa, Italy.,Department of Internal Medicine, University of Genova, Genoa, Italy
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11
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Seferović PM, Vardas P, Jankowska EA, Maggioni AP, Timmis A, Milinković I, Polovina M, Gale CP, Lund LH, Lopatin Y, Lainscak M, Savarese G, Huculeci R, Kazakiewicz D, Coats AJS. The Heart Failure Association Atlas: Heart Failure Epidemiology and Management Statistics 2019. Eur J Heart Fail 2021; 23:906-914. [PMID: 33634931 DOI: 10.1002/ejhf.2143] [Citation(s) in RCA: 124] [Impact Index Per Article: 41.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 02/17/2021] [Accepted: 02/23/2021] [Indexed: 12/15/2022] Open
Abstract
AIMS The Heart Failure Association (HFA) of the European Society of Cardiology (ESC) developed the HFA Atlas to provide a contemporary description of heart failure (HF) epidemiology, resources, reimbursement of guideline-directed medical therapy (GDMT) and activities of the National Heart Failure Societies (NHFS) in ESC member countries. METHODS AND RESULTS The HFA Atlas survey was conducted in 2018-2019 in 42 ESC countries. The quality and completeness of source data varied across countries. The median incidence of HF was 3.20 [interquartile range (IQR) 2.66-4.17] cases per 1000 person-years, ranging from ≤2 in Italy and Denmark to >6 in Germany. The median HF prevalence was 17.20 (IQR 14.30-21) cases per 1000 people, ranging from ≤12 in Greece and Spain to >30 in Lithuania and Germany. The median number of HF hospitalizations was 2671 (IQR 1771-4317) per million people annually, ranging from <1000 in Latvia and North Macedonia to >6000 in Romania, Germany and Norway. The median length of hospital stay for an admission with HF was 8.50 (IQR 7.38-10) days. Diagnostic and management resources for HF varied, with high-income ESC member countries having substantially more resources compared with middle-income countries. The median number of hospitals with dedicated HF centres was 1.16 (IQR 0.51-2.97) per million people, ranging from <0.10 in Russian Federation and Ukraine to >7 in Norway and Italy. Nearly all countries reported full or partial reimbursement of standard GDMT, except ivabradine and sacubitril/valsartan. Almost all countries reported having NHFS or working groups and nearly half had HF patient organizations. CONCLUSIONS The first report from the HFA Atlas has shown considerable heterogeneity in HF disease burden, the resources available for its management and data quality across ESC member countries. The findings emphasize the need for a systematic approach to the capture of HF statistics so that inequalities and improvements in care may be quantified and addressed.
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Affiliation(s)
- Petar M Seferović
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Panagiotis Vardas
- Hygeia Heart Sector, Hygeia Group of Hospitals, Athens, Greece.,European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, Brussels, Belgium
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University, and Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | | | - Ivan Milinković
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Department of Cardiology, Clinical Centre of Serbia, Belgrade, Serbia
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, University of Leeds, Leeds, UK.,Leeds Institute for Data Analytics, University of Leeds, Leeds, UK.,Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Lars H Lund
- Department of Medicine, Karolinska Institute, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Yuri Lopatin
- Volgograd State Medical University, Regional Cardiology Centre Volgograd, Volgograd, Russia
| | - Mitja Lainscak
- Department of Internal Medicine, and Department of Research and Education, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institute, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Radu Huculeci
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, Brussels, Belgium
| | - Dzianis Kazakiewicz
- European Society of Cardiology Health Policy Unit, European Heart Health Institute, European Heart Agency, Brussels, Belgium
| | - Andrew J S Coats
- Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana, Rome, Italy
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12
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Moliner-Abós C, Mojón Álvarez D, Rivas-Lasarte M, Belarte LC, Pamies Besora J, Solé-González E, Fluvià-Brugues P, Zegrí-Reiriz I, López López L, Brossa V, Pirla MJ, Mesado N, Mirabet S, Roig E, Álvarez-García J. A Simple Score to Identify Super-Responders to Sacubitril/Valsartan in Ambulatory Patients With Heart Failure. Front Physiol 2021; 12:642117. [PMID: 33679455 PMCID: PMC7930570 DOI: 10.3389/fphys.2021.642117] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2020] [Accepted: 01/26/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Sacubitril/valsartan (SV) promotes cardiac remodeling and improves prognosis in patients with heart failure (HF). However, the response to the drug may vary between patients and its implementation in daily clinical practice has been slower than expected. Our objective was to develop a score predicting the super-response to SV in HF outpatients. METHODS This is a retrospective analysis of 185 consecutive patients prescribed SV from two tertiary hospitals between September 2016 and February 2018. Super-responder was defined as a patient taking the drug and (i) without HF admissions, death, or heart transplant, and (ii) with a ≥50% reduction in NT-proBNP levels and/or an increase of ≥10 points in LVEF in a 12-month follow-up period after starting SV. Clinical, echocardiographic, ECG, and biochemical variables were used in a logistic regression analysis to construct a score for super-response to SV which was internally validated using bootstrap method. RESULTS Out of 185 patients, 65 (35%) fulfilled the super-responder criteria. Predictors for super-response to SV were absence of both previous aldosterone antagonist and diuretic treatment, NYHA I-II class, female gender, previous 1-year HF admission, and sinus rhythm. An integrating score distinguished a low- (<25%), intermediate- (∼46%), and high-probability (>80%) for 1-year super-response to SV. The AUC for the model was 0.72 (95%CI: 0.64-0.80), remaining consistent after internal validation. CONCLUSION One-third of our patients presented a super-response to SV. We propose an easy-to-calculate score to predict super-response to SV after 1-year initiation based on variables that are currently assessed in clinical practice.
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Affiliation(s)
- Carles Moliner-Abós
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Mercedes Rivas-Lasarte
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Julia Pamies Besora
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Paula Fluvià-Brugues
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Isabel Zegrí-Reiriz
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Laura López López
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Vicens Brossa
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Maria José Pirla
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Nuria Mesado
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Sonia Mirabet
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Eulàlia Roig
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Jesús Álvarez-García
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Barcelona, Spain
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
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13
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Effect of frailty on treatment, hospitalisation and death in patients with chronic heart failure. Clin Res Cardiol 2021; 110:1249-1258. [PMID: 33399955 PMCID: PMC8318949 DOI: 10.1007/s00392-020-01792-w] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 12/09/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Frailty is common in patients with chronic heart failure (CHF) and is associated with poor outcomes. The natural history of frail patients with CHF is unknown. METHODS Frailty was assessed using the clinical frailty scale (CFS) in 467 consecutive patients with CHF (67% male, median age 76 years, median NT-proBNP 1156 ng/L) attending a routine follow-up visit. Those with CFS > 4 were classified as frail. We investigated the relation between frailty and treatments, hospitalisation and death in patients with CHF. RESULTS 206 patients (44%) were frail. Of 291 patients with HF with reduced ejection fraction (HeFREF), those who were frail (N = 117; 40%) were less likely to receive optimal treatment, with many not receiving a renin-angiotensin-aldosterone system inhibitor (frail: 25% vs. non-frail: 4%), a beta-blocker (16% vs. 8%) or a mineralocorticoid receptor antagonist (50% vs 41%). By 1 year, there were 56 deaths and 322 hospitalisations, of which 25 (45%) and 198 (61%), respectively, were due to non-cardiovascular (non-CV) causes. Most deaths (N = 46, 82%) and hospitalisations (N = 215, 67%) occurred in frail patients. Amongst frail patients, 43% of deaths and 64% of hospitalisations were for non-CV causes; 58% of cardiovascular (CV) deaths were due to advancing HF. Among non-frail patients, 50% of deaths and 57% of hospitalisations were for non-CV causes; all CV deaths were due to advancing HF. CONCLUSION Frailty in patients with HeFREF is associated with sub-optimal medical treatment. Frail patients are more likely to die or be admitted to hospital, but whether frail or not, many events are non-CV.
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14
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Fu M, Vedin O, Svennblad B, Lampa E, Johansson D, Dahlström U, Lindmark K, Vasko P, Lundberg A, Costa‐Scharplatz M, Lund LH. Implementation of sacubitril/valsartan in Sweden: clinical characteristics, titration patterns, and determinants. ESC Heart Fail 2020; 7:3633-3643. [PMID: 32881399 PMCID: PMC7754959 DOI: 10.1002/ehf2.12883] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/04/2020] [Accepted: 06/17/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS The aim of this study is to study the introduction of sacubitril/valsartan (sac/val) in Sweden with regards to regional differences, clinical characteristics, titration patterns, and determinants of use and discontinuation. METHODS AND RESULTS A national cohort of heart failure was defined from the Swedish Prescribed Drug Register and National Patient Register. A subcohort with additional data from the Swedish Heart Failure Registry (SwedeHF) was also studied. Cohorts were subdivided as per sac/val prescription and registration in SwedeHF. Median sac/val prescription rate was 20 per 100 000 inhabitants. Between April 2016 and December 2017, we identified 2037 patients with ≥1 sac/val prescription, of which 1144 (56%) were registered in SwedeHF. Overall, patients prescribed with sac/val were younger, more frequently male, and had less prior cardiovascular disease than non-sac/val patients. In SwedeHF subcohort, patients prescribed with sac/val had lower ejection fraction. Overall, younger age [hazard ratio 2.81 (95% confidence interval 2.45-3.22)], registration in SwedeHF [1.97 (1.83-2.12)], male gender [1.50 (1.37-1.64)], ischaemic heart disease [1.50 (1.39-1.62)], lower left ventricular ejection fraction [3.06 (2.18-4.31)], and New York Heart Association IV [1.50 (1.22-1.84)] were predictors for sac/val use. As initiation dose in the sac/val cohort, 38% received 24/26 mg, 54% 49/51 mg, and 9% 97/103 mg. Up-titration to the target dose was achieved in 57% of the overall cohort over a median follow-up of 6 months. The estimated treatment persistence for any dose at 360 days was 82%. CONCLUSIONS Implementation of sac/val in Sweden was slow and varied five-fold across different regions; younger age, male, SwedeHF registration, and ischaemic heart disease were among the independent predictors of receiving sac/val. Overall, treatment persistence and tolerability was high.
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Affiliation(s)
- Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska AcademyUniversity of GothenburgGothenburgSweden
| | - Ola Vedin
- Department of Medical Sciences, CardiologyUppsala UniversityUppsalaSweden
- Uppsala Clinical Research CenterUppsala UniversityUppsalaSweden
| | - Bodil Svennblad
- Uppsala Clinical Research CenterUppsala UniversityUppsalaSweden
| | - Erik Lampa
- Uppsala Clinical Research CenterUppsala UniversityUppsalaSweden
| | | | - Ulf Dahlström
- Department of Cardiology and Department of Medical and Health SciencesLinköping University HospitalLinköpingSweden
| | - Krister Lindmark
- Heart Centre, Department of Public Health and Clinical MedicineUmeå UniversityUmeåSweden
| | | | | | | | - Lars H. Lund
- Department of MedicineKarolinska InstitutetStockholmSweden
- Heart and Vascular ThemeKarolinska University HospitalStockholmSweden
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15
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Pellicori P, Zhang J, Cuthbert J, Urbinati A, Shah P, Kazmi S, Clark AL, Cleland JGF. High-sensitivity C-reactive protein in chronic heart failure: patient characteristics, phenotypes, and mode of death. Cardiovasc Res 2020; 116:91-100. [PMID: 31350553 DOI: 10.1093/cvr/cvz198] [Citation(s) in RCA: 49] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2019] [Revised: 06/17/2019] [Accepted: 07/19/2019] [Indexed: 12/28/2022] Open
Abstract
AIMS Plasma concentrations of high-sensitivity C-reactive protein (hsCRP) are often raised in chronic heart failure (CHF) and might indicate inflammatory processes that could be a therapeutic target. We aimed to study the associations between hsCRP, mode and cause of death in patients with CHF. METHODS AND RESULTS We enrolled 4423 patients referred to a heart failure clinic serving a local population. CHF was defined as relevant symptoms or signs with either a reduced left ventricular ejection fraction <40% or raised plasma concentrations of amino-terminal pro-B type natriuretic peptide (NT-proBNP >125 pg/mL). The median [interquartile range (IQR)] plasma hsCRP for patients diagnosed with CHF (n = 3756) was 3.9 (1.6-8.5) mg/L and 2.7 (1.3-5.1) mg/L for those who were not (n = 667; P < 0.001). Patients with hsCRP ≥10 mg/L (N = 809; 22%) were older and more congested than those with hsCRP <2 mg/L (N = 1117, 30%). During a median follow-up of 53 (IQR 28-93) months, 1784 (48%) patients with CHF died. Higher plasma hsCRP was associated with greater mortality, independent of age, symptom severity, creatinine, and NT-proBNP. Comparing a hsCRP ≥10 mg/L to <2 mg/L, the hazard ratio for all-cause mortality was 2.49 (95% confidence interval 2.19-2.84; P < 0.001), for cardiovascular (CV) mortality was 2.26 (1.91-2.68; P < 0.001), and for non-CV mortality was 2.96 (2.40-3.65; P < 0.001). CONCLUSION In patients with CHF, a raised plasma hsCRP is associated with more congestion and a worse prognosis. The proportion of deaths that are non-CV also increases with higher hsCRP.
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Affiliation(s)
- Pierpaolo Pellicori
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull HU16 5JQ, UK.,Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Jufen Zhang
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull HU16 5JQ, UK.,Faculty of Medical Science, Anglia Ruskin University, Chelmsford, UK
| | - Joe Cuthbert
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull HU16 5JQ, UK
| | - Alessia Urbinati
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull HU16 5JQ, UK
| | - Parin Shah
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull HU16 5JQ, UK
| | - Syed Kazmi
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull HU16 5JQ, UK
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull HU16 5JQ, UK
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK.,>National Heart & Lung Institute and National Institute of Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield Hospitals, Imperial College, London, UK
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16
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Cuthbert JJ, Pellicori P, Clark AL. Cardiovascular Outcomes with Sacubitril-Valsartan in Heart Failure: Emerging Clinical Data. Ther Clin Risk Manag 2020; 16:715-726. [PMID: 32848403 PMCID: PMC7425097 DOI: 10.2147/tcrm.s234772] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022] Open
Abstract
One of the defining features of heart failure (HF) is neurohormonal activation. The renin-angiotensin-aldosterone-system (RAAS) and sympathetic nervous system (SNS) cause vasoconstriction and fluid retention and, in response, the secretion of natriuretic peptides (NPs) from volume and pressure-overloaded myocardium promotes vasodilation and diuresis. Inhibition of the RAAS with either angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) has been the cornerstone of medical treatment for HF with a reduced ejection fraction (HFrEF) but, until recently, it was unclear how the beneficial effects of NPs may be augmented in patients with HF. Neprilysin, a metalloproteinase widely distributed throughout the body, plays a role in degrading the gross excess of circulating NPs in patients with HF. Early studies of neprilysin inhibition suggested possible physiological benefits. In 2014, the PARADIGM-HF trial found that sacubitril-valsartan, a combination of the ARB valsartan, and the neprilysin inhibitor sacubitril, was superior to enalapril in patients with HFrEF, reducing the relative risk of cardiovascular (CV) death or first hospitalisation with HF by 20%. Almost half of the patients with HF symptoms have a “preserved” ejection fraction (HFpEF); however, the PARAGON-HF study found that sacubitril-valsartan in patients with LVEF ≥45% had no effect on CV death or first and recurrent hospitalisations with HF compared to valsartan. Guidelines across the world have changed to include sacubitril-valsartan for patients with HFrEF yet, nearly 6 years after PARADIGM-HF, there is still uncertainty as to when and in whom sacubitril-valsartan should be started. Furthermore, there may yet be subsets of patients with HFpEF who might benefit from treatment with sacubitril-valsartan. This review will describe the mechanisms behind the outcome benefit of sacubitril-valsartan in patients with HFrEF and to consider its future role in the management of patients with HF.
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Affiliation(s)
- Joseph J Cuthbert
- Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Kingston upon Hull HU16 5JQ, UK
| | - Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Kingston upon Hull HU16 5JQ, UK
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17
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Cleland JGF, Li C, Jones Y. Artificial Intelligence Needs Clinical Intelligence to Succeed. JACC. HEART FAILURE 2020; 8:588-591. [PMID: 32616167 DOI: 10.1016/j.jchf.2020.06.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 06/01/2020] [Indexed: 11/19/2022]
Affiliation(s)
- John G F Cleland
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom; National Heart & Lung Institute, Imperial College, London.
| | - Charles Li
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
| | - Yola Jones
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, United Kingdom
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18
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Abumayyaleh M, El-Battrawy I, Behnes M, Borggrefe M, Akin I. Current evidence of sacubitril/valsartan in the treatment of heart failure with reduced ejection fraction. Future Cardiol 2020; 16:227-236. [DOI: 10.2217/fca-2020-0002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Heart failure (HF) is one of the most common reasons for hospital admission in western countries. The measurement of the left ventricular ejection fraction is essential for the classification of HF and deciding on HF treatment. The treatment of HF has been improved in both diagnostic and therapeutic fields over the past two decades. The angiotensin receptor-neprilysin inhibitor decreased the cardiovascular mortality in patients with chronic HF with reduced ejection fraction. Sacubitril/valsartan (LCZ696) improves the imbalance between the renin-angiotensin-aldosterone and natriuretic peptide systems. We present the clinical efficacy, real-world experience, safety and tolerability, the relevance of etiology of cardiomyopathy, and gender differences and regulatory affairs of LCZ696 in the treatment of patients with HF with reduced ejection fraction.
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Affiliation(s)
- Mohammad Abumayyaleh
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
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19
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Kennedy C, Smith A, Doran S, Barry M. Sacubitril/valsartan (Entresto) utilisation and prescribing patterns in the context of a reimbursement application system. Br J Clin Pharmacol 2020; 87:406-413. [PMID: 32470158 DOI: 10.1111/bcp.14393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2020] [Revised: 05/05/2020] [Accepted: 05/19/2020] [Indexed: 01/19/2023] Open
Abstract
AIMS Entresto (sacubitril/valsartan) is used to treat symptomatic chronic heart failure with reduced ejection fraction. Given its high potential budget impact, the Health Services Executive introduced a reimbursement application system (RAS) to ensure its appropriate use. The aim of this study was to evaluate the utilisation of Entresto in Ireland and compare patient characteristics to those of the pivotal PARADIGM-HF trial. METHODS We used dispensed claims data from the Primary Care Reimbursement Services, clinical data obtained from the RAS, and data from published studies of Entresto utilisation. Differences in the baseline characteristics in the study populations vs the Entresto arm of the PARADIGM-HF trial were analysed. We also investigated cardiovascular medication use in the 6 months pre- and post-Entresto initiation. RESULTS In 2018, there were 1043 individuals receiving Entresto, corresponding to an expenditure of €1.2 million. Patients prescribed Entresto in Ireland were older, had lower left ventricular ejection fraction and were more symptomatic than those in the PARADIGM-HF trial. Irish patient characteristics were reflective of Entresto-treated populations in other real-world studies. More than 63% of patients were commenced on the lowest Entresto dose. Entresto initiation was associated with a reduction in the use of other medications for heart failure. CONCLUSION The utilisation of Entresto has been steadily increasing in Ireland since its reimbursement approval. The expenditure in the first year was substantially lower than predicted, and the RAS is an example of how health technology management can facilitate appropriate and cost-effective use of medicines.
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Affiliation(s)
- Cormac Kennedy
- Dept. Pharmacology and Therapeutics, Trinity College Dublin, Trinity Centre for Health Sciences, St. James' Hospital, Dublin, 8, Ireland
| | - Amelia Smith
- Dept. Pharmacology and Therapeutics, Trinity College Dublin, Trinity Centre for Health Sciences, St. James' Hospital, Dublin, 8, Ireland.,Medicines Management Programme, Health Service Executive, St. James' Hospital, Dublin, 8, Ireland
| | - Stephen Doran
- Dept. Pharmacology and Therapeutics, Trinity College Dublin, Trinity Centre for Health Sciences, St. James' Hospital, Dublin, 8, Ireland.,Medicines Management Programme, Health Service Executive, St. James' Hospital, Dublin, 8, Ireland
| | - Michael Barry
- Dept. Pharmacology and Therapeutics, Trinity College Dublin, Trinity Centre for Health Sciences, St. James' Hospital, Dublin, 8, Ireland.,Medicines Management Programme, Health Service Executive, St. James' Hospital, Dublin, 8, Ireland
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20
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Carballo S, Stirnemann J, Garin N, Darbellay Farhoumand P, Serratrice J, Carballo D. Prognosis of patients eligible for dapagliflozin in acute heart failure. Eur J Clin Invest 2020; 50:e13245. [PMID: 32306388 DOI: 10.1111/eci.13245] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 04/03/2020] [Accepted: 04/12/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Dapagliflozin, a sodium-glucose cotransporter 2 inhibitor, was shown in the DAPA-HF study to reduce the risk of worsening heart failure or death in symptomatic patients with left ejection fraction <40%, irrespective of diabetes. The aim of this study was to evaluate eligibility status for dapagliflozin in non-selected patients hospitalized for acute decompensated heart failure (ADHF), as well as prognostic implications of this status. MATERIALS AND METHODS Analysis of 815 patients recruited in a prospective cohort of acute heart failure at the University Hospitals of Geneva, consisting of consecutive patients admitted with ADHF. Eligibility for dapagliflozin was determined using criteria described DAPA-HF. RESULTS Of 815 patients, 220 (27%) were eligible for dapagliflozin treatment. In survival analysis, patients who were eligible for dapagliflozin had better clinical outcomes with respect to all-cause mortality and rehospitalization as compared to those who were not eligible. In multivariate analysis, the hazard ratio for all-cause mortality or readmission in patients eligible for dapagliflozin was 0.82 (95% CI 0.68-0.999, P = .049) as compared to the non-eligible. CONCLUSIONS Using DAPA-HF criteria, only 27% of non-selected patients admitted for ADHF are theoretically eligible for dapagliflozin. This eligibility for dapagliflozin is associated with better outcomes. Further evaluation of the benefits of dapagliflozin in selected HF patients may be of interest. This may have implications for selection criteria in future randomized effectiveness studies.
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Affiliation(s)
- Sebastian Carballo
- Service of Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Jérôme Stirnemann
- Service of Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nicolas Garin
- Service of Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | | | - Jacques Serratrice
- Service of Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - David Carballo
- Service of Cardiology, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
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21
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Real-Life Indications to Sacubitril/Valsartan Treatment in Patients With Chronic Systolic Heart Failure. J Cardiovasc Pharmacol 2020; 73:301-306. [PMID: 30855406 DOI: 10.1097/fjc.0000000000000665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE International guidelines recommend the introduction of sacubitril/valsartan (Entresto) in patients with heart failure (HF) and reduced ejection fraction (EF), who remain symptomatic, despite optimal uptitrated therapy. The purpose of the following analysis is to verify the real-life eligibility for sacubitril/valsartan in a population of patients suffering from chronic HF, regularly monitored in a single HF clinic and treated according to guideline-directed medical therapy (GDMT). METHODS From a total of 1070 patients regularly monitored in our HF Clinic between January 2011 and September 2017, the clinical records of 224 patients with HF and reduced EF on optimized GDMT were retrospectively analyzed. RESULTS Of 224 analyzed patients, 75 improved their EF or were asymptomatic after uptitration of GDMT during follow-up; 50 were not on angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for different reasons; 13 patients had systolic blood pressure ≤100 mm Hg, so they were not eligible for sacubitril/valsartan introduction. The remaining patients were still symptomatic (NYHA ≥2), and therefore, sacubitril/valsartan introduction was indicated in these 86 patients (38.4%) of 224 enrolled. CONCLUSION In patients with HF and reduced EF, where GDMT is appropriately achieved, indication to sacubitril/valsartan treatment is around 38%.
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22
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Moliner-Abós C, Rivas-Lasarte M, Pamies Besora J, Fluvià-Brugues P, Solé-González E, Mirabet S, López López L, Brossa V, Pirla MJ, Mesado N, Álvarez-García J, Roig E. Sacubitril/Valsartan in Real-Life Practice: Experience in Patients with Advanced Heart Failure and Systematic Review. Cardiovasc Drugs Ther 2020; 33:307-314. [PMID: 30820802 DOI: 10.1007/s10557-019-06858-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
PURPOSE Sacubitril/valsartan reduced heart failure (HF) admissions and cardiovascular mortality in the PARADIGM-HF trial. However, real-life studies are scarce comparing daily practice patients with those of the trial. The aim of our study was to analyze the efficacy and safety of the drug in an advanced heart failure cohort and to review systematically the previous real-life studies published to date. METHODS We performed a retrospective analysis of consecutive patients prescribed sacubitril/valsartan in a single tertiary HF clinic between September 2016 and February 2018. HF admissions before and after the initiation of the drug were assessed in a paired fashion. A systematic review of real-life studies published to date was also conducted. RESULTS Sacubitril/valsartan was started in 108 patients who were in a more advanced NYHA class and more frequently treated with mineral receptor antagonists, internal cardiac defibrillator, and cardiac resynchronization therapy than in the PARADIGM-HF trial. After a 6-month follow-up, we observed a significant reduction in the HF hospitalizations, median levels of NT-proBNP, and need for levosimendan ambulatory perfusion. Likewise, we found a significant improvement in mean LVEF and end diastolic left ventricle diameter. Regarding safety, sacubitril/valsartan was well-tolerated without any severe adverse effect. CONCLUSION Sacubitril/valsartan in real-life is prescribed to a more advanced HF population, which could be responsible for the difficulties in reaching high doses of the drug. However, after a 6-month follow-up, sacubitril/valsartan significantly reduces HF hospitalization and induces cardiac reverse remodeling, without remarkable adverse events.
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Affiliation(s)
- Carles Moliner-Abós
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Mercedes Rivas-Lasarte
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Julia Pamies Besora
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Paula Fluvià-Brugues
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Eduard Solé-González
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Sonia Mirabet
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Laura López López
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Vicens Brossa
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Maria José Pirla
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Nuria Mesado
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
| | - Jesús Álvarez-García
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain.
| | - Eulàlia Roig
- Cardiology Department, Hospital de la Santa Creu i Sant Pau, IIB-SantPau, CIBERCV, Universidad Autónoma de Barcelona, Calle Sant Antoni Maria Claret 167, 08025, Barcelona, Spain
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23
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"Real World" Eligibility for Sacubitril/Valsartan in Unselected Heart Failure Patients: Data from the Swedish Heart Failure Registry. Cardiovasc Drugs Ther 2020; 33:315-322. [PMID: 30903545 PMCID: PMC6538576 DOI: 10.1007/s10557-019-06873-1] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
PURPOSE PARADIGM-HF demonstrated the superiority of sacubitril/valsartan over enalapril in patients with heart failure and reduced ejection fraction (HF-REF). How widely applicable sacubitril/valsartan treatment is in unselected patients with HF-REF is not known. We examined eligibility of patients with HF-REF for treatment with sacubitril/valsartan, according to the criteria used in PARADIGM-HF, in the Swedish Heart Failure Registry (SwedeHF). METHODS Patients were considered potentially eligible if they were not hospitalized, had symptoms (NYHA class II-IV) and a reduced LVEF (≤ 40%), and were prescribed an angiotensin-converting enzyme inhibitor (ACEI) or angiotensin receptor blocker (ARB) at a dose equivalent to enalapril ≥ 10 mg daily. In these patients, we evaluated further eligibility according to the main additional PARADIGM-HF inclusion criteria. RESULTS Of 12,866 outpatients in NYHA functional class II-IV with an LVEF ≤ 40%, 9577 were prescribed at least 10 mg of enalapril (or equivalent) daily. Complete additional data were available for 3099 of these patients (32.4%) and of them 75.5% were potentially eligible for treatment with sacubitril/valsartan. The most common reason for ineligibility was a low natriuretic peptide level (n = 462, 14.9%). Only a small proportion of patients were ineligible due to low eGFR or serum potassium level. Because only 78% of patients were taking ≥ 10 mg enalapril or equivalent daily, only 58.9% of all patients (75.5% of 78%) were eligible for sacubitril/valsartan. CONCLUSIONS Between 34 and 76% of symptomatic patients with HF-REF in a 'real world' population are eligible for treatment with sacubitril/valsartan, depending on background ACEI/ARB dose. The most common reason for ineligibility is a low natriuretic peptide level.
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Carballo D, Stirnemann J, Garin N, Marti C, Serratrice J, Carballo S. Eligibility for sacubitril-valsartan in patients with acute decompensated heart failure. ESC Heart Fail 2020; 7:1282-1290. [PMID: 32167679 PMCID: PMC7261587 DOI: 10.1002/ehf2.12676] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 01/30/2020] [Accepted: 02/19/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Large‐scale clinical trials have demonstrated clinical benefits of sacubitril–valsartan in symptomatic heart failure with reduced ejection fraction patients (PARADIGM‐HF), with potential benefits in patients hospitalized for acute decompensated heart failure (ADHF) (PIONEER‐HF) and fewer benefits in patients with heart failure with preserved ejection fraction (PARAGON‐HF). The aim of this study was to evaluate eligibility for sacubitril–valsartan using criteria described in PIONNER‐HF in non‐selected patients hospitalized for ADHF. Methods and results Between November 2014 and May 2019, 799 patients were recruited in a prospective registry of acute heart failure at the University Hospitals of Geneva (http://ClinicalTrials.gov: NCT02444416). The cohort consists of consecutive patients admitted to the Department of Medicine with ADHF. Eligibility for sacubitril–valsartan was determined using criteria described in PIONEER‐HF, including left ventricular ejection fraction, clinical parameters, and co‐morbidities. Of 799 patients, 123 (15.39%) were eligible for sacubitril–valsartan treatment. Clinical outcomes including all‐cause mortality and readmission were similar in eligible and non‐eligible groups, hazard ratio 1.02 (95% confidence interval 0.81–1.29, P = 083). Conclusions Using current criteria from randomized controlled trials, only 15% of non‐selected patients admitted for ADHF are theoretically eligible for sacubitril–valsartan. Eligibility for sacubitril–valsartan using published criteria is not associated with worse outcome, suggesting that further evaluation of benefits of sacubitril–valsartan in heart failure patients based on parameters other than left ventricular ejection fraction may be of interest.
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Affiliation(s)
- David Carballo
- Service of Cardiology, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Jérôme Stirnemann
- Service of Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Nicolas Garin
- Service of Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Chistophe Marti
- Service of Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Jacques Serratrice
- Service of Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
| | - Sebastian Carballo
- Service of Internal Medicine, Department of Medicine, Geneva University Hospitals, Geneva, Switzerland
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25
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Nordberg Backelin C, Fu M, Ljungman C. Early experience of Sacubitril-Valsartan in heart failure with reduced ejection fraction in real-world clinical setting. ESC Heart Fail 2020; 7:1049-1055. [PMID: 32030899 PMCID: PMC7261574 DOI: 10.1002/ehf2.12644] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/17/2020] [Accepted: 01/26/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Sacubitril/Valsartan (Sac/Val) was proven more effective than enalapril for symptomatic patients with heart failure (HF) with reduced ejection fraction (HFrEF). This study aimed to investigate eligibility, titration, and tolerability for Sac/Val in a real‐world clinical setting. Methods and results This retrospective cohort study consists of two parts. In Part 1 (eligibility study), all patients discharged from Sahlgrenska University Hospital due to HF were consecutively included during 1 year. Data from the patients' medical records were collected. Patients were adjudicated to be eligible based on European Society of Cardiology (ESC) criteria for angiotensin receptor neprilysin inhibitor (ARNI) with the exception of N‐terminal (NT)‐proBNP levels. Patients who received <50% of target dose angiotensin‐converting enzyme/angiotensin receptor blocker and otherwise fulfilled ESC criteria were adjudicated to be potentially eligible. In Part 2 (tolerability study), all patients receiving Sac/Val during the same period were included. Medical data regarding dose, titration, and adverse effects and events were registered. A total of 1355 patients (mean age 78 ± 13 years) were hospitalized for HF and 619 patients had an EF ≤40%. Twenty percent were eligible for initiation of ARNI, and additionally 8% were potentially eligible. In all 95 patients (mean age 65 ± 12 years) were initiated with Sac/Val, which correlates to 13%. The patients who were initiated were younger (65 years), more often had dilated cardiomyopathy (31%), more often were on guideline‐directed medical therapy, and had a higher frequency of cardiac resynchronization therapy and implantable cardioverter–defibrillator compared with the patients who did not receive Sac/Val. Of the initiated patients, 59% reached target dose of Sac/Val, and 15% discontinued due to adverse effects. The most common cause of discontinuation was benign gastrointestinal adverse effects, followed by elevated creatinine, malaise, and vertigo. Female gender [odds ratio (OR) 3.58; 95% CI 1.07–2.00; P = 0.038] and NT‐proBNP ≥ median level (OR 0.48; 95% CI 0.26–0.90; P = 0.021) was associated with termination of the medication. Conclusions Among HFrEF patients in this real‐world cohort, 20% were eligible for ARNI; however, only 13% received the treatment. Sac/Val was well tolerated, but 41% of the patients did not reach target dose. How this affects outcome is not known and needs further investigation.
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Affiliation(s)
- Charlotte Nordberg Backelin
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Charlotta Ljungman
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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Pharithi RB, Ferre-Vallverdu M, Maisel AS, O'Connell E, Walshe M, Sweeney C, Barton J, McDonald K, O'Hare D, Watson C, Gallagher J, Ledwidge M, McDonald K. Sacubitril-Valsartan in a routine community population: attention to volume status critical to achieving target dose. ESC Heart Fail 2020; 7:158-166. [PMID: 31903729 PMCID: PMC7083433 DOI: 10.1002/ehf2.12547] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Revised: 09/18/2019] [Accepted: 09/23/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS In the PARADIGM-heart failure trial, sacubitril-valsartan demonstrated a reduction in heart failure admissions and reduced all-cause mortality in patients with heart failure with reduced ejection fraction. Although real world data have shown similar benefits regarding efficacy and safety, there has been difficulty in achieving the target dose (TD). The factors preventing the achievement of TD remains unclear. This study assesses the tolerability, ability to achieve, and factors linked to attaining TD in a routine clinical population. METHODS AND RESULTS This is a retrospective single-centre review of patients switched from angiotensin-converting enzyme inhibitors/angiotensin receptor blockers to sacubitril-valsartan between May 2016 and August 2018. Baseline and follow-up clinical characteristics and biomarker profiles were collected. Univariate and multivariate analyses were used to analyse predictors of achieving TD. Clinical response to sacubitril-valsartan was defined as a reduction in N terminal pro BNP of ≥30%, or an increase in left ventricular ejection fraction of ≥5% compared with baseline values. To date, a total of 322 patients (75% male patients) have been switched to sacubitril-valsartan. Those still in the titration phase were excluded (n = 25). Sacubitril-valsartan was not tolerated in 40 patients (12.4%). Those intolerant were older (73.4 years [68.3, 80.6] vs. 69.1 years [61.2, 76]; P = 0.003) and had worse renal function with estimated glomerular filtration rate (53.5 mL/min/1.72 m2 [36.8, 60.2] vs 60 mL/min/1.72 m2 [47, 77]; P ≤ 0.001). Of the remaining 257 patients, TD (97/103 mg BD) was achieved in 194 patients (75.5%), while 37 patients (11.4%) were maintained on 49/51 mg BD and 26 patients (8.1%) remained on 24/26 mg BD. Symptomatic hypotension (74.6%) was the main impediment to attaining TD, followed by renal deterioration (12.7%), and to a lesser extent hyperkalaemia and gastrointestinal symptoms (4.8% each). Diuretic dose decrease was achieved in 37.2% of patients, and this was the strongest independent predictor of achieving TD (odds ratio = 2.1; 95% confidence interval [1.16, 3.8]; P = 0.014). Responder status by N terminal pro BNP criterion was observed in 99 of 214 patients (46.3%) while 70 of 142 (49.3%) attained the left ventricular ejection fraction response status. Achieving this response was independently linked to achieving TD. CONCLUSIONS Sacubitril-valsartan was well tolerated. Achievement of TD was possible in the majority of the cohort and was linked to response metrics. Reduction in diuretic was required in a large percentage of the population and was the strongest predictor of attaining TD. Therefore, careful clinical attention to volume status assessment is essential to maximising the benefits of sacubitril-valsartan.
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Affiliation(s)
- Rebabonye B Pharithi
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland.,University College Dublin, Belfield, Dublin, Ireland
| | - Maria Ferre-Vallverdu
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland
| | - Alan S Maisel
- Division of Cardiovascular Medicine, Coronary Care Unit and Heart Failure Programme, Veterans Affairs San Diego Healthcare System, University of San Diego, San Diego, USA, CA
| | - Eoin O'Connell
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland
| | - Myra Walshe
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland
| | - Claire Sweeney
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland
| | - James Barton
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland
| | | | - Daniel O'Hare
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland
| | - Chris Watson
- University College Dublin, Belfield, Dublin, Ireland.,Centre for Experimental Medicine, Queen's University Belfast, Northern Ireland
| | - Joe Gallagher
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland
| | - Mark Ledwidge
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland.,University College Dublin, Belfield, Dublin, Ireland
| | - Kenneth McDonald
- Heart Failure Unit, St. Vincent University Hospital Health Care Group, Elm Park, Dublin, DO4 T6F4, Ireland.,University College Dublin, Belfield, Dublin, Ireland
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27
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Differences in medical treatment and clinical characteristics between men and women with heart failure – a single-centre multivariable analysis. Eur J Clin Pharmacol 2020; 76:539-546. [DOI: 10.1007/s00228-019-02782-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
Abstract
Purpose
The aims of this study were to examine sex differences in a heart failure population with regards to treatment and patient characteristics and to investigate the impact of sex on achieved doses of heart failure medications.
Methods and results
A total of 1924 patients with heart failure in a regional hospital were analysed, 622 patients had ejection fraction ≤ 40% of which 30% were women. In patients with reduced ejection fraction, women were older (79 ± 11 vs. 74 ± 12 years, P < 0.001), had lower body weight (70 ± 17 vs. 86 ± 18 kg, P < 0.001), lower estimated glomerular filtration rate (eGFR) (49 ± 24 vs. 71 ± 30 ml/min, P < 0.001) and received lower doses of heart failure medications than men. Multivariable linear regression on patients with reduced ejection fraction showed that sex was not associated with achieved dose of any heart failure medication. For angiotensin-converting enzyme inhibitors and angiotensin receptor blockers associated factors were eGFR, systolic blood pressure, age, ejection fraction, and heart rate. For beta-blockers associated factors were body weight, atrial fibrillation and age. For mineralocorticoid receptor antagonists associated factors were eGFR, serum potassium, age, systolic blood pressure, ejection fraction and heart rate.
Conclusion
Women with heart failure and reduced ejection fraction were prescribed lower doses of heart failure medications, were older, had worse renal function, and lower body weight than men. Sex was not independently associated with achieved doses of heart failure medications, instead age, renal function and body weight explained the differences in treatment.
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Abstract
The management of heart failure has changed significantly over the last 30 years, leading to improvements in the quality of life and outcomes, at least for patients with a substantially reduced left ventricular ejection fraction (HFrEF). This has been made possible by the identification of various pathways leading to the development and progression of heart failure, which have been successfully targeted with effective therapies. Meanwhile, many other potential targets of treatment have been identified, and the list is constantly expanding. In this review, we summarise planned and ongoing trials exploring the potential benefit, or harm, of old and new pharmacological interventions that might offer further improvements in treatment for those with HFrEF and extend success to the treatment of patients with heart failure with preserved left ventricular ejection fraction (HFpEF) and other heart failure phenotypes.
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Affiliation(s)
- Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK.
| | - Muhammad Javed Iqbal Khan
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK
| | - Fraser John Graham
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow, G12 8QQ, UK
- National Heart & Lung Institute and National Institute of Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield Hospitals, Imperial College, London, UK
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Chen X, Schaufelberger M, Fu M. The eligible population of the PARADIGM-HF trial in a real-world outpatient clinic and its cardiovascular risk between 2005 and 2016. J Cardiovasc Med (Hagerstown) 2019; 21:6-12. [PMID: 31789711 DOI: 10.2459/jcm.0000000000000889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The PARADIGM-HF trial showed that sacubitril-valsartan - an angiotensin receptor-neprilysin inhibitor (ARNI) - is more effective than enalapril for some patients with heart failure. However, the eligibility of the PARADIGM-HF study to a real-world heart failure population was not well established. METHODS We made secondary analysis of patients (n = 4872) with heart failure prospectively enrolled in the Swedish Heart Failure Registry from Sahlgrenska University Hospital/Östra Hospital, Sweden during 2005-2016. The eligibility of the PARADIGM-HF trial in the real world was studied based on patients whether they were either fully or partially compatible with the PARADIGM-HF population. Patients were judged to be fully eligible for the PARADIGM-HF trial if they completely met the inclusion and exclusion criteria, and partially eligible if they did not stay on target dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), despite their having been treated with ACEI/ARB for at least 6 months. RESULTS Among patients who had heart failure with reduced left ventricular ejection fraction (≤40%) (HFrEF) (n = 2165), 653 (30%) and 958 (44%) patients were fully and partially compatible with PARADIGM-HF criteria, respectively. In both fully and partially eligible groups, patients were more male. Despite those fully eligible patients being younger (77.6 ± 12.7 vs. 84.0 ± 13.7 years) than noneligible patients, they were much older than in the PARADIGM-HF trial. Moreover, those fully eligible patients had lower all-cause mortality compared with both partially and noneligible patients. However, both fully and partially eligible patients had higher all-cause mortality than that in the PARADIGM-HF trial. CONCLUSION In a real-world outpatient clinical setting, around 1/3-1/2 of HFrEF were eligible for treatment of Sac/Val except that they are older, sicker, and carry higher risk for all-cause mortality than the PARADIGM-HF trial population.
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Affiliation(s)
- Xiaojing Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria Schaufelberger
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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Tomasoni D, Adamo M, Lombardi CM, Metra M. Highlights in heart failure. ESC Heart Fail 2019; 6:1105-1127. [PMID: 31997538 PMCID: PMC6989277 DOI: 10.1002/ehf2.12555] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Revised: 10/29/2019] [Accepted: 10/30/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) remains a major cause of mortality, morbidity, and poor quality of life. It is an area of active research. This article is aimed to give an update on recent advances in all aspects of this syndrome. Major changes occurred in drug treatment of HF with reduced ejection fraction (HFrEF). Sacubitril/valsartan is indicated as a substitute to ACEi/ARBs after PARADIGM-HF (hazard ratio [HR], 0.80; 95% confidence interval [CI], 0.73 to 0.87 for sacubitril/valsartan vs. enalapril for the primary endpoint and Wei, Lin and Weissfeld HR 0.79, 95% CI 0.71-0.89 for recurrent events). Its initiation was then shown as safe and potentially useful in recent studies in patients hospitalized for acute HF. More recently, dapagliflozin and prevention of adverse-outcomes in DAPA-HF trial showed the beneficial effects of the sodium-glucose transporter type 2 inhibitor dapaglifozin vs. placebo, added to optimal standard therapy [HR, 0.74; 95% CI, 0.65 to 0.85;0.74; 95% CI, 0.65 to 0.85 for the primary endpoint]. Trials with other SGLT 2 inhibitors and in other patients, such as those with HF with preserved ejection fraction (HFpEF) or with recent decompensation, are ongoing. Multiple studies showed the unfavourable prognostic significance of abnormalities in serum potassium levels. Potassium lowering agents may allow initiation and titration of mineralocorticoid antagonists in a larger proportion of patients. Meta-analyses suggest better outcomes with ferric carboxymaltose in patients with iron deficiency. Drugs effective in HFrEF may be useful also in HF with mid-range ejection fraction. Better diagnosis and phenotype characterization seem warranted in HF with preserved ejection fraction. These and other burning aspects of HF research are summarized and reviewed in this article.
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Affiliation(s)
- Daniela Tomasoni
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| | - Marianna Adamo
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| | - Carlo Mario Lombardi
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaCardiothoracic DepartmentCivil HospitalsBresciaItaly
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31
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López-Azor JC, Vicent L, Valero-Masa MJ, Esteban-Fernández A, Gómez-Bueno M, Pérez Á, Díez-Villanueva P, De-Juan J, Manuel-Iniesta Á, Bover R, Del Prado S, Martínez-Sellés M. Safety of sacubitril/valsartan initiated during hospitalization: data from a non-selected cohort. ESC Heart Fail 2019; 6:1161-1166. [PMID: 31701680 PMCID: PMC6989298 DOI: 10.1002/ehf2.12527] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 07/25/2019] [Accepted: 09/06/2019] [Indexed: 12/11/2022] Open
Abstract
Aims Sacubitril/valsartan is safe when initiated during hospitalization in a clinical trial setting. Its safety in real‐life population is not stablished. We compared the initiation of sacubitril/valsartan during hospitalization in a non‐selected population, in the PIONEER‐HF trial, and in non‐selected outpatients. Methods and results Multicentre registry included 527 patients: 100 were started on sacubitril/valsartan during hospitalization (19.0%) and 427 as outpatients (81.0%). Compared with those in the pivotal trial, inpatients in our cohort were older (71 ± 12 vs. 61 ± 14 years; P < 0.001); had more frequently Functional Class II (41 [41.0%] vs. 100 [22.7%]; P < 0.001), higher levels of N‐terminal pro‐B type natriuretic peptide (4044 [1630–8680] vs. 2013 [1002–4132] pg/mL; P < 0.001), better glomerular filtration rate (63.5 [51.0–80.0] vs. 58.4 [47.5–71.5] mL/min; P = 0.01), and higher systolic blood pressure (121 [110–136] vs. 118 [110–133] mmHg; P = 0.03); and received angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers more frequently (92 [92.0%] vs. 208 [52.7%]; P < 0.001). Compared with non‐selected outpatients, inpatients were older (71 ± 12 vs. 68 ± 12 years, P = 0.02), had more frequent Functional Class III–IV (58 [58.0%] vs. 129 [30.3%], P < 0.001), had higher levels of N‐terminal pro‐B type natriuretic peptide (4044 [1630–8680] vs. 2182 [1134–4172]; P < 0.001), and were receiving angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers target dose less frequently (55 [55.0%] vs. 335 [78.5%]; P < 0.001). They also started sacubitril/valsartan with a low dose (50 mg/12 h) more frequently (80 [80.0%] vs. 209 [48.8%], P < 0.001). The initiation of sacubitril/valsartan in outpatients was an independent predictor of high‐dose use (OR 3.1; 95% confidence interval 1.7–5.6, P < 0.001). The follow‐up time in both cohorts, including all patients enrolled, was similar (7.0 ± 0.1 vs. 7.2 ± 2.6 months, P = 0.72). All‐cause admissions during follow‐up were more frequent in inpatients (30 [30.0%] vs. 68 outpatients [15.9%], P = 0.001), with no relevant differences in all‐cause mortality. There was no significant difference in sacubitril/valsartan withdrawal rate (17 inpatients [17.0%] vs. 49 outpatients [11.5%], P = 0.13). The incidence of adverse effects was also similar: hypotension (16 inpatients [16.0%] vs. 71 outpatients [16.7%], P = 0.88), worsening renal function (7 inpatients [7.0%] vs. 29 outpatients [6.8%], P = 0.94), and hyperkalaemia (1 inpatient [1.0%] vs. 21 outpatients [4.9%], P = 0.09). We did not register any case of angioedema. Conclusions It is safe to initiate sacubitril/valsartan during hospitalization in daily clinical practice. Inpatients have a higher risk profile and receive low starting doses more frequently than outpatients.
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Affiliation(s)
- Juan Carlos López-Azor
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Lourdes Vicent
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - María Jesús Valero-Masa
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | | | - Manuel Gómez-Bueno
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, CIBERCV, Madrid, Spain
| | - Ángel Pérez
- Servicio de Cardiología, Hospital de Burgos, Burgos, Spain
| | | | - Javier De-Juan
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Ramón Bover
- Servicio de Cardiología, Hospital Universitario Clínico de San Carlos. Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Susana Del Prado
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Servicio de Cardiología, Universidad Complutense, Universidad Europea, Madrid, Spain
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32
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Liu Z, Wang J, Li Y. Efficacy of sacubitril valsartan sodium tablet for the treatment of chronic heart failure: A systematic review protocol of randomized controlled trials. Medicine (Baltimore) 2019; 98:e18050. [PMID: 31764831 PMCID: PMC6882600 DOI: 10.1097/md.0000000000018050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND This study aims to systematically explore the efficacy of sacubitril valsartan sodium tablet (SVST) for the treatment of chronic heart failure (CHF). METHODS Nine electronic databases, including PUBMED, Cochrane Library, EMBASE, PsycINFO, Web of Science, Allied and Complementary Medicine Database, WANGFANG, Chinese Biomedical Literature Database, and China National Knowledge Infrastructure will be searched. Randomized controlled trials on SVST in the treatment of CHF will be collected. The search time limit will be from the establishment of each electronic database until June 1, 2019. Two authors will independently select the literature, carry out the data, and assess the methodological quality. RESULTS This study will systematically investigate the efficacy and safety of SVST for CHF. The outcomes consist of all-cause mortality, change in body weight, urine output, change in serum sodium; and incidence of any expected and unexpected adverse events. CONCLUSION The findings of this study will summarize from evidence-based medicine and a scientific basis for the efficacy and safety of SVST in the clinical treatment of CHF. PROSPERO REGISTRATION NUMBER PROSPERO CRD42019138882.
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Affiliation(s)
- Zhe Liu
- Department of Cardiology, Yanan University Affiliated Hospital
| | - Jing Wang
- Department of Endocrine and Metabolism, Yanan University Affiliated Hospital
| | - Yi Li
- Department of Geriatrics, Yan’an People's Hospital, Yan’an, China
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33
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Han J, Chung F, Nguyen QL, Mody FV, Jackevicius CA. Evaluation of Patients with Heart Failure to Determine Eligibility for Treatment with Sacubitril/Valsartan: Insights from a Veterans Administration Healthcare System. Pharmacotherapy 2019; 39:1053-1059. [DOI: 10.1002/phar.2328] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Jamie Han
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Francisco Chung
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Quyen L. Nguyen
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Freny Vaghaiwalla Mody
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
- Division of Cardiology University of California, Los Angeles Los Angeles California
- David Geffen School of Medicine University of California, Los Angeles Los Angeles California
| | - Cynthia A. Jackevicius
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
- Department of Pharmacy Practice and Administration Western University of Health Sciences Pomona California
- Institute for Clinical Evaluative Sciences University of Toronto Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation University of Toronto Toronto Ontario Canada
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34
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Sciatti E, Dallapellegrina L, Metra M, Lombardi CM. New drugs for the treatment of chronic heart failure with a reduced ejection fraction. J Cardiovasc Med (Hagerstown) 2019; 20:650-659. [DOI: 10.2459/jcm.0000000000000850] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
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35
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Lau CW, Martens P, Lambeets S, Dupont M, Mullens W. Effects of sacubitril/valsartan on functional status and exercise capacity in real-world patients. Acta Cardiol 2019; 74:405-412. [PMID: 30474478 DOI: 10.1080/00015385.2018.1521054] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Sacubitril/valsartan significantly reduced heart failure(HF) hospitalisations and mortality in the PARADIGM-HF-trial. However real-world data on symptomatic and functional improvement are lacking. Methods: Between December 2016 and January 2018, we retrospectively collected baseline and follow-up data including New York Heart Association (NYHA)-functional class and Cardio-pulmonary exercise data(CPET) in all HF-patients receiving sacubitril/valsartan. Additionally, in patients with an implantable electric cardiovascular device (IECD) enrolled in remote telemonitoring, we quantified patient level activity before and after initiation. Results: A total of 201 patients (82% males) were identified. NYHA-functional class was reassessed after an average of 221 ± 114 days. Overall, 3.3% of patients improved 2 NYHA classes, 28.7% improved 1 NYHA class, 64% remained stable and 4% deteriorated 1 NYHA class. Patients with symptomatic improvement exhibited a larger reduction in Left Ventricular End Systolic Volume(LVESV) and a larger increase in Left Ventricular Ejection Fraction(LVEF[p-value both <.05]). In total, 110 patients (55%) were equipped with an IECD capable of quantifying outpatient activity-level. On an average of 364 days before sacubitril/valsartan, an activity expressed as %-of-the-day was 13 ± 2%, vs. 18 ± 3% the 364 days following sacubitril/valsartan initiation. Signifying a 38% improvement in the out-patient activity level. CPET-data was obtained in paired-fashion in 45 patients (22%). VO2max at baseline (14.7 ± 3.8 mL/kg/min) did not significantly change at follow-up (14.1 ± 4.7 mL/min/kg; p = .237). Conclusion: Real-world patients exhibit significant symptomatic and functional improvement following the initiation of sacubitril/valsartan. However, larger prospective studies are necessary to assess the impact of sacubitril/valsartan on indices of maximal exercise performance measured during CPET.
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Affiliation(s)
- Chirik Wah Lau
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Seppe Lambeets
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine and Life Sciences, Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium
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Seferovic PM, Ponikowski P, Anker SD, Bauersachs J, Chioncel O, Cleland JGF, de Boer RA, Drexel H, Ben Gal T, Hill L, Jaarsma T, Jankowska EA, Anker MS, Lainscak M, Lewis BS, McDonagh T, Metra M, Milicic D, Mullens W, Piepoli MF, Rosano G, Ruschitzka F, Volterrani M, Voors AA, Filippatos G, Coats AJS. Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2019; 21:1169-1186. [PMID: 31129923 DOI: 10.1002/ejhf.1531] [Citation(s) in RCA: 418] [Impact Index Per Article: 83.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 05/17/2019] [Accepted: 05/17/2019] [Indexed: 12/15/2022] Open
Abstract
The European Society of Cardiology (ESC) has published a series of guidelines on heart failure (HF) over the last 25 years, most recently in 2016. Given the amount of new information that has become available since then, the Heart Failure Association (HFA) of the ESC recognized the need to review and summarise recent developments in a consensus document. Here we report from the HFA workshop that was held in January 2019 in Frankfurt, Germany. This expert consensus report is neither a guideline update nor a position statement, but rather a summary and consensus view in the form of consensus recommendations. The report describes how these guidance statements are supported by evidence, it makes some practical comments, and it highlights new research areas and how progress might change the clinical management of HF. We have avoided re-interpretation of information already considered in the 2016 ESC/HFA guidelines. Specific new recommendations have been made based on the evidence from major trials published since 2016, including sodium-glucose co-transporter 2 inhibitors in type 2 diabetes mellitus, MitraClip for functional mitral regurgitation, atrial fibrillation ablation in HF, tafamidis in cardiac transthyretin amyloidosis, rivaroxaban in HF, implantable cardioverter-defibrillators in non-ischaemic HF, and telemedicine for HF. In addition, new trial evidence from smaller trials and updated meta-analyses have given us the chance to provide refined recommendations in selected other areas. Further, new trial evidence is due in many of these areas and others over the next 2 years, in time for the planned 2021 ESC guidelines on the diagnosis and treatment of acute and chronic heart failure.
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Affiliation(s)
- Petar M Seferovic
- Serbian Academy of Sciences and Arts, Heart Failure Center, Faculty of Medicine, Belgrade University Medical Center, Belgrade, Serbia
| | - Piotr Ponikowski
- Centre for Heart Diseases, University Hospital, Wroclaw, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, and University of Medicine Carol Davila, Bucharest, Romania
| | - John G F Cleland
- National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, UK.,Robertson Centre for Biostatistics and Clinical Trials, Glasgow, UK
| | - Rudolf A de Boer
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Heinz Drexel
- Vorarlberg Institute for Vascular Investigation and Treatment (VIVIT), Feldkirch, Austria.,Private University of the Principality of Liechtenstein, Triesen, Liechtenstein.,Division of Angiology, Swiss Cardiovascular Center, University Hospital Berne, Berne, Switzerland.,Drexel University College of Medicine, Philadelphia, PA, USA
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center (Beilinson Campus), Petah Tikva, Israel.,Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Tiny Jaarsma
- Department of Nursing, Faculty of Medicine and Health Sciences, University of Linköping, Linköping, Sweden
| | - Ewa A Jankowska
- Centre for Heart Diseases, University Hospital, Wroclaw, Department of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Markus S Anker
- Division of Cardiology and Metabolism, Department of Cardiology & Berlin Institute of Health Center for Regenerative Therapies (BCRT), DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Charité-Universitätsmedizin Berlin (CVK), Berlin, Germany.,Department of Cardiology, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Basil S Lewis
- Lady Davis Carmel Medical Center and Ruth and Bruce Rappaport School of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Davor Milicic
- Department for Cardiovascular Diseases, University Hospital Center Zagreb, University of Zagreb, Croatia
| | | | - Massimo F Piepoli
- Heart Failure Unit, Cardiology, G. da Saliceto Hospital, Piacenza, Italy
| | - Giuseppe Rosano
- Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK.,IRCCS San Raffaele Pisana, Rome, Italy
| | - Frank Ruschitzka
- Department of Cardiology, University Hospital, University Heart Center, Zurich, Switzerland
| | | | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gerasimos Filippatos
- Heart Failure Unit, Attikon University Hospital, National and Kapodistrian University of Athens, Greece.,School of Medicine, University of Cyprus, Nicosia, Cyprus
| | - Andrew J S Coats
- Department of Cardiology, IRCCS San Raffaele Pisana, Rome, Italy
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37
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Cleland JGF, Hindricks G, Petrie M. The shocking lack of evidence for implantable cardioverter defibrillators for heart failure; with or without cardiac resynchronization. Eur Heart J 2019; 40:2128-2130. [PMID: 31257403 DOI: 10.1093/eurheartj/ehz409] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, University of Glasgow, Glasgow, Scotland, UK.,National Heart and Lung Institute, Imperial College, London, UK
| | - Gerhard Hindricks
- Department of Electrophysiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Mark Petrie
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, UK
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38
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Kapelios CJ, Lainscak M, Savarese G, Laroche C, Seferovic P, Ruschitzka F, Coats A, Anker SD, Crespo-Leiro MG, Filippatos G, Piepoli MF, Rosano G, Zanolla L, Aguiar C, Murin J, Leszek P, McDonagh T, Maggioni AP, Lund LH. Sacubitril/valsartan eligibility and outcomes in the ESC-EORP-HFA Heart Failure Long-Term Registry: bridging between European Medicines Agency/Food and Drug Administration label, the PARADIGM-HF trial, ESC guidelines, and real world. Eur J Heart Fail 2019; 21:1383-1397. [PMID: 31132222 DOI: 10.1002/ejhf.1532] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2019] [Revised: 05/15/2019] [Accepted: 05/17/2019] [Indexed: 12/28/2022] Open
Abstract
AIMS To assess the proportion of patients with heart failure and reduced ejection fraction (HFrEF) who are eligible for sacubitril/valsartan (LCZ696) based on the European Medicines Agency/Food and Drug Administration (EMA/FDA) label, the PARADIGM-HF trial and the 2016 ESC guidelines, and the association between eligibility and outcomes. METHODS AND RESULTS Outpatients with HFrEF in the ESC-EORP-HFA Long-Term Heart Failure (HF-LT) Registry between March 2011 and November 2013 were considered. Criteria for LCZ696 based on EMA/FDA label, PARADIGM-HF and ESC guidelines were applied. Of 5443 patients, 2197 and 2373 had complete information for trial and guideline eligibility assessment, and 84%, 12% and 12% met EMA/FDA label, PARADIGM-HF and guideline criteria, respectively. Absent PARADIGM-HF criteria were low natriuretic peptides (21%), hyperkalemia (4%), hypotension (7%) and sub-optimal pharmacotherapy (74%); absent Guidelines criteria were LVEF>35% (23%), insufficient NP levels (30%) and sub-optimal pharmacotherapy (82%); absent label criteria were absence of symptoms (New York Heart Association class I). When a daily requirement of ACEi/ARB ≥ 10 mg enalapril (instead of ≥ 20 mg) was used, eligibility rose from 12% to 28% based on both PARADIGM-HF and guidelines. One-year heart failure hospitalization was higher (12% and 17% vs. 12%) and all-cause mortality lower (5.3% and 6.5% vs. 7.7%) in registry eligible patients compared to the enalapril arm of PARADIGM-HF. CONCLUSIONS Among outpatients with HFrEF in the ESC-EORP-HFA HF-LT Registry, 84% met label criteria, while only 12% and 28% met PARADIGM-HF and guideline criteria for LCZ696 if requiring ≥ 20 mg and ≥ 10 mg enalapril, respectively. Registry patients eligible for LCZ696 had greater heart failure hospitalization but lower mortality rates than the PARADIGM-HF enalapril group.
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Affiliation(s)
- Chris J Kapelios
- Department of Cardiology, Laiko General Hospital, Athens, Greece
| | - Mitja Lainscak
- Division of Cardiology, Murska Sobota, Murska Sobota and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Cécile Laroche
- EURObservational Research Programme, European Society of Cardiology, Sophia-Antipolis, France
| | - Petar Seferovic
- Clinical Center of Serbia, Cardiology II, Department for Heart Failure, University of Belgrade, Belgrade, Serbia
| | - Frank Ruschitzka
- Department of Cardiology, Heart Failure Clinic and Transplantation, University Heart Centre Zurich, Zurich, Switzerland
| | | | - Stefan D Anker
- Division of Cardiology and Metabolism; Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany & Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Göttingen, Germany
| | - Maria G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Complexo Hospitalario Universitario A Coruna, La Coruna, Spain
| | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, University Hospital Attikon, Athens, Greece
| | - Massimo F Piepoli
- Heart Failure Unit, Cardiac Department, Guglielmo da Saliceto Hospital, Piacenza, Italy
| | - Giuseppe Rosano
- Cardiovascular Clinical Academic Group St George's Hospitals NHS Trust University of London, Cranmer Terrace, London, IRCCS San Raffaele, Rome, Italy
| | | | - Carlos Aguiar
- Unidade de Insuficiência Cardíaca Avançada e Transplantação Cardíaca, Hospital de Santa Cruz, Carnaxide, Portugal
| | - Jan Murin
- University Hospital Bratislava, Bratislava, Slovakia
| | - Przemyslaw Leszek
- The Cardinal Stefan Wyszynski Institute of Cardiology, Warsaw, Poland
| | | | - Aldo P Maggioni
- EURObservational Research Programme, European Society of Cardiology, Sophia-Antipolis, France.,ANMCO Research Centre, Heart Care Foundation, Florence, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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Sivagnanam K, Mendes LA, Schlendorf KH, Damp JB, Stevenson LW, Ramu V, Walsh MN, Jessup M, Lindenfeld J. Bridge to Transplantation: Advanced Heart Failure and Transplant Cardiology Training for Cardiovascular Disease Fellows. J Am Coll Cardiol 2019; 70:1413-1416. [PMID: 28882239 DOI: 10.1016/j.jacc.2017.07.769] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
| | - Lisa A Mendes
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Julie B Damp
- Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Vijay Ramu
- East Tennessee State University, Johnson City, Tennessee
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40
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Metra M. May 2019 at a glance: epidemiology, drug effects on biomarkers, adverse events with LVAD. Eur J Heart Fail 2019; 21:541-542. [PMID: 31069909 DOI: 10.1002/ejhf.1262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] 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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41
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Sciatti E, Senni M, Lombardi CM, Gori M, Metra M. Sacubitril/valsartan: from a large clinical trial to clinical practice. J Cardiovasc Med (Hagerstown) 2019; 19:473-479. [PMID: 29917003 DOI: 10.2459/jcm.0000000000000687] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
: The Prospective Comparison of Angiotensin Receptor Antagonist and Neprilysin Inhibitor with Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial (PARADIGM-HF) has shown a reduction in the risk of death and heart failure hospitalizations with sacubitril/valsartan, compared with enalapril, in patients with heart failure and reduced ejection fraction. Guidelines now recommend the substitution of angiotensin-converting enzyme inhibitors or AT1 blockers with sacubitril/valsartan in patients with heart failure and reduced ejection fraction. The aim of this review is to discuss factors that may have an impact on the implementation of these guidelines into clinical practice. The main limitation is that, based on the inclusion criteria of PARADIGM-HF, sacubitril/valsartan is not indicated in patients with heart failure and preserved ejection fraction, although they may be the majority of the patients with heart failure. The trial enrolled ambulatory patients and thus start of sacubitril/valsartan is not indicated in those hospitalized for heart failure. A drug's tolerability may be limited by hypotension with, however, a lower rate of renal dysfunction, compared with enalapril. The cost of the new treatment is also an issue. Similarly to what occurred when other neurohormonal antagonists have been introduced in clinical practice, increased awareness of poor heart failure outcomes and better patients' management programs may be of utmost importance for the implementation of this new agent.
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Affiliation(s)
- Edoardo Sciatti
- Cardiology, Department of medical and surgical specialties, radiological sciences and public health, University and ASST Spedali Civili, Brescia
| | - Michele Senni
- Cardiovascular Department, Cardiology Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Carlo M Lombardi
- Cardiology, Department of medical and surgical specialties, radiological sciences and public health, University and ASST Spedali Civili, Brescia
| | - Mauro Gori
- Cardiovascular Department, Cardiology Unit, ASST Papa Giovanni XXIII, Bergamo, Italy
| | - Marco Metra
- Cardiology, Department of medical and surgical specialties, radiological sciences and public health, University and ASST Spedali Civili, Brescia
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42
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Cleland JGF, van Veldhuisen DJ, Ponikowski P. The year in cardiology 2018: heart failure. Eur Heart J 2019; 40:651-661. [DOI: 10.1093/eurheartj/ehz010] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/02/2019] [Accepted: 01/08/2019] [Indexed: 12/19/2022] Open
Affiliation(s)
- John G F Cleland
- Robertson Centre for Biostatistics & Clinical Trials, University of Glasgow, Glasgow, UK
- National Heart & Lung Institute, Royal Brompton & Harefield Hospitals, Imperial College, London, UK
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Centre for Heart Diseases, Military Hospital, ul.Weigla 5, 50-981 Wroclaw, Poland
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43
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Response to the Letter to the Editor – “The PARADIGM-HF population may be very different from real-world heart failure patients”. Rev Port Cardiol 2019; 38:165. [DOI: 10.1016/j.repc.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Rodrigues G, Tralhão A, Aguiar C, Freitas P, Ventosa A, Mendes M. Response to the Letter to the Editor – “The PARADIGM-HF population may be very different from real-world heart failure patients”. REVISTA PORTUGUESA DE CARDIOLOGIA (ENGLISH EDITION) 2019. [DOI: 10.1016/j.repce.2019.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
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45
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Manolis AS, Manolis TA, Manolis AA, Melita H. Neprilysin Inhibitors: Filling a Gap in Heart Failure Management, Albeit Amidst Controversy and at a Significant Cost. Am J Cardiovasc Drugs 2019; 19:21-36. [PMID: 29926350 DOI: 10.1007/s40256-018-0289-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Dual angiotensin and neprilysin inhibition using the combination drug sacubitril-valsartan has ushered in a new era in the treatment of heart failure (HF). The randomized controlled PARADIGM-HF trial, which randomized 8399 patients with HF to enalapril or sacubitril-valsartan, showed a 20% reduction in mortality and HF hospitalization with the new drug. This has been heralded as a step toward filling a crucial gap in HF management by providing strong evidence that combined inhibition of the angiotensin receptor and neprilysin is superior to inhibition of the renin-angiotensin system alone in stable patients with chronic HF as it negates the deleterious effects of angiotensin while concomitantly augmenting the beneficial effects of the endogenous natriuretic peptide system. This new therapy is costly, and other confirmatory studies have been lacking for over 2 years since its approval by major regulatory authorities. As such, controversy and heated discussions have amassed, as has detailed information from a plethora of secondary analyses of this pivotal trial about the pros and cons of this promising new therapeutic strategy in HF management. The aim of this review was to provide a critical assessment of all these aspects.
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Affiliation(s)
- Antonis S Manolis
- Third Department of Cardiology, Athens University School of Medicine, Vas. Sofias 114, 115 27, Athens, Greece.
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Pellicori P, Shah P, Cuthbert J, Urbinati A, Zhang J, Kallvikbacka-Bennett A, Clark AL, Cleland JGF. Prevalence, pattern and clinical relevance of ultrasound indices of congestion in outpatients with heart failure. Eur J Heart Fail 2019; 21:904-916. [PMID: 30666769 DOI: 10.1002/ejhf.1383] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Revised: 07/13/2018] [Accepted: 11/11/2018] [Indexed: 12/28/2022] Open
Abstract
AIMS Even if treatment controls symptoms, patients with heart failure may still be congested. We aimed at assessing the prevalence and clinical relevance of congestion in outpatients with chronic heart failure. METHODS AND RESULTS We recorded clinical and ultrasound [lung B-lines; inferior vena cava (IVC) diameter; internal jugular vein diameter before and after a Valsalva manoeuvre (JVD ratio)] features of congestion in heart failure patients during a routine check-up. Of 342 patients who attended, predominantly in New York Heart Association class I or II (n = 257; 75%), 242 (71%) had at least one feature of congestion, either clinical (n = 139; 41%) or by ultrasound (n = 199; 58%). Amongst patients (n = 203, 59%) clinically free of congestion, 31 (15%) had ≥ 14 B-lines, 57 (29%) had a dilated IVC (> 2.0 cm), 38 (20%) had an abnormal JVD ratio (< 4), 87 (43%) had at least one of these, and 27 (13%) had two or more. During a median follow-up of 234 (interquartile range 136-351) days, 60 patients (18%) died or were hospitalized for heart failure. In univariable analysis, each clinical and ultrasound measure of congestion was associated with increased risk but, in multivariable models, only higher N-terminal pro-B-type natriuretic peptide and IVC, and lower JVD ratio, were associated with the composite outcome. CONCLUSIONS Many patients with chronic heart failure with few symptoms have objective evidence of congestion and this is associated with an adverse prognosis. Whether using these measures of congestion to guide management improves outcomes requires investigation.
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Affiliation(s)
- Pierpaolo Pellicori
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK.,Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Parin Shah
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Joe Cuthbert
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Alessia Urbinati
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Jufen Zhang
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK.,Faculty of Medical Science, Anglia Ruskin University, Chelmsford, UK
| | - Anna Kallvikbacka-Bennett
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - Andrew L Clark
- Department of Cardiology, Castle Hill Hospital, Hull York Medical School (at University of Hull), Kingston upon Hull, UK
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK.,National Heart & Lung Institute and National Institute of Health Research Cardiovascular Biomedical Research Unit, Royal Brompton & Harefield Hospitals, Imperial College London, London, UK
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Real-World Eligibility for Sacubitril/Valsartan in Heart Failure with Reduced Ejection Fraction Patients in Korea: Data from the Korean Acute Heart Failure (KorAHF) Registry. INTERNATIONAL JOURNAL OF HEART FAILURE 2019; 1:57-68. [PMID: 36262737 PMCID: PMC9536672 DOI: 10.36628/ijhf.2019.0007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/06/2019] [Accepted: 10/07/2019] [Indexed: 12/11/2022]
Abstract
Background and Objectives Sacubitril/valsartan (SV, LCZ696), the first in class drug, called as angiotensin receptor-neprilysin inhibitor (ARNI) can reduce heart failure (HF) hospitalization and cardiovascular mortality. However, SV prescription rate remains still low despite current HF guideline recommendations. Considering the complex inclusion criteria of Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, the real-world eligibility for SV remains uncertain in Asian heart failure with reduced ejection fraction (HFrEF) patients. Therefore, we aimed to assess real-world HF population eligibility for SV in a large Korean acute HF registry. Methods From March 2011 to February 2014, a total of 5,625 patients who were admitted for HF were enrolled in Korea. After excluding HF patients with left ventricular ejection fraction > 40% and in-hospital death, 2,941 patients were analyzed. Criteria for SV based on Korean Food and Drug Administration (KFDA) label and PARADIGM-HF were applied. Results Of 2,941 patients, KFDA label criteria excludes the absence of symptoms (New York Heart Association class I, 20%); PARADIGM-HF criteria excludes chronic kidney disease stage IV (9%), hyperkalemia (1%), hypotension (6%), and sub-optimal pharmacotherapy (52%, e.g. lower dose use of angiotensin converting enzyme inhibitor/angiotensin receptor blocker [ACEI/ARB], beta blocker use). When a daily requirement of ACEI/ARB ≥5 mg enalapril (instead of ≥10 mg) was used, the percent of eligibility for SV rose from 12% to 30% based on the PARADIGM-HF criteria. Conclusions Among the Korean hospitalized HFrEF patients, 80% met KFDA label criteria, while only 12% met the inclusion criteria of PARADIGM-HF trial for SV if requiring ≥10 mg enalapril. Sub-optimal pharmacotherapy could be the main reason for ineligible SV use based on the PARADIGM-HF criteria.
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48
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Dinatolo E, Sciatti E, Anker MS, Lombardi C, Dasseni N, Metra M. Updates in heart failure: what last year brought to us. ESC Heart Fail 2018; 5:989-1007. [PMID: 30570225 PMCID: PMC6300825 DOI: 10.1002/ehf2.12385] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Indexed: 12/21/2022] Open
Affiliation(s)
- Elisabetta Dinatolo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Edoardo Sciatti
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Markus S. Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Berlin‐Brandenburg Center for Regenerative Therapies (BCRT), DZHK (German Centre for Cardiovascular Research), partner site BerlinCharité—Universitätsmedizin BerlinBerlinGermany
| | - Carlo Lombardi
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Nicolò Dasseni
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public HealthUniversity of BresciaBresciaItaly
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Khan Z, Gholkar G, Tolia S, Kado H, Zughaib M. Effect of sacubitril/valsartan on cardiac filling pressures in patients with left ventricular systolic dysfunction. Int J Cardiol 2018; 271:169-173. [DOI: 10.1016/j.ijcard.2018.03.093] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2018] [Accepted: 03/19/2018] [Indexed: 12/28/2022]
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50
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Fontes‐Carvalho R. Uso do Sacubitril/Valsartan no «mundo real»: da teoria à prática clínica. Rev Port Cardiol 2018; 37:497-498. [DOI: 10.1016/j.repc.2018.04.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
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