1
|
Narayan SI, Terre GV, Amin R, Shanghavi KV, Chandrashekar G, Ghouse F, Ahmad BA, S GN, Satram C, Majid HA, Bayoro DK. The Pathophysiology and New Advancements in the Pharmacologic and Exercise-Based Management of Heart Failure With Reduced Ejection Fraction: A Narrative Review. Cureus 2023; 15:e45719. [PMID: 37868488 PMCID: PMC10590213 DOI: 10.7759/cureus.45719] [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] [Accepted: 09/21/2023] [Indexed: 10/24/2023] Open
Abstract
Heart failure with reduced ejection fraction (HFrEF) is a clinical syndrome whose management has significantly evolved based on the pathophysiology and disease process. It is widely prevalent, has a relatively high mortality rate, and is comparatively more common in men than women. In HFrEF, the series of maladaptive processes that occur lead to an inability of the muscle of the left ventricle to pump blood efficiently and effectively, causing cardiac dysfunction. The neurohormonal and hemodynamic adaptations play a significant role in the advancement of the disease and are critical to guiding the treatment and management of HFrEF. The first-line therapy, which includes loop diuretics, β-blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, hydralazine/isosorbide-dinitrate, and mineralocorticoid receptor antagonists (MRAs), has been proven to provide symptomatic relief and decrease mortality and complications. The newly recommended drugs for guideline-based therapy, angiotensin receptor/neprilysin inhibitor (ARNI), sodium-glucose cotransporter 2 inhibitors, soluble guanylate cyclase, and myosin activators and modulators have also been shown to improve cardiac function, reverse cardiac remodeling, and reduce mortality rates. Recent studies have demonstrated that exercise-based therapy has resulted in an improved quality of life, exercise capacity, cardiac function, and decreased hospital readmission rates, but it has not had a considerable reduction in mortality rates. Combining multiple therapies alongside holistic advances such as exercise therapy may provide synergistic benefits, ultimately leading to improved outcomes for patients with HFrEF. Although first-line treatment, novel pharmacologic management, and exercise-based therapy have been shown to improve prognosis, the existing literature suggests a need for further studies evaluating the long-term effects of MRA and ARNI.
Collapse
Affiliation(s)
| | - Giselle V Terre
- Department of Medicine, Universidad Iberoamericana (UNIBE), Santo Domingo, DOM
| | - Rutvi Amin
- Department of Medicine, Surat Municipal Institute of Medical Education and Research, Surat, IND
| | - Keshvi V Shanghavi
- Department of Medicine, Lokmanya Tilak Municipal Medical College and Sion Hospital, Mumbai, IND
| | | | - Farhana Ghouse
- Department of Medicine, Saint James School of Medicine, St. Vincent, VCT
| | - Binish A Ahmad
- Department of Medicine, King Edward Medical University, Lahore, PAK
| | - Gowri N S
- Department of Medicine, Taras Shevchenko National University of Kyiv, Kyiv, UKR
| | - Christena Satram
- Department of Medicine, Lincoln American University, Georgetown, GUY
| | - Hamna A Majid
- Department of Medicine, Dow University of Health Sciences, Dow International Medical College, Karachi, PAK
| | - Danielle K Bayoro
- Department of Medicine, Medical University of the Americas, Nevis, KNA
| |
Collapse
|
2
|
Pagnesi M, Metra M, Cohen-Solal A, Edwards C, Adamo M, Tomasoni D, Lam CSP, Chioncel O, Diaz R, Filippatos G, Ponikowski P, Sliwa K, Voors AA, Kimmoun A, Novosadova M, Takagi K, Barros M, Damasceno A, Saidu H, Gayat E, Pang PS, Celutkiene J, Cotter G, Mebazaa A, Davison B. Uptitrating Treatment After Heart Failure Hospitalization Across the Spectrum of Left Ventricular Ejection Fraction. J Am Coll Cardiol 2023; 81:2131-2144. [PMID: 37257948 DOI: 10.1016/j.jacc.2023.03.426] [Citation(s) in RCA: 21] [Impact Index Per Article: 21.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/28/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Acute heart failure (AHF) is associated with a poor prognosis regardless of left ventricular ejection fraction (LVEF). STRONG-HF showed the efficacy and safety of a strategy of rapid uptitration of oral treatment for heart failure (HF) and close follow-up (high-intensity care), compared with usual care, in patients recently hospitalized for AHF and enrolled independently from their LVEF. OBJECTIVES In this study, we sought to assess the impact of baseline LVEF on the effects of high-intensity care vs usual care in STRONG-HF. METHODS The STRONG-HF trial enrolled patients hospitalized for AHF with any LVEF and not treated with full doses of renin-angiotensin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists. High-intensity care with uptitration of oral medications was performed independently from LVEF. The primary endpoint was the composite of HF rehospitalization or all-cause death at day 180. RESULTS Among the 1,078 patients randomized, 731 (68%) had LVEF ≤40% and 347 (32%) had LVEF >40%. The treatment benefit of high-intensity care vs usual care on the primary endpoint was consistent across the whole LVEF spectrum (interaction P with LVEF as a continuous variable = 0.372). Mean difference in the EQ-5D visual analog scale change from baseline to day 90 between treatment arms was slightly greater at higher LVEF values, but with no interaction between LVEF as a continuous variable and the treatment strategy (interaction P = 0.358). Serious adverse events were also independent from LVEF. CONCLUSIONS Rapid uptitration of oral medications for HF and close follow-up reduce 180-day death and HF rehospitalization after AHF hospitalization independently from LVEF. (Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-ProBNP Testing, of Heart Failure Therapies [STRONG-HF]; NCT03412201).
Collapse
Affiliation(s)
- Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia, Brescia, Italy.
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia, Brescia, Italy.
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Department of Cardiology, Lariboisière University Hospital, AP-HP Nord, Paris, France
| | | | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiologic Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore; Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof C.C. Iliescu," University of Medicine "Carol Davila," Bucharest, Romania
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Gerasimos Filippatos
- School of Medicine, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Antoine Kimmoun
- Université de Lorraine, INSERM, Défaillance Circulatoire Aigue et Chronique, and Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | | | - Koji Takagi
- Momentum Research, Durham, North Carolina, USA
| | | | | | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital/Bayero University Kano, Kano, Nigeria
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, AP/HP Nord, Paris, France
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Momentum Research, Durham, North Carolina, USA
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, AP/HP Nord, Paris, France
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Momentum Research, Durham, North Carolina, USA
| |
Collapse
|
3
|
Mebazaa A, Davison B, Chioncel O, Cohen-Solal A, Diaz R, Filippatos G, Metra M, Ponikowski P, Sliwa K, Voors AA, Edwards C, Novosadova M, Takagi K, Damasceno A, Saidu H, Gayat E, Pang PS, Celutkiene J, Cotter G. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial. Lancet 2022; 400:1938-1952. [PMID: 36356631 DOI: 10.1016/s0140-6736(22)02076-1] [Citation(s) in RCA: 226] [Impact Index Per Article: 113.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is a paucity of evidence for dose and pace of up-titration of guideline-directed medical therapies after admission to hospital for acute heart failure. METHODS In this multinational, open-label, randomised, parallel-group trial (STRONG-HF), patients aged 18-85 years admitted to hospital with acute heart failure, not treated with full doses of guideline-directed drug treatment, were recruited from 87 hospitals in 14 countries. Before discharge, eligible patients were randomly assigned (1:1), stratified by left ventricular ejection fraction (≤40% vs >40%) and country, with blocks of size 30 within strata and randomly ordered sub-blocks of 2, 4, and 6, to either usual care or high-intensity care. Usual care followed usual local practice, and high-intensity care involved the up-titration of treatments to 100% of recommended doses within 2 weeks of discharge and four scheduled outpatient visits over the 2 months after discharge that closely monitored clinical status, laboratory values, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations. The primary endpoint was 180-day readmission to hospital due to heart failure or all-cause death. Efficacy and safety were assessed in the intention-to-treat (ITT) population (ie, all patients validly randomly assigned to treatment). The primary endpoint was assessed in all patients enrolled at hospitals that followed up patients to day 180. Because of a protocol amendment to the primary endpoint, the results of patients enrolled on or before this amendment were down-weighted. This study is registered with ClinicalTrials.gov, NCT03412201, and is now complete. FINDINGS Between May 10, 2018, and Sept 23, 2022, 1641 patients were screened and 1078 were successfully randomly assigned to high-intensity care (n=542) or usual care (n=536; ITT population). Mean age was 63·0 years (SD 13·6), 416 (39%) of 1078 patients were female, 662 (61%) were male, 832 (77%) were White or Caucasian, 230 (21%) were Black, 12 (1%) were other races, one (<1%) was Native American, and one (<1%) was Pacific Islander (two [<1%] had missing data on race). The study was stopped early per the data and safety monitoring board's recommendation because of greater than expected between-group differences. As of data cutoff (Oct 13, 2022), by day 90, a higher proportion of patients in the high-intensity care group had been up-titrated to full doses of prescribed drugs (renin-angiotensin blockers 278 [55%] of 505 vs 11 [2%] of 497; β blockers 249 [49%] vs 20 [4%]; and mineralocorticoid receptor antagonists 423 [84%] vs 231 [46%]). By day 90, blood pressure, pulse, New York Heart Association class, bodyweight, and NT-proBNP concentration had decreased more in the high-intensity care group than in the usual care group. Heart failure readmission or all-cause death up to day 180 occurred in 74 (15·2% down-weighted adjusted Kaplan-Meier estimate) of 506 patients in the high-intensity care group and 109 (23·3%) of 502 patients in the usual care group (adjusted risk difference 8·1% [95% CI 2·9-13·2]; p=0·0021; risk ratio 0·66 [95% CI 0·50-0·86]). More adverse events by 90 days occurred in the high-intensity care group (223 [41%] of 542) than in the usual care group (158 [29%] of 536) but similar incidences of serious adverse events (88 [16%] vs 92 [17%]) and fatal adverse events (25 [5%] vs 32 [6%]) were reported in each group. INTERPRETATION An intensive treatment strategy of rapid up-titration of guideline-directed medication and close follow-up after an acute heart failure admission was readily accepted by patients because it reduced symptoms, improved quality of life, and reduced the risk of 180-day all-cause death or heart failure readmission compared with usual care. FUNDING Roche Diagnostics.
Collapse
Affiliation(s)
- Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France.
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Momentum Research, Durham, NC, USA
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof C C Iliescu", University of Medicine "Carol Davila", Bucharest, Romania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; APHP Nord, Department of Cardiology, Lariboisière University Hospital, Paris, France
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | | | | | | | | | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital, Bayero University Kano, Kano, Nigeria
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Momentum Research, Durham, NC, USA
| |
Collapse
|
4
|
Jacob J, Haro A, Tost J, Rossello X, Llorens P, Herrero P, Martín-Sánchez FJ, Gil V, López-Grima ML, Millán J, Aguirre A, Garrido JM, Calvo-Rodríguez R, Pérez-Llantada E, Sánchez-Nicolás JA, Mir M, Rodríguez-Adrada E, Fuentes-De Frutos M, Roset A, Miró Ò. Short-term outcomes by chronic betablocker treatment in patients presenting to emergency departments with acute heart failure: BB-EAHFE. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2022; 11:761-771. [PMID: 36018216 DOI: 10.1093/ehjacc/zuac100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/10/2022] [Revised: 08/06/2022] [Accepted: 08/08/2022] [Indexed: 06/15/2023]
Abstract
AIMS To evaluate the association between chronic treatment with betablockers (BB) and the severity of decompensation and short-term outcomes of patients with acute heart failure (AHF). METHODS AND RESULTS We consecutively included all patients presenting with AHF to 45 Spanish emergency departments (ED) during six different time-periods between 2007 and 2018. Patients were stratified according to whether they were on chronic treatment with BB at the time of ED consultation. Those receiving BB were compared (adjusted odds ratio-OR-with 95% confidence interval-CI-) with those not receiving BB group in terms of in-hospital and 7-day all-cause mortality, need for hospitalization, and prolonged length of stay (≥7 days). Among the 17 923 recruited patients (median age: 80 years; 56% women), 7795 (43%) were on chronic treatment with BB. Based on the MEESSI-AHF risk score, those on BB were at lower risk. In-hospital mortality was observed in 1310 patients (7.4%), 7-day mortality in 765 (4.3%), need for hospitalization in 13 428 (75.0%), and prolonged length of stay (43.3%). After adjustment for confounding, those on chronic BB were at lower risk for in-hospital all-cause mortality (OR = 0.85, 95% CI = 0.79-0.92, P < 0.001); 7-day all-cause mortality (OR = 0.77, 95% CI = 0.70-0.85, P < 0.001); need for hospitalization (OR = 0.89, 95% CI = 0.85-0.94, P < 0.001); prolonged length of stay (OR = 0.90, 95% CI = 0.86-0.94, P < 0.001). A propensity matching approach yielded consistent findings. CONCLUSION In patients presenting to ED with AHF, those on BB had better short-term outcomes than those not receiving BB.
Collapse
Affiliation(s)
- Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, Institute of Biomedical Research of Bellvitge (IDIBELL), University of Barcelona (UB), Feixa Llarga s/n, L'Hospitalet de Llobregat 08907, Barcelona, Spain
| | - Antoni Haro
- Emergency Department, Hospital Universitari de Bellvitge, Institute of Biomedical Research of Bellvitge (IDIBELL), University of Barcelona (UB), Feixa Llarga s/n, L'Hospitalet de Llobregat 08907, Barcelona, Spain
| | - Josep Tost
- Emergency Department, Consorci Hospitalari de Terrassa, 08227 Terrassa, Barcelona, Spain
| | - Xavier Rossello
- Cardiology Department, Health Research Institute of the Balearic Islands (IdISBa), Hospital Universitari Son Espases, 07010 Palma, Spain
| | - Pere Llorens
- Emergency Department, Short Stay Unit and Hospital at Home, Hospital General de Alicante, Instituto de Investigación Sanitaria y Biómedica de Alicante (ISABIAL), Miguel Hernández University, 03010 Alicante, Spain
| | - Pablo Herrero
- Emergency Department, Hospital Central Asturias, 33011 Oviedo, Spain
| | | | - Víctor Gil
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
| | | | - Javier Millán
- Emergency Department, Hospital Universitario La Fe, 46009 Valencia, Spain
| | - Alfons Aguirre
- Emergency Department, Hospital del Mar, 08003 Barcelona, Spain
| | | | - Rafael Calvo-Rodríguez
- Emergency Department, Hospital Reina Sofía de Córdoba, Instituto Maimónides de Investigación Biomédica de Córdoba (IMIBIC), 14004 Córdoba, Spain
| | | | | | - María Mir
- Emergency Department, Hospital Infanta Leonor, 28031 Madrid, Spain
| | | | | | - Alex Roset
- Emergency Department, Hospital Universitari de Bellvitge, Institute of Biomedical Research of Bellvitge (IDIBELL), University of Barcelona (UB), Feixa Llarga s/n, L'Hospitalet de Llobregat 08907, Barcelona, Spain
| | - Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, University of Barcelona, 08036 Barcelona, Spain
| |
Collapse
|
5
|
Hemodynamic Impact of Cardiovascular Antihypertensive Medications in Patients With Sepsis-Related Acute Circulatory Failure. Shock 2021; 54:315-320. [PMID: 32080062 DOI: 10.1097/shk.0000000000001524] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Impact of prior cardiovascular antihypertensive medication during the initial phase of septic shock in terms of catecholamine requirements and mortality has been poorly investigated and remains unclear. OBJECTIVES To investigate the association between chronic prescription of cardiovascular antihypertensive medication prior to intensive care unit (ICU) admission, catecholamine requirement, and mortality in patients with septic shock. METHODS We included all consecutive patients diagnosed with septic shock within the first 24 h of ICU admission, defined as a microbiologically proven or clinically suspected infection, associated with acute circulatory failure requiring vasopressors despite adequate fluid filling. Prior cardiovascular antihypertensive medication was defined as the chronic use of betablockers (BB), calcium channel blockers (CCB), angiotensin converting enzyme inhibitor (ACEi)/angiotensin receptor blockers (ARB). ICU mortality was investigated using multivariate competitive risk analysis. RESULTS Among 735 patients admitted for septic shock between 2008 and 2016, 46.9% received prior cardiovascular antihypertensive medication. Prior cardiovascular antihypertensive therapy was not associated with increased norepinephrine requirements during the first 24 h (median = 0.28 μg/kg/min in patients previously treated vs. 0.26 μg/kg/min). Prior cardiovascular antihypertensive medication was not associated with a higher risk of ICU mortality after adjustment (cause-specific hazard = 1.28, 95% confidence interval [0.98-1.66], P = 0.06). Subgroups analyses for BB, CCB, and ACEi/ARB using propensity score analyses retrieved similar results. CONCLUSION In patients admitted with septic shock, prior cardiovascular antihypertensive medication seems to have limited impact on initial hemodynamic failure and catecholamine requirement.
Collapse
|
6
|
Tamaki Y, Yaku H, Morimoto T, Inuzuka Y, Ozasa N, Yamamoto E, Yoshikawa Y, Miyake M, Kondo H, Tamura T, Kitai T, Iguchi M, Nagao K, Nishikawa R, Kawase Y, Morinaga T, Kawato M, Toyofuku M, Sato Y, Kuwahara K, Nakagawa Y, Kato T, Kimura T. Lower In-Hospital Mortality With Beta-Blocker Use at Admission in Patients With Acute Decompensated Heart Failure. J Am Heart Assoc 2021; 10:e020012. [PMID: 34180244 PMCID: PMC8403288 DOI: 10.1161/jaha.120.020012] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background It remains unclear whether beta‐blocker use at hospital admission is associated with better in‐hospital outcomes in patients with acute decompensated heart failure. Methods and Results We evaluated the factors independently associated with beta‐blocker use at admission, and the effect of beta‐blocker use at admission on in‐hospital mortality in 3817 patients with acute decompensated heart failure enrolled in the Kyoto Congestive Heart Failure registry. There were 1512 patients (39.7%) receiving, and 2305 patients (60.3%) not receiving beta‐blockers at admission for the index acute decompensated heart failure hospitalization. Factors independently associated with beta‐blocker use at admission were previous heart failure hospitalization, history of myocardial infarction, atrial fibrillation, cardiomyopathy, and estimated glomerular filtration rate <30 mL/min per 1.73 m2. Factors independently associated with no beta‐blocker use were asthma, chronic obstructive pulmonary disease, lower body mass index, dementia, older age, and left ventricular ejection fraction <40%. Patients on beta‐blockers had significantly lower in‐hospital mortality rates (4.4% versus 7.6%, P<0.001). Even after adjusting for confounders, beta‐blocker use at admission remained significantly associated with lower in‐hospital mortality risk (odds ratio, 0.41; 95% CI, 0.27–0.60, P<0.001). Furthermore, beta‐blocker use at admission was significantly associated with both lower cardiovascular mortality risk and lower noncardiovascular mortality risk. The association of beta‐blocker use with lower in‐hospital mortality risk was relatively more prominent in patients receiving high dose beta‐blockers. The magnitude of the effect of beta‐blocker use was greater in patients with previous heart failure hospitalization than in patients without (P for interaction 0.04). Conclusions Beta‐blocker use at admission was associated with lower in‐hospital mortality in patients with acute decompensated heart failure. Registration URL: https://www.upload.umin.ac.jp/; Unique identifier: UMIN000015238.
Collapse
Affiliation(s)
- Yodo Tamaki
- Department of Cardiology Tenri Hospital Nara Japan
| | - Hidenori Yaku
- Department of Cardiology Mitsubishi Kyoto Hospital Kyoto Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology Hyogo College of Medicine Hyogo Japan
| | - Yasutaka Inuzuka
- Department of Cardiovascular Medicine Shiga General Hospital Shiga Japan
| | - Neiko Ozasa
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Erika Yamamoto
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Yusuke Yoshikawa
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | | | | | | | - Takeshi Kitai
- Department of Cardiovascular Medicine Kobe City Medical Center General Hospital Hyogo Japan
| | - Moritake Iguchi
- Department of Cardiology National Hospital Organization Kyoto Medical Center Kyoto Japan
| | - Kazuya Nagao
- Cardiovascular Center Osaka Red Cross Hospital Osaka Japan
| | | | - Yuichi Kawase
- Department of Cardiovascular Medicine Kurashiki Central Hospital Okayama Japan
| | | | | | - Mamoru Toyofuku
- Department of Cardiology Japanese Red Cross Wakayama Medical Center Wakayama Japan
| | - Yukihito Sato
- Department of Cardiology Hyogo Prefectural Amagasaki General Medical Center Hyogo Japan
| | - Koichiro Kuwahara
- Department of Cardiovascular Medicine Shinshu University Nagano Japan
| | - Yoshihisa Nakagawa
- Division of Cardiovascular Medicine Shiga University of Medical Science Shiga Japan
| | - Takao Kato
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | - Takeshi Kimura
- Department of Cardiovascular Medicine Kyoto University Graduate School of Medicine Kyoto Japan
| | | |
Collapse
|
7
|
Miró Ò, Martínez G, Masip J, Gil V, Martín-Sánchez FJ, Llorens P, Herrero-Puente P, Sánchez C, Richard F, Lucas-Invernón J, Garrido JM, Mebazaa A, Ríos J, Peacock WF, Hollander JE, Jacob J. Effects on short term outcome of non-invasive ventilation use in the emergency department to treat patients with acute heart failure: A propensity score-based analysis of the EAHFE Registry. Eur J Intern Med 2018; 53:45-51. [PMID: 29572091 DOI: 10.1016/j.ejim.2018.03.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2017] [Revised: 01/24/2018] [Accepted: 03/11/2018] [Indexed: 10/17/2022]
Abstract
OBJECTIVE To assess the effects of non-invasive ventilation (NIV) in emergency department (ED) patients with acute heart failure (AHF) on short term outcomes. METHODS Patients from the EAHFE Registry (a multicenter, observational, multipurpose, cohort-designed database including consecutive AHF patients in 41 Spanish EDs) were grouped based on NIV treatment (NIV+ and NIV-groups). Using propensity score (PS) methodology, we identified two subgroups of patients matched by 38 covariates and compared regarding 30-day survival (primary outcome). Interaction was investigated for age, sex, ischemic cardiomyopathy, chronic obstructive pulmonary disease, AHF precipitated by an acute coronary syndrome (ACS), AHF classified as hypertensive or acute pulmonary edema (APE), and systolic blood pressure (SBP). Secondary outcomes were intensive care unit (ICU) admission; mechanical ventilation; in-hospital, 3-day and 7-day mortality; and prolonged hospitalization (>7 days). RESULTS Of 11,152 patients from the EAHFE (age (SD): 80 (10) years; 55.5% women), 718 (6.4%) were NIV+ and had a higher 30-day mortality (HR = 2.229; 95%CI = 1.861-2.670) (p < 0.001). PS matching provided 2 groups of 490 patients each with no significant differences in 30-day mortality (HR = 1.239; 95%CI = 0.905-1.696) (p = 0.182). Interaction analysis suggested a worse effect of NIV on elderly patients (>85 years, p < 0.001), AHF associated with ACS (p = 0.045), and SBP < 100 mmHg (p < 0.001). No significant differences were found in the secondary endpoints except for more prolonged hospitalizations in NIV+ patients (OR = 1.445; 95%CI = 1.122-1.862) (p = 0.004). CONCLUSION The use of NIV to treat AHF in ED is not associated with improved mortality outcomes and should be cautious in old patients and those with ACS and hypotension.
Collapse
Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, Spain; Medical School, University of Barcelona, Spain; The GREAT Network, Italy.
| | | | - Josep Masip
- The GREAT Network, Italy; Cardiology Department, Hospital Sanitas CIMA Barcelona, Spain; Hospital de St Joan Despí Moisès Broggi, University of Barcelona, Spain
| | - Víctor Gil
- Emergency Department, Hospital Clínic, Barcelona, Spain
| | | | - Pere Llorens
- Emergency Department, Home Hospitalization and Short Stay Unit, Hospital General de Alicante, Alicante, Spain
| | | | | | | | | | | | - Alexandre Mebazaa
- The GREAT Network, Italy; Department of Anesthesiology and Critical Care Medicine, Hospital Lariboisière, Université Paris Diderot, Paris, France
| | - José Ríos
- Laboratory of Biostatistics & Epidemiology, Universitat Autònoma de Barcelona, Medical Statistics Core Facility, IDIBAPS, Hospital Clinic, Barcelona, Spain
| | - W Frank Peacock
- The GREAT Network, Italy; Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Judd E Hollander
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, USA
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| |
Collapse
|
8
|
Abstract
Heart failure is one of the leading diseases in internal medicine worldwide. Because of the increase in population aging, the incidence and prevalence of heart insufficiency is rising annually and is now the most frequent individual diagnosis among hospitalized patients in Germany. The mortality rate has recently been reduced, since new pharmacological options, especially the inhibition of neprilysin, have been developed; however, heart failure is still associated with a high mortality and morbidity rate. Thus, guideline-conform treatment is of crucial importance. This review highlights and summarizes the current scientific knowledge on heart failure from 2017 and 2018 based on the guidelines of the European Society of Cardiology. New aspects about heart failure with middle grade limitations of ejection fraction are firstly presented. Subsequently, innovative diagnostic and therapeutic strategies, new pharmacological developments and handling of frequent comorbidities in patients with heart failure are discussed.
Collapse
Affiliation(s)
- J Wintrich
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrbergerstraße, 66421, Homburg/Saar, Deutschland.
| | - I Kindermann
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrbergerstraße, 66421, Homburg/Saar, Deutschland
| | - M Böhm
- Klinik für Innere Medizin III - Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Kirrbergerstraße, 66421, Homburg/Saar, Deutschland
| |
Collapse
|
9
|
Tasas de reconsulta, hospitalización y muerte a corto plazo tras el alta directa desde Urgencias de pacientes con insuficiencia cardiaca aguda y análisis de los factores asociados. Estudio ALTUR-ICA. Med Clin (Barc) 2018; 150:167-177. [DOI: 10.1016/j.medcli.2017.06.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 06/01/2017] [Accepted: 06/08/2017] [Indexed: 01/15/2023]
|
10
|
Miró Ò, Estruch R, Martín-Sánchez FJ, Gil V, Jacob J, Herrero-Puente P, Herrera Mateo S, Aguirre A, Andueza JA, Llorens P. Adherence to Mediterranean Diet and All-Cause Mortality After an Episode of Acute Heart Failure: Results of the MEDIT-AHF Study. JACC-HEART FAILURE 2017; 6:52-62. [PMID: 29226819 DOI: 10.1016/j.jchf.2017.09.020] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/29/2017] [Revised: 09/17/2017] [Accepted: 09/19/2017] [Indexed: 12/21/2022]
Abstract
OBJECTIVES The authors sought to evaluate clinical outcomes of patients after an episode of acute heart failure (AHF) according to their adherence to the Mediterranean diet (MedDiet). BACKGROUND It has been proved that MedDiet is a useful tool in primary prevention of cardiovascular diseases. However, it is unknown whether adherence to MedDiet is associated with better outcomes in patients who have already experienced an episode of AHF. METHODS We designed a prospective study that included consecutive patients diagnosed with AHF in 7 Spanish emergency departments (EDs). Patients were included if they or their relatives were able to answer a 14-point score of adherence to the MedDiet, which classified patients as adherents (≥9 points) or nonadherents (≤8 points). The primary endpoint was all-cause mortality at the end of follow-up, and secondary endpoints were 1-year ED revisit without hospitalization, rehospitalization, death, and a combined endpoint of all these variables for patients discharged after the index episode. Unadjusted and adjusted hazard ratios (HRs) were calculated. RESULTS We included 991 patients (mean age of 80 ± 10 years, 57.8% women); 523 (52.9%) of whom were adherent to the MedDiet. After a mean follow-up period of 2.1 ± 1.3 years, no differences were observed in survival between adherent and nonadherent patients (HR of adherents [HRadh] = 0.86; 95% confidence interval [CI]: 0.73 to 1.02). The 1-year cumulative ED revisit for the whole cohort was 24.5% (HRadh = 1.10; 95% CI: 0.84 to 1.42), hospitalization 43.7% (HRadh = 0.74; 95% CI: 0.61 to 0.90), death 22.7% (HRadh = 1.05; 95% CI: 0.8 to 1.38), and combined endpoint 66.8% (HRadh = 0.89; 95% CI: 0.76 to 1.04). Adjustment by age, hypertension, peripheral arterial disease, previous episodes of AHF, treatment with statins, air-room pulsioxymetry, and need for ventilation support in the ED rendered similar results, with no statistically significant differences in mortality (HRadh = 0.94; 95% CI: 0.80 to 1.13) and persistence of lower 1-year hospitalization for adherents (HRadh = 0.76; 95% CI: 0.62 to 0.93). CONCLUSIONS Adherence to the MedDiet did not influence long-term mortality after an episode of AHF, but it was associated with decreased rates of rehospitalization during the next year.
Collapse
Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clínic, IDIBAPS, Barcelona, Spain; School of Medicine, University of Barcelona, Barcelona, Spain.
| | - Ramon Estruch
- School of Medicine, University of Barcelona, Barcelona, Spain; Department of Internal Medicine, Hospital Clínic, IDIBAPS, Barcelona, Spain; CIBER OBN, Physiopathology of Obesity and Nutrition, Instituto de Salud Carlos III, Madrid, Spain
| | - Francisco J Martín-Sánchez
- Emergency Department, Hospital Clínico San Carlos, Madrid, Universidad Complutense de Madrid, Madrid, Spain
| | - Víctor Gil
- Emergency Department, Hospital Clínic, IDIBAPS, Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | | | - Alfons Aguirre
- Emergency Department, Hospital del Mar, Barcelona, Spain
| | - Juan A Andueza
- Emergency Department, Hospital Universitario Gregorio Marañón, Madrid, Spain
| | - Pere Llorens
- Emergency Department, Home Hospitalization and Short Stay Unit, Hospital General de Alicante, ISABIAL-FISABIO, Alicante, Spain
| |
Collapse
|
11
|
Réplica a «¿Influye la asistencia prehospitalaria en el perfil de los pacientes con insuficiencia cardiaca aguda?»Réplica a «¿Influye la asistencia prehospitalaria en pacientes con Insuficiencia cardiaca Aguda?». Rev Clin Esp 2017; 217:554-555. [DOI: 10.1016/j.rce.2017.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2017] [Accepted: 08/04/2017] [Indexed: 11/22/2022]
|
12
|
Rivinius R, Helmschrott M, Ruhparwar A, Rahm AK, Darche FF, Thomas D, Bruckner T, Ehlermann P, Katus HA, Doesch AO. Control of cardiac chronotropic function in patients after heart transplantation: effects of ivabradine and metoprolol succinate on resting heart rate in the denervated heart. Clin Res Cardiol 2017; 107:138-147. [DOI: 10.1007/s00392-017-1165-3] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2017] [Accepted: 09/19/2017] [Indexed: 01/15/2023]
|
13
|
Association of mineralocorticoid receptor antagonist use and in-hospital outcomes in patients with acute heart failure. Clin Res Cardiol 2017; 107:76-86. [DOI: 10.1007/s00392-017-1161-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/09/2017] [Accepted: 09/13/2017] [Indexed: 12/12/2022]
|
14
|
Miró Ò, Gil V, Peacock WF. Morphine in acute heart failure: good in relieving symptoms, bad in improving outcomes. J Thorac Dis 2017; 9:E871-E874. [PMID: 29221365 PMCID: PMC5708430 DOI: 10.21037/jtd.2017.08.22] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2017] [Accepted: 07/21/2017] [Indexed: 01/07/2023]
Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, Spain
- Medical School, University of Barcelona, Barcelona, Spain
- The GREAT Network, Roma, Italy
| | - Víctor Gil
- Emergency Department, Hospital Clínic, Barcelona, Spain
| | - W. Frank Peacock
- The GREAT Network, Roma, Italy
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
15
|
Miró Ò, Gil V, Martín-Sánchez FJ, Herrero-Puente P, Jacob J, Mebazaa A, Harjola VP, Ríos J, Hollander JE, Peacock WF, Llorens P. Morphine Use in the ED and Outcomes of Patients With Acute Heart Failure: A Propensity Score-Matching Analysis Based on the EAHFE Registry. Chest 2017; 152:821-832. [PMID: 28411112 DOI: 10.1016/j.chest.2017.03.037] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2016] [Revised: 02/28/2017] [Accepted: 03/31/2017] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE The objective was to determine the relationship between short-term mortality and intravenous morphine use in ED patients who received a diagnosis of acute heart failure (AHF). METHODS Consecutive patients with AHF presenting to 34 Spanish EDs from 2011 to 2014 were eligible for inclusion. The subjects were divided into those with (M) or without IV morphine treatment (WOM) groups during ED stay. The primary outcome was 30-day all-cause mortality, and secondary outcomes were mortality at different intermediate time points, in-hospital mortality, and length of hospital stay. We generated a propensity score to match the M and WOM groups that were 1:1 according to 46 different epidemiological, baseline, clinical, and therapeutic factors. We investigated independent risk factors for 30-day mortality in patients receiving morphine. RESULTS We included 6,516 patients (mean age, 81 [SD, 10] years; 56% women): 416 (6.4%) in the M and 6,100 (93.6%) in the WOM group. Overall, 635 (9.7%; M, 26.7%; WOM, 8.6%) died by day 30. After propensity score matching, 275 paired patients constituted each group. Patients receiving morphine had a higher 30-day mortality (55 [20.0%] vs 35 [12.7%] deaths; hazard ratio, 1.66; 95% CI, 1.09-2.54; P = .017). In patients receiving morphine, death was directly related to glycemia (P = .013) and inversely related to the baseline Barthel index and systolic BP (P = .021) at ED arrival (P = .021). Mortality was increased at every intermediate time point, although the greatest risk was at the shortest time (at 3 days: 22 [8.0%] vs 7 [2.5%] deaths; OR, 3.33; 95% CI, 1.40-7.93; P = .014). In-hospital mortality did not increase (39 [14.2%] vs 26 [9.1%] deaths; OR, 1.65; 95% CI, 0.97-2.82; P = .083) and LOS did not differ between groups (median [interquartile range] in M, 8 [7]; WOM, 8 [6]; P = .79). CONCLUSIONS This propensity score-matched analysis suggests that the use of IV morphine in AHF could be associated with increased 30-day mortality.
Collapse
Affiliation(s)
- Òscar Miró
- Emergency Department, Hospital Clínic, Barcelona, Spain.
| | - Víctor Gil
- Emergency Department, Hospital Clínic, Barcelona, Spain
| | | | | | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care Medicine, Hospital Lariboisière, Université Paris Diderot, Paris, France
| | - Veli-Pekka Harjola
- Emergency Medicine, Helsinki University, Department of Emergency Medicine and Services, Helsinki University Hospital, Helsinki, Finland
| | - José Ríos
- Laboratory of Biostatistics & Epidemiology, Universitat Autonoma de Barcelona; Medical Statistics Core Facility, Institut d'Investigacions Biomèdiques August Pi i Sunyer, Hospital Clinic, Barcelona, Spain
| | - Judd E Hollander
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - Pere Llorens
- Emergency Department, Home Hospitalization and Short Stay Unit, Hospital General de Alicante, Alicante, Spain
| | | |
Collapse
|
16
|
Escoda R, Miró Ò, Martín-Sánchez F, Jacob J, Herrero P, Gil V, Garrido J, Pérez-Durá M, Fuentes M, Llorens P. Evolution of the clinical profile of patients with acute heart failure treated in Spanish emergency departments. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2016.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
|
17
|
Evolución del perfil clínico de los pacientes con insuficiencia cardiaca aguda atendidos en servicios de urgencias españoles. Rev Clin Esp 2017; 217:127-135. [DOI: 10.1016/j.rce.2016.10.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 09/11/2016] [Accepted: 10/23/2016] [Indexed: 11/23/2022]
|