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Bismpos D, Wintrich J, Hövelmann J, Böhm M. Latest pharmaceutical approaches across the spectrum of heart failure. Heart Fail Rev 2024; 29:675-687. [PMID: 38349462 PMCID: PMC11035443 DOI: 10.1007/s10741-024-10389-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
Despite major advances in prevention and medical therapy, heart failure (HF) remains associated with high morbidity and mortality, especially in older and frailer patients. Therefore, a complete, guideline-based treatment is essential, even in HF patients with conditions traditionally associated with a problematic initiation and escalation of the medical HF therapy, such as chronic kidney disease and arterial hypotension, as the potential adverse effects are overcome by the overall decrease of the absolute risk. Furthermore, since the latest data suggest that the benefit of a combined medical therapy (MRA, ARNI, SGLT2i, beta-blocker) may extend up to a LVEF of 65%, further trials on these subgroups of patients (HFmrEF, HFpEF) are needed to re-evaluate the guideline-directed medical therapy across the HF spectrum. In particular, the use of SGLT2i was recently extended to HFpEF patients, as evidenced by the DELIVER and EMPEROR-preserved trials. Moreover, the indication for other conservative treatments in HF patients, such as the intravenous iron supplementation, was accordingly strengthened in the latest guidelines. Finally, the possible implementation of newer substances, such as finerenone, in guideline-directed medical practice for HF is anticipated with great interest.
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Affiliation(s)
- Dimitrios Bismpos
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany.
- Department of Internal Medicine II, Cardiology and Angiology, Marien Hospital Herne, University Clinic of the Ruhr University, Bochum University, Herne, Germany.
| | - Jan Wintrich
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Julian Hövelmann
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
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Prescription Rates and Prognostic Implications of Optimally Targeted Guideline-Directed Medical Treatment in Heart Failure and Atrial Fibrillation: Insights From The MISOAC-AF Trial. J Cardiovasc Pharmacol 2023; 81:203-211. [PMID: 36626410 DOI: 10.1097/fjc.0000000000001390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2022] [Accepted: 10/22/2022] [Indexed: 01/07/2023]
Abstract
ABSTRACT Heart failure (HF) and atrial fibrillation (AF) commonly coexist in real-life clinical practice. Among patients with HF with reduced ejection fraction (HFrEF) or HF with mildly reduced ejection fraction (HFmrEF), guidelines call for evidence-based target doses of renin-angiotensin-aldosterone system inhibitors and beta-blockers. However, target doses of guideline-directed medical treatment (GDMT) are often underused in real-world conditions, including HF-AF comorbidity. This retrospective cohort study of a randomized trial (Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with nonvalvular AF) included hospitalized patients with AF and HFrEF or HFmrEF. Optimally targeted GDMT was defined as intake of evidence-based target doses of renin-angiotensin-aldosterone system and beta-blockers at 3 months after discharge. Rates of optimally targeted GDMT achievement across the baseline estimated glomerular filtration rate (eGFR) were assessed. Independent predictors of nontargeted GDMT and its association with all-cause mortality and the composite of cardiovascular death or HF hospitalization were assessed by regression analyses. In total, 374 patients with AF and HFrEF or HFmrEF were studied. At 3 months after discharge, 30.7% received target doses of GDMT medications. The rate of optimally targeted GDMT was reduced by 11% for every 10 mg/min/1.73 m 2 decrease in baseline eGFR [adjusted β = 0.99; 95% confidence interval (CI), 0.98-0.99] levels. After a median 31-month follow-up period, 37.8% patients in the optimally targeted GDMT group died, as compared with 67.8% (adjusted hazard ratio: 1.49; 95% CI, 1.05-2.13) in the nontargeted GDMT group. The risk of cardiovascular death or HF hospitalization was also higher in these patients (adjusted hazard ratio: 1.60; 95% CI, 1.17-2.20). Target doses of all HF drugs were reached in roughly one-third of patients with AF and HFrEF or HFmrEF 3 months after hospital discharge. Nontargeted GDMT was more frequent across lower eGFR levels and was associated with worse outcomes.
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Jug B. Heart failure with reduced ejection fraction and low blood pressure: Overcoming another barrier to guideline-directed medical therapy? Int J Cardiol 2023; 372:83-84. [PMID: 36503083 DOI: 10.1016/j.ijcard.2022.12.007] [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: 11/12/2022] [Revised: 11/21/2022] [Accepted: 12/02/2022] [Indexed: 12/13/2022]
Affiliation(s)
- Borut Jug
- Department of Vascular Medicine, University Medical Center Ljubljana, Faculty of Medicine, University of Ljubljana, Slovenia.
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Low blood pressure and guideline-directed medical therapy in patients with heart failure with reduced ejection fraction. Int J Cardiol 2023; 370:255-262. [PMID: 36270494 DOI: 10.1016/j.ijcard.2022.10.129] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/11/2022] [Revised: 09/23/2022] [Accepted: 10/16/2022] [Indexed: 11/05/2022]
Abstract
BACKGROUND Patients with heart failure (HF) presenting with low blood pressure (BP) have been underrepresented in large-scale clinical trials. We investigated the characteristics and implementation of conventional guideline-directed medical therapy (GDMT; renin-angiotensin system inhibitors and β-blockers) in patients with low BP hospitalized for HF with systolic dysfunction. METHODS Conventional GDMT was evaluated by discharge BP among 2043 consecutive patients with HF and left ventricular ejection fraction (LVEF) < 50% in the WET-HF registry. Among the 708 (34.7%) patients with lower discharge BP (≤ 100 mmHg; the lower tertiles), exploratory subgroups included patients with previous HF hospitalization, inotrope use, New York Heart Association (NYHA) III-IV class, and lower estimated glomerular filtration rate (eGFR) and LVEF (lower than median value). We evaluated the risk-adjusted association between GDMT implementation and 2-year adverse events (all-cause mortality or HF rehospitalization). RESULTS Among the 2043 patients (age 74 [63-82] years), the median systolic BP was 108 (98-120) mmHg. Among patients with lower BP, GDMT prescription rate was 62.7%, and GDMT use was associated with decreased adverse events (HR:0.74, 95%CI:0.58-0.94). GDMT prescription rates were lower among higher-NYHA class and lower-eGFR subgroups compared with their reference subgroups, and directionally similar outcomes were noted in all subgroups (favoring GDMT use); however, this association was somewhat attenuated in the lower-eGFR group (HR:0.87, 95%CI:0.64-1.17). CONCLUSIONS Conventional GDMT use was associated with decreased adverse outcomes in most patients with HF compounded by systolic dysfunction and low BP, albeit caution is warranted in patients with renal dysfunction.
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Martin RC. Disparities in Heart Failure Management in Older Adults. CURRENT GERIATRICS REPORTS 2022. [DOI: 10.1007/s13670-022-00378-w] [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]
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Tomasoni D, Fonarow GC, Adamo M, Anker SD, Butler J, Coats AJS, Filippatos G, Greene SJ, McDonagh TA, Ponikowski P, Rosano G, Seferovic P, Vaduganathan M, Voors AA, Metra M. Sodium-glucose co-transporter 2 inhibitors as an early, first-line therapy in patients with heart failure and reduced ejection fraction. Eur J Heart Fail 2022; 24:431-441. [PMID: 34894038 PMCID: PMC9303969 DOI: 10.1002/ejhf.2397] [Citation(s) in RCA: 65] [Impact Index Per Article: 32.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/07/2021] [Indexed: 11/20/2022] Open
Abstract
Sodium-glucose co-transporter 2 (SGLT2) inhibitors have recently been recommended as a foundational therapy for patients with heart failure (HF) and reduced ejection fraction (HFrEF) because of their favourable effects on mortality, clinical events and quality of life. While clinical practice guidelines have recommended dapagliflozin or empagliflozin in all patients with HFrEF, or sotagliflozin in those with HFrEF and concomitant diabetes, the timing and practical integration of these drugs in clinical practice is less well defined. We propose that these drugs are candidates for early, upfront administration to patients with newly diagnosed HFrEF and for patients hospitalized with HF. Growing evidence has established early benefits, with clinically meaningful reductions in clinical events that reach statistical significance within days to weeks, following dapagliflozin, empagliflozin or, in diabetic patients, sotagliflozin initiation. Secondly, although major clinical trials have tested these drugs in patients already receiving background HF therapy, secondary analyses showed that their efficacy is independent of that. Third, SGLT2 inhibitors are generally safe and well tolerated, with clinical trial data reporting minimal effects on blood pressure, glycaemia-related adverse events, and no excess in acute kidney injury. Rather, they exert renal protective effects and reduce risk of hyperkalaemia, properties that favour initiation, tolerance and persistence of renin-angiotensin system inhibitors and mineralocorticoid receptor antagonists. This review supports the early initiation of dapagliflozin and empagliflozin (or sotagliflozin limited to patients with diabetes) to rapidly improve clinical outcome and quality of life of HFrEF patients.
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Affiliation(s)
- Daniela Tomasoni
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Andrew J S Coats
- Department of Cardiology, IRCCS San Raffaele Pisana, Rome, Italy.,Faculty of Medicine, University of Warwick, Coventry, UK
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Theresa A McDonagh
- School of Cardiovascular Medicine and Sciences, King's College London British Heart Foundation Centre of Excellence, James Black Centre, London, UK.,Department of Cardiology, King's College Hospital London, London, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University & Centre for Heart Diseases, University Hospital, Wroclaw, Poland
| | - Giuseppe Rosano
- Department of Cardiology, IRCCS San Raffaele Pisana, Rome, Italy.,Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust University of London, London, UK
| | - Petar Seferovic
- Department Faculty of Medicine, University of Belgrade, Belgrade & Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Napoli C, Gabrielli D, Gronda E. Tandem positive action of SGLT2 inhibitors and ARNI in patients with heart failure. Acta Diabetol 2021; 58:1579-1580. [PMID: 34216234 DOI: 10.1007/s00592-021-01757-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/03/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Claudio Napoli
- University Department of Advanced Medical and Surgical Sciences (DAMSS) and Clinical Department of Internal Medicine and Specialistic Units, Azienda Ospedaliera Universitaria, University of Campania "Luigi Vanvitelli", 80138, Naples, Italy.
| | - Domenico Gabrielli
- Division of Cardiology, Azienda Ospedaliera San Camillo Forlanini, Roma, Italy
- Associazione Nazionale Medici Cardiologi Ospedalieri (ANMCO), Florence, Italy
| | - Edoardo Gronda
- Fondazione IRCCS Ca' Granda - Ospedale Maggiore Policlinico Di Milano UOC Di Nefrologia, Dialisi e Trapianto Renale Dell'adulto, Dipartimento Di Medicina E Specialità Mediche, Milan, Italy
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Abdin A, Bauersachs J, Frey N, Kindermann I, Link A, Marx N, Lainscak M, Slawik J, Werner C, Wintrich J, Böhm M. Timely and individualized heart failure management: need for implementation into the new guidelines. Clin Res Cardiol 2021; 110:1150-1158. [PMID: 33983472 PMCID: PMC8117452 DOI: 10.1007/s00392-021-01867-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/30/2021] [Indexed: 01/10/2023]
Abstract
Due to remarkable improvements in heart failure (HF) management over the last 30 years, a significant reduction in mortality and hospitalization rates in HF patients with reduced ejection fraction (HFrEF) has been observed. Currently, the optimization of guideline-directed chronic HF therapy remains the mainstay to further improve outcomes for patients with HFrEF to reduce mortality and HF hospitalization. This includes established device therapies, such as implantable defibrillators and cardiac resynchronization therapies, which improved patients' symptoms and prognosis. Over the last 10 years, new HF drugs have merged targeting various pathways, such as those that simultaneously suppress the renin-angiotensin-aldosterone system and the breakdown of endogenous natriuretic peptides (e.g., sacubitril/valsartan), and those that inhibit the If channel and, thus, reduce heart rate (e.g., ivabradine). Furthermore, the treatment of patient comorbidities (e.g., iron deficiency) has shown to improve functional capacity and to reduce hospitalization rates, when added to standard therapy. More recently, other potential treatment mechanisms have been explored, such as the sodium/glucose co-transporter inhibitors, the guanylate cyclase stimulators and the cardiac myosin activators. In this review, we summarize the novel developments in HFrEF pharmacological and device therapy and discuss their implementation strategies into practice to further improve outcomes.
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Affiliation(s)
- Amr Abdin
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany.
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Norbert Frey
- Department of Internal Medicine III, University of Heidelberg, 69120, Heidelberg, Germany
| | - Ingrid Kindermann
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Andreas Link
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Nikolaus Marx
- Department of Internal Medicine I, Cardiology, University Hospital Aachen, RWTH Aachen University, Aachen, Germany
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
| | - Jonathan Slawik
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Christian Werner
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Jan Wintrich
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
| | - Michael Böhm
- Klinik Für Innere Medizin III-Kardiologie, Angiologie Und Internistische Intensivmedizin, Universitätsklinikum Des Saarlandes, Kirrberger Strasse 100, 66421, Homburg, Germany
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Schumacher PM, Becker N, Tsuyuki RT, Griese-Mammen N, Koshman SL, McDonald MA, Bouvy M, Rutten FH, Laufs U, Böhm M, Schulz M. The evidence for pharmacist care in outpatients with heart failure: a systematic review and meta-analysis. ESC Heart Fail 2021; 8:3566-3576. [PMID: 34240570 PMCID: PMC8497358 DOI: 10.1002/ehf2.13508] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Revised: 06/18/2021] [Accepted: 06/23/2021] [Indexed: 12/22/2022] Open
Abstract
Aims Patients with heart failure (HF) have poor outcomes, including poor quality of life, and high morbidity and mortality. In addition, they have a high medication burden due to the multiple drug therapies now recommended by guidelines. Previous reviews, including studies in hospital settings, provided evidence that pharmacist care improves outcomes in patients with HF. Because most HF is managed outside of hospitals, we aimed to synthesize the evidence for pharmacist care in outpatients with HF. Methods and results We conducted a systematic literature search in PubMed of randomized controlled trials (RCTs) and integrated the evidence on patient outcomes in a meta‐analysis. We found 24 RCTs performed in 10 countries, including 8029 patients. The data revealed consistent improvements in medication adherence (independent of the measuring instrument) and knowledge, physical function, and disease and medication management. Sixteen RCTs were included in meta‐analyses. Differences in all‐cause mortality (odds ratio (OR) = 0.97 [95% CI, 0.84–1.12], Q‐statistic, P = 0.49, I2 = 0%), all‐cause hospitalizations (OR = 0.86 [0.73–1.03], Q‐statistic, P = 0.01, I2 = 45.5%), and HF hospitalizations (OR = 0.89 [0.77–1.02], Q‐statistic, P = 0.11, I2 = 0%) were not statistically significant. We also observed an improvement in the standardized mean difference for generic quality of life of 0.75 ([0.49–1.01], P < 0.01), with no indication of heterogeneity (Q‐statistic, P = 0.64; I2 = 0%). Conclusions Results indicate that pharmacist care improves medication adherence and knowledge, symptom control, and some measures of quality of life in outpatients with HF. Given the increasing complexity of guideline‐directed medical therapy, pharmacists' unique focus on medication management, titration, adherence, and patient teaching should be considered part of the management strategy for these vulnerable patients.
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Affiliation(s)
- Pia M Schumacher
- Department of Medicine, ABDA - Federal Union of German Associations of Pharmacists, Berlin, Germany
| | - Nicolas Becker
- Personality Psychology and Psychological Assessment, Saarland University, Saarbrücken, Germany
| | - Ross T Tsuyuki
- Department of Pharmacology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.,Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Nina Griese-Mammen
- Department of Medicine, ABDA - Federal Union of German Associations of Pharmacists, Berlin, Germany
| | - Sheri L Koshman
- Division of Cardiology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Michael A McDonald
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
| | - Marcel Bouvy
- Department of Pharmacoepidemiology & Pharmacotherapy, Utrecht Institute for Pharmaceutical Sciences, Utrecht, The Netherlands
| | - Frans H Rutten
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Ulrich Laufs
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Michael Böhm
- Internal Medicine III - Cardiology, Angiology and Intensive Care Medicine, University Hospital of Saarland, Saarland University, Homburg/Saar, Germany
| | - Martin Schulz
- Department of Medicine, ABDA - Federal Union of German Associations of Pharmacists, Berlin, Germany.,Institute of Pharmacy, Freie Universität Berlin, Berlin, Germany
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