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Aydin D, Allach Y, Brugts JJ. Implications of Sex Differences on the Treatment Effectiveness in Heart Failure with Reduced Ejection Fraction Related to Clinical Endpoints and Quality of Life. Curr Heart Fail Rep 2024; 21:43-52. [PMID: 38060192 PMCID: PMC10827832 DOI: 10.1007/s11897-023-00638-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/17/2023] [Indexed: 12/08/2023]
Abstract
PURPOSE OF THE REVIEW This narrative review will emphasize the necessity for more female enrollment in heart failure (HF) trials and proposes future investigations regarding optimal dosages. Ultimately, a deeper understanding of the unique pathophysiology and medication responses in both men and women is crucial for effective HF management and may improve the quality of life in women. RECENT FINDINGS An analysis of 740 cardiovascular studies reveals that women make up only 38.2% of participants on average. Regarding to trials testing the effectiveness of HF medications, women's involvement are as low as 23.1%. While current guidelines lack sex-specific treatment recommendations, emerging research suggests differential medication dosages could be beneficial. Studies indicate that women may achieve comparable outcomes with lower doses of certain medications (angiotensin-receptor blockers) compared to men, signaling potential for more tailored dosing approaches. We advocate that the next step in HF research should prioritize the importance of tailoring treatment for HF patients by taking into account the variations in drug absorption and distribution among women.
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Affiliation(s)
- D Aydin
- Department of Cardiology, Erasmus University Medical Centre, 3015, Rotterdam, The Netherlands.
| | - Y Allach
- Department of Cardiology, Erasmus University Medical Centre, 3015, Rotterdam, The Netherlands
| | - J J Brugts
- Department of Cardiology, Erasmus University Medical Centre, 3015, Rotterdam, The Netherlands
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Jaarsma T, Hill L, Bayes-Genis A, La Rocca HPB, Castiello T, Čelutkienė J, Marques-Sule E, Plymen CM, Piper SE, Riegel B, Rutten FH, Ben Gal T, Bauersachs J, Coats AJS, Chioncel O, Lopatin Y, Lund LH, Lainscak M, Moura B, Mullens W, Piepoli MF, Rosano G, Seferovic P, Strömberg A. Self-care of heart failure patients: practical management recommendations from the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2020; 23:157-174. [PMID: 32945600 PMCID: PMC8048442 DOI: 10.1002/ejhf.2008] [Citation(s) in RCA: 188] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 12/21/2022] Open
Abstract
Self-care is essential in the long-term management of chronic heart failure. Heart failure guidelines stress the importance of patient education on treatment adherence, lifestyle changes, symptom monitoring and adequate response to possible deterioration. Self-care is related to medical and person-centred outcomes in patients with heart failure such as better quality of life as well as lower mortality and readmission rates. Although guidelines give general direction for self-care advice, health care professionals working with patients with heart failure need more specific recommendations. The aim of the management recommendations in this paper is to provide practical advice for health professionals delivering care to patients with heart failure. Recommendations for nutrition, physical activity, medication adherence, psychological status, sleep, leisure and travel, smoking, immunization and preventing infections, symptom monitoring, and symptom management are consistent with information from guidelines, expert consensus documents, recent evidence and expert opinion.
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Affiliation(s)
- Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Nursing Science, Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias i Pujol, Badalona, Spain; and CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Teresa Castiello
- Department of Cardiology, Croydon Health Service and Department of Cardiovascular Imaging, Kings College London, London, UK
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | | | - Carla M Plymen
- Cardiology Department, Hammersmith Hospital, Imperial College Healthcare NHS Trust, London, UK
| | - Susan E Piper
- Department of Cardiology, King's College Hospital, London, UK
| | - Barbara Riegel
- School of Nursing, University of Pennsylvania, Philadelphia, PA, USA
| | - Frans H Rutten
- Department of General Practice. Julius Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Tuvia Ben Gal
- Heart Failure Unit, Cardiology department, Rabin Medical Center, Petah Tikva and Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Ovidiu Chioncel
- University of Medicine Carol Davila/Institute of Emergency for Cardiovascular Disease, Bucharest, Romania
| | - Yuri Lopatin
- Department of Cardiology, Cardiology Centre, Volgograd State Medical University, Volgograd, Russia
| | - Lars H Lund
- Department of Medicine Karolinska Institutet and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Mitja Lainscak
- Department of Internal Medicine, General Hospital Murska Sobota, Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Brenda Moura
- Hospital das Forças Armadas and Cintesis- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium; and Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Massimo F Piepoli
- Department of Cardiology, G. da Saliceto Hospital, Piacenza, Italy.,Institute of Life Sciences, Sant'Anna School of Advanced Studies, Pisa, Italy
| | - Giuseppe Rosano
- Centre for Clinical and Basic Research, IRCCS San Raffaele Roma, Rome, Italy
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Anna Strömberg
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Cardiology, Linköping University, Linköping, Sweden
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Adverse Drug Reactions to Guideline-Recommended Heart Failure Drugs in Women: A Systematic Review of the Literature. JACC-HEART FAILURE 2020; 7:258-266. [PMID: 30819382 DOI: 10.1016/j.jchf.2019.01.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 01/15/2019] [Accepted: 01/16/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES This study sought to summarize all available evidence on sex differences in adverse drug reactions (ADRs) to heart failure (HF) medication. BACKGROUND Women are more likely to experience ADRs than men, and these reactions may negatively affect women's immediate and long-term health. HF in particular is associated with increased ADR risk because of the high number of comorbidities and older age. However, little is known about ADRs in women with HF who are treated with guideline-recommended drugs. METHODS A systematic search of PubMed and EMBASE was performed to collect all available information on ADRs to angiotensin-converting enzyme inhibitors, β-blockers, angiotensin II receptor blockers, mineralocorticoid receptor antagonists, ivabradine, and digoxin in both women and men with HF. RESULTS The search identified 155 eligible records, of which only 11 (7%) reported ADR data for women and men separately. Sex-stratified reporting of ADRs did not increase over the last decades. Six of the 11 studies did not report sex differences. Three studies reported a higher risk of angiotensin-converting enzyme inhibitor-related ADRs in women, 1 study showed higher digoxin-related mortality risk for women, and 1 study reported a higher risk of mineralocorticoid receptor antagonist-related ADRs in men. No sex differences in ADRs were reported for angiotensin II receptor blockers and β-blockers. Sex-stratified data were not available for ivabradine. CONCLUSIONS These results underline the scarcity of ADR data stratified by sex. The study investigators call for a change in standard scientific practice toward reporting of ADR data for women and men separately.
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Vardeny O, Claggett B, Kachadourian J, Pearson SM, Desai AS, Packer M, Rouleau J, Zile MR, Swedberg K, Lefkowitz M, Shi V, McMurray JJV, Solomon SD. Incidence, Predictors, and Outcomes Associated With Hypotensive Episodes Among Heart Failure Patients Receiving Sacubitril/Valsartan or Enalapril: The PARADIGM-HF Trial (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure). Circ Heart Fail 2019; 11:e004745. [PMID: 29643067 DOI: 10.1161/circheartfailure.117.004745] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 03/02/2018] [Indexed: 12/25/2022]
Abstract
BACKGROUND In PARADIGM-HF (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure), heart failure treatment with sacubitril/valsartan reduced the primary composite outcome of cardiovascular death or heart failure hospitalization compared with enalapril but resulted in more symptomatic hypotension. Concern on hypotension may be limiting use of sacubitril/valsartan in appropriate patients. METHODS AND RESULTS We characterized patients in PARADIGM-HF by whether they reported hypotension during study run-in periods (enalapril, followed by sacubitril/valsartan) and after randomization and assessed whether hypotension modified the efficacy of sacubitril/valsartan. Of the 10 513 patients entering the enalapril run-in, 136 (1.3%) experienced hypotension and 93 (68%) were unable to continue to the next phase; of 9419 patients entering the sacubitril/valsartan run-in period, 228 (2.4%) patients experienced hypotension and 51% were unable to successfully complete the run-in. After randomization, 388 (9.2%) participants had 501 hypotensive events with enalapril, and 588 (14.0%) participants had 803 hypotensive events with sacubitril/valsartan (P<0.001). There was no difference between randomized treatment groups in the number of participants who discontinued therapy because of hypotension. Individuals with a hypotensive event in either group were older, had lower blood pressure at randomization, and were more likely to have an implantable cardioverter defibrillator. Participants with hypotensive events during run-in who were ultimately randomized derived similar efficacy from sacubitril/valsartan compared with enalapril as those without hypotensive events (P interaction>0.90). CONCLUSIONS Hypotension was more common with sacubitril/valsartan relative to enalapril in PARADIGM-HF but did not differentially affect permanent discontinuations. Patients with hypotension during run-in derived similar benefit from sacubitril/valsartan compared with enalapril as those who did not experience hypotension.
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Affiliation(s)
- Orly Vardeny
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Brian Claggett
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Jessica Kachadourian
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Scott M Pearson
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Akshay S Desai
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Milton Packer
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Jean Rouleau
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Michael R Zile
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Karl Swedberg
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Martin Lefkowitz
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Victor Shi
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - John J V McMurray
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.)
| | - Scott D Solomon
- Minneapolis VA Health Care System and University of Minnesota (O.V.). University of Colorado, Aurora (S.M.P.). Brigham and Women's Hospital, Harvard University, Boston, MA (B.C., A.S.D., S.D.S.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (J.K., M.L., V.S.). University of Glasgow, United Kingdom (J.J.V.M.). Baylor University Medical Center, Dallas, TX (M.P.). Université de Montréal, Canada (J.R.). Medical University of South Carolina, Charleston (M.R.Z.). University of Gothenburg, Sweden (K.S.).
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Ventura HO, Mehra MR. Blood pressure and goal titration of neurohormonal antagonists: the tortoise wins again? Eur J Heart Fail 2018; 20:501-503. [PMID: 29333669 DOI: 10.1002/ejhf.1094] [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: 11/01/2017] [Accepted: 11/05/2017] [Indexed: 11/05/2022] Open
Affiliation(s)
- Hector O Ventura
- John Ochsner Heart and Vascular Institute, Ochsner Clinical School-The University of Queensland School of Medicine, New Orleans, LA, USA
| | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Abushouk AI, El-Husseny MWA, Bahbah EI, Elmaraezy A, Ali AA, Ashraf A, Abdel-Daim MM. Peroxisome proliferator-activated receptors as therapeutic targets for heart failure. Biomed Pharmacother 2017; 95:692-700. [PMID: 28886529 DOI: 10.1016/j.biopha.2017.08.083] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 08/05/2017] [Accepted: 08/23/2017] [Indexed: 01/06/2023] Open
Abstract
Heart failure (HF) is a common clinical syndrome that affects more than 23 million individuals worldwide. Despite the marked advances in its management, the mortality rates in HF patients have remained unacceptably high. Peroxisome proliferator-activated receptors (PPARs) are nuclear transcription regulators, involved in the regulation of fatty acid and glucose metabolism. PPAR agonists are currently used for the treatment of type II diabetes mellitus and hyperlipidemia; however, their role as therapeutic agents for HF remains under investigation. Preclinical studies have shown that pharmacological modulation of PPARs can upregulate the expression of fatty acid oxidation genes in cardiomyocytes. Moreover, PPAR agonists were proven able to improve ventricular contractility and reduce cardiac remodelling in animal models through their anti-inflammatory, anti-oxidant, anti-fibrotic, and anti-apoptotic activities. Whether these effects can be replicated in humans is yet to be proven. This article reviews the interactions of PPARs with the pathophysiological mechanisms of HF and how the pharmacological modulation of these receptors can be of benefit for HF patients.
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Affiliation(s)
| | | | - Eshak I Bahbah
- Faculty of Medicine, Al-Azhar University, Damietta, Egypt
| | - Ahmed Elmaraezy
- NovaMed Medical Research Association, Cairo, Egypt; Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Aya Ashraf Ali
- Faculty of Medicine, Minia University, Minia, Egypt; Minia Medical Research Society, Minia University, Minia, Egypt
| | - Asmaa Ashraf
- Faculty of Medicine, Minia University, Minia, Egypt; Minia Medical Research Society, Minia University, Minia, Egypt
| | - Mohamed M Abdel-Daim
- Pharmacology Department, Faculty of Veterinary Medicine, Suez Canal University, Ismailia 41522, Egypt; Department of Ophthalmology and Micro-Technology, Yokohama City University, Yokohama, Japan.
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De Smedt RHE, Denig P, van der Meer K, Haaijer-Ruskamp FM, Jaarsma T. Self-reported adverse drug events and the role of illness perception and medication beliefs in ambulatory heart failure patients: A cross-sectional survey. Int J Nurs Stud 2011; 48:1540-50. [PMID: 21774932 DOI: 10.1016/j.ijnurstu.2011.05.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2010] [Revised: 05/29/2011] [Accepted: 05/31/2011] [Indexed: 01/02/2023]
Abstract
BACKGROUND Identifying patients with heart failure (HF) who are at risk of experiencing symptomatic adverse drug events (ADEs) is important for improving patient care and quality of life. Several demographic and clinical variables have been identified as potential risk factors for ADEs but limited knowledge is available on the impact of HF patients' beliefs and perceptions on their experience of ADEs. OBJECTIVE The purpose of the study was to identify the relationship between HF patients' illness perception and medication beliefs and self-reported ADEs. DESIGN A cross-sectional survey was performed between November 2008 and March 2009. SETTINGS One university medical centre, two regional hospitals and 20 general practitioners in the Netherlands participated in the study. PARTICIPANTS 495 patients with HF were included. METHODS Patients completed the validated Revised Illness Perception Questionnaire (IPQ-R) and the Beliefs about Medication Questionnaire (BMQ) which collected data on their illness perception and medication beliefs. In addition, data on ADEs as experienced in the previous four weeks were collected through an open-ended question and a symptom checklist. Multivariate logistic regression was performed to identify factors associated with these ADEs. RESULTS In total, 332 (67%) patients had experienced ADEs in the previous four weeks, of whom 28% reported dry mouth, 27% dizziness and 19% itchiness as the most prevalent. In the adjusted multivariate analysis, disease-related symptoms (illness identity) (OR for 1-5 symptoms 3.57; 95% CI 2.22-5.75, OR for >5 symptoms 7.37; 95% CI 3.44-15.8), and general beliefs about medication overuse (OR 1.07; 95% CI 1.01-1.13) were independently associated with experiencing ADEs, whereas none of the demographic or clinical factors were significant. CONCLUSIONS HF patients who perceive a high number of disease symptoms and have negative medication beliefs are at higher risk of experiencing self-reported ADEs. We suggest that future studies and interventions to improve ADE management should focus on negative medication beliefs and assisting patients in differentiating disease symptoms from ADEs.
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Affiliation(s)
- Ruth H E De Smedt
- Department of Clinical Pharmacology, University of Medical Center Groningen, Graduate School for Health Research Share, University of Groningen, The Netherlands.
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De Smedt RHE, Denig P, Haaijer-Ruskamp FM, Jaarsma T. Perceived medication adverse effects and coping strategies reported by chronic heart failure patients. Int J Clin Pract 2009; 63:233-42. [PMID: 19196362 DOI: 10.1111/j.1742-1241.2008.01954.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Data on medication adverse effects (AEs) in chronic heart failure (CHF) are primarily based on results from clinical trials. Little is known about AEs perceived by CHF patients in daily practice and how patients deal with these subjective AEs. AIMS To describe the scope and nature of perceived AEs of CHF patients, their coping strategies and the relationship of perceived AEs to medication, patient characteristics and quality of life. METHODS This cross-sectional observational study included a sample of 680 patients previously hospitalised for CHF. Perceived AEs and coping strategies were collected by interviews based on a structured questionnaire. Medication and clinical information were collected by chart review. RESULTS Of the 670 CHF patients completing the questionnaire, 17% reported at least one AE. In total, 186 AEs were reported of which 15% could not be linked to any medication. Nausea (4%), dizziness (4%), itches (3%) and rash (3%) were the most prevalent. The drug associated with the highest AE rate was pravastatin (27%). On average, more than five different drugs could be related to the AEs headache, dizziness and nausea. Patients reporting AEs had a lower general health perception, younger age and were more often using antiarrhythmic drugs. Of patients experiencing AEs, 69% conferred with their doctor, 24% reported having done nothing in reaction and 2% discontinued their medication without discussing it with the doctor. CONCLUSION Adverse effects are frequently perceived by CHF patients, but they are difficult to recognise and manage in daily practice.
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Affiliation(s)
- R H E De Smedt
- Department of Clinical Pharmacology, University Medical Center Groningen, University of Groningen, The Netherlands.
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Meredith PA, Östergren J, Anand I, Puu M, Solomon SD, Michelson EL, Olofsson B, Granger CB, Yusuf S, Swedberg K, Pfeffer MA, McMurray JJ. Clinical Outcomes According to Baseline Blood Pressure in Patients With a Low Ejection Fraction in the CHARM (Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity) Program. J Am Coll Cardiol 2008; 52:2000-7. [DOI: 10.1016/j.jacc.2008.09.011] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2008] [Revised: 08/18/2008] [Accepted: 09/08/2008] [Indexed: 02/01/2023]
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Seed A, Gardner R, McMurray J, Hillier C, Murdoch D, MacFadyen R, Bobillier A, Mann J, McDonagh T. Neurohumoral effects of the new orally active renin inhibitor, aliskiren, in chronic heart failure. Eur J Heart Fail 2007; 9:1120-7. [DOI: 10.1016/j.ejheart.2007.09.002] [Citation(s) in RCA: 59] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2007] [Revised: 06/27/2007] [Accepted: 09/11/2007] [Indexed: 11/30/2022] Open
Affiliation(s)
- Alison Seed
- Department of Cardiology; Western Infirmary; Glasgow United Kingdom
| | - Roy Gardner
- Department of Cardiology; Royal Infirmary; Glasgow United Kingdom
| | - John McMurray
- Department of Cardiology; Western Infirmary; Glasgow United Kingdom
| | - Chris Hillier
- School of Biological and Biomedical Sciences; Caledonian University; Glasgow United Kingdom
| | - David Murdoch
- Department of Cardiology; Southern General Hospital; Glasgow United Kingdom
| | - Robert MacFadyen
- University Department of Medicine; City Hospital; Birmingham United Kingdom
| | | | | | - Theresa McDonagh
- Department of Cardiology; Royal Brompton Hospital; London United Kingdom
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de Denus S, Tardif JC, White M, Bourassa MG, Racine N, Levesque S, Ducharme A. Quantification of the risk and predictors of hyperkalemia in patients with left ventricular dysfunction: a retrospective analysis of the Studies of Left Ventricular Dysfunction (SOLVD) trials. Am Heart J 2006; 152:705-12. [PMID: 16996842 DOI: 10.1016/j.ahj.2006.05.030] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2004] [Accepted: 05/02/2006] [Indexed: 01/11/2023]
Abstract
BACKGROUND Limited data are available to predict the occurrence of hyperkalemia. Risk assessment is complicated by the lack of consistency of definition between trials. METHODS We conducted a retrospective analysis of the SOLVD to evaluate the incidence of hyperkalemia and the value of several baseline characteristics as predictors of hyperkalemia in patients with left ventricular dysfunction. RESULTS The incidence of hyperkalemia was 6.0% and 1.1% using a definition of > or = 5.5 and > or = 6.0 mmol/L, respectively. Independent predictors of hyperkalemia (> or = 5.5 mmol/L) were randomization to enalapril, baseline serum creatinine, serum potassium, New York Heart Association functional class III or IV, a history of diabetes, and atrial fibrillation (all P < .05). The use of loop diuretics was also associated with an increased risk of hyperkalemia but only in patients included in the SOLVD prevention trial. Similar results were obtained when renal function was evaluated using the estimated creatinine clearance. CONCLUSIONS The definition of hyperkalemia is important when evaluating its incidence in clinical trials. Renal dysfunction, baseline serum potassium, diabetes, atrial fibrillation, New York Heart Association functional class, and treatment with an angiotensin-converting enzyme inhibitor are factors associated with the development of hyperkalemia in patients with left ventricular dysfunction. More specifically, our results suggests that before initiating drugs that can cause hyperkalemia in patients with heart failure, a strong consideration should be given to calculate creatinine clearance and that patients with a creatinine clearance < 60 mL/min should undergo a close monitoring of their serum potassium to prevent the development of hyperkalemia.
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Affiliation(s)
- Simon de Denus
- Faculty of Pharmacy, University of Montreal, Montreal, Quebec, Canada
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Ahmed A, Aronow WS, Fleg JL. Predictors of Mortality and Hospitalization in Women with Heart Failure in the Digitalis Investigation Group Trial. Am J Ther 2006; 13:325-31. [PMID: 16858168 PMCID: PMC2745160 DOI: 10.1097/00045391-200607000-00009] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
We performed a retrospective follow-up study of 1926 women with heart failure who participated in the Digitalis Investigation Group trial. Adjusted hazard ratios and 95% confidence intervals for covariates that were significant independent predictors of all-cause mortality were age in years (1.02; 1.01-1.03; P<0.001), NYHA class IH-IV (1.56; 1.31-1.87), diabetes (1.63; 1.36-1.95), glomerular filtration rate in mL/min/1.73 m(2) (0.99; 0.98-4).996; P=0.001), pulmonary congestion by chest x-ray (1.57; 1.22-2.02), left ventricular ejection fraction (LVEF) (0.99; 0.98-0.993; P<0.001), and use of digoxin (1.20; 1.02-1.42). Covariates that were significant independent predictors of hospitalization due to worsening heart failure were: nonwhite race (1.28; 1.03-1.58), NYHA class III-IV (1.55; 1.30-1.84), diabetes (1.75; 1.47-2.09), glomerular filtration rate as mL/min/1.73 m(2) (0.99; 0.986-0.996; P<0.001), pulmonary congestion by chest x-ray (1.42; 1.12-1.81), and use of ACE inhibitors (0.67; 0.49-0.91). Longer duration of heart failure, higher NYHA classes, diabetes, chronic kidney disease, pulmonary congestion, and lower LVEF were significant independent predictors of all-cause mortality, all-cause hospitalization, and hospitalization for heart failure in women with heart failure.
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Affiliation(s)
- Ali Ahmed
- Division of Gerontology and Geriatric Medicine, Department of Medicine, School of Medicine, Department of Epidemiology, School of Public Health, Center for Aging and Geriatric Heart Failure Clinic, University of Alabama at Birmingham (UAB), Section of Geriatrics and Geriatric Heart Failure Clinic, Veteran Affairs Medical Center (VAMC), and Heart Failure Project, Alabama Quality Assurance Foundation (AQAF), 1530 3rd Ave South,CH-19, Ste-219, Birmingham, AL, USA
- Corresponding author Tel.: 205-934-9632; fax: 205-975-7099, Email address:
| | - Wilbert S Aronow
- Cardiology Division, Department of Medicine, New York Medical College, Valhalla, NY, USA
| | - Jerome L Fleg
- The National Heart Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA
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Jessup M, Piña IL. Is it important to examine gender differences in the epidemiology and outcome of severe heart failure? J Thorac Cardiovasc Surg 2004; 127:1247-52. [PMID: 15115978 DOI: 10.1016/j.jtcvs.2003.09.032] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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Moser DK, Biddle MJ. Angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers: what we know and current controversies. Crit Care Nurs Clin North Am 2004; 15:423-37, vii-viii. [PMID: 14717387 DOI: 10.1016/s0899-5885(02)00107-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A little more than a decade ago, management of heart failure was changed forever when a number of randomized clinical trials confirmed that a class of drugs, angiotensin-converting enzyme (ACE) inhibitors, could improve survival in patients with heart failure. The recognition that blockade of one of the neurohumoral systems activated in heart failure could improve outcomes prompted widespread testing of other neurohumoral blockers, such as beta-adrenergic blocking agents, aldosterone antagonists, and most recently, angiotensin II type 1 receptor blockers (ARBs) for the treatment of heart failure. This article describes what is known about the use of ACE inhibitors and ARBs in the management of heart failure and presents the current controversies surrounding the use of these agents.
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Affiliation(s)
- Debra K Moser
- Department of Cardiovascular Nursing, College of Nursing, University of Kentucky, 52777 CON/HSLC Building, 760 Rose Avenue, Lexington, KY 40536-0232, USA.
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Kittleson M, Hurwitz S, Shah MR, Nohria A, Lewis E, Givertz M, Fang J, Jarcho J, Mudge G, Stevenson LW. Development of circulatory-renal limitations to angiotensin-converting enzyme inhibitors identifies patients with severe heart failure and early mortality. J Am Coll Cardiol 2003; 41:2029-35. [PMID: 12798577 DOI: 10.1016/s0735-1097(03)00417-0] [Citation(s) in RCA: 174] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
OBJECTIVES This study examined the hypothesis that patients who develop angiotensin-converting enzyme inhibitor intolerance attributable to circulatory-renal limitations (CRLimit) have more severe underlying disease and worse outcome. BACKGROUND Although the renin-angiotensin system contributes to the progression of heart failure (HF), it also supports the failing circulation. Patients with the most severe disease may not tolerate inhibition of this system. METHODS Consecutive inpatient admissions to the cardiomyopathy service of the Brigham and Women's Hospital between 2000 and 2002 were reviewed retrospectively for initial profiles, discharge medications, and documented reasons for discontinuation of angiotensin-converting enzyme inhibitors. Outcomes of death and transplantation were determined. RESULTS Of the 259 patients, 86 were not on an angiotensin-converting enzyme inhibitor at discharge. Circulatory-renal limitations of symptomatic hypotension, progressive renal dysfunction, or hyperkalemia were documented in 60 patients (23%); other adverse effects, including cough, in 24 patients; and absent reasons in 2 patients. Compared with patients on angiotensin-converting enzyme inhibitors, patients with CRLimit were older (60 vs. 55 years; p = 0.006), with longer history of HF (5 vs. 2 years; p = 0.009), lower systolic blood pressure (104 vs. 110 mm Hg; p = 0.05), lower sodium (135 vs. 138 mEql/l; p = 0.002), and higher initial creatinine (2.5 vs. 1.2 mg/dl; p = 0.0001). Mortality was 57% in patients with CRLimit and 22% in the patients on angiotensin-converting enzyme inhibitors during a median 8.5-month follow-up (p = 0.0001). CONCLUSIONS Development of CRLimit to angiotensin-converting enzyme inhibitor intolerance identifies patients with severe disease who are likely to die during the next year. New treatment strategies should be targeted to this population.
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Affiliation(s)
- Michelle Kittleson
- Departments of Medicine and Cardiology, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
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16
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McMurray J, Ostergren J, Pfeffer M, Swedberg K, Granger C, Yusuf S, Held P, Michelson E, Olofsson B. Clinical features and contemporary management of patients with low and preserved ejection fraction heart failure: baseline characteristics of patients in the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme. Eur J Heart Fail 2003; 5:261-70. [PMID: 12798823 DOI: 10.1016/s1388-9842(03)00052-7] [Citation(s) in RCA: 104] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
AIMS To describe the clinical characteristics and contemporary treatment of a broad spectrum of patients with chronic heart failure (CHF) randomised in the Candesartan in Heart failure-Assessment of Reduction in Mortality and morbidity (CHARM) programme, consisting of three component studies comparing placebo to candesartan. METHODS AND RESULTS CHARM Alternative, CHARM Added and CHARM Preserved enrolled 2028 low left ventricular ejection fraction (LVEF) ACE inhibitor intolerant patients, 2548 low LVEF ACE inhibitor treated patients and 3025 preserved LVEF patients, respectively. Patients in CHARM Preserved were more often female. The proportion of women in CHARM Preserved was 40% compared to 32% in CHARM Alternative and 21% in CHARM Added. Patients in CHARM Preserved were also more often hypertensive than in the other two trials (64% vs. 50% and 48%, respectively). Symptoms and signs (with the exception of a third heart sound) were similar in all three patient groups. Beta-blockers were used in over half of patients in all three groups. Digoxin and spironolactone were used less frequently and calcium antagonists more frequently in CHARM Preserved. Spironolactone was used most frequently in CHARM Alternative, i.e. in ACE inhibitor intolerant patients. CONCLUSIONS The CHARM Programme provides the largest and most detailed comparison to date of patients low- and preserved-LVEF CHF. It also describes the causes of ACE-inhibitor intolerance in a large cohort of patients and the other treatment which these patients receive.
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Affiliation(s)
- J McMurray
- Department of Cardiology, Western Infirmary, University of Glasgow, Glasgow G11 6NT, Scotland, UK.
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Richardson LG. Psychosocial issues in patients with congestive heart failure. PROGRESS IN CARDIOVASCULAR NURSING 2003; 18:19-27. [PMID: 12624569 DOI: 10.1111/j.0889-7204.2003.00835.x] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Psychosocial issues are important variables that need to be addressed in patients with congestive heart failure (CHF). Unfortunately, these issues are often overlooked. Depression and lack of social support have been shown to have a negative impact on patients with CHF. Patients with CHF who are depressed or who lack social support have been shown to have increased morbidity and hospital readmission rates, to be less adherent to their medical regimen, and to have an overall increase in cost of care. The variables are often interrelated, as high levels of social support may lessen the impact of depression on mortality. In addition, certain biologic factors may influence the impact of psychosocial factors in patients with CHF. This review addresses the effects of depression, treatment adherence, and social support in patients with CHF and suggests interventions targeted to these problems. Health care professionals must assess these issues in all patients with CHF, address their specific needs, and intervene appropriately when warranted.
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Affiliation(s)
- Luann G Richardson
- West Penn Allegheny Health System, Allegheny General Hospital, Pittsburgh, PA, USA
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18
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Polypharmacy in chronic heart failure: practical issues regarding the use of angiotensin-converting enzyme inhibitors, beta-blockers and other drugs. Eur Heart J Suppl 2002. [DOI: 10.1093/ehjsupp/4.suppl_d.d111] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Tang WHW, Vagelos RH, Yee YG, Benedict CR, Willson K, Liss CL, Fowler MB. Neurohormonal and clinical responses to high- versus low-dose enalapril therapy in chronic heart failure. J Am Coll Cardiol 2002; 39:70-8. [PMID: 11755289 DOI: 10.1016/s0735-1097(01)01714-4] [Citation(s) in RCA: 71] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
OBJECTIVES We sought to compare the neurohormonal responses and clinical effects of long-term, high-dose versus low-dose enalapril in patients with chronic heart failure (CHF). BACKGROUND Examination of neurohormonal and clinical responses in patients receiving different doses of angiotensin-converting enzyme (ACE) inhibitors may provide insight into the potential for additional suppression with angiotensin II (AT-II) or aldosterone antagonists. METHODS Seventy-five patients with CHF were randomized to receive either high-dose (40 mg/day, n = 37) or low-dose (5 mg/day, n = 38) enalapril over six months. The results from exercise testing, echocardiography, tissue-specific ACE activity and monthly pre- and post-enalapril neurohormonal levels were compared. RESULTS Despite greater intra-group improvements in plasma renin activity and serum aldosterone levels in the high-dose group, no statistically significant differences were observed between the two groups in all variables, except for serum ACE activity at the end of study. Elevated serum aldosterone and plasma AT-II levels were observed in 35% and 85% of patients, respectively, at 34 weeks, an inter-group difference that was not statistically significant. A trend toward higher levels of tissue-specific ACE activity in the high-dose group compared with the low-dose group at the end of study was observed (p = 0.054). A predefined composite end point of clinical events had a trend toward better improvement in the high-dose group. CONCLUSIONS This study could not demonstrate a difference between high- and low-dose enalapril in terms of serum aldosterone and plasma AT-II suppression, despite a dose-dependent reduction in serum ACE activity. Even at maximal doses of enalapril, elevated serum aldosterone and plasma AT-II levels were frequently observed.
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Affiliation(s)
- W H Wilson Tang
- Stanford University Medical School, Stanford, California, USA
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Shah MR, Granger CB, Bart BA, McMurray JJ, Petrie MC, Michelson EL, Tudor GE, Swedberg K, Stevenson LW, Califf RM, Pfeffer MA. Sex-related differences in the use and adverse effects of angiotensin-converting enzyme inhibitors in heart failure: the study of patients intolerant of converting enzyme inhibitors registry. Am J Med 2000; 109:489-92. [PMID: 11042239 DOI: 10.1016/s0002-9343(00)00529-5] [Citation(s) in RCA: 20] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- M R Shah
- Duke Clinical Research Institute (MRS, CBG, BAB, GET, RMC), Durham, North Carolina, USA
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21
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Riedinger MS, Dracup KA, Brecht ML. Predictors of quality of life in women with heart failure. SOLVD Investigators. Studies of Left Ventricular Dysfunction. J Heart Lung Transplant 2000; 19:598-608. [PMID: 10867341 DOI: 10.1016/s1053-2498(00)00117-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Two and one half million women have heart failure (HF). Yet little is known about quality of life (QOL) in this population and the factors influencing it. Given the importance of QOL as an outcome of care, we conducted a study to evaluate predictors of QOL in women with HF. METHODS Using baseline QOL data collected in the Studies of Left Ventricular Dysfunction (SOLVD) trials, we studied predictors of QOL in 691 women with HF. Univariate, bivariate, and multiple regression analyses were used. Potential predictors included age, education, tobacco use, social isolation, life stresses, comorbidity index, New York Heart Association (NYHA) class, HF symptoms, etiology, and medications. We measured global QOL and QOL dimensions of physical function, emotional distress, and social and general health. RESULTS Women were older (61+/-10.5 years), predominantly Caucasian (75%), and their mean ejection fraction was 0.27 (+/-6.51). Variables with the strongest relationship to QOL included dyspnea, NYHA class, and life stresses. As dyspnea, life stresses, and NYHA class increased, QOL decreased. Additionally, smoking behavior and vasodilator use was associated with decreased QOL. Heart failure etiology of ischemic origin was associated with decreased social life satisfaction, and use of digitalis was predictive of increased social life satisfaction. Finally, increasing age was related to an increase in general life satisfaction. CONCLUSION Symptom amelioration, which may improve functional ability, has the greatest potential for increasing QOL in women with HF. Programs to increase physical activity in women with HF should be developed and tested. Finally, clinicians may need to optimize HF medications in women.
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Affiliation(s)
- M S Riedinger
- Cedars-Sinai Medical Center, Los Angeles, California, USA.
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22
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Bart BA. Concern for azotemia with angiotensin-converting enzyme inhibitors: public health implications and clinical relevance. Am Heart J 1999; 138:801-3. [PMID: 10539807 DOI: 10.1016/s0002-8703(99)70001-3] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Knight EL, Glynn RJ, McIntyre KM, Mogun H, Avorn J. Predictors of decreased renal function in patients with heart failure during angiotensin-converting enzyme inhibitor therapy: results from the studies of left ventricular dysfunction (SOLVD). Am Heart J 1999; 138:849-55. [PMID: 10539815 DOI: 10.1016/s0002-8703(99)70009-8] [Citation(s) in RCA: 109] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND Although angiotensin-converting enzyme inhibitor therapy reduces mortality rates in patients with congestive heart failure (CHF), it may also cause decreased renal function. Little information is available to predict which patients are at highest risk for this complication. OBJECTIVE To quantify specific clinical predictors of reduction in renal function in patients with CHF who are prescribed angiotensin-converting enzyme inhibitor therapy. METHOD We analyzed data from the Studies of Left Ventricular Dysfunction (SOLVD), a randomized, double-blind, placebo-controlled trial of enalapril for the treatment of CHF. There were 3379 patients randomly assigned to enalapril with a median follow-up of 974 days and 3379 patients randomly assigned to placebo with a mean follow-up of 967 days. Decreased renal function was defined as a rise in serum creatinine >/=0.5 mg/dL (44 micromol/L) from baseline. We used time-to-event analysis to identify potential predictors of decrease in renal function including age, baseline ejection fraction, baseline creatinine, low systolic blood pressure (<100 mm Hg), history of hypertension, diabetes, and use of antiplatelet, diuretic, and beta-blocker therapy. RESULTS Patients randomly assigned to enalapril had a 33% greater likelihood of decreased renal function than controls (P =.003). By multivariate analysis, in both the placebo and enalapril groups older age, diuretic therapy, and diabetes were associated with decreased renal function, whereas beta-blocker therapy and higher ejection fraction were renoprotective. Older age was associated with a greater risk of developing decreased renal function in both groups, but significantly more so in the enalapril group (enalapril: risk ratio [RR] 1.42 per 10 years, 95% confidence interval [CI] 1.32-1.52 with enalapril; placebo: RR 1.18, 95% CI 1.12-1.25). Diuretic therapy was likewise associated with a greater risk of decreased renal function in the enalapril group (RR 1.89, 95% CI 1.70-2.08) than in the placebo group (RR 1.35, 95% CI 1.09-1.66). Conversely, enalapril had a relative renoprotective effect (RR 1.33, 95% CI 1.13-1.53) compared with placebo (RR 1.96, 95% CI 1.57-2.44) in patients with diabetes. A lower risk of renal impairment was seen in both groups with beta-blocker therapy (RR 0.70, 95% CI 0.57-0.85) and higher baseline ejection fraction (RR 0.93 per 5% increment, 95% CI 0.91-0. 96). CONCLUSIONS Enalapril use caused a 33% increase in the risk of decreased renal function in patients with CHF. Diuretic use and advanced age increased this risk. Diabetes was associated with an increased risk of renal impairment in all patients with CHF, but this risk was reduced in the enalapril group compared with the placebo group. beta-Blocker therapy and higher ejection fraction were renoprotective in all patients regardless of therapy.
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Affiliation(s)
- E L Knight
- Division of Pharmacoepidemiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
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Bart BA, Ertl G, Held P, Kuch J, Maggioni AP, McMurray J, Michelson EL, Rouleau JL, Warner Stevenson L, Swedberg K, Young JB, Yusuf S, Sellers MA, Granger CB, Califf RM, Pfeffer MA. Contemporary management of patients with left ventricular systolic dysfunction. Results from the Study of Patients Intolerant of Converting Enzyme Inhibitors (SPICE) Registry. Eur Heart J 1999; 20:1182-90. [PMID: 10448027 DOI: 10.1053/euhj.1998.1481] [Citation(s) in RCA: 73] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
AIMS The reported prevalence of angiotensin-converting enzyme (ACE) inhibitor use in patients with heart failure varies considerably. Recent reports suggest that many patients who could benefit from such therapy are not receiving ACE inhibitors. The Study of Patients Intolerant of Converting Enzyme Inhibitors (SPICE) Registry was established to understand better the demographics, characteristics, and contemporary use of ACE inhibitors in an international registry. METHODS AND RESULTS Between August 1996 and April 1997, each of 105 study centres from eight countries in North America and Europe was invited to review retrospectively the medical records of 100 consecutive patients with left ventricular ejection fractions </=35%. The median age of the 9580 Registry patients was 66 years, 26% were women, the median ejection fraction was 27%, and the primary aetiology of left ventricular dysfunction was ischaemic (63%). Eighty percent of patients were receiving ACE inhibitors. The most common reason for non-use of ACE inhibitors was intolerance (9%). CONCLUSION The SPICE Registry provides a contemporary description of the demographics and management of patients with documented left ventricular systolic dysfunction. The contemporary use of ACE inhibitors (80%) appears to be higher than previously reported and the main reason for non-use is perceived intolerance (9%).
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Affiliation(s)
- M C Petrie
- Medical Research Council Clinical Research Initiative in Heart Failure, Wolfson Building, University of Glasgow, Scotland
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Adams KF, Ellis ML, Williamson KM, Patterson JH. The AHCPR clinical practice guideline for heart failure revisited. Ann Pharmacother 1997; 31:1197-204. [PMID: 9337446 DOI: 10.1177/106002809703101013] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE To review the Agency for Health Care Policy and Research (AHCPR) clinical practice guideline for heart failure and comment on the guideline regarding pharmacotherapy from the perspective of the latest clinical trial data and the authors' clinical experience. DATA SOURCES A MEDLINE search (1966 to June 1997) of English-language literature pertaining to the pharmacotherapy of heart failure was performed. Special emphasis was placed on literature published in the last 5 years. Additional literature was obtained from reference lists of key articles identified through the search. DATA SYNTHESIS Pertinent clinical trials were reviewed and considered along with information from the authors' database of over 800 patients with heart failure. Evidence concerning the use of angiotensin-converting enzyme inhibitors at appropriate dosages in all New York Heart Association classes of heart failure and the inclusion of digoxin as part of triple therapy in all symptomatic patients with left ventricular systolic dysfunction are reviewed. Strategies to circumvent clinical problems that may limit the proper application of standard therapeutic agents are considered, and the possible future role of beta-blockers as the therapeutic agents in patients with heart failure is discussed. CONCLUSIONS The AHCPR guideline provides the clinician with an excellent framework for treating the patient with heart failure. Building on the fundamentals of the guideline, the clinician can carefully apply current therapy at appropriate dosages and in the best combinations to individualize and thereby optimize pharmacologic therapy for this patient population.
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Affiliation(s)
- K F Adams
- Heart Failure Program, University of North Carolina at Chapel Hill 27599, USA
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Kostis JB, Lacy CR, Cosgrove NM, Wilson AC. Association of calcium channel blocker use with increased rate of acute myocardial infarction in patients with left ventricular dysfunction. Am Heart J 1997; 133:550-7. [PMID: 9141377 DOI: 10.1016/s0002-8703(97)70150-9] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
The Studies of Left Ventricular Dysfunction (SOLVD) assessed the effect of enalapril in patients with systolic left ventricular dysfunction (LVD). We performed retrospective analyses of the association between calcium channel blocker (CCB) use and fatal and nonfatal myocardial infarction (MI) in these patients. MI occurred in 11.5% of 845 patients receiving CCBs versus 7.5% of 2551 patients not receiving CCBs in the enalapril group and in 14.4% of 874 patients receiving CCBs versus 9.3% of 2527 patients not receiving CCBs in the placebo group. By multivariate Cox regression analysis, adjusting for comorbidity, cause and severity of LVD, heart failure, and concomitant drug use, CCB use was an independent predictor of MI (relative risk [RR] 1.37, confidence interval [CI] 1.14 to 1.63). The increase in MI risk was greater among patients with a higher heart rate (RR 1.46, CI 1.14 to 1.86) and lower blood pressure (RR 1.45, CI 1.14 to 1.86). The adjusted risk ratio for all-cause mortality associated with CCB use was 1.14 (CI 1.00 to 1.28; p = 0.0454). In this analysis of patients with LVD, CCB use was associated with significantly increased risk of fatal or nonfatal MI.
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Affiliation(s)
- J B Kostis
- Department of Medicine, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School, New Brunswick 08903-0019, USA.
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Kostis JB, Shelton B, Gosselin G, Goulet C, Hood WB, Kohn RM, Kubo SH, Schron E, Weiss MB, Willis PW, Young JB, Probstfield J. Adverse effects of enalapril in the Studies of Left Ventricular Dysfunction (SOLVD). SOLVD Investigators. Am Heart J 1996; 131:350-5. [PMID: 8579032 DOI: 10.1016/s0002-8703(96)90365-8] [Citation(s) in RCA: 102] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
In the Studies of Left Ventricular Dysfunction (LVD), enalapril or placebo was administered in a double-blind fashion to 6797 participants with ejection fraction < or = 0.35. During 40 months' average follow-up, 28.1% of participants randomized to enalapril reported side effects compared with 16.0% in the placebo group (p < 0.0001). Enalapril use was associated with a higher rate of symptoms related to hypotension (14.8% vs 7.1%, p < 0.0001), azotemia (3.8% vs 1.6%, p < 0.0001), cough (5.0% vs 2.0%, p < 0.0001), fatigue (5.8% vs 3.5%, p < 0.0001), hyperkalemia (1.2% vs 0.4%, p = 0.0002), and angioedema (0.4% vs 0.1%, p < 0.05). Side effects resulted in discontinuation of blinded therapy in 15.2% of the enalapril group compared with 8.6% in the placebo group (p < 0.0001). Thus enalapril is well tolerated by patients with LVD; however, hypotension, azotemia, cough, fatigue, and other side effects result in discontinuation of therapy in a significant minority of patients.
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Affiliation(s)
- J B Kostis
- University of Medicine and Dentistry of New Jersey-Robert Wood Johnson Medical School, New Brunswick 08903-0019, USA
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Abstract
High blood pressure (BP) in the elderly must not be ignored as a normal consequence of aging. The criteria for the diagnosis of hypertension and the necessity to treat it are the same in elderly and younger patients. The aim of treatment of elderly hypertensive patients is to decrease BP safely and to reduce risk factors associated with cerebrovascular, cardiovascular and renal morbidity and mortality. The treatment of elderly hypertensive patients should be adjusted according to the needs of the individual, based upon age, race, severity of hypertension, co-existing medical problems, other cardiovascular risk factors, target-organ damage, risk-benefit considerations and costs. In addition to the elevated BP, other cardiovascular risk factors include smoking, glucose intolerance, hyperinsulinaemia, dyslipidaemia, hypercreatininaemia, peripheral vascular disease, left ventricular hypertrophy, and microalbuminuria (or albuminuria). Thus, the choice of initial antihypertensive therapy in elderly hypertensive patients should be based not only on the expected response, but also on the effects of therapy on lipid, potassium, glucose and uric acid levels, and left ventricular anatomy and function. Co-existing medical conditions (such as asthma, diabetes mellitus, heart failure, renal failure, gout, coronary artery disease, hyperlipidaemia and peripheral vascular disease) are major determinants for the selection of antihypertensive medications. With previous therapies (diuretics, beta-blockers, etc.), good BP control in the elderly was associated with clear and statistically significant reductions in stroke-related morbidity and mortality, but the overall effects on cardiovascular and renal complications of hypertension was either more variable or less obvious. Angiotensin converting enzyme (ACE) inhibitors are not only efficacious antihypertensive agents in the elderly, but also appear promising in counteracting some of the cardiovascular and renal consequences of hypertension. They are well tolerated and have a relatively low incidence of adverse effects. ACE inhibitors possess ancillary characteristics that are potentially beneficial for many elderly patients, including reduction of left ventricular mass, lack of metabolic and lipid disturbances, no adverse CNS effects, no risk of induction of heart failure, and a low risk of orthostatic hypotension. Since ACE inhibitors may improve perfusion to the heart, kidney and brain, they are well worth considering for the treatment of elderly patients with hypertensive target organ damage, especially in patients with heart failure, and diabetic patients with early nephropathy.
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Affiliation(s)
- Z H Israili
- Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
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