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Sapp JL, Tang ASL, Parkash R, Stevenson WG, Healey JS, Wells G. A randomized clinical trial of catheter ablation and antiarrhythmic drug therapy for suppression of ventricular tachycardia in ischemic cardiomyopathy: The VANISH2 trial. Am Heart J 2024; 274:1-10. [PMID: 38649085 DOI: 10.1016/j.ahj.2024.04.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 04/18/2024] [Accepted: 04/19/2024] [Indexed: 04/25/2024]
Abstract
BACKGROUND Recurrent ventricular tachycardia (VT) in patients with prior myocardial infarction is associated with adverse quality of life and clinical outcomes, despite the presence of implanted defibrillators (ICDs). Suppression of recurrent VT can be accomplished with antiarrhythmic drug therapy or catheter ablation. The Ventricular Tachycardia Antiarrhythmics or Ablation In Structural Heart Disease 2 (VANISH2) trial is designed to determine whether ablation is superior to antiarrhythmic drug therapy as first line therapy for patients with ischemic cardiomyopathy and VT. METHODS The VANISH2 trial enrolls patients with prior myocardial infarction and VT (with one of: ≥1 ICD shock; ≥3 episodes treated with antitachycardia pacing (ATP) and symptoms; ≥5 episodes treated with ATP regardless of symptoms; ≥3 episodes within 24 hours; or sustained VT treated with electrical cardioversion or pharmacologic conversion). Enrolled patients are classified as either sotalol-eligible, or amiodarone-eligible, and then are randomized to either catheter ablation or to that antiarrhythmic drug therapy, with randomization stratified by drug-eligibility group. Drug therapy, catheter ablation procedures and ICD programming are standardized. All patients will be followed until two years after randomization. The primary endpoint is a composite of mortality at any time, appropriate ICD shock after 14 days, VT storm after 14 days, and treated sustained VT below detection of the ICD after 14 days. The outcomes will be analyzed according to the intention-to-treat principle using survival analysis techniques RESULTS: The results of the VANISH2 trial are intended to provide data to support clinical decisions on how to suppress VT for patients with prior myocardial infarction. CLINICALTRIALS gov registration NCT02830360.
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Affiliation(s)
- John L Sapp
- Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax, Canada.
| | | | - Ratika Parkash
- Department of Medicine, QEII Health Sciences Centre, Dalhousie University, Halifax, Canada
| | - William G Stevenson
- Department of Medicine, Vanderbilt University Medical Center, Vanderbilt University, Nashville, TN
| | - Jeff S Healey
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - George Wells
- School of Epidemiology and Public Health, University of Ottawa, Ottawa, Canada
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Saldarriaga C, Colin-Ramirez E, Islam S, Alemayehu W, Macdonald P, Ross H, Escobedo J, Lanas F, Troughton RW, McAlister FA, Ezekowitz JA. DIETARY SODIUM INTAKE AND OUTCOMES: A SECONDARY ANALYSIS FROM SODIUM-HF: Sodium Intake and Outcomes in Heart Failure. J Card Fail 2024:S1071-9164(24)00224-0. [PMID: 38971298 DOI: 10.1016/j.cardfail.2024.04.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Revised: 04/22/2024] [Accepted: 04/23/2024] [Indexed: 07/08/2024]
Abstract
OBJECTIVES This post-hoc analysis of SODIUM-HF assessed the association between baseline dietary sodium intake and change at 6 months with a composite of cardiovascular (CV) hospitalizations, emergency department visits, and all-cause death at 12 and 24 months. BACKGROUND Dietary sodium restriction is common advice for patients with heart failure (HF). Randomized clinical trials have not shown a beneficial effect of dietary sodium restriction on clinical outcomes. METHODS Multivariable Cox proportional hazard regression model was used to assess the association of dietary sodium intake measured at randomization with primary and secondary endpoints. RESULTS 792 participants were included. Baseline sodium intake was ≤1500 mg/day in 19.9% (n=158), 1501-3000 mg/day in 56.5% (n=448), and >3000 mg/day in 23.4% (n=186) of participants. The factors associated with higher baseline sodium intake were higher calorie consumption, higher body mass index and recruitment from Canada. Multivariable analyses showed no association between baseline sodium intake nor magnitude of 6 months change and 12 or 24-month outcomes. In a responder analysis, participants achieving a sodium intake <1500 mg at 6 months showed an association with a decreased risk for the composite outcome (adjusted HR 0.52 [95% CI 0.25, 1.07] P=0.08) and CV hospitalization (adjusted HR 0.51 [95% CI 0.24, 1.09] P=0.08) at 12 months. CONCLUSION There was no association between dietary sodium intake and clinical outcomes over 24 months in patients with HF. Responder analyses suggest the need for further investigation of the effects of sodium reduction in those who achieve the targeted dietary sodium reduction level.
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Affiliation(s)
- Clara Saldarriaga
- Centro Cardiovascular Colombiano Clinica Santa Maria (Clinica Cardio VID), Antioquia, Colombia
| | - Eloisa Colin-Ramirez
- Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Sunjidatul Islam
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | | | | | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City, Mexico
| | | | | | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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Somé NH, Devlin RA, Mehta N, Sarma S. Primary care payment models and avoidable hospitalizations in Ontario, Canada: A multivalued treatment effects analysis. HEALTH ECONOMICS 2024. [PMID: 38898671 DOI: 10.1002/hec.4872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 03/28/2024] [Accepted: 04/30/2024] [Indexed: 06/21/2024]
Abstract
Improving access to primary care physicians' services may help reduce hospitalizations due to Ambulatory Care Sensitive Conditions (ACSCs). Ontario, Canada's most populous province, introduced blended payment models for primary care physicians in the early- to mid-2000s to increase access to primary care, preventive care, and better chronic disease management. We study the impact of payment models on avoidable hospitalizations due to two incentivized ACSCs (diabetes and congestive heart failure) and two non-incentivized ACSCs (angina and asthma). The data for our study came from health administrative data on practicing primary care physicians in Ontario between 2006 and 2015. We employ a two-stage estimation strategy on a balanced panel of 3710 primary care physicians (1158 blended-fee-for-service (FFS), 1388 blended-capitation models, and 1164 interprofessional team-based practices). First, we account for the differences in physician practices using a generalized propensity score based on a multinomial logit regression model, corresponding to three primary care payment models. Second, we use fractional regression models to estimate the average treatment effects on the treated outcome (i.e., avoidable hospitalizations). The capitation-based model sometimes increases avoidable hospitalizations due to angina (by 7 per 100,000 patients) and congestive heart failure (40 per 100,000) relative to the blended-FFS-based model. Switching capitation physicians into interprofessional teams mitigates this effect, reducing avoidable hospitalizations from congestive heart failure by 30 per 100,000 patients and suggesting better access to primary care and chronic disease management in team-based practices.
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Affiliation(s)
- Nibene Habib Somé
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Institute for Mental Health Policy Research, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Campbell Family Mental Health Research Institute, Centre for Addiction and Mental Health, Toronto, Ontario, Canada
- Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Rose Anne Devlin
- Department of Economics, University of Ottawa, Ottawa, Ontario, Canada
| | - Nirav Mehta
- Department of Economics, Western University, London, Ontario, Canada
| | - Sisira Sarma
- Department of Epidemiology and Biostatistics, Western University, London, Ontario, Canada
- ICES, Toronto, Ontario, Canada
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Mulligan K, Harris K, Rixon L, Burls A. A systematic mapping review of clinical guidelines for the management of fatigue in long-term physical health conditions. Disabil Rehabil 2024:1-18. [PMID: 38832888 DOI: 10.1080/09638288.2024.2353855] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Accepted: 05/04/2024] [Indexed: 06/06/2024]
Abstract
PURPOSE Despite a high prevalence of fatigue and its importance to patients, many people with long-term conditions do not receive fatigue management as part of their treatment. This review is aimed to identify clinical guidance for the management of fatigue in long-term physical health conditions. METHODS A systematic mapping review was conducted in accordance with Social Care Institute for Excellence systematic review guidance. Bibliographic databases and guideline repositories were searched for clinical guidelines for long-term conditions, published between January 2008 and July 2018, with a search for updates conducted in May 2023. Data were extracted on the recommendations made for managing fatigue and, where cited, the underlying research evidence used to support these recommendations was also extracted. RESULTS The review included 221 guidelines on 67 different long-term conditions. Only 30 (13.6%) of the guidelines contained recommendations for managing fatigue. These were categorised as clinical (e.g. conduct further investigations), pharmacological, behavioural (e.g. physical activity), psychological, nutritional, complementary, environmental, and multicomponent. The guidelines rated much of the evidence for fatigue management as fairly low quality, highlighting the need to develop and test fatigue-management strategies in high-quality trials. CONCLUSION This review highlights that management of fatigue is a very important neglected area in the clinical guidelines for managing long-term conditions.
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Affiliation(s)
- Kathleen Mulligan
- School of Health and Psychological Sciences, City, University of London, London, United Kingdom
- East London NHS Foundation Trust, London, United Kingdom
| | - Katherine Harris
- Centre for Genomics and Child Health, the Blizard Institute, Queen Mary University of London, London, United Kingdom
| | - Lorna Rixon
- School of Health and Psychological Sciences, City, University of London, London, United Kingdom
| | - Amanda Burls
- School of Health and Psychological Sciences, City, University of London, London, United Kingdom
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Bews H, Jia S, Liu Y, Sklar J, Ducas J, Kirkpatrick I, Tam JW, Shah AH. High output cardiac state: evaluating the incidence, plausible etiologies and outcomes. Curr Probl Cardiol 2024; 49:102561. [PMID: 38599560 DOI: 10.1016/j.cpcardiol.2024.102561] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Accepted: 04/07/2024] [Indexed: 04/12/2024]
Abstract
INTRODUCTION The high output cardiac state (HOCS) [cardiac index (CI) >4 L/min/m2 ], primarily driven by abnormally low systemic vascular resistance (SVR), is a relatively under-recognized condition. Although, majority of these patients meet criteria for heart failure (HF), their treatment should be aimed at the primary pathology, as the majority of guideline directed HF therapies can reduce SVR further. OBJECTIVES To characterize patients with HOCS and provide valuable insight into the condition. METHODS Patients investigated by right heart catheterization (RHC) at the St. Boniface Hospital, Winnipeg, Canada between January 2009 and November 2021 were reviewed. Two groups of patients were included: 1) HOCS [CI >4 L/min/m2], and 2) pre-HOCS [CI between 3.8-4.0 L/min/m2]. Their medical records were reviewed to identify plausible etiologies, relevant investigations, and outcomes. RESULTS 177/2950 (6 %) patients met criteria for inclusion: 144/177 (81 %) with HOCS [mean age 51 years (range 19 - 82); 67/144 (47 %) female] and 33/177 (19 %) with pre-HOCS [mean age 55 years (range 30 - 83); 6/33 (18 %) female]. The most common plausible etiologies for the HOCS included anemia (36 %), obesity (34 %), cirrhosis (17 %), and lung disease (32 %). Trans-thoracic echocardiography and magnetic resonance imaging findings were non-specific and predominantly described preserved left ventricular ejection fraction, and pulmonary hypertension. The population experienced high rates of hospitalization, and significantly high mortality [36/144 (25 %) of HOCS at a median follow-up of 31.5 months, and 13/33 (39 %) of pre-HOCS at a median follow-up of 17 months]. CONCLUSIONS HOCS is not an uncommon condition and is associated with high mortality. Current HF guideline should incorporate such evaluation into the diagnostic criteria.
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Affiliation(s)
- Hilary Bews
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Sangyang Jia
- Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Yixiu Liu
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jaime Sklar
- Department of Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - John Ducas
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Iain Kirkpatrick
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - James W Tam
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ashish H Shah
- Section of Cardiology, Department of Internal Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.
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Zheng Y, Chen Q, Xia C, Liu H. Thirst symptoms in patients with heart failure: An integrative review. J Adv Nurs 2024. [PMID: 38771082 DOI: 10.1111/jan.16250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Revised: 03/29/2024] [Accepted: 05/10/2024] [Indexed: 05/22/2024]
Abstract
AIM To identify the risk and protective factors affecting thirst symptoms in patients with heart failure (HF) and intervention strategies to alleviate thirst symptoms. DESIGN An integrative review. METHODS A total of 61 articles were retrieved. Screening yielded a total of 21 articles which were appraised for quality. The quality of studies was assessed using the Mixed Methods Appraisal Tool. DATA SOURCES Ten electronic databases were searched in October 2023, including Embase, Pubmed, CINAHL, Cochrane, Web of Science, Wiley, CNKI, VIP, CBM and WanFang. In addition, we searched grey databases and manually searched reference lists of included and relevant reviews. RESULTS In total, 1644 articles were retrieved, of which 21 were included. Eight studies addressed the factors. Six themes emerged as risk factors, including demographics, severity of disease, psycho-environmental, medication, fluid restriction and homeostasis. Conversely, an increase in fluid intake, a high score of sodium restriction diet attitude and using ARB were identified as protective factors. Thirteen studies focus on intervention strategies. Five unique intervention strategies were identified, including Traditional Chinese Medicine, mint-related interventions, sour-flavour interventions, improved water restriction and cluster nursing strategy. CONCLUSION This finding identified the factors associated with thirst symptoms in patients with HF, especially concerning the elaboration of risk factors, which suggests that healthcare professionals should focus on the risk factors for thirst in patients with HF and consciously avoid the occurrence of these risk factors. Additionally, there are considerable cultural differences in interventions, therefore, to increase adherence during symptom management, careful selection of appropriate intervention strategies based on the requirements and preferences of patients is required. While there are some therapies, there aren't enough high-quality empirical investigations. Thus, multi-centre, large-sample studies are also required in subsequent research to demonstrate the interventions' effectiveness. IMPLICATIONS FOR THE PROFESSION The nurse must notice the symptoms of thirst in HF to slow down the disease's progression and improve the patient's physical and emotional well-being. REPORTING METHOD The review complies with the PRISMA guidelines for reporting systematic reviews. PATIENT OR PUBLIC CONTRIBUTION No patient or public contribution.
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Affiliation(s)
- Yingjun Zheng
- Shantou University Medical College, Shantou, Guangdong Province, China
- The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Qiongshan Chen
- Shantou University Medical College, Shantou, Guangdong Province, China
- The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Chengyu Xia
- Shantou University Medical College, Shantou, Guangdong Province, China
- The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
| | - Hui Liu
- The Second Affiliated Hospital of Shantou University Medical College, Shantou, Guangdong Province, China
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Logan S, Di Meo A, Shapero S, Fabros A, Taher J, Kulasingam V. Evaluation of a New NT-proBNP Immunoassay on an Automated Core Laboratory System. J Appl Lab Med 2024; 9:579-585. [PMID: 38170842 DOI: 10.1093/jalm/jfad117] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/07/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND Heart failure remains a major cause of morbidity and mortality despite improvements in treatment. This study aimed to evaluate the Alere N-terminal pro B-type natriuretic peptide (NT-proBNP) immunoassay on the Abbott Alinity i platform. METHODS The analytical performance including precision, linearity, limit of quantitation (LOQ), carryover, dilution-recovery, and stability was evaluated. A method comparison between the Abbott Alere NT-proBNP assay and Roche Elecsys proBNP II assay was performed using 70 residual plasma samples. RESULTS Total imprecision was 4.1%, 3.5%, and 2.3% for low (120.9 ng/L), medium (333.9 ng/L), and high (4767.4 ng/L) QC levels, respectively. The manufacturer's claimed LOQ of 8.3 ng/L was verified. Method comparison between the Alere NT-proBNP assay and the Elecsys proBNP II assay showed good agreement between assays with an R value of 0.998, a slope of 1.05 (95% CI, 1.03-1.06), and an intercept of 45.81 (95% CI, -46.6.84 to 138.22). The Bland-Altman plot showed an absolute bias of 250 ng/L or 6.02%. Subrange analysis (NT-proBNP <2000 ng/L) showed good agreement with an R value of 0.998, a slope of 1.04 (95% CI, 1.02-1.06), and an intercept of -4.83 (95% CI, -26.95 to 17.28), with a mean bias of 26 ng/L or 3.2%. The stability of NT-proBNP was also verified in lithium heparin plasma samples stored at 4°C over a 7-day period. Hemolysis and lipemia interference thresholds were verified, but icterus impacted NT-proBNP recovery by >20% at low analyte concentrations. CONCLUSIONS The Alere NT-proBNP assay demonstrated acceptable analytical performance and very good clinical concordance with the Elecsys proBNP II assay.
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Affiliation(s)
- Samantha Logan
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
| | - Ashley Di Meo
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Clinical Biochemistry, Laboratory Medicine Program, University Health Network (UHN), Toronto, ON, Canada
| | - Stacey Shapero
- Department of Clinical Biochemistry, Laboratory Medicine Program, University Health Network (UHN), Toronto, ON, Canada
| | - Anselmo Fabros
- Department of Clinical Biochemistry, Laboratory Medicine Program, University Health Network (UHN), Toronto, ON, Canada
| | - Jennifer Taher
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Pathology and Laboratory Medicine, Mount Sinai Hospital, Toronto, ON, Canada
| | - Vathany Kulasingam
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, ON, Canada
- Department of Clinical Biochemistry, Laboratory Medicine Program, University Health Network (UHN), Toronto, ON, Canada
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Boulet J, Sridhar VS, Bouabdallaoui N, Tardif JC, White M. Inflammation in heart failure: pathophysiology and therapeutic strategies. Inflamm Res 2024; 73:709-723. [PMID: 38546848 PMCID: PMC11058911 DOI: 10.1007/s00011-023-01845-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Revised: 11/09/2023] [Accepted: 12/19/2023] [Indexed: 04/30/2024] Open
Abstract
A role for inflammation in the development and progression of heart failure (HF) has been proposed for decades. Multiple studies have demonstrated the potential involvement of several groups of cytokines and chemokines in acute and chronic HF, though targeting these pathways in early therapeutic trials have produced mixed results. These studies served to highlight the complexity and nuances of how pro-inflammatory pathways contribute to the pathogenesis of HF. More recent investigations have highlighted how inflammation may play distinct roles based on HF syndrome phenotypes, findings that may guide the development of novel therapies. In this review, we propose a contemporary update on the role of inflammation mediated by the innate and adaptive immune systems with HF, highlighting differences that exist across the ejection fraction spectrum. This will specifically be looked at through the lens of established and novel biomarkers of inflammation. Subsequently, we review how improvements in inflammatory pathways may mediate clinical benefits of existing guideline-directed medical therapies for HF, as well as future therapies in the pipeline targeting HF and inflammation.
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Affiliation(s)
- Jacinthe Boulet
- Department of Medicine, Division of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Vikas S Sridhar
- Department of Medicine, Division of Nephrology, University Health Network, Toronto, ON, Canada
| | - Nadia Bouabdallaoui
- Department of Medicine, Division of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Jean-Claude Tardif
- Department of Medicine, Division of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada
| | - Michel White
- Department of Medicine, Division of Cardiology, Montreal Heart Institute, Université de Montréal, Montreal, QC, Canada.
- Department of Medicine, Division of Cardiology, Montreal Heart Institute, Université de Montréal, 5000 Belanger Street, QC, H1C 1C8, Montreal, Canada.
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Haraf R, Habib H, Masri A. The Revolution of Cardiac Myosin Inhibitors in Patients With Hypertrophic Cardiomyopathy. Can J Cardiol 2024; 40:800-819. [PMID: 38280487 DOI: 10.1016/j.cjca.2024.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/02/2023] [Revised: 01/02/2024] [Accepted: 01/08/2024] [Indexed: 01/29/2024] Open
Abstract
Hypertrophic cardiomyopathy (HCM) is the most common genetic cardiomyopathy worldwide and causes significant morbidity and mortality. For decades, medical treatment options have been limited and untargeted, with frequent need for invasive interventions not readily accessible to many HCM patients. More recently, our understanding of the genetic basis and pathophysiologic mechanism of HCM has grown significantly, leading to the discovery of a new class of medications, cardiac myosin inhibitors (CMIs), that shift myosin into the super-relaxed state to counteract the hypercontractility in HCM. Subsequent clinical trials have proven the mechanism and efficacy of CMIs in humans with obstructive HCM, and additional trials are under way in patients with nonobstructive HCM. With favourable results in the completed clinical trials and ongoing research on the horizon, CMIs represent a bright new era in the targeted management of HCM. This review is focused on the discovery of CMIs, provides a summary of the results of clinical trials to date, provides clinicians with a roadmap for implementing CMIs into practice, and identifies gaps in our current understanding as well as areas of ongoing investigation.
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Affiliation(s)
- Rebecca Haraf
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Hany Habib
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA
| | - Ahmad Masri
- The Hypertrophic Cardiomyopathy Center, Knight Cardiovascular Institute, Oregon Health & Science University, Portland, Oregon, USA.
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Brahmbhatt DH, Ross HJ, O'Sullivan M, Artanian V, Mueller B, Runeckles K, Steve Fan CP, Rac VE, Seto E. The Effect of Using a Remote Patient Management Platform in Optimizing Guideline-Directed Medical Therapy in Heart Failure Patients: A Randomized Controlled Trial. JACC. HEART FAILURE 2024; 12:678-690. [PMID: 38569821 DOI: 10.1016/j.jchf.2024.02.008] [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: 09/06/2023] [Revised: 01/23/2024] [Accepted: 02/06/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Guideline-directed medical therapy (GDMT) remains underutilized in patients with heart failure with reduced ejection fraction, leading to morbidity and mortality. OBJECTIVES The Medly Titrate (Use of Telemonitoring to Facilitate Heart Failure Mediation Titration) study was an open-label, randomized controlled trial to determine whether remote medication titration for patients with heart failure with reduced ejection fraction was more effective than usual care (UC). METHODS In this study, 108 patients were randomized to remote GDMT titration through the Medly heart failure program (n = 56) vs UC (n = 52). The primary outcome was the proportion of patients completing GDMT titration at 6 months. Secondary outcomes included the number of clinic visits and time required to achieve titration, patient health outcomes, and health care utilization, including urgent clinic/emergency department visits and hospitalization. RESULTS At 6 months, GDMT titration was completed in 82.1% (95% CI: 71.2%-90.8%) of patients in the intervention arm vs 53.8% in UC (95% CI: 41.1%-67.7%; P = 0.001). Remote titration required fewer in-person (1.62 ± 1.09 vs 2.42 ± 1.65; P = 0.004) and virtual clinic visits (0.50 ± 1.08 vs 1.29 ± 1.86; P = 0.009) to complete titration. Median time to optimization was shorter with remote titration (3.42 months [Q1-Q3: 2.99-4.04 months] vs 5.47 months [Q1-Q3: 4.14-7.33 months]; P < 0.001). The number of urgent clinic/emergency department visits (incidence rate ratio of remote vs control groups: 0.90 [95% CI: 0.53-1.56]; P = 0.70) were similar between groups, with a reduction in all-cause hospitalization with remote titration (incidence rate ratio: 0.55 [95% CI: 0.31-0.97]; P = 0.042). CONCLUSIONS Remote titration of GDMT in heart failure with reduced ejection fraction was effective, safe, feasible, and increased the proportion of patients achieving target doses, in a shorter period of time with no excess adverse events compared with UC. (Use of Telemonitoring to Facilitate Heart Failure Mediation Titration [Medly Titrate]; NCT04205513).
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Affiliation(s)
- Darshan H Brahmbhatt
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Heather J Ross
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Division of Cardiology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada; Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada
| | - Mary O'Sullivan
- Centre for Digital Therapeutics, University Health Network, Toronto, Ontario, Canada
| | - Veronica Artanian
- Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Brigitte Mueller
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Kyle Runeckles
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Chun-Po Steve Fan
- Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Valeria E Rac
- Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada; Ted Rogers Computational Program, Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada; Program for Health System and Technology Evaluation, University Health Network, Toronto, Ontario, Canada
| | - Emily Seto
- Toronto General Hospital Research Institute, University Health Network, Toronto, Ontario, Canada; Centre for Digital Therapeutics, University Health Network, Toronto, Ontario, Canada; Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada.
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11
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Rheaume MJ, Um KJ, Amin F, Belley-Côté EP. Pulmonary Artery Catheters: Old Dog With New Tricks? Can J Cardiol 2024; 40:674-676. [PMID: 38141811 DOI: 10.1016/j.cjca.2023.12.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/16/2023] [Indexed: 12/25/2023] Open
Affiliation(s)
- Michael J Rheaume
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Kevin J Um
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research, Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Faizan Amin
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Emilie P Belley-Côté
- Division of Cardiology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Health Research, Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada; Population Health Research Institute, Hamilton, Ontario, Canada.
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Wahid M, Islam S, Sepehrvand N, Dover DC, McAlister FA, Kaul P, Ezekowitz JA. Iron Deficiency, Anemia, and Iron Supplementation in Patients With Heart Failure: A Population-Level Study. Circ Heart Fail 2024; 17:e011351. [PMID: 38572652 DOI: 10.1161/circheartfailure.123.011351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/24/2023] [Accepted: 01/08/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Studies have shown an association between iron deficiency (ID) and clinical outcomes in patients with heart failure (HF), irrespective of the presence of ID anemia (IDA). The current study used population-level data from a large, single-payer health care system in Canada to investigate the epidemiology of ID and IDA in patients with acute HF and those with chronic HF, and the iron supplementation practices in these settings. METHODS All adult patients with HF in Alberta between 2012 and 2019 were identified and categorized as acute or chronic HF. HF subtypes were determined through echocardiography data, and ID (serum ferritin concentration <100 μg/L, or ferritin concentration between 100 and 300 μg/L along with transferrin saturation <20%), and IDA through laboratory data. Broad eligibility for 3 clinical trials (AFFIRM-AHF [Study to Compare Ferric Carboxymaltose With Placebo in Patients With Acute HF and ID], IRONMAN [Intravenous Iron Treatment in Patients With Heart Failure and Iron Deficiency], and HEART-FID [Randomized Placebocontrolled Trial of Ferric Carboxymaltose as Treatment for HF With ID]) was determined. RESULTS Among the 17 463 patients with acute HF, 38.5% had iron studies tested within 30 days post-index-HF episode (and 34.2% of the 11 320 patients with chronic HF). Among tested patients, 72.6% of the acute HF and 73.9% of the chronic HF were iron-deficient, and 51.4% and 49.0% had IDA, respectively. Iron therapy was provided to 41.8% and 40.5% of patients with IDA and acute or chronic HF, respectively. Of ID patients without anemia, 19.9% and 21.7% were prescribed iron therapy. The most common type of iron therapy was oral (28.1% of patients). Approximately half of the cohort was eligible for each of the AFFIRM-AHF, intravenous iron treatment in patients with HF and ID, and HEART-FID trials. CONCLUSIONS Current practices for investigating and treating ID in patients with HF do not align with existing guideline recommendations. Considering the gap in care, innovative strategies to optimize iron therapy in patients with HF are required.
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Affiliation(s)
- Muizz Wahid
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (M.W., S.I., N.S., D.C.D., F.A.M., P.K., J.A.E.)
- Department of Medicine (M.W., N.S., F.A.M., P.K.), University of Alberta, Edmonton, AB, Canada
| | - Sunjidatul Islam
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (M.W., S.I., N.S., D.C.D., F.A.M., P.K., J.A.E.)
| | - Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (M.W., S.I., N.S., D.C.D., F.A.M., P.K., J.A.E.)
- Department of Medicine (M.W., N.S., F.A.M., P.K.), University of Alberta, Edmonton, AB, Canada
| | - Douglas C Dover
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (M.W., S.I., N.S., D.C.D., F.A.M., P.K., J.A.E.)
| | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (M.W., S.I., N.S., D.C.D., F.A.M., P.K., J.A.E.)
- Department of Medicine (M.W., N.S., F.A.M., P.K.), University of Alberta, Edmonton, AB, Canada
- Alberta Strategy for Patient-Oriented Research Support Unit, Edmonton, AB, Canada (F.A.M.)
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (M.W., S.I., N.S., D.C.D., F.A.M., P.K., J.A.E.)
- Department of Medicine (M.W., N.S., F.A.M., P.K.), University of Alberta, Edmonton, AB, Canada
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (M.W., S.I., N.S., D.C.D., F.A.M., P.K., J.A.E.)
- Division of Cardiology, Department of Medicine (J.A.E.), University of Alberta, Edmonton, AB, Canada
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13
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Mamataz T, Virani SA, McDonald M, Edgell H, Grace SL. Heart failure clinic inclusion and exclusion criteria: cross-sectional study of clinic's and referring provider's perspectives. BMJ Open 2024; 14:e076664. [PMID: 38485484 PMCID: PMC10941180 DOI: 10.1136/bmjopen-2023-076664] [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] [Received: 06/13/2023] [Accepted: 02/28/2024] [Indexed: 03/17/2024] Open
Abstract
OBJECTIVES There are substantial variations in entry criteria for heart failure (HF) clinics, leading to variations in whom providers refer for these life-saving services. This study investigated actual versus ideal HF clinic inclusion or exclusion criteria and how that related to referring providers' perspectives of ideal criteria. DESIGN, SETTING AND PARTICIPANTS Two cross-sectional surveys were administered via research electronic data capture to clinic providers and referrers (eg, cardiologists, family physicians and nurse practitioners) across Canada. MEASURES Twenty-seven criteria selected based on the literature and HF guidelines were tested. Respondents were asked to list any additional criteria. The degree of agreement was assessed (eg, Kappa). RESULTS Responses were received from providers at 48 clinics (37.5% response rate). The most common actual inclusion criteria were newly diagnosed HF with reduced or preserved ejection fraction, New York Heart Association class IIIB/IV and recent hospitalisation (each endorsed by >74% of respondents). Exclusion criteria included congenital aetiology, intravenous inotropes, a lack of specialists, some non-cardiac comorbidities and logistical factors (eg, rurality and technology access). There was the greatest discordance between actual and ideal criteria for the following: inpatient at the same institution (κ=0.14), congenital heart disease, pulmonary hypertension or genetic cardiomyopathies (all κ=0.36). One-third (n=16) of clinics had changed criteria, often for non-clinical reasons. Seventy-three referring providers completed the survey. Criteria endorsed more by referrers than clinics included low blood pressure with a high heart rate, recurrent defibrillator shocks and intravenous inotropes-criteria also consistent with guidelines. CONCLUSIONS There is considerable agreement on the main clinic entry criteria, but given some discordance, two levels of clinics may be warranted. Publicising evidence-based criteria and applying them systematically at referral sources could support improved HF patient care journeys and outcomes.
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Affiliation(s)
- Taslima Mamataz
- Faculty of Health, York University, Keele Campus, Toronto, Ontario, Canada
| | - Sean A Virani
- Medicine, The University of British Columbia Faculty of Medicine, Vancouver, British Columbia, Canada
| | - Michael McDonald
- Peter Munk Cardiac Centre, University of Toronto, University Health Network, Toronto, Ontario, Canada
| | - Heather Edgell
- Faculty of Health, York University, Keele Campus, Toronto, Ontario, Canada
| | - Sherry L Grace
- Faculty of Health, York University, Keele Campus, Toronto, Ontario, Canada
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14
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Hindi J, Fréchette-Le Bel M, Rouleau JL, de Denus S. Influence of Weight and Body Size on the Pharmacokinetics of Heart Failure Pharmacotherapy: A Systematic Review. Ann Pharmacother 2024; 58:255-272. [PMID: 37338205 DOI: 10.1177/10600280231179484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023] Open
Abstract
OBJECTIVE To conduct a review of studies evaluating the influence of body size and weight (WT) on the pharmacokinetics (PK) of drugs recommended for heart failure (HF) treatment. DATA SOURCES A systematic search of the MEDLINE (1946 to April 2023) and EMBASE (1974 to April 2023) databases was conducted for articles that focused on the impact of WT or body size on the PK of drugs of interest used in HF patients. STUDY SELECTION AND DATA EXTRACTION Articles written in English or French related to the aim of our study were retained for analysis. DATA SYNTHESIS Of 6493 articles, 20 were retained for analysis. Weight was associated with the clearance of digoxin, carvedilol, enalapril, and candesartan as well as the volume of distribution of eplerenone and bisoprolol. There was no documented direct impact of WT on the PK of furosemide, valsartan, and metoprolol, although these studies were limited or confounded by the small sample size, adjustment of PK factors by WT, or the use of the Cockroff-Gault equation for the evaluation of creatinine clearance, which includes WT. RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE This review highlights and summarizes the available data on the importance of WT on the PK of HF treatment. CONCLUSION Considering the significant impact of WT on most HF drugs in this review, it may be important to further investigate it in the context of personalized therapy, particularly in patients presenting extreme WTs.
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Affiliation(s)
- Jessica Hindi
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Montreal Heart Institute, Montreal, QC, Canada
- Beaulieu-Saucier Pharmacogenomics Center, Université de Montréal, Montreal, QC, Canada
| | | | - Jean Lucien Rouleau
- Montreal Heart Institute, Montreal, QC, Canada
- Faculty of Medicine, Université de Montréal, Montreal, QC, Canada
| | - Simon de Denus
- Faculty of Pharmacy, Université de Montréal, Montreal, QC, Canada
- Montreal Heart Institute, Montreal, QC, Canada
- Beaulieu-Saucier Pharmacogenomics Center, Université de Montréal, Montreal, QC, Canada
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15
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Jairoun AA, Al-Hemyari SS, Shahwan M, Zyoud SH, Jairoun M. Guideline-directed medical therapy in heart failure patients with reduced ejection fraction in Palestine: Retrospective clinical audit study. Saudi Pharm J 2024; 32:101965. [PMID: 38313821 PMCID: PMC10832460 DOI: 10.1016/j.jsps.2024.101965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 01/21/2024] [Indexed: 02/06/2024] Open
Abstract
Objectives To assess the characteristics of patients with heart failure with reduced ejection fraction (HFrEF) and heart failure with mid-range ejection fraction (HFmrEF), as well as the current application of guideline-directed medical therapy (GDMT) in Palestine. Methods This retrospective cohort study involved a population of heart failure (HF) patients who visited cardiology clinics at An-Najah National University Hospital and the National Hospital, Palestine. The primary outcome measures of interest were the proportions of patients prescribed guideline-based cardiovascular medications (GBCMs), such as angiotensin-converting enzyme inhibitors (ACEIs)/angiotensin II receptor blockers (ARBs), β-blockers, and mineralocorticoid receptor antagonists (MRAs), and the corresponding optimized doses at ≥ 50 % of targets and the reasons underlying the non-prescription of GDMT. Results A total of 70.5%, 56.6%, and 88.6% of patients were on ACEIs/ARBs, MRAs, and β-blockers, respectively. Of all patients, 38.7% were on the triple GDMT regimen. Conclusion Less than half the patients received the triple combination treatment. Age, diabetes mellitus, chronic renal disease, and admission to the hospital for HF all had significant independent relationships with the reduced utilization and inadequate dosage of GDMT.
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Affiliation(s)
- Ammar Abdulrahman Jairoun
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Gelugor 11800, Malaysia
- Health and Safety Department, Dubai Municipality, Dubai, UAE
| | - Sabaa Saleh Al-Hemyari
- Discipline of Clinical Pharmacy, School of Pharmaceutical Sciences, Universiti Sains Malaysia, Pulau Pinang, Gelugor 11800, Malaysia
- Pharmacy Department, Emirates Health Services, Dubai, UAE
| | - Moyad Shahwan
- College of Pharmacy and Health Sciences, Ajman University, Ajman, 346, UAE
- Centre of Medical and Bio–allied Health Sciences Research, Ajman University, United Arab Emirates
| | - Sa'ed H. Zyoud
- Department of Clinical and Community Pharmacy, College of Medicine and Health Sciences, An-Najah National University, Nablus, 44839, Palestine
- Clinical Research Centre, An-Najah National University Hospital, Nablus, 44839, Palestine
| | - Maimona Jairoun
- College of Pharmacy and Health Sciences, Ajman University, Ajman, 346, UAE
- Centre of Medical and Bio–allied Health Sciences Research, Ajman University, United Arab Emirates
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Qian Y, Tan JYB, Wang T, Bressington D, Zhou HJ, Li MY, Liu XL. Quality appraisal and descriptive analysis of clinical practice guidelines for self-managed non-pharmacological interventions of cardiovascular diseases: a systematic review. J Transl Med 2024; 22:215. [PMID: 38424641 PMCID: PMC10903016 DOI: 10.1186/s12967-024-04959-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Accepted: 02/07/2024] [Indexed: 03/02/2024] Open
Abstract
BACKGROUND Cardiovascular diseases (CVDs) are the leading cause of death around the world. Most CVDs-related death can be prevented by the optimal management of risk factors such as unhealthy diet and physical inactivity. Clinical practice guidelines (CPGs) for CVDs, provide some evidence-based recommendations which help healthcare professionals to achieve the best care for patients with CVDs. This systematic review aims to appraise the methodological quality of CPGs systematically and summarize the recommendations of self-managed non-pharmacological interventions for the prevention and management of CVDs provided by the selected guidelines. METHODS A comprehensive electronic literature search was conducted via six databases (PubMed, Medline, The Cochrane Library, Embase, CINAHL, and Web of Science), seven professional heart association websites, and nine guideline repositories. The Appraisal of Guidelines, Research and Evaluation II (AGREE II) instrument was adopted to critically appraise the methodological quality of the selected guidelines. Content analysis was used to summarise recommended self-managed non-pharmacological interventions for CVDs. RESULTS Twenty-three CPGs regarding different CVDs were included, in which four guidelines of CVDs, three for coronary heart diseases, seven for heart failure, two for atrial fibrillation, three for stroke, three for peripheral arterial disease, and one for hypertrophic cardiomyopathy. Twenty CPGs were appraised as high quality, and three CPGs as moderate quality. All twenty-three CPGs were recommended for use with or without modification. The domain of "Editorial Independence" had the highest standardized percentage (93.47%), whereas the domain of "Applicability" had the lowest mean domain score of 75.41%. The content analysis findings summarised some common self-managed non-pharmacological interventions, which include healthy diet, physical activity, smoking cessation, alcohol control, and weight management. Healthy diet and physical acidity are the most common and agreed on self-managed interventions for patients with CVDs. There are some inconsistencies identified in the details of recommended interventions, the intervention itself, the grade of recommendation, and the supported level of evidence. CONCLUSION The majority of the summarized non-pharmacological interventions were strongly recommended with moderate to high-quality levels of evidence. Healthcare professionals and researchers can adopt the results of this review to design self-managed non-pharmacological interventions for patients with CVDs.
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Affiliation(s)
- Yun Qian
- Faculty of Health, Charles Darwin University, Casuarina, Australia
- Maroondah Hospital, Eastern Health, Melbourne, Australia
| | - Jing-Yu Benjamin Tan
- Faculty of Health, Charles Darwin University, Casuarina, Australia
- School of Nursing and Midwifery, University of Southern Queensland, Ipswich, QLD, Australia
- Centre for Health Research, University of Southern Queensland, Springfield, QLD, Australia
| | - Tao Wang
- Faculty of Health, Charles Darwin University, Casuarina, Australia
| | | | - Hong-Juan Zhou
- School of Nursing, Putian University, Putian, Fujian, China
| | - Meng-Yuan Li
- Faculty of Health, Charles Darwin University, Casuarina, Australia
| | - Xian-Liang Liu
- School of Nursing and Health Studies, Hong Kong Metropolitan University, Homantin, Kowloon, Hong Kong, China.
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Gewarges M, Mainland R, Wilkinson K, Sklar J, Gentilin A, McLean B, Hajjaj OI, Worme M, Lalonde S, Patel R, Lin Y, Callum J, Poon S. Increasing rates of screening and treatment of iron deficiency in ambulatory patients with heart failure with reduced ejection fraction: a quality improvement cohort study. BMJ Open Qual 2024; 13:e002584. [PMID: 38395465 PMCID: PMC10895242 DOI: 10.1136/bmjoq-2023-002584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Accepted: 02/14/2024] [Indexed: 02/25/2024] Open
Abstract
INTRODUCTION Iron deficiency anaemia (IDA) is common in patients with heart failure (HF) and is associated with advanced HF and increased mortality. Intravenous iron supplementation increases exercise tolerance, improves quality of life, and decreases symptoms among patients with HF with reduced ejection fraction (HFrEF) and iron deficiency. Despite this, many patients are not screened or treated for IDA. We aimed to increase rates of screening and treatment of IDA among HF patients through the introduction of curated materials to aid HF clinicians with appropriate screening and treatment. METHODS We conducted a retrospective chart review to identify the baseline number of HFrEF patients screened and treated for IDA at two ambulatory cardiology clinics in Toronto, Ontario. A quality improvement initiative was then introduced, which consisted of education and curated materials to aid clinicians in the screening and treatment of IDA among HFrEF patients. The proportion of patients screened and treated for IDA preintervention and postintervention were compared using χ2 tests of Independence. RESULTS In the preintervention cohort, 36.3% (n=45) of patients with anaemia were screened for IDA. Among those screened, 64.4% (n=29) had IDA. Only 17.2% (n=5) of these were treated with IV iron. After implementation of the quality improvement initiative, 90.9% (n=60) of patients with anaemia were screened for IDA (p<0.001) and 90.3% (n=28) of those with IDA were treated with IV iron (p<0.001). CONCLUSION The introduction of curated materials to aid clinicians was associated with increased rates of screening and treatment of IDA among ambulatory HFrEF patients. Further work is required to identify barriers and implement strategies to increase screening and treatment rates of IDA among HFrEF patients.
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Affiliation(s)
- Mena Gewarges
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Roslyn Mainland
- Division of General Internal Medicine, Queen's University, Kingston, Ontario, Canada
| | - Katherine Wilkinson
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Jaime Sklar
- Division of General Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Andrew Gentilin
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Bianca McLean
- McMaster University Michael G DeGroote School of Medicine, Hamilton, Ontario, Canada
| | - Omar I Hajjaj
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Mali Worme
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Spencer Lalonde
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - Raumil Patel
- Division of General Internal Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Yulia Lin
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
| | - Jeannie Callum
- Department of Laboratory Medicine and Pathobiology, University of Toronto, Toronto, Ontario, Canada
- Department of Pathology and Molecular Medicine, Kingston Health Sciences Centre, Kingston, Ontario, Canada
| | - Stephanie Poon
- Division of Cardiology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
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Schiavo S, Brenna CTA, Albertini L, Djaiani G, Marinov A, Katznelson R. Safety of hyperbaric oxygen therapy in patients with heart failure: A retrospective cohort study. PLoS One 2024; 19:e0293484. [PMID: 38330042 PMCID: PMC10852233 DOI: 10.1371/journal.pone.0293484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 12/25/2023] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Hyperbaric oxygen therapy (HBOT) has several hemodynamic effects including increases in afterload (due to vasoconstriction) and decreases in cardiac output. This, along with rare reports of pulmonary edema during emergency treatment, has led providers to consider HBOT relatively contraindicated in patients with reduced left ventricular ejection fraction (LVEF). However, there is limited evidence regarding the safety of elective HBOT in patients with heart failure (HF), and no existing reports of complications among patients with HF and preserved LVEF. We aimed to retrospectively review patients with preexisting diagnoses of HF who underwent elective HBOT, to analyze HBOT-related acute HF complications. METHODS Research Ethics Board approvals were received to retrospectively review patient charts. Patients with a history of HF with either preserved ejection fraction (HFpEF), mid-range ejection fraction (HFmEF), or reduced ejection fraction (HFrEF) who underwent elective HBOT at two Hyperbaric Centers (Toronto General Hospital, Rouge Valley Hyperbaric Medical Centre) between June 2018 and December 2020 were reviewed. RESULTS Twenty-three patients with a history of HF underwent HBOT, completing an average of 39 (range 6-62) consecutive sessions at 2.0 atmospheres absolute (ATA) (n = 11) or at 2.4 ATA (n = 12); only two patients received fewer than 10 sessions. Thirteen patients had HFpEF (mean LVEF 55 ± 7%), and seven patients had HFrEF (mean LVEF 35 ± 8%) as well as concomitantly decreased right ventricle function (n = 5), moderate/severe tricuspid regurgitation (n = 3), or pulmonary hypertension (n = 5). The remaining three patients had HFmEF (mean LVEF 44 ± 4%). All but one patient was receiving fluid balance therapy either with loop diuretics or dialysis. Twenty-one patients completed HBOT without complications. We observed symptoms consistent with HBOT-related HF exacerbation in two patients. One patient with HFrEF (LVEF 24%) developed dyspnea attributed to pulmonary edema after the fourth treatment, and later admitted to voluntarily holding his diuretics before the session. He was managed with increased oral diuretics as an outpatient, and ultimately completed a course of 33 HBOT sessions uneventfully. Another patient with HFpEF (LVEF 64%) developed dyspnea and desaturation after six sessions, requiring hospital admission. Acute coronary ischemia and pulmonary embolism were ruled out, and an elevated BNP and normal LVEF on echocardiogram confirmed a diagnosis of pulmonary edema in the context of HFpEF. Symptoms subsided after diuretic treatment and the patient was discharged home in stable condition, but elected not to resume HBOT. CONCLUSIONS Patients with HF, including HFpEF, may develop HF symptoms during HBOT and warrant ongoing surveillance. However, these patients can receive HBOT safely after optimization of HF therapy and fluid restriction.
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Affiliation(s)
- Simone Schiavo
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, ON, Canada
- Department of Anesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Connor T. A. Brenna
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
| | - Lisa Albertini
- Department of Medicine, Division of Cardiology, University of Toronto, Toronto, ON, Canada
| | - George Djaiani
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, ON, Canada
| | - Anton Marinov
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, ON, Canada
- Rouge Valley Hyperbaric Medical Center, Scarborough, ON, Canada
| | - Rita Katznelson
- Department of Anesthesiology & Pain Medicine, University of Toronto, Toronto, ON, Canada
- Hyperbaric Medicine Unit, Toronto General Hospital, Toronto, ON, Canada
- Rouge Valley Hyperbaric Medical Center, Scarborough, ON, Canada
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Clavel MA, Van Spall HG, Mantella LE, Foulds H, Randhawa V, Parry M, Liblik K, Kirkham AA, Cotie L, Jaffer S, Bruneau J, Colella TJ, Ahmed S, Dhukai A, Gomes Z, Adreak N, Keeping-Burke L, Limbachia J, Liu S, Jacques KE, Mullen KA, Mulvagh SL, Norris CM. The Canadian Women's Heart Health Alliance ATLAS on the Epidemiology, Diagnosis, and Management of Cardiovascular Disease in Women - Chapter 8: Knowledge Gaps and Status of Existing Research Programs in Canada. CJC Open 2024; 6:220-257. [PMID: 38487042 PMCID: PMC10935691 DOI: 10.1016/j.cjco.2023.11.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Accepted: 11/14/2023] [Indexed: 03/17/2024] Open
Abstract
Despite significant progress in medical research and public health efforts, gaps in knowledge of women's heart health remain across epidemiology, presentation, management, outcomes, education, research, and publications. Historically, heart disease was viewed primarily as a condition in men and male individuals, leading to limited understanding of the unique risks and symptoms that women experience. These knowledge gaps are particularly problematic because globally heart disease is the leading cause of death for women. Until recently, sex and gender have not been addressed in cardiovascular research, including in preclinical and clinical research. Recruitment was often limited to male participants and individuals identifying as men, and data analysis according to sex or gender was not conducted, leading to a lack of data on how treatments and interventions might affect female patients and individuals who identify as women differently. This lack of data has led to suboptimal treatment and limitations in our understanding of the underlying mechanisms of heart disease in women, and is directly related to limited awareness and knowledge gaps in professional training and public education. Women are often unaware of their risk factors for heart disease or symptoms they might experience, leading to delays in diagnosis and treatments. Additionally, health care providers might not receive adequate training to diagnose and treat heart disease in women, leading to misdiagnosis or undertreatment. Addressing these knowledge gaps requires a multipronged approach, including education and policy change, built on evidence-based research. In this chapter we review the current state of existing cardiovascular research in Canada with a specific focus on women.
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Affiliation(s)
- Marie-Annick Clavel
- Institut Universitaire de Cardiologie et de Pneumologie de Québec, Université Laval, Québec, Québec, Canada
| | - Harriette G.C. Van Spall
- Department of Medicine, Department of Health Research Methods, Evidence, and Impact, McMaster University, Toronto, Ontario, Canada
| | - Laura E. Mantella
- Department of Biomedical and Molecular Sciences, Queen’s University, Kingston, Ontario, Canada
| | - Heather Foulds
- College of Kinesiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Varinder Randhawa
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Monica Parry
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Kiera Liblik
- Department of Medicine, Kingston Health Science Center, Kingston, Ontario, Canada
| | - Amy A. Kirkham
- Faculty of Kinesiology and Physical Education, University of Toronto, Toronto, Ontario, Canada
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Lisa Cotie
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Shahin Jaffer
- General Internal Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Jill Bruneau
- Faculty of Nursing, Memorial University of Newfoundland and Labrador, St John, Newfoundland and Labrador, Canada
| | - Tracey J.F. Colella
- Toronto Rehabilitation Institute (KITE), University Health Network, Toronto, Ontario, Canada
| | - Sofia Ahmed
- Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Abida Dhukai
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Zoya Gomes
- Faculty of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Najah Adreak
- Department of Surgery, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lisa Keeping-Burke
- Department of Nursing and Health Sciences, University of New Brunswick, Saint John, New Brunswick, Canada
| | - Jayneel Limbachia
- Schulich School of Medicine, Western University, London, Ontario, Canada
| | - Shuangbo Liu
- Section of Cardiology, Department of Medicine, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Karen E. Jacques
- Person with lived experience, Canadian Women’s Heart Health Alliance, Ottawa, Ontario, Canada
| | - Kerri A. Mullen
- University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Sharon L. Mulvagh
- Faculty of Medicine, Division of Cardiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Colleen M. Norris
- Faculty of Nursing, University of Alberta, Edmonton, Alberta, Canada
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Sohn SH, Kang Y, Kim JS, Park EA, Lee W, Hwang HY. Impact of Myocardial Viability on Long-term Outcomes after Surgical Revascularization. Thorac Cardiovasc Surg 2024. [PMID: 38092064 DOI: 10.1055/a-2228-7104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024]
Abstract
BACKGROUND This study was conducted to evaluate whether myocardial viability assessed with cardiac magnetic resonance (CMR) affected long-term clinical outcomes after coronary artery bypass grafting (CABG) in patients with ischemic cardiomyopathy (ICMP). METHODS Preoperative CMR with late gadolinium enhancement (LGE) was performed in 103 patients (64.9 ± 10.1 years, male:female = 82:21) with 3-vessel disease and left ventricular dysfunction (ejection fraction ≤ 0.35). Transmural extent of LGE was evaluated on a 16-segment model, and transmurality was graded on a 5-point scale: grades-0, absence; 1, 1 to 25%; 2, 26 to 50%; 3, 51 to 75%; 4, 76 to 100%. Median follow-up duration was 65.5 months (interquartile range = 27.5-95.3 months). Primary endpoint was the composite of all-cause mortality or hospitalization for congestive heart failure. RESULTS Operative mortality was 1.9%. During the follow-up, all-cause mortality and readmission for congestive heart failure occurred in 29 and 8 patients, respectively. The cumulative incidence of the primary endpoint was 31.3 and 46.8% at 5 and 10 years, respectively. Multivariable analysis demonstrated that the number of segments with LGE grade 4 was a significant risk factor (hazard ratio 1.42, 95% confidence interval 1.10-1.83, p = 0.007) for the primary endpoint among the variables assessed by CMR. Other risk factors included age, dialysis, chronic obstructive pulmonary disease, and EuroSCORE II. CONCLUSION The number of myocardial segments with transmurality of LGE >75% might be a prognostic factor associated with the composite of all-cause mortality or hospitalization for congestive heart failure after CABG in patients with 3-vessel disease and ICMP.
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Affiliation(s)
- Suk Ho Sohn
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Yoonjin Kang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ji Seong Kim
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Eun-Ah Park
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Whal Lee
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
| | - Ho Young Hwang
- Department of Thoracic and Cardiovascular Surgery, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Republic of Korea
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21
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Wang CN, Lu Z, Simpson CS, Lee DS, Tranmer JE. Predicting long-term survival after de novo cardioverter-defibrillator implantation for primary prevention: A population based study. Heliyon 2024; 10:e23355. [PMID: 38223713 PMCID: PMC10784147 DOI: 10.1016/j.heliyon.2023.e23355] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/22/2023] [Accepted: 12/01/2023] [Indexed: 01/16/2024] Open
Abstract
Background Implantable cardioverter-defibrillators (ICDs) reduce the risk of sudden cardiac death in patients with left ventricular dysfunction. While short-term mortality benefit of ICD insertion has been established in landmark randomized controlled trials, little is known about the long-term outcomes of patients with ICDs in clinical practice. In this paper, we describe the long-term survival of patients following de novo ICD implantation for primary prevention in clinical practice and determine the factors which help predict survival after ICD implant. Methods Retrospective population-based study of all patients receiving a de novo ICD for primary prevention in Ontario, Canada from 2007 to 2011 using the Ontario ICD Database housed within ICES. Simple random selection was used to split the population into a derivation and internal validation cohort in a ratio of 2:1. Cox proportional hazards regression was used to determine predictors of interest and predict 10-year survival, model performance was assessed using calibration and validation. Results In the derivation cohort (n = 3399), mean age was 65.3 years (standard deviation [SD] = 11.0), 664 patients were female (19.5 %) and 2344 patients (69.0 %) had ischemic cardiomyopathy. Ten year survival was 45.7 % (95 % confidence interval [CI] 44.0 %-47.4 %). The final prediction model included age, sex, disease factors (ischemic vs nonischemic cardiomyopathy, left ventricular ejection fraction) and patient factors (symptoms, comorbidities), and biomarkers at the time of ICD assessment. This model had good discrimination and calibration in derivation (0.79, 95 % CI 0.77, 0.81) and validation samples (0.78, 95 % CI 0.76, 0.79). Conclusions A combination of demographic and clinical factors determined at baseline can be used to predict 10-year survival in patients with implantable cardioverter-defibrillators with good accuracy. Our findings help to identify individuals at risk of long-term mortality and may be useful in targeting future prevention strategies to enhance longevity in this high-risk population.
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Affiliation(s)
- Chang Nancy Wang
- Division of Cardiology, Department of Medicine, Western University, London, Ontario, Canada
- ICES Central, Toronto, Ontario, Canada
| | - Zihang Lu
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
| | - Christopher S. Simpson
- Division of Cardiology, Department of Medicine, Queen's University, Kingston, Ontario, Canada
- ICES Queen's, Kingston, Ontario, Canada
- Ontario Health, Toronto, Ontario, Canada
| | - Douglas S. Lee
- ICES Central, Toronto, Ontario, Canada
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Peter Munk Cardiac Center, University Health Network, Toronto, Ontario, Canada
- Ted Rogers Center for Heart Research, Toronto, Ontario, Canada
| | - Joan E. Tranmer
- Department of Public Health Sciences, Queen's University, Kingston, Ontario, Canada
- ICES Queen's, Kingston, Ontario, Canada
- School of Nursing, Queen's University, Kingston, Ontario, Canada
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22
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Shahid I, Khan MS, Fonarow GC, Butler J, Greene SJ. Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure. Prog Cardiovasc Dis 2024; 82:61-69. [PMID: 38244825 DOI: 10.1016/j.pcad.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
Despite robust scientific evidence and strong guideline recommendations, there remain significant gaps in initiation and dose titration of guideline-directed medical therapy (GDMT) for heart failure (HF) among eligible patients. Reasons surrounding these gaps are multifactorial, and largely attributed to patient, healthcare professionals, and institutional challenges. Concurrently, HF remains a predominant cause of mortality and hospitalization, emphasizing the critical need for improved delivery of therapy to patients in routine clinical practice. To optimize GDMT, various implementation strategies have emerged in the recent decade such as in-hospital rapid initiation of GDMT, improving patient adherence, addressing clinical inertia, improving affordability, engagement in quality improvement registries, multidisciplinary clinics, and EHR-integrated interventions. This review highlights the current use and barriers to optimal utilization of GDMT, and proposes novel strategies aimed at improving GDMT in HF.
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Affiliation(s)
- Izza Shahid
- Division of Preventive Cardiology, Houston Methodist Academic Institute, Houston, TX, USA
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA; Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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23
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Colin-Ramirez E, Arcand J, Saldarriaga C, Ezekowitz JA. The current state of evidence for sodium and fluid restriction in heart failure. Prog Cardiovasc Dis 2024; 82:43-54. [PMID: 38215917 DOI: 10.1016/j.pcad.2024.01.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 01/14/2024]
Abstract
The field of heart failure has evolved in terms of the therapies that are available including pharmaceutical and device therapies. There is now substantial randomized trial data to indicate that dietary sodium restriction does not provide the reduction in clinical events with accepted heterogeneity in the clinical trial results. Dietary sodium restriction should be considered for some but not all patients and with different objectives than clinical outcomes but instead for potential quality of life benefit. In addition, fluid restriction, once the mainstay of clinical practice, has not shown to be of any additional benefit for patients in hospital or in the ambulatory care setting and therefore should be considered to be used cautiously (if at all) in clinical practice. Further developments and clinical trials are needed in this area to better identify patients who may benefit or have harm from these lower cost interventions and future research should focus on large scale, high quality, clinical trials rather than observational data to drive clinical practice.
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Affiliation(s)
| | - Joanne Arcand
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Clara Saldarriaga
- Centro Cardiovascular Colombiano Clinica Santa Maria (Clinica Cardio VID), Antioquia, Colombia
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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24
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Sawano S, Kodera S, Sato M, Shinohara H, Kobayashi A, Takiguchi H, Hirose K, Kamon T, Saito A, Kiriyama H, Miura M, Minatsuki S, Kikuchi H, Takeda N, Morita H, Komuro I. Multimodality Risk Assessment of Patients with Ischemic Heart Disease Using Deep Learning Models Applied to Electrocardiograms and Chest X-rays. Int Heart J 2024; 65:29-38. [PMID: 38296576 DOI: 10.1536/ihj.23-402] [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] [Indexed: 02/08/2024]
Abstract
Comprehensive management approaches for patients with ischemic heart disease (IHD) are important aids for prognostication and treatment planning. While single-modality deep neural networks (DNNs) have shown promising performance for detecting cardiac abnormalities, the potential benefits of using DNNs for multimodality risk assessment in patients with IHD have not been reported. The purpose of this study was to investigate the effectiveness of multimodality risk assessment in patients with IHD using a DNN that utilizes 12-lead electrocardiograms (ECGs) and chest X-rays (CXRs), with the prediction of major adverse cardiovascular events (MACEs) being of particular concern.DNN models were applied to detection of left ventricular systolic dysfunction (LVSD) on ECGs and identification of cardiomegaly findings on CXRs. A total of 2107 patients who underwent elective percutaneous coronary intervention were categorized into 4 groups according to the models' outputs: Dual-modality high-risk (n = 105), ECG high-risk (n = 181), CXR high-risk (n = 392), and No-risk (n = 1,429).A total of 342 MACEs were observed. The incidence of a MACE was the highest in the Dual-modality high-risk group (P < 0.001). Multivariate Cox hazards analysis for predicting MACE revealed that the Dual-modality high-risk group had a significantly higher risk of MACE than the No-risk group (hazard ratio (HR): 2.370, P < 0.001), the ECG high-risk group (HR: 1.906, P = 0.010), and the CXR high-risk group (HR: 1.624, P = 0.018), after controlling for confounding factors.The results suggest the usefulness of multimodality risk assessment using DNN models applied to 12-lead ECG and CXR data from patients with IHD.
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Affiliation(s)
- Shinnosuke Sawano
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Satoshi Kodera
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Masataka Sato
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Hiroki Shinohara
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Atsushi Kobayashi
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Hiroshi Takiguchi
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Kazutoshi Hirose
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Tatsuya Kamon
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Akihito Saito
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Hiroyuki Kiriyama
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Mizuki Miura
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Shun Minatsuki
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Hironobu Kikuchi
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Norifumi Takeda
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Hiroyuki Morita
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
| | - Issei Komuro
- Department of Cardiovascular Medicine, The University of Tokyo Hospital
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25
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Mamataz T, Lee DS, Turk-Adawi K, Hajaj A, Code J, Grace SL. Factors Affecting Healthcare Provider Referral to Heart Function Clinics: A Mixed-Methods Study. J Cardiovasc Nurs 2024; 39:18-30. [PMID: 37669639 DOI: 10.1097/jcn.0000000000001029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023]
Abstract
BACKGROUND Heart failure (HF) care providers are gatekeepers for patients to appropriately access lifesaving HF clinics. OBJECTIVE The aim of this study was to investigate referring providers' perceptions regarding referral to HF clinics, including the impact of provider specialty and the coronavirus disease pandemic. METHODS An exploratory, sequential design was used in this mixed-methods study. For the qualitative stage, semistructured interviews were performed with a purposive sample of HF providers eligible to refer (ie, nurse practitioners, cardiologists, internists, primary care and emergency medicine physicians) in Ontario. Interviews were conducted via Microsoft Teams. Transcripts were analyzed concurrently by 2 researchers independently using NVivo, using a deductive-thematic approach. Then, a cross-sectional survey of similar providers across Canada was undertaken via REDCap (Research Electronic Data Capture), using an adapted version of the Provider Attitudes toward Cardiac Rehabilitation and Referral scale. RESULTS Saturation was achieved upon interviewing 7 providers. Four themes arose: knowledge about clinics and their characteristics, providers' clinical expertise, communication and relationship with their patients, and clinic referral process and care continuity. Seventy-three providers completed the survey. The major negative factors affecting referral were skepticism regarding clinic benefit (4.1 ± 0.9/5), a bad patient experience and believing they are better equipped to manage the patient (both 3.9). Cardiologists more strongly endorsed clarity of referral criteria, referral as normative and within-practice referral supports as supporting appropriate referral versus other professionals ( P s < .02), among other differences. One-third (n = 13) reported the pandemic impacted their referral practices (eg, limits to in-person care, patient concerns). CONCLUSION Although there are some legitimate barriers to appropriate clinic referral, greater provider education and support could facilitate optimal patient access.
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26
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Jaiswal V, Mukherjee D, Peng Ang S, Kainth T, Naz S, Babu Shrestha A, Agrawal V, Mitra S, Ee Chia J, Jilma B, Mamas MA, Gebhard C, Postula M, Siller-Matula JM. COVID-19 vaccine-associated myocarditis: Analysis of the suspected cases reported to the EudraVigilance and a systematic review of the published literature. IJC HEART & VASCULATURE 2023; 49:101280. [PMID: 38143781 PMCID: PMC10746454 DOI: 10.1016/j.ijcha.2023.101280] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 08/31/2023] [Accepted: 09/21/2023] [Indexed: 12/26/2023]
Abstract
Background Myocarditis secondary to Coronavirus Disease 2019 (COVID-19) vaccination has been reported in the literature. Objective This study aimed to characterize the reported cases of myocarditis after COVID-19 vaccination based on age, gender, doses, and vaccine type from published literature and the EudraVigilance database. Methods We performed an analysis in the EudraVigilance database (until December 18, 2021) and a systematic review of published literature for reported cases of suspected myocarditis and pericarditis (until 30th June 2022) after the COVID-19 vaccination. Results EudraVigilance database analysis revealed 16,514 reported cases of myocarditis or pericarditis due to the vaccination with COVID-19 vaccines. The cases of myo- or pericarditis were reported predominantly in the age group of 18-64 (n = 12,214), and in males with a male-to-female (M: F) ratio of 1.7:1. The mortality among myocarditis patients was low, with 128 deaths (2 cases per 10.000.000 administered doses) being reported. For the systematic review, 72 studies with 1026 cases of myocarditis due to the vaccination with COVID-19 vaccines were included. The analysis of published cases has revealed that the male gender was primarily affected with myocarditis post-COVID-vaccination. The median (IQR) age of the myocarditis cases was 24.6 [19.5-34.6] years, according to the systematic review of the literature. Myocarditis cases were most frequently published after the vaccination with m-RNA vaccines and after the second vaccination dose. The overall mortality of published cases was low (n = 5). Conclusion Myocarditis is a rare serious adverse event associated with a COVID-19 vaccination. With early recognition and management, the prognosis of COVID-19 vaccine-induced myocarditis is favorable.
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Affiliation(s)
| | | | - Song Peng Ang
- Department of Internal Medicine, Rutgers Health Community Medical Center, Toms River, NJ, USA
| | - Tejasvi Kainth
- Department of Psychiatry, Bronxcare Health System, NY, USA
| | - Sidra Naz
- Department of Internal Medicine, Harvard Medical School/BIDMC, Boston, USA
| | | | | | - Saloni Mitra
- OO Bogomolets National Medical University, Kyiv, Ukraine
| | - Jia Ee Chia
- Department of Internal Medicine, Texas Tech University Health Sciences, El Paso, TX, USA
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Austria
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Keele University, Keele, UK
| | - Catherine Gebhard
- Department of Cardiology, Inselspital, Bern University Hospital, Switzerland
| | - Marek Postula
- Department of Experimental and Clinical Pharmacology, Medical University of Warsaw, Center for Preclinical Research and Technology CEPT, Warsaw, Poland
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27
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Bobrowski D, Dorovenis A, Abdel-Qadir H, McNaughton CD, Alonzo R, Fang J, Austin PC, Udell JA, Jackevicius CA, Alter DA, Atzema CL, Bhatia RS, Booth GL, Ha ACT, Johnston S, Dhalla I, Kapral MK, Krumholz HM, Roifman I, Wijeysundera HC, Ko DT, Tu K, Ross HJ, Schull MJ, Lee DS. Association of neighbourhood-level material deprivation with adverse outcomes and processes of care among patients with heart failure in a single-payer healthcare system: A population-based cohort study. Eur J Heart Fail 2023; 25:2274-2286. [PMID: 37953731 DOI: 10.1002/ejhf.3090] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/10/2023] [Accepted: 11/07/2023] [Indexed: 11/14/2023] Open
Abstract
AIM We studied the association between neighbourhood material deprivation, a metric estimating inability to attain basic material needs, with outcomes and processes of care among incident heart failure patients in a universal healthcare system. METHODS AND RESULTS In a population-based retrospective study (2007-2019), we examined the association of material deprivation with 1-year all-cause mortality, cause-specific hospitalization, and 90-day processes of care. Using cause-specific hazards regression, we quantified the relative rate of events after multiple covariate adjustment, stratifying by age ≤65 or ≥66 years. Among 395 763 patients (median age 76 [interquartile range 66-84] years, 47% women), there was significant interaction between age and deprivation quintile for mortality/hospitalization outcomes (p ≤ 0.001). Younger residents (age ≤65 years) of the most versus least deprived neighbourhoods had higher hazards of all-cause death (hazard ratio [HR] 1.19, 95% confidence interval [CI] 1.10-1.29]) and cardiovascular hospitalization (HR 1.29 [95% CI 1.19-1.39]). Older individuals (≥66 years) in the most deprived neighbourhoods had significantly higher hazard of death (HR 1.11 [95% CI 1.08-1.14]) and cardiovascular hospitalization (HR 1.13 [95% CI 1.09-1.18]) compared to the least deprived. The magnitude of the association between deprivation and outcomes was amplified in the younger compared to the older age group. More deprived individuals in both age groups had a lower hazard of cardiology visits and advanced cardiac imaging (all p < 0.001), while the most deprived of younger ages were less likely to undergo implantable cardioverter-defibrillator/cardiac resynchronization therapy-pacemaker implantation (p = 0.023), compared to the least deprived. CONCLUSION Patients with newly-diagnosed heart failure residing in the most deprived neighbourhoods had worse outcomes and reduced access to care than those less deprived.
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Affiliation(s)
- David Bobrowski
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - Husam Abdel-Qadir
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Candace D McNaughton
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Rea Alonzo
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Jiming Fang
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
| | - Peter C Austin
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Jacob A Udell
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Women's College Hospital, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Cynthia A Jackevicius
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Western University of Health Sciences, Pomona, CA, USA
| | - David A Alter
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Clare L Atzema
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - R Sacha Bhatia
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Gillian L Booth
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
| | - Andrew C T Ha
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Sharon Johnston
- Departments of Family Medicine, University of Ottawa, Ottawa, ON, Canada
- Institut du Savoir, Hôpital Montfort, Ottawa, ON, Canada
| | - Irfan Dhalla
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Li Ka Shing Knowledge Institute of St Michael's Hospital, Toronto, ON, Canada
| | - Moira K Kapral
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, CT, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Idan Roifman
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Harindra C Wijeysundera
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Dennis T Ko
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Karen Tu
- University Health Network, Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Department of Family and Community Medicine, University of Toronto, Toronto, ON, Canada
- North York General Hospital, Toronto, ON, Canada
| | - Heather J Ross
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
| | - Michael J Schull
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
- Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Douglas S Lee
- Department of Medicine, University of Toronto, Toronto, ON, Canada
- University Health Network, Toronto, ON, Canada
- ICES (formerly known as the Institute for Clinical Evaluative Sciences), Toronto, ON, Canada
- Institute of Health Policy, Management, and Evaluation, University of Toronto, Toronto, ON, Canada
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Botti G, Thirunavukarasu S, Ziviello F, Chieffo A. Peripartum Cardiogenic Shock and Mechanical Circulatory Support. Interv Cardiol 2023; 18:e28. [PMID: 38213746 PMCID: PMC10782424 DOI: 10.15420/icr.2020.09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2020] [Accepted: 10/08/2023] [Indexed: 01/13/2024] Open
Abstract
Despite remarkable improvements in the past two decades, the annual cardiovascular mortality rate has remained higher for women than for men. Pregnant women represent an underinvestigated population in clinical research, and the mechanisms of long-term cardiovascular complications in women with obstetric complications remain to be elucidated. Regarding advanced heart failure during pregnancy, interventional approaches are effective but still underutilised. Percutaneous mechanical circulatory support is a valuable option for peripartum cardiogenic shock, although its use during pregnancy is still limited. Survival rates have improved in recent years, but further emphasis on the importance of early recognition and initiation of heart failure treatment in this patient group is warranted. The aims of this review are to summarise the current literature on the implementation of mechanical circulatory support in cardiogenic shock during pregnancy and delivery and to understand the role of percutaneous ventricular assist devices in the management of such conditions.
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Affiliation(s)
- Giulia Botti
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific InstituteMilan, Italy
- Vita Salute San Raffaele UniversityMilan, Italy
| | | | - Francesca Ziviello
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific InstituteMilan, Italy
| | - Alaide Chieffo
- Interventional Cardiology Unit, IRCCS San Raffaele Scientific InstituteMilan, Italy
- Vita Salute San Raffaele UniversityMilan, Italy
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Ali S, Tyerman J. Palliative Care for the Elderly With Heart Diseases in Tertiary Health care: A Concept Analysis. Am J Hosp Palliat Care 2023:10499091231213606. [PMID: 37963548 DOI: 10.1177/10499091231213606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023] Open
Abstract
BACKGROUND The increasing incidence of heart failure (HF) in the elderly leads to increased mortality, hospitalization, length of hospital stay, and health care costs. Older adults often face multiple drug treatments, comorbidities, frailty, and cognitive problems, which require early palliative care. However, these patients do not receive adequate palliative care. OBJECTIVE This concept analysis aimed to develop an in-depth understanding of palliative care for elderly patients with cardiac diseases in tertiary care. DESIGN The analysis was guided by Walker and Avant's method, and databases were searched using keywords, such as palliative care, tertiary care, elderly, and heart. Covidence was used to review the results using the inclusion and exclusion criteria. RESULTS The World Health Organisation's definition of palliative care is widely accepted. Palliative care for older adults with heart disease in tertiary care is preceded by chronic illness, polypharmacy, symptom burden, physical and cognitive decline, comorbidities, and psychosocial/spiritual issues. The main attributes of palliative care for this population include health care professionals and patient education, holistic patient/family-centered care, symptom management, shared decision-making, early integration, advanced care planning, and a multidisciplinary approach. Palliative care improves elderly cardiac patients' and their family satisfaction while reducing readmission, hospital stays, and unnecessary invasive procedures. CONCLUSION Collaboration between hospitals, community organizations, transitional palliative care services, and research has the potential to improve early palliative care and the well-being of the elderly cardiac population. Advanced Practice Nurses (APNs) competencies play a crucial role in promoting palliative care in the elderly HF population.
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Affiliation(s)
- Sana Ali
- School of Nursing, Faculty of Health Sciences, The University of Ottawa, Ottawa, ON, Canada
| | - Jane Tyerman
- School of Nursing, Faculty of Health Sciences, The University of Ottawa, Ottawa, ON, Canada
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Gore S, Khanna H, Kumar A. Effects of Comprehensive Outpatient Cardiac Rehabilitation on Exercise Capacity, Functional Status, and Quality of Life in People With Heart Failure: A Systematic Review and Meta-Analysis. Phys Ther 2023; 103:pzad119. [PMID: 37658777 PMCID: PMC10630615 DOI: 10.1093/ptj/pzad119] [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] [Received: 09/19/2022] [Revised: 04/20/2023] [Accepted: 07/02/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE The purpose of this study was to systematically review and conduct a meta-analysis to examine the impact of comprehensive outpatient cardiac rehabilitation on exercise capacity, functional status, and quality of life in patients with heart failure. METHODS PubMed, Embase, and CINAHL were searched using keywords and MeSH terms on heart failure and cardiac rehabilitation. Randomized clinical trials published in English using outpatient exercise-based cardiac rehabilitation in patients with heart failure were included. The Grading of Recommendations Assessment, Development, and Evaluation was utilized for quality appraisal. Pooled estimates were computed using standardized mean differences (SMDs) and 95% CIs. Primary outcomes were functional status (6-minute walk distance, quality of life, exercise capacity using peak oxygen consumption, muscle strength, and endurance). RESULTS Eleven randomized controlled trials including 1523 participants ranging from 45 to 80 years old and an intervention duration ranging from 2 to 26 weeks were analyzed. Pooled results indicated significant improvements with comprehensive cardiac rehabilitation on 6-minute walk distance (SMD = 0.30; 95% CI = 0.06 to 0.54) and oxygen consumption (SMD = 0.23; 95% CI = 0.06 to 0.40). However, there was no additional benefit for the quality of life beyond that seen in the comparison groups. CONCLUSION Results of this study suggest that comprehensive outpatient cardiac rehabilitation is associated with significantly better clinical outcomes than single-component exercise programs in cardiac rehabilitation settings, multicomponent exercise in noncardiac rehabilitation settings, or no exercise. IMPACT Heart failure is significantly associated with an increased risk of poor exercise tolerance. Despite the proven benefit of cardiac rehabilitation on exercise tolerance and physical activities from individual randomized clinical trials, questions regarding its impact on clinical outcomes such as exercise capacity, functional status, and quality of life remain inadequate. This systematic review and meta-analysis provides strong evidence supporting comprehensive outpatient cardiac rehabilitation for improving clinical outcomes in heart failure.
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Affiliation(s)
- Shweta Gore
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - Hargun Khanna
- Department of Physical Therapy, School of Health and Rehabilitation Sciences, MGH Institute of Health Professions, Boston, Massachusetts, USA
| | - Amit Kumar
- Department of Physical Therapy and Athletic Training, College of Health, University of Utah, Salt Lake City, Utah, USA
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Doumouras BS, Abdel-Qadir H, McNaughton CD, Kavsak PA, Austin PC, Wang X, Chu A, Udell JA, Ross HJ, Lee DS. Trends in B-Type Natriuretic Peptide Testing: A Population-Based Cohort Study. JACC. HEART FAILURE 2023; 11:1645-1647. [PMID: 37480879 DOI: 10.1016/j.jchf.2023.05.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 07/24/2023]
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Masterson Creber R, Dodson JA, Bidwell J, Breathett K, Lyles C, Harmon Still C, Ooi SY, Yancy C, Kitsiou S. Telehealth and Health Equity in Older Adults With Heart Failure: A Scientific Statement From the American Heart Association. Circ Cardiovasc Qual Outcomes 2023; 16:e000123. [PMID: 37909212 DOI: 10.1161/hcq.0000000000000123] [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] [Indexed: 11/02/2023]
Abstract
Enhancing access to care using telehealth is a priority for improving outcomes among older adults with heart failure, increasing quality of care, and decreasing costs. Telehealth has the potential to increase access to care for patients who live in underresourced geographic regions, have physical disabilities or poor access to transportation, and may not otherwise have access to cardiologists with expertise in heart failure. During the COVID-19 pandemic, access to telehealth expanded, and yet barriers to access, including broadband inequality, low digital literacy, and structural barriers, prevented many of the disadvantaged patients from getting equitable access. Using a health equity lens, this scientific statement reviews the literature on telehealth for older adults with heart failure; provides an overview of structural, organizational, and personal barriers to telehealth; and presents novel interventions that pair telemedicine with in-person services to mitigate existing barriers and structural inequities.
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Shah V, Yang X, Arnheim A, Udani S, Tseng D, Luo Y, Ouyang M, Destgeer G, Garner OB, Koydemir HC, Ozcan A, Di Carlo D. Amphiphilic Particle-Stabilized Nanoliter Droplet Reactors with a Multimodal Portable Reader for Distributive Biomarker Quantification. ACS NANO 2023; 17:19952-19960. [PMID: 37824510 PMCID: PMC10604076 DOI: 10.1021/acsnano.3c04994] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Accepted: 10/06/2023] [Indexed: 10/14/2023]
Abstract
Compartmentalization, leveraging microfluidics, enables highly sensitive assays, but the requirement for significant infrastructure for their design, build, and operation limits access. Multimaterial particle-based technologies thermodynamically stabilize monodisperse droplets as individual reaction compartments with simple liquid handling steps, precluding the need for expensive microfluidic equipment. Here, we further improve the accessibility of this lab on a particle technology to resource-limited settings by combining this assay system with a portable multimodal reader, thus enabling nanoliter droplet assays in an accessible platform. We show the utility of this platform in measuring N-terminal propeptide B-type natriuretic peptide (NT-proBNP), a heart failure biomarker, in complex medium and patient samples. We report a limit of detection of ∼0.05 ng/mL and a linear response between 0.2 and 2 ng/mL in spiked plasma samples. We also show that, owing to the plurality of measurements per sample, "swarm" sensing acquires better statistical quantitation with a portable reader. Monte Carlo simulations show the increasing capability of this platform to differentiate between negative and positive samples, i.e., below or above the clinical cutoff for acute heart failure (∼0.1 ng/mL), as a function of the number of particles measured. Our platform measurements correlate with gold standard ELISA measurement in cardiac patient samples, and achieve lower variation in measurement across samples compared to the standard well plate-based ELISA. Thus, we show the capabilities of a cost-effective droplet-reader system in accurately measuring biomarkers in nanoliter droplets for diseases that disproportionately affect underserved communities in resource-limited settings.
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Affiliation(s)
- Vishwesh Shah
- Department
of Bioengineering, University of California
- Los Angeles, Los Angeles, California 90095, United States
| | - Xilin Yang
- Department
of Electrical and Computer Engineering, University of California - Los Angeles, Los Angeles, California 90095, United States
| | - Alyssa Arnheim
- Department
of Bioengineering, University of California
- Los Angeles, Los Angeles, California 90095, United States
| | - Shreya Udani
- Department
of Bioengineering, University of California
- Los Angeles, Los Angeles, California 90095, United States
| | - Derek Tseng
- Department
of Electrical and Computer Engineering, University of California - Los Angeles, Los Angeles, California 90095, United States
| | - Yi Luo
- Department
of Electrical and Computer Engineering, University of California - Los Angeles, Los Angeles, California 90095, United States
| | - Mengxing Ouyang
- Department
of Bioengineering, University of California
- Los Angeles, Los Angeles, California 90095, United States
| | - Ghulam Destgeer
- Department
of Electrical Engineering, Technical University
of Munich, Munich 80333, Germany
| | - Omai B. Garner
- Department
of Pathology and Laboratory Medicine, University
of California - Los Angeles, Los
Angeles, California 90095, United States
| | - Hatice C. Koydemir
- Center
for Remote Health Technologies and Systems, Texas A&M Engineering Experiment Station, College Station, Texas 77843, United States
- Department
of Biomedical Engineering, Texas A&M
University, College Station, Texas 77843, United States
| | - Aydogan Ozcan
- Department
of Electrical and Computer Engineering, University of California - Los Angeles, Los Angeles, California 90095, United States
- California
Nanosystems Institute (CNSI), University
of California - Los Angeles, Los
Angeles, California 90095, United States
| | - Dino Di Carlo
- Department
of Bioengineering, University of California
- Los Angeles, Los Angeles, California 90095, United States
- California
Nanosystems Institute (CNSI), University
of California - Los Angeles, Los
Angeles, California 90095, United States
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Al Younis SM, Hadjileontiadis LJ, Stefanini C, Khandoker AH. Non-invasive technologies for heart failure, systolic and diastolic dysfunction modeling: a scoping review. Front Bioeng Biotechnol 2023; 11:1261022. [PMID: 37920244 PMCID: PMC10619666 DOI: 10.3389/fbioe.2023.1261022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2023] [Accepted: 10/09/2023] [Indexed: 11/04/2023] Open
Abstract
The growing global prevalence of heart failure (HF) necessitates innovative methods for early diagnosis and classification of myocardial dysfunction. In recent decades, non-invasive sensor-based technologies have significantly advanced cardiac care. These technologies ease research, aid in early detection, confirm hemodynamic parameters, and support clinical decision-making for assessing myocardial performance. This discussion explores validated enhancements, challenges, and future trends in heart failure and dysfunction modeling, all grounded in the use of non-invasive sensing technologies. This synthesis of methodologies addresses real-world complexities and predicts transformative shifts in cardiac assessment. A comprehensive search was performed across five databases, including PubMed, Web of Science, Scopus, IEEE Xplore, and Google Scholar, to find articles published between 2009 and March 2023. The aim was to identify research projects displaying excellence in quality assessment of their proposed methodologies, achieved through a comparative criteria-based rating approach. The intention was to pinpoint distinctive features that differentiate these projects from others with comparable objectives. The techniques identified for the diagnosis, classification, and characterization of heart failure, systolic and diastolic dysfunction encompass two primary categories. The first involves indirect interaction with the patient, such as ballistocardiogram (BCG), impedance cardiography (ICG), photoplethysmography (PPG), and electrocardiogram (ECG). These methods translate or convey the effects of myocardial activity. The second category comprises non-contact sensing setups like cardiac simulators based on imaging tools, where the manifestations of myocardial performance propagate through a medium. Contemporary non-invasive sensor-based methodologies are primarily tailored for home, remote, and continuous monitoring of myocardial performance. These techniques leverage machine learning approaches, proving encouraging outcomes. Evaluation of algorithms is centered on how clinical endpoints are selected, showing promising progress in assessing these approaches' efficacy.
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Affiliation(s)
- Sona M. Al Younis
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center (HEIC), Khalifa University, Abu Dhabi, United Arab Emirates
| | - Leontios J. Hadjileontiadis
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center (HEIC), Khalifa University, Abu Dhabi, United Arab Emirates
| | - Cesare Stefanini
- Creative Engineering Design Lab at the BioRobotics Institute, Applied Experimental Sciences Scuola Superiore Sant'Anna, Pontedera (Pisa), Italy
| | - Ahsan H. Khandoker
- Department of Biomedical Engineering, Healthcare Engineering Innovation Center (HEIC), Khalifa University, Abu Dhabi, United Arab Emirates
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Moghaddam N, Lindsay MP, Hawkins NM, Anderson K, Ducharme A, Lee DS, McKelvie R, Poon S, Desmarais O, Desbiens M, Virani S. Access to Heart Failure Services in Canada: Findings of the Heart and Stroke National Heart Failure Resources and Services Inventory. Can J Cardiol 2023; 39:1469-1479. [PMID: 37422257 DOI: 10.1016/j.cjca.2023.06.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND The rising incidence of heart failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched an HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources. METHODS A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted from 2020 to 2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, service,s and processes across acute care hospitals and related ambulatory settings. RESULTS HF-RaSIs were completed by 501 acute care hospitals and urgent care centres, representing 94.7% of all HF hospitalisations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centres with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to B-type natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present at 21.6% of sites (108), and 16.2% sites (81) had dedicated inpatient interdisciplinary HF teams. Among all of the sites, 28.1% (141) were HF clinics, and of those, 40.4% (57) had average wait times from referral to first appointment of more than 2 weeks. CONCLUSIONS Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.
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Affiliation(s)
- Nima Moghaddam
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Nathaniel M Hawkins
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim Anderson
- Dalhousie, University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Anique Ducharme
- Institut de Cardiologie, de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Douglas S Lee
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Robert McKelvie
- St Joseph's Health Care, Western University, London, Ontario, Canada
| | - Stephanie Poon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Sean Virani
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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Kazory A. Combination Diuretic Therapy to Counter Renal Sodium Avidity in Acute Heart Failure: Trials and Tribulations. Clin J Am Soc Nephrol 2023; 18:1372-1381. [PMID: 37102974 PMCID: PMC10578637 DOI: 10.2215/cjn.0000000000000188] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 04/20/2023] [Indexed: 04/28/2023]
Abstract
In contrast to significant advances in the management of patients with chronic heart failure over the past few years, there has been little change in how patients with acute heart failure are treated. Symptoms and signs of fluid overload are the primary reason for hospitalization of patients who experience acute decompensation of heart failure. Intravenous loop diuretics remain the mainstay of therapy in this patient population, with a significant subset of them showing suboptimal response to these agents leading to incomplete decongestion at the time of discharge. Combination diuretic therapy, that is, using loop diuretics along with an add-on agent, is a widely applied strategy to counter renal sodium avidity through sequential blockade of sodium absorption within renal tubules. The choice of the second diuretic is affected by several factors, including the site of action, the anticipated secondary effects, and the available evidence on their efficacy and safety. While the current guidelines recommend combination diuretic therapy as a viable option to overcome suboptimal response to loop diuretics, it is also acknowledged that this strategy is not supported by strong evidence and remains an area of uncertainty. The recent publication of landmark studies has regenerated the interest in sequential nephron blockade. In this article, we provide an overview of the results of the key studies on combination diuretic therapy in the setting of acute heart failure and discuss their findings primarily with regard to the effect on renal sodium avidity and cardiorenal outcomes.
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Affiliation(s)
- Amir Kazory
- Division of Nephrology, Hypertension, and Renal Transplantation, University of Florida, Gainesville, Florida
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Ballantyne BA, Vandenberk B, Dykstra S, Labib D, Chew DS, Lydell C, Howarth A, Heydari B, Fine N, Howlett J, White JA, Miller R. Patients with non-ischemic cardiomyopathy and mid-wall striae have similar arrhythmic outcomes as ischemic cardiomyopathy. THE INTERNATIONAL JOURNAL OF CARDIOVASCULAR IMAGING 2023; 39:2005-2014. [PMID: 37421578 DOI: 10.1007/s10554-023-02904-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 06/16/2023] [Indexed: 07/10/2023]
Abstract
PURPOSE While implantable cardioverter-defibrillator (ICD) therapy provides clear benefit in patients with ischemic cardiomyopathy (ICM), this is less clear in patients with non-ischemic cardiomyopathy (NICM). Mid-wall striae (MWS) fibrosis is an established cardiovascular magnetic resonance (CMR) risk marker observed in patients with NICM. We evaluated whether patients with NICM and MWS have similar risk of arrhythmia-related cardiovascular events as patients with ICM. METHODS We studied a cohort of patients undergoing CMR. The presence of MWS was adjudicated by experienced physicians. The primary outcome was a composite of implantable cardioverter-defibrillator (ICD) implant, hospitalization for ventricular tachycardia, resuscitated cardiac arrest, or sudden cardiac death. Propensity-matched analysis was performed to compare outcomes for patients NICM with MWS and ICM. RESULTS A total of 1,732 patients were studied, 972 NICM (706 without MWS, 266 with MWS) and 760 ICM. NICM patients with MWS were more likely to experience the primary outcome versus those without MWS (unadjusted subdistribution hazard ratio (subHR) 2.26, 95% confidence interval [CI] 1.51-3.41) with no difference versus ICM patients (unadjusted subHR 1.32, 95% CI 0.93-1.86). Similar results were seen in a propensity-matched population (adjusted subHR 1.11, 95% CI 0.63-1.98, p = 0.711). CONCLUSION Patients with NICM and MWS demonstrate significantly higher arrhythmic risk compared to NICM without MWS. After adjustment, the arrhythmia risk of patients with NICM and MWS was similar to patients with ICM. Accordingly, physicians could consider the presence of MWS when making clinical decisions regarding arrhythmia risk management in patients with NICM.
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Affiliation(s)
- Brennan A Ballantyne
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Bert Vandenberk
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
| | - Steven Dykstra
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Dina Labib
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Derek S Chew
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Carmen Lydell
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Andrew Howarth
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Bobak Heydari
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Nowell Fine
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Jonathan Howlett
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - James A White
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Diagnostic Imaging, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Stephenson Cardiac Imaging Centre, Libin Cardiovascular Institute, Calgary, AB, Canada
| | - Robert Miller
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
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Yogasundaram H, Zheng Y, Ly E, Ezekowitz J, Ponikowski P, Lam CSP, O'Connor C, Blaustein RO, Roessig L, Temple T, Westerhout CM, Armstrong PW, Sandhu RK. Relationship between baseline electrocardiographic measurements and outcomes in patients with high-risk heart failure: Insights from the VerICiguaT Global Study in Subjects with Heart Failure with Reduced Ejection Fraction (VICTORIA) trial. Eur J Heart Fail 2023; 25:1822-1830. [PMID: 37655679 DOI: 10.1002/ejhf.3021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 08/03/2023] [Accepted: 08/28/2023] [Indexed: 09/02/2023] Open
Abstract
AIMS Whether electrocardiographic (ECG) measurements predict mortality in chronic heart failure with reduced ejection fraction (HFrEF) is unknown. METHODS AND RESULTS We studied 4880 patients from the Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction (VICTORIA) trial with a baseline 12-lead ECG. Associations between ECG measurements and mortality were estimated as hazard ratios (HR) and adjusted for the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) risk score, N-terminal pro-B-type natriuretic peptide, and index event. Select interactions between ECG measurements, patient characteristics and mortality were examined. Over a median of 10.8 months, there were 824 cardiovascular (CV) deaths (214 sudden) and 1005 all-cause deaths. Median age was 68 years (interquartile range [IQR] 60-76), 24% were women, median ejection fraction was 30% (IQR 23-35), 41% had New York Heart Association class III/IV, and median MAGGIC score was 24 (IQR 19-28). After multivariable adjustment, significant associations existed between heart rate (per 5 bpm: HR 1.02), QRS duration (per 10 ms: HR 1.02), absence of left ventricular hypertrophy (HR 0.64) and CV death, and similarly so with all-cause death (HR 1.02; HR 1.02; HR 0.61, respectively). Contiguous pathologic Q waves were significantly associated with sudden death (HR 1.46), and right ventricular hypertrophy with all-cause death (HR 1.44). The only sex-based interaction observed was for pathologic Q waves on CV (men: HR 1.05; women: HR 1.64, pinteraction = 0.024) and all-cause death (men: HR 0.99; women: HR 1.57; pinteraction = 0.010). Whereas sudden death doubled in females, it did not differ among males (male: HR 1.25, 95% confidence interval [CI] 0.87-1.79; female: HR 2.50, 95% CI 1.23-5.06; pinteraction = 0.141). CONCLUSION Routine ECG measurements provide additional prognostication of mortality in high-risk HFrEF patients, particularly in women with contiguous pathologic Q waves.
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Affiliation(s)
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Eric Ly
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Justin Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore & Duke-National University of Singapore, Singapore, Singapore
| | | | | | | | - Tracy Temple
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
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Hu H, Li J, Wei X, Zhang J, Wang J. Elevated level of high-sensitivity cardiac troponin I as a predictor of adverse cardiovascular events in patients with heart failure with preserved ejection fraction. Chin Med J (Engl) 2023; 136:2195-2202. [PMID: 37279378 PMCID: PMC10508375 DOI: 10.1097/cm9.0000000000002639] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Indexed: 06/08/2023] Open
Abstract
BACKGROUND The relationship between the elevation of cardiac troponin and the increase of mortality and hospitalization rate in patients with heart failure with reduced ejection fraction is clear. This study investigated the association between the extent of elevated levels of high-sensitivity cardiac troponin I (hs-cTnI) and the prognosis in heart failure with preserved ejection fraction patients. METHODS A retrospective cohort study consecutively enrolled 470 patients with heart failure with preserved ejection fraction from September 2014 to August 2017. According to the level of hs-cTnI, the patients were divided into the elevated level group (hs-cTnI >0.034 ng/mL in male and hs-cTnI >0.016 ng/mL in female) and the normal level group. All of the patients were followed up once every 6 months. Adverse cardiovascular events were cardiogenic death and heart failure hospitalization. RESULTS The mean follow-up period was 36.2 ± 7.9 months. Cardiogenic mortality (18.6% [26/140] vs. 1.5% [5/330], P <0.001) and heart failure (HF) hospitalization rate (74.3% [104/140] vs. 43.6% [144/330], P <0.001) were significantly higher in the elevated level group. The Cox regression analysis showed that the elevated level of hs-cTnI was a predictor of cardiogenic death (hazard ratio [HR]: 5.578, 95% confidence interval [CI]: 2.995-10.386, P <0.001) and HF hospitalization (HR: 3.254, 95% CI: 2.698-3.923, P <0.001). The receiver operating characteristic curve demonstrated that a sensitivity of 72.6% and specificity of 88.8% for correct prediction of adverse cardiovascular events when a level of hs-cTnI of 0.1305 ng/mL in male and a sensitivity of 70.6% and specificity of 90.2% when a level of hs-cTnI of 0.0755 ng/mL in female were used as the cut-off value. CONCLUSION Significant elevation of hs-cTnI (≥0.1305 ng/mL in male and ≥0.0755 ng/mL in female) is an effective indicator of the increased risk of cardiogenic death and HF hospitalization in heart failure with preserved ejection fraction patients.
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Affiliation(s)
- Hongyu Hu
- Department of Cardiovascular, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Jingjin Li
- Department of Cardiovascular, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Xin Wei
- Department of Cardiovascular, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Jia Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
| | - Jiayu Wang
- Department of Neurocardiology, Beijing Tiantan Hospital, Capital Medical University, Beijing 100070, China
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MacDonald BJ, Turgeon RD. Incorporation of Shared Decision-Making in International Cardiovascular Guidelines, 2012-2022. JAMA Netw Open 2023; 6:e2332793. [PMID: 37676658 PMCID: PMC10485733 DOI: 10.1001/jamanetworkopen.2023.32793] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Accepted: 08/01/2023] [Indexed: 09/08/2023] Open
Abstract
Importance Shared decision-making (SDM) is a key component of the provision of ethical care, but prior reviews have indicated that clinical practice guidelines seldom promote or facilitate SDM. It is currently unknown whether these findings extend to contemporary cardiovascular guidelines. Objective To identify and characterize integration of SDM in contemporary cardiovascular guideline recommendations using a systematic classification system. Design, Setting, and Participants This cross-sectional study assessed the latest guidelines or subsequent updates that included pharmacotherapy recommendations and were published between January 2012 and December 2022 by the American College of Cardiology (ACC), Canadian Cardiovascular Society (CCS), and European Society of Cardiology (ESC). Data were analyzed from February 21 to July 21, 2023. Main Outcomes and Measures All pharmacotherapy recommendations were identified within each guideline. Recommendations that incorporated SDM were rated according to a systematic rating framework to evaluate the quality of SDM incorporation based on directness (range, 1-3; assessing whether SDM was incorporated directly and impartially into the recommendation's text, with 1 indicating direct and impartial incorporation of SDM into the recommendation's text) and facilitation (range, A-D; assessing whether decision aids or quantified benefits and harms were provided, with A indicating that a decision aid quantifying benefits and harms was provided). The proportion of recommendations incorporating SDM was also analyzed according to guideline society and category (eg, general cardiology, heart failure). Results Analyses included 65 guideline documents, and 33 documents (51%) incorporated SDM either in a general statement or within specific recommendations. Of 7499 recommendations, 2655 (35%) recommendations addressed pharmacotherapy, and of these, 170 (6%) incorporated SDM. By category, general cardiology guidelines contained the highest proportion of pharmacotherapy recommendations incorporating SDM (86 of 865 recommendations [10%]), whereas heart failure and myocardial disease contained the least (9 of 315 recommendations [3%]). The proportion of pharmacotherapy recommendations incorporating SDM was comparable across societies (ACC: 75 of 978 recommendations [8%]; CCS: 29 of 333 recommendations [9%]; ESC: 67 of 1344 recommendations [5%]), with no trend for change over time. Only 5 of 170 SDM recommendations (3%) were classified as grade 1A (impartial recommendations for SDM supported by a decision aid), whereas 114 of 170 recommendations (67%) were grade 3D (SDM mentioned only in supporting text and without any tools or information to facilitate SDM). Conclusions and Relevance In this cross-sectional study across guidelines published by 3 major cardiovascular societies over the last decade, 51% of guidelines mentioned the importance of SDM, yet only 6% of recommendations incorporated SDM in any form, and fewer adequately facilitated SDM.
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Affiliation(s)
- Blair J. MacDonald
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
| | - Ricky D. Turgeon
- Faculty of Pharmaceutical Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Poliwoda J, Eagles D, Yadav K, Nemnom MJ, Walmsley CG, Mielniczuk L, Stiell IG. Outcomes of acute heart failure patients managed in the emergency department. CAN J EMERG MED 2023; 25:752-760. [PMID: 37537320 DOI: 10.1007/s43678-023-00555-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/24/2023] [Indexed: 08/05/2023]
Abstract
BACKGROUND Acute heart failure is a serious condition commonly seen in the emergency department (ED). The HEARTRISK6 Scale has been recently developed to identify the risk of poor outcomes but has not been tested. We sought to describe the management and outcomes of ED patients with acute heart failure and to evaluate the potential impact of the HEARTRISK6 Scale. METHODS We conducted a health records review of 300 consecutive acute heart failure patients presenting to two tertiary care EDs. Two evaluators abstracted clinical variables, ED management and treatment details, and patient outcomes using the electronic health records platform (EPIC) and attending physicians verified the data. The primary outcome measure was a short-term serious outcome, as shown in Results. In addition, the HEARTRISK6 score was calculated retrospectively. RESULTS We included 300 patients with mean age of 78.5 years, 51.0% male, 56.3% arrival by ambulance, and 67.0% admitted to hospital. 25.3% experienced a short-term serious outcome 1) after admission (N = 201): non-invasive ventilation 14.9%, intubation 1.5%, major cardiac procedure 5.0%, myocardial infarction 2.0%, death 8.5%; 2) after ED discharge (N = 99): return to ED 21.2%, death 4.0%. Those initially admitted experienced a much higher proportion of serious outcomes compared to those discharged (29.9% vs. 16.2%). A HEARTRISK6 Scale cut-point score of ≥ 1 would have had a sensitivity of 91.0%, specificity 24.5%, and negative likelihood ratio 0.37 for short-term serious outcomes and suggested hospital admission for 80.7% of cases. CONCLUSION There was a large range of severity of illness of acute heart failure patients and a wide variety of treatments were administered in the ED. Both admitted and discharged patients experienced a high proportion of poor outcomes. The HEARTRISK6 Scale showed a high sensitivity for short-term serious outcomes but with the potential to increase hospital admissions. Further validation of the HEARTRISK6 Scale is required before routine clinical use.
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Affiliation(s)
| | - Debra Eagles
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Krishan Yadav
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | - Marie-Joe Nemnom
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada
| | | | - Lisa Mielniczuk
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, ON, Canada
| | - Ian G Stiell
- Department of Emergency Medicine, University of Ottawa, Ottawa, ON, Canada.
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, ON, Canada.
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Ezekowitz JA, McMullan CJ, Westerhout CM, Piña IL, Lopez-Sendon J, Anstrom KJ, Hernandez AF, Lam CSP, O'Connor CM, Pieske B, Ponikowski P, Roessig L, Voors AA, Koglin J, Armstrong PW, Butler J. Background Medical Therapy and Clinical Outcomes From the VICTORIA Trial. Circ Heart Fail 2023; 16:e010599. [PMID: 37417824 DOI: 10.1161/circheartfailure.123.010599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/18/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND We examined whether the primary composite outcome (cardiovascular death or heart failure hospitalization) was related to differences in background use and dosing of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction enrolled in VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction), a randomized trial of vericiguat versus placebo. METHODS We evaluated the adherence to guideline use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists. We assessed basic adherence; indication-corrected adherence accounting for guideline indications and contraindications; and dose-corrected adherence (indication-corrected adherence+≥50% of drug dose target). Associations between study treatment and the primary composite outcome according to the adherence to guidelines were assessed using multivariable adjustment; adjusted hazard ratios with 95% CIs and Pinteraction are reported. RESULTS Of 5050 patients, 5040 (99.8%) had medication data at baseline. For angiotensin-converting enzyme inhibitor, angiotensin-receptor blockers, and angiotensin receptor-neprilysin inhibitors, basic adherence to guidelines was 87.4%, indication-corrected was 95.7%, and dose-corrected was 50.9%. For beta-blockers, basic adherence was 93.1%, indication-corrected was 96.2%, and dose-corrected was 45.4%. For mineralocorticoid receptor antagonists, basic adherence was 70.3%, indication-corrected was 87.1%, and dose-corrected was 82.2%. For triple therapy (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, or angiotensin receptor-neprilysin inhibitors+beta-blocker+mineralocorticoid receptor antagonist), basic adherence was 59.7%, indication-corrected was 83.3%, and dose-corrected was 25.5%. Using basic or dose-corrected adherence, the treatment effect of vericiguat was consistent across adherence to guidelines groups, with or without multivariable adjustment with no treatment heterogeneity. CONCLUSIONS Patients in VICTORIA were well treated with heart failure with reduced ejection fraction medications. The efficacy of vericiguat was consistent across background therapy with very high adherence to guidelines accounting for patient-level indications, contraindications, and tolerance. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02861534.
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Affiliation(s)
- Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (J.A.E., C.M.W., P.W.A.)
| | | | - Cynthia M Westerhout
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (J.A.E., C.M.W., P.W.A.)
| | - Ileana L Piña
- Central Michigan University, Mount Pleasant (I.L.P.)
| | - Jose Lopez-Sendon
- IdiPaz Research Institute, Hospital Universitario La Paz, Universidad Autonoma de Madrid, Spain (J.L.-S.)
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University, Durham, NC (K.J.A., A.F.H.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, NC (K.J.A., A.F.H.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | | | - Burkert Pieske
- Charité University Medicine German Heart Center, Berlin, Germany (B.P.)
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Poland (P.P.)
| | | | - Adriaan A Voors
- University Medical Center Groningen, University of Groningen, the Netherlands (A.A.V.)
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (J.A.E., C.M.W., P.W.A.)
| | - Javed Butler
- Baylor University Medical Center, Dallas, TX (J.B.)
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Kotrri G, Youngson E, Fine NM, Howlett JG, Lyons K, Paterson DI, Ezekowitz J, McAlister FA, Miller RJ. Right Ventricular Systolic Pressure Trajectory as a Predictor of Hospitalization and Mortality in Patients With Chronic Heart Failure. CJC Open 2023; 5:671-679. [PMID: 37744660 PMCID: PMC10516718 DOI: 10.1016/j.cjco.2023.05.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 05/25/2023] [Indexed: 09/26/2023] Open
Abstract
Background Pulmonary hypertension is common among patients with heart failure (HF). Right ventricular systolic pressure (RVSP) is frequently used to assess its presence and severity. Although RVSP has been associated with adverse outcomes, the importance of serial measurements has not been studied. We evaluated associations between serial RVSP measurements and cardiovascular events in patients with HF. Methods Patients with HF and 2 echocardiograms performed ≥ 6 months apart were included. RVSP was categorized, using the second echocardiogram, as follows: normal (< 40 mm Hg); severely elevated (≥ 60 mm Hg); moderately elevated (50-59 mm Hg); or mildly elevated (40-49 mm Hg). Patients also were classified according to change in RVSP categories between echocardiograms. The primary outcome was time to HF hospitalization (HFH) or all-cause mortality (ACM) after the second echocardiogram. Results In total, 4319 patients were included (median age: 78 years; 52.1% female). During a median follow-up period of 19.4 months, HFH/ACM occurred in 2714 patients (62.8%). In multivariable analysis, baseline RSVP that was mildly elevated (1069 patients, hazard ratio [HR] 1.31, 95% confidence interval [CI] 1.12-1.54), moderately elevated (797 patients, HR 1.54, 95% CI 1.30-1.82), or severely elevated (837 patients, HR 1.92, 95% CI 1.60-2.31) was independently associated with HFH/ACM. Additionally, improving RVSP was associated with increased HFH/ACM in both categorical (HR 1.16, 95% CI 1.01-1.33) and continuous analyses. Conclusions RVSP measurements identify patients at increased risk who may require more-aggressive monitoring and medical therapy. Our study raises the hypothesis that, in addition to the absolute value of RVSP, improving RVSP category may identify higher-risk patients, but further study is needed to elucidate the underlying reasons.
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Affiliation(s)
- Gynter Kotrri
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Erik Youngson
- Data and Research Services, Alberta SPOR SUPPORT Unit and Provincial Research Data Services, Alberta Health Services, Edmonton, Alberta, Canada
| | - Nowell M. Fine
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan G. Howlett
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Kristin Lyons
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - D. Ian Paterson
- Faculty of Medicine and Dentistry, University of Alberta Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Justin Ezekowitz
- Faculty of Medicine and Dentistry, University of Alberta Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A. McAlister
- Faculty of Medicine and Dentistry, University of Alberta Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert J.H. Miller
- Division of Cardiology, Department of Cardiac Sciences, Libin Cardiovascular Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Mapelli M, Mattavelli I, Paolillo S, Salvioni E, Magrì D, Galotta A, De Martino F, Mantegazza V, Vignati C, Esposito I, Dell’Aversana S, Paolillo R, Capovilla T, Tamborini G, Nepitella AA, Filardi PP, Agostoni P. Effects of sacubitril/valsartan on exercise capacity: a prognostic improvement that starts during uptitration. Eur J Clin Pharmacol 2023; 79:1173-1184. [PMID: 37368004 PMCID: PMC10427709 DOI: 10.1007/s00228-023-03527-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 06/15/2023] [Indexed: 06/28/2023]
Abstract
PURPOSE Sacubitril/valsartan is a mainstay of the treatment of heart failure with reduced ejection fraction (HFrEF); however, its effects on exercise performance yielded conflicting results. Aim of our study was to evaluate the impact of sacubitril/valsartan on exercise parameters and echocardiographic and biomarker changes at different drug doses. METHODS We prospectively enrolled consecutive HFrEF outpatients eligible to start sacubitril/valsartan. Patients underwent clinical assessment, cardiopulmonary exercise test (CPET), blood sampling, echocardiography, and completed the Kansas City Cardiomyopathy Questionnaire (KCCQ-12). Sacubitril/valsartan was introduced at 24/26 mg b.i.d. dose and progressively uptitrated in a standard monthly-based fashion to 97/103 mg b.i.d. or maximum tolerated dose. Study procedures were repeated at each titration visit and 6 months after reaching the maximum tolerated dose. RESULTS Ninety-six patients completed the study, 73 (75%) reached maximum sacubitril/valsartan dose. We observed a significant improvement in functional capacity across all study steps: oxygen intake increased, at peak exercise (from 15.6 ± 4.5 to 16.5 ± 4.9 mL/min/kg; p trend = 0.001), while minute ventilation/carbon dioxide production relationship reduced in patients with an abnormal value at baseline. Sacubitril/valsartan induced positive left ventricle reverse remodeling (EF from 31 ± 5 to 37 ± 8%; p trend < 0.001), while NT-proBNP reduced from 1179 [610-2757] to 780 [372-1344] pg/ml (p trend < 0.0001). NYHA functional class and the subjective perception of limitation in daily life at KCCQ-12 significantly improved. The Metabolic Exercise Cardiac Kidney Index (MECKI) score progressively improved from 4.35 [2.42-7.71] to 2.35% [1.24-4.96], p = 0.003. CONCLUSIONS A holistic and progressive HF improvement was observed with sacubitril/valsartan in parallel with quality of life. Likewise, a prognostic enhancement was observed.
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Affiliation(s)
- Massimo Mapelli
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | | | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | | | - Damiano Magrì
- Department of Clinical and Molecular Medicine, University “La Sapienza”, Rome, Italy
| | | | - Fabiana De Martino
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Casa di Cura Tortorella, Salerno, Italy
| | - Valentina Mantegazza
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Carlo Vignati
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
| | - Immacolata Esposito
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Simona Dell’Aversana
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Roberta Paolillo
- Department of Advanced Biomedical Sciences, Federico II University of Naples, Naples, Italy
| | - Teresa Capovilla
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- University of Trieste, Trieste, Italy
| | | | - Alessandro Alberto Nepitella
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Policlinico Universitario D. Casula, Cardiologia – AOU Cagliari Cagliari, Italy
| | | | - Piergiuseppe Agostoni
- Centro Cardiologico Monzino, IRCCS, Milan, Italy
- Department of Clinical Sciences and Community Health, Cardiovascular Section, University of Milan, Milan, Italy
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Ahmad F, Fountotos R, Goldfarb M, Bharaj N, Munir H, Marsala J, Rudski LG, Afilalo J. De-frailing intervention for hospitalized cardiovascular patients in the TARGET-EFT randomized clinical trial. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2023; 9:482-489. [PMID: 36026532 PMCID: PMC10405162 DOI: 10.1093/ehjqcco/qcac050] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Revised: 08/01/2022] [Accepted: 08/17/2022] [Indexed: 06/15/2023]
Abstract
AIMS Frailty is disproportionately prevalent in cardiovascular disease patients and exacerbated during hospital admissions, heightening the risk for adverse events and functional decline. Using the Essential Frailty Toolset (EFT) to target physical weakness, cognitive impairment, malnourishment, and anaemia, we tested a multicomponent targeted intervention to de-frail older adults with acute cardiovascular conditions during their hospital admission. METHODS AND RESULTS The TARGET-EFT trial was a single-center randomized clinical trial at the Jewish General Hospital, Montreal, Canada. We compared a multicomponent de-frailing intervention with usual clinical care. Intervention group patients received exercise, cognitive stimulation, protein supplementation, and iron replacement, as required. In this study, the primary outcome was frailty, as assessed by the SPPB score (Short Physical Performance Battery) at discharge, and the secondary outcome was the SARC-F score (Strength, Assistance walking, Rising from chair, Climbing, Falls) assessed 30 days later. The analysis consisted of 135 patients (mean age of 79.3 years; 54% female) who survived and completed the frailty assessments.Compared with control patients, intervention group patients had a 1.52-point superior SPPB score and a 0.74-point superior SARC-F score. Subgroup analysis suggested that patients with low left ventricular ejection fraction may have attenuated benefits, and that patients who underwent invasive cardiac procedures had the greatest benefits from the intervention. CONCLUSION We achieved our objective of de-frailing older cardiac inpatients on a short-term basis by improving their physical performance and functioning using a pragmatic multicomponent intervention. This could have positive impacts on their clinical outcomes and ability to maintain independent living in the future. ONE SENTENCE SUMMARY The multicomponent intervention targeted to the deficits of vulnerable older adults hospitalized with acute cardiovascular diseases successfully de-frailed them on a short-term basis, which can have positive implications on their post-discharge health outcomes.
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Affiliation(s)
- Fayeza Ahmad
- Division of Experimental Medicine, McGill University, Montreal,QC H4A 3J1,Canada
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC H3T 1E2,Canada
| | - Rosie Fountotos
- Division of Experimental Medicine, McGill University, Montreal,QC H4A 3J1,Canada
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC H3T 1E2,Canada
| | - Michael Goldfarb
- Division of Experimental Medicine, McGill University, Montreal,QC H4A 3J1,Canada
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2,Canada
| | - Neetika Bharaj
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC H3T 1E2,Canada
- Department of Kinesiology & Physical Education, McGill University, Montreal, QC H2W 1S4, Canada. Institution of research trial: Jewish General Hospital, Montreal, QC H3T 1E2, Canada
| | - Haroon Munir
- Division of Experimental Medicine, McGill University, Montreal,QC H4A 3J1,Canada
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC H3T 1E2,Canada
| | - John Marsala
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2,Canada
| | - Lawrence G Rudski
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2,Canada
| | - Jonathan Afilalo
- Division of Experimental Medicine, McGill University, Montreal,QC H4A 3J1,Canada
- Centre for Clinical Epidemiology, Jewish General Hospital, Montreal, QC H3T 1E2,Canada
- Division of Cardiology, Jewish General Hospital, McGill University, Montreal, QC H3T 1E2,Canada
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Fremes SE, Marquis-Gravel G, Gaudino MFL, Jolicoeur EM, Bédard S, Masterson Creber R, Ruel M, Vervoort D, Wijeysundera HC, Farkouh ME, Rouleau JL. STICH3C: Rationale and Study Protocol. Circ Cardiovasc Interv 2023; 16:e012527. [PMID: 37582169 DOI: 10.1161/circinterventions.122.012527] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 07/03/2023] [Indexed: 08/17/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) is the recommended mode of revascularization in patients with ischemic left ventricular dysfunction (iLVSD) and multivessel disease. However, contemporary percutaneous coronary intervention (PCI) outcomes have improved with the integration of novel technologies and refinement of revascularization strategies, and PCI is often used in clinical practice in this population. There is a lack of evidence from randomized trials comparing contemporary state-of-the-art PCI versus CABG for the treatment of iLVSD and multivessel disease. This was the impetus for the STICH3C trial (Canadian CABG or PCI in Patients With Ischemic Cardiomyopathy), described here. METHODS The STICH3C trial is a prospective, unblinded, international, multicenter trial with an expected sample size of 754 participants from ≈45 centers. Patients with multivessel/left main coronary artery disease and iLVSD with left ventricular ejection fraction ≤40% considered by the local Heart Team appropriate for and amenable to revascularization by both modes of revascularization will be randomized in a 1:1 ratio to state-of-the-art PCI or CABG. RESULTS The primary end point is the composite of death from any cause, stroke, spontaneous myocardial infarction, urgent repeat revascularization, or heart failure readmission, summarized as a time-to-event outcome. The key hierarchical end point is time to death and frequency of hospitalizations for heart failure. The key safety outcome is a composite of major adverse events. Disease-specific quality-of-life and health economics measures will be compared between groups. Participants will be followed for a median of 5 years, with a minimum follow-up of 4 years. CONCLUSIONS STICH3C will directly inform patients, clinicians, and international practice guidelines about the efficacy and safety of CABG versus PCI in patients with iLVSD. The results will provide novel and broad evidence, including clinical events, health status, and economic assessments, to guide care for patients with iLVSD and severe coronary artery disease. REGISTRATION URL: https://clinicaltrials.gov/; Unique identifier: NCT05427370.
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Affiliation(s)
- Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | | | - Mario F L Gaudino
- Department of Cardiothoracic Surgery (M.F.L.G.), Weill Cornell Medicine, New York City, NY
| | - E Marc Jolicoeur
- Department of Cardiothoracic Surgery (M.F.L.G.), Weill Cornell Medicine, New York City, NY
| | - Sylvain Bédard
- Centre d'excellence sur le partenariat avec les patients et le public, Montreal, Quebec, Canada (S.B.)
| | | | - Marc Ruel
- Division of Cardiac Surgery, University of Ottawa Heart Institute, Ontario, Canada (M.R.)
| | - Dominique Vervoort
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | - Harindra C Wijeysundera
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Ontario, Canada (S.E.F., D.V., H.C.W.)
| | - Michael E Farkouh
- Division of Cardiology, Peter Munk Cardiac Centre, Toronto General Hospital, Ontario, Canada (M.E.F.)
| | - Jean-Lucien Rouleau
- Montreal Heart Institute, University of Montreal, Quebec, Canada (G.M.-G., E.M.J., J.-L.R.)
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Gómez-Mesa JE, Márquez-Murillo M, Figueiredo M, Berni A, Jerez AM, Núñez-Ayala E, Pow-Chon F, Sáenz-Morales LC, Pava-Molano LF, Montes MC, Garillo R, Galindo-Coral S, Reyes-Caorsi W, Speranza M, Romero A. Inter-American Society of Cardiology (CIFACAH-ELECTROSIAC) and Latin-American Heart Rhythm Society (LAHRS): multidisciplinary review on the appropriate use of implantable cardiodefibrillator in heart failure with reduced ejection fraction. J Interv Card Electrophysiol 2023; 66:1211-1229. [PMID: 36469237 PMCID: PMC10333140 DOI: 10.1007/s10840-022-01425-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 11/10/2022] [Indexed: 12/07/2022]
Abstract
BACKGROUND Our main objective was to present a multidisciplinary review on the epidemiology of sudden cardiac death (SCD) and the tools that could be used to identify malignant ventricular arrhythmias (VAs) and to perform risk stratification. In addition, indications and contraindications for the use of implantable cardioverter defibrillator (ICD) in general and in special populations including the elderly and patients with chronic kidney disease (CKD) are also given. METHODS An expert group from the Inter American Society of Cardiology (IASC), through their HF Council (CIFACAH) and Electrocardiology Council (ElectroSIAC), together with the Latin American Heart Rhythm Society (LAHRS), reviewed and discussed the literature regarding the appropriate use of an ICD in people with heart failure (HF) with reduced ejection fraction (HFpEF). Indications and contraindications for the use of ICD are presented in this multidisciplinary review. RESULTS Numerous clinical studies have demonstrated the usefulness of ICD in both primary and secondary prevention of SCD in HFpEF. There are currently precise indications and contraindications for the use of these devices. CONCLUSIONS In some Latin American countries, a low rate of implantation is correlated with low incomes, but this is not the case for all Latin America. Determinants of the low rates of ICD implantation in many Latin American countries are still a matter of research. VA remains one of the most common causes of cardiovascular death associated with HFrEF and different tools are available for stratifying the risk of SCD in this population.
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Affiliation(s)
- Juan Esteban Gómez-Mesa
- Cardiology Department, Fundación Valle del Lili, Cali, Colombia.
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia.
- Inter-American Council of Heart Failure and Pulmonary Hypertension/CIFACAH, Mexico City, Mexico.
- Inter-American Society of Cardiology/IASC, Mexico City, Mexico.
| | - Manlio Márquez-Murillo
- Inter-American Society of Cardiology/IASC, Mexico City, Mexico
- Instituto Nacional de Cardiología Ignacio Chávez, Mexico City, Mexico
- Inter-American Council of Electrocardiography and Arrhythmias/ELECTROSIAC, Mexico City, Mexico
| | - Marcio Figueiredo
- University of Campinas (UNICAMP) Hospital, Campinas, Brazil
- Latin American Heart Rhythm Society/LAHRS, Montevideo, Uruguay
| | - Ana Berni
- Inter-American Society of Cardiology/IASC, Mexico City, Mexico
- Inter-American Council of Electrocardiography and Arrhythmias/ELECTROSIAC, Mexico City, Mexico
- Hospital Angeles Pedregal, Mexico City, Mexico
| | - Ana Margarita Jerez
- Inter-American Council of Heart Failure and Pulmonary Hypertension/CIFACAH, Mexico City, Mexico
- Inter-American Society of Cardiology/IASC, Mexico City, Mexico
- Instituto de Cardiología Y Cirugía Cardiovascular, La Habana, Cuba
| | - Elaine Núñez-Ayala
- Inter-American Council of Heart Failure and Pulmonary Hypertension/CIFACAH, Mexico City, Mexico
- Inter-American Society of Cardiology/IASC, Mexico City, Mexico
- Electrophysiology, Arrhythmias and Pacemaker Unit, CEDIMAT, Centro Cardiovascular, Santo Domingo, Dominican Republic
| | - Freddy Pow-Chon
- Inter-American Council of Heart Failure and Pulmonary Hypertension/CIFACAH, Mexico City, Mexico
- Inter-American Society of Cardiology/IASC, Mexico City, Mexico
- Hospital Luis Vernaza, Guayaquil, Ecuador
| | - Luis Carlos Sáenz-Morales
- Latin American Heart Rhythm Society/LAHRS, Montevideo, Uruguay
- Fundación Cardioinfantil-Instituto de Cardiología, Bogotá, Colombia
| | - Luis Fernando Pava-Molano
- Cardiology Department, Fundación Valle del Lili, Cali, Colombia
- Latin American Heart Rhythm Society/LAHRS, Montevideo, Uruguay
| | - María Claudia Montes
- Cardiology Department, Fundación Valle del Lili, Cali, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Raúl Garillo
- Inter-American Society of Cardiology/IASC, Mexico City, Mexico
- Inter-American Council of Electrocardiography and Arrhythmias/ELECTROSIAC, Mexico City, Mexico
- Facultad de Ciencias Médicas, Pontificia Universidad Católica Argentina, Buenos Aires, Argentina
| | - Stephania Galindo-Coral
- Cardiology Department, Fundación Valle del Lili, Cali, Colombia
- Centro de Investigaciones Clínicas, Fundación Valle del Lili, Cali, Colombia
| | - Walter Reyes-Caorsi
- Inter-American Council of Electrocardiography and Arrhythmias/ELECTROSIAC, Mexico City, Mexico
- Latin American Heart Rhythm Society/LAHRS, Montevideo, Uruguay
- Comisión Honoraria Para La Salud Cardiovascular, Montevideo, Uruguay
| | - Mario Speranza
- Inter-American Council of Heart Failure and Pulmonary Hypertension/CIFACAH, Mexico City, Mexico
- Inter-American Society of Cardiology/IASC, Mexico City, Mexico
- Hospital Clínica Bíblica, Ciudad de Costa Rica, Costa Rica
| | - Alexander Romero
- Inter-American Council of Heart Failure and Pulmonary Hypertension/CIFACAH, Mexico City, Mexico
- Inter-American Society of Cardiology/IASC, Mexico City, Mexico
- Hospital Santo Tomas, Ciudad de Panama, Panama
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48
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Ducharme A, Zieroth S, Ahooja V, Anderson K, Andrade J, Boivin-Proulx LA, Ezekowitz J, Howlett J, Lepage S, Leong D, McDonald MA, O'Meara E, Poon S, Swiggum E, Virani S. Canadian Cardiovascular Society-Canadian Heart Failure Society Focused Clinical Practice Update of Patients With Differing Heart Failure Phenotypes. Can J Cardiol 2023; 39:1030-1040. [PMID: 37169222 DOI: 10.1016/j.cjca.2023.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/13/2023] Open
Abstract
A number of societies produce heart failure (HF) management guidelines, comprising official recommendations on the basis of recent research discoveries, but their applicability to specific situations encountered in daily practice might be difficult. In this clinical practice update we aim to provide responses to fundamental questions that face health care providers, like appropriate timing for the introduction and optimization of different classes of medication according to specific patient phenotypes, when second-line therapies and valvular interventions should be considered, and management of difficult clinical scenarios such as cardiorenal syndrome and frailty. A consensus-based methodology was used. Approaches to 5 different phenotypes are presented: (1) The wet HF phenotype is the easiest to manage, decongestion being performed alongside introduction of guideline-directed medical therapy (GDMT); (2) The de novo HF phenotype requires the introduction of the 4 pillars of GDMT, personalizing the order on the basis of the individuals' biological and physiological characteristics; (3) The worsening HF phenotype is a marker of poor prognosis, and therefore should motivate optimization of GDMT, start second-line therapies, and/or reevaluate goals of care/advanced HF therapies; (4) The cardiorenal phenotypes require correct volume assessment, because renal function usually improves with decongestion; and (5) The frail HF phenotype require special attention, careful drug titration, and consideration of cardiac rehabilitation programs. In conclusion, specific common HF phenotypes call for a personalized approach to improve adoption of the HF guidelines into clinical practice.
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Affiliation(s)
- Anique Ducharme
- Department of Medicine, Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Shelley Zieroth
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Vineeta Ahooja
- Department of Medicine, The Heart Health Institute, Scarborough, Ontario, Canada
| | - Kim Anderson
- Department of Medicine, Dalhousie University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Jason Andrade
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Justin Ezekowitz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Howlett
- Department of Medicine, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Serge Lepage
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Derek Leong
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael A McDonald
- Department of Medicine, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Eileen O'Meara
- Department of Medicine, Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Stephanie Poon
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Swiggum
- Department of Medicine, Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Sean Virani
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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49
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MacDonald BJ, Virani SA, Zieroth S, Turgeon R. Heart Failure Management in 2023: A Pharmacotherapy- and Lifestyle-Focused Comparison of Current International Guidelines. CJC Open 2023; 5:629-640. [PMID: 37720183 PMCID: PMC10502425 DOI: 10.1016/j.cjco.2023.05.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 05/17/2023] [Indexed: 09/19/2023] Open
Abstract
This review examines the pharmacotherapy and lifestyle recommendations of the most recent iterations of the Canadian Cardiovascular Society (CCS) / Canadian Heart Failure Society (CHFS), the European Society of Cardiology (ESC), and the American Heart Association (AHA) / American College of Cardiology (ACC) / Heart Failure Society of America (HFSA) heart failure (HF) guidelines, which all have been updated in response to therapeutic developments across the spectrum of left ventricular ejection fraction. Identified areas of unanimity across these guidelines include the following: recommending quadruple therapy for patients with HF with reduced ejection fraction (HFrEF; although no guideline proposed an ideal sequence of initiation); intravenous iron administration for patients with HFrEF and iron deficiency; and sodium restriction for patients with HF. Recent evidence regarding the harms of HFrEF medication withdrawal in patients with HF with improved ejection fraction has prompted subsequent guidelines to recommend against withdrawal. Due to the lower quality of evidence, there are disagreements regarding management of HF with preserved ejection fraction and uncertainty regarding management of HF with mildly reduced ejection fraction. Practical guidance is provided to clinicians navigating these challenging areas. In addition to these clinically focused comparisons, we describe opportunities for guideline improvement and harmonization. Specifically, these include opportunities regarding HFrEF sequencing, the need for timely updates, shared decision-making, Grading of Recommendations, Assessment, Development and Evaluations (GRADE) framework adoption, and the creation of recommendations where high-quality evidence is lacking. Although these guidelines have broad agreement, key areas of controversy remain that may be addressed by emerging evidence and changes in guideline methodology.
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Affiliation(s)
| | - Sean A. Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Ricky Turgeon
- University of British Columbia, Vancouver, British Columbia, Canada
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50
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Taylor RS, Fredericks S, Jones I, Neubeck L, Sanders J, De Stoutz N, Thompson DR, Wadhwa DN, Grace SL. Global perspectives on heart disease rehabilitation and secondary prevention: a scientific statement from the Association of Cardiovascular Nursing and Allied Professions, European Association of Preventive Cardiology, and International Council of Cardiovascular Prevention and Rehabilitation. Eur Heart J 2023; 44:2515-2525. [PMID: 37477626 PMCID: PMC10361025 DOI: 10.1093/eurheartj/ehad225] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 01/26/2023] [Accepted: 03/30/2023] [Indexed: 07/22/2023] Open
Abstract
Cardiovascular disease is a leading cause of death, morbidity, disability, and reduced health-related quality of life, as well as economic burden worldwide, with some 80% of disease burden occurring in the low- and middle-income country (LMIC) settings. With increasing numbers of people living longer with symptomatic disease, the effectiveness and accessibility of secondary preventative and rehabilitative health services have never been more important. Whilst LMICs experience the highest prevalence and mortality rates, the global approach to secondary prevention and cardiac rehabilitation, which mitigates this burden, has traditionally been driven from clinical guidelines emanating from high-income settings. This state-of-the art review provides a contemporary global perspective on cardiac rehabilitation and secondary prevention, contrasting the challenges of and opportunities for high vs. lower income settings. Actionable solutions to overcome system, clinician, programme, and patient level barriers to cardiac rehabilitation access in LMICs are provided.
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Affiliation(s)
- Rod S Taylor
- Former ACNAP Science committee member, Professor of Population Health, School of Health and Well Being, University of Glasgow, Glasgow G12 8QQ, UK
| | - Suzanne Fredericks
- ACNAP Science committee member, Professor, Daphne Cockwell School of Nursing, Toronto Metropolitan University, Toronto, Canada
| | - Ian Jones
- ACNAP Science committee member, Professor of Cardiovascular Nursing, Liverpool Centre for Cardiovascular Science, Liverpool John Moores University, Liverpool, UK
| | - Lis Neubeck
- ACNAP President, Professor and Head of Cardiovascular Health, Centre for Cardiovascular Health, Edinburgh Napier University, Edinburgh, UK
| | - Julie Sanders
- ACNAP Science committee chair, Director of Clinical Research, St Bartholomew’s Hospital, Barts Health NHS Trust, West Smithfield, UK
- Clinical Professor of Cardiovascular Nursing, William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Noemi De Stoutz
- ESC Patient forum representative, Member of ‘Cuore Matto’ and Global ARCH, Zumikon, Switzerland
| | - David R Thompson
- EAPC representative, Professor of Nursing, School of Nursing and Midwifery, Queen’s University Belfast, Belfast, UK
| | - Deepti N Wadhwa
- ACNAP Young community member, Associate Professor, MVPS College of Physiotherapy, Nashik, India
| | - Sherry L Grace
- ICCPR Immediate past-Chair, Professor, Faculty of Health, York University, Toronto, Canada
- KITE-Toronto Rehabilitation Institute & Peter Munk Cardiac Centre, University Health Network, University of Toronto, Canada
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