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Herrera-Martínez AD, Jiménez CM, Romo AN, Aguilera JL, Crespin MC, Baena BT, Casado-Díaz A, Moreno MÁG, Puerta MJM, Roger AJ. Nutritional Support Reduces Circulating Cytokines in Patients with Heart Failure. Nutrients 2024; 16:1637. [PMID: 38892570 PMCID: PMC11174422 DOI: 10.3390/nu16111637] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2024] [Revised: 05/17/2024] [Accepted: 05/24/2024] [Indexed: 06/21/2024] Open
Abstract
Increased inflammation is associated with the pathogenesis of heart failure (HF). Increased circulating levels of cytokines have been previously reported and generally associated with worse clinical outcomes. In this context, the modulation of inflammation-related parameters seems to be a reasonable therapeutic option for improving the clinical course of the disease. Based on this, we aimed to compare changes in circulating cytokines when Mediterranean diet alone or in combination with hypercaloric, hyperproteic oral nutritional supplements (ONS), enriched with omega-3 (n-3) polyunsaturated fatty acids were administered to patients with HF. Briefly, patients were randomly assigned to receive Mediterranean Diet (control group) vs. Mediterranean Diet plus ONS (intervention group). We observed increased circulating levels of IL-6, IL-8, MCP-1 and IP-10. MCP-1 and IL-6 were associated with overweight and obesity (p = 0.01-0.01-0.04, respectively); IL-6 and IL-8 were positively correlated with fat mass and CRP serum levels (p = 0.02-0.04, respectively). Circulating levels of IL-8 significantly decreased in all patients treated with the Mediterranean diet, while IL-6 and IP-10 only significantly decreased in patients that received plus ONS. In the univariate analysis, MCP-1 and its combination with IL-6 were associated with increased mortality (p = 0.02), while the multivariate analysis confirmed that MCP-1 was an independent factor for mortality (OR 1.01, 95%ci 1.01-1.02). In conclusion, nutritional support using hypercaloric, hyperproteic, n-3 enriched ONS in combination with Mediterranean Diet was associated with decreased circulating levels of some cytokines and could represent an interesting step for improving heart functionality of patients with HF.
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Affiliation(s)
- Aura D. Herrera-Martínez
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Av. Menéndez Pidal s/n, 14004 Córdoba, Spain (B.T.B.); (M.Á.G.M.)
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, 14004 Córdoba, Spain
| | - Concepción Muñoz Jiménez
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Av. Menéndez Pidal s/n, 14004 Córdoba, Spain (B.T.B.); (M.Á.G.M.)
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, 14004 Córdoba, Spain
| | - Ana Navas Romo
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Av. Menéndez Pidal s/n, 14004 Córdoba, Spain (B.T.B.); (M.Á.G.M.)
- Immunology Service, Reina Sofia University Hospital, 14004 Córdoba, Spain
| | - José López Aguilera
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Av. Menéndez Pidal s/n, 14004 Córdoba, Spain (B.T.B.); (M.Á.G.M.)
- Cardiology Service, Reina Sofia University Hospital, 14004 Córdoba, Spain
| | | | - Bárbara Torrecillas Baena
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Av. Menéndez Pidal s/n, 14004 Córdoba, Spain (B.T.B.); (M.Á.G.M.)
| | - Antonio Casado-Díaz
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Av. Menéndez Pidal s/n, 14004 Córdoba, Spain (B.T.B.); (M.Á.G.M.)
| | - María Ángeles Gálvez Moreno
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Av. Menéndez Pidal s/n, 14004 Córdoba, Spain (B.T.B.); (M.Á.G.M.)
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, 14004 Córdoba, Spain
| | - María José Molina Puerta
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Av. Menéndez Pidal s/n, 14004 Córdoba, Spain (B.T.B.); (M.Á.G.M.)
- Endocrinology and Nutrition Service, Reina Sofia University Hospital, 14004 Córdoba, Spain
| | - Aurora Jurado Roger
- Maimonides Institute for Biomedical Research of Cordoba (IMIBIC), Av. Menéndez Pidal s/n, 14004 Córdoba, Spain (B.T.B.); (M.Á.G.M.)
- Immunology Service, Reina Sofia University Hospital, 14004 Córdoba, Spain
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Iyngkaran P, Usmani W, Bahmani Z, Hanna F. Burden from Study Questionnaire on Patient Fatigue in Qualitative Congestive Heart Failure Research. J Cardiovasc Dev Dis 2024; 11:96. [PMID: 38667714 PMCID: PMC11049876 DOI: 10.3390/jcdd11040096] [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: 01/08/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Mixed methods research forms the backbone of translational research methodologies. Qualitative research and subjective data lead to hypothesis generation and ideas that are then proven via quantitative methodologies and gathering objective data. In this vein, clinical trials that generate subjective data may have limitations, when they are not followed through with quantitative data, in terms of their ability to be considered gold standard evidence and inform guidelines and clinical management. However, since many research methods utilise qualitative tools, an initial factor is that such tools can create a burden on patients and researchers. In addition, the quantity of data and its storage contributes to noise and quality issues for its primary and post hoc use. This paper discusses the issue of the burden of subjective data collected and fatigue in the context of congestive heart failure (CHF) research. The CHF population has a high baseline morbidity, so no doubt the focus should be on the content; however, the lengths of the instruments are a product of their vigorous validation processes. Nonetheless, as an important source of hypothesis generation, if a choice of follow-up qualitative assessment is required for a clinical trial, shorter versions of the questionnaire should be used, without compromising the data collection requirements; otherwise, we need to invest in this area and find suitable solutions.
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Affiliation(s)
- Pupalan Iyngkaran
- Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.I.); (W.U.)
- HeartWest, Hoppers Crossing, VIC 3029, Australia;
| | - Wania Usmani
- Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.I.); (W.U.)
| | | | - Fahad Hanna
- Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.I.); (W.U.)
- Public Health Program, Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia
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Kittleson MM, Panjrath GS, Amancherla K, Davis LL, Deswal A, Dixon DL, Januzzi JL, Yancy CW. 2023 ACC Expert Consensus Decision Pathway on Management of Heart Failure With Preserved Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2023; 81:1835-1878. [PMID: 37137593 DOI: 10.1016/j.jacc.2023.03.393] [Citation(s) in RCA: 80] [Impact Index Per Article: 80.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/05/2023]
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Chunawala ZS, Fudim M, Arora S, Qamar A, Vaduganathan M, Mentz RJ, Pandey A, Caughey MC. Clinical and Echocardiographic Characteristics of Patients Hospitalized With Acute Versus Chronic Heart Failure With Preserved Ejection Fraction (From the ARIC Study). Am J Cardiol 2021; 158:59-65. [PMID: 34474908 PMCID: PMC8577211 DOI: 10.1016/j.amjcard.2021.07.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2021] [Revised: 07/23/2021] [Accepted: 07/27/2021] [Indexed: 01/06/2023]
Abstract
An expanding number of therapies are now indicated for comorbidity management in heart failure with preserved ejection fraction (HFpEF). Whether comorbidity burdens differ for patients with HFpEF who are hospitalized for acute decompensated heart failure (ADHF) versus those with chronic stable heart failure (CSHF) who are hospitalized for other causes is uncertain. Since 2005, the Atherosclerosis Risk in Communities (ARIC) study has conducted adjudicated community surveillance of hospitalized heart failure. Hospitalized ADHF and CSHF were sampled identically, using prespecified discharge codes and demographic strata, but were differentiated by signs or symptoms of acute or worsening heart failure upon physician review of the medical record. HFpEF was defined by an ejection fraction ≥50%. All events were weighted by the inverse of the sampling probability for statistical analyses. From 2005 to 2014, 13,706 weighted (2,936 unweighted) hospitalizations (mean age 77 years, 64% women, 29% Black) were sampled among patients with HFpEF and adjudicated ADHF (86%) or CSHF (14%). Comorbidity prevalence was high both for ADHF and CSHF hospitalizations, irrespective of gender. Women hospitalized with ADHF versus CSHF had greater prevalence of hypertension (89% vs 84%) diabetes mellitus (48% vs 39%) and renal disease (85% vs 74%). Echocardiographic features such as left ventricular hypertrophy and valvular abnormalities were more common with ADHF than CSHF, for both genders. However, the 28-day and 1-year mortality risk were comparable for ADHF and CSHF. In conclusion, hospitalized patients with HFpEF have a high comorbidity burden and risk of death, irrespective of the cause of hospitalization.
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Affiliation(s)
- Zainali S Chunawala
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Marat Fudim
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
| | - Sameer Arora
- Division of Cardiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Arman Qamar
- Section of Interventional Cardiology and Vascular Medicine, Northshore University Healthsystem, Chicago, Illinois
| | - Muthiah Vaduganathan
- Divison of Cardiovascular Medicine, Brigham and Womens Hospital, Boston, Massachusetts
| | - Robert J Mentz
- Division of Cardiology, Duke University Medical Center, Duke Clinical Research Institute, Durham, North Carolina
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas
| | - Melissa C Caughey
- Joint Department of Biomedical Engineering, University of North Carolina and North Carolina State University, Chapel Hill, North Carolina.
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Khan MS, Tahhan AS, Vaduganathan M, Greene SJ, Alrohaibani A, Anker SD, Vardeny O, Fonarow GC, Butler J. Trends in prevalence of comorbidities in heart failure clinical trials. Eur J Heart Fail 2020; 22:1032-1042. [PMID: 32293090 PMCID: PMC7906002 DOI: 10.1002/ejhf.1818] [Citation(s) in RCA: 76] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 03/19/2020] [Accepted: 03/19/2020] [Indexed: 12/16/2022] Open
Abstract
AIMS The primary objective of this systematic review was to estimate the prevalence and temporal changes in chronic comorbid conditions reported in heart failure (HF) clinical trials. METHODS AND RESULTS We searched MEDLINE for HF trials enrolling more than 400 patients published between 2001 and 2016.Trials were divided into HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or trials enrolling regardless of ejection fraction. The prevalence of baseline chronic comorbid conditions was categorized according to the algorithm proposed by the Chronic Conditions Data Warehouse, which is used to analyse Medicare data. To test for a trend in the prevalence of comorbid conditions, linear regression models were used to evaluate temporal trends in prevalence of comorbidities. Overall, 118 clinical trials enrolling a cumulative total of 215 508 patients were included. Across all comorbidities examined, data were reported in a mean of 35% of trials, without significant improvement during the study period. Reporting of comorbidities was more common in HFrEF trials (51%) compared with HFpEF trials (27%). Among trials reporting data, hypertension (63%), ischaemic heart disease (44%), hyperlipidaemia (48%), diabetes (33%), chronic kidney disease (25%) and atrial fibrillation (25%) were the major comorbidities. The prevalence of comorbidities including hypertension, atrial fibrillation and chronic kidney disease increased over time while the prevalence of smoking decreased in HFrEF trials. CONCLUSION Many HF trials do not report baseline comorbidities. A more rigorous, systematic, and standardized framework needs to be adopted for future clinical trials to ensure adequate comorbidity reporting and improve recruitment of multi-morbid HF patients.
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Affiliation(s)
| | - Ayman Samman Tahhan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Muthiah Vaduganathan
- Brigham and Women’s Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Stephen J. Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Stefan D. Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT), |German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS, USA
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6
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Khan MS, Samman Tahhan A, Vaduganathan M, Greene SJ, Alrohaibani A, Anker SD, Vardeny O, Fonarow GC, Butler J. Trends in prevalence of comorbidities in heart failure clinical trials. Eur J Heart Fail 2020. [PMID: 32293090 DOI: 10.1002/ejhf.1818 10.1002/ejhf.1818] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
Abstract
AIMS The primary objective of this systematic review was to estimate the prevalence and temporal changes in chronic comorbid conditions reported in heart failure (HF) clinical trials. METHODS AND RESULTS We searched MEDLINE for HF trials enrolling more than 400 patients published between 2001 and 2016.Trials were divided into HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), or trials enrolling regardless of ejection fraction. The prevalence of baseline chronic comorbid conditions was categorized according to the algorithm proposed by the Chronic Conditions Data Warehouse, which is used to analyse Medicare data. To test for a trend in the prevalence of comorbid conditions, linear regression models were used to evaluate temporal trends in prevalence of comorbidities. Overall, 118 clinical trials enrolling a cumulative total of 215 508 patients were included. Across all comorbidities examined, data were reported in a mean of 35% of trials, without significant improvement during the study period. Reporting of comorbidities was more common in HFrEF trials (51%) compared with HFpEF trials (27%). Among trials reporting data, hypertension (63%), ischaemic heart disease (44%), hyperlipidaemia (48%), diabetes (33%), chronic kidney disease (25%) and atrial fibrillation (25%) were the major comorbidities. The prevalence of comorbidities including hypertension, atrial fibrillation and chronic kidney disease increased over time while the prevalence of smoking decreased in HFrEF trials. CONCLUSION Many HF trials do not report baseline comorbidities. A more rigorous, systematic, and standardized framework needs to be adopted for future clinical trials to ensure adequate comorbidity reporting and improve recruitment of multi-morbid HF patients.
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Affiliation(s)
| | - Ayman Samman Tahhan
- Division of Cardiology, Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Stephen J Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | | | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT)
- German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS, USA
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7
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Iyngkaran P, Thomas M, Majoni SW. Perspectives On Optimizing Chronic Heart Failure Care Beyond Randomised Controlled Trials - What do we Consolidate and how do we Plan for the Future? Curr Cardiol Rev 2019; 15:158-160. [PMID: 31084591 PMCID: PMC6719389 DOI: 10.2174/1573403x1503190506101720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Pupalan Iyngkaran
- Consultant Cardiologist Heart West and Senior Lecturer Flinders University, NT Medical School, Darwin, Australia
| | - Merlin Thomas
- Biochemistry of Diabetes Complications, The Department of Diabetes, Monash University, Melbourne, Australia
| | - Sandawana W Majoni
- Clinical Dean Royal Darwin Hospital, TEHS, Renal Transplantation, Royal Darwin Hospital, Department of Nephrology, Division of Medicine, P.O. Box 41326, Tiwi, Darwin, Australia
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Iyngkaran P, Jelinek M. Health care in a globalised world: is there more than one type of patient? Med J Aust 2019; 210:211-212. [PMID: 30773648 DOI: 10.5694/mja2.50035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Iyngkaran P, Liew D, Neil C, Driscoll A, Marwick TH, Hare DL. Moving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2018; 12:1179546818809358. [PMID: 30618487 PMCID: PMC6299336 DOI: 10.1177/1179546818809358] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 09/14/2018] [Indexed: 12/20/2022]
Abstract
This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.
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Affiliation(s)
- Pupalan Iyngkaran
- Northern Territory Medical Program, Flinders University, Darwin, NT, Australia
- Pupalan Iyngkaran, Yellow Building 4 Cnr University Drive North & University Drive West Charles Darwin University, Casuarina, NT 0815, Australia.
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Christopher Neil
- Department of Medicine—Western Precinct, The University of Melbourne, Melbourne, VIC, Australia
| | - Andrea Driscoll
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
- Austin Health, Melbourne, VIC, Australia
| | | | - David L Hare
- Cardiovascular Research, The University of Melbourne, Melbourne, VIC, Australia
- Heart Failure Services, Austin Health, Melbourne, VIC, Australia
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Preeti J, Alexandre M, Pupalan I, Merlin TC, Claudio R. Chronic Heart Failure and Comorbid Renal Dysfunction - A Focus on Type 2 Cardiorenal Syndrome. Curr Cardiol Rev 2016; 12:186-94. [PMID: 27280302 PMCID: PMC5011190 DOI: 10.2174/1573403x12666160606120958] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/18/2015] [Accepted: 01/11/2016] [Indexed: 01/02/2023] Open
Abstract
The most important advancements in the Cardiorenal syndrome (CRS) are its definition and subsequent classifications. When the predominant pathology and pathophysiology is the heart, i.e. chronic heart failure (CHF), and where any renal impairment (RI) subsequent to this is secondary, the classification is type 2 CRS. There are unique differences in the pathophysiology and progression of individual subclasses. It is important to understand the evolution of CHF and consequences of subsequent RI as they are becoming increasingly prevalent, aggravate morbidity and mortality and limit many therapeutic options. In this paper we discuss the significance of the type 2 CRS patients in the context of the thematic series.
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Affiliation(s)
| | | | | | | | - Ronco Claudio
- Department of Nephrology Dialysis & Transplantation International Renal Research Institute (IRRIV) San Bortolo Hospital Viale Rodolfi, 37 36100 Vicenza, Italy.
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Iyngkaran P, Liew D, McDonald P, Thomas MC, Reid C, Chew D, Hare DL. Phase 4 Studies in Heart Failure - What is Done and What is Needed? Curr Cardiol Rev 2016; 12:216-30. [PMID: 27280303 PMCID: PMC5011189 DOI: 10.2174/1573403x12666160606121458] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/18/2015] [Accepted: 01/11/2016] [Indexed: 02/07/2023] Open
Abstract
Congestive heart failure (CHF) therapeutics is generated through a well-described evidence generating process. Phases 1 - 3 of this process are required prior to approval and widespread clinical use. Phase 3 in almost all cases is a methodologically sound randomized controlled trial (RCT). After this phase it is generally accepted that the treatment has a significant, independent and prognostically beneficial effect on the pathophysiological process. A major criticism of RCTs is the population to whom the result is applicable. When this population is significantly different from the trial cohort the external validity comes into question. Should the continuation of the evidence generating process continue these problems might be identified. Post marketing surveillance through phase 4 and comparative effectiveness studies through phase 5 trials are often underperformed in comparison to the RCT. These processes can help identify remote adverse events and define new hypotheses for community level benefits. This review is aimed at exploring the post-marketing scene for CHF therapeutics from an Australian health system perspective. We explore the phases of clinical trials, the level of evidence currently available and options for ensuring greater accountability for community level CHF clinical outcomes.
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Affiliation(s)
- Pupalan Iyngkaran
- Cardiologist & Senior Lecturer NT Medical School, Flinders University, Australia.
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12
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Iyngkaran P, Kangaharan N, Zimmet H, Arstall M, Minson R, Thomas MC, Bergin P, Atherton J, MacDonald P, Hare DL, Horowitz JD, Ilton M. Heart Failure in Minority Populations - Impediments to Optimal Treatment in Australian Aborigines. Curr Cardiol Rev 2016; 12:166-79. [PMID: 27280307 PMCID: PMC5011191 DOI: 10.2174/1573403x12666160606115034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/18/2015] [Accepted: 01/11/2016] [Indexed: 01/30/2023] Open
Abstract
Chronic heart failure (CHF) among Aboriginal/Indigenous Australians is endemic. There are also grave concerns for outcomes once acquired. This point is compounded by a lack of prospective and objective studies to plan care. To capture the essence of the presented topic it is essential to broadly understand Indigenous health. Key words such as ‘worsening’, ‘gaps’, ‘need to do more’, ‘poorly studied’, or ‘future studies should inform’ occur frequently in contrast to CHF research for almost all other groups. This narrative styled opinion piece attempts to discuss future directions for CHF care for Indigenous Australians. We provide a synopsis of the problem, highlight the treatment gaps, and define the impediments that present hurdles in optimising CHF care for Indigenous Australians.
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Affiliation(s)
- Pupalan Iyngkaran
- Cardiologist and Senior Lecturer NT Medical School, Flinders University, Tiwi, NT 0811, Australia.
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13
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Iyngkaran P, Toukhsati SR, Thomas MC, Jelinek MV, Hare DL, Horowitz JD. A Review of the External Validity of Clinical Trials with Beta-Blockers in Heart Failure. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:163-171. [PMID: 27773994 PMCID: PMC5063839 DOI: 10.4137/cmc.s38444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/03/2016] [Accepted: 07/16/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Beta-blockers (BBs) are the mainstay prognostic medication for all stages of chronic heart failure (CHF). There are many classes of BBs, each of which has varying levels of evidence to support its efficacy in CHF. However, most CHF patients have one or more comorbid conditions such as diabetes, renal impairment, and/or atrial fibrillation. Patient enrollment to randomized controlled trials (RCTs) often excludes those with certain comorbidities, particularly if the symptoms are severe. Consequently, the extent to which evidence drawn from RCTs is generalizable to CHF patients has not been well described. Clinical guidelines also underrepresent this point by providing generic advice for all patients. The aim of this review is to examine the evidence to support the use of BBs in CHF patients with common comorbid conditions. METHODS We searched MEDLINE, PubMed, and the reference lists of reviews for RCTs, post hoc analyses, systematic reviews, and meta-analyses that report on use of BBs in CHF along with patient demographics and comorbidities. RESULTS In total, 38 studies from 28 RCTs were identified, which provided data on six BBs against placebo or head to head with another BB agent in ischemic and nonischemic cardiomyopathies. Several studies explored BBs in older patients. Female patients and non-Caucasian race were underrepresented in trials. End points were cardiovascular hospitalization and mortality. Comorbid diabetes, renal impairment, or atrial fibrillation was detailed; however, no reference to disease spectrum or management goals as a focus could be seen in any of the studies. In this sense, enrollment may have limited more severe grades of these comorbidities. CONCLUSIONS RCTs provide authoritative information for a spectrum of CHF presentations that support guidelines. RCTs may provide inadequate information for more heterogeneous CHF patient cohorts. Greater Phase IV research may be needed to fill this gap and inform guidelines for a more global patient population.
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Affiliation(s)
- Pupalan Iyngkaran
- Cardiologist and Senior Lecturer, Northern Territory School of Medicine, Flinders University, Bedford Park, South Australia
| | - Samia R Toukhsati
- Department of Cardiology, Austin Health, Heidelberg, Victoria, Australia
| | - Merlin C Thomas
- Professor, NHMRC Senior Research Fellow, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Michael V Jelinek
- Professor, Department of Cardiology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - David L Hare
- Professor, Coordinator, Cardiovascular Research, University of Melbourne; Director of Heart Failure Services, Austin Health, Melbourne, Victoria, Australia
| | - John D Horowitz
- Professor of Cardiology, Director, Cardiology Unit, Discipline of Medicine, Cardiology Research Laboratory, The Basil Hetzel Institute, Woodville South, South Australia, Australia
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Iyngkaran P, Thomas M. Bedside-to-Bench Translational Research for Chronic Heart Failure: Creating an Agenda for Clients Who Do Not Meet Trial Enrollment Criteria. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2015; 9:121-32. [PMID: 26309418 PMCID: PMC4527366 DOI: 10.4137/cmc.s18737] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2015] [Revised: 03/09/2015] [Accepted: 03/25/2015] [Indexed: 01/09/2023]
Abstract
Congestive heart failure (CHF) is a chronic condition usually without cure. Significant developments, particularly those addressing pathophysiology, mainly started at the bench. This approach has seen many clinical observations initially explored at the bench, subsequently being trialed at the bedside, and eventually translated into clinical practice. This evidence, however, has several limitations, importantly the generalizability or external validity. We now acknowledge that clinical management of CHF is more complicated than merely translating bench-to-bedside evidence in a linear fashion. This review aims to help explore this evolving area from an Australian perspective. We describe the continuation of research once core evidence is established and describe how clinician-scientist collaboration with a bedside-to-bench view can help enhance evidence translation and generalizability. We describe why an extension of the available evidence or generating new evidence is occasionally needed to address the increasingly diverse cohort of patients. Finally, we explore some of the tools used by basic scientists and clinicians to develop evidence and describe the ones we feel may be most beneficial.
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Affiliation(s)
- P Iyngkaran
- Flinders University, NT Medical School, Darwin, Australia
| | - M Thomas
- Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
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