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Jarjour M, Ducharme A. Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines? Drugs Context 2023; 12:2023-5-6. [PMID: 38021409 PMCID: PMC10664772 DOI: 10.7573/dic.2023-5-6] [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: 05/29/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Heart failure is a growing epidemic with high mortality rates and recurrent hospital admissions that creates a burden on affected individuals, their caregivers and the whole healthcare system. Throughout the years, many randomized trials have established the effectiveness of several pharmacological therapies and electrophysiological devices to reduce hospitalizations and improve quality of life and survival, mostly for patients with heart failure with reduced ejection fraction (HFrEF). These studies led to the publication of national societies' recommendations to guide clinicians in the management of HFrEF. Yet, many reports have shown significant care gaps in adherence to these recommendations in clinical practice, highlighting suboptimal use and/or dosing of evidence-based therapies. Adherence to guidelines has been shown to be associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events; however, it remains unclear whether this association is causal or merely a marker of more advanced disease. Furthermore, individual characteristics may limit the possibility of reaching the targeted dosage of specific agents. Herein, we provide a comprehensive overview of clinicians' adherence to heart failure guidelines in a specialized real-life setting, particularly regarding use and optimization of guideline-derived medical therapies, as well as the implementation of more recent agents such as sacubitril/valsartan and SGLT2 inhibitors. We seek potential explanations for suboptimal treatment and its impact on patient outcomes.
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Affiliation(s)
- Marilyne Jarjour
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
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Jackson AM, Dewan P, Anand IS, Bělohlávek J, Bengtsson O, de Boer RA, Böhm M, Boulton DW, Chopra VK, DeMets DL, Docherty KF, Dukát A, Greasley PJ, Howlett JG, Inzucchi SE, Katova T, Køber L, Kosiborod MN, Langkilde AM, Lindholm D, Ljungman CE, Martinez FA, O’Meara E, Sabatine MS, Sjöstrand M, Solomon SD, Tereshchenko S, Verma S, Jhund PS, McMurray JJ. Dapagliflozin and Diuretic Use in Patients With Heart Failure and Reduced Ejection Fraction in DAPA-HF. Circulation 2020; 142:1040-1054. [PMID: 32673497 PMCID: PMC7664959 DOI: 10.1161/circulationaha.120.047077] [Citation(s) in RCA: 125] [Impact Index Per Article: 31.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/24/2020] [Accepted: 06/16/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the DAPA-HF trial (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure), the sodium-glucose cotransporter 2 inhibitor dapagliflozin reduced the risk of worsening heart failure and death in patients with heart failure and reduced ejection fraction. We examined the efficacy and tolerability of dapagliflozin in relation to background diuretic treatment and change in diuretic therapy after randomization to dapagliflozin or placebo. METHODS We examined the effects of study treatment in the following subgroups: no diuretic and diuretic dose equivalent to furosemide <40, 40, and >40 mg daily at baseline. We examined the primary composite end point of cardiovascular death or a worsening heart failure event and its components, all-cause death and symptoms. RESULTS Of 4616 analyzable patients, 736 (15.9%) were on no diuretic, 1311 (28.4%) were on <40 mg, 1365 (29.6%) were on 40 mg, and 1204 (26.1%) were taking >40 mg. Compared with placebo, dapagliflozin reduced the risk of the primary end point across each of these subgroups: hazard ratios were 0.57 (95% CI, 0.36-0.92), 0.83 (95% CI, 0.63-1.10), 0.77 (95% CI, 0.60-0.99), and 0.78 (95% CI, 0.63-0.97), respectively (P for interaction=0.61). The hazard ratio in patients taking any diuretic was 0.78 (95% CI, 0.68-0.90). Improvements in symptoms and treatment toleration were consistent across the diuretic subgroups. Diuretic dose did not change in most patients during follow-up, and mean diuretic dose did not differ between the dapagliflozin and placebo groups after randomization. CONCLUSIONS The efficacy and safety of dapagliflozin were consistent across the diuretic subgroups examined in DAPA-HF. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03036124.
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Affiliation(s)
- Alice M. Jackson
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
| | - Pooja Dewan
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
| | - Inder S. Anand
- Department of Cardiology, University of Minnesota, Minneapolis (I.S.A.)
| | - Jan Bělohlávek
- 2nd Department of Internal Medicine, Cardiovascular Medicine, General Teaching Hospital and 1st Faculty of Medicine, Charles University, Prague, Czech Republic (J.B.)
| | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D (O.B., A.M.L., D.L., M.S.), AstraZeneca, Gothenburg, Sweden
| | - Rudolf A. de Boer
- Department of Cardiology, University Medical Center and University of Groningen, The Netherlands (R.A.d.B.)
| | - Michael Böhm
- Department of Medicine, Saarland University Hospital, Homburg–Saar, Germany (M.B.)
| | - David W. Boulton
- Quantitative Clinical Pharmacology, IMED Biotech Unit, Astra-Zeneca, Gaithersburg, MD (D.W.B.)
| | | | - David L. DeMets
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison (D.L.D.)
| | - Kieran F. Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
| | - Andrej Dukát
- 5th Department of Internal Medicine, Comenius University in Bratislava, Slovakia (A.D.)
| | - Peter J. Greasley
- Cardiovascular, Renal and Metabolism Translational Medicines Unit, Early Clinical Development, IMED Biotech Unit (P.J.G.), AstraZeneca, Gothenburg, Sweden
| | - Jonathan G. Howlett
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, AB, Canada (J.G.W.)
| | - Silvio E. Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.)
| | - Tzvetana Katova
- Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.)
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Denmark (L.K.)
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.)
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D (O.B., A.M.L., D.L., M.S.), AstraZeneca, Gothenburg, Sweden
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D (O.B., A.M.L., D.L., M.S.), AstraZeneca, Gothenburg, Sweden
| | - Charlotta E.A. Ljungman
- Department of Molecular and Clinical Medicine and Cardiology, Sahlgrenska Academy, Gothenburg, Sweden (C.E.A.L.)
| | | | - Eileen O’Meara
- Department of Cardiology, Montreal Heart Institute, QC, Canada (E.O.)
| | - Marc S. Sabatine
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (M.S.S., S.D.S.)
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D (O.B., A.M.L., D.L., M.S.), AstraZeneca, Gothenburg, Sweden
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA (M.S.S., S.D.S.)
| | - Sergey Tereshchenko
- Department of Myocardial Disease and Heart Failure, National Medical Research Center of Cardiology, Moscow, Russia (S.T.)
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, ON, Canada (S.V.)
| | - Pardeep S. Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
| | - John J.V. McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, UK (A.M.J., P.D., K.F.D., P.S.J., J.J.V.M.)
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Arvanitaki A, Michou E, Kalogeropoulos A, Karvounis H, Giannakoulas G. Mildly symptomatic heart failure with reduced ejection fraction: diagnostic and therapeutic considerations. ESC Heart Fail 2020; 7:1477-1487. [PMID: 32368873 PMCID: PMC7373907 DOI: 10.1002/ehf2.12701] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2019] [Revised: 03/06/2020] [Accepted: 03/18/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Whereas up to about half of patients with heart failure with reduced ejection fraction (HFrEF) report no or only mild symptoms and are considered as clinically stable, the progressive nature of HFrEF, often silent, renders clinical stability a misleading situation, especially if disease progression is unrecognized. We highlight the challenges in the definition of clinical stability and mild symptomatic status in HFrEF, outline clinical characteristics and available diagnostic tools, and discuss evidence and gaps in the current guidelines for the management of these patients. METHODS AND RESULTS This is a state-of-the-art review that focuses on clinical, diagnostic, and therapeutic aspects in mildly symptomatic HFrEF patients; summarizes the challenges; and proposes directions for future research in this group of patients. The New York Heart Association classification has been widely used as a measure of prognosis in HFrEF, but it lacks objectivity and reproducibility in terms of symptoms assessment. The definition of clinical stability as described in current guidelines is vague and may often lead to underdiagnosis of disease progression in patients who appear to be 'stable' but in fact are at an increased risk of clinical worsening, hospitalization, or death. Although an increasing number of clinical trials proved that the efficacy of HFrEF therapies was unrelated to the symptomatic status of patients and led to their implementation early in the course of the disease, clinical inertia in terms of under-prescription or underdosing of guideline-recommended medications in mildly symptomatic HFrEF patients is still a challenging issue to deal with. CONCLUSIONS Mildly symptomatic status in a patient with HFrEF is very frequent; it should not be ignored and should not be regarded as an index of disease stability. The application of risk scores designed to predict mortality and mode of death should be engaged among mildly symptomatic patients, not only to identify the most suitable HF candidates for cardioverter defibrillator implantation, but also to identify patients who might benefit from early intensification of medical treatment before the implementation of more interventional approaches.
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Affiliation(s)
- Alexandra Arvanitaki
- 1st Department of Cardiology, AHEPA University Hospital, School of MedicineAristotle University of ThessalonikiThessaloniki54636Greece
- Department of Cardiology III—Adult Congenital and Valvular Heart Disease CenterUniversity Hospital Muenster, University of MuensterAlbert‐Schweitzer‐Campus 148149MünsterGermany
| | - Eleni Michou
- 1st Department of Cardiology, AHEPA University Hospital, School of MedicineAristotle University of ThessalonikiThessaloniki54636Greece
- Cardiovascular Research Institute Basel and Department of Cardiology, University Hospital BaselUniversity of BaselBaselSwitzerland
| | - Andreas Kalogeropoulos
- Division of Cardiology, Department of MedicineStony Brook University, Stony Brook University Medical Center, Health Sciences CenterStony BrookNY11794‐8167USA
- Division of CardiologyUniversity of PatrasPatraGreece
| | - Haralambos Karvounis
- 1st Department of Cardiology, AHEPA University Hospital, School of MedicineAristotle University of ThessalonikiThessaloniki54636Greece
| | - George Giannakoulas
- 1st Department of Cardiology, AHEPA University Hospital, School of MedicineAristotle University of ThessalonikiThessaloniki54636Greece
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Zeymer U, Clark AL, Barrios V, Damy T, Drożdż J, Fonseca C, Lund LH, Comite GD, Hupfer S, Maggioni AP. Management of heart failure with reduced ejection fraction in Europe: design of the ARIADNE registry. ESC Heart Fail 2020; 7:727-736. [PMID: 32027782 PMCID: PMC7160498 DOI: 10.1002/ehf2.12569] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Revised: 10/21/2019] [Accepted: 11/04/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS The introduction of sacubitril/valsartan (an angiotensin receptor-neprilysin inhibitor) is likely to change the approach to the management of patients with chronic heart failure with reduced ejection fraction (HFrEF). The Assessment of Real Life Care-Describing European Heart Failure Management (ARIADNE) registry will evaluate patient characteristics, practice patterns, outcomes, and healthcare resource utilization in the outpatient setting across Europe, with the main focus on factors that guide physicians' decisions to start and continue sacubitril/valsartan in patients with HFrEF. METHODS AND RESULTS ARIADNE, a prospective, observational registry will enrol 9000 ambulatory patients with HFrEF in 23 European countries Supplement 1. The study will describe 4500 patients treated with conventional treatment (including an angiotensin-converting enzyme inhibitor/angiotensin receptor blocker), and 4500 patients started on sacubitril/valsartan. In each country, patients will be enrolled consecutively over an expected period of 12 months, and followed-up for 12 months. The primary objective is to describe the baseline clinical and demographic characteristics of patients with chronic HFrEF, which guide the decision of the treating physician to initiate sacubitril/valsartan or to continue conventional treatment. A co-primary objective is to identify the baseline characteristics that are associated with the likelihood of reaching the target dose of sacubitril/valsartan 97/103 mg twice daily during follow-up. CONCLUSIONS The ARIADNE registry will provide a comprehensive profile of patients with chronic HFrEF in Europe, will elucidate how management varies between countries, and will help clarify the usage and outcomes associated with use of sacubitril/valsartan in real life.
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Affiliation(s)
- Uwe Zeymer
- Klinikum Ludwigshafen, Institut für Herzinfarktforschung LudwigshafenBremserstrasse 79Ludwigshafen67063Germany
| | - Andrew L. Clark
- Department of CardiologyHull York Medical School, Castle Hill HospitalKingston upon HullUK
| | | | - Thibaud Damy
- Department of CardiologyHenri Mondor HospitalCreteilFrance
| | | | - Candida Fonseca
- S. Francisco Xavier Hospital, NOVA Medical School, Faculdade de Ciências MédicasUniversidade Nova de LisboaLisbonPortugal
| | - Lars H. Lund
- Department of Medicine, Unit of CardiologyKarolinska InstitutetStockholmSweden
| | | | | | - Aldo P. Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research CenterFlorenceItaly
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Álvarez-García J, Salamanca-Bautista P, Ferrero-Gregori A, Montero-Pérez-Barquero M, Puig T, Aramburu-Bodas Ó, Vázquez R, Formiga F, Delgado J, Arias-Jiménez JL, Vives-Borrás M, Cerqueiro González JM, Manzano L, Cinca J. Impacto pronóstico de la especialidad en el paciente ambulatorio con insuficiencia cardiaca: un análisis emparejado de los registros REDINSCOR y RICA. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.09.021] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
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Álvarez-García J, Salamanca-Bautista P, Ferrero-Gregori A, Montero-Pérez-Barquero M, Puig T, Aramburu-Bodas Ó, Vázquez R, Formiga F, Delgado J, Arias-Jiménez JL, Vives-Borrás M, Cerqueiro González JM, Manzano L, Cinca J. Prognostic Impact of Physician Specialty on the Prognosis of Outpatients With Heart Failure: Propensity Matched Analysis of the REDINSCOR and RICA Registries. ACTA ACUST UNITED AC 2017; 70:347-354. [PMID: 28189543 DOI: 10.1016/j.rec.2016.12.026] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2016] [Accepted: 09/19/2016] [Indexed: 12/16/2022]
Abstract
INTRODUCTION AND OBJECTIVES The specialty treating patients with heart failure (HF) has a prognostic impact in the hospital setting but this issue remains under debate in the ambulatory environment. We aimed to compare the clinical profile and outcomes of outpatients with HF treated by cardiologists or internists. METHODS We analyzed the clinical, electrocardiogram, laboratory, and echocardiographic data of 2 prospective multicenter Spanish cohorts of outpatients with HF treated by cardiologists (REDINSCOR, n=2150) or by internists (RICA, n=1396). Propensity score matching analysis was used to test the influence of physician specialty on outcome. RESULTS Cardiologist-treated patients were often men, were younger, and had ischemic etiology and reduced left ventricular ejection fraction (LVEF). Patients followed up by internists were predominantly women, were older, and a higher percentage had preserved LVEF and associated comorbidities. The 9-month mortality was lower in the REDINSCOR cohort (11.6% vs 16.9%; P<.001), but the 9-month HF-readmission rates were similar (15.7% vs 16.9%; P=.349). The propensity matching analysis selected 558 pairs of comparable patients and continued to show significantly lower 9-month mortality in the cardiology cohort (12.0% vs 18.8%; RR, 0.64; 95% confidence interval [95%CI], 0.48-0.85; P=.002), with no relevant differences in the 9-month HF-readmission rate (18.1% vs 17.2%; RR, 0.95; 95%CI, 0.74-1.22; P=.695). CONCLUSIONS Age, sex, LVEF and comorbidities were major determinants of specialty-related referral in HF outpatients. An in-depth propensity matched analysis showed significantly lower 9-month mortality in the cardiologist cohort.
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Affiliation(s)
- Jesús Álvarez-García
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain.
| | | | - Andreu Ferrero-Gregori
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Teresa Puig
- Servicio de Epidemiología y Salud Pública, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | - Óscar Aramburu-Bodas
- Servicio de Medicina Interna, Hospital Universitario Virgen Macarena, Seville, Spain
| | - Rafael Vázquez
- Servicio de Cardiología, Hospital Puerta del Mar, Cádiz, Spain
| | - Francesc Formiga
- Servicio de Medicina Interna, IDIBELL, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Juan Delgado
- Servicio de Cardiología, Hospital 12 de Octubre, Madrid, Spain
| | | | - Miquel Vives-Borrás
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
| | | | - Luis Manzano
- Servicio de Medicina Interna, Hospital Ramón y Cajal, Madrid, Spain
| | - Juan Cinca
- Servicio de Cardiología, Hospital de la Santa Creu i Sant Pau, IIb-SantPau, Universidad Autónoma de Barcelona, Barcelona, Spain
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Clinical and laboratory determinants of low serum level of 25-hydroxyvitamin D during escalation of pharmacotherapy in heart failure patients. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2015; 12:216-27. [PMID: 26702277 PMCID: PMC4631913 DOI: 10.5114/kitp.2015.54457] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/17/2015] [Revised: 08/18/2015] [Accepted: 09/03/2015] [Indexed: 01/08/2023]
Abstract
INTRODUCTION The activation of the renin-angiotensin-aldosterone (RAA) system is a main element of the pathophysiology of chronic heart failure (CHF), determining its symptoms and prognosis. Vitamin D is an RAA inhibitor, and its deficiency frequently accompanies CHF. The factors determining the concentration of 25-hydroxyvitamin D [25(OH)D] in CHF are not well understood, although an association has been suggested between the deficiency and the advancement of CHF. Also unknown is the influence of therapeutic escalation using recommended agents on the serum level of 25(OH)D. The aim of this study was to examine the incidence of abnormal 25(OH)D concentrations in CHF patients and to establish the clinical and laboratory determinants of low activity of this metabolite. MATERIAL AND METHODS The retrospective analysis included the data of 412 CHF patients not receiving optimal pharmacological treatment who were initially in NYHA (New York Heart Association) class III or IV. Over the period of 3 months the therapy was escalated until reaching maximum tolerated doses or those recommended by the current guidelines. After optimizing the therapy, the incidence of 25(OH)D deficiency (< 30 ng/ml) and insufficiency (< 20 ng/ml) was established, and clinical and laboratory determinants for these abnormal concentrations were analyzed. RESULTS Normal serum level, insufficiency, and deficiency of 25(OH)D were observed in, respectively, 41.5%, 26.0% and 32.5% of patients. The NYHA class improved by at least 1 class in 63.6% of patients, remained unchanged in 32.8% of patients, and deteriorated in 3.6% of patients. In multivariables analysis, low availability of natural ultraviolet B (UVB) radiation, loss of body mass during the CHF, higher concentrations of phosphates and albumins, and the presence of diabetes increased the risk of 25(OH)D deficiency, while higher concentrations of uric acid reduced this risk. In patients with a positive response to therapy, the concentration of 25(OH)D was borderline significantly higher (p = 0.055), while insufficiency and deficiency were less frequent (p = 0.02) than in patients without a treatment response, but this pertained only to patients with higher exposure to UVB. These differences were not observed in patients with low UVB exposure. CONCLUSIONS The concentration of 25(OH)D in CHF patients is not associated with the advancement of the disease, but is strongly determined by the potential availability of UVB radiation. A positive response to therapy increases the concentration of 25(OH)D only in the case of high UVB exposure; other determinants of 25(OH)D level include the patient's metabolic profile and the presence of diabetes.
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