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Karakasis P. Comment on "Beta-blocker therapy in heart failure with preserved ejection fraction (B-HFpEF): A systematic review and meta-analysis". Curr Probl Cardiol 2024; 49:102520. [PMID: 38492621 DOI: 10.1016/j.cpcardiol.2024.102520] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 03/13/2024] [Indexed: 03/18/2024]
Affiliation(s)
- Paschalis Karakasis
- Second Department of Cardiology, General Hospital Hippokration, Aristotle University of Thessaloniki, Thessaloniki, Greece.
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2
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Kaddoura R, Madurasinghe V, Chapra A, Abushanab D, Al-Badriyeh D, Patel A. Beta-blocker therapy in heart failure with preserved ejection fraction (B-HFpEF): A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102376. [PMID: 38184132 DOI: 10.1016/j.cpcardiol.2024.102376] [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: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/08/2024]
Abstract
INTRODUCTION While beta-blockers are considered the cornerstone of treatment for heart failure with reduced ejection fraction, the same may not apply to patients with heart failure with preserved ejection fraction (HFpEF). To date, the benefit of beta-blockers remains uncertain, and there is no current consensus on their effectiveness. This study sought to evaluate the efficacy of beta-blockers on mortality and rehospitalization among patients with HFpEF. METHODS A systematic review and meta-analysis of randomized or observational cohort studies examined the efficacy of beta-blocker therapy in comparison with placebo, control, or standard medical care in patients with HFpEF, defined as left ventricular ejection fraction ≥50 %. The main endpoints were mortality (i.e., all-cause and cardiovascular), rehospitalization (i.e., all-cause and for heart failure) and a composite of the two. RESULTS Out of the 13,189 records initially identified, 16 full-text records met the inclusion criteria and were analyzed recruiting a total of 27,188 patients. The mean age range was 62-84 years old, predominantly female, with HFpEF in which 63.4 % of patients received a beta-blocker and 36.6 % did not. The pooled analysis of included cohort studies, of variable follow-up durations, showed a significant reduction in all-cause mortality by 19 % (odds ratio (OR) 0.81; 95 % confidence interval (CI): 0.65-0.99, p = 0.044) whereas rehospitalization for heart failure (OR 1.13; 95 % CI: 0.91-1.41, p = 0.27) or its composite with all-cause mortality (OR 1.01; 95 % CI: 0.78-1.32, p = 0.92) were similar between the beta-blocker and control groups. CONCLUSION This meta-analysis showed that beta-blocker therapy has the potential to reduce all-cause mortality in patients with HFpEF based on observational studies. Nevertheless, it did not affect rehospitalization for heart failure or its composite with all-cause mortality. Large scale randomized trials are needed to clarify this uncertainty.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
| | | | - Ammar Chapra
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Dina Abushanab
- Drug Information Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Ashfaq Patel
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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3
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Güven B, Sun Q, Wagg CS, Almeida de Oliveira A, Silver H, Persad KL, Onay-Besikci A, Vu J, Oudit GY, Lopaschuk GD. Obesity Is a Major Determinant of Impaired Cardiac Energy Metabolism in Heart Failure with Preserved Ejection Fraction. J Pharmacol Exp Ther 2024; 388:145-155. [PMID: 37977817 DOI: 10.1124/jpet.123.001791] [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: 06/14/2023] [Revised: 09/28/2023] [Accepted: 10/05/2023] [Indexed: 11/19/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a major health problem with limited treatment options. Although optimizing cardiac energy metabolism is a potential approach to treating heart failure, it is poorly understood what alterations in cardiac energy metabolism actually occur in HFpEF. To determine this, we used mice in which HFpEF was induced using an obesity and hypertension HFpEF protocol for 10 weeks. Next, carvedilol, a third-generation β-blocker and a biased agonist that exhibits agonist-like effects through β arrestins by activating extracellular signal-regulated kinase, was used to decrease one of these parameters, namely hypertension. Heart function was evaluated by invasive pressure-volume loops and echocardiography as well as by ex vivo working heart perfusions. Glycolysis and oxidation rates of glucose, fatty acids, and ketones were measured in the isolated working hearts. The development of HFpEF was associated with a dramatic decrease in cardiac glucose oxidation rates, with a parallel increase in palmitate oxidation rates. Carvedilol treatment decreased the development of HFpEF but had no major effect on cardiac energy substrate metabolism. Carvedilol treatment did increase the expression of cardiac β arrestin 2 and proteins involved in mitochondrial biogenesis. Decreasing bodyweight in obese HFpEF mice increased glucose oxidation and improved heart function. This suggests that the dramatic energy metabolic changes in HFpEF mice hearts are primarily due to the obesity component of the HFpEF model. SIGNIFICANCE STATEMENT: Metabolic inflexibility occurs in heart failure with preserved ejection fraction (HFpEF) mice hearts. Lowering blood pressure improves heart function in HFpEF mice with no major effect on energy metabolism. Between hypertension and obesity, the latter appears to have the major role in HFpEF cardiac energetic changes. Carvedilol increases mitochondrial biogenesis and overall energy expenditure in HFpEF hearts.
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Affiliation(s)
- Berna Güven
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
| | - Qiuyu Sun
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
| | - Cory S Wagg
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
| | - Amanda Almeida de Oliveira
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
| | - Heidi Silver
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
| | - Kaya L Persad
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
| | - Arzu Onay-Besikci
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
| | - Jennie Vu
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
| | - Gavin Y Oudit
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
| | - Gary D Lopaschuk
- Cardiovascular Research Centre, Department of Pediatrics (B.G., Q.S., C.S.W., H.S., K.L.P., G.D.L.), Department of Medicine, Division of Cardiology (A.A.O., J.V., G.Y.O.), and Mazankowski Alberta Heart Institute (A.A.O., J.V., G.Y.O.), University of Alberta, Edmonton, Canada and Faculty of Pharmacy, Department of Pharmacology, Ankara University, Ankara, Turkey (B.G., A.O.-B.)
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Kaddoura R, Patel A. Revisiting Beta-Blocker Therapy in Heart Failure with Preserved Ejection Fraction. Curr Probl Cardiol 2023; 48:102015. [PMID: 37544622 DOI: 10.1016/j.cpcardiol.2023.102015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogenous disorder and tends to be predominant in elderly, female, and obese patients. HFpEF has been classified using various cut-offs of left ventricular ejection fraction in the published studies with a current cut-off of ≥50%. The evidence of beta-blocker therapy in HFpEF patients showed conflicting findings with variably reported efficacy. This review aims to examine the published studies on the use of beta blockers for the treatment of patients with HFpEF.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
| | - Ashfaq Patel
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Impact of β-Blockers on Heart Rate and Oxygen Uptake During Exercise and Recovery in Older Patients With Heart Failure With Preserved Ejection Fraction. J Cardiopulm Rehabil Prev 2021; 40:174-177. [PMID: 31899703 DOI: 10.1097/hcr.0000000000000459] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
PURPOSE The study aimed to investigate the differences in oxygen uptake ((Equation is included in full-text article.)O2) and heart rate (HR) (at rest, submaximal exercise, peak exercise, and recovery) in patients with heart failure with preserved ejection fraction (HFpEF) with β-blockers (BB) or without BB treatment (NBB) and to analyze the relationship between HR reserve (HRresv) and peak (Equation is included in full-text article.)O2 ((Equation is included in full-text article.)O2peak) in BB and NBB. METHODS A total of 174 HFpEF patients (>65 yr; BB, n = 59; NBB, n = 115) were assessed with a cardiopulmonary exercise test to peak exertion using an incremental protocol. After 5 min of supine rest, HR and (Equation is included in full-text article.)O2 (HRrest, (Equation is included in full-text article.)O2rest) at submaximal exercise (HRsubmax, (Equation is included in full-text article.)O2submax), at peak exercise (HRpeak, (Equation is included in full-text article.)O2peak), at 1 min of passive recovery (HRrec1), HRresv (HRpeak- HRrest), and HR recovery (HRrecov = HRpeak- HRrec1) were evaluated. RESULTS Analysis showed that HRrest (66.0 ± 12.2 vs 69.7 ± 10.6 bpm), HRsubmax (91.7 ± 16.2 vs 98.6 ± 15.2 bpm), and HRrec1 (102.9 ± 18.9 vs 109.4 ± 16.9 bpm) were significantly lower (P ≤ .05) in BB than in NBB, respectively. However, there were no significant differences (P > .05) between the BB and the NBB for HRpeak, HRresv, HRrecov, (Equation is included in full-text article.)O2rest, (Equation is included in full-text article.)O2submax, and (Equation is included in full-text article.)O2peak. A significant relationship was found between HRresv and (Equation is included in full-text article.)O2peak values in both groups (BB, r = 0.52; NBB, r = 0.49, P < .001). CONCLUSIONS The nonsignificant differences in HRpeak, HRresv, HRrecov, or (Equation is included in full-text article.)O2 values between BB and NBB HFpEF patients, along with significant correlation between HRresv and (Equation is included in full-text article.)O2peak, suggest that these measures may have equal utility in prognostic and functional assessment as well as clinical applications, including the prescription of exercise, in elderly HFpEF patients.
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Dunkley JC, Irion CI, Yousefi K, Shehadeh SA, Lambert G, John-Williams K, Webster KA, Goldberger JJ, Shehadeh LA. Carvedilol and exercise combination therapy improves systolic but not diastolic function and reduces plasma osteopontin in Col4a3-/- Alport mice. Am J Physiol Heart Circ Physiol 2021; 320:H1862-H1872. [PMID: 33769915 PMCID: PMC8163658 DOI: 10.1152/ajpheart.00535.2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 02/16/2021] [Accepted: 03/19/2021] [Indexed: 11/22/2022]
Abstract
There are currently no Food and Drug Administration-approved treatments for heart failure with preserved ejection fraction (HFpEF). Here we compared the effects of exercise with and without α/β-adrenergic blockade with carvedilol in Col4a3-/- Alport mice, a model of the phenogroup 3 subclass of HFpEF with underlying renal dysfunction. Alport mice were assigned to the following groups: no treatment control (n = 29), carvedilol (n = 11), voluntary exercise (n = 9), and combination carvedilol and exercise (n = 8). Cardiac function was assessed by echocardiography after 4-wk treatments. Running activity of Alport mice was similar to wild types at 1 mo of age but markedly reduced at 2 mo (1.3 ± 0.40 vs. 4.5 ± 1.02 km/day, P < 0.05). There was a nonsignificant trend for increased running activity at 2 mo by carvedilol in the combination treatment group. Combination treatments conferred increased body weight of Col4a3-/- mice (22.0 ± 1.18 vs. 17.8 ± 0.29 g in untreated mice, P < 0.01), suggesting improved physiology, and heart rates declined by similar increments in all carvedilol-treatment groups. The combination treatment improved systolic parameters; stroke volume (30.5 ± 1.99 vs. 17.8 ± 0.77 μL, P < 0.0001) as well as ejection fraction and global longitudinal strain compared with controls. Myocardial performance index was normalized by all interventions (P < 0.0001). Elevated osteopontin plasma levels in control Alport mice were significantly lowered only by combination treatment, and renal function of the Alport group assessed by urine albumin creatinine ratio was significantly improved by all treatments. The results support synergistic roles for exercise and carvedilol to augment cardiac systolic function of Alport mice with moderately improved renal functions but no change in diastole.NEW & NOTEWORTHY In an Alport mouse model of heart failure with preserved ejection fraction (HFpEF), exercise and carvedilol synergistically improved systolic function without affecting diastole. Carvedilol alone or in combination with exercise also improved kidney function. Molecular analyses indicate that the observed improvements in cardiorenal functions were mediated at least in part by effects on serum osteopontin and related inflammatory cytokine cascades. The work presents new potential therapeutic targets and approaches for HFpEF.
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MESH Headings
- Adrenergic beta-Antagonists/pharmacology
- Animals
- Autoantigens/genetics
- Biomarkers/blood
- Carvedilol/pharmacology
- Collagen Type IV/deficiency
- Collagen Type IV/genetics
- Combined Modality Therapy
- Diastole
- Disease Models, Animal
- Down-Regulation
- Exercise Therapy
- Heart Failure/blood
- Heart Failure/genetics
- Heart Failure/physiopathology
- Heart Failure/therapy
- Mice, 129 Strain
- Mice, Knockout
- Nephritis, Hereditary/blood
- Nephritis, Hereditary/genetics
- Nephritis, Hereditary/physiopathology
- Nephritis, Hereditary/therapy
- Osteopontin/blood
- Recovery of Function
- Systole
- Ventricular Dysfunction, Left/blood
- Ventricular Dysfunction, Left/genetics
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Dysfunction, Left/therapy
- Ventricular Function, Left/drug effects
- Mice
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Affiliation(s)
- Julian C Dunkley
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
- Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Camila I Irion
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
- Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Keyvan Yousefi
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
- Department of Molecular and Cellular Pharmacology, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Serene A Shehadeh
- Department of Surgery, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Guerline Lambert
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
- Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Krista John-Williams
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
- Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Keith A Webster
- Vascular Biology Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Jeffrey J Goldberger
- Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
| | - Lina A Shehadeh
- Interdisciplinary Stem Cell Institute, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
- Division of Cardiology, Department of Medicine, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
- Peggy and Harold Katz Family Drug Discovery Center, University of Miami Leonard M. Miller School of Medicine, Miami, Florida
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7
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Cattadori G, Di Marco S, Farina S, Limongelli G, Monda E, Badagliacca R, Papa S, Tricarico L, Correale M. Beta-blockers in heart failure prognosis: Lessons learned by MECKI Score Group papers. Eur J Prev Cardiol 2020; 27:65-71. [PMID: 33238743 PMCID: PMC7691627 DOI: 10.1177/2047487320951109] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Heart failure is a complex syndrome affecting several organs including kidney,
lungs, liver, brain muscles and sympathetic system. Each of these organs might
contribute to its severity and prognosis. The prognosis assessment is critical
for a correct heart failure management. It has already been demonstrated that a
single parameter is weaker for prognosis than different parameters combined. The
Metabolic Exercise test data combined with Cardiac and Kidney Indexes (MECKI)
score has been built and validated for heart failure with reduced ejection
fraction (HFrEF) patients by considering cardiopulmonary exercise test data
combined with clinical, laboratory and echocardiographic measurements. The
betablockers treatment is a milestone in the HFrEF management. In the MECKI
score database, the association of betablockers treatment with outcome has been
investigated in different settings.
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Affiliation(s)
| | | | | | - Giuseppe Limongelli
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Italy
| | - Emanuele Monda
- Cardiologia SUN, Ospedale Monaldi (Azienda dei Colli), Seconda Università di Napoli, Italy
| | - Roberto Badagliacca
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesioloigiche e Geriatriche, 'Sapienza', Rome University, Italy
| | - Silvia Papa
- Dipartimento di Scienze Cardiovascolari, Respiratorie, Nefrologiche, Anestesioloigiche e Geriatriche, 'Sapienza', Rome University, Italy
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Tadic M, Cuspidi C, Frydas A, Grassi G. The role of arterial hypertension in development heart failure with preserved ejection fraction: just a risk factor or something more? Heart Fail Rev 2019; 23:631-639. [PMID: 29619635 DOI: 10.1007/s10741-018-9698-8] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is an entity that still raises many questions. The agreement about definition, pathophysiology, and therapeutic approach is still missing. Arterial hypertension is present in majority of patients with HFpEF, and it is still not clear if it represent a risk factor or "sine qua non" condition for HFpEF development. The underlying mechanisms of hypertension and HFpEF involve the same biohumoral systems: renin-angiotensin-aldosterone, sympathetic nervous system, and oxidative stress. However, not all hypertensive patients have HFpEF. The predisposition of some hypertensive patients to develop HFpEF needs to be resolved. Large randomized controlled trials did not prove the usefulness of renin-angiotensin-aldosterone inhibitors, diuretics, calcium channel blockers, and beta-blockers in HFpEF patients. The majority of studies did not succeed to demonstrate the reduction of cardiovascular and all-cause mortality in HFpEF individuals. One of the major limitations in these investigations was the inconsistency of HFpEF definition, which mainly refers to left ventricular ejection fraction (LVEF) cut-off that ranged from 40 to 50% in different studies. This review article provides the available data about pathophysiology and mechanisms that connect hypertension and HFpEF, investigations and therapy used in both conditions.
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Affiliation(s)
- Marijana Tadic
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Germany.
| | - Cesare Cuspidi
- Istituto Auxologico Italiano, Clinical Research Unit, University of Milan-Bicocca, Viale della Resistenza 23, 20036, Meda, Italy
| | - Athanasios Frydas
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Augustenburgerplatz 1, 13353, Berlin, Germany
| | - Guido Grassi
- Department of Health Science, University of Milano-Bicocca, Milan, Italy
- IRCCS Multimedica, Sesto San Giovanni, Milan, Italy
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Rush CJ, Campbell RT, Jhund PS, Petrie MC, McMurray JJV. Association is not causation: treatment effects cannot be estimated from observational data in heart failure. Eur Heart J 2018; 39:3417-3438. [PMID: 30085087 PMCID: PMC6166137 DOI: 10.1093/eurheartj/ehy407] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Revised: 04/01/2018] [Accepted: 06/27/2018] [Indexed: 12/21/2022] Open
Abstract
Aims Treatment 'effects' are often inferred from non-randomized and observational studies. These studies have inherent biases and limitations, which may make therapeutic inferences based on their results unreliable. We compared the conflicting findings of these studies to those of prospective randomized controlled trials (RCTs) in relation to pharmacological treatments for heart failure (HF). Methods and results We searched Medline and Embase to identify studies of the association between non-randomized drug therapy and all-cause mortality in patients with HF until 31 December 2017. The treatments of interest were: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, mineralocorticoid receptor antagonists (MRAs), statins, and digoxin. We compared the findings of these observational studies with those of relevant RCTs. We identified 92 publications, reporting 94 non-randomized studies, describing 158 estimates of the 'effect' of the six treatments of interest on all-cause mortality, i.e. some studies examined more than one treatment and/or HF phenotype. These six treatments had been tested in 25 RCTs. For example, two pivotal RCTs showed that MRAs reduced mortality in patients with HF with reduced ejection fraction. However, only one of 12 non-randomized studies found that MRAs were of benefit, with 10 finding a neutral effect, and one a harmful effect. Conclusion This comprehensive comparison of studies of non-randomized data with the findings of RCTs in HF shows that it is not possible to make reliable therapeutic inferences from observational associations. While trials undoubtedly leave gaps in evidence and enrol selected participants, they clearly remain the best guide to the treatment of patients.
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Affiliation(s)
- Christopher J Rush
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Ross T Campbell
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, 126 University Place, Glasgow, UK
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Hitsumoto T. Efficacy of the Reactive Oxygen Metabolite Test as a Predictor of Initial Heart Failure Hospitalization in Elderly Patients With Chronic Heart Failure. Cardiol Res 2018; 9:153-160. [PMID: 29904450 PMCID: PMC5997435 DOI: 10.14740/cr733w] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Accepted: 05/25/2018] [Indexed: 02/07/2023] Open
Abstract
Background The reactive oxygen metabolites (d-ROMs) test has recently been explored as a novel marker of oxidative stress in vivo and used in clinical settings. Conversely, data regarding the utility of the d-ROMs test as a predictor of patients with chronic heart failure (CHF) are limited. This prospective study aims to elucidate the efficacy of the d-ROMs test as a predictor of initial heart failure (HF) hospitalization in elderly patients with CHF. Methods A total of 428 elderly outpatients with CHF with no history of HF hospitalization (108 males, 320 females; mean age, 75 ± 7 years) were enrolled. Based on the median value of d-ROMs test levels (303 U.CARR), the patients were divided into the following two groups: group L (low d-ROMs test levels) and group H (high d-ROMs test levels). The utility of the d-ROMs test as a predictor of initial HF hospitalization was evaluated. Results During the 88.1-month follow-up period, 58 HF cases were hospitalized (group L, 17 cases; group H, 41 cases; P < 0.001, log-rank test). Multivariate Cox regression analyses revealed that group H exhibited a significantly higher risk for HF hospitalization than did group L (hazard ratio (HR), 2.35; 95% confidence interval (CI), 1.37 - 4.43; P < 0.01). Furthermore, the HR (vs. group L with low brain natriuretic peptide (BNP) levels (< 200 pg/mL), HR, 9.18; 95% CI, 4.78 - 22.94; P < 0.001) for the incidence of HF hospitalization increased in group H with high BNP levels (≥ 200 pg/mL). Conclusions The present study demonstrates that high d-ROMs test levels predict initial HF hospitalization in elderly patients with CHF. In addition, the predictive value for the incidence of HF hospitalization increases by using a combination of two biomarkers as d-ROMs test and BNP levels.
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Affiliation(s)
- Takashi Hitsumoto
- Hitsumoto Medical Clinic, 2-7-7, Takezakicyou, Shimonoseki City, Yamaguchi, 750-0025, Japan.
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11
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Domagoj M, Branka JZ, Jelena M, Davor M, Duska G. Effects of carvedilol therapy in patients with heart failure with preserved ejection fraction - Results from the Croatian heart failure (CRO-HF) registry. Med Clin (Barc) 2018; 152:43-49. [PMID: 29678315 DOI: 10.1016/j.medcli.2018.02.011] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2017] [Revised: 01/31/2018] [Accepted: 02/08/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND OBJECTIVE According to recent guidelines, the best approach for treatment of heart failure patients with preserved ejection function is still not defined. The aim of this study was to investigate how carvedilol therapy influences the survival rate, ejection fraction and NYHA class in these patients. PATIENTS AND METHODS We conducted study on heart failure patients with preserved systolic function from the Croatian heart failure registry who were hospitalized in the period between 2005 and 2010. We enrolled patients with carvedilol listed as treatment on their discharge letters and patients who had been using carvedilol for at least 4 years, while for the control group we selected patients with no beta-blockers on their discharge letters (113 vs 204 respectively). The primary outcome was the overall survival rate and the secondary outcome was the change in ejection fraction of the left ventricle and NYHA class during the study. RESULTS Patients in the carvedilol group had a higher overall survival rate compared to patients in the control group (chi-square=14.1, P<0.001). Patients in the carvedilol group in two measurements had a significantly higher ejection fraction compared to the control group (F=148.04, P<0.001). Also, patients in the carvedilol group showed improvement in NYHA class (chi-square=29.768, P<0.001). CONCLUSION Long term carvedilol therapy appears to be associated with a higher overall survival rate, improvement in ejection fraction and NYHA class in heart failure patients with preserved ejection fraction.
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Affiliation(s)
- Markovic Domagoj
- Clinic for Heart and Cardiovascular Diseases, University Hospital of Split, Croatia.
| | | | - Macanovic Jelena
- Clinic for Heart and Cardiovascular Diseases, University Hospital of Split, Croatia
| | - Milicic Davor
- Clinic for Heart and Cardiovascular Diseases, University Hospital of Zagreb, Croatia
| | - Glavas Duska
- Clinic for Heart and Cardiovascular Diseases, University Hospital of Split, Croatia
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12
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Zhai XB, Gu ZC, Liu XY. Clinical pharmacist intervention reduces mortality in patients with acute myocardial infarction: a propensity score matched analysis. Eur J Hosp Pharm 2018; 26:248-252. [PMID: 31656610 DOI: 10.1136/ejhpharm-2017-001344] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 02/12/2018] [Accepted: 02/15/2018] [Indexed: 11/04/2022] Open
Abstract
Background Is it possible that the mortality rate from acute myocardial infarction (AMI) may decline after interventions by pharmacists? Objective To evaluate the impact of clinical pharmacist on the mortality of AMI. Methods Clinical pharmacists did not perform any interventions during phase 1 (pre-intervention), and consulted with physicians to address drug related problems (DRPs) during phase 2 (post-intervention). The main outcome was a decrease in mortality from AMI. The two phases were compared using propensity score matching (PSM). Results 1388 interventions were suggested by clinical pharmacists during phase 2, of which 1239 (89.2%) were accepted. Logistic regression analysis demonstrated that interventions of clinical pharmacists were significantly associated with a reduced mortality in patients with both ST segment elevation myocardial infarction (STEMI) (OR 0.449; 95% CI 0.296 to 0.680) and non-ST segment elevation myocardial infarction (NSTEMI) (OR 0.268; 95% CI 0.125 to 0.572). Using PSM analysis, mortality reduced from 6.8% to 4.3% in STEMI patients (P=0.0034) and from 3.2% to 0.7% in NSTEMI patients (P=0.0202) after the interventions. Conclusions DRPs that caused or contributed to possible mortality were detected by clinical pharmacists in patients with AMI. Correcting these DRPs after pharmacists' interventions could result in a significant decrease in mortality.
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Affiliation(s)
- Xiao-Bo Zhai
- Department of Pharmacy, Shanghai East Hospital, Affiliated to Tongji University Shanghai, Shanghai, China
| | - Zhi-Chun Gu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
| | - Xiao-Yan Liu
- Department of Pharmacy, Renji Hospital, School of Medicine, Shanghai Jiaotong University, Shanghai, China
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13
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Zheng SL, Chan FT, Nabeebaccus AA, Shah AM, McDonagh T, Okonko DO, Ayis S. Drug treatment effects on outcomes in heart failure with preserved ejection fraction: a systematic review and meta-analysis. Heart 2017; 104:407-415. [PMID: 28780577 PMCID: PMC5861385 DOI: 10.1136/heartjnl-2017-311652] [Citation(s) in RCA: 97] [Impact Index Per Article: 13.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2017] [Revised: 06/19/2017] [Accepted: 07/05/2017] [Indexed: 02/06/2023] Open
Abstract
Background Clinical drug trials in patients with heart failure and preserved ejection fraction have failed to demonstrate improvements in mortality. Methods We systematically searched Medline, Embase and the Cochrane Central Register of Controlled Trials for randomised controlled trials (RCT) assessing pharmacological treatments in patients with heart failure with left ventricular (LV) ejection fraction≥40% from January 1996 to May 2016. The primary efficacy outcome was all-cause mortality. Secondary outcomes were cardiovascular mortality, heart failure hospitalisation, exercise capacity (6-min walk distance, exercise duration, VO2 max), quality of life and biomarkers (B-type natriuretic peptide, N-terminal pro-B-type natriuretic peptide). Random-effects models were used to estimate pooled relative risks (RR) for the binary outcomes, and weighted mean differences for continuous outcomes, with 95% CI. Results We included data from 25 RCTs comprising data for 18101 patients. All-cause mortality was reduced with beta-blocker therapy compared with placebo (RR: 0.78, 95%CI 0.65 to 0.94, p=0.008). There was no effect seen with ACE inhibitors, aldosterone receptor blockers, mineralocorticoid receptor antagonists and other drug classes, compared with placebo. Similar results were observed for cardiovascular mortality. No single drug class reduced heart failure hospitalisation compared with placebo. Conclusion The efficacy of treatments in patients with heart failure and an LV ejection fraction≥40% differ depending on the type of therapy, with beta-blockers demonstrating reductions in all-cause and cardiovascular mortality. Further trials are warranted to confirm treatment effects of beta-blockers in this patient group.
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Affiliation(s)
- Sean Lee Zheng
- Cardiovascular Division, King's College Hospital London, British Heart Foundation Centre of Research Excellence, London, UK.,Department of Cardiovascular Medicine, King's College Hospital, London, UK.,Imperial College Healthcare NHS Trust, London, UK
| | - Fiona T Chan
- Imperial College Healthcare NHS Trust, London, UK
| | - Adam A Nabeebaccus
- Cardiovascular Division, King's College Hospital London, British Heart Foundation Centre of Research Excellence, London, UK.,Department of Cardiovascular Medicine, King's College Hospital, London, UK
| | - Ajay M Shah
- Cardiovascular Division, King's College Hospital London, British Heart Foundation Centre of Research Excellence, London, UK.,Department of Cardiovascular Medicine, King's College Hospital, London, UK
| | - Theresa McDonagh
- Cardiovascular Division, King's College Hospital London, British Heart Foundation Centre of Research Excellence, London, UK.,Department of Cardiovascular Medicine, King's College Hospital, London, UK
| | - Darlington O Okonko
- Cardiovascular Division, King's College Hospital London, British Heart Foundation Centre of Research Excellence, London, UK.,Department of Cardiovascular Medicine, King's College Hospital, London, UK
| | - Salma Ayis
- Department of Primary Care and Public Health Sciences, King's College London, London, UK
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