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Meguro T. Diversity in heart failure management: Quo Vadis, guideline-directed medical therapy? Int J Cardiol 2024:132325. [PMID: 38972489 DOI: 10.1016/j.ijcard.2024.132325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 07/01/2024] [Indexed: 07/09/2024]
Affiliation(s)
- Tomomi Meguro
- International University of Health and Welfare Ichikawa Hospital, Japan.
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2
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Li J, Chen Y, Wang Y, Liu X, Li P, He Y, Hao Y, Huang L, Jin J, Wang J, Anderson C. Impact of guideline-directed medical therapy on systolic blood pressure and cardiovascular outcomes in patients with heart failure and low blood pressure: A systematic review and meta-analysis. Eur J Heart Fail 2024; 26:1435-1442. [PMID: 38606573 DOI: 10.1002/ejhf.3208] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 03/07/2024] [Indexed: 04/13/2024] Open
Abstract
AIMS Existing research indicates that patients with heart failure (HF) may have restricted access to guideline-directed medical therapy (GDMT) when their blood pressure (BP) is comparatively low. However, recent clinical trials suggest that HF patients with low BP could still benefit from certain HF medications, which have a minimal impact on BP. This systematic review and meta-analysis was conducted to determine whether this applies to all GDMT. METHODS AND RESULTS A systematic search of MEDLINE and EMBASE was conducted for studies published from inception to 10 January 2024. Randomized controlled trials were selected if they reported on the longitudinal change of systolic BP (SBP) due to GDMT, or the risks of cardiovascular events in HF patients based on SBP categories. Weighted mean difference (WMD), hazard ratio or relative risk, and corresponding 95% confidence intervals (CI) were pooled for meta-analysis where possible. Data from 20 studies, encompassing information on 84 782 individuals, were analysed. Overall, GDMT is associated with lower SBP (WMD, -2.16; 95% CI -2.86 to -1.46), with no significant difference between baseline low and non-low BP subgroups (interaction p = 0.810). However, SBP of the treatment group increased by 5.8 mmHg from baseline in the low SBP subgroup during follow-up, while it decreased by 4.0 mmHg in the baseline non-low SBP subgroup. GDMT demonstrated similar cardiovascular benefits and risk of hypotension between low and non-low SBP subgroups (interaction p = 0.318 and 0.903, respectively). CONCLUSIONS Guideline-directed medical therapy is associated with a negligible decrease in SBP, but can provide similar cardiovascular benefits in both low and non-low SBP HF patients, with no significant interaction with SBP as to hypotension. Therefore, GDMT should be initiated and maintained in HF patients with low BP.
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Affiliation(s)
- Jingwei Li
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Yunlong Chen
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Yi Wang
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Xiaoyan Liu
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Ping Li
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Yongming He
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Yang Hao
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Lan Huang
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Jun Jin
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Jiang Wang
- Department of Cardiology, Xinqiao Hospital, Army Military Medical University, Chongqing, China
| | - Craig Anderson
- The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, NSW, Australia
- Department of Neurology, Royal Prince Alfred Hospital, The University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine Clinica Alemana Universidad del Desarrollo, Santiago, Chile
- Heart Health Research Center, Beijing, China
- The George Institute China, Beijing, China
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Zhang Z, Wang C, Tu T, Lin Q, Zhou J, Huang Y, Wu K, Zhang Z, Zuo W, Liu N, Xiao Y, Liu Q. Advancing Guideline-Directed Medical Therapy in Heart Failure: Overcoming Challenges and Maximizing Benefits. Am J Cardiovasc Drugs 2024; 24:329-342. [PMID: 38568400 PMCID: PMC11093832 DOI: 10.1007/s40256-024-00646-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/20/2024] [Indexed: 05/15/2024]
Abstract
The delayed titration of guideline-directed drug therapy (GDMT) is a complex event influenced by multiple factors that often result in poor prognosis for patients with heart failure (HF). Individualized adjustments in GDMT titration may be necessary based on patient characteristics, and every clinician is responsible for promptly initiating GDMT and titrating it appropriately within the patient's tolerance range. This review examines the current challenges in GDMT implementation and scrutinizes titration considerations within distinct subsets of HF patients, with the overarching goal of enhancing the adoption and effectiveness of GDMT. The authors also underscore the significance of establishing a novel management strategy that integrates cardiologists, nurse practitioners, pharmacists, and patients as a unified team that can contribute to the improved promotion and implementation of GDMT.
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Affiliation(s)
- Zixi Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Cancan Wang
- Department of Metabolic Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Tao Tu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Qiuzhen Lin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Jiabao Zhou
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yunying Huang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Keke Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Zeying Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Wanyun Zuo
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Na Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
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Ohata T, Niimi N, Shiraishi Y, Nakatsu F, Umemura I, Kohno T, Nagatomo Y, Takei M, Ono T, Sakamoto M, Nakano S, Fukuda K, Kohsaka S, Yoshikawa T. Initiation and Up-Titration of Guideline-Based Medications in Hospitalized Acute Heart Failure Patients - A Report From the West Tokyo Heart Failure Registry. Circ J 2023; 88:22-30. [PMID: 37914282 DOI: 10.1253/circj.cj-23-0356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Despite recommendations from clinical practice guidelines to initiate and titrate guideline-directed medical therapy (GDMT) during their hospitalization, patients with acute heart failure (AHF) are frequently undertreated. In this study we aimed to clarify GDMT implementation and titration rates, as well as the long-term outcomes, in hospitalized AHF patients.Methods and Results: Among 3,164 consecutive hospitalized AHF patients included in a Japanese multicenter registry, 1,400 (44.2%) with ejection fraction ≤40% were analyzed. We assessed GDMT dosage (β-blockers, renin-angiotensin inhibitors, and mineralocorticoid-receptor antagonists) at admission and discharge, examined the contributing factors for up-titration, and evaluated associations between drug initiation/up-titration and 1-year post-discharge all-cause death and rehospitalization for HF via propensity score matching. The mean age of the patients was 71.5 years and 30.7% were female. Overall, 1,051 patients (75.0%) were deemed eligible for GDMT, based on their baseline vital signs, renal function, and electrolyte values. At discharge, only 180 patients (17.1%) received GDMT agents up-titrated to >50% of the maximum titrated dose. Up-titration was associated with a lower risk of 1-year clinical outcomes (adjusted hazard ratio: 0.58, 95% confidence interval: 0.35-0.96). Younger age and higher body mass index were significant predictors of drug up-titration. CONCLUSIONS Significant evidence-practice gaps in the use and dose of GDMT remain. Considering the associated favorable outcomes, further efforts to improve its implementation seem crucial.
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Affiliation(s)
- Takanori Ohata
- Department of Cardiology, Keio University School of Medicine
| | - Nozomi Niimi
- General Internal Medicine, National Hospital Organization Tokyo Medical Center
| | | | | | | | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College Hospital
| | - Makoto Takei
- Department of Cardiology, Saiseikai Central Hospital
| | - Tomohiko Ono
- Department of Cardiology, National Hospital Organization Saitama National Hospital
| | - Munehisa Sakamoto
- Department of Cardiology, National Hospital Organization Tokyo Medical Center
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University International Medical Center
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
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5
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Onoue K. Optimizing Guideline-Directed Medical Therapy for Heart Failure - Challenges and Strategies. Circ J 2023; 88:31-32. [PMID: 38030299 DOI: 10.1253/circj.cj-23-0828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Affiliation(s)
- Kenji Onoue
- Department of Cardiovascular Medicine, Nara Medical University
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