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Kittleson MM, Breathett K, Ziaeian B, Aguilar D, Blumer V, Bozkurt B, Diekemper RL, Dorsch MP, Heidenreich PA, Jurgens CY, Khazanie P, Koromia GA, Van Spall HGC. 2024 Update to the 2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: A Report of the American Heart Association/American College of Cardiology Joint Committee on Performance Measures. J Am Coll Cardiol 2024; 84:1123-1143. [PMID: 39127953 DOI: 10.1016/j.jacc.2024.05.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/12/2024]
Abstract
This document describes performance measures for heart failure that are appropriate for public reporting or pay-for-performance programs and is meant to serve as a focused update of the "2020 ACC/AHA Clinical Performance and Quality Measures for Adults With Heart Failure: A Report of the American College of Cardiology/American Heart Association Task Force on Performance Measures." The new performance measures are taken from the "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines" and are selected from the strongest recommendations (Class 1 or Class 3). In contrast, quality measures may not have as much evidence base and generally comprise metrics that might be useful for clinicians and health care organizations for quality improvement but are not yet appropriate for public reporting or pay-for-performance programs. New performance measures include optimal blood pressure control in patients with heart failure with preserved ejection fraction, the use of sodium-glucose cotransporter-2 inhibitors for patients with heart failure with reduced ejection fraction, and the use of guideline-directed medical therapy in hospitalized patients. New quality measures include the use of sodium-glucose cotransporter-2 inhibitors in patients with heart failure with mildly reduced and preserved ejection fraction, the optimization of guideline-directed medical therapy prior to intervention for chronic secondary severe mitral regurgitation, continuation of guideline-directed medical therapy for patients with heart failure with improved ejection fraction, identifying both known risks for cardiovascular disease and social determinants of health, patient-centered counseling regarding contraception and pregnancy risks for individuals with cardiomyopathy, and the need for a monoclonal protein screen to exclude light chain amyloidosis when interpreting a bone scintigraphy scan assessing for transthyretin cardiac amyloidosis.
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Minciunescu A, Rosner C, Kepplinger D, Del Castillo T, Overbeck D, Levy WS, O'Connor CM, Haddad TM. Novel Initiative Increasing GDMT Use Among Patients With Heart Failure With Reduced Ejection Fraction. JACC. HEART FAILURE 2024; 12:1487-1493. [PMID: 38934962 DOI: 10.1016/j.jchf.2024.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 02/20/2024] [Accepted: 03/18/2024] [Indexed: 06/28/2024]
Abstract
Guideline-directed medical therapy utilization in patients with heart failure with reduced ejection fraction (HFrEF) remains low despite benefits in morbidity and mortality. The authors describe a unique quality improvement initiative designed to increase angiotensin receptor-neprilysin inhibitor (ARNI) and mineralocorticoid receptor antagonist (MRA) utilization in outpatients with HFrEF in a large cardiology practice, whereby eligible patients were identified in a standardized review process and medication utilization rates were linked to group quality metrics. Eligible HFrEF patients were defined as having a left ventricular ejection fraction (LVEF) ≤40% and NYHA functional class II to IV level of symptoms. Those with an LVEF >40%, no documented LVEF, or with NYHA functional class I symptoms were excluded. ARNI utilization was defined as any dose of sacubitril/valsartan prescribed, and MRA utilization was defined as any dose of either spironolactone or eplerenone prescribed. Group quality metric targets were set at >25% ARNI prescription and >60% MRA prescription in eligible patients. Following project implementation, ARNI utilization rose from 31% to 67% and MRA increased from 28% to 66%. Establishing clear quality metrics and formulating a proactive evaluation process was associated with a significant increase in prescription rates.
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Affiliation(s)
| | - Carolyn Rosner
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA
| | - David Kepplinger
- Department of Statistics, George Mason University, Fairfax, Virginia, USA
| | | | | | - Warren S Levy
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | | | - Tariq M Haddad
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
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Iyngkaran P, Buhler M, de Courten M, Hanna F. Effectiveness of self-management programmes for heart failure with reduced ejection fraction: a systematic review protocol. BMJ Open 2024; 14:e079830. [PMID: 38839380 PMCID: PMC11163658 DOI: 10.1136/bmjopen-2023-079830] [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: 09/13/2023] [Accepted: 05/13/2024] [Indexed: 06/07/2024] Open
Abstract
INTRODUCTION Chronic disease self-management (CDSM) is a vital component of congestive heart failure (CHF) programmes. Recent CHF guidelines have downgraded CDSM programmes citing a lack of gold-standard evidence. This protocol describes the aims and methods of a systematic review to collate and synthesise the published research evidence to determine the effectiveness of CDSM programmes and interventions for patients treated for CHF. METHODS Medline, PubMed, Embase, CENTRAL, CINAHL, Cochrane Central Register of Controlled Trials, PsycINFO, SCOPUS, Web of Science, the Science Citation Index and registers of clinical trials will be searched from 1966 to 2024. In addition, the reference lists of shortlisted articles will be reviewed. Randomised controlled trials, with case management interventions of CDSM and CHF with reported major adverse cardiovascular events (MACEs), will be extracted and analysed. There is no restriction on language. Study protocol template developed from Cochrane Collaboration and Reporting adheres to Preferred Reporting Items for Systematic Reviews and Meta-Analyses Protocol guidelines for systematic review and meta-analyses 2020. Two independent authors will apply inclusions and exclusion criteria to limit article search and assess bias and certainty of evidence rating. Data extraction and study description of included studies will include quality appraisal of studies and quantitative synthesis of data will then be undertaken to ascertain evidence for the study aims. Subgroup analyses will be conducted for different CDSM programmes. The primary outcome will be a significant change in MACE parameters between intervention and control arms. Meta-analysis will be conducted using statistical software, if feasible. ETHICS AND DISSEMINATION Ethics approval is not sought as the study is not collecting primary patient data. The results of this study will be disseminated through peer-reviewed scientific journals and also presented to audiences through meetings and scientific conferences. PROSPERO REGISTRATION NUMBER CRD42023431539.
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Affiliation(s)
- Pupalan Iyngkaran
- NT Medical School, The University of Notre Dame Australia Melbourne Clinical School, Werribee, Victoria, Australia
- Health and Education, Torrens University Australia, Melbourne, Victoria, Australia
| | - Monika Buhler
- Cardiology, Heart West, Melbourne, Victoria, Australia
| | | | - Fahad Hanna
- Health and Education, Torrens University Australia, Melbourne, Victoria, Australia
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Hess PL, Langner P, Heidenreich PA, Essien U, Leonard C, Swat SA, Polsinelli V, Orlando ST, Grunwald GK, Ho PM. National Trends in Hospital Performance in Guideline-Recommended Pharmacologic Treatment for Heart Failure at Discharge. JACC. HEART FAILURE 2024; 12:1059-1070. [PMID: 38573268 DOI: 10.1016/j.jchf.2024.02.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/31/2023] [Revised: 01/16/2024] [Accepted: 02/13/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND The use of recommended heart failure (HF) medications has improved over time, but opportunities for improvement persist among women and at rural hospitals. OBJECTIVES This study aims to characterize national trends in performance in the use of guideline-recommended pharmacologic treatment for HF at U.S. Department of Veterans Affairs (VA) hospitals, at which medication copayments are modest. METHODS Among patients discharged from VA hospitals with HF between January 1, 2013, and December 31, 2019, receipt of all guideline-recommended HF pharmacotherapy among eligible patients was assessed, consisting of evidence-based beta-blockers; angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or angiotensin receptor neprilysin inhibitors; mineralocorticoid receptor antagonists; and oral anticoagulation. RESULTS Of 55,560 patients at 122 hospitals, 32,304 (58.1%) received all guideline-recommended HF medications for which they were eligible. The proportion of patients receiving all recommended medications was higher in 2019 relative to 2013 (OR: 1.54; 95% CI: 1.44-1.65). The median of hospital performance was 59.1% (Q1-Q3: 53.2%-66.2%), improving with substantial variation across sites from 2013 (median 56.4%; Q1-Q3: 50.0%-62.0%) to 2019 (median 65.7%; Q1-Q3: 56.3%-73.5%). Women were less likely to receive recommended therapies than men (adjusted OR [aOR]: 0.84; 95% CI: 0.74-0.96). Compared with non-Hispanic White patients, non-Hispanic Black patients were less likely to receive recommended therapies (aOR: 0.83; 95% CI: 0.79-0.87). Urban hospital location was associated with lower likelihood of medication receipt (aOR: 0.73; 95% CI: 0.59-0.92). CONCLUSIONS Forty-two percent of patients did not receive all recommended HF medications at discharge, particularly women, minority patients, and those receiving care at urban hospitals. Rates of use increased over time, with variation in performance across hospitals.
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Affiliation(s)
- Paul L Hess
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA; University of Colorado Anschutz Medical Campus, Aurora, Colorado.
| | - Paula Langner
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA; University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Paul A Heidenreich
- Palo Alto VA Medical Center, Palo Alto, California, USA; Stanford University School of Medicine, Palo Alto, California, USA
| | - Utibe Essien
- Greater Los Angeles VA Medical Center, Los Angeles, California, USA
| | - Chelsea Leonard
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA; University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Stanley A Swat
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA; University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Vincenzo Polsinelli
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA; University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Steven T Orlando
- University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - Gary K Grunwald
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA; University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - P Michael Ho
- Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA; University of Colorado Anschutz Medical Campus, Aurora, Colorado
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Sandhu AT, Calma J, Skye M, Kalwani N, Zheng J, Schirmer J, Din N, Brown Johnson C, Gupta A, Lan R, Yu B, Spertus JA, Heidenreich PA. Clinical Impact of Routine Assessment of Patient-Reported Health Status in Heart Failure Clinic: The PRO-HF Trial. Circulation 2024; 149:1717-1728. [PMID: 38583147 DOI: 10.1161/circulationaha.124.069624] [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: 03/13/2024] [Accepted: 03/29/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND The impact of routine clinic use of patient-reported outcome (PRO) measures on clinical outcomes in patients with heart failure (HF) has not been well-characterized. We tested if clinic-based use of a disease-specific PRO improves patient-reported quality of life at 1 year. METHODS The PRO-HF trial (Patient-Reported Outcome Measurement in Heart Failure Clinic) was an open-label, parallel, patient-level randomized clinical trial of routine PRO assessment or usual care at an academic HF clinic between August 30, 2021, and June 30, 2022, with 1 year of follow-up. In the PRO assessment arm, participants completed the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) at each HF clinic visit, and results were shared with their treating clinician. The usual care arm completed the KCCQ-12 at randomization and 1 year later, which was not shared with the treating clinician. The primary outcome was the KCCQ-12 overall summary score (OSS) between 12 and 15 months after randomization. Secondary outcomes included domains of the KCCQ-12, hospitalization and emergency department visit rates, HF medication therapy, clinic visit frequency, and testing rates. RESULTS Across 17 clinicians, 1248 participants were enrolled and randomized to PRO assessment (n=624) or usual care (n=624). The median age was 63.9 years (interquartile range [IQR], 51.8-72.8), 38.9% were women, and the median baseline KCCQ-12 OSS was 82.3 (IQR, 58.3-94.8). Final KCCQ-12 (available in 87.9% of the PRO arm and 85.1% in usual care; P=0.16) median OSS were 87.5 (IQR, 68.8-96.9) in the PRO arm and 87.6 (IQR, 69.7-96.9) in the usual care arm with a baseline-adjusted mean difference of 0.2 ([95% CI, -1.7 to 2.0]; P=0.85). The results were consistent across prespecified subgroups. A post hoc analysis demonstrated a significant interaction with greater benefit among participants with a baseline KCCQ-12 OSS of 60 to 80 but not in less or more symptomatic participants. No significant differences were found in 1-year mortality, hospitalizations, emergency department visits, medication therapy, clinic follow-up, or testing rates between arms. CONCLUSIONS Routine PRO assessment in HF clinic visits did not impact patient-reported quality of life or other clinical outcomes. Alternate strategies and settings for embedding PROs into routine clinical care should be tested. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04164004.
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Affiliation(s)
- Alexander T Sandhu
- Division of Cardiovascular Medicine (A.T.S., J.C., M.S., N.K., J.S., P.A.H.), Stanford University, CA
- Stanford Prevention Research Center (A.T.S.), Stanford University, CA
- Palo Alto Veteran's Affairs Healthcare System, CA (A.T.S., M.S., N.K., N.D., P.A.H.)
| | - Jamie Calma
- Division of Cardiovascular Medicine (A.T.S., J.C., M.S., N.K., J.S., P.A.H.), Stanford University, CA
| | - Megan Skye
- Division of Cardiovascular Medicine (A.T.S., J.C., M.S., N.K., J.S., P.A.H.), Stanford University, CA
- Palo Alto Veteran's Affairs Healthcare System, CA (A.T.S., M.S., N.K., N.D., P.A.H.)
| | - Neil Kalwani
- Division of Cardiovascular Medicine (A.T.S., J.C., M.S., N.K., J.S., P.A.H.), Stanford University, CA
- Palo Alto Veteran's Affairs Healthcare System, CA (A.T.S., M.S., N.K., N.D., P.A.H.)
| | - Jimmy Zheng
- Department of Medicine (J.Z., C.B.J., A.G., R.L., B.Y.), Stanford University, CA
| | - Jessica Schirmer
- Division of Cardiovascular Medicine (A.T.S., J.C., M.S., N.K., J.S., P.A.H.), Stanford University, CA
| | - Natasha Din
- Palo Alto Veteran's Affairs Healthcare System, CA (A.T.S., M.S., N.K., N.D., P.A.H.)
| | - Cati Brown Johnson
- Department of Medicine (J.Z., C.B.J., A.G., R.L., B.Y.), Stanford University, CA
| | - Anshal Gupta
- Department of Medicine (J.Z., C.B.J., A.G., R.L., B.Y.), Stanford University, CA
| | - Roy Lan
- Department of Medicine (J.Z., C.B.J., A.G., R.L., B.Y.), Stanford University, CA
| | - Brian Yu
- Department of Medicine (J.Z., C.B.J., A.G., R.L., B.Y.), Stanford University, CA
| | - John A Spertus
- University of Missouri-Kansas City Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, MO (J.A.S.)
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine (A.T.S., J.C., M.S., N.K., J.S., P.A.H.), Stanford University, CA
- Palo Alto Veteran's Affairs Healthcare System, CA (A.T.S., M.S., N.K., N.D., P.A.H.)
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Khan MS, Chan PS, Sherrod CF, Ikemura N, Sauer AJ, Jones PG, Fonarow GC, Butler J, DeVore AD, Lund LH, Spertus JA. Generalizable Approach to Quantifying Guideline-Directed Medical Therapy. Circ Heart Fail 2024; 17:e011164. [PMID: 38742418 PMCID: PMC11108743 DOI: 10.1161/circheartfailure.123.011164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. METHODS The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, β-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. RESULTS Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. CONCLUSIONS KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed.
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Affiliation(s)
- Mirza S. Khan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Paul S. Chan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Charles F. Sherrod
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Nobuhiro Ikemura
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Andrew J. Sauer
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Philip G. Jones
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Gregg C. Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Adam D. DeVore
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - John A. Spertus
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
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Badrish N, Sheifer S, Rosner CM. Systems of care for ambulatory management of decompensated heart failure. Front Cardiovasc Med 2024; 11:1350846. [PMID: 38455722 PMCID: PMC10918851 DOI: 10.3389/fcvm.2024.1350846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2023] [Accepted: 01/25/2024] [Indexed: 03/09/2024] Open
Abstract
Heart failure (HF) represents a worldwide health burden and the annual per patient cost to treat HF in the US is estimated at $24,383, with most of this expense driven by HF related hospitalizations. Decompensated HF is a leading cause for hospital admissions and is associated with an increased risk of subsequent morbidity and mortality. Many hospital admissions for decompensated HF are considered preventable with timely recognition and effective intervention.Systems of care that include interventions to facilitate early recognition, timely and appropriate intervention, intensification of care, and optimization to prevent recurrence can help successfully manage decompensated HF in the ambulatory setting and avoid hospitalization.
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Affiliation(s)
- Narotham Badrish
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
| | - Stuart Sheifer
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
- Department of Cardiology, Virginia Heart, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
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Shahid I, Khan MS, Fonarow GC, Butler J, Greene SJ. Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure. Prog Cardiovasc Dis 2024; 82:61-69. [PMID: 38244825 DOI: 10.1016/j.pcad.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
Despite robust scientific evidence and strong guideline recommendations, there remain significant gaps in initiation and dose titration of guideline-directed medical therapy (GDMT) for heart failure (HF) among eligible patients. Reasons surrounding these gaps are multifactorial, and largely attributed to patient, healthcare professionals, and institutional challenges. Concurrently, HF remains a predominant cause of mortality and hospitalization, emphasizing the critical need for improved delivery of therapy to patients in routine clinical practice. To optimize GDMT, various implementation strategies have emerged in the recent decade such as in-hospital rapid initiation of GDMT, improving patient adherence, addressing clinical inertia, improving affordability, engagement in quality improvement registries, multidisciplinary clinics, and EHR-integrated interventions. This review highlights the current use and barriers to optimal utilization of GDMT, and proposes novel strategies aimed at improving GDMT in HF.
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Affiliation(s)
- Izza Shahid
- Division of Preventive Cardiology, Houston Methodist Academic Institute, Houston, TX, USA
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA; Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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Austin MA, Chuzi S, Cascino TM, Vest AR, Reza N. Patient reported outcomes measures are infrequently used in clinical studies of heart transplant recipients. JHLT OPEN 2023; 2:100019. [PMID: 39193271 PMCID: PMC11349310 DOI: 10.1016/j.jhlto.2023.100019] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 08/29/2024]
Abstract
BACKGROUND Clinical trials in heart transplantation (HT) recipients have largely focused on objective outcomes such as survival; however, there is a paucity of data regarding the use of patient-reported outcome measures (PROMs) in these studies. We aimed to characterize the use of PROMs in registered clinical studies of HT recipients. METHODS All clinical studies of adult HT recipients were queried from ClinicalTrials.gov and stratified by inclusion of PROMs. Studies reporting PROMs were identified via specific search terms using the "outcomes measures" field. Summary statistics compared characteristics of studies with and without PROMs. RESULTS Between November 1999 and August 2022, 227 studies of HT recipients were registered on ClinicalTrials.gov. PROMs were included in 11% (n = 24/227) of studies. Studies reporting PROMs were more likely to be conducted outside of the United States (91.7% vs 54.2%, p < 0.001) and report a greater number of primary/secondary outcomes (PROMs: median 7 [interquartile ranges (IQR): 4, 9] vs no PROMs: median 3 [IQR: 2, 6]; p < 0.001). The majority of studies reporting PROMs (58.3%) were initiated after 2020. Twenty-one distinct PROM tools/domains were reported as outcome measures, with the Short Form Health Survey 36 being most frequently used (n = 10/24). Thirteen of the 21 PROMs included questions assessing mental health, whereas only 3 PROM tools were cardiac-specific. CONCLUSIONS About 1 in 10 registered clinical trials of HT recipients includes PROMs, and mental health is the most commonly assessed PROM domain. Development and validation of PROM tools is needed to fully assess health-related quality of life in HT recipients.
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Affiliation(s)
- Melissa A. Austin
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah Chuzi
- Division of Cardiovascular Medicine, Department of Medicine, Feinberg School of Medicine at Northwestern University, Chicago, Illinois
| | - Thomas M. Cascino
- Division of Cardiovascular Medicine, Department of Medicine, University of Michigan Medical School, Ann Arbor, Michigan
| | - Amanda R. Vest
- Division of Cardiovascular Medicine, Department of Medicine, Tufts Medical Center, Boston, Massachusetts
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Nishi M, Shikuma A, Seki T, Horiguchi G, Matoba S. In-hospital mortality and cardiovascular treatment during hospitalization for heart failure among patients with schizophrenia: a nationwide cohort study. Epidemiol Psychiatr Sci 2023; 32:e62. [PMID: 37849318 PMCID: PMC10594642 DOI: 10.1017/s2045796023000744] [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: 07/03/2023] [Revised: 09/06/2023] [Accepted: 09/17/2023] [Indexed: 10/19/2023] Open
Abstract
AIMS Schizophrenia is associated with cardiovascular disease (CVD) risk, and patients with schizophrenia are more likely to receive suboptimal care for CVD. However, there is limited knowledge regarding in-hospital prognosis and quality of care for patients with schizophrenia hospitalized for heart failure (HF). This study sought to elucidate the association between schizophrenia and in-hospital mortality, as well as cardiovascular treatment in patients hospitalized with HF. METHODS Using the nationwide cardiovascular registry data in Japan, a total of 704,193 patients hospitalized with HF from 2012 to 2019 were included and stratified by age: young age, > 18 to 45 years (n = 20,289); middle age, >45 to 65 years (n = 114,947); and old age, >65 to 85 years (n = 568,957). All and 30-day in-hospital mortality as well as prescription of cardiovascular medications were assessed. After multiple imputation for missing values, mixed-effect multivariable logistic regression analysis was performed using patient and hospital characteristics with hospital identifier as a variable with random effects. RESULTS Patients with schizophrenia were more likely to experience prolonged hospital stays, and incur higher hospitalization costs. In-hospital mortality for non-elderly patients with schizophrenia was significantly worse than for those without schizophrenia: the mortality rate was 7.6% vs 3.5% and the adjusted odds ratio (OR) was 1.96 (95% confidence interval (CI): 1.24-3.10, P = 0.0037) in young adult patients; 6.2% vs 4.0% and 1.49 (95% CI: 1.17-1.88, P < 0.001) in middle-aged patients. Thirty-day in-hospital mortality was significantly worse in middle-aged patients: the mortality rate was 4.7% vs 3.0% and an adjusted OR was 1.40 (95% CI: 1.07-1.83, P = 0.012). In-hospital mortality in elderly patients did not differ between those with and without schizophrenia. Prescriptions of beta-blockers and angiotensin-converting enzyme inhibitors or angiotensin II receptor blockers were significantly lower in patients with schizophrenia across all age groups. CONCLUSION Schizophrenia was identified as a risk factor for in-hospital mortality and reduced prescription of cardioprotective medications in non-elderly patients hospitalized with HF. These findings highlight the necessity for differentiated care and management of HF in patients with severe mental illnesses.
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Affiliation(s)
- Masahiro Nishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akira Shikuma
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Go Horiguchi
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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11
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Yuan C, He L, Du X, Jiang C, Xia S, Zhao X, Li S, Sang C, Long D, Dong J, Ma C. Impact of age on characteristics, performance measures and outcomes of inpatients for heart failure in Beijing, China. ESC Heart Fail 2023; 10:2990-2997. [PMID: 37528635 PMCID: PMC10567638 DOI: 10.1002/ehf2.14487] [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: 12/12/2022] [Revised: 06/21/2023] [Accepted: 07/16/2023] [Indexed: 08/03/2023] Open
Abstract
AIMS This study aims to provide representative information on heart failure (HF) patients in China, especially older adults aged ≥75 years. We aim to clarify the age-related discrepancies in performance measures and the modifying effect of age on the impact of HF patients' characteristics on clinical outcomes. METHODS AND RESULTS All HF patients admitted into five tertiary and four secondary hospitals of the Capital Medical University were divided into two groups according to age: 1419 (53.3%) were <75 years, and 1244 (46.7%) were ≥75 years. Older HF patients were more likely to be women, with higher left ventricular ejection fraction, with co-morbidities including chronic obstructive pulmonary disease/asthma, anaemia, chronic kidney disease, stroke/transient ischemic attack (TIA), atrial fibrillation/atrial flutter, hypertension, and coronary artery disease, while obesity, diabetes mellitus, hypercholesterolaemia and valvular heart disease were more prevalent among younger HF patients. Left ventricular ejection fraction assessment was performed in a similar proportion of patients in the younger and older groups (81.7% vs. 80.5%, P = 0.426), while B-type natriuretic peptide/N terminal pro brain natriuretic peptide was tested in a lower proportion in the younger group (84.8% vs. 89%, P = 0.001). At discharge, HF with reduced ejection fraction patients were less likely to receive beta-blockers, angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, or combined beta-blockers and angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers therapy in the older group (49.74% vs. 63.2%, P = 0.002; 52.9% vs. 64.7%, P = 0.006; and 28.57% vs. 45.5%, P < 0.001, respectively) but were equally likely to receive mineralocorticoid receptor antagonists in the two age groups (80.8% vs. 84.1%, P = 0.322). Older patients with HF had higher risk of in-hospital and 1 year mortality (2.7% vs. 1.3%, P = 0.011; 21.7% vs. 12.5%; P < 0.001, respectively). Higher body mass index was associated with better outcomes in both age groups. New York Heart Association functional class IV and estimated glomerular filtration rate < 60 mL/min/1.73 m2 were independent predictors of 1 year mortality. The associations between patients' characteristics and risk of mortality were not modified by age. CONCLUSIONS HF patients aged ≥75 years had distinct clinical profiles, received worse in-hospital therapies and experienced higher in-hospital and 1 year mortality.
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Affiliation(s)
- Cong Yuan
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
- The Affiliated Changsha Hospital of Xiangya School of MedicineCentral South UniversityChangshaChina
| | - Liu He
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
| | - Xin Du
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
- Heart Health Research CenterBeijingChina
- The George Institute for Global HealthUniversity of New South WalesSydneyAustralia
| | - Chao Jiang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
| | - Shi‐Jun Xia
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
| | - Xin Zhao
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
| | - Song‐Nan Li
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
| | - Cai‐Hua Sang
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
| | - De‐Yong Long
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
| | - Jian‐Zeng Dong
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
| | - Chang‐Sheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, National Clinical Research Center for Cardiovascular DiseasesBeijing Advanced Innovation Center for Big Data‐Based Precision Medicine for Cardiovascular DiseasesBeijingChina
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12
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Sherrod CF, Ikemura N, Spertus JA. Knowledge is power, can it be leveraged to improve heart failure care? Eur J Heart Fail 2023; 25:1840-1841. [PMID: 37671602 PMCID: PMC10901464 DOI: 10.1002/ejhf.3027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 09/02/2023] [Indexed: 09/07/2023] Open
Affiliation(s)
- Charles F Sherrod
- University of Missouri-Kansas City Healthcare Institute for Innovations in Quality, Kansas City, MO, USA
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
| | - Nobuhiro Ikemura
- University of Missouri-Kansas City Healthcare Institute for Innovations in Quality, Kansas City, MO, USA
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - John A Spertus
- University of Missouri-Kansas City Healthcare Institute for Innovations in Quality, Kansas City, MO, USA
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
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13
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Nargesi AA, Adejumo P, Dhingra L, Rosand B, Hengartner A, Coppi A, Benigeri S, Sen S, Ahmad T, Nadkarni GN, Lin Z, Ahmad FS, Krumholz HM, Khera R. Automated Identification of Heart Failure with Reduced Ejection Fraction using Deep Learning-based Natural Language Processing. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2023:2023.09.10.23295315. [PMID: 37745445 PMCID: PMC10516088 DOI: 10.1101/2023.09.10.23295315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/26/2023]
Abstract
Background The lack of automated tools for measuring care quality has limited the implementation of a national program to assess and improve guideline-directed care in heart failure with reduced ejection fraction (HFrEF). A key challenge for constructing such a tool has been an accurate, accessible approach for identifying patients with HFrEF at hospital discharge, an opportunity to evaluate and improve the quality of care. Methods We developed a novel deep learning-based language model for identifying patients with HFrEF from discharge summaries using a semi-supervised learning framework. For this purpose, hospitalizations with heart failure at Yale New Haven Hospital (YNHH) between 2015 to 2019 were labeled as HFrEF if the left ventricular ejection fraction was under 40% on antecedent echocardiography. The model was internally validated with model-based net reclassification improvement (NRI) assessed against chart-based diagnosis codes. We externally validated the model on discharge summaries from hospitalizations with heart failure at Northwestern Medicine, community hospitals of Yale New Haven Health in Connecticut and Rhode Island, and the publicly accessible MIMIC-III database, confirmed with chart abstraction. Results A total of 13,251 notes from 5,392 unique individuals (mean age 73 ± 14 years, 48% female), including 2,487 patients with HFrEF (46.1%), were used for model development (train/held-out test: 70/30%). The deep learning model achieved an area under receiving operating characteristic (AUROC) of 0.97 and an area under precision-recall curve (AUPRC) of 0.97 in detecting HFrEF on the held-out set. In external validation, the model had high performance in identifying HFrEF from discharge summaries with AUROC 0.94 and AUPRC 0.91 on 19,242 notes from Northwestern Medicine, AUROC 0.95 and AUPRC 0.96 on 139 manually abstracted notes from Yale community hospitals, and AUROC 0.91 and AUPRC 0.92 on 146 manually reviewed notes at MIMIC-III. Model-based prediction of HFrEF corresponded to an overall NRI of 60.2 ± 1.9% compared with the chart diagnosis codes (p-value < 0.001) and an increase in AUROC from 0.61 [95% CI: 060-0.63] to 0.91 [95% CI 0.90-0.92]. Conclusions We developed and externally validated a deep learning language model that automatically identifies HFrEF from clinical notes with high precision and accuracy, representing a key element in automating quality assessment and improvement for individuals with HFrEF.
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Affiliation(s)
- Arash A. Nargesi
- Heart and Vascular Center, Brigham and Women’s Hospital, Harvard School of Medicine, Boston, MA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Philip Adejumo
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Lovedeep Dhingra
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Benjamin Rosand
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Astrid Hengartner
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Andreas Coppi
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT
| | - Simon Benigeri
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Sounok Sen
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
| | - Girish N Nadkarni
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zhenqiu Lin
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT
| | - Faraz S. Ahmad
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, CT
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT
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14
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Tower-Rader A, Szpakowski N, Popovic ZB, Bittel B, Fava A, Ospina S, Xu B, Thamilarasan M, Mentias A, Smedira NG, Desai MY. Patient reported outcomes in obstructive hypertrophic cardiomyopathy undergoing myectomy: Results from SPIRIT-HCM study. Prog Cardiovasc Dis 2023; 80:66-73. [PMID: 37302651 DOI: 10.1016/j.pcad.2023.06.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 06/13/2023]
Abstract
BACKGROUND Patient reported outcomes (PRO) can assess quality of life (QOL) in obstructive hypertrophic cardiomyopathy (oHCM). In symptomatic oHCM patients, we sought to study the correlation between various PROs, their association with physician reported New York Heart Association (NYHA) class and changes after surgical myectomy. METHODS We prospectively studied 173 symptomatic oHCM patients undergoing myectomy (age 51 years, 62% men) between 3/17-6/20. PROs, including a) Kansas City Cardiomyopathy Questionnaire (KCCQ) summary score b) Patient-Reported Outcomes Measurement Information System [PROMIS] c) Duke Activity Status Index [DASI] & d) European QOL score [EQ-5D], along with NYHA class, 6-min walk test (6MWT) distance and peak left ventricular outflow tract gradient (PLVOTG) were recorded at baseline and 12 month follow-up. RESULTS The median baseline PRO scores (KCCQ summary, PROMIS physical, PROMIS mental, DASI, EQ-5D) were 50, 67, 63, 25, 50, 37, 44, 25 and 0.61, respectively; 6MWT distance was 366 m. There were significant correlations between various PROs (r-values between 0.66 and 0.92, p < 0.001), but only modest correlations with 6MWT and provokable LVOTG (r-values between 0.2 and 0.5, p < 0.01). At baseline, 35-49% patients in NYHA class II had PROs worse than median, while 30-39% patients in NYHA Class III/IV had PROs better than median. At follow-up, a 20 point improvement in KCCQ summary score was observed in 80%, 4 point improvement in DASI score in 83%, 4 point improvement in PROMIS physical score 86% and a 0.04 point improvement in EQ-5D in 85%); along with improvements in NYHA class (67% in Class I) and peak LVOTG (median 13 mmHg) and 6MWT (median distance 438 m). CONCLUSIONS In a prospective study of symptomatic oHCM patients, surgical myectomy significantly improved PROs, LVOT obstruction, and functional capacity, with a high correlation between various PROs. However, there was high rate of discordance between PROs and NYHA class. STUDY REGISTRATION ClinicalTrials.gov: NCT03092843.
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Affiliation(s)
- Albree Tower-Rader
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America; Department of Cardiovascular Medicine, Massachusetts General Hospital, Boston, MA, United States of America
| | - Natalie Szpakowski
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Zoran B Popovic
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Barabara Bittel
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Agostina Fava
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Susan Ospina
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Bo Xu
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Maran Thamilarasan
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Amgad Mentias
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Nicholas G Smedira
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America
| | - Milind Y Desai
- Hypertrophic Cardiomyopathy Center, Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, United States of America.
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15
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Patolia H, Khan MS, Fonarow GC, Butler J, Greene SJ. Implementing Guideline-Directed Medical Therapy for Heart Failure: JACC Focus Seminar 1/3. J Am Coll Cardiol 2023; 82:529-543. [PMID: 37532424 DOI: 10.1016/j.jacc.2023.03.430] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 08/04/2023]
Abstract
Despite the availability of lifesaving guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), there remain major gaps in utilization of these therapies among eligible patients. Simultaneous with these gaps in quality of care, HFrEF continues as a leading cause of death and hospitalization with associated clinical risk far exceeding most other cardiovascular and noncardiovascular conditions. In the context of this urgent need to improve provision of appropriate therapy, multiple lines of evidence support various implementation strategies. Such strategies include in-hospital initiation of GDMT, simultaneous or rapid sequence initiation of GDMT, participation in quality improvement registries to assess site performance and provide feedback, multidisciplinary titration clinics, virtual consult teams, reduction of cost-sharing, remote algorithm-based medication optimization, electronic health record-based interventions, and direct-to-patient educational initiatives. This review describes and contextualizes the evidence surrounding each of these potential avenues for improving use of foundational GDMTs for patients with HFrEF.
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Affiliation(s)
- Harsh Patolia
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
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16
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Swat SA, Xu H, Allen LA, Greene SJ, DeVore AD, Matsouaka RA, Goyal P, Peterson PN, Hernandez AF, Krumholz HM, Yancy CW, Fonarow GC, Hess PL. Opportunities and Achievement of Medication Initiation Among Inpatients With Heart Failure With Reduced Ejection Fraction. JACC. HEART FAILURE 2023; 11:918-929. [PMID: 37318420 DOI: 10.1016/j.jchf.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Initiation of evidence-based medications for patients with heart failure with reduced ejection fraction (HFrEF) during hospitalization in contemporary practice is unknown. OBJECTIVES This study characterized opportunities for and achievement of heart failure (HF) medication initiation. METHODS Using the GWTG-HF (Get With The Guidelines-Heart Failure) Registry 2017-2020, which collected data on contraindications and prescribing for 7 evidence-based HF-related medications, we assessed the number of medications for which each patient with HFrEF was eligible, use before admission, and prescribed at discharge. Multivariable logistic regression identified factors associated with medication initiation. RESULTS Among 50,170 patients from 160 sites, patients were eligible for mean number of 3.9 ± 1.1 evidence-based medications with 2.1 ± 1.3 used before admission and 3.0 ± 1.0 prescribed on discharge. The number of patients receiving all indicated medications increased from admission (14.9%) to discharge (32.8%), a mean net gain of 0.9 ± 1.3 medications over a mean of 5.6 ± 5.3 days. In multivariable analysis, factors associated with lower odds of HF medication initiation included older age, female sex, medical pre-existing conditions (stroke, peripheral arterial disease, pulmonary disease, and renal insufficiency), and rural location. Odds of medication initiation increased during the study period (adjusted OR: 1.08; 95% CI: 1.06-1.10). CONCLUSIONS Nearly 1 in 6 patients received all indicated HF-related medications on admission, increasing to 1 in 3 on discharge with an average of 1 new medication initiation. Opportunities to initiate evidence-based medications persist, particularly among women, those with comorbidities, and those receiving care at rural hospitals.
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Affiliation(s)
- Stanley A Swat
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Parag Goyal
- Weill Cornell Medicine Division of Cardiology, New York, New York, USA
| | - Pamela N Peterson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Gregg C Fonarow
- Ronald Reagan-University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Paul L Hess
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.
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17
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Sokos G, Kido K, Panjrath G, Benton E, Page R, Patel J, Smith PJ, Korous S, Guglin M. Multidisciplinary Care in Heart Failure Services. J Card Fail 2023; 29:943-958. [PMID: 36921886 DOI: 10.1016/j.cardfail.2023.02.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Revised: 02/01/2023] [Accepted: 02/05/2023] [Indexed: 03/18/2023]
Abstract
The American College of Cardiology/American Heart Association/Heart Failure Society of American 2022 guidelines for heart failure (HF) recommend a multidisciplinary team approach for patients with HF. The multidisciplinary HF team-based approach decreases the hospitalization rate for HF and health care costs and improves adherence to self-care and the use of guideline-directed medical therapy. This article proposes the optimal multidisciplinary team structure and each team member's delineated role to achieve institutional goals and metrics for HF care. The proposed HF-specific multidisciplinary team comprises cardiologists, surgeons, advanced practice providers, clinical pharmacists, specialty nurses, dieticians, physical therapists, psychologists, social workers, immunologists, and palliative care clinicians. A standardized multidisciplinary HF team-based approach should be incorporated to optimize the structure, minimize the redundancy of clinical responsibilities among team members, and improve clinical outcomes and patient satisfaction in their HF care.
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Affiliation(s)
- George Sokos
- Department of Cardiology, West Virginia University School of Medicine, Morgantown, West Virginia
| | - Kazuhiko Kido
- Department of Clinical Pharmacy, West Virginia University School of Pharmacy, Morgantown, West Virginia.
| | - Gurusher Panjrath
- School of Medicine and Health Sciences, George Washington University, North Englewood, Maryland
| | - Emily Benton
- Department of Medicine, University of Colorado, Boulder, Colorado
| | - Robert Page
- Department of Clinical Pharmacy, at the University of Colorado Denver Skaggs School of Pharmacy, Denver, Colorado
| | - Jignesh Patel
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Patrick J Smith
- Psychiatry, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Shelly Korous
- Advanced Heart Failure Program, Indiana University Health, Indianapolis, Indiana
| | - Maya Guglin
- Department of Medicine, Indiana University Health, Indianapolis, Indiana
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18
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Nishi M, Seki T, Shikuma A, Kawamata H, Horiguchi G, Matoba S. Association between patient volume to cardiologist, process of care, and clinical outcomes in heart failure. ESC Heart Fail 2023. [PMID: 37075756 PMCID: PMC10375098 DOI: 10.1002/ehf2.14385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2022] [Revised: 03/07/2023] [Accepted: 04/04/2023] [Indexed: 04/21/2023] Open
Abstract
AIMS The impact of hospital volume on clinical performance has been investigated by many researchers to date and thought that it is associated with quality of care and outcome for patients with heart failure (HF). This study sought to determine whether annual admissions of HF per cardiologist are associated with process of care, mortality, and readmission. METHODS AND RESULTS Among the nationwide registry 'Japanese registry of all cardiac and vascular diseases - diagnostics procedure combination' data collected from 2012 to 2019, a total of 1 127 113 adult patients with HF and 1046 hospitals were included in the study. Primary outcome was in-hospital mortality, and secondary outcome was 30 day in-hospital mortality and readmission at 30 days and 6 months. Hospital and patient characteristics and process of care measures were also assessed. Mixed-effect logistic regression and Cox proportional-hazards model was used for multivariable analysis, and adjusted odds ratio and hazard ratio were evaluated. Process of care measures had inverse trends for annual admissions of HF per cardiologist (P < 0.01 for all measures: prescription rate of beta-blocker, angiotensin converting enzyme inhibitor or angiotensin II receptor blocker, mineralocorticoid receptor antagonist, and anticoagulant for atrial fibrillation). Adjusted odds ratio for in-hospital mortality was 1.04 (95% confidence interval (CI): 1.04-1.08, P = 0.04) and 30 day in-hospital mortality was 1.05 (95% CI: 1.01-1.09, P = 0.01) for interval of 50 annual admissions of HF per cardiologist. Adjusted hazard ratio for 30 day readmission was 1.05 (95% CI: 1.02-1.08, P < 0.01) and 6 month readmission was 1.07 (95% CI: 1.03-1.11, P < 0.01). Plots of the adjusted odds indicated 300 as the threshold of annual admissions of HF per cardiologist for substantial increase of in-hospital mortality risk. CONCLUSIONS Our findings demonstrated that annual admissions of HF per cardiologist are associated with worse process of care, mortality, and readmission with the threshold for mortality risk increased, emphasizing the optimal proportion of patients admitted with HF to cardiologist for better clinical performance.
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Affiliation(s)
- Masahiro Nishi
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Tomotsugu Seki
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Akira Shikuma
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Hirofumi Kawamata
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Go Horiguchi
- Department of Biostatistics, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Satoaki Matoba
- Department of Cardiovascular Medicine, Graduate School of Medical Science, Kyoto Prefectural University of Medicine, Kyoto, Japan
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19
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Mukhopadhyay A, Reynolds HR, Xia Y, Phillips LM, Aminian R, Diah RA, Nagler AR, Szerencsy A, Saxena A, Horwitz LI, Katz SD, Blecker S. Design and pilot implementation for the BETTER CARE-HF trial: A pragmatic cluster-randomized controlled trial comparing two targeted approaches to ambulatory clinical decision support for cardiologists. Am Heart J 2023; 258:38-48. [PMID: 36640860 PMCID: PMC10023424 DOI: 10.1016/j.ahj.2022.12.016] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2022] [Revised: 12/15/2022] [Accepted: 12/30/2022] [Indexed: 05/11/2023]
Abstract
BACKGROUND Beart failure with reduced ejection fraction (HFrEF) is a leading cause of morbidity and mortality. However, shortfalls in prescribing of proven therapies, particularly mineralocorticoid receptor antagonist (MRA) therapy, account for several thousand preventable deaths per year nationwide. Electronic clinical decision support (CDS) is a potential low-cost and scalable solution to improve prescribing of therapies. However, the optimal timing and format of CDS tools is unknown. METHODS AND RESULTS We developed two targeted CDS tools to inform cardiologists of gaps in MRA therapy for patients with HFrEF and without contraindication to MRA therapy: (1) an alert that notifies cardiologists at the time of patient visit, and (2) an automated electronic message that allows for review between visits. We designed these tools using an established CDS framework and findings from semistructured interviews with cardiologists. We then pilot tested both CDS tools (n = 596 patients) and further enhanced them based on additional semistructured interviews (n = 11 cardiologists). The message was modified to reduce the number of patients listed, include future visits, and list date of next visit. The alert was modified to improve noticeability, reduce extraneous information on guidelines, and include key information on contraindications. CONCLUSIONS The BETTER CARE-HF (Building Electronic Tools to Enhance and Reinforce CArdiovascular REcommendations for Heart Failure) trial aims to compare the effectiveness of the alert vs. the automated message vs. usual care on the primary outcome of MRA prescribing. To our knowledge, no study has directly compared the efficacy of these two different types of electronic CDS interventions. If effective, our findings can be rapidly disseminated to improve morbidity and mortality for patients with HFrEF, and can also inform the development of future CDS interventions for other disease states. (Trial registration: Clinicaltrials.gov NCT05275920).
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Affiliation(s)
- Amrita Mukhopadhyay
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY.
| | - Harmony R Reynolds
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Yuhe Xia
- Division of Biostatistics, Department of Population Health, New York, NY
| | - Lawrence M Phillips
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Rod Aminian
- Medical Center Information Technology, New York University Langone Health, New York, NY
| | - Ruth-Ann Diah
- Medical Center Information Technology, New York University Langone Health, New York, NY
| | - Arielle R Nagler
- Ronald O. Perelman Department of Dermatology, New York University School Grossman of Medicine, New York, NY
| | - Adam Szerencsy
- Medical Center Information Technology, New York University Langone Health, New York, NY; Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Archana Saxena
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY; Medical Center Information Technology, New York University Langone Health, New York, NY
| | - Leora I Horwitz
- Department of Medicine, New York University Grossman School of Medicine, New York, NY; Department of Population Health, New York University Grossman School of Medicine, New York, NY
| | - Stuart D Katz
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY
| | - Saul Blecker
- Department of Medicine, New York University Grossman School of Medicine, New York, NY; Department of Population Health, New York University Grossman School of Medicine, New York, NY.
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20
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Dai L, Dorje T, Gootjes J, Shah A, Dembo L, Rankin J, Hillis G, Robinson S, Atherton JJ, Jacques A, Reid CM, Maiorana A. Primary care Adherence To Heart Failure guidelines IN Diagnosis, Evaluation and Routine management (PATHFINDER): a randomised controlled trial protocol. BMJ Open 2023; 13:e063656. [PMID: 36972959 PMCID: PMC10069547 DOI: 10.1136/bmjopen-2022-063656] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 02/06/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION General practitioners (GPs) routinely provide care for patients with heart failure (HF); however, adherence to management guidelines, including titrating medication to optimal dose, can be challenging in this setting. This study will evaluate the effectiveness of a multifaceted intervention to support adherence to HF management guidelines in primary care. METHODS AND ANALYSIS We will undertake a multicentre, parallel-group, randomised controlled trial of 200 participants with HF with reduced ejection fraction. Participants will be recruited during a hospital admission due to HF. Following hospital discharge, the intervention group will have follow-up with their GP scheduled at 1 week, 4 weeks and 3 months with the provision of a medication titration plan approved by a specialist HF cardiologist. The control group will receive usual care. The primary endpoint, assessed at 6 months, will be the difference between groups in the proportion of participants being prescribed five guideline-recommended treatments; (1) ACE inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor at least 50% of target dose, (2) beta-blocker at least 50% of target dose, (3) mineralocorticoid receptor antagonist at any dose, (4) anticoagulation for patients diagnosed with atrial fibrillation, (5) referral to cardiac rehabilitation. Secondary outcomes will include functional capacity (6-minute walk test); quality of life (Kansas City Cardiomyopathy Questionnaire); depressive symptoms (Patient Health Questionnaire-2); self-care behaviour (Self-Care of Heart Failure Index). Resource utilisation will also be assessed. ETHICS AND DISSEMINATION Ethical approval was granted by the South Metropolitan Health Service Ethics Committee (RGS3531), with reciprocal approval at Curtin University (HRE2020-0322). Results will be disseminated via peer-reviewed publications and conferences. TRIAL REGISTRATION NUMBER ACTRN12620001069943.
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Affiliation(s)
- Liying Dai
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Tashi Dorje
- Department of Cardiology, Mount Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Jan Gootjes
- WA Cardiology, Perth, Western Australia, Australia
| | - Amit Shah
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Lawrence Dembo
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Jamie Rankin
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Graham Hillis
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Suzanne Robinson
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- Deakin Health Economics, Deakin University, Melbourne, Western Australia, Australia
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Angela Jacques
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Institute for Health Research, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Christopher M Reid
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maiorana
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Department of Allied Health, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
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21
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Chui PW, Lan Z, Freeman JV, Enriquez AD, Khera R, Akar JG, Masoudi FA, Ong EL, Curtis JP. Variation in hospital use of cardiac resynchronization therapy-defibrillator among eligible patients and association with clinical outcomes. Heart Rhythm 2023:S1547-5271(23)00293-X. [PMID: 36963741 DOI: 10.1016/j.hrthm.2023.03.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 02/23/2023] [Accepted: 03/14/2023] [Indexed: 03/26/2023]
Abstract
BACKGROUND Despite strong guideline recommendations for cardiac resynchronization therapy-defibrillator (CRT-D) In select patients, this therapy is underutilized with substantial variation among hospitals, and the association of this variation with outcomes is unknown. OBJECTIVE To assess if facility variation in CRT-D utilization is associated with differences in hospital-level outcomes METHODS: We linked Medicare claims data with the NCDR ICD Registry from 2010 to 2015. We assessed the intraclass correlation coefficient to quantify the degree of variation in patient-level CRT usage that can be explained by interfacility variation on a hospital level. To quantify the degree of hospital variation in patient-level outcomes (all-cause mortality, readmissions, and cardiac readmissions) that can be attributed to variations in CRT-D usage, we utilized multi-level modeling. RESULTS The study included 30,134 patients across 1,377 hospitals. The median rate of CRT-D implantation among those meeting guideline indications was 89%, but there was a wide variation across hospitals. After adjustment, most of the variation (74%) in hospital rates of CRT-D utilization was attributable to the hospital in which the patient was treated. Differences in hospital CRT-D utilization was associated with 8.76%, 5.26%, and 4.71% of differences in hospital mortality, readmissions, and cardiac readmission rates, respectively (p<0.001 for all outcomes). CONCLUSIONS There is wide variation in the use of CRT-D across hospitals that was not explained by case mix. Hospital-level variation in CRT-D utilization was associated with clinically significant differences in outcomes. A measure of CRT-D utilization in eligible patients may serve as a useful metric for quality improvement efforts.
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Affiliation(s)
- Philip W Chui
- Kaiser Permanente Los Angeles Medical Center; Department of Cardiology, Los Angeles, CA 90027; Yale School of Medicine; Department of Cardiology, New Haven, CT 06510.
| | - Zhou Lan
- Brigham and Women's Hospital; Department of Radiology, Boston 02115
| | - James V Freeman
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Alan D Enriquez
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Rohan Khera
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Joseph G Akar
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Fred A Masoudi
- University of Colorado School of Medicine; Aurora CO, 80045
| | - Emily L Ong
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
| | - Jeptha P Curtis
- Yale School of Medicine; Department of Cardiology, New Haven, CT 06510
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Shahid I, Fonarow GC, Greene SJ. Time to Quadruple Guideline-Directed Medical Therapy as a Key Performance Measure for Heart Failure. J Card Fail 2023; 29:730-733. [PMID: 36925046 DOI: 10.1016/j.cardfail.2023.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 03/17/2023]
Affiliation(s)
- Izza Shahid
- Division of Preventive Cardiology, Department of Cardiology, Houston Methodist Academic Institute, Houston, TX, USA
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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Ghazi L, O'Connor K, Yamamoto Y, Fuery M, Sen S, Samsky M, Riello RJ, Huang J, Olufade T, McDermott J, Inzucchi SE, Velazquez EJ, Wilson FP, Desai NR, Ahmad T. Pragmatic trial of messaging to providers about treatment of acute heart failure: The PROMPT-AHF trial. Am Heart J 2023; 257:111-119. [PMID: 36493842 DOI: 10.1016/j.ahj.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 05/11/2023]
Abstract
Acute Heart failure (AHF) is among the most frequent causes of hospitalization in the United States, contributing to substantial health care costs, morbidity, and mortality. Inpatient initiation of guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF) to reduce the risk of cardiovascular death or HF hospitalization. However, underutilization of GDMT prior to discharge is pervasive, representing a valuable missed opportunity to optimize evidence-based care. The PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failure tests the effectiveness of an electronic health record embedded clinical decision support system that informs providers during hospital management about indicated but not yet prescribed GDMT for eligible AHF patients with HFrEF. PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failureis an open-label, multicenter, pragmatic randomized controlled trial of 1,012 patients hospitalized with HFrEF. Eligible patients randomized to the intervention group are exposed to a tailored best practice advisory embedded within the electronic health record that alerts providers to prescribe omitted GDMT. The primary outcome is an increase in the proportion of additional GDMT medication classes prescribed at the time of discharge compared to those in the usual care arm.
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Affiliation(s)
- Lama Ghazi
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Kyle O'Connor
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Michael Fuery
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Marc Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ralph J Riello
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Silvio E Inzucchi
- Section of Endocrine & Metabolism, Yale School of Medicine, New Haven, CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Francis Perry Wilson
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Nihar R Desai
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tariq Ahmad
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.
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24
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Voluntary Reporting of Guideline-Directed Medical Therapy Use Rates in the Public Domain: A Challenge to the Heart Failure Community. J Card Fail 2023; 29:858-860. [PMID: 36813108 DOI: 10.1016/j.cardfail.2023.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/10/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
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Giorgi MA, Boissonnet CP, Luque PS, Piastrella J, Porley C, Ditata F, Volman S. Cost-effectiveness in unstable economies: the case of sacubitril/valsartan in heart failure with reduced ejection fraction in Argentina. HEALTH ECONOMICS REVIEW 2023; 13:13. [PMID: 36808581 PMCID: PMC9938575 DOI: 10.1186/s13561-023-00427-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Accepted: 02/13/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Sacubitril/valsartan (an Angiotensin receptor-neprilysin inhibitor-ARNI) is one of the cornerstones in the management of patients with heart failure with reduced ejection fraction (HFrEF) having demonstrated significant reductions in both mortality and hospitalisations as compared with enalapril. It proved to be a cost-effective treatment in many countries with stable economies. In Argentina, a country with chronic financial instability and a fragmented health care system, the estimation of its cost-effectiveness requires to consider local financial data. OBJECTIVES To estimate the cost-effectiveness of sacubitril/valsartan in HFrEF in Argentina. METHODS We populated an Excel-based cost-effectiveness model, previously validated, using inputs from the pivotal phase-3 PARADIGM-HF trial and from local sources. As the main problem to consider was the financial instability, we adopted a differential approach to cost discounting based on the opportunity cost of capital. Thus, a discount rate for costs were set at 31.6%, using the BADLAR rate published by the Central Bank of Argentina. Discount for effects were set at 5% as is the current practice. Costs were expressed in Argentinian pesos (ARS). We used the perspective for both the social security and private payers at a 30-year horizon. The primary analysis was the incremental cost-effectiveness ratio (ICER) versus enalapril, the previous standard of care. Alternative scenarios performed included a 5% cost discount rate and 3 a 5-year horizon (as is usually used). RESULTS In Argentina the cost-per quality adjusted life-year (QALY) gained for sacubitril/valsartan versus enalapril was 391,158 ARS and 376,665 ARS for a social security and a private payer, respectively, at a 30- year horizon. These ICERs were under the cost- effectiveness threshold of 520,405.79 ARS (1 Gross domestic product (GDP) per capita) suggested by Argentinian health technology assessment bodies. Probabilistic sensitivity analysis showed an acceptability of sacubitril/valsartan as a cost-effective alternative of 86.40% and 88.25% for social security and private payers, respectively. CONCLUSION Sacubitril/valsartan is a cost-effective treatment in HFrEF using local inputs that considered the financial instability. For both payers considered the cost per QALY gained are under the cost-effectiveness threshold considered.
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Affiliation(s)
- Mariano A Giorgi
- Health Economics and Technology Assessment Unit. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno" (CEMIC), Instituto Universitario CEMIC (IUC), Buenos Aires, Argentina
- Cardiology Section. Department of Internal Medicine. Centro de Educación Médica e Investigaciones Clínicas, Norberto Quirno" (CEMIC), Buenos Aires, Argentina
- Associate Professor of Pharmacology, Instituto Universitario CEMIC (IUC), Buenos Aires, Argentina
| | - Carlos P Boissonnet
- Health Economics and Technology Assessment Unit. Centro de Educación Médica e Investigaciones Clínicas "Norberto Quirno" (CEMIC), Instituto Universitario CEMIC (IUC), Buenos Aires, Argentina
- Cardiology Section. Department of Internal Medicine. Centro de Educación Médica e Investigaciones Clínicas, Norberto Quirno" (CEMIC), Buenos Aires, Argentina
| | | | - Jimena Piastrella
- Piastrella Worked at Novartis at the Time This Research Was Conducted, Basel, Switzerland
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Witting C, Zheng J, Tisdale RL, Shannon E, Kohsaka S, Lewis EF, Heidenreich P, Sandhu A. Treatment Differences in Medical Therapy for Heart Failure With Reduced Ejection Fraction Between Sociodemographic Groups. JACC. HEART FAILURE 2023; 11:161-172. [PMID: 36647925 PMCID: PMC10069379 DOI: 10.1016/j.jchf.2022.08.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Revised: 08/15/2022] [Accepted: 08/16/2022] [Indexed: 11/10/2022]
Abstract
BACKGROUND There are sociodemographic disparities in outcomes of heart failure with reduced ejection fraction (HFrEF), but disparities in guideline-directed medical therapy (GDMT) remain poorly characterized. OBJECTIVES This study aimed to analyze GDMT treatment rates in eligible patients with recently diagnosed HFrEF, and to determine how rates vary by sociodemographic characteristics. METHODS This retrospective cohort study included patients diagnosed with HFrEF at Veterans Affairs (VA) hospitals from 2013 to 2019. The authors analyzed GDMT treatment rates and doses, excluding patients with contraindications. Therapies of interest were evidence-based beta-blockers (BBs), renin-angiotensin system inhibitors (RASIs), angiotensin receptor-neprilysin inhibitors (ARNIs), and mineralocorticoid antagonists (MRAs). The authors compared adjusted treatment rates by race and ethnicity, neighborhood social vulnerability, rurality, distance to medical care, and sex. RESULTS The cohort comprised 126,670 VA patients with recently diagnosed HFrEF. The study found that racial and ethnic minorities had similar or higher treatment rates than White patients. Patients residing in socially vulnerable neighborhoods had 3.4% lower ARNI (95% CI: 1.9%-5.0%) treatment rates. Patients residing farther from specialty care had similar rates of GDMT therapy overall, but were less likely to be taking at least 50% of the target doses of either BBs (4.0% less likely; 95% CI: 3.1%-5.0%) or RASIs (5.0% less likely; 95% CI: 4.1%-6.0%) compared with those closer to care. CONCLUSIONS Among VA patients with recently diagnosed HFrEF, the authors did not find that racial and ethnic minority patients were less likely to receive GDMT. However, appropriate dose up-titration may occur less frequently in more remote patients.
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Affiliation(s)
- Celeste Witting
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Jimmy Zheng
- School of Medicine, Stanford University, Stanford, California, USA
| | - Rebecca L Tisdale
- VA Palo Alto Health Care System, Palo Alto, California, USA; Department of Health Policy, Stanford University, Stanford, California, USA
| | - Evan Shannon
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine, Los Angeles, California, USA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Eldrin F Lewis
- Department of Medicine, Stanford University, Stanford, California, USA
| | - Paul Heidenreich
- Department of Medicine, Stanford University, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA
| | - Alexander Sandhu
- Department of Medicine, Stanford University, Stanford, California, USA; VA Palo Alto Health Care System, Palo Alto, California, USA.
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Kim SE, Yoo BS. Treatment Strategies of Improving Quality of Care in Patients With Heart Failure. Korean Circ J 2023; 53:294-312. [PMID: 37161744 PMCID: PMC10172273 DOI: 10.4070/kcj.2023.0024] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/19/2023] [Indexed: 04/03/2023] Open
Abstract
Heart failure (HF) is a global health problem closely related to morbidity and mortality. As the burden of HF increases, it is necessary to manage and treat this condition well. However, there are differences between real-world practice and guidelines for the optimal treatment for HF. Patient-related, healthcare provider-related, and health system-related factors contribute to poor adherence to optimal care. This review article aims to examine HF treatment patterns and treatment adherence in real-world practice, identify clinical gaps to suggest ways to improve the quality of care for HF and clinical outcomes for patients with HF. Although it is important to optimize treatment based on evidence-based guidelines to the greatest extent, it is known that there is still poor treatment adherence, and many patients do not receive guideline-directed medical therapy, especially at the early stages. To improve medication adherence, qualitative evaluation through performance measurement, as well as education of patients, caregivers and medical staff through a multidisciplinary approach are important.
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28
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Hashimoto S, Kitakata H, Kohsaka S, Fujisawa D, Shiraishi Y, Nakano N, Sekine O, Kishino Y, Katsumata Y, Yuasa S, Fukuda K, Kohno T. Confidence in self-care after heart failure hospitalization. J Cardiol 2023; 81:42-48. [PMID: 36241046 DOI: 10.1016/j.jjcc.2022.10.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 09/02/2022] [Accepted: 09/25/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND Understanding patient perspectives of self-care is critical for improving multidisciplinary education programs and adherence to such programs. However, perspectives of self-care for patients with heart failure (HF) as well as the association between patient perspectives and patient-physician communication remain unclear. METHODS Confidence levels regarding self-care behaviors (eight lifestyle behaviors and four consulting behaviors) and self-monitoring were assessed using a self-administered questionnaire survey, which was directly distributed by dedicated physicians and nurses to consecutive patients hospitalized with HF in a tertiary-level hospital. Patient-physician communication was evaluated according to the quality of physician-provided information regarding "treatment and treatment choices" and "prognosis" using the Prognosis and Treatment Perception Questionnaire. Out of 202 patients, 187 (92.6 %) agreed to participate, and 176 completed the survey [valid response rate, 87.1 %; male, 67.0 %; median age, 73 (63-81) years]. Multivariate logistic regression analyses were conducted to predict low confidence in self-care (score in the lowest quartile). RESULTS High confidence (confident or completely confident >75 % of patients) was observed for all self-care behavior categories except low-salt diet (63.1 %), regular exercise (63.1 %), and flu vaccination (65.9 %). Lower confidence in self-care behavior was associated with low quality of patient-physician communication. With regard to self-monitoring, 62.5 % of patients were not confident in distinguishing worsening symptoms of HF from other diseases; non-confidence was also associated with low quality of patient-physician communication. CONCLUSIONS Hospitalized patients with HF had low confidence regarding regular exercise, salt restriction, and flu vaccination. The results also suggest patient-physician communication affects patient confidence.
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Affiliation(s)
- Shun Hashimoto
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Hiroki Kitakata
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Fujisawa
- Department of Neuropsychiatry, Keio University School of Medicine, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Naomi Nakano
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Otoya Sekine
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshikazu Kishino
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yoshinori Katsumata
- Institute for Integrated Sports Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Shinsuke Yuasa
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan; Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan.
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Roussia S, Muthu P, Ilesanmi RE. Self-care Management in Heart Failure Using Roy Adaptation Theory-guided Intervention in the United Arab Emirates. SAGE Open Nurs 2023; 9:23779608231160484. [PMID: 36895709 PMCID: PMC9989373 DOI: 10.1177/23779608231160484] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 01/05/2023] [Accepted: 02/12/2023] [Indexed: 03/08/2023] Open
Abstract
Purpose To assess the knowledge and practice of self-care management among patients with heart failure (HF) after Roy adaptation theory-guided educational program. Methodology One group quasi-experimental pretest-posttest design of 30 purposively selected patients with HF was conducted. Outcomes were examined under three domains: knowledge, self-care maintenance, and monitoring pre- and post-intervention, using a validated instrument based on four adaptive modes of Roy's theory. Major results Most of the respondents were male (76.6%) and 56.7% were over 60 years of age. At the pretest, only 16.7% demonstrated adequate knowledge of self-care, and 76.7% reported poor practices in the domains of self-care maintenance and monitoring. Also, 90% scored poorly in self-care management. Knowledge of self-care practices increased at post-test (93.3%). There was a significant difference in knowledge (t = 15.79, df = 29, p < .001) and practice (t = 9.35, df = 29, p < .001) pre- and post-intervention. However, there was no significant association between selected demographic characteristics, knowledge, and self-care practice (p > .05). Conclusion Knowledge and practice of self-care management are poor among patients with HF. However, theory-driven practice can enhance care and patients' quality of life.
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Affiliation(s)
- Soufiane Roussia
- RAK Medical and Health Sciences University, Ras Alkhiama, UAE.,Cardiac Intensive Care Unit, Sheik Shakhbout Medical City, Abu Dhabi, UAE
| | - Priyalatha Muthu
- RAK College of Nursing, RAK Medical and Health Sciences University, Ras Al-Khaimah, UAE
| | - Rose Ekama Ilesanmi
- RAK College of Nursing, RAK Medical and Health Sciences University, Ras Al-Khaimah, UAE.,Department of Nursing, University of Ibadan, Ibadan, Nigeria
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Abstract
PURPOSE This research was conducted to determine whether early participation in cardiac rehabilitation (CR) reduces readmissions following heart failure (HF) hospitalization. METHODS A retrospective quasiexperimental comparison group design was used. Electronic medical records were abstracted for HF patients discharged between March 2013 and December 2017. The treatment group was defined as patients with HF who attended ≥1 CR session within 6 wk following discharge. The comparison group was defined as patients with HF without additional HF hospitalizations during the previous year, discharged to home/self-care, and did not attend CR within 6 wk. Readmission rates at 30 d and 6 wk were compared between groups using χ 2 analysis and logistic regression. RESULTS Out of 8613 patients with HF, 205 (2.4%) attended ≥1 CR within 6 wk post-discharge. The treatment group had lower, but not statistically significant, readmission rates than the comparison group for 30-d readmissions for HF ( P = .13), and 6-wk readmission rates for HF ( P = .05). The treatment group had lower all-cause readmissions at 30 d (P < .01) and 6 wk ( P < .01) than the comparison group. Multivariable logistic regression revealed that early CR attendance was associated with reduced 30-d all-cause readmissions (adjusted OR = 0.4: 95% CI, 0.2-0.7) and 6-wk all-cause readmissions (adjusted OR = 0.5: 95% CI, 0.3-0.8). CONCLUSIONS This study contributes to the existing evidence for allowing early unrestricted CR participation with the aim of improving the health of patients with HF and reducing rehospitalization rates.
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Mukhopadhyay A, Reynolds HR, Nagler AR, Phillips LM, Horwitz LI, Katz SD, Blecker S. Missed opportunities in medical therapy for patients with heart failure in an electronically-identified cohort. BMC Cardiovasc Disord 2022; 22:354. [PMID: 35927632 PMCID: PMC9354331 DOI: 10.1186/s12872-022-02734-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 06/10/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND National registries reveal significant gaps in medical therapy for patients with heart failure and reduced ejection fraction (HFrEF), but may not accurately (or fully) characterize the population eligible for therapy. OBJECTIVE We developed an automated, electronic health record-based algorithm to identify HFrEF patients eligible for evidence-based therapy, and extracted treatment data to assess gaps in therapy in a large, diverse health system. METHODS In this cross-sectional study of all NYU Langone Health outpatients with EF ≤ 40% on echocardiogram and an outpatient visit from 3/1/2019 to 2/29/2020, we assessed prescription of the following therapies: beta-blocker (BB), angiotensin converting enzyme inhibitor (ACE-I)/angiotensin receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNI), and mineralocorticoid receptor antagonist (MRA). Our algorithm accounted for contraindications such as medication allergy, bradycardia, hypotension, renal dysfunction, and hyperkalemia. RESULTS We electronically identified 2732 patients meeting inclusion criteria. Among those eligible for each medication class, 84.8% and 79.7% were appropriately prescribed BB and ACE-I/ARB/ARNI, respectively, while only 23.9% and 22.7% were appropriately prescribed MRA and ARNI, respectively. In adjusted models, younger age, cardiology visit and lower EF were associated with increased prescribing of medications. Private insurance and Medicaid were associated with increased prescribing of ARNI (OR = 1.40, 95% CI = 1.02-2.00; and OR = 1.70, 95% CI = 1.07-2.67). CONCLUSIONS We observed substantial shortfalls in prescribing of MRA and ARNI therapy to ambulatory HFrEF patients. Subspecialty care setting, and Medicaid insurance were associated with higher rates of ARNI prescribing. Further studies are warranted to prospectively evaluate provider- and policy-level interventions to improve prescribing of these evidence-based therapies.
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Affiliation(s)
- Amrita Mukhopadhyay
- grid.137628.90000 0004 1936 8753Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Harmony R. Reynolds
- grid.137628.90000 0004 1936 8753Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Arielle R. Nagler
- grid.137628.90000 0004 1936 8753Ronald O. Perelman Department of Dermatology, New York University School Grossman of Medicine, New York, NY USA
| | - Lawrence M. Phillips
- grid.137628.90000 0004 1936 8753Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Leora I. Horwitz
- grid.137628.90000 0004 1936 8753Departments of Population Health and Medicine, New York University Grossman School of Medicine, 227 East 30th St., #637, New York, NY 10016 USA
| | - Stuart D. Katz
- grid.137628.90000 0004 1936 8753Leon H. Charney Division of Cardiology, Department of Medicine, New York University Grossman School of Medicine, New York, NY USA
| | - Saul Blecker
- Departments of Population Health and Medicine, New York University Grossman School of Medicine, 227 East 30th St., #637, New York, NY, 10016, USA.
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Kanaoka K, Iwanaga Y, Tsujimoto Y, Shiroshita A, Suzuki T, Nakai M, Miyamoto Y. Quality indicators for acute cardiovascular diseases: a scoping review. BMC Health Serv Res 2022; 22:862. [PMID: 35790957 PMCID: PMC9254543 DOI: 10.1186/s12913-022-08239-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2022] [Accepted: 06/23/2022] [Indexed: 01/06/2023] Open
Abstract
Abstract
Background
Although many quality indicator (QI) sets have been developed for acute cardiovascular diseases, a comprehensive summary is lacking. In this scoping review we aimed to summarize the available evidence on the QI sets for acute cardiovascular diseases, and assess the QI set development process. We followed the Joanna Briggs Institute framework and the PRISMA extension for scoping reviews.
Methods
We conducted a systematic search of MEDLINE, EMBASE, and major international guidelines on QIs for acute major cardiovascular diseases. The study included articles published after 2000.
Results
Among the 3112 articles screened, 18 were included in this scoping review. Among the 18 articles included, 12 were on acute coronary syndrome (ACS), five on acute heart failure (AHF), and two on acute aortic dissection (AAD); one article included QIs for both ACS and AHF. Only four of these studies conducted a systematic search with a search strategy. From the 18 articles, 268 QIs containing duplication between articles were identified (191 QIs were for ACS, 57 were for AHF, and 20 were for AAD) and QI measurements varied across articles.
Conclusions
This scoping review provides a comprehensive list of QIs for acute cardiovascular diseases. Our results may be helpful to clinicians and organizations seeking to develop QIs for acute cardiovascular care in the future.
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Mareev VY, Mareev YV, Begrambekova YL. [Coenzyme Q-10 in the treatment of patients with chronic heart failure and reduced left ventricular ejection fraction: systematic review and meta-analysis]. KARDIOLOGIIA 2022; 62:3-14. [PMID: 35834336 DOI: 10.18087/cardio.2022.6.n2050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 03/28/2022] [Indexed: 06/15/2023]
Abstract
Aim The aim of the study was evaluation of the effect of the coenzyme Q10 (Q10) treatment on all-cause and cardiovascular mortality of patients with chronic heart failure (CHF). Q-10 increases the electron transfer in the mitochondrial respiratory chain and exerts anti-inflammatory and antioxidant effects. These effects improve the endothelial function and reduce afterload, which facilitates the heart pumping function. Patients with reduced left ventricular (LV) ejection fraction (EF) (CHFrEF) have low Q10.Material and methods Criteria of inclusion in the meta-analysis: 1) placebo-controlled studies; 2) enrollment of at least 100 patients; 3) publications after 2010, which implies an optimal basic therapy for CHF; 4) duration of at least 6 months; 5) reported cardiovascular and/or all-cause mortality; 6) using sufficient doses of Q10 (>100 mg/day). The search was performed in CENTRAL, MEDLINE, Embase, Web of Science, E-library, and ClinicalTrials.gov databases. All-cause mortality was the primary efficacy endpoint in this systematic review and the meta-analysis. The secondary endpoint was cardiovascular mortality. Meta-analysis was performed according to the Mantel-Haenszel methods. The Cochrane criterion (I2) was used for evaluation of statistical heterogeneity. The random effects model was used at I2≥50 %, whereas the fixed effects model was used at I2<50.Results Analysis of studies published from 01.01.2011 to 01.12.2021 identified 357 publications, 23 of which corresponded to the study topic, but only 6 (providing results of four randomized clinical trials, RCT) completely met the predefined criteria. The final analysis included results of managing 1139 patients (586 received Q10 and 553 received placebo). Risk of all-cause death was analyzed by data of four RCTs (1139 patients). The decrease in the risk associated with the Q10 treatment was 36 % (OR=0.64, 95 % CI 0.48-0.87, р=0.004). The heterogeneity of studies was low (Chi2=0.84; p=0.84; I2=0 %). Risk of cardiovascular mortality was analyzed by data of two RCTs (863 patients). The decrease in the risk associated with the Q10 treatment was significant, 55% (OR=0.45, 95 % CI: 0.32-0.64, р=0.00001). In this case, the data heterogeneity was also low (Chi2=0.41; p=0.52; I2=0 %).Conclusion The meta-analysis confirmed the beneficial effect of coenzyme Q10 on the prognosis of patients with CHFrEF receiving the recommended basic therapy.
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Affiliation(s)
- V Yu Mareev
- Medical Research and Educational Center, Lomonosov Moscow State University; School of Fundamental Medicine, Lomonosov Moscow State University
| | - Yu V Mareev
- Medical Research and Educational Center, Lomonosov Moscow State University; National Medical Research Center for Therapy and Preventive Medicine
| | - Yu L Begrambekova
- Medical Research and Educational Center, Lomonosov Moscow State University; School of Fundamental Medicine, Lomonosov Moscow State University
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34
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Cohen AB, Stump L, Krumholz HM, Cartiera M, Jain S, Scott Sussman L, Hsiao A, Lindop W, Ying AK, Kaul RL, Balcezak TJ, Tereffe W, Comerford M, Jacoby D, Navai N. Aligning mission to digital health strategy in academic medical centers. NPJ Digit Med 2022; 5:67. [PMID: 35654885 PMCID: PMC9163186 DOI: 10.1038/s41746-022-00608-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 04/29/2022] [Indexed: 01/09/2023] Open
Abstract
The strategies of academic medical centers arise from core values and missions that aim to provide unmatched clinical care, patient experience, research, education, and training. These missions drive nearly all activities. They should also drive digital health activities - and particularly now given the rapid adoption of digital health, marking one of the great transformations of healthcare; increasing pressures on health systems to provide more cost-effective care; the pandemic-accelerated funding and rise of well-funded new entrants and technology giants that provide more convenient forms of care; and a more favorable regulatory and reimbursement landscape to incorporate digital health approaches. As academic medical centers emerge from a pandemic-related reactionary digital health posture, where pressures to adopt more digital health technologies mount, a broad digital health realignment that leverages the strengths of such centers is required to accomplish their missions.
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Affiliation(s)
- Adam B Cohen
- Yale New Haven Health, 20 York Street, New Haven, CT, 06510, USA.
| | - Lisa Stump
- Yale New Haven Health, 20 York Street, New Haven, CT, 06510, USA
| | | | | | - Sanchita Jain
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - L Scott Sussman
- Yale New Haven Health, 20 York Street, New Haven, CT, 06510, USA
| | - Allen Hsiao
- Yale New Haven Health, 20 York Street, New Haven, CT, 06510, USA
| | - Walter Lindop
- Yale New Haven Health, 20 York Street, New Haven, CT, 06510, USA
| | - Anita Kuo Ying
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | - Rebecca L Kaul
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | | | - Welela Tereffe
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
| | | | - Daniel Jacoby
- Yale New Haven Health, 20 York Street, New Haven, CT, 06510, USA
| | - Neema Navai
- The University of Texas MD Anderson Cancer Center, 1515 Holcombe Blvd., Houston, TX, 77030, USA
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Essayagh B, Benfari G, Antoine C, Maalouf J, Pislaru S, Thapa P, Michelena HI, Enriquez‐Sarano M. Incremental Prognosis by Left Atrial Functional Assessment: The Left Atrial Coupling Index in Patients With Floppy Mitral Valves. J Am Heart Assoc 2022; 11:e024814. [PMID: 35470696 PMCID: PMC9238580 DOI: 10.1161/jaha.121.024814] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2021] [Accepted: 03/04/2022] [Indexed: 11/16/2022]
Abstract
Background Emerging data suggest important prognostic value to left atrial (LA) characteristics, but the independent impact of LA function on outcome remains unsubstantiated. Thus, we aimed to define the incremental prognostic value of LA coupling index (LACI), coupling volumetric and mechanical LA characteristics and calculated as the ratio of left atrial volume index to tissue Doppler imaging a', in a large cohort of patients with isolated floppy mitral valve. Methods and Results All consecutive 4792 patients (61±16 years, 48% women) with isolated floppy mitral valve in sinus rhythm diagnosed at Mayo Clinic from 2003 to 2011, comprehensively characterized and with prospectively measured left atrial volume index and tissue Doppler imaging a' in routine practice, were enrolled, and their long-term survival analyzed. Overall, LACI was 5.8±3.7 and was <5 in 2422 versus ≥5 in 2370 patients. LACI was independently higher with older age, more mitral regurgitation (no 3.8±2.3, mild 5.1±3.0, moderate 6.5±3.8, and severe 7.8±4.3), and with diastolic (higher E/e') and systolic (higher end-systolic dimension) left ventricular dysfunction (all P≤0.0001). At diagnosis, higher LACI was associated with more severe presentation (more dyspnea, more severe functional tricuspid regurgitation, and elevated pulmonary artery pressure, all P≤0.0001) independently of age, sex, comorbidity index, ventricular function, and mitral regurgitation severity. During 7.0±3.0 years follow-up, 1146 patients underwent mitral valve surgery (94% repair, 6% replacement), and 880 died, 780 under medical management. In spline curve analysis, LACI ≥5 was identified as the threshold for excess mortality, with much reduced 10-year survival under medical management (60±2% versus 85±1% for LACI <5, P<0.0001), even after comprehensive adjustment (adjusted hazard ratio, 1.30 [95% CI, 1.10-1.53] for LACI ≥5; P=0.002). Association of LACI ≥5 with higher mortality persisted, stratifying by mitral regurgitation severity of LA enlargement grade (all P<0.001) and after propensity-score matching (P=0.02). Multiple statistical methods confirmed the significant incremental predictive power of LACI over left atrial volume index (all P<0.0001). Conclusions LA functional assessment by LACI in routine practice is achievable in a large number of patients with floppy mitral valve using conventional Doppler echocardiographic measurements. Higher LACI is associated with worse clinical presentation, but irrespective of baseline characteristics, LACI is strongly, independently, and incrementally determinant of outcome, demonstrating the crucial importance of LA functional response to mitral valve disease.
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Affiliation(s)
- Benjamin Essayagh
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Department of Cardiovascular MedicineSimone Veil HospitalCannesFrance
| | - Giovanni Benfari
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Department of Cardiovascular MedicineUniversity of VeronaVeronaItaly
| | | | - Joseph Maalouf
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | - Sorin Pislaru
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | - Prabin Thapa
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
| | | | - Maurice Enriquez‐Sarano
- Department of Cardiovascular MedicineMayo ClinicRochesterMN
- Minneapolis Heart InstituteMinneapolisMN
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Chen S, Huang Z, Liang Y, Zhao X, Aobuliksimu X, Wang B, He Y, Kang Y, Huang H, Li Q, Yao Y, Lu X, Qian X, Xie X, Liu J, Liu Y. Five-year mortality of heart failure with preserved, mildly reduced, and reduced ejection fraction in a 4880 Chinese cohort. ESC Heart Fail 2022; 9:2336-2347. [PMID: 35437939 PMCID: PMC9288761 DOI: 10.1002/ehf2.13921] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2021] [Revised: 02/18/2022] [Accepted: 03/27/2022] [Indexed: 12/29/2022] Open
Abstract
Aims Available evidence is incomplete and inconsistent in the outcomes of heart failure (HF) patients with preserved ejection fraction (HFpEF), mildly reduced ejection fraction (HFmrEF), and reduced ejection fraction (HFrEF). There are also limited data on the proportions and long‐term prognosis among the three HF phenotypes in China. We aimed to characterize the 5 year prognosis in three HF phenotypes according to EF in a cohort of hospitalized HF patients undergoing coronary angiography in southern China. Methods and results Hospitalized patients with HF were enrolled from the Cardiorenal ImprovemeNt registry (CIN; ClinicalTrials.gov NCT04407936) between January 2007 and December 2014. HF phenotypes were defined as HFpEF (EF ≥ 50%), HFmrEF (EF 41–49%), and HFrEF (EF ≤ 40%). Kaplan–Meier and Cox proportional hazards models were constructed to examine differences in 5 year outcomes in HF patients with different phenotypes. A total of 4880 HF patients [mean age: 61.8 ± 10.3, male: 3156 (64.7%)] were included: 2768 (57%) had HFpEF, 1015 (21%) had HFmrEF, and 1097 (22%) had HFrEF. Patients with HFrEF were older than those with HFpEF (62.5 ± 10.6 vs. 61.3 ± 10.1, P < 0.001) and more likely to be male (78.0% vs. 55.9%, P < 0.001). With 5 year follow‐up through the end of December 2019, 1624 (27.6%) patients died. Controlling confounding variables, declined EF category was independently associated with increased 5 year mortality {HFrEF 25.2% vs. HFpEF 13.4%, adjusted hazard ratio [aHR]: 1.85 [95% confidence interval (CI): 1.45 to 2.35]; HFmrEF 18.1% vs. HFpEF 13.4%, aHR: 1.40 [95% CI: 1.08 to 1.81]; HFrEF 25.2% vs. HFmrEF 18.1%, aHR: 1.32 [95% CI: 1.02 to 1.71]}. Conclusions In this Chinese cohort, patients with HFrEF account for less than a fourth of HF patients. One‐sixth individuals with HF died in 5 years. HFrEF was associated with a nearly two‐fold increased risk of 5 year mortality than HFpEF. Further studies are needed to prospectively evaluate the efficacy of improving treatment on outcomes in all three HF phenotypes.
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Affiliation(s)
- Shiqun Chen
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Zhidong Huang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Yan Liang
- Maoming People's Hospital, Maoming, China
| | - Xiaoli Zhao
- The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | | | - Bo Wang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Yibo He
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Yu Kang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Haozhang Huang
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Qiang Li
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Younan Yao
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Xiaozhao Lu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Xiaoxian Qian
- The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Xujing Xie
- The Third Affiliated Hospital of Sun Yat-Sen University, Guangzhou, China
| | - Jin Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
| | - Yong Liu
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, 510080, China
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Quality of life assessed six months after hospitalisation for acute heart failure: An analysis from
REPORT‐HF
(International Registry to assess
mEdical
Practice with
lOngitudinal obseRvation
for Treatment of Heart Failure). Eur J Heart Fail 2022; 24:1020-1029. [DOI: 10.1002/ejhf.2508] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Revised: 04/04/2022] [Accepted: 04/06/2022] [Indexed: 11/07/2022] Open
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Wang M, Liu J, Liu J, Hao Y, Yang N, Liu T, Smith SC, Huo Y, Fonarow GC, Ge J, Morgan L, Ma C, Han Y, Zhao D, Zhan S. Association Between Early Oral β-Blocker Therapy and In-Hospital Outcomes in Patients With ST-Elevation Myocardial Infarction With Mild-Moderate Heart Failure: Findings From the CCC-ACS Project. Front Cardiovasc Med 2022; 9:828614. [PMID: 35497978 PMCID: PMC9051227 DOI: 10.3389/fcvm.2022.828614] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Accepted: 03/14/2022] [Indexed: 11/18/2022] Open
Abstract
Background There are limited data available on the impact of early (within 24 h of admission) β-blocker therapy on in-hospital outcomes of patients with ST-elevation myocardial infarction (STEMI) and mild-moderate acute heart failure. This study aimed to explore the association between early oral β-blocker therapy and in-hospital outcomes. Methods Inpatients with STEMI and Killip class II or III heart failure from the Improving Care for Cardiovascular Disease in China project (n = 10,239) were enrolled. The primary outcome was a combined endpoint composed of in-hospital all-cause mortality, successful cardiopulmonary resuscitation after cardiac arrest, and cardiogenic shock. Inverse-probability-of-treatment weighting, multivariate Cox regression, and propensity score matching were performed. Results Early oral β-blocker therapy was administered to 56.5% of patients. The incidence of the combined endpoint events was significantly lower in patients with early therapy than in those without (2.7 vs. 5.1%, P < 0.001). Inverse-probability-of-treatment weighting analysis demonstrated that early β-blocker therapy was associated with a low risk of combined endpoint events (HR = 0.641, 95% CI: 0.486-0.844, P = 0.002). Similar results were shown in multivariate Cox regression (HR = 0.665, 95% CI: 0.496-0.894, P = 0.007) and propensity score matching (HR = 0.633, 95% CI: 0.453-0.884, P = 0.007) analyses. A dose-response trend between the first-day β-blocker dosages and adverse outcomes was observed in a subset of participants with available data. No factor could modify the association of early treatment and the primary outcomes among the subgroups analyses. Conclusion Based on nationwide Chinese data, early oral β-blocker therapy is independently associated with a lower risk of poor in-hospital outcome in patients with STEMI and Killip class II or III heart failure.
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Affiliation(s)
- Miao Wang
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
- Department of Epidemiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Jing Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Jun Liu
- Department of Epidemiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Yongchen Hao
- Department of Epidemiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Na Yang
- Department of Epidemiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Tong Liu
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Sidney C. Smith
- Division of Cardiology, University of North Carolina at Chapel Hill, Chapel Hill, NC, United States
| | - Yong Huo
- Department of Cardiology, Peking University First Hospital, Beijing, China
| | - Gregg C. Fonarow
- Division of Cardiology, Geffen School of Medicine at University of California, Los Angeles, Los Angeles, CA, United States
| | - Junbo Ge
- Department of Cardiology, Zhongshan Hospital, Shanghai Institute of Cardiovascular Diseases, Fudan University, Shanghai, China
| | - Louise Morgan
- International Quality Improvement Department, American Heart Association, Dallas, TX, United States
| | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yaling Han
- Cardiovascular Research Institute and Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | - Dong Zhao
- Department of Epidemiology, Beijing Anzhen Hospital, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Capital Medical University, Beijing, China
| | - Siyan Zhan
- Department of Epidemiology and Biostatistics, School of Public Health, Peking University, Beijing, China
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 873] [Impact Index Per Article: 436.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Takaoka Y, Hamatani Y, Shibata T, Oishi S, Utsunomiya A, Kawai F, Komiyama N, Mizuno A. Quality indicators of palliative care for cardiovascular intensive care. J Intensive Care 2022; 10:15. [PMID: 35287745 PMCID: PMC8922808 DOI: 10.1186/s40560-022-00607-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 03/01/2022] [Indexed: 01/11/2023] Open
Abstract
Healthcare providers working for cardiovascular intensive care often face challenges and they play an essential role in palliative care and end-of-life care because of the high mortality rates in the cardiac intensive care unit. Unfortunately, there are several barriers to integrating palliative care, cardiovascular care, and intensive care. The main reasons are as follows: cardiovascular disease-specific trajectories differ from cancer, there is uncertainty associated with treatments and diagnoses, aggressive treatments are necessary for symptom relief, and there is ethical dilemma regarding withholding and withdrawal of life-sustaining therapy. Quality indicators that can iterate the minimum requirements of each medical discipline could be used to overcome these barriers and effectively practice palliative care in cardiovascular intensive care. Unfortunately, there are no specific quality indicators for palliative care in cardiovascular intensive care. A few indicators and their domains are useful for understanding current palliative care in cardiovascular intensive care. Among them, several domains, such as symptom palliation, patient- and family-centered decision-making, continuity of care, and support for health care providers that are particularly important in cardiovascular intensive care. Historically, the motivation for using quality indicators is to summarize mechanisms for external accountability and verification, and formative mechanisms for quality improvement. Practically, when using quality indicators, it is necessary to check structural indicators in each healthcare service line, screen palliative care at the first visit, and integrate palliative care teams with other professionals. Finally, we would like to state that quality indicators in cardiovascular intensive care could be useful as an educational tool for practicing palliative care, understanding the minimum requirements, and as a basic structure for future discussions.
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Affiliation(s)
- Yoshimitsu Takaoka
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, Japan
| | - Yasuhiro Hamatani
- Department of Cardiology, National Hospital Organization Kyoto Medical Center, Kyoto, Japan
| | - Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Fukuoka, Japan
| | - Shogo Oishi
- Division of Cardiovascular Medicine, Hyogo Brain and Heart Center, Himeji, Japan
| | - Akemi Utsunomiya
- Department of Critical Care Nursing, Human Health Sciences, Kyoto University Graduate School of Medicine, Kyoto, Japan
| | - Fujimi Kawai
- St. Luke's International University Library, Tokyo, Japan
| | - Nobuyuki Komiyama
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, Japan
| | - Atsushi Mizuno
- Department of Cardiovascular Medicine, St. Luke's International Hospital, 9-1, Akashi-cho, Chuo-ku, Tokyo, Japan. .,Penn Medicine Nudge Unit, University of Pennsylvania Philadelphia, Philadelphia, PA, USA. .,Leonard Davis Institute for Health Economics, University of Pennsylvania, Philadelphia, PA, USA. .,Division of Cardiovascular Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
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Alonso WW, Kupzyk KA, Norman JF, Lundgren SW, Fisher A, Lindsey ML, Keteyian SJ, Pozehl BJ. The HEART Camp Exercise Intervention Improves Exercise Adherence, Physical Function, and Patient-Reported Outcomes in Adults With Preserved Ejection Fraction Heart Failure. J Card Fail 2022; 28:431-442. [PMID: 34534664 PMCID: PMC8920955 DOI: 10.1016/j.cardfail.2021.09.003] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2021] [Revised: 09/01/2021] [Accepted: 09/02/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Despite exercise being one of few strategies to improve outcomes for individuals with heart failure with preserved ejection fraction (HFpEF), exercise clinical trials in HFpEF are plagued by poor interventional adherence. Over the last 2 decades, our research team has developed, tested, and refined Heart failure Exercise And Resistance Training (HEART) Camp, a multicomponent behavioral intervention to promote adherence to exercise in HF. We evaluated the effects of this intervention designed to promote adherence to exercise in HF focusing on subgroups of participants with HFpEF and heart failure with reduced ejection fraction (HFrEF). METHODS AND RESULTS This randomized controlled trial included 204 adults with stable, chronic HF. Of those enrolled, 59 had HFpEF and 145 had HFrEF. We tested adherence to exercise (defined as ≥120 minutes of moderate-intensity [40%-80% of heart rate reserve] exercise per week validated with a heart rate monitor) at 6, 12, and 18 months. We also tested intervention effects on symptoms (Patient-Reported Outcomes Measurement Information System-29 and dyspnea-fatigue index), HF-related health status (Kansas City Cardiomyopathy Questionnaire), and physical function (6-minute walk test). Participants with HFpEF (n = 59) were a mean of 64.6 ± 9.3 years old, 54% male, and 46% non-White with a mean ejection fraction of 55 ± 6%. Participants with HFpEF in the HEART Camp intervention group had significantly greater adherence compared with enhanced usual care at both 12 (43% vs 14%, phi = 0.32, medium effect) and 18 months (56% vs 0%, phi = 0.67, large effect). HEART Camp significantly improved walking distance on the 6-minute walk test (η2 = 0.13, large effect) and the Kansas City Cardiomyopathy Questionnaire overall (η2 = 0.09, medium effect), clinical summary (η2 = 0.16, large effect), and total symptom (η2 = 0.14, large effect) scores. In the HFrEF subgroup, only patient-reported anxiety improved significantly in the intervention group. CONCLUSIONS A multicomponent, behavioral intervention is associated with improvements in long-term adherence to exercise, physical function, and patient-reported outcomes in adults with HFpEF and anxiety in HFrEF. Our results provide a strong rationale for a large HFpEF clinical trial to validate these findings and examine interventional mechanisms and delivery modes that may further promote adherence and improve clinical outcomes in this population. CLINICAL TRIAL REGISTRATION URL: https://clinicaltrials.gov/. Unique identifier: NCT01658670.
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Affiliation(s)
- Windy W Alonso
- College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska.
| | - Kevin A Kupzyk
- College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska
| | - Joseph F Norman
- College of Allied Health Professions, University of Nebraska Medical Center, Omaha, Nebraska
| | - Scott W Lundgren
- Division of Cardiology, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Alfred Fisher
- Division of Geriatrics, Gerontology, and Palliative Medicine, Department of Internal Medicine, University of Nebraska Medical Center, Omaha, Nebraska
| | - Merry L Lindsey
- Department of Cellular and Integrative Physiology, Center for Heart and Vascular Research, University of Nebraska Medical Center, Omaha, Nebraska; Research Service, Nebraska-Western Iowa Health Care System, Omaha, Nebraska
| | | | - Bunny J Pozehl
- College of Nursing, University of Nebraska Medical Center, Omaha, Nebraska
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Chen L, Huang Z, Zhao X, Liang J, Lu X, He Y, Kang Y, Xie Y, Liu J, Liu Y, Yang J, Yu W, Deng W, Pan Y, Lu J, Yang Y, Xie X, Qian X, Xu Q, Chen L, Chen K, Chen S. Predictors and Mortality for Worsening Left Ventricular Ejection Fraction in Patients With HFpEF. Front Cardiovasc Med 2022; 9:820178. [PMID: 35282383 PMCID: PMC8907533 DOI: 10.3389/fcvm.2022.820178] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/11/2022] [Indexed: 11/21/2022] Open
Abstract
Background Definitions of declined left ventricular ejection fraction (LVEF) vary across studies and research results concerning the association of mortality with declined LVEF are inconsistent. Thus, this study aimed to assess the impact of early worsening LVEF on mortality in patients with heart failure (HF) with preserved ejection fraction (HFpEF) and to establish independent predictors of early worsening LVEF. Methods and Results A total of 1,418 consecutive patients with HFpEF with LVEF remeasurement from the Cardiorenal Improvement registry were included in this study. Worsening LVEF was defined as an absolute decline ≥ 5% from baseline LVEF within 3 to 12 months after discharge. The Cox and logistic regression analyses were performed to assess prognostic effects and predictors for worsening LVEF, respectively. Among 1,418 patients with HFpEF, 457 (32.2%) patients exhibited worsening LVEF. During a median follow-up of 3.2 years (interquartile range: 2.3–4.0 years), 92 (6.5%) patients died. Patients with HFpEF with worsening LVEF had higher mortality relative to those with nonworsening LVEF [9.2 vs. 5.2%; adjusted hazard ratio (aHR): 2.18, 95% CI: 1.35–3.52]. In the multivariate binary logistic regression analysis, baseline left ventricular end-diastolic dimension (LVEDD), LVEF, high-density lipoprotein cholesterol (HDL-C), atrial fibrillation (AF), and diabetes mellitus (DM) emerged as predictive factors of worsening LVEF. Conclusion This study demonstrated that about one out of three patients with HFpEF experiences worsening LVEF during follow-up, which is associated with 2.2-fold increased mortality. Increased LVEDD and LVEF, low HDL-C levels, AF, and DM were predictors of worsening LVEF. Further studies are needed to prospectively assess the efficacy of early active management on prognosis in patients with HF with worsening LVEF. Registration ClinicalTrials.gov, identifier NCT04407936.
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Affiliation(s)
- Liling Chen
- Department of Cardiology, Longyan First Hospital Affiliated of Fujian Medical University, Longyan, China
| | - Zhidong Huang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Xiaoli Zhao
- Department of Cardiology, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, China
| | - Jingjing Liang
- Department of Cardiology, Shunde Hospital, Southern Medical University, Guangzhou, China
| | - Xiaozhao Lu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yibo He
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yu Kang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yun Xie
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jin Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Yong Liu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Jin Yang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Weixu Yu
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Wanling Deng
- Department of Cardiology, Longyan First Hospital Affiliated of Fujian Medical University, Longyan, China
| | - Yuxiong Pan
- Department of Cardiology, Longyan First Hospital Affiliated of Fujian Medical University, Longyan, China
| | - Jin Lu
- Department of Cardiology, Longyan First Hospital Affiliated of Fujian Medical University, Longyan, China
| | - Yanfang Yang
- Department of Cardiology, Longyan First Hospital Affiliated of Fujian Medical University, Longyan, China
| | - Xujing Xie
- Department of Cardiology, Longyan First Hospital Affiliated of Fujian Medical University, Longyan, China
| | - Xiaoxian Qian
- Department of Cardiology, Guangdong Provincial Key Laboratory of Coronary Heart Disease Prevention, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Qingbo Xu
- Department of Cardiology, Shunde Hospital, Southern Medical University, Guangzhou, China
- Department of Cardiology, Maoming People's Hospital, Maoming, China
- *Correspondence: Qingbo Xu
| | - Longtian Chen
- Department of Hematology, Longyan First Hospital Affiliated of Fujian Medical University, Longyan, China
- Longtian Chen
| | - Kaihong Chen
- Department of Cardiology, Longyan First Hospital Affiliated of Fujian Medical University, Longyan, China
- Kaihong Chen
| | - Shiqun Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
- Shiqun Chen
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Sandhu AT, Kohsaka S, Turakhia MP, Lewis EF, Heidenreich PA. Evaluation of Quality of Care for US Veterans With Recent-Onset Heart Failure With Reduced Ejection Fraction. JAMA Cardiol 2021; 7:130-139. [PMID: 34757380 DOI: 10.1001/jamacardio.2021.4585] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
Importance Multiple guideline-recommended therapies for heart failure with reduced ejection fraction (HFrEF) are available and promoted by performance measures. However, contemporary data on the use of these therapies are limited. Objective To evaluate trends in guideline-directed medical therapy, implantable cardioverter-defibrillator (ICD) use, and risk-adjusted mortality among patients with recent-onset HFrEF. Design, Setting, and Participants This cohort study analyzed claims and electronic health record data of patients with recent-onset HFrEF diagnosed at US Department of Veterans Affairs (VA) health care system facilities from July 1, 2013, through June 30, 2019. Veterans who had a history of heart transplant or used a ventricular assist device were among the patients who were excluded. Exposures Guideline-directed medical therapy (any β-blocker, guideline-recommended β-blocker [bisoprolol, carvedilol, or metoprolol succinate], angiotensin-converting enzyme inhibitor, angiotensin receptor blocker, angiotensin receptor-neprilysin inhibitor, mineralocorticoid receptor antagonist, and hydralazine plus nitrate) and ICD. Main Outcomes and Measures Treatment rates for guideline-directed medical therapies and ICDs were calculated within 6 months of the index HFrEF date using medication fills, procedural codes for implantation and monitoring, and diagnosis codes. Risk-adjusted mortality was calculated after adjusting for baseline patient characteristics. For both treatment rates and risk-adjusted mortality, we evaluated the change over 3 periods (period 1: July 1, 2013, to June 30, 2015; period 2: July 1, 2015, to June 30, 2017; and period 3: July 1, 2017, to June 30, 2019) and variation across VA facilities. Results The final cohort comprised 144 074 eligible patients with incident HFrEF that was diagnosed between July 1, 2013, and June 30, 2019. The cohort had a mean (SD) age of 71.0 (11.4) years and was mostly composed of men (140 765 [97.7%]). Overall, changes in medical therapy rates were minimal over time, with the use of a guideline-recommended β-blocker increasing from 64.2% in 2013 to 72.0% in 2019. Rates for mineralocorticoid receptor antagonist therapy increased from 23.9% in 2013 to 26.9% in 2019, and rates for hydralazine plus nitrate therapy remained stable at 24.2% over the study period. Rates for angiotensin receptor-neprilysin inhibitor therapy increased since its introduction in 2015 but only to 22.6% in 2019. Among patients with an ICD indication, early use rates decreased over time. Substantial variation in medical therapy rates persisted across VA facilities. Risk-adjusted mortality decreased over the study period from 19.9% (95% CI, 19.6%-20.2%) in July 1, 2013, to June 30, 2015, to 18.4% (95% CI, 18.0%-18.7%) in July 1, 2017, to June 30, 2019 (OR, 0.96 per additional year; 95% CI, 0.96-0.97). Conclusions and Relevance This study found only marginal improvement between 2013 and 2019 in the guideline-recommended therapy and mortality rates among patients with recent-onset HFrEF. New approaches to increase the uptake of evidence-based HFrEF treatment are urgently needed and could lead to larger reductions in mortality.
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Affiliation(s)
- Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California.,Medical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Mintu P Turakhia
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California.,Medical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California.,Center for Digital Health, Stanford University, Stanford, California.,Associate Editor, JAMA Cardiology
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California.,Medical Service, Veterans Affairs Palo Alto Health Care System, Palo Alto, California
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Spertus JA, Fine JT, Elliott P, Ho CY, Olivotto I, Saberi S, Li W, Dolan C, Reaney M, Sehnert AJ, Jacoby D. Mavacamten for treatment of symptomatic obstructive hypertrophic cardiomyopathy (EXPLORER-HCM): health status analysis of a randomised, double-blind, placebo-controlled, phase 3 trial. Lancet 2021; 397:2467-2475. [PMID: 34004177 DOI: 10.1016/s0140-6736(21)00763-7] [Citation(s) in RCA: 98] [Impact Index Per Article: 32.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/24/2021] [Accepted: 03/26/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Improving symptoms is a primary treatment goal in patients with obstructive hypertrophic cardiomyopathy. Currently available pharmacological options for hypertrophic cardiomyopathy are not disease-specific and are often inadequate or poorly tolerated. We aimed to assess the effect of mavacamten, a first-in-class cardiac myosin inhibitor, on patients' health status-ie, symptoms, physical and social function, and quality of life. METHODS We did a health status analysis of EXPLORER-HCM, a phase 3, double-blind, randomised, placebo-controlled trial. The study took place at 68 clinical cardiovascular centres in 13 countries. Adult patients (≥18 years) with symptomatic obstructive hypertrophic cardiomyopathy (gradient ≥50 mm Hg and New York Heart Association class II-III) were randomly assigned (1:1) to mavacamten or placebo for 30 weeks, followed by an 8-week washout period. Both patients and staff were masked to study treatment. The primary outcome for this secondary analysis was the Kansas City Cardiomyopathy Questionnaire (KCCQ), a well validated disease-specific measure of patients' health status. It was administered at baseline and weeks 6, 12, 18, 30 (end of treatment), and 38 (end of study). Changes from baseline to week 30 in KCCQ overall summary (OS) score and all subscales were analysed using mixed model repeated measures. This study is registered with ClinicalTrials.gov, NCT03470545. FINDINGS Between May 30, 2018, and July 12, 2019, 429 adults were assessed for eligibility, of whom 251 (59%) were enrolled and randomly assigned. Of 123 patients randomly assigned to mavacamten, 92 (75%) completed the KCCQ at baseline and week 30 and of the 128 patients randomly assigned to placebo 88 (69%) completed the KCCQ at baseline and week 30. At 30 weeks, the change in KCCQ-OS score was greater with mavacamten than placebo (mean score 14·9 [SD 15·8] vs 5·4 [13·7]; difference +9·1 [95% CI 5·5-12·8]; p<0·0001), with similar benefits across all KCCQ subscales. The proportion of patients with a very large change (KCCQ-OS ≥20 points) was 36% (33 of 92) in the mavacamten group versus 15% (13 of 88) in the placebo group, with an estimated absolute difference of 21% (95% CI 8·8-33·4) and number needed to treat of five (95% CI 3-11). These gains returned to baseline after treatment was stopped. INTERPRETATION Mavacamten markedly improved the health status of patients with symptomatic obstructive hypertrophic cardiomyopathy compared with placebo, with a low number needed to treat for marked improvement. Given that the primary goals of treatment are to improve symptoms, physical and social function, and quality of life, mavacamten represents a new potential strategy for achieving these goals. FUNDING MyoKardia, a Bristol Myers Squibb company.
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Affiliation(s)
- John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA; University of Missouri, Kansas City, MO, USA.
| | - Jennifer T Fine
- MyoKardia, a Bristol Myers Squibb company, Brisbane, CA, USA
| | - Perry Elliott
- Centre for Heart Muscle Disease, Institute of Cardiovascular Science, University College London, London, UK
| | - Carolyn Y Ho
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Iacopo Olivotto
- Cardiomyopathy Unit, Azienda Ospedaliera Universitaria Careggi, Florence, Italy
| | - Sara Saberi
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Wanying Li
- MyoKardia, a Bristol Myers Squibb company, Brisbane, CA, USA
| | | | | | - Amy J Sehnert
- MyoKardia, a Bristol Myers Squibb company, Brisbane, CA, USA
| | - Daniel Jacoby
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
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Affiliation(s)
- Paul A Heidenreich
- Medical Service, VA Palo Alto Health Care System, Palo Alto, California.,Department of Medicine, Stanford University School of Medicine, Stanford, California
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Agarwal A, Mohanan PP, Kondal D, Baldridge A, Davies D, Devarajan R, Unni G, Abdullakutty J, Natesan S, Joseph J, Jayagopal PB, Joseph S, Gopinath R, Huffman MD, Prabhakaran D. Effect of a quality improvement intervention for acute heart failure in South India: An interrupted time series study. Int J Cardiol 2020; 329:123-129. [PMID: 33358838 DOI: 10.1016/j.ijcard.2020.12.048] [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] [Received: 08/26/2020] [Revised: 11/16/2020] [Accepted: 12/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND Although quality improvement interventions for acute heart failure have been studied in high-income countries, none have been studied in low- or middle-income country settings where quality of care can be lower. We evaluated the effect of a quality improvement toolkit on process of care measures and clinical outcomes in patients hospitalized for acute heart failure in 8 hospitals in Kerala, India utilizing an interrupted time series design from February 2018 to August 2018. METHODS The quality improvement toolkit included checklists, audit-and-feedback reports, and patient education materials. The primary outcome was rate of discharge guideline-directed medical therapy for patients with heart failure with reduced ejection fraction. We used mixed effect logistic regression and interrupted time series models for analysis. RESULTS Among 1400 participants, mean (SD) age was 66.6 (12.2) years, and 38% were female. Mean (SD) left ventricular ejection fraction was 35.2% (9.7%). The primary outcome was observed in 41.3% of participants in the intervention period and 28.1% of participants in the control period (difference 13.2%; 95% CI 6.8, 19.0; adjusted OR = 1.70; 95% CI 1.17, 2.48). Interrupted time series model demonstrated highest rate of guideline-directed medical therapy at discharge in the initial weeks following intervention delivery with a concomitant decline over time. Improvements were observed in discharge process of care measures, including diet counseling, weight monitoring instructions, and scheduling of outpatient clinic follow-up but not hospital length of stay nor inpatient mortality. CONCLUSIONS Higher rates of guideline-directed medical therapy at discharge were observed in Kerala. Broader implementation of this quality improvement intervention may improve heart failure care in low- and middle-income countries.
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Affiliation(s)
- Anubha Agarwal
- Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA.
| | | | - Dimple Kondal
- Centre for Chronic Disease Control, New Delhi, Delhi, India
| | - Abigail Baldridge
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Divin Davies
- WestFort Hi-Tech Hospital, Thrissur, Kerala, India
| | - Raji Devarajan
- Centre for Chronic Disease Control, New Delhi, Delhi, India
| | - Govindan Unni
- Jubilee Mission Medical College and Hospital, Thrissur, Kerala, India
| | | | | | | | | | - Stigi Joseph
- Little Flower Hospital and Research Centre, Angamaly, Kerala, India
| | - Rajesh Gopinath
- Amala Institute of Medical Sciences, Thrissur, Kerala, India
| | - Mark D Huffman
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA; The George Institute for Global Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Dorairaj Prabhakaran
- Centre for Chronic Disease Control, New Delhi, Delhi, India; The Public Health Foundation of India, Gurugram, Haryana, India
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