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Ketabi M, Mohammadi Z, Fereidouni Z, Keshavarzian O, Karimimoghadam Z, Sarvi F, Tabrizi R, Khodadost M. The Effect of Recurrent Heart Failure Hospitalizations on the Risk of Cardiovascular and all-Cause Mortality: a Systematic Review and Meta-Analysis. Curr Cardiol Rep 2024; 26:1113-1122. [PMID: 39230619 DOI: 10.1007/s11886-024-02112-8] [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] [Accepted: 08/01/2024] [Indexed: 09/05/2024]
Abstract
INTRODUCTION Heart failure (HF) is a significant worldwide concern due to its substantial impact on mortality rates and recurrent hospitalizations. The relationship between recurrent hospitalizations and mortality in individuals diagnosed with heart failure has been the subject of conflicting findings in previous studies. A meta-analysis was conducted to investigate the association between recurrent heart failure hospitalizations (HFHs) and mortality. METHODS We conducted a systematic search across various online databases, such as PubMed, Embase, Web of Science, ProQuest, Scopus, Science Direct, and Google Scholar, to locate studies that examined the connection between recurrent HFHs and cardiovascular (CV) mortality as well as all-cause mortality until January 2023. To evaluate the heterogeneity among the studies, we employed I2 and Cochran's Q test. RESULTS In total, 143,867 participants from seven studies were included in the analysis. Recurrent HFHs were found to be strongly associated with elevated risks of both cardiovascular (CV) mortality and all-cause mortality. The pooled hazard ratios (HRs) indicated a non-significant association for CV mortality (HR = 4.28, 95% CI: 0.86-7.71) but a significant association for all-cause mortality (HR = 2.76, 95% CI: 2.05-3.48). Subgroup analyses revealed a reduction in heterogeneity when stratified by factors such as quality score, sample size, hypertension comorbidity, number of recurrent HFHs, and follow-up time. A clear correlation was observed between the frequency of HFH and the mortality risk. Various subgroups, including those with diabetes, atrial fibrillation, and chronic kidney disease, showed significant associations between recurrent HFHs and all-cause mortality. Additionally, recurrent HFHs were significantly associated with CV mortality in subgroups such as heart failure with reduced ejection fraction (HFrEF), atrial fibrillation, and diabetes. CONCLUSION This meta-analysis provides evidence of an association between recurrent HFH and elevated risk of both CV mortality and all-cause mortality. The findings consistently indicate that a higher frequency of HFH is strongly associated with an increased likelihood of mortality.
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Affiliation(s)
- Marzieh Ketabi
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
- USERN Office, Fasa University of Medical Sciences, Fasa, Iran
| | - Zahra Mohammadi
- Student Research Committee, Fasa University of Medical Sciences, Fasa, Iran
| | - Zhila Fereidouni
- Department of Medical Surgical Nursing, Fasa University of Medical Sciences, Fars, Iran
| | - Omid Keshavarzian
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Zeinab Karimimoghadam
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran
| | - Fatemeh Sarvi
- Department of Public Health, School of Health, Larestan University of Medical Sciences, Larestan, Iran
| | - Reza Tabrizi
- Noncommunicable Diseases Research Center, Fasa University of Medical Sciences, Fasa, Iran.
- Clinical Research Development Unit, Valiasr Hospital, Fasa University of Medical Sciences, Fasa, Iran.
| | - Mahmoud Khodadost
- Department of Public Health, School of Health, Larestan University of Medical Sciences, Larestan, Iran.
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Isogai T, Morita K, Okada A, Michihata N, Matsui H, Miyawaki A, Jo T, Yasunaga H. Association between complementary use of Goreisan (a Japanese herbal Kampo medicine) and heart failure readmission: A nationwide propensity score-matched study. J Cardiol 2024:S0914-5087(24)00182-5. [PMID: 39341374 DOI: 10.1016/j.jjcc.2024.09.010] [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: 05/06/2024] [Revised: 09/02/2024] [Accepted: 09/16/2024] [Indexed: 10/01/2024]
Abstract
BACKGROUND Goreisan, a Japanese herbal medicine, possesses aquaretic properties to regulate body fluid homeostasis and may therefore be effective as a complement to standard therapy in improving outcomes in patients with heart failure (HF). METHODS We retrospectively identified 431,393 patients (mean age 79.2 ± 12.6 years; male 52.3 %) who were admitted for HF for the first time and were discharged alive with standard HF medications between April 2016 and March 2022, using the Japanese Diagnosis Procedure Combination database. We divided patients into two groups according to the prescription of Goreisan at discharge: patients who received standard HF medications plus Goreisan and those who received standard medications alone. We compared the incidence of HF readmission within 1 year after discharge between the groups using propensity score matching. RESULTS Overall, Goreisan was prescribed in 1957 (0.45 %) patients at discharge. Patients who received Goreisan were older and received diuretics more frequently than those who did not. One-to-four propensity score matching created a cohort of 1957 and 7828 patients treated with and without Goreisan, respectively. No significant difference was found in the incidence of 1-year HF readmission between the groups [22.1 % vs. 21.7 %; hazard ratio (HR) = 1.02, 95 % confidence interval (CI) = 0.92-1.13]. This result was consistent with that from competing risk analysis (subdistribution HR = 1.02, 95 % CI = 0.92-1.13) and across clinically relevant subgroups except for renal disease. Goreisan use was associated with a lower incidence of HF readmission among patients with renal disease (HR = 0.77, 95 % CI = 0.60-0.97), but not among those without (HR = 1.09, 95 % CI = 0.97-1.23; p for interaction = 0.009). CONCLUSIONS This nationwide propensity score-matched analysis did not demonstrate that complementary Goreisan use at discharge was associated with a lower incidence of 1-year HF readmission in patients with HF receiving standard medications. An ongoing randomized trial is awaited to establish the effectiveness of Goreisan use in patients with HF.
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Affiliation(s)
- Toshiaki Isogai
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Cardiology, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan.
| | - Kojiro Morita
- Department of Nursing Administration and Advanced Clinical Nursing, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Akira Okada
- Department of Prevention of Diabetes and Lifestyle-related Diseases, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Nobuaki Michihata
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan; Cancer Prevention Center, Chiba Cancer Center Research Institute, Chiba, Japan
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Atsushi Miyawaki
- Department of Health Services Research, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan; Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Taisuke Jo
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
| | - Hideo Yasunaga
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo, Tokyo, Japan
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Li X, Si J, Liu Y, Xu D. Real world experience in effect of torsemide vs. furosemide after discharge in patients with HFpEF. ESC Heart Fail 2024. [PMID: 39238285 DOI: 10.1002/ehf2.15071] [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: 04/06/2024] [Revised: 08/20/2024] [Accepted: 08/23/2024] [Indexed: 09/07/2024] Open
Abstract
AIMS Few studies have focused on the effect of torsemide versus furosemide after discharge on prognosis in patients with heart failure with preserved ejection fraction (HFpEF). This single-centre retrospective real-world study was conducted to evaluate the effect of torsemide versus furosemide after discharge on all-cause mortality and rehospitalization for heart failure in patients with HFpEF. METHODS Consecutive patients who were diagnosis with HFpEF after discharge between January 2015 and April 2018 at the First Affiliated Hospital of Dalian Medical University and who had been treated with torsemide or furosemide were included in this study. The primary outcome was all-cause mortality. The second outcome was rehospitalization for heart failure. RESULTS A total of 445 patients (mean age 68.56 ± 8.07, female 55%) were divided into the torsemide group (N = 258) or furosemide group (N = 187) based on the treatment course at discharge from the hospital. During a mean follow-up of 87.67 ± 11.15 months, death occurred in 68 of 258 patients (26.36%) in the torsemide group and 60 of 187 patients (30.09%) in the furosemide group [hazard ratio (HR) 0.81, 95% confidence interval (CI) 0.57-1.15, P = 0.239]. Rehospitalization for heart failure occurred in 111 of 258 patients (43.02%) in the torsemide groups and 110 of 187 patients (58.82%) in the furosemide group (HR 0.64, 95% CI 0.49-0.85, P = 0.002). CONCLUSIONS Compared with furosemide, torsemide did not significantly reduce all-cause mortality, but there was association between torsemide and reduced rehospitalization for heart failure in patients with HFpEF.
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Affiliation(s)
- Xiao Li
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Jinping Si
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Ying Liu
- Department of Cardiology, First Affiliated Hospital of Dalian Medical University, Dalian, China
| | - Danyan Xu
- Department of Cardiology, The Second Xiangya Hospital, Central South University, Changsha, China
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Shahim A, Donal E, Hage C, Oger E, Savarese G, Persson H, Haugen-Löfman I, Ennezat PV, Sportouch-Dukhan C, Drouet E, Daubert JC, Linde C, Lund LH. Rates and predictors of cardiovascular and non-cardiovascular outcomes in heart failure with preserved ejection fraction. ESC Heart Fail 2024. [PMID: 39075721 DOI: 10.1002/ehf2.14928] [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: 12/11/2023] [Revised: 05/24/2024] [Accepted: 06/14/2024] [Indexed: 07/31/2024] Open
Abstract
AIMS The detailed sub-categories of death and hospitalization, and the impact of comorbidities on cause-specific outcomes, remain poorly understood in heart failure (HF) with preserved ejection fraction (HFpEF). We sought to evaluate rates and predictors of cardiovascular (CV) and non-CV outcomes in HFpEF. METHODS The Karolinska-Rennes study was a bi-national prospective observational study designed to characterize HFpEF (ejection fraction ≥45%). Patients were followed for cause-specific death and hospitalization. Baseline characteristics were pre-selected based on clinical relevance and potential eligibility criteria for HFpEF trials. The associations between characteristics and cause-specific outcomes were assessed with univariable and multivariable Cox regressions. RESULTS Five hundred thirty-nine patients [56% females; median (inter-quartile range) age 79 (72-84) years; NT-proBNP/BNP 2448 (1290-4790)/429 (229-805) ng/L] were included. Over 1196 patient-years follow-up [median (min, max) 744 days (13-1959)], there were 159 (29%) deaths (13 per 100 patient-years: CV 5.1 per 100, dominated by HF 3.9 per 100; and non-CV 5.8 per 100, dominated by cancer, 2.3 per 100). There were 723 hospitalizations in 338 patients (63%; 60 per 100 patient-years: CV 33 per 100, dominated by HF 17 per 100; and non-CV 27 per 100, dominated by lung disease 5 per 100). Higher age and natriuretic peptides, lower serum natraemia and NYHA class III-IV were independent predictors of CV death; lower serum natraemia, anaemia and stroke of non-CV death; and anaemia and lower serum natraemia of non-CV death or hospitalizations. There were no apparent predictors of CV death or hospitalization. CONCLUSIONS In a clinical cohort hospitalized and diagnosed with HFpEF, death and hospitalization rates were roughly similar for CV and non-CV causes. CV deaths were predicted primarily by severity of HF; non-CV deaths primarily by anaemia and prior stroke. Lower serum sodium predicted both. Hospitalizations were difficult to predict.
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Affiliation(s)
- Angiza Shahim
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Erwan Donal
- Département de Cardiologie & CIC-IT U 804, Centre Hospitalier Universitaire de Rennes, Rennes, France
- LTSI, Université Rennes 1, INSERM, Rennes, France
| | - Camilla Hage
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Emmanuel Oger
- Pharmacoepidemiology and Health Services Research, REPERES, University of Rennes, Rennes, France
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Hans Persson
- Department of Clinical Sciences, Danderyd Hospital, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Danderyd Hospital, Stockholm, Sweden
| | - Ida Haugen-Löfman
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | | | | | - Jean-Claude Daubert
- Département de Cardiologie & CIC-IT U 804, Centre Hospitalier Universitaire de Rennes, Rennes, France
- LTSI, Université Rennes 1, INSERM, Rennes, France
| | - Cecilia Linde
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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Fazio S, Mercurio V, Fazio V, Ruvolo A, Affuso F. Insulin Resistance/Hyperinsulinemia, Neglected Risk Factor for the Development and Worsening of Heart Failure with Preserved Ejection Fraction. Biomedicines 2024; 12:806. [PMID: 38672161 PMCID: PMC11047865 DOI: 10.3390/biomedicines12040806] [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: 03/12/2024] [Revised: 03/27/2024] [Accepted: 04/03/2024] [Indexed: 04/28/2024] Open
Abstract
Heart failure (HF) has become a subject of continuous interest since it was declared a new pandemic in 1997 because of the exponential increase in hospitalizations for HF in the latest years. HF is the final state to which all heart diseases of different etiologies lead if not adequately treated. It is highly prevalent worldwide, with a progressive increase with age, reaching a prevalence of 10% in subjects over the age of 65 years. During the last two decades, it was possible to see that the prevalence of heart failure with preserved ejection fraction (HFpEF) was increasing while that of heart failure with reduced ejection fraction (HFrEF) was decreasing. HFpEF is typically characterized by concentric remodeling of the left ventricle (LV) with impaired diastolic function and increased filling pressures. Over the years, also the prevalence of insulin resistance (IR)/hyperinsulinemia (Hyperins) in the general adult population has progressively increased, primarily due to lifestyle changes, particularly in developed and developing countries, with a range that globally ranges between 15.5% and 46.5%. Notably, over 50% of patients with HF also have IR/Hyperins, and the percentage is even higher in those with HFpEF. In the scientific literature, it has been well highlighted that the increased circulating levels of insulin, associated with conditions of insulin resistance, are responsible for progressive cardiovascular alterations over the years that could stimulate the development and/or the worsening of HFpEF. The aim of this manuscript was to review the scientific literature that supports a pathophysiologic connection between IR/Hyperins and HFpEF to stimulate the scientific community toward the identification of hyperinsulinemia associated with insulin resistance as an independent cardiovascular risk factor in the development and worsening of HF, believing that its adequate screening in the general population and an appropriate treatment could reduce the prevalence of HFpEF and improve its progression.
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Affiliation(s)
- Serafino Fazio
- Department of Internal Medicine, School of Medicine, Federico II University, Via Sergio Pansini 5, 80135 Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences, Federico II University, Via Sergio Pasini 5, 80135 Naples, Italy;
| | - Valeria Fazio
- UOC Medicina Interna, Azienda Ospedaliera di Caserta, 81100 Caserta, Italy;
| | - Antonio Ruvolo
- UOC Cardiologia AORN dei colli PO CTO, Viale Colli Aminei 21, 80100 Naples, Italy;
| | - Flora Affuso
- Independent Researcher, Viale Raffaello 74, 80129 Naples, Italy;
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Santas E, Llácer P, Palau P, de la Espriella R, Miñana G, Lorenzo M, Núñez-Marín G, Miró Ò, Chorro FJ, Bayés-Genís A, Sanchis J, Núñez J. Noncardiovascular morbidity and mortality across left ventricular ejection fraction categories following hospitalization for heart failure. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:206-214. [PMID: 37315921 DOI: 10.1016/j.rec.2023.05.005] [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: 02/12/2023] [Accepted: 05/16/2023] [Indexed: 06/16/2023]
Abstract
INTRODUCTION AND OBJECTIVES Noncardiovascular events represent a significant proportion of the morbidity and mortality burden in patients with heart failure (HF). However, the risk of these events appears to differ by left ventricular ejection fraction (LVEF) status. In this study, we sought to evaluate the risk of noncardiovascular death and recurrent noncardiovascular readmission by LVEF status following an admission for acute HF. METHODS We retrospectively assessed a cohort of 4595 patients discharged after acute HF in a multicenter registry. We evaluated LVEF as a continuum, stratified in 4 categories (LVEF ≤ 40%, 41%-49%, 50%-59%, and ≥ 60%). Study endpoints were the risks of noncardiovascular mortality and recurrent noncardiovascular admissions during follow-up. RESULTS At a median follow-up of 2.2 [interquartile range, 0.76-4.8] years, we registered 646 noncardiovascular deaths and 4014 noncardiovascular readmissions. After multivariable adjustment including cardiovascular events as a competing event, LVEF status was associated with the risk of noncardiovascular mortality and recurrent noncardiovascular admissions. When compared with patients with LVEF ≤ 40%, those with LVEF 51%-59%, and especially those with LVEF ≥ 60%, were at higher risk of noncardiovascular mortality (HR, 1.31; 95%CI, 1.02-1,68; P=.032; and HR, 1.47; 95%CI, 1.15-1.86; P=.002; respectively), and at higher risk of recurrent noncardiovascular admissions (IRR, 1.17; 95%CI, 1.02-1.35; P=.024; and IRR, 1.26; 95%CI, 1.11-1.45; P=.001; respectively). CONCLUSIONS Following an admission for HF, LVEF status was directly associated with the risk of noncardiovascular morbidity and mortality. Patients with HFpEF were at higher risk of noncardiovascular death and total noncardiovascular readmissions, especially those with LVEF ≥ 60%.
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Affiliation(s)
- Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Pau Llácer
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Patricia Palau
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Rafael de la Espriella
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Miguel Lorenzo
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Gonzalo Núñez-Marín
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain
| | - Òscar Miró
- Servicio de Urgencias, Hospital Clinic de Barcelona, Barcelona, Spain
| | - Francisco Javier Chorro
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Antoni Bayés-Genís
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain; Servicio de Cardiología, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario, Universitat de València, Instituto de Investigación Sanitaria INCLIVA, Valencia, Spain; Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Spain.
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Kaddoura R, Madurasinghe V, Chapra A, Abushanab D, Al-Badriyeh D, Patel A. Beta-blocker therapy in heart failure with preserved ejection fraction (B-HFpEF): A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102376. [PMID: 38184132 DOI: 10.1016/j.cpcardiol.2024.102376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/08/2024]
Abstract
INTRODUCTION While beta-blockers are considered the cornerstone of treatment for heart failure with reduced ejection fraction, the same may not apply to patients with heart failure with preserved ejection fraction (HFpEF). To date, the benefit of beta-blockers remains uncertain, and there is no current consensus on their effectiveness. This study sought to evaluate the efficacy of beta-blockers on mortality and rehospitalization among patients with HFpEF. METHODS A systematic review and meta-analysis of randomized or observational cohort studies examined the efficacy of beta-blocker therapy in comparison with placebo, control, or standard medical care in patients with HFpEF, defined as left ventricular ejection fraction ≥50 %. The main endpoints were mortality (i.e., all-cause and cardiovascular), rehospitalization (i.e., all-cause and for heart failure) and a composite of the two. RESULTS Out of the 13,189 records initially identified, 16 full-text records met the inclusion criteria and were analyzed recruiting a total of 27,188 patients. The mean age range was 62-84 years old, predominantly female, with HFpEF in which 63.4 % of patients received a beta-blocker and 36.6 % did not. The pooled analysis of included cohort studies, of variable follow-up durations, showed a significant reduction in all-cause mortality by 19 % (odds ratio (OR) 0.81; 95 % confidence interval (CI): 0.65-0.99, p = 0.044) whereas rehospitalization for heart failure (OR 1.13; 95 % CI: 0.91-1.41, p = 0.27) or its composite with all-cause mortality (OR 1.01; 95 % CI: 0.78-1.32, p = 0.92) were similar between the beta-blocker and control groups. CONCLUSION This meta-analysis showed that beta-blocker therapy has the potential to reduce all-cause mortality in patients with HFpEF based on observational studies. Nevertheless, it did not affect rehospitalization for heart failure or its composite with all-cause mortality. Large scale randomized trials are needed to clarify this uncertainty.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
| | | | - Ammar Chapra
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Dina Abushanab
- Drug Information Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Ashfaq Patel
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Sreenivasan J, Malik A, Khan MS, Lloji A, Hooda U, Aronow WS, Lanier GM, Pan S, Greene SJ, Murad MH, Michos ED, Cooper HA, Gass A, Gupta R, Desai NR, Mentz RJ, Frishman WH, Panza JA. Pharmacotherapies in Heart Failure With Preserved Ejection Fraction: A Systematic Review and Network Meta-Analysis. Cardiol Rev 2024; 32:114-123. [PMID: 36576372 DOI: 10.1097/crd.0000000000000484] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Various pharmacotherapies exist for heart failure with preserved ejection fraction (HFpEF), but with unclear comparative efficacy. We searched EMBASE, Medline, and Cochrane Library from inception through August 2021 for all randomized clinical trials in HFpEF (EF >40%) that evaluated beta-blockers, mineralocorticoid receptor antagonist (MRA), angiotensin-converting enzyme inhibitors (ACE), angiotensin receptor blockers (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), and sodium-glucose cotransporter-2 inhibitors (SGLT2i). Outcomes assessed were cardiovascular mortality, all-cause mortality, and HF hospitalization. A frequentist network meta-analysis was performed with a random-effects model. We included 22 randomized clinical trials (30,673 participants; mean age = 71.7 ± 4.2 years; females = 49.3 ± 7.7%; median follow-up = 24.4 ± 11.1 months). Compared with placebo, there was no statistically significant difference in cardiovascular mortality [beta-blockers; odds ratio (OR) 0.79 (0.46-1.34), MRA; OR 0.90 (0.70-1.14), ACE OR 0.95 (0.59-1.53), ARB; OR 1.02 (0.87-1.19), ARNI; OR 0.97 (0.74-1.26) and SGLT2i; OR 1.00 (0.84-1.18)] or all-cause mortality [beta blockers; OR 0.75 (0.54-1.04), MRA; OR 0.90 (0.75-1.08) ACE; OR 1.05 (0.71-1.54), ARB; OR 1.03 (0.91-1.15), ARNI; OR 0.99 (0.82-1.20) and SGLT2i; OR 1.00 (0.89-1.13)]. The certainty in these estimates was low or very low. There was a significantly reduction in HF hospitalization with the use of SGLT2i [OR 0.71 (0.62-0.82), moderate certainty], ARNI [OR 0.77 (0.63-0.94), low certainty], and MRA [OR 0.81 (0.66-0.98), moderate certainty]; with corresponding P scores of 0.84, 0.68, and 0.58, respectively. In HFpEF, the use of beta-blockers, MRA, ACE/ARB/ARNI, or SGLT2i was not associated with improved cardiovascular or all-cause mortality. SGLT2i, ARNI, and MRA reduced the risk of HF hospitalizations.
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Affiliation(s)
- Jayakumar Sreenivasan
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Aaqib Malik
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Muhammad Shahzeb Khan
- Duke Clinical Research Institute, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Amanda Lloji
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Urvashi Hooda
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Wilbert S Aronow
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Gregg M Lanier
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Stephen Pan
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - M Hassan Murad
- Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, MN
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD
| | - Howard A Cooper
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Alan Gass
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
| | - Rahul Gupta
- Division of Cardiology, Lehigh Valley Heart Institute, Lehigh Valley Health Network, Allentown, PA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, NC
- Division of Cardiology, Duke University School of Medicine, Durham, NC
| | | | - Julio A Panza
- From the Department of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY
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9
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Kaddoura R, Patel A. Revisiting Beta-Blocker Therapy in Heart Failure with Preserved Ejection Fraction. Curr Probl Cardiol 2023; 48:102015. [PMID: 37544622 DOI: 10.1016/j.cpcardiol.2023.102015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogenous disorder and tends to be predominant in elderly, female, and obese patients. HFpEF has been classified using various cut-offs of left ventricular ejection fraction in the published studies with a current cut-off of ≥50%. The evidence of beta-blocker therapy in HFpEF patients showed conflicting findings with variably reported efficacy. This review aims to examine the published studies on the use of beta blockers for the treatment of patients with HFpEF.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
| | - Ashfaq Patel
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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10
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Waksman R, Pahuja M, van Diepen S, Proudfoot AG, Morrow D, Spitzer E, Nichol G, Weisfeldt ML, Moscucci M, Lawler PR, Mebazaa A, Fan E, Dickert NW, Samsky M, Kormos R, Piña IL, Zuckerman B, Farb A, Sapirstein JS, Simonton C, West NEJ, Damluji AA, Gilchrist IC, Zeymer U, Thiele H, Cutlip DE, Krucoff M, Abraham WT. Standardized Definitions for Cardiogenic Shock Research and Mechanical Circulatory Support Devices: Scientific Expert Panel From the Shock Academic Research Consortium (SHARC). Circulation 2023; 148:1113-1126. [PMID: 37782695 PMCID: PMC11025346 DOI: 10.1161/circulationaha.123.064527] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2023] [Accepted: 07/31/2023] [Indexed: 10/04/2023]
Abstract
The Shock Academic Research Consortium is a multi-stakeholder group, including representatives from the US Food and Drug Administration and other government agencies, industry, and payers, convened to develop pragmatic consensus definitions useful for the evaluation of clinical trials enrolling patients with cardiogenic shock, including trials evaluating mechanical circulatory support devices. Several in-person and virtual meetings were convened between 2020 and 2022 to discuss the need for developing the standardized definitions required for evaluation of mechanical circulatory support devices in clinical trials for cardiogenic shock patients. The expert panel identified key concepts and topics by performing literature reviews, including previous clinical trials, while recognizing current challenges and the need to advance evidence-based practice and statistical analysis to support future clinical trials. For each category, a lead (primary) author was assigned to perform a literature search and draft a proposed definition, which was presented to the subgroup. These definitions were further modified after feedback from the expert panel meetings until a consensus was reached. This manuscript summarizes the expert panel recommendations focused on outcome definitions, including efficacy and safety.
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Affiliation(s)
- Ron Waksman
- Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC (R.W.)
| | - Mohit Pahuja
- Division of Cardiology, University of Oklahoma Health Sciences Center, Oklahoma City (M.P.)
| | - Sean van Diepen
- Department of Critical Care Medicine and Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Canada (S.v.D.)
| | - Alastair G Proudfoot
- Department of Perioperative Medicine, Barts Heart Centre, London, UK (A.G.P.)
- Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité-Universitätsmedizin Berlin, Germany (A.G.P.)
| | - David Morrow
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (D.M.)
| | - Ernest Spitzer
- Cardialysis, Rotterdam, The Netherlands (E.S.)
- Cardiology Department, Thoraxcenter, Erasmus University Medical Center, Rotterdam, The Netherlands (E.S.)
| | - Graham Nichol
- University of Washington-Harborview Center for Prehospital Emergency Care, University of Washington Harborview Center, Seattle (G.N.)
| | - Myron L Weisfeldt
- Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD (M.L.W.)
| | - Mauro Moscucci
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Patrick R Lawler
- Peter Munk Cardiac Centre, Toronto General Hospital Research Institute, Canada (P.R.L.)
- McGill University Health Centre, Montreal, Canada (P.R.L.)
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (P.R.L.)
| | - Alexandre Mebazaa
- Université Paris Cité, Department of Anesthesiology and Critical Care Medicine, Hôpital Lariboisière, France (A.M.)
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Canada (E.F.)
| | - Neal W Dickert
- Department of Medicine, Division of Cardiology, Emory University School of Medicine, Atlanta, GA (N.W.D.)
| | - Marc Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (M.S.)
| | - Robert Kormos
- Global Medical Affairs Heart Failure, Abbott Laboratories, Austin, TX (R.K.)
| | - Ileana L Piña
- Division of Cardiology, Thomas Jefferson University, Philadelphia, PA (I.L.P.)
| | - Bram Zuckerman
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - Andrew Farb
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | - John S Sapirstein
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, US Food and Drug Administration, Silver Spring, MD (M.M., B.Z., A.F., J.S.S.)
| | | | | | - Abdulla A Damluji
- Inova Center of Outcomes Research, Inova Heart and Vascular Institute, Falls Church, VA (A.A.D.)
| | - Ian C Gilchrist
- Department of Interventional Cardiology/Heart and Vascular Institute, Penn State Health/Hershey Medical Center (I.C.G.)
| | - Uwe Zeymer
- Institut für Herzinfarktforschung Ludwigshafen, Germany (U.Z.)
| | - Holger Thiele
- Heart Center Leipzig at University of Leipzig, Germany (H.T.)
- Leipzig Heart Science, Germany (H.T.)
| | - Donald E Cutlip
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston MA (D.E.C.)
| | - Mitchell Krucoff
- Department of Medicine, Duke University School of Medicine, Durham, NC (M.K.)
| | - William T Abraham
- Division of Cardiovascular Medicine and the Davis Heart and Lung Research Institute, The Ohio State University College of Medicine/Ohio State University Wexner Medical Center, Columbus (W.T.A.)
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11
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Tang Y, Sang H. Cost-utility analysis of add-on dapagliflozin in heart failure with preserved or mildly reduced ejection fraction. ESC Heart Fail 2023; 10:2524-2533. [PMID: 37290665 PMCID: PMC10375078 DOI: 10.1002/ehf2.14426] [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: 10/20/2022] [Revised: 05/02/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023] Open
Abstract
AIMS The DELIVER study demonstrates a significant improvement in cardiovascular death or hospitalization for heart failure among heart failure with mildly reduced ejection fraction (HFmrEF) or heart failure with preserved ejection fraction (HFpEF).Cost-utility of the adjunct use of dapagliflozin to standard therapy among patients with HFpEF or HFmrEF remains unclear. METHODS AND RESULTS A five-state Markov mode was constructed to project health and clinical outcomes of the adjunct use of dapagliflozin to standard therapy among 65-year-old patients with HFpEF or HFmrEF. A cost-utility analysis was performed based on the DELIVER study and national statistical database. The cost and utility was inflated to 2022 by the usual discount rate of 5%. The primary outcomes were total cost and quality-adjusted life-years (QALYs) per patients as well as the incremental cost-effectiveness ratio. Sensitivity analyses were also applied. Over a 15 year lifetime horizon, the average cost per patient was $7245.77 and $5407.55 in the dapagliflozin group and the standard group, along with an incremental cost of $1838.22. The average QALYs per patient was 6.00 QALYs and 5.84 QALYs in the dapagliflozin group and the standard group, along with an incremental QALYs of 0.15 QALYs, resulting in the incremental cost-effectiveness ratio of $11 865.33/QALY, which was below the willingness-to-pay (WTP) of $12 652.5/QALY. The univariate sensitivity analysis indicated the cardiovascular death in both group was the most sensitive variable. Probability sensitivity analysis revealed that when the WTP thresholds were $12 652.5/QALY and $37 957.5/QALY, the probabilities of being cost-effective with dapagliflozin as an add-on were 54.6% and 71.6%, respectively. CONCLUSIONS From a public healthcare system perspective, the adjunct use of dapagliflozin to standard therapy among patients with HFpEF or HFmrEF generated advantages in cost-effectiveness in China at a WTP of $12 652.5/QALY, which promoted the rational use of dapagliflozin for heart failure.
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Affiliation(s)
- Yi Tang
- Department CardiologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
| | - Haiqiang Sang
- Department CardiologyThe First Affiliated Hospital of Zhengzhou UniversityZhengzhouChina
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12
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Zhou Y, Li H, Fang L, Wu W, Sun Z, Zhang Z, Liu M, Liu J, He L, Chen Y, Xie Y, Li Y, Xie M. Biventricular longitudinal strain as a predictor of functional improvement after D-shant device implantation in patients with heart failure. Front Cardiovasc Med 2023; 10:1121689. [PMID: 37139125 PMCID: PMC10149702 DOI: 10.3389/fcvm.2023.1121689] [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: 12/12/2022] [Accepted: 03/29/2023] [Indexed: 05/05/2023] Open
Abstract
Background The creation of an atrial shunt is a novel approach for the management of heart failure (HF), and there is a need for advanced methods for detection of cardiac function response to an interatrial shunt device. Ventricular longitudinal strain is a more sensitive marker of cardiac function than conventional echocardiographic parameters, but data on the value of longitudinal strain as a predictor of improvement in cardiac function after implantation of an interatrial shunt device are scarce. We aimed to investigate the exploratory efficacy of the D-Shant device for interatrial shunting in treating heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF), and to explore the predictive value of biventricular longitudinal strain for functional improvement in such patients. Methods A total of 34 patients were enrolled (25 with HFrEF and 9 with HFpEF). All patients underwent conventional echocardiography and two-dimensional speckle tracking echocardiogram (2D-STE) at baseline and 6 months after implantation of a D-Shant device (WeiKe Medical Inc., WuHan, CN). Left ventricular global longitudinal strain (LVGLS) and right ventricular free wall longitudinal strain (RVFWLS) were evaluated by 2D-STE. Results The D-Shant device was successfully implanted in all cases without periprocedural mortality. At 6-month follow-up, an improvement in New York Heart Association (NYHA) functional class was observed in 20 of 28 patients with HF. Compared with baseline, patients with HFrEF showed significant reduced left atrial volume index (LAVI) and increased right atrial (RA) dimensions, as well as improved LVGLS and RVFWLS, at 6-month follow-up. Despite reduction in LAVI and increase in RA dimensions, improvements in biventricular longitudinal strain did not occur in HFpEF patients. Multivariate logistic regression demonstrated that LVGLS [odds ratio (OR): 5.930; 95% CI: 1.463-24.038; P = 0.013] and RVFWLS (OR: 4.852; 95% CI: 1.372-17.159; P = 0.014) were predictive of improvement in NYHA functional class after D-Shant device implantation. Conclusion Improvements in clinical and functional status are observed in patients with HF 6 months after implantation of a D-Shant device. Preoperative biventricular longitudinal strain is predictive of improvement in NYHA functional class and may be helpful to identify patients who will experience better outcomes following implantation of an interatrial shunt device.
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Affiliation(s)
- Yi Zhou
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - He Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Lingyun Fang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Wenqian Wu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Zhenxing Sun
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Ziming Zhang
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Manwei Liu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Jie Liu
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Lin He
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yihan Chen
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yuji Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
| | - Yuman Li
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- Correspondence: Yuman Li Mingxing Xie
| | - Mingxing Xie
- Department of Ultrasound, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
- Clinical Research Center for Medical Imaging in Hubei Province, Wuhan, China
- Hubei Province Key Laboratory of Molecular Imaging, Wuhan, China
- Correspondence: Yuman Li Mingxing Xie
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13
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Tang Y, Sang H. Cost-utility analysis of empagliflozin in heart failure patients with reduced and preserved ejection fraction in China. Front Pharmacol 2022; 13:1030642. [PMID: 36386229 PMCID: PMC9649680 DOI: 10.3389/fphar.2022.1030642] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 10/05/2022] [Indexed: 08/21/2023] Open
Abstract
Objective: EMPEROR-Reduced and EMPEROR-Preserved studies showed the benefits of empagliflozin along with a reduction in cardiovascular death or hospitalisation for heart failure (HF). Our aim was to evaluate the economics and effectiveness of adding empagliflozin to the standard therapy for HF with reduced ejection fraction (HFrEF) and HF preserved ejection fraction (HFpEF) in China. Methods: A multistate Markov model was constructed to yield the clinical and economic outcomes of adding empagliflozin to the standard therapy for 65-year-old patients with HFrEF and HFpEF. A cost-utility analysis was conducted, mostly derived from the EMPEROR-Reduced study, EMPEROR-Preserved study, and national statistical database. All costs and outcomes were discounted at the rate of 5% per annum. The primary outcomes were total and incremental costs, quality-adjusted life years (QALYs), and incremental cost-effectiveness ratio (ICER). Sensitivity analyses were also performed. Results: In the HFrEF population, the 10-year incremental cost was $827.52 and the 10-year incremental QALY was 0.15 QALYs, resulting in an ICER of $5,612.06/QALY, which was below the WTP of $12,652.5/QALY. In the HFpEF population, compared with the control group, the incremental cost was $1,271.27, and the incremental QALY was 0.11 QALYs, yielding an ICER of 11,312.65 $/QALY, which was also below the WTP of $12,652.5/QALY. In the HFrEF and HFpEF populations, the results of a one-way sensitivity analysis showed that the risk of cardiovascular death in both groups was the most influential parameter. In the HFrEF population, a probability sensitivity analysis (PSA) revealed that when the WTP thresholds were $12,652.5/QALY and $37,957.5/QALY, the probabilities of being cost-effective with empagliflozin as an add-on were 59.4% and 72.6%, respectively. In the HFpEF population, the PSA results revealed that the probabilities of being cost-effective with empagliflozin as an add-on were 53.1% and 72.2%, respectively. Conclusion: Considering that the WTP threshold was $12,652.5/QALY, adding empagliflozin to standard therapy was proven to be a slightly more cost-effective option for the treatment of HFrEF and HFpEF from a Chinese healthcare system perspective, which promoted the rational use of empagliflozin for HF.
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Affiliation(s)
| | - Haiqiang Sang
- Department Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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14
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Jiang Y, Xie J. Cost-effectiveness of adding empagliflozin to the standard therapy for Heart Failure with Preserved Ejection Fraction from the perspective of healthcare systems in China. Front Cardiovasc Med 2022; 9:946399. [PMID: 36119747 PMCID: PMC9479072 DOI: 10.3389/fcvm.2022.946399] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Accepted: 08/11/2022] [Indexed: 11/13/2022] Open
Abstract
Background The Empagliflozin Outcome Trial in Patients with Chronic Heart Failure with Preserved Ejection Fraction (EMPEROR-Preserved) is the first randomized controlled trial to provide promising evidence on the efficacy of adding empagliflozin to the standard therapy in patients with Heart Failure with Preserved Ejection Fraction (HFpEF), but the cost-effectiveness of add-on empagliflozin treatment remains unclear. Method A Markov model using data from the EMPEROR-Preserved trial and national database was constructed to assess lifetime costs and utility from a China healthcare system perspective. The time horizon was 10 years and a 5% discount rate was applied. Incremental cost-effectiveness ratio (ICER) against willingness to pay (WTP) threshold was performed to evaluate the cost-effectiveness. A series of sensitivity analyses was applied to ensure the robustness of the results. Results Compared to standard therapy, the increased cost of adding empagliflozin from $4,645.23 to $5,916.50 was associated with a quality-adjusted life years (QALYs) gain from 4.70 to 4.81, projecting an ICER of $11,292.06, which was lower than a WTP threshold of $12,652.5. Univariate sensitivity analysis revealed that the parameters with the largest impact on ICER were cardiovascular mortality in both groups, followed by the cost of empagliflozin and the cost of hospitalization for heart failure. Probabilistic sensitivity analysis indicated that when the WTP threshold was $12,652.5 and $37,957.5, the probability of being cost-effective for adding empagliflozin was 52.7% and 67.6%, respectively. Scenario analysis demonstrated that the cost of empagliflozin, the cost of hospitalization for heart failure, NYHA functional classes, and time horizon had a greater impact on the ICER. Conclusion At a WTP threshold of $12,652.5, the add-on empagliflozin treatment for HFpEF was cost-effective in healthcare systems in China, which promoted the rational use of empagliflozin for HFpEF.
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Affiliation(s)
| | - Jun Xie
- Department of Cardiology, Nanjing Drum Tower Hospital, Affiliated Hospital of Medical School, Nanjing University, Nanjing, China
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15
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Khan MS, Butler J, Vaduganathan M, Greene SJ. Heart Failure Specific Versus All-Cause Endpoints in Heart Failure Clinical Trials. J Card Fail 2022; 28:1398-1400. [PMID: 35843491 DOI: 10.1016/j.cardfail.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 11/19/2022]
Affiliation(s)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; Department of Medicine, University of Mississippi, Jackson, Mississippi
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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16
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Barkoudah E, Claggett BL, Lewis EF, O'Meara E, Clausell N, Diaz R, Fleg JL, Pitt B, Rouleau JL, Solomon SD, Pfeffer MA, Desai AS. Prognostic Impact of Cardiovascular versus Noncardiovascular Hospitalizations in Heart Failure with Preserved Ejection Fraction: Insights from TOPCAT. J Card Fail 2022; 28:1390-1397. [PMID: 35636727 DOI: 10.1016/j.cardfail.2022.05.004] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Revised: 05/11/2022] [Accepted: 05/13/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients with heart failure (HF) with preserved ejection fraction (HFpEF) are commonly admitted to the hospital for both cardiovascular (CV) and noncardiovascular (non-CV) reasons. The prognostic implications of non-CV hospitalizations in this population are not well understood. In this study, we aimed to examine the prognostic implications of hospitalizations due to CV and non-CV reasons in a HFpEF population. METHODS AND RESULTS The Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist trial (TOPCAT) randomized 3,445 stable outpatients with chronic HF with left ventricular ejection fraction >=45% and either prior hospitalization for HF or elevated natriuretic peptides to treatment with spironolactone or placebo. Hospitalizations for any cause were reported by investigators during study follow-up and characterized according to prespecified category causes. This analysis focused on the subset of TOPCAT participants enrolled in the Americas (N=1,767), in which 2,973 hospitalizations were observed in 1,062 subjects (60%) over a mean follow-up of 3.3 years of study follow-up, of which 1,474 (49%) were ascribed to CV causes. Among 1,056 first hospitalizations, 478 (45%) were for CV reasons and 578 (55%) for non-CV reasons. Mortality rates were lowest for participants not hospitalized during the trial (3.2 per 100 patient-years (PY)), but similarly elevated following first hospitalization for CV and non-CV reasons (11.0 per 100 PY vs. 12.6 per 100 PY, respectively, p=0.24). Among those hospitalized for CV reasons, mortality rates were similar following hospitalization for HF and non-CV related reasons (15.2 per 100 PY vs. 12.6 per 100 PY, p=0.23). Recurrent hospitalization, whether due to CV or non-CV causes, was associated with heightened risk for subsequent mortality, with similar death rates following hospitalization twice for CV reasons (18.5 per 100 PY), twice for non-CV reasons (21.6 per 100 PY), or once each for CV and non-CV reasons (18.4 per 100 PY). CONCLUSION Among patients with HFpEF, hospitalization for any cause is associated with heightened risk for post-discharge mortality, with even higher risk associated with recurrent hospitalization. Given the high burden of non-CV hospitalizations in this population, targeted management of comorbid medical illness may be critical to reducing morbidity and mortality.
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Affiliation(s)
- Ebrahim Barkoudah
- Cardiovascular Division; Department of Medicine, Brigham and Women's Hospital, Boston, MA
| | | | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA
| | - Eileen O'Meara
- Montreal Heart Institute Department of Medicine and Research Centre, and Université de Montréal, 5000 Belanger Street, Montréal, Québec, Canada
| | - Nadine Clausell
- Division of Cardiology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Rafael Diaz
- Estudios Cardiológicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Jerome L Fleg
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD
| | - Bertram Pitt
- Division of Cardiology, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI
| | - Jean L Rouleau
- Montreal Heart Institute Department of Medicine and Research Centre, and Université de Montréal, 5000 Belanger Street, Montréal, Québec, Canada
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17
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Agrawal V, Hardas S, Gujar H, Phalgune DS. Correlation of serum ST2 levels with severity of diastolic dysfunction on echocardiography and findings on cardiac MRI in patients with heart failure with preserved ejection fraction. Indian Heart J 2022; 74:229-234. [PMID: 35278459 PMCID: PMC9243600 DOI: 10.1016/j.ihj.2022.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2022] [Revised: 02/21/2022] [Accepted: 03/07/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE The aim of the present study was to find a correlation of serum Suppression of tumorigenicity 2 (ST2) levels with severity of diastolic dysfunction on echocardiography and cardiac magnetic resonance imaging (CMRI) in heart failure with preserved ejection fraction (HFpEF) patients. METHODS Fifty patients aged ≥18 years fulfilling diagnostic criteria for HFpEF were included. ST2 levels, 2D echocardiography and CMRI were performed. Left ventricular ejection fraction, E/A, Septal E/E', left atrial volume index (LAVI), tricuspid regurgitation (TR), assessment of diastolic dysfunction, T1 mapping in milliseconds and late gadolinium enhancement (LGE) in percentage were noted. The primary outcome measure was to study correlation of ST2 levels with severity of diastolic dysfunction, whereas the secondary outcome measures were to study correlation of ST2 levels with native T1 mapping and LGE on CMRI. RESULTS ST2 levels showed statistically significant and positive correlation with E/E' (r = 0.837), peak TR velocity (r = 0.373), LAVI (r = 0.74), E/A (r = 0.420), and T1 values in milliseconds (r = 0.619). There was no statistically significant correlation between ST2 level and LGE in % (r = 0.145). The median ST2 levels in patients with E/E' > 14 and E/E' ≤ 14 were 110.8 and 36.1 respectively (p-value < 0.05). The mean ST2 levels were significantly higher in patients who had diastolic dysfunction grade III (126.4) and New York Heart Association class IV (133.3). CONCLUSIONS Evaluation of ST2 adds important information to support the diagnosis of left ventricular diastolic dysfunction in patients with HFpEF.
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Affiliation(s)
- Vivek Agrawal
- Dept. of Cardiology, Poona Hospital & Research Centre, Pune, India.
| | - Suhas Hardas
- Dept. of Cardiology, Poona Hospital & Research Centre, Pune, India.
| | - Hasmukh Gujar
- Dept. of Cardiology, Poona Hospital & Research Centre, Pune, India.
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18
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Jentzer JC, Reddy YN, Rosenbaum AN, Dunlay SM, Borlaug BA, Hollenberg SM. Outcomes and predictors of mortality among cardiac intensive care unit patients with heart failure. J Card Fail 2022; 28:1088-1099. [DOI: 10.1016/j.cardfail.2022.02.015] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 02/08/2022] [Accepted: 02/09/2022] [Indexed: 12/11/2022]
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19
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Upadhya B, Willard JJ, Lovato LC, Rocco MV, Lewis CE, Oparil S, Cushman WC, Bates JT, Bello NA, Aurigemma G, Johnson KC, Rodriguez CJ, Raj DS, Rastogi A, Tamariz L, Wiggers A, Kitzman DW. Incidence and Outcomes of Acute Heart Failure With Preserved Versus Reduced Ejection Fraction in SPRINT. Circ Heart Fail 2021; 14:e008322. [PMID: 34823375 DOI: 10.1161/circheartfailure.121.008322] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND In the SPRINT (Systolic Blood Pressure Intervention Trial), intensive BP treatment reduced acute decompensated heart failure (ADHF) events. Here, we report the effect on HF with preserved ejection fraction (HFpEF) and HF with reduced EF (HFrEF) and their subsequent outcomes. METHODS Incident ADHF was defined as hospitalization or emergency department visit, confirmed, and formally adjudicated by a blinded events committee using standardized protocols. HFpEF was defined as EF ≥45%, and HFrEF was EF <45%. RESULTS Among the 133 participants with incident ADHF who had EF assessment, 69 (52%) had HFpEF and 64 (48%) had HFrEF (P value: 0.73). During average 3.3 years follow-up in those who developed incident ADHF, rates of subsequent all-cause and HF hospital readmission and mortality were high, but there were no significant differences between those who developed HFpEF versus HFrEF. Randomization to the intensive arm had no effect on subsequent mortality or readmissions after the initial ADHF event, irrespective of EF subtype. During follow-up among participants who developed HFpEF, although relatively modest number of events limited statistical power, age was an independent predictor of all-cause mortality, and Black race independently predicted all-cause and HF hospital readmission. CONCLUSIONS In SPRINT, intensive BP reduction decreased both acute decompensated HFpEF and HFrEF events. After initial incident ADHF, rates of subsequent hospital admission and mortality were high and were similar for those who developed HFpEF or HFrEF. Randomization to the intensive arm did not alter the risks for subsequent all-cause, or HF events in either HFpEF or HFrEF. Among those who developed HFpEF, age and Black race were independent predictors of clinical outcomes. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01206062.
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Affiliation(s)
- Bharathi Upadhya
- Cardiovascular Medicine Section (B.U., D.W.K.), Wake Forest School of Medicine, Winston-Salem, NC
| | - James J Willard
- Biostatistics (J.J.W., L.C.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Laura C Lovato
- Biostatistics (J.J.W., L.C.L.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Michael V Rocco
- Nephrology Section, Department of Internal Medicine (M.V.R.), Wake Forest School of Medicine, Winston-Salem, NC
| | - Cora E Lewis
- Department of Epidemiology, School of Public Health (C.E.L.), University of Alabama at Birmingham
| | - Suzanne Oparil
- Division of Cardiovascular Disease, Department of Medicine (S.O.), University of Alabama at Birmingham
| | - William C Cushman
- Division of Cardiovascular Disease, Department of Medicine (S.O.), University of Alabama at Birmingham.,Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis (W.C.C.)
| | - Jeffrey T Bates
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX (J.T.B.)
| | - Natalie A Bello
- Cardiovascular Division, Department of Medicine, Columbia University Medical Center, New York, NY (N.A.B.)
| | - Gerard Aurigemma
- Cardiology, University of Massachusetts Medical School, Worcester (G.A.)
| | - Karen C Johnson
- Department of Preventive Medicine, University of Tennessee Health Science Center, Memphis (K.C.J.)
| | - Carlos J Rodriguez
- Department of Medicine, Epidemiology & Population Health, Albert Einstein College of Medicine, Bronx, NY (C.J.R.)
| | - Dominic S Raj
- Medicine-Nephrology, George Washington University School of Medicine, Washington, DC (D.S.R.)
| | - Anjay Rastogi
- Division of Nephrology, Department of Medicine, David Geffen School of Medicine, University of California, Los Angeles (A.R.)
| | - Leonardo Tamariz
- University of Miami Miller School of Medicine, FL (L.T.).,Veterans Affairs Medical Center, Miami, FL (L.T.)
| | - Alan Wiggers
- University Hospitals Harrington Heart and Vascular Institute, Cleveland Medical Center, OH (A.W.)
| | - Dalane W Kitzman
- Cardiovascular Medicine Section (B.U., D.W.K.), Wake Forest School of Medicine, Winston-Salem, NC
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20
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Bae S, Yoon HJ, Kim KH, Kim HY, Park H, Cho JY, Kim MC, Kim Y, Ahn Y, Cho JG, Jeong MH. Usefulness of Diastolic Function Score as a Predictor of Long-Term Prognosis in Patients With Acute Myocardial Infarction. Front Cardiovasc Med 2021; 8:730872. [PMID: 34568464 PMCID: PMC8460859 DOI: 10.3389/fcvm.2021.730872] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Accepted: 08/19/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Left ventricular diastolic function (LVDF) evaluation using a combination of several echocardiographic parameters is an important predictor of adverse events in patients with acute myocardial infarction (AMI). To date, the clinical impact of each individual LVDF marker is well-known, but the clinical significance of the sum of the abnormal diastolic function markers and the long-term clinical outcome are not well-known. This study aimed to investigate the usefulness of LVDF score in predicting clinical outcomes of patients with AMI. Methods: LVDF scores were measured in a 2,030 patients with AMI who underwent successful percutaneous coronary intervention from 2012 to 2015. Four LVDF parameters (septal e' ≥ 7 cm/s, septal E/e' ≤ 15, TR velocity ≤ 2.8 m/s, and LAVI ≤ 34 ml/m2) were used for LVDF scoring. The presence of each abnormal LVDF parameter was scored as 1, and the total LVDF score ranged from 0 to 4. Mortality and hospitalization due to heart failure (HHF) in relation to LVDF score were evaluated. To compare the predictive ability of LVDF scores and left ventricular ejection fraction (LVEF) for mortality and HHF, receiver operating characteristic (ROC) curve and landmark analyses were performed. Results: Over the 3-year clinical follow-up, all-cause mortality occurred in 278 patients (13.7%), while 91 patients (4.5%) developed HHF. All-cause mortality and HHF significantly increased as LVDF scores increased (all-cause mortality-LVDF score 0: 2.3%, score 1: 8.8%, score 2: 16.7%, score 3: 31.8%, and score 4: 44.5%, p < 0.001; HHF-LVDF score 0: 0.6%, score 1: 1.8%, score 2: 6.3%, score 3: 10.3%, and score 4: 18.2%, p < 0.001). In multivariate analysis, a higher LVDF score was associated with significantly higher adjusted hazard ratios for all-cause mortality and HHF. In landmark analysis, LVDF score was a better predictor of long-term mortality than LVEF (area under the ROC curve: 0.739 vs. 0.640, p < 0.001). Conclusion: The present study demonstrated that LVDF score was a significant predictor of mortality and HHF in patients with AMI. LVDF scores are useful for risk stratification of patients with AMI; therefore, careful monitoring and management should be performed for patients with AMI with higher LVDF scores.
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Affiliation(s)
- SungA Bae
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea
| | - Hyun Ju Yoon
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Kye Hun Kim
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Hyung Yoon Kim
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Hyukjin Park
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Jae Yeong Cho
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Min Chul Kim
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Yongcheol Kim
- Division of Cardiology, Department of Internal Medicine, Yonsei University College of Medicine and Cardiovascular Center, Yongin Severance Hospital, Yongin, South Korea
| | - Youngkeun Ahn
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Jeong Gwan Cho
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
| | - Myung Ho Jeong
- Division of Cardiology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, South Korea
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21
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Prognostic association of medication trajectories with 3-year mortality in heart failure and preserved ejection fraction: findings from the EPICAL2 cohort study. Eur J Clin Pharmacol 2021; 77:1569-1581. [PMID: 33970296 DOI: 10.1007/s00228-021-03153-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 05/02/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The aims of this study were to describe combinations of beta-blockers (BB), renin-angiotensin system (RAS) blockers, and mineralocorticoid receptor antagonist (MRA) prescriptions and their trajectories in heart failure with preserved ejection fraction (HFpEF) patients, and to assess their effect on the three-year all-cause and cardiovascular (CV)-mortality. METHODS We used data from the EPICAL2 cohort of 689 hospitalized HFpEF patients. Medication prescriptions were collected at hospital discharge and at 6, 12, and 24 months after discharge. A multi-trajectory approach was used to conjointly model groups of individuals following similar trajectories over medications prescriptions. We used Cox and Fine-Gray models, to evaluate respectively the associations between 3-year all-cause mortality and CV-mortality and the trajectory groups. RESULTS Multi-trajectory modelling revealed five distinct trajectory groups: group1 (N = 232, 33.6%) stable ACEI/ARB and BB prescriptions, group 2 (N = 199, 28.8%) stable ACEI/ARB prescription, group 3 (N = 133, 19.3%) stable BB prescriptions, group 4 (N = 78, 11.3%) stable prescriptions of none of the medications, and group 5 (N = 47, 6.8%) stable ACEI/ARB, BB, and MRA prescriptions. As compared to the group 4 of patients receiving none of the three medications, patients receiving a stable prescription of one or a combination of two or the three medications over 2 years) had a lower overall mortality over 3-year follow-up, i.e., group 1 (HR = 0.5, 95% CI 0.4-0.8), group 2 (HR = 0.6, 95% CI:0.4-0.8), group 3 (HR = 0.5, 95% CI:0.4-0.7), and group 5 (HR = 0.5, 95% CI:0.3-0.9). However, none of these trajectory groups was associated with a lower CV-mortality over 3 years. CONCLUSION In an unselected population-based sample of HFpEF patients, the long-term stable use of the combination ACEI/ARB and BB, BB exclusively, ACEI/ARB exclusively, or the combination ACEI/ARB and BB and MRAs was associated with reduced three-year all-cause mortality.
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22
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Berthelot E, Broussier A, Damy T, Donadio C, Cosson S, Rovani X, Salengro E, Billebeau G, Megbemado R, Rekik N, Godreuil C, Richard K, Shourick J, Assayag P, Belmin J, David JP, Hittinger L. Good performance in the management of acute heart failure in cardiogeriatric departments: the ICREX-94 experience. BMC Geriatr 2021; 21:288. [PMID: 33933023 PMCID: PMC8088705 DOI: 10.1186/s12877-021-02210-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 03/30/2021] [Indexed: 11/10/2022] Open
Abstract
CONTEXT A growing number of elderly patients hospitalized for Acute Heart Failure (AHF) are being managed in cardiogeriatrics departments, but their characteristics and prognosis are poorly known. This study aimed to investigate the profile and outcome (rehospitalization at 90 days) of patients hospitalized for AHF in cardiogeriatrics departments in the Val-de-Marne area in the suburbs of Paris, and to compare them to AHF patients hospitalized in cardiology departments in the same area. METHODS Observational study, ICREX-94, conducted in seven cardiology departments in France and three specific cardiogeriatrics departments in Val-de-Marne. RESULTS A total of 308 patients were hospitalized for AHF between October 2017 and January 2019. During the 90 days following discharge, 29.6% patients were readmitted to the hospital. Compared with patients hospitalized in cardiology departments, patients in cardiogeriatrics departments were older (p < 0.001), less independent (living more often alone or in an institution) (p < 0.001), more often depressed (p < 0.001), had more often major neurocognitive disorder (p < 0.001), had a higher Human Development Index (HDI, p < 0.001), and were less often diagnosed with amyloidosis (p < 0.001). There was no difference in outcome whether patients were discharged from cardiology or cardiogeriatrics departments. The most frequent precipitating factors underlying AHF decompensation between the first and second hospitalization were arrhythmia and infection. CONCLUSION AHF patients discharged from cardiogeriatrics departments, compared to cardiology departments, showed clinical differences but had the same prognosis regarding AHF rehospitalization at 90 days.
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Affiliation(s)
- Emmanuelle Berthelot
- Université Paris Sud, Le Kremlin-Bicêtre, France.
- APHP, Department of Cardiology, Hopital Bicêtre, 78, rue du général Leclerc, 94270, Le Kremlin Bicêtre, France.
| | - Amaury Broussier
- Université Paris Est, Créteil, INSERM, IMRB, Equipe CEpiA, F-94010, Créteil, France
- Department of Geriatrics, AP-HP, Henri-Mondor/Emile-Roux hospitals, F-94456, Limeil-Brevannes, France
| | - Thibaud Damy
- Université Paris Est, Créteil, INSERM, IMRB, Equipe CEpiA, F-94010, Créteil, France
- Department of Cardiology, heart failure and amyloidosis unit, Referral Center For Cardiac Amyloidosis, AP-HP, Henri-Mondor/Albert-Chenevier hospitals, F-94010, Créteil, France
| | - Cristiano Donadio
- Université Paris Sud, Le Kremlin-Bicêtre, France
- APHP, Department of Cardiology, Hopital Bicêtre, 78, rue du général Leclerc, 94270, Le Kremlin Bicêtre, France
- Department of geriatrics, AP-HP, Hôpital Charles Foix and Sorbonne Université, F-94200, Ivry-sur-Seine, France
| | - Stephane Cosson
- Hôpital privé Paul Dégine, 4 avenue Marx Dormoy, F-94500, Champigny-sur-Marne, France
| | - Xavier Rovani
- Hôpital privé Paul Dégine, 4 avenue Marx Dormoy, F-94500, Champigny-sur-Marne, France
| | - Emmanuel Salengro
- Centre Hospitalier de Villeneuve St Georges, 40 allée de la Source, F-94190, Villeneuve-Saint-Georges, France
| | - Gilles Billebeau
- Centre Hospitalier de Villeneuve St Georges, 40 allée de la Source, F-94190, Villeneuve-Saint-Georges, France
| | - Richard Megbemado
- Hôpital Sainte Camille, 2 rue des Pères Camilliens, F-94360, Bry-sur-Marne, France
| | - Noomen Rekik
- Hôpital Sainte Camille, 2 rue des Pères Camilliens, F-94360, Bry-sur-Marne, France
| | - Christian Godreuil
- Hôpital d'Instruction des Armées Bégin, 69 avenue de Paris, F-94160, Saint-Mandé, France
| | - Kevin Richard
- AP-HP Centre hospitalier Chenevier, 40 rue de Mesly, F-94000, Créteil, France
| | | | - Patrick Assayag
- Université Paris Sud, Le Kremlin-Bicêtre, France
- APHP, Department of Cardiology, Hopital Bicêtre, 78, rue du général Leclerc, 94270, Le Kremlin Bicêtre, France
| | - Joel Belmin
- Department of geriatrics, AP-HP, Hôpital Charles Foix and Sorbonne Université, F-94200, Ivry-sur-Seine, France
| | - Jean Philippe David
- Université Paris Est, Créteil, INSERM, IMRB, Equipe CEpiA, F-94010, Créteil, France
- Department of Internal Medicine and Geriatrics, AP-HP, Henri Mondor hospitals, F-94010, Créteil, France
| | - Luc Hittinger
- Université Paris Est, Créteil, INSERM, IMRB, Equipe CEpiA, F-94010, Créteil, France
- Department of Cardiology, heart failure and amyloidosis unit, Referral Center For Cardiac Amyloidosis, AP-HP, Henri-Mondor/Albert-Chenevier hospitals, F-94010, Créteil, France
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23
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Pan KL, Wu YL, Lee M, Ovbiagele B. Catheter Ablation Compared with Medical Therapy for Atrial Fibrillation with Heart Failure: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Int J Med Sci 2021; 18:1325-1331. [PMID: 33628087 PMCID: PMC7893556 DOI: 10.7150/ijms.52257] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2020] [Accepted: 01/04/2021] [Indexed: 11/23/2022] Open
Abstract
Background: The optimal strategy for patients with coexisting atrial fibrillation (AF) and heart failure (HF) was not settled. Our purpose was to conduct a systematic review and meta-analysis of randomized controlled trials to evaluate the effect of catheter ablation compared with medical therapy for AF on mortality, HF hospitalization, left ventricular (LV) function, and quality of life among patients with HF and AF. Materials and Methods: We searched Pubmed (1966 to September 20, 2019), EMBASE (1966 to September 20, 2019), the Cochrane Central Register of Controlled Trials (CENTRAL), and ClinicalTrials.gov for randomized controlled trials with a comparison of catheter ablation for AF with medical therapy among patients with coexisting AF and HF. Risk ratio (RR) or mean difference (MD) with 95% confidence interval (CI) was used as a measure of the effect of catheter ablation versus medical therapy on endpoints. Our final analysis included 6 randomized control trials with 775 patients. Results: Pooled results from the random-effects model showed that compared with medical therapy for AF, catheter ablation was associated with reduced all-cause mortality (RR 0.52, 95%Cl, 0.35 to 0.76) and HF hospitalization (RR 0.56, 95%Cl, 0.44 to 0.71), as well as increased LV ejection fraction (LVEF), distance walked in six minutes, and improvements in quality of life. Conclusions: This updated meta-analysis showed that compared to medical therapy, catheter ablation for AF was associated with significant benefits in several key clinical and biomarker endpoints, including reductions in all-cause mortality and HF hospitalization.
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Affiliation(s)
- Kuo-Li Pan
- Division of Cardiology, Department of internal medicine, Chang Gung Memorial Hospital, Chiayi, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Heart Failure Center, Chang Gung Memorial Hospital, Chiayi branch, Taiwan
| | - Yi-Ling Wu
- Institute of Population Health Sciences, National Health Research Institutes, Miaoli County, Taiwan
| | - Meng Lee
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Department of Neurology, Chang Gung Memorial Hospital, Chiayi Branch, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, California, USA
- San Francisco VA Healthcare System, San Francisco, California, USA
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24
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Shen L, Jhund PS, Anand IS, Carson PE, Desai AS, Granger CB, Køber L, Komajda M, McKelvie RS, Pfeffer MA, Solomon SD, Swedberg K, Zile MR, McMurray JJV. Developing and validating models to predict sudden death and pump failure death in patients with heart failure and preserved ejection fraction. Clin Res Cardiol 2020; 110:1234-1248. [PMID: 33301080 PMCID: PMC8318942 DOI: 10.1007/s00392-020-01786-8] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 11/24/2020] [Indexed: 01/12/2023]
Abstract
BACKGROUND Sudden death (SD) and pump failure death (PFD) are leading modes of death in heart failure and preserved ejection fraction (HFpEF). Risk stratification for mode-specific death may aid in patient enrichment for new device trials in HFpEF. METHODS Models were derived in 4116 patients in the Irbesartan in Heart Failure with Preserved Ejection Fraction trial (I-Preserve), using competing risks regression analysis. A series of models were built in a stepwise manner, and were validated in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM)-Preserved and Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist (TOPCAT) trials. RESULTS The clinical model for SD included older age, men, lower LVEF, higher heart rate, history of diabetes or myocardial infarction, and HF hospitalization within previous 6 months, all of which were associated with a higher SD risk. The clinical model predicting PFD included older age, men, lower LVEF or diastolic blood pressure, higher heart rate, and history of diabetes or atrial fibrillation, all for a higher PFD risk, and dyslipidaemia for a lower risk of PFD. In each model, the observed and predicted incidences were similar in each risk subgroup, suggesting good calibration. Model discrimination was good for SD and excellent for PFD with Harrell's C of 0.71 (95% CI 0.68-0.75) and 0.78 (95% CI 0.75-0.82), respectively. Both models were robust in external validation. Adding ECG and biochemical parameters, model performance improved little in the derivation cohort but decreased in validation. Including NT-proBNP substantially increased discrimination of the SD model, and simplified the PFD model with marginal increase in discrimination. CONCLUSIONS The clinical models can predict risks for SD and PFD separately with good discrimination and calibration in HFpEF and are robust in external validation. Adding NT-proBNP further improved model performance. These models may help to identify high-risk individuals for device intervention in future trials. CLINICAL TRIAL REGISTRATION I-Preserve: ClinicalTrials.gov NCT00095238; TOPCAT: ClinicalTrials.gov NCT00094302; CHARM-Preserved: ClinicalTrials.gov NCT00634712.
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Affiliation(s)
- Li Shen
- Department of Medicine, Hangzhou Normal University, Hangzhou, 310003, China.,British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK
| | - Inder S Anand
- Department of Medicine, University of Minnesota Medical School and VA Medical Center, Minneapolis, USA
| | - Peter E Carson
- Department of Cardiology, Washington VA Medical Center, Washington, DC, USA
| | - Akshay S Desai
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | | | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Michel Komajda
- Department of Cardiology, Hospital Saint Joseph, Paris, France
| | | | - Marc A Pfeffer
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Scott D Solomon
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Michael R Zile
- Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow, G12 8TA, UK.
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25
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Abraham WT, Psotka MA, Fiuzat M, Filippatos G, Lindenfeld J, Mehran R, Ambardekar AV, Carson PE, Jacob R, Januzzi JL, Konstam MA, Krucoff MW, Lewis EF, Piccini JP, Solomon SD, Stockbridge N, Teerlink JR, Unger EF, Zeitler EP, Anker SD, O'Connor CM. Standardized definitions for evaluation of heart failure therapies: scientific expert panel from the Heart Failure Collaboratory and Academic Research Consortium. Eur J Heart Fail 2020; 22:2175-2186. [PMID: 33017862 DOI: 10.1002/ejhf.2018] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 12/28/2022] Open
Abstract
The Heart Failure Academic Research Consortium is a partnership between the Heart Failure Collaboratory (HFC) and Academic Research Consortium (ARC), comprised of leading heart failure (HF) academic research investigators, patients, United States (US) Food and Drug Administration representatives, and industry members from the US and Europe. A series of meetings were convened to establish definitions and key concepts for the evaluation of HF therapies including optimal medical and device background therapy, clinical trial design elements and statistical concepts, and study endpoints. This manuscript summarizes the expert panel discussions as consensus recommendations focused on populations and endpoint definitions; it is not exhaustive or restrictive, but designed to stimulate HF clinical trial innovation.
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Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | | | - Mona Fiuzat
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | - Gerasimos Filippatos
- University of Cyprus Medical School, Shakolas Educational Center for Clinical Medicine, Nicosia, Cyprus
| | - JoAnn Lindenfeld
- Heart Failure and Transplantation Section, Vanderbilt Heart and Vascular Institute, Nashville, TN, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Peter E Carson
- Department of Cardiology, Washington Veterans Affairs Medical Center, Washington, DC, USA
| | | | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, MA, USA
| | - Marvin A Konstam
- The CardioVascular Center of Tufts Medical Center, Boston, MA, USA
| | - Mitchell W Krucoff
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, USA
| | - Jonathan P Piccini
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Ellis F Unger
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily P Zeitler
- Dartmouth-Hitchcock Medical Center and The Dartmouth Institute, Lebanon, NH, USA
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Berlin-Brandenburg Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher M O'Connor
- Inova Heart and Vascular Institute, Falls Church, VA, USA.,Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
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Reddy YNV, Obokata M, Jones AD, Lewis GD, Shah SJ, AbouEzzedine OF, Fudim M, Alhanti B, Stevenson LW, Redfield MM, Borlaug BA. Characterization of the Progression From Ambulatory to Hospitalized Heart Failure With Preserved Ejection Fraction. J Card Fail 2020; 26:919-928. [PMID: 32827644 PMCID: PMC7704788 DOI: 10.1016/j.cardfail.2020.08.008] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 08/03/2020] [Accepted: 08/12/2020] [Indexed: 12/14/2022]
Abstract
BACKGROUND Heart failure (HF) with preserved ejection fraction (HFpEF) is a heterogeneous syndrome. Some patients develop elevated filling pressures exclusively during exercise and never require hospitalization, whereas others periodically develop congestion that requires inpatient treatment. The features differentiating these cohorts are unclear. METHODS We performed a secondary analysis of 7 National Institutes of Health-sponsored multicenter trials of HFpEF (EF ≥ 50%, N = 727). Patients were stratified by history of hospitalization because of HF, comparing patients never hospitalized (HFpEFNH) to those with a prior hospitalization (HFpEFPH). Currently hospitalized (HFpEFCH) patients were included to fill the spectrum. Clinical characteristics, cardiac structure, biomarkers, quality of life, functional capacity, activity levels, and outcomes were compared. RESULTS As expected, HFpEFCH (n = 338) displayed the greatest severity of congestion, as assessed by N-terminal pro B-type natriuretic peptide levels, edema and orthopnea. As compared to HFpEFNH (n = 109), HFpEFPH (n = 280) displayed greater comorbidity burden, with more lung disease, renal dysfunction and anemia, along with lower activity levels (accelerometry), poorer exercise capacity (6-minute walk distance and peak exercise capacity), and more orthopnea. Patients with current or prior hospitalization displayed higher rates of future HF hospitalization, but quality of life was similarly impaired in all patients with HFpEF, regardless of hospitalization history. CONCLUSIONS A greater burden of noncardiac organ dysfunction, sedentariness, functional impairment, and higher event rates distinguish patients with HFpEF and prior HF hospitalization from those never hospitalized. Despite lower event rates, quality of life is severely and similarly limited in patients with no history of hospitalization. These data suggest that the 2 clinical profiles of HFpEF may require different treatment strategies.
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Affiliation(s)
| | - Masaru Obokata
- Mayo Clinic, Department of Cardiovascular Medicine, Rochester, MN
| | | | - Gregory D. Lewis
- Massachussetts General Hospital, Division of Cardiology, Boston, MA
| | - Sanjiv J. Shah
- Northwestern University; Division of Cardiology, Chicago, IL
| | | | - Marat Fudim
- Duke University, Division of Cardiology, Durham, NC
| | | | | | | | - Barry A. Borlaug
- Mayo Clinic, Department of Cardiovascular Medicine, Rochester, MN
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27
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Tanaka H, Nabeshima Y, Kitano T, Nagumo S, Tsujiuchi M, Ebato M, Mataki H, Takada M, Hayashi T, Sato D, Miyasaka Y, Araki K, Iwahashi N, Takeuchi M, Nakatani S. Optimal timing of echocardiography for heart failure inpatients in Japanese institutions: OPTIMAL Study. ESC Heart Fail 2020; 7:4213-4221. [PMID: 33006275 PMCID: PMC7754717 DOI: 10.1002/ehf2.13050] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2020] [Revised: 08/18/2020] [Accepted: 09/15/2020] [Indexed: 11/11/2022] Open
Abstract
AIMS Guidelines for the diagnosis and treatment of acute and chronic heart failure (HF) provided by the European Society of Cardiology state that echocardiography is recommended for the assessment of the myocardial structure and function of subjects with suspected HF including HF with reduced (HFrEF), mid-range (HFmrEF), and preserved ejection fraction (HFpEF) as class I of recommendation and level C of evidence. However, the impact of timing of echocardiography on survival for hospitalized HF patients or the prevalence of echocardiography during their stay has not yet been fully investigated. Therefore, we designed and conducted a prospective multicentre study, Optimal Timing of Echocardiography for Heart Failure Inpatients in Japanese Institutions (OPTIMAL) study, to investigate and evaluate the prevalence of echocardiography during the in-hospital stay of HF patients, and the impact of timing of echocardiography on their survival. METHODS AND RESULTS OPTIMAL was based on a nationwide, prospective, multicentre registry at 10 institutions in Japan endorsed by the Japanese Society of Echocardiography. A total of 601 patients hospitalized with HF were enrolled between August 2016 and July 2018 at the participating centres. Their mean age was 73.9 ± 13.0 years, left ventricular ejection fraction was 37.0% (26.0-50.0), and 256 patients (42.6%) were female. Admission echocardiography (admission echo) was categorized as either standard or point-of-care echocardiography performed within 3 days of admission, as was pre-discharge echocardiography (pre-discharge echo) within 3 days of discharge. The primary endpoint was defined as cardiovascular death over a median follow-up period of 18.9 months (9.3-26.5 months). Admission echo was performed for 476 patients (79.2%) and pre-discharge echo for 216 patients (35.9%). The primary endpoint of cardiovascular death occurred in 65 patients (10.8%). Kaplan-Meier curve findings indicated that survival of patients with pre-discharge echo was significantly better than that of patients without it (log-rank P < 0.001), and the same findings were obtained for patients with HFrEF, HFmrEF, and HFpEF. However, survival of patients with and without admission echo was similar (log-rank P = 0.33). CONCLUSIONS This OPTIMAL study prospectively showed the importance of pre-discharge echo for hospitalized HF patients. Careful attention is needed regarding the haemodynamic status of HF patients by administering pre-discharge echo to avoid HF re-hospitalization after discharge, and pre-discharge echo may provide additional information for deciding the appropriate discharge time. Our findings may thus offer a new insight into the management of hospitalized HF patients.
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Affiliation(s)
- Hidekazu Tanaka
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kobe University Graduate School of Medicine, Kobe, Japan
| | - Yosuke Nabeshima
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyusyu, Japan
| | - Tetsuji Kitano
- Second Department of Internal Medicine, University of Occupational and Environmental Health, School of Medicine, Kitakyusyu, Japan
| | - Sakura Nagumo
- Division of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Miki Tsujiuchi
- Division of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Mio Ebato
- Division of Cardiology, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Hiroyuki Mataki
- Division of Cardiology, Kobe Century Memorial Hospital, Kobe, Japan
| | - Masanori Takada
- Division of Cardiology, Medical Corporation Kawasaki Hospital, Kobe, Japan
| | - Taichi Hayashi
- Department of Cardiovascular Medicine, Faculty of Medicine and Graduate School of Medicine, Hokkaido University, Sapporo, Japan
| | - Daisuke Sato
- Department of Cardiovascular Medicine, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Yoko Miyasaka
- Division of Cardiology, Department of Medicine II, Kansai Medical University, Hirakata, Japan
| | - Keiko Araki
- Department of Cardiology, Hiratsuka Kyosai Hospital, Hiratsuka, Japan
| | - Noriaki Iwahashi
- Division of Cardiology, Yokohama City University Medical Center, Yokohama, Japan
| | - Masaaki Takeuchi
- Department of Laboratory and Transfusion Medicine, Hospital of University of Occupational and Environmental Health, School of Medicine, Kitakyushu, Japan
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Kapłon-Cieślicka A, Kupczyńska K, Dobrowolski P, Michalski B, Jaguszewski MJ, Banasiak W, Burchardt P, Chrzanowski Ł, Darocha S, Domienik-Karłowicz J, Drożdż J, Fijałkowski M, Filipiak KJ, Gruchała M, Jankowska EA, Jankowski P, Kasprzak JD, Kosmala W, Lipiec P, Mitkowski P, Mizia-Stec K, Szymański P, Tycińska A, Wańha W, Wybraniec M, Witkowski A, Ponikowski P, "Club 30" Of The Polish Cardiac Society OBO. On the search for the right definition of heart failure with preserved ejection fraction. Cardiol J 2020; 27:449-468. [PMID: 32986238 PMCID: PMC8078979 DOI: 10.5603/cj.a2020.0124] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 09/21/2020] [Accepted: 09/10/2020] [Indexed: 12/22/2022] Open
Abstract
The definition of heart failure with preserved ejection fraction (HFpEF) has evolved from a clinically based "diagnosis of exclusion" to definitions focused on objective evidence of diastolic dysfunction and/or elevated left ventricular filling pressures. Despite advances in our understanding of HFpEF pathophysiology and the development of more sophisticated imaging modalities, the diagnosis of HFpEF remains challenging, especially in the chronic setting, given that symptoms are provoked by exertion and diagnostic evaluation is largely conducted at rest. Invasive hemodynamic study, and in particular - invasive exercise testing, is considered the reference method for HFpEF diagnosis. However, its use is limited as opposed to the high number of patients with suspected HFpEF. Thus, diagnostic criteria for HFpEF should be principally based on non-invasive measurements. As no single non-invasive variable can adequately corroborate or refute the diagnosis, different combinations of clinical, echocardiographic, and/or biochemical parameters have been introduced. Recent years have brought an abundance of HFpEF definitions. Here, we present and compare four of them: 1) the 2016 European Society of Cardiology criteria for HFpEF; 2) the 2016 echocardiographic algorithm for diagnosing diastolic dysfunction; 3) the 2018 evidence-based H2FPEF score; and 4) the most recent, 2019 Heart Failure Association HFA-PEFF algorithm. These definitions vary in their approach to diagnosis, as well as sensitivity and specificity. Further studies to validate and compare the diagnostic accuracy of HFpEF definitions are warranted. Nevertheless, it seems that the best HFpEF definition would originate from a randomized clinical trial showing a favorable effect of an intervention on prognosis in HFpEF.
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Affiliation(s)
- Agnieszka Kapłon-Cieślicka
- "Club 30", Polish Cardiac Society, Poland.
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland.
| | - Karolina Kupczyńska
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Piotr Dobrowolski
- "Club 30", Polish Cardiac Society, Poland
- Department of Hypertension, National Institute of Cardiology, Warsaw, Poland
| | - Błażej Michalski
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Miłosz J Jaguszewski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Waldemar Banasiak
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology, 4th Military Hospital, Wrocław, Poland
| | - Paweł Burchardt
- "Club 30", Polish Cardiac Society, Poland
- Department of Hypertension, Angiology, and Internal Medicine, Poznan University of Medical Sciences, Poznań, Poland, and Department of Cardiology, J. Strus Hospital, Poznań, Poland
| | - Łukasz Chrzanowski
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Szymon Darocha
- "Club 30", Polish Cardiac Society, Poland
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology, Centre of Postgraduate Medical Education, Otwock, Poland
| | - Justyna Domienik-Karłowicz
- "Club 30", Polish Cardiac Society, Poland
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Jarosław Drożdż
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Marcin Fijałkowski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Krzysztof J Filipiak
- "Club 30", Polish Cardiac Society, Poland
- 1st Chair and Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
| | - Marcin Gruchała
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Medical University of Gdansk, Gdańsk, Poland
| | - Ewa A Jankowska
- "Club 30", Polish Cardiac Society, Poland
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
| | - Piotr Jankowski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Interventional Electrocardiology and Hypertension, Institute of Cardiology, Jagiellonian University Medical College, Kraków, Poland
| | - Jarosław D Kasprzak
- "Club 30", Polish Cardiac Society, Poland
- I Department and Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Wojciech Kosmala
- "Club 30", Polish Cardiac Society, Poland
- Chair and Department of Cardiology, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
| | - Piotr Lipiec
- "Club 30", Polish Cardiac Society, Poland
- Department of Rapid Cardiac Diagnostics, Chair of Cardiology, Medical University of Lodz, Łódź, Poland
| | - Przemysław Mitkowski
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, Chair of Cardiology, Karol Marcinkowski University of Medical Sciences, Poznań, Poland
| | - Katarzyna Mizia-Stec
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Piotr Szymański
- "Club 30", Polish Cardiac Society, Poland
- Centre of Postgraduate Medical Education, Central Clinical Hospital of the Ministry of the Interior in Warsaw, Warsaw, Poland
| | - Agnieszka Tycińska
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology, Medical University of Bialystok, Białystok, Poland
| | - Wojciech Wańha
- "Club 30", Polish Cardiac Society, Poland
- Department of Cardiology and Structural Heart Diseases, Medical University of Silesia, Katowice, Poland
| | - Maciej Wybraniec
- "Club 30", Polish Cardiac Society, Poland
- 1st Department of Cardiology, School of Medicine in Katowice, Medical University of Silesia, Katowice, Poland
| | - Adam Witkowski
- "Club 30", Polish Cardiac Society, Poland
- Department of Interventional Cardiology and Angiology, National Institute of Cardiology, Warsaw, Poland
| | - Piotr Ponikowski
- "Club 30", Polish Cardiac Society, Poland
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
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29
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Dong B, He X, Xue R, Chen Y, Zhao J, Zhu W, Liang W, Wu Z, Wu D, Huang H, Zhou Y, Dong Y, Liu C. Clinical implication of pulmonary hospitalization in heart failure with preserved ejection fraction: from the TOPCAT. ESC Heart Fail 2020; 7:3801-3809. [PMID: 32964677 PMCID: PMC7754907 DOI: 10.1002/ehf2.12966] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2020] [Revised: 07/07/2020] [Accepted: 08/06/2020] [Indexed: 12/21/2022] Open
Abstract
Aims The aim of the study was to explore the risk factors and evaluate the prognostic implication of pulmonary hospitalization on heart failure (HF) with preserved ejection fraction (HFpEF). Methods and results We performed a secondary analysis of the Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist Trial (TOPCAT). A total of 1714 patients with HFpEF were analysed in our study. In the multivariate Cox proportional hazards regression analysis, history of chronic obstructive pulmonary disease (COPD), smoking, bone fracture after the age of 45, and previous HF hospitalization were identified as independent risk factors for pulmonary hospitalization. To evaluate the prognostic significance of pulmonary hospitalization, patients were categorized into five groups according to the causes of their first hospitalization. The all‐cause and cardiovascular (CV) mortality risks in these five groups were compared using time‐varying Cox proportional hazards model. Compared with patients without hospitalization during follow‐up, those with pulmonary hospitalization were associated with a 204% increase [hazard ratio (HR) 3.04, 95% confidence interval (CI) 2.07–4.47, P < 0.001] and 164% increase (HR 2.64, 95% CI 1.60–4.36, P < 0.001) in risks of all‐cause and CV mortality, respectively, while the corresponding risk increases associated with HF hospitalization were 146% (HR 2.46, 95% CI 1.74–3.48, P < 0.001) for all‐cause mortality and 186% (HR 2.86, 95% CI 1.87–4.36, P < 0.001) for CV mortality. Conclusions Pulmonary hospitalization was associated with a significant increase in risks of all‐cause and CV mortality, which was comparable with that associated with HF hospitalization. The results suggested that pulmonary hospitalization could be another important clinical endpoint of HFpEF.
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Affiliation(s)
- Bin Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Xin He
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Ruicong Xue
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Yili Chen
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Jingjing Zhao
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Wengen Zhu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Weihao Liang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Zexuan Wu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Dexi Wu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Huiling Huang
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Yuanyuan Zhou
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Yugang Dong
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
| | - Chen Liu
- Department of Cardiology, The First Affiliated Hospital of Sun Yat-sen University, Guangzhou, 510080, China.,NHC Key Laboratory of Assisted Circulation (Sun Yat-sen University), Guangzhou, 510080, China.,National-Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular Diseases, Guangzhou, 510080, China
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30
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Transcatheter InterAtrial Shunt Device for the treatment of heart failure: Rationale and design of the pivotal randomized trial to REDUCE Elevated Left Atrial Pressure in Patients with Heart Failure II (REDUCE LAP-HF II). Am Heart J 2020; 226:222-231. [PMID: 32629295 DOI: 10.1016/j.ahj.2019.10.015] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2018] [Accepted: 10/23/2019] [Indexed: 01/08/2023]
Abstract
BACKGROUND A randomized, sham-controlled trial in patients with heart failure (HF) and left ventricular ejection fraction (LVEF) ≥40% demonstrated reductions in pulmonary capillary wedge pressure (PCWP) with a novel transcatheter InterAtrial Shunt Device (IASD). Whether this hemodynamic effect will translate to an improvement in cardiovascular outcomes and symptoms requires additional study. STUDY DESIGN AND OBJECTIVES REDUCE Elevated Left Atrial Pressure in Patients with Heart Failure II (REDUCE LAP HF-II) is a multicenter, prospective, randomized, sham-controlled, blinded trial designed to evaluate the clinical efficacy of the IASD in symptomatic HF and elevated left atrial pressures. Up to 608 HF patients age ≥ 40 years with LVEF ≥40%, PCWP ≥25 mm Hg during supine ergometer exercise, and PCWP ≥5 mm Hg higher than right atrial pressure will be randomized 1:1 to the IASD versus sham control. Key exclusion criteria include hemodynamically significant valvular disease, evidence of pulmonary arterial hypertension, and right heart dysfunction. The primary endpoint is a hierarchical composite, analyzed by the Finkelstein-Schoenfeld methodology, that includes (1) cardiovascular mortality or first nonfatal ischemic stroke through 12 months; (2) total (first plus recurrent) HF hospitalizations or healthcare facility visits for intravenous diuretics up to 24 months, analyzed when the last randomized patient completes 12 months of follow-up; and (3) change in Kansas City Cardiomyopathy Questionnaire overall summary score from baseline to 12 months. Follow-up echocardiography will be performed at 6, 12, and 24 months to evaluate shunt flow and cardiac chamber size/function. Patients will be followed for a total of 5 years after the index procedure. CONCLUSIONS REDUCE LAP-HF II is designed to evaluate the clinical efficacy of the IASD device in patients with symptomatic HF with elevated left atrial pressure and LVEF ≥40%.
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31
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Carlson B, Hoyt H, Kunath J, Bratzke LC. Gender Differences in Hispanic Patients of Mexican Origin Hospitalized with Heart Failure. Womens Health Issues 2020; 30:384-392. [PMID: 32660828 DOI: 10.1016/j.whi.2020.06.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Revised: 05/15/2020] [Accepted: 06/05/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND More than 3 million women in the United States die of heart failure (HF) annually. Women are significantly underrepresented in studies that inform practice guidelines, especially women hospitalized for HF despite the associated negative outcomes. HF is common in Hispanic people, the largest ethnic minority group in the United States, who are mostly of Mexican origin. There are no studies of gender differences in Mexican-Hispanic persons hospitalized for HF. We sought to describe gender differences in demographic and clinical characteristics, clinical presentation, treatment, in-hospital outcomes, and discharge status in Mexican-Hispanic patients hospitalized for HF. METHODS We conducted a secondary analysis of data collected for a study examining readmission in patients hospitalized with HF in a 107-bed community; hospital near the U.S.-Mexico border. RESULTS Of 155 self-identified Hispanic patients, 43.2% (n = 67) were women. Compared with men, women were equally affected by obesity, on average 6 years older (p < .01), and more likely to be widowed (31% vs 6%; p < .001). Women had significantly higher ejection fractions, more total comorbid conditions, more hyperlipidemia, more arthritis, more anxiety, and were less likely to be treated with digoxin and more likely to be treated with calcium channel blockers. At discharge, women were significantly less likely to receive an angiotensin-converting enzyme inhibitor or an aldosterone receptor blocker and had a higher systolic blood pressure. CONCLUSIONS Key gender differences in chronic illness burden, treatment, and discharge status were found, highlighting the heterogeneity of women with HF and the need for further gender-specific research to develop care strategies specific to women of all races and ethnicities.
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Affiliation(s)
- Beverly Carlson
- San Diego State University, School of Nursing, San Diego, California.
| | - Helina Hoyt
- San Diego State University, School of Nursing, San Diego, California
| | - Julie Kunath
- San Diego State University, School of Nursing, San Diego, California; Pioneers Memorial Hospital, Brawley, California
| | - Lisa C Bratzke
- University of Wisconsin - Madison, School of Nursing, Madison, Wisconsin
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32
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Kapłon-Cieślicka A, Laroche C, Crespo-Leiro MG, Coats AJS, Anker SD, Filippatos G, Maggioni AP, Hage C, Lara-Padrón A, Fucili A, Drożdż J, Seferovic P, Rosano GMC, Mebazaa A, McDonagh T, Lainscak M, Ruschitzka F, Lund LH. Is heart failure misdiagnosed in hospitalized patients with preserved ejection fraction? From the European Society of Cardiology - Heart Failure Association EURObservational Research Programme Heart Failure Long-Term Registry. ESC Heart Fail 2020; 7:2098-2112. [PMID: 32618139 PMCID: PMC7524216 DOI: 10.1002/ehf2.12817] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 05/12/2020] [Accepted: 05/20/2020] [Indexed: 01/14/2023] Open
Abstract
Aims In hospitalized patients with a clinical diagnosis of acute heart failure (HF) with preserved ejection fraction (HFpEF), the aims of this study were (i) to assess the proportion meeting the 2016 European Society of Cardiology (ESC) HFpEF criteria and (ii) to compare patients with restrictive/pseudonormal mitral inflow pattern (MIP) vs. patients with MIP other than restrictive/pseudonormal. Methods and results We included hospitalized participants of the ESC‐Heart Failure Association (HFA) EURObservational Research Programme (EORP) HF Long‐Term Registry who had echocardiogram with ejection fraction (EF) ≥ 50% during index hospitalization. As no data on e', E/e' and left ventricular (LV) mass index were gathered in the registry, the 2016 ESC HFpEF definition was modified as follows: elevated B‐type natriuretic peptide (BNP) (≥100 pg/mL for acute HF) and/or N‐terminal pro‐BNP (≥300 pg/mL) and at least one of the echocardiographic criteria: (i) presence of LV hypertrophy (yes/no), (ii) left atrial volume index (LAVI) of >34 mL/m2), or (iii) restrictive/pseudonormal MIP. Next, all patients were divided into four groups: (i) patients with restrictive/pseudonormal MIP on echocardiography [i.e. with presumably elevated left atrial (LA) pressure], (ii) patients with MIP other than restrictive/pseudonormal (i.e. with presumably normal LA pressure), (iii) atrial fibrillation (AF) group, and (iv) ‘grey area’ (no consistent description of MIP despite no report of AF). Of 6365 hospitalized patients, 1848 (29%) had EF ≥ 50%. Natriuretic peptides were assessed in 28%, LV hypertrophy in 92%, LAVI in 13%, and MIP in 67%. The 2016 ESC HFpEF criteria could be assessed in 27% of the 1848 patients and, if assessed, were met in 52%. Of the 1848 patients, 19% had restrictive/pseudonormal MIP, 43% had MIP other than restrictive/pseudonormal, 18% had AF and 20% were grey area. There were no differences in long‐term all‐cause or cardiovascular mortality, or all‐cause hospitalizations or HF rehospitalizations between the four groups. Despite fewer non‐cardiac comorbidities reported at baseline, patients with MIP other than restrictive/pseudonormal (i.e. with presumably normal LA pressure) had more non‐cardiovascular (14.0 vs. 6.7 per 100 patient‐years, P < 0.001) and cardiovascular non‐HF (13.2 vs. 8.0 per 100 patient‐years, P = 0.016) hospitalizations in long‐term follow‐up than patients with restrictive/pseudonormal MIP. Conclusions Acute HFpEF diagnosis could be assessed (based on the 2016 ESC criteria) in only a quarter of patients and confirmed in half of these. When assessed, only one in three patients had restrictive/pseudonormal MIP suggestive of elevated LA pressure. Patients with MIP other than restrictive/pseudonormal (suggestive of normal LA pressure) could have been misdiagnosed with acute HFpEF or had echocardiography performed after normalization of LA pressure. They were more often hospitalized for non‐HF reasons during follow‐up. Symptoms suggestive of acute HFpEF may in some patients represent non‐HF comorbidities.
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Affiliation(s)
| | - Cécile Laroche
- EURObservational Research Programme (EORP), European Society of Cardiology, Sophia-Antipolis, France
| | - Maria G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca y Trasplante Cardiaco, Complexo Hospitalario Universitario A Coruna (CHUAC), INIBIC, UDC, CIBERCV, A Coruña, Spain
| | | | - Stefan D Anker
- Division of Cardiology and Metabolism; Department of Cardiology (CVK); and Berlin-Brandenburg Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany & Department of Cardiology and Pneumology, University Medicine Göttingen (UMG), Göttingen, Germany
| | - Gerasimos Filippatos
- School of Medicine, University of Cyprus & Heart Failure Unit, Department of Cardiology, University Hospital Attikon, National and Kapodistrian University of Athens, Athens, Greece
| | - Aldo P Maggioni
- EURObservational Research Programme (EORP), European Society of Cardiology, Sophia-Antipolis, France.,ANMCO Research Centre, Florence, Italy
| | - Camilla Hage
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Antonio Lara-Padrón
- Unidad de Insuficiencia Cardiaca, Servicio de Cardiología, Complejo Hospital Universitario de Canarias, San Cristóbal de La Laguna, Santa Cruz de Tenerife, Spain
| | - Alessandro Fucili
- Department of Medical Sciences, University of Ferrara, Ferrara, Italy
| | - Jarosław Drożdż
- Department of Cardiology, Medical University of Lodz, Lodz, Poland
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade; Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | - Alexandre Mebazaa
- Department of Anaesthesia and Critical Care, University Hospitals Saint Louis-Lariboisière, APHP; University Paris Diderot; UMR 942 Inserm - MASCOT, Paris, France
| | | | - Mitja Lainscak
- Department of Internal Medicine, General Hospital Murska Sobota, Slovenia, and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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Saberinia A, Vafaei A, Kashani P. A narrative review on the management of Acute Heart Failure in Emergency Medicine Department. Eur J Transl Myol 2020; 30:8612. [PMID: 32499877 PMCID: PMC7254439 DOI: 10.4081/ejtm.2019.8612] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2019] [Accepted: 11/08/2019] [Indexed: 12/28/2022] Open
Abstract
The main urgent symptom presented to an emergency department is acute heart failure (AHF). In that considerable risksof morbidity and mortality, it is important to plan precision medicine to achieve the most suitable outcomes. The object of this review is to provide a summary of contemporary management procedures of emergency medicine in a department of acute heart failure. Heart failure could be presented with a broad range of symptoms, in particular a sudden worsening of those of Chronic Obstructive Pulmonary Disease. The treatment should focus on acute and chronic underlying disorders with instructions focusing on haemodynamics and blood pressure status. Treatment of patients suffering with worsening symptoms of AHF mainly focuses on intravenous diuretics. In emergency situations, patients suffering with AHF with low blood pressure must receive emergency consultation and a primary fluid bolus therapy (range 250-500 mL) followed by inotropic therapy with or without antihypotensive agents. For treatment of severe heart failure and cardiogenic shock in patients treated with noradrenalin, when blood pressure support is required, a direct-acting inotropic agent, dobutamine, could be applied effectively. When non-invasive positive pressure ventilation is needed, suppliers must track for any possibility of sudden worsening, i.e., for acute decompensated heart failure. When cardiac output is high the disorder could be treated with vasopressors.
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Affiliation(s)
- Amin Saberinia
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Loghman Hakim Hospital, Tehran, Iran
| | - Ali Vafaei
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Loghman Hakim Hospital, Tehran, Iran
| | - Parvin Kashani
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
- Department of Emergency Medicine, School of Medicine, Shahid Beheshti University of Medical Sciences, Loghman Hakim Hospital, Tehran, Iran
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GF, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Marinella Ruospo
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Patrizia Natale
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Robert R Quinn
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Paul E Ronksley
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical Center, Department of Medicine, 3459 Fifth Avenue, Pittsburgh, PA, USA, 15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of Otago, Department of Medicine, Nephrologist, Christchurch, New Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Giovanni Fm Strippoli
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
- The Children's Hospital at Westmead, Cochrane Kidney and Transplant, Centre for Kidney Research, Westmead, NSW, Australia, 2145
| | - Pietro Ravani
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
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Sokos GG, Raina A. Understanding the early mortality benefit observed in the PARADIGM-HF trial: considerations for the management of heart failure with sacubitril/valsartan. Vasc Health Risk Manag 2020; 16:41-51. [PMID: 32021227 PMCID: PMC6972579 DOI: 10.2147/vhrm.s197291] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2018] [Accepted: 08/02/2019] [Indexed: 12/11/2022] Open
Abstract
This review aims to elucidate the optimal dosing of angiotensin receptor-neprilysin inhibitor (ARNI) therapy in the heart failure (HF) treatment paradigm through examination of the trial population characteristics and the mortality benefit observed in the Prospective Comparison of ARNI with angiotensin-converting enzyme inhibitor (ACEI) to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF; NCT01035255) trial. Considerations regarding the initiation and titration of sacubitril/valsartan, a first-in-class ARNI, will also be addressed. The approval of sacubitril/valsartan heralded the first novel pharmacological class in over a decade for the treatment of heart failure with reduced ejection fraction (HFrEF). The PARADIGM-HF trial showed that treatment with valsartan/valsartan reduced the risk of first occurrence of either cardiovascular death or HF-related hospitalization (composite primary endpoint) by 20% compared with enalapril in patients with HFrEF. The incremental benefits of treatment with valsartan/valsartan over enalapril demonstrated in the PARADIGM-HF trial led to strong recommendations for its use over ACEIs or angiotensin receptor blockers to further reduce morbidity and mortality in the 2016 and 2017 American College of Cardiology/American Heart Association/Heart Failure Society of America updates to the guidelines for the management of HF. Although the optimal timing for the initiation of valsartan/valsartan has yet to be determined, its early use is likely to have a positive impact on patient outcomes.
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Affiliation(s)
- George G Sokos
- Department of Medicine, Division of Cardiology, West Virginia School of Medicine, Morgantown, WV, USA
| | - Amresh Raina
- Pulmonary Hypertension Program, Section of Heart Failure/Transplant/MCS & Pulmonary Hypertension, Allegheny General Hospital, AGH McGinnis Cardiovascular Institute, Pittsburgh, PA, USA
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Body mass index and all-cause readmissions following acute heart failure hospitalization. Int J Obes (Lond) 2019; 44:1227-1235. [PMID: 31863028 DOI: 10.1038/s41366-019-0518-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 11/12/2019] [Accepted: 12/11/2019] [Indexed: 11/08/2022]
Abstract
BACKGROUND/OBJECTIVES Obesity is associated with a lower mortality risk among patients with heart failure (HF). Whether this obesity paradox applies to all-cause hospitalizations is unknown. We aimed to investigate the association between body mass index (BMI) and 30-day all-cause readmissions following HF hospitalization. SUBJECTS/METHODS We retrospectively evaluated 2252 HF hospital admissions of Centers of Medicare Services beneficiaries from an academic medical center. We classified obesity using established BMI categories. All 30-day postdischarge readmission to all hospitals and mortality events were documented. We evaluated 30-day postdischarge unplanned, all-cause readmission and death in the total cohort, propensity-matched cohort, and by ejection fraction (EF). RESULTS An Overweight-Obese BMI (BMI ≥ 25 kg/m2) was paradoxically associated with a lower mortality rate than a Normal BMI (18.5-24.9 kg/m2) (5.0% vs 8.5%, p = 0.0018). In contrast, an Overweight-Obese BMI was associated with a 29% (95% CI: 1.03-1.63) increased relative risk of all-cause readmission compared with a Normal BMI (23.2% vs 18.9%, p = 0.0288), which was consistent across obesity severity subgroups. Among 966 matched admissions, an Overweight-Obese BMI retained higher readmission risk compared with a Normal BMI (25.1% vs 17.2%, p = 0.003). After matching, readmissions remained higher for Overweight-Obese vs Normal BMI in admissions with reduced EF (25.7% vs 17.8%, p = 0.032) and preserved EF (23.0% vs 15.0%, p = 0.048). No difference in the percentage of readmissions for HF (40%) or noncardiovascular causes (45%) existed between Overweight-Obese and Normal BMI groups. CONCLUSIONS Despite a lower mortality risk, increased BMI is associated with increased all-cause hospital readmission rates in an elderly HF population which persists after propensity matching.
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Reed SD, Fairchild AO, Johnson FR, Gonzalez JM, Mentz RJ, Krucoff MW, Vemulapalli S. Patients' Willingness to Accept Mitral Valve Procedure-Associated Risks Varies Across Severity of Heart Failure Symptoms. Circ Cardiovasc Interv 2019; 12:e008051. [PMID: 31752516 DOI: 10.1161/circinterventions.119.008051] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
BACKGROUND The Food and Drug Administration's Center for Drugs and Radiological Health issued Guidance in 2016 on generating patient preference information to aid evaluation of medical devices. Consistent with this guidance, we aimed to provide quantitative patient preference evidence on benefit-risk tradeoffs relevant to transcatheter mitral valve repair versus medical therapy for patients with heart failure and symptomatic secondary mitral regurgitation. METHODS A discrete-choice experiment survey was designed to quantify patients' tolerance for 30-day mortality or serious bleeding risks to achieve improvements in physical functioning or reductions in heart failure hospitalizations. Two samples were recruited: an online US panel of individuals reporting a diagnosis of heart failure (n=244) and patients with heart failure treated at Duke University Health System (n=175). Random-effects logit regression was used to model treatment choices as a function of benefit and risk levels. RESULTS Across both samples, approximately one-quarter (23.5%) consistently chose device profiles offering the higher level of physical functioning despite mortality and bleeding risks as high as 10%. Among respondents who at least once chose a device profile offering a lower level of functioning, improvement in physical functioning equivalent to a change from New York Heart Association class IV to III was ≈6 times more preferred than a change from New York Heart Association class III to II. Estimated discrete-choice experiment utility gains and losses revealed that respondents would accept up to a 9.7 percentage-point (95% CI, 8.2%-13.3%) increase in risk of 30-day mortality with devices that could improve functioning from New York Heart Association class IV to III, or up to 2.0% (95% CI, 1.4%-2.7%) for an improvement from New York Heart Association class III to II. CONCLUSIONS Severity of heart failure symptoms influences patients' willingness to accept risks associated with mitral valve medical devices. These findings can inform shared decision-making discussions with patients who are being evaluated for transcatheter mitral valve repair.
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Affiliation(s)
- Shelby D Reed
- Department of Population Health Sciences (S.D.R., F.R.J., J.M.G.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (S.D.R., A.O.F., F.R.J., J.M.G., R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC
| | - Angelyn O Fairchild
- Duke Clinical Research Institute (S.D.R., A.O.F., F.R.J., J.M.G., R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC
| | - F Reed Johnson
- Department of Population Health Sciences (S.D.R., F.R.J., J.M.G.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (S.D.R., A.O.F., F.R.J., J.M.G., R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC
| | - Juan Marcos Gonzalez
- Department of Population Health Sciences (S.D.R., F.R.J., J.M.G.), Duke University School of Medicine, Durham, NC.,Duke Clinical Research Institute (S.D.R., A.O.F., F.R.J., J.M.G., R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC
| | - Robert J Mentz
- Duke Clinical Research Institute (S.D.R., A.O.F., F.R.J., J.M.G., R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC.,Division of Cardiology, Department of Medicine (R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC
| | - Mitchell W Krucoff
- Duke Clinical Research Institute (S.D.R., A.O.F., F.R.J., J.M.G., R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC.,Division of Cardiology, Department of Medicine (R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute (S.D.R., A.O.F., F.R.J., J.M.G., R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC.,Division of Cardiology, Department of Medicine (R.J.M., M.W.K., S.V.), Duke University School of Medicine, Durham, NC
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Evans M, Morgan AR, Yousef Z. What Next After Metformin? Thinking Beyond Glycaemia: Are SGLT2 Inhibitors the Answer? Diabetes Ther 2019; 10:1719-1731. [PMID: 31410711 PMCID: PMC6778564 DOI: 10.1007/s13300-019-00678-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Indexed: 02/07/2023] Open
Abstract
The prevalence of type 2 diabetes continues to increase, along with a proliferation of glucose-lowering treatment options. There is universal agreement in the clinical community for the use of metformin as the first-line glucose-lowering therapy for the majority of patients. However, controversy exists regarding the choice of second-line therapy once metformin is no longer effective. The most recent treatment consensus focuses on the presence of cardiovascular disease, heart failure or kidney disease as a determinant of therapy choice. The majority of patients in routine practice, however, do not fall into such categories. Heart failure and kidney disease represent significant clinical and cost considerations in patients with type 2 diabetes and have a close pathophysiological association. Recent data has illustrated that sodium-glucose transporter 2 (SGLT2) inhibitor therapy can reduce the burden of heart failure and the progression of renal disease across a wide range of patients including those with and without established disease, supported by an increased understanding of the mechanistic effects of these agents. Furthermore, there is growing evidence to illustrate the overall safety profile of this class of agents and support the benefit-risk profile of SGLT2 inhibitors as a preferred option following metformin monotherapy failure, with respect to both kidney disease progression and heart failure outcomes.
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Affiliation(s)
- Marc Evans
- Diabetes Resource Centre, University Hospital Llandough, Cardiff, UK.
| | | | - Zaheer Yousef
- Wales Heart Research Institute, Cardiff University, Cardiff, UK
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Juni RP, Kuster DW, Goebel M, Helmes M, Musters RJ, van der Velden J, Koolwijk P, Paulus WJ, van Hinsbergh VW. Cardiac Microvascular Endothelial Enhancement of Cardiomyocyte Function Is Impaired by Inflammation and Restored by Empagliflozin. JACC Basic Transl Sci 2019; 4:575-591. [PMID: 31768475 PMCID: PMC6872802 DOI: 10.1016/j.jacbts.2019.04.003] [Citation(s) in RCA: 126] [Impact Index Per Article: 25.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 04/23/2019] [Accepted: 04/27/2019] [Indexed: 12/17/2022]
Abstract
The positive findings of the EMPA-REG OUTCOME trial (Randomized, Placebo-Controlled Cardiovascular Outcome Trial of Empagliflozin) on heart failure (HF) outcome in patients with type 2 diabetes mellitus suggest a direct effect of empagliflozin on the heart. These patients frequently have HF with preserved ejection fraction (HFpEF), in which a metabolic risk-related pro-inflammatory state induces cardiac microvascular endothelial cell (CMEC) dysfunction with subsequent cardiomyocyte (CM) contractility impairment. This study showed that CMECs confer a direct positive effect on contraction and relaxation of CMs, an effect that requires nitric oxide, is diminished after CMEC stimulation with tumor necrosis factor-α, and is restored by empagliflozin. Our findings on the effect of empagliflozin on CMEC-mediated preservation of CM function suggests that empagliflozin can be used to treat the cardiac mechanical implications of microvascular dysfunction in HFpEF.
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Key Words
- CM, cardiomyocyte
- CMEC, cardiac microvascular endothelial cell
- Ca, calcium
- DM, diabetes mellitus
- DPPH, 1,1-diphenyl-picrylhydrazyl
- EC, endothelial cell
- HF, heart failure
- HFpEF, heart failure with preserved ejection fraction
- HFrEF, heart failure with reduced ejection fraction
- JNK, Jun N-terminal kinase
- L-NAME, N(ω)-nitro-L-arginine methyl ester
- LV, left ventricular
- NK-κB, nuclear factor-κB
- NO, nitric oxide
- ROS, reactive oxygen species
- SGLT2, sodium glucose transporter 2
- contraction and relaxation
- eNOS, endothelial nitric oxide synthase
- empagliflozin
- endothelial cell–derived nitric oxide
- heart failure
- oxidative stress
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Affiliation(s)
- Rio P. Juni
- Amsterdam Cardiovascular Sciences, Department of Physiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Diederik W.D. Kuster
- Amsterdam Cardiovascular Sciences, Department of Physiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Max Goebel
- Amsterdam Cardiovascular Sciences, Department of Physiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Michiel Helmes
- Amsterdam Cardiovascular Sciences, Department of Physiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- CytoCypher B.V., Wageningen, the Netherlands
| | - René J.P. Musters
- Amsterdam Cardiovascular Sciences, Department of Physiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Jolanda van der Velden
- Amsterdam Cardiovascular Sciences, Department of Physiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
| | - Pieter Koolwijk
- Amsterdam Cardiovascular Sciences, Department of Physiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Walter J. Paulus
- Amsterdam Cardiovascular Sciences, Department of Physiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Victor W.M. van Hinsbergh
- Amsterdam Cardiovascular Sciences, Department of Physiology, Amsterdam University Medical Centers, Amsterdam, the Netherlands
- Netherlands Heart Institute, Utrecht, the Netherlands
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40
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Abstract
PURPOSE OF REVIEW Heart failure (HF) is the first cause of hospitalization in the elderly in Western countries, generating tremendous healthcare costs. Despite the spread of multidisciplinary post-discharge programs, readmission rates have remained unchanged over time. We review the recent developments in this setting. RECENT FINDINGS Recent data plead for global reorganization of HF care, specifically targeting patients at high risk for further readmission, as well as a stronger involvement of primary care providers (PCP) in patients' care plan. Besides, tools, devices, and new interdisciplinary expertise have emerged to support and be integrated into those programs; they have been greeted with great enthusiasm, but their routine applicability remains to be determined. HF programs in 2018 should focus on pragmatic assessments of patients that will benefit the most from the multidisciplinary care; delegating the management of low-risk patients to trained PCP and empowering the patient himself, using the newly available tools as needed.
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Affiliation(s)
- Nadia Bouabdallaoui
- Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000, Belanger East, Montreal, Quebec, H1T1C8, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, Université de Montréal, 5000, Belanger East, Montreal, Quebec, H1T1C8, Canada.
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41
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Oglesby M, Escobedo D, Escobar GP, Fatemifar F, Sako EY, Bailey SR, Han HC, Feldman MD. Trabecular cutting: a novel surgical therapy to increase diastolic compliance. J Appl Physiol (1985) 2019; 127:457-463. [PMID: 31219774 DOI: 10.1152/japplphysiol.00087.2019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a common cause of hospital admission in patients over 65 yr old and has high mortality. HFpEF is characterized by left ventricular (LV) hypertrophy that reduces compliance. Current HFpEF therapies control symptoms, but no existing medications or therapies can sustainably increase LV compliance. LV trabeculae develop hypertrophy and fibrosis that contribute to reduced LV compliance. This study expands our previous results in ex vivo human hearts to show that severing LV trabeculae increases diastolic compliance in an ex vivo working rabbit heart model. Trabecular cutting was performed in ex vivo rabbit hearts set up in a working heart perfusion system perfused with oxygenated Krebs-Henseleit buffer. A hook was inserted in the LV to cut trabeculae. End-systolic and end-diastolic pressure-volume relationships during transient preload reduction were recorded using an admittance catheter in the following three groups: control (no cutting; n = 9), mild cutting (15 cuts; n = 5), and aggressive cutting (30 cuts; n = 5). In a second experiment, each heart served as its own control. Hemodynamic data were recorded before and after trabecular cutting (n = 10) or sham cutting (n = 5) within the same heart. In the first experiments, trabecular cutting did not affect systolic function (P > 0.05) but significantly increased overall diastolic compliance (P = 0.009). Greater compliance was seen as trabecular cutting increased (P = 0.002, r2 = 0.435). In the second experiment, significant increases in systolic function (P = 0.048) and diastolic compliance (P = 0.002) were seen after trabecular cutting compared with baseline. In conclusion, trabecular cutting significantly increases diastolic compliance without reducing systolic function.NEW & NOTEWORTHY We postulate that, in mammalian hearts, free-running trabeculae carneae exist to provide tensile support to the left ventricle and minimize diastolic wall stress. Because of hypertrophy and fibrosis of trabeculae in patients with left ventricular hypertrophy, this supportive role can become pathologic, worsening diastolic compliance. We demonstrate a novel operation involving cutting trabeculae as a method to acutely increase diastolic compliance in patients presenting with heart failure and diastolic dysfunction to improve their left ventricle compliance.
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Affiliation(s)
- Meagan Oglesby
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Danny Escobedo
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Gladys Patricia Escobar
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Fatemeh Fatemifar
- Department of Mechanical Engineering, University of Texas at San Antonio, San Antonio, Texas
| | - Edward Y Sako
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Steven R Bailey
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
| | - Hai-Chao Han
- Department of Mechanical Engineering, University of Texas at San Antonio, San Antonio, Texas
| | - Marc D Feldman
- Division of Cardiology, Department of Medicine, University of Texas Health Science Center at San Antonio, San Antonio, Texas
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42
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Azad N. Opportunities for Care Optimization and Hospitalization Reduction for Older Persons With Heart Failure. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2019; 13:1179546819841597. [PMID: 31105431 PMCID: PMC6503604 DOI: 10.1177/1179546819841597] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2018] [Accepted: 02/27/2019] [Indexed: 12/12/2022]
Affiliation(s)
- Nahid Azad
- The Ottawa Hospital, University of Ottawa,
Ottawa, ON, Canada
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43
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Bottle A, Kim D, Hayhoe B, Majeed A, Aylin P, Clegg A, Cowie MR. Frailty and co-morbidity predict first hospitalisation after heart failure diagnosis in primary care: population-based observational study in England. Age Ageing 2019; 48:347-354. [PMID: 30624588 DOI: 10.1093/ageing/afy194] [Citation(s) in RCA: 38] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2018] [Revised: 01/11/2018] [Accepted: 12/07/2018] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND frailty has only recently been recognised as important in patients with heart failure (HF), but little has been done to predict the first hospitalisation after diagnosis in unselected primary care populations. OBJECTIVES to predict the first unplanned HF or all-cause admission after diagnosis, comparing the effects of co-morbidity and frailty, the latter measured by the recently validated electronic frailty index (eFI). DESIGN observational study. SETTING primary care in England. SUBJECTS all adult patients diagnosed with HF in primary care between 2010 and 2013. METHODS we used electronic health records of patients registered with primary care practices sending records to the Clinical Practice Research Datalink (CPRD) in England with linkage to national hospital admissions and death data. Competing-risk time-to-event analyses identified predictors of first unplanned hospitalisation for HF or for any condition after diagnosis. RESULTS of 6,360 patients, 9% had an emergency hospitalisation for their HF, and 39% had one for any cause within a year of diagnosis; 578 (9.1%) died within a year without having any emergency admission. The main predictors of HF admission were older age, elevated serum creatinine and not being on a beta-blocker. The main predictors of all-cause admission were age, co-morbidity, frailty, prior admission, not being on a beta-blocker, low haematocrit and living alone. Frailty effects were largest in patients aged under 85. CONCLUSIONS this study suggests that frailty has predictive power beyond its co-morbidity components. HF patients in the community should be assessed for frailty, which should be reflected in future HF guidelines.
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Affiliation(s)
- Alex Bottle
- Department of Primary Care and Public Health, Dr Foster Unit, Imperial College London, 3 Dorset Rise, London, UK
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan’s Road, London, UK
| | - Dani Kim
- Department of Primary Care and Public Health, Dr Foster Unit, Imperial College London, 3 Dorset Rise, London, UK
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan’s Road, London, UK
| | - Benedict Hayhoe
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan’s Road, London, UK
| | - Azeem Majeed
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan’s Road, London, UK
| | - Paul Aylin
- Department of Primary Care and Public Health, Dr Foster Unit, Imperial College London, 3 Dorset Rise, London, UK
- Department of Primary Care and Public Health, Imperial College London, Charing Cross Campus, The Reynolds Building, St Dunstan’s Road, London, UK
| | - Andrew Clegg
- Academic Unit of Elderly Care and Rehabilitation, University of Leeds, Bradford Royal Infirmary, Duckworth Lane, Bradford, UK
| | - Martin R Cowie
- National Heart & Lung Institute, Royal Brompton Hospital, Imperial College London, Sydney St, Chelsea, London, UK
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44
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Weeda ER, Su Z, Taber DJ, Bian J, Morinelli TA, Pilch NA, Mauldin PD, DuBay DA. Hospital admissions and emergency department visits among kidney transplant recipients. Clin Transplant 2019; 33:e13522. [DOI: 10.1111/ctr.13522] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/22/2019] [Accepted: 02/22/2019] [Indexed: 12/31/2022]
Affiliation(s)
- Erin R. Weeda
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy Medical University of South Carolina Charleston South Carolina
| | - Zemin Su
- Division of General Internal Medicine and Geriatrics Medical University of South Carolina Charleston South Carolina
| | - David J. Taber
- Department of Pharmacy Ralph H Johnson VAMC Charleston South Carolina
- Department of Surgery Medical University of South Carolina Charleston South Carolina
| | - John Bian
- Division of General Internal Medicine and Geriatrics Medical University of South Carolina Charleston South Carolina
| | - Thomas A. Morinelli
- Department of Surgery Medical University of South Carolina Charleston South Carolina
| | - Nicole A. Pilch
- Department of Clinical Pharmacy and Outcomes Sciences, College of Pharmacy Medical University of South Carolina Charleston South Carolina
| | - Patrick D. Mauldin
- Division of General Internal Medicine and Geriatrics Medical University of South Carolina Charleston South Carolina
| | - Derek A. DuBay
- Department of Surgery Medical University of South Carolina Charleston South Carolina
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45
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Pandey A, Patel KV, Ayers C, Tang WHW, Fang JC, Drazner MH, Berry J, Grodin JL. Temporal association between hospitalization event and subsequent risk of mortality among patients with stable chronic heart failure with preserved ejection fraction: insights from the TOPCAT trial. Eur J Heart Fail 2019; 21:693-695. [PMID: 30933394 DOI: 10.1002/ejhf.1460] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2019] [Accepted: 02/26/2019] [Indexed: 11/06/2022] Open
Affiliation(s)
- Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Kershaw V Patel
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Colby Ayers
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah Health Sciences Center, Salt Lake City, UT, USA
| | - Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Jarett Berry
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Justin L Grodin
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
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46
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Abstract
Heart failure (HF) is a clinical syndrome that associates clinical signs in people over 80 years of age, an increase in natriuretic peptides and abnormal cardiac structures that result from cardiac aging in many cases. The most common symptoms are grouped according to the acronym "EPOF" (shortness of breath, weight gain, edema, fatigue). Over the age of 80, comorbidities must be taken into account. The incidence and prevalence of HF significantly increases with age and makes HF the most common reason for hospitalization for people over 80, and an important health expense. The management of HF, necessarily multidisciplinary with a geriatric evaluation, has improved over time due to effective targeted treatment, but mortality, hospitalization and readmission rates remain high. Therapeutic education and patient follow-up for treatment optimization are needed.
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47
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Vilaro JR, Ahmed M, Aranda JM. Heart Failure with Preserved Ejection Fraction: Time to Revisit the Stiff Heart. CARDIOVASCULAR INNOVATIONS AND APPLICATIONS 2019. [DOI: 10.15212/cvia.2017.0062] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022] Open
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48
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Lower-Extremity Function as a Marker of Frailty and Outcomes of Heart Failure With Preserved Ejection Fraction in Older Adults. J Card Fail 2019; 25:10-11. [DOI: 10.1016/j.cardfail.2018.11.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/08/2018] [Indexed: 01/06/2023]
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49
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Yousufuddin M, Young N, Shultz J, Doyle T, Fuerstenberg KM, Jensen K, Arumaithurai K, Murad MH. Predictors of Recurrent Hospitalizations and the Importance of These Hospitalizations for Subsequent Mortality After Incident Transient Ischemic Attack. J Stroke Cerebrovasc Dis 2019; 28:167-174. [PMID: 30340936 DOI: 10.1016/j.jstrokecerebrovasdis.2018.09.028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2018] [Revised: 09/08/2018] [Accepted: 09/15/2018] [Indexed: 10/28/2022] Open
Abstract
BACKGROUND We examined predictors of recurrent hospitalizations and the importance of these hospitalizations for subsequent mortality after incident transient ischemic attacks (TIA) that have not yet been investigated. METHODS Adults hospitalized for TIA from 2000 through 2017 were examined for recurrent hospitalizations, days, and percentage of time spent hospitalized and long-term mortality. RESULTS Of 266 patients hospitalized for TIA, 122 died, 212 had 826 anycondition hospitalization (59 from TIA-related conditions) corresponding to 3384 inpatient days during 1693 person-years of follow-up. Of 42 patient-level characteristics, age greater than or equal to 65 years (Incidence rate ratio [IRR] 1.75, 95% confidence interval [CI] 1.19-2.55), current smoking (IRR 2.15, 95% CI 1.39-3.33), concurrent heart failure (IRR 1.81, 95% CI 1.17-2.80) or anemia (IRR 1.90, 95% CI 1.40-2.48), and no prescription statin (IRR 1.45, 95% CI 1.04-2.03, P = .0289) emerged as significant predictors of anycondition rehospitalization. All these variables except heart failure remained significant predictors of TIA-related rehospitalizations. All-cause mortality was significantly increased after each hospitalization from anycondition (hazard ratio [HR] 1.32, 95% CI 1.26-1.39), TIA-related condition (HR 1.72; 95% CI 1.28-2.30), and per each day (HR 1.05, 95% CI 1.04-1.05) and per 1% of follow-up time spent hospitalized from anycondition (HR 1.45, 95% CI 1.34-1.58). CONCLUSIONS Older age, current tobacco smoking, concurrent heart failure or anemia, and no prescription statin, easily measured patient-level characteristics, identifies patients with TIA at high risk for recurrent hospitalizations and the burden of these hospitalizations predicts subsequent mortality.
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Affiliation(s)
| | - Nathan Young
- Division of Neurology, Mayo Clinic, Rochester, Minnesota
| | - Jessica Shultz
- Division of Internal Medicine, Mayo Clinic Health System, Austin, Minnesota
| | - Taylor Doyle
- Division of Internal Medicine, Mayo Clinic Health System, Austin, Minnesota
| | | | - Kelsey Jensen
- Division of Internal Medicine, Mayo Clinic Health System, Austin, Minnesota
| | | | - Mohammad H Murad
- Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota; Division of Preventive Medicine, Mayo Clinic, Rochester, Minnesota
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50
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Aquaro GD, Pizzino F, Terrizzi A, Carerj S, Khandheria BK, Di Bella G. Diastolic dysfunction evaluated by cardiac magnetic resonance: the value of the combined assessment of atrial and ventricular function. Eur Radiol 2018; 29:1555-1564. [PMID: 30128617 DOI: 10.1007/s00330-018-5571-3] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 05/14/2018] [Accepted: 05/28/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVES We sought to evaluate the role of cardiac magnetic resonance imaging (CMR) in the evaluation of diastolic function by a combined assessment of left ventricular (LV) and left atrial (LA) function in a cohort of subjects with various degrees of diastolic dysfunction (DD) detected by echocardiography. METHODS Forty patients with different stages of DD and 18 healthy controls underwent CMR. Short-axis cine steady-state free precession images covering the entire LA and LV were acquired. Parameters of diastolic function were measured by the analysis of the LV and LA volume/time (V/t) curves and the respective derivative dV/dt curves. RESULTS At receiver operating characteristic (ROC) curve analysis, the peak of emptying rate A indexed by the LV filling volume with a cut-off of 3.8 was able to detect patients with grade I DD from other groups (area under the curve [AUC] 0.975, 95% confidence interval [CI] 0.86-1). ROC analysis showed that LA ejection fraction with a cut-off of ≤36% was able to distinguish controls and grade I DD patients from those with grade II and grade III DD (AUC 0.996, 95% CI 0.92-1, p < 0.001). The isovolumetric pulmonary vein transit ratio with a cut-off of 2.4 allowed class III DD to be distinguished from other groups (AUC 1.0, 95%CI 0.93-1, p < 0.001). CONCLUSIONS Analysis of LV and LA V/t curves by CMR may be useful for the evaluation of DD. KEY POINTS • Combined atrial and ventricular volume/time curves allow evaluation of diastolic function. • Atrial emptying fraction allows distinction between impaired relaxation and restrictive/pseudo-normal filling. • Isovolumetric pulmonary vein transit ratio allows distinction between restrictive and pseudo-normal filling.
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Affiliation(s)
| | - Fausto Pizzino
- Scuola Superiore Sant'Anna di Studi Universitari e di Perfezionamento, Pisa, Italy
| | - Anna Terrizzi
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Scipione Carerj
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
| | - Bijoy K Khandheria
- Aurora Cardiovascular Services, Aurora Sinai/Aurora St. Luke's Medical Centers, University of Wisconsin School of Medicine and Public Health, Milwaukee, WI, USA
| | - Gianluca Di Bella
- Dipartimento di Medicina Clinica e Sperimentale, University of Messina, Messina, Italy
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