Trends in the Use of Guideline-Directed Therapies Among Dialysis Patients Hospitalized With Systolic Heart Failure: Findings From the American Heart Association Get With The Guidelines-Heart Failure Program

What to do with foundation therapies for heart failure for patients with end-stage kidney disease on haemodialysis

There is a significant burden of cardiovascular disease morbidity and mortality in the end-stage kidney disease population, driven by traditional and non-traditional risk factors. Despite its prevalence, heart failure is difficult to diagnose in the dialysis population due to overlapping clinical presentations, limitations of investigations, and the impact on the cardiorenal axis. 'Foundation therapies' are the key medications which improve patient outcomes in heart failure with reduced ejection fraction and include beta-blockers, renin-angiotensin-aldosterone system inhibitors and sodium-glucose cotransporter-2 inhibitors. They are underutilised in the dialysis population due to the exclusion of chronic kidney disease patients from major trials and legitimate clinical concerns e.g. hyperkalaemia, intradialytic hypotension and residual kidney function preservation. A coordinated cardiorenal multidisciplinary approach can guide appropriate diagnostic considerations (biomarkers interpretation, imaging, addressing unique complications of kidney disease), optimise dialysis management (prescription length, frequency and ultrafiltration targets) and when at euvolaemia facilitate the stepwise introduction of appropriate foundation therapies.

The effect of kidney function on guideline-directed medical therapy implementation and prognosis in heart failure with reduced ejection fraction

BACKGROUND

Kidney dysfunction (KD) is a main limiting factor of applying guideline-directed medical therapy (GDMT) and reaching the recommended target doses (TD) in heart failure (HF) with reduced ejection fraction (HFrEF).

HYPOTHESIS

We aimed to assess the success of optimization, long-term applicability, and adherence of neurohormonal antagonist triple therapy (TT:RASi [ACEi/ARB/ARNI] + βB + MRA) according to the KD after a HF hospitalization and to investigate its impact on prognosis.

METHODS

The data of 247 real-world, consecutive patients were analyzed who were hospitalized in 2019-2021 for HFrEF and then were followed-up for 1 year. The application and the ratio of reached TD of TT at hospital discharge and at 1 year were assessed comparing KD categories (eGFR: ≥90, 60-89, 45-59, 30-44, <30 mL/min/1.73 m2 ). Moreover, 1-year all-cause mortality and rehospitalization rates in KD subgroups were investigated.

RESULTS

Majority of the patients received TT at hospital discharge (77%) and at 1 year (73%). More severe KD led to a lower application ratio (p < .05) of TT (92%, 88%, 80%, 73%, 31%) at discharge and at 1 year (81%, 76%, 76%, 68%, 40%). Patients with more severe KD were less likely (p < .05) to receive TD of MRA (81%, 68%, 78%, 61%, 52%) at discharge and a RASi (53%, 49%, 45%, 21%, 27%) at 1 year. One-year all-cause mortality (14%, 15%, 16%, 33%, 48%, p < .001), the ratio of all-cause rehospitalizations (30%, 35%, 40%, 43%, 52%, p = .028), and rehospitalizations for HF (8%, 13%, 18%, 20%, 38%, p = .001) were significantly higher in more severe KD categories.

CONCLUSIONS

KD unfavorably affects the application of TT in HFrEF, however poorer mortality and rehospitalization rates among them highlight the role of the conscious implementation and up-titration of GDMT.

Prescription Rates and Prognostic Implications of Optimally Targeted Guideline-Directed Medical Treatment in Heart Failure and Atrial Fibrillation: Insights From The MISOAC-AF Trial

ABSTRACT

Heart failure (HF) and atrial fibrillation (AF) commonly coexist in real-life clinical practice. Among patients with HF with reduced ejection fraction (HFrEF) or HF with mildly reduced ejection fraction (HFmrEF), guidelines call for evidence-based target doses of renin-angiotensin-aldosterone system inhibitors and beta-blockers. However, target doses of guideline-directed medical treatment (GDMT) are often underused in real-world conditions, including HF-AF comorbidity. This retrospective cohort study of a randomized trial (Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with nonvalvular AF) included hospitalized patients with AF and HFrEF or HFmrEF. Optimally targeted GDMT was defined as intake of evidence-based target doses of renin-angiotensin-aldosterone system and beta-blockers at 3 months after discharge. Rates of optimally targeted GDMT achievement across the baseline estimated glomerular filtration rate (eGFR) were assessed. Independent predictors of nontargeted GDMT and its association with all-cause mortality and the composite of cardiovascular death or HF hospitalization were assessed by regression analyses. In total, 374 patients with AF and HFrEF or HFmrEF were studied. At 3 months after discharge, 30.7% received target doses of GDMT medications. The rate of optimally targeted GDMT was reduced by 11% for every 10 mg/min/1.73 m 2 decrease in baseline eGFR [adjusted β = 0.99; 95% confidence interval (CI), 0.98-0.99] levels. After a median 31-month follow-up period, 37.8% patients in the optimally targeted GDMT group died, as compared with 67.8% (adjusted hazard ratio: 1.49; 95% CI, 1.05-2.13) in the nontargeted GDMT group. The risk of cardiovascular death or HF hospitalization was also higher in these patients (adjusted hazard ratio: 1.60; 95% CI, 1.17-2.20). Target doses of all HF drugs were reached in roughly one-third of patients with AF and HFrEF or HFmrEF 3 months after hospital discharge. Nontargeted GDMT was more frequent across lower eGFR levels and was associated with worse outcomes.

Managing Heart Failure in Patients on Dialysis: State-of-the-Art Review

Heart failure (HF) and end-stage kidney disease (ESKD) frequently coexist; 1 comorbidity worsens the prognosis of the other. HF is responsible for almost half the deaths of patients on dialysis. Despite patients' with ESKD composing an extremely high-risk population, they have been largely excluded from landmark clinical trials of HF, and there is, thus, a paucity of data regarding the management of HF in patients on dialysis, and most of the available evidence is observational. Likewise, in clinical practice, guideline-directed medical therapy for HF is often down-titrated or discontinued in patients with ESKD who are undergoing dialysis; this is due to concerns about safety and tolerability. In this state-of-the-art review, we discuss the available evidence for each of the foundational HF therapies in ESKD, review current challenges and barriers to managing patients with HF on dialysis, and outline future directions to optimize the management of HF in these high-risk patients.

Infrequent use of nighttime dialysis for emergency admission due to worsening heart failure in patients on maintenance hemodialysis

In the emergency admission due to worsening heart failure (HF) in patients on maintenance hemodialysis, emergent dialysis may be indicated, which increases personnel expenses. To clarify the characteristics and in-hospital management of the patients, we conducted a multicenter retrospective study including 142 patients on maintenance hemodialysis emergently admitted for worsening HF (71.6 ± 9.2 years, 69.0% male, 44.4% HF with preserved [≥50%] ejection fraction). The interval between last hemodialysis and admission was long (median 55 h), suggesting that fluid accumulation triggered HF events. Although most patients (73.9%) were admitted in the nighttime (5 p.m. to 9 a.m.), only 17.9% of them needed nighttime dialysis and were managed medically until the first in-hospital dialysis, with the use of noninvasive positive pressure ventilation in 45.1% and oxygen supplementation in 95.8%. While patients on hemodialysis with worsening HF were frequently admitted in the nighttime, nighttime dialysis was indicated in a limited population.

Left-sided heart disease and risk of death in patients with end-stage kidney disease receiving haemodialysis: an observational study

BACKGROUND

Cardiovascular disease is the most common cause of death in patients with end-stage kidney disease on haemodialysis. The potential clinical consequence of systematic echocardiographic assessment is however not clear. In an unselected, contemporary population of patients on maintenance haemodialysis we aimed to assess: the prevalence of structural and functional heart disease, the potential therapeutic consequences of echocardiographic screening and whether left-sided heart disease is associated with prognosis.

METHODS

Adult chronic haemodialysis patients in two large dialysis centres had transthoracic echocardiography performed prior to dialysis and were followed prospectively. Significant left-sided heart disease was defined as moderate or severe left-sided valve disease or left ventricular ejection fraction (LVEF) ≤40%.

RESULTS

Among the 247 included patients (mean 66 years of age [95%CI 64-67], 68% male), 54 (22%) had significant left-sided heart disease. An LVEF ≤40% was observed in 31 patients (13%) and severe or moderate valve disease in 27 (11%) patients. The findings were not previously recognized in more than half of the patients (56%) prior to the study. Diagnosis had a potential impact on management in 31 (13%) patients including for 18 (7%) who would benefit from initiation of evidence-based heart failure therapy. After 2.8 years of follow-up, all-cause mortality among patients with and without left-sided heart disease was 52 and 32% respectively (hazard ratio [HR] 1.95 (95%CI 1.25-3.06). A multivariable adjusted Cox proportional hazard analysis showed that left-sided heart disease was an independent predictor of mortality with a HR of 1.60 (95%CI 1.01-2.55) along with age (HR per year 1.05 [95%CI 1.03-1.07]).

CONCLUSION

Left ventricular systolic dysfunction and moderate to severe valve disease are common and often unrecognized in patients with end-stage kidney failure on haemodialysis and are associated with a higher risk of death. For more than 10% of the included patients, systematic echocardiographic assessment had a potential clinical consequence.

[Frequency of use and Indications for Beta-Blockers in Heart Failure with Preserved Ejection Fraction]

Aim      To evaluate trends in beta-blocker prescribing and incidence of possible reasons for beta-blocker administration, including arterial hypertension (AH), atrial fibrillation (AF), ischemic heart disease (IHD), and myocardial infarction, in participants of clinical studies enrolling patients with chronic heart failure with preserved ejection fraction (CHF-PEF).Material and methods  A systematic literature search was performed in the PubMed and EMBASE databases. The study included RCSs of pharmacological therapies for patients with CHF-PEF conducted from 1993 through 2019. Studies of beta-blocker efficacy or those including a specific population (CHF-PEF+IHD or CHF-PEF+AH, etc.) were excluded from the analysis. Baseline characteristics of patients, incidence rate of beta-blocker prescribing, and prevalence of AH, AF, IHD, and MI were recorded. Trends in prevalence of concomitant diseases and the proportion of patients using beta-blockers by the year of enrollment to the study were analyzed with the Mann-Kendall test.Results 14 RCSs of 718 selected publications completely met the inclusion and exclusion criteria. Beta-blocker prescribing significantly increased between 1993 and 2019 (tau=0.51; p=0.014) and reached 80 % in recent studies. Furthermore, prevalence of IHD, MI, AH, and AF did not significantly change among the RCS participants (p&gt;0.05 for all). However, while for AH and AF, a tendency toward an increasing prevalence (tau=0.4; p=0.055 and tau=0.043; p=0.063, respectively) could be considered and became statistically significant for AF when the ALDO-DHF study was excluded from the analysis (tau=0.5; p=0.042), the MI prevalence tended to decrease (tau= -0.73; p=0.06).Conclusion      Beta-blocker prescribing to patients upon inclusion into RCSs for CHF-PEF has significantly increased for the recent 20 years while the incidence of formal reasons for beta-blocker administration (AF, AH, MI, IHD) did not significantly change.

Causes and impact on survival of underuse of angiotensin-converting enzyme inhibitors and angiotensin II receptor blockers in heart failure

Guidelines recommend angiotensin-converting enzyme inhibitors (ACEi) and angiotensin II receptor blockers (ARB) for treatment of heart failure with reduced ejection fraction (HFrEF), but these medications are underprescribed in clinical practice. We reviewed the records of HF patients receiving a first visit in a tertiary outpatient clinic from January 1st 2004 to May 31st 2015, and selected those with a serum creatinine concentration (sCr) available at both the first and last visit and < 3.5 mg/dL at baseline, and a left ventricular ejection fraction (LVEF) < 50% at the first visit. Of 570 eligible patients, 92 (16.1%) never received ACEi/ARB. Compared to ACEi/ARB users, never-users were older, more often women, had higher sCr and lower systolic blood pressure, were less commonly on beta-blocker, and had more frequently anemia. Current or prior cancer also tended to be more common in ACEi/ARB never-users. ACEi/ARB users displayed an improvement in LVEF by ≥ 10% of the baseline value more often than ACEi/ARB never-users (33.7% vs. 20.7%, respectively, P = 0.01), whereas no difference in percent variation of sCr levels was found between the two groups (8.2% vs. 3.1%, respectively; P = 0.13). Over a median follow-up of 56 months (range 1-137 months), 215 (37.7%) patients died. After multiple adjustments, ACEi/ARB never-use was associated with an almost twofold increased risk of all-cause mortality (HR 1.97, 95%CI 1.39-2.80). ACEi/ARB underuse in HFrEF is a standing issue with dramatic prognostic consequences. Efforts are needed to eliminate perceived contraindications to these drugs and ensure their implementation in real-life cardiology.

Hospitalization rate and outcomes in patients with left ventricular dysfunction receiving hemodialysis

Introduction

Left ventricular dysfunction (LVD) is characterized as left ventricular ejection fraction (EF) below half of the systolic capacity of the left ventricle. Patients on hemodialysis have higher risk of developing LVD than the general population. Our aim was to assess hospitalization rate and outcomes in hemodialysis patients with LVD.

Patients and methods

All patients ≥18 years old, who started hemodialysis therapy at King Abdulaziz University Hospital between January 2011 and December 2011, were identified using medical records of hemodialysis unit. Patients were then divided into three groups, according to their EF results prior to the initiation of hemodialysis, as patients with EF <40%, EF between 40% and 49%, and EF ≥50%. Patients were then followed for 5 years by reviewing their hospital records to assess their outcomes, hospital admissions, and length of hospital stay.

Results

Analysis included 333 patients. Patients with EF <40% were 40, 36 patients with EF 40%–49%, and 257 patients had an EF >50%. Patients with EF <50% were significantly older than patients with EF >50% (P=0.002). Diabetes mellitus and hypertension were more prevalent in patients with EF <40% and EF 40%–49% when compared with patients with EF >50% (P<0.001, P=0.002). The average length of stay between the three groups was significantly different (P=0.007). Intensive care unit admissions were significantly different when comparing the three groups (P=0.013) and was found to be an independent risk factor for mortality in our patients. Half of the patients with EF <40% and 44% of patients with EF of 40%–49% died compared with only 27% of patients with EF >50% (P=0.002). However, Kaplan–Meier analysis showed no significant difference in the survival time among the three groups (P=0.845).

Conclusion

Mortality and morbidity increased in patients with LVD on hemodialysis compared with patients with normal EF.

Assessing Guideline-Directed Medication Therapy for Heart Failure in End-Stage Renal Disease

BACKGROUND

Treatment of heart failure with reduced ejection fraction (HFrEF) requires guideline-directed medication therapy (GDMT) consisting of either an angiotensin-converting enzyme inhibitor or an angiotensin receptor blocker in combination with an indicated beta-blocker. There is concern that end-stage renal disease (ESRD) patients are not being prescribed GDMT. The study aim was to determine whether outcomes differ for patients with HFrEF and ESRD receiving GDMT compared to those not receiving GDMT.

MATERIALS AND METHODS

Adult patients with ESRD and HFrEF admitted to a tertiary teaching hospital over a 2-year period were included. Patients were categorized into GDMT or non-GDMT groups based on their home medications. The length of stay (LOS), mortality, and 30-day hospital readmissions were compared between groups. The incidence of hyperkalemia, hypotension and bradycardia were also evaluated.

RESULTS

A total of 109 patients were included: 88% African-American, 61% males, median age 63 (28-93) years with 25 in the GDMT group and 84 in the non-GDMT group. The LOS did not differ between the GDMT (5 days; 3-14) compared to the non-GDMT group (7 days; 3-28), P = 0.14. Thirty-day hospital readmission and in-hospital mortality were also similar. Hypotension occurred less frequently in the GDMT group compared to the non-GDMT group, 4% versus 27% (P = 0.01).

CONCLUSIONS

Although there were no differences in the primary outcomes, the shorter LOS in the GDMT group may be clinically significant. The fact that most patients with ESRD and HFrEF were not receiving GDMT is a finding that requires further evaluation.

Change the management of patients with heart failure: Rationale and design of the CHAMP-HF registry

Heart failure (HF) with reduced ejection fraction (HFrEF) is a common and costly condition that diminishes patients' health status and confers a poor prognosis. Despite the availability of multiple guideline-recommended pharmacologic and cardiac device therapies for patients with chronic HFrEF, outcomes remain suboptimal. Currently, there is limited insight into the rationale underlying clinical decisions by health care providers and patient factors that guide the use and intensity of outpatient HF treatments. A better understanding of current practice patterns has the potential to improve patients' outcomes. The CHAnge the Management of Patients with Heart Failure (CHAMP-HF) registry will evaluate the care and outcomes of patients with chronic HFrEF by assessing real-world treatment patterns, as well as the reasons for and barriers to medication treatment changes. CHAMP-HF will enroll approximately 5,000 patients with chronic HFrEF (left ventricular ejection fraction ≤40%) at approximately 150 US sites, and patients will be followed for a maximum duration of 24 months. Participating sites will collect data from both providers (HF history, examination findings, results of diagnostic studies, pharmacotherapy treatment patterns, decision-making factors, and clinical outcomes) and patients (medication adherence and patient-reported outcomes). The CHAMP-HF registry will provide a unique opportunity to study practice patterns and the adoption of new HF therapies across a diverse mix of health care providers and outpatient practices in the United States that care for HFrEF patients.