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Packer M. COUNTERPOINT: the Seductive Trap of Relying on Exaggerated Effects in Short-Term Heart Failure Trials to Predict Benefits and Risks in Patients With Long-Term Disease. J Card Fail 2023; 29:1214-1217. [PMID: 37330198 DOI: 10.1016/j.cardfail.2023.05.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 05/30/2023] [Accepted: 05/30/2023] [Indexed: 06/19/2023]
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Dallas, TX, USA; Imperial College, London, UK.
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2
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Packer M. The First Dedicated Comprehensive Heart Failure Program in the United States: The Division of Circulatory Physiology at Columbia Presbyterian (1992-2004). J Card Fail 2023; 29:1078-1090. [PMID: 37075940 DOI: 10.1016/j.cardfail.2023.03.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 03/31/2023] [Accepted: 03/31/2023] [Indexed: 04/21/2023]
Abstract
The first dedicated multidisciplinary heart failure program in the United States was founded as the Division of Circulatory Physiology at the Columbia University College of Physicians & Surgeons in 1992. The Division was administratively and financially independent of the Division of Cardiology and grew to 24 faculty members at its peak. Its administrative innovations included (1) a comprehensive full-integrated service line, with 2 differentiated clinical teams, one devoted to drug therapy and the other to heart transplantation and ventricular assist devices; (2) a nurse specialist/physician assistant-led clinical service; and (3) a financial structure independent of (and not supported by) other cardiovascular medical or surgical services. The division had 3 overarching missions: (1) to promote a unique career development path for each faculty member to be linked to recognition in a specific area of heart failure expertise; (2) to change the trajectory and enhance the richness of intellectual discourse in the discipline of heart failure, so as to foster an understanding of fundamental mechanisms and to develop new therapeutics; and (3) to provide optimal medical care to patients and to promote the ability of other physicians to provide optimal care. The major research achievements of the division included (1) the development of beta-blockers for heart failure, from initial hemodynamic assessments to proof-of-concept studies to large-scale international trials; (2) the development and definitive assessment of flosequinan, amlodipine, and endothelin antagonists; (3) initial clinical trials and concerns with nesiritide; (4) large-scale trials evaluating dosing of angiotensin converting-enzyme inhibitors and the efficacy and safety of neprilysin inhibition; (5) identification of key mechanisms in heart failure, including neurohormonal activation, microcirculatory endothelial dysfunction, deficiencies in peripheral vasodilator pathways, noncardiac factors in driving dyspnea, and the first identification of subphenotypes of heart failure and a preserved ejection fraction; (6) the development of a volumetric approach to the assessment of myocardial shortening; (7) conceptualization and early studies of cardiac contractility modulation as a treatment for heart failure; (8) novel approaches to the identification of cardiac allograft rejection and new therapeutics to prevent allograft vasculopathy; and (9) demonstration of the effect of left ventricular assist devices to induce reverse remodeling, and the first randomized trial showing a survival benefit with ventricular assist devices. Above all, the division served as an exceptional incubator for a generation of leaders in the field of heart failure.
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Affiliation(s)
- Milton Packer
- From the Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, and Imperial College, London, UK.
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3
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Drazner MH. Omecamtiv Mecarbil as a Therapy for Heart Failure With Low Ejection Fraction. JAMA 2022; 328:249-250. [PMID: 35852543 DOI: 10.1001/jama.2022.6805] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Mark H Drazner
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
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Maurer MS, Dunnmon P, Fontana M, Quarta CC, Prasad K, Witteles RM, Rapezzi C, Signorovitch J, Lousada I, Merlini G. Proposed Cardiac End Points for Clinical Trials in Immunoglobulin Light Chain Amyloidosis: Report From the Amyloidosis Forum Cardiac Working Group. Circ Heart Fail 2022; 15:e009038. [PMID: 35331001 PMCID: PMC9202961 DOI: 10.1161/circheartfailure.121.009038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Immunoglobulin light chain amyloidosis is a rare, multisystemic, phenotypically heterogenous disease affecting cardiovascular, renal, neurological, and gastrointestinal systems to varying degrees. Its underlying cause is a plasma cell dyscrasia characterized by misfolding of monoclonal immunoglobulin light chains which leads to aggregation and deposition of insoluble amyloid fibrils in target organs. Prognosis is primarily dependent on extent of cardiac involvement and depth of hematologic response to treatment. To facilitate development of new therapies, a public-private partnership was formed between the nonprofit Amyloidosis Research Consortium and the US Food and Drug Administration Center for Drug Evaluation and Research. In 2020, the Amyloidosis Forum launched an initiative to identify novel/composite end points and analytic strategies to expedite clinical trials for development of new therapies for the primary hematologic disorder and organ system manifestations. Specialized working groups identified organ-specific end points; additional working groups reviewed health-related quality of life measures and statistical approaches to data analysis. Each working group comprised amyloidosis experts, patient representatives, statisticians, and representatives from the Food and Drug Administration, the UK Medicines and Healthcare Products Regulatory Agency, and pharmaceutical companies. This review summarizes the proceedings and recommendations of the Cardiac Working Group. Using a modified Delphi method, the group identified, reviewed, and prioritized cardiac end points relevant to immunoglobulin light chain amyloidosis in the context of an antiplasma cell therapy. Prioritized cardiovascular end points included overall survival, hospitalization, N-terminal pro-B-type natriuretic peptide level, 6-minute walk test, Kansas City Cardiac Questionnaire, and cardiac deterioration progression-free survival. These recommended components will be further explored through evaluation of clinical trial datasets and formal guidance from regulatory authorities.
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Affiliation(s)
- Mathew S. Maurer
- Columbia University Irving Medical Center‚ New York‚ NY (M.S.M.)
| | | | | | | | - Krishna Prasad
- UK Medicines and Healthcare Products Regulatory Agency‚ London (K.P.)
| | | | - Claudio Rapezzi
- University of Ferrara, Italy (C.R.)
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Ravenna, Italy (C.R.)
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5
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Hiremath CN. Abbreviated Profile of Drugs (APOD): modeling drug safety profiles to prioritize investigational COVID-19 treatments. Heliyon 2021; 7:e07666. [PMID: 34337170 PMCID: PMC8317482 DOI: 10.1016/j.heliyon.2021.e07666] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2021] [Revised: 05/19/2021] [Accepted: 07/23/2021] [Indexed: 01/18/2023] Open
Abstract
Safe and effective oral formulation of a drug, that is easy to store, transport, and administer, is imperative to reach the masses including those without adequate facilities and resources, in order to combat globally transmitted coronavirus disease 2019 (COVID-19). In this decision analytic modeling study, the safety of investigational COVID-19 drugs in clinical trials was assessed using the Abbreviated Profile of Drugs (APOD) methodology. The method was extensively tested for various unbiased datasets based on different criteria such as drugs recalled worldwide for failing to meet safety standards, organ-specific toxicities, cytochrome P450 inhibitors, and Food and Drug Administration (FDA) approved drugs with remarkable successes. Experimental validation of the predictions made by APOD were demonstrated by comparison with a progression of multiparametric optimization of a series of cancer drugs that led to a potent drug (GDC-0941) which went into the clinical development. The drugs were classified into three categories of safety profiles: strong, moderate and weak. A total of 3556 drugs available in public databases were examined. According to the results, drugs with strong safety profiles included molnupiravir (EIDD-2801), moderate safety profiles included dexamethasone, and weak safety profiles included lopinavir. In this analysis, the physicochemical-pharmacokinetic APOD fingerprint was associated with the drug safety profile of withdrawn, approved, as well as drugs in clinical trials and the APOD method facilitated decision-making and prioritization of the investigational treatments. Drugs with only strong and moderate safety profiles can be repurposed for COVID-19 or any other disease targets. The existing effective drugs with weak safety profiles can be modified into effective drugs with moderate/strong profiles. Unification, uniformity, and integration of drug properties by the APOD method represents an advancement in drug discovery.
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DesJardin JT, Teerlink JR. Inotropic therapies in heart failure and cardiogenic shock: an educational review. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2021; 10:676-686. [PMID: 34219157 DOI: 10.1093/ehjacc/zuab047] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Indexed: 01/11/2023]
Abstract
Reduced systolic function is central to the pathophysiology and clinical sequelae of acute decompensated heart failure (ADHF) with reduced ejection fraction and cardiogenic shock. These clinical entities are the final common pathway for marked deterioration of right or left ventricular function and can occur in multiple clinical presentations including severe ADHF, myocardial infarction, post-cardiac surgery, severe pulmonary hypertension, and advanced or end-stage chronic heart failure. Inotropic therapies improve ventricular systolic function and may be divided into three classes on the basis of their mechanism of action (calcitropes, mitotropes, and myotropes). Most currently available therapies for cardiogenic shock are calcitropes which can provide critical haemodynamic support, but also may increase myocardial oxygen demand, ischaemia, arrhythmia, and mortality. Emerging therapies to improve cardiac function such as mitotropes (e.g. perhexiline, SGLT2i) or myotropes (e.g. omecamtiv mecarbil) may provide useful alternatives in the future.
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Affiliation(s)
- Jacqueline T DesJardin
- Division of Cardiology, School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - John R Teerlink
- Division of Cardiology, School of Medicine, University of California San Francisco, San Francisco, CA, USA.,Section of Cardiology, San Francisco Veterans Affairs Medical Center, 111C, 4150 Clement Street, San Francisco, CA 94121-1545, USA
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7
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Khan MS, Kristensen SL, Vaduganathan M, Kober L, Abraham WT, Desai AS, Solomon SD, Swedberg K, Dickstein K, Zile MR, Packer M, McMurray JJ, Butler J. Natriuretic peptide plasma concentrations and risk of cardiovascular versus non-cardiovascular events in heart failure with reduced ejection fraction: Insights from the PARADIGM-HF and ATMOSPHERE trials. Am Heart J 2021; 237:45-53. [PMID: 33621540 DOI: 10.1016/j.ahj.2021.02.015] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2020] [Accepted: 02/17/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND N-terminal pro-B-type natriuretic peptide (NT-proBNP) plasma concentrations are independent prognostic markers in patients with heart failure and reduced ejection fraction (HFrEF). Whether a differential risk association between NT-proBNP plasma concentrations and risk of cardiovascular (CV) vs non-CV adverse events exists is not well known. OBJECTIVE To assess if there is a differential proportional risk of CV vs non-CV adverse events by NT-proBNP plasma concentrations. METHODS In this post hoc combined analysis of PARADIGM-HF and ATMOSPHERE trials, proportion of CV vs non-CV mortality and hospitalizations were assessed by NT-proBNP levels (<400, 400-999, 1000-1999, 2000-2999, and >3000 pg/mL) at baseline using Cox regression adjusting for traditional risk factors. RESULTS A total of 14,737 patients with mean age of 62 ± 8 years (24% history of atrial fibrillation [AF]) were studied. For CV deaths, the event rates per 1000 patient-years steeply increased from 33.8 in the ≤400 pg/mL group to 142.3 in the ≥3000 pg/mL group, while the non-CV death event rates modestly increased from 9.0 to 22.7, respectively. Proportion of non-CV deaths decreased across the 5 NT-proBNP groups (21.1%, 18.4%, 17.9%, 17.4%, and 13.7% respectively). Similar trend was observed for non-CV hospitalizations (46.4%, 42.6%, 42.9%, 42.0%, and 36.9% respectively). These results remained similar when stratified according to the presence of AF at baseline and prior HF hospitalization within last 12 months. CONCLUSIONS The absolute CV event rates per patient years of follow-up were greater and had higher stepwise increases than non-CV event rates across a broad range of NT-proBNP plasma concentrations indicating a differential risk of CV events at varying baseline NT-proBNP values. These results have implications for future design of clinical trials.
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Affiliation(s)
| | | | | | - Lars Kober
- Division of Cardiology, Rigshospitalet University Hospital, Copenhagen, Denmark
| | - William T Abraham
- Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, Ohio State University, Columbus, OH
| | - Akshay S Desai
- Brigham and Women's Hospital Heart & Vascular Center, Boston, MA
| | - Scott D Solomon
- Brigham and Women's Hospital Heart & Vascular Center, Boston, MA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Kenneth Dickstein
- Department of Cardiology, University of Bergen, Stavanger University Hospital, Stavanger, Norway
| | - Michael R Zile
- Division of Cardiology, Medical University of South Carolina, and Ralph H Johnson Veterans Administration Medical Centre, Charleston, SC
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX
| | - John Jv McMurray
- BHF Cardiovascular Research Center, University of Glasgow, Glasgow, United Kingdom
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS
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8
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Chen YJ, Chien CS, Chiang CE, Chen CH, Cheng HM. From Genetic Mutations to Molecular Basis of Heart Failure Treatment: An Overview of the Mechanism and Implication of the Novel Modulators for Cardiac Myosin. Int J Mol Sci 2021; 22:6617. [PMID: 34205587 PMCID: PMC8234187 DOI: 10.3390/ijms22126617] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Revised: 06/11/2021] [Accepted: 06/17/2021] [Indexed: 02/06/2023] Open
Abstract
Heart failure (HF) is a syndrome encompassing several important etiologies that lead to the imbalance between oxygen demand and supply. Despite the usage of guideline-directed medical therapy for HF has shown better outcomes, novel therapeutic strategies are desirable, especially for patients with preserved or mildly reduced left ventricular ejection fraction. In this regard, understanding the molecular basis for cardiomyopathies is expected to fill in the knowledge gap and generate new therapies to improve prognosis for HF. This review discusses an evolutionary mechanism designed to regulate cardiac contraction and relaxation through the most often genetically determined cardiomyopathies associated with HF. In addition, both the myosin inhibitor and myosin activator are promising new treatments for cardiomyopathies. A comprehensive review from genetic mutations to the molecular basis of direct sarcomere modulators will help shed light on future studies for a better characterization of HF etiologies and potential therapeutic targets.
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Affiliation(s)
- Yu-Jen Chen
- Department of Internal Medicine, Division of Cardiovascular Medicine, Wan Fang Hospital, Taipei Medical University, Taipei 116081, Taiwan;
- Department of Internal Medicine, Division of Cardiology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 110301, Taiwan
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
| | - Chian-Shiu Chien
- Innovative Cellular Therapy Center, Department of Medical Research, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
| | - Chern-En Chiang
- General Clinical Research Center, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei 112304, Taiwan
| | - Chen-Huan Chen
- Department of Medical Education, Taipei Veterans General Hospital, Taipei 112201, Taiwan;
- College of Medicine, National Yang Ming Chiao Tung University, Taipei 112201, Taiwan
| | - Hao-Min Cheng
- Institute of Public Health, National Yang Ming Chiao Tung University, Taipei 112304, Taiwan
- Department of Medicine, National Yang Ming Chiao Tung University College of Medicine, Taipei 112304, Taiwan
- Center for Evidence-Based Medicine, Taipei Veterans General Hospital, Taipei 112201, Taiwan
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9
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Topf A, Mirna M, Ohnewein B, Jirak P, Kopp K, Fejzic D, Haslinger M, Motloch LJ, Hoppe UC, Berezin A, Lichtenauer M. The Diagnostic and Therapeutic Value of Multimarker Analysis in Heart Failure. An Approach to Biomarker-Targeted Therapy. Front Cardiovasc Med 2020; 7:579567. [PMID: 33344515 PMCID: PMC7746655 DOI: 10.3389/fcvm.2020.579567] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2020] [Accepted: 11/02/2020] [Indexed: 12/12/2022] Open
Abstract
Background: Heart failure is a pathophysiological state, which is still associated with high morbidity and mortality despite established therapies. Diverse well-known biomarkers fail to assess the variety of individual pathophysiology in the context of heart failure. Methods: An analysis of prospective, multimarker-specific therapeutic approaches to heart failure based on studies in current literature was performed. A total of 159 screened publications in the field of biomarkers in heart failure were hand-selected and found to be eligible for this study by a team of experts. Results: Established biomarkers of the inflammatory axis, matrix remodeling, fibrosis and oxidative stress axis, as well as potential therapeutic interventions were investigated. Interaction with end organs, such as cardio-hepatic, cardio-renal and cardio-gastrointestinal interactions show the complexity of the syndrome and could be of further therapeutic value. MicroRNAs are involved in a wide variety of physiologic and pathophysiologic processes in heart failure and could be useful in diagnostic as well as therapeutic setting. Conclusion: Based on our analysis by a biomarker-driven approach in heart failure therapy, patients could be treated more specifically in long term with a consideration of different aspects of heart failure. New studies evaluating a multimarker – based therapeutic approach could lead in a decrease in the morbidity and mortality of heart failure patients.
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Affiliation(s)
- Albert Topf
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Moritz Mirna
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Bernhard Ohnewein
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Peter Jirak
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Kristen Kopp
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Dzeneta Fejzic
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Michael Haslinger
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Lukas J Motloch
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Uta C Hoppe
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
| | - Alexander Berezin
- Internal Medicine Department, State Medical University, Zaporozhye, Ukraine
| | - Michael Lichtenauer
- Department of Cardiology, Clinic of Internal Medicine II, Paracelsus Medical University of Salzburg, Salzburg, Austria
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10
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Mann DL, Greene SJ, Givertz MM, Vader JM, Starling RC, Ambrosy AP, Shah P, McNulty SE, Mahr C, Gupta D, Redfield MM, Lala A, Lewis GD, Mohammed SF, Gilotra NA, DeVore AD, Gorodeski EZ, Desvigne-Nickens P, Hernandez AF, Braunwald E. Sacubitril/Valsartan in Advanced Heart Failure With Reduced Ejection Fraction: Rationale and Design of the LIFE Trial. JACC. HEART FAILURE 2020; 8:789-799. [PMID: 32641226 PMCID: PMC7286640 DOI: 10.1016/j.jchf.2020.05.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/18/2020] [Accepted: 05/19/2020] [Indexed: 12/11/2022]
Abstract
The PARADIGM-HF (Prospective Comparison of Angiotensin II Receptor Blocker Neprilysin Inhibitor With Angiotensin-Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial reported that sacubitril/valsartan (S/V), an angiotensin receptor-neprilysin inhibitor, significantly reduced mortality and heart failure (HF) hospitalization in HF patients with a reduced ejection fraction (HFrEF). However, fewer than 1% of patients in the PARADIGM-HF study had New York Heart Association (NYHA) functional class IV symptoms. Accordingly, data that informed the use of S/V among patients with advanced HF were limited. The LIFE (LCZ696 in Hospitalized Advanced Heart Failure) study was a 24-week prospective, multicenter, double-blinded, double-dummy, active comparator trial that compared the safety, efficacy, and tolerability of S/V with those of valsartan in patients with advanced HFrEF. The trial planned to randomize 400 patients ≥18 years of age with advanced HF, defined as an EF ≤35%, New York Heart Association functional class IV symptoms, elevated natriuretic peptide concentration (B-type natriuretic peptide [BNP] ≥250 pg/ml or N-terminal pro-B-type natriuretic peptide [NT-proBNP] ≥800 pg/ml), and ≥1 objective finding of advanced HF. Following a 3- to 7-day open label run-in period with S/V (24 mg/26 mg twice daily), patients were randomized 1:1 to S/V titrated to 97 mg/103 mg twice daily versus 160 mg of V twice daily. The primary endpoint was the proportional change from baseline in the area under the curve for NT-proBNP levels measured through week 24. Secondary and tertiary endpoints included clinical outcomes and safety and tolerability. Because of the COVID-19 pandemic, enrollment in the LIFE trial was stopped prematurely to ensure patient safety and data integrity. The primary analysis consists of the first 335 randomized patients whose clinical follow-up examination results were not severely impacted by COVID-19. (Entresto [LCZ696] in Advanced Heart Failure [LIFE STUDY] [HFN-LIFE]; NCT02816736).
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Affiliation(s)
- Douglas L Mann
- Department of Medicine, Washington University, St. Louis, Missouri.
| | - Stephen J Greene
- Department of Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Michael M Givertz
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Justin M Vader
- Department of Medicine, Washington University, St. Louis, Missouri
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Steven E McNulty
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Claudius Mahr
- Department of Medicine, University of Washington, Seattle, Washington
| | - Divya Gupta
- Department of Medicine, Emory University, Atlanta, Georgia
| | | | - Anuradha Lala
- Icahn School of Medicine at Mount Sinai, New York, New York
| | - Gregory D Lewis
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Nisha A Gilotra
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Adam D DeVore
- Department of Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Eiran Z Gorodeski
- Department of Medicine, Harrington Heart and Vascular Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Baltimore, Maryland
| | - Adrian F Hernandez
- Department of Medicine, Duke University, Durham, North Carolina; Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Eugene Braunwald
- Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
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11
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Packer M. Molecular, Cellular, and Clinical Evidence That Sodium-Glucose Cotransporter 2 Inhibitors Act as Neurohormonal Antagonists When Used for the Treatment of Chronic Heart Failure. J Am Heart Assoc 2020; 9:e016270. [PMID: 32791029 PMCID: PMC7660825 DOI: 10.1161/jaha.120.016270] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Sodium-glucose cotransporter 2 (SGLT2) inhibitors reduce the risk of cardiovascular death and hospitalization for heart failure in patients with chronic heart failure. Initially, these drugs were believed to have a profile similar to diuretics or hemodynamically active drugs, but they do not rapidly reduce natriuretic peptides or cardiac filling pressures, and they exert little early benefit on symptoms, exercise tolerance, quality of life, or signs of congestion. Clinically, the profile of SGLT2 inhibitors resembles that of neurohormonal antagonists, whose benefits emerge gradually during sustained therapy. In experimental models, SGLT2 inhibitors produce a characteristic pattern of cellular effects, which includes amelioration of oxidative stress, mitigation of mitochondrial dysfunction, attenuation of proinflammatory pathways, and a reduction in myocardial fibrosis. These cellular effects are similar to those produced by angiotensin converting enzyme inhibitors, β-blockers, mineralocorticoid receptor antagonists, and neprilysin inhibitors. At a molecular level, SGLT2 inhibitors induce transcriptional reprogramming of cardiomyocytes that closely mimics that seen during nutrient deprivation. This shift in signaling activates the housekeeping pathway of autophagy, which clears the cytosol of dangerous cytosolic constituents that are responsible for cellular stress, thereby ameliorating the development of cardiomyopathy. Interestingly, similar changes in cellular signaling and autophagic flux have been seen with inhibitors of the renin-angiotensin system, β-blockers, mineralocorticoid receptor antagonists, and neprilysin inhibitors. The striking parallelism of these molecular, cellular, and clinical profiles supports the premise that SGLT2 inhibitors should be regarded as neurohormonal antagonists when prescribed for the treatment of heart failure with a reduced ejection fraction.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical CenterDallasTX
- Imperial CollegeLondonUnited Kingdom
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12
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, 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 CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
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13
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Barnhart DA, Semrau KEA, Zigler CM, Molina RL, Delaney MM, Hirschhorn LR, Spiegelman D. Optimizing the development and evaluation of complex interventions: lessons learned from the BetterBirth Program and associated trial. Implement Sci Commun 2020; 1:29. [PMID: 32885188 PMCID: PMC7427863 DOI: 10.1186/s43058-020-00014-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 01/27/2020] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Despite extensive efforts to develop and refine intervention packages, complex interventions often fail to produce the desired health impacts in full-scale evaluations. A recent example of this phenomenon is BetterBirth, a complex intervention designed to implement the World Health Organization's Safe Childbirth Checklist and improve maternal and neonatal health. Using data from the BetterBirth Program and its associated trial as a case study, we identified lessons to assist in the development and evaluation of future complex interventions. METHODS BetterBirth was refined across three sequential development phases prior to being tested in a matched-pair, cluster randomized trial in Uttar Pradesh, India. We reviewed published and internal materials from all three development phases to identify barriers hindering the identification of an optimal intervention package and identified corresponding lessons learned. For each lesson, we describe its importance and provide an example motivated by the BetterBirth Program's development to illustrate how it could be applied to future studies. RESULTS We identified three lessons: (1) develop a robust theory of change (TOC); (2) define optimization outcomes, which are used to assess the effectiveness of the intervention across development phases, and corresponding criteria for success, which determine whether the intervention has been sufficiently optimized to warrant full-scale evaluation; and (3) create and capture variation in the implementation intensity of components. When applying these lessons to the BetterBirth intervention, we demonstrate how a TOC could have promoted more complete data collection. We propose an optimization outcome and related criteria for success and illustrate how they could have resulted in additional development phases prior to the full-scale trial. Finally, we show how variation in components' implementation intensities could have been used to identify effective intervention components. CONCLUSION These lessons learned can be applied during both early and advanced stages of complex intervention development and evaluation. By using examples from a real-world study to demonstrate the relevance of these lessons and illustrating how they can be applied in practice, we hope to encourage future researchers to collect and analyze data in a way that promotes more effective complex intervention development and evaluation. TRIAL REGISTRATION ClinicalTrials.gov, NCT02148952; registered on May 29, 2014.
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Affiliation(s)
| | - Katherine E. A. Semrau
- Ariadne Labs, Boston, MA USA
- Brigham and Women’s Hospital, Boston, MA USA
- Harvard Medical School, Boston, MA USA
| | - Corwin M. Zigler
- University of Texas, Austin, TX USA
- Dell Medical School, Austin, TX USA
| | - Rose L. Molina
- Ariadne Labs, Boston, MA USA
- Harvard Medical School, Boston, MA USA
- Beth Israel Deaconess Medical Center, Boston, MA USA
| | - Megan Marx Delaney
- Harvard T.H. Chan School of Public Health, Boston, MA USA
- Ariadne Labs, Boston, MA USA
| | | | - Donna Spiegelman
- Harvard T.H. Chan School of Public Health, Boston, MA USA
- Center for Methods in Implementation and Prevention Science and Department of Biostatistics, Yale School of Public Health, New Haven, CT USA
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14
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Kim ES, Youn JC, Baek SH. Update on the Pharmacotherapy of Heart Failure with Reduced Ejection Fraction. ACTA ACUST UNITED AC 2020. [DOI: 10.36011/cpp.2020.2.e17] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Affiliation(s)
- Eui-Soon Kim
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Sang Hong Baek
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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15
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Ahmad T, Miller PE, McCullough M, Desai NR, Riello R, Psotka M, Böhm M, Allen LA, Teerlink JR, Rosano GMC, Lindenfeld J. Why has positive inotropy failed in chronic heart failure? Lessons from prior inotrope trials. Eur J Heart Fail 2019; 21:1064-1078. [PMID: 31407860 PMCID: PMC6774302 DOI: 10.1002/ejhf.1557] [Citation(s) in RCA: 80] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 06/19/2019] [Accepted: 06/21/2019] [Indexed: 12/11/2022] Open
Abstract
Current pharmacological therapies for heart failure with reduced ejection fraction are largely either repurposed anti‐hypertensives that blunt overactivation of the neurohormonal system or diuretics that decrease congestion. However, they do not address the symptoms of heart failure that result from reductions in cardiac output and reserve. Over the last few decades, numerous attempts have been made to develop and test positive cardiac inotropes that improve cardiac haemodynamics. However, definitive clinical trials have failed to show a survival benefit. As a result, no positive inotrope is currently approved for long‐term use in heart failure. The focus of this state‐of‐the‐art review is to revisit prior clinical trials and to understand the causes for their findings. Using the learnings from those experiences, we propose a framework for future trials of such agents that maximizes their potential for success. This includes enriching the trials with patients who are most likely to derive benefit, using biomarkers and imaging in trial design and execution, evaluating efficacy based on a wider range of intermediate phenotypes, and collecting detailed data on functional status and quality of life. With a rapidly growing population of patients with advanced heart failure, the epidemiologic insignificance of heart transplantation as a therapeutic intervention, and both the cost and morbidity associated with ventricular assist devices, there is an enormous potential for positive inotropic therapies to impact the outcomes that matter most to patients.
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Affiliation(s)
- Tariq Ahmad
- Section of Cardiovascular Medicine, New Haven, CT, USA.,Center for Outcome Research & Evaluation (CORE), Yale University School of Medicine, New Haven, CT, USA
| | | | | | - Nihar R Desai
- Section of Cardiovascular Medicine, New Haven, CT, USA.,Center for Outcome Research & Evaluation (CORE), Yale University School of Medicine, New Haven, CT, USA
| | - Ralph Riello
- Section of Cardiovascular Medicine, New Haven, CT, USA
| | | | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Homburg, Germany
| | - Larry A Allen
- Division of Cardiology, School of Medicine, University of Colorado, Aurora, CO, USA
| | - John R Teerlink
- San Francisco Veterans Affairs Medical Center, University of California San Francisco, San Francisco, CA, USA
| | - Giuseppe M C Rosano
- Cardiovascular and Cell Sciences Research Institute, St George's University of London, London, UK
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16
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Van Norman GA. Phase II Trials in Drug Development and Adaptive Trial Design. JACC Basic Transl Sci 2019; 4:428-437. [PMID: 31312766 PMCID: PMC6609997 DOI: 10.1016/j.jacbts.2019.02.005] [Citation(s) in RCA: 55] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022]
Abstract
Phase II clinical studies represent a critical point in determining drug costs, and phase II is a poor predictor of drug success: >30% of drugs entering phase II studies fail to progress, and >58% of drugs go on to fail in phase III. Adaptive clinical trial design has been proposed as a way to reduce the costs of phase II testing by providing earlier determination of futility and prediction of phase III success, reducing overall phase II and III trial sizes, and shortening overall drug development time. This review examines issues in phase II testing and adaptive trial design.
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Affiliation(s)
- Gail A. Van Norman
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, Washington
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17
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Abstract
Approximately half of the patients with signs and symptoms of heart failure have a left ventricular ejection fraction that is not markedly abnormal. Despite the historically initial surprise, heightened risks for heart failure specific major adverse events occur across the broad range of ejection fraction, including normal. The recognition of the magnitude of the problem of heart failure with preserved ejection fraction in the past 20 years has spurred an explosion of clinical investigation and growing intensity of informative outcome trials. This article addresses the historic development of this component of the heart failure syndrome, including the epidemiology, pathophysiology, and existing and planned therapeutic studies. Looking forward, more specific phenotyping and even genotyping of subpopulations should lead to improvements in outcomes from future trials.
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Affiliation(s)
- Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amil M. Shah
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Barry A. Borlaug
- Cardiovascular Medicine Division, Mayo Clinic, Rochester, Minnesota
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18
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Wessler BS, McCauley M, Morine K, Konstam MA, Udelson JE. Relation between therapy-induced changes in natriuretic peptide levels and long-term therapeutic effects on mortality in patients with heart failure and reduced ejection fraction. Eur J Heart Fail 2019; 21:613-620. [PMID: 30919541 DOI: 10.1002/ejhf.1411] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Revised: 12/13/2018] [Accepted: 12/17/2018] [Indexed: 12/11/2022] Open
Abstract
AIMS To assess whether natriuretic peptides (NPs) can be used to reliably predict long-term therapeutic effect on clinical outcomes for patients with heart failure and reduced ejection fraction (HFrEF). METHODS AND RESULTS HFrEF intervention trials with mortality data were identified. Subsequently, we identified trials assessing therapy-induced changes in NPs. We assessed the correlation between the average short-term placebo-corrected drug or device effect on NPs and the longer-term therapeutic effect on clinical outcomes. Of 35 distinct therapies with an identifiable mortality result (n = 105 062 patients), 20 therapies had corresponding data on therapeutic effect on NPs. No correlation was observed between therapy-induced placebo-corrected change in brain natriuretic peptide or N-terminal pro-brain natriuretic peptide and therapeutic effect on all-cause mortality (ACM) (Spearman r = -0.32, P = 0.18 and r = -0.20, P = 0.47, respectively). There was no correlation between therapy-induced placebo-corrected per cent change in NP and intervention effect on ACM or ACM-heart failure hospitalizations (r = -0.30, P = 0.11 and r = 0.10, P = 0.75, respectively). CONCLUSIONS Short-term intervention-induced changes in NP levels are not reliable predictors of therapeutic long-term effect on mortality or morbidity outcomes for patients with HFrEF.
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Affiliation(s)
- Benjamin S Wessler
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Michael McCauley
- Department of Neurology, The Warren Alpert Medical School at Brown University, Providence, RI, USA
| | - Kevin Morine
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - Marvin A Konstam
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA, USA
| | - James E Udelson
- Division of Cardiology and the CardioVascular Center, Tufts Medical Center, Boston, MA, USA
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19
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Greene SJ, Mentz RJ, Fiuzat M, Butler J, Solomon SD, Ambrosy AP, Mehta C, Teerlink JR, Zannad F, O'Connor CM. Reassessing the Role of Surrogate End Points in Drug Development for Heart Failure. Circulation 2018; 138:1039-1053. [PMID: 30354535 PMCID: PMC6205720 DOI: 10.1161/circulationaha.118.034668] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
With few notable exceptions, drug development for heart failure (HF) has become progressively more challenging, and there remain no definitively proven therapies for patients with acute HF or HF with preserved ejection fraction. Inspection of temporal trends suggests an increasing rate of disagreement between early-phase and phase III trial end points. Preliminary results from phase II HF trials are frequently promising, but increasingly followed by disappointing phase III results. Given this potential disconnect, it is reasonable to carefully re-evaluate the purpose, design, and execution of phase II HF trials, with particular attention directed toward the surrogate end points commonly used by these studies. In this review, we offer a critical reappraisal of the role of phase II HF trials and surrogate end points, highlighting challenges in their use and interpretation, lessons learned from past experiences, and specific strengths and weaknesses of various surrogate outcomes. We conclude by proposing a series of approaches that should be considered for the goal of optimizing the efficiency of HF drug development. This review is based on discussions between scientists, clinical trialists, industry and government sponsors, and regulators that took place at the Cardiovascular Clinical Trialists Forum in Washington, DC, on December 2, 2016.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.J.M., M.F., C.M.O.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., R.J.M.)
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.J.M., M.F., C.M.O.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., R.J.M.)
| | - Mona Fiuzat
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.J.M., M.F., C.M.O.)
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson (J.B.)
| | - Scott D Solomon
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA (S.D.S.)
| | - Andrew P Ambrosy
- Division of Cardiology, The Permanente Medical Group, San Francisco, CA (A.P.A.)
- Division of Research, Kaiser Permanente Northern California, Oakland, CA (A.P.A.)
| | - Cyrus Mehta
- Harvard School of Public Health, Boston, MA (C.M.)
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, CA (J.R.T.)
- School of Medicine, University of California, San Francisco (J.R.T.)
| | - Faiez Zannad
- Université de Lorraine, Institut National de la Santé et de la Recherche Médicale U1116 and Centre d'Investigation Clinique 1433, FCRIN INI-CRCT, Centre Hospitalier Régional Universitaire de Nancy, Vandoeuvre les Nancy, France (F.Z.)
| | - Christopher M O'Connor
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.J.M., M.F., C.M.O.)
- Inova Heart and Vascular Institute, Falls Church, VA (C.M.O.)
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20
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Xu Z, Chen L, Jin S, Yang B, Chen X, Wu Z. Effect of Palliative Care for Patients with Heart Failure. Int Heart J 2018; 59:503-509. [DOI: 10.1536/ihj.17-289] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Zhili Xu
- Department of Emergency, Wenzhou People Hospital
| | | | - Shuang Jin
- Department of Emergency, Wenzhou People Hospital
| | - Baohua Yang
- Department of Emergency, Wenzhou People Hospital
| | - Xinguo Chen
- Department of Emergency, Wenzhou People Hospital
| | - Zhang Wu
- Department of Emergency, Wenzhou People Hospital
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21
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Zhou K, Mao Y. Palliative care in heart failure : A meta-analysis of randomized controlled trials. Herz 2018; 44:440-444. [PMID: 29468259 DOI: 10.1007/s00059-017-4677-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/23/2017] [Accepted: 12/26/2017] [Indexed: 12/25/2022]
Abstract
BACKGROUND Palliative care can play an important role in the management of heart failure. We conducted a systematic review and meta-analysis to compare the efficacy and safety of palliative care in patients with heart failure. METHODS PubMed, Embase, Web of Science, EBSCO, and the Cochrane Library databases were systematically searched. Randomized controlled trials (RCTs) on the impact of palliative care on heart failure were included. Two investigators independently searched the articles, extracted data, and assessed the quality of included studies. The primary outcome was mortality. RESULTS Seven RCTs were included in the meta-analysis. Compared with usual care for heart failure, palliative care was associated with a significantly increased quality of life (standardized mean difference = 1.46; 95% confidence interval [CI] = 0.12 to 2.79; p = 0.03) and reduced depression scores (standardized mean difference = -0.62; 95% CI = -0.99 to -0.25; p = 0.03), but demonstrated no impact on mortality (risk ratio [RR] = 1.28; 95% CI = 0.86 to 1.92; p = 0.22) and rehospitalization (RR = 0.84; 95% CI = 0.66 to 1.07; p = 0.16). CONCLUSION Palliative care can improve the quality of life and reduce the occurrence of depression in patients with heart failure.
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Affiliation(s)
- K Zhou
- Department Rehabilitation Medicine, Ningbo No. 2 Hospital, Ningbo, Zhejiang Province, China
| | - Y Mao
- Emergency Department, Ninghai First Hospital, Ninghai, Zhejiang Province, China.
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22
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Packer M. Why Has a Run-In Period Been a Design Element in Most Landmark Clinical Trials? Analysis of the Critical Role of Run-In Periods in Drug Development. J Card Fail 2017; 23:697-699. [DOI: 10.1016/j.cardfail.2017.07.401] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2017] [Revised: 06/18/2017] [Accepted: 07/24/2017] [Indexed: 11/25/2022]
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