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Kondo T, Jhund PS, McMurray JJ. Drug therapy for HFrEF: What is the "right" dose? Eur J Heart Fail 2022; 24:421-430. [PMID: 35119172 PMCID: PMC9303189 DOI: 10.1002/ejhf.2447] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 01/16/2022] [Accepted: 01/31/2022] [Indexed: 12/03/2022] Open
Abstract
New guidelines have emphasized the primacy of starting the four key life‐saving therapies for patients with heart failure and reduced ejection fraction as quickly as possible, with titration to ‘target dose’ of these, as secondary consideration. In this article, we examine the reasons for this change in emphasis and revisit the evidence regarding the dosing of pharmacological therapy in heart failure. We demonstrate the early benefits obtained with even low doses of most of the foundational therapies for heart failure and reduced ejection fraction. We also clarify that the ‘target dose’ of those therapies requiring titration was a goal based on tolerability and often not reached in trials, i.e. the proven benefits of our foundational therapies were demonstrated with an average dose that was less than target and many patients in these trials were treated with sub‐target doses.
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John Jv McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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2
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Jhund PS, Ponikowski P, Docherty KF, Gasparyan SB, Böhm M, Chiang CE, Desai AS, Howlett J, Kitakaze M, Petrie MC, Verma S, Bengtsson O, Langkilde AM, Sjöstrand M, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA, Sabatine MS, Solomon SD, McMurray JJ. Dapagliflozin and Recurrent Heart Failure Hospitalizations in Heart Failure With Reduced Ejection Fraction: An Analysis of DAPA-HF. Circulation 2021; 143:1962-1972. [PMID: 33832352 PMCID: PMC8126492 DOI: 10.1161/circulationaha.121.053659] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2021] [Accepted: 03/22/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND Patients with heart failure (HF) and reduced ejection fraction will experience multiple hospitalizations for heart failure during the course of their disease. We assessed the efficacy of dapagliflozin on reducing the rate of total (ie, first and repeat) hospitalizations for heart failure in the DAPA-HF trial (Dapagliflozin and Prevention of Adverse-Outcomes in Heart Failure). METHODS The total number of HF hospitalizations and cardiovascular deaths was examined by using the proportional-rates approach of Lei-Wei-Yang-Ying and a joint frailty model for each of recurrent HF hospitalizations and time to cardiovascular death. Variables associated with the risk of recurrent hospitalizations were explored in a multivariable Lei-Wei-Yang-Ying model. RESULTS Of 2371 participants randomly assigned to placebo, 318 experienced 469 hospitalizations for HF; of 2373 assigned to dapagliflozin, 230 patients experienced 340 admissions. In a multivariable model, factors associated with a higher risk of recurrent HF hospitalizations included higher heart rate, higher N-terminal pro-B-type natriuretic peptide, and New York Heart Association class. In the Lei-Wei-Yang-Ying model, the rate ratio for the effect of dapagliflozin on recurrent HF hospitalizations or cardiovascular death was 0.75 (95% CI, 0.65-0.88), P=0.0002. In the joint frailty model, the rate ratio for total HF hospitalizations was 0.71 (95% CI, 0.61-0.82), P<0.0001, whereas, for cardiovascular death, the hazard ratio was 0.81 (95% CI, 0.67-0.98), P=0.0282. CONCLUSIONS Dapagliflozin reduced the risk of total (first and repeat) HF hospitalizations and cardiovascular death. Time-to-first event analysis underestimated the benefit of dapagliflozin in HF and reduced ejection fraction. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03036124.
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Affiliation(s)
- Pardeep S. Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (P.S.J., K.F.D., M.C.P., J.J.V.M.)
| | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Poland (P.P.)
| | - Kieran F. Docherty
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (P.S.J., K.F.D., M.C.P., J.J.V.M.)
| | - Samvel B. Gasparyan
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (S.B.G., O.B., A.-M.L., M.S.)
| | - Michael Böhm
- The Department of Medicine, Saarland University Hospital, Homburg-Saar, Germany (M.B.)
| | - Chern-En Chiang
- Division of Cardiology, Taipei Veterans General Hospital and National Yang-Ming University, Taiwan (C.-E.C.)
| | - Akshay S. Desai
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (A.S.D., S.D.S.)
| | - Jonathon Howlett
- Cumming School of Medicine and Libin Cardiovascular Institute, University of Calgary, Alberta, Canada (J.H.)
| | - Masafumi Kitakaze
- Cardiovascular Division of Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan (M.K.)
| | - Mark C. Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (P.S.J., K.F.D., M.C.P., J.J.V.M.)
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Canada (S.V.)
| | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (S.B.G., O.B., A.-M.L., M.S.)
| | - Anna-Maria Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (S.B.G., O.B., A.-M.L., M.S.)
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (S.B.G., O.B., A.-M.L., M.S.)
| | - Silvio E. Inzucchi
- Section of Endocrinology, Yale School of Medicine, New Haven, CT (S.E.I.)
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark (L.K.)
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, University of Missouri, Kansas City (M.N.K.)
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | | | - Marc S. Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (M.S.S.)
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA (A.S.D., S.D.S.)
| | - John J.V. McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (P.S.J., K.F.D., M.C.P., J.J.V.M.)
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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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4
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Jhund PS. The recurring problem of heart failure hospitalisations. Eur J Heart Fail 2020; 22:249-250. [DOI: 10.1002/ejhf.1721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pardeep S. Jhund
- British Heart Foundation Glasgow Cardiovascular Research CentreInstitute of Cardiovascular and Medical Sciences, University of Glasgow Glasgow UK
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5
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Sharma A, Vaduganathan M, Ferreira JP, Liu Y, Bakris GL, Cannon CP, White WB, Zannad F. Clinical and Biomarker Predictors of Expanded Heart Failure Outcomes in Patients With Type 2 Diabetes Mellitus After a Recent Acute Coronary Syndrome: Insights From the EXAMINE Trial. J Am Heart Assoc 2020; 9:e012797. [PMID: 31902327 PMCID: PMC6988143 DOI: 10.1161/jaha.119.012797] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2019] [Accepted: 08/26/2019] [Indexed: 12/13/2022]
Abstract
Background Improved heart failure (HF) risk stratification after a recent acute coronary syndrome may identify those who can benefit from therapies that reduce HF risk. We aimed to identify clinical and biomarker predictors for expanded HF outcomes in patients with type 2 diabetes mellitus after recent acute coronary syndrome. Methods and Results The EXAMINE (Examination of Cardiovascular Outcomes with Alogliptin versus Standard of Care) trial was a multicenter, non-inferiority, double-masked, placebo-controlled study which randomized 5380 patients with type 2 diabetes mellitus after recent acute coronary syndrome to alogliptin or placebo. Baseline biomarkers were measured in 5154 patients: NT-proBNP (N-terminal pro-B-type natriuretic peptide), high-sensitivity troponin I, adiponectin, growth-differentiation-factor-15, and galectin-3. Our primary outcome was cardiovascular) death, HF hospitalization, elevated NT-proBNP during follow-up, or loop diuretics initiation. The association between clinical variables, biomarkers, and outcomes were assessed using Cox regression models. In the study population, the median age was 61.0 years, 67.7% were men, and 28.0% had baseline HF (median follow-up was 18 months). In multivariable analyses, NT-proBNP had the strongest association with the primary outcome (per log2, hazard ratio 1.24; Wald χ2 67.4; P<0.0001) followed by a prior HF history (hazard ratio 1.42; Wald χ2 20.8; P<0.0001). A model with clinical variables and biomarkers allowed for risk prediction for expanded HF outcomes (C-statistic=0.72). Discrimination results were similar for cardiovascular death or HF hospitalization. Conclusions Among patients with type 2 diabetes mellitus after recent acute coronary syndrome, the use biomarkers such as N-terminal pro-B-type natriuretic peptide and clinical variables enables risk stratification for expanded HF outcomes. Clinical Trial Registration URL: https://www.clinicaltrials.gov/. Unique identifier: NCT00968708.
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Affiliation(s)
- Abhinav Sharma
- INSERM CIC 1433NI‐CRCT (Cardiovascular and Renal Clinical Trialists) F‐CRIN networkUniversité de Lorraine and CHRUNancyFrance
- Division of CardiologyStanford UniversityPalo AltoCA
- Division of CardiologyMcGill UniversityMontrealQCCanada
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular CenterHarvard Medical School BostonMA
| | - João Pedro Ferreira
- INSERM CIC 1433NI‐CRCT (Cardiovascular and Renal Clinical Trialists) F‐CRIN networkUniversité de Lorraine and CHRUNancyFrance
- Department of PhysiologyUniversity of PortoPortugal
| | - Yuyin Liu
- Baim Institute for Clinical ResearchBostonMA
| | | | | | | | - Faiez Zannad
- INSERM CIC 1433NI‐CRCT (Cardiovascular and Renal Clinical Trialists) F‐CRIN networkUniversité de Lorraine and CHRUNancyFrance
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6
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Butler J, Packer M, Greene SJ, Fiuzat M, Anker SD, Anstrom KJ, Carson PE, Cooper LB, Fonarow GC, Hernandez AF, Januzzi JL, Jessup M, Kalyani RR, Kaul S, Kosiborod M, Lindenfeld J, McGuire DK, Sabatine MS, Solomon SD, Teerlink JR, Vaduganathan M, Yancy CW, Stockbridge N, O'Connor CM. Heart Failure End Points in Cardiovascular Outcome Trials of Sodium Glucose Cotransporter 2 Inhibitors in Patients With Type 2 Diabetes Mellitus: A Critical Evaluation of Clinical and Regulatory Issues. Circulation 2019; 140:2108-2118. [PMID: 31841369 PMCID: PMC7027964 DOI: 10.1161/circulationaha.119.042155] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Following regulatory guidance set forth in 2008 by the US Food and Drug Administration for new drugs for type 2 diabetes mellitus, many large randomized, controlled trials have been conducted with the primary goal of assessing the safety of antihyperglycemic medications on the primary end point of major adverse cardiovascular events, defined as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. Heart failure (HF) was not specifically mentioned in the US Food and Drug Administration guidance and therefore it was not a focus of these studies when planned. Several trials subsequently showed the impact of antihyperglycemic drugs on HF outcomes, which were not originally specified as the primary end point of the trials. The most impressive finding has been the substantial and consistent risk reduction in HF hospitalization seen across 4 trials of sodium glucose cotransporter 2 inhibitors. However, to date, these results have not led to regulatory approval of any of these drugs for a HF indication or a recommendation for use by US HF guidelines. It is therefore important to explore to what extent persuasive treatment effects on nonprimary end points can be used to support regulatory claims and guideline recommendations. This topic was discussed by researchers, clinicians, industry sponsors, regulators, and representatives from professional societies, who convened on the US Food and Drug Administration campus on March 6, 2019. This report summarizes these discussions and the key takeaway messages from this meeting.
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Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson (J.B.)
| | | | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., A.F.H.)
| | - Mona Fiuzat
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
| | - Stefan D Anker
- Berlin-Brandenburg Center for Regenerative Therapies, Germany (S.D.A.)
- Department of Cardiology, German Center for Cardiovascular Research partner site Berlin, Charite Universitatsmedizin Berlin (S.D.A.)
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
| | - Peter E Carson
- Cardiovascular Division, Department of Cardiology, Washington Veterans Affairs Medical Center (P.E.C.)
| | - Lauren B Cooper
- Inova Heart and Vascular Institute, Falls Church, VA (L.B.C., C.M.O.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles (G.C.F.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., A.F.H.)
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Baim Institute for Clinical Research, Boston (J.L.J.)
| | | | - Rita R Kalyani
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD (R.R.K.)
| | - Sanjay Kaul
- Cedars-Sinai Medical Center, Los Angeles, CA (S.K.)
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (M.K.)
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.K.)
| | | | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Marc S Sabatine
- TIMI Study Group (M.S.S.), Brigham and Women's Hospital, Boston, MA
- Division of Cardiovascular Medicine (M.S.S., S.D.S., M.V.), Brigham and Women's Hospital, Boston, MA
| | - Scott D Solomon
- Division of Cardiovascular Medicine (M.S.S., S.D.S., M.V.), Brigham and Women's Hospital, Boston, MA
| | - 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.)
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine (M.S.S., S.D.S., M.V.), Brigham and Women's Hospital, Boston, MA
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.)
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.)
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7
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Howlett JG, Stebbins A, Petrie MC, Jhund PS, Castelvecchio S, Cherniavsky A, Sueta CA, Roy A, Piña IL, Wurm R, Drazner MH, Andersson B, Batlle C, Senni M, Chrzanowski L, Merkely B, Carson P, Desvigne-Nickens PM, Lee KL, Velazquez EJ, Al-Khalidi HR. CABG Improves Outcomes in Patients With Ischemic Cardiomyopathy: 10-Year Follow-Up of the STICH Trial. JACC. HEART FAILURE 2019; 7:878-887. [PMID: 31521682 PMCID: PMC7375257 DOI: 10.1016/j.jchf.2019.04.018] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/08/2019] [Accepted: 04/14/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVES The authors investigated the impact of coronary artery bypass grafting (CABG) on first and recurrent hospitalization in this population. BACKGROUND In the STICH (Surgical Treatment for Ischemic Heart Failure) trial, CABG reduced all-cause death and hospitalization in patients with and ischemic cardiomyopathy and left ventricular ejection fraction <35%. METHODS A total of 1,212 patients were randomized (610 to CABG + optimal medical therapy [CABG] and 602 to optimal medical therapy alone [MED] alone) and followed for a median of 9.8 years. All-cause and cause-specific hospitalizations were analyzed as time-to-first-event and as recurrent event analysis. RESULTS Of the 1,212 patients, 757 died (62.4%) and 732 (60.4%) were hospitalized at least once, for a total of 2,549 total all-cause hospitalizations. Most hospitalizations (66.2%) were for cardiovascular causes, of which approximately one-half (907 or 52.9%) were for heart failure. More than 70% of all hospitalizations (1,817 or 71.3%) were recurrent events. The CABG group experienced fewer all-cause hospitalizations in the time-to-first-event (349 CABG vs. 383 MED, adjusted hazard ratio [HR]: 0.85; 95% confidence interval [CI]: 0.74 to 0.98; p = 0.03) and in recurrent event analyses (1,199 CABG vs. 1,350 MED, HR: 0.78, 95% CI: 0.65 to 0.94; p < 0.001). This was driven by fewer total cardiovascular (CV) hospitalizations (744 vs. 968; p < 0.001, adjusted HR: 0.66, 95% CI: 0.55 to 0.81; p = 0.001), the majority of which were due to HF (395 vs. 512; p < 0.001, adjusted HR: 0.68, 95% CI: 0.52-0.89; p = 0.005). We did not observe a difference in non-CV events. CONCLUSIONS CABG reduces all-cause, CV, and HF hospitalizations in time-to-first-event and recurrent event analyses. (Comparison of Surgical and Medical Treatment for Congestive Heart Failure and Coronary Artery Disease [STICH]; NCT00023595).
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Affiliation(s)
- Jonathan G Howlett
- Libin Cardiovascular Institute and University of Calgary Medical Centre, Calgary, Canada.
| | - Amanda Stebbins
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Serenella Castelvecchio
- Istituto Di Ricovero e Cura a Carattere Scientifico Policlinico San Donato, San Donato Milanese, Milan, Italy
| | - Alexander Cherniavsky
- E. Meshalkin National Medical Research Center of the Ministry of Health of the Russian Federation, Novosibirsk, Russia
| | - Carla A Sueta
- University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Ambuj Roy
- All India Institute of Medical Sciences, New Delhi, India
| | - Ileana L Piña
- Albert Einstein College of Medicine, Montefiore Medical Center, New York City, New York
| | | | - Mark H Drazner
- University of Texas Southwestern Medical Center, Dallas, Texas
| | - Bert Andersson
- Department of Cardiology, Sahlgrenska University Hospital, Goteborg, Sweden
| | - Carmen Batlle
- Centro de Investigación Cardiovascular Uruguayo Casa De Galicia, Montevideo, Uruguay
| | | | | | - Bela Merkely
- Semmelweis University, Budapest, Budapest, Hungary
| | | | - Patrice M Desvigne-Nickens
- Division of Cardiovascular Sciences, National Institutes of Health, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Kerry L Lee
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Durham, North Carolina
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Durham, North Carolina
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Spitzer E, Hahn RT, Pibarot P, de Vries T, Bax JJ, Leon MB, Van Mieghem NM. Aortic Stenosis and Heart Failure: Disease Ascertainment and Statistical Considerations for Clinical Trials. Card Fail Rev 2019; 5:99-105. [PMID: 31179020 PMCID: PMC6545996 DOI: 10.15420/cfr.2018.41.2] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Accepted: 03/17/2019] [Indexed: 12/20/2022] Open
Abstract
Aortic stenosis is a progressive disease that develops over decades, and once symptomatic and untreated, is associated with poor survival. Transcatheter aortic valve replacement has evolved significantly in the past decade and has expanded its indication from surgically inoperable and high-risk patients to patients with intermediate risk. Assessment of heart failure-related outcomes include the use of functional assessments, disease-specific quality of life surveys and standardised ascertainment of events, such as hospitalisations. Multiple statistical approaches are currently being tested to account for recurrent events such as hospitalisations for heart failure or to combine binary and continuous outcomes, both intended to assess the holistic burden of the disease, as opposed to the traditional analysis of time to first event.
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Affiliation(s)
- Ernest Spitzer
- Thoraxcenter, Erasmus University Medical Center Rotterdam, the Netherlands.,Cardialysis, Clinical Trial Management and Core Laboratories Rotterdam, the Netherlands
| | - Rebecca T Hahn
- New York Presbyterian Hospital/Columbia University Medical Center New York, NY, US.,Cardiovascular Research Foundation New York, NY, US
| | - Philippe Pibarot
- Quebec Heart and Lung Institute, Laval University Quebec, Canada
| | - Ton de Vries
- Cardialysis, Clinical Trial Management and Core Laboratories Rotterdam, the Netherlands
| | - Jeroen J Bax
- Department of Cardiology, Leiden University Medical Center Leiden, the Netherlands
| | - Martin B Leon
- New York Presbyterian Hospital/Columbia University Medical Center New York, NY, US.,Cardiovascular Research Foundation New York, NY, US
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Samman Tahhan A, Vaduganathan M, Greene SJ, Okafor M, Kumar S, Butler J. Evolving Landscape of Clinical Trials in Heart Failure: Patient Populations, Endpoint Selection, and Regions of Enrollment. Curr Heart Fail Rep 2019; 15:10-16. [PMID: 29350324 DOI: 10.1007/s11897-018-0374-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
PURPOSE OF REVIEW Clinical trial design and execution are evolving as increasingly important considerations with respect to the success of heart failure trials. The current review highlights temporal trends in characteristics of heart failure clinical trials. RECENT FINDINGS Recent trials in heart failure have required longer recruitment phases, displayed inefficient enrollment rates, increased use of composite and nonfatal endpoints, undergone rapid globalization, and gradually increased focus on heart failure with preserved ejection fraction. Understanding patterns and trends in clinical trial design and execution may inform future planning and conduct of trials of heart failure therapeutics.
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Affiliation(s)
- Ayman Samman Tahhan
- Emory Clinical Cardiovascular Research Institute, Emory University School of Medicine, Atlanta, GA, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA, USA
| | - Stephen J Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Maureen Okafor
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Sonali Kumar
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Javed Butler
- Division of Cardiology, Health Sciences Center, Stony Brook University, T-16, Room 080, SUNY, Stony Brook, NY, 11794, USA.
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10
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Greene SJ, Vaduganathan M, Khan MS, Bakris GL, Weir MR, Seltzer JH, Sattar N, McGuire DK, Januzzi JL, Stockbridge N, Butler J. Prevalent and Incident Heart Failure in Cardiovascular Outcome Trials of Patients With Type 2 Diabetes. J Am Coll Cardiol 2018; 71:1379-1390. [PMID: 29534825 PMCID: PMC5832063 DOI: 10.1016/j.jacc.2018.01.047] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/16/2018] [Accepted: 01/22/2018] [Indexed: 02/06/2023]
Abstract
Despite multiple examples of glucose-lowering therapies affecting heart failure (HF) risk, ascertainment of HF data in cardiovascular outcome trials of these medications has not been systematically characterized. In this review, large (n >1,000) published phase III and IV cardiovascular outcome trials evaluating glucose-lowering therapies through June 2017 were identified. Data were abstracted from publications, U.S. Food and Drug Administration advisory committee records, and U.S. Food and Drug Administration labeling documents. Overall, 21 trials including 152,737 patients were evaluated. Rates and definitions of baseline HF and incident HF were inconsistently provided. Baseline ejection fraction data were provided in 3 studies but not specific to patients with HF. No trial reported functional class, ejection fraction, or HF therapy at the time of incident HF diagnosis. HF hospitalization data were available in 15 trials, but only 2 included HF-related events within the primary composite endpoint. This systematic review highlights gaps in HF data capture within cardiovascular outcome trials of glucose-lowering therapies and outlines rationale and strategies for improving HF characterization.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | | | - George L Bakris
- ASH Comprehensive Hypertension Center, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi.
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