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Hong D, Choi KH, Ahn CM, Yu CW, Park IH, Jang WJ, Kim HJ, Bae JW, Kwon SU, Lee HJ, Lee WS, Jeong JO, Park SD, Park TK, Lee JM, Song YB, Hahn JY, Choi SH, Gwon HC, Yang JH. Clinical significance of residual ischaemia in acute myocardial infarction complicated by cardiogenic shock undergoing venoarterial-extracorporeal membrane oxygenation. EUROPEAN HEART JOURNAL. ACUTE CARDIOVASCULAR CARE 2024; 13:525-534. [PMID: 38701179 DOI: 10.1093/ehjacc/zuae058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2024] [Revised: 04/15/2024] [Accepted: 04/16/2024] [Indexed: 05/05/2024]
Abstract
AIMS Although culprit-only revascularization during the index procedure has been recommended in patients with acute myocardial infarction (AMI) complicated by cardiogenic shock (CS), the reduction in residual ischaemia is also emphasized to improve clinical outcomes. However, few data are available about the significance of residual ischaemia in patients undergoing mechanical circulatory supports. This study aimed to evaluate the effects of residual ischaemia on clinical outcomes in patients with AMI undergoing venoarterial-extracorporeal membrane oxygenation (VA-ECMO). METHODS AND RESULTS Patients with AMI with multivessel disease who underwent VA-ECMO due to refractory CS were pooled from the RESCUE and SMC-ECMO registries. The included patients were classified into three groups according to residual ischaemia evaluated using the residual Synergy between percutaneous coronary intervention with Taxus and Cardiac Surgery (SYNTAX) score (rSS): rSS = 0, 0 < rSS ≤ 8, and rSS > 8. The primary outcome was 1-year all-cause death. A total of 408 patients were classified into the rSS = 0 (n = 100, 24.5%), 0 < rSS ≤ 8 (n = 136, 33.3%), and rSS > 8 (n = 172, 42.2%) groups. The cumulative incidence of the primary outcome differed significantly according to rSS (33.9 vs. 55.4 vs. 66.1% for rSS = 0, 0 < rSS ≤ 8, and rSS > 8, respectively, overall P < 0.001). In a multivariable model, rSS was independently associated with the risk of 1-year all-cause death (adjusted hazard ratio 1.03, 95% confidence interval 1.01-1.05, P = 0.003). Conversely, the baseline SYNTAX score was not associated with the risk of the primary outcome. Furthermore, when patients were stratified by rSS, the primary outcome did not differ significantly between the high and low delta SYNTAX score groups. CONCLUSION In patients with AMI with refractory CS who underwent VA-ECMO, residual ischaemia was associated with an increased risk of 1-year mortality. Future studies are needed to evaluate the efficacy and safety of revascularization strategies to minimize residual ischaemia in patients with CS supported with VA-ECMO. CLINICAL TRIAL REGISTRATION REtrospective and Prospective Observational Study to Investigate Clinical oUtcomes and Efficacy of Left Ventricular Assist Device for Korean Patients With Cardiogenic Shock (RESCUE), NCT02985008.
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Affiliation(s)
- David Hong
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Ki Hong Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Chul-Min Ahn
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Cheol Woong Yu
- Division of Cardiology, Department of Internal Medicine, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Ik Hyun Park
- Department of Cardiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon, Korea
| | - Woo Jin Jang
- Department of Cardiology, Ewha Woman's University Seoul Hospital, Ewha Woman's University School of Medicine, Seoul, Republic of Korea
| | - Hyun-Joong Kim
- Division of Cardiology, Department of Internal Medicine, Konkuk University Medical Center, School of Medicine, Konkuk University, Seoul, Korea
| | - Jang-Whan Bae
- Department of Internal Medicine, Chungbuk National University College of Medicine, Cheongju, Korea
| | - Sung Uk Kwon
- Division of Cardiology, Department of Internal Medicine, Ilsan Paik Hospital, University of Inje College of Medicine, Seoul, Korea
| | - Hyun-Jong Lee
- Division of Cardiology, Department of Medicine, Sejong General Hospital, Bucheon, Korea
| | - Wang Soo Lee
- Division of Cardiology, Department of Medicine, Chung-Ang University Hospital, Seoul, Korea
| | - Jin-Ok Jeong
- Division of Cardiology, Department of Internal Medicine, Chungnam National University Hospital, Daejeon, Republic of Korea
| | - Sang-Don Park
- Division of Cardiology, Department of Medicine, Inha University Hospital, Incheon, Korea
| | - Taek Kyu Park
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Joo Myung Lee
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Young Bin Song
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Joo-Yong Hahn
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Seung-Hyuk Choi
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Hyeon-Cheol Gwon
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
| | - Jeong Hoon Yang
- Division of Cardiology, Department of Medicine, Heart Vascular Stroke Institute, Samsung Medical Center, Sungkyunkwan University School of Medicine, 81 Irwon-ro, Gangnam-gu, Seoul 06351, Korea
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2
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Jeon KH, Lee HS, Kang S, Jang JH, Jo YY, Son JM, Lee MS, Kwon JM, Kwun JS, Cho HW, Kang SH, Lee W, Yoon CH, Suh JW, Youn TJ, Chae IH. AI-enabled ECG index for predicting left ventricular dysfunction in patients with ST-segment elevation myocardial infarction. Sci Rep 2024; 14:16575. [PMID: 39019962 PMCID: PMC11255326 DOI: 10.1038/s41598-024-67532-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2024] [Accepted: 07/12/2024] [Indexed: 07/19/2024] Open
Abstract
Electrocardiogram (ECG) changes after primary percutaneous coronary intervention (PCI) in ST-segment elevation myocardial infarction (STEMI) patients are associated with prognosis. This study investigated the feasibility of predicting left ventricular (LV) dysfunction in STEMI patients using an artificial intelligence (AI)-enabled ECG algorithm developed to diagnose STEMI. Serial ECGs from 637 STEMI patients were analyzed with the AI algorithm, which quantified the probability of STEMI at various time points. The time points included pre-PCI, immediately post-PCI, 6 h post-PCI, 24 h post-PCI, at discharge, and one-month post-PCI. The prevalence of LV dysfunction was significantly associated with the AI-derived probability index. A high probability index was an independent predictor of LV dysfunction, with higher cardiac death and heart failure hospitalization rates observed in patients with higher indices. The study demonstrates that the AI-enabled ECG index effectively quantifies ECG changes post-PCI and serves as a digital biomarker capable of predicting post-STEMI LV dysfunction, heart failure, and mortality. These findings suggest that AI-enabled ECG analysis can be a valuable tool in the early identification of high-risk patients, enabling timely and targeted interventions to improve clinical outcomes in STEMI patients.
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Affiliation(s)
- Ki-Hyun Jeon
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea.
| | - Hak Seung Lee
- Medical AI Co., Ltd, Seoul, South Korea.
- Artificial Intelligence and Big Data Research Center, Sejong Medical Research Institute, Bucheon, South Korea.
| | - Sora Kang
- Medical AI Co., Ltd, Seoul, South Korea
- Artificial Intelligence and Big Data Research Center, Sejong Medical Research Institute, Bucheon, South Korea
| | - Jong-Hwan Jang
- Medical AI Co., Ltd, Seoul, South Korea
- Artificial Intelligence and Big Data Research Center, Sejong Medical Research Institute, Bucheon, South Korea
| | - Yong-Yeon Jo
- Medical AI Co., Ltd, Seoul, South Korea
- Artificial Intelligence and Big Data Research Center, Sejong Medical Research Institute, Bucheon, South Korea
| | - Jeong Min Son
- Medical AI Co., Ltd, Seoul, South Korea
- Artificial Intelligence and Big Data Research Center, Sejong Medical Research Institute, Bucheon, South Korea
| | - Min Sung Lee
- Medical AI Co., Ltd, Seoul, South Korea
- Artificial Intelligence and Big Data Research Center, Sejong Medical Research Institute, Bucheon, South Korea
| | - Joon-Myoung Kwon
- Medical AI Co., Ltd, Seoul, South Korea
- Artificial Intelligence and Big Data Research Center, Sejong Medical Research Institute, Bucheon, South Korea
| | - Ju-Seung Kwun
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Hyoung-Won Cho
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Si-Hyuck Kang
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Wonjae Lee
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Chang-Hwan Yoon
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jung-Won Suh
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Tae-Jin Youn
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - In-Ho Chae
- Department of Internal Medicine, Seoul National University College of Medicine and Department of Cardiology, Seoul National University Bundang Hospital, Seongnam, South Korea
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3
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Asano T, Maeno Y, Nakano M, Taguri M, Miyasaka M, Nakai D, Miyazaki I, Nasu T, Tanimoto S, Masuda N, Morino Y, Isshiki T, Ogata N. Validation of a New Scoring Method to Assess the Efficacy of Rapid Initiation and Titration of Combination Pharmacotherapy for Patients Hospitalized with Acute Decompensated Heart Failure with Reduced and Mildly Reduced Ejection Fraction. J Clin Med 2024; 13:2775. [PMID: 38792317 PMCID: PMC11122539 DOI: 10.3390/jcm13102775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/28/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Despite the encouragement of early initiation and titration of guideline-directed medical therapy (GDMT) for the treatment of heart failure (HF), most patients do not receive an adequate type and dose of pharmacotherapy in the real world. Objectives: This study aimed to determine the efficacy of titrating composite GDMT in patients with HF with reduced and mildly reduced ejection fraction and to identify patient conditions that may benefit from titration of GDMT. Methods: This was a two-center, retrospective study of consecutive patients hospitalized with acute decompensated heart failure (ADHF). Patients were classified into two groups according to a scoring scale determined by combination and doses of four types of HF agents (ACEis/ARBs/ARNis, BBs, MRAs, and SGLT2is) at discharge. A score of 5 or greater was defined as titrated GDMT, and a score of 4 or less was regarded as sub-optimal medical therapy (MT). Results: A total of 979 ADHF patients were screened. After 553 patients were excluded based on exclusion criteria, 426 patients (90 patients in the titrated GDMT group and 336 patients in the sub-optimal MT group) were enrolled for the analysis. The median follow-up period was 612 (453-798) days. Following statistical adjustment using the propensity score weighting method, the 2-year composite endpoint (composite of cardiac death and HF rehospitalization) rate was significantly lower in the titrated GDMT group, at 19%, compared with the sub-optimal MT group: 31% (score 3-4 points) and 43% (score 0-2 points). Subgroup analysis indicated a marked benefit of titrated GDMT in particular patient subgroups: age < 80 years, BMI 19.0-24.9, eGFR > 20 mL/min/1.73 m2, and serum potassium level ≤ 5.5 mmol/L. Conclusions: Prompt initiation and dose adjustment of multiple HF medications, with careful monitoring of the patient's physiologic and laboratory values, is a prerequisite for improving the prognosis of patients with heart failure.
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Affiliation(s)
- Takaaki Asano
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun 028-3694, Japan; (T.A.)
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Yoshio Maeno
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Masataka Nakano
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Masataka Taguri
- Department of Health Data Science, Tokyo Medical University, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Masaki Miyasaka
- Department of Cardiology, Jikei University, Minato-ku, Tokyo 105-0003, Japan
| | - Daisuke Nakai
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Itaru Miyazaki
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Takahito Nasu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun 028-3694, Japan; (T.A.)
| | - Shuzou Tanimoto
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Naoki Masuda
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun 028-3694, Japan; (T.A.)
| | - Takaaki Isshiki
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Nobuhiko Ogata
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
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4
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Ross HJ, Peikari M, Vishram-Nielsen JKK, Fan CPS, Hearn J, Walker M, Crowdy E, Alba AC, Manlhiot C. Predicting heart failure outcomes by integrating breath-by-breath measurements from cardiopulmonary exercise testing and clinical data through a deep learning survival neural network. EUROPEAN HEART JOURNAL. DIGITAL HEALTH 2024; 5:324-334. [PMID: 38774366 PMCID: PMC11104469 DOI: 10.1093/ehjdh/ztae005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Revised: 12/15/2023] [Accepted: 01/02/2024] [Indexed: 05/24/2024]
Abstract
Aims Mathematical models previously developed to predict outcomes in patients with heart failure (HF) generally have limited performance and have yet to integrate complex data derived from cardiopulmonary exercise testing (CPET), including breath-by-breath data. We aimed to develop and validate a time-to-event prediction model using a deep learning framework using the DeepSurv algorithm to predict outcomes of HF. Methods and results Inception cohort of 2490 adult patients with high-risk cardiac conditions or HF underwent CPET with breath-by-breath measurements. Potential predictive features included known clinical indicators, standard summary statistics from CPETs, and mathematical features extracted from the breath-by-breath time series of 13 measurements. The primary outcome was a composite of death, heart transplant, or mechanical circulatory support treated as a time-to-event outcomes. Predictive features ranked as most important included many of the features engineered from the breath-by-breath data in addition to traditional clinical risk factors. The prediction model showed excellent performance in predicting the composite outcome with an area under the curve of 0.93 in the training and 0.87 in the validation data sets. Both the predicted vs. actual freedom from the composite outcome and the calibration of the prediction model were excellent. Model performance remained stable in multiple subgroups of patients. Conclusion Using a combined deep learning and survival algorithm, integrating breath-by-breath data from CPETs resulted in improved predictive accuracy for long-term (up to 10 years) outcomes in HF. DeepSurv opens the door for future prediction models that are both highly performing and can more fully use the large and complex quantity of data generated during the care of patients with HF.
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Affiliation(s)
- Heather J Ross
- The Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Mohammad Peikari
- The Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Julie K K Vishram-Nielsen
- The Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Chun-Po S Fan
- The Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Jason Hearn
- The Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Mike Walker
- The Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Edgar Crowdy
- The Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Ana Carolina Alba
- The Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
| | - Cedric Manlhiot
- The Ted Rogers Centre for Heart Research, Peter Munk Cardiac Centre, University Health Network, Department of Medicine, University of Toronto, 200 Elizabeth Street, Toronto, ON M5G 2C4, Canada
- The Blalock-Taussig-Thomas Pediatric and Congenital Heart Center, Department of Pediatrics, Johns Hopkins School of Medicine, Johns Hopkins University, 1800 Orleans Street, Baltimore, MD 21287, USA
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Khan MS, Chan PS, Sherrod CF, Ikemura N, Sauer AJ, Jones PG, Fonarow GC, Butler J, DeVore AD, Lund LH, Spertus JA. Generalizable Approach to Quantifying Guideline-Directed Medical Therapy. Circ Heart Fail 2024; 17:e011164. [PMID: 38742418 PMCID: PMC11108743 DOI: 10.1161/circheartfailure.123.011164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. METHODS The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, β-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. RESULTS Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. CONCLUSIONS KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed.
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Affiliation(s)
- Mirza S. Khan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Paul S. Chan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Charles F. Sherrod
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Nobuhiro Ikemura
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Andrew J. Sauer
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Philip G. Jones
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Gregg C. Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Adam D. DeVore
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - John A. Spertus
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
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Bhatt AS, Fiuzat M. How Did We Score? Evaluating the Utility of a Score-Based System for Heart Failure Medical Therapy. Circ Heart Fail 2024; 17:e011654. [PMID: 38742414 DOI: 10.1161/circheartfailure.124.011654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
Affiliation(s)
- Ankeet S Bhatt
- Division of Research, Department of Cardiology, Kaiser Permanente Northern California, San Francisco (A.S.B.)
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Palo Alto, CA (A.S.B.)
| | - Mona Fiuzat
- Division of Cardiology, Duke University Medical Center, Durham, NC (M.F.)
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Claudel SE, Powell-Wiley TM. Outcomes Associated With Surgical and Pharmacologic Treatment of Obesity in Heart Failure. Circ Heart Fail 2024; 17:e011323. [PMID: 38275126 PMCID: PMC10922798 DOI: 10.1161/circheartfailure.123.011323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/27/2024]
Affiliation(s)
| | - Tiffany M. Powell-Wiley
- Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
- Intramural Research Program, National Institute on Minority Health and Health Disparities, National Institutes of Health, Bethesda, MD, USA
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Matsukawa R, Okahara A, Tokutome M, Itonaga J, Koga E, Hara A, Kisanuki H, Sada M, Okabe K, Kawai S, Ogawa K, Matsuura H, Mukai Y. A scoring evaluation for the practical introduction of guideline-directed medical therapy in heart failure patients. ESC Heart Fail 2023; 10:3352-3363. [PMID: 37671603 PMCID: PMC10682854 DOI: 10.1002/ehf2.14524] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 07/19/2023] [Accepted: 08/22/2023] [Indexed: 09/07/2023] Open
Abstract
AIMS The guideline-directed medical therapy (GDMT) has been recommended for heart failure (HF) with reduced ejection fraction (HFrEF) based on the accumulating clinical evidence. However, it is difficult to implement all the trial-proven medications for every patient in the real world. METHODS AND RESULTS A simple GDMT score was created, according to the combination of GDMT drugs (renin-angiotensin system inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose transporter 2 inhibitors) administration and their dosage (0-9 points). Its impact on the prognosis of HF patients was investigated. Admitted HF patients [HFrEF and HF with mildly reduced ejection fraction (HFmrEF), n = 1054] were retrospectively analysed (excluding those with in-hospital death and dialysis). A simple GDMT score ≥5, but not the number of medications, was significantly associated with a reduction of all-cause death, HF readmission, and composite outcome (HF readmission and all-cause death) (P < 0.001). Subgroup analysis showed that almost all groups with a simple GDMT score of 5 or higher had a better prognosis. CONCLUSIONS The developed simple GDMT score was associated with prognosis in HFrEF and HFmrEF patients. Even if all four drugs cannot be introduced for some reason, a regimen with a simple GDMT score ≥5 may lead to a prognosis in HF patients.
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Affiliation(s)
- Ryuichi Matsukawa
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Arihide Okahara
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Masaki Tokutome
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Junpei Itonaga
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Eiichi Koga
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Ayano Hara
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Hiroshi Kisanuki
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Masashi Sada
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Kousuke Okabe
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Shunsuke Kawai
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Kiyohiro Ogawa
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Hirohide Matsuura
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
| | - Yasushi Mukai
- Department of CardiologyJapanese Red Cross Fukuoka HospitalFukuokaJapan
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Georges G, Fudim M, Burkhoff D, Leon MB, Généreux P. Patient Selection and End Point Definitions for Decongestion Studies in Acute Decompensated Heart Failure: Part 2. JOURNAL OF THE SOCIETY FOR CARDIOVASCULAR ANGIOGRAPHY & INTERVENTIONS 2023; 2:101059. [PMID: 39131062 PMCID: PMC11307977 DOI: 10.1016/j.jscai.2023.101059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/13/2024]
Abstract
Congestion is the most common manifestation of acute decompensated heart failure (ADHF). Residual congestion despite initial medical therapy is common and is recognized to be associated with worse outcomes; however, there are currently no standardized definition regarding decongestion end point. In the second part of this 2-part review, we provide a critical appraisal of decongestion definitions previously used in ADHF studies, review alternative metrics to define severity of volume overload, and propose a more granular 4-class congestion grading scheme and decongestion end point definitions that could potentially be included in future ADHF trials and consensus definitions.
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Affiliation(s)
- Gabriel Georges
- Quebec Heart and Lung Institute, Quebec City, Quebec, Canada
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Martin B. Leon
- Division of Cardiology, Columbia University Irving Medical Center/NewYork-Presbyterian Hospital, New York, New York
| | - Philippe Généreux
- Gagnon Cardiovascular Institute, Morristown Medical Center, Morristown, New Jersey
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10
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Chen S, Liang W, Wu Y, Chen X, He X, Zhao J, He J, Dong Y, Staessen JA, Liu C, Wei F. Associations of short- and long-term mortality with admission blood pressure in Chinese patients with different heart failure subtypes. J Clin Hypertens (Greenwich) 2022; 24:1577-1586. [PMID: 36321681 PMCID: PMC9731597 DOI: 10.1111/jch.14589] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 09/04/2022] [Accepted: 10/03/2022] [Indexed: 11/05/2022]
Abstract
It remains unknown whether systolic (SBP) and diastolic (DBP) pressure on admission are associated with short- and long-term mortality in Chinese patients with heart failure with preserved (HFpEF), mildly reduced (HFmrEF), and reduced (HFrEF) ejection fraction. In 2706 HF patients (39.1% women; mean age, 68.8 years), we assessed the risk of 30-day, 1-year, and long-term (> 1 year) mortality with 1-SD increment in SBP and DBP, using multivariable logistic and Cox regression, respectively. During a median follow-up of 4.1 years, 1341 patients died. The 30-day, 1-year, and long-term mortality were 3.5%, 16.7%, and 39.4%, respectively. In multivariable-adjusted analyses additionally accounted for DBP or SBP, a higher SBP conferred a higher risk of long-term mortality (hazard ratio, 1.11; 95% CI, 1.02-1.22; p = .017) and a lower DBP was associated with a higher risk of all types of mortality (p ≤ .011) in all HF patients. Independent of potential confounders including DBP or SBP, in patients with HFpEF, higher SBP and lower DBP levels predicted a higher risk of long-term mortality with hazard ratios amounting to 1.16 (95% CI, 1.04-1.29; p = .007) and .89 (95% CI, .80-.99; p = .028), respectively. In patients with HFmrEF and HFrEF, irrespective of adjustments of potential confounders, DBP was associated with 1-year mortality with odds ratios ranging from .49 to .62 (p ≤ .006). In conclusion, lower DBP and higher SBP levels on admission were associated with a higher risk of different types of all-cause mortality in Chinese patients with different HF subtypes. Our observations highlight that admission BP may help to improve risk stratification.
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Affiliation(s)
- Shilan Chen
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Weihao Liang
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Yuzhong Wu
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Xuwei Chen
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Xin He
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Jingjing Zhao
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Jiangui He
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
| | - Yugang Dong
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina,National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Jan A. Staessen
- Research Institute Alliance for the Promotion of Preventive MedicineMechelenBelgium,Biomedical Science GroupUniversity of LeuvenLeuvenBelgium
| | - Chen Liu
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina,National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Fang‐Fei Wei
- Department of Cardiologythe First Affiliated Hospital of Sun Yat‐Sen UniversityGuangzhouGuangdongChina,NHC Key Laboratory of Assisted CirculationSun Yat‐sen UniversityGuangzhouGuangdongChina
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11
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Nguyen DT, Bilchick KC, Narayan SM, Chung MK, Thomas KL, Laurita KR, Vaseghi M, Sandhu R, Chelu MG, Kannankeril PJ, Packer DL, McManus DD, Verma A, Singleton M, Tarakji K, Al-Khatib SM, Kaltman JR, Balijepalli RC, Van Hare GF, Hurwitz JL, Russo AM, Kusumoto FM, Albert CM. Opportunities and challenges in heart rhythm research: Rationale and development of an electrophysiology collaboratory. Heart Rhythm 2022; 19:1927-1945. [PMID: 37850602 PMCID: PMC10824490 DOI: 10.1016/j.hrthm.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Accepted: 08/02/2022] [Indexed: 11/04/2022]
Abstract
There are many challenges in the current landscape of electrophysiology (EP) clinical and translational research, including increasing costs and complexity, competing demands, regulatory requirements, and challenges with study implementation. This review seeks to broadly discuss the state of EP research, including challenges and opportunities. Included here are results from a Heart Rhythm Society (HRS) Research Committee member survey detailing HRS members' perspectives regarding both barriers to clinical and translational research and opportunities to address these challenges. We also provide stakeholder perspectives on barriers and opportunities for future EP research, including input from representatives of the U.S. Food and Drug Administration, industry, and research funding institutions that participated in a Research Collaboratory Summit convened by HRS. This review further summarizes the experiences of the heart failure and heart valve communities and how they have approached similar challenges in their own fields. We then explore potential solutions, including various models of research ecosystems designed to identify research challenges and to coordinate ways to address them in a collaborative fashion in order to optimize innovation, increase efficiency of evidence generation, and advance the development of new therapeutic products. The objectives of the proposed collaborative cardiac EP research community are to encourage and support scientific discourse, research efficiency, and evidence generation by exploring collaborative and equitable solutions in which stakeholders within the EP community can interact to address knowledge gaps, innovate, and advance new therapies.
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Affiliation(s)
| | | | | | - Mina K Chung
- Department of Cardiology, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Marmar Vaseghi
- University of California, Los Angeles Cardiac Arrhythmia Center, Los Angeles, California
| | - Roopinder Sandhu
- Department of Cardiology and Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | | | - David D McManus
- University of Massachusetts Medical School, Worcester, Massachusetts
| | - Atul Verma
- Southlake Regional Health Center, Toronto, Ontario, Canada
| | | | | | | | | | - Ravi C Balijepalli
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
| | - George F Van Hare
- Office of Cardiovascular Devices, Center for Devices and Radiological Health, U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | | | | | - Christine M Albert
- Department of Cardiology and Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
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Verma S, Dhingra NK, Butler J, Anker SD, Ferreira JP, Filippatos G, Januzzi JL, Lam CSP, Sattar N, Peil B, Nordaby M, Brueckmann M, Pocock SJ, Zannad F, Packer M. Empagliflozin in the treatment of heart failure with reduced ejection fraction in addition to background therapies and therapeutic combinations (EMPEROR-Reduced): a post-hoc analysis of a randomised, double-blind trial. Lancet Diabetes Endocrinol 2022; 10:35-45. [PMID: 34861154 DOI: 10.1016/s2213-8587(21)00292-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Revised: 10/19/2021] [Accepted: 10/20/2021] [Indexed: 12/31/2022]
Abstract
BACKGROUND It is important to evaluate whether a new treatment for heart failure with reduced ejection fraction (HFrEF) provides additive benefit to background foundational treatments. As such, we aimed to evaluate the efficacy and safety of empagliflozin in patients with HFrEF in addition to baseline treatment with specific doses and combinations of disease-modifying therapies. METHODS We performed a post-hoc analysis of the EMPEROR-Reduced randomised, double-blind, parallel-group trial, which took place in 520 centres (hospitals and medical clinics) in 20 countries in Asia, Australia, Europe, North America, and South America. Patients with New York Heart Association (NYHA) classification II-IV with an ejection fraction of 40% or less were randomly assigned (1:1) to receive the addition of either oral empagliflozin 10 mg per day or placebo to background therapy. The primary composite outcome was cardiovascular death and heart failure hospitalisation; the secondary outcome was total heart failure hospital admissions. An extended composite outcome consisted of inpatient and outpatient HFrEF events was also evaluated. Outcomes were analysed according to background use of angiotensin-converting enzyme (ACE) inhibitors, angiotensin II receptor blockers (ARBs) or angiotensin receptor neprilysin inhibitors (ARNIs), as well as β blockers and mineralocorticoid receptor antagonists (MRAs) at less than 50% or 50% or more of target doses and in various combinations. This study is registered with ClinicalTrials.gov, NCT03057977. FINDINGS In this post-hoc analysis of 3730 patients (mean age 66·8 years [SD 11·0], 893 [23·9%] women; 1863 [49·9%] in the empagliflozin group, 1867 [50·1%] in the placebo group) assessed between March 6, 2017, and May 28, 2020, empagliflozin reduced the risk of the primary outcome (361 in 1863 participants in the empagliflozin group and 462 of 1867 in the placebo group; HR 0·75 [95% CI 0·65-0·86]) regardless of background therapy or its target doses for ACE inhibitors or ARBs at doses of less than 50% of the target dose (HR 0·85 [0·69-1·06]) and for doses of 50% or more of the target dose (HR 0·67 [0·52-0·88]; pinteraction=0·18). A similar result was seen for β blockers at doses of less than 50% of the target dose (HR 0·66 [0·54-0·80]) and for doses of 50% or more of the target dose (HR 0·81 [0·66-1·00]; pinteraction=0·15). Empagliflozin also reduced the risk of the primary outcome irrespective of background use of triple therapy with an ACE inhibitor, ARB, or ARNI plus β blocker plus MRA (given combination HR 0·73 [0·61-0·88]; not given combination HR 0·76 [0·62-0·94]; pinteraction=0·77). Similar patterns of benefit were observed for the secondary and extended composite outcomes. Empagliflozin was well tolerated and rates of hypotension, symptomatic hypotension, and hyperkalaemia were similar across all subgroups. INTERPRETATION Empagliflozin reduced serious heart failure outcomes across doses and combinations of disease-modifying therapies for HFrEF. Clinically, these data suggest that empagliflozin might be considered as a foundational therapy in patients with HFrEF regardless of their existing background therapy. FUNDING Boehringer Ingelheim and Eli Lilly and Company.
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Affiliation(s)
- Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada.
| | - Nitish K Dhingra
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Joao Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, Institut National de la Santé et de la Recherche Médicale 1116, Centre Hospitalier Régional Universitaire de Nancy, French Clinical Research Infrastructure Network, Investigation Network Initiative- Cardiovascular and Renal Clinical Trialists, Nancy, France; Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - James L Januzzi
- Division of Cardiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke- National University of Singapore Medical School, Singapore
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | | | - Martina Brueckmann
- Boehringer Ingelheim International, Ingelheim, Germany; Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, Institut National de la Santé et de la Recherche Médicale 1116, Centre Hospitalier Régional Universitaire de Nancy, French Clinical Research Infrastructure Network, Investigation Network Initiative- Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA; Imperial College London, London, UK
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13
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Hypertension and heart failure with preserved ejection fraction: position paper by the European Society of Hypertension. J Hypertens 2021; 39:1522-1545. [PMID: 34102660 DOI: 10.1097/hjh.0000000000002910] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Hypertension constitutes a major risk factor for heart failure with preserved ejection fraction (HFpEF). HFpEF is a prevalent clinical syndrome with increased cardiovascular morbidity and mortality. Specific guideline-directed medical therapy (GDMT) for HFpEF is not established due to lack of positive outcome data from randomized controlled trials (RCTs) and limitations of available studies. Although available evidence is limited, control of blood pressure (BP) is widely regarded as central to the prevention and clinical care in HFpEF. Thus, in current guidelines including the 2018 European Society of Cardiology (ESC) and European Society of Hypertension (ESH) Guidelines, blockade of the renin-angiotensin system (RAS) with either angiotensin-converting enzyme inhibitors or angiotensin receptor blockers provides the backbone of BP-lowering therapy in hypertensive patients. Although superiority of RAS blockers has not been clearly shown in dedicated RCTs designed for HFpEF, we propose that this core drug treatment strategy is also applicable for hypertensive patients with HFpEF with the addition of some modifications. The latter apply to the use of spironolactone apart from the treatment of resistant hypertension and the use of the angiotensin receptor neprilysin inhibitor. In addition, novel agents such as sodium-glucose co-transporter-2 inhibitors, currently already indicated for high-risk patients with diabetes to reduce heart failure hospitalizations, and finerenone represent promising therapies and results from ongoing RCTs are eagerly awaited. The development of an effective and practical classification of HFpEF phenotypes and GDMT through dedicated high-quality RCTs are major unmet needs in hypertension research and calls for action.
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14
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Affiliation(s)
- Eugene Braunwald
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Boston, MA, USA
| | - Elliott M Antman
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Department of Medicine, Harvard Medical School, Boston, MA, USA
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15
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Bozkurt B, Coats AJS, Tsutsui H, Abdelhamid CM, Adamopoulos S, Albert N, Anker SD, Atherton J, Böhm M, Butler J, Drazner MH, Michael Felker G, Filippatos G, Fiuzat M, Fonarow GC, Gomez-Mesa JE, Heidenreich P, Imamura T, Jankowska EA, Januzzi J, Khazanie P, Kinugawa K, Lam CSP, Matsue Y, Metra M, Ohtani T, Francesco Piepoli M, Ponikowski P, Rosano GMC, Sakata Y, Seferović P, Starling RC, Teerlink JR, Vardeny O, Yamamoto K, Yancy C, Zhang J, Zieroth S. Universal definition and classification of heart failure: a report of the Heart Failure Society of America, Heart Failure Association of the European Society of Cardiology, Japanese Heart Failure Society and Writing Committee of the Universal Definition of Heart Failure: Endorsed by the Canadian Heart Failure Society, Heart Failure Association of India, Cardiac Society of Australia and New Zealand, and Chinese Heart Failure Association. Eur J Heart Fail 2021; 23:352-380. [PMID: 33605000 DOI: 10.1002/ejhf.2115] [Citation(s) in RCA: 572] [Impact Index Per Article: 190.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2021] [Revised: 01/27/2021] [Accepted: 01/27/2021] [Indexed: 12/12/2022] Open
Abstract
In this document, we propose a universal definition of heart failure (HF) as a clinical syndrome with symptoms and/or signs caused by a structural and/or functional cardiac abnormality and corroborated by elevated natriuretic peptide levels and/or objective evidence of pulmonary or systemic congestion. We also propose revised stages of HF as: At risk for HF (Stage A), Pre-HF (Stage B), Symptomatic HF (Stage C) and Advanced HF (Stage D). Finally, we propose a new and revised classification of HF according to left ventricular ejection fraction (LVEF). This includes HF with reduced ejection fraction (HFrEF): symptomatic HF with LVEF ≤40%; HF with mildly reduced ejection fraction (HFmrEF): symptomatic HF with LVEF 41-49%; HF with preserved ejection fraction (HFpEF): symptomatic HF with LVEF ≥50%; and HF with improved ejection fraction (HFimpEF): symptomatic HF with a baseline LVEF ≤40%, a ≥10 point increase from baseline LVEF, and a second measurement of LVEF > 40%.
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