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Gottlieb M, Schraft E, O'Brien J, Patel D, Peksa GD. Prevalence of undiagnosed stage B heart failure among emergency department patients. Am J Emerg Med 2024; 85:153-157. [PMID: 39270552 DOI: 10.1016/j.ajem.2024.09.026] [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: 07/21/2024] [Revised: 09/05/2024] [Accepted: 09/09/2024] [Indexed: 09/15/2024] Open
Abstract
INTRODUCTION Heart failure (HF) is associated with significant morbidity, mortality, and health care costs. Stage B HF is defined as structural heart disease prior to developing symptomatic HF. If identified early in the disease process, preventative measures may be implemented to slow disease progression to Stage C (symptomatic) or Stage D (refractory) HF. Previous research has focused on outpatient screening for HF in the primary care setting; however, there are limited data on Stage B HF screening in the Emergency Department (ED) setting. The objective of this study was to determine the prevalence of undiagnosed Stage B HF among those with cardiovascular risk factors in the ED setting and identify which risk factors were associated with a greater risk of having Stage B HF. METHODS A prospective, observational study was performed in a single, urban academic ED from 07/2023 to 05/2024. Inclusion criteria were age ≥ 45 years with hypertension, diabetes, obesity, coronary heart disease, previous cardiotoxic chemotherapy, or family history of HF. Exclusion criteria included signs or symptoms of HF, known history of HF, valvular disease, current atrial fibrillation, or primary language other than English. A focused cardiac ultrasound was performed and interpreted by ultrasound-fellowship trained emergency physicians. Sonographers assessed systolic function as ejection fraction <50 % using visual assessment in at least two different views. Sonographers assessed diastolic dysfunction as an E/A ratio < 0.8, or if ≥2 of the following were present: septal e' < 7 cm/s or lateral e' < 10 cm/s, E/e' ratio > 14, or left atrial volume > 34 mL/m2. Descriptive statistics were performed, followed by comparative analyses and regression modeling. RESULTS 209 participants were included in the study, with a mean age of 60 years and 51.7 % women. Of these, 125 (59.8 %) had undiagnosed Stage B HF, with 13 (10.4 %) having systolic dysfunction and 112 (89.6 %) having isolated diastolic dysfunction. Among those with isolated diastolic dysfunction, 44 (39.3 %) were grade I, 66 (58.9 %) were grade II, and 2 (1.8 %) were grade III. Predictors of undiagnosed Stage B HF included age (odds ratio 1.06; 95 % CI 1.02 to 1.10) and BMI (odds ratio 1.06; 95 % CI 1.01 to 1.10). CONCLUSION A large majority of ED patients with cardiovascular risk factors had undiagnosed Stage B HF. Age and obesity were associated with a higher risk of Stage B HF. This provides an opportunity for early identification and intervention for patients with undiagnosed Stage B HF to reduce progression to more severe HF.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America.
| | - Evelyn Schraft
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - James O'Brien
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Daven Patel
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Gary D Peksa
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America.
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ElSayed NA, Aleppo G, Bannuru RR, Bruemmer D, Collins BS, Das SR, Ekhlaspour L, Hilliard ME, Johnson EL, Khunti K, Kosiborod MN, Lingvay I, Matfin G, McCoy RG, Perry ML, Pilla SJ, Polsky S, Prahalad P, Pratley RE, Segal AR, Seley JJ, Stanton RC, Gabbay RA. 10. Cardiovascular Disease and Risk Management: Standards of Care in Diabetes-2024. Diabetes Care 2024; 47:S179-S218. [PMID: 38078592 PMCID: PMC10725811 DOI: 10.2337/dc24-s010] [Citation(s) in RCA: 44] [Impact Index Per Article: 44.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2023]
Abstract
The American Diabetes Association (ADA) "Standards of Care in Diabetes" includes the ADA's current clinical practice recommendations and is intended to provide the components of diabetes care, general treatment goals and guidelines, and tools to evaluate quality of care. Members of the ADA Professional Practice Committee, an interprofessional expert committee, are responsible for updating the Standards of Care annually, or more frequently as warranted. For a detailed description of ADA standards, statements, and reports, as well as the evidence-grading system for ADA's clinical practice recommendations and a full list of Professional Practice Committee members, please refer to Introduction and Methodology. Readers who wish to comment on the Standards of Care are invited to do so at professional.diabetes.org/SOC.
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Abovich A, Matasic DS, Cardoso R, Ndumele CE, Blumenthal RS, Blankstein R, Gulati M. The AHA/ACC/HFSA 2022 Heart Failure Guidelines: Changing the Focus to Heart Failure Prevention. Am J Prev Cardiol 2023; 15:100527. [PMID: 37637197 PMCID: PMC10457686 DOI: 10.1016/j.ajpc.2023.100527] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 07/13/2023] [Accepted: 07/19/2023] [Indexed: 08/29/2023] Open
Abstract
The prevalence of heart failure (HF) in the United States (U.S.) is estimated at over 6 million adults, with the incidence continuing to increase. A large proportion of the U.S. population is also at risk of HF due to the high prevalence of established HF risk factors, such as hypertension, diabetes, and obesity. Many individuals have multiple risk factors, placing them at even higher risk. In addition, these risk factors disproportionately impact various racial and ethnic groups. Recognizing the rising health and economic burden of HF in the U.S., the 2022 American Heart Association / American College of Cardiology / Heart Failure Society of America (AHA/ACC/HFSA) Heart Failure Guideline placed a strong emphasis on prevention of HF. The purpose of this review is to highlight the role of both primary and secondary prevention in HF, as outlined by the recent guideline, and address the role of the preventive cardiology community in reducing the prevalence of HF in at-risk individuals.
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Affiliation(s)
- Arielle Abovich
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Daniel S. Matasic
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Rhanderson Cardoso
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Chiadi E. Ndumele
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Roger S. Blumenthal
- Ciccarone Center for the Prevention of Cardiovascular Disease, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Ron Blankstein
- Division of Cardiology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, United States
| | - Martha Gulati
- Barbra Streisand Women's Heart Center, Smidt Heart Institute, Cedars Sinai Medical Center, Los Angeles, CA, United States
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Huang YC, Hsu YC, Liu ZY, Lin CH, Tsai R, Chen JS, Chang PC, Liu HT, Lee WC, Wo HT, Chou CC, Wang CC, Wen MS, Kuo CF. Artificial intelligence-enabled electrocardiographic screening for left ventricular systolic dysfunction and mortality risk prediction. Front Cardiovasc Med 2023; 10:1070641. [PMID: 36960474 PMCID: PMC10029758 DOI: 10.3389/fcvm.2023.1070641] [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: 10/15/2022] [Accepted: 02/14/2023] [Indexed: 03/06/2023] Open
Abstract
Background Left ventricular systolic dysfunction (LVSD) characterized by a reduced left ventricular ejection fraction (LVEF) is associated with adverse patient outcomes. We aimed to build a deep neural network (DNN)-based model using standard 12-lead electrocardiogram (ECG) to screen for LVSD and stratify patient prognosis. Methods This retrospective chart review study was conducted using data from consecutive adults who underwent ECG examinations at Chang Gung Memorial Hospital in Taiwan between October 2007 and December 2019. DNN models were developed to recognize LVSD, defined as LVEF <40%, using original ECG signals or transformed images from 190,359 patients with paired ECG and echocardiogram within 14 days. The 190,359 patients were divided into a training set of 133,225 and a validation set of 57,134. The accuracy of recognizing LVSD and subsequent mortality predictions were tested using ECGs from 190,316 patients with paired data. Of these 190,316 patients, we further selected 49,564 patients with multiple echocardiographic data to predict LVSD incidence. We additionally used data from 1,194,982 patients who underwent ECG only to assess mortality prognostication. External validation was performed using data of 91,425 patients from Tri-Service General Hospital, Taiwan. Results The mean age of patients in the testing dataset was 63.7 ± 16.3 years (46.3% women), and 8,216 patients (4.3%) had LVSD. The median follow-up period was 3.9 years (interquartile range 1.5-7.9 years). The area under the receiver-operating characteristic curve (AUROC), sensitivity, and specificity of the signal-based DNN (DNN-signal) to identify LVSD were 0.95, 0.91, and 0.86, respectively. DNN signal-predicted LVSD was associated with age- and sex-adjusted hazard ratios (HRs) of 2.57 (95% confidence interval [CI], 2.53-2.62) for all-cause mortality and 6.09 (5.83-6.37) for cardiovascular mortality. In patients with multiple echocardiograms, a positive DNN prediction in patients with preserved LVEF was associated with an adjusted HR (95% CI) of 8.33 (7.71 to 9.00) for incident LVSD. Signal- and image-based DNNs performed equally well in the primary and additional datasets. Conclusion Using DNNs, ECG becomes a low-cost, clinically feasible tool to screen LVSD and facilitate accurate prognostication.
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Affiliation(s)
- Yu-Chang Huang
- Division of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Yu-Chun Hsu
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, United States
| | - Zhi-Yong Liu
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Ching-Heng Lin
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Richard Tsai
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jung-Sheng Chen
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Po-Cheng Chang
- Division of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Hao-Tien Liu
- Division of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wen-Chen Lee
- Division of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hung-Ta Wo
- Division of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chung-Chuan Chou
- Division of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Chun-Chieh Wang
- Division of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Shien Wen
- Division of Cardiology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- *Correspondence: Ming-Shien Wen,
| | - Chang-Fu Kuo
- Center for Artificial Intelligence in Medicine, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- School of Medicine, Chang Gung University, Taoyuan, Taiwan
- Division of Rheumatology, Allergy and Immunology, Chang Gung Memorial Hospital, Taoyuan, Taiwan
- Chang-Fu Kuo,
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Miao H, Zou C, Yang S, Chia Y, Van Huynh M, Sogunuru GP, Tay JC, Wang T, Kario K, Zhang Y. Targets and management of hypertension in heart failure: focusing on the stages of heart failure. J Clin Hypertens (Greenwich) 2022; 24:1218-1225. [PMID: 36196463 PMCID: PMC9532909 DOI: 10.1111/jch.14553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 06/30/2022] [Accepted: 07/09/2022] [Indexed: 11/05/2022]
Abstract
Hypertension is highly prevalent worldwide and is the major risk factor for heart failure (HF). More than half of the patients with HF in Asia suffer from hypertension. According to the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America HF guideline, there are four stages of HF, including at risk for HF (stage A), pre-HF (stage B), symptomatic HF (stage C), and advanced HF (stage D). Given the high prevalence of hypertension as well as HF and the stronger association between hypertension and cardiovascular diseases in Asians compared to the west, measures to prevent and alleviate the progression to clinical HF, especially controlling the blood pressure (BP), are of priority for Asian populations. After reviewing evidence-based studies, we propose a BP target of less than 130/80 mmHg for patients at stages A, B, and C. However, relatively higher BP may represent an opportunity to maximize guideline-directed medical therapy (GDMT), which could potentially result in a better prognosis for patients at stage D. Traditional antihypertensive drugs are the cornerstones for the management of hypertension at stages A and B. Notably, calcium channel blockers (CCBs) are inferior to other drug classes for the preventing of HF, whereas diuretics are superior to others. For patients at stage C, GDMT is essential which also helps the control of BP. In particular, sodium-glucose cotransporter-2 (SGLT2) inhibitors are newer therapies recommended for the treatment of HF and presumably even in hypertension to prevent HF. Regarding patients at stage D, GDMT is also recommended if tolerable and measures should be taken to improve hemodynamics.
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Affiliation(s)
- Huanhuan Miao
- Department of CardiologyFuwai HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Changhong Zou
- Department of CardiologyFuwai HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Shijie Yang
- Department of CardiologyFuwai HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
| | - Yook‐Chin Chia
- Department of Medical SciencesSchool of Medical and Life SciencesSunway UniversityBandar SunwayMalaysia
- Department of Primary Care MedicineFaculty of MedicineUniversity of MalayaKuala LumpurMalaysia
| | - Minh Van Huynh
- Department of Internal MedicineUniversity of Medicine and PharmacyHue UniversityVietnam
| | - Guru Prasad Sogunuru
- Advanced Heart Failure & Device Therapies, MEDWAY HEART INSTITUTEChennaiTamil NaduIndia
- College of Medical SciencesKathmandu UniversityBharatpurNepal
| | - Jam Chin Tay
- Department of General MedicineTan Tock Seng HospitalSingaporeSingapore
| | - Tzung‐Dau Wang
- Cardiovascular Center and Divisions of Cardiology and Hospital MedicineDepartment of Internal MedicineNational Taiwan University HospitalTaipei CityTaiwan
| | - Kazuomi Kario
- Division of Cardiovascular MedicineDepartment of MedicineJichi Medical University School of MedicineTochigiJapan
| | - Yuqing Zhang
- Department of CardiologyFuwai HospitalChinese Academy of Medical Sciences & Peking Union Medical CollegeBeijingChina
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Larson J, Rich L, Deshmukh A, Judge EC, Liang JJ. Pharmacologic Management for Ventricular Arrhythmias: Overview of Anti-Arrhythmic Drugs. J Clin Med 2022; 11:3233. [PMID: 35683620 PMCID: PMC9181251 DOI: 10.3390/jcm11113233] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2022] [Revised: 05/17/2022] [Accepted: 05/28/2022] [Indexed: 01/27/2023] Open
Abstract
Ventricular arrhythmias (Vas) are a life-threatening condition and preventable cause of sudden cardiac death (SCD). With the increased utilization of implantable cardiac defibrillators (ICD), the focus of VA management has shifted toward reduction of morbidity from VAs and ICD therapies. Anti-arrhythmic drugs (AADs) can be an important adjunct therapy in the treatment of recurrent VAs. In the treatment of VAs secondary to structural heart disease, amiodarone remains the most well studied and current guideline-directed pharmacologic therapy. Beta blockers also serve as an important adjunct and are a largely underutilized medication with strong evidentiary support. In patients with defined syndromes in structurally normal hearts, AADs can offer tailored therapies in prevention of SCD and improvement in quality of life. Further clinical trials are warranted to investigate the role of newer therapeutic options and for the direct comparison of established AADs.
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Affiliation(s)
- John Larson
- Division of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (J.L.); (L.R.)
| | - Lucas Rich
- Division of Internal Medicine, University of Michigan, Ann Arbor, MI 48109, USA; (J.L.); (L.R.)
| | - Amrish Deshmukh
- Division of Cardiovascular Medicine, Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, MI 48109, USA; (A.D.); (E.C.J.)
| | - Erin C. Judge
- Division of Cardiovascular Medicine, Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, MI 48109, USA; (A.D.); (E.C.J.)
| | - Jackson J. Liang
- Division of Cardiovascular Medicine, Cardiac Arrhythmia Service, University of Michigan, Ann Arbor, MI 48109, USA; (A.D.); (E.C.J.)
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 710] [Impact Index Per Article: 355.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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Cavallari I, Maddaloni E, Nusca A, Tuccinardi D, Buzzetti R, Pozzilli P, Grigioni F. SGLT-2 Inhibitors on Top of Current Pharmacological Treatments for Heart Failure: A Comparative Review on Outcomes and Cost Effectiveness. Am J Cardiovasc Drugs 2022; 22:263-270. [PMID: 34786655 DOI: 10.1007/s40256-021-00508-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/06/2021] [Indexed: 10/19/2022]
Abstract
Heart failure (HF) represents a major global health and economic burden with still unacceptably high morbidity and mortality rates. In recent decades, novel therapeutic opportunities with a significant impact on HF outcomes have been introduced in addition to angiotensin-converting enzyme (ACE) inhibitors, β-blockers, and mineralocorticoid receptor antagonists. These include drugs such as ivabradine, sacubitril-valsartan, and sodium-glucose cotransporter-2 (SGLT-2) inhibitors. The availability of an extremely large pharmacological armamentarium to face this chronic global disease highlights the importance of assessing cost effectiveness to promote sustainable healthcare. In light of the recent approval of SGLT-2 inhibitors for the treatment of HF with reduced ejection fraction, including in individuals without type 2 diabetes mellitus, the aim of this review was to provide an updated comparative evaluation of the efficacy and cost effectiveness of different pharmacological treatments for the prevention (stage A) and treatment of asymptomatic (stage B) and symptomatic (stages C-D) left ventricular dysfunction.
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary. J Am Coll Cardiol 2022; 79:1757-1780. [DOI: 10.1016/j.jacc.2021.12.011] [Citation(s) in RCA: 45] [Impact Index Per Article: 22.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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10
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: Executive Summary: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e876-e894. [PMID: 35363500 DOI: 10.1161/cir.0000000000001062] [Citation(s) in RCA: 146] [Impact Index Per Article: 73.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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11
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 886] [Impact Index Per Article: 443.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Heidenreich PAULA, BOZKURT BIYKEM, AGUILAR DAVID, ALLEN LARRYA, BYUN JONIJ, COLVIN MONICAM, DESWAL ANITA, DRAZNER MARKH, DUNLAY SHANNONM, EVERS LINDAR, FANG JAMESC, FEDSON SAVITRIE, FONAROW GREGGC, HAYEK SALIMS, HERNANDEZ ADRIANF, KHAZANIE PRATEETI, KITTLESON MICHELLEM, LEE CHRISTOPHERS, LINK MARKS, MILANO CARMELOA, NNACHETA LORRAINEC, SANDHU ALEXANDERT, STEVENSON LYNNEWARNER, VARDENY ORLY, VEST AMANDAR, YANCY CLYDEW. 2022 American College of Cardiology/American Heart Association/Heart Failure Society of America Guideline for the Management of Heart Failure: Executive Summary. J Card Fail 2022; 28:810-830. [DOI: 10.1016/j.cardfail.2022.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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13
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Abrahão R, Huynh JC, Benjamin DJ, Li QW, Winestone LE, Muffly L, Keegan THM. Chronic medical conditions and late effects after acute myeloid leukaemia in adolescents and young adults: a population-based study. Int J Epidemiol 2021; 50:663-674. [PMID: 34000732 DOI: 10.1093/ije/dyaa184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/25/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Curative-intent treatment of acute myeloid leukaemia (AML) can lead to multiple chronic medical conditions ('late effects'). Little is known about the burden of late effects in adolescent and young adult (AYA, 15-39 years) survivors of AML. We aimed to estimate the cumulative incidence and investigate the main predictors of late effects among these patients. METHODS During 1996-2012, 1168 eligible AYAs with AML who survived ≥2 years after diagnosis were identified in the California Cancer Registry. Late effects were reported from State hospital discharge data, and patients were followed through 2014. Hazard ratios and 95% confidence intervals of late effects occurrence were estimated using Cox proportional hazard models, adjusted for sociodemographic and clinical factors. RESULTS The most common late effects at 10 years after diagnosis were: endocrine (26.1%), cardiovascular (18.6%) and respiratory (6.6%), followed by neurologic (4.9%), liver/pancreatic (4.3%), renal (3.1%), avascular necrosis (2.7%) and second primary malignancies (2.4%). Of 1168 survivors, 547 (46.8%) received a haematopoietic stem cell transplant (HSCT). After multivariable adjustments, AYAs who underwent HSCT or had a non-favourable risk AML experienced ∼2-fold or higher increased likelihood of all late effects. Additionally, AYAs of Hispanic, Black or Asian/Pacific Islander (vs non-Hispanic White) race/ethnicity and those who resided in lower socio-economic neighbourhoods were at higher risk of numerous late effects. CONCLUSIONS Our findings underscore the need for long-term surveillance for the prevention, early detection and treatment of late effects, and can inform the development of AYA-focused consensus-based guidelines that will ultimately improve the quality of life and survival of these young vulnerable patients.
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Affiliation(s)
- Renata Abrahão
- Division of Hematology and Oncology, Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California, Davis, Sacramento, CA, USA.,Center for Healthcare Policy and Research, University of California, Davis, Sacramento, CA, USA
| | - Jasmine C Huynh
- Division of Hematology and Oncology, Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California, Davis, Sacramento, CA, USA
| | - David J Benjamin
- Department of Internal Medicine, Division of Hematology and Oncology, University of California, Irvine, Orange, CA, USA
| | - Qian W Li
- Division of Hematology and Oncology, Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California, Davis, Sacramento, CA, USA
| | - Lena E Winestone
- Department of Pediatrics, School of Medicine, University of California, San Francisco, CA, USA
| | - Lori Muffly
- Division of Blood and Marrow Transplantation, Department of Medicine, Stanford University, Stanford, CA, USA
| | - Theresa H M Keegan
- Division of Hematology and Oncology, Center for Oncology Hematology Outcomes Research and Training (COHORT), University of California, Davis, Sacramento, CA, USA
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14
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Teuteberg JJ. Classifying and Risk Stratifying Heart Failure: Easy as A, B, C? JACC Cardiovasc Imaging 2021; 14:1189-1191. [PMID: 33582057 DOI: 10.1016/j.jcmg.2020.12.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 12/08/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Jeffrey J Teuteberg
- Cardiac Transplantation and Mechanical Circulatory Support, Stanford University, Falk Cardiovascular Institute, Stanford, California, USA.
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15
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Sinha A, Gupta DK, Yancy CW, Shah SJ, Rasmussen-Torvik LJ, McNally EM, Greenland P, Lloyd-Jones DM, Khan SS. Risk-Based Approach for the Prediction and Prevention of Heart Failure. Circ Heart Fail 2021; 14:e007761. [PMID: 33535771 DOI: 10.1161/circheartfailure.120.007761] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Targeted prevention of heart failure (HF) remains a critical need given the high prevalence of HF morbidity and mortality. Similar to risk-based prevention of atherosclerotic cardiovascular disease, optimal HF prevention strategies should include quantification of risk in the individual patient. In this review, we discuss incorporation of a quantitative risk-based approach into the existing HF staging landscape and the clinical opportunity that exists to translate available data on risk estimation to help guide personalized decision making. We first summarize the recent development of key HF risk prediction tools that can be applied broadly at a population level to estimate risk of incident HF. Next, we provide an in-depth description of the clinical utility of biomarkers to personalize risk estimation in select patients at the highest risk of developing HF. We also discuss integration of genomics-enhanced approaches (eg, Titin [TTN]) and other risk-enhancing features to reclassify risk with a precision medicine approach to HF prevention. Although sequential testing is very likely to identify low and high-risk individuals with excellent accuracy, whether or not interventions based on these risk models prevent HF in clinical practice requires prompt attention including randomized placebo-controlled trials of candidate therapies in risk-enriched populations. We conclude with a summary of unanswered questions and gaps in evidence that must be addressed to move the field of HF risk assessment forward.
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Affiliation(s)
- Arjun Sinha
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine (A.S., C.W.Y., S.J.S., E.M.N., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL.,Department of Preventive Medicine, Feinberg School of Medicine (A.S., L.J.R.-T., P.G., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL
| | - Deepak K Gupta
- Vanderbilt Translational and Clinical Cardiovascular Research Center, Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, TN (D.K.G.)
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine (A.S., C.W.Y., S.J.S., E.M.N., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine (A.S., C.W.Y., S.J.S., E.M.N., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL
| | - Laura J Rasmussen-Torvik
- Department of Preventive Medicine, Feinberg School of Medicine (A.S., L.J.R.-T., P.G., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL
| | - Elizabeth M McNally
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine (A.S., C.W.Y., S.J.S., E.M.N., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL
| | - Philip Greenland
- Department of Preventive Medicine, Feinberg School of Medicine (A.S., L.J.R.-T., P.G., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL
| | - Donald M Lloyd-Jones
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine (A.S., C.W.Y., S.J.S., E.M.N., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL.,Department of Preventive Medicine, Feinberg School of Medicine (A.S., L.J.R.-T., P.G., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL
| | - Sadiya S Khan
- Division of Cardiology, Department of Medicine, Feinberg School of Medicine (A.S., C.W.Y., S.J.S., E.M.N., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL.,Department of Preventive Medicine, Feinberg School of Medicine (A.S., L.J.R.-T., P.G., D.M.L.-J., S.S.K.), Northwestern University, Chicago, IL
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16
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Ehrhardt MJ, Ward ZJ, Liu Q, Chaudhry A, Nohria A, Border W, Fulbright JM, Mulrooney DA, Oeffinger KC, Nathan PC, Leisenring WM, Constine LS, Gibson TM, Chow EJ, Howell RM, Robison LL, Armstrong GT, Hudson MM, Diller L, Yasui Y, Armenian SH, Yeh JM. Cost-Effectiveness of the International Late Effects of Childhood Cancer Guideline Harmonization Group Screening Guidelines to Prevent Heart Failure in Survivors of Childhood Cancer. J Clin Oncol 2020; 38:3851-3862. [PMID: 32795226 PMCID: PMC7676889 DOI: 10.1200/jco.20.00418] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/09/2020] [Indexed: 02/06/2023] Open
Abstract
PURPOSE Survivors of childhood cancer treated with anthracyclines and/or chest-directed radiation are at increased risk for heart failure (HF). The International Late Effects of Childhood Cancer Guideline Harmonization Group (IGHG) recommends risk-based screening echocardiograms, but evidence supporting its frequency and cost-effectiveness is limited. PATIENTS AND METHODS Using the Childhood Cancer Survivor Study and St Jude Lifetime Cohort, we developed a microsimulation model of the clinical course of HF. We estimated long-term health outcomes and economic impact of screening according to IGHG-defined risk groups (low [doxorubicin-equivalent anthracycline dose of 1-99 mg/m2 and/or radiotherapy < 15 Gy], moderate [100 to < 250 mg/m2 or 15 to < 35 Gy], or high [≥ 250 mg/m2 or ≥ 35 Gy or both ≥ 100 mg/m2 and ≥ 15 Gy]). We compared 1-, 2-, 5-, and 10-year interval-based screening with no screening. Screening performance and treatment effectiveness were estimated based on published studies. Costs and quality-of-life weights were based on national averages and published reports. Outcomes included lifetime HF risk, quality-adjusted life-years (QALYs), lifetime costs, and incremental cost-effectiveness ratios (ICERs). Strategies with ICERs < $100,000 per QALY gained were considered cost-effective. RESULTS Among the IGHG risk groups, cumulative lifetime risks of HF without screening were 36.7% (high risk), 24.7% (moderate risk), and 16.9% (low risk). Routine screening reduced this risk by 4% to 11%, depending on frequency. Screening every 2, 5, and 10 years was cost-effective for high-risk survivors, and every 5 and 10 years for moderate-risk survivors. In contrast, ICERs were > $175,000 per QALY gained for all strategies for low-risk survivors, representing approximately 40% of those for whom screening is currently recommended. CONCLUSION Our findings suggest that refinement of recommended screening strategies for IGHG high- and low-risk survivors is needed, including careful reconsideration of discontinuing asymptomatic left ventricular dysfunction and HF screening in low-risk survivors.
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Affiliation(s)
- Matthew J. Ehrhardt
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Zachary J. Ward
- Center for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA
| | - Qi Liu
- Department of Public Health Sciences, University of Alberta, Edmonton, Alberta, Canada
| | - Aeysha Chaudhry
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA
| | - Anju Nohria
- Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - William Border
- Department of Pediatrics, Emory University School of Medicine, Atlanta, GA
| | - Joy M. Fulbright
- Department of Pediatrics, The Children’s Mercy Hospital, Kansas City, MO
| | - Daniel A. Mulrooney
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | | | - Paul C. Nathan
- Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada
| | - Wendy M. Leisenring
- Clinical Statistics and Cancer Prevention Programs, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Louis S. Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY
| | - Todd M. Gibson
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Eric J. Chow
- Department of Pediatrics, Seattle Children’s Hospital, University of Washington, Seattle, WA
- Clinical Research and Public Health Sciences Divisions, Fred Hutchinson Cancer Research Center, Seattle, WA
| | - Rebecca M. Howell
- Department of Radiation Physics, The University of Texas MD Anderson Cancer Center, Houston, TX
| | - Leslie L. Robison
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Gregory T. Armstrong
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Melissa M. Hudson
- Department of Oncology, St Jude Children’s Research Hospital, Memphis, TN
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Lisa Diller
- Dana-Farber/Boston Children’s Cancer and Blood Disorders Center, Boston, MA
| | - Yutaka Yasui
- Department of Epidemiology and Cancer Control, St Jude Children’s Research Hospital, Memphis, TN
| | - Saro H. Armenian
- Department of Population Sciences, City of Hope Medical Center, Duarte, CA
| | - Jennifer M. Yeh
- Division of General Pediatrics, Boston Children’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA
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17
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Hodgson DC. Cardiac Screening for Childhood Cancer Survivors Can Be Improved With Existing Technology. J Clin Oncol 2020; 38:3827-3829. [PMID: 33026936 DOI: 10.1200/jco.20.02374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Affiliation(s)
- David C Hodgson
- Department of Radiation Oncology, University of Toronto, Toronto, ON, Canada.,Radiation Medicine Program, Princess Margaret Cancer Centre, Toronto, ON, Canada.,Pediatric Oncology Group of Ontario, Toronto, ON, Canada
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18
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Bavishi A, Patel RB. Addressing Comorbidities in Heart Failure: Hypertension, Atrial Fibrillation, and Diabetes. Heart Fail Clin 2020; 16:441-456. [PMID: 32888639 DOI: 10.1016/j.hfc.2020.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Heart failure (HF) is a growing global epidemic and an increasingly cumbersome burden on health care systems worldwide. As such, optimal management of existing comorbidities in the setting of HF is particularly important to prevent disease progression, reduce HF hospitalizations, and improve quality of life. In this review, the authors address 3 key comorbidities commonly associated with HF: hypertension, atrial fibrillation, and diabetes mellitus. They comprehensively describe the epidemiology, management, and emerging therapies in these 3 disease states as they relate to the overall HF syndrome.
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Affiliation(s)
- Aakash Bavishi
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, 676 North St Clair Street, Suite 600, Chicago, IL 60611, USA.
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19
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Daubert MA, Douglas PS. Primary Prevention of Heart Failure in Women. JACC-HEART FAILURE 2020; 7:181-191. [PMID: 30819373 DOI: 10.1016/j.jchf.2019.01.011] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/04/2018] [Revised: 01/22/2019] [Accepted: 01/24/2019] [Indexed: 12/17/2022]
Abstract
The incidence of heart failure (HF) is increasing, particularly among women, and constitutes a rapidly growing public health problem. The primary prevention of HF in women should involve targeted, sex-specific strategies to increase awareness, promote a heart healthy lifestyle, and improve treatments that optimally control the risk factors for HF with reduced ejection fraction and HF with preserved ejection fraction. Epidemiological and pathophysiological differences in both HF subtypes strongly suggest that sex-specific preventive strategies and risk factor reduction may be particularly beneficial. However, significant gaps in sex-specific knowledge exist and are impeding preventive efforts. To overcome these limitations, women need to be adequately represented in HF research, sex differences must be prospectively investigated, and effective sex-specific interventions should be incorporated into clinical practice guidelines. This review summarizes the existing evidence that supports the primary prevention of HF in women and identifies potential strategies that are most likely to be effective in reducing the burden of HF among women.
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Affiliation(s)
- Melissa A Daubert
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina.
| | - Pamela S Douglas
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
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20
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Bottinor WJ, Friedman DL, Ryan TD, Wang L, Yu C, Borinstein SC, Godown J. Cardiovascular disease and asymptomatic childhood cancer survivors: Current clinical practice. Cancer Med 2020; 9:5500-5508. [PMID: 32558321 PMCID: PMC7402829 DOI: 10.1002/cam4.3190] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 03/19/2020] [Accepted: 05/13/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND It is poorly understood how cardiovascular screening in asymptomatic childhood cancer survivors (CCS) is applied to and impacts clinical care. OBJECTIVES To describe the current role of cardiovascular screening in the clinical care of asymptomatic CCS. METHODS At 50 pediatric academic medical centers, a childhood cancer survivorship clinic director, pediatric cardiologist, and adult cardiologist with a focus on CCS were identified and invited to participate in a survey. Surveys were managed electronically. Categorical data were analyzed using nonparametric methods. RESULTS Of the 95 (63%) respondents, 39% were survivorship practitioners, and 61% were cardiologists. Eighty-eight percent of survivorship practitioners reported that greater than half of CCS received cardiovascular screening. CCS followed by adult cardiology were more likely to be seen by a cardio-oncologist. Those followed by pediatric cardiology were more likely to be seen by a heart failure/transplant specialist. Common reasons for referral to cardiology were abnormal cardiovascular imaging or concerns a CCS was at high risk for cardiovascular disease. Ninety-two percent of cardiologists initiated angiotensin converting enzyme inhibitor or angiotensin receptor blocker therapy for mild systolic dysfunction. Adult cardiologists initiated beta-blocker therapy for less severe systolic dysfunction compared to pediatric cardiologists (P < .001). Pediatric cardiologists initiated mineralocorticoid therapy for less severe systolic dysfunction compared to adult cardiologists (P = .025). Practitioners (93%) support a multi-institutional collaboration to standardize cardiovascular care for CCS. CONCLUSIONS While there is much common ground in the clinical approach to CCS, heterogeneity is evident. This highlights the need for cohesive, multi-institutional, standardized approaches to cardiovascular management in CCS.
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Affiliation(s)
- Wendy J Bottinor
- Division of Cardiovascular Medicine, Department of Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA
| | - Debra L Friedman
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Thomas D Ryan
- Department of Pediatrics, University of Cincinnati College of Medicine; Heart Institute, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Li Wang
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Chang Yu
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Scott C Borinstein
- Department of Pediatrics, Division of Hematology-Oncology, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Justin Godown
- Department of Pediatrics, Division of Pediatric Cardiology, Vanderbilt University Medical Center, Nashville, TN, USA
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21
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Guppy-Coles KB, Prasad SB, Smith KC, Lo A, Beard P, Ng A, Atherton JJ. Accuracy of Cardiac Nurse Acquired and Measured Three-Dimensional Echocardiographic Left Ventricular Ejection Fraction: Comparison to Echosonographer. Heart Lung Circ 2019; 29:703-709. [PMID: 31320256 DOI: 10.1016/j.hlc.2019.04.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 03/14/2019] [Accepted: 04/08/2019] [Indexed: 12/22/2022]
Abstract
BACKGROUND Three-dimensional echocardiography (3D-Echo) performed by novice health care staff to measure left ventricular ejection fraction (LVEF) could allow cost-effective screening and monitoring for left ventricular systolic dysfunction (LVSD) prior to the development of heart failure. The aim of this study was to determine feasibility and accuracy of cardiac nurses (after completing focussed training) independently acquiring 3D-Echo images, and measuring LVEF using semi-automated software when compared to an echosonographer. METHODS One echosonographer and three cardiac nurses acquired 3D-Echo images on 73 patients (62 ± 16 years, 62% male) with good image quality, and subsequently measured LVEF using a semi-automated algorithm. RESULTS Overall feasibility was 89% with the three nurses successfully acquiring 3D-Echo images suitable for LVEF assessment in 65 of the 73 patients. High accuracy (r = 0.82; p < 0.0001) with minimal bias (+0.1, -10.6 to +10.8 limits of agreement; p = 0.91) was observed comparing the nurses to the echosonographer for measuring LVEF. Individual nurses demonstrated high feasibility (86%-92%), accuracy (r = 0.83-0.87; all p < 0.0001) and intra-observer reproducibility (r = 0.96-0.97; all p < 0.0001), with good inter-observer consistency in accuracy compared to the echosonographer (one-way analysis of variance p = 0.559). CONCLUSIONS We have demonstrated that, following a focussed training protocol, it was feasible for cardiac nurses to acquire 3D-Echo images of sufficient image quality to allow measurement of LVEF using a semi-automated algorithm, with comparable accuracy and intra-observer variability to an expert echosonographer. This could potentially allow the broader application of echocardiography to screen for LVSD in high-risk cohorts.
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Affiliation(s)
- Kristyan B Guppy-Coles
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Sandhir B Prasad
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia
| | - Kym C Smith
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Ada Lo
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Patrick Beard
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia
| | - Arnold Ng
- Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia; Department of Cardiology, Princess Alexandra Hospital, Brisbane, Qld, Australia
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Brisbane, Qld, Australia; Faculty of Medicine, University of Queensland, Brisbane, Qld, Australia.
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22
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AlTurki A, Proietti R, Russo V, Dhanjal T, Banerjee P, Essebag V. Anti-arrhythmic drug therapy in implantable cardioverter-defibrillator recipients. Pharmacol Res 2019; 143:133-142. [PMID: 30914300 DOI: 10.1016/j.phrs.2019.03.020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2019] [Revised: 03/20/2019] [Accepted: 03/22/2019] [Indexed: 01/14/2023]
Abstract
Implantable cardioverter-defibrillators (ICDs) have revolutionized the primary and secondary prevention of patients with ventricular arrhythmias. However, the adverse effects of appropriate or inappropriate shocks may require the adjunctive use of anti-arrhythmic drugs (AADs). Beta blockers are the cornerstone of pharmacological primary and secondary prevention of ventricular arrhythmias. In addition to their established efficacy at reducing the incidence of ventricular arrhythmias, beta-blockers are safe with few side effects. Amiodarone is superior to beta blockers and sotalol for the prevention of ventricular arrhythmia recurrence. However, long-term amiodarone use is associated with significant side effects that limit its utility. Sotalol and mexiletine are the main alternatives to amiodarone with a better side effect profile though they are less efficacious at preventing ventricular arrhythmia recurrence. Dofetilide, azimilide and ranolazine are emerging as therapeutic options for secondary prevention; more studies are needed to assess efficacy and safety in comparison to currently used agents. Beta blockers and amiodarone are the mainstay of therapy in patients experiencing electrical storm; their use reduces the frequency of ventricular arrhythmias and ICD intervention as well as affording time until catheter ablation can be considered.
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Affiliation(s)
- Ahmed AlTurki
- Division of Cardiology, McGill University Health Center, Quebec, Canada.
| | - Riccardo Proietti
- Department of Cardiac, Thoracic, and Vascular Sciences, Padua, Italy
| | - Vincenzo Russo
- Chair of Cardiology, University of Campania, Ospedale Monaldi, Naples, Italy
| | - Tarvinder Dhanjal
- Cardiology Department, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Prithwish Banerjee
- Cardiology Department, University Hospital Coventry & Warwickshire, Coventry, UK
| | - Vidal Essebag
- Division of Cardiology, McGill University Health Center, Quebec, Canada; Hôpital Sacré-Coeur de Montréal, Montreal, Quebec, Canada
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23
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National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Guidelines for the Prevention, Detection, and Management of Heart Failure in Australia 2018. Heart Lung Circ 2018; 27:1123-1208. [DOI: 10.1016/j.hlc.2018.06.1042] [Citation(s) in RCA: 203] [Impact Index Per Article: 33.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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24
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Cho JH, Zhang R, Kilfoil PJ, Gallet R, de Couto G, Bresee C, Goldhaber JI, Marbán E, Cingolani E. Delayed Repolarization Underlies Ventricular Arrhythmias in Rats With Heart Failure and Preserved Ejection Fraction. Circulation 2017; 136:2037-2050. [PMID: 28974519 DOI: 10.1161/circulationaha.117.028202] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2017] [Accepted: 09/07/2017] [Indexed: 12/20/2022]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) represents approximately half of heart failure, and its incidence continues to increase. The leading cause of mortality in HFpEF is sudden death, but little is known about the underlying mechanisms. METHODS Dahl salt-sensitive rats were fed a high-salt diet (8% NaCl) from 7 weeks of age to induce HFpEF (n=38). Rats fed a normal-salt diet (0.3% NaCl) served as controls (n=13). Echocardiograms were performed to assess systolic and diastolic function from 14 weeks of age. HFpEF-verified and control rats underwent programmed electrical stimulation. Corrected QT interval was measured by surface ECG. The mechanisms of ventricular arrhythmias (VA) were probed by optical mapping, whole-cell patch clamp to measure action potential duration and ionic currents, and quantitative polymerase chain reaction and Western blotting to investigate changes in ion channel expression. RESULTS After 7 weeks of a high-salt diet, 31 of 38 rats showed diastolic dysfunction and preserved ejection fraction along with signs of heart failure and hence were diagnosed with HFpEF. Programmed electric stimulation demonstrated increased susceptibility to VA in HFpEF rats (P<0.001 versus controls). The arrhythmogenicity index was increased (P<0.001) and the corrected QT interval on ECG was prolonged (P<0.001) in HFpEF rats. Optical mapping of HFpEF hearts demonstrated prolonged action potentials (P<0.05) and multiple reentry circuits during induced VA. Single-cell recordings of cardiomyocytes isolated from HFpEF rats confirmed a delay of repolarization (P=0.001) and revealed downregulation of transient outward potassium current (Ito; P<0.05). The rapid components of the delayed rectifier potassium current (IKr) and the inward rectifier potassium current (IK1) were also downregulated (P<0.05), but the current densities were much lower than for Ito. In accordance with the reduction of Ito, both Kcnd3 transcript and Kv4.3 protein levels were decreased in HFpEF rat hearts. CONCLUSIONS Susceptibility to VA was markedly increased in rats with HFpEF. Underlying abnormalities include QT prolongation, delayed repolarization from downregulation of potassium currents, and multiple reentry circuits during VA. Our findings are consistent with the hypothesis that potassium current downregulation leads to abnormal repolarization in HFpEF, which in turn predisposes to VA and sudden cardiac death.
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Affiliation(s)
- Jae Hyung Cho
- Cedars-Sinai Heart Institute, Los Angeles, CA (J.H.C., R.Z., P.J.K., G.d.C., J.I.G., E.M., E.C.)
| | - Rui Zhang
- Cedars-Sinai Heart Institute, Los Angeles, CA (J.H.C., R.Z., P.J.K., G.d.C., J.I.G., E.M., E.C.)
| | - Peter J Kilfoil
- Cedars-Sinai Heart Institute, Los Angeles, CA (J.H.C., R.Z., P.J.K., G.d.C., J.I.G., E.M., E.C.)
| | - Romain Gallet
- Henri Mondor University Hospital, Créteil, France (R.G.)
| | - Geoffrey de Couto
- Cedars-Sinai Heart Institute, Los Angeles, CA (J.H.C., R.Z., P.J.K., G.d.C., J.I.G., E.M., E.C.)
| | - Catherine Bresee
- Biostatistics and Bioinformatics Research Center, Cedars-Sinai Medical Center, Los Angeles, CA (C.B.)
| | - Joshua I Goldhaber
- Cedars-Sinai Heart Institute, Los Angeles, CA (J.H.C., R.Z., P.J.K., G.d.C., J.I.G., E.M., E.C.)
| | - Eduardo Marbán
- Cedars-Sinai Heart Institute, Los Angeles, CA (J.H.C., R.Z., P.J.K., G.d.C., J.I.G., E.M., E.C.)
| | - Eugenio Cingolani
- Cedars-Sinai Heart Institute, Los Angeles, CA (J.H.C., R.Z., P.J.K., G.d.C., J.I.G., E.M., E.C.)
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25
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The Initial Evaluation and Management of a Patient with Heart Failure. Curr Cardiol Rep 2017; 19:103. [PMID: 28879633 DOI: 10.1007/s11886-017-0900-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
PURPOSE OF REVIEW The goal of this review is to summarize and discuss a thorough and effective manner in the evaluation of the patient with heart failure. RECENT FINDINGS Heart failure is a prevalent disease worldwide and while the diagnosis of heart failure has remained relatively unchanged via a careful history and physical examination, identification of the etiology of the heart failure and treatment has made significant advances. Mechanical circulatory support (MCS), neprilysin inhibitors, and chronic resynchronization therapy (CRT) are just some of the relatively recent therapies afforded to assist heart failure patients. Heart failure is a complicated, multifactorial diagnosis that requires a careful history and physical for diagnosis with the support of laboratory tests. While the prognosis for heart failure patients remains poor in comparison to other cardiovascular disease and even certain cancers, new advancements in therapy have shown survival and quality of life improvement.
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Abstract
Heart failure (HF) with abnormal left ventricular (LV) ejection fraction should be identified and treated. Treat hypertension with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Treat myocardial ischemia with nitrates and β-blockers. Treat volume overload and HF with diuretics. Treat HF with ACE inhibitors and β-blockers. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in chronic symptomatic HF and abnormal LV ejection fraction. Add isosorbide dinitrate/hydralazine in African Americans with class II to IV HF treated with diuretics, ACE inhibitors, and β-blockers. Exercise training is recommended. Indications for implantable cardioverter-defibrillator and cardiac resynchronization therapy are discussed.
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Affiliation(s)
- Wilbert S Aronow
- Division of Cardiology, Department of Medicine, Westchester Medical Center, New York Medical College, Macy Pavilion, Room 141, Valhalla, NY 10595, USA.
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Bozkurt B, Aguilar D, Deswal A, Dunbar SB, Francis GS, Horwich T, Jessup M, Kosiborod M, Pritchett AM, Ramasubbu K, Rosendorff C, Yancy C. Contributory Risk and Management of Comorbidities of Hypertension, Obesity, Diabetes Mellitus, Hyperlipidemia, and Metabolic Syndrome in Chronic Heart Failure: A Scientific Statement From the American Heart Association. Circulation 2016; 134:e535-e578. [DOI: 10.1161/cir.0000000000000450] [Citation(s) in RCA: 182] [Impact Index Per Article: 22.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Reiffel JA. Drug and Drug-Device Therapy in Heart Failure Patients in the Post-COMET and SCD-HeFT Era. J Cardiovasc Pharmacol Ther 2016; 10 Suppl 1:S45-58. [PMID: 15965572 DOI: 10.1177/10742484050100i406] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Reduced left ventricular ejection fraction and heart failure are the most important risk factors for sudden cardiac death. Recent trials have contributed to the knowledge base of critical therapies for the treatment of left ventricular systolic dysfunction and heart failure as it relates to arrhythmic and sudden cardiac death. Both pharmacologic and device therapies can reduce sudden cardiac death. The trials discussed in this paper have identified the pharmacologic and device interventions that are likely to improve the length and quality of life of the patient with left ventricular dysfunction and reduce the risk of sudden cardiac death. The mortality and anti-arrhythmic effects of angiotensin-converting enzyme inhibitors and β-blockers have been confirmed in large-scale controlled clinical heart failure trials. Recent trials have evaluated which agents are most effective and which patients will derive the most benefit from device therapy in terms of the reduction in the risk of sudden cardiac death and in the amelioration of heart failure. The recent data from the Carvedilol or Metoprolol European Trial (COMET) and the Sudden Cardiac Death in Heart Failure Trial (SCD-HeFT) are discussed as the latest in the series of landmark studies that have shaped the current approaches to treating patients with heart failure and that have altered the heart failure treatment paradigm.
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Affiliation(s)
- James A Reiffel
- Department of Medicine, Columbia University Medical Center, New York, NY 10032, USA.
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Aronow WS. Update of treatment of heart failure with reduction of left ventricular ejection fraction. Arch Med Sci Atheroscler Dis 2016; 1:e106-e116. [PMID: 28905031 PMCID: PMC5421520 DOI: 10.5114/amsad.2016.63002] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2016] [Accepted: 10/02/2016] [Indexed: 12/11/2022] Open
Abstract
Underlying and precipitating causes of heart failure (HF) with reduced left ventricular ejection fraction (HFrEF) should be identified and treated when possible. Hypertension should be treated with diuretics, angiotensin-converting enzyme (ACE) inhibitors, and β-blockers. Diuretics are the first-line drugs in the treatment of patients with HFrEF and volume overload. Angiotensin-converting enzyme inhibitors and β-blockers (carvedilol, sustained-release metoprolol succinate, or bisoprolol) should be used in treatment of HFrEF. Use an angiotensin II receptor blocker (ARB) (candesartan or valsartan) if intolerant to ACE inhibitors because of cough or angioneurotic edema. Sacubitril/valsartan may be used instead of an ACE inhibitor or ARB in patients with chronic symptomatic HFrEF class II or III to further reduce morbidity and mortality. Add an aldosterone antagonist (spironolactone or eplerenone) in selected patients with class II-IV HF who can be carefully monitored for renal function and potassium concentration. (Serum creatinine should be ≤ 2.5 mg/dl in men and ≤ 2.0 mg/dl in women. Serum potassium should be < 5.0 mEq/l). Add isosorbide dinitrate plus hydralazine in patients self-described as African Americans with class II-IV HF being treated with diuretics, ACE inhibitors, and β-blockers. Ivabradine can be used in selected patients with HFrEF.
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Affiliation(s)
- Wilbert S Aronow
- Department of Medicine, Division of Cardiology, Westchester Medical Center/New York Medical College, Valhalla, NY, USA
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Aronow WS. Current treatment of heart failure with reduction of left ventricular ejection fraction. Expert Rev Clin Pharmacol 2016; 9:1619-1631. [PMID: 27673415 DOI: 10.1080/17512433.2016.1242067] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Cheuk DKL, Sieswerda E, van Dalen EC, Postma A, Kremer LCM. Medical interventions for treating anthracycline-induced symptomatic and asymptomatic cardiotoxicity during and after treatment for childhood cancer. Cochrane Database Syst Rev 2016; 2016:CD008011. [PMID: 27552363 PMCID: PMC8626738 DOI: 10.1002/14651858.cd008011.pub3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Anthracyclines are frequently used chemotherapeutic agents for childhood cancer that can cause cardiotoxicity during and after treatment. Although several medical interventions in adults with symptomatic or asymptomatic cardiac dysfunction due to other causes are beneficial, it is not known if the same treatments are effective for childhood cancer patients and survivors with anthracycline-induced cardiotoxicity. This review is an update of a previously published Cochrane review. OBJECTIVES To compare the effect of medical interventions on anthracycline-induced cardiotoxicity in childhood cancer patients or survivors with the effect of placebo, other medical interventions, or no treatment. SEARCH METHODS We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2015, Issue 8), MEDLINE/PubMed (1949 to September 2015), and EMBASE/Ovid (1980 to September 2015) for potentially relevant articles. In addition, we searched reference lists of relevant articles, conference proceedings of the International Society for Paediatric Oncology (SIOP), the American Society of Clinical Oncology (ASCO), the American Society of Hematology (ASH), the International Conference on Long-Term Complications of Treatment of Children & Adolescents for Cancer, and the European Symposium on Late Complications from Childhood Cancer (from 2005 to 2015), and ongoing trial databases (the ISRCTN Register, the National Institutes of Health (NIH) Register, and the trials register of the World Health Organization (WHO); all searched in September 2015). SELECTION CRITERIA Randomised controlled trials (RCTs) or controlled clinical trials (CCTs) comparing the effectiveness of medical interventions to treat anthracycline-induced cardiotoxicity with either placebo, other medical interventions, or no treatment. DATA COLLECTION AND ANALYSIS Two review authors independently performed the study selection. One review author performed the data extraction and 'Risk of bias' assessments, which another review author checked. We performed analyses according to the guidelines in the Cochrane Handbook for Systematic Reviews of Interventions. MAIN RESULTS In the original version of the review we identified two RCTs; in this update we identified no additional studies. One trial (135 participants) compared enalapril with placebo in childhood cancer survivors with asymptomatic anthracycline-induced cardiac dysfunction. The other trial (68 participants) compared a two-week treatment of phosphocreatine with a control treatment (vitamin C, adenosine triphosphate, vitamin E, oral coenzyme Q10) in leukaemia patients with anthracycline-induced cardiotoxicity. Both studies had methodological limitations.The RCT on enalapril showed no statistically significant differences in overall survival, mortality due to heart failure, development of clinical heart failure, and quality of life between treatment and control groups. A post-hoc analysis showed a decrease (that is improvement) in one measure of cardiac function (left ventricular end-systolic wall stress (LVESWS): -8.62% change) compared with placebo (+1.66% change) in the first year of treatment (P = 0.036), but not afterwards. Participants treated with enalapril had a higher risk of dizziness or hypotension (risk ratio 7.17, 95% confidence interval 1.71 to 30.17) and fatigue (Fisher's exact test, P = 0.013).The RCT on phosphocreatine found no differences in overall survival, mortality due to heart failure, echocardiographic cardiac function, and adverse events between treatment and control groups. AUTHORS' CONCLUSIONS Only one trial evaluated the effect of enalapril in childhood cancer survivors with asymptomatic cardiac dysfunction. Although there is some evidence that enalapril temporarily improves one parameter of cardiac function (LVESWS), it is unclear whether it improves clinical outcomes. Enalapril was associated with a higher risk of dizziness or hypotension and fatigue. Clinicians should weigh the possible benefits with the known side effects of enalapril in childhood cancer survivors with asymptomatic anthracycline-induced cardiotoxicity.Only one trial evaluated the effect of phosphocreatine in childhood cancer patients with anthracycline-induced cardiotoxicity. Limited data with a high risk of bias showed no significant difference between phosphocreatine and control treatments on echocardiographic function and clinical outcomes.We did not identify any RCTs or CCTs studying other medical interventions for symptomatic or asymptomatic cardiotoxicity in childhood cancer patients or survivors.High-quality studies should be performed.
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Affiliation(s)
- Daniel KL Cheuk
- The University of Hong Kong, Queen Mary HospitalDepartment of Pediatrics and Adolescent MedicinePokfulam RoadHong KongChina
| | - Elske Sieswerda
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660AmsterdamNetherlands1100 DD
| | - Elvira C van Dalen
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660AmsterdamNetherlands1100 DD
| | - Aleida Postma
- University Medical Center Groningen and University of Groningen, Beatrix Children's HospitalDepartment of Paediatric OncologyPostbus 30.000GroningenNetherlands9700 RB
| | - Leontien CM Kremer
- Emma Children's Hospital/Academic Medical CenterDepartment of Paediatric OncologyPO Box 22660AmsterdamNetherlands1100 DD
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Tan TC, Neilan TG, Francis S, Plana JC, Scherrer-Crosbie M. Anthracycline-Induced Cardiomyopathy in Adults. Compr Physiol 2016; 5:1517-40. [PMID: 26140726 DOI: 10.1002/cphy.c140059] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Anthracyclines are one of the most commonly used antineoplastic agent classes, and a core part of the treatment in breast cancers, hematological malignancies, and sarcomas. Their benefit is decreased by their well-recognized cardiotoxicity. The purpose of this review is to outline the presentation, mechanisms, diagnosis, and treatment of anthracyclines-induced cardiotoxicity. Symptomatic heart failure occurs in 2% to 5% of patients treated with anthrayclines and may be higher in older patients or patients with cardiovascular risk factors. The mechanisms involved in anthracycline-induced cardiotoxicity involve myocyte loss by apoptosis in the presence of a limited regenerative capacity. Once symptomatic, anthracycline-induced cardiotoxicity is associated with markedly decreased survival. Left ventricular ejection fraction (LVEF), mostly determined using echocardiography, is used to monitor patients treated with anthracyclines. As more than 1/3 of patients treated with anthracyclines do not recover their baseline LVEF once it is decreased, more sensitive echocardiographic indices of LV function such as myocardial deformation or biomarkers have been studied in patients monitoring. Cardioprotective treatments such as angiotensin-converting enzyme inhibitors, beta-blockers, iron chelators, statins, and metformin are also the topic of research efforts.
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Affiliation(s)
- Timothy C Tan
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Division of Cardiology, Blacktown Hospital, University of Western Sydney, Australia
| | - Tomas G Neilan
- Cardio-oncology program, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiac MR PET CT Program, Division of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Sanjeev Francis
- Cardio-oncology program, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardiac MR PET CT Program, Division of Radiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Juan Carlos Plana
- Division of Cardiology, Baylor College of Medicine, Houston, Texas, USA
| | - Marielle Scherrer-Crosbie
- Cardiac Ultrasound Laboratory, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA.,Cardio-oncology program, Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA
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Echouffo-Tcheugui JB, Erqou S, Butler J, Yancy CW, Fonarow GC. Assessing the Risk of Progression From Asymptomatic Left Ventricular Dysfunction to Overt Heart Failure: A Systematic Overview and Meta-Analysis. JACC-HEART FAILURE 2015; 4:237-48. [PMID: 26682794 DOI: 10.1016/j.jchf.2015.09.015] [Citation(s) in RCA: 87] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/12/2015] [Revised: 08/25/2015] [Accepted: 09/04/2015] [Indexed: 01/08/2023]
Abstract
OBJECTIVES This study sought to provide estimates of the risk of progression to overt heart failure (HF) from systolic or diastolic asymptomatic left ventricular dysfunction through a systematic review and meta-analysis. BACKGROUND Precise population-based estimates on the progression from asymptomatic left ventricular dysfunction (or stage B HF) to clinical HF (stage C HF) remain limited, despite its prognostic and clinical implications. Pre-emptive intervention with neurohormonal modulation may attenuate disease progression. METHODS MEDLINE and EMBASE were systematically searched (until March 2015). Cohort studies reporting on the progression from asymptomatic left ventricular systolic dysfunction (ALVSD) or asymptomatic left ventricular diastolic dysfunction (ALVDD) to overt HF were included. Effect estimates (prevalence, incidence, and relative risk) were pooled using a random-effects model meta-analysis, separately for systolic and diastolic dysfunction, with heterogeneity assessed with the I(2) statistic. RESULTS Thirteen reports based on 11 distinct studies of progression of ALVSD were included in the meta-analysis assessing a total of 25,369 participants followed for 7.9 years on average. The absolute risks of progression to HF were 8.4 per 100 person-years (95% confidence interval [CI]: 4.0 to 12.8 per 100 person-years) for those with ALVSD, 2.8 per 100 person-years (95% CI: 1.9 to 3.7 per 100 person-years) for those with ALVDD, and 1.04 per 100 person-years (95% CI: 0.0 to 2.2 per 100 person-years) without any ventricular dysfunction evident. The combined maximally adjusted relative risk of HF for ALVSD was 4.6 (95% CI: 2.2 to 9.8), and that of ALVDD was 1.7 (95% CI: 1.3 to 2.2). CONCLUSIONS ALVSD and ALVDD are each associated with a substantial risk for incident HF indicating an imperative to develop effective intervention at these stages.
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Affiliation(s)
- Justin B Echouffo-Tcheugui
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts; Rollins School of Public Health, Emory University, Atlanta, Georgia.
| | - Sebhat Erqou
- Cardiology Division, Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Javed Butler
- Cardiology Division, Department of Medicine, Stony Brook University, Stony Brook, New York
| | - Clyde W Yancy
- Cardiology Division, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Division of Cardiology, Department of Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, California
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Abstract
The newly available clinical guidelines in heart failure (HF) from Europe (2012), the United States (2010 and 2013), and Canada (2015) were compared, focusing on the systems for grading the evidence and classifying the recommendations, HF definitions, pharmacologic treatment, and devices used in HF. Some gaps were evident in the methodology for assessing evidence or in HF definitions. Pharmacologic treatments and recommendations for cardiac resynchronization therapy and implantable cardioverter-defibrillators are similar but some differences need to be considered by the practicing clinician. Guideline recommendations regarding new emergent treatments are becoming available.
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Affiliation(s)
- Juan F Bulnes
- Division of Internal Medicine, School of Medicine, Pontificia Universidad Catolica de Chile, Marcoleta 367, Santiago 8320000, Chile
| | - Jorge E Jalil
- Division of Cardiovascular Diseases, School of Medicine, Pontificia Universidad Catolica de Chile, Marcoleta 367, 8th Floor, Santiago 8320000, Chile.
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Foundations of Pharmacotherapy for Heart Failure With Reduced Ejection Fraction: Evidence Meets Practice, Part I. J Cardiovasc Nurs 2015; 31:101-13. [PMID: 26296245 DOI: 10.1097/jcn.0000000000000284] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Pharmacologic treatment for systolic heart failure, otherwise known as heart failure with reduced ejection fraction, has been established through clinical trials and is formulated into guidelines to standardize the diagnosis and treatment. The premise of pharmacologic therapy in heart failure with reduced ejection fraction is aimed primarily at interrupting the neurohormonal cascade that is responsible for altering left ventricular shape and function. This is the first in a series of articles to describe the pharmacologic agents in the guidelines that impact the morbidity and mortality associated with heart failure. Angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and vasodilators will be presented in the context of the mechanism of action in heart failure, investigational trials that showed beneficial effects, and the practical application for clinical use.
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Wasilewski MA, Myers VD, Recchia FA, Feldman AM, Tilley DG. Arginine vasopressin receptor signaling and functional outcomes in heart failure. Cell Signal 2015; 28:224-233. [PMID: 26232615 DOI: 10.1016/j.cellsig.2015.07.021] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 07/27/2015] [Indexed: 01/09/2023]
Affiliation(s)
- Melissa A Wasilewski
- Center for Translational Medicine, Temple University School of Medicine, Philadelphia, PA, USA
| | - Valerie D Myers
- Cardiovascular Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Fabio A Recchia
- Cardiovascular Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Arthur M Feldman
- Cardiovascular Research Center, Temple University School of Medicine, Philadelphia, PA, USA
| | - Douglas G Tilley
- Center for Translational Medicine, Temple University School of Medicine, Philadelphia, PA, USA.
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38
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Abstract
Cirrhotic cardiomyopathy, a cardiac dysfunction presented in patients with cirrhosis, represents a recently recognized clinical entity. It is characterized by altered diastolic relaxation, impaired contractility, and electrophysiological abnormalities, in particular prolongation of the QT interval. Several mechanisms seem to be involved in the pathogenesis of cirrhotic cardiomyopathy, including impaired function of beta-receptors, altered transmembrane currents, and overproduction of cardiodepressant factors, like nitric oxide, tumor necrosis factor α, and endogenous cannabinoids. Diastolic dysfunction is the first manifestation of cirrhotic cardiomyopathy and reflects the increased stiffness of the cardiac mass, which leads to delayed left ventricular filling. On the other hand, systolic incompetence is presented later, is usually unmasked during pharmacological or physical stress, and predisposes to the development of hepatorenal syndrome. The prolongation of QT is found in about 50 % of cirrhotic patients, but rarely leads to fatal arrhythmias. Cirrhotics with blunted cardiac function seem to have poorer survival rates compared to those without, and the risk is particularly increased during the insertion of transjugular intrahepatic portosystemic shunt or liver transplantation. Till now, there is no specific treatment for the management of cirrhotic cardiomyopathy. New agents, targeting to its pathogenetical mechanisms, may play some role as future therapeutic options.
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Myotonic dystrophy and the heart: A systematic review of evaluation and management. Int J Cardiol 2015; 184:600-608. [PMID: 25769007 DOI: 10.1016/j.ijcard.2015.03.069] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Revised: 02/11/2015] [Accepted: 03/03/2015] [Indexed: 01/16/2023]
Abstract
UNLABELLED Myotonic dystrophy (MD) is a multisystem, autosomal dominant disorder best known for its skeletal muscle manifestations. Cardiac manifestations arise as a result of myocardial fatty infiltration, degeneration and fibrosis and present most commonly as arrhythmias or conduction disturbances. Guidelines regarding the optimal cardiac management of patients with MD are lacking. The present article provides a summary of the pathophysiology of cardiac problems in patients with MD and provides a practical approach to contemporary cardiac monitoring and management of these patients with a focus on the prevention of complications related to conduction disturbances and arrhythmias. METHODS A literature search was performed using PubMed and Medline. The keywords used in the search included "myotonic dystrophy", "cardiac manifestations", "heart", "arrhythmia", "pacemaker" and "defibrillator", all terms were used in combination. In addition, "myotonic dystrophy" was searched in conjunction with "electrophysiology", "electrocardiogram", "echocardiograph", "signal averaged electrocardiograph", "magnetic resonance imaging" and "exercise stress testing". The titles of all the articles revealed by the search were screened for relevance. The abstracts of relevant titles were read and those articles which concerned the cardiac manifestations of myotonic dystrophy or the investigation and management of cardiac manifestations underwent a full manuscript review.
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Armenian SH, Hudson MM, Mulder RL, Chen MH, Constine LS, Dwyer M, Nathan PC, Tissing WJE, Shankar S, Sieswerda E, Skinner R, Steinberger J, van Dalen EC, van der Pal H, Wallace WH, Levitt G, Kremer LCM. Recommendations for cardiomyopathy surveillance for survivors of childhood cancer: a report from the International Late Effects of Childhood Cancer Guideline Harmonization Group. Lancet Oncol 2015; 16:e123-36. [PMID: 25752563 PMCID: PMC4485458 DOI: 10.1016/s1470-2045(14)70409-7] [Citation(s) in RCA: 374] [Impact Index Per Article: 41.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Survivors of childhood cancer treated with anthracycline chemotherapy or chest radiation are at an increased risk of developing congestive heart failure. In this population, congestive heart failure is well recognised as a progressive disorder, with a variable period of asymptomatic cardiomyopathy that precedes signs and symptoms. As a result, several clinical practice guidelines have been developed independently to help with detection and treatment of asymptomatic cardiomyopathy. These guidelines differ with regards to definitions of at-risk populations, surveillance modality and frequency, and recommendations for interventions. Differences between these guidelines could hinder the effective implementation of these recommendations. We report on the results of an international collaboration to harmonise existing cardiomyopathy surveillance recommendations using an evidence-based approach that relied on standardised definitions for outcomes of interest and transparent presentation of the quality of the evidence. The resultant recommendations were graded according to the quality of the evidence and the potential benefit gained from early detection and intervention.
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Affiliation(s)
- Saro H Armenian
- Department of Population Sciences, City of Hope, Duarte, USA.
| | - Melissa M Hudson
- Departments of Oncology and Epidemiology and Cancer Control, St Jude Children's Research Hospital, Memphis, TN, USA
| | - Renee L Mulder
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Ming Hui Chen
- Department of Pediatrics, Boston Children's Hospital and Dana-Farber Cancer Institute, Harvard Medical School, Boston, MA, USA
| | - Louis S Constine
- Departments of Radiation Oncology and Pediatrics, University of Rochester Medical Center, Rochester, NY, USA
| | - Mary Dwyer
- Peter MacCallum Cancer Centre, East Melbourne, VIC, Australia
| | - Paul C Nathan
- The Hospital for Sick Children and the University of Toronto, Department of Pediatrics and Institute of Health Policy, Management and Evaluation, Toronto, ON, Canada
| | - Wim J E Tissing
- Division of Pediatric Oncology and Pediatric Hematology, Beatrix Children's Hospital, University of Groningen, University Medical Center Groningen, Groningen, Netherlands
| | - Sadhna Shankar
- Division of Oncology, Center for Cancer and Blood Disorders, Children's National Medical Center, Washington, DC, USA
| | - Elske Sieswerda
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - Rod Skinner
- Department of Paediatric and Adolescent Haematology/Oncology, Great North Children's Hospital and University of Newcastle, Newcastle upon Tyne, UK
| | - Julia Steinberger
- Department of Pediatrics, Division of Cardiology, University of Minnesota Amplatz Childrens' Hospital, Minneapolis, MN, USA
| | - Elvira C van Dalen
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Center, Amsterdam, the Netherlands
| | - Helena van der Pal
- Department of Pediatric Oncology and Medical Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
| | - W Hamish Wallace
- Department of Hematology/Oncology, Royal Hospital for Sick Children, Edinburgh, Scotland
| | - Gill Levitt
- Department of Oncology/Haematology, Great Ormond Street Hospital for Children NHS Trust, London, UK
| | - Leontien C M Kremer
- Department of Pediatric Oncology, Emma Children's Hospital/Academic Medical Centre, Amsterdam, Netherlands
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Reed BN, Sueta CA. Stage B: what is the evidence for treatment of asymptomatic left ventricular dysfunction? Curr Cardiol Rev 2015; 11:18-22. [PMID: 24251458 PMCID: PMC4347204 DOI: 10.2174/1573403x09666131117164352] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Revised: 07/09/2013] [Accepted: 09/27/2013] [Indexed: 01/11/2023] Open
Abstract
Although patients with American College of Cardiology / American Heart Association (ACC/AHA) Stage B heart failure, or asymptomatic left ventricular dysfunction (ALVD) are at high risk for developing symptomatic heart failure, few management strategies have been shown to slow disease state progression or improve long-term morbidity and mortality. Of the pharmacologic therapies utilized in patients with symptomatic disease, only angiotensin converting enzyme (ACE) inhibitors (and to a lesser extent, angiotensin receptor blockers, or ARBs) have been shown to improve clinical outcomes among patients with ALVD. Although evidence to support the use of beta blockers in this setting has been primarily derived from retrospective studies or subgroup analyses, they are generally recommended in most patients with ALVD, especially those with ischemic etiology. Statins are associated with improvements in both major adverse cardiovascular events and heart failure events among patients with a history of acute myocardial infarction. Finally, in eligible patients, placement of an automatic implantable cardioverter defibrillator (ICD) has been associated with reduced mortality rates among those with ALVD due to ischemic cardiomyopathy, and some subgroups may derive benefit from cardiac resynchronization therapy or biventricular pacing.
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Affiliation(s)
| | - Carla A Sueta
- Center for Heart & Vascular Care, University of North Carolina, 160 Dental Circle, CB 7075, Chapel Hill, NC 27599-7075, USA.
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Nelson OL, Robbins CT. Cardiovascular function in large to small hibernators: bears to ground squirrels. J Comp Physiol B 2014; 185:265-79. [PMID: 25542162 DOI: 10.1007/s00360-014-0881-5] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2014] [Revised: 11/25/2014] [Accepted: 12/02/2014] [Indexed: 01/19/2023]
Abstract
Mammalian hibernation has intrigued scientists due to extreme variations in normal seasonal physiological homeostasis. Numerous species manifest a hibernation phenotype although the characteristics of the hypometabolic state can be quite different. Ground squirrels (e.g., Sciuridae) are often considered the prototypical hibernator as individuals in this genus transition from an active, euthermic state (37 °C) to a nonresponsive hibernating state where torpid body temperature commonly falls to 3-5 °C. However, the hibernating state is not continuous as periodic warming and arousals occur. In contrast, the larger hibernators of genus Ursus are less hypothermic (body temperatures decline from approximately 37°-33 °C), are more reactive, and cyclical arousals do not occur. Both species dramatically reduce cardiac output during hibernation from the active state (bears ~75 % reduction in bears and ~97 % reduction in ground squirrels), and both species demonstrate hypokinetic atrial chamber activity. However, there are several important differences in cardiac function between the two groups during hibernation. Left ventricular diastolic filling volumes and stroke volumes do not differ in bears between seasons, but increased diastolic and stroke volumes during hibernation are important contributors to cardiac output in ground squirrels. Decreased cardiac muscle mass and increased ventricular stiffness have been found in bears, whereas ground squirrels have increased cardiac muscle mass and decreased ventricular stiffness during hibernation. Molecular pathways of cardiac muscle plasticity reveal differences between the species in the modification of sarcomeric proteins such as titin and α myosin heavy chain during hibernation. The differences in hibernation character are likely to account for the alternative cardiac phenotypes and functional strategies manifested by the two species. Molecular investigation coupled with better knowledge of seasonal physiological alterations is dramatically advancing our understanding of small and large hibernators and their evolutionary differences.
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Affiliation(s)
- O Lynne Nelson
- Department of Veterinary Clinical Sciences, Washington State University, 100 Grimes Way, Pullman, WA, 99164, USA,
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Wong FL, Bhatia S, Landier W, Francisco L, Leisenring W, Hudson MM, Armstrong GT, Mertens A, Stovall M, Robison LL, Lyman GH, Lipshultz SE, Armenian SH. Cost-effectiveness of the children's oncology group long-term follow-up screening guidelines for childhood cancer survivors at risk for treatment-related heart failure. Ann Intern Med 2014; 160:672-83. [PMID: 24842414 PMCID: PMC4073480 DOI: 10.7326/m13-2498] [Citation(s) in RCA: 84] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Childhood cancer survivors treated with anthracyclines are at high risk for asymptomatic left ventricular dysfunction (ALVD), subsequent heart failure, and death. The consensus-based Children's Oncology Group (COG) Long-Term Follow-up Guidelines recommend lifetime echocardiographic screening for ALVD. OBJECTIVE To evaluate the efficacy and cost-effectiveness of the COG guidelines and to identify more cost-effective screening strategies. DESIGN Simulation of life histories using Markov health states. DATA SOURCES Childhood Cancer Survivor Study; published literature. TARGET POPULATION Childhood cancer survivors. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Echocardiographic screening followed by angiotensin-converting enzyme (ACE) inhibitor and β-blocker therapies after ALVD diagnosis. OUTCOME MEASURES Quality-adjusted life-years (QALYs), costs, incremental cost-effectiveness ratios (ICERs) in dollars per QALY, and cumulative incidence of heart failure. RESULTS OF BASE-CASE ANALYSIS The COG guidelines versus no screening have an ICER of $61 500, extend life expectancy by 6 months and QALYs by 1.6 months, and reduce the cumulative incidence of heart failure by 18% at 30 years after cancer diagnosis. However, less frequent screenings are more cost-effective than the guidelines and maintain 80% of the health benefits. RESULTS OF SENSITIVITY ANALYSIS The ICER was most sensitive to the magnitude of ALVD treatment efficacy; higher treatment efficacy resulted in lower ICER. LIMITATION Lifetime non-heart failure mortality and the cumulative incidence of heart failure more than 20 years after diagnosis were extrapolated; the efficacy of ACE inhibitor and β-blocker therapy in childhood cancer survivors with ALVD is undetermined (or unknown). CONCLUSION The COG guidelines could reduce the risk for heart failure in survivors at less than $100 000/QALY. Less frequent screening achieves most of the benefits and would be more cost-effective than the COG guidelines.
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Yeh JM, Nohria A, Diller L. Routine echocardiography screening for asymptomatic left ventricular dysfunction in childhood cancer survivors: a model-based estimation of the clinical and economic effects. Ann Intern Med 2014; 160:661-71. [PMID: 24842413 PMCID: PMC4089868 DOI: 10.7326/m13-2266] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Childhood cancer survivors treated with cardiotoxic therapies are recommended to have routine cardiac assessment every 1 to 5 years, but the long-term benefits are uncertain. OBJECTIVE To estimate the cost-effectiveness of routine cardiac assessment to detect asymptomatic left ventricular dysfunction and of angiotensin-converting enzyme inhibitor and β-blocker treatment to reduce congestive heart failure (CHF) incidence in childhood cancer survivors. DESIGN Simulation model. DATA SOURCES Literature, including data from the Childhood Cancer Survivor Study. TARGET POPULATION Childhood cancer survivors. TIME HORIZON Lifetime. PERSPECTIVE Societal. INTERVENTION Interval-based echocardiography assessment every 1, 2, 5, or 10 years, with subsequent angiotensin-converting enzyme inhibitor or β-blocker treatment for patients with positive test results. OUTCOME MEASURES Lifetime risk for systolic CHF, lifetime costs, quality-adjusted life expectancy, and incremental cost-effectiveness ratios (ICERs). RESULTS OF BASE-CASE ANALYSIS The lifetime risk for systolic CHF among 5-year childhood cancer survivors aged 15 years was 18.8% without routine cardiac assessment (average age at onset, 58.8 years). Routine echocardiography reduced lifetime risk for CHF by 2.3% (with assessment every 10 years) to 8.7% (annual assessment). The ICER for assessment every 10 years was $111 600 per quality-adjusted life-year (QALY) compared with no assessment. Assessment every 5 years had an ICER of $117 900 per QALY, and ICERs for more frequent assessment exceeded $165 000 per QALY. RESULTS OF SENSITIVITY ANALYSIS Results were sensitive to treatment effectiveness, absolute excess risk for CHF, and asymptomatic left ventricular dysfunction asymptomatic period. The probability that assessment every 10 or 5 years was preferred at a $100 000-per-QALY threshold was 0.33 for the overall cohort. LIMITATION Treatment effectiveness was based on adult data. CONCLUSION Current recommendations for cardiac assessment may reduce CHF incidence, but less frequent assessment may be preferable.
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Affiliation(s)
- Jennifer M. Yeh
- From the Harvard School of Public Health, Brigham and Women's Hospital, Dana-Farber Cancer Institute, and Boston Children's Hospital, Boston, Massachusetts
| | - Anju Nohria
- From the Harvard School of Public Health, Brigham and Women's Hospital, Dana-Farber Cancer Institute, and Boston Children's Hospital, Boston, Massachusetts
| | - Lisa Diller
- From the Harvard School of Public Health, Brigham and Women's Hospital, Dana-Farber Cancer Institute, and Boston Children's Hospital, Boston, Massachusetts
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 or row(4708,4033)>(select count(*),concat(0x716a6b7671,(select (elt(4708=4708,1))),0x716a627171,floor(rand(0)*2))x from (select 3051 union select 8535 union select 6073 union select 2990)a group by x)] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and 8965=8965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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Yancy CW, Jessup M, Bozkurt B, Butler J, Casey DE, Drazner MH, Fonarow GC, Geraci SA, Horwich T, Januzzi JL, Johnson MR, Kasper EK, Levy WC, Masoudi FA, McBride PE, McMurray JJ, Mitchell JE, Peterson PN, Riegel B, Sam F, Stevenson LW, Tang WW, Tsai EJ, Wilkoff BL. 2013 ACCF/AHA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2013. [DOI: 10.1016/j.jacc.2013.05.019 and (select (case when (1210=1210) then null else ctxsys.drithsx.sn(1,1210) end) from dual) is null-- xobr] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
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