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Balestrieri G, Limonta R, Ponti E, Merlo A, Sciatti E, D'Isa S, Gori M, Casu G, Giannattasio C, Senni M, D'Elia E. The Therapy and Management of Heart Failure with Preserved Ejection Fraction: New Insights on Treatment. Card Fail Rev 2024; 10:e05. [PMID: 38708376 PMCID: PMC11066852 DOI: 10.15420/cfr.2023.13] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 10/28/2023] [Indexed: 05/07/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a clinical syndrome characterised by the presence of diastolic dysfunction and elevated left ventricular filling pressure, in the setting of a left ventricular ejection fraction of at least 50%. Despite the epidemiological prevalence of HFpEF, a prompt diagnosis is challenging and many uncertainties exist. HFpEF is characterised by different phenotypes driven by various cardiac and non-cardiac comorbidities. This is probably the reason why several HFpEF clinical trials in the past did not reach strong outcomes to recommend a single therapy for this syndrome; however, this paradigm has recently changed, and the unmet clinical need for HFpEF treatment found a proper response as a result of a new class of drug, the sodium-glucose cotransporter 2 inhibitors, which beneficially act through the whole spectrum of left ventricular ejection fraction. The aim of this review was to focus on the therapeutic target of HFpEF, the role of new drugs and the potential role of new devices to manage the syndrome.
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Affiliation(s)
| | - Raul Limonta
- School of Medicine and Surgery, Milano Bicocca UniversityMilan, Italy
| | - Enrico Ponti
- Department of Medical, Surgical and Experimental Sciences, University of SassariSassari, Italy
| | - Anna Merlo
- School of Medicine and Surgery, Milano Bicocca UniversityMilan, Italy
| | - Edoardo Sciatti
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
| | - Salvatore D'Isa
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
| | - Mauro Gori
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
| | - Gavino Casu
- Department of Medical, Surgical and Experimental Sciences, University of SassariSassari, Italy
| | | | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
- Department of Medicine and Surgery, University of Milano BicoccaMilan, Italy
| | - Emilia D'Elia
- Cardiovascular Department, ASST Papa Giovanni XXIIIBergamo, Italy
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Kondo T, Dewan P, Anand IS, Desai AS, Packer M, Zile MR, Pfeffer MA, Solomon SD, Abraham WT, Shah SJ, Lam CSP, Jhund PS, McMurray JJV. Clinical Characteristics and Outcomes in Patients With Heart Failure: Are There Thresholds and Inflection Points in Left Ventricular Ejection Fraction and Thresholds Justifying a Clinical Classification? Circulation 2023; 148:732-749. [PMID: 37366061 DOI: 10.1161/circulationaha.122.063642] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/30/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND Recent guidelines proposed a classification for heart failure (HF) on the basis of left ventricular ejection fraction (LVEF), although it remains unclear whether the divisions chosen were biologically rational. Using patients spanning the full range of LVEF, we examined whether there was evidence of LVEF thresholds in patient characteristics or inflection points in clinical outcomes. METHODS Using patient-level information, we created a merged dataset of 33 699 participants who had been enrolled in 6 randomized controlled HF trials including patients with reduced and preserved ejection fraction. The relationship between the incidence of all-cause death (and specific causes of death) and HF hospitalization, and LVEF, was evaluated using Poisson regression models. RESULTS As LVEF increased, age, the proportion of women, body mass index, systolic blood pressure, and prevalence of atrial fibrillation and diabetes increased, whereas ischemic pathogenesis, estimated glomerular filtration rate, and NT-proBNP (N-terminal pro-B-type natriuretic peptide) decreased. As LVEF increased >50%, age and the proportion of women continued to increase, and ischemic pathogenesis and NT-proBNP decreased, but other characteristics did not change meaningfully. The incidence of most clinical outcomes (except noncardiovascular death) decreased as LVEF increased, with a LVEF inflection point of around 50% for all-cause death and cardiovascular death, around 40% for pump failure death, and around 35% for HF hospitalization. Higher than those thresholds, there was little further decline in the incidence rate. There was no evidence of a J-shaped relationship between LVEF and death; no evidence of worse outcomes in patients with high-normal ("supranormal") LVEF. Similarly, in a subset of patients with echocardiographic data, there were no structural differences in patients with a high-normal LVEF suggestive of amyloidosis, and NT-proBNP levels were consistent with this conclusion. CONCLUSIONS In patients with HF, there was a LVEF threshold of around 40% to 50% where the pattern of patient characteristics changed, and event rates began to increase compared with higher LVEF values. Our findings provide evidence to support current upper LVEF thresholds defining HF with mildly reduced ejection fraction on the basis of prognosis. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT00634309, NCT00634400, NCT00634712, NCT00095238, NCT01035255, NCT00094302, NCT00853658, and NCT01920711.
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Affiliation(s)
- Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (T.K., P.D., P.S.J., J.J.V.M.)
- Department of Cardiology, Nagoya University Graduate School of Medicine, Japan (T.K.)
| | - Pooja Dewan
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (T.K., P.D., P.S.J., J.J.V.M.)
| | - Inder S Anand
- VA Medical Center and University of Minnesota, Minneapolis (I.S.A.)
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (A.S.D., M.A.P., S.D.S.)
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Michael R Zile
- Department of Medicine, Medical University of South Carolina, Charleston (M.R.Z.)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (A.S.D., M.A.P., S.D.S.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (A.S.D., M.A.P., S.D.S.)
| | - William T Abraham
- The Ohio State University, Division of Cardiovascular Medicine (W.T.A.)
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore (C.S.P.L.)
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (T.K., P.D., P.S.J., J.J.V.M.)
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (T.K., P.D., P.S.J., J.J.V.M.)
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Bodnar P, Mazurkiewicz M, Chwalba T, Romuk E, Ciszek-Chwalba A, Jacheć W, Wojciechowska C. The Impact of Pharmacotherapy for Heart Failure on Oxidative Stress-Role of New Drugs, Flozins. Biomedicines 2023; 11:2236. [PMID: 37626732 PMCID: PMC10452694 DOI: 10.3390/biomedicines11082236] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 08/02/2023] [Accepted: 08/03/2023] [Indexed: 08/27/2023] Open
Abstract
Heart failure (HF) is a multifactorial clinical syndrome involving many complex processes. The causes may be related to abnormal heart structure and/or function. Changes in the renin-angiotensin-aldosterone system, the sympathetic nervous system, and the natriuretic peptide system are important in the pathophysiology of HF. Dysregulation or overexpression of these processes leads to changes in cardiac preload and afterload, changes in the vascular system, peripheral vascular dysfunction and remodeling, and endothelial dysfunction. One of the important factors responsible for the development of heart failure at the cellular level is oxidative stress. This condition leads to deleterious cellular effects as increased levels of free radicals gradually disrupt the state of equilibrium, and, as a consequence, the internal antioxidant defense system is damaged. This review focuses on pharmacotherapy for chronic heart failure with regard to oxidation-reduction metabolism, with special attention paid to the latest group of drugs, SGLT2 inhibitors-an integral part of HF treatment. These drugs have been shown to have beneficial effects by protecting the antioxidant system at the cellular level.
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Affiliation(s)
- Patryk Bodnar
- Student Research Team at the Second Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, M. C. Skłodowskiej 10 Street, 41-800 Zabrze, Poland; (P.B.); (T.C.); (A.C.-C.)
| | | | - Tomasz Chwalba
- Student Research Team at the Second Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, M. C. Skłodowskiej 10 Street, 41-800 Zabrze, Poland; (P.B.); (T.C.); (A.C.-C.)
| | - Ewa Romuk
- Department of Biochemistry, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Jordana 19 Street, 41-808 Zabrze, Poland
| | - Anna Ciszek-Chwalba
- Student Research Team at the Second Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, M. C. Skłodowskiej 10 Street, 41-800 Zabrze, Poland; (P.B.); (T.C.); (A.C.-C.)
| | - Wojciech Jacheć
- Second Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, M. C. Skłodowskiej 10 Street, 41-800 Zabrze, Poland; (W.J.); (C.W.)
| | - Celina Wojciechowska
- Second Department of Cardiology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, M. C. Skłodowskiej 10 Street, 41-800 Zabrze, Poland; (W.J.); (C.W.)
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Dubé M, Chazara O, Lemaçon A, Asselin G, Provost S, Barhdadi A, Lemieux Perreault L, Mongrain I, Wang Q, Carss K, Paul DS, Cunningham JW, Rouleau J, Solomon SD, McMurray JJ, Yusuf S, Granger CB, Haefliger C, de Denus S, Tardif J. Pharmacogenomic study of heart failure and candesartan response from the CHARM programme. ESC Heart Fail 2022; 9:2997-3008. [PMID: 35736394 PMCID: PMC9715825 DOI: 10.1002/ehf2.14026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 03/21/2022] [Accepted: 06/03/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS The Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) programme consisted of three parallel, randomized, double-blind clinical trials comparing candesartan with placebo in patients with heart failure (HF) categorized according to left ventricular ejection fraction and tolerability to an angiotensin-converting enzyme inhibitor. We conducted a pharmacogenomic study of the CHARM trials with the objective of identifying genetic predictors of HF progression and of the efficacy and safety of treatment with candesartan. METHODS We performed genome-wide association studies in 2727 patients of European ancestry from CHARM-Overall and stratified by CHARM study according to preserved and reduced ejection fraction and according to assignment to the interventional treatment with candesartan. We tested genetic association with the composite endpoint of cardiovascular death or hospitalization for heart failure for drug efficacy in candesartan-treated patients and for HF progression using patients from both candesartan and placebo arms. The safety endpoints for response to candesartan were hyperkalaemia, renal dysfunction, hypotension, and change in systolic blood pressure between baseline and 6 weeks of treatment. To support our observations, we conducted a genome-wide gene-level collapsing analysis from whole-exome sequencing data with the composite cardiovascular endpoint. RESULTS We found that the A allele (14% allele frequency) of the genetic variant rs66886237 at 8p21.3 near the gene GFRA2 was associated with the composite cardiovascular endpoint in 1029 HF patients with preserved ejection fraction from the CHARM-Preserved study (hazard ratio: 1.91, 95% confidence interval: 1.55-2.35; P = 1.7 × 10-9 ). The association was independent of candesartan treatment, and the genetic variant was not associated with the cardiovascular endpoint in patients with reduced ejection fraction. None of the genome-wide association studies for candesartan safety or efficacy conducted in patients treated with candesartan passed the significance threshold. We found no significant association from the gene-level collapsing analysis. CONCLUSIONS We have identified a candidate genetic variant potentially predictive of the progression of heart failure in patients with preserved ejection fraction. The findings require further replication, and we cannot exclude the possibility that the results may be chance findings.
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Affiliation(s)
- Marie‐Pierre Dubé
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
- Université de Montréal, Faculty of Medicine, Department of medicineUniversité de MontréalMontrealCanada
| | - Olympe Chazara
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | - Audrey Lemaçon
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
- Université de Montréal, Faculty of Medicine, Department of medicineUniversité de MontréalMontrealCanada
| | - Géraldine Asselin
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
| | - Sylvie Provost
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
| | - Amina Barhdadi
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
| | | | - Ian Mongrain
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
| | - Quanli Wang
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | - Keren Carss
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | - Dirk S. Paul
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | | | - Jean Rouleau
- Montreal Heart InstituteMontrealCanada
- Université de Montréal, Faculty of Medicine, Department of medicineUniversité de MontréalMontrealCanada
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
| | | | - Salim Yusuf
- The Population Health Research Institute, Hamilton Health Sciences and the School of Rehabilitation ScienceMcMaster UniversityHamiltonONCanada
| | - Chris B. Granger
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNCUSA
| | - Carolina Haefliger
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | - Simon de Denus
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
- Faculty of PharmacyUniversité de MontréalMontrealCanada
| | - Jean‐Claude Tardif
- Montreal Heart InstituteMontrealCanada
- Université de Montréal, Faculty of Medicine, Department of medicineUniversité de MontréalMontrealCanada
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Stolfo D, Fabris E, Lund LH, Savarese G, Sinagra G. From mid-range to mildly reduced ejection fraction heart failure: A call to treat. Eur J Intern Med 2022; 103:29-35. [PMID: 35710614 DOI: 10.1016/j.ejim.2022.05.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 05/27/2022] [Indexed: 11/22/2022]
Abstract
The historical classification of heart failure (HF) has considered two distinct subgroups, HF with reduced ejection fraction (HFrEF), generally classified as EF below 40%, and HF with preserved ejection fraction (HFpEF) variably classified as EF above 40%, 45% or 50%. One of the principal reasons behind this distinction was related to presence of effective therapy in HFrEF, but not in HFpEF. Recently the expanding knowledge in the specific subgroup of patient with a LVEF between 41% and 49% and the potential benefit of new therapies and of those used in patients with LVEF below 40%, has led to rename this group as HF with mildly reduced EF (HFmrEF). In this review we discuss the reasons behind this modification, we summarize the main characteristics of HFmrEF the similarities and differences with the two other EF categories, and finally we provide a comprehensive overview of the current available evidence supporting the treatment of patients with HFmrEF.
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Affiliation(s)
- Davide Stolfo
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and Univeristy Hospital of Trieste, Trieste, Italy; Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Enrico Fabris
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and Univeristy Hospital of Trieste, Trieste, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and Univeristy Hospital of Trieste, Trieste, Italy.
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In-Hospital Mortality Rate and Predictors of 30-Day Readmission in Patients With Heart Failure Exacerbation and Atrial Fibrillation: A Cross-Sectional Study. INTERNATIONAL JOURNAL OF HEART FAILURE 2022; 4:145-153. [PMID: 36262793 PMCID: PMC9383350 DOI: 10.36628/ijhf.2022.0002] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Revised: 05/22/2022] [Accepted: 07/08/2022] [Indexed: 01/05/2023]
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Mooney L, Hawkins NM, Jhund PS, Redfield MM, Vaduganathan M, Desai AS, Rouleau JL, Minamisawa M, Shah AM, Lefkowitz MP, Zile MR, Van Veldhuisen DJ, Pfeffer MA, Anand IS, Maggioni AP, Senni M, Claggett BL, Solomon SD, McMurray JJV. Impact of Chronic Obstructive Pulmonary Disease in Patients With Heart Failure With Preserved Ejection Fraction: Insights From PARAGON-HF. J Am Heart Assoc 2021; 10:e021494. [PMID: 34796742 PMCID: PMC9075384 DOI: 10.1161/jaha.121.021494] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022]
Abstract
Background Little is known about the impact of chronic obstructive pulmonary disease (COPD) in patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results We examined outcomes in patients with heart failure with preserved ejection fraction, according to COPD status, in the PARAGON-HF (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in Heart Failure With Preserved Ejection Fraction) trial. The primary outcome was a composite of first and recurrent hospitalizations for heart failure and cardiovascular death. Of 4791 patients, 670 (14%) had COPD. Patients with COPD were more likely to be men (58% versus 47%; P<0.001) and had worse New York Heart Association functional class (class III/IV 24% versus 19%), worse Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores (69 versus 76; P<0.001) and more frequent history of heart failure hospitalization (54% versus 47%; P<0.001). The decrement in Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores with COPD was greater than for other common comorbidities. Patients with COPD had echocardiographic right ventricular enlargement, higher serum creatinine (100 μmol/L versus 96 μmol/L) and neutrophil-to-lymphocyte ratio (2.7 versus 2.5), than those without COPD. After multivariable adjustment, COPD was associated with worse outcomes: adjusted rate ratio for the primary outcome 1.51 (95% CI, 1.25-1.83), total heart failure hospitalization 1.54 (95% CI, 1.24-1.90), cardiovascular death (adjusted hazard ratio [HR], 1.42; 95% CI, 1.10-1.82), and all-cause death (adjusted HR, 1.52; 95% CI, 1.25-1.84). COPD was associated with worse outcomes than other comorbidities and Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores declined more in patients with COPD than in those without. Conclusions Approximately 1 in 7 patients with heart failure with preserved ejection fraction had concomitant COPD, which was associated with greater functional limitation and a higher risk of heart failure hospitalization and death. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.
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Affiliation(s)
- Leanne Mooney
- BHF Glasgow Cardiovascular Research CentreUniversity of GlasgowUnited Kingdom
| | | | - Pardeep S. Jhund
- BHF Glasgow Cardiovascular Research CentreUniversity of GlasgowUnited Kingdom
| | | | | | - Akshay S. Desai
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | | | | | - Amil M. Shah
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | | | - Michael R. Zile
- Department of MedicineMedical University of South CarolinaCharlestonSC
| | | | - Marc A. Pfeffer
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | | | | | - Michele Senni
- Cardiovascular Department & Cardiology UnitPapa Giovanni XXIII HospitalBergamoItaly
| | - Brian L. Claggett
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | - Scott D. Solomon
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | - John J. V. McMurray
- BHF Glasgow Cardiovascular Research CentreUniversity of GlasgowUnited Kingdom
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Leache L, Gutiérrez-Valencia M, Finizola RM, Infante E, Finizola B, Pardo Pardo J, Flores Y, Granero R, Arai KJ. Pharmacotherapy for hypertension-induced left ventricular hypertrophy. Cochrane Database Syst Rev 2021; 10:CD012039. [PMID: 34628642 PMCID: PMC8502530 DOI: 10.1002/14651858.cd012039.pub3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hypertension is the leading preventable risk factor for cardiovascular disease and premature death worldwide. One of the clinical effects of hypertension is left ventricular hypertrophy (LVH), a process of cardiac remodelling. It is estimated that over 30% of people with hypertension also suffer from LVH, although the prevalence rates vary according to the LVH diagnostic criteria. Severity of LVH is associated with a higher prevalence of cardiovascular disease and an increased risk of death. The role of antihypertensives in the regression of left ventricular mass has been extensively studied. However, uncertainty exists regarding the role of antihypertensive therapy compared to placebo in the morbidity and mortality of individuals with hypertension-induced LVH. OBJECTIVES To assess the effect of antihypertensive pharmacotherapy compared to placebo or no treatment on morbidity and mortality of adults with hypertension-induced LVH. SEARCH METHODS Cochrane Hypertension's Information Specialist searched the following databases for studies: Cochrane Hypertension Specialised Register (to 26 September 2020), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library; 2020, Issue 9), Ovid MEDLINE (1946 to 22 September 2020), and Ovid Embase (1974 to 22 September 2020). We searched the World Health Organization International Clinical Trials Registry Platform and the ClinicalTrials.gov for ongoing trials. We also searched Epistemonikos (to 19 February 2021), LILACS BIREME (to 19 February 2021), and Clarivate Web of Science (to 26 February 2021), and contacted authors and funders of the identified trials to obtain additional information and individual participant data. There were no language restrictions. SELECTION CRITERIA Randomised controlled trials (RCTs) with at least 12 months' follow-up comparing antihypertensive pharmacological therapy (monotherapy or in combination) with placebo or no treatment in adults (18 years of age or older) with hypertension-induced LVH were eligible for inclusion. The trials must have analysed at least one primary outcome (all-cause mortality, cardiovascular events, or total serious adverse events) to be considered for inclusion. DATA COLLECTION AND ANALYSIS Two review authors screened the search results, with any disagreements resolved by consensus amongst all review authors. Two review authors carried out the data extraction and analyses. We assessed risk of bias of the included studies following Cochrane methodology. We used the GRADE approach to assess the certainty of the body of evidence. MAIN RESULTS We included three multicentre RCTs. We selected 930 participants from the included studies for the analyses, with a mean follow-up of 3.8 years (range 3.5 to 4.3 years). All of the included trials performed an intention-to-treat analysis. We obtained evidence for the review by identifying the population of interest from the trials' total samples. None of the trials provided information on the cause of LVH. The intervention varied amongst the included trials: hydrochlorothiazide plus triamterene with the possibility of adding alpha methyldopa, spironolactone, or olmesartan. Placebo was administered to participants in the control arm in two trials, whereas participants in the control arm of the remaining trial did not receive any add-on treatment. The evidence is very uncertain regarding the effect of additional antihypertensive pharmacological therapy compared to placebo or no treatment on mortality (14.3% intervention versus 13.6% control; risk ratio (RR) 1.02, 95% confidence interval (CI) 0.74 to 1.40; 3 studies; 930 participants; very low-certainty evidence); cardiovascular events (12.6% intervention versus 11.5% control; RR 1.09, 95% CI 0.77 to 1.55; 3 studies; 930 participants; very low-certainty evidence); and hospitalisation for heart failure (10.7% intervention versus 12.5% control; RR 0.82, 95% CI 0.57 to 1.17; 2 studies; 915 participants; very low-certainty evidence). Although both arms yielded similar results for total serious adverse events (48.9% intervention versus 48.1% control; RR 1.02, 95% CI 0.89 to 1.16; 3 studies; 930 participants; very low-certainty evidence) and total adverse events (68.3% intervention versus 67.2% control; RR 1.07, 95% CI 0.86 to 1.34; 2 studies; 915 participants), the incidence of withdrawal due to adverse events may be significantly higher with antihypertensive drug therapy (15.2% intervention versus 4.9% control; RR 3.09, 95% CI 1.69 to 5.66; 1 study; 522 participants; very low-certainty evidence). Sensitivity analyses limited to blinded trials, trials with low risk of bias in core domains, and trials with no funding from the pharmaceutical industry did not change the results of the main analyses. Limited evidence on the change in left ventricular mass index prevented us from drawing any firm conclusions. AUTHORS' CONCLUSIONS We are uncertain about the effects of adding additional antihypertensive drug therapy on the morbidity and mortality of participants with LVH and hypertension compared to placebo. Although the incidence of serious adverse events was similar between study arms, additional antihypertensive therapy may be associated with more withdrawals due to adverse events. Limited and low-certainty evidence requires that caution be used when interpreting the findings. High-quality clinical trials addressing the effect of antihypertensives on clinically relevant variables and carried out specifically in individuals with hypertension-induced LVH are warranted.
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Affiliation(s)
- Leire Leache
- Unit of Innovation and Organization, Navarre Health Service, Pamplona, Spain
| | | | - Rosa M Finizola
- Unit of Special Projects, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Elizabeth Infante
- Unit of Systems, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Bartolome Finizola
- General Coordination, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | - Jordi Pardo Pardo
- Centre for Practice-Changing Research, Ottawa Hospital Research Institute, The Ottawa Hospital - General Campus, Ottawa, Canada
| | - Yris Flores
- Echocardiography Department and Cardiac Tomography Department, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
| | | | - Kaduo J Arai
- Coronary Care Unit, Cardiovascular Association Centroccidental, Barquisimeto, Venezuela
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Martin N, Manoharan K, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2021; 5:CD012721. [PMID: 34022072 PMCID: PMC8140651 DOI: 10.1002/14651858.cd012721.pub3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin-aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction (LVEF); a review of the evidence is required to determine whether these treatments are beneficial for people with heart failure with preserved ejection fraction (HFpEF). OBJECTIVES To assess the effects of beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with HFpEF. SEARCH METHODS We updated searches of CENTRAL, MEDLINE, Embase, and one clinical trial register on 14 May 2020 to identify eligible studies, with no language or date restrictions. We checked references from trial reports and review articles for additional studies. SELECTION CRITERIA: We included randomised controlled trials with a parallel group design, enrolling adults with HFpEF, defined by LVEF greater than 40%. DATA COLLECTION AND ANALYSIS We used standard methodological procedures expected by Cochrane. MAIN RESULTS We included 41 randomised controlled trials (231 reports), totalling 23,492 participants across all comparisons. The risk of bias was frequently unclear and only five studies had a low risk of bias in all domains. Beta-blockers (BBs) We included 10 studies (3087 participants) investigating BBs. Five studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 30 years to 81 years. A possible reduction in cardiovascular mortality was observed (risk ratio (RR) 0.78, 95% confidence interval (CI) 0.62 to 0.99; number needed to treat for an additional benefit (NNTB) 25; 1046 participants; three studies), however, the certainty of evidence was low. There may be little to no effect on all-cause mortality (RR 0.82, 95% CI 0.67 to 1.00; 1105 participants; four studies; low-certainty evidence). The effects on heart failure hospitalisation, hyperkalaemia, and quality of life remain uncertain. Mineralocorticoid receptor antagonists (MRAs) We included 13 studies (4459 participants) investigating MRA. Eight studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 54.5 to 80 years. Pooled analysis indicated that MRA treatment probably reduces heart failure hospitalisation (RR 0.82, 95% CI 0.69 to 0.98; NNTB = 41; 3714 participants; three studies; moderate-certainty evidence). However, MRA treatment probably has little or no effect on all-cause mortality (RR 0.91, 95% CI 0.78 to 1.06; 4207 participants; five studies; moderate-certainty evidence) and cardiovascular mortality (RR 0.90, 95% CI 0.74 to 1.11; 4070 participants; three studies; moderate-certainty evidence). MRA treatment may have little or no effect on quality of life measures (mean difference (MD) 0.84, 95% CI -2.30 to 3.98; 511 participants; three studies; low-certainty evidence). MRA treatment was associated with a higher risk of hyperkalaemia (RR 2.11, 95% CI 1.77 to 2.51; number needed to treat for an additional harmful outcome (NNTH) = 11; 4291 participants; six studies; high-certainty evidence). Angiotensin-converting enzyme inhibitors (ACEIs) We included eight studies (2061 participants) investigating ACEIs. Three studies used a placebo comparator and in five the comparator was usual care. The mean age of participants ranged from 70 to 82 years. Pooled analyses with moderate-certainty evidence suggest that ACEI treatment likely has little or no effect on cardiovascular mortality (RR 0.93, 95% CI 0.61 to 1.42; 945 participants; two studies), all-cause mortality (RR 1.04, 95% CI 0.75 to 1.45; 1187 participants; five studies) and heart failure hospitalisation (RR 0.86, 95% CI 0.64 to 1.15; 1019 participants; three studies), and may result in little or no effect on the quality of life (MD -0.09, 95% CI -3.66 to 3.48; 154 participants; two studies; low-certainty evidence). The effects on hyperkalaemia remain uncertain. Angiotensin receptor blockers (ARBs) Eight studies (8755 participants) investigating ARBs were included. Five studies used a placebo comparator and in three the comparator was usual care. The mean age of participants ranged from 61 to 75 years. Pooled analyses with high certainty of evidence suggest that ARB treatment has little or no effect on cardiovascular mortality (RR 1.02, 95% 0.90 to 1.14; 7254 participants; three studies), all-cause mortality (RR 1.01, 95% CI 0.92 to 1.11; 7964 participants; four studies), heart failure hospitalisation (RR 0.92, 95% CI 0.83 to 1.02; 7254 participants; three studies), and quality of life (MD 0.41, 95% CI -0.86 to 1.67; 3117 participants; three studies). ARB was associated with a higher risk of hyperkalaemia (RR 1.88, 95% CI 1.07 to 3.33; 7148 participants; two studies; high-certainty evidence). Angiotensin receptor neprilysin inhibitors (ARNIs) Three studies (7702 participants) investigating ARNIs were included. Two studies used ARBs as the comparator and one used standardised medical therapy, based on participants' established treatments at enrolment. The mean age of participants ranged from 71 to 73 years. Results suggest that ARNIs may have little or no effect on cardiovascular mortality (RR 0.96, 95% CI 0.79 to 1.15; 4796 participants; one study; moderate-certainty evidence), all-cause mortality (RR 0.97, 95% CI 0.84 to 1.11; 7663 participants; three studies; high-certainty evidence), or quality of life (high-certainty evidence). However, ARNI treatment may result in a slight reduction in heart failure hospitalisation, compared to usual care (RR 0.89, 95% CI 0.80 to 1.00; 7362 participants; two studies; moderate-certainty evidence). ARNI treatment was associated with a reduced risk of hyperkalaemia compared with valsartan (RR 0.88, 95% CI 0.77 to 1.01; 5054 participants; two studies; moderate-certainty evidence). AUTHORS' CONCLUSIONS There is evidence that MRA and ARNI treatment in HFpEF probably reduces heart failure hospitalisation but probably has little or no effect on cardiovascular mortality and quality of life. BB treatment may reduce the risk of cardiovascular mortality, however, further trials are needed. The current evidence for BBs, ACEIs, and ARBs is limited and does not support their use in HFpEF in the absence of an alternative indication. Although MRAs and ARNIs are probably effective at reducing the risk of heart failure hospitalisation, the treatment effect sizes are modest. There is a need for improved approaches to patient stratification to identify the subgroup of patients who are most likely to benefit from MRAs and ARNIs, as well as for an improved understanding of disease biology, and for new therapeutic approaches.
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Affiliation(s)
- Nicole Martin
- Institute of Health Informatics Research, University College London, London, UK
| | | | - Ceri Davies
- Department of Cardiology, Barts Heart Centre, St Bartholomew's Hospital, London, UK
| | - R Thomas Lumbers
- Institute of Health Informatics, University College London, London, UK
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Xu HX, Zhu YM, Hua Y, Huang YH, Lu Q. Association between atrial fibrillation and heart failure with different ejection fraction categories and its influence on outcomes. Acta Cardiol 2020; 75:423-432. [PMID: 31141463 DOI: 10.1080/00015385.2019.1610834] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Background: The important role of atrial fibrillation (AF) in different types of heart failure (HF) according to ejection fraction (EF) is much less explored. In this study, we compared AF in HF with preserved (HFpEF), mid-range (HFmrEF) and reduced (HFrEF) EF with regard to prevalence, association, and prognostic role.Methods and results: A total of 405 inpatients with HF between February 2014 and June 2016 were prospectively analysed in this study. Patients were divided into three groups: HFrEF group (n = 109, 26.9%), HFmrEF group (n = 94, 23.2%), and HFpEF group (n = 202, 49.8%). There was a higher prevalence of AF in patients in the HFpEF and HFmrEF groups than in patients in the HFrEF. Several baseline variables were found to be independently associated with AF, including age, coronary heart disease, heart rate, left atrial diameter, and left ventricular (LV) end-diastolic diameter, regardless of EF category after multivariable adjustment. In addition, AF was found to be a more powerful predictor of all-cause mortality, HF rehospitalisation, and the composite event of all-cause mortality or rehospitalisation in HFpEF and HFmrEF patients, but not in HFrEF patients.Conclusions: HFmrEF resembled HFpEF rather than HFrEF with regard to both a higher prevalence of AF and a greater risk of all-cause mortality, HF rehospitalisation, and the composite event of all-cause mortality or rehospitalisation.
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Affiliation(s)
- Hai-Xia Xu
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, PR China
| | - Yan-Min- Zhu
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, PR China
| | - Ying Hua
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, PR China
| | - Yin-Hao Huang
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, PR China
| | - Qi Lu
- Department of Cardiology, Affiliated Hospital of Nantong University, Nantong, PR China
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11
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Tratamiento de la insuficiencia cardiaca en el paciente diabético: ¿Cuáles son las diferencias? REVISTA COLOMBIANA DE CARDIOLOGÍA 2020. [DOI: 10.1016/j.rccar.2019.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
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12
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Affiliation(s)
- Julie K Freed
- From the Department of Anesthesiology, Cardiovascular Center, Medical College of Wisconsin, Milwaukee
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13
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Abstract
Approximately half of the patients with signs and symptoms of heart failure have a left ventricular ejection fraction that is not markedly abnormal. Despite the historically initial surprise, heightened risks for heart failure specific major adverse events occur across the broad range of ejection fraction, including normal. The recognition of the magnitude of the problem of heart failure with preserved ejection fraction in the past 20 years has spurred an explosion of clinical investigation and growing intensity of informative outcome trials. This article addresses the historic development of this component of the heart failure syndrome, including the epidemiology, pathophysiology, and existing and planned therapeutic studies. Looking forward, more specific phenotyping and even genotyping of subpopulations should lead to improvements in outcomes from future trials.
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Affiliation(s)
- Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Amil M. Shah
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts
| | - Barry A. Borlaug
- Cardiovascular Medicine Division, Mayo Clinic, Rochester, Minnesota
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14
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Demographics of patients with heart failure who were over 80 years old and were admitted to the cardiology clinics in Turkey. Anatol J Cardiol 2019; 21:196-205. [PMID: 30930455 PMCID: PMC6528498 DOI: 10.14744/anatoljcardiol.2018.94556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
Objective: Heart failure (HF) has a high prevalence and mortality rate in elderly patients; however, there are few studies that have focused on patients older than 80 years. The aim of this study is to describe and compare the age-specific demographics and clinical features of Turkish elderly patients with HF who were admitted to cardiology clinics. Methods: The Epidemiology of Cardiovascular Disease in Elderly Turkish population (ELDER-TURK) study was conducted in 73 centers in Turkey, and it recruited a total of 5694 patients aged 65 years or older. In this study, the clinical profile of the patients who were aged 80 years or older and those between 65 and 79 years with HF were described and compared based on the ejection fraction (EF)-related classification: HFrEF and HFpEF (is considered as EF: ≥50%). Results: A total of 1098 patients (male, 47.5%; mean age, 83.5±3.1 years) aged ≥80 years and 4596 patients (male, 50.2 %; mean age, 71.1±4.31 years) aged 65-79 years were enrolled in this study. The prevalence of HF was 39.8% for patients who were ≥80 years and 27.1% for patients 65–79 years old. For patients aged ≥80 years with HF, the prevalence rate was 67% for hypertension (HT), 25.6% for diabetes mellitus (DM), 54.3% for coronary artery disease (CAD), and 42.3% for atrial fibrilation. Female proportion was lower in the HFrEF group (p=0.019). The prevalence of HT and DM was higher in the HFpEF group (p<0.01), whereas CAD had a higher prevalence in the HFrEF group (p=0.02). Among patients aged 65–79 years, 43.9% (548) had HFpEF, and 56.1% (700) had HFrEF. In this group of patients aged 65-79 years with HFrEF, the prevalence of DM was significantly higher than in patients aged ≥80 years with HFrEF (p<0.01). Conclusion: HF is common in elderly Turkish population, and its frequency increases significantly with age. Females, diabetics, and hypertensives are more likely to have HFpEF, whereas CAD patients are more likely to have HFrEF.
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Martin N, Manoharan K, Thomas J, Davies C, Lumbers RT. Beta-blockers and inhibitors of the renin-angiotensin aldosterone system for chronic heart failure with preserved ejection fraction. Cochrane Database Syst Rev 2018; 6:CD012721. [PMID: 29952095 PMCID: PMC6513293 DOI: 10.1002/14651858.cd012721.pub2] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Beta-blockers and inhibitors of the renin-angiotensin aldosterone system improve survival and reduce morbidity in people with heart failure with reduced left ventricular ejection fraction. There is uncertainty whether these treatments are beneficial for people with heart failure with preserved ejection fraction and a comprehensive review of the evidence is required. OBJECTIVES To assess the effects of beta-blockers, angiotensin converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors, and mineralocorticoid receptor antagonists in people with heart failure with preserved ejection fraction. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase and two clinical trial registries on 25 July 2017 to identify eligible studies. Reference lists from primary studies and review articles were checked for additional studies. There were no language or date restrictions. SELECTION CRITERIA We included randomised controlled trials with a parallel group design enrolling adult participants with heart failure with preserved ejection fraction, defined by a left ventricular ejection fraction of greater than 40 percent. DATA COLLECTION AND ANALYSIS Two review authors independently selected studies for inclusion and extracted data. The outcomes assessed included cardiovascular mortality, heart failure hospitalisation, hyperkalaemia, all-cause mortality and quality of life. Risk ratios (RR) and, where possible, hazard ratios (HR) were calculated for dichotomous outcomes. For continuous data, mean difference (MD) or standardised mean difference (SMD) were calculated. We contacted trialists where neccessary to obtain missing data. MAIN RESULTS 37 randomised controlled trials (207 reports) were included across all comparisons with a total of 18,311 participants.Ten studies (3087 participants) investigating beta-blockers (BB) were included. A pooled analysis indicated a reduction in cardiovascular mortality (15% of participants in the intervention arm versus 19% in the control arm; RR 0.78; 95% confidence interval (CI) 0.62 to 0.99; number needed to treat to benefit (NNTB) 25; 1046 participants; 3 studies). However, the quality of evidence was low and no effect on cardiovascular mortality was observed when the analysis was limited to studies with a low risk of bias (RR 0.81; 95% CI 0.50 to 1.29; 643 participants; 1 study). There was no effect on all-cause mortality, heart failure hospitalisation or quality of life measures, however there is uncertainty about these effects given the limited evidence available.12 studies (4408 participants) investigating mineralocorticoid receptor antagonists (MRA) were included with the quality of evidence assessed as moderate. MRA treatment reduced heart failure hospitalisation (11% of participants in the intervention arm versus 14% in the control arm; RR 0.82; 95% CI 0.69 to 0.98; NNTB 41; 3714 participants; 3 studies; moderate-quality evidence) however, little or no effect on all-cause and cardiovascular mortality and quality of life measures was observed. MRA treatment was associated with a greater risk of hyperkalaemia (16% of participants in the intervention group versus 8% in the control group; RR 2.11; 95% CI 1.77 to 2.51; 4291 participants; 6 studies; high-quality evidence).Eight studies (2061 participants) investigating angiotensin converting enzyme inhibitors (ACEI) were included with the overall quality of evidence assessed as moderate. The evidence suggested that ACEI treatment likely has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. Data for the effect of ACEI on hyperkalaemia were only available from one of the included studies.Eight studies (8755 participants) investigating angiotensin receptor blockers (ARB) were included with the overall quality of evidence assessed as high. The evidence suggested that treatment with ARB has little or no effect on cardiovascular mortality, all-cause mortality, heart failure hospitalisation, or quality of life. ARB was associated with an increased risk of hyperkalaemia (0.9% of participants in the intervention group versus 0.5% in the control group; RR 1.88; 95% CI 1.07 to 3.33; 7148 participants; 2 studies; high-quality evidence).We identified a single ongoing placebo-controlled study investigating the effect of angiotensin receptor neprilysin inhibitors (ARNI) in people with heart failure with preserved ejection fraction. AUTHORS' CONCLUSIONS There is evidence that MRA treatment reduces heart failure hospitalisation in heart failure with preserverd ejection fraction, however the effects on mortality related outcomes and quality of life remain unclear. The available evidence for beta-blockers, ACEI, ARB and ARNI is limited and it remains uncertain whether these treatments have a role in the treatment of HFpEF in the absence of an alternative indication for their use. This comprehensive review highlights a persistent gap in the evidence that is currently being addressed through several large ongoing clinical trials.
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Affiliation(s)
- Nicole Martin
- University College LondonFarr Institute of Health Informatics Research222 Euston RoadLondonUKNW1 2DA
| | - Karthick Manoharan
- John Radcliffe HospitalEmergency Department3 Sherwood AvenueLondonMiddlesexUKUb6 0pg
| | - James Thomas
- University College LondonEPPI‐Centre, Social Science Research Unit, UCL Institute of EducationLondonUK
| | - Ceri Davies
- Barts Heart Centre, St Bartholomew's HospitalDepartment of CardiologyWest SmithfieldLondonUKEC1A 7BE
| | - R Thomas Lumbers
- University College LondonInstitute of Health InformaticsLondonUK
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16
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Abdul-Rahim AH, Perez AC, MacIsaac RL, Jhund PS, Claggett BL, Carson PE, Komajda M, McKelvie RS, Zile MR, Swedberg K, Yusuf S, Pfeffer MA, Solomon SD, Lip GYH, Lees KR, McMurray JJV. Risk of stroke in chronic heart failure patients with preserved ejection fraction, but without atrial fibrillation: analysis of the CHARM-Preserved and I-Preserve trials. Eur Heart J 2018; 38:742-750. [PMID: 28426886 PMCID: PMC5460584 DOI: 10.1093/eurheartj/ehw509] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2016] [Accepted: 10/04/2016] [Indexed: 01/07/2023] Open
Abstract
Aims The incidence and predictors of stroke in patients with heart failure and preserved ejection fraction (HF-PEF), but without atrial fibrillation (AF), are unknown. We described the incidence of stroke in HF-PEF patients with and without AF and predictors of stroke in those without AF. Methods and results We pooled data from the CHARM-Preserved and I-Preserve trials. Using Cox regression, we derived a model for stroke in patients without AF in this cohort and compared its performance with a published model in heart failure patients with reduced ejection fraction (HF-REF)—predictive variables: age, body mass index, New York Heart Association class, history of stroke, and insulin-treated diabetes. The two stroke models were compared and Kaplan–Meier curves for stroke estimated. The risk model was validated in a third HF-PEF trial. Of the 6701 patients, 4676 did not have AF. Stroke occurred in 124 (6.1%) with AF and in 171 (3.7%) without AF (rates 1.80 and 1.00 per 100 patient-years, respectively). There was no difference in performance of the stroke model derived in the HF-PEF cohort and the published HF-REF model (c-index 0.71, 95% confidence interval 0.57–0.84 vs. 0.73, 0.59–0.85, respectively) as the predictive variables overlapped. The model performed well in the validation cohort (0.86, 0.62–0.99). The rate of stroke in patients in the upper third of risk approximated to that in patients with AF (1.60 and 1.80 per 100 patient-years, respectively). Conclusions A small number of clinical variables identify a subset of patients with HF-PEF, but without AF, at elevated risk of stroke.
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Affiliation(s)
- Azmil H Abdul-Rahim
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - Ana-Cristina Perez
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - Rachael L MacIsaac
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Peter E Carson
- Division of Cardiology, The VeteransAffairs Medical Center, Washington, DC, USA
| | - Michel Komajda
- Department of Cardiology, University Pierre and Marie Curie, Paris, France
| | - Robert S McKelvie
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada
| | - Michael R Zile
- Division of Cardiology, Medical University of South Carolina, Charleston, SC, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Göteborg, Sweden.,National Heart and Lung Institute, Imperial College, London, UK
| | - Salim Yusuf
- Population Health Research Institute, McMaster University, Hamilton, ON, Canada.,Hamilton Health Sciences, Hamilton, ON, Canada
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Gregory Y H Lip
- University of Birmingham Institute of Cardiovascular Sciences, City Hospital, Birmingham, UK
| | - Kennedy R Lees
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow G12 8TA, UK
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Lund LH, Claggett B, Liu J, Lam CS, Jhund PS, Rosano GM, Swedberg K, Yusuf S, Granger CB, Pfeffer MA, McMurray JJ, Solomon SD. Heart failure with mid-range ejection fraction in CHARM: characteristics, outcomes and effect of candesartan across the entire ejection fraction spectrum. Eur J Heart Fail 2018; 20:1230-1239. [DOI: 10.1002/ejhf.1149] [Citation(s) in RCA: 209] [Impact Index Per Article: 34.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 01/02/2018] [Accepted: 01/08/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Lars H. Lund
- Unit of Cardiology, Department of Medicine; Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital; Stockholm Sweden
| | - Brian Claggett
- Division of Cardiovascular Medicine; Brigham and Women's Hospital; Boston MA USA
| | - Jiankang Liu
- Division of Cardiovascular Medicine; Brigham and Women's Hospital; Boston MA USA
| | - Carolyn S. Lam
- National Heart Centre Singapore; Duke-NUS Medical School, and Cardiovascular Research Institute, National University Health System; Singapore
| | - Pardeep S. Jhund
- BHF Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow UK
| | - Giuseppe M. Rosano
- Cardiovascular and Cell Sciences Research Institute, St George's University, London, UK; and IRCCS San Raffaele Pisana; Rome Italy
| | - Karl Swedberg
- Sahlgrenska Academy; University of Gothenburg; Gothenburg Sweden
| | - Salim Yusuf
- Department of Medicine and Population Health Research Institute; McMaster University and Hamilton Health Sciences; Ontario Canada
| | | | - Marc A. Pfeffer
- Division of Cardiovascular Medicine; Brigham and Women's Hospital; Boston MA USA
| | - John J.V. McMurray
- BHF Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow UK
| | - Scott D. Solomon
- Division of Cardiovascular Medicine; Brigham and Women's Hospital; Boston MA USA
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18
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Nochioka K, Sakata Y, Shimokawa H. Combination Therapy of Renin Angiotensin System Inhibitors and β-Blockers in Patients with Heart Failure. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2018. [DOI: 10.1007/5584_2018_179] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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19
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Wolsk E, Claggett B, Køber L, Pocock S, Yusuf S, Swedberg K, McMurray JJV, Granger CB, Pfeffer MA, Solomon SD. Contribution of cardiac and extra-cardiac disease burden to risk of cardiovascular outcomes varies by ejection fraction in heart failure. Eur J Heart Fail 2017; 20:504-510. [PMID: 29193462 DOI: 10.1002/ejhf.1073] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2017] [Revised: 09/10/2017] [Accepted: 10/05/2017] [Indexed: 12/28/2022] Open
Abstract
AIMS Patients with heart failure (HF) often have multiple co-morbidities that contribute to the risk of adverse cardiovascular (CV) and non-CV outcomes. We assessed the relative contribution of cardiac and extra-cardiac disease burden and demographic factors to CV outcomes in HF patients with reduced (HFrEF) or preserved (HFpEF) left ventricular ejection fraction (LVEF). METHODS AND RESULTS We utilized data from the CHARM trial, which enrolled HF patients across the ejection fraction spectrum. We decomposed the previously validated MAGGIC risk score into cardiac (LVEF, New York Heart Association class, systolic blood pressure, time since HF diagnosis, HF medication use), extra-cardiac (body mass index, creatinine, diabetes mellitus, chronic obstructive pulmonary disease, smoker), and demographic (age, gender) categories, and calculated subscores for each patient representing the burden of each component. Cox proportional hazards models were used to estimate the population attributable risk (PAR) associated with each component to the outcomes of death, CV death, HF, myocardial infarction, and stroke relative to patients with the lowest risk score. PARs for each component were depicted across the spectrum of LVEF. in 2675 chronic HF patients from North America [HFrEF (LVEF ≤40%): n = 1589, HFpEF (LVEF >40%): n = 1086] with data available for calculation of the MAGGIC score, the highest risk of death and CV death was attributed to cardiac burden. This was especially evident in HFrEF patients (PAR: 76% cardiac disease vs. 58% extra-cardiac disease, P < 0.05). Conversely, in HFpEF patients, extra-cardiac burden accounted for a greater proportion of risk for death than cardiac burden (PAR: 15% cardiac disease vs. 49% extra-cardiac disease, P < 0.05). For HF hospitalization, the contribution of both cardiac and extra-cardiac burden was comparable in HFpEF patients (PAR: 42% cardiac disease vs. 53% extra-cardiac disease, P = NS). In addition, demographic burden was especially high in HFpEF patients, with 62% of deaths attributable to demographic characteristics. CONCLUSION In North American HF patients enrolled in the CHARM trials, the relative contribution of cardiac and extra-cardiac disease burden to CV outcomes and death differed depending on LVEF. The high risk of events attributable to non-cardiac disease burden may help explain why cardiac disease-modifying medication proven to be efficacious in HFrEF patients has not proven beneficial in HFpEF.
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Affiliation(s)
- Emil Wolsk
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.,Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Stuart Pocock
- Department of Medical Statistics, London, School of Hygiene & Tropical Medicine, London, UK
| | - Salim Yusuf
- Department of Medicine, McMaster University, Ontario, Canada
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.,National Heart and Lung Institute, Imperial College London, London, UK
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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Elze MC, Gregson J, Baber U, Williamson E, Sartori S, Mehran R, Nichols M, Stone GW, Pocock SJ. Comparison of Propensity Score Methods and Covariate Adjustment: Evaluation in 4 Cardiovascular Studies. J Am Coll Cardiol 2017; 69:345-357. [PMID: 28104076 DOI: 10.1016/j.jacc.2016.10.060] [Citation(s) in RCA: 437] [Impact Index Per Article: 62.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2016] [Accepted: 10/19/2016] [Indexed: 12/21/2022]
Abstract
Propensity scores (PS) are an increasingly popular method to adjust for confounding in observational studies. Propensity score methods have theoretical advantages over conventional covariate adjustment, but their relative performance in real-word scenarios is poorly characterized. We used datasets from 4 large-scale cardiovascular observational studies (PROMETHEUS, ADAPT-DES [the Assessment of Dual AntiPlatelet Therapy with Drug-Eluting Stents], THIN [The Health Improvement Network], and CHARM [Candesartan in Heart Failure-Assessment of Reduction in Mortality and Morbidity]) to compare the performance of conventional covariate adjustment with 4 common PS methods: matching, stratification, inverse probability weighting, and use of PS as a covariate. We found that stratification performed poorly with few outcome events, and inverse probability weighting gave imprecise estimates of treatment effect and undue influence to a small number of observations when substantial confounding was present. Covariate adjustment and matching performed well in all of our examples, although matching tended to give less precise estimates in some cases. PS methods are not necessarily superior to conventional covariate adjustment, and care should be taken to select the most suitable method.
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Affiliation(s)
- Markus C Elze
- Department of Biostatistics, London School of Hygiene and Tropical Medicine, London, United Kingdom; Innovative Pediatric Oncology Drug Development, F. Hoffmann-La Roche AG, Basel, Switzerland
| | - John Gregson
- Department of Biostatistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Usman Baber
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Elizabeth Williamson
- Department of Biostatistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Samantha Sartori
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Roxana Mehran
- Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Melissa Nichols
- Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Gregg W Stone
- Division of Cardiology, Columbia University Medical Center, New York-Presbyterian Hospital, New York, New York; Cardiovascular Research Foundation, New York, New York
| | - Stuart J Pocock
- Department of Biostatistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.
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Matheson A. Marketing trials, marketing tricks - how to spot them and how to stop them. Trials 2017; 18:105. [PMID: 28270221 PMCID: PMC5341186 DOI: 10.1186/s13063-017-1827-5] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 02/08/2017] [Indexed: 01/10/2023] Open
Abstract
Background Last this year in this journal, Barbour and colleagues reported a study of “marketing trials” in leading medical journals (Trials 2016;17:31). In this commentary I discuss their research, describe new analyses of the study cohort and consider measures to address marketing within academic medical literature. Discussion Barbour et al. sought to identify a subgroup of “marketing trials” within leading medical journals, but in reality, nearly all industry-financed trials serve marketing functions, and many exhibit marketing-related features, including biases, in their framing, methodology or reporting. I conducted new analyses of the cohort of Barbour et al., showing that most trials funded exclusively by drug manufacturers had direct involvement of the manufacturer in design, analysis and reporting, and features supportive of product seeding. However, these commercial enterprises were without exception presented to journal readers as academic-led projects, using attributional spin, which should itself be considered an important form of marketing bias. Barbour et al. correctly conclude that commercial bias in industry clinical trials articles often requires expertise to recognize, and in many cases cannot be identified from the published journal report. Several potential remedies are discussed, including independent clinical research, data sharing, improved reporting guidance, improved tools for assessing research quality, reforms to article attribution, submission checklists and new editorial standards. Conclusion Medicine’s journals have a responsibility to uphold rigorous scientific and reporting standards, require ready trials data access and ensure the commercial dimensions of research are brought prominently to their readers’ attention. Failure to meet these responsibilities constitutes an enduring threat to the integrity of biomedical literature. Electronic supplementary material The online version of this article (doi:10.1186/s13063-017-1827-5) contains supplementary material, which is available to authorized users.
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Hawkins NM, Jhund PS, Pozzi A, O'Meara E, Solomon SD, Granger CB, Yusuf S, Pfeffer MA, Swedberg K, Petrie MC, Virani S, McMurray JJ. Severity of renal impairment in patients with heart failure and atrial fibrillation: implications for non-vitamin K antagonist oral anticoagulant dose adjustment. Eur J Heart Fail 2016; 18:1162-71. [DOI: 10.1002/ejhf.614] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2016] [Revised: 05/13/2016] [Accepted: 06/04/2016] [Indexed: 11/06/2022] Open
Affiliation(s)
| | - Pardeep S. Jhund
- BHF Glasgow Cardiovascular Research Centre; University of Glasgow; Glasgow UK
| | - Andrea Pozzi
- BHF Glasgow Cardiovascular Research Centre; University of Glasgow; Glasgow UK
| | | | - Scott D. Solomon
- Division of Cardiovascular Medicine; Brigham and Women's Hospital; Boston MA USA
| | | | - Salim Yusuf
- Population Health Research Institute; McMaster University; Hamilton Canada
| | - Marc A. Pfeffer
- Division of Cardiovascular Medicine; Brigham and Women's Hospital; Boston MA USA
| | | | - Mark C. Petrie
- Scottish National Advanced Heart Failure Service; Golden Jubilee National Hospital; Clydebank Glasgow UK
| | - Sean Virani
- Division of Cardiology; University of British Columbia; Vancouver Canada
| | - John J.V. McMurray
- BHF Glasgow Cardiovascular Research Centre; University of Glasgow; Glasgow UK
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23
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Stergren J, McMurray JJV. Angiotensin receptor blockers in heart failure. J Renin Angiotensin Aldosterone Syst 2016; 4:171-5. [PMID: 14608522 DOI: 10.3317/jraas.2003.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
Collectively, a series of large, prospective randomised outcome trials has now shown that angiotensin receptor blockers (ARBs) are of clinical value in a broad spectrum of patients with symptomatic heart failure, regardless of background therapy and ventricular function. There is a clear benefit of ARBs in patients unable to tolerate an angiotensin-converting enzyme (ACE) inhibitor and this benefit is of a similar magnitude to that obtained with an ACE inhibitor (ACE-I). Both Val-HeFT and, particularly, CHARM-Added, also show that symptoms, morbidity and mortality are further reduced if an ARB is added to an ACE-I. This benefit is not only statistically significant but clinically important. CHARM-Preserved showed that candesartan can reduce hospital admission for heart failure in patients with preserved systolic function though more definitive outcome data are needed in this group.
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Damman K, Solomon SD, Pfeffer MA, Swedberg K, Yusuf S, Young JB, Rouleau JL, Granger CB, McMurray JJ. Worsening renal function and outcome in heart failure patients with reduced and preserved ejection fraction and the impact of angiotensin receptor blocker treatment: data from the CHARM-study programme. Eur J Heart Fail 2016; 18:1508-1517. [DOI: 10.1002/ejhf.609] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2016] [Revised: 03/17/2016] [Accepted: 05/04/2016] [Indexed: 01/11/2023] Open
Affiliation(s)
- Kevin Damman
- British Heart Foundation Cardiovascular Research Centre; University of Glasgow; Glasgow UK
- University of Groningen, Department of Cardiology; University Medical Center Groningen; Groningen The Netherlands
| | | | | | | | - Salim Yusuf
- Population Health Research Institute; McMaster University; Hamilton Canada
| | | | - Jean L. Rouleau
- Faculty of Medicine; University of Montreal; Montreal Canada
| | | | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre; University of Glasgow; Glasgow UK
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Abstract
BACKGROUND In hypertension, changes in small arterial structure are characterized by an increased wall-to-lumen ratio (WLR). These adaptive processes are modulated by the rennin-angiotensin system. It is unclear whether direct renin inhibitors exert protective effects on small arteries in hypertensive patients. METHODS In this double-blind, randomized, placebo-controlled study (http://www.clinicaltrials.gov: NCT01318395), 114 patients with primary hypertension were randomized to additional therapy with either placebo or aliskiren 300 mg for 8 weeks after 4 weeks of standardized open-label treatment with valsartan 320 mg (run-in phase). Parameter of arteriolar remodelling was WLR of retinal arterioles (80 - 140 μm) assessed noninvasively and in vivo by scanning laser Doppler flowmetry (Heidelberg Engineering, Germany). In addition, pulse wave analysis (SphygmoCor, AtCor Medical, Australia) and pulse pressure (PP) amplification were determined. RESULTS In the whole study population, no clear effect of additional therapy with aliskiren on vascular parameters was documented. When analyses were restricted to patients with vascular remodelling, defined by a median of WLR more than 0.3326 (n = 57), WLR was reduced after 8 weeks by the treatment with aliskiren compared with placebo (-0.044 ± 0.07 versus 0.0043 ± 0.07, P = 0.015). Consistently, after 8 weeks of on-top treatment with aliskiren, there was an improvement of PP amplification compared with placebo (0.025 ± 0.07 versus -0.034 ± 0.08, P = 0.013), indicative of less stiff arteries in the peripheral circulation. CONCLUSION Thus, our data indicate that treatment with aliskiren, given on top of valsartan therapy, improves altered vascular remodelling in hypertensive patients.
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Girerd N, Zannad F, Rossignol P. Review of heart failure treatment in type 2 diabetes patients: It's at least as effective as in non-diabetic patients! DIABETES & METABOLISM 2015; 41:446-55. [DOI: 10.1016/j.diabet.2015.06.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/13/2015] [Revised: 06/25/2015] [Accepted: 06/28/2015] [Indexed: 01/26/2023]
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Badar AA, Perez-Moreno AC, Hawkins NM, Brunton AP, Jhund PS, Wong CM, Solomon SD, Granger CB, Yusuf S, Pfeffer MA, Swedberg K, Gardner RS, Petrie MC, McMurray JJ. Clinical characteristics and outcomes of patients with angina and heart failure in the CHARM (Candesartan in Heart Failure Assessment of Reduction in Mortality and Morbidity) Programme. Eur J Heart Fail 2015; 17:196-204. [DOI: 10.1002/ejhf.221] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Revised: 11/15/2014] [Accepted: 11/21/2014] [Indexed: 11/06/2022] Open
Affiliation(s)
- Athar A. Badar
- BHF Glasgow Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow G12 8TA UK
- Golden Jubilee National Hospital; Glasgow UK
| | - Ana C. Perez-Moreno
- BHF Glasgow Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow G12 8TA UK
| | | | - Alan P.T. Brunton
- BHF Glasgow Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow G12 8TA UK
| | - Pardeep S. Jhund
- BHF Glasgow Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow G12 8TA UK
| | - Chih M. Wong
- BHF Glasgow Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow G12 8TA UK
| | | | | | - Salim Yusuf
- Population Health Research Institute; McMaster University; Hamilton Ontario Canada
| | | | - Karl Swedberg
- Department of Molecular and Clinical Medicine; University of Gothenburg; Sweden
- National Heart and Lung Institute; Imperial College; London UK
| | - Roy S. Gardner
- BHF Glasgow Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow G12 8TA UK
- Golden Jubilee National Hospital; Glasgow UK
| | - Mark C. Petrie
- BHF Glasgow Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow G12 8TA UK
- Golden Jubilee National Hospital; Glasgow UK
| | - John J.V. McMurray
- BHF Glasgow Cardiovascular Research Centre; Institute of Cardiovascular and Medical Sciences, University of Glasgow; Glasgow G12 8TA UK
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28
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Abstract
Heart failure is defined as a clinical syndrome and is known to present with a number of different pathophysiological patterns. There is a remarkable degree of variation in measures of left ventricular systolic emptying and this has been used to categorise heart failure into two separate types: low ejection fraction (EF) heart failure or HF-REF and high EF heart failure or HF-PEF. Here we review the pathophysiology, epidemiology and management of HF-PEF and argue that sharp separation of heart failure into two forms is misguided and illogical, and the present scarcity of clinical trial evidence for effective treatment for HF-PEF is a problem of our own making; we should never have excluded patients from major trials on the basis of EF in the first place. Whilst as many heart failure patients have preserved EFs as reduced we have dramatically under-represented HF-PEF patients in trials. Only four trials have been performed in HF-PEF specifically, and another two trials that recruited both HF-PEF and HF-REF can be considered. When we consider the similarity in outcomes and neurohormonal activation between HF-REF and HF-REF, the vast corpus of trial data that we have to attest to the efficacy of various treatment (angiotensin-converting-enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], beta-blockers and aldosterone antagonists) in HF-REF, and the much more limited number of trials of similar agents showing near statistically significant benefits in HF-PEF the time has come rethink our management of HF-PEF, and in particular our selection of patients for trials.
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Affiliation(s)
- Andrew Js Coats
- Monash University, Melbourne, Australia.,University of Warwick, Coventry, UK
| | - Louise G Shewan
- Monash University, Melbourne, Australia.,University of Warwick, Coventry, UK.,Sydney Medical School, University of Sydney, Australia
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29
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Desai AS, Claggett B, Pfeffer MA, Bello N, Finn PV, Granger CB, McMurray JJV, Pocock S, Swedberg K, Yusuf S, Solomon SD. Influence of hospitalization for cardiovascular versus noncardiovascular reasons on subsequent mortality in patients with chronic heart failure across the spectrum of ejection fraction. Circ Heart Fail 2014; 7:895-902. [PMID: 25326006 DOI: 10.1161/circheartfailure.114.001567] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Noncardiovascular (non-CV) comorbidities may contribute to hospitalizations in patients with heart failure (HF). We examined the incidence of mortality following hospitalization for cardiovascular (CV) versus non-CV reasons in the Candesartan in Heart Failure: Assessment of Reduction in Mortality and Morbidity (CHARM) Program. METHODS AND RESULTS First hospitalizations for CV or non-CV reasons during the CHARM trial (N=7599) were related to subsequent risk of all-cause death using time-updated proportional hazards models. Over median 37.7 month follow-up, 2816 subjects (37.1%) were not hospitalized, 2893 (38.1%) were first hospitalized for CV reasons, and 1890 (24.9%) for non-CV reasons. The death rate (per 100 patient-years) among those not hospitalized was 2.8 compared with 17.8 after CV and 16.5 after non-CV hospitalization (both P<0.001 versus not hospitalized). Mortality at 30 days was higher after CV than non-CV hospitalization; however, among 30-day survivors of CV and non-CV hospitalization, rates of subsequent mortality were similar (14.5 versus 14.6 per 100 patient-years; P=0.62). Rates of CV hospitalization were higher for those with ejection fraction (EF) ≤40% than those with EF >40% (P<0.001), but rates of non-CV hospitalization did not vary by EF. Low EF patients had higher risk for mortality than preserved EF patients after any hospitalization, but within each EF subgroup, mortality in 30-day survivors of CV versus non-CV hospitalization was similar. CONCLUSIONS Non-CV hospitalization is frequent in patients with symptomatic heart failure and associated with risk of subsequent mortality similar to CV hospitalization across the spectrum of EF. These findings may have implications for developing strategies to prevent readmissions. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00634309 (CHARM-Added), NCT00634712 (CHARM-Preserved), NCT00634400 (CHARM-Alternative).
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Affiliation(s)
- Akshay S Desai
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.).
| | - Brian Claggett
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
| | - Marc A Pfeffer
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
| | - Natalie Bello
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
| | - Peter V Finn
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
| | - Christopher B Granger
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
| | - John J V McMurray
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
| | - Stuart Pocock
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
| | - Karl Swedberg
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
| | - Salim Yusuf
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
| | - Scott D Solomon
- From the Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., B.C., M.A.P., N.B., P.V.F., S.D.S.); Cardiology, Duke University, Durham, NC (C.B.G.); Cardiology, Western Infirmary, Glasgow, United Kingdom (J.J.V.M.); Medical Statistics Unit, London School of Hygiene and Tropical Medicine, London, United Kingdom (S.P.); Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital/Östra, Göteborg, Sweden (K.S.); and Population Health Research Institute, McMaster University, Hamilton, ON, Canada (S.Y.)
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30
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Pieske B, Butler J, Filippatos G, Lam C, Maggioni AP, Ponikowski P, Shah S, Solomon S, Kraigher-Krainer E, Samano ET, Scalise AV, Müller K, Roessig L, Gheorghiade M. Rationale and design of the SOluble guanylate Cyclase stimulatoR in heArT failurE Studies (SOCRATES). Eur J Heart Fail 2014; 16:1026-38. [DOI: 10.1002/ejhf.135] [Citation(s) in RCA: 111] [Impact Index Per Article: 11.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2014] [Revised: 06/06/2014] [Accepted: 06/13/2014] [Indexed: 12/24/2022] Open
Affiliation(s)
- Burkert Pieske
- Department of Cardiology; Medical University Graz; Graz Austria
| | - Javed Butler
- Division of Cardiology; Emory University School of Medicine; Atlanta GA USA
| | | | - Carolyn Lam
- Cardiovascular Research Institute; Singapore
| | - Aldo Pietro Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center; Florence Italy
| | - Piotr Ponikowski
- Department of Heart Diseases; Medical University; Military Hospital Wroclaw Poland
| | - Sanjiv Shah
- Division of Cardiology, Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
| | - Scott Solomon
- Cardiovascular Division; Brigham and Women's Hospital; Boston MA USA
| | | | | | | | | | | | - Mihai Gheorghiade
- Division of Cardiology, Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL USA
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31
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Bello NA, Claggett B, Desai AS, McMurray JJV, Granger CB, Yusuf S, Swedberg K, Pfeffer MA, Solomon SD. Influence of previous heart failure hospitalization on cardiovascular events in patients with reduced and preserved ejection fraction. Circ Heart Fail 2014; 7:590-5. [PMID: 24874200 DOI: 10.1161/circheartfailure.113.001281] [Citation(s) in RCA: 108] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospitalization for acute heart failure (HF) is associated with high rates of subsequent mortality and readmission. We assessed the influence of the time interval between previous HF hospitalization and randomization in the Candesartan in Heart failure: Reduction in Mortality and morbidity (CHARM) trials on clinical outcomes in patients with both reduced and preserved ejection fraction. METHODS AND RESULTS CHARM enrolled 7599 patients with New York Heart Association class II to IV HF, of whom 5426 had a history of previous HF hospitalization. Cox proportional hazards regression models were used to assess the association between time from previous HF hospitalization and randomization and the primary outcome of cardiovascular death or unplanned admission to hospital for the management of worsening HF during a median of 36.6 months. For patients with HF and reduced or preserved ejection fraction, rates of cardiovascular mortality and HF hospitalization were higher among patients with previous HF hospitalization than those without. The risk for mortality and hospitalization varied inversely with the time interval between hospitalization and randomization. Rates were higher for patients with HF and reduced ejection fraction within each category. Event rates for those with HF with preserved ejection fraction and a HF hospitalization in the 6 months before randomization were comparable with the rate in patients with HF and reduced ejection fraction with no previous HF hospitalization. CONCLUSIONS Rates of cardiovascular death or HF hospitalization are greatest in those who have been previously hospitalized for HF. Independent of EF, rates of death and readmission decline as time from HF hospitalization to trial enrollment increased. Recent HF hospitalization identifies a high-risk population for future clinical trials in HF and reduced ejection fraction and HF with preserved ejection fraction. CLINICAL TRIAL REGISTRATION URL http://www.clinicaltrials.gov. Unique identifier: NCT00634400.
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Affiliation(s)
- Natalie A Bello
- From the Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (N.A.B., B.C., A.S.D., M.A.P., S.D.S.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (C.B.G.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (S.Y.); and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden (K.S.)
| | - Brian Claggett
- From the Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (N.A.B., B.C., A.S.D., M.A.P., S.D.S.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (C.B.G.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (S.Y.); and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden (K.S.)
| | - Akshay S Desai
- From the Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (N.A.B., B.C., A.S.D., M.A.P., S.D.S.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (C.B.G.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (S.Y.); and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden (K.S.)
| | - John J V McMurray
- From the Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (N.A.B., B.C., A.S.D., M.A.P., S.D.S.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (C.B.G.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (S.Y.); and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden (K.S.)
| | - Christopher B Granger
- From the Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (N.A.B., B.C., A.S.D., M.A.P., S.D.S.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (C.B.G.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (S.Y.); and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden (K.S.)
| | - Salim Yusuf
- From the Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (N.A.B., B.C., A.S.D., M.A.P., S.D.S.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (C.B.G.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (S.Y.); and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden (K.S.)
| | - Karl Swedberg
- From the Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (N.A.B., B.C., A.S.D., M.A.P., S.D.S.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (C.B.G.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (S.Y.); and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden (K.S.)
| | - Marc A Pfeffer
- From the Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (N.A.B., B.C., A.S.D., M.A.P., S.D.S.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (C.B.G.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (S.Y.); and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden (K.S.)
| | - Scott D Solomon
- From the Department of Medicine, Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (N.A.B., B.C., A.S.D., M.A.P., S.D.S.); Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom (J.J.V.M.); Department of Medicine, Division of Cardiology, Duke University Medical Center, Durham, NC (C.B.G.); Population Health Research Institute, Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada (S.Y.); and Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden (K.S.).
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Kaiser EA, Lotze U, Schäfer HH. Increasing complexity: which drug class to choose for treatment of hypertension in the elderly? Clin Interv Aging 2014; 9:459-75. [PMID: 24711696 PMCID: PMC3969251 DOI: 10.2147/cia.s40154] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Treatment of hypertension in the elderly is expected to become more complex in the coming decades. Based on the current landscape of clinical trials, guideline recommendations remain inconclusive. The present review discusses the latest evidence derived from studies available in 2013 and investigates optimal blood pressure (BP) and preferred treatment substances. Three common archetypes are discussed that hamper the treatment of hypertension in the very elderly. In addition, this paper presents the current recommendations of the NICE 2011, JNC7 2013-update, ESH/ESC 2013, CHEP 2013, JNC8 and ASH/ISH guidelines for elderly patients. Advantages of the six main substance classes, namely diuretics, beta-blockers (BBs), calcium channel blockers (CCBs), angiotensin-converting enzyme inhibitors (ACEIs), angiotensin receptor blockers (ARBs), and direct renin inhibitors (DRIs) are discussed. Medical and economic implications of drug administration in the very elderly are presented. Avoidance of treatment-related adverse effects has become increasingly relevant. Current substance classes are equally effective, with similar effects on cardiovascular outcomes. Selection of substances should therefore also be based on collateral advantages of drugs that extend beyond BP reduction. The combination of ACEIs and diuretics appears to be favorable in managing systolic/diastolic hypertension. Diuretics are a preferred and cheap combination drug, and the combination with CCBs is recommended for patients with isolated systolic hypertension. ACEIs and CCBs are favorable for patients with dementia, while CCBs and ARBs imply substantial cost savings due to high adherence.
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Affiliation(s)
| | - Ulrich Lotze
- Department of Internal Medicine, DRK-Manniske-Krankenhaus Bad Frankenhausen, Bad Frankenhausen, Germany
| | - Hans Hendrik Schäfer
- Roche Diagnostics International AG, Rotkreuz, Switzerland ; Institute of Anatomy II, University Hospital Jena, Friedrich-Schiller University, Jena, Germany
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Efficacy and tolerability of adding an angiotensin receptor blocker in patients with heart failure already receiving an angiotensin-converting inhibitor plus aldosterone antagonist, with or without a beta blocker. Findings from the Candesartan in Heart fa. Eur J Heart Fail 2014; 10:157-63. [DOI: 10.1016/j.ejheart.2007.12.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2007] [Revised: 11/01/2007] [Accepted: 12/12/2007] [Indexed: 11/24/2022] Open
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Azadpour M, Lamas GA. AT1 receptor blockade for the prevention of cardiovascular events after myocardial infarction. Expert Rev Cardiovasc Ther 2014; 2:891-902. [PMID: 15500434 DOI: 10.1586/14779072.2.6.891] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Myocardial infarction is associated with high morbidity and mortality. Multiple therapeutic modalities have been shown to be effective in reducing adverse postmyocardial infarction outcomes. The most prominent drugs that have been used in this group of patients are those that oppose the effects of the renin-angiotensin-aldosterone system. These drugs include beta-blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and aldosterone blockers. Following initial success with angiotensin-converting enzyme inhibitors in reducing mortality and cardiac remodeling in postmyocardial infarction patients, recent focus has been on adjunctive or alternative use of angiotensin II-receptor antagonists. Multiple large-scale, randomized trials have been conducted in order to compare angiotensin II-receptor antagonists with a combination of angiotensin II-receptor antagonists and angiotensin-converting enzyme inhibitors, and with angiotensin-converting enzyme inhibitors alone in postmyocardial infarction patients and also in heart failure. Although some results are conflicting, the weight of evidence is towards equivalency of these two groups of medicines, provided that the maximum effective dose of the angiotensin II-receptor antagonists is used. The combination of an angiotensin-converting enzyme inhibitor and an angiotensin II-receptor antagonist may have additional benefits for some, but not all, patients; for example, reducing morbidity and mortality in patients with chronic heart failure but not in postmyocardial infarction patients. Indeed, in the postmyocardial infarction setting, the combination appears simply to increase the side effects, without conferring additional benefits. Use of aldosterone antagonists as adjunctive therapy in postmyocardial infarction patients is associated with added benefits in terms of mortality reduction and will become the standard of care in this group of patients.
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Affiliation(s)
- Maziar Azadpour
- Mount Sinai Medical Center and Miami Heart Institute, Miami Beach, FL 33140, USA.
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35
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McKelvie RS. The CHARM program: the effects of candesartan for the management of patients with chronic heart failure. Expert Rev Cardiovasc Ther 2014; 7:9-16. [DOI: 10.1586/14779072.7.1.9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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36
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Wong CM, Hawkins NM, Jhund PS, MacDonald MR, Solomon SD, Granger CB, Yusuf S, Pfeffer MA, Swedberg K, Petrie MC, McMurray JJ. Clinical Characteristics and Outcomes of Young and Very Young Adults With Heart Failure. J Am Coll Cardiol 2013; 62:1845-54. [DOI: 10.1016/j.jacc.2013.05.072] [Citation(s) in RCA: 67] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2013] [Revised: 05/15/2013] [Accepted: 05/21/2013] [Indexed: 11/28/2022]
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Friedrich S, Schmieder RE. Review of direct renin inhibition by aliskiren. J Renin Angiotensin Aldosterone Syst 2013; 14:193-6. [PMID: 23873285 DOI: 10.1177/1470320313497328] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Numerous clinical studies have been conducted to analyse the ability of renin-angiotensin system blockade to lower blood pressure and to reduce end-organ damage. In addition to angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, direct renin inhibitors emerged as an attractive option to inhibit the renin-angiotensin system and thus to prevent cardiovascular damage. Based on the publication of the most recent available results of ALTITUDE and ASTRONAUT, we review the data with respect to the direct renin inhibitor aliskiren given as an antihypertensive drug, in monotherapy and combination therapy, and the most recent publication analysing the effects of aliskiren on end-organ protection.
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Affiliation(s)
- Stefanie Friedrich
- Nephrology and Hypertension, University Hospital Erlangen, Erlangen, Germany
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38
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Nasim S, Nadeem N, Zahidie A, Sharif T. Relationship between exercise induced dyspnea and functional capacity with doppler-derived diastolic function'. BMC Res Notes 2013; 6:150. [PMID: 23587172 PMCID: PMC3636105 DOI: 10.1186/1756-0500-6-150] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Accepted: 04/05/2013] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Dyspnea is the frequent cause of exercise intolerance and physical inactivity among patients referred for exercise tolerance test. Diastolic dysfunction has shown significant correlation with exercise capacity and exercise induced dyspnea. To find out the frequency of diastolic dysfunction (DD) and the relationships between impaired exercise capacity and exercise induced dyspnea with DD by Doppler-derived indices among patients referred for stress test in a tertiary care hospital of Karachi. METHODS For this study 135 consecutive patients who were referred for stress test at our non-invasive lab were screened for eligibility. Patients with valvular pathology, atrial fibrillation (AF) and coronary artery disease (CAD) were excluded. Stress test was performed on treadmill using Bruce protocol. Assessment of diastolic function as determined by trans-mitral flow velocity pattern was carried at baseline and at peak exercise. We evaluated impaired exercise capacity and exercise induced dyspnea using validated Borg Scale among study subjects. RESULTS Study subjects 88% were males, mean age was 46 ± 16 years, BMI 27 ± 5 kg/m2, prevalence of diabetes mellitus (DM) 15%, hypertension 28% and smoking 21%. Exercise induced DD occurred among 44.6%. Patients with exercise induced DD had lower exercise capacity (9.2 vs. 10.2 METS; p = 0.04) and higher Borg Scale (5.2 vs. 4.0; p < 0.001). DD at baseline was present in 25(26%) of patients so they were excluded from the study. Five patients develop ischemia during stress test so were also excluded. So final analysis was done on 105 patients. Among patients without DD at baseline, there was significant vicariate linear inverse correlation between post exercise E/A ratio and Borg scale (r = -0.23; p = 0.02) and exercise capacity was assessed by exercise duration and MET (r-0.825; p = 0.04). Multivariate regression analysis revealed post exercise E/A ratio as an independent determinant of severity of exercise induced dyspnea and impaired exercise tolerance. CONCLUSION DD is significantly associated with impaired functional capacity and dyspnea among patients referred for exercise tolerance test.
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39
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Association of Heart Rate and Outcomes in a Broad Spectrum of Patients With Chronic Heart Failure. J Am Coll Cardiol 2012; 59:1785-95. [DOI: 10.1016/j.jacc.2011.12.044] [Citation(s) in RCA: 127] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2011] [Revised: 12/05/2011] [Accepted: 12/15/2011] [Indexed: 11/18/2022]
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40
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Ariti CA, Cleland JGF, Pocock SJ, Pfeffer MA, Swedberg K, Granger CB, McMurray JJV, Michelson EL, Ostergren J, Yusuf S. Days alive and out of hospital and the patient journey in patients with heart failure: Insights from the candesartan in heart failure: assessment of reduction in mortality and morbidity (CHARM) program. Am Heart J 2011; 162:900-906. [PMID: 22093207 DOI: 10.1016/j.ahj.2011.08.003] [Citation(s) in RCA: 137] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2011] [Accepted: 08/04/2011] [Indexed: 05/31/2023]
Abstract
BACKGROUND Conventional composite outcomes in heart failure (HF) trials, for example, time to cardiovascular death or first HF hospitalization, have recognized limitations. We propose an alternative outcome, days alive and out of hospital (DAOH), which incorporates mortality and all hospitalizations into a single measure. A refinement, the patient journey, also uses functional status (New York Heart Association [NYHA] class) measured during follow-up. The CHARM program is used to illustrate the methodology. METHODS CHARM randomized 7,599 patients with symptomatic HF to placebo or candesartan, with median follow-up of 38 months. We related DAOH and percent DAOH (ie, percentage of time spent alive and out of hospital) to treatment using linear regression adjusting for follow-up time. RESULTS Mean increase in DAOH for patients on candesartan versus placebo was 24.1 days (95% CI 9.8-38.3 days, P < .001). The corresponding mean increase in percent DAOH was 2.0% (95% CI 0.8%-3.1%, P < .001). These findings were dominated by reduced mortality (23 days) but enhanced by reduced time in hospital (1 day). Percent time spent in hospital because of HF was reduced by 0.10% (95% CI 0.04%-0.14%, P < .001). The patient journey analysis showed that patients in the candesartan group spent more follow-up time in NYHA classes I and II and less in NYHA class IV. CONCLUSIONS Days alive and out of hospital, especially percent DAOH, provide a valuable tool for summarizing the overall absolute treatment effect on mortality and morbidity. In future HF trials, percent DAOH can provide a useful alternative perspective on the effects of treatment.
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Affiliation(s)
- Cono A Ariti
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom.
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41
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Barrios V, Escobar C. Candesartan in the treatment of hypertension: what have we learnt in the last decade? Expert Opin Drug Saf 2011; 10:957-68. [PMID: 21848481 DOI: 10.1517/14740338.2011.608064] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Although all of the first-line antihypertensive drugs effectively reduce blood pressure, there are some conditions that may favor the use of angiotensin receptor blockers over others, such as left ventricular hypertrophy, microalbuminuria, renal dysfunction, diabetes, or metabolic syndrome, among others. AREAS COVERED This manuscript reviewed the data supporting the use of candesartan cilexetil in hypertensive population with a special focus on its efficacy and safety. For this purpose, a search on MEDLINE and EMBASE databases was performed. The MEDLINE and EMBASE search included both medical subject headings (MeSH) and keywords including: candesartan OR angiotensin receptor blockers OR renin angiotensin system AND hypertension treatment. References of the retrieved articles were also screened for additional studies. There were no language restrictions. EXPERT OPINION Candesartan, a long-acting angiotensin receptor antagonist, has been shown to be an effective and well-tolerated therapy in the entire spectrum of hypertensive patients, including those at higher risk, such as those with diabetes, metabolic syndrome, left ventricular hypertrophy, or microalbuminuria.
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Affiliation(s)
- Vivencio Barrios
- Hospital Ramon y Cajal, Department of Cardiology, Madrid, Spain.
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Shah SJ, Fonarow GC, Gheorghiade M, Lang RM. Phase II trials in heart failure: the role of cardiovascular imaging. Am Heart J 2011; 162:3-15.e3. [PMID: 21742085 DOI: 10.1016/j.ahj.2011.03.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2010] [Accepted: 03/21/2011] [Indexed: 02/04/2023]
Abstract
The development of new therapies for heart failure (HF), especially acute HF, has proven to be quite challenging; and therapies evaluated in HF have greatly outnumbered treatments that are eventually successful in obtaining regulatory approval. Thus, the development of therapies for HF remains a vexing problem for pharmaceutical and device companies, clinical trialists, and health care professionals. Nowhere is this more apparent than in the phase II HF clinical trial, in which the goal is to determine whether an investigational agent should move forward to a phase III trial. Recent advancements in noninvasive cardiovascular imaging have allowed a new era of comprehensive phenotyping of cardiac structure and function in phase II HF trials. Besides using imaging parameters to predict success of subsequent phase III outcome studies, it is essential to also use imaging in phase II HF trials in a way that increases understanding of drug or device mechanism. Determination of the patients who would benefit most from a particular drug or device could decrease heterogeneity of phase III trial participants and lead to more successful HF clinical trials. In this review, we outline advantages and disadvantages of imaging various aspects of cardiac structure and function that are potential targets for therapy in HF, compare and contrast imaging modalities, provide practical advice for the use of cardiovascular imaging in drug development, and conclude with some novel uses of cardiac imaging in phase II HF trials.
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Affiliation(s)
- Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL 60611, USA.
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Nantel P, René de Cotret P. The evolution of angiotensin blockade in the management of cardiovascular disease. Can J Cardiol 2011; 26 Suppl E:7E-13E. [PMID: 21620285 DOI: 10.1016/s0828-282x(10)71168-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 10/07/2010] [Indexed: 01/01/2023] Open
Abstract
Dysregulation of the renin-angiotensin system is implicated in many cardiovascular and renal pathologies. Discovery of the renin-angiotensin system represents a major advance in the understanding of hypertension and cardiovascular disease, leading to the development of the anti-angiotensin medications: angiotensin-converting enzyme inhibitors, angiotensin receptor blockers and direct renin inhibitors. Clinical trials have shown that drugs in each of these classes have a protective effect on vascular organs that surpass the protection associated with the lowering of blood pressure alone.
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Affiliation(s)
- Pierre Nantel
- Hotel-Dieu de Sorel, 130 St Nicholas, Sorel-Tracy, Québec.
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44
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Jenkins K, Kirk M. Heart failure and chronic kidney disease: an integrated care approach. J Ren Care 2010; 36 Suppl 1:127-35. [PMID: 20586908 DOI: 10.1111/j.1755-6686.2010.00158.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Renal impairment may be evident at any stage of heart failure (CHF). Up to 30% of patients with heart failure have abnormal renal function. Chronic kidney disease (CKD) can be a complication of heart failure and chronic heart disease can be a consequence of CKD. Members of the multidisciplinary team, such as nurses, dieticians and physiotherapists should be encouraged to maximise their knowledge and skills across disease areas to influence and improve outcomes of those with CKD and CHF. In particular management of fluid balance, blood pressure control/monitoring, discussion of blood results and reduction of cardiovascular risk factors. Close monitoring and effective management of modifiable cardiac risk factors, such as diabetes and hypertension can reduce onset and slow progression of CKD. This can be done by applying the key principles of good practice, such as communication between healthcare professionals, patient education and empowerment alongside early identification and management of symptoms of CKD and CHF.
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Affiliation(s)
- Karen Jenkins
- East Kent Hospitals University NHS Foundation Trust, Kent Kidney Care Centre, Kent & Canterbury Hospital,University of Kent, Canterbury, UK.
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Abstract
BACKGROUND Dual renin-angiotensin system (RAS) blockade, mostly by combining an angiotensin converting enzyme (ACE) inhibitor with an angiotensin receptor blocker (ARB), is increasingly used in patients with hypertension and diabetes and/or proteinuria and in those with resistant heart failure. However, in the zest of achieving greater nephroprotection and cardioprotection, even patients with uncomplicated essential hypertension are not uncommonly treated with dual RAS blockade. EVIDENCE In 2003 the COOPERATE trial, seemed to confirm that dual RAS blockade was beneficial and that proteinuria reduction was synonymous with nephroprotection. This study had to be withdrawn recently attesting to the suspicion that the data looked to good to be true. Moreover, the large prospective ONTARGET data argue against a nephroprotective effect of dual RAS blockade and together with renal findings from ACCOMPLISH, cast doubt on albuminuria/proteinuria being a reliable surrogate endpoint for renal outcome. Although in heart failure, dual RAS blockade had some benefit without reducing mortality, there remains a distinct safety issue with regard to hyperkalemia and elevated creatinine. Neither in ischaemic heart disease nor in left ventricular hypertrophy had dual RAS blockade any benefits when compared with single RAS blockade. Of note, the combination of an ACE inhibitor with an ARB was recently shown to reduce the risk of dementia. All dual RAS blockade may be created equal and the combination of valsartan with aliskiren, a direct renin inhibitor will be evaluated in diabetic patients in the prospective, randomized ALTITUDE study. CONCLUSIONS For the time being, given the adverse effects and lack of consistent survival benefits, the use of dual RAS blockade should be avoided unless ironclad data emerge to the contrary.
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Affiliation(s)
- Franz H Messerli
- Division of Cardiology, St. Luke's and Roosevelt Hospitals, Columbia University College of Physicians and Surgeons, 1000 Tenth Avenue, New York, NY, USA.
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Maisch B, Pankuweit S. [Treatment of progressive heart failure: pharmacotherapy, resynchronization (CRT), surgery]. Herz 2010; 35:94-101. [PMID: 20376643 DOI: 10.1007/s00059-010-3329-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The treatment of progressive and terminal heart failure follows the principle of causative therapy. Therefore, etiology and pathophysiology of the underlying disease and its hemodynamic conditions are indispensable. This applies to coronary artery disease, hypertension, valvular heart disease, the cardiomyopathies with and without inflammation, and microbial persistence similarly. The classic treatment algorithms both in heart failure with and without reduced ejection fraction are based on measures onloading the heart (angiotensin-converting enzyme inhibitors, angiotensin antagonists, beta-blockers, diuretics) and on antiarrhythmics and anticoagulation, when needed. Device therapy for cardiac resynchronization in left bundle branch block and permanent stimulation therapy may contribute to the hemodynamic benefit. ICD (implantable cardioverter defibrillator) therapy prevents sudden cardiac death, which is often associated with progressive heart failure. Heart transplantation and left ventricular assist devices are final options in the treatment repertoire of terminal heart failure.
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Affiliation(s)
- Bernhard Maisch
- Klinik für Innere Medizin - Kardiologie, Philipps-Universität, Marburg und UKGM GmbH, Standort Marburg, Marburg, Germany.
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47
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Hawkins NM, Wang D, Petrie MC, Pfeffer MA, Swedberg K, Granger CB, Yusuf S, Solomon SD, Östergren J, Michelson EL, Pocock SJ, Maggioni AP, McMurray JJ. Baseline characteristics and outcomes of patients with heart failure receiving bronchodilators in the CHARM programme. Eur J Heart Fail 2010; 12:557-65. [DOI: 10.1093/eurjhf/hfq040] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Duolao Wang
- Medical Statistics Unit; London School of Hygiene and Tropical Medicine; London UK
| | | | | | - Karl Swedberg
- Sahlgrenska University Hospital/Östra; Göteborg Sweden
| | | | - Salim Yusuf
- Hamilton Health Sciences and McMaster University; Hamilton ON Canada
| | | | | | | | - Stuart J. Pocock
- Medical Statistics Unit; London School of Hygiene and Tropical Medicine; London UK
| | - Aldo P. Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center; Florence Italy
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Mehta PA, McDonagh S, Phillips J, Grocott-Mason R, Dubrey SW. Angiotensin receptor blocker therapy for heart failure patients: is combination treatment a feasible prospect? Clin Cardiol 2009; 32:513-8. [PMID: 19743497 DOI: 10.1002/clc.20635] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
BACKGROUND The addition of the angiotensin II type 1 receptor blocker (ARB) candesartan to a angiotensin-converting enzyme inhibitor (ACEI) has been associated with improved clinical outcomes in patients with heart failure. However many do not tolerate combination therapy and concerns have been raised regarding excessive neurohormonal inhibition. HYPOTHESIS The majority of patients with chronic heart failure are not eligible or do not tolerate combination therapy with an ACEEI and ARB. METHODS We prospectively evaluated 115 consecutive patients with heart failure (median age 74 y; 74% males; mean left ventricular ejection fraction 30%) within a district general hospital for eligibility and tolerance to combination therapy using candesartan in addition to recommended doses of an ACEI. RESULTS Overall, 109 (95%) were ineligible to initiate candesartan. The most frequent reasons were that, despite best efforts at optimization, 77% of patients were unable to achieve recommended doses of an ACEI, 29% were relatively asymptomatic, 20% had symptomatic hypotension, and 35% were already taking an ARB due to previous ACEI "intolerance." Overall, 6 (5%) of patients satisfied the eligibility criteria of whom 3 (3% of total) were already taking "optimal" doses of an ARB in addition to an ACEI. The remaining 3 patients commenced the titration schedule with candesartan. All 3 patients failed the first titration phase (4 mg once daily) within 2 weeks of initiation, due to the development of hyperkalemia. CONCLUSIONS The use of combination therapy with an ARB in addition to recommended doses of ACEI does not appear feasible in patients with heart failure in the general population, as the vast majority are not eligible.
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Affiliation(s)
- P A Mehta
- Clinical Cardiology, National Heart and Lung Institute, Imperial College, London, United Kingdom.
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Jackson CE, Solomon SD, Gerstein HC, Zetterstrand S, Olofsson B, Michelson EL, Granger CB, Swedberg K, Pfeffer MA, Yusuf S, McMurray JJV. Albuminuria in chronic heart failure: prevalence and prognostic importance. Lancet 2009; 374:543-50. [PMID: 19683640 DOI: 10.1016/s0140-6736(09)61378-7] [Citation(s) in RCA: 200] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND Increased excretion of albumin in urine might be a marker of the various pathophysiological changes that arise in patients with heart failure. Therefore our aim was to assess the prevalence and prognostic value of a spot urinary albumin to creatinine ratio (UACR) in patients with heart failure. METHODS UACR was measured at baseline and during follow-up of 2310 patients in the Candesartan in Heart failure: Assessment of Reduction in Mortality and morbidity (CHARM) Programme. The prevalence of microalbuminuria and macroalbuminuria, and the predictive value of UACR for the primary composite outcome of each CHARM study--ie, death from cardiovascular causes or admission to hospital with worsening heart failure--and death from any cause were assessed. FINDINGS 1349 (58%) patients had a normal UACR, 704 (30%) had microalbuminuria, and 257 (11%) had macroalbuminuria. The prevalence of increased UACR was similar in patients with reduced and preserved left ventricular ejection fractions. Patients with an increased UACR were older, had more cardiovascular comorbidity, worse renal function, and a higher prevalence of diabetes mellitus than did those with normoalbuminuria. However, a high prevalence of increased UACR was still noted among patients without diabetes, hypertension, or renal dysfunction. Elevated UACR was associated with increased risk of the composite outcome and death even after adjustment for other prognostic variables including renal function, diabetes, and haemoglobin A1c. The adjusted hazard ratio (HR) for the composite outcome in patients with microalbuminuria versus normoalbuminuria was 1.43 (95% CI 1.21-1.69; p<0.0001) and for macroalbuminuria versus normoalbuminuria was 1.75 (1.39-2.20; p<0.0001). The adjusted values for death were 1.62 (1.32-1.99; p<0.0001) for microalbuminuria versus normoalbuminuria, and 1.76 (1.32-2.35; p=0.0001) for macroalbuminuria versus normoalbuminuria. Treatment with candesartan did not reduce or prevent the development of excessive excretion of urinary albumin. INTERPRETATION Increased UACR is a powerful and independent predictor of prognosis in heart failure. FUNDING AstraZeneca.
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Affiliation(s)
- Colette E Jackson
- British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Abstract
Diabetic cardiomyopathy is a distinct primary disease process, independent of coronary artery disease, which leads to heart failure in diabetic patients. Epidemiological and clinical trial data have confirmed the greater incidence and prevalence of heart failure in diabetes. Novel echocardiographic and MR (magnetic resonance) techniques have enabled a more accurate means of phenotyping diabetic cardiomyopathy. Experimental models of diabetes have provided a range of novel molecular targets for this condition, but none have been substantiated in humans. Similarly, although ultrastructural pathology of the microvessels and cardiomyocytes is well described in animal models, studies in humans are small and limited to light microscopy. With regard to treatment, recent data with thiazoledinediones has generated much controversy in terms of the cardiac safety of both these and other drugs currently in use and under development. Clinical trials are urgently required to establish the efficacy of currently available agents for heart failure, as well as novel therapies in patients specifically with diabetic cardiomyopathy.
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