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Formiga F, Nuñez J, Castillo Moraga MJ, Cobo Marcos M, Egocheaga MI, García-Prieto CF, Trueba-Sáiz A, Matalí Gilarranz A, Fernández Rodriguez JM. Diagnosis of heart failure with preserved ejection fraction: a systematic narrative review of the evidence. Heart Fail Rev 2024; 29:179-189. [PMID: 37861854 PMCID: PMC10904432 DOI: 10.1007/s10741-023-10360-z] [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] [Accepted: 10/05/2023] [Indexed: 10/21/2023]
Abstract
Heart failure (HF) with preserved ejection fraction (HFpEF) is a common condition in clinical practice, affecting more than half of patients with HF. HFpEF is associated with morbidity and mortality and with considerable healthcare resource utilization and costs. Therefore, early diagnosis is crucial to facilitate prompt management, particularly initiation of sodium-glucose co-transporter 2 inhibitors. Although European guidelines define HFpEF as the presence of symptoms with or without signs of HF, left ventricular EF ≥ 50%, and objective evidence of cardiac structural and/or functional abnormalities, together with elevated natriuretic peptide levels, the diagnosis of HFpEF remains challenging. First, there is no clear consensus on how HFpEF should be defined. Furthermore, diagnostic tools, such as natriuretic peptide levels and resting echocardiogram findings, are significantly limited in the diagnosis of HFpEF. As a result, some patients are overdiagnosed (i.e., elderly people with comorbidities that mimic HF), although in other cases, HFpEF is overlooked. In this manuscript, we perform a systematic narrative review of the diagnostic approach to patients with HFpEF. We also propose a comprehensible algorithm that can be easily applied in daily clinical practice and could prove useful for confirming or ruling out a diagnosis of HFpEF.
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Affiliation(s)
- Francesc Formiga
- Servicio de Medicina Interna, Hospital Universitari de Bellvitge, Barcelona, Spain.
| | - Julio Nuñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia-España, Valencia, Spain
- Departamento de Medicina, Universidad de Valencia, Fundación de Investigación INCLIVA, Valencia, Spain
| | | | - Marta Cobo Marcos
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro Majadahonda (IDIPHISA), Madrid, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | | | | | - Angel Trueba-Sáiz
- Medical Affairs Department, Eli Lilly and Company España, Alcobendas, Madrid, Spain
| | | | - José María Fernández Rodriguez
- Área Cardiorrenometabólica del Servicio de Medicina Interna del Hospital Universitario Ramon y Cajal, Madrid, Spain
- Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Madrid, Spain
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2
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Ferreira AI, Silva JE, Melo N, Oliveira D, Silva C, Lume M, Pereira J, Almeida J, Araújo JP, Lourenço P. Prognostic impact of red blood cell distribution width in chronic heart failure patients with left ventricular dysfunction. J Cardiovasc Med (Hagerstown) 2023; 24:746-751. [PMID: 37642949 DOI: 10.2459/jcm.0000000000001543] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023]
Abstract
AIMS Red blood cell (RBC) distribution width (RDW) measures RBC variations in size. Higher RDW values have been associated with poor outcome in acute heart failure (HF). We aimed to assess the prognostic impact of the RDW in chronic HF. METHODS We retrospectively analysed a cohort of chronic HF patients with left ventricular systolic dysfunction followed in our HF clinic between January 2012 and May 2018. Patients with missing data concerning RDW were excluded. Patients were categorized according to RDW tertiles: ≤13.5%; between 13.5 and 14.7%; and >14.7%. Patients were followed until January 2021; all-cause mortality was the end point analysed. The association of RDW with all-cause mortality was assessed with a Cox-regression analysis. Two multivariate models were built. RESULTS We studied 860 chronic HF patients, 66.4% males, mean age 70 (standard deviation, SD 13) years. Patients were followed for a median of 49 (29-82) months. During this period, 423 (49.2%) patients died. Mortality increased with increasing RDW tertiles. Patients with RDW >14.7% had a HR of mortality of 1.95 (1.47-2.58), p < 0.001 (model 1) and of 1.81 (1.35-2.41), p < 0.001 (model 2) when compared with those with RDW ≤13.5. Patients in the second RDW tertile had an all-cause death HR of 1.47 (1.12-1.93) and of 1.44 (1.09-1.90) in models 1 and 2, respectively. CONCLUSIONS Chronic HF patients with RDW values >14.7% presented an almost 2-fold higher risk of dying in the long term than those with RDW <13.5%. RDW is a widely available and easily measured parameter that can help clinicians in the risk stratification of chronic HF patients.
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Affiliation(s)
| | - João Enes Silva
- Internal Medicine Department, Centro Hospitalar Universitário de São João
| | - Nuno Melo
- Internal Medicine Department, Centro Hospitalar Universitário de São João
| | - Diana Oliveira
- Internal Medicine Department, Centro Hospitalar Universitário de São João
| | - Clara Silva
- Internal Medicine Department, Centro Hospitalar Universitário de São João
| | - Maria Lume
- Internal Medicine Department, Centro Hospitalar Universitário de São João
| | - Joana Pereira
- Internal Medicine Department, Centro Hospitalar Universitário de São João
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Jorge Almeida
- Internal Medicine Department, Centro Hospitalar Universitário de São João
| | - José Paulo Araújo
- Internal Medicine Department, Centro Hospitalar Universitário de São João
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
| | - Patrícia Lourenço
- Internal Medicine Department, Centro Hospitalar Universitário de São João
- Faculdade de Medicina da Universidade do Porto, Porto, Portugal
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Siddiqi TJ, Anker SD, Filippatos G, Ferreira JP, Pocock SJ, Böhm M, Brueckmann M, Chopra VK, Iwata T, Januzzi J, Piña IL, Ponikowski P, Senni M, Vedin O, Verma S, Zhang Y, Zannad F, Packer M, Butler J. Health status across major subgroups of patients with heart failure and preserved ejection fraction. Eur J Heart Fail 2023; 25:1623-1631. [PMID: 36974746 DOI: 10.1002/ejhf.2831] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Revised: 02/10/2023] [Accepted: 03/18/2023] [Indexed: 03/29/2023] Open
Abstract
AIMS There are limited data on health status and changes in it over time across major subgroups of patients with heart failure and preserved ejection fraction (HFpEF), including ejection fraction spectrum, age, sex, region, body mass index (BMI), and comorbidities including diabetes, chronic kidney disease (CKD), anaemia, and atrial fibrillation/flutter. METHODS AND RESULTS In the EMPEROR-Preserved trial, the Kansas City Cardiomyopathy Questionnaire (KCCQ) was assessed at baseline, 12, 32 and 52 weeks. Determinants of baseline KCCQ score and change over time, and the impact of empagliflozin on KCCQ scores were studied in specified subgroups. A Cox model was used to assess the association between 5- and 10-point increase and 5-point decrease in KCCQ score from baseline to week 12 and later outcomes. Among 2979 participants in the placebo arm, mean KCCQ clinical summary score (CSS) was 70.7 (20.8). Older age, female sex, BMI, anaemia, and a history of diabetes, and CKD were associated with worse scores. KCCQ-CSS score improved during follow-up; patients with atrial fibrillation/flutter at enrollment (p trend = 0.014) and CKD (p trend < 0.001) had less improvement. A 5-point increase in KCCQ-CSS at week 12 was associated with lower risk of cardiovascular death or heart failure hospitalization (5%), cardiovascular death (8%), and first heart failure hospitalization (4%) subsequently. A similar trend was seen with KCCQ total symptom score (TSS) and overall summary score (OSS). Empagliflozin improved KCCQ-CSS, -TSS and -OSS scores similarly across subgroups studied except for greater improvement in patients with the highest BMI (p trend = 0.153, 0.08 and 0.078, respectively). CONCLUSION Health status in patients with HFpEF is impaired, especially in elderly, women, and those with obesity and comorbidities. Empagliflozin improved health status among all key subgroups studied with a greater effect in obese patients.
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Affiliation(s)
- Tariq Jamal Siddiqi
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, Berlin, Germany
- German Centre for Cardiovascular Research partner site, Berlin, Germany
- Charité Universitätsmedizin, Berlin, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Chaidari, Greece
| | - João Pedro Ferreira
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Portugal
- Inserm, Centre d'Investigations Cliniques - Plurithématique 14-33, Université de Lorraine, Nancy, France
- Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | | | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - James Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
| | - Ileana L Piña
- Central Michigan University, Mount Pleasant, MI, USA
| | | | - Michele Senni
- Cardiology Division, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ola Vedin
- Boehringer Ingelheim AB, Stockholm, Sweden
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Yuhui Zhang
- Heart Failure Center, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, Beijing, China
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Research Institute, Dallas, TX, USA
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4
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Does the Measurement of Ejection Fraction Still Make Sense in the HFpEF Framework? What Recent Trials Suggest. J Clin Med 2023; 12:jcm12020693. [PMID: 36675622 PMCID: PMC9867046 DOI: 10.3390/jcm12020693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Revised: 01/06/2023] [Accepted: 01/11/2023] [Indexed: 01/17/2023] Open
Abstract
Left ventricular ejection fraction (LVEF) is universally accepted as a cardiac systolic function index and it provides intuitive interpretation of cardiac performance. Over the last two decades, it has erroneously become the leading feature used by clinicians to characterize the left ventricular function in heart failure (HF). Notably, LVEF sets the basis for structural and functional HF phenotype classification in current guidelines. However, its diagnostic and prognostic role in patients with preserved or mildly reduced contractile function is less clear. This is related to several concerns due to intrinsic technical, methodological and hemodynamic limitations entailed in LVEF measurement that do not describe the chamber's real contractile performance as expressed by pressure volume loop relationship. In patients with HF and preserved ejection fraction (HFpEF), it does not reflect the effective systolic function because it is prone to preload and afterload variability and it does not account for both longitudinal and torsional contraction. Moreover, a repetitive measurement could be assessed over time to better identify HF progression related to natural evolution of disease and to the treatment response. Current gaps may partially explain the causes of negative or neutral effects of traditional medical agents observed in HFpEF. Nevertheless, recent pooled analysis has evidenced the positive effects of new therapies across the LVEF range, suggesting a potential role irrespective of functional status. Additionally, a more detailed analysis of randomized trials suggests that patients with higher LVEF show a risk reduction strictly related to overall cardiovascular (CV) events; on the other hand, patients experiencing lower LVEF values have a decrease in HF-related events. The current paper reports the main limitations and shortcomings in LVEF assessment, with specific focus on patients affected by HFpEF, and it suggests alternative measurements better reflecting the real hemodynamic status. Future investigations may elucidate whether the development of non-invasive stroke volume and longitudinal function measurements could be extensively applied in clinical trials for better phenotyping and screening of HFpEF patients.
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Solomon SD, Vaduganathan M, Claggett BL, de Boer RA, DeMets D, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez F, Shah SJ, Belohlavek J, Chiang CE, Willem Borleffs CJ, Comin-Colet J, Dobreanu D, Drozdz J, Fang JC, Alcocer Gamba MA, Al Habeeb W, Han Y, Cabrera Honorio JW, Janssens SP, Katova T, Kitakaze M, Merkely B, O'Meara E, Kerr Saraiva JF, Tereschenko SN, Thierer J, Vardeny O, Verma S, Vinh PN, Wilderäng U, Zaozerska N, Lindholm D, Petersson M, McMurray JJV. Baseline Characteristics of Patients With HF With Mildly Reduced and Preserved Ejection Fraction: DELIVER Trial. JACC. HEART FAILURE 2022; 10:184-197. [PMID: 35241246 DOI: 10.1016/j.jchf.2021.11.006] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Revised: 11/09/2021] [Accepted: 11/10/2021] [Indexed: 02/07/2023]
Abstract
OBJECTIVES This report describes the baseline clinical profiles and management of DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trial participants and how these compare with those in other contemporary heart failure with preserved ejection fraction trials. BACKGROUND The DELIVER trial was designed to evaluate the effects of the sodium-glucose cotransporter-2 inhibitor dapagliflozin on cardiovascular death, heart failure (HF) hospitalization, or urgent HF visits in patients with HF with mildly reduced and preserved left ventricular ejection fraction (LVEF). METHODS Adults with symptomatic HF and LVEF >40%, with or without type 2 diabetes mellitus, elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels, and evidence of structural heart disease were randomized to dapagliflozin 10 mg once daily or matching placebo. RESULTS A total of 6,263 patients were randomized (mean age: 72 ± 10 years; 44% women; 45% type 2 diabetes mellitus; 45% with body mass index ≥30 kg/m2; and 57% with history of atrial fibrillation or flutter). Most participants had New York Heart Association functional class II symptoms (75%). Baseline mean LVEF was 54.2 ± 8.8% and median NT-proBNP of 1,399 pg/mL (IQR: 962 to 2,210 pg/mL) for patients in atrial fibrillation/flutter compared with 716 pg/mL (IQR: 469 to 1,281 pg/mL) in those who were not. Patients in both hospitalized and ambulatory settings were enrolled, including 10% enrolled in-hospital or within 30 days of a hospitalization for HF. Eighteen percent of participants had HF with improved LVEF. CONCLUSIONS DELIVER is the largest and broadest clinical trial of this population to date and enrolled high-risk, well-treated patients with HF with mildly reduced and preserved LVEF. (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure [NCT03619213]).
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Affiliation(s)
- Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - David DeMets
- University of Wisconsin, Madison, Wisconsin, USA
| | | | | | | | - Carolyn S P Lam
- University of Groningen, Groningen, the Netherlands; National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Jan Belohlavek
- General University Hospital, Charles University, Prague, Czech Republic
| | - Chern-En Chiang
- General Clinical Research Center and Division of Cardiology, Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | | | - Josep Comin-Colet
- Cardiology Department, Bellvitge University Hospital, Bio-Heart (IDIBELL), University of Barcelona, Hospitalet de Llobregat, Barcelona, Spain
| | - Dan Dobreanu
- University of Medicine, Pharmacy, Science and Technology "G.E.Palade," Târgu Mureș, Romania
| | - Jaroslaw Drozdz
- Department Cardiology, Medical University Lodz, Lodz, Poland
| | - James C Fang
- University of Utah Medical Center, Salt Lake City, Utah, USA
| | | | - Waleed Al Habeeb
- Cardiac Sciences Department, King Saud University, Riyadh, Saudi Arabia
| | - Yaling Han
- Cardiovascular Research Institute, Department of Cardiology, General Hospital of Northern Theater Command, Shenyang, China
| | | | - Stefan P Janssens
- Cardiac Intensive Care, Department of Cardiovascular Diseases, University Hospitals Leuven, Leuven, Belgium
| | - Tsvetana Katova
- Department of Noninvasive Cardiology, National Cardiology Hospital, Sofia, Bulgaria
| | - Masafumi Kitakaze
- Kinshukai Hanwa Daini Senboku Hospital, Osaka, JapanHeart and Vascular Center
| | | | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Sergey N Tereschenko
- Department of Myocardial Disease and Heart Failure, National Medical Research Center of Cardiology, Moscow, Russia
| | - Jorge Thierer
- Jefe de Unidad de Insuficiencia Cardíaca, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno (CEMIC), Argentina
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada
| | - Pham Nguyen Vinh
- Cardiovascular Center, Tam Anh hospital, Tan Tao University, Vietnam
| | - Ulrica Wilderäng
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Natalia Zaozerska
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Daniel Lindholm
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
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6
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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: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 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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7
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Butler J, Filippatos G, Siddiqi TJ, Brueckmann M, Böhm M, Chopra V, Ferreira JP, Januzzi JL, Kaul S, Piña IL, Ponikowski P, Shah SJ, Senni M, Vedin O, Verma S, Peil B, Pocock SJ, Zannad F, Packer M, Anker SD. Empagliflozin, Health Status, and Quality of Life in Patients with Heart Failure and Preserved Ejection Fraction: The EMPEROR-Preserved Trial. Circulation 2021; 145:184-193. [PMID: 34779658 PMCID: PMC8763045 DOI: 10.1161/circulationaha.121.057812] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Supplemental Digital Content is available in the text. Background: Patients with heart failure with preserved ejection fraction have significant impairment in health-related quality of life. In the EMPEROR-Preserved trial (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction), we evaluated the efficacy of empagliflozin on health-related quality of life in patients with heart failure with preserved ejection fraction and whether the clinical benefit observed with empagliflozin varies according to baseline health status. Methods: Health-related quality of life was measured with the Kansas City Cardiomyopathy Questionnaire (KCCQ) at baseline and 12, 32, and 52 weeks. Patients were divided by baseline KCCQ Clinical Summary Score (CSS) tertiles, and the effect of empagliflozin on outcomes was examined. The effect of empagliflozin on KCCQ-CSS, Total Symptom Score, and Overall Summary Score was evaluated. Responder analyses were performed to compare the odds of improvement and deterioration in KCCQ related to treatment with empagliflozin. Results: The effect of empagliflozin on reducing the risk of time to cardiovascular death or heart failure hospitalization was consistent across baseline KCCQ-CSS tertiles (hazard ratio, 0.83 [95% CI, 0.69–1.00], 0.70 [95% CI, 0.55–0.88], and 0.82 [95% CI, 0.62–1.08] for scores <62.5, 62.5–83.3, and ≥83.3, respectively; P trend=0.77). Similar results were seen for total heart failure hospitalizations. Patients treated with empagliflozin had significant improvement in KCCQ-CSS versus placebo (+1.03, +1.24, and +1.50 at 12, 32, and 52 weeks, respectively; P<0.01); similar results were seen for Total Symptom Score and Overall Summary Score. At 12 weeks, patients on empagliflozin had higher odds of improvement ≥5 points (odds ratio, 1.23 [95% CI, 1.10–1.37]), ≥10 points (odds ratio, 1.15 [95% CI, 1.03–1.27]), and ≥15 points (odds ratio, 1.13 [95% CI, 1.02–1.26]) and lower odds of deterioration ≥5 points in KCCQ-CSS (odds ratio, 0.85 [95% CI, 0.75–0.97]). A similar pattern was seen at 32 and 52 weeks, and results were consistent for Total Symptom Score and Overall Summary Score. Conclusions: In patients with heart failure with preserved ejection fraction, empagliflozin reduced the risk for major heart failure outcomes across the range of baseline KCCQ scores. Empagliflozin improved health-related quality of life, an effect that appeared early and was sustained for at least 1 year. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03057951.
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Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Tariq Jamal Siddiqi
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany; Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg/Saar, Germany
| | - Vijay Chopra
- Max Superspeciality Hospital, Saket, New Delhi, India
| | - João Pedro Ferreira
- Universit é de Lorraine, Inserm, Centre d'Investigations Cliniques, - Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France; Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - James L Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA
| | - Sanjay Kaul
- Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Michele Senni
- Cardiovascular Department, Cardiology Division, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ola Vedin
- Boehringer Ingelheim AB, Stockholm, Sweden
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael's Hospital, University of Toronto, Toronto, Canada
| | - Barbara Peil
- Boehringer Ingelheim Pharma GmbH & Co. KG, Ingelheim, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Faiez Zannad
- Universit é de Lorraine, Inserm, Centre d'Investigations Cliniques, - Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX; Imperial College, London UK
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
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8
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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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9
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Swedberg K. Heart failure subtypes: Pathophysiology and definitions. Diabetes Res Clin Pract 2021; 175:108815. [PMID: 33862057 DOI: 10.1016/j.diabres.2021.108815] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Revised: 04/07/2021] [Accepted: 04/08/2021] [Indexed: 12/12/2022]
Abstract
The diagnosis of heart failure is classified in two main types depending on left ventricular ejection fraction usually by ejection fraction < or > 40%. The division has important implications for the treatment of heart failure. Type 2 diabetes is an important and common co-morbidity in chronic heart failure. It makes the prognosis of heart failure worse and chronic heart failure impacts the choice of treatment for type 2 diabetes.
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Affiliation(s)
- Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.
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10
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Snapshot evaluation of acute and chronic heart failure in real-life in Turkey: A follow-up data for mortality. Anatol J Cardiol 2020; 23:160-168. [PMID: 32120368 PMCID: PMC7222636 DOI: 10.14744/anatoljcardiol.2019.87894] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Objective: Heart failure (HF) is a progressive clinical syndrome. SELFIE-TR is a registry illustrating the overall HF patient profile of Turkey. Herein, all-cause mortality (ACM) data during follow-up were provided. Methods: This is a prospective outcome analysis of SELFIE-TR. Patients were classified as acute HF (AHF) versus chronic HF (CHF) and HF with reduced ejection fraction (HFrEF), HF with mid-range ejection fraction, and HF with preserved ejection fraction and were followed up for ACM. Results: There were 1054 patients with a mean age of 63.3±13.3 years and with a median follow-up period of 16 (7–17) months. Survival data within 1 year were available in 1022 patients. Crude ACM was 19.9% for 1 year in the whole group. ACM within 1 year was 13.7% versus 32.6% in patients with CHF and AHF, respectively (p<0.001). Angiotensin-converting enzyme inhibitor/angiotensin receptor blocker, beta blocker, and mineralocorticoid receptor antagonist were present in 70.6%, 88.2%, and 50.7%, respectively. In the whole cohort, survival curves were graded according to guideline-directed medical therapy (GDMT) scores ≤1 versus 2 versus 3 as 28% versus 20.2% versus 12.2%, respectively (p<0.001). Multivariate analysis of the whole cohort yielded age (p=0.009) and AHF (p=0.028) as independent predictors of mortality in 1 year. Conclusion: One-year mortality is high in Turkish patients with HF compared with contemporary cohorts with AHF and CHF. Of note, GDMT score is influential on 1-year mortality being the most striking one on chronic HFrEF. On the other hand, in the whole cohort, age and AHF were the only independent predictors of death in 1 year. (Anatol J Cardiol 2020; 23: 160-8)
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11
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Rueda-Camino JA, Saíz-Lou EM, Del Peral-Rodríguez LJ, Satué-Bartolomé JÁ, Zapatero-Gaviria A, Canora-Lebrato J. Prognostic utility of bedside lung ultrasound before discharge in patients with acute heart failure with preserved ejection fraction. Med Clin (Barc) 2020; 156:214-220. [PMID: 32546316 DOI: 10.1016/j.medcli.2020.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Revised: 03/05/2020] [Accepted: 03/12/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND AND OBJECTIVE The utility of lung ultrasound as a prognostic tool for patients with acute heart failure is well known, but most studies have been conducted in mixed groups of patients with preserved and reduced ejection fraction. While some subgroup analysis suggests that lung ultrasound is useful regardless of ejection fraction, no specific studies have addressed this question. Our objective is to determine the utility of bedside lung ultrasound as a prognostic tool for patients with preserved ejection fraction, acute heart failure. MATERIAL AND METHODS Prospective cohort study with 3-month follow-up after bedside lung ultrasound before discharge in patients hospitalized for acute heart failure with preserved ejection fraction. The number of Blines was determined. Two groups were formed: less than 15Blines (unexposed) and 15Blines or more (exposed). They were compared in terms of readmission and death attributable to worsening heart failure. RESULTS The exposed group was at higher risk of readmission (HR: 2.39; 95%CI: 1.12-5.12; P=.024), even after multivariable adjustment (HR: 2.46; 95%CI: 1.11-5.46, P=.03). Differences between groups in terms of mortality were not statistically significant (HR: 1.28; 95%CI: .23-6.98). CONCLUSION Subclinical congestion evaluated with lung ultrasound before discharge is associated with worse prognosis in patients with acute heart failure and preserved ejection fraction. Patients with 15Blines are 2.5times more likely to be readmitted for acute heart failure than less congestive patients.
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Affiliation(s)
- José Antonio Rueda-Camino
- Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España; Escuela Internacional de Doctorado, Universidad Rey Juan Carlos, Móstoles, Madrid, España.
| | - Elena María Saíz-Lou
- Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España
| | | | | | - Antonio Zapatero-Gaviria
- Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España; Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
| | - Jesús Canora-Lebrato
- Medicina Interna, Hospital Universitario de Fuenlabrada, Fuenlabrada, Madrid, España; Facultad de Ciencias de la Salud, Universidad Rey Juan Carlos, Alcorcón, Madrid, España
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12
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GFM, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Marinella Ruospo
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Patrizia Natale
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
| | - Robert R Quinn
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Paul E Ronksley
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical CenterDepartment of Medicine3459 Fifth AvenuePittsburghPAUSA15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of OtagoDepartment of Medicine, NephrologistChristchurchNew Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
| | - Giovanni FM Strippoli
- The University of SydneySydney School of Public HealthSydneyAustralia
- University of BariDepartment of Emergency and Organ TransplantationBariItaly
- The Children's Hospital at WestmeadCochrane Kidney and Transplant, Centre for Kidney ResearchWestmeadNSWAustralia2145
| | - Pietro Ravani
- University of CalgaryDepartment of Community Health Sciences3330 Hospital Drive NWCalgaryAlbertaCanadaT2N 4N1
- Cumming School of Medicine, University of CalgaryDepartment of MedicineCalgaryCanada
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13
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Berger S, Meyre P, Blum S, Aeschbacher S, Ruegg M, Briel M, Conen D. Bariatric surgery among patients with heart failure: a systematic review and meta-analysis. Open Heart 2018; 5:e000910. [PMID: 30613414 PMCID: PMC6307626 DOI: 10.1136/openhrt-2018-000910] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/22/2018] [Accepted: 11/15/2018] [Indexed: 02/06/2023] Open
Abstract
Background Bariatric surgery reduces cardiovascular risk in obese patients. Heart failure (HF) is associated with an increased perioperative risk following bariatric surgery. This systematic review aimed to assemble the evidence on bariatric surgery in patients with known HF and the potential effect of bariatric surgery on incident HF in obese patients without prevalent HF. Methods We performed a comprehensive literature search up to 30 September 2017 and included studies comparing bariatric surgery to non-surgical treatment in patients with known presurgical HF. To assess whether bariatric surgery has any effect on incident HF, we also assembled studies looking at new-onset HF among patients without HF prior to surgery. Results We found five observational studies (0 randomised trials) comparing bariatric surgery with non-surgical treatment in patients with a diagnosis of HF prior to surgery. A review of the available studies (n=676 patients) suggested reduced admission rates for HF exacerbation and increased left ventricular ejection fraction after bariatric surgery. No meta-analysis was possible due to the heterogeneous nature of these studies. Seven studies (one randomised trial) reported data on new-onset HF in obese patients without HF prior to bariatric surgery (n=111 127 patients). When comparing surgical to non-surgical treatment groups, the pooled univariable and multivariable HRs for incident HF were 0.28 (95% CI 0.13 to 0.55) and 0.44 (95% CI 0.36 to 0.55), respectively. Conclusion In this systematic review, no randomised trial assessed the benefits and risks of bariatric surgery in obese patients with concomitant HF. Available studies do, however, show that surgery might prevent incident HF.
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Affiliation(s)
- Sebastian Berger
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital of Basel, Basel, Switzerland
| | - Pascal Meyre
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital of Basel, Basel, Switzerland
| | - Steffen Blum
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital of Basel, Basel, Switzerland
| | - Stefanie Aeschbacher
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital of Basel, Basel, Switzerland
| | - Marco Ruegg
- Cardiovascular Research Institute Basel, University Hospital of Basel, Basel, Switzerland
| | - Matthias Briel
- Basel Institute for Clinical Epidemiology and Biostatistics, Department of Clinical Research, University Hospital of Basel, University of Basel, Basel, Switzerland.,Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - David Conen
- Cardiology Division, Department of Medicine, University Hospital of Basel, Basel, Switzerland.,Cardiovascular Research Institute Basel, University Hospital of Basel, Basel, Switzerland.,Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
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14
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Steinmann E, Brunner-La Rocca HP, Maeder MT, Kaufmann BA, Pfisterer M, Rickenbacher P. Is the clinical presentation of chronic heart failure different in elderly versus younger patients and those with preserved versus reduced ejection fraction? Eur J Intern Med 2018; 57:61-69. [PMID: 29908708 DOI: 10.1016/j.ejim.2018.06.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2018] [Revised: 05/16/2018] [Accepted: 06/06/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Whether the clinical presentation and in particular prevalence of symptoms and signs of heart failure (HF) is different in elderly versus younger patients and in those with reduced (HFrEF) versus preserved (HFpEF) left ventricular ejection fraction (LVEF) is a matter of ongoing debate. AIMS To compare detailed clinical characteristics of these important subgroups and to develop a prediction rule for the differentiation of HFpEF and HFrEF based on clinical parameters. METHODS The analysis was based on the Trial of Intensified versus standard Medical therapy in Elderly patients with Congestive Heart Failure (TIME-CHF) comprising 622 patients ≥60 years with HF including the whole LVEF spectrum. RESULTS In the groups ≥75 years and with HFpEF typical symptoms and clinical signs of HF were more prevalent as compared to those <75 years or with HFrEF, respectively. The burden of comorbidities was higher in the older age group. HFrEF could not be differentiated from HFpEF by symptom history and clinical examination alone. However, a combination of age, presence of pulmonary rales, systolic blood pressure, cause of heart failure, osteoporosis, current smoking, NT-proBNP, haemoglobin, QRS width and heart rhythm allowed to identify HFrEF versus HFpEF with a sensitivity of 81% and specificity of 90% (c-statistics 0.91). CONCLUSIONS More symptoms and signs of HF were present both in the older age group and in patients with HFpEF. HFpEF versus HFrEF could be differentiated by a set of simple clinical, laboratory and ECG parameters but not by symptom history and physical examination alone.
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Affiliation(s)
- Eva Steinmann
- Division of Cardiology, Internal Medicine University Department, Kantonsspital Baselland, 4101 Bruderholz, Switzerland
| | - Hans-Peter Brunner-La Rocca
- Division of Cardiology, University Hospital, University of Basel, Petersgraben 4, 4031 Basel, Switzerland; Department of Cardiology, Maastricht University Medical Center, P. Debyelaan 25, PO Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Micha T Maeder
- Cardiology Division, Kantonsspital St Gallen, Rohrschacherstr. 95, 9007 St. Gallen, Switzerland
| | - Beat A Kaufmann
- Division of Cardiology, University Hospital, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Matthias Pfisterer
- Division of Cardiology, University Hospital, University of Basel, Petersgraben 4, 4031 Basel, Switzerland
| | - Peter Rickenbacher
- Division of Cardiology, Internal Medicine University Department, Kantonsspital Baselland, 4101 Bruderholz, Switzerland; Division of Cardiology, University Hospital, University of Basel, Petersgraben 4, 4031 Basel, Switzerland.
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15
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Saksena S, Slee A, Saad M. Atrial resynchronization therapy in patients with atrial fibrillation and heart failure with and without systolic left ventricular dysfunction: a pilot study. J Interv Card Electrophysiol 2018; 53:9-17. [PMID: 29987682 DOI: 10.1007/s10840-018-0408-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 06/28/2018] [Indexed: 01/02/2023]
Abstract
BACKGROUND We examined the long-term (≥ 5 years) outcomes of dual-site atrial pacing (DAP) when added to background antiarrhythmic drugs (AADs) and/or ablation in patients with refractory atrial fibrillation (AF) and heart failure (HF). METHODS Seventy-three patients with HF (mean NYHA HF class of 2.5) and AF refractory to AADs and/or ablation were implanted with DAP systems to achieve biatrial electrical and mechanical resynchronization (ART) and rhythm control (RC). RESULTS Thirty-eight patients with refractory AF and HF with preserved ejection fraction (HFpEF) and 35 with reduced ejection fraction (HFrEF) were enrolled. HFpEF patients had higher left ventricular ejection fraction compared to HFrEF (53 ± 5 vs. 31 ± 10% p < 0.001). Median follow-up for survival was 9.3 years (mean 9.0 years, SE 0.63) and was similar across subgroups (p = 0.127). After DAP, 87% maintained RC with improvement in NYHA HF class (mean 1.8) at 3 years. RC was similar in HFpEF compared with HFrEF patients (89 vs. 85% respectively, p = NS) and in paroxysmal versus persistent AF (90 vs. 85% respectively, p = NS). Total survival was superior in HFpEF compared HFrEF patients (75% in HFpEF vs. 45% in HFrEF at 5 years, and 60% in HFpEF vs. 34% in HFrEF at 10 years, p = 0.036). Survival trended to be better in patients with RC than those without RC (75 vs. 54% respectively at 5 years, p = .13). CONCLUSIONS ART using DAP as add on therapy improved HF and established long-term RC in many patients with HFrEF and HFpEF with refractory AF. Long-term survival rates were superior in HFpEF than HFrEF.
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Affiliation(s)
- Sanjeev Saksena
- Electrophysiology Research Foundation, 161 Washington Valley Road, Suite 201, Warren, NJ, 07059, USA. .,Rutgers'- Robert Wood Johnson Medical School, Piscataway, NJ, USA.
| | - April Slee
- Electrophysiology Research Foundation, 161 Washington Valley Road, Suite 201, Warren, NJ, 07059, USA.,Rutgers'- Robert Wood Johnson Medical School, Piscataway, NJ, USA
| | - Marwan Saad
- Electrophysiology Research Foundation, 161 Washington Valley Road, Suite 201, Warren, NJ, 07059, USA.,Rutgers'- Robert Wood Johnson Medical School, Piscataway, NJ, USA
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16
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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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17
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Rossignol P, Ferreira JP, Zannad F. Fibrosis mechanistic phenotyping and antifibrotic response determination with biomarkers in heart failure: one single biomarker may not fit all settings. Eur J Heart Fail 2018; 20:1300-1302. [PMID: 29851257 DOI: 10.1002/ejhf.1214] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Affiliation(s)
- Patrick Rossignol
- Université de Lorraine, Inserm, Centre, d'Investigations Cliniques-Plurithématique 14-33, and Inserm U1116, Nancy CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre, d'Investigations Cliniques-Plurithématique 14-33, and Inserm U1116, Nancy CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre, d'Investigations Cliniques-Plurithématique 14-33, and Inserm U1116, Nancy CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
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18
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Eisenberg E, Di Palo KE, Piña IL. Sex differences in heart failure. Clin Cardiol 2018; 41:211-216. [PMID: 29485677 DOI: 10.1002/clc.22917] [Citation(s) in RCA: 86] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2017] [Revised: 01/24/2018] [Accepted: 02/02/2018] [Indexed: 12/17/2022] Open
Abstract
Heart failure (HF) numbers continue to grow in the United States and approximately 50% of patients living with HF are women. For the provider, it is critical to understand the role that gender plays in recognition, diagnosis, and management. The purpose of this literature review is to highlight the prevalence of heart failure in women and discuss gender variations in epidemiology, symptoms, pharmacology, and treatment as well as examine the representation of women in clinical trials.
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Affiliation(s)
- Evann Eisenberg
- Department of Cardiology, Cedars-Sinai Medical Center, California, Los Angeles
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19
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Pathogenesis, Clinical Features and Treatment of Diabetic Cardiomyopathy. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2017; 1067:197-217. [DOI: 10.1007/5584_2017_105] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
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20
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MacDonald MR, Wee PP, Cao Y, Yang DM, Lee S, Tong KL, Leong KTG. Comparison of Characteristics and Outcomes of Heart Failure Patients With Preserved Versus Reduced Ejection Fraction in a Multiethnic Southeast Asian Cohort. Am J Cardiol 2016; 118:1233-1238. [PMID: 27561195 DOI: 10.1016/j.amjcard.2016.07.039] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 07/10/2016] [Accepted: 07/10/2016] [Indexed: 11/28/2022]
Abstract
There are few data comparing the patient characteristics and outcomes of heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced EF (HFrEF) in Asian cohorts. We aimed to evaluate the prevalence, clinical characteristics, and 1-year outcomes of a well-defined Southeast Asian HFpEF cohort in comparison to an HFrEF cohort. We conducted a retrospective observational study of 1,978 patients discharged from Changi General Hospital, Singapore with a primary diagnosis of HF from 2009 to 2013. About 29% of discharges had HFpEF. Patients with HFpEF were more likely to be women, older age, and have a higher prevalence of hypertension. There were no significant differences in the absolute rates of 30-day outcomes between the 2 groups. The absolute rate of death at 1 year was similar in HFrEF and HFpEF at 17% and 15%, respectively (p = 0.3). After multivariate adjustment, there was no difference in the outcomes of the 2 groups. Atrial fibrillation at baseline was a predictor of death or HF hospitalization in HFpEF but not HFrEF (interaction p = 0.003). In conclusion, in this study of a Southeast Asian population with well-defined HF, we found that the clinical profile of patients with HF was similar to that in the West and 30-day and 1-year mortality and morbidity were not significantly different between cohorts.
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Affiliation(s)
| | - Pang Ping Wee
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Yan Cao
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Dong Mei Yang
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Sheldon Lee
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
| | - Khim Leng Tong
- Department of Cardiology, Changi General Hospital, Singapore, Singapore
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21
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Girerd N, Ferreira JP, Rossignol P, Zannad F. A tentative interpretation of the TOPCAT trial based on randomized evidence from the brain natriuretic peptide stratum analysis. Eur J Heart Fail 2016; 18:1411-1414. [DOI: 10.1002/ejhf.621] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2016] [Revised: 06/17/2016] [Accepted: 07/04/2016] [Indexed: 12/21/2022] Open
Affiliation(s)
- Nicolas Girerd
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116; Université de Lorraine; CHRU de Nancy, F-CRIN INI-CRCT Nancy France
| | - João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116; Université de Lorraine; CHRU de Nancy, F-CRIN INI-CRCT Nancy France
- Department of Physiology and Cardiothoracic Surgery, Cardiovascular Research and Development Unit, Faculty of Medicine; University of Porto; Porto Portugal
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116; Université de Lorraine; CHRU de Nancy, F-CRIN INI-CRCT Nancy France
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116; Université de Lorraine; CHRU de Nancy, F-CRIN INI-CRCT Nancy France
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22
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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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23
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Lewis EF, Kim HY, Claggett B, Spertus J, Heitner JF, Assmann SF, Kenwood CT, Solomon SD, Desai AS, Fang JC, McKinlay SA, Pitt BA, Pfeffer MA. Impact of Spironolactone on Longitudinal Changes in Health-Related Quality of Life in the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial. Circ Heart Fail 2016; 9:e001937. [PMID: 26962133 DOI: 10.1161/circheartfailure.114.001937] [Citation(s) in RCA: 61] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Heart failure (HF) with preserved ejection fraction patients have equally impaired health-related quality of life (HRQL) compared with those with HF with reduced ejection fraction, but limited studies have evaluated the impact of therapies on changes in HRQL. METHODS AND RESULTS Patients ≥50 years of age, with symptomatic HF and left ventricular ejection fraction ≥45%, were enrolled in Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist (TOPCAT) and randomized to spironolactone or placebo. Patients completed the Kansas City Cardiomyopathy Questionnaire (KCCQ), which was the primary HRQL instrument, and EQ5D visual analog scale at baseline, 4 months, 12 months, and annually thereafter. McMaster Overall Treatment Evaluation was assessed at 4 and 12 months to assess global change scores. Change scores (+SD) were calculated to determine between-group differences, and multivariable repeated-measures models were created to identify other factors associated with change scores. Paired KCCQ data were available for 91.7% of 3445 TOPCAT patients. By 4 months, the mean change in KCCQ was 7.7±16 and mean change in EQ5D visual analog scale was 4.7±16. Adjusted mean changes in KCCQ for the spironolactone group were significantly better than those for the placebo group at 4-month (1.54 better; P=0.002), 12-month (1.35 better; P=0.02), and 36-month (1.86 better; P=0.02) visits. No between-group differences in EQ5D visual analog scale change scores or McMaster Overall Treatment Evaluation were noted. Older age, obesity, current smoking, New York Heart Association class III/IV, and comorbid illnesses were associated with declines in KCCQ scores. Use of spironolactone was an independent predictor of improved KCCQ scores. CONCLUSIONS In symptomatic HF with preserved ejection fraction patients, use of spironolactone was associated with an improvement in HF-specific HRQL. Several modifiable risk factors were associated with HRQL deterioration. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT00094302.
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Affiliation(s)
- Eldrin F Lewis
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.).
| | - Hae-Young Kim
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Brian Claggett
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - John Spertus
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - John F Heitner
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Susan F Assmann
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Christopher T Kenwood
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Scott D Solomon
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Akshay S Desai
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - James C Fang
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Sonia A McKinlay
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Bertram A Pitt
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
| | - Marc A Pfeffer
- From the Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (E.F.L., B.C., S.D.S., A.S.D., M.A.P.); New England Research Institutes, Watertown, MA (H.-Y.K., S.F.A., C.T.K., S.A.M.); Mid America Heart Institute/UMKC, Kansas City, MO (J.S.); Division of Cardiology, New York Methodist Hospital, Brooklyn (J.F.H.); University of Utah, Division of Cardiology, Salt Lake City (J.C.F.); and University of Michigan School of Medicine, Ann Arbor (B.A.P.)
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Desai AS, Jhund PS. After TOPCAT: What to do now in Heart Failure with Preserved Ejection Fraction. Eur Heart J 2016; 37:3135-3140. [PMID: 27075872 DOI: 10.1093/eurheartj/ehw114] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2015] [Revised: 03/01/2016] [Accepted: 03/01/2016] [Indexed: 12/13/2022] Open
Abstract
Although patients with heart failure and preserved ejection fraction (HF-PEF) represent nearly half of the population with chronic heart failure, few evidence-based medical therapies are available. The neutral overall results of the TOPCAT trial of spironolactone in HF-PEF leave clinicians who treat heart failure with an ongoing clinical dilemma. In this review, we outline an approach to the clinical management of the patient with HF-PEF synthesizing data from available clinical trials and expert consensus.
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Affiliation(s)
- Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, 75 Francis Street, MA 02115, Boston, USA
| | - Pardeep S Jhund
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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25
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Alehagen U, Benson L, Edner M, Dahlström U, Lund LH. Association Between Use of Statins and Mortality in Patients With Heart Failure and Ejection Fraction of ≥50%. Circ Heart Fail 2015; 8:862-70. [DOI: 10.1161/circheartfailure.115.002143] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Accepted: 07/29/2015] [Indexed: 11/16/2022]
Abstract
Background—
The pathophysiology of heart failure with preserved ejection fraction is poorly understood, but may involve a systemic proinflammatory state. Therefore, statins might improve outcomes in patients with heart failure with preserved ejection fraction defined as ≥50%.
Methods and Results—
Of 46 959 unique patients in the prospective Swedish Heart Failure Registry, 9140 patients had heart failure and ejection fraction ≥50% (age 77±11 years, 54.0% women), and of these, 3427 (37.5%) were treated with statins. Propensity scores for statin treatment were derived from 40 baseline variables. The association between statin use and primary (all-cause mortality) and secondary (separately, cardiovascular mortality, and combined all-cause mortality or cardiovascular hospitalization) end points was assessed with Cox regressions in a population matched 1:1 based on age and propensity score. In the matched population, 1-year survival was 85.1% for statin-treated versus 80.9% for untreated patients (hazard ratio, 0.80; 95% confidence interval, 0.72–0.89;
P
<0.001). Statins were also associated with reduced cardiovascular death (hazard ratio, 0.86; 95% confidence interval, 0.75–0.98;
P
=0.026) and composite all-cause mortality or cardiovascular hospitalization (hazard ratio, 0.89; 95% confidence interval, 0.82–0.96;
P
=0.003).
Conclusions—
In heart failure with ejection fraction ≥50%, the use of statins was associated with improved outcomes. The mechanisms should be evaluated and the effects tested in a randomized trial.
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Affiliation(s)
- Urban Alehagen
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
| | - Lina Benson
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
| | - Magnus Edner
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
| | - Ulf Dahlström
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
| | - Lars H. Lund
- From the Department of Cardiology and Department of Medical and Health Sciences, Linköping University, Linköping, Sweden (U.A., U.D.); Department of Clinical Science and Education, Karolinska Institutet, Stockholm, Sweden (L.B.); and Department of Cardiology, Karolinska University Hospital and Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden (M.E., L.H.L.)
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Campbell RT, McMurray JJV. Comorbidities and differential diagnosis in heart failure with preserved ejection fraction. Heart Fail Clin 2015; 10:481-501. [PMID: 24975911 DOI: 10.1016/j.hfc.2014.04.009] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Careful consideration must be given when diagnosing heart failure with preserved ejection fraction (HF-PEF). HF-PEF diagnosis is challenging and essentially a diagnosis of exclusion, with comorbidities potentially making the diagnosis more difficult. This article describes the comorbidities commonly associated with HF-PEF, the potential influence of these comorbidities on morbidity and mortality, and the differential diagnosis.
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Affiliation(s)
- Ross T Campbell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK.
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Gopal CP, Ranga A, Joseph KL, Tangiisuran B. Development and validation of algorithms for heart failure patient care: a Delphi study. Singapore Med J 2014; 56:217-23. [PMID: 25532514 DOI: 10.11622/smedj.2014190] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
INTRODUCTION Although heart failure (HF) management is available at primary and secondary care facilities in Malaysia, the optimisation of drug therapy is still suboptimal. Although pharmacists can help bridge the gap in optimising HF therapy, pharmacists in Malaysia currently do not manage and titrate HF pharmacotherapy. The aim of this study was to develop treatment algorithms and monitoring protocols for angiotensin converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers and spironolactone based on extensive literature review for validation and utilization by pharmacists involved in HF management. METHODS A Delphi survey involving 32 panellists, from private and government hospitals that provide cardiac services in Malaysia, was conducted to obtain a consensus opinion on the treatment protocols. The panellists completed two rounds of self-administered questionnaires to determine their level of agreement with all the components in the protocols. RESULTS Consensus agreement was achieved for most of the sections of the protocols for the four classes of drugs. Panellists' opinions were taken into consideration when amending the components of the protocols that did not achieve consensus opinion. Full consensus agreement was achieved with the second survey conducted, enabling the finalisation of the drug titration protocols. CONCLUSION The resulting validated HF titration protocols can be used as a guide for pharmacists when recommending the initiation and titration of HF drug therapy in daily clinical practice. Recommendations should be made in collaboration with the patient's treating physician, with concomitant monitoring of patient's response to the drugs.
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The accuracy of interqual criteria in determining the need for observation versus hospitalization in emergency department patients with chronic heart failure. Crit Pathw Cardiol 2014; 12:192-6. [PMID: 24240548 DOI: 10.1097/hpc.0b013e3182a313e1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
McKesson's Interqual criteria are one of the medical screening criteria that are widely used in emergency departments (EDs) to determine if patients qualify for observation or inpatient admission. Chronic heart failure (CHF) is one of the most common yet severe cardiovascular diseases seen in the ED with a relatively higher admission rate. This study is to evaluate the accuracy of Interqual criteria in determining observation versus hospitalization need in CHF patients. From January 2009 till December 2010, data from 503 CHF patients were reviewed. One hundred twenty-two patients were observed and 381 patients were admitted. Only one variable (blood urea nitrogen, ≥30 mg/dL; odds ratio, 2.44) from Interqual criteria had reached statistical significant difference between observation and hospitalization groups. Our results showed that based on the initial review at ED, clinical variables from Interqual criteria did not appear to help accurately predict the level of care in CHF patient in our patient population. Other clinical variables may need to be added in the criteria for better prediction.
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McMurray JJV, Packer M, Desai AS, Gong J, Lefkowitz M, Rizkala AR, Rouleau JL, Shi VC, Solomon SD, Swedberg K, Zile MR. Baseline characteristics and treatment of patients in prospective comparison of ARNI with ACEI to determine impact on global mortality and morbidity in heart failure trial (PARADIGM-HF). Eur J Heart Fail 2014; 16:817-25. [PMID: 24828035 PMCID: PMC4312884 DOI: 10.1002/ejhf.115] [Citation(s) in RCA: 137] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2014] [Accepted: 04/02/2014] [Indexed: 11/12/2022] Open
Abstract
AIM To describe the baseline characteristics and treatment of the patients randomized in the PARADIGM-HF (Prospective comparison of ARNi with ACEi to Determine Impact on Global Mortality and morbidity in Heart Failure) trial, testing the hypothesis that the strategy of simultaneously blocking the renin-angiotensin-aldosterone system and augmenting natriuretic peptides with LCZ696 200 mg b.i.d. is superior to enalapril 10 mg b.i.d. in reducing mortality and morbidity in patients with heart failure and reduced ejection fraction. METHODS Key demographic, clinical and laboratory findings, along with baseline treatment, are reported and compared with those of patients in the treatment arm of the Studies Of Left Ventricular Dysfunction (SOLVD-T) and more contemporary drug and device trials in heart failure and reduced ejection fraction. RESULTS The mean age of the 8442 patients in PARADIGM-HF is 64 (SD 11) years and 78% are male, which is similar to SOLVD-T and more recent trials. Despite extensive background therapy with beta-blockers (93% patients) and mineralocorticoid receptor antagonists (60%), patients in PARADIGM-HF have persisting symptoms and signs, reduced health related quality of life, a low LVEF (mean 29 ± SD 6%) and elevated N-terminal-proB type-natriuretic peptide levels (median 1608 inter-quartile range 886-3221 pg/mL). CONCLUSION PARADIGM-HF will determine whether LCZ696 is more beneficial than enalapril when added to other disease-modifying therapies and if further augmentation of endogenous natriuretic peptides will reduce morbidity and mortality in heart failure and reduced ejection fraction.
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Affiliation(s)
- John J V McMurray
- BHF Cardiovascular Research Centre, University of GlasgowGlasgow, Scotland, UK
| | - Milton Packer
- University of Texas Southwestern Medical CenterDallas, TX, USA
| | - Akshay S Desai
- Brigham and Women's Hospital, Cardiovascular MedicineMA, USA
| | - Jianjian Gong
- Novartis Pharmaceutical CorporationEast Hanover, NJ, USA
| | | | - Adel R Rizkala
- Novartis Pharmaceutical CorporationEast Hanover, NJ, USA
| | - Jean L Rouleau
- Université de Montréal, Institut de CardiologieMontréal, Canada
| | - Victor C Shi
- Novartis Pharmaceutical CorporationEast Hanover, NJ, USA
| | - Scott D Solomon
- Brigham and Women's Hospital, Cardiovascular MedicineMA, USA
| | - Karl Swedberg
- Department of Molecular and Clinical MedicineGothenburg, Sweden
| | - Michael R Zile
- The Medical University of South Carolina and RHJ Department of Veterans Administration Medical CenterCharleston, SC, USA
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Pitt B, Pfeffer MA, Assmann SF, Boineau R, Anand IS, Claggett B, Clausell N, Desai AS, Diaz R, Fleg JL, Gordeev I, Harty B, Heitner JF, Kenwood CT, Lewis EF, O'Meara E, Probstfield JL, Shaburishvili T, Shah SJ, Solomon SD, Sweitzer NK, Yang S, McKinlay SM. Spironolactone for heart failure with preserved ejection fraction. N Engl J Med 2014; 370:1383-92. [PMID: 24716680 DOI: 10.1056/nejmoa1313731] [Citation(s) in RCA: 1724] [Impact Index Per Article: 172.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Mineralocorticoid-receptor antagonists improve the prognosis for patients with heart failure and a reduced left ventricular ejection fraction. We evaluated the effects of spironolactone in patients with heart failure and a preserved left ventricular ejection fraction. METHODS In this randomized, double-blind trial, we assigned 3445 patients with symptomatic heart failure and a left ventricular ejection fraction of 45% or more to receive either spironolactone (15 to 45 mg daily) or placebo. The primary outcome was a composite of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for the management of heart failure. RESULTS With a mean follow-up of 3.3 years, the primary outcome occurred in 320 of 1722 patients in the spironolactone group (18.6%) and 351 of 1723 patients in the placebo group (20.4%) (hazard ratio, 0.89; 95% confidence interval [CI], 0.77 to 1.04; P=0.14). Of the components of the primary outcome, only hospitalization for heart failure had a significantly lower incidence in the spironolactone group than in the placebo group (206 patients [12.0%] vs. 245 patients [14.2%]; hazard ratio, 0.83; 95% CI, 0.69 to 0.99, P=0.04). Neither total deaths nor hospitalizations for any reason were significantly reduced by spironolactone. Treatment with spironolactone was associated with increased serum creatinine levels and a doubling of the rate of hyperkalemia (18.7%, vs. 9.1% in the placebo group) but reduced hypokalemia. With frequent monitoring, there were no significant differences in the incidence of serious adverse events, a serum creatinine level of 3.0 mg per deciliter (265 μmol per liter) or higher, or dialysis. CONCLUSIONS In patients with heart failure and a preserved ejection fraction, treatment with spironolactone did not significantly reduce the incidence of the primary composite outcome of death from cardiovascular causes, aborted cardiac arrest, or hospitalization for the management of heart failure. (Funded by the National Heart, Lung, and Blood Institute; TOPCAT ClinicalTrials.gov number, NCT00094302.).
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Affiliation(s)
- Bertram Pitt
- From the University of Michigan School of Medicine, Ann Arbor (B.P.); the Cardiovascular Division, Brigham and Women's Hospital, Boston (M.A.P., B.C., A.S.D., E.F.L., S.D.S.); New England Research Institutes, Watertown, MA (S.F.A., B.H., C.T.K., S.M.M.); National Heart, Lung, and Blood Institute, Bethesda, MD (R.B., J.L.F., S.Y.); Veterans Affairs Medical Center and University of Minnesota, Minneapolis (I.S.A.); Hospital de Clinicas de Porto Alegre, Porto Alegre, Brazil (N.C.); Estudios Clinicos Latinoamerica, Rosario, Argentina (R.D.); Pirogov Russian National Research Medical University, Moscow (I.G.); New York Methodist Hospital, Brooklyn (J.F.H.); Montreal Heart Institute, Montreal (E.O.); University of Washington Medical Center, Seattle (J.L.P.); Diagnostic Services Clinic, Tbilisi, Georgia (T.S.); Northwestern University, Chicago (S.J.S.); and the University of Wisconsin, Madison (N.K.S.)
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Iversen KK, Kjaergaard J, Akkan D, Kober L, Torp-Pedersen C, Hassager C, Vestbo J, Kjoller E. The prognostic importance of lung function in patients admitted with heart failure. Eur J Heart Fail 2014; 12:685-91. [DOI: 10.1093/eurjhf/hfq050] [Citation(s) in RCA: 87] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
| | - Jesper Kjaergaard
- The Heart Centre; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Dilek Akkan
- The Heart Centre; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Lars Kober
- The Heart Centre; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Christian Torp-Pedersen
- Department of Cardiology; Copenhagen University Hospital, Gentofte Hospital; Copenhagen Denmark
| | - Christian Hassager
- The Heart Centre; Copenhagen University Hospital, Rigshospitalet; Copenhagen Denmark
| | - Jorgen Vestbo
- Department of Cardiology and Respiratory Medicine; Copenhagen University Hospital, Hvidovre Hospital; Hvidovre Denmark
- School of Translational Medicine; University of Manchester, Wythenshawe Hospital; Manchester UK
| | - Erik Kjoller
- Department of Cardiology S105; Copenhagen University Hospital, Herlev Hospital; Herlev Ringvej 75, DK-2730 Herlev Copenhagen Denmark
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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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Ghali JK, Lindenfeld J. Sex differences in response to chronic heart failure therapies. Expert Rev Cardiovasc Ther 2014; 6:555-65. [DOI: 10.1586/14779072.6.4.555] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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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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Effects of co-administration of candesartan with pioglitazone on inflammatory parameters in hypertensive patients with type 2 diabetes mellitus: a preliminary report. Cardiovasc Diabetol 2013; 12:71. [PMID: 23635096 PMCID: PMC3663745 DOI: 10.1186/1475-2840-12-71] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2013] [Accepted: 04/19/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Angiotensin receptor blockers (ARBs) are reported to provide direct protection to many organs by controlling inflammation and decreasing oxidant stress. Pioglitazone, an anti-diabetic agent that improves insulin resistance, was also reported to decrease inflammation and protect against atherosclerosis. This study aimed to evaluate the utility of combination therapy with both medicines from the viewpoint of anti-inflammatory effects. METHODS We administered candesartan (12 mg daily) and pioglitazone (15 mg daily) simultaneously for 6 months to hypertensive patients with type 2 diabetes mellitus (T2DM) and evaluated whether there were improvements in the serum inflammatory parameters of high-molecular-weight adiponectin (HMW-ADN), plasminogen activator inhibitor-1 (PAI-1), highly sensitive C-reactive protein (Hs-CRP), vascular cell adhesion molecule-1 (VCAM-1), and urinary-8-hydroxydeoxyguanosine (U-8-OHdG). We then analyzed the relationship between the degree of reductions in blood pressure and HbA1c values and improvements in inflammatory factors. Furthermore, we analyzed the relationship between pulse pressure and the degree of lowering of HbA1c and improvements in inflammatory factors. Finally, we examined predictive factors in patients who received benefits from the co-administration of candesartan with pioglitazone from the viewpoint of inflammatory factors. RESULTS After 6 months of treatment, in all patients significant improvements from baseline values were observed in HMW-ADN and PAI-1 but not in VCAM-1, Hs-CRP, and U-8-OHdG. Changes in HbA1c were significantly correlated with changes in HMW-ADN and PAI-1 in all patients, but changes in blood pressure were not correlated with any of the parameters examined. Correlation and multilinear regression analyses were performed to determine which factors could best predict changes in HbA1c. Interestingly, we found a significant positive correlation of pulse pressure values at baseline with changes in HbA1c. CONCLUSIONS Our data suggest that the pulse pressure value at baseline is a key predictive factor of changes in HbA1c. Co-administration of candesartan with pioglitazone, which have anti-inflammatory (changes in HMW-ADN and PAI-1) effects and protective effects on organs, could be an effective therapeutic strategy for treating hypertensive patients with type 2 diabetes mellitus. TRIAL REGISTRATION UMIN-CTR: UMIN000010142.
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McMurray JJ, Anand IS, Diaz R, Maggioni AP, O'Connor C, Pfeffer MA, Solomon SD, Tendera M, van Veldhuisen DJ, Albizem M, Cheng S, Scarlata D, Swedberg K, Young JB. Baseline characteristics of patients in the Reduction of Events with Darbepoetin alfa in Heart Failure trial (RED-HF). Eur J Heart Fail 2013; 15:334-41. [PMID: 23329651 PMCID: PMC3576902 DOI: 10.1093/eurjhf/hfs204] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2012] [Accepted: 11/07/2012] [Indexed: 12/12/2022] Open
Abstract
AIMS This report describes the baseline characteristics of patients in the Reduction of Events with Darbepoetin alfa in Heart Failure trial (RED-HF) which is testing the hypothesis that anaemia correction with darbepoetin alfa will reduce the composite endpoint of death from any cause or hospital admission for worsening heart failure, and improve other outcomes. METHODS AND RESULTS Key demographic, clinical, and laboratory findings, along with baseline treatment, are reported and compared with those of patients in other recent clinical trials in heart failure. Compared with other recent trials, RED-HF enrolled more elderly [mean age 70 (SD 11.4) years], female (41%), and black (9%) patients. RED-HF patients more often had diabetes (46%) and renal impairment (72% had an estimated glomerular filtration rate < 60 mL/min/1.73 m2). Patients in RED-HF had heart failure of longer duration [5.3 (5.4) years], worse NYHA class (35% II, 63% III, and 2% IV), and more signs of congestion. Mean EF was 30% (6.8%). RED-HF patients were well treated at randomization, and pharmacological therapy at baseline was broadly similar to that of other recent trials, taking account of study-specific inclusion/exclusion criteria. Median (interquartile range) haemoglobin at baseline was 112 (106-117) g/L. CONCLUSION The anaemic patients enrolled in RED-HF were older, moderately to markedly symptomatic, and had extensive co-morbidity.
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Affiliation(s)
- John J.V. McMurray
- Institute of Cardiovascular and Medical Sciences, BHF Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - Inder S. Anand
- University of Minnesota Medical School and VA Medical Center, Minneapolis, MN, USA
| | - Rafael Diaz
- Estudios Clinicos Latinoamerica, Rosario, Argentina
| | | | | | | | | | - Michal Tendera
- Division of Cardiology, Medical University of Silesia, Katowice, Poland
| | | | | | | | | | - Karl Swedberg
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Sweden
| | - James B. Young
- Department of Medicine, Endocrinology and Metabolism Institute, Cleveland Clinic, Cleveland, OH, USA
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Falla cardiaca con función sistólica preservada: Estudio i-prefer colombia, reflejo de la vida real. REVISTA COLOMBIANA DE CARDIOLOGÍA 2013. [DOI: 10.1016/s0120-5633(13)70028-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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Shah SJ, Heitner JF, Sweitzer NK, Anand IS, Kim HY, Harty B, Boineau R, Clausell N, Desai AS, Diaz R, Fleg JL, Gordeev I, Lewis EF, Markov V, O'Meara E, Kobulia B, Shaburishvili T, Solomon SD, Pitt B, Pfeffer MA, Li R. Baseline characteristics of patients in the treatment of preserved cardiac function heart failure with an aldosterone antagonist trial. Circ Heart Fail 2013; 6:184-92. [PMID: 23258572 PMCID: PMC3605409 DOI: 10.1161/circheartfailure.112.972794] [Citation(s) in RCA: 138] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2012] [Accepted: 12/10/2012] [Indexed: 01/15/2023]
Abstract
BACKGROUND Treatment of Preserved Cardiac Function with an Aldosterone Antagonist (TOPCAT) is an ongoing randomized controlled trial of spironolactone versus placebo for heart failure with preserved ejection fraction (HFpEF). We sought to describe the baseline clinical characteristics of subjects enrolled in TOPCAT relative to other contemporary observational studies and randomized clinical trials of HFpEF. METHODS AND RESULTS Between August 2006 and January 2012, 3445 patients with symptomatic HFpEF from 270 sites in 6 countries were enrolled in TOPCAT. At the baseline study visit, all subjects provided a detailed medical history and underwent physical examination, electrocardiography, quality of life, and laboratory assessment. Key parameters were compared with other large, contemporary HFpEF studies. The mean age was 68.6±9.6 years with a slight female predominance (52%); mean body mass index was 32 kg/m2; and comorbidities were common. History of hypertension (91% prevalence in TOPCAT) exceeded all other major HFpEF clinical trials. However, baseline blood pressure was well controlled (129/76 mm Hg; systolic blood pressure 7-16 mm Hg lower than other similar trials). Other common comorbidities included coronary artery disease (57%), atrial fibrillation (35%), chronic kidney disease (38%) and diabetes mellitus (32%). Self-reported activity levels were low, quality of life scores were comparable with those reported for patients with end-stage renal disease, and the prevalence of moderate or greater depression was 27%. CONCLUSIONS TOPCAT subjects share many common characteristics with contemporary HFpEF cohorts. Low activity level, significantly decreased quality of life, and depression were common at baseline in TOPCAT, underscoring the continued unmet need for evidence-based treatment strategies in HFpEF. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. UNIQUE IDENTIFIER: NCT00094302.
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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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50 years of thiazides: should thiazide diuretics be considered third-line hypertension treatment? Am J Ther 2013; 18:e244-54. [PMID: 21436766 DOI: 10.1097/mjt.0b013e3181e90863] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
The purpose of this report is to review available and emerging antihypertensive treatment options in light of current guidelines and evidence from large clinical trials. The published literature was reviewed for evidence regarding first-line options for antihypertensive agents, including thiazide-type diuretics, as monotherapy or as part of combination therapy. Current guidelines recommend using thiazide-type diuretics as first-line therapy alone or in combination with another agent. Other commonly used antihypertensive agents include calcium channel blockers, β-adrenergic receptor blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and the direct renin inhibitor, aliskiren. These agents are associated with varying degrees of evidence that they may provide protection from cardiovascular or renal disease beyond that associated with blood pressure reduction. Thiazide diuretics are inexpensive and effective but may not be preferable to other classes of antihypertensives that reduce blood pressure to a similar extent with a better safety profile and superior reductions in cardiovascular event rates. However, calcium channel blockers, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, and direct renin inhibitors also show promise as initial monotherapy or as part of a combination therapy regimen. In patients requiring additional blood pressure reduction, add-on therapy with a diuretic could provide additional blood pressure-lowering efficacy.
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Benge CD, Muldowney JAS. The pharmacokinetics and pharmacodynamics of valsartan in the post-myocardial infarction population. Expert Opin Drug Metab Toxicol 2012; 8:1469-82. [PMID: 22998368 DOI: 10.1517/17425255.2012.725721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
INTRODUCTION The most common risk factors for heart failure are hypertension and myocardial infarction. Angiotensin receptor blockers (ARBs) attenuate the deleterious effects of angiotensin II. Valsartan is a once or twice daily ARB that is FDA-approved for hypertension, LV dysfunction post-myocardial infarction and congestive heart failure as both an adjunct in ACE-inhibitor tolerant, and alternative in ACE-I intolerant patients. AREAS COVERED This article presents a comprehensive review of the literature regarding the pharmacokinetics and pharmacodynamics of valsartan, with particular attention paid to the post-myocardial infarction population. EXPERT OPINION Valsartan is a safe, well-tolerated and readily titratable ARB. In addition to its vasodilatory effects there are pleotropic effects associated with the ARB such as modulation of a number of neurohormonal regulators, cytokines and small molecules. Given the clear evidence-based benefits above and beyond its hypertensive properties, it has the potential, if priced appropriately, to grow in its impact as a pharmacotherapeutic long after its patent expires.
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Affiliation(s)
- Cassandra D Benge
- Nashville Veterans Affairs Medical Center, Cardiology Section, 1310 24th Avenue South, Nashville, TN 37212-263, USA
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McSweeney J, Pettey C, Lefler LL, Heo S. Disparities in heart failure and other cardiovascular diseases among women. WOMEN'S HEALTH (LONDON, ENGLAND) 2012; 8:473-85. [PMID: 22757737 PMCID: PMC3459240 DOI: 10.2217/whe.12.22] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
This article reviews literature pertinent to cardiovascular disparities in women, focusing primarily on heart failure (HF). It provides an in-depth look at causes, biological influences, self-management and lack of adherence to HF-treatment guidelines in women. Disparities in treatment of causative factors of HF, such as myocardial infarction and hypertension, contribute to women having poorer HF outcomes than men. This article discusses major contributing reasons for nonadherence to medication regimes for HF in women, including advanced age at time of diagnosis, likelihood of multiple comorbidities, lack of social support and low socioeconomic status. Limited inclusion of women in clinical trials and the scarcity of gender analyses for HF and other cardiovascular diseases continues to limit the applicability of research findings to women.
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Affiliation(s)
- Jean McSweeney
- College of Nursing, University of Arkansas for Medical Sciences, Little Rock, AR 72205, USA.
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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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Cardiovascular medications and risk of cancer. Am J Cardiol 2011; 108:1045-51. [PMID: 21784384 DOI: 10.1016/j.amjcard.2011.05.041] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2011] [Revised: 05/23/2011] [Accepted: 05/23/2011] [Indexed: 02/08/2023]
Abstract
Cardiovascular disease and cancer are 2 of the leading causes of death globally. Certain cardiovascular medications have been linked to an increased risk for cancer. Although individual reviews of specific classes of cardiovascular medications have been published previously, a more complete review of several classes has not been performed. The aim of this review is to evaluate the associations of various cardiovascular agents with the risk for developing cancer and provide guidance for clinicians. A comprehensive search of published research was conducted using MEDLINE from 1994 to 2011. Three trials demonstrated an increased risk for cancer using angiotensin II receptor blockers. Additionally, risk for cancer was shown in a number of trials that included the use of angiotensin II receptor blockers in combination with angiotensin-converting enzyme inhibitors. Five trials suggested that diuretics increased the risk for specific cancers, especially in women and those who had been using diuretics for >4 years. Statins and ezetimibe, in contrast, did not show this increased risk. Prasugrel was shown to be associated with an increased risk for cancer in 1 study. It appears that the use of certain cardiovascular medications is associated with an increased risk for cancer. In conclusion, clinicians need to balance the risks and benefits of the use of these agents and provide the appropriate therapy on an individual basis.
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Ezekowitz JA, Thai V, Hodnefield TS, Sanderson L, Cujec B. The correlation of standard heart failure assessment and palliative care questionnaires in a multidisciplinary heart failure clinic. J Pain Symptom Manage 2011; 42:379-87. [PMID: 21444186 DOI: 10.1016/j.jpainsymman.2010.11.013] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2010] [Revised: 11/27/2010] [Accepted: 12/03/2010] [Indexed: 11/20/2022]
Abstract
CONTEXT Heart failure (HF) is a leading cause of death and disability, and despite optimal care, patients may eventually require palliative care. Little is known about how palliative care questionnaires (the Edmonton Symptom Assessment Scale [ESAS] and the Palliative Performance Scale [PPS]) perform compared with HF assessment using the New York Heart Association (NYHA) functional class and the Kansas City Cardiomyopathy Questionnaire (KCCQ). OBJECTIVES To assess the utility of a palliative care questionnaire in patients with HF. METHODS One hundred and five patients (mean age=65 years, 76% male, mean ejection fraction=28%) followed in an HF clinic were surveyed with the NYHA, PPS, ESAS, and KCCQ. RESULTS The PPS and ESAS were each correlated to the NYHA class (P<0.0001 for both) and the KCCQ score (PPS: R(2)=0.57; ESAS: R(2)=-0.72; both P<0.0001). There were 33 patients who either died (10 deaths) or were hospitalized (26 patients) for more than one year. In addition to age and gender, a higher (worse) ESAS score trended toward significance (P=0.07) and a lower (worse) PPS was a significant (P=0.04) predictor of all-cause hospitalization or death. CONCLUSION In a cohort of HF patients, we found a modest correlation with NYHA class and KCCQ assessment with the PPS and ESAS, two standard palliative care questionnaires. Given the difficulty in identifying patients with HF eligible for palliative or hospice care, these tools may be of use in clinical practice.
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Affiliation(s)
- Justin A Ezekowitz
- Division of Cardiology and Mazankowski Alberta Heart Institute, University of Alberta, Edmonton, Alberta.
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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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Demede M, Pandey A, Innasimuthu L, Jean-Louis G, McFarlane SI, Ogedegbe G. Management of hypertension in high-risk ethnic minority with heart failure. Int J Hypertens 2011; 2011:417594. [PMID: 21747977 PMCID: PMC3124316 DOI: 10.4061/2011/417594] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2011] [Accepted: 03/28/2011] [Indexed: 01/13/2023] Open
Abstract
Hypertension (HTN) is the most common co-morbidity in the world, and its sequelae, heart failure (HF) is one of most common causes of mortality and morbidity in the world. Current understanding of pathophysiology and management of HTN in HF is mainly based on studies, which have mainly included whites. Among racial groups, African-American adults have the highest rates (44%) of hypertension in the world and are more resistant to treatment. There is an emerging consensus on the significance of racial disparities in the pathophysiology and treatment options of hypertension and heart failure. However, African Americans had been underrepresented in all the trials until the initiation of the A-HEFT trial. Since the recognition of obstructive sleep apnea (OSA) as an important medical condition, large clinical trials have shown benefits of OSA treatment among patients with HTN and HF. This paper focuses on the pathophysiology, causes of secondary hypertension, and treatment of hypertension among African-American patients with heart failure. There is increasing need for randomized clinical trials testing innovative treatment options for African-American patients.
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Affiliation(s)
- M. Demede
- Division of Cardiovascular Medicine, Department of Medicine SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
- Brooklyn Health Disparities Center, Department of Medicine, SUNY Downstate Medical Center, NY 11203-2098, USA
| | - A. Pandey
- Division of Cardiovascular Medicine, Department of Medicine SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
- Brooklyn Health Disparities Center, Department of Medicine, SUNY Downstate Medical Center, NY 11203-2098, USA
| | - L. Innasimuthu
- Division of Cardiovascular Medicine, Department of Medicine SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
| | - G. Jean-Louis
- Division of Cardiovascular Medicine, Department of Medicine SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
- Sleep Disorders Center, Department of Medicine, SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
| | - S. I. McFarlane
- Division of Endocrinology, Department of Medicine SUNY Downstate Medical Center, 450 Clarkson Avenue, Brooklyn, NY 11203-2098, USA
| | - G. Ogedegbe
- Center for Healthful Behavior Change, Division of Internal Medicine, NYU Medical Center, New York, NY, USA
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Adlbrecht C, Neuhold S, Hülsmann M, Strunk G, Ehmsen U, Scholten C, Maurer G, Pacher R. NT-proBNP as a means of triage for the risk of hospitalisation in primary care. Eur J Prev Cardiol 2011; 19:55-61. [DOI: 10.1177/1741826710391545] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Christopher Adlbrecht
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Stephanie Neuhold
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Guido Strunk
- Complexity-Research, Research Institute for Complex Systems, Vienna, Austria
| | - Udo Ehmsen
- Physician in Private Practice, Vienna, Austria
| | | | - Gerald Maurer
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Richard Pacher
- Department of Internal Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria
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Amigoni M, Giannattasio C, Fraschini D, Galbiati M, Capra ACM, Madotto F, Cesana F, Jankovic M, Masera G, Mancia G. Low anthracyclines doses-induced cardiotoxicity in acute lymphoblastic leukemia long-term female survivors. Pediatr Blood Cancer 2010; 55:1343-7. [PMID: 20589666 DOI: 10.1002/pbc.22637] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
BACKGROUND High dosage anthracyclines in pediatric patients with acute lymphoblastic leukemia (ALL) is associated with cardiotoxicity. However, data on the cardiac effects of lower cumulative doses of these drugs are not conclusive. The aim of this study was to assess the cardiac effects of low cumulative anthracycline doses in long-term survivors of ALL. PROCEDURE Echocardiograms were performed on 62 long-term ALL survivors, without any overt or sub-clinical signs or symptoms of heart failure. The interval after stopping therapy was 12.6 ± 4.3 years; the mean cumulative dose of anthracyclines was 228.2 ± 42.3 mg/m(2) . Left ventricular (LV) structure and function were studied by echocolor-Doppler. An age, gender and body surface area (BSA) matched group of healthy subjects was used as controls. Cardiac data were analyzed before and after BSA normalization. RESULTS Long term survivors of ALL, showed a lower LV mass index, interventricular septal and posterior wall thickness, which were independently related to gender and to age at which the ALL diagnosis was made. Data analyzed according to gender showed that abnormalities were confined to the female group. No alterations were observed in the ALL male group versus the corresponding control group. No relationship was observed between the echocardiografic abnormalities and the duration of follow-up or the anthracycline mean dose employed. CONCLUSIONS In the absence of any signs or symptoms of heart failure, female ALL survivors treated with low cumulative anthracycline doses, showed a reduced LV mass and wall thickness. This suggests that in female ALL survivors an echocardyographic follow-up should be recommended.
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Affiliation(s)
- Maria Amigoni
- Clinica Medica, Milano-Bicocca University and S.Gerardo Hospital, Monza, Milan, Italy
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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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Granger BB, Ekman I, Granger CB, Ostergren J, Olofsson B, Michelson E, McMurray JJ, Yusuf S, Pfeffer MA, Swedberg K. Adherence to medication according to sex and age in the CHARM programme. Eur J Heart Fail 2009; 11:1092-8. [DOI: 10.1093/eurjhf/hfp142] [Citation(s) in RCA: 84] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Bradi B. Granger
- Duke University Health System; Duke University School of Nursing; DUMC PO Box 3943 Durham NC 27710 USA
| | - Inger Ekman
- Sahlgrenska Academy at University of Gothenburg; Institute of Health and Care Sciences; Gothenburg Sweden
| | | | | | | | | | | | - Salim Yusuf
- Hamilton Health Sciences and University; Hamilton ON Canada
| | - Marc A. Pfeffer
- Harvard Medical School; Brigham and Women's Hospital; Boston MA USA
| | - Karl Swedberg
- Department of Emergency and Cardiovascular Medicine; Sahlgrenska University Hospital/Ostra, Goteborg/Sahlgrenska Academy at University of Gothenburg; Gothenburg Sweden
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