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Sun J, Xie Z, Ye M, Xu H, Dong Y, Liu C, Zhu W. S 2I 2N 0-3 score predicts short- and long-term mortality and morbidity in HFrEF: a post-hoc analysis of the GUIDE-IT trial. ESC Heart Fail 2024; 11:1422-1434. [PMID: 38327133 PMCID: PMC11098633 DOI: 10.1002/ehf2.14689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/11/2023] [Accepted: 01/08/2024] [Indexed: 02/09/2024] Open
Abstract
AIMS This study investigated the S2I2N0-3 score, a simple tool comprising stroke history, insulin-treated diabetes, and N-terminal pro-brain natriuretic peptide, for forecasting mortality and morbidity in heart failure (HF) with reduced ejection fraction (HFrEF). METHODS AND RESULTS Analysing 890 GUIDE-IT HFrEF trial participants, we stratified them by baseline S2I2N0-3 risk score into three risk groups. We examined the score's association with five adverse outcomes over short (90 days) and extended periods (median follow-up of 15 months) using Cox and competing risk models. Our analysis revealed significant positive associations between the S2I2N0-3 strata and adverse outcomes. When analysed as a continuous variable, each point increment of the S2I2N0-3 score was associated with a higher risk of short- and long-term cardiovascular death [short term: hazard ratio (HR) 1.43, 95% confidence interval (CI) 1.03-1.98; long term: HR 1.18, 95% CI 1.02-1.38], all-cause death (HR 1.52, 95% CI 1.12-2.07; HR 1.18, 95% CI 1.03-1.36), HF hospitalization (HR 1.39, 95% CI 1.20-1.62; HR 1.18, 95% CI 1.06-1.31), any hospitalization (HR 1.19, 95% CI 1.06-1.34; HR 1.09, 95% CI 1.00-1.19), and the composite outcome of cardiovascular death and HF hospitalization (HR 1.39, 95% CI 1.21-1.60; HR 1.17, 95% CI 1.06-1.30). The S2I2N0-3 demonstrated reliable prognostic value, with C-indices ranging from 0.619 to 0.753 across outcomes and time points. When compared with the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score using Z-statistics, net reclassification index, and integrated discrimination improvement, the S2I2N0-3 showed comparable predictive power for all outcomes during both short- and long-term follow-ups. CONCLUSIONS The S2I2N0-3 risk score had modest predictive values for both short- and long-term clinical outcomes in HFrEF patients, offering equivalent performance to the established MAGGIC score.
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Affiliation(s)
- Junyi Sun
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Zhengshuo Xie
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Min Ye
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- Department of Medical Ultrasound, Institute of Diagnostic and Interventional UltrasoundThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - He Xu
- Center of Translational MedicineThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhouChina
| | - Yugang Dong
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Chen Liu
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
| | - Wengen Zhu
- Department of CardiologyThe First Affiliated Hospital of Sun Yat‐sen UniversityGuangzhou510080China
- NHC Key Laboratory of Assisted Circulation (Sun Yat‐sen University)GuangzhouChina
- National‐Guangdong Joint Engineering Laboratory for Diagnosis and Treatment of Vascular DiseasesGuangzhouChina
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McDowell K, Kondo T, Talebi A, Teh K, Bachus E, de Boer RA, Campbell RT, Claggett B, Desai AS, Docherty KF, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez F, Simpson J, Vaduganathan M, Jhund PS, Solomon SD, McMurray JJV. Prognostic Models for Mortality and Morbidity in Heart Failure With Preserved Ejection Fraction. JAMA Cardiol 2024; 9:457-465. [PMID: 38536153 PMCID: PMC10974691 DOI: 10.1001/jamacardio.2024.0284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/02/2024] [Indexed: 05/09/2024]
Abstract
Importance Accurate risk prediction of morbidity and mortality in patients with heart failure with preserved ejection fraction (HFpEF) may help clinicians risk stratify and inform care decisions. Objective To develop and validate a novel prediction model for clinical outcomes in patients with HFpEF using routinely collected variables and to compare it with a biomarker-driven approach. Design, Setting, and Participants Data were used from the Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure (DELIVER) trial to derive the prediction model, and data from the Angiotensin Receptor Neprilysin Inhibition in Heart Failure With Preserved Ejection Fraction (PARAGON-HF) and the Irbesartan in Heart Failure With Preserved Ejection Fraction Study (I-PRESERVE) trials were used to validate it. The outcomes were the composite of HF hospitalization (HFH) or cardiovascular death, cardiovascular death, and all-cause death. A total of 30 baseline candidate variables were selected in a stepwise fashion using multivariable analyses to create the models. Data were analyzed from January 2023 to June 2023. Exposures Models to estimate the 1-year and 2-year risk of cardiovascular death or hospitalization for heart failure, cardiovascular death, and all-cause death. Results Data from 6263 individuals in the DELIVER trial were used to derive the prediction model and data from 4796 individuals in the PARAGON-HF trial and 4128 individuals in the I-PRESERVE trial were used to validate it. The final prediction model for the composite outcome included 11 variables: N-terminal pro-brain natriuretic peptide (NT-proBNP) level, HFH within the past 6 months, creatinine level, diabetes, geographic region, HF duration, treatment with a sodium-glucose cotransporter 2 inhibitor, chronic obstructive pulmonary disease, transient ischemic attack/stroke, any previous HFH, and heart rate. This model showed good discrimination (C statistic at 1 year, 0.73; 95% CI, 0.71-0.75) in both validation cohorts (C statistic at 1 year, 0.71; 95% CI, 0.69-0.74 in PARAGON-HF and 0.75; 95% CI, 0.73-0.78 in I-PRESERVE) and calibration. The model showed similar discrimination to a biomarker-driven model including high-sensitivity cardiac troponin T and significantly better discrimination than the Meta-Analysis Global Group in Chronic (MAGGIC) risk score (C statistic at 1 year, 0.60; 95% CI, 0.58-0.63; delta C statistic, 0.13; 95% CI, 0.10-0.15; P < .001) and NT-proBNP level alone (C statistic at 1 year, 0.66; 95% CI, 0.64-0.68; delta C statistic, 0.07; 95% CI, 0.05-0.08; P < .001). Models derived for the prediction of all-cause and cardiovascular death also performed well. An online calculator was created to allow calculation of an individual's risk. Conclusions and Relevance In this prognostic study, a robust prediction model for clinical outcomes in HFpEF was developed and validated using routinely collected variables. The model performed better than NT-proBNP level alone. The model may help clinicians to identify high-risk patients and guide treatment decisions in HFpEF.
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Affiliation(s)
- Kirsty McDowell
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Atefeh Talebi
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Ken Teh
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Erasmus Bachus
- Department of Clinical Science, Lunds University Faculty of Medicine, Malmoe, Sweden
| | - Rudolf A. de Boer
- Erasmus Medical Centre, Department of Cardiology, Rotterdam, the Netherlands
| | - Ross T. Campbell
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Ashkay S. Desai
- Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Kieran F. Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | | | - Silvio E. Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, Connecticut
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, University of Missouri-Kansas City, Kansas City
| | - Carolyn S. P. Lam
- National Heart Centre Singapore, Singapore
- Cardiovascular Sciences Academic Clinical Programme, Duke-National University of Singapore, Singapore
| | - Felipe Martinez
- Instituto DAMIC, Cordoba National University, Cordoba, Argentina
| | - Joanne Simpson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, and Harvard Medical School, Boston, Massachusetts
| | - John J. V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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3
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Ferreira JP, Packer M, Sattar N, Butler J, González Maldonado S, Panova-Noeva M, Sumin M, Masson S, Pocock SJ, Anker SD, Zannad F, Januzzi JL. Insulin-like growth factor binding protein-7 concentrations in chronic heart failure: Results from the EMPEROR programme. Eur J Heart Fail 2024; 26:806-816. [PMID: 38587259 DOI: 10.1002/ejhf.3227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 03/12/2024] [Accepted: 03/26/2024] [Indexed: 04/09/2024] Open
Abstract
AIMS Insulin-like growth factor binding protein-7 (IGFBP7) is a biomarker of tissue senescence with a role in cardio-renal pathophysiology. The role of IGFBP7 as a prognostic biomarker across the full ejection fraction (EF) spectrum of heart failure (HF) remains less well understood. We examined associations between IGFBP7 and risk of cardio-renal outcomes regardless of EF and the effect of empagliflozin treatment on IGFBP7 concentrations among individuals with HF. METHODS AND RESULTS IGFBP7 was measured in 1125 study participants from the EMPEROR-Reduced and EMPEROR-Preserved trials. Cox regression was used to study associations with outcomes. Study participants with IGFBP7 levels in the highest tertile had a higher-risk clinical profile. In Cox proportional hazards models adjusted for clinical variables, N-terminal pro-B-type natriuretic peptide and high-sensitivity cardiac troponin T, baseline IGFBP7 values in the highest tertile predicted an increased risk of HF hospitalization or cardiovascular death (hazard ratio [HR] 2.00, 95% confidence interval [CI] 1.28-3.10, p = 0.002, p for trend <0.001) and higher risk of the renal composite endpoint (HR 4.66, 95% CI 1.61-13.53, p = 0.005, p for trend = 0.001), regardless of EF. Empagliflozin reduced risk for cardiovascular death/HF hospitalization irrespective of baseline IGFBP7 (p for trend across IGFBP7 tertiles = 0.26). Empagliflozin treatment was not associated with meaningful change in IGFBP7 at 12 or 52 weeks. CONCLUSION Across the entire left ventricular EF spectrum in the EMPEROR Programme, concentrations of the senescence-associated biomarker IGFBP7 were associated with higher risk clinical status and predicted adverse cardio-renal outcomes even in models adjusted for conventional biomarkers. Empagliflozin did not significantly affect IGFBP7 levels over time.
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Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM, Université de Lorraine, Nancy, France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), INSERM U1116, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Milton Packer
- Imperial College London, London, UK; Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Dallas, TX, USA; University of Mississippi Medical Center, Jackson, MS, USA
| | | | | | - Mikhail Sumin
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Serge Masson
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | | | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433, INSERM, CHRU, Nancy, France
| | - James L Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
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Ferreira JP, Packer M, Sattar N, Butler J, Pocock SJ, Anker SD, Maldonado SG, Panova-Noeva M, Sumin M, Masson S, Zannad F, Januzzi JL. Carbohydrate antigen 125 concentrations across the ejection fraction spectrum in chronic heart failure: The EMPEROR programme. Eur J Heart Fail 2024; 26:788-802. [PMID: 38439582 DOI: 10.1002/ejhf.3166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 01/30/2024] [Accepted: 02/01/2024] [Indexed: 03/06/2024] Open
Abstract
AIM Vascular congestion may lead to an increase of carbohydrate antigen 125 (CA-125). The role of CA-125 as a biomarker of congestion or for prognosis across the full ejection fraction (EF) spectrum of chronic heart failure (HF) remains unknown. METHODS AND RESULTS Serum CA-125 was measured in 1111 study participants from the EMPEROR-Reduced and EMPEROR-Preserved trials. Congestive signs and symptoms were evaluated across CA-125 tertiles. Cox regression was used to study the association with outcomes. The primary outcome was a composite of first HF hospitalization or cardiovascular (CV) death. No significant association was present between baseline CA-125 levels and congestive signs or symptoms. In the overall population, higher CA-125 levels were not associated with an increased risk of primary outcome (tertile 3 vs. tertile 1: hazard ratio [HR] 1.34; 95% confidence interval [CI] 0.91-1.96; p-trend = 0.11). However, higher CA-125 levels were associated with an increased risk of primary outcome in patients with HF and reduced EF (HFrEF; tertile 3 vs. tertile 1: HR 2.25 [95% CI 1.30-3.89]), but not among patients with preserved EF (HFpEF; tertile 3 vs. tertile 1: HR 0.68 [95% CI 0.38-1.21]); interaction-p = 0.02). Patients in the upper CA-125 tertile also showed the steepest estimated glomerular filtration rate decline over time (p-trend = 0.03). The effect of empagliflozin to reduce the risk of CV death or HF hospitalization appeared to be attenuated in those with lower baseline CA-125 levels (interaction-p-trend = 0.09). CONCLUSION Across the range of EF in patients with chronic HF enrolled in the EMPEROR trials, the majority of whom did not have clinical evidence of congestion, CA-125 concentrations were not significantly associated with congestive signs or symptoms. CA-125 concentrations may predict HF hospitalization/CV death in patients with HFrEF, but not those with HFpEF. CLINICAL TRIAL REGISTRATION EMPEROR-Reduced (NCT03057977), EMPEROR-Preserved (NCT03057951).
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Affiliation(s)
- João Pedro Ferreira
- Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Cardiovascular Research and Development Center (UnIC@RISE), Porto, Portugal
- Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Gaia, Portugal
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Cardiovascular Research and Development Center, Université de Lorraine, Nancy, France
| | - Milton Packer
- Imperial College London, London, UK
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Naveed Sattar
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | | | - Stefan D Anker
- Center for Regenerative Therapies, Berlin Institute of Health, Department of Cardiology, German Centre for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | | | - Mikhail Sumin
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Serge Masson
- Roche Diagnostics International Ltd, Rotkreuz, Switzerland
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM, Université de Lorraine, Nancy, France
| | - James L Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
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Duca ȘT, Badescu MC, Costache AD, Chetran A, Miftode RȘ, Tudorancea I, Mitu O, Afrăsânie I, Ciorap RG, Șerban IL, Pavăl DR, Dmour B, Cepoi MR, Costache-Enache II. Harmony in Chaos: Deciphering the Influence of Ischemic Cardiomyopathy and Non-Cardiac Comorbidities on Holter ECG Parameters in Chronic Heart Failure Patients: A Pilot Study. MEDICINA (KAUNAS, LITHUANIA) 2024; 60:342. [PMID: 38399629 PMCID: PMC10889994 DOI: 10.3390/medicina60020342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2024] [Revised: 02/06/2024] [Accepted: 02/17/2024] [Indexed: 02/25/2024]
Abstract
Background and Objective: In the landscape of heart failure, non-cardiac comorbidities represent a formidable challenge, imparting adverse prognostic implications. Holter ECG monitoring assumes a supplementary role in delineating myocardial susceptibility and autonomic nervous system dynamics. This study aims to explore the potential correlation between Holter ECG parameters and comorbidities in individuals with ischemic cardiomyopathy experiencing heart failure (HF), with a particular focus on the primary utility of these parameters as prognostic indicators. Materials and Methods: In this prospective inquiry, a cohort of 60 individuals diagnosed with heart failure underwent stratification into subgroups based on the presence of comorbidities, including diabetes, chronic kidney disease, obesity, or hyperuricemia. Upon admission, a thorough evaluation of all participants encompassed echocardiography, laboratory panel analysis, and 24 h Holter monitoring. Results: Significant associations were uncovered between diabetes and unconventional physiological indicators, specifically the Triangular index (p = 0.035) and deceleration capacity (p = 0.002). Pertaining to creatinine clearance, notable correlations surfaced with RMSSD (p = 0.026), PNN50 (p = 0.013), and high-frequency power (p = 0.026). An examination of uric acid levels and distinctive Holter ECG patterns unveiled statistical significance, particularly regarding the deceleration capacity (p = 0.045). Nevertheless, in the evaluation of the Body Mass Index, no statistically significant findings emerged concerning Holter ECG parameters. Conclusions: The identified statistical correlations between non-cardiac comorbidities and patterns elucidated in Holter ECG recordings underscore the heightened diagnostic utility of this investigative modality in the comprehensive evaluation of individuals grappling with HF. Furthermore, we underscore the critical importance of the thorough analysis of Holter ECG recordings, particularly with regard to subtle and emerging parameters that may be overlooked or insufficiently acknowledged.
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Affiliation(s)
- Ștefania-Teodora Duca
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
- Department of Cardiology, “St. Spiridon” Emergency County Hospital, 700111 Iasi, Romania;
| | - Minerva Codruta Badescu
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
- Department of III Internal Medicine Clinic, “St. Spiridon” Emergency County Hospital, 700111 Iasi, Romania
| | - Alexandru-Dan Costache
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
- Department of Cardiovascular Rehabilitation, Clinical Rehabilitation Hospital, 700661 Iasi, Romania
| | - Adriana Chetran
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
- Department of Cardiology, “St. Spiridon” Emergency County Hospital, 700111 Iasi, Romania;
| | - Radu Ștefan Miftode
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
- Department of Cardiology, “St. Spiridon” Emergency County Hospital, 700111 Iasi, Romania;
| | - Ionuț Tudorancea
- Department of Cardiology, “St. Spiridon” Emergency County Hospital, 700111 Iasi, Romania;
- Department of Morpho-Functional Science II-Physiology, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
| | - Ovidiu Mitu
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
- Department of Cardiology, “St. Spiridon” Emergency County Hospital, 700111 Iasi, Romania;
| | - Irina Afrăsânie
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
- Department of Cardiology, “St. Spiridon” Emergency County Hospital, 700111 Iasi, Romania;
| | - Radu-George Ciorap
- Department of Biomedical Science, Faculty of Medical Bioengineering, University of Medicine and Pharmacy “Grigore T. Popa”, 700145 Iasi, Romania;
| | - Ionela-Lăcrămioara Șerban
- Department of Morpho-Functional Science II-Physiology, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania;
| | - D. Robert Pavăl
- Faculty of Health Sciences and Sport, University of Stirling, Stirling FK9 4LA, UK;
| | - Bianca Dmour
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
| | - Maria-Ruxandra Cepoi
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
| | - Irina-Iuliana Costache-Enache
- Department of Internal Medicine I, Faculty of Medicine, University of Medicine and Pharmacy “Grigore T. Popa”, 700115 Iasi, Romania; (Ș.-T.D.); (A.C.); (R.Ș.M.); (O.M.); (I.A.); (B.D.); (M.-R.C.); (I.-I.C.-E.)
- Department of Cardiology, “St. Spiridon” Emergency County Hospital, 700111 Iasi, Romania;
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Ferreira JP, Butler J, Anker SD, Januzzi JL, Panova-Noeva M, Reese-Petersen AL, Sattar N, Schueler E, Pocock SJ, Filippatos G, Packer M, Sumin M, Zannad F. Effects of empagliflozin on collagen biomarkers in patients with heart failure: Findings from the EMPEROR trials. Eur J Heart Fail 2024; 26:274-284. [PMID: 38037709 DOI: 10.1002/ejhf.3101] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 11/09/2023] [Accepted: 11/27/2023] [Indexed: 12/02/2023] Open
Abstract
AIMS Extracellular matrix remodelling is one of the key pathways involved in heart failure (HF) progression. Sodium-glucose cotransporter 2 inhibitors (SGLT2i) may have a role in attenuating myocardial fibrosis. The impact of SGLT2i on blood markers of collagen turnover in humans is not fully elucidated. This study aimed to investigate the effect of empagliflozin on serum markers of collagen turnover in patients enrolled in the EMPEROR-Preserved and EMPEROR-Reduced trials. METHODS AND RESULTS Overall, 1084 patients (545 in empagliflozin and 539 in placebo) were included in the analysis. Procollagen type I carboxy-terminal propeptide (PICP), a fragment of N-terminal type III collagen (PRO-C3), procollagen type I amino-terminal peptide (PINP), a fragment of C-terminal type VIa3 collagen (PRO-C6), a fragment of type I collagen (C1M), and a fragment of type III collagen (C3M) were measured in serum at baseline, 12 and 52 weeks. A mixed model repeated measurements model was used to evaluate the effect of empagliflozin versus placebo on the analysed biomarkers. Higher baseline PICP, PRO-C6 and PINP levels were associated with older age, a more severe HF presentation, higher levels of natriuretic peptides and high-sensitivity troponin T, and the presence of comorbid conditions such as chronic kidney disease and atrial fibrillation. Higher PICP levels were associated with the occurrence of the study primary endpoint (a composite of HF hospitalization or cardiovascular death), and PRO-C6 and PINP were associated with the occurrence of sustained worsening of kidney function. On the other hand, PRO-C3, C1M, and C3M were not associated with worse HF severity or study outcomes. Compared to placebo, empagliflozin reduced PICP at week 12 by 5% and at week 52 by 8% (week 12: geometric mean ratio = 0.95, 95% confidence interval [CI] 0.91-0.99, p = 0.012; week 52: geometric mean ratio = 0.92, 95% CI 0.88-0.97, p = 0.003). Additionally, empagliflozin reduced PRO-C3 at week 52 by 7% (week 12: geometric mean ratio = 0.98, 95% CI 0.95-1.02, p = 0.42; week 52: geometric mean ratio = 0.93, 95% CI 0.89-0.98, p = 0.003), without impact on other collagen markers. CONCLUSION Our observations are consistent with experimental observations that empagliflozin down-regulates profibrotic signalling. The importance of such an effect for the clinical benefits of SGLT2i in HF remains to be elucidated.
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Affiliation(s)
- João Pedro Ferreira
- Department of Surgery and Physiology, Cardiovascular Research and Development Center (UnIC@RISE), Faculty of Medicine of the University of Porto, Porto, Portugal
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
- Cardiovascular Research and Development Center, Nancy, France
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS, USA
| | - Stefan D Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
- Institute of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - James L Januzzi
- Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | | | | | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Milton Packer
- Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Mikhail Sumin
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France
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7
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Burger PM, Savarese G, Tromp J, Adamson C, Jhund PS, Benson L, Hage C, Tay WT, Solomon SD, Packer M, Rossello X, McEvoy JW, De Bacquer D, Timmis A, Vardas P, Graham IM, Di Angelantonio E, Visseren FLJ, McMurray JJV, Lam CSP, Lund LH, Koudstaal S, Dorresteijn JAN, Mosterd A. Personalized lifetime prediction of survival and treatment benefit in patients with heart failure with reduced ejection fraction: The LIFE-HF model. Eur J Heart Fail 2023; 25:1962-1975. [PMID: 37691140 DOI: 10.1002/ejhf.3028] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2023] [Revised: 08/22/2023] [Accepted: 09/04/2023] [Indexed: 09/12/2023] Open
Abstract
AIMS Although trials have proven the group-level effectiveness of various therapies for heart failure with reduced ejection fraction (HFrEF), important differences in absolute effectiveness exist between individuals. We developed and validated the LIFEtime-perspective for Heart Failure (LIFE-HF) model for the prediction of individual (lifetime) risk and treatment benefit in patients with HFrEF. METHODS AND RESULTS Cox proportional hazards functions with age as the time scale were developed in the PARADIGM-HF and ATMOSPHERE trials (n = 15 415). Outcomes were cardiovascular death, heart failure (HF) hospitalization or cardiovascular death, and non-cardiovascular mortality. Predictors were age, sex, New York Heart Association class, prior HF hospitalization, diabetes mellitus, extracardiac vascular disease, systolic blood pressure, left ventricular ejection fraction, N-terminal pro-B-type natriuretic peptide, and glomerular filtration rate. The functions were combined in life-tables to predict individual overall and HF hospitalization-free survival. External validation was performed in the SwedeHF registry, ASIAN-HF registry, and DAPA-HF trial (n = 51 286). Calibration of 2- to 10-year risk was adequate, and c-statistics were 0.65-0.74. An interactive tool was developed combining the model with hazard ratios from trials to allow estimation of an individual's (lifetime) risk and treatment benefit in clinical practice. Applying the tool to the development cohort, combined treatment with a mineralocorticoid receptor antagonist, sodium-glucose cotransporter 2 inhibitor, and angiotensin receptor-neprilysin inhibitor was estimated to afford a median of 2.5 (interquartile range [IQR] 1.7-3.7) and 3.7 (IQR 2.4-5.5) additional years of overall and HF hospitalization-free survival, respectively. CONCLUSION The LIFE-HF model enables estimation of lifelong overall and HF hospitalization-free survival, and (lifetime) treatment benefit for individual patients with HFrEF. It could serve as a tool to improve the management of HFrEF by facilitating personalized medicine and shared decision-making.
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Affiliation(s)
- Pascal M Burger
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, Singapore, Singapore
- National University Health System Singapore, Singapore, Singapore
| | - Carly Adamson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lina Benson
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Camilla Hage
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Wan Ting Tay
- National Heart Centre Singapore, Singapore, Singapore
| | - Scott D Solomon
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Centre, Dallas, TX, USA
| | - Xavier Rossello
- Centro Nacional de Investigaciones Cardiovasculares, Madrid, Spain
| | - John W McEvoy
- National Institute for Prevention and Cardiovascular Health, National University of Ireland Galway, Galway, Ireland
| | - Dirk De Bacquer
- Department of Public Health and Primary Care, Ghent University, Ghent, Belgium
| | - Adam Timmis
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | | | - Ian M Graham
- School of Medicine, Trinity College Dublin, The University of Dublin, College Green, Dublin, Ireland
| | | | - Frank L J Visseren
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore, Singapore
- Duke-National University of Singapore, Singapore, Singapore
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | | | - Jannick A N Dorresteijn
- Department of Vascular Medicine, University Medical Centre Utrecht, Utrecht, The Netherlands
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8
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Zannad F, Crea F, Keaney J, Spencer S, Hill JA, Pfeffer MA, Pocock S, Raderschadt E, Ross JS, Sacks CA, Van Spall HGC, Winslow R, Jessup M. Rapid, accurate publication and dissemination of clinical trial results: benefits and challenges. Eur Heart J 2023; 44:4220-4229. [PMID: 37165687 DOI: 10.1093/eurheartj/ehad279] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2023] [Revised: 03/13/2023] [Accepted: 04/02/2023] [Indexed: 05/12/2023] Open
Abstract
Large-scale clinical trials are essential in cardiology and require rapid, accurate publication, and dissemination. Whereas conference presentations, press releases, and social media disseminate information quickly and often receive considerable coverage by mainstream and healthcare media, they lack detail, may emphasize selected data, and can be open to misinterpretation. Preprint servers speed access to research manuscripts while awaiting acceptance for publication by a journal, but these articles are not formally peer-reviewed and sometimes overstate the findings. Publication of trial results in a major journal is very demanding but the use of existing checklists can help accelerate the process. In case of rejection, procedures such as easing formatting requirements and possibly carrying over peer-review to other journals could speed resubmission. Secondary publications can help maximize benefits from clinical trials; publications of secondary endpoints and subgroup analyses further define treatment effects and the patient populations most likely to benefit. These rely on data access, and although data sharing is becoming more common, many challenges remain. Beyond publication in medical journals, there is a need for wider knowledge dissemination to maximize impact on clinical practice. This might be facilitated through plain language summary publications. Social media, websites, mainstream news outlets, and other publications, although not peer-reviewed, are important sources of medical information for both the public and for clinicians. This underscores the importance of ensuring that the information is understandable, accessible, balanced, and trustworthy. This report is based on discussions held on December 2021, at the 18th Global Cardiovascular Clinical Trialists meeting, involving a panel of editors of some of the top medical journals, as well as members of the lay press, industry, and clinical trialists.
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Affiliation(s)
- Faiez Zannad
- Université de Lorraine, INSERM, CIC 1439, Institut Lorrain du Coeur et des Vaisseaux, CHU 54500, Vandoeuvre-lès-Nancy, France
| | - Filippo Crea
- Department of Cardiovascular and Pneumological Sciences, Catholic University of the Sacred Heart, Rome 00168, Italy
| | - John Keaney
- Division of Cardiovascular Medicine, Heart and Vascular Center, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | | | - Joseph A Hill
- Department of Internal Medicine and Department of Molecular Biology, UT Southwestern Medical Center, Dallas, TX 75390, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School Boston, MA 02115, USA
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, London, WC1E 7HT, UK
| | - Emma Raderschadt
- Global Medical Affairs, Boehringer Ingelheim, Siegburg, 55218, Germany
| | - Joseph S Ross
- Department of Medicine, Yale School of Medicine, New Haven, 06510, USA
| | | | - Harriette G C Van Spall
- Department of Medicine, and Department of Health Research Methods, Evidence, and Impact, McMaster University; Population Health Research Institute; Research Institute of St. Joseph's, Hamilton, ON L8N 4A6, Canada
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Packer M, Butler J, Zeller C, Pocock SJ, Brueckmann M, Ferreira JP, Filippatos G, Usman MS, Zannad F, Anker SD. Blinded Withdrawal of Long-Term Randomized Treatment With Empagliflozin or Placebo in Patients With Heart Failure. Circulation 2023; 148:1011-1022. [PMID: 37621153 PMCID: PMC10516173 DOI: 10.1161/circulationaha.123.065748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 08/03/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND It is not known whether the benefits of sodium-glucose cotransporter 2 inhibitors in heart failure persist after years of therapy. METHODS In the EMPEROR-Reduced (Empagliflozin Outcome Trials in Chronic Heart Failure With Reduced Ejection Fraction) and EMPEROR-Preserved (Empagliflozin Outcome Trials in Chronic Heart Failure With Preserved Ejection Fraction) trials, patients with heart failure were randomly assigned (double-blind) to placebo or empagliflozin 10 mg/day for a median of 16 and 26 months, respectively. At the end of the trials, 6799 patients (placebo 3381, empagliflozin 3418) were prospectively withdrawn from treatment in a blinded manner, and, of these, 3981 patients (placebo 2020, empagliflozin 1961) underwent prespecified in-person assessments after ≈30 days off treatment. RESULTS From 90 days from the start of closeout to the end of double-blind treatment, the annualized risk of cardiovascular death or hospitalization for heart failure was lower in empagliflozin-treated patients than in placebo-treated patients (10.7 [95% CI, 9.0-12.6] versus 13.5 [95% CI, 11.5-15.6] events per 100 patient-years, respectively; hazard ratio 0.76 [95% CI, 0.60-0.96]). When the study drugs were withdrawn for ≈30 days, the annualized risk of cardiovascular death or hospitalization for heart failure increased in patients withdrawn from empagliflozin but not in those withdrawn from placebo (17.0 [95% CI, 12.6-22.1] versus 14.1 [95% CI, 10.1-18.8] events per 100 patient-years for empagliflozin and placebo, respectively). The hazard ratio for the change in risk in the patients withdrawn from empagliflozin was 1.75 (95% CI, 1.20-2.54), P=0.0034, whereas the change in the risk in patients withdrawn from placebo was not significant (hazard ratio 1.12 [95% CI, 0.76-1.66]); time period-by-treatment interaction, P=0.068. After withdrawal, the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score declined by 1.6±0.4 in patients withdrawn from empagliflozin versus placebo (P<0.0001). Furthermore, withdrawal of empagliflozin was accompanied by increases in fasting glucose, body weight, systolic blood pressure, estimated glomerular filtration rate, N-terminal pro-hormone B-type natriuretic peptide, uric acid, and serum bicarbonate and decreases in hemoglobin and hematocrit (all P<0.01). These physiological and laboratory changes were the inverse of the effects of the drug seen at the start of the trials during the initiation of treatment (≈1-3 years earlier) in the same cohort of patients. CONCLUSIONS These observations demonstrate a persistent effect of empagliflozin in patients with heart failure even after years of treatment, which dissipated rapidly after withdrawal of the drug. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifiers: NCT03057977 and NCT03057951.
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Affiliation(s)
- Milton Packer
- Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, United Kingdom (M.P.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi School of Medicine, Jackson, MS (J.B.)
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH and Co KG, Biberach, Germany (C.Z.)
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, United Kingdom (S.J.P.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (M.B.)
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Germany (M.B.)
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
- Centre d'Investigations Cliniques Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France (J.P.F., F.Z.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece (G.F.)
| | - Muhammad Shariq Usman
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (M.S.U.)
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Université de Lorraine, Nancy, France (J.P.F., F.Z.)
| | - 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 (S.D.A.)
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Mendonça L, Bigotte Vieira M, Neves JS, Castro Chaves P, Ferreira JP. A 4-Variable Model to Predict Cardio-Kidney Events and Mortality in Chronic Kidney Disease: The Chronic Renal Insufficiency Cohort (CRIC) Study. Am J Nephrol 2023; 54:391-398. [PMID: 37673057 DOI: 10.1159/000533223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2023] [Accepted: 07/20/2023] [Indexed: 09/08/2023]
Abstract
INTRODUCTION Current prognostic models for chronic kidney disease (CKD) are complex and were designed to predict a single outcome. We aimed to develop and validate a simple and parsimonious prognostic model to predict cardio-kidney events and mortality. METHODS Patients from the CRIC Study (n = 3,718) were randomly divided into derivation (n = 2,478) and validation (n = 1,240) cohorts. Twenty-nine candidate variables were preselected. Multivariable Cox regression models were developed using stepwise selection for various cardio-kidney endpoints, namely, (i) the primary composite outcome of 50% decline in estimated glomerular filtration rate (eGFR) from baseline, end-stage renal disease, or cardiovascular (CV) mortality; (ii) hospitalization for heart failure (HHF) or CV mortality; (iii) 3-point major CV endpoints (3P-MACE); (iv) all-cause death. RESULTS During a median follow-up of 9 years, the primary outcome occurred in 977 patients of the derivation cohort and 501 patients of the validation cohort. Log-transformed N-terminal pro-B-type natriuretic peptide (NT-proBNP), log-transformed high-sensitive cardiac troponin T (hs-cTnT), log-transformed albuminuria, and eGFR were the dominant predictors. The primary outcome risk score discriminated well (c-statistic = 0.83) with a proportion of events of 11.4% in the lowest tertile of risk and 91.5% in the highest tertile at 10 years. The risk model presented good discrimination for HHF or CV mortality, 3P-MACE, and all-cause death (c-statistics = 0.80, 0.75, and 0.75, respectively). The 4-variable risk model achieved similar c-statistics for all tested outcomes in the validation cohort. The discrimination of the 4-variable risk model was mostly superior to that of published models. CONCLUSION The combination of NT-proBNP, hs-cTnT, albuminuria, and eGFR in a single 4-variable model provides a unique individual prognostic assessment of multiple cardio-kidney outcomes in CKD.
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Affiliation(s)
- Luís Mendonça
- Nephrology Department, Centro Hospitalar Universitário de São João, Porto, Portugal
- 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, Espinho, Portugal
| | - Miguel Bigotte Vieira
- Nephrology Department, Hospital Curry Cabral, Centro Hospitalar Universitário De Lisboa Central, Lisboa, Portugal
- Nova Medical School, Lisboa, Portugal
| | - João Sérgio Neves
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Endocrinology, Diabetes and Metabolism Department, Centro Hospitalar Universitário De São João, Porto, Portugal
| | - Paulo Castro Chaves
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Internal Medicine Department, Centro Hospitalar Universitário De São João, Porto, Portugal
| | - Joao Pedro Ferreira
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine, University of Porto, Porto, Portugal
- Inserm, Centre D'Investigations Cliniques - Plurithématique 14-33, Université De Lorraine, and Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
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11
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Bayes-Genis A, Lupón J, Codina P. Quality over quantity: Assessing the need for multiple biomarkers in predicting heart failure outcomes. Eur J Heart Fail 2023; 25:1415-1417. [PMID: 37401453 DOI: 10.1002/ejhf.2956] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2023] [Accepted: 06/22/2023] [Indexed: 07/05/2023] Open
Affiliation(s)
- Antoni Bayes-Genis
- Heart Institute, University Hospital Germans Trias i Pujol, Badalona, Spain
- Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Josep Lupón
- Heart Institute, University Hospital Germans Trias i Pujol, Badalona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Pau Codina
- Heart Institute, University Hospital Germans Trias i Pujol, Badalona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
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12
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Horiuchi YU, Wettersten N, Vanveldhuisen DJ, Mueller C, Nowak R, Hogan C, Kontos MC, Cannon CM, Birkhahn R, Vilke GM, Mahon N, Nuñez J, Briguori C, Duff S, Murray PT, Maisel A. The Influence of Body Mass Index on Clinical Interpretation of Established and Novel Biomarkers in Acute Heart Failure. J Card Fail 2023; 29:1121-1131. [PMID: 37127240 DOI: 10.1016/j.cardfail.2023.03.029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2022] [Revised: 03/12/2023] [Accepted: 03/23/2023] [Indexed: 05/03/2023]
Abstract
BACKGROUND Body mass index (BMI) is a known confounder for natriuretic peptides, but its influence on other biomarkers is less well described. We investigated whether BMI interacts with biomarkers' association with prognosis in patients with acute heart failure (AHF). METHODS AND RESULTS B-type natriuretic peptide (BNP), high-sensitivity cardiac troponin I (hs-cTnI), galectin-3, serum neutrophil gelatinase-associated lipocalin (sNGAL), and urine NGAL were measured serially in patients with AHF during hospitalization in the AKINESIS (Acute Kidney Injury Neutrophil gelatinase-associated lipocalin Evaluation of Symptomatic Heart Failure) study. Cox regression analysis was used to determine the association of biomarkers and their interaction with BMI for 30-day, 90-day and 1-year composite outcomes of death or HF readmission. Among 866 patients, 21.2%, 29.7% and 46.8% had normal (18.5-24.9 kg/m2), overweight (25-29.9 kg/m2) or obese (≥ 30 kg/m2) BMIs on admission, respectively. Admission values of BNP and hs-cTnI were negatively associated with BMI, whereas galectin-3 and sNGAL were positively associated with BMI. Admission BNP and hs-cTnI levels were associated with the composite outcome within 30 days, 90 days and 1 year. Only BNP had a significant interaction with BMI. When BNP was analyzed by BMI category, its association with the composite outcome attenuated at higher BMIs and was no longer significant in obese individuals. Findings were similar when evaluated by the last-measured biomarkers and BMIs. CONCLUSIONS In patients with AHF, only BNP had a significant interaction with BMI for the outcomes, with its association attenuating as BMI increased; hs-cTnI was prognostic, regardless of BMI.
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Affiliation(s)
- Y U Horiuchi
- Division of Cardiology, Mitsui Memorial Hospital, Tokyo, Japan
| | - Nicholas Wettersten
- Division of Cardiovascular Medicine, San Diego Veterans Affairs Medical Center, San Diego, CA, USA; Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Dirk J Vanveldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Christian Mueller
- Department of Cardiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Hospital System, Detroit, MI; USA
| | - Christopher Hogan
- Division of Emergency Medicine and Acute Care Surgical Services, VCU Medical Center, Virginia Commonwealth University, Richmond, VA, USA
| | - Michael C Kontos
- Division of Cardiology, VCU Medical Center, Virginia Commonwealth University, Richmond, VA
| | - Chad M Cannon
- Department of Emergency Medicine, University of Kansas Medical Center, Kansas City, KS, USA
| | - Robert Birkhahn
- Department of Emergency Medicine, New York Methodist Hospital, Brooklyn, NY, USA
| | - Gary M Vilke
- Department of Emergency Medicine, University of California, San Diego, La Jolla, CA, USA
| | - Niall Mahon
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Julio Nuñez
- Department of Cardiology, Hospital Clínico Universitario Valencia, INCLIVA, University of Valencia, Valencia, Spain and CIBER in Cardiovascular Diseases, Madrid, Spain
| | - Carlo Briguori
- Department of Cardiology, Interventional Cardiology, Mediterranea Cardiocentro, Naples, Italy
| | - Stephen Duff
- School of Medicine, University College Dublin, Dublin, Ireland
| | | | - Alan Maisel
- Division of Cardiovascular Medicine, University of California, San Diego, La Jolla, CA, USA.
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McDowell K, Campbell R, Simpson J, Cunningham JW, Desai AS, Jhund PS, Lefkowitz MP, Rouleau JL, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. Incremental prognostic value of biomarkers in PARADIGM-HF. Eur J Heart Fail 2023; 25:1406-1414. [PMID: 37191207 DOI: 10.1002/ejhf.2887] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023] Open
Abstract
AIMS It is uncertain how much candidate biomarkers improve risk prediction when added to comprehensive models including routinely collected clinical and laboratory variables in heart failure. METHODS AND RESULTS Aldosterone, cystatin C, high-sensitivity troponin T (hs-TnT), galectin-3, growth differentiation factor-15 (GDF-15), kidney injury molecule-1, matrix metalloproteinase-2 and -9, soluble suppression of tumourigenicity-2, tissue inhibitor of metalloproteinase-1 (TIMP-1) and urinary albumin to creatinine ratio were measured in 1559 of PARADIGM-HF participants. We tested whether these biomarkers, individually or collectively, improved the performance of the PREDICT-HF prognostic model, which includes clinical, routine laboratory, and natriuretic peptide data, for the primary endpoint and cardiovascular and all-cause mortality. The mean age of participants was 67.3 ± 9.9 years, 1254 (80.4%) were men and 1103 (71%) were in New York Heart Association class II. During a mean follow-up of 30.7 months, 300 patients experienced the primary outcome and 197 died. Added individually, only four biomarkers were independently associated with all outcomes: hs-TnT, GDF-15, cystatin C and TIMP-1. When all biomarkers were added simultaneously to the PREDICT-HF models, only hs-TnT remained an independent predictor of all three endpoints. GDF-15 also remained predictive of the primary endpoint; TIMP-1 was the only other predictor of both cardiovascular and all-cause mortality. Individually or in combination, these biomarkers did not lead to significant improvements in discrimination or reclassification. CONCLUSIONS None of the biomarkers studied individually or collectively led to a meaningful improvement in the prediction of outcomes over what is provided by clinical, routine laboratory, and natriuretic peptide variables.
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Affiliation(s)
- Kirsty McDowell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Ross Campbell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Joanne Simpson
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael R Zile
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Metra M, Adamo M, Tomasoni D, Mebazaa A, Bayes-Genis A, Abdelhamid M, Adamopoulos S, Anker SD, Bauersachs J, Belenkov Y, Böhm M, Gal TB, Butler J, Cohen-Solal A, Filippatos G, Gustafsson F, Hill L, Jaarsma T, Jankowska EA, Lainscak M, Lopatin Y, Lund LH, McDonagh T, Milicic D, Moura B, Mullens W, Piepoli M, Polovina M, Ponikowski P, Rakisheva A, Ristic A, Savarese G, Seferovic P, Sharma R, Thum T, Tocchetti CG, Van Linthout S, Vitale C, Von Haehling S, Volterrani M, Coats AJS, Chioncel O, Rosano G. Pre-discharge and early post-discharge management of patients hospitalized for acute heart failure: A scientific statement by the Heart Failure Association of the ESC. Eur J Heart Fail 2023; 25:1115-1131. [PMID: 37448210 DOI: 10.1002/ejhf.2888] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/16/2023] [Accepted: 04/30/2023] [Indexed: 07/15/2023] Open
Abstract
Acute heart failure is a major cause of urgent hospitalizations. These are followed by marked increases in death and rehospitalization rates, which then decline exponentially though they remain higher than in patients without a recent hospitalization. Therefore, optimal management of patients with acute heart failure before discharge and in the early post-discharge phase is critical. First, it may prevent rehospitalizations through the early detection and effective treatment of residual or recurrent congestion, the main manifestation of decompensation. Second, initiation at pre-discharge and titration to target doses in the early post-discharge period, of guideline-directed medical therapy may improve both short- and long-term outcomes. Third, in chronic heart failure, medical treatment is often left unchanged, so the acute heart failure hospitalization presents an opportunity for implementation of therapy. The aim of this scientific statement by the Heart Failure Association of the European Society of Cardiology is to summarize recent findings that have implications for clinical management both in the pre-discharge and the early post-discharge phase after a hospitalization for acute heart failure.
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Affiliation(s)
- Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alexandre Mebazaa
- AP-HP Department of Anesthesia and Critical Care, Hôpital Lariboisière, Université Paris Cité, Inserm MASCOT, Paris, France
| | - Antoni Bayes-Genis
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Stamatis Adamopoulos
- Second Department of Cardiovascular Medicine, Onassis Cardiac Surgery Center, Athens, Greece
| | - 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
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Michael Böhm
- Saarland University Hospital, Homburg/Saar, Germany
| | - Tuvia Ben Gal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Alain Cohen-Solal
- Inserm 942 MASCOT, Université de Paris, AP-HP, Hopital Lariboisière, Paris, France
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Finn Gustafsson
- Rigshospitalet-Copenhagen University Hospital, Heart Centre, Department of Cardiology, Copenhagen, Denmark
| | | | | | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yuri Lopatin
- Volgograd State Medical University, Volgograd, Russia
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Theresa McDonagh
- Department of Cardiovascular Science, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Davor Milicic
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
| | - Brenda Moura
- Faculty of Medicine, University of Porto, Porto, Portugal
- Cardiology Department, Porto Armed Forces Hospital, Porto, Portugal
| | | | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Marija Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Amina Rakisheva
- Scientific Research Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Arsen Ristic
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Rajan Sharma
- St. George's Hospitals NHS Trust University of London, London, UK
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS) and Rebirth Center for Translational Regenerative Therapies, Hannover Medical School, Hannover, Germany
- Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | - Carlo G Tocchetti
- Cardio-Oncology Unit, Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Sophie Van Linthout
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Cristiana Vitale
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | - Stephan Von Haehling
- Department of Cardiology and Pneumology, University Medical Center Goettingen, Georg-August University, Goettingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Goettingen, Goettingen, Germany
| | - Maurizio Volterrani
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | | | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Giuseppe Rosano
- St. George's Hospitals NHS Trust University of London, London, UK
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
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15
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Zierfuss B, Feldscher A, Höbaus C, Hannes A, Koppensteiner R, Schernthaner GH. NT-proBNP as a surrogate for unknown heart failure and its predictive power for peripheral artery disease outcome and phenotype. Sci Rep 2023; 13:8029. [PMID: 37198240 DOI: 10.1038/s41598-023-35073-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 05/12/2023] [Indexed: 05/19/2023] Open
Abstract
Patients with peripheral artery disease (PAD) are at high risk of excess mortality despite major improvements in multimodal pharmacotherapy for cardiovascular disease. However, little is known about co-prevalences and implications for the combination of heart failure (HF) and PAD. Thus, NT-proBNP as a suggested surrogate for HF was evaluated in symptomatic PAD regarding long-term mortality. After approval by the institutional ethics committee a total of 1028 patients with PAD, both with intermittent claudication or critical limb ischemia were included after admission for endovascular repair and were followed up for a median of 4.6 years. Survival information was obtained from central death database queries. During the observation period a total of 336 patients died (calculated annual death rate of 7.1%). NT-proBNP (per one standard deviation increase) was highly associated with outcome in the general cohort in crude (HR 1.86, 95%CI 1.73-2.01) and multivariable-adjusted Cox-regression analyses with all-cause mortality (HR 1.71, 95%CI 1.56-1.89) and CV mortality (HR 1.86, 95% CI 1.55-2.15). Similar HR's were found in patients with previously documented HF (HR 1.90, 95% CI 1.54-2.38) and without (HR 1.88, 95%CI 1.72-2.05). NT-proBNP levels were independently associated with below-the-knee lesions or multisite target lesions (OR 1.14, 95% CI 1.01-1.30). Our data indicate that increasing NT-proBNP levels are independently associated with long-term mortality in symptomatic PAD patients irrespective of a previously documented HF diagnosis. HF might thus be highly underreported in PAD, especially in patients with the need for below-the-knee revascularization.
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Affiliation(s)
- Bernhard Zierfuss
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Anna Feldscher
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Clemens Höbaus
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Antonia Hannes
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Renate Koppensteiner
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Gerit-Holger Schernthaner
- Division of Angiology, Department of Medicine 2, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
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16
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Zhang L, Zhang H, Xie X, Tie R, Shang X, Zhao Q, Xu J, Jin L, Zhang J, Ye P. Empagliflozin ameliorates diabetic cardiomyopathy via regulated branched-chain amino acid metabolism and mTOR/p-ULK1 signaling pathway-mediated autophagy. Diabetol Metab Syndr 2023; 15:93. [PMID: 37149696 PMCID: PMC10163822 DOI: 10.1186/s13098-023-01061-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 04/14/2023] [Indexed: 05/08/2023] Open
Abstract
BACKGROUND Empagliflozin, a sodium-glucose co-transporter 2 inhibitor (SGLT2i), has been reported to significantly reduce the risk of heart failure in multiple clinical studies. However, the underlying mechanisms remain elusive. This study aimed to investigate the effect of empagliflozin on branched-chain amino acid (BCAA) metabolism in diabetic cardiomyopathy. METHODS Thirty male 8-week KK Cg-Ay/J mice were used to study diabetic cardiomyopathy; here, 15 were used as the model group, and the remaining 15 were administered empagliflozin (3.75 mg/kg/day) by gavage daily for 16 weeks. The control group consisted of fifteen male 8-week C57BL/6J mice, whose blood glucose and body weight were measured simultaneously with the diabetic mice until 16 weeks without additional intervention. Echocardiography and histopathology were performed to evaluate cardiac structure and function. Proteomic sequencing and biogenic analysis were performed on mouse hearts. Parallel Reaction Monitoring and western blotting were performed to validate the expression levels of differentially expressed proteins. RESULTS The results showed that empagliflozin improved ventricular dilatation and ejection fraction reduction in diabetic hearts, as well as the elevation of myocardial injury biomarkers hs-cTnT and NT-proBNP. At the same time, empagliflozin alleviates myocardial inflammatory infiltration, calcification foci deposition, and fibrosis caused by diabetes. The results of the proteomics assay showed that empagliflozin could improve the metabolism of various substances, especially promoting the BCAA metabolism of diabetic hearts by up-regulating PP2Cm. Furthermore, empagliflozin could affect the mTOR/p-ULK1 signaling pathway by reducing the concentration of BCAA in diabetic hearts. When mTOR/p-ULK1 protein was inhibited, ULK1, the autophagy initiation molecule, increased. Moreover, autophagy substrate p62 and autophagy marker LC3B were significantly reduced, indicating that the autophagy activity of diabetes inhibition was reactivated. CONCLUSIONS Empagliflozin may attenuate diabetic cardiomyopathy-related myocardial injury by promoting the catabolism of BCAA and inhibiting mTOR/p-ULK1 to enhance autophagy. These findings suggest that empagliflozin could be a potential candidate drug against BCAA increase and could be used for other cardiovascular diseases with a metabolic disorder of BCAA.
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Affiliation(s)
- Lin Zhang
- Medical School of Chinese PLA, Department of Geriatric Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Heming Zhang
- Department of Anesthesiology, The 963 Hospital of the PLA Joint Logistics Support Force, Jiamusi, China
- Department of Anesthesiology, The Second Affiliated Hospital of Air Force Medical University, Xi'an, China
| | - Xiuzhu Xie
- Medical School of Chinese PLA, Department of Geriatric Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Ruping Tie
- Medical School of Chinese PLA, Department of Geriatric Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Xiaolin Shang
- Department of Pharmacy, Medical Support Center of Chinese PLA General Hospital, Beijing, China
| | - Qianqian Zhao
- Medical School of Chinese PLA, Department of Cardiology, The Sixth Medical Centre, Chinese PLA General Hospital, Beijing, China
| | - Junjie Xu
- Health Service Department of the Guard Bureau of the General Office of the Central Committee of the Communist Party of China, Beijing, China
| | - Liyuan Jin
- Department of Geriatric Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing, China.
| | - Jinying Zhang
- Department of Basic Medicine, Medical School of Chinese PLA, Chinese PLA General Hospital, Beijing, China.
| | - Ping Ye
- Department of Geriatric Cardiology, The Second Medical Centre, Chinese PLA General Hospital, Beijing, China.
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17
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Zhang AB, Wang CC, Zhao P, Tong KT, He Y, Zhu XL, Fu HX, Wang FR, Mo XD, Wang Y, Zhao XY, Zhang YY, Han W, Chen H, Chen Y, Yan CH, Wang JZ, Han TT, Sun YQ, Chen YH, Chang YJ, Xu LP, Liu KY, Huang XJ, Zhang XH. A Prognostic Model Based on Clinical Biomarkers for Heart Failure in Adult Patients Following Allogeneic Hematopoietic Stem Cell Transplantation. Transplant Cell Ther 2023; 29:240.e1-240.e10. [PMID: 36634739 DOI: 10.1016/j.jtct.2022.12.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 11/05/2022] [Accepted: 12/13/2022] [Indexed: 01/11/2023]
Abstract
Heart failure (HF) is an uncommon but serious cardiovascular complication after allogeneic hematopoietic stem cell transplantation (allo-HSCT). Unfortunately, knowledge about early mortality prognostic factors in patients with HF after allo-HSCT is limited, and an easy-to-use prognostic model is not available. This study aimed to develop and validate a clinical-biomarker prognostic model capable of predicting HF mortality following allo-HSCT that uses a combination of variables readily available in clinical practice. To investigate this issue, we conducted a retrospective analysis at our center with 154 HF patients who underwent allo-HSCT between 2008 and 2021. The patients were separated according to the time of transplantation, with 100 patients composing the derivation cohort and the other 54 patients composing the external validation cohort. We first calculated the univariable association for each variable with 2-month mortality in the derivation cohort. We then included the variables with a P value <.1 in univariate analysis as candidate predictors in the multivariate analysis using a backward stepwise logistic regression model. Variables remaining in the final model were identified as independent prognostic factors. To predict the prognosis of HF, a scoring system was established, and scores were assigned to the prognostic factors based on the regression coefficient. Finally, 4 strongly significant independent prognostic factors for 2-month mortality from HF were identified using multivariable logistic regression methods with stepwise variable selection: pulmonary infection (P = .005), grade III to IV acute graft-versus-host disease (severe aGVHD; P = .033), lactate dehydrogenase (LDH) >426 U/L (P = .049), and brain natriuretic peptide (BNP) >1799 pg/mL (P = .026). A risk grading model termed the BLIPS score (for BNP, LDH, cardiac troponin I, pulmonary infection, and severe aGVHD) was constructed according to the regression coefficients. The validated internal C-statistic was .870 (95% confidence interval [CI], .798 to .942), and the external C-statistic was .882 (95% CI, .791-.973). According to the calibration plots, the model-predicted probability correlated well with the actual observed frequencies. The clinical use of the prognostic model, according to decision curve analysis, could benefit HF patients. The BLIPS model in our study can serve to identify HF patients at higher risk for mortality early, which might aid designing timely targeted therapies and eventually improving patients' survival and prognosis.
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Affiliation(s)
- Ao-Bei Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Chen-Cong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Peng Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Ke-Ting Tong
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yun He
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Lu Zhu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Hai-Xia Fu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Feng-Rong Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Dong Mo
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiang-Yu Zhao
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yuan-Yuan Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Wei Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Huan Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yao Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Chen-Hua Yan
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Jing-Zhi Wang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Ting-Ting Han
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu-Qian Sun
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Yu-Hong Chen
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Ying-Jun Chang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Lan-Ping Xu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Kai-Yan Liu
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Jun Huang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China
| | - Xiao-Hui Zhang
- Peking University People's Hospital, Peking University Institute of Hematology, Beijing, China.
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Girerd N, Zannad F. SGLT2 inhibition in heart failure with reduced or preserved ejection fraction: Finding the right patients to treat. J Intern Med 2023; 293:550-558. [PMID: 36871279 DOI: 10.1111/joim.13620] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
Abstract
Sodium-glucose transport inhibitors (SGLT2i) are effective in heart failure (HF) with ejection fraction (EF) <40% (referred to as HF with reduced EF - HFrEF) and left ventricular EF (LVEF) >40%. Current evidence suggests that SGLT2i should be initiated across a large spectrum of EFs and renal function in patients with HF and with and without diabetes. We reviewed the benefits of SGLT2i in the entire spectrum of HF and provided some clues that may guide physicians in their strategy of initiating and maintaining SGLT2i (with or without SGLT1i effect) therapy. Taken together, the evidence thus far arises from an array of trials performed in different settings (acute/chronic), risk categories, and phenotypes of HF (HFrEF/HFpEF), and in addition to the most common HF therapies, supports the homogenous effect of SGLT2i across a large spectrum of patients with HF. SGLT2i appear to be effective and well-tolerated drugs in the majority of clinical HF scenarios, regardless of LVEF, estimated glomerular filtration rate, diabetic status or the level of the acuteness of the clinical setting. Therefore, most patients with HF should be treated with SGLT2i. However, in the face of the therapeutic inertia that has been observed in HF over the past decades, the actual implementation of SGLT2i in routine practice remains the most significant challenge.
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Affiliation(s)
- Nicolas Girerd
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques-Plurithématique 14-33, CHRU Nancy, Vandoeuvre les Nancy, France
| | - Faiez Zannad
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques-Plurithématique 14-33, CHRU Nancy, Vandoeuvre les Nancy, France
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19
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Ferreira JP, Zannad F, Butler J, Filippatos G, Pocock S, Iwata T, Sumin M, Zeller C, Januzzi JL, Anker SD, Packer M. Recency of Heart Failure Hospitalization, Outcomes, and the Effect of Empagliflozin: An EMPEROR-Pooled Analysis. JACC. HEART FAILURE 2023:S2213-1779(23)00073-2. [PMID: 36872213 DOI: 10.1016/j.jchf.2023.01.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 02/22/2023]
Abstract
BACKGROUND Patients with a recent heart failure (HF) hospitalization have a high risk of rehospitalization and mortality. Early treatment may have a substantial impact on patient outcomes. OBJECTIVES The study sought to study the outcomes and effect of empagliflozin according to timing of prior HF hospitalization. METHODS EMPEROR-Pooled (EMPEROR-Reduced (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction) and EMPEROR-Preserved (EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction) combined) included 9,718 HF patients who were grouped according to the recency of HF hospitalization (none, <3 months, 3-6 months, 6-12 months, >12 months). The primary outcome was a composite of time to first of HF hospitalization or cardiovascular death, over a median follow-up of 21 months. RESULTS The primary outcome event rates (per 100 person-years) in the placebo group were 26.7, 18.1, 13.7, and 2.8 for patients hospitalized within 3 months, 3-6 months, 6-12 months, and >12 months, respectively. The relative risk reduction of primary outcome events with empagliflozin was similar across HF hospitalization categories (P interaction = 0.67). The primary outcome absolute risk reduction was more pronounced among patients with a recent HF hospitalization but without statistical heterogeneity of treatment effect: -6.9, -5.5, -0.8, and -0.6 events prevented per 100 person-years for patients hospitalized within <3 months, 3-6 months, 6-12 months, and >12 months, respectively, and -2.4 events prevented per 100 person-years of follow-up in those without a prior HF hospitalization (P interaction = 0.64). Empagliflozin was safe irrespective of HF hospitalization recency. CONCLUSIONS Patients with a recent HF hospitalization have a high risk of events. Empagliflozin reduced HF events regardless of HF hospitalization recency.
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Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM, Université de Lorraine, Nancy, France; F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), INSERM U1116, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France; UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal.
| | - Faiez Zannad
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM, Université de Lorraine, Nancy, France
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Stuart Pocock
- London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH and Co KG, Biberach, Germany
| | - Mikhail Sumin
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH and Co KG, Biberach, Germany
| | - James L Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Stefan D Anker
- Center for Regenerative Therapies, Berlin Institute of Health, Department of Cardiology, German Centre for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Milton Packer
- Imperial College London, London, United Kingdom; Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA
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20
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Worsening Heart Failure: Nomenclature, Epidemiology, and Future Directions: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:413-424. [PMID: 36697141 DOI: 10.1016/j.jacc.2022.11.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 01/25/2023]
Abstract
Heart failure (HF) is a progressive disease characterized by variable durations of symptomatic stability often punctuated by episodes of worsening despite continued therapy. These periods of clinical worsening are increasingly recognized as a distinct phase in the history of HF, termed worsening HF (WHF). The definition of WHF continues to evolve from a historical focus solely on hospitalization to now include nonhospitalization events (eg, need for intravenous diuretic therapy in the emergency or outpatient setting). Most HF clinical trials to date have had HF hospitalization and death as primary endpoints, and only recently, some studies have included other WHF events regardless of location of care. This article reviews the evolution of the WHF definition, highlights the importance of considering the onset of WHF as an event that marks a new phase of HF, summarizes the latest clinical trials investigating novel therapies, and outlines unmet needs regarding identification and treatment of WHF.
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21
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Crea F. Management of atrial fibrillation: role of population screening, biomarkers, and polygenic risk scores. Eur Heart J 2023; 44:167-170. [PMID: 36638838 DOI: 10.1093/eurheartj/ehac802] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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22
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Forzano I, Mone P, Mottola G, Kansakar U, Salemme L, De Luca A, Tesorio T, Varzideh F, Santulli G. Efficacy of the New Inotropic Agent Istaroxime in Acute Heart Failure. J Clin Med 2022; 11:7503. [PMID: 36556120 PMCID: PMC9786901 DOI: 10.3390/jcm11247503] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2022] [Revised: 12/14/2022] [Accepted: 12/15/2022] [Indexed: 12/24/2022] Open
Abstract
Current therapeutic strategies for acute heart failure (AHF) are based on traditional inotropic agents that are often associated with untoward effects; therefore, finding new effective approaches with a safer profile is dramatically needed. Istaroxime is a novel compound, chemically unrelated to cardiac glycosides, that is currently being studied for the treatment of AHF. Its effects are essentially related to its inotropic and lusitropic positive properties exerted through a dual mechanism of action: activation of the sarcoplasmic reticulum Ca2+ ATPase isoform 2a (SERCA2a) and inhibition of the Na+/K+-ATPase (NKA) activity. The advantages of istaroxime over the available inotropic agents include its lower arrhythmogenic action combined with its capability of increasing systolic blood pressure without augmenting heart rate. However, it has a limited half-life (1 hour) and is associated with adverse effects including pain at the injection site and gastrointestinal issues. Herein, we describe the main mechanism of action of istaroxime and we present a systematic overview of both clinical and preclinical trials testing this drug, underlining the latest insights regarding its adoption in clinical practice for AHF.
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Affiliation(s)
- Imma Forzano
- Division of Cardiology, Department of Advanced Biomedical Sciences, “Federico II” University, 80131 Naples, Italy
| | - Pasquale Mone
- Division of Cardiology, Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA
| | - Gaetano Mottola
- Casa di Cura “Montevergine”, Mercogliano, 83013 Avellino, Italy
| | - Urna Kansakar
- Division of Cardiology, Department of Advanced Biomedical Sciences, “Federico II” University, 80131 Naples, Italy
| | - Luigi Salemme
- Casa di Cura “Montevergine”, Mercogliano, 83013 Avellino, Italy
| | - Antonio De Luca
- Department of Mental and Physical Health and Preventive Medicine, University of Campania “Vanvitelli”, 81100 Caserta, Italy
| | - Tullio Tesorio
- Casa di Cura “Montevergine”, Mercogliano, 83013 Avellino, Italy
| | - Fahimeh Varzideh
- Division of Cardiology, Department of Advanced Biomedical Sciences, “Federico II” University, 80131 Naples, Italy
| | - Gaetano Santulli
- Division of Cardiology, Department of Advanced Biomedical Sciences, “Federico II” University, 80131 Naples, Italy
- Division of Cardiology, Department of Medicine, Wilf Family Cardiovascular Research Institute, Einstein Institute for Aging Research, Albert Einstein College of Medicine, New York, NY 10461, USA
- Department of Molecular Pharmacology, Einstein-Mount Sinai Diabetes Research Center (ES-DRC), Einstein Institute for Neuroimmunology and Inflammation (INI), Fleischer Institute for Diabetes and Metabolism (FIDAM), Albert Einstein College of Medicine, New York, NY 10461, USA
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23
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Gtif I, Abdelhedi R, Ouarda W, Bouzid F, Charfeddine S, Zouari F, Abid L, Rebai A, Kharrat N. Oxidative stress markers-driven prognostic model to predict post-discharge mortality in heart failure with reduced ejection fraction. Front Cardiovasc Med 2022; 9:1017673. [DOI: 10.3389/fcvm.2022.1017673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022] Open
Abstract
BackgroundCurrent predictive models based on biomarkers reflective of different pathways of heart failure with reduced ejection fraction (HFrEF) pathogenesis constitute a useful tool for predicting death risk among HFrEF patients. The purpose of the study was to develop a new predictive model for post-discharge mortality risk among HFrEF patients, based on a combination of clinical patients’ characteristics, N-terminal pro-B-type Natriuretic peptide (NT-proBNP) and oxidative stress markers as a potentially valuable tool for routine clinical practice.Methods116 patients with stable HFrEF were recruited in a prospective single-center study. Plasma levels of NT-proBNP and oxidative stress markers [superoxide dismutase (SOD), glutathione peroxidase (GPX), uric acid (UA), total bilirubin (TB), gamma-glutamyl transferase (GGT) and total antioxidant capacity (TAC)] were measured in the stable predischarge condition. Generalized linear model (GLM), random forest and extreme gradient boosting models were developed to predict post-discharge mortality risk using clinical and laboratory data. Through comprehensive evaluation, the most performant model was selected.ResultsDuring a median follow-up of 525 days (7–930), 33 (28%) patients died. Among the three created models, the GLM presented the best performance for post-discharge death prediction in HFrEF. The predictors included in the GLM model were age, female sex, beta blockers, NT-proBNP, left ventricular ejection fraction (LVEF), TAC levels, admission systolic blood pressure (SBP), angiotensin-converting enzyme inhibitors/angiotensin receptor II blockers (ACEI/ARBs) and UA levels. Our model had a good discriminatory power for post-discharge mortality [The area under the curve (AUC) = 74.5%]. Based on the retained model, an online calculator was developed to allow the identification of patients with heightened post-discharge death risk.ConclusionIn conclusion, we created a new and simple tool that may allow the identification of patients at heightened post-discharge mortality risk and could assist the treatment decision-making.
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24
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Bayes-Genis A, Aimo A, Jhund P, Richards M, de Boer RA, Arfsten H, Fabiani I, Lupón J, Anker SD, González A, Castiglione V, Metra M, Mueller C, Núñez J, Rossignol P, Barison A, Butler J, Teerlink J, Filippatos G, Ponikowski P, Vergaro G, Zannad F, Seferovic P, Rosano G, Coats AJS, Emdin M, Januzzi JL. Biomarkers in heart failure clinical trials. A review from the Biomarkers Working Group of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2022; 24:1767-1777. [PMID: 36073112 DOI: 10.1002/ejhf.2675] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 08/29/2022] [Accepted: 08/31/2022] [Indexed: 11/09/2022] Open
Abstract
The approval of new heart failure (HF) therapies has slowed over the past two decades in part due to the high costs of conducting large randomized clinical trials that are needed to adequately power major clinical endpoint studies. Several biomarkers have been identified reflecting different elements of HF pathophysiology, with possible applications in diagnosis, risk stratification, treatment monitoring, and even in the design of clinical trials. Biomarkers could potentially be used to refine study inclusion criteria to enable enrolment of patients who are more likely to respond to a therapeutic intervention, despite being at sufficient risk to meet pre-determined study endpoint rates. When there is a close relationship between biomarker levels and clinical endpoints, changes in biomarker levels after a given treatment can act as a surrogate endpoint, potentially reducing the duration and cost of a clinical trial. Natriuretic peptides have been widely used in clinical trials with a variable amount of added value, which such variation being probably due to the absence of a close pathophysiological connection to the study drug. Notable exceptions to this include sacubitril/valsartan and vericiguat. Future studies should seek to adopt unbiased approaches for discovery of true companion diagnostics; with -omics-based tools, biomarkers might be more precisely selected for use in clinical trials to identify responses that closely reflect the biological effects of the drug under investigation. Finally, biomarkers associated with cardiac damage and remodelling, such as cardiac troponin, could be employed as safety endpoints provided that standardization between different assays is achieved.
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Affiliation(s)
- Antoni Bayes-Genis
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain.,Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain.,CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Alberto Aimo
- Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Pardeep Jhund
- Institute of Cardiovascular & Medical Sciences, University of Glasgow, Glasgow, UK
| | | | - Rudolf A de Boer
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Henrike Arfsten
- Clinical Division of Cardiology, Department of Internal Medicine II, Medical University of Vienna, Vienna, Austria
| | - Iacopo Fabiani
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Josep Lupón
- Institut del Cor, Hospital Universitari Germans Trias i Pujol, Barcelona, Spain
| | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapy (BCRT), German Center for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Arantxa González
- CIBERCV, Carlos III Institute of Health, Madrid, Spain.,Program of Cardiovascular Diseases, CIMA Universidad de Navarra and IdiSNA, Navarra Institute for Health Research, Pamplona, Spain
| | | | - Marco Metra
- Cardiology Department, ASST Spedali Civili; Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Julio Núñez
- CIBERCV, Carlos III Institute of Health, Madrid, Spain.,Hospital Clínico Universitario de Valencia, INCLIVA, Universidad de Valencia, Valencia, Spain
| | | | - Andrea Barison
- Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - John Teerlink
- Heart Failure and of the Echocardiography Laboratory, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | | | | | - Giuseppe Vergaro
- Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigations Cliniques-Plurithématique 1433, and Inserm U1116 CHRU Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Petar Seferovic
- Department of Cardiology, University Clinical Center of Serbia, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | | | | | - Michele Emdin
- Scuola Superiore Sant'Anna, Pisa, Italy.,Cardiology Division, Fondazione Toscana Gabriele Monasterio, Pisa, Italy
| | - James L Januzzi
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
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25
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Pocock SJ, Ferreira JP, Packer M, Zannad F, Filippatos G, Kondo T, McMurray JJ, Solomon SD, Januzzi JL, Iwata T, Salsali A, Butler J, Anker SD. Biomarker-driven prognostic models in chronic heart failure with preserved ejection fraction: the EMPEROR-Preserved trial. Eur J Heart Fail 2022; 24:1869-1878. [PMID: 35796209 PMCID: PMC9796853 DOI: 10.1002/ejhf.2607] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2022] [Revised: 07/01/2022] [Accepted: 07/02/2022] [Indexed: 01/07/2023] Open
Abstract
AIMS Biomarker-driven prognostic models incorporating N-terminal pro-B-type natriuretic peptide (NT-proBNP) and high-sensitivity cardiac troponin T (hs-cTnT) in heart failure (HF) with preserved ejection fraction (HFpEF) are lacking. We aimed to generate a biomarker-driven prognostic tool for patients with chronic HFpEF enrolled in EMPEROR-Preserved. METHODS AND RESULTS Multivariable Cox regression models were created for (i) the primary composite outcome of HF hospitalization or cardiovascular death, (ii) all-cause death, (iii) cardiovascular death, and (iv) HF hospitalization. PARAGON-HF was used as a validation cohort. NT-proBNP and hs-cTnT were the dominant predictors of the primary outcome, and in addition, a shorter time since last hospitalization, New York Heart Association (NYHA) class III or IV, history of chronic obstructive pulmonary disease (COPD), insulin-treated diabetes, low haemoglobin, and a longer time since HF diagnosis were key predictors (eight variables, all p < 0.001). The consequent primary outcome risk score discriminated well (c-statistic = 0.75) with patients in the top 10th of risk having an event rate >22× higher than those in the bottom 10th. A model for HF hospitalization alone had even better discrimination (c = 0.79). Empagliflozin reduced the risk of cardiovascular death or hospitalization for HF in patients across all risk levels. NT-proBNP and hs-cTnT were also the dominant predictors of all-cause and cardiovascular mortality followed by history of COPD, low albumin, older age, left ventricular ejection fraction ≥50%, NYHA class III or IV and insulin-treated diabetes (eight variables, all p < 0.001). The mortality risk model had similar discrimination for all-cause and cardiovascular mortality (c-statistic = 0.72 for both). External validation provided c-statistics of 0.71, 0.71, 0.72, and 0.72 for the primary outcome, HF hospitalization alone, all-cause death, and cardiovascular death, respectively. CONCLUSIONS The combination of NT-proBNP and hs-cTnT along with a few readily available clinical variables provides effective risk discrimination both for morbidity and mortality in patients with HFpEF. A predictive tool-kit facilitates the ready implementation of these risk models in routine clinical practice.
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Affiliation(s)
- Stuart J. Pocock
- Department of Medical StatisticsLondon School of Hygiene and Tropical MedicineLondonUK
| | - João Pedro Ferreira
- UnIC@Rise, Department of Surgery and Physiology, Faculty of Medicine, Cardiovascular Research and Development CenterUniversity of PortoPortoPortugal,Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists)Université de LorraineNancyFrance
| | - Milton Packer
- Baylor Heart and Vascular HospitalBaylor University Medical CenterDallasTXUSA,Imperial CollegeLondonUK
| | - Faiez Zannad
- Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F‐CRIN INI‐CRCT (Cardiovascular and Renal Clinical Trialists)Université de LorraineNancyFrance
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Department of CardiologyAttikon University HospitalAthensGreece
| | - Toru Kondo
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan,British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowGlasgowUK
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
| | | | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Afshin Salsali
- Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Javed Butler
- Baylor Scott and White Research InstituteDallasTXUSA,Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - Stefan D. Anker
- Department of Cardiology, and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site BerlinCharité UniversitätsmedizinBerlinGermany
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26
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Zannad F, Ferreira JP, Gregson J, Kraus BJ, Mattheus M, Hauske SJ, Butler J, Filippatos G, Wanner C, Anker SD, Pocock SJ, Packer M. Early changes in estimated glomerular filtration rate post-initiation of empagliflozin in EMPEROR-Reduced. Eur J Heart Fail 2022; 24:1829-1839. [PMID: 35711093 DOI: 10.1002/ejhf.2578] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Revised: 05/18/2022] [Accepted: 06/09/2022] [Indexed: 11/06/2022] Open
Abstract
AIMS Sodium-glucose cotransporter 2 inhibitors (SGLT2i) may induce an early post-initiation decrease of estimated glomerular filtration rate (eGFR), which does not impact the SGLT2i benefits. The occurrence, characteristics, determinants, and clinical significance of an initial eGFR change among patients with heart failure with reduced ejection fraction require further study. In this study we aimed to describe eGFR change from randomization to week 4 (as percent of change relative to randomization) and assess its impact in EMPEROR-Reduced. METHODS AND RESULTS Landmark analyses (week 4) were performed. eGFR change was available in 3547 patients out of 3730 (95%). The tertiles of post-initiation % eGFR change for empagliflozin were: tertile 1 (T1) ≤-11.4%; T2 ≥-11.4% to ≤-1.0% and T3 ≥0.0%. The placebo group tertiles were: T1 ≤-6.5%; T2 ≥-6.4% to ≤+3.6%; and T3 ≥+3.6%. On average, empagliflozin induced a leftward distributional shift of initial eGFR changes of -2.5 ml/min/1.73 m2 versus placebo. In the empagliflozin group, after covariate adjustment, the risk of cardiovascular and renal outcomes did not differ between patients in whom early post-treatment initiation eGFR decreased (T1) and patients in whom it increased (T3). However, in the placebo group, patients in whom early post-treatment initiation eGFR decreased (T1) had a higher risk of sustained worsening kidney function and all-cause mortality compared to patients in whom eGFR increased (T3) (hazard ratio [HR] 2.38, 95% confidence interval [CI] 1.25-4.55 and HR 1.37, 95% CI 1.01-1.85, respectively). CONCLUSION A mild eGFR decrease may be expected after the initiation of empagliflozin, and it is not associated with untoward heart failure, mortality, or kidney safety events. Clinicians should not be concerned with early eGFR changes post-initiation of empagliflozin.
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Affiliation(s)
- Faiez Zannad
- Université de Lorraine, Inserm, Center d'Investigations Cliniques, - Plurithématique 14-33, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Center 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
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Bettina Johanna Kraus
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
- Würzburg University Clinic, Würzburg, Germany
| | - Michaela Mattheus
- Biostatistics, Boehringer Ingelheim Pharma GmbH & Co KG, Ingelheim, Germany
| | - Sibylle Jenny Hauske
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- Vth Department of Medicine, University Medical Center Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, TX and University of Mississippi, Jackson, MS, USA
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | | | - Stefan D Anker
- Department of Cardiology (CVK), and Berlin Institute of Health Center for Regenerative Therapies, German Center for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
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Abstract
Clinical prediction models include a diagnostic prediction model to estimate the probability of an individual currently having a disease (e.g., pulmonary embolism) and a prognostic prediction model to estimate the probability of an individual developing a specific health outcome over a specific time period (e.g., myocardial infarction and stroke in 10 years). Clinical prediction models can be developed by applying traditional regression models (e.g., logistic and Cox regression models) or emerging machine learning models to real-world data, such as electronic health records and administrative claims data. For derivation, researchers select candidate variables based on a literature review and clinical knowledge, and predictor variables in the final model based on pre-defined criteria (e.g., thresholds for the size of relative risk and p-values) or strategies such as the stepwise regression and the least absolute shrinkage and selection operator (LASSO) regression. For validation, the clinical prediction model's performance is evaluated in terms of goodness of fit (e.g., R2), discrimination (e.g., area under the receiver operating characteristic curve or c-statistics), and calibration (e.g., calibration plot and Hosmer-Lemeshow test). Performance of a new variable added to an existing clinical prediction model is evaluated in terms of reclassification (e.g., net reclassification improvement and integrated discrimination improvement). The model should be validated using the original data to examine internal validity through methods such as resampling (e.g., cross-validation and bootstrapping) and using other participants' data to examine external validity. For successful implementation of a clinical prediction model in actual clinical practice, presentation methods such as paper-based (nomogram) or web-based calculator and an easy-to-use risk score should be considered.
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Affiliation(s)
- Masao Iwagami
- Department of Health Services Research, Faculty of Medicine, University of Tsukuba
- Faculty of Epidemiology and Population Health, London School of Hygiene and Tropical Medicine
| | - Hiroki Matsui
- Department of Clinical Epidemiology and Health Economics, School of Public Health, The University of Tokyo
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28
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Curtis AB, Manrodt C, Jacobsen LD, Soderlund D, Fonarow GC. Guideline-directed device therapies in heart failure: A clinical practice-based analysis using electronic health record data. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 16:100139. [PMID: 38559281 PMCID: PMC10976280 DOI: 10.1016/j.ahjo.2022.100139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 04/13/2022] [Accepted: 04/26/2022] [Indexed: 04/04/2024]
Abstract
Background Guideline-directed device therapies (GDDT) improve outcomes for eligible patients with heart failure (HF) with reduced ejection fraction (HFrEF). Utilization rates of device therapies in HFrEF after the 2012 ACCF/AHA/HRS Focused Update for Device-based Therapies of Cardiac Rhythm Abnormalities have not been well studied. Objective Characterize the use of GDDT in newly indicated HFrEF patients from 2012 to 2019 using aggregated electronic health record (EHR) data. Methods Computable phenotyping algorithms for implantable cardioverter defibrillator/cardiac resynchronization therapy-defibrillator (ICD/CRT-D) indications from the GuideLine Indications Detected in EHR for Heart Failure program (GLIDE-HF) used diagnoses, procedures, measures, prescriptions, and the output of natural language processed provider notes from de-identified Optum® EHR data. Patients had a diagnosis of HF, dilated cardiomyopathy, or prior infarct, and were included if they had HFrEF with >1 year of records prior to a new Class 1 or Class 2a indication for an ICD or cardiac resynchronization therapy with defibrillator (CRT-D) from 2012 to 2019. Results Records showed 137,476 HFrEF patients were newly indicated for an ICD or CRT-D. GDDT was used in 14,892 of 36,358 (41.0%) CRT-D indicated patients and in 14,904 of 101,118 (14.7%) ICD-indicated patients. While GDDT use was low, 95.7% had echocardiography and 92.1% had prescriptions for beta-blockers or angiotensin-converting enzyme/angiotensin-receptor blockers medications. Conclusions In this modern cohort of HF patients, a large proportion of eligible patients did not receive ICDs or CRT-Ds, while frequently receiving other indicated cardiovascular interventions and treatments.
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Affiliation(s)
- Anne B. Curtis
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, United States of America
| | | | | | - Dana Soderlund
- Medtronic, Inc., Mounds View, MS, United States of America
| | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, United States of America
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29
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Crea F. Hot topics in ischaemic heart disease: revascularization, hibernation, type 2 infarction, and proteomics. Eur Heart J 2022; 43:89-92. [PMID: 35025998 DOI: 10.1093/eurheartj/ehab902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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30
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Berezin AA, Fushtey IM, Berezin AE. Discriminative Utility of Apelin-to-NT-Pro-Brain Natriuretic Peptide Ratio for Heart Failure with Preserved Ejection Fraction among Type 2 Diabetes Mellitus Patients. J Cardiovasc Dev Dis 2022; 9:jcdd9010023. [PMID: 35050233 PMCID: PMC8779441 DOI: 10.3390/jcdd9010023] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2021] [Revised: 01/01/2022] [Accepted: 01/11/2022] [Indexed: 02/05/2023] Open
Abstract
Background: Apelin is a regulatory vasoactive peptide, which plays a pivotal role in adverse cardiac remodeling and heart failure (HF) with reduced ejection fraction. The purpose of the study was to investigate whether serum levels of apelin is associated with HF with preserved election fraction (HFpEF) in patients with T2DM. Methods: The study retrospectively involved 101 T2DM patients aged 41 to 62 years (48 patients with HFpEF and 28 non-HFpEF patients). The healthy control group consisted of 25 individuals with matched age and sex. Data collection included demographic and anthropometric information, hemodynamic performances and biomarkers of the disease. Transthoracic B-mode echocardiography, Doppler and TDI were performed at baseline. Serum levels of N-terminal pro-brain natriuretic peptide (NT-proBNP) and apelin were measured by ELISA in all patients at the study entry. Results: Unadjusted multivariate logistic model yielded the only apelin to NT-proBNP ratio (OR = 1.44; p = 0.001), BMI > 34 кг/м2 (OR = 1.07; p = 0.036), NT-proBNP > 458 pmol/mL (OR = 1.17; p = 0.042), LAVI > 34 mL/m2 (OR = 1.06; p = 0.042) and E/e’ > 11 (OR = 1.04; p = 0.044) remained to be strong predictors for HFpEF. After obesity adjustment, multivariate logistic regression showed that the apelin to NT-proBNP ratio < 0.82 × 10−2 units remained sole independent predictor for HFpEF (OR = 1.44; 95% CI: 1.18–2.77; p = 0.001) HFpEF in T2DM patients. In conclusion, we found that apelin to NT-proBNP ratio < 0.82 × 10−2 units better predicted HFpEF in T2DM patients than apelin and NT-proBNP alone. This finding could open new approach for CV risk stratification of T2DM at higher risk of HF.
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Affiliation(s)
- Alexander A. Berezin
- Internal Medicine Department, Medical Academy of Postgraduate Education, 69096 Zaporozhye, Ukraine; (A.A.B.); (I.M.F.)
| | - Ivan M. Fushtey
- Internal Medicine Department, Medical Academy of Postgraduate Education, 69096 Zaporozhye, Ukraine; (A.A.B.); (I.M.F.)
| | - Alexander E. Berezin
- Internal Medicine Department, State Medical University, 69096 Zaporozhye, Ukraine
- Correspondence: ; Tel.: +390-612-894-585
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31
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Crea F. Mechanisms of heart failure with preserved ejection fraction, risk stratification of heart failure with reduced ejection fraction, and new light on resistance to diuretics in acute decompensated heart failure. Eur Heart J 2021; 42:4405-4409. [PMID: 34791148 DOI: 10.1093/eurheartj/ehab791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Filippo Crea
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.,Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
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Berg DD, Docherty KF, Sattar N, Jarolim P, Welsh P, Jhund PS, Anand IS, Chopra V, de Boer RA, Kosiborod MN, Nicolau JC, O'Meara E, Schou M, Hammarstedt A, Langkilde AM, Lindholm D, Sjöstrand M, McMurray JJV, Sabatine MS, Morrow DA. Serial Assessment of High-Sensitivity Cardiac Troponin and the Effect of Dapagliflozin in Patients with Heart Failure with Reduced Ejection Fraction: An Analysis of the DAPA-HF Trial. Circulation 2021; 145:158-169. [PMID: 34743554 DOI: 10.1161/circulationaha.121.057852] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background: Circulating high-sensitivity cardiac troponin T (hsTnT) predominantly reflects myocardial injury, and higher levels are associated with a higher risk of worsening heart failure (HF) and death in patients with HF with reduced ejection fraction (HFrEF). Less is known about the prognostic significance of changes in hsTnT over time, the effects of dapagliflozin on clinical outcomes in relation to baseline hsTnT levels, and the effect of dapagliflozin on hsTnT levels. Methods: DAPA-HF was a randomized, double-blind, placebo-controlled trial of dapagliflozin (10 mg daily) in patients with NYHA class II-IV symptoms and left ventricular ejection fraction ≤40% (median follow-up = 18.2 months). hsTnT (Roche Diagnostics) was measured at baseline in 3,112 patients and at 1 year in 2,506 patients. The primary endpoint was adjudicated worsening HF or cardiovascular death. Clinical endpoints were analyzed according to baseline hsTnT and change in hsTnT from baseline to 1 year. Comparative treatment effects on clinical endpoints with dapagliflozin vs. placebo were assessed by baseline hsTnT. The effect of dapagliflozin on hsTnT was explored. Results: Median baseline hsTnT concentration was 20.0 (25th-75th percentile, 13.7 to 30.2) ng/L. Over 1 year, 67.9% of patients had a ≥10% relative increase or decrease in hsTnT concentrations, and 43.5% had a ≥20% relative change. A stepwise gradient of higher risk for the primary endpoint was observed across increasing quartiles of baseline hsTnT concentration (adjusted hazard ratio [aHR] Q4 vs. Q1, 5.10; 95% CI, 3.67-7.08). Relative and absolute increases in hsTnT over 1 year were associated with higher subsequent risk of the primary endpoint. The relative reduction in the primary endpoint with dapagliflozin was consistent across quartiles of baseline hsTnT (p-interaction = 0.55), but patients in the top quartile tended to have the greatest absolute risk reduction (absolute risk difference, 7.5%; 95% CI, 1.0% - 14.0%). Dapagliflozin tended to attenuate the increase in hsTnT over time compared to placebo (relative least squares mean reduction, -3% [-6% to 0%]; p=0.076). Conclusions: Higher baseline hsTnT and greater increase in hsTnT over 1 year are associated with worse clinical outcomes. Dapagliflozin consistently reduced the risk of the primary endpoint, irrespective of baseline hsTnT levels. Clinical Trial Registration: URL: https://www.clinicaltrials.gov. Unique Identifier: NCT03036124.
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Affiliation(s)
- David D Berg
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Kieran F Docherty
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Naveed Sattar
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Petr Jarolim
- Department of Pathology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Paul Welsh
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Pardeep S Jhund
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | | | - Vijay Chopra
- Max Superspeciality Hospital, Saket, New Delhi, India
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, MO
| | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | - Eileen O'Meara
- Department of Cardiology, Montreal Heart Institute and Université de Montréal, Montreal, Canada
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Herlev, Denmark
| | | | | | | | | | - John J V McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - David A Morrow
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Wussler D, Mueller C. Biomarker-driven prognostic model for risk prediction in heart failure: ready for Prime time? Eur Heart J 2021; 42:4465-4467. [PMID: 34534295 DOI: 10.1093/eurheartj/ehab645] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Desiree Wussler
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland.,Department of Internal Medicine, University Hospital Basel, University of Basel, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), Basel, Switzerland
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