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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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Romiti GF, Nabrdalik K, Corica B, Bucci T, Proietti M, Qian M, Chen Y, Thompson JLP, Homma S, Lip GYH. Diabetes mellitus in patients with heart failure and reduced ejection fraction: a post hoc analysis from the WARCEF trial. Intern Emerg Med 2024; 19:931-939. [PMID: 38393500 PMCID: PMC11186946 DOI: 10.1007/s11739-024-03544-4] [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: 11/16/2023] [Accepted: 01/16/2024] [Indexed: 02/25/2024]
Abstract
Patients with heart failure with reduced ejection fraction (HFrEF) and diabetes mellitus (DM) have an increased risk of adverse events, including thromboembolism. In this analysis, we aimed to explore the association between DM and HFrEF using data from the "Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction" (WARCEF) trial. We analyzed factors associated with DM using multiple logistic regression models and evaluated the effect of DM on long-term prognosis, through adjusted Cox regressions. The primary outcome was the composite of all-cause death, ischemic stroke, or intracerebral hemorrhage; we explored individual components as the secondary outcomes and the interaction between treatment (warfarin or aspirin) and DM on the risk of the primary outcome, stratified by relevant characteristics. Of 2294 patients (mean age 60.8 (SD 11.3) years, 19.9% females) included in this analysis, 722 (31.5%) had DM. On logistic regression, cardiovascular comorbidities, symptoms and ethnicity were associated with DM at baseline, while age and body mass index showed a nonlinear association. Patients with DM had a higher risk of the primary composite outcome (Hazard Ratio [HR] and 95% Confidence Intervals [CI]: 1.48 [1.24-1.77]), as well as all-cause death (HR [95%CI]: 1.52 [1.25-1.84]). As in prior analyses, no statistically significant interaction was observed between DM and effect of Warfarin on the risk of the primary outcome, in any of the subgroups explored. In conclusion, we found that DM is common in HFrEF patients, and is associated with other cardiovascular comorbidities and risk factors, and with a worse prognosis.
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Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Katarzyna Nabrdalik
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Bernadette Corica
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Min Qian
- Mailman School of Public Health, Columbia University, New York, USA
| | - Yineng Chen
- Center for Preventive Ophthalmology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Shunichi Homma
- Cardiology Division, Columbia University Medical Center, New York, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
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Lee HJ, Kim HK, Kim BS, Han KD, Kwak S, Park CS, Rhee TM, Park JB, Lee H, Kim YJ. Sacubitril/valsartan and the risk of incident dementia in heart failure: a nationwide propensity-matched cohort study. Clin Res Cardiol 2024; 113:875-883. [PMID: 37906294 DOI: 10.1007/s00392-023-02322-0] [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: 07/16/2023] [Accepted: 10/09/2023] [Indexed: 11/02/2023]
Abstract
BACKGROUND Sacubitril acts to inhibit neprilysin and as neprilysin is involved in amyloid-beta degradation in the central nervous system, and there is concern that sacubitril/valsartan may increase the risk of dementia. We aimed to compare the risk of incident dementia associated with sacubitril/valsartan and angiotensin II receptor blockers (ARBs). METHODS Patients with heart failure with reduced ejection fraction treated with either sacubitril/valsartan or ARB, identified from the Korean National Health Insurance Service database, were matched in a 1:2 ratio using propensity scores (6789 on sacubitril/valsartan and 13,578 on ARBs) and followed up for incident dementia. RESULTS During a mean follow-up of 2.5 years, 526 (2.6%) patients were newly diagnosed with dementia: Alzheimer dementia in 282, vascular dementia in 8, and other dementia in 236. There was no significant difference in the risk of overall dementia (hazard ratio [HR] 0.84, 95% confidence interval [CI] 0.70-1.01), Alzheimer dementia (HR 0.85, 95% CI 0.67-1.10), vascular dementia (HR 0.98, 95% CI 0.23-4.11), and all other dementias (HR 0.81, 95% CI 0.62-1.07) between sacubitril/valsartan users and ARB users. These results were consistent regardless of initial sacubitril/valsartan dose and subgroups including old age, previous mild cognitive impairment, previous stroke, and concomitant antiplatelet or anticoagulation. Sensitivity analysis with a 1-year lag period for dementia assessment confirmed the main analysis. Meanwhile, risk of incident stroke was lower in sacubitril/valsartan users compared to ARBs users. CONCLUSIONS In a nationwide propensity-matched cohort of patients with heart failure, sacubitril/valsartan was not associated with an increased risk of incident dementia compared to ARBs.
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Affiliation(s)
- Hyun-Jung Lee
- Section of Cardiovascular Imaging, Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, 10103080, Korea
- Division of Cardiology, Severance Cardiovascular Hospital, Yonsei University College of Medicine, 50-1, Yonsei-ro, Seo-Daemun-gu, Seoul, Korea
| | - Hyung-Kwan Kim
- Section of Cardiovascular Imaging, Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, 10103080, Korea.
| | - Bong-Seong Kim
- Department of Statistics and Actuarial Science, Soongsil University, 369, Sangdo-ro, Dongjak-gu, Seoul, Korea
| | - Kyung-Do Han
- Department of Statistics and Actuarial Science, Soongsil University, 369, Sangdo-ro, Dongjak-gu, Seoul, Korea
| | - Soongu Kwak
- Section of Cardiovascular Imaging, Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, 10103080, Korea
| | - Chan Soon Park
- Section of Cardiovascular Imaging, Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, 10103080, Korea
| | - Tae-Min Rhee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, 152, Teheran-ro, Gangnam-gu, Seoul, Korea
| | - Jun-Bean Park
- Section of Cardiovascular Imaging, Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, 10103080, Korea
| | - Heesun Lee
- Division of Cardiology, Department of Internal Medicine, Seoul National University Hospital Healthcare System Gangnam Center, 152, Teheran-ro, Gangnam-gu, Seoul, Korea
| | - Yong-Jin Kim
- Section of Cardiovascular Imaging, Division of Cardiology, Department of Internal Medicine, Cardiovascular Center, Seoul National University Hospital, Seoul National University College of Medicine, Daehak-ro, Jongno-gu, Seoul, 10103080, Korea
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Hellwig S, Krause T, Scheitz JF, Herm J, Grittner U, Jauert N, Fiebach JB, Kasner M, Doehner W, Endres M, Wachter R, Elgeti T, Nolte CH, Haeusler KG. Enhanced diagnostic workup increases pathological findings in patients with acute ischaemic stroke: results of the prospective HEBRAS study. Stroke Vasc Neurol 2024; 9:145-152. [PMID: 37353342 PMCID: PMC11103153 DOI: 10.1136/svn-2022-002179] [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: 11/17/2022] [Accepted: 06/05/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Stroke aetiology remains cryptogenic in a relevant proportion of patients with acute ischaemic stroke (AIS). We assessed whether enhanced diagnostic workup after AIS yields a higher rate of prespecified pathological findings compared with routine diagnostic care in-hospital. METHODS Hospitalised patients with AIS were prospectively enrolled in the investigator-initiated observational HEart and BRain Interfaces in Acute Ischaemic Stroke (HEBRAS) study at the Charité, Berlin, Germany. Patients with AIS without known atrial fibrillation (AF) underwent cardiovascular MR imaging (CMR), MR-angiography of the aortic arch and prolonged Holter-ECG monitoring on top of routine diagnostic care. RESULTS Among 356 patients with AIS (mean age 66 years, 37.6% female), enhanced workup yielded a higher rate of prespecified pathological findings compared with routine care (17.7% vs 5.3%; p<0.001). Consequently, fewer patients were classified as cryptogenic after enhanced diagnostic workup (38.5% vs 45.5%, p<0.001). Routine care included echocardiography in 228 (64.0%) patients. CMR was successfully performed in 292 (82.0%) patients and revealed more often a prespecified pathological finding compared with routine echocardiography (16.1% vs 5.3%). Furthermore, study-related ECG monitoring (median duration 162 hours (IQR 98-210)) detected AF in 16 (4.5%) patients, while routine monitoring (median duration 51 hours (IQR 34-74)) detected AF in seven (2.0%) patients. CONCLUSIONS Enhanced diagnostic workup revealed a higher rate of prespecified pathological findings in patients with AIS compared with routine diagnostic care and significantly reduced the proportion of patients with cryptogenic stroke. TRIAL REGISTRATION NUMBER NCT02142413.
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Affiliation(s)
- Simon Hellwig
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité -Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
| | - Thomas Krause
- Department of Neurology, Jüdisches Krankenhaus Berlin, Berlin, Germany
| | - Jan F Scheitz
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité -Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
| | - Juliane Herm
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
| | - Ulrike Grittner
- Institute of Biometry and Clinical Epidemiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Nadja Jauert
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité -Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | | | - Mario Kasner
- Department of Cardiology, Campus Benjamin Franklin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wolfram Doehner
- Center for Stroke Research Berlin, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
- BIH Center for Regenerative Therapies (BCRT), Berlin Institute of Health at Charité -Universitätsmedizin Berlin, Berlin, Germany
- Department of Cardiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Matthias Endres
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité -Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| | - Rolf Wachter
- Department of Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Thomas Elgeti
- Department of Radiology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin, Germany
- Berlin Institute of Health at Charité -Universitätsmedizin Berlin, BIH Biomedical Innovation Academy, Berlin, Germany
- German Center for Cardiovascular Diseases (DZHK), Partner Site Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
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Monzo L, Girerd N, Ferreira JP, Lamiral Z, Anker SD, Cleland JGF, Kondo T, McMurray JJV, Lam CSP, Mehra MR, Veldhuisen DJVAN, Greenberg B, Zannad F. High Risk of Stroke in Patients With Worsening Heart Failure, Reduced Ejection Fraction, Coronary Heart Disease and Sinus Rhythm: Risk Prediction Score Analysis From the COMMANDER-HF Trial. J Card Fail 2024; 30:618-623. [PMID: 38122924 DOI: 10.1016/j.cardfail.2023.11.020] [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: 09/12/2023] [Revised: 11/21/2023] [Accepted: 11/26/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Patients with heart failure with reduced ejection fraction (HFrEF) and sinus rhythm have a heightened risk of stroke. Whether anticoagulation benefits these patients is uncertain. In this post hoc analysis of the A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction, or Stroke in Participants with Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure (COMMANDER-HF) trial we evaluated how a previously validated risk model consisting of 3 variables (history of prior stroke, insulin-treated diabetes, and N-terminal pro-B-type natriuretic peptide level) would perform, compared with plasma d-dimer, for stroke prediction and estimation of the benefit of low-dose rivaroxaban. METHODS AND RESULTS Stroke risk and treatment effect were computed across risk score and plasma d-dimer tertiles. Risk score was available in 58% of the COMMANDER-HF population (n = 2928). Over a median follow-up of 512 days (range 342-747 days), 60 patients experienced a stroke (14.6 per 1000 patient-years). The risk model did not identify patients at higher risk of stroke and showed a low overall prognostic performance (C-index = 0.53). The effect of rivaroxaban on stroke was homogeneous across risk score tertiles (P-interaction = .67). Among patients in whom the risk score was estimated, d-dimer was available in 2343 (80%). d-dimer had an acceptable discrimination performance for stroke prediction (C-index = 0.66) and higher plasma d-dimer concentrations were associated with higher rates of stroke (ie, tertile 3 vs tertile 1, hazard ratio 3.65, 95% confidence interval 1.59-8.39, P = .002). Treatment with low-dose rivaroxaban reduced the incidence of stroke in patients at highest risk by d-dimer levels (ie, >515 ng/mL, hazard ratio 0.42, 95% confidence interval 0.18-0.95, P-interaction = .074), without any safety concerns. CONCLUSIONS In our analysis, plasma d-dimer concentrations performed better than a previously described 3-variable risk score for stroke prediction in patients with heart failure with reduced ejection fraction, a recent clinical worsening and sinus rhythm as enrolled in the COMMANDER-HF trial. In these patients, a raised plasma d-dimer concentration identified patients who might benefit most from rivaroxaban.
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Affiliation(s)
- Luca Monzo
- From the Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU Nancy, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Nicolas Girerd
- From the Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU Nancy, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - João Pedro Ferreira
- From the Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU Nancy, FCRIN 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, Portugal
| | - Zohra Lamiral
- From the Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU Nancy, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Stefan D Anker
- Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies, German Center for Cardiovascular Research partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - John G F Cleland
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK; Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore; Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Mandeep R Mehra
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Dirk J VAN Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Barry Greenberg
- Cardiology Division, Department of Medicine, University of California, San Diego, California
| | - Faiez Zannad
- From the Université de Lorraine, Centre d'Investigations Cliniques Plurithématique 1433 and Inserm U1116, CHRU Nancy, FCRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.
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Doehner W, Böhm M, Boriani G, Christersson C, Coats AJS, Haeusler KG, Jones ID, Lip GYH, Metra M, Ntaios G, Savarese G, Shantsila E, Vilahur G, Rosano G. Interaction of heart failure and stroke: A clinical consensus statement of the ESC Council on Stroke, the Heart Failure Association (HFA) and the ESC Working Group on Thrombosis. Eur J Heart Fail 2023; 25:2107-2129. [PMID: 37905380 DOI: 10.1002/ejhf.3071] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Revised: 10/06/2023] [Accepted: 10/16/2023] [Indexed: 11/02/2023] Open
Abstract
Heart failure (HF) is a major disease in our society that often presents with multiple comorbidities with mutual interaction and aggravation. The comorbidity of HF and stroke is a high risk condition that requires particular attention to ensure early detection of complications, efficient diagnostic workup, close monitoring, and consequent treatment of the patient. The bi-directional interaction between the heart and the brain is inherent in the pathophysiology of HF where HF may be causal for acute cerebral injury, and - in turn - acute cerebral injury may induce or aggravate HF via imbalanced neural and neurovegetative control of cardiovascular regulation. The present document represents the consensus view of the ESC Council on Stroke, the Heart Failure Association and the ESC Working Group on Thrombosis to summarize current insights on pathophysiological interactions of the heart and the brain in the comorbidity of HF and stroke. Principal aspects of diagnostic workup, pathophysiological mechanisms, complications, clinical management in acute conditions and in long-term care of patients with the comorbidity are presented and state-of-the-art clinical management and current evidence from clinical trials is discussed. Beside the physicians perspective, also the patients values and preferences are taken into account. Interdisciplinary cooperation of cardiologists, stroke specialists, other specialists and primary care physicians is pivotal to ensure optimal treatment in acute events and in continued long-term treatment of these patients. Key consensus statements are presented in a concise overview on mechanistic insights, diagnostic workup, prevention and treatment to inform clinical acute and continued care of patients with the comorbidity of HF and stroke.
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Affiliation(s)
- Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiology (Campus Virchow) and German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Michael Böhm
- Universitätsklinikum des Saarlandes, Klinik für Innere Medizin III, Saarland University (Kardiologie, Angiologie und Internistische Intensivmedizin), Homburg, Germany
| | - Giuseppe Boriani
- Cardiology Division, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Policlinico di Modena, Modena, Italy
| | | | | | - Karl Georg Haeusler
- Department of Neurology, Universitätsklinikum Würzburg (UKW), Würzburg, Germany
| | - Ian D Jones
- Liverpool Centre for Cardiovascular Science, School of Nursing and Allied Health, Liverpool John Moores University, Liverpool, UK
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - George Ntaios
- Department of Internal Medicine, School of Health Sciences, Faculty of Medicine, University of Thessaly, Larissa, Greece
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Eduard Shantsila
- Department of Primary Care, University of Liverpool, Liverpool, UK
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital, Liverpool, UK
| | - Gemma Vilahur
- Institut de Recerca de l'Hospital de la Santa Creu i Sant Pau and CIBERCV, Barcelona, Spain
| | - Giuseppe Rosano
- St George's University Hospital, London, UK, San Raffaele Cassino, Rome, Italy
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7
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Crea F. Challenges and opportunities in prognostication: focus on ischaemic heart disease and atrial fibrillation. Eur Heart J 2023; 44:3391-3394. [PMID: 37738644 DOI: 10.1093/eurheartj/ehad614] [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] [Indexed: 09/24/2023] 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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Crea F. Focus on atrial fibrillation in specific clinical settings and on calmodulinopathy. Eur Heart J 2023; 44:3299-3302. [PMID: 37704265 DOI: 10.1093/eurheartj/ehad590] [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] [Indexed: 09/15/2023] 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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9
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Yang M, Kondo T, Butt JH, Abraham WT, Anand IS, Desai AS, Køber L, Packer M, Pfeffer MA, Rouleau JL, Sabatine MS, Solomon SD, Swedberg K, Zile MR, Jhund PS, McMurray JJV. Stroke in patients with heart failure and reduced or preserved ejection fraction. Eur Heart J 2023; 44:2998-3013. [PMID: 37358785 PMCID: PMC10424882 DOI: 10.1093/eurheartj/ehad338] [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: 09/27/2022] [Revised: 02/17/2023] [Accepted: 05/16/2023] [Indexed: 06/27/2023] Open
Abstract
AIMS Stroke is an important problem in patients with heart failure (HF), but the intersection between the two conditions is poorly studied across the range of ejection fraction. The prevalence of history of stroke and related outcomes were investigated in patients with HF. METHODS AND RESULTS Individual patient meta-analysis of seven clinical trials enrolling patients with HF with reduced (HFrEF) and preserved ejection fraction (HFpEF). Of the 20 159 patients with HFrEF, 1683 (8.3%) had a history of stroke, and of the 13 252 patients with HFpEF, 1287 (9.7%) had a history of stroke. Regardless of ejection fraction, patients with a history of stroke had more vascular comorbidity and worse HF. Among those with HFrEF, the incidence of the composite of cardiovascular death, HF hospitalization, stroke, or myocardial infarction was 18.23 (16.81-19.77) per 100 person-years in those with prior stroke vs. 13.12 (12.77-13.48) in those without [hazard ratio 1.37 (1.26-1.49), P < 0.001]. The corresponding rates in patients with HFpEF were 14.16 (12.96-15.48) and 9.37 (9.06-9.70) [hazard ratio 1.49 (1.36-1.64), P < 0.001]. Each component of the composite was more frequent in patients with stroke history, and the risk of future stroke was doubled in patients with prior stroke. Among patients with prior stroke, 30% with concomitant atrial fibrillation were not anticoagulated, and 29% with arterial disease were not taking statins; 17% with HFrEF and 38% with HFpEF had uncontrolled systolic blood pressure (≥140 mmHg). CONCLUSION Heart failure patients with a history of stroke are at high risk of subsequent cardiovascular events, and targeting underutilization of guideline-recommended treatments might be a way to improve outcomes in this high-risk population.
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Affiliation(s)
- Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, OH, USA
| | - Inder S Anand
- VA Medical Center, Minneapolis, MN, USA
- University of Minnesota, Minneapolis, MN, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA
| | - 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
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
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10
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Witsch J, Kasner SE. Redefining the role of heart failure in stroke. Eur Heart J 2023; 44:3014-3016. [PMID: 37358891 DOI: 10.1093/eurheartj/ehad360] [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] [Indexed: 06/27/2023] Open
Affiliation(s)
- Jens Witsch
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA
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11
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Iaconelli A, Pellicori P, Caiazzo E, Rezig AOM, Bruzzese D, Maffia P, Cleland JGF. Implanted haemodynamic telemonitoring devices to guide management of heart failure: a review and meta-analysis of randomised trials. Clin Res Cardiol 2023; 112:1007-1019. [PMID: 36241896 PMCID: PMC9568893 DOI: 10.1007/s00392-022-02104-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/06/2022] [Indexed: 11/23/2022]
Abstract
BACKGROUND AND AIMS Congestion is a key driver of morbidity and mortality in heart failure. Implanted haemodynamic monitoring devices might allow early identification and management of congestion. Here, we provide a state-of-the-art review of implanted haemodynamic monitoring devices for patients with heart failure, including a meta-analysis of randomised trials. METHODS AND RESULTS We did a systematic search for pre-print and published trials in Medline, Embase, and the Cochrane Central Register of Controlled Trials (CENTRAL) on the 22nd of September 2021. We included randomised trials that compared management with or without information from implanted haemodynamic monitoring devices for patients with heart failure. Outcomes selected were hospitalisation for heart failure and all-cause mortality. Changes in treatment associated with haemodynamic monitoring resulted in only a small reduction in mean pulmonary artery pressure (typically < 1 mmHg as a daily average), which generally remained much greater than 20 mmHg. Haemodynamic monitoring reduced hospitalisations for heart failure (HR 0.75; 95% CI 0.58-0.96; p = 0.03) but not mortality (RR 0.92; 95% CI 0.68-1.26; p = 0.48). CONCLUSIONS Haemodynamic monitoring for patients with heart failure may reduce the risk of hospitalization for heart failure but this has not yet translated into a reduction in mortality, perhaps because the duration of trials was too short or the reduction in pulmonary artery pressure was not sufficiently large. The efficacy and safety of aiming for larger reductions in pulmonary artery pressure should be explored. After selecting key words, a systematic review for implanted haemodynamic telemonitoring devices was performed in different dataset and 4 randomised clinical trials were identified and included in this meta-analysis. Three different devices (Chronicle, Chronicle/ICD and CardioMEMS) were tested. All-cause mortality and total heart failure hospitalisations were selected as outcomes. No reduction in all-cause mortality rate was reported but a potential benefit on total heart failure hospitalisation was identified.
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Affiliation(s)
- Antonio Iaconelli
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168, Rome, Italy.
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Elisabetta Caiazzo
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Asma O M Rezig
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
| | - Dario Bruzzese
- Department of Public Health, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - Pasquale Maffia
- School of Infection and Immunity, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
- Department of Pharmacy, School of Medicine and Surgery, University of Naples Federico II, Naples, Italy
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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12
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Haseeb ul Rasool M, Persand D, Salam S. The Dilemma of Use of Anticoagulation in Patients With Heart Failure With Reduced Ejection Fraction and Sinus Rhythm: A Case Report and Literature Review. Cureus 2023; 15:e35211. [PMID: 36968886 PMCID: PMC10032553 DOI: 10.7759/cureus.35211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/20/2023] [Indexed: 02/22/2023] Open
Abstract
Heart failure results in significant morbidity and mortality. Heart failure with reduced ejection fraction (HfrEF) in the absence of atrial fibrillation has been increasingly considered an independent risk factor for ischemic stroke, partly because of the development of left ventricular thrombus and subsequent cardioembolic stroke and partly because of hemodynamic impairment. Here, we present a case of a 60-year-old male with heart failure with reduced ejection fraction, who presented with cardioembolic ischemic stroke. In the investigation to localize the source, he was found to have slow intra-ventricular blood flow, which over shorter periods of follow up lead to the development of left ventricle intra-mural thrombi. Meanwhile, the patient also developed hemorrhagic conversion in the ischemic stroke, which further complicated the choice of anticoagulation. To date, no consensus has been developed on the choice of anticoagulation and clinical criteria for the use of anticoagulation in patients having HfrEF and sinus rhythm. This case brings forth a need for further research on whether anticoagulation would be beneficial in patients with HfrEF and sinus rhythm.
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13
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Crea F. Heart failure in cardio-oncology and adult congenital heart disease: new challenges and therapeutic targets. Eur Heart J 2022; 43:4443-4446. [PMID: 36335981 DOI: 10.1093/eurheartj/ehac621] [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: 11/09/2022] 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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