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Cuthbert JJ, Clark AL. The beginning of wisdom is the definition of terms: counting heart failure hospitalizations. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2024; 10:481-482. [PMID: 39038988 DOI: 10.1093/ehjqcco/qcae062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2024] [Accepted: 07/19/2024] [Indexed: 07/24/2024]
Affiliation(s)
- J J Cuthbert
- Clinical Sciences Centre, Hull York Medical School, University of Hull, Cottingham Road, Kingston-Upon-Hull, East Riding of Yorkshire, HU6 7RX, UK
- Department of Cardiology, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham, East Riding of Yorkshire, HU16 5JQ, UK
| | - A L Clark
- Department of Cardiology, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham, East Riding of Yorkshire, HU16 5JQ, UK
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2
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Puthenpura M, Wilcox J, Tang WHW. Worsening heart failure: a concept in evolution. Curr Opin Cardiol 2024; 39:119-127. [PMID: 38116785 DOI: 10.1097/hco.0000000000001108] [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] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW Worsening heart failure (WHF) has developed as a unique definition within heart failure (HF) in recent years. It captures the disease as a dynamic process. This review describes what is currently known about WHF, why it should be considered a discrete scientific endpoint, and future directions for research. RECENT FINDINGS There is no single agreed upon definition for WHF. It can be identified as being due to treatment side-effects, related to concomitant comorbidity, or true disease progression. Risk scores based on criteria like those already developed for HF can be created to stratify risk for WHF. CONCLUSIONS WHF is an emerging entity within HF that defines itself as a unique point of interest. Understanding it as a clinical measure of where a patient's HF is evolving allows for identifying patients that require a refreshed approach to their care. Keeping this in mind will help redefine more patient-centric outcome measures in research to come.
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Affiliation(s)
| | - Jennifer Wilcox
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute
| | - W H Wilson Tang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute
- Kaufman Center for Heart Failure Treatment and Recovery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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3
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Mohan JC, Sathyamurthy I, Panja M, Agarwala R, Ponde CK, Kumar AS, Mahala BK, Kolapkar V, Kumar RVL, Patel K. Expert Consensus on Ivabradine-based Therapy for Heart Rate Management in Chronic Coronary Syndrome and Heart Failure with Reduced Ejection Fraction in India. Curr Cardiol Rev 2023; 19:97-106. [PMID: 36941812 PMCID: PMC10518888 DOI: 10.2174/1573403x19666230320105623] [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: 09/12/2022] [Revised: 01/10/2023] [Accepted: 01/10/2023] [Indexed: 03/23/2023] Open
Abstract
Heart rate is an important indicator of health and disease and the modulation of heart rate can help to improve cardiovascular outcomes. Besides β-blockers, Ivabradine is a wellestablished heart rate modulating drug that reduces heart rate without any hemodynamic effects. This consensus document was developed with the help of expert opinions from cardiologists across India on effective heart rate management in routine clinical practice and choosing an appropriate Ivabradine-based therapy considering the available scientific data and guideline recommendations. Based on the discussion during the meetings, increased heart rate was recognized as a significant predictor of adverse cardiovascular outcomes among patients with chronic coronary syndromes and heart failure with reduced ejection fraction making heart rate modulation important in these subsets. Ivabradine is indicated in the management of chronic coronary syndromes and heart failure with reduced ejection fraction for patients in whom heart rate targets cannot be achieved despite guideline-directed β-blocker dosing or having contraindication/intolerance to β-blockers. A prolonged release once-daily dosage of Ivabradine can be considered in patients already stabilized on Ivabradine twice-daily. Ivabradine/β-blocker fixed-dose combination can also be considered to reduce pill burden. Two consensus algorithms have been developed for further guidance on the appropriate usage of Ivabradine-based therapies. Ivabradine and β-blockers can provide more pronounced clinical improvement in most chronic coronary syndromes and heart failure with reduced ejection fraction patients with a fixed-dose combination providing an opportunity to improve adherence.
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Affiliation(s)
- J C Mohan
- Head of Department & Senior Consultant Cardiology, Jaipur Golden Hospital, Delhi, India
| | - I Sathyamurthy
- Senior Interventional Cardiologist, Apollo Hospitals, Chennai, India
| | - Monotosh Panja
- Senior Interventional Cardiologist, AMRI Hospitals, Kolkata, India
| | - Rajeev Agarwala
- Head of Department and Consultant Cardiologist, Jaswant Rai Speciality Hospital, Meerut, India
| | - C K Ponde
- Head of Department and Consultant Cardiologist, P. D. Hinduja National Hospital & Medical Research Centre, Mumbai, India
| | - A Sreenivas Kumar
- Director Cardiology & Clinical Research, Apollo Health City, Hyderabad, India; Apollo Hospitals, Hyderabad, India
| | - Bijay Kumar Mahala
- Senior Consultant Cardiology, Narayana Institute of Cardiac Sciences, Bangalore, India
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4
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Tymińska A, Ozierański K, Wawrzacz M, Balsam P, Maciejewski C, Kleszczewska M, Zawadzka M, Marchel M, Crespo-Leiro MG, Maggioni AP, Drożdż J, Opolski G, Grabowski M, Kapłon-Cieślicka A. Heart rate control and its predictors in patients with heart failure and sinus rhythm. Data from the European Society of Cardiology Long-Term Registry. Cardiol J 2022; 30:VM/OJS/J/88117. [PMID: 35975794 PMCID: PMC10713215 DOI: 10.5603/cj.a2022.0076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 07/04/2022] [Accepted: 07/17/2022] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Higher resting heart rate (HR) in patients with heart failure (HF) and sinus rhythm (SR) is associated with increased mortality. In patients hospitalized for HF, the aim herein, was to assess the use and dosage of guideline-recommended HR lowering medications, HR control at discharge and predictors of HR control. METHODS In the present study, were Polish participants of the European Society of Cardiology HF Long-Term (ESC-HF-LT) Registry. Those selected were hospitalized for HF, with reduced ejection fraction (HFrEF) and SR at discharge (n = 236). The patients were divided in two groups ( < 70 and ≥ 70 bpm). Logistic regression was used to identify the predictors of HR ≥ 70 bpm. RESULTS Of patients with HFrEF and SR, 59% had HR ≥ 70 bpm at hospital discharge. At discharge, 96% and only 0.5% of the patients with HFrEF and SR received beta-blocker and ivabradine, respectively. In the HF groups < 70 and ≥ 70 bpm, only 11% and 4% of patients received beta-blocker target doses, respectively. There was no difference in the use of other guideline-recommended medications. Age, New York Heart Association class, HR on admission and lack of HR lowering medications were predictors of discharge HR ≥ 70 bpm. CONCLUSIONS Heart rate control after hospitalization for HFrEF is unsatisfactory, which may be attributed to suboptimal doses of beta-blockers, and negligence in use other HR lowering drugs (including ivabradine).
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Affiliation(s)
- Agata Tymińska
- 1st Department of Cardiology, Medical University of Warsaw, Poland
| | | | - Marek Wawrzacz
- 1st Department of Cardiology, Medical University of Warsaw, Poland
| | - Paweł Balsam
- 1st Department of Cardiology, Medical University of Warsaw, Poland
| | | | | | | | - Michał Marchel
- 1st Department of Cardiology, Medical University of Warsaw, Poland
| | | | - Aldo P Maggioni
- Centro Studi ANMCO (Associazione Nazionale Medici Cardiologi Ospedalieri), Florence, Italy
| | - Jarosław Drożdż
- Department of Cardiology, 1st Chair of Cardiology and Cardiac Surgery, Medical University of Lodz, Poland
| | - Grzegorz Opolski
- 1st Department of Cardiology, Medical University of Warsaw, Poland
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, Poland
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5
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Successful use of ivabradine in a 10-year-old patient with graft failure after heart transplantation. Cardiol Young 2022; 33:649-651. [PMID: 35864814 DOI: 10.1017/s1047951122002335] [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: 11/06/2022]
Abstract
We encountered a paediatric case of graft failure due to antibody-mediated rejection after heart transplantation in which ivabradine was effective. Inappropriate sinus tachycardia in denervated transplanted hearts is a good indication for ivabradine administration as beta-blockers have a limited efficacy. To our knowledge, this is the first report on the effectiveness of ivabradine in a paediatric heart transplant rejection case.
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Gilyarevsky SR. Modern Approaches to the Interpretation of the Results of Large Randomized Clinical Trials. RATIONAL PHARMACOTHERAPY IN CARDIOLOGY 2022. [DOI: 10.20996/1819-6446-2022-05-01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Modern approaches to interpreting the results of randomized trials, which can reduce the distortion of information when they are presented to a wide range of doctors, are discussed in the article. Data on the role of taking into account multiple comparisons in the planning and analysis of large randomized clinical trials are given. The validity and approaches to using a hierarchical approach to assessing the statistical significance of indicators (“endpoints”) in cases where, in accordance with a pre-adopted study protocol, several indicators are supposed to be evaluated are considered in detail. Approaches to interpreting the p value as well as 95% confidence intervals are considered. Particular attention is paid to the interpretation of the components of the main combined indicator, since when interpreting just such data, the presentation of the results of the study and the manipulation of doctors' opinions may be distorted. This is especially true for data on mortality and mortality from complications of cardiovascular diseases. Modern approaches to the analysis of research results using methods other than the usual Kaplan-Meier analysis, in particular, the method based on the calculation of the "win ratio" are discussed. Data obtained in modern clinical studies are given as examples.
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 710] [Impact Index Per Article: 355.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
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8
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Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 891] [Impact Index Per Article: 445.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
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Piantoni C, Paina M, Molla D, Liu S, Bertoli G, Jiang H, Wang Y, Wang Y, Wang Y, DiFrancesco D, Barbuti A, Bucchi A, Baruscotti M. Chinese natural compound decreases pacemaking of rabbit cardiac sinoatrial cells by targeting second messenger regulation of f-channels. eLife 2022; 11:75119. [PMID: 35315774 PMCID: PMC8940175 DOI: 10.7554/elife.75119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
Tongmai Yangxin (TMYX) is a complex compound of the Traditional Chinese Medicine (TCM) used to treat several cardiac rhythm disorders; however, no information regarding its mechanism of action is available. In this study we provide a detailed characterization of the effects of TMYX on the electrical activity of pacemaker cells and unravel its mechanism of action. Single-cell electrophysiology revealed that TMYX elicits a reversible and dose-dependent (2/6 mg/ml) slowing of spontaneous action potentials rate (−20.8/–50.2%) by a selective reduction of the diastolic phase (−50.1/–76.0%). This action is mediated by a negative shift of the If activation curve (−6.7/–11.9 mV) and is caused by a reduction of the cyclic adenosine monophosphate (cAMP)-induced stimulation of pacemaker channels. We provide evidence that TMYX acts by directly antagonizing the cAMP-induced allosteric modulation of the pacemaker channels. Noticeably, this mechanism functionally resembles the pharmacological actions of muscarinic stimulation or β-blockers, but it does not require generalized changes in cytoplasmic cAMP levels thus ensuring a selective action on rate. In agreement with a competitive inhibition mechanism, TMYX exerts its maximal antagonistic action at submaximal cAMP concentrations and then progressively becomes less effective thus ensuring a full contribution of If to pacemaker rate during high metabolic demand and sympathetic stimulation.
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Affiliation(s)
- Chiara Piantoni
- Department of Biosciences, The Cell Physiology Lab and "Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata", Università degli Studi di Milano, Milano, Italy
| | - Manuel Paina
- Department of Biosciences, The Cell Physiology Lab and "Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata", Università degli Studi di Milano, Milano, Italy
| | - David Molla
- Department of Biosciences, The Cell Physiology Lab and "Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata", Università degli Studi di Milano, Milano, Italy
| | - Sheng Liu
- Department of Physiology and Pathophysiology, School of Basic Medical Science, Tianjin Medical University, Tianjin, China
| | - Giorgia Bertoli
- Department of Biosciences, The Cell Physiology Lab and "Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata", Università degli Studi di Milano, Milano, Italy
| | - Hongmei Jiang
- Department of Physiology and Pathophysiology, School of Basic Medical Science, Tianjin Medical University, Tianjin, China
| | - Yanyan Wang
- School of Integrative Medicine, Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Yi Wang
- College of Pharmaceutical Sciences, Zhejiang University, Hangzhou, China
| | - Yi Wang
- Institute of Traditional Chinese Medicine Tianjin University of Traditional Chinese Medicine, Tianjin, China
| | - Dario DiFrancesco
- Department of Biosciences, The Cell Physiology Lab and "Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata", Università degli Studi di Milano, Milano, Italy
| | - Andrea Barbuti
- Department of Biosciences, The Cell Physiology Lab and "Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata", Università degli Studi di Milano, Milano, Italy
| | - Annalisa Bucchi
- Department of Biosciences, The Cell Physiology Lab and "Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata", Università degli Studi di Milano, Milano, Italy
| | - Mirko Baruscotti
- Department of Biosciences, The Cell Physiology Lab and "Centro Interuniversitario di Medicina Molecolare e Biofisica Applicata", Università degli Studi di Milano, Milano, Italy
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10
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Hanif M, Khan HU, Maheen S, Shafqat SS, Shah S, Masood SA, Abbas G, Rizwan M, Rasheed T, Bilal M. Formulation, characterization, and pharmacokinetic evaluation of Ivabradine-Nebivolol co-encapsulated lipospheres. J Mol Liq 2021. [DOI: 10.1016/j.molliq.2021.117704] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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11
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Mareev VY, Kapanadze LG, Kheimets GI, Mareev YV. Effect of 24-hour blood pressure and heart rate on the prognosis of patients with reduced and midrange LVEF. ACTA ACUST UNITED AC 2021; 61:4-13. [PMID: 34397336 DOI: 10.18087/cardio.2021.7.n1684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2021] [Accepted: 07/13/2021] [Indexed: 11/18/2022]
Abstract
Aim Optimal combination therapy for chronic heart failure (CHF) currently implies the mandatory use of at least four classes of drugs: renin-angiotensin-aldosterone (RAAS) system inhibitors or angiotensin receptor blocker neprilysin inhibitors (ARNI); beta-adrenoblockers (BAB); mineralocorticoid receptor antagonists; and sodium-glucose cotransporter 2 inhibitors. Furthermore, many of these drugs are able to decrease blood pressure even to hypotension and alleviate tachycardia. This study focused on the relationship of 24-h blood pressure (BP) and heart rate (HR) with the prognosis for CHF patients with sinus rhythm and left ventricular ejection fraction (LV EF) <50 % as well as on suggesting possible variants of safe therapy for CHF depending on the combination of studied factors.Material and methods Effects of clinical data, echocardiographic parameters, 24-h BP, and heart rhythm (data from 24-h BP and ECG monitors) on the prognosis of 155 patients with clinically pronounced CHF, LV EF <50 %, and sinus rhythm who were followed up for 5 years after discharge from the hospital.Results The one-factor analysis showed that the prognosis of CHF patients was statistically significantly influenced by the more severe functional class (FC) III CHF compared to FC II, reduced LV EF (<35 %), a lower 24-h systolic BP (SBP) (<103 mm Hg), the absence of hypotensive episodes in daytime, a low variability of nighttime BP (<7.5 mm Hg), a higher 24-h HR (>71 bpm vs. <60 bpm), the absence of therapy with RAAS inhibitors + BAB, and a lower body weight index. The multi-factor analysis showed that more severe CHF FC, lower LV EF, and the absence of RAAS inhibitors + BAB therapy retained the influence on the prognosis. After eliminating the influencing factor of drug therapy, also a low SBP variability significantly influenced the prognosis. An additional analysis determined the following four groups of CHF patients with reduced heart systolic function according to mean 24-h HR and SBP: the largest group (38.1 % of all patients) with controlled HR (≤69 bpm), preserved SBP (>103 mm Hg), and the lowest death rate of 15.3 %; the group with increased HR (>69 bpm) but preserved SBP (30.3 % of all patients) where the death rate was 44.7 %, which was significantly higher than in the first group; the group with normal HR (≤69 bpm) but reduced SBP (≤103 mm Hg) (16.1 % of patients) where the death rate was 40 %, which was comparable with the second group and significantly worse than in the first group; and the group with both increased HR (>69 bpm) and reduced SBP (≤103 mm Hg) (15.5 % of patients), which resulted in the maximal risk of death (70.8 % of patients with CHF and LV EF <50 %), which was significantly higher than in the three other groups.Conclusion Low SBP (including 24-h SBP with reduced variability in day- and nighttime) in combination with high HR (including by data of Holter monitoring), low LV EF, more severe clinical course of CHF, and the absence of an adequate treatment with neurohormonal modulators (RAAS inhibitors and BAB) significantly increased the risk of death. Isolating four types of FC II-III CHF with sinus rhythm and EF <50% based on the combination of HR and BP identifies patients with an unfavorable prognosis, which will help developing differentiated therapeutic approaches taking into account clinical features.
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Affiliation(s)
- V Yu Mareev
- Medical Research and Educational Center of the M. V. Lomonosov Moscow State University, Moscow, Russia Faculty of Fundamental Medicine, Lomonosov Moscow State University, Russia
| | - L G Kapanadze
- Academician Chapidze Center for Emergency Cardiology, Tbilisi, Georgia
| | - G I Kheimets
- Scientific Medical Research Center of Cardiology, Moscow, Russia
| | - Yu V Mareev
- National Medical Research Centre for Therapy and Preventive Medicine, Moscow, Russia Robertson Centre for Biostatistics, Glasgow, Great Britain
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12
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Faragli A, Tano GD, Carlini CD, Nassiacos D, Gori M, Confortola G, Lo Muzio FP, Rapis K, Abawi D, Post H, Kelle S, Pieske B, Alogna A, Campana C. In-hospital Heart Rate Reduction With Beta Blockers and Ivabradine Early After Recovery in Patients With Acute Decompensated Heart Failure Reduces Short-Term Mortality and Rehospitalization. Front Cardiovasc Med 2021; 8:665202. [PMID: 34395550 PMCID: PMC8363305 DOI: 10.3389/fcvm.2021.665202] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 05/31/2021] [Indexed: 11/21/2022] Open
Abstract
Objective: In the past years, heart rate (HR) has emerged as a highly relevant modifiable risk factor for heart failure (HF) patients. However, most of the clinical trials so far evaluated the role of HR in stable chronic HF cohorts. The aim of this multi-center, prospective observational study was to assess the association between HR and therapy with HR modulators (beta blockers, ivabradine, or a combination of ivabradine and beta blockers) at hospital discharge with patients' cardiovascular mortality and re-hospitalization at 6 months in acutely decompensated HF patients. Materials and Methods: We recruited 289 HF patients discharged alive after admission for HF decompensation from 10 centers in northern Italy over 9 months (from April 2017 to January 2018). The primary endpoint was the combination of cardiovascular mortality or re-hospitalizations for HF at 6 months. Results: At 6 months after discharge, 64 patients were readmitted (32%), and 39 patients died (16%). Multivariate analysis showed that HR at discharge ≥ 90 bpm (OR = 8.47; p = 0.016) independently predicted cardiovascular mortality, while therapy with beta blockers at discharge was found to reduce the risk of the composite endpoint. In patients receiving HR modulators the event rates for the composite endpoint, all-cause mortality, and cardiovascular mortality were lower than in patients not receiving HR modulators. Conclusions: Heart rate at discharge ≥90 bpm predicts cardiovascular mortality, while therapy with beta blockers is negatively associated with the composite endpoint of cardiovascular mortality and hospitalization at 6 months in acutely decompensated HF patients. Patients receiving a HR modulation therapy at hospital discharge showed the lowest rate of cardiovascular mortality and re-hospitalization.
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Affiliation(s)
- Alessandro Faragli
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Giuseppe Di Tano
- Department of Cardiology Ospedale Maggiore, ASST Cremona, Cremona, Italy
| | | | - Daniel Nassiacos
- Department of Cardiology, Ospedale di Circolo, ASST Valle Olona, Saronno VA, Italy
| | - Mauro Gori
- Department of Cardiology, ASST Ospedale Papa Giovanni XXXIII, Bergamo, Italy
| | - Giada Confortola
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Francesco Paolo Lo Muzio
- Department of Surgery, Dentistry, Paediatrics and Gynaecology, University of Verona, Verona, Italy.,Department of Medicine and Surgery, University of Parma, Parma, Italy
| | - Konstantinos Rapis
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dawud Abawi
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Heiner Post
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Cardiology, Contilia Heart and Vessel Centre, St. Marien-Hospital Mülheim, Mülheim, Germany
| | - Sebastian Kelle
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany.,Department of Internal Medicine/Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Alessio Alogna
- Department of Internal Medicine and Cardiology, Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), Partner Site Berlin, Berlin, Germany
| | - Carlo Campana
- Department of Cardiology Sant'Anna Hospital, ASST-Lariana, Como, Italy
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Miller AB, Januzzi JL, O'Neill BJ, Gundapaneni B, Patterson TA, Sultan MB, López-Sendón J. Causes of Cardiovascular Hospitalization and Death in Patients With Transthyretin Amyloid Cardiomyopathy (from the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial [ATTR-ACT]). Am J Cardiol 2021; 148:146-150. [PMID: 33667442 DOI: 10.1016/j.amjcard.2021.02.035] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2020] [Revised: 02/23/2021] [Accepted: 02/26/2021] [Indexed: 01/19/2023]
Abstract
In the Tafamidis in Transthyretin Cardiomyopathy Clinical Trial (ATTR-ACT), tafamidis significantly reduced mortality and cardiovascular (CV)-related hospitalizations compared with placebo in patients with transthyretin amyloid cardiomyopathy (ATTR-CM). This analysis aimed to assess the causes of CV-related death and hospitalization in ATTR-ACT to provide further insight into the progression of ATTR-CM and efficacy of tafamidis. ATTR-ACT was an international, double-blind, placebo-controlled, and randomized study. Patients with hereditary or wild-type ATTR-CM were randomized to tafamidis (n = 264) or placebo (n = 177) for 30 months. The independent Endpoint Adjudication Committee determined whether certain investigator-reported events met the definition of disease-related efficacy endpoints using predefined criteria. Cause-specific reasons for CV-related deaths (heart failure [HF], arrhythmia, myocardial infarction, sudden death, stroke, and other CV causes) and hospitalizations (HF, arrhythmia, myocardial infarction, transient ischemic attack/stroke, and other CV causes) were assessed. Total CV-related deaths was 53 (20.1%) with tafamidis and 50 (28.2%) with placebo, with HF (15.5% tafamidis, 22.6% placebo), followed by sudden death (2.7% tafamidis, 5.1% placebo), the most common causes. The number of patients with a CV-related hospitalization was 138 (52.3%) with tafamidis and 107 (60.5%) with placebo; with HF the most common cause (43.2% tafamidis, 50.3% placebo). All predefined causes of CV-related death or hospitalization were less frequent with tafamidis than placebo. In conclusion, these data provide further insight into CV disease progression in patients with ATTR-CM, with HF the most common adjudicated cause of CV-related hospitalization or death in ATTR-ACT. Clinical trial registration ClinicalTrials.gov: NCT01994889.
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Lee Y, Lin P, Chiou W, Huang J, Lin W, Liao C, Chung F, Liang H, Hsu C, Chang H. Combination of ivabradine and sacubitril/valsartan in patients with heart failure and reduced ejection fraction. ESC Heart Fail 2021; 8:1204-1215. [PMID: 33410280 PMCID: PMC8006660 DOI: 10.1002/ehf2.13182] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Revised: 11/09/2020] [Accepted: 12/03/2020] [Indexed: 12/11/2022] Open
Abstract
AIMS Ivabradine and sacubitril/valsartan are second-line therapies for patients with heart failure and reduced ejection fraction (HFrEF) based on guideline recommendations. We aimed to evaluate the synergistic effects of these two medications. METHODS AND RESULTS Patients' data were extracted from a multicentre database between 2016 and 2018. Patients were classified into (1) Simultaneous group: simultaneous prescription of ivabradine and sacubitril/valsartan within 6 weeks; (2A) Sequential group, ivabradine-first: ivabradine was prescribed first, followed by sacubitril/valsartan; and (2B) Sequential group, sacubitril/valsartan-first: sacubitril/valsartan was prescribed first, followed by ivabradine. A total of 464 patients with HFrEF were enrolled. Cardiovascular death and/or unplanned re-hospitalizations for HF were less frequent (28.6% vs. 44.8%, P = 0.01), and the improvement of left ventricular ejection fraction (LVEF) was significantly greater in patients from the Simultaneous group than those from the Sequential group (∆LVEF 12.8 ± 12.9% vs. 9.3 ± 12.6%, P = 0.007). Among Sequential subgroups, the ivabradine-first treatment decreased heart rate and increased systolic blood pressure (SBP) compared with sacubitril/valsartan-first treatment (∆heart rate -9.1 ± 12.9 b.p.m. vs. 2.6 ± 16.0 b.p.m., P < 0.001; ∆SBP 4.6 ± 16.5 mmHg vs. -4.8 ± 17.2 mmHg, P < 0.001), whereas sacubitril/valsartan-first treatment showed a higher degree of LVEF improvement (∆LVEF 3.6 ± 7.8% vs. 0.7 ± 7.7%, P = 0.002) than ivabradine-first treatment. At the end of follow-up, SBP, LVEF, and left ventricular volume were comparable between two Sequential subgroups. CONCLUSIONS Among patients with HFrEF, simultaneous rather than sequential treatment with sacubitril/valsartan and ivabradine was a better strategy to reduce adverse events and achieve left ventricular reverse remodelling. Ivabradine treatment had a more significant benefit on improving haemodynamic stability, whereas sacubitril/valsartan treatment showed a more significant effect on improving LVEF.
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Affiliation(s)
- Ying‐Hsiang Lee
- Cardiovascular CenterMacKay Memorial HospitalTaipeiTaiwan
- Department of MedicineMackay Medical CollegeNew TaipeiTaiwan
| | - Po‐Lin Lin
- Department of MedicineMackay Medical CollegeNew TaipeiTaiwan
- Division of Cardiology, Department of Internal MedicineHsinchu MacKay Memorial HospitalHsinchuTaiwan
| | - Wei‐Ru Chiou
- Department of MedicineMackay Medical CollegeNew TaipeiTaiwan
- Division of CardiologyTaitung MacKay Memorial HospitalTaitungTaiwan
| | - Jin‐Long Huang
- Cardiovascular CenterTaichung Veterans General HospitalTaichungTaiwan
- Faculty of Medicine, School of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
| | - Wen‐Yu Lin
- Division of Cardiology, Department of MedicineTri‐Service General Hospital, National Defense Medical CenterTaipeiTaiwan
| | - Chia‐Te Liao
- Division of CardiologyChi‐Mei Medical CenterTainanTaiwan
| | - Fa‐Po Chung
- Faculty of Medicine, School of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
- Division of Cardiology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Huai‐Wen Liang
- Division of Cardiology, Department of Internal MedicineE‐Da Hospital; I‐Shou UniversityKaohsiungTaiwan
| | - Chien‐Yi Hsu
- Faculty of Medicine, School of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
- Division of Cardiology and Cardiovascular Research Center, Department of Internal MedicineTaipei Medical University HospitalTaipeiTaiwan
- Taipei Heart Institute, Division of Cardiology, Department of Internal Medicine, School of Medicine, College of MedicineTaipei Medical UniversityTaipeiTaiwan
| | - Hung‐Yu Chang
- Faculty of Medicine, School of MedicineNational Yang‐Ming UniversityTaipeiTaiwan
- Heart CenterCheng Hsin General HospitalNo. 45 Cheng‐Hsin Street, 112 BeitouTaipeiTaiwan
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15
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Abstract
Ivabradine is a unique agent that is distinct from beta-blockers and calcium channel blockers as it reduces heart rate without affecting myocardial contractility or vascular tone. Ivabradine is a use-dependent inhibitor targeting the sinoatrial node. It is approved for use in the United States as an adjunct therapy for heart rate reduction in patients with heart failure with reduced ejection fraction. In this scenario, ivabradine has demonstrated improved clinical outcomes due to reduction in heart failure readmissions. However, there has been conflicting evidence from prospective studies and randomized controlled trials for its use in stable ischemic heart disease regarding efficacy in symptom reduction and mortality benefit. Ivabradine may also play a role in the treatment of patients with inappropriate sinus tachycardia, who often cannot tolerate beta-blockers and/or calcium channel blockers. In this review, we highlight the evidence for the nuances of using ivabradine in heart failure, stable ischemic heart disease, and inappropriate sinus tachycardia to raise awareness for its vital role in the treatment of select populations.
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16
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Benstoem C, Kalvelage C, Breuer T, Heussen N, Marx G, Stoppe C, Brandenburg V. Ivabradine as adjuvant treatment for chronic heart failure. Cochrane Database Syst Rev 2020; 11:CD013004. [PMID: 33147368 PMCID: PMC8094176 DOI: 10.1002/14651858.cd013004.pub2] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND Chronic heart failure is one of the most common medical conditions, affecting more than 23 million people worldwide. Despite established guideline-based, multidrug pharmacotherapy, chronic heart failure is still the cause of frequent hospitalisation, and about 50% die within five years of diagnosis. OBJECTIVES To assess the effectiveness and safety of ivabradine in individuals with chronic heart failure. SEARCH METHODS We searched CENTRAL, MEDLINE, Embase, and CPCI-S Web of Science in March 2020. We also searched ClinicalTrials.gov and the WHO ICTRP. We checked reference lists of included studies. We did not apply any time or language restrictions. SELECTION CRITERIA We included randomised controlled trials in which adult participants diagnosed with chronic heart failure were randomly assigned to receive either ivabradine or placebo/usual care/no treatment. We distinguished between type of heart failure (heart failure with a reduced ejection fraction or heart failure with a preserved ejection fraction) as well as between duration of ivabradine treatment (short term (< 6 months) or long term (≥ 6 months)). DATA COLLECTION AND ANALYSIS Two review authors independently assessed trials for inclusion, extracted data, and checked data for accuracy. We calculated risk ratios (RR) using a random-effects model. We completed a comprehensive 'Risk of bias' assessment for all studies. We contacted authors for missing data. Our primary endpoints were: mortality from cardiovascular causes; quality of life; time to first hospitalisation for heart failure during follow-up; and number of days spent in hospital due to heart failure during follow-up. Our secondary endpoints were: rate of serious adverse events; exercise capacity; and economic costs (narrative report). We assessed the certainty of the evidence applying the GRADE methodology. MAIN RESULTS We included 19 studies (76 reports) involving a total of 19,628 participants (mean age 60.76 years, 69% male). However, few studies contributed data to meta-analyses due to inconsistency in trial design (type of heart failure) and outcome reporting and measurement. In general, risk of bias varied from low to high across the included studies, with insufficient detail provided to inform judgement in several cases. We were able to perform two meta-analyses focusing on participants with heart failure with a reduced ejection fraction (HFrEF) and long-term ivabradine treatment. There was evidence of no difference between ivabradine and placebo/usual care/no treatment for mortality from cardiovascular causes (RR 0.99, 95% confidence interval (CI) 0.88 to 1.11; 3 studies; 17,676 participants; I2 = 33%; moderate-certainty evidence). Furthermore, we found evidence of no difference in rate of serious adverse events amongst HFrEF participants randomised to receive long-term ivabradine compared with those randomised to placebo, usual care, or no treatment (RR 0.96, 95% CI 0.92 to 1.00; 2 studies; 17,399 participants; I2 = 12%; moderate-certainty evidence). We were not able to perform meta-analysis for all other outcomes, and have low confidence in the findings based on the individual studies. AUTHORS' CONCLUSIONS We found evidence of no difference in cardiovascular mortality and serious adverse events between long-term treatment with ivabradine and placebo/usual care/no treatment in participants with heart failure with HFrEF. Nevertheless, due to indirectness (male predominance), the certainty of the available evidence is rated as moderate.
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Affiliation(s)
- Carina Benstoem
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Christina Kalvelage
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Thomas Breuer
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Nicole Heussen
- Department of Medical Statistics, Medical Faculty RWTH Aachen University, Aachen, Germany
- Center of Biostatistic and Epidemiology, Medical School, Sigmund Freud Private University, Vienna, Austria
| | - Gernot Marx
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Christian Stoppe
- Department of Intensive Care Medicine, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Vincent Brandenburg
- Department of Cardiology, Medical Faculty, University Hospital RWTH Aachen, Aachen, Germany
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17
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Gebski V, Byth K, Asher R, Marschner I. Recurrent time-to-event models with ordinal outcomes. Pharm Stat 2020; 20:77-92. [PMID: 33006268 DOI: 10.1002/pst.2057] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2020] [Revised: 05/20/2020] [Accepted: 07/21/2020] [Indexed: 11/07/2022]
Abstract
A model to accommodate time-to-event ordinal outcomes was proposed by Berridge and Whitehead. Very few studies have adopted this approach, despite its appeal in incorporating several ordered categories of event outcome. More recently, there has been increased interest in utilizing recurrent events to analyze practical endpoints in the study of disease history and to help quantify the changing pattern of disease over time. For example, in studies of heart failure, the analysis of a single fatal event no longer provides sufficient clinical information to manage the disease. Similarly, the grade/frequency/severity of adverse events may be more important than simply prolonged survival in studies of toxic therapies in oncology. We propose an extension of the ordinal time-to-event model to allow for multiple/recurrent events in the case of marginal models (where all subjects are at risk for each recurrence, irrespective of whether they have experienced previous recurrences) and conditional models (subjects are at risk of a recurrence only if they have experienced a previous recurrence). These models rely on marginal and conditional estimates of the instantaneous baseline hazard and provide estimates of the probabilities of an event of each severity for each recurrence over time. We outline how confidence intervals for these probabilities can be constructed and illustrate how to fit these models and provide examples of the methods, together with an interpretation of the results.
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Affiliation(s)
- Val Gebski
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Karen Byth
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Rebecca Asher
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Ian Marschner
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
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18
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Lunney M, Ruospo M, Natale P, Quinn RR, Ronksley PE, Konstantinidis I, Palmer SC, Tonelli M, Strippoli GF, Ravani P. Pharmacological interventions for heart failure in people with chronic kidney disease. Cochrane Database Syst Rev 2020; 2:CD012466. [PMID: 32103487 PMCID: PMC7044419 DOI: 10.1002/14651858.cd012466.pub2] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Approximately half of people with heart failure have chronic kidney disease (CKD). Pharmacological interventions for heart failure in people with CKD have the potential to reduce death (any cause) or hospitalisations for decompensated heart failure. However, these interventions are of uncertain benefit and may increase the risk of harm, such as hypotension and electrolyte abnormalities, in those with CKD. OBJECTIVES This review aims to look at the benefits and harms of pharmacological interventions for HF (i.e., antihypertensive agents, inotropes, and agents that may improve the heart performance indirectly) in people with HF and CKD. SEARCH METHODS We searched the Cochrane Kidney and Transplant Register of Studies through 12 September 2019 in consultation with an Information Specialist and using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials of any pharmacological intervention for acute or chronic heart failure, among people of any age with chronic kidney disease of at least three months duration. DATA COLLECTION AND ANALYSIS Two authors independently screened the records to identify eligible studies and extracted data on the following dichotomous outcomes: death, hospitalisations, worsening heart failure, worsening kidney function, hyperkalaemia, and hypotension. We used random effects meta-analysis to estimate treatment effects, which we expressed as a risk ratio (RR) with 95% confidence intervals (CI). We assessed the risk of bias using the Cochrane tool. We applied the GRADE methodology to rate the certainty of evidence. MAIN RESULTS One hundred and twelve studies met our selection criteria: 15 were studies of adults with CKD; 16 studies were conducted in the general population but provided subgroup data for people with CKD; and 81 studies included individuals with CKD, however, data for this subgroup were not provided. The risk of bias in all 112 studies was frequently high or unclear. Of the 31 studies (23,762 participants) with data on CKD patients, follow-up ranged from three months to five years, and study size ranged from 16 to 2916 participants. In total, 26 studies (19,612 participants) reported disaggregated and extractable data on at least one outcome of interest for our review and were included in our meta-analyses. In acute heart failure, the effects of adenosine A1-receptor antagonists, dopamine, nesiritide, or serelaxin on death, hospitalisations, worsening heart failure or kidney function, hyperkalaemia, hypotension or quality of life were uncertain due to sparse data or were not reported. In chronic heart failure, the effects of angiotensin-converting enzyme inhibitors (ACEi) or angiotensin receptor blockers (ARB) (4 studies, 5003 participants: RR 0.85, 95% CI 0.70 to 1.02; I2 = 78%; low certainty evidence), aldosterone antagonists (2 studies, 34 participants: RR 0.61 95% CI 0.06 to 6.59; very low certainty evidence), and vasopressin receptor antagonists (RR 1.26, 95% CI 0.55 to 2.89; 2 studies, 1840 participants; low certainty evidence) on death (any cause) were uncertain. Treatment with beta-blockers may reduce the risk of death (any cause) (4 studies, 3136 participants: RR 0.69, 95% CI 0.60 to 0.79; I2 = 0%; moderate certainty evidence). Treatment with ACEi or ARB (2 studies, 1368 participants: RR 0.90, 95% CI 0.43 to 1.90; I2 = 97%; very low certainty evidence) had uncertain effects on hospitalisation for heart failure, as treatment estimates were consistent with either benefit or harm. Treatment with beta-blockers may decrease hospitalisation for heart failure (3 studies, 2287 participants: RR 0.67, 95% CI 0.43 to 1.05; I2 = 87%; low certainty evidence). Aldosterone antagonists may increase the risk of hyperkalaemia compared to placebo or no treatment (3 studies, 826 participants: RR 2.91, 95% CI 2.03 to 4.17; I2 = 0%; low certainty evidence). Renin inhibitors had uncertain risks of hyperkalaemia (2 studies, 142 participants: RR 0.86, 95% CI 0.49 to 1.49; I2 = 0%; very low certainty). We were unable to estimate whether treatment with sinus node inhibitors affects the risk of hyperkalaemia, as there were few studies and meta-analysis was not possible. Hyperkalaemia was not reported for the CKD subgroup in studies investigating other therapies. The effects of ACEi or ARB, or aldosterone antagonists on worsening heart failure or kidney function, hypotension, or quality of life were uncertain due to sparse data or were not reported. Effects of anti-arrhythmic agents, digoxin, phosphodiesterase inhibitors, renin inhibitors, sinus node inhibitors, vasodilators, and vasopressin receptor antagonists were very uncertain due to the paucity of studies. AUTHORS' CONCLUSIONS The effects of pharmacological interventions for heart failure in people with CKD are uncertain and there is insufficient evidence to inform clinical practice. Study data for treatment outcomes in patients with heart failure and CKD are sparse despite the potential impact of kidney impairment on the benefits and harms of treatment. Future research aimed at analysing existing data in general population HF studies to explore the effect in subgroups of patients with CKD, considering stage of disease, may yield valuable insights for the management of people with HF and CKD.
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Affiliation(s)
- Meaghan Lunney
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Marinella Ruospo
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Patrizia Natale
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
| | - Robert R Quinn
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Paul E Ronksley
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
| | - Ioannis Konstantinidis
- University of Pittsburgh Medical Center, Department of Medicine, 3459 Fifth Avenue, Pittsburgh, PA, USA, 15213
| | - Suetonia C Palmer
- Christchurch Hospital, University of Otago, Department of Medicine, Nephrologist, Christchurch, New Zealand
| | - Marcello Tonelli
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
| | - Giovanni Fm Strippoli
- The University of Sydney, Sydney School of Public Health, Sydney, Australia
- University of Bari, Department of Emergency and Organ Transplantation, Bari, Italy
- The Children's Hospital at Westmead, Cochrane Kidney and Transplant, Centre for Kidney Research, Westmead, NSW, Australia, 2145
| | - Pietro Ravani
- University of Calgary, Department of Community Health Sciences, 3330 Hospital Drive NW, Calgary, Alberta, Canada, T2N 4N1
- Cumming School of Medicine, University of Calgary, Department of Medicine, Calgary, Canada
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19
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Jhund PS. The recurring problem of heart failure hospitalisations. Eur J Heart Fail 2020; 22:249-250. [DOI: 10.1002/ejhf.1721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Accepted: 11/26/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Pardeep S. Jhund
- British Heart Foundation Glasgow Cardiovascular Research CentreInstitute of Cardiovascular and Medical Sciences, University of Glasgow Glasgow UK
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20
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Akacha M, Binkowitz B, Claggett B, Hung HMJ, Mueller-Velten G, Stockbridge N. Assessing Treatment Effects That Capture Disease Burden in Serious Chronic Diseases. Ther Innov Regul Sci 2019; 53:387-397. [DOI: 10.1177/2168479018784912] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
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21
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Jackson AM, Jhund PS. The price of a failing heart. Eur J Heart Fail 2019; 21:1532-1533. [PMID: 31815336 DOI: 10.1002/ejhf.1605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Revised: 07/27/2019] [Accepted: 08/14/2019] [Indexed: 11/11/2022] Open
Affiliation(s)
- Alice M Jackson
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- British Heart Foundation Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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22
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McMurray JJ, DeMets DL, Inzucchi SE, Køber L, Kosiborod MN, Langkilde AM, Martinez FA, Bengtsson O, Ponikowski P, Sabatine MS, Sjöstrand M, Solomon SD. A trial to evaluate the effect of the sodium-glucose co-transporter 2 inhibitor dapagliflozin on morbidity and mortality in patients with heart failure and reduced left ventricular ejection fraction (DAPA-HF). Eur J Heart Fail 2019; 21:665-675. [PMID: 30895697 PMCID: PMC6607736 DOI: 10.1002/ejhf.1432] [Citation(s) in RCA: 254] [Impact Index Per Article: 50.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/21/2018] [Accepted: 01/03/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to reduce the risk of incident heart failure hospitalization in individuals with type 2 diabetes who have, or are at high risk of, cardiovascular disease. Most patients in these trials did not have heart failure at baseline and the effect of SGLT2 inhibitors on outcomes in individuals with established heart failure (with or without diabetes) is unknown. DESIGN AND METHODS The Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure trial (DAPA-HF) is an international, multicentre, parallel group, randomized, double-blind, study in patients with chronic heart failure, evaluating the effect of dapagliflozin 10 mg, compared with placebo, given once daily, in addition to standard care, on the primary composite outcome of a worsening heart failure event (hospitalization or equivalent event, i.e. an urgent heart failure visit) or cardiovascular death. Patients with and without diabetes are eligible and must have a left ventricular ejection fraction ≤ 40%, a moderately elevated N-terminal pro B-type natriuretic peptide level, and an estimated glomerular filtration rate ≥ 30 mL/min/1.73 m2 . The trial is event-driven, with a target of 844 primary outcomes. Secondary outcomes include the composite of total heart failure hospitalizations (including repeat episodes), and cardiovascular death and patient-reported outcomes. A total of 4744 patients have been randomized. CONCLUSIONS DAPA-HF will determine the efficacy and safety of the SGLT2 inhibitor dapagliflozin, added to conventional therapy, in a broad spectrum of patients with heart failure and reduced ejection fraction.
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Affiliation(s)
| | - David L. DeMets
- Department of Biostatistics and Medical Informatics, School of Medicine and Public HealthUniversity of WisconsinMadisonWIUSA
| | - Silvio E. Inzucchi
- Section of EndocrinologyYale University School of MedicineNew HavenCTUSA
| | - Lars Køber
- Rigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Mikhail N. Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMOUSA
- The George Institute for Global HealthSydneyAustralia
| | | | | | | | | | - Marc S. Sabatine
- TIMI Study Group, Division of Cardiovascular MedicineBrigham and Women's Hospital, and Harvard Medical SchoolBostonMAUSA
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23
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Vasudevan A, Choi JW, Feghali GA, Lander SR, Jialiang L, Schussler JM, Stoler RC, Vallabhan RC, Velasco CE, McCullough PA. Event dependence in the analysis of cardiovascular readmissions postpercutaneous coronary intervention. J Investig Med 2019; 67:943-949. [PMID: 30659091 DOI: 10.1136/jim-2018-000873] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/14/2018] [Indexed: 11/04/2022]
Abstract
Recurrent hospitalizations are common in longitudinal studies; however, many forms of cumulative event analyses assume recurrent events are independent. We explore the presence of event dependence when readmissions are spaced apart by at least 30 and 60 days. We set up a comparative framework with the assumption that patients with emergency percutaneous coronary intervention (PCI) will be at higher risk for recurrent cardiovascular readmissions than those with elective procedures. A retrospective study of patients who underwent PCI (January 2008-December 2012) with their follow-up information obtained from a regional database for hospitalization was conducted. Conditional gap time (CG), frailty gamma (FG) and conditional frailty models (CFM) were constructed to evaluate the dependence of events. Relative bias (%RB) in point estimates using CFM as the reference was calculated for comparison of the models. Among 4380 patients, emergent cases were at higher risk as compared with elective cases for recurrent events in different statistical models and time-spaced data sets, but the magnitude of HRs varied across the models (adjusted HR [95% CI]: all readmissions [unstructured data]-CG 1.16 [1.09 to 1.22], FG 1.45 [1.33 to 1.57], CFM 1.24 [1.16 to 1.32]; 30-day spaced-CG1.14 [1.08 to 1.21], FG 1.28 [1.17 to 1.39], CFM 1.17 [1.10 to 1.26]; and 60-day spaced-CG 1.14 [1.07 to 1.22], FG 1.23 [1.13 to 1.34] CFM 1.18 [1.09 to 1.26]). For all of the time-spaced readmissions, we found that the values of %RB were closer to the conditional models, suggesting that event dependence dominated the data despite attempts to create independence by increasing the space in time between admissions. Our analysis showed that independent of the intercurrent event duration, prior events have an influence on future events. Hence, event dependence should be accounted for when analyzing recurrent events and challenges contemporary methods for such analysis.
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Affiliation(s)
- Anupama Vasudevan
- Department of Cardiology, Baylor Scott & White Research Institute, Plano, Texas, USA
| | - James W Choi
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Georges A Feghali
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Stuart R Lander
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Li Jialiang
- National University of Singapore Yong Loo Lin School of Medicine, Singapore, Singapore
| | - Jeffrey M Schussler
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Robert C Stoler
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Ravi C Vallabhan
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Carlos E Velasco
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
| | - Peter A McCullough
- Baylor Heart and Vascular Institute, Baylor University Medical Center at Dallas, Dallas, Texas, USA
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Ide T, Ohtani K, Higo T, Tanaka M, Kawasaki Y, Tsutsui H. Ivabradine for the Treatment of Cardiovascular Diseases. Circ J 2018; 83:252-260. [PMID: 30606942 DOI: 10.1253/circj.cj-18-1184] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Higher heart rate (HR) is independently related to worse outcomes in various cardiac diseases, including hypertension, coronary artery disease, and heart failure (HF). HR is determined by the pacemaker activity of cells within the sinoatrial node. The hyperpolarization-activated cyclic nucleotide-gated (HCN) 4 channel, one of 4 HCN isoforms, generates the If current and plays an important role in the regulation of pacemaker activity in the sinoatrial node. Ivabradine is a novel and only available HCN inhibitor, which can reduce HR and has been approved for stable angina and chronic HF in many countries other than Japan. In this review, we summarize the current knowledge of the HCN4 channel and ivabradine, including the function of HCN4 in cardiac pacemaking, the mechanism of action of If inhibition by ivabradine, and the pharmacological and clinical effects of ivabradine in cardiac diseases as HF, coronary artery disease, and atrial fibrillation.
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Affiliation(s)
- Tomomi Ide
- Department of Experimental and Clinical Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Kisho Ohtani
- Department of Experimental and Clinical Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | - Taiki Higo
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
| | | | | | - Hiroyuki Tsutsui
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kyushu University
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COST-EFFECTIVENESS ANALYSIS OF IVABRADINE IN TREATMENT OF PATIENTS WITH HEART FAILURE IN IRAN. Int J Technol Assess Health Care 2018; 34:576-583. [PMID: 30560749 DOI: 10.1017/s0266462318003598] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVES This study aimed to assess the cost-effectiveness of ivabradine plus standard of care (SoC) in comparison with current SoC alone from the Iranian payer perspective. METHODS A cohort-based Markov model was developed to assess the incremental cost-effectiveness ratio (ICER) over a 10-year time horizon in a cohort of 1,000 patients. The baseline transition probabilities between New York Heart Association (NYHA), mortality rate, and hospitalization rate were extracted from the literature. The effect of ivabradine on mortality, hospitalization, and NYHA improvement or worsening were retrieved from the SHIFT study. The effectiveness was measured as quality-adjusted life-years (QALYs) using the utility values derived from Iranian Heart Failure Quality of Life study. Direct medical costs were obtained from hospital records and national tariffs. Deterministic and probabilistic sensitivity analyses were conducted to show the robustness of the model. RESULTS Ivabradine therapy was associated with an incremental cost per QALY of USD $5,437 (incremental cost of USD $2,207 and QALYs gained 0.41) versus SoC. The probabilistic sensitivity analysis showed that ivabradine is expected to have a 60 percent chance of being cost-effective accepting a threshold of USD $6,550 per QALY. Furthermore, deterministic sensitivity analysis indicated that the model is sensitive to the ivabradine drug acquisition cost. CONCLUSIONS The cost-effectiveness model suggested that the addition of ivabradine to SoC therapy was associated with improved clinical outcomes along with increased costs. The analysis indicates that the clinical benefit of ivabradine can be achieved at a reasonable cost in eligible heart failure patients with sinus rhythm and a baseline heart rate ≥ 75 beats per minute (bpm).
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Guzman M, Gomez R, Romero SP, Aranda R, Andrey JL, Pedrosa MJ, Egido J, Gomez F. Prognosis of heart failure treated with digoxin or with ivabradine: A cohort study in the community. Int J Clin Pract 2018; 72:e13217. [PMID: 30248211 DOI: 10.1111/ijcp.13217] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Accepted: 05/09/2018] [Indexed: 12/28/2022] Open
Abstract
BACKGROUND Resting heart rate (HR) reduction with ivabradine (IVA) improves outcomes of patients with heart failure and reduced ejection fraction (HFrEF). Nevertheless, the best option to slow HR in patients with HFrEF treated with beta-blockers and a HR >70 bpm is unsettled. AIMS To evaluate whether, in patients with HFrEF, commencing therapy with digoxin (CT-DIG) is associated to a worse prognosis than commencing treatment with ivabradine (CT-IVA). METHODS Observational study over 10 years on 2364 patients with HFrEF in sinus rhythm and a HR >70 bpm. Main outcomes were mortality, hospitalisations and visits. We analyse the independent relationship of CT-DIG or CT-IVA with the prognosis, stratifying patients for cardiovascular comorbidity, and for other potential confounders (378 patients who CT-DIG vs another 355 patients who CT-IVA vs another 1631 patients non-exposed to IVA or DIG). RESULTS During a median follow-up of 57.5 months, 1751 patients (74.1%) died, and 2151 (91.0%) were hospitalised for HF. CT-DIG or CT-IVA was associated with a lower all-cause mortality (DIG: HR = 0.86 [95% CI, 0.82-0.90], and IVA: HR = 0.88 [0.83-0.93]), cardiovascular mortality (DIG: HR = 0.84 [0.80-0.89] and IVA: HR = 0.83 [0.78-0.89]), hospitalisation (DIG: HR = 0.86 [0.83-0.89] and IVA: HR = 0.87 [0.83-0.91]) and 30-day readmission (DIG: HR = 0.84 [0.79-0.90] and IVA: HR = 0.88 [0.79-0.95]), after adjustment for cardiovascular comorbidity, and other potential confounders. These associations with the prognosis of HFrEF did not differ between patients who CT-DIG and those who CT-IVA. CONCLUSION Commencing therapy with digoxin or with ivabradine is associated with an improved prognosis of patients with HFrEF.
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Affiliation(s)
- Marcos Guzman
- Department of Medicine, School of Medicine, Hospital Universitario Puerto Real, University of Cadiz, Cadiz, Spain
| | - Rocio Gomez
- Department of Medicine, School of Medicine, Hospital Universitario Puerto Real, University of Cadiz, Cadiz, Spain
| | - Sotero P Romero
- Department of Medicine, School of Medicine, Hospital Universitario Puerto Real, University of Cadiz, Cadiz, Spain
| | - Rocio Aranda
- Department of Medicine, School of Medicine, Hospital Universitario Puerto Real, University of Cadiz, Cadiz, Spain
| | - Jose L Andrey
- Department of Medicine, School of Medicine, Hospital Universitario Puerto Real, University of Cadiz, Cadiz, Spain
| | - Maria J Pedrosa
- Department of Medicine, School of Medicine, Hospital Universitario Puerto Real, University of Cadiz, Cadiz, Spain
| | - Julio Egido
- Department of Medicine, School of Medicine, Hospital Universitario Puerto Real, University of Cadiz, Cadiz, Spain
| | - Francisco Gomez
- Department of Medicine, School of Medicine, Hospital Universitario Puerto Real, University of Cadiz, Cadiz, Spain
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Woldman S. Multimorbidity in heart failure patients. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 4:4-5. [PMID: 29045585 DOI: 10.1093/ehjqcco/qcx035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Affiliation(s)
- Simon Woldman
- St Bartholomew's Hospital, West Smithfiled, London, EC1A 7BE, UK
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Andries G, Yandrapalli S, Aronow WS. Benefit–risk review of different drug classes used in chronic heart failure. Expert Opin Drug Saf 2018; 18:37-49. [PMID: 30114943 DOI: 10.1080/14740338.2018.1512580] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Affiliation(s)
- Gabriela Andries
- Cardiology Division, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Srikanth Yandrapalli
- Cardiology Division, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S. Aronow
- Cardiology Division, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Claggett B, Pocock S, Wei L, Pfeffer MA, McMurray JJ, Solomon SD. Comparison of Time-to-First Event and Recurrent-Event Methods in Randomized Clinical Trials. Circulation 2018; 138:570-577. [DOI: 10.1161/circulationaha.117.033065] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Most phase-3 trials feature time-to-first event end points for their primary and secondary analyses. In chronic diseases, where a clinical event can occur >1 time, recurrent-event methods have been proposed to more fully capture disease burden and have been assumed to improve statistical precision and power compared with conventional time-to-first methods.
Methods:
To better characterize factors that influence statistical properties of recurrent-event and time-to-first methods in the evaluation of randomized therapy, we repeatedly simulated trials with 1:1 randomization of 4000 patients to active versus control therapy, with true patient-level risk reduction of 20% (ie, relative risk=0.80). For patients who discontinued active therapy after a first event, we assumed their risk reverted subsequently to their original placebo-level risk. Through simulation, we varied the degree of between-patient heterogeneity of risk and the extent of treatment discontinuation. Findings were compared with those from actual randomized clinical trials.
Results:
As the degree of between-patient heterogeneity of risk increased, both time-to-first and recurrent-event methods lost statistical power to detect a true risk reduction and confidence intervals widened. The recurrent-event analyses continued to estimate the true relative risk (0.80) as heterogeneity increased, whereas the Cox model produced attenuated estimates. The power of recurrent-event methods declined as the rate of study drug discontinuation postevent increased. Recurrent-event methods provided greater power than time-to-first methods in scenarios where drug discontinuation was ≤30% after a first event, lesser power with drug discontinuation rates of ≥60%, and comparable power otherwise. We confirmed in several actual trials of chronic heart failure that treatment effect estimates were attenuated when estimated via the Cox model and that increased statistical power from recurrent-event methods was most pronounced in trials with lower treatment discontinuation rates.
Conclusions:
We find that the statistical power of both recurrent-events and time-to-first methods are reduced by increasing heterogeneity of patient risk, a parameter not included in conventional power and sample size formulas. Data from real clinical trials are consistent with simulation studies, confirming that the greatest statistical gains from use of recurrent-events methods occur in the presence of high patient heterogeneity and low rates of study drug discontinuation.
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Affiliation(s)
- Brian Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (B.C., M.A.P., S.D.S.)
| | - Stuart Pocock
- Department of Medical Statistics, London School of Hygiene, UK (S.P.)
| | - L.J. Wei
- Department of Biostatistics, Harvard School of Public Health, Boston, MA (L.J.W.)
| | - Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (B.C., M.A.P., S.D.S.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M.)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (B.C., M.A.P., S.D.S.)
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30
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Role of the Funny Current Inhibitor Ivabradine in Cardiac Pharmacotherapy: A Systematic Review. Am J Ther 2018; 25:e247-e266. [DOI: 10.1097/mjt.0000000000000388] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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31
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Ivabradine for systolic heart failure. JAAPA 2018; 31:52-54. [PMID: 29470374 DOI: 10.1097/01.jaa.0000530305.69021.02] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Ivabradine works in the sinoatrial node to prolong diastolic depolarization and reduce heart rate. In patients with chronic systolic heart failure, this drug has reduced the risk of hospitalization when used in combination with other optimal pharmacotherapy.
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Mogensen UM, Gong J, Jhund PS, Shen L, Køber L, Desai AS, Lefkowitz MP, Packer M, Rouleau JL, Solomon SD, Claggett BL, Swedberg K, Zile MR, Mueller-Velten G, McMurray JJV. Effect of sacubitril/valsartan on recurrent events in the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure trial (PARADIGM-HF). Eur J Heart Fail 2018; 20:760-768. [PMID: 29431251 PMCID: PMC6607507 DOI: 10.1002/ejhf.1139] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 12/11/2022] Open
Abstract
Aims Recurrent hospitalizations are a major part of the disease burden in heart failure (HF), but conventional analyses consider only the first event. We compared the effect of sacubitril/valsartan vs. enalapril on recurrent events, incorporating all HF hospitalizations and cardiovascular (CV) deaths in PARADIGM‐HF, using a variety of statistical approaches advocated for this type of analysis. Methods and results In PARADIGM‐HF, a total of 8399 patients were randomized and followed for a median of 27 months. We applied various recurrent event analyses, including a negative binomial model, the Wei, Lin and Weissfeld (WLW), and Lin, Wei, Ying and Yang (LWYY) methods, and a joint frailty model, all adjusted for treatment and region. Among a total of 3181 primary endpoint events (including 1251 CV deaths) during the trial, only 2031 (63.8%) were first events (836 CV deaths). Among a total of 1195 patients with at least one HF hospitalization, 410 (34%) had at least one further HF hospitalization. Sacubitril/valsartan compared with enalapril reduced the risk of recurrent HF hospitalization using the negative binomial model [rate ratio (RR) 0.77, 95% confidence interval (CI) 0.67–0.89], the WLW method [hazard ratio (HR) 0.79, 95% CI 0.71–0.89], the LWYY method (RR 0.78, 95% CI 0.68–0.90), and the joint frailty model (HR 0.75, 95% CI 0.66–0.86) (all P < 0.001). The effect of sacubitril/valsartan vs. enalapril on recurrent HF hospitalizations/CV death was similar. Conclusions In PARADIGM‐HF, approximately one third of patients with a primary endpoint (time‐to‐first) experienced a further event. Compared with enalapril, sacubitril/valsartan reduced both first and recurrent events. The treatment effect size was similar, regardless of the statistical approach applied.
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Affiliation(s)
- Ulrik M Mogensen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Jianjian Gong
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Li Shen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Akshay S Desai
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Scott D Solomon
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian L Claggett
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden, and National Heart and Lung Institute, Imperial College, London, UK
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Oliva F, Sormani P, Contri R, Campana C, Carubelli V, Cirò A, Morandi F, Di Tano G, Mortara A, Senni M, Metra M, Ammirati E. Heart rate as a prognostic marker and therapeutic target in acute and chronic heart failure. Int J Cardiol 2018; 253:97-104. [DOI: 10.1016/j.ijcard.2017.09.191] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 06/12/2017] [Accepted: 09/22/2017] [Indexed: 12/28/2022]
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Cheema B, Ambrosy AP, Kaplan RM, Senni M, Fonarow GC, Chioncel O, Butler J, Gheorghiade M. Lessons learned in acute heart failure. Eur J Heart Fail 2017; 20:630-641. [PMID: 29082676 DOI: 10.1002/ejhf.1042] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2016] [Revised: 09/18/2017] [Accepted: 09/20/2017] [Indexed: 12/11/2022] Open
Abstract
Acute heart failure (HF) is a global pandemic with more than one million admissions to hospital annually in the US and millions more worldwide. Post-discharge mortality and readmission rates remain unchanged and unacceptably high. Although recent drug development programmes have failed to deliver novel therapies capable of reducing cardiovascular morbidity and mortality in patients hospitalized for worsening chronic HF, hospitalized HF registries and clinical trial databases have generated a wealth of information improving our collective understanding of the HF syndrome. This review will summarize key insights from clinical trials in acute HF and hospitalized HF registries over the last several decades, focusing on improving the management of patients with HF and reduced ejection fraction.
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Affiliation(s)
- Baljash Cheema
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Andrew P Ambrosy
- Duke University Medical Center, Durham, NC, USA.,Duke Clinical Research Institute, Durham, NC, USA
| | - Rachel M Kaplan
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Michele Senni
- Cardiovascular Department, Papa Giovannni XXIII Hospital, Bergamo, Italy
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| | - Ovidiu Chioncel
- Institute of Emergency for Cardiovascular Diseases 'Prof. C.C. Iliescu', Cardiology 1, UMF Carol Davila, Bucharest, Romania
| | | | - Mihai Gheorghiade
- Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
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35
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Shaaya G, Al-Khazaali A, Arora R. Heart Rate As a Biomarker in Heart Failure: Role of Heart Rate Lowering Agents. Am J Ther 2017; 24:e532-e539. [DOI: 10.1097/mjt.0000000000000336] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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36
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Adherence to optimal heart rate control in heart failure with reduced ejection fraction: insight from a survey of heart rate in heart failure in Sweden (HR-HF study). Clin Res Cardiol 2017; 106:960-973. [PMID: 28795299 PMCID: PMC5696492 DOI: 10.1007/s00392-017-1146-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Accepted: 07/31/2017] [Indexed: 01/12/2023]
Abstract
Introduction Despite that heart rate (HR) control is one of the guideline-recommended treatment goals for heart failure (HF) patients, implementation has been painstakingly slow. Therefore, it would be important to identify patients who have not yet achieved their target heart rates and assess possible underlying reasons as to why the target rates are not met. Materials and methods The survey of HR in patients with HF in Sweden (HR-HF survey) is an investigator-initiated, prospective, multicenter, observational longitudinal study designed to investigate the state of the art in the control of HR in HF and to explore potential underlying mechanisms for suboptimal HR control with focus on awareness of and adherence to guidelines for HR control among physicians who focus on the contributing role of beta-blockers (BBs). Results In 734 HF patients the mean HR was 68 ± 12 beats per minute (bpm) (37.2% of the patients had a HR >70 bpm). Patients with HF with reduced ejection fraction (HFrEF) (n = 425) had the highest HR (70 ± 13 bpm, with 42% >70 bpm), followed by HF with preserved ejection fraction and HF with mid-range ejection fraction. Atrial fibrillation, irrespective of HF type, had higher HR than sinus rhythm. A similar pattern was observed with BB treatment. Moreover, non-achievement of the recommended target HR (<70 bpm) in HFrEF and sinus rhythm was unrelated to age, sex, cardiovascular risk factors, cardiovascular diseases, and comorbidities, but was related to EF and the clinical decision of the physician. Approximately 50% of the physicians considered a HR of >70 bpm optimal and an equal number considered a HR of >70 bpm too high, but without recommending further action. Furthermore, suboptimal HR control cannot be attributed to the use of BBs because there was neither a difference in use of BBs nor an interaction with BBs for HR >70 bpm compared with HR <70 bpm. Conclusion Suboptimal control of HR was noted in HFrEF with sinus rhythm, which appeared to be attributable to physician decision making rather than to the use of BBs. Therefore, our results underline the need for greater attention to HR control in patients with HFrEF and sinus rhythm and thus a potential for improved HF care.
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Long-term treatment with ivabradine over 12 months in patients with chronic heart failure in clinical practice: Effect on symptoms, quality of life and hospitalizations. Int J Cardiol 2017; 240:258-264. [DOI: 10.1016/j.ijcard.2017.03.131] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Accepted: 03/28/2017] [Indexed: 11/18/2022]
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Gilbert EM, Xu WD. Rationales and choices for the treatment of patients with NYHA class II heart failure. Postgrad Med 2017; 129:619-631. [PMID: 28670961 DOI: 10.1080/00325481.2017.1344082] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Heart failure (HF) in the United States represents a significant burden for patients and a tremendous strain on the healthcare system. Patients receiving a diagnosis of HF can be placed into 1 of 4 New York Heart Association (NYHA) functional classifications; the greatest proportion of patients are in the NYHA class II category, which is defined as patients having a slight limitation of physical activity but who are comfortable at rest, and for whom ordinary physical activity results in symptoms of HF. Because the severity of NYHA class II HF may be perceived as mild or unalarming by this definition, the urgency to treat this type of HF may be overlooked. However, these patients are optimal candidates for active intervention because their HF is at a critical point on the disease progression continuum when untoward changes can be halted or reversed. This review discusses the physiological consequences of NYHA class II HF with reduced ejection fraction and describes recent clinical trials that have demonstrated a therapeutic benefit for patients in this population. In doing so, we hope to establish that patients with NYHA class II disease merit careful attention and to provide reassurance to the treating community that options are available for these patients.
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Affiliation(s)
- Edward M Gilbert
- a Division of Cardiology , University of Utah , Salt Lake City , UT , USA
| | - Weining David Xu
- a Division of Cardiology , University of Utah , Salt Lake City , UT , USA
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Baydemir C, Ural D, Karaüzüm K, Balcı S, Argan O, Karaüzüm I, Kozdağ G, Ağır AA. Predictors of Long-Term Mortality and Frequent Re-Hospitalization in Patients with Acute Decompensated Heart Failure and Kidney Dysfunction Treated with Renin-Angiotensin System Blockers. Med Sci Monit 2017; 23:3335-3344. [PMID: 28690311 PMCID: PMC5515119 DOI: 10.12659/msm.902786] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2016] [Accepted: 01/02/2017] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Assessment of risk for all-cause mortality and re-hospitalization is an important task during discharge of acute heart failure (AHF) patients, as they warrant different management strategies. Treatment with optimal medical therapy may change predictors for these 2 end-points in AHF patients with renal dysfunction. The aim of this study was to evaluate the predictors for long-term outcome in AHF patients with kidney dysfunction who were discharged on optimal medical therapy. MATERIAL AND METHODS The study was conducted retrospectively. The study group consisted of 225 AHF patients with moderate-to-severe kidney dysfunction, who were hospitalized at Kocaeli University Hospital Cardiology Clinic and who were prescribed beta-blockers and ACE-inhibitors or angiotensin II receptor blockers at discharge. Clinical, echocardiographic, and biochemical predictors of the composite of total mortality and frequent re-hospitalization (≥3 hospitalizations during the follow-up) were assessed using Cox regression and the predictors for each end-point were assessed by competing risk regression analysis. RESULTS Incidence of all-cause mortality was 45.3% and frequent readmissions were 49.8% in a median follow-up of 54 months. The associates of the composite end-point were age, NYHA class, respiration rate on admission, eGFR, hypoalbuminemia, mitral valve E/E' ratio, and ejection fraction. In competing risk regression analysis, right-sided HF, hypoalbuminemia, age, and uric acid appeared as independent associates of all-cause mortality, whereas NYHA class, NT-proBNP, mitral valve E/E' ratio, and uric acid were predictors for re-hospitalization. CONCLUSIONS Predictors for all-cause mortality in AHF with kidney dysfunction treated with optimal therapy are mainly related to advanced HF with right-sided dysfunction, whereas frequent re-hospitalization is associated with volume overload manifested by increased mitral E/E' ratio and NT-proBNP levels.
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Affiliation(s)
- Canan Baydemir
- Department of Biostatistics and Medical Informatics, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Dilek Ural
- Department of Cardiology, Koç University, School of Medicine, Istanbul, Turkey
| | - Kurtuluş Karaüzüm
- Department of Cardiology, Derince Education and Research Hospital, Kocaeli, Turkey
| | - Sibel Balcı
- Department of Biostatistics and Medical Informatics, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Onur Argan
- Department of Cardiology, Kocaeli State Hospital, Kocaeli, Turkey
| | - Irem Karaüzüm
- Department of Cardiology, Izmit Seka State Hospital, Kocaeli, Turkey
| | - Güliz Kozdağ
- Department of Cardiology, Kocaeli University, School of Medicine, Kocaeli, Turkey
| | - Ayşen A. Ağır
- Department of Cardiology, Kocaeli University, School of Medicine, Kocaeli, Turkey
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Santas E, Valero E, Mollar A, García-Blas S, Palau P, Miñana G, Núñez E, Sanchis J, Chorro FJ, Núñez J. Carga de hospitalizaciones recurrentes tras una hospitalización por insuficiencia cardiaca aguda: insuficiencia cardiaca con función sistólica conservada frente a reducida. Rev Esp Cardiol 2017. [DOI: 10.1016/j.recesp.2016.06.027] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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Escribano D, Santas E, Miñana G, Mollar A, García-Blas S, Valero E, Payá A, Chorro F, Sanchis J, Núñez J. High-sensitivity troponin T and the risk of recurrent readmissions after hospitalization for acute heart failure. Rev Clin Esp 2017. [DOI: 10.1016/j.rceng.2016.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Escribano D, Santas E, Miñana G, Mollar A, García-Blas S, Valero E, Payá A, Chorro F, Sanchis J, Núñez J. Troponina T de alta sensibilidad y riesgo de hospitalizaciones recurrentes tras un ingreso por insuficiencia cardíaca aguda. Rev Clin Esp 2017; 217:63-70. [DOI: 10.1016/j.rce.2016.10.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 07/24/2016] [Accepted: 10/18/2016] [Indexed: 11/28/2022]
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Davarzani N, Sanders-van Wijk S, Karel J, Maeder MT, Leibundgut G, Gutmann M, Pfisterer ME, Rickenbacher P, Peeters R, Brunner-la Rocca HP. N-Terminal Pro-B-Type Natriuretic Peptide-Guided Therapy in Chronic Heart Failure Reduces Repeated Hospitalizations-Results From TIME-CHF. J Card Fail 2017; 23:382-389. [PMID: 28232046 DOI: 10.1016/j.cardfail.2017.02.001] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2016] [Revised: 11/29/2016] [Accepted: 02/08/2017] [Indexed: 12/31/2022]
Abstract
BACKGROUND Although heart failure (HF) patients are known to experience repeated hospitalizations, most studies evaluated only time to first event. N-Terminal B-type natriuretic peptide (NT-proBNP)-guided therapy has not convincingly been shown to improve HF-specific outcomes, and effects on recurrent all-cause hospitalization are uncertain. Therefore, we investigated the effect of NT-proBNP-guided therapy on recurrent events in HF with the use of a time-between-events approach in a hypothesis-generating analysis. METHODS AND RESULTS The Trial of Intensified Versus Standard Medical Therapy in Elderly Patients With Congestive Heart Failure (TIME-CHF) randomized 499 HF patients, aged ≥60 years, left ventricular ejection fraction ≤45%, New York Heart Association functional class ≥I,I to NT-proBNP-guided versus symptom-guided therapy for 18 months, with further follow-up for 5.5 years. The effect of NT-proBNP-guided therapy on recurrent HF-related and all-cause hospitalizations and/or all-cause death was explored. One hundred four patients (49 NT-proBNP-guided, 55 symptom-guided) experienced 1 and 275 patients (133 NT-proBNP-guided, 142 symptom-guided) experienced ≥2 all-cause hospitalization events. Regarding HF hospitalization, 132 patients (57 NT-proBNP-guided, 75 symptom-guided) experienced 1 and 122 patients (57 NT-proBNP-guided, 65 symptom-guided) experienced ≥2 events. NT-proBNP-guided therapy was significant in preventing 2nd all-cause hospitalizations (hazard ratio [HR] 0.83; P = .01), in contrast to nonsignificant results in preventing 1st all-cause hospitalization events (HR 0.91; P = .35). This was not the case regarding HF hospitalization events (HR 0.85 [P = .14] vs HR 0.73 [P = .01]) The beneficial effect of NT-proBNP-guided therapy was seen only in patients aged <75 years, and not in those aged ≥75 years (interaction terms with P = .01 and P = .03 for all-cause hospitalization and HF hospitalization events, respectively). CONCLUSION NT-proBNP-guided therapy reduces the risk of recurrent events in patients <75 years of age. This included all-cause hospitalization by mainly reducing later events, adding knowledge to the neutral effect on this end point when shown using time-to-first-event analysis only. CLINICAL TRIAL REGISTRATION isrctn.org, identifier: ISRCTN43596477.
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Affiliation(s)
- Nasser Davarzani
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, The Netherlands; Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands.
| | | | - Joël Karel
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, The Netherlands
| | - Micha T Maeder
- Department of Cardiology, Kantonsspital St. Gallen, St Gallen, Switzerland
| | - Gregor Leibundgut
- Department of Cardiology, University Hospital Liestal, Liestal, Switzerland
| | - Marc Gutmann
- Department of Cardiology, University Hospital Liestal, Liestal, Switzerland
| | | | - Peter Rickenbacher
- Department of Cardiology, University Hospital Bruderholz, Bruderholz, Switzerland
| | - Ralf Peeters
- Department of Data Science and Knowledge Engineering, Maastricht University, Maastricht, The Netherlands
| | - Hans-Peter Brunner-la Rocca
- Department of Cardiology, Maastricht University Medical Center, Maastricht, The Netherlands; Department of Cardiology, University Hospital Basel, Basel, Switzerland
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Kansal AR, Krotneva S, Tafazzoli A, Patel HK, Borer JS, Böhm M, Komajda M, Maya J, Tavazzi L, Ford I, Kielhorn A. Financial impact of ivabradine on reducing heart failure penalties under the Hospital Readmission Reduction Program. Curr Med Res Opin 2017; 33:185-191. [PMID: 27733074 DOI: 10.1080/03007995.2016.1248381] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
OBJECTIVE The introduction of the Hospital Readmission Reduction Program (HRRP) has led to renewed interest in developing strategies to reduce 30 day readmissions among patients with heart failure (HF). In this study, a model was developed to investigate whether the addition of ivabradine to a standard-of-care (SoC) treatment regimen for patients with HF would reduce HRRP penalties incurred by a hypothetical hospital with excess 30 day readmissions. RESEARCH DESIGN A model using a Monte Carlo simulation framework was developed. Model inputs included national hospital characteristics, hospital-specific characteristics, and the ivabradine treatment effect as quantified by a post hoc analysis of the Systolic Heart failure treatment with the If inhibitor ivabradine Trial (SHIFT). RESULTS The model computed an 83% reduction in HF readmission penalty payments in a hypothetical hospital with a readmission rate of 22.95% (excess readmission ratio = 1.056 over the national average readmission rate of 21.73%), translating into net savings of $44,016. A sensitivity analysis indicated that the readmission penalty is affected by the specific characteristics of the hospital, including the readmission rate, size of the ivabradine-eligible population, and ivabradine utilization. CONCLUSIONS The results of this study indicate that the addition of ivabradine to an SoC treatment regimen for patients with HF may lead to a reduction in the penalties incurred by hospitals under the HRRP. This highlights the role ivabradine can play as part of a wider effort to optimize the care of patients with HF.
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Affiliation(s)
| | | | | | | | - Jeffrey S Borer
- c Division of Cardiovascular Medicine , The Howard Gilman Institute for Heart Valve Diseases and Ronald and Joan Schiavone Cardiovascular Translational Research Institute, State University of New York Downstate Medical Center , Brooklyn and New York , NY , USA
| | - Michael Böhm
- d Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes , Homburg/Saar , Germany
| | - Michel Komajda
- e Department of Cardiology , Pitié-Salpétrière Hospital, University Pierre et Marie Curie and IHU ICAN , Paris , France
| | - Juan Maya
- b Amgen Inc. , Thousand Oaks , CA , USA
| | - Luigi Tavazzi
- f Maria Cecilia Hospital, GVM Care & Research, Ettore Sansavini Health Science Foundation , Cotignola , Italy
| | - Ian Ford
- g Robertson Centre for Biostatistics, University of Glasgow , Glasgow , Scotland
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Ivabradine in Patients with ST-Elevation Myocardial Infarction Complicated by Cardiogenic Shock: A Preliminary Randomized Prospective Study. Clin Drug Investig 2017; 36:849-56. [PMID: 27312076 DOI: 10.1007/s40261-016-0424-9] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND OBJECTIVE An elevated heart rate (HR) is an independent risk factor for mortality and morbidity in patients with acute heart failure (HF). The purpose of this study was to evaluate the impact of ivabradine, a selective HR-lowering agent, in patients with cardiogenic shock (CS) complicating ST-elevation acute myocardial infarction (AMI). METHODS Patients with post-AMI CS were randomized to standard treatment (SDT, 28 patients) or to standard treatment plus ivabradine (I + SDT, 30 patients). In the presence of orotracheal intubation (OTI), ivabradine was administered by nasogastric intubation. HR, BP, New York Heart Association (NYHA) class, NT-proBNP, left ventricular ejection fraction (LVEF) and diastolic function (LVDF) were monitored at specific times after the onset of AMI. The primary (surrogate) end-point was the in-hospital halving of plasma NT-proBNP levels. The secondary end-points were cardiovascular death, hospital re-admission for worsening HF, and clinical and haemodynamic improvement. RESULTS Treatment groups were statistically similar with regard to age, gender distribution, cardiovascular risk factors, number of diseased vessels and overall treated lesions, AMI site and occurrence of OTI. In-hospital mortality was double in the SDT group in comparison with the I + SDT group (14.3 vs. 6.7 %), but the difference was not statistically significant. HR, BP, NT-proBNP and LVEF favorably changed in both groups, but the change was more relevant in the I + SDT group. LVDF significantly changed only in the I + SDT group (p < 0.01). Patients in the I + SDT group did not experience adverse effects. CONCLUSION Ivabradine in CS complicating AMI is safe, is associated with a short-term favourable outcome and can be effectively administered by nasogastric intubation.
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Mizzaci CC, Porfírio GJM, Vilela AT, Guillhen JCS, Riera R. RETRACTED: Ivabradine as adjuvant treatment for chronic heart failure. Int J Cardiol 2017; 227:43-50. [PMID: 27846461 DOI: 10.1016/j.ijcard.2016.11.081] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 11/05/2016] [Indexed: 11/28/2022]
Abstract
This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal).
This article has been retracted at the request of editors as it is contains multiple serious errors in the data of its primary end-point that make its conclusions unreliable. For example, in Figure 4, the cardiovascular death rates cited from Fox 2008 and Swedberg 2010 are incorrect.
K. Fox, et al. Lancet, 372 (2008), pp. 807–816; K. Swedberg et al. Lancet, 376 (2010), pp. 875–885.
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Affiliation(s)
- Carolina C Mizzaci
- Department of Medicine, Urgency Medicine and Evidence Based Medicine, Federal University of São Paulo, São Paulo, Brazil.
| | - Gustavo J M Porfírio
- Department of Medicine, Urgency Medicine and Evidence Based Medicine, Federal University of São Paulo, São Paulo, Brazil
| | - André T Vilela
- Department of Medicine, Urgency Medicine and Evidence Based Medicine, Federal University of São Paulo, São Paulo, Brazil
| | | | - Rachel Riera
- Department of Medicine, Urgency Medicine and Evidence Based Medicine, Federal University of São Paulo, São Paulo, Brazil
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Borer JS, Deedwania PC, Kim JB, Böhm M. Benefits of Heart Rate Slowing With Ivabradine in Patients With Systolic Heart Failure and Coronary Artery Disease. Am J Cardiol 2016; 118:1948-1953. [PMID: 27780557 DOI: 10.1016/j.amjcard.2016.08.089] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2015] [Revised: 08/24/2016] [Accepted: 08/24/2016] [Indexed: 10/21/2022]
Abstract
Heart rate (HR) is a risk factor in patients with chronic systolic heart failure (HF) that, when reduced, provides outcome benefits. It is also a target for angina pectoris prevention and a risk marker in chronic coronary artery disease without HF. HR can be reduced by drugs; however, among those used clinically, only ivabradine reduces HR directly in the sinoatrial nodal cells without other known effects on the cardiovascular system. This review provides current information regarding the safety and efficacy of HR reduction with ivabradine in clinical studies involving >36,000 patients with chronic stable coronary artery disease and >6,500 patients with systolic HF. The largest trials, Morbidity-Mortality Evaluation of the If Inhibitor Ivabradine in Patients With Coronary Disease and Left Ventricular Dysfunction and Study Assessing the Morbidity-Mortality Benefits of the If Inhibitor Ivabradine in Patients With Coronary Artery Disease, showed no effect on outcomes. The Systolic Heart Failure Treatment With the If Inhibitor Ivabradine Trial, a randomized controlled trial in >6,500 patients with HF, revealed marked and significant HR-mediated reduction in cardiovascular mortality or HF hospitalizations while improving quality of life and left ventricular mechanical function after treatment with ivabradine. The adverse effects of ivabradine predominantly included bradycardia and atrial fibrillation (both uncommon) and ocular flashing scotomata (phosphenes) but otherwise were similar to placebo. In conclusion, ivabradine improves outcomes in patients with systolic HF; rates of overall adverse events are similar to placebo.
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Santas E, Valero E, Mollar A, García-Blas S, Palau P, Miñana G, Núñez E, Sanchis J, Chorro FJ, Núñez J. Burden of Recurrent Hospitalizations Following an Admission for Acute Heart Failure: Preserved Versus Reduced Ejection Fraction. ACTA ACUST UNITED AC 2016; 70:239-246. [PMID: 27816423 DOI: 10.1016/j.rec.2016.06.021] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2016] [Accepted: 06/09/2016] [Indexed: 11/29/2022]
Abstract
INTRODUCTION AND OBJECTIVES Heart failure with preserved ejection fraction and reduced ejection fraction share a high mortality risk. However, differences in the rehospitalization burden over time between these 2 entities remains unclear. METHODS We prospectively included 2013 consecutive patients discharged for acute heart failure. Of these, 1082 (53.7%) had heart failure with preserved ejection fraction and 931 (46.2%) had heart failure with reduced ejection fraction. Cox and negative binomial regression methods were used to evaluate the risks of death and repeat hospitalizations, respectively. RESULTS At a median follow-up of 2.36 years (interquartile range: 0.96-4.65), 1018 patients (50.6%) died, and 3804 readmissions were registered in 1406 patients (69.8%). Overall, there were no differences in mortality between heart failure with preserved ejection fraction and heart failure with reduced ejection fraction (16.7 vs 16.1 per 100 person-years, respectively; P=0794), or all-cause repeat hospitalization rates (62.1 vs 62.2 per 100 person-years, respectively; P=.944). After multivariable adjustment, and compared with patients with heart failure with reduced ejection fraction, patients with heart failure with preserved ejection fraction exhibited a similar risk of all-cause readmissions (incidence rate ratio=1.04; 95%CI, 0.93-1.17; P=.461). Regarding specific causes, heart failure with preserved ejection fraction showed similar risks of cardiovascular and heart failure-related rehospitalizations (incidence rate ratio=0.93; 95%CI, 0.82-1.06; P=.304; incidence rate ratio=0.96; 95% confidence interval, 0.83-1.13; P=.677, respectively), but had a higher risk of noncardiovascular readmissions (incidence rate ratio=1.24; 95%CI, 1.04-1.47; P=.012). CONCLUSIONS Following an admission for acute heart failure, patients with heart failure with preserved ejection fraction have a similar rehospitalization burden to those with heart failure with reduced ejection fraction. However, patients with heart failure with preserved ejection fraction are more likely to be readmitted for noncardiovascular causes.
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Affiliation(s)
- Enrique Santas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Ernesto Valero
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Anna Mollar
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Sergio García-Blas
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Patricia Palau
- Servicio de Cardiología, Hospital La Plana, Universitat Jaume I, Castellón, Spain
| | - Gema Miñana
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Eduardo Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Juan Sanchis
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Francisco Javier Chorro
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario de Valencia, INCLIVA, Universitat de Valencia, Valencia, Spain.
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Abstract
Ivabradine is a blocker of the funny current channels in the sinoatrial node cells. This results in pure heart rate reduction when elevated without direct effect on contractility or on the vessels. It was tested in a large outcome clinical trial in stable chronic heart failure (CHF) with low ejection fraction, in sinus rhythm, on a contemporary background therapy including betablockers (SHIFT: Systolic Heart Failure Treatment with the If inhibitor Trial).The primary composite endpoint (cardiovascular mortality or heart failure hospitalization) was reduced by 18% whereas the first occurrence of heart failure hospitalizations was reduced by 26%. The effect was of greater magnitude in patients with baseline heart rate ≥75 beats per minute. Ivabradine improved also the quality of life and induced a reverse remodelling.The safety was overall good with an increase in (a)symptomatic bradycardia and visual side effects.The efficacy and tolerability were similar to those observed in the overall trial in subgroups with diabetes mellitus, low systolic blood pressure (SBP), renal dysfunction or chronic obstructive pulmonary disease (COPD).Ivabradine is indicated in CHF with systolic dysfunction, in patients in sinus rhythm with a heart rate ≥75 bpm in combination with standard therapy including betablocker therapy or when betablocker therapy is contraindicated or not tolerated (European Medicine Agency).
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Iliza AC, Matteau A, Guertin JR, Mitchell D, Fanton-Aita F, Dubois A, Dubé MP, Tardif JC, LeLorier J. A model to assess the cost–effectiveness of pharmacogenomics tests in chronic heart failure: the case of ivabradine. Pharmacogenomics 2016; 17:1693-1706. [DOI: 10.2217/pgs-2016-0054] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Pharmacogenomics (PGx) tests have the potential of improving the effectiveness of expensive new drugs by predicting the likelihood, for a particular patient, to respond to a treatment. The objective of this study was to develop a pharmacoeconomic model to determine the characteristics and the cost–effectiveness of a hypothetical PGx test, which would identify patients who are most likely to respond to an expensive treatment for chronic heart failure. For this purpose, we chose the example of ivabradine. Our results suggest that the use of a PGx test that could select a subgroup of patients to be treated with an expensive drug has the potential to provide more efficient drug utilization.
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Affiliation(s)
- Ange C Iliza
- Faculté de médicine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada
| | - Alexis Matteau
- Faculté de médicine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada
- Division of General Cardiology, Centre hospitalier de l’Université de Montréal, Montréal, Quebec, Canada
| | - Jason R Guertin
- McMaster University, Department of Clinical Epidemiology and Biostatistics, Hamilton, Ontario, Canada
- Programs for Assessment of Technology in Health, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Dominic Mitchell
- Faculté de médicine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada
| | - Fiorella Fanton-Aita
- Faculté de médicine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada
| | - Anick Dubois
- Beaulieu–Saucier Pharmacogenomics Centre, Montreal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | - Marie-Pierre Dubé
- Faculté de médicine, Université de Montréal, Montréal, Québec, Canada
- Beaulieu–Saucier Pharmacogenomics Centre, Montreal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | - Jean-Claude Tardif
- Faculté de médicine, Université de Montréal, Montréal, Québec, Canada
- Beaulieu–Saucier Pharmacogenomics Centre, Montreal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | - Jacques LeLorier
- Faculté de médicine, Université de Montréal, Montréal, Québec, Canada
- Centre de Recherche du Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada
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