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Kaddoura R, Madurasinghe V, Chapra A, Abushanab D, Al-Badriyeh D, Patel A. Beta-blocker therapy in heart failure with preserved ejection fraction (B-HFpEF): A systematic review and meta-analysis. Curr Probl Cardiol 2024; 49:102376. [PMID: 38184132 DOI: 10.1016/j.cpcardiol.2024.102376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2023] [Accepted: 01/03/2024] [Indexed: 01/08/2024]
Abstract
INTRODUCTION While beta-blockers are considered the cornerstone of treatment for heart failure with reduced ejection fraction, the same may not apply to patients with heart failure with preserved ejection fraction (HFpEF). To date, the benefit of beta-blockers remains uncertain, and there is no current consensus on their effectiveness. This study sought to evaluate the efficacy of beta-blockers on mortality and rehospitalization among patients with HFpEF. METHODS A systematic review and meta-analysis of randomized or observational cohort studies examined the efficacy of beta-blocker therapy in comparison with placebo, control, or standard medical care in patients with HFpEF, defined as left ventricular ejection fraction ≥50 %. The main endpoints were mortality (i.e., all-cause and cardiovascular), rehospitalization (i.e., all-cause and for heart failure) and a composite of the two. RESULTS Out of the 13,189 records initially identified, 16 full-text records met the inclusion criteria and were analyzed recruiting a total of 27,188 patients. The mean age range was 62-84 years old, predominantly female, with HFpEF in which 63.4 % of patients received a beta-blocker and 36.6 % did not. The pooled analysis of included cohort studies, of variable follow-up durations, showed a significant reduction in all-cause mortality by 19 % (odds ratio (OR) 0.81; 95 % confidence interval (CI): 0.65-0.99, p = 0.044) whereas rehospitalization for heart failure (OR 1.13; 95 % CI: 0.91-1.41, p = 0.27) or its composite with all-cause mortality (OR 1.01; 95 % CI: 0.78-1.32, p = 0.92) were similar between the beta-blocker and control groups. CONCLUSION This meta-analysis showed that beta-blocker therapy has the potential to reduce all-cause mortality in patients with HFpEF based on observational studies. Nevertheless, it did not affect rehospitalization for heart failure or its composite with all-cause mortality. Large scale randomized trials are needed to clarify this uncertainty.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
| | | | - Ammar Chapra
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
| | - Dina Abushanab
- Drug Information Center, Hamad Medical Corporation, Doha, Qatar
| | | | - Ashfaq Patel
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Smetana GW, Ho JE, Orkaby AR, Reynolds EE. How Would You Manage This Patient With Heart Failure With Preserved Ejection Fraction? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2023; 176:1656-1665. [PMID: 38079640 DOI: 10.7326/m23-2384] [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: 12/20/2023] Open
Abstract
The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease. Whereas the diagnosis of HFrEF is relatively straightforward, the diagnosis of HFpEF is often more challenging because there can be other causes for symptoms, including dyspnea and fatigue, and cardinal physical examination findings of elevated jugular venous pressure or pulmonary congestion may not be evident at rest. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America published a comprehensive guideline on heart failure that included recommendations for the management of HFpEF. The use of diuretics for the management of congestion remained the only class 1 (strong) recommendation. New recommendations included broader use of sodium-glucose cotransporter-2 inhibitors (SGLT2i, class 2a), and angiotensin receptor-neprilysin inhibitors (class 2b). In 2023, the American College of Cardiology published an expert consensus decision pathway for the management of HFpEF that suggests treatment strategies based on sex assigned at birth, ejection fraction, clinical evidence of congestion, and candidacy for SGLT2i therapy. Here, 2 experts, a cardiologist and a geriatrician, discuss their approach to the diagnosis and management of HFpEF and how they would apply guidelines to an individual patient.
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Affiliation(s)
- Gerald W Smetana
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (G.W.S., J.E.H., E.E.R.)
| | - Jennifer E Ho
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (G.W.S., J.E.H., E.E.R.)
| | - Ariela R Orkaby
- VA Boston Healthcare System and Brigham & Women's Hospital, Boston, Massachusetts (A.R.O.)
| | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (G.W.S., J.E.H., E.E.R.)
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Kaddoura R, Patel A. Revisiting Beta-Blocker Therapy in Heart Failure with Preserved Ejection Fraction. Curr Probl Cardiol 2023; 48:102015. [PMID: 37544622 DOI: 10.1016/j.cpcardiol.2023.102015] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 08/01/2023] [Indexed: 08/08/2023]
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogenous disorder and tends to be predominant in elderly, female, and obese patients. HFpEF has been classified using various cut-offs of left ventricular ejection fraction in the published studies with a current cut-off of ≥50%. The evidence of beta-blocker therapy in HFpEF patients showed conflicting findings with variably reported efficacy. This review aims to examine the published studies on the use of beta blockers for the treatment of patients with HFpEF.
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Affiliation(s)
- Rasha Kaddoura
- Pharmacy Department, Heart Hospital, Hamad Medical Corporation, Doha, Qatar.
| | - Ashfaq Patel
- Department of Cardiology, Heart Hospital, Hamad Medical Corporation, Doha, Qatar
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Wu M, Ni D, Huang L, Qiu S. Association between the beta-blockers, calcium channel blockers, all-cause mortality and length of hospitalization in patients with heart failure with preserved ejection fraction: A meta-analysis of randomized controlled trials. Clin Cardiol 2023; 46:845-852. [PMID: 37272188 PMCID: PMC10436801 DOI: 10.1002/clc.24058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/01/2023] [Accepted: 05/08/2023] [Indexed: 06/06/2023] Open
Abstract
PURPOSE To establish an association between beta-blockers (BBs), calcium channel blockers (CCBs), all-cause mortality, and hospitalization in patients with Heart failure with preserved Ejection Fraction (HFpEF). METHODS The present meta-analysis has been performed as per the guidelines of (PRISMA). An inclusive literature search was made without any limitations on language using the electronic databases Cochrane Library, EMBASE, and PubMed up to November 2022. The outcomes evaluated in this meta-analysis involved all-cause mortality and hospitalization due to heart failure. The number of patients with HFpEF and their positive outcomes was extracted and analyzed using RevMan software. RESULTS In total, 10 articles were included in the present meta-analysis, with a pooled sample size of 12 940 HFpEF patients. In comparison with placebo, both BB and CCB substantially reduced the risk of all-cause mortality and hospitalization. However, BB are more effective because they provide a significant reduction in all-cause mortality (risk ratio (RR) = 0.60; 95% confidence interval [CI] = 0.43-0.83; p = .002] and hospitalization (RR = 0.54; 95% CI = 0.37-0.80; p = .002) as compared with CCB with a risk ratio of all-cause mortality (RR = 0.77; 95% CI = 0.60-0.98; p = .03) and hospitalization (RR = 0.63; 95% CI = 0.44-0.90; p < .00001). A random-effects model was used because of high heterogeneity between the studies (I2 > 70%). CONCLUSIONS The current meta-analysis suggests that BBs were more beneficial than CCB in reducing all-cause mortality and hospitalization duration in patients with HFpEF.
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Affiliation(s)
- Mingming Wu
- Department of CardiologyJiangsu Rudong County People's HospitalNantongJiangsuChina
| | - Dan Ni
- Department of GeriatricsMeishan People's HospitalSichuanMeishanChina
| | - Lin‐ling Huang
- Department of CardiologyJiangsu Rudong County People's HospitalNantongJiangsuChina
| | - Shengjun Qiu
- Department of Medical CollegeWuhan Railway Vocational College of TechnologyWuhanHubeiChina
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5
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Musse M, Lau JD, Yum B, Pinheiro LC, Curtis H, Anderson T, Steinman MA, Meyer M, Dorsch M, Hummel SL, Goyal P. Physician Perspectives on the Use of Beta Blockers in Heart Failure With Preserved Ejection Fraction. Am J Cardiol 2023; 193:70-74. [PMID: 36878055 PMCID: PMC10114214 DOI: 10.1016/j.amjcard.2023.01.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/10/2022] [Revised: 01/25/2023] [Accepted: 01/27/2023] [Indexed: 03/07/2023]
Abstract
β-blockers are commonly used in heart failure with preserved ejection fraction (HFpEF), even in the absence of a compelling indication and despite the potential to cause harm. Identifying reasons for β-blocker prescription in HFpEF could permit the development of strategies to reduce unnecessary use and potentially improve medication prescribing patterns in this vulnerable population. We administered an online survey regarding β-blocker prescribing behavior to physicians trained in internal medicine or geriatrics (noncardiology physicians) and to cardiologists at 2 large academic medical centers. The survey assessed the reasons for β-blocker initiation, agreement regarding initiation and/or continuation of β-blockers by another clinician, and deprescribing behavior. The response rate was 28.2% (n = 231). Among respondents, 68.2% reported initiating β-blockers in patients with HFpEF. The most common reason for initiating a β-blocker was for treatment of an atrial arrhythmia. Notably, 23.7% of physicians reported initiating a β-blocker without an evidence-based indication. When a β-blocker was considered not necessary, 40.1% of physicians reported they were rarely or never willing to deprescribe. The most common reason for not deprescribing a β-blocker when the physician felt that a β-blocker was unnecessary was the concern about interfering with another physicians' treatment plan (76.6%). In conclusion, a significant proportion of noncardiology physicians and cardiologists report prescribing β-blockers to patients with HFpEF, even when evidence-based indications are absent, and rarely deprescribe β-blockers in these scenarios.
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Affiliation(s)
- Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Jennifer D Lau
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Brian Yum
- Texas Heart Institute, Houston, Texas
| | - Laura C Pinheiro
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Hannah Curtis
- Department of Medicine, Weill Cornell Medicine, New York, New York
| | - Timothy Anderson
- Division of General Medicine, Beth Israel Deaconess, Boston, Massachusetts
| | - Michael A Steinman
- Division of Geriatrics, University of California San Francisco; San Francisco Veterans Affairs Medical Center, San Francisco, California
| | | | - Michael Dorsch
- College of Pharmacy, University of Michigan, Ann Arbor, Michigan
| | - Scott L Hummel
- University of Michigan Frankel Cardiovascular Center; VA Ann Arbor Health System, Ann Arbor, Michigan
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York.
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Goyal P, Safford M, Hilmer SN, Steinman MA, Matlock D, Maurer MS, Lachs M, Kronish IM. N-of-1 trials to facilitate evidence-based deprescribing: Rationale and case study. Br J Clin Pharmacol 2022; 88:4460-4473. [PMID: 35705532 PMCID: PMC9464693 DOI: 10.1111/bcp.15442] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2022] [Revised: 05/24/2022] [Accepted: 05/26/2022] [Indexed: 11/30/2022] Open
Abstract
Deprescribing has emerged as an important aspect of patient-centred medication management but is vastly underutilized in clinical practice. The current narrative review will describe an innovative patient-centred approach to deprescribing-N-of-1 trials. N-of-1 trials involve multiple-period crossover design experiments conducted within individual patients. They enable patients to compare the effects of two or more treatments or, in the case of deprescribing N-of-1 trials, continuation with a current treatment versus no treatment or placebo. N-of-1 trials are distinct from traditional between-patient studies such as parallel-group or crossover designs which provide an average effect across a group of patients and obscure differences between individuals. By generating data on the effect of an intervention for the individual rather than the population, N-of-1 trials can promote therapeutic precision. N-of-1 trials are a particularly appealing strategy to inform deprescribing because they can generate individual-level evidence for deprescribing when evidence is uncertain, and can thus allay patient and physician concerns about discontinuing medications. To illustrate the use of deprescribing N-of-1 trials, we share a case example of an ongoing series of N-of-1 trials that compare maintenance versus deprescribing of beta-blockers in patients with heart failure with preserved ejection fraction. By providing quantifiable data on patient-reported outcomes, promoting personalized pharmacotherapy, and facilitating shared decision making, N-of-1 trials represent a potentially transformative strategy to address polypharmacy.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology, Weill Cornell Medicine (New York, NY)
- Division of General Internal Medicine, Weill Cornell Medicine (New York, NY)
| | - Monika Safford
- Division of General Internal Medicine, Weill Cornell Medicine (New York, NY)
| | - Sarah N. Hilmer
- Kolling Institute, University of Sydney and Royal North Shore Hospital (Sydney, Australia)
| | - Michael A. Steinman
- Division of Geriatrics, University of California San Francisco (San Francisco, CA)
| | - Daniel Matlock
- Division of Geriatrics, University of Colorado (Denver, CO)
| | - Mathew S. Maurer
- Department of Medicine, Columbia University Irving Medical Center (New York, NY)
| | - Mark Lachs
- Division of Geriatrics, Weill Cornell Medicine (New York, NY)
| | - Ian M. Kronish
- Center for Behavioral Cardiovascular Health, Columbia University, (New York, NY)
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Harada E, Mizuno Y, Ishii M, Ishida T, Yamada T, Kugimiya F, Yasue H. Beta-blockers are associated with increased B-type natriuretic peptide levels differently in men and women in heart failure with preserved ejection fraction. Am J Physiol Heart Circ Physiol 2022; 323:H276-H284. [PMID: 35714176 DOI: 10.1152/ajpheart.00029.2022] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
Beta-blocker (BB) use is a mainstay for treatment of heart failure (HF) with reduced ejection fraction (HFrEF), whereas its efficacy for heart failure with preserved ejection fraction (HFpEF) remains controversial. Women outnumber men in HFpEF, whereas men outnumber women in HFrEF. Plasma B-type natriuretic peptide (BNP) is established as a biomarker for HF. We examined whether BB use is associated with plasma BNP levels differently in men and women with HFpEF. The study subjects comprised 721 patients with HFpEF (LVEF≥50%) (184 men, mean age 78.2±9.2 and 537 women, mean age 83.1±8.8), 179 on BB (66 men and 113 women) and 542 (118 men and 424 women) not, 583 in sinus rhythm (SR) and 138 in atrial fibrillation (AF). Multivariable logistic regression test was utilized. Plasma BNP levels were higher (P=0.0005), systolic blood pressure and LVEF lower (P=0.0003, and P=0.0059, respectively) on BBs than on no-BBs in women, whereas in men plasma BNP levels, systolic blood pressure, and LVEF were not altered significantly (P=0.0849, P=0.9129, and P=0.4718, respectively) on BBs compared to no-BBs in patients with SR. Multivariable logistic regression analysis revealed that BB use and women were a positive and a negative predictor for high BNP levels (P=0.003 and P=0.032, respectively) in SR but not in AF. BB use was associated with high plasma BNP levels and lower LVEF in women but not in men with HFpEF and SR, suggesting that the pathogenesis and of HFpEF may differ in men and women in SR.
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Affiliation(s)
- Eisaku Harada
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Yuji Mizuno
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Masanobu Ishii
- Department of Cardiovascular Medicine, Faculty of Life Science, Graduate School of Medical Sciences, Kumamoto University, Kumamoto City, Japan
| | - Toshifumi Ishida
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Toshihiro Yamada
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Fumihito Kugimiya
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
| | - Hirofumi Yasue
- Division of Cardiovascular Medicine, Kumamoto Kinoh Hospital, Kumamoto Aging Research Institute, Kumamoto, Japan
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Briasoulis A, Stamatelopoulos K, Petropoulos I, Patras R, Theodorakakou F, Gavriatopoulou M, Ntalianis A, Dimopoulos MA, Kastritis E. Utilization and tolerance of beta-blockers among patients with AL amyloidosis. Amyloid 2022; 29:31-37. [PMID: 34549676 DOI: 10.1080/13506129.2021.1981281] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
BACKGROUND The utilization and clinical impact of beta-blockers (BBs) in cardiac amyloidosis (CA) is largely unexplored. METHODS We conducted a retrospective, single-center analysis of indications, timing of initiation, types and doses of BB used, reasons to discontinue BB and association between BB tolerance and outcomes in a cohort of patients with immunoglobulin light chain amyloidosis (AL). RESULTS We reviewed 236 patients with AL CA and identified 53 patients taking BB (22.5%). Most patients presented in New York Heart Association Class (NYHA) II or III (74.5%) and 24% presented in Mayo stage IIIB. The most frequent indications for BB initiation were atrial fibrillation (AF) and coronary artery disease (CAD). In most cases (59%) BB was started before the diagnosis of CA. The median duration of BB treatment was 9 months (interquartile range [IQR] 3-24 months). Among patients receiving BB, 28 tolerated BB during follow-up whereas 25 patients discontinued BB. The main causes of BB discontinuation were hypotension and heart failure (HF) exacerbation. Patients intolerant to BB presented with more advanced NYHA class, worse performance status and lower median left ventricular ejection fraction (LVEF) at baseline. At median follow-up duration of 17.7 months, patients who did not tolerate BB had a poor survival. CONCLUSIONS Although some patients with CA may have indications for treatment with BB, their use is uncommon and those with more advanced disease tolerate BB poorly. Intolerance to BB in patients with cardiac AL is an indicator of poorer outcome.
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Affiliation(s)
- Alexandros Briasoulis
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Kimon Stamatelopoulos
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Ioannis Petropoulos
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Raphael Patras
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Foteini Theodorakakou
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Maria Gavriatopoulou
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Argyrios Ntalianis
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
| | | | - Efstathios Kastritis
- Department of Clinical Therapeutics, National Kapodistrian University of Athens, Medical School, Athens, Greece
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Ma D, Mandour AS, Yoshida T, Matsuura K, Shimada K, Kitpipatkun P, Uemura A, Ifuku M, Takahashi K, Tanaka R. Intraventricular pressure gradients change during the development of left ventricular hypertrophy: Effect of salvianolic acid B and beta-blocker. ULTRASOUND : JOURNAL OF THE BRITISH MEDICAL ULTRASOUND SOCIETY 2021; 29:229-240. [PMID: 34777543 DOI: 10.1177/1742271x20987584] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 12/21/2020] [Indexed: 12/19/2022]
Abstract
Introduction Intraventricular pressure gradient is regarded as a non-invasive indicator of diastolic function. Salvianolic acid B (Sal-B), a traditional Asian medicine, revealed its usefulness in myocardial infarction models; however, the hemodynamic effect of salvianolic acid B is still unknown. The present study aimed to investigate the intraventricular pressure gradient changes during the development of left ventricular hypertrophy with or without salvianolic acid B and a beta-blocker. Methods In total, 48 rats were divided into four groups; Sham, Non-treatment, salvianolic acid B, and Carvedilol. Aortic coarctation-induced left ventricular hypertrophy was done in three groups and the treatment was started from the third to the sixth week. Blood pressure, conventional echocardiography, and color M-mode echocardiography for measurement of intraventricular pressure gradient were carried out for six consecutive weeks. Results At 4.5 weeks, the LV mass was elevated in the coarctation groups but the blood pressure was significantly lower in salvianolic acid B and Carvedilol groups (P < 0.05). In the Non-treatment group, the total intraventricular pressure gradient was increased at 4.5 and 6 weeks (2.60 and 2.65, respectively). Meanwhile, the basal intraventricular pressure gradient was elevated at 3 and 6 weeks (1.67 and 1.75) compared with the Sham group. Salvianolic acid B and Carvedilol significantly reduced the basal intraventricular pressure gradient at six weeks compared with the Non-treatment group (1.52 and 1.51 vs 1.75, respectively). Conclusions Salvianolic acid B and Carvedilol promote cardiac function by decreasing the elevated basal intraventricular pressure gradient. The current preclinical results revealed the efficacy of salvianolic acid B as a potential therapy for left ventricular hypertrophy because of the non-blood pressure lowering effect.
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Affiliation(s)
- Danfu Ma
- Departments of Veterinary Surgery, Faculty of Veterinary Medicine, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Ahmed S Mandour
- Departments of Veterinary Surgery, Faculty of Veterinary Medicine, Tokyo University of Agriculture and Technology, Tokyo, Japan.,Department of Animal Medicine (Internal Medicine), Faculty of Veterinary Medicine, Suez Canal University, Ismailia, Egypt
| | - Tomohiko Yoshida
- Departments of Veterinary Surgery, Faculty of Veterinary Medicine, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Katsuhiro Matsuura
- Departments of Veterinary Surgery, Faculty of Veterinary Medicine, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Kazumi Shimada
- Departments of Veterinary Surgery, Faculty of Veterinary Medicine, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Pitipat Kitpipatkun
- Departments of Veterinary Surgery, Faculty of Veterinary Medicine, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Akiko Uemura
- Departments of Veterinary Surgery, Faculty of Veterinary Medicine, Tokyo University of Agriculture and Technology, Tokyo, Japan
| | - Mayumi Ifuku
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Ken Takahashi
- Department of Pediatrics and Adolescent Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Ryou Tanaka
- Departments of Veterinary Surgery, Faculty of Veterinary Medicine, Tokyo University of Agriculture and Technology, Tokyo, Japan
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Navid P, Nguyen L, Jaber D, Zarzuela K, Musse M, Lu Wang M, Requijo T, Kozlov E, Masterson Creber RM, Hilmer SN, Lachs M, Goyal P. Attitudes toward deprescribing among adults with heart failure with preserved ejection fraction. J Am Geriatr Soc 2021; 69:1948-1955. [PMID: 33978239 PMCID: PMC9198814 DOI: 10.1111/jgs.17204] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 03/12/2021] [Accepted: 03/14/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND/OBJECTIVES Attitudes toward deprescribing could vary among subpopulations. We sought to understand patient attitudes toward deprescribing among patients with heart failure with preserved ejection fraction (HFpEF). DESIGN Retrospective cohort study. SETTING Academic medical center in New York City. PARTICIPANTS Consecutive patients with HFpEF seen in July 2018-December 2019 at a program dedicated to providing care to older adults with HFpEF. MEASUREMENTS We assessed the prevalence of vulnerabilities outlined in the domain management approach for caring for patients with heart failure and examined data on patient attitudes toward having their medicines deprescribed via the revised Patient Attitudes Toward Deprescribing (rPATD). RESULTS Among 134 patients with HFpEF, median age was 75 (interquartile range 69-82), 60.4% were women, and 35.8% were nonwhite. Almost all patients had polypharmacy (94.0%) and 56.0% had hyperpolypharmacy; multimorbidity (80.6%) and frailty (78.7%) were also common. Overall, 90.3% reported that they would be willing to have one or more of their medicines deprescribed if told it was possible by their doctors; and 26.9% reported that they would like to try stopping one of their medicines to see how they feel without it. Notably, 91.8% of patients reported that they would like to be involved in decisions about their medicines. In bivariate logistic regression, nonwhite participants were less likely to want to try stopping one of their medicines to see how they feel without it (odds ratio 0.25, 95% confidence interval [0.09-0.62], p = 0.005). CONCLUSIONS Patients with HFpEF contend with many vulnerabilities that could prompt consideration for deprescribing. Most patients with HFpEF were amenable to deprescribing. Race may be an important factor that impacts patient attitudes toward deprescribing.
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Affiliation(s)
- Pedram Navid
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Linh Nguyen
- School of Medicine, University of Colorado, Boulder, Colorado, USA
| | - Diana Jaber
- School of Medicine and Health Sciences, George Washington University, Washington, District of Columbia, USA
| | - Kate Zarzuela
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Mahad Musse
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Marcos Lu Wang
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Tatiana Requijo
- Department of Medicine, Weill Cornell Medical College, New York, New York, USA
| | - Elissa Kozlov
- Institute for Health, Health Policy and Aging Research, Rutgers University, New Brunswick, New Jersey, USA
| | | | - Sarah N Hilmer
- Kolling Institute, University of Sydney and Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mark Lachs
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, New York, USA
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11
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Brinker LM, Konerman MC, Navid P, Dorsch MP, McNamara J, Willer CJ, Tinetti ME, Hummel SL, Goyal P. Complex and Potentially Harmful Medication Patterns in Heart Failure with Preserved Ejection Fraction. Am J Med 2021; 134:374-382. [PMID: 32822663 PMCID: PMC8811797 DOI: 10.1016/j.amjmed.2020.07.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Revised: 06/28/2020] [Accepted: 07/01/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Complex medication regimens, often present in heart failure with preserved ejection fraction, may increase the risk of adverse drug effects and harm. We sought to characterize this complexity by determining the prevalence of polypharmacy, potentially inappropriate medications, and therapeutic competition (where a medication for 1 condition may worsen another condition) in 1 of the few dedicated heart failure with preserved ejection fraction programs in the United States. METHODS We conducted chart review on 231 patients with heart failure with preserved ejection fraction seen in the University of Michigan's Heart Failure with Preserved Ejection Fraction Clinic between July 2016 and September 2019. We recorded: 1) standing medications to determine the presence of polypharmacy, defined as ≥10 medications; 2) potentially inappropriate medications based on the 2016 American Heart Association Scientific Statement on drugs that pose a major risk of causing or exacerbating heart failure, the 2019 Beers Criteria update, or a previously described list of medications associated with geriatric syndromes; and 3) competing conditions and subsequent medications that could create therapeutic competition. RESULTS The prevalence of polypharmacy was 74%, and the prevalence of potentially inappropriate medications was 100%. Competing conditions were present in 81% of patients, of whom 49% took a medication that created therapeutic competition. CONCLUSION In addition to confirming that polypharmacy was highly prevalent, we found that potentially inappropriate medications and therapeutic competition were also frequently present. This supports the urgent need to develop patient-centered approaches to mitigate the negative effects of complex medication regimens endemic to adults with heart failure with preserved ejection fraction.
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Affiliation(s)
- Lina M Brinker
- Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Matthew C Konerman
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor
| | - Pedram Navid
- Department of Medicine, Weill Cornell Medicine, New York, NY
| | - Michael P Dorsch
- Department of Clinical Pharmacy, College of Pharmacy, University of Michigan, Ann Arbor
| | - Jennifer McNamara
- University of Michigan Frankel Cardiovascular Center Administration, University of Michigan, Ann Arbor
| | - Cristen J Willer
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor; Department of Computational Medicine and Bioinformatics, University of Michigan, Ann Arbor; Department of Human Genetics, University of Michigan, Ann Arbor
| | - Mary E Tinetti
- Department of Medicine, Yale University School of Medicine, New Haven, CT
| | - Scott L Hummel
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Michigan, Ann Arbor; Section of Cardiology, Ann Arbor Veterans Affairs Health System, Ann Arbor, Mich
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, NY.
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12
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Yao Y, Zhang R, Zhang Q, Zhao X, Zhang J. Does higher SBP at discharge explain better outcomes in non-heart failure with reduced ejection fraction patients? Insights from Fuwai Hospital. J Hypertens 2020; 39:356-366. [PMID: 33031173 DOI: 10.1097/hjh.0000000000002633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE We hypothesized that discharge SBP had different associations with outcomes in non-HFrEF (left ventricular ejection fraction ≥40%) patients with or without high blood pressure (HBP) at admission. METHODS Non-HFrEF patients hospitalized for decompensated heart failure were consecutively recruited and were categorized into HBP (admission SBP ≥130 mmHg) group and non-HBP group. The primary outcome was a composite of cardiovascular death and heart transplantation. Multivariate Cox and penalized spline analyses were used to assess the relationships between discharge SBP and outcomes. RESULTS Nine hundred and sixty-four non-HFrEF patients were enrolled with a median follow-up of 71.8 months. Three hundred and sixty-five (37.9%) patients had HBP. In multivariate Cox analyses, non-HBP patients with higher discharge SBP were associated with a better outcome (per 10 mmHg increased, hazard ratio = 0.788, P = 0.001). However, an opposite relationship between discharge SBP and the primary outcome was observed in HBP group (per 10 mmHg increased, hazard ratio = 1.312, P = 0.002). Results of penalized spline regression models showed that there was a U-shaped association between discharge SBP and outcomes in the total cohort. Compared with 120 mmHg, the risk of the primary outcome increased when discharge SBP was below 99 mmHg in non-HBP group; in HBP group, a worse outcome was observed when discharged SBP was above 145 mmHg. CONCLUSION Non-HFrEF had a U-shaped association between discharge SBP and adverse events. Such an association was modified by admission HBP. Higher discharge SBP correlated with a worse outcome in non-HFrEF patients with admission HBP, as opposed to patients admitted without HBP.
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Affiliation(s)
- Younan Yao
- The State Key Laboratory of Cardiovascular Disease, Heart Failure Center of Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Rongcheng Zhang
- The State Key Laboratory of Cardiovascular Disease, Heart Failure Center of Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Qi Zhang
- The State Key Laboratory of Cardiovascular Disease, Heart Failure Center of Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
| | - Xinke Zhao
- The Affiliated Hospital of Gansu University of Chinese Medicine, Lanzhou, China
| | - Jian Zhang
- The State Key Laboratory of Cardiovascular Disease, Heart Failure Center of Fuwai Hospital, National Center for Cardiovascular Disease, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing
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13
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Goyal P, Requijo T, Siceloff B, Shen MJ, Masterson Creber R, Hilmer SN, Kronish IM, Lachs MS, Safford MM. Patient-Reported Barriers and Facilitators to Deprescribing Cardiovascular Medications. Drugs Aging 2020; 37:125-135. [PMID: 31858449 PMCID: PMC7339041 DOI: 10.1007/s40266-019-00729-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Medications endorsed by clinical practice guidelines, such as cardiovascular medications, could still have risks that outweigh potential benefits, and could thus warrant deprescribing. OBJECTIVES The objective of this study was to develop a framework of facilitators and barriers specific to deprescribing cardiovascular medications in the setting of uncertain benefit. Given the frequent use of β-blockers in heart failure with preserved ejection fraction, and its uncertain benefits with potential for harm, we used this scenario as an example case for a cardiovascular medication that may be reasonable to deprescribe. METHODS We conducted one-on-one, semi-structured interviews of older adults until we reached thematic saturation. Two coders independently reviewed each interview, and developed codes using deductive thematic analysis based on a prior conceptual framework for deprescribing. Subthemes and themes were finalized with a third coder. RESULTS Ten participants were interviewed. We identified three key previously described patient-reported facilitators to deprescribing: (1) appropriateness of cessation; (2) process of cessation; and (3) dislike of medications; and identified three key previously described patient-reported barriers: (1) appropriateness of cessation; (2) process of cessation; and (3) fear. We found that these facilitators and barriers often co-occurred within the same individual. This observation, coupled with subthemes from our patient interviews, yielded two barriers to deprescribing specific to cardiovascular medications-uncertainty and conflicting attitudes. CONCLUSION We adapted a new framework of patient-reported barriers and facilitators specific to deprescribing cardiovascular medications. In addition to addressing barriers previously described, future deprescribing interventions targeting cardiovascular medications must also address uncertainty and conflicting attitudes.
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Affiliation(s)
- Parag Goyal
- Division of Cardiology/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA. .,Division of General Internal Medicine/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA.
| | - Tatiana Requijo
- School of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Birgit Siceloff
- Division of Cardiology/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA.,Division of General Internal Medicine/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA
| | - Megan J Shen
- Division of Geriatrics/Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Ruth Masterson Creber
- Department of Healthcare Policy and Research, Weill Cornell Medicine, New York, NY, USA
| | - Sarah N Hilmer
- Department of Clinical Pharmacology, Royal North Shore Hospital, Sydney, NSW, Australia.,Sydney Medical School and Kolling Institute of Medical Research, University of Sydney, Sydney, NSW, Australia
| | - Ian M Kronish
- Center for Behavioral Cardiovascular Health, Columbia University Medical Center, New York, NY, USA
| | - Mark S Lachs
- Division of Geriatrics/Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Monika M Safford
- Division of General Internal Medicine/Department of Medicine, Weill Cornell Medicine, 420 East 70th Street, New York, NY, 10063, USA
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