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Takeuchi S, Kohno T, Goda A, Shiraishi Y, Kitamura M, Nagatomo Y, Takei M, Nomoto M, Soejima K, Kohsaka S, Yoshikawa T. Renin-angiotensin system inhibitors for patients with mild or moderate chronic kidney disease and heart failure with mildly reduced or preserved ejection fraction. Int J Cardiol 2024; 409:132190. [PMID: 38761975 DOI: 10.1016/j.ijcard.2024.132190] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Revised: 05/04/2024] [Accepted: 05/15/2024] [Indexed: 05/20/2024]
Abstract
BACKGROUND Renin-angiotensin system inhibitors (RASI) reduce adverse cardiovascular events in patients with heart failure (HF) with left ventricular ejection fraction (LVEF) ≤40% and mild or moderate chronic kidney disease (CKD). However, RASI administration rate and its association with long-term outcomes in patients with CKD complicated by HF with LVEF >40% remain unclear. METHODS We analyzed 1923 consecutive patients with LVEF >40% registered within the multicenter database for hospitalized HF. We assessed RASI administration rate and its association with all-cause mortality among patients with mild or moderate CKD (estimated glomerular filtration rate [eGFR]: 30-60 mL/min/1.73 m2). Exploratory subgroups included patients grouped by age (<80, ≥80 years), sex, previous HF hospitalization, B-type natriuretic peptide (higher, lower than median), eGFR (30-44, 45-59 mL/min/1.73 m2), systolic blood pressure (<120, ≥120 mmHg), LVEF (41-49, ≥50%), and mineralocorticoid receptor antagonists (MRA) use. RESULTS Among patients with LVEF >40%, 980 (51.0%) had mild or moderate CKD (age: 81 [74-86] years; male, 52.6%; hypertension, 69.7%; diabetes, 25.9%), and 370 (37.8%) did not receive RASI. RASI use was associated with hypertension, absence of atrial fibrillation, and MRA use. After multivariable adjustments, RASI use was independently associated with lower all-cause mortality over a 2-year median follow-up (hazard ratio: 0.58, 95% confidence interval: 0.43-0.79, P = 0.001), and the mortality rate difference was predominantly due to cardiac death, consistent in all subgroups. CONCLUSIONS Approximately one-third of HF patients with mild or moderate CKD and LVEF >40% were discharged without RASI administration and demonstrated relatively guarded outcomes.
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Affiliation(s)
- Shinsuke Takeuchi
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan.
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Saitama, Japan
| | - Makoto Takei
- Department of Cardiology, Tokyo Saiseikai Central Hospital, Tokyo, Japan
| | - Michiru Nomoto
- Department of Cardiology, Saitama Medical University, International Medical Center, Saitama, Japan
| | - Kyoko Soejima
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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Malgie J, Wilde MI, Clephas PRD, Emans ME, Koudstaal S, Schaap J, Mosterd A, van Ramshorst J, Wardeh AJ, van Wijk S, van den Heuvel M, Wierda E, Borleffs CJW, Saraber C, Beeres SLMA, van Kimmenade R, Jansen Klomp W, Denham R, da Fonseca CA, Klip IJT, Manintveld OC, van der Boon RMA, van Ofwegen CEE, Yilmaz A, Pisters R, Linssen GCM, Faber N, van Heerebeek L, van de Swaluw JEC, Bouhuijzen LJ, Post MC, Kuijper AFM, Wu KW, van Beek EA, Hesselink T, Kleijn L, Kurvers MJM, Tio RA, Langerveld J, van Dalen BM, van Eck JWM, Handoko ML, Hermans WRM, Koornstra-Wortel HJJ, Szymanski MK, Rooker D, Tandjung K, Eijsbouts SCM, Asselbergs FW, van der Meer P, Brunner-La Rocca HP, de Boer RA, Brugts JJ. Contemporary guideline-directed medical therapy in de novo, chronic, and worsening heart failure patients: First data from the TITRATE-HF study. Eur J Heart Fail 2024; 26:1549-1560. [PMID: 38734980 DOI: 10.1002/ejhf.3267] [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: 04/05/2024] [Revised: 04/19/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
AIMS Despite clear guideline recommendations for initiating four drug classes in all patients with heart failure (HF) with reduced ejection fraction (HFrEF) and the availability of rapid titration schemes, information on real-world implementation lags behind. Closely following the 2021 ESC HF guidelines and 2023 focused update, the TITRATE-HF study started to prospectively investigate the use, sequencing, and titration of guideline-directed medical therapy (GDMT) in HF patients, including the identification of implementation barriers. METHODS AND RESULTS TITRATE-HF is an ongoing long-term HF registry conducted in the Netherlands. Overall, 4288 patients from 48 hospitals were included. Among these patients, 1732 presented with de novo, 2240 with chronic, and 316 with worsening HF. The median age was 71 years (interquartile range [IQR] 63-78), 29% were female, and median ejection fraction was 35% (IQR 25-40). In total, 44% of chronic and worsening HFrEF patients were prescribed quadruple therapy. However, only 1% of HFrEF patients achieved target dose for all drug classes. In addition, quadruple therapy was more often prescribed to patients treated in a dedicated HF outpatient clinic as compared to a general cardiology outpatient clinic. In each GDMT drug class, 19% to 36% of non-use in HFrEF patients was related to side-effects, intolerances, or contraindications. In the de novo HF cohort, 49% of patients already used one or more GDMT drug classes for other indications than HF. CONCLUSION This first analysis of the TITRATE-HF study reports relatively high use of GDMT in a contemporary HF cohort, while still showing room for improvement regarding quadruple therapy. Importantly, the use and dose of GDMT were suboptimal, with the reasons often remaining unclear. This underscores the urgency for further optimization of GDMT and implementation strategies within HF management.
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Affiliation(s)
- Jishnu Malgie
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thorax Center, Rotterdam, The Netherlands
| | - Mariëlle I Wilde
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thorax Center, Rotterdam, The Netherlands
| | - Pascal R D Clephas
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thorax Center, Rotterdam, The Netherlands
| | - Mireille E Emans
- Department of Cardiology, Ikazia Ziekenhuis, Rotterdam, The Netherlands
| | - Stefan Koudstaal
- Department of Cardiology, Groene Hart Ziekenhuis, Gouda, The Netherlands
| | - Jeroen Schaap
- Department of Cardiology, Amphia Ziekenhuis, Breda, The Netherlands
- Dutch Network for Cardiovascular Research (WCN), Utrecht, The Netherlands
| | - Arend Mosterd
- Department of Cardiology, Meander Medical Centre, Amersfoort, The Netherlands
| | - Jan van Ramshorst
- Department of Cardiology, Noordwest Hospital Group, Alkmaar, The Netherlands
| | - Alexander J Wardeh
- Department of Cardiology, Haaglanden Medical Centre, The Hague, The Netherlands
| | - Sandra van Wijk
- Department of Cardiology, Zuyderland Hospital, Sittard, The Netherlands
| | | | - Eric Wierda
- Department of Cardiology, Dijklander Ziekenhuis, Hoorn Purmerend, The Netherlands
| | | | - Colette Saraber
- Department of Cardiology, Tergooi Medical Centre, Hilversum, The Netherlands
| | - Saskia L M A Beeres
- Department of Cardiology, Leids University Medical Centre, Leiden, The Netherlands
| | - Roland van Kimmenade
- Department of Cardiology, Radboud University Medical Center, Nijmegen, The Netherlands
| | | | - Robert Denham
- Department of Cardiology, Admiraal de Ruyter Ziekenhuis, Goes, The Netherlands
| | - Carlos A da Fonseca
- Department of Cardiology, Medisch Centrum Leeuwarden, Leeuwarden, The Netherlands
| | - IJsbrand T Klip
- Department of Cardiology, Amphia Ziekenhuis, Breda, The Netherlands
- Department of Cardiology, Antonius Ziekenhuis, Sneek, The Netherlands
| | - Olivier C Manintveld
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thorax Center, Rotterdam, The Netherlands
| | - Robert M A van der Boon
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thorax Center, Rotterdam, The Netherlands
| | | | - Ayten Yilmaz
- Department of Cardiology, Bernhoven, Uden, The Netherlands
| | - Ron Pisters
- Department of Cardiology, Rijnstate, Arnhem, The Netherlands
| | - Gerard C M Linssen
- Department of Cardiology, Hospital Group Twente, Almelo Hengelo, The Netherlands
| | - Nikola Faber
- Department of Cardiology, Bravis Ziekenhuis, Bergen op Zoom Roosendaal, The Netherlands
| | - Loek van Heerebeek
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
| | | | - Lex J Bouhuijzen
- Department of Cardiology, Saxenburg Medical Centre, Hardenberg, The Netherlands
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Nieuwegein, The Netherlands
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Aaf F M Kuijper
- Department of Cardiology, Spaarne Gasthuis, Haarlem, The Netherlands
| | - Ka Wai Wu
- Department of Cardiology, Het Van Weel-Bethesda Ziekenhuis, Dirksland, The Netherlands
| | - Eugène A van Beek
- Department of Cardiology, Hospital St Jansdal, Harderwijk, The Netherlands
| | - Tim Hesselink
- Department of Cardiology, Streekziekenhuis Koninging Beatrix, Winterswijk, The Netherlands
| | - Lennaert Kleijn
- Department of Cardiology, Treant Zorggroep, Emmen Hoogeveen Stadskanaal, The Netherlands
| | - Maurice J M Kurvers
- Department of Cardiology, Albert Schweitzer Ziekenhuis, Dordrecht, The Netherlands
| | - René A Tio
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Jorina Langerveld
- Department of Cardiology, Ziekenhuis Rivierenland, Tiel, The Netherlands
| | - Bas M van Dalen
- Department of Cardiology, Franciscus Gasthuis & Vlietland, Rotterdam Schiedam, The Netherlands
| | - J W Martijn van Eck
- Department of Cardiology's, Jeroen Bosch Ziekenhuis, Hertogenbosch, The Netherlands
| | - M Louis Handoko
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Walter R M Hermans
- Department of Cardiology, Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
| | | | - Mariusz K Szymanski
- Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Dennis Rooker
- Department of Cardiology, Gelre Ziekenhuizen, Apeldoorn Zutphen, The Netherlands
| | - Kenneth Tandjung
- Department of Cardiology, Ziekenhuis Amstelland, Amstelveen, The Netherlands
| | - Sabine C M Eijsbouts
- Department of Cardiology, Maxima Medical Centre, Eindhoven Veldhoven, The Netherlands
| | - Folkert W Asselbergs
- Department of Cardiology, Amsterdam University Medical Centre, Amsterdam, The Netherlands
| | - Peter van der Meer
- Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Hans-Peter Brunner-La Rocca
- Department of Cardiology, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), University of Maastricht, Maastricht, The Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thorax Center, Rotterdam, The Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC, Cardiovascular Institute, Thorax Center, Rotterdam, The Netherlands
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Zhang Z, Wang C, Tu T, Lin Q, Zhou J, Huang Y, Wu K, Zhang Z, Zuo W, Liu N, Xiao Y, Liu Q. Advancing Guideline-Directed Medical Therapy in Heart Failure: Overcoming Challenges and Maximizing Benefits. Am J Cardiovasc Drugs 2024; 24:329-342. [PMID: 38568400 PMCID: PMC11093832 DOI: 10.1007/s40256-024-00646-4] [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] [Accepted: 03/20/2024] [Indexed: 05/15/2024]
Abstract
The delayed titration of guideline-directed drug therapy (GDMT) is a complex event influenced by multiple factors that often result in poor prognosis for patients with heart failure (HF). Individualized adjustments in GDMT titration may be necessary based on patient characteristics, and every clinician is responsible for promptly initiating GDMT and titrating it appropriately within the patient's tolerance range. This review examines the current challenges in GDMT implementation and scrutinizes titration considerations within distinct subsets of HF patients, with the overarching goal of enhancing the adoption and effectiveness of GDMT. The authors also underscore the significance of establishing a novel management strategy that integrates cardiologists, nurse practitioners, pharmacists, and patients as a unified team that can contribute to the improved promotion and implementation of GDMT.
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Affiliation(s)
- Zixi Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Cancan Wang
- Department of Metabolic Endocrinology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Tao Tu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Qiuzhen Lin
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Jiabao Zhou
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yunying Huang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Keke Wu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Zeying Zhang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Wanyun Zuo
- Department of Hematology, The Second Xiangya Hospital, Central South University, Changsha, 410011, Hunan Province, People's Republic of China
| | - Na Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China
| | - Yichao Xiao
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
| | - Qiming Liu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, 139 Renmin Road, Furong District, Changsha, 410011, Hunan Province, People's Republic of China.
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Scrutinio D, Guida P, La Rovere MT, Vecchia LAD, Forni G, Raimondo R, Scalvini S, Passantino A. Incremental prognostic value of functional impairment assessed by 6-min walking test for the prediction of mortality in heart failure. Sci Rep 2024; 14:3089. [PMID: 38321196 PMCID: PMC10847418 DOI: 10.1038/s41598-024-53817-3] [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: 06/01/2023] [Accepted: 02/05/2024] [Indexed: 02/08/2024] Open
Abstract
Natriuretic peptides (NP) are recognized as the most powerful predictors of adverse outcomes in heart failure (HF). We hypothesized that a measure of functional limitation, as assessed by 6-min walking test (6MWT), would improve the accuracy of a prognostic model incorporating a NP. This was a multicenter observational retrospective study. We studied the prognostic value of severe functional impairment (SFI), defined as the inability to perform a 6MWT or a distance walked during a 6MWT < 300 m, in 1696 patients with HF admitted to cardiac rehabilitation. The primary outcome was 1-year all-cause mortality. After adjusting for the baseline multivariable risk model-including age, sex, systolic blood pressure, anemia, renal dysfunction, sodium level, and NT-proBNP-or for the MAGGIC score, SFI had an odds ratio of 2.58 (95% CI 1.72-3.88; p < 0.001) and 3.12 (95% CI 2.16-4.52; p < 0.001), respectively. Adding SFI to the baseline risk model or the MAGGIC score yielded a significant improvement in discrimination and risk classification. Our data suggest that a simple, 6MWT-derived measure of SFI is a strong predictor of death and provide incremental prognostic information over well-established risk markers in HF, including NP, and the MAGGIC score.
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Affiliation(s)
- Domenico Scrutinio
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari, Via Generale Nicola Bellomo 73/75, Bari, Italy.
| | - Pietro Guida
- Regional General Hospital "F. Miulli", Acquaviva Delle Fonti, Bari, Italy
| | | | | | - Giovanni Forni
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Pavia, Pavia, Italy
| | - Rosa Raimondo
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Tradate, Varese, Italy
| | - Simonetta Scalvini
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Lumezzane, Brescia, Italy
| | - Andrea Passantino
- Istituti Clinici Scientifici Maugeri IRCCS, Institute of Bari, Via Generale Nicola Bellomo 73/75, Bari, Italy
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Gonzalez-Franco J, Caicedo-Espinosa J, Cardona-Tobon C, Jaramillo-Jara N, Aguilar-Molina O, Jaimes-Barragan FA, Saldarriaga-Giraldo CI. Application of eligibility criteria from DAPA-HF, EMPEROR-Reduced, and PARADIGM-HF trials to a population with heart failure with reduced ejection fraction at a specialized cardiology Clinic in Medellin, Colombia: A retrospective cohort study. Curr Probl Cardiol 2024; 49:102193. [PMID: 37952788 DOI: 10.1016/j.cpcardiol.2023.102193] [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: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION The evidence supporting pharmacological heart failure treatment relies on randomized clinical trials with stringent inclusion and exclusion criteria. OBJECTIVES Assess the eligibility of outpatients with chronic heart failure for the trials DAPA-HF, EMPEROR-reduced, and PARADIGM-HF, while exploring potential differences among study populations. METHODS By reviewing medical records, we determined the eligibility rate for each study and evaluated the incidence of heart failure hospitalizations and all-cause mortality during this period. RESULTS A total of 446 patients were included in the cohort. Approximately 75% would be ineligible for the trials, mainly because of their comorbidities. Ineligible patients had a higher all-cause mortality, but a similar incidence of hospitalization. CONCLUSION Approximately 1 in 4 patients from a heart failure clinic in Medellin, Colombia would meet the eligibility criteria for the DAPA-HF, EMPEROR-reduced, and PARADIGM-HF trials. These findings highlight the need to complement randomized clinical trials with real-world data.
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Affiliation(s)
- Juliana Gonzalez-Franco
- Department of Internal Medicine, Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia.
| | - Javier Caicedo-Espinosa
- Department of Internal Medicine, Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia
| | | | - Natalia Jaramillo-Jara
- Department of Internal Medicine, Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia
| | | | | | - Clara-Ines Saldarriaga-Giraldo
- CardioVID Clinic, Medellín, Colombia; Department of Internal Medicine, Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia
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Kocabaş U, Ergin I, Kıvrak T, Yılmaz Öztekin GM, Tanık VO, Özdemir İ, Avcı Demir F, Doğduş M, Şen T, Altınsoy M, Üstündağ S, Urgun ÖD, Sinan ÜY, Uygur B, Yeni M, Özçalık E. Prognostic significance of medical therapy in patients with heart failure with reduced ejection fraction. ESC Heart Fail 2023; 10:3677-3689. [PMID: 37804042 PMCID: PMC10682872 DOI: 10.1002/ehf2.14559] [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: 06/22/2023] [Revised: 08/31/2023] [Accepted: 09/21/2023] [Indexed: 10/08/2023] Open
Abstract
AIMS The use of guideline-directed medical therapy (GDMT) among patients with heart failure (HF) with reduced ejection fraction (HFrEF) remains suboptimal. The SMYRNA study aims to identify the clinical factors for the non-use of GDMT and to determine the prognostic significance of GDMT in patients with HFrEF in a real-life setting. METHODS AND RESULTS The SMYRNA study is a prospective, multicentre, and observational study that included outpatients with HFrEF. Patients were divided into three groups according to the status of GDMT at the time of enrolment: (i) patients receiving all classes of HF medications including renin-angiotensin system (RAS) inhibitors, beta-blockers, and mineralocorticoid receptor antagonists (MRAs); (ii) patients receiving any two classes of HF medications (RAS inhibitors and beta-blockers, or RAS inhibitors and MRAs, or beta-blockers and MRAs); and (iii) either patients receiving class of HF medications (only one therapy) or patients not receiving any class of HF medications. The primary outcome was a composite of hospitalization for HF or cardiovascular death. The study population consisted of 1062 patients with HFrEF, predominantly men (69.1%), with a median age of 68 (range: 20-96) years. RAS inhibitors, beta-blockers, and MRAs were prescribed in 76.0%, 89.4%, and 55.1% of the patients, respectively. The proportions of patients receiving target doses of guideline-directed medications were 24.4% for RAS inhibitors, 11.0% for beta-blockers, and 11.1% for MRAs. Overall, 491 patients (46.2%) were treated with triple therapy, 353 patients (33.2%) were treated with any two classes of HF medications, and 218 patients (20.6%) were receiving only one class of HF medication or not receiving any HF medication. Patient-related factors comprising older age, New York Heart Association functional class, rural living, presence of hypertension, and history of myocardial infarction were independently associated with the use or non-use of GDMT. During the median 24-month period, the primary composite endpoint occurred in 362 patients (34.1%), and 177 of 1062 (16.7%) patients died. Patients treated with two or three classes of HF medications had a decreased risk of hospitalization for HF or cardiovascular death compared with those patients receiving ≤1 class of HF medication [hazard ratio (HR): 0.65; 95% confidence interval (CI): 0.49-0.85; P = 0.002, and HR: 0.61; 95% CI: 0.47-0.79; P < 0.001, respectively]. CONCLUSIONS The real-life SMYRNA study provided comprehensive data about the clinical factors associated with the non-use of GDMT and showed that suboptimal GDMT is associated with an increased risk of hospitalization for HF or cardiovascular death in patients with HFrEF.
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Affiliation(s)
- Umut Kocabaş
- Department of CardiologyBaşkent University Izmir HospitalIzmirTurkey
| | - Isil Ergin
- Department of Public Health, Faculty of MedicineEge UniversityIzmirTurkey
| | - Tarık Kıvrak
- Department of Cardiology, Faculty of MedicineElazığ Fırat UniversityElazığTurkey
| | | | - Veysel Ozan Tanık
- Department of CardiologyDışkapı Yıldırım Beyazıt Training and Research Hospital, Health Sciences UniversityAnkaraTurkey
| | | | | | - Mustafa Doğduş
- Department of CardiologyKaraman State HospitalKaramanTurkey
| | - Taner Şen
- Department of Cardiology, Faculty of MedicineKütahya Health Sciences UniversityKütahyaTurkey
| | - Meltem Altınsoy
- Department of CardiologyAnkara Atatürk Chest Diseases and Chest Surgery Training and Research Hospital, Health Sciences UniversityAnkaraTurkey
| | - Songül Üstündağ
- Department of CardiologyMengücek Gazi Educatıon and Research Hospıtal, Erzincan Binali Yıldırım UniversityErzincanTurkey
| | | | - Ümit Yaşar Sinan
- Faculty of Medicine, Institute of CardiologyIstanbul UniversityIstanbulTurkey
| | - Begüm Uygur
- Department of CardiologyIstanbul Mehmet Akif Ersoy Thoracic and Cardiovascular Surgery Training and Research Hospital, Health Sciences UniversityIstanbulTurkey
| | - Mehtap Yeni
- Department of CardiologyIsparta State HospitalIspartaTurkey
| | - Emre Özçalık
- Department of CardiologyBaşkent University Izmir HospitalIzmirTurkey
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7
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Jarjour M, Ducharme A. Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines? Drugs Context 2023; 12:2023-5-6. [PMID: 38021409 PMCID: PMC10664772 DOI: 10.7573/dic.2023-5-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Heart failure is a growing epidemic with high mortality rates and recurrent hospital admissions that creates a burden on affected individuals, their caregivers and the whole healthcare system. Throughout the years, many randomized trials have established the effectiveness of several pharmacological therapies and electrophysiological devices to reduce hospitalizations and improve quality of life and survival, mostly for patients with heart failure with reduced ejection fraction (HFrEF). These studies led to the publication of national societies' recommendations to guide clinicians in the management of HFrEF. Yet, many reports have shown significant care gaps in adherence to these recommendations in clinical practice, highlighting suboptimal use and/or dosing of evidence-based therapies. Adherence to guidelines has been shown to be associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events; however, it remains unclear whether this association is causal or merely a marker of more advanced disease. Furthermore, individual characteristics may limit the possibility of reaching the targeted dosage of specific agents. Herein, we provide a comprehensive overview of clinicians' adherence to heart failure guidelines in a specialized real-life setting, particularly regarding use and optimization of guideline-derived medical therapies, as well as the implementation of more recent agents such as sacubitril/valsartan and SGLT2 inhibitors. We seek potential explanations for suboptimal treatment and its impact on patient outcomes.
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Affiliation(s)
- Marilyne Jarjour
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
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Bánfi-Bacsárdi F, Vámos M, Majoros Z, Török G, Pilecky D, Duray GZ, Kiss RG, Nyolczas N, Muk B. [The effect of kidney function on the optimization of medical therapy and on mortality in heart failure with reduced ejection fraction]. Orv Hetil 2023; 164:1387-1396. [PMID: 37660348 DOI: 10.1556/650.2023.32836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2023] [Accepted: 05/23/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Renal dysfunction is a main limiting factor of applying and up-titrating guideline-directed medical therapy (GDMT) among patients with heart failure with reduced ejection fraction (HFrEF). OBJECTIVE Our retrospective monocentric observational study aimed to analyse the application ratio of combined neurohormonal antagonist therapy (RASi: ACEI/ARB/ARNI + βB + MRA) and 12-month all-cause mortality differences in terms of renal dysfunction among HFrEF patients hospitalized for heart failure. METHOD We retrospectively analysed the cohort of consecutive HFrEF patients, hospitalized at the Heart Failure Unit of our tertiary cardiological centre in 2019-2021. The application ratio of discharge triple therapy (TT) in five groups established on admission eGFR parameters, representing severity of renal dysfunction (eGFR≥90, eGFR = 60-89, eGFR = 45-59, eGFR = 30-44, eGFR<30 ml/min/1.73 m2) was investigated with chi-square test, while 12-month mortality differences were analysed with Kaplan-Meier method and log-rank test. RESULTS 257 patients were included. Median eGFR was 57 (39-75) ml/min/1.73 m2, 54% of patients had eGFR<60 ml/min/1.73 m2. The proportion of patients in eGFR≥90, 60-89, 45-59, 30-44, <30 ml/min/1.73 m2 subgroups was 12%, 34%, 18%, 21%, 15%, respectively. 2% of patients were on dialysis. Even though the application rate of TT was notably high (77%) in the total cohort, more severe renal dysfunction led to a significantly lower implementation rate of TT (94%, 86%, 91%, 70%, 34%; p<0.0001): the application rate of RASi (100%, 98%, 96%, 89%, 50%, p<0.0001), βB (94%, 88%, 96%, 79%, 68%; p = 0.003) and MRA therapy (97%, 99%, 98%, 94%, 82%; p = 0.001) differed significantly. 12-month all-cause mortality was 23% in the whole cohort. Mortality rates were higher in more severe renal dysfunction (3%, 15%, 22%, 31%, 46%; p<0.0001). CONCLUSION Even though the proportion of patients on TT in the whole cohort was remarkably high, renal dysfunction led to a significantly lower application ratio of TT, associating with worse survival. Our results highlight that despite renal dysfunction the application of HFrEF cornerstone pharmacotherapy is essential. Orv Hetil. 2023; 164(35): 1387-1396.
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Affiliation(s)
- Fanni Bánfi-Bacsárdi
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
- 2 Gottsegen György Országos Kardiovaszkuláris Intézet, Felnőtt Kardiológiai Osztály Budapest, Haller u. 29., 1096 Magyarország
| | - Máté Vámos
- 3 Szegedi Tudományegyetem, Szent-Györgyi Albert Orvostudományi Kar, Belgyógyászati Klinika, Elektrofiziológiai Részleg Szeged Magyarország
| | - Zsuzsanna Majoros
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
| | - Gábor Török
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
| | - Dávid Pilecky
- 2 Gottsegen György Országos Kardiovaszkuláris Intézet, Felnőtt Kardiológiai Osztály Budapest, Haller u. 29., 1096 Magyarország
- 4 Szegedi Tudományegyetem, Szent-Györgyi Albert Orvostudományi Kar, Klinikai Orvostudományi Doktori Iskola Szeged Magyarország
| | - Gábor Zoltán Duray
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
| | - Róbert Gábor Kiss
- 1 Észak-Pesti Centrumkórház - Honvédkórház, Kardiológiai Osztály Budapest Magyarország
| | - Noémi Nyolczas
- 2 Gottsegen György Országos Kardiovaszkuláris Intézet, Felnőtt Kardiológiai Osztály Budapest, Haller u. 29., 1096 Magyarország
- 4 Szegedi Tudományegyetem, Szent-Györgyi Albert Orvostudományi Kar, Klinikai Orvostudományi Doktori Iskola Szeged Magyarország
| | - Balázs Muk
- 2 Gottsegen György Országos Kardiovaszkuláris Intézet, Felnőtt Kardiológiai Osztály Budapest, Haller u. 29., 1096 Magyarország
- 4 Szegedi Tudományegyetem, Szent-Györgyi Albert Orvostudományi Kar, Klinikai Orvostudományi Doktori Iskola Szeged Magyarország
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9
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Malgie J, Clephas PRD, Brunner-La Rocca HP, de Boer RA, Brugts JJ. Guideline-directed medical therapy for HFrEF: sequencing strategies and barriers for life-saving drug therapy. Heart Fail Rev 2023; 28:1221-1234. [PMID: 37311917 PMCID: PMC10403394 DOI: 10.1007/s10741-023-10325-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/31/2023] [Indexed: 06/15/2023]
Abstract
Multiple landmark trials have helped to advance the treatment of heart failure with reduced ejection fraction (HFrEF) significantly over the past decade. These trials have led to the introduction of four main drug classes into the 2021 ESC guideline, namely angiotensin-receptor neprilysin inhibitors/angiotensin-converting-enzyme inhibitors, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors. The life-saving effect of these therapies has been shown to be additive and becomes apparent within weeks, which is why maximally tolerated or target doses of all drug classes should be strived for as quickly as possible. Recent evidence, such as the STRONG-HF trial, demonstrated that rapid drug implementation and up-titration is superior to the traditional and more gradual step-by-step approach where valuable time is lost to up-titration. Accordingly, multiple rapid drug implementation and sequencing strategies have been proposed to significantly reduce the time needed for the titration process. Such strategies are urgently needed since previous large-scale registries have shown that guideline-directed medical therapy (GDMT) implementation is a challenge. This challenge is reflected by generally low adherence rates, which can be attributed to factors considering the patient, health care system, and local hospital/health care provider. This review of the four medication classes used to treat HFrEF seeks to present a thorough overview of the data supporting current GDMT, discuss the obstacles to GDMT implementation and up-titration, and identify multiple sequencing strategies that could improve GDMT adherence. Sequencing strategies for GDMT implementation. GDMT: guideline-directed medical therapy; ACEi: angiotensin-converting enzyme inhibitor; ARB: Angiotensin II receptor blocker; ARNi: angiotensin receptor-neprilysin inhibitor; BB: beta-blocker; MRA: mineralocorticoid receptor antagonist; SGLT2i: sodium-glucose co-transporter 2 inhibitor.
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Affiliation(s)
- Jishnu Malgie
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - Pascal R D Clephas
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | | | - Rudolf A de Boer
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
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10
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Patolia H, Khan MS, Fonarow GC, Butler J, Greene SJ. Implementing Guideline-Directed Medical Therapy for Heart Failure: JACC Focus Seminar 1/3. J Am Coll Cardiol 2023; 82:529-543. [PMID: 37532424 DOI: 10.1016/j.jacc.2023.03.430] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 08/04/2023]
Abstract
Despite the availability of lifesaving guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), there remain major gaps in utilization of these therapies among eligible patients. Simultaneous with these gaps in quality of care, HFrEF continues as a leading cause of death and hospitalization with associated clinical risk far exceeding most other cardiovascular and noncardiovascular conditions. In the context of this urgent need to improve provision of appropriate therapy, multiple lines of evidence support various implementation strategies. Such strategies include in-hospital initiation of GDMT, simultaneous or rapid sequence initiation of GDMT, participation in quality improvement registries to assess site performance and provide feedback, multidisciplinary titration clinics, virtual consult teams, reduction of cost-sharing, remote algorithm-based medication optimization, electronic health record-based interventions, and direct-to-patient educational initiatives. This review describes and contextualizes the evidence surrounding each of these potential avenues for improving use of foundational GDMTs for patients with HFrEF.
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Affiliation(s)
- Harsh Patolia
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
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11
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Fragasso G. Severe Left Ventricular Dysfunction After Acute Myocardial Infarction: A Call for Development of Adequately Targeted Treatments. Am J Cardiol 2023; 200:213-214. [PMID: 37385147 DOI: 10.1016/j.amjcard.2023.06.030] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 07/01/2023]
Affiliation(s)
- Gabriele Fragasso
- Heart Failure Clinic, Istituto Scientifico San Raffaele, Milano, Italy.
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12
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Zheng J, Heidenreich PA, Kohsaka S, Fearon WF, Sandhu AT. Long-Term Outcomes of Early Coronary Artery Disease Testing After New-Onset Heart Failure. Circ Heart Fail 2023; 16:e010426. [PMID: 37212148 PMCID: PMC10523905 DOI: 10.1161/circheartfailure.122.010426] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Accepted: 04/07/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Coronary artery disease (CAD) testing remains underutilized in patients with newly diagnosed heart failure (HF). The longitudinal clinical impact of early CAD testing has not been well-characterized. We investigated changes in clinical management and long-term outcomes after early CAD evaluation in patients with incident HF. METHODS We identified Medicare patients with incident HF from 2006 to 2018. The exposure variable was early CAD testing within 1 month of initial HF diagnosis. Covariate-adjusted rates of cardiovascular interventions after testing, including CAD-related management, were modeled using mixed-effects regression with clinician as a random intercept. We assessed mortality and hospitalization outcomes using landmark analyses with inverse probability-weighted Cox proportional hazards models. Falsification end points and mediation analysis were employed for bias assessment. RESULTS Among 309 559 patients with new-onset HF without prior CAD, 15.7% underwent early CAD testing. Patients who underwent prompt CAD evaluation had higher adjusted rates of subsequent antiplatelet/statin prescriptions and revascularization, guideline-directed therapy for HF, and stroke prophylaxis for atrial fibrillation/flutter than controls. In weighted Cox models, 1-month CAD testing was associated with significantly reduced all-cause mortality (hazard ratio, 0.93 [95% CI, 0.91-0.96]). Mediation analyses indicated that ≈70% of this association was explained by CAD management, largely from new statin prescriptions. Falsification end points (outpatient diagnoses of urinary tract infection and hospitalizations for hip/vertebral fracture) were nonsignificant. CONCLUSIONS Early CAD testing after incident HF was associated with a modest mortality benefit, driven mostly by subsequent statin therapy. Further investigation on clinician barriers to testing and treating high-risk patients may improve adherence to guideline-recommended cardiovascular interventions.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, CA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
- Department of Medicine, Palo Alto VA Veteran’s Affairs Hospitals, Palo Alto, CA
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - William F Fearon
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
- Department of Medicine, Palo Alto VA Veteran’s Affairs Hospitals, Palo Alto, CA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
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13
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Kondo T, Adachi T, Kobayashi K, Okumura T, Izawa H, Murohara T, McMurray JJV, Yamada S. Physical Frailty and Use of Guideline-Recommended Drugs in Patients With Heart Failure and Reduced Ejection Fraction. J Am Heart Assoc 2023; 12:e026844. [PMID: 37301739 PMCID: PMC10356033 DOI: 10.1161/jaha.122.026844] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 10/19/2022] [Indexed: 06/12/2023]
Abstract
BACKGROUND Guideline-recommended therapies that improve prognosis remain underused in clinical practice. Physical frailty may lead to underprescription of life-saving therapy. We aimed to investigate the association between physical frailty and the use of evidence-based pharmacological therapy for heart failure with reduced ejection fraction and the impact of this on prognosis. METHODS AND RESULTS The FLAGSHIP (Multicentre Prospective Cohort Study to Develop Frailty-Based Prognostic Criteria for Heart Failure Patients) included patients hospitalized for acute heart failure, and data on physical frailty were collected prospectively. We analyzed 1041 patients with heart failure with reduced ejection fraction (aged 70 years; 73% male) and divided them by physical frailty categories using grip strength, walking speed, Self-Efficacy for Walking-7 score, and Performance Measures for Activities of Daily Living-8 score: categories I (n=371; least frail), II (n=275), III (n=224), and IV (n=171). Overall prescription rates of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, β-blockers, and mineralocorticoid receptor antagonists were 69.7%, 87.8%, and 51.9%, respectively. The proportion of patients receiving all 3 drugs decreased as physical frailty increased (in category I patients, 40.2%; IV patients, 23.4%; P for trend<0.001). In adjusted analyses, the severity of physical frailty was an independent predictor for nonuse of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (odds ratio [OR], 1.23 [95% CI, 1.05-1.43] per 1 category increase) and β-blockers (OR, 1.32 [95% CI, 1.06-1.64]), but not mineralocorticoid receptor antagonists (OR, 0.97 [95% CI, 0.84-1.12]). Patients receiving 0 to 1 drug had a higher risk of the composite outcome of all-cause death or heart failure rehospitalization than those treated with 3 drugs in physical frailty categories I and II (hazard ratio [HR], 1.80 [95% CI, 1.08-2.98]) and III and IV (HR, 1.53 [95% CI, 1.01-2.32]) in the multivariate Cox proportional hazard model. CONCLUSIONS Prescription of guideline-recommended therapy decreased as severity of physical frailty increased in heart failure with reduced ejection fraction. Underprescription of guideline-recommended therapy may contribute to the poor prognosis associated with physical frailty.
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Affiliation(s)
- Toru Kondo
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowUK
| | - Takuji Adachi
- Department of Integrated Health SciencesNagoya University Graduate School of MedicineNagoyaJapan
| | | | - Takahiro Okumura
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - Hideo Izawa
- Department of CardiologyFujita Health UniversityToyoakeJapan
| | - Toyoaki Murohara
- Department of CardiologyNagoya University Graduate School of MedicineNagoyaJapan
| | - John J. V. McMurray
- British Heart Foundation Cardiovascular Research CentreUniversity of GlasgowUK
| | - Sumio Yamada
- Department of Integrated Health SciencesNagoya University Graduate School of MedicineNagoyaJapan
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14
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Leibowitz D, Haberman D, Goland S, George J, Beeri R, Planer D, Wolf R, Kutsher B, Hasin T, Shuvy M. Outcomes following transcatheter repair in patients with functional mitral regurgitation not receiving guideline directed medical therapy in Israel. BMC Cardiovasc Disord 2023; 23:304. [PMID: 37328829 PMCID: PMC10276417 DOI: 10.1186/s12872-023-03344-2] [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: 11/17/2022] [Accepted: 06/13/2023] [Indexed: 06/18/2023] Open
Abstract
BACKGROUND Transcatheter edge to edge repair (TEER) improves prognosis in patients with functional mitral regurgitation (FMR) receiving guideline directed medical therapy (GDMT). Many patients with FMR do not receive GDMT and the utility of TEER in this population remains unclear. METHODS We retrospectively studied patients undergoing TEER. Clinical, echocardiographic and procedural variables were recorded. GDMT was defined as use of RAAS inhibitors and MRAs unless GFR was under 30 as well as beta blockers. The primary endpoint of the study was one year mortality. RESULTS 168 patients (mean age 71.3 ± 9.3; 66% males) with FMR who underwent TEER were included of whom 116 (69%) received GDMT at the time of TEER and 52 (31%) did not. There were no significant demographic or clinical differences between the groups. There were no significant differences in procedural success and complications between groups. One year mortality was identical in the two groups (15% vs. 15%; RR 1.06, CI 0.43-2.63, P = 0.90). CONCLUSIONS Our findings suggest that procedural success and one year mortality following TEER was not significantly different in HFREF patients with FMR with or without GDMT. Larger, prospective studies are necessary to define the benefit of TEER in this population.
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Affiliation(s)
- David Leibowitz
- Department of Cardiology, Faculty of Medicine Hadassah, Hebrew University Medical Center, Jerusalem, Israel.
- Coronary Care Unit, Hadassah Medical Center Mount Scopus Jerusalem, Jerusalem, Israel.
| | - Dan Haberman
- Department of Cardiology, Kaplan Medical Center, Rehovot, Israel
| | - Sorel Goland
- Department of Cardiology, Kaplan Medical Center, Rehovot, Israel
| | - Jacob George
- Department of Cardiology, Kaplan Medical Center, Rehovot, Israel
| | - Ronen Beeri
- Department of Cardiology, Faculty of Medicine Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | - David Planer
- Department of Cardiology, Faculty of Medicine Hadassah, Hebrew University Medical Center, Jerusalem, Israel
| | - Rafael Wolf
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Becky Kutsher
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Tal Hasin
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Mony Shuvy
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
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15
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Harrington J, Sun JL, Fonarow GC, Heitner SB, Divanji PH, Binder G, Allen LA, Alhanti B, Yancy CW, Albert NM, DeVore AD, Felker GM, Greene SJ. Clinical Profile, Health Care Costs, and Outcomes of Patients Hospitalized for Heart Failure With Severely Reduced Ejection Fraction. J Am Heart Assoc 2023; 12:e028820. [PMID: 37158118 DOI: 10.1161/jaha.122.028820] [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: 05/10/2023]
Abstract
Background Many patients with heart failure (HF) have severely reduced ejection fraction but do not meet threshold for consideration of advanced therapies (ie, stage D HF). The clinical profile and health care costs associated with these patients in US practice is not well described. Methods and Results We examined patients hospitalized for worsening chronic heart failure with reduced ejection fraction ≤40% from 2014 to 2019 in the GWTG-HF (Get With The Guidelines-Heart Failure) registry, who did not receive advanced HF therapies or have end-stage kidney disease. Patients with severely reduced EF defined as EF ≤30% were compared with those with EF 31% to 40% in terms of clinical profile and guideline-directed medical therapy. Among Medicare beneficiaries, postdischarge outcomes and health care expenditure were compared. Among 113 348 patients with EF ≤40%, 69% (78 589) had an EF ≤30%. Patients with severely reduced EF ≤30% tended to be younger and were more likely to be Black. Patients with EF ≤30% also tended to have fewer comorbidities and were more likely to be prescribed guideline-directed medical therapy ("triple therapy" 28.3% versus 18.2%, P<0.001). At 12-months postdischarge, patients with EF ≤30% had significantly higher risk of death (HR, 1.13 [95% CI, 1.08-1.18]) and HF hospitalization (HR, 1.14 [95% CI, 1.09-1.19]), with similar risk of all-cause hospitalizations. Health care expenditures were numerically higher for patients with EF ≤30% (median US$22 648 versus $21 392, P=0.11). Conclusions Among patients hospitalized for worsening chronic heart failure with reduced ejection fraction in US clinical practice, most patients have severely reduced EF ≤30%. Despite younger age and modestly higher use of guideline-directed medical therapy at discharge, patients with severely reduced EF face heightened postdischarge risk of death and HF hospitalization.
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Affiliation(s)
- Josephine Harrington
- Division of Cardiology Duke University School of Medicine Durham NC
- Duke Clinical Research Institute Durham NC USA
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center University of California Los Angeles Medical Center Los Angeles CA
| | | | | | | | - Larry A Allen
- Division of Cardiology & Colorado Cardiovascular Outcomes Research Consortium University of Colorado School of Medicine Aurora CO
| | | | - Clyde W Yancy
- Division of Cardiology Northwestern University Feinberg School of Medicine Chicago IL
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure Cleveland Clinic Cleveland OH
| | - Adam D DeVore
- Division of Cardiology Duke University School of Medicine Durham NC
- Duke Clinical Research Institute Durham NC USA
| | - G Michael Felker
- Division of Cardiology Duke University School of Medicine Durham NC
- Duke Clinical Research Institute Durham NC USA
| | - Stephen J Greene
- Division of Cardiology Duke University School of Medicine Durham NC
- Duke Clinical Research Institute Durham NC USA
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16
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Optimization of pharmacotherapies for ambulatory patients with heart failure and reduced ejection fraction is associated with improved outcomes. Int J Cardiol 2023; 370:300-308. [PMID: 36174819 DOI: 10.1016/j.ijcard.2022.09.058] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Revised: 09/20/2022] [Accepted: 09/21/2022] [Indexed: 01/02/2023]
Abstract
BACKGROUND In heart failure, specific target doses for each drug are recommended, but some patients receive suboptimal dosing, others are undertreated or remain chronically in a titration phase, despite having no apparent contraindication or intolerance. We assessed the association of different levels of adherence to guidelines with outcomes in patients with heart failure and reduced ejection fraction (HFrEF). METHODS Medical records of patients with HFrEF followed at our heart failure (HF) clinic for at least 6 months (n = 511) were reviewed and patients categorized as: 1) optimized (25.4%); 2) in-titration (29.0%); 3) undertreated (32.7%); and 4) intolerant/contraindicated (12.9%). Risk of mortality or HF events (hospitalization, emergency visit or ambulatory administration of intravenous diuretics) within one year was assessed using Cox regression models and Kaplan-Meier curves. RESULTS Compared to optimized patients, those intolerant (HR: 4.60 [95%CI: 2.23-9.48]; p < 0.0001) had the highest risk of outcomes, followed by those undertreated (3.45 [1.78-6.67]; p = 0.0002) and in-titration (1.99 [0.97-4.06]; p = 0.0588). Overall predictors of outcomes included loop diuretics' use (4.54 [2.39-8.60]), undertreatment (2.38 [1.22-4.67]), intolerance/ contraindication to triple therapy (3.08 [1.47-6.42]), peripheral vascular disease (2.13 [1.29-3.50]) and NYHA class III-IV (1.89 [1.25-2.85]); all p < 0.05. CONCLUSION Level of adherence to guidelines is associated with outcomes, with intolerant/contraindicated patients having the worst prognosis and those undertreated and in-titration at intermediate risk compared to those optimized. Up-titration of therapy should be attempted whenever possible, considering patients' limitations, to potentially improve outcomes.
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17
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Vinter N, Cordsen P, Fenger-Grøn M, Lip GYH, Benjamin EJ, Frost L, Johnsen SP. Quality of care and risk of incident atrial fibrillation in patients with newly diagnosed heart failure: a nationwide cohort study. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2022; 8:539-547. [PMID: 33963404 PMCID: PMC9989597 DOI: 10.1093/ehjqcco/qcab036] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/28/2021] [Accepted: 05/05/2021] [Indexed: 12/29/2022]
Abstract
AIMS Incident atrial fibrillation (AF) is an adverse prognostic indicator in heart failure (HF); identifying modifiable targets may be relevant to reduce the incidence and morbidity of AF. Therefore, we examined the association between quality of HF care and risk of AF. METHODS AND RESULTS Using the Danish Heart Failure Registry, we conducted a nationwide registry-based cohort study of all incident HF patients diagnosed between 2008 and 2018 and without history of AF. Quality of HF care was assessed by seven process performance measures, including echocardiographic examination, New York Heart Association classification, treatment with angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers, beta-blockers, and mineralocorticoid antagonists, physical training, and patient education. In the main analysis, we examined adherence with all measures in a cohort of 25 100 patients (mean age 68.5 ± 13.2 years; 33.6% women). The median follow-up was 3.1 years. Cox proportional hazard regressions estimated the hazard ratios (HRs) with 95% confidence intervals (95% CIs) between the number of fulfilled measures and incident AF. In a multivariable-adjusted analysis with 0 fulfilled performance measures as reference, the HRs (95% CIs) were 1: 0.78 (0.61-1.00), 2: 0.63 (0.49-0.80), 3: 0.53 (0.36-0.80), 4: 0.64 (0.44-0.94), 5: 0.56 (0.39-0.82), 6: 0.51 (0.35-0.74), and 7: 0.49 (0.33-0.73), with a significant decreasing linear trend (P < 0.001). CONCLUSION In patients with incident HF, fulfilment of guideline-based process performance measures was associated with decreased long-term risk of AF. This study supports initiatives to improve the quality of care for patients with HF to prevent incident AF.
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Affiliation(s)
- Nicklas Vinter
- Diagnostic Centre, University Clinic for Development of Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 3, 8600 Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark.,Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | - Pia Cordsen
- Danish Center for Clinical Health Services Research, Aalborg University, Aalborg, Denmark
| | | | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Chest & Heart Hospital, Liverpool, UK.,Aalborg Thrombosis Research Unit, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | | | - Lars Frost
- Diagnostic Centre, University Clinic for Development of Innovative Patient Pathways, Silkeborg Regional Hospital, Falkevej 3, 8600 Silkeborg, Denmark.,Department of Clinical Medicine, Aarhus University, Aarhus, Denmark
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18
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Poon S, Leis B, Lambert L, MacFarlane K, Anderson K, Blais C, Demers C, Ezekowitz JA, Hawkins NM, Lee DS, Moe G, Sandhu RK, Virani SA, Wilton S, Zieroth S, McKelvie R. The State of Heart Failure Care in Canada: Minimal Improvement in Readmissions Over Time Despite an Increased Number of Evidence-Based Therapies. CJC Open 2022; 4:667-675. [PMID: 36035740 PMCID: PMC9402962 DOI: 10.1016/j.cjco.2022.04.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 04/26/2022] [Indexed: 11/01/2022] Open
Abstract
Background Methods Results Conclusions
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19
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Ilonze O, Free K, Breathett K. Unequitable Heart Failure Therapy for Black, Hispanic and American-Indian Patients. Card Fail Rev 2022; 8:e25. [PMID: 35865458 PMCID: PMC9295006 DOI: 10.15420/cfr.2022.02] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 03/03/2022] [Indexed: 12/02/2022] Open
Abstract
Despite the high prevalence of heart failure among Black and Hispanic populations, patients of colour are frequently under-prescribed guideline-directed medical therapy (GDMT) and American-Indian populations are not well characterised. Clinical inertia, financial toxicity, underrepresentation in trials, non-trustworthy medical systems, bias and structural racism are contributing factors. There is an urgent need to develop evidence-based strategies to increase the uptake of GDMT for heart failure in patients of colour. Postulated strategies include prescribing all GDMT upon first encounter, aggressive outpatient uptitration of GDMT, intervening upon social determinants of health, addressing bias and racism through changing processes or policies that unfairly disadvantage patients of colour, engagement of stakeholders and implementation of national quality improvement programmes.
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Affiliation(s)
- Onyedika Ilonze
- Division of Cardiovascular Medicine, Krannert Cardiovascular Institute, Indiana University, Indianapolis, IN, US
| | - Kendall Free
- Department of Biofunction Research, Tokyo Medical and Dental University, Tokyo, Japan
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Krannert Cardiovascular Institute, Indiana University, Indianapolis, IN, US
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20
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Ostrominski JW, Vaduganathan M. Evolving therapeutic strategies for patients hospitalized with new or worsening heart failure across the spectrum of left ventricular ejection fraction. Clin Cardiol 2022; 45 Suppl 1:S40-S51. [PMID: 35789014 PMCID: PMC9254675 DOI: 10.1002/clc.23849] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/03/2022] [Indexed: 11/24/2022] Open
Abstract
Heart failure (HF) is a chronic, progressive, and increasingly prevalent syndrome characterized by stepwise declines in health status and residual lifespan. Despite significant advancements in both pharmacologic and nonpharmacologic management approaches for chronic HF, the burden of HF hospitalization-whether attributable to new-onset (de novo) HF or worsening of established HF-remains high and contributes to excess HF-related morbidity, mortality, and healthcare expenditures. Owing to a paucity of evidence to guide tailored interventions in this heterogeneous group, management of acute HF events remains largely subject to clinician discretion, relying principally on alleviation of clinical congestion, as-needed correction of hemodynamic perturbations, and concomitant reversal of underlying trigger(s). Following acute stabilization, the subsequent phase of care primarily involves interventions known to improve long-term outcomes and rehospitalization risk, including initiation and optimization of disease-modifying pharmacotherapy, targeted use of adjunctive therapies, and attention to contributing comorbid conditions. However, even with current standards of care many patients experience recurrent HF hospitalization, or after admission incur worsening clinical trajectories. These patterns highlight a persistent unmet need for evidence-based approaches to inform in-hospital HF care and call for renewed focus on urgent implementation of interventions capable of ameliorating risk of worsening HF. In this review, we discuss key contemporary and emerging therapeutic strategies for patients hospitalized with de novo or worsening HF.
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Affiliation(s)
- John W. Ostrominski
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical SchoolBostonMAUSA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical SchoolBostonMAUSA
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21
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Banerjee S, Halder SK, Kimani P, Tran P, Ali D, Roelas M, Weight N, Dungarwalla M, Banerjee P. Kolkata-Coventry comparative registry study of acute heart failure: an insight into the impact of public, private and universal health systems on patient outcomes in low-middle income cities (KOLCOV HF Study). Open Heart 2022; 9:openhrt-2022-001964. [PMID: 35641099 PMCID: PMC9157346 DOI: 10.1136/openhrt-2022-001964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/11/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction Survival gaps in acute heart failure (AHF) continue to expand globally. Multinational heart failure (HF) registries have highlighted variations between countries. Whether discrepancies in HF practice and outcomes occur across different health systems (ie, private, public or universal healthcare) within a city or between countries remain unclear. Insight into organisational care is also scarce. With increasing public scrutiny of health inequalities, a study to address these limitations is timely. Method KOLCOV-HF study prospectively compared patients with AHF in public (Nil Ratan Sircar Hospital (NRS)) versus private (Apollo Gleneagles Hospital (AGH)) hospitals of Kolkata, India, and one with universal health coverage in a socioeconomically comparable city of Coventry, England (University Hospitals Coventry & Warwickshire (UHCW)). Data variables were adapted from UK’s National HF Audit programme, collected over 24 months. Predictors of in-hospital mortality and length of hospitalisation were assessed for each centre. Results Among 1652 patients, in-hospital mortality was highest in government-funded NRS (11.9%) while 3 miles north, AGH had significantly lower mortality (7.5%, p=0.034), similar to UHCW (8%). This could be attributed to distinct HF phenotypes and differences in clinical and organisational care. As expected, low blood pressure was associated with a significantly greater risk of death in patients served by public hospitals UHCW and NRS. Conclusion Marked differences in HF characteristics, management and outcomes exist intra-regionally, and between low–middle versus high-income countries across private, public and universal healthcare systems. Physicians and policymakers should take caution when applying country-level data locally when developing strategies to address local evidence-practice gaps in HF.
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Affiliation(s)
- Suvro Banerjee
- Department of Cardiology, Apollo Gleneagles Hospital, Kolkata, West Bengal, India
| | - Swapan Kumar Halder
- Department of Cardiology, Nilratan Sircar Medical College and Hospital, Kolkata, West Bengal, India
| | - Peter Kimani
- Statistics and Epidemiology Unit, Warwick Medical School, University of Warwick, Coventry, UK
| | - Patrick Tran
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK.,Centre for Sport, Exercise & Life Scienes, Faculty of Health & Life Sciences, Coventry University, Coventry, UK
| | | | - Marina Roelas
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Nicholas Weight
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Moez Dungarwalla
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | - Prithwish Banerjee
- Department of Cardiology, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK .,Centre for Sport, Exercise & Life Scienes, Faculty of Health & Life Sciences, Coventry University, Coventry, UK.,Clinical Trials Unit, Warwick Medical School, University of Warwick, Coventry, UK
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22
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SeferoviĆ PM, Polovina M, Adlbrecht C, BĚlohlávek J, Chioncel O, Goncalvesová E, MilinkoviĆ I, Grupper A, Halmosi R, Kamzola G, Koskinas KC, Lopatin Y, Parkhomenko A, Põder P, RistiĆ AD, Šakalyt G, TrbušiĆ M, Tundybayeva M, Vrtovec B, Yotov YT, MiličiĆ D, Ponikowski P, Metra M, Rosano G, Coats AJ. Navigating between Scylla and Charybdis: challenges and strategies for implementing guideline-directed medical treatment in heart failure with reduced ejection fraction. Eur J Heart Fail 2021; 23:1999-2007. [PMID: 34755422 DOI: 10.1002/ejhf.2378] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 09/18/2021] [Accepted: 11/05/2021] [Indexed: 11/07/2022] Open
Abstract
Guideline-directed medical therapy (GDMT) has the potential to reduce the risks of mortality and hospitalisation in patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, real-world data indicate that many patients with HFrEF do not receive optimised GDMT, which involves several different medications, many of which require up-titration to target doses. There are many challenges to implementing GDMT, the most important being patient-related factors (comorbidities, advanced age, frailty, cognitive impairment, poor adherence, low socioeconomic status), treatment-related factors (intolerance, side-effects) and healthcare-related factors that influence availability and accessibility of HF care. Accordingly, international disparities in resources for HF management and limited public reimbursement of GDMT, coupled with clinical inertia for treatment intensification combine to hinder efforts to provide GDMT. In this review paper, authors aim to provide solutions based on available evidence, practical experience, and expert consensus on how to utilise evolving strategies, novel medications, and patient profiling to allow the more comprehensive uptake of GDMT. Authors discuss professional education, motivation, and training, as well as patient empowerment for self-care as important tools to overcome clinical inertia and boost GDMT implementation. We provide evidence on how multidisciplinary care and institutional accreditation can be successfully used to increase prescription rates and adherence to GDMT. We consider the role of modern technologies in advancing professional and patient education and facilitating patient-provider communication. Finally, authors emphasise the role of novel drugs (especially sodium-glucose cotransporter-2 inhibitors), and a tailored approach to drug management as evolving strategies for the more successful implementation of GDMT. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Petar M SeferoviĆ
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Marija Polovina
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Department of Cardiology, University Clinical Centre, Belgrade, Serbia
| | | | - Jan BĚlohlávek
- Second Department of Medicine - Department of Cardiovascular Medicine, First Faculty of Medicine, Charles University in Prague and General University Hospital in Prague, Czech Republic
| | - Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest, Romania.,Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu'Bucharest, Romania
| | - Eva Goncalvesová
- Dept Cardiology, Faculty of Medicine, Comenius University and Nat Cardiovasc Inst, Bratislava, Slovakia
| | - Ivan MilinkoviĆ
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Department of Cardiology, University Clinical Centre, Belgrade, Serbia
| | - Avishay Grupper
- Cardiology division, Sheba Medical Center and Sackler Faculty of Medicine, Tel-Aviv University, Israel
| | - Róbert Halmosi
- First Department of Medicine, University of Pecs, Medical School, Pecs, Hungary
| | - Ginta Kamzola
- Kamzola: Latvian Centre of Cardiology, Pauls Stradins Clinical University hospital, Riga, Latvia
| | | | - Yuri Lopatin
- Volgograd State Medical University, Regional Cardiology Centre Volgograd, Volgograd, Russian Federation
| | | | - Pentti Põder
- First Cardiology Department, North Estonia Medical Centre Foundation, Tallinn, Estonia
| | - Arsen D RistiĆ
- Faculty of Medicine, Belgrade University, Belgrade, Serbia.,Department of Cardiology, University Clinical Centre, Belgrade, Serbia
| | - Gintar Šakalyt
- Department of Cardiology, Medical Academy, Faculty of Medicine Lithuanian University of Health Sciences
| | - Matias TrbušiĆ
- University of Zagreb School of Medicine, Zagreb, Croatia
| | | | | | - Yoto T Yotov
- First Department of Internal Medicine, Medical University of Varna, Varna, Bulgaria.,Second Cardiology Clinic, University Hospital St. Marina, Varna, Bulgaria
| | - Davor MiličiĆ
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Piotr Ponikowski
- Centre for Heart Diseases, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
| | - Marco Metra
- Cardiology, ASST Spedali Civili; Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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23
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Jonsson Holmdahl A, Norberg H, Valham F, Bergdahl E, Lindmark K. Mineralocorticoid receptor antagonists use in patients with heart failure and impaired renal function. PLoS One 2021; 16:e0258949. [PMID: 34710128 PMCID: PMC8553049 DOI: 10.1371/journal.pone.0258949] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 10/10/2021] [Indexed: 11/24/2022] Open
Abstract
AIMS Impaired renal function is a major contributor to the low proportion of mineralocorticoid receptor antagonist (MRA) treatment in patients with heart failure with reduced ejection fraction (HFrEF). Our aims were to investigate the impact of MRA treatment on all-cause mortality and worsening renal function (WRF) in patients with HFrEF and moderately impaired renal function. METHODS Retrospective data between 2010-2018 on HFrEF patients from a single-centre hospital with estimated glomerular renal function (eGFR) < 60 ml/min/1.73 m2 were analysed. WRF was defined as a decline of by eGFR ≥ 20%. RESULTS 416 patients were included, 131 patients on MRA and 285 without MRA, mean age was 77 years (SD ± 9) and 82 years (SD ± 9), respectively. Median follow-up was 2 years. 128 patients (32%) experienced WRF, 25% in the MRA group and 30% in patients without MRA (p = 0.293). In multivariable analysis, hospitalization for heart failure and systolic blood pressure were associated with WRF (p = 0.015 and p = <0.001), but not use of MRA (p = 0.421). MRA treatment had no impact on the risk of adjusted all-cause mortality (HR 0.93; 95% CI, 0.66-1.32 p = 0.685). WRF was associated with increased adjusted risk of all-cause mortality (HR 1.43; 95% CI, 1.07-1.89 p = 0.014). Use of MRA did not increase the adjusted overall risk of mortality even when experiencing WRF (HR 1.15; 95% CI, 0.81-1.63 p = 0.422). CONCLUSION In this cohort of elderly HFrEF patients with moderately impaired renal function, MRA did not increase risk for WRF or all-cause mortality.
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Affiliation(s)
| | - Helena Norberg
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
| | - Fredrik Valham
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Ellinor Bergdahl
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Krister Lindmark
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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24
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Greene SJ, Butler J, Hellkamp AS, Spertus JA, Vaduganathan M, Devore AD, Albert NM, Patterson JH, Thomas L, Williams FB, Hernandez AF, Fonarow GC. Comparative Effectiveness of Dosing of Medical Therapy for Heart Failure: From the CHAMP-HF Registry. J Card Fail 2021; 28:370-384. [PMID: 34793971 DOI: 10.1016/j.cardfail.2021.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/30/2021] [Accepted: 08/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The comparative effectiveness of differing doses of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) on clinical and patient-reported outcomes in US clinical practice is unknown. This study sought to characterize associations between dosing of GDMT and outcomes for patients with HFrEF in U.S. clinical practice METHODS: : This analysis included 4,832 US outpatients with chronic HFrEF across 150 practices in the CHAMP-HF registry with no contraindication and available dosing data for at least 1 GDMT at baseline. Baseline dosing of angiotensin-converting enzyme (ACEI)/ angiotensin II receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) therapies were examined. For each medication class, multivariable models assessed associations between medication dosing and clinical outcomes over 24 months (all-cause mortality, HF hospitalization) and patient-reported outcomes at 12 months (change in Kansas City Cardiomyopathy Questionnaire Overall Summary Score [KCCQ-OS]). RESULTS After adjustment, compared with target dosing, lower dosing was associated with higher all-cause mortality for ACEI/ARB/ARNI (50% to <100% target dose, HR 1.16 [95% CI 0.87-1.55]; <50% target dose, HR 1.37 [95% CI 1.05-1.79]; none, HR 1.75 [95% CI 1.32-2.34; overall p<0.001) and beta-blocker (50% to <100% target dose, HR 1.30 [95% CI 1.00-1.69]; <50% target dose, HR 1.41 [95% CI 1.11-1.79; none, HR 1.24 [95% CI 0.92-1.67]; overall p=0.042). Lower dosing of ACEI/ARB/ARNI was independently associated with higher risk of HF hospitalization (50% to <100% target dose, HR 1.08 [95% CI 0.90-1.30]; <50% target dose, HR 1.23 [1.04-1.47]; none, HR 1.29 [1.04-1.60]; overall p=0.046), but beta-blocker dosing was not (overall p=0.085). Target dosing of MRA was not associated with risk of mortality or HF hospitalization. For each GDMT, compared with target dosing, lower dosing was not associated with change in KCCQ-OS at 12 months, with potential exception of worsening KCCQ-OS with lower dosing of ACEI/ARB/ARNI. CONCLUSIONS In this contemporary US outpatient HFrEF registry, target dosing of ACEI/ARB/ARNI and beta-blocker therapy was associated with reduced mortality, and variably associated with HF hospitalization and patient-reported outcomes. MRA dosing was not associated with outcomes. The totality of these findings support the benefits of target dosing of GDMT in routine practice, as tolerated, with unmeasured differences between patients receiving differing dosages potentially explaining differing results seen here compared with randomized clinical trials.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Adam D Devore
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Nancy M Albert
- Nursing Institute and Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, California.
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25
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Rosano GMC, Moura B, Metra M, Böhm M, Bauersachs J, Ben Gal T, Adamopoulos S, Abdelhamid M, Bistola V, Čelutkienė J, Chioncel O, Farmakis D, Ferrari R, Filippatos G, Hill L, Jankowska EA, Jaarsma T, Jhund P, Lainscak M, Lopatin Y, Lund LH, Milicic D, Mullens W, Pinto F, Ponikowski P, Savarese G, Thum T, Volterrani M, Anker SD, Seferovic PM, Coats AJS. Patient profiling in heart failure for tailoring medical therapy. A consensus document of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2021; 23:872-881. [PMID: 33932268 DOI: 10.1002/ejhf.2206] [Citation(s) in RCA: 150] [Impact Index Per Article: 50.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/17/2021] [Accepted: 04/29/2021] [Indexed: 12/22/2022] Open
Abstract
Despite guideline recommendations and available evidence, implementation of treatment in heart failure (HF) is poor. The majority of patients are not prescribed drugs at target doses that have been proven to positively impact morbidity and mortality. Among others, tolerability issues related to low blood pressure, heart rate, impaired renal function or hyperkalaemia are responsible. Chronic kidney disease plays an important role as it affects up to 50% of patients with HF. Also, dynamic changes in estimated glomerular filtration rate may occur during the course of HF, resulting in inappropriate dose reduction or even discontinuation of decongestive or neurohormonal modulating therapy in clinical practice. As patients with HF are rarely naïve to pharmacologic therapies, the challenge is to adequately prioritize or select the most appropriate up-titration schedule according to patient profile. In this consensus document, we identified nine patient profiles that may be relevant for treatment implementation in HF patients with a reduced ejection fraction. These profiles take into account heart rate (<60 bpm or >70 bpm), the presence of atrial fibrillation, symptomatic low blood pressure, estimated glomerular filtration rate (<30 or >30 mL/min/1.73 m2 ) or hyperkalaemia. The pre-discharge patient, frequently still congestive, is also addressed. A personalized approach, adjusting guideline-directed medical therapy to patient profile, may allow to achieve a better and more comprehensive therapy for each individual patient than the more traditional, forced titration of each drug class before initiating treatment with the next.
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Affiliation(s)
| | - Brenda Moura
- Armed Forces Hospital, Porto, Portugal.,Faculty of Medicine, University of Porto, Porto, Portugal
| | - Marco Metra
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Centre, Petah Tikva, Israel
| | | | - Magdy Abdelhamid
- Faculty of Medicine, Department of Cardiology, Cairo University, Giza, Egypt
| | - Vasiliki Bistola
- Department of Cardiology, Attikon University Hospital, University of Athens Medical School, Athens, Greece
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, State Research Institute Centre for Innovative Medicine, Vilnius, Lithuania
| | - Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest, Romania.,Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
| | | | - Roberto Ferrari
- Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy.,Centro Cardiologico Universitario di Ferrara, University of Ferrara, Ferrara, Italy
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, University Hospital Attikon, Athens, Greece
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University Belfast, Northern Ireland, UK
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University and Center for Heart Diseases, University Hospital in Wroclaw, Wroclaw, Poland
| | - Tiny Jaarsma
- Department of Health, Medicine and Caring Sciences, Linkoping University, Linköping, Sweden.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Pardeep Jhund
- Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia.,Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yuri Lopatin
- Volgograd State Medical University, Regional Cardiology Centre Volgograd, Volgograd, Russian Federation
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Davor Milicic
- University of Zagreb School of Medicine, Zagreb, Croatia
| | - Wilfried Mullens
- Faculty of Medicine and Life Sciences, BIOMED - Biomedical Research Institute, Hasselt University, Diepenbeek, Belgium.,Department of Cardiology, Ziekenhuis Oost, Genk, Belgium
| | - Fausto Pinto
- Cardiology Department, University Hospital Santa Maria (CHULN), CAML, CCUL, Faculty of Medicine, University of Lisbon, Lisbon, Portugal
| | - Piotr Ponikowski
- Centre for Heart Diseases, Faculty of Health Sciences, Wroclaw Medical University, Wroclaw, Poland
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Thomas Thum
- Hannover Medical School, Institute of Molecular and Translational Therapeutic Strategies, Hannover, Germany
| | | | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Petar M Seferovic
- Department Faculty of Medicine, University of Belgrade, Belgrade, Serbia.,Serbian Academy of Sciences and Arts, Belgrade, Serbia
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26
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Fuery MA, Chouairi F, Januzzi JL, Moe GW, Caraballo C, McCullough M, Miller PE, Reinhardt SW, Clark K, Oseran A, Milner A, Pacor J, Kahn PA, Singh A, Ravindra N, Guha A, Vadlamani L, Kulkarni NS, Fiuzat M, Felker GM, O'Connor CM, Ahmad T, Ezekowitz J, Desai NR. Intercountry Differences in Guideline-Directed Medical Therapy and Outcomes Among Patients With Heart Failure. JACC-HEART FAILURE 2021; 9:497-505. [PMID: 33992564 DOI: 10.1016/j.jchf.2021.02.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 02/04/2021] [Accepted: 02/08/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVES The aim of this study was to examine patterns of care and clinical outcomes among patients with heart failure with reduced ejection fraction (HFrEF) in the United States and Canada. BACKGROUND In the GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment) trial, the use of N-terminal pro-B-type natriuretic peptide-guided titration of guideline-directed medical therapy (GDMT) was compared with usual care alone for patients with HFrEF in the United States and Canada. It remains unknown whether the country of enrollment had an impact on outcomes or GDMT use. METHODS A total of 894 patients at 45 sites across the United States and Canada with HFrEF (ejection fraction ≤40%) were enrolled in the trial. Kaplan-Meier survival estimates stratified by country of enrollment were developed for the trial outcomes, and log-rank testing was compared between the groups. GDMT use and titration were also compared. RESULTS U.S. patients were more likely to be younger, to be Black, to have higher body mass index, and to have histories of defibrillator placement or sleep apnea. Use of β-blockers was significantly higher in Canada at baseline (99.3% vs. 94.0%; p = 0.01) and 6 months (99.0% vs. 94.1%; p = 0.04), and use of mineralocorticoid receptor antagonists was higher in Canada at 6 months (68.3% vs. 55.1%; p = 0.01). Canadian patients were less likely to experience the primary study endpoint (hazard ratio [HR]: 0.65; 95% confidence interval [CI]: 0.45 to 0.93; p = 0.01) due to decreased rates of HF hospitalization (HR: 0.57; 95% CI: 0.38 to 0.86; p = 0.003). The differences in outcomes were driven by increased heart failure hospitalization among U.S. Black patients. CONCLUSIONS In GUIDE-IT, patients with HFrEF in Canada were significantly less likely to be hospitalized for heart failure. Differences in GDMT use, along with differences in sociodemographics and care delivery structures, may contribute to these differences, highlighting the importance of increasing diversity in clinical trials. (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment [GUIDE-IT]; NCT01685840).
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Affiliation(s)
- Michael A Fuery
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Fouad Chouairi
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James L Januzzi
- Division of Cardiology, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Gordon W Moe
- St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Cesar Caraballo
- Center for Outcomes Research & Evaluation, Yale University and Yale University School of Medicine, New Haven, Connecticut, USA
| | - Megan McCullough
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Samuel W Reinhardt
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Katherine Clark
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Andrew Oseran
- Division of Cardiology, Department of Medicine, Harvard Medical School, Boston, Massachusetts, USA
| | - Aidan Milner
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Justin Pacor
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Peter A Kahn
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Avinainder Singh
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Neal Ravindra
- Cardiovascular Research Center, Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Avirup Guha
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, Ohio, USA
| | - Lina Vadlamani
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Mona Fiuzat
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - G Michael Felker
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | | | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research & Evaluation, Yale University and Yale University School of Medicine, New Haven, Connecticut, USA
| | - Justin Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research & Evaluation, Yale University and Yale University School of Medicine, New Haven, Connecticut, USA.
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Patel RB, Fonarow GC, Greene SJ, Zhang S, Alhanti B, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Vaduganathan M. Kidney Function and Outcomes in Patients Hospitalized With Heart Failure. J Am Coll Cardiol 2021; 78:330-343. [PMID: 33989713 DOI: 10.1016/j.jacc.2021.05.002] [Citation(s) in RCA: 102] [Impact Index Per Article: 34.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Revised: 04/28/2021] [Accepted: 05/03/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Few contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function. OBJECTIVES This study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction. METHODS Guideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines-Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality. RESULTS Among 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR <60 ml/min/1.73 m2, and 18,869 (5%) were on dialysis. eGFR distribution remained stable from 2014 to 2019. Among 157,439 patients with HF with reduced EF (≤40%), discharge guideline-directed medical therapies, including beta-blockers, were lowest in discharge eGFR <30 mL/min/1.73 m2 or dialysis (p < 0.001). "Triple therapy" with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor + beta-blocker + mineralocorticoid receptor antagonist was used in 38%, 33%, 25%, 15%, 5%, and 3% for eGFR ≥90, 60 to 89, 45 to 59, 30 to 44, <30 ml/min/1.73 m2, and dialysis, respectively; p < 0.001. Mortality was higher in a graded fashion at lower admission eGFR groups (1.1%, 1.5%, 2.0%, 3.0%, 5.0%, and 4.2%, respectively; p < 0.001). Steep covariate-adjusted associations between admission eGFR and mortality were observed across EF subgroups, but was slightly stronger for HF with reduced EF compared with HF with mid-range or preserved EF (pinteraction = 0.045). CONCLUSIONS Despite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.
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Affiliation(s)
- Ravi B Patel
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA. https://twitter.com/RBPatelMD
| | - Gregg C Fonarow
- Ahmanson-University of California, Los Angeles Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA.
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/SJGreene_md
| | - Shuaiqi Zhang
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA. https://twitter.com/_adevore
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA. https://twitter.com/JavedButler1
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | | | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai, Los Angeles, California, USA. https://twitter.com/MKIttlesonMD
| | - Karen E Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, Missouri, USA. https://twitter.com/kejoynt
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA. https://twitter.com/tikuowens
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA; Department of Medicine, Anschutz Medical Center, Aurora, Colorado, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/scottdsolomon
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System, University of Minnesota, Minnesota, USA. https://twitter.com/orlyvardeny
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA. https://twitter.com/mvaduganathan
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28
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Benedetto M, Nardozi L, Baca GL, Loforte A, Baiocchi M. Heart failure: role and point of view of cardiac intensivist. Cardiovasc Diagn Ther 2021; 11:301-308. [PMID: 33708501 DOI: 10.21037/cdt-20-339] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Heart failure is an acute or chronic syndrome where the heart is unable to provide adequate amount of oxygen to body tissues. The treatment of heart failure aims to give an immediate answer in terms of regression of volume overload and restoration of hemodynamic stability and then to ensure management of clinical exacerbation, reduction in hospital stay, and increasing of survival. The pharmacological treatment of heart failure includes drugs with different strength of evidence. When the patient is no more responsive to medical therapy a non-pharmacological approach may be required. The first step is cardiac resynchronization therapy and implantable cardiac defibrillator. Then hospitalization and inotropic support may be needed. When cardiac disease reaches the end stage, the severe decrease in multi organ perfusion requires a quick therapeutic response. This is a time dependent scenario, when mechanical circulatory support (MCS) plays a crucial role. MCS may be used as temporary hemodynamic support on situations where myocardial recovery is likely, such as after revascularization and in cases of fulminant acute myocarditis. Conversion to ventricular assist devices or transplantation should be considered if longer duration of MCS is required. Advances in the treatment of cardiogenic shock patients in terms of pharmacological therapies, short term and long term MCS could provide opportunities to improve survival, but they also increase the complexity of clinical care. For this reason a multidisciplinary shock team approach is paramount for early symptom detection, to guide initial haemodynamic therapy and for the right choice of MCS device at the right time.
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Affiliation(s)
- Maria Benedetto
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, Sant' Orsola Malpighi University Hospital, Bologna, Italy
| | - Ludovica Nardozi
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, Sant' Orsola Malpighi University Hospital, Bologna, Italy
| | | | - Antonio Loforte
- Cardiothoracic Department, Sant' Orsola Malpighi University Hospital, Bologna, Italy
| | - Massimo Baiocchi
- Cardiothoracic and Vascular Anesthesia and Intensive Care Unit, Sant' Orsola Malpighi University Hospital, Bologna, Italy
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29
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Nasir K, Javed Z, Khan SU, Jones SL, Andrieni J. Big Data and Digital Solutions: Laying the Foundation for Cardiovascular Population Management CME. Methodist Debakey Cardiovasc J 2021; 16:272-282. [PMID: 33500755 DOI: 10.14797/mdcj-16-4-272] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
There are huge gaps in evidence-based cardiovascular care at the national, organizational, practice, and provider level that can be attributed to variation in provider attitudes, lack of incentives for positive change and care standardization, and observed uncertainty in clinical decision making. Big data analytics and digital application platforms-such as patient care dashboards, clinical decision support systems, mobile patient engagement applications, and key performance indicators-offer unique opportunities for value-based healthcare delivery and efficient cardiovascular population management. Successful implementation of big data solutions must include a multidisciplinary approach, including investment in big data platforms, harnessing technology to create novel digital applications, developing digital solutions that can inform the actions of clinical and policy decision makers and relevant stakeholders, and optimizing engagement strategies with the public and information-empowered patients.
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Affiliation(s)
- Khurram Nasir
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON, TEXAS.,HOUSTON METHODIST RESEARCH INSTITUTE, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - Zulqarnain Javed
- HOUSTON METHODIST DEBAKEY HEART & VASCULAR CENTER, HOUSTON, TEXAS.,HOUSTON METHODIST RESEARCH INSTITUTE, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
| | - Safi U Khan
- WEST VIRGINIA UNIVERSITY, MORGANTOWN, WEST VIRGINIA
| | - Stephen L Jones
- HOUSTON METHODIST RESEARCH INSTITUTE, HOUSTON METHODIST HOSPITAL, HOUSTON, TEXAS
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Hashmi KA, Adnan F, Ahmed O, Yaqeen SR, Ali J, Irfan M, Edhi MM, Hashmi AA. Risk Assessment of Patients After ST-Segment Elevation Myocardial Infarction by Killip Classification: An Institutional Experience. Cureus 2020; 12:e12209. [PMID: 33489617 PMCID: PMC7815264 DOI: 10.7759/cureus.12209] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/21/2020] [Indexed: 11/05/2022] Open
Abstract
Introduction The Killip classification system was introduced for clinical assessment of patients with acute myocardial infarction (MI). It stratifies individuals according to the severity of their post-MI heart failure. This system provides effective stratification of long-term and short-term outcomes in patients with acute MI and influences the treatment strategies. Revalidation of Killip class in our local population is mandatory. We planned this study to increase cardiologist's readiness to tackle the risks associated with increased mortality in each class post ST-segment elevation MI (STEMI). Objectives were to determine the frequency of Killip classes I, II, III, and IV and in-hospital mortality in each Killip class in patients with left ventricular failure secondary to STEMI. Methods A retrospective cross-sectional study was conducted in the Department of Cardiology, Jinnah Hospital, Lahore, over a period of three years. Patients with STEMI were stratified using Killip classification, and validation was performed by determining the within 15 days in-hospital mortality in each Killip class. Results The frequency (percentage) of patients with STEMI in each Killip class from I to IV was 395 (81.4%), 46 (9.5%), 27 (5.6%), and 17 (3.5%), respectively, while the in-hospital mortality in each Killip class came out to be 39 (9.9%), 4 (8.7%), 25 (92.6%) and 17 (100%), respectively. The presence of diabetes, history of smoking, and body mass index (BMI) of more than 30 kg/m2 were significant contributors to mortality, along with higher Killip class and age of presentation. Conclusions It is concluded that the Killip classification system is a valid tool for risk stratification for patients after STEMI, especially in resource-limited countries.
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Affiliation(s)
- Kashif A Hashmi
- Cardiology, Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, PAK
| | - Fahar Adnan
- Cardiology, Chaudhry Pervaiz Elahi Institute of Cardiology, Multan, PAK
- Cardiology, Jinnah Hospital, Lahore, PAK
| | - Omer Ahmed
- Internal Medicine, Liaquat National Hospital and Medical College, Karachi, PAK
| | | | - Javaria Ali
- Pathology, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Muhammad Irfan
- Statistics, Liaquat National Hospital and Medical College, Karachi, PAK
| | - Muhammad M Edhi
- Neuroscience/Neurosurgery, Rhode Island Hospital, Warren Alpert Medical School of Brown University, Providence, USA
| | - Atif A Hashmi
- Pathology, Liaquat National Hospital and Medical College, Karachi, PAK
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Hanbali DA, Hashmi KA, Za'abi MA, Al-Zakwani I. Evaluation of guideline-based cardiovascular medications and their respective doses in heart failure patients in Oman. Int J Clin Pharm 2020; 43:878-883. [PMID: 33140296 DOI: 10.1007/s11096-020-01190-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2020] [Accepted: 10/28/2020] [Indexed: 11/26/2022]
Abstract
Background Significant gaps exist between guidelines and practice in the management of heart failure, not only in Oman but the Arabian Gulf region in general. Currently, only limited research exists on the use of these guideline-based cardiovascular medications and their corresponding target doses in the region. Objective To evaluate the use of guideline-based cardiovascular medications and their corresponding target doses in heart failure patients with reduced (< 40%) and mid-range (40-49%) ejection fraction in Oman. Setting Cardiology clinics at Sultan Qaboos University Hospital, Muscat, Oman. Methods The study included heart failure patients seen at the clinics between January 2016 and December 2019. The use of angiotensin-converting-enzyme inhibitors (captopril, lisinopril) or angiotensin II receptor blockers (irbesartan, valsartan), β-blockers (bisoprolol, carvedilol) and spironolactone along with their respective target doses were evaluated as per the European, American, and Canadian heart failure guidelines. Analyses were performed using univariate statistics. Main outcome measure The proportion of patients that was prescribed guideline-based heart failure medications along with their target doses as per guidelines. Results The overall mean age of the cohort (N = 249) was 63 ± 15 years and 61% (n = 151) were males. Seventy-one percent (n = 177) of the patients had heart failure with reduced ejection fraction while 29% (n = 72) had heart failure with mid-range ejection fraction. A total of 87% (n = 216), 62% (n = 154) and 39% (n = 96) of the patients were on β-blockers, angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers and spironolactone, respectively. Only 33% (n = 81) of the patients were on the triple guideline-based cardiovascular medication classes concurrently. Patients with reduced ejection fraction were more likely to be prescribed the triple guideline-based cardiovascular medication classes concurrently than those that had heart failure with mid-range ejection fraction (37% vs 22%; p = 0.027). A total of 100% (96/96), 56% (121/216) and 42% (64/153) of the patients were prescribed ≥ 50% of target dose for spironolactone, β-blockers and angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers, respectively. Conclusions The use of guideline-based cardiovascular medications in heart failure patients with reduced and mid-range ejection fraction is low in Oman. They were also largely not optimally dosed at target levels.
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Affiliation(s)
- Diana Arandi Hanbali
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Sultan Qaboos University, PO Box 38, Al-Khodh, PC-123, Muscat, Sultanate of Oman
| | - Khamis Al Hashmi
- Department of Physiology, College of Medicine and Health Sciences, Sultan Qaboos University, Muscat, Sultanate of Oman
| | - Mohammed Al Za'abi
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Sultan Qaboos University, PO Box 38, Al-Khodh, PC-123, Muscat, Sultanate of Oman
| | - Ibrahim Al-Zakwani
- Department of Pharmacology and Clinical Pharmacy, College of Medicine and Health Sciences, Sultan Qaboos University, PO Box 38, Al-Khodh, PC-123, Muscat, Sultanate of Oman.
- Gulf Health Research, Muscat, Sultanate of Oman.
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Greene SJ, Triana TS, Ionescu-Ittu R, Burne RM, Guérin A, Borentain M, Kessler PD, Tugcu A, DeSouza MM, Felker GM, Chen L. In-Hospital Therapy for Heart Failure With Reduced Ejection Fraction in the United States. JACC-HEART FAILURE 2020; 8:943-953. [PMID: 32800512 DOI: 10.1016/j.jchf.2020.05.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Revised: 05/11/2020] [Accepted: 05/12/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES This study sought to characterize in-hospital treatment patterns and associated patient outcomes among patients hospitalized for heart failure (HF) in U.S. clinical practice. BACKGROUND Hospitalizations for HF are common and associated with poor patient outcomes. Real-world patterns of in-hospital treatment, including diuretic therapy, in contemporary U.S. practice are unknown. METHODS Using Optum de-identified Electronic Health Record data from 2007 through 2018, patients hospitalized for a primary diagnosis of HF (ejection fraction ≤40%) and who were hemodynamically stable at admission, without concurrent acute coronary syndrome or end-stage renal disease, and treated with intravenous (IV) diuretic agents within 48 h of admission were identified. Patients were categorized into 1 of 4 mutually exclusive hierarchical treatment groups defined by complexity of treatment during hospitalization (intensified treatment with mechanical support or IV vasoactive therapy, IV diuretic therapy reinitiated after discontinuation for ≥1 day without intensified treatment, IV diuretic dose increase/combination diuretic treatment without intensified treatment or IV diuretic reinitiation, or uncomplicated). RESULTS Of 22,677 patients hospitalized for HF with reduced ejection fraction (HFrEF), 66% had uncomplicated hospitalizations without escalation of treatment beyond initial IV diuretic therapy. Among 7,809 remaining patients, the highest level of therapy received was IV diuretic dose increase/combination diuretic treatment in 25%, IV diuretic reinitiation in 36%, and intensified therapy in 39%. Overall, 19% of all patients had reinitiation of IV diuretic agents (26% of such patients had multiple instances), 12% were simultaneously treated with multiple diuretics, and 61% were transitioned to oral diuretic agents before discharge. Compared with uncomplicated treatment, IV diuretic reinitiation and intensified treatment were associated with significantly longer median length of stay (uncomplicated: 4 days; IV diuretic reinitiation: 8 days; intensified: 10 days) and higher rates of in-hospital (uncomplicated: 1.6%; IV diuretic reinitiation: 4.2%; intensified: 13.2%) and 30-day post-discharge mortality (uncomplicated: 5.2%; IV diuretic reinitiation: 9.7%; intensified: 12.7%). CONCLUSIONS In this contemporary real-world population of U.S. patients hospitalized for HFrEF, one-third of patients had in-hospital treatment escalated beyond initial IV diuretic therapy. These more complex treatment patterns were associated with highly variable patterns of diuretic use, longer hospital lengths of stay, and higher mortality. Standardized and evidence-based approaches are needed to improve the efficiency and effectiveness of in-hospital HFrEF care.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
| | - Taylor S Triana
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | | | | | | | | | - G Michael Felker
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
| | - Lei Chen
- Bristol-Myers Squibb, Princeton, New Jersey
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Jarjour M, Henri C, de Denus S, Fortier A, Bouabdallaoui N, Nigam A, O'Meara E, Ahnadi C, White M, Garceau P, Racine N, Parent MC, Liszkowski M, Giraldeau G, Rouleau JL, Ducharme A. Care Gaps in Adherence to Heart Failure Guidelines: Clinical Inertia or Physiological Limitations? JACC-HEART FAILURE 2020; 8:725-738. [PMID: 32800509 DOI: 10.1016/j.jchf.2020.04.019] [Citation(s) in RCA: 56] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 04/13/2020] [Accepted: 04/30/2020] [Indexed: 12/31/2022]
Abstract
OBJECTIVES This study evaluated the impact of clinical and physiological factors limiting treatment optimization toward recommended medical therapy in heart failure (HF). BACKGROUND Although guidelines aim to assist physicians in prescribing evidence-based therapies and to improve outcomes of patients with HF and reduced ejection fraction (HFrEF), gaps in clinical care persist. METHODS Medical records of all patients with HFrEF followed for at least 6 months at the authors' HF clinic (n = 511) allowed for drug optimization and were reviewed regarding the prescription rates of recommended pharmacological agents and devices (implantable cardioverter-defibrillator [ICD] or cardiac resynchronization therapy [CRT]). Then, an algorithm integrating clinical (New York Heart Association [NYHA] functional class, heart rate, blood pressure and biologic parameters (creatinine, serum potassium) based on the inclusion/exclusion criteria of landmark trials guiding these recommendations) was applied for each agent and device to identify potential explanations for treatment gaps. RESULTS Gross prescription rates were high for beta-blockers (98.6%), mineralocorticoid receptor antagonist (MRA) (93.4%), vasodilators (90.3%), ICDs (75.1%), and CRT (82.1%) among those eligible, except for ivabradine (46.3%, n = 41). However, achievement of target physiological doses was lower (beta-blockers, 67.5%; MRA, 58.9%; and vasodilators, 63.4%), and one-fifth of patient dosages were still being up-titrated. Suboptimal doses were associated with older age (odds ratio [OR]: 1.221; p < 0.0001) and history of stroke or transient ischemic attack (TIA) (no vs. yes, OR: 0.264; p = 0.0336). CONCLUSIONS Gaps in adherence to guidelines exist in specialized HF setting and are mostly explained by limiting physiological factors rather than inertia. Older age and history of stroke/TIA, potential markers of frailty, are associated with suboptimal doses of guideline-directed medical therapy, suggesting that an individualized rather than a "one-size-fits-all" approach may be required.
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Affiliation(s)
- Marilyne Jarjour
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Christine Henri
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Simon de Denus
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Annik Fortier
- Biostatistics, Montreal Health Innovation Coordinating Center, Montreal, Quebec, Canada
| | | | - Anil Nigam
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Eileen O'Meara
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Charaf Ahnadi
- Collaborative Research for Effective Diagnostics, University Hospital Center of Sherbrooke, Sherbrooke, Quebec, Canada
| | - Michel White
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Patrick Garceau
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | - Normand Racine
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | | | - Mark Liszkowski
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada
| | | | | | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute, Montreal, Quebec, Canada.
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Evaluation, Management, and Outcomes of Patients Poorly Responsive to Cardiac Resynchronization Device Therapy. J Am Coll Cardiol 2019; 74:2588-2603. [DOI: 10.1016/j.jacc.2019.09.043] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 08/15/2019] [Accepted: 09/09/2019] [Indexed: 11/20/2022]
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35
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Greene SJ, Fonarow GC, DeVore AD, Sharma PP, Vaduganathan M, Albert NM, Duffy CI, Hill CL, McCague K, Patterson JH, Spertus JA, Thomas L, Williams FB, Hernandez AF, Butler J. Titration of Medical Therapy for Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2019; 73:2365-2383. [PMID: 30844480 PMCID: PMC7197490 DOI: 10.1016/j.jacc.2019.02.015] [Citation(s) in RCA: 341] [Impact Index Per Article: 68.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF) have medical therapy titrated to target doses derived from clinical trials, as tolerated. The degree to which titration occurs in contemporary U.S. practice is unknown. OBJECTIVES This study sought to characterize longitudinal titration of HFrEF medical therapy in clinical practice and to identify associated factors and reasons for medication changes. METHODS Among 2,588 U.S. outpatients with chronic HFrEF in the CHAMP-HF (Change the Management of Patients with Heart Failure) registry with complete medication data and no contraindications to medical therapy, use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) were examined at baseline and at 12-month follow-up. RESULTS At baseline, 658 (25%), 525 (20%), 287 (11%), and 45 (2%) patients were receiving target doses of MRA, beta-blocker, ACEI/ARB, and ARNI therapy, respectively. At 12 months, proportions of patients with medication initiation or dose increase were 6% for MRA, 10% for beta-blocker, 7% for ACEI/ARB, and 10% for ARNI; corresponding proportions with discontinuation or dose decrease were 4%, 7%, 11%, and 3%, respectively. Over 12 months, <1% of patients were simultaneously treated with target doses of ACEI/ARB/ARNI, beta-blocker, and MRA. In multivariate analysis, across the classes of medications, multiple patient characteristics were associated with a higher likelihood of initiation or dose increase (e.g., previous HF hospitalization, higher blood pressure, lower ejection fraction) and discontinuation or dose decrease (e.g., previous HF hospitalization, impaired quality of life, more severe functional class). Medical reasons were the most common reasons for discontinuations and dose decreases of each therapy, but the relative contributions from patient preference, health team, and systems-based reasons varied by medication. CONCLUSIONS In this contemporary U.S. registry, most eligible HFrEF patients did not receive target doses of medical therapy at any point during follow-up, and few patients had doses increased over time. Although most patients had no alterations in medical therapy, multiple clinical factors were independently associated with medication changes. Further quality improvement efforts are urgently needed to improve guideline-directed medication titration for HFrEF.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina. https://twitter.com/SJGreene_md
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, California. https://twitter.com/gcfmd
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Puza P Sharma
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - C Larry Hill
- Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin McCague
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
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Chioncel O, Collins SP, Ambrosy AP, Pang PS, Antohi EL, Iliescu VA, Maggioni AP, Butler J, Mebazaa A. Improving Postdischarge Outcomes in Acute Heart Failure. Am J Ther 2019; 25:e475-e486. [PMID: 29985826 PMCID: PMC6114135 DOI: 10.1097/mjt.0000000000000791] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- Ovidiu Chioncel
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville,
TN, USA
| | - Andrew P Ambrosy
- Division of Cardiology, Duke University Medical Center, Durham, NC,
USA Duke Clinical Research Institute, Durham, NC, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of
Medicine, Indiana USA
| | - Elena-Laura Antohi
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Vlad Anton Iliescu
- University of Medicine Carol Davila, Bucharest; Emergency Institute
for Cardiovascular Diseases-“Prof. C.C. Iliescu”, Bucharest,
Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Florence, Italy; EORP-European Society of
Cardiology, Sophia Antipolis, France
| | - Javed Butler
- Department of Medicine, University of Mississippi School of
Medicine, Jackson, MI, USA
| | - Alexandre Mebazaa
- Department of Anesthesiology and Critical Care, APHP – Saint
Louis Lariboisière University Hospitals, University Paris Diderot and INSERM
UMR-S 942, Paris, France
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The Urgency of Doing. JACC-HEART FAILURE 2019; 7:22-24. [DOI: 10.1016/j.jchf.2018.11.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/08/2018] [Accepted: 11/09/2018] [Indexed: 01/07/2023]
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Diagnostic and prognostic value of plasma volume status at emergency department admission in dyspneic patients: results from the PARADISE cohort. Clin Res Cardiol 2018; 108:563-573. [DOI: 10.1007/s00392-018-1388-y] [Citation(s) in RCA: 26] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Accepted: 10/18/2018] [Indexed: 12/20/2022]
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39
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Jefferies JL, Ibrahim NE. Are Guidelines Merely Suggestions? J Am Coll Cardiol 2018; 72:367-369. [DOI: 10.1016/j.jacc.2018.05.023] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2018] [Accepted: 05/03/2018] [Indexed: 01/30/2023]
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40
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Medical Therapy for Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2018; 72:351-366. [DOI: 10.1016/j.jacc.2018.04.070] [Citation(s) in RCA: 494] [Impact Index Per Article: 82.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Revised: 04/21/2018] [Accepted: 04/23/2018] [Indexed: 12/11/2022]
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Parajuli N, Takahara S, Matsumura N, Kim TT, Ferdaoussi M, Migglautsch AK, Zechner R, Breinbauer R, Kershaw EE, Dyck JRB. Atglistatin ameliorates functional decline in heart failure via adipocyte-specific inhibition of adipose triglyceride lipase. Am J Physiol Heart Circ Physiol 2018; 315:H879-H884. [PMID: 29932770 DOI: 10.1152/ajpheart.00308.2018] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Despite advancements in therapies for cardiovascular disease and heart failure (HF), the incidence and prevalence of HF are increasing. Previous work has suggested that inhibiting adipose triglyceride lipase (ATGL) in adipose tissue during HF development may assist in the treatment of HF. The ability to specifically target the adipocyte as a potential treatment for HF is a novel approach that could significantly influence the management of HF in the future. Our objectives were to assess the cardiac structural and functional effects of pharmacological inhibition of ATGL in mice with HF, to assess whether ATGL inhibition works in an adipocyte-autonomous manner, and to determine the role that adiposity and glucose homeostasis play in this HF treatment approach. Using a known ATGL inhibitor, atglistatin, as well as mice with germline deletion of adipocyte-specific ATGL, we tested the effectiveness of ATGL inhibition in mice with pressure overload-induced HF. Here, we show that atglistatin can prevent the functional decline in HF and provide evidence that specifically targeting ATGL in the adipocyte is sufficient to prevent worsening of HF. We further demonstrate that the benefit resulting from atglistatin in HF is not dependent on previously suggested improvements in glucose homeostasis, nor are the benefits derived from increased adiposity. Overall, the results of this study suggest that adipocyte-specific pharmacological inhibition of ATGL may represent a novel therapeutic option for HF. NEW & NOTEWORTHY This work shows for the first time that the adipose triglyceride lipase (ATGL)-specific inhibitor atglistatin can prevent worsening heart failure. Furthermore, using mice with adipocyte-specific ATGL ablation, this study demonstrates that ATGL inhibition works in an adipocyte-autonomous manner to ameliorate a functional decline in heart failure. Overall, this work demonstrates that specifically targeting the adipocyte to inhibit ATGL is a potential treatment for heart failure.
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Affiliation(s)
- Nirmal Parajuli
- Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, and Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, Alberta , Canada.,Division of Basic Biomedical Science, University of South Dakota, Vermillion, South Dakota
| | - Shingo Takahara
- Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, and Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, Alberta , Canada.,Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi , Japan
| | - Nobutoshi Matsumura
- Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, and Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, Alberta , Canada.,Division of Cardiovascular Surgery, Tohoku University Graduate School of Medicine, Sendai, Miyagi , Japan
| | - Ty T Kim
- Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, and Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, Alberta , Canada
| | - Mourad Ferdaoussi
- Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, and Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, Alberta , Canada
| | - Anna K Migglautsch
- Institute of Organic Chemistry, Graz University of Technology , Graz , Austria
| | - Rudolf Zechner
- Institute of Molecular Biosciences, University of Graz , Graz , Austria
| | - Rolf Breinbauer
- Institute of Organic Chemistry, Graz University of Technology , Graz , Austria
| | - Erin E Kershaw
- Division of Endocrinology and Metabolism, University of Pittsburgh , Pittsburgh, Pennsylvania
| | - Jason R B Dyck
- Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, and Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta , Edmonton, Alberta , Canada
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O'Brien EC, Zhao X, Fonarow GC, Schulte PJ, Dai D, Smith EE, Schwamm LH, Bhatt DL, Xian Y, Saver JL, Reeves MJ, Peterson ED, Hernandez AF. Quality of Care and Ischemic Stroke Risk After Hospitalization for Transient Ischemic Attack: Findings From Get With The Guidelines-Stroke. CIRCULATION-CARDIOVASCULAR QUALITY AND OUTCOMES 2016; 8:S117-24. [PMID: 26515199 DOI: 10.1161/circoutcomes.115.002048] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients with transient ischemic attack (TIA) are at increased risk for ischemic stroke. We derived a prediction rule for 1-year ischemic stroke risk post-TIA, examining estimated risk, receipt of inpatient quality of care measures for TIA, and the presence or absence of stroke at 1 year post discharge. METHODS AND RESULTS We linked 67 892 TIA Get With The Guidelines-Stroke patients >65 years (2003-2008) to Medicare inpatient claims to obtain longitudinal outcomes. Using Cox proportional hazards modeling in a split sample, we identified baseline demographics and clinical characteristics associated with ischemic stroke admission during the year post-TIA, and developed a Get With The Guidelines Ischemic Stroke after TIA Risk Score; performance was examined in the validation sample. Quality of care was estimated by a global defect-free care measure, and individual performance measures within estimated risk score quintiles. The overall hospital admission rate for ischemic stroke during the year post-TIA was 5.7%. Patients with ischemic stroke were more likely to be older, black, and have higher rates of smoking, previous stroke, diabetes mellitus, previous myocardial infarction, heart failure, and atrial fibrillation. The Risk Score showed moderate discriminative performance (c-statistic=0.606); highest quintile patients were less likely to receive statins, smoking cessation counseling, and defect-free care. Although not associated with 1-year ischemic stroke, DCF was associated with a significantly lower risk of all-cause mortality. CONCLUSIONS TIA patients with high estimated ischemic stroke risk are less likely to receive defect-free care than low-risk patients. Standardized risk assessment and delivery of optimal inpatient care are needed to reduce this risk-treatment mismatch.
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Affiliation(s)
- Emily C O'Brien
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.).
| | - Xin Zhao
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Gregg C Fonarow
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Phillip J Schulte
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - David Dai
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Eric E Smith
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Lee H Schwamm
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Deepak L Bhatt
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Ying Xian
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Jeffrey L Saver
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Mathew J Reeves
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Eric D Peterson
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
| | - Adrian F Hernandez
- From the Duke Clinical Research Institute, Department of Medicine, Durham, NC (E.C.O.B., X.Z., P.J.S., D.D., Y.X., E.D.P., A.F.H.); Department of Medicine, Ronald-Reagan UCLA Medical Center, Los Angeles, CA (G.C.F., J.L.S.); Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada (E.E.S.); Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA (L.H.S.); Department of Medicine, Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA (D.L.B.); and Department of Epidemiology, Michigan State University, East Lansing (M.J.R.)
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Detiček A, Locatelli I, Roblek T, Mrhar A, Lainscak M. Therapy modifications during hospitalization in patients with chronic heart failure. Eur J Intern Med 2016; 29:52-8. [PMID: 26775137 DOI: 10.1016/j.ejim.2015.12.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Accepted: 12/12/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Guidelines on suggested pharmacological treatments for heart failure (HF) are not optimally implemented in clinical practice and whether pharmacotherapy adjustment actually happens in daily practice is largely unknown. We aimed to investigate pharmacotherapy modifications during hospitalization. METHODS This was a prospective observational survey where all admissions were screened for HF; 210 patients were included. The guideline adherence index (GAI) and modified GAI (mGAI, if ≥50% of target dose) were used to grade the pharmacotherapy. RESULTS Among 198 patients discharged alive (mean age 77years, 51% male), 49% had preserved left ventricular ejection fraction (PLVEF) and 30% had left ventricular systolic dysfunction (LVSD); the echocardiography report was unavailable for 21%. Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists were prescribed to 78%, 58% and 20% of patients on admission and 72%, 65% and 23% at discharge, respectively. Overall, 14% of patients met GAI-3, but at discharge only 7% met mGAI-3. One of the key drugs was stopped or down-titrated in 27%. During follow-up, 21% of patients died (25% with LVSD). Patients with LVSD discharged with at least one HF drug had a lower risk of death than patients with none (HR=0.142, 95% CI=0.029-0.683, p=0.015). Patients with PLVEF had better prognosis than LVSD patients when no HF drugs were prescribed at discharge (HR=0.075, 95% CI=0.009-0.627, p=0.017). CONCLUSIONS The pharmacotherapy of HF patients did not improve significantly during hospitalization, remaining suboptimal. Treatment with key drugs was terminated or reduced in a significant proportion of patients, mostly without specific written justification.
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Affiliation(s)
- Andreja Detiček
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, SI-1000 Ljubljana, Slovenia
| | - Igor Locatelli
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, SI-1000 Ljubljana, Slovenia
| | - Tina Roblek
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, SI-1000 Ljubljana, Slovenia
| | - Aleš Mrhar
- Faculty of Pharmacy, University of Ljubljana, Askerceva cesta 7, SI-1000 Ljubljana, Slovenia
| | - Mitja Lainscak
- Department of Cardiology and Department of Research and Education, General Hospital Celje, Oblakova 5, SI-3000 Celje, Slovenia; Faculty of Medicine, University of Ljubljana, Vrazov trg 2, SI-1104 Ljubljana, Slovenia.
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44
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Affiliation(s)
- Fasiha Kanwal
- Division of Gastroenterology and Hepatology, Baylor College of Medicine, Houston, Texas.
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45
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Liu J, Masoudi FA, Spertus JA, Wang Q, Murugiah K, Spatz ES, Li J, Li X, Ross JS, Krumholz HM, Jiang L. Patterns of use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers among patients with acute myocardial infarction in China from 2001 to 2011: China PEACE-Retrospective AMI Study. J Am Heart Assoc 2015; 4:jah3856. [PMID: 25713293 PMCID: PMC4345866 DOI: 10.1161/jaha.114.001343] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Chinese and U.S. guidelines recommend angiotensin‐converting enzyme inhibitors (ACEIs)/angiotensin receptor blockers (ARBs) for all patients with acute myocardial infarction (AMI) in the absence of contraindications as either a Class I or Class IIa recommendation. Little is known about the use and trends of ACEI/ARB therapy in China over the past decade. Methods and Results Using nationally representative data from the China Patient‐centered Evaluative Assessment of Cardiac Events Retrospective Study of Acute Myocardial Infarction (China PEACE‐Retrospective AMI Study), we assessed use of ACEI/ARB therapy in 2001, 2006, and 2011, overall and across geographic regions and strata of estimated mortality risk, and predictors of ACEI/ARB therapy, among patients with Class I indication by Chinese guidelines. The weighted rate of ACEI/ARB therapy increased from 62.0% in 2001 to 71.4% in 2006, decreasing to 67.6% in 2011. Use was low across all 5 geographic regions. By strata of estimated mortality risk, in 2001, rates of therapy increased with increasing risk; however, by 2011, this reversed and those at higher risk were less likely to be treated (70.7% in lowest‐risk quintile vs. 63.5% in the highest‐risk quintile; P<0.001). Conclusion One third of Chinese AMI patients with Class I indications do not receive ACEI/ARB therapy during hospitalization, with little improvement in rates over time. Patients at higher mortality risk in 2011 were less likely to be treated, highlighting important opportunities to optimize the use of this cost‐effective therapy. Clinical Trial Registration URL: ClinicalTrials.gov. Unique identifier: NCT01624883.
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Affiliation(s)
- Jiamin Liu
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (J.L., Q.W., J.L., X.L., L.J.)
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Anschutz Medical Campus, Aurora, CO (F.A.M.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, MO (J.A.S.)
| | - Qing Wang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (J.L., Q.W., J.L., X.L., L.J.)
| | - Karthik Murugiah
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M., E.S.S., J.S.R., H.M.K.)
| | - Erica S Spatz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M., E.S.S., J.S.R., H.M.K.)
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (J.L., Q.W., J.L., X.L., L.J.)
| | - Xi Li
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (J.L., Q.W., J.L., X.L., L.J.)
| | - Joseph S Ross
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M., E.S.S., J.S.R., H.M.K.)
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT (K.M., E.S.S., J.S.R., H.M.K.)
| | - Lixin Jiang
- National Clinical Research Center of Cardiovascular Diseases, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China (J.L., Q.W., J.L., X.L., L.J.)
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46
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Kim TT, Dyck JRB. Is AMPK the savior of the failing heart? Trends Endocrinol Metab 2015; 26:40-8. [PMID: 25439672 DOI: 10.1016/j.tem.2014.11.001] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 11/03/2014] [Accepted: 11/07/2014] [Indexed: 02/08/2023]
Abstract
Heart failure (HF) is one of the leading causes of death, affecting more than 20 million people worldwide. A vast array of pathophysiological and molecular events contributes to the development and eventual worsening of HF. Of these, defects in myocardial metabolic processes that normally result in proper ATP production necessary to maintain contractile function appear to be a major contributor to HF pathogenesis. A key player involved in regulating myocardial metabolism is AMP-activated protein kinase (AMPK), a major regulatory kinase controlling numerous metabolic pathways. Here, we review the metabolic changes that occur in HF, what role alterations in energy metabolism has in its progression, and the involvement of AMPK in this context.
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Affiliation(s)
- Ty T Kim
- Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, Department of Pediatrics, Faculty of Medicine and Dentistry, 458 Heritage Medical Research Centre, University of Alberta, Edmonton, AB, T6G 2S2, Canada
| | - Jason R B Dyck
- Cardiovascular Research Centre, Mazankowski Alberta Heart Institute, Department of Pediatrics, Faculty of Medicine and Dentistry, 458 Heritage Medical Research Centre, University of Alberta, Edmonton, AB, T6G 2S2, Canada.
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Vivo RP, Krim SR, Liang L, Neely M, Hernandez AF, Eapen ZJ, Peterson ED, Bhatt DL, Heidenreich PA, Yancy CW, Fonarow GC. Short- and long-term rehospitalization and mortality for heart failure in 4 racial/ethnic populations. J Am Heart Assoc 2014; 3:e001134. [PMID: 25324354 PMCID: PMC4323790 DOI: 10.1161/jaha.114.001134] [Citation(s) in RCA: 63] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background The degree to which outcomes following hospitalization for acute heart failure (HF) vary by racial and ethnic groups is poorly characterized. We sought to compare 30‐day and 1‐year rehospitalization and mortality rates for HF among 4 race/ethnic groups. Methods and Results Using the Get With The Guidelines–HF registry linked with Medicare data, we compared 30‐day and 1‐year outcomes between racial/ethnic groups by using a multivariable Cox proportional hazards model adjusting for clinical, hospital, and socioeconomic status characteristics. We analyzed 47 149 Medicare patients aged ≥65 years who had been discharged for HF between 2005 and 2011: there were 39 213 whites (83.2%), 4946 blacks (10.5%), 2347 Hispanics (5.0%), and 643 Asians/Pacific Islanders (1.4%). Relative to whites, blacks and Hispanics had higher 30‐day and 1‐year unadjusted readmission rates but lower 30‐day and 1‐year mortality; Asians had similar 30‐day readmission rates but lower 1‐year mortality. After risk adjustment, blacks had higher 30‐day and 1‐year CV readmission than whites but modestly lower short‐ and long‐term mortality; Hispanics had higher 30‐day and 1‐year readmission rates and similar 1‐year mortality than whites, while Asians had similar outcomes. When socioeconomic status data were added to the model, the majority of associations persisted, but the difference in 30‐day and 1‐year readmission rates between white and Hispanic patients became nonsignificant. Conclusions Among Medicare patients hospitalized with HF, short‐ and long‐term readmission rates and mortality differed among the 4 major racial/ethnic populations and persisted even after controlling for clinical, hospital, and socioeconomic status variables.
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Affiliation(s)
- Rey P Vivo
- Ronald Reagan-UCLA Medical Center, Los Angeles, CA (R.P.V., G.C.F.)
| | - Selim R Krim
- Ochsner Heart and Vascular Institute, New Orleans, LA (S.R.K.)
| | - Li Liang
- Duke Clinical Research Institute, Durham, NC (L.L., M.N., A.F.H., Z.J.E., E.D.P.)
| | - Megan Neely
- Duke Clinical Research Institute, Durham, NC (L.L., M.N., A.F.H., Z.J.E., E.D.P.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (L.L., M.N., A.F.H., Z.J.E., E.D.P.)
| | - Zubin J Eapen
- Duke Clinical Research Institute, Durham, NC (L.L., M.N., A.F.H., Z.J.E., E.D.P.)
| | - Eric D Peterson
- Duke Clinical Research Institute, Durham, NC (L.L., M.N., A.F.H., Z.J.E., E.D.P.)
| | - Deepak L Bhatt
- Brigham and Women's Hospital and Harvard Medical School, Boston, MA (D.L.B.)
| | - Paul A Heidenreich
- VA Palo Alto Health Care System, 3801 Miranda Ave., Palo Alto, CA (P.A.H.)
| | - Clyde W Yancy
- Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.)
| | - Gregg C Fonarow
- Ronald Reagan-UCLA Medical Center, Los Angeles, CA (R.P.V., G.C.F.)
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48
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TNM-like classification: a new proposed method for heart failure staging. ScientificWorldJournal 2013; 2013:175925. [PMID: 24376377 PMCID: PMC3859030 DOI: 10.1155/2013/175925] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Accepted: 09/29/2013] [Indexed: 11/18/2022] Open
Abstract
Heart Failure (HF) is an acute or chronic syndrome, that causes a lot of damaging effects to every system. The involvement of different systems is variably related to age and others comorbidities. The severity of organ damage is often proportional to the duration of heart failure. The typology of HF and the duration determine which organs will be affected and vice versa the severity of organ damage supplies precious information about prognosis and outcome of patients with heart failure. Moreover, a classification based not only on symptomatic and syndromic typical features of heart failure, but also on functional data of each system, could allow us to apply the most appropriate therapies, to obtain a more accurate prognosis, and to employ necessary and not redundant human and financial resources. With an eye on the TNM staging used in oncology, we drawn up a classification that will consider the different involvement of organs such as lungs, kidneys, and liver in addition to psychological pattern and quality of life in HF patients. For all these reasons, it is our intention to propose a valid and more specific classification available for the clinical staging of HF that takes into account pathophysiological and structural changes that can remark prognosis and management of HF.
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Ellrodt AG, Fonarow GC, Schwamm LH, Albert N, Bhatt DL, Cannon CP, Hernandez AF, Hlatky MA, Luepker RV, Peterson PN, Reeves M, Smith EE. Synthesizing lessons learned from get with the guidelines: the value of disease-based registries in improving quality and outcomes. Circulation 2013; 128:2447-60. [PMID: 24166574 DOI: 10.1161/01.cir.0000435779.48007.5c] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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50
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Peterson PN, Chan PS, Spertus JA, Tang F, Jones PG, Ezekowitz JA, Allen LA, Masoudi FA, Maddox TM. Practice-level variation in use of recommended medications among outpatients with heart failure: Insights from the NCDR PINNACLE program. Circ Heart Fail 2013; 6:1132-8. [PMID: 24130004 DOI: 10.1161/circheartfailure.113.000163] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The objective of this study is to examine practice-level variation in rates of guideline-recommended treatment for outpatients with heart failure and reduced ejection fraction, and to examine the association between treatment variation and practice site, independent of patient factors. METHODS AND RESULTS Cardiology practices participating in the National Cardiovascular Disease Registry Practice Innovation and Clinical Excellence registry from July 2008 to December 2010 were evaluated. Practice rates of treatment with angiotensin-converting enzyme inhibitors/angiotensin receptor blockers and β-blockers and an optimal combined treatment measure were determined for patients with heart failure and reduced ejection fraction and no documented contraindications. Multivariable hierarchical regression models were adjusted for demographics, insurance status, and comorbidities. A median rate ratio was calculated for each therapy, which describes the likelihood that the treatment of a patient with given comorbidities would differ at 2 randomly selected practices. We identified 12 556 patients from 45 practices. The unadjusted practice-level prescription rates ranged from 44% to 100% for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (median, 85%; interquartile range, 75%-89%), from 49% to 100% for β-blockers (median, 92%; interquartile range, 83%-95%), and from 37% to 100% for optimal combined treatment (median, 79%; interquartile range, 66%-85%). The adjusted median rate ratio was 1.11 (95% confidence interval, 1.08-1.18) for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers therapy, 1.08 (95% confidence interval, 1.05-1.15) for β-blockers therapy, and 1.17 (1.13-1.26) for optimal combined treatment. CONCLUSIONS Variation in the use of guideline-recommended medications for patients with heart failure and reduced ejection fraction exists in the outpatient setting. Addressing practice-level differences may be an important component of improving quality of care for patients with heart failure and reduced ejection fraction.
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