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Hilmer SN, Schwartz J, Petrovic M, Walker LE, Thürmann P, Le Couteur DG. Addressing the gaps in evaluation of new drugs for older adults: Strategies from the International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee. J Am Geriatr Soc 2024; 72:2942-2950. [PMID: 38485461 DOI: 10.1111/jgs.18826] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 09/03/2024]
Abstract
The International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee aims to improve the use of drugs in older adults and develop new therapeutic approaches for the syndromes and diseases of old age through advocacy, education, and research. In the present paper, we propose strategies relevant to drug development and evaluation, spanning preclinical and the full range of clinical studies. Drugs for older adults need to consider not only age, but also other characteristics common in geriatric patients, such as multimorbidity, polypharmacy, falls, cognitive impairment, and frailty. The IUPHAR Geriatric Committee's position statement on 'Measurement of Frailty in Drug Development and Evaluation' is included, highlighting 12 key principles that cover the spectrum of translational research. We propose that where older adults are likely to be major users of a drug, that frailty is measured at baseline and as an outcome. Preclinical models that replicate the age, frailty, duration of exposure, comorbidities, and co-medications of the proposed patients may improve translation. We highlight the potential application of recent technologies, such as physiologically based pharmacokinetic-pharmacodynamic modeling informed by frailty biology, and Artificial Intelligence, to inform personalized medicine for older patients. Considerations for the rapidly aging populations in low- and middle-income countries related to health-care and clinical trials are outlined. Involving older adults, their caregivers and health-care providers in all phases of research should improve drug development, evaluation, and outcomes for older adults internationally.
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Affiliation(s)
- Sarah N Hilmer
- Kolling Institute, The University of Sydney and Northern Sydney Local Health District, St Leonards, New South Wales, Australia
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
| | - Janice Schwartz
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Divisions of Geriatrics and Clinical Pharmacology, Department of Medicine, University of California San Francisco, San Francisco, California, USA
| | - Mirko Petrovic
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Ghent University, Ghent, Belgium
| | - Lauren E Walker
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Institute of Systems, Molecular and Integrative Biology (ISMIB), University of Liverpool, Liverpool, UK
| | - Petra Thürmann
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Helios University Hospital Wuppertal, Chair of Clinical Pharmacology, University Witten/Herdecke, Witten, Germany
| | - David G Le Couteur
- International Union of Basic and Clinical Pharmacology (IUPHAR) Geriatric Committee, Brentwood, Tennessee, USA
- Centre for Education and Research on Ageing, University of Sydney and Concord RG Hospital, Concord, New South Wales, Australia
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Kim DH. Unleashing frailty from laboratory into real world: A critical step toward frailty-guided clinical care of older adults. J Am Geriatr Soc 2024. [PMID: 39166879 DOI: 10.1111/jgs.19151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/21/2024] [Accepted: 06/30/2024] [Indexed: 08/23/2024]
Abstract
Understanding patients' degree of frailty is crucial for tailoring clinical care for older adults based on their physiologic reserve and health needs ("frailty-guided clinical care"). Two prerequisites for frailty-guided clinical care are: (1) access to frailty information at the point of care and (2) evidence to inform decisions based on frailty information. Recent advancements include web-based frailty assessment tools and their electronic health records integration for time-efficient, standardized assessments in clinical practice. Additionally, database frailty scores from administrative claims and electronic health records data enable scalable assessments and evaluation of the effectiveness and safety of medical interventions across different frailty levels using real-world data. Given limited evidence from clinical trials, real-world database studies can complement trial results and help treatment decisions for individuals with frailty. This article, based on the Thomas and Catherine Yoshikawa Award lecture I gave at the American Geriatrics Society Annual Meeting in Long Beach, California, on May 5, 2023, outlines our group's contributions: (1) developing and integrating a frailty index calculator (Senior Health Calculator) into the electronic health records at an academic medical center; (2) developing a claims-based frailty index for Medicare claims; (3) applying this index to evaluate the effect of medical interventions for patients with and without frailty; and (4) efforts to disseminate frailty assessment tools through the launch of the eFrailty website and the forthcoming addition of the claims-based frailty index to the Centers for Medicare and Medicaid Services Chronic Conditions Data Warehouse. This article concludes with future directions for frailty-guided clinical care.
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Affiliation(s)
- Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
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3
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Yang M, Kondo T, Anand IS, de Boer RA, Campbell RT, Køber L, Lam CSP, Maggioni AP, Martinez FA, O'Meara E, Packer M, Sabatine MS, Kerr Saraiva JF, Shah SJ, Zannad F, Zile MR, Jhund PS, Solomon SD, McMurray JJV. Clinical characteristics and outcomes of patients aged 80 years and over with heart failure: Need for better treatment. Eur J Heart Fail 2024. [PMID: 39169481 DOI: 10.1002/ejhf.3417] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Revised: 06/28/2024] [Accepted: 07/21/2024] [Indexed: 08/23/2024] Open
Abstract
AIMS Although the prevalence of heart failure (HF) increases markedly with advancing age, surprisingly little is known about HF in the very elderly. The aim of this study was to describe the clinical characteristics and outcomes of octogenarians with HF. METHODS AND RESULTS Individual participant meta-analysis of patients with HF and reduced, mildly reduced, and preserved ejection fraction (HFrEF, HFmrEF, and HFpEF, respectively) enrolled in eight large randomized trials. Overall, the proportion of octogenarians was 1518 of 20 168 patients (7.5%) with HFrEF, 610 of 4609 (13.2%) with HFmrEF, and 3130 of 15 354 (20.4%) with HFpEF. Regardless of HF phenotype, octogenarian patients were more often female and had more comorbidities, more symptoms and signs of congestion, and worse health status (but not quality of life), in comparison to patients aged <80 years. The incidence (per 100 person-years) of the composite of cardiovascular death or HF hospitalization was 13.3 (95% confidence interval [CI] 12.7-14.0) in octogenarians versus 9.5 (95% CI 9.3-9.7) in non-octogenarians (adjusted hazard ratio [aHR] 1.40, 95% CI 1.32-1.48). Each component of the composite was more frequent in octogenarians with rates of cardiovascular mortality of 7.0 (95% CI 6.5-7.4) per 100 person-years versus 4.9 (95% CI 4.8-5.1) in non-octogenarians (aHR 1.60, 95% CI 1.48-1.72, p < 0.001). Octogenarians received less evidence-based therapy, especially mineralocorticoid receptor antagonists, than younger patients. CONCLUSION Despite worse health status and higher hospitalization and mortality rates, octogenarians were undertreated compared to younger patients.
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Affiliation(s)
- Mingming Yang
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Zhongda Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Inder S Anand
- Department of Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Rudolf A de Boer
- Department of Cardiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Ross T Campbell
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore, Singapore
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | | | - Eileen O'Meara
- Montreal Heart Institute Department of Medicine (Cardiology) and Research Centre, Université de Montréal, Montreal, QC, Canada
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Marc S Sabatine
- TIMI Study Group, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jose F Kerr Saraiva
- Cardiovascular Division, Instituto de Pesquisa Clínica de Campinas, Campinas, Brazil
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Faiez Zannad
- Inserm CIC 1433 and Université de Lorraine, Centre Hospitalier Régional Universitaire, Nancy, France
| | - Michael R Zile
- RHJ Department of Veterans Affairs Medical Center, Medical University of South Carolina, Charleston, SC, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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Wang C, Guan L, Han S, Tong F, Li Y, Li Z, Sun H, Sun Z. Systematic review and meta-analysis to predict mortality in heart failure with preserved ejection fraction: Development and validation of the HF-DANAS score. ESC Heart Fail 2024. [PMID: 39118428 DOI: 10.1002/ehf2.15008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Revised: 06/25/2024] [Accepted: 07/15/2024] [Indexed: 08/10/2024] Open
Abstract
AIMS The morbidity and mortality of heart failure with preserved ejection fraction (HFpEF) continue to increase with the accelerating global aging process. During the past decade, the pathophysiology, diagnostic methods, and prognostic prediction of HFpEF have been revolutionized, resulting in new and effective management strategies. Dynamic prognostic assessment facilitates systematic clinical management of patients, and the aim of this study was to investigate the risk factors for mortality in patients with HFpEF and to develop a risk prediction assessment model. METHODS AND REULTS Data for the derivation cohort were obtained from three databases, PubMed, Embase, and Cochrane. The validation cohort was obtained from the Chinese Heart Failure Center database. The β-coefficient was calculated based on the risk ratio (RR) and 95% confidence intervals (CI) corresponding to each risk factor to construct a mortality risk assessment model. A total of 30 studies were included in the meta-analysis: 22 prospective cohort studies and 8 retrospective cohort studies, including 34 196 HFpEF patients. Seven predictors of all-cause mortality in HFpEF patients were derived. Considering the need for feasibility in clinical practice, we performed subgroup and sensitivity analyses and determined the following cutoff values: age > 75 years (RR: 2.07, 95% CI: 1.83-2.35; P < 0.001), male sex (RR: 1.36, 95% CI: 1.17-1.59; P < 0.001), DM (RR: 1.23, 95% CI: 1.11-1.36; P < 0.001), anaemia (RR: 1.53, 95% CI: 1.41-1.67; P < 0.001), albumin concentration < 3.2 g/dL (RR: 1.29, 95% CI: 1.14-1.47; P < 0.001), AF (RR: 1.27, 95% CI: 1.12-1.43; P < 0.001), and NYHA class III/IV (RR: 1.63, 95% CI: 1.43-1.87; P < 0.001). The area under the receiver operating characteristic (ROC) curve (AUC) for this model was 71.3% (95% CI: 0.696-0.736), with an optimal cut-off value of 10.75. The sensitivity and specificity were 0.778 and 0.566, respectively. According to this risk score, we divided patients into three risk classes (low, moderate, and high risk), the numbers of patients who died by the end of the 1-year follow-up were 23 (1.87%), 82 (5.62%), and 382 (15.52%) in these three groups, and the 5-year mortality rates were 9.82%, 20.68%, and 43.28%, respectively. CONCLUSIONS This study developed an HF-DANAS scoring system for the HFpEF mortality risk containing seven predictors, providing clinicians with a simple assessment tool that can help improve clinical management.
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Affiliation(s)
- Chuanhe Wang
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Lin Guan
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Su Han
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Fei Tong
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Ying Li
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Zhichao Li
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
| | - Hao Sun
- Department of Clinical Epidemiology and Evidence-Based Medicine, The First Hospital of China Medical University, Shenyang, China
| | - Zhijun Sun
- Department of Cardiology, Shengjing Hospital of China Medical University, Shenyang, China
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Ko D, Evans PT, Lin KJ, Pande AN, Cervone A, Lee SB, Cheng S, Tsacogianis T, Glynn RJ, Kim DH. Frailty and Clinical Outcomes of Ticagrelor Versus Clopidogrel in Older Adults With Acute Myocardial Infarction. J Am Heart Assoc 2024; 13:e034529. [PMID: 39056329 DOI: 10.1161/jaha.124.034529] [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: 01/19/2024] [Accepted: 07/02/2024] [Indexed: 07/28/2024]
Abstract
BACKGROUND Ticagrelor is recommended over clopidogrel in acute coronary syndrome based on the results of the PLATO (Study of Platelet Inhibition and Patient Outcomes) trial. We aimed to emulate PLATO in older adults with and without frailty and with acute coronary syndrome treated with percutaneous coronary intervention. METHODS AND RESULTS We created a new-user cohort of Medicare fee-for-service beneficiaries aged ≥65 years hospitalized for acute coronary syndrome from 2014 to 2018 and initiated ticagrelor or clopidogrel following percutaneous coronary intervention. Frailty was defined using a validated claims-based frailty index ≥0.25. Coprimary outcomes were major adverse cardiovascular events and major bleeding. Follow-up began on the date of first outpatient prescription for ticagrelor or clopidogrel and ended on the earliest date for an outcome event, death, discontinuation of the index drug, or disenrollment from Medicare. The study included 42 843 older adults; 23% were frail. After propensity score matching, the rates of major adverse cardiovascular events per 100 person-years comparing ticagrelor versus clopidogrel groups were 7.8 and 7.3 in the frail cohort (hazard ratio [HR], 1.07 [95% CI, 0.84-1.36]) and 3.7 and 4.2 in the nonfrail cohort (HR, 0.87 [95% CI, 0.75-1.02]). The corresponding rates of major bleeding were 4.3 and 3.8 in the frail cohort (HR, 1.12 95% CI, [0.80-1.56]) and 2.2 and 1.8 in the nonfrail cohort (HR, 1.22 [95% CI, 0.98-1.51]). CONCLUSIONS There was a trend toward a modest reduction in risk of major adverse cardiovascular events and a trend toward a modest increase in risk of major bleeding with ticagrelor compared with clopidogrel in the nonfrail cohort. There was insufficient evidence for the benefit of ticagrelor in frail older adults.
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Affiliation(s)
- Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research Hebrew SeniorLife Boston MA
- Section of Cardiovascular Medicine Boston Medical Center Boston MA
| | - Peter T Evans
- Section of Cardiovascular Medicine Boston Medical Center Boston MA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women's Hospital Boston MA
- Division of General Internal Medicine, Department of Medicine Massachusetts General Hospital Boston MA
| | - Ashvin N Pande
- Section of Cardiovascular Medicine Boston Medical Center Boston MA
| | - Alexander Cervone
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women's Hospital Boston MA
| | - Su Been Lee
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women's Hospital Boston MA
| | - Susan Cheng
- Department of Cardiology Cedars-Sinai Medical Center Los Angeles CA
| | - Theodore Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women's Hospital Boston MA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women's Hospital Boston MA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research Hebrew SeniorLife Boston MA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine Brigham and Women's Hospital Boston MA
- Division of Gerontology, Department of Medicine Beth Israel Deaconess Medical Center Boston MA
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Gharagozloo K, Mehdizadeh M, Heckman G, Rose RA, Howlett J, Howlett SE, Nattel S. Heart Failure With Preserved Ejection Fraction in the Elderly Population: Basic Mechanisms and Clinical Considerations. Can J Cardiol 2024; 40:1424-1444. [PMID: 38604339 DOI: 10.1016/j.cjca.2024.04.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/04/2024] [Accepted: 04/06/2024] [Indexed: 04/13/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) refers to a clinical condition in which the signs of heart failure, such as pulmonary congestion, peripheral edema, and increased natriuretic peptide levels, are present despite normal ejection fractions and the absence of other causes (eg, pericardial disease). The ejection fraction cutoff for the definition of HFpEF has varied in the past, but recent society guidelines have settled on a consensus of 50%. HFpEF is particularly common in the elderly population. The aim of this narrative review is to summarize the available literature regarding HFpEF in elderly patients in terms of evidence for the age dependence, specific clinical features, and underlying mechanisms. In the clinical arena, we review the epidemiology, discuss distinct clinical phenotypes typically seen in elderly patients, the importance of frailty, the role of biomarkers, and the role of medical therapies (including sodium-glucose cotransport protein 2 inhibitors, renin-angiotensin-aldosterone system blockers, angiotensin receptor/neprilysin inhibitors, diuretics, and β-adrenergic receptor blockers). We then go on to discuss the basic mechanisms implicated in HFpEF, including cellular senescence, fibrosis, inflammation, mitochondrial dysfunction, enhanced production of reactive oxygen species, abnormal cellular calcium handling, changes in microRNA signalling, insulin resistance, and sex hormone changes. Finally, we review knowledge gaps and promising areas of future investigation. Improved understanding of the specific clinical manifestations of HFpEF in elderly individuals and of the fundamental mechanisms that contribute to the age-related risk of HFpEF promises to lead to novel diagnostic and treatment approaches that will improve outcomes for this common cardiac disorder in a vulnerable population.
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Affiliation(s)
- Kimia Gharagozloo
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada
| | - Mozhdeh Mehdizadeh
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada
| | - George Heckman
- Schlegel Research Institute for Aging and University of Waterloo, Waterloo, Ontario, Canada
| | - Robert A Rose
- Department of Cardiac Sciences, Department of Physiology and Pharmacology, Libin Cardiovascular Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jonathan Howlett
- Libin Cardiovascular Institute and Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Susan E Howlett
- Departments of Pharmacology and Medicine (Geriatric Medicine), Dalhousie University, Halifax, Nova Scotia, Canada
| | - Stanley Nattel
- Montreal Heart Institute Research Center and Université de Montréal, Montréal, Quebec, Canada; McGill University Departments of Pharmacology and Therapeutics, Montréal, Quebec, Canada; Institute of Pharmacology, West German Heart and Vascular Center, University Duisburg-Essen, Essen, Germany.
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7
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Kittipibul V, Vaduganathan M, Ikeaba U, Chiswell K, Butler J, DeVore AD, Heidenreich PA, Huang JC, Kittleson MM, Joynt Maddox KE, Linganathan KK, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Fonarow GC, Greene SJ. Cause-Specific Health Care Costs Following Hospitalization for Heart Failure and Cost Offset With SGLT2i Therapy. JACC. HEART FAILURE 2024; 12:1409-1421. [PMID: 38727651 DOI: 10.1016/j.jchf.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/01/2024] [Accepted: 04/02/2024] [Indexed: 08/09/2024]
Abstract
BACKGROUND Little is known regarding differences in cause-specific costs between heart failure (HF) with ejection fraction (EF) ≤40% vs >40%, and potential cost implications of sodium glucose co-transporter 2 inhibitor (SGLT2i) therapy. OBJECTIVES This study sought to compare cause-specific health care costs following hospitalization for HF with EF ≤40% vs >40% and estimate the cost offset with implementation of SGLT2i therapy. METHODS This study examined Medicare beneficiaries hospitalized for HF in the Get With The Guidelines-Heart Failure registry from 2016 to 2020. Mean per-patient total (excluding drug costs) and cause-specific costs from discharge through 1-year follow-up were calculated and compared between EF ≤40% vs >40%. Next, risk reductions on total all-cause and HF hospitalizations were estimated in a trial-level meta-analysis of 5 pivotal trials of SGLT2is in HF. Finally, these relative treatment effects were applied to Medicare beneficiaries eligible for SGLT2i therapy to estimate the projected cost offset with implementation of SGLT2i, excluding drug costs. RESULTS Among 146,003 patients, 50,598 (34.7%) had EF ≤40% and 95,405 (65.3%) had EF >40%. Mean total cost through 1 year was $40,557. Total costs were similar between EF groups overall but were higher for EF ≤40% among patients surviving the 1-year follow-up period. Patients with EF >40% had higher costs caused by non-HF and noncardiovascular hospitalizations, and skilled nursing facilities (all P < 0.001). Trial-level meta-analysis of the 5 SGLT2i clinical trials estimated 11% (rate ratio: 0.89; 95% CI: 0.84-0.93; P < 0.001) and 29% (rate ratio: 0.71; 95% CI: 0.66-0.76; P < 0.001) relative reductions in rates of total all-cause and HF hospitalizations, respectively, regardless of EF. Reductions in all-cause and HF hospitalizations were projected to reduce annual costs of readmission by $2,451 to $2,668 per patient with EF ≤40% and $1,439 to $2,410 per patient with EF >40%. CONCLUSIONS In this large cohort of older U.S. adults hospitalized for HF, cause-specific costs of care differed among patients with EF ≤40% vs >40%. SGLT2i significantly reduced the rate of HF and all-cause hospitalizations irrespective of EF in clinical trials, and implementation of SGLT2i therapy in clinical practice is projected to reduce costs by $1,439 to $2,668 per patient over the 1 year post-discharge, excluding drug costs.
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Affiliation(s)
- Veraprapas Kittipibul
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - 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 Medical Center, Los Angeles, California, USA
| | - Karen E Joynt Maddox
- Cardiology Division, Department of Medicine, Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | | | | | - Anjali Tiku Owens
- Division of Cardiology, Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA; Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Scott D Solomon
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis, Minnesota, USA
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA.
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8
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Zahir Anjum D, Strange JE, Fosbøl E, Garred CH, Elmegaard M, Andersson C, Jhund PS, McMurray JJV, Petrie MC, Kober L, Schou M. Use of medical therapy and risk of clinical events according to frailty in heart failure patients - A real-life cohort study. Eur J Heart Fail 2024; 26:1717-1726. [PMID: 38700461 DOI: 10.1002/ejhf.3249] [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: 08/17/2023] [Revised: 03/21/2024] [Accepted: 04/08/2024] [Indexed: 05/05/2024] Open
Abstract
AIMS Although recent randomized clinical trials have demonstrated the advantages of heart failure (HF) therapy in both frail and not frail patients, there is insufficient information on the use of HF therapy based on frailty status in a real-world setting. The aim was to examine how frailty status in HF patients associates with use of HF therapy and with clinical outcomes. METHODS AND RESULTS Patients with new-onset HF between 2014 and 2021 were identified using the nationwide Danish registers. Patients across the entire range of ejection fraction were included. The associations between frailty status (using the Hospital Frailty Risk Score) and use of HF therapy and clinical outcomes (all-cause mortality, HF hospitalization, and non-HF hospitalization) were evaluated using multivariable-adjusted Cox models adjusting for age, sex, diagnostic setting, calendar year, comorbidities, pharmacotherapy, and socioeconomic status. Of 35 999 participants (mean age 69.1 years), 68% were not frail, 26% were moderately frail, and 6% were severely frail. The use of HF therapy was significantly lower in frailer patients. The hazard ratio (HR) for angiotensin-converting enzyme inhibitor/angiotensin receptor blocker initiation was 0.74 (95% confidence interval 0.70-0.77) and 0.48 (0.43-0.53) for moderate frailty and severe frailty, respectively. For beta-blockers, the corresponding HRs were 0.74 (0.71-0.78) and 0.51 (0.46-0.56), respectively, and for mineralocorticoid receptor antagonists, 0.83 (0.80-0.87) and 0.58 (0.53-0.64), respectively. The prevalence of death and non-HF hospitalization increased with frailty status. The HR for death was 1.55 (1.47-1.63) and 2.32 (2.16-2.49) for moderate and severe frailty, respectively, and the HR for non-HF hospitalization was 1.37 (1.32-1.41) and 1.82 (1.72-1.92), respectively. The association between frailty status and HF hospitalization was not significant (HR 1.08 [1.02-1.14] and 1.08 [0.97-1.20], respectively). CONCLUSION In real-world HF patients, frailty was associated with lower HF therapy use and with a higher incidence of clinical outcomes including mortality and non-HF hospitalization.
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Affiliation(s)
- Deewa Zahir Anjum
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Jarl E Strange
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Mariam Elmegaard
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Charlotte Andersson
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Kober
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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9
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Goyal P, Chen L, Lau JD, Rosenson RS, Levitan EB. Reductions in renin-angiotensin system inhibitors following hospitalization for heart failure. ESC Heart Fail 2024. [PMID: 39030944 DOI: 10.1002/ehf2.14953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 04/29/2024] [Accepted: 06/23/2024] [Indexed: 07/22/2024] Open
Abstract
AIMS Limited data are available that evaluate the efficacy of renin-angiotensin system inhibitor (RASI) dose-reduction in older adults with heart failure with reduced ejection fraction following a heart failure hospitalization. METHODS AND RESULTS We examined a 5% random sample of Medicare beneficiaries with prescription coverage who were discharged to home following a hospitalization for heart failure with reduced ejection fraction between 1 January 2007 and 30 June 2018 and were treated with RASI prior to hospitalization. We classified patients into three mutually exclusive groups based on RASI dosage before (prescription fills up to 90 days prior to) and after a hospitalization (prescription fills up to 365 days that were most proximate to the discharge date as possible)-same/increased dose, dose-reduction, and discontinuation. We examined associations between RASI prescribing patterns and outcomes (mortality and all-cause readmission at 30 days and 1 year) using Cox proportional hazards models. Among 12 794 unique older adults, 36.8% experienced a RASI reduction following their hospitalization for HFrEF-15.7% had a dose-reduction and 21.1% had a discontinuation. Neither dose-reduction nor discontinuation was associated with 30-day mortality. Discontinuation was associated 1-year mortality, 30-day all-cause readmission, and 1-year all-cause readmission, whereas dose-reduction was not. CONCLUSION RASI dose-reduction occurs in 1 out of 7 HF hospitalizations. In contrast to RASI discontinuation, RASI dose-reduction was not associated with adverse short or long-term outcomes. These findings indicate that RASI dose-reduction is preferred over RASI discontinuation in selected situations where RASI reduction is needed.
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Affiliation(s)
- Parag Goyal
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Ligong Chen
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Jennifer D Lau
- Department of Medicine, Weill Cornell Medicine, New York, NY, USA
| | - Robert S Rosenson
- Department of Cardiovascular Medicine, Mount Sinai, New York, NY, USA
| | - Emily B Levitan
- Department of Epidemiology, University of Alabama at Birmingham, Birmingham, AL, USA
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10
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Rakisheva A, Soloveva A, Shchendrygina A, Giverts I. Heart Failure With Preserved Ejection Fraction and Frailty: From Young to Superaged Coexisting HFpEF and Frailty. INTERNATIONAL JOURNAL OF HEART FAILURE 2024; 6:93-106. [PMID: 39081641 PMCID: PMC11284337 DOI: 10.36628/ijhf.2023.0064] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/14/2023] [Revised: 04/01/2024] [Accepted: 06/14/2024] [Indexed: 08/02/2024]
Abstract
Being commonly diagnosed in elderly women and associated with comorbidities as well as ageing-related cardio-vascular changes, heart failure with preserved ejection fraction (HFpEF) has been recently considered as a distinct cardiogeriatric syndrome. Frailty is another frequent geriatric syndrome. HFpEF and frailty share common underlying mechanisms, often co-exist, and represent each other's risk factors. A threshold of 65 years old is usually used to screen patients for both frailty and HFpEF in research and clinical settings. However, both HFpEF and frailty are very heterogenous conditions that may develop at younger ages. In this review we aim to provide a broader overview on the coexistence of HFpEF and frailty throughout the lifetime. We hypothesize that HFpEF and frailty patients' profiles (young, elderly, superaged) represent a continuum of the common ageing process modified by cumulative exposure to risk factors resulting to a presentation of HFpEF and frailty at different ages. We believe, that suggested approach might stimulate assessment of frailty in HFpEF assessment and vice versa regardless of age and early implementation of targeted interventions. Future studies of pathophysiology, clinical features, and outcomes of frailty in HFpEF by age are needed.
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Affiliation(s)
| | - Anzhela Soloveva
- Department of Cardiology, Almazov Almazov National Medical Research Centre, Saint Petersburg, Russia
| | | | - Ilya Giverts
- Maimonides Medical Center, Brooklyn, NY, USA
- Massachusetts General Hospital, Boston, MA, USA
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11
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Kim DH, Park CM, Ko D, Lin KJ, Glynn RJ. Assessing the Benefits and Harms of Pharmacotherapy in Older Adults with Frailty: Insights from Pharmacoepidemiologic Studies of Routine Health Care Data. Drugs Aging 2024; 41:583-600. [PMID: 38954400 DOI: 10.1007/s40266-024-01121-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/07/2024] [Indexed: 07/04/2024]
Abstract
The objective of this review is to summarize and appraise the research methodology, emerging findings, and future directions in pharmacoepidemiologic studies assessing the benefits and harms of pharmacotherapies in older adults with different levels of frailty. Older adults living with frailty are at elevated risk for poor health outcomes and adverse effects from pharmacotherapy. However, current evidence is limited due to the under-enrollment of frail older adults and the lack of validated frailty assessments in clinical trials. Recent advancements in measuring frailty in administrative claims and electronic health records (database-derived frailty scores) have enabled researchers to identify patients with frailty and to evaluate the heterogeneity of treatment effects by patients' frailty levels using routine health care data. When selecting a database-derived frailty score, researchers must consider the type of data (e.g., different coding systems), the length of the predictor assessment period, the extent of validation against clinically validated frailty measures, and the possibility of surveillance bias arising from unequal access to care. We reviewed 13 pharmacoepidemiologic studies published on PubMed from 2013 to 2023 that evaluated the benefits and harms of cardiovascular medications, diabetes medications, anti-neoplastic agents, antipsychotic medications, and vaccines by frailty levels. These studies suggest that, while greater frailty is positively associated with adverse treatment outcomes, older adults with frailty can still benefit from pharmacotherapy. Therefore, we recommend routine frailty subgroup analyses in pharmacoepidemiologic studies. Despite data and design limitations, the findings from such studies may be informative to tailor pharmacotherapy for older adults across the frailty spectrum.
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Affiliation(s)
- Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA.
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA.
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | - Chan Mi Park
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Harvard Medical School, Boston, MA, USA
| | - Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, 1200 Centre Street, Boston, MA, 02131, USA
- Harvard Medical School, Boston, MA, USA
- Section of Cardiovascular Medicine, Boston Medical Center, Boston, MA, USA
- Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Kueiyu Joshua Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Robert J Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
- Division of Preventive Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Boston, MA, USA
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12
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Moras E, Zaid S, Gandhi K, Barman N, Birnbaum Y, Virani SS, Tamis-Holland J, Jneid H, Krittanawong C. Pharmacotherapy for Coronary Artery Disease and Acute Coronary Syndrome in the Aging Population. Curr Atheroscler Rep 2024; 26:231-248. [PMID: 38722473 DOI: 10.1007/s11883-024-01203-9] [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] [Accepted: 04/19/2024] [Indexed: 06/22/2024]
Abstract
PURPOSE OF REVIEW To provide a comprehensive summary of relevant studies and evidence concerning the utilization of different pharmacotherapeutic and revascularization strategies in managing coronary artery disease and acute coronary syndrome specifically in the older adult population. RECENT FINDINGS Approximately 30% to 40% of hospitalized patients with acute coronary syndrome are older adults, among whom the majority of cardiovascular-related deaths occur. When compared to younger patients, these individuals generally experience inferior clinical outcomes. Most clinical trials assessing the efficacy and safety of various therapeutics have primarily enrolled patients under the age of 75, in addition to excluding those with geriatric complexities. In this review, we emphasize the need for a personalized and comprehensive approach to pharmacotherapy for coronary heart disease and acute coronary syndrome in older adults, considering concomitant geriatric syndromes and age-related factors to optimize treatment outcomes while minimizing potential risks and complications. In the realm of clinical practice, cardiovascular and geriatric risks are closely intertwined, with both being significant factors in determining treatments aimed at reducing negative outcomes and attaining health conditions most valued by older adults.
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Affiliation(s)
- Errol Moras
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Syed Zaid
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | - Kruti Gandhi
- Department of Internal Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Nitin Barman
- Cardiac Catheterization Laboratory, Mount Sinai Morningside Hospital, New York, NY, USA
| | - Yochai Birnbaum
- Section of Cardiology, Baylor College of Medicine, Houston, TX, USA
| | | | | | - Hani Jneid
- Division of Cardiology, University of Texas Medical Branch, Houston, TX, USA
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13
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Villaschi A, Chiarito M, Pagnesi M, Stolfo D, Baldetti L, Lombardi CM, Adamo M, Loiacono F, Sammartino AM, Colombo G, Tomasoni D, Inciardi RM, Maccallini M, Gasparini G, Montella M, Contessi S, Cocianni D, Perotto M, Barone G, Merlo M, Vitale C, Rosano GMC, Cappelletti AM, Sinagra G, Metra M, Pini D. Frailty according to the 2019 HFA-ESC definition in patients at risk for advanced heart failure: Insights from the HELP-HF registry. Eur J Heart Fail 2024; 26:1399-1407. [PMID: 38741569 DOI: 10.1002/ejhf.3234] [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: 01/01/2024] [Revised: 03/05/2024] [Accepted: 03/27/2024] [Indexed: 05/16/2024] Open
Abstract
AIMS Frailty is highly prevalent in patients with heart failure (HF), but a concordant definition of this condition is lacking. The Heart Failure Association of the European Society of Cardiology (HFA-ESC) proposed in 2019 a new multi-domain definition of frailty, but it has never been validated. METHODS AND RESULTS Patients from the HELP-HF registry were stratified according to the number of HFA-ESC frailty domains fulfilled and to the cumulative deficits frailty index (FI) quintiles. Prevalence of frailty and of each domain was reported, as well as the rate of the composite of all-cause death and HF hospitalization, its single components, and cardiovascular death in each group and quintile. Among 854 included patients, 37 (4.3%), 206 (24.1%), 365 (42.8%), 217 (25.4%), and 29 (3.4%) patients fulfilled zero, one, two, three, or four domains, respectively, while 179 patients had a FI < 0.21 and were considered not frail. The 1-year risk of adverse events increased proportionally to the number of domains fulfilled (for each criterion increase, all-cause death or HF hospitalization: hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.27-1.62; all-cause death: HR 1.72, 95% CI 1.46-2.02, HF hospitalizations: subHR 1.21, 95% CI 1.04-1.31; cardiovascular death: HR 1.77, 95% CI 1.45-2.15). Consistent results were found stratifying the cohort for FI quintiles. The FI as a continuous variable demonstrated higher discriminative ability than the number of domains fulfilled (area under the curve = 0.68 vs. 0.64, p = 0.004). CONCLUSION Frailty in patients at risk for advanced HF, assessed via a multi-domain approach and the FI, is highly prevalent and identifies those at increased risk of adverse events. The FI was found to be slightly more effective in identifying patients at increased risk of mortality.
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Affiliation(s)
- Alessandro Villaschi
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Mauro Chiarito
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giada Colombo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Maria Inciardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marta Maccallini
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Gaia Gasparini
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Marco Montella
- Humanitas Research Hospital IRCCS, Milan, Italy
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Stefano Contessi
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniele Cocianni
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Maria Perotto
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Giuseppe Barone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Merlo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Cristiana Vitale
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | | | | | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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14
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McNally T, Tumelty E, Chung I, Hussain S, Mookerjee S, Ali MA, Anderson L, Rosano G, Banerjee D. Investigating the relationship between FRailty And Quality of LIfe in patients with heart faiLure and CKD (FRAIL study). ESC Heart Fail 2024; 11:1411-1421. [PMID: 38320815 PMCID: PMC11098643 DOI: 10.1002/ehf2.14693] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Revised: 12/27/2023] [Accepted: 01/09/2024] [Indexed: 05/18/2024] Open
Abstract
AIMS Patients with chronic kidney disease (CKD) or heart failure (HF) are disproportionally affected by frailty, an independent predictor of morbidity. The prevalence of frailty and its impact on quality of life (QoL) in a unique population of patients with both CKD and HF (CKD-HF) is unclear. The aim of this study was to investigate the association between frailty and QoL in patients with CKD-HF. METHODS AND RESULTS Patients were identified from a tertiary care cardiorenal clinic. Eligible patients had CKD-HF with a stable estimated glomerular filtration rate of <60 mL/min/1.732. Data were collected from each participant at one point in time using surveys delivered by study personnel between 14 July 2022 and 31 March 2023. Frailty was defined as Modified Frailty Phenotype (MFP) score ≥3. The Medical Outcomes Study 36-item Short Form Health Survey (SF-36) was used to assess QoL. Demographic data were retrospectively collected from electronic patient records. Demographics and QoL were compared between frail and non-frail cohorts using Pearson's R and Student's t-test (two-tailed, alpha-priori = 0.05). One hundred five participants consented, and 103 completed the questionnaires in full. Amongst the 103 participants, 49.5% (n = 51) were frail. Frailty was related to sex (P = 0.021) and medication count (P = 0.007), however not to other clinical measures, including estimated glomerular filtration rate (P = 0.437) and ejection fraction (P = 0.911). Frail patients reported poorer QoL across physical functioning (P < 0.001), general health (P < 0.001), bodily pain (P = 0.004), social functioning (P < 0.001), and energy levels (P < 0.001), however not emotional wellbeing (P = 0.058); 51.5% cited 'better quality of life' as their healthcare priority, over longer survival (23.3%) or avoiding hospital admissions (22.3%). This was consistent across frail and non-frail groups. CONCLUSIONS A large proportion of CKD-HF patients are frail, regardless of disease severity, and more susceptible to significantly poorer QoL across physical and social domains. Improving QoL is the priority of patients across both frail and non-frail cohorts, further emphasizing the need for prompt recognition of frailty as well as possible intervention and prevention.
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Affiliation(s)
- Thomas McNally
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Ella Tumelty
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Isaac Chung
- St George's University Hospitals NHS Foundation TrustLondonUK
| | - Sabba Hussain
- St George's University Hospitals NHS Foundation TrustLondonUK
| | | | | | - Lisa Anderson
- St George's University Hospitals NHS Foundation TrustLondonUK
| | | | - Debasish Banerjee
- St George's University Hospitals NHS Foundation TrustLondonUK
- St George's University of LondonLondonUK
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15
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Yao A, Gao L, Zhang J, Cheng JM, Kim DH. Frailty as an Effect Modifier in Randomized Controlled Trials: A Systematic Review. J Gen Intern Med 2024; 39:1452-1473. [PMID: 38592606 PMCID: PMC11169165 DOI: 10.1007/s11606-024-08732-8] [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: 10/19/2023] [Accepted: 03/15/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The effect of clinical interventions may vary by patients' frailty status. Understanding treatment effect heterogeneity by frailty could lead to frailty-guided treatment strategies and reduce overtreatment and undertreatment. This systematic review aimed to examine the effect modification by frailty in randomized controlled trials (RCTs) that evaluate pharmacological, non-pharmacological, and multicomponent interventions. METHODS We searched PubMed, Web of Science, EMBASE, and ClinicalTrial.gov, from their inception to 8 December 2023. Two reviewers independently extracted trial data and examined the study quality with senior authors. RESULTS Sixty-one RCTs that evaluated the interaction between frailty and treatment effects in older adults were included. Frailty was evaluated using different tools such as the deficit accumulation frailty index, frailty phenotype, and other methods. The effect of several pharmacological interventions (e.g., edoxaban, sacubitril/valsartan, prasugrel, and chemotherapy) varied according to the degree of frailty, whereas other treatments (e.g., antihypertensives, vaccinations, osteoporosis medications, and androgen medications) demonstrated consistent benefits across different frailty levels. Some non-pharmacological interventions had greater benefits in patients with higher (e.g., chair yoga, functional walking, physical rehabilitation, and higher dose exercise program) or lower (e.g., intensive lifestyle intervention, psychosocial intervention) levels of frailty, while others (e.g., resistance-type exercise training, moderate-intensive physical activity, walking and nutrition or walking) produced similar intervention effects. Specific combined interventions (e.g., hospital-based disease management programs) demonstrated inconsistent effects across different frailty levels. DISCUSSION The efficacy of clinical interventions often varied by frailty levels, suggesting that frailty is an important factor to consider in recommending clinical interventions in older adults. REGISTRATION PROSPERO registration number CRD42021283051.
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Affiliation(s)
- Aaron Yao
- VillageMD Research Institute, Chicago, IL, USA.
- Virginia Commonwealth University, Richmond, VA, USA.
| | | | - Jiajun Zhang
- Qingdao Municipal Hospital, Qingdao, Shandong, China
| | - Joyce M Cheng
- The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA, USA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
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16
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Mayne KJ, Hanlon P, Lees JS. Detecting and managing the patient with chronic kidney disease in primary care: A review of the latest guidelines. Diabetes Obes Metab 2024. [PMID: 38699995 DOI: 10.1111/dom.15625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 04/14/2024] [Accepted: 04/15/2024] [Indexed: 05/05/2024]
Abstract
Chronic kidney disease (CKD) is a major global health problem, affecting about 9.5% of the population and 850 million people worldwide. In primary care, most CKD is caused by diabetes and/or hypertension, but a substantial proportion of cases may have alternative causes. During the early stages, CKD is asymptomatic, and many people are unaware that they are living with the disease. Despite the lack of symptoms, CKD is associated with elevated risks of cardiovascular disease, progressive kidney disease, kidney failure and premature mortality. Risk reduction strategies are effective and cost-effective but require early diagnosis through testing of the estimated glomerular filtration rate and albuminuria in high-risk populations. Once diagnosed, the treatment of CKD centres around lifestyle interventions, blood pressure and glycaemic control, and preventative treatments for cardiovascular disease and kidney disease progression. Most patients with CKD should be managed with statins, renin-angiotensin-aldosterone system inhibitors and sodium-glucose cotransporter-2 inhibitors. Additional treatment options to reduce cardiorenal risk are available in patients with diabetes, including glucagon-like peptide-1 receptor agonists and non-steroidal mineralocorticoid receptor antagonists. The Kidney Failure Risk Equation is a new tool that can support the identification of patients at high risk of progressive kidney disease and kidney failure and can be used to guide referrals to nephrology. This review summarizes the latest guidance relevant to managing adults with, or at risk of, CKD and provides practical advice for managing patients with CKD in primary care.
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Affiliation(s)
- Kaitlin J Mayne
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, NHS Greater Glasgow and Clyde, Glasgow, UK
| | - Peter Hanlon
- School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Jennifer S Lees
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Glasgow Renal and Transplant Unit, NHS Greater Glasgow and Clyde, Glasgow, UK
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17
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Seidu S, Alabraba V, Davies S, Newland-Jones P, Fernando K, Bain SC, Diggle J, Evans M, James J, Kanumilli N, Milne N, Viljoen A, Wheeler DC, Wilding JPH. SGLT2 Inhibitors - The New Standard of Care for Cardiovascular, Renal and Metabolic Protection in Type 2 Diabetes: A Narrative Review. Diabetes Ther 2024; 15:1099-1124. [PMID: 38578397 PMCID: PMC11043288 DOI: 10.1007/s13300-024-01550-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/19/2023] [Accepted: 02/06/2024] [Indexed: 04/06/2024] Open
Abstract
A substantial evidence base supports the use of sodium-glucose cotransporter-2 inhibitors (SGLT2is) in the treatment of type 2 diabetes mellitus (T2DM). This class of medicines has demonstrated important benefits that extend beyond glucose-lowering efficacy to protective mechanisms capable of slowing or preventing the onset of long-term cardiovascular, renal and metabolic (CVRM) complications, making their use highly applicable for organ protection and the maintenance of long-term health outcomes. SGLT2is have shown cost-effectiveness in T2DM management and economic savings over other glucose-lowering therapies due to reduced incidence of cardiovascular and renal events. National and international guidelines advocate SGLT2i use early in the T2DM management pathway, based upon a plethora of supporting data from large-scale cardiovascular outcome trials, renal outcomes trials and real-world studies. While most people with T2DM would benefit from CVRM protection through SGLT2i use, prescribing hesitancy remains, potentially due to confusion concerning their place in the complex therapeutic paradigm, variation in licensed indications or safety perceptions/misunderstandings associated with historical data that have since been superseded by robust clinical evidence and long-term pharmacovigilance reporting. This latest narrative review developed by the Improving Diabetes Steering Committee (IDSC) outlines the place of SGLT2is within current evidence-informed guidelines, examines their potential as the standard of care for the majority of newly diagnosed people with T2DM and sets into context the perceived risks and proven advantages of SGLT2is in terms of sustained health outcomes. The authors discuss the cost-effectiveness case for SGLT2is and provide user-friendly tools to support healthcare professionals in the correct application of these medicines in T2DM management. The previously published IDSC SGLT2i Prescribing Tool for T2DM Management has undergone updates and reformatting and is now available as a Decision Tool in an interactive pdf format as well as an abbreviated printable A4 poster/wall chart.
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Affiliation(s)
- Samuel Seidu
- Diabetes Research Centre, Leicester General Hospital, University of Leicester, Leicester, UK
| | - Vicki Alabraba
- Leicester Diabetes Centre, University Hospitals Leicester NHS Trust, Leicester, UK
| | | | | | | | - Stephen C Bain
- Diabetes Research Group, Swansea University Medical School, Swansea University, Swansea, UK
- Department of Diabetes and Endocrinology, Singleton Hospital, Swansea Bay University Health Board, Swansea, UK
| | - Jane Diggle
- College Lane Surgery, Ackworth, West Yorkshire, UK
| | - Marc Evans
- University Hospital Llandough, Cardiff, UK
| | - June James
- Leicester Diabetes Centre, University Hospitals Leicester NHS Trust, Leicester, UK
| | - Naresh Kanumilli
- Brooklands Northenden Primary Care Network, Manchester, UK
- Manchester University Foundation Trust, Manchester, UK
| | - Nicola Milne
- Brooklands Northenden Primary Care Network, Manchester, UK
| | - Adie Viljoen
- Borthwick Diabetes Research Unit, Lister Hospital, Stevenage, UK
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - John P H Wilding
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, Clinical Sciences Centre, Aintree University Hospital, University of Liverpool, Liverpool, UK.
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18
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Zhang N, Qu X, Kang L, Liu X, Zhu W. Mapping Knowledge Landscapes and Emerging Trends of the Links Between Frailty and Heart Failure: A Bibliometric Analysis From 2000 to 2023. Cureus 2024; 16:e60511. [PMID: 38764704 PMCID: PMC11101057 DOI: 10.7759/cureus.60511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/17/2024] [Indexed: 05/21/2024] Open
Abstract
Background Frailty, within the context of heart failure (HF), is strongly linked to poor patient outcomes. Investigating the vulnerable condition of individuals with HF is crucial, not only for medical reasons but also as a significant public health challenge, especially among the elderly population where both HF and frailty are common. Therefore, it is essential to prioritize HF patients with frailty over those without such symptoms. To begin, promptly assessing the impact of academic research in this area is crucial, considering factors such as geographical regions, authors, journals, and institutions. Additionally, it is important to explore current topics and identify potential areas that could inspire future researchers to conduct further studies to advance public health. Methodology We conducted a search in the Web of Science Core Collection database to identify articles and reviews in the English language focusing on frailty and HF which were published from January 1, 2000, to December 31, 2023. To perform bibliometric analysis, VOSviewer (v.1.6.18) and CiteSpace (v.6.1.R2) were utilized. Results A total of 1,381 original English-language articles were gathered, comprising 1,162 articles and 219 reviews. The quantity of research publications in this area has experienced significant growth since 2013. Among all countries, the United States has contributed the largest number of publications, accounting for 409 articles (29.62% of the total). Additionally, the United States has received the highest number of citations, being cited a total of 13,329 times, as well as boasting the greatest total link strength. Duke University stands out as the institution with the highest number of research papers, having published 40 articles (2.90% of the total). It has also received the most citations, with a total of 2,455 times, and possesses the highest total link strength, which amounts to 212. Within the realm of prolific authors, Kentaro Kamiya from Kitasato University emerges as the most productive, having authored 28 articles (2.03% of the total). When considering scholarly journals, "Esc Heart Failure" contains the highest number of articles pertaining to frailty and HF, publishing a noteworthy 36 articles (2.61% of the total). Noteworthy keywords within this field encompass frailty, heart failure, elderly, mortality, and cardiovascular disease. Over the past five years, the most popular keywords have centered around "frailty syndrome," "sarcopenia," and "therapeutic interventions." Conclusions Research on frailty and HF at a global scale has experienced substantial growth between 2000 and 2023, demonstrating a prospective field for further exploration with potential advantages from ongoing progress. Prospective studies could prioritize the enhancement of cardiac rehabilitation for patients coping with HF and frailty while ensuring the preservation of their overall quality of life.
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Affiliation(s)
- Ning Zhang
- Department of Geriatrics, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
| | - Xuan Qu
- Department of Geriatrics, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
| | - Lin Kang
- Department of Geriatrics, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
| | - Xiaohong Liu
- Department of Geriatrics, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
| | - Wenling Zhu
- Department of Cardiology, Peking Union Medical College Hospital, Peking Union Medical College, Beijing, CHN
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19
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Tumelty E, Chung I, Hussain S, Ali MA, Addada H, Banerjee D. An Updated Review of the Management of Chronic Heart Failure in Patients with Chronic Kidney Disease. Rev Cardiovasc Med 2024; 25:144. [PMID: 39076544 PMCID: PMC11264008 DOI: 10.31083/j.rcm2504144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2023] [Revised: 12/01/2023] [Accepted: 12/07/2023] [Indexed: 07/31/2024] Open
Abstract
Chronic kidney disease (CKD) is common in patients with heart failure (HF) and is associated with high morbidity and mortality. There has been remarkable progress in the treatment of HF over recent years with the establishment of guideline-directed medical therapies including: (1) Beta-blockers, (2) renal angiotensin aldosterone system (RAAS) inhibition (i.e., angiotensin-converting enzyme inhibitor [ACEi], aldosterone receptor blocker [ARB] or angiotensin receptor-neprilysin inhibitor [ARNI]); (3) mineralocorticoid receptor antagonists (MRA), and (4) sodium-glucose cotransporter-2 inhibitors (SGLT2i). However, there are challenges to the implementation of these medications in patients with concomitant CKD due to increased vulnerability to common side-effects (including worsening renal function, hyperkalaemia, hypotension), and most of the pivotal trials which provide evidence of the efficacy of these medications excluded patients with severe CKD. Patients with CKD and HF often have regular healthcare encounters with multiple professionals and can receive conflicting guidance regarding their medication. Thus, despite being at higher risk of adverse cardiovascular events, patients who have both HF and CKD are more likely to be under-optimised on evidence-based therapies. This review is an updated summary of the evidence available for the management of HF (including reduced, mildly reduced and preserved left ventricular ejection fraction) in patients with various stages of CKD. The review covers the evidence for recommended medications, devices such as implantable cardioverter-defibrillator (ICD), cardiac resynchronization therapy (CRT), intravenous (IV) iron, and discusses how frailty affects the management of these patients. It also considers emerging evidence for the prevention of HF in the cohort of patients with CKD. It synthesises the available evidence regarding when to temporarily stop, continue or rechallenge medications in this cohort. Chronic HF in context of CKD remains a challenging scenario for clinicians to manage, which is usually complicated by frailty, multimorbidity and polypharmacy. Treatment should be tailored to a patients individual needs and management in specialised cardio-renal clinics with a multi-disciplinary team approach has been recommended. This review offers a concise summary on this expansive topic.
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Affiliation(s)
- Ella Tumelty
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Isaac Chung
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Sabba Hussain
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Mahrukh Ayesha Ali
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
| | - Harshavardhani Addada
- Cardiovascular and Genetics Research Institute St George’s University of London, SW17 0QT London, UK
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George’s University Hospitals NHS Foundation Trust London, SW17 0QT London, UK
- Cardiovascular and Genetics Research Institute St George’s University of London, SW17 0QT London, UK
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20
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Tian J, Li W, Zeng L, Li Y, Du J, Li Y, Li B, Su G. HBI-8000 improves heart failure with preserved ejection fraction via the TGF-β1/MAPK signalling pathway. J Cell Mol Med 2024; 28:e18238. [PMID: 38509729 PMCID: PMC10955178 DOI: 10.1111/jcmm.18238] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Revised: 01/18/2024] [Accepted: 02/09/2024] [Indexed: 03/22/2024] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) accounts for approximately 50% of total heart failure patients and is characterized by peripheral circulation, cardiac remodelling and comorbidities (such as advanced age, obesity, hypertension and diabetes) with limited treatment options. Chidamide (HBI-8000) is a domestically produced benzamide-based histone deacetylase isoform-selective inhibitor used for the treatment of relapsed refractory peripheral T-cell lymphomas. Based on our in vivo studies, we propose that HBI-8000 exerts its therapeutic effects by inhibiting myocardial fibrosis and myocardial hypertrophy in HFpEF patients. At the cellular level, we found that HBI-8000 inhibits AngII-induced proliferation and activation of CFs and downregulates the expression of fibrosis-related factors. In addition, we observed that the HFpEF group and AngII stimulation significantly increased the expression of TGF-β1 as well as phosphorylated p38MAPK, JNK and ERK, whereas the expression of the above factors was significantly reduced after HBI-8000 treatment. Activation of the TGF-β1/MAPK pathway promotes the development of fibrotic remodelling, and pretreatment with SB203580 (p38MAPK inhibitor) reverses this pathological change. In conclusion, our data suggest that HBI-8000 inhibits fibrosis by modulating the TGF-β1/MAPK pathway thereby improving HFpEF. Therefore, HBI-8000 may become a new hope for the treatment of HFpEF patients.
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Affiliation(s)
- Jing Tian
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Wenjing Li
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Lu Zeng
- Research Center of Translational Medicine, Jinan Central HospitalShandong First Medical UniversityJinanShandongChina
| | - Yang Li
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
| | - Jiamin Du
- Department of Cardiology, Jinan Central Hospital, Cheeloo College of MedicineShandong UniversityJinanShandongChina
| | - Ying Li
- Research Center of Translational Medicine, Jinan Central HospitalShandong First Medical UniversityJinanShandongChina
| | - Bin Li
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
- Research Center of Translational Medicine, Jinan Central HospitalShandong First Medical UniversityJinanShandongChina
| | - Guohai Su
- Central Hospital Affiliated to Shandong First Medical UniversityJinanShandongChina
- Research Center of Translational Medicine, Jinan Central HospitalShandong First Medical UniversityJinanShandongChina
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21
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Kuthi LK, Schwertner WR, Veres B, Merkel ED, Masszi R, Behon A, Kovács A, Osztheimer I, Zima E, Molnár L, Gellér L, Kosztin A, Merkely B. The prevalence of frailty and its effect on the outcome in cardiac resynchronization therapy patients. GeroScience 2024; 46:2671-2679. [PMID: 38127223 PMCID: PMC10828248 DOI: 10.1007/s11357-023-01023-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023] Open
Abstract
Frailty is a complex clinical syndrome associated with aging and comorbidities, which correlates with unfavorable outcomes. However, in heart failure patients, frailty is very common, data is scarce about those, who are eligible for Cardiac Resynchronization Therapy (CRT) implantation. We investigated the incidence of frailty and the association of Frailty Index (FI) with the outcome. Thirty baseline clinical parameters were used by the Rockwood cumulative deficit method to determine patients' FI in our single-center cohort. Based on previous studies, patients with FI ≤ 0.210 were considered as non-frail, those with FI 0.10-0.210 were classified in Frail-1, with FI > 0.10 in Frail-2 groups, respectively. Echocardiographic response after 12 months and all-cause mortality were investigated by frailty groups. Among 1004 included patients, 75 (7%) were considered Non-frail, 271 (27%) grouped in Frail-1, and 658 (66%) in Frail-2 with a median FI of 0.36 (0.28-0.43). Patients in Frail-2 group were older, with more comorbidities compared with non-frail patients or those in Group Frail-1. During the median follow-up time of 4.8 years, 29 (39%) patients died in the Non-frail, 140 (52%) in Frail-1, and 471 (72%) in the Frail-2 groups (log-rank p < 0.001). Group Frail-2 showed an unfavorable outcome compared to the non-frail (HR 2.49, 95%CI 1.92-3.22; p < 0.001) and the Frail-1 group (1.83, 95%CI 1.55-2.16; p < 0.001). In our HFrEF patients eligible for CRT implantation, patients were exceedingly vulnerable with a high prevalence of frailty. The calculated frailty index was associated with outcome and proved to be prevalent in individual risk stratification.
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Affiliation(s)
- Luca Katalin Kuthi
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | | | - Boglárka Veres
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Eperke Dóra Merkel
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Richard Masszi
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Anett Behon
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Attila Kovács
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - István Osztheimer
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Endre Zima
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Levente Molnár
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - László Gellér
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Annamária Kosztin
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, 68 Városmajor Street, Budapest, 1122, Hungary.
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22
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Nguyen TN, Ahmad F, Lindley RI. Frailty in clinical drug trials: Frailty assessments, subgroup analyses and outcomes. Br J Clin Pharmacol 2024. [PMID: 38509766 DOI: 10.1111/bcp.16034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 12/23/2023] [Accepted: 01/18/2024] [Indexed: 03/22/2024] Open
Abstract
With population ageing, drug trials are increasingly turning their attention to including older, frailer people. This review aimed to provide an overview of how frailty was assessed in published studies related to clinical pharmacological trials, and on the interaction of frailty on the efficacy of the treatments. We searched MEDLINE, EMBASE and Cochrane for clinical drug trials in older people. A total of 4031 abstracts were screened and 17 relevant studies were included in this review. We summarized the findings of these 17 trials into five main clinical areas: cardiovascular (eight studies), cognition (one study), vaccination (two studies), cancer (four studies) and other (two studies). Frailty was assessed retrospectively in most of the studies. Frailty was treated as an ordinal variable (with different levels of frailty) or binary variable (frail/non-frail) using cut-offs in some studies, and as a continuous in some other studies. The effect of frailty on the treatment efficacy was not consistent among the studies. While several trials, such as the Action in Diabetes and Vascular Disease-Preterax and Diamicron Modified Release Controlled Evaluation trials, the Systolic Blood Pressure Intervention Trial and the Aspirin in Reducing Events in the Elderly trial, showed some reduced effects of the treatment in frail patients, most of the trials showed that the benefits of the treatment are not affected by frailty. Some trials even showed that the benefits of the treatment were more significant in frailer patients (the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure and the Dapagliflozin Evaluation to Improve the Lives of Patients with Preserved Ejection Fraction Heart Failure trials). The results of this review suggest that routine measurement of frailty in participants in clinical drug trials would improve our knowledge of the effect of treatment in the frail and identify those who have more or least to gain from treatment.
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Affiliation(s)
- Tu N Nguyen
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Fahed Ahmad
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
| | - Richard I Lindley
- Westmead Applied Research Centre, Sydney Medical School, Faculty of Medicine and Health, University of Sydney, Sydney, New South Wales, Australia
- George Institute for Global Health, Sydney, New South Wales, Australia
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23
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Beussink-Nelson L, Freed BH, Chirinos JA, Brubaker PH, Kitzman DW, Yeboah J, Rosas SE, Hu M, Lima JAC, Pandit J, Bertoni AG, Shah SJ. Multi-Ethnic Study of Atherosclerosis Early Heart Failure Study: Rationale, Design, and Baseline Characteristics. Circ Heart Fail 2024; 17:e010289. [PMID: 38456289 PMCID: PMC11073782 DOI: 10.1161/circheartfailure.122.010289] [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: 10/25/2022] [Accepted: 12/20/2023] [Indexed: 03/09/2024]
Abstract
BACKGROUND Current prevalence estimates of heart failure (HF) are primarily based on self-report or HF hospitalizations. There is an unmet need to define the prevalence and pathogenesis of early symptomatic HF, which may be undiagnosed and precedes HF hospitalization. METHODS The MESA (Multi-Ethnic Study of Atherosclerosis) Early HF study was conducted during MESA exam 6 to determine the prevalence of early HF and investigate the transition from risk factors to early HF in a diverse population-based cohort of older adults. Between 2016 and 2018, 3285 MESA participants from 6 field centers underwent comprehensive speckle-tracking echocardiography with passive leg raise maneuver, Kansas City Cardiomyopathy Questionnaire, 6-minute walk test, arterial stiffness assessment, and proteomics (including NT-proBNP [N-terminal pro-B-type natriuretic peptide]). RESULTS Median age was 73 (25th-75th percentile 67-81) years, 53.2% were female, 25.6% were Black, 12.8% were Chinese, and 40.0% were White. The prevalence of HF risk factors was high: hypertension, 61.9%; former or current smoking, 53.7%; obesity 34.8%; diabetes; 24.7%; and chronic kidney disease; 22%. Overt cardiovascular disease, which ranged from 2.1% (HF) to 13.6% (atrial fibrillation), was less common. Of the 3285 participants, 96% underwent proteomics, 94% Kansas City Cardiomyopathy Questionnaire, 93% speckle-tracking echocardiography with passive leg raise, 82% arterial stiffness exam, and 77% 6-minute walk test. Feasibility of resting speckle-tracking echocardiography (87%-99% across cardiac chambers) and passive leg raise Doppler/speckle-tracking echocardiography (>84%) measurements was high. A total of 120 unique echocardiographic indices were measured. CONCLUSIONS The MESA Early HF study is a key resource for cardiovascular researchers who are interested in improving the epidemiological and phenotypic characterization of early HF. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT00005487.
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Affiliation(s)
- Lauren Beussink-Nelson
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
| | - Benjamin H Freed
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
| | - Julio A Chirinos
- Division of Cardiology, Department of Medicine, University of Pennsylvania Perelman School of Medicine, Hospital of the University of Pennsylvania and Perelman Center for Advanced Medicine, Philadelphia (J.A.C.)
| | - Peter H Brubaker
- Wake Forest School of Medicine (P.H.B., D.W.K., J.Y., A.G.B.), Harvard Medical School, Boston, MA
| | - Dalane W Kitzman
- Wake Forest School of Medicine (P.H.B., D.W.K., J.Y., A.G.B.), Harvard Medical School, Boston, MA
| | - Joseph Yeboah
- Wake Forest School of Medicine (P.H.B., D.W.K., J.Y., A.G.B.), Harvard Medical School, Boston, MA
| | - Sylvia E Rosas
- Kidney and Hypertension Unit, Joslin Diabetes Center (S.E.R.), Harvard Medical School, Boston, MA
| | - Mo Hu
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
| | - João A C Lima
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD (J.A.C.L.)
| | - Jay Pandit
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
| | - Alain G Bertoni
- Wake Forest School of Medicine (P.H.B., D.W.K., J.Y., A.G.B.), Harvard Medical School, Boston, MA
| | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (L.B.-N., B.H.F., M.H., J.P., S.J.S.)
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24
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Aliberti MJR, Tavares CAM, Pajewski NM. Awaiting the verdict: Statins and the road ahead for primary prevention in older adults. J Am Geriatr Soc 2024; 72:332-336. [PMID: 38217414 PMCID: PMC10922889 DOI: 10.1111/jgs.18764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 12/27/2023] [Indexed: 01/15/2024]
Abstract
This editorial comments on the article by Orkaby et al. in this issue.
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Affiliation(s)
- Márlon Juliano Romero Aliberti
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Research Institute, Hospital Sirio-Libanes, Sao Paulo, Brazil
| | - Caio A M Tavares
- Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Servico de Geriatria, Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, Brazil
- Academic Research Organization, Hospital Israelita Albert Einstein, São Paulo, Brazil
- Geriatric Cardiology Unit, Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
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25
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Vart P, Butt JH, Jongs N, Schechter M, Chertow GM, Wheeler DC, Pecoits-Filho R, Langkilde AM, Correa-Rotter R, Rossing P, McMurray JJV, Heerspink HJL. Efficacy and Safety of Dapagliflozin in Patients With Chronic Kidney Disease Across the Spectrum of Frailty. J Gerontol A Biol Sci Med Sci 2024; 79:glad181. [PMID: 37527836 PMCID: PMC10809037 DOI: 10.1093/gerona/glad181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Indexed: 08/03/2023] Open
Abstract
BACKGROUND A sizeable proportion of patients with chronic kidney disease (CKD) are reported to be frail. Here we examined the safety and efficacy of dapagliflozin in patients with CKD by frailty level. METHODS Adults with CKD, with/without type 2 diabetes, with an estimated glomerular filtration rate (eGFR) of 25-75 mL/min/1.73 m2, and urinary albumin-to-creatinine ratio 200-5 000 mg/g were randomized to dapagliflozin (10 mg/day) or placebo. The primary endpoint was a composite of sustained ≥50% eGFR decline, end-stage kidney disease (ESKD), or death from kidney or cardiovascular (CV) causes. RESULTS Frailty index (FI), assessed by Rockwood cumulative deficit approach, was calculable in 4 303/4 304 (99.9%) patients: 1 162 (27.0%) in not-to-mildly frail (FI ≤0.210), 1 642 (38.2%) in moderately frail (FI 0.211-0.310), and 1 499 (34.8%) in severely frail categories (FI >0.311). Dapagliflozin reduced the risk of the primary composite endpoint across all FI categories (hazard ratios [95% confidence interval {CI}]: 0.50 [0.33-0.76], 0.62 [0.45-0.85], and 0.64 [0.49--0.83], respectively; p-interaction = 0.67). Results were similar for secondary outcomes including kidney composite outcome (sustained ≥50% eGFR decline, ESKD or death from kidney cause; p-interaction = 0.44), CV endpoint (heart failure hospitalization or CV death; p-interaction = 0.63), and all-cause mortality (p-interaction p = .42). Results were consistent when using FI as a continuous variable. Occurrence of serious adverse events was numerically lower in patients receiving dapagliflozin versus placebo in all FI categories (16.9% vs 20.1%, 26.3% vs 30.7%, and 42.9% vs 47.8%, in not-to-mildly, moderately, and severely frail categories, respectively). CONCLUSIONS The relative benefit of dapagliflozin for all outcomes was consistent across all frailty categories, with no difference in associated safety.
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Affiliation(s)
- Priya Vart
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Internal Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jawad H Butt
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
- Department of Cardiology, Copenhagen University Hospital Rigshospitalet, Copenhagen, Denmark
| | - Niels Jongs
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Meir Schechter
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Glenn M Chertow
- Department of Medicine, Stanford University School of Medicine, Stanford, California, USA
- Department of Epidemiology and Population Health, Stanford University School of Medicine, Stanford, California, USA
| | - David C Wheeler
- Department of Renal Medicine, University College London, London, UK
| | - Roberto Pecoits-Filho
- Arbor Research Collaborative for Health, Ann Arbor, Michigan, USA
- School of Medicine, Pontificia Universidade Catolica do Parana, Curitiba, Brazil
| | | | - Ricardo Correa-Rotter
- The National Medical Science and Nutrition Institute Salvador Zubiran, Mexico City, Mexico
| | - Peter Rossing
- Steno Diabetes Center Copenhagen, Gentofte, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - John J V McMurray
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Hiddo J L Heerspink
- Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- The George Institute for Global Health, Sydney, New South Wales, Australia
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26
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Orkaby AR, Callahan KE, Driver JA, Hudson K, Clegg AJ, Pajewski NM. New horizons in frailty identification via electronic frailty indices: early implementation lessons from experiences in England and the United States. Age Ageing 2024; 53:afae025. [PMID: 38421151 PMCID: PMC10903644 DOI: 10.1093/ageing/afae025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Indexed: 03/02/2024] Open
Abstract
Frailty represents an integrative prognostic marker of risk that associates with a myriad of age-related adverse outcomes in older adults. As a concept, frailty can help to target scarce resources and identify subgroups of vulnerable older adults that may benefit from interventions or changes in medical management, such as pursing less aggressive glycaemic targets for frail older adults with diabetes. In practice, however, there are several operational challenges to implementing frailty screening outside the confines of geriatric medicine. Electronic frailty indices (eFIs) based on the theory of deficit accumulation, derived from routine data housed in the electronic health record, have emerged as a rapid, feasible and valid approach to screen for frailty at scale. The goal of this paper is to describe the early experience of three diverse groups in developing, implementing and adopting eFIs (The English National Health Service, US Department of Veterans Affairs and Atrium Health-Wake Forest Baptist). These groups span different countries and organisational complexity, using eFIs for both research and clinical care, and represent different levels of progress with clinical implementation. Using an implementation science framework, we describe common elements of successful implementation in these settings and set an agenda for future research and expansion of eFI-informed initiatives.
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Affiliation(s)
- Ariela R Orkaby
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA
- Division of Aging, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kathryn E Callahan
- Section on Geriatrics and Gerontologic Medicine, Department of Internal Medicine, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Jane A Driver
- New England Geriatric Research, Education, and Clinical Center (GRECC), VA Boston Healthcare System, Boston, MA, USA
- Division of Aging, Department of Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Kristian Hudson
- The Improvement Academy, Bradford Institute for Health Research, Bradford, UK
| | - Andrew J Clegg
- Academic Unit for Ageing & Stroke Research, University of Leeds, Bradford Teaching Hospitals NHS Foundation Trust, Bradford, UK
| | - Nicholas M Pajewski
- Department of Biostatistics and Data Science, Division of Public Health Sciences, Wake Forest University School of Medicine, Winston-Salem, NC, USA
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Coats AJS, Butler J, Tsutsui H, Doehner W, Filippatos G, Ferreira JP, Böhm M, Chopra VK, Verma S, Nordaby M, Iwata T, Nitta D, Ponikowski P, Zannad F, Packer M, Anker SD. Efficacy of empagliflozin in heart failure with preserved ejection fraction according to frailty status in EMPEROR-Preserved. J Cachexia Sarcopenia Muscle 2024; 15:412-424. [PMID: 38158636 PMCID: PMC10834334 DOI: 10.1002/jcsm.13393] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/22/2023] [Accepted: 11/06/2023] [Indexed: 01/03/2024] Open
Abstract
BACKGROUND Frailty is a severe, common co-morbidity associated with heart failure (HF) with preserved ejection fraction (HFpEF). The impact of frailty on HFpEF outcomes may affect treatment choices in HFpEF. The impact of frailty on HFpEF patients and any impact on the clinical benefits of sodium glucose co-transporter 2 (SGLT2) inhibition in HFpEF have been described in only a limited number of trials. Whether the SGLT2 inhibitor empagliflozin would improve or worsen frailty status when given to HFpEF patients is also not known. The aims of this study were, therefore, to evaluate, in HFpEF patients enrolled in the EMPEROR-Preserved trial (Empagliflozin Outcome Trial in Patients With Chronic Heart Failure With Preserved Ejection Fraction), the impact of frailty on clinical outcomes, and on the effects of empagliflozin, as well as the effect of empagliflozin on frailty status during treatment period. METHODS We calculated a cumulative deficit-derived frailty index (FI) using 44 variables including clinical, laboratory and quality of life parameters recorded in EMPEROR-Preserved. Patients were classified into four groups: non-frail (FI < 0.21), mild frailty (0.21 to <0.30), moderate frailty (0.30 to <0.40) and severe frailty (≥0.40). Clinical outcomes and health-related quality of life were evaluated according to baseline FI along with the effect of empagliflozin on chronological changes in FI (at 12, 32 and 52 weeks). RESULTS The patient distribution was 1514 (25.3%), 2100 (35.1%), 1501 (25.1%) and 873 (14.6%) in non-frail, mild frailty, moderate frailty and severe frailty, respectively. Severe frailty patients tended to be female and have low Kansas City Cardiomyopathy Questionnaire (KCCQ) scores, more co-morbidities and more polypharmacy. Incidence rates of the primary outcome of cardiovascular death or HF hospitalization increased as frailty worsened (hazard ratio [HR] of each FI category compared with the non-frail group: 1.10 [95% confidence interval, CI, 0.89-1.35], 2.00 [1.63-2.47] and 2.61 [2.08-3.27] in the mild frailty, moderate frailty and severe frailty groups, respectively; P trend < 0.001). Compared with placebo, empagliflozin reduced the risk for the primary outcome across the four FI categories, HR: 0.59 [95% CI 0.42-0.83], 0.79 [0.61-1.01], 0.77 [0.61-0.96] and 0.90 [0.69-1.16] in non-frail to severe frailty categories, respectively (P value for trend = 0.097). Empagliflozin also improved other clinical outcomes and KCCQ score across frailty categories. Compared with placebo, empagliflozin-treated patients had a higher likelihood of being in a lower FI category at Weeks 12, 32 and 52 (P < 0.05), odds ratio: 1.12 [95% CI 1.01-1.24] at Week 12, 1.21 [1.09-1.34] at Week 32 and 1.20 [1.09-1.33] at Week 52. CONCLUSIONS Empagliflozin improved key efficacy outcomes with a possible diminution of effect in very frail patients. Empagliflozin also improved frailty status during follow-up.
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Affiliation(s)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Hiroyuki Tsutsui
- School of Medicine and Graduate School, International University of Health and Welfare, Okawa, Japan
| | - Wolfram Doehner
- Berlin Institute of Health Center for Regenerative Therapies (BCRT), Charité Universitätsmedizin, Berlin, Germany
- Deutsches Herzzentrum der Charité, Department of Cardiology (Campus Virchow), Charité Universitätsmedizin, Berlin, Germany
- German Centre for Cardiovascular Research (DZHK) Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - João Pedro Ferreira
- Cardiovascular R&D Centre-UnIC@RISE, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine of the University of Porto, Porto, Portugal
- Department of Internal Medicine, Heart Failure Clinic, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Michael Böhm
- Department of Internal Medicine III, University Hospital Saarland, Saarland University, Homburg, Germany
| | | | - Subodh Verma
- Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, ON, Canada
| | - Matias Nordaby
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Tomoko Iwata
- Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany
| | - Daisuke Nitta
- Medicine Division, Nippon Boehringer Ingelheim Co. Ltd, Tokyo, Japan
| | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Wrocław, Poland
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
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Naito A, Nagatomo Y, Kawai A, Yukino-Iwashita M, Nakazawa R, Taruoka A, Takefuji A, Yasuda R, Toya T, Ikegami Y, Masaki N, Ido Y, Adachi T. The Safety and Efficacy of Sodium-Glucose Cotransporter-2 Inhibitors for Patients with Sarcopenia or Frailty: Double Edged Sword? J Pers Med 2024; 14:141. [PMID: 38392575 PMCID: PMC10890336 DOI: 10.3390/jpm14020141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 01/19/2024] [Accepted: 01/24/2024] [Indexed: 02/24/2024] Open
Abstract
Sodium-glucose cotransporter-2 inhibitors (SGLT-2is) show cardiovascular protective effects, regardless of the patient's history of diabetes mellitus (DM). SGLT2is suppressed cardiovascular adverse events in patients with type 2 DM, and furthermore, SGLT-2is reduced the risk of worsening heart failure (HF) events or cardiovascular death in patients with HF. Along with these research findings, SGLT-2is are recommended for patients with HF in the latest guidelines. Despite these benefits, the concern surrounding the increasing risk of body weight loss and other adverse events has not yet been resolved, especially for patients with sarcopenia or frailty. The DAPA-HF and DELIVER trials consistently showed the efficacy and safety of SGLT-2i for HF patients with frailty. However, the Rockwood frailty index that derived from a cumulative deficit model was employed for frailty assessment in these trials, which might not be suitable for the evaluation of physical frailty or sarcopenia alone. There is no fixed consensus on which evaluation tool to use or its cutoff value for the diagnosis and assessment of frailty in HF patients, or which patients can receive SGLT-2i safely. In this review, we summarize the methodology of frailty assessment and discuss the efficacy and safety of SGLT-2i for HF patients with sarcopenia or frailty.
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Affiliation(s)
- Ayami Naito
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Akane Kawai
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | | | - Ryota Nakazawa
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Akira Taruoka
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Asako Takefuji
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Risako Yasuda
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takumi Toya
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yukinori Ikegami
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Nobuyuki Masaki
- Department of Intensive Care, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Yasuo Ido
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
| | - Takeshi Adachi
- Department of Cardiology, National Defense Medical College, Tokorozawa 359-8513, Japan
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Aldafas R, Crabtree T, Alkharaiji M, Vinogradova Y, Idris I. Sodium-glucose cotransporter-2 inhibitors (SGLT2) in frail or older people with type 2 diabetes and heart failure: a systematic review and meta-analysis. Age Ageing 2024; 53:afad254. [PMID: 38287703 PMCID: PMC10825241 DOI: 10.1093/ageing/afad254] [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: 08/18/2023] [Revised: 11/09/2023] [Indexed: 01/31/2024] Open
Abstract
OBJECTIVE Sodium-glucose cotransporter-2 inhibitors (SGLT2Is) reduce cardio-metabolic and renal outcomes in patients with type 2 diabetes (T2D) but their efficacy and safety in older or frail individuals remains unclear. METHODS We searched PubMed, Scopus, Web of Science, Cochrane CENTRA and Google Scholar and selected randomised controlled trials and observational studies comparing SGLT2Is versus placebo/other glucose-lowering agent for people with frailty or older individuals (>65 years) with T2D and heart failure (HF). Extracted data on the change in HbA1c % and safety outcomes were pooled in a random-effects meta-analysis model. RESULTS We included data from 20 studies (22 reports; N = 77,083 patients). SGLT2Is did not significantly reduce HbA1c level (mean difference -0.13, 95%CI: -0.41 to 0.14). SGLT2Is were associated with a significant reduction in the risk of all-cause mortality (risk ratio (RR) 0.81, 95%CI: -0.69 to 0.95), cardiac death (RR 0.80, 95%CI: -0.94 to 0.69) and hospitalisation for heart failure (HHF) (RR 0.69, 95%CI: 0.59-0.81). However, SGLT2Is did not demonstrate significant effect in reducing in the risk of macrovascular events (acute coronary syndrome or cerebral vascular occlusion), renal progression/composite renal endpoint, acute kidney injury, worsening HF, atrial fibrillation or diabetic ketoacidosis. CONCLUSIONS In older or frail patients with T2D and HF, SGLT2Is are consistently linked with a decrease in total mortality and the overall burden of cardiovascular (CV) events, including HHF events and cardiac death, but not protective for macrovascular death or renal events. Adverse events were more difficult to quantify but the risk of diabetic ketoacidosis or acute kidney injury was not significantly increase.
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Affiliation(s)
- Rami Aldafas
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Faculty of Public Health, College of Health Science, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Tomas Crabtree
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
| | - Mohammed Alkharaiji
- Faculty of Public Health, College of Health Science, The Saudi Electronic University, Riyadh, Saudi Arabia
| | - Yana Vinogradova
- Division of Primary Care, University of Nottingham, Nottingham NG2 7RD, UK
| | - Iskandar Idris
- Division of Graduate Entry Medicine and Health Sciences, University of Nottingham, Derby, UK
- Department of Endocrinology and Diabetes, University Hospitals Derby and Burton NHS Foundation Trust, Derby, UK
- MRC-Versus Arthritis Centre for Musculoskeletal Ageing Research, NIHR, Nottingham BRC, University of Nottingham, Derby, UK
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Greene SJ, Fonarow GC, Butler J. SGLT2 Inhibitors for Heart Failure with Preserved Ejection Fraction: What Hospitalists Need to Know. Am J Cardiovasc Drugs 2024; 24:1-4. [PMID: 38157160 DOI: 10.1007/s40256-023-00624-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 12/11/2023] [Indexed: 01/03/2024]
Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, 300 West Morgan Street, Durham, NC, 27701, USA.
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA.
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
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31
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Hawker K, Akter R, Molnar F, Frank C. Prise en charge du diabète de type 2 chez les patients fragiles. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2024; 70:e10-e13. [PMID: 38262767 PMCID: PMC11126283 DOI: 10.46747/cfp.7001e10] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Kara Hawker
- Résidente en médecine interne au Département de médecine de l'Université d'Ottawa (Ontario)
| | - Ripa Akter
- Directrice du programme de formation postdoctorale à la Division de médecine gériatrique de l'Université d'Ottawa et clinicienne chercheuse à l'Institut de recherche de l'Hôpital d'Ottawa
| | - Frank Molnar
- Spécialiste en médecine gériatrique; il exerce au Département de médecine de l'Université d'Ottawa et à l'Institut de recherche de l'Hôpital d'Ottawa
| | - Chris Frank
- Médecin de famille; il se concentre sur les soins palliatifs et aux personnes âgées, et est professeur au Département de médecine de l'Université Queen's à Kingston (Ontario)
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32
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Hawker K, Akter R, Molnar F, Frank C. Management of type 2 diabetes in patients with frailty. CANADIAN FAMILY PHYSICIAN MEDECIN DE FAMILLE CANADIEN 2024; 70:30-32. [PMID: 38262761 PMCID: PMC11126279 DOI: 10.46747/cfp.700130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2024]
Affiliation(s)
- Kara Hawker
- Internal medicine resident in the Department of Medicine at the University of Ottawa in Ontario
| | - Ripa Akter
- Residency Training Program Director in the Division of Geriatric Medicine in the Department of Medicine at the University of Ottawa and Clinician Investigator at the Ottawa Hospital Research Institute
| | - Frank Molnar
- Specialist in geriatric medicine practising in the Department of Medicine at the University of Ottawa and at the Ottawa Hospital Research Institute
| | - Chris Frank
- Family physician focusing on care of the elderly and palliative care and Professor in the Department of Medicine at Queen's University in Kingston, Ont
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Smetana GW, Ho JE, Orkaby AR, Reynolds EE. How Would You Manage This Patient With Heart Failure With Preserved Ejection Fraction? : Grand Rounds Discussion From Beth Israel Deaconess Medical Center. Ann Intern Med 2023; 176:1656-1665. [PMID: 38079640 DOI: 10.7326/m23-2384] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2023] Open
Abstract
The proportion of patients with new-onset heart failure who have preserved rather than reduced left ventricular ejection fraction (HFpEF and HFrEF) has been increasing over recent decades. In fact, HFpEF now outweighs HFrEF as the predominant heart failure subtype and likely remains underdiagnosed in the community. This is due in part to an aging population and a rise in other risk factors for HFpEF, including obesity and associated cardiometabolic disease. Whereas the diagnosis of HFrEF is relatively straightforward, the diagnosis of HFpEF is often more challenging because there can be other causes for symptoms, including dyspnea and fatigue, and cardinal physical examination findings of elevated jugular venous pressure or pulmonary congestion may not be evident at rest. In 2022, the American College of Cardiology, the American Heart Association, and the Heart Failure Society of America published a comprehensive guideline on heart failure that included recommendations for the management of HFpEF. The use of diuretics for the management of congestion remained the only class 1 (strong) recommendation. New recommendations included broader use of sodium-glucose cotransporter-2 inhibitors (SGLT2i, class 2a), and angiotensin receptor-neprilysin inhibitors (class 2b). In 2023, the American College of Cardiology published an expert consensus decision pathway for the management of HFpEF that suggests treatment strategies based on sex assigned at birth, ejection fraction, clinical evidence of congestion, and candidacy for SGLT2i therapy. Here, 2 experts, a cardiologist and a geriatrician, discuss their approach to the diagnosis and management of HFpEF and how they would apply guidelines to an individual patient.
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Affiliation(s)
- Gerald W Smetana
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (G.W.S., J.E.H., E.E.R.)
| | - Jennifer E Ho
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (G.W.S., J.E.H., E.E.R.)
| | - Ariela R Orkaby
- VA Boston Healthcare System and Brigham & Women's Hospital, Boston, Massachusetts (A.R.O.)
| | - Eileen E Reynolds
- Beth Israel Deaconess Medical Center, Boston, Massachusetts (G.W.S., J.E.H., E.E.R.)
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Leong DP, Joseph P, McMurray JJV, Rouleau J, Maggioni AP, Lanas F, Sharma SK, Núñez J, Mohan B, Celik A, Abdullakutty J, Ogah OS, Mielniczuk LM, Balasubramanian K, McCready T, Grinvalds A, Yusuf S. Frailty and outcomes in heart failure patients from high-, middle-, and low-income countries. Eur Heart J 2023; 44:4435-4444. [PMID: 37639487 PMCID: PMC10635666 DOI: 10.1093/eurheartj/ehad595] [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: 07/12/2023] [Revised: 08/21/2023] [Accepted: 08/25/2023] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND AND AIMS There is little information on the incremental prognostic importance of frailty beyond conventional prognostic variables in heart failure (HF) populations from different country income levels. METHODS A total of 3429 adults with HF (age 61 ± 14 years, 33% women) from 27 high-, middle- and low-income countries were prospectively studied. Baseline frailty was evaluated by the Fried index, incorporating handgrip strength, gait speed, physical activity, unintended weight loss, and self-reported exhaustion. Mean left ventricular ejection fraction was 39 ± 14% and 26% had New York Heart Association Class III/IV symptoms. Participants were followed for a median (25th to 75th percentile) of 3.1 (2.0-4.3) years. Cox proportional hazard models for death and HF hospitalization adjusted for country income level; age; sex; education; HF aetiology; left ventricular ejection fraction; diabetes; tobacco and alcohol use; New York Heart Association functional class; HF medication use; blood pressure; and haemoglobin, sodium, and creatinine concentrations were performed. The incremental discriminatory value of frailty over and above the MAGGIC risk score was evaluated by the area under the receiver-operating characteristic curve. RESULTS At baseline, 18% of participants were robust, 61% pre-frail, and 21% frail. During follow-up, 565 (16%) participants died and 471 (14%) were hospitalized for HF. Respective adjusted hazard ratios (95% confidence interval) for death among the pre-frail and frail were 1.59 (1.12-2.26) and 2.92 (1.99-4.27). Respective adjusted hazard ratios (95% confidence interval) for HF hospitalization were 1.32 (0.93-1.87) and 1.97 (1.33-2.91). Findings were consistent among different country income levels and by most subgroups. Adding frailty to the MAGGIC risk score improved the discrimination of future death and HF hospitalization. CONCLUSIONS Frailty confers substantial incremental prognostic information to prognostic variables for predicting death and HF hospitalization. The relationship between frailty and these outcomes is consistent across countries at all income levels.
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Affiliation(s)
- Darryl P Leong
- The Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton General Hospital, C2-238 David Braley Building, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
| | - Philip Joseph
- The Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton General Hospital, C2-238 David Braley Building, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Jean Rouleau
- Department of Medicine, Université de Montréal, 2900 Edouard Montpetit Blvd, Montréal, QC H3T 1J4, Canada
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Via La Marmora, 36 – 50121 Firenze, Italy
| | - Fernando Lanas
- Department of Internal Medicine, Universidad de La Frontera, Temuco 4780000, Chile
| | - Sanjib K Sharma
- B.P. Koirala Institute of Health Sciences, Buddha Road, Dharan 56700, Nepal
| | - Julio Núñez
- Servicio de Cardiología, Hospital Clínico Universitario Valencia, Avda. Blasco Ibáñez 17, 46010 Valencia, Spain
| | - Bishav Mohan
- Dayanand Medical College and Hospital, Civil Lines, Tagore Nagar, Ludhiana 141001, India
| | - Ahmet Celik
- Faculty of Medicine, Mersin University, 31168 Sokak, Ritim Ofis, A Blok 1 Kat, 33000 Mersin, Türkiye
| | | | - Okechukwu S Ogah
- Department of Medicine, University of Ibadan and University College Hospital Ibadan, PO Box 14343, Ibadan, Nigeria
| | - Lisa M Mielniczuk
- University of Ottawa Heart Institute, 40 Ruskin St, Ottawa, ON K1Y 4W7, Canada
| | - Kumar Balasubramanian
- The Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton General Hospital, C2-238 David Braley Building, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
| | - Tara McCready
- The Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton General Hospital, C2-238 David Braley Building, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
| | - Alex Grinvalds
- The Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton General Hospital, C2-238 David Braley Building, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
| | - Salim Yusuf
- The Population Health Research Institute, McMaster University, Hamilton Health Sciences, Hamilton General Hospital, C2-238 David Braley Building, 237 Barton St. East, Hamilton, ON L8L 2X2, Canada
- Department of Medicine, McMaster University, 1280 Main Street West, Hamilton, ON, Canada
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35
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Kutz A, Kim DH, Wexler DJ, Liu J, Schneeweiss S, Glynn RJ, Patorno E. Comparative Cardiovascular Effectiveness and Safety of SGLT-2 Inhibitors, GLP-1 Receptor Agonists, and DPP-4 Inhibitors According to Frailty in Type 2 Diabetes. Diabetes Care 2023; 46:2004-2014. [PMID: 37677118 PMCID: PMC10620535 DOI: 10.2337/dc23-0671] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 08/16/2023] [Indexed: 09/09/2023]
Abstract
OBJECTIVE To evaluate the comparative cardiovascular effectiveness and safety of sodium-glucose cotransporter 2 inhibitors (SGLT-2is), glucagon-like peptide 1 receptor agonists (GLP-1RAs), and dipeptidyl peptidase 4 inhibitors (DPP-4is) in older adults with type 2 diabetes (T2D) across different frailty strata. RESEARCH DESIGN AND METHODS We performed three 1:1 propensity score-matched cohort studies, each stratified by three frailty strata, using data from Medicare beneficiaries (2013-2019) with T2D who initiated SGLT-2is, GLP-1RAs, or DPP-4is. In time-to-event analyses, we assessed the primary cardiovascular effectiveness composite outcome of acute myocardial infarction, ischemic stroke, hospitalization for heart failure, and all-cause mortality. The primary safety outcome was a composite of severe adverse events that have been linked to SGLT-2i or GLP-1RA use. RESULTS Compared with DPP-4is, the overall hazard ratio (HR) for the primary effectiveness outcome associated with SGLT-2is (n = 120,202 matched pairs) was 0.72 (95% CI 0.69-0.75), corresponding to an incidence rate difference (IRD) of -13.35 (95% CI -15.06 to -11.64). IRD ranged from -6.74 (95% CI -8.61 to -4.87) in nonfrail to -27.24 (95% CI -41.64 to -12.84) in frail people (P for interaction < 0.01). Consistent benefits were observed for GLP-1RAs compared with DPP-4is (n = 113,864), with an overall HR of 0.74 (95% CI 0.71-0.77) and an IRD of -15.49 (95% CI -17.46 to -13.52). IRD in the lowest frailty stratum was -7.02 (95% CI -9.23 to -4.81) and -25.88 (95% CI -38.30 to -13.46) in the highest (P for interaction < 0.01). Results for SGLT-2is versus GLP-1RAs (n = 89,865) were comparable. Severe adverse events were not more frequent with SGLT-2is or GLP-1RAs than DPP-4is. CONCLUSIONS SGLT-2is and GLP-1RAs safely improved cardiovascular outcomes and all-cause mortality, with the largest absolute benefits among frail people.
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Affiliation(s)
- Alexander Kutz
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Dae Hyun Kim
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
- Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | - Deborah J. Wexler
- Massachusetts General Hospital Diabetes Center and Harvard Medical School, Boston, MA
| | - Jun Liu
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Sebastian Schneeweiss
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Robert J. Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital and Harvard Medical School, Boston, MA
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Orkaby AR, Huan T, Intrator O, Cai S, Schwartz AW, Wieland D, Hall DE, Figueroa JF, Strom JB, Kim DH, Driver JA, Kinosian B. Comparison of Claims-Based Frailty Indices in U.S. Veterans 65 and Older for Prediction of Long-Term Institutionalization and Mortality. J Gerontol A Biol Sci Med Sci 2023; 78:2136-2144. [PMID: 37395654 PMCID: PMC10613003 DOI: 10.1093/gerona/glad157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Indexed: 07/04/2023] Open
Abstract
BACKGROUND Frailty is increasingly recognized as a useful measure of vulnerability in older adults. Multiple claims-based frailty indices (CFIs) can readily identify individuals with frailty, but whether 1 CFI improves prediction over another is unknown. We sought to assess the ability of 5 distinct CFIs to predict long-term institutionalization (LTI) and mortality in older Veterans. METHODS Retrospective study conducted in U.S. Veterans ≥65 years without prior LTI or hospice use in 2014. Five CFIs were compared: Kim, Orkaby (Veteran Affairs Frailty Index [VAFI]), Segal, Figueroa, and the JEN-FI, grounded in different theories of frailty: Rockwood cumulative deficit (Kim and VAFI), Fried physical phenotype (Segal), or expert opinion (Figueroa and JFI). The prevalence of frailty according to each CFI was compared. CFI performance for the coprimary outcomes of any LTI or mortality from 2015 to 2017 was examined. Because Segal and Kim include age, sex, or prior utilization, these variables were added to regression models to compare all 5 CFIs. Logistic regression was used to calculate model discrimination and calibration for both outcomes. RESULTS A total of 3 million Veterans were included (mean age 75, 98% male participants, 80% White, and 9% Black). Frailty was identified for between 6.8% and 25.7% of the cohort with 2.6% identified as frail by all 5 CFIs. There was no meaningful difference between CFIs in the area under the receiver operating characteristic curve for LTI (0.78-0.80) or mortality (0.77-0.79). CONCLUSIONS Based on different frailty constructs, and identifying different subsets of the population, all 5 CFIs similarly predicted LTI or death, suggesting each could be used for prediction or analytics.
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Affiliation(s)
- Ariela R Orkaby
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, Boston, Massachusetts, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Tianwen Huan
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, New York, USA
- Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Orna Intrator
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, New York, USA
- Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Shubing Cai
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, New York, USA
- Department of Public Health Sciences, University of Rochester, Rochester, New York, USA
| | - Andrea W Schwartz
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, Boston, Massachusetts, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Darryl Wieland
- Geriatrics and Extended Care Data and Analysis Center, Canandaigua VA Medical Center, Canandaigua, New York, USA
- Biodemography of Aging Research Unit, Duke University, Durham, North Carolina, USA
| | - Daniel E Hall
- Center for Health Equity Research and Promotion; and Pittsburgh GRECC, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania, USA
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
| | - Jose F Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts, USA
| | - Jordan B Strom
- Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School Boston, Boston, Massachusetts, USA
- Richard A and Susan F Smith Center for Outcomes Research in Cardiology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Dae H Kim
- The Marcus Institute for Aging Research, Hebrew SeniorLife, Harvard Medical School, Boston, Massachusetts, USA
| | - Jane A Driver
- New England GRECC (Geriatric Research, Education, and Clinical Center) VA Boston Healthcare System, Boston, Massachusetts, USA
- Division of Aging, Brigham & Women’s Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Bruce Kinosian
- Geriatrics and Extended Care Data Analysis Center and Center for Health Equity Research and Promotion, Cpl. Michael J Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Department of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Escobar C, Pascual-Figal D, Manzano L, Nuñez J, Camafort M. Current Role of SLGT2 Inhibitors in the Management of the Whole Spectrum of Heart Failure: Focus on Dapagliflozin. J Clin Med 2023; 12:6798. [PMID: 37959263 PMCID: PMC10649290 DOI: 10.3390/jcm12216798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 10/21/2023] [Accepted: 10/25/2023] [Indexed: 11/15/2023] Open
Abstract
Heart failure (HF) is associated with a high morbidity and mortality burden. In light of more recent evidence, SGLT2 inhibitors are currently recommended as first-line therapy in managing patients with HF, regardless of ejection fraction, to reduce HF burden. The DAPA-HF and DELIVER trials, and particularly, the pooled analysis of both studies, have shown that dapagliflozin significantly reduces the risk of cardiovascular death, all-cause death, total HF hospitalizations, and MACE in the whole spectrum of HF, with sustained benefits over time. Recent data have shown that the full implementation of dapagliflozin in clinical practice would translate into a robust reduction in hospitalizations for HF and death in real-life populations. Many pathophysiological mechanisms have been involved in these benefits, particularly the positive effects of dapagliflozin on reversing cardiac (atrial and ventricular) remodeling, reducing cardiac fibrosis and inflammation, and improving endothelial dysfunction. In this manuscript, we reviewed from a practical point of view the role of dapagliflozin in the management of the whole spectrum of patients with HF.
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Affiliation(s)
- Carlos Escobar
- Cardiology Department, University Hospital La Paz, 28046 Madrid, Spain
| | - Domingo Pascual-Figal
- Cardiology Department, Hospital Clinico Universitario Virgen de la Arrixaca, 30120 Murcia, Spain;
- Spanish National Cardiovascular Research Centre (CNIC), 28029 Madrid, Spain
- Department of Medicine, Universidad de Murcia, 30100 Murcia, Spain
| | - Luis Manzano
- Internal Medicine Department, University Hospital Ramon y Cajal, Alcala de Henares University, 28034 Madrid, Spain;
| | - Julio Nuñez
- Cardiology Department, University Hospital Clínico of Valencia, Instituto de Investigación Sanitaria (INCLIVA), 46010 Valencia, Spain;
- CIBER Cardiovascular, 28029 Madrid, Spain
| | - Miguel Camafort
- Internal Medicine Department, Hospital Clinic, University of Barcelona, 08036 Barcelona, Spain;
- CIBER OBN, ISCIII (Centro de Investigación Biomédica en Red, Instituto de Salud Carlos III), 28222 Madrid, Spain
- Working Group of Cardiovascular Risk, Nutrition, and Aging, IDIBAPS (Instituto de Investigaciones Biomédicas August Pi i Sunyer), 08036 Barcelona, Spain
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Major K, Bodys-Pełka A, Grabowski M, Lelonek M. Quality of life in heart failure: New data, new drugs and devices. Cardiol J 2023; 31:156-167. [PMID: 37822076 PMCID: PMC10919569 DOI: 10.5603/cj.92243] [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: 10/10/2022] [Revised: 09/29/2023] [Accepted: 06/23/2023] [Indexed: 10/13/2023] Open
Abstract
Quality of life (QoL) is a therapeutic goal in heart failure. There are many EBM therapies for improving QoL. In this study, data is presented on new pharmacotherapies and devices that impact QoL in the heart failure population.
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Affiliation(s)
- Katarzyna Major
- Department of Noninvasive Cardiology, Medical University of Lodz, Poland.
| | - Aleksandra Bodys-Pełka
- 1st Department of Cardiology, Medical University of Warsaw, Poland
- Doctoral School, Medical University of Warsaw, Poland
| | - Marcin Grabowski
- 1st Department of Cardiology, Medical University of Warsaw, Poland
| | - Małgorzata Lelonek
- Department of Noninvasive Cardiology, Medical University of Lodz, Poland
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Lv J, Guo L, Wang R, Chen J. Efficacy and Safety of Sodium-Glucose Cotransporter-2 Inhibitors in Nondiabetic Patients with Chronic Kidney Disease: A Review of Recent Evidence. KIDNEY DISEASES (BASEL, SWITZERLAND) 2023; 9:326-341. [PMID: 37901712 PMCID: PMC10601939 DOI: 10.1159/000530395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 03/20/2023] [Indexed: 10/31/2023]
Abstract
Background Sodium-glucose cotransporter-2 inhibitors (SGLT2i) were initially developed as glucose-lowering agents in patients with type-2 diabetes. However, available data from clinical trials and meta-analyses suggest that SGLT2i have pleiotropic benefits in reducing mortality and delaying the progression of chronic kidney disease (CKD) in both diabetic and nondiabetic patients. Thus, we herein review the current evidence regarding the efficacy and safety of SGLT2i in patients with nondiabetic CKD and appraise the recently reported clinical trials that might facilitate the management of CKD in routine clinical practice. Summary The benefits of SGLT2i on nondiabetic CKD are multifactorial and are mediated by a combination of mechanisms. The landmark DAPA-CKD trial revealed that dapagliflozin administered with renin-angiotensin system blockade drugs reduced the risk of a sustained decline (at least 50%) in the estimated glomerular filtration rate, end-stage kidney disease, or death from cardiorenal causes. The recent EMPA-KIDNEY trial showed that empagliflozin therapy led to a lower risk of progression of kidney disease or death from cardiovascular causes. These benefits were consistent in patients with and without diabetes. Moreover, a meta-analysis of DAPA-HF and EMPEROR-Reduced trials confirmed reductions in the combined risk of cardiovascular death or worsening heart failure including composite renal endpoint. Key Messages Considering the robust data available from DAPA-CKD, EMPA-KIDNEY, and other trials such as EMPEROR-Preserved, DIAMOND that included nondiabetic patients, it may be necessary to update current guidelines to include SGLT2i as a first-line therapy for CKD and reevaluate current CKD therapeutic approaches.
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Affiliation(s)
- Junhao Lv
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Luying Guo
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Rending Wang
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
| | - Jianghua Chen
- Kidney Disease Center, The First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou, China
- Key Laboratory of Kidney Disease Prevention and Control Technology, Hangzhou, China
- National Key Clinical Department of Kidney Diseases, Institute of Nephrology, Zhejiang University, Hangzhou, China
- Zhejiang Clinical Research Center of Kidney and Urinary System Disease, Hangzhou, China
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Lee YC, Lin JK, Ko D, Cheng S, Patorno E, Glynn RJ, Tsacogianis T, Kim DH. Frailty and uptake of angiotensin receptor neprilysin inhibitor for heart failure with reduced ejection fraction. J Am Geriatr Soc 2023; 71:3110-3121. [PMID: 37345734 PMCID: PMC10592538 DOI: 10.1111/jgs.18481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2023] [Revised: 05/18/2023] [Accepted: 05/26/2023] [Indexed: 06/23/2023]
Abstract
BACKGROUND Frail older adults may be less likely to receive guideline-directed medical therapy (GDMT)-renin-angiotensin blockers, beta-blockers, and mineralocorticoid receptor antagonists-for heart failure with reduced ejection fraction (HFrEF). We aimed to examine the uptake of angiotensin receptor neprilysin inhibitor (ARNI) and GDMT in frail older adults with HFrEF. METHODS Using 2015-2019 Medicare data, we estimated the proportion of beneficiaries with HFrEF receiving ARNI and GDMT each year by frailty status, defined by a claims-based frailty index. Logistic regression was used to identify clinical characteristics associated with ARNI initiation. Cox proportional hazards regression was used to examine the association of GDMT use in 2015 and death or heart failure hospitalization in 2016-2019. RESULTS Among 147,506-180,386 beneficiaries with HFrEF (mean age: 77 years; 27% women; 42.6-49.1% frail) in 2015-2019, the proportion of patients receiving ARNI increased in both non-frail (0.4%-16.4%) and frail (0.3%-13.7%) patients (p for yearly-trend-by-frailty = 0.970). Among those not receiving a renin-angiotensin system blocker, patients with age ≥ 85 years (odds ratio [95% CI], 0.89 [0.80-0.99]), dementia (0.88 [0.81-0.96]), and frailty (0.87 [0.81-0.94]) were less likely to initiate ARNI. The proportion of patients receiving all 3 GDMT classes increased in non-frail patients (22.0%-27.0%) but changed minimally in frail patients (19.6%-21.8%). Regardless of frailty status, treatment with at least 1 class of GDMT was associated with lower death or heart failure hospitalization than no GDMT medications (hazard ratio [95% CI], 0.94 [0.91-0.97], 0.92 [0.89-0.94], 0.94 [0.91-0.97] for 1, 2, and 3 classes, respectively). CONCLUSIONS Our results suggest an evidence-practice gap in the use of ARNI and GDMT in Medicare beneficiaries with HFrEF, particularly those with frailty. Efforts to narrow this gap are needed to reduce the burden of HFrEF in older adults.
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Affiliation(s)
- Yu-Chien Lee
- Harvard T.H. Chan School of Public Health, Boston, MA
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Department of Family Medicine, Chang Gung Memorial Hospital, Linko Branch, Taiwan
| | - Joshua K. Lin
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Darae Ko
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Section of Cardiovascular Medicine, Boston University School of Medicine, Boston, MA
| | - Susan Cheng
- Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Elisabetta Patorno
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Robert J. Glynn
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Theodore Tsacogianis
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
| | - Dae Hyun Kim
- Hinda and Arthur Marcus Institute for Aging Research, Hebrew SeniorLife, Boston, MA
- Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women’s Hospital, Boston, MA
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Peikert A, Goyal P, Vaduganathan M, Claggett BL, Kulac IJ, Miao ZM, Vardeny O, Kosiborod MN, Desai AS, Jhund PS, Lam CSP, Inzucchi SE, Martinez FA, de Boer RA, Hernandez AF, Shah SJ, Petersson M, Langkilde AM, McMurray JJV, Solomon SD. Dapagliflozin in Heart Failure With Mildly Reduced or Preserved Ejection Fraction According to Polypharmacy Status. JACC. HEART FAILURE 2023; 11:1380-1393. [PMID: 37294244 DOI: 10.1016/j.jchf.2023.05.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Revised: 05/17/2023] [Accepted: 05/17/2023] [Indexed: 06/10/2023]
Abstract
BACKGROUND Patients with heart failure (HF) have a high burden of multimorbidity, often necessitating numerous medications. There may be clinical concern about introducing another medication, especially among individuals with polypharmacy. OBJECTIVES This study examined the efficacy and safety of addition of dapagliflozin according to the number of concomitant medications in HF with mildly reduced or preserved ejection fraction. METHODS In this post hoc analysis of the DELIVER (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure) trial, 6,263 participants with symptomatic HF with left ventricular ejection fraction >40% were randomized to dapagliflozin or placebo. Baseline medication use (including vitamins and supplements) was collected. Efficacy and safety outcomes were assessed by medication use categories ("nonpolypharmacy": <5 medications; "polypharmacy": 5 to 9 medications; and "hyperpolypharmacy": ≥10 medications) and continuously. The primary outcome was worsening HF or cardiovascular death. RESULTS Overall, 3,795 (60.6%) patients met polypharmacy and 1,886 (30.1%) met hyperpolypharmacy criteria. Higher numbers of medications were strongly associated with higher comorbidity burden and increased rates of the primary outcome. Compared with placebo, dapagliflozin similarly reduced the risk of the primary outcome irrespective of polypharmacy status (nonpolypharmacy HR: 0.88 [95% CI: 0.58-1.34]; polypharmacy HR: 0.88 [95% CI: 0.75-1.03]; hyperpolypharmacy HR: 0.73 [95% CI: 0.60-0.88]; Pinteraction = 0.30). Similarly, benefits with dapagliflozin were consistent across the spectrum of total medication use (Pinteraction = 0.06). Although adverse events increased with higher number of medications, they were not more frequent with dapagliflozin, regardless of polypharmacy status. CONCLUSIONS In the DELIVER trial, dapagliflozin safely reduced worsening HF or cardiovascular death across a broad range of baseline medication use, including among individuals with polypharmacy (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).
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Affiliation(s)
- Alexander Peikert
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Parag Goyal
- Division of Cardiology and Division of General Internal Medicine, Department of Medicine, Weill Cornell Medicine, New York, New York, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ian J Kulac
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Zi Michael Miao
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore; University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | | | | | - Rudolf A de Boer
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R and D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R and D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Center, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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Malik ME, Butt JH, Strange JE, Falkentoft AC, Jensen J, Andersson C, Zahir D, Fosbøl E, Petrie MC, Sattar N, McMurray JJV, Køber L, Schou M. Initiation of SGLT2 inhibitors and GLP-1 receptor agonists according to level of frailty in people with type 2 diabetes and cardiovascular disease in Denmark: a cross-sectional, nationwide study. THE LANCET. HEALTHY LONGEVITY 2023; 4:e552-e560. [PMID: 37734395 DOI: 10.1016/s2666-7568(23)00164-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 09/23/2023] Open
Abstract
BACKGROUND Whether frailty influences the initiation of two cardioprotective diabetes drug therapies (ie, SGLT2 inhibitors and GLP-1 receptor agonists) in people with type 2 diabetes and cardiovascular disease is unknown. We aimed to assess rates of initiation of SGLT2 inhibitors and GLP-1 receptor agonists according to frailty in people with type 2 diabetes and cardiovascular disease. METHODS For this cross-sectional, nationwide study, all people with type 2 diabetes and cardiovascular disease in Denmark between Jan 1, 2015, and Dec 31, 2021, from six Danish health-data registers were identified. People younger than 40 years, with end-stage renal disease, with registered contraindications to SGLT2 inhibitors or GLP-1 receptor agonists, or with previous use of either drug therapy were excluded. The Hospital Frailty Risk Score was used to categorise people as either non-frail, moderately frail, or severely frail. Cox proportional hazards models were used to analyse the association between frailty and initiation of an SGLT2 inhibitor or a GLP-1 receptor agonist. FINDINGS Of 119 390 people with type 2 diabetes and cardiovascular disease, 103 790 were included. Median follow-up time was 4·5 years (IQR 2·7-6·1) and median age across the three frailty groups was 71 years (64-79). 65 959 (63·6%) of 103 790 people were male and 37 831 (36·5%) were female. At index date, 66 910 (64·5%) people were non-frail, 29 250 (28·2%) were moderately frail, and 7630 (7·4%) were severely frail. Frailty was associated with a significantly lower probability of initiating therapy with an SGLT2 inhibitor or a GLP-1 receptor agonist than in people who were non-frail (moderately frail hazard ratio 0·91, 95% CI 0·88-0·94, p<0·0001; severely frail 0·75, 0·70-0·80, p<0·0001). This association persisted after adjustment for age, sex, socioeconomic status, year of inclusion, duration of type 2 diabetes, duration of cardiovascular disease, polypharmacy, and comorbidity. INTERPRETATION In people with type 2 diabetes and cardiovascular disease in Denmark, frailty was associated with a significantly lower probability of SGLT2-inhibitor or GLP-1 receptor-agonist initiation, despite their benefits. Formulating clear and updated guidelines on the use of SGLT2 inhibitors and GLP-1 receptor agonists in people who are frail with type 2 diabetes and cardiovascular disease should be a priority. FUNDING Department of Cardiology, Herlev and Gentofte University Hospital. TRANSLATION For the Danish translation of the abstract see Supplementary Materials section.
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Affiliation(s)
| | - Jawad Haider Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jarl Emanuel Strange
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | | | - Jesper Jensen
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Charlotte Andersson
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - Deewa Zahir
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
| | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Naveed Sattar
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Harvard University, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Køber
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Herlev and Gentofte University Hospital, Copenhagen, Denmark
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Talha KM, Pandey A, Fudim M, Butler J, Anker SD, Khan MS. Frailty and heart failure: State-of-the-art review. J Cachexia Sarcopenia Muscle 2023; 14:1959-1972. [PMID: 37586848 PMCID: PMC10570089 DOI: 10.1002/jcsm.13306] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Revised: 06/16/2023] [Accepted: 07/11/2023] [Indexed: 08/18/2023] Open
Abstract
At least half of all patients with heart failure (HF) are affected by frailty, a syndrome that limits an individual ability to recover from acute stressors. While frailty affects up to 90% of patients with HF with preserved ejection fraction, it is also seen in ~30-60% of patients with HF with reduced ejection fraction, with ~26% higher prevalence in women compared with men. The relationship between frailty and HF is bidirectional, with both conditions exacerbating the other. Frailty is further complicated by a higher prevalence of sarcopenia (by ~20%) in HF patients compared with patients without HF, which negatively affects outcomes. Several frailty assessment methods have been employed historically including the Fried frailty phenotype and Rockwood Clinical Frailty Scale to classify HF patients based on the severity of frailty; however, a validated HF-specific frailty assessment tool does not currently exist. Frailty in HF is associated with a poor prognosis with a 1.5-fold to 2-fold higher risk of all-cause death and hospitalizations compared to non-frail patients. Frailty is also highly prevalent in patients with worsening HF, affecting >50% of patients hospitalized for HF. Such patients with multiple readmissions for decompensated HF have markedly poor outcomes compared to younger, non-frail cohorts, and it is hypothesized that it may be due to major physical and functional limitations that limit recovery from an acute episode of worsening HF, a care aspect that has not been addressed in HF guidelines. Frail patients are thought to confer less benefit from therapeutic interventions due to an increased risk of perceived harm, resulting in lower adherence to HF interventions, which may worsen outcomes. Multiple studies report that <40% of frail patients are on guideline-directed medical therapy for HF, of which most are on suboptimal doses of these medications. There is a lack of evidence generated from randomized trials in this incredibly vulnerable population, and most current practice is governed by post hoc analyses of trials, observational registry-based data and providers' clinical judgement. The current body of evidence suggests that the treatment effect of most guideline-based interventions, including medications, cardiac rehabilitation and device therapy, is consistent across all age groups and frailty subgroups and, in some cases, may be amplified in the older, more frail population. In this review, we discuss the characteristics, assessment tools, impact on prognosis and impact on therapeutic interventions of frailty in patients with HF.
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Affiliation(s)
- Khawaja M. Talha
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
| | - Ambarish Pandey
- Division of CardiologyUniversity of Texas Southwestern Medical CenterDallasTXUSA
| | - Marat Fudim
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
- Duke Clinical Research InstituteDurhamNCUSA
| | - Javed Butler
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMSUSA
- Baylor Scott and White Research InstituteDallasTXUSA
| | - Stefan D. Anker
- Department of Cardiology (CVK) of German Heart Center CharitéInstitute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité UniversitätsmedizinBerlinGermany
- Institute of Heart DiseasesWroclaw Medical UniversityWroclawPoland
| | - Muhammad Shahzeb Khan
- Division of CardiologyDuke University Hospital, Duke University School of MedicineDurhamNCUSA
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Hershkowitz I, Cahn A. Prescription patterns in people who are frail. THE LANCET. HEALTHY LONGEVITY 2023; 4:e522-e523. [PMID: 37734396 DOI: 10.1016/s2666-7568(23)00177-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 09/23/2023] Open
Affiliation(s)
- Isca Hershkowitz
- Department of Medicine, Hadassah Medical Center, Jerusalem 91120, Israel
| | - Avivit Cahn
- Diabetes Unit, Department of Endocrinology and Metabolism, Hadassah Medical Center, Jerusalem 91120, Israel; Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
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Axenfeld E, Katz S, Faye AS. Management Considerations for the Older Adult With Inflammatory Bowel Disease. Gastroenterol Hepatol (N Y) 2023; 19:592-599. [PMID: 38404957 PMCID: PMC10882858] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2024]
Abstract
As the prevalence of older adults with inflammatory bowel disease (IBD) is rising, understanding the unique challenges in both diagnosis and management is becoming increasingly important. Knowledge of phenotypic differences as well as overlapping symptoms with other medical conditions is critical to obtaining a timely diagnosis of IBD in older adults. Although older adults with IBD are at higher risk for adverse events compared with younger adults with IBD, recent data have suggested that ongoing disease activity may be a significant driver of adverse clinical outcomes rather than use of current treatment modalities. Ultimately, earlier and effective treatments can improve outcomes and quality of life for older adults with IBD. However, to help improve medical decision-making, clinicians must move away from the use of chronological age alone and begin to integrate measures of biological age, such as frailty and sarcopenia, into risk stratification tools. This article reviews the management considerations for older adults with IBD and provides the rationale for incorporating measures of biological age into current practice.
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Affiliation(s)
- Ellen Axenfeld
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Langone Health, New York, New York
| | - Seymour Katz
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Langone Health, New York, New York
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, New York University Langone Health, New York, New York
| | - Adam S. Faye
- Division of Gastroenterology and Hepatology, Department of Medicine, New York University Langone Health, New York, New York
- Inflammatory Bowel Disease Center, Division of Gastroenterology and Hepatology, New York University Langone Health, New York, New York
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Cunningham C, Jabri A, Alhuneafat L, Aneja A. A Comprehensive Guide to Sodium Glucose Cotransport Inhibitors. Curr Probl Cardiol 2023; 48:101817. [PMID: 37211299 DOI: 10.1016/j.cpcardiol.2023.101817] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023]
Abstract
Sodium-glucose cotransport 2 inhibitors (SGLT2i) are a class of drugs initially approved by the Food and Drug Association (FDA) as antihyperglycemic agents for patients with type 2 diabetes mellitus (DM). However, lately, these agents (Canagliflozin, Empagliflozin, Ertugliflozin, Sotagliflozin, and Dapagliflozin) have become better known for their cardiovascular (CV) and reno-protective effects. In this comprehensive review and analysis, we display the advancement of Sodium Glucose Cotransport Inhibitors have shown in cardiology, specifically heart failure in a concise, yet thorough manner.
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Affiliation(s)
| | - Ahmad Jabri
- Department of Cardiovascular Disease, Henry Ford, Detroit, Michigan, USA.
| | - Laith Alhuneafat
- Department of Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Ashish Aneja
- Heart and Vascular Division, The MetroHealth System, Cleveland, OH
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Zahir Anjum D, Strange JE, Fosbøl E, Garred CH, Malik ME, Andersson C, Jhund PS, McMurray JJV, Petrie MC, Kober L, Schou M. Initiation of Medical Therapy for Heart Failure Patients According to Kidney Function: A Danish Nationwide Study. Clin Epidemiol 2023; 15:855-866. [PMID: 37489222 PMCID: PMC10363354 DOI: 10.2147/clep.s412787] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/09/2023] [Indexed: 07/26/2023] Open
Abstract
Background Use of medical therapies for heart failure (HF) patients with moderate kidney dysfunction is low. We hypothesized that lack of initiation of HF therapy reflects the clinicians' reluctance in very elderly and frail patients more than kidney dysfunction itself. Methods HF patients were identified from nationwide registers between 2014 and 2021. Information was obtained on eGFR, frailty status, and prescription of HF therapy. Patients were divided into three groups: normal kidney function (eGFR ≥ 60); moderate kidney dysfunction (GFR between 30 and 59); and severe kidney dysfunction (GFR < 30). Multivariate Cox models were used to study the association of eGFR, age, and frailty with use of HF therapy. Results Of the 42,320 HF patients included those with lower eGFR were significantly older and frailer (median age 74.3 years and 37.8% frail). The crude initiation rate of all three drug classes decreased with decreasing eGFR in a stepwise fashion. After adjusting for age and frailty status, initiation of MRA decreased with decreasing kidney function (moderate kidney function HR 0.80(95% CI 0.77-0.84) and severe kidney function HR 0.24(0.21-0.27)). After adjusting for age and frailty status, initiation of RAS inhibitor and BB was not significantly lower for moderate kidney dysfunction (HR 0.97(0.93-1.02), and HR 1.06(0.97-1.16, respectively)). Initiation of RAS inhibitor was significantly lower for patients with severe kidney dysfunction, HR 0.45(0.41-0.50), but not for BB initiation HR 1.09(1.05-1.14). Conclusion In a real-world HF cohort, patients with moderate and severe kidney dysfunction were associated with reduced use of MRA irrespective of age and frailty. Reduced use of RASi was associated with severe kidney dysfunction, whereas for patients with moderate kidney dysfunction, reduced use was mainly driven by aging and frailty. Reduced use of BB seemed to be primarily explained by aging and frailty.
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Affiliation(s)
- Deewa Zahir Anjum
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | | | - Emil Fosbøl
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
| | | | | | - Charlotte Andersson
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Kober
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
- Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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Tang Y, Sang H. Cost-utility analysis of add-on dapagliflozin in heart failure with preserved or mildly reduced ejection fraction. ESC Heart Fail 2023. [PMID: 37290665 PMCID: PMC10375078 DOI: 10.1002/ehf2.14426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 05/02/2023] [Accepted: 05/24/2023] [Indexed: 06/10/2023] Open
Abstract
AIMS The DELIVER study demonstrates a significant improvement in cardiovascular death or hospitalization for heart failure among heart failure with mildly reduced ejection fraction (HFmrEF) or heart failure with preserved ejection fraction (HFpEF).Cost-utility of the adjunct use of dapagliflozin to standard therapy among patients with HFpEF or HFmrEF remains unclear. METHODS AND RESULTS A five-state Markov mode was constructed to project health and clinical outcomes of the adjunct use of dapagliflozin to standard therapy among 65-year-old patients with HFpEF or HFmrEF. A cost-utility analysis was performed based on the DELIVER study and national statistical database. The cost and utility was inflated to 2022 by the usual discount rate of 5%. The primary outcomes were total cost and quality-adjusted life-years (QALYs) per patients as well as the incremental cost-effectiveness ratio. Sensitivity analyses were also applied. Over a 15 year lifetime horizon, the average cost per patient was $7245.77 and $5407.55 in the dapagliflozin group and the standard group, along with an incremental cost of $1838.22. The average QALYs per patient was 6.00 QALYs and 5.84 QALYs in the dapagliflozin group and the standard group, along with an incremental QALYs of 0.15 QALYs, resulting in the incremental cost-effectiveness ratio of $11 865.33/QALY, which was below the willingness-to-pay (WTP) of $12 652.5/QALY. The univariate sensitivity analysis indicated the cardiovascular death in both group was the most sensitive variable. Probability sensitivity analysis revealed that when the WTP thresholds were $12 652.5/QALY and $37 957.5/QALY, the probabilities of being cost-effective with dapagliflozin as an add-on were 54.6% and 71.6%, respectively. CONCLUSIONS From a public healthcare system perspective, the adjunct use of dapagliflozin to standard therapy among patients with HFpEF or HFmrEF generated advantages in cost-effectiveness in China at a WTP of $12 652.5/QALY, which promoted the rational use of dapagliflozin for heart failure.
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Affiliation(s)
- Yi Tang
- Department Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Haiqiang Sang
- Department Cardiology, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
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Jensen J, Poulsen MK, Petersen PW, Gerdes B, Rossing K, Schou M. Prevalence of heart failure phenotypes and current use of therapies in primary care: results from a nationwide study. ESC Heart Fail 2023; 10:1745-1756. [PMID: 36852608 PMCID: PMC10192278 DOI: 10.1002/ehf2.14324] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2022] [Revised: 01/11/2023] [Accepted: 01/31/2023] [Indexed: 03/01/2023] Open
Abstract
AIMS Heart failure (HF) is an increasing concern worldwide. A rising HF burden is expected due to the prospected future demographic changes with aging populations. Consequently, the long-term follow-up and treatment will be performed increasingly by primary care physicians in the future. Contemporary data on HF patients in primary care are needed to plan and ensure an effective and safe follow-up of future patients. METHODS AND RESULTS The electronic patient journals of 148 primary care clinics in Denmark were searched in a standardized manner to identify patients with HF [code K77 of the International Classification of Primary Care, Second Edition]. Prespecified variables including demographic information, clinical variables, co-morbidities, prescribed medications, and setting of follow-up were recorded. In total, 1111 patients were included in the study. The mean timepoint for the HF diagnosis was August 2018. In 95% of cases, the diagnosis of HF was made in a specialized setting. The echocardiogram data used for phenotyping were available in 1042 (94%) of the 1111 patients. HF with reduced ejection fraction (HFrEF) was present in 43%, recovered HFrEF in 31%, and HF with mildly reduced (HFmrEF) or preserved ejection fraction (HFpEF) in 26%. In patients with HFrEF or recovered HFrEF, fundamental treatments were prescribed in 86% for angiotensin converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or angiotensin receptor neprilysin inhibitor (ARNI), in 82% for beta-blocker, in 38% for mineralocorticoid receptor antagonist (MRA), and in 12% for sodium-glucose co-transporter-2 inhibitor (SGLT2i). Older patients were treated to a significantly lesser extent than young patients for all drug classes [odds ratio (OR) point estimates 0.50 to 0.69, all P-values < 0.05]. In patients with HFmrEF or HFpEF, an ACEI, ARB, or ARNI was prescribed in 67%, beta-blocker in 67%, MRA in 22%, and SGLT2i in 7.4% with significantly lower probability of treatment compared to patients with HFrEF or recovered HFrEF [OR point estimates 0.33 to 0.57, all P-values < 0.05]. The setting of follow-up was available in 96% of patients. Irrespective of HF phenotype, follow-up was performed solely in primary care in 64%. These patients were generally treated to a lesser extent with HF therapies compared with patients where follow-up included specialized care, yet differences were generally small. CONCLUSIONS HFrEF is the most common phenotype of HF in primary care followed by recovered HFrEF and fundamental therapies are markedly underutilized. Initiatives to increase the use of recommended therapies are needed to improve the future care of patients with HF.
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Affiliation(s)
- Jesper Jensen
- Department of CardiologyHerlev and Gentofte University HospitalHellerupDenmark
| | | | | | - Bo Gerdes
- General PracticeLæge Bo GerdesHedehuseneDenmark
| | | | - Morten Schou
- Department of CardiologyHerlev and Gentofte University HospitalHellerupDenmark
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50
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Montero-Pérez-Barquero M, Escobar-Cervantes C, Llàcer P, Quirós-López R, Trullás JC, Cerqueiro JM, Epelde-Gonzálo F, Carrera-Izquierdo M, Formiga F, González-Franco A, Casado-Cerrada J. Projected clinical benefits of dapagliflozin in patients with heart failure with preserved ejection fraction. Future Cardiol 2023; 19:333-342. [PMID: 37382199 DOI: 10.2217/fca-2023-0015] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/30/2023] Open
Abstract
Aims: To address the projected clinical benefits of dapagliflozin among patients with heart failure (HF) with mildly reduced ejection fraction (HFmrEF) and preserved ejection fraction (HFpEF). Methods: A multicenter, prospective, cohort study of patients ≥50 years admitted with HF to Spanish internal medicine departments. The projected clinical benefits of dapagliflozin were calculated from the DELIVER trial. Results: A total of 4049 patients were included; 3271 (80.8%) were eligible for dapagliflozin treatment, according to DELIVER criteria. Within 1 year after discharge, 22.2% were rehospitalized for HF and 21.6% died. Implementation of dapagliflozin would translate into an absolute risk reduction of 1.3% for mortality and 5.1% for HF readmission. Conclusion: HF patients with preserved or mildly reduced ejection fraction have a high risk of events. The use of dapagliflozin could substantially reduce the HF burden.
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Affiliation(s)
| | | | - Pau Llàcer
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, IRYCIS, 28034, Madrid, Spain
| | - Raúl Quirós-López
- Servicio de Medicina Interna, Hospital de la Costa del Sol, Marbella, 29603, Málaga, Spain
| | - Joan C Trullás
- Internal Medicine Department, Hospital d'Olot, Tissue Repair & Regeneration Laboratory (TR2Lab), Universitat Central de Catalunya, Vic, 17800, Barcelona, Spain
| | - Jose M Cerqueiro
- Servicio de Medicina Interna, Hospital Universitario Lucus Augusti, 27003, Lugo, Spain
| | | | | | - Francesc Formiga
- Internal Medicine Department, Hospital Universitari de Bellvitge, 08907, Barcelona, Spain
| | - Alvaro González-Franco
- Servicio de Medicina Interna, Hospital Universitario Central de Asturias, 33011, Oviedo, Spain
| | - Jesús Casado-Cerrada
- Internal Medicine Department, University Hospital of Getafe, 28905, Madrid, Spain
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