Signs, symptoms, and treatment patterns across serial ambulatory cardiology visits in patients with heart failure: insights from the NCDR PINNACLE® registry

Obesity and metabolic syndrome in patients with heart failure with preserved ejection fraction: a cross-sectional analysis of the Veradigm Cardiology Registry

BACKGROUND

The proportion of heart failure patients with preserved ejection fraction has been rising over the past decades and has coincided with increases in the prevalence of obesity and metabolic syndrome. The relationship between these interconnected comorbidities and heart failure with preserved ejection fraction (HFpEF) is still poorly understood. This study characterized obesity and metabolic syndrome among real-world patients with HFpEF.

METHODS

We identified adults with heart failure in the Veradigm Cardiology Registry, previously the PINNACLE Registry, with a left ventricular ejection fraction measurement ≥ 50% between 01/01/2016 and 12/31/2019. Patients were stratified by obesity diagnosis and presence of metabolic syndrome (≥ 3 of the following: diabetes, hypertension, hyperlipidemia, and obesity). We captured baseline demographic and clinical characteristics and used multivariable logistic regression to examine the odds of having cardiac (atrial fibrillation, coronary artery disease, coronary artery bypass surgery, myocardial infarction, and stroke/transient ischemic attack) and non-cardiac (chronic kidney disease, chronic liver disease, and peripheral artery disease) comorbidities of interest. The models adjusted for age and sex, and the main covariates of interest were obesity and metabolic burden score (0-3 based on the presence of diabetes, hypertension, and hyperlipidemia). The models were run with and without an obesity*metabolic burden score interaction term.

RESULTS

This study included 264,571 patients with HFpEF, of whom 55.7% had obesity, 52.5% had metabolic syndrome, 42.5% had both, and 34.3% had neither. After adjusting for age, sex, and burden of other metabolic syndrome-associated diagnoses, patients with HFpEF with obesity had lower odds of a diagnosis of other evaluated comorbidities relative to patients without obesity. The presence of metabolic syndrome in HFpEF appears to increase comorbidity burden as each additional metabolic syndrome-associated diagnosis was associated with higher odds of assessed comorbidities except atrial fibrillation.

CONCLUSION

Obesity was common among patients with HFpEF and not always co-occurring with metabolic syndrome. Multivariable analysis suggested that patients with obesity may develop HFpEF in the absence of other driving factors such as cardiovascular disease or metabolic syndrome.

Clinician challenges to evidence-based prescribing for heart failure and reduced ejection fraction: A qualitative evaluation

BACKGROUND

Reasons for suboptimal prescribing for heart failure with reduced ejection fraction (HFrEF) have been identified, but it is unclear if they remain relevant with recent advances in healthcare delivery and technologies. This study aimed to identify and understand current clinician-perceived challenges to prescribing guideline-directed HFrEF medications.

METHODS

We conducted content analysis methodology, including interviews and member-checking focus groups with primary care and cardiology clinicians. Interview guides were informed by the Cabana Framework.

RESULTS

We conducted interviews with 33 clinicians (13 cardiology specialists, 22 physicians) and member checking with 10 of these. We identified four levels of challenges from the clinician perspective. Clinician level challenges included misconceptions about guideline recommendations, clinician assumptions (e.g., drug cost or affordability), and clinical inertia. Patient-clinician level challenges included misalignment of priorities and insufficient communication. Clinician-clinician level challenges were primarily between generalists and specialists, including lack of role clarity, competing priorities of providing focused versus holistic care, and contrasting confidence regarding safety of newer drugs. Policy and system/organisation level challenges included insufficient access to timely/reliable patient data, and unintended care gaps for medications without financially incentivized metrics.

CONCLUSION

This study presents current challenges faced by cardiology and primary care which can be used to strategically design interventions to improve guideline-directed care for HFrEF. The findings support the persistence of many challenges and also sheds light on new challenges. New challenges identified include conflicting perspectives between generalists and specialists, hesitancy to prescribe newer medications due to safety concerns, and unintended consequences related to value-based reimbursement metrics for select medications.

A machine learning evaluation of patient characteristics associated with prescribing of guideline-directed medical therapy for heart failure

Introduction/background

Patients with heart failure and reduced ejection fraction (HFrEF) are consistently underprescribed guideline-directed medications. Although many barriers to prescribing are known, identification of these barriers has relied on traditional a priori hypotheses or qualitative methods. Machine learning can overcome many limitations of traditional methods to capture complex relationships in data and lead to a more comprehensive understanding of the underpinnings driving underprescribing. Here, we used machine learning methods and routinely available electronic health record data to identify predictors of prescribing.

Methods

We evaluated the predictive performance of machine learning algorithms to predict prescription of four types of medications for adults with HFrEF: angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACE/ARB), angiotensin receptor-neprilysin inhibitor (ARNI), evidence-based beta blocker (BB), or mineralocorticoid receptor antagonist (MRA). The models with the best predictive performance were used to identify the top 20 characteristics associated with prescribing each medication type. Shapley values were used to provide insight into the importance and direction of the predictor relationships with medication prescribing.

Results

For 3,832 patients meeting the inclusion criteria, 70% were prescribed an ACE/ARB, 8% an ARNI, 75% a BB, and 40% an MRA. The best-predicting model for each medication type was a random forest (area under the curve: 0.788-0.821; Brier score: 0.063-0.185). Across all medications, top predictors of prescribing included prescription of other evidence-based medications and younger age. Unique to prescribing an ARNI, the top predictors included lack of diagnoses of chronic kidney disease, chronic obstructive pulmonary disease, or hypotension, as well as being in a relationship, nontobacco use, and alcohol use.

Discussion/conclusions

We identified multiple predictors of prescribing for HFrEF medications that are being used to strategically design interventions to address barriers to prescribing and to inform further investigations. The machine learning approach used in this study to identify predictors of suboptimal prescribing can also be used by other health systems to identify and address locally relevant gaps and solutions to prescribing.

Effect of Entresto on Clinical Symptoms, Ventricular Remodeling, Rehabilitation, and Hospitalization Rate in Patients with Both Acute Myocardial Infarction and Acute Heart Failure

Objective

To determine the influence of Entresto on clinical symptoms, ventricular remodeling (VR), and economic stress of patients with both acute myocardial infarction (AMI) and acute heart failure (AHF).

Methods

Totally 120 patients with AMI complicated with AHF admitted to our hospital between January 2017 and August 2019 were enrolled and randomly assigned to an observation group (obs group) and a control group (con group) (each n = 60). The obs group was treated with Entresto, while the other with angiotensin-converting enzyme inhibitors (ACEI). After treatment, the efficacy on both groups was evaluated, and their cardiac function-associated indexes (left ventricular end-systolic diameter (LVESd), left ventricular end-diastolic dimension (LVEDd), left ventricular ejection fraction (LVEF), VR-associated indexes (interventricular septal thickness (IVST), and left ventricular mass index (LVMI)) were determined and compared before treatment and after 1 month of treatment. Additionally, their NT-pro-BNP, CRP, and TNF-α were tested and compared before and after treatment, and they were also compared in hospitalization time, treatment expense, readmission rate within one year after discharge, and adverse events.

Results

After treatment, the obs group showed notably higher efficacy than the con group (P < 0.05). Before treatment, the two groups were not greatly different in LVESd, LVEDd, LVEF, IVST, LVMI, NT-pro BNP, CRP, and TNF-α (all P > 0.05), while after treatment, these indexes of both groups were improved, but the improvement in the obs group was more notable (P < 0.05). Additionally, the hospitalization time, treatment expense, readmission rate one year after discharge, and incidence of adverse events in the obs group were notably lower (all P < 0.05).

Conclusion

For patients with both AMI and AHF, Entresto can contribute to strong amelioration of their clinical symptoms and prognosis and ventricular reverse-remodeling, with a high safety, so it is worthy of clinical promotion.

Out-of-Pocket Annual Health Expenditures and Financial Toxicity From Healthcare Costs in Patients With Heart Failure in the United States

Background

Heart failure (HF) poses a major public health burden in the United States. We examined the burden of out‐of‐pocket healthcare costs on patients with HF and their families.

Methods and Results

In the Medical Expenditure Panel Survey, we identified all families with ≥1 adult member with HF during 2014 to 2018. Total out‐of‐pocket healthcare expenditures included yearly care‐specific costs and insurance premiums. We evaluated 2 outcomes of financial toxicity: (1) high financial burden—total out‐of‐pocket healthcare expense to postsubsistence income ratio of >20%, and (2) catastrophic financial burden with the ratio of >40%—a bankrupting expense defined by the World Health Organization. There were 788 families in the Medical Expenditure Panel Survey with a member with HF representing 0.54% (95% CI, 0.48%–0.60%) of all families nationally. The overall mean annual out‐of‐pocket healthcare expenses were $4423 (95% CI, $3908–$4939), with medications and health insurance premiums representing the largest categories of cost. Overall, 14% (95% CI, 11%–18%) of families experienced a high burden and 5% (95% CI, 3%–6%) experienced a catastrophic burden. Among the two‐fifths of families considered low income, 24% (95% CI, 18%–30%) experienced a high financial burden, whereas 10% (95% CI, 6%–14%) experienced a catastrophic burden. Low‐income families had 4‐fold greater risk‐adjusted odds of high financial burden (odds ratio [OR] , 3.9; 95% CI, 2.3–6.6), and 14‐fold greater risk‐adjusted odds of catastrophic financial burden (OR, 14.2; 95% CI, 5.1–39.5) compared with middle/high‐income families.

Conclusions

Patients with HF and their families experience large out‐of‐pocket healthcare expenses. A large proportion encounter financial toxicity, with a disproportionate effect on low‐income families.

Variation in use and dosing escalation of renin angiotensin system, mineralocorticoid receptor antagonist, angiotensin receptor neprilysin inhibitor and beta-blocker therapies in heart failure and reduced ejection fraction: Association of comorbidities

BACKGROUND

In patients with heart failure and reduced ejection fraction (HFrEF), angiotensin converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), or angiotensin receptor neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists (MRA), and beta-blockers (βB) are underutilized. It is unknown if patients with and without comorbidities have similar ACEi/ARB/ARNI, MRA, and βB prescription patterns.

METHODS

Baseline data from the CHAMP-HF (Change the Management of Patients with Heart Failure) registry were categorized by history of atrial fibrillation, asthma/chronic lung disease, obstructive sleep apnea, and depression. Using multivariate hierarchical logistic models, associations of ACEi/ARB/ARNI, MRA and βB medication use and dose by comorbidities were assessed after adjusting for patient characteristics.

RESULTS

Of 4,815 HFrEF patients from 152 CHAMP-HF sites, ACEi/ARB/ARNI use was lower in patients with more comorbidities, and generally, MRA use was low and βB use was high. In adjusted analyses, patients with HFrEF and comorbid obstructive sleep apnea, vs. without, were more likely to be prescribed ARNI (OR [95% CI]: 1.25 [1.00, 1.55]); P = .047 and MRA (1.31 [1.11, 1.55]); P = .002 and less likely to be prescribed ACEi (0.74 [0.63, 0.88]); P < .001. Patients with atrial fibrillation, vs. without, were less likely to receive ACEi/ARB (0.82 [0.71, 0.95]); P = .006 and any study medication (0.81 [0.67, 0.97]); P = .020. Comorbid lung disease and history of depression were not associated with HFrEF prescriptions.

CONCLUSIONS

Renin-angiotensin-aldosterone blockade therapy prescription and dose varied by comorbidity status, but βB therapy did not. In quality efforts, leaders need to consider use and dosing of prescriptions in light of prevalent comorbidities.

An Electronically Delivered Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure With Reduced Ejection Fraction: The EPIC-HF Trial

BACKGROUND

Major gaps exist in the routine initiation and dose up-titration of guideline-directed medical therapies (GDMT) for patients with heart failure with reduced ejection fraction. Without novel approaches to improve prescribing, the cumulative benefits of heart failure with reduced ejection fraction treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients.

METHODS

The EPIC-HF (Electronically Delivered, Patient-Activation Tool for Intensification of Medications for Chronic Heart Failure with Reduced Ejection Fraction) trial randomized patients with heart failure with reduced ejection fraction from a diverse health system to usual care versus patient activation tools-a 3-minute video and 1-page checklist-delivered electronically 1 week before, 3 days before, and 24 hours before a cardiology clinic visit. The tools encouraged patients to work collaboratively with their clinicians to "make one positive change" in heart failure with reduced ejection fraction prescribing. The primary endpoint was the percentage of patients with GDMT medication initiations and dose intensifications from immediately preceding the cardiology clinic visit to 30 days after, compared with usual care during the same period.

RESULTS

EPIC-HF enrolled 306 patients, 290 of whom attended a clinic visit during the study period: 145 were sent the patient activation tools and 145 were controls. The median age of patients was 65 years; 29% were female, 11% were Black, 7% were Hispanic, and the median ejection fraction was 32%. Preclinic data revealed significant GDMT opportunities, with no patients on target doses of β-blocker, sacubitril/valsartan, and mineralocorticoid receptor antagonists. From immediately preceding the cardiology clinic visit to 30 days after, 49.0% in the intervention and 29.7% in the control experienced an initiation or intensification of their GDMT (P=0.001). The majority of these changes were made at the clinician encounter itself and involved dose uptitrations. There were no deaths and no significant differences in hospitalization or emergency department visits at 30 days between groups.

CONCLUSIONS

A patient activation tool delivered electronically before a cardiology clinic visit improved clinician intensification of GDMT. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03334188.

An Electronically delivered, Patient-activation tool for Intensification of medications for Chronic Heart Failure with reduced ejection fraction: Rationale and design of the EPIC-HF trial

BACKGROUND

Heart failure with reduced ejection fraction (HFrEF) benefits from initiation and intensification of multiple pharmacotherapies. Unfortunately, there are major gaps in the routine use of these drugs. Without novel approaches to improve prescribing, the cumulative benefits of HFrEF treatment will be largely unrealized. Direct-to-consumer marketing and shared decision making reflect a culture where patients are increasingly involved in treatment choices, creating opportunities for prescribing interventions that engage patients.

HYPOTHESIS

Encouraging patients to engage providers in HFrEF prescribing decisions will improve the use of guideline-directed medical therapies.

DESIGN

The Electronically delivered, Patient-activation tool for Intensification of Chronic medications for Heart Failure with reduced ejection fraction (EPIC-HF) trial randomizes patients with HFrEF to usual care versus patient-activation tools-a 3-minute video and 1-page checklist-delivered prior to cardiology clinic visits that encourage patients to work collaboratively with their clinicians to intensify HFrEF prescribing. The study assesses the effectiveness of the EPIC-HF intervention to improve guideline-directed medical therapy in the month after its delivery while using an implementation design to also understand the reach, adoption, implementation, and maintenance of this approach within the context of real-world care delivery. Study enrollment was completed in January 2020, with a total 305 patients. Baseline data revealed significant opportunities, with <1% of patients on optimal HFrEF medical therapy.

SUMMARY

The EPIC-HF trial assesses the implementation, effectiveness, and safety of patient engagement in HFrEF prescribing decisions. If successful, the tool can be easily disseminated and may inform similar interventions for other chronic conditions.

The Utilization of Spironolactone in Heart Failure Patients at a Tertiary Hospital in Saudi Arabia

INTRODUCTION

Heart failure (HF) has high morbidity and mortality rates. Spironolactone has shown a 30% reduction in all-cause mortality, reduction in hospitalizations, and sudden death. However, data shows low use of spironolactone in HF patients. We aim to assess spironolactone utilization in HF reduced Ejection Fraction (HFrEF) patients and to identify the factors affecting its prescribing.

METHODS

A retrospective cross-sectional study of patients diagnosed with HF from January 2016 to January 2017 conducted at King Abdulaziz Medical City-Riyadh.

INCLUSION CRITERIA

all adult HFrEF <40% who are eligible for spironolactone with New York Heart Association (NYHA) class II-IV. Serum creatinine should be <2.5 mg/dL in men or <2.0 mg/dL in women, or estimated glomerular filtration rate (eGFR) >30 mL/min/1.73m² and potassium <5.0 mEq/L.

EXCLUSION CRITERIA

pediatrics, end-stage renal disease, primary aldosteronism, and allergy to spironolactone.

RESULTS

We screened around 5000 HF patients, of whom 368 were included. Among 195 patients who were not on spironolactone, 121 patients were eligible to use it; however, they did not receive it. One hundred seventy-three patients were on spironolactone, of whom 30 received the drug although they did not meet the eligibility criteria. The mean age of patients on spironolactone was 61±14 and the mean age of patients not on spironolactone was 66.6±15.6. Two hundred seventy-seven patients in the study population were male. Regarding comorbidities, 265 patients were diabetic. As for laboratory findings, the mean potassium for patients on spironolactone was 4.3 mEq/L; the creatinine and eGFR for patients on spironolactone were 82 umol/L (0.9 mg/dl) and 88 mL/min/1.73m² while those not on spironolactone had higher creatinine at 93 umol/L (1 mg/dl) and eGFR 80 mL/min/1.73m². Using multivariate regression, we found many factors affecting spironolactone utilization, including EF before spironolactone, serum creatinine, angiotensin-converting enzyme inhibitors (ACEI), angiotensin-II receptor antagonists (ARBs), furosemide, statin, and stroke.

CONCLUSIONS

Spironolactone for HFrEF is underutilized. EF before spironolactone, serum creatinine, ACEI, ARBs, furosemide, statin, and stroke significantly affect spironolactone utilization. Further studies are warranted to identify barriers affecting spironolactone utilization in HF patients from prescribers' perspectives.

Prioritizing symptom management in the treatment of chronic heart failure

Chronic heart failure (CHF) is a chronic, progressive disease that has detrimental consequences on a patient's quality of life (QoL). In part due to requirements for market access and licensing, the assessment of current and future treatments focuses on reducing mortality and hospitalizations. Few drugs are available principally for their symptomatic effect despite the fact that most patients' symptoms persist or worsen over time and an acceptance that the survival gains of modern therapies are mitigated by poorly controlled symptoms. Additional contributors to the failure to focus on symptoms could be the result of under‐reporting of symptoms by patients and carers and a reliance on insensitive symptomatic categories in which patients frequently remain despite additional therapies. Hence, formal symptom assessment tools, such as questionnaires, can be useful prompts to encourage more fidelity and reproducibility in the assessment of symptoms. This scoping review explores for the first time the assessment options and management of common symptoms in CHF with a focus on patient‐reported outcome tools. The integration of patient‐reported outcomes for symptom assessment into the routine of a CHF clinic could improve the monitoring of disease progression and QoL, especially following changes in treatment or intervention with a targeted symptom approach expected to improve QoL and patient outcomes.

Trends in U.S. Ambulatory Cardiovascular Care 2013 to 2017: JACC Review Topic of the Week

The National Cardiovascular Data Registry PINNACLE (Practice Innovation and Clinical Excellence) Registry is the largest outpatient cardiovascular practice registry in the world. It tracks real-world management and quality of 4 common cardiovascular conditions: heart failure, coronary artery disease, atrial fibrillation, and hypertension. In 2013, the PINNACLE Registry contained information on 2,898,505 patients, cared for by 4,859 providers in 431 practices. By 2017, the registry contained information on 6,040,996 patients, cared for by 8,853 providers in 724 practices. During this time period, care processes for PINNACLE patients generally improved. Among patients with heart failure, combined beta-blocker and renin-angiotensin antagonist medication rates increased from 60.7% to 72.8%. Among patients with coronary artery disease, statin medication rates increased from 66% to 80.1%. Among patients with atrial fibrillation, oral anticoagulation rates increased from 52.7% to 65.2%. In contrast, blood pressure control rates among patients with hypertension were largely stable. PINNACLE data also fueled a variety of quality measurement programs and 51 peer-reviewed publications.