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Iyngkaran P, Usmani W, Bahmani Z, Hanna F. Burden from Study Questionnaire on Patient Fatigue in Qualitative Congestive Heart Failure Research. J Cardiovasc Dev Dis 2024; 11:96. [PMID: 38667714 PMCID: PMC11049876 DOI: 10.3390/jcdd11040096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 03/18/2024] [Accepted: 03/21/2024] [Indexed: 04/28/2024] Open
Abstract
Mixed methods research forms the backbone of translational research methodologies. Qualitative research and subjective data lead to hypothesis generation and ideas that are then proven via quantitative methodologies and gathering objective data. In this vein, clinical trials that generate subjective data may have limitations, when they are not followed through with quantitative data, in terms of their ability to be considered gold standard evidence and inform guidelines and clinical management. However, since many research methods utilise qualitative tools, an initial factor is that such tools can create a burden on patients and researchers. In addition, the quantity of data and its storage contributes to noise and quality issues for its primary and post hoc use. This paper discusses the issue of the burden of subjective data collected and fatigue in the context of congestive heart failure (CHF) research. The CHF population has a high baseline morbidity, so no doubt the focus should be on the content; however, the lengths of the instruments are a product of their vigorous validation processes. Nonetheless, as an important source of hypothesis generation, if a choice of follow-up qualitative assessment is required for a clinical trial, shorter versions of the questionnaire should be used, without compromising the data collection requirements; otherwise, we need to invest in this area and find suitable solutions.
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Affiliation(s)
- Pupalan Iyngkaran
- Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.I.); (W.U.)
- HeartWest, Hoppers Crossing, VIC 3029, Australia;
| | - Wania Usmani
- Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.I.); (W.U.)
| | | | - Fahad Hanna
- Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia; (P.I.); (W.U.)
- Public Health Program, Department of Health and Education, Torrens University Australia, Melbourne, VIC 3000, Australia
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Iyngkaran P, Usmani W, Hanna F, de Courten M. Challenges of Health Data Use in Multidisciplinary Chronic Disease Care: Perspective from Heart Failure Care. J Cardiovasc Dev Dis 2023; 10:486. [PMID: 38132654 PMCID: PMC10743507 DOI: 10.3390/jcdd10120486] [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: 09/24/2023] [Revised: 11/13/2023] [Accepted: 11/28/2023] [Indexed: 12/23/2023] Open
Abstract
The healthcare sector generates approximately 30% of all the world's data volume, mostly for record keeping, compliance and regulatory requirements, and patient care. Healthcare data often exist in silos or on different systems and platforms due to decentralised storage and data protection laws, limiting accessibility for health service research. Thus, both the lack of access to data and more importantly the inability to control data quality and explore post-trial (phase IV) data or data with translational relevance have an impact on optimising care and research of congestive heart failure (CHF). We highlight that for some diseases, such as CHF, generating non-traditional data has significant importance, but is hindered by the logistics of accessing chronic disease data from separate health silos and by various levels of data quality. Modern multidisciplinary healthcare management of cardiovascular diseases-especially when spanning across community hubs to tertiary healthcare centres-increases the complexities involved between data privacy and access to data for healthcare and health service research. We call for an increased ability to leverage health data across systems, devices, and countries.
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Affiliation(s)
- Pupalan Iyngkaran
- Department of Health Sciences, Torrens University Australia, Melbourne 3000, Australia;
| | - Wania Usmani
- Department of Health Sciences, Torrens University Australia, Melbourne 3000, Australia;
| | - Fahad Hanna
- Public Health Program, Department of Health and Education, Torrens University Australia, Melbourne 3000, Australia;
| | - Maximilian de Courten
- Mitchell Institute for Health and Education Policy, Victoria University, Melbourne 3000, Australia;
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Iyngkaran P, Hespe C, Hanna F, Horowitz JD, Battersby M, Nelson C, Andrew S, de Courten MP. The Wider Considerations in Closing Chronic Disease Gaps - Focus on Heart Failure and Implementation. Curr Cardiol Rev 2023; 19:e120522204690. [PMID: 35549873 PMCID: PMC10201899 DOI: 10.2174/1573403x18666220512160737] [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: 09/17/2021] [Revised: 02/09/2022] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Heart failure (HF) is predominately a chronic disease. There are overlaps in HF and chronic disease research and care. Chronic disease and HF research are conducted with multiple goals. The overarching goal is "optimized patient outcomes at maximum costeffectiveness". However, observations on patients can come with many variables; thus, we see differences in clinical translation. This document discusses an argument for three important gaps common to HF and chronic disease, i.e., screening, self-management, and patient-reported outcomes (PRO), and provides a glance of how it could fit into the evidence tree. Pertinent arguments for a framework for health services and models of care are provided as a prelude to future consensus. METHODOLOGY 1) A preliminary literature review to identify a taxonomy for cardiovascular research, and 2) a review of the published literature describing the translation of research studies into clinical practice for cardiovascular disorders. A spectrum from observational to large randomized controlled trials to post-marketing studies were identified. DISCUSSION A brief discussion on traditional research and differences focusing on screening, mixed methods research concepts, and chronic diseases models of care. Six steps to facilitate this: 1) Research design; 2) Research application (translation) i. routine ii. challenges; 3. Transforming research to translational level; 4. Funding and infrastructure; 5. Clinical Centres of Research Excellence (CCRE) and collaboration; 6. Governance and cost-effectiveness. CONCLUSION Implementation research that aims to link research findings to improved patient outcomes in an efficient and effective way is a neglected area. Skills required to perform implementation research are complex. Ways to maximize translational impacts for chronic disease research to clinical practice are described in a HF context.
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Affiliation(s)
- Pupalan Iyngkaran
- Heart Failure & Cardiac Imaging, University of Notre Dame, Werribee Mercy Sub School, School of Medicine Sydney; Research Fellow Mitchell Institute, Victoria University, Victoria, Australia
| | - Charlotte Hespe
- General Practice and Primary Care Research, School of Medicine, Sydney, The University of Notre Dame Australia, 160 Oxford St, Darlinghurst, NSW 2010, PO Box 944 Broadway, NSW 2007, Australia
| | - Fahad Hanna
- Program of Public Health, Department of Health, Torrens University Australia, Australia
| | | | - Malcolm Battersby
- College of Medicine and Public Health, Flinders University Mental Health Program Lead, Flinders Health and Medical Research Institute, Southern Adelaide Local Health Network Mental Health Service, Melbourne, Australia
| | - Craig Nelson
- Division of Chronic and Complex Care and the Director of Nephrology, Melbourne, Australia
| | - Sharon Andrew
- Adjunct Professor of Nursing, Institute Health and Sport, Victoria University, PO Box 14428 Melbourne, Victoria 8001, Australia
| | - Maximilian P. de Courten
- Mitchell Institute for Education and Health Policy, Victoria University, 300 Queen St, Melbourne 3000, Australia
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Redfors B, Omerovic E. Expanding the evidence base of new cardiovascular treatments by systematic registry-based evaluation of their implementation in clinical practice. Scand Cardiovasc J Suppl 2022; 56:264-265. [PMID: 35866317 DOI: 10.1080/14017431.2022.2100474] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Affiliation(s)
- Björn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Redfors B, Angerås O, Omerovic E. Confirming the performance of new coronary stent platforms by systematic registry-based cluster-randomised evaluation of their implementation in clinical practice. EUROINTERVENTION 2022; 18:e620-e622. [PMID: 36205731 PMCID: PMC10241258 DOI: 10.4244/eij-d-22-00592] [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] [Received: 07/05/2022] [Accepted: 07/27/2022] [Indexed: 10/09/2023]
Affiliation(s)
- Björn Redfors
- Cardiovascular Research Foundation, New York, NY, USA
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Oskar Angerås
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Elmir Omerovic
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden
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Azad A, Hanna F, Battersby M, Iyngkaran P, de Courten MP. Perspective on 'Phase V' or Logistics and Regression as Logical Progression for Community Heart Failure Triage. Curr Cardiol Rev 2022; 18:e160721194360. [PMID: 34191700 PMCID: PMC9893139 DOI: 10.2174/1573403x17666210629115743] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2020] [Revised: 02/10/2021] [Accepted: 02/12/2021] [Indexed: 11/22/2022] Open
Abstract
Congestive Heart Filur is an epidemic and its trajectory apppears to be escaling. Undoubtly tremendous gains have seen improvement in life expectancy and quality of life, however, hospital readmissions, resource utilization and health system cost continue to create challenges. In this short perspective, we raise the prospect of extending the research phases the community and real world setting. Logistic have supported service supply chains during the COVID-19 pandemic and there are lesson here to be learned.
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Affiliation(s)
- Atro Azad
- Address correspondence to this author at the Mitchell Institute, Victoria University, Melbourne, Australia; E-mail:
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The Heart Failure with Preserved Ejection Fraction Conundrum-Redefining the Problem and Finding Common Ground? Curr Heart Fail Rep 2021; 17:34-42. [PMID: 32112345 DOI: 10.1007/s11897-020-00454-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
PURPOSE OF REVIEW Heart failure with preserved ejection fraction (HFpEF) or diastolic heart failure (DHF) makes up more than half of all congestive heart failure presentations (CHF). With an ageing population, the case load and the financial burden is projected to increase, even to epidemic proportions. CHF hospitalizations add too much of the financial and infrastructure strain. Unlike systolic heart failure (SHF), much is still either uncertain or unknown. Specifically, in epidemiology, the disease burden is established; however, risk factors and pathophysiological associations are less clear; diagnostic tools are based on rigid parameters without the ability to accurately monitor treatments effects and disease progression; finally, therapeutics are similar to SHF but without prognostic data for efficacy. RECENT FINDINGS The last several years have seen guidelines changing to account for greater epidemiological observations. Most of these remain general observation of shortness of breath symptom matched to static echocardiographic parameters. The introduction of exercise diastolic stress test has been welcome and warrants greater focus. HFpEF is likely to see new thinking in the coming decades. This review provides some of perspective on this topic.
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Rey A, Batteux B, Laville SM, Marienne J, Masmoudi K, Gras-Champel V, Liabeuf S. Acute kidney injury associated with febuxostat and allopurinol: a post-marketing study. Arthritis Res Ther 2019; 21:229. [PMID: 31703711 PMCID: PMC6842268 DOI: 10.1186/s13075-019-2011-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2019] [Accepted: 09/23/2019] [Indexed: 02/03/2023] Open
Abstract
Background For patients with recurrent flares of gout, tophi, urate crystal arthropathy, and renal stones, urate-lowering therapies (ULTs, including allopurinol and febuxostat) are the first-line treatment. Due to the widespread use of these ULTs (especially in patients with impaired renal function), assessment of the associated renal risk is essential. Accordingly, we performed a disproportionality analysis of reported cases of acute renal failure (ARF) associated with allopurinol and febuxostat. Methods We carried out a case/non-case study of the World Health Organization’s VigiBase® pharmacovigilance database between January 1, 2008, and December 31, 2018. The frequency of reports of ARF as a standardized Medical Dictionary for Regulatory Activities query for allopurinol and febuxostat was compared with that of all other reports for the two drugs and quoted as the reporting odds ratio (ROR) [95% confidence interval (CI)]. The results’ stability was assessed in a series of sensitivity analyses (notably after the exclusion of putative competing drugs). Results Among 3509 “suspected drug” notifications for febuxostat and 18,730 for allopurinol, we identified respectively 317 and 1008 cases of ARF. Acute renal failure was reported significantly more frequently for febuxostat and allopurinol than for other drugs (ROR [95%CI] 5.67 [5.05–6.36] and 3.25 [3.05–3.47], respectively). For both drugs, the ROR was higher in women than in men, respectively 11.60 [9.74–13.82] vs. 3.14 [2.69–3.67] for febuxostat and 4.45 [4.04–4.91] vs. 2.29 [2.11–2.50] for allopurinol. The sensitivity analyses confirmed the disproportionality for these two ULTs. Conclusions Acute renal failure was reported respectively 5.7 and 3.3 times more frequently for febuxostat and for allopurinol than for other drugs. Due to the potential consequences of ARF, physicians should take account of this disproportionality signal when prescribing the ULTs febuxostat and allopurinol.
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Affiliation(s)
- Amayelle Rey
- Regional Pharmacovigilance Centre, Division of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,MP3CV Laboratory, EA7517, University of Picardie Jules Verne, F-80000, Amiens, France
| | - Benjamin Batteux
- Regional Pharmacovigilance Centre, Division of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,MP3CV Laboratory, EA7517, University of Picardie Jules Verne, F-80000, Amiens, France
| | - Solène M Laville
- CESP Centre for Research in Epidemiology and Population Health, Université Paris-Saclay, Université Paris Sud, UVSQ, UMRS 1018, F-94807, Villejuif, France
| | - Justine Marienne
- Regional Pharmacovigilance Centre, Division of Clinical Pharmacology, Amiens University Hospital, Amiens, France
| | - Kamel Masmoudi
- Regional Pharmacovigilance Centre, Division of Clinical Pharmacology, Amiens University Hospital, Amiens, France
| | - Valérie Gras-Champel
- Regional Pharmacovigilance Centre, Division of Clinical Pharmacology, Amiens University Hospital, Amiens, France.,MP3CV Laboratory, EA7517, University of Picardie Jules Verne, F-80000, Amiens, France
| | - Sophie Liabeuf
- Regional Pharmacovigilance Centre, Division of Clinical Pharmacology, Amiens University Hospital, Amiens, France. .,MP3CV Laboratory, EA7517, University of Picardie Jules Verne, F-80000, Amiens, France. .,Clinical Pharmacology Division, Amiens University Medical Center, Avenue René Laennec, F-80000, Amiens, France.
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Iyngkaran P, Noaman S, Chan W, Mahadavan G, Thomas MC, Rajendran S. Non-invasive Risk Stratification for Coronary Artery Disease: Is It Time for Subclassifications? Curr Cardiol Rep 2019; 21:87. [PMID: 31342185 DOI: 10.1007/s11886-019-1174-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE OF REVIEW Coronary artery disease (CAD) is the leading contributor to cardiovascular disease; it is the most prevalent non-communicable disease globally and has high morbidity, mortality and health care cost. Risk stratification is defined as prevention or containment of disease prior to it occurring or progressing, and non-invasive surrogates include history, examination, biomarkers and non-invasive imaging. This review aims to highlight advancement in current diagnostic strategies and explores gaps for CAD secondary to atherosclerosis and non-obstructive vascular diseases. RECENT FINDINGS Cardiac risk scores have largely proven inadequate in risk stratifying heterogeneous patient populations. Greater emphasis should also be provided to posttest risk stratification. Non-invasive imaging with MRI is the most accurate but least cost efficacious presently due to availability and expertise. Echocardiography and nuclear imaging have good accuracy, but radiation limits the latter. Novel echocardiographic technologies may increase its appeal. Cardiac CT angiography is increasingly promising. Non-invasive and minimally invasive imaging has significantly influenced the cost-efficacy trajectory of coronary artery disease diagnosis and management. Recent studies suggest that future guidelines will incorporate more subclassifications from the findings of these novel technologies and for more diverse patient demographics.
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Affiliation(s)
- Pupalan Iyngkaran
- Consultant Cardiologist Heart West Melbourne Victoria and Senior Lecturer, NT Medical School, Flinders University, Darwin, Australia.
| | | | - William Chan
- University of Melbourne; Consultant & Interventional Cardiologist Alfred/Western/ Epworth, Melbourne, Victoria, Australia
| | - Gnanadevan Mahadavan
- Northern and Central Adelaide Local Network, University of Adelaide, Adelaide, Australia
| | - Merlin C Thomas
- Biochemistry of Diabetes Complications, Melbourne, Australia
| | - Sharmalar Rajendran
- Northern and Central Adelaide Local Network, University of Adelaide, Adelaide, Australia
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Clinical Profile of a Nonselected Population Treated With Sacubitril/Valsartan Is Different From PARADIGM-HF Trial. J Cardiovasc Pharmacol 2019; 72:112-116. [PMID: 29878937 DOI: 10.1097/fjc.0000000000000603] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Our aim is to describe the characteristics of the patients receiving sacubitril/valsartan (SV) in daily clinical practice. This is a prospective registry in 10 hospitals including all patients who started SV in everyday clinical practice. From October 2016 to March 2017, 427 patients started treatment with SV. The mean age was 68.1 ± 12.4 years, and 30.5% were women (22.0% in PARADIGM-HF, P < 0.001). Comparing our cohort with patients included in PARADIGM-HF, baseline treatment was different, with a lower ratio of angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (2.7 vs. 3.5, P < 0.001), and a higher proportion of patients with implantable cardioverter defibrillator (53.8% vs. 15%, P < 0.001), and cardiac resynchronization therapy (25.8% vs. 5%, P < 0.001). Treatment with mineralocorticoid receptor antagonists was more frequent (76.7% vs. 60.0%, P < 0.001), and the use of beta-blockers was similar (94.6% vs. 93.0%, P = 0.43). We observed more patients in functional class III-IV (30.4 vs. 24.8, P = 0.015), higher levels of Nt pro-BNP [3421 (904-4161) vs. 1631 (885-3154) pg/mL] and worse renal function (creatinine level 1.3 ± 0.7 vs. 1.1 ± 0.3 mg/dL, P < 0.001). In real life, patients receiving SV have a higher risk profile than in the pivotal trial, poorer functional class, higher levels of natriuretic peptides, and worse renal function.
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Iyngkaran P, Thomas M, Majoni SW. Perspectives On Optimizing Chronic Heart Failure Care Beyond Randomised Controlled Trials - What do we Consolidate and how do we Plan for the Future? Curr Cardiol Rev 2019; 15:158-160. [PMID: 31084591 PMCID: PMC6719389 DOI: 10.2174/1573403x1503190506101720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
- Pupalan Iyngkaran
- Consultant Cardiologist Heart West and Senior Lecturer Flinders University, NT Medical School, Darwin, Australia
| | - Merlin Thomas
- Biochemistry of Diabetes Complications, The Department of Diabetes, Monash University, Melbourne, Australia
| | - Sandawana W Majoni
- Clinical Dean Royal Darwin Hospital, TEHS, Renal Transplantation, Royal Darwin Hospital, Department of Nephrology, Division of Medicine, P.O. Box 41326, Tiwi, Darwin, Australia
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Iyngkaran P, Jelinek M. Health care in a globalised world: is there more than one type of patient? Med J Aust 2019; 210:211-212. [PMID: 30773648 DOI: 10.5694/mja2.50035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
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Iyngkaran P, Chan W, Liew D, Zamani J, Horowitz JD, Jelinek M, Hare DL, Shaw JA. Risk stratification for coronary artery disease in multi-ethnic populations: Are there broader considerations for cost efficiency? World J Methodol 2019; 9:1-19. [PMID: 30705870 PMCID: PMC6354077 DOI: 10.5662/wjm.v9.i1.1] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 11/22/2018] [Accepted: 12/24/2018] [Indexed: 02/06/2023] Open
Abstract
Coronary artery disease (CAD) screening and diagnosis are core cardiac specialty services. From symptoms, autopsy correlations supported reductions in coronary blood flow and dynamic epicardial and microcirculatory coronaries artery disease as etiologies. While angina remains a clinical diagnosis, most cases require correlation with a diagnostic modality. At the onset of the evidence building process much research, now factored into guidelines were conducted among population and demographics that were homogenous and often prior to newer technologies being available. Today we see a more diverse multi-ethnic population whose characteristics and risks may not consistently match the populations from which guideline evidence is derived. While it would seem very unlikely that for the majority, scientific arguments against guidelines would differ, however from a translational perspective, there will be populations who differ and importantly there are cost-efficacy questions, e.g., the most suitable first-line tests or what parameters equate to an adequate test. This article reviews non-invasive diagnosis of CAD within the context of multi-ethnic patient populations.
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Affiliation(s)
- Pupalan Iyngkaran
- Department of Cardiology, Flinders University, NT Medical School, Darwin 0810, Australia
| | - William Chan
- Department of Cardiology Alfred and Western Health, University of Melbourne, Victoria 3004, Australia
| | - Danny Liew
- Clinical Outcomes Research, School of Public Health and Preventive Medicine, Monash University, Melbourne VIC 3004, Australia
| | - Jalal Zamani
- Department of Interventional Cardiology, Feris Shiraz University, Shiraz University of Medical Sciences, Shiraz 71348-14336, Iran
| | - John D Horowitz
- Department of Cardiology and Clinical Pharmacology, the Queen Elizabeth Hospital, University of Adelaide, Adelaide 5011, Australia
| | - Michael Jelinek
- Department of Cardiology, Vincent’s Hospital, Melbourne, Victoria 3065, Australia
| | - David L Hare
- Cardiovascular Research, University of Melbourne, Melbourne, Victoria 3084, Australia
| | - James A Shaw
- Department of Cardiology, The Alfred Hospital, Baker IDI Heart and Diabetes Institute, Melbourne, Vic 3004, Australia
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Iyngkaran P, Liew D, Neil C, Driscoll A, Marwick TH, Hare DL. Moving From Heart Failure Guidelines to Clinical Practice: Gaps Contributing to Readmissions in Patients With Multiple Comorbidities and Older Age. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2018; 12:1179546818809358. [PMID: 30618487 PMCID: PMC6299336 DOI: 10.1177/1179546818809358] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2017] [Accepted: 09/14/2018] [Indexed: 12/20/2022]
Abstract
This feature article for the thematic series on congestive heart failure (CHF) readmissions aims to outline important gaps in guidelines for patients with multiple comorbidities and the elderly. Congestive heart failure diagnosis manifests as a 3-phase journey between the hospital and community, during acute, chronic stable, and end-of-life (palliative) phases. This journey requires in variable intensities a combination of multidisciplinary care within tertiary hospital or ambulatory care from hospital outpatients or primary health services, within the general community. Management goals are uniform, ie, to achieve the lowest New York Heart Association class possible, with improvement in ejection fraction, by delivering gold standard therapies within a CHF program. Comorbidities are an important common denominator that influences outcomes. Comorbidities include diabetes mellitus, chronic obstructive airways disease, chronic renal impairment, hypertension, obesity, sleep apnea, and advancing age. Geriatric care includes the latter as well as syndromes such as frailty, falls, incontinence, and confusion. Many systems still fail to comprehensively achieve all aspects of such programs. This review explores these factors.
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Affiliation(s)
- Pupalan Iyngkaran
- Northern Territory Medical Program, Flinders University, Darwin, NT, Australia
- Pupalan Iyngkaran, Yellow Building 4 Cnr University Drive North & University Drive West Charles Darwin University, Casuarina, NT 0815, Australia.
| | - Danny Liew
- School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Christopher Neil
- Department of Medicine—Western Precinct, The University of Melbourne, Melbourne, VIC, Australia
| | - Andrea Driscoll
- School of Nursing and Midwifery, Deakin University, Geelong, VIC, Australia
- Austin Health, Melbourne, VIC, Australia
| | | | - David L Hare
- Cardiovascular Research, The University of Melbourne, Melbourne, VIC, Australia
- Heart Failure Services, Austin Health, Melbourne, VIC, Australia
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Iyngkaran P, Kangaharan N, Zimmet H, Arstall M, Minson R, Thomas MC, Bergin P, Atherton J, MacDonald P, Hare DL, Horowitz JD, Ilton M. Heart Failure in Minority Populations - Impediments to Optimal Treatment in Australian Aborigines. Curr Cardiol Rev 2016; 12:166-79. [PMID: 27280307 PMCID: PMC5011191 DOI: 10.2174/1573403x12666160606115034] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2015] [Revised: 12/18/2015] [Accepted: 01/11/2016] [Indexed: 01/30/2023] Open
Abstract
Chronic heart failure (CHF) among Aboriginal/Indigenous Australians is endemic. There are also grave concerns for outcomes once acquired. This point is compounded by a lack of prospective and objective studies to plan care. To capture the essence of the presented topic it is essential to broadly understand Indigenous health. Key words such as ‘worsening’, ‘gaps’, ‘need to do more’, ‘poorly studied’, or ‘future studies should inform’ occur frequently in contrast to CHF research for almost all other groups. This narrative styled opinion piece attempts to discuss future directions for CHF care for Indigenous Australians. We provide a synopsis of the problem, highlight the treatment gaps, and define the impediments that present hurdles in optimising CHF care for Indigenous Australians.
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Affiliation(s)
- Pupalan Iyngkaran
- Cardiologist and Senior Lecturer NT Medical School, Flinders University, Tiwi, NT 0811, Australia.
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Iyngkaran P, Toukhsati SR, Thomas MC, Jelinek MV, Hare DL, Horowitz JD. A Review of the External Validity of Clinical Trials with Beta-Blockers in Heart Failure. CLINICAL MEDICINE INSIGHTS-CARDIOLOGY 2016; 10:163-171. [PMID: 27773994 PMCID: PMC5063839 DOI: 10.4137/cmc.s38444] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 07/03/2016] [Accepted: 07/16/2016] [Indexed: 12/20/2022]
Abstract
BACKGROUND Beta-blockers (BBs) are the mainstay prognostic medication for all stages of chronic heart failure (CHF). There are many classes of BBs, each of which has varying levels of evidence to support its efficacy in CHF. However, most CHF patients have one or more comorbid conditions such as diabetes, renal impairment, and/or atrial fibrillation. Patient enrollment to randomized controlled trials (RCTs) often excludes those with certain comorbidities, particularly if the symptoms are severe. Consequently, the extent to which evidence drawn from RCTs is generalizable to CHF patients has not been well described. Clinical guidelines also underrepresent this point by providing generic advice for all patients. The aim of this review is to examine the evidence to support the use of BBs in CHF patients with common comorbid conditions. METHODS We searched MEDLINE, PubMed, and the reference lists of reviews for RCTs, post hoc analyses, systematic reviews, and meta-analyses that report on use of BBs in CHF along with patient demographics and comorbidities. RESULTS In total, 38 studies from 28 RCTs were identified, which provided data on six BBs against placebo or head to head with another BB agent in ischemic and nonischemic cardiomyopathies. Several studies explored BBs in older patients. Female patients and non-Caucasian race were underrepresented in trials. End points were cardiovascular hospitalization and mortality. Comorbid diabetes, renal impairment, or atrial fibrillation was detailed; however, no reference to disease spectrum or management goals as a focus could be seen in any of the studies. In this sense, enrollment may have limited more severe grades of these comorbidities. CONCLUSIONS RCTs provide authoritative information for a spectrum of CHF presentations that support guidelines. RCTs may provide inadequate information for more heterogeneous CHF patient cohorts. Greater Phase IV research may be needed to fill this gap and inform guidelines for a more global patient population.
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Affiliation(s)
- Pupalan Iyngkaran
- Cardiologist and Senior Lecturer, Northern Territory School of Medicine, Flinders University, Bedford Park, South Australia
| | - Samia R Toukhsati
- Department of Cardiology, Austin Health, Heidelberg, Victoria, Australia
| | - Merlin C Thomas
- Professor, NHMRC Senior Research Fellow, Baker IDI Heart and Diabetes Institute, Melbourne, Victoria, Australia
| | - Michael V Jelinek
- Professor, Department of Cardiology, St. Vincent's Hospital, Melbourne, Victoria, Australia
| | - David L Hare
- Professor, Coordinator, Cardiovascular Research, University of Melbourne; Director of Heart Failure Services, Austin Health, Melbourne, Victoria, Australia
| | - John D Horowitz
- Professor of Cardiology, Director, Cardiology Unit, Discipline of Medicine, Cardiology Research Laboratory, The Basil Hetzel Institute, Woodville South, South Australia, Australia
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