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Veltmann C, Duncker D, Doering M, Gummadi S, Robertson M, Wittlinger T, Colley BJ, Perings C, Jonsson O, Bauersachs J, Sanchez R, Maier LS. Therapy duration and improvement of ventricular function in de novo heart failure: the Heart Failure Optimization study. Eur Heart J 2024; 45:2771-2781. [PMID: 38864173 PMCID: PMC11313580 DOI: 10.1093/eurheartj/ehae334] [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: 06/26/2023] [Revised: 04/30/2024] [Accepted: 05/15/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND AND AIMS In patients with de novo heart failure with reduced ejection fraction (HFrEF), improvement of left ventricular ejection fraction (LVEF) is expected to occur when started on guideline-recommended medical therapy. However, improvement may not be completed within 90 days. METHODS Patients with HFrEF and LVEF ≤ 35% prescribed a wearable cardioverter-defibrillator between 2017 and 2022 from 68 sites were enrolled, starting with a registry phase for 3 months and followed by a study phase up to 1 year. The primary endpoints were LVEF improvement > 35% between Days 90 and 180 following guideline-recommended medical therapy initiation and the percentage of target dose reached at Days 90 and 180. RESULTS A total of 598 patients with de novo HFrEF [59 years (interquartile range 51-68), 27% female] entered the study phase. During the first 180 days, a significant increase in dosage of beta-blockers, renin-angiotensin system inhibitors, and mineralocorticoid receptor antagonists was observed (P < .001). At Day 90, 46% [95% confidence interval (CI) 41%-50%] of study phase patients had LVEF improvement > 35%; 46% (95% CI 40%-52%) of those with persistently low LVEF at Day 90 had LVEF improvement > 35% by Day 180, increasing the total rate of improvement > 35% to 68% (95% CI 63%-72%). In 392 patients followed for 360 days, improvement > 35% was observed in 77% (95% CI 72%-81%) of the patients. Until Day 90, sustained ventricular tachyarrhythmias were observed in 24 wearable cardioverter-defibrillator carriers (1.8%). After 90 days, no sustained ventricular tachyarrhythmia occurred in wearable cardioverter-defibrillator carriers. CONCLUSIONS Continuous optimization of guideline-recommended medical therapy for at least 180 days in HFrEF is associated with additional LVEF improvement > 35%, allowing for better decision-making regarding preventive implantable cardioverter-defibrillator therapy.
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Affiliation(s)
- Christian Veltmann
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
- Heart Center Bremen, Electrophysiology Bremen, Senator-Wessling-Str. 1, 28277 Bremen, Germany
| | - David Duncker
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Michael Doering
- Heart Center Leipzig, University of Leipzig, Leipzig, Germany
| | - Siva Gummadi
- Department of Cardiology, CVI of Central Florida, Ocala, FL, USA
| | | | - Thomas Wittlinger
- Department of Cardiology, Asklepios Harzklinik Goslar, Goslar, Germany
| | - Byron J Colley
- Department of Cardiology, Jackson Heart Clinic, Jackson, MS, USA
| | - Christian Perings
- Department of Cardiology, Katholisches Klinikum Luenen, Luenen, Germany
| | - Orvar Jonsson
- Department of Cardiology, Sanford Cardiovascular Institute, Sioux Falls, SD, USA
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Robert Sanchez
- Department of Cardiology, HCA Florida Heart Institute, St. Petersburg, FL, USA
| | - Lars S Maier
- Department of Internal Medicine II, University Hospital Regensburg, Regensburg, Germany
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Ezhumalai B, Modi R, Panchanatham M, Kaliyamoorthy D. The contemporary role of sodium-glucose co-transporter 2 inhibitor (SGLT2i) and angiotensin receptor-neprilysin inhibitor (ARNI) in the management of heart failure: State-of-the-art review. Indian Heart J 2024:S0019-4832(24)00158-5. [PMID: 39009078 DOI: 10.1016/j.ihj.2024.07.005] [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: 10/30/2023] [Revised: 05/11/2024] [Accepted: 07/12/2024] [Indexed: 07/17/2024] Open
Abstract
Novel therapies for heart failure with reduced ejection fraction (HFrEF) are angiotensin receptor-neprilysin inhibitor (ARNI), sodium-glucose co-transporter 2 inhibitor (SGLT2i), etc. The purpose of this review is to determine the effects of ARNI and SGLT2i in heart failure (HF), compare the impact of SGLT2i with ARNI, and finally evaluate the current data regarding the combination of these two drugs in HF. Various trials on the respective medications have shown some significant reduction in all-cause mortality and cardiovascular (CV) death. The combination of these drugs has shown more CV benefits than monotherapy. There is emerging data about these two drugs in patients with heart failure with preserved ejection fraction (HFpEF). At present, there are less head-to-head comparison trials of these two drugs. This review provides insights on the current evidence, comparative efficacy, and combination therapy of ARNI and SGLT2i in managing HF, focussing on HFrEF and HFpEF.
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Affiliation(s)
- Babu Ezhumalai
- Department of Cardiology, Apollo Speciality Hospitals Vanagaram, Chennai, India.
| | - Ranjan Modi
- Department of Cardiology, Indraprastha Apollo Hospitals, New Delhi, India
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Nelson RK, Solomon R, Hosmer E, Zuhl M. Cardiac rehabilitation utilization, barriers, and outcomes among patients with heart failure. Heart Fail Rev 2023; 28:1239-1249. [PMID: 37039955 DOI: 10.1007/s10741-023-10309-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/27/2023] [Indexed: 04/12/2023]
Abstract
Exercise-based cardiac rehabilitation (CR) is effective for improving both primary (i.e., mortality and hospitalizations) and secondary (i.e., functional capacity and quality of life among) clinical outcomes among patients with heart failure (HF). The mechanisms that explain these benefits are complex and are linked to exercise adaptations such as central and peripheral hemodynamics combined with improved overall medical management. Despite the benefits of CR, utilization rates are low among CR eligible patients. Clinician-, patient-, and health system-related barriers have been identified as primary factors contributing to the lack of CR utilization among HF patients. These include patient referrals (clinician-related), psychosocial factors (patient-related), and patient access to CR services (health system-related). The aims of this review are to detail the components of each barrier as well as identify evidence-based strategies to improve CR utilization and adherence among HF. The improvements in primary and secondary outcomes along with the mechanisms that are linked to these changes will also be examined.
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Affiliation(s)
- Rachael K Nelson
- School of Health Sciences, Central Michigan University, Mt. Pleasant, MI, USA
| | - Robert Solomon
- Department of Cardiology, Henry Ford Hospital, Detroit, MI, USA
| | - Emily Hosmer
- School of Health Sciences, Central Michigan University, Mt. Pleasant, MI, USA
| | - Micah Zuhl
- School of Health Sciences, Central Michigan University, Mt. Pleasant, MI, USA.
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Borges JI, Ferraino KE, Cora N, Nagliya D, Suster MS, Carbone AM, Lymperopoulos A. Adrenal G Protein-Coupled Receptors and the Failing Heart: A Long-distance, Yet Intimate Affair. J Cardiovasc Pharmacol 2022; 80:386-392. [PMID: 34983911 PMCID: PMC9294064 DOI: 10.1097/fjc.0000000000001213] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2021] [Accepted: 12/11/2021] [Indexed: 01/31/2023]
Abstract
ABSTRACT Systolic heart failure (HF) is a chronic clinical syndrome characterized by the reduction in cardiac function and still remains the disease with the highest mortality worldwide. Despite considerable advances in pharmacological treatment, HF represents a severe clinical and social burden. Chronic human HF is characterized by several important neurohormonal perturbations, emanating from both the autonomic nervous system and the adrenal glands. Circulating catecholamines (norepinephrine and epinephrine) and aldosterone elevations are among the salient alterations that confer significant hormonal burden on the already compromised function of the failing heart. This is why sympatholytic treatments (such as β-blockers) and renin-angiotensin system inhibitors or mineralocorticoid receptor antagonists, which block the effects of angiotensin II (AngII) and aldosterone on the failing heart, are part of the mainstay HF pharmacotherapy presently. The adrenal gland plays an important role in the modulation of cardiac neurohormonal stress because it is the source of almost all aldosterone, of all epinephrine, and of a significant amount of norepinephrine reaching the failing myocardium from the blood circulation. Synthesis and release of these hormones in the adrenals is tightly regulated by adrenal G protein-coupled receptors (GPCRs), such as adrenergic receptors and AngII receptors. In this review, we discuss important aspects of adrenal GPCR signaling and regulation, as they pertain to modulation of cardiac function in the context of chronic HF, by focusing on the 2 best studied adrenal GPCR types in that context, adrenergic receptors and AngII receptors (AT 1 Rs). Particular emphasis is given to findings from the past decade and a half that highlight the emerging roles of the GPCR-kinases and the β-arrestins in the adrenals, 2 protein families that regulate the signaling and functioning of GPCRs in all tissues, including the myocardium and the adrenal gland.
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Affiliation(s)
- Jordana I. Borges
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, FL 33328-2018, USA
| | - Krysten E. Ferraino
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, FL 33328-2018, USA
| | - Natalie Cora
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, FL 33328-2018, USA
| | - Deepika Nagliya
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, FL 33328-2018, USA
| | - Malka S. Suster
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, FL 33328-2018, USA
| | - Alexandra M. Carbone
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, FL 33328-2018, USA
| | - Anastasios Lymperopoulos
- Laboratory for the Study of Neurohormonal Control of the Circulation, Department of Pharmaceutical Sciences, Nova Southeastern University, Fort Lauderdale, FL 33328-2018, USA
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De Marzo V, Savarese G, Tricarico L, Hassan S, Iacoviello M, Porto I, Ameri P. Network meta-analysis of medical therapy efficacy in more than 90,000 patients with heart failure and reduced ejection fraction. J Intern Med 2022; 292:333-349. [PMID: 35332595 PMCID: PMC9546056 DOI: 10.1111/joim.13487] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Following the availability of new drugs for chronic heart failure (HF) with reduced ejection fraction (HFrEF), we sought to provide an updated and comparative synthesis of the evidence on HFrEF pharmacotherapy efficacy. METHODS We performed a Bayesian network meta-analysis of phase 2 and 3 randomized controlled trials (RCTs) of medical therapy in HFrEF patient cohorts with more than 90% of the participants with left ventricular ejection fraction less than 45% and all-cause mortality reported. RESULTS Sixty-nine RCTs, accounting for 91,741 subjects, were evaluated. The step-wise introduction of new drugs progressively decreased the risk of all-cause death, up to reaching a random-effects hazard ratio (HR) of 0.43 (95% credible intervals [CrI] 0.27-0.63) with beta blockers (BB), angiotensin-converting enzyme inhibitors (ACEi), and mineralocorticoid receptor antagonist (MRA) versus placebo. The risk was further reduced by adding sodium-glucose cotransporter-2 inhibitors (SGLT2i; HR 0.38, 95% CrI 0.22-0.60), ivabradine (HR 0.39, 95% CrI 0.21-0.64), or vericiguat (HR 0.40, 95% CrI 0.22-0.65) to neurohormonal inhibitors, and by angiotensin receptor-neprilysin inhibitor (ARNI), BB, and MRA (HR 0.36, 95% CrI 0.20-0.60). In a sensitivity analysis considering the ARNI and non-ARNI subgroups of SGLT2i RCTs, the combination SGLT2i + ARNI + BB + MRA was associated with the lowest HR (0.28, 95% CrI 0.16-0.45 vs. 0.40, 95% CrI 0.24-0.60 for SGLT2i + BB + ACEi + MRA). Consistent results were obtained in sensitivity analyses and by calculating surface under the cumulative ranking area, as well as for cardiovascular mortality (information available for 56 RCTs), HF hospitalization (45 RCTs), and all-cause hospitalization (26 RCTs). CONCLUSIONS Combination medical therapy including neurohormonal inhibitors and newer drugs, especially ARNI and SGLT2i, confers the maximum benefit with regard to HFrEF prognosis.
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Affiliation(s)
- Vincenzo De Marzo
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lucia Tricarico
- Cardiology Unit, Ospedali Riuniti di Foggia, Foggia, Italy.,Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Sofia Hassan
- Department of Internal Medicine, University of Genova, Genova, Italy
| | - Massimo Iacoviello
- Cardiology Unit, Ospedali Riuniti di Foggia, Foggia, Italy.,Department of Medical and Surgical Sciences, University of Foggia, Foggia, Italy
| | - Italo Porto
- Department of Internal Medicine, University of Genova, Genova, Italy.,Cardiology Unit, Cardio-Thoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Pietro Ameri
- Department of Internal Medicine, University of Genova, Genova, Italy.,Cardiology Unit, Cardio-Thoracic and Vascular Department, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Blazek O, Bakris GL. The evolution of "pillars of therapy" to reduce heart failure risk and slow diabetic kidney disease progression. AMERICAN HEART JOURNAL PLUS : CARDIOLOGY RESEARCH AND PRACTICE 2022; 19:100187. [PMID: 38558865 PMCID: PMC10978322 DOI: 10.1016/j.ahjo.2022.100187] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Accepted: 08/03/2022] [Indexed: 04/04/2024]
Abstract
The evolution of therapy to slow chronic kidney disease progression has changed dramatically over the last five years and is anticipated to change even more in the coming two to four years. What was traditionally noted as "renal sparing therapy" with blockers of the renin-angiotensin system (RAS) has now expanded to the use of inhibitors of sodium-glucose transport 2 (SGLT2) agents as well as the nonsteroidal mineralocorticoid receptor blocker, finerenone. These three "pillars of therapy" have slowed kidney disease progression by more than 50% compared to RAS blockers alone. Additionally, finerenone and SGLT2 inhibitors significantly reduce heart failure hospitalizations and the development of heart failure. Moreover, they improve exercise tolerance and reduce the risk of cardiovascular death, even though they do not affect atherosclerotic heart disease development. These data, taken together, demonstrate a "three pillar" therapy approach for cardiorenal risk reduction in people with type 2 diabetes who have any level of kidney disease.
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Affiliation(s)
- Olivia Blazek
- Department of Medicine, Am Heart Assoc Comprehensive Hypertension Center, University of Chicago Medicine, United States of America
| | - George L. Bakris
- Department of Medicine, Am Heart Assoc Comprehensive Hypertension Center, University of Chicago Medicine, United States of America
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