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Riaz M, Smith SM, Dietrich EA, Winchester DE, Guo J, Park H. Comparative effectiveness of sacubitril/valsartan versus angiotensin receptor blockers in patients with heart failure with preserved ejection fraction: A real-world study. Am J Health Syst Pharm 2024; 81:599-607. [PMID: 38427969 DOI: 10.1093/ajhp/zxae053] [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: 02/21/2024] [Indexed: 03/03/2024] Open
Abstract
PURPOSE Sacubitril/valsartan (SAC/VAL) or angiotensin receptor blockers (ARBs) are recommended therapy for heart failure with preserved ejection fraction (HFpEF), but little is known about their real-world comparative effectiveness among patients with HFpEF. The objective of this study was to determine the comparative effectiveness of SAC/VAL vs ARBs in preventing HF-related hospitalization or all-cause hospitalization among patients with HFpEF. METHODS We conducted a cohort study using IBM MarketScan commercial and Medicare supplemental databases to identify patients aged 18 years or older with a diagnosis of HFpEF and initiation of SAC/VAL (2015-2020) or ARB (2009-2014) therapy. The index date was the date of the first SAC/VAL or ARB prescription fill. After propensity score (PS) matching with a ratio of 1 up to 3, Cox proportional hazards regression was used with robust variance estimators to compare the risks of HF-related hospitalization and all-cause hospitalization between the 2 therapies. Several subgroup and sensitivity analyses were conducted to check the robustness of the main analysis. RESULTS After PS matching, 2,520 patients (846 receiving SAC/VAL and 1,674 receiving an ARB) were included in the final analyses. After controlling for covariates, there was no difference in the risk of HF-related hospitalization between SAC/VAL and ARB recipients (adjusted hazard ratio [aHR], 1.33; 95% confidence interval [CI], 0.99-1.77). There was also no difference in the risk of all-cause hospitalization between SAC/VAL and ARB recipients (aHR, 1.06; 95% CI, 0.91-1.24). CONCLUSION Among individuals with private or Medicare Advantage insurance plans, there was no significant difference in the risk of HF-related hospitalization or all-cause hospitalization between adults with HFpEF who received SAC/VAL and those who received ARB therapy.
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Affiliation(s)
- Munaza Riaz
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
- Lahore College for Women University, Lahore, Pakistan
| | - Steven M Smith
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Eric A Dietrich
- Department of Pharmacotherapy and Translational Research, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - David E Winchester
- Division of Cardiovascular Medicine, Department of Medicine, College of Medicine, University of Florida, Gainesville, FL, USA
| | - Jingchuan Guo
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
| | - Haesuk Park
- Department of Pharmaceutical Outcomes and Policy, College of Pharmacy, University of Florida, Gainesville, FL, USA
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2
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Santner V, Riepl HS, Posch F, Wallner M, Rainer PP, Ablasser K, Kolesnik E, Hoeller V, Zach D, Schwegel N, Kreuzer P, Lueger A, Petutschnigg J, Pieske B, Zirlik A, Edelmann F, Verheyen N. Non-eligibility for pivotal HFpEF/HFmrEF outcome trials and mortality in a contemporary heart failure cohort. Eur J Intern Med 2023; 118:73-81. [PMID: 37517939 DOI: 10.1016/j.ejim.2023.07.027] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Revised: 06/27/2023] [Accepted: 07/23/2023] [Indexed: 08/01/2023]
Abstract
Pivotal outcome trials targeting heart failure with preserved (HFpEF) and mildly-reduced ejection fraction (HFmrEF) may have excluded patients at highest risk of poor outcomes. We aimed to assess eligibility for HFpEF/HFmrEF outcome trials in an unselected heart failure cohort and its association with all-cause mortality. Among 32.028 patients presenting to a tertiary care center emergency unit for any reason between August 2018 and July 2019, we identified 407 admissions with evident HFpEF and HFmrEF. Eligibility criteria for pivotal trials CHARM-Preserved, I-PRESERVE, TOPCAT, PARAGON-HF, EMPEROR-Preserved and DELIVER were assessed by chart review. The proportions of admissions fulfilling HFpEF/HFmrEF trial eligibility criteria were 88% for CHARM-Preserved, 40% for I-PRESERVE, 35% for TOPCAT, 28% for PARAGON-HF, 51% for EMPEROR-Preserved, and 49% for DELIVER. During a median follow-up of 1.9 years, death-from-any-cause occurred in 121 cases (30%). Twenty-four-month overall survival estimates for non-eligible and eligible admissions were 53% vs. 76% for CHARM-Preserved (HR=2.32, 95% CI: 1.47-3.67, p<0.001), 62% vs. 87% for I-PRESERVE (HR=2.97, 1.85-4.77, p<0.001), 67% vs. 84% for TOPCAT (HR=2.04, 1.29-3.24, p = 0.002), 68% vs. 85% for PARAGONHF (HR=2.28, 1.33-3.90, p = 0.003), 64% vs. 81% for EMPEROR-Preserved (HR=1.90, 1.27-2.84, p = 0.002), and 65% vs. 80% for DELIVER (HR=1.71, 1.14-2.57, p = 0.010). Exclusion criteria independently predicting death were eGFR <20 ml/min/1.73 m2, COPD with home oxygen therapy, and severe valvular heart disease. Conclusively, in a contemporary HFpEF/HFmrEF cohort, non-eligibility for outcome trials predicted for strongly increased mortality. HFpEF/HFmrEF patients at highest mortality risk were likely underrepresented in previous outcome trials and their treatment remains an unmet medical need.
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Affiliation(s)
- Viktoria Santner
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Hermann S Riepl
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Florian Posch
- Division of Hematology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Markus Wallner
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Peter P Rainer
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria; Department of Medicine, St. Johann in Tirol General Hospital, St. Johann in Tirol, Austria; BioTechMed Graz, Graz, Austria
| | - Klemens Ablasser
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Ewald Kolesnik
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Viktoria Hoeller
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - David Zach
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Nora Schwegel
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp Kreuzer
- Emergency Medicine Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Andreas Lueger
- Emergency Medicine Unit, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Johannes Petutschnigg
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany; German Center for Cardiovascular Research, Partner Site Berlin, Germany
| | | | - Andreas Zirlik
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité-Universitätsmedizin Berlin, Campus Virchow Klinikum, Berlin, Germany; German Center for Cardiovascular Research, Partner Site Berlin, Germany
| | - Nicolas Verheyen
- Division of Cardiology, University Heart Center and Department of Internal Medicine, Medical University of Graz, Graz, Austria.
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Wan Ahmad WA, Mohd Ghazi A, Abdul Ghapar AK, Muthusamy TS, Liew HB, Zainal Abidin I, Ong ML, Ross NT, Cham YL, Ho WS, Fegade M, Chew DSP. From Primary to Tertiary Care: Expert Position Statements to Guide Heart Failure with Preserved Ejection Fraction Diagnosis. Malays J Med Sci 2023; 30:49-66. [PMID: 36875198 PMCID: PMC9984115 DOI: 10.21315/mjms2023.30.1.5] [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: 04/05/2022] [Accepted: 07/31/2022] [Indexed: 03/05/2023] Open
Abstract
Globally, heart failure with preserved ejection fraction (HFpEF) is quickly becoming the dominant form of heart failure (HF) in ageing populations. However, there are still multiple gaps and challenges in making a firm diagnosis of HFpEF in many low-to-middle income Asian countries. In response to this unmet need, the Malaysian HFpEF Working Group (MY-HPWG) gathered and reviewed evidence surrounding the use of different diagnostic modalities indicated for patients with HFpEF to identify diagnostic tools that could be conveniently accessed across different healthcare settings. As a result, five recommendation statements were proposed and an accompanying algorithm was developed, with the aim of improving the diagnostic rate of HFpEF. The MY-HPWG recommends using more easily accessible and non-invasive tools, such as natriuretic peptide (NP) biomarkers and basic echocardiogram (ECHO), to ensure timely HFpEF diagnosis in the primary and secondary care settings, and prompt referral to a tertiary care centre for more comprehensive assessments in uncertain cases.
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Affiliation(s)
- Wan Azman Wan Ahmad
- Division of Cardiology, Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Azmee Mohd Ghazi
- Cardiology Department, The National Heart Institute of Malaysia, Kuala Lumpur, Malaysia
| | | | | | - Houng Bang Liew
- Cardiology Department, Queen Elizabeth Hospital II, Sabah, Malaysia
| | - Imran Zainal Abidin
- Department of Medicine, University Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Mei Lin Ong
- Cardiology Department, Gleneagles Hospital Penang, Pulau Pinang, Malaysia
| | - Noel Thomas Ross
- Medical Department, Kuala Lumpur Hospital, Kuala Lumpur, Malaysia
| | - Yee Ling Cham
- Cardiology Department, Sarawak Heart Centre, Sarawak, Malaysia
| | - Wing Sze Ho
- Novartis Corporation (Malaysia) Sdn. Bhd., Selangor, Malaysia
| | - Mayuresh Fegade
- Novartis Corporation (Malaysia) Sdn. Bhd., Selangor, Malaysia
| | - David Soon Ping Chew
- Cardiology Department, Cardiac Vascular Sentral Kuala Lumpur, Kuala Lumpur, Malaysia
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Lund LH, Savarese G, Venkateshvaran A, Benson L, Lundberg A, Donal E, Daubert JC, Oger E, Linde C, Hage C. Eligibility of patients with heart failure with preserved ejection fraction for sacubitril/valsartan according to the PARAGON-HF trial. ESC Heart Fail 2021; 9:164-177. [PMID: 34811954 PMCID: PMC8788030 DOI: 10.1002/ehf2.13705] [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: 08/08/2021] [Revised: 10/04/2021] [Accepted: 10/29/2021] [Indexed: 11/08/2022] Open
Abstract
Aims In the heart failure (HF) with preserved ejection fraction (HFpEF) PARAGON‐HF trial, sacubitril/valsartan vs. valsartan improved mortality/morbidity in patients with left ventricular ejection fraction (LVEF) below median (57%). We assessed eligibility for sacubitril/valsartan based on four scenarios. Methods and results Eligibility was assessed in the Karolinska‐Rennes study (acute HFpEF, LVEF ≥ 45%, and N‐terminal pro‐B‐type natriuretic peptide ≥300 pg/mL subsequently assessed as outpatients including echocardiography) in (i) a trial scenario (all trial criteria); (ii) a pragmatic scenario (selected trial criteria); (iii) LVEF below lower limit of normal range (<54% in women and <52% in men); and (iv) LVEF below mean of normal range (<64% in women and <62% in men). Among 425 patients [age 78 (72–83) years, 57% women, 28% LVEF ≤ 57% (median in PARAGON‐HF), the trial scenario, identified 34% as eligible. Left atrial enlargement and/or left ventricular hypertrophy were present in 99%. Inclusion criteria not met were diuretic treatment and New York Heart Association class. Important exclusion criteria were estimated glomerular filtration rate <30 mL/min/1.73 m2, haemoglobin <10 g/day, and cancer. In the pragmatic scenario, 63% were eligible. In LVEF below lower limit of normal range, 5.4% were eligible, and in LVEF below mean of normal range, 41% were eligible. In patients with LVEF ≤ 57%, eligibility was 42%, 69%, 21%, and 91% according to the trial scenario, pragmatic scenario, LVEF below lower limit of normal range, and LVEF below mean of normal range, respectively. Conclusions In real‐world HFpEF (LVEF ≥ 45%) with N‐terminal pro‐B‐type natriuretic peptide and cardiac structure/function assessed, eligibility for sacubitril/valsartan was according to PARAGON‐HF complete criteria 34%, pragmatic criteria 63%, LVEF below lower limit of normal range 5.4%, and LVEF below mean of normal range 41%. Cardiac structural impairment was almost ubiquitous. Ineligibility was more due to exclusion criteria than failing to meet inclusion criteria.
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Affiliation(s)
- Lars H Lund
- Cardiology Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Heart, Vascular and Neuro Theme, Department of Cardiology, Heart Failure Section, Karolinska University Hospital, Stockholm, SE-171 64, Sweden
| | - Gianluigi Savarese
- Cardiology Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Heart, Vascular and Neuro Theme, Department of Cardiology, Heart Failure Section, Karolinska University Hospital, Stockholm, SE-171 64, Sweden
| | - Ashwin Venkateshvaran
- Cardiology Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Heart, Vascular and Neuro Theme, Department of Cardiology, Heart Failure Section, Karolinska University Hospital, Stockholm, SE-171 64, Sweden
| | - Lina Benson
- Cardiology Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | | | - Erwan Donal
- University of Rennes, CHU Rennes, Inserm, LTSI-UMR 1099, Rennes, France
| | | | - Emmanuel Oger
- Pharmacologie Clinique et CIC-IP 1414, CHU Rennes et Université Rennes-1, Rennes, France
| | - Cecilia Linde
- Cardiology Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden
| | - Camilla Hage
- Cardiology Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden.,Heart, Vascular and Neuro Theme, Department of Cardiology, Heart Failure Section, Karolinska University Hospital, Stockholm, SE-171 64, Sweden
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Tourki B, Halade GV. Heart Failure Syndrome With Preserved Ejection Fraction Is a Metabolic Cluster of Non-resolving Inflammation in Obesity. Front Cardiovasc Med 2021; 8:695952. [PMID: 34409075 PMCID: PMC8367012 DOI: 10.3389/fcvm.2021.695952] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/08/2021] [Indexed: 12/20/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is an emerging disease with signs of nonresolving inflammation, endothelial dysfunction, and multiorgan defects. Moreover, based on the clinical signs and symptoms and the rise of the obesity epidemic, the number of patients developing HFpEF is increasing. From recent molecular and cellular studies, it becomes evident that HFpEF is not a single and homogenous disease but a cluster of heterogeneous pathophysiology with aging at the base of the pyramid. Obesity superimposed on aging drives the number of inflammatory pathways that intersect with metabolic dysfunction and suboptimal inflammation. Here, we compiled information on obesity-directed macrophage dysfunction that coincide with metabolic defects. Obesity-associated proinflammatory stimuli facilitates heart and interorgan inflammation in HFpEF. Furthermore, diversified mechanisms that drive heart failure urge the need of studying pervasive and unresolved inflammation in animal models to understand HFpEF. A broad and system-based approach will help to study major translational aspects of HFpEF, since no single animal model recapitulates all signs of differential HFpEF stages in the clinical setting. Here, we covered experimental models that target HFpEF and emphasized the advances observed with formyl peptide 2 (FPR2) receptor, a prime sensor that is important in inflammation-resolution signaling. Dysfunction of FPR2 led to the development of spontaneous obesity, impaired macrophage function, and triggered kidney fibrosis, providing evidence of multiorgan defects in HFpEF in an obesogenic aging experimental model.
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Affiliation(s)
- Bochra Tourki
- Division of Cardiovascular Sciences, Department of Medicine, The University of South Florida, Tampa, FL, United States
| | - Ganesh V Halade
- Division of Cardiovascular Sciences, Department of Medicine, The University of South Florida, Tampa, FL, United States
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Miñana G, Núñez J. Heart Failure with Preserved Ejection Fraction: An Urgent Need for Precision Medicine. J Clin Med 2021; 10:jcm10091801. [PMID: 33918988 PMCID: PMC8122509 DOI: 10.3390/jcm10091801] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Accepted: 04/19/2021] [Indexed: 01/02/2023] Open
Affiliation(s)
- Gema Miñana
- Cardiology Department and Heart Failure Unit, Hospital Clínico Universitario de Valencia, INCLIVA, 46010 Valencia, Spain;
- Medicine Department, Universitat de Valencia, 46010 Valencia, Spain
- CIBER Cardiovascular, 28029 Madrid, Spain
| | - Julio Núñez
- Cardiology Department and Heart Failure Unit, Hospital Clínico Universitario de Valencia, INCLIVA, 46010 Valencia, Spain;
- Medicine Department, Universitat de Valencia, 46010 Valencia, Spain
- CIBER Cardiovascular, 28029 Madrid, Spain
- Correspondence:
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Pleiotropic Properties of Valsartan: Do They Result from the Antiglycooxidant Activity? Literature Review and In Vitro Study. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2021; 2021:5575545. [PMID: 33763167 PMCID: PMC7946482 DOI: 10.1155/2021/5575545] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 02/13/2021] [Accepted: 02/16/2021] [Indexed: 12/15/2022]
Abstract
Valsartan belongs to angiotensin II type 1 (AT1) receptor blockers (ARB) used in cardiovascular diseases like heart failure and hypertension. Except for its AT1-antagonism, another mechanism of drug action has been suggested in recent research. One of the supposed actions refers to the positive impact on redox balance and reducing protein glycation. Our study is aimed at assessing the antiglycooxidant properties of valsartan in an in vitro model of oxidized bovine serum albumin (BSA). Glucose, fructose, ribose, glyoxal (GO), methylglyoxal (MGO), and chloramine T were used as glycation or oxidation agents. Protein oxidation products (total thiols, protein carbonyls (PC), and advanced oxidation protein products (AOPP)), glycooxidation products (tryptophan, kynurenine, N-formylkynurenine, and dityrosine), glycation products (amyloid-β structure, fructosamine, and advanced glycation end products (AGE)), and albumin antioxidant activity (total antioxidant capacity (TAC), DPPH assay, and ferric reducing antioxidant power (FRAP)) were measured in each sample. In the presence of valsartan, concentrations of protein oxidation and glycation products were significantly lower comparing to control. Moreover, albumin antioxidant activity was significantly higher in those samples. The drug's action was comparable to renowned antiglycation agents and antioxidants, e.g., aminoguanidine, metformin, Trolox, N-acetylcysteine, or alpha-lipoic acid. The conducted experiment proves that valsartan can ameliorate protein glycation and oxidation in vitro in various conditions. Available animal and clinical studies uphold this statement, but further research is needed to confirm it, as reduction of protein oxidation and glycation may prevent cardiovascular disease development.
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Bonderman D. How to ATTR-ACT the perfect match? Eur J Heart Fail 2021; 23:275-276. [PMID: 33342016 DOI: 10.1002/ejhf.2080] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 12/12/2020] [Indexed: 11/08/2022] Open
Affiliation(s)
- Diana Bonderman
- Division of Cardiology, Clinic Favoriten, Vienna, Austria.,Division of Cardiology, Medical University of Vienna, Vienna, Austria
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