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Tromp J, Kosiborod MN, Angermann CE, Collins SP, Teerlink JR, Ponikowski P, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Brueckmann M, Blatchford JP, Steubl D, Voors AA. Treatment effects of empagliflozin in hospitalized heart failure patients across the range of left ventricular ejection fraction - Results from the EMPULSE trial. Eur J Heart Fail 2024. [PMID: 38572654 DOI: 10.1002/ejhf.3218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2023] [Revised: 02/23/2024] [Accepted: 03/12/2024] [Indexed: 04/05/2024] Open
Abstract
AIM The EMPULSE (EMPagliflozin in patients hospitalised with acUte heart faiLure who have been StabilizEd) trial showed that, compared to placebo, the sodium-glucose cotransporter 2 inhibitor empagliflozin (10 mg/day) improved clinical outcomes of patients hospitalized for acute heart failure (HF). We investigated whether efficacy and safety of empagliflozin were consistent across the spectrum of left ventricular ejection fraction (LVEF). METHODS AND RESULTS A total of 530 patients hospitalized for acute de novo or decompensated HF were included irrespective of LVEF. For the present analysis, patients were classified as HF with reduced (HFrEF, LVEF ≤40%), mildly reduced (HFmrEF, LVEF 41-49%) or preserved (HFpEF, LVEF ≥50%) ejection fraction at baseline. The primary endpoint was a hierarchical outcome of death, worsening HF events (HFE) and quality of life over 90 days, assessed by the win ratio. Secondary endpoints included individual components of the primary endpoint and safety. Out of 523 patients with baseline data, 354 (67.7%) had HFrEF, 54 (10.3%) had HFmrEF and 115 (22.0%) had HFpEF. The clinical benefit (hierarchical composite of all-cause death, HFE and Kansas City Cardiomyopathy Questionnaire total symptom score) of empagliflozin at 90 days compared to placebo was consistent across LVEF categories (≤40%: win ratio 1.35 [95% confidence interval 1.04, 1.75]; 41-49%: win ratio 1.25 [0.66, 2.37)] and ≥50%: win ratio 1.40 [0.87, 2.23], pinteraction = 0.96) with a favourable safety profile. Results were consistent across individual components of the hierarchical primary endpoint. CONCLUSION The clinical benefit of empagliflozin proved consistent across LVEF categories in the EMPULSE trial. These results support early in-hospital initiation of empagliflozin regardless of LVEF.
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Affiliation(s)
- Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore & the National University Health System, Singapore, Singapore
- Duke-NUS Medical School, Singapore, Singapore
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre and Department of Medicine I (Cardiology), University and University Hospital of Würzburg, Würzburg, Germany
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - João Pedro Ferreira
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Dominik Steubl
- Boehringer Ingelheim International, Ingelheim, Germany
- Department of Nephrology, Klinikum rechts der Isar, Faculty of Medicine, Technical University, Munich, Germany
| | - Adriaan A Voors
- University of Groningen Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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Gerhardt T, Gerhardt LMS, Ouwerkerk W, Roth GA, Dickstein K, Collins SP, Cleland JGF, Dahlstrom U, Tay WT, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Filippatos G, Lam CSP, Tromp J, Angermann CE. Multimorbidity in patients with acute heart failure across world regions and country income levels (REPORT-HF): a prospective, multicentre, global cohort study. Lancet Glob Health 2023; 11:e1874-e1884. [PMID: 37973338 DOI: 10.1016/s2214-109x(23)00408-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 08/07/2023] [Accepted: 08/16/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND Multimorbidity (two or more comorbidities) is common among patients with acute heart failure, but comprehensive global information on its prevalence and clinical consequences across different world regions and income levels is scarce. This study aimed to investigate the prevalence of multimorbidity and its effect on pharmacotherapy and prognosis in participants of the REPORT-HF study. METHODS REPORT-HF was a prospective, multicentre, global cohort study that enrolled adults (aged ≥18 years) admitted to hospital with a primary diagnosis of acute heart failure from 358 hospitals in 44 countries on six continents. Patients who currently or recently participated in a clinical treatment trial were excluded. Follow-up data were collected at 1-year post-discharge. The primary outcome was 1-year post-discharge mortality. All patients in the REPORT-HF cohort with full data on comorbidities were eligible for the present study. We stratified patients according to the number of comorbidities, and countries by world region and country income level. We used one-way ANOVA, χ2 test, or Mann-Whitney U test for comparisons between groups, as applicable, and Cox regression to analyse the association between multimorbidity and 1-year mortality. FINDINGS Between July 23, 2014, and March 24, 2017, 18 553 patients were included in the REPORT-HF study. Of these, 18 528 patients had full data on comorbidities, of whom 11 360 (61%) were men and 7168 (39%) were women. Prevalence rates of multimorbidity were lowest in southeast Asia (72%) and highest in North America (92%). Fewer patients from lower-middle-income countries had multimorbidity than patients from high-income countries (73% vs 85%, p<0·0001). With increasing comorbidity burden, patients received fewer guideline-directed heart failure medications, yet more drugs potentially causing or worsening heart failure. Having more comorbidities was associated with worse outcomes: 1-year mortality increased from 13% (no comorbidities) to 26% (five or more comorbidities). This finding was independent of common baseline risk factors, including age and sex. The population-attributable fraction of multimorbidity for mortality was higher in high-income countries than in upper-middle-income or lower-middle-income countries (for patients with five or more comorbidities: 61% vs 27% and 31%, respectively). INTERPRETATION Multimorbidity is highly prevalent among patients with acute heart failure across world regions, especially in high-income countries, and is associated with higher mortality, less prescription of guideline-directed heart failure pharmacotherapy, and increased use of potentially harmful medications. FUNDING Novartis Pharma. TRANSLATIONS For the Arabic, French, German, Hindi, Mandarin, Russian and Spanish translations of the abstract see Supplementary Materials section.
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Affiliation(s)
- Teresa Gerhardt
- Cardiovascular Research Institute and the Department of Medicine, Cardiology, Icahn School of Medicine at Mount Sinai, New York, NY, USA; Department of Cardiology, Angiology and Intensive Care Medicine, Deutsches Herzzentrum der Charité, Berlin, Germany; Berlin Institute of Health, Berlin, Germany; DZHK German Centre for Cardiovascular Research, Partner Site Berlin, Berlin, Germany
| | - Louisa M S Gerhardt
- Fifth Department of Medicine, University Medical Centre Mannheim, University of Heidelberg, Mannheim, Germany
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore; Department of Dermatology, University of Amsterdam Medical Centre, Amsterdam, Netherlands
| | - Gregory A Roth
- Division of Cardiology, Department of Medicine and Institute for Health Metrics and Evaluation, University of Washington, Seattle, WA, USA
| | - Kenneth Dickstein
- University of Bergen, Stavanger University Hospital, Stavanger, Norway
| | - Sean P Collins
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, TN, USA; Veterans Affairs Tennessee Valley Healthcare System, Geriatric Research, Education and Clinical Center, Nashville, TN, USA
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Well-Being, University of Glasgow, Glasgow, UK; National Heart and Lung Institute, Imperial College London, London, UK
| | - Ulf Dahlstrom
- Department of Cardiology, Linkoping University, Linkoping, Sweden; Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | | | - Georg Ertl
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Würzburg, Germany; Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany
| | - Mahmoud Hassanein
- Alexandria University, Faculty of Medicine, Cardiology Department, Alexandria, Egypt
| | - Sergio V Perrone
- FLENI Institute, Argentine Institute of Diagnosis and Treatment, Hospital El Cruce de Florencio Barela, Universidad Catolica Argentina, Buenos Aires, Argentina
| | | | | | | | - Gerasimos Filippatos
- School of Medicine, University of Cyprus, Nicosia, Cyprus; School of Medicine, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore; Duke-National University of Singapore Medical School, Singapore; University Medical Centre Groningen, University of Groningen Department of Cardiology, Groningen, Netherlands
| | - Jasper Tromp
- Duke-National University of Singapore Medical School, Singapore; Saw Swee Hock School of Public Health, National University of Singapore and the National University Health System, Singapore
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Würzburg, Germany; Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany.
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de Gonzalo-Calvo D, Martinez-Camblor P, Belmonte T, Barbé F, Duarte K, Cowie MR, Angermann CE, Korte A, Riedel I, Labus J, Koenig W, Zannad F, Thum T, Bär C. Circulating miR-133a-3p defines a low-risk subphenotype in patients with heart failure and central sleep apnea: a decision tree machine learning approach. J Transl Med 2023; 21:742. [PMID: 37864227 PMCID: PMC10588036 DOI: 10.1186/s12967-023-04558-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 09/22/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Patients with heart failure with reduced ejection fraction (HFrEF) and central sleep apnea (CSA) are at a very high risk of fatal outcomes. OBJECTIVE To test whether the circulating miRNome provides additional information for risk stratification on top of clinical predictors in patients with HFrEF and CSA. METHODS The study included patients with HFrEF and CSA from the SERVE-HF trial. A three-step protocol was applied: microRNA (miRNA) screening (n = 20), technical validation (n = 60), and biological validation (n = 587). The primary outcome was either death from any cause, lifesaving cardiovascular intervention, or unplanned hospitalization for worsening of heart failure, whatever occurred first. MiRNA quantification was performed in plasma samples using miRNA sequencing and RT-qPCR. RESULTS Circulating miR-133a-3p levels were inversely associated with the primary study outcome. Nonetheless, miR-133a-3p did not improve a previously established clinical prognostic model in terms of discrimination or reclassification. A customized regression tree model constructed using the Classification and Regression Tree (CART) algorithm identified eight patient subphenotypes with specific risk patterns based on clinical and molecular characteristics. MiR-133a-3p entered the regression tree defining the group at the lowest risk; patients with log(NT-proBNP) ≤ 6 pg/mL (miR-133a-3p levels above 1.5 arbitrary units). The overall predictive capacity of suffering the event was highly stable over the follow-up (from 0.735 to 0.767). CONCLUSIONS The combination of clinical information, circulating miRNAs, and decision tree learning allows the identification of specific risk subphenotypes in patients with HFrEF and CSA.
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Affiliation(s)
- David de Gonzalo-Calvo
- Translational Research in Respiratory Medicine, IRBLleida, University Hospital Arnau de Vilanova and Santa Maria, Lleida, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
| | - Pablo Martinez-Camblor
- Anesthesiology Department, Geisel School of Medicine at Dartmouth, Hanover, NH, USA
- Faculty of Health Sciences, Universidad Autonoma de Chile, Providencia, Chile
| | - Thalia Belmonte
- Translational Research in Respiratory Medicine, IRBLleida, University Hospital Arnau de Vilanova and Santa Maria, Lleida, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
| | - Ferran Barbé
- Translational Research in Respiratory Medicine, IRBLleida, University Hospital Arnau de Vilanova and Santa Maria, Lleida, Spain
- CIBER of Respiratory Diseases (CIBERES), Institute of Health Carlos III, Madrid, Spain
| | - Kevin Duarte
- INSERM 1433, CHRU de Nancy, Centre d'Investigations Cliniques Plurithématique, Institut Lorrain du Cœur et des Vaisseaux, Université de Lorraine, Nancy, France
| | - Martin R Cowie
- Department of Cardiology, Royal Brompton Hospital (Guy's & St Thomas's NHS Foundation Trust), London, UK
| | - Christiane E Angermann
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany
- Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Andrea Korte
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Isabelle Riedel
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Josephine Labus
- Cellular Neurophysiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany
| | - Wolfgang Koenig
- Deutsches Herzzentrum München, Technische Universität München, Munich, Germany
- German Centre for Cardiovascular Research (DZHK), Partner Site Munich Heart Alliance, Munich, Germany
- Institute of Epidemiology and Medical Biometry, University of Ulm, Ulm, Germany
| | - Faiez Zannad
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques-Plurithématique 1433, Inserm U1116, CHRU Nancy, F-CRIN INI-CRCT Network, Nancy, France
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Nikolai-Fuchs-Str. 1, 30625, Hannover, Germany.
| | - Christian Bär
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS), Hannover Medical School, Carl-Neuberg-Str. 1, 30625, Hannover, Germany.
- Fraunhofer Institute for Toxicology and Experimental Medicine (ITEM), Nikolai-Fuchs-Str. 1, 30625, Hannover, Germany.
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Ferreira JP, Blatchford JP, Teerlink JR, Kosiborod MN, Angermann CE, Biegus J, Collins SP, Tromp J, Nassif ME, Psotka MA, Comin-Colet J, Mentz RJ, Brueckmann M, Nordaby M, Ponikowski P, Voors AA. Mineralocorticoid receptor antagonist use and the effects of empagliflozin on clinical outcomes in patients admitted for acute heart failure: Findings from EMPULSE. Eur J Heart Fail 2023; 25:1797-1805. [PMID: 37540060 DOI: 10.1002/ejhf.2982] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2023] [Revised: 07/18/2023] [Accepted: 07/18/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS In patients hospitalized for acute heart failure (AHF) empagliflozin produced greater clinical benefit than placebo. Many patients with AHF are treated with mineralocorticoid receptor antagonists (MRAs). The interplay between empagliflozin and MRAs in AHF is yet to be explored. This study aimed to evaluate the efficacy and safety of empagliflozin versus placebo according to MRA use at baseline in the EMPULSE trial (NCT04157751). METHODS AND RESULTS In this analysis all comparisons were performed between empagliflozin and placebo, stratified by baseline MRA use. The primary outcome included all-cause death, heart failure events, and a ≥5 point difference in Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score at 90 days, assessed using the win ratio (WR). First heart failure hospitalization or cardiovascular death was a secondary outcome. From the 530 patients randomized, 276 (52%) were receiving MRAs at baseline. MRA users were younger, had lower ejection fraction, better renal function, and higher KCCQ scores. The primary outcome showed benefit of empagliflozin irrespective of baseline MRA use (WR 1.46, 95% confidence interval [CI] 1.08-1.97 and WR 1.27, 95% CI 0.93-1.73 in MRA users and non-users, respectively; interaction p = 0.52). The effect of empagliflozin on first heart failure hospitalization or cardiovascular death was not modified by MRA use (hazard ratio [HR] 0.58, 95% CI 0.30-1.11 and HR 0.85, 95% CI 0.47-1.52 in MRA users and non-users, respectively; interaction p = 0.39). Investigator-reported and severe hyperkalaemia events were infrequent (<6%) irrespective of MRA use. CONCLUSIONS In patients admitted for AHF, initiation of empagliflozin produced clinical benefit and was well tolerated irrespective of background MRA use. These findings support the early use of empagliflozin on top of MRA therapy in patients admitted for AHF.
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Affiliation(s)
- João Pedro Ferreira
- Centre d'Investigations Cliniques Plurithématique 1433, INSERM, Université de Lorraine, Nancy, France
- F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), INSERM U1116, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
- UnIC@RISE, Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH, Bietigheim-Bissingen, Germany on behalf of Boehringer Ingelheim, Pharma GmbH & Co. KG, Biberach, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas, MO, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, and Department of Medicine 1, University Hospital Würzburg, Würzburg, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, the National University Health System, Singapore, Singapore, Singapore
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas, MO, USA
| | | | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, University of Barcelona, IDIBELL and CIBERCV, Barcelona, Spain
| | - Robert J Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim am Rhein, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Matias Nordaby
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Angermann CE, Ertl G. Remote heart failure management guided by pulmonary artery pressure home monitoring: rewriting the future? Eur Heart J 2023; 44:3669-3671. [PMID: 37670404 DOI: 10.1093/eurheartj/ehad525] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Affiliation(s)
- Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, D-97078 Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Georg Ertl
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, D-97078 Würzburg, Germany
- Department of Internal Medicine I, University Hospital Würzburg, Würzburg, Germany
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Morbach C, Beyersdorf N, Moser N, Pelin D, Afshar B, Ramos G, Kerkau T, Kaiser E, Lamers J, Pätkau J, Sahiti F, Albert J, Güder G, Ertl G, Angermann CE, Frantz S, Hofmann U, Jahns R, Jahns V, Störk S. Prevalence of anti-beta-1 antibody 6 months after hospitalization for acute heart failure predicts adverse outcome. ESC Heart Fail 2023; 10:3227-3231. [PMID: 37688355 PMCID: PMC10567622 DOI: 10.1002/ehf2.14509] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2022] [Revised: 07/13/2023] [Accepted: 08/10/2023] [Indexed: 09/10/2023] Open
Abstract
AIMS Agonistic antibodies against neurohumoral receptors can induce cardio-noxious effects by altering the baseline receptor activity. To estimate the prevalence of autoantibodies directed against the beta-1 receptor (b1-AAB) in patients admitted to the hospital for acute heart failure (HF) at (i) baseline and (ii) after 6 months of follow-up (F6) and (iii) after another 12 months of follow-up (i.e. 18 months after index hospitalization), to estimate their prognostic impact on clinical outcome (death or first hospitalization for HF). METHODS AND RESULTS In 47 patients, b1-AAB were serially determined in serum samples collected at index hospitalization and at 6 months of follow-up (F6) with a flow cytometry-based assay: median age 71 years (quartiles 60, 80), 23 (49%) women, 24 (51%) HF with preserved ejection fraction. Beta1-AAB were detected in three subjects at index hospitalization (6%), and in eight subjects at F6 (17%). There were no differences apparent between patients with and without b1-AAB at F6 with regard to age, sex, type, duration, or main cause of HF. During the 12 month period following F6 (i.e. up to month 18), eight events occurred. Event-free survival was associated with prevalence of b1-AAB at F6. Compared with patients without b1-AAB at F6, age-adjusted Cox regression indicated a higher event risk in patients harbouring b1-AAB, with a hazard ratio of 8.96 (95% confidence interval 1.81-44.50, P = 0.007). CONCLUSIONS Our results suggest a possible adverse prognostic relevance of b1-AAB in patients with acute HF, but this observation needs to be confirmed in larger patient collectives.
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Affiliation(s)
- Caroline Morbach
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Niklas Beyersdorf
- Institute for Virology and ImmunobiologyUniversity WürzburgWürzburgGermany
| | - Nicola Moser
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Dora Pelin
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Boshra Afshar
- Institute for Virology and ImmunobiologyUniversity WürzburgWürzburgGermany
| | - Gustavo Ramos
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Thomas Kerkau
- Institute for Virology and ImmunobiologyUniversity WürzburgWürzburgGermany
| | - Elisa Kaiser
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Janna Lamers
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Jannika Pätkau
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Floran Sahiti
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Judith Albert
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Gülmisal Güder
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Georg Ertl
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
| | - Christiane E. Angermann
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
| | - Stefan Frantz
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Ulrich Hofmann
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
| | - Roland Jahns
- Interdisciplinary Bank of biological materials and Data Würzburg (ibdw)University Hospital WürzburgWürzburgGermany
| | - Valerie Jahns
- Institute for Pharmacology and ToxicologyUniversity WürzburgWürzburgGermany
| | - Stefan Störk
- Comprehensive Heart Failure Center, Department for Clinical Research and EpidemiologyUniversity and University Hospital WürzburgAm Schwarzenberg 15WürzburgGermany
- Department of Medicine IUniversity Hospital WürzburgWürzburgGermany
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7
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Katsanos S, Ouwerkerk W, Farmakis D, Collins SP, Angermann CE, Dickstein K, Tomp J, Ertl G, Cleland J, Dahlström U, Obergfell A, Ghadanfar M, Perrone SV, Hassanein M, Stamoulis K, Parissis J, Lam C, Filippatos G. Hospitalization for acute heart failure during non-working hours impacts on long-term mortality: the REPORT-HF registry. ESC Heart Fail 2023; 10:3164-3173. [PMID: 37649316 PMCID: PMC10567635 DOI: 10.1002/ehf2.14506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 08/10/2023] [Indexed: 09/01/2023] Open
Abstract
AIMS Hospital admission during nighttime and off hours may affect the outcome of patients with various cardiovascular conditions due to suboptimal resources and personnel availability, but data for acute heart failure remain controversial. Therefore, we studied outcomes of acute heart failure patients according to their time of admission from the global International Registry to assess medical practice with lOngitudinal obseRvation for Treatment of Heart Failure. METHODS AND RESULTS Overall, 18 553 acute heart failure patients were divided according to time of admission into 'morning' (7:00-14:59), 'evening' (15:00-22:59), and 'night' (23:00-06:59) shift groups. Patients were also dichotomized to admission during 'working hours' (9:00-16:59 during standard working days) and 'non-working hours' (any other time). Clinical characteristics, treatments, and outcomes were compared across groups. The hospital length of stay was longer for morning (odds ratio: 1.08; 95% confidence interval: 1.06-1.10, P < 0.001) and evening shift (odds ratio: 1.10; 95% confidence interval: 1.07-1.12, P < 0.001) as compared with night shift. The length of stay was also longer for working vs. non-working hours (odds ratio: 1.03; 95% confidence interval: 1.02-1.05, P < 0.001). There were no significant differences in in-hospital mortality among the groups. Admission during working hours, compared with non-working hours, was associated with significantly lower mortality at 1 year (hazard ratio: 0.88; 95% confidence interval: 0.80-0.96, P = 0.003). CONCLUSIONS Acute heart failure patients admitted during the night shift and non-working hours had shorter length of stay but similar in-hospital mortality. However, patients admitted during non-working hours were at a higher risk for 1 year mortality. These findings may have implications for the health policies and heart failure trials.
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Affiliation(s)
- Spyridon Katsanos
- Department of Emergency MedicineAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolAthensGreece
| | - Wouter Ouwerkerk
- National Heart Centre SingaporeSingapore
- Department of DermatologyAmsterdam UMC, University of Amsterdam, Amsterdam Infection and Immunity InstituteAmsterdamThe Netherlands
| | - Dimitrios Farmakis
- Cardio‐Oncology Clinic, Heart Failure UnitAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolAthensGreece
- University of Cyprus Medical SchoolNicosiaCyprus
| | - Sean P. Collins
- Department of Emergency MedicineVanderbilt University Medical Center and Geriatric Research and Education Center, Nashville VANashvilleTNUSA
| | - Christiane E. Angermann
- Department of Medicine 1Comprehensive Heart Failure Center University and University Hospital WürzburgWürzburgGermany
| | | | - Jasper Tomp
- Saw Swee Hock School of Public HealthNational University of Singapore and the National University Health SystemSingapore
- Duke‐NUS Medical SchoolSingapore
- Yong Loo Lin School of MedicineSingapore
| | - Georg Ertl
- Department of Medicine 1Comprehensive Heart Failure Center University and University Hospital WürzburgWürzburgGermany
| | - John Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well‐BeingUniversity of GlasgowGlasgowScotland
- National Heart and Lung InstituteImperial CollegeLondonUK
| | - Ulf Dahlström
- Department of CardiologyLinkoping UniversityLinkopingSweden
- Department of Health, Medicine and Caring SciencesLinkoping UniversityLinkopingSweden
| | | | | | - Sergio V. Perrone
- El Cruce Hospital by Florencio Varela, Lezica Cardiovascular Institute, Sanctuary of the Trinidad MiterBuenos AiresArgentina
| | - Mahmoud Hassanein
- Faculty of Medicine, Department of CardiologyAlexandria UniversityAlexandriaEgypt
| | - Konstantinos Stamoulis
- Second Department of CardiologyAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolRimini 1 ChardairiAthensGreece
| | - John Parissis
- Department of Emergency MedicineAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolAthensGreece
| | - Carolyn Lam
- National Heart Centre SingaporeSingapore
- Duke‐NUS Medical SchoolSingapore
| | - Gerasimos Filippatos
- Second Department of CardiologyAttikon University Hospital, National and Kapodistrian University of Athens Medical SchoolRimini 1 ChardairiAthensGreece
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8
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Tromp J, Ezekowitz JA, Ouwerkerk W, Chandramouli C, Yiu KH, Angermann CE, Dahlstrom U, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Dickstein K, Collins SP, Filippatos G, Cleland JGF, Lam CSP. Global Variations According to Sex in Patients Hospitalized for Heart Failure in the REPORT-HF Registry. JACC Heart Fail 2023; 11:1262-1271. [PMID: 37678961 DOI: 10.1016/j.jchf.2023.06.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/09/2023] [Accepted: 06/20/2023] [Indexed: 09/09/2023]
Abstract
BACKGROUND Previous reports suggest that risk factors, management, and outcomes of acute heart failure (AHF) may differ by sex, but they rarely extended analysis to low- and middle-income countries. OBJECTIVES In this study, the authors sought to analyze sex differences in treatment and outcomes in patients hospitalized for AHF in 44 countries. METHODS The authors investigated differences between men and women in treatment and outcomes in 18,553 patients hospitalized for AHF in 44 countries in the REPORT-HF (Registry to Assess Medical Practice With Longitudinal Observation for the Treatment of Heart Failure) registry stratified by country income level, income disparity, and world region. The primary outcome was 1-year all-cause mortality. RESULTS Women (n = 7,181) were older than men (n = 11,372), were more likely to have heart failure with preserved left ventricular ejection fraction, had more comorbid conditions except for coronary artery disease, and had more severe signs and symptoms at admission. Coronary angiography, cardiac stress tests, and coronary revascularization were less frequently performed in women than in men. Women with AHF and reduced left ventricular ejection fraction were less likely to receive an implanted device, regardless of region or country income level. Women were more likely to receive treatments that could worsen HF than men (18% vs 13%; P < 0.0001). In countries with low-income disparity, women had better 1-year survival than men. This advantage was lost in countries with greater income disparity (Pinteraction < 0.001). CONCLUSIONS Women were less likely to have diagnostic testing or receive guideline-directed care than men. A survival advantage for women was observed only in countries with low income disparity, suggesting that equity of HF care between sexes remains an unmet goal worldwide.
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Affiliation(s)
- Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore; Duke-NUS Medical School, Singapore.
| | - Justin A Ezekowitz
- The Canadian VIGOUR Centre, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Wouter Ouwerkerk
- National Heart Centre, Singapore; Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam Infection and Immunity Institute, Amsterdam, the Netherlands
| | | | - Kai Hang Yiu
- Division of Cardiology, Department of Medicine, The University of Hong Kong, Hong Kong, China; Division of Cardiology, Department of Medicine, The University of Hong Kong-Shenzhen Hospital, Shenzhen, China
| | - Christiane E Angermann
- Comprehensive Heart Failure Center, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Ulf Dahlstrom
- Departments of Cardiology and Health, Medicine, and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Georg Ertl
- Comprehensive Heart Failure Center, Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Mahmoud Hassanein
- Cardiology Department, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Sergio V Perrone
- Sanctuary of the Trinidad Miter, Lezica Cardiovascular Institute, El Cruce Hospital by Florencio Varela, Buenos Aires, Argentina
| | | | | | | | | | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gerasimos Filippatos
- School of Medicine, University of Cyprus, Nicosia, Cyprus; Department of Cardiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-Being, University of Glasgow, Scotland, United Kingdom; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Carolyn S P Lam
- Duke-NUS Medical School, Singapore; National Heart Centre, Singapore.
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9
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Gerhardt LMS, Kordsmeyer M, Sehner S, Güder G, Störk S, Edelmann F, Wachter R, Pankuweit S, Prettin C, Ertl G, Wanner C, Angermann CE. Prevalence and prognostic impact of chronic kidney disease and anaemia across ACC/AHA precursor and symptomatic heart failure stages. Clin Res Cardiol 2023; 112:868-879. [PMID: 35648270 PMCID: PMC10293329 DOI: 10.1007/s00392-022-02027-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 04/25/2022] [Indexed: 12/23/2022]
Abstract
BACKGROUND The importance of chronic kidney disease (CKD) and anaemia has not been comprehensively studied in asymptomatic patients at risk for heart failure (HF) versus those with symptomatic HF. We analysed the prevalence, characteristics and prognostic impact of both conditions across American College of Cardiology/American Heart Association (ACC/AHA) precursor and HF stages A-D. METHODS AND RESULTS 2496 participants from three non-pharmacological German Competence Network HF studies were categorized by ACC/AHA stage; stage C patients were subdivided into C1 and C2 (corresponding to NYHA classes I/II and III, respectively). Overall, patient distribution was 8.1%/35.3%/32.9% and 23.7% in ACC/AHA stages A/B/C1 and C2/D, respectively. These subgroups were stratified by the absence ( - ) or presence ( +) of CKD (estimated glomerular filtration rate [eGFR] < 60 mL/min/1.73m2) and anaemia (haemoglobin in women/men < 12/ < 13 g/dL). The primary outcome was all-cause mortality at 5-year follow-up. Prevalence increased across stages A/B/C1 and C2/D (CKD: 22.3%/23.6%/31.6%/54.7%; anaemia: 3.0%/7.9%/21.7%/33.2%, respectively), with concordant decreases in median eGFR and haemoglobin (all p < 0.001). Across all stages, hazard ratios [95% confidence intervals] for all-cause mortality were 2.1 [1.8-2.6] for CKD + , 1.7 [1.4-2.0] for anaemia, and 3.6 [2.9-4.6] for CKD + /anaemia + (all p < 0.001). Population attributable fractions (PAFs) for 5-year mortality related to CKD and/or anaemia were similar across stages A/B, C1 and C2/D (up to 33.4%, 30.8% and 34.7%, respectively). CONCLUSIONS Prevalence and severity of CKD and anaemia increased across ACC/AHA stages. Both conditions were individually and additively associated with increased 5-year mortality risk, with similar PAFs in asymptomatic patients and those with symptomatic HF.
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Affiliation(s)
- Louisa M S Gerhardt
- Department of Stem Cell Biology and Regenerative Medicine, Eli and Edythe Broad Center for Regenerative Medicine and Stem Cell Research, Keck School of Medicine of the University of Southern California, Los Angeles, CA, USA
| | - Maren Kordsmeyer
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I, St Josefs-Hospital Wiesbaden, Wiesbaden, Germany
| | - Susanne Sehner
- Medical Centre Hamburg-Eppendorf, Institute of Medical Biometry and Epidemiology, Hamburg, Germany
| | - Gülmisal Güder
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Frank Edelmann
- Department of Internal Medicine, Cardiology, Charité - Campus Virchow Klinikum, Universitätsmedizin Berlin, and German Centre for Cardiovascular Research, Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Rolf Wachter
- Clinic and Policlinic for Cardiology and Pneumology, University Hospital Leipzig, Leipzig, Germany
| | - Sabine Pankuweit
- Department of Cardiology, Philips-University Marburg, Marburg, Germany
| | | | - Georg Ertl
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
| | - Christoph Wanner
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany
- Department of Medicine I (Nephrology), University Hospital Würzburg, Würzburg, Germany
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Am Schwarzenberg 15, 97078, Würzburg, Germany.
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10
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Affiliation(s)
- Christiane E Angermann
- Comprehensive Heart Failure Centre and Department of Medicine I (Cardiology) University and University Hospital Würzburg, Würzburg 97078, Germany.
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11
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Pocock SJ, Ferreira JP, Collier TJ, Angermann CE, Biegus J, Collins SP, Kosiborod M, Nassif ME, Ponikowski P, Psotka MA, Teerlink JR, Tromp J, Gregson J, Blatchford JP, Zeller C, Voors AA. The win ratio method in heart failure trials: lessons learnt from EMPULSE. Eur J Heart Fail 2023; 25:632-641. [PMID: 37038330 PMCID: PMC10330107 DOI: 10.1002/ejhf.2853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Revised: 02/28/2023] [Accepted: 04/08/2023] [Indexed: 04/12/2023] Open
Abstract
AIMS The EMPULSE trial evaluated the clinical benefit of empagliflozin versus placebo using the stratified win ratio approach in 530 patients with acute heart failure (HF) after initial stabilization. We aim to elucidate how this method works and what it means, thereby giving guidance for use of the win ratio in future trials. METHODS AND RESULTS The primary trial outcome is a hierarchical composite of death, number of HF events, time to first HF event, or a ≥5-point difference in Kansas City Cardiomyopathy Questionnaire (KCCQ) total symptom score change at 90 days. In an overall (unstratified) analysis we show how comparison of all 265 x 265 patients pairs contribute to 'wins' for empagliflozin and placebo at all four levels of the hierarchy, leading to an unstratified win ratio of 1.38 (95% confidence interval [CI] 1.11-1.71; p = 0.0036). How such a win ratio should (and should not) be interpreted is then described. The more complex primary analysis using a stratified win ratio is then presented in detail leading to a very similar overall result. Win ratios for de novo acute HF and decompensated chronic HF patients were 1.29 and 1.39, respectively, their weighted combination yielding an overall stratified win ratio of 1.36 (95% CI 1.09-1.68) (p = 0.0054). Alternative ways of including HF events and KCCQ scores in the clinical hierarchy are presented, leading to recommendations for their use in future trials. Specifically, inclusion of both number of HF events and time-to-first HF event appears an unnecessary complication. Also, the use of a 5-point margin for KCCQ score paired comparisons is not statistically necessary. CONCLUSIONS The EMPULSE trial findings illustrate how deaths, clinical events and patient-reported outcomes can be integrated into a win ratio analysis strategy that yields clinically meaningful findings of patient benefit. This has implications for future trial designs that recognize the clinical priorities of patient evaluation and the need for efficient progress towards approval of new treatments.
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Affiliation(s)
- Stuart J Pocock
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - João Pedro Ferreira
- Heart Failure Clinic, Internal Medicine Department, Centro Hospitalar de Vila Nova de Gaia/Espinho, Vila Nova de Gaia, Portugal
- Inserm, Centre d'Investigations Cliniques-Plurithématique 14-33, Université de Lorraine, and Inserm U1116, CHRU, Nancy, France
| | - Timothy J Collier
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, and Department of Medicine I, University Hospital of Würzburg, Würzburg, Germany
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
- George Institute for Global Health, Sydney, NSW, Australia
- University of New South Wales, Sydney, NSW, Australia
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA
- School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, and the National University Health System, Singapore, Singapore
| | - John Gregson
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Cordula Zeller
- Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Adriaan A Voors
- Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
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12
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Farmakis D, Tromp J, Marinaki S, Ouwerkerk W, Angermann CE, Bistola V, Dahlstrom U, Dickstein K, Ertl G, Ghadanfar M, Hassanein M, Obergfell A, Perrone SV, Polyzogopoulou E, Schweizer A, Boletis I, Cleland JG, Collins SP, Lam CS, FIlippatos G. Impact of left ventricular ejection fraction phenotypes on healthcare-resource utilization in hospitalized heart failure: A secondary analysis of REPORT-HF. Eur J Heart Fail 2023. [PMID: 36974770 DOI: 10.1002/ejhf.2833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2022] [Revised: 03/23/2023] [Accepted: 03/23/2023] [Indexed: 03/29/2023] Open
Abstract
BACKGROUND Evidence on healthcare resource utilization (HCRU) for hospitalized patients with heart failure (HF) and reduced (HFrEF), mildly-reduced (HFmrEF) and preserved (HFpEF) left ventricular ejection fraction (LVEF) is limited. METHODS We analysed HCRU in relation to LVEF phenotypes, clinical features and in-hospital and 12-month outcomes in 16,943 patients hospitalized for HF in a worldwide registry. RESULTS HFrEF was more prevalent (53%) than HFmrEF (17%) or HFpEF (30%). Patients with HFmrEF and HFpEF were older, more often women, with milder symptoms and more comorbidities, but differences were not pronounced. HCRU was high in all three groups; 2 or more in- and out-hospital services were required by 51%, 49% and 52% of patients with HFrEF, HFmrEF and HFpEF, respectively, and ICU by 41%, 41% and 37%, respectively.Hospitalization length was similar (median, 8 days). Discharge prescription of neurohormonal inhibitors was <80% for each agent in HFrEF and only slightly lower in HFmrEF and HFpEF (74% and 67%, respectively for beta-blockers). Compared to HFrEF, 12-month all-cause and cardiovascular mortality were lower for HFmrEF [adjusted hazard ratios, 0.76 (0.68-0.84) and 0.77 (0.68-0.88)] and HFpEF [0.62 (0.56-0.68) and 0.60 (0.53-0.68)]; 12-month HF hospitalization was also lower for HFpEF and HFmrEF (21% and 20% versus 25% for HFrEF). In-hospital mortality, 12-month non-cardiovascular mortality and 12-month all-cause hospitalization were similar among groups. CONCLUSIONS In patients hospitalized for HF, overall HCRU was similarly high across LVEF spectrum, reflecting the subtle clinical differences among LVEF phenotypes during hospitalization. Discharge prescription of neurohormonal inhibitors were suboptimal in HFrEF and lower but significant in patients with HFpEF and HFmrEF, who had better long-term cardiovascular outcomes than HFrEF, but similar risk for non-cardiovascular events. This article is protected by copyright. All rights reserved.
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Affiliation(s)
| | - Jasper Tromp
- National Heart Centre Singapore, Singapore
- Duke-National University of Singapore, Singapore
- University Medical Centre Groningen, Groningen, Netherlands
- Saw Swee Hock school of Public Health, National University of Singapore, Singapore
| | - Smaragdi Marinaki
- National and Kapodistrian University of Athens Medical School, Laiko Hospital, Athens, Greece
| | - Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore
- Amsterdam University Medical Centre
| | | | - Vasiliki Bistola
- Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | - Ulf Dahlstrom
- Department of Cardiology, and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | | | - Georg Ertl
- National Heart Centre Singapore, Singapore
- Amsterdam University Medical Centre
| | | | - Mahmoud Hassanein
- Alexandria University, Faculty of Medicine, Cardiology Department, Alexandria, Egypt
| | | | - Sergio V Perrone
- El Cruce Hospital by Florencio Varela, Lezica Cardiovascular Institute, Sanctuary of the Trinidad Miter, Buenos Aires, Argentina
| | - Eftihia Polyzogopoulou
- Department of Emergency Medicine, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
| | | | - Ioannis Boletis
- National and Kapodistrian University of Athens Medical School, Laiko Hospital, Athens, Greece
| | - John Gf Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-Being, University of Glasgow, Glasgow, UK
- National Heart and Lung Institute, Imperial College, London, UK
| | - Sean P Collins
- Vanderbilt University Medical Center, Department of Emergency Medicine, Nashville, TN, USA
| | - Carolyn Sp Lam
- National Heart Centre Singapore, Singapore
- Duke-National University of Singapore, Singapore
- University Medical Centre Groningen, Groningen, Netherlands
- Saw Swee Hock school of Public Health, National University of Singapore, Singapore
| | - Gerasimos FIlippatos
- Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens Medical School, Athens, Greece
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13
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Biegus J, Voors AA, Collins SP, Kosiborod MN, Teerlink JR, Angermann CE, Tromp J, Ferreira JP, Nassif ME, Psotka MA, Brueckmann M, Salsali A, Blatchford JP, Ponikowski P. Impact of empagliflozin on decongestion in acute heart failure: the EMPULSE trial. Eur Heart J 2023; 44:41-50. [PMID: 36254693 PMCID: PMC9805406 DOI: 10.1093/eurheartj/ehac530] [Citation(s) in RCA: 49] [Impact Index Per Article: 49.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2022] [Revised: 08/25/2022] [Accepted: 09/13/2022] [Indexed: 02/06/2023] Open
Abstract
AIMS Effective and safe decongestion remains a major goal for optimal management of patients with acute heart failure (AHF). The effects of the sodium-glucose cotransporter 2 inhibitor empagliflozin on decongestion-related endpoints in the EMPULSE trial (NCT0415775) were evaluated. METHODS AND RESULTS A total of 530 patients hospitalized for AHF were randomized 1:1 to either empagliflozin 10 mg once daily or placebo for 90 days. The outcomes investigated were: weight loss (WL), WL adjusted for mean daily loop diuretic dose (WL-adjusted), area under the curve of change from baseline in N-terminal pro-B-type natriuretic peptide levels, hemoconcentration, and clinical congestion score after 15, 30, and 90 days of treatment. Compared with placebo, patients treated with empagliflozin demonstrated significantly greater reductions in all studied markers of decongestion at all time-points, adjusted mean differences (95% confidence interval) at Days 15, 30, and 90 were: for WL -1.97 (-2.86, -1.08), -1.74 (-2.73, -0.74); -1.53 (-2.75, -0.31) kg; for WL-adjusted: -2.31 (-3.77, -0.85), -2.79 (-5.03, -0.54), -3.18 (-6.08, -0.28) kg/40 mg furosemide i.v. or equivalent; respectively (all P < 0.05). Greater WL at Day 15 (i.e. above the median WL in the entire population) was associated with significantly higher probability for clinical benefit at Day 90 (hierarchical composite of all-cause death, heart failure events, and a 5-point or greater difference in Kansas City Cardiomyopathy Questionnaire total symptom score change from baseline to 90 days) with the win ratio of 1.75 (95% confidence interval 1.37, 2.23; P < 0.0001). CONCLUSION Initiation of empagliflozin in patients hospitalized for AHF resulted in an early, effective and sustained decongestion which was associated with clinical benefit at Day 90.
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Affiliation(s)
- Jan Biegus
- Corresponding author. Tel: +48 71 733 11 12,
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Hanzeplein 1, P.O Box 30001, 9700 RB Groningen, HPC AB 31, The Netherlands
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
- Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
- The George Institute for Global Health and the University of New South Wales, Sydney, New South Wales, Australia
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, 4150 Clement Street San Francisco, CA 94121, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, and Department of Medicine 1, University Hospital Würzburg, Am Schwarzenberg 15, Haus A15 97078 Würzburg, Germany
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, the National University Health System, Singapore; 12 Science Drive 2, #10-01, Singapore 117549
| | - Joao Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigations Cliniques Plurithématique 1433, and Inserm U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
- UnIC@RISE, Department of Surgery and Physiology, Cardiovascular Research and Development Center, University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, USA
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA, 3300 Gallows Road Falls Church, Virginia 22042, USA
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Binger Straße 173, 55216 Ingelheim am Rhein, Germany
- First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167 Mannheim, Germany
| | - Afshin Salsali
- Novo Nordisk pharmaceutical company, Vandtårnsvej 110, 2860 Søborg, Copenhagen, Denmark
- Faculty of Medicine, Rutgers University, New Brunswick, NJ, 125 Paterson street, New Brunswick, NJ 08901, USA
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH, Sky Tower, Borsigstr. 4, D-74321 Bietigheim-Bissingen, Germany
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, ul. Borowska 213, Wroclaw 50-556, Poland
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14
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Ouwerkerk W, Tromp J, Cleland JGF, Angermann CE, Dahlstrom U, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Dickstein K, Filippatos G, Collins SP, Lam CSP. Association of time-to-intravenous furosemide with mortality in acute heart failure: data from REPORT-HF. Eur J Heart Fail 2023; 25:43-51. [PMID: 36196060 PMCID: PMC10099670 DOI: 10.1002/ejhf.2708] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 09/08/2022] [Accepted: 09/27/2022] [Indexed: 02/03/2023] Open
Abstract
AIM Acute heart failure can be a life-threatening medical condition. Delaying administration of intravenous furosemide (time-to-diuretics) has been postulated to increase mortality, but prior reports have been inconclusive. We aimed to evaluate the association between time-to-diuretics and mortality in the international REPORT-HF registry. METHODS AND RESULTS We assessed the association of time-to-diuretics within the first 24 h with in-hospital and 30-day post-discharge mortality in 15 078 patients from seven world regions in the REPORT-HF registry. We further tested for effect modification by baseline mortality risk (ADHERE risk score), left ventricular ejection fraction (LVEF) and region. The median time-to-diuretics was 67 (25th-75th percentiles 17-190) min. Women, patients with more signs and symptoms of heart failure, and patients from Eastern Europe or Southeast Asia had shorter time-to-diuretics. There was no significant association between time-to-diuretics and in-hospital mortality (p > 0.1). The 30-day mortality risk increased linearly with longer time-to-diuretics (administered between hospital arrival and 8 h post-hospital arrival) (p = 0.016). This increase was more significant in patients with a higher ADHERE risk score (pinteraction = 0.008), and not modified by LVEF or geographic region (pinteraction > 0.1 for both). CONCLUSION In REPORT-HF, longer time-to-diuretics was not associated with higher in-hospital mortality. However, we did found an association with increased 30-day mortality, particularly in high-risk patients, and irrespective of LVEF or geographic region. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT02595814.
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Affiliation(s)
- Wouter Ouwerkerk
- National Heart Centre Singapore, Singapore.,Department of Dermatology, Amsterdam UMC, University of Amsterdam, Amsterdam Infection & Immunity Institute, Amsterdam, The Netherlands
| | - Jasper Tromp
- Duke-National University of Singapore, Singapore.,Saw Swee Hock School of Public Health, National University of Singapore and National University Health System, Singapore
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Well-Being, University of Glasgow and National Heart & Lung Institute, Imperial College, London, UK
| | - Christiane E Angermann
- University and University Hospital Würzburg, Comprehensive Heart Failure Center, Würzburg, Germany
| | - Ulf Dahlstrom
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Georg Ertl
- University and University Hospital Würzburg, Comprehensive Heart Failure Center, Würzburg, Germany
| | - Mahmoud Hassanein
- Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Sergio V Perrone
- El Cruce Hospital by Florencio Varela, Lezica Cardiovascular Institute, Sanctuary of the Trinidad Miter, Buenos Aires, Argentina
| | | | | | | | - Kenneth Dickstein
- University of Bergen, Stavanger University Hospital, Stavanger, Norway
| | - Gerasimos Filippatos
- School of Medicine, Department of Cardiology, Attikon University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore.,Duke-National University of Singapore, Singapore
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15
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Assmus B, Angermann CE, Alkhlout B, Asselbergs FW, Schnupp S, Brugts JJ, Nordbeck P, Zhou Q, Brett ME, Ginn G, Adamson PB, Böhm M, Rosenkranz S. Effects of remote haemodynamic-guided heart failure management in patients with different subtypes of pulmonary hypertension: insights from the MEMS-HF study. Eur J Heart Fail 2022; 24:2320-2330. [PMID: 36054647 DOI: 10.1002/ejhf.2656] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 07/17/2022] [Accepted: 08/10/2022] [Indexed: 01/18/2023] Open
Abstract
AIM The CardioMEMS European Monitoring Study for Heart Failure (MEMS-HF) investigated safety and efficacy of pulmonary artery pressure (PAP)-guided remote patient management (RPM) in New York Heart Association (NYHA) class III outpatients with at least one heart failure hospitalization (HFH) during the previous 12 months. This pre-specified subgroup analysis investigated whether RPM effects depended on presence and subtype of pulmonary hypertension (PH). METHODS AND RESULTS In 106/234 MEMS-HF participants, Swan-Ganz catheter tracings obtained during sensor implant were available for off-line manual analysis jointly performed by two experts. Patients were classified into subgroups according to current PH definitions. Isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH) were present in 38 and 36 patients, respectively, whereas 31 patients had no PH. Clinical characteristics were comparable between subgroups, but among patients with PH pulmonary vascular resistance was higher (p = 0.029) and pulmonary artery compliance lower (p = 0.003) in patients with CpcPH. During 12 months of PAP-guided RPM, all PAPs declined in IpcPH and CpcPH subgroups (all p < 0.05), whereas only mean and diastolic PAP decreased in patients without PH (both p < 0.05). Improvements in post- versus pre-implant HFH rates were similar in CpcPH (0.639 events/patient-year; hazard ratio [HR] 0.37) and IpcPH (0.72 events/patient-year; HR 0.45) patients. Participants without PH benefited most (0.26 events/patient-year; HR 0.17, p = 0.04 vs. IpcPH/CpcPH patients). Quality of life and NYHA class improved significantly in all subgroups. CONCLUSIONS Outpatients with NYHA class III symptoms with at least one HFH during 1 year pre-implant benefitted significantly from PAP-guided RPM during post-implant follow-up irrespective of presence or subtype of PH at baseline.
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Affiliation(s)
- Birgit Assmus
- Cardiology, Department of Medicine, Goethe University Hospital, Frankfurt, Germany.,Medical Clinic I, Department of Cardiology, University Hospital Giessen, Justus Liebig University Giessen, Giessen, Germany
| | | | - Basil Alkhlout
- Klinikum Karlsburg, Heart and Diabetes Center Mecklenburg-Western Pommerania, Karlsburg, Germany
| | - Folkert W Asselbergs
- Division Heart & Lungs, Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Steffen Schnupp
- Medical Centre Coburg GmbH II, Medical Clinic Cardiology, Angiology, Pulmonology, Coburg, Germany
| | - Jasper J Brugts
- Thorax Center, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Peter Nordbeck
- Comprehensive Heart Failure Center, University Hospital Würzburg, Würzburg, Germany.,Cardiology, Department of Medicine I, Centre for Internal Medicine, University Hospital Würzburg, Würzburg, Germany
| | - Qian Zhou
- Department of Cardiology and Angiology I, University Heart Center Freiburg, University of Freiburg, Bad Krozingen, Germany
| | | | | | | | - Michael Böhm
- Klinik für Innere Medizin III, Universitätsklinikum des Saarlandes, Saarland University, Homburg, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine, and Cologne Cardiovascular Research Center (CCRC), University of Cologne Heart Center, Köln, Germany
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16
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Kerwagen F, Sahiti F, Sehner S, Albert J, Cejka V, Moser N, Morbach C, Gueder G, Frantz S, Ertl G, Angermann CE, Stoerk S. MR-proADM is a strong independent predictor of long-term all-cause mortality risk in patients with chronic heart failure: results from the E-INH study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.920] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Mid-regional proadrenomedullin (MR-proADM) is a blood biomarker indicating critical illness. Its short-term prognostic relevance has been investigated in several conditions including heart failure (HF). Yet, the long-term prognostic utility is unknown.
Methods
We conducted a post-hoc analysis of the Extended Interdisciplinary Network for Heart Failure (E-INH) study, which investigated the long-term effects of a HF nurse-led remote patient care program (HeartNetCare-HFTM [HNC]). Patients from nine regional centers in Germany hospitalized with HF and a left ventricular ejection fraction (LVEF) <40% were randomized into HNC vs. Usual Care. MR-proADM and other standard biomarkers for disease progression and systemic inflammation were measured from venous blood collected at study inclusion, i.e. during index hospitalization. The prognostic utility was assessed using Kaplan-Meier plots and Cox proportional hazard models, and compared with other biomarkers by ROC curves.
Results
From 919 out of the 1022 recruited patients (90%), baseline levels of MR-proADM were available: median MR-proADM 0.89 (quartiles 0.63, 1.28) nmol/l; mean age 68±12 years; 28% women; 45% in class III or IV of the New York Heart Association (NYHA) classification.
Median LVEF was 31 (25, 37) %. Median levels of NT-proBNP, high sensitive C-reactive protein (hsCRP), tumor necrosis factor (TNF)-a, and interleukin-6 (IL-6) were 3045 (1087, 7759) pg/ml, 9.2 (3.3, 25.2) mg/l, 13.4 (10.4, 17.5) pg/ml, and 4.9 (2.0, 11.4) pg/ml, respectively. Higher levels of MR-proADM at baseline were associated with age, female sex, NYHA class, NT-proBNP, hsCRP, IL-6, and TNF-α, while there was an inverse association with LVEF.
In the course of 10 years of follow-up, 691 (68%) patients died. Unadjusted MR-proADM strongly predicted all-cause death when used as a continuous variable (HR 1.31 per nmol/l, 95% CI 1.26–1.37; p<0.001) or when grouped into quartiles (HR 1.85, 95% CI 1.71–2.0; p<0.001). Adjustments for age, sex and NYHA functional class did not materially alter the strong association. Plotting quartiles of MR-proADM in a Kaplan-Meier curve (see Figure 1) confirmed this findings. As shown in Figure 2, MR-proADM had the highest area under the curve (AUC) in ROC analysis when compared to other biomarkers.
Conclusion
MR-proADM appears to be a strong and independent predictor for long-term all-cause mortality risk in HF with reduced ejection fraction (HFrEF). Therefore, assessing MR-proADM may contribute to better categorization of risk and tailored care. Its clinical utility needs to be investigated in future studies.
Funding Acknowledgement
Type of funding sources: Public grant(s) – National budget only. Main funding source(s): BMBF
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Affiliation(s)
- F Kerwagen
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
| | - F Sahiti
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
| | - S Sehner
- The University Medical Center Hamburg-Eppendorf, Department of Medical Biometry and Epidemiology , Hamburg , Germany
| | - J Albert
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
| | - V Cejka
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
| | - N Moser
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
| | - C Morbach
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
| | - G Gueder
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
| | - S Frantz
- University Hospital of Wurzburg, Department of Medicine I , Würzburg , Germany
| | - G Ertl
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
| | - C E Angermann
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
| | - S Stoerk
- University Hospital Wuerzburg, Comprehensive Heart Failure Center , Wuerzburg , Germany
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17
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Voors AA, Damman K, Teerlink JR, Angermann CE, Collins SP, Kosiborod M, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Tromp J, Brueckmann M, Blatchford JP, Salsali A, Ponikowski P. Renal effects of empagliflozin in patients hospitalized for acute heart failure: from the EMPULSE trial. Eur J Heart Fail 2022; 24:1844-1852. [PMID: 36066557 PMCID: PMC9828037 DOI: 10.1002/ejhf.2681] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 01/12/2023] Open
Abstract
AIM The sodium-glucose cotransporter 2 (SGLT2) inhibitor empagliflozin improved clinical outcomes in patients hospitalized for acute heart failure. In patients with chronic heart failure, SGLT2 inhibitors cause an early decline in estimated glomerular filtration rate (eGFR) followed by a slower eGFR decline over time than placebo. However, the effects of SGLT2 inhibitors on renal function during a hospital admission for acute heart failure remain largely unknown. METHODS AND RESULTS Between 1 and 5 days after a hospitalization for acute heart failure, 530 patients with an eGFR >20 ml/min/1.73 m2 were randomized to 10 mg of empagliflozin or placebo and treated for 90 days. Renal function and electrolytes were measured at baseline, and after 15, 30 and 90 days. We evaluated the effect of empagliflozin on eGFR over time and the impact of baseline eGFR on the primary hierarchical outcome of death, worsening heart failure events and quality of life. Mean baseline eGFR was 52.4 ml/min/1.73 m2 in the empagliflozin group and 55.7 ml/min/1.73 m2 in the placebo group. Empagliflozin caused an initial decline in eGFR (-2 ml/min/1.73 m2 at day 15 compared to placebo). At day 90, eGFR was similar between empagliflozin and placebo. Investigator-reported acute renal failure occurred in 7.7% of empagliflozin versus 12.1% of placebo patients. The overall clinical benefit (hierarchical composite of all-cause death, heart failure events and quality of life) of empagliflozin was unaffected by baseline eGFR. CONCLUSION In patients hospitalized for acute heart failure, empagliflozin caused an early modest decline in renal function which was no longer evident after 90 days. Acute renal events were similar in both groups. The clinical benefit of empagliflozin was consistent regardless of baseline renal function.
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Affiliation(s)
- Adriaan A. Voors
- Department of Cardiology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - Kevin Damman
- Department of Cardiology, University Medical Center GroningenUniversity of GroningenGroningenThe Netherlands
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of MedicineUniversity of California San FranciscoSan FranciscoCAUSA
| | - Christiane E. Angermann
- Comprehensive Heart Failure CentreUniversity & University Hospital of WürzburgWürzburgGermany
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical CareTennessee Valley Healthcare Facility VA Medical CenterNashvilleTNUSA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMSUSA,The George Institute for Global Health and The University of New South WalesSydneyNSWAustralia
| | - Jan Biegus
- Institute of Heart DiseasesMedical UniversityWroclawPoland
| | - João Pedro Ferreira
- Inserm INI‐CRCT, CHRUUniversité de LorraineNancyFrance,Cardiovascular Research and Development Center, Department of Surgery and PhysiologyFaculty of Medicine of the University of PortoPortoPortugal
| | - Michael E. Nassif
- Saint Luke's Mid America Heart Institute and the University of MissouriKansas CityMSUSA
| | | | - Jasper Tromp
- Saw Swee Hock School of Public HealthNational University of Singapore, and the National University Health SystemSingapore
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbHIngelheimGermany,First Department of Medicine faculty of Medicine MannheimUniversity of HeidelbergMannheimGermany
| | - Jonathan P. Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KGBiberachGermany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc.RidgefieldCTUSA,Faculty of MedicineRutgers UniversityNew BrunswickNJUSA
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18
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Kosiborod MN, Angermann CE, Collins SP, Teerlink JR, Ponikowski P, Biegus J, Comin-Colet J, Ferreira JP, Mentz RJ, Nassif ME, Psotka MA, Tromp J, Brueckmann M, Blatchford JP, Salsali A, Voors AA. Effects of Empagliflozin on Symptoms, Physical Limitations, and Quality of Life in Patients Hospitalized for Acute Heart Failure: Results From the EMPULSE Trial. Circulation 2022; 146:279-288. [PMID: 35377706 PMCID: PMC9311476 DOI: 10.1161/circulationaha.122.059725] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND Patients hospitalized for acute heart failure experience poor health status, including a high burden of symptoms and physical limitations, and poor quality of life. SGLT2 (sodium-glucose cotransporter 2) inhibitors improve health status in chronic heart failure, but their effect on these outcomes in acute heart failure is not well characterized. We investigated the effects of the SGLT2 inhibitor empagliflozin on symptoms, physical limitations, and quality of life, using the Kansas City Cardiomyopathy Questionnaire (KCCQ) in the EMPULSE trial (Empagliflozin in Patients Hospitalized With Acute Heart Failure Who Have Been Stabilized). METHODS Patients hospitalized for acute heart failure were randomized to empagliflozin 10 mg daily or placebo for 90 days. The KCCQ was assessed at randomization and 15, 30, and 90 days. The effects of empagliflozin on the primary end point of clinical benefit (hierarchical composite of all-cause death, heart failure events, and a 5-point or greater difference in KCCQ Total Symptom Score [TSS] change from baseline to 90 days) were examined post hoc across the tertiles of baseline KCCQ-TSS. In prespecified analyses, changes (randomization to day 90) in KCCQ domains, including TSS, physical limitations, quality of life, clinical summary, and overall summary scores were evaluated using a repeated measures model. RESULTS In total, 530 patients were randomized (265 each arm). Baseline KCCQ-TSS was low overall (mean [SD], 40.8 [24.0] points). Empagliflozin-treated patients experienced greater clinical benefit across the range of KCCQ-TSS, with no treatment effect heterogeneity (win ratio [95% CIs] from lowest to highest tertile: 1.49 [1.01-2.20], 1.37 [0.94-1.99], and 1.48 [1.00-2.20], respectively; P for interaction=0.94). Beneficial effects of empagliflozin on health status were observed as early as 15 days and persisted through 90 days, at which point empagliflozin-treated patients experienced a greater improvement in KCCQ TSS, physical limitations, quality of life, clinical summary, and overall summary (placebo-adjusted mean differences [95% CI]: 4.45 [95% CI, 0.32-8.59], P=0.03; 4.80 [95% CI, 0.00-9.61], P=0.05; 4.66 [95% CI, 0.32-9.01], P=0.04; 4.85 [95% CI, 0.77-8.92], P=0.02; and 4.40 points [95% CI, 0.33-8.48], P=0.03, respectively). CONCLUSIONS Initiation of empagliflozin in patients hospitalized for acute heart failure produced clinical benefit regardless of the degree of symptomatic impairment at baseline, and improved symptoms, physical limitations, and quality of life, with benefits seen as early as 15 days and maintained through 90 days. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT0415775.
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Affiliation(s)
- Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.).,The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.N.K.)
| | - Christiane E. Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, Germany (C.E.A.)
| | - Sean P. Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN (S.P.C.).,Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville (S.P.C.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco (J.R.T.)
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland (P.P., J.B.)
| | - Josep Comin-Colet
- Hospital Universitari de Bellvitge, The Institute of Biomedical Research of Bellvitge (IDIBELL), Barcelona, Spain (J.C.-C.)
| | - João Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France (J.P.F.).,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University Medical Center, Durham, NC (R.J.M.)
| | - Michael E. Nassif
- Saint Luke’s Mid America Heart Institute, Kansas City, MO (M.N.K., M.E.N.).,School of Medicine, University of Missouri-Kansas City (M.N.K., M.E.N.)
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore (J.T.)
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Germany (M.B.).,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany (M.B.)
| | - Jonathan P. Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany (J.P.B.)
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc, Ridgefield, CT (A.S.).,Faculty of Medicine, Rutgers University, New Brunswick, NJ (A.S.)
| | - Adriaan A. Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, The Netherlands (A.A.V.)
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19
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Abstract
PURPOSE OF REVIEW In this article, we review a range of digital technologies for possible application in heart failure patients, with a focus on lessons learned. We also discuss a future model of heart failure management, as digital technologies continue to become part of standard care. RECENT FINDINGS Digital technologies are increasingly used by healthcare professionals and those living with heart failure to support more personalised and timely shared decision-making, earlier identification of problems, and an improved experience of care. The COVID-19 pandemic has accelerated the acceptability and implementation of a range of digital technologies, including remote monitoring and health tracking, mobile health (wearable technology and smartphone-based applications), and the use of machine learning to augment data interpretation and decision-making. Much has been learned over recent decades on the challenges and opportunities of technology development, including how best to evaluate the impact of digital health interventions on health and healthcare, the human factors involved in implementation and how best to integrate dataflows into the clinical pathway. Supporting patients with heart failure as well as healthcare professionals (both with a broad range of health and digital literacy skills) is crucial to success. Access to digital technologies and the internet remains a challenge for some patients. The aim should be to identify the right technology for the right patient at the right time, in a process of co-design and co-implementation with patients.
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Affiliation(s)
- K C C McBeath
- Royal Brompton Hospital (Guy's & St Thomas' NHS Foundation Trust), Sydney Street, London, SW3 6NP, UK
| | - C E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital Würzburg, Würzburg, Germany
| | - M R Cowie
- Royal Brompton Hospital (Guy's & St Thomas' NHS Foundation Trust), Sydney Street, London, SW3 6NP, UK.
- School of Cardiovascular Medicine, Faculty of Medicine & Lifesciences, King's College London, London, UK.
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20
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Voors AA, Angermann CE, Teerlink JR, Collins SP, Kosiborod M, Biegus J, Ferreira JP, Nassif ME, Psotka MA, Tromp J, Borleffs CJW, Ma C, Comin-Colet J, Fu M, Janssens SP, Kiss RG, Mentz RJ, Sakata Y, Schirmer H, Schou M, Schulze PC, Spinarova L, Volterrani M, Wranicz JK, Zeymer U, Zieroth S, Brueckmann M, Blatchford JP, Salsali A, Ponikowski P. The SGLT2 inhibitor empagliflozin in patients hospitalized for acute heart failure: a multinational randomized trial. Nat Med 2022; 28:568-574. [PMID: 35228754 PMCID: PMC8938265 DOI: 10.1038/s41591-021-01659-1] [Citation(s) in RCA: 315] [Impact Index Per Article: 157.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 12/14/2021] [Indexed: 12/22/2022]
Abstract
The sodium–glucose cotransporter 2 inhibitor empagliflozin reduces the risk of cardiovascular death or heart failure hospitalization in patients with chronic heart failure, but whether empagliflozin also improves clinical outcomes when initiated in patients who are hospitalized for acute heart failure is unknown. In this double-blind trial (EMPULSE; NCT04157751), 530 patients with a primary diagnosis of acute de novo or decompensated chronic heart failure regardless of left ventricular ejection fraction were randomly assigned to receive empagliflozin 10 mg once daily or placebo. Patients were randomized in-hospital when clinically stable (median time from hospital admission to randomization, 3 days) and were treated for up to 90 days. The primary outcome of the trial was clinical benefit, defined as a hierarchical composite of death from any cause, number of heart failure events and time to first heart failure event, or a 5 point or greater difference in change from baseline in the Kansas City Cardiomyopathy Questionnaire Total Symptom Score at 90 days, as assessed using a win ratio. More patients treated with empagliflozin had clinical benefit compared with placebo (stratified win ratio, 1.36; 95% confidence interval, 1.09–1.68; P = 0.0054), meeting the primary endpoint. Clinical benefit was observed for both acute de novo and decompensated chronic heart failure and was observed regardless of ejection fraction or the presence or absence of diabetes. Empagliflozin was well tolerated; serious adverse events were reported in 32.3% and 43.6% of the empagliflozin- and placebo-treated patients, respectively. These findings indicate that initiation of empagliflozin in patients hospitalized for acute heart failure is well tolerated and results in significant clinical benefit in the 90 days after starting treatment. In a multinational trial, empagliflozin has clinical benefit when administered to hospitalized patients with acute heart failure, extending the reach of SGLT2 inhibitor therapy to this patient population.
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Affiliation(s)
- Adriaan A Voors
- University of Groningen Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands.
| | - Christiane E Angermann
- Comprehensive Heart Failure Centre, University and University Hospital of Würzburg, Würzburg, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center and Geriatric Research and Education Clinical Care, Tennessee Valley Healthcare Facility VA Medical Center, Nashville, TN, USA
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA.,George Institute for Global Health, Sydney, New South Wales, Australia.,University of New South Wales, Sydney, New South Wales, Australia
| | - Jan Biegus
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
| | - João Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT (Cardiovascular and Renal Clinical Trialists), Centre Hospitalier Régional Universitaire, Nancy, France.,Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, Kansas City, MO, USA.,School of Medicine, University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore, and the National University Health System, Singapore, Singapore
| | | | - Changsheng Ma
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | | | - Michael Fu
- Section of Cardiology, Sahlgrenska University Hospital, University of Gothenburg, Gothenburg, Sweden
| | - Stefan P Janssens
- Department of Cardiovascular Sciences, Clinical Cardiology, Belgium University Hospital, Katholieke Universiteit Leuven, Leuven, Belgium
| | - Robert G Kiss
- Department of Cardiology, Military Hospital, Budapest, Hungary
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Yasushi Sakata
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Henrik Schirmer
- Department of Cardiology, Division of Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Morten Schou
- Department of Cardiology, Gentofte University Hospital Copenhagen, Copenhagen, Denmark
| | | | - Lenka Spinarova
- First Department of Medicine, Masaryk University Hospital, Brno, Czech Republic
| | | | - Jerzy K Wranicz
- Department of Electrocardiology, Medical University of Lodz, Central Clinical Hospital, Lodz, Poland
| | - Uwe Zeymer
- Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,First Department of Medicine, Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jonathan P Blatchford
- Elderbrook Solutions GmbH on behalf of Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals Inc., Ridgefield, CT, USA.,Faculty of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Medical University, Wroclaw, Poland
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21
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Aßmus B, Angermann CE. Geschlechtsspezifische Unterschiede bei Herzinsuffizienz: Pathophysiologie,
Risikofaktoren und Bildgebung. Aktuelle Kardiologie 2022. [DOI: 10.1055/a-1692-1023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
ZusammenfassungHerzinsuffizienz betrifft etwa 4 Millionen Menschen in Deutschland, stellt die häufigste
Ursache für Hospitalisierungen dar und trägt wesentlich zur Morbidität und Letalität einer
älter werdenden Gesellschaft bei. Bei der Herzinsuffizienz gibt es ausgeprägte
geschlechtsspezifische Unterschiede, sowohl bezüglich Epidemiologie, Pathophysiologie und
Risikofaktoren als auch in der bildgebenden Diagnostik. Daher ist die Kenntnis der
Unterschiede zwischen Männern und Frauen mit Herzinsuffizienz in Hinblick auf die
genannten Faktoren essenziell sowohl für das Erkennen der Erkrankung als auch für
Interpretation der Diagnostik. Mit dem aktuellen Artikel wollen wir einen kurzen Überblick
zu geschlechtsspezifischen Unterschieden der Herzinsuffizienz-Entwicklung geben und zum
Weiterlesen inspirieren.
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Affiliation(s)
- Birgit Aßmus
- Med. Klinik I Kardiologie, Justus Liebig Universität Gießen
Fachbereich Medizin, Gießen, Deutschland
| | - Christiane E. Angermann
- Deutsches Zentrum für Herzinsuffizienz der Universität und des
Universitätsklinikums Würzburg, Würzburg, Deutschland
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22
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Angermann CE, Aßmus B. Geschlechtsunterschiede bei Herzinsuffizienz – Behandlung und
Prognose. Aktuelle Kardiologie 2022. [DOI: 10.1055/a-1692-1070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
ZusammenfassungWeltweit sind bei Frauen kardiovaskuläre Erkrankungen die Haupttodesursache. Bei
Ätiologie, Epidemiologie, Pathophysiologie, Symptomatik und Komorbiditäten der
Herzinsuffizienz (HI) sowie bei Wirkungen und Nebenwirkungen von Therapiemaßnahmen und der
Prognose gibt es relevante Geschlechtsunterschiede. Trotzdem sind in klinischen Studien
Frauen als Teilnehmerinnen bzw. in der Studienleitung unterrepräsentiert. Sekundäre
Analysen aus Therapiestudien legen Geschlechtsunterschiede bei Wirksamkeit,
Nebenwirkungsprofil und optimaler Dosierung von Medikamenten und beim Nutzen von
Device-Therapien nahe. Prospektive Studiendesigns mit dem Ziel, Geschlechtsunterschiede zu
herauszuarbeiten, gibt es kaum, und Leitlinienempfehlungen sind meist geschlechtsneutral.
Dieser Übersichtsartikel beschreibt Unterschiede bei Behandlungseffekten, Verfügbarkeit
von Therapien und Krankheitsprognose, beleuchtet Wissenslücken und zeigt, wo
Handlungsbedarf besteht, um die Situation von Frauen mit HI zu verbessern.
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Affiliation(s)
- Christiane E. Angermann
- Deutsches Zentrum für Herzinsuffizienz, Universität und Universitätsklinikum
Würzburg, Würzburg, Deutschland
| | - Birgit Aßmus
- Kardiologie-Angiologie, Universitätsklinikum Gießen und Marburg, Gießen,
Deutschland
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23
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Tromp J, Beusekamp JC, Ouwerkerk W, Meer P, Cleland JG, Angermann CE, Dahlstrom U, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Filippatos G, Dickstein K, Collins SP, Lam CS. Regional Differences in Precipitating Factors of Hospitalization for Acute Heart Failure: Insights from the
REPORT‐HF
Registry. Eur J Heart Fail 2022; 24:645-652. [PMID: 35064730 PMCID: PMC9106888 DOI: 10.1002/ejhf.2431] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/07/2021] [Revised: 01/05/2022] [Accepted: 01/14/2022] [Indexed: 11/11/2022] Open
Abstract
AIMS Few prior studies have investigated differences in precipitants leading to hospitalizations for acute heart failure (AHF) in a cohort with global representation. METHODS AND RESULTS We analysed the prevalence of precipitants and their association with outcomes in 18 553 patients hospitalized for AHF in REPORT-HF (prospective international REgistry to assess medical Practice with lOngitudinal obseRvation for Treatment of Heart Failure) according to left ventricular ejection fraction subtype (reduced [HFrEF] and preserved ejection fraction [HFpEF]) and presentation (new-onset vs. decompensated chronic heart failure [DCHF]). Patients were enrolled from 358 centres in 44 countries stratified according to Latin America, North America, Western Europe, Eastern Europe, Eastern Mediterranean and Africa, Southeast Asia, and Western Pacific. Precipitants were pre-with mutually exclusive categories and selected according to the local investigator's discretion. Outcomes included in-hospital and 1-year mortality. The median age was 67 (interquartile range 57-77) years, and 39% were women. Acute coronary syndrome (ACS) was the most common precipitant in patients with new-onset heart failure in all regions except for North America and Western Europe, where uncontrolled hypertension and arrhythmia, respectively, were the most common precipitants, independent of confounders. In patients with DCHF, non-adherence to diet/medication was the most common precipitant regardless of region. Uncontrolled hypertension was a more likely precipitant in HFpEF, non-adherence to diet/medication, and ACS were more likely precipitants in HFrEF. Patients admitted due to worsening renal function had the worst in-hospital (5%) and 1-year post-discharge (30%) mortality rates, regardless of region, heart failure subtype and admission type (pinteraction >0.05 for all). CONCLUSION Data on global differences in precipitants for AHF highlight potential regional differences in targets for preventing hospitalization for AHF and identifying those at highest risk for early mortality.
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Affiliation(s)
- Jasper Tromp
- Saw Swee Hock School of Public Health National University of Singapore and National University Health System Singapore
- Duke‐NUS Medical School Singapore
| | - Joost C. Beusekamp
- University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - Wouter Ouwerkerk
- National Heart Centre Singapore Singapore
- Dept of Dermatology Amsterdam UMC, University of Amsterdam, Amsterdam Infection & Immunity Institute Amsterdam The Netherlands
| | - Peter Meer
- University of Groningen, University Medical Center Groningen Groningen The Netherlands
| | - John G.F. Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Well‐Being, University of Glasgow and National Heart & Lung Institute, Imperial College London
| | - Christiane E. Angermann
- Comprehensive Heart Failure Centre, University Hospital and University of Würzburg Würzburg Germany
| | - Ulf Dahlstrom
- Department of Cardiology and Department of Health, Medicine and Caring Sciences Linkoping University Linkoping Sweden
| | - Georg Ertl
- Comprehensive Heart Failure Centre, University Hospital and University of Würzburg Würzburg Germany
| | - Mahmoud Hassanein
- Alexandria University, Faculty of Medicine, Cardiology Department Alexandria Egypt
| | - Sergio V. Perrone
- El Cruce Hospital by Florencio Varela, Lezica Cardiovascular Institute, Sanctuary of the Trinidad Miter Buenos Aires Argentina
| | | | | | | | - Gerasimos Filippatos
- University of Cyprus, School of Medicine & National and Kapodistrian University of Athens, School of Medicine, Department of Cardiology Attikon University Hospital Athens Greece
| | | | - Sean P Collins
- Vanderbilt University Medical Center, Department of Emergency Medicine Nashville TN USA
| | - Carolyn S.P. Lam
- Duke‐NUS Medical School Singapore
- University of Groningen, University Medical Center Groningen Groningen The Netherlands
- National Heart Centre Singapore Singapore
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24
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Tromp J, Ouwerkerk W, Cleland JG, Chandramouli C, Angermann CE, Dahlstrom U, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Dickstein K, Collins SP, Filippatos G, Lam CSP. A global perspective of racial differences and outcomes in patients presenting with acute heart failure. Am Heart J 2022; 243:11-14. [PMID: 34516969 DOI: 10.1016/j.ahj.2021.09.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 09/01/2021] [Indexed: 11/01/2022]
Abstract
Important racial differences in characteristics, treatment, and outcomes of patients with acute heart failure (AHF) have been described. The objective of this analysis of the International Registry to assess medical Practice with longitudinal observation for Treatment of Heart Failure (REPORT-HF) registry was to investigate racial differences in patients with AHF according to country income level.
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25
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Henneges C, Morbach C, Sahiti F, Scholz N, Frantz S, Ertl G, Angermann CE, Störk S. Sex-specific bimodal clustering of left ventricular ejection fraction in patients with acute heart failure. ESC Heart Fail 2021; 9:786-790. [PMID: 34913270 PMCID: PMC8788060 DOI: 10.1002/ehf2.13618] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/11/2021] [Accepted: 09/04/2021] [Indexed: 12/23/2022] Open
Abstract
Aims There is an ongoing discussion whether the categorization of patients with heart failure according to left ventricular ejection fraction (LVEF) is scientifically justified and clinically relevant. Major efforts are directed towards the identification of appropriate cut‐off values to correctly allocate heart failure‐specific pharmacotherapy. Alternatively, an LVEF continuum without definite subgroups is discussed. This study aimed to evaluate the natural distribution of LVEF in patients presenting with acutely decompensated heart failure and to identify potential subgroups of LVEF in male and female patients. Methods and results We identified 470 patients (mean age 75 ± 11 years, n = 137 female) hospitalized for acute heart failure in whom LVEF could be quantified by Simpson's method in an in‐hospital echocardiogram. Non‐parametric modelling revealed a bimodal shape of the LVEF distribution. Parametric modelling identified two clusters suggesting two LVEF peaks with mean (variance) of 61% (9%) and 31% (10%), respectively. Sub‐differentiation by sex revealed a sex‐specific bimodal clustering of LVEF. The respective threshold differentiating between ‘high’ and ‘low’ LVEF was 45% in men and 52% in women. Conclusions In patients presenting with acute heart failure, LVEF clustered in two subgroups and exhibited profound sex‐specific distributional differences. These findings might enrich the scientific process to identify distinct subgroups of heart failure patients, which might each benefit from respectively tailored (pharmaco)therapies.
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Affiliation(s)
- Carsten Henneges
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Floran Sahiti
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany
| | - Nina Scholz
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany
| | - Stefan Frantz
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Georg Ertl
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany
| | - Christiane E Angermann
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center Würzburg, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
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26
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Böhm M, Assmus B, Anker SD, Asselbergs FW, Brachmann J, Brett ME, Brugts JJ, Ertl G, Wang A, Hilker L, Koehler F, Rosenkranz S, Leistner DM, Abdin A, Wintrich J, Zhou Q, Adamson PB, Angermann CE. Less loop diuretic use in patients on sacubitril/valsartan undergoing remote pulmonary artery pressure monitoring. ESC Heart Fail 2021; 9:155-163. [PMID: 34738340 PMCID: PMC8787966 DOI: 10.1002/ehf2.13665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 09/21/2021] [Accepted: 09/27/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS Control of pulmonary pressures monitored remotely reduced heart failure hospitalizations mainly by lowering filling pressures through the use of loop diuretics. Sacubitril/valsartan improves heart failure outcomes and increases the kidney sensitivity for diuretics. We explored whether sacubitril/valsartan is associated with less utilization of loop diuretics in patients guided with haemodynamic monitoring in the CardioMEMS European Monitoring Study for Heart Failure (MEMS-HF). METHODS AND RESULTS The MEMS-HF population (n = 239) was separated by the use of sacubitril/valsartan (n = 68) or no use of it (n = 164). Utilization of diuretics and their doses was prespecified in the protocol and was monitored in both groups. Multivariable regression, ANCOVA, and a generalized linear model were used to fit baseline covariates with furosemide equivalents and changes for 12 months. MEMS-HF participants (n = 239) were grouped in sacubitril/valsartan users [n = 68, 64 ± 11 years, left ventricular ejection fraction (LVEF) 25 ± 9%, cardiac index (CI) 1.89 ± 0.4 L/min/m2 ] vs. non-users (n = 164, 70 ± 10 years, LVEF 36 ± 16%, CI 2.11 ± 0.58 L/min/m2 , P = 0.0002, P < 0.0001, and P = 0.0015, respectively). In contrast, mean pulmonary artery pressure (PAP) values were comparable between groups (29 ± 11 vs. 31 ± 11 mmHg, P = 0.127). Utilization of loop diuretics was lower in patients taking sacubitril/valsartan compared with those without (P = 0.01). Significant predictor of loop diuretic use was a history of renal failure (P = 0.005) but not age (P = 0.091). After subjects were stratified by sacubitril/valsartan or other diuretic use, PAP was nominally, but not significantly lower in sacubitril/valsartan-treated patients (baseline: P = 0.52; 6 months: P = 0.07; 12 months: P = 0.53), while there was no difference in outcome or PAP changes. This difference was observed despite lower CI (P = 0.0015). Comparable changes were not observed for other non-loop diuretics (P = 0.21). CONCLUSIONS In patients whose treatment was guided by remote PAP monitoring, concomitant use of sacubitril/valsartan was associated with reduced utilization of loop diuretics, which could potentially be relevant for outcomes.
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Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 1, Homburg/Saar, 66421, Germany
| | - Birgit Assmus
- Department of Medicine, Cardiology, Goethe University Hospital, Frankfurt, Frankfurt am Main, Germany.,Department of Medicine I, Cardiology/Angiology, University Hospital, Giessen, Germany
| | - Stefan D Anker
- Division of Cardiology & Metabolism and Department of Cardiology & Berlin-Brandenburg Center for Regenerative Therapies, and German Center for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Folkert W Asselbergs
- Division Heart & Lungs, Department of Cardiology, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Johannes Brachmann
- Medical Centre Coburg GmbH II, Medical Clinic Cardiology, Angiology, Pulmonology, Coburg, Germany
| | | | - Jasper J Brugts
- Erasmus MC University Medical Center, Thorax Center, Rotterdam, The Netherlands
| | - Georg Ertl
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany
| | | | - Lutz Hilker
- Klinikum Karlsburg, Heart and Diabetes Center Mecklenburg-Western Pommerania, Karlsburg, Germany
| | - Friedrich Koehler
- Division of Cardiology and Angiology, Medical Department, Campus Charité Mitte, Centre for Cardiovascular Telemedicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine, University of Cologne Heart Center, and Cologne Cardiovascular Research Center (CCRC), Köln, Germany
| | - David M Leistner
- Department of Cardiology, University Heart Center Berlin and Charite University Medicine Berlin, Campus Benjamin-Franklin (CBF), Berlin, Germany
| | - Amr Abdin
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 1, Homburg/Saar, 66421, Germany
| | - Jan Wintrich
- Klinik für Innere Medizin III, Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes, Saarland University, Kirrberger Str. 1, Homburg/Saar, 66421, Germany
| | - Qian Zhou
- Department of Cardiology and Angiology I, University Heart Center Freiburg - Bad Krozingen, University of Freiburg, Bad Krozingen, Germany.,Department of Cardiology, University Hospital Basel, Basel, Switzerland
| | | | - Christiane E Angermann
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Würzburg, Germany
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27
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Sahiti F, Morbach C, Henneges C, Stefenelli U, Scholz N, Cejka V, Albert J, Heuschmann PU, Ertl G, Frantz S, Angermann CE, Störk S. Dynamics of Left Ventricular Myocardial Work in Patients Hospitalized for Acute Heart Failure. J Card Fail 2021; 27:1393-1403. [PMID: 34332057 DOI: 10.1016/j.cardfail.2021.07.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Revised: 06/30/2021] [Accepted: 07/13/2021] [Indexed: 02/09/2023]
Abstract
BACKGROUND The left ventricular ejection fraction (LVEF) is the most commonly used measure describing pumping efficiency, but it is heavily dependent on loading conditions and therefore not well-suited to study pathophysiologic changes. The novel concept of echocardiography-derived myocardial work (MyW) overcomes this disadvantage as it is based on LV pressure-strain loops. We tracked the in-hospital changes of indices of MyW in patients admitted for acute heart failure (AHF) in relation to their recompensation status and explored the prognostic utility of MyW indices METHODS AND RESULTS: We studied 126 patients admitted for AHF (mean 73 ± 12 years, 37% female, 40% with a reduced LVEF [<40%]), providing pairs of echocardiograms obtained both on hospital admission and prior to discharge. The following MyW indices were derived: global constructive and wasted work (GCW, GWW), global work index (GWI), and global work efficiency. In patients with HF with reduced ejection fraction with decreasing N-terminal prohormone B-natriuretic peptide levels during hospitalization, the GCW and GWI improved significantly, whereas the GWW remained unchanged. In patients with HF with preserved ejection fraction, the GCW and GWI were unchanged; however, in patients with no decrease or eventual increase in N-terminal prohormone B-natriuretic peptide, we observed an increase in GWW. In all patients with AHF, higher values of GWW were associated with a higher risk of death or rehospitalization within 6 months after discharge (per 10-point increment hazard ratio 1.035, 95% confidence interval 1.005-1.065). CONCLUSIONS Our results suggest differential myocardial responses to decompensation and recompensation, depending on the HF phenotype in patients presenting with AHF. The GWW predicted the 6-month prognosis in these patients, regardless of LVEF. Future studies in larger cohorts need to confirm our results and identify determinants of short-term and longer term changes in MyW.
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Affiliation(s)
- Floran Sahiti
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany; Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany; Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Carsten Henneges
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany
| | - Ulrich Stefenelli
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany
| | - Nina Scholz
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany
| | - Vladimir Cejka
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany
| | - Judith Albert
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany; Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Peter U Heuschmann
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany; Institute of Clinical Epidemiology and Biometry, University of Würzburg, Würzburg, Germany; Clinical Trial Center, University Hospital Würzburg, Würzburg, Germany
| | - Georg Ertl
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany; Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Frantz
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany; Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Christiane E Angermann
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany; Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Würzburg, Germany; Department of Medicine I, University Hospital Würzburg, Würzburg, Germany.
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28
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Morbach C, Beyersdorf N, Kerkau T, Ramos G, Sahiti F, Albert J, Jahns R, Ertl G, Angermann CE, Frantz S, Hofmann U, Störk S. Adaptive anti-myocardial immune response following hospitalization for acute heart failure. ESC Heart Fail 2021; 8:3348-3353. [PMID: 33934554 PMCID: PMC8318503 DOI: 10.1002/ehf2.13376] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 03/07/2021] [Accepted: 04/08/2021] [Indexed: 11/25/2022] Open
Abstract
Aims It has been hypothesized that cardiac decompensation accompanying acute heart failure (AHF) episodes generates a pro‐inflammatory environment boosting an adaptive immune response against myocardial antigens, thus contributing to progression of heart failure (HF) and poor prognosis. We assessed the prevalence of anti‐myocardial autoantibodies (AMyA) as biomarkers reflecting adaptive immune responses in patients admitted to the hospital for AHF, followed the change in AMyA titres for 6 months after discharge, and evaluated their prognostic utility. Methods and results AMyA were determined in n = 47 patients, median age 71 (quartiles 60; 80) years, 23 (49%) female, and 24 (51%) with HF with preserved ejection fraction, from blood collected at baseline (time point of hospitalization) and at 6 month follow‐up (visit F6). Patients were followed for 18 months (visit F18). The prevalence of AMyA increased from baseline (n = 21, 45%) to F6 (n = 36, 77%; P < 0.001). At F6, the prevalence of AMyA was higher in patients with HF with preserved ejection fraction (n = 21, 88%) compared with patients with reduced ejection fraction (n = 14, 61%; P = 0.036). During the subsequent 12 months after F6, that is up to F18, patients with newly developed AMyA at F6 had a higher risk for the combined endpoint of death or rehospitalization for HF (hazard ratio 4.79, 95% confidence interval 1.13–20.21; P = 0.033) compared with patients with persistent or without AMyA at F6. Conclusions Our results support the hypothesis that AHF may induce patterns of adaptive immune responses. More studies in larger populations and well‐defined patient subgroups are needed to further clarify the role of the adaptive immune system in HF progression.
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Affiliation(s)
- Caroline Morbach
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Niklas Beyersdorf
- Institute for Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | - Thomas Kerkau
- Institute for Virology and Immunobiology, University of Würzburg, Würzburg, Germany
| | - Gustavo Ramos
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Floran Sahiti
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Judith Albert
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Roland Jahns
- Interdisciplinary Bank of Biomaterials and Data Würzburg (ibdw), University Hospital Würzburg, Würzburg, Germany
| | - Georg Ertl
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany
| | - Christiane E Angermann
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany
| | - Stefan Frantz
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Ulrich Hofmann
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Am Schwarzenberg 15, Würzburg, D-97078, Germany.,Department of Medicine I, University Hospital Würzburg, Würzburg, Germany
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Tromp J, Ponikowski P, Salsali A, Angermann CE, Biegus J, Blatchford J, Collins SP, Ferreira JP, Grauer C, Kosiborod M, Nassif ME, Psotka MA, Brueckmann M, Teerlink JR, Voors AA. Sodium-glucose co-transporter 2 inhibition in patients hospitalized for acute decompensated heart failure: rationale for and design of the EMPULSE trial. Eur J Heart Fail 2021; 23:826-834. [PMID: 33609072 PMCID: PMC8358952 DOI: 10.1002/ejhf.2137] [Citation(s) in RCA: 50] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 02/02/2021] [Accepted: 02/16/2021] [Indexed: 12/12/2022] Open
Abstract
Aims Treatment with sodium–glucose co‐transporter 2 (SGLT2) inhibitors improves outcomes in patients with chronic heart failure (HF) with reduced ejection fraction. There is limited experience with the in‐hospital initiation of SGLT2 inhibitors in patients with acute HF (AHF) with or without diabetes. EMPULSE is designed to assess the clinical benefit and safety of the SGLT2 inhibitor empagliflozin compared with placebo in patients hospitalized with AHF. Methods EMPULSE is a randomized, double‐blind, parallel‐group, placebo‐controlled multinational trial comparing the in‐hospital initiation of empagliflozin (10 mg once daily) with placebo. Approximately 500 patients admitted for AHF with dyspnoea, signs of fluid overload, and elevated natriuretic peptides will be randomized 1:1 stratified to HF status (de‐novo and decompensated chronic HF) to either empagliflozin or placebo at approximately 165 sites across North America, Europe and Asia. Patients will be enrolled regardless of ejection fraction and diabetes status and will be randomized during hospitalization and after stabilization (between 24 h and 5 days after admission), with treatment continued up to 90 days after initiation. The primary outcome is clinical benefit at 90 days, consisting of a composite of all‐cause death, HF events, and ≥5 point change from baseline in Kansas City Cardiomyopathy Questionnaire total symptom score (KCCQ‐TSS), assessed using a ‘win‐ratio’ approach. Secondary outcomes include assessments of safety, change in KCCQ‐TSS from baseline to 90 days and change in natriuretic peptides from baseline to 30 days. Conclusion The EMPULSE trial will evaluate the clinical benefit and safety of empagliflozin in patients hospitalized for AHF.
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Affiliation(s)
- Jasper Tromp
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Duke-NUS Medical School, Singapore.,National Heart Centre Singapore, Singapore
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Wroclaw, Poland
| | - Afshin Salsali
- Boehringer Ingelheim Pharmaceuticals, Ridgefield, CT, USA.,Faculty of Medicine, Rutgers University, New Brunswick, NJ, USA
| | - Christiane E Angermann
- Comprehensive Heart Failure Center, University and University Hospital, Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Jan Biegus
- Department of Heart Diseases, Medical University, Wroclaw, Poland
| | - Jon Blatchford
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - João Pedro Ferreira
- Université de Lorraine, Inserm, Centre d'Investigation Clinique Plurithématique 1433, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Claudia Grauer
- Boehringer Ingelheim International GmbH, Ingelheim, Germany
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, USA.,The George Institute for Global Health and the University of New South Wales, Sydney, NSW, Australia
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute and the University of Missouri, Kansas City, MO, USA
| | | | - Martina Brueckmann
- Boehringer Ingelheim International GmbH, Ingelheim, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, San Francisco, CA, USA
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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30
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Morbach C, Henneges C, Sahiti F, Breunig M, Cejka V, Ertl G, Frantz S, Angermann CE, Stoerk S. Distribution pattern of left ventricular ejection fraction in patients with decompensated heart failure depends on sex results of a latent class analysis. Eur Heart J Cardiovasc Imaging 2021. [DOI: 10.1093/ehjci/jeaa356.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): unrestricted grant from Boehringer Ingelheim
Background & Aims Since 2016, heart failure (HF) is classified using left ventricular ejection fraction (LVEF) thresholds of 40% and 50%. However, HF phenotypes may develop across the entire LVEF spectrum depending on individual patient characteristics including the risk and comorbidity profile. Using latent class analysis, we explored the sex-specific distribution of in-hospital LVEF in patients hospitalized for acute heart failure (AHF) at a tertiary care center in Germany.
Methods Consecutive patients (≥18 years) hospitalized for AHF were recruited and phenotyped prospectively on a 7/24 basis. Exclusion criteria were high output heart failure, cardiogenic shock, and being listed for high urgency cardiac transplantation. LVEF was determined by transthoracic echocardiography using Simpson´s biplane or monoplane method. First, we estimated the distribution of LVEF in both sexes using histogram and kernel density estimation methods (bandwidth was selected by biased cross-validation). Then, Gaussian Mixture Models were fitted with increasing number of components. To identify the optimal number of subgroups we calculated the Bayesian Information Criterion (BIC). The minimum of the BIC criterion suggests the optimal number of subgroups for the final model. This analysis was performed on subsets including only male and only female patients.
Results Out of 629 patients (39.8% female) admitted with AHF between 09/2014 and 12/2017, 93% patients received in-hospital echocardiography, and in 79.2% LVEF could be quantitatively assessed. The BIC suggested two subgroups each for male (Fig. A) and female patients (Fig. B). In the male two-subgroup model, mean ± SD LVEF values were 30 ± 9% and 59 ± 8%, thus covering 48% and 52% of the men, respectively (Fig. C). In the female two-subgroup model, respective LVEF values were 36 ± 13% and 65 ± 8%, thus covering 47% and 53% of patients (Fig. D). The "male" model suggested 45% as cut-point, whilst the "female" model suggested 51% as cut-point differentiating between lower and higher LVEF.
Conclusions Using non-parametric and parametric statistical approaches, specific subgroups of patients hospitalized with AHF were identified among male and female patients hospitalized for AHF, which each time comprised subgroups with impaired vs. more preserved LVEF. Future analyses in larger AHF cohorts as well as in populations with chronic stable HF are warranted which take also into consideration sex differences in HF aetiology.
Figure
A) Minimum number of components (BIC) in men. B) Minimum BIC in women. C) LVEF distribution in men (2 components). D) LVEF distribution in women (2 components). The orange line indicates the respective cut-points between low and high LVEF.
Abstract Figure.
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Affiliation(s)
- C Morbach
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - C Henneges
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - F Sahiti
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - M Breunig
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - V Cejka
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - G Ertl
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - S Frantz
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - CE Angermann
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - S Stoerk
- University Hospital Wuerzburg, Wuerzburg, Germany
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Albert J, Lezius S, Störk S, Morbach C, Güder G, Frantz S, Wegscheider K, Ertl G, Angermann CE. Trajectories of Left Ventricular Ejection Fraction After Acute Decompensation for Systolic Heart Failure: Concomitant Echocardiographic and Systemic Changes, Predictors, and Impact on Clinical Outcomes. J Am Heart Assoc 2021; 10:e017822. [PMID: 33496189 PMCID: PMC7955416 DOI: 10.1161/jaha.120.017822] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Background Prospective longitudinal follow‐up of left ventricular ejection fraction (LVEF) trajectories after acute cardiac decompensation of heart failure is lacking. We investigated changes in LVEF and covariates at 6‐months' follow‐up in patients with a predischarge LVEF ≤40%, and determined predictors and prognostic implications of LVEF changes through 18‐months' follow‐up. Methods and Results Interdisciplinary Network Heart Failure program participants (n=633) were categorized into subgroups based on LVEF at 6‐months' follow‐up: normalized LVEF (>50%; heart failure with normalized ejection fraction, n=147); midrange LVEF (41%–50%; heart failure with midrange ejection fraction, n=195), or persistently reduced LVEF (≤40%; heart failure with persistently reduced LVEF , n=291). All received guideline‐directed medical therapies. At 6‐months' follow‐up, compared with patients with heart failure with persistently reduced LVEF, heart failure with normalized LVEF or heart failure with midrange LVEF subgroups showed greater reductions in LV end‐diastolic/end‐systolic diameters (both P<0.001), and left atrial systolic diameter (P=0.002), more increased septal/posterior end‐diastolic wall‐thickness (both P<0.001), and significantly greater improvement in diastolic function, biomarkers, symptoms, and health status. Heart failure duration <1 year, female sex, higher predischarge blood pressure, and baseline LVEF were independent predictors of LVEF improvement. Mortality and event‐free survival rates were lower in patients with heart failure with normalized LVEF (P=0.002). Overall, LVEF increased further at 18‐months' follow‐up (P<0.001), while LV end‐diastolic diameter decreased (P=0.048). However, LVEF worsened (P=0.002) and LV end‐diastolic diameter increased (P=0.047) in patients with heart failure with normalized LVEF hospitalized between 6‐months' follow‐up and 18‐months' follow‐up. Conclusions Six‐month survivors of acute cardiac decompensation for systolic heart failure showed variable LVEF trajectories, with >50% showing improvements by ≥1 LVEF category. LVEF changes correlated with various parameters, suggesting multilevel reverse remodeling, were predictable from several baseline characteristics, and were associated with clinical outcomes at 18‐months' follow‐up. Repeat hospitalizations were associated with attenuation of reverse remodeling. Registration URL: https://www.controlled‐trials.com; Unique identifier: ISRCTN23325295.
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Affiliation(s)
- Judith Albert
- Department of Internal Medicine I Cardiology University Hospital Würzburg Würzburg Germany.,Comprehensive Heart Failure Centre University and University Hospital Würzburg Germany
| | - Susanne Lezius
- Medical Center Hamburg-EppendorfInstitute of Medical Biometry and Epidemiology Hamburg Germany
| | - Stefan Störk
- Department of Internal Medicine I Cardiology University Hospital Würzburg Würzburg Germany.,Comprehensive Heart Failure Centre University and University Hospital Würzburg Germany
| | - Caroline Morbach
- Department of Internal Medicine I Cardiology University Hospital Würzburg Würzburg Germany.,Comprehensive Heart Failure Centre University and University Hospital Würzburg Germany
| | - Gülmisal Güder
- Department of Internal Medicine I Cardiology University Hospital Würzburg Würzburg Germany.,Comprehensive Heart Failure Centre University and University Hospital Würzburg Germany
| | - Stefan Frantz
- Department of Internal Medicine I Cardiology University Hospital Würzburg Würzburg Germany.,Comprehensive Heart Failure Centre University and University Hospital Würzburg Germany
| | - Karl Wegscheider
- Medical Center Hamburg-EppendorfInstitute of Medical Biometry and Epidemiology Hamburg Germany
| | - Georg Ertl
- Comprehensive Heart Failure Centre University and University Hospital Würzburg Germany
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Filippatos G, Angermann CE, Cleland JGF, Lam CSP, Dahlström U, Dickstein K, Ertl G, Hassanein M, Hart KW, Lindsell CJ, Perrone SV, Guerin T, Ghadanfar M, Schweizer A, Obergfell A, Collins SP. Global Differences in Characteristics, Precipitants, and Initial Management of Patients Presenting With Acute Heart Failure. JAMA Cardiol 2021; 5:401-410. [PMID: 31913404 DOI: 10.1001/jamacardio.2019.5108] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Acute heart failure (AHF) precipitates millions of hospital admissions worldwide, but previous registries have been country or region specific. Objective To conduct a prospective contemporaneous comparison of AHF presentations, etiologic factors and precipitants, treatments, and in-hospital outcomes among global regions through the International Registry to Assess Medical Practice with Longitudinal Observation for Treatment of Heart Failure (REPORT-HF). Design, Setting, and Participants A total of 18 553 adults were enrolled during a hospitalization for AHF. Patients were recruited from the acute setting in Western Europe (WE), Eastern Europe (EE), Eastern Mediterranean and Africa (EMA), Southeast Asia (SEA), Western Pacific (WP), North America (NA), and Central and South America (CSA). Patients with AHF were approached for consent and excluded only if there was recent participation in a clinical trial. Patients were enrolled from July 23, 2014, to March 24, 2017. Statistical analysis was conducted from April 18 to June 29, 2018; revised analyses occurred between August 6 and 29, 2019. Main Outcomes and Measures Heart failure etiologic factors and precipitants, treatments, and in-hospital outcomes among global regions. Results A total of 18 553 patients were enrolled at 358 sites in 44 countries. The median age was 67.0 years (interquartile range [IQR], 57-77), 11 372 were men (61.3%), 9656 were white (52.0%), 5738 were Asian (30.9%), and 867 were black (4.7%). A history of HF was present in more than 50% of the patients and 40% were known to have a prior left-ventricular ejection fraction lower than 40%. Ischemia was a common AHF precipitant in SEA (596 of 2329 [25.6%]), WP (572 of 3354 [17.1%]), and EMA (364 of 2241 [16.2%]), whereas nonadherence to diet and medications was most common in NA (306 of 1592 [19.2%]). Median time to the first intravenous therapy was 3.0 (IQR, 1.4-5.6) hours in NA; no other region had a median time above 1.2 hours (P < .001). This treatment delay remained after adjusting for severity of illness (P < .001). Intravenous loop diuretics were the most common medication administered in the first 6 hours of AHF management across all regions (65.4%-89.9%). Despite similar initial blood pressure across all regions, inotropic agents were used approximately 3 times more often in SEA, WP, and EE (11.3%-13.5%) compared with NA and WE (3.1%-4.3%) (P < .001). Older age (odds ratio [OR], 1.0; 95% CI, 1.00-1.02), HF etiology (ischemia: OR, 1.65; 95% CI, 1.11-2.44; valvular: OR, 2.10; 95% CI, 1.36-3.25), creatinine level greater than 2.75 mg/dL (OR, 1.85; 95% CI, 0.71-2.40), and chest radiograph signs of congestion (OR, 2.03; 95% CI, 1.39-2.97) were all associated with increased in-hospital mortality. Similarly, younger age (OR, -0.04; 95% CI, -0.05 to -0.02), HF etiology (ischemia: OR, 0.77; 95% CI, 0.26-1.29; valvular: OR, 2.01; 95% CI, 1.38-2.65), creatinine level greater than 2.75 mg/dL (OR, 1.16; 95% CI, 0.31-2.00), and chest radiograph signs of congestion (OR, 1.02; 95% CI, 0.57-1.47) were all associated with increased in-hospital LOS. Conclusions and Relevance Data from REPORT-HF suggest that patients are similar across regions in many respects, but important differences in timing and type of treatment exist, identifying region-specific gaps in medical management that may be associated with patient outcomes.
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Affiliation(s)
- Gerasimos Filippatos
- University of Cyprus School of Medicine, Cyprus, Greece.,Attikon University Hospital, Department of Cardiology, National and Kapodistrian University of Athens School of Medicine, Athens, Greece
| | - Christiane E Angermann
- Comprehensive Heart Failure Center, University Hospital, Department of Medicine I-Cardiology, University of Würzburg, Würzburg, Germany
| | - John G F Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health & Well-Being, University of Glasgow, Glasgow, United Kingdom.,National Heart & Lung Institute, Imperial College London, London, United Kingdom
| | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore.,Cardiovascular Academic Clinical Program, Duke-National University of Singapore, Singapore.,Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Ulf Dahlström
- Department of Cardiology, Department of Medical and Health Sciences, Linkoping University, Linkoping, Sweden
| | | | - Georg Ertl
- Comprehensive Heart Failure Center, University Hospital, Department of Medicine I-Cardiology, University of Würzburg, Würzburg, Germany
| | - Mahmoud Hassanein
- Department of Cardiology, Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Kimberly W Hart
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, Tennessee
| | | | - Sergio V Perrone
- El Cruce Hospital by Florencio Varela, Lezica Cardiovascular Institute, Sanctuary of the Trinidad Miter, Buenos Aires, Argentina
| | | | | | | | | | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
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Angermann CE, Assmus B, Anker SD, Asselbergs FW, Brachmann J, Brett M, Brugts JJ, Ertl G, Ginn G, Hilker L, Koehler F, Rosenkranz S, Zhou Q, Adamson PB, Böhm M. Pulmonary artery pressure‐guided therapy in ambulatory patients with symptomatic heart failure: the
CardioMEMS E
uropean
M
onitoring
S
tudy for
H
eart
F
ailure (
MEMS‐HF
). Eur J Heart Fail 2020; 22:1891-1901. [DOI: 10.1002/ejhf.1943] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2020] [Revised: 05/27/2020] [Accepted: 06/20/2020] [Indexed: 12/28/2022] Open
Affiliation(s)
- Christiane E. Angermann
- Comprehensive Heart Failure Center, University and University Hospital, Würzburg University Hospital Würzburg Würzburg Germany
| | - Birgit Assmus
- Department of Medicine, Cardiology Goethe University Hospital Frankfurt Germany
- Department of Medicine I, Cardiology/Angiology University Hospital Giessen Germany
| | - Stefan D. Anker
- Division of Cardiology & Metabolism and Department of Cardiology & Berlin‐Brandenburg Center for Regenerative Therapies, and German Center for Cardiovascular Research, partner site Berlin Charité Universitätsmedizin Berlin Berlin Germany
| | - Folkert W. Asselbergs
- Division Heart & Lungs, Department of Cardiology University Medical Centre Utrecht Utrecht The Netherlands
| | - Johannes Brachmann
- Medical Centre Coburg GmbH II, Medical Clinic Cardiology, Angiology, Pulmonology Coburg Germany
| | | | - Jasper J. Brugts
- Erasmus MC University Medical Centre, Thoraxcenter Rotterdam The Netherlands
| | - Georg Ertl
- Comprehensive Heart Failure Center, University and University Hospital, Würzburg University Hospital Würzburg Würzburg Germany
| | | | - Lutz Hilker
- Klinikum Karlsburg, Heart and Diabetes Center Mecklenburg‐Western Pommerania Karlsburg Germany
| | - Friedrich Koehler
- Division of Cardiology and Angiology, Medical Department, Campus Charité Mitte, Centre for Cardiovascular Telemedicine Charité Universitätsmedizin Berlin Berlin Germany
| | - Stephan Rosenkranz
- Clinic III for Internal Medicine University of Cologne Heart Center, and Cologne Cardiovascular Research Center (CCRC) Cologne Germany
| | - Qian Zhou
- Department of Cardiology and Angiology I University Heart Center Freiburg – Bad Krozingen, University of Freiburg Freiburg Germany
- Department of Cardiology University Hospital Basel Basel Switzerland
| | | | - Michael Böhm
- Internal Medicine III Cardiology, Angiology, Intensive Care Saarland University Medical Centre Homburg Germany
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Tromp J, Bamadhaj S, Cleland JGF, Angermann CE, Dahlstrom U, Ouwerkerk W, Tay WT, Dickstein K, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Lam CSP, Filippatos G, Collins SP. Correction to: Post-discharge prognosis of patients admitted to hospital for heart failure by world region, and national level of income and income disparity (REPORT-HF): a cohort study. The Lancet Global Health 2020; 8:e1001. [DOI: 10.1016/s2214-109x(20)30294-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 06/10/2020] [Indexed: 10/23/2022] Open
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Tromp J, Bamadhaj S, Cleland JGF, Angermann CE, Dahlstrom U, Ouwerkerk W, Tay WT, Dickstein K, Ertl G, Hassanein M, Perrone SV, Ghadanfar M, Schweizer A, Obergfell A, Lam CSP, Filippatos G, Collins SP. Post-discharge prognosis of patients admitted to hospital for heart failure by world region, and national level of income and income disparity (REPORT-HF): a cohort study. The Lancet Global Health 2020; 8:e411-e422. [DOI: 10.1016/s2214-109x(20)30004-8] [Citation(s) in RCA: 64] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Revised: 11/19/2019] [Accepted: 01/06/2020] [Indexed: 01/23/2023]
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Güder G, Ertl G, Angermann CE. [Diagnostics and treatment of chronic heart failure : Update 2020]. Herz 2020:10.1007/s00059-019-04877-z. [PMID: 32016486 DOI: 10.1007/s00059-019-04877-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/28/2024]
Abstract
Heart failure is a systemic disease. As populations are aging worldwide, the prevalence and importance of comorbidities as major determinants of heart failure symptoms, disease progression and prognosis are increasing. Since the last version of the European Society of Cardiology guidelines for the diagnosis and treatment of heart failure was published in 2016, promising novel pharmacotherapies for chronic heart failure and its comorbidities and new device-based treatment and monitoring options have become available; however, the broad range of therapeutic options as well as the diagnostic and therapeutic implications of comorbidities render the treatment of heart failure increasingly more complex. This review aims to provide practical guidance for a rational up-to-date approach to the evidence-based management of heart failure.
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Affiliation(s)
- Gülmisal Güder
- Medizinische Klinik und Poliklinik I, Kardiologie, Universität Würzburg, Würzburg, Deutschland
- Deutsches Zentrum für Herzinsuffizienz, Universität und Universitätsklinikum Würzburg, Haus A 15, Am Schwarzenberg 15, 97078, Würzburg, Deutschland
| | - Georg Ertl
- Deutsches Zentrum für Herzinsuffizienz, Universität und Universitätsklinikum Würzburg, Haus A 15, Am Schwarzenberg 15, 97078, Würzburg, Deutschland
| | - Christiane E Angermann
- Deutsches Zentrum für Herzinsuffizienz, Universität und Universitätsklinikum Würzburg, Haus A 15, Am Schwarzenberg 15, 97078, Würzburg, Deutschland.
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Hashemi D, Blum M, Mende M, Störk S, Angermann CE, Pankuweit S, Tahirovic E, Wachter R, Pieske B, Edelmann F, Düngen HD. Syncopes and clinical outcome in heart failure: results from prospective clinical study data in Germany. ESC Heart Fail 2020; 7:942-952. [PMID: 32003157 PMCID: PMC7261586 DOI: 10.1002/ehf2.12605] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 12/04/2019] [Accepted: 12/09/2019] [Indexed: 12/11/2022] Open
Abstract
AIMS Whereas syncopal episodes are a frequent complication of cardiovascular disorders, including heart failure (HF), little is known whether syncopes impact the prognosis of patients with HF. We aimed to assess the impact of a history of syncope (HoS) on overall and hospitalization-free survival of these patients. METHODS AND RESULTS We pooled the data of prospective, nationwide, multicentre studies conducted within the framework of the German Competence Network for Heart Failure including 11 335 subjects. Excluding studies with follow-up periods <10 years, we assessed 5318 subjects. We excluded a study focusing on cardiac changes in patients with an HIV infection because of possible confounding factors and 849 patients due to either missing key parameters or missing follow-up data, resulting in 3594 eligible subjects, including 2130 patients with HF [1564 patients with heart failure with reduced ejection fraction (HFrEF), 314 patients with heart failure with mid-range ejection fraction, and 252 patients with heart failure with preserved ejection fraction (HFpEF)] and 1464 subjects without HF considered as controls. HoS was more frequent in the overall cohort of patients with HF compared with controls (P < 0.001)-mainly driven by the HFpEF subgroup (HFpEF vs. controls: 25.0% vs. 12.8%, P < 0.001). Of all the subjects, 14.6% reported a HoS. Patients with HFrEF in our pooled cohort showed more often syncopes than subjects without HF (15.0% vs. 12.8%, P = 0.082). Subjects with HoS showed worse overall survival [42.4% vs. 37.9%, hazard ratio (HR) = 1.21, 99% confidence interval (0.99, 1.46), P = 0.04] and less days alive out of hospital [HR = 1.39, 99% confidence interval (1.18, 1.64), P < 0.001] compared with all subjects without HoS. Patients with HFrEF with HoS died earlier [30.3% vs. 41.6%, HR = 1.40, 99% confidence interval (1.12, 1.74), P < 0.001] and lived fewer days out of hospital than those without HoS. We could not find these changes in mortality and hospital-free survival in the heart failure with mid-range ejection fraction and HFpEF cohorts. HoS represented a clinically high-risk profile within the HFrEF group-combining different risk factors. Further analyses showed that among patients with HFrEF with HoS, known cardiovascular risk factors (e.g. age, male sex, diabetes mellitus, and anaemia) were more prevalent. These constellations of the risk factors explained the effect of HoS in a multivariable Cox regression models. CONCLUSIONS In a large cohort of patients with HF, HoS was found to be a clinically and easily accessible predictor of both overall and hospitalization-free survival in patients with HFrEF and should thus routinely be assessed.
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Affiliation(s)
- Djawid Hashemi
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Medizinische Klinik m. S. Kardiologie, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Moritz Blum
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Medizinische Klinik m. S. Kardiologie, Augustenburger Platz 1, 13353, Berlin, Germany
| | - Meinhard Mende
- Clinical Trial Centre, University of Leipzig, Leipzig, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University of Würzburg, Würzburg, Germany
| | | | - Sabine Pankuweit
- Department of Cardiology, University Hospital Giessen & Marburg, Marburg, Germany
| | - Elvis Tahirovic
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Medizinische Klinik m. S. Kardiologie, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Rolf Wachter
- DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany.,Department of Internal Medicine and Cardiology, University of Leipzig, Leipzig, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Medizinische Klinik m. S. Kardiologie, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, German Heart Institute Berlin (DHZB), Berlin, Germany
| | - Frank Edelmann
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Medizinische Klinik m. S. Kardiologie, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Hans-Dirk Düngen
- Department of Internal Medicine and Cardiology, Charité - Universitätsmedizin Berlin, Campus Virchow Klinikum, Medizinische Klinik m. S. Kardiologie, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
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Morbach C, Sahiti F, Henneges C, Breunig M, Kaspar M, Ertl G, Frantz S, Angermann CE, Stoerk S. 411 Recompensation induces distinct changes in myocardial work in patients with acutely decompensated heart failure and reduced vs preserved left ventricular ejection fraction. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Funding Acknowledgements
German Research Foundation (BMBF 01EO1004 and 01EO1504)
OnBehalf
Acute Heart Failure Registry
Background & Aim A new, less load-dependent echocardiographic tool to determine left ventricular (LV) myocardial work (MyW) based on longitudinal strain and blood pressure has recently been introduced and validated against invasive measurements. We investigated the impact of change in N-terminal pro-B-natriuretic peptide (NT-proBNP; i.e. surrogate of recompensation) during the hospital phase on changes in MyW (global work efficiency [GWE]; global constructive work [GCW]; and global wasted work [GWW]), in patients admitted for acutely decompensated heart failure (AHF).
Methods The AHF registry is a monocentric prospective follow-up study that comprehensively phenotypes consecutive patients hospitalized for AHF. Echocardiography was performed and NT-proBNP measured on the day of admission and within 72 hours prior to discharge. MyW assessment was performed off-line using EchoPAC (GE, version 202). In order to quantify changes in MyW and NT-proBNP, we used the respective discharge-to-admission ratio (DAR). Local polynomial regression was applied to model these associations in patients with LV ejection fraction (LVEF) <40% vs ≥40%.
Results We analyzed 111 patients: mean age 73 ± 11 yrs; 32% female; 46 patients (41.4%) with LVEF < 40%. The median [Q1, Q3] NT-proBNP level at admission was 5883 pg/ml (2589, 10188). Median length of stay in hospital was 12.0 days (9.0, 16.5). The DAR for NT-proBNP was 0.55 (0.34; 0.80) indicating that the majority of patients experienced a marked lowering of NT-proBNP. The figure demonstrates that the association between DAR of MyW parameters and DAR of NT-proBNP showed distinct profiles depending on admission LVEF. E.g., in panel A, the arrows indicate that a NT-proBNP reduction by 50% was associated with a 45% increment in GCW if admission LVEF was <40%, but with an 8% increment only if LVEF was ≥40%.
Conclusions Our preliminary analysis indicates that a decrease in NT-proBNP may be associated with an improvement in GCW and GWE in patients with reduced LVEF, while these parameters were non-responsive in the other patient group. Although these results require confirmation in a larger cohort, they encourage further research in to MyW as a less load-dependent measure of LV function, shedding new light on echocardiographically manifest alterations of myocardial texture and the timing of healing processes after an acute cardiac event.
Figure
Discharge-to-admission ratio (DAR) of A) global work efficiency (GWE, >1= improvement), B) global constructive work (GCW, >1= improvement), and C) global wasted work (GWW, <1 = improvement) as a function of discharge to admission NT-proBNP in acute heart failure patients with left ventricular ejection fraction ≥ and <40%.
Abstract 411 Figure
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Affiliation(s)
- C Morbach
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - F Sahiti
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - C Henneges
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - M Breunig
- Comprehensive Heart Failure Center and Department for Medicine I, Wurzburg, Germany
| | - M Kaspar
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - G Ertl
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - S Frantz
- University Hospital Wuerzburg, Comprehensive Heart Failure Center and Dept. of Medicine I, Wuerzburg, Germany
| | - C E Angermann
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - S Stoerk
- University Hospital Wuerzburg, Comprehensive Heart Failure Center and Dept. of Medicine I, Wuerzburg, Germany
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Morbach C, Henneges C, Sahiti F, Breunig M, Cejka V, Ertl G, Frantz S, Angermann CE, Stoerk S. P1432 Heart failure subgroups according to left ventricular ejection fraction A latent class analysis. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Funding Acknowledgements
German Research Foundation (BMBF 01EO1004 and 01EO1504)
OnBehalf
AHF
Background & Aims Heart failure (HF) is classified according to left ventricular (LV) ejection fraction (EF) into heart failure with reduced (HFrEF) and heart failure with preserved EF (HFpEF). In 2016, a third subgroup, heart failure with mid-range EF (HFmrEF), has been introduced by the ESC. We aimed to identify the number of naturally occurring heart failure subgroups according to LVEF using latent class analysis.
Methods The AHF registry is a monocentric prospective follow-up study that comprehensively phenotypes consecutive patients hospitalized for acute heart failure (AHF). Echocardiography was performed within 72 hours prior to discharge. We first estimated the distribution of LVEF using histogram and kernel density estimation methods (bandwidth was selected by biased cross-validation). We then fitted Gaussian Mixture Models with increasing number of components to the data. To select the optimal number of components we calculated the Akaike Information Criterion (AIC) and the Bayesian Information Criterion (BIC). The minimum of each criterion suggests the optimal number of components for the final model. The BIC requires more data to select more components than the AIC and hence is more conservative. Finally, for each criterion the optimal model was determined.
Results Out of 629 patients, 585 (93%) patients received echocardiography and in 498 (79.2%) the LVEF could be calculated using Simpson´s biplane or monoplane method.
The BIC suggested two (panel B), the AIC three components (panel A). In the two-component model, mean ± SD LVEF values were 60.2 ± 8.7% and 30.8 ± 9.6%, thus covering 56% and 44% of patients, respectively (panel D). In the three-component model, respective LVEF values were 64.9 ± 6.2%, 50.2 ± 6.9%, and 28.4 ± 8.1%, thus covering 35%, 27%, and 38% of patients (panel C).
Conclusions Our analysis suggests that LVEF in patients with AHF is not a continuum, but clusters in two or three subgroups. In line with the HFrEF and HFpEF classification, the more conservative model suggested two subgroups of LVEF. The less restrictive model allowed for a third subgroup, compatible with HFmrEF. Future analyses will better characterize the identified subgroups.
Abstract P1432 Figure
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Affiliation(s)
- C Morbach
- University Hospital Wuerzburg, Wuerzburg, Germany
| | - C Henneges
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - F Sahiti
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - M Breunig
- University Hospital Wuerzburg, Comprehensive Heart Failure Center and Dept. of Medicine I, Wuerzburg, Germany
| | - V Cejka
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - G Ertl
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - S Frantz
- University Hospital Wuerzburg, Comprehensive Heart Failure Center and Dept. of Medicine I, Wuerzburg, Germany
| | - C E Angermann
- Comprehensive Heart Failure Center (CHFC), Wurzburg, Germany
| | - S Stoerk
- University Hospital Wuerzburg, Comprehensive Heart Failure Center and Dept. of Medicine I, Wuerzburg, Germany
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Abstract
Due to contrasting results from clinical trials, remote monitoring devices have so far rarely been approved for heart failure (HF) management in European countries. Implementation of telemedicine into clinical practice of heart failure outpatient care is still limited. As part of an expert meeting on physiological monitoring in the complex mutimorbid HF patient, the needs to establish evidence supporting the use of devices in heart failure outpatient care was discussed according to a trialist's perspective. This document reflects the key points debated by a multidisciplinary panel of leading international experts on this topic.
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Affiliation(s)
- Christiane E Angermann
- Department of Medicine I- and Comprehensive Heart Failure Center, University Hospital and University of Würzburg, Am Schwarzenberg 15, 97078 Würzburg, Germany
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Abstract
Hyperkalemia increases morbidity and mortalilty risk in both in- and outpatients. Common causes are decreased renal excretion, excess intake or potassium shifting from the intra- to the extracellular space in combination with reduced renal excretion or impairment of regulation. Hyperkalemia may alter the cellular transmembrane potential and cause life-threatening arrhythmias. Heart failure patients with comorbid renal insufficiency and/or diabetes mellitus are at increased risk of developing hyperkalemia, which thus constitutes a common reason for insufficient up-titration, down-titration or discontinuation of prognostically relevant heart failure medications predisposing to hyperkalemia (e. g. angiotensin-converting-enzyme inhibitors, angiotensin-receptor blockers and mineralocorticoid receptor antagonists). New oral potassium binders may enhance treatment opportunities in this respect.
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Affiliation(s)
- Louisa M S Gerhardt
- Medizinische Universitätsklinik, Allgemeine Innere und Notfallmedizin, Kantonsspital Aarau, Aarau, Schweiz
| | - Christiane E Angermann
- Medizinische Klinik I und Deutsches Zentrum für Herzinsuffizienz, Universität und Universitätsklinikum Würzburg, Würzburg, Deutschland
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Barthel L, Kroiss M, Sehner S, Lezius S, Gunold H, Edelmann F, Wachter R, Graf T, Pankuweit S, Knappe D, Stork S, Deckert J, Ertl G, Fassnacht M, Angermann CE. P5450Evening levels and circadian changes of salivary cortisol predict adverse events in heart failure patients with comorbid depression - a MOOD-HF substudy. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz746.0406] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Depression is frequent in heart failure (HF) and associated with adverse clinical outcomes. The randomized MOOD-HF trial showed that in depressed patients with systolic heart failure (HF) the selective serotonin reuptake inhibitor escitalopram (E) improved neither survival nor depression compared to placebo (P). The hypothalamic-pituitary-adrenocortical axis is known to be altered in depression or HF. This MOOD-HF substudy aimed to clarify whether circadian salivary cortisol levels (SCL) were predictive of adverse events in depressed MOOD-HF participants and whether outcomes differed according to treatment with E.
Methods
MOOD-HF participants (all suffering from symptomatic systolic HF with left ventricular ejection fraction (LVEF) <45% and current major depression) were eligible for the present analysis if providing samples for SCL determination (luminescence immunoassay) at baseline visit (BL) and if not on oral glucocorticosteroid therapy. Depression severity was determined with the Montgomery–Åsberg Depression Rating Scale (MADRS) and LVEF measured by echocardiography.
Results
In the total study cohort (146 patients on E, 147 on P) median morning SCL at BL was 0.210 μg/dL (IQR 0.141–0.338 μg/dL) and median evening (pm) SCL 0.067 μg/dL (0.036–0.128 μg/dL, p<0.001). Median circadian change was 0.124 μg/dL (0.044–0.239 μg/dL). In patients with BL pm-SCL above the median MADRS-score was 21.7±9.1 and LVEF 33.7±8.4% respectively, in patients with pm-SCL below the median these values were 19.6±9.1 and 36.5±7.8% (p=0.048; p=0.004).
During 12 months follow-up the composite endpoint (all-cause death or rehospitalization) occurred least in E-treated patients with low pm-SCL and most often in E-treated patients with high pm-SCL (HR 2.02, 95% CI 1.12–3.65, p=0.010); patients on P had comparable event rates irrespective of BL pm-SCL (Figure A). Thus, numerically patients on E with low BL pm-SCL had lower event rates compared with corresponding P-treated patients (HR 0.76 (0.41–1.40, p=0.796)), while patients with high BL pm-SCL had higher event rates (HR 1.29 (0.74–2.24, p=0.799)) than corresponding P-treated patients. Patients with circadian SCL changes above the median receiving P experienced the composite primary endpoint least, while both subgroups with circadian SCL changes below the median and also patients with circadian SCL changes above the median on E had higher event rates (HR 0.66 (0.45–0.97, p=0.039), Figure B).
Conclusion
In depressed patients with systolic HF high pm-SCL are associated with more severe disease (depression and cardiac dysfunction). Extending primary MOOD-HF results indicating unfavourable outcomes related to E, the current findings suggest a SCL x treatment interaction with higher event rates in (sicker) patients with high pm-SCL and lower event rates in (less sick) patients with low pm-SCL when treated with the antidepressant. Low circadian changes of SCL were always associated with higher event rates.
Acknowledgement/Funding
BMBF (Grant 01 KG0702) and Lundbeck A/S Denmark
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Affiliation(s)
- L Barthel
- University Hospital Würzburg, Comprehensive Heart Failure Center, Würzburg, Germany
| | - M Kroiss
- University Hospital Würzburg, Department of Medicine I, Endocrinology, Würzburg, Germany
| | - S Sehner
- University Medical Center Hamburg Eppendorf, Department of Biometry and Epidemiology, Hamburg, Germany
| | - S Lezius
- University Medical Center Hamburg Eppendorf, Department of Biometry and Epidemiology, Hamburg, Germany
| | - H Gunold
- University Hospital Leipzig, Department of Medicine and Cardiology and Heart Center, Leipzig, Germany
| | - F Edelmann
- University Hospital Berlin, Department of Internal Medicine, Cardiology, Charité – Campus Virchow-Klinikum, Berlin, Germany
| | - R Wachter
- University Hospital Leipzig, Department of Cardiology, Leipzig, Germany
| | - T Graf
- University Hospital Lübeck, Department of Medicine II, Cardiology, Lübeck, Germany
| | - S Pankuweit
- University Hospital Marburg, Department of Cardiology, Marburg, Germany
| | - D Knappe
- University Heart Center Hamburg, Hamburg, Germany
| | - S Stork
- University Hospital Würzburg, Comprehensive Heart Failure Center and Department of Medicine I, Würzburg, Germany
| | - J Deckert
- University Hospital Würzburg, Department of Psychiatry, Psychosomatic Medicine and Psychotherapy, Center of Mental Health, Würzburg, Germany
| | - G Ertl
- University Hospital Wurzburg, Wurzburg, Germany
| | - M Fassnacht
- University Hospital Würzburg, Department of Medicine I, Endocrinology, Würzburg, Germany
| | - C E Angermann
- University Hospital Würzburg, Comprehensive Heart Failure Center and Department of Medicine I, Würzburg, Germany
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Abstract
Heart failure (HF) is an emerging epidemic associated with significant morbidity and mortality, impaired quality of life and high healthcare costs. Despite major advances in pharmacological and device-based therapies, mortality and morbidity have remained high after an index hospitalization for acute cardiac decompensation (ACD). Randomized trials evaluating various forms of noninvasive telemonitoring failed to improve rehospitalization rates in such patients, possibly due to lack of sensitivity of clinical signs and symptoms as early indicators of HF. Among different implantable monitoring devices, wireless remote monitoring of the pulmonary artery pressure (PAP) with the CardioMEMS™ sensor (Abbott, Sylmar, CA, USA) has been shown to be safe and clinically effective in the USA. The patients showed substantial reductions in hospital admissions for ACD, irrespective of left ventricular pump function, because PAP-guided HF management facilitates timely recognition of incipient ACD and appropriate modification of medical treatment before hospitalization becomes unavoidable. These encouraging results have also stimulated evaluation of this novel technology outside the USA. Studies are also underway in Europe and European HF guidelines recommend considering implantation of a CardioMEMS™ sensor in high-risk patients (class IIb-B). More technologically refined implantable hemodynamic monitoring systems allowing, for example, left atrial pressure measurements, are under development. Promising novel approaches to using information from such devices include continuous hemodynamic monitoring and patient self-management based on the pressure information. Thus, pressure-guided HF management is likely to further expand in the future and may help improve clinical outcomes also in high-risk HF populations.
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Affiliation(s)
- C E Angermann
- Deutsches Zentrum für Herzinsuffizienz, Universität und Universitätsklinikum Würzburg, Am Schwarzenberg 15, Haus A15, 97078, Würzburg, Deutschland.
| | - S Rosenkranz
- Medizinische Klinik III für Kardiologie, Pneumologie, Angiologie und internistische Intensivmedizin, Uniklinik Köln, Kerpener Str. 62, 50937, Köln, Deutschland.
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Nolte K, Herrmann-Lingen C, Platschek L, Holzendorf V, Pilz S, Tomaschitz A, Düngen HD, Angermann CE, Hasenfuß G, Pieske B, Wachter R, Edelmann F. Vitamin D deficiency in patients with diastolic dysfunction or heart failure with preserved ejection fraction. ESC Heart Fail 2019; 6:262-270. [PMID: 30784226 PMCID: PMC6437442 DOI: 10.1002/ehf2.12413] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2018] [Accepted: 01/06/2019] [Indexed: 11/09/2022] Open
Abstract
AIMS Vitamin D deficiency is prevalent in heart failure (HF), but its relevance in early stages of heart failure with preserved ejection fraction (HFpEF) is unknown. We tested the association of 25-hydroxyvitamin D [25(OH)D] serum levels with mortality, hospitalizations, cardiovascular risk factors, and echocardiographic parameters in patients with asymptomatic diastolic dysfunction (DD) or newly diagnosed HFpEF. METHODS AND RESULTS We measured 25(OH)D serum levels in outpatients with risk factors for DD or history of HF derived from the DIAST-CHF study. Participants were comprehensively phenotyped including physical examination, echocardiography, and 6 min walk test and were followed up to 5 years. Quality of life was evaluated by the Short Form 36 (SF-36) questionnaire. We included 787 patients with available 25(OH)D levels. Median 25(OH)D levels were 13.1 ng/mL, mean E/e' medial was 13.2, and mean left ventricular ejection fraction was 59.1%. Only 9% (n = 73) showed a left ventricular ejection fraction <50%. Fifteen per cent (n = 119) of the recruited participants had symptomatic HFpEF. At baseline, participants with 25(OH)D levels in the lowest tertile (≤10.9 ng/L; n = 263) were older, more often symptomatic (oedema and fatigue, all P ≤ 0.002) and had worse cardiac [higher N-terminal pro-brain natriuretic peptide (NT-proBNP) and left atrial volume index, both P ≤ 0.023], renal (lower glomerular filtration rate, P = 0.012), metabolic (higher uric acid levels, P < 0.001), and functional (reduced exercise capacity, 6 min walk distance, and SF-36 physical functioning score, all P < 0.001) parameters. Increased NT-proBNP, uric acid, and left atrial volume index and decreased SF-36 physical functioning scores were independently associated with lower 25(OH)D levels. There was a higher risk for lower 25(OH)D levels in association with HF, DD, and atrial fibrillation (all P ≤ 0.004), which remained significant after adjusting for age. Lower 25(OH)D levels (per 10 ng/mL decrease) tended to be associated with higher 5 year mortality, P = 0.05, hazard ratio (HR) 1.55 [1.00; 2.42]. Furthermore, lower 25(OH)D levels (per 10 ng/mL decrease) were related to an increased rate of cardiovascular hospitalizations, P = 0.023, HR = 1.74 [1.08; 2.80], and remained significant after adjusting for age, P = 0.046, HR = 1.63 [1.01; 2.64], baseline NT-proBNP, P = 0.048, HR = 1.62 [1.01; 2.61], and other selected baseline characteristics and co-morbidities, P = 0.043, HR = 3.60 [1.04; 12.43]. CONCLUSIONS Lower 25(OH)D levels were associated with reduced functional capacity in patients with DD or HFpEF and were significantly predictive for an increased rate of cardiovascular hospitalizations, also after adjusting for age, NT-proBNP, and selected baseline characteristics and co-morbidities.
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Affiliation(s)
- Kathleen Nolte
- Department of Cardiology, University of Göttingen, Göttingen, Germany
| | | | - Lars Platschek
- Department of Cardiology, University of Göttingen, Göttingen, Germany
| | | | - Stefan Pilz
- Department of Internal Medicine, Division of Endocrinology and Diabetology, Medical University of Graz, Graz, Austria
| | - Andreas Tomaschitz
- Department of Cardiology, Medical University of Graz, Graz, Austria.,Specialist Clinic of Rehabilitation Bad Gleichenberg, Bad Gleichenberg, Austria
| | - Hans-Dirk Düngen
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK partner site Berlin, Berlin, Germany
| | - Christiane E Angermann
- Department of Internal Medicine I, Comprehensive Heart Failure Center Würzburg, University Hospital Würzburg, Würzburg, Germany
| | - Gerd Hasenfuß
- Department of Cardiology, University of Göttingen, Göttingen, Germany.,DZHK partner site Göttingen, Göttingen, Germany
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK partner site Berlin, Berlin, Germany.,Department of Internal Medicine and Cardiology, German Heart Center Berlin, Berlin, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
| | - Rolf Wachter
- Department of Cardiology, University of Göttingen, Göttingen, Germany.,DZHK partner site Göttingen, Göttingen, Germany.,Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany
| | - Frank Edelmann
- Department of Cardiology, University of Göttingen, Göttingen, Germany.,Department of Internal Medicine and Cardiology, Charité University Medicine, Campus Virchow Klinikum, Augustenburger Platz 1, 13353, Berlin, Germany.,DZHK partner site Göttingen, Göttingen, Germany.,Clinic and Policlinic for Cardiology, University Hospital Leipzig, Leipzig, Germany.,Berlin Institute of Health (BIH), Berlin, Germany
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Berliner D, Mattern S, Wellige M, Malsch C, Güder G, Brenner S, Morbach C, Deubner N, Breunig M, Kiefl R, Angermann CE, Ertl G, von Schacky C, Störk S. The omega-3 index in patients with heart failure: A prospective cohort study. Prostaglandins Leukot Essent Fatty Acids 2019; 140:34-41. [PMID: 30553401 DOI: 10.1016/j.plefa.2018.11.012] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 11/26/2018] [Accepted: 11/27/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND Epidemiologic studies on the omega-3 fatty acids eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA) in heart failure are scarce, while one large intervention trial demonstrated a modest benefit. METHODS This is a secondary analysis from the Interdisciplinary Network Heart Failure (INH) program. Patients hospitalized for systolic heart failure were enrolled and followed for 36 months. At baseline, whole blood samples from 899 patients were analyzed for fatty acid composition using a standardized analytical procedure (HS-Omega-3 Index®, O3-I). Associations of the O3-I with markers of heart failure severity, clinical characteristics, biomarkers, and mortality were analyzed. RESULTS The mean O3-I was 3.7 ± 1.0%. Patient mean age was 68 ± 12 years (72% male, 43% in New York Heart Association (NYHA) class III or IV, mean LVEF 30 ± 8%). During follow-up 258 patients (28.7%) died. After adjustment for potential confounders, the O3-I showed weak associations with uncured malignancy, end-systolic diameter of the left atrium, left ventricular end-diastolic and end-systolic diameters, and blood lipids and other laboratory parameters (all p < 0.05), but not with NYHA class, left ventricular ejection fraction, and the underlying cause of heart failure. The O3-I did not predict the 3-year mortality risk. CONCLUSIONS Our results show a marked depletion of omega-3 fatty acids in patients hospitalized for decompensated heart failure (suggested target range 8-11%). Although the O3-I was associated with a panel of established risk indicators in heart failure, it did not predict mortality risk. CLINICAL TRIAL REGISTRATION www.controlled-trials.com; ISRCTN23325295.
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Affiliation(s)
- Dominik Berliner
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Hannover Medical School (MHH), Dept. of Cardiology and Angiology, Hannover, Germany
| | - Sarah Mattern
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany
| | - Mareike Wellige
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany
| | - Carolin Malsch
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Institute of Clinical Epidemiology and Biometry, University of Würzburg, Germany
| | - Gülmisal Güder
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Dept. of Internal Medicine I - Cardiology, University Hospital Würzburg, Germany
| | - Susanne Brenner
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Dept. of Internal Medicine I - Cardiology, University Hospital Würzburg, Germany
| | - Caroline Morbach
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Dept. of Internal Medicine I - Cardiology, University Hospital Würzburg, Germany
| | - Nikolas Deubner
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Kerckhoff Clinic, Centre for Heart, Thoracic and Rheumatic Diseases, Bad Nauheim, Germany
| | - Margret Breunig
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Dept. of Internal Medicine I - Cardiology, University Hospital Würzburg, Germany
| | | | - Christiane E Angermann
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Dept. of Internal Medicine I - Cardiology, University Hospital Würzburg, Germany
| | - Georg Ertl
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Dept. of Internal Medicine I - Cardiology, University Hospital Würzburg, Germany
| | - Clemens von Schacky
- Omegametrix, Martinsried, Germany; Preventive Cardiology, Medical Clinic I, Ludwig Maximilians-University, Munich, Germany
| | - Stefan Störk
- Comprehensive Heart Failure Center, University and University Hospital Würzburg, Germany; Dept. of Internal Medicine I - Cardiology, University Hospital Würzburg, Germany.
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Morbach C, Stoerk S, Buck T, Peter S, Rost C, Prettin C, Holzendorf V, Erbel R, Ertl G, Angermann CE. P3753Portable echocardiography in patients with suspected heart failure in primary care. Prevalence and prognostic significance of abnormal findings. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy563.p3753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- C Morbach
- University Hospital Wuerzburg, Comprehensive Heart Failure Center and Department of Medicine I, Wuerzburg, Germany
| | - S Stoerk
- University Hospital Wuerzburg, Comprehensive Heart Failure Center and Department of Medicine I, Wuerzburg, Germany
| | - T Buck
- University Clinic Essen and Heart Center Westfalen, Klinikum Westfalen, Department of Cardiology, Dortmund, Germany
| | - S Peter
- University Hospital Würzburg and Kitzinger Land Hospital, Kitzingen, Germany
| | - C Rost
- University Hospital Würzburg and Cardiological Practice, Würzburg, Germany
| | - C Prettin
- Clinical Trial Center, Leipzig, Germany
| | | | - R Erbel
- University Clinic Essen, Institute of Medical Informatics, Biometry and Epidemiology, Essen, Germany
| | - G Ertl
- University Hospital Wuerzburg, Comprehensive Heart Failure Center and Department of Medicine I, Wuerzburg, Germany
| | - C E Angermann
- University Hospital Wuerzburg, Comprehensive Heart Failure Center and Department of Medicine I, Wuerzburg, Germany
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Breunig M, Morbach C, Kleinert S, Tony HP, Angermann CE, Stoerk S. P5422Cardiovascular risk and death in patients with rheumatic diseases and heart failure with preserved ejection fraction. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- M Breunig
- University Hospital of Würzburg, Comprehensive Heart Failure Center and Dept. of Medicine I, Würzburg, Germany
| | - C Morbach
- University Hospital of Würzburg, Comprehensive Heart Failure Center and Dept. of Medicine I, Würzburg, Germany
| | - S Kleinert
- University Hospital of Würzburg, Dept. of Rheumatology/Clinical Immunology and Rheumatology and Nephrology Erlangen, Erlangen, Würzburg, Germany
| | - H P Tony
- University Hospital of Würzburg, Dept. of Rheumatology/ Clinical Immunology, Würzburg, Germany
| | - C E Angermann
- University of Würzburg, Comprehensive Heart Failure Center, Würzburg, Germany
| | - S Stoerk
- University Hospital of Würzburg, Comprehensive Heart Failure Center and Dept. of Medicine I, Würzburg, Germany
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Albert J, Morbach C, Brenner S, Stoerk S, Ertl G, Angermann CE. 4935Biomarker profile of patients with recovery of left ventricular systolic function following acute cardiac decompensation. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.4935] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- J Albert
- Comprehensive Heart Failure Center, Wuerzburg, Germany
| | - C Morbach
- Comprehensive Heart Failure Center, Wuerzburg, Germany
| | - S Brenner
- Comprehensive Heart Failure Center, Wuerzburg, Germany
| | - S Stoerk
- Comprehensive Heart Failure Center, Wuerzburg, Germany
| | - G Ertl
- Comprehensive Heart Failure Center, Wuerzburg, Germany
| | - C E Angermann
- Comprehensive Heart Failure Center, Wuerzburg, Germany
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49
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Hilfiker-Kleiner D, Haghikia A, Berliner D, Vogel-Claussen J, Schwab J, Franke A, Schwarzkopf M, Ehlermann P, Pfister R, Michels G, Westenfeld R, Stangl V, Kindermann I, Kühl U, Angermann CE, Schlitt A, Fischer D, Podewski E, Böhm M, Sliwa K, Bauersachs J. Bromocriptine for the treatment of peripartum cardiomyopathy: a multicentre randomized study. Eur Heart J 2018; 38:2671-2679. [PMID: 28934837 PMCID: PMC5837241 DOI: 10.1093/eurheartj/ehx355] [Citation(s) in RCA: 194] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 06/23/2017] [Indexed: 12/28/2022] Open
Abstract
Aims An anti-angiogenic cleaved prolactin fragment is considered causal for peripartum cardiomyopathy (PPCM). Experimental and first clinical observations suggested beneficial effects of the prolactin release inhibitor bromocriptine in PPCM. Methods and results In this multicentre trial, 63 PPCM patients with left ventricular ejection fraction (LVEF) ≤35% were randomly assigned to short-term (1W: bromocriptine, 2.5 mg, 7 days) or long-term bromocriptine treatment (8W: 5 mg for 2 weeks followed by 2.5 mg for 6 weeks) in addition to standard heart failure therapy. Primary end point was LVEF change (delta) from baseline to 6 months assessed by magnetic resonance imaging. Bromocriptine was well tolerated. Left ventricular ejection fraction increased from 28 ± 10% to 49 ± 12% with a delta-LVEF of + 21 ± 11% in the 1W-group, and from 27 ± 10% to 51 ± 10% with a delta-LVEF of + 24 ± 11% in the 8W-group (delta-LVEF: P = 0.381). Full-recovery (LVEF ≥ 50%) was present in 52% of the 1W- and in 68% of the 8W-group with no differences in secondary end points between both groups (hospitalizations for heart failure: 1W: 9.7% vs. 8W: 6.5%, P = 0.651). The risk within the 8W-group to fail full-recovery after 6 months tended to be lower. No patient in the study needed heart transplantation, LV assist device or died. Conclusion Bromocriptine treatment was associated with high rate of full LV-recovery and low morbidity and mortality in PPCM patients compared with other PPCM cohorts not treated with bromocriptine. No significant differences were observed between 1W and 8W treatment suggesting that 1-week addition of bromocriptine to standard heart failure treatment is already beneficial with a trend for better full-recovery in the 8W group. Clinical trial registration ClinicalTrials.gov, study number: NCT00998556.
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Affiliation(s)
- Denise Hilfiker-Kleiner
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
| | - Arash Haghikia
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany.,Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Dominik Berliner
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
| | - Jens Vogel-Claussen
- Institute for Diagnostic and Interventional Radiology, Hannover Medical School, Carl-Neuberg-Str. 1, 30625 Hannover, Germany
| | - Johannes Schwab
- Universitätsklinik für Innere Medizin 8 - Schwerpunkt Kardiologie und Institut für Radiologie und Neuroradiologie, Klinikum Nürnberg Süd, Paracelsus, Medizinische Privatuniversität Nürnberg, Breslauer Str. 201, 90471 Nürnberg, Germany
| | - Annegret Franke
- Faculty of Medicine, University Leipzig, Clinical Trial Centre (KKS), ZKS Leipzig, Haertelstr. 16-18, D-04103 Leipzig, Germany
| | - Marziel Schwarzkopf
- Faculty of Medicine, University Leipzig, Clinical Trial Centre (KKS), ZKS Leipzig, Haertelstr. 16-18, D-04103 Leipzig, Germany
| | - Philipp Ehlermann
- Department of Cardiology, Angiology, and Pneumology, University of Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany
| | - Roman Pfister
- Department of Cardiology, Pulmonology, and Vascular Medicine, University of Cologne, Cologne, Kerpenerstr. 62, 50937 Köln, Germany
| | - Guido Michels
- Department of Cardiology, Pulmonology, and Vascular Medicine, University of Cologne, Cologne, Kerpenerstr. 62, 50937 Köln, Germany
| | - Ralf Westenfeld
- Department of Cardiology, Pulmonology, and Vascular Medicine, Medical Faculty, University Duesseldorf, Duesseldorf, Germany
| | - Verena Stangl
- Department for Cardiology and Angiology, Angiologie, Center for Cardiovascular Research (CCR), Charité-Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany
| | - Ingrid Kindermann
- Department of Internal Medicine III, University Hospital of the Saarland, 66421 Homburg/Saar, Germany
| | - Uwe Kühl
- Department of Cardiology, Charité-Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12203 Berlin, Germany
| | - Christiane E Angermann
- Department of Internal Medicine I, University Hospital Wuerzburg, Am Schwarzenberg 15, Haus A1597078 Würzburg, Germany
| | - Axel Schlitt
- Department of Medicine III, Medizinische Fakultät der Martin Luther-Universität Halle-Wittenberg, Magdeburger Straße 8, 06108 Halle, Germany
| | - Dieter Fischer
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
| | - Edith Podewski
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
| | - Michael Böhm
- Department of Internal Medicine III, University Hospital of the Saarland, 66421 Homburg/Saar, Germany
| | - Karen Sliwa
- Faculty of Health Sciences, Hatter Institute of Cardiology Research in Africa, 2 Anzio Road, Chris Barnard Building, 4th Floor, OBSERVATORY 7925, South Africa
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Carl-Neuberg-Str. 1. D-30625 Hannover, Germany
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50
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Angermann CE, Frantz S, Maack C. The Comprehensive Heart Failure Centre in Würzburg, Germany. Eur Heart J 2018; 39:1757-1760. [DOI: 10.1093/eurheartj/ehy202] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Christiane E Angermann
- Professor of Medicine and Cardiology, Comprehensive Heart Failure Centre, Building A15 University & University Hospital Würzburg, Am Schwarzenberg 15, 97078 Würzburg, Tel: ++49-931-201-46360, Fax: ++49-931-201-646360, © Romana Kochanowsk
| | - Stefan Frantz
- Professor of Medicine and Cardiology, Department of Medicine I (Cardiology), ZIM Building A3, Level -2, University Hospital Würzburg, Oberdürrbacher- Straße 6, 97080 Würzburg, Tel: ++49-931-201-39001, Fax: ++49-931-201-639001, © Romana Kochanowsk
| | - Christoph Maack
- Professor of Medicine and Cardiology, Comprehensive Heart Failure Centre, Building A15, University & University Hospital Würzburg, Am Schwarzenberg 15, 97078 Würzburg, Tel: ++49-931-201-46502, Fax: ++49-931-201-646502, © SebastianZiegaus
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