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Greene SJ, Spertus JA, Tang W, Kang A, Zhong Y, Myers MC, Shen S, Jiang J, Liu X, Steffen DR, Viola MG, Felker GM. Heart Failure Across the Range of Mildly Reduced and Preserved Ejection Fraction in the United States. Circ Heart Fail 2023; 16:e010430. [PMID: 37078276 PMCID: PMC10179973 DOI: 10.1161/circheartfailure.123.010430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/21/2023]
Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (S.J.G., G.M.F.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., G.M.F.)
| | - John A Spertus
- University of Missouri-Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute (J.A.S.)
| | - Wenxi Tang
- Analysis Group Inc, NY (W.T., D.R.S., M.G.V.)
| | - Amiee Kang
- Bristol Myers Squibb, Lawrenceville, NJ (A.K., Y.Z., M.C.M., S.S., J.J., X.L.)
| | - Yue Zhong
- Bristol Myers Squibb, Lawrenceville, NJ (A.K., Y.Z., M.C.M., S.S., J.J., X.L.)
| | - Michael C Myers
- Bristol Myers Squibb, Lawrenceville, NJ (A.K., Y.Z., M.C.M., S.S., J.J., X.L.)
| | - Sophie Shen
- Bristol Myers Squibb, Lawrenceville, NJ (A.K., Y.Z., M.C.M., S.S., J.J., X.L.)
| | - Jenny Jiang
- Bristol Myers Squibb, Lawrenceville, NJ (A.K., Y.Z., M.C.M., S.S., J.J., X.L.)
| | - Xuejun Liu
- Bristol Myers Squibb, Lawrenceville, NJ (A.K., Y.Z., M.C.M., S.S., J.J., X.L.)
- Department of Health Policy and Management, Gillings School of Global Public Health, University of North Carolina at Chapel Hill (X.L.)
| | | | | | - G Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (S.J.G., G.M.F.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., G.M.F.)
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Greene S, Spertus JA, Tang W, Kang A, Zhong Y, Myers M, Shen S, Jiang J, Liu X, Steffen DR, Viola M, Felker GM. Heart failure across the range of preserved ejection fraction in United States clinical practice. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.863] [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
Introduction
Recent clinical trials of heart failure with preserved ejection fraction (HFpEF) have observed varying patient profiles by ejection fraction (EF), with attenuation of treatment benefits as EF increases. In routine clinical practice, the degree to which patients hospitalized for HF with EF≥60% may differ from those with lower EF is unknown.
Purpose
To compare patient characteristics, treatment patterns, and clinical outcomes across the range of EF among patients hospitalized for HFpEF.
Methods
Using the Humedica electronic medical records database between Jan 2010 and Dec 2020, patients hospitalized for a primary diagnosis of HF with EF>40% and who were haemodynamically stable at admission, without concurrent acute coronary syndrome or end-stage renal disease, and treated with intravenous (IV) diuretic agents within 48 h of admission were identified. Patient characteristics, treatment patterns, and clinical outcomes were compared by EF ranges of 41–49%, 50–59%, and ≥60%.
Results
Of 47,026 patients hospitalized with HFpEF, 6,335 (13%) had EF 41–49%, 18,603 (40%) had EF 50–59%, and 22,088 (47%) had EF≥60%. Across all 3 groups, patients were similar with respect to age (median 77 years for each group), race (83–84% White, 12–13% Black), systolic blood pressure (137–138 mmHg at admission), and eGFR (63–64 mL/min/1.73 m2 at admission). With progressively higher EF group, the proportion of women increased (45% vs 54% vs 65%) and median NT-proBNP decreased (4,221 vs 2,945 vs 2,234 pg/mL). Patients with EF ≥60% had the lowest rates of coronary artery disease and atrial fibrillation, and the highest rates of chronic pulmonary disease (Figure 1, Panel A). Discharge medications were generally similar, with exception of less beta-blocker use and more calcium channel blocker use among those with EF ≥60% (Figure 1, Panel B). Discharge use of angiotensin receptor-neprilysin inhibitor and sodium glucose cotransporter-2 inhibitor therapies were each <1% in all groups. Hospital length of stay (median 4 days for each group) and in-hospital mortality (1.1–1.3%) were similar across groups, but rates of in-hospital acute respiratory failure were higher among patients with EF ≥60% (27% vs 230-25% for lower EF groups). Rates of 30-day and 12-month post-discharge clinical events were high irrespective of EF, without meaningful differences between groups (Figure 2).
Conclusion
In a contemporary real-world population of US patients hospitalized for HF with EF >40%, nearly half had an EF≥60%. While clinical profiles and discharge medications varied, post-discharge outcomes were similarly poor irrespective of EF. There remain important opportunities to improve the care and outcomes for patients with HF across the range of preserved ejection fraction.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): MyoKardia, Inc., a wholly owned subsidiary of Bristol Myers Squibb
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Affiliation(s)
- S Greene
- Duke Clinical Research Institute , Durham , United States of America
| | - J A Spertus
- St. Luke's Mid America Heart Institute , Kansas City , United States of America
| | - W Tang
- Duke Clinical Research Institute , Durham , United States of America
| | - A Kang
- Bristol-Myers Squibb Company , Lawrenceville , United States of America
| | - Y Zhong
- Bristol-Myers Squibb Company , Lawrenceville , United States of America
| | - M Myers
- Bristol-Myers Squibb Company , Lawrenceville , United States of America
| | - S Shen
- Bristol-Myers Squibb Company , Lawrenceville , United States of America
| | - J Jiang
- Bristol-Myers Squibb Company , Lawrenceville , United States of America
| | - X Liu
- Bristol-Myers Squibb Company , Lawrenceville , United States of America
| | - D R Steffen
- Analysis Group Inc. , New York , United States of America
| | - M Viola
- Analysis Group Inc. , New York , United States of America
| | - G M Felker
- Duke Clinical Research Institute , Durham , United States of America
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Pahwa R, Aldred J, Gupta N, Terasawa E, Garcia-Horton V, Steffen DR, Kandukuri PL, Chaudhari VS, Jalundhwala YJ, Bao Y, Kukreja P, Isaacson SH. Patterns of Daily Motor-Symptom Control with Carbidopa/Levodopa Enteral Suspension Versus Oral Carbidopa/Levodopa Therapy in Advanced Parkinson's Disease: Clinical Trial Post Hoc Analyses. Neurol Ther 2022; 11:711-723. [PMID: 35192177 PMCID: PMC9095782 DOI: 10.1007/s40120-022-00332-0] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2021] [Accepted: 01/26/2022] [Indexed: 11/30/2022] Open
Abstract
Introduction A clinical trial in advanced Parkinson’s disease (APD) has established the superiority of carbidopa/levodopa enteral suspension (CLES) in reducing total patient “off” time (OFF) and increasing total “on” time without troublesome dyskinesia (ON-woTD) over orally administered immediate-release carbidopa/levodopa tablets (IR–CL). However, temporal patterns of these improvements throughout the waking day have not been examined. In this analysis, time to ON-woTD after waking and patterns of motor-symptom control throughout the waking day were compared between CLES and IR–CL. Methods Post hoc analyses of APD patient-diary data from the phase 3 randomized controlled trial were used to compare changes in time to ON-woTD after waking, motor-symptom control throughout the waking day, occurrence of extreme fluctuations between OFF and “on” with troublesome dyskinesia, and motor-state transitions with CLES versus IR–CL from baseline to week 12. Results The sample included 33 CLES-treated and 30 IR–CL-treated patients. Among the CLES group, the percentage of patient days achieving ON-woTD within 30 min of waking was three times higher at week 12 versus baseline (33% vs. 11%, p = 0.0043); no significant change occurred with IR–CL. When the waking day was divided into four 4-h periods, CLES versus IR–CL treatment produced significantly greater reductions in OFF during three periods, and two periods had increased ON-woTD. Fewer CLES-treated patients had extreme fluctuations at week 12 (3% vs. 23%, p = 0.0224) compared to IR–CL-treated patients. From baseline to week 12, CLES-treated patients had greater reductions in the average number of motor-state transitions compared to IR–CL-treated patients (− 1.6, p = 0.0295). Conclusion CLES-treated patients experienced a more rapid onset of ON-woTD after waking and greater consistency of ON-woTD throughout their waking day than IR–CL-treated patients. Supplementary Information The online version contains supplementary material available at 10.1007/s40120-022-00332-0. In advanced Parkinson’s disease, patients’ motor-symptom states (such as “on” time without troublesome dyskinesia [good “on” time] and “off” time), and the timing at which they occur, can impact patients’ quality of life and ability to complete activities of daily living. Carbidopa/levodopa enteral suspension is administered continuously into the jejunum, potentially reducing some of the motor-state variation that is common with orally administered carbidopa/levodopa, including delayed “on” time after waking and transitions between “off” and “on” throughout the day. In post hoc analyses of clinical trial data, patterns of motor-states across the waking day were compared between carbidopa/levodopa enteral suspension and orally administered immediate-release carbidopa/levodopa at week 12. Outcomes included time to good “on” after waking; occurrence of extreme fluctuations between “off” time and “on” time with troublesome dyskinesia; time in each motor-state during 4-h intervals across the day; and frequency of motor-state transitions. Three times as many carbidopa/levodopa enteral suspension-treated patients achieved good “on” within 30 min of waking after 12 weeks versus baseline, whereas no significant change was observed for the orally administered immediate-release carbidopa/levodopa group. Compared to orally administered immediate-release carbidopa/levodopa-treated patients, fewer carbidopa/levodopa enteral suspension-treated patients experienced extreme fluctuations, had greater reductions in motor-state transitions, and greater reductions in duration of “off” during three of the four intervals in the day. These findings provide a first look at the impact of carbidopa/levodopa enteral suspension on motor-state patterns throughout the day, and suggest that carbidopa/levodopa enteral suspension provides more consistent motor-symptom control and predictable benefit throughout the day than orally administered carbidopa/levodopa.
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Affiliation(s)
- Rajesh Pahwa
- University of Kansas Medical Center, 3901 Rainbow Boulevard, Kansas City, KS, 66160, USA.
| | | | | | | | | | | | | | | | | | | | | | - Stuart H Isaacson
- Parkinson's Disease and Movement Disorders Center, Boca Raton, FL, USA
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