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Chapman B, Hellkamp AS, Thomas LE, Albert NM, Butler J, Patterson JH, Hernandez AF, Williams FB, Shen X, Spertus JA, Fonarow GC, DeVore AD. Angiotensin Receptor Neprilysin Inhibition and Associated Outcomes by Race and Ethnicity in Patients With Heart Failure With Reduced Ejection Fraction: Data From CHAMP-HF. J Am Heart Assoc 2022; 11:e022889. [PMID: 35722989 PMCID: PMC9238653 DOI: 10.1161/jaha.121.022889] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2022] [Accepted: 03/29/2022] [Indexed: 12/11/2022]
Abstract
Background There are limited data on the use of angiotensin receptor neprilysin inhibitors (ARNIs) in minority populations with heart failure (HF) with reduced ejection fraction. We used data from the CHAMP-HF (Change the Management of Patients With Heart Failure) registry to evaluate ARNI initiation and associated changes in health status and clinical outcomes across different races and ethnicities. Methods and Results CHAMP-HF was a prospective, observational registry of US outpatients with chronic HF with reduced ejection fraction. We compared patients starting ARNI with patients not starting ARNI using a propensity-matched analysis. Patients were grouped as Hispanic, non-Hispanic Black, non-Hispanic White, or non-Hispanic other individuals, where "non-Hispanic other" consists of all patients who did not identify as Hispanic, Black, or White. Health status was assessed using the 12-item Kansas City Cardiomyopathy Questionnaire. Outcomes were analyzed with multivariable models that included race and ethnicity, ARNI initiation, and an interaction term between race and ethnicity and ARNI initiation. Cox proportional hazards models were used for death/HF hospitalization, and multiple regression was used for change in Kansas City Cardiomyopathy Questionnaire score. The analysis included 1516 patients, with 758 patients in each group (ARNI and no ARNI). Changes in Kansas City Cardiomyopathy Questionnaire score after ARNI initiation were similar among all race and ethnicity groups (mean [SD], non-Hispanic White individuals, 3.5 [19.0]; non-Hispanic Black individuals, 2.0 [17.0]; non-Hispanic other individuals, 5.5 [20.3]; and Hispanic individuals, 3.2 [20.1]), with no statistically significant interaction between race and ethnicity and ARNI initiation (P=0.21). There was similarly no statistically significant interaction between race and ethnicity and ARNI initiation for HF hospitalization (P=0.82) or all-cause mortality (P=0.92). Conclusions In a large registry of outpatients with HF with reduced ejection fraction, the association between ARNI initiation and outcomes did not differ by race and ethnicity. These data support the use of ARNI therapy for chronic HF with reduced ejection fraction irrespective of race and ethnicity.
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Affiliation(s)
- Brittany Chapman
- Department of MedicineDuke University School of MedicineDurhamNC
| | | | | | | | - Javed Butler
- University of Mississippi Medical CenterJacksonMS
| | | | - Adrian F. Hernandez
- Department of MedicineDuke University School of MedicineDurhamNC
- Duke Clinical Research InstituteDurhamNC
| | | | - Xian Shen
- Novartis Pharmaceuticals CorporationEast HanoverNJ
| | - John A. Spertus
- Saint Luke’s Mid America Heart Institute and the University of Missouri–Kansas CityKansas CityMO
| | - Gregg C. Fonarow
- Ahmanson‐UCLA Cardiomyopathy CenterRonald Reagan UCLA Medical CenterLos AngelesCA
| | - Adam D. DeVore
- Department of MedicineDuke University School of MedicineDurhamNC
- Duke Clinical Research InstituteDurhamNC
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Mohammed M, Hill CL, Thomas L, Nassif M, DeVore AD, Albert NM, Butler J, Patterson JH, Williams FB, Hernandez A, Fonarow GC, Spertus JA. Poor Medication Adherence Is Associated With Worse Health Status In Heart Failure With Reduced Ejection Fraction. J Card Fail 2022. [DOI: 10.1016/j.cardfail.2022.03.304] [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] [Indexed: 11/30/2022]
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DeVore AD, Hellkamp AS, Thomas L, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Shen X, Hernandez AF, Fonarow GC. The Association of Improvement in Left Ventricular Ejection Fraction with Outcomes in Patients with Heart Failure with Reduced Ejection Fraction: Data from CHAMP-HF. Eur J Heart Fail 2022; 24:762-770. [PMID: 35293088 DOI: 10.1002/ejhf.2486] [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] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Revised: 03/08/2022] [Accepted: 03/10/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS We assessed for an association between improvements in left ventricular ejection fraction (LVEF) and future outcomes, including health status, in routine clinical practice. METHODS AND RESULTS CHAMP-HF was a registry of outpatients with heart failure (HF) and LVEF <40%. Enrolled participants completed the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) at regular intervals and were followed as part of routine care. We assessed for associations between improvements in LVEF (>10%) over time and concurrent changes in KCCQ-12, as well as the subsequent risk of poor outcomes. We included 2092 participants in the study. They had the following characteristics: median age 67 years (25th , 75th percentile 58, 75), 29% female, median duration of HF 2.7 years (0.6, 6.8), and median baseline LVEF 30% (23, 35). Of the study participants, 689 (34%) had a >10% absolute improvement in LVEF. Participants with an LVEF improvement also had an improvement in KCCQ-12 overall summary score compared with participants without an LVEF improvement (+7.6 vs +3.5, adjusted effect estimate +4.1 [95% CI 2.3 to 5.7]). Similarly, subsequent all-cause death or HF hospitalization occurred in 12% in the LVEF improvement group vs 25% in the group without an LVEF improvement (adjusted HR 0.50, 95% CI 0.41 to 0.61). CONCLUSION In a large cohort of outpatients with chronic HF, improvements in LVEF were associated with improved health status and a reduced risk for future clinical events. These data underscore the importance of improvement in LVEF as a treatment target for medical interventions for patients with chronic HF.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO, USA
| | | | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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DeVore AD, Hill CL, Thomas LE, Albert NM, Butler J, Patterson JH, Hernandez AF, Williams FB, Shen X, Spertus JA, Fonarow GC. Identifying patients at increased risk for poor outcomes from heart failure with reduced ejection fraction: the PROMPT-HF risk model. ESC Heart Fail 2021; 9:178-185. [PMID: 34791838 PMCID: PMC8787961 DOI: 10.1002/ehf2.13709] [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: 08/09/2021] [Revised: 10/04/2021] [Accepted: 10/29/2021] [Indexed: 01/14/2023] Open
Abstract
Aims We aimed to develop a risk prediction tool that incorporated both clinical events and worsening health status for patients with heart failure (HF) with reduced ejection fraction (HFrEF). Identifying patients with HFrEF at increased risk of a poor outcome may enable proactive interventions that improve outcomes. Methods and results We used data from a longitudinal HF registry, CHAMP‐HF, to develop a risk prediction tool for poor outcomes over the next 6 months. A poor outcome was defined as death, an HF hospitalization, or a ≥20‐point decrease (or decrease below 25) in 12‐item Kansas City Cardiomyopathy Questionnaire (KCCQ‐12) overall summary score. Among 4546 patients in CHAMP‐HF, 1066 (23%) experienced a poor outcome within 6 months (1.3% death, 11% HF hospitalization, and 11% change in KCCQ‐12). The model demonstrated moderate discrimination (c‐index = 0.65) and excellent calibration with observed data. The following variables were associated with a poor outcome: age, race, education, New York Heart Association class, baseline KCCQ‐12, atrial fibrillation, coronary disease, diabetes, chronic kidney disease, smoking, prior HF hospitalization, and systolic blood pressure. We also created a simplified model with a 0–10 score using six variables (New York Heart Association class, KCCQ‐12, coronary disease, chronic kidney disease, prior HF hospitalization, and systolic blood pressure) with similar discrimination (c‐index = 0.63). Patients scoring 0–3 were considered low risk (event rate <20%), 4–6 were considered intermediate risk (event rate 20–40%), and 7–10 were considered high risk (event rate >40%). Conclusions The PROMPT‐HF risk model can identify outpatients with HFrEF at increased risk of poor outcomes, including clinical events and health status deterioration. With further validation, this model may help inform therapeutic decision making.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, 200 Morris Street, Office 6318, Durham, NC, 27701, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Claude Larry Hill
- Duke Clinical Research Institute, 200 Morris Street, Office 6318, Durham, NC, 27701, USA
| | - Laine E Thomas
- Duke Clinical Research Institute, 200 Morris Street, Office 6318, Durham, NC, 27701, USA
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, 200 Morris Street, Office 6318, Durham, NC, 27701, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | | | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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Khan MS, Greene SJ, Hellkamp AS, DeVore AD, Shen X, Albert NM, Patterson JH, Spertus JA, Thomas LE, Williams FB, Hernandez AF, Fonarow GC, Butler J. Diuretic Changes, Health Care Resource Utilization, and Clinical Outcomes for Heart Failure With Reduced Ejection Fraction: From the Change the Management of Patients With Heart Failure Registry. Circ Heart Fail 2021; 14:e008351. [PMID: 34674536 DOI: 10.1161/circheartfailure.121.008351] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diuretics are a mainstay therapy for the symptomatic treatment of heart failure. However, in contemporary US outpatient practice, the degree to which diuretic dosing changes over time and the associations with clinical outcomes and health care resource utilization are unknown. METHODS Among 3426 US outpatients with chronic heart failure with reduced ejection fraction in the Change the Management of Patients with Heart Failure registry with complete medication data and who were prescribed a loop diuretic, diuretic dose increase was defined as: (1) change to a total daily dose higher than their previous total daily dose, (2) addition of metolazone to the regimen, (3) change from furosemide to either bumetanide or torsemide, and the change persists for at least 7 days. Adjusted hazard ratios or rate ratios along with 95% CIs were reported for clinical outcomes among patients with an increase in oral diuretic dose versus no increase in diuretic dose. RESULTS Overall, 796 (23%) had a diuretic dose increase (18 episodes per 100 patient-years). The proportion of patients with dyspnea at rest (38% versus 26%), dyspnea at exertion (79% versus 67%), orthopnea (32% versus 21%), edema (60% versus 43%), and weight gain (40% versus 23%) were significantly (all P <0.001) higher in the diuretic increase group. Baseline angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (hazard ratio, 0.75 [95% CI, 0.65-0.87]) use were associated with lower likelihood of diuretic increase over time. Patients with a diuretic dose increase had a significantly higher number of heart failure hospitalizations (rate ratio, 2.53 [95% CI, 2.10-3.05]), emergency department visits (rate ratio, 1.84 [95% CI, 1.56-2.17]), and home health visits (rate ratio, 1.88 [95% CI, 1.39-2.54]), but not all-cause mortality (hazard ratio, 1.10 [95% CI, 0.89-1.36]). Similarly, greater furosemide dose equivalent increases were associated with greater resource utilization but not with mortality, compared with smaller increases. CONCLUSIONS In this contemporary US registry, 1 in 4 patients with heart failure with reduced ejection fraction had outpatient escalation of diuretic therapy over longitudinal follow-up, and these patients were more likely to have sign/symptoms of congestion. Outpatient diuretic dose escalation of any magnitude was associated with heart failure hospitalizations and resource utilization, but not all-cause mortality.
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Affiliation(s)
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.).,Department of Biostatistics and Bioinformatics (A.S.H., L.E.T.), Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (X.S.)
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, OH (N.M.A.)
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City (J.A.S.)
| | - Laine E Thomas
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.).,Department of Biostatistics and Bioinformatics (A.S.H., L.E.T.), Duke University School of Medicine, Durham, NC
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson (J.B.)
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Greene SJ, Butler J, Hellkamp AS, Spertus JA, Vaduganathan M, Devore AD, Albert NM, Patterson JH, Thomas L, Williams FB, Hernandez AF, Fonarow GC. Comparative Effectiveness of Dosing of Medical Therapy for Heart Failure: From the CHAMP-HF Registry. J Card Fail 2021; 28:370-384. [PMID: 34793971 DOI: 10.1016/j.cardfail.2021.08.023] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Revised: 07/30/2021] [Accepted: 08/15/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND The comparative effectiveness of differing doses of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) on clinical and patient-reported outcomes in US clinical practice is unknown. This study sought to characterize associations between dosing of GDMT and outcomes for patients with HFrEF in U.S. clinical practice METHODS: : This analysis included 4,832 US outpatients with chronic HFrEF across 150 practices in the CHAMP-HF registry with no contraindication and available dosing data for at least 1 GDMT at baseline. Baseline dosing of angiotensin-converting enzyme (ACEI)/ angiotensin II receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) therapies were examined. For each medication class, multivariable models assessed associations between medication dosing and clinical outcomes over 24 months (all-cause mortality, HF hospitalization) and patient-reported outcomes at 12 months (change in Kansas City Cardiomyopathy Questionnaire Overall Summary Score [KCCQ-OS]). RESULTS After adjustment, compared with target dosing, lower dosing was associated with higher all-cause mortality for ACEI/ARB/ARNI (50% to <100% target dose, HR 1.16 [95% CI 0.87-1.55]; <50% target dose, HR 1.37 [95% CI 1.05-1.79]; none, HR 1.75 [95% CI 1.32-2.34; overall p<0.001) and beta-blocker (50% to <100% target dose, HR 1.30 [95% CI 1.00-1.69]; <50% target dose, HR 1.41 [95% CI 1.11-1.79; none, HR 1.24 [95% CI 0.92-1.67]; overall p=0.042). Lower dosing of ACEI/ARB/ARNI was independently associated with higher risk of HF hospitalization (50% to <100% target dose, HR 1.08 [95% CI 0.90-1.30]; <50% target dose, HR 1.23 [1.04-1.47]; none, HR 1.29 [1.04-1.60]; overall p=0.046), but beta-blocker dosing was not (overall p=0.085). Target dosing of MRA was not associated with risk of mortality or HF hospitalization. For each GDMT, compared with target dosing, lower dosing was not associated with change in KCCQ-OS at 12 months, with potential exception of worsening KCCQ-OS with lower dosing of ACEI/ARB/ARNI. CONCLUSIONS In this contemporary US outpatient HFrEF registry, target dosing of ACEI/ARB/ARNI and beta-blocker therapy was associated with reduced mortality, and variably associated with HF hospitalization and patient-reported outcomes. MRA dosing was not associated with outcomes. The totality of these findings support the benefits of target dosing of GDMT in routine practice, as tolerated, with unmeasured differences between patients receiving differing dosages potentially explaining differing results seen here compared with randomized clinical trials.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Adam D Devore
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Nancy M Albert
- Nursing Institute and Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, California.
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Vaduganathan M, Fonarow GC, Greene SJ, Devore AD, Albert NM, Duffy CI, Hill CL, Patterson JH, Spertus JA, Thomas LE, Williams FB, Hernandez AF, Butler J. Treatment Persistence of Renin-Angiotensin-Aldosterone-System Inhibitors Over Time in Heart Failure with Reduced Ejection Fraction. J Card Fail 2021; 28:191-201. [PMID: 34428591 DOI: 10.1016/j.cardfail.2021.08.008] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Revised: 08/03/2021] [Accepted: 08/04/2021] [Indexed: 12/29/2022]
Abstract
BACKGROUND Clinical practice guidelines support sustained use of renin-angiotensin-aldosterone-system (RAAS) inhibitors over time in heart failure with reduced ejection fraction, yet few data are available regarding the frequency, timing or predictors of early treatment discontinuation in clinical practice. METHODS Among prevalent or new users of angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs), angiotensin receptor-neprilysin inhibitors (ARNIs), and mineralocorticoid receptor antagonists (MRAs) in the CHAMP-HF (Change the Management of Patients with Heart Failure) registry, we estimated the frequency and independent predictors of treatment discontinuation during follow-up. Among sites with > 5 users of a given RAAS inhibitor, we evaluated practice variation in the proportion of patients with treatment discontinuation. RESULTS Over median follow-up of 18 months, frequency of drug discontinuation of ACEis/ARBs, ARNIs and MRAs was 12.7% (444 of 3509 users), 10.4% (140 of 1352 users), and 20.4% (435 of 2129 users), respectively. An additional, 149 (11.0%) of ARNI users were switched to ACEis/ARBs, and 447 (12.7%) of ACEi/ARB users were switched to ARNIs during follow-up. Across sites, the median proportion of discontinuation of ACEis/ARBs, ARNIs and MRAs was 12.5% (25th-75th percentiles 6.9%-18.9%), 18.8% (25th-75th percentiles 12.5%-28.6%), and 19.6% (25th-75th percentiles 10.7%-27.0%), respectively. Chronic kidney disease was the only independent predictor of increased risk of discontinuation of each of the RAAS inhibitor classes (P < 0.02 for all). Higher Kansas City Cardiomyopathy Questionnaire overall summary scores independently predicted lower risk of discontinuation of ACEis/ARBs and ARNIs (both P < 0.001) but not of MRAs. Investigator clinical experience was predictive of lower risks of discontinuation of ACEis/ARBs and MRAs (P < 0.02) but not of ARNIs. All other independent predictors of discontinuation were unique to individual therapeutic classes. CONCLUSIONS One in 10 patients discontinue ACEis/ARBs or ARNIs, and 1 in 5 discontinue MRAs in routine clinical practice of heart failure with reduced ejection fraction. Unique patient-level and clinician/practice-level factors are associated with premature discontinuation of individual RAAS inhibitors, which may help to guide structured efforts to promote treatment persistence in clinical care.
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Affiliation(s)
- Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, MA.
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA
| | - Stephen J Greene
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Adam D Devore
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, OH
| | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - John A Spertus
- Saint Luke's Mid-America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO
| | - Laine E Thomas
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS.
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Albert NM, Tyson RJ, Hill CL, DeVore AD, Spertus JA, Duffy C, Butler J, Patterson JH, Hernandez AF, Williams FB, Thomas L, Fonarow GC. Variation in use and dosing escalation of renin angiotensin system, mineralocorticoid receptor antagonist, angiotensin receptor neprilysin inhibitor and beta-blocker therapies in heart failure and reduced ejection fraction: Association of comorbidities. Am Heart J 2021; 235:82-96. [PMID: 33497697 DOI: 10.1016/j.ahj.2021.01.017] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Accepted: 01/21/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND In patients with heart failure and reduced ejection fraction (HFrEF), angiotensin converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), or angiotensin receptor neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists (MRA), and beta-blockers (βB) are underutilized. It is unknown if patients with and without comorbidities have similar ACEi/ARB/ARNI, MRA, and βB prescription patterns. METHODS Baseline data from the CHAMP-HF (Change the Management of Patients with Heart Failure) registry were categorized by history of atrial fibrillation, asthma/chronic lung disease, obstructive sleep apnea, and depression. Using multivariate hierarchical logistic models, associations of ACEi/ARB/ARNI, MRA and βB medication use and dose by comorbidities were assessed after adjusting for patient characteristics. RESULTS Of 4,815 HFrEF patients from 152 CHAMP-HF sites, ACEi/ARB/ARNI use was lower in patients with more comorbidities, and generally, MRA use was low and βB use was high. In adjusted analyses, patients with HFrEF and comorbid obstructive sleep apnea, vs. without, were more likely to be prescribed ARNI (OR [95% CI]: 1.25 [1.00, 1.55]); P = .047 and MRA (1.31 [1.11, 1.55]); P = .002 and less likely to be prescribed ACEi (0.74 [0.63, 0.88]); P < .001. Patients with atrial fibrillation, vs. without, were less likely to receive ACEi/ARB (0.82 [0.71, 0.95]); P = .006 and any study medication (0.81 [0.67, 0.97]); P = .020. Comorbid lung disease and history of depression were not associated with HFrEF prescriptions. CONCLUSIONS Renin-angiotensin-aldosterone blockade therapy prescription and dose varied by comorbidity status, but βB therapy did not. In quality efforts, leaders need to consider use and dosing of prescriptions in light of prevalent comorbidities.
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Greene SJ, Butler J, Spertus JA, Hellkamp AS, Vaduganathan M, DeVore AD, Albert NM, Duffy CI, Patterson JH, Thomas L, Williams FB, Hernandez AF, Fonarow GC. Comparison of New York Heart Association Class and Patient-Reported Outcomes for Heart Failure With Reduced Ejection Fraction. JAMA Cardiol 2021; 6:522-531. [PMID: 33760037 DOI: 10.1001/jamacardio.2021.0372] [Citation(s) in RCA: 55] [Impact Index Per Article: 18.3] [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: 01/10/2023]
Abstract
Importance It is unclear how New York Heart Association (NYHA) functional class compares with patient-reported outcomes among patients with heart failure (HF) in contemporary US clinical practice. Objective To characterize longitudinal changes and concordance between NYHA class and the Kansas City Cardiomyopathy Questionnaire Overall Summary Score (KCCQ-OS), and their associations with clinical outcomes. Design, Setting, and Participants This cohort study included 2872 US outpatients with chronic HF with reduced ejection fraction across 145 practices enrolled in the CHAMP-HF registry between December 2015 and October 2017. All patients had complete NYHA class and KCCQ-OS data at baseline and 12 months. Longitudinal changes and correlations between the 2 measure were examined. Multivariable models landmarked at 12 months evaluated associations between improvement in NYHA and KCCQ-OS from baseline to 12 months with clinical outcomes occurring from months 12 through 24. Statistical analyses were performed from March to August 2020. Exposure Change in health status, as defined by 12-month change in NYHA class or KCCQ-OS. Main Outcomes and Measures All-cause mortality, HF hospitalization, and mortality or HF hospitalization. Results In total, 2872 patients were included in this analysis (median [interquartile range] age, 68 [59-75] years; 872 [30.4%] were women; and 2156 [75.1%] were of White race). At baseline, 312 patients (10.9%) were NYHA class I, 1710 patients (59.5%) were class II, 804 patients (28.0%) were class III, and 46 patients (1.6%) were class IV. For KCCQ-OS, 1131 patients (39.4%) scored 75 to 100 (best health status), 967 patients (33.7%) scored 50 to 74, 612 patients (21.3%) scored 25 to 49, and 162 patients (5.6%) scored 0 to 24 (worst health status). At 12 months, 1002 patients (34.9%) had a change in NYHA class (599 [20.9%] with improvement; 403 [14.0%] with worsening) and 2158 patients (75.1%) had a change of 5 or more points in KCCQ-OS (1388 [48.3%] with improvement; 770 [26.8%] with worsening). The most common trajectory for NYHA class was no change (1870 [65.1%]), and the most common trajectory for KCCQ-OS was an improvement of at least 10 points (1047 [36.5%]). After adjustment, improvement in NYHA class was not associated with subsequent clinical outcomes, whereas an improvement of 5 or more points in KCCQ-OS was independently associated with decreased mortality (hazard ratio, 0.59; 95% CI, 0.44-0.80; P < .001) and mortality or HF hospitalization (hazard ratio, 0.73; 95% CI, 0.59-0.89; P = .002). Conclusions and Relevance Findings of this cohort study suggest that, in contemporary US clinical practice, compared with NYHA class, KCCQ-OS is more sensitive to clinically meaningful changes in health status over time. Changes in KCCQ-OS may have more prognostic value than changes in NYHA class.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City
| | | | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Nancy M Albert
- Nursing Institute and Heart, Vascular and Thoracic Institute, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina.,Assistant Editor for Statistics, JAMA Cardiology
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.,Associate Editor, JAMA Cardiology
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles.,Associate Editor for Health Care Quality and Guidelines, JAMA Cardiology
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10
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Thomas M, Khariton Y, Fonarow GC, Arnold SV, Hill L, Nassif ME, Chan PS, Butler J, Thomas L, DeVore AD, Hernandez AF, Albert NM, Patterson JH, Williams FB, Spertus JA. Association between sacubitril/valsartan initiation and real-world health status trajectories over 18 months in heart failure with reduced ejection fraction. ESC Heart Fail 2021; 8:2670-2678. [PMID: 33932120 PMCID: PMC8318450 DOI: 10.1002/ehf2.13298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [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: 01/13/2021] [Revised: 02/09/2021] [Accepted: 02/24/2021] [Indexed: 12/11/2022] Open
Abstract
Aims Improving the health status (symptoms, function, and quality of life) of patients with heart failure with reduced ejection fraction (HFrEF) is a primary treatment goal. Angiotensin receptor neprilysin inhibitors (ARNI) improve short‐term health status in clinical practice, but the sustainability of these improvements is unknown. Methods and results In CHAMP‐HF, a multicentre observational study of outpatients with HFrEF, patients initiated on ARNI were propensity score matched 1:2 to patients not using ARNI with Cox regression modelling time to ARNI initiation, adjusted for sociodemographic and clinical variables, medical history, medications, and baseline Kansas City Cardiomyopathy Questionnaire (KCCQ) scores. Repeated measures models for the overall KCCQ score and each domain compared the health status trajectories of patients initiated on ARNI vs. not. Among 3930 participants, 746 (19.0%) began ARNI, of whom 576 were matched to 1152 non‐ARNI patients. Prior to matching, participants initiated on ARNI were younger, non‐Hispanic, had lower EFs, more commonly had a history of ventricular arrhythmia, were less likely to be taking an ACEI/ARB, and more likely to be treated with beta‐blockers and mineralocorticoid receptor antagonists. There were no differences after matching. In the matched cohort, participants initiated on ARNI experienced improved health status by 3 months that persisted through 12 months [KCCQ Overall Summary Score (OSS) = 73.4 vs. 70.8; P < 0.001], with the largest benefit observed in the KCCQ Quality of Life domain (68.7 vs. 64.7; P < 0.001). Similar health status benefits were noted through 18 months (KCCQ‐OSS = 73.9 vs. 71.3; P < 0.001). A responder analysis showed that 12 patients would need to be initiated on ARNI for one to experience at least a large improvement (≥10 points) in health status benefit at 12 months. Conclusions In outpatient practice, ARNI therapy was associated with improved health status by 3 months and continued to 18 months after initiating therapy.
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Affiliation(s)
- Merrill Thomas
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Yevgeniy Khariton
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Larry Hill
- Duke Clinical Research Institute, Durham, NC, USA
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | - Paul S Chan
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
| | | | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Department of Medicine, and the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Department of Medicine, and the Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO, 64111, USA
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11
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Srivastava PK, DeVore AD, Hellkamp AS, Thomas L, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Duffy CI, Hernandez AF, Fonarow GC. Heart Failure Hospitalization and Guideline-Directed Prescribing Patterns Among Heart Failure With Reduced Ejection Fraction Patients. JACC Heart Fail 2020; 9:28-38. [PMID: 33309579 DOI: 10.1016/j.jchf.2020.08.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The authors sought to evaluate the association of heart failure hospitalization (HFH) with guideline-directed medical therapy (GDMT) prescribing patterns among patients with heart failure with reduced ejection fraction (HFrEF). BACKGROUND HFH represents an important opportunity to titrate GDMT among patients with HFrEF. METHODS The CHAMP-HF (Change the Management of Patients With Heart Failure) registry is a prospective registry of adults with HFrEF (ejection fraction ≤40%). Using data from the CHAMP-HF registry (N = 4,365), adjusted time-to-event models were created to study the association of HFH with GDMT prescribing patterns. RESULTS HFH (compared with no HFH) was positively associated with initiation of angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), angiotensin receptor-neprilysin inhibitor, beta-blocker, and mineralocorticoid receptor antagonist (MRA). HFH positively associated with dose escalation of ACE inhibitor/ARB (probability ratio: 1.71, 95% confidence interval [CI]: 1.36 to 2.16) and MRA (probability ratio: 8.71, 95% CI: 4.19 to 18.10). In those on prior therapy, HFH was associated with discontinuation and de-escalation of all classes of GDMT. ACE inhibitor/ARB, angiotensin receptor-neprilysin inhibitor, beta-blocker, and MRA de-escalation/discontinuation after HFH was associated with increased risk of all-cause mortality with hazard ratios of 3.82 (95% CI: 2.42 to 6.03), 4.76 (95% CI: 2.06 to 11.03), 2.94 (95% CI: 2.04 to 4.25), and 4.81 (95% CI: 2.61 to 8.87), respectively. CONCLUSIONS HFH positively associated with changes in GDMT, including initiation, dose escalation, discontinuation, and dose de-escalation. De-escalation/discontinuation of GDMT after HFH associated with increased risk of all-cause mortality. Educational endeavors are needed to ensure GDMT is not inappropriately held in the setting of HFH. For those in whom GDMT must be held/decreased, improvement tools at discharge and post-discharge titration clinics may help ensure lifesaving GDMT regimens remain optimized.
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Affiliation(s)
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Nancy M Albert
- Office of Nursing Research and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA.
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12
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Thomas M, Khariton Y, Fonarow GC, Hill CL, Thomas L, Nassif ME, Arnold S, Chan PC, DeVore AD, Albert NM, Butler J, Patterson JH, Williams FB, Hernandez A, Spertus JA. Association Between Sacubitril/valsartan Initiation And Real-world Health Status Trajectories Over 1 Year In Heart Failure With Reduced Ejection Fraction. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.116] [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] [Indexed: 11/16/2022]
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13
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DeVore AD, Hellkamp AS, Thomas L, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Duffy CI, Hernandez AF, Fonarow GC. Improvement in Left Ventricular Ejection Fraction in Outpatients With Heart Failure With Reduced Ejection Fraction: Data From CHAMP-HF. Circ Heart Fail 2020; 13:e006833. [PMID: 32580657 DOI: 10.1161/circheartfailure.119.006833] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Among patients with heart failure (HF) with reduced ejection fraction (EF), improvements in left ventricular EF (LVEF) are associated with better outcomes and remain an important treatment goal. Patient factors associated with LVEF improvement in routine clinical practice have not been clearly defined. METHODS CHAMP-HF (Change the Management of Patients with Heart Failure) is a prospective registry of outpatients with HF with reduced EF. Assessments of LVEF are recorded when performed for routine care. We analyzed patients with both baseline and ≥1 follow-up LVEF assessments to describe factors associated with LVEF improvement. RESULTS In CHAMP-HF, 2623 patients had a baseline and follow-up LVEF assessment. The median age was 67 (interquartile range, 58-75) years, 40% had an ischemic cardiomyopathy, and median HF duration was 2.8 years (0.7-6.8). Median LVEF was 30% (23-35), and median change on follow-up was 4% (-2 to -13); 19% of patients had a decrease in LVEF, 31% had no change, 49% had a ≥5% increase, and 34% had a ≥10% increase. In a multivariable model, the following factors were associated with ≥5% LVEF increase: shorter HF duration (odds ratio [OR], 1.21 [95% CI, 1.17-1.25]), no implantable cardioverter defibrillator (OR, 1.46 [95% CI, 1.34-1.55]), lower LVEF (OR, 1.15 [95% CI, 1.10-1.19]), nonischemic cardiomyopathy (OR, 1.24 [95% CI, 1.09-1.36]), and no coronary disease (OR, 1.20 [95% CI, 1.03-1.35]). CONCLUSIONS In a large cohort of outpatients with chronic HF with reduced EF, improvements in LVEF were common. Common baseline cardiac characteristics identified a population that was more likely to respond over time. These data may inform clinical decision making and should be the basis for future research on myocardial recovery.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.)
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.)
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO (J.A.S.)
| | | | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (C.I.D.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (A.D.D., A.S.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.)
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14
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Vaduganathan M, Fonarow GC, Greene SJ, DeVore AD, Kavati A, Sikirica S, Albert NM, Duffy CI, Hill CL, Patterson JH, Spertus JA, Thomas LE, Williams FB, Hernandez AF, Butler J. Contemporary Treatment Patterns and Clinical Outcomes of Comorbid Diabetes Mellitus and HFrEF: The CHAMP-HF Registry. JACC Heart Fail 2020; 8:469-480. [PMID: 32387066 DOI: 10.1016/j.jchf.2019.12.015] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/23/2019] [Accepted: 12/24/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES The purpose of this study was to characterize the clinical profile, treatment patterns, and clinical outcomes of patients with comorbid diabetes mellitus (DM) and heart failure with reduced ejection fraction (HFrEF) in a contemporary, real-world U.S. outpatient registry in the context of evolving treatment strategies. BACKGROUND Specific antihyperglycemic classes have differential risks and benefits with respect to HF. Limited data are available evaluating contemporary treatment patterns and outcomes of patients with comorbid DM and HFrEF. METHODS Among 4,970 patients with chronic HFrEF (≤40%) across 152 U.S. sites in the CHAMP-HF prospective, observational registry (2015 to 2017), we examined therapies and clinical outcomes by DM status. RESULTS Median age was 68 (58 to 75) years of age; 29% were women; 73.5% were white; and 64% had coronary artery disease. Overall, 42% (n = 2,085) had comorbid DM with a median hemoglobin A1c (HbA1c) level of 7.2% (interquartile range [IQR]: 6.4% to 8.3%). One-fourth of DM patients (24%) were not treated with an antihyperglycemic therapy. Most patients with DM were taking 1 (46%) or 2 (23%) antihyperglycemic therapies: metformin (40%); insulin (33%); sulfonylureas (24%); dipeptidyl peptidase-4 inhibitors (10%); glucagon-like peptide (GLP)-1 receptor agonists (4%); sodium-glucose cotransporter (SGLT)-2 inhibitors (2%); and thiazolidinediones (2%). Among patients with DM, 62%, 16%, 80%, and 33.5% were receiving any angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blockers (ARBs), angiotensin receptor-neprilysin inhibitor (ARNI), β-blockers, or mineralocorticoid receptor antagonists (MRAs) at baseline, respectively. Among patients without DM, corresponding baseline rates were 65%, 15%, 80%, and 37%, respectively. Patients with or without DM were infrequently treated with guideline-directed HFrEF therapies at target doses (≤27% across classes). During median 15-month follow-up, patients with DM experienced higher rates of all-cause mortality or HF hospitalization (30% vs. 23%, respectively), independent of 11 pre-specified covariates (adjusted hazard ratio: 1.35 (95% confidence interval: 1.21 to 1.52); p < 0.001). CONCLUSIONS Despite higher risk-adjusted clinical event rates in patients with comorbid HFrEF and DM, guideline-directed medical therapies for both disease states are incomplete and represent an important target for quality improvement through multidisciplinary care pathways.
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Affiliation(s)
- Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts. https://twitter.com/@mvaduganathan
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, California. https://twitter.com/@gcfmd
| | - Stephen J Greene
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina. https://twitter.com/@SJGreene_md
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina. https://twitter.com/@_adevore
| | - Abhishek Kavati
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Slaven Sikirica
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri. https://twitter.com/@jspertus
| | - Laine E Thomas
- Duke Clinical Research Institute and Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina. https://twitter.com/@texhern
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
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Giblin EM, Adams KF, Hill L, Fonarow GC, Williams FB, Sharma PP, Albert NM, Butler J, DeVore AD, Duffy CI, Hernandez AF, McCague K, Spertus JA, Thomas L, Patterson JH. Comparison of Hydralazine/Nitrate and Angiotensin Receptor Neprilysin Inhibitor Use Among Black Versus Nonblack Americans With Heart Failure and Reduced Ejection Fraction (from CHAMP-HF). Am J Cardiol 2019; 124:1900-1906. [PMID: 31679641 DOI: 10.1016/j.amjcard.2019.09.020] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2019] [Revised: 09/06/2019] [Accepted: 09/09/2019] [Indexed: 12/21/2022]
Abstract
Underuse of hydralazine/nitrate (HYD/NIT) in black patients with heart failure and reduced ejection fraction (HFrEF) has been previously described, but whether this important treatment gap persists in contemporary practice is unknown. Sacubitril/valsartan has become a part of guideline-directed medical therapy for HFrEF but data on utilization of this therapy in black patients is lacking. This study addressed these issues by assessing the frequency of HYD/NIT and sacubitril/valsartan use in black patients with HFrEF in the Change the Management of Patients with Heart Failure Registry, a multicenter cohort study. The association of race with utilization rates of these agents was also evaluated. Clinical and medication data at baseline and during 12 months of follow-up from black and nonblack registry patients without documented contraindications or intolerance to the medications of interest were analyzed. Data were available from December 2015 to October 2017, in 4,848 HFrEF patients, of whom 853 were black (18%) and 3995 were nonblack. Black patients were younger, more likely to be female, and had lower ejection fractions compared with nonblacks. Only 11% of black patients were receiving HYD/NIT therapy at baseline and 13% at 1 year. The percentage of black patients treated at baseline with sacubitril/valsartan was also low at 18% and remained unchanged at 1 year. After adjustment for covariates, race was independently associated with HYD/NIT use (odds ratio 8.32; 95% confidence interval 6.12 to 11.3; p < 0.0001), but not for sacubitril/valsartan. In conclusion, study findings demonstrate a marked persistent treatment gap for HYD/NIT and similar poor utilization of sacubitril/valsartan in black patients with HFrEF despite current guideline recommendations.
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Affiliation(s)
- Erika M Giblin
- Department of Pharmacy, Vidant Medical Center, Greenville, North Carolina; Department of Pharmacy Practice, Campbell University College of Pharmacy and Health Sciences, Buies Creek, North Carolina
| | - Kirkwood F Adams
- Department of Medicine, University of North Carolina, Chapel Hill, North Carolina
| | - Larry Hill
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - Gregg C Fonarow
- Department of Medicine, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | | | | | - Nancy M Albert
- Office of Nursing Research and Innovation, Cleveland Clinic Health System, Cleveland, Ohio
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Adam D DeVore
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Adrian F Hernandez
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - John A Spertus
- Department of Medicine, Washington School of Medicine in St. Louis, St. Louis, Missouri
| | - Laine Thomas
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina
| | - J Herbert Patterson
- Department of Pharmacotherapy and Experimental Therapeutics, University of North Carolina Eshelman School of Pharmacy, Chapel Hill, North Carolina.
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Khariton Y, Fonarow GC, Arnold SV, Hellkamp A, Nassif ME, Sharma PP, Butler J, Thomas L, Duffy CI, DeVore AD, Albert NM, Patterson JH, Williams FB, McCague K, Spertus JA. Association Between Sacubitril/Valsartan Initiation and Health Status Outcomes in Heart Failure With Reduced Ejection Fraction. JACC Heart Fail 2019; 7:933-941. [PMID: 31521679 DOI: 10.1016/j.jchf.2019.05.016] [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] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 05/28/2019] [Accepted: 05/29/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study sought to describe the short-term health status benefits of angiotensin-neprilysin inhibitor (ARNI) therapy in patients with heart failure and reduced ejection fraction (HFrEF). BACKGROUND Although therapy with sacubitril/valsartan, a neprilysin inhibitor, improved patients' health status (compared with enalapril) at 8 months in the PARADIGM-HF (Prospective Comparison of ARNI with ACE inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) study, the early impact of ARNI on patients' symptoms, functions, and quality of life is unknown. METHODS Health status was assessed by using the 12-item Kansas City Cardiomyopathy Questionnaire (KCCQ) in 3,918 outpatients with HFrEF and left ventricular ejection fraction ≤40% across 140 U.S. centers in the CHAMP-HF (Change the Management of Patients with Heart Failure) registry. ARNI therapy was initiated in 508 patients who were matched 1:2 to 1,016 patients who were not initiated on ARNI (no-ARNI), using a nonparsimonious time-dependent propensity score (6 sociodemographic factors, 23 clinical characteristics), prior KCCQ overall summary (KCCQ-OS) score, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker status. RESULTS Multivariate linear regression demonstrated a greater mean improvement in KCCQ-OS in patients initiated on ARNI therapy (5.3 ± 19 vs. 2.5 ± 17.4, respectively; p < 0.001) over a median (interquartile range [IQR]) of 57 (32 to 104) days. The proportions of ARNI versus no-ARNI groups with ≥10-point (large) and ≥20-point (very large) improvements in KCCQ-OS were 32.7% versus 26.9%, respectively, and 20.5% versus 12.1%, respectively, consistent with numbers needed to treat of 18 and 12, respectively. CONCLUSIONS In routine clinical care, ARNI therapy was associated with early improvements in health status, with 20% experiencing a very large health status benefit compared with 12% who were not started on ARNI therapy. These findings support the use of ARNI to improve patients' symptoms, functions, and quality of life.
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Affiliation(s)
- Yevgeniy Khariton
- Departments of Cardiology and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri.
| | - Gregg C Fonarow
- Department of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan University of California Los Angeles Medical Center, Los Angeles, California
| | - Suzanne V Arnold
- Departments of Cardiology and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Ann Hellkamp
- Duke Clinical Research Institute, Durham, North Carolina
| | - Michael E Nassif
- Department of Cardiology, Washington University School of Medicine in Saint Louis, Saint Louis, Missouri
| | - Puza P Sharma
- Novartis Pharmaceuticals Corp, East Hanover, New Jersey
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina
| | - Carol I Duffy
- Novartis Pharmaceuticals Corp, East Hanover, New Jersey
| | - Adam D DeVore
- Division of Cardiology, Department of Medicine, and the Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | | | - Kevin McCague
- Novartis Pharmaceuticals Corp, East Hanover, New Jersey
| | - John A Spertus
- Departments of Cardiology and Cardiovascular Outcomes Research, Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
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DeVore AD, Hill CL, Thomas L, Sharma PP, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Duffy CI, McCague K, Hernandez AF, Fonarow GC. Patient, Provider, and Practice Characteristics Associated With Sacubitril/Valsartan Use in the United States. Circ Heart Fail 2019; 11:e005400. [PMID: 30354360 DOI: 10.1161/circheartfailure.118.005400] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [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] [Indexed: 01/30/2023]
Abstract
Background Current guidelines recommend sacubitril/valsartan for patients with heart failure with reduced ejection fraction, but the rate of adoption in the United States has been slow. Methods and Results Using data from CHAMP-HF (Change the Management of Patients With Heart Failure), we described current sacubitril/valsartan use and identified patient, provider, and practice characteristics associated with its use. We considered patients to be on sacubitril/valsartan if they were prescribed it before enrollment or initiated on it at the baseline visit. We excluded patients with a contraindication to sacubitril/valsartan and practices with <10 patients enrolled. Of 4216 patients from 121 sites, 616 (15%) were prescribed sacubitril/valsartan, 2506 (59%) an angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), and 1094 (26%) neither. Patients prescribed sacubitril/valsartan were younger (63 years versus 66 years ACE inhibitor/ARB versus 69 years neither, P<0.001), less likely to have chronic kidney disease (15% versus 17% ACE inhibitor/ARB versus 30% neither, P<0.001), more likely to have cardiac resynchronization therapy (12% versus 7% ACE inhibitor/ARB versus 7% neither, P<0.001), and had lower ejection fraction (27% versus 30% ACE inhibitor/ARB versus 30% neither, P<0.001). Larger practices, based on number of cardiologists and advanced practice providers, were associated with the highest sacubitril/valsartan use. After multivariable adjustment, the number of advanced practice providers was associated with sacubitril/valsartan use (adjusted odds ratio,1.08; 95% CI, 1.03-1.14). Conclusions Despite current guideline recommendations, adoption of sacubitril/valsartan remains low. Provider and practice characteristics associated with sacubitril/valsartan use were related to general practice size and were not associated with practice characteristics specific for heart failure. Further research is needed to identify strategies for effective quality improvement interventions in chronic heart failure with reduced ejection fraction.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (A.D.D., C.L.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - C Larry Hill
- Duke Clinical Research Institute, Durham, NC (A.D.D., C.L.H., L.T., A.F.H.)
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, NC (A.D.D., C.L.H., L.T., A.F.H.)
| | - Puza P Sharma
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.)
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson (J.B.)
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City (J.A.S.)
| | | | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.)
| | - Kevin McCague
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (A.D.D., C.L.H., L.T., A.F.H.).,Department of Medicine, Duke University School of Medicine, Durham, NC (A.D.D., A.F.H.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center (G.C.F.)
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18
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Thomas M, Khariton Y, Fonarow GC, Arnold SV, Hill L, Nassif ME, Sharma PP, Butler J, Thomas L, Duffy CI, DeVore AD, Hernandez A, Albert NM, Patterson JH, Williams FB, McCague K, Spertus JA. Association of Changes in Heart Failure Treatment With Patients' Health Status: Real-World Evidence From CHAMP-HF. JACC Heart Fail 2019; 7:615-625. [PMID: 31176672 DOI: 10.1016/j.jchf.2019.03.020] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 03/13/2019] [Accepted: 03/14/2019] [Indexed: 12/11/2022]
Abstract
OBJECTIVES The aim of this study was to use a multicenter, observational outpatient registry of patients with heart failure with reduced ejection fraction (HFrEF) to describe the association between changes in patients' medications with changes in health status. BACKGROUND Alleviating symptoms and improving function and quality of life for patients with HFrEF are primary treatment goals and potential indicators of quality. Whether titrating medications in routine clinical care improves patients' health status is unknown. METHODS The association of any change in HFrEF medications with 3-month change in health status, as measured using the 12-item Kansas City Cardiomyopathy Questionnaire Overall Summary Scale, was determined in unadjusted and multivariate-adjusted (25 clinical characteristics, baseline health status) models using hierarchical linear regression. RESULTS Among 3,313 outpatients with HFrEF from 140 centers, 21.9% had medication changes. Three months later, 23.7% and 46.4% had clinically meaningfully worse (≥5-point decrease) and improved (≥5-point increase) Kansas City Cardiomyopathy Questionnaire Overall Summary Scale scores. The 3-month median change in Kansas City Cardiomyopathy Questionnaire Overall Summary Scale score for patients whose HFrEF medications were changed was significantly larger (7.3 points; interquartile range: -3.1 to 20.8 points) than in patients whose medications were not changed (3.1 points; interquartile range: -4.7 to 12.5 points) (adjusted difference 3.0 points; 95% confidence interval: 1.4 to 4.6 points; p < 0.001). Among patients whose medications were adjusted, 26% had very large clinical improvement (≥20 points) compared with 14% whose regimens were not changed. CONCLUSIONS In routine care of patients with HFrEF, changes in HFrEF medications were associated with significant improvements in patients' health status, suggesting that health status-based performance measures can quantify the benefits of titrating medicines in patients with HFrEF.
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Affiliation(s)
- Merrill Thomas
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Yevgeniy Khariton
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
| | - Suzanne V Arnold
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri
| | - Larry Hill
- Duke Clinical Research Institute, Durham, North Carolina
| | - Michael E Nassif
- Washington University School of Medicine in Saint Louis, Saint Louis, Missouri
| | - Puza P Sharma
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | | | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina
| | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, and the Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Adrian Hernandez
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Department of Medicine, and the Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | | | - Kevin McCague
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - John A Spertus
- Saint Luke's Mid America Heart Institute/University of Missouri-Kansas City, Kansas City, Missouri.
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19
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Greene SJ, Fonarow GC, DeVore AD, Sharma PP, Vaduganathan M, Albert NM, Duffy CI, Hill CL, McCague K, Patterson JH, Spertus JA, Thomas L, Williams FB, Hernandez AF, Butler J. Titration of Medical Therapy for Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2019; 73:2365-2383. [PMID: 30844480 PMCID: PMC7197490 DOI: 10.1016/j.jacc.2019.02.015] [Citation(s) in RCA: 301] [Impact Index Per Article: 60.2] [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: 02/01/2019] [Revised: 02/17/2019] [Accepted: 02/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Guidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF) have medical therapy titrated to target doses derived from clinical trials, as tolerated. The degree to which titration occurs in contemporary U.S. practice is unknown. OBJECTIVES This study sought to characterize longitudinal titration of HFrEF medical therapy in clinical practice and to identify associated factors and reasons for medication changes. METHODS Among 2,588 U.S. outpatients with chronic HFrEF in the CHAMP-HF (Change the Management of Patients with Heart Failure) registry with complete medication data and no contraindications to medical therapy, use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) were examined at baseline and at 12-month follow-up. RESULTS At baseline, 658 (25%), 525 (20%), 287 (11%), and 45 (2%) patients were receiving target doses of MRA, beta-blocker, ACEI/ARB, and ARNI therapy, respectively. At 12 months, proportions of patients with medication initiation or dose increase were 6% for MRA, 10% for beta-blocker, 7% for ACEI/ARB, and 10% for ARNI; corresponding proportions with discontinuation or dose decrease were 4%, 7%, 11%, and 3%, respectively. Over 12 months, <1% of patients were simultaneously treated with target doses of ACEI/ARB/ARNI, beta-blocker, and MRA. In multivariate analysis, across the classes of medications, multiple patient characteristics were associated with a higher likelihood of initiation or dose increase (e.g., previous HF hospitalization, higher blood pressure, lower ejection fraction) and discontinuation or dose decrease (e.g., previous HF hospitalization, impaired quality of life, more severe functional class). Medical reasons were the most common reasons for discontinuations and dose decreases of each therapy, but the relative contributions from patient preference, health team, and systems-based reasons varied by medication. CONCLUSIONS In this contemporary U.S. registry, most eligible HFrEF patients did not receive target doses of medical therapy at any point during follow-up, and few patients had doses increased over time. Although most patients had no alterations in medical therapy, multiple clinical factors were independently associated with medication changes. Further quality improvement efforts are urgently needed to improve guideline-directed medication titration for HFrEF.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina. https://twitter.com/SJGreene_md
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, California. https://twitter.com/gcfmd
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Puza P Sharma
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - C Larry Hill
- Duke Clinical Research Institute, Durham, North Carolina
| | - Kevin McCague
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
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20
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DeVore AD, Mi X, Thomas L, Sharma PP, Albert NM, Butler J, Hernandez AF, Patterson JH, Spertus JA, Williams FB, Duffy CI, McCague K, Fonarow GC. Characteristics and Treatments of Patients Enrolled in the CHAMP-HF Registry Compared With Patients Enrolled in the PARADIGM-HF Trial. J Am Heart Assoc 2018; 7:JAHA.118.009237. [PMID: 29895587 PMCID: PMC6220559 DOI: 10.1161/jaha.118.009237] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The US Food and Drug Administration approved sacubitril/valsartan for patients with chronic heart failure (HF) with reduced ejection fraction in 2015 on the basis of the results of the PARADIGM-HF (Prospective Comparison of ARNI [Angiotensin Receptor Neprilysin Inhibitor] With ACEI [Angiotensin-Converting Enzyme Inhibitor] to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial. There are limited data assessing the generalizability of PARADIGM-HF trial participants to a broader population of patients with HF with reduced ejection fraction routinely encountered in outpatient clinical practice. METHODS AND RESULTS We compared the baseline characteristics of patients in the PARADIGM-HF trial with those in the CHAMP-HF (Change the Management of Patients With Heart Failure) study a large US outpatient registry of patients with HF with reduced ejection fraction. Patients in the PARADIGM-HF trial (n=8442) were similar to those in the CHAMP-HF registry (n=3497) in terms of age (mean, 64 versus 66 years), sex (22% versus 29% women), New York Heart Association class III to IV (25% versus 32%), systolic blood pressure (mean, 121 versus 121 mm Hg), left ventricular ejection fraction (mean, 29% versus 29%), and other key baseline characteristics. The median (25th-75th percentile) Meta-Analysis Global Group in Chronic Heart Failure risk scores were similar for the 2 studies (20 [16-24] versus 22 [8-27]). Despite this, only 13% of patients in the CHAMP-HF registry were prescribed sacubitril/valsartan at baseline. CONCLUSIONS These data suggest participants randomized in the PARADIGM-HF trial have similar baseline characteristics to those encountered in routine outpatient clinical practice, but there is a substantial lag in the adoption of sacubitril/valsartan for patients with chronic HF with reduced ejection fraction.
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Affiliation(s)
- Adam D DeVore
- Duke Clinical Research Institute, Durham, NC .,Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Xiaojuan Mi
- Duke Clinical Research Institute, Durham, NC
| | | | - Puza P Sharma
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC.,Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, MO
| | | | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Kevin McCague
- Novartis Pharmaceuticals Corporation, East Hanover, NJ
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center Ronald Reagan UCLA Medical Center, Los Angeles, CA
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21
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Khariton Y, Nassif ME, Thomas L, Fonarow GC, Mi X, DeVore AD, Duffy C, Sharma PP, Albert NM, Patterson JH, Butler J, Hernandez AF, Williams FB, McCague K, Spertus JA. Health Status Disparities by Sex, Race/Ethnicity, and Socioeconomic Status in Outpatients With Heart Failure. JACC Heart Fail 2018; 6:465-473. [PMID: 29852931 PMCID: PMC6003698 DOI: 10.1016/j.jchf.2018.02.002] [Citation(s) in RCA: 61] [Impact Index Per Article: 10.2] [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] [Subscribe] [Scholar Register] [Received: 11/14/2017] [Revised: 01/26/2018] [Accepted: 02/06/2018] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study sought to describe the health status of outpatients with heart failure and reduced ejection fraction (HFrEF) by sex, race/ethnicity, and socioeconomic status (SES). BACKGROUND Although a primary goal in treating patients with HFrEF is to optimize health status, whether disparities by sex, race/ethnicity, and SES exist is unknown. METHODS In the CHAMP-HF (Change the Management of Patients with Heart Failure) registry, the associations among sex, race, and SES and health status, as measured by the Kansas City Cardiomyopathy Questionnaire-overall summary (KCCQ-os) score (range 0 to 100; higher scores indicate better health status) was compared among 3,494 patients from 140 U.S. clinics. SES was categorized by total household income. Hierarchical multivariate linear regression estimated differences in KCCQ-os score after adjusting for 31 patient characteristics and 10 medications. RESULTS Overall mean KCCQ-os scores were 64.2 ± 24.0 but lower for women (29% of sample; 60.3 ± 24.0 vs. 65.9 ± 24.0, respectively; p < 0.001), for blacks (60.5 ± 25.0 vs. 64.9 ± 23.0, respectively; p < 0.001), for Hispanics (59.1 ± 21.0 vs. 64.9 ± 23.0, respectively; p < 0.001), and for those with the lowest income (<$25,000; mean: 57.1 vs. 63.1 to 74.7 for other income categories; p < 0.001). Fully adjusted KCCQ-os scores were 2.2 points lower for women (95% confidence interval [CI]: -3.8 to -0.6; p = 0.007), no different for blacks (p = 0.74), 4.0 points lower for Hispanics (95% CI: -6.6 to -1.3; p = 0.003), and lowest in the poorest patients (4.7 points lower than those with the highest income (95% CI: 0.1 to 9.2; p = 0.045; p for trend = 0.003). CONCLUSIONS Among outpatients with HFrEF, women, blacks, Hispanics, and poorer patients had worse health status, which remained significant for women, Hispanics, and poorer patients in fully adjusted analyses. This suggests an opportunity to further optimize treatment to reduce these observed disparities.
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Affiliation(s)
- Yevgeniy Khariton
- Cardiovascular Outcomes Research, University of Missouri-Kansas City, Saint-Luke's Mid-America Heart Institute, Kansas City, Missouri
| | - Michael E Nassif
- Division of Cardiology, Washington University School of Medicine in Saint Louis, Barnes-Jewish Hospital, Saint Louis, Missouri
| | - Laine Thomas
- Duke Department of Biostatistics and Informatics, Duke Clinical Research Institute, Durham, North Carolina
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, California
| | - Xiaojuan Mi
- Duke Department of Biostatistics and Informatics, Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D DeVore
- Duke Department of Biostatistics and Informatics, Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Carol Duffy
- Novartis Pharmaceuticals Corp., East Hanover, New Jersey
| | - Puza P Sharma
- Novartis Pharmaceuticals Corp., East Hanover, New Jersey
| | - Nancy M Albert
- Office of Nursing Research and Innovation, Cleveland Clinic School of Medicine, Cleveland Clinic Kaufman Center for Heart Failure, Cleveland, Ohio
| | - J Herbert Patterson
- Division of Pharmacotherapy and Experimental Therapeutics, Eshelman School of Pharmacy, University of North Carolina Hospitals, Chapel Hill, North Carolina
| | - Javed Butler
- Division of Cardiovascular Medicine, Stony Brook School of Medicine, Stony Brook, New York
| | - Adrian F Hernandez
- Duke Department of Biostatistics and Informatics, Duke Clinical Research Institute, Durham, North Carolina; Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Kevin McCague
- Novartis Pharmaceuticals Corp., East Hanover, New Jersey
| | - John A Spertus
- Cardiovascular Outcomes Research, University of Missouri-Kansas City, Saint-Luke's Mid-America Heart Institute, Kansas City, Missouri.
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22
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Khariton Y, Hernandez AF, Fonarow GC, Sharma PP, Duffy CI, Thomas L, Mi X, Albert NM, Butler J, McCague K, Nassif ME, Williams FB, DeVore A, Patterson JH, Spertus JA. Health Status Variation Across Practices in Outpatients With Heart Failure: Insights From the CHAMP-HF (Change the Management of Patients With Heart Failure) Registry. Circ Cardiovasc Qual Outcomes 2018; 11:e004668. [PMID: 29627798 PMCID: PMC5891827 DOI: 10.1161/circoutcomes.118.004668] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [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] [Indexed: 01/06/2023]
Abstract
BACKGROUND Although a key treatment goal for patients with heart failure with reduced ejection fraction is to optimize their health status (their symptoms, function, and quality of life), the variability across outpatient practices in achieving this goal is unknown. METHODS AND RESULTS In the CHAMP-HF (Change the Management of Patients With Heart Failure) registry, associations between baseline practice characteristics and Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary (OS) and Symptom Frequency (SF) scores were assessed in 3494 patients across 140 US practices using hierarchical regression after accounting for 23 patient and 11 treatment characteristics. We then calculated an adjusted median odds ratio to quantify the average difference in likelihood that a patient would have excellent (KCCQ-OS, ≥75) health status or minimal (monthly or fewer) symptoms (KCCQ-SF, ≥75) when treated at one practice versus another, at random. The mean (±SD) KCCQ-OS and KCCQ-SF were 64.2±24 and 68.9±25.6, with 40% (n=1380) and 50% (n=1760) having KCCQ scores ≥75, respectively. The adjusted median odds ratio across practices, for KCCQ-OS ≥75, was 1.70 (95% confidence interval, 1.54-1.99; P<0.001) indicating a median 70% higher odds of a patient having good-to-excellent health status when treated at one random practice versus another. In regard to KCCQ-SF, the adjusted median odds ratio for KCCQ-SF ≥75 was 1.54 (95% confidence interval, 1.41-1.76; P=0.001). CONCLUSIONS In a large, contemporary registry of outpatients with chronic heart failure with reduced ejection fraction, we observed significant practice-level variability in patients' health status. Quantifying patients' health status as a measure of quality should be explored as a foundation for improving care. CLINICAL TRIAL REGISTRATION URL: https://www.centerwatch.com. Unique identifier: TX144901.
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Affiliation(s)
- Yevgeniy Khariton
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.).
| | - Adrian F Hernandez
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Gregg C Fonarow
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Puza P Sharma
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Carol I Duffy
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Laine Thomas
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Xiaojuan Mi
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Nancy M Albert
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Javed Butler
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Kevin McCague
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Michael E Nassif
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Fredonia B Williams
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - Adam DeVore
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - J Herbert Patterson
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Department of Cardiology, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (Y.K., J.A.S.). Department of Medicine, Duke University School of Medicine, Durham, NC (A.F.H., A.D.). Department of Cardiology, Duke Clinical Research Institute, Durham, NC (A.F.H., L.T., X.M., A.D.). Department of Cardiovascular Medicine Ronald Reagan UCLA Medical Center, Los Angeles, CA (G.C.F.). Novartis Pharmaceuticals Corporation, East Hanover, NJ (P.P.S., C.I.D., K.M.). Department of Cardiology Cleveland Clinic, OH (N.M.A.). Stony Brook University, NY (J.B.). Washington University School of Medicine, Saint Louis, MO (M.E.N.). Mended Hearts, Huntsville, AL (F.B.W.). Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
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DeVore AD, Thomas L, Albert NM, Butler J, Hernandez AF, Patterson JH, Spertus JA, Williams FB, Turner SJ, Chan WW, Duffy CI, McCague K, Mi X, Fonarow GC. Change the management of patients with heart failure: Rationale and design of the CHAMP-HF registry. Am Heart J 2017. [PMID: 28625374 DOI: 10.1016/j.ahj.2017.04.010] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Heart failure (HF) with reduced ejection fraction (HFrEF) is a common and costly condition that diminishes patients' health status and confers a poor prognosis. Despite the availability of multiple guideline-recommended pharmacologic and cardiac device therapies for patients with chronic HFrEF, outcomes remain suboptimal. Currently, there is limited insight into the rationale underlying clinical decisions by health care providers and patient factors that guide the use and intensity of outpatient HF treatments. A better understanding of current practice patterns has the potential to improve patients' outcomes. The CHAnge the Management of Patients with Heart Failure (CHAMP-HF) registry will evaluate the care and outcomes of patients with chronic HFrEF by assessing real-world treatment patterns, as well as the reasons for and barriers to medication treatment changes. CHAMP-HF will enroll approximately 5,000 patients with chronic HFrEF (left ventricular ejection fraction ≤40%) at approximately 150 US sites, and patients will be followed for a maximum duration of 24 months. Participating sites will collect data from both providers (HF history, examination findings, results of diagnostic studies, pharmacotherapy treatment patterns, decision-making factors, and clinical outcomes) and patients (medication adherence and patient-reported outcomes). The CHAMP-HF registry will provide a unique opportunity to study practice patterns and the adoption of new HF therapies across a diverse mix of health care providers and outpatient practices in the United States that care for HFrEF patients.
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Fonarow GC, Albert NM, Butler J, Chan WW, Duffy CI, Hernandez AF, Patterson JH, Spertus JA, Turner SJ, Waltman Johnson K, Williams FB. Abstract 255: The Development of an Observational Registry of Treatment Patterns in US Heart Failure Patients with Reduced Ejection Fraction (HFrEF). Circ Cardiovasc Qual Outcomes 2016. [DOI: 10.1161/circoutcomes.9.suppl_2.255] [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: 11/16/2022]
Abstract
Background:
Efficient heart failure management can minimize symptoms, optimize clinical outcomes and lower costs. Novel heart failure treatments can provide an important opportunity to better understand the patterns by which beneficial therapies are adopted. To date, there have been few formal studies quantifying the underlying patient and physician factors associated with the integration of novel therapies into care.
Methods:
This study is an observational, nonrandomized, multi-center US cohort study of adult patients with HFrEF. The goal is to consecutively recruit an estimated 5000 patients with HFrEF at approximately 150-200 US clinical sites. The primary objective of this study is to better understand contemporary heart failure treatment patterns, as well as the reasons and barriers for treatment changes in patients with HFrEF. Secondary outcomes include healthcare provider- and patient-reported decision-making factors and perceptions of treatment, patient-reported heart-failure-related quality of life, and health care resource utilization. The primary analysis of study outcomes - changes in chronic heart failure therapy - will occur at 12 months. Patients will be followed through a maximum duration of 24 months or until death or study withdrawal, with patient-reported data and healthcare resource utilization collected at 30 days, 3 months, 6 months, 12 months, 18 months, and 24 months.
Results:
Table 1 lists variables being collected during registry participation.
Conclusion:
This study will provide a unique opportunity to understand the initiation and titration of outpatient medications, adoption of novel therapies, and the reasons for treatment changes and outcomes in US HFrEF patients.
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Affiliation(s)
| | | | | | - Wing W Chan
- Novartis Pharmaceuticals Corp, East Hanover, NJ
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