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Yeoh SE, Docherty KF, Jhund PS, Hammarstedt A, Inzucchi SE, Kober L, Kosiborod MN, Martinez FA, Ponikowski P, Solomon SD, Sattar N, Welsh P, Sabatine MS, Morrow DA, McMurray JJV. Relationship between endothelin-1, heart failure with reduced ejection fraction and dapagliflozin: findings from DAPA-HF. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Circulating Endothelin-1 (ET-1) is associated with heart failure (HF) severity and has also been widely implicated in the pathophysiology of renal disease. However, its prognostic importance and relationship with kidney function in patients with HFrEF receiving contemporary treatment is uncertain.
Purpose
To investigate the association of ET-1 with heart failure outcomes, as well as change in kidney function; and the efficacy of dapagliflozin according to baseline serum ET-1 in the Dapagliflozin And Prevention of Adverse outcomes in Heart Failure trial (DAPA-HF).
Methods
Serum ET-1 was measured at randomization and at 12 months and analysed using a Microfluidics immunoassay. We investigated the incidence of the primary outcome (cardiovascular death or worsening HF), and analysed change in kidney function according to tertile of baseline ET-1 concentration. Additionally, we assessed whether baseline ET-1 modified the treatment effect of dapagliflozin.
Results
Of 4744 randomized participants, 3048 (64.2%) had a baseline ET-1 measurement: tertile 1 (≤3.28 pg/mL, n=1016), tertile 2 (>3.28 to 4.41 pg/mL, n=1022), and tertile 3 (>4.41 pg/mL, n=1010). Patients with higher baseline ET-1 concentrations were more likely male, obese and to have lower LVEF, lower eGFR, worse functional status, and elevated NT-proBNP and high-sensitivity troponin-T.
Adjusting for other predictive variables including NT-proBNP, higher baseline ET-1 was independently associated with worse outcomes and steeper decline in kidney function: adjusted hazard ratio (aHR) for the primary outcome of 1.95 (1.53–2.50) for tertile 3 and 1.36 (95% CI 1.06–1.75) for tertile 2; aHR for worsening HF of 2.54 (1.82–3.53) for tertile 3 and 1.54 (1.10–2.18) for tertile 2; aHR for cardiovascular death of 1.39 (1.01–1.92) for tertile 3 and 1.13 (0.82–1.57) for tertile 2; and eGFR slope −3.19 (95% CI −3.66 to −2.72) mL/min/1.73 m2 per year in tertile 3 versus −2.06 (−2.51 to −1.62) in tertile 2 and −2.35 (−2.79 to −1.91) in tertile 1, p for difference (eGFR slope)=0.002.
The benefit of dapagliflozin was consistent regardless of baseline ET-1, whether analysed according to tertiles or as a continuous variable, with p-interaction for primary outcome 0.47 and 0.10 respectively. Compared to placebo, there was a trend to reduction in ET-1 level at 12 months with dapagliflozin (difference −0.12 pg/mL, p-value=0.07).
Conclusions
Baseline ET-1 concentration was independently associated with clinical outcomes and with more rapid decline in kidney function. The benefit of dapagliflozin was consistent across the range of ET-1 concentrations measured.
Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The DAPA-HF trial was funded by AstraZeneca. Professor John McMurray is supported by a British Heart Foundation Centre of Research Excellence Grant RE/18/6/34217.
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Affiliation(s)
- S E Yeoh
- University of Glasgow , Glasgow , United Kingdom
| | - K F Docherty
- University of Glasgow , Glasgow , United Kingdom
| | - P S Jhund
- University of Glasgow , Glasgow , United Kingdom
| | | | - S E Inzucchi
- Yale University , New Haven , United States of America
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | - M N Kosiborod
- St. Luke's Mid America Heart Institute , Kansas City , United States of America
| | - F A Martinez
- National University of Cordoba , Cordoba , Argentina
| | | | - S D Solomon
- Brigham and Women's Hospital , Boston , United States of America
| | - N Sattar
- University of Glasgow , Glasgow , United Kingdom
| | - P Welsh
- University of Glasgow , Glasgow , United Kingdom
| | - M S Sabatine
- Brigham and Women's Hospital , Boston , United States of America
| | - D A Morrow
- Brigham and Women's Hospital , Boston , United States of America
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2
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Butt JH, Dewan P, Kober L, Jhund PS, Solomon SD, McMurray JJV. Efficacy and safety of sacubitril/valsartan according to frailty in heart failure with preserved ejection fraction: a post hoc analysis of the PARAGON-HF trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.1052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Frailty is an increasingly common problem and frail patients are less likely to receive pharmacological therapy because the benefit/risk profile is perceived to be less favorable than in non-frail patients.
Purpose
We investigated the prevalence of frailty, the relationship between frailty status and outcomes, and the efficacy of sacubitril/valsartan, compared with valsartan, according to frailty status in patients with heart failure (HF) with preserved fraction (HFpEF) randomized in PARAGON-HF.
Methods
Patients aged ≥50 years with a left ventricular ejection fraction ≥45%, structural heart disease, and elevated natriuretic peptide were enrolled in PARAGON-HF. Using the Rockwood cumulative deficit approach, a 41-item Frailty Index (FI) was constructed, and a FI score was calculated, with higher scores indicating greater frailty. The primary endpoint was a composite of total HF hospitalizations and cardiovascular death.
Results
Of the 4,796 patients randomized in PARAGON-HF, a FI was calculable in 4,795. Mean FI was 0.227 (standard deviation, 0.091; range, 0.061–0.537). In total, 2,165 (45.2%) patients had class 1 frailty (FI <0.210, i.e., not frail), 2.084 (43.5%) had class 2 (FI 0.211–0.310, i.e. more frail), and 546 (11.4%) were in class 3 frailty (FI >0.311, i.e. most frail). There was a graded relationship between FI class and the primary endpoint, with a significantly higher risk associated with greater frailty (class 1, reference; class 2, rate ratio 2.19 [95% CI, 1.85–2.60]; class 3, 3.29 [95% CI, 2.65–4.09]). The effect of sacubitril/valsartan versus valsartan on the primary endpoint from lowest to highest FI class (as a rate ratio) was: 0.98 [95% CI, 0.76–1.27], 0.92 [95% CI, 0.76–1.12], and 0.69 [95% CI, 0.51–0.95]), respectively (P for interaction=0.23) (Table). When FI was examined as a continuous variable, the interaction with treatment was significant for the primary outcome (P for interaction 0.002) and total HF hospitalizations (P for interaction <0.001) with those most frail deriving greater benefit (Figure). Adverse reactions and discontinuation of trial treatment were not more frequent with sacubitril/valsartan than valsartan, in frailer patients.
Conclusions
Frailty was common in patients with HFpEF in PARAGON-HF and associated with worse outcomes. There was a greater reduction in total HF hospitalizations with sacubitril/valsartan, compared with valsartan, in the frailest patients.
Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): The PARAGON trial was sponsored by Novartis
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Affiliation(s)
- J H Butt
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology , Copenhagen , Denmark
| | - P Dewan
- Cardiovascular Research Centre of Glasgow , Glasgow , United Kingdom
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology , Copenhagen , Denmark
| | - P S Jhund
- Cardiovascular Research Centre of Glasgow , Glasgow , United Kingdom
| | - S D Solomon
- Brigham and Women's Hospital , Boston , United States of America
| | - J J V McMurray
- Cardiovascular Research Centre of Glasgow , Glasgow , United Kingdom
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McDowell K, Simpson J, Jhund PS, Abraham WT, Claggett B, Cunningham J, Desai AS, Kober L, Prescott M, Rouleau JL, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. A comprehensive study of the incremental prognostic value of novel biomarkers in PARADIGM-HF (Bio-PREDICT-HF). Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Although multiple novel biomarkers have individually been shown to predict outcomes in patients with HFrEF, the value of these over and above conventional clinical and laboratory variables, plus natriuretic peptides, is uncertain.
Purpose
To test the incremental predictive value of 11 novel biomarkers added to a recent prognostic model 1 (PREDICT-HF) derived in PARADIGM-HF and validated in ATMOSPHERE and the Swedish heart failure registry. The PREDICT-HF model includes clinical variables, standard laboratory variables, and BNP or NT-proBNP.
Methods
1559 participants enrolled in PARADIGM-HF had all 11 biomarkers of interest measured. These reflected different pathophysiological pathways: (i) myocyte injury (high sensitivity cardiac troponin T), (ii) cardiac remodelling and inflammation (growth stimulation expressed gene 2, growth differentiation factor-15 and galectin-3), (iii) extracellular matrix remodelling (matrix metalloproteinase-2, matrix metalloproteinase-9, tissue inhibitor of metalloproteinase-1), (iv) neurohormonal pathways (aldosterone) and (v) renal dysfunction and injury (cystatin C, kidney injury molecule-1 and urinary albumin to creatinine ratio). The incremental prognostic value of these biomarkers was evaluated using Harrell's C statistic.
Results
The mean age of participants studied was 67.3 (SD 9.9) years, 1254 (80%) were men and 1103 (71%) were in NYHA class II. During a median follow-up of 31 months, 197 patients died and 300 experienced the primary composite outcome (cardiovascular death or heart failure hospitalization).
When each candidate biomarker (log unit) was added individually to the PREDICT-HF base model, GDF-15, ST2, TIMP1, cystatin C, hsTnT and UACR were independent predictors of all-cause mortality (Table 1). GDF-15, TIMP1, hs-TnT and cystatin C consistently increased the risk of both all-cause mortality and the primary outcome. Individuals who had all 4 biomarkers elevated (compared to none elevated) had the highest risk: HR for all-cause mortality 3.65 (2.01–6.64), p<0.0001. Adding these 4 biomarkers to the baseline PREDICT HF model improved the C statistic for all-cause mortality from 0.726 to 0.745.
Conclusion
Several novel biomarkers provide meaningful additional prognostic information in patients with HFrEF. A multimarker approach incorporating biomarkers reflecting different pathophysiological pathways added most information. This approach may be useful in refining risk and targeting treatment.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The PARADIGM-HF trial was funded by Novartis.J.J.V.M is supported by a British Heart Foundation Centre of Excellence Grant
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Affiliation(s)
- K McDowell
- University of Glasgow, BHF Cardiovascular Research Centre , Glasgow , United Kingdom
| | - J Simpson
- University of Glasgow, BHF Cardiovascular Research Centre , Glasgow , United Kingdom
| | - P S Jhund
- University of Glasgow, BHF Cardiovascular Research Centre , Glasgow , United Kingdom
| | - W T Abraham
- Ohio State University, Davis Heart and Lung Research Institiute, Division of Cardiovascular Medicine , Ohio , United States of America
| | - B Claggett
- Brigham and Women's Hospital, Cardiovascular medicine , Boston , United States of America
| | - J Cunningham
- Brigham and Women's Hospital, Cardiovascular medicine , Boston , United States of America
| | - A S Desai
- Brigham and Women's Hospital, Cardiovascular medicine , Boston , United States of America
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | - M Prescott
- Novartis , East Hanover , United States of America
| | - J L Rouleau
- Montreal Heart Institute, Institute of Cardiology , Montreal , Canada
| | - K Swedberg
- University of Gothenburg, Department of Molecular and Clinical Medicine , Gothenburg , Sweden
| | - M R Zile
- Medical University of South Carolina , Charleston , United States of America
| | - S D Solomon
- Brigham and Women's Hospital, Cardiovascular medicine , Boston , United States of America
| | - M Packer
- Baylor University Medical Centre, Baylor Heart and Vascular Institiute , Dallas , United States of America
| | - J J V McMurray
- University of Glasgow, BHF Cardiovascular Research Centre , Glasgow , United Kingdom
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4
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Adamson C, Welsh P, Morrow DA, Docherty KF, Hammarstedt A, Inzucchi SE, Kober L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Solomon SD, Sattar N, Jhund PS, McMurray JJV. Outcomes related to IGFBP-7 in patients with heart failure and reduced ejection fraction and effects of dapagliflozin: findings from DAPA-HF. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.913] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Introduction
Insulin-like growth factor binding protein 7 (IGFBP-7) has been proposed as a novel prognostic biomarker in heart failure, but the association between IGFBP-7 and cardiovascular outcomes has not been examined in a large cohort of patients with heart failure and reduced ejection fraction (HFrEF).
Purpose
In this post-hoc analysis of the Dapagliflozin And Prevention of Adverse outcomes in Heart Failure trial (DAPA-HF) we examined the relationship between plasma IGFBP-7 level and outcomes in patients with HFrEF, the effect of dapagliflozin according to IGFBP-7 level and change in IGFBP-7 at 12 months.
Methods
Patients in NYHA class II–IV with LVEF ≤40% and elevated NT-proBNP were included in DAPA-HF. Participants were randomly allocated to dapagliflozin 10mg or matching placebo. In this analysis, patients were categorized by IGFBP-7 tertile. The primary outcome was a composite of cardiovascular death or worsening HF event; secondary outcomes were components of the primary outcome and all-cause mortality. The risk of each outcome was compared across thirds of IGFBP-7 using Cox regression models with adjustment for NT-proBNP and high-sensitivity troponin T as well as: randomised treatment, age, sex, race, region, systolic blood pressure, heart rate, ejection fraction, estimated glomerular filtration rate, NYHA class, history of HF hospitalisation, ischaemic aetiology of HF, hypertension, stroke, atrial fibrillation, prior MI and stratified by diabetes status. The efficacy of dapagliflozin was assessed according to baseline IGFBP-7 level. Change in IGFBP-7 at 12 months was assessed using the ratio of geometric means.
Results
3158 patients had measurement of IGFBP-7 at baseline. The median value of IGFBP-7 was 192 ng/mL (interquartile range 158–246). Patients in the highest third of IGFBP-7 levels had more advanced HF, with higher NYHA class and NT-proBNP, had worse renal function and more type 2 diabetes. Patients in the highest third had the highest rate of the primary outcome (Figure 1). The adjusted hazard ratio (aHR) for the primary endpoint (with lowest third of IGFBP-7 as reference) was 0.94 (95% CI 0.74–1.20) for middle third and 1.49 (95% CI 1.17–1.89) for top third. The corresponding aHRs for worsening HF event were 0.99 (95% CI 0.72–1.36) for middle third and 1.84 (95% CI 1.35–2.50) for top third. Cardiovascular and all-cause mortality did not vary by IGFBP-7 tertile. The benefit of dapagliflozin was consistent regardless of baseline IGFBP-7 (p for interaction for primary endpoint = 0.34). The change in IGFBP-7 from baseline to 12 months did not differ between placebo and dapagliflozin.
Conclusions
Elevation of IGFBP-7 in patients with HFrEF was associated with more adverse HF outcomes, even after adjustment for both NT-proBNP and hsTnT. The treatment benefit of dapagliflozin did not vary by baseline IGFBP-7.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): The DAPA-HF trial was funded by AstraZeneca.CA and JJVM are supported by a British Heart Foundation Centre of Research Excellence Grant.
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Affiliation(s)
- C Adamson
- University of Glasgow , Glasgow , United Kingdom
| | - P Welsh
- University of Glasgow , Glasgow , United Kingdom
| | - D A Morrow
- Brigham and Women's Hospital , Boston , United States of America
| | - K F Docherty
- University of Glasgow , Glasgow , United Kingdom
| | | | - S E Inzucchi
- Yale University , New Haven , United States of America
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | - M N Kosiborod
- University of Missouri , Kansas City , United States of America
| | - F A Martinez
- National University of Cordoba , Cordoba , Argentina
| | | | - M S Sabatine
- Brigham and Women's Hospital , Boston , United States of America
| | - S D Solomon
- Brigham and Women's Hospital , Boston , United States of America
| | - N Sattar
- University of Glasgow , Glasgow , United Kingdom
| | - P S Jhund
- University of Glasgow , Glasgow , United Kingdom
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5
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Yang M, Kondo T, Butt JH, Abraham WT, Desai AS, Kober L, Martinez FA, Packer M, Pfeffer MA, Rouleau JL, Solomon SD, Zile MR, Jhund PS, McMurray JJV. History of stroke in patients with heart failure: prevalence, baseline characteristics and clinical outcomes. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Stroke is an important but neglected comorbidity in patients with heart failure (HF). Little is known about the characteristics and outcomes of HF patients with a history of stroke.
Purpose
To examine the prevalence of prior stroke in patients with HF and reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF), the clinical characteristics of patients with a history of stroke, and the clinical outcomes in patients with prior stroke compared to those without.
Methods
Individual patient data analysis using three recent HFrEF trials (ATMOSPHERE, PARADIGM-HF, and DAPA-HF) and HFpEF trials (CHARM-Preserved, I-Preserve, TOPCAT-Americas, and PARAGON-HF). Cox regression was used to analyze clinical outcomes.
Results
Among 20159 HFrEF patients enrolled, 1683 (8.3%) had a history of stroke and among the 13252 patients with HFpEF 1287 (9.7%) had a prior stroke. Compared to patients without stroke, those with stroke were slightly older and more likely to have a history of hypertension, myocardial infarction, atrial fibrillation, diabetes, carotid artery disease, and peripheral artery disease (for both HFrEF and HFpEF). Patients with a history of stroke had worse NYHA class and KCCQ scores, and a higher rate of fatigue; they also had a higher median NT-proBNP level and lower eGFR than those without prior stroke (whether HFrEF or HFpEF). Systolic BP, pulse pressure and LVEF did not differ susbtantialy between patients with and without a history of stroke. The table shows outcomes according to history of stroke or not, stratified by LVEF phenotype. During follow-up, all fatal and non-fatal outcomes were significantly more common in patients with a history of stroke. The augmentation of risk tended to be greater in patients with HFpEF than HFrEF, but was not statistically different.
Conclusion
Approximately 1 in 11 patients in recent HF trials had a history of stroke and these patients were at higher risk of fatal and non-fatal events than those without prior stroke. HF hospitalization as well as atherothrombotic events (myocardial infarction and stroke) were more common among patients with prior stroke – patients with prior stroke had at least 30% higher risk of all events examined, regardless of LVEF, and more than double incidence of repeat stroke.
Funding Acknowledgement
Type of funding sources: Other.
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Affiliation(s)
- M Yang
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - T Kondo
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - J H Butt
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | - W T Abraham
- The Ohio State University , Columbus , United States of America
| | - A S Desai
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | - F A Martinez
- National University of Cordoba , Cordoba , Argentina
| | - M Packer
- Baylor University Medical Center , Dallas , United States of America
| | - M A Pfeffer
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - J L Rouleau
- Montreal Heart Institute , Montreal , Canada
| | - S D Solomon
- Brigham and Women'S Hospital, Harvard Medical School , Boston , United States of America
| | - M R Zile
- Medical University of South Carolina , Charleston , United States of America
| | - P S Jhund
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - J J V McMurray
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
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6
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Kondo T, Jhund PS, Abraham WT, Rouleau JL, Packer M, Desai AS, Kober LV, Solomon SD, Zile MR, Inzucchi SE, Kosiborod MN, Sabatine MS, Ponikowski P, Martinez F, McMurray JJV. Stroke in patients with heart failure and reduced ejection fraction without atrial fibrillation: external validation of a risk model. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.869] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Heart failure (HF) ranks only second to atrial fibrillation (AF) as a cause of cardio-embolic stroke. Although anticoagulation reduces this risk in HF patients not in AF, the risk/benefit profile in relatively unselected populations is not favourable. Identification of patients at high risk of stroke may allow targeted and safer use of prophylactic anticoagulant therapy. Previously, we proposed a simple risk model for stroke in patients with HF and reduced ejection fraction (HFrEF). However, this model was derived from the two older trials (published in 2007/2008) and was not externally validated.
Purpose
We aimed to evaluate the current incidence of stroke in patients with HFrEF not in AF receiving modern pharmacological therapy and to validate our stroke prediction model.
Methods
We examined patient-level data from the PARADIGM-HF, ATMOSPHERE, and DAPA-HF trials. The risk score was calculated following: 7.39×(insulin-treated diabetes) + 6.53×(previous stroke) + 2.80×[ln(NT-proBNP (pg/ml)) × 0.1182]). According to the tertile of risk score, we divided the patients into three groups. Patients with AF were defined as those with either AF on an ECG or a history of AF.
Results
Of the total of 20,159 patients (who experienced 590 strokes) enrolled in the three trials, 12,751 patients did not have AF at baseline. Of those, 1,143 patients (9%) had insulin-treated diabetes, 873 patients (6.8%) had a history of the previous stroke, and the median value of NT-proBNP was 1,243 pg/ml. During a median follow-up of 2.0 years, 346 (2.7%) experienced a stroke (11.7 per 1000 patient-years). Figure 1 shows cumulative incidence function plots for stroke according to the tertile of risk score in 12,331 patients whose risk score can be calculated. The number of strokes in tertile 1, 2 and 3 were 80, 102 and 149, respectively. The 3-year cumulative incidence function rates of stroke were 2.0 (95% CI: 1.5–2.5) % in tertile 1, 2.6 (95% CI: 2.1–3.2) % in tertile 2, and 4.3 (95% CI: 3.6–5.2) % in tertile 3, respectively. In patients with tertile 3, the stroke rate was 18.1 per 1000 patient-years (compared to 20.1 per 1000 patient-years in patients with AF not receiving anticoagulation). In the Cox model, risk for stroke increased according to the elevation in the risk score (tertile 2: HR 1.47 (95% CI 1.09–1.97), tertile 3: HR 2.53 (95% CI 1.92–3.33), with tertile 1 as reference). Figure 2 shows calibration plots by comparing observed and predicted probabilities of stroke at 1 to 3 years. Discrimination evaluated using the overall c-index 0.84 (95% CI: 0.75–0.91) was good.
Conclusions
These findings validate a previously described predictive model and confirm that it is possible to identify a subset of HFrEF patients without AF who have a risk of stroke that approximates to that in patients with AF. In these patients, the risk/benefit balance might justify the use of prophylactic anticoagulation, but this hypothesis needs to be tested prospectively.
Funding Acknowledgement
Type of funding sources: Foundation.
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Affiliation(s)
- T Kondo
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
| | - P S Jhund
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
| | - W T Abraham
- The Ohio State University, Division of Cardiovascular Medicine , Ohio , United States of America
| | - J L Rouleau
- University of Montreal, Montreal Heart Institute , Montreal , Canada
| | - M Packer
- Baylor University Medical Center, Baylor Heart and Vascular Institute , Dallas , United States of America
| | - A S Desai
- Brigham and Women's Hospital, Harvard Medical School, Cardiovascular Division , Boston , United States of America
| | - L V Kober
- Rigshospitalet - Copenhagen University Hospital, Department of Cardiology , Copenhagen , Denmark
| | - S D Solomon
- Brigham and Women's Hospital, Harvard Medical School, Cardiovascular Division , Boston , United States of America
| | - M R Zile
- Medical University of South Carolina , Charleston , United States of America
| | - S E Inzucchi
- Yale University School of Medicine, Section of Endocrinology, Diabetes, and Metabolism , New Haven , United States of America
| | - M N Kosiborod
- St. Luke's Mid America Heart Institute, Department of Cardiology , Kansas City , United States of America
| | - M S Sabatine
- Brigham and Women's Hospital, Harvard Medical School, Thrombolysis in Myocardial Infarction Study Group , Boston , United States of America
| | - P Ponikowski
- Wroclaw Medical University, Department of Heart Disease , Wroclaw , Poland
| | - F Martinez
- Cordoba National University , Cordoba , Argentina
| | - J J V McMurray
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
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7
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Adamson C, Butt JH, Rouleau J, Abraham W, Desai A, Dickstein K, Kober L, Lefkowitz MP, Packer M, Petrie MC, Swedberg K, Solomon SD, Zile M, Jhund PS, McMurray JJV. Alkaline phosphatase and bilirubin combined are a powerful predictor of outcome in patients with heart failure and reduced ejection fraction: an analysis of the ATMOSPHERE and PARADIGM-HF trials. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Bilirubin is a recognized predictor of adverse outcomes in patients with heart failure and reduced ejection fraction (HFrEF), possibly because it is a marker of congestion. Alkaline phosphatase (ALP) is an enzyme produced in many tissues including the biliary ducts and elevated levels are also associated with congestion.
Purpose
To examine the prognostic value of ALP alone and in combination with bilirubin in patients with HFrEF.
Methods
The study population was ambulatory patients with HFrEF enrolled in 2 recent clinical trials with similar inclusion and exclusion criteria: ATMOSPHERE (derivation cohort) and PARADIGM-HF (validation). Cut points to define elevated bilirubin and alkaline phosphatase were >17mg/dL and >120 U/L respectively. The composite of cardiovascular death or HF hospitalization, its components, and all-cause death related to elevation of one, other or both of bilirubin and ALP was examined using Cox regression. Univariable and multivariable models with adjustment for other recognized prognostic variables including NT-proBNP were analyzed.
Results
Of 7016 patients with HFrEF enrolled in ATMOSPHERE, 6870 had a measurement of both bilirubin and ALP at baseline: mean age 63 years, 22% women, mean LVEF 28% and proportion NYHA class III/IV 37%. Bilirubin and ALP were both normal in 4810 (70.0%) patients, bilirubin was elevated in 1393 (20.3%), ALP was elevated in 360 (5.2%) and both were elevated in 307 (4.5%) patients. Patients with elevation of both ALP and bilirubin were older, had lower systolic blood pressure, higher heart rate, higher NT-pro BNP, more clinical features of congestion, more atrial fibrillation and a greater proportion were treated with diuretics and digoxin. The primary endpoint rates (per 100 person-years) were 10.4 (95% CI 9.9–11.0) when both markers were normal, 15.1 (13.9–16.4) when bilirubin was elevated, 12.4 (10.4–14.9) when alkaline phosphatase was elevated, and 25.6 (22.0–29.9) when both markers were elevated (Figure 1). The adjusted hazard ratios (95% CI) were (both biomarkers normal = reference): elevated bilirubin 1.19 (1.07–1.31), P=0.001; elevated ALP 1.03 (0.84–1.26), P=0.81; both elevated 1.45 (1.21–1.73), P<0.001. Elevation of both bilirubin and ALP was a significant independent predictor of the components of the primary outcome and all-cause death, the corresponding hazard ratios for all cause death were 1.12 (0.99–1.25), p=0.06; 1.19 (0.96–1.47), p=0.12; and 1.51 (1.25–1.82), p<0.001. These findings were validated in PARADIGM-HF (Table 1).
Conclusions
Elevation of ALP in combination with elevated bilirubin identifies a small group of patients at very high risk of adverse outcomes. This may reflect more significant congestion. ALP and bilirubin, inexpensive and routinely measured biochemical tests, are useful prognostic markers in patients with HFrEF.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship.
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Affiliation(s)
- C Adamson
- University of Glasgow , Glasgow , United Kingdom
| | - J H Butt
- University of Glasgow , Glasgow , United Kingdom
| | - J Rouleau
- University of Montreal , Montreal , Canada
| | - W Abraham
- Ohio State University Hospital , Ohio , United States of America
| | - A Desai
- Brigham and Women's Hospital , Boston , United States of America
| | - K Dickstein
- Medical University of South Carolina , Charleston , United States of America
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | | | - M Packer
- Baylor University Medical Center , Dallas , United States of America
| | - M C Petrie
- University of Glasgow , Glasgow , United Kingdom
| | - K Swedberg
- University of Gothenburg , Gothenburg , Sweden
| | - S D Solomon
- Brigham and Women's Hospital , Boston , United States of America
| | - M Zile
- Medical University of South Carolina , Charleston , United States of America
| | - P S Jhund
- University of Glasgow , Glasgow , United Kingdom
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8
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Sun G, Petrie M, Lang NN, McMurray JJV, Jhund PS, Cheng LL, Schou M, Torp-Pedersen C, Fosboel EL, Koeber L, Butt JH. Long-term cardiovascular outcomes in five-year cancer survivors: a nationwide cohort study. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.2568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Patients with cancer have higher short-term rates of cardiovascular events than the general population. However, little is known about rates of long-term cardiovascular outcomes in 5-year cancer survivors, especially in older patients.
Objective
We investigated the long-term rates of cardiovascular outcomes, including heart failure, atrial fibrillation, venous thromboembolism, ischemic stroke and myocardial infarction in five-year cancer survivors, overall and according to age.
Methods
Using Danish nationwide registries, five-year survivors of 20 of the most common cancers (diagnosed between 1994 and 2013; 15 years of age or older at the time of the diagnosis) were matched with four non-cancer controls from the background population by age and sex. Study participants with a history of any the outcomes of interest prior to index date were excluded. Rates of outcomes in the cancer and non-cancer group were compared with Cox regression models, overall and according to age (i.e., 15–39, 40–59, and >60 years).
Results
In total, 167,215 five-year cancer survivors were age- and sex-matched with 668,860 non-cancer controls (median age 66 years; 34.4% men, median follow-up of 6.8 years). Five-year survivors had higher associated rates of cardiovascular outcomes, irrespective of age, and the incidence rates per 1,000 person-years of cardiovascular outcomes for cancer survivors and non-cancer controls were: HF: 6.2 (95% CI: 6.1–6.4) and 5.2 (5.1–5.3), respectively; atrial fibrillation: 11.1 (10.9–11.3) and 9.3 (9.3–9.4), respectively; venous thromboembolism: 5.1 (5.0–5.2) and 2.8 (2.8–2.9), respectively; ischemic stroke: 5.8 (5.6–5.9) and 5.4 (5.4–5.5), respectively; and myocardial infarction: 3.6 (3.5–3.7) and 3.4 (3.3–3.4), respectively. The absolute rates of cardiovascular outcomes were highest in the oldest group, whereas the relative rates were more pronounced in the youngest cancer group compared with matched controls (Figure 1).
Conclusions
Compared with the general population, five-year cancer survivors had higher associated rates of cardiovascular outcomes across the spectrum of age. The increased rates of cardiovascular outcomes were more pronounced in the youngest group. These data underline the importance of risk assessment and prevention of cardiovascular diseases in five-year cancer survivors.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- G Sun
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | - M Petrie
- Cardiovascular Research Centre of Glasgow , Glasgow , United Kingdom
| | - N N Lang
- Cardiovascular Research Centre of Glasgow , Glasgow , United Kingdom
| | - J J V McMurray
- Cardiovascular Research Centre of Glasgow , Glasgow , United Kingdom
| | - P S Jhund
- Cardiovascular Research Centre of Glasgow , Glasgow , United Kingdom
| | - L L Cheng
- Zhongshan Hospital - Fudan University, Cardiology , Shanghai , China
| | - M Schou
- Herlev and Gentofte Hospital , Copenhagen , Denmark
| | | | - E L Fosboel
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | - L Koeber
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | - J H Butt
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
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9
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Curtain J, Adamson C, Jhund PS, Desai AS, Lefkowitz MP, Rizkala AR, Rouleau JL, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. Prevalent and incident anaemia in PARADIGM-HF and effect of sacubitril/valsartan. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Anaemia is common in patients with HFrEF and is associated with poor clinical outcomes. Although they reduce rates of mortality and heart failure hospitalization, renin-angiotensin (RAS) blockers lower haemoglobin and may induce anaemia. Concomitant neprilysin inhibition might ameliorate this effect of RAS blockers.
Purpose
We investigated the effect of sacubitril/valsartan compared with enalapril on clinical outcomes, according to anaemia status, and on haemoglobin levels in PARADIGM-HF.
Methods
Patient characteristics and clinical outcomes were compared between patients with and without anaemia (defined as haemoglobin <120 g/L in women and <130 g/L in men) at baseline. We investigated the effect of randomized treatment (sacubitril/valsartan or enalapril) on clinical outcomes according to anaemia status at screening. We also examined the effect of treatment on change in haemoglobin from baseline and on the incidence of anaemia. The primary endpoint in PARADIGM-HF was the composite of heart failure hospitalization or cardiovascular death.
Results
Of 8239 participants with a baseline haemoglobin measurement, 1677 (20.4%) were anaemic. Compared to those without anaemia, patients with anaemia had a more severe heart failure profile, worse kidney function, greater neurohormonal derangement and worse clinical outcomes. Sacubitril/valsartan, compared to enalapril, reduced the risk of the primary endpoint similarly in patients with anaemia (HR 0.84, 95% CI 0.71–1.00) and without anaemia (HR 0.78, 95% CI 0.71–0.87), p-value for interaction=0.478. Between baseline and 12 months, haemoglobin decreased by 1.5 (95% CI 1.7 to 1.2) g/L with sacubitril/valsartan compared with 2.3 (2.6 to 2.0) g/L with enalapril group: mean difference 0.8 (95% CI 0.5 to 1.2) g/L, p<0.001. The between-treatment difference apparent by 12 months, persisted up to 36 months. Patients assigned to sacubitril/valsartan were less likely to develop new anaemia at 12 months [321 of 2806 (11.4%)] compared to patients randomized to enalapril [440 of 2384 (15.6%)], odds ratio 0.70 (95% CI 0.60–0.81), p<0.001.
Conclusions
Compared to enalapril, sacubitril/valsartan reduced mortality and hospitalization in HFrEF patients with and without anaemia. Haemoglobin decreased less with sacubitril/valsartan and the incidence of new anaemia was lower in the sacubitril/valsartan group compared with the enalapril group.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): PARADIGM-HF was funded by Novartis.
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Affiliation(s)
- J Curtain
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - C Adamson
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - P S Jhund
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - A S Desai
- Brigham and Women's Hospital, Division of Cardiovascular Medicine , Boston , United States of America
| | | | - A R Rizkala
- Novartis , East Hanover , United States of America
| | - J L Rouleau
- Montreal Heart Institute , Montreal , Canada
| | - K Swedberg
- University of Gothenburg , Gothenburg , Sweden
| | - M R Zile
- Medical University of South Carolina , Charleston , United States of America
| | - S D Solomon
- Brigham and Women's Hospital, Division of Cardiovascular Medicine , Boston , United States of America
| | - M Packer
- Baylor University Medical Center , Dallas , United States of America
| | - J J V McMurray
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
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10
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Tolomeo P, Kondo T, Butt JH, Desai AS, Lefkowitz MP, Rouleau JL, Solomon SD, Swedberg K, Zile MR, Campo G, Jhund PS, Packer M, McMurray JJV. Implications of the 2021 CKD-EPI cystatin C/creatinine eGFR equation for eligibility for therapy in HFrEF: insights from PARADIGM-HF. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Estimated glomerular filtration rate (eGFR) is a key determinant of eligibility for many life-saving therapies in HFrEF. Recently, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) provided new equations based on creatinine (CKD-EPIcr), cystatin C (CKD-EPIcys) or both (CKD-EPIcyscr) that do not include race. These new equations may reclassify individuals, irrespective of race, from one eGFR category to another, with implications for eligibility for HFrEF treatments.
Purpose
To assess the difference between eGFR estimation using the 2021 CKD-EPIcyscr equation and the 2009 CKD-EPIcr and Modification of Diet in Renal Disease Study (MDRD)-4 equations which are still standard in many European laboratories.
Methods
We included patients from PARADIGM-HF with cystatin C and creatinine values available at the time of randomization. For each patient, baseline eGFRs were calculated using the 3 equations described. Our focus was on patients with chronic kidney disease (CKD) stages III–V.
Results
Overall, 1910 patients were eligible. Mean age was 67.3 (10.1) year and 385 (18.7%) were female. Using 2009 CKD-EPIcr, 779 patients were in CKD stages 3–5, of which 233 (30%) were reclassified to a better CKD stage (higher eGFR) with the 2021 CKD-EPIcyscr equation (Table 1). Similar reclassification was seen when comparing MDRD-4 with the 2021 CKD-EPIcyscr equation: 277 (33%) of 831 patients in CKD stages 3–5 were reclassified to a better CKD stage (Figure 1).
Conclusions
The 2021 CKD-EPIcyscr equation favourably reclassified CKD stage in a large percentage of patients with HFrEF and a low eGFR, potentially increasing the proportion of these patients considered eligible for guideline-recommended therapies.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- P Tolomeo
- University Hospital of Ferrara , Ferrara , Italy
| | - T Kondo
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
| | - J H Butt
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
| | - A S Desai
- Brigham and Women's, Hospital Harvard Medical School, Cardiovascular Division , Boston , United States of America
| | | | - J L Rouleau
- University of Montreal, Montreal Heart Institute , Montreal , Canada
| | - S D Solomon
- Brigham and Women's, Hospital Harvard Medical School, Cardiovascular Division , Boston , United States of America
| | - K Swedberg
- University of Gothenburg, Department of Molecular and Clinical Medicine , Gothenburg , Sweden
| | - M R Zile
- Medical University of South Carolina , Charleston , United States of America
| | - G Campo
- University Hospital of Ferrara , Ferrara , Italy
| | - P S Jhund
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
| | - M Packer
- Baylor University Medical Center, Baylor Heart and Vascular Institute , Dallas , United States of America
| | - J J V McMurray
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
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11
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Camafort M, Jhund PS, Formiga F, Castro-Salomó A, Arévalo-Lorido JC, Sobrino-Martínez J, Manzano L, Díez-Manglano J, Aramburu Ó, Montero Pérez-Barquero M. Prognostic value of ambulatory blood pressure values in elderly patients with heart failure. Results of the DICUMAP study. Rev Clin Esp 2021; 221:433-440. [PMID: 34130947 DOI: 10.1016/j.rceng.2020.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 11/10/2020] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Ambulatory blood pressure monitoring (ABPM) has demonstrated value in the prognostic assessment of hypertensive patients with heart failure (HF) with or without other cardiovascular diseases. The objective of this study was to evaluate whether ABPM can identify subjects with HF with a worse prognosis. METHODS AND RESULTS Prospective multicenter study that included clinically stable outpatients with HF. All patients underwent ABPM. A total of 154 patients from 17 centers were included. Their mean age was 76.8 years (± 8.3) and 55.2% were female. In total, 23.7% had HF with a reduced ejection fraction (HFrEF), 68.2% were in NYHA functional class II, and 19.5% were in NYHA functional class III. At one year of follow up, there were 13 (8.4%) deaths, of which 10 were attributed to HF. Twenty-nine patients required hospitalization, of which 19 were due to HF. The presence of a non-dipper BP pattern was associated with an increased risk for readmission or death at one year of follow-up (25% vs. 5%; p=.024). According to a Cox regression analysis, more advanced NYHA functional class (hazard ratio 3.51; 95% CI 1.70-7.26; p=.001; for NYHA class III vs. II) and a higher proportional nocturnal reduction in diastolic BP (hazard ratio 0.961; 95%CI 0.926-0.997; p=.032 per 1% diastolic BP reduction) were independently associated with death or readmission at one year. CONCLUSION In older patients with chronic HF, a non-dipper BP pattern measured by ABPM was associated with a higher risk of hospitalization and death due to HF.
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Affiliation(s)
- M Camafort
- Unidad de Insuficiencia Cardíaca, Servicio de Medicina Interna-ICMiD, Hospital Clínic, Universidad de Barcelona, Barcelona, Spain.
| | - P S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - F Formiga
- Servicio de Medicina Interna, Hospital Universitario de Bellvitge-IDIBELL, Universidad de Barcelona, Barcelona, Spain
| | - A Castro-Salomó
- Servicio de Medicina Interna, Hospital Sant Joan, Universidad Rovira i Virgili, Reus, Spain
| | - J C Arévalo-Lorido
- Servicio de Medicina Interna, Hospital Regional de Zafra, Badajoz, Spain
| | - J Sobrino-Martínez
- Servicio de Medicina Interna, Hospital l'Esperit Sant, Santa Coloma de Gramanet, Spain
| | - L Manzano
- Servicio de Medicina Interna, Hospital Universitario Ramón y Cajal, Universidad de Alcalá, IRYCIS, Madrid, Spain
| | - J Díez-Manglano
- Servicio de Medicina Interna, Hospital Royo Villanova, Zaragoza, Spain
| | - Ó Aramburu
- Servicio de Medicina Interna, Hospital Universitario Virgen de la Macarena, Sevilla, Spain
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Kristensen SL, Roerth R, Jhund PS, Beggs S, Kober L, Abraham WT, Desai A, Solomon S, Packer M, Rouleau J, Zile M, Dickstein K, Petrie MC, McMurray JJV. P2630Incidence and prognostic impact of new-onset left bundle branch block in patients with heart failure and reduced ejection fraction. Eur Heart J 2019. [DOI: 10.1093/eurheartj/ehz748.0953] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Cardiac resynchronization therapy (CRT) improves survival in patients with heart failure, reduced ejection fraction (HFrEF) and left bundle branch block (LBBB). However, little is known about the incidence of LBBB in HFrEF and the risk factors for developing this. We addressed these questions in the PARADIGM-HF and ATMOSPHERE trials.
Methods
We identified 7703 patients with a non-paced rhythm on their baseline ECG, a QRS<130 ms, and at least one follow-up ECG (done at annual visits and end of study). Patients were stratified by baseline QRS duration (≤100 ms - reference; 101–115 ms and 116–129 ms) and followed until development of QRS duration ≥130 ms with a LBBB configuration or latest available ECG. The crude LBBB incidence rate per 100 person-years (py) was identified in the three QRS duration subgroups. Additionally, we examined risk of the primary composite outcome of cardiovascular death or HF hospitalization, and all-cause mortality, in patients with incident LBBB vs. no incident LBBB.
Results
Overall, 313 of 7703 patients (4%) developed LBBB during a mean follow-up of 2.7 years, yielding an incidence rate of 1.5 per 100 py. The rate ranged from 0.9 in those with QRS ≤100 ms to 4.0 per 100 py in patients with QRS 116–129 ms. Other predictors of incident LBBB included male sex, age, lower LVEF, HF duration and absence of AF. The risk of the primary composite endpoint was higher among those who developed incident LBBB vs no incident LBBB; event rates 13.5 vs 10.0 per 100 py, yielding an adjusted HR of 1.43 (1.05–1.96). For all-cause mortality the corresponding rates were 12.6 vs 7.3 per 100 py; HR 1.55 (1.16–2.07) (Table 1).
Table 1. Risk of outcomes according to incident LBBB during follow-up No. events Crude rate per 100py Adjusted* HR (95% CI) HF hospitalization or CV death No incident LBBB 2145 10.0 (9.6–10.4) 1.00 (ref.) Incident LBBB 43 13.5 (10.0–18.2) 1.43 (1.05–1.96) All-cause mortality No incident LBBB 1662 7.3 (6.9–7.6) 1.00 (ref.) Incident LBBB 48 12.6 (9.5–16.7) 1.55 (1.16–2.07)
Conclusion
Among patients with HFrEF, the annual incidence of new-onset LBBB (and a potential indication for CRT), was around 1.5%, ranging from 1% in those with QRS duration below 100 ms to 4% in those with QRS 116–129 ms. Incident LBBB was associated with a much higher risk of adverse outcomes, highlighting the importance of repeat ECG monitoring in patients with HFrEF.
Acknowledgement/Funding
Novartis
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Affiliation(s)
- S L Kristensen
- Gentofte Hospital - Copenhagen University Hospital, Department of Cardiology, Hellerup, Denmark
| | - R Roerth
- Cardiovascular Research Centre of Glasgow, Cardiology, Glasgow, United Kingdom
| | - P S Jhund
- Cardiovascular Research Centre of Glasgow, Cardiology, Glasgow, United Kingdom
| | - S Beggs
- Cardiovascular Research Centre of Glasgow, Cardiology, Glasgow, United Kingdom
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital, Cardiology, Copenhagen, Denmark
| | - W T Abraham
- Ohio State University Hospital, Cardiology, Columbus, United States of America
| | - A Desai
- Brigham and Womens Hospital, Cardiology, Boston, United States of America
| | - S Solomon
- Brigham and Womens Hospital, Cardiology, Boston, United States of America
| | - M Packer
- Baylor University Medical Center, Cardiology, Dallas, United States of America
| | - J Rouleau
- Montreal Heart Institute, Cardiology, Montreal, Canada
| | - M Zile
- Medical University of South Carolina, Charleston, United States of America
| | - K Dickstein
- Stavanger University Hospital, Cardiology, Stavanger, Norway
| | - M C Petrie
- Cardiovascular Research Centre of Glasgow, Cardiology, Glasgow, United Kingdom
| | - J J V McMurray
- Cardiovascular Research Centre of Glasgow, Cardiology, Glasgow, United Kingdom
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13
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Roerth R, Kober L, Jhund PS, Kristensen SL, Aukrust P, Nymo SH, Ueland T, Wikstrand J, Kjekshus J, Gullestad L, McMurray JJV. P1803Biomarkers in heart failure patients with and without diabetes. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy565.p1803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- R Roerth
- Rigshospitalet - Copenhagen University Hospital, Heart Center, Department of Cardiology, Copenhagen, Denmark
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital, Heart Center, Department of Cardiology, Copenhagen, Denmark
| | - P S Jhund
- University of Glasgow, BHF Cardiovascular Research Centre, Glasgow, United Kingdom
| | - S L Kristensen
- Rigshospitalet - Copenhagen University Hospital, Heart Center, Department of Cardiology, Copenhagen, Denmark
| | - P Aukrust
- Oslo University Hospital, Cardiology, Oslo, Norway
| | - S H Nymo
- Oslo University Hospital, Cardiology, Oslo, Norway
| | - T Ueland
- Oslo University Hospital, Cardiology, Oslo, Norway
| | - J Wikstrand
- University of Gothenburg, Gothenburg, Sweden
| | - J Kjekshus
- Oslo University Hospital, Cardiology, Oslo, Norway
| | - L Gullestad
- Oslo University Hospital, Cardiology, Oslo, Norway
| | - J J V McMurray
- University of Glasgow, BHF Cardiovascular Research Centre, Glasgow, United Kingdom
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Davies CA, Dundas R, Hotchkiss JW, Hawkins N, Jhund PS, Scholes S, Bajekal M, O’Flaherty M, Critchley J, Leyland AH, Capewell S. The contribution of population-wide changes and preventive medications to coronary mortality reductions attributable to blood pressure changes in Scotland 2000 to 2010. Eur J Public Health 2014. [DOI: 10.1093/eurpub/cku165.038] [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: 11/13/2022] Open
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15
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Badar AA, Perez-Moreno AC, Jhund PS, Wong CM, Hawkins NM, Cleland JGF, van Veldhuisen DJ, Wikstrand J, Kjekshus J, Wedel H, Watkins S, Gardner RS, Petrie MC, McMurray JJV. Relationship between angina pectoris and outcomes in patients with heart failure and reduced ejection fraction: an analysis of the Controlled Rosuvastatin Multinational Trial in Heart Failure (CORONA). Eur Heart J 2014; 35:3426-33. [DOI: 10.1093/eurheartj/ehu342] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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16
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Dundas R, Hotchkiss JW, Davies CA, Hawkins N, Jhund PS, Scholes S, Bajekal M, O’Flaherty M, Critchley J, Leyland AH, Capewell S. OP09 Coronary mortality reductions attributable to primary prevention medications versus dietary changes in Scotland 2000–2010: modelling study using routine linked data. Br J Soc Med 2014. [DOI: 10.1136/jech-2014-204726.12] [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: 11/04/2022]
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Hotchkiss JW, Dundas R, Davies CA, Hawkins NM, Jhund PS, Scholes S, Bajekal M, O’Flaherty M, Critchley JA, Leyland AH, Capewell S. OP53 Explaining Scottish Coronary Heart Disease Mortality Trends between 2000 and 2010: Socioeconomic Analyses using the Impact Sec Model. Br J Soc Med 2013. [DOI: 10.1136/jech-2013-203126.53] [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: 11/04/2022]
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18
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Rush CJ, Campbell RT, Jhund PS, Petrie MC, Mcmurray JJV. All-cause mortality is an insensitive endpoint for clinical trials in heart failure. Eur Heart J 2013. [DOI: 10.1093/eurheartj/eht309.3551] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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Al Suhaim SA, Lewsey JL, Jhund PS, McMurray JJV. 129 PRESCRIBING MULTIPLE CLASSES OF EVIDENCE BASED PHARMACOTHERAPY IN THE COMMUNITY IS ASSOCIATED WITH LOWER MORTALITY. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Gillies M, Jhund PS, MacTeague K, MacIntyre P, Allardyce J, Batty GD, MacIntyre K. Prior psychiatric hospitalization is associated with excess mortality in patients hospitalized with non-cardiac chest pain: a data linkage study based on the full Scottish population (1991-2006). Eur Heart J 2011; 33:760-7. [DOI: 10.1093/eurheartj/ehr401] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Jhund PS, Dawson N, Davie AP, Sattar N, Norrie J, O'Kane KP, McMurray JJ. Attenuation of endothelin-1 induced vasoconstriction by 17beta estradiol is not sustained during long-term therapy in postmenopausal women with coronary heart disease. J Am Coll Cardiol 2001; 37:1367-73. [PMID: 11300448 DOI: 10.1016/s0735-1097(01)01168-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES The goal of this study was to determine the long-term effects of estrogen replacement therapy on the response to endothelin-1 (ET-1) in postmenopausal women with coronary heart disease. BACKGROUND It is thought that the vasoconstrictor ET-1 is involved in the development and progression of atherosclerosis. Estrogen replacement may slow the development of atherosclerosis in postmenopausal women. METHODS Nineteen of 20 postmenopausal women randomized to either three months of 2 mg oral estradiol or placebo completed the double-blind placebo-controlled protocol. Change in forearm blood flow (FBF) in response to a 60 min brachial arterial infusion of ET-1 (5 pmol/min) was measured before randomization, after one month of randomized therapy and after three months of therapy using venous occlusion plethysmography. RESULTS Estrogen treatment had no effect on baseline FBF. Systolic and diastolic blood pressure and heart rate did not change in response to estrogen therapy or ET-1. Before randomization, in response to ET-1, FBF was reduced by -21.9% (mean response over 60 min) in the placebo group and -19.0% in the estradiol group (p = 0.67). After one month of therapy, the response was attenuated in the estrogen group, -10.0%, compared with the placebo group, -23.6 (difference in means 13.6%, 95% confidence interval [0.7%, 26.6%], p = 0.041). After three months of therapy, there was no difference in response between the placebo group, -27.0%, and estrogen group, -30.2% (p = 0.65). CONCLUSIONS In postmenopausal women with coronary heart disease, estrogen therapy inhibits the vasoconstrictor response to ET-1 after one month of therapy. This effect is lost after three months of therapy, suggesting that tachyphylaxis to one potentially beneficial action of estradiol develops during chronic treatment.
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Affiliation(s)
- P S Jhund
- Department of Cardiology, Western Infirmary, Glasgow, Scotland
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Abstract
OBJECTIVES We sought to determine the effect of aspirin on the venodilator effect of furosemide in patients with chronic heart failure (CHF) BACKGROUND: Furosemide has an acute venodilator effect preceding its diuretic action, which is blocked by nonsteroidal anti-inflammatory, drugs. The ability of therapeutic doses of aspirin to block this effect of furosemide in patients with CHF has not been studied. For comparison, the venodilator response to nitroglycerin (NTG) was also studied. METHODS Eleven patients with CHF were randomized to receive placebo, aspirin at 75 mg/day or aspirin at 300 mg/day for 14 days in a double-blind, crossover study. The effect of these pretreatments on the change in forearm venous capacitance (FVC) after 20 mg of intravenous furosemide was measured over 20 min by using venous occlusion plethysmography. In a second study, the effect of 400 microg of sublingual NTG on FVC was documented in 11 similar patients (nine participated in the first study). RESULTS Mean arterial pressure, heart rate and forearm blood flow did not change in response to furosemide. After placebo pretreatment, furosemide caused an increase in FVC of 2.2% (95% confidence interval [CI] -0.9% to 5.2%; mean response over 20 min). By comparison, FVC fell by -1.1% (95% CI -4.2% to 1.9%) after pretreatment with aspirin at 75 mg/day, and by -3.7% (95% CI -6.8% to -0.7%) after aspirin at 300 mg/day (p = 0.020). In the second study, NTG increased FVC by 2.1% (95% CI -1.6% to 5.8%) (p = 0.95 vs. furosemide). CONCLUSIONS In patients with CHF, venodilation occurs within minutes of the administration of intravenous dose of furosemide. Our observation that aspirin inhibits this effect further questions the use of aspirin in patients with CHF.
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Affiliation(s)
- P S Jhund
- Clinical Research Initiative in Heart Failure, University of Glasgow, United Kingdom
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Affiliation(s)
- P S Jhund
- Clinical Research Initiative in Heart Failure, University of Glasgow, United Kingdom
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