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Cox Z, Zalawadiya S, Simonato M, Redfors B, Zhou Z, Kotinkaduwa L, Zile M, Udelson J, Lim DS, Grayburn PA, Mack MJ, Abraham WT, Stone GW, Lindenfeld J. Maximally tolerated guideline-directed medical therapy and barriers to optimization in patients with heart failure with reduced ejection fraction: the COAPT trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.975] [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
The COAPT trial of MitraClip therapy employed a central screening eligibility committee (CSEC) of heart failure (HF) experts to ensure the use of maximally tolerated guideline-directed medical therapy (GDMT) and systematically document intolerances in all potential patients prior to approval for randomization.
Purpose
To describe the percentage of GDMT classes, doses tolerated, predictors of intolerance, and specific intolerances limiting GDMT among patients approved for randomization by the CSEC.
Methods
We analyzed baseline use, dose, and intolerances of i) angiotensin-converting enzyme inhibitors (ACEI), angiotensin II receptor blockers (ARB) or angiotensin receptor neprilysin inhibitor (ARNI); ii) beta-blockers (BB); and iii) mineralocorticoid receptor antagonists (MRA) in the CSEC-approved COAPT population with HF with reduced ejection fraction (HFrEF; LVEF ≤40%). We analyzed variables associated with GDMT tolerance.
Results
In COAPT, 464 patients had HFrEF and complete screening medication information. Any dose of all 3, 2 or 1 GDMT classes were tolerated in 39%, 39% and 20% of patients respectively; only 2% of patients (n=9) could not tolerate any GDMT (Figure 1). BB were prescribed in the most (93%) patients followed by ACEI/ARB/ARNI (69%) and MRA (55%). Intolerances limiting each GDMT class differed, but hypotension and kidney dysfunction were most common (Figure 2). No patients tolerated goal doses of all 3 GDMT classes. For BB, only 32% tolerated ≥50% of the goal dose; while for ACEI/ARB/ARNI, no patients achieved goal doses, and only 1% tolerated ≥50% of the goal dose. For MRA, 86% of patients tolerated 25mg/day or less. Patients intolerant of BB were less likely to tolerate an ACEI/ARB/ARNI (OR 0.39, 95% CI 0.20–0.76; p=0.004) but not a MRA (p=0.21) compared with patients tolerating a low dose BB. Patients intolerant of MRA were less likely to tolerate ACEI/ARB/ARNI therapy (OR 0.37, 95% CI 0.25–0.57; p<0.0001) but not a BB (p=0.31) compared with patients tolerating MRA. Patients tolerating low dose ACEI/ARB/ARNI had a higher baseline mean eGFR (52±21 versus 40±21 ml/min/m2; p<0.0001) compared with patients intolerant of ACEI/ARB/ARNI. Likewise, patients tolerating MRA had a higher baseline mean eGFR (52±21 versus 42±21 ml/min/m2; p<0.0001) compared with patients intolerant of MRA.
Conclusion
In a contemporary trial in which HF specialists ensured GDMT optimization, many patients had medical intolerances prohibiting use of one or more GDMT classes, and few patients tolerated target doses. These findings indicate medical intolerances are the primary cause of low GDMT prescription rates in patients with moderate to severe HFrEF. Yet, use of GDMT in this very ill population was much better than “real world” registries of HFrEF suggesting that mandating careful CSEC review prior to study enrollment is important for clinical trials having the objective of randomizing a maximally treated patient cohort.
Funding Acknowledgement
Type of funding sources: None.
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Affiliation(s)
- Z Cox
- Lipscomb University College of Pharmacy , Nashville , United States of America
| | - S Zalawadiya
- Vanderbilt University Medical Center , Nashville , United States of America
| | - M Simonato
- Cardiovascular Research Foundation , New York , United States of America
| | - B Redfors
- Cardiovascular Research Foundation , New York , United States of America
| | - Z Zhou
- Cardiovascular Research Foundation , New York , United States of America
| | - L Kotinkaduwa
- Cardiovascular Research Foundation , New York , United States of America
| | - M Zile
- Ralph H. Johnson Department of Veteran's Affairs Medical Center , Charleston , United States of America
| | - J Udelson
- Tufts Medical Center, Inc. , Boston , United States of America
| | - D S Lim
- University of Virginia , Charlottesville , United States of America
| | - P A Grayburn
- Baylor University Medical Center , Dallas , United States of America
| | - M J Mack
- Baylor Scott and White The Heart Hospital , Plano , United States of America
| | - W T Abraham
- The Ohio State University , Columbus , United States of America
| | - G W Stone
- The Zena and Michael A. Wiener Cardiovascular Institute , New York , United States of America
| | - J Lindenfeld
- Vanderbilt University Medical Center , Nashville , United States of America
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Wurtele ES, Li J, Diao L, Zhang H, Foster CM, Fatland B, Dickerson J, Brown A, Cox Z, Cook D, Lee EK, Hofmann H. MetNet: Software to Build and Model the Biogenetic Lattice of Arabidopsis. Comp Funct Genomics 2011; 4:239-45. [PMID: 18629120 PMCID: PMC2447407 DOI: 10.1002/cfg.285] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2003] [Revised: 02/07/2003] [Accepted: 02/10/2003] [Indexed: 11/06/2022] Open
Abstract
MetNet (http://www.botany.iastate.edu/∼mash/metnetex/metabolicnetex.html) is publicly
available software in development for analysis of genome-wide RNA, protein
and metabolite profiling data. The software is designed to enable the biologist to
visualize, statistically analyse and model a metabolic and regulatory network map
of Arabidopsis, combined with gene expression profiling data. It contains a JAVA
interface to an interactions database (MetNetDB) containing information on regulatory
and metabolic interactions derived from a combination of web databases (TAIR,
KEGG, BRENDA) and input from biologists in their area of expertise. FCModeler
captures input from MetNetDB in a graphical form. Sub-networks can be identified
and interpreted using simple fuzzy cognitive maps. FCModeler is intended to develop
and evaluate hypotheses, and provide a modelling framework for assessing the large
amounts of data captured by high-throughput gene expression experiments. FCModeler
and MetNetDB are currently being extended to three-dimensional virtual reality
display. The MetNet map, together with gene expression data, can be viewed using
multivariate graphics tools in GGobi linked with the data analytic tools in R. Users
can highlight different parts of the metabolic network and see the relevant expression
data highlighted in other data plots. Multi-dimensional expression data can be
rotated through different dimensions. Statistical analysis can be computed alongside
the visual. MetNet is designed to provide a framework for the formulation of testable
hypotheses regarding the function of specific genes, and in the long term provide
the basis for identification of metabolic and regulatory networks that control plant
composition and development.
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Affiliation(s)
- Eve Syrkin Wurtele
- Department of Genetics Cellular and Developmental Biology Iowa State University Ames IA 50011 USA
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Cunningham B, Lewis C, Cox Z, Lenihan D. 12. Newly designed heart failure education in a H2H demonstration project. Heart Lung 2011. [DOI: 10.1016/j.hrtlng.2011.04.028] [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: 10/28/2022]
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Sutherland P, Rossini A, Lumley T, Lewin-Koh N, Dickerson J, Cox Z, Cook D. Orca: A Visualization Toolkit for High-Dimensional Data. J Comput Graph Stat 2000. [DOI: 10.2307/1390943] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
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Sutherland P, Rossini A, Lumley T, Lewin-Koh N, Dickerson J, Cox Z, Cook D. Orca: A Visualization Toolkit for High-Dimensional Data. J Comput Graph Stat 2000. [DOI: 10.1080/10618600.2000.10474896] [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: 10/28/2022]
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