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Cavagnini ME, Best EE, Skersick PT, Truitt KP, Musick KL, Mangum BR, Hollis IB, Rodgers JE. Impact of Inpatient Initiation of SGLT2 Inhibitors on Diuretic Requirements in Patients With Heart Failure. J Pharm Pract 2024; 37:683-689. [PMID: 37032494 DOI: 10.1177/08971900231159739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/11/2023]
Abstract
Background: Sodium-glucose cotransporter 2 inhibitors (SGLT2i) have been shown to improve outcomes in patients with heart failure (HF) and are now included in guideline-directed medical therapy. Trials reporting the change in loop diuretic dose following SGLT2i initiation have indicated conflicting results. There is no clear guidance on whether reducing loop diuretic doses following SGLT2i initiation is appropriate. Objective: The purpose of this study is to assess the impact of SGLT2i initiation on diuretic adjustment in hospitalized patients with known or new HF. Methods: This was a retrospective, single health-system study assessing the change in loop diuretic dose in the 60 days following discharge for patients with HF initiated on SGLT2i therapy during a hospital admission or upon discharge. Secondary outcomes assessed effect on renal function and discontinuation of SGLT2i within the 60 day follow up period. Results: Forty percent of patients required loop diuretic dose adjustment, with 29% requiring a dose reduction within the 60 days following discharge. There was minimal change in serum creatinine or blood urea nitrogen. The SGLT2i was discontinued in 6 patients. Conclusions: After inpatient initiation of SGLT2is, approximately one-third of patients required a reduction in loop diuretic dose within 60 days following hospital discharge. Further study is recommended to confirm if empiric diuretic dose adjustments are appropriate in this HF population.
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Affiliation(s)
| | | | | | | | | | - Blake R Mangum
- University of Mississippi Medical Center, Jackson, MS, USA
| | - Ian B Hollis
- UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
- UNC Medical Center, Chapel Hill, NC, USA
| | - Jo E Rodgers
- UNC Eshelman School of Pharmacy, Chapel Hill, NC, USA
- UNC Medical Center, Chapel Hill, NC, USA
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Boonyapiphat T, Tangkittikasem T, Torpongpun A, Senthong V, Jiampo P. Real-World Clinical Burden of Newly Diagnosed Heart failure in Thai Patients. Cardiol Ther 2024:10.1007/s40119-024-00366-5. [PMID: 38709436 DOI: 10.1007/s40119-024-00366-5] [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: 01/22/2024] [Accepted: 03/18/2024] [Indexed: 05/07/2024] Open
Abstract
INTRODUCTION There are limited data on the burden of newly diagnosed patients with heart failure (HF) in Thailand. Thus, this study aimed to fully understand the hospitalization, rehospitalization, mortality rates, demographics and characteristics, and quality of care in these patients. METHOD A retrospective review of all eligible adult patients' medical records from 2018 and 2019 was conducted at five hospitals. The patients were newly diagnosed with HF, as indicated by the International Classification of Diseases (ICD)-10 code "I50." Descriptive statistics was used to investigate patients' hospital burden and clinical outcome data. RESULTS There were 1134 patients newly diagnosed with HF, classified as HF with reduced ejection fraction (HFrEF), HF with preserved ejection fraction (HFpEF), and HF with mildly reduced ejection fraction (HFmrEF) (44.0, 40.0, and 16.0%, respectively). The male-to-female ratios in HFmrEF and HFpEF were similar. In contrast, the proportion of men with HFrEF was greater. The mean age of all patients was 66.0 years. The hospitalization rate was 1.3. Rehospitalization rates for HF-related issues were 0.1, 0.2, 0.4, and 0.5 at 30 days, 60 days, 180 days, and 1 year, respectively. The percentage of deaths from all causes among these patients was 9.8%, while the percentage of deaths from cardiovascular-related causes was 8.5%. Only a small proportion of patients received a target dose of guideline-directed medical therapy (GDMT). CONCLUSIONS The study revealed that the characteristics, hospitalization rate for HF, and in-hospital mortality rate among newly diagnosed patients with HF were higher compared to similar studies conducted in Thailand and other countries. Moreover, a high quality of care is needed to improve the morbidity and mortality associated with HF in Thailand.
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Affiliation(s)
| | | | | | - Vichai Senthong
- Queen Sirikit Heart Center of the Northeast, Khon Kaen University, Mueang, Khon Kaen, Thailand
| | - Panyapat Jiampo
- Bhumibol Adulyadej Hospital, 171 Phahonyothin Road, Khlong Thanon Subdistrict, Sai Mai District, Bangkok, 10220, Thailand.
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Hamo CE, Mukhopadhyay A, Li X, Zheng Y, Kronish IM, Chunara R, Dodson J, Adhikari S, Blecker S. Association between Visit Frequency, Continuity of Care, and Pharmacy Fill Adherence in Heart Failure Patients. Am Heart J 2024:S0002-8703(24)00090-5. [PMID: 38621576 DOI: 10.1016/j.ahj.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/25/2024] [Accepted: 04/09/2024] [Indexed: 04/17/2024]
Abstract
BACKGROUND Despite advances in medical therapy for heart failure with reduced ejection fraction (HFrEF), major gaps in medication adherence to guideline-directed medical therapies (GDMT) remain. Greater continuity of care may impact medication adherence and reduced hospitalizations. METHODS We conducted a cross-sectional study of adults with a diagnosis of HF and EF≤40% with ≥2 outpatient encounters between 1/1/2017 and 10/1/2021, prescribed ≥1 of the following GDMT: 1) Beta Blocker, 2) Angiotensin Converting Enzyme Inhibitor/Angiotensin Receptor Blocker/Angiotensin Receptor Neprilysin Inhibitor, 3) Mineralocorticoid Receptor Antagonist, 4) Sodium Glucose Cotransporter-2 Inhibitor. Continuity of care was calculated using the Bice-Boxerman Continuity of Care Index (COC) and the Usual Provider of Care (UPC) index, categorized by quantile. The primary outcome was adherence to GDMT, defined as average proportion of days covered ≥80% over one year. Secondary outcomes included all-cause and HF hospitalization at 1-year. We performed multivariable logistic regression analyses adjusted for demographics, insurance status, comorbidity index, number of visits and neighborhood SES index. RESULTS Overall, 3,971 individuals were included (mean age 72 years (SD 14), 71% male, 66% White race). In adjusted analyses, compared to individuals in the highest COC quartile, individuals in the third COC quartile had higher odds of GDMT adherence (OR 1.26, 95% CI 1.03-1.53, p=0.024). UPC tertile was not associated with adherence (all p>0.05). Compared to the highest quantiles, the lowest UPC and COC quantiles had higher odds of all-cause (UPC: OR 1.53, 95% CI 1.23-1.91; COC: OR 2.54, 95% CI 1.94-3.34) and HF (UPC: OR 1.81, 95% CI 1.23-2.67; COC: OR 1.77, 95% CI 1.09-2.95) hospitalizations. CONCLUSIONS Continuity of care was not associated with GDMT adherence among patients with HFrEF but lower continuity of care was associated with increased all-cause and HF-hospitalizations.
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Affiliation(s)
- Carine E Hamo
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY.
| | - Amrita Mukhopadhyay
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Xiyue Li
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Yaguang Zheng
- New York University Rory Meyers College of Nursing, New York, NY
| | - Ian M Kronish
- Department of Medicine, Center for Behavioral Cardiovascular Health, Columbia University Irving Medical Center, New York, New York
| | - Rumi Chunara
- Department of Biostatistics, NYU School of Global Public Health, New York, New York
| | - John Dodson
- Leon H. Charney Division of Cardiology, Department of Medicine, New York University School of Medicine, New York, NY; New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Samrachana Adhikari
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
| | - Saul Blecker
- New York University Grossman School of Medicine, Department of Population Health, New York, NY
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Man JP, Klopotowska J, Asselbergs FW, Handoko ML, Chamuleau SAJ, Schuuring MJ. Digital Solutions to Optimize Guideline-Directed Medical Therapy Prescriptions in Heart Failure Patients: Current Applications and Future Directions. Curr Heart Fail Rep 2024; 21:147-161. [PMID: 38363516 PMCID: PMC10924030 DOI: 10.1007/s11897-024-00649-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Abstract
PURPOSEOF REVIEW Guideline-directed medical therapy (GDMT) underuse is common in heart failure (HF) patients. Digital solutions have the potential to support medical professionals to optimize GDMT prescriptions in a growing HF population. We aimed to review current literature on the effectiveness of digital solutions on optimization of GDMT prescriptions in patients with HF. RECENT FINDINGS We report on the efficacy, characteristics of the study, and population of published digital solutions for GDMT optimization. The following digital solutions are discussed: teleconsultation, telemonitoring, cardiac implantable electronic devices, clinical decision support embedded within electronic health records, and multifaceted interventions. Effect of digital solutions is reported in dedicated studies, retrospective studies, or larger studies with another focus that also commented on GDMT use. Overall, we see more studies on digital solutions that report a significant increase in GDMT use. However, there is a large heterogeneity in study design, outcomes used, and populations studied, which hampers comparison of the different digital solutions. Barriers, facilitators, study designs, and future directions are discussed. There remains a need for well-designed evaluation studies to determine safety and effectiveness of digital solutions for GDMT optimization in patients with HF. Based on this review, measuring and controlling vital signs in telemedicine studies should be encouraged, professionals should be actively alerted about suboptimal GDMT, the researchers should consider employing multifaceted digital solutions to optimize effectiveness, and use study designs that fit the unique sociotechnical aspects of digital solutions. Future directions are expected to include artificial intelligence solutions to handle larger datasets and relieve medical professional's workload.
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Affiliation(s)
- Jelle P Man
- Department of Cardiology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Joanna Klopotowska
- Department of Medical Informatics, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Folkert W Asselbergs
- Institute of Health Informatics, University College London, London, UK
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M Louis Handoko
- Department of Cardiology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Mark J Schuuring
- Department of Cardiology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Netherlands Heart Institute, Utrecht, The Netherlands.
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Sharif F, Rosenkranz S, Bartunek J, Kempf T, Aßmus B, Mahon NG, Hiivala NJ, Mullens W. Twelve-month follow-up results from the SIRONA 2 clinical trial. ESC Heart Fail 2024; 11:1133-1143. [PMID: 38271076 DOI: 10.1002/ehf2.14657] [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] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Revised: 11/07/2023] [Accepted: 12/18/2023] [Indexed: 01/27/2024] Open
Abstract
AIMS In the SIRONA 2 trial, the safety and efficacy of pulmonary artery (PA) pressure (PAP)-guided heart failure (HF) management using a novel PAP sensor were assessed at 30 and 90 days, respectively, and both endpoints were met. The current study examines the prespecified secondary endpoints of safety and accuracy of the PA sensor along with HF hospitalizations and mortality, HF symptoms, functional capacity, quality of life, and patient compliance through 12 months. METHODS AND RESULTS SIRONA 2 is a prospective, multi-centre, open-label, single-arm trial evaluating the Cordella™ PA Sensor System in 70 patients with New York Heart Association (NYHA) functional class III HF with a prior HF hospitalization and/or increase of N-terminal pro-brain natriuretic peptide within 12 months of enrolment. Sensor accuracy was assessed and compared with measurements obtained by standard right heart catheterization (RHC). Safety was defined as freedom from prespecified adverse events associated with use of the Cordella PA Sensor System and was assessed in all patients who entered the cath lab for PA sensor implant. HF hospitalizations and mortality, HF symptoms, functional capacity, quality of life, and patient compliance were also assessed. At 12 months, there was good agreement between the Cordella PA Sensor System and RHC, with the average difference for mean PAP being 2.9 ± 7.3 mmHg. The device safety profile was excellent with 98.4% freedom from device/system-related complications. There were no pressure sensor failures. HF hospitalizations and mortality were low with a rate of 0.33 event per patient year. Symptoms as assessed by NYHA (P < 0.0001) and functional capacity as measured by 6 min walk test (P = 0.02) were significantly improved. Patients' adherence to daily transmissions of PAP and vital signs measurements was 95%. CONCLUSIONS Long-term follow-up of the SIRONA 2 trial supports the safety and accuracy of the Cordella PA Sensor System in enabling comprehensive HF management in NYHA class III HF patients.
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Affiliation(s)
- Faisal Sharif
- Department of Cardiology, Galway University Hospital, Saolta Group, CURAM and University of Galway, Galway, Ireland
| | - Stephen Rosenkranz
- Clinic III for Internal Medicine, University of Cologne Heart Center and Cologne Cardiovascular Research Center (CCRC), Cologne, Germany
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Ziekenhuis Aalst, Aalst, Belgium
| | - Tibor Kempf
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Birgit Aßmus
- Department of Cardiology and Angiology, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Niall G Mahon
- Department of Cardiovascular Medicine, Mater University Hospital and University College Dublin, Dublin, Ireland
| | | | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
- University of Hasselt, Hasselt, Belgium
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Philip A, Dwivedi PSR, Shastry CS, Utagi B. Guideline directed medical therapy induced nephrotoxicity in HFrEF patients; an insight to its mechanism. J Biomol Struct Dyn 2024:1-15. [PMID: 38466079 DOI: 10.1080/07391102.2024.2326193] [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: 11/26/2023] [Accepted: 02/27/2024] [Indexed: 03/12/2024]
Abstract
Guideline Directed Medical Therapy (GDMT) has been the standard pharmacotherapy for the treatment of Heart Failure patients with reduced Ejection Fraction (HFrEF) recommended by the European Society of Cardiology (ESC). However, patients on GDMT are likely to possess nephrotoxicity as an adverse effect. We utilized multiple system biology tools like ADVER-Pred, gene enrichment analysis, molecular docking, molecular dynamic simulations, and MMPBSA analysis to predict a possible molecular mechanism of how selected combinations of GDMT may cause nephrotoxicity. As per the ACC/AHA/ESC guidelines, we categorized the drugs as category 1 including β-blockers (BB), angiotensin receptor blockers (ARB), and sodium-glucose cotransporter-2 inhibitors (SGLT2I), category 2 includes BB's, SGLT2I, and angiotensin receptor-neprilysin inhibitors (ARNI), and category 3 includes BB's, SGLT2I, and angiotensin-converting enzyme (ACE) inhibitors. Enrichment analysis predicted category 2 drugs to possess the highest number of proteins to be involved in the development of nephrotoxicity i.e. 79.41%. The targets HBA1, CBR1, ATG5, and SLC6A3 were the top hub genes with an edge count of 7 followed by GPX1 with an edge count of 6. Molecular docking studies revealed candesartan-SLC6A3 to possess the highest binding affinity of -10.2 kcal/mol. In addition, simulation studies displayed empagliflozin-CBR1 to possess the highest stability followed by candesartan-ATG5. A combination of β-blockers, ARBs, and SGLT2I are predicted to likely possess nephrotoxicity which may be due to the modulation of HBA1, CBR1, ATG5, and GPX1. In conclusion, candesartan and empagliflozin are most likely to cause nephrotoxicity via the modulation of HBA1, CBR1, ATG5, and GPX1.Communicated by Ramaswamy H. Sarma.
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Affiliation(s)
- Anu Philip
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Prarambh S R Dwivedi
- Department of Pharmacology, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - C S Shastry
- Department of Pharmacy Practice, NGSM Institute of Pharmaceutical Sciences (NGSMIPS), Nitte (Deemed to be University), Mangalore, India
| | - Basavaraj Utagi
- Department of Cardiology, KS Hegde Medical Academy (KSHEMA), Nitte (Deemed to be University), Mangalore, India
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Shahid I, Khan MS, Fonarow GC, Butler J, Greene SJ. Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure. Prog Cardiovasc Dis 2024; 82:61-69. [PMID: 38244825 DOI: 10.1016/j.pcad.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
Despite robust scientific evidence and strong guideline recommendations, there remain significant gaps in initiation and dose titration of guideline-directed medical therapy (GDMT) for heart failure (HF) among eligible patients. Reasons surrounding these gaps are multifactorial, and largely attributed to patient, healthcare professionals, and institutional challenges. Concurrently, HF remains a predominant cause of mortality and hospitalization, emphasizing the critical need for improved delivery of therapy to patients in routine clinical practice. To optimize GDMT, various implementation strategies have emerged in the recent decade such as in-hospital rapid initiation of GDMT, improving patient adherence, addressing clinical inertia, improving affordability, engagement in quality improvement registries, multidisciplinary clinics, and EHR-integrated interventions. This review highlights the current use and barriers to optimal utilization of GDMT, and proposes novel strategies aimed at improving GDMT in HF.
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Affiliation(s)
- Izza Shahid
- Division of Preventive Cardiology, Houston Methodist Academic Institute, Houston, TX, USA
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA; Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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Alnahhal KI, Sorour AA, Lyden SP, Caputo FJ, Park WM, Rowse JW, Quatromoni JG, Khalifeh A, Dehaini H, Bena JF, Kirksey L. Management of patients with chronic mesenteric ischemia across three consecutive eras. J Vasc Surg 2023; 78:1228-1238.e1. [PMID: 37399971 DOI: 10.1016/j.jvs.2023.06.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/05/2023]
Abstract
BACKGROUND Endovascular intervention (EI) is the most commonly used modality for chronic mesenteric ischemia (CMI). Since the inception of this technique, numerous publications have reported the associated clinical outcomes. However, no publication has reported the comparative outcomes over a period of time in which both the stent platform and adjunctive medical therapy have evolved. This study aims to assess the impact of the concomitant evolution of both the endovascular approach and optimal guideline-directed medical therapy (GDMT) on CMI outcomes over three consecutive time eras. METHODS A retrospective review at a quaternary center from January 2003 to August 2020 was performed to identify patients who underwent EIs for CMI. The patients were divided into three groups based on the date of intervention: early (2003-2009), mid (2010-2014), and late (2015-2020). At least one angioplasty/stent was performed for the superior mesenteric artery (SMA) and/or celiac artery. The patients' short- and mid-term outcomes were compared between the groups. Univariable and multivariable Cox proportional hazard models were also conducted to evaluate the clinical predictors for primary patency loss in SMA only subgroup. RESULTS A total of 278 patients were included (early, 74; mid, 95; late, 109). The overall mean age was 71 years, and 70% were females. High technical success (early, 98.6%; mid, 100%; late, 100%; P = .27) and immediate resolution of symptoms (early, 86.3%; mid, 93.7%; late, 90.8%; P = .27) were noted over the three eras. In both the celiac artery and SMA cohorts, the use of bare metal stents (BMS) declined over time (early, 99.0%; mid, 90.3%; late, 65.5%; P < .001) with a proportionate increase in covered stents (CS) (early, 0.99%; mid, 9.7%; late, 28.9%; P < .001). The use of postoperative antiplatelet and statins has increased over time (early, 89.2%; mid, 97.9%; late, 99.1%; P = .003) and (early, 47%; mid, 68%; late, 81%; P = .001), respectively. In the SMA stent-only cohort, no significant differences were noted in primary patency rates between BMS and CS (hazard ratio, 0.95; 95% confidence interval, 0.26-2.87; P = .94). High-intensity preoperative statins were associated with fewer primary patency loss events compared to none/low- or moderate-intensity statins (hazard ratio, 0.30; 95% confidence interval, 0.11-0.72; P = .014). CONCLUSIONS Consistent outcomes were observed for CMI EIs across three consecutive eras. In the SMA stent-only cohort, no statistically significant difference in early primary patency was noted for CS and BMS, making the use of CS at additional cost controversial and possibly not cost effective. Notably, the preoperative high-intensity statins were associated with improved SMA primary patency. These findings demonstrate the importance of guideline-directed medical therapy as an essential adjunct to EI in the treatment of CMI.
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Affiliation(s)
- Khaled I Alnahhal
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ahmed A Sorour
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sean P Lyden
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Francis J Caputo
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Woosup M Park
- Division of Vascular Surgery, Harrington Heart and Vascular Institute, University Hospitals, Cleveland, OH
| | - Jarrad W Rowse
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Jon G Quatromoni
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Ali Khalifeh
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Hassan Dehaini
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - James F Bena
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH
| | - Lee Kirksey
- Department of Vascular Surgery, Miller Family Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH.
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9
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Khan MS, Singh S, Segar MW, Usman MS, Keshvani N, Ambrosy AP, Fiuzat M, Van Spall HGC, Fonarow GC, Zannad F, Felker GM, Januzzi JL, O'Connor C, Butler J, Pandey A. Polypharmacy and Optimization of Guideline-Directed Medical Therapy in Heart Failure: The GUIDE-IT Trial. JACC Heart Fail 2023; 11:1507-1517. [PMID: 37115133 DOI: 10.1016/j.jchf.2023.03.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/06/2022] [Revised: 03/03/2023] [Accepted: 03/16/2023] [Indexed: 04/29/2023]
Abstract
BACKGROUND Polypharmacy is common among patients with heart failure with reduced ejection fraction (HFrEF). However, its impact on the use of optimal guideline-directed medical therapy (GDMT) is not well established. OBJECTIVES This study sought to evaluate the association between polypharmacy and odds of receiving optimal GDMT over time among patients with HFrEF. METHODS The authors conducted a post hoc analysis of the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment) trial. Polypharmacy was defined as receiving ≥5 medications (excluding HFrEF GDMT) at baseline. The outcome of interest was optimal triple therapy GDMT (concurrent administration of a renin-angiotensin-aldosterone blocker and beta-blocker at 50% of the target dose and a mineralocorticoid receptor antagonist at any dose) achieved over the 12-month follow-up. Multivariable adjusted mixed-effect logistic regression models with multiplicative interaction terms (time × polypharmacy) were constructed to evaluate how polypharmacy at baseline modified the odds of achieving optimal GDMT on follow-up. RESULTS The study included 891 participants with HFrEF. The median number of non-GDMT medications at baseline was 4 (IQR: 3-6), with 414 (46.5%) prescribed ≥5 and identified as being on polypharmacy. The proportion of participants who achieved optimal GDMT at the end of the 12-month follow-up was lower with vs without polypharmacy at baseline (15% vs 19%, respectively). In adjusted mixed models, the odds of achieving optimal GDMT over time were modified by baseline polypharmacy status (P for interaction < 0.001). Patients without polypharmacy at baseline had increased odds of achieving GDMT (OR: 1.16 [95% CI: 1.12-1.21] per 1-month increase; P < 0.001) but not patients with polypharmacy (OR: 1.01 [95% CI: 0.96-1.06)] per 1-month increase). CONCLUSIONS Patients with HFrEF who are on non-GDMT polypharmacy have lower odds of achieving optimal GDMT on follow-up.
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Affiliation(s)
- Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Sumitabh Singh
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Matthew W Segar
- Department of Cardiology, Texas Heart Institute, Houston, Texas, USA
| | - Muhammad Shariq Usman
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Neil Keshvani
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Harriette G C Van Spall
- Department of Medicine, Population Health Research Institute, Research Institute of St. Joseph's, McMaster University, Hamilton, Ontario, Canada
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm Centre d'Investigation, Centre Hospitalier Régional Universitaire, Université de Lorraine, Nancy, France
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - James L Januzzi
- Division of Cardiology, Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Ambarish Pandey
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
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10
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Davis JD. Beyond the Status Quo: Reimagining a New Era of Heart Failure Care. JACC Heart Fail 2023; 11:1546-1548. [PMID: 37589615 DOI: 10.1016/j.jchf.2023.07.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 07/19/2023] [Indexed: 08/18/2023]
Affiliation(s)
- Jonathan D Davis
- Division of Cardiology, San Francisco General Hospital, San Francisco, California, USA; Department of Medicine, University of California-San Francisco, San Francisco, California, USA.
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11
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Hamad EA, Byku M, Larson SB, Billia F. LVAD therapy as a catalyst to heart failure remission and myocardial recovery. Clin Cardiol 2023; 46:1154-1162. [PMID: 37526373 PMCID: PMC10577530 DOI: 10.1002/clc.24094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/04/2023] [Accepted: 07/11/2023] [Indexed: 08/02/2023] Open
Abstract
The management of chronic heart failure over the past decade has witnessed tremendous strides in medical optimization and device therapy including the use of left ventricular assist devices (LVAD). What we once thought of as irreversible damage to the myocardium is now demonstrating signs of reverse remodeling and recovery. Myocardial recovery on the structural, molecular, and hemodynamic level is necessary for sufficient recovery to withstand explant and achieve sustained recovery post-LVAD. Guideline-directed medical therapy and unloading have been shown to aid in recovery with the potential to successfully explant the LVAD. This review will summarize medical optimization, assessment for recovery, explant methodologies and outcomes post-recovery with explant of durable LVAD.
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Affiliation(s)
- Eman A. Hamad
- Lewis Katz School of MedicineTemple UniversityPhiladelphiaPennsylvaniaUSA
| | - Mirnela Byku
- Department of MedicineUniversity of North CarolinaChapel HillNorth CarolinaUSA
| | - Sharon B. Larson
- Baptist Heart Institute at Baptist Memorial HospitalMemphisTennesseeUSA
| | - Filio Billia
- Peter Munk Cardiac CenterUniversity Health NetworkTorontoOntarioCanada
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12
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Salah HM, Fudim M, Burkhoff D. Device Interventions for Heart Failure. JACC Heart Fail 2023; 11:1039-1054. [PMID: 37611987 DOI: 10.1016/j.jchf.2023.07.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Revised: 06/26/2023] [Accepted: 07/05/2023] [Indexed: 08/25/2023]
Abstract
Despite remarkable advances in drug therapy for heart failure (HF), the residual HF-related morbidity, mortality, and hospitalizations remain substantial across all HF phenotypes, and significant proportions of patients with HF remain symptomatic despite optimal drug therapy. Driven by these unmet clinical needs, the exponential growth of transcatheter interventions, and a recent shift in the regulatory landscape of device-based therapies, novel device-based interventions have emerged as a potential therapy for various phenotypes of HF. Device-based interventions can overcome some of the limitations of drug therapy (eg, intolerance, nonadherence, inconsistent delivery, and recurrent and long-term cost) and can target some HF-related pathophysiologic pathways more effectively than drug therapy. This paper reviews the current evolving landscape of device-based interventions in HF and highlights critical points related to implementation of these therapies in the current workflow of HF management.
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Affiliation(s)
- Husam M Salah
- Department of Internal Medicine, University of Arkansas for Medical Sciences, Little Rock, Arkansas, USA
| | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Daniel Burkhoff
- Cardiovascular Research Foundation, New York, New York, USA.
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13
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Romero E, Yala S, Sellers-Porter C, Lynch G, Mwathi V, Hellier Y, Goldman S, Rocha P, Fine JR, Liem D, Bidwell JT, Ebong I, Gibson M, Cadeiras M. Remote monitoring titration clinic to implement guideline-directed therapy for heart failure patients with reduced ejection fraction: a pilot quality-improvement intervention. Front Cardiovasc Med 2023; 10:1202615. [PMID: 37404735 PMCID: PMC10316022 DOI: 10.3389/fcvm.2023.1202615] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 05/30/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction Guideline-directed medical therapy (GDMT) is the recommended treatment for heart failure with reduced ejection fraction (HFrEF). However, the implementation remains limited, with suboptimal use and dosing. The study aimed to assess the feasibility and effect of a remote monitoring titration program on GDMT implementation. Methods HFrEF patients were randomly assigned to receive either usual care or a quality-improvement remote titration with remote monitoring intervention. The intervention group used wireless devices to transmit heart rate, blood pressure, and weight data daily, which were reviewed by physicians and nurses every 2-4 weeks. Medication tolerance was assessed via phone, and dosage instructions were given. This workflow was repeated until target doses were reached or further adjustments were not tolerated. A 4-GDMT score measured use and target dosage, with the primary endpoint being the score at 6 months follow-up. Results Baseline characteristics were similar (n = 55). A median of 85% of patients complied with transmitting device data every week. At the 6-month follow-up, the intervention group had a 4-GDMT score of 64.6% compared to 56.5% in the usual care group (p = 0.01), with a difference of 8.1% (95% CI: 1.7%-14.5%). Similar results were seen at the 12-month follow-up [difference 12.8% (CI: 5.0%-20.6%)]. The intervention group showed a positive trend in ejection fraction and natriuretic peptides, with no significant difference between groups. Conclusions The study suggests that a full-scale trial is feasible and that utilizing a remote titration clinic with remote monitoring has the potential to enhance the implementation of guideline-directed therapy for HFrEF.
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Affiliation(s)
- Erick Romero
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Stella Yala
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Camryn Sellers-Porter
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Genevieve Lynch
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Veronicah Mwathi
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Yvette Hellier
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Svetlana Goldman
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Paulo Rocha
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Jeffrey R. Fine
- Department of Public Health Sciences, University of California Davis, Davis, CA, United States
| | - David Liem
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Julie T. Bidwell
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, CA, United States
| | - Imo Ebong
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Michael Gibson
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Martin Cadeiras
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
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14
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Brooksbank JA, Faulkenberg KD, Tang WHW, Martyn T. Novel Strategies to Improve Prescription of Guideline-Directed Medical Therapy in Heart Failure. Curr Treat Options Cardiovasc Med 2023; 25:93-110. [PMID: 37077616 PMCID: PMC10073621 DOI: 10.1007/s11936-023-00979-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE OF REVIEW To examine the emerging data for novel strategies being studied to improve use and dose titration of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). RECENT FINDINGS There is mounting evidence to employ novel multi-pronged strategies to address HF implementation gaps. SUMMARY Despite high-level randomized evidence and clear national society recommendations, a large gap persists in use and dose titration of guideline-directed medical therapy (GDMT) in patients with heart failure (HF). Accelerating the safe implementation of GDMT has proven to reduce the morbidity and mortality associated with HF but remains an ongoing challenge for patients, clinicians, and health systems. In this review, we examine the emerging data for novel strategies to improve the use of GDMT including the use of multidisciplinary team-based approaches, nontraditional patient encounters, patient messaging/engagement, remote patient monitoring, and electronic health record (EHR)-based clinical alerts. While societal guidelines and implementation studies have focused on heart failure with reduced ejection fraction (HFrEF), expanding indications and evidence for the use of sodium glucose cotransporter2 (SGLT2i) will necessitate implementation efforts across the LVEF spectrum.
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Affiliation(s)
- Jeremy A. Brooksbank
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
| | | | - W. H. Wilson Tang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
- George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, OH USA
| | - Trejeeve Martyn
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
- George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, OH USA
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15
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Ahmed A, Ahmed W, Arshad MS, Suri A, Amin E, Shahid I, Memon MM. Meta-Analysis Evaluating Risk of Hyperkalemia Stratified by Baseline MRA Usage in Patients with Heart Failure Receiving SGLT2 Inhibitors. Cardiovasc Drugs Ther 2023. [PMID: 36920647 DOI: 10.1007/s10557-023-07446-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/07/2023] [Indexed: 03/16/2023]
Abstract
BACKGROUND Both mineralocorticoid receptor antagonists (MRAs) and sodium-glucose co-transporter type 2 inhibitors (SGLT2is) have demonstrated beneficial reductions in cardiovascular outcomes. However, the risk of precipitating hyperkalemia with their concomitant usage remains unclear. METHODS MEDLINE and Cochrane were searched from inception through March 2022. Randomized controlled trials on patients with heart failure (HF) evaluating the effect of SGLT2is on clinical outcomes between MRA users and non-users were considered for inclusion. Outcomes of interest were mild and moderate/severe hyperkalemia, for which hazard ratios (HR) were pooled using a random effects model. RESULTS From the 972 articles retrieved from the initial search, three RCTs (n = 14,462 patients) were included in our meta-analysis. Pooled analysis demonstrated no significant difference in the incidence of mild hyperkalemia between MRA users (HR 0.82 [0.70-0.97]) and non-users (HR 0.95 [0.77-1.17]) (P-interaction = 0.28). The risk of severe hyperkalemia was significantly decreased in MRA users (HR 0.59 [0.44-0.78]; p = 0.0002; I2 = 0%) but not in non-users (HR 0.76 [0.56-1.02]; p = 0.07; I2 = 0%) (P-interaction = 0.22). Sensitivity analysis including patients with HF with reduced ejection fraction (HFrEF) revealed similar results across all subgroups, but no significant reduction in the incidence of mild hyperkalemia (HR 0.89 [0.76-1.04] was noted in MRA users with HFrEF. CONCLUSION MRAs reduced the risk of mild or moderate/severe hyperkalemia, when added to SGLT2is. Future clinical trials should target scrupulous assessment of the risk of mild and moderate/severe hyperkalemia when used concomitantly with MRAs.
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16
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Thibodeau JT, Hendren NS, Drazner MH. Voluntary Reporting of Guideline-Directed Medical Therapy Use Rates in the Public Domain: A Challenge to the Heart Failure Community. J Card Fail 2023:S1071-9164(23)00041-6. [PMID: 36813108 DOI: 10.1016/j.cardfail.2023.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 02/10/2023] [Accepted: 02/10/2023] [Indexed: 02/24/2023]
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17
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Parwani P, Yancy CW. Sociodemographic Disparities in the GDMT Usage. JACC Heart Fail 2023; 11:173-175. [PMID: 36754527 DOI: 10.1016/j.jchf.2022.11.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 11/23/2022] [Indexed: 02/09/2023]
Affiliation(s)
- Purvi Parwani
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, California, USA.
| | - Clyde W Yancy
- Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois, USA
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18
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Guichard JL, Cowger JA, Chaparro SV, Kiernan MS, Mullens W, Mahr C, Mullin C, Forouzan O, Hiivala NJ, Sauerland A, Leadley K, Klein L. Rationale and Design of the Proactive-HF Trial for Managing Patients With NYHA Class III Heart Failure by Using the Combined Cordella Pulmonary Artery Sensor and the Cordella Heart Failure System. J Card Fail 2023; 29:171-180. [PMID: 36191758 DOI: 10.1016/j.cardfail.2022.09.006] [Citation(s) in RCA: 9] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Revised: 09/20/2022] [Accepted: 09/20/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Optimizing guideline-directed medical therapy (GDMT) and monitoring congestion in patients with heart failure (HF) are key to disease management and preventing hospitalizations. A pulmonary artery pressure (PAP)-guided HF management system providing access to body weight, blood pressure, heart rate, blood oxygen saturation, PAP, and symptoms, may provide new insights into the effects of patient engagement and comprehensive care for remote GDMT titration and congestion management. METHODS The PROACTIVE-HF study was originally approved in 2018 as a prospective, randomized, controlled, single-blind, multicenter trial to evaluate the safety and effectiveness of the Cordella PAP Sensor in patients with HF and with New York Heart Association (NYHA) functional class III symptoms. Since then, robust clinical evidence supporting PAP-guided HF management has emerged, making clinical equipoise and enrolling patients into a standard-of-care control arm challenging. Therefore, PROACTIVE-HF was changed to a single-arm trial in 2021 with prespecified safety and effectiveness endpoints to provide evidence for a similar risk/benefit profile as the CardioMEMS HF System. CONCLUSION The single-arm PROACTIVE-HF trial is expected to further demonstrate the benefits of PAP-guided HF management of patients with NYHA class III HF. The addition of vital signs, patient engagement and self-reported symptoms may provide new insights into remote GDMT titration and congestion management.
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Affiliation(s)
- Jason L Guichard
- Department of Medicine, Division of Cardiology, Section for Advanced Heart Failure, Pulmonary Hypertension, and Mechanical Circulatory Support, Prisma Health-Upstate, Greenville, South Carolina, United States
| | - Jennifer A Cowger
- Department of Medicine, Division of Cardiology, Henry Ford Health, Detroit, Michigan, United States
| | - Sandra V Chaparro
- Miami Cardiac and Vascular Institute, Division of Cardiology, Baptist South Florida, Miami, Florida, United States
| | - Michael S Kiernan
- Department of Medicine, Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, United States
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Claudius Mahr
- Department of Medicine, Division of Cardiology, University of Washington, Seattle, Washington, United States
| | - Chris Mullin
- NAMSA, Product Development Strategy, Saint Paul, Minnesota, United States
| | - Omid Forouzan
- Clinical Development, Endotronix, Lisle, Chicago, Illinois, United States
| | - Nicholas J Hiivala
- Clinical Development, Endotronix, Lisle, Chicago, Illinois, United States
| | - Andrea Sauerland
- Clinical Development, Endotronix, Lisle, Chicago, Illinois, United States
| | | | - Liviu Klein
- Advanced Heart Failure Comprehensive Care Center and Division of Cardiology, University of California San Francisco, San Francisco, California, United States.
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19
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Wilcox JE, Al-Khatib SM. Personalizing Risk Assessment for Sudden Cardiac Death in Heart Failure: A Dream or a Reality? JACC Heart Fail 2023; 11:55-57. [PMID: 36599550 DOI: 10.1016/j.jchf.2022.10.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 10/25/2022] [Indexed: 01/03/2023]
Affiliation(s)
- Jane E Wilcox
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.
| | - Sana M Al-Khatib
- Duke Clinical Research Institute and Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA
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20
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Nakamura M, Imamura T, Izumida T, Nakagaito M, Ushijima R, Kinugawa K. Feasibility and Efficacy of Exercise Training Concomitant with Re-Assessment of Medical Therapy in Patients with Heart Failure Receiving Intravenous Inotropes. Int Heart J 2023; 64:641-646. [PMID: 37518345 DOI: 10.1536/ihj.23-043] [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: 08/01/2023]
Abstract
Exercise training in addition to re-assessment of medical treatments is recommended for patients with advanced heart failure. However, the feasibility and efficacy of exercise training in patients with heart failure receiving intravenous inotropes remains uncertain.Clinical data were analyzed from consecutive patients with stabilized hemodynamics receiving intravenous inotropes for more than 1 week and undergoing cardiac rehabilitation at our institute between February 2020 and May 2022. All patients received re-assessment of guideline-directed medical therapy and non-pharmacological treatment, in addition to the exercise therapy. The intensity of exercise training was determined based on the results of cardiopulmonary exercise testing.A total of 10 patients receiving intravenous inotropes (median age 60 years, left ventricular ejection fraction 23%) were included. All patients received low-dose dobutamine and 4 patients received concomitant milrinone. Exercise training was continued for 112 days on median without any critical complications. Intravenous inotropes were continued for 41 days on median and weaned off in all patients. Plasma B-type natriuretic peptide decreased slightly from 291 (129, 526) to 177 (54, 278) pg/mL (P = 0.070) and peak oxygen consumption increased from 10.0 (8.3, 15.3) to 15.2 (10.9, 17.2) mL/kg/minute (P = 0.142) during the 6-month observational period following the initiation of exercise intervention.Exercise training might be feasible and effective in patients with advanced heart failure receiving low-dose intravenous inotrope support concomitant with re-assessment of medical treatment.
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Affiliation(s)
- Makiko Nakamura
- Second Department of Internal Medicine, University of Toyama
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21
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Waezsada E, Hutter J, Kahle P, Yogarajah J, Sperzel J, Kuniss M, Neumann T, Esser H, Hamm C, Hain A. Guideline Directed Medical Therapy at Discharge and Further Uptitration Leading to Reduction in Indication for Prophylactic ICD Implantation during Protected Waiting Period. J Clin Med 2022; 11. [PMID: 36294443 DOI: 10.3390/jcm11206122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/05/2022] [Accepted: 10/13/2022] [Indexed: 12/02/2022] Open
Abstract
Heart failure with reduced ejection fraction (LV-EF < 35%) is diagnosed in app. 11,000,000 patients worldwide. For the treatment of these patients, guideline directed medical therapy has proven to reduce mortality and rehospitalization regardless of the disease’s etiology. It is implemented to treat clinical symptoms by improving the left ventricular ejection fraction. Patients with a transient risk of ventricular tachycardia and sudden cardiac death can be protected by a defibrillator vest. The defibrillator vest is capable to detect and terminate ventricular arrhythmias during Guideline Directed Medical Therapy (GDMT). It is based on the recommendations of the European society of cardiology for 3 months. Afterwards, the WCD wear time could be prolonged, or, in case of persistent low ejection fraction (LV-EF ≤ 35%), an implantable cardioverter defibrillator (ICD) should be implanted, as shown in the WEARIT-II-registry. Our goal was to evaluate the effects of GDMT on LV-recovery and reduction of ICD implantations under protection with a defibrillator vest—depending on the uptitration of GDMT. Methods: 339 consecutive patients between August 2017 and September 2020 with newly diagnosed cardiomyopathy and an EF ≤ 35% were analyzed retrospectively by chart review. All patients were protected by a wearable cardioverter defibrillator (WCD). GDMT as recommended by the ESC started at discharge from hospital. The left ventricular ejection fraction (LV-EF) was determined by transthoracic echocardiography at week 4, 8 and at week 12 (in case of prolonged WCD wear time). Uptitration was performed after 4 and 8 weeks during patient visits. We focused on baseline medication as per GDMT and the dosage increase at week 4, 8 and 12. The aim was the uptitration to the maximum dosage tolerated by the patient. We also compared the LV-EF improvement in the group with and without uptitration of medication dosage. Results: The patient age was, on average, 63.2 years (SD ± 11.9 years). A total of 129 pts (38%) had ICM, 196 (58%) had NICM (incl 66 pts (19%) with DCM and 51 pts (15%) with Myocarditis, 79 pts (24%) with unknown origin) and 14 pts (4%) had other entities (e.g., Tachycardiomyopathy). In total, 21 pts (6%) had an LV-EF of less than 16%, 130 pts (38%) between 16−25% and 183 pts (54%) between 26−35%. GDMT started at discharge from the hospital included treatment with beta blocker for 327 pts (96.5%), ACE-inhibitors/Angiotensin/ARNI for 283 pts (83.5%) and Mineralcorticoid receptor antagonists (MRA) for 334 pts (88.4%). Uptitration was performed in all groups at a rate of 82.3%, 91.1% and 81.0% after 4 weeks and 64.7%, 50.3% and 66.3% after 8 weeks, respectively. After 4 weeks, 25 pts (7.4%) and, after 8 weeks, 171 pts (50.4%) had an EF increase of 5% or more (mean 14.2%). After 4 weeks, 81 patients had an LV-EF more than 35%. A total of 169 pts had a wear time of 12 weeks and an improvement of LVEF of more than 35%. Interestingly, in our study we did not find a significant difference in LV-EF improvement between the group with no uptitration and the group with uptitration. Conclusions: Guideline-directed medical therapy under protection with a WCD from ventricular arrhythmia can reduce the need for implantation of an ICD and can lead to an improvement of ejection fraction. Interestingly, the LV-EF improvement depends on the GDMT at discharge. Current guidelines recommend an initiation of all therapy columns of GDMT (sacubitril/valsartan, ACE-inhibitor/AT1-blocker, mineralcorticoidreceptorblocker, beta blocker) at once and further uptitration to the maximal dosage (ESC Guidelines 2021). A further uptitration of all drugs of GDMT should lead to improvement of LV-EF and consequently to a reduction in ICD implantations.
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22
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Kanwar MK, Selzman CH, Ton VK, Miera O, Cornwell WK, Antaki J, Drakos S, Shah P. Clinical myocardial recovery in advanced heart failure with long term left ventricular assist device support. J Heart Lung Transplant 2022; 41:1324-1334. [PMID: 35835680 PMCID: PMC10257189 DOI: 10.1016/j.healun.2022.05.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 05/16/2022] [Accepted: 05/23/2022] [Indexed: 10/18/2022] Open
Abstract
Left ventricular assist-device (LVAD) implantation is a life-saving therapy for patients with advanced heart failure (HF). With chronic unloading and circulatory support, LVAD-supported hearts often show significant reverse remodeling at the structural, cellular and molecular level. However, translation of these changes into meaningful cardiac recovery allowing LVAD explant is lagging. Part of the reason for this discrepancy is lack of anticipation and hence promotion and evaluation for recovery post LVAD implant. There is additional uncertainty about the long-term course of HF following LVAD explant. In selected patients, however, guided by the etiology of HF, duration of disease and other clinical factors, significant functional improvement and LVAD explantation with long-term freedom from recurrent HF events has been demonstrated to be feasible in a reproducible manner. The identified predictors of myocardial recovery suggest that the elective therapeutic use of potentially less invasive VADs for reversal of HF earlier in the disease process is a future goal that warrants further investigation. Hence, it is prudent to develop and implement tools to predict HF reversibility prior to LVAD implant, optimize unloading-promoted recovery with guideline directed medical therapy and monitor for myocardial improvement. This review article summarizes the clinical aspects of myocardial recovery and together with its companion review article focused on the biological aspects of recovery, they aim to provide a useful framework for clinicians and investigators.
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Affiliation(s)
- Manreet K Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania.
| | - Craig H Selzman
- Division of Cardiothoracic Surgery, University of Utah, Salt Lake City, Utah
| | - Van-Khue Ton
- Massachusetts General Hospital, Harvard Medical School, Boston, Maryland
| | - Oliver Miera
- Department of Congenital Heart Disease, Pediatric Cardiology, German Heart Center, Berlin, Germany
| | - William K Cornwell
- Department of Medicine Cardiology, University of Colorado Anschutz Medical Campus, Aurora, Colorado
| | - James Antaki
- Meinig School of Biomedical Engineering, Cornell University, Ithaca, New York
| | - Stavros Drakos
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City, Utah
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
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23
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Tseliou E, Lavine KJ, Wever-Pinzon O, Topkara VK, Meyns B, Adachi I, Zimpfer D, Birks EJ, Burkhoff D, Drakos SG. Biology of myocardial recovery in advanced heart failure with long-term mechanical support. J Heart Lung Transplant 2022; 41:1309-1323. [PMID: 35965183 DOI: 10.1016/j.healun.2022.07.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [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: 12/13/2021] [Revised: 07/03/2022] [Accepted: 07/07/2022] [Indexed: 10/17/2022] Open
Abstract
Cardiac remodeling is an adaptive, compensatory biological process following an initial insult to the myocardium that gradually becomes maladaptive and causes clinical deterioration and chronic heart failure (HF). This biological process involves several pathophysiological adaptations at the genetic, molecular, cellular, and tissue levels. A growing body of clinical and translational investigations demonstrated that cardiac remodeling and chronic HF does not invariably result in a static, end-stage phenotype but can be at least partially reversed. One of the paradigms which shed some additional light on the breadth and limits of myocardial elasticity and plasticity is long term mechanical circulatory support (MCS) in advanced HF pediatric and adult patients. MCS by providing (a) ventricular mechanical unloading and (b) effective hemodynamic support to the periphery results in functional, structural, cellular and molecular changes, known as cardiac reverse remodeling. Herein, we analyze and synthesize the advances in our understanding of the biology of MCS-mediated reverse remodeling and myocardial recovery. The MCS investigational setting offers access to human tissue, providing an unparalleled opportunity in cardiovascular medicine to perform in-depth characterizations of myocardial biology and the associated molecular, cellular, and structural recovery signatures. These human tissue findings have triggered and effectively fueled a "bedside to bench and back" approach through a variety of knockout, inhibition or overexpression mechanistic investigations in vitro and in vivo using small animal models. These follow-up translational and basic science studies leveraging human tissue findings have unveiled mechanistic myocardial recovery pathways which are currently undergoing further testing for potential therapeutic drug development. Essentially, the field is advancing by extending the lessons learned from the MCS cardiac recovery investigational setting to develop therapies applicable to the greater, not end-stage, HF population. This review article focuses on the biological aspects of the MCS-mediated myocardial recovery and together with its companion review article, focused on the clinical aspects, they aim to provide a useful framework for clinicians and investigators.
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Affiliation(s)
- Eleni Tseliou
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Kory J Lavine
- Division of Cardiology, Washington University School of Medicine, St Louis, MO
| | - Omar Wever-Pinzon
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT
| | - Veli K Topkara
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY
| | - Bart Meyns
- Department of Cardiology and Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Iki Adachi
- Division of Cardiac Surgery, Texas Children's Hospital, Houston, TX
| | - Daniel Zimpfer
- Department of Surgery, Division of Cardiac Surgery, Medical University of Vienna, Vienna, Austria
| | | | - Daniel Burkhoff
- Department of Medicine, Division of Cardiology, Columbia University College of Physicians and Surgeons, New York, NY; Cardiovascular Research Foundation (CRF), New York, NY
| | - Stavros G Drakos
- Division of Cardiovascular Medicine, University of Utah Health, Salt Lake City, UT; Nora Eccles Harrison Cardiovascular Research and Training Institute, University of Utah Health, Salt Lake City, UT.
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24
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Sharif F, Rosenkranz S, Bartunek J, Kempf T, Assmus B, Mahon NG, Mullens W. Safety and efficacy of a wireless pulmonary artery pressure sensor: primary endpoint results of the SIRONA 2 clinical trial. ESC Heart Fail 2022; 9:2862-2872. [PMID: 35686479 DOI: 10.1002/ehf2.14006] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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: 05/11/2022] [Accepted: 05/19/2022] [Indexed: 11/11/2022] Open
Abstract
AIMS Implantable pulmonary artery pressure (PAP) sensors have been shown to reduce heart failure hospitalizations (HFH) in selected patients. The goal of this study was to evaluate the safety and efficacy of a novel wireless PAP monitoring system in patients with heart failure (HF). METHODS AND RESULTS This is a prospective, multi-centre, open-label, single-arm trial evaluating the safety and efficacy of the Cordella™ PA Sensor System including the comprehensive Cordella™ Heart Failure System (CHFS) in patients with New York Heart Association (NYHA) Class III heart failure with a heart failure hospitalization and/or increase of N-terminal pro-Brain Natriuretic Peptide (NT-proBNP) within 12 months of enrolment. The primary efficacy endpoint was the accuracy of PA sensor mean PAP measurements, compared with fluid-filled catheter mean PAP measurements obtained by standard right heart catheterization (RHC) at 90 days post-implant, assessed in all patients with a successful implant. The primary safety endpoint was freedom from adverse events associated with use of the Cordella PA Sensor System through 30 days post-implant, assessed in all patients who entered the cath lab for PA sensor implant. The PA sensor was successfully implanted in 70 patients. Equivalence between the PA sensor and RHC for mean pulmonary artery pressures was excellent with measurements confined within the equivalence bounds of -4.0 to 4.0 mmHg (mean PAP: 0.0 to 2.9 mmHg, P = 0.003). The device safety profile was excellent with 98.6% freedom from Device System Related Complications, defined as invasive treatment, device explant or death. There were no pressure sensor failures. Patients' adherence to daily measurement transmissions of PAP and vital signs was 94%. CONCLUSIONS This trial supports the safety and efficacy of the Cordella PA Sensor System and in conjunction with the CHFS enables comprehensive HF management in NYHA class III heart failure patients.
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Affiliation(s)
- Faisal Sharif
- Department of Cardiology, Galway University Hospital, Saolta Group, CURAM and BioInnovate Ireland, National University of Ireland Galway, Galway, Ireland
| | - Stephen Rosenkranz
- Clinic III for Internal Medicine, University of Cologne Heart Center and Cologne Cardiovascular Research Center (CCRC), Cologne, Germany
| | - Jozef Bartunek
- Cardiovascular Center Aalst, OLV Ziekenhuis Aalst, Aalst, Belgium
| | - Tibor Kempf
- Department of Cardiology and Angiology, Centre for Internal Medicine, Hannover Medical School, Hannover, Germany
| | - Birgit Assmus
- Department of Cardiology and Angiology, University Hospital Giessen and Marburg GmbH, Giessen, Germany
| | - Niall G Mahon
- Department of Cardiovascular Medicine, Mater University Hospital and University College Dublin, Dublin, Ireland
| | - Wilfried Mullens
- Department of Cardiovascular Medicine, Ziekenhuis Oost Limburg, University Hasselt, Genk, Belgium
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Hain A, Busch N, Waezsada SE, Hutter J, Kahle P, Kuniss M, Neumann T, Masuda T, Esser HO, Hamm C, Sperzel J. High Resting Heart Rates Are Associated with Early Posthospitalization Mortality in Low Ejection Fraction Patients. J Clin Med 2022; 11:jcm11102901. [PMID: 35629031 PMCID: PMC9148130 DOI: 10.3390/jcm11102901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 05/10/2022] [Accepted: 05/16/2022] [Indexed: 11/26/2022] Open
Abstract
Guideline-directed medical therapy (GDMT) is crucial in reducing mortality in patients with heart failure with heart rate lowering by a beta blocker (BB) being an important therapeutic concept. We aimed to assess the usefulness of a wearable cardioverter/defibrillator (WCD) to provide detailed information about heart rate for managing patients with reduced left ventricular ejection fraction (LVEF) and symptoms of heart failure and to correlate mortality with the mean heart rate. A total of 4509 consecutive patients (mean age: 59 + 13 years, 88% male) were analyzed retrospectively. All patients had reduced LVEF and were prescribed a WCD for protection from sudden cardiac death (SCD) during GDMT uptitration awaiting LVEF recovery. The device continuously measured nighttime and daytime HR at the beginning and end of WCD use. Patients who died during wear time had significantly higher HRs compared with survivors: daytime beginning of use (BOU), 80 ± 15 bpm vs. 76 ± 13, p < 0.01; nighttime BOU, 76 ± 14 vs. 69 ± 13, p < 0.0001; daytime end of use (EOU), 84 ± 20 vs. 73 ± 13, p < 0.0001; nighttime EOU, 80 ± 20 vs. 65 ± 12, p < 0.0001). In conclusion, HR monitoring with a WCD yields important prognostic information and may assist in optimal usage of BB in patients with low LVEF.
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Affiliation(s)
- Andreas Hain
- Kerckhoff Klinik Bad Nauheim, 61231 Bad Nauheim, Germany; (N.B.); (S.E.W.); (J.H.); (P.K.); (M.K.); (T.N.); (J.S.)
- Correspondence:
| | - Nikolai Busch
- Kerckhoff Klinik Bad Nauheim, 61231 Bad Nauheim, Germany; (N.B.); (S.E.W.); (J.H.); (P.K.); (M.K.); (T.N.); (J.S.)
| | - Said Elias Waezsada
- Kerckhoff Klinik Bad Nauheim, 61231 Bad Nauheim, Germany; (N.B.); (S.E.W.); (J.H.); (P.K.); (M.K.); (T.N.); (J.S.)
| | - Julie Hutter
- Kerckhoff Klinik Bad Nauheim, 61231 Bad Nauheim, Germany; (N.B.); (S.E.W.); (J.H.); (P.K.); (M.K.); (T.N.); (J.S.)
| | - Patrick Kahle
- Kerckhoff Klinik Bad Nauheim, 61231 Bad Nauheim, Germany; (N.B.); (S.E.W.); (J.H.); (P.K.); (M.K.); (T.N.); (J.S.)
| | - Malte Kuniss
- Kerckhoff Klinik Bad Nauheim, 61231 Bad Nauheim, Germany; (N.B.); (S.E.W.); (J.H.); (P.K.); (M.K.); (T.N.); (J.S.)
| | - Thomas Neumann
- Kerckhoff Klinik Bad Nauheim, 61231 Bad Nauheim, Germany; (N.B.); (S.E.W.); (J.H.); (P.K.); (M.K.); (T.N.); (J.S.)
| | - Tsyuoshi Masuda
- ZOLL Services LLC, Pittsburgh, PA 15238, USA; (T.M.); (H.O.E.)
| | - Horst O. Esser
- ZOLL Services LLC, Pittsburgh, PA 15238, USA; (T.M.); (H.O.E.)
| | - Christian Hamm
- Department of Cardiology, University Hospital Giessen, 35392 Giessen, Germany;
| | - Johannes Sperzel
- Kerckhoff Klinik Bad Nauheim, 61231 Bad Nauheim, Germany; (N.B.); (S.E.W.); (J.H.); (P.K.); (M.K.); (T.N.); (J.S.)
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Yehya A, Davis JD, Sauer AJ, Ibrahim NE. Is it time to revisit ICD indications? Heart Fail Rev 2022; 27:2177-2179. [PMID: 35080736 DOI: 10.1007/s10741-022-10215-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/10/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Amin Yehya
- Sentara Heart Hospital, Norfolk, VA, USA.
| | | | - Andrew J Sauer
- The University of Kansas Health System, Kansas City, KS, USA
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Joseph S, Panniyammakal J, Abdullakutty J, S S, Vaikathuseril L J, Joseph J, Mattummal S, Punnose E, Unni G, Natesan S, Sivadasanpillai H. The Cardiology Society of India-Kerala Acute Heart Failure Registry: poor adherence to guideline-directed medical therapy. Eur Heart J 2021:ehab793. [PMID: 34931232 DOI: 10.1093/eurheartj/ehab793] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/12/2021] [Revised: 04/08/2021] [Accepted: 11/03/2021] [Indexed: 12/19/2022] Open
Abstract
AIMS Data on the burden of acute heart failure (AHF) admissions, practice patterns, and outcomes are rare from India and other low- and middle-income countries. We aimed to describe the baseline characteristics, guideline-directed medical therapy (GDMT) prescribing patterns and 90-day mortality rates in patients admitted with AHF in Kerala, India. METHODS AND RESULTS The Cardiology Society of India-Kerala Acute Heart Failure Registry (CSI-KHFR) is an observational registry from 50 hospitals in Kerala, India, with prospective follow-up. Consecutive patients with AHF, who consented to participate, were enrolled. The 2016 European Society of Cardiology criteria were used for the diagnosis of AHF. Kaplan-Meier survival analysis and Cox-proportional hazard models were used for data analysis. The variables in the MAGGIC risk score were used in the multivariable model. A total of 7507 patients with AHF (37% female) participated in the CSI-KHFR. The mean age was 64.3 (12.9) years. More than two-third had reduced ejection fraction (EF) (67.5%). Nearly one-fourth (28%) of patients with heart failure (HF) with reduced EF received GDMT. Overall, in-hospital and 90-day mortality rates were 7% and 11.6%, respectively. Prescriptions of different components of GDMT were independently associated with 90-day mortality. CONCLUSION The CSI-KHFR recorded an in-hospital and 90-day mortality of 7% and 11.6%, respectively. Only one of four patients received GDMT. AHF mortality was independently associated with GDMT initiation. Quality improvement initiatives that focus on increasing GDMT prescription may improve the survival of HF patients in India.
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Affiliation(s)
- Stigi Joseph
- Department of Cardiology, Little Flower Hospital and Research Centre, Angamaly, Ernakulam, Kerala 683572, India
| | - Jeemon Panniyammakal
- Sree Chitra Tirunal Institute for Medical Sciences and Technology, Trivandrum, India
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Shukkoor AA, George NE, Radhakrishnan S, Velusamy S, Kaliappan T, Gopalan R, Anandan P, Palanimuthu R, Balasubramanian VR. Impact of Clinical Audit on Adherence to the Guidelines Directed Medical Therapy in Patients Admitted with Heart Failure. Curr Drug Saf 2021; 15:117-123. [PMID: 32156240 DOI: 10.2174/1574886315666200310114528] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [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: 09/16/2019] [Revised: 12/19/2019] [Accepted: 02/24/2020] [Indexed: 11/22/2022]
Abstract
BACKGROUND The adoption of guideline recommendations of pharmacotherapy to improve the clinical course of Heart Failure (HF) remains below par. Our objective is to evaluate the impact of clinical audit on adherence to the Guideline-Directed Medical Therapy (GDMT) in patients admitted with acute heart failure with reduced ejection fraction (EF). METHODS A prospective interventional study was conducted over a period of 12 months from June 2018 to May 2019 in all patients admitted with acute heart failure with reduced ejection fraction. The discharge prescriptions of patients who met the inclusion criteria were audited for appropriateness in the usage of neurohormonal blockers and Ivabradine, by a clinical pharmacist on a monthly basis. Audit results were presented to the practicing physicians every month and feedback was given. RESULTS Discharge prescriptions of 716 patients who presented with HF were audited for the reasonable or unreasonable omission of neurohormonal blocking drugs. The first-month audit revealed that the unreasonable omission of Angiotensin-Converting Enzyme Inhibitors/ Angiotensin Receptor Blockers/ Angiotensin Receptor Neprilisin Inhibitors ( ACEI/ARB/ARNI), Betablockers and Mineralocorticoid Receptor Antagonists (MRA) were 24.5%, 13.1%, and 9.09% respectively, which reduced to nil at the end of the study period (p=0.00). Initiation of Ivabradine before prescribing or achieving the target dose of Betablocker was noted in 38.18% of patients in the first month, which was also reduced to nil (p=0.00) at the end of the study. CONCLUSION This study reveals that periodic clinical audit improves adherence to GDMT in patients admitted with heart failure with reduced ejection fraction.
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Affiliation(s)
| | - Nimmy E George
- Department of Cardiology, PSG Hospitals, Tamilnadu, India
| | | | - Sivakumar Velusamy
- Department of Pharmacy Practice, PSG College of Pharmacy, Tamil Nadu, India
| | - Tamilarasu Kaliappan
- Department of Cardiology, PSG Institute of Medical Science and Research, Tamil Nadu, India
| | - Rajendiran Gopalan
- Department of Cardiology, PSG Institute of Medical Science and Research, Tamil Nadu, India
| | - Premkrishna Anandan
- Department of Cardiology, PSG Institute of Medical Science and Research, Tamil Nadu, India
| | - Ramasamy Palanimuthu
- Department of Cardiology, PSG Institute of Medical Science and Research, Tamil Nadu, India
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29
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Egbuche O, Hanna B, Onuorah I, Uko E, Taha Y, Ghali JK, Onwuanyi A. Contemporary Pharmacologic Management of Heart Failure with Reduced Ejection Fraction: A Review. Curr Cardiol Rev 2020; 16:55-64. [PMID: 31288726 PMCID: PMC7393599 DOI: 10.2174/1573403x15666190709185011] [Citation(s) in RCA: 5] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2019] [Revised: 06/11/2019] [Accepted: 06/21/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure with reduced ejection fraction (HFrEF) is defined as the presence of typical symptoms of heart failure (HF) and a left ventricular ejection fraction ≤ 40%. HFrEF patients constitute approximately 50% of all patients with clinical HF. Despite breakthrough discoveries and advances in the pharmacologic management of HF, HFrEF patients continue to pose a significant economic burden due to a progressive disease characterized by recurrent hospitalizations and need for advanced therapy. Although there are effective, guideline-directed medical therapies for patients with HFrEF, a significant proportion of these patients are either not on appropriate medications’ combination or on optimal tolerable medications’ doses. Since the morbidity and mortality benefits of some of the pharmacologic therapies are dose-dependent, optimal medical therapy is required to impact the burden of disease, quality of life, prognosis, and to curb health care expenditure. In this review, we summarize landmark trials that have impacted the management of HF and we review contemporary pharmacologic management of patients with HFrEF. We also provide insight on general considerations in the management of HFrEF in specific populations. We searched PubMed, Scopus, Medline and Cochrane library for relevant articles published until April 2019 using the following key words “heart failure”, “management”, “treatment”, “device therapy”, “reduced ejection fraction”, “guidelines”, “guideline directed medical therapy”, “trials” either by itself or in combination. We also utilized the cardiology trials portal to identify trials related to heart failure. We reviewed guidelines, full articles, review articles and clinical trials and focused on the pharmacologic management of HFrEF.
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Affiliation(s)
- Obiora Egbuche
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
| | - Bishoy Hanna
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
| | - Ifeoma Onuorah
- Division of Cardiovascular Disease, Emory University Hospital, Atlanta, GA 30322, United States
| | - Emmanuela Uko
- Division of Peadiatric Medicine, Icahn School of Medicine at Mount Sinai, NYC, New York, United States
| | - Yasir Taha
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
| | - Jalal K Ghali
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
| | - Anekwe Onwuanyi
- Division of Cardiovascular Disease, Morehouse School of Medicine, Atlanta, GA 30303, United States
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30
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Abstract
Heart failure (HF) and HF 30-day readmission rates have been a major focus of efforts to reduce health care cost in the recent era. Since the implementation of the Affordable Care Act (ACA) in 2012 and the Hospital Readmission Reduction Program (HRRP), concerted efforts have focused on reduction of 30-day HF readmissions and other admission diagnoses targeted by the HRRP. Hospitals and organizations have instituted wide-ranging programs to reduce short-term readmissions, but the data supporting these programs is often mixed. In this review, we will discuss the challenges associated with reducing HF readmissions and summarize the rationale and effect of specific programs on HF 30-day readmission rates, ranging from medical therapy and adherence to remote hemodynamic monitoring. Finally, we will review the effect that the focus on reducing 30-day HF readmissions has had on the care of the HF patient.
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Affiliation(s)
- David Goldgrab
- University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06032, USA
| | - Kathir Balakumaran
- University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06032, USA
| | - Min Jung Kim
- University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06032, USA
| | - Sara R Tabtabai
- University of Connecticut Health Center, 263 Farmington Avenue, Farmington, CT, 06032, USA.
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31
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Abstract
PURPOSE OF REVIEW Heart failure is associated with an enormous burden on both patients and health care systems in the USA. Several national policy initiatives have focused on improving the quality of heart failure care, including reducing readmissions following hospitalization, which are common, costly, and, at least in part, preventable. The transition from inpatient to ambulatory care setting and the immediate post-hospitalization period present an opportunity to further optimize guideline concordant medical therapy, identify reversible issues related to worsening heart failure, and evaluate prognosis. It can also provide opportunities for medication reconciliation and optimization, consideration of device-based therapies, appropriate management of comorbidities, identification of individual barriers to care, and a discussion of goals of care based on prognosis. RECENT FINDINGS Recent studies suggest that attention to detail regarding patient comorbidities, barriers to care, optimization of both diuretic and neurohormonal therapies, and assessment of prognosis improve patient outcomes. Despite the fact that the transition period appears to be an optimal time to address these issues in a comprehensive manner, most patients are not referred to programs specializing in this approach post hospital discharge. The objective of this review is to provide an outline for early post discharge care that allows clinicians and other health care providers to care for these heart failure patients in a manner that is both firmly rooted in the guidelines and patient-centered. Data regarding which intervention is most likely to confer benefit to which subset of patients with this disease is lacking and warrants further study.
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Affiliation(s)
- Richard J Soucier
- Sections of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT, 06520, USA
| | - P Elliott Miller
- Sections of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT, 06520, USA
| | - Joseph J Ingrassia
- Division of Cardiology, University of Connecticut Health Center, 263 Farmington Ave, Farmington, CT, 06032, USA
| | - Ralph Riello
- Division of Pharmacy, Yale University School of Medicine, New Haven, CT, USA
| | - Nihar R Desai
- Sections of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT, 06520, USA.,Center for Outcomes Research and Evaluation, Yale New Haven Health System, Yale New Haven Hospital, New Haven, CT, USA
| | - Tariq Ahmad
- Sections of Cardiovascular Medicine, Yale University School of Medicine, 135 College Street, Suite 230, New Haven, CT, 06520, USA.
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