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Manito N, Cepeda‐Rodrigo JM, Farré N, Castillo Orive M, Galve E, Jiménez‐Candil J, García‐Pinilla JM, López Sánchez ES, Rafols C, Gómez Doblas JJ. Factors associated with disease progression in patients with atrial fibrillation and heart failure anticoagulated with rivaroxaban. Clin Cardiol 2024; 47:e24189. [PMID: 38018889 PMCID: PMC10823448 DOI: 10.1002/clc.24189] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 10/09/2023] [Accepted: 10/30/2023] [Indexed: 11/30/2023] Open
Abstract
BACKGROUND Patients with atrial fibrillation (AF) and heart failure (HF) have a high risk of thromboembolism and other outcomes and anticoagulation is recommended. HYPOTHESIS This study was aimed to explore the risk factors associated with HF worsening in patients with AF and HF taking rivaroxaban in Spain. METHODS Multicenter, prospective, observational study that included adults with AF and chronic HF, receiving rivaroxaban ≥4 months before entering. HF worsening was defined as first hospitalization or emergency visit because of HF exacerbation. RESULTS A total of 672 patients from 71 Spanish centers were recruited, of whom 658 (97.9%) were included in the safety analysis and 552 (82.1%) in the per protocol analysis. At baseline, mean age was 73.7 ± 10.9 years, 64.9% were male, CHA2 DS2 -VASc was 4.1 ± 1.5, HAS-BLED was 1.6 ± 0.9% and 51.3% had HF with preserved ejection fraction. After 24 months of follow-up, 24.9% of patients developed HF worsening, 11.6% died, 2.9% had a thromboembolic event, 3.1% a major bleeding, 0.5% an intracranial bleeding and no patient had a fatal hemorrhage. Older age, the history of chronic obstructive pulmonary disease, the previous use of vitamin K antagonists, and restrictive or infiltrative cardiomyopathies, were independently associated with HF worsening. Only 6.9% of patients permanently discontinued rivaroxaban treatment. CONCLUSIONS Approximately one out of four patients with HF and AF treated with rivaroxaban developed a HF worsening episode after 2 years of follow-up. The identification of those factors that increase the risk of HF worsening could be helpful in the comprehensive management of this population.
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Affiliation(s)
- Nicolás Manito
- Cardiology DepartmentHospital Universitario de BellvitgeBarcelonaSpain
| | | | - Nuria Farré
- Cardiology DepartmentHospital del MarBarcelonaSpain
| | | | | | - Javier Jiménez‐Candil
- Cardiology DepartmentIBSAL‐Hospital Universitario de Salamanca, Universidad de Salamanca, CIBER‐CVSalamancaSpain
| | - José M. García‐Pinilla
- Cardiology DepartmentHospital Universitario Virgen de la VictoriaMálagaSpain
- Instituto de Investigación Biomédica de Málaga‐Plataforma BIONANDMálagaSpain
- Ciber‐CardiovascularInstituto de Salud Carlos IIIMadridSpain
- Department of Medicine and DermatologyUniversidad de MálagaMálagaSpain
| | | | | | - Juan José Gómez Doblas
- Cardiology DepartmentHospital Universitario Virgen de la VictoriaMálagaSpain
- Instituto de Investigación Biomédica de Málaga‐Plataforma BIONANDMálagaSpain
- Ciber‐CardiovascularInstituto de Salud Carlos IIIMadridSpain
- Department of Medicine and DermatologyUniversidad de MálagaMálagaSpain
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D'Amato A, Prosperi S, Severino P, Myftari V, Labbro Francia A, Cestiè C, Pierucci N, Marek-Iannucci S, Mariani MV, Germanò R, Fanisio F, Lavalle C, Maestrini V, Badagliacca R, Mancone M, Fedele F, Vizza CD. Current Approaches to Worsening Heart Failure: Pathophysiological and Molecular Insights. Int J Mol Sci 2024; 25:1574. [PMID: 38338853 PMCID: PMC10855688 DOI: 10.3390/ijms25031574] [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] [Subscribe] [Scholar Register] [Received: 12/17/2023] [Revised: 01/20/2024] [Accepted: 01/23/2024] [Indexed: 02/12/2024] Open
Abstract
Worsening heart failure (WHF) is a severe and dynamic condition characterized by significant clinical and hemodynamic deterioration. It is characterized by worsening HF signs, symptoms and biomarkers, despite the achievement of an optimized medical therapy. It remains a significant challenge in cardiology, as it evolves into advanced and end-stage HF. The hyperactivation of the neurohormonal, adrenergic and renin-angiotensin-aldosterone system are well known pathophysiological pathways involved in HF. Several drugs have been developed to inhibit the latter, resulting in an improvement in life expectancy. Nevertheless, patients are exposed to a residual risk of adverse events, and the exploration of new molecular pathways and therapeutic targets is required. This review explores the current landscape of WHF, highlighting the complexities and factors contributing to this critical condition. Most recent medical advances have introduced cutting-edge pharmacological agents, such as guanylate cyclase stimulators and myosin activators. Regarding device-based therapies, invasive pulmonary pressure measurement and cardiac contractility modulation have emerged as promising tools to increase the quality of life and reduce hospitalizations due to HF exacerbations. Recent innovations in terms of WHF management emphasize the need for a multifaceted and patient-centric approach to address the complex HF syndrome.
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Affiliation(s)
- Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Aurora Labbro Francia
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Claudia Cestiè
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Nicola Pierucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Stefanie Marek-Iannucci
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Rosanna Germanò
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
| | | | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, 00161 Rome, Italy
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3
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Long A, Salvo M. Sotagliflozin: Efficacy, Safety, and Potential Therapeutic Applications in Heart Failure. Ann Pharmacother 2023:10600280231211179. [PMID: 38014844 DOI: 10.1177/10600280231211179] [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: 11/29/2023] Open
Abstract
OBJECTIVE To describe the pharmacology, clinical efficacy, and safety evidence of sotagliflozin, the first approved dual inhibitor of sodium-glucose cotransporter (SGLT) 1 and SGLT2, in heart failure (HF) management. DATA SOURCES A literature search of studies published between January 2012 and September 2023 were identified using PubMed, MEDLINE, and clinicaltrials.gov with search terms of "sotagliflozin," "Inpefa," or "LX4211." STUDY SELECTION AND DATA EXTRACTION All available studies in English were considered. Studies were included if they investigated drug pharmacology, efficacy, or safety information. DATA SYNTHESIS Two phase 3 trials of sotagliflozin, SOLOIST-WHF and SCORED, evaluated sotagliflozin compared with placebo in patients with type 2 diabetes mellitus (T2DM). SOLOIST-WHF reported a statistically decreased rate of cardiovascular and HF events with sotagliflozin (hazard ratio [HR] = 0.67, 95% CI = 0.52-0.85), while SCORED found a statistically significant decrease in incidence of cardiovascular events in patients with T2DM, chronic kidney disease (CKD), and risk factors for cardiovascular disease in patients in the sotagliflozin group (HR = 0.74, 95% CI = 0.63-0.88). RELEVANCE TO PATIENT CARE AND CLINICAL PRACTICE IN COMPARISON TO EXISTING AGENTS While approval of sotagliflozin expands treatment options for patients with HF, the SGLT2 inhibitors, dapagliflozin and empagliflozin, have more data supporting their use in HF, additional risk reduction benefits in patients with CKD, and approval for use in T2DM. Landmark trials of sotagliflozin required a previous diagnosis of T2DM, despite the broader approved indication. Where sotagliflozin will be adopted into the treatment of HF is unclear due to the evidence and benefits of already established SGLT2 inhibitors and the need for comparison with SGLT2 inhibitors. CONCLUSION Given the limitations of currently available evidence, including difficulty in fully interpreting the trial results due to changes in primary endpoints, not adjudicating the events, and not reaching the original power calculations, more investigation is warranted to determine the benefit of sotagliflozin compared with SGLT2 inhibitors.
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Affiliation(s)
- Allissa Long
- Department of Pharmacy Practice and Administration, School of Pharmacy and Physician Assistant Studies, University of Saint Joseph, West Hartford, CT, USA
| | - Marissa Salvo
- Department of Pharmacy Practice, School of Pharmacy, University of Connecticut, Storrs, CT, USA
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Lavalle C, Di Lullo L, Jabbour JP, Palombi M, Trivigno S, Mariani MV, Summaria F, Severino P, Badagliacca R, Miraldi F, Bellasi A, Vizza CD. New Challenges in Heart Failure with Reduced Ejection Fraction: Managing Worsening Events. J Clin Med 2023; 12:6956. [PMID: 38002571 PMCID: PMC10672118 DOI: 10.3390/jcm12226956] [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: 09/29/2023] [Revised: 10/25/2023] [Accepted: 11/05/2023] [Indexed: 11/26/2023] Open
Abstract
Patients with an established diagnosis of heart failure (HF) with reduced ejection fraction (HFrEF) are prone to experience episodes of worsening symptoms and signs despite continued therapy, termed "worsening heart failure" (WHF). Despite guideline-directed medical therapy, worsening of chronic heart failure accounts for almost 50% of all hospital admissions for HF, and patients experiencing WHF carry a substantially higher risk of death and hospitalization than patients with "stable" HF. New drugs are emerging as arrows in the quiver for clinicians to address the residual risk of HF hospitalization and cardiovascular deaths in patients with WHF. This question-and-answer-based review will discuss the emerging definition of WHF in light of the recent clinical consensus released by the Heart Failure Association (HFA) of the European Society of Cardiology (ESC), the new therapeutic approaches to treat WHF and then move on to their timing and safety concerns (i.e., renal profile).
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Affiliation(s)
- Carlo Lavalle
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Luca Di Lullo
- Department of Nephrology and Dialysis, L. Parodi—Delfino Hospital, 00034 Rome, Italy;
| | - Jean Pierre Jabbour
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Marta Palombi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Sara Trivigno
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | | | - Paolo Severino
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Fabio Miraldi
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
| | - Antonio Bellasi
- Department of Medicine, Division of Nephrology, Ente Ospedaliero Cantonale, 6900 Lugano, Switzerland
| | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiologist and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico 155, 00161 Rome, Italy; (C.L.); (J.P.J.); (M.P.); (S.T.); (M.V.M.); (P.S.); (R.B.); (F.M.); (C.D.V.)
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5
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Zhirov IV, Safronova NV, Tereshchenko SN. [Sacubitril/valsartan in patients with mildly reduced or preserved ejection fraction and worsening heart failure: A review]. TERAPEVT ARKH 2023; 95:802-809. [PMID: 38158925 DOI: 10.26442/00403660.2023.09.202400] [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] [Subscribe] [Scholar Register] [Received: 11/04/2023] [Accepted: 11/04/2023] [Indexed: 01/03/2024]
Abstract
Heart failure with mildly reduced ejection fraction and heart failure with preserved ejection fraction are associated with significant morbidity and mortality, as well as growing economic burden. This review describes recent studies on the use of sacubitril/valsartan in heart failure patients with mildly reduced or preserved ejection fraction.
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Affiliation(s)
- I V Zhirov
- Chazov National Medical Research Center of Cardiology
- Russian Medical Academy of Continuous Professional Education
| | - N V Safronova
- Chazov National Medical Research Center of Cardiology
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6
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Gómez Doblas JJ, Cepeda‐Rodrigo JM, Agra Bermejo R, Blanco Labrador E, Blasco MT, Carrera Izquierdo M, Lekuona I, Recio Mayoral A, Rafols C, Manito N. Outcomes and factors associated with mortality in patients with atrial fibrillation and heart failure: FARAONIC study. Clin Cardiol 2023; 46:1390-1397. [PMID: 37596723 PMCID: PMC10642327 DOI: 10.1002/clc.24106] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/14/2023] [Indexed: 08/20/2023] Open
Abstract
BACKGROUND Heart failure (HF) and atrial fibrillation (AF) are common and coexistent conditions. HYPOTHESIS To investigate the adverse events and mortality risk factors in patients with AF and HF treated with rivaroxaban in Spain. METHODS Multicenter, prospective and observational study with a follow-up of 2 years, that included adults, with a diagnosis of nonvalvular AF and chronic HF, anticoagulated with rivaroxaban at least 4 months before being enrolled. RESULTS A total of 672 patients from 71 Spanish centers were recruited, of whom 658 (97.9%) were included in the safety analysis and 552 (82.1%) in the per protocol analysis. At baseline, the mean age was 73.7 ± 10.9 years, 65.9% were male, 51.3% had HF with preserved ejection fraction and 58.7% were on New York Heart Association functional class II. CHA2 DS2 -VASc was 4.1 ± 1.5. During the follow-up, 11.6% of patients died and around one-quarter of patients were hospitalized or visited the emergency department, being HF worsening/progression the main cause (51.1%), with a 2.9% of thromboembolic events and 2.0% of acute coronary syndromes. Major bleeding occurred in 3.1% of patients, with 0.5% experiencing intracranial bleeding but no fatalities. Compliance with HF treatment was associated with a lower risk of death (hazard ratio: 0.092; 95% confidence interval: 0.03-0.31). CONCLUSIONS Among patients with HF and AF anticoagulated with rivaroxaban, incidences of thromboembolic or hemorrhagic complications were low. The most important factor for improving survival was compliance with HF drugs, what strengths the need for early treatment with HF disease-modifying therapy and anticoagulation.
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Affiliation(s)
- Juan José Gómez Doblas
- Cardiology DepartmentHospital Clínico Universitario Virgen de la VictoriaMálagaSpain
- Centro de Investigación Biomédica en Red de Enfermedades CardiovascularesCIBERCVMadridSpain
| | | | - Rosa Agra Bermejo
- Cardiology DepartmentHospital Universitario de Santiago de CompostelaA CoruñaSpain
| | | | | | | | - Iñaki Lekuona
- Cardiology DepartmentHospital Galdakao‐UsansoloBizkaiaSpain
| | | | | | - Nicolás Manito
- Cardiology DepartmentHospital Universitario de BellvitgeBarcelonaSpain
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7
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Sandhu AT, Khera R. Lifting the Veil on Advanced Heart Failure. JACC Heart Fail 2023; 11:1607-1610. [PMID: 37737760 PMCID: PMC11009373 DOI: 10.1016/j.jchf.2023.07.031] [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] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/24/2023] [Accepted: 07/25/2023] [Indexed: 09/23/2023]
Affiliation(s)
- Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, California, USA; Stanford Prevention Research Center, Department of Medicine, Stanford University, Stanford, California, USA; Veterans Affairs Palo Alto Health Care System, Palo Alto, California, USA.
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA; Section of Biomedical Informatics and Data Science, Yale School of Public Health, New Haven, Connecticut, USA; Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, USA
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8
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Parikh RV, Go AS, Bhatt AS, Tan TC, Allen AR, Feng KY, Hamilton SA, Tai AS, Fitzpatrick JK, Lee KK, Adatya S, Avula HR, Sax DR, Shen X, Cristino J, Sandhu AT, Heidenreich PA, Ambrosy AP. Developing Clinical Risk Prediction Models for Worsening Heart Failure Events and Death by Left Ventricular Ejection Fraction. J Am Heart Assoc 2023; 12:e029736. [PMID: 37776209 PMCID: PMC10727243 DOI: 10.1161/jaha.122.029736] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 07/24/2023] [Indexed: 10/02/2023]
Abstract
Background There is a need to develop electronic health record-based predictive models for worsening heart failure (WHF) events across clinical settings and across the spectrum of left ventricular ejection fraction (LVEF). Methods and Results We studied adults with heart failure (HF) from 2011 to 2019 within an integrated health care delivery system. WHF encounters were ascertained using natural language processing and structured data. We conducted boosted decision tree ensemble models to predict 1-year hospitalizations, emergency department visits/observation stays, and outpatient encounters for WHF and all-cause death within each LVEF category: HF with reduced ejection fraction (EF) (LVEF <40%), HF with mildly reduced EF (LVEF 40%-49%), and HF with preserved EF (LVEF ≥50%). Model discrimination was evaluated using area under the curve and calibration using mean squared error. We identified 338 426 adults with HF: 61 045 (18.0%) had HF with reduced EF, 49 618 (14.7%) had HF with mildly reduced EF, and 227 763 (67.3%) had HF with preserved EF. The 1-year risks of any WHF event and death were, respectively, 22.3% and 13.0% for HF with reduced EF, 17.0% and 10.1% for HF with mildly reduced EF, and 16.3% and 10.3% for HF with preserved EF. The WHF model displayed an area under the curve of 0.76 and mean squared error of 0.13, whereas the model for death displayed an area under the curve of 0.83 and mean squared error of 0.076. Performance and predictors were similar across WHF encounter types and LVEF categories. Conclusions We developed risk prediction models for 1-year WHF events and death across the LVEF spectrum using structured and unstructured electronic health record data and observed no substantial differences in model performance or predictors except for death, despite differences in underlying HF cause.
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Affiliation(s)
- Rishi V. Parikh
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of Epidemiology and Population HealthStanford UniversityPalo AltoCAUSA
| | - Alan S. Go
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of Health Systems ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCAUSA
- Departments of Epidemiology, Biostatistics and MedicineUniversity of California, San FranciscoSan FranciscoCAUSA
- Department of MedicineStanford UniversityPalo AltoCAUSA
| | - Ankeet S. Bhatt
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Thida C. Tan
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Amanda R. Allen
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Kent Y. Feng
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Steven A. Hamilton
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Andrew S. Tai
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
| | - Jesse K. Fitzpatrick
- Department of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCAUSA
| | - Keane K. Lee
- Department of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCAUSA
| | - Sirtaz Adatya
- Department of CardiologyKaiser Permanente Santa Clara Medical CenterSanta ClaraCAUSA
| | - Harshith R. Avula
- Department of CardiologyKaiser Permanente Walnut Creek Medical CenterWalnut CreekCAUSA
| | - Dana R. Sax
- Department of Emergency MedicineKaiser Permanente Oakland Medical CenterOaklandCAUSA
| | - Xian Shen
- Novartis Pharmaceuticals CorporationEast HanoverNJUSA
| | | | - Alexander T. Sandhu
- Division of Cardiovascular Medicine, Department of MedicineStanford UniversityStanfordCAUSA
- Medical Service, VA Palo Alto Health Care SystemPalo AltoCAUSA
| | - Paul A. Heidenreich
- Division of Cardiovascular Medicine, Department of MedicineStanford UniversityStanfordCAUSA
- Medical Service, VA Palo Alto Health Care SystemPalo AltoCAUSA
| | - Andrew P. Ambrosy
- Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
- Department of Health Systems ScienceKaiser Permanente Bernard J. Tyson School of MedicinePasadenaCAUSA
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA
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9
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Haywood HB, Fonarow GC, Khan MS, Nassif ME, Butler J, Greene SJ. Hospital at Home as a Novel Care Strategy for Worsening Heart Failure. JACC Heart Fail 2023; 11:1443-1448. [PMID: 37115128 DOI: 10.1016/j.jchf.2023.02.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 02/21/2023] [Indexed: 04/29/2023]
Affiliation(s)
- Hubert B Haywood
- Department of Medicine, Duke University Medical Center, Durham, North Carolina, USA.
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, California, USA
| | | | - Michael E Nassif
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Javed Butler
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA; Baylor Scott and White Research Institute, Dallas, Texas, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
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10
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Falco L, Brescia B, Catapano D, Martucci ML, Valente F, Gravino R, Contaldi C, Pacileo G, Masarone D. Vericiguat: The Fifth Harmony of Heart Failure with Reduced Ejection Fraction. J Cardiovasc Dev Dis 2023; 10:388. [PMID: 37754817 PMCID: PMC10531735 DOI: 10.3390/jcdd10090388] [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: 08/12/2023] [Revised: 09/01/2023] [Accepted: 09/08/2023] [Indexed: 09/28/2023] Open
Abstract
Heart failure with reduced ejection fraction is a chronic and progressive syndrome that continues to be a substantial financial burden for health systems in Western countries. Despite remarkable advances in pharmacologic and device-based therapy over the last few years, patients with heart failure with reduced ejection fraction have a high residual risk of adverse outcomes, even when treated with optimal guideline-directed medical therapy and in a clinically stable state. Worsening heart failure episodes represent a critical event in the heart failure trajectory, carrying high residual risk at discharge and dismal short- or long-term prognosis. Recently, vericiguat, a soluble guanylate cyclase stimulator, has been proposed as a novel drug whose use is already associated with a reduction in heart failure-related hospitalizations in patients in guideline-directed medical therapy. In this review, we summarized the pathophysiology of the nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate cascade in patients with heart failure with reduced ejection fraction, the pharmacology of vericiguat as well as the evidence regarding their use in patients with HFrEF. Finally, tips and tricks for its use in standard clinical practice are provided.
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Affiliation(s)
- Luigi Falco
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (D.C.); (M.L.M.); (F.V.); (R.G.); (C.C.); (G.P.)
| | - Benedetta Brescia
- Department of Experimental Medicine, University of Campania “Luigi Vanvitelli”, 80131 Naples, Italy;
| | - Dario Catapano
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (D.C.); (M.L.M.); (F.V.); (R.G.); (C.C.); (G.P.)
| | - Maria Luigia Martucci
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (D.C.); (M.L.M.); (F.V.); (R.G.); (C.C.); (G.P.)
| | - Fabio Valente
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (D.C.); (M.L.M.); (F.V.); (R.G.); (C.C.); (G.P.)
| | - Rita Gravino
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (D.C.); (M.L.M.); (F.V.); (R.G.); (C.C.); (G.P.)
| | - Carla Contaldi
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (D.C.); (M.L.M.); (F.V.); (R.G.); (C.C.); (G.P.)
| | - Giuseppe Pacileo
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (D.C.); (M.L.M.); (F.V.); (R.G.); (C.C.); (G.P.)
| | - Daniele Masarone
- Heart Failure Unit, Department of Cardiology, AORN dei Colli-Monaldi Hospital, 80131 Naples, Italy; (L.F.); (D.C.); (M.L.M.); (F.V.); (R.G.); (C.C.); (G.P.)
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Greene SJ, Bauersachs J, Brugts JJ, Ezekowitz JA, Filippatos G, Gustafsson F, Lam CSP, Lund LH, Mentz RJ, Pieske B, Ponikowski P, Senni M, Skopicki N, Voors AA, Zannad F, Zieroth S, Butler J. Management of Worsening Heart Failure With Reduced Ejection Fraction: JACC Focus Seminar 3/3. J Am Coll Cardiol 2023; 82:559-571. [PMID: 37532426 DOI: 10.1016/j.jacc.2023.04.057] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 12/27/2022] [Revised: 04/03/2023] [Accepted: 04/03/2023] [Indexed: 08/04/2023]
Abstract
Despite worsening heart failure (HF) being extremely common, expensive, and associated with substantial risk of death, there remain no dedicated clinical practice guidelines for the specific management of these patients. The lack of a management guideline is despite a rapidly evolving evidence-base, as a number of recent clinical trials have demonstrated multiple therapies to be safe and efficacious in this high-risk population. Herein, we propose a framework for treating worsening HF with reduced ejection fraction with the sense of urgency it deserves. This includes treating congestion; managing precipitants; and establishing a foundation of rapid-sequence, simultaneous, and/or in-hospital initiation of quadruple medical therapy for HF with reduced ejection fraction, with the top priority being at least low doses of all 4 medications. Moreover, to maximally reduce residual clinical risk, we further propose consideration of upfront simultaneous use of vericiguat (ie, quintuple medical therapy) and administration of intravenous iron for those who are iron deficient.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | - Jasper J Brugts
- Division of Cardiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Finn Gustafsson
- Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Lars H Lund
- Department of Medicine Solna, Unit of Cardiology, Karolinska Institute, Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Michele Senni
- Cardiovascular Department and Cardiology Unit, University of Milano-Bicocca, Bergamo, Italy
| | | | - Adriaan A Voors
- University of Groningen, University Medical Center Groningen, Department of Cardiology, Groningen, the Netherlands
| | - Faiez Zannad
- Université de Lorraine, Centre d'Investigation Clinique-Plurithématique Inserm 1433, Centre Hospitalier Regional Universitaire, Nancy Brabois, France; Inserm U1116, CHRU Nancy Brabois, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | | | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; Department of Medicine, University of Mississippi, Jackson, Mississippi, USA.
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Ren L, Li F, Tan X, Fan Y, Ke B, Zhang Y, Jiang H, Jia L, Wang Y, Du J. Abnormal plasma ceramides refine high-risk patients with worsening heart failure. Front Cardiovasc Med 2023; 10:1185595. [PMID: 37456812 PMCID: PMC10339027 DOI: 10.3389/fcvm.2023.1185595] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 03/14/2023] [Accepted: 06/13/2023] [Indexed: 07/18/2023] Open
Abstract
Background Worsening heart failure (WHF) is a heterogeneous clinical syndrome with poor prognosis. More effective risk stratification tools are required to identify high-risk patients. Evidence suggest that aberrant ceramide accumulation can be affected by heart failure risk factors and as a driver of tissue damage. We hypothesized that specific ceramide lengths and ratios serve as biomarkers for risk stratification in WHF patients by reflecting pathological changes of distinct organ dysfunctions. Medthods We measured seven plasma ceramides using liquid chromatography-mass spectrometry (LC-MS) in 1,558 patients, including 1,262 participants in retrospective discovery set and 296 WHF patients in prospective validation set in BIOMS-HF study (Registry Study of Biomarkers in Heart Failure). Univariable and multivariable logistic regression models were constructed to identify associations of ceramides with organ dysfunctions. Results We constructed three ceramide-based scores linked independently to heart, liver, and kidney dysfunction, with ceramides and ratios included in each score specifying systemic inflammation, chronic metabolic disorder, and water-sodium retention. The combined ceramide heart failure score (CHFS) was independently associated with adverse outcomes [Hazard Ratio, 2.80 (95% CI: 1.78-4.40; P < 0.001); 2.68 995% CI: 1.12-6.46; P = 0.028)] and improved the predictive value of Acute Decompensated Heart Failure National Registry score and BNP [net reclassification index, 0.34 (95% confidence interval, CI: 0.19-0.50); 0.42 (95% CI: 0.13-0.70)] in the discovery and validation set, respectively. Lower BNP levels, but higher CHFS had the highest hazard of future adverse events in WHF patients. Conclusion Abnormal plasma ceramides, associated with heart and peripheral organ dysfunctions, provide incremental prognostic information over the ADHERE score and brain natriuretic peptide concentration for risk stratification in WHF patients. This may facilitate the reclassification of high-risk patients in need of aggressive therapeutic interventions.
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Affiliation(s)
- Lu Ren
- Beijing Collaborative Innovation Centre for Cardiovascular Disorders, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing lnstitute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Fengjuan Li
- Beijing Collaborative Innovation Centre for Cardiovascular Disorders, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing lnstitute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Tan
- Beijing Collaborative Innovation Centre for Cardiovascular Disorders, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing lnstitute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yangkai Fan
- Beijing Collaborative Innovation Centre for Cardiovascular Disorders, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing lnstitute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Bingbing Ke
- Department of Cardiology, Cardiovascular Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
| | - Yixin Zhang
- Institute for Cardiovascular Prevention, Ludwig-Maximilians-Universitat Munchen (LMU), Munich, Germany
| | - Hongfeng Jiang
- Beijing Collaborative Innovation Centre for Cardiovascular Disorders, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing lnstitute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lixin Jia
- Beijing Collaborative Innovation Centre for Cardiovascular Disorders, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing lnstitute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Department of Cardiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yuan Wang
- Beijing Collaborative Innovation Centre for Cardiovascular Disorders, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing lnstitute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Jie Du
- Beijing Collaborative Innovation Centre for Cardiovascular Disorders, The Key Laboratory of Remodeling-Related Cardiovascular Disease, Ministry of Education, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
- Beijing lnstitute of Heart, Lung, and Blood Vessel Diseases, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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Zieroth S, Rizi SS. Time Is of the Essence. JACC Heart Fail 2023:S2213-1779(23)00183-X. [PMID: 37178084 DOI: 10.1016/j.jchf.2023.03.022] [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: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Shekoofeh Saboktakin Rizi
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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Esteban Fernández A, Recio Mayoral A, González Franco A, Núñez Villota J, Mirabet S, Rubio Gracia J, González Costello J, Bonilla Palomas JL, Escobar Cervantes C. Optimizing the management of patients with worsening heart failure: beyond heart failure hospitalization. Expert Opin Pharmacother 2023; 24:705-713. [PMID: 36961877 DOI: 10.1080/14656566.2023.2195540] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023]
Abstract
INTRODUCTION Worsening heart failure (HF) is associated with a high risk of death and HF hospitalization. AREAS COVERED A systematic search was conducted on PubMed (MEDLINE), using the MeSH terms [Heart failure] + [Worsening] + [Treatment] + [Vulnerable period] up to February 2023. Original data from clinical trials, and observational studies were critically analyzed. EXPERT OPINION Although the vulnerable period has been traditionally limited to the first 6 months after HF hospitalization, the fact is that there are other clinical scenarios in which the patient is particularly vulnerable. These vulnerable patients may also include those that require parenteral administration of diuretics in the day hospital or emergency department, those in which the increase of oral diuretic dose in an outpatient setting is needed to relief congestive symptoms, as well as those that remain symptomatic despite treatment. On the other hand, HF is a complex disease in which different neurohormonal systems are involved. Therefore, to actually reduce the HF burden, a comprehensive management, targeting all the neurohormonal systems that are involved in the pathogenesis of HF, through the use of those drugs that have demonstrated to positively modify the clinical course of HF, is needed.
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Affiliation(s)
| | | | | | - Julio Núñez Villota
- Cardiology Department, Hospital Clínico Universitario de Valencia; Universidad de Valencia, INCLIVA, CIBER Cardiovascular, Valencia, Spain
| | - Sonia Mirabet
- Cardiology Department, Hospital de Sant Pau, CIBERCV, Barcelona, Spain
| | - Jorge Rubio Gracia
- Internal Medicine Department. Hospital Clínico Universitario Lozano Blesa. University of Zaragoza, Spain
| | - José González Costello
- Department of Cardiology, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
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Rao VN, Diez J, Gustafsson F, Mentz RJ, Senni M, Jankowska EA, Bauersachs J. Practical Patient Care Considerations With Use of Vericiguat After Worsening Heart Failure Events. J Card Fail 2023; 29:389-402. [PMID: 36529314 DOI: 10.1016/j.cardfail.2022.10.431] [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: 03/16/2022] [Revised: 10/10/2022] [Accepted: 10/29/2022] [Indexed: 12/23/2022]
Abstract
Vericiguat is a soluble guanylate cyclase stimulator approved by multiple global regulatory bodies and recommended in recently updated clinical practice guidelines to reduce morbidity and mortality in patients with worsening chronic heart failure (HF) with reduced ejection fraction (HFrEF). Despite the growing armaments of evidence-based medical therapy for HFrEF that have demonstrated clinical outcome benefits, there is a need to address residual risk following worsening HF events. When considering therapies aimed to mitigate postevent cardiovascular risk, potential barriers preventing the prescription of vericiguat in eligible patients may include providers' lack of familiarity with it, clinical inertia, limited knowledge about monitoring response to therapy, and concerns about potential adverse effects as well as integration of its routine use during an era of in-person and telehealth hybrid ambulatory care. This review provides an overview of vericiguat therapy and proposes an evidence-based and practical guidance strategy toward implementing its use in various clinical settings. This review additionally summarizes patient counseling points for its initiation and maintenance.
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Affiliation(s)
- Vishal N Rao
- Division of Cardiology, Duke University Medical Center; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Javier Diez
- Program of Cardiovascular Diseases, CIMA Universidad de Navarra, Pamplona, Spain, and CIBERCV, Carlos III Institute of Health, Madrid, Spain
| | - Finn Gustafsson
- Department of Cardiology, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark
| | - Robert J Mentz
- Division of Cardiology, Duke University Medical Center; Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Michele Senni
- University of Milano-Bicocca, Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Ewa A Jankowska
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland, and Center for Heart Diseases, University Hospital, Wrocław, Poland
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
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16
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Greene SJ, Bauersachs J, Brugts JJ, Ezekowitz JA, Lam CSP, Lund LH, Ponikowski P, Voors AA, Zannad F, Zieroth S, Butler J. Worsening Heart Failure: Nomenclature, Epidemiology, and Future Directions: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:413-24. [PMID: 36697141 DOI: 10.1016/j.jacc.2022.11.023] [Citation(s) in RCA: 39] [Impact Index Per Article: 39.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 01/25/2023]
Abstract
Heart failure (HF) is a progressive disease characterized by variable durations of symptomatic stability often punctuated by episodes of worsening despite continued therapy. These periods of clinical worsening are increasingly recognized as a distinct phase in the history of HF, termed worsening HF (WHF). The definition of WHF continues to evolve from a historical focus solely on hospitalization to now include nonhospitalization events (eg, need for intravenous diuretic therapy in the emergency or outpatient setting). Most HF clinical trials to date have had HF hospitalization and death as primary endpoints, and only recently, some studies have included other WHF events regardless of location of care. This article reviews the evolution of the WHF definition, highlights the importance of considering the onset of WHF as an event that marks a new phase of HF, summarizes the latest clinical trials investigating novel therapies, and outlines unmet needs regarding identification and treatment of WHF.
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González-Juanatey JR, Comín-Colet J, Pascual Figal D, Bayes-Genis A, Cepeda JM, García-Pinilla JM, García-Quintana A, Manzano L, Zamorano JL. Optimization of Patient Pathway in Heart Failure with Reduced Ejection Fraction and Worsening Heart Failure. Role of Vericiguat. Patient Prefer Adherence 2023; 17:839-849. [PMID: 36999163 PMCID: PMC10044168 DOI: 10.2147/ppa.s400403] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 03/10/2023] [Indexed: 04/01/2023] Open
Abstract
Heart failure (HF) is a progressive condition with periods of apparent stability and repeated worsening HF events. Over time, unless optimization of HF treatment, worsening HF events become more frequent and patients enter into a cycle of recurrent events with high morbidity and mortality. In patients with HF there is an activation of deleterious neurohormonal pathways, such as the renin angiotensin aldosterone system and the sympathetic system, and an inhibition of protective pathways, including natriuretic peptides and guanylate cyclase. Therefore, HF burden can be reduced only through a holistic approach that targets all neurohormonal systems. In this context, vericiguat may play a key role, as it is the only HF drug that activates the nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate system. On the other hand, it has been described relevant disparities in the management of HF population. Consequently, it is necessary to homogenize the management of these patients, through an integrated patient-care pathway that should be adapted at the local level. In this context, the development of new technologies (ie, video call, specific platforms, remote control devices, etc.) may be very helpful. In this manuscript, a multidisciplinary group of experts analyzed the current evidence and shared their own experience to provide some recommendations about the therapeutic optimization of patients with recent worsening HF, with a particular focus on vericiguat, and also about how the integrated patient-care pathway should be performed.
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Affiliation(s)
- José Ramón González-Juanatey
- Cardiology Department, Hospital Clínico Universitario Santiago de Compostela, Centro de investigación Biomédica en Red Enfermedades Cardiovasculares (CIBERCV), Santiago de Compostela, Spain
- Correspondence: José Ramón González-Juanatey, Email
| | - Josep Comín-Colet
- Cardiology Department, Hospital Universitario de Bellvitge, L’Hospitalet de Llobregat, Barcelona, Spain
| | - Domingo Pascual Figal
- Cardiology Department, Hospital Virgen de la Arrixaca, University of Murcia, Murcia, Spain
| | - Antoni Bayes-Genis
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Spain
| | - Jose Maria Cepeda
- Department of Internal Medicine, Hospital Vega Baja, Orihuela, Alicante, Spain
| | - José M García-Pinilla
- Cardiology Department, Hospital Universitario Virgen de la Victoria, IBIMA, Málaga, Spain
- Department of Medicine and Dermatology, Universidad de Málaga, Málaga, Spain
| | - Antonio García-Quintana
- Cardiology Department, Hospital Universitario de Gran Canaria Doctor Negrín, Universidad de Las Palmas de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Luis Manzano
- Department of Internal Medicine, Hospital Universitario Ramón y Cajal, Instituto Ramón y Cajal de Investigación Sanitaria (IRYCIS), Universidad de Alcalá, Madrid, Spain
| | - Jose Luis Zamorano
- Cardiology Department, Hospital Universitario Ramón y Cajal, Madrid, Spain
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Ostrominski JW, Vaduganathan M. Evolving therapeutic strategies for patients hospitalized with new or worsening heart failure across the spectrum of left ventricular ejection fraction. Clin Cardiol 2022; 45 Suppl 1:S40-S51. [PMID: 35789014 PMCID: PMC9254675 DOI: 10.1002/clc.23849] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2022] [Accepted: 03/03/2022] [Indexed: 11/24/2022] Open
Abstract
Heart failure (HF) is a chronic, progressive, and increasingly prevalent syndrome characterized by stepwise declines in health status and residual lifespan. Despite significant advancements in both pharmacologic and nonpharmacologic management approaches for chronic HF, the burden of HF hospitalization-whether attributable to new-onset (de novo) HF or worsening of established HF-remains high and contributes to excess HF-related morbidity, mortality, and healthcare expenditures. Owing to a paucity of evidence to guide tailored interventions in this heterogeneous group, management of acute HF events remains largely subject to clinician discretion, relying principally on alleviation of clinical congestion, as-needed correction of hemodynamic perturbations, and concomitant reversal of underlying trigger(s). Following acute stabilization, the subsequent phase of care primarily involves interventions known to improve long-term outcomes and rehospitalization risk, including initiation and optimization of disease-modifying pharmacotherapy, targeted use of adjunctive therapies, and attention to contributing comorbid conditions. However, even with current standards of care many patients experience recurrent HF hospitalization, or after admission incur worsening clinical trajectories. These patterns highlight a persistent unmet need for evidence-based approaches to inform in-hospital HF care and call for renewed focus on urgent implementation of interventions capable of ameliorating risk of worsening HF. In this review, we discuss key contemporary and emerging therapeutic strategies for patients hospitalized with de novo or worsening HF.
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Affiliation(s)
- John W. Ostrominski
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical SchoolBostonMAUSA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical SchoolBostonMAUSA
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Sepehrvand N, Islam S, Dover DC, Kaul P, McAlister FA, Armstrong PW, Ezekowitz JA. Epidemiology of worsening heart failure in a population-based cohort from Alberta, Canada: Evaluating eligibility for treatment with vericiguat. J Card Fail 2022; 28:1298-1308. [PMID: 35589087 DOI: 10.1016/j.cardfail.2022.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [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: 01/17/2022] [Revised: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients with heart failure (HF) and a reduced ejection fraction (HFrEF) who experience worsening heart failure (WHF) events are at increased risk of adverse outcomes and experience significant morbidity and mortality. We herein describe the epidemiology of these patients and identify those potentially eligible for vericiguat therapy in this population-based study. METHODS This retrospective cohort study included hospitalized or emergency department (ED) patients with a primary diagnosis of HF and left ventricular ejection fraction (LVEF) <45% diagnosed between April 1st, 2009 and March 31st, 2019 in Alberta, Canada, with follow-up to March 31st 2020. Inclusion criteria from the VICTORIA trial were applied to explore eligibility for vericiguat. RESULTS Among 25,629 patients with HF and LVEF data, 9,948 (38.8%) had HFrEF, of which 5,259 (52.8%) experienced WHF at some point during a median 5.8 years of follow-up, and 38.3% of those met the vericiguat trial eligibility criteria. Compared to HFrEF patients without WHF, those with WHF were older, with more comorbidities, worse renal function, similar LVEF status, but more use of HF medications, at baseline. At the time of WHF, 27% of those with HFrEF and WHF were on triple therapy, 50.6% were on dual therapy, and 15.4% were on monotherapy. All-cause mortality and the composite outcome of all-cause mortality or cardiovascular hospitalization at 1-year of follow-up were higher in the HFrEF with WHF cohort compared to HFrEF without WHF (adjusted hazard ratios of 1.92 and 1.51, respectively, both p<.0001). CONCLUSION Approximately, one-half of patients with HFrEF experienced WHF over long-term follow-up. Most were not on triple therapy, highlighting the underutilization of the existing standard-of-care treatments and opportunities for application of newer therapies; more than one-third of patients with HFrEF may be eligible for vericiguat. LAY SUMMARY Among patients with heart failure (HF), those who experience worsening HF are at increased risk of adverse outcomes. A few new therapies, including vericiguat, have emerged recently for patients with HF and reduced ejection fraction. However, the epidemiology, treatment patterns, and outcomes of patients with worsening HF in large representative populations is unclear. In current study, roughly, half of the patients with HF and reduced ejection fraction experienced worsening HF and 38.3% were potentially eligible for vericiguat therapy. The guideline-recommended therapies were under-utilized among patients with worsening HF, which highlights the need for initiatives to address this care gap.
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Affiliation(s)
- Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sunjidatul Islam
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Douglas C Dover
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Alberta Strategy for Patient Oriented Research Support Unit, Canada
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
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Suzuki S, Yoshihisa A, Yokokawa T, Kobayashi A, Yamaki T, Kunii H, Nakazato K, Tsuda A, Tsuda T, Ishibashi T, Konno I, Yamaguchi O, Machii H, Nozaki N, Niizeki T, Miyamoto T, Takeishi Y. Comparison between febuxostat and allopurinol uric acid-lowering therapy in patients with chronic heart failure and hyperuricemia: a multicenter randomized controlled trial. J Int Med Res 2021; 49:3000605211062770. [PMID: 34914568 PMCID: PMC8689623 DOI: 10.1177/03000605211062770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [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] [Indexed: 12/28/2022] Open
Abstract
Objective Heart failure (HF) is a common and highly morbid cardiovascular disorder. Oxidative stress worsens HF, and uric acid (UA) is a useful oxidative stress marker. The novel anti-hyperuricemic drug febuxostat is a potent non-purine selective xanthine oxidase inhibitor. The present study examined the UA-lowering and prognostic effects of febuxostat in patients with HF compared with conventional allopurinol. Methods This multicenter, randomized trial included 263 patients with chronic HF who were randomly assigned to two groups and received allopurinol or febuxostat (UA >7.0 mg/dL). All patients were followed up for 3 years after enrollment. Results There were no significant differences in baseline clinical characteristics between the two groups. The UA level was significantly decreased after 3 years of drug administration compared with the baseline in both groups. Urine levels of the oxidative stress marker 8-hydroxy-2′-deoxyguanosine were lower in the febuxostat group than in the allopurinol group (11.0 ± 9.6 vs. 22.9 ± 15.9 ng/mL), and the rate of patients free from hospitalization due to worsening HF tended to be higher in the febuxostat group than in the allopurinol group (89.0% vs. 83.0%). Conclusions Febuxostat is potentially more effective than allopurinol for treating patients with chronic HF and hyperuricemia. This study was registered in the University Hospital Medical Information Network Clinical Trials Registry (https://www.umin.ac.jp/ctr/; ID: 000009817).
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Affiliation(s)
- Satoshi Suzuki
- Department of Cardiovascular Medicine, 12775Fukushima Medical University, Fukushima Medical University, Fukushima, Japan.,Cardiology Department, 13881Takeda General Hospital, Takeda General Hospital, Aizuwakamatsu, Japan
| | - Akiomi Yoshihisa
- Department of Cardiovascular Medicine, 12775Fukushima Medical University, Fukushima Medical University, Fukushima, Japan
| | - Tetsuro Yokokawa
- Department of Cardiovascular Medicine, 12775Fukushima Medical University, Fukushima Medical University, Fukushima, Japan
| | - Atsushi Kobayashi
- Department of Cardiovascular Medicine, 12775Fukushima Medical University, Fukushima Medical University, Fukushima, Japan
| | - Takayoshi Yamaki
- Department of Cardiovascular Medicine, 12775Fukushima Medical University, Fukushima Medical University, Fukushima, Japan
| | - Hiroyuki Kunii
- Department of Cardiovascular Medicine, 12775Fukushima Medical University, Fukushima Medical University, Fukushima, Japan
| | - Kazuhiko Nakazato
- Department of Cardiovascular Medicine, 12775Fukushima Medical University, Fukushima Medical University, Fukushima, Japan
| | - Akihiro Tsuda
- Cardiology Department, 274894Sukagawa Hospital, 274894Sukagawa Hospital, Sukagawa, Japan
| | - Tatsunori Tsuda
- Cardiology Department, 274894Sukagawa Hospital, 274894Sukagawa Hospital, Sukagawa, Japan
| | - Toshiyuki Ishibashi
- Department of Cardiovascular Medicine, 36952Ohara General Hospital, Ohara General Hospital, Fukushima, Japan
| | - Ichiro Konno
- Department of Cardiovascular Medicine, 36952Ohara General Hospital, Ohara General Hospital, Fukushima, Japan
| | - Osamu Yamaguchi
- Department of Cardiovascular Medicine, 36952Ohara General Hospital, Ohara General Hospital, Fukushima, Japan
| | - Hirofumi Machii
- Department of Cardiovascular Medicine, 36952Ohara General Hospital, Ohara General Hospital, Fukushima, Japan
| | - Naoki Nozaki
- Cardiology Department, Ayase Heart Hospital, Tokyo, Japan
| | - Takeshi Niizeki
- Department of Cardiology, 50191Okitama Public General Hospital, 50191Okitama Public General Hospital, Kawanishi, Japan
| | - Takuya Miyamoto
- First Department of Internal Medicine, 538443Yamagata University Hospital, Yamagata University Hospital, Yamagata, Japan
| | - Yasuchika Takeishi
- Department of Cardiovascular Medicine, 12775Fukushima Medical University, Fukushima Medical University, Fukushima, Japan
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21
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Grand J, Miger K, Sajadieh A, Køber L, Torp-Pedersen C, Ertl G, López-Sendón J, Pietro Maggioni A, Teerlink JR, Sato N, Gimpelewicz C, Metra M, Holbro T, Nielsen OW. Systolic Blood Pressure and Outcome in Patients Admitted With Acute Heart Failure: An Analysis of Individual Patient Data From 4 Randomized Clinical Trials. J Am Heart Assoc 2021; 10:e022288. [PMID: 34514815 PMCID: PMC8649519 DOI: 10.1161/jaha.121.022288] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND In acute heart failure (AHF), systolic blood pressure (SBP) is an important clinical variable. This study assessed the association between SBP and short‐term and long‐term outcomes in a large cohort of patients with AHF. METHODS AND RESULTS This is an analysis of 4 randomized controlled trials investigating serelaxin versus placebo in patients admitted with AHF and SBPs from 125 to 180 mm Hg. Outcomes were 180‐day all‐cause mortality and a composite end point of all‐cause mortality, worsening heart failure, or hospital readmission for heart failure the first 14 days. Left ventricular ejection fraction (LVEF) was examined as LVEF<40% and LVEF≥40%. Multivariable Cox regression models were adjusted for known confounders of outcomes in AHF. A total of 10 533 patients with a mean age of 73 (±12) years and a mean SBP of 145 (±7) mm Hg were included. LVEF was assessed in 9863 patients (93%); 4737 patients (45%) had LVEF<40%. Increasing SBP was inversely associated with 180‐day mortality (adjusted hazard ratio [HRadjusted], 0.93; 95% CI, 0.89–0.98; P=0.008 per 10 mm Hg increase) and with the composite end point (HRadjusted, 0.90; 95% CI, 0.85–0.94; P<0.001 per 10 mm Hg increase). A significant interaction with LVEF was observed, revealing that SBP was not associated with mortality in patients with LVEF≥40% (HRadjusted, 0.98; 95% CI, 0.91–1.04; per 10 mm Hg increase), but was strongly associated with increased mortality in LVEF<40% (HRadjusted, 0.84; 95% CI, 0.77–0.92; per 10 mm Hg increase). CONCLUSIONS Elevated SBP is associated with favorable short‐term and long‐term outcomes in patients with AHF. In our predefined subgroup analysis, we found that baseline SBP was not associated with mortality in LVEF≥40%, but was strongly associated with mortality in patients with LVEF<40%.
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Affiliation(s)
- Johannes Grand
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Kristina Miger
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Ahmad Sajadieh
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
| | - Lars Køber
- Department of Cardiology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | | | - Georg Ertl
- Comprehensive Heart Failure Center University Hospital Würzburg Germany.,Department of Cardiology Associazione Nazionale Medicin Cardiologi Ospedalieri Research Center Florence Italy
| | - José López-Sendón
- Department of Cardiology Hospital La PazIdiPazUniversidad Autonoma de Madrid Madrid Spain.,Department of Cardiology Maria Cecilia HospitalGruppo Villa Maria S.p.A Care & Research Lugo Italy
| | - Aldo Pietro Maggioni
- Department of Cardiology Hospital La PazIdiPazUniversidad Autonoma de Madrid Madrid Spain.,Department of Cardiology Maria Cecilia HospitalGruppo Villa Maria S.p.A Care & Research Lugo Italy
| | - John R Teerlink
- Department of Cardiology University of CaliforniaSan FranciscoSan Francisco VA Medical Center Cardiology San Francisco CA
| | - Naoki Sato
- Department of Cardiovascular Medicine Kawaguchi Cardiovascular and Respiratory Hospital Saitama Japan
| | | | - Marco Metra
- Cardiology Department of Medical and Surgical Specialties Cardiothoracic Department Radiological Sciences and Public Health Civil HospitalsUniversity of Brescia Brescia Italy
| | | | - Olav W Nielsen
- Department of Cardiology Bispebjerg Hospital University of Copenhagen Copenhagen Denmark
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22
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Uemura Y, Shibata R, Ishikawa S, Takemoto K, Murohara T, Watarai M. Initiation and long-term use of tolvaptan for patients with worsening heart failure through hospital and clinic cooperation. Nagoya J Med Sci 2021; 83:431-441. [PMID: 34552281 PMCID: PMC8438006 DOI: 10.18999/nagjms.83.3.431] [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] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2020] [Accepted: 11/19/2020] [Indexed: 11/30/2022]
Abstract
Worsening heart failure (WHF) has a negative impact on the prognosis of patients with heart failure. Adequate management of non-hospitalized episodes of WHF, regarded as "outpatient WHF", may reduce the frequency of emergent/urgent hospitalization for acute heart failure; thus, the patients' cardiac parameters return to their clinical baseline. This study aimed to investigate the efficacy of tolvaptan initiation during planned hospitalization of patients with "outpatient WHF" through hospital and clinic cooperation. The data from 28 patients with outpatient WHF referred by general practitioners to hospital were assessed. Tolvaptan administration was initiated during planned hospitalization and continued in the clinics. Patients were followed-up for 12 months. None of the patients required withdrawal of tolvaptan due to adverse effects. During the follow-up period, the loop diuretic dosage significantly decreased. There were significant favorable changes in the levels of serum creatinine, estimated glomerular filtration rate, natriuretic peptide and body weight. Kaplan-Meier survival analysis revealed that the cardiac death- and HF-related hospitalization-free survival rates were significantly higher among the patients who were administered tolvaptan for the outpatient WHF than the propensity score-matched patients who were administered tolvaptan for acute heart failure requiring emergent/urgent hospitalization. In conclusion, tolvaptan may be safe and effective for the long-term management of outpatient WHF through hospital and clinic cooperation.
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Affiliation(s)
- Yusuke Uemura
- Cardiovascular Center, Anjo Kosei Hospital, Anjo, Japan
| | - Rei Shibata
- Department of Advanced Cardiovascular Therapeutics, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
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23
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Butler J, Djatche LM, Lautsch D, Yang L, Patel MJ, Mentz RJ. Representativeness of the VICTORIA Trial Population in Clinical Practice: Analysis of the PINNACLE Registry. J Card Fail 2021; 27:1374-1381. [PMID: 34271161 DOI: 10.1016/j.cardfail.2021.06.019] [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: 04/30/2021] [Revised: 06/26/2021] [Accepted: 06/27/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND In the VerICiguaT Global Study in Subjects with Heart Failure with Reduced Ejection Fraction (VICTORIA) trial, vericiguat reduced the risk of mortality due to cardiovascular problems and of hospitalization due to heart failure (HF) among patients with HF with reduced ejection fraction (HFrEF) and recent worsening HF events (WHFEs). The representativeness of the VICTORIA population of patients with WHFE in clinical practice is unknown. METHODS AND RESULTS Patients with HF and ejection fraction <45% were identified in the Practice Innovation And Clinical Excellence (PINNACLE) registry and were stratified by the occurrence of WHFEs. Characteristics and outcomes of patients in the PINNACLE registry with and without WHFEs were compared to the VICTORIA population. Of the 14,180 PINNACLE patients identified with HFrEF, 26.5% had had a WHFE. The VICTORIA population was similar to PINNACLE patients with WHFEs in mean age (67.3 vs 66.7), ejection fraction (28.9% vs 28.3%), body mass index (26.8 vs 27.6), and comorbidity burden. The rate of hospitalization because of HF at 1 year was 29.6% in the placebo group of VICTORIA, compared to 35.8% in PINNACLE patients with WHFEs and 13.3% in patients without WHFEs. CONCLUSIONS The PINNACLE patients with WHFEs meeting the VICTORIA definition resembled the VICTORIA population in characteristics and outcomes, suggesting that VICTORIA's population may be generalizable to patients with WHFEs in clinical practice.
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Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi.
| | | | | | | | | | - Robert J Mentz
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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24
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Wand AL, Russell SD, Gilotra NA. Ambulatory Management of Worsening Heart Failure: Current Strategies and Future Directions. Heart Int 2021; 15:49-53. [PMID: 36277316 PMCID: PMC9524605 DOI: 10.17925/hi.2021.15.1.49] [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: 01/20/2021] [Accepted: 02/16/2021] [Indexed: 10/29/2023] Open
Abstract
Heart failure (HF) is a highly prevalent and morbid disease in the USA. The chronic, progressive course of HF is defined by periodic exacerbations of symptoms, described as 'worsening heart failure' (WHF). Previously, episodes of WHF have required hospitalization for intravenous diuretics; however, recent innovations in care delivery models for patients with HF have allowed a transition from the acute care setting to the ambulatory setting. The development of remote monitoring strategies, including device-based algorithms and implantable haemodynamic monitoring systems, has facilitated more advanced surveillance of patients, aiming to prevent the clinical deterioration that leads to hospitalization. Additionally, the establishment of multidisciplinary HF clinics has provided the setting and resources for the outpatient treatment of WHF, specifically the administration of intravenous diuretics. Here we review the current state of ambulatory HF management, including mechanisms for patient monitoring and treatment, and outline future opportunities for outpatient management of this patient population.
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Affiliation(s)
- Alison L Wand
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stuart D Russell
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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25
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Mentz RJ, Rao VN. Worsening Heart Failure Events in HFpEF: Underlying Biology Not Treatment Location. JACC Heart Fail 2021; 9:383-385. [PMID: 33839077 PMCID: PMC9941978 DOI: 10.1016/j.jchf.2021.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Accepted: 02/01/2021] [Indexed: 10/21/2022]
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26
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Abstract
Hospitalisation for acute heart failure (AHF) is associated with high mortality and high rehospitalisation rates. In the absence of evidence-based therapy, treatment is aimed at stabilisation and symptom relief. The majority of AHF patients have signs and symptoms of fluid overload, and, therefore, decongestion is the number one treatment goal. Diuretics are the cornerstone of therapy in AHF, but the treatment effect is challenged by diuretic resistance and poor diuretic response throughout the spectrum of chronic to worsening to acute to post-worsening HF. Adequate dosing and monitoring and evaluation of diuretic effect are important for treatment success. Residual congestion at discharge is a strong predictor of worse outcomes. Therefore, achieving euvolaemia is crucial despite transient worsening renal function.
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Affiliation(s)
- Ingibjörg Kristjánsdóttir
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; and Karolinska University Hospital, Heart and Vascular Theme Stockholm, Sweden
| | - Tonje Thorvaldsen
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; and Karolinska University Hospital, Heart and Vascular Theme Stockholm, Sweden
| | - Lars H Lund
- Karolinska Institutet, Department of Medicine, Stockholm, Sweden; and Karolinska University Hospital, Heart and Vascular Theme Stockholm, Sweden
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27
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Packer M. Acute Heart Failure Is an Event Rather Than a Disease: Plea for a Radical Change in Thinking and in Therapeutic Drug Development. JACC Heart Fail 2019; 6:73-75. [PMID: 29284579 DOI: 10.1016/j.jchf.2017.05.008] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/03/2017] [Accepted: 05/17/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas.
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28
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Iacovoni A, D'Elia E, Gori M, Oliva F, Lorini FL, Senni M. Treating Patients Following Hospitalisation for Acute Decompensated Heart Failure: An Insight into Reducing Early Rehospitalisations. Card Fail Rev 2019; 5:78-82. [PMID: 31179016 PMCID: PMC6545980 DOI: 10.15420/cfr.2018.46.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [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: 12/30/2018] [Accepted: 04/19/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is a pandemic syndrome characterised by raised morbidity and mortality. An acute HF event requiring hospitalisation is associated with a poor prognosis, in both the short and the long term. Moreover, early rehospitalisation after discharge negatively affects HF management and survival rates. Cardiovascular and non-cardiovascular conditions combine to increase rates of HF hospital readmission at 30 days. A tailored approach for HF pharmacotherapy while the patient is in hospital and immediately after discharge could be useful in reducing early adverse events that cause rehospitalisation and, consequently, prevent worsening HF and readmission during the vulnerable phase after discharge.
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Affiliation(s)
- Attilio Iacovoni
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| | - Emilia D'Elia
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| | - Mauro Gori
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| | - Fabrizio Oliva
- Cardiovascular Department, ASST Grande Ospedale Metropolitano Niguarda Milan, Italy
| | | | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
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29
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Affiliation(s)
- Adam P Bress
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah.
| | - Jordan B King
- Department of Population Health Sciences, University of Utah, Salt Lake City, Utah
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30
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Davison BA, Metra M, Cotter G, Massie BM, Cleland JGF, Dittrich HC, Edwards C, Filippatos G, Givertz MM, Greenberg B, Ponikowski P, Voors AA, O'Connor CM, Teerlink JR. Worsening Heart Failure Following Admission for Acute Heart Failure: A Pooled Analysis of the PROTECT and RELAX-AHF Studies. JACC Heart Fail 2016; 3:395-403. [PMID: 25951761 DOI: 10.1016/j.jchf.2015.01.007] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.0] [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: 09/15/2014] [Revised: 01/06/2015] [Accepted: 01/07/2015] [Indexed: 12/22/2022]
Abstract
OBJECTIVES These studies conducted analyses to examine patient characteristics and outcomes associated with worsening heart failure (WHF). BACKGROUND WHF during an admission for acute heart failure (AHF) represents treatment failure and is a potential therapeutic target for clinical trials of AHF. METHODS Individual patient data from the PROTECT (Placebo-Controlled Randomized Study of the Selective A1 Adenosine Receptor Antagonist Rolofylline for Patients Hospitalized with Acute Decompensated Heart Failure and Volume Overload to Assess Treatment Effect on Congestion and Renal Function) and RELAX-AHF (Relaxin in Acute Heart Failure) phase II and III studies were pooled for analysis. RESULTS Of 3,691 patients, death or WHF through day 5 occurred in 12.4%, ranging from 9.5% to 14.5% among studies. A multivariable model provided modest discrimination between patients who did or did not develop WHF (C-index = 0.68). After multivariable adjustment, WHF was associated with a mean increase in length of stay of 5.2 days (95% confidence interval [CI]: 4.6 to 5.8 days) and increased risks of 60-day HF or renal failure readmission or cardiovascular death (hazard ratio [HR]: 1.64, 95% CI: 1.34 to 2.01) and 180-day mortality (HR: 1.93, 95% CI: 1.55 to 2.41) (all p < 0.001). The risk of mortality was higher in patients whose WHF required intravenous inotropes or mechanical therapy (HR: 3.03, 95% CI: 2.11 to 4.36) compared with patients whose WHF was treated with intravenous loop diuretic alone (HR: 1.80, 95% CI: 1.36 to 2.36) (both p < 0.001). WHF was associated with larger increases in markers of renal and hepatic dysfunction during the first days of admission, but remained significantly associated with adverse outcomes after adjustment for these changes. CONCLUSIONS WHF during the first 5 days of admission for AHF occurred in approximately 10% to 15% of patients and was associated with longer length of stay and higher risk for readmission and death.
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Affiliation(s)
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gad Cotter
- Momentum Research Inc., Durham, North Carolina
| | - Barry M Massie
- Division of Cardiology, School of Medicine, University of California-San Francisco, San Francisco, California
| | - John G F Cleland
- Department of Cardiology, University of Hull, Kingston upon Hull, United Kingdom; National Heart and Lung Institute, Royal Brompton and Harefield Hospitals National Health Service Trust, Imperial College, London, United Kingdom
| | | | | | | | - Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Barry Greenberg
- Division of Cardiology, University of California at San Diego, San Diego, California
| | - Piotr Ponikowski
- Department of Cardiology, Medical University, Clinical Military Hospital, Wroclaw, Poland
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, Groningen, the Netherlands
| | | | - John R Teerlink
- Division of Cardiology, School of Medicine, University of California-San Francisco, San Francisco, California; Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California
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