1
|
Chatur S, Neuen BL, Claggett BL, Beldhuis IE, Mc Causland FR, Desai AS, Rouleau JL, Zile MR, Lefkowitz MP, Packer M, McMurray JJ, Solomon SD, Vaduganathan M. Effects of Sacubitril/Valsartan Across the Spectrum of Renal Impairment in Patients With Heart Failure. J Am Coll Cardiol 2024:S0735-1097(24)06691-9. [PMID: 38588927 DOI: 10.1016/j.jacc.2024.03.392] [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: 03/04/2024] [Revised: 03/20/2024] [Accepted: 03/20/2024] [Indexed: 04/10/2024]
Abstract
BACKGROUND The Kidney Disease Improving Global Outcomes (KDIGO) classification integrates both estimated glomerular filtration rate(eGFR) and urine-albumin-creatinine-ratio to stratify risk more comprehensively in patients with chronic kidney disease. There are limited data assessing whether this classification system is associated with prognosis and treatment response in heart failure populations. METHODS PARADIGM-HF was a global RCT evaluating sacubitril/valsartan vs. enalapril in patients with HFrEF. Patients were classified according to low, moderate, and high/very high KDIGO risk. Treatment responses were assessed according to baseline KDIGO risk. The primary outcome was a composite of CV death or HF hospitalization. A renal composite outcome was defined as sustained decline in eGFR by ≥40% or end stage kidney disease. RESULTS Among 1,910 (23% of total) participants with available data, 42%, 32%, and 26% were classified as low, moderate, and high/very high KDIGO risk, respectively. Patients in the highest KDIGO risk categories experienced the highest rates of the primary composite outcome (7.6[6.5-9.0], 9.4[7.9-11.2], 14.9[12.7-17.6] per 100py; P<0.001). Sacubitril/valsartan had a similar safety profile and similarly reduced the risk of both the primary outcome (PInteraction=0.31) and the renal composite outcome (PInteraction=0.50) across the spectrum of KDIGO risk. CONCLUSION One in 4 patients with HFrEF were classified as at least high KDIGO kidney risk; these individuals faced concordantly the highest risks of CV events. Sacubitril/valsartan exhibited consistent CV and kidney protective benefits as well as safety across the spectrum of baseline kidney risk. These data further support initiation of sacubitril/valsartan in HFrEF across a broad range of kidney risk.
Collapse
Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brendon L Neuen
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Iris E Beldhuis
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; University of Groningen, Department of Cardiology, University of Medical Center Groningen, The Netherlands
| | - Finnian R Mc Causland
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA; Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Michael R Zile
- Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | | | - Milton Packer
- Baylor University Medical Center, Dallas, Texas, USA
| | - John Jv McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
2
|
Butt JH, McDowell K, Kondo T, Desai AS, Lefkowitz MP, Packer M, Petrie MC, Pfeffer MA, Rouleau JL, Vaduganathan M, Zile MR, Jhund PS, Køber L, Solomon S, McMurray JJ. Heart failure with preserved ejection fraction, red cell distribution width, and sacubitril/valsartan. ESC Heart Fail 2024; 11:65-77. [PMID: 37813587 PMCID: PMC10804200 DOI: 10.1002/ehf2.14558] [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: 06/19/2023] [Revised: 09/12/2023] [Accepted: 09/21/2023] [Indexed: 10/17/2023] Open
Abstract
AIMS Red cell distribution width (RDW) is a strong prognostic marker in patients with heart failure (HF) and reduced ejection fraction and other conditions. However, very little is known about its prognostic significance in HF with preserved ejection fraction. We examined the relationship between RDW and outcomes and the effect of sacubitril/valsartan, compared with valsartan, on RDW and clinical outcomes in PARAGON-HF. METHODS AND RESULTS PARAGON-HF enrolled patients with a left ventricular ejection fraction of ≥45%, structural heart disease, and elevated N-terminal pro-B-type natriuretic peptide (NT-proBNP). The primary endpoint was a composite of total HF hospitalizations and cardiovascular deaths. Median RDW at randomization was 14.1% (interquartile range 13.5-15.0%). Patients with higher RDW levels were more often men and had more comorbidity, a higher heart rate and NT-proBNP concentration, more advanced New York Heart Association class, and worse Kansas City Cardiomyopathy Questionnaire scores. There was a graded relationship between quartiles of RDW at randomization and the primary endpoint, with a significantly higher risk associated with increasing RDW, even after adjustment for NT-proBNP and other prognostic variables {Quartile 1, reference; Quartile 2, rate ratio 1.03 [95% confidence interval (CI) 0.83 to 1.28]; Quartile 3, 1.25 [1.01 to 1.54]; Quartile 4, 1.70 [1.39 to 2.08]}. This association was seen for each of the secondary outcomes, including cardiovascular and all-cause death. Compared with valsartan, sacubitril/valsartan reduced RDW at 48 weeks [mean change -0.09 (95% CI -0.15 to -0.02)]. The effect of sacubitril/valsartan vs. valsartan was not significantly modified by RDW levels at randomization. CONCLUSIONS RDW, a routinely available and inexpensive biomarker, provides incremental prognostic information when added to established predictors. Compared with valsartan, sacubitril/valsartan led to a small reduction in RDW.
Collapse
Affiliation(s)
- Jawad H. Butt
- British Heart Foundation Cardiovascular Research CentreUniversity of Glasgow126 University PlaceGlasgowG12 8TAUK
- Department of CardiologyRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Kirsty McDowell
- British Heart Foundation Cardiovascular Research CentreUniversity of Glasgow126 University PlaceGlasgowG12 8TAUK
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research CentreUniversity of Glasgow126 University PlaceGlasgowG12 8TAUK
| | - Akshay S. Desai
- Cardiovascular DivisionBrigham and Women's HospitalBostonMAUSA
| | | | - Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical CenterDallasTXUSA
| | - Mark C. Petrie
- British Heart Foundation Cardiovascular Research CentreUniversity of Glasgow126 University PlaceGlasgowG12 8TAUK
| | - Marc A. Pfeffer
- Cardiovascular DivisionBrigham and Women's HospitalBostonMAUSA
| | - Jean L. Rouleau
- Institut de Cardiologie de MontréalUniversité de MontréalMontrealQCCanada
| | | | - Michael R. Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical CenterCharlestonSCUSA
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research CentreUniversity of Glasgow126 University PlaceGlasgowG12 8TAUK
| | - Lars Køber
- Department of CardiologyRigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Scott Solomon
- Cardiovascular DivisionBrigham and Women's HospitalBostonMAUSA
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research CentreUniversity of Glasgow126 University PlaceGlasgowG12 8TAUK
| |
Collapse
|
3
|
Tolomeo P, Butt JH, Kondo T, Campo G, Desai AS, Jhund PS, Køber L, Lefkowitz MP, Rouleau JL, Solomon SD, Swedberg K, Vaduganathan M, Zile MR, Packer M, McMurray JJV. Independent prognostic importance of blood urea nitrogen to creatinine ratio in heart failure. Eur J Heart Fail 2024; 26:245-256. [PMID: 38124454 DOI: 10.1002/ejhf.3114] [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: 08/16/2023] [Revised: 11/24/2023] [Accepted: 12/19/2023] [Indexed: 12/23/2023] Open
Abstract
AIM Blood urea nitrogen (BUN) to creatinine ratio is associated with worse outcomes in acute heart failure (HF) but little is known about its importance in chronic HF. METHODS AND RESULTS We combined individual patient data from clinical trials (HF with reduced ejection fraction [HFrEF]: PARADIGM-HF, ATMOSPHERE and DAPA-HF, and HF with preserved ejection fraction [HFpEF]: PARAGON-HF and I-PRESERVE). The primary outcome examined was a composite time to first HF hospitalization or cardiovascular death; its components and all-cause death were also examined. Each HF phenotype was categorized according to median BUN/creatinine ratio, generating four groups that is, HFpEF ≤ and >median BUN/creatinine ratio and HFrEF ≤ and >median BUN/creatinine ratio. The association between BUN/creatinine ratio and outcomes was evaluated using the Kaplan-Meier estimator and Cox proportional hazard models. Overall, 28 820 patients were analysed. The median (IQR) BUN/creatinine ratio was 20.1 (Q1-Q3 16.7-24.7) in HFpEF and 18.7 (15.2-22.8) in HFrEF. In both HFpEF and HFrEF, higher BUN/creatinine ratio was associated with older age, female sex, and diabetes, but similar estimated glomerular filtration rate (eGFR). The risk of each outcome examined was significantly higher in patients with BUN/creatinine ratio ≥median, compared to CONCLUSION Higher BUN/creatinine ratio was associated with worse outcomes in patients with chronic HF across the spectrum of left ventricular ejection fraction, independently of eGFR and NT-proBNP. BUN/creatinine ratio may reflect neurohumoral activation (especially increased arginine vasopressin), altered renal blood flow or other pathophysiologic mechanisms not incorporated in conventional prognostic variables.
Collapse
Affiliation(s)
- Paolo Tolomeo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, Italy
| | - Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, Italy
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, QC, Canada
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| |
Collapse
|
4
|
McDowell K, Campbell R, Simpson J, Cunningham JW, Desai AS, Jhund PS, Lefkowitz MP, Rouleau JL, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. Incremental prognostic value of biomarkers in PARADIGM-HF. Eur J Heart Fail 2023; 25:1406-1414. [PMID: 37191207 DOI: 10.1002/ejhf.2887] [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: 02/10/2023] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023] Open
Abstract
AIMS It is uncertain how much candidate biomarkers improve risk prediction when added to comprehensive models including routinely collected clinical and laboratory variables in heart failure. METHODS AND RESULTS Aldosterone, cystatin C, high-sensitivity troponin T (hs-TnT), galectin-3, growth differentiation factor-15 (GDF-15), kidney injury molecule-1, matrix metalloproteinase-2 and -9, soluble suppression of tumourigenicity-2, tissue inhibitor of metalloproteinase-1 (TIMP-1) and urinary albumin to creatinine ratio were measured in 1559 of PARADIGM-HF participants. We tested whether these biomarkers, individually or collectively, improved the performance of the PREDICT-HF prognostic model, which includes clinical, routine laboratory, and natriuretic peptide data, for the primary endpoint and cardiovascular and all-cause mortality. The mean age of participants was 67.3 ± 9.9 years, 1254 (80.4%) were men and 1103 (71%) were in New York Heart Association class II. During a mean follow-up of 30.7 months, 300 patients experienced the primary outcome and 197 died. Added individually, only four biomarkers were independently associated with all outcomes: hs-TnT, GDF-15, cystatin C and TIMP-1. When all biomarkers were added simultaneously to the PREDICT-HF models, only hs-TnT remained an independent predictor of all three endpoints. GDF-15 also remained predictive of the primary endpoint; TIMP-1 was the only other predictor of both cardiovascular and all-cause mortality. Individually or in combination, these biomarkers did not lead to significant improvements in discrimination or reclassification. CONCLUSIONS None of the biomarkers studied individually or collectively led to a meaningful improvement in the prediction of outcomes over what is provided by clinical, routine laboratory, and natriuretic peptide variables.
Collapse
Affiliation(s)
- Kirsty McDowell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Ross Campbell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Joanne Simpson
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael R Zile
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| |
Collapse
|
5
|
Curtain JP, Adamson C, Docherty KF, Jhund PS, Desai AS, Lefkowitz MP, Rizkala AR, Rouleau JL, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. Prevalent and Incident Anemia in PARADIGM-HF and the Effect of Sacubitril/Valsartan. JACC Heart Fail 2023; 11:749-759. [PMID: 37407154 DOI: 10.1016/j.jchf.2022.12.012] [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] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Revised: 11/16/2022] [Accepted: 12/20/2022] [Indexed: 07/07/2023]
Abstract
BACKGROUND Anemia is common in patients with heart failure with reduced ejection fraction and is associated with poor clinical outcomes. Renin-angiotensin system blockers lower hemoglobin and may induce anemia. OBJECTIVES The authors investigated whether concomitant neprilysin inhibition might ameliorate this effect of renin-angiotensin system blockers in PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure). METHODS Anemia was defined as hemoglobin <120 g/L in women and <130 g/L in men at screening. The authors investigated the effect of randomized treatment on clinical outcomes according to anemia status, change in hemoglobin from baseline, and the incidence of anemia. RESULTS Of 8,239 participants with a baseline hemoglobin measurement, 1,677 (20.4%) were anemic. Patients with anemia had a more severe heart failure profile, worse kidney function, greater neurohormonal derangement, and worse clinical outcomes. Sacubitril/valsartan, compared with enalapril, decreased the risk of cardiovascular death or heart failure hospitalization similarly in patients with (HR: 0.84; 95% CI: 0.71-1.00) and without anemia (HR: 0.78 [95% CI: 0.71-0.87]; P value for interaction = 0.478). Between baseline and 12 months, hemoglobin decreased by 1.5 g/L (95% CI: 1.2-1.7 g/L) with sacubitril/valsartan compared with 2.3 g/L (95% CI: 2.0-2.6 g/L) with enalapril: mean difference 0.8 g/L (95% CI: 0.5-1.2 g/L; P < 0.001). Patients assigned to sacubitril/valsartan were less likely to develop anemia at 12 months (321 of 2,806 [11.4%]) compared with patients randomized to enalapril (440 of 2,824 [15.6%]) (OR: 0.70 [95% CI: 0.60-0.81]; P < 0.001). These findings were similar in PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction) (sacubitril/valsartan vs valsartan). There was biomarker evidence of increased iron utilization with sacubitril/valsartan. CONCLUSIONS Irrespective of anemia status, sacubitril/valsartan compared with enalapril, decreased mortality and hospitalization. Hemoglobin decreased less with sacubitril/valsartan and the incidence of new anemia was lower with sacubitril/valsartan. (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure [PARADIGM-HF] trial; NCT01035255).
Collapse
Affiliation(s)
- James P Curtain
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Carly Adamson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Kieran F Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | | | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Quebec, Canada
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
| | - Michael R Zile
- The Medical University of South Carolina, Charleston, South Carolina, USA; The Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
| |
Collapse
|
6
|
Tolomeo P, Butt JH, Kondo T, Campo G, Desai AS, Jhund PS, Køber L, Lefkowitz MP, Rouleau JL, Solomon SD, Swedberg K, Vaduganathan M, Zile MR, Packer M, McMurray JJV. Importance of cystatin C in estimating glomerular filtration rate: the PARADIGM-HF trial. Eur Heart J 2023:7116658. [PMID: 37051752 DOI: 10.1093/eurheartj/ehad210] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 02/17/2023] [Accepted: 03/21/2023] [Indexed: 04/14/2023] Open
Abstract
AIMS The 2021 Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) equation combining creatinine and cystatin C provides a better estimation of glomerular filtration rate (GFR) compared to the creatinine-only equation. METHODS AND RESULTS CKD-EPI creatinine-cystatin C equation (creatinine-cystatin) was compared to creatinine-only (creatinine) equation in a subpopulation of Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure (PARADIGM-HF). Patients were categorized according to difference in eGFR using the two equations: Group 1 (<-10 mL/min/1.73 m2, i.e. creatinine-cystatin more than 10 mL/min lower than creatinine), Group 2 (>-10 and <10 mL/min/1.73 m2), and Group 3 (>10 mL/min/1.73 m2, i.e. creatinine-cystatin more than 10 mL/min higher than creatinine). Cystatin C and creatinine were available in 1966 patients at randomization. Median (interquartile range) eGFR difference was -0.7 (-6.4-4.8) mL/min/1.73 m2. Compared to creatinine, creatinine-cystatin led to a substantial reclassification of chronic kidney disease stages. Overall, 212 (11%) and 355 (18%) patients were reallocated to a better and worse eGFR category, respectively. Compared to patients in Group 2, those in Group 1 (lower eGFR with creatinine-cystatin) had higher mortality and those in Group 3 (higher eGFR with creatinine-cystatin) had lower mortality. Increasing difference in eGFR (due to lower eGFR with creatinine-cystatin compared to creatinine) was associated with increasing elevation of biomarkers (including N-terminal pro-B-type natriuretic peptide and troponin) and worsening Kansas City Cardiomyopathy Questionnaire clinical summary score. The reason why the equations diverged with increasing severity of heart failure was that creatinine did not rise as steeply as cystatin C. CONCLUSION The CKD-EPI creatinine-only equation may overestimate GFR in sicker patients. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov; Unique Identifier: NCT01035255.
Collapse
Affiliation(s)
- Paolo Tolomeo
- BHF Glasgow Cardiovascular Research Centre (GCRC)126 University Place, Glasgow, G12 8TA
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, FE, Italy
| | - Jawad H Butt
- BHF Glasgow Cardiovascular Research Centre (GCRC)126 University Place, Glasgow, G12 8TA
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | - Toru Kondo
- BHF Glasgow Cardiovascular Research Centre (GCRC)126 University Place, Glasgow, G12 8TA
- Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Gianluca Campo
- Cardiology Unit, Azienda Ospedaliera Universitaria di Ferrara, Cona, FE, Italy
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre (GCRC)126 University Place, Glasgow, G12 8TA
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Copenhagen, Denmark
| | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, QC, Canada
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre (GCRC)126 University Place, Glasgow, G12 8TA
| |
Collapse
|
7
|
Platz E, Claggett B, Jering KS, Kovacs A, Cikes M, Winzer EB, Rad A, Lefkowitz MP, Gong J, Køber L, McMurray JJV, Solomon SD, Pfeffer MA, Shah A. Trajectory and correlates of pulmonary congestion by lung ultrasound in patients with acute myocardial infarction: insights from PARADISE-MI. Eur Heart J Acute Cardiovasc Care 2023; 12:155-164. [PMID: 36649251 PMCID: PMC10319964 DOI: 10.1093/ehjacc/zuad001] [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] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/06/2023] [Accepted: 01/13/2023] [Indexed: 01/18/2023]
Abstract
AIM PARADISE-MI examined the efficacy of sacubitril/valsartan in acute myocardial infarction (AMI) complicated by reduced left ventricular ejection fraction (LVEF), pulmonary congestion, or both. We sought to assess the trajectory of pulmonary congestion using lung ultrasound (LUS) and its association with cardiac structure and function in a pre-specified substudy. METHODS AND RESULTS Patients without prior heart failure (HF) underwent eight-zone LUS and echocardiography at baseline (±2 days of randomization) and after 8 months. B-lines were quantified offline, blinded to treatment, clinical findings, time point, and outcomes. Among 152 patients (median age 65, 32% women, mean LVEF 41%), B-lines were detectable in 87% at baseline [median B-line count: 4 (interquartile range 2-8)]. Among 115 patients with LUS data at baseline and follow-up, B-lines decreased significantly from baseline (mean ± standard deviation: -1.6 ± 7.3; P = 0.018). The proportion of patients without pulmonary congestion at follow-up was significantly higher in those with fewer B-lines at baseline. Adjusted for baseline, B-lines at follow-up were on average 6 (95% confidence interval: 3-9) higher in patients who experienced an intercurrent HF event vs. those who did not (P = 0.001). A greater number of B-lines at baseline was associated with larger left atrial size, higher E/e' and E/A ratios, greater degree of mitral regurgitation, worse right ventricular systolic function, and higher tricuspid regurgitation velocity (P-trend <0.05 for all). CONCLUSION In this AMI cohort, B-lines, indicating pulmonary congestion, were common at baseline and, on average, decreased significantly from baseline to follow-up. Worse pulmonary congestion was associated with prognostically important echocardiographic markers.
Collapse
Affiliation(s)
- Elke Platz
- Cardiovascular Division, Brigham and Women’s Hospital, 360 Longwood Ave, 7th Floor, Boston, MA 02115, USA
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, 360 Longwood Ave, 7th Floor, Boston, MA 02115, USA
| | - Karola S Jering
- Cardiovascular Division, Brigham and Women’s Hospital, 360 Longwood Ave, 7th Floor, Boston, MA 02115, USA
| | - Attila Kovacs
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Maja Cikes
- Department of Cardiovascular Diseases, University of Zagreb School of Medicine and University Hospital Centre Zagreb, Zagreb, Croatia
| | - Ephraim B Winzer
- Heart Center Dresden—University Clinic, Department of Internal Medicine and Cardiology, Technische Universität Dresden, Dresden, Germany
| | - Aria Rad
- Cardiovascular Division, Brigham and Women’s Hospital, 360 Longwood Ave, 7th Floor, Boston, MA 02115, USA
| | | | - Jianjian Gong
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Lars Køber
- Rigshospitalet, Blegdamsvej, University of Copenhagen, Copenhagen, Denmark
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, 360 Longwood Ave, 7th Floor, Boston, MA 02115, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, 360 Longwood Ave, 7th Floor, Boston, MA 02115, USA
| | - Amil Shah
- Cardiovascular Division, Brigham and Women’s Hospital, 360 Longwood Ave, 7th Floor, Boston, MA 02115, USA
| |
Collapse
|
8
|
Butt JH, Ibrahim W, Dewan P, Desai AS, Køber L, Prescott MF, Lefkowitz MP, Rouleau JL, Solomon SD, Zile MR, Packer M, Jhund PS, McMurray JJV. Urinary cGMP (Cyclic Guanosine Monophosphate)/BNP (B-Type Natriuretic Peptide) Ratio, Sacubitril/Valsartan, and Outcomes in Heart Failure With Reduced Ejection Fraction: An Analysis of the PARADIGM-HF Trial. Circ Heart Fail 2023; 16:e010111. [PMID: 36943907 PMCID: PMC10022671 DOI: 10.1161/circheartfailure.122.010111] [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: 01/26/2023]
Abstract
BACKGROUND The ratio of ucGMP (urinary cyclic guanosine monophosphate) to BNP (B-type natriuretic peptide) is thought to reflect the responsiveness of tissues to natriuretic peptides. METHODS We examined the relationship between ucGMP/BNP ratio and clinical outcomes, the effect of sacubitril/valsartan, compared with enalapril, on the ucGMP/BNP ratio, and the efficacy of sacubitril/valsartan on clinical outcomes according to baseline ucGMP/BNP ratio in PARADIGM-HF trial (Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure). ucGMP/BNP ratio was available at baseline (N=2031), 1 month (N=1959), and 8 months after randomization (N=1746). The primary outcome was a composite of heart failure hospitalization or cardiovascular death. RESULTS Compared with the lowest tertile of baseline ucGMP/BNP ratio, patients in the higher tertiles had a lower risk of the primary outcome (tertile 1, reference; tertile 2, hazard ratio 0.57 [95% CI, 0.45-0.71]; tertile 3, hazard ratio, 0.54 [0.43-0.67]). Compared with baseline, the ucGMP/BNP ratio at 1 month and 8 months after randomization was higher with sacubitril/valsartan than with enalapril: ratio of geometric mean ratios at 1 month, 1.38 (95% CI, 1.27-1.51) and 8 months, 1.32 (95% CI, 1.20-1.45), and this difference was consistent across tertiles of ucGMP/BNP ratio at baseline (Pinteraction=0.19 and 0.91, respectively). The effect of sacubitril/valsartan, compared with enalapril, was consistent across tertiles of ucGMP/BNP ratio at baseline for all outcomes (Pinteraction ≥0.31). CONCLUSIONS In patients with heart failure and reduced ejection fraction, higher ucGMP/BNP ratio was associated with better outcomes. Sacubitril/valsartan increased the ucGMP/BNP ratio, compared with enalapril, and the effect of sacubitril/valsartan on clinical outcomes was not modified by baseline ucGMP/BNP ratio. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique Identifier: NCT01035255.
Collapse
Affiliation(s)
- Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.H.B., W.I., P.D., P.S.J., J.J.V.M.)
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Denmark (J.H.B., L.K.)
| | - Wasyla Ibrahim
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.H.B., W.I., P.D., P.S.J., J.J.V.M.)
| | - Pooja Dewan
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.H.B., W.I., P.D., P.S.J., J.J.V.M.)
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., S.D.S.)
| | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Denmark (J.H.B., L.K.)
| | | | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, QC, Canada (J.L.R.)
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (A.S.D., S.D.S.)
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.H.B., W.I., P.D., P.S.J., J.J.V.M.)
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.H.B., W.I., P.D., P.S.J., J.J.V.M.)
| |
Collapse
|
9
|
Curtain JP, Adamson C, Kondo T, Butt JH, Desai AS, Zannad F, Rouleau JL, Rohde LE, Kober L, Anand IS, van Veldhuisen DJ, Zile MR, Lefkowitz MP, Solomon SD, Packer M, Petrie MC, Jhund PS, McMurray JJV. Investigator-reported ventricular arrhythmias and mortality in heart failure with mildly reduced or preserved ejection fraction. Eur Heart J 2023; 44:668-677. [PMID: 36632831 DOI: 10.1093/eurheartj/ehac801] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2022] [Revised: 11/16/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023] Open
Abstract
AIMS Few reports have examined the incidence of ventricular tachycardia (VT) and ventricular fibrillation (VF) or their relationship with mortality in patients with heart failure with mildly reduced ejection fraction (HFmrEF) or heart failure with preserved ejection fraction (HFpEF). METHODS AND RESULTS Data from the PARAGON-HF, TOPCAT, I-Preserve, and CHARM-Preserved trials were merged. VT/VF, reported as adverse events, were identified. Patients who experienced VT/VF were compared with patients who did not. The relationship between VT/VF and mortality was examined in time-updated Cox proportional hazard regression models. Variables associated with VT/VF were examined in Cox proportional hazard regression models. The rate of VT/VF in patients with HFmrEF compared with patients with HFpEF was examined in a Cox proportional hazards regression model. Of 13 609 patients, over a median follow-up of 1170 days (interquartile range: 966-1451), 146 (1.1%) experienced an investigator-reported VT/VF (incidence rate 0.3 per 100 person-years). Patients who experienced VT/VF were more likely to be male, have had a myocardial infarction, poorer renal function, more adverse left ventricular remodelling, and higher N-terminal pro-B-type natriuretic peptide (NT-proBNP) than patients who did not. Occurrence of VT/VF was associated with NT-proBNP, history of atrial fibrillation/flutter, male sex, lower ejection fraction, and history of hypertension. VT/VF was associated with all-cause death [adjusted hazard ratio (HR): 3.95, 95% confidence interval (CI): 2.80-5.57; P < 0.001] and cardiovascular death, driven by death from heart failure and not sudden death. Patients with HFmrEF had a higher rate of VT/VF than patients with HFpEF (adjusted HR: 2.19, 95% CI: 1.77-2.71). CONCLUSION VT/VF was uncommon in patients with HFmrEF and HFpEF. However, such events were strongly associated with mortality and appear to be a marker of disease severity rather than risk of sudden death. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov unique identifier: NCT01920711(PARAGON-HF); NCT00094302 (TOPCAT); NCT00095238 (I-Preserve); NCT00634712 (CHARM-Preserved).
Collapse
Affiliation(s)
- James P Curtain
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, United Kingdom
| | - Carly Adamson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, United Kingdom
| | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, United Kingdom
| | - Jawad Haider Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, United Kingdom
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Faiez Zannad
- Centre d'Investigations Cliniques Pluithématique 1433 and Inserm U116, CHRU, FCRIN INICRCT (Cardiovascular and Renal Trialists), Université de Lorraine, 5 rue du Morvan 54500 Vandoeuvre-Les-Nancy, France
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, 5000, Bélanger street, Montreal, H1T 1C8, Canada
| | - Luis E Rohde
- Cardiovascular Division, Hospital Moinhos de Vento and Hospital de Clinicas de Porto Alegre, Medical School, UFRGS, Rua Ramiro Barcelos, 2400, Porto Alegre, RS 90.035-003, Brazil
| | - Lars Kober
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Blegdamsvej 9, 2100 Copenhagen, Denmark
| | - Inder S Anand
- Department of Cardiovascular Medicine, University of Minnesota, 401 East River Parkway, VCRC 1st Floor, Suite 131, Minneapolis, MN 55455, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Postbus 30.001, 9700 RB, Groningen, The Netherlands
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, 109 Bee St, Charleston, SC 29401, USA
| | | | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, 3500 Gaston Avenue, Dallas, TX 75246, USA
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, United Kingdom
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, United Kingdom
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, United Kingdom
| |
Collapse
|
10
|
Bhatt AS, Dimond M, Fiuzat M, Vaduganathan M, Vardeny O, Divanji P, Komtebedde J, Lefkowitz MP, Nkulikiyinka R, Petersson M, Roessig L, Schaber D, O'Connor CM, Solomon SD. Impact of COVID-19 on Heart Failure Clinical Trials: Insights From the Heart Failure Collaboratory. JACC Heart Fail 2023; 11:254-257. [PMID: 36754534 PMCID: PMC9901495 DOI: 10.1016/j.jchf.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/29/2022] [Indexed: 02/09/2023]
|
11
|
Chandra A, Polanczyk CA, Claggett BL, Vaduganathan M, Packer M, Lefkowitz MP, Rouleau JL, Liu J, Shi VC, Schwende H, Zile MR, Desai AS, Pfeffer MA, McMurray JJV, Solomon SD, Lewis EF. Health-related quality of life outcomes in PARAGON-HF. Eur J Heart Fail 2022; 24:2264-2274. [PMID: 36394533 DOI: 10.1002/ejhf.2738] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 03/02/2022] [Revised: 11/03/2022] [Accepted: 11/16/2022] [Indexed: 11/19/2022] Open
Abstract
AIMS Heart failure (HF) is associated with poor health-related quality of life (HRQL). Patients with HF with preserved ejection fraction (HFpEF) have similar HRQL impairment as those with reduced ejection fraction. This study describes the impact of sacubitril/valsartan on HRQL in patients with HFpEF enrolled in the PARAGON-HF trial. METHODS AND RESULTS Patients completed the Kansas City Cardiomyopathy Questionnaire (KCCQ) and EuroQol (EQ-5D) at randomization, 4, 8 months, and annually thereafter. Changes in HRQL scores were evaluated using repeated measures models adjusted for treatment, baseline values and region. The pre-specified principal efficacy assessment was at 8 months at which time patients randomized to sacubitril/valsartan had borderline higher KCCQ clinical summary score (CSS) with least squares mean (LSM) adjusted difference of 1.0 (95% confidence interval [CI] 0.0, 2.1; p = 0.051). Including all visits up to 36 months, the LSM difference in KCCQ-CSS favoured sacubitril/valsartan with average adjusted difference of 1.1 (95% CI 0.1, 2.0; p = 0.034). Patients treated with sacubitril/valsartan had greater odds of clinically meaningful improvement (≥5-point increase) in KCCQ-CSS (odds ratio 1.31; 95% CI 1.06, 1.61) at 8 months. At 8 months, there was no significant difference in the EQ visual analogue scale between the treatment arms, but sacubitril/valsartan was associated with higher EQ-5D utility score (US-based) with LSM adjusted difference of 0.01 (95% CI 0.00, 0.02; p = 0.019). CONCLUSION Compared with valsartan, sacubitril/valsartan had a borderline benefit on KCCQ-CSS at 8 months in patients with HFpEF. This benefit became more significant when data from all visits up to 36 months were included. This modest overall benefit was also supported by greater odds of patients reporting a clinically meaningful improvement in HRQL with sacubitril/valsartan.
Collapse
Affiliation(s)
- Alvin Chandra
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | | | - Jean L Rouleau
- Institut de Cardiologie de Montreal, Université de Montreal Canada, Montreal, Canada
| | | | | | | | - Michael R Zile
- RHJ Department of Veterans Administration Medical Center, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - Eldrin F Lewis
- Cardiovascular Division, Stanford University School of Medicine, Palo Alto, CA, USA
| |
Collapse
|
12
|
Adamson C, Butt JH, Rouleau J, Abraham W, Desai A, Dickstein K, Kober L, Lefkowitz MP, Packer M, Petrie MC, Swedberg K, Solomon SD, Zile M, Jhund PS, McMurray JJV. Alkaline phosphatase and bilirubin combined are a powerful predictor of outcome in patients with heart failure and reduced ejection fraction: an analysis of the ATMOSPHERE and PARADIGM-HF trials. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Introduction
Bilirubin is a recognized predictor of adverse outcomes in patients with heart failure and reduced ejection fraction (HFrEF), possibly because it is a marker of congestion. Alkaline phosphatase (ALP) is an enzyme produced in many tissues including the biliary ducts and elevated levels are also associated with congestion.
Purpose
To examine the prognostic value of ALP alone and in combination with bilirubin in patients with HFrEF.
Methods
The study population was ambulatory patients with HFrEF enrolled in 2 recent clinical trials with similar inclusion and exclusion criteria: ATMOSPHERE (derivation cohort) and PARADIGM-HF (validation). Cut points to define elevated bilirubin and alkaline phosphatase were >17mg/dL and >120 U/L respectively. The composite of cardiovascular death or HF hospitalization, its components, and all-cause death related to elevation of one, other or both of bilirubin and ALP was examined using Cox regression. Univariable and multivariable models with adjustment for other recognized prognostic variables including NT-proBNP were analyzed.
Results
Of 7016 patients with HFrEF enrolled in ATMOSPHERE, 6870 had a measurement of both bilirubin and ALP at baseline: mean age 63 years, 22% women, mean LVEF 28% and proportion NYHA class III/IV 37%. Bilirubin and ALP were both normal in 4810 (70.0%) patients, bilirubin was elevated in 1393 (20.3%), ALP was elevated in 360 (5.2%) and both were elevated in 307 (4.5%) patients. Patients with elevation of both ALP and bilirubin were older, had lower systolic blood pressure, higher heart rate, higher NT-pro BNP, more clinical features of congestion, more atrial fibrillation and a greater proportion were treated with diuretics and digoxin. The primary endpoint rates (per 100 person-years) were 10.4 (95% CI 9.9–11.0) when both markers were normal, 15.1 (13.9–16.4) when bilirubin was elevated, 12.4 (10.4–14.9) when alkaline phosphatase was elevated, and 25.6 (22.0–29.9) when both markers were elevated (Figure 1). The adjusted hazard ratios (95% CI) were (both biomarkers normal = reference): elevated bilirubin 1.19 (1.07–1.31), P=0.001; elevated ALP 1.03 (0.84–1.26), P=0.81; both elevated 1.45 (1.21–1.73), P<0.001. Elevation of both bilirubin and ALP was a significant independent predictor of the components of the primary outcome and all-cause death, the corresponding hazard ratios for all cause death were 1.12 (0.99–1.25), p=0.06; 1.19 (0.96–1.47), p=0.12; and 1.51 (1.25–1.82), p<0.001. These findings were validated in PARADIGM-HF (Table 1).
Conclusions
Elevation of ALP in combination with elevated bilirubin identifies a small group of patients at very high risk of adverse outcomes. This may reflect more significant congestion. ALP and bilirubin, inexpensive and routinely measured biochemical tests, are useful prognostic markers in patients with HFrEF.
Funding Acknowledgement
Type of funding sources: Private grant(s) and/or Sponsorship.
Collapse
Affiliation(s)
- C Adamson
- University of Glasgow , Glasgow , United Kingdom
| | - J H Butt
- University of Glasgow , Glasgow , United Kingdom
| | - J Rouleau
- University of Montreal , Montreal , Canada
| | - W Abraham
- Ohio State University Hospital , Ohio , United States of America
| | - A Desai
- Brigham and Women's Hospital , Boston , United States of America
| | - K Dickstein
- Medical University of South Carolina , Charleston , United States of America
| | - L Kober
- Rigshospitalet - Copenhagen University Hospital , Copenhagen , Denmark
| | | | - M Packer
- Baylor University Medical Center , Dallas , United States of America
| | - M C Petrie
- University of Glasgow , Glasgow , United Kingdom
| | - K Swedberg
- University of Gothenburg , Gothenburg , Sweden
| | - S D Solomon
- Brigham and Women's Hospital , Boston , United States of America
| | - M Zile
- Medical University of South Carolina , Charleston , United States of America
| | - P S Jhund
- University of Glasgow , Glasgow , United Kingdom
| | | |
Collapse
|
13
|
Curtain J, Adamson C, Jhund PS, Desai AS, Lefkowitz MP, Rizkala AR, Rouleau JL, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. Prevalent and incident anaemia in PARADIGM-HF and effect of sacubitril/valsartan. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Anaemia is common in patients with HFrEF and is associated with poor clinical outcomes. Although they reduce rates of mortality and heart failure hospitalization, renin-angiotensin (RAS) blockers lower haemoglobin and may induce anaemia. Concomitant neprilysin inhibition might ameliorate this effect of RAS blockers.
Purpose
We investigated the effect of sacubitril/valsartan compared with enalapril on clinical outcomes, according to anaemia status, and on haemoglobin levels in PARADIGM-HF.
Methods
Patient characteristics and clinical outcomes were compared between patients with and without anaemia (defined as haemoglobin <120 g/L in women and <130 g/L in men) at baseline. We investigated the effect of randomized treatment (sacubitril/valsartan or enalapril) on clinical outcomes according to anaemia status at screening. We also examined the effect of treatment on change in haemoglobin from baseline and on the incidence of anaemia. The primary endpoint in PARADIGM-HF was the composite of heart failure hospitalization or cardiovascular death.
Results
Of 8239 participants with a baseline haemoglobin measurement, 1677 (20.4%) were anaemic. Compared to those without anaemia, patients with anaemia had a more severe heart failure profile, worse kidney function, greater neurohormonal derangement and worse clinical outcomes. Sacubitril/valsartan, compared to enalapril, reduced the risk of the primary endpoint similarly in patients with anaemia (HR 0.84, 95% CI 0.71–1.00) and without anaemia (HR 0.78, 95% CI 0.71–0.87), p-value for interaction=0.478. Between baseline and 12 months, haemoglobin decreased by 1.5 (95% CI 1.7 to 1.2) g/L with sacubitril/valsartan compared with 2.3 (2.6 to 2.0) g/L with enalapril group: mean difference 0.8 (95% CI 0.5 to 1.2) g/L, p<0.001. The between-treatment difference apparent by 12 months, persisted up to 36 months. Patients assigned to sacubitril/valsartan were less likely to develop new anaemia at 12 months [321 of 2806 (11.4%)] compared to patients randomized to enalapril [440 of 2384 (15.6%)], odds ratio 0.70 (95% CI 0.60–0.81), p<0.001.
Conclusions
Compared to enalapril, sacubitril/valsartan reduced mortality and hospitalization in HFrEF patients with and without anaemia. Haemoglobin decreased less with sacubitril/valsartan and the incidence of new anaemia was lower in the sacubitril/valsartan group compared with the enalapril group.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): PARADIGM-HF was funded by Novartis.
Collapse
Affiliation(s)
- J Curtain
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - C Adamson
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - P S Jhund
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| | - A S Desai
- Brigham and Women's Hospital, Division of Cardiovascular Medicine , Boston , United States of America
| | | | - A R Rizkala
- Novartis , East Hanover , United States of America
| | - J L Rouleau
- Montreal Heart Institute , Montreal , Canada
| | - K Swedberg
- University of Gothenburg , Gothenburg , Sweden
| | - M R Zile
- Medical University of South Carolina , Charleston , United States of America
| | - S D Solomon
- Brigham and Women's Hospital, Division of Cardiovascular Medicine , Boston , United States of America
| | - M Packer
- Baylor University Medical Center , Dallas , United States of America
| | - J J V McMurray
- BHF Glasgow Cardiovascular Research Centre , Glasgow , United Kingdom
| |
Collapse
|
14
|
Tolomeo P, Kondo T, Butt JH, Desai AS, Lefkowitz MP, Rouleau JL, Solomon SD, Swedberg K, Zile MR, Campo G, Jhund PS, Packer M, McMurray JJV. Implications of the 2021 CKD-EPI cystatin C/creatinine eGFR equation for eligibility for therapy in HFrEF: insights from PARADIGM-HF. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Estimated glomerular filtration rate (eGFR) is a key determinant of eligibility for many life-saving therapies in HFrEF. Recently, the Chronic Kidney Disease Epidemiology Collaboration (CKD-EPI) provided new equations based on creatinine (CKD-EPIcr), cystatin C (CKD-EPIcys) or both (CKD-EPIcyscr) that do not include race. These new equations may reclassify individuals, irrespective of race, from one eGFR category to another, with implications for eligibility for HFrEF treatments.
Purpose
To assess the difference between eGFR estimation using the 2021 CKD-EPIcyscr equation and the 2009 CKD-EPIcr and Modification of Diet in Renal Disease Study (MDRD)-4 equations which are still standard in many European laboratories.
Methods
We included patients from PARADIGM-HF with cystatin C and creatinine values available at the time of randomization. For each patient, baseline eGFRs were calculated using the 3 equations described. Our focus was on patients with chronic kidney disease (CKD) stages III–V.
Results
Overall, 1910 patients were eligible. Mean age was 67.3 (10.1) year and 385 (18.7%) were female. Using 2009 CKD-EPIcr, 779 patients were in CKD stages 3–5, of which 233 (30%) were reclassified to a better CKD stage (higher eGFR) with the 2021 CKD-EPIcyscr equation (Table 1). Similar reclassification was seen when comparing MDRD-4 with the 2021 CKD-EPIcyscr equation: 277 (33%) of 831 patients in CKD stages 3–5 were reclassified to a better CKD stage (Figure 1).
Conclusions
The 2021 CKD-EPIcyscr equation favourably reclassified CKD stage in a large percentage of patients with HFrEF and a low eGFR, potentially increasing the proportion of these patients considered eligible for guideline-recommended therapies.
Funding Acknowledgement
Type of funding sources: None.
Collapse
Affiliation(s)
- P Tolomeo
- University Hospital of Ferrara , Ferrara , Italy
| | - T Kondo
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
| | - J H Butt
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
| | - A S Desai
- Brigham and Women's, Hospital Harvard Medical School, Cardiovascular Division , Boston , United States of America
| | | | - J L Rouleau
- University of Montreal, Montreal Heart Institute , Montreal , Canada
| | - S D Solomon
- Brigham and Women's, Hospital Harvard Medical School, Cardiovascular Division , Boston , United States of America
| | - K Swedberg
- University of Gothenburg, Department of Molecular and Clinical Medicine , Gothenburg , Sweden
| | - M R Zile
- Medical University of South Carolina , Charleston , United States of America
| | - G Campo
- University Hospital of Ferrara , Ferrara , Italy
| | - P S Jhund
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
| | - M Packer
- Baylor University Medical Center, Baylor Heart and Vascular Institute , Dallas , United States of America
| | - J J V McMurray
- University of Glasgow, British Heart Foundation Cardiovascular Research Centre , Glasgow , United Kingdom
| |
Collapse
|
15
|
Mc Causland FR, Lefkowitz MP, Claggett B, Packer M, Senni M, Gori M, Jhund PS, McGrath MM, Rouleau JL, Shi V, Swedberg K, Vaduganathan M, Zannad F, Pfeffer MA, Zile M, McMurray JJV, Solomon SD. Angiotensin-neprilysin inhibition and renal outcomes across the spectrum of ejection fraction in heart failure. Eur J Heart Fail 2022; 24:1591-1598. [PMID: 34989105 PMCID: PMC9253196 DOI: 10.1002/ejhf.2421] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 12/01/2021] [Accepted: 01/03/2022] [Indexed: 12/11/2022] Open
Abstract
AIMS Patients with heart failure are at higher risk of progression to end-stage renal disease (ESRD), regardless of ejection fraction (EF). We assessed the renal effects of angiotensin-neprilysin inhibition in a pooled analysis of 13 195 patients with heart failure with reduced and preserved EF. METHODS AND RESULTS We combined data from PARADIGM-HF (EF ≤40%; n = 8399) and PARAGON-HF (EF ≥45%; n = 4796) in a pre-specified pooled analysis. We assessed the effect of treatment (sacubitril/valsartan vs. enalapril or valsartan) on a composite of either ≥50% reduction in estimated glomerular filtration rate (eGFR), ESRD, or death from renal causes, in addition to changes in eGFR slope. We assessed whether baseline renal function or EF modified the effect of therapy on renal outcomes. At randomization, eGFR was 68 ± 20 ml/min/1.73 m2 in PARADIGM-HF and 63 ± 19 ml/min/1.73 m2 in PARAGON-HF. The composite renal outcome occurred in 70 of 6594 patients (1.1%) in the sacubitril/valsartan group and in 123 of 6601 patients (1.9%) in the valsartan or enalapril group (hazard ratio 0.56, 95% confidence interval [CI] 0.42-0.75; p < 0.001). The mean eGFR change was -1.8 (95% CI -1.9 to -1.7) ml/min/1.73 m2 /year for the sacubitril/valsartan group, compared with -2.4 (95% CI -2.5 to -2.2) ml/min/1.73 m2 /year for the valsartan or enalapril group. The treatment effect on the composite renal endpoint was not modified by categories of baseline eGFR (p-interaction = 0.64), but was most pronounced in those with baseline EF between 30% and 60% (p-interaction = 0.001). CONCLUSIONS In patients with heart failure, sacubitril/valsartan reduced the risk of serious adverse renal outcomes and slowed decline in eGFR, compared with valsartan or enalapril, independent of baseline renal function.
Collapse
Affiliation(s)
- Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Brian Claggett
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Michele Senni
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Mauro Gori
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Martina M. McGrath
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Jean L. Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Canada
| | - Victor Shi
- Novartis Pharmaceuticals, East Hanover, NJ, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
| | - Muthiah Vaduganathan
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Faiez Zannad
- Université de Lorraine, Inserm CIC1433, CHRU de Nancy, France
| | - Marc A. Pfeffer
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Michael Zile
- Medical University of South Carolina, Charleston, South Carolina, USA
- Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina, USA
| | - John J. V. McMurray
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Scott D. Solomon
- Harvard Medical School, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| |
Collapse
|
16
|
Butt JH, Dewan P, Jhund PS, Anand IS, Atar D, Ge J, Desai AS, Echeverria LE, Køber L, Lam CSP, Maggioni AP, Martinez F, Packer M, Rouleau JL, Sim D, Van Veldhuisen DJ, Vrtovec B, Zannad F, Zile MR, Gong J, Lefkowitz MP, Rizkala AR, Solomon SD, McMurray JJV. Sacubitril/Valsartan and Frailty in Patients With Heart Failure and Preserved Ejection Fraction. J Am Coll Cardiol 2022; 80:1130-1143. [PMID: 36050227 DOI: 10.1016/j.jacc.2022.06.037] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [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: 06/27/2022] [Accepted: 06/27/2022] [Indexed: 02/05/2023]
Abstract
BACKGROUND Frailty is an increasingly common problem, and frail patients are less likely to receive new pharmacologic therapies because the risk-benefit profile is perceived to be less favorable than in nonfrail patients. OBJECTIVES This study investigated the efficacy of sacubitril/valsartan according to frailty status in 4,796 patients with heart failure with preserved ejection fraction randomized in the PARAGON-HF (Prospective Comparison of ARNI With ARB Global Outcomes in Heart Failure With Preserved Ejection Fraction) trial. METHODS Frailty was measured by using the Rockwood cumulative deficit approach. The primary endpoint was total heart failure hospitalizations or cardiovascular death. RESULTS A frailty index (FI) was calculable in 4,795 patients. In total, 45.2% had class 1 frailty (FI ≤0.210, not frail), 43.5% had class 2 frailty (FI 0.211-0.310, more frail), and 11.4% had class 3 frailty (FI ≥0.311, most frail). There was a graded relationship between FI class and the primary endpoint, with a significantly higher risk associated with greater frailty (class 1: reference; class 2 rate ratio: 2.19 [95% CI: 1.85-2.60]; class 3 rate ratio: 3.29 [95% CI: 2.65-4.09]). The effect of sacubitril/valsartan vs valsartan on the primary endpoint from lowest to highest FI class (as a rate ratio) was: 0.98 [95% CI: 0.76-1.27], 0.92 [95% CI: 0.76-1.12], and 0.69 [95% CI: 0.51-0.95]), respectively (Pinteraction = 0.23). When FI was examined as a continuous variable, the interaction with treatment was significant for the primary outcome (Pinteraction = 0.002) and total heart failure hospitalizations (Pinteraction < 0.001), with those most frail deriving greater benefit. CONCLUSIONS Frailty was common in heart failure with preserved ejection fraction and associated with worse outcomes. Compared with valsartan, sacubitril/valsartan seemed to show a greater reduction in the primary endpoint with increasing frailty, although this was not significant when FI was examined as a categorical variable. (Prospective Comparison of ARNI With ARB Global Outcomes in Heart Failure With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
Collapse
Affiliation(s)
- Jawad H Butt
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Pooja Dewan
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Inder S Anand
- Department of Medicine, VA Medical Center, Minneapolis, Minnesota, USA; University of Minnesota Medical Center, University of Minnesota, Minneapolis, Minnesota, USA
| | - Dan Atar
- Department of Cardiology, Oslo University Hospital Ulleval, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Akshay S Desai
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Luis E Echeverria
- Heart Failure Unit and Cardiac Transplant Program, Fundación Cardiovascular de Colombia, Floridablanca, Santander, Colombia
| | - Lars Køber
- Department of Cardiology, Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri, Florence, Italy
| | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - David Sim
- Department of Cardiology, National Heart Centre Singapore, Singapore
| | - Dirk J Van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Faiez Zannad
- Inserm CIC 1433 and Université de Lorraine, Centre Hospitalier Régional Universitaire, Nancy, France
| | - Michael R Zile
- Medical University of South Carolina, Charleston, South Carolina, USA; Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina, USA
| | - Jianjian Gong
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Adel R Rizkala
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
| |
Collapse
|
17
|
Peikert A, Vaduganathan M, McCausland F, Claggett BL, Chatur S, Packer M, Pfeffer MA, Zannad F, Lefkowitz MP, Pieske B, Düngen HD, McMurray JJV, Solomon SD. Effects of Sacubitril/Valsartan Versus Valsartan on Renal Function in Patients with and without Diabetes and Heart Failure with Preserved Ejection Fraction: Insights From PARAGON-HF. Eur J Heart Fail 2022; 24:794-803. [PMID: 35119183 PMCID: PMC9305963 DOI: 10.1002/ejhf.2450] [Citation(s) in RCA: 4] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Revised: 01/18/2022] [Accepted: 01/31/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Diabetes is associated with a faster rate of renal function decline in patients with heart failure (HF). Sacubitril/valsartan attenuates the deterioration of renal function to a greater extent in patients with diabetes and HF with reduced ejection fraction compared with renin-angiotensin-system inhibitors alone. We assessed whether the same may be true in HF with preserved ejection fraction (HFpEF). METHODS AND RESULTS In the PARAGON-HF trial in patients with HF and LVEF of 45% or greater (n=4,796), we characterized the effects of sacubitril/valsartan on changes in estimated glomerular filtration rate (eGFR) over a period of 192 weeks, and on the prespecified renal composite outcome (eGFR reduction of ≥50%, end-stage renal disease, or death attributable to renal causes) in patients with (n=2,388) and without diabetes (n=2,408). The decline in eGFR was greater in patients with diabetes than in those without (-2.6 vs. -1.7 mL/min per 1·73 m2 per year, p<0.001), regardless of treatment assignment. Sacubitril/valsartan attenuated decline in eGFR similarly in patients with (-2.2 vs. -2.9 mL/min per 1·73 m2 per year, p=0.001) and without diabetes (-1.5 vs. -2.0 mL/min per 1·73 m2 per year, p=0.006) (Pinteraction for difference in eGFR slopes = 0.40). Compared with valsartan, sacubitril/valsartan reduced the renal composite outcome similarly in patients without diabetes (HR 0.42 (95% CI 0.19-0.91) and those with diabetes (HR 0.54 (95% CI 0.33-0.89); Pinteraction =0.59), as well as across a range of baseline HbA1c (Pinteraction =0.71). CONCLUSION Sacubitril/valsartan, compared with valsartan, attenuates the decline of eGFR and reduces clinically relevant kidney events similarly among patients with HFpEF with and without diabetes. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Alexander Peikert
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Finnian McCausland
- Renal Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Safia Chatur
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Milton Packer
- Baylor Heart and Vascular Hospital, Baylor University Medical Center, Dallas, TX, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - Burkert Pieske
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Hans-Dirk Düngen
- Department of Internal Medicine and Cardiology, Campus Virchow Klinikum, Charité Universitätsmedizin Berlin, Berlin, Germany.,DZHK (German Center for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - John J V McMurray
- New British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
18
|
Curtain JP, Jackson A, Shen L, Jhund PS, Docherty KF, Petrie MC, Castagno D, Desai AS, Rohde LE, Lefkowitz MP, Rouleau JL, Zile MR, Solomon SD, Swedberg K, Packer M, McMurray JJV. Effect of sacubitril/valsartan on investigator-reported ventricular arrhythmias in PARADIGM-HF. Eur J Heart Fail 2021; 24:551-561. [PMID: 34969175 PMCID: PMC9542658 DOI: 10.1002/ejhf.2419] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 12/17/2021] [Accepted: 12/23/2021] [Indexed: 11/17/2022] Open
Abstract
Aims Sudden death is a leading cause of mortality in heart failure with reduced ejection fraction (HFrEF). In PARADIGM‐HF, sacubitril/valsartan reduced the incidence of sudden death. The purpose of this post hoc study was to analyse the effect of sacubitril/valsartan, compared to enalapril, on the incidence of ventricular arrhythmias. Methods and results Adverse event reports related to ventricular arrhythmias were examined in PARADIGM‐HF. The effect of randomized treatment on two arrhythmia outcomes was analysed: ventricular arrhythmias and the composite of a ventricular arrhythmia, implantable cardioverter defibrillator (ICD) shock or resuscitated cardiac arrest. The risk of death related to a ventricular arrhythmia was examined in time‐updated models. The interaction between heart failure aetiology, or baseline ICD/cardiac resynchronization therapy‐defibrillator (CRT‐D) use, and the effect of sacubitril/valsartan was analysed. Of the 8399 participants, 333 (4.0%) reported a ventricular arrhythmia and 372 (4.4%) the composite arrhythmia outcome. Ventricular arrhythmias were associated with higher mortality. Compared with enalapril, sacubitril/valsartan reduced the risk of a ventricular arrhythmia (hazard ratio [HR] 0.76, 95% confidence interval [CI] 0.62–0.95; p = 0.015) and the composite arrhythmia outcome (HR 0.79, 95% CI 0.65–0.97; p = 0.025). The treatment effect was maintained after adjustment and accounting for the competing risk of death. Baseline ICD/CRT‐D use did not modify the effect of sacubitril/valsartan, but aetiology did: HR in patients with an ischaemic aetiology 0.93 (95% CI 0.71–1.21) versus 0.53 (95% CI 0.37–0.78) in those without an ischaemic aetiology (p for interaction = 0.020). Conclusions Sacubitril/valsartan reduced the incidence of investigator‐reported ventricular arrhythmias in patients with HFrEF. This effect may have been greater in patients with a non‐ischaemic aetiology.
Collapse
Affiliation(s)
- James P Curtain
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Alice Jackson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Li Shen
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Division of Health Sciences, Hangzhou Normal University, Hangzhou, 311121, China
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Kieran F Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Davide Castagno
- Division of Cardiology, Città della Salute e della Scienza Hospital, Department of Medical Sciences, University of Turin, Torino, Italy
| | - Akshay S Desai
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Luis E Rohde
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Hospital de Clínicas de Porto Alegre and UFRGS Medical School, Porto Alegre, Brazil
| | | | - Jean-Lucien Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montreal, Canada
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, South Carolina, USA
| | - Scott D Solomon
- Division of Cardiovascular, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| |
Collapse
|
19
|
Jackson AM, Rørth R, Liu J, Kristensen SL, Anand IS, Claggett BL, Cleland JGF, Chopra VK, Desai AS, Ge J, Gong J, Lam CSP, Lefkowitz MP, Maggioni AP, Martinez F, Packer M, Pfeffer MA, Pieske B, Redfield MM, Rizkala AR, Rouleau JL, Seferović PM, Tromp J, Van Veldhuisen DJ, Yilmaz MB, Zannad F, Zile MR, Køber L, Petrie MC, Jhund PS, Solomon SD, McMurray JJV. Diabetes and prediabetes in patients with heart failure and preserved ejection fraction. Eur J Heart Fail 2021; 24:497-509. [PMID: 34918855 PMCID: PMC9542636 DOI: 10.1002/ejhf.2403] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Revised: 12/05/2021] [Accepted: 12/08/2021] [Indexed: 11/24/2022] Open
Abstract
Aim There is an association between heart failure with preserved ejection fraction (HFpEF) and insulin resistance, but less is known about the diabetic continuum, and in particular about pre‐diabetes, in HFpEF. We examined characteristics and outcomes of participants with diabetes or pre‐diabetes in PARAGON‐HF. Methods and results Patients aged ≥50 years with left ventricular ejection fraction ≥45%, structural heart disease and elevated N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) were eligible. Patients were classified according to glycated haemoglobin (HbA1c): (i) normal HbA1c, <6.0%; (ii) pre‐diabetes, 6.0%–6.4%; (iii) diabetes, ≥6.5% or history of diabetes. The primary outcome was a composite of cardiovascular (CV) death and total heart failure hospitalizations (HFH). Of 4796 patients, 50% had diabetes and 18% had pre‐diabetes. Compared to patients with normal HbA1c, patients with pre‐diabetes and diabetes more often were obese, had a history of myocardial infarction and had lower Kansas City Cardiomyopathy Questionnaire scores, while patients with diabetes had more clinical evidence of congestion, but similar NT‐proBNP concentrations. The risks of the primary composite outcome (rate ratio [RR] 1.59, 95% confidence interval [CI] 1.35–1.88), total HFH (RR 1.67, 95% CI 1.39–2.02) and CV death (hazard ratio [HR] 1.35, 95% CI 1.07–1.71) were higher among patients with diabetes, compared to those with normal HbA1c. Patients with pre‐diabetes had a higher risk (which was intermediate between that of patients with diabetes and those with normal HbA1c) of the primary outcome (HR 1.27, 95% CI 1.00–1.60) and HFH (HR 1.35, 95% CI 1.03–1.77), but not of CV death (HR 1.02, 95% CI 0.75–1.40). Patients with diabetes treated with insulin had worse outcomes than those not, and those with ‘lean diabetes’ had similar mortality rates to those with a higher body mass index, but lower rates of HFH. Conclusion Pre‐diabetes is common in patients with HFpEF and is associated with worse clinical status and greater risk of HFH. Clinical Trial Registration: ClinicalTrials.gov Identifier NCT01920711.
Collapse
Affiliation(s)
- Alice M Jackson
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Rasmus Rørth
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Rigshospitalet Copenhagen University Hospital, Copenhagen
| | - Jiankang Liu
- Brigham and Women's Hospital, Boston, Massachusetts
| | - Søren Lund Kristensen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Rigshospitalet Copenhagen University Hospital, Copenhagen
| | | | | | - John G F Cleland
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | | | | | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases
| | | | - Carolyn S P Lam
- National Heart Center Singapore and Duke-National University of Singapore, Singapore.,Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Aldo P Maggioni
- National Association of Hospital Cardiologists Research Center, Florence
| | | | | | | | - Burkert Pieske
- Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin
| | | | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Canada
| | | | - Jasper Tromp
- National Heart Center Singapore and Duke-National University of Singapore, Singapore.,Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Dirk J Van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | | | - Faiez Zannad
- INSERM Centre d'Investigation Clinic 1433 and Universite de Lorraine, Centre Hospitalier Regional et Universitaire, Nancy, France
| | - Michael R Zile
- Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | |
Collapse
|
20
|
Mooney L, Hawkins NM, Jhund PS, Redfield MM, Vaduganathan M, Desai AS, Rouleau JL, Minamisawa M, Shah AM, Lefkowitz MP, Zile MR, Van Veldhuisen DJ, Pfeffer MA, Anand IS, Maggioni AP, Senni M, Claggett BL, Solomon SD, McMurray JJV. Impact of Chronic Obstructive Pulmonary Disease in Patients With Heart Failure With Preserved Ejection Fraction: Insights From PARAGON-HF. J Am Heart Assoc 2021; 10:e021494. [PMID: 34796742 PMCID: PMC9075384 DOI: 10.1161/jaha.121.021494] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 10/21/2021] [Indexed: 12/12/2022]
Abstract
Background Little is known about the impact of chronic obstructive pulmonary disease (COPD) in patients with heart failure with preserved ejection fraction (HFpEF). Methods and Results We examined outcomes in patients with heart failure with preserved ejection fraction, according to COPD status, in the PARAGON-HF (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in Heart Failure With Preserved Ejection Fraction) trial. The primary outcome was a composite of first and recurrent hospitalizations for heart failure and cardiovascular death. Of 4791 patients, 670 (14%) had COPD. Patients with COPD were more likely to be men (58% versus 47%; P<0.001) and had worse New York Heart Association functional class (class III/IV 24% versus 19%), worse Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores (69 versus 76; P<0.001) and more frequent history of heart failure hospitalization (54% versus 47%; P<0.001). The decrement in Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores with COPD was greater than for other common comorbidities. Patients with COPD had echocardiographic right ventricular enlargement, higher serum creatinine (100 μmol/L versus 96 μmol/L) and neutrophil-to-lymphocyte ratio (2.7 versus 2.5), than those without COPD. After multivariable adjustment, COPD was associated with worse outcomes: adjusted rate ratio for the primary outcome 1.51 (95% CI, 1.25-1.83), total heart failure hospitalization 1.54 (95% CI, 1.24-1.90), cardiovascular death (adjusted hazard ratio [HR], 1.42; 95% CI, 1.10-1.82), and all-cause death (adjusted HR, 1.52; 95% CI, 1.25-1.84). COPD was associated with worse outcomes than other comorbidities and Kansas City Cardiomyopathy Questionnaire Clinical Summary Scores declined more in patients with COPD than in those without. Conclusions Approximately 1 in 7 patients with heart failure with preserved ejection fraction had concomitant COPD, which was associated with greater functional limitation and a higher risk of heart failure hospitalization and death. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.
Collapse
Affiliation(s)
- Leanne Mooney
- BHF Glasgow Cardiovascular Research CentreUniversity of GlasgowUnited Kingdom
| | | | - Pardeep S. Jhund
- BHF Glasgow Cardiovascular Research CentreUniversity of GlasgowUnited Kingdom
| | | | | | - Akshay S. Desai
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | | | | | - Amil M. Shah
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | | | - Michael R. Zile
- Department of MedicineMedical University of South CarolinaCharlestonSC
| | | | - Marc A. Pfeffer
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | | | | | - Michele Senni
- Cardiovascular Department & Cardiology UnitPapa Giovanni XXIII HospitalBergamoItaly
| | - Brian L. Claggett
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | - Scott D. Solomon
- Division of Cardiovascular MedicineBrigham and Women’s HospitalBostonMA
| | - John J. V. McMurray
- BHF Glasgow Cardiovascular Research CentreUniversity of GlasgowUnited Kingdom
| |
Collapse
|
21
|
Bhatt AS, Vaduganathan M, Claggett BL, Liu J, Packer M, Desai AS, Lefkowitz MP, Rouleau JL, Shi VC, Zile MR, Swedberg K, Vardeny O, McMurray JJV, Solomon SD. Effect of sacubitril/valsartan vs. enalapril on changes in heart failure therapies over time: the PARADIGM-HF trial. Eur J Heart Fail 2021; 23:1518-1524. [PMID: 34101308 PMCID: PMC9291580 DOI: 10.1002/ejhf.2259] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2021] [Revised: 04/28/2021] [Accepted: 05/30/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS Sacubitril/valsartan improves morbidity and mortality in patients with heart failure and reduced ejection fraction (HFrEF). Whether initiation of sacubitril/valsartan limits the use and dosing of other elements of guideline-directed medical therapy for HFrEF is unknown. We examined the effects of sacubitril/valsartan, compared with enalapril, on β-blocker and mineralocorticoid receptor antagonist (MRA) use and dosing in a large randomized clinical trial. METHODS AND RESULTS Patients with full data on medication use were included. We examined β-blocker and MRA use in patients randomized to sacubitril/valsartan vs. enalapril through 12-month follow-up. New initiations and discontinuations of β-blocker and MRA were compared between treatment groups. Overall, 8398 (99.9%) had full medication and dose data at baseline. Baseline use of β-blocker and MRA at any dose was 87% and 56%, respectively. Mean doses of β-blocker and MRA were similar between treatment groups at baseline and at 6-month and 12-month follow-up. New initiations through 12-month follow-up were infrequent and similar in the sacubitril/valsartan and enalapril groups for β-blockers [37 (9.0%) vs. 42 (10.2%), P = 0.56] and MRA [127 (7.6%) vs. 143 (9.2%), P = 0.10]. Among patients on MRA therapy at baseline, there were fewer MRA discontinuations in patients on sacubitril/valsartan as compared with enalapril at 12 months [125 (6.2%) vs. 187 (9.0%), P = 0.001]. Discontinuations of β-blockers were not significantly different between groups in follow-up (2.2% vs. 2.6%, P = 0.26). CONCLUSIONS Initiation of sacubitril/valsartan, even when titrated to target dose, did not appear to lead to greater discontinuation or dose down-titration of other key guideline-directed medical therapies, and was associated with fewer discontinuations of MRA. Use of sacubitril/valsartan (when compared with enalapril) may promote sustained MRA use in follow-up.
Collapse
Affiliation(s)
- Ankeet S Bhatt
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Brian L Claggett
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jiankang Liu
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Akshay S Desai
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Jean L Rouleau
- Montreal Heart Institute, Université de Montréal, Montréal, QC, Canada
| | - Victor C Shi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ, USA
| | - Michael R Zile
- Medical University of South Carolina, Charleston and Ralph H. Johnston Veterans Administration Medical Center, Charleston, SC, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, and University of Minnesota, Minneapolis, MN, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
22
|
Selvaraj S, Claggett BL, Packer M, Zannad F, Anand IS, Pieske B, Zhao Z, Shi VC, Lefkowitz MP, McMurray JJV, Solomon SD. Effects of Sacubitril/Valsartan on Serum Lipids in Heart Failure With Preserved Ejection Fraction. J Am Heart Assoc 2021; 10:e022069. [PMID: 33998278 PMCID: PMC8649234 DOI: 10.1161/jaha.121.022069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Dyslipidemia is common in heart failure with preserved ejection fraction. Sacubitril/valsartan improves glycemic control and augments natriuretic peptide signaling, providing mechanisms by which sacubitril/valsartan may affect serum lipids. However, empiric data on these effects are lacking. Methods and Results We analyzed 4774 participants from PARAGON‐HF (Prospective Comparison of Angiotensin Receptor–Neprilysin Inhibitor With Angiotensin‐Receptor Blockers Global Outcomes in Heart Failure With Preserved Ejection Fraction) with available screening lipids. During follow‐up visits, we analyzed the treatment effect on lipid levels and assessed for interaction by baseline lipid levels. At the 16‐week visit, we adjusted these treatment effects for the change in several biomarkers (including hemoglobin A1c and urinary cyclic guanosine monophosphate/creatinine [a biomarker of natriuretic peptide activation]). The average age was 73±8 years, 52% were women, 43% had diabetes mellitus, and 64% were on statin therapy. Compared with valsartan, sacubitril/valsartan reduced triglycerides −5.0% (95% CI, −6.6% to −3.5%), increased high‐density lipoprotein cholesterol +2.6% (95% CI, +1.7% to +3.4%), and increased low‐density lipoprotein cholesterol +1.7% (95% CI, +0.4% to +3.0%). Sacubitril/valsartan reduced triglycerides most among those with elevated baseline levels (triglycerides≥200 mg/dL) (P‐interaction<0.001), and at 16 weeks by −13.0% (95% CI, −18.1% to −7.6%), or −29.9 (95% CI, −44.3 to −15.5) mg/dL, in this group. Adjusting for the change in urinary cyclic guanosine monophosphate/creatinine significantly attenuated treatment effects on triglycerides and high‐density lipoprotein cholesterol, but not low‐density lipoprotein cholesterol, while adjusting for other biomarkers did not significantly alter the treatment effects. Conclusions Sacubitril/valsartan significantly reduces triglycerides compared with valsartan, an effect that was nearly threefold stronger in those with elevated baseline triglycerides. Modest increases in high‐density lipoprotein cholesterol and low‐density lipoprotein cholesterol cholesterol were also observed with therapy. The underlying mechanism(s) of changes in high‐density lipoprotein cholesterol and triglycerides are related to sacubitril/valsartan’s effects on natriuretic peptide activity. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.
Collapse
Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA
| | - Brian L Claggett
- Division of Cardiology Department of Medicine Brigham and Women's Hospital Boston MA
| | - Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical Center Dallas TX.,Imperial College London UK
| | - Faiez Zannad
- INSERM Centre d'Investigation Clinic 1433 and Universite de LorraineCentre Hospitalier Regional et Universitaire Nancy France
| | - Inder S Anand
- Department of Cardiovascular Medicine University of Minnesota Minneapolis MN
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology German Center for Cardiovascular Research partner site Berlin Berlin Germany
| | | | | | | | | | - Scott D Solomon
- Division of Cardiology Department of Medicine Brigham and Women's Hospital Boston MA
| |
Collapse
|
23
|
Tromp J, Claggett BL, Liu J, Jackson AM, Jhund PS, Køber L, Widimský J, Boytsov SA, Chopra VK, Anand IS, Ge J, Chen CH, Maggioni AP, Martinez F, Packer M, Pfeffer MA, Pieske B, Redfield MM, Rouleau JL, Van Veldhuisen DJ, Zannad F, Zile MR, Rizkala AR, Inubushi-Molessa A, Lefkowitz MP, Shi VC, McMurray JJV, Solomon SD, Lam CSP. Global Differences in Heart Failure With Preserved Ejection Fraction: The PARAGON-HF Trial. Circ Heart Fail 2021; 14:e007901. [PMID: 33866828 DOI: 10.1161/circheartfailure.120.007901] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [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: 01/09/2023]
Abstract
BACKGROUND Heart failure with preserved ejection fraction (HFpEF) is a global public health problem with important regional differences. We investigated these differences in the PARAGON-HF trial (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in HFpEF), the largest and most inclusive global HFpEF trial. METHODS We studied differences in clinical characteristics, outcomes, and treatment effects of sacubitril/valsartan in 4796 patients with HFpEF from the PARAGON-HF trial, grouped according to geographic region. RESULTS Regional differences in patient characteristics and comorbidities were observed: patients from Western Europe were oldest (mean 75±7 years) with the highest prevalence of atrial fibrillation/flutter (36%); Central/Eastern European patients were youngest (mean 71±8 years) with the highest prevalence of coronary artery disease (50%); North American patients had the highest prevalence of obesity (65%) and diabetes (49%); Latin American patients were younger (73±9 years) and had a high prevalence of obesity (53%); and Asia-Pacific patients had a high prevalence of diabetes (44%), despite a low prevalence of obesity (26%). Rates of the primary composite end point of total hospitalizations for HF and death from cardiovascular causes were lower in patients from Central Europe (9 per 100 patient-years) and highest in patients from North America (28 per 100 patient-years), which was primarily driven by a greater number of total hospitalizations for HF. The effect of treatment with sacubitril-valsartan was not modified by region (interaction P>0.05). CONCLUSIONS Among patients with HFpEF recruited worldwide in PARAGON-HF, there were important regional differences in clinical characteristics and outcomes, which may have implications for the design of future clinical trials. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.
Collapse
Affiliation(s)
- Jasper Tromp
- National Heart Centre Singapore (J.T., C.S.P.L.).,Duke-NUS Medical School, Singapore (J.T., C.S.P.L.).,Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands (J.T., D.J.V.V., C.S.P.L.).,Saw Swee Hock School of Public Health, National University of Singapore, Singapore (J.T.)
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.C., J.L., M.A.P., S.D.S.)
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.C., J.L., M.A.P., S.D.S.)
| | - Alice M Jackson
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.M.J., P.S.J., J.J.V.M.)
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.M.J., P.S.J., J.J.V.M.)
| | - Lars Køber
- Department of Cardiology, Heart Centre, Rigshospitalet, Copenhagen University Hospital, Denmark (L.K.)
| | - Jiří Widimský
- First Faculty of Medicine, Charles University Prague, Czech Republic (J.W.)
| | - Sergey A Boytsov
- National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.B.)
| | - Vijay K Chopra
- Heart Failure and Research Max Super Specialty Hospital Saket, New Delhi, India (V.C.)
| | - Inder S Anand
- Department of Medicine, VA Medical Center and University of Minnesota, Minneapolis (I.S.A.)
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, China (J.G.)
| | - Chen-Huan Chen
- Faculty of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China (C.-H.C.)
| | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri, Florence, Italy (A.P.M.)
| | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.C., J.L., M.A.P., S.D.S.)
| | - Burkert Pieske
- Department of Internal Medicine, Cardiology Charité, Universitaetsmedizin Berlin, Campus Virchow Klinikum Berlin, Germany (B.P.)
| | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, QC, Canada (J.L.R.)
| | - Dirk J Van Veldhuisen
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands (J.T., D.J.V.V., C.S.P.L.)
| | - Faiez Zannad
- Inserm CIC 1433 and Université de Lorraine, Centre Hospitalier Régional Universitaire, Nancy, France (F.Z.)
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Adel R Rizkala
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (A.R.R., A.I.-M., M.P.L., V.C.S.)
| | - Akiko Inubushi-Molessa
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (A.R.R., A.I.-M., M.P.L., V.C.S.)
| | - Martin P Lefkowitz
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (A.R.R., A.I.-M., M.P.L., V.C.S.)
| | - Victor C Shi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (A.R.R., A.I.-M., M.P.L., V.C.S.)
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (A.M.J., P.S.J., J.J.V.M.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (B.L.C., J.L., M.A.P., S.D.S.)
| | - Carolyn S P Lam
- National Heart Centre Singapore (J.T., C.S.P.L.).,Duke-NUS Medical School, Singapore (J.T., C.S.P.L.).,Department of Cardiology, University Medical Centre Groningen, University of Groningen, the Netherlands (J.T., D.J.V.V., C.S.P.L.)
| | | |
Collapse
|
24
|
Ferreira JP, Claggett BL, Liu J, Desai AS, Pfeffer MA, Anand IS, van Veldhuisen DJ, Kober L, Cleland JGF, Rouleau JL, Packer M, Zile MR, Shi VC, Lefkowitz MP, Shah SJ, Vardeny O, Zannad F, Solomon SD, McMurray JJV. Serum potassium and outcomes in heart failure with preserved ejection fraction: a post-hoc analysis of the PARAGON-HF trial. Eur J Heart Fail 2021; 23:776-784. [PMID: 33609066 DOI: 10.1002/ejhf.2134] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [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: 11/06/2020] [Revised: 02/08/2021] [Accepted: 02/18/2021] [Indexed: 12/13/2022] Open
Abstract
AIMS The relationship between serum potassium concentration and outcomes in patients with heart failure and preserved ejection fraction (HFpEF) is not well-established. The aim of this study was to explore the association between serum potassium and clinical outcomes in the PARAGON-HF trial in which 4822 patients with HFpEF were randomised to treatment with sacubitril/valsartan or valsartan. METHODS AND RESULTS The relationship between serum potassium concentrations and the primary study composite outcome of total (first and recurrent) heart failure hospitalisations and cardiovascular death was analysed. Hypo-, normo-, and hyperkalaemia were defined as serum potassium <4 mmol/L, 4-5 mmol/L and >5 mmol/L, respectively. Both screening and time-updated potassium (categorical and continuous spline-transformed) were studied. Patient mean age was 73 years and 52% were women. Patients with higher baseline potassium more often had an ischaemic aetiology and diabetes and mineralocorticoid receptor antagonist treatment. Compared with normokalaemia, both time-updated (but not screening) hypo- and hyperkalaemia were associated with a higher risk of the primary outcome [adjusted hazard ratio (HR) for hypokalaemia 1.55, 95% confidence interval (CI) 1.30-1.85; P < 0.001, and for hyperkalaemia HR 1.21, 95% CI 1.02-1.44; P = 0.025]. Hypokalaemia had a stronger association with a higher risk of all-cause, cardiovascular and non-cardiovascular death than hyperkalaemia. The association of hypokalaemia with increased risk of all-cause and cardiovascular death was most marked in participants with impaired kidney function (interaction P < 0.05). Serum potassium did not significantly differ between sacubitril/valsartan and valsartan throughout the follow-up. CONCLUSIONS Both hypo- and hyperkalaemia were associated with heart failure hospitalisation but only hypokalaemia was associated with mortality, especially in the context of renal impairment. Hypokalaemia was as strongly associated with death from non-cardiovascular causes as with cardiovascular death. Collectively, these findings suggest that potassium disturbances are a more of a marker of HFpEF severity rather than a direct cause of death.
Collapse
Affiliation(s)
- João Pedro Ferreira
- National Institute of Health and Medical Research, Center for Clinical Multidisciplinary Research, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France.,British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Jiankang Liu
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Inder S Anand
- Department of Cardiovascular Medicine, University of Minnesota, Minneapolis, MN, USA
| | - Dirk J van Veldhuisen
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Lars Kober
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - John G F Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, Glasgow, UK
| | - Jean L Rouleau
- Montreal Institute of Cardiology, University of Montreal, Montreal, Canada
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA.,Imperial College, London, UK
| | - Michael R Zile
- Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC, USA
| | | | | | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, MN, USA
| | - Faiez Zannad
- National Institute of Health and Medical Research, Center for Clinical Multidisciplinary Research, INSERM U1116, University of Lorraine, Regional University Hospital of Nancy, French Clinical Research Infrastructure Network Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Nancy, France
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| |
Collapse
|
25
|
Ehteshami-Afshar S, Mooney L, Dewan P, Desai AS, Lang NN, Lefkowitz MP, Petrie MC, Rizkala AR, Rouleau JL, Solomon SD, Swedberg K, Shi VC, Zile MR, Packer M, McMurray JJV, Jhund PS, Hawkins NM. Clinical Characteristics and Outcomes of Patients With Heart Failure With Reduced Ejection Fraction and Chronic Obstructive Pulmonary Disease: Insights From PARADIGM-HF. J Am Heart Assoc 2021; 10:e019238. [PMID: 33522249 PMCID: PMC7955331 DOI: 10.1161/jaha.120.019238] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background Chronic obstructive pulmonary disease (COPD) is a common comorbidity in heart failure with reduced ejection fraction, associated with undertreatment and worse outcomes. New treatments for heart failure with reduced ejection fraction may be particularly important in patients with concomitant COPD. Methods and Results We examined outcomes in 8399 patients with heart failure with reduced ejection fraction, according to COPD status, in the PARADIGM‐HF (Prospective Comparison of Angiotensin Receptor Blocker–Neprilysin Inhibitor With Angiotensin‐Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure) trial. Cox regression models were used to compare COPD versus non‐COPD subgroups and the effects of sacubitril/valsartan versus enalapril. Patients with COPD (n=1080, 12.9%) were older than patients without COPD (mean 67 versus 63 years; P<0.001), with similar left ventricular ejection fraction (29.9% versus 29.4%), but higher NT‐proBNP (N‐terminal pro‐B‐type natriuretic peptide; median, 1741 pg/mL versus 1591 pg/mL; P=0.01), worse functional class (New York Heart Association III/IV 37% versus 23%; P<0.001) and Kansas City Cardiomyopathy Questionnaire–Clinical Summary Score (73 versus 81; P<0.001), and more congestion and comorbidity. Medical therapy was similar in patients with and without COPD except for beta‐blockade (87% versus 94%; P<0.001) and diuretics (85% versus 80%; P<0.001). After multivariable adjustment, COPD was associated with higher risks of heart failure hospitalization (hazard ratio [HR], 1.32; 95% CI, 1.13–1.54), and the composite of cardiovascular death or heart failure hospitalization (HR, 1.18; 95% CI, 1.05–1.34), but not cardiovascular death (HR, 1.10; 95% CI, 0.94–1.30), or all‐cause mortality (HR, 1.14; 95% CI, 0.99–1.31). COPD was also associated with higher risk of all cardiovascular hospitalization (HR, 1.17; 95% CI, 1.05–1.31) and noncardiovascular hospitalization (HR, 1.45; 95% CI, 1.29–1.64). The benefit of sacubitril/valsartan over enalapril was consistent in patients with and without COPD for all end points. Conclusions In PARADIGM‐HF, COPD was associated with lower use of beta‐blockers and worse health status and was an independent predictor of cardiovascular and noncardiovascular hospitalization. Sacubitril/valsartan was beneficial in this high‐risk subgroup. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT01035255.
Collapse
Affiliation(s)
| | - Leanne Mooney
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Pooja Dewan
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Akshay S Desai
- Division of Cardiovascular Medicine Brigham and Women's Hospital Boston MA
| | - Ninian N Lang
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | | | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | | | - Jean L Rouleau
- Institut de Cardiologie Université de Montréal Montréal Québec Canada
| | - Scott D Solomon
- Division of Cardiovascular Medicine Brigham and Women's Hospital Boston MA
| | | | - Victor C Shi
- Novartis Pharmaceutical Corporation East Hanover NJ
| | - Michael R Zile
- Department of Medicine Medical University of South Carolina Charleston SC
| | - Milton Packer
- Baylor Heart and Vascular InstituteBaylor University Medical CenterImperial College Dallas TX USA.,Imperial College London UK
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre University of Glasgow Glasgow UK
| | | |
Collapse
|
26
|
Selvaraj S, Claggett BL, Pfeffer MA, Desai AS, Mc Causland FR, McGrath MM, Anand IS, Veldhuisen DJ, Kober L, Janssens S, Cleland JG, Pieske B, Rouleau JL, Zile MR, Shi VC, Lefkowitz MP, McMurray JJ, Solomon SD. Serum uric acid, influence of sacubitril–valsartan, and cardiovascular outcomes in heart failure with preserved ejection fraction:
PARAGON‐HF. Eur J Heart Fail 2020; 22:2093-2101. [DOI: 10.1002/ejhf.1984] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Revised: 08/06/2020] [Accepted: 08/17/2020] [Indexed: 01/05/2023] Open
Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine Hospital of the University of Pennsylvania Philadelphia PA USA
| | - Brian L. Claggett
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | - Marc A. Pfeffer
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | - Akshay S. Desai
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital Boston MA USA
| | | | - Martina M. McGrath
- Renal Division Brigham and Women's Hospital, Harvard Medical School Boston MA USA
| | - Inder S. Anand
- Department of Cardiovascular Medicine University of Minnesota Minneapolis MN USA
| | - Dirk J. Veldhuisen
- Department of Cardiology University of Groningen, University Medical Centre Groningen Groningen the Netherlands
| | - Lars Kober
- Rigshospitalet Copenhagen University Hospital Copenhagen Denmark
| | - Stefan Janssens
- Department of Cardiology University Hospitals Leuven Belgium
| | - John G.F. Cleland
- Robertson Institute of Biostatistics and Clinical Trials Unit University of Glasgow Glasgow UK
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology German Centre for Cardiovascular Research partner site Berlin Berlin Germany
| | - Jean L. Rouleau
- Montreal Institute of Cardiology University of Montreal Montreal QC Canada
| | - Michael R. Zile
- Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center Charleston SC USA
| | | | | | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre University of Glasgow Glasgow UK
| | - Scott D. Solomon
- Division of Cardiology, Department of Medicine Brigham and Women's Hospital Boston MA USA
| |
Collapse
|
27
|
Mc Causland FR, Lefkowitz MP, Claggett B, Anavekar NS, Senni M, Gori M, Jhund PS, McGrath MM, Packer M, Shi V, Van Veldhuisen DJ, Zannad F, Comin-Colet J, Pfeffer MA, McMurray JJ, Solomon SD. Angiotensin-Neprilysin Inhibition and Renal Outcomes in Heart Failure With Preserved Ejection Fraction. Circulation 2020; 142:1236-1245. [DOI: 10.1161/circulationaha.120.047643] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
In patients with heart failure, chronic kidney disease is common and associated with a higher risk of renal events than in patients without chronic kidney disease. We assessed the renal effects of angiotensin/neprilysin inhibition in patients who have heart failure with preserved ejection fraction enrolled in the PARAGON-HF trial (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction).
Methods:
In this randomized, double-blind, event-driven trial, we assigned 4822 patients who had heart failure with preserved ejection fraction to receive sacubitril/valsartan (n=2419) or valsartan (n=2403). Herein, we present the results of the prespecified renal composite outcome (time to first occurrence of either: ≥50% reduction in estimated glomerular filtration rate (eGFR), end-stage renal disease, or death from renal causes), the individual components of this composite, and the influence of therapy on eGFR slope.
Results:
At randomization, eGFR was 63±19 mL·min
–1
·1.73 m
–
2. At study closure, the composite renal outcome occurred in 33 patients (1.4%) assigned to sacubitril/valsartan and 64 patients (2.7%) assigned to valsartan (hazard ratio, 0.50 [95% CI, 0.33–0.77];
P
=0.001). The treatment effect on the composite renal end point did not differ according to the baseline eGFR (<60 versus ≥60 mL·min
–1
·1.73 m
–2
(
P
-interaction=0.92). The decline in eGFR was less for sacubitril/valsartan than for valsartan (–2.0 [95% CI, –2.2 to –1.9] versus –2.7 [95% CI, –2.8 to –2.5] mL·min
–1
·1.73 m
–2
per year).
Conclusions:
In patients with heart failure with preserved ejection fraction, sacubitril/valsartan reduced the risk of renal events, and slowed decline in eGFR, in comparison with valsartan.
Registration:
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT01920711.
Collapse
Affiliation(s)
- Finnian R. Mc Causland
- Renal Division, Department of Medicine(F.R.M., M.M.M.), Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA (F.R.M., B.C., M.M.M., F.Z., M.A.P., S.D.S.)
| | | | - Brian Claggett
- Cardiovascular Division, Department of Medicine (B.C., M.A.P., S.D.S.), Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA (F.R.M., B.C., M.M.M., F.Z., M.A.P., S.D.S.)
| | - Nagesh S. Anavekar
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia (N.S.A.)
| | - Michele Senni
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy (M.S., M.G.)
| | - Mauro Gori
- Cardiology Division, Cardiovascular Department, Azienda Ospedaliera Papa Giovanni XXIII Hospital, Bergamo, Italy (M.S., M.G.)
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (P.S.J., J.J.V.M.)
| | - Martina M. McGrath
- Renal Division, Department of Medicine(F.R.M., M.M.M.), Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA (F.R.M., B.C., M.M.M., F.Z., M.A.P., S.D.S.)
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Victor Shi
- Novartis Pharmaceuticals, East Hanover, NJ (M.P.L., V.S.)
| | - Dirk J. Van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (D.J.W.)
| | - Faiez Zannad
- Harvard Medical School, Boston, MA (F.R.M., B.C., M.M.M., F.Z., M.A.P., S.D.S.)
- Université de Lorraine, Inserm CIC1433, CHRU de Nancy, France (F.Z.)
| | - Josep Comin-Colet
- Department of Cardiology, Bellvitge University Hospital and Bellvitge Biomedical Research Institute (IDIBELL), L’Hospitalet de Llobregat, Barcelona, Spain (J.C.-C.)
- Department of Clinical Sciences, School of Medicine, University of Barcelona, Spain (J.C.-C.)
| | - Marc A. Pfeffer
- Cardiovascular Division, Department of Medicine (B.C., M.A.P., S.D.S.), Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA (F.R.M., B.C., M.M.M., F.Z., M.A.P., S.D.S.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (P.S.J., J.J.V.M.)
| | - Scott D. Solomon
- Cardiovascular Division, Department of Medicine (B.C., M.A.P., S.D.S.), Brigham and Women’s Hospital, Boston, MA
- Harvard Medical School, Boston, MA (F.R.M., B.C., M.M.M., F.Z., M.A.P., S.D.S.)
| |
Collapse
|
28
|
Cunningham JW, Claggett BL, O'Meara E, Prescott MF, Pfeffer MA, Shah SJ, Redfield MM, Zannad F, Chiang LM, Rizkala AR, Shi VC, Lefkowitz MP, Rouleau J, McMurray JJV, Solomon SD, Zile MR. Effect of Sacubitril/Valsartan on Biomarkers of Extracellular Matrix Regulation in Patients With HFpEF. J Am Coll Cardiol 2020; 76:503-514. [PMID: 32731928 DOI: 10.1016/j.jacc.2020.05.072] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [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: 04/20/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Myocardial fibrosis may contribute to the pathophysiology of heart failure with preserved ejection fraction. Given the biochemical targets of sacubitril/valsartan, this study hypothesized that circulating biomarkers reflecting the mechanisms that determine extracellular matrix homeostasis are altered by sacubitril/valsartan compared with valsartan alone. OBJECTIVES This study investigated the effects of sacubitril/valsartan on biomarkers of extracellular matrix homeostasis and the association between biomarkers and the primary endpoint (total heart failure hospitalizations and cardiovascular death). METHODS N-terminal propeptide of collagen I and III, tissue inhibitor of matrix metalloproteinase 1, carboxyl-terminal telopeptide of collagen type I, and soluble ST2 were measured at baseline (n = 1,135) and 16 (n = 1,113) and 48 weeks (n = 1,016) after randomization. The effects of sacubitril/valsartan on these biomarkers were compared with those of valsartan alone. Baseline biomarker values and changes from baseline to 16 weeks were related to primary endpoint. RESULTS At baseline, all 5 biomarkers were higher than published referent control values. Sixteen weeks after randomization, sacubitril/valsartan decreased tissue inhibitor of matrix metalloproteinase 1 by 8% (95% confidence interval [CI]: 6% to 10%; p < 0.001), soluble ST2 by 4% (95% CI: 1% to 7%; p = 0.002), and N-terminal propeptide of collagen III by 3% (95% CI: 0% to 6%; p = 0.04) and increased carboxyl-terminal telopeptide of collagen type I by 4% (95% CI: 1% to 8%; p = 0.02) compared with valsartan alone, consistently in men and women and patients with left ventricular ejection fraction above or below the median of 57%. Higher levels of tissue inhibitor of matrix metalloproteinase 1 and soluble ST2 at baseline and increases in these markers at 16 weeks were associated with higher primary endpoint event rates. CONCLUSIONS Biomarkers reflecting extracellular matrix homeostasis are elevated in heart failure with preserved ejection fraction, favorably altered by sacubitril/valsartan, and have important prognostic value. (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
Collapse
Affiliation(s)
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eileen O'Meara
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Faiez Zannad
- Centre d'Investigations Cliniques-Plurithématique 1433, and Institut National de la Santé et de la Recherche Médicale U1116, Centre Hospitalier Regional Universitaire, French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Clinical Trialists, Nancy, France
| | | | | | | | | | - Jean Rouleau
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Michael R Zile
- Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina; Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina.
| |
Collapse
|
29
|
Cunningham JW, Vaduganathan M, Claggett BL, Zile MR, Anand IS, Packer M, Zannad F, Lam CSP, Janssens S, Jhund PS, Kober L, Rouleau J, Shah SJ, Chopra VK, Shi VC, Lefkowitz MP, Prescott MF, Pfeffer MA, McMurray JJV, Solomon SD. Effects of Sacubitril/Valsartan on N-Terminal Pro-B-Type Natriuretic Peptide in Heart Failure With Preserved Ejection Fraction. JACC Heart Fail 2020; 8:372-381. [PMID: 32241619 DOI: 10.1016/j.jchf.2020.03.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [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: 02/20/2020] [Revised: 02/25/2020] [Accepted: 03/05/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The authors sought to evaluate the prognostic significance of baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP), whether NT-proBNP modified the treatment response to sacubitril/valsartan, and the treatment effect of sacubitril/valsartan on NT-proBNP overall and in key subgroups. BACKGROUND Sacubitril/valsartan reduces NT-proBNP in heart failure (HF) with both reduced and preserved ejection fraction (EF), but did not significantly reduce total HF hospitalizations and cardiovascular death compared with valsartan in patients with HF with preserved EF (HFpEF). METHODS In the PARAGON-HF (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction) trial, 4,796 patients with HFpEF and elevated NT-proBNP were randomized to sacubitril/valsartan or valsartan. NT-proBNP was measured at screening in all patients and at 5 subsequent times in >2,700 patients: before, between, and after sequential valsartan and sacubitril/valsartan run-in periods, and 16 and 48 weeks post-randomization. RESULTS Median NT-proBNP was 911 pg/ml (interquartile range: 464 to 1,613 pg/ml) at screening. Screening NT-proBNP was strongly associated with the primary endpoint, total HF hospitalizations and cardiovascular death (rate ratio [RR]: 1.68 per log increase in NT-proBNP, 95% confidence interval [CI]: 1.53 to 1.85; p < 0.001). This relationship was stronger in patients with atrial fibrillation (adjusted RR: 2.33 [95% CI: 1.89 to 2.87] vs. 1.58 [95% CI: 1.42 to 1.75] in patients without atrial fibrillation; p interaction <0.001) and weaker in obese patients (adjusted RR: 1.50 [95% CI: 1.31 to 1.71] vs. 1.92 [95% CI: 1.70 to 2.17] in nonobese patients; p interaction <0.001). Screening NT-proBNP did not modify the treatment effect of sacubitril/valsartan compared with valsartan (p interaction = 0.96). Sacubitril/valsartan reduced NT-proBNP by 19% (95% CI: 14% to 23%; p < 0.001) compared with valsartan 16 weeks post-randomization, with similar reductions in men (20%) and women (18%), and in patients with left ventricular EF ≤57% (20%) and >57% (18%). Decreases in NT-proBNP predicted lower subsequent risk of the primary endpoint. CONCLUSIONS Baseline NT-proBNP predicted HF events but did not modify the sacubitril/valsartan treatment effect in patients with HFpEF. Sacubitril/valsartan reduced NT-proBNP consistently in men and women, and in patients with lower or higher EF. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
Collapse
Affiliation(s)
- Jonathan W Cunningham
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts. https://twitter.com/JonWCunningham
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts. https://twitter.com/mvaduganathan
| | - Brian L Claggett
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts
| | - Michael R Zile
- RHJ Department of Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, South Carolina
| | - Inder S Anand
- VA Medical Center and University of Minnesota, Minneapolis, Minnesota
| | | | - Faiez Zannad
- Centre d'Investigations Cliniques-Plurithématique 1433, and INSERM U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore; Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; The George Institute for Global Health, Australia
| | - Stefan Janssens
- Department of Cardiology, University Hospitals, Leuven, Belgium
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Lars Kober
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean Rouleau
- Montreal Heart Institute and Université de Montréal, Montreal, Canada
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vijay K Chopra
- Heart Failure Unit, Medanta Medicity, Gurugram, Haryana, India
| | | | | | | | - Marc A Pfeffer
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts
| | - John J V McMurray
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts.
| |
Collapse
|
30
|
Selvaraj S, Claggett BL, Böhm M, Anker SD, Vaduganathan M, Zannad F, Pieske B, Lam CSP, Anand IS, Shi VC, Lefkowitz MP, McMurray JJV, Solomon SD. Systolic Blood Pressure in Heart Failure With Preserved Ejection Fraction Treated With Sacubitril/Valsartan. J Am Coll Cardiol 2020; 75:1644-1656. [PMID: 32192799 DOI: 10.1016/j.jacc.2020.02.009] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/30/2020] [Accepted: 02/03/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND Guidelines recommend targeting systolic blood pressure (SBP) <130 mm Hg in heart failure with preserved ejection fraction (HFpEF) with limited data. OBJECTIVES This study sought to determine the optimal achieved SBP and whether the treatment effects of sacubitril/valsartan on outcomes are related to BP lowering, particularly among women who derive greater benefit from sacubitril/valsartan. METHODS Using 4,795 trial participants, this study related baseline and time-updated mean achieved SBP quartiles (<120, 120 to 129, 130 to 139, ≥140 mm Hg) to the primary outcome (cardiovascular death and total heart failure hospitalization), its components, myocardial infarction or stroke, and a renal composite outcome. At the 16-week visit, the study assessed the relationship between SBP change and Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OSS) and N-terminal pro-B-type natriuretic peptide (NT-proBNP). The study analyzed whether the BP-lowering effects of sacubitril/valsartan accounted for its treatment effects. RESULTS Average age was 73 ± 8 years, and 52% of participants were women. After multivariable adjustment, baseline and mean achieved SBP of 120 to 129 mm Hg demonstrated the lowest risk for all outcomes. Sacubitril/valsartan reduced SBP by 5.2 mm Hg (95% confidence interval: 4.4 to 6.0) compared with valsartan at 4 weeks, which was not modified by baseline SBP. However, sacubitril/valsartan reduced SBP more in women (6.3 mm Hg) than men (4.0 mm Hg) (interaction p = 0.005). Change in SBP was directly associated with change in NT-proBNP (p < 0.001) but not KCCQ-OSS (p = 0.40). The association between sacubitril/valsartan and the primary outcome was not modified by baseline SBP (interaction p = 0.50) and was similar when adjusting for time-updated SBP, regardless of sex. CONCLUSIONS Baseline and mean achieved SBP of 120 to 129 mm Hg identified the lowest risk patients with HFpEF. Baseline SBP did not modify the treatment effect of sacubitril/valsartan, and the BP-lowering effects of sacubitril/valsartan did not account for its effects on outcomes, regardless of sex. (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
Collapse
Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania. https://twitter.com/senthil_selv
| | - Brian L Claggett
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michael Böhm
- Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin, Berlin, Germany; Klinik für Innere Medizin III, Universität des Saarlandes, Homburg, Germany
| | - Stefan D Anker
- Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin, Berlin, Germany; Klinik für Innere Medizin III, Universität des Saarlandes, Homburg, Germany
| | - Muthiah Vaduganathan
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Faiez Zannad
- INSERM Centre d'Investigation Clinic 1433 and Universite de Lorraine, Centre Hospitalier Regional et Universitaire, Nancy, France
| | - Burkert Pieske
- Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin, Berlin, Germany
| | - Carolyn S P Lam
- National Heart Center Singapore and Duke-National University of Singapore, Singapore
| | - Inder S Anand
- Department of Cardiovascular Medicine, University of Minnesota, Minneapolis, Minnesota
| | | | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
| |
Collapse
|
31
|
Vaduganathan M, Claggett BL, Desai AS, Anker SD, Perrone SV, Janssens S, Milicic D, Arango JL, Packer M, Shi VC, Lefkowitz MP, McMurray JJV, Solomon SD. Prior Heart Failure Hospitalization, Clinical Outcomes, and Response to Sacubitril/Valsartan Compared With Valsartan in HFpEF. J Am Coll Cardiol 2019; 75:245-254. [PMID: 31726194 DOI: 10.1016/j.jacc.2019.11.003] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 11/05/2019] [Accepted: 11/05/2019] [Indexed: 12/12/2022]
Abstract
BACKGROUND The period shortly after hospitalization for heart failure (HF) represents a high-risk window for recurrent clinical events, including rehospitalization or death. OBJECTIVES This study sought to determine whether the efficacy and safety of sacubitril/valsartan varies in relation to the proximity to hospitalization for HF among patients with HF with preserved ejection fraction (HFpEF). METHODS In this post hoc analysis of PARAGON-HF (Prospective Comparison of ARNI [Angiotensin Receptor-Neprilysin Inhibitor] with ARB [Angiotensin Receptor Blocker] Global Outcomes in HFpEF), we assessed the risk of clinical events and response to sacubitril/valsartan in relation to time from last HF hospitalization among patients with HFpEF (≥45%). The primary outcome was composite total HF hospitalizations and cardiovascular death, analyzed by using a semiparametric proportional rates method, stratified by geographic region. RESULTS Of 4,796 validly randomized patients in PARAGON-HF, 622 (13%) were screened during hospitalization or within 30 days of prior hospitalization, 555 (12%) within 31 to 90 days, 435 (9%) within 91 to 180 days, and 694 (14%) after 180 days; 2,490 (52%) were never previously hospitalized. Over a median follow-up of 35 months, risk of total HF hospitalizations and cardiovascular death was inversely and nonlinearly associated with timing from prior HF hospitalization (p < 0.001). There was a gradient in relative risk reduction in primary events with sacubitril/valsartan from patients hospitalized within 30 days (rate ratio: 0.73; 95% confidence interval: 0.53 to 0.99) to patients never hospitalized (rate ratio: 1.00; 95% confidence interval: 0.80 to 1.24; trend in relative risk reduction: pinteraction = 0.15). With valsartan alone, the rate of total primary events was 26.7 (≤30 days), 24.2 (31 to 90 days), 20.7 (91 to 180 days), 15.7 (>180 days), and 7.9 (not previously hospitalized) per 100 patient-years. Compared with valsartan, absolute risk reductions with sacubitril/valsartan were more prominent in patients enrolled early after hospitalization: 6.4% (≤30 days), 4.6% (31 to 90 days), and 3.4% (91 to 180 days), whereas no risk reduction was observed in patients screened >180 days or who were never hospitalized (trend in absolute risk reduction: pinteraction = 0.050). CONCLUSIONS Recent hospitalization for HFpEF identifies patients at high risk for near-term clinical progression. In the PARAGON-HF trial, the relative and absolute benefits of sacubitril/valsartan compared with valsartan in HFpEF appear to be amplified when initiated in the high-risk window after hospitalization and warrant prospective validation. (PARAGON-HF; NCT01920711).
Collapse
Affiliation(s)
- Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/mvaduganathan
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. https://twitter.com/akshaydesaimd
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology and Berlin-Brandenburg Center for Regenerative Therapies; German Centre for Cardiovascular Research (Deutsches Zentrum für Herz-Kreislauf-Forschung), Berlin, Germany; Charité Universitätsmedizin, Berlin, Germany
| | - Sergio V Perrone
- Instituto Fleni, Buenos Aires, Argentina. https://twitter.com/svperrone
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Davor Milicic
- Department of Cardiovascular Diseases, University Hospital Center Zagreb, Zagreb, Croatia
| | - Juan L Arango
- Guatemalan Heart Institute, Guatemala City, Guatemala
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas; Imperial College, London, United Kingdom
| | - Victor C Shi
- Novartis Pharmaceuticals, East Hanover, New Jersey
| | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| |
Collapse
|
32
|
Solomon SD, McMurray JJV, Anand IS, Ge J, Lam CSP, Maggioni AP, Martinez F, Packer M, Pfeffer MA, Pieske B, Redfield MM, Rouleau JL, van Veldhuisen DJ, Zannad F, Zile MR, Desai AS, Claggett B, Jhund PS, Boytsov SA, Comin-Colet J, Cleland J, Düngen HD, Goncalvesova E, Katova T, Kerr Saraiva JF, Lelonek M, Merkely B, Senni M, Shah SJ, Zhou J, Rizkala AR, Gong J, Shi VC, Lefkowitz MP. Angiotensin-Neprilysin Inhibition in Heart Failure with Preserved Ejection Fraction. N Engl J Med 2019; 381:1609-1620. [PMID: 31475794 DOI: 10.1056/nejmoa1908655] [Citation(s) in RCA: 1292] [Impact Index Per Article: 258.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND The angiotensin receptor-neprilysin inhibitor sacubitril-valsartan led to a reduced risk of hospitalization for heart failure or death from cardiovascular causes among patients with heart failure and reduced ejection fraction. The effect of angiotensin receptor-neprilysin inhibition in patients with heart failure with preserved ejection fraction is unclear. METHODS We randomly assigned 4822 patients with New York Heart Association (NYHA) class II to IV heart failure, ejection fraction of 45% or higher, elevated level of natriuretic peptides, and structural heart disease to receive sacubitril-valsartan (target dose, 97 mg of sacubitril with 103 mg of valsartan twice daily) or valsartan (target dose, 160 mg twice daily). The primary outcome was a composite of total hospitalizations for heart failure and death from cardiovascular causes. Primary outcome components, secondary outcomes (including NYHA class change, worsening renal function, and change in Kansas City Cardiomyopathy Questionnaire [KCCQ] clinical summary score [scale, 0 to 100, with higher scores indicating fewer symptoms and physical limitations]), and safety were also assessed. RESULTS There were 894 primary events in 526 patients in the sacubitril-valsartan group and 1009 primary events in 557 patients in the valsartan group (rate ratio, 0.87; 95% confidence interval [CI], 0.75 to 1.01; P = 0.06). The incidence of death from cardiovascular causes was 8.5% in the sacubitril-valsartan group and 8.9% in the valsartan group (hazard ratio, 0.95; 95% CI, 0.79 to 1.16); there were 690 and 797 total hospitalizations for heart failure, respectively (rate ratio, 0.85; 95% CI, 0.72 to 1.00). NYHA class improved in 15.0% of the patients in the sacubitril-valsartan group and in 12.6% of those in the valsartan group (odds ratio, 1.45; 95% CI, 1.13 to 1.86); renal function worsened in 1.4% and 2.7%, respectively (hazard ratio, 0.50; 95% CI, 0.33 to 0.77). The mean change in the KCCQ clinical summary score at 8 months was 1.0 point (95% CI, 0.0 to 2.1) higher in the sacubitril-valsartan group. Patients in the sacubitril-valsartan group had a higher incidence of hypotension and angioedema and a lower incidence of hyperkalemia. Among 12 prespecified subgroups, there was suggestion of heterogeneity with possible benefit with sacubitril-valsartan in patients with lower ejection fraction and in women. CONCLUSIONS Sacubitril-valsartan did not result in a significantly lower rate of total hospitalizations for heart failure and death from cardiovascular causes among patients with heart failure and an ejection fraction of 45% or higher. (Funded by Novartis; PARAGON-HF ClinicalTrials.gov number, NCT01920711.).
Collapse
Affiliation(s)
- Scott D Solomon
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - John J V McMurray
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Inder S Anand
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Junbo Ge
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Carolyn S P Lam
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Aldo P Maggioni
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Felipe Martinez
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Milton Packer
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Marc A Pfeffer
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Burkert Pieske
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Margaret M Redfield
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Jean L Rouleau
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Dirk J van Veldhuisen
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Faiez Zannad
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Michael R Zile
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Akshay S Desai
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Brian Claggett
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Pardeep S Jhund
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Sergey A Boytsov
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Josep Comin-Colet
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - John Cleland
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Hans-Dirk Düngen
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Eva Goncalvesova
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Tzvetana Katova
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Jose F Kerr Saraiva
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Małgorzata Lelonek
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Bela Merkely
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Michele Senni
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Sanjiv J Shah
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Jingmin Zhou
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Adel R Rizkala
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Jianjian Gong
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Victor C Shi
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| | - Martin P Lefkowitz
- From the Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston (S.D.S., M.A.P., A.S.D., B.C.); the British Heart Foundation Cardiovascular Research Centre (J.J.V.M., P.S.J.) and the Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Well-being (J.C.), University of Glasgow, Glasgow, and the National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London (J.C.) - all in the United Kingdom; University of Minnesota, Minneapolis (I.S.A), and Mayo Clinic, Rochester (M.M.R.) - both in Minnesota; Shanghai Institute of Cardiovascular Diseases (J. Ge) and the Department of Cardiology (J.Z.), Zhongshan Hospital, Fudan University, Shanghai, China; National Heart Center Singapore and Duke-National University of Singapore, Singapore (C.S.P.L); National Association of Hospital Cardiologists Research Center, Florence (A.P.M.), and the Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo (M.S.) - both in Italy; National University of Cordoba, Cordoba, Argentina (F.M.); Baylor University Medical Center, Dallas (M.P.); the Department of Internal Medicine and Cardiology, German Center for Cardiovascular Research partner site Berlin (B.P.), and the Department of Cardiology, Charité Universitätsmedizin, Campus Virchow-Klinikum (H.-D.D.) - both in Berlin; Institut de Cardiologie de Montréal, Université de Montréal, Montreal (J.L.R.); the Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands (D.J.V.); INSERM Centre d'Investigation Clinic 1433 and Université de Lorraine, Centre Hospitalier Régional et Universitaire, Nancy, France (F.Z.); Medical University of South Carolina and the Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston (M.R.Z.); National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow (S.A.B.); Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Bellvitge Institute for Biomedical Research, University of Barcelona, Barcelona (J.C.-C.); Department of Heart Failure-Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.); Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.); Disciplina de Cardiologia Faculdade de Medicina Pontifícia Universidade Católica de Campinas, São Paulo (J.F.K.S.); the Department of Noninvasive Cardiology, Medical University of Lodz, Lodz, Poland (M.L.); Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.); Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago (S.J.S); and Novartis Pharmaceuticals, East Hanover, NJ (A.R.R., J. Gong, V.C.S., M.P.L.)
| |
Collapse
|
33
|
Selvaraj S, Claggett B, Pozzi A, McMurray JJ, Jhund PS, Packer M, Desai AS, Lewis EF, Vaduganathan M, Lefkowitz MP, Rouleau JL, Shi VC, Zile MR, Swedberg K, Solomon SD. Prognostic Implications of Congestion on Physical Examination Among Contemporary Patients With Heart Failure and Reduced Ejection Fraction. Circulation 2019; 140:1369-1379. [DOI: 10.1161/circulationaha.119.039920] [Citation(s) in RCA: 50] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The contemporary prognostic value of the physical examination— beyond traditional risk factors including natriuretic peptides, risk scores, and symptoms—in heart failure (HF) with reduced ejection fraction is unknown. We aimed to determine the association between physical signs of congestion at baseline and during study follow-up with quality of life and clinical outcomes and to assess the treatment effects of sacubitril/valsartan on congestion.
Methods:
We analyzed participants from PARADIGM-HF (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin Converting Enzyme Inhibitor to Determine Impact on Global Mortality and Morbidity in HF) with an available physical examination at baseline. We examined the association of the number of signs of congestion (jugular venous distention, edema, rales, and third heart sound) with the primary outcome (cardiovascular death or HF hospitalization), its individual components, and all-cause mortality using time-updated, multivariable-adjusted Cox regression. We further evaluated whether sacubitril/valsartan reduced congestion during follow-up and whether improvement in congestion is related to changes in clinical outcomes and quality of life, assessed by Kansas City Cardiomyopathy Questionnaire overall summary scores.
Results:
Among 8380 participants, 0, 1, 2, and 3+ signs of congestion were present in 70%, 21%, 7%, and 2% of patients, respectively. Patients with baseline congestion were older, more often female, had higher MAGGIC risk scores (Meta-Analysis Global Group in Chronic Heart Failure) and lower Kansas City Cardiomyopathy Questionnaire overall summary scores (
P
<0.05). After adjusting for baseline natriuretic peptides, time-updated Meta-Analysis Global Group in Chronic Heart Failure score, and time-updated New York Heart Association class, increasing time-updated congestion was associated with all outcomes (
P
<0.001). Sacubitril/valsartan reduced the risk of the primary outcome irrespective of clinical signs of congestion at baseline (
P
=0.16 for interaction), and treatment with the drug improved congestion to a greater extent than did enalapril (
P
=0.011). Each 1-sign reduction was independently associated with a 5.1 (95% CI, 4.7–5.5) point improvement in Kansas City Cardiomyopathy Questionnaire overall summary scores. Change in congestion strongly predicted outcomes even after adjusting for baseline congestion (
P
<0.001).
Conclusions:
In HF with reduced ejection fraction, the physical exam continues to provide significant independent prognostic value even beyond symptoms, natriuretic peptides, and Meta-Analysis Global Group in Chronic Heart Failure risk score. Sacubitril/valsartan improved congestion to a greater extent than did enalapril. Reducing congestion in the outpatient setting is independently associated with improved quality of life and reduced cardiovascular events, including mortality.
Clinical Trial Registration:
https://www.clinicaltrials.gov
. Unique identifier: NCT01035255.
Collapse
Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia (S.S.)
| | - Brian Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | - Andrea Pozzi
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (A.P., J.J.V.M., P.S.J.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (A.P., J.J.V.M., P.S.J.)
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (A.P., J.J.V.M., P.S.J.)
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, United Kingdom (M.P.)
| | - Akshay S. Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | - Eldrin F. Lewis
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| | | | - Jean L. Rouleau
- Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.)
| | | | - Michael R. Zile
- Medical University of South Carolina and Ralph H. Johnson Department of Veterans Administration Medical Center, Charleston (M.R.Z.)
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.)
- National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.)
| | - Scott D. Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, MA (B.C., A.S.D., E.F.L, M.V., S.D.S.)
| |
Collapse
|
34
|
Chandra A, Vaduganathan M, Lewis EF, Claggett BL, Rizkala AR, Wang W, Lefkowitz MP, Shi VC, Anand IS, Ge J, Lam CS, Maggioni AP, Martinez F, Packer M, Pfeffer MA, Pieske B, Redfield MM, Rouleau JL, Van Veldhuisen DJ, Zannad F, Zile MR, McMurray JJ, Solomon SD. Health-Related Quality of Life in Heart Failure With Preserved Ejection Fraction. JACC: Heart Failure 2019; 7:862-874. [DOI: 10.1016/j.jchf.2019.05.015] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Revised: 05/22/2019] [Accepted: 05/22/2019] [Indexed: 11/30/2022]
|
35
|
Chandra A, Lewis EF, Claggett BL, Desai AS, Packer M, Zile MR, Swedberg K, Rouleau JL, Shi VC, Lefkowitz MP, Katova T, McMurray JJV, Solomon SD. Effects of Sacubitril/Valsartan on Physical and Social Activity Limitations in Patients With Heart Failure: A Secondary Analysis of the PARADIGM-HF Trial. JAMA Cardiol 2019; 3:498-505. [PMID: 29617523 DOI: 10.1001/jamacardio.2018.0398] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Health-related quality of life (HRQL) of patients with heart failure is markedly reduced compared with that in patients with other chronic diseases, demonstrating substantial limitations in physical and social activities. In the Prospective Comparison of ARNI With an ACE-Inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, sacubitril/valsartan improved overall HRQL compared with enalapril, as determined by the Kansas City Cardiomyopathy Questionnaire (KCCQ). Objective To examine the effects of sacubitril/valsartan on physical and social activities. Design, Setting, and Participants The PARADIGM-HF trial was a randomized, double-blind, active treatment-controlled clinical trial performed from December 8, 2009, to March 31, 2014, in 8399 patients with New York Heart Association class II to IV disease and a left ventricular ejection fraction of 40% or less at 1043 centers in 38 countries. Data analysis was performed from August 1, 2017, to December 25, 2017. Interventions Sacubitril/valsartan, 200 mg twice daily, or enalapril, 10 mg twice daily. Main Outcomes and Measures Patients completed HRQL assessments using the KCCQ at randomization, 4-month, 8-month, and annual visits. The effect of sacubitril/valsartan on components of the physical and social limitation sections of the KCCQ at 8 months and longitudinally and related biomarkers and clinical outcomes were studied. Results At baseline, 7618 of 8399 patients (90.7%) (mean [SD] age, 64 [11] years; 5987 [78.6%] male and 1631 [21.4%] female) completed the initial KCCQ assessment. Patients reported the greatest limitations at baseline in jogging and sexual relationships. Patients receiving sacubitril/valsartan had significantly better adjusted change scores in most physical and social activities at 8 months and during 36 months compared with those receiving enalapril. The largest improvement over enalapril was in household chores (adjusted change score difference, 2.35; 95% CI, 1.19-3.50; P < .001) and sexual relationships (adjusted change score difference, 2.72; 95% CI, 0.97-4.46; P = .002); both persisted through 36 months (overall change score difference, 1.69 [95% CI, 0.78-2.60], P < .001; and 2.36 [95% CI, 1.01-3.71], P = .001, respectively). Conclusions and Relevance In patients with heart failure with reduced ejection fraction, sacubitril/valsartan significantly improved nearly all KCCQ physical and social activities compared with enalapril, with the largest responses in household chores and sexual relationships. In addition to reduced likelihood of cardiovascular death, all-cause mortality, and heart failure hospitalization, sacubitril/valsartan may improve limitations in common activities in these patients. Trial Registration clinicaltrials.gov Identifier: NCT01035255.
Collapse
Affiliation(s)
| | | | | | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden.,National Heart and Lung Institute, Imperial College, London, England
| | - Jean L Rouleau
- National Heart and Lung Institute, Imperial College, London, England.,Institut Cardiologie de Montreal, Université de Montreal, Montreal, Quebec, Canada
| | | | | | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland
| | | |
Collapse
|
36
|
Januzzi JL, Packer M, Claggett B, Liu J, Shah AM, Zile MR, Pieske B, Voors A, Gandhi PU, Prescott MF, Shi V, Lefkowitz MP, McMurray JJV, Solomon SD. IGFBP7 (Insulin-Like Growth Factor-Binding Protein-7) and Neprilysin Inhibition in Patients With Heart Failure. Circ Heart Fail 2019; 11:e005133. [PMID: 30354399 DOI: 10.1161/circheartfailure.118.005133] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [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: 12/23/2022]
Abstract
BACKGROUND Increased activity of IGFBP7 (insulin-like growth factor-binding protein-7) is associated with cellular senescence, tissue aging, and obesity. IGFBP7 may be related to heart failure with preserved ejection fraction, a disease of elderly obese people. METHODS AND RESULTS In a subset of patients with heart failure with preserved ejection fraction (N=228) randomized to receive sacubitril/valsartan versus valsartan, IGFBP7 concentrations were measured at baseline, 12 weeks, and 36 weeks. Patient characteristics and echocardiographic measures including left atrial (LA) size and volume, ratio of early mitral inflow velocity/annular diastolic velocity, and ratio of early diastole/peak late diastolic velocity were assessed as a function of IGFBP7 concentration. Effect of sacubitril/valsartan on IGFBP7 concentrations was analyzed. With increasing baseline IGFBP7 quartiles, LA size and LA volume index (LAVi) were higher (both P<0.001); modest association between IGFBP7 and higher early mitral inflow velocity/annular diastolic velocity ( P=0.03) and early diastole/peak late diastolic velocity ratio ( P=0.04) was also seen. IGFBP7 concentrations were higher in those with LAVi ≥34 mL/m2 compared with lower LAVi at all time points (all P<0.01). IGFBP7 independently predicted LAVi at baseline even in the presence of NT-proBNP (N-terminal pro-B-type natriuretic peptide) concentrations; highest LAVi was seen in those with elevation in both biomarkers. Treatment with sacubitril/valsartan resulted in lower IGFBP7 concentrations over 36 weeks compared with valsartan (adjusted treatment effect, -7%; P<0.001). CONCLUSIONS Among patients with heart failure with preserved ejection fraction, concentrations of the cellular senescence biomarker IGFBP7 were associated with abnormalities in diastolic filling and LA dilation. Treatment with sacubitril/valsartan resulted in lower IGFBP7 concentrations compared with valsartan. CLINICAL TRIAL REGISTRATION URL: https://www.clinicaltrials.gov . Unique identifier: NCT00887588.
Collapse
Affiliation(s)
- James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston (J.L.J.).,Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, MA (J.L.J.)
| | - Milton Packer
- Division of Cardiology, Baylor University Medical Center, Dallas, TX (M.P., S.D.S.)
| | - Brian Claggett
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA (B.C., J.L., A.M.S.)
| | - Jiankang Liu
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA (B.C., J.L., A.M.S.)
| | - Amil M Shah
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA (B.C., J.L., A.M.S.)
| | - Michael R Zile
- Division of Cardiology, Medical University of South Carolina, Charleston (M.R.Z.)
| | - Burkert Pieske
- Division of Cardiology, Charite Hospital, Berlin, Germany (B.P.)
| | - Adriaan Voors
- Division of Cardiology, University Medical Center Groningen, The Netherlands (A.V.)
| | - Parul U Gandhi
- Division of Cardiology, Yale University Medical Center, New Haven, CT (P.U.G.)
| | | | - Victor Shi
- Novartis Pharmaceutical Corporation, Hanover, NJ (M.F.P., V.S., M.P.L.)
| | | | - John J V McMurray
- Division of Cardiology, University of Glasgow, United Kingdom (J.J.V.M.)
| | - Scott D Solomon
- Division of Cardiology, Baylor University Medical Center, Dallas, TX (M.P., S.D.S.)
| |
Collapse
|
37
|
Solomon SD, Rizkala AR, Lefkowitz MP, Shi VC, Gong J, Anavekar N, Anker SD, Arango JL, Arenas JL, Atar D, Ben-Gal T, Boytsov SA, Chen CH, Chopra VK, Cleland J, Comin-Colet J, Duengen HD, Echeverría Correa LE, Filippatos G, Flammer AJ, Galinier M, Godoy A, Goncalvesova E, Janssens S, Katova T, Køber L, Lelonek M, Linssen G, Lund LH, O’Meara E, Merkely B, Milicic D, Oh BH, Perrone SV, Ranjith N, Saito Y, Saraiva JF, Shah S, Seferovic PM, Senni M, Sibulo AS, Sim D, Sweitzer NK, Taurio J, Vinereanu D, Vrtovec B, Widimský J, Yilmaz MB, Zhou J, Zweiker R, Anand IS, Ge J, Lam CS, Maggioni AP, Martinez F, Packer M, Pfeffer MA, Pieske B, Redfield MM, Rouleau JL, Van Veldhuisen DJ, Zannad F, Zile MR, McMurray JJ. Baseline Characteristics of Patients With Heart Failure and Preserved Ejection Fraction in the PARAGON-HF Trial. Circ Heart Fail 2018; 11:e004962. [DOI: 10.1161/circheartfailure.118.004962] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2018] [Accepted: 06/05/2018] [Indexed: 11/16/2022]
Affiliation(s)
- Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.D.S., M.A.P.)
| | - Adel R. Rizkala
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (V.C.S., A.R.R., J.J.G., M.P.L.)
| | - Martin P. Lefkowitz
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (V.C.S., A.R.R., J.J.G., M.P.L.)
| | - Victor C. Shi
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (V.C.S., A.R.R., J.J.G., M.P.L.)
| | - JianJian Gong
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (V.C.S., A.R.R., J.J.G., M.P.L.)
| | - Nagesh Anavekar
- Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Australia (N.A.)
| | - Stefan D. Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK) and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Deutsches Zentrum für Herz-Kreislauf-Forschung (DZHK) Berlin, Charité Universitätsmedizin Berlin, Germany (S.D.A.)
- Department of Cardiology and Pneumology, University of Göttingen Medical Center, Germany (S.D.A.)
| | | | - Jose L. Arenas
- Centro de Atención e Investigación Cardiovascular del Potosi SC and Hospital Ángeles San Luis, México (J.L. Arenas)
| | - Dan Atar
- Department of Cardiology B, Oslo University Hospital, University of Oslo, Norway (D.A.)
| | - Turia Ben-Gal
- Heart Failure Unit, Cardiology Department, Rabin Medical Center, Petah Tikva, Israel (T.B.-G.)
| | - Sergey A. Boytsov
- National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow, Russia (S.A.B.)
| | - Chen-Huan Chen
- Department of Medicine, National Yang-Ming University, Taipei, Taiwan, Republic of China (C.-H.C.)
| | - Vijay K. Chopra
- Heart Failure Unit, Medanta Medicity, Gurugram, Haryana, India (V.K.C.)
| | - John Cleland
- Robertson Centre for Biostatistics and Clinical Trials, Institute of Health and Wellbeing (J.C.)
- University of Glasgow, United Kingdom. National Heart and Lung Institute, Royal Brompton and Harefield Hospitals, Imperial College, London, United Kingdom (J.C.)
- Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Institut d’Investigació Biomèdica de Bellvitge, University of Barcelona, Spain (J.C.-C.)
| | - Josep Comin-Colet
- Community Heart Failure Program, Department of Cardiology, Bellvitge University Hospital and Institut d’Investigació Biomèdica de Bellvitge, University of Barcelona, Spain (J.C.-C.)
| | - Hans-Dirk Duengen
- National Research Center for Cardiology of the Ministry of Health of the Russian Federation, Moscow, Russia (S.A.B.)
| | | | - Gerasimos Filippatos
- Attikon University Hospital, National and Kapodistrian University of Athens, Greece (G.F.)
- School of Medicine, University of Cyprus, Greece (G.F.)
| | - Andreas J. Flammer
- Department of Cardiology, University Heart Center Zurich, University Hospital Zurich, Switzerland (A.J.F.)
| | - Michel Galinier
- Department of Cardiology, Rangueil University Hospital, Toulouse, France (M.G.)
| | - Armando Godoy
- Universidad Nacional Mayor de San Marcos, Lima, Perú (A.G.)
- Instituto Nacional Cardiovascular INCOR, Lima, Perú (A.G.)
- Scientia Clinical and Epidemiological Research Institute, Trujillo, Perú (A.G.)
| | - Eva Goncalvesova
- Department of Heart Failure/Transplantation, National Cardiovascular Institute, Bratislava, Slovakia (E.G.)
| | - Stefan Janssens
- Department of Cardiology, University Hospitals Leuven, Belgium (S.J.)
| | - Tzvetana Katova
- Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.)
| | - Lars Køber
- Department of Cardiology, Heart Centre, Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark (L.K.)
| | - Małgorzata Lelonek
- Department of Noninvasive Cardiology, Medical University of Lodz, Poland (M.L.)
| | - Gerard Linssen
- Department of Cardiology, Hospital Group Twente, Almelo and Hengelo, The Netherlands (G.L.)
| | - Lars H. Lund
- Department of Medicine, Karolinska Institutet, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden (L.H.L.)
| | - Eileen O’Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Québec, Canada (E.O.M., J.L.R.)
| | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.)
| | - Davor Milicic
- Department of Cardiovascular Diseases, University Hospital Center Zagreb, Croatia (D.M.)
| | - Byung-Hee Oh
- Seoul National University Hospital, Seoul National University College of Medicine, Korea (B.-H.O.)
| | | | - Naresh Ranjith
- Department of Cardiology, City Hospital, Durban, South Africa (N.R.)
| | - Yoshihiko Saito
- First Department of Internal Medicine, Nara Medical University, Kashihara, Japan (Y.S.)
| | - Jose F. Saraiva
- Disciplina de Cardiologia Faculdade de Medicina, Pontifícia Universidade Católica de Campinas, Sao Paulo, Brazil (J.F.K.S.)
| | - Sanjiv Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.S.)
| | - Petar M. Seferovic
- Department of Cardiology, University of Belgrade School of Medicine, Belgrade University Medical Center, Serbia (P.M.S.)
| | - Michele Senni
- Cardiology Division, Cardiovascular Department, Hospital Papa Giovanni XXIII, Bergamo, Italy (M.S.)
| | - Antonio S. Sibulo
- St Luke’s Heart Institute, St. Luke’s Medical Center, Taguig, Philippines (A.S.S.)
| | - David Sim
- Department of Cardiology, National Heart Centre Singapore (D.S.)
| | - Nancy K. Sweitzer
- Sarver Heart Center, University of Arizona College of Medicine, Tucson (N.K.S.)
| | - Jyrki Taurio
- Department of Cardiology, Tampere University Hospital, Finland (J.T.)
| | - Dragos Vinereanu
- University of Medicine and Pharmacy Carol Davila, University and Emergency Hospital of Bucharest, Romania (D.V.)
| | - Bojan Vrtovec
- University Medical Centre, Ljubljana, Slovenia (B.V.)
| | - Jiří Widimský
- First Faculty of Medicine, Charles University Prague, Czech Republic (J.W.)
| | - Mehmet B. Yilmaz
- Department of Cardiology, Faculty of Medicine, Cumhuriyet University, Sivas, Turkey (M.B.Y.)
| | - Jingmin Zhou
- Department of Cardiology, Tongji Hospital, Tongji University School of Medicine, Shanghai, China (J.Z.)
| | - Robert Zweiker
- Department of Cardiology, Medical University Graz, Austria (R.Z.)
| | - Inder S. Anand
- Department of Medicine, VA Medical Center and University of Minnesota, Minneapolis (I.S.A.)
| | - Junbo Ge
- Shanghai Institute of Cardiovascular Diseases, Zhongshan Hospital, Fudan University, China (J.G.)
| | - Carolyn S.P. Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | - Aldo P. Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri, Florence, Italy (A.P.M.)
| | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.D.S., M.A.P.)
| | - Burkert Pieske
- Department of Internal Medicine, Cardiology Charité, Universitaetsmedizin Berlin, Campus Virchow Klinikum Berlin, Germany (B.P., H.-D.D.)
| | | | - Jean L. Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Québec, Canada (E.O.M., J.L.R.)
| | - Dirk J. Van Veldhuisen
- University Medical Center Groningen, University of Groningen, The Netherlands (D.J.V.V.)
| | - Faiez Zannad
- Inserm CIC 1433 and Université de Lorraine, Centre Hospitalier Ré gional Universitaire, Nancy, France (F.Z.)
| | - Michael R. Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston (M.R.Z.)
| | | |
Collapse
|
38
|
Packer M, Claggett B, Lefkowitz MP, McMurray JJV, Rouleau JL, Solomon SD, Zile MR. Effect of neprilysin inhibition on renal function in patients with type 2 diabetes and chronic heart failure who are receiving target doses of inhibitors of the renin-angiotensin system: a secondary analysis of the PARADIGM-HF trial. Lancet Diabetes Endocrinol 2018; 6:547-554. [PMID: 29661699 DOI: 10.1016/s2213-8587(18)30100-1] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2018] [Revised: 03/15/2018] [Accepted: 03/19/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND Neprilysin inhibition has favourable effects on experimental diabetic nephropathy. We sought to assess the effects of neprilysin inhibition on the course of renal function in patients with type 2 diabetes. METHODS In the randomised, double-blind PARADIGM-HF trial, the effects of sacubitril/valsartan (97 mg/103 mg twice daily) were compared with enalapril (10 mg twice daily) in 8399 patients with mild-to-moderate chronic heart failure and systolic dysfunction. In this secondary intention-to-treat analysis, we assessed the change in estimated glomerular filtration rate (eGFR) over a 44-month follow-up period in patients with (n=3784) and those without (n=4615) diabetes. PARADIGM-HF is registered with ClinicalTrials.gov, number NCT01035255. FINDINGS eGFR decreased by 1·1 mL/min per 1·73 m2 per year (95% CI 1·0-1·2) in patients without diabetes, but by 2·0 mL/min per 1·73 m2 per year (1·9-2·1) in those with diabetes (p<0·0001). Compared with patients treated with enalapril, those treated with sacubitril/valsartan had a slower rate of decline in eGFR (-1·3 vs -1·8 mL/min per 1·73 m2 per year; p<0·0001), and the magnitude of the benefit was larger in patients with versus those without diabetes (difference 0·6 mL/min per 1·73 m2 per year [95% CI 0·4-0·8] in patients with vs 0·3 mL/min per 1·73 m2 per year [0·2-0·5] in those without diabetes; pinteraction=0·038). The greater effect of neprilysin inhibition in patients with diabetes could not be explained by the effects of treatment on the course of heart failure or on HbA1c. The incremental benefit of sacubitril/valsartan in patients with diabetes was no longer apparent when changes in eGFR were adjusted for urinary cyclic guanosine monophosphate (p=0·41). INTERPRETATION In patients in whom the renin-angiotensin system is already maximally blocked, the addition of neprilysin inhibition attenuates the effect of diabetes to accelerate the deterioration of renal function that occurs in patients with chronic heart failure. FUNDING Novartis.
Collapse
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Hospital, Baylor University Medical Center, Dallas, TX, USA.
| | - Brian Claggett
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, University of Montreal, Montreal, QC, Canada
| | - Scott D Solomon
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michael R Zile
- Medical University of South Carolina and Ralph H Johnson Veterans Administration Medical Center, Charleston, SC, USA
| |
Collapse
|
39
|
Povsic TJ, Scott R, Mahaffey KW, Blaustein R, Edelberg JM, Lefkowitz MP, Solomon SD, Fox JC, Healy KE, Khakoo AY, Losordo DW, Malik FI, Monia BP, Montgomery RL, Riesmeyer J, Schwartz GG, Zelenkofske SL, Wu JC, Wasserman SM, Roe MT. Navigating the Future of Cardiovascular Drug Development-Leveraging Novel Approaches to Drive Innovation and Drug Discovery: Summary of Findings from the Novel Cardiovascular Therapeutics Conference. Cardiovasc Drugs Ther 2018; 31:445-458. [PMID: 28735360 DOI: 10.1007/s10557-017-6739-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [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] [Indexed: 12/14/2022]
Abstract
PURPOSE The need for novel approaches to cardiovascular drug development served as the impetus to convene an open meeting of experts from the pharmaceutical industry and academia to assess the challenges and develop solutions for drug discovery in cardiovascular disease. METHODS The Novel Cardiovascular Therapeutics Summit first reviewed recent examples of ongoing or recently completed programs translating basic science observations to targeted drug development, highlighting successes (protein convertase sutilisin/kexin type 9 [PCSK9] and neprilysin inhibition) and targets still under evaluation (cholesteryl ester transfer protein [CETP] inhibition), with the hope of gleaning key lessons to successful drug development in the current era. Participants then reviewed the use of innovative approaches being explored to facilitate rapid and more cost-efficient evaluations of drug candidates in a short timeframe. RESULTS We summarize observations gleaned from this summit and offer insight into future cardiovascular drug development. CONCLUSIONS The rapid development in genetic and high-throughput drug evaluation technologies, coupled with new approaches to rapidly evaluate potential cardiovascular therapies with in vitro techniques, offer opportunities to identify new drug targets for cardiovascular disease, study new therapies with better efficiency and higher throughput in the preclinical setting, and more rapidly bring the most promising therapies to human testing. However, there must be a critical interface between industry and academia to guide the future of cardiovascular drug development. The shared interest among academic institutions and pharmaceutical companies in developing promising therapies to address unmet clinical needs for patients with cardiovascular disease underlies and guides innovation and discovery platforms that are significantly altering the landscape of cardiovascular drug development.
Collapse
Affiliation(s)
- Thomas J Povsic
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Duke Medicine, Durham, NC, 27705, USA.
| | - Rob Scott
- AbbVie Pharmaceuticals, Chicago, IL, USA
| | - Kenneth W Mahaffey
- Stanford Center for Clinical Research (SCCR), Stanford University School of Medicine, Stanford, CA, USA
| | - Robert Blaustein
- Merck Research Laboratories, Merck & Co., Inc, Kenilworth, NJ, USA
| | | | | | | | | | - Kevin E Healy
- University of California, Berkeley, Berkeley, CA, USA
| | | | | | | | | | | | | | | | | | - Joseph C Wu
- Stanford Cardiovascular Institute, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Matthew T Roe
- Duke Clinical Research Institute, Duke University School of Medicine, 2400 Pratt Street, Duke Medicine, Durham, NC, 27705, USA
| |
Collapse
|
40
|
Mogensen UM, Gong J, Jhund PS, Shen L, Køber L, Desai AS, Lefkowitz MP, Packer M, Rouleau JL, Solomon SD, Claggett BL, Swedberg K, Zile MR, Mueller-Velten G, McMurray JJV. Effect of sacubitril/valsartan on recurrent events in the Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure trial (PARADIGM-HF). Eur J Heart Fail 2018; 20:760-768. [PMID: 29431251 PMCID: PMC6607507 DOI: 10.1002/ejhf.1139] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 12/18/2017] [Accepted: 12/21/2017] [Indexed: 12/11/2022] Open
Abstract
Aims Recurrent hospitalizations are a major part of the disease burden in heart failure (HF), but conventional analyses consider only the first event. We compared the effect of sacubitril/valsartan vs. enalapril on recurrent events, incorporating all HF hospitalizations and cardiovascular (CV) deaths in PARADIGM‐HF, using a variety of statistical approaches advocated for this type of analysis. Methods and results In PARADIGM‐HF, a total of 8399 patients were randomized and followed for a median of 27 months. We applied various recurrent event analyses, including a negative binomial model, the Wei, Lin and Weissfeld (WLW), and Lin, Wei, Ying and Yang (LWYY) methods, and a joint frailty model, all adjusted for treatment and region. Among a total of 3181 primary endpoint events (including 1251 CV deaths) during the trial, only 2031 (63.8%) were first events (836 CV deaths). Among a total of 1195 patients with at least one HF hospitalization, 410 (34%) had at least one further HF hospitalization. Sacubitril/valsartan compared with enalapril reduced the risk of recurrent HF hospitalization using the negative binomial model [rate ratio (RR) 0.77, 95% confidence interval (CI) 0.67–0.89], the WLW method [hazard ratio (HR) 0.79, 95% CI 0.71–0.89], the LWYY method (RR 0.78, 95% CI 0.68–0.90), and the joint frailty model (HR 0.75, 95% CI 0.66–0.86) (all P < 0.001). The effect of sacubitril/valsartan vs. enalapril on recurrent HF hospitalizations/CV death was similar. Conclusions In PARADIGM‐HF, approximately one third of patients with a primary endpoint (time‐to‐first) experienced a further event. Compared with enalapril, sacubitril/valsartan reduced both first and recurrent events. The treatment effect size was similar, regardless of the statistical approach applied.
Collapse
Affiliation(s)
- Ulrik M Mogensen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Jianjian Gong
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Li Shen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Akshay S Desai
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Scott D Solomon
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Brian L Claggett
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden, and National Heart and Lung Institute, Imperial College, London, UK
| | - Michael R Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC, USA
| | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| |
Collapse
|
41
|
Mogensen UM, Køber L, Jhund PS, Desai AS, Senni M, Kristensen SL, Dukát A, Chen CH, Ramires F, Lefkowitz MP, Prescott MF, Shi VC, Rouleau JL, Solomon SD, Swedberg K, Packer M, McMurray JJV. Sacubitril/valsartan reduces serum uric acid concentration, an independent predictor of adverse outcomes in PARADIGM-HF. Eur J Heart Fail 2017; 20:514-522. [PMID: 29193563 PMCID: PMC6607477 DOI: 10.1002/ejhf.1056] [Citation(s) in RCA: 32] [Impact Index Per Article: 4.6] [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] [Received: 06/04/2017] [Revised: 07/28/2017] [Accepted: 08/11/2017] [Indexed: 12/22/2022] Open
Abstract
Aims Elevated serum uric acid concentration (SUA) has been associated with an increased risk of cardiovascular disease, but this may be due to unmeasured confounders. We examined the association between SUA and outcomes as well as the effect of sacubitril/valsartan on SUA in patients with heart failure with reduced ejection fraction (HFrEF) in PARADIGM‐HF. Methods and results The association between SUA and the primary composite outcome of cardiovascular death or heart failure (HF) hospitalization, its components, and all‐cause mortality was examined using Cox regression analyses among 8213 patients using quintiles (Q1–Q5) of SUA adjusted for baseline prognostic variables including estimated glomerular filtration rate (eGFR), diuretic dose, and log N‐terminal pro‐brain natriuretic peptide. Change in SUA from baseline over 12 months was also evaluated in each treatment group. Patients in Q5 (SUA ≥8.6 mg/dL) compared with Q1 (<5.4 mg/dL) were younger (62.8 vs. 64.2 years), more often male (88.7% vs. 63.1%), had lower systolic blood pressure (119 vs. 123 mmHg), lower eGFR (57.4 vs. 76.6 mL/min/1.73 m2), and greater diuretic use. Higher SUA was associated with a higher risk of the primary outcome (adjusted hazard ratios) Q5 vs. Q1 = 1.28 [95% confidence intervals (1.09–1.50), P = 0.003], cardiovascular death [1.44 (1.11–1.77), P = 0.001], HF hospitalization [1.37 (1.11–1.70), P = 0.004], and all‐cause mortality [1.36 (1.13–1.64), P = 0.001]. Compared with enalapril, sacubitril/valsartan reduced SUA by 0.24 (0.17–0.32) mg/dL over 12 months (P < 0.0001). Sacubitril/valsartan improved outcomes, irrespective of SUA concentration. Conclusion Serum uric acid concentration was an independent predictor of worse outcomes after multivariable adjustment in patients with HFrEF. Compared with enalapril, sacubitril/valsartan reduced SUA and improved outcomes irrespective of SUA.
Collapse
Affiliation(s)
- Ulrik M Mogensen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Akshay S Desai
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Michele Senni
- Cardiology, Heart Failure and Heart Transplant Unit, Hospital Papa Giovanni XXIII, Bergamo, Italy
| | - Søren L Kristensen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.,Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Andrej Dukát
- Second Department of Internal Medicine, Comenius University, Bratislava, Slovakia
| | - Chen-Huan Chen
- Department of Medicine, National Yang-Ming University, Republic of China, Department of Medical Education, Taipei Veterans General Hospital, Taipei, Taiwan, Republic of China
| | - Felix Ramires
- Heart Institute (InCor) - University of São Paulo, Medical School, Brazil
| | | | | | - Victor C Shi
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Jean L Rouleau
- Institut de Cardiologie, Université de Montréal, Montréal, Canada
| | - Scott D Solomon
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden and National Heart and Lung Institute, Imperial College London, London, UK
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | |
Collapse
|
42
|
Böhm M, Young R, Jhund PS, Solomon SD, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Swedberg K, Zile MR, Packer M, McMurray JJV. Systolic blood pressure, cardiovascular outcomes and efficacy and safety of sacubitril/valsartan (LCZ696) in patients with chronic heart failure and reduced ejection fraction: results from PARADIGM-HF. Eur Heart J 2017; 38:1132-1143. [PMID: 28158398 DOI: 10.1093/eurheartj/ehw570] [Citation(s) in RCA: 141] [Impact Index Per Article: 20.1] [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: 04/25/2016] [Accepted: 11/04/2016] [Indexed: 12/11/2022] Open
Abstract
Background Compared to heart failure patients with higher systolic blood pressure (SBP), those with lower SBP have a worse prognosis. To make matters worse, the latter patients often do not receive treatment with life-saving therapies that might lower blood pressure further. We examined the association between SBP and outcomes in the Prospective Comparison of angiotensin receptor-neprilysin inhibitor (ARNI) with an angiotensin-converting enzyme (ACE) inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure trial (PARADIGM-HF), as well as the effect of sacubitril/valsartan, compared with enalapril, according to baseline SBP. Methods We analysed the effect of treatment on SBP and on the primary composite outcome (cardiovascular death or heart failure hospitalization), its components and all-cause death. We examined baseline SBP as a categorical (<110, 110 to < 120, 120 to < 130, 130 to < 140 and ≥140 mmHg) and continuous variable, as well as average in-trial SBP and time-updated SBP. Findings All-cause and cardiovascular mortality rates were highest in patients with the lowest SBP whereas there was a U-shaped relationship between SBP and the rate of heart failure hospitalization. The benefit of sacubitril/valsartan over enalapril was consistent across all baseline SBP categories for all outcomes. For example, the sacubitril/valsartan versus enalapril hazard ratio for the primary endpoint was 0.88 (95%CI 0.74-1.06) in patients with a baseline SBP <110 mmHg and 0.81 (0.65-1.02) for those with a SBP ≥140 mmHg (P for interaction = 0.55). Symptomatic hypotension, study drug dose-reduction and discontinuation were more frequent in patients with a lower SBP. Interpretation In PARADIGM-HF, patients with lower SBP at randomization, notably after tolerating full doses of both study drugs during a run-in period, were at higher risk but generally tolerated sacubitril/valsartan and had the same relative benefit over enalapril as patients with higher baseline SBP.
Collapse
Affiliation(s)
- Michael Böhm
- Klinik für Innere Medizin III, Universität des Saarlandes, Universitätsklinikum des Saarlandes, Homburg, Saar, Germany
| | - Robin Young
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | | | - Karl Swedberg
- Department of Molecular and Clinical Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Michael R Zile
- Division of Cardiology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| |
Collapse
|
43
|
Lewis EF, Claggett BL, McMurray JJV, Packer M, Lefkowitz MP, Rouleau JL, Liu J, Shi VC, Zile MR, Desai AS, Solomon SD, Swedberg K. Health-Related Quality of Life Outcomes in PARADIGM-HF. Circ Heart Fail 2017; 10:CIRCHEARTFAILURE.116.003430. [DOI: 10.1161/circheartfailure.116.003430] [Citation(s) in RCA: 123] [Impact Index Per Article: 17.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 07/17/2017] [Indexed: 12/20/2022]
Affiliation(s)
- Eldrin F. Lewis
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Brian L. Claggett
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - John J. V. McMurray
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Milton Packer
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Martin P. Lefkowitz
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Jean L. Rouleau
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Jiankang Liu
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Victor C. Shi
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Michael R. Zile
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Akshay S. Desai
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Scott D. Solomon
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Karl Swedberg
- From the Brigham and Women’s Hospital, Boston, MA (E.F.L., B.L.C., J.L., A.S.D., S.D.S.); BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (J.J.V.M.); Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.); Novartis, East Hanover, NJ (M.P.L., V.C.S.); Institut de Cardiologie de Montreal, Université de Montreal, Canada (J.L.R.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| |
Collapse
|
44
|
Okumura N, Jhund PS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. Effects of Sacubitril/Valsartan in the PARADIGM-HF Trial (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure) According to Background Therapy. Circ Heart Fail 2017; 9:CIRCHEARTFAILURE.116.003212. [PMID: 27618854 DOI: 10.1161/circheartfailure.116.003212] [Citation(s) in RCA: 73] [Impact Index Per Article: 10.4] [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: 04/20/2016] [Accepted: 08/22/2016] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the PARADIGM-HF trial (Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure), the angiotensin receptor neprilysin inhibitor sacubitril/valsartan was more effective than the angiotensin-converting enzyme inhibitorenalapril in patients with heart failure and reduced ejection fraction. We examined whether this benefit was consistent irrespective of background therapy. METHODS AND RESULTS We examined the effect of study treatment in the following subgroups: diuretics (yes/no), digitalis glycoside (yes/no), mineralocorticoid receptor antagonist (yes/no),and defibrillating device (implanted defibrillating device, yes/no). We also examined the effect of study drug according to β-blocker dose (≥50% and <50% of target dose) and according to whether patients had undergone previous coronary revascularization. We analyzed the primary composite end point of cardiovascular death or heart failure hospitalization, as well as cardiovascular death. Most randomized patients (n=8399)were treated with a diuretic (80%) and β-blocker (93%); 47% of those taking a β-blocker were treated with ≥50% of the recommended dose. In addition, 4671 (56%) were treated with a mineralocorticoid receptor antagonist, 2539 (30%) with digoxin, and 1243 (15%) had a defibrillating device; 2640 (31%) had undergone coronary revascularization. Overall, the sacubitril/valsartan versus enalapril hazard ratio for the primary composite end point was 0.80 (95% confidence interval,0.73-0.87;P<0.001) and for cardiovascular death was0.80 (0.71-0.89;P<0.001). The effect of sacubitril/valsartan was consistent across all subgroups examined. The hazard ratio for primary end point ranged from 0.74 to 0.85 and for cardiovascular death rangedfrom 0.75 to 0.89, with no treatment-by-subgroup interaction. CONCLUSIONS The benefit of sacubitril/valsartan, over an angiotensin-converting enzyme inhibitor, was consistent regardless of background therapy and irrespective of previouscoronary revascularization or β-blocker dose. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01035255.
Collapse
Affiliation(s)
- Naoki Okumura
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Pardeep S Jhund
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Jianjian Gong
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Martin P Lefkowitz
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Adel R Rizkala
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Jean L Rouleau
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Victor C Shi
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Karl Swedberg
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Michael R Zile
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Scott D Solomon
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Milton Packer
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - John J V McMurray
- From the BHF Cardiovascular Research Centre, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie de Montréal, Université de Montréal, Quebec, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden (K.S.); National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.).
| | | |
Collapse
|
45
|
Solomon SD, Rizkala AR, Gong J, Wang W, Anand IS, Ge J, Lam CS, Maggioni AP, Martinez F, Packer M, Pfeffer MA, Pieske B, Redfield MM, Rouleau JL, Van Veldhuisen DJ, Zannad F, Zile MR, Desai AS, Shi VC, Lefkowitz MP, McMurray JJ. Angiotensin Receptor Neprilysin Inhibition in Heart Failure With Preserved Ejection Fraction. JACC: Heart Failure 2017; 5:471-482. [DOI: 10.1016/j.jchf.2017.04.013] [Citation(s) in RCA: 161] [Impact Index Per Article: 23.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/13/2017] [Revised: 04/03/2017] [Accepted: 04/21/2017] [Indexed: 10/19/2022]
|
46
|
Mogensen UM, Køber L, Kristensen SL, Jhund PS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. The effects of sacubitril/valsartan on coronary outcomes in PARADIGM-HF. Am Heart J 2017; 188:35-41. [PMID: 28577679 DOI: 10.1016/j.ahj.2017.02.034] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2017] [Accepted: 02/23/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND Angiotensin converting enzyme inhibitors (ACE-I), are beneficial both in heart failure with reduced ejection fraction (HF-REF) and after myocardial infarction (MI). We examined the effects of the angiotensin-receptor neprilysin inhibitor sacubitril/valsartan, compared with the ACE-I enalapril, on coronary outcomes in PARADIGM-HF. METHODS AND RESULTS We examined the effect of sacubitril/valsartan compared with enalapril on the following outcomes: i) the primary composite endpoint of cardiovascular (CV) death or HF hospitalization, ii) a pre-defined broader composite including, in addition, MI, stroke, and resuscitated sudden death, and iii) a post hoc coronary composite of CV-death, non-fatal MI, angina hospitalization or coronary revascularization. At baseline, of 8399 patients, 3634 (43.3%) had a prior MI and 4796 (57.1%) had a history of any coronary artery disease. Among all patients, compared with enalapril, sacubitril/valsartan reduced the risk of the primary outcome (HR 0.80 [0.73-0.87], P<.001), the broader composite (HR 0.83 [0.76-0.90], P<.001) and the coronary composite (HR 0.83 [0.75-0.92], P<.001). Although each of the components of the coronary composite occurred less frequently in the sacubitril/valsartan group, compared with the enalapril group, only CV death was reduced significantly. CONCLUSIONS Compared with enalapril, sacubitril/valsartan reduced the risk of both the primary endpoint and a coronary composite outcome in PARADIGM-HF. Additional studies on the effect of sacubitril/valsartan on atherothrombotic outcomes in high-risk patients are merited.
Collapse
Affiliation(s)
- Ulrik M Mogensen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK; Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | | | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jianjian Gong
- Novartis Pharmaceutical Corporation, East Hanover, NJ
| | | | | | | | - Victor C Shi
- Novartis Pharmaceutical Corporation, East Hanover, NJ
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden; National Heart and Lung Institute, Imperial College, London, United Kingdom
| | - Michael R Zile
- Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC
| | - Scott D Solomon
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| |
Collapse
|
47
|
Abstract
It has been known since the 1990s that long-term morbidity and mortality is improved in patients with heart failure with reduced ejection fraction (HFrEF) by treatments that target the renin-angiotensin-aldosterone system (RAAS). It has also long been thought that enhancement of the activity of natriuretic peptides (NPs) could potentially benefit patients with HFrEF, but multiple attempts to realize this benefit had failed over the years - until 2014, when a large, phase III, randomized, controlled clinical trial (PARADIGM-HF) was completed comparing sacubitril/valsartan with enalapril, a well-established treatment for HFrEF. Sacubitril/valsartan (formerly known as LCZ696) is a first-in-class angiotensin receptor neprilysin inhibitor (ARNI) that simultaneously suppresses RAAS activation through blockade of angiotensin II type 1 receptors and enhances vasoactive peptides including NPs through inhibition of neprilysin, the enzyme responsible for their degradation. In PARADIGM-HF, patients with HFrEF treated with sacubitril/valsartan had 20% less risk for cardiovascular death or hospitalization for heart failure (the primary endpoint), 20% less risk for cardiovascular death, 21% less risk for first hospitalization for heart failure, and 16% less risk for death from any cause, compared with enalapril (all p < 0.001). Concerning tolerability, the sacubitril/valsartan group had higher proportions of patients with hypotension and nonserious angioedema but lower proportions with renal impairment, hyperkalemia, and cough, compared with the enalapril group. The use of sacubitril/valsartan has been endorsed by the latest heart failure treatment guidelines in Europe and the USA. This chapter reviews the discoveries, scientific reasoning, and clinical evidence that led to the development of sacubitril/valsartan, the first novel therapy in a new drug class to improve survival in HFrEF in the last 15 years.
Collapse
Affiliation(s)
- Yasser Khder
- Novartis Institutes for Biomedical Research, Postfach, 4002, Basel, Switzerland.
| | - Victor Shi
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ, 07936-1080, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, G12 8QQ, UK
| | - Martin P Lefkowitz
- Novartis Pharmaceuticals Corporation, One Health Plaza, East Hanover, NJ, 07936-1080, USA
| |
Collapse
|
48
|
Cannon JA, Shen L, Jhund PS, Kristensen SL, Køber L, Chen F, Gong J, Lefkowitz MP, Rouleau JL, Shi VC, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. Dementia-related adverse events in PARADIGM-HF and other trials in heart failure with reduced ejection fraction. Eur J Heart Fail 2016; 19:129-137. [PMID: 27868321 PMCID: PMC5248626 DOI: 10.1002/ejhf.687] [Citation(s) in RCA: 80] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Revised: 09/14/2016] [Accepted: 10/07/2016] [Indexed: 12/11/2022] Open
Abstract
Aims Inhibition of neprilysin, an enzyme degrading natriuretic and other vasoactive peptides, is beneficial in heart failure with reduced ejection fraction (HFrEF), as shown in PARADIGM‐HF which compared the angiotensin receptor–neprilysin inhibitor (ARNI) sacubitril/valsartan with enalapril. As neprilysin is also one of many enzymes clearing amyloid‐β peptides from the brain, there is a theoretical concern about the long‐term effects of sacubitril/valsartan on cognition. Therefore, we have examined dementia‐related adverse effects (AEs) in PARADIGM‐HF and placed these findings in the context of other recently conducted HFrEF trials. Methods and results In PARADIGM‐HF, patients with symptomatic HFrEF were randomized to sacubitril/valsartan 97/103 mg b.i.d. or enalapril 10 mg b.i.d. in a 1:1 ratio. We systematically searched AE reports, coded using the Medical Dictionary for Regulatory Activities (MedDRA), using Standardized MedDRA Queries (SMQs) with ‘broad’ and ‘narrow’ preferred terms related to dementia. In PARADIGM‐HF, 8399 patients aged 18–96 years were randomized and followed for a median of 2.25 years (up to 4.3 years). The narrow SMQ search identified 27 dementia‐related AEs: 15 (0.36%) on enalapril and 12 (0.29%) on sacubitril/valsartan [hazard ratio (HR) 0.73, 95% confidence interval (CI) 0.33–1.59]. The broad search identified 97 (2.30%) and 104 (2.48%) AEs (HR 1.01, 95% CI 0.75–1.37), respectively. The rates of dementia‐related AEs in both treatment groups in PARADIGM‐HF were similar to those in three other recent trials in HFrEF. Conclusion We found no evidence that sacubitril/valsartan, compared with enalapril, increased dementia‐related AEs, although longer follow‐up may be necessary to detect such a signal and more sensitive tools are needed to detect lesser degrees of cognitive impairment. Further studies to address this question are warranted.
Collapse
Affiliation(s)
- Jane A Cannon
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Li Shen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen
| | - Fabian Chen
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Jianjian Gong
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | | | - Jean L Rouleau
- Institut de Cardiologie, Université de Montréal, Montréal, Canada
| | - Victor C Shi
- Novartis Pharmaceutical Corporation, East Hanover, NJ, USA
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London
| | - Michael R Zile
- Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC, USA
| | - Scott D Solomon
- Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | |
Collapse
|
49
|
Lewis EF, Claggett B, McMurray JJ, Packer M, Liu J, Solomon SD, Desai AS, Rouleau JL, Zile M, Shi VC, Lefkowitz MP, Swedberg K. Sacubitril/Valsartan Associated with Lower Declines in Health-Related Quality of Life Compared with Enalapril in Patients with Heart Failure Hospitalization. J Card Fail 2016. [DOI: 10.1016/j.cardfail.2016.06.080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
50
|
Mogensen UM, Jhund PS, Køber L, Prescott MF, Lefkowitz MP, Rouleau JL, Solomon SD, Swedberg K, Zile MR, Packer M, McMurray JJ. Sacubitril/Valsartan Reduces Serum Uric Acid Level, an Independent Predictor of Adverse Outcomes in HFrEF: Results From PARADIGM-HF. J Card Fail 2016. [DOI: 10.1016/j.cardfail.2016.06.052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|