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Zeymer U, Groves R, Hupfer S. Use of sacubitril/valsartan in patients with heart failure in primary care in Germany: the AURORA-HF noninterventional study. Herz 2024:10.1007/s00059-024-05248-z. [PMID: 38656397 DOI: 10.1007/s00059-024-05248-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2023] [Revised: 03/22/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024]
Abstract
BACKGROUND Sacubitril/valsartan (Sac/Val) is the first angiotensin receptor-neprilysin inhibitor indicated for symptomatic chronic heart failure (HF) with reduced ejection fraction (HFrEF). Given most patients with HF in Germany are managed by general practitioners, AURORA-HF investigated the baseline characteristics and 1‑year follow-up of patients starting Sac/Val in primary care in Germany. METHODS This was a prospective, multicenter, observational study, with all treatment decisions independent of participation. The only inclusion criteria were adults (age ≥ 18 years) with symptomatic HFrEF. The study comprised four groups, depending on therapy on entry: initiation of (1) Sac/Val or (2) other HF therapy; and no change in HF regimen that (3) included or (4) did not include Sac/Val. Baseline data were captured for all groups; 1‑year follow-up was recorded in groups 1 and 2. RESULTS Of 1278 patients in the baseline analyses, 513 (40.1%) had newly started Sac/Val (449 [87.5%] completing the 1‑year follow-up), 265 (20.7%) had newly started other HF regimens (245, 92.5%) with 1‑year follow-up, while 249 with Sac/Val (19.5%) and 251 without Sac/Val (19.6%) patients had unchanged therapies. Patients treated with Sac/Val had a higher New York Heart Association (NYHA) class at baseline and more often a left ventricular ejection fraction (LVEF) < 35%. The only baseline parameter significantly correlating with Sac/Val discontinuation during the 1‑year follow-up was diabetes mellitus (odds ratio: 2.44; 95% confidence interval: 1.14-5.24). In the Sac/Val group, 30.7% of patients were in NYHA class I/II on study entry, improving to 51.0% at 1‑year follow-up. In the no Sac/Val group, the corresponding rates of NYHA I and II classes were 49.8% and 58.2%, respectively. The overall adverse event profile of Sac/Val was good, with only 6.0% patients experiencing serious adverse events leading to permanent discontinuation. CONCLUSION In patients with symptomatic HFrEF treated in primary care, the group in whom Sac/Val was initiated was characterized by a higher NYHA class and lower LVEF compared to patients in whom Sac/Val was not initiated. Sac/Val was well tolerated, with a high proportion completing 1 year of therapy.
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Affiliation(s)
- Uwe Zeymer
- Institut für Herzinfarktforschung, Klinikum Ludwigshafen, Bremserstraße 79, 67063, Ludwigshafen, Germany.
- Institut für Herzinfarktforschung Ludwigshafen, Ludwigshafen, Germany.
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Iannaccone M, Gamardella M, Chieffo A. Inclusivity in randomised clinical trials: myth or reality? Heart 2024; 110:459-460. [PMID: 38199671 DOI: 10.1136/heartjnl-2023-323703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/12/2024] Open
Affiliation(s)
- Mario Iannaccone
- Cath Lab, Unit of Cardiology, Ospedale San Giovanni Bosco, Torino, Italy
| | - Marco Gamardella
- Vita-Salute San Raffaele University, Milano, Italy
- IRCCS Ospedale San Raffaele, Milano, Italy
| | - Alaide Chieffo
- Vita-Salute San Raffaele University, Milano, Italy
- IRCCS Ospedale San Raffaele, Milano, Italy
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Sheikh H, Walczak N, Rana H, Tseng NW, Syed MK, Collier C, Rezk M, Gong IY, Tan NS, Ali SH, Yan AT, Randhawa VK, Banks L. Temporal Trends of Enrollment by Sex and Race in Major Cardiovascular Randomized Clinical Trials. CJC Open 2024; 6:454-462. [PMID: 38487060 PMCID: PMC10935985 DOI: 10.1016/j.cjco.2023.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Accepted: 10/24/2023] [Indexed: 03/17/2024] Open
Abstract
Background Women and racialized minorities continue to be underrepresented in cardiovascular (CV) trial outcomes data, despite comprising a significant global burden of CV disease. This study evaluated the impact of trial characteristics on the temporal enrollment of women and racialized minorities in prominent CV trials published in the period 1986-2023. Methods MEDLINE was searched for CV trials published in The Lancet, the Journal of the American Medical Association, and the New England Journal of Medicine. Participant and investigator demographics, types of interventions, clinical indications, and funding sources were compared according to the enrollment of women or racialized minorities. Results From 799 studies, including 4,071,921 patients, the enrollment of women and racialized minorities significantly increased from 1986 to 2023 (both P ≤ 0.001). Although the enrollment of women varied by trial indication, comprising 25.0% of coronary artery disease, 35.2% of noncoronary and/or vascular disease, 13.8% of heart failure, 17.0% of arrhythmia, and 28.7% of other CV trials (P ≤ 0.001), it did not differ by peer-reviewed vs industry funding. First authors who were women were more likely than first authors who were men to enroll significantly more women (P = 0.01). Conclusions Active efforts to increase diverse enrollment, along with improved reporting, including of sex and race, in future CV trials may increase the generalizability of their findings and applicability to global populations.
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Affiliation(s)
- Hassan Sheikh
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicole Walczak
- Department of Epidemiology and Biostatistics, University of Western Ontario, London, Ontario, Canada
| | - Haaris Rana
- Faculty of Medicine, University of Ottawa, Ottawa, Ontario, Canada
| | - Nicholas W.H. Tseng
- Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
| | - Mohammad K. Syed
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Chris Collier
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Moemin Rezk
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
| | - Inna Y. Gong
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Nigel S. Tan
- Division of Cardiology, Niagara Health System, Niagara, Ontario, Canada
- Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Sammy H. Ali
- Department of Medicine, St Mary’s General Hospital, Toronto, Ontario, Canada
| | - Andrew T. Yan
- Department of Medicine, University of Toronto, Toronto, Ontario, Canada
- Terrence Donnelly Heart Centre, St. Michael’s Hospital, Kitchener, Ontario, Canada
| | - Varinder K. Randhawa
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Laura Banks
- Faculty of Health Sciences, Ontario Tech University, Oshawa, Ontario, Canada
- Knowledge, Innovation, Talent, Everywhere (KITE), Toronto Rehabilitation Institute, University Health Network, Toronto, Ontario, Canada
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Gonzalez-Franco J, Caicedo-Espinosa J, Cardona-Tobon C, Jaramillo-Jara N, Aguilar-Molina O, Jaimes-Barragan FA, Saldarriaga-Giraldo CI. Application of eligibility criteria from DAPA-HF, EMPEROR-Reduced, and PARADIGM-HF trials to a population with heart failure with reduced ejection fraction at a specialized cardiology Clinic in Medellin, Colombia: A retrospective cohort study. Curr Probl Cardiol 2024; 49:102193. [PMID: 37952788 DOI: 10.1016/j.cpcardiol.2023.102193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 11/09/2023] [Indexed: 11/14/2023]
Abstract
INTRODUCTION The evidence supporting pharmacological heart failure treatment relies on randomized clinical trials with stringent inclusion and exclusion criteria. OBJECTIVES Assess the eligibility of outpatients with chronic heart failure for the trials DAPA-HF, EMPEROR-reduced, and PARADIGM-HF, while exploring potential differences among study populations. METHODS By reviewing medical records, we determined the eligibility rate for each study and evaluated the incidence of heart failure hospitalizations and all-cause mortality during this period. RESULTS A total of 446 patients were included in the cohort. Approximately 75% would be ineligible for the trials, mainly because of their comorbidities. Ineligible patients had a higher all-cause mortality, but a similar incidence of hospitalization. CONCLUSION Approximately 1 in 4 patients from a heart failure clinic in Medellin, Colombia would meet the eligibility criteria for the DAPA-HF, EMPEROR-reduced, and PARADIGM-HF trials. These findings highlight the need to complement randomized clinical trials with real-world data.
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Affiliation(s)
- Juliana Gonzalez-Franco
- Department of Internal Medicine, Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia.
| | - Javier Caicedo-Espinosa
- Department of Internal Medicine, Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia
| | | | - Natalia Jaramillo-Jara
- Department of Internal Medicine, Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia
| | | | | | - Clara-Ines Saldarriaga-Giraldo
- CardioVID Clinic, Medellín, Colombia; Department of Internal Medicine, Faculty of Medicine, Universidad de Antioquia, Medellín, Colombia
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Kim ES, Park SK, Youn JC, Lee HS, Lee HY, Cho HJ, Choi JO, Jeon ES, Lee SE, Kim MS, Kim JJ, Hwang KK, Cho MC, Chae SC, Kang SM, Park JJ, Choi DJ, Yoo BS, Cho JY, Kim KH, Oh BH, Greenberg B, Baek SH. Real-World Eligibility and Cost-Effectiveness Analysis of Empagliflozin for Heart Failure in Korea. J Korean Med Sci 2024; 39:e8. [PMID: 38193327 PMCID: PMC10782045 DOI: 10.3346/jkms.2024.39.e8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Accepted: 10/16/2023] [Indexed: 01/10/2024] Open
Abstract
BACKGROUND The US Food and Drug Administration (FDA) and European Medicines Agency (EMA) approved empagliflozin for reducing cardiovascular mortality and heart failure (HF) hospitalization in patients with both HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF). However, limited data are available on the generalizability of empagliflozin to clinical practice. Therefore, we evaluated real-world eligibility and potential cost-effectiveness based on a nationwide prospective HF registry. METHODS A total of 3,108 HFrEF and 2,070 HFpEF patients from the Korean Acute Heart Failure (KorAHF) registry were analyzed. Eligibility was estimated by inclusion and exclusion criteria of EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Reduced Ejection Fraction (EMPEROR-Reduced) and EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trials and by FDA & EMA label criteria. The cost-utility analysis was done using a Markov model to project the lifetime medical cost and quality-adjusted life year (QALY). RESULTS Among the KorAHF patients, 91.4% met FDA & EMA label criteria, while 44.7% met the clinical trial criteria. The incremental cost-effectiveness ratio of empagliflozin was calculated at US$6,764 per QALY in the overall population, which is far below a threshold of US$18,182 per QALY. The cost-effectiveness benefit was more evident in patients with HFrEF (US$5,012 per QALY) than HFpEF (US$8,971 per QALY). CONCLUSION There is a large discrepancy in real-world eligibility for empagliflozin between FDA & EMA labels and clinical trial criteria. Empagliflozin is cost-effective in HF patients regardless of ejection fraction in South Korea health care setting. The efficacy and safety of empagliflozin in real-world HF patients should be further investigated for a broader range of clinical applications. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT01389843.
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Affiliation(s)
- Eui-Soon Kim
- Graduate School of Medical Science and Engineering, Korea Advanced Institute of Science and Technology, Daejeon, Korea
| | - Sun-Kyeong Park
- College of Pharmacy, The Catholic University of Korea, Bucheon, Korea
| | - Jong-Chan Youn
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea.
| | - Hye Sun Lee
- Biostatistics Collaboration Unit, Yonsei University College of Medicine, Seoul, Korea
| | - Hae-Young Lee
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Seoul National University School of Medicine, Seoul, Korea
| | - Hyun-Jai Cho
- Department of Internal Medicine, Seoul National University Hospital, Seoul, Korea
- Seoul National University School of Medicine, Seoul, Korea
| | - Jin-Oh Choi
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Eun-Seok Jeon
- Department of Internal Medicine, Sungkyunkwan University College of Medicine, Seoul, Korea
| | - Sang Eun Lee
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Min-Seok Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Joong Kim
- Department of Internal Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Kyung-Kuk Hwang
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Myeong-Chan Cho
- Department of Internal Medicine, Chungbuk National University Hospital, Cheongju, Korea
| | - Shung Chull Chae
- Department of Internal Medicine, Kyungpook National University College of Medicine, Daegu, Korea
| | - Seok-Min Kang
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul, Korea
| | - Jin Joo Park
- Seoul National University School of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Dong-Ju Choi
- Seoul National University School of Medicine, Seoul, Korea
- Department of Internal Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - Byung-Su Yoo
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Yeong Cho
- Department of Cardiovascular Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Kye Hun Kim
- Department of Cardiovascular Medicine, Chonnam National University Medical School, Gwangju, Korea
| | - Byung-Hee Oh
- Department of Cardiovascular medicine, Incheon Sejong Hospital, Incheon, Korea
| | - Barry Greenberg
- Department of Cardiology, UC San Diego Health System, La Jolla, CA, USA
| | - Sang Hong Baek
- Division of Cardiology, Department of Internal Medicine, Seoul St. Mary's Hospital, Catholic Research Institute for Intractable Cardiovascular Disease, College of Medicine, The Catholic University of Korea, Seoul, Korea
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Matsumoto S, McMurray JJV, Nasu T, Ishii S, Kagiyama N, Kida K, Fujimoto W, Kikuchi A, Ijichi T, Shibata T, Ikeda T, Kanaoka K. Relevant adverse events and drug discontinuation of Sacubitril/valsartan in a real-world Japanese cohort: REVIEW-HF registry. J Cardiol 2023:S0914-5087(23)00276-9. [PMID: 38000538 DOI: 10.1016/j.jjcc.2023.11.005] [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: 09/10/2023] [Revised: 11/10/2023] [Accepted: 11/16/2023] [Indexed: 11/26/2023]
Abstract
BACKGROUND The characteristics, tolerability, and outcomes in patients with heart failure (HF) who are treated with sacubitril/valsartan remain unclear in Japan. METHODS We conducted a nationwide multicenter study to evaluate the features and outcomes of patients newly prescribed sacubitril/valsartan for the management of HF. We analyzed adverse events (AEs) related to sacubitril/valsartan at 3 months, which were defined as hypotension, worsening renal function, hyperkalemia, and angioedema. Additionally, the association between AEs and outcomes was examined. RESULTS Among 993 patients, the mean age was 70 years and 291 (29.3 %) were female, and 22.8 % had left ventricular ejection fraction ≥50 %. Of them, 20.8 % had systolic blood pressure (sBP) <100 mmHg, and 19.5 % had estimated glomerular filtration rate (eGFR) <30 ml/min/1.73m2 at baseline, which were the populations excluded from the eligibility in landmark trials. AEs related to sacubitril/valsartan were observed in 22.5 % of the patients at 3 months. Overall, 22.6 % of patients discontinued sacubitril/valsartan, and hypotension was the most common event leading to drug discontinuation. After adjustment, patients who had worse HF symptoms (New York Heart Association III or IV), sBP <100 mmHg, and eGFR <30 ml/min/1.73m2 were associated with a higher risk of AEs related to sacubitril/valsartan. Additionally, patients experiencing AEs had a higher risk of cardiovascular death or HF hospitalization than those who did not. CONCLUSION In Japan, sacubitril/valsartan was also prescribed to patients not eligible for landmark trials, and AEs were observed at a relatively high rate from soon after treatment initiation. Physicians should closely monitor patients for these events, especially in patients anticipated to have a higher risk of AEs.
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Affiliation(s)
- Shingo Matsumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan; British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Takahito Nasu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Iwate, Japan
| | - Shunsuke Ishii
- Department of Cardiovascular Medicine, Kitasato University School of Medicine, Kanagawa, Japan
| | - Nobuyuki Kagiyama
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan; Department of Digital Health and Telemedicine, R&D, Tokyo, Japan
| | - Keisuke Kida
- Department of Pharmacology, St. Marianna University School of Medicine, Kanagawa, Japan
| | - Wataru Fujimoto
- Department of Cardiology, Hyogo Prefectural Awaji Medicine Center, Hyogo, Japan
| | - Atsushi Kikuchi
- Division of Cardiology, Osaka General Medical Center, Osaka, Japan
| | - Takeshi Ijichi
- Department of Cardiology, Tokai University School of Medicine, Osaka, Japan
| | - Tatsuhiro Shibata
- Division of Cardiovascular Medicine, Department of Internal Medicine, Kurume University School of Medicine, Kurume, Japan
| | - Takanori Ikeda
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Koshiro Kanaoka
- Department of Medical and Health Information Management, National Cerebral and Cardiovascular Center, Osaka, Japan; Department of Cardiovascular Medicine, Nara Medical University, Nara, Japan
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Nguyen NV, Lindberg F, Benson L, Ferrannini G, Imbalzano E, Mol PGM, Dahlström U, Rosano GMC, Ezekowitz J, Butler J, Lund LH, Savarese G. Eligibility for vericiguat in a real-world heart failure population according to trial, guideline and label criteria: Data from the Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:1418-1428. [PMID: 37323078 DOI: 10.1002/ejhf.2939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/29/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023] Open
Abstract
AIM We investigated the eligibility for vericiguat in a real-world heart failure (HF) population based on trial, guideline and label criteria. METHODS AND RESULTS From the Swedish HF registry, 23 573 patients with HF with reduced ejection fraction (HFrEF) enrolled between 2000 and 2018, with a HF duration ≥6 months, were considered. Eligibility for vericiguat was calculated based on criteria from (i) the Vericiguat Global Study in Subjects with Heart Failure and Reduced Ejection Fraction (VICTORIA) trial; (ii) European and American guidelines on HF; (iii) product labelling according to the Food and Drug Administration and European Medicines Agency. Estimated eligibility for vericiguat in the trial, guidelines, and label scenarios was 21.4%, 47.4%, and 47.4%, respectively. Prior HF hospitalization within 6 months was the criterion limiting eligibility the most in all scenarios (met by 49.1% of the population). In the trial scenario, other criteria meaningfully limiting eligibility were elevated N-terminal pro-B-type natriuretic peptide levels and nitrate use. In all scenarios, eligibility was higher among patients hospitalized for HF at baseline (44.3% vs. 21.4% [trial scenario] and 97.3% vs. 47.4% [guideline/label scenarios] for hospitalized vs. non-hospitalized patients). Overall, eligible patients were older, had more severe HF, more comorbidities, and consequently higher cardiovascular mortality and HF hospitalization rates compared with ineligible patients across all scenarios. CONCLUSION In a large and contemporary real-world HFrEF cohort, we estimated that 21.4% of patients would be eligible for vericiguat according to the VICTORIA trial selection criteria, 47.4% based on guidelines and labelling. Eligibility for vericiguat translated into the selection of a population at high risk of morbidity/mortality.
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Affiliation(s)
- Ngoc V Nguyen
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Peter G M Mol
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | - Justin Ezekowitz
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Institute, Dallas, TX, USA
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
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Jiang J, Gao J, Zhang X, Li Y, Dang H, Liu Y, Chen W. Combined treatment with sacubitril/valsartan plus dapagliflozin in patients affected by heart failure with reduced ejection fraction. Front Cardiovasc Med 2023; 10:1097066. [PMID: 37034349 PMCID: PMC10073490 DOI: 10.3389/fcvm.2023.1097066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 03/07/2023] [Indexed: 04/11/2023] Open
Abstract
Background Data about real-world effects of combined therapy with sacubitril/valsartan plus dapagliflozin in patients affected by heart failure (HF) with reduced ejection fraction (HFrEF) has not been widely reported. In this article, the benefits of dapagliflozin and sacubitril/valsartan respect to improvements of cardiac function in patients with HFrEF would be investigated. Methods HF patients prescribed sacubitril/valsartan between January 2020 and January 2022 in a tertiary teaching hospital were selected using the Computerized Patient Record System. Patients were divided into two groups according to whether they were taking dapagliflozin. Clinical parameters at baseline and during follow-up were retrospectively collected and analyzed. Results Total of 136 consecutive patients were recruited for this study. 72 patients treated with sacubitril/valsartan and dapagliflozin were assigned to Group A, and another 64 patients receiving sacubitril/valsartan monotherapy were assigned to Group B. After treatment with sacubitril/valsartan plus dapagliflozin for a median follow-up period of 189 days (IQR, 180-276), significant improvements of cardiac function were achieved in Group A. Median N-terminal pro-B-type natriuretic peptide (NT-proBNP) level was significantly decreased from 2585 pg/ml (1014-3702.5) to 1260.5 pg/ml (439.8-2214.3) (P < 0.001). Mean left ventricular ejection fraction (LVEF) improved from 34.7 ± 4.6% to 39.2 ± 7.5% (P < 0.001). Mean daily dose of loop diuretics decreased from 37.1 ± 17.3 mg/day to 25.9 ± 18.5 mg/day (P < 0.001). Regarding safety, both systolic blood pressure (P = 0.002) and diastolic blood pressure (P = 0.002) significantly decreased. For patients in Group B, significant improvements in mean LVEF (P < 0.001), decreases in mean daily dose of loop diuretics (P = 0.001) and reductions in diastolic blood pressure (P = 0.023) were observed. Strikingly, both median Δ NT-proBNP (P = 0.04) and median Δ LAD (P = 0.006) in Group A were more pronounced in comparison with those seen in Group B. Conclusions The combined use of sacubitril/valsartan and dapagliflozin was associated with improved cardiac function in patents with HFrEF, and led to greater reductions in LAD and NT-proBNP levels compared to sacubitril/valsartan monotherapy. These findings suggest that the combination therapy may offer more potent cardiovascular benefits.
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Affiliation(s)
- Juan Jiang
- Department of Stomatology, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Jie Gao
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Xiuzhen Zhang
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Yuanmin Li
- Department of Cardiology, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Heqin Dang
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Yanlin Liu
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Wenwen Chen
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
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Chen WW, Jiang J, Gao J, Zhang XZ, Li YM, Liu YL, Dang HQ. Efficacy and safety of low-dose sacubitril/valsartan in heart failure patients: A systematic review and meta-analysis. Clin Cardiol 2023; 46:296-303. [PMID: 36648084 PMCID: PMC10018087 DOI: 10.1002/clc.23971] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2022] [Revised: 12/09/2022] [Accepted: 01/04/2023] [Indexed: 01/18/2023] Open
Abstract
BACKGROUND Controversy has persisted over the clinical benefits of low-dose sacubitril/valsartan in patients with heart failure (HF). HYPOTHESIS Low-dose sacubitril/valsartan might also be effective and safe in HF patients. METHODS Electronic databases including PubMed, Ovid, and Cochrane Library were systematically retrieved from inception to August 5, 2021. Review manager 5.4 and Stata 15.1 were employed in this systematic review and meta-analysis. Key efficacy outcomes of interest included HF hospitalization, all-cause mortality, left ventricular ejection fraction (LVEF), N-terminal pro-B-type natriuretic peptide (NT-proBNP), together with New York Heart Association (NYHA) functional class. The safety outcome was systolic blood pressure (SBP). The grading of recommendations assessment, development, and evaluation approach was conducted to evaluate the quality of evidence for each outcome. RESULTS A total of 1269 studies were screened and 9 real-world studies met the inclusion criteria were included in the meta-analysis, with 1697 participants. Compared with low-dose sacubitril/valsartan, high-dose sacubitril/valsartan significantly reduced the risk of HF hospitalization (odds ratio [OR]: 0.4, 95% confidence interval [CI]: 0.27-0.61, p < .0001) and the risk of all-cause mortality (OR: 0.23, 95% CI: 0.11-0.47, p < .0001). However, there were no appreciable differences in improvements of NYHA (OR: 0.59, 95% CI: 0.15-2.35, p = .45), changes of LVEF (mean difference [MD]: 2.73%, 95% CI: -2.24% to 7.7%, p = .28), changes of NT-proBNP (MD: 43.09, 95% CI: -28.41 to 114.59, p = .24) and changes of SBP (MD: 3.01, 95% CI: -4.62 to 10.64, p = .44) between groups with low-dose and high-dose sacubitril/valsartan. CONCLUSIONS Compared with high-dose sacubitril/valsartan, low-dose sacubitril/valsartan was associated with increased risks of HF hospitalization and all-cause mortality. However, no distinct between-group differences in improvements of NYHA, changes of LVEF, changes of NT-proBNP and changes of SBP were observed.
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Affiliation(s)
- Wen-Wen Chen
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Juan Jiang
- Department of Stomatology, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Jie Gao
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Xiu-Zhen Zhang
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Yuan-Min Li
- Department of Cardiology, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - Yan-Lin Liu
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
| | - He-Qin Dang
- Department of Pharmacy, The Second Affiliated Hospital of Shandong First Medical University, Tai'an, China
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10
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Håkansson E, Brunström M, Norberg H, Själander S, Lindmark K. Prevalence and treatment of diabetes and pre-diabetes in a real-world heart failure population: a single-centre cross-sectional study. Open Heart 2022; 9:openhrt-2022-002133. [PMID: 36600650 PMCID: PMC9748948 DOI: 10.1136/openhrt-2022-002133] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Accepted: 11/28/2022] [Indexed: 12/15/2022] Open
Abstract
AIMS The aim of this study was to investigate a real-world heart failure (HF) cohort regarding (1) prevalence of known diabetes mellitus (DM), undiagnosed DM and pre-diabetes, (2) if hf treatment differs depending on glycaemic status and (3) if treatment of DM differs depending on HF phenotype. METHODS All patients who had received a diagnosis of HF at Umeå University Hospital between 2010 and 2019 were identified and data were extracted from patient files according to a prespecified protocol containing parameters for clinical characteristics, including echocardiogram results, comorbidities, fasting plasma glucose (FPG) and hemoglobin A1c (HbA1c) values. Patients' HF phenotype was determined using the latest available echocardiogram. The number of patients with previous DM diagnosis was assessed. Patients without a previous diagnosis of DM were classified as non-DM, pre-diabetes or probable DM according to FPG and HbA1c levels using WHO criteria. RESULTS In total, 2326 patients (59% male, mean age 76±13 years) with HF and at least one echocardiogram were assessed. Of these, 617 (27%) patients had a previous diagnosis of DM. Of the 1709 patients without a previous diagnosis of DM, 1092 (67%) patients had either an FPG or HbA1c recorded, of which 441 (41%) met criteria for pre-diabetes and 97 (9%) met criteria for probable diabetes, corresponding to 19% and 4% of the entire cohort, respectively. Patients with HF and diabetes were more often treated with diuretics and beta blockers compared with non-DM patients (64% vs 42%, p<0.001 and 88% vs 83%, p<0.001, respectively). There was no difference in DM treatment between HF phenotypes. CONCLUSIONS DM and pre-diabetes are common in this HF population with 50% of patients having either known DM, probable DM or pre-diabetes. Patients with HF and DM are more often treated with common HF medications. HF phenotype did not affect choice of DM therapy.
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Affiliation(s)
- Erik Håkansson
- Department of Public Health and Clinical Medicine, Umeå University, Umea, Sweden
| | - Mattias Brunström
- Department of Public Health and Clinical Medicine, Umeå University, Umea, Sweden
| | - Helena Norberg
- Department of Integrative Medical Biology, Umeå universitet Medicinska fakulteten, Umea, Sweden
| | - Sara Själander
- Department of Public Health and Clinical Medicine, Umeå University, Umea, Sweden
| | - Krister Lindmark
- Department of Clinical Sciences Danderyd Hospital, Karolinska Institute, Danderyd, Sweden
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11
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Jern I, Forsell S, Norberg H. Eligibility for faricimab in a real-world neovascular age-related macular degeneration population: a cross-sectional study. BMJ Open 2022; 12:e065001. [PMID: 36096541 PMCID: PMC9472139 DOI: 10.1136/bmjopen-2022-065001] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
OBJECTIVES To investigate the eligibility of a real-world neovascular age-related macular degeneration (nAMD) population for the TENAYA and LUCERNE trials (testing faricimab), and to compare the eligible real-world patients to trial participants. DESIGN, SETTINGS AND PARTICIPANTS In this retrospective cross-sectional study, we used data from the Swedish Macula Registry (SMR) between 1 January 2017 and 31 December 2020. Persons were eligible if they fulfilled the main inclusion criteria in TENAYA and LUCERNE: (1) nAMD diagnosis, (2) treatment naïve, (3) ≥50 years and (4) best-corrected visual acuity (BCVA) of 78-24 letters. MAIN OUTCOME MEASURES Characteristics at the original visit of the eligible SMR population and baseline data from the clinical trials were compared. RESULTS In total, 27 962 individuals with nAMD were registered in SMR. A total of 15 399 (55%) individuals were treatment naïve; of these, 15 368 (55%) were ≥50 years and 13 265 (47%) also had BCVA of 78-24 letters and fulfilled eligibility. Among treatment-naïve individuals, 86% were eligible and the BCVA criterion was the most common reason for non-eligibility. The eligible SMR population was significantly older than either TENAYA or LUCERNE. SMR included more women and patients with worse visual acuity than TENAYA, while SMR patients were diagnosed more quickly than LUCERNE. CONCLUSIONS Almost half of the real-world nAMD population in SMR fulfilled the main inclusion criteria of the TENAYA and LUCERNE trials. Among treatment-naïve individuals, 86% were eligible. Marginally differences were shown between the eligible SMR population and the trial populations. The SMR population were older and more similar to the population in LUCERNE than TENAYA.
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Affiliation(s)
- Iréne Jern
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
| | - Sara Forsell
- Department of Clinical Sciences/Ophthalmology, Umeå University, Umeå, Sweden
| | - Helena Norberg
- Department of Integrative Medical Biology, Umeå University, Umeå, Sweden
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12
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Morgan H, Sinha A, Mcentegart M, Hardman SM, Perera D. Evaluation of the causes of sex disparity in heart failure trials. Heart 2022; 108:1547-1552. [PMID: 35361671 PMCID: PMC9484380 DOI: 10.1136/heartjnl-2021-320696] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/09/2021] [Accepted: 03/08/2022] [Indexed: 12/31/2022]
Abstract
ObjectivesCardiovascular disease is one of the leading causes of mortality and morbidity in women. Despite this, even in contemporary research, female patients are poorly represented in trials. This study aimed to explore reasons behind the sex disparity in heart failure (HF) trials.MethodsHF trials published in seven high-impact clinical journals (impact factor >20), between 2000 and 2020, were identified. Trials with over 300 participants of both sexes were included. Large HF registries, as well as population statistics, were also identified using the same criteria.ResultsWe identified 146 HF trials, which included 248 620 patients in total. The median proportion of female patients was 25.8%, with the lowest proportions seen in trials enrolling patients with ischaemic cardiomyopathy (17.9%), severe systolic dysfunction (left ventricular ejection fraction (LVEF) <35%) (21.4%) and those involving an invasive procedure (21.1%). The highest proportion of women was seen in trials assessing HF with preserved LVEF (51.6%), as well as trials including older participants (40.5%). Significant differences were seen between prevalence of female trial participants and population prevalence in all LVEF categories (25.8% vs 49.0%, p<0.01).ConclusionsA significant sex disparity was identified in HF trials, most visible in trials assessing patients with severely reduced LVEF and ischaemic aetiology. This is likely due to a complex interplay between enrolment bias and biological variation. Furthermore, the degree of both these aspects may vary according to trial type. Going forward, we should encourage all HF trials to appraise their recruitment log and suggest reasons for any reported sex disparity.
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Affiliation(s)
- Holly Morgan
- Cardiovascular Division, King's College London, London, UK
| | - Aish Sinha
- Cardiovascular Division, King's College London, London, UK
| | | | - Suzanna Marie Hardman
- Clinical and Academic Department of Cardiovascular Medicine, Whittington Hospital, London, UK
| | - Divaka Perera
- Cardiovascular Division, King's College London, London, UK
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13
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Myhre PL, Prescott MF, Murphy SP, Fang JC, Mitchell GF, Ward JH, Claggett B, Desai AS, Solomon SD, Januzzi JL. Early B-Type Natriuretic Peptide Change in HFrEF Patients Treated With Sacubitril/Valsartan: A Pooled Analysis of EVALUATE-HF and PROVE-HF. JACC Heart Fail 2022; 10:119-128. [PMID: 35115085 DOI: 10.1016/j.jchf.2021.09.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Revised: 09/27/2021] [Accepted: 09/27/2021] [Indexed: 12/11/2022]
Abstract
OBJECTIVES This study assessed changes in B-type natriuretic peptide (BNP) among patients with heart failure with reduced ejection fraction (HFrEF) treated with sacubitril/valsartan (Sac/Val) according to standard prescribing information. BACKGROUND Through inhibition of neprilysin, Sac/Val may increase BNP concentrations. METHODS In an individual patient analysis from the EVALUATE-HF (Study of Effects of Sacubitril/Valsartan vs. Enalapril on Aortic Stiffness in Patients With Mild to Moderate HF With Reduced Ejection Fraction) (n = 221) and the PROVE-HF (Effects of Sacubitril/Valsartan Therapy on Biomarkers, Myocardial Remodeling and Outcomes) (n = 146) studies, we examined changes in BNP, N-terminal pro-BNP (NT-proBNP), and urinary cyclic guanosine monophosphate (ucGMP) from baseline to week 4 and week 12. RESULTS Median (IQRs) concentration of BNP at baseline, week 4, and week 12 were 145 [IQR: 55-329], 136 [IQR: 50-338], and 135 [IQR: 51-299] ng/L, respectively. There was no significant change from baseline to week 4 (0% [-30% to +41%]; P = 0.36) or week 12 (+1% [-36% to +50%]; P = 0.97). By week 12, one-half of the study participants had a BNP decline. There was no association between Sac/Val dose and BNP changes. Change in BNP was directly associated with change in NT-proBNP (rho: = 0.81; P < 0.001), which decreased by -30% (-50% to -8%) and -32% (-54% to -1%) to weeks 4 and 12 (P < 0.001 for both). In contrast, change in BNP was only weakly associated with change in ucGMP (rho: = 0.19; P < 0.001). Increases in ucGMP were observed regardless of whether BNP was decreased (+11% [-34% to +115%]), unchanged (+34% [-15% to +205%]), or increased (+57% [-12% to +14%]). CONCLUSIONS In this pooled analysis of patients with HFrEF with standard indications for Sac/Val treatment, there was no significant overall increase in BNP concentrations, and patients demonstrated increase in ucGMP regardless of the trajectory of BNP change. (Study of Effects of Sacubitril/Valsartan vs. Enalapril on Aortic Stiffness in Patients With Mild to Moderate HF With Reduced Ejection Fraction [EVALUATE-HF]; NCT02874794) (Effects of Sacubitril/Valsartan Therapy on Biomarkers, Myocardial Remodeling and Outcomes [PROVE-HF]; NCT02887183).
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Affiliation(s)
- Peder L Myhre
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA; Division of Medicine, Akershus University Hospital and University of Oslo, Oslo, Norway
| | | | - Sean P Murphy
- Cardiovascular Division, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Engineering, Inc, Norwood, Massachusetts, USA
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah School of Medicine, Salt Lake City, Utah, USA
| | - Gary F Mitchell
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - James L Januzzi
- Cardiovascular Division, Massachusetts General Hospital, Boston, Massachusetts, USA; Cardiovascular Engineering, Inc, Norwood, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA.
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14
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Håkansson E, Norberg H, Själander S, Lindmark K. Eligibility of Dapagliflozin and Empagliflozin in a Real-World Heart Failure Population. Cardiovasc Ther 2021; 2021:1894155. [PMID: 35024052 DOI: 10.1155/2021/1894155] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2021] [Revised: 10/25/2021] [Accepted: 11/26/2021] [Indexed: 01/10/2023] Open
Abstract
Aims This study is aimed at investigating the eligibility in a real-world heart failure population for the DAPA-HF (testing dapagliflozin) and EMPEROR-reduced (testing empagliflozin) trials, comparing the eligible real-world patients to trial participants and to characterize the noneligible patients. Methods Medical records of all heart failure patients who had a diagnosis of heart failure from the Heart Centre or Department of Internal Medicine at Umeå University Hospital were reviewed. Results 2433 of the hospital's uptake population of 150 000 had a diagnosis of heart failure. 681 patients had left ventricle ejection fraction ≤ 40%, and of these 352 (52%) and 268 (39%) patients met eligibility criteria for DAPA-HF and EMPEROR-reduced, respectively. Comparing eligible patients in our population with the DAPA-HF- and EMPEROR-reduced trial populations, we found that eligible real-world patients were older (79.0 vs. 66.2 years and 80.3 vs. 67.2 years, respectively), had worse renal function (eGFR 54.4 vs. 66.0 ml/min/1.73m2 and 49.5 vs. 61.8 ml/min/1.73m2, respectively), higher prevalence of atrial fibrillation (56.0% vs. 36.1% and 53.0% vs. 35.6%, respectively), and lower prevalence of diabetes mellitus (21.0% vs. 41.8% and 26.1% vs. 49.8%, respectively). The main reasons for ineligibility were low NT-proBNP or low eGFR. Noneligible patients differed according to reason for ineligibility, where patients with low NT-proBNP were generally younger and healthier, and patients with low eGFR were older and had more comorbidities. Conclusions 39-52% of patients with heart failure and reduced ejection fraction in this real-world heart failure population were eligible for SGLT2-inhibitor treatment, corresponding to 11-14% of all heart failure patients. Compared to trial participants, eligible real-world patients were significantly older with worse renal function, more atrial fibrillation, and less diabetes mellitus. Trial entry criteria exclude comparatively young and healthy patients, as well as comparatively old patients with more comorbid conditions.
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15
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Sharma Y, Horwood C, Hakendorf P, Thompson C. Benefits of Sacubitril/Valsartan in Frail Older Hospitalised Patients. Heart Lung Circ 2022; 31:S72. [DOI: 10.1016/j.hlc.2022.06.066] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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16
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Maltês S, Cunha GJL, Rocha BML, Presume J, Guerreiro R, Henriques C, Rodrigues C, Araújo I, Fonseca C. Dapagliflozin in a Real-World Chronic Heart Failure Population: How Many Are Actually Eligible? Cardiology 2021; 146:201-206. [PMID: 33524984 DOI: 10.1159/000512432] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2020] [Accepted: 10/16/2020] [Indexed: 11/19/2022]
Abstract
BACKGROUND In patients with heart failure (HF) and reduced ejection fraction (HFrEF) with or without type 2 diabetes mellitus, the sodium-glucose cotransporter 2 inhibitor (SGLT2i) dapagliflozin was recently shown to reduce the risk of worsening HF or death from cardiovascular causes in the dapagliflozin in patients with heart failure and reduced ejection fraction (DAPA-HF) trial. Our goal was to investigate how many patients in a real-world setting would be eligible for dapagliflozin according to the DAPA-HF enrolment criteria. METHODS This is a single-center retrospective study enrolling consecutive, unselected patients followed up in an HF clinic from 2013 to 2019. Key DAPA-HF inclusion criteria (i.e., left ventricular ejection fraction [LVEF] ≤40% and NT-proBNP ≥600 pg/mL [or ≥900 pg/mL if atrial fibrillation]) and exclusion criteria (estimated glomerular filtration rate [eGFR] <30 mL/kg/1.73 m2 and systolic blood pressure [SBP] <95 mm Hg) were considered. RESULTS Overall, 479 patients (age 76 ± 13 years; 50.5% male; 78.9% hypertensive; 45.1% with an eGFR <60 mL/min/1.73 m2; 36.5% with TD2M; and 33.5% with ischaemic HF) were assessed. The median SBP was 128.5 (112.0-146.0) mm Hg, mean eGFR was 50.8 ± 23.7 mL/min/1.73 m2, and median NT-proBNP was 2,183 (IQR 1,010-5,310) pg/mL. Overall, 155 (32.4%) patients had LVEF ≤40%. According to the DAPA-HF trial key criteria, 90 patients (18.8%) would be eligible for dapagliflozin. The remainder would be excluded due to LVEF >40% (67.6%), eGFR <30 mL/min/1.73 m2 (19.4%), NT-proBNP below the cutoff (16.7%), and/or SBP <95 mm Hg (6.5%). If we center the analysis to those with LVEF ≤40%, 58.1% would be eligible for dapagliflozin. The remainder would be excluded due to an eGFR <30 mL/min/1.73 m2 (20%), NT-proBNP below the cutoff (16.1%), and/or SBP <95 mm Hg (8.4%). CONCLUSION Roughly half of our real-world HFrEF cohort would be eligible for dapagliflozin according to the key criteria of the DAPA-HF trial. The main reason for non-eligibility was an eGFR <30 mL/min/1.73 m2. However, two-thirds of patients had LVEF >40%. These findings show that dapagliflozin is a promising complementary new drug in the therapeutic armamentarium of most patients with HFrEF, while highlighting the urgent need for disease-modifying drugs in mid-range and preserved LVEF and the need to assess the efficacy and safety of SLGT2i in advanced kidney disease patients. The results of ongoing SGLT2i trials in these LVEF subgroups are eagerly awaited.
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Affiliation(s)
- Sérgio Maltês
- Clínica de Insuficiência Cardíaca, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal,
| | - Gonçalo J L Cunha
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Bruno M L Rocha
- Cardiology Department, Hospital de Santa Cruz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - João Presume
- Clínica de Insuficiência Cardíaca, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Renato Guerreiro
- Clínica de Insuficiência Cardíaca, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Célia Henriques
- Clínica de Insuficiência Cardíaca, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Catarina Rodrigues
- Clínica de Insuficiência Cardíaca, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Inês Araújo
- Clínica de Insuficiência Cardíaca, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Cândida Fonseca
- Clínica de Insuficiência Cardíaca, Hospital São Francisco Xavier, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal.,NOVA Medical School, Faculdade de Ciências Médicas, Universidade Nova de Lisboa, Lisbon, Portugal
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17
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Pathadka S, Yan VKC, Li X, Tse G, Wan EYF, Lau H, Lau WCY, Siu DCW, Chan EW, Wong ICK. Hospitalization and Mortality in Patients With Heart Failure Treated With Sacubitril/Valsartan vs. Enalapril: A Real-World, Population-Based Study. Front Cardiovasc Med 2021; 7:602363. [PMID: 33553256 PMCID: PMC7855850 DOI: 10.3389/fcvm.2020.602363] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 12/21/2020] [Indexed: 12/11/2022] Open
Abstract
Background: The effect of sacubitril/valsartan on survival and hospitalization risk in older patients with heart failure has not been explored. We aimed to investigate the risk of hospitalization and mortality with the use of sacubitril/valsartan vs. enalapril in patients with heart failure. Methods: This was a population-based cohort study using the Hong Kong-wide electronic healthcare database. Patients diagnosed with heart failure and newly prescribed sacubitril/valsartan or enalapril between July 2016 and June 2019 were included. The risk of primary composite outcome of cardiovascular mortality or heart failure-related hospitalization, all-cause hospitalization, heart failure-related hospitalization, cardiovascular mortality and all-cause mortality were compared using Cox regression with inverse probability treatment weighting. Additional analysis was conducted by age stratification. Results: Of the 44,503 patients who received sacubitril/valsartan or enalapril, 3,237 new users (sacubitril/valsartan, n = 1,056; enalapril, n = 2,181) with a diagnosis of heart failure were identified. Compared with enalapril, sacubitril/valsartan users were associated with a lower risk of primary composite outcome [hazard ratio (HR) 0.58; 95% confidence interval (CI), 0.45–0.75], heart failure-related hospitalization (HR 0.59; 95% CI, 0.45–0.77), all-cause mortality (HR 0.51; 95% CI, 0.36–0.74) and borderline non-significant reductions in all-cause hospitalization (HR 0.85; 95% CI, 0.70–1.04) and cardiovascular mortality (HR 0.63; 95% CI, 0.39–1.02). The treatment effect of sacubitril/valsartan remains unaltered in the patient subgroup age ≥ 65 years (73%). Conclusions: In real-world settings, sacubitril/valsartan was associated with improved survival and reduced heart failure-related hospitalization compared to enalapril in Asian patients with heart failure. The effectiveness remains consistent in the older population.
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Affiliation(s)
- Swathi Pathadka
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China
| | - Vincent K C Yan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China
| | - Xue Li
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Department of Paediatrics and Adolescent Medicine, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong, China.,Department of Social Work and Social Administration, Faculty of Social Science, University of Hong Kong, Hong Kong, China
| | - Gary Tse
- Xiamen Cardiovascular Hospital, Xiamen University, Xiamen, China
| | - Eric Y F Wan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Department of Family Medicine and Primary Care, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Hayden Lau
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Department of Accident & Emergency, Li Ka Shing Faculty of Medicine, Queen Mary Hospital, University of Hong Kong, Hong Kong, China
| | - Wallis C Y Lau
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Research Department of Practice and Policy, University College of London School of Pharmacy, London, United Kingdom
| | - David C W Siu
- Department of Medicine, Li Ka Shing Faculty of Medicine, The University of Hong Kong, Hong Kong, China
| | - Esther W Chan
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China
| | - Ian C K Wong
- Department of Pharmacology and Pharmacy, Li Ka Shing Faculty of Medicine, Centre for Safe Medication Practice and Research, University of Hong Kong, Hong Kong, China.,Research Department of Practice and Policy, University College of London School of Pharmacy, London, United Kingdom
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18
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Affiliation(s)
- Diana Bonderman
- Division of Cardiology, Clinic Favoriten, Vienna, Austria.,Division of Cardiology, Medical University of Vienna, Vienna, Austria
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19
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Pandey AC, Jer D, Kuo RS, Yoo DH, Christophy A, Mohan RC, Srivastava AV, Heywood JT. Novel doses of sacubitril/valsartan in patients unable to tolerate traditional therapy: Effects on N-terminal pro B-type natriuretic peptide levels. Clin Cardiol 2020; 44:85-90. [PMID: 33277928 PMCID: PMC7803354 DOI: 10.1002/clc.23509] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [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: 06/26/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Widespread use of angiotensin receptor blocker and neprilysin inhibitor (ARNI) remains low, and many patients are unable to tolerate the medication due to hypotension at the currently recommended starting dose. HYPOTHESIS The aim of this study is to assess if lower than standard doses of ARNI, sacubitril/valsartan (S/V), significantly reduces NT-proBNP and leads to any change in diuretic dose, serum potassium, or creatinine. METHODS In a retrospective study of 278 patients who were started on a low dose S/V at a single medical center, 45 patients were selected for the study cohort. Patients were subcategorized to Group 1 (n = 10): very low dose S/V (half a tab of 24/26 mg BID), Group 2 (n = 10): very low dose titrated to low dose S/V, and Group 3 (n = 25): low dose S/V (24/26 mg BID). NT-proBNP, diuretic dose, serum potassium, and creatinine were compared before and after initiation of S/V. RESULTS Among all groups, there was a significant reduction in NT-proBNP level (Group 1: p < .01, Group 2: p < .01, and Group 3: p < .001). In addition, there was a significant reduction in diuretic dose across all groups combined (furosemide 53 mg/day vs. 73 mg/day; p = .03), with 17.8% (8/45) patients being able to discontinue their diuretic completely. There was no significant change in potassium or creatinine. CONCLUSIONS Lower than standard dose of S/V significantly reduces NT-proBNP and diuretic requirement without change in potassium or creatinine, which provides hope that patients who cannot tolerate standard doses of S/V due to hypotension may be able to receive the benefits of S/V therapy.
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Affiliation(s)
- Amitabh C Pandey
- Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA.,Scripps Research Translational Institute, The Scripps Research Institute, La Jolla, California, USA
| | - Derek Jer
- Department of Pharmacy, Scripps Clinic, La Jolla, California, USA
| | - Ruth S Kuo
- Department of Pharmacy, Scripps Clinic, La Jolla, California, USA
| | - David H Yoo
- Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA
| | - Antonio Christophy
- Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA.,Section of Advanced Heart Failure and Mechanical Circulatory Support, Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA
| | - Rajeev C Mohan
- Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA.,Section of Advanced Heart Failure and Mechanical Circulatory Support, Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA
| | - Ajay V Srivastava
- Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA.,Section of Advanced Heart Failure and Mechanical Circulatory Support, Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA
| | - James Thomas Heywood
- Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA.,Section of Advanced Heart Failure and Mechanical Circulatory Support, Division of Cardiology, Scripps Prebys Cardiovascular Institute, Scripps Clinic, La Jolla, California, USA
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20
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Affiliation(s)
- Markus S Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), Charité University Medicine Berlin, Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany.,Department of Cardiology (CBF), Charité University Medicine Berlin, Berlin, Germany
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary.,HAS-UD Vascular Biology and Myocardial Pathophysiology Research Group, Hungarian Academy of Sciences, Budapest, Hungary
| | - Gábor Földes
- National Heart and Lung Institute, Imperial College London, London, UK.,Heart and Vascular Center, Semmelweis University, Budapest, Hungary
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, University Medical Center Göttingen, Göttingen, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Göttingen, Göttingen, Germany
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21
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Fu M, Vedin O, Svennblad B, Lampa E, Johansson D, Dahlström U, Lindmark K, Vasko P, Lundberg A, Costa-Scharplatz M, Lund LH. Implementation of sacubitril/valsartan in Sweden: clinical characteristics, titration patterns, and determinants. ESC Heart Fail 2020; 7:3633-3643. [PMID: 32881399 PMCID: PMC7754959 DOI: 10.1002/ehf2.12883] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2020] [Revised: 06/04/2020] [Accepted: 06/17/2020] [Indexed: 12/11/2022] Open
Abstract
Aims The aim of this study is to study the introduction of sacubitril/valsartan (sac/val) in Sweden with regards to regional differences, clinical characteristics, titration patterns, and determinants of use and discontinuation. Methods and results A national cohort of heart failure was defined from the Swedish Prescribed Drug Register and National Patient Register. A subcohort with additional data from the Swedish Heart Failure Registry (SwedeHF) was also studied. Cohorts were subdivided as per sac/val prescription and registration in SwedeHF. Median sac/val prescription rate was 20 per 100 000 inhabitants. Between April 2016 and December 2017, we identified 2037 patients with ≥1 sac/val prescription, of which 1144 (56%) were registered in SwedeHF. Overall, patients prescribed with sac/val were younger, more frequently male, and had less prior cardiovascular disease than non‐sac/val patients. In SwedeHF subcohort, patients prescribed with sac/val had lower ejection fraction. Overall, younger age [hazard ratio 2.81 (95% confidence interval 2.45–3.22)], registration in SwedeHF [1.97 (1.83–2.12)], male gender [1.50 (1.37–1.64)], ischaemic heart disease [1.50 (1.39–1.62)], lower left ventricular ejection fraction [3.06 (2.18–4.31)], and New York Heart Association IV [1.50 (1.22–1.84)] were predictors for sac/val use. As initiation dose in the sac/val cohort, 38% received 24/26 mg, 54% 49/51 mg, and 9% 97/103 mg. Up‐titration to the target dose was achieved in 57% of the overall cohort over a median follow‐up of 6 months. The estimated treatment persistence for any dose at 360 days was 82%. Conclusions Implementation of sac/val in Sweden was slow and varied five‐fold across different regions; younger age, male, SwedeHF registration, and ischaemic heart disease were among the independent predictors of receiving sac/val. Overall, treatment persistence and tolerability was high.
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Affiliation(s)
- Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Ola Vedin
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.,Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Bodil Svennblad
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Erik Lampa
- Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | | | - Ulf Dahlström
- Department of Cardiology and Department of Medical and Health Sciences, Linköping University Hospital, Linköping, Sweden
| | - Krister Lindmark
- Heart Centre, Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | | | | | | | - Lars H Lund
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
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22
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Cuthbert JJ, Pellicori P, Clark AL. Cardiovascular Outcomes with Sacubitril-Valsartan in Heart Failure: Emerging Clinical Data. Ther Clin Risk Manag 2020; 16:715-726. [PMID: 32848403 PMCID: PMC7425097 DOI: 10.2147/tcrm.s234772] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2020] [Accepted: 06/28/2020] [Indexed: 12/11/2022] Open
Abstract
One of the defining features of heart failure (HF) is neurohormonal activation. The renin-angiotensin-aldosterone-system (RAAS) and sympathetic nervous system (SNS) cause vasoconstriction and fluid retention and, in response, the secretion of natriuretic peptides (NPs) from volume and pressure-overloaded myocardium promotes vasodilation and diuresis. Inhibition of the RAAS with either angiotensin-converting enzyme inhibitors (ACEI) or angiotensin receptor blockers (ARB) has been the cornerstone of medical treatment for HF with a reduced ejection fraction (HFrEF) but, until recently, it was unclear how the beneficial effects of NPs may be augmented in patients with HF. Neprilysin, a metalloproteinase widely distributed throughout the body, plays a role in degrading the gross excess of circulating NPs in patients with HF. Early studies of neprilysin inhibition suggested possible physiological benefits. In 2014, the PARADIGM-HF trial found that sacubitril-valsartan, a combination of the ARB valsartan, and the neprilysin inhibitor sacubitril, was superior to enalapril in patients with HFrEF, reducing the relative risk of cardiovascular (CV) death or first hospitalisation with HF by 20%. Almost half of the patients with HF symptoms have a “preserved” ejection fraction (HFpEF); however, the PARAGON-HF study found that sacubitril-valsartan in patients with LVEF ≥45% had no effect on CV death or first and recurrent hospitalisations with HF compared to valsartan. Guidelines across the world have changed to include sacubitril-valsartan for patients with HFrEF yet, nearly 6 years after PARADIGM-HF, there is still uncertainty as to when and in whom sacubitril-valsartan should be started. Furthermore, there may yet be subsets of patients with HFpEF who might benefit from treatment with sacubitril-valsartan. This review will describe the mechanisms behind the outcome benefit of sacubitril-valsartan in patients with HFrEF and to consider its future role in the management of patients with HF.
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Affiliation(s)
- Joseph J Cuthbert
- Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Kingston upon Hull HU16 5JQ, UK
| | - Pierpaolo Pellicori
- Robertson Institute of Biostatistics and Clinical Trials Unit, University of Glasgow, University Avenue, Glasgow G12 8QQ, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Hull York Medical School, Hull and East Yorkshire Medical Research and Teaching Centre, Castle Hill Hospital, Kingston upon Hull HU16 5JQ, UK
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23
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Abumayyaleh M, El-Battrawy I, Behnes M, Borggrefe M, Akin I. Current evidence of sacubitril/valsartan in the treatment of heart failure with reduced ejection fraction. Future Cardiol 2020; 16:227-236. [DOI: 10.2217/fca-2020-0002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Heart failure (HF) is one of the most common reasons for hospital admission in western countries. The measurement of the left ventricular ejection fraction is essential for the classification of HF and deciding on HF treatment. The treatment of HF has been improved in both diagnostic and therapeutic fields over the past two decades. The angiotensin receptor-neprilysin inhibitor decreased the cardiovascular mortality in patients with chronic HF with reduced ejection fraction. Sacubitril/valsartan (LCZ696) improves the imbalance between the renin-angiotensin-aldosterone and natriuretic peptide systems. We present the clinical efficacy, real-world experience, safety and tolerability, the relevance of etiology of cardiomyopathy, and gender differences and regulatory affairs of LCZ696 in the treatment of patients with HF with reduced ejection fraction.
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Affiliation(s)
- Mohammad Abumayyaleh
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Ibrahim El-Battrawy
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Michael Behnes
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Martin Borggrefe
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
| | - Ibrahim Akin
- First Department of Medicine, Medical Faculty Mannheim, University Heidelberg, Mannheim, 68167, Germany
- DZHK (German Center for Cardiovascular Research), Partner Site, Heidelberg–Mannheim, Mannheim, Germany
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24
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Pinto G, Tondi L, Gemma M, De Marco A, Silipigni C, Spoladore R, Margonato A, Fragasso G. Real-Life Indications to Sacubitril/Valsartan Treatment in Patients With Chronic Systolic Heart Failure. J Cardiovasc Pharmacol 2019; 73:301-6. [PMID: 30855406 DOI: 10.1097/FJC.0000000000000665] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
OBJECTIVE International guidelines recommend the introduction of sacubitril/valsartan (Entresto) in patients with heart failure (HF) and reduced ejection fraction (EF), who remain symptomatic, despite optimal uptitrated therapy. The purpose of the following analysis is to verify the real-life eligibility for sacubitril/valsartan in a population of patients suffering from chronic HF, regularly monitored in a single HF clinic and treated according to guideline-directed medical therapy (GDMT). METHODS From a total of 1070 patients regularly monitored in our HF Clinic between January 2011 and September 2017, the clinical records of 224 patients with HF and reduced EF on optimized GDMT were retrospectively analyzed. RESULTS Of 224 analyzed patients, 75 improved their EF or were asymptomatic after uptitration of GDMT during follow-up; 50 were not on angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for different reasons; 13 patients had systolic blood pressure ≤100 mm Hg, so they were not eligible for sacubitril/valsartan introduction. The remaining patients were still symptomatic (NYHA ≥2), and therefore, sacubitril/valsartan introduction was indicated in these 86 patients (38.4%) of 224 enrolled. CONCLUSION In patients with HF and reduced EF, where GDMT is appropriately achieved, indication to sacubitril/valsartan treatment is around 38%.
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25
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Barry AR, Lee C. Pharmacist- or Nurse Practitioner-Led Assessment and Titration of Sacubitril/Valsartan in a Heart Failure Clinic: A Cohort Study. Can J Hosp Pharm 2020; 73:186-192. [PMID: 32616944 PMCID: PMC7308157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/11/2023]
Abstract
BACKGROUND Sacubitril/valsartan is a first-in-class angiotensin receptor-neprilysin inhibitor indicated in the management of heart failure with reduced ejection fraction, based on the results of the PARADIGM-HF trial. Practice-based studies are needed to validate its effect in real-world settings. Clinical pharmacists are ideally situated to assess and titrate sacubitril/valsartan. OBJECTIVE To evaluate the utilization, safety, and tolerability of sacubitril/valsartan in a multidisciplinary heart failure clinic, with assessment and titration by a clinical pharmacist or a nurse practitioner. METHODS A retrospective cohort study was conducted at a heart failure clinic in Abbotsford, Canada. Included were adult patients with heart failure who were currently or formerly taking sacubitril/valsartan. Data collected for the period October 2015 to February 2019 included patient characteristics, New York Heart Association (NYHA) classification, concurrent medications, sacubitril/valsartan dose, adverse effects, and discontinuation rate. RESULTS In total, 128 patients were included. Mean age was 70.1 years, 98 (77%) of the patients were men, and 79 (62%) had NYHA class 2 heart failure. The clinical pharmacist managed care for 78 (61%) of the patients, and the nurse practitioner managed care for 50 (39%). Forty-one (32%) of the patients met modified PARADIGM-HF inclusion criteria. Eighty-five (66%) of the patients achieved the target dose of sacubitril/valsartan, with similar proportions for the clinical pharmacist and nurse practitioner groups, over a mean of 2.2 clinic visits. Patients who achieved the sacubitril/valsartan target dose, relative to those who did not, were significantly younger and had higher mean systolic blood pressure at baseline. Twenty-nine percent of patients (35/119) had an improvement in NYHA classification from before initiation of sacubitril/valsartan to achievement of target or maximally tolerated dose. Eighty-five (66%) of the patients experienced an adverse effect, primarily hypotension, and 12 (9%) required a dose reduction. Only 9 (7%) patients discontinued therapy. CONCLUSIONS This study demonstrates the real-world safety and tolerability of sacubitril/valsartan in the treatment of heart failure, and reinforces that clinical pharmacists can effectively assess and titrate medications in a multidisciplinary heart failure clinic.
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Affiliation(s)
- Arden R Barry
- , BSc, BSc(Pharm), PharmD, ACPR, is a Clinical Pharmacy and Research Specialist with the Abbotsford Regional Hospital and Cancer Centre, Lower Mainland Pharmacy Services, Abbotsford, British Columbia, and Assistant Professor (Partner) with the Faculty of Pharmaceutical Sciences, The University of British Columbia, Vancouver, British Columbia
| | - Candy Lee
- , BSc(Pharm), ACPR, is Clinical Pharmacist with the Surrey Memorial Hospital, Lower Mainland Pharmacy Services, Surrey, British Columbia
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26
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Polito MV, Silverio A, Rispoli A, Vitulano G, Auria F, De Angelis E, Loria F, Gigantino A, Bonadies D, Citro R, Carrizzo A, Galasso G, Iaccarino G, Vecchione C, Ciccarelli M. Clinical and echocardiographic benefit of Sacubitril/Valsartan in a real-world population with HF with reduced ejection fraction. Sci Rep 2020; 10:6665. [PMID: 32313194 DOI: 10.1038/s41598-020-63801-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2019] [Accepted: 04/03/2020] [Indexed: 11/24/2022] Open
Abstract
The aim of this study was to evaluate the effects of Sacubitril/Valsartan (S/V) on clinical, laboratory and echocardiographic parameters and outcomes in a real-world population with heart failure with reduced ejection fraction (HFrEF). This was a prospective observational study enrolling patients with HFrEF undergoing treatment with S/V. The primary outcome was the composite of cardiac death and HF rehospitalization at 12 months follow-up; secondary outcomes were all-cause death, cardiac death and the occurrence of rehospitalization for worsening HF. The clinical outcome was compared with a retrospective cohort of 90 HFrEF patients treated with standard medical therapy. The study included 90 patients (66.1 ± 11.7 years) treated with S/V. The adjusted regression analysis showed a significantly lower risk for the primary outcome (HR:0.31; 95%CI, 0.11–0.83; p = 0.019) and for HF rehospitalization (HR:0.27; 95%CI, 0.08–0.94; p = 0.039) in S/V patients as compared to the control group. A significant improvement in NYHA class, left ventricular ejection fraction, left ventricular end systolic volume and systolic pulmonary arterial pressure was observed up to 6 months. S/V did not affect negatively renal function and was associated with a significantly lower dose of furosemide dose prescribed at 6- and 12-month follow-up. In this study, S/V reduced the risk of HF rehospitalization and cardiac death at 1 year in patients with HFrEF. S/V improved NYHA class, echocardiographic parameters and need of furosemide, and preserved renal function.
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27
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Holmlund L, Brännström M, Lindmark K, Sandberg C, Hellström Ängerud K. Health-related quality of life in patients with heart failure eligible for treatment with sacubitril-valsartan. Nurs Open 2020; 7:556-562. [PMID: 32089852 PMCID: PMC7024611 DOI: 10.1002/nop2.420] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2019] [Revised: 10/07/2019] [Accepted: 11/01/2019] [Indexed: 12/11/2022] Open
Abstract
Aim To describe and compare self‐reported health‐related quality of life between younger and older patients with severe heart failure eligible for treatment with sacubitril–valsartan and to explore the association between health‐related quality of life and age, NYHA classification, systolic blood pressure and NT‐proBNP level. Design Cross‐sectional study. Methods A total of 59 patients, eligible for treatment with sacubitril–valsartan were consecutively included and divided into a younger (≤75 years) and older group (>75 years). Health‐related quality of life was assessed using the Kansas City Cardiomyopathy Questionnaire and the EuroQol 5‐dimensions. Data were collected between June 2016 and January 2018. The STROBE checklist was used. Results There were no differences in overall health‐related quality of life between the age groups. The older patients reported lower scores in two domains measured with the Kansas City Cardiomyopathy Questionnaire, namely self‐efficacy (67.0 SD 22.1 vs. 78.8 SD 19.7) and physical limitation (75.6 SD 19.0 vs. 86.3 SD 14.4). Higher NYHA class was independently associated with lower Kansas City Cardiomyopathy Questionnaire Overall Summary Score.
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Affiliation(s)
| | | | - Krister Lindmark
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
| | - Camilla Sandberg
- Department of Public Health and Clinical Medicine Umeå University Umeå Sweden
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28
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Nordberg Backelin C, Fu M, Ljungman C. Early experience of Sacubitril-Valsartan in heart failure with reduced ejection fraction in real-world clinical setting. ESC Heart Fail 2020; 7:1049-1055. [PMID: 32030899 PMCID: PMC7261574 DOI: 10.1002/ehf2.12644] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2019] [Revised: 01/17/2020] [Accepted: 01/26/2020] [Indexed: 12/11/2022] Open
Abstract
Aims Sacubitril/Valsartan (Sac/Val) was proven more effective than enalapril for symptomatic patients with heart failure (HF) with reduced ejection fraction (HFrEF). This study aimed to investigate eligibility, titration, and tolerability for Sac/Val in a real‐world clinical setting. Methods and results This retrospective cohort study consists of two parts. In Part 1 (eligibility study), all patients discharged from Sahlgrenska University Hospital due to HF were consecutively included during 1 year. Data from the patients' medical records were collected. Patients were adjudicated to be eligible based on European Society of Cardiology (ESC) criteria for angiotensin receptor neprilysin inhibitor (ARNI) with the exception of N‐terminal (NT)‐proBNP levels. Patients who received <50% of target dose angiotensin‐converting enzyme/angiotensin receptor blocker and otherwise fulfilled ESC criteria were adjudicated to be potentially eligible. In Part 2 (tolerability study), all patients receiving Sac/Val during the same period were included. Medical data regarding dose, titration, and adverse effects and events were registered. A total of 1355 patients (mean age 78 ± 13 years) were hospitalized for HF and 619 patients had an EF ≤40%. Twenty percent were eligible for initiation of ARNI, and additionally 8% were potentially eligible. In all 95 patients (mean age 65 ± 12 years) were initiated with Sac/Val, which correlates to 13%. The patients who were initiated were younger (65 years), more often had dilated cardiomyopathy (31%), more often were on guideline‐directed medical therapy, and had a higher frequency of cardiac resynchronization therapy and implantable cardioverter–defibrillator compared with the patients who did not receive Sac/Val. Of the initiated patients, 59% reached target dose of Sac/Val, and 15% discontinued due to adverse effects. The most common cause of discontinuation was benign gastrointestinal adverse effects, followed by elevated creatinine, malaise, and vertigo. Female gender [odds ratio (OR) 3.58; 95% CI 1.07–2.00; P = 0.038] and NT‐proBNP ≥ median level (OR 0.48; 95% CI 0.26–0.90; P = 0.021) was associated with termination of the medication. Conclusions Among HFrEF patients in this real‐world cohort, 20% were eligible for ARNI; however, only 13% received the treatment. Sac/Val was well tolerated, but 41% of the patients did not reach target dose. How this affects outcome is not known and needs further investigation.
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Affiliation(s)
- Charlotte Nordberg Backelin
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
| | - Charlotta Ljungman
- Department of Molecular and Clinical Medicine/Cardiology, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Göteborg, Sweden
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29
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Norberg H, Pranic V, Bergdahl E, Lindmark K. Differences in medical treatment and clinical characteristics between men and women with heart failure – a single-centre multivariable analysis. Eur J Clin Pharmacol 2020; 76:539-46. [DOI: 10.1007/s00228-019-02782-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2019] [Accepted: 10/10/2019] [Indexed: 10/25/2022]
Abstract
Abstract
Purpose
The aims of this study were to examine sex differences in a heart failure population with regards to treatment and patient characteristics and to investigate the impact of sex on achieved doses of heart failure medications.
Methods and results
A total of 1924 patients with heart failure in a regional hospital were analysed, 622 patients had ejection fraction ≤ 40% of which 30% were women. In patients with reduced ejection fraction, women were older (79 ± 11 vs. 74 ± 12 years, P < 0.001), had lower body weight (70 ± 17 vs. 86 ± 18 kg, P < 0.001), lower estimated glomerular filtration rate (eGFR) (49 ± 24 vs. 71 ± 30 ml/min, P < 0.001) and received lower doses of heart failure medications than men. Multivariable linear regression on patients with reduced ejection fraction showed that sex was not associated with achieved dose of any heart failure medication. For angiotensin-converting enzyme inhibitors and angiotensin receptor blockers associated factors were eGFR, systolic blood pressure, age, ejection fraction, and heart rate. For beta-blockers associated factors were body weight, atrial fibrillation and age. For mineralocorticoid receptor antagonists associated factors were eGFR, serum potassium, age, systolic blood pressure, ejection fraction and heart rate.
Conclusion
Women with heart failure and reduced ejection fraction were prescribed lower doses of heart failure medications, were older, had worse renal function, and lower body weight than men. Sex was not independently associated with achieved doses of heart failure medications, instead age, renal function and body weight explained the differences in treatment.
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30
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Anker MS, Hadzibegovic S, Lena A, Haverkamp W. The difference in referencing in Web of Science, Scopus, and Google Scholar. ESC Heart Fail 2019; 6:1291-1312. [PMID: 31886636 PMCID: PMC6989289 DOI: 10.1002/ehf2.12583] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2019] [Revised: 11/15/2019] [Accepted: 11/19/2019] [Indexed: 02/06/2023] Open
Abstract
AIMS How often a medical article is cited is important for many people because it is used to calculate different variables such as the h-index and the journal impact factor. The aim of this analysis was to assess how the citation count varies between Web of Science (WoS), Scopus, and Google Scholar in the current literature. METHODS We included the top 50 cited articles of four journals ESC Heart Failure; Journal of cachexia, sarcopenia and muscle; European Journal of Preventive Cardiology; and European Journal of Heart Failure in our analysis that were published between 1 January 2016 and 10 October 2019. We recorded the number of citations of these articles according to WoS, Scopus, and Google Scholar on 10 October 2019. RESULTS The top 50 articles in ESC Heart Failure were on average cited 12 (WoS), 13 (Scopus), and 17 times (Google Scholar); in Journal of cachexia, sarcopenia and muscle 37 (WoS), 43 (Scopus), and 60 times (Google Scholar); in European Journal of Preventive Cardiology 41 (WoS), 56 (Scopus), and 67 times (Google Scholar); and in European Journal of Heart Failure 76 (WoS), 108 (Scopus), and 230 times (Google Scholar). On average, the top 50 articles in all four journals were cited 41 (WoS), 52 (Scopus, 26% higher citations count than WoS, range 8-42% in the different journals), and 93 times (Google Scholar, 116% higher citation count than WoS, range 42-203%). CONCLUSION Scopus and Google Scholar on average have a higher citation count than WoS, whereas the difference is much larger between Google Scholar and WoS.
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Affiliation(s)
- Markus S Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Charité Campus Virchow Klinikum (CVK), Berlin, Germany.,Department of Cardiology, Charité Campus Benjamin Franklin (CBF), Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Sara Hadzibegovic
- Division of Cardiology and Metabolism, Department of Cardiology, Charité Campus Virchow Klinikum (CVK), Berlin, Germany.,Department of Cardiology, Charité Campus Benjamin Franklin (CBF), Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Alessia Lena
- Division of Cardiology and Metabolism, Department of Cardiology, Charité Campus Virchow Klinikum (CVK), Berlin, Germany.,Department of Cardiology, Charité Campus Benjamin Franklin (CBF), Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
| | - Wilhelm Haverkamp
- Division of Cardiology and Metabolism, Department of Cardiology, Charité Campus Virchow Klinikum (CVK), Berlin, Germany.,Berlin Institute of Health Center for Regenerative Therapies (BCRT), Berlin, Germany.,DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
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Anker MS, von Haehling S, Papp Z, Anker SD. ESC Heart Failure receives its first impact factor. Eur J Heart Fail 2019; 21:1490-e8. [PMID: 31883221 DOI: 10.1002/ejhf.1665] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Markus S Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Charité and Berlin Institute of Health Center for Regenerative Therapies (BCRT) and DZHK (German Centre for Cardiovascular Research), partner site Berlin and Department of Cardiology, Charité Campus Benjamin Franklin, Berlin, Germany
| | - Stephan von Haehling
- Department of Cardiology and Pneumology, Heart Center Göttingen, University of Göttingen Medical Center, George August University, Göttingen, Germany and German Center for Cardiovascular Medicine (DZHK), partner site Göttingen, Göttingen, Germany
| | - Zoltán Papp
- Division of Clinical Physiology, Department of Cardiology, Faculty of Medicine, University of Debrecen, Debrecen, Hungary
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Berlin, Germany; Berlin-Brandenburg Center for Regenerative Therapies (BCRT), Berlin, Germany, DZHK (German Centre for Cardiovascular Research), partner site Berlin, Berlin, Germany
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Chen X, Schaufelberger M, Fu M. The eligible population of the PARADIGM-HF trial in a real-world outpatient clinic and its cardiovascular risk between 2005 and 2016. J Cardiovasc Med (Hagerstown) 2019; 21:6-12. [PMID: 31789711 DOI: 10.2459/jcm.0000000000000889] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND The PARADIGM-HF trial showed that sacubitril-valsartan - an angiotensin receptor-neprilysin inhibitor (ARNI) - is more effective than enalapril for some patients with heart failure. However, the eligibility of the PARADIGM-HF study to a real-world heart failure population was not well established. METHODS We made secondary analysis of patients (n = 4872) with heart failure prospectively enrolled in the Swedish Heart Failure Registry from Sahlgrenska University Hospital/Östra Hospital, Sweden during 2005-2016. The eligibility of the PARADIGM-HF trial in the real world was studied based on patients whether they were either fully or partially compatible with the PARADIGM-HF population. Patients were judged to be fully eligible for the PARADIGM-HF trial if they completely met the inclusion and exclusion criteria, and partially eligible if they did not stay on target dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), despite their having been treated with ACEI/ARB for at least 6 months. RESULTS Among patients who had heart failure with reduced left ventricular ejection fraction (≤40%) (HFrEF) (n = 2165), 653 (30%) and 958 (44%) patients were fully and partially compatible with PARADIGM-HF criteria, respectively. In both fully and partially eligible groups, patients were more male. Despite those fully eligible patients being younger (77.6 ± 12.7 vs. 84.0 ± 13.7 years) than noneligible patients, they were much older than in the PARADIGM-HF trial. Moreover, those fully eligible patients had lower all-cause mortality compared with both partially and noneligible patients. However, both fully and partially eligible patients had higher all-cause mortality than that in the PARADIGM-HF trial. CONCLUSION In a real-world outpatient clinical setting, around 1/3-1/2 of HFrEF were eligible for treatment of Sac/Val except that they are older, sicker, and carry higher risk for all-cause mortality than the PARADIGM-HF trial population.
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Affiliation(s)
- Xiaojing Chen
- Department of Cardiology, West China Hospital, Sichuan University, Chengdu, Sichuan, China.,Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Maria Schaufelberger
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Michael Fu
- Department of Molecular and Clinical Medicine, Institute of Medicine, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
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López-Azor JC, Vicent L, Valero-Masa MJ, Esteban-Fernández A, Gómez-Bueno M, Pérez Á, Díez-Villanueva P, De-Juan J, Manuel-Iniesta Á, Bover R, Del Prado S, Martínez-Sellés M. Safety of sacubitril/valsartan initiated during hospitalization: data from a non-selected cohort. ESC Heart Fail 2019; 6:1161-1166. [PMID: 31701680 PMCID: PMC6989298 DOI: 10.1002/ehf2.12527] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 07/25/2019] [Accepted: 09/06/2019] [Indexed: 12/11/2022] Open
Abstract
Aims Sacubitril/valsartan is safe when initiated during hospitalization in a clinical trial setting. Its safety in real‐life population is not stablished. We compared the initiation of sacubitril/valsartan during hospitalization in a non‐selected population, in the PIONEER‐HF trial, and in non‐selected outpatients. Methods and results Multicentre registry included 527 patients: 100 were started on sacubitril/valsartan during hospitalization (19.0%) and 427 as outpatients (81.0%). Compared with those in the pivotal trial, inpatients in our cohort were older (71 ± 12 vs. 61 ± 14 years; P < 0.001); had more frequently Functional Class II (41 [41.0%] vs. 100 [22.7%]; P < 0.001), higher levels of N‐terminal pro‐B type natriuretic peptide (4044 [1630–8680] vs. 2013 [1002–4132] pg/mL; P < 0.001), better glomerular filtration rate (63.5 [51.0–80.0] vs. 58.4 [47.5–71.5] mL/min; P = 0.01), and higher systolic blood pressure (121 [110–136] vs. 118 [110–133] mmHg; P = 0.03); and received angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers more frequently (92 [92.0%] vs. 208 [52.7%]; P < 0.001). Compared with non‐selected outpatients, inpatients were older (71 ± 12 vs. 68 ± 12 years, P = 0.02), had more frequent Functional Class III–IV (58 [58.0%] vs. 129 [30.3%], P < 0.001), had higher levels of N‐terminal pro‐B type natriuretic peptide (4044 [1630–8680] vs. 2182 [1134–4172]; P < 0.001), and were receiving angiotensin‐converting enzyme inhibitors/angiotensin receptor blockers target dose less frequently (55 [55.0%] vs. 335 [78.5%]; P < 0.001). They also started sacubitril/valsartan with a low dose (50 mg/12 h) more frequently (80 [80.0%] vs. 209 [48.8%], P < 0.001). The initiation of sacubitril/valsartan in outpatients was an independent predictor of high‐dose use (OR 3.1; 95% confidence interval 1.7–5.6, P < 0.001). The follow‐up time in both cohorts, including all patients enrolled, was similar (7.0 ± 0.1 vs. 7.2 ± 2.6 months, P = 0.72). All‐cause admissions during follow‐up were more frequent in inpatients (30 [30.0%] vs. 68 outpatients [15.9%], P = 0.001), with no relevant differences in all‐cause mortality. There was no significant difference in sacubitril/valsartan withdrawal rate (17 inpatients [17.0%] vs. 49 outpatients [11.5%], P = 0.13). The incidence of adverse effects was also similar: hypotension (16 inpatients [16.0%] vs. 71 outpatients [16.7%], P = 0.88), worsening renal function (7 inpatients [7.0%] vs. 29 outpatients [6.8%], P = 0.94), and hyperkalaemia (1 inpatient [1.0%] vs. 21 outpatients [4.9%], P = 0.09). We did not register any case of angioedema. Conclusions It is safe to initiate sacubitril/valsartan during hospitalization in daily clinical practice. Inpatients have a higher risk profile and receive low starting doses more frequently than outpatients.
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Affiliation(s)
- Juan Carlos López-Azor
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - Lourdes Vicent
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | - María Jesús Valero-Masa
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain
| | | | - Manuel Gómez-Bueno
- Servicio de Cardiología, Hospital Universitario Puerta de Hierro, CIBERCV, Madrid, Spain
| | - Ángel Pérez
- Servicio de Cardiología, Hospital de Burgos, Burgos, Spain
| | | | - Javier De-Juan
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | | | - Ramón Bover
- Servicio de Cardiología, Hospital Universitario Clínico de San Carlos. Instituto de Investigación Sanitaria del Hospital Clínico San Carlos (IdISSC), Madrid, Spain
| | - Susana Del Prado
- Servicio de Cardiología, Hospital Universitario 12 de Octubre, Madrid, Spain
| | - Manuel Martínez-Sellés
- Servicio de Cardiología, Hospital Universitario Gregorio Marañón, CIBERCV, Calle Doctor Esquerdo, 46, 28007, Madrid, Spain.,Servicio de Cardiología, Universidad Complutense, Universidad Europea, Madrid, Spain
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Spannella F, Marini M, Giulietti F, Rosettani G, Francioni M, Perna GP, Sarzani R. Renal effects of Sacubitril/Valsartan in heart failure with reduced ejection fraction: a real life 1-year follow-up study. Intern Emerg Med 2019; 14:1287-1297. [PMID: 31147823 PMCID: PMC6853858 DOI: 10.1007/s11739-019-02111-6] [Citation(s) in RCA: 34] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 05/16/2019] [Indexed: 12/11/2022]
Abstract
Real-life data confirming the favourable renal outcome in patients with heart failure (HF) treated with Sacubitril/Valsartan, previously found in several trials (RCTs), are still scant. We evaluated the renal effects of Sacubitril/Valsartan in a real-life sample of HF patients. Observational analysis of 54 consecutive outpatients affected by HF with reduced ejection fraction (HFrEF) and clinical indication for Sacubitril/Valsartan. Patients were evaluated at baseline (T0) and after six (T6) and twelve (T12) months after initiating Sacubitril/Valsartan and compared with a group of 30 historical controls. Mean age: 65.5 ± 11.7 years. Older patients: 29 (53.7%). Mean baseline estimated glomerular filtration rate (eGFR): 59.4 ± 19.2 ml/min/1.73 m2. Patients with chronic kidney disease (CKD), defined by an eGFR < 60 ml/min/1.73 m2, were 29 (53.7%). Sacubitril/Valsartan was less titrated in both older patients and patients with CKD. There were no changes in diuretics during follow-up. Systolic blood pressure (BP) decreased during follow-up (p = 0.014), while left ventricular ejection fraction (LVEF) slighly increased (p < 0.001). Renal function improved after 12 months compared to historical controls (p for interaction < 0.001) and a greater benefit was found in subjects aged < 65 years (p for interaction = 0.002) and patients with CKD (p for interaction = 0.009). A statistically (p = 0.009), but not clinically significant increase in serum potassium was also found, regardless of age and CKD. This is the first study focused on the renal effects of Sacubitril/Valsartan in HFrEF patients followed for 12 months in a real-life clinical context. The improved eGFR, despite lower BP, represents an important confirmation outside the peculiar world of RCTs.
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Affiliation(s)
- Francesco Spannella
- Internal Medicine and Geriatrics, IRCCS-INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Marco Marini
- Department of Cardiovascular Sciences, Ospedali Riuniti, Ancona, Italy
| | - Federico Giulietti
- Internal Medicine and Geriatrics, IRCCS-INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Giulia Rosettani
- Internal Medicine and Geriatrics, IRCCS-INRCA, Ancona, Italy
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy
| | - Matteo Francioni
- Department of Cardiovascular Sciences, Ospedali Riuniti, Ancona, Italy
| | - Gian Piero Perna
- Department of Cardiovascular Sciences, Ospedali Riuniti, Ancona, Italy
| | - Riccardo Sarzani
- Internal Medicine and Geriatrics, IRCCS-INRCA, Ancona, Italy.
- Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Ancona, Italy.
- Internal Medicine and Geriatrics, Department of Clinical and Molecular Sciences, University "Politecnica Delle Marche", Italian National Research Centre on Aging, Hospital "U. Sestilli", IRCCS-INRCA, Via Della Montagnola n. 81, 60127, Ancona, Italy.
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Spoto S, Valeriani E, Locorriere L, Anguissola GB, Pantano AL, Terracciani F, Bono MC, Costantino S, Ciccozzi M, Angeletti S. Use of sacubitril/valsartan in Marfan syndrome-related cardiomyopathy: The first case report. Medicine (Baltimore) 2019; 98:e17978. [PMID: 31764806 PMCID: PMC6882602 DOI: 10.1097/md.0000000000017978] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
RATIONALE Marfan syndrome is a rare cause of heart failure due to primary or secondary cardiomyopathy. Recently, sacubitril/valsartan-an angiotensin receptor blocker-neprilysin inhibitor-has been added in clinical practice as a standard therapy for heart failure. To our knowledge, there are no data on sacubitril/valsartan's effects on cardiovascular outcomes in patients with Marfan syndrome. PATIENT CONCERNS A 24-year-old man was admitted to our Internal Medicine Department due to dyspnea, ascites, and leg swelling. Arterial blood gas analysis revealed severe hypoxemia with respiratory and metabolic alkalosis. Hilar congestion was highlighted on chest x-ray. DIAGNOSES Recurrent acute decompensated heart failure with reduced ejection fraction despite optimal medical therapy in Marfan-related cardiomyopathy. INTERVENTIONS AND OUTCOMES Sacubitril/valsartan was added to optimal medical therapy after hemodynamic stabilization allowing progressive clinical, laboratoristic, and echocardiographic improvement. Patient maintained a free survival from heart failure and a good quality of life until 9-month follow-up. LESSONS Sacubitril/valsartan should be effective on pathophysiologic mechanisms and cardiovascular outcomes of Marfan syndrome-related cardiovascular complications.
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Affiliation(s)
- Silvia Spoto
- Internal Medicine Department, University Campus Bio-Medico of Rome, Rome
| | | | - Luciana Locorriere
- Internal Medicine Department, University Campus Bio-Medico of Rome, Rome
| | | | | | | | | | | | | | - Silvia Angeletti
- Unit of Clinical Laboratory Science, University Campus Bio-Medico of Rome, Rome, Italy
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Han J, Chung F, Nguyen QL, Mody FV, Jackevicius CA. Evaluation of Patients with Heart Failure to Determine Eligibility for Treatment with Sacubitril/Valsartan: Insights from a Veterans Administration Healthcare System. Pharmacotherapy 2019; 39:1053-1059. [DOI: 10.1002/phar.2328] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Jamie Han
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Francisco Chung
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Quyen L. Nguyen
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
| | - Freny Vaghaiwalla Mody
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
- Division of Cardiology University of California, Los Angeles Los Angeles California
- David Geffen School of Medicine University of California, Los Angeles Los Angeles California
| | - Cynthia A. Jackevicius
- Veterans Affairs Greater Los Angeles Healthcare System Los Angeles California
- Department of Pharmacy Practice and Administration Western University of Health Sciences Pomona California
- Institute for Clinical Evaluative Sciences University of Toronto Toronto Ontario Canada
- Institute of Health Policy, Management and Evaluation University of Toronto Toronto Ontario Canada
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Norberg H, Bergdahl E, Lindmark K. Safety and Tolerability of Initiating Maximum-Dose Sacubitril-Valsartan in Patients on Target Dose Renin-Angiotensin System Inhibitors. Cardiovasc Ther 2019; 2019:6745074. [PMID: 31772613 PMCID: PMC6739794 DOI: 10.1155/2019/6745074] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2019] [Revised: 07/03/2019] [Accepted: 07/09/2019] [Indexed: 12/11/2022] Open
Abstract
AIM Sacubitril-valsartan has proven beneficial in heart failure with reduced ejection fraction. Guidelines recommend initiating half-dose sacubitril-valsartan before up-titration even to patients already on target dose angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). To reduce the number of titration steps needed in order to simplify for the patient as well as the clinic, we aimed to investigate the safety and tolerability of switching patients on target dose ACE inhibitors or ARBs directly to maximum-dose sacubitril-valsartan. METHODS This prospective cohort study was conducted between April 2016 and November 2017. A total of 66 patients with heart failure and reduced ejection fraction already on guideline-recommended target dose ACE inhibitors or ARBs (equivalent to enalapril 10 mg twice daily) were switched to maximum-dose sacubitril-valsartan (200 mg twice daily). The patients were followed for twelve months. RESULTS Patients had a mean age of 72 ± 10 years, mean systolic blood pressure of 121 ± 17 mmHg, and 92% were male. At 12-month follow-up, nine patients (14%) had discontinued sacubitril-valsartan, four patients (6%) had a dose reduction, and 17 patients (26%) had developed symptomatic hypotension. No angioedema occurred within the 12-month follow-up and there were no hospitalizations or emergency room visits within the first 14 days. CONCLUSIONS Switching directly from target dose ACE inhibitors or ARBs to maximum-dose sacubitril-valsartan was safe and generally well tolerated.
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Affiliation(s)
- Helena Norberg
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
- Department of Pharmacology and Clinical Neuroscience, Umeå University, 901 87 Umeå, Sweden
| | - Ellinor Bergdahl
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
| | - Krister Lindmark
- Department of Public Health and Clinical Medicine, Umeå University, 901 87 Umeå, Sweden
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Morillas-Climent H, Seller-Moya J, Vicedo-López Á, Galcerá-Jornet E, Alania-Torres E, Rodríguez-Pichardo Y, Larumbe-Rodríguez A, Valle-Muñoz A. Evolution of functional class, biochemical and echocardiographic parameters and clinical outcomes after sacubitril/valsartan initiation in daily practice. J Comp Eff Res 2019; 8:685-697. [DOI: 10.2217/cer-2019-0014] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Aim: To analyze the impact of sacubitril/valsartan on functional class, surrogate parameters and clinical outcomes in clinical practice. Methods: Retrospective study of patients with heart failure and reduced ejection fraction that started treatment with sacubitril/valsartan. Results: 149 patients (70.7 ± 9.6 years) were included. At baseline, 83.9, 15.4 and 0.7% were taking sacubitril/valsartan 24/26, 49/51 and 97/103 mg, respectively. After 316.1 ± 155.9 days, these numbers moved to 38.9, 39.6, 12.8% (8.7% discontinued). Sacubitril/valsartan improved functional class (from 2.3 ± 0.6 to 1.8 ± 0.5; p < 0.001), increased ejection fraction (from 31.2 ± 7.0 to 37.3 ± 10.5%; p < 0.001) and reduced NT-proBNP (from 3884 ± 4871 to 1975.3 ± 3006.6 pg/ml; p = 0.0001). Rates of any event, cardiovascular death and heart failure hospitalization/decompensation were 13.2 events/100 patient-years. Conclusion: Sacubitril/valsartan is effective and safe in routine practice.
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Rodrigues G, Tralhão A, Aguiar C, Freitas P, Ventosa A, Mendes M. Response to the Letter to the Editor – “The PARADIGM-HF population may be very different from real-world heart failure patients”. Rev Port Cardiol 2019; 38:165. [DOI: 10.1016/j.repc.2019.02.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Rodrigues G, Tralhão A, Aguiar C, Freitas P, Ventosa A, Mendes M. Response to the Letter to the Editor – “The PARADIGM-HF population may be very different from real-world heart failure patients”. Revista Portuguesa de Cardiologia (English Edition) 2019. [DOI: 10.1016/j.repce.2019.03.006] [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: 10/27/2022] Open
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Oh J, Lee CJ, Park JJ, Lee SE, Kim M, Cho H, Choi J, Lee H, Hwang K, Kim KH, Yoo B, Choi D, Baek SH, Jeon E, Kim J, Cho M, Chae SC, Oh B, Kang S. Real-World Eligibility for Sacubitril/Valsartan in Heart Failure with Reduced Ejection Fraction Patients in Korea: Data from the Korean Acute Heart Failure (KorAHF) Registry. Int J Heart Fail 2019; 1:57. [PMID: 36262737 PMCID: PMC9536672 DOI: 10.36628/ijhf.2019.0007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Revised: 10/06/2019] [Accepted: 10/07/2019] [Indexed: 12/11/2022]
Abstract
Background and Objectives Sacubitril/valsartan (SV, LCZ696), the first in class drug, called as angiotensin receptor-neprilysin inhibitor (ARNI) can reduce heart failure (HF) hospitalization and cardiovascular mortality. However, SV prescription rate remains still low despite current HF guideline recommendations. Considering the complex inclusion criteria of Prospective Comparison of ARNI with ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) trial, the real-world eligibility for SV remains uncertain in Asian heart failure with reduced ejection fraction (HFrEF) patients. Therefore, we aimed to assess real-world HF population eligibility for SV in a large Korean acute HF registry. Methods From March 2011 to February 2014, a total of 5,625 patients who were admitted for HF were enrolled in Korea. After excluding HF patients with left ventricular ejection fraction > 40% and in-hospital death, 2,941 patients were analyzed. Criteria for SV based on Korean Food and Drug Administration (KFDA) label and PARADIGM-HF were applied. Results Of 2,941 patients, KFDA label criteria excludes the absence of symptoms (New York Heart Association class I, 20%); PARADIGM-HF criteria excludes chronic kidney disease stage IV (9%), hyperkalemia (1%), hypotension (6%), and sub-optimal pharmacotherapy (52%, e.g. lower dose use of angiotensin converting enzyme inhibitor/angiotensin receptor blocker [ACEI/ARB], beta blocker use). When a daily requirement of ACEI/ARB ≥5 mg enalapril (instead of ≥10 mg) was used, the percent of eligibility for SV rose from 12% to 30% based on the PARADIGM-HF criteria. Conclusions Among the Korean hospitalized HFrEF patients, 80% met KFDA label criteria, while only 12% met the inclusion criteria of PARADIGM-HF trial for SV if requiring ≥10 mg enalapril. Sub-optimal pharmacotherapy could be the main reason for ineligible SV use based on the PARADIGM-HF criteria.
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Affiliation(s)
- Gabriela Andries
- Cardiology Division, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Srikanth Yandrapalli
- Cardiology Division, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
| | - Wilbert S. Aronow
- Cardiology Division, Department of Medicine, Westchester Medical Center and New York Medical College, Valhalla, NY, USA
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Jonsson A, Norberg H, Bergdahl E, Lindmark K. Obstacles to mineralocorticoid receptor antagonists in a community-based heart failure population. Cardiovasc Ther 2018; 36:e12459. [PMID: 30019390 PMCID: PMC6175311 DOI: 10.1111/1755-5922.12459] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 06/20/2018] [Accepted: 07/13/2018] [Indexed: 12/11/2022] Open
Abstract
AIM Previous studies and national assessments indicate an undertreatment of mineralocorticoid receptor antagonists (MRA) in heart failure with reduced ejection fraction (HFrEF). This study aimed to investigate why MRA is not used to full extent. METHODS A complete community-based heart failure population was studied. Several variables were collected, and medical records were scrutinized to identify reasons for not prescribing MRA. RESULTS Of 2029 patients, 812 had EF ≤40%. Five hundred and fifty-three patients (68%) tried MRA at some point but 184 of these (33%) discontinued therapy. There were 259 patients that never tried MRA with 177 with a listed explanation or contraindication. Eighty-two patients, 10% of the total HFrEF population, had no clear contraindications. They were older and had less HF hospitalizations compared to patients on MRA (P < 0.05) and 32% did not have any follow-up at the cardiology clinic. Contraindications to MRA were renal dysfunction (93 patients), hypotension (28 patients), and hyperkalemia (25 patients). Only six patients had hyperkalemia without renal dysfunction. Of the patients with renal dysfunction, 66 (72%) had eGFR >30 mL/min. CONCLUSIONS The reasons why MRA are underutilized were mainly because of contraindications. However, the data suggest that physicians are overly cautious about moderately reduced kidney function. There seems to be a 10%-18% avoidable undertreatment with MRA, especially for elderly patients that are admitted to the hospital for other reasons than heart failure. This suggests that patients with heart failure would benefit from routine follow-up at a cardiology clinic.
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Affiliation(s)
- Anna Jonsson
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Helena Norberg
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.,Department of Pharmacology and Clinical Neuroscience, Umeå University, Umeå, Sweden
| | - Ellinor Bergdahl
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
| | - Krister Lindmark
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden
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Martens P, Beliën H, Dupont M, Vandervoort P, Mullens W. The reverse remodeling response to sacubitril/valsartan therapy in heart failure with reduced ejection fraction. Cardiovasc Ther 2018; 36:e12435. [PMID: 29771478 DOI: 10.1111/1755-5922.12435] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [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: 04/12/2018] [Revised: 05/04/2018] [Accepted: 05/09/2018] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Major classes of medical therapy for heart failure with reduced ejection fraction (HFrEF) induce reverse remodeling. The revere remodeling response to sacubitril/valsartan remains unstudied. METHODS We performed a single-center, prospective assessor-blinded study to determine the reverse remodeling response of sacubitril/valsartan therapy in HFrEF patients with a class I indication (New York heart Association [NYHA]-class II-IV, Left ventricular ejection fraction [LVEF] < 35%, optimal dose with Renin-Angiotensin-System-Blocker [RAS-blocker]). Doses of sacubitril/valsartan were optimized to individual tolerance. Echocardiographic images were assessed offline by 2 investigators blinded to both the clinical data and timing of echocardiograms. RESULTS One-hundred-twenty-five HFrEF patients (66 ± 10 years) were prospectively included. The amount of RAS-blocker before and after switch to sacubitril/valsartan was similar(P = .290), indicating individual optimal dosing of sacubitril/valsartan. Over a median(IQR) follow-up of 118(77-160) days after initiation of sacubitril/valsartan, LVEF improved (29.6 ± 6% vs 34.8 ± 6%; P < .001) and Left ventricular end-systolic (LVESV) and end-diastolic volume (LVEDV) decreased (LVESV; 147 ± 57 mL vs 129 ± 55 mL; P < .001 and LVEDV; 206 ± 71 mL vs197 ± 72 mL; P = .027). Volumetric remodeling was associated with a reduction in the degree of mitral regurgitation (1.59 ± 1.0 vs 1.11 ± 0.8; P < .001; [scale from 0-4]). Metrics of diastolic function improved; including a drop in the E/A-wave ratio (1.75 ± 1.13 vs 1.38 ± 0.88; P = .002) and diastolic filling time (% of cycle length) prolonged (48 ± 9% vs 52 ± 1%; P = .005). The percent of patients with a restrictive mitral filling pattern dropped from 47% to 23% (P = .004). A dose-dependent effect was noted for changes in LVEF (P < .001) and LVESV (P = .031), with higher doses of sacubitril/valsartan leading to more reverse remodeling. CONCLUSION Switching therapy in eligible HFrEF patients from a RAS-blocker to sacubitril/valsartan induces beneficial reverse remodeling of both metrics of systolic as diastolic function.
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Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Doctoral School for Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Hanne Beliën
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Matthias Dupont
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Pieter Vandervoort
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg, Genk, Belgium.,Biomedical Research Institute, Faculty of Medicine and Life Sciences, Hasselt University, Diepenbeek, Belgium
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Norberg H, Bergdahl E, Lindmark K. Eligibility of sacubitril-valsartan in a real-world heart failure population: a community-based single-centre study. ESC Heart Fail 2018; 5:337-343. [PMID: 29345425 PMCID: PMC5880656 DOI: 10.1002/ehf2.12251] [Citation(s) in RCA: 43] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2017] [Revised: 11/23/2017] [Accepted: 11/23/2017] [Indexed: 12/11/2022] Open
Abstract
AIMS This study aims to investigate the eligibility of the Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor (ARNI) with ACE inhibitor to Determine Impact on Global Mortality and Morbidity in Heart Failure (PARADIGM-HF) study to a real-world heart failure population. METHODS AND RESULTS Medical records of all heart failure patients living within the catchment area of Umeå University Hospital were reviewed. This district consists of around 150 000 people. Out of 2029 patients with a diagnosis of heart failure, 1924 (95%) had at least one echocardiography performed, and 401 patients had an ejection fraction of ≤35% at their latest examination. The major PARADIGM-HF criteria were applied, and 95 patients fulfilled all enrolment criteria and thus were eligible for sacubitril-valsartan. This corresponds to 5% of the overall heart failure population and 24% of the population with ejection fraction ≤ 35%. The eligible patients were significantly older (73.2 ± 10.3 vs. 63.8 ± 11.5 years), had higher blood pressure (128 ± 17 vs. 122 ± 15 mmHg), had higher heart rate (77 ± 17 vs. 72 ± 12 b.p.m.), and had more atrial fibrillation (51.6% vs. 36.2%) than did the PARADIGM-HF population. CONCLUSIONS Only 24% of our real-world heart failure and reduced ejection fraction population was eligible for sacubitril-valsartan, and the real-world heart failure and reduced ejection fraction patients were significantly older than the PARADIGM-HF population. The lack of data on a majority of the patients that we see in clinical practice is a real problem, and we are limited to extrapolation of results on a slightly different population. This is difficult to address, but perhaps registry-based randomized clinical trials will help to solve this issue.
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Affiliation(s)
- Helena Norberg
- Department of Pharmacology and Clinical NeuroscienceUmeå UniversityS‐901 87UmeåSweden
- Department of Public Health and Clinical MedicineUmeå UniversityS‐901 87UmeåSweden
| | - Ellinor Bergdahl
- Department of Public Health and Clinical MedicineUmeå UniversityS‐901 87UmeåSweden
| | - Krister Lindmark
- Department of Public Health and Clinical MedicineUmeå UniversityS‐901 87UmeåSweden
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