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Savarese G, Lindberg F, Cannata A, Chioncel O, Stolfo D, Musella F, Tomasoni D, Abdelhamid M, Banerjee D, Bayes-Genis A, Berthelot E, Braunschweig F, Coats AJS, Girerd N, Jankowska EA, Hill L, Lainscak M, Lopatin Y, Lund LH, Maggioni AP, Moura B, Rakisheva A, Ray R, Seferovic PM, Skouri H, Vitale C, Volterrani M, Metra M, Rosano GMC. How to tackle therapeutic inertia in heart failure with reduced ejection fraction. A scientific statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024. [PMID: 38778738 DOI: 10.1002/ejhf.3295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
Guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF) reduces morbidity and mortality, but its implementation is often poor in daily clinical practice. Barriers to implementation include clinical and organizational factors that might contribute to clinical inertia, i.e. avoidance/delay of recommended treatment initiation/optimization. The spectrum of strategies that might be applied to foster GDMT implementation is wide, and involves the organizational set-up of heart failure care pathways, tailored drug initiation/optimization strategies increasing the chance of successful implementation, digital tools/telehealth interventions, educational activities and strategies targeting patient/physician awareness, and use of quality registries. This scientific statement by the Heart Failure Association of the ESC provides an overview of the current state of GDMT implementation in HFrEF, clinical and organizational barriers to implementation, and aims at suggesting a comprehensive framework on how to overcome clinical inertia and ultimately improve implementation of GDMT in HFrEF based on up-to-date evidence.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Antonio Cannata
- School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', and University of Medicine Carol Davila, Bucharest, Romania
| | - Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | - Daniela Tomasoni
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Magdy Abdelhamid
- Faculty of Medicine, Kasr Al Ainy, Department of Cardiology, Cairo University, Cairo, Egypt
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, Cardiovascular and Genetics Research Institute, St George's University, London, UK
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias I Pujol, CIBERCV, Badalona, Spain
| | | | - Frieder Braunschweig
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | | | - Nicolas Girerd
- Centre d'Investigation Clinique Plurithémathique Pierre Drouin & Département de Cardiologie Institut Lorrain du Cœur et des Vaisseaux, Université de Lorraine, CHRU-Nancy, Vandœuvre-lès-Nancy, France
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University and Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Mitja Lainscak
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yury Lopatin
- Volgograd State Medical University, Regional Cardiology Centre, Volgograd, Russia
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Amina Rakisheva
- City Cardiology Center, Konaev City Hospital, Almaty Region, Kazakhstan
| | - Robin Ray
- Department of Cardiology, St George's University Hospital, London, UK
| | - Petar M Seferovic
- University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Hadi Skouri
- Cardiology Division, Internal Medicine Department, Balamand University School of Medicine, Beirut, Lebanon
| | - Cristiana Vitale
- Department of Cardiology, St George's University Hospital, London, UK
| | - Maurizio Volterrani
- Department of Human Sciences and Promotion of Quality of Life, San Raffaele Open University of Rome, Rome, Italy
| | - Marco Metra
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe M C Rosano
- Department of Cardiology, St George's University Hospital, London, UK
- Cardiology, San Raffaele Hospital, Cassino, Italy
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Asano T, Maeno Y, Nakano M, Taguri M, Miyasaka M, Nakai D, Miyazaki I, Nasu T, Tanimoto S, Masuda N, Morino Y, Isshiki T, Ogata N. Validation of a New Scoring Method to Assess the Efficacy of Rapid Initiation and Titration of Combination Pharmacotherapy for Patients Hospitalized with Acute Decompensated Heart Failure with Reduced and Mildly Reduced Ejection Fraction. J Clin Med 2024; 13:2775. [PMID: 38792317 PMCID: PMC11122539 DOI: 10.3390/jcm13102775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2024] [Revised: 04/28/2024] [Accepted: 05/03/2024] [Indexed: 05/26/2024] Open
Abstract
Background: Despite the encouragement of early initiation and titration of guideline-directed medical therapy (GDMT) for the treatment of heart failure (HF), most patients do not receive an adequate type and dose of pharmacotherapy in the real world. Objectives: This study aimed to determine the efficacy of titrating composite GDMT in patients with HF with reduced and mildly reduced ejection fraction and to identify patient conditions that may benefit from titration of GDMT. Methods: This was a two-center, retrospective study of consecutive patients hospitalized with acute decompensated heart failure (ADHF). Patients were classified into two groups according to a scoring scale determined by combination and doses of four types of HF agents (ACEis/ARBs/ARNis, BBs, MRAs, and SGLT2is) at discharge. A score of 5 or greater was defined as titrated GDMT, and a score of 4 or less was regarded as sub-optimal medical therapy (MT). Results: A total of 979 ADHF patients were screened. After 553 patients were excluded based on exclusion criteria, 426 patients (90 patients in the titrated GDMT group and 336 patients in the sub-optimal MT group) were enrolled for the analysis. The median follow-up period was 612 (453-798) days. Following statistical adjustment using the propensity score weighting method, the 2-year composite endpoint (composite of cardiac death and HF rehospitalization) rate was significantly lower in the titrated GDMT group, at 19%, compared with the sub-optimal MT group: 31% (score 3-4 points) and 43% (score 0-2 points). Subgroup analysis indicated a marked benefit of titrated GDMT in particular patient subgroups: age < 80 years, BMI 19.0-24.9, eGFR > 20 mL/min/1.73 m2, and serum potassium level ≤ 5.5 mmol/L. Conclusions: Prompt initiation and dose adjustment of multiple HF medications, with careful monitoring of the patient's physiologic and laboratory values, is a prerequisite for improving the prognosis of patients with heart failure.
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Affiliation(s)
- Takaaki Asano
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun 028-3694, Japan; (T.A.)
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Yoshio Maeno
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Masataka Nakano
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Masataka Taguri
- Department of Health Data Science, Tokyo Medical University, Shinjuku-ku, Tokyo 160-0023, Japan
| | - Masaki Miyasaka
- Department of Cardiology, Jikei University, Minato-ku, Tokyo 105-0003, Japan
| | - Daisuke Nakai
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Itaru Miyazaki
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Takahito Nasu
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun 028-3694, Japan; (T.A.)
| | - Shuzou Tanimoto
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Naoki Masuda
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Yoshihiro Morino
- Division of Cardiology, Department of Internal Medicine, Iwate Medical University, Yahaba-cho, Shiwa-gun 028-3694, Japan; (T.A.)
| | - Takaaki Isshiki
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
| | - Nobuhiko Ogata
- Department of Cardiology, Ageo Central General Hospital, Kashiwaza, Ageo-shi 362-8588, Japan
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Khan MS, Chan PS, Sherrod CF, Ikemura N, Sauer AJ, Jones PG, Fonarow GC, Butler J, DeVore AD, Lund LH, Spertus JA. Generalizable Approach to Quantifying Guideline-Directed Medical Therapy. Circ Heart Fail 2024; 17:e011164. [PMID: 38742418 PMCID: PMC11108743 DOI: 10.1161/circheartfailure.123.011164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2023] [Accepted: 01/30/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND Quantifying guideline-directed medical therapy (GDMT) intensity is foundational for improving heart failure (HF) care. Existing measures discount dose intensity or use inconsistent weighting. METHODS The Kansas City Medical Optimization (KCMO) score is the average of total daily to target dose percentages for eligible GDMT, reflecting the percentage of optimal GDMT prescribed (range, 0-100). In Change the Management of Patients With HF, we computed KCMO, HF collaboratory (0-7), and modified HF Collaboratory (0-100) scores for each patient at baseline and for 1-year change in established GDMT at the time (mineralocorticoid receptor antagonist, β-blocker, ACE [angiotensin-converting enzyme] inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor). We compared baseline and 1-year change distributions and the coefficient of variation (SD/mean) across scores. RESULTS Among 4532 patients at baseline, mean KCMO, HF collaboratory, and modified HF Collaboratory scores were 38.8 (SD, 25.7), 3.4 (1.7), and 42.2 (22.2), respectively. The mean 1-year change (n=4061) for KCMO was -1.94 (17.8); HF collaborator, -0.11 (1.32); and modified HF Collaboratory, -1.35 (19.8). KCMO had the highest coefficient of variation (0.66), indicating greater variability around the mean than the HF collaboratory (0.49) and modified HF Collaboratory (0.53) scores, reflecting higher resolution of the variability in GDMT intensity across patients. CONCLUSIONS KCMO measures GDMT intensity by incorporating dosing and treatment eligibility, provides more granularity than existing methods, is easily interpretable (percentage of ideal GDMT), and can be adapted as performance measures evolve. Further study of its association with outcomes and its usefulness for quality assessment and improvement is needed.
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Affiliation(s)
- Mirza S. Khan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Paul S. Chan
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Charles F. Sherrod
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Nobuhiro Ikemura
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Andrew J. Sauer
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Philip G. Jones
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
| | - Gregg C. Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Adam D. DeVore
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - John A. Spertus
- Healthcare Institute for Innovations in Quality, University of Missouri-Kansas City, Kansas City, MO, USA
- Saint Luke’s Mid America Heart Institute, Kansas City, MO, USA
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Scarà A, Palamà Z, Robles AG, Dei LL, Borrelli A, Zanin F, Pignalosa L, Romano S, Sciarra L. Non-Pharmacological Treatment of Heart Failure-From Physical Activity to Electrical Therapies: A Literature Review. J Cardiovasc Dev Dis 2024; 11:122. [PMID: 38667740 PMCID: PMC11050051 DOI: 10.3390/jcdd11040122] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Revised: 04/11/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Heart failure (HF) represents a significant global health challenge that is still responsible for increasing morbidity and mortality despite advancements in pharmacological treatments. This review investigates the effectiveness of non-pharmacological interventions in the management of HF, examining lifestyle measures, physical activity, and the role of some electrical therapies such as catheter ablation, cardiac resynchronization therapy (CRT), and cardiac contractility modulation (CCM). Structured exercise training is a cornerstone in this field, demonstrating terrific improvements in functional status, quality of life, and mortality risk reduction, particularly in patients with HF with reduced ejection fraction (HFrEF). Catheter ablation for atrial fibrillation, premature ventricular beats, and ventricular tachycardia aids in improving left ventricular function by reducing arrhythmic burden. CRT remains a key intervention for selected HF patients, helping achieve left ventricular reverse remodeling and improving symptoms. Additionally, the emerging therapy of CCM provides a novel opportunity for patients who do not meet CRT criteria or are non-responders. Integrating non-pharmacological interventions such as digital health alongside specific medications is key for optimizing outcomes in HF management. It is imperative to tailor approaches to individual patients in this diverse patient population to maximize benefits. Further research is warranted to improve treatment strategies and enhance patient outcomes in HF management.
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Affiliation(s)
- Antonio Scarà
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Zefferino Palamà
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
- Electrophysiology Unit “Casa di Cura Villa Verde”, 74121 Taranto, Italy
| | - Antonio Gianluca Robles
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
- Electrophysiology Unit “Casa di Cura Villa Verde”, 74121 Taranto, Italy
- Department of Cardiology, “L. Bonomo” Hospital, 76123 Andria, Italy
| | - Lorenzo-Lupo Dei
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Alessio Borrelli
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Federico Zanin
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
| | - Leonardo Pignalosa
- San Carlo di Nancy Hospital—GVM, 00165 Roma, Italy; (A.B.); (F.Z.); (L.P.)
| | - Silvio Romano
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
| | - Luigi Sciarra
- Department of Life, Health and Environmental Sciences, University of L’Aquila, 67100 L’Aquila, Italy; (Z.P.); (A.G.R.); (L.-L.D.); (S.R.); (L.S.)
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Man JP, Klopotowska J, Asselbergs FW, Handoko ML, Chamuleau SAJ, Schuuring MJ. Digital Solutions to Optimize Guideline-Directed Medical Therapy Prescriptions in Heart Failure Patients: Current Applications and Future Directions. Curr Heart Fail Rep 2024; 21:147-161. [PMID: 38363516 PMCID: PMC10924030 DOI: 10.1007/s11897-024-00649-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2024] [Indexed: 02/17/2024]
Abstract
PURPOSEOF REVIEW Guideline-directed medical therapy (GDMT) underuse is common in heart failure (HF) patients. Digital solutions have the potential to support medical professionals to optimize GDMT prescriptions in a growing HF population. We aimed to review current literature on the effectiveness of digital solutions on optimization of GDMT prescriptions in patients with HF. RECENT FINDINGS We report on the efficacy, characteristics of the study, and population of published digital solutions for GDMT optimization. The following digital solutions are discussed: teleconsultation, telemonitoring, cardiac implantable electronic devices, clinical decision support embedded within electronic health records, and multifaceted interventions. Effect of digital solutions is reported in dedicated studies, retrospective studies, or larger studies with another focus that also commented on GDMT use. Overall, we see more studies on digital solutions that report a significant increase in GDMT use. However, there is a large heterogeneity in study design, outcomes used, and populations studied, which hampers comparison of the different digital solutions. Barriers, facilitators, study designs, and future directions are discussed. There remains a need for well-designed evaluation studies to determine safety and effectiveness of digital solutions for GDMT optimization in patients with HF. Based on this review, measuring and controlling vital signs in telemedicine studies should be encouraged, professionals should be actively alerted about suboptimal GDMT, the researchers should consider employing multifaceted digital solutions to optimize effectiveness, and use study designs that fit the unique sociotechnical aspects of digital solutions. Future directions are expected to include artificial intelligence solutions to handle larger datasets and relieve medical professional's workload.
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Affiliation(s)
- Jelle P Man
- Department of Cardiology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Joanna Klopotowska
- Department of Medical Informatics, Amsterdam University Medical Center, Amsterdam, The Netherlands
- Amsterdam Public Health, Amsterdam, The Netherlands
| | - Folkert W Asselbergs
- Institute of Health Informatics, University College London, London, UK
- The National Institute for Health Research University College London Hospitals Biomedical Research Centre, University College London, London, UK
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - M Louis Handoko
- Department of Cardiology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam University Medical Centre, University of Amsterdam, Amsterdam, The Netherlands
| | - Steven A J Chamuleau
- Department of Cardiology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Netherlands Heart Institute, Utrecht, The Netherlands
| | - Mark J Schuuring
- Department of Cardiology, Amsterdam University Medical Center, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Netherlands Heart Institute, Utrecht, The Netherlands.
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Puthenpura M, Wilcox J, Tang WHW. Worsening heart failure: a concept in evolution. Curr Opin Cardiol 2024; 39:119-127. [PMID: 38116785 DOI: 10.1097/hco.0000000000001108] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023]
Abstract
PURPOSE OF REVIEW Worsening heart failure (WHF) has developed as a unique definition within heart failure (HF) in recent years. It captures the disease as a dynamic process. This review describes what is currently known about WHF, why it should be considered a discrete scientific endpoint, and future directions for research. RECENT FINDINGS There is no single agreed upon definition for WHF. It can be identified as being due to treatment side-effects, related to concomitant comorbidity, or true disease progression. Risk scores based on criteria like those already developed for HF can be created to stratify risk for WHF. CONCLUSIONS WHF is an emerging entity within HF that defines itself as a unique point of interest. Understanding it as a clinical measure of where a patient's HF is evolving allows for identifying patients that require a refreshed approach to their care. Keeping this in mind will help redefine more patient-centric outcome measures in research to come.
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Affiliation(s)
| | - Jennifer Wilcox
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute
| | - W H Wilson Tang
- Department of Cardiovascular and Metabolic Sciences, Lerner Research Institute
- Kaufman Center for Heart Failure Treatment and Recovery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
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7
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Lyle MA, Belkin MN. The Veterans Affairs' Dashboard Confessional: Vindication of the VA HF Dashboard. J Card Fail 2024; 30:460-461. [PMID: 38218347 DOI: 10.1016/j.cardfail.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/15/2024]
Affiliation(s)
- Melissa A Lyle
- Division of Advanced Heart Failure and Transplant Cardiology, Mayo Clinic, Jacksonville, Florida.
| | - Mark N Belkin
- Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois
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Sumarsono A, Xie L, Keshvani N, Zhang C, Patel L, Alonso W, Thibodeau J, Fonarow GC, Van Spall HGC, Messiah SE, Pandey A. Sex Disparities in Longitudinal Use and Intensification of Guideline-Directed Medical Therapy Among Patients With Newly Diagnosed Heart Failure With Reduced Ejection Fraction. Circulation 2024; 149:510-520. [PMID: 38258605 PMCID: PMC11069415 DOI: 10.1161/circulationaha.123.067489] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Accepted: 12/28/2023] [Indexed: 01/24/2024]
Abstract
BACKGROUND Guideline-directed medical therapies (GDMTs) are the mainstay of treatment for heart failure with reduced ejection fraction (HFrEF), but they are underused. Whether sex differences exist in the initiation and intensification of GDMT for newly diagnosed HFrEF is not well established. METHODS Patients with incident HFrEF were identified from the 2016 to 2020 Optum deidentified Clinformatics Data Mart Database, which is derived from a database of administrative health claims for members of large commercial and Medicare Advantage health plans. The primary outcome was the use of optimal GDMT within 12 months of HFrEF diagnosis. Consistent with the guideline recommendations during the time period of the study, optimal GDMT was defined as ≥50% of the target dose of evidence-based beta-blocker plus ≥50% of the target dose of angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, or any dose of angiotensin receptor neprilysin inhibitor plus any dose of mineralocorticoid receptor antagonist. The probability of achieving optimal GDMT on follow-up and predictors of optimal GDMT were evaluated with time-to-event analysis with adjusted Cox proportional hazard models. RESULTS The study cohort included 63 759 patients (mean age, 71.3 years; 15.2% non-Hispanic Black race; 56.6% male). Optimal GDMT use was achieved by 6.2% of patients at 12 months after diagnosis. Female (compared with male) patients with HFrEF had lower use across every GDMT class and lower use of optimal GDMT at each time point at follow-up. In an adjusted Cox model, female sex was associated with a 23% lower probability of achieving optimal GDMT after diagnosis (hazard ratio [HR], 0.77 [95% CI, 0.71-0.83]; P<0.001). The sex disparities in GDMT use after HFrEF diagnosis were most pronounced among patients with commercial insurance (females compared with males; HR, 0.66 [95% CI, 0.58-0.76]) compared with Medicare (HR, 0.85 [95% CI, 0.77-0.92]); Pinteraction sex×insurance status=0.005) and for younger patients (age <65 years: HR, 0.65 [95% CI, 0.58-0.74]) compared with older patients (age ≥65 years: HR, 87 [95% CI, 80-96]) Pinteraction sex×age=0.009). CONCLUSIONS Overall use of optimal GDMT after HFrEF diagnosis was low, with significantly lower use among female (compared with male) patients. These findings highlight the need for implementation efforts directed at improving GDMT initiation and titration.
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Affiliation(s)
- Andrew Sumarsono
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Luyu Xie
- School of Public Health, University of Texas Health Science Center at Houston, Dallas, TX
| | - Neil Keshvani
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Chenguang Zhang
- School of Public Health, University of Texas Health Science Center at Houston, Dallas, TX
| | - LajjaBen Patel
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Windy Alonso
- College of Nursing, University of Nebraska Medical Center, Omaha, NE
| | - Jennifer Thibodeau
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
| | - Gregg C. Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Los Angeles, CA
| | - Harriette GC Van Spall
- Population Health Research Institute, Hamilton, Ontario, CA
- McMaster University, Hamilton, Ontario, CA
- Research Institute of St. Joseph’s, Hamilton, Ontario, CA
| | - Sarah E. Messiah
- School of Public Health, University of Texas Health Science Center at Houston, Dallas, TX
| | - Ambarish Pandey
- Division of Cardiology, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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9
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Bhatt AS, Fonarow GC, Greene SJ, Holmes DN, Alhanti B, Devore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Linganathan K, Joyntmaddox KE, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Vaduganathan M. Medical Therapy Before, During and After Hospitalization in Medicare Beneficiaries With Heart Failure and Diabetes: Get With The Guidelines - Heart Failure Registry. J Card Fail 2024; 30:319-328. [PMID: 37757995 DOI: 10.1016/j.cardfail.2023.09.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Revised: 08/23/2023] [Accepted: 09/03/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND Patients hospitalized with heart failure (HF) and diabetes mellitus (DM) are at risk for worsening clinical status. Little is known about the frequency of therapeutic changes during hospitalization. We characterized the use of medical therapies before, during and after hospitalization in patients with HF and DM. METHODS We identified Medicare beneficiaries in Get With The Guidelines-Heart Failure (GWTG-HF) hospitalized between July 2014 and September 2019 with Part D prescription coverage. We evaluated trends in the use of 7 classes of antihyperglycemic therapies (metformin, sulfonylureas, GLP-1RA, SGLT2-inhibitors, DPP-4 inhibitors, thiazolidinediones, and insulins) and 4 classes of HF therapies (evidence-based β-blockers, ACEi or ARB, MRA, and ARNI). Medication fills were assessed at 6 and 3 months before hospitalization, at hospital discharge and at 3 months post-discharge. RESULTS Among 35,165 Medicare beneficiaries, the median age was 77 years, 54% were women, and 76% were white; 11,660 (33%) had HFrEF (LVEF ≤ 40%), 3700 (11%) had HFmrEF (LVEF 41%-49%), and 19,805 (56%) had HFpEF (LVEF ≥ 50%). Overall, insulin was the most commonly prescribed antihyperglycemic after HF hospitalization (n = 12,919, 37%), followed by metformin (n = 7460, 21%) and sulfonylureas (n = 7030, 20%). GLP-1RA (n = 700, 2.0%) and SGLT2i (n = 287, 1.0%) use was low and did not improve over time. In patients with HFrEF, evidence-based beta-blocker, RASi, MRA, and ARNI fills during the 6 months preceding HF hospitalization were 63%, 62%, 19%, and 4%, respectively. Fills initially declined prior to hospitalization, but then rose from 3 months before hospitalization to discharge (beta-blocker: 56%-82%; RASi: 51%-57%, MRA: 15%-28%, ARNI: 3%-6%, triple therapy: 8%-20%; P < 0.01 for all). Prescription rates 3 months after hospitalization were similar to those at hospital discharge. CONCLUSIONS In-hospital optimization of medical therapy in patients with HF and DM is common in participating hospitals of a large US quality improvement registry.
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Affiliation(s)
- Ankeet S Bhatt
- Kaiser Permanente San Francisco Medical Center and Division of Research, Oakland, CA; Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California, Los Angeles, Los Angeles, CA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | - Adam D Devore
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | | | | | | | - Karen E Joyntmaddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St. Louis, MO
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, CO; Department of Medicine, University of Colorado Anschutz Medical Center, Aurora, CO
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, University of Minnesota, Minneapolis, MN
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA.
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10
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Harrington J, Rao VN, Leyva M, Oakes M, Mentz RJ, Bosworth HB, Pagidipati NJ. Improving Guideline-Directed Medical Therapy for Patients With Heart Failure With Reduced Ejection Fraction: A Review of Implementation Strategies. J Card Fail 2024; 30:376-390. [PMID: 38142886 DOI: 10.1016/j.cardfail.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2023] [Revised: 12/08/2023] [Accepted: 12/12/2023] [Indexed: 12/26/2023]
Abstract
Despite recent advances in the use of guideline-directed medical therapy (GDMT) for patients with heart failure with reduced ejection fraction (HFrEF), achievement of target GDMT use and up-titration to goal dosages continue to be modest. In recent years, a number of interventional approaches to improve the usage of GDMT have been published, but many are limited by single-center experiences with small sample sizes. However, strategies including the use of multidisciplinary teams, dedicated GDMT titration algorithms and clinician audits with feedback have shown promise. There remains a critical need for large, rigorous trials to assess the utility of differing interventions to improve the use and titration of GDMT in HFrEF. Here, we review existing literature in GDMT implementation for those with HFrEF and discuss future directions and considerations in the field.
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Affiliation(s)
- Josephine Harrington
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC.
| | - Vishal N Rao
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Monica Leyva
- Department of Population Health Sciences, Durham, NC
| | - Megan Oakes
- Department of Population Health Sciences, Durham, NC
| | - Robert J Mentz
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Hayden B Bosworth
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Department of Population Health Sciences, Durham, NC
| | - Neha J Pagidipati
- Department of Medicine, Division of Cardiology Duke University, Durham, NC; Duke Clinical Research Institute, Durham, NC
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11
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Shahid I, Khan MS, Fonarow GC, Butler J, Greene SJ. Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure. Prog Cardiovasc Dis 2024; 82:61-69. [PMID: 38244825 DOI: 10.1016/j.pcad.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
Despite robust scientific evidence and strong guideline recommendations, there remain significant gaps in initiation and dose titration of guideline-directed medical therapy (GDMT) for heart failure (HF) among eligible patients. Reasons surrounding these gaps are multifactorial, and largely attributed to patient, healthcare professionals, and institutional challenges. Concurrently, HF remains a predominant cause of mortality and hospitalization, emphasizing the critical need for improved delivery of therapy to patients in routine clinical practice. To optimize GDMT, various implementation strategies have emerged in the recent decade such as in-hospital rapid initiation of GDMT, improving patient adherence, addressing clinical inertia, improving affordability, engagement in quality improvement registries, multidisciplinary clinics, and EHR-integrated interventions. This review highlights the current use and barriers to optimal utilization of GDMT, and proposes novel strategies aimed at improving GDMT in HF.
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Affiliation(s)
- Izza Shahid
- Division of Preventive Cardiology, Houston Methodist Academic Institute, Houston, TX, USA
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA; Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
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12
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Xia J, Brownell NK, Fonarow GC, Ziaeian B. New models for heart failure care delivery. Prog Cardiovasc Dis 2024; 82:70-89. [PMID: 38311306 DOI: 10.1016/j.pcad.2024.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 02/10/2024]
Abstract
Heart failure (HF) is a common disease with increasing prevalence around the world. There is high morbidity and mortality associated with poorly controlled HF along with increasing costs and strain on healthcare systems due to a high rate of rehospitalization and resource utilization. Despite the establishment of clear evidence-based guideline directed medical therapies (GDMT) proven to improve HF morbidity and mortality, there remains significant clinical inertia to optimizing HF patients on GDMT. Only a minority of HF patients are prescribed on all four classes of GDMT. To bridge the gap between the vulnerable population of HF patients and lifesaving GDMT, HF implementation is of increasing importance. HF implementation involves strategies and techniques to improve GDMT optimization along with other modalities to improve HF management. HF implementation meets patients where they are, including at the time of acute decompensation in the inpatient setting, at the vulnerable discharge stage, and at the chronic management stage in the outpatient setting. Inpatient HF implementation strategies include protocolized rapid titration of GDMT, site-level audit-and-feedback, virtual GDMT optimization teams, and electronic health record notifications and alerts. Discharge HF implementation strategies include education at patient and provider levels, discharge summaries, and HF transitional programs. Outpatient HF implementation strategies include digital innovations such as electronic health record utilization and mobile applications, population level strategies such as registries and clinical dashboards), changes in HF team structure and member roles, remote monitoring with implanted devices and telemonitoring, and hospital at home care model. With a growing population of HF patients, there is an increasing need for novel and creative HF implementation and monitoring methods.
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Affiliation(s)
- Jeffrey Xia
- Department of Medicine David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Nicholas K Brownell
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
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13
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Vijay A, Yancy CW. Health equity in heart failure. Prog Cardiovasc Dis 2024; 82:55-60. [PMID: 38215916 DOI: 10.1016/j.pcad.2024.01.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 01/08/2024] [Indexed: 01/14/2024]
Abstract
The treatment of heart failure (HF) with reduced ejection fraction (HFrEF) has substantially developed over the past decades. More than ever before, the application of appropriate evidence-based medical therapy for HFrEF is associated with remarkable improvements in survival, noteworthy increases in quality of life, and a marked reduction in symptomatic HF sufficient to warrant hospitalization. These enhanced clinical outcomes are driven by the "four pillars" of HF therapy: 1) evidence-based beta blockers, 2) Renin-angiotensin-aldosterone system inhibitors (angiotensin-converting enzyme inhibitors /angiotensin II receptor blockers or angiotensin receptor-neprilysin inhibitors, 3) mineralocorticoid receptor antagonists, and most recently, 4) sodium-glucose cotransporter-2 inhibitors. Despite robust evidence from well-conducted randomized clinical trials, guideline-directed medical therapies with established cardiovascular benefits remain significantly underutilized in clinical practice, particularly among under-represented minority populations. This phenomenon has led to class 1 level recommendations from the 2022 American Heart Association/American College of Cardiology/Heart Failure Society of America Guidelines to address HF disparities among vulnerable populations as follows. In this article, we highlight the difference between health equality and health equity and discuss the need to address equity in the treatment of heart failure, ensuring that the impressive progress made in the treatment of HFrEF is equally beneficial to all individuals. We discuss strategies to reduce and ultimately eliminate disparities in the determinants of health that particularly affect marginalized groups, including the socioeconomic determinants and racism as a threat to public health. Finally, we discuss and propose a combination of the four pillars of ethics with the four pillars of GDMT to optimize and personalize treatment of all patients with HFrEF, to achieve true equity in the treatment of HF.
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Affiliation(s)
- Aishwarya Vijay
- Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States of America
| | - Clyde W Yancy
- Department of Internal Medicine, Division of Cardiology, Northwestern University, Feinberg School of Medicine, Chicago, IL, United States of America.
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14
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Ohata T, Niimi N, Shiraishi Y, Nakatsu F, Umemura I, Kohno T, Nagatomo Y, Takei M, Ono T, Sakamoto M, Nakano S, Fukuda K, Kohsaka S, Yoshikawa T. Initiation and Up-Titration of Guideline-Based Medications in Hospitalized Acute Heart Failure Patients - A Report From the West Tokyo Heart Failure Registry. Circ J 2023; 88:22-30. [PMID: 37914282 DOI: 10.1253/circj.cj-23-0356] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2023]
Abstract
BACKGROUND Despite recommendations from clinical practice guidelines to initiate and titrate guideline-directed medical therapy (GDMT) during their hospitalization, patients with acute heart failure (AHF) are frequently undertreated. In this study we aimed to clarify GDMT implementation and titration rates, as well as the long-term outcomes, in hospitalized AHF patients.Methods and Results: Among 3,164 consecutive hospitalized AHF patients included in a Japanese multicenter registry, 1,400 (44.2%) with ejection fraction ≤40% were analyzed. We assessed GDMT dosage (β-blockers, renin-angiotensin inhibitors, and mineralocorticoid-receptor antagonists) at admission and discharge, examined the contributing factors for up-titration, and evaluated associations between drug initiation/up-titration and 1-year post-discharge all-cause death and rehospitalization for HF via propensity score matching. The mean age of the patients was 71.5 years and 30.7% were female. Overall, 1,051 patients (75.0%) were deemed eligible for GDMT, based on their baseline vital signs, renal function, and electrolyte values. At discharge, only 180 patients (17.1%) received GDMT agents up-titrated to >50% of the maximum titrated dose. Up-titration was associated with a lower risk of 1-year clinical outcomes (adjusted hazard ratio: 0.58, 95% confidence interval: 0.35-0.96). Younger age and higher body mass index were significant predictors of drug up-titration. CONCLUSIONS Significant evidence-practice gaps in the use and dose of GDMT remain. Considering the associated favorable outcomes, further efforts to improve its implementation seem crucial.
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Affiliation(s)
- Takanori Ohata
- Department of Cardiology, Keio University School of Medicine
| | - Nozomi Niimi
- General Internal Medicine, National Hospital Organization Tokyo Medical Center
| | | | | | | | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Faculty of Medicine
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College Hospital
| | - Makoto Takei
- Department of Cardiology, Saiseikai Central Hospital
| | - Tomohiko Ono
- Department of Cardiology, National Hospital Organization Saitama National Hospital
| | - Munehisa Sakamoto
- Department of Cardiology, National Hospital Organization Tokyo Medical Center
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University International Medical Center
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine
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15
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Brownell NK, Fonarow GC. Hospitalization for heart failure requires a PROMPT response. Eur Heart J 2023; 44:4243-4245. [PMID: 37670351 DOI: 10.1093/eurheartj/ehad444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 09/07/2023] Open
Affiliation(s)
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, CA, USA
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan-UCLA Medical Center, 10833 LeConte Ave, Room A2-237 CHS, Los Angeles, CA 90095, USA
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16
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Trinkley KE, Wright G, Allen LA, Bennett TD, Glasgow RE, Hale G, Heckman S, Huebschmann AG, Kahn MG, Kao DP, Lin CT, Malone DC, Matlock DD, Wells L, Wysocki V, Zhang S, Suresh K. Sustained Effect of Clinical Decision Support for Heart Failure: A Natural Experiment Using Implementation Science. Appl Clin Inform 2023; 14:822-832. [PMID: 37852249 PMCID: PMC10584394 DOI: 10.1055/s-0043-1775566] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/02/2023] [Indexed: 10/20/2023] Open
Abstract
OBJECTIVES In a randomized controlled trial, we found that applying implementation science (IS) methods and best practices in clinical decision support (CDS) design to create a locally customized, "enhanced" CDS significantly improved evidence-based prescribing of β blockers (BB) for heart failure compared with an unmodified commercially available CDS. At trial conclusion, the enhanced CDS was expanded to all sites. The purpose of this study was to evaluate the real-world sustained effect of the enhanced CDS compared with the commercial CDS. METHODS In this natural experiment of 28 primary care clinics, we compared clinics exposed to the commercial CDS (preperiod) to clinics exposed to the enhanced CDS (both periods). The primary effectiveness outcome was the proportion of alerts resulting in a BB prescription. Secondary outcomes included patient reach and clinician adoption (dismissals). RESULTS There were 367 alerts for 183 unique patients and 171 unique clinicians (pre: March 2019-August 2019; post: October 2019-March 2020). The enhanced CDS increased prescribing by 26.1% compared with the commercial (95% confidence interval [CI]: 17.0-35.1%), which is consistent with the 24% increase in the previous study. The odds of adopting the enhanced CDS was 81% compared with 29% with the commercial (odds ratio: 4.17, 95% CI: 1.96-8.85). The enhanced CDS adoption and effectiveness rates were 62 and 14% in the preperiod and 92 and 10% in the postperiod. CONCLUSION Applying IS methods with CDS best practices was associated with improved and sustained clinician adoption and effectiveness compared with a commercially available CDS tool.
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Affiliation(s)
- Katy E. Trinkley
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
- UCHealth, Aurora, Colorado, United States
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Garth Wright
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Larry A. Allen
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Division of Cardiology, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
| | - Tellen D. Bennett
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - Russell E. Glasgow
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado, United States
| | - Gary Hale
- UCHealth, Aurora, Colorado, United States
| | | | - Amy G. Huebschmann
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Division of Internal Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
- University of Colorado Anschutz Medical Campus Ludeman Family Center for Women's Health Research, Aurora, Colorado, United States
| | - Michael G. Kahn
- Department of Biomedical Informatics, University of Colorado School of Medicine, Aurora, Colorado, United States
| | - David P. Kao
- UCHealth, Aurora, Colorado, United States
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Chen-Tan Lin
- UCHealth, Aurora, Colorado, United States
- Division of Internal Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
| | - Daniel C. Malone
- Department of Pharmacotherapy, University of Utah Skaggs College of Pharmacy, Salt Lake City, Utah, United States
| | - Daniel D. Matlock
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Veterans Affairs Eastern Colorado Geriatric Research Education and Clinical Center, Aurora, Colorado, United States
- Division of Internal Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
- Division of Geriatrics, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
| | - Lauren Wells
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Vincent Wysocki
- Department of Clinical Pharmacy, University of Colorado Anschutz Medical Campus Skaggs School of Pharmacy and Pharmaceutical Sciences, Aurora, Colorado, United States
| | - Shelley Zhang
- Department of Family Medicine, University of Colorado Anschutz Medical Campus, School of Medicine, Aurora, Colorado, United States
| | - Krithika Suresh
- Adult and Child Center for Outcomes Research and Delivery Science, Aurora, Colorado, United States
- Department of Biostatistics and Informatics, Colorado School of Public Health, Aurora, Colorado, United States
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17
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Severino P, Prosperi S, D'Amato A, Cestiè C, Myftari V, Maestrini V, Birtolo LI, Filomena D, Mariani MV, Lavalle C, Badagliacca R, Mancone M, Fedele F, Vizza CD. Telemedicine: an Effective and Low-Cost Lesson From the COVID-19 Pandemic for the Management of Heart Failure Patients. Curr Heart Fail Rep 2023; 20:382-389. [PMID: 37665424 PMCID: PMC10589137 DOI: 10.1007/s11897-023-00624-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/09/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE The purpose of this review is to explore the benefits and controversies that telemedicine (TM), applied to patients with heart failure (HF), can provide in terms of diagnosis, therapeutic management, and prognosis improvement. During the coronavirus disease 19 (COVID-19) outbreak, TM emerged as the most effective and feasible method available to ensure continuous care for chronic diseases. Among these, HF, characterized by high mortality, morbidity, and the need for frequent visits, may benefit of the TM role. HF patients are affected by frequent exacerbations undergoing a progressive prognosis impoverishment, strongly depending on the disease's management. A precise clinical handling is always required, with a constant optimization of the therapy, a continuous control of risk factors, and a sensitive attention to any change in symptoms, clinical signs, and laboratory tests. In this context, TM has shown to improve therapy adherence and HF: patients' self-care, impacting the prognosis even if specific results are controversial. Major evidence shows that TM may allow an adequate primary prevention, reducing the impact of the main cardiovascular risk factors. TM can also be useful for the secondary prevention, early detecting a likely HF exacerbation before it becomes clinically manifest, thereby lowering the need for hospitalization. Moreover, an optimal up-titration of the therapy and an increase in treatment adherence are feasible by using TM. However, some studies did not show unambiguous results, and uncertainties still remain.
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Affiliation(s)
- Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Claudia Cestiè
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Domenico Filomena
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
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18
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Bayes-Genis A, Pascual-Figal D. Making STRONGer the transition phase: personalized GDMT through NT-proBNP monitoring. Eur Heart J 2023; 44:2963-2965. [PMID: 37220888 DOI: 10.1093/eurheartj/ehad356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Revised: 05/16/2023] [Accepted: 05/19/2023] [Indexed: 05/25/2023] Open
Affiliation(s)
- Antoni Bayes-Genis
- Heart Institute, University Hospital Germans Trias i Pujol, Crta. Canyet s/n, 08916 Badalona, Spain
- Department of Medicine, Universitat Autonoma de Barcelona, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | - Domingo Pascual-Figal
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
- Cardiology Department, Hospital Universitario Virgen de la Arrixaca, University of Murcia, Murcia, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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19
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Olson M, Thompson Z, Xie L, Nair A. Broadening Heart Failure Care Beyond Cardiology: Challenges and Successes Within the Landscape of Multidisciplinary Heart Failure Care. Curr Cardiol Rep 2023; 25:851-861. [PMID: 37436647 DOI: 10.1007/s11886-023-01907-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/13/2023]
Abstract
PURPOSE OF REVIEW Heart failure (HF) is a growing public health concern that impairs the quality of life and is associated with significant mortality. As the prevalence of heart failure increases, multidisciplinary care is essential to provide comprehensive care to individuals. RECENT FINDINGS The challenges of implementing an effective multidisciplinary care team can be daunting. Effective multidisciplinary care begins at the initial diagnosis of heart failure. The transition of care from the inpatient to the outpatient setting is critically important. The use of home visits, case management, and multidisciplinary clinics has been shown to decrease mortality and heart failure hospitalizations, and major society guidelines endorse multidisciplinary care for heart failure patients. Expanding heart failure care beyond cardiology entails incorporating primary care, advanced practice providers, and other disciplines. Patient education and self-management are fundamental to multidisciplinary care, as is a holistic approach to effectively address comorbid conditions. Ongoing challenges include navigating social disparities within heart failure care and limiting the economic burden of the disease.
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Affiliation(s)
- Michael Olson
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA
| | - Zachary Thompson
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA
| | - Lola Xie
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA
- The Texas Heart Institute, Cardiology, Houston, TX, 77030, USA
| | - Ajith Nair
- Baylor College of Medicine, 7200 Cambridge St, Ste 6C, Houston, TX, 77030, USA.
- The Texas Heart Institute, Cardiology, Houston, TX, 77030, USA.
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Tomasoni D, Adamo M, Metra M. July 2023 at a glance: heart failure with preserved ejection fraction and comorbidities. Eur J Heart Fail 2023; 25:925-928. [PMID: 37550181 DOI: 10.1002/ejhf.2976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 08/09/2023] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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21
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Zheng J, Mednick T, Heidenreich PA, Sandhu AT. Pharmacist- and Nurse-Led Medical Optimization in Heart Failure: A Systematic Review and Meta-Analysis. J Card Fail 2023; 29:1000-1013. [PMID: 37004867 PMCID: PMC10524094 DOI: 10.1016/j.cardfail.2023.03.012] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 03/09/2023] [Accepted: 03/10/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Traditional approaches to guideline-directed medical therapy (GDMT) management often lead to delayed initiation and titration of therapies in patients with heart failure. This study sought to characterize alternative models of care involving nonphysician provider-led GDMT interventions and their associations with therapy use and clinical outcomes. METHODS We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and observational studies comparing nonphysician provider-led GDMT initiation and/or uptitration interventions vs usual physician care (PROSPERO ID: CRD42022334661). We queried PubMed, Embase, the Cochrane Library, and the World Health Organization International Clinical Trial Registry Platform for peer-reviewed studies from database inception to July 31, 2022. In the meta-analysis, we used RCT data only and leveraged random-effects models to estimate pooled outcomes. Primary outcomes were GDMT initiation and titration to target dosages by therapeutic class. Secondary outcomes included all-cause mortality and HF hospitalizations. RESULTS We reviewed 33 studies, of which 17 (52%) were randomized controlled trials with median follow-ups of 6 months; 14 (82%) trials evaluated nurse interventions, and the remainder assessed pharmacists' interventions. The primary analysis pooled data from 16 RCTs, which enrolled 5268 patients. Pooled risk ratios (RR) for renin-angiotensin system inhibitor (RASI) and beta-blocker initiation were 2.09 (95% CI 1.05-4.16; I2 = 68%) and 1.91 (95% CI1.35-2.70; I2 = 37%), respectively. Outcomes were similar for uptitration of RASI (RR 1.99, 95% CI 1.24-3.20; I2 = 77%) and beta-blocker (RR 2.22, 95% CI 1.29-3.83; I2 = 66%). No association was found with mineralocorticoid receptor antagonist initiation (RR 1.01, 95% CI 0.47-2.19). There were lower rates of mortality (RR 0.82, 95% CI 0.67-1.04; I2 = 12%) and hospitalization due to HF (RR 0.80, 95% CI 0.63-1.01; I2 = 25%) across intervention arms, but these differences were small and not statistically significant. Prediction intervals were wide due to moderate-to-high heterogeneity across trial populations and interventions. Subgroup analyses by provider type did not show significant effect modification. CONCLUSIONS Pharmacist- and nurse-led interventions for GDMT initiation and/or uptitration improved guideline concordance. Further research evaluating newer therapies and titration strategies integrated with pharmacist- and/or nurse-based care may be valuable.
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Affiliation(s)
- Jimmy Zheng
- Stanford University School of Medicine, Stanford, CA.
| | - Thomas Mednick
- Sutter Health, California Pacific Medical Center, San Francisco, CA
| | - Paul A Heidenreich
- Division of Cardiology, Veterans Affairs Palo Alto Health Care System, Palo Alto, CA; Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA
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Romero E, Yala S, Sellers-Porter C, Lynch G, Mwathi V, Hellier Y, Goldman S, Rocha P, Fine JR, Liem D, Bidwell JT, Ebong I, Gibson M, Cadeiras M. Remote monitoring titration clinic to implement guideline-directed therapy for heart failure patients with reduced ejection fraction: a pilot quality-improvement intervention. Front Cardiovasc Med 2023; 10:1202615. [PMID: 37404735 PMCID: PMC10316022 DOI: 10.3389/fcvm.2023.1202615] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 05/30/2023] [Indexed: 07/06/2023] Open
Abstract
Introduction Guideline-directed medical therapy (GDMT) is the recommended treatment for heart failure with reduced ejection fraction (HFrEF). However, the implementation remains limited, with suboptimal use and dosing. The study aimed to assess the feasibility and effect of a remote monitoring titration program on GDMT implementation. Methods HFrEF patients were randomly assigned to receive either usual care or a quality-improvement remote titration with remote monitoring intervention. The intervention group used wireless devices to transmit heart rate, blood pressure, and weight data daily, which were reviewed by physicians and nurses every 2-4 weeks. Medication tolerance was assessed via phone, and dosage instructions were given. This workflow was repeated until target doses were reached or further adjustments were not tolerated. A 4-GDMT score measured use and target dosage, with the primary endpoint being the score at 6 months follow-up. Results Baseline characteristics were similar (n = 55). A median of 85% of patients complied with transmitting device data every week. At the 6-month follow-up, the intervention group had a 4-GDMT score of 64.6% compared to 56.5% in the usual care group (p = 0.01), with a difference of 8.1% (95% CI: 1.7%-14.5%). Similar results were seen at the 12-month follow-up [difference 12.8% (CI: 5.0%-20.6%)]. The intervention group showed a positive trend in ejection fraction and natriuretic peptides, with no significant difference between groups. Conclusions The study suggests that a full-scale trial is feasible and that utilizing a remote titration clinic with remote monitoring has the potential to enhance the implementation of guideline-directed therapy for HFrEF.
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Affiliation(s)
- Erick Romero
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Stella Yala
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Camryn Sellers-Porter
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Genevieve Lynch
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Veronicah Mwathi
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Yvette Hellier
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Svetlana Goldman
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Paulo Rocha
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Jeffrey R. Fine
- Department of Public Health Sciences, University of California Davis, Davis, CA, United States
| | - David Liem
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Julie T. Bidwell
- Betty Irene Moore School of Nursing, University of California Davis, Sacramento, CA, United States
| | - Imo Ebong
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Michael Gibson
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
| | - Martin Cadeiras
- Division of Cardiovascular Medicine, UC Davis Medical Center, Sacramento, CA, United States
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23
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Bhatt AS, Varshney AS, Moscone A, Claggett BL, Miao ZM, Chatur S, Lopes MS, Ostrominski JW, Pabon MA, Unlu O, Wang X, Bernier TD, Buckley LF, Cook B, Eaton R, Fiene J, Kanaan D, Kelly J, Knowles DM, Lupi K, Matta LS, Pimentel LY, Rhoten MN, Malloy R, Ting C, Chhor R, Guerin JR, Schissel SL, Hoa B, Lio CH, Milewski K, Espinosa ME, Liu Z, McHatton R, Cunningham JW, Jering KS, Bertot JH, Kaur G, Ahmad A, Akash M, Davoudi F, Hinrichsen MZ, Rabin DL, Gordan PL, Roberts DJ, Urma D, McElrath EE, Hinchey ED, Choudhry NK, Nekoui M, Solomon SD, Adler DS, Vaduganathan M. Virtual Care Team Guided Management of Patients With Heart Failure During Hospitalization. J Am Coll Cardiol 2023; 81:1680-1693. [PMID: 36889612 PMCID: PMC10947307 DOI: 10.1016/j.jacc.2023.02.029] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Scalable and safe approaches for heart failure guideline-directed medical therapy (GDMT) optimization are needed. OBJECTIVES The authors assessed the safety and effectiveness of a virtual care team guided strategy on GDMT optimization in hospitalized patients with heart failure with reduced ejection fraction (HFrEF). METHODS In a multicenter implementation trial, we allocated 252 hospital encounters in patients with left ventricular ejection fraction ≤40% to a virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) across 3 centers in an integrated health system. In the virtual care team group, clinicians received up to 1 daily GDMT optimization suggestion from a physician-pharmacist team. The primary effectiveness outcome was in-hospital change in GDMT optimization score (+2 initiations, +1 dose up-titrations, -1 dose down-titrations, -2 discontinuations summed across classes). In-hospital safety outcomes were adjudicated by an independent clinical events committee. RESULTS Among 252 encounters, the mean age was 69 ± 14 years, 85 (34%) were women, 35 (14%) were Black, and 43 (17%) were Hispanic. The virtual care team strategy significantly improved GDMT optimization scores vs usual care (adjusted difference: +1.2; 95% CI: 0.7-1.8; P < 0.001). New initiations (44% vs 23%; absolute difference: +21%; P = 0.001) and net intensifications (44% vs 24%; absolute difference: +20%; P = 0.002) during hospitalization were higher in the virtual care team group, translating to a number needed to intervene of 5 encounters. Overall, 23 (21%) in the virtual care team group and 40 (28%) in usual care experienced 1 or more adverse events (P = 0.30). Acute kidney injury, bradycardia, hypotension, hyperkalemia, and hospital length of stay were similar between groups. CONCLUSIONS Among patients hospitalized with HFrEF, a virtual care team guided strategy for GDMT optimization was safe and improved GDMT across multiple hospitals in an integrated health system. Virtual teams represent a centralized and scalable approach to optimize GDMT.
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Affiliation(s)
- Ankeet S Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA; Kaiser Permanente San Francisco Medical Center and Division of Research, San Francisco, California, USA
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Alea Moscone
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Zi Michael Miao
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Safia Chatur
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Mathew S Lopes
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - John W Ostrominski
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria A Pabon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Ozan Unlu
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Xiaowen Wang
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Leo F Buckley
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bryan Cook
- Mass General Brigham Center for Drug Policy, Boston, Massachusetts, USA
| | - Rachael Eaton
- Department of Pharmacy, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jillian Fiene
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dareen Kanaan
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julie Kelly
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Danielle M Knowles
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kenneth Lupi
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lina S Matta
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Liriany Y Pimentel
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Megan N Rhoten
- Department of Pharmacy Services, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, USA
| | - Rhynn Malloy
- Department of Pharmacy, Children's Hospital Colorado, Denver, Colorado, USA
| | - Clara Ting
- University of Chicago Medical Center, Chicago, Illinois, USA
| | - Rosette Chhor
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Joshua R Guerin
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Scott L Schissel
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Brenda Hoa
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Connie H Lio
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Kristina Milewski
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Michelle E Espinosa
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Zhenzhen Liu
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Ralph McHatton
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Jonathan W Cunningham
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Karola S Jering
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Bertot
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adeel Ahmad
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Muhammad Akash
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Farideh Davoudi
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | | | - David L Rabin
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | | | - David J Roberts
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Daniela Urma
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Erin E McElrath
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily D Hinchey
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Niteesh K Choudhry
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mahan Nekoui
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Dale S Adler
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA.
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Brooksbank JA, Faulkenberg KD, Tang WHW, Martyn T. Novel Strategies to Improve Prescription of Guideline-Directed Medical Therapy in Heart Failure. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2023; 25:93-110. [PMID: 37077616 PMCID: PMC10073621 DOI: 10.1007/s11936-023-00979-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/22/2023] [Indexed: 04/07/2023]
Abstract
PURPOSE OF REVIEW To examine the emerging data for novel strategies being studied to improve use and dose titration of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). RECENT FINDINGS There is mounting evidence to employ novel multi-pronged strategies to address HF implementation gaps. SUMMARY Despite high-level randomized evidence and clear national society recommendations, a large gap persists in use and dose titration of guideline-directed medical therapy (GDMT) in patients with heart failure (HF). Accelerating the safe implementation of GDMT has proven to reduce the morbidity and mortality associated with HF but remains an ongoing challenge for patients, clinicians, and health systems. In this review, we examine the emerging data for novel strategies to improve the use of GDMT including the use of multidisciplinary team-based approaches, nontraditional patient encounters, patient messaging/engagement, remote patient monitoring, and electronic health record (EHR)-based clinical alerts. While societal guidelines and implementation studies have focused on heart failure with reduced ejection fraction (HFrEF), expanding indications and evidence for the use of sodium glucose cotransporter2 (SGLT2i) will necessitate implementation efforts across the LVEF spectrum.
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Affiliation(s)
- Jeremy A. Brooksbank
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
| | | | - W. H. Wilson Tang
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
- George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, OH USA
| | - Trejeeve Martyn
- Robert and Suzanne Tomsich Department of Cardiovascular Medicine, Sydell and Arnold Miller Family Heart and Vascular Institute, Cleveland Clinic, Euclid Ave, Cleveland, OH USA
- George M. and Linda H. Kaufman Center for Heart Failure and Recovery, Cleveland Clinic, Cleveland, OH USA
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25
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Aldhaeefi M, Beers B, Shah J, Rizi SS, Rungkitwattanakul D, Nimoh O, Frimpong V, Gonzalez J, Belrhiti S, Urooj F, Williams D. Sodium-Glucose Cotransporter-2 (SGLT-2) Inhibitors Use among Heart Failure Patients and the Role of Pharmacists in Early Initiation of Therapy. PHARMACY 2023; 11:pharmacy11020058. [PMID: 36961036 PMCID: PMC10037629 DOI: 10.3390/pharmacy11020058] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/19/2023] Open
Abstract
Heart failure (HF) is a growing major public health and economic concern in the United States and worldwide. Heart failure mortality rates can be as high as 75% despite advances in therapies. HF is expected to be the fastest growing among all cardiovascular diseases, with HF-associated direct medical costs projected to nearly double over the next 10 years. Hospital admissions, re-admission, and medical cost are a huge burden to the healthcare system, and this is estimated to have increased gradually over the past decades despite the available advances in HF treatment and prevention. Many heart failure therapies have shown improvement in terms of mortality, morbidity, and symptomatic management. Guideline-directed medical therapy (GDMT) for heart failure has proven its ability to reduce morbidity and mortality by 66%. GDMT is recommended to be used among all HF patients when appropriate. In recent years, two new drug classes, angiotensin receptor-neprilysin inhibitor (ARNi) and sodium-glucose cotransporter-2 (SGLT-2) inhibitors, were approved by the United States Food and Drug Administration (US FDA) for the management of heart failure. The exact mechanism by which the SGLT-2 inhibitors attenuate the inflammatory process remains unclear. Several mechanisms have been suggested related to the cardiovascular benefit of SGLT-2 inhibitors, including a reduction in inflammation, improvement in natriuresis/diuresis, and promotion of the use of ketones as a secondary energy source. Clinical data showed that SGLT-2 inhibitors have morbidity and mortality benefits within 30 days of initiation. Studies have proven that clinical pharmacists practicing in HF inpatient and outpatient settings resulted in a reduction of HF hospitalization and an increase in the uptake of GDMT by initiating or up-titrating GDMT agents as well as providing patient education.
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Affiliation(s)
- Mohammed Aldhaeefi
- Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC 20059, USA
| | - Brandon Beers
- Department of Pharmacy Services, Cone Health Alamance Regional Medical Center, Burlington, NC 27215, USA
| | - Jenny Shah
- Department of Pharmacy Services, Howard University Hospital, Washington, DC 20060, USA
| | - Saba Saeidi Rizi
- College of Pharmacy, Howard University, Washington, DC 20059, USA
| | - Dhakrit Rungkitwattanakul
- Clinical and Administrative Pharmacy Sciences, College of Pharmacy, Howard University, Washington, DC 20059, USA
| | - Oliver Nimoh
- College of Pharmacy, Howard University, Washington, DC 20059, USA
| | | | - Jackie Gonzalez
- Heart Centre, Howard University Hospital, Washington, DC 20060, USA
| | - Sanaa Belrhiti
- Department of Pharmacy Services, Howard University Hospital, Washington, DC 20060, USA
| | - Fatima Urooj
- Heart Centre, Howard University Hospital, Washington, DC 20060, USA
- College of Medicine, Howard University, Washington, DC 20059, USA
| | - Deborah Williams
- Heart Centre, Howard University Hospital, Washington, DC 20060, USA
- College of Medicine, Howard University, Washington, DC 20059, USA
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26
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Patel HC, Kaye DM. Sodium-glucose cotransporter 2 inhibitors: efficacious and safe in elderly patients with heart failure. Eur J Heart Fail 2022; 24:2305-2306. [PMID: 36394526 DOI: 10.1002/ejhf.2744] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2022] [Accepted: 11/16/2022] [Indexed: 11/18/2022] Open
Affiliation(s)
- Hitesh C Patel
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
| | - David M Kaye
- Department of Cardiology, Alfred Hospital, Melbourne, Victoria, Australia
- Heart Failure Research Group, Baker Heart and Diabetes Institute, Melbourne, Victoria, Australia
- Central Clinical School, Monash University, Melbourne, Victoria, Australia
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27
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Patil T, Ali S, Kaur A, Akridge M, Eppes D, Paarlberg J, Parashar A, Jarmukli N. Impact of Pharmacist-Led Heart Failure Clinic on Optimization of Guideline-Directed Medical Therapy (PHARM-HF). J Cardiovasc Transl Res 2022; 15:1424-1435. [PMID: 35501544 PMCID: PMC9060399 DOI: 10.1007/s12265-022-10262-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2021] [Accepted: 04/20/2022] [Indexed: 12/16/2022]
Abstract
This prospective study included patients with heart failure (HF) with reduced ejection fraction (HFrEF) with LVEF < = 40% to evaluate the impact of pharmacist on guideline directed medical therapy (GDMT). The primary outcome was to compare proportion of triple GDMT achieved for Angiotensin-Converting-Enzyme-Inhibitors (ACEI)/Angiotensin-Receptor-Blockers (ARB)/Angiotensin-Receptor-Neprilysin-Inhibitors (ARNI), beta-blockers, aldosterone antagonists (AA), and quadruple GDMT which in additional to triple therapy, included Sodium glucose co-transporter 2 inhibitor (SGLT2i) at 90-day post-enrollment compared to baseline. Secondary endpoints included achieving target and/or maximally tolerated ACEI/ARB/ARNI and beta-blockers combined and individually as well as SGLT2i and AA GDMT at 90-day post-enrollment compared to baseline. We also compared combined and individual HF-related hospitalization/emergency room (ER) visits 90 days pre-/post-enrollment. Of the total 974 patients screened, 80 patients seen at least once in the heart failure medication titration clinic (HMTC) were included in the analysis. Median (IQR) age was 71 (57-69) years with majority white male. There was a significant improvement in the proportion of patients who achieved quadruple GDMT (p = 0.001) and triple GDMT (p-value = 0.020) at 90-day post-enrollment compared to baseline. The secondary GDMT outcomes were also significantly increased at 90 days post-enrollment compared to baseline. Significant difference in mean as well as proportion of combined HF-related hospitalization/ER-visits was found 90 days pre-/post-enrollment (p = 0.047). Our study found that pharmacist's intervention increased the proportion of patients who achieved GDMT at 90 days.
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Affiliation(s)
- Tanvi Patil
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Salihah Ali
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Alamdeep Kaur
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Meghan Akridge
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Davida Eppes
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - James Paarlberg
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Amitabh Parashar
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
| | - Nabil Jarmukli
- Salem Veterans Affair Medical Center, 1970 Roanoke Blvd., Salem, VA 24153 USA
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Riccardi M, Sammartino AM, Piepoli M, Adamo M, Pagnesi M, Rosano G, Metra M, von Haehling S, Tomasoni D. Heart failure: an update from the last years and a look at the near future. ESC Heart Fail 2022; 9:3667-3693. [PMID: 36546712 PMCID: PMC9773737 DOI: 10.1002/ehf2.14257] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
In the last years, major progress occurred in heart failure (HF) management. Quadruple therapy is now mandatory for all the patients with HF with reduced ejection fraction. Whilst verciguat is becoming available across several countries, omecamtiv mecarbil is waiting to be released for clinical use. Concurrent use of potassium-lowering agents may counteract hyperkalaemia and facilitate renin-angiotensin-aldosterone system inhibitor implementations. The results of the EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trial were confirmed by the Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER) trial, and we now have, for the first time, evidence for treatment of also patients with HF with preserved ejection fraction. In a pre-specified meta-analysis of major randomized controlled trials, sodium-glucose co-transporter-2 inhibitors reduced all-cause mortality, cardiovascular (CV) mortality, and HF hospitalization in the patients with HF regardless of left ventricular ejection fraction. Other steps forward have occurred in the treatment of decompensated HF. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload (ADVOR) trial showed that the addition of intravenous acetazolamide to loop diuretics leads to greater decongestion vs. placebo. The addition of hydrochlorothiazide to loop diuretics was evaluated in the CLOROTIC trial. Torasemide did not change outcomes, compared with furosemide, in TRANSFORM-HF. Ferric derisomaltose had an effect on the primary outcome of CV mortality or HF rehospitalizations in IRONMAN (rate ratio 0.82; 95% confidence interval 0.66-1.02; P = 0.070). Further options for the treatment of HF, including device therapies, cardiac contractility modulation, and percutaneous treatment of valvulopathies, are summarized in this article.
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Affiliation(s)
- Mauro Riccardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San DonatoUniversity of MilanMilanItaly
- Department of Preventive CardiologyUniversity of WrocławWrocławPoland
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | | | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Stephan von Haehling
- Department of Cardiology and PneumologyUniversity of Goettingen Medical CenterGottingenGermany
- German Center for Cardiovascular Research (DZHK), Partner Site GöttingenGottingenGermany
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
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Tomasoni D, Adamo M, Metra M. November 2022 at a glance: focus on epidemiology, prognosis and comorbidities. Eur J Heart Fail 2022; 24:1997-1999. [PMID: 36482159 DOI: 10.1002/ejhf.2242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Building a Curriculum for the Cardiovascular Implementation Scientist. J Am Coll Cardiol 2022; 80:1023-1027. [PMID: 36049800 DOI: 10.1016/j.jacc.2022.06.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Revised: 06/02/2022] [Accepted: 06/07/2022] [Indexed: 11/21/2022]
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Cunningham JW, Vaduganathan M, Claggett BL, Kulac IJ, Desai AS, Jhund PS, de Boer RA, DeMets D, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez F, Shah SJ, McGrath MM, O'Meara E, Wilderäng U, Lindholm D, Petersson M, Langkilde AM, McMurray JJV, Solomon SD. Dapagliflozin in Patients Recently Hospitalized With Heart Failure and Mildly Reduced or Preserved Ejection Fraction. J Am Coll Cardiol 2022; 80:1302-1310. [PMID: 36041912 DOI: 10.1016/j.jacc.2022.07.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients recently hospitalized for heart failure (HF) are at high risk for rehospitalization and death. OBJECTIVES The purpose of this study was to investigate clinical outcomes and response to dapagliflozin in patients with HF with mildly reduced or preserved left ventricular ejection fraction (LVEF) who were enrolled during or following hospitalization. METHODS The DELIVER (Dapagliflozin Evaluation to Improve the LIVES of Patients With PReserved Ejection Fraction Heart Failure) trial randomized patients with HF and LVEF >40% to dapagliflozin or placebo. DELIVER permitted randomization during or shortly after hospitalization for HF in clinically stable patients off intravenous HF therapies. This prespecified analysis investigated whether recent HF hospitalization modified risk of clinical events or response to dapagliflozin. The primary outcome was worsening HF event or cardiovascular death. RESULTS Of 6,263 patients in DELIVER, 654 (10.4%) were randomized during HF hospitalization or within 30 days of discharge. Recent HF hospitalization was associated with greater risk of the primary outcome after multivariable adjustment (HR: 1.88; 95% CI: 1.60-2.21; P < 0.001). Dapagliflozin reduced the primary outcome by 22% in recently hospitalized patients (HR: 0.78; 95% CI: 0.60-1.03) and 18% in patients without recent hospitalization (HR: 0.82; 95% CI: 0.72-0.94; Pinteraction = 0.71). Rates of adverse events, including volume depletion, diabetic ketoacidosis, or renal events, were similar with dapagliflozin and placebo in recently hospitalized patients. CONCLUSIONS Dapagliflozin safely reduced risk of worsening HF or cardiovascular death similarly in patients with and without history of recent HF hospitalization. Starting dapagliflozin during or shortly after HF hospitalization in patients with mildly reduced or preserved LVEF appears safe and effective. (Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).
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Affiliation(s)
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ian J Kulac
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | | | - David DeMets
- University of Wisconsin, Madison, Wisconsin, USA
| | | | | | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Martina M McGrath
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Ulrica Wilderäng
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Daniel Lindholm
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Scott D Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Tomasoni D, Adamo M, Metra M. June 2022 at a glance: prevention, outcomes and treatment. Eur J Heart Fail 2022; 24:913-915. [PMID: 35796283 DOI: 10.1002/ejhf.2232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 03/22/2021] [Accepted: 05/06/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Tomasoni D, Adamo M, Metra M. May 2022 at a glance. Focus on treatment: from epidemiologic data to randomized trials and new devices. Eur J Heart Fail 2022; 24:735-737. [PMID: 35592905 DOI: 10.1002/ejhf.2230] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Revised: 04/10/2022] [Accepted: 04/16/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Berezin AE, Berezin AA. Point-of-care heart failure platform: where are we now and where are we going to? Expert Rev Cardiovasc Ther 2022; 20:419-429. [PMID: 35588730 DOI: 10.1080/14779072.2022.2080657] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
INTRODUCTION Heart failure (HF) remains a leading cause of cardiovascular (CV) mortality in patients with CV disease. The point-of-care (POC) HF platform seems to be an ideal non-invasive workflow-adapted system for personally adjusted management of patients with HF. AREAS COVERED In the present manuscript, we reviewed the literature covering some relevant studies regarding the role of point-of care heart failure platform in the risk stratification, earlier diagnosis and prognostically beneficial treatment of patients with different phenotypes of HF. EXPERT OPINION POC HF platform including personal consultation, optimization of the comorbidity treatment, step-by-step HF diagnostic algorithm, single biomarker measurements, has also partially been provided in the current guidelines. Although there are several obstacles to implement POC in routine practice, such as education level, aging, affordability of health care, even partial implementation of POC can also improve clinical outcomes. POC seems to be an evolving model, more research studies are required to clearly see whether it helps to make better decisions with diagnosis and care of HF, as well helps to achieve better clinical outcomes.In summary, the POC HF platform is considered to be a more effective tool than conventional algorithm of HF management.
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Affiliation(s)
- Alexander E Berezin
- Internal Medicine Department, Zaporozhye State Medical University, 26, Mayakovsky av., Zaporozhye, Ukraine
| | - Alexander A Berezin
- Internal Medicine Department, Zaporozhye Medical Academy of Postgraduate Education, Zaporozhye, Ukraine
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Tomasoni D, Adamo M, Metra M. April 2022 at a glance: focus on prevention, acute heart failure and heart failure with preserved ejection fraction. Eur J Heart Fail 2022; 24:593-595. [PMID: 35545950 DOI: 10.1002/ejhf.2228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 04/14/2022] [Indexed: 11/07/2022] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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The use of multidisciplinary teams, electronic health records tools, and technology to optimize heart failure population health. Curr Opin Cardiol 2022; 37:302-306. [PMID: 35612941 DOI: 10.1097/hco.0000000000000968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Given the limited population level, adoption of optimal therapy that has been shown in recent clinical trials and heart failure registries, efforts to rapidly and safely improve adoption of guideline-directed medical therapy for heart failure should be prioritized. Opportunities to leverage remote monitoring technology, the electronic health record (EHR), and multidisciplinary teams to improve heart failure care merit review. RECENT FINDINGS Dedicated multidisciplinary teams employing algorithmic medication titration schema have shown better efficacy than clinician alerts or quality initiatives that focus on education and audit-feedback processes alone. Technology that enables invasive pressure monitoring and wearable devices that transmit physiologic data have the potential to predict decompensation and allow for early intervention by alerting clinicians to signs of congestion/clinical worsening but further real-world data is needed to prove efficacy and develop effective treatment protocols. SUMMARY The combination of technology, multidisciplinary teams, and identification of populations for intervention using the EHR will be central to impactful innovation in heart failure population health and prevention of avoidable morbidity. Novel approaches to study implementation efforts including cluster randomized trials are needed.
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Davidson BT, Dunham S. The Perfect Storm. Crit Care Nurs Clin North Am 2022; 34:141-150. [DOI: 10.1016/j.cnc.2022.02.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Bhatt AS. Adherence to Evidence-Based Therapies in Heart Failure: Deepening the Implementation Divide. JACC. HEART FAILURE 2021; 9:887-889. [PMID: 34509411 DOI: 10.1016/j.jchf.2021.07.007] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 07/26/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Ankeet S Bhatt
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Vaduganathan M, Greene SJ, Zhang S, Solomon N, Chiswell K, DeVore AD, Butler J, Heidenreich PA, Huang JC, Kittleson MM, Maddox KEJ, McDermott JJ, Owens AT, Peterson PN, Solomon SD, Vardeny O, Yancy CW, Fonarow GC. Projected Clinical Benefits of Implementation of SGLT-2 Inhibitors among Medicare Beneficiaries Hospitalized for Heart Failure. J Card Fail 2021; 28:554-563. [PMID: 34785402 DOI: 10.1016/j.cardfail.2021.11.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2021] [Revised: 11/08/2021] [Accepted: 11/09/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The sodium-glucose cotransporter-2 (SGLT-2) inhibitors form the latest pillar in the management of heart failure with reduced ejection fraction (HFrEF) and appear effective across a range of patient profiles. There is increasing interest around initiation of SGLT-2 inhibitor during hospitalization, yet little is known about the putative benefits of this implementation strategy. METHODS We evaluated Medicare beneficiaries with HFrEF (≤40%) hospitalized at 228 sites in the Get With The Guidelines®-Heart Failure (GWTG-HF) Registry in 2016 who had linked claims data for ≥1 year post-discharge. We identified those eligible for dapagliflozin under the latest US Food and Drug Administration label (excluding eGFR<25 mL/min per 1.73 m2, dialysis, or type 1 diabetes). We evaluated 1-year outcomes overall and among key subgroups (age≥75 years, sex, race, hospital region, kidney function, diabetes status, triple therapy). We then projected the potential benefits of implementation of dapagliflozin based on risk reductions from DAPA-HF. RESULTS Among 7,523 patients hospitalized for HFrEF, 6,576 (87%) would be dapagliflozin candidates (mean age 79±8 years, 39% women, 11% Black). Among eligible candidates, discharge use of β-blockers, ACEi/ARB, MRA, ARNI, and triple therapy (ACEi/ARB/ARNI+β-blocker+MRA) was recorded in 88%, 64%, 29%, 3%, and 20%, respectively. Among treatment-eligible patients, 1-year incidence (95% CI) of mortality was 37% (36-38%) and of HF readmission was 33% (32-34%), and each exceeded 25% across all key subgroups. Among 1,333 beneficiaries eligible for dapagliflozin who were already on triple therapy, 1-year incidence of mortality was 26% (24-29%) and 1-year HF readmission was 30% (27-32%). Applying the relative risk reductions observed in DAPA-HF, absolute risk reductions with complete implementation of dapagliflozin among treatment-eligible Medicare beneficiaries are projected to be 5% (1-9%) for mortality and 9% (5-12%) for HF readmission by 1 year. The projected number of Medicare beneficiaries that would need to be treated for 1 year to prevent 1 death is 19 (11-114) and 12 (8-21) would need to be treated to prevent 1 HF readmission. CONCLUSIONS Medicare beneficiaries with HFrEF eligible for dapagliflozin after HF hospitalization, including those well-treated with other disease-modifying therapies, face high risks of mortality and HF readmission by 1 year. If benefits in reduction in death and HF hospitalization observed in clinical trials can be fully realized, absolute benefits of implementation of SGLT-2 inhibitors among treatment eligible candidates are anticipated to be substantial in this high-risk post-discharge setting.
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Affiliation(s)
- Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | | | - Adam D DeVore
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | | | | | - Karen E Joynt Maddox
- Department of Medicine, Cardiovascular Division, Washington University School of Medicine, St Louis, MO
| | | | - Anjali Tiku Owens
- Heart and Vascular Center, Perelman Center for Advanced Medicine, University of Pennsylvania, Philadelphia, PA
| | - Pamela N Peterson
- Department of Medicine, Denver Health Medical Center, Denver, CO; Department of Medicine, Anschutz Medical Center, Aurora, CO
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, University of Minnesota, MN, USA
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA.
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Varshney AS, Minhas AMK, Bhatt AS, Ambrosy AP, Fudim M, Vaduganathan M. Contemporary Burden of Primary Versus Secondary Heart Failure Hospitalizations in the United States. Am J Cardiol 2021; 156:140-142. [PMID: 34315568 PMCID: PMC8750211 DOI: 10.1016/j.amjcard.2021.06.036] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Revised: 06/15/2021] [Accepted: 06/18/2021] [Indexed: 10/20/2022]
Affiliation(s)
- Anubodh S Varshney
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | | | - Ankeet S Bhatt
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, California
| | - Marat Fudim
- Duke Clinical Research Institute and Division of Cardiology, North Carolina; Duke University Medical Center, Durham, North Carolina
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts.
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Tomasoni D, Adamo M, Metra M. July 2021 at a glance: focus on blood volume distribution, haemodynamics and adherence to therapy. Eur J Heart Fail 2021; 23:1059-1061. [PMID: 34291869 DOI: 10.1002/ejhf.1886] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Affiliation(s)
- Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Hospitalization of Patients With (But Not for) Heart Failure: An Opportunity for Accelerated Guideline-Directed Medical Therapy Optimization? J Card Fail 2021; 27:910-912. [PMID: 34364668 DOI: 10.1016/j.cardfail.2021.04.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 03/29/2021] [Accepted: 04/02/2021] [Indexed: 11/21/2022]
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DeVore AD, Granger BB, Fonarow GC, Al-Khalidi HR, Albert NM, Lewis EF, Butler J, Piña IL, Allen LA, Yancy CW, Cooper LB, Felker GM, Kaltenbach LA, McRae AT, Lanfear DE, Harrison RW, Disch M, Ariely D, Miller JM, Granger CB, Hernandez AF. Effect of a Hospital and Postdischarge Quality Improvement Intervention on Clinical Outcomes and Quality of Care for Patients With Heart Failure With Reduced Ejection Fraction: The CONNECT-HF Randomized Clinical Trial. JAMA 2021; 326:314-323. [PMID: 34313687 PMCID: PMC8317015 DOI: 10.1001/jama.2021.8844] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
IMPORTANCE Adoption of guideline-directed medical therapy for patients with heart failure is variable. Interventions to improve guideline-directed medical therapy have failed to consistently achieve target metrics, and limited data exist to inform efforts to improve heart failure quality of care. OBJECTIVE To evaluate the effect of a hospital and postdischarge quality improvement intervention compared with usual care on heart failure outcomes and care. DESIGN, SETTING, AND PARTICIPANTS This cluster randomized clinical trial was conducted at 161 US hospitals and included 5647 patients (2675 intervention vs 2972 usual care) followed up after a hospital discharge for acute heart failure with reduced ejection fraction (HFrEF). The trial was performed from 2017 to 2020, and the date of final follow-up was August 31, 2020. INTERVENTIONS Hospitals (n = 82) randomized to a hospital and postdischarge quality improvement intervention received regular education of clinicians by a trained group of heart failure and quality improvement experts and audit and feedback on heart failure process measures (eg, use of guideline-directed medical therapy for HFrEF) and outcomes. Hospitals (n = 79) randomized to usual care received access to a generalized heart failure education website. MAIN OUTCOMES AND MEASURES The coprimary outcomes were a composite of first heart failure rehospitalization or all-cause mortality and change in an opportunity-based composite score for heart failure quality (percentage of recommendations followed). RESULTS Among 5647 patients (mean age, 63 years; 33% women; 38% Black; 87% chronic heart failure; 49% recent heart failure hospitalization), vital status was known for 5636 (99.8%). Heart failure rehospitalization or all-cause mortality occurred in 38.6% in the intervention group vs 39.2% in usual care (adjusted hazard ratio, 0.92 [95% CI, 0.81 to 1.05). The baseline quality-of-care score was 42.1% vs 45.5%, respectively, and the change from baseline to follow-up was 2.3% vs -1.0% (difference, 3.3% [95% CI, -0.8% to 7.3%]), with no significant difference between the 2 groups in the odds of achieving a higher composite quality score at last follow-up (adjusted odds ratio, 1.06 [95% CI, 0.93 to 1.21]). CONCLUSIONS AND RELEVANCE Among patients with HFrEF in hospitals randomized to a hospital and postdischarge quality improvement intervention vs usual care, there was no significant difference in time to first heart failure rehospitalization or death, or in change in a composite heart failure quality-of-care score. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03035474.
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Affiliation(s)
- Adam D. DeVore
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Gregg C. Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California
- Associate Section Editor, JAMA Cardiology
| | - Hussein R. Al-Khalidi
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Nancy M. Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Eldrin F. Lewis
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson
| | - Ileana L. Piña
- Wayne State University and Detroit Medical Center, Detroit, Michigan
| | - Larry A. Allen
- Adult and Child Consortium for Health Outcomes Research and Delivery Science, University of Colorado School of Medicine, Aurora
| | - Clyde W. Yancy
- Division of Cardiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Lauren B. Cooper
- Department of Heart Failure and Transplantation, Inova Heart and Vascular Institute, Falls Church, Virginia
| | - G. Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Lisa A. Kaltenbach
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | - David E. Lanfear
- Henry Ford Heart and Vascular Institute, Department of Medicine, Cardiovascular Division, Henry Ford Hospital, Detroit, Michigan
| | - Robert W. Harrison
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | | | - Dan Ariely
- Center for Advanced Hindsight, Duke University, Durham, North Carolina
| | - Julie M. Miller
- Center for Advanced Hindsight, Duke University, Durham, North Carolina
| | - Christopher B. Granger
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Adrian F. Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina
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45
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Savarese G, Bodegard J, Norhammar A, Sartipy P, Thuresson M, Cowie MR, Fonarow GC, Vaduganathan M, Coats AJS. Heart failure drug titration, discontinuation, mortality and heart failure hospitalization risk: a multinational observational study (US, UK and Sweden). Eur J Heart Fail 2021; 23:1499-1511. [PMID: 34132001 DOI: 10.1002/ejhf.2271] [Citation(s) in RCA: 65] [Impact Index Per Article: 21.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2021] [Revised: 06/08/2021] [Accepted: 06/12/2021] [Indexed: 12/20/2022] Open
Abstract
AIMS Use and dosing of guideline-directed medical therapy (GDMT) in patients with heart failure (HF) have been shown to be suboptimal. Among new users of GDMT in HF, we followed the real-life patterns of dose titration and discontinuation of angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARB), beta-blockers, mineralocorticoid receptor antagonists (MRA) and angiotensin receptor-neprilysin inhibitors (ARNI). METHODS AND RESULTS New users were identified in health care databases in Sweden, UK and US between 2016-2019. Inclusion criterion was a recent HF hospitalization (HHF) triggering the initiation of GDMT. Patients were grouped by GDMT, i.e. ACEi, ARB, beta-blocker, MRA and ARNI, and stratified by initial dose. Follow-up was 12 months, until death or study end. Outcomes were dose titration within each drug class, discontinuation and first HHF or death. Dose/discontinuation follow-up was assessed daily based on the coverage length of a filled prescription and reported on day 365. New users of ACEi (n = 8426), ARB (n = 2303), beta-blockers (n = 10 476), MRA (n = 17 421), and ARNI (n = 29 546) were identified. Over 12 months, target dose achievement was 15%, 10%, 12%, 30%, and discontinuation was 55%, 33%, 24% and 27% for ACEi, ARB, beta-blockers and ARNI, respectively. MRA was rarely titrated and discontinuation rates were high (40%). Event rates for HHF or death ranged from 40.0-86.9 per 100 patient-years across the treatment groups. CONCLUSION Despite high risk of clinical events following HHF, new initiation of GDMT was followed by consistent patterns of low up-titration and early GDMT discontinuation in three countries with different health care and economies. Our data highlight the urgent need for moving away from long sequential approach when initiating HF treatment and for improving just-in-time decision support for patients and health care providers.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institute, and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Anna Norhammar
- Cardiology Unit, Department of Medicine, Solna, Karolinska Institute, Stockholm, Sweden
| | - Peter Sartipy
- AstraZeneca, Gothenburg, Sweden.,Systems Biology Research Center, School of Bioscience, University of Skövde, Skövde, Sweden
| | | | - Martin R Cowie
- Faculty of Lifesciences & Medicine, King's College London, London, UK.,Division of Guy's & St Thomas' NHS Foundation Trust, Royal Brompton Hospital, London, UK
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Los Angeles, CA, USA
| | | | - Andrew J S Coats
- University of Warwick, Coventry, UK.,Monash University, Clayton, Australia.,Pharmacology, Centre of Clinical and Experimental Medicine, IRCCS San Raffaele Pisana, Rome, Italy.,St George's University of London, London, UK
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46
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Hill L, Lambrinou E, Antoniou S. Optimizing evidence-based heart failure medication: every contact counts. Eur J Heart Fail 2021; 23:1202-1204. [PMID: 33932310 DOI: 10.1002/ejhf.2213] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 04/27/2021] [Accepted: 04/29/2021] [Indexed: 12/19/2022] Open
Affiliation(s)
- Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | | | - Sotiris Antoniou
- Pharmacy Department, St Bartholomew's Hospital, Barts Health NHS Trust, London, UK
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