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Tomasoni D, Pagnesi M, Colombo G, Chiarito M, Stolfo D, Baldetti L, Lombardi CM, Adamo M, Maggi G, Inciardi RM, Loiacono F, Maccallini M, Villaschi A, Gasparini G, Montella M, Contessi S, Cocianni D, Perotto M, Barone G, Merlo M, Cappelletti AM, Rosano G, Sinagra G, Pini D, Savarese G, Metra M. Guideline-directed medical therapy in severe heart failure with reduced ejection fraction: An analysis from the HELP-HF registry. Eur J Heart Fail 2024; 26:327-337. [PMID: 37933210 DOI: 10.1002/ejhf.3081] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 10/24/2023] [Accepted: 10/29/2023] [Indexed: 11/08/2023] Open
Abstract
AIM Persistent symptoms despite guideline-directed medical therapy (GDMT) and poor tolerance of GDMT are hallmarks of patients with advanced heart failure (HF) with reduced ejection fraction (HFrEF). However, real-world data on GDMT use, dose, and prognostic implications are lacking. METHODS AND RESULTS We included 699 consecutive patients with HFrEF and at least one 'I NEED HELP' marker for advanced HF enrolled in a multicentre registry. Beta-blockers (BB) were administered to 574 (82%) patients, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers or angiotensin receptor-neprilysin inhibitors (ACEi/ARB/ARNI) were administered to 381 (55%) patients and 416 (60%) received mineralocorticoid receptor antagonists (MRA). Overall, ≥50% of target doses were reached in 41%, 22%, and 56% of the patients on BB, ACEi/ARB/ARNI and MRA, respectively. Hypotension, bradycardia, kidney dysfunction and hyperkalaemia were the main causes of underprescription and/or underdosing, but up to a half of the patients did not receive target doses for unknown causes (51%, 41%, and 55% for BB, ACEi/ARB/ARNI and MRA, respectively). The proportions of patients receiving BB and ACEi/ARB/ARNI were lower among those fulfilling the 2018 HFA-ESC criteria for advanced HF. Treatment with BB and ACEi/ARB/ARNI were associated with a lower risk of death or HF hospitalizations (adjusted hazard ratio [HR] 0.63, 95% confidence interval [CI] 0.48-0.84, and HR 0.74, 95% CI 0.58-0.95, respectively). CONCLUSIONS In a large, real-world, contemporary cohort of patients with severe HFrEF, with at least one marker for advanced HF, prescription and uptitration of GDMT remained limited. A significant proportion of patients were undertreated due to unknown reasons suggesting a potential role of clinical inertia either by the prescribing healthcare professional or by the patient. Treatment with BB and ACEi/ARB/ARNI was associated with lower mortality/morbidity.
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Affiliation(s)
- Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giada Colombo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Mauro Chiarito
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe Maggi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Riccardo Maria Inciardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Marta Maccallini
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Alessandro Villaschi
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Gaia Gasparini
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Marco Montella
- Humanitas Research Hospital IRCCS, Rozzano, Italy
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Italy
| | - Stefano Contessi
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniele Cocianni
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Maria Perotto
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Giuseppe Barone
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marco Merlo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | | | - Giuseppe Rosano
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste, Italy
| | - Daniela Pini
- Humanitas Research Hospital IRCCS, Rozzano, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, and Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Driscoll A, Meagher S, Kennedy R, Currey J. Effect of Intensive Nurse-Led Optimization of Heart Failure Medications in Patients With Heart Failure: A Meta-analysis of Randomized Controlled Trials. J Cardiovasc Nurs 2024:00005082-990000000-00166. [PMID: 38227630 DOI: 10.1097/jcn.0000000000001068] [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: 01/18/2024]
Abstract
BACKGROUND Prescribing of recommended medications for heart failure (HF) is suboptimal, leaving patients at a high risk of death or rehospitalization post discharge. Nurse-led titration (NLT) clinics are one strategy that could potentially improve the prescription of these medications. OBJECTIVE The aim of this article was to determine the effect of NLT clinics on all-cause mortality, all-cause or HF rehospitalizations, and adverse effects in patients with HF. METHODS We searched MEDLINE, EMBASE, Cochrane CENTRAL, International Clinical Trials Registry Platform, and ClinicalTrials.gov to identify randomized controlled trials comparing NLT of β-blocking agents, angiotensin receptor-neprilysin inhibitors, angiotensin-converting enzyme inhibitors, and/or angiotensin receptor blockers to optimization by another health professional in patients with HF. We used the fixed-effects Mantel-Haenszel method or meta-analyses. We assessed heterogeneity between studies using χ2 and I2. RESULTS Eight studies with 2025 participants were included. Participants in the NLT group experienced a lower rate of all-cause rehospitalizations (relative risk, 0.76, 95% confidence interval, 0.68-0.85; moderate quality of evidence) and less HF-related rehospitalizations (relative risk, 0.47; 95% confidence interval, 0.33-0.66; high quality of evidence) compared with the usual care group. All-cause mortality was lower in the NLT group (relative risk, 0.67; 95% confidence interval, 0.48-0.92; moderate quality of evidence) compared with the usual care group. Authors of one study reported no adverse events, and another study found one adverse event. CONCLUSION This meta-analysis indicates that NLT clinics may improve optimization of guideline-recommended medications with the potential to reduce rehospitalization and improve survival in a cohort of patients known for their poor outcomes.
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Metra M, Adamo M, Tomasoni D, Mebazaa A, Bayes-Genis A, Abdelhamid M, Adamopoulos S, Anker SD, Bauersachs J, Belenkov Y, Böhm M, Gal TB, Butler J, Cohen-Solal A, Filippatos G, Gustafsson F, Hill L, Jaarsma T, Jankowska EA, Lainscak M, Lopatin Y, Lund LH, McDonagh T, Milicic D, Moura B, Mullens W, Piepoli M, Polovina M, Ponikowski P, Rakisheva A, Ristic A, Savarese G, Seferovic P, Sharma R, Thum T, Tocchetti CG, Van Linthout S, Vitale C, Von Haehling S, Volterrani M, Coats AJS, Chioncel O, Rosano G. Pre-discharge and early post-discharge management of patients hospitalized for acute heart failure: A scientific statement by the Heart Failure Association of the ESC. Eur J Heart Fail 2023; 25:1115-1131. [PMID: 37448210 DOI: 10.1002/ejhf.2888] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/16/2023] [Accepted: 04/30/2023] [Indexed: 07/15/2023] Open
Abstract
Acute heart failure is a major cause of urgent hospitalizations. These are followed by marked increases in death and rehospitalization rates, which then decline exponentially though they remain higher than in patients without a recent hospitalization. Therefore, optimal management of patients with acute heart failure before discharge and in the early post-discharge phase is critical. First, it may prevent rehospitalizations through the early detection and effective treatment of residual or recurrent congestion, the main manifestation of decompensation. Second, initiation at pre-discharge and titration to target doses in the early post-discharge period, of guideline-directed medical therapy may improve both short- and long-term outcomes. Third, in chronic heart failure, medical treatment is often left unchanged, so the acute heart failure hospitalization presents an opportunity for implementation of therapy. The aim of this scientific statement by the Heart Failure Association of the European Society of Cardiology is to summarize recent findings that have implications for clinical management both in the pre-discharge and the early post-discharge phase after a hospitalization for acute heart failure.
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Affiliation(s)
- Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alexandre Mebazaa
- AP-HP Department of Anesthesia and Critical Care, Hôpital Lariboisière, Université Paris Cité, Inserm MASCOT, Paris, France
| | - Antoni Bayes-Genis
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Stamatis Adamopoulos
- Second Department of Cardiovascular Medicine, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Michael Böhm
- Saarland University Hospital, Homburg/Saar, Germany
| | - Tuvia Ben Gal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Alain Cohen-Solal
- Inserm 942 MASCOT, Université de Paris, AP-HP, Hopital Lariboisière, Paris, France
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Finn Gustafsson
- Rigshospitalet-Copenhagen University Hospital, Heart Centre, Department of Cardiology, Copenhagen, Denmark
| | | | | | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yuri Lopatin
- Volgograd State Medical University, Volgograd, Russia
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Theresa McDonagh
- Department of Cardiovascular Science, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Davor Milicic
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
| | - Brenda Moura
- Faculty of Medicine, University of Porto, Porto, Portugal
- Cardiology Department, Porto Armed Forces Hospital, Porto, Portugal
| | | | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Marija Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Amina Rakisheva
- Scientific Research Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Arsen Ristic
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Rajan Sharma
- St. George's Hospitals NHS Trust University of London, London, UK
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS) and Rebirth Center for Translational Regenerative Therapies, Hannover Medical School, Hannover, Germany
- Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | - Carlo G Tocchetti
- Cardio-Oncology Unit, Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Sophie Van Linthout
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Cristiana Vitale
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | - Stephan Von Haehling
- Department of Cardiology and Pneumology, University Medical Center Goettingen, Georg-August University, Goettingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Goettingen, Goettingen, Germany
| | - Maurizio Volterrani
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | | | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Giuseppe Rosano
- St. George's Hospitals NHS Trust University of London, London, UK
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
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Marques I, Mendonça D, Teixeira L. One-year rehospitalisation and mortality after acute heart failure hospitalisation: a competing risk analysis. Open Heart 2023; 10:openhrt-2022-002167. [PMID: 36941025 PMCID: PMC10030761 DOI: 10.1136/openhrt-2022-002167] [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: 10/07/2022] [Accepted: 01/04/2023] [Indexed: 03/23/2023] Open
Abstract
OBJECTIVE To identify factors that independently predict the risk of rehospitalisation and death after acute heart failure (AHF) hospital discharge in a real-world setting, considering death without rehospitalisation as a competing event. METHODS Single-centre, retrospective, observational study enrolling 394 patients discharged from an index AHF hospitalisation. Overall survival was evaluated using Kaplan-Meier and Cox regression models. For the risk of rehospitalisation, survival analysis considering competing risks was performed: rehospitalisation was the event of interest, and death without rehospitalisation was the competing event. RESULTS During the first year after discharge, 131 (33.3%) patients were rehospitalised for AHF and 67 (17.0%) died without being readmitted; the remaining 196 patients (49.7%) lived without further hospitalisations. The 1-year overall survival estimate was 0.71 (SE=0.02). After adjusting for gender, age and left ventricle ejection fraction, the results showed that the risk of death was higher in patients with dementia, higher levels of plasma creatinine (PCr), lower levels of platelet distribution width (PDW) and at Q4 of red cell distribution width (RDW). Multivariable models showed that the risk of rehospitalisation was increased in patients with atrial fibrillation, higher PCr or taking beta-blockers at discharge. Furthermore, the risk of death without AHF rehospitalisation was higher in males, those aged ≥80 years, patients with dementia or RDW at Q4 on admission (compared with Q1). Taking beta-blockers at discharge and having a higher PDW on admission reduced the risk of death without rehospitalisation. CONCLUSION When assessing rehospitalisation as a study endpoint, death without rehospitalisation should be considered a competing event in the analyses. Data from this study reveal that patients with atrial fibrillation, renal dysfunction or taking beta-blockers are more likely to be rehospitalised for AHF, while older men with dementia or high RDW are more prone to die without hospital readmission.
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Affiliation(s)
- Irene Marques
- Serviço de Medicina Interna, Centro Hospitalar Universitário de Santo António, Porto, Portugal
- Unidade Multidisciplinar de Investigação Biomédica (UMIB), Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
| | - Denisa Mendonça
- ITR - Laboratory for Integrative and Translational Research in Population Health, Porto, Portugal
- Departamento de Estudos de Populações, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
- Unidade de Investigação em Epidemiologia (EPIUnit), Instituto de Saúde Pública da Universidade do Porto (ISPUP), Porto, Portugal
| | - Laetitia Teixeira
- Departamento de Estudos de Populações, Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
- Centro de Investigação em Tecnologias e Serviços de Saúde (CINTESIS), Instituto de Ciências Biomédicas de Abel Salazar (ICBAS), Universidade do Porto, Porto, Portugal
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Mebazaa A, Davison B, Chioncel O, Cohen-Solal A, Diaz R, Filippatos G, Metra M, Ponikowski P, Sliwa K, Voors AA, Edwards C, Novosadova M, Takagi K, Damasceno A, Saidu H, Gayat E, Pang PS, Celutkiene J, Cotter G. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure (STRONG-HF): a multinational, open-label, randomised, trial. Lancet 2022; 400:1938-1952. [PMID: 36356631 DOI: 10.1016/s0140-6736(22)02076-1] [Citation(s) in RCA: 213] [Impact Index Per Article: 106.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/09/2022]
Abstract
BACKGROUND There is a paucity of evidence for dose and pace of up-titration of guideline-directed medical therapies after admission to hospital for acute heart failure. METHODS In this multinational, open-label, randomised, parallel-group trial (STRONG-HF), patients aged 18-85 years admitted to hospital with acute heart failure, not treated with full doses of guideline-directed drug treatment, were recruited from 87 hospitals in 14 countries. Before discharge, eligible patients were randomly assigned (1:1), stratified by left ventricular ejection fraction (≤40% vs >40%) and country, with blocks of size 30 within strata and randomly ordered sub-blocks of 2, 4, and 6, to either usual care or high-intensity care. Usual care followed usual local practice, and high-intensity care involved the up-titration of treatments to 100% of recommended doses within 2 weeks of discharge and four scheduled outpatient visits over the 2 months after discharge that closely monitored clinical status, laboratory values, and N-terminal pro-B-type natriuretic peptide (NT-proBNP) concentrations. The primary endpoint was 180-day readmission to hospital due to heart failure or all-cause death. Efficacy and safety were assessed in the intention-to-treat (ITT) population (ie, all patients validly randomly assigned to treatment). The primary endpoint was assessed in all patients enrolled at hospitals that followed up patients to day 180. Because of a protocol amendment to the primary endpoint, the results of patients enrolled on or before this amendment were down-weighted. This study is registered with ClinicalTrials.gov, NCT03412201, and is now complete. FINDINGS Between May 10, 2018, and Sept 23, 2022, 1641 patients were screened and 1078 were successfully randomly assigned to high-intensity care (n=542) or usual care (n=536; ITT population). Mean age was 63·0 years (SD 13·6), 416 (39%) of 1078 patients were female, 662 (61%) were male, 832 (77%) were White or Caucasian, 230 (21%) were Black, 12 (1%) were other races, one (<1%) was Native American, and one (<1%) was Pacific Islander (two [<1%] had missing data on race). The study was stopped early per the data and safety monitoring board's recommendation because of greater than expected between-group differences. As of data cutoff (Oct 13, 2022), by day 90, a higher proportion of patients in the high-intensity care group had been up-titrated to full doses of prescribed drugs (renin-angiotensin blockers 278 [55%] of 505 vs 11 [2%] of 497; β blockers 249 [49%] vs 20 [4%]; and mineralocorticoid receptor antagonists 423 [84%] vs 231 [46%]). By day 90, blood pressure, pulse, New York Heart Association class, bodyweight, and NT-proBNP concentration had decreased more in the high-intensity care group than in the usual care group. Heart failure readmission or all-cause death up to day 180 occurred in 74 (15·2% down-weighted adjusted Kaplan-Meier estimate) of 506 patients in the high-intensity care group and 109 (23·3%) of 502 patients in the usual care group (adjusted risk difference 8·1% [95% CI 2·9-13·2]; p=0·0021; risk ratio 0·66 [95% CI 0·50-0·86]). More adverse events by 90 days occurred in the high-intensity care group (223 [41%] of 542) than in the usual care group (158 [29%] of 536) but similar incidences of serious adverse events (88 [16%] vs 92 [17%]) and fatal adverse events (25 [5%] vs 32 [6%]) were reported in each group. INTERPRETATION An intensive treatment strategy of rapid up-titration of guideline-directed medication and close follow-up after an acute heart failure admission was readily accepted by patients because it reduced symptoms, improved quality of life, and reduced the risk of 180-day all-cause death or heart failure readmission compared with usual care. FUNDING Roche Diagnostics.
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Affiliation(s)
- Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France.
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Momentum Research, Durham, NC, USA
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases "Prof C C Iliescu", University of Medicine "Carol Davila", Bucharest, Romania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; APHP Nord, Department of Cardiology, Lariboisière University Hospital, Paris, France
| | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, Netherlands
| | | | | | | | | | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital, Bayero University Kano, Kano, Nigeria
| | - Etienne Gayat
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France; Momentum Research, Durham, NC, USA
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Tomasoni D, Adamo M, Metra M. September 2022 at a glance. Eur J Heart Fail 2022; 24:1455-1457. [DOI: 10.1002/ejhf.2238] [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: 09/21/2022] [Accepted: 09/24/2022] [Indexed: 11/09/2022] 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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Butler J, Anker SD, Lund LH, Coats AJS, Filippatos G, Siddiqi TJ, Friede T, Fabien V, Kosiborod M, Metra M, Piña IL, Pinto F, Rossignol P, van der Meer P, Bahit C, Belohlavek J, Böhm M, Brugts JJ, Cleland JG, Ezekowitz J, Bayes-Genis A, Gotsman I, Goudev A, Khintibidze I, Lindenfeld J, Mentz RJ, Merkely B, Montes EC, Mullens W, Nicolau JC, Parkhomenko A, Ponikowski P, Seferovic PM, Senni M, Shlyakhto E, Cohen-Solal A, Szecsödy P, Jensen K, Dorigotti F, Weir MR, Pitt B. Patiromer for the management of hyperkalemia in heart failure with reduced ejection fraction: the DIAMOND trial. Eur Heart J 2022; 43:4362-4373. [PMID: 35900838 DOI: 10.1093/eurheartj/ehac401] [Citation(s) in RCA: 57] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/01/2022] [Accepted: 07/12/2022] [Indexed: 11/12/2022] Open
Abstract
AIMS To investigate the impact of patiromer on serum potassium level and its ability to enable specified target doses of renin-angiotensin-aldosterone system inhibitor (RAASi) use in patients with heart failure and reduced ejection fraction (HFrEF). METHODS AND RESULTS A total of 1642 patients with HFrEF and current or a history of RAASi-related hyperkalemia were screened and 1195 were enrolled in the run-in phase with patiromer and optimization of RAASi therapy (≥50% recommended dose of angiotensin-converting-enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, and 50 mg of mineralocorticoid receptor antagonist [MRA] spironolactone or eplerenone). Specified target doses of RAASi therapy were achieved in 878 (84.6%) patients; 439 were randomized to patiromer and 439 to placebo. All patients, physicians, and outcome assessors were blinded to treatment assignment. The primary endpoint was between-group difference in adjusted mean change in serum potassium. Five hierarchical secondary endpoints were assessed. At the end of treatment, the median (interquartile range) duration of follow-up was 27 (13, 43) weeks, the adjusted mean change in potassium was +0.03 mmol/L in the patiromer group and +0.13 mmol/L in the placebo group (difference in adjusted mean change between patiromer and placebo: -0.10 [95% confidence interval, CI -0.13, -0.07] mmol/L, P<0.001). Risk of hyperkalemia >5.5 mmol/L (hazard ratio [HR] 0.63; 95% CI 0.45, 0.87; P=0.006), reduction of MRA dose (HR 0.62; 95% CI 0.45, 0.87; P=0.006), and total adjusted hyperkalemia events/100 person-years (77.7 vs. 118.2; HR 0.66; 95% CI 0.53, 0.81; P<0.001) were lower with patiromer. Hyperkalemia-related morbidity-adjusted events (win ratio 1.53, P<0.001) and total RAASi use score (win ratio 1.25, P=0.048) favored the patiromer arm. Adverse events were similar between groups. CONCLUSION Concurrent use of patiromer and high-dose MRAs reduces the risk of recurrent hyperkalemia (ClinicalTrials.gov: NCT03888066).
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Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Center for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin, Germany
| | - Lars H Lund
- Department of Medicine, Unit of Cardiology, Karolinska Institutet, Solna, Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Tariq Jamal Siddiqi
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Tim Friede
- University Medical Center Göttingen, Göttingen, Germany; DZHK (German Center for Cardiovascular Research), Göttingen partner site, Göttingen, Germany
| | | | - Mikhail Kosiborod
- Department of Cardiovascular Disease, Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri
| | - Marco Metra
- Cardiology, ASST Spedali Civili and University, Brescia, Italy
| | - Ileana L Piña
- Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA
| | - Fausto Pinto
- Santa Maria University Hospital, CAML, CCUL, Faculdade de Medicina da Universidade de Lisboa, Lisbon, Portugal
| | - Patrick Rossignol
- X Université de Lorraine, INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, INSERM Unit 1116, Centre Hospitalier Régional Universitaire (CHRU) de Nancy, and F-CRIN INI-CRCT, Nancy, France
| | - Peter van der Meer
- Department of Cardiology, University Medical Center Groningen, Groningen, Netherlands
| | - Cecilia Bahit
- INECO Neurociencias Oroño, Rosario, Santa Fe, New Mexico, USA
| | - Jan Belohlavek
- Clinic of Cardiology and Angiology, General University Hospital Prague, Prague, Czech Republic
| | - Michael Böhm
- Klinik für Innere Medizin III, Saarland University, Homburg/Saar, Germany
| | - Jasper J Brugts
- Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - John Gf Cleland
- Institute of Health & Wellbeing, University of Glasgow, Glasgow, UK
| | - Justin Ezekowitz
- Faculty of Medicine & Dentistry, University of Alberta, Alberta, Canada
| | - Antoni Bayes-Genis
- Cardiology Department, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, CIBERCV, Spain
| | | | - Assen Goudev
- Department of Emergency Medicine, Medical University of Sofia, Sofia, Bulgaria
| | - Irakli Khintibidze
- Alexandre Aladashvili Clinic, Tbilisi State Medical University, Tbilisi, Georgia
| | - Joann Lindenfeld
- Department of Medicine, Vanderbilt University Medical Centre, Nashville, Tennessee, USA
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bela Merkely
- Semmelweis University Heart and Vascular Center, Budapest, Hungary
| | | | | | - Jose C Nicolau
- Instituto do Coracao (InCor), Hospital das Clinicas HCFMUSP, Faculdade de Medicina, Universidade de Sao Paulo, Sao Paulo, SP, Brazil
| | | | - Piotr Ponikowski
- Insitute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Petar M Seferovic
- Faculty of Medicine Belgrade, Serbia, and Serbian Academy of Sciences and Arts
| | - Michele Senni
- University of Milano - Bicocca, Cardiovascular Department, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Evgeny Shlyakhto
- Almazov Federal Heart, Blood and Endocrinology Centre, Saint-Petersburg, Russia
| | - Alain Cohen-Solal
- Université de Paris, INSERM U942, APHP, Hospital Lariboisiere, Paris, France
| | | | | | | | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, USA
| | - Bertram Pitt
- Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
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Abstract
The introduction of multiple new pharmacological agents over the past three decades in the field of heart failure with reduced ejection fraction (HFrEF) has led to reduced rates of mortality and hospitalizations, and consequently the prevalence of HFrEF has increased, and up to 10% of patients progress to more advanced stages, characterized by high rates of mortality, hospitalizations, and poor quality of life. Advanced HFrEF patients often show persistent or progressive signs of severe HF symptoms corresponding to New York Heart Association class III or IV despite being on optimal medical, surgical, and device therapies. However, a subpopulation of patients with advanced HF, those with the most advanced stages of disease, were often insufficiently represented in the major trials demonstrating efficacy and tolerability of the drugs used in HFrEF due to exclusion criteria such as low BP and kidney dysfunction. Consequently, the results of many landmark trials cannot necessarily be transferred to patients with the most advanced stages of HFrEF. Thus, the efficacy and tolerability of guideline-directed medical therapies in patients with the most advanced stages of HFrEF often remain unsettled, and this knowledge is of crucial importance in the planning and timing of consideration for referral for advanced therapies. This review discusses the evidence regarding the use of contemporary drugs in the advanced HFrEF population, covering components such as guideline HFrEF drugs, diuretics, inotropes, and the use of HFrEF drugs in LVAD recipients, and provides suggestions on how to manage guideline-directed therapy in this patient group.
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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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