1
|
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.
Collapse
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
| |
Collapse
|
2
|
Ferrannini G, Biber ME, Abdi S, Ståhlberg M, Lund LH, Savarese G. The management of heart failure in Sweden-the physician's perspective: a survey. Front Cardiovasc Med 2024; 11:1385281. [PMID: 38807949 PMCID: PMC11130511 DOI: 10.3389/fcvm.2024.1385281] [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: 02/12/2024] [Accepted: 04/17/2024] [Indexed: 05/30/2024] Open
Abstract
Aims To assess the barriers to guideline-directed medical therapy (GDMT) use in heart failure (HF), diagnostic workup and general knowledge about HF among physicians in Sweden. Methods A survey about the management of HF was sent to 828 Swedish physicians including general practitioners (GPs) and specialists during 2021-2022. Answers were reported as percentages and comparisons were made by specialty (GPs vs. specialists). Results One hundred sixty-eight physicians participated in the survey (40% females, median age 43 years; 41% GPs and 59% specialists). Electrocardiography and New York Heart Association class evaluations are mostly performed once a year by GPs (46%) and at every outpatient visit by specialists (40%). Echocardiography is mostly requested if there is clinical deterioration (60%). One-third of participants screen for iron deficiency only if there is anemia. Major obstacles to implementation of different drug classes in HF with reduced ejection fraction are related to side effects, with no significant differences between specialties. Device implantation is deemed appropriate regardless of aetiology (69%) and patient age (86%). Specialists answered correctly to knowledge questions more often than GPs. Eighty-six percent of participants think that GDMT should be implemented as much as possible. Most participants (57%) believe that regular patient assessment in nurse-led HF clinics improve adherence to GDMT. Conclusion Obstacles to GDMT implementation according to physicians in Sweden mainly relate to potential side effects, lack of specialist knowledge and organizational aspects. Further efforts should be placed in educational activities and structuring of nurse-led clinics.
Collapse
Affiliation(s)
- Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Internal Medicine Unit, Södertälje Hospital, Södertälje, Sweden
| | - Mattia Emanuele Biber
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Studies, University of Trieste School of Medicine, Trieste, Italy
| | - Sam Abdi
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Internal Medicine, Acute and Reparative Medicine Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Marcus Ståhlberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lars H. Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Department of Cardiology, Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
3
|
Defieuw L, Hias J, Karapinar-Carkıt F, Forsyth P, Van der Linden LR. Empowering European hospital pharmacists in the face of heart failure. Eur J Hosp Pharm 2024:ejhpharm-2023-004068. [PMID: 38740548 DOI: 10.1136/ejhpharm-2023-004068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024] Open
Affiliation(s)
- Lise Defieuw
- Hospital Pharmacy Department, UZ Leuven, Leuven, Flanders, Belgium
| | - Julie Hias
- Hospital Pharmacy Department, UZ Leuven, Leuven, Flanders, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Flanders, Belgium
| | - Fatma Karapinar-Carkıt
- Department of Clinical Pharmacy and Toxicology, Maastricht University Medical Centre, Maastricht, Limburg, The Netherlands
- CARIM School for Cardiovascular Disease, Maastricht University, Maastricht, The Netherlands
| | - Paul Forsyth
- Pharmacy, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - Lorenz Roger Van der Linden
- Hospital Pharmacy Department, UZ Leuven, Leuven, Flanders, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Flanders, Belgium
| |
Collapse
|
4
|
Assmus B, Sossalla S. What we claim to do and what we really do - a discrepancy in heart failure treatment. Eur J Heart Fail 2024. [PMID: 38740572 DOI: 10.1002/ejhf.3279] [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: 04/16/2024] [Accepted: 04/22/2024] [Indexed: 05/16/2024] Open
Affiliation(s)
- Birgit Assmus
- Department of Cardiology and Angiology, University of Giessen, Giessen, Germany
- Department of Cardiology and DZHK (German Centre for Cardiovascular Research), Partner Site Rhein/Main, Kerckhoff Heart Center, Bad Nauheim, Hessen, Germany
| | - Samuel Sossalla
- Department of Cardiology and Angiology, University of Giessen, Giessen, Germany
- Department of Cardiology and DZHK (German Centre for Cardiovascular Research), Partner Site Rhein/Main, Kerckhoff Heart Center, Bad Nauheim, Hessen, Germany
| |
Collapse
|
5
|
Michel A, Lecomte C, Ohlmeier C, Raad H, Basedow F, Haeckl D, Beier D, Evers T. Treatment Patterns, Outcomes, and Persistence to Newly Started Heart Failure Medications in Patients with Worsening Heart Failure: A Cohort Study from the United States and Germany. Am J Cardiovasc Drugs 2024; 24:409-418. [PMID: 38573461 DOI: 10.1007/s40256-024-00643-7] [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] [Accepted: 03/19/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Data are limited regarding guideline-directed medical therapy (GDMT) treatment patterns in patients with worsening heart failure (HF). METHODS We used administrative claims databases in Germany and the USA to conduct a retrospective cohort study of patients with worsening HF. Two cohorts of patients with prevalent HF and a HF hospitalization (HFH) from 2016 to 2019, alive at discharge (N = 75,140 USA; N = 47,003 Germany) were identified. Index date was the first HFH during the study period. One-year HF rehospitalization and mortality rates were calculated and a composite endpoint of both outcomes assessed using Kaplan-Meier estimation. We evaluated HF medication patterns in the 6 months before and after the index date. New users of a HF medication (at discharge/after index HFH) were followed for 1 year to evaluate persistence (no treatment gaps > 2 months) RESULTS: One-year HF rehospitalization rates were 36.2% (USA) and 47.7% (Germany). One year mortality rates were 30.0% (USA) and 23.0% (Germany), and the composite endpoint (mortality/HF rehospitalization) was reached in 55.1 % (USA) and 56.6% (Germany). Kaplan-Meier plots showed the risk for the composite endpoint was high in the early post discharge period. Comparison of patterns pre- and postindex HFH showed some increase in use of mineralocorticoid receptor antagonists (MRAs), angiotensin receptor-neprilysin inhibitor (ARNI), and triple therapy; use of angiotensin-converting enzyme (ACE) inhibitor/ angiotensin receptor blocker (ARB) plus beta-blockers remained constant/slightly declined; < 20% patients received triple therapy (ACE inhibitor/ARB plus beta-blocker plus MRA). A third of patients were new users; 1 year persistence rates were often low. CONCLUSIONS Morbidity, mortality, and rehospitalization risk is high among patients with worsening HF; uptake and continuation of GDMT is suboptimal.
Collapse
Affiliation(s)
- Alexander Michel
- Bayer Consumer Care AG, Pharmaceuticals, Peter Merian Straße 84, 4052, Basel, Switzerland.
| | | | | | | | - Frederike Basedow
- InGef-Institute for Applied Health Research, Berlin GmbH, Berlin, Germany
| | | | - Dominik Beier
- InGef-Institute for Applied Health Research, Berlin GmbH, Berlin, Germany
| | | |
Collapse
|
6
|
Bismpos D, Wintrich J, Hövelmann J, Böhm M. Latest pharmaceutical approaches across the spectrum of heart failure. Heart Fail Rev 2024; 29:675-687. [PMID: 38349462 PMCID: PMC11035443 DOI: 10.1007/s10741-024-10389-8] [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] [Accepted: 01/30/2024] [Indexed: 03/02/2024]
Abstract
Despite major advances in prevention and medical therapy, heart failure (HF) remains associated with high morbidity and mortality, especially in older and frailer patients. Therefore, a complete, guideline-based treatment is essential, even in HF patients with conditions traditionally associated with a problematic initiation and escalation of the medical HF therapy, such as chronic kidney disease and arterial hypotension, as the potential adverse effects are overcome by the overall decrease of the absolute risk. Furthermore, since the latest data suggest that the benefit of a combined medical therapy (MRA, ARNI, SGLT2i, beta-blocker) may extend up to a LVEF of 65%, further trials on these subgroups of patients (HFmrEF, HFpEF) are needed to re-evaluate the guideline-directed medical therapy across the HF spectrum. In particular, the use of SGLT2i was recently extended to HFpEF patients, as evidenced by the DELIVER and EMPEROR-preserved trials. Moreover, the indication for other conservative treatments in HF patients, such as the intravenous iron supplementation, was accordingly strengthened in the latest guidelines. Finally, the possible implementation of newer substances, such as finerenone, in guideline-directed medical practice for HF is anticipated with great interest.
Collapse
Affiliation(s)
- Dimitrios Bismpos
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany.
- Department of Internal Medicine II, Cardiology and Angiology, Marien Hospital Herne, University Clinic of the Ruhr University, Bochum University, Herne, Germany.
| | - Jan Wintrich
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Julian Hövelmann
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care Medicine, University Hospital, Saarland University, Homburg, Saar, Germany
| |
Collapse
|
7
|
Tomasoni D, Davison B, Adamo M, Pagnesi M, Mebazaa A, Edwards C, Arrigo M, Barros M, Biegus J, Čelutkienė J, Čerlinskaitė-Bajorė K, Chioncel O, Cohen-Solal A, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Lam CSP, Novosadova M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Maaten JMT, Voors A, Cotter G, Metra M. Safety Indicators in Patients Receiving High-intensity Care After Hospital Admission for Acute Heart Failure: The STRONG-HF Trial. J Card Fail 2024; 30:525-537. [PMID: 37820896 DOI: 10.1016/j.cardfail.2023.09.002] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 09/19/2023] [Accepted: 09/19/2023] [Indexed: 10/13/2023]
Abstract
BACKGROUND Safety, Tolerability and Efficacy of Rapid Optimization, Helped by NT-proBNP Testing, of Heart Failure Therapies (STRONG-HF) demonstrated the safety and efficacy of rapid up-titration of guideline-directed medical therapy (GDMT) with high-intensity care (HIC) compared with usual care in patients hospitalized for acute heart failure (HF). In the HIC group, the following safety indicators were used to guide up-titration: estimated glomerular filtration rate of <30 mL/min/1.73 m2, serum potassium of >5.0 mmol/L, systolic blood pressure (SBP) of <95 mmHg, heart rate of <55 bpm, and N-terminal pro-B-type natriuretic peptide concentration of >10% higher than predischarge values. METHODS AND RESULTS We examined the impact of protocol-specified safety indicators on achieved dose of GDMT and clinical outcomes. Three hundred thirteen of the 542 patients in the HIC arm (57.7%) met ≥1 safety indicator at any follow-up visit 1-6 weeks after discharge. As compared with those without, patients meeting ≥1 safety indicator had more severe HF symptoms, lower SBP, and higher heart rate at baseline and achieved a lower average percentage of GDMT optimal doses (mean difference vs the HIC arm patients not reaching any safety indicator, -11.0% [95% confidence interval [CI] -13.6 to -8.4%], P < .001). The primary end point of 180-day all-cause death or HF readmission occurred in 15.0% of patients with any safety indicator vs 14.2% of those without (adjusted hazard ratio 0.84, 95% CI 0.48-1.46, P = .540). None of each of the safety indicators, considered alone, was significantly associated with the primary end point, but an SBP of <95 mm Hg was associated with a trend toward increased 180-day all-cause mortality (adjusted hazard ratio 2.68, 95% CI 0.94-7.64, P = .065) and estimated glomerular filtration rate decreased to <30 mL/min/1.73 m2 with more HF readmissions (adjusted hazard ratio 3.60, 95% CI 1.22-10.60, P = .0203). The occurrence of a safety indicator was associated with a smaller 90-day improvement in the EURO-QoL 5-Dimension visual analog scale (adjusted mean difference -3.32 points, 95% CI -5.97 to -0.66, P = .015). CONCLUSIONS Among patients with acute HF enrolled in STRONG-HF in the HIC arm, the occurrence of any safety indicator was associated with the administration of slightly lower GDMT doses and less improvement in quality of life, but with no significant increase in the primary outcome of 180-day HF readmission or death when appropriately addressed according to the study protocol.
Collapse
Affiliation(s)
- Daniela Tomasoni
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina; Heart Initiative, Durham, North Carolina
| | - Marianna Adamo
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Matteo Pagnesi
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - 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
| | | | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Jelena Čelutkienė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - 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; AP-HP 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
| | - 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
| | - Antoine Kimmoun
- Université de Lorraine, Nancy; INSERM, Défaillance Circulatoire Aigue et Chronique; Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, Francel
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore; Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | | | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Murtala Muhammed Specialist Hospital, Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Department of Medicine and Cardiology, Groote Schuur Hospital, University of Cape Town, Cape Town, South Africa
| | - Koji Takagi
- Momentum Research Inc, Durham, North Carolina
| | - Jozine M Ter Maaten
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Adriaan Voors
- Department of Cardiology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France; Momentum Research Inc, Durham, North Carolina; Heart Initiative, Durham, North Carolina
| | - Marco Metra
- Depaetment of Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy.
| |
Collapse
|
8
|
Savarese G, Lindberg F, Christodorescu RM, Ferrini M, Kumler T, Toutoutzas K, Dattilo G, Bayes-Genis A, Moura B, Amir O, Petrie MC, Seferovic P, Chioncel O, Metra M, Coats AJS, Rosano GMC. Physician perceptions, attitudes, and strategies towards implementing guideline-directed medical therapy in heart failure with reduced ejection fraction. A survey of the Heart Failure Association of the ESC and the ESC Council for Cardiology Practice. Eur J Heart Fail 2024. [PMID: 38515385 DOI: 10.1002/ejhf.3214] [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: 01/13/2024] [Revised: 02/14/2024] [Accepted: 03/13/2024] [Indexed: 03/23/2024] Open
Abstract
AIMS Recent guidelines recommend four core drug classes (renin-angiotensin system/angiotensin receptor-neprilysin inhibitor [RASi/ARNi], beta-blocker, mineralocorticoid receptor antagonist [MRA], and sodium-glucose cotransporter 2 inhibitor [SGLT2i]) for the pharmacological management of heart failure (HF) with reduced ejection fraction (HFrEF). We assessed physicians' perceived (i) comfort with implementing the recent HFrEF guideline recommendations; (ii) status of guideline-directed medical therapy (GDMT) implementation; (iii) use of different GDMT sequencing strategies; and (iv) barriers and strategies for achieving implementation. METHODS AND RESULTS A 26-question survey was disseminated via bulletin, e-mail and social channels directed to physicians with an interest in HF. Of 432 respondents representing 91 countries, 36% were female, 52% were aged <50 years, and 90% mainly practiced in cardiology (30% HF). Overall comfort with implementing quadruple therapy was high (87%). Only 12% estimated that >90% of patients with HFrEF without contraindications received quadruple therapy. The time required to initiate quadruple therapy was estimated at 1-2 weeks by 34% of respondents, 1 month by 36%, 3 months by 24%, and ≥6 months by 6%. The average respondent favoured traditional drug sequencing strategies (RASi/ARNi with/followed by beta-blocker, and then MRA with/followed by SGLT2i) over simultaneous initiation or SGLT2i-first sequences. The most frequently perceived clinical barriers to implementation were hypotension (70%), creatinine increase (47%), hyperkalaemia (45%) and patient adherence (42%). CONCLUSIONS Although comfort with implementing all four core drug classes in patients with HFrEF was high among physicians, a majority estimated implementation of GDMT in HFrEF to be low. We identified several important perceived clinical and non-clinical barriers that can be targeted to improve implementation.
Collapse
Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ruxandra M Christodorescu
- Department V Internal Medicine, University of Medicine and Pharmacy V. Babes Timisoara, Institute of Cardiology Research Center, Timișoara, Romania
| | - Marc Ferrini
- Department of Cardiology and Vascular Pathology, CH Saint Joseph and Saint Luc, Lyon, France
| | - Thomas Kumler
- Department of Cardiology, Herlev-Gentofte University Hospital, Copenhagen, Denmark
- Steno Diabetes Center Copenhagen, Denmark
| | - Konstantinos Toutoutzas
- First Department of Cardiology, Medical School, National and Kapodistrian University of Athens, 'Hippokration' General Hospital of Athens, Athens, Greece
| | - Giuseppe Dattilo
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Antoni Bayes-Genis
- Institut del Cor, Hospital Universitari Germans Trias I Pujol, Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Cardiovasculares (CIBERCV; Departamento de Medicina, Universitat Autònoma de Barcelona), Barcelona, Spain
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Offer Amir
- Heart Institute, Hadassah Medical Center & Faculty of Medicine, Hebrew University, Jerusalem, Israel
| | - Mark C Petrie
- Institute of Cardiovascular and Medical Sciences, The University Court of the University of Glasgow, Glasgow, UK
| | - Petar Seferovic
- University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', Bucharest, Romania
- University of Medicine Carol Davila, Bucharest, Romania
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | | | - Giuseppe M C Rosano
- Cardiovascular Clinical Academic Group, St George's University Hospital, London, UK
- Cardiology, IRCCS San Raffaele, Rome, Italy
| |
Collapse
|
9
|
Romiti GF, Nabrdalik K, Corica B, Bucci T, Proietti M, Qian M, Chen Y, Thompson JLP, Homma S, Lip GYH. Diabetes mellitus in patients with heart failure and reduced ejection fraction: a post hoc analysis from the WARCEF trial. Intern Emerg Med 2024:10.1007/s11739-024-03544-4. [PMID: 38393500 DOI: 10.1007/s11739-024-03544-4] [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: 11/16/2023] [Accepted: 01/16/2024] [Indexed: 02/25/2024]
Abstract
Patients with heart failure with reduced ejection fraction (HFrEF) and diabetes mellitus (DM) have an increased risk of adverse events, including thromboembolism. In this analysis, we aimed to explore the association between DM and HFrEF using data from the "Warfarin versus Aspirin in Reduced Cardiac Ejection Fraction" (WARCEF) trial. We analyzed factors associated with DM using multiple logistic regression models and evaluated the effect of DM on long-term prognosis, through adjusted Cox regressions. The primary outcome was the composite of all-cause death, ischemic stroke, or intracerebral hemorrhage; we explored individual components as the secondary outcomes and the interaction between treatment (warfarin or aspirin) and DM on the risk of the primary outcome, stratified by relevant characteristics. Of 2294 patients (mean age 60.8 (SD 11.3) years, 19.9% females) included in this analysis, 722 (31.5%) had DM. On logistic regression, cardiovascular comorbidities, symptoms and ethnicity were associated with DM at baseline, while age and body mass index showed a nonlinear association. Patients with DM had a higher risk of the primary composite outcome (Hazard Ratio [HR] and 95% Confidence Intervals [CI]: 1.48 [1.24-1.77]), as well as all-cause death (HR [95%CI]: 1.52 [1.25-1.84]). As in prior analyses, no statistically significant interaction was observed between DM and effect of Warfarin on the risk of the primary outcome, in any of the subgroups explored. In conclusion, we found that DM is common in HFrEF patients, and is associated with other cardiovascular comorbidities and risk factors, and with a worse prognosis.
Collapse
Affiliation(s)
- Giulio Francesco Romiti
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Katarzyna Nabrdalik
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Internal Medicine, Diabetology and Nephrology, Faculty of Medical Sciences in Zabrze, Medical University of Silesia, Katowice, Poland
| | - Bernadette Corica
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Tommaso Bucci
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of General Surgery and Surgical Specialties "Paride Stefanini", Sapienza University of Rome, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy
- Division of Subacute Care, IRCCS Istituti Clinici Scientifici Maugeri, Milan, Italy
| | - Min Qian
- Mailman School of Public Health, Columbia University, New York, USA
| | - Yineng Chen
- Center for Preventive Ophthalmology and Biostatistics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | | | - Shunichi Homma
- Cardiology Division, Columbia University Medical Center, New York, USA
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK.
- Danish Center for Health Services Research, Department of Clinical Medicine, Aalborg University, Aalborg, Denmark.
| |
Collapse
|
10
|
Pol T, Karlström P, Lund LH. Heart failure registries - Future directions. J Cardiol 2024; 83:84-90. [PMID: 37844799 DOI: 10.1016/j.jjcc.2023.10.006] [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: 06/27/2023] [Revised: 09/13/2023] [Accepted: 10/11/2023] [Indexed: 10/18/2023]
Abstract
Heart failure (HF) is a growing, global public health issue. Despite advances in HF care, many challenges remain and HF outcomes are poor. Some of the major reasons for this are the lack of understanding and treatment for certain HF sub-types as well as the lack of implementation of treatment in areas where effective treatment exists. HF registries provide the opportunity to transform clinical research and patient care. Recently the registry-based randomized clinical trial has emerged as a pragmatic and inexpensive alternative to the gold standard in clinical trial design, the randomized controlled trial. Registries may also provide platforms for strategy trials, implementation trials, and screening. Using examples from the Swedish Heart Failure Registry and others, the present review provides insights into how registry-based research can address many of the unmet needs in HF.
Collapse
Affiliation(s)
- Tymon Pol
- Department of Medical Sciences, Cardiology, Uppsala University, Uppsala, Sweden.
| | - Patric Karlström
- Department of Internal Medicine, Ryhov County Hospital, Region Jönköping County, Jönköping, Sweden; Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
11
|
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.
Collapse
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
| |
Collapse
|
12
|
Savarese G, Gatti P, Benson L, Adamo M, Chioncel O, Crespo-Leiro MG, Anker SD, Coats AJS, Filippatos G, Lainscak M, McDonagh T, Mebazaa A, Metra M, Piepoli MF, Rosano GMC, Ruschitzka F, Seferovic P, Volterrani M, Maggioni AP, Lund LH. Left ventricular ejection fraction digit bias and reclassification of heart failure with mildly reduced vs reduced ejection fraction based on the 2021 definition and classification of heart failure. Am Heart J 2024; 267:52-61. [PMID: 37972677 DOI: 10.1016/j.ahj.2023.11.008] [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] [Received: 08/14/2023] [Revised: 10/23/2023] [Accepted: 11/04/2023] [Indexed: 11/19/2023]
Abstract
AIMS Aims were to evaluate (1) reclassification of patients from heart failure with mildly reduced (HFmrEF) to reduced (HFrEF) ejection fraction when an EF = 40% was considered as HFrEF, (2) role of EF digit bias, ie, EF reporting favouring 5% increments; (3) outcomes in relation to missing and biased EF reports, in a large multinational HF registry. METHODS AND RESULTS Of 25,154 patients in the European Society of Cardiology (ESC) HF Long-Term registry, 17% had missing EF and of those with available EF, 24% had HFpEF (EF≥50%), 21% HFmrEF (40%-49%) and 55% HFrEF (<40%) according to the 2016 ESC guidelines´ classification. EF was "exactly" 40% in 7%, leading to reclassifying 34% of the HFmrEF population defined as EF = 40% to 49% to HFrEF when applying the 2021 ESC Guidelines classification (14% had HFmrEF as EF = 41% to 49% and 62% had HFrEF as EF≤40%). EF was reported as a value ending with 0 or 5 in ∼37% of the population. Such potential digit bias was associated with more missing values for other characteristics and higher risk of all-cause death and HF hospitalization. Patients with missing EF had higher risk of all-cause and CV mortality, and HF hospitalization compared to those with recorded EF. CONCLUSIONS Many patients had reported EF = 40%. This led to substantial reclassification of EF from old HFmrEF (40%-49%) to new HFrEF (≤40%). There was considerable digit bias in EF reporting and missing EF reporting, which appeared to occur not at random and may reflect less rigorous overall care and worse outcomes.
Collapse
Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden.
| | - Paolo Gatti
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Maria G Crespo-Leiro
- Unidad de Insuficiencia Cardiaca Avanzada y Trasplante Cardiaco, Complexo Hospitalario Universitario A Coruna, CHUAC, INIBIC, UDC, CIBERCV, La Coruna, Spain
| | - 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, Germany
| | | | - Gerasimos Filippatos
- Heart Failure Unit, Department of Cardiology, University Hospital Attikon, National and Kapodistrian Univeristy of Athens, Athens, Greece
| | - Mitja Lainscak
- Division of Cardiology, Murska Sobota, Murska Sobota and Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | | | - Alexandre Mebazaa
- UMR 942 Inserm - MASCOT; University of Paris, Paris, France; Department of Anesthesia-Burn-Critical Care, APHP Saint Louis Lariboisière University Hospitals, Paris, France
| | - Marco Metra
- Cardiology, ASST Spedali Civili, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Massimo F Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | | | | | - Petar Seferovic
- University of Belgrade Faculty of Medicine, Belgrade, Serbia
| | | | - Aldo P Maggioni
- ANMCO Research Center, He 1 art Care Foundation, Firenze, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
13
|
Lund LH, Crespo-Leiro MG, Laroche C, Garcia-Pinilla JM, Bennis A, Vataman EB, Polovina M, Radovanovic S, Apostolovic SR, Ašanin M, Gackowski A, Kaplon-Cieslicka A, Cabac-Pogorevici I, Anker SD, Chioncel O, Coats AJS, Filippatos G, Lainscak M, Mcdonagh T, Mebazaa A, Metra M, Piepoli M, Rosano GM, Ruschitzka F, Savarese G, Seferović PM, Iung B, Popescu BA, Maggioni AP. Rationale and design of the ESC Heart Failure III Registry - Implementation and discovery. Eur J Heart Fail 2023; 25:2316-2330. [PMID: 37990135 DOI: 10.1002/ejhf.3087] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 10/31/2023] [Accepted: 11/04/2023] [Indexed: 11/23/2023] Open
Abstract
AIMS Heart failure outcomes remain poor despite advances in therapy. The European Society of Cardiology Heart Failure III Registry (ESC HF III Registry) aims to characterize HF clinical features and outcomes and to assess implementation of guideline-recommended therapy in Europe and other ESC affiliated countries. METHODS Between 1 November 2018 and 31 December 2020, 10 162 patients with chronic or acute/worsening HF with reduced, mildly reduced, or preserved ejection fraction were enrolled from 220 centres in 41 European or ESC affiliated countries. The ESC HF III Registry collected data on baseline characteristics (hospital or clinic presentation), hospital course, diagnostic and therapeutic decisions in hospital and at the clinic visit; and on outcomes at 12-month follow-up. These data include demographics, medical history, physical examination, biomarkers and imaging, quality of life, treatments, and interventions - including drug doses and reasons for non-use, and cause-specific outcomes. CONCLUSION The ESC HF III Registry will provide comprehensive and unique insight into contemporary HF characteristics, treatment implementation, and outcomes, and may impact implementation strategies, clinical discovery, trial design, and public policy.
Collapse
Affiliation(s)
- Lars H Lund
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
| | - Maria Generosa Crespo-Leiro
- Department of Cardiology, Hospital Universitario A Coruña (CHUAC), A Coruña, Spain
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Fisioterapia, Medicina y Ciencias Biomédicas, Universidad de A Coruña (UDC), A Coruña, Spain
- Instituto Investigación Biomedica A Coruña (INIBIC), A Coruña, Spain
| | - Cecile Laroche
- EURObservational Research Programme, European Society of Cardiology, Sophia Antipolis, France
| | - Jose M Garcia-Pinilla
- Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Instituto de Salud Carlos III, Madrid, Spain
- Servicio de Cardiología, Hospital Universitario Virgen de la Victoria, Málaga Biomedical Research Institute (IBIMA), Málaga, Spain
- Departamento de Medicina y Dermatología, Universidad de Málaga, Málaga, Spain
| | - Ahmed Bennis
- Department of Cardiology, Ibn Rochd University Center, Casablanca, Morocco
| | - Eleonora B Vataman
- Heart Failure Department, Institute of Cardiology, Chișinău, Moldova
- Cardiac Rehabilitation Department, Institute of Cardiology, Chișinău, Moldova
| | - Marija Polovina
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
| | - Slavica Radovanovic
- Department of Cardiology, Heart Failure Center, University Hospital Center 'Dr Dragisa Misovic-Dedinje', Belgrade, Serbia
| | - Svetlana R Apostolovic
- Department of Cardiology, University Clinical Centre of Serbia, Nis, Serbia
- Medical School, University Clinical Centre of Serbia, Nis, Serbia
| | - Milika Ašanin
- Department of Cardiology, University Clinical Centre of Serbia, Belgrade, Serbia
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
| | - Andrzej Gackowski
- Department of Coronary Disease and Heart Failure, Jagiellonian University, Medical College, John Paul II Hospital, Krakow, Poland
- Noninvasive Cardiovascular Laboratory, John Paul II Hospital, Krakow, Poland
| | | | - Irina Cabac-Pogorevici
- Department of Cardiology, State University of Medicine and Pharmacy 'Nicolae Testemitanu', Chișinău, Moldova
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité, Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Ovidiu Chioncel
- 1st Cardiology Department, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Bucharest, Romania
- University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
| | - Andrew J S Coats
- Office of the CEO, Heart Research Institute, Sydney, NSW, Australia
| | - Gerasimos Filippatos
- Department of Cardiology, National and Kapodistrian, University of Athens, Athens, Greece
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Theresa Mcdonagh
- Cardiovascular Science, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Alexandre Mebazaa
- Anaethesia and Critical Care, APHP, Hôpital Lariboisière, Paris, France
- Burn and the multi-organ retrieval, APHP, Hôpital Saint Louis, Paris, France
- Cardiovascular MArkers in Stressed COndiTions, UMRS INSERM 942, Université Paris-Cité, Paris, France
| | - Marco Metra
- Department of Cardiology, Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
- Department of Cardiology, ASST Spedali Civili, Brescia, Italy
| | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | - Giuseppe M Rosano
- Department of Medical Sciences, IRCCS Ospedale San Raffaele, Rome, Italy
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich and University of Zurich, Zurich, Switzerland
- Department of Cardiology, Center for Translational and Experimental Cardiology (CTEC), University Hospital Zurich and University of Zurich, Zurich, Switzerland
| | - Gianluigi Savarese
- Unit of Cardiology, Department of Medicine, Karolinska Institutet, Karolinska University Hospital, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Petar M Seferović
- Faculty of Medicine, Belgrade University, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Bernard Iung
- Department of Cardiology, APHP, Hôpital Bichat Claude-Bernard, Paris, France
- LVTS INSERM 1148, Université Paris-Cité, Paris, France
| | - Bogdan A Popescu
- Department of Cardiology, University of Medicine and Pharmacy 'Carol Davila', Bucharest, Romania
- Department of Cardiology, Emergency Institute for Cardiovascular Diseases 'Prof. Dr. C.C. Iliescu', Bucharest, Romania
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| |
Collapse
|
14
|
Guidetti F, Lund LH, Benson L, Hage C, Musella F, Stolfo D, Mol PGM, Flammer AJ, Ruschitzka F, Dahlstrom U, Rosano GMC, Braun OÖ, Savarese G. Safety of continuing mineralocorticoid receptor antagonist treatment in patients with heart failure with reduced ejection fraction and severe kidney disease: Data from Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:2164-2173. [PMID: 37795642 DOI: 10.1002/ejhf.3049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
AIMS Mineralocorticoid receptor antagonists (MRAs) improve outcomes in heart failure with reduced ejection fraction (HFrEF) but remain underused and are often discontinued especially in patients with chronic kidney disease (CKD) due to concerns on renal safety. Therefore, in a real-world HFrEF population we investigated the safety of MRA use, in terms of risk of renal events, any mortality and any hospitalization, across the estimated glomerular filtration rate (eGFR) spectrum including severe CKD. METHODS AND RESULTS We analysed patients with HFrEF (ejection fraction <40%), not on dialysis, from the Swedish Heart Failure Registry. We performed multivariable logistic regression models to investigate patient characteristics independently associated with MRA use, and univariable and multivariable Cox regression models to assess the associations between MRA use and outcomes. Of 33 942 patients, 17 489 (51%) received MRA, 32%, 45%, 54%, 54% with eGFR <30, 30-44, 45-59 or ≥60 ml/min/1.73 m2 , respectively. An eGFR ≥60 ml/min/1.73 m2 and patient characteristics linked with more severe HF were independently associated with more likely MRA use. In multivariable analyses, MRA use was consistently not associated with a higher risk of renal events (i.e. composite of dialysis/renal death/hospitalization for renal failure or hyperkalaemia) (hazard ratio [HR] 1.04, 95% confidence interval [CI] 0.98-1.10), all-cause death (HR 1.02, 95% CI 0.97-1.08) as well as of all-cause hospitalization (HR 0.99, 95% CI 0.95-1.02) across the eGFR spectrum including also severe CKD. CONCLUSIONS The use of MRAs in patients with HFrEF decreased with worse renal function; however their safety profile was demonstrated to be consistent across the entire eGFR spectrum.
Collapse
Affiliation(s)
- Federica Guidetti
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Camilla Hage
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | - Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Cardiology, Cardiovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - Peter G M Mol
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Andreas J Flammer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Ulf Dahlstrom
- Department of Cardiology and Department of Health, Medicine and Caring Sciences Linköping University, Linköping, Sweden
| | | | - Oscar Ö Braun
- Cardiology, Department of Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
15
|
Jarjour M, Ducharme A. Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines? Drugs Context 2023; 12:2023-5-6. [PMID: 38021409 PMCID: PMC10664772 DOI: 10.7573/dic.2023-5-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Heart failure is a growing epidemic with high mortality rates and recurrent hospital admissions that creates a burden on affected individuals, their caregivers and the whole healthcare system. Throughout the years, many randomized trials have established the effectiveness of several pharmacological therapies and electrophysiological devices to reduce hospitalizations and improve quality of life and survival, mostly for patients with heart failure with reduced ejection fraction (HFrEF). These studies led to the publication of national societies' recommendations to guide clinicians in the management of HFrEF. Yet, many reports have shown significant care gaps in adherence to these recommendations in clinical practice, highlighting suboptimal use and/or dosing of evidence-based therapies. Adherence to guidelines has been shown to be associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events; however, it remains unclear whether this association is causal or merely a marker of more advanced disease. Furthermore, individual characteristics may limit the possibility of reaching the targeted dosage of specific agents. Herein, we provide a comprehensive overview of clinicians' adherence to heart failure guidelines in a specialized real-life setting, particularly regarding use and optimization of guideline-derived medical therapies, as well as the implementation of more recent agents such as sacubitril/valsartan and SGLT2 inhibitors. We seek potential explanations for suboptimal treatment and its impact on patient outcomes.
Collapse
Affiliation(s)
- Marilyne Jarjour
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
| |
Collapse
|
16
|
Bozkurt B, Savarese G, Adamsson Eryd S, Bodegård J, Cleland JGF, Khordoc C, Kishi T, Thuresson M, Vardeny O, Zhang R, Lund LH. Mortality, Outcomes, Costs, and Use of Medicines Following a First Heart Failure Hospitalization: EVOLUTION HF. JACC. HEART FAILURE 2023; 11:1320-1332. [PMID: 37354145 DOI: 10.1016/j.jchf.2023.04.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND There are few contemporary data on outcomes, costs, and treatment following a hospitalization for heart failure (hHF) in epidemiologically representative cohorts. OBJECTIVES This study sought to describe rehospitalizations, hospitalization costs, use of guideline-directed medical therapy (GDMT) (renin-angiotensin system inhibitors, sacubitril/valsartan, beta-blockers, mineralocorticoid receptor antagonists, and sodium-glucose cotransporter-2 inhibitors), and mortality after hHF. METHODS EVOLUTION HF (Utilization of Dapagliflozin and Other Guideline Directed Medical Therapies in Heart Failure Patients: A Multinational Observational Study Based on Secondary Data) is an observational, longitudinal cohort study using data from electronic health records or claims data sources in Japan, Sweden, the United Kingdom, and the United States. Adults with a first hHF discharge between 2018 and 2022 were included. The 1-year event rates per 100 patient-years (ERs) for death and rehospitalizations (with a primary diagnosis of heart failure (HF), chronic kidney disease [CKD], myocardial infarction, stroke, or peripheral artery disease) were calculated. Hospital health care costs were cumulatively summarized. Cumulative GDMT use was assessed using Kaplan-Meier estimates. RESULTS Of 263,525 patients, 28% died within the first year post-hHF (ER: 28.4 [95% CI: 27.0-29.9]). Rehospitalizations were mainly driven by HF (ER: 13.6 [95% CI: 9.8-17.4]) and CKD (ER: 4.5 [95% CI: 3.6-5.3]), whereas the ERs for myocardial infarction, stroke, and peripheral artery disease were lower. Health care costs were predominantly driven by HF and CKD. Between 2020 and 2022, use of renin-angiotensin system inhibitors, sacubitril/valsartan, beta-blockers, and mineralocorticoid receptor antagonists changed little, whereas uptake of sodium-glucose cotransporter-2 inhibitors increased 2- to 7-fold. CONCLUSIONS Incident post-hHF rehospitalization risks and costs were high, and GDMT use changed little in the year following discharge, highlighting the need to consider earlier and greater implementation of GDMT to manage risks and reduce costs.
Collapse
Affiliation(s)
- Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas, USA
| | - Gianluigi Savarese
- Cardiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.
| | | | - Johan Bodegård
- CVRM Evidence, BioPharmaceuticals Medical, AstraZeneca, Gothenburg, Sweden
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, United Kingdom
| | - Cindy Khordoc
- Global Medical Affairs, BioPharmaceuticals Medical, AstraZeneca, Wilmington, Delaware, USA
| | - Takuya Kishi
- Department of Graduate School of Medicine (Cardiology), International University of Health and Welfare, Okawa, Japan
| | | | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
| | - Ruiqi Zhang
- Medical and Scientific Affairs, BioPharmaceuticals Medical, AstraZeneca, London, United Kingdom
| | - Lars H Lund
- Cardiology Unit, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
17
|
Stolfo D, Lund LH, Sinagra G, Lindberg F, Dahlström U, Rosano G, Savarese G. Heart failure pharmacological treatments and outcomes in heart failure with mildly reduced ejection fraction. EUROPEAN HEART JOURNAL. CARDIOVASCULAR PHARMACOTHERAPY 2023; 9:526-535. [PMID: 37204037 PMCID: PMC10509568 DOI: 10.1093/ehjcvp/pvad036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Revised: 04/25/2023] [Accepted: 05/17/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND Guideline recommendations for the treatment of heart failure with mildly reduced ejection fraction (HFmrEF) derive from small subgroups in post-hoc analyses of randomized trials. OBJECTIVES We investigated predictors of renin-angiotensin system inhibitors/angiotensin receptor neprilysin inhibitors (RASI/ARNI) and beta-blockers use, and the associations between these medications and mortality/morbidity in a large real-world cohort with HFmrEF. METHODS AND RESULTS Patients with HFmrEF (EF 40-49%) from the Swedish HF Registry were included. The associations between medications and cardiovascular (CV) mortality/HF hospitalization (HFH), and all-cause mortality were assessed through Cox regressions in a 1:1 propensity score-matched cohort. A positive control analysis was performed in patients with EF < 40%, while a negative control outcome analysis had cancer-related hospitalization as endpoint. Of 12 421 patients with HFmrEF, 84% received RASI/ARNI and 88% beta-blockers. Shared-independent predictors of RASI/ARNI and beta-blockers use were younger age, being an outpatient, follow-up in specialty care, and hypertension. In the matched cohorts, use of both RASI/ARNI and beta-blocker use was separately associated with lower risk of CV mortality/HFH [hazard ratio (HR) = 0.90, 95% confidence interval (CI): 0.83-0.98 and HR = 0.82, 95% CI: 0.74-0.90, respectively] and of all-cause mortality (HR = 0.75, 95% CI: 0.69-0.81 and HR = 0.79, 95% CI: 0.72-0.87, respectively). Results were consistent at the positive control analysis, and there were no associations between treatment use and the negative control outcome. CONCLUSIONS RASI/ARNI and beta-blockers were extensively used in this large real-world cohort with HFmrEF. Their use was safe since associated with lower mortality and morbidity. Our findings confirm the real-world evidence from previous post-hoc analyses of trials, and represent a further call for implementing guideline recommendations.
Collapse
Affiliation(s)
- Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart, Vascular and Neuro Theme Karolinska University Hospital, Norrbacka S3:00, Stockholm 171 76, Sweden
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and Univeristy Hospital of Trieste, Trieste, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart, Vascular and Neuro Theme Karolinska University Hospital, Norrbacka S3:00, Stockholm 171 76, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and Univeristy Hospital of Trieste, Trieste, Italy
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart, Vascular and Neuro Theme Karolinska University Hospital, Norrbacka S3:00, Stockholm 171 76, Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Giuseppe Rosano
- Department of Medical Sciences, IRCCS San Raffaele, Rome, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Heart, Vascular and Neuro Theme Karolinska University Hospital, Norrbacka S3:00, Stockholm 171 76, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
18
|
Stolfo D, Lund LH, Benson L, Lindberg F, Ferrannini G, Dahlström U, Sinagra G, Rosano GMC, Savarese G. Real-world use of sodium-glucose cotransporter 2 inhibitors in patients with heart failure and reduced ejection fraction: Data from the Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:1648-1658. [PMID: 37419495 DOI: 10.1002/ejhf.2971] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 06/28/2023] [Accepted: 07/04/2023] [Indexed: 07/09/2023] Open
Abstract
AIMS Sodium-glucose cotransporter 2 inhibitors (SGLT2i) reduce mortality/morbidity in heart failure (HF). We explored the implementation of SGLT2i over time, and patient characteristics associated with their use, in a large, nationwide population with HF with reduced ejection fraction (HFrEF). METHODS AND RESULTS Patients with HFrEF (ejection fraction <40%), no type 1 diabetes, estimated glomerular filtration rate (eGFR) <20 ml/min/1.73 m2 and/or on dialysis, registered in the Swedish HF Registry between 1 November 2020 and 5 August 2022 were included. Independent predictors of use were investigated by multivariable logistic regressions. Of 8192 patients, 37% received SGLT2i. Use increased overall from 20.5% to 59.0% over time, from 46.2% and 12.5% to 69.8% and 55.4% in patients with and without type 2 diabetes, from 14.7% and 22.3% to 58.0% and 59.8% in eGFR <60 versus ≥60 ml/min/1.73 m2 , from 21.0% and 18.9% to 61.6% and 52.0% in males versus females, from 24.2% and 18.0% to 60.8% and 57.7% in patients with versus without recent HF hospitalization, from 26.1% and 19.8% to 54.7% and 59.6% in inpatients versus outpatients, and from 20.2% and 21.2% to 59.2% and 58.7% in those with HF duration <6 versus ≥6 months, respectively. Important characteristics associated with SGLT2i use were male sex, recent HF hospitalization, specialized HF follow-up, lower ejection fraction, type 2 diabetes, higher education level, use of other HF/cardiovascular interventions. Older age, higher blood pressure, atrial fibrillation and anaemia were associated with less use. Discontinuation rate at 6 and 12 months was 13.1% and 20.0%, respectively. CONCLUSIONS Use of SGLT2i increased three-fold over 2 years. Although this indicates a more rapid translation of trial results and guidelines into clinical practice compared to previous HF drugs, further efforts are advocated to complete the implementation process while avoiding inequities across different patient subgroups and discontinuations.
Collapse
Affiliation(s)
- Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI) and University Hospital of Trieste, Trieste, Italy
| | | | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
19
|
Nguyen NV, Lindberg F, Benson L, Ferrannini G, Imbalzano E, Mol PGM, Dahlström U, Rosano GMC, Ezekowitz J, Butler J, Lund LH, Savarese G. Eligibility for vericiguat in a real-world heart failure population according to trial, guideline and label criteria: Data from the Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:1418-1428. [PMID: 37323078 DOI: 10.1002/ejhf.2939] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Revised: 05/29/2023] [Accepted: 06/08/2023] [Indexed: 06/17/2023] Open
Abstract
AIM We investigated the eligibility for vericiguat in a real-world heart failure (HF) population based on trial, guideline and label criteria. METHODS AND RESULTS From the Swedish HF registry, 23 573 patients with HF with reduced ejection fraction (HFrEF) enrolled between 2000 and 2018, with a HF duration ≥6 months, were considered. Eligibility for vericiguat was calculated based on criteria from (i) the Vericiguat Global Study in Subjects with Heart Failure and Reduced Ejection Fraction (VICTORIA) trial; (ii) European and American guidelines on HF; (iii) product labelling according to the Food and Drug Administration and European Medicines Agency. Estimated eligibility for vericiguat in the trial, guidelines, and label scenarios was 21.4%, 47.4%, and 47.4%, respectively. Prior HF hospitalization within 6 months was the criterion limiting eligibility the most in all scenarios (met by 49.1% of the population). In the trial scenario, other criteria meaningfully limiting eligibility were elevated N-terminal pro-B-type natriuretic peptide levels and nitrate use. In all scenarios, eligibility was higher among patients hospitalized for HF at baseline (44.3% vs. 21.4% [trial scenario] and 97.3% vs. 47.4% [guideline/label scenarios] for hospitalized vs. non-hospitalized patients). Overall, eligible patients were older, had more severe HF, more comorbidities, and consequently higher cardiovascular mortality and HF hospitalization rates compared with ineligible patients across all scenarios. CONCLUSION In a large and contemporary real-world HFrEF cohort, we estimated that 21.4% of patients would be eligible for vericiguat according to the VICTORIA trial selection criteria, 47.4% based on guidelines and labelling. Eligibility for vericiguat translated into the selection of a population at high risk of morbidity/mortality.
Collapse
Affiliation(s)
- Ngoc V Nguyen
- Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Peter G M Mol
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | | | - Justin Ezekowitz
- Division of Cardiology, University of Alberta, Edmonton, Alberta, Canada
| | - Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA
- Baylor Scott and White Institute, Dallas, TX, USA
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
20
|
Van der Linden L, Hias J, Walgraeve K, Petrovic M, Tournoy J, Vandenbriele C, Van Aelst L. Guideline-Directed Medical Therapies for Heart Failure with a Reduced Ejection Fraction in Older Adults: A Narrative Review on Efficacy, Safety and Timeliness. Drugs Aging 2023; 40:691-702. [PMID: 37452262 DOI: 10.1007/s40266-023-01046-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2023] [Indexed: 07/18/2023]
Abstract
Heart failure is a prevalent syndrome among older adults, with a major impact on morbidity and mortality. Higher age is correlated with underuse of guideline-directed medical therapies which, in turn, has been linked to worse clinical outcomes. Importantly, most evidence so far has been collected in adults who were younger, less multi-morbid and polymedicated compared with those who are commonly treated in daily clinical practice. Hence, we aimed to assess and describe the evidence base for pharmacotherapy in older adults with heart failure with a reduced ejection. First, a narrative review was undertaken using Medline, from inception to January 2023. Four foundational therapies were selected based on the latest European Society of Cardiology clinical practice guideline: angiotensin-converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors, beta blockers, mineralocorticoid receptor antagonists and sodium-glucose cotransporter-2 inhibitors. Post hoc analyses from landmark heart failure drug trials were searched and included if they contained data on the impact of age on efficacy, safety and/or timeliness of therapies in the management of heart failure with a reduced ejection fraction. Second, a proposal was developed to support and promote the use of evidence-based heart failure pharmacotherapy in complex, older adults. In total, 11 articles were selected: 4 meta-analyses, 6 post hoc analyses and 1 review paper. No attenuation of efficacy for any of the foundational agents was found in older adults. Regarding safety, dedicated analyses showed that beta blockers, mineraloid receptor antagonists, sacubitril-valsartan, dapagliflozin and empagliflozin retained their overall benefit-risk profile regardless of age. Time to benefit was short and occurred generally within 1 month. Consensus was achieved on a five-step proposal to manage complex medication regimens in older adults suffering from heart failure. In conclusion, older adults suffering from heart failure with a reduced ejection fraction should not be denied treatment based on their age.
Collapse
Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
- Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karolien Walgraeve
- Pharmacy Department, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Mirko Petrovic
- Section of Geriatrics, Department of Internal Medicine and Paediatrics, Faculty of Medicine and Health Sciences, Ghent University, Ghent, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Public Health and Primary care, KU Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Adult intensive Care, Royal Brompton Hospital, Guy's & St. Thomas' NHS Foundations Trust, London, UK
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium
- Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
21
|
Gatti P, Lind S, Kristjánsdóttir I, Azari A, Savarese G, Anselmino M, Linde C, Gadler F. Prognosis of CRT-treated and CRT-untreated unselected population with LBBB in Stockholm County. Europace 2023; 25:euad192. [PMID: 37403689 PMCID: PMC10365846 DOI: 10.1093/europace/euad192] [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: 04/13/2023] [Accepted: 05/23/2023] [Indexed: 07/06/2023] Open
Abstract
AIMS Left bundle branch block (LBBB) might be the first finding of cardiovascular diseases but also the prerequisite for cardiac resynchronization therapy (CRT) in heart failure (HF) with reduced ejection fraction (HFrEF). The prognosis for patients with LBBB and the implications of CRT in an unselected real-world setting are the focus of our study. METHODS AND RESULTS A central electrocardiogram (ECG) database and national registers have been screened to identify patients with LBBB. Predictors of HF and the use of CRT were identified with Cox models. The hazard ratios (HRs) of death, cardiovascular death (CVD), and HF hospitalization (HFH) were estimated according to CRT use. Of 5359 patients with LBBB and QRS > 150 ms, median age 76 years, 36% were female. At the time of index ECG, 41% had a previous history of HF and 27% developed HF. Among 1053 patients with a class I indication for CRT, only 60% received CRT with a median delay of 137 days, and it was associated with a lower risk of death [HR: 0.45, 95% confidence interval (CI): 0.36-0.57], CVD (HR: 0.47, 95% CI: 0.35-0.63), and HFH (HR: 0.56, 95% CI: 0.48-0.66). The age of over 75 years and the diagnosis of dementia and chronic obstructive pulmonary disease were predictors of CRT non-use, while having a pacing/defibrillator device independently predicted CRT use. CONCLUSION In an unselected LBBB population, CRT is underused but of great value for HF patients. Therefore, it is crucial to find ways of better implementing and understanding CRT utilization and characteristics that influence the management of our patients.
Collapse
Affiliation(s)
- Paolo Gatti
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
| | - Stefan Lind
- Department of Cardiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Ingibjörg Kristjánsdóttir
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
| | - Ava Azari
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
- Department of Cardiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Matteo Anselmino
- Division of Cardiology, Department of Medical Sciences, University of Turin, Azienda Ospedaliero Universitaria (A.O.U.) Città della Salute e della Scienza di Torino, 10126 Turin, Italy
| | - Cecilia Linde
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
- Department of Cardiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| | - Fredrik Gadler
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Norrbacka S1:02, Eugeniavägen 27-31, 171 76 Stockholm, Sweden
- Department of Cardiology, Karolinska Universitetssjukhuset, Stockholm, Sweden
| |
Collapse
|
22
|
Schrage B, Lund LH, Benson L, Braunschweig F, Ferreira JP, Dahlström U, Metra M, Rosano GMC, Savarese G. Association between a hospitalization for heart failure and the initiation/discontinuation of guideline-recommended treatments: An analysis from the Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:1132-1144. [PMID: 37317585 DOI: 10.1002/ejhf.2928] [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: 12/22/2022] [Revised: 04/25/2023] [Accepted: 06/07/2023] [Indexed: 06/16/2023] Open
Abstract
AIMS To investigate whether a heart failure (HF) hospitalization is associated with initiation/discontinuation of guideline-directed medical HF therapy (GDMT) and consequent outcomes. METHODS AND RESULTS Among patients in the Swedish HF registry with an ejection fraction <50% enrolled in 2009-2018, initiation/discontinuation of GDMT was investigated by assessing dispensations of GDMT in those with versus without a HF hospitalization. Of 14 737 patients, 6893 (47%) were enrolled when hospitalized for HF. Initiation of GDMT was more likely than discontinuation following a HF hospitalization compared to a control group of patients without a HF hospitalization (odds ratio range 2.1-4.0 vs. 1.4-1.6 for the individual medications), although the proportion of patients not on GDMT was still high (8.1-44.0%). Key patient characteristics triggering less use of GDMT (i.e. less initiation or more discontinuation) were older age and worse renal function. Following a HF hospitalization, initiation of renin-angiotensin system inhibitors/angiotensin receptor-neprilysin inhibitors or beta-blockers was associated with lower and their discontinuation with higher mortality risk, but no association with mortality was observed for initiation/discontinuation of mineralocorticoid receptor antagonists. CONCLUSIONS Following a HF hospitalization, initiation of GDMT was more likely than discontinuation, although still limited. Perceived or actual low tolerance were barriers to GDMT implementation. Early re-/initiation of GDMT was associated with better survival. Our findings represent a call for further implementing the current guideline recommendation for an early re-/initiation of GDMT following a HF hospitalization.
Collapse
Affiliation(s)
- Benedikt Schrage
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- University Heart and Vascular Centre Hamburg, Department of Cardiology and German Center for Cardiovascular Research (DZHK), partner site Hamburg/Lübeck/Kiel, Hamburg, Germany
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Frieder Braunschweig
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Université de Lorraine, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Marco Metra
- Department of Medical and Surgical Specialities, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe M C Rosano
- Centre for Clinical and Basic Research, IRCCS San Raffaele Roma, Rome, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
23
|
Arrigo M, Biegus J, Asakage A, Mebazaa A, Davison B, Edwards C, Adamo M, Barros M, Celutkiene J, Čerlinskaitė-Bajorė K, Chioncel O, Damasceno A, Diaz R, Filippatos G, Gayat E, Kimmoun A, Lam CSP, Metra M, Novosadova M, Pagnesi M, Pang PS, Ponikowski P, Saidu H, Sliwa K, Takagi K, Ter Maaten JM, Tomasoni D, Voors AA, Cotter G, Cohen-Solal A. Safety, tolerability and efficacy of up-titration of guideline-directed medical therapies for acute heart failure in elderly patients: A sub-analysis of the STRONG-HF randomized clinical trial. Eur J Heart Fail 2023; 25:1145-1155. [PMID: 37246591 DOI: 10.1002/ejhf.2920] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 05/11/2023] [Accepted: 05/23/2023] [Indexed: 05/30/2023] Open
Abstract
AIMS STRONG-HF examined a high-intensity care (HIC) strategy of rapid up-titration of guideline-directed medical therapy (GDMT) and close follow-up after acute heart failure (AHF) admission. We assess the role of age on efficacy and safety of HIC. METHODS AND RESULTS Hospitalized AHF patients, not treated with optimal GDMT were randomized to HIC or usual care. The primary endpoint of 180-day death or HF readmission occurred equally in older (>65 years, n = 493, 74 ± 5 years) and younger patients (53 ± 11 years, adjusted hazard ratio [aHR] 1.02, 95% confidence interval [CI] 0.73-1.43, p = 0.89). Older patients received slightly lower GDMT to day 21, but same doses at day 90 and 180. The effect of HIC on the primary endpoint was numerically higher in younger (aHR 0.51, 95% CI 0.32-0.82) than older patients (aHR 0.73, 95% CI 0.46-1.15, adjusted interaction p = 0.30), partially related to COVID-19 deaths. After exclusion of COVID-19 deaths, the effect of HIC was similar in younger (aHR 0.51, 95% CI 0.32-0.82) and older patients (aHR 0.63, 95% CI 0.32-1.02, adjusted interaction p = 0.56), with no treatment-by-age interaction (interaction p = 0.57). HIC induced larger improvements in quality of life to day 90 in younger (EQ-VAS adjusted-mean difference 5.51, 95% CI 3.20-7.82) than in older patients (1.77, 95% CI -0.75 to 4.29, interaction p = 0.032). HIC was associated with similar rates of adverse events in older and younger patients. CONCLUSION High-intensity care after AHF was safe and resulted in a significant reduction of all-cause death or HF readmission at 180 days across the study age spectrum. Older patients have smaller benefits in terms of quality of life.
Collapse
Affiliation(s)
- Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Ayu Asakage
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
| | - 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
- Heart Initiative, Durham, NC, USA
| | | | - Marianna Adamo
- Cardiology, Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine 'Carol Davila', Bucharest, Romania
| | | | - 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
| | - 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
| | - Antoine Kimmoun
- Université de Lorraine, Nancy, France
- INSERM, Défaillance Circulatoire Aigue et Chronique; Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Nancy, France
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Marco Metra
- Cardiology, Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Matteo Pagnesi
- Cardiology, Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Hadiza Saidu
- Department of Medicine, Murtala Muhammed Specialist Hospital/Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Cape Heart Institute, Division of Cardiology, Department of Medicine, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | | | - Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Daniela Tomasoni
- Cardiology, Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Heart Initiative, Durham, NC, USA
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942 (MASCOT), Paris, France
- Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| |
Collapse
|
24
|
Rosano GMC, Savarese G. Implementing an earlier and more intensive follow-up in acute heart failure: the STRONG-HF and COACH trials. Nat Rev Cardiol 2023; 20:213-214. [PMID: 36747103 DOI: 10.1038/s41569-023-00841-x] [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: 02/08/2023]
Affiliation(s)
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| |
Collapse
|
25
|
Dai L, Dorje T, Gootjes J, Shah A, Dembo L, Rankin J, Hillis G, Robinson S, Atherton JJ, Jacques A, Reid CM, Maiorana A. Primary care Adherence To Heart Failure guidelines IN Diagnosis, Evaluation and Routine management (PATHFINDER): a randomised controlled trial protocol. BMJ Open 2023; 13:e063656. [PMID: 36972959 PMCID: PMC10069547 DOI: 10.1136/bmjopen-2022-063656] [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: 04/29/2022] [Accepted: 02/06/2023] [Indexed: 03/29/2023] Open
Abstract
INTRODUCTION General practitioners (GPs) routinely provide care for patients with heart failure (HF); however, adherence to management guidelines, including titrating medication to optimal dose, can be challenging in this setting. This study will evaluate the effectiveness of a multifaceted intervention to support adherence to HF management guidelines in primary care. METHODS AND ANALYSIS We will undertake a multicentre, parallel-group, randomised controlled trial of 200 participants with HF with reduced ejection fraction. Participants will be recruited during a hospital admission due to HF. Following hospital discharge, the intervention group will have follow-up with their GP scheduled at 1 week, 4 weeks and 3 months with the provision of a medication titration plan approved by a specialist HF cardiologist. The control group will receive usual care. The primary endpoint, assessed at 6 months, will be the difference between groups in the proportion of participants being prescribed five guideline-recommended treatments; (1) ACE inhibitor/angiotensin receptor blocker/angiotensin receptor neprilysin inhibitor at least 50% of target dose, (2) beta-blocker at least 50% of target dose, (3) mineralocorticoid receptor antagonist at any dose, (4) anticoagulation for patients diagnosed with atrial fibrillation, (5) referral to cardiac rehabilitation. Secondary outcomes will include functional capacity (6-minute walk test); quality of life (Kansas City Cardiomyopathy Questionnaire); depressive symptoms (Patient Health Questionnaire-2); self-care behaviour (Self-Care of Heart Failure Index). Resource utilisation will also be assessed. ETHICS AND DISSEMINATION Ethical approval was granted by the South Metropolitan Health Service Ethics Committee (RGS3531), with reciprocal approval at Curtin University (HRE2020-0322). Results will be disseminated via peer-reviewed publications and conferences. TRIAL REGISTRATION NUMBER ACTRN12620001069943.
Collapse
Affiliation(s)
- Liying Dai
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
| | - Tashi Dorje
- Department of Cardiology, Mount Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Department of Cardiology, Joondalup Health Campus, Joondalup, Western Australia, Australia
| | - Jan Gootjes
- WA Cardiology, Perth, Western Australia, Australia
| | - Amit Shah
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Lawrence Dembo
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Jamie Rankin
- Department of Cardiology and Advanced Heart Failure and Cardiac Transplant Service, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| | - Graham Hillis
- Department of Cardiology, Royal Perth Hospital, Perth, Western Australia, Australia
- Medical School, The University of Western Australia, Perth, Western Australia, Australia
| | - Suzanne Robinson
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- Deakin Health Economics, Deakin University, Melbourne, Western Australia, Australia
| | - John J Atherton
- Department of Cardiology, Royal Brisbane and Women's Hospital, Herston, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Angela Jacques
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Institute for Health Research, The University of Notre Dame, Fremantle, Western Australia, Australia
| | - Christopher M Reid
- Curtin School of Population Health, Curtin University, Perth, Western Australia, Australia
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrew Maiorana
- Curtin School of Allied Health, Curtin University, Perth, Western Australia, Australia
- Department of Allied Health, Fiona Stanley Hospital, Murdoch, Western Australia, Australia
| |
Collapse
|
26
|
Clark KAA, Nanna MG. Doing Harm by Doing No Harm? Resisting the Urge to Retire GDMT in Older Adults With Heart Failure. J Card Fail 2023; 29:445-447. [PMID: 36841428 DOI: 10.1016/j.cardfail.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2023] [Accepted: 02/16/2023] [Indexed: 02/26/2023]
Affiliation(s)
- Katherine A A Clark
- From the Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT.
| | - Michael G Nanna
- From the Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT
| |
Collapse
|
27
|
Sepehrvand N, Nabipoor M, Youngson E, McAlister FA, Ezekowitz JA. Time to Triple Therapy in Patients With de Novo Heart Failure With Reduced Ejection Fraction: a Population-Based Study. J Card Fail 2023; 29:719-729. [PMID: 36754252 DOI: 10.1016/j.cardfail.2023.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Quadruple therapy is recommended for the management of patients with heart failure (HF) and reduced ejection fraction (HFrEF). In order to provide background and identify barriers to quadruple therapy, in this study, the aim was to explore the time to initiation of triple therapy in a population-based cohort of patients with de novo HF. METHODS Adult patients with de novo hospital or emergency department (ED) diagnosis of HF between April 1, 2008, and March 31, 2018, in Alberta, Canada, were included and were linked to echocardiography data to identify patients with HFrEF (EF ≤ 40%). Any treatment with angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers/ angiotensin receptor neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists was captured if prescribed for ≥ 28 days and filled at least once during the 12 months after the index episode. RESULTS Among 14,092 patients with de novo HF and available echocardiography data, 54.9% had HFrEF. By 1 year after diagnosis, of those in the HFrEF cohort, 9.5% had received no therapy, 27.5% monotherapy, 41.6% dual therapy, and 21.4% triple therapy. The median (interquartile range) of time to mono-, dual- and triple therapy in patients with HFrEF were 1 (0, 26), 8 (0, 44), and 14 (0, 52) days, respectively. Patients who received triple therapy were younger, more likely to be male and to have higher frequencies of coronary artery disease, higher glomerular filtration rates and lower left ventricular ejection fraction levels compared to their counterparts. Patients with triple therapy had lower rates of clinical outcomes compared to those on no, mono or dual therapy (adjusted hazard ratio 0.15, 95% confidence interval 0.13, 0.17 for the composite outcome of death, hospitalization due to HF, or ED visit due to HF). CONCLUSION Despite guideline recommendations, triple therapy is underused and is slowly deployed in patients with HFrEF, even after hospitalization and ED presentation.
Collapse
Affiliation(s)
- Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Majid Nabipoor
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
28
|
Savarese G, Kishi T, Vardeny O, Adamsson Eryd S, Bodegård J, Lund LH, Thuresson M, Bozkurt B. Heart Failure Drug Treatment-Inertia, Titration, and Discontinuation: A Multinational Observational Study (EVOLUTION HF). JACC. HEART FAILURE 2023; 11:1-14. [PMID: 36202739 DOI: 10.1016/j.jchf.2022.08.009] [Citation(s) in RCA: 53] [Impact Index Per Article: 53.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/24/2022] [Accepted: 08/26/2022] [Indexed: 01/20/2023]
Abstract
BACKGROUND Guidelines recommend early initiation of multiple guideline-directed medical therapies (GDMTs) to reduce mortality/rehospitalization in patients with heart failure and reduced ejection fraction. Understanding GDMT use is critical to improving clinical practice. OBJECTIVES This study sought to describe GDMT use in Japan, Sweden, and the United States in contemporary real-world settings. METHODS EVOLUTION HF (Utilization of Dapagliflozin and Other Guideline Directed Medical Therapies in Heart Failure Patients: A Multinational Observational Study Based on Secondary Data) is an observational cohort study using routine-care databases. Patients initiating any GDMT within 12 months of a hospitalization for heart failure (hHF) discharge were included. Dapagliflozin (the only sodium-glucose cotransporter-2 inhibitor approved at study onset), sacubitril/valsartan, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), beta-blockers, and mineralocorticoid receptor antagonists (MRAs) were considered separately. Doses and discontinuation were assessed in the 12 months following initiation. Target dose was defined as ≥100% of the guideline-recommended dose. RESULTS Overall, 266,589 patients were included. Mean times from hHF to GDMT initiation were longer for novel GDMTs (dapagliflozin or sacubitril/valsartan) than for other GDMTs: 39 and 44 vs 12 to 13 days (Japan), 44 and 33 vs 22 to 31 days (Sweden), and 33 and 19 vs 18 to 24 days (United States). Pooled across countries, proportions of patients who discontinued therapy (not including switches from ACE inhibitor or ARB to sacubitril/valsartan) within 12 months were 23.5% (dapagliflozin), 26.4% (sacubitril/valsartan), 38.4% (ACE inhibitors), 33.4% (ARBs), 25.2% (beta-blockers), and 42.2% (MRAs). Corresponding target dose achievements were 75.7%, 28.2%, 20.1%, 6.7%, 7.2%, and 5.1%, respectively. CONCLUSIONS Initiation of novel GDMTs is delayed compared with other GDMTs. Few patients received target doses of GDMTs requiring uptitration. Persistence was higher for dapagliflozin than other GDMTs.
Collapse
Affiliation(s)
- Gianluigi Savarese
- Cardiology Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden.
| | - Takuya Kishi
- Department of Graduate School of Medicine (Cardiology), International University of Health and Welfare, Okawa, Japan
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research, University of Minnesota, Minneapolis, Minnesota, USA
| | | | - Johan Bodegård
- CVRM Evidence, BioPharmaceuticals Medical, AstraZeneca, Oslo, Norway
| | - Lars H Lund
- Cardiology Unit, Department of Medicine, Karolinska Institute, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiovascular Research Institute, Baylor College of Medicine, Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| |
Collapse
|
29
|
Van der Linden L, Hias J, Walgraeve K, Tournoy J, Van Aelst L, Vandenbriele C. Estimating the Time to Benefit for Therapies in Heart Failure with Reduced Ejection Fraction: A Case Study of Sacubitril-Valsartan Using Reconstructed Data from a Randomized Controlled Trial. Drugs Aging 2022; 39:959-966. [PMID: 36404386 DOI: 10.1007/s40266-022-00987-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/02/2022] [Indexed: 11/22/2022]
Abstract
BACKGROUND Foundational therapies in heart failure improve clinical outcomes in heart failure with a reduced ejection fraction (HFrEF). Underuse of these life-prolonging heart failure therapies, such as sacubitril-valsartan, is common in older adults and has been associated with worse clinical outcomes. Characterizing the early benefits seen with these therapies might help increase their uptake in older adults. OBJECTIVE We applied several methods to estimate the time to benefit of an HFrEF therapy, using sacubitril-valsartan as a case study. METHODS PARADIGM-HF was a randomized controlled study on sacubitril-valsartan versus enalapril in stable, ambulatory HFrEF patients (n = 8399). The primary endpoint, a composite of death from cardiovascular causes or a first hospitalization for heart failure, was significantly reduced (sacubitril-valsartan (21.8%) versus enalapril (26.5%), hazard ratio (HR) 0.80 (95% confidence interval [CI] 0.73-0.87). We extracted and tabulated the Kaplan-Meier (KM) curves of the primary endpoint. An individual patient dataset was then reconstructed. The following methods were applied to explore the time to benefit of sacubitril-valsartan versus enalapril: visual estimation of the point of divergence of the KM curves, statistical process control (SPC), unadjusted landmark analyses using Cox proportional hazards analysis with 30-day increments until significance was persistently achieved, and comparing the survival probabilities of the extracted life tables. RESULTS Six raters visually estimated the time to benefit at a median of 60 days (interquartile range 38-10 days). Using SPC we found an early benefit from 28 days on, using the longest predefined control period of 28 days. An absolute risk reduction of 1 and 2% was found after 59 and 250 days, respectively. The reconstructed dataset provided a similar HR of 0.8004 (95% CI 0.7331-0.8739). Landmark analyses persistently showed statistical significance from 390 days and later. Survival probabilities differed from 35 days onward. CONCLUSION Using multiple approaches, the earliest benefit of sacubitril-valsartan compared to enalapril in stable HFrEF was found at about 1 month after initiation.
Collapse
Affiliation(s)
- Lorenz Van der Linden
- Pharmacy Department, University Hospitals Leuven, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium. .,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium.
| | - Julie Hias
- Pharmacy Department, University Hospitals Leuven, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium.,Department of Pharmaceutical and Pharmacological Sciences, KU Leuven, Leuven, Belgium
| | - Karolien Walgraeve
- Pharmacy Department, University Hospitals Leuven, UZ Leuven, Herestraat 49, 3000, Leuven, Belgium
| | - Jos Tournoy
- Department of Geriatric Medicine, University Hospitals Leuven, Leuven, Belgium.,Department of Public Health and Primary care, KU Leuven, Leuven, Belgium
| | - Lucas Van Aelst
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| | - Christophe Vandenbriele
- Department of Cardiovascular Sciences, KU Leuven, Leuven, Belgium.,Department of Cardiology, University Hospitals Leuven, Leuven, Belgium
| |
Collapse
|
30
|
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
| |
Collapse
|
31
|
Batra G, Aktaa S, Benson L, Dahlström U, Hage C, Savarese G, Vasko P, Gale CP, Lund LH. Association between heart failure quality of care and mortality: a population-based cohort study using nationwide registries. Eur J Heart Fail 2022; 24:2066-2077. [PMID: 36303264 PMCID: PMC10099535 DOI: 10.1002/ejhf.2725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2022] [Revised: 09/25/2022] [Accepted: 10/24/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS To evaluate the quality of heart failure (HF) care using the European Society of Cardiology (ESC) quality indicators (QIs) for HF and to assess whether better quality of care is associated with improved outcomes. METHODS AND RESULTS We performed a nationwide cohort study using the Swedish HF registry, consisting of patients with any type of HF at their first outpatient visit or hospitalization. Independent participant data for quality of HF care was evaluated against the ESC QIs for HF, and association with mortality estimated using multivariable Cox regression. In total, 43 704 patients from 80 hospitals across Sweden enrolled between 2013-2019 were included, with median follow-up 23.6 months. Of the 16 QIs for HF, 13 could be measured and 5 were inversely associated with all-cause mortality during follow-up. Higher attainment (≥50% vs. <50% attainment) of the composite opportunity-based score (combination of QIs into a single score) for patients with reduced ejection fraction was associated with lower all-cause mortality (adjusted hazard ratio 0.81; 95% confidence interval 0.72-0.91). Attainment of the composite score was less in the outpatient than inpatient setting (adjusted odds ratio 0.85; 95% confidence interval 0.72-0.99). Quality of care varied across hospitals, with assessment of health-related quality of life being the indicator with the widest variation in attainment (interquartile range 61.7%). CONCLUSION Quality of HF care may be measured using the ESC HF QIs. In Sweden, attainment of HF care evaluated using the QIs demonstrated between and within hospital variation, and many QIs were inversely associated with mortality.
Collapse
Affiliation(s)
- Gorav Batra
- Department of Medical Sciences, Cardiology and Uppsala Clinical Research Center, Uppsala University, Uppsala, Sweden
| | - Suleman Aktaa
- Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds Institute for Data Analytics, University of Leeds and Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ulf Dahlström
- Department of Cardiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Camilla Hage
- Department of Medicine, Karolinska Institute and Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Peter Vasko
- Department of Cardiology, Linköping University Hospital, Linköping, Sweden
| | - Chris P Gale
- Leeds Institute of Cardiovascular and Metabolic Medicine, Leeds Institute for Data Analytics, University of Leeds and Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet and Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
32
|
Lindberg F, Lund LH, Benson L, Dahlström U, Karlström P, Linde C, Rosano G, Savarese G. Trajectories in New York Heart Association functional class in heart failure across the ejection fraction spectrum: data from the Swedish Heart Failure Registry. Eur J Heart Fail 2022; 24:2093-2104. [PMID: 35999668 PMCID: PMC10087442 DOI: 10.1002/ejhf.2644] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Revised: 07/09/2022] [Accepted: 07/31/2022] [Indexed: 01/18/2023] Open
Abstract
AIMS To investigate incidence, predictors and prognostic implications of longitudinal New York Heart Association (NYHA) class changes (i.e. improving or worsening vs. stable NYHA class) in heart failure (HF) across the ejection fraction (EF) spectrum. METHODS AND RESULTS From the Swedish HF Registry, 13 535 patients with EF and ≥2 NYHA class assessments were considered. Multivariable multinomial regressions were fitted to identify the independent predictors of NYHA change. Over a 1-year follow-up, 69% of patients had stable, 17% improved, and 14% worsened NYHA class. Follow-up in specialty care predicted improving NYHA class, whereas an in-hospital patient registration, lower EF, renal disease, lower mean arterial pressure, older age, and longer HF duration predicted worsening. The association between NYHA change and subsequent outcomes was assessed with multivariable Cox models. When adjusting for the NYHA class at baseline, improving NYHA class was independently associated with lower while worsening with higher risk of all-cause and cardiovascular mortality, and first HF hospitalization. After adjustment for the NYHA class at follow-up, NYHA class change did not predict morbidity/mortality. NYHA class assessment at baseline and follow-up predicted morbidity/mortality on top of the changes. Results were consistent across the EF spectrum. CONCLUSION In a large real-world HF population, NYHA class trajectories predicted morbidity/mortality after extensive adjustments. However, the prognostic role was entirely explained by the resulting NYHA class, i.e. the follow-up value. Our results highlight that considering one-time NYHA class assessment, rather than trajectories, might be the preferable approach in clinical practice and for clinical trial design.
Collapse
Affiliation(s)
- Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Ulf Dahlström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Patric Karlström
- Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden.,Department of Internal Medicine, Ryhov County Hospital, Jönköping, Sweden
| | - Cecilia Linde
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | | | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
33
|
Janse RJ, Fu EL, Dahlström U, Benson L, Lindholm B, van Diepen M, Dekker FW, Lund LH, Carrero JJ, Savarese G. Use of guideline-recommended medical therapy in patients with heart failure and chronic kidney disease: from physician's prescriptions to patient's dispensations, medication adherence and persistence. Eur J Heart Fail 2022; 24:2185-2195. [PMID: 35851740 PMCID: PMC10087537 DOI: 10.1002/ejhf.2620] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 06/25/2022] [Accepted: 07/13/2022] [Indexed: 01/18/2023] Open
Abstract
AIM Half of heart failure (HF) patients have chronic kidney disease (CKD) complicating their pharmacological management. We evaluated physicians' and patients' patterns of use of evidence-based medical therapies in HF across CKD stages. METHODS AND RESULTS We studied HF patients with reduced (HFrEF) and mildly reduced (HFmrEF) ejection fraction enrolled in the Swedish Heart Failure Registry in 2009-2018. We investigated the likelihood of physicians to prescribe guideline-recommended therapies to patients with CKD, and of patients to fill the prescriptions within 90 days of incident HF (initiating therapy), to adhere (proportion of days covered ≥80%) and persist (continued use) on these treatments during the first year of therapy. We identified 31 668 patients with HFrEF (median age 74 years, 46% CKD). The proportions receiving a prescription for angiotensin-converting enzyme inhibitors/angiotensin receptor blockers/angiotensin receptor-neprilysin inhibitors (ACEi/ARB/ARNi) were 96%, 92%, 86%, and 68%, for estimated glomerular filtration rate (eGFR) ≥60, 45-59, 30-44, and <30 ml/min/1.73 m2 , respectively; for beta-blockers 94%, 93%, 92%, and 92%, for mineralocorticoid receptor antagonists (MRAs) 45%, 44%, 37%, 24%; and for triple therapy (combination of ACEi/ARB/ARNi + beta-blockers + MRA) 38%, 35%, 28%, and 15%. Patients with CKD were less likely to initiate these medications, and less likely to adhere to and persist on ACEi/ARB/ARNi, MRA, and triple therapy. Among stoppers, CKD patients were less likely to restart these medications. Results were consistent after multivariable adjustment and in patients with HFmrEF (n = 15 114). CONCLUSIONS Patients with HF and CKD are less likely to be prescribed and to fill prescriptions for evidence-based therapies, showing lower adherence and persistence, even at eGFR categories where these therapies are recommended and have shown efficacy in clinical trials.
Collapse
Affiliation(s)
- Roemer J Janse
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Edouard L Fu
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands.,Division of Pharmacoepidemiology and Pharmacoeconomics, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Ulf Dahlström
- Department of Cardiology and the Department of Health, Medicine and Caring Sciences, Linkoping University, Linkoping, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Bengt Lindholm
- Renal Medicine and Baxter Novum, Department of Clinical Science, Intervention and Technology, Karolinska Institutet, Stockholm, Sweden
| | - Merel van Diepen
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Friedo W Dekker
- Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Juan-Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.,Division of Nephrology, Department of Clinical Sciences, Karolinska Institutet, Danderyd Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden.,Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
34
|
Garred CH, Zahir D, Butt JH, Ravn PB, Bruhn J, Gislason GH, Fosbøl EL, Torp-Pedersen C, Petrie MC, McMurray JJV, Køber L, Schou M. Adherence and Discontinuation of Optimal Heart Failure Therapies According to Age: A Danish Nationwide Study. J Am Heart Assoc 2022; 11:e026187. [PMID: 36172925 PMCID: PMC9673698 DOI: 10.1161/jaha.122.026187] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Abstract
Background Guideline‐recommended disease‐modifying pharmacological therapies for heart failure (HF) with reduced ejection fraction are underutilized, particularly among elderly patients. We studied the association of age in adherence and discontinuation of angiotensin‐converting enzyme inhibitors/angiotensin‐II receptor blockers (ACEi/ARB), β‐blockers (BB), and mineralocorticoid receptor antagonists. Methods and Results Patients with a first heart failure diagnosis who had initiated ACEi/ARB and BB within 120 days of presentation were included from nationwide registries and divided into 3 age groups: <65 years (reference), 65 to 79, and ≥80. One‐year median proportions of daily target doses were calculated. Adherence was estimated by the proportion of days covered. The 5‐year risk of discontinuation was assessed with the Aalen‐Johansen estimator. Discontinuation rates were evaluated using Multivariable Cox regression. Twenty‐nine thousand four hundred eighty‐two patients were included. Advancing age was associated with lower median proportions of daily target doses and adherence (ACEi/ARB 79.1%, 77.5%, and 69.4%; BB 79.1%, 78.6%, and 73.8%), in the <65, 65 to 79, and ≥80 age groups, respectively. Age ≥80 was associated with higher discontinuation rates (cumulative incidence, ACEi/ARB 41%, 44%, and 51%; BB 38%, 35%, and 39%; hazard ratio, ACEi/ARB 1.60 [95% CI, 1.51–1.69]; BB 1.33 [95% CI, 1.25–1.41]). The risk of mineralocorticoid receptor antagonists discontinuation differed little with age (50%, 54%, and 56%), although mineralocorticoid receptor antagonists initiation in the most elderly was less frequent (33%, 33%, and 22%). Conclusions In a nationwide cohort of patients with heart failure, advanced age was associated with lower proportions of daily target doses, lower adherence, and higher discontinuation rates of ACEi/ARB and BBs. Focus on treatment adherence and optimal dosages among elderly patients with heart failure could improve outcomes.
Collapse
Affiliation(s)
- Caroline H Garred
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
| | - Deewa Zahir
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
| | - Jawad H Butt
- Department of Cardiology, Rigshospitalet University of Copenhagen Denmark
| | - Pauline B Ravn
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
| | - Jonas Bruhn
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
| | - Gunnar H Gislason
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
| | - Emil L Fosbøl
- Department of Cardiology, Rigshospitalet University of Copenhagen Denmark
| | | | - Mark C Petrie
- BHF Cardiovascular Research Centre University of Glasgow UK
| | | | - Lars Køber
- Department of Cardiology, Rigshospitalet University of Copenhagen Denmark
| | - Morten Schou
- Department of Cardiology Herlev and Gentofte University Hospital Copenhagen Denmark
| |
Collapse
|
35
|
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
| |
Collapse
|
36
|
Herrmann EJ, Raghavan B, Eissing N, Fichtlscherer S, Hamm CW, Assmus B. Pulmonary Artery Pressure-Guided Telemonitoring Reduced Pulmonary Artery Pressure but Did Not Result in Higher Doses of Guideline-Directed Medical Therapy-Observations from an Advanced Elderly German Heart Failure Cohort. Life (Basel) 2022; 12:life12050766. [PMID: 35629432 PMCID: PMC9147310 DOI: 10.3390/life12050766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Revised: 05/16/2022] [Accepted: 05/19/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction: Remote pulmonary artery pressure (PAP)-guided heart failure (HF) therapy for NYHA class III patients has been shown to reduce hospitalizations and increase survival. We aimed to assess whether PAP monitoring allows for the increase in HF directed medication in an elderly German cohort of advanced HF patients already receiving clinically optimized HF medication. Methods: We analyzed PAP and HF medication dosage, including diuretics, in 24 patients (mean age, 76 years) using implanted PAP-sensors during the first 12 months of PAP-guided HF care in an interdisciplinary HF unit. Results: During 12 months of PAP-guided HF therapy, PAP decreased significantly (△PAP systolic−6 ± 10, △PAP diastolic−4 ± 7, △PAP mean−4 ± 8 mm Hg, p < 0.01 for all). 16% of patients had an unplanned HF hospitalization. There was no significant change over time with respect to the dosage of RAAS inhibitors (ACE-I/ARB/ARNI), Beta blockers, or MRA treatments. In contrast, the dosage of loop diuretics increased significantly (2.1 ± 0.5-fold) over time. In the comparison of a “responder” (patients with PAP and diuretic dose decline) and “non-responder” (patients with PAP and diuretic dose increase) group, there were no significant differences between any of the baseline, medication, or HF hospitalization characteristics between the two groups. Conclusions: In elderly patients treated with clinically optimized HF medication, no further evidence-based medication increase could be achieved using PAP-guided HF care. However, by individual adjustment of diuretic dosage, a significant decline in PAP over time occurred, which could not be predicted by any of the baseline characteristics.
Collapse
Affiliation(s)
- Ester J. Herrmann
- Department of Medicine I, Cardiology, University Hospital Giessen and Marburg, 35392 Giessen, Germany; (E.J.H.); (B.R.); (C.W.H.)
| | - Badrinarayanan Raghavan
- Department of Medicine I, Cardiology, University Hospital Giessen and Marburg, 35392 Giessen, Germany; (E.J.H.); (B.R.); (C.W.H.)
| | - Nina Eissing
- Department of Medicine III, Cardiology, University Hospital Frankfurt am Main, 60590 Frankfurt am Main, Germany; (N.E.); (S.F.)
| | - Stephan Fichtlscherer
- Department of Medicine III, Cardiology, University Hospital Frankfurt am Main, 60590 Frankfurt am Main, Germany; (N.E.); (S.F.)
- German Center for Cardiovascular Research, DZHK, 10115 Berlin, Germany
| | - Christian W. Hamm
- Department of Medicine I, Cardiology, University Hospital Giessen and Marburg, 35392 Giessen, Germany; (E.J.H.); (B.R.); (C.W.H.)
- German Center for Cardiovascular Research, DZHK, 10115 Berlin, Germany
| | - Birgit Assmus
- Department of Medicine I, Cardiology, University Hospital Giessen and Marburg, 35392 Giessen, Germany; (E.J.H.); (B.R.); (C.W.H.)
- Department of Medicine III, Cardiology, University Hospital Frankfurt am Main, 60590 Frankfurt am Main, Germany; (N.E.); (S.F.)
- German Center for Cardiovascular Research, DZHK, 10115 Berlin, Germany
- Correspondence:
| |
Collapse
|
37
|
Pellicori P, Cleland JGF. Heart failure: age is no excuse for complacency. Eur J Heart Fail 2022; 24:1063-1065. [PMID: 35481861 DOI: 10.1002/ejhf.2517] [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: 04/13/2022] [Accepted: 04/22/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Pierpaolo Pellicori
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - John G F Cleland
- Robertson Centre for Biostatistics, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK
| |
Collapse
|
38
|
Stolfo D, Sinagra G, Savarese G. Evidence-based Therapy in Older Patients with Heart Failure with Reduced Ejection Fraction. Card Fail Rev 2022; 8:e16. [PMID: 35541287 PMCID: PMC9069263 DOI: 10.15420/cfr.2021.34] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2021] [Accepted: 02/15/2022] [Indexed: 11/06/2022] Open
Abstract
Older patients are becoming prevalent among people with heart failure (HF) as the overall population ages. However, older patients are largely under-represented, or even excluded, from randomised controlled trials on HF with reduced ejection fraction, limiting the generalisability of trial results in the real world and leading to weaker evidence supporting the use and titration of guideline-directed medical therapy (GDMT) in older patients with HF with reduced ejection fraction. This, in combination with other factors limiting the application of guideline recommendations, including a fear of poor tolerability or adverse effects, the heavy burden of comorbidities and the need for multiple therapies, classically leads to lower adherence to GDMT in older patients. Although there are no data supporting the under-use and under-dosing of HF medications in older patients, large registry-based studies have confirmed age as one of the major obstacles to treatment optimisation. In this review, the authors provide an overview of the contemporary state of implementation of GDMT in older groups and the reasons for the lower use of treatments, and discuss some measures that may help improve adherence to evidence-based recommendations in older age groups.
Collapse
Affiliation(s)
- Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina and University Hospital of Trieste, Trieste, Italy
| | - Gianfranco Sinagra
- Cardiothoracovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina and University Hospital of Trieste, Trieste, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|