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Mefford MT, Ambrosy AP, Wei R, Zheng C, Parikh RV, Harrison TN, Lee MS, Go AS, Reynolds K. Rule-based natural language processing to examine variation in worsening heart failure hospitalizations by age, sex, race and ethnicity, and left ventricular ejection fraction. Am Heart J 2024:S0002-8703(24)00234-5. [PMID: 39251103 DOI: 10.1016/j.ahj.2024.09.001] [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: 05/06/2024] [Revised: 09/04/2024] [Accepted: 09/05/2024] [Indexed: 09/11/2024]
Abstract
BACKGROUND Prior studies characterizing worsening heart failure events (WHFE) have been limited in using structured healthcare data from hospitalizations, and with little exploration of sociodemographic variation. The current study examined the impact of incorporating unstructured data to identify WHFE, describing age-, sex-, race and ethnicity-, and left ventricular ejection fraction (LVEF)-specific rates. METHODS Adult members of Kaiser Permanente Southern California (KPSC) with a HF diagnosis between 2014-2018 were followed through 2019 to identify hospitalized WHFE. The main outcome was hospitalizations with a principal or secondary HF discharge diagnosis meeting rule-based Natural Language Processing (NLP) criteria for WHFE. In comparison, we examined hospitalizations with a principal discharge diagnosis of HF. Age-, sex-, and race and ethnicity-adjusted rates per 100 person-years (PY) were calculated among age, sex, race and ethnicity (non-Hispanic (NH) Asian/Pacific Islander [API], Hispanic, NH Black, NH White) and LVEF subgroups. RESULTS Among 44,863 adults with HF, 10,560 (23.5%) had an NLP-defined, hospitalized WHFE. Adjusted rates (per 100 PY) of WHFE using NLP were higher compared to rates based only on HF principal discharge diagnosis codes (12.7 and 9.3, respectively), and this followed similar patterns among subgroups, with the highest rates among adults ≥75 years (16.3 and 11.2), men (13.2 and 9.7), and NH Black (16.9 and 14.3) and Hispanic adults (15.3 and 11.4), and adults with reduced LVEF (16.2 and 14.0). Using NLP disproportionately increased the perceived burden of WHFE among API and adults with mid-range and preserved LVEF. CONCLUSION Rule-based NLP improved the capture of hospitalized WHFE above principal discharge diagnosis codes alone. Applying standardized consensus definitions to EHR data may improve understanding of the burden of WHFE and promote optimal care overall and in specific sociodemographic groups.
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Affiliation(s)
- Matthew T Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA.
| | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California; Division of Research, Kaiser Permanente Northern California, Oakland, CA USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA USA
| | - Rong Wei
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA
| | - Chengyi Zheng
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA
| | - Rishi V Parikh
- Division of Research, Kaiser Permanente Northern California, Oakland, CA USA; Department of Epidemiology and Population Health, Stanford School of Medicine, Stanford, CA
| | - Teresa N Harrison
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA
| | - Ming-Sum Lee
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, CA USA
| | - Alan S Go
- Division of Research, Kaiser Permanente Northern California, Oakland, CA USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA USA; Departments of Epidemiology, Biostatistics and Medicine, University of California, San Francisco, San Francisco, CA USA
| | - Kristi Reynolds
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, CA USA; Department of Health Systems Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, CA USA
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Mansoor T, Khalid SN, Bilal MI, Ijaz SH, Fudim M, Greene SJ, Warraich HJ, Nambi V, Virani SS, Fonarow GC, Abramov D, Minhas AMK. Ongoing and Future Clinical Trials of Pharmacotherapy for Heart Failure. Am J Cardiovasc Drugs 2024; 24:481-504. [PMID: 38907865 DOI: 10.1007/s40256-024-00658-0] [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: 05/30/2024] [Indexed: 06/24/2024]
Abstract
Increasing knowledge of the processes leading to heart failure (HF) has allowed significant developments in therapies for HF over the past few decades. Despite the evolution of HF treatment, it still places a large burden on patients and health care systems across the world.We used clinicaltrials.gov to gather information about clinical trials as of August 2023 studying pharmacotherapy for HF. We included interventional trials that were "active, not recruiting", "recruiting", or looking for participants but "not yet recruiting". In total, 119 studies met our criteria of ongoing clinical trials studying novel as well as currently approved HF pharmacotherapies. The major interventions were novel medications/already approved medications for other diseases 29 % (34 trials), sodium-glucose co-transporter inhibitors 21 % (25 trials), angiotensin receptor blocker-neprilysin inhibitors 10 % (12 trials), diuretics 14 % (17 trials) and mineralocorticoid receptor antagonists 5 % (6 trials). Ongoing research will aid in reducing the impact of HF and we summarize clinical trials leading the way to better HF treatment in this review.
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Affiliation(s)
- Taha Mansoor
- Department of Internal Medicine, Western Michigan University Homer Stryker M.D. School of Medicine, 1000 Oakland Drive, Kalamazoo, MI, 49008, USA.
| | - Subaina N Khalid
- Department of Internal Medicine, SUNY Upstate Medical University, Syracruse, NY, USA
| | | | | | - Marat Fudim
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Haider J Warraich
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Vijay Nambi
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
- Michael E. DeBakey, Veterans Affair Medical Center, Houston, TX, USA
| | - Salim S Virani
- Section of Cardiovascular Research, Baylor College of Medicine, Houston, TX, USA
- Department of Medicine, Aga Khan University, Karachi, Pakistan
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Dmitry Abramov
- Division of Cardiology, Department of Medicine, Loma Linda University Health, Loma Linda, CA, USA
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Ferrannini G, Benson L, Lautsch D, Dahlström U, Lund LH, Savarese G, Carrero JJ. N-terminal pro-B-type natriuretic peptide concentrations, testing and associations with worsening heart failure events. ESC Heart Fail 2024; 11:759-771. [PMID: 38115625 DOI: 10.1002/ehf2.14613] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Revised: 10/23/2023] [Accepted: 11/16/2023] [Indexed: 12/21/2023] Open
Abstract
AIMS In patients with heart failure (HF), we aimed to assess (i) the time trends in N-terminal pro-B-type natriuretic peptide (NT-proBNP) testing; (ii) patient characteristics associated with NT-proBNP testing; (iii) distribution of NT-proBNP levels, focusing on the subgroups with (WHFE) vs. without (NWHFE) a worsening HF event, defined as an HF hospitalization; and (iv) changes of NT-proBNP levels over time. METHODS AND RESULTS NT-proBNP testing and levels were investigated in HF patients enrolled in the Swedish Heart Failure Registry (SwedeHF) linked with the Stockholm CREAtinine Measurements project from January 2011 to December 2018. Index date was the first registration in SwedeHF. Patterns of change in NT-proBNP levels before (in the previous 6 ± 3 months) and after (in the following 6 ± 3 months) the index date were categorized as follows: (i) <3000 ng/L at both measurements = stable low; (ii) <3000 ng/L at the first measurement and ≥3000 ng/L at the second measurement = increased; (iii) ≥3000 ng/L at the first measurement and <3000 ng/L at the second measurement = decreased; and (iv) ≥3000 ng/L at both measurements = stable high. Univariable and multivariable logistic regression models, expressed as odds ratios (ORs) and 95% confidence intervals (95% CIs), were performed to assess the associations between (i) clinical characteristics and NT-proBNP testing and (ii) changes in NT-proBNP from 6 months prior to the index date and the index date and a WHFE. Consistency analyses were performed in HF with reduced ejection fraction (HFrEF) alone. A total of 4424 HF patients were included (median age 74 years, women 34%, HFrEF 53%), 33% with a WHFE. NT-proBNP testing increased over time, up to 55% in 2018, and was almost two-fold as frequent, and time to testing was less than half, in patients with WHFE vs. NWHFE. Independent predictors of testing were WHFE, higher heart rate, diuretic use, and preserved ejection fraction. Median NT-proBNP was 3070 ng/L (Q1-Q3: 1220-7395), approximately three-fold higher in WHFE vs. NWHFE. Compared with stable low NT-proBNP levels, increased (OR 4.27, 95% CI 2.47-7.37) and stable high levels (OR 2.48, 95% CI 1.58-3.88) were independently associated with a higher risk of WHFE. Results were consistent in the HFrEF population. CONCLUSIONS NT-proBNP testing increased over time but still was only performed in half of the patients. Testing was associated with a WHFE, with features of more severe HF and for differential diagnosis purposes. Increased and stable high levels were associated with a WHFE. Overall, our data highlight the potential benefits of carrying further implementation of NT-proBNP testing in clinical practice.
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Affiliation(s)
- Giulia Ferrannini
- Division of Cardiology, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Norrbacka S1:02, SE-17176, Stockholm, Sweden
- Internal Medicine Unit, Södertälje Hospital, Södertälje, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Norrbacka S1:02, SE-17176, Stockholm, Sweden
| | | | - Ulf Dahlström
- Division of Cardiology, Department of Medical and Health Sciences, Linköping University, Linköping, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Norrbacka S1:02, SE-17176, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska University Hospital, Karolinska Institutet, Norrbacka S1:02, SE-17176, Stockholm, Sweden
- Heart and Vascular Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Juan Jesus Carrero
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
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Pagnesi M, Sammartino AM, Chiarito M, Stolfo D, Baldetti L, Adamo M, Maggi G, Inciardi RM, Tomasoni D, Loiacono F, Maccallini M, Villaschi A, Gasparini G, Montella M, Contessi S, Cocianni D, Perotto M, Barone G, Merlo M, Cappelletti AM, Sinagra G, Pini D, Metra M, Lombardi CM. Clinical and prognostic implications of heart failure hospitalization in patients with advanced heart failure. J Cardiovasc Med (Hagerstown) 2024; 25:149-157. [PMID: 38149701 DOI: 10.2459/jcm.0000000000001581] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2023]
Abstract
BACKGROUND Hospitalization is associated with poor outcomes in patients with heart failure, but its prognostic role in advanced heart failure is still unsettled. We evaluated the prognostic role of heart failure hospitalization in patients with advanced heart failure. METHODS The multicenter HELP-HF registry enrolled consecutive patients with heart failure and at least one high-risk 'I NEED HELP' marker. Characteristics and outcomes were compared between patients who were hospitalized for decompensated heart failure (inpatients) or not (outpatients) at the time of enrolment. The primary endpoint was the composite of all-cause mortality or first heart failure hospitalization. RESULTS Among the 1149 patients included [mean age 75.1 ± 11.5 years, 67.3% men, median left ventricular ejection fraction (LVEF) 35% (IQR 25-50%)], 777 (67.6%) were inpatients at the time of enrolment. As compared with outpatients, inpatients had lower LVEF, higher natriuretic peptides and a worse clinical profile. The 1-year rate of the primary endpoint was 50.9% in inpatients versus 36.8% in outpatients [crude hazard ratio 1.70, 95% confidence interval (CI) 1.39-2.07, P < 0.001]. At multivariable analysis, inpatient status was independently associated with a higher risk of the primary endpoint (adjusted hazard ratio 1.54, 95% CI 1.23-1.93, P < 0.001). Among inpatients, the independent predictors of the primary endpoint were older age, lower SBP, heart failure association criteria for advanced heart failure and glomerular filtration rate 30 ml/min/1.73 m2 or less. CONCLUSION Hospitalization for heart failure in patients with at least one high-risk 'I NEED HELP' marker is associated with an extremely poor prognosis supporting the need for specific interventions, such as mechanical circulatory support or heart transplantation.
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Affiliation(s)
- Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia, Brescia
| | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia, Brescia
| | - Mauro Chiarito
- Humanitas Research Hospital IRCCS, Rozzano-Milan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan
| | - Davide Stolfo
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - Luca Baldetti
- Cardiac Intensive Care Unit, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia, Brescia
| | - Giuseppe Maggi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia, Brescia
| | - Riccardo Maria Inciardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia, Brescia
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia, Brescia
| | | | - Marta Maccallini
- Humanitas Research Hospital IRCCS, Rozzano-Milan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan
| | - Alessandro Villaschi
- Humanitas Research Hospital IRCCS, Rozzano-Milan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan
| | - Gaia Gasparini
- Humanitas Research Hospital IRCCS, Rozzano-Milan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan
| | - Marco Montella
- Humanitas Research Hospital IRCCS, Rozzano-Milan
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele-Milan
| | - Stefano Contessi
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - Daniele Cocianni
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - Maria Perotto
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - 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
| | | | - Gianfranco Sinagra
- Cardiovascular Department, Azienda Sanitaria Universitaria Giuliano Isontina (ASUGI), University of Trieste, Trieste
| | - Daniela Pini
- Humanitas Research Hospital IRCCS, Rozzano-Milan
| | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia, Brescia
| | - Carlo Mario Lombardi
- Institute of Cardiology, ASST Spedali Civili, Department of Medical and Surgical specialties, Radiological sciences and Public Health, University of Brescia, Brescia
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5
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González-Del-Hoyo M, Rossello X. Worsening heart failure comes into focus, chronic heart failure takes a backseat. Eur J Heart Fail 2024; 26:230-232. [PMID: 38247189 DOI: 10.1002/ejhf.3143] [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: 12/22/2023] [Revised: 12/30/2023] [Accepted: 01/02/2024] [Indexed: 01/23/2024] Open
Affiliation(s)
- Maribel González-Del-Hoyo
- Department of Cardiology, University Heart Center, University Hospital Zurich, University of Zurich, Zurich, Switzerland
| | - Xavier Rossello
- Cardiology Department, Hospital Universitari Son Espases, Palma, Spain
- Health Research Institute of the Balearic Islands (IdISBa), Palma, Spain
- Facultat de Medicina, Universitat de les Illes Balears (UIB), Palma, Spain
- Centro Nacional de Investigaciones Cardiovasculares (CNIC), Madrid, Spain
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Chatur S, Vaduganathan M, Claggett BL, Cunningham JW, Docherty KF, Desai AS, Jhund PS, de Boer RA, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CS, Martinez FA, Shah SJ, Petersson M, Langkilde AM, McMurray JJ, Solomon SD. Outpatient Worsening Among Patients With Mildly Reduced and Preserved Ejection Fraction Heart Failure in the DELIVER Trial. Circulation 2023; 148:1735-1745. [PMID: 37632455 PMCID: PMC10664793 DOI: 10.1161/circulationaha.123.066506] [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: 07/26/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Hospitalization is recognized as a sentinel event in the disease trajectory of patients with heart failure (HF), but not all patients experiencing clinical decompensation are ultimately hospitalized. Outpatient intensification of diuretics is common in response to symptoms of worsening HF, yet its prognostic and clinical relevance, specifically for patients with HF with mildly reduced or preserved ejection fraction, is uncertain. METHODS In this prespecified analysis of the DELIVER trial (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure), we assessed the association between various nonfatal worsening HF events (those requiring hospitalization, urgent outpatient visits requiring intravenous HF therapies, and outpatient oral diuretic intensification) and rates of subsequent mortality. We further examined the treatment effect of dapagliflozin on an expanded composite end point of cardiovascular death, HF hospitalization, urgent HF visit, or outpatient oral diuretic intensification. RESULTS In DELIVER, 4532 (72%) patients experienced no worsening HF event, whereas 789 (13%) had outpatient oral diuretic intensification, 86 (1%) required an urgent HF visit, 585 (9%) had an HF hospitalization, and 271 (4%) died of cardiovascular causes as a first presentation. Patients with a first presentation manifesting as outpatient oral diuretic intensification experienced rates of subsequent mortality that were higher (10 [8-12] per 100 patient-years) than those without a worsening HF event (4 [3-4] per 100 patient-years) but similar to rates of subsequent death after an urgent HF visit (10 [6-18] per 100 patient-years). Patients with an HF hospitalization as a first presentation of worsening HF had the highest rates of subsequent death (35 [31-40] per 100 patient-years). The addition of outpatient diuretic intensification to the adjudicated DELIVER primary end point (cardiovascular death, HF hospitalization, or urgent HF visit) increased the overall number of patients experiencing an event from 1122 to 1731 (a 54% increase). Dapagliflozin reduced the need for outpatient diuretic intensification alone (hazard ratio, 0.72 [95% CI, 0.64-0.82]) and when analyzed as a part of an expanded composite end point of worsening HF or cardiovascular death (hazard ratio, 0.76 [95% CI, 0.69-0.84]). CONCLUSIONS In patients with HF with mildly reduced or preserved ejection fraction, worsening HF requiring oral diuretic intensification in ambulatory care was frequent, adversely prognostic, and significantly reduced by dapagliflozin. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03619213.
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Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Brian L. Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Jonathan W. Cunningham
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Kieran F. Docherty
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
| | - Akshay S. Desai
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Pardeep S. Jhund
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
| | - Rudolf A. de Boer
- Erasmus Medical Center, Department of Cardiology, Rotterdam, the Netherlands (R.A.d.B.)
| | | | | | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City (M.N.K.)
| | - Carolyn S.P. Lam
- National Heart Centre Singapore & Duke-National University of Singapore (C.S.P.L.)
| | | | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (M.P., A.M.K.)
| | - Anna Maria Langkilde
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
- Erasmus Medical Center, Department of Cardiology, Rotterdam, the Netherlands (R.A.d.B.)
- Duke University Medical Center, Durham, NC (A.F.H.)
- Yale School of Medicine, New Haven, CT (S.E.I.)
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City (M.N.K.)
- National Heart Centre Singapore & Duke-National University of Singapore (C.S.P.L.)
- Universidad Nacional de Córdoba, Argentina (F.A.M.)
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (M.P., A.M.K.)
| | - John J.V. McMurray
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
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7
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Haywood HB, Fonarow GC, Khan MS, Van Spall HGC, Morris AA, Nassif ME, Kittleson MM, Butler J, Greene SJ. Hospital at Home as a Treatment Strategy for Worsening Heart Failure. Circ Heart Fail 2023; 16:e010456. [PMID: 37646170 DOI: 10.1161/circheartfailure.122.010456] [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: 12/21/2022] [Accepted: 07/17/2023] [Indexed: 09/01/2023]
Abstract
Hospital at home (HaH) is an innovative care model that may be particularly suited for heart failure (HF). Outpatient visits and inpatient care have been the 2 traditional settings for HF care, yet may not match the social and medical needs of patients at all times. Alternative models such as HaH may represent an effective and patient-centered option for select patients with worsening HF. To date, limited research in HF and other disease states has supported HaH as being safe and lower cost than traditional inpatient admission. Supporting HaH are new payment structures, such as Medicare's Acute Hospital Care at Home waiver program. In combination with outpatient visits, outpatient intravenous diuretic clinics, inpatient care, and cardiac intensive care, HaH could be a core component of a comprehensive care model with the potential to match resource utilization with the needs of patients across the spectrum of HF severity, and improve patient outcomes.
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Affiliation(s)
- Hubert B Haywood
- Department of Medicine, Duke University Medical Center, Durham, NC (H.B.H.)
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center (G.C.F.)
| | | | - Harriette G C Van Spall
- Department of Medicine (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
- Population Health Research Institute (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
| | | | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (M.E.N.)
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi, Jackson (J.B.)
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, NC (M.S.K., S.J.G.)
- Duke Clinical Research Institute, Durham, NC (S.J.G.)
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8
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Dattilo G, Laterra G, Licordari R, Parisi F, Pistelli L, Colarusso L, Zappia L, Vaccaro V, Demurtas E, Allegra M, Crea P, Di Bella G, Signorelli SS, Aspromonte N, Imbalzano E, Correale M. The Long-Term Benefit of Sacubitril/Valsartan in Patients with HFrEF: A 5-Year Follow-Up Study in a Real World Population. J Clin Med 2023; 12:6247. [PMID: 37834892 PMCID: PMC10573839 DOI: 10.3390/jcm12196247] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 09/11/2023] [Accepted: 09/26/2023] [Indexed: 10/15/2023] Open
Abstract
Heart failure (HF) is a progressive condition with an increasing prevalence, and the scientific evidence of heart failure with reduced ejection fraction (HFrEF) reports a 6% rate of 1-year mortality in stable patients, whereas, in recently hospitalized patients, the 1-year mortality rates exceed 20%. The Sacubitril/Valsartan (S/V), the first angiotensin receptor neprilysin inhibitor (ARNI), significantly reduced both HF hospitalization and cardiovascular mortality. AIM OF THE STUDY to evaluate the effect of S/V in a follow-up period of 5 years from the beginning of the therapy. We compared the one-year outcomes of S/V use with those obtained after 5 years of therapy, monitoring the long-term effects in a real-world population with HFrEF. METHODS Seventy consecutive patients with HFrEF and eligible for ARNI, according to PARADIGM-HF criteria, were enrolled. All patients had an overall follow-up of 60 months, during which time they underwent standard transthoracic echocardiography (TTE) with Global Longitudinal Strain (GLS) evaluation, the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Six Minutes Walking Test (6MWT), and blood tests (NT-pro-BNP and BNP, renal function tests). RESULTS NTproBNP values were reduced significantly among the three time-points (p < 0.001). Among echocardiographic parameters, left ventricle end-diastolic volume (LV EDV) and E/e' significantly were reduced at the first evaluation (12 months), while left ventricle end-systolic volume (LV ESV) decreased during all follow-ups (p < 0.001). LV EF (p < 0.001) and GLS (p < 0.001) significantly increased at both evaluations. The 6MWT (p < 0.001) and KCCQ scores (p < 0.001) increased significantly in the first 12 months and remained stable along the other time-points. NYHA class showed an increase in class 1 subjects and a decrease in class 3 subjects during follow-up. NTproBNP, BNP, 6MWT, and KCCQ scores showed a significant change in the first 12 months, while LVEF, GLS, and ESV changed during all evaluations. CONCLUSIONS We verified that the improvements obtained after one year of therapy had not reached a plateau phase but continued to improve and were statistically significant at 5 years. Although our data should be confirmed in larger and multicentre studies, we can state that the utilization of Sacubitril/Valsartan has catalysed substantial transformations in the prognostic landscape of chronic HFrEF, yielding profound clinical implications.
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Affiliation(s)
- Giuseppe Dattilo
- Section of Cardiology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98122 Messina, Italy; (G.D.); (R.L.)
| | - Giulia Laterra
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Roberto Licordari
- Section of Cardiology, Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, 98122 Messina, Italy; (G.D.); (R.L.)
| | - Francesca Parisi
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Lorenzo Pistelli
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Luigi Colarusso
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Luca Zappia
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Vittoria Vaccaro
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Elisabetta Demurtas
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Marta Allegra
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Pasquale Crea
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Gianluca Di Bella
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Salvatore Santo Signorelli
- Internal Medicine Unit, Department of Clinical and Experimental Medicine, University of Catania, 95125 Catania, Italy;
| | - Nadia Aspromonte
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy;
| | - Egidio Imbalzano
- Department of Clinical and Experimental Medicine, Policlinic University Hospital of Messina, 98122 Messina, Italy; (G.L.); (F.P.); (L.P.); (L.C.); (L.Z.); (V.V.); (E.D.); (M.A.); (P.C.); (G.D.B.)
| | - Michele Correale
- Cardiothoracic Department, Policlinico Riuniti University Hospital, 71100 Foggia, Italy;
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9
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Ducharme A, Zieroth S, Ahooja V, Anderson K, Andrade J, Boivin-Proulx LA, Ezekowitz J, Howlett J, Lepage S, Leong D, McDonald MA, O'Meara E, Poon S, Swiggum E, Virani S. Canadian Cardiovascular Society-Canadian Heart Failure Society Focused Clinical Practice Update of Patients With Differing Heart Failure Phenotypes. Can J Cardiol 2023; 39:1030-1040. [PMID: 37169222 DOI: 10.1016/j.cjca.2023.04.022] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 04/20/2023] [Accepted: 04/21/2023] [Indexed: 05/13/2023] Open
Abstract
A number of societies produce heart failure (HF) management guidelines, comprising official recommendations on the basis of recent research discoveries, but their applicability to specific situations encountered in daily practice might be difficult. In this clinical practice update we aim to provide responses to fundamental questions that face health care providers, like appropriate timing for the introduction and optimization of different classes of medication according to specific patient phenotypes, when second-line therapies and valvular interventions should be considered, and management of difficult clinical scenarios such as cardiorenal syndrome and frailty. A consensus-based methodology was used. Approaches to 5 different phenotypes are presented: (1) The wet HF phenotype is the easiest to manage, decongestion being performed alongside introduction of guideline-directed medical therapy (GDMT); (2) The de novo HF phenotype requires the introduction of the 4 pillars of GDMT, personalizing the order on the basis of the individuals' biological and physiological characteristics; (3) The worsening HF phenotype is a marker of poor prognosis, and therefore should motivate optimization of GDMT, start second-line therapies, and/or reevaluate goals of care/advanced HF therapies; (4) The cardiorenal phenotypes require correct volume assessment, because renal function usually improves with decongestion; and (5) The frail HF phenotype require special attention, careful drug titration, and consideration of cardiac rehabilitation programs. In conclusion, specific common HF phenotypes call for a personalized approach to improve adoption of the HF guidelines into clinical practice.
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Affiliation(s)
- Anique Ducharme
- Department of Medicine, Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada.
| | - Shelley Zieroth
- Department of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Vineeta Ahooja
- Department of Medicine, The Heart Health Institute, Scarborough, Ontario, Canada
| | - Kim Anderson
- Department of Medicine, Dalhousie University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Jason Andrade
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | | | - Justin Ezekowitz
- Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Jonathan Howlett
- Department of Medicine, Cumming School of Medicine, University of Calgary, Libin Cardiovascular Institute, Calgary, Alberta, Canada
| | - Serge Lepage
- Department of Medicine, Université de Sherbrooke, Sherbrooke, Québec, Canada
| | - Derek Leong
- Department of Medicine, Toronto General Hospital, University Health Network, Toronto, Ontario, Canada
| | - Michael A McDonald
- Department of Medicine, Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Eileen O'Meara
- Department of Medicine, Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Stephanie Poon
- Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Elizabeth Swiggum
- Department of Medicine, Royal Jubilee Hospital, University of British Columbia, Victoria, British Columbia, Canada
| | - Sean Virani
- Department of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
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10
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Worsening Heart Failure: Nomenclature, Epidemiology, and Future Directions: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:413-424. [PMID: 36697141 DOI: 10.1016/j.jacc.2022.11.023] [Citation(s) in RCA: 51] [Impact Index Per Article: 51.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Revised: 10/26/2022] [Accepted: 11/02/2022] [Indexed: 01/25/2023]
Abstract
Heart failure (HF) is a progressive disease characterized by variable durations of symptomatic stability often punctuated by episodes of worsening despite continued therapy. These periods of clinical worsening are increasingly recognized as a distinct phase in the history of HF, termed worsening HF (WHF). The definition of WHF continues to evolve from a historical focus solely on hospitalization to now include nonhospitalization events (eg, need for intravenous diuretic therapy in the emergency or outpatient setting). Most HF clinical trials to date have had HF hospitalization and death as primary endpoints, and only recently, some studies have included other WHF events regardless of location of care. This article reviews the evolution of the WHF definition, highlights the importance of considering the onset of WHF as an event that marks a new phase of HF, summarizes the latest clinical trials investigating novel therapies, and outlines unmet needs regarding identification and treatment of WHF.
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11
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Wierda E, van Maarschalkerwaart W(W, van Seumeren E, Dickhoff C, Montanus I, de Boer D, Kop E, de Mol BA, Schroeder‐Tanka JM, van Heerbeek L. Outpatient treatment of worsening heart failure with intravenous diuretics: first results from a multicentre 2-year experience. ESC Heart Fail 2022; 10:594-600. [PMID: 36377206 PMCID: PMC9871674 DOI: 10.1002/ehf2.14168] [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: 10/04/2021] [Revised: 09/11/2022] [Accepted: 09/15/2022] [Indexed: 11/17/2022] Open
Abstract
AIMS The aim of this study is to examine the safety and efficacy of outpatient treatment of worsening heart failure (WHF) with intravenous diuretics. METHODS AND RESULTS This is a multicentre retrospective observational research study. Patients with all types of heart failure (HF) were included: heart failure with reduced ejection fraction (HFrEF), heart failure with mildly reduced ejection fraction (HFmrEF), and heart failure with preserved ejection fraction (HFpEF). Patients included in this study were 18 years or older, had symptoms of WHF, had weight gain of more than 2 kg, and were not responding to uptitrating of oral diuretic therapy. Patients were treated for one or more days at the outpatient department with administration of intravenous loop diuretics with or without a bolus. In this study, 259 patients were included (mean age of 76 years, mean left ventricular ejection fraction of 41%). Rehospitalization rates for HF were 30.5% and 53.3%, respectively, at 30 days and 1 year. All-cause mortality was 5.8% and 26.3%, respectively, at 30 days and 1 year. Rehospitalization rates for HF and all-cause mortality were highest in patients with HFrEF. In a total of 322 individual outpatient treatments with intravenous diuretics, only one adverse event was registered. CONCLUSIONS Outpatient treatment with intravenous diuretics of patients with WHF is a safe alternative strategy compared with the same treatment in hospitalized patients. However, only non-randomized data are available and rehospitalization rates for this group with WHF are high. No data are available on the best selection criteria and the cost-effectiveness of outpatient treatment with intravenous diuretics.
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Affiliation(s)
- Eric Wierda
- Department of CardiologyDijklander ZiekenhuisHoornThe Netherlands
| | | | | | | | | | | | - Esther Kop
- Department of CardiologyOLVGAmsterdamThe Netherlands
| | - Bas A.J.M. de Mol
- Department of Cardiothoracic SurgeryAmsterdam University Medical CenterAmsterdamThe Netherlands
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12
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Sepehrvand N, Islam S, Dover DC, Kaul P, McAlister FA, Armstrong PW, Ezekowitz JA. Epidemiology of worsening heart failure in a population-based cohort from Alberta, Canada: Evaluating eligibility for treatment with vericiguat. J Card Fail 2022; 28:1298-1308. [PMID: 35589087 DOI: 10.1016/j.cardfail.2022.04.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2022] [Revised: 04/19/2022] [Accepted: 04/26/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Patients with heart failure (HF) and a reduced ejection fraction (HFrEF) who experience worsening heart failure (WHF) events are at increased risk of adverse outcomes and experience significant morbidity and mortality. We herein describe the epidemiology of these patients and identify those potentially eligible for vericiguat therapy in this population-based study. METHODS This retrospective cohort study included hospitalized or emergency department (ED) patients with a primary diagnosis of HF and left ventricular ejection fraction (LVEF) <45% diagnosed between April 1st, 2009 and March 31st, 2019 in Alberta, Canada, with follow-up to March 31st 2020. Inclusion criteria from the VICTORIA trial were applied to explore eligibility for vericiguat. RESULTS Among 25,629 patients with HF and LVEF data, 9,948 (38.8%) had HFrEF, of which 5,259 (52.8%) experienced WHF at some point during a median 5.8 years of follow-up, and 38.3% of those met the vericiguat trial eligibility criteria. Compared to HFrEF patients without WHF, those with WHF were older, with more comorbidities, worse renal function, similar LVEF status, but more use of HF medications, at baseline. At the time of WHF, 27% of those with HFrEF and WHF were on triple therapy, 50.6% were on dual therapy, and 15.4% were on monotherapy. All-cause mortality and the composite outcome of all-cause mortality or cardiovascular hospitalization at 1-year of follow-up were higher in the HFrEF with WHF cohort compared to HFrEF without WHF (adjusted hazard ratios of 1.92 and 1.51, respectively, both p<.0001). CONCLUSION Approximately, one-half of patients with HFrEF experienced WHF over long-term follow-up. Most were not on triple therapy, highlighting the underutilization of the existing standard-of-care treatments and opportunities for application of newer therapies; more than one-third of patients with HFrEF may be eligible for vericiguat. LAY SUMMARY Among patients with heart failure (HF), those who experience worsening HF are at increased risk of adverse outcomes. A few new therapies, including vericiguat, have emerged recently for patients with HF and reduced ejection fraction. However, the epidemiology, treatment patterns, and outcomes of patients with worsening HF in large representative populations is unclear. In current study, roughly, half of the patients with HF and reduced ejection fraction experienced worsening HF and 38.3% were potentially eligible for vericiguat therapy. The guideline-recommended therapies were under-utilized among patients with worsening HF, which highlights the need for initiatives to address this care gap.
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Affiliation(s)
- Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Sunjidatul Islam
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Douglas C Dover
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Padma Kaul
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, 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; Alberta Strategy for Patient Oriented Research Support Unit, Canada
| | - Paul W Armstrong
- Canadian VIGOUR Centre, 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.
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13
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Shah A, Mentz RJ, Sun JL, Rao VN, Alhanti B, Blumer V, Starling R, Butler J, Greene SJ. Emergency Department Visits Versus Hospital Readmissions Among Patients Hospitalized for Heart Failure. J Card Fail 2022; 28:916-923. [PMID: 34987009 DOI: 10.1016/j.cardfail.2021.11.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 11/20/2021] [Accepted: 11/23/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Worsening heart failure (HF) often requires hospitalization but in some cases may be managed in the outpatient or emergency department (ED) settings. The predictors and clinical significance of ED visits without admission vs hospitalization are unclear. METHODS The ASCEND-HF trial included 2661 US patients hospitalized for HF with reduced or preserved ejection fraction. Clinical characteristics were compared between patients with a subsequent all-cause ED visit (with ED discharge) within 30 days vs all-cause readmission within 30 days. Factors associated with each type of care were assessed in multivariable models. Multivariable models landmarked at 30 days evaluated associations between each type of care and subsequent 150-day mortality. RESULTS Through 30-day follow-up, 193 patients (7%) had ED discharge, 459 (17%) had readmission, and 2009 (76%) had neither urgent visit. Patients with ED discharge vs readmission were similar with respect to age, sex, systolic blood pressure, ejection fraction, and coronary artery disease, whereas ED discharge patients had a modestly lower creatinine (P < .01). Among patients with either event within 30 days, a higher creatinine and prior HF hospitalization were associated with a higher likelihood of readmission, as compared with ED discharge (P < .02). Landmarked at 30 days, rates of death during the subsequent 150 days were 21.0% for patients who were readmitted and 11.4% for patients discharged from the ED. Compared with patients who were readmitted, ED discharge was independently associated with lower 150-day mortality (adjusted hazard ratio 0.58, 95% confidence interval 0.36-0.92, P = .02). CONCLUSIONS In this cohort of US patients hospitalized for HF, worse renal function and prior HF hospitalization were associated with a higher likelihood of early postdischarge readmission, as compared with ED discharge. Although subsequent mortality was high after discharge from the ED, this risk of mortality was significantly lower than patients who were readmitted to the hospital.
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Affiliation(s)
- Anand Shah
- Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, North Carolina
| | - Vishal N Rao
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Brooke Alhanti
- Duke Clinical Research Institute, Durham, North Carolina
| | - Vanessa Blumer
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, NC
| | - Randall Starling
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, NC.
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14
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Khan MS, Greene SJ, Hellkamp AS, DeVore AD, Shen X, Albert NM, Patterson JH, Spertus JA, Thomas LE, Williams FB, Hernandez AF, Fonarow GC, Butler J. Diuretic Changes, Health Care Resource Utilization, and Clinical Outcomes for Heart Failure With Reduced Ejection Fraction: From the Change the Management of Patients With Heart Failure Registry. Circ Heart Fail 2021; 14:e008351. [PMID: 34674536 DOI: 10.1161/circheartfailure.121.008351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Diuretics are a mainstay therapy for the symptomatic treatment of heart failure. However, in contemporary US outpatient practice, the degree to which diuretic dosing changes over time and the associations with clinical outcomes and health care resource utilization are unknown. METHODS Among 3426 US outpatients with chronic heart failure with reduced ejection fraction in the Change the Management of Patients with Heart Failure registry with complete medication data and who were prescribed a loop diuretic, diuretic dose increase was defined as: (1) change to a total daily dose higher than their previous total daily dose, (2) addition of metolazone to the regimen, (3) change from furosemide to either bumetanide or torsemide, and the change persists for at least 7 days. Adjusted hazard ratios or rate ratios along with 95% CIs were reported for clinical outcomes among patients with an increase in oral diuretic dose versus no increase in diuretic dose. RESULTS Overall, 796 (23%) had a diuretic dose increase (18 episodes per 100 patient-years). The proportion of patients with dyspnea at rest (38% versus 26%), dyspnea at exertion (79% versus 67%), orthopnea (32% versus 21%), edema (60% versus 43%), and weight gain (40% versus 23%) were significantly (all P <0.001) higher in the diuretic increase group. Baseline angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (hazard ratio, 0.75 [95% CI, 0.65-0.87]) use were associated with lower likelihood of diuretic increase over time. Patients with a diuretic dose increase had a significantly higher number of heart failure hospitalizations (rate ratio, 2.53 [95% CI, 2.10-3.05]), emergency department visits (rate ratio, 1.84 [95% CI, 1.56-2.17]), and home health visits (rate ratio, 1.88 [95% CI, 1.39-2.54]), but not all-cause mortality (hazard ratio, 1.10 [95% CI, 0.89-1.36]). Similarly, greater furosemide dose equivalent increases were associated with greater resource utilization but not with mortality, compared with smaller increases. CONCLUSIONS In this contemporary US registry, 1 in 4 patients with heart failure with reduced ejection fraction had outpatient escalation of diuretic therapy over longitudinal follow-up, and these patients were more likely to have sign/symptoms of congestion. Outpatient diuretic dose escalation of any magnitude was associated with heart failure hospitalizations and resource utilization, but not all-cause mortality.
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Affiliation(s)
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.).,Department of Biostatistics and Bioinformatics (A.S.H., L.E.T.), Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Xian Shen
- Novartis Pharmaceuticals Corporation, East Hanover, NJ (X.S.)
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure, Cleveland Clinic, OH (N.M.A.)
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill (J.H.P.)
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City (J.A.S.)
| | - Laine E Thomas
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.).,Department of Biostatistics and Bioinformatics (A.S.H., L.E.T.), Duke University School of Medicine, Durham, NC
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (S.J.G., A.S.H., A.D.D., L.E.T., A.F.H.)
| | - Gregg C Fonarow
- Division of Cardiology, Ronald Reagan-UCLA Medical Center, Los Angeles, CA (G.C.F.)
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson (J.B.)
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15
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Packer M, Butler J, Zannad F, Filippatos G, Ferreira JP, Pocock SJ, Carson P, Anand I, Doehner W, Haass M, Komajda M, Miller A, Pehrson S, Teerlink JR, Schnaidt S, Zeller C, Schnee JM, Anker SD. Effect of Empagliflozin on Worsening Heart Failure Events in Patients With Heart Failure and Preserved Ejection Fraction: EMPEROR-Preserved Trial. Circulation 2021; 144:1284-1294. [PMID: 34459213 PMCID: PMC8522627 DOI: 10.1161/circulationaha.121.056824] [Citation(s) in RCA: 197] [Impact Index Per Article: 65.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2021] [Accepted: 08/13/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Empagliflozin reduces the risk of cardiovascular death or hospitalization for heart failure in patients with heart failure with preserved ejection fraction, but additional data are needed about its effect on inpatient and outpatient heart failure events. METHODS We randomly assigned 5988 patients with class II through IV heart failure with an ejection fraction of >40% to double-blind treatment with placebo or empagliflozin (10 mg once daily), in addition to usual therapy, for a median of 26 months. We prospectively collected information on inpatient and outpatient events reflecting worsening heart failure and prespecified their analysis in individual and composite end points. RESULTS Empagliflozin reduced the combined risk of cardiovascular death, hospitalization for heart failure, or an emergency or urgent heart failure visit requiring intravenous treatment (432 versus 546 patients [empagliflozin versus placebo, respectively]; hazard ratio, 0.77 [95% CI, 0.67-0.87]; P<0.0001). This benefit reached statistical significance at 18 days after randomization. Empagliflozin reduced the total number of heart failure hospitalizations that required intensive care (hazard ratio, 0.71 [95% CI, 0.52-0.96]; P=0.028) and the total number of all hospitalizations that required a vasopressor or positive inotropic drug (hazard ratio, 0.73 [95% CI, 0.55-0.97]; P=0.033). Compared with patients in the placebo group, fewer patients in the empagliflozin group reported outpatient intensification of diuretics (482 versus 610; hazard ratio, 0.76 [95% CI, 0.67-0.86]; P<0.0001), and patients assigned to empagliflozin were 20% to 50% more likely to have a better New York Heart Association functional class, with significant effects at 12 weeks that were maintained for at least 2 years. The benefit on total heart failure hospitalizations was similar in patients with an ejection fraction of >40% to <50% and 50% to <60%, but was attenuated at higher ejection fractions. CONCLUSIONS In patients with heart failure with preserved ejection fraction, empagliflozin produced a meaningful, early, and sustained reduction in the risk and severity of a broad range of inpatient and outpatient worsening heart failure events. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03057977.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, United Kingdom (M.P.)
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson (J.B.)
| | - Faiez Zannad
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France (F.Z., J.P.F.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Greece (G.F.)
| | - Joao Pedro Ferreira
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France (F.Z., J.P.F.)
- Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Portugal (J.P.F.)
| | - Stuart J. Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (S.J.P.)
| | - Peter Carson
- Washington DC Veterans Affairs Medical Center (P.C.)
| | - Inder Anand
- Department of Cardiology, University of Minnesota, Minneapolis (I.A.)
| | - Wolfram Doehner
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany (W.D., S.D.A.)
| | - Markus Haass
- Theresienkrankenhaus and St Hedwig-Klinik, Mannheim, Germany (M.H.)
| | - Michel Komajda
- Department of Cardiology, Hospital Saint Joseph, Paris, France (M.K.)
| | | | - Steen Pehrson
- Department of Cardiology, University Hospital, Rigshospitalet, Copenhagen, Denmark (S.P.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California (J.R.T.)
| | - Sven Schnaidt
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany (S.S., C.Z.)
| | - Cordula Zeller
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co KG, Biberach, Germany (S.S., C.Z.)
| | - Janet M. Schnee
- Boehringer Ingelheim Pharmaceuticals, Inc, Ridgefield, CT (J.M.S.)
| | - Stefan D. Anker
- Department of Cardiology (CVK) and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany (W.D., S.D.A.)
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16
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Solomon SD, de Boer RA, DeMets D, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez F, Shah SJ, Lindholm D, Wilderäng U, Öhrn F, Claggett B, Langkilde AM, Petersson M, McMurray JJV. Dapagliflozin in heart failure with preserved and mildly reduced ejection fraction: rationale and design of the DELIVER trial. Eur J Heart Fail 2021; 23:1217-1225. [PMID: 34051124 PMCID: PMC8361994 DOI: 10.1002/ejhf.2249] [Citation(s) in RCA: 189] [Impact Index Per Article: 63.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2021] [Revised: 04/13/2021] [Accepted: 05/18/2021] [Indexed: 12/12/2022] Open
Abstract
Aims Sodium–glucose co‐transporter 2 (SGLT2) inhibitors, originally developed as glucose‐lowering agents, have been shown to reduce heart failure hospitalizations in patients with type 2 diabetes without established heart failure, and in patients with heart failure with and without diabetes. Their role in patients with heart failure with preserved and mildly reduced ejection fraction remains unknown. Methods Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure (DELIVER) is an international, multicentre, parallel group, event‐driven, randomized, double‐blind trial in patients with chronic heart failure and left ventricular ejection fraction (LVEF) >40%, comparing the effect of dapagliflozin 10 mg once daily, vs. placebo, in addition to standard of care. Patients with or without diabetes, with signs and symptoms of heart failure, a LVEF >40%, elevation in natriuretic peptides and evidence of structural heart disease are eligible. The primary endpoint is time‐to‐first cardiovascular death or worsening heart failure event (heart failure hospitalization or urgent heart failure visit), and will be assessed in dual primary analyses – the full population and in those with LVEF <60%. The study is event‐driven and will target 1117 primary events. A total of 6263 patients have been randomized. Conclusions DELIVER will determine the efficacy and safety of the SGLT2 inhibitor dapagliflozin, added to conventional therapy, in patients with heart failure and preserved and mildly reduced ejection fraction.
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Affiliation(s)
- Scott D Solomon
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | | | | | | | | | - Carolyn S P Lam
- University of Groningen, Groningen, The Netherlands.,National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | | | | | | | - Brian Claggett
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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17
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Wand AL, Russell SD, Gilotra NA. Ambulatory Management of Worsening Heart Failure: Current Strategies and Future Directions. Heart Int 2021; 15:49-53. [PMID: 36277316 PMCID: PMC9524605 DOI: 10.17925/hi.2021.15.1.49] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Accepted: 02/16/2021] [Indexed: 10/29/2023] Open
Abstract
Heart failure (HF) is a highly prevalent and morbid disease in the USA. The chronic, progressive course of HF is defined by periodic exacerbations of symptoms, described as 'worsening heart failure' (WHF). Previously, episodes of WHF have required hospitalization for intravenous diuretics; however, recent innovations in care delivery models for patients with HF have allowed a transition from the acute care setting to the ambulatory setting. The development of remote monitoring strategies, including device-based algorithms and implantable haemodynamic monitoring systems, has facilitated more advanced surveillance of patients, aiming to prevent the clinical deterioration that leads to hospitalization. Additionally, the establishment of multidisciplinary HF clinics has provided the setting and resources for the outpatient treatment of WHF, specifically the administration of intravenous diuretics. Here we review the current state of ambulatory HF management, including mechanisms for patient monitoring and treatment, and outline future opportunities for outpatient management of this patient population.
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Affiliation(s)
- Alison L Wand
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Stuart D Russell
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Nisha A Gilotra
- Division of Cardiology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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18
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Lam CSP, Giczewska A, Sliwa K, Edelmann F, Refsgaard J, Bocchi E, Ezekowitz JA, Hernandez AF, O'Connor CM, Roessig L, Patel MJ, Pieske B, Anstrom KJ, Armstrong PW. Clinical Outcomes and Response to Vericiguat According to Index Heart Failure Event: Insights From the VICTORIA Trial. JAMA Cardiol 2021; 6:706-712. [PMID: 33185650 DOI: 10.1001/jamacardio.2020.6455] [Citation(s) in RCA: 41] [Impact Index Per Article: 13.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
Importance The period following heart failure hospitalization (HFH) is a vulnerable time with high rates of death or recurrent HFH. Objective To evaluate clinical characteristics, outcomes, and treatment response to vericiguat according to prespecified index event subgroups and time from index HFH in the Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction (VICTORIA) trial. Design, Setting, and Participants Analysis of an international, randomized, placebo-controlled trial. All VICTORIA patients had recent (<6 months) worsening HF (ejection fraction <45%). Index event subgroups were less than 3 months after HFH (n = 3378), 3 to 6 months after HFH (n = 871), and those requiring outpatient intravenous diuretic therapy only for worsening HF (without HFH) in the previous 3 months (n = 801). Data were analyzed between May 2, 2020, and May 9, 2020. Intervention Vericiguat titrated to 10 mg daily vs placebo. Main Outcomes and Measures The primary outcome was time to a composite of HFH or cardiovascular death; secondary outcomes were time to HFH, cardiovascular death, a composite of all-cause mortality or HFH, all-cause death, and total HFH. Results Among 5050 patients in the VICTORIA trial, mean age was 67 years, 24% were women, 64% were White, 22% were Asian, and 5% were Black. Baseline characteristics were balanced between treatment arms within each subgroup. Over a median follow-up of 10.8 months, the primary event rates were 40.9, 29.6, and 23.4 events per 100 patient-years in the HFH at less than 3 months, HFH 3 to 6 months, and outpatient worsening subgroups, respectively. Compared with the outpatient worsening subgroup, the multivariable-adjusted relative risk of the primary outcome was higher in HFH less than 3 months (adjusted hazard ratio, 1.48; 95% CI, 1.27-1.73), with a time-dependent gradient of risk demonstrating that patients closest to their index HFH had the highest risk. Vericiguat was associated with reduced risk of the primary outcome overall and in all subgroups, without evidence of treatment heterogeneity. Similar results were evident for all-cause death and HFH. Addtionally, a continuous association between time from HFH and vericiguat treatment showed a trend toward greater benefit with longer duration since HFH. Safety events (symptomatic hypotension and syncope) were infrequent in all subgroups, with no difference between treatment arms. Conclusions and Relevance Among patients with worsening chronic HF, those in closest proximity to their index HFH had the highest risk of cardiovascular death or HFH, irrespective of age or clinical risk factors. The benefit of vericiguat did not differ significantly across the spectrum of risk in worsening HF. Trial Registration ClinicalTrials.gov Identifier: NCT02861534.
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Affiliation(s)
- Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Anna Giczewska
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Karen Sliwa
- University of Cape Town, Cape Town, South Africa
| | - Frank Edelmann
- Charité University Medicine, German Heart Center, Berlin, Germany
| | | | - Edimar Bocchi
- Heart Institute (InCor), São Paulo University Medical School, São Paulo, Brazil
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | | | | | | | - Burkert Pieske
- Charité University Medicine, German Heart Center, Berlin, Germany
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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19
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Vaduganathan M, Cunningham JW, Claggett BL, Causland FM, Barkoudah E, Finn P, Zannad F, Pfeffer MA, Rizkala AR, Sabarwal S, McMurray JJV, Solomon S, Desai AS. Worsening Heart Failure Episodes Outside a Hospital Setting in Heart Failure With Preserved Ejection Fraction: The PARAGON-HF Trial. JACC. HEART FAILURE 2021; 9:374-382. [PMID: 33839075 DOI: 10.1016/j.jchf.2021.01.014] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study sought to evaluate the frequency and prognostic implications of urgent heart failure (HF) visits in a large global clinical trial of HF with preserved ejection fraction (HFpEF). BACKGROUND Episodes of worsening HF managed without hospitalization are common and prognostically important in HF with reduced ejection fraction (EF). The significance of these ambulatory worsening HF events in HFpEF is uncertain. METHODS PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction) randomly assigned 4,796 patients with HFpEF (≥45%) to treatment with sacubitril/valsartan vs. valsartan with a primary composite endpoint of total HF hospitalizations and cardiovascular death. Urgent ambulatory HF visits requiring intravenous diuretic treatment were prospectively collected and adjudicated by a blinded committee. We examined the effect of study treatment on a prespecified expanded composite of cardiovascular death and worsening HF events (including HF hospitalizations and urgent HF visits) and the effect of each type of HF event on subsequent mortality. RESULTS Of 884 first worsening HF events, 66 (7.5%) were urgent HF visits. Patients whose first episode of worsening HF event was an urgent visit had similar age, comorbidities, baseline N-terminal prohormone of B-type natriuretic peptide, and Meta-Analysis Global Group in Chronic Heart Failure risk scores to those in whom the first HF event was a hospitalization (all comparisons p > 0.05). Regardless of the treatment setting, patients with a first episode of worsening HF had higher rates of subsequent death (19.2 per 100 patient-years; 95% confidence interval [CI]: 16.9 to 21.8 for HF hospitalization and 10.1 per 100 patients-years; 95% CI: 5.4 to 18.7 for urgent HF visit) compared with those who did not experience worsening HF (death rate 4.0 per 100 patient-years; 95% CI: 3.6 to 4.4). Including total urgent HF visits in the composite study endpoint added 95 total events and would have shortened the trial duration needed for event accrual. The addition of urgent HF visits in a prespecified composite endpoint reinforced the treatment efficacy of sacubitril/valsartan compared with valsartan (rate ratio 0.86; 95% CI: 0.75 to 0.99; p = 0.040). CONCLUSIONS Like HF hospitalizations, worsening HF events treated in the ambulatory setting are prognostically important in HFpEF. Inclusion of these events in the composite primary endpoint underscores the benefit of sacubitril/valsartan compared with valsartan in PARAGON-HF. (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
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Affiliation(s)
- Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Finnian Mc Causland
- Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ebrahim Barkoudah
- Hospital Medicine Unit and Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Finn
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Faiez Zannad
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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20
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Solomon SD, McMURRAY JJV. Making the Case for an Expanded Indication for Sacubitril/Valsartan in Heart Failure. J Card Fail 2021; 27:693-695. [PMID: 33872760 DOI: 10.1016/j.cardfail.2021.04.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 04/12/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Scott D Solomon
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (SDS), and the British Heart Foundation Research Centre, University of Glasgow, Glasgow, UK (JJVM).
| | - John J V McMURRAY
- Cardiovascular Medicine Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts (SDS), and the British Heart Foundation Research Centre, University of Glasgow, Glasgow, UK (JJVM)
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21
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Blumer V, Mentz RJ, Sun JL, Butler J, Metra M, Voors AA, Hernandez AF, O'Connor CM, Greene SJ. Prognostic Role of Prior Heart Failure Hospitalization Among Patients Hospitalized for Worsening Chronic Heart Failure. Circ Heart Fail 2021; 14:e007871. [PMID: 33775110 PMCID: PMC9990499 DOI: 10.1161/circheartfailure.120.007871] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2020] [Accepted: 12/16/2020] [Indexed: 11/16/2022]
Abstract
BACKGROUND Hospitalization for heart failure (HF) is associated with increased risk of death among patients with chronic HF. The degree to which hospitalization for HF is a distinct biologic entity with independent prognostic value versus a marker of higher risk chronic HF patients is unclear. METHODS After excluding patients with new-onset HF, the ASCEND-HF trial (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) included 4205 patients hospitalized for worsening chronic HF with reduced or preserved ejection fraction. The present analysis compared patients by presence or absence of prior HF hospitalization within 12 months and by timing of prior HF hospitalization relative to index hospitalization. Associations with 180-day all-cause mortality were assessed, including adjustment for 27 prespecified clinical factors. RESULTS Overall, 2241 (53.3%) patients had a HF hospitalization within the prior 12 months and 1964 (46.7%) did not. Mortality rates at 180 days were 15.5% and 11.9%, respectively. In unadjusted analyses, prior HF hospitalization was associated with increased risk of 180-day mortality (HR, 1.35 [95% CI, 1.14-1.59]; P<0.01). After adjustment, the point estimate was attenuated and the association not statistically significant (HR, 1.18 [95% CI, 0.99-1.40]; P=0.064). Similarly, after adjustment, compared with patients without prior hospitalization, prior HF hospitalization was not associated with mortality, irrespective of timing (0-4 months: HR, 1.10 [95% CI, 0.87-1.39], P=0.41; 4-8 months: HR, 0.95 [95% CI, 0.70-1.27]; P=0.72; 8-12 months: HR, 1.06 [95% CI, 0.74-1.51], P=0.77; >12 months: HR, 0.81 [95% CI, 0.63-1.06], P=0.12). CONCLUSIONS In this cohort of patients hospitalized for worsening HF, prior HF hospitalization was not associated with 180-day mortality after comprehensively accounting for patient characteristics measured during the index patient visit. Clinical confounders measured at the point-of-care may explain previously observed associations between prior HF hospitalization and mortality, and these clinical factors may be a more direct means of predicting patient survival. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT00475852.
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Affiliation(s)
- Vanessa Blumer
- Division of Cardiology, Duke University School of Medicine, Durham, NC (V.B., R.J.M., A.F.H., S.J.G.)
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, NC (V.B., R.J.M., A.F.H., S.J.G.)
- Duke Clinical Research Institute, Durham, NC (R.J.M., J.-L.S., A.F.H., S.J.G.)
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Durham, NC (R.J.M., J.-L.S., A.F.H., S.J.G.)
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS (J.B.)
| | - Marco Metra
- Cardiology, ASST Spedali Civili di Brescia and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy (M.M.)
| | | | - Adrian F Hernandez
- Division of Cardiology, Duke University School of Medicine, Durham, NC (V.B., R.J.M., A.F.H., S.J.G.)
- Duke Clinical Research Institute, Durham, NC (R.J.M., J.-L.S., A.F.H., S.J.G.)
| | | | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC (V.B., R.J.M., A.F.H., S.J.G.)
- Duke Clinical Research Institute, Durham, NC (R.J.M., J.-L.S., A.F.H., S.J.G.)
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22
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Givertz MM, Yang M, Hess GP, Zhao B, Rai A, Butler J. Resource utilization and costs among patients with heart failure with reduced ejection fraction following a worsening heart failure event. ESC Heart Fail 2021; 8:1915-1923. [PMID: 33689217 PMCID: PMC8120411 DOI: 10.1002/ehf2.13155] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 11/05/2020] [Accepted: 11/15/2020] [Indexed: 01/14/2023] Open
Abstract
Aims The aim of this study is to characterize healthcare resource utilization and costs in patients with heart failure with reduced ejection fraction (HFrEF) following a worsening heart failure event. Methods and results This was a retrospective observational cohort analysis. Patients with HFrEF were identified from the PINNACLE Registry and linked to a nationwide pharmacy and medical claims database. Worsening heart failure was defined as stable heart failure with a subsequent hospitalization and/or intravenous diuretic therapy. Healthcare resource use and costs in 2015 US dollars were analysed for dispensed prescriptions, outpatient encounters, and hospital encounters. Among 11 064 patients with HFrEF, 3087 (27.9%) experienced a worsening heart failure event during an average follow‐up of 973 days. During the first 30 days after the worsening event, 19.8% of patients had hospital readmissions with heart failure as the primary or secondary diagnosis. During that same time period, mean per patient heart failure‐related healthcare resource use included 1.3 prescriptions, 0.5 practitioner visits, and 0.5 hospital encounters (admissions, observations, or emergency care), for an average total medical cost of $8779 per patient including $5359 in heart failure‐related costs. During the first year following worsening heart failure onset, mean per patient total and heart failure‐related costs were $62 615 and $35 329, respectively. Conclusions The economic burden following a worsening heart failure event calls for further review of methods to prevent progressive disease, improve adherence to guideline‐directed therapy, and develop novel treatments and care strategies to moderate further progression.
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Affiliation(s)
- Michael M Givertz
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Mei Yang
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Gregory P Hess
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Bin Zhao
- Merck & Co., Inc., Kenilworth, NJ, USA
| | - Ashwin Rai
- PRA Health Sciences, Kansas City, MO, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
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23
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Packer M, Anker SD, Butler J, Filippatos G, Ferreira JP, Pocock SJ, Carson P, Anand I, Doehner W, Haass M, Komajda M, Miller A, Pehrson S, Teerlink JR, Brueckmann M, Jamal W, Zeller C, Schnaidt S, Zannad F. Effect of Empagliflozin on the Clinical Stability of Patients With Heart Failure and a Reduced Ejection Fraction: The EMPEROR-Reduced Trial. Circulation 2021; 143:326-336. [PMID: 33081531 PMCID: PMC7834905 DOI: 10.1161/circulationaha.120.051783] [Citation(s) in RCA: 217] [Impact Index Per Article: 72.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 10/13/2020] [Indexed: 12/25/2022]
Abstract
BACKGROUND Empagliflozin reduces the risk of cardiovascular death or hospitalization for heart failure in patients with heart failure and a reduced ejection fraction, with or without diabetes, but additional data are needed about the effect of the drug on inpatient and outpatient events that reflect worsening heart failure. METHODS We randomly assigned 3730 patients with class II to IV heart failure with an ejection fraction of ≤40% to double-blind treatment with placebo or empagliflozin (10 mg once daily), in addition to recommended treatments for heart failure, for a median of 16 months. We prospectively collected information on inpatient and outpatient events reflecting worsening heart failure and prespecified their analysis in individual and composite end points. RESULTS Empagliflozin reduced the combined risk of death, hospitalization for heart failure or an emergent/urgent heart failure visit requiring intravenous treatment (415 versus 519 patients; empagliflozin versus placebo, respectively; hazard ratio [HR], 0.76; 95% CI, 0.67-0.87; P<0.0001). This benefit reached statistical significance at 12 days after randomization. Empagliflozin reduced the total number of heart failure hospitalizations that required intensive care (HR, 0.67; 95% CI, 0.50-0.90; P=0.008) and that required a vasopressor or positive inotropic drug or mechanical or surgical intervention (HR, 0.64; 95% CI, 0.47-0.87; P=0.005). As compared with placebo, fewer patients in the empagliflozin group reported intensification of diuretics (297 versus 414 [HR, 0.67; 95% CI, 0.56-0.78; P<0.0001]). Additionally, patients assigned to empagliflozin were 20% to 40% more likely to experience an improvement in New York Heart Association functional class and were 20% to 40% less likely to experience worsening of New York Heart Association functional class, with statistically significant effects that were apparent 28 days after randomization and maintained during long-term follow-up. The risk of any inpatient or outpatient worsening heart failure event in the placebo group was high (48.1 per 100 patient-years of follow-up), and it was reduced by empagliflozin (HR, 0.70; 95% CI, 0.63-0.78; P<0.0001). CONCLUSIONS In patients with heart failure and a reduced ejection fraction, empagliflozin reduced the risk and total number of inpatient and outpatient worsening heart failure events, with benefits seen early after initiation of treatment and sustained for the duration of double-blind therapy. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03057977.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
- Imperial College, London, UK (M.P.)
| | - Stefan D. Anker
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany (S.D.A., W.D.)
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson (J.B.)
| | - Gerasimos Filippatos
- National and Kapodistrian University of Athens School of Medicine, Athens University Hospital Attikon, Greece (G.F.)
| | | | - Stuart J. Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, UK (S.J.P.)
| | - Peter Carson
- Washington DC Veterans Affairs Medical Center (P.C.)
| | - Inder Anand
- Department of Cardiology, University of Minnesota, Minneapolis (I.A.)
| | - Wolfram Doehner
- Department of Cardiology and Berlin Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin, Berlin, Germany (S.D.A., W.D.)
| | - Markus Haass
- Theresienkrankenhaus and St.Hedwig-Klinik, Mannheim, Germany (M.H.)
| | - Michel Komajda
- Department of Cardiology, Hospital Saint Joseph, Paris, France (M.K.)
| | | | - Steen Pehrson
- Department of Cardiology, University Hospital, Rigshospitalet, Copenhagen, Denmark (S.P.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, CA (J.R.T.)
| | | | - Waheed Jamal
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (M.B., W.J., C.Z.)
| | - Cordula Zeller
- Boehringer Ingelheim International GmbH, Ingelheim, Germany (M.B., W.J., C.Z.)
| | - Sven Schnaidt
- Biostatistics and Data Sciences, Boehringer Ingelheim Pharma GmbH & Co. KG, Biberach, Germany (D.M., S.S.)
| | - Faiez Zannad
- Université de Lorraine, Inserm INI-CRCT, CHRU, Nancy, France (J.P.F., F.Z.)
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Abraham WT, Psotka MA, Fiuzat M, Filippatos G, Lindenfeld J, Mehran R, Ambardekar AV, Carson PE, Jacob R, Januzzi JL, Konstam MA, Krucoff MW, Lewis EF, Piccini JP, Solomon SD, Stockbridge N, Teerlink JR, Unger EF, Zeitler EP, Anker SD, O’Connor CM. Standardized Definitions for Evaluation of Heart Failure Therapies: Scientific Expert Panel From the Heart Failure Collaboratory and Academic Research Consortium. JACC-HEART FAILURE 2020; 8:961-972. [DOI: 10.1016/j.jchf.2020.10.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 12/28/2022]
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25
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Abraham WT, Psotka MA, Fiuzat M, Filippatos G, Lindenfeld J, Mehran R, Ambardekar AV, Carson PE, Jacob R, Januzzi JL, Konstam MA, Krucoff MW, Lewis EF, Piccini JP, Solomon SD, Stockbridge N, Teerlink JR, Unger EF, Zeitler EP, Anker SD, O'Connor CM. Standardized definitions for evaluation of heart failure therapies: scientific expert panel from the Heart Failure Collaboratory and Academic Research Consortium. Eur J Heart Fail 2020; 22:2175-2186. [PMID: 33017862 DOI: 10.1002/ejhf.2018] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 09/28/2020] [Accepted: 09/30/2020] [Indexed: 12/28/2022] Open
Abstract
The Heart Failure Academic Research Consortium is a partnership between the Heart Failure Collaboratory (HFC) and Academic Research Consortium (ARC), comprised of leading heart failure (HF) academic research investigators, patients, United States (US) Food and Drug Administration representatives, and industry members from the US and Europe. A series of meetings were convened to establish definitions and key concepts for the evaluation of HF therapies including optimal medical and device background therapy, clinical trial design elements and statistical concepts, and study endpoints. This manuscript summarizes the expert panel discussions as consensus recommendations focused on populations and endpoint definitions; it is not exhaustive or restrictive, but designed to stimulate HF clinical trial innovation.
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Affiliation(s)
- William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, OH, USA
| | | | - Mona Fiuzat
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | - Gerasimos Filippatos
- University of Cyprus Medical School, Shakolas Educational Center for Clinical Medicine, Nicosia, Cyprus
| | - JoAnn Lindenfeld
- Heart Failure and Transplantation Section, Vanderbilt Heart and Vascular Institute, Nashville, TN, USA
| | - Roxana Mehran
- The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | | | - Peter E Carson
- Department of Cardiology, Washington Veterans Affairs Medical Center, Washington, DC, USA
| | | | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital, Cardiometabolic Trials, Baim Institute for Clinical Research, Boston, MA, USA
| | - Marvin A Konstam
- The CardioVascular Center of Tufts Medical Center, Boston, MA, USA
| | - Mitchell W Krucoff
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, CA, USA
| | - Jonathan P Piccini
- Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - Ellis F Unger
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
| | - Emily P Zeitler
- Dartmouth-Hitchcock Medical Center and The Dartmouth Institute, Lebanon, NH, USA
| | - Stefan D Anker
- Division of Cardiology and Metabolism, Department of Cardiology, Berlin-Brandenburg Center for Regenerative Therapies, German Centre for Cardiovascular Research Partner Site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christopher M O'Connor
- Inova Heart and Vascular Institute, Falls Church, VA, USA.,Duke University Medical Center and Duke Clinical Research Institute, Durham, NC, USA
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Docherty KF, Jhund PS, Anand I, Bengtsson O, Böhm M, de Boer RA, DeMets DL, Desai AS, Drozdz J, Howlett J, Inzucchi SE, Johanson P, Katova T, Køber L, Kosiborod MN, Langkilde AM, Lindholm D, Martinez FA, Merkely B, Nicolau JC, O’Meara E, Ponikowski P, Sabatine MS, Sjöstrand M, Solomon SD, Tereshchenko S, Verma S, McMurray JJ. Effect of Dapagliflozin on Outpatient Worsening of Patients With Heart Failure and Reduced Ejection Fraction: A Prespecified Analysis of DAPA-HF. Circulation 2020; 142:1623-1632. [PMID: 32883108 PMCID: PMC7580857 DOI: 10.1161/circulationaha.120.047480] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/06/2020] [Accepted: 08/03/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND In the DAPA-HF trial (Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure), dapagliflozin, added to guideline-recommended therapies, reduced the risk of mortality and heart failure (HF) hospitalization. We examined the frequency and significance of episodes of outpatient HF worsening, requiring the augmentation of oral therapy, and the effects of dapagliflozin on these additional events. METHODS Patients in New York Heart Association functional class II to IV, with a left ventricular ejection fraction ≤40% and elevation of NT-proBNP (N-terminal pro-B-type natriuretic peptide), were eligible. The primary outcome was the composite of an episode of worsening HF (HF hospitalization or an urgent HF visit requiring intravenous therapy) or cardiovascular death, whichever occurred first. An additional prespecified exploratory outcome was the primary outcome plus worsening HF symptoms/signs leading to the initiation of new, or the augmentation of existing, oral treatment. RESULTS Overall, 36% more patients experienced the expanded, in comparison with the primary, composite outcome. In the placebo group, 684 of 2371 (28.8%) patients and, in the dapagliflozin group, 527 of 2373 (22.2%) participants experienced the expanded outcome (hazard ratio, 0.73 [95% CI, 0.65-0.82]; P<0.0001). Each component of the composite was reduced significantly by dapagliflozin. Over the median follow-up of 18.2 months, the number of patients needed to treat with dapagliflozin to prevent 1 experiencing an episode of fatal or nonfatal worsening was 16. Among the 4744 randomly assigned patients, the first episode of worsening was outpatient augmentation of treatment in 407 participants (8.6%), an urgent HF visit with intravenous therapy in 20 (0.4%), HF hospitalization in 489 (10.3%), and cardiovascular death in 295 (6.2%). The adjusted risk of death from any cause (in comparison with no event) after an outpatient worsening was hazard ratio, 2.67 (95% CI, 2.03-3.52); after an urgent HF visit, the adjusted risk of death was hazard ratio, 3.00 (95% CI, 1.39-6.48); and after a HF hospitalization, the adjusted risk of death was hazard ratio, 6.21 (95% CI, 5.07-7.62). CONCLUSION In DAPA-HF, outpatient episodes of HF worsening were common, were of prognostic importance, and were reduced by dapagliflozin. Registration: URL: https://www.clinicaltrials.gov; Unique Identifier: NCT03036124.
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Affiliation(s)
- Kieran F. Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (K.F.D., P.S.J., J.J.V.M.)
| | - Pardeep S. Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (K.F.D., P.S.J., J.J.V.M.)
| | - Inder Anand
- Department of Cardiology, University of Minnesota, Minneapolis (I.A.)
| | - Olof Bengtsson
- Late Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (O.B., P.J., A.M.L., D.L., M.S.)
| | - Michael Böhm
- Department of Medicine, Saarland University Hospital, Homburg/Saar, Germany (M.B.)
| | - Rudolf A. de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, The Netherlands (R.A.d.B.)
| | - David L. DeMets
- Department of Biostatistics & Medical Informatics, University of Wisconsin, Madison (D.L.D.)
| | - Akshay S. Desai
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (A.S.D., S.D.S.)
| | - Jaroslaw Drozdz
- Department of Cardiology, Medical University of Lodz, Poland (J.D.)
| | - Jonathan Howlett
- University of Calgary, Cumming School of Medicine and Libin Cardiovascular Institute, Alberta, Canada (J.H.)
| | - Silvio E. Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT (S.E.I.)
| | - Per Johanson
- Late Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (O.B., P.J., A.M.L., D.L., M.S.)
| | - Tzvetana Katova
- Clinic of Cardiology, National Cardiology Hospital, Sofia, Bulgaria (T.K.)
| | - Lars Køber
- Department of Cardiology Copenhagen University Hospital, Denmark (L.K.)
| | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City (M.N.K.)
- The George Institute for Global Health and University of New South Wales, Sydney, Australia (M.N.K.)
| | - Anna Maria Langkilde
- Late Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (O.B., P.J., A.M.L., D.L., M.S.)
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (O.B., P.J., A.M.L., D.L., M.S.)
| | | | - Béla Merkely
- Heart and Vascular Center, Semmelweis University, Budapest, Hungary (B.M.)
| | - Jose C. Nicolau
- Instituto do Coracao (InCor), Hospital das Clínicas Faculdade de Medicina, Universidade de São Paulo, Brazil (J.C.N.)
| | - Eileen O’Meara
- Department of Cardiology, Montreal Heart Institute, Ontario, Canada (E.O’M.)
| | - Piotr Ponikowski
- Center for Heart Diseases, University Hospital, Wroclaw Medical University, Poland (P.P.)
| | - Marc S. Sabatine
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (M.S.S.)
| | - Mikaela Sjöstrand
- Late Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (O.B., P.J., A.M.L., D.L., M.S.)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (A.S.D., S.D.S.)
| | - Sergey Tereshchenko
- Department of Myocardial Disease and Heart Failure, National Medical Research Center of Cardiology, Moscow, Russia (S.T.)
| | - Subodh Verma
- Division of Cardiac Surgery, St. Michael’s Hospital, University of Toronto, Ontario, Canada (S.V.)
| | - John J.V. McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (K.F.D., P.S.J., J.J.V.M.)
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Butler J, Djatche LM, Sawhney B, Chakladar S, Yang L, Brady JE, Yang M. Clinical and Economic Burden of Chronic Heart Failure and Reduced Ejection Fraction Following a Worsening Heart Failure Event. Adv Ther 2020; 37:4015-4032. [PMID: 32761552 PMCID: PMC7444407 DOI: 10.1007/s12325-020-01456-1] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2020] [Indexed: 01/14/2023]
Abstract
Introduction A worsening heart failure event (WHFE) is defined as progressively escalating heart failure signs/symptoms requiring intravenous diuretic treatment or hospitalization. No studies have compared the burden of chronic heart failure with reduced ejection fraction (HFrEF) following a WHFE versus stable disease to inform healthcare decision makers. Methods A retrospective study using the IBM® MarketScan® Commercial Database included patients younger than 65 years of age with HFrEF (one inpatient or two outpatient claims of systolic HF or one outpatient claim of systolic HF plus one outpatient claim of any HF). The first claim for HFrEF during 2016 was the index date. Patients were followed for the first 12 months after the index date (the worsening assessment period) to identify a WHFE, and for an additional 12 months or until the end of continuous enrollment (the post-worsening assessment period). Mean per patient per month (PPPM) health care resource use (HCRU) and costs were compared between patients following a WHFE and stable patients during the two periods using generalized linear models adjusting for patient characteristics. Results Of 16,646 patients with chronic HFrEF, 26.8% developed a WHFE. Adjusted all-cause hospitalizations (0.16 vs. 0.02 PPPM, P < 0.0001), outpatient visits (3.54 vs. 2.73 PPPM, P < 0.0001), and emergency department visits (0.25 vs. 0.06 PPPM, P < 0.0001) were higher in patients following a WHFE than stable patients during the worsening assessment period. Similar differences in HCRU were observed between the two cohorts during the post-worsening assessment period. Mean total adjusted cost of care PPPM was $8657 in patients with HFrEF following a WHFE versus $2195 in stable patients during the worsening assessment period, and $6809 versus $2849, respectively, during the post-worsening assessment period. Conclusion HCRU and costs were significantly greater in patients with chronic HFrEF following a WHFE compared to those who remained stable, suggesting an unmet need to improve clinical and economic outcomes among these patients. Electronic supplementary material The online version of this article (10.1007/s12325-020-01456-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Javed Butler
- University of Mississippi Medical Center, Jackson, MS, USA.
| | | | - Baanie Sawhney
- Complete Health Economics and Outcomes Research Solutions, North Wales, PA, USA
| | - Sreya Chakladar
- Complete Health Economics and Outcomes Research Solutions, North Wales, PA, USA
| | | | | | - Mei Yang
- Merck & Co., Inc., Kenilworth, NJ, USA
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28
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Affiliation(s)
| | - Javed Butler
- Department of Medicine University of Mississippi Jackson MS
| | - Stephen J Greene
- Division of Cardiology Duke University School of Medicine Durham NC.,Duke Clinical Research Institute Durham NC
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Wierda E, Dickhoff C, Handoko ML, Oosterom L, Kok WE, de Rover Y, de Mol BAJM, van Heerebeek L, Schroeder-Tanka JM. Outpatient treatment of worsening heart failure with intravenous and subcutaneous diuretics: a systematic review of the literature. ESC Heart Fail 2020; 7:892-902. [PMID: 32159279 PMCID: PMC7261522 DOI: 10.1002/ehf2.12677] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2019] [Revised: 01/20/2020] [Accepted: 02/18/2020] [Indexed: 12/15/2022] Open
Abstract
Aims In the coming decade, heart failure (HF) represents a major global healthcare challenge due to an ageing population and rising prevalence combined with scarcity of medical resources and increasing healthcare costs. A transitional care strategy within the period of clinical worsening of HF before hospitalization may offer a solution to prevent hospitalization. The outpatient treatment of worsening HF with intravenous or subcutaneous diuretics as an alternative strategy for hospitalization has been described in the literature. Methods and results In this systematic review, the available evidence for the efficacy and safety of outpatient treatment with intravenous or subcutaneous diuretics of patients with worsening HF is analysed. A search was performed in the electronic databases MEDLINE and EMBASE. Of the 11 included studies 10 were single‐centre, using non‐randomized, observational registries of treatment with intravenous or subcutaneous diuretics for patients with worsening HF with highly variable selection criteria, baseline characteristics, and treatment design. One study was a randomized study comparing subcutaneous furosemide with intravenous furosemide. In a total of 984 unique individual patients treated in the reviewed studies, only a few adverse events were reported. Re‐hospitalization rates for HF at 30 and 180 days were 28 and 46%, respectively. All‐cause re‐hospitalization rates at 30 and 60 days were 18–37 and 22%, respectively. The highest HF re‐hospitalization was 52% in 30 days in the subcutaneous diuretic group and 42% in 30 days in the intravenous diuretic group. Conclusions The reviewed studies present practice‐based results of treatment of patients with worsening HF with intravenous or subcutaneous diuretics in an outpatient HF care unit and report that it is effective by relieving symptoms with a low risk of adverse events. The studies do not provide satisfactory evidence for reduction in rates of re‐hospitalization or improvement in mortality or quality of life. The conclusions drawn from these studies are limited by the quality of the individual studies. Prospective randomized studies are needed to determine the safety and effectiveness of outpatient intravenous or subcutaneous diuretic treatment for patient with worsening HF.
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Affiliation(s)
- Eric Wierda
- Department of Cardiology, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | | | - Martin Louis Handoko
- Department of Cardiology, Amsterdam University Medical Center, location VU University Medical Center, Amsterdam, The Netherlands
| | - Liane Oosterom
- Department of Cardiology, Dijklander Ziekenhuis, Purmerend, The Netherlands
| | - Wouter Emmanuel Kok
- Department of Cardiology, Amsterdam University Medical Center, location Academic Medical Center, Amsterdam, The Netherlands
| | - Y de Rover
- Department of Medical Library, Dijklander Ziekenhuis, Hoorn, The Netherlands
| | - B A J M de Mol
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, The Netherlands
| | - Loek van Heerebeek
- Department of Cardiology, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands
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Butler J, Packer M, Greene SJ, Fiuzat M, Anker SD, Anstrom KJ, Carson PE, Cooper LB, Fonarow GC, Hernandez AF, Januzzi JL, Jessup M, Kalyani RR, Kaul S, Kosiborod M, Lindenfeld J, McGuire DK, Sabatine MS, Solomon SD, Teerlink JR, Vaduganathan M, Yancy CW, Stockbridge N, O'Connor CM. Heart Failure End Points in Cardiovascular Outcome Trials of Sodium Glucose Cotransporter 2 Inhibitors in Patients With Type 2 Diabetes Mellitus: A Critical Evaluation of Clinical and Regulatory Issues. Circulation 2019; 140:2108-2118. [PMID: 31841369 PMCID: PMC7027964 DOI: 10.1161/circulationaha.119.042155] [Citation(s) in RCA: 20] [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] [Indexed: 12/25/2022]
Abstract
Following regulatory guidance set forth in 2008 by the US Food and Drug Administration for new drugs for type 2 diabetes mellitus, many large randomized, controlled trials have been conducted with the primary goal of assessing the safety of antihyperglycemic medications on the primary end point of major adverse cardiovascular events, defined as cardiovascular death, nonfatal myocardial infarction, or nonfatal stroke. Heart failure (HF) was not specifically mentioned in the US Food and Drug Administration guidance and therefore it was not a focus of these studies when planned. Several trials subsequently showed the impact of antihyperglycemic drugs on HF outcomes, which were not originally specified as the primary end point of the trials. The most impressive finding has been the substantial and consistent risk reduction in HF hospitalization seen across 4 trials of sodium glucose cotransporter 2 inhibitors. However, to date, these results have not led to regulatory approval of any of these drugs for a HF indication or a recommendation for use by US HF guidelines. It is therefore important to explore to what extent persuasive treatment effects on nonprimary end points can be used to support regulatory claims and guideline recommendations. This topic was discussed by researchers, clinicians, industry sponsors, regulators, and representatives from professional societies, who convened on the US Food and Drug Administration campus on March 6, 2019. This report summarizes these discussions and the key takeaway messages from this meeting.
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Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson (J.B.)
| | | | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., A.F.H.)
| | - Mona Fiuzat
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
| | - Stefan D Anker
- Berlin-Brandenburg Center for Regenerative Therapies, Germany (S.D.A.)
- Department of Cardiology, German Center for Cardiovascular Research partner site Berlin, Charite Universitatsmedizin Berlin (S.D.A.)
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
| | - Peter E Carson
- Cardiovascular Division, Department of Cardiology, Washington Veterans Affairs Medical Center (P.E.C.)
| | - Lauren B Cooper
- Inova Heart and Vascular Institute, Falls Church, VA (L.B.C., C.M.O.)
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles (G.C.F.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC (S.J.G., M.F., K.J.A., A.F.H.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., A.F.H.)
| | - James L Januzzi
- Cardiology Division, Massachusetts General Hospital and Baim Institute for Clinical Research, Boston (J.L.J.)
| | | | - Rita R Kalyani
- Division of Endocrinology, Diabetes, and Metabolism, Johns Hopkins University School of Medicine, Baltimore, MD (R.R.K.)
| | - Sanjay Kaul
- Cedars-Sinai Medical Center, Los Angeles, CA (S.K.)
| | - Mikhail Kosiborod
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (M.K.)
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (M.K.)
| | | | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas (D.K.M.)
| | - Marc S Sabatine
- TIMI Study Group (M.S.S.), Brigham and Women's Hospital, Boston, MA
- Division of Cardiovascular Medicine (M.S.S., S.D.S., M.V.), Brigham and Women's Hospital, Boston, MA
| | - Scott D Solomon
- Division of Cardiovascular Medicine (M.S.S., S.D.S., M.V.), Brigham and Women's Hospital, Boston, MA
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, CA (J.R.T.)
- School of Medicine, University of California, San Francisco (J.R.T.)
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine (M.S.S., S.D.S., M.V.), Brigham and Women's Hospital, Boston, MA
| | - Clyde W Yancy
- Division of Cardiology, Northwestern University Feinberg School of Medicine, Chicago, IL (C.W.Y.)
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, United States Food and Drug Administration, Silver Spring, MD (N.S.)
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Abstract
Importance Hospitalizations for worsening heart failure (WHF) represent an enormous public health and financial burden, with physicians, health systems, and payers placing increasing emphasis on hospitalization prevention. In addition, maximizing time out of the hospital is an important patient-centered outcome. In this review, we discuss the concept of outpatient WHF, highlight the rationale and data for the outpatient treatment of WHF as an alternative to hospitalization, and examine opportunities and strategies for developing outpatient "interceptive" therapies for treatment of worsening symptoms and prevention of hospitalization. Observations Worsening heart failure has traditionally been synonymous with an episode of in-hospital care for worsening symptoms. While WHF often leads to hospitalization, many patients experience WHF in the outpatient setting and carry a similarly poor prognosis. These findings support WHF as a distinct condition, independent of location of care. For those that are hospitalized, most patients have an uncomplicated clinical course, with diuretics as the only intravenous therapy. Although complicated scenarios exist, it is conceivable that improved tools for outpatient management of clinical congestion would allow a greater proportion of hospitalized patients to receive comparable care outside the hospital. Most patients with WHF have a gradual onset of congestive signs and symptoms, offering a potential window in which effective therapy may abort continued worsening and obviate the need for hospitalization. To date, outpatient WHF has received minimal attention in randomized clinical trials, but this high-risk group possesses key features that favor effective clinical trial investigation. Conclusions and Relevance As the public health and economic burdens of heart failure continue to grow, recognizing the entity of outpatient WHF is critical. Efforts to reduce heart failure hospitalization should include developing effective therapies and care strategies for outpatient WHF. The outpatient WHF population represents a major opportunity for therapeutic advancements that could fundamentally change heart failure care delivery.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - G Michael Felker
- Duke Clinical Research Institute, Durham, North Carolina.,Division of Cardiology, Duke University Medical Center, Durham, North Carolina
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McMurray JJ, DeMets DL, Inzucchi SE, Køber L, Kosiborod MN, Langkilde AM, Martinez FA, Bengtsson O, Ponikowski P, Sabatine MS, Sjöstrand M, Solomon SD. A trial to evaluate the effect of the sodium-glucose co-transporter 2 inhibitor dapagliflozin on morbidity and mortality in patients with heart failure and reduced left ventricular ejection fraction (DAPA-HF). Eur J Heart Fail 2019; 21:665-675. [PMID: 30895697 PMCID: PMC6607736 DOI: 10.1002/ejhf.1432] [Citation(s) in RCA: 252] [Impact Index Per Article: 50.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2018] [Revised: 12/21/2018] [Accepted: 01/03/2019] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Sodium-glucose co-transporter 2 (SGLT2) inhibitors have been shown to reduce the risk of incident heart failure hospitalization in individuals with type 2 diabetes who have, or are at high risk of, cardiovascular disease. Most patients in these trials did not have heart failure at baseline and the effect of SGLT2 inhibitors on outcomes in individuals with established heart failure (with or without diabetes) is unknown. DESIGN AND METHODS The Dapagliflozin And Prevention of Adverse-outcomes in Heart Failure trial (DAPA-HF) is an international, multicentre, parallel group, randomized, double-blind, study in patients with chronic heart failure, evaluating the effect of dapagliflozin 10 mg, compared with placebo, given once daily, in addition to standard care, on the primary composite outcome of a worsening heart failure event (hospitalization or equivalent event, i.e. an urgent heart failure visit) or cardiovascular death. Patients with and without diabetes are eligible and must have a left ventricular ejection fraction ≤ 40%, a moderately elevated N-terminal pro B-type natriuretic peptide level, and an estimated glomerular filtration rate ≥ 30 mL/min/1.73 m2 . The trial is event-driven, with a target of 844 primary outcomes. Secondary outcomes include the composite of total heart failure hospitalizations (including repeat episodes), and cardiovascular death and patient-reported outcomes. A total of 4744 patients have been randomized. CONCLUSIONS DAPA-HF will determine the efficacy and safety of the SGLT2 inhibitor dapagliflozin, added to conventional therapy, in a broad spectrum of patients with heart failure and reduced ejection fraction.
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Affiliation(s)
| | - David L. DeMets
- Department of Biostatistics and Medical Informatics, School of Medicine and Public HealthUniversity of WisconsinMadisonWIUSA
| | - Silvio E. Inzucchi
- Section of EndocrinologyYale University School of MedicineNew HavenCTUSA
| | - Lars Køber
- Rigshospitalet Copenhagen University HospitalCopenhagenDenmark
| | - Mikhail N. Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri‐Kansas CityKansas CityMOUSA
- The George Institute for Global HealthSydneyAustralia
| | | | | | | | | | - Marc S. Sabatine
- TIMI Study Group, Division of Cardiovascular MedicineBrigham and Women's Hospital, and Harvard Medical SchoolBostonMAUSA
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33
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Clinical Course of Patients With Worsening Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2019; 73:935-944. [DOI: 10.1016/j.jacc.2018.11.049] [Citation(s) in RCA: 100] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Accepted: 11/26/2018] [Indexed: 11/23/2022]
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Abstract
The clinical course of heart failure is characterised by progressive worsening of cardiac function and symptoms. Patients progress to a condition where traditional treatment is no longer effective and advanced therapies, such as mechanical circulatory support, heart transplantation and/or palliative care, are needed. This condition is called advanced chronic heart failure. The Heart Failure Association first defined it in 2007 and this definition was updated in 2018. The updated version emphasises the role of comorbidities, including tachyarrhythmias, and the role of heart failure with preserved ejection fraction. Improvements in mechanical circulatory support technology and better disease management programmes are major advances and are radically changing the management of these patients.
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Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia Brescia, Italy
| | - Elisabetta Dinatolo
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia Brescia, Italy
| | - Nicolò Dasseni
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University and Civil Hospital of Brescia Brescia, Italy
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Greene SJ, Felker GM, Butler J. Outpatient versus inpatient worsening heart failure: distinguishing biology and risk from location of care. Eur J Heart Fail 2018; 21:121-124. [PMID: 30394644 DOI: 10.1002/ejhf.1341] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2018] [Accepted: 09/29/2018] [Indexed: 12/30/2022] Open
Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - G Michael Felker
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University Medical Center, Durham, NC, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, MS, USA
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Ferreira JP, Metra M, Mordi I, Gregson J, ter Maaten JM, Tromp J, Anker SD, Dickstein K, Hillege HL, Ng LL, van Veldhuisen DJ, Lang CC, Voors AA, Zannad F. Heart failure in the outpatient versus inpatient setting: findings from the BIOSTAT-CHF study. Eur J Heart Fail 2018; 21:112-120. [DOI: 10.1002/ejhf.1323] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/06/2018] [Revised: 08/14/2018] [Accepted: 08/29/2018] [Indexed: 01/08/2023] Open
Affiliation(s)
- João Pedro Ferreira
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433; Université de Lorraine; CHRU de Nancy and F-CRIN INI-CRCT, Nancy France
- Cardiovascular Research and Development Unit, Department of Physiology and Cardiothoracic Surgery, Faculty of Medicine; University of Porto; Porto Portugal
| | - Marco Metra
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health; University of Brescia; Brescia Italy
| | - Ify Mordi
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School; University of Dundee; Dundee UK
| | - John Gregson
- Department of Biostatistics; London School of Hygiene & Tropical Medicine; London UK
| | - Jozine M. ter Maaten
- Department of Cardiology, University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - Jasper Tromp
- Department of Cardiology, University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - Stefan D. Anker
- Division of Cardiology and Metabolism, Department of Cardiology (CVK), and Berlin-Brandenburg Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin; Charité Universitätsmedizin Berlin; Germany
- Department of Cardiology and Pneumology; University Medicine Göttingen (UMG); Göttingen Germany
| | - Kenneth Dickstein
- Department of Internal Medicine; University of Bergen; Bergen Norway
- Department of Cardiology; Stavanger University Hospital; Stavanger Norway
| | - Hans L. Hillege
- Department of Cardiology, University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - Leong L. Ng
- Department of Cardiovascular Sciences, University of Leicester, Glenfield Hospital, Leicester, UK, and NIHR Leicester Biomedical Research Centre; Glenfield Hospital; Leicester UK
| | - Dirk J. van Veldhuisen
- Department of Cardiology, University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - Chim C. Lang
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School; University of Dundee; Dundee UK
| | - Adriaan A. Voors
- Department of Cardiology, University of Groningen; University Medical Center Groningen; Groningen The Netherlands
| | - Faiez Zannad
- INSERM, Centre d'Investigations Cliniques Plurithématique 1433; Université de Lorraine; CHRU de Nancy and F-CRIN INI-CRCT, Nancy France
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Gori M, Redfield MM, Calabrese A, Canova P, Cioffi G, De Maria R, Grosu A, Fontana A, Iacovoni A, Ferrari P, Parati G, Gavazzi A, Senni M. Is mild asymptomatic left ventricular systolic dysfunction always predictive of adverse events in high-risk populations? Insights from the DAVID-Berg study. Eur J Heart Fail 2018; 20:1540-1548. [DOI: 10.1002/ejhf.1298] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Revised: 07/09/2018] [Accepted: 07/16/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Mauro Gori
- Cardiovascular Department; ASST Papa Giovanni XXIII Hospital; Bergamo Italy
| | | | - Alice Calabrese
- Cardiovascular Department; ASST Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Paolo Canova
- Cardiovascular Department; ASST Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Giovanni Cioffi
- Department of Cardiology; Villa Bianca Hospital; Trento Italy
| | - Renata De Maria
- CNR Institute of Clinical Physiology, Cardio-Thoracic and Vascular Department; Niguarda Hospital; Milan Italy
| | - Aurelia Grosu
- Cardiovascular Department; ASST Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Alessandra Fontana
- Cardiovascular Department; ASST Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Attilio Iacovoni
- Cardiovascular Department; ASST Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Paola Ferrari
- Cardiovascular Department; ASST Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Gianfranco Parati
- Department of Cardiovascular, Neural and Metabolic Sciences, S. Luca Hospital, Istituto Auxologico Italiano, IRCCS, Milan, Italy; Department of Health Sciences; University of Milano-Bicocca; Milan Italy
| | - Antonello Gavazzi
- FROM Research Foundation; ASST Papa Giovanni XXIII Hospital; Bergamo Italy
| | - Michele Senni
- Cardiovascular Department; ASST Papa Giovanni XXIII Hospital; Bergamo Italy
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Crespo-Leiro MG, Metra M, Lund LH, Milicic D, Costanzo MR, Filippatos G, Gustafsson F, Tsui S, Barge-Caballero E, De Jonge N, Frigerio M, Hamdan R, Hasin T, Hülsmann M, Nalbantgil S, Potena L, Bauersachs J, Gkouziouta A, Ruhparwar A, Ristic AD, Straburzynska-Migaj E, McDonagh T, Seferovic P, Ruschitzka F. Advanced heart failure: a position statement of the Heart Failure Association of the European Society of Cardiology. Eur J Heart Fail 2018; 20:1505-1535. [DOI: 10.1002/ejhf.1236] [Citation(s) in RCA: 373] [Impact Index Per Article: 62.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/04/2018] [Revised: 05/17/2018] [Accepted: 05/21/2018] [Indexed: 12/28/2022] Open
Affiliation(s)
- Maria G. Crespo-Leiro
- Complexo Hospitalario Universitario A Coruña (CHUAC); Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC; La Coruña Spain
| | - Marco Metra
- Cardiology; University of Brescia; Brescia Italy
| | - Lars H. Lund
- Department of Medicine, Unit of Cardiology; Karolinska Institute; Stockholm Sweden
| | - Davor Milicic
- Department for Cardiovascular Diseases; University Hospital Center Zagreb, University of Zagreb; Zagreb Croatia
| | | | | | - Finn Gustafsson
- Department of Cardiology; Rigshospitalet; Copenhagen Denmark
| | - Steven Tsui
- Transplant Unit; Royal Papworth Hospital; Cambridge UK
| | - Eduardo Barge-Caballero
- Complexo Hospitalario Universitario A Coruña (CHUAC); Instituto de Investigación Biomédica de A Coruña (INIBIC), CIBERCV, UDC; La Coruña Spain
| | - Nicolaas De Jonge
- Department of Cardiology; University Medical Center Utrecht; Utrecht The Netherlands
| | - Maria Frigerio
- Transplant Center and De Gasperis Cardio Center; Niguarda Hospital; Milan Italy
| | - Righab Hamdan
- Department of Cardiology; Beirut Cardiac Institute; Beirut Lebanon
| | - Tal Hasin
- Jesselson Integrated Heart Center; Shaare Zedek Medical Center; Jerusalem Israel
| | - Martin Hülsmann
- Department of Internal Medicine II; Medical University of Vienna; Vienna Austria
| | | | - Luciano Potena
- Heart and Lung Transplant Program; Bologna University Hospital; Bologna Italy
| | - Johann Bauersachs
- Department of Cardiology and Angiology; Medical School Hannover; Hannover Germany
| | - Aggeliki Gkouziouta
- Heart Failure and Transplant Unit; Onassis Cardiac Surgery Centre; Athens Greece
| | - Arjang Ruhparwar
- Department of Cardiac Surgery; University of Heidelberg; Heidelberg Germany
| | - Arsen D. Ristic
- Department of Cardiology of the Clinical Center of Serbia; Belgrade University School of Medicine; Belgrade Serbia
| | | | | | - Petar Seferovic
- Department of Internal Medicine; Belgrade University School of Medicine and Heart Failure Center, Belgrade University Medical Center; Belgrade Serbia
| | - Frank Ruschitzka
- University Heart Center; University Hospital Zurich; Zurich Switzerland
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Shen L, Jhund PS, Mogensen UM, Køber L, Claggett B, Rogers JK, McMurray JJV. Re-Examination of the BEST Trial Using Composite Outcomes, Including Emergency Department Visits. JACC-HEART FAILURE 2018; 5:591-599. [PMID: 28774394 DOI: 10.1016/j.jchf.2017.04.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/16/2017] [Revised: 04/13/2017] [Accepted: 04/17/2017] [Indexed: 11/18/2022]
Abstract
OBJECTIVES The influence of choice of endpoint on trial size, duration, and interpretation of results was examined in patients with heart failure who were enrolled in BEST (Beta-blocker Evaluation of Survival Trial). BACKGROUND The choice of endpoints in heart failure trials has evolved over the past 3 decades. METHODS In the BEST trial, we used Cox regression analysis to examine the effect of bucindolol on the current standard composite of cardiovascular death or heart failure hospitalization (CVD/HFH) compared with the original primary mortality endpoint and the expanded composite that included emergency department (ED) visits. We also undertook an analysis of recurrent events primarily using the Lin, Wei, Ying, and Yang model. RESULTS Overall, 448 (33%) patients on placebo and 411 (30%) patients on bucindolol died (hazard ratio [HR]: 0.90; 95% confidence interval [CI]: 0.78 to 1.02; p = 0.11). A total of 730 (54%) patients experienced CVD/HFH on placebo and 624 (46%) on bucindolol (HR: 0.80; 95% CI: 0.72 to 0.89; p < 0.001). Adding ED visits increased these numbers to 768 (57%) and 668 (49%), respectively (HR: 0.81; 95% CI: 0.73 to 0.90; p < 0.001). A total of 568 (42%) patients on placebo experienced HFH compared with 476 (35%) patients on bucindolol (HR: 0.78; 95% CI: 0.69 to 0.89; p < 0.001), with a total of 1,333 and 1,124 admissions, respectively. With the same statistical assumptions, using the composite endpoint instead of all-cause mortality would have reduced the trial size by 40% and follow-up duration by 69%. The rate ratio for recurrent events (CVD/HFH) was 0.83 (95% CI: 0.73 to 0.94; p = 0.003). CONCLUSIONS Choice of endpoint has major implications for trial size and duration, as well as interpretation of results. The value of broader composite endpoints and inclusion of recurrent events needs further investigation. (Beta Blocker Evaluation in Survival Trial [BEST]; NCT00000560).
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Affiliation(s)
- Li Shen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Ulrik M Mogensen
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Lars Køber
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham & Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom.
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Greene SJ, Vaduganathan M, Khan MS, Bakris GL, Weir MR, Seltzer JH, Sattar N, McGuire DK, Januzzi JL, Stockbridge N, Butler J. Prevalent and Incident Heart Failure in Cardiovascular Outcome Trials of Patients With Type 2 Diabetes. J Am Coll Cardiol 2018; 71:1379-1390. [PMID: 29534825 PMCID: PMC5832063 DOI: 10.1016/j.jacc.2018.01.047] [Citation(s) in RCA: 47] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/03/2017] [Revised: 01/16/2018] [Accepted: 01/22/2018] [Indexed: 02/06/2023]
Abstract
Despite multiple examples of glucose-lowering therapies affecting heart failure (HF) risk, ascertainment of HF data in cardiovascular outcome trials of these medications has not been systematically characterized. In this review, large (n >1,000) published phase III and IV cardiovascular outcome trials evaluating glucose-lowering therapies through June 2017 were identified. Data were abstracted from publications, U.S. Food and Drug Administration advisory committee records, and U.S. Food and Drug Administration labeling documents. Overall, 21 trials including 152,737 patients were evaluated. Rates and definitions of baseline HF and incident HF were inconsistently provided. Baseline ejection fraction data were provided in 3 studies but not specific to patients with HF. No trial reported functional class, ejection fraction, or HF therapy at the time of incident HF diagnosis. HF hospitalization data were available in 15 trials, but only 2 included HF-related events within the primary composite endpoint. This systematic review highlights gaps in HF data capture within cardiovascular outcome trials of glucose-lowering therapies and outlines rationale and strategies for improving HF characterization.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | | | - George L Bakris
- ASH Comprehensive Hypertension Center, Department of Medicine, University of Chicago, Chicago, Illinois
| | - Matthew R Weir
- Division of Nephrology, Department of Medicine, University of Maryland School of Medicine, Baltimore, Maryland
| | | | - Naveed Sattar
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Darren K McGuire
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Norman Stockbridge
- Division of Cardiovascular and Renal Products, U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi.
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Ferrari R, Bueno H, Chioncel O, Cleland JG, Stough WG, Lettino M, Metra M, Parissis JT, Pinto F, Ponikowski P, Ruschitzka F, Tavazzi L. Acute heart failure: lessons learned, roads ahead. Eur J Heart Fail 2018. [DOI: 10.1002/ejhf.1169] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Roberto Ferrari
- Department of Cardiology and LTTA Centre; University Hospital of Ferrara; Ferrara Italy
- Maria Cecilia Hospital, GVM Care & Research; E.S. Health Science Foundation; Cotignola Italy
| | - Héctor Bueno
- Department of Cardiology; Hospital 12 de Octubre; Madrid Spain
| | - Ovidiu Chioncel
- University of Medicine Carol Davila Bucuresti; Institutul de Urgente Boli Cardiovasculare CC; Iliescu Romania
| | - John G. Cleland
- National Heart & Lung Institute; Harefield Hospital, Imperial College; London UK
| | - Wendy Gattis Stough
- Departments of Pharmacy Practice and Clinical Research; Campbell University College of Pharmacy and Health Sciences; Cary NC USA
| | | | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health; University of Brescia; Brescia Italy
| | | | - Fausto Pinto
- Departamento de Cardiologia, CCUL, CAML, Faculdade de Medicina; Universidade de Lisboa; Lisbon Portugal
| | - Piotr Ponikowski
- Medical University, Centre for Heart Disease; Clinical Military Hospital; Wroclaw Poland
| | - Frank Ruschitzka
- Department of Cardiology; University Heart Center; Zürich Switzerland
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research; E.S. Health Science Foundation; Cotignola Italy
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Hicks KA, Mahaffey KW, Mehran R, Nissen SE, Wiviott SD, Dunn B, Solomon SD, Marler JR, Teerlink JR, Farb A, Morrow DA, Targum SL, Sila CA, Thanh Hai MT, Jaff MR, Joffe HV, Cutlip DE, Desai AS, Lewis EF, Gibson CM, Landray MJ, Lincoff AM, White CJ, Brooks SS, Rosenfield K, Domanski MJ, Lansky AJ, McMurray JJ, Tcheng JE, Steinhubl SR, Burton P, Mauri L, O’Connor CM, Pfeffer MA, Hung HJ, Stockbridge NL, Chaitman BR, Temple RJ, Fitter HD, Illoh K, Cavanaugh KJ, Scirica BM, Irony I, Brown Kichline RE, Levine JG, Park A, Sacks L, Szarfman A, Unger EF, Wachter LA, Zuckerman B, Mitchel Y, Peddicord D, Shook T, Kisler B, Jaffe C, Bartley R, DeMets DL, Mencini M, Janning C, Bai S, Lawrence J, D’Agostino RB, Pocock SJ. 2017 Cardiovascular and Stroke Endpoint Definitions for Clinical Trials. J Am Coll Cardiol 2018; 71:1021-1034. [DOI: 10.1016/j.jacc.2017.12.048] [Citation(s) in RCA: 148] [Impact Index Per Article: 24.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Revised: 12/21/2017] [Accepted: 12/22/2017] [Indexed: 11/25/2022]
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Hicks KA, Mahaffey KW, Mehran R, Nissen SE, Wiviott SD, Dunn B, Solomon SD, Marler JR, Teerlink JR, Farb A, Morrow DA, Targum SL, Sila CA, Hai MTT, Jaff MR, Joffe HV, Cutlip DE, Desai AS, Lewis EF, Gibson CM, Landray MJ, Lincoff AM, White CJ, Brooks SS, Rosenfield K, Domanski MJ, Lansky AJ, McMurray JJ, Tcheng JE, Steinhubl SR, Burton P, Mauri L, O’Connor CM, Pfeffer MA, Hung HJ, Stockbridge NL, Chaitman BR, Temple RJ. 2017 Cardiovascular and Stroke Endpoint Definitions for Clinical Trials. Circulation 2018; 137:961-972. [DOI: 10.1161/circulationaha.117.033502] [Citation(s) in RCA: 214] [Impact Index Per Article: 35.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2017] [Accepted: 12/22/2017] [Indexed: 11/16/2022]
Abstract
This publication describes uniform definitions for cardiovascular and stroke outcomes developed by the Standardized Data Collection for Cardiovascular Trials Initiative and the US Food and Drug Administration (FDA). The FDA established the Standardized Data Collection for Cardiovascular Trials Initiative in 2009 to simplify the design and conduct of clinical trials intended to support marketing applications. The writing committee recognizes that these definitions may be used in other types of clinical trials and clinical care processes where appropriate. Use of these definitions at the FDA has enhanced the ability to aggregate data within and across medical product development programs, conduct meta-analyses to evaluate cardiovascular safety, integrate data from multiple trials, and compare effectiveness of drugs and devices. Further study is needed to determine whether prospective data collection using these common definitions improves the design, conduct, and interpretability of the results of clinical trials.
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Affiliation(s)
- Karen A. Hicks
- Division of Cardiovascular and Renal Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (K.A.H., S.L.T., N.L.S.)
| | - Kenneth W. Mahaffey
- Stanford Center for Clinical Research, Department of Medicine, Stanford University School of Medicine, Stanford, California (K.W.M.)
| | - Roxana Mehran
- Division of Cardiology, Icahn School of Medicine at Mount Sinai, New York, New York (R.M.)
| | - Steven E. Nissen
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio (S.E.N., A.M.L.)
| | - Stephen D. Wiviott
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.W., D.A.M.)
| | - Billy Dunn
- Division of Neurology Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (B.D., J.R.M.)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.S., A.S.D., E.F.L., M.A.P.)
| | - John R. Marler
- Division of Neurology Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (B.D., J.R.M.)
| | - John R. Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, California (J.R.T.)
| | - Andrew Farb
- Division of Cardiovascular Devices, Center for Devices and Radiological Health (CDRH), United States Food and Drug Administration (FDA), Silver Spring, Maryland (A.F.)
| | - David A. Morrow
- TIMI Study Group, Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.W., D.A.M.)
| | - Shari L. Targum
- Division of Cardiovascular and Renal Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (K.A.H., S.L.T., N.L.S.)
| | - Cathy A. Sila
- Neurological Institute, University Hospitals-Cleveland Medical Center, Cleveland, Ohio (C.A.S.)
| | - Mary T. Thanh Hai
- Office of Drug Evaluation II, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (M.T.T.)
| | - Michael R. Jaff
- Department of Medicine, Harvard Medical School, Boston, Massachusetts (M.R.J.)
| | - Hylton V. Joffe
- Division of Bone, Reproductive and Urologic Products, Office of Drug Evaluation III, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (H.V.J.)
| | - Donald E. Cutlip
- Cardiology Division, Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts (D.E.C.)
| | - Akshay S. Desai
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.S., A.S.D., E.F.L., M.A.P.)
| | - Eldrin F. Lewis
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.S., A.S.D., E.F.L., M.A.P.)
| | - C. Michael Gibson
- Cardiovascular Division, Department of Medicine, Harvard Medical School, Boston, Massachusetts (C.M.G.)
| | - Martin J. Landray
- Clinical Trial Service Unit & Epidemiological Studies Unit (CTSU), University of Oxford, Oxford, United Kingdom (M.J.L.)
| | - A. Michael Lincoff
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio (S.E.N., A.M.L.)
| | - Christopher J. White
- Department of Cardiology, Ochsner Clinical School, New Orleans, Louisiana (C.J.W.)
| | | | - Kenneth Rosenfield
- Vascular Medicine and Intervention, Corrigan Minehan Heart Center, Massachusetts General Hospital, Boston, Massachusetts (K.R.)
| | - Michael J. Domanski
- Peter Munk Cardiac Centre, University Health Network/Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada (M.J.D.)
| | - Alexandra J. Lansky
- Department of Internal Medicine, Section of Cardiology, Yale School of Medicine, New Haven, Connecticut (A.J.L.)
| | - John J.V. McMurray
- Institute of Cardiovascular & Medical Sciences, BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland (J.J.V.M.)
| | - James E. Tcheng
- Division of Cardiovascular Medicine, Duke University Medical Center, Durham, North Carolina (J.E.T.)
| | - Steven R. Steinhubl
- Division of Digital Medicine, Scripps Translational Science Institute, La Jolla, California (S.R.S.)
| | - Paul Burton
- Cardiovascular and Metabolism Medical Affairs, Janssen Pharmaceuticals Inc., Titusville, New Jersey (P.B.)
| | - Laura Mauri
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, Massachusetts (L.M.)
| | | | - Marc A. Pfeffer
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, Massachusetts (S.D.S., A.S.D., E.F.L., M.A.P.)
| | - H.M. James Hung
- Division of Biometrics I, Office of Biostatistics, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (H.M.J.H.)
| | - Norman L. Stockbridge
- Division of Cardiovascular and Renal Products, Office of Drug Evaluation I, Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (K.A.H., S.L.T., N.L.S.)
| | - Bernard R. Chaitman
- Center for Comprehensive Cardiovascular Care, St. Louis University School of Medicine, St. Louis, Missouri (B.R.C.)
| | - Robert J. Temple
- Center for Drug Evaluation and Research (CDER), United States Food and Drug Administration (FDA), Silver Spring, Maryland (R.J.T.)
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Greene SJ, Felker GM. Innovation in Diuretic Therapy: The Missing Ingredient for Treating Worsening Heart Failure Outside the Hospital? JACC Basic Transl Sci 2018; 3:35-37. [PMID: 30062192 PMCID: PMC6058943 DOI: 10.1016/j.jacbts.2018.01.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Affiliation(s)
- Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | - G. Michael Felker
- Duke Clinical Research Institute, Durham, North Carolina
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
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Bash LD, Weitzman D, Blaustein RO, Sharon O, Shalev V, Chodick G. Comprehensive healthcare resource use among newly diagnosed congestive heart failure. Isr J Health Policy Res 2017; 6:26. [PMID: 28593038 PMCID: PMC5458478 DOI: 10.1186/s13584-017-0149-0] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2016] [Accepted: 04/01/2017] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND Congestive heart failure (CHF) is among the most common causes of hospital admissions and readmissions in the Western world. However, the burden of ambulatory care has not been as well investigated. The objective of this study was to assess the relative burden and direct medical costs of CHF including inpatient and outpatient care. METHODS We used longitudinal clinical data from a two-million member health organization in Israel (Maccabi Healthcare Services) to identify adults with newly diagnosed CHF between January 2006 and December 2012, either in the in- or outpatient setting. Adults without CHF were age- and sex-matched to CHF patients and healthcare utilization and all modes of healthcare costs were compared among them, excluding those in their last year of life. RESULTS The burden posed by 6592 CHF patients was significantly (p < 0.001) larger than that of 32,960 matched controls. CHF patients had significantly higher rates of baseline comorbidity and healthcare utilization compared to non-CHF controls. This was evident in all categories of healthcare services and expenses, including in- and outpatient visits, laboratory expenses, medication costs, among younger and older, men and women. Among those who incurred any healthcare costs, younger (45-64y) and older (65 + y) subjects with CHF were observed to have about 3.25 (95% CI: 2.96-3.56) and 2.08 (95% CI: 1.99-2.17) times the healthcare costs, respectively, compared to subjects without CHF after adjusting for patient characteristics. CONCLUSION CHF is associated with an overall two- to three-fold higher cost of healthcare services depending on patient age, accounting for over half of all healthcare costs incurred by elderly CHF patients, and more than two-thirds of all costs among younger CHF patients. Observations of the large burden posed on one of the youngest societies in the developed world are profound, implicative of great opportunities to control the costs of CHF. Further research to understand how resource use impacts health outcomes and quality of care is warranted.
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Affiliation(s)
| | - Dahlia Weitzman
- Maccabitech, Maccabi Healthcare Services, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | | | | | - Varda Shalev
- Maccabitech, Maccabi Healthcare Services, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Gabriel Chodick
- Maccabitech, Maccabi Healthcare Services, Tel-Aviv, Israel.,Sackler Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
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Greene SJ, Hernandez AF, Dunning A, Ambrosy AP, Armstrong PW, Butler J, Cerbin LP, Coles A, Ezekowitz JA, Metra M, Starling RC, Teerlink JR, Voors AA, O’Connor CM, Mentz RJ. Hospitalization for Recently Diagnosed Versus Worsening Chronic Heart Failure. J Am Coll Cardiol 2017. [DOI: 10.1016/j.jacc.2017.04.043] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
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47
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Cowie MR, Filippatos GS, Alonso Garcia MDLA, Anker SD, Baczynska A, Bloomfield DM, Borentain M, Bruins Slot K, Cronin M, Doevendans PA, El-Gazayerly A, Gimpelewicz C, Honarpour N, Janmohamed S, Janssen H, Kim AM, Lautsch D, Laws I, Lefkowitz M, Lopez-Sendon J, Lyon AR, Malik FI, McMurray JJV, Metra M, Figueroa Perez S, Pfeffer MA, Pocock SJ, Ponikowski P, Prasad K, Richard-Lordereau I, Roessig L, Rosano GMC, Sherman W, Stough WG, Swedberg K, Tyl B, Zannad F, Boulton C, De Graeff P. New medicinal products for chronic heart failure: advances in clinical trial design and efficacy assessment. Eur J Heart Fail 2017; 19:718-727. [PMID: 28345190 DOI: 10.1002/ejhf.809] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2016] [Revised: 01/30/2017] [Accepted: 02/07/2017] [Indexed: 12/13/2022] Open
Abstract
Despite the availability of a number of different classes of therapeutic agents with proven efficacy in heart failure, the clinical course of heart failure patients is characterized by a reduction in life expectancy, a progressive decline in health-related quality of life and functional status, as well as a high risk of hospitalization. New approaches are needed to address the unmet medical needs of this patient population. The European Medicines Agency (EMA) is undertaking a revision of its Guideline on Clinical Investigation of Medicinal Products for the Treatment of Chronic Heart Failure. The draft version of the Guideline was released for public consultation in January 2016. The Cardiovascular Round Table of the European Society of Cardiology (ESC), in partnership with the Heart Failure Association of the ESC, convened a dedicated two-day workshop to discuss three main topic areas of major interest in the field and addressed in this draft EMA guideline: (i) assessment of efficacy (i.e. endpoint selection and statistical analysis); (ii) clinical trial design (i.e. issues pertaining to patient population, optimal medical therapy, run-in period); and (iii) research approaches for testing novel therapeutic principles (i.e. cell therapy). This paper summarizes the key outputs from the workshop, reviews areas of expert consensus, and identifies gaps that require further research or discussion. Collaboration between regulators, industry, clinical trialists, cardiologists, health technology assessment bodies, payers, and patient organizations is critical to address the ongoing challenge of heart failure and to ensure the development and market access of new therapeutics in a scientifically robust, practical and safe way.
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Affiliation(s)
- Martin R Cowie
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Sydney Street, London, SW3 6HP, UK
| | - Gerasimos S Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Athens University Hospital Attikon, Athens, Greece
| | - Maria de Los Angeles Alonso Garcia
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Sydney Street, London, SW3 6HP, UK.,Scientific Advice Working Party European Medicines Agency, Medical Assessor Medicines and Healthcare Products Regulatory Agency (MHRA), London, UK
| | - Stefan D Anker
- Innovative Clinical Trials, Department of Cardiology and Pneumology, University Medical Centre Göttingen (UMG), Göttingen, Germany.,Division of Homeostasis Research, Dept of Cardiology, Charité Campus CVK, Berlin, Germany
| | | | | | | | | | | | - Pieter A Doevendans
- European Medicines Agency Committee for Advanced Therapy, London, UK.,UMC, Utrecht, the Netherlands
| | | | | | | | | | | | | | | | | | - Martin Lefkowitz
- Novartis Pharmaceuticals, East Hanover, New Jersey, United States
| | - Jose Lopez-Sendon
- Cardiology Department, Hospital Universitario La Paz; IdiPaz, CIBER-CV, Madrid, Spain
| | - Alexander R Lyon
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Sydney Street, London, SW3 6HP, UK
| | | | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, UK
| | - Marco Metra
- Cardiology, University of Brescia, Brescia, Italy
| | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
| | - Piotr Ponikowski
- Department of Heart Diseases, Medical University, Military Hospital, Wroclaw, Poland
| | - Krishna Prasad
- United Kingdom Medicines and Healthcare Products Regulatory Agency, London, UK
| | | | | | - Giuseppe M C Rosano
- IRCCS San Raffaele Hospital Roma, Rome, Italy.,Cardiovascular Clinical Academic Group, St George's Hospitals NHS Trust, University of London, London, UK
| | | | | | - Karl Swedberg
- National Heart and Lung Institute, Imperial College London and Royal Brompton Hospital, Sydney Street, London, SW3 6HP, UK.,Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | | | - Faiez Zannad
- INSERM, Centre d'Investigation Clinique 1433 and Unité 1116, Université de Lorraine and CHU, Nancy, France
| | | | - Pieter De Graeff
- Dutch Medicines Evaluation Board (CBG-MEB), Utrecht, the Netherlands.,Department of Clinical Pharmacy and Pharmacology, University of Groningen, University Medical Centre Groningen, Groningen, the Netherlands
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48
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Metra M, Carubelli V, Ravera A, Stewart Coats AJ. Heart failure 2016: still more questions than answers. Int J Cardiol 2016; 227:766-777. [PMID: 27838123 DOI: 10.1016/j.ijcard.2016.10.060] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Revised: 10/23/2016] [Accepted: 10/23/2016] [Indexed: 12/21/2022]
Abstract
Heart failure has reached epidemic proportions given the ageing of populations and is associated with high mortality and re-hospitalization rates. This article reviews and summarizes recent advances in the diagnosis, assessment and treatment of the patients with heart failure. Data are discussed based also on the most recent guidelines indications. Open issues and unmet needs are highlighted.
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Affiliation(s)
- Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy.
| | - Valentina Carubelli
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Alice Ravera
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
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Okumura N, Jhund PS, Gong J, Lefkowitz MP, Rizkala AR, Rouleau JL, Shi VC, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. Importance of Clinical Worsening of Heart Failure Treated in the Outpatient Setting: Evidence From the Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial (PARADIGM-HF). Circulation 2016; 133:2254-62. [PMID: 27143684 DOI: 10.1161/circulationaha.115.020729] [Citation(s) in RCA: 132] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 04/05/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND Many episodes of worsening of heart failure (HF) are treated by increasing oral therapy or temporary intravenous treatment in the community or emergency department (ED), without hospital admission. We studied the frequency and prognostic importance of these episodes of worsening in the Prospective Comparison of ARNI (angiotensin-receptor-neprilysin inhibitor) with ACEI (angiotensin-converting enzyme inhibitor) to Determine Impact on Global Mortality and Morbidity in Heart Failure Trial (PARADIGM-HF). METHODS AND RESULTS Outpatient intensification of HF therapy was added to an expanded composite outcome with ED visits, HF hospitalizations, and cardiovascular deaths. In an examination of first nonfatal events, 361 of 8399 patients (4.3%) had outpatient intensification of HF therapy without a subsequent event (ie, ED visit/HF hospitalizations) within 30 days; 78 of 8399 (1.0%) had an ED visit without previous outpatient intensification of HF therapy or a subsequent event within 30 days; and 1107 of 8399 (13.2%) had HF hospitalizations without a preceding event. The risk of death (in comparison with no-event patients) was similar after each manifestation of worsening: outpatient intensification of HF therapy (hazard ratio, 4.8; 95% confidence interval, 3.9-5.9); ED visit (hazard ratio, 4.5; 95% confidence interval, 3.0-6.7); HF hospitalizations (hazard ratio, 5.9; 95% confidence interval, 5.2-6.6). The expanded composite added 14% more events and shortened time to accrual of a fixed number of events. The benefit of sacubitril/valsartan over enalapril was similar to the primary outcome for the expanded composite (hazard ratio, 0.79; 95% confidence interval, 0.73-0.86) and was consistent across the components of the latter. CONCLUSIONS Focusing only on HF hospitalizations underestimates the frequency of worsening and the serious implications of all manifestations of worsening. For clinical trials conducted in an era of heightened efforts to avoid HF hospitalizations, inclusion of episodes of outpatient treatment intensification (and ED visits) in a composite outcome adds an important number of events and shortens the time taken to accrue a target number of end points in an event-driven trial. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT01035255.
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Affiliation(s)
- Naoki Okumura
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Pardeep S Jhund
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Jianjian Gong
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Martin P Lefkowitz
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Adel R Rizkala
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Jean L Rouleau
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Victor C Shi
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Karl Swedberg
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Michael R Zile
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Scott D Solomon
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - Milton Packer
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.)
| | - John J V McMurray
- From BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, United Kingdom (N.O., P.S.J., J.J.V.M.); Novartis Pharmaceutical Corporation, East Hanover, NJ (J.G., M.P.L., A.R.R., V.C.S.); Institut de Cardiologie, Université de Montréal, Canada (J.L.R.); Department of Molecular and Clinical Medicine, University of Gothenburg, Sweden and National Heart and Lung Institute, Imperial College, London, United Kingdom (K.S.); Medical University of South Carolina and RHJ Department of Veterans Administration Medical Center, Charleston, SC (M.R.Z.); Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA (S.D.S.); and Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX (M.P.).
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Cook TD, Greene SJ, Kalogeropoulos AP, Fonarow GC, Zea R, Swedberg K, Zannad F, Maggioni AP, Konstam MA, Gheorghiade M, Butler J. Temporal Changes in Postdischarge Mortality Risk After Hospitalization for Heart Failure (from the EVEREST Trial). Am J Cardiol 2016; 117:611-616. [PMID: 26742474 DOI: 10.1016/j.amjcard.2015.11.050] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2015] [Revised: 11/18/2015] [Accepted: 11/18/2015] [Indexed: 11/18/2022]
Abstract
In observational studies of patients hospitalized for heart failure (HHF), risk of death is highest immediately after discharge and decreases over time. It is unclear whether this population risk trajectory reflects (1) lowering of individual patient mortality risk with increasing time from index hospitalization or (2) temporal changes in population case-mix with earlier postdischarge death for "sicker" patients. Survival rate and longitudinal models were used to estimate temporal changes in postdischarge all-cause mortality risk in 3,993 HHF patients discharged alive in the Efficacy of Vasopressin Antagonism in Heart Failure Outcome Study with Tolvaptan (EVEREST) trial. After median follow-up of 9.9 months, 971 patients died (24.2%). Predicted mortality rate decreased from 15.9 per 100 patient-years immediately after discharge to 13.4 at 30 days and 12.8 at 90 days; mortality rate increased steadily thereafter. Risk variation between quintiles of risk was considerably larger than the temporal variation within risk strata. In a longitudinal model serially reassessing predicted patient mortality risk after each follow-up visit using data collected at these visits, predicted mortality risk increased during the 90 days preceding subsequent heart failure readmission and then followed a postdischarge trajectory similar to the index admission. In conclusion, although there is transiently elevated individual patient risk in the 90 days before and after discharge, the patient's individual risk profile, rather than temporal change in risk relative to hospitalization, remains the main determinant of mortality. For purposes of reducing all-cause mortality in HF patients, preventative and therapeutic measures may be best implemented as long-term interventions for high mortality risk patients based on serial risk assessments, irrespective of recent hospitalization.
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Affiliation(s)
- Thomas D Cook
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina
| | | | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, California
| | - Ryan Zea
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Faiez Zannad
- CHU Nancy, Institute of Lorraine Heart and Blood Vessels, Nancy, France
| | - Aldo P Maggioni
- Associazione Nazionale Medici Cardiologi Ospedalieri Research Center, Florence, Italy
| | - Marvin A Konstam
- The CardioVascular Center, Tufts Medical Center, Boston, Massachusetts
| | - Mihai Gheorghiade
- Center for Cardiovascular Innovation, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Javed Butler
- Division of Cardiology, Stony Brook University, Stony Brook, New York.
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