1
|
Huang CW, Park JS, Liu ILA, Lee JS, Kohan S, Mefford M, Wu SS, Subject CC, Nguyen HQ, Lee MS. Effectiveness and safety of early treatment with spironolactone for new-onset acute heart failure. J Hosp Med 2024; 19:267-277. [PMID: 38415888 DOI: 10.1002/jhm.13317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2023] [Revised: 02/01/2024] [Accepted: 02/05/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND The effectiveness and safety of mineralocorticoid receptor antagonists (MRA) in acute heart failure (HF) is uncertain. We sought to describe the prescription of spironolactone during acute HF and whether early treatment is effective and safe in a real-world setting. METHODS We performed a retrospective cohort study of adult (≥18 years) nonpregnant patients hospitalized with new-onset HF with reduced ejection fraction (HFrEF, defined by ejection fraction ≤40%) within 15 Kaiser Permanente Southern California medical centers between 2016 and 2021. Early treatment was defined by spironolactone prescription at discharge. The primary effectiveness outcome was a composite of HF readmission or all-cause mortality at 180 days. Safety outcomes were hypotension and hyperkalemia at 90 days. RESULTS Among 2318 HFrEF patients, 368 (15.9%) were treated with spironolactone at discharge. After 1:2 propensity score matching, 354 early treatment and 708 delayed/no treatment patients were included in the analysis. The median age was 63 (IQR: 52-74) years; 61.6% were male, and 38.6% were White. By 90 days, ~20% had crossed over in the two groups. Early treatment was not associated with the composite outcome at 180 days (HR [95% CI]: 0.81 [0.56-1.17]), but a trend towards benefit by 365 days that did not reach statistical significance (0.78 [0.58-1.06]). Early treatment was also associated with hyperkalemia (subdistribution HR [95% CI]: 2.33 [1.30-4.18]) but not hypotension (0.93 [0.51-1.72]). CONCLUSIONS Early treatment with spironolactone at discharge for new-onset HFrEF in a real-world setting did not reduce the risk of HF readmission or mortality in the first year after discharge. The risk of hyperkalemia was increased.
Collapse
Affiliation(s)
- Cheng-Wei Huang
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - Joon S Park
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
| | - In-Lu Amy Liu
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Janet S Lee
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Siamak Kohan
- Department of Internal Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Mathew Mefford
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Stefanie S Wu
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Christopher C Subject
- Department of Hospital Medicine, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| | - Huong Q Nguyen
- Department of Research and Evaluation, Kaiser Permanente Southern California, Pasadena, California, USA
| | - Ming-Sum Lee
- Department of Clinical Science, Kaiser Permanente Bernard J. Tyson School of Medicine, Pasadena, California, USA
- Department of Cardiology, Kaiser Permanente Los Angeles Medical Center, Los Angeles, California, USA
| |
Collapse
|
2
|
Shahid I, Khan MS, Fonarow GC, Butler J, Greene SJ. Bridging gaps and optimizing implementation of guideline-directed medical therapy for heart failure. Prog Cardiovasc Dis 2024; 82:61-69. [PMID: 38244825 DOI: 10.1016/j.pcad.2024.01.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
Despite robust scientific evidence and strong guideline recommendations, there remain significant gaps in initiation and dose titration of guideline-directed medical therapy (GDMT) for heart failure (HF) among eligible patients. Reasons surrounding these gaps are multifactorial, and largely attributed to patient, healthcare professionals, and institutional challenges. Concurrently, HF remains a predominant cause of mortality and hospitalization, emphasizing the critical need for improved delivery of therapy to patients in routine clinical practice. To optimize GDMT, various implementation strategies have emerged in the recent decade such as in-hospital rapid initiation of GDMT, improving patient adherence, addressing clinical inertia, improving affordability, engagement in quality improvement registries, multidisciplinary clinics, and EHR-integrated interventions. This review highlights the current use and barriers to optimal utilization of GDMT, and proposes novel strategies aimed at improving GDMT in HF.
Collapse
Affiliation(s)
- Izza Shahid
- Division of Preventive Cardiology, Houston Methodist Academic Institute, Houston, TX, USA
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, CA, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA; Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| |
Collapse
|
3
|
Docherty KF, McMurray JJV, Diaz R, Felker GM, Metra M, Solomon SD, Adams KF, Böhm M, Brinkley DM, Echeverria LE, Goudev AR, Howlett JG, Lund M, Ponikowski P, Yilmaz MB, Zannad F, Claggett BL, Miao ZM, Abbasi SA, Divanji P, Heitner SB, Kupfer S, Malik FI, Teerlink JR. The Effect of Omecamtiv Mecarbil in Hospitalized Patients as Compared With Outpatients With HFrEF: An Analysis of GALACTIC-HF. J Card Fail 2024; 30:26-35. [PMID: 37683911 DOI: 10.1016/j.cardfail.2023.08.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 08/19/2023] [Accepted: 08/22/2023] [Indexed: 09/10/2023]
Abstract
BACKGROUND In the Global Approach to Lowering Adverse Cardiac Outcomes Through Improving Contractility in Heart Failure (GALACTIC-HF) trial, omecamtiv mecarbil, compared with placebo, reduced the risk of worsening heart failure (HF) events, or cardiovascular death in patients with HF and reduced ejection fraction. The primary aim of this prespecified analysis was to evaluate the safety and efficacy of omecamtiv mecarbil by randomization setting, that is, whether participants were enrolled as outpatients or inpatients. METHODS AND RESULTS Patients were randomized either during a HF hospitalization or as an outpatient, within one year of a worsening HF event (hospitalization or emergency department visit). The primary outcome was a composite of worsening HF event (HF hospitalization or an urgent emergency department or clinic visit) or cardiovascular death. Of the 8232 patients analyzed, 2084 (25%) were hospitalized at randomization. Hospitalized patients had higher N-terminal prohormone of B-type natriuretic peptide concentrations, lower systolic blood pressure, reported more symptoms, and were less frequently treated with a renin-angiotensin system blocker or a beta-blocker than outpatients. The rate (per 100 person-years) of the primary outcome was higher in hospitalized patients (placebo group = 38.3/100 person-years) than in outpatients (23.1/100 person-years); adjusted hazard ratio 1.21 (95% confidence interval 1.12-1.31). The effect of omecamtiv mecarbil versus placebo on the primary outcome was similar in hospitalized patients (hazard ratio 0.89, 95% confidence interval 0.78-1.01) and outpatients (hazard ratio 0.94, 95% confidence interval 0.86-1.02) (interaction P = .51). CONCLUSIONS Hospitalized patients with HF with reduced ejection fraction had a higher rate of the primary outcome than outpatients. Omecamtiv mecarbil decreased the risk of the primary outcome both when initiated in hospitalized patients and in outpatients.
Collapse
Affiliation(s)
- Kieran F Docherty
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK.
| | - Rafael Diaz
- Estudios Clinicos Latinoamérica, Rosario, Argentina
| | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Italy
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | - Michael Böhm
- Saarland University, Klink für Innere Medizin III (Kardiologie, Angiologie und Internistische Intensivmedizin, Universitätsklinikum des Saarlandes), Homburg, Germany
| | | | - Luis E Echeverria
- Heart Failure and Heart Transplant Clinic, Fundación Cardiovascular de Colombia, Floridablanca, Colombia
| | - Assen R Goudev
- Department of Cardiology, Queen Giovanna University Hospital, Sofia, Bulgaria
| | - Jonathan G Howlett
- Division of Cardiology, Libin Cardiovascular Institute of Alberta, University of Calgary, Calgary, Alberta, Canada
| | - Mayanna Lund
- Middlemore Hospital, Otahuhu, Auckland, New Zealand
| | - Piotr Ponikowski
- Department of Heart Diseases, Wrocław Medical University, Wrocław, Poland
| | - Mehmet B Yilmaz
- Department of Cardiology, Dokuz Eylul University, Izmir, Turkey
| | - Faiez Zannad
- Université de Lorraine, INSERM Investigation Network Initiative Cardiovascular and Renal Clinical Trialists, Centre Hospitalier Régional Universitaire de Nancy, Nancy, France
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Zi Michael Miao
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | | | | | | | | | - Fady I Malik
- Cytokinetics, Inc., South San Francisco, California
| | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, California
| |
Collapse
|
4
|
Adhikari S, Mukhyopadhyay A, Kolzoff S, Li X, Nadel T, Fitchett C, Chunara R, Dodson J, Kronish I, Blecker SB. Cohort profile: a large EHR-based cohort with linked pharmacy refill and neighbourhood social determinants of health data to assess heart failure medication adherence. BMJ Open 2023; 13:e076812. [PMID: 38040431 PMCID: PMC10693878 DOI: 10.1136/bmjopen-2023-076812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 11/06/2023] [Indexed: 12/03/2023] Open
Abstract
PURPOSE Clinic-based or community-based interventions can improve adherence to guideline-directed medication therapies (GDMTs) among patients with heart failure (HF). However, opportunities for such interventions are frequently missed, as providers may be unable to recognise risk patterns for medication non-adherence. Machine learning algorithms can help in identifying patients with high likelihood of non-adherence. While a number of multilevel factors influence adherence, prior models predicting non-adherence have been limited by data availability. We have established an electronic health record (EHR)-based cohort with comprehensive data elements from multiple sources to improve on existing models. We linked EHR data with pharmacy refill data for real-time incorporation of prescription fills and with social determinants data to incorporate neighbourhood factors. PARTICIPANTS Patients seen at a large health system in New York City (NYC), who were >18 years old with diagnosis of HF or reduced ejection fraction (<40%) since 2017, had at least one clinical encounter between 1 April 2021 and 31 October 2022 and active prescriptions for any of the four GDMTs (beta-blocker, ACEi/angiotensin receptor blocker (ARB)/angiotensin receptor neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonist (MRA) and sodium-glucose cotransporter 2 inhibitor (SGLT2i)) during the study period. Patients with non-geocodable address or outside the continental USA were excluded. FINDINGS TO DATE Among 39 963 patients in the cohort, the average age was 73±14 years old, 44% were female and 48% were current/former smokers. The common comorbid conditions were hypertension (77%), cardiac arrhythmias (56%), obesity (33%) and valvular disease (33%). During the study period, 33 606 (84%) patients had an active prescription of beta blocker, 32 626 (82%) had ACEi/ARB/ARNI, 11 611 (29%) MRA and 7472 (19%) SGLT2i. Ninety-nine per cent were from urban metropolitan areas. FUTURE PLANS We will use the established cohort to develop a machine learning model to predict medication adherence, and to support ancillary studies assessing associates of adherence. For external validation, we will include data from an additional hospital system in NYC.
Collapse
Affiliation(s)
- Samrachana Adhikari
- New York University Grossman School of Medicine, New York City, New York, USA
| | | | | | - Xiyue Li
- New York University Grossman School of Medicine, New York City, New York, USA
| | - Talia Nadel
- New York University Grossman School of Medicine, New York City, New York, USA
| | - Cassidy Fitchett
- New York University Grossman School of Medicine, New York City, New York, USA
| | - Rumi Chunara
- New York University, New York City, New York, USA
| | - John Dodson
- New York University Grossman School of Medicine, New York City, New York, USA
| | - Ian Kronish
- Center Behavioral Cardiovascular Health, Columbia University Medical Center, New York City, New York, USA
| | - Saul B Blecker
- New York University Grossman School of Medicine, New York City, New York, USA
| |
Collapse
|
5
|
Guidetti F, Lund LH, Benson L, Hage C, Musella F, Stolfo D, Mol PGM, Flammer AJ, Ruschitzka F, Dahlstrom U, Rosano GMC, Braun OÖ, Savarese G. Safety of continuing mineralocorticoid receptor antagonist treatment in patients with heart failure with reduced ejection fraction and severe kidney disease: Data from Swedish Heart Failure Registry. Eur J Heart Fail 2023; 25:2164-2173. [PMID: 37795642 DOI: 10.1002/ejhf.3049] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 09/25/2023] [Accepted: 09/26/2023] [Indexed: 10/06/2023] Open
Abstract
AIMS Mineralocorticoid receptor antagonists (MRAs) improve outcomes in heart failure with reduced ejection fraction (HFrEF) but remain underused and are often discontinued especially in patients with chronic kidney disease (CKD) due to concerns on renal safety. Therefore, in a real-world HFrEF population we investigated the safety of MRA use, in terms of risk of renal events, any mortality and any hospitalization, across the estimated glomerular filtration rate (eGFR) spectrum including severe CKD. METHODS AND RESULTS We analysed patients with HFrEF (ejection fraction <40%), not on dialysis, from the Swedish Heart Failure Registry. We performed multivariable logistic regression models to investigate patient characteristics independently associated with MRA use, and univariable and multivariable Cox regression models to assess the associations between MRA use and outcomes. Of 33 942 patients, 17 489 (51%) received MRA, 32%, 45%, 54%, 54% with eGFR <30, 30-44, 45-59 or ≥60 ml/min/1.73 m2 , respectively. An eGFR ≥60 ml/min/1.73 m2 and patient characteristics linked with more severe HF were independently associated with more likely MRA use. In multivariable analyses, MRA use was consistently not associated with a higher risk of renal events (i.e. composite of dialysis/renal death/hospitalization for renal failure or hyperkalaemia) (hazard ratio [HR] 1.04, 95% confidence interval [CI] 0.98-1.10), all-cause death (HR 1.02, 95% CI 0.97-1.08) as well as of all-cause hospitalization (HR 0.99, 95% CI 0.95-1.02) across the eGFR spectrum including also severe CKD. CONCLUSIONS The use of MRAs in patients with HFrEF decreased with worse renal function; however their safety profile was demonstrated to be consistent across the entire eGFR spectrum.
Collapse
Affiliation(s)
- Federica Guidetti
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| | - Lina Benson
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Camilla Hage
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | - Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Cardiology, Cardiovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste (ASUITS), Trieste, Italy
| | - Peter G M Mol
- Department of Clinical Pharmacy and Pharmacology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Andreas J Flammer
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Frank Ruschitzka
- Department of Cardiology, University Heart Center, University Hospital Zurich, Zurich, Switzerland
| | - Ulf Dahlstrom
- Department of Cardiology and Department of Health, Medicine and Caring Sciences Linköping University, Linköping, Sweden
| | | | - Oscar Ö Braun
- Cardiology, Department of Clinical Sciences, Lund University and Skåne University Hospital, Lund, Sweden
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart, Vascular and Neuro Theme, Karolinska University Hospital, Stockholm, Sweden
| |
Collapse
|
6
|
Charbonnel C, Jagu A, Vannier C, De Cordoue M, Aroulanda MJ, Lozinguez O, Komajda M, Garcon P, Antakly-Hanon Y, Moeuf Y, Lesage JB, Mantes L, Midey C, Izabel M, Boukefoussa W, Manne J, Standish B, Duc P, Iliou MC, Cador R. [Introduction of treatments for heart failure and reduced ejection fraction under 50 % : In-hospital optimization using an algorithmic approach]. Ann Cardiol Angeiol (Paris) 2023; 72:101640. [PMID: 37677914 DOI: 10.1016/j.ancard.2023.101640] [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: 07/07/2023] [Revised: 08/07/2023] [Accepted: 08/08/2023] [Indexed: 09/09/2023]
Abstract
Recent international guidelines recommend rapid initiation and titration of basic treatments of heart failure but do not explain how to achieve this goal. Despite these recommendations, implementation of treatment in daily practice is poor. This may be partly explained by the profile of the patients (frailty, comorbidities), safety considerations and tolerability issues related to kydney function, low blood pressure or heart rate and hyperkalaemia. In this special article, we intended to help the physician, through an algorithmic approach, to quickly and safely introduce guideline-directed medical therapy in the field of heart failure with ejection fraction under 50%.
Collapse
Affiliation(s)
- Clément Charbonnel
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France.
| | - Annabelle Jagu
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Claire Vannier
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Maylis De Cordoue
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | - Olivier Lozinguez
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Michel Komajda
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Philippe Garcon
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Yara Antakly-Hanon
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Yoann Moeuf
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | - Lucie Mantes
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Charlotte Midey
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Mathilde Izabel
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Wahiba Boukefoussa
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Julien Manne
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Brigitte Standish
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | - Philippe Duc
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | - Romain Cador
- Service de Cardiologie, Groupe Hospitalier Paris Saint Joseph, Paris, France
| |
Collapse
|
7
|
Chioncel O, Davison B, Adamo M, Antohi LE, Arrigo M, Barros M, Biegus J, Čerlinskaitė-Bajorė K, Celutkiene J, Cohen-Solal A, Damasceno A, Diaz R, Edwards C, Filippatos G, Kimmoun A, Lam CSP, Metra M, Novosadova M, Pagnesi M, Pang PS, Ponikowski P, Radu RI, Saidu H, Sliwa K, Voors AA, Takagi K, Ter Maaten JM, Tomasoni D, Cotter G, Mebazaa A. Non-cardiac comorbidities and intensive up-titration of oral treatment in patients recently hospitalized for heart failure: Insights from the STRONG-HF trial. Eur J Heart Fail 2023; 25:1994-2006. [PMID: 37728038 DOI: 10.1002/ejhf.3039] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/17/2023] [Indexed: 09/21/2023] Open
Abstract
AIMS To assess the potential interaction between non-cardiac comorbidities (NCCs) and the efficacy and safety of high-intensity care (HIC) versus usual care (UC) in the STRONG-HF trial, including stable patients with improved but still elevated natriuretic peptides. METHODS AND RESULTS In the trial, eight NCCs were reported: anaemia, diabetes, renal dysfunction, severe liver disease, chronic obstructive pulmonary disease/asthma, stroke/transient ischaemic attack, psychiatric/neurological disorders, and malignancies. Patients were classified by NCC number (0, 1, 2 and ≥3). The treatment effect of HIC versus UC on the primary endpoint, 180-day death or heart failure (HF) rehospitalization, was compared by NCC number and by each individual comorbidity. Among the 1078 patients, the prevalence of 0, 1, 2 and ≥3 NCCs was 24.3%, 39.8%, 24.5% and 11.4%, respectively. Achievement of full doses of HF therapies at 90 and 180 days in the HIC was similar irrespective of NCC number. In HIC, the primary endpoint occurred in 10.0%, 16.6%, 13.6% and 26.2%, in those with 0, 1, 2 and ≥3 NCCs, respectively, as compared to 19.1%, 25.4%, 23.3% and 26.2% in UC (interaction-p = 0.80). The treatment benefit of HIC versus UC on the primary endpoint did not differ significantly by each individual comorbidity. There was no significant treatment interaction by NCC number in quality-of-life improvement (p = 0.98) or the incidence of serious adverse events (p = 0.11). CONCLUSIONS In the STRONG-HF trial, NCCs neither limited the rapid up-titration of HF therapies, nor attenuated the benefit of HIC on the primary endpoint. In the context of a clinical trial, the benefit-risk ratio favours the rapid up-titration of HF therapies even in patients with multiple NCCs.
Collapse
Affiliation(s)
- Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine "Carol Davila", Bucharest, Romania
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Laura E Antohi
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine "Carol Davila", Bucharest, Romania
| | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Antoine Kimmoun
- Université de Lorraine, Nancy; INSERM, Défaillance Circulatoire Aigue et Chronique, Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Razvan I Radu
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine "Carol Davila", Bucharest, Romania
| | - Hadiza Saidu
- Department of Medicine, Murtala Muhammed Specialist Hospital/Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, Cape Heart Institute, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Adriaan A Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Koji Takagi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Jozine M Ter Maaten
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
| |
Collapse
|
8
|
Patolia H, Khan MS, Fonarow GC, Butler J, Greene SJ. Implementing Guideline-Directed Medical Therapy for Heart Failure: JACC Focus Seminar 1/3. J Am Coll Cardiol 2023; 82:529-543. [PMID: 37532424 DOI: 10.1016/j.jacc.2023.03.430] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Revised: 03/20/2023] [Accepted: 03/23/2023] [Indexed: 08/04/2023]
Abstract
Despite the availability of lifesaving guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF), there remain major gaps in utilization of these therapies among eligible patients. Simultaneous with these gaps in quality of care, HFrEF continues as a leading cause of death and hospitalization with associated clinical risk far exceeding most other cardiovascular and noncardiovascular conditions. In the context of this urgent need to improve provision of appropriate therapy, multiple lines of evidence support various implementation strategies. Such strategies include in-hospital initiation of GDMT, simultaneous or rapid sequence initiation of GDMT, participation in quality improvement registries to assess site performance and provide feedback, multidisciplinary titration clinics, virtual consult teams, reduction of cost-sharing, remote algorithm-based medication optimization, electronic health record-based interventions, and direct-to-patient educational initiatives. This review describes and contextualizes the evidence surrounding each of these potential avenues for improving use of foundational GDMTs for patients with HFrEF.
Collapse
Affiliation(s)
- Harsh Patolia
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muhammad Shahzeb Khan
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| |
Collapse
|
9
|
Swat SA, Xu H, Allen LA, Greene SJ, DeVore AD, Matsouaka RA, Goyal P, Peterson PN, Hernandez AF, Krumholz HM, Yancy CW, Fonarow GC, Hess PL. Opportunities and Achievement of Medication Initiation Among Inpatients With Heart Failure With Reduced Ejection Fraction. JACC. HEART FAILURE 2023; 11:918-929. [PMID: 37318420 DOI: 10.1016/j.jchf.2023.04.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Revised: 04/11/2023] [Accepted: 04/12/2023] [Indexed: 06/16/2023]
Abstract
BACKGROUND Initiation of evidence-based medications for patients with heart failure with reduced ejection fraction (HFrEF) during hospitalization in contemporary practice is unknown. OBJECTIVES This study characterized opportunities for and achievement of heart failure (HF) medication initiation. METHODS Using the GWTG-HF (Get With The Guidelines-Heart Failure) Registry 2017-2020, which collected data on contraindications and prescribing for 7 evidence-based HF-related medications, we assessed the number of medications for which each patient with HFrEF was eligible, use before admission, and prescribed at discharge. Multivariable logistic regression identified factors associated with medication initiation. RESULTS Among 50,170 patients from 160 sites, patients were eligible for mean number of 3.9 ± 1.1 evidence-based medications with 2.1 ± 1.3 used before admission and 3.0 ± 1.0 prescribed on discharge. The number of patients receiving all indicated medications increased from admission (14.9%) to discharge (32.8%), a mean net gain of 0.9 ± 1.3 medications over a mean of 5.6 ± 5.3 days. In multivariable analysis, factors associated with lower odds of HF medication initiation included older age, female sex, medical pre-existing conditions (stroke, peripheral arterial disease, pulmonary disease, and renal insufficiency), and rural location. Odds of medication initiation increased during the study period (adjusted OR: 1.08; 95% CI: 1.06-1.10). CONCLUSIONS Nearly 1 in 6 patients received all indicated HF-related medications on admission, increasing to 1 in 3 on discharge with an average of 1 new medication initiation. Opportunities to initiate evidence-based medications persist, particularly among women, those with comorbidities, and those receiving care at rural hospitals.
Collapse
Affiliation(s)
- Stanley A Swat
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Haolin Xu
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Larry A Allen
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Roland A Matsouaka
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Biostatistics and Bioinformatics, Duke University, Durham, North Carolina, USA
| | - Parag Goyal
- Weill Cornell Medicine Division of Cardiology, New York, New York, USA
| | - Pamela N Peterson
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Gregg C Fonarow
- Ronald Reagan-University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Paul L Hess
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA; Rocky Mountain Regional VA Medical Center, Aurora, Colorado, USA.
| |
Collapse
|
10
|
Pitt B, Bhatt DL, Szarek M, Cannon CP, Leiter LA, McGuire DK, Lewis JB, Riddle MC, Voors AA, Metra M, Lund LH, Komajda M, Testani JM, Wilcox CS, Ponikowski P, Lopes RD, Ezekowitz JA, Sun F, Davies MJ, Verma S, Kosiborod MN, Steg PG. Effect of Sotagliflozin on Early Mortality and Heart Failure-Related Events: A Post Hoc Analysis of SOLOIST-WHF. JACC. HEART FAILURE 2023; 11:879-889. [PMID: 37558385 DOI: 10.1016/j.jchf.2023.05.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Revised: 04/05/2023] [Accepted: 05/01/2023] [Indexed: 08/11/2023]
Abstract
BACKGROUND Approximately 25% of patients admitted to hospitals for worsening heart failure (WHF) are readmitted within 30 days. OBJECTIVES The authors conducted a post hoc analysis of the SOLOIST-WHF (Effect of Sotagliflozin on Cardiovascular Events in Patients With Type 2 Diabetes Post-WHF) trial to evaluate the efficacy of sotagliflozin versus placebo to decrease mortality and HF-related events among patients who began study treatment on or before discharge from their index hospitalization. METHODS The main endpoint of interest was cardiovascular death or HF-related event (HF hospitalization or urgent care visit) occurring within 90 and 30 days after discharge for the index WHF hospitalization. Treatment comparisons were by proportional hazards models, generating HRs, 95% CIs, and P values. RESULTS Of 1,222 randomized patients, 596 received study drug on or before their date of discharge. Sotagliflozin reduced the main endpoint at 90 days after discharge (HR: 0.54 [95% CI: 0.35-0.82]; P = 0.004) and at 30 days (HR: 0.49 [95% CI: 0.27-0.91]; P = 0.023) and all-cause mortality at 90 days (HR: 0.39 [95% CI: 0.17-0.88]; P = 0.024). In subgroup analyses, sotagliflozin reduced the 90-day main endpoint regardless of sex, age, estimated glomerular filtration rate, N-terminal pro-B-type natriuretic peptide, left ventricular ejection fraction, or mineralocorticoid receptor agonist use. Sotagliflozin was well-tolerated but with slightly higher rates of diarrhea and volume-related events than placebo. CONCLUSIONS Starting sotagliflozin before discharge in patients with type 2 diabetes hospitalized for WHF significantly decreased cardiovascular deaths and HF events through 30 and 90 days after discharge, emphasizing the importance of beginning sodium glucose cotransporter treatment before discharge.
Collapse
Affiliation(s)
- Bertram Pitt
- Department of Internal Medicine (Emeritus), University of Michigan School of Medicine, Ann Arbor, Michigan, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
| | - Michael Szarek
- School of Public Health, SUNY Downstate Health Sciences University, Brooklyn, New York, USA; University of Colorado School of Medicine, Aurora, CO, USA; CPC Clinical Research, Aurora, Colorado, USA
| | - Christopher P Cannon
- Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lawrence A Leiter
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Darren K McGuire
- University of Texas Southwestern Medical Center, and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Julia B Lewis
- Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Adriaan A Voors
- University of Groningen-University Medical Center Groningen, Groningen, the Netherlands
| | - Marco Metra
- Azienda Socio Sanitaria Territoriale Spedali Civili and University of Brescia, Brescia, Italy
| | - Lars H Lund
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Michel Komajda
- Paris Sorbonne University and Groupe Hospitalier Paris Saint Joseph, Paris, France
| | | | | | | | - Renato D Lopes
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Justin A Ezekowitz
- University of Alberta and Mazankowski Alberta Heart Institute, Edmonton, Alberta, Canada
| | - Franklin Sun
- Lexicon Pharmaceuticals Inc., The Woodlands, Texas, USA
| | - Michael J Davies
- Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Subodh Verma
- Li Ka Shing Knowledge Institute, St. Michael's Hospital, and University of Toronto, Toronto, Ontario, Canada
| | - Mikhail N Kosiborod
- Department of Cardiovascular Medicine, Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City School of Medicine, Kansas City, Missouri, USA
| | - Ph Gabriel Steg
- Université Paris-Cité, Institut Universitaire de France, INSERM U-1148, FACT (French Alliance for Cardiovascular Trials) and AP-HP (Assistance Publique-Hôpitaux de Paris), Hopital Bichat Paris, Paris, France
| |
Collapse
|
11
|
Metra M, Adamo M, Tomasoni D, Mebazaa A, Bayes-Genis A, Abdelhamid M, Adamopoulos S, Anker SD, Bauersachs J, Belenkov Y, Böhm M, Gal TB, Butler J, Cohen-Solal A, Filippatos G, Gustafsson F, Hill L, Jaarsma T, Jankowska EA, Lainscak M, Lopatin Y, Lund LH, McDonagh T, Milicic D, Moura B, Mullens W, Piepoli M, Polovina M, Ponikowski P, Rakisheva A, Ristic A, Savarese G, Seferovic P, Sharma R, Thum T, Tocchetti CG, Van Linthout S, Vitale C, Von Haehling S, Volterrani M, Coats AJS, Chioncel O, Rosano G. Pre-discharge and early post-discharge management of patients hospitalized for acute heart failure: A scientific statement by the Heart Failure Association of the ESC. Eur J Heart Fail 2023; 25:1115-1131. [PMID: 37448210 DOI: 10.1002/ejhf.2888] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Revised: 04/16/2023] [Accepted: 04/30/2023] [Indexed: 07/15/2023] Open
Abstract
Acute heart failure is a major cause of urgent hospitalizations. These are followed by marked increases in death and rehospitalization rates, which then decline exponentially though they remain higher than in patients without a recent hospitalization. Therefore, optimal management of patients with acute heart failure before discharge and in the early post-discharge phase is critical. First, it may prevent rehospitalizations through the early detection and effective treatment of residual or recurrent congestion, the main manifestation of decompensation. Second, initiation at pre-discharge and titration to target doses in the early post-discharge period, of guideline-directed medical therapy may improve both short- and long-term outcomes. Third, in chronic heart failure, medical treatment is often left unchanged, so the acute heart failure hospitalization presents an opportunity for implementation of therapy. The aim of this scientific statement by the Heart Failure Association of the European Society of Cardiology is to summarize recent findings that have implications for clinical management both in the pre-discharge and the early post-discharge phase after a hospitalization for acute heart failure.
Collapse
Affiliation(s)
- Marco Metra
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Marianna Adamo
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Daniela Tomasoni
- Cardiology and Cardiac Catheterization Laboratory, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Alexandre Mebazaa
- AP-HP Department of Anesthesia and Critical Care, Hôpital Lariboisière, Université Paris Cité, Inserm MASCOT, Paris, France
| | - Antoni Bayes-Genis
- Heart Failure Clinic and Cardiology Service, University Hospital Germans Trias i Pujol, Badalona, Spain
- Department of Medicine, Universitat Autònoma de Barcelona, Barcelona, Spain
- CIBERCV, Instituto de Salud Carlos III, Madrid, Spain
| | | | - Stamatis Adamopoulos
- Second Department of Cardiovascular Medicine, Onassis Cardiac Surgery Center, Athens, Greece
| | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT); German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Johann Bauersachs
- Department of Cardiology and Angiology, Hannover Medical School, Hannover, Germany
| | | | - Michael Böhm
- Saarland University Hospital, Homburg/Saar, Germany
| | - Tuvia Ben Gal
- Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX, USA
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Alain Cohen-Solal
- Inserm 942 MASCOT, Université de Paris, AP-HP, Hopital Lariboisière, Paris, France
| | - Gerasimos Filippatos
- Department of Cardiology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
| | - Finn Gustafsson
- Rigshospitalet-Copenhagen University Hospital, Heart Centre, Department of Cardiology, Copenhagen, Denmark
| | | | | | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Mitja Lainscak
- Division of Cardiology, General Hospital Murska Sobota, Murska Sobota, Slovenia
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yuri Lopatin
- Volgograd State Medical University, Volgograd, Russia
| | - Lars H Lund
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Theresa McDonagh
- Department of Cardiovascular Science, Faculty of Life Science and Medicine, King's College London, London, UK
| | - Davor Milicic
- Massachusetts General Hospital and Baim Institute for Clinical Research, Boston, MA, USA
| | - Brenda Moura
- Faculty of Medicine, University of Porto, Porto, Portugal
- Cardiology Department, Porto Armed Forces Hospital, Porto, Portugal
| | | | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San Donato, Milan, Italy
- Department of Biomedical Science for Health, University of Milan, Milan, Italy
| | - Marija Polovina
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Amina Rakisheva
- Scientific Research Institute of Cardiology and Internal Medicine, Almaty, Kazakhstan
| | - Arsen Ristic
- School of Medicine, University of Belgrade, Belgrade, Serbia
| | - Gianluigi Savarese
- Department of Medicine, Karolinska Institutet, and Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | - Petar Seferovic
- Faculty of Medicine, University of Belgrade, Belgrade, Serbia
- Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Rajan Sharma
- St. George's Hospitals NHS Trust University of London, London, UK
| | - Thomas Thum
- Institute of Molecular and Translational Therapeutic Strategies (IMTTS) and Rebirth Center for Translational Regenerative Therapies, Hannover Medical School, Hannover, Germany
- Fraunhofer Institute of Toxicology and Experimental Medicine, Hannover, Germany
| | - Carlo G Tocchetti
- Cardio-Oncology Unit, Department of Translational Medical Sciences, Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Sophie Van Linthout
- German Centre for Cardiovascular Research (DZHK), partner site Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité-Universitätmedizin Berlin, BIH Center for Regenerative Therapies (BCRT), Berlin, Germany
| | - Cristiana Vitale
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | - Stephan Von Haehling
- Department of Cardiology and Pneumology, University Medical Center Goettingen, Georg-August University, Goettingen, Germany
- German Center for Cardiovascular Research (DZHK), partner site Goettingen, Goettingen, Germany
| | - Maurizio Volterrani
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| | | | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine Carol Davila, Bucharest, Romania
| | - Giuseppe Rosano
- St. George's Hospitals NHS Trust University of London, London, UK
- Department of Medical Sciences, Centre for Clinical and Basic Research, IRCCS San Raffaele Pisana, Rome, Italy
| |
Collapse
|
12
|
Zafrir B, Ovdat T, Abu Akel M, Bahouth F, Orvin K, Beigel R, Amir O, Elbaz-Greener G. Heart Failure Therapies following Acute Coronary Syndromes with Reduced Ejection Fraction: Data from the ACSIS Survey. J Pers Med 2023; 13:1015. [PMID: 37374004 PMCID: PMC10304454 DOI: 10.3390/jpm13061015] [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: 05/09/2023] [Revised: 06/10/2023] [Accepted: 06/15/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Guideline-directed medical therapies for heart failure (HF) may benefit patients with reduced left ventricular ejection fraction (LVEF) following acute coronary syndromes (ACS). Few real-world data are available regarding the early implementation of HF therapies in patients with ACS and reduced LVEF. METHODS Data collected from the 2021 nationwide, prospective ACS Israeli Survey (ACSIS). Drug classes included: (a) angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB) or angiotensin receptor-neprilysin inhibitors (ARNI); (b) beta-blockers; (c) mineralocorticoid receptor antagonist (MRA) and (d) sodium-glucose cotransporter-2 inhibitors (SGLT2I). The utilization of HF therapies at discharge or 90 days following ACS was analyzed in relation to LVEF [reduced ≤40% (n = 406) or mildly-reduced 41-49% (n = 255)] and short-term adverse outcomes. RESULTS History of HF, anterior wall myocardial infarction and Killip class II-IV (32% vs. 14% p < 0.001) were more prevalent in those with reduced compared to mildly-reduced LVEF. ACEI/ARB/ARNI and beta-blockers were used by the majority of patients in both LVEF groups, though ARNI was prescribed to only 3.9% (LVEF ≤ 40%). MRA was used by 42.9% and 12.2% of patients with LVEF ≤40% and 41-49%, respectively, and SGLT2I in about a quarter of both LVEF groups. Overall, ≥3 HF drug classes were documented in 44% of the patients. A trend towards higher rates of 90-day HF rehospitalizations, recurrent ACS or all-cause death was noted in those with reduced (7.6%) vs. mildly-reduced (3.7%) LVEF, p = 0.084. No association was observed between the number of HF drug classes or the use of ARNI and/or SGLT2I with adverse clinical outcomes. CONCLUSIONS In current clinical practice, the majority of patients with reduced and mildly-reduced LVEF are treated by ACEI/ARB and beta-blockers early following ACS, whereas MRA is underutilized and the adoption of SGLT2I and ARNI is low. A greater number of therapeutic classes was not associated with reduced short-term rehospitalizations or mortality.
Collapse
Affiliation(s)
- Barak Zafrir
- Lady Davis Carmel Medical Center, Cardiology Department, Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 7 Michal St., Haifa, Israel;
| | - Tal Ovdat
- Leviev Heart Center, Sheba Medical Center, Tel Hashomer, Israel;
| | - Mahmood Abu Akel
- Lady Davis Carmel Medical Center, Cardiology Department, Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, 7 Michal St., Haifa, Israel;
| | - Fadel Bahouth
- Cardiology Department, Bnai Zion Medical Center, Ruth and Bruce Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel
| | - Katia Orvin
- Rabin Medical Center, Cardiology Department, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel;
| | - Roy Beigel
- Leviev Heart Center, Sheba Medical Center, Cardiovascular Division, Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel;
| | - Offer Amir
- Hadassah Medical Center, Faculty of Medicine, Heart Institute, Hebrew University of Jerusalem, Jerusalem, Israel; (O.A.); (G.E.-G.)
| | - Gabby Elbaz-Greener
- Hadassah Medical Center, Faculty of Medicine, Heart Institute, Hebrew University of Jerusalem, Jerusalem, Israel; (O.A.); (G.E.-G.)
| |
Collapse
|
13
|
Shahid I, Fonarow GC, Greene SJ. Time to Quadruple Guideline-Directed Medical Therapy as a Key Performance Measure for Heart Failure. J Card Fail 2023; 29:730-733. [PMID: 36925046 DOI: 10.1016/j.cardfail.2023.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 02/13/2023] [Indexed: 03/17/2023]
Affiliation(s)
- Izza Shahid
- Division of Preventive Cardiology, Department of Cardiology, Houston Methodist Academic Institute, Houston, TX, USA
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA; Duke Clinical Research Institute, Durham, NC, USA.
| |
Collapse
|
14
|
Kobayashi M, Ferreira JP, Matsue Y, Chikamori T, Ito S, Asakura M, Yamashina A, Kitakaze M. Effect of eplerenone on clinical stability of Japanese patients with acute heart failure. Int J Cardiol 2023; 374:73-78. [PMID: 36586516 DOI: 10.1016/j.ijcard.2022.12.045] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2022] [Revised: 12/20/2022] [Accepted: 12/23/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND In the EARLIER (Efficacy and Safety of Early Initiation of Eplerenone Treatment in Patients with Acute Heart Failure) trial, eplerenone did not reduce heart failure (HF) hospitalizations or all-cause mortality in 300 patients admitted for acute HF (AHF). However, the trial might have been underpowered for these endpoints, and a comprehensive overview of the effect of eplerenone on diuretic doses and patients' clinical stability is warranted. METHODS The EARLIER trial included Japanese patients hospitalized for AHF randomly assigned to eplerenone or placebo over 6 months. Cox proportional hazards and mixed-effects models were used for analyses. RESULTS Three hundred patients were included (mean age, 67 ± 13 years; 73% males). The median furosemide equivalent dose was 40 (20-62) mg at randomization. Patients with higher furosemide-equivalent doses had more severe signs and symptoms of congestion and a higher risk of all-cause mortality or HF hospitalization during 6-month follow-up (adjusted-hazard ratio per 10 mg/day increase = 1.25, 95% confidence interval: 1.05-1.49). Eplerenone significantly decreased furosemide-equivalent diuretic doses and b-type natriuretic levels throughout the follow-up (overall-joint-p < 0.05 for both) and reduced E/e' and inferior vena cava diameter at 4 weeks (both p < 0.05). Additionally, eplerenone significantly reduced left ventricular (LV) end-diastolic diameter at 24 weeks (p < 0.05). CONCLUSIONS Eplerenone treatment improved the clinical stability particularly during short period following hospitalization for AHF, translated by lower diuretic doses, natriuretic peptide levels, indirect markers of filling pressure and venous congestion, and a smaller LV volume.
Collapse
Affiliation(s)
| | - João Pedro Ferreira
- Université de Lorraine, INSERM, Centre d'Investigations Cliniques Plurithématique 1433, Inserm U1116, CHRU de Nancy and F-CRIN INI-CRCT, Nancy, France; Cardiovascular Research and Development Center, Department of Surgery and Physiology, Faculty of Medicine of the University of Porto, Porto, Portugal
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | | | - Shin Ito
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masanori Asakura
- Department of Cardiovascular and Renal Medicine, Hyogo Medical University, Hyogo, Japan
| | - Akira Yamashina
- Department of Cardiology, Tokyo medical university, Tokyo, Japan; Department of Nursing, Kiryu University, Gunma, Japan
| | - Masafumi Kitakaze
- Department of Clinical Research and Development, National Cerebral and Cardiovascular Center, Osaka, Japan; Hanwa Memorial Hospital, Osaka, Japan.
| |
Collapse
|
15
|
Sepehrvand N, Nabipoor M, Youngson E, McAlister FA, Ezekowitz JA. Time to Triple Therapy in Patients With de Novo Heart Failure With Reduced Ejection Fraction: a Population-Based Study. J Card Fail 2023; 29:719-729. [PMID: 36754252 DOI: 10.1016/j.cardfail.2023.01.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/13/2023] [Accepted: 01/17/2023] [Indexed: 02/10/2023]
Abstract
BACKGROUND Quadruple therapy is recommended for the management of patients with heart failure (HF) and reduced ejection fraction (HFrEF). In order to provide background and identify barriers to quadruple therapy, in this study, the aim was to explore the time to initiation of triple therapy in a population-based cohort of patients with de novo HF. METHODS Adult patients with de novo hospital or emergency department (ED) diagnosis of HF between April 1, 2008, and March 31, 2018, in Alberta, Canada, were included and were linked to echocardiography data to identify patients with HFrEF (EF ≤ 40%). Any treatment with angiotensin-converting enzyme inhibitors/ angiotensin receptor blockers/ angiotensin receptor neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists was captured if prescribed for ≥ 28 days and filled at least once during the 12 months after the index episode. RESULTS Among 14,092 patients with de novo HF and available echocardiography data, 54.9% had HFrEF. By 1 year after diagnosis, of those in the HFrEF cohort, 9.5% had received no therapy, 27.5% monotherapy, 41.6% dual therapy, and 21.4% triple therapy. The median (interquartile range) of time to mono-, dual- and triple therapy in patients with HFrEF were 1 (0, 26), 8 (0, 44), and 14 (0, 52) days, respectively. Patients who received triple therapy were younger, more likely to be male and to have higher frequencies of coronary artery disease, higher glomerular filtration rates and lower left ventricular ejection fraction levels compared to their counterparts. Patients with triple therapy had lower rates of clinical outcomes compared to those on no, mono or dual therapy (adjusted hazard ratio 0.15, 95% confidence interval 0.13, 0.17 for the composite outcome of death, hospitalization due to HF, or ED visit due to HF). CONCLUSION Despite guideline recommendations, triple therapy is underused and is slowly deployed in patients with HFrEF, even after hospitalization and ED presentation.
Collapse
Affiliation(s)
- Nariman Sepehrvand
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada
| | - Majid Nabipoor
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Erik Youngson
- Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Finlay A McAlister
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Department of Medicine, University of Alberta, Edmonton, Alberta, Canada; Patient Health Outcomes Research and Clinical Effectiveness Unit, University of Alberta, Edmonton, Alberta, Canada
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada; Division of Cardiology, Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
16
|
Mathews L, Ding N, Sang Y, Loehr LR, Shin JI, Punjabi NM, Bertoni AG, Crews DC, Rosamond WD, Coresh J, Ndumele CE, Matsushita K, Chang PP. Racial Differences in Trends and Prognosis of Guideline-Directed Medical Therapy for Heart Failure with Reduced Ejection Fraction: the Atherosclerosis Risk in Communities (ARIC) Surveillance Study. J Racial Ethn Health Disparities 2023; 10:118-129. [PMID: 35001343 PMCID: PMC9271140 DOI: 10.1007/s40615-021-01202-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Revised: 11/24/2021] [Accepted: 12/01/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Racial disparities in guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) have not been fully documented in a community setting. METHODS In the ARIC Surveillance Study (2005-2014), we examined racial differences in GDMT at discharge, its temporal trends, and the prognostic impact among individuals with hospitalized HFrEF, using weighted regression models to account for sampling design. Optimal GDMT was defined as beta blockers (BB), mineralocorticoid receptor antagonist (MRA) and ACE inhibitors (ACEI) or angiotensin II receptor blockers (ARB). Acceptable GDMT included either one of BB, MRA, ACEI/ARB or hydralazine plus nitrates (H-N). RESULTS Of 16,455 (unweighted n = 3,669) HFrEF cases, 47% were Black. Only ~ 10% were discharged with optimal GDMT with higher proportion in Black than White individuals (11.1% vs. 8.6%, p < 0.001). BB use was > 80% in both racial groups while Black individuals were more likely to receive ACEI/ARB (62.0% vs. 54.6%) and MRA (18.0% vs. 13.8%) than Whites, with a similar pattern for H-N (21.8% vs. 10.1%). There was a trend of decreasing use of optimal GDMT in both groups, with significant decline of ACEI/ARB use in Whites (- 2.8% p < 0.01) but increasing H-N use in both groups (+ 6.5% and + 9.2%, p < 0.01). Only ACEI/ARB and BB were associated with lower 1-year mortality. CONCLUSIONS Optimal GDMT was prescribed in only ~ 10% of HFrEF patients at discharge but was more so in Black than White individuals. ACEI/ARB use declined in Whites while H-N use increased in both races. GDMT utilization, particularly ACEI/ARB, should be improved in Black and Whites individuals with HFrEF.
Collapse
Affiliation(s)
- Lena Mathews
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 600 North Wolfe Street Blalock 524D, Baltimore, MD, 21287, USA.
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA.
| | - Ning Ding
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Yingying Sang
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Laura R Loehr
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Jung-Im Shin
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Naresh M Punjabi
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Pulmonary and Critical Care, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Alain G Bertoni
- Department of Epidemiology and Prevention, Wake Forest University School of Medicine, Winston-Salem, NC, USA
| | - Deidra C Crews
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Division of Nephrology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
- Johns Hopkins Center for Health Equity, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Wayne D Rosamond
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Josef Coresh
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Chiadi E Ndumele
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 600 North Wolfe Street Blalock 524D, Baltimore, MD, 21287, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
- Johns Hopkins Center for Health Equity, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Kunihiro Matsushita
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, 600 North Wolfe Street Blalock 524D, Baltimore, MD, 21287, USA
- Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Patricia P Chang
- Division of General Medicine and Clinical Epidemiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
- Division of Cardiology, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| |
Collapse
|
17
|
Patient Eligibility for Established and Novel Guideline-Directed Medical Therapies After Acute Heart Failure Hospitalization. JACC. HEART FAILURE 2023; 11:596-606. [PMID: 36732099 DOI: 10.1016/j.jchf.2022.10.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/03/2022] [Accepted: 10/11/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND Acute heart failure (AHF) hospitalization presents an opportunity to optimize pharmacotherapy to improve outcomes. OBJECTIVES This study's aim was to define eligibility for initiation of guideline-directed medical therapy and newer heart failure (HF) agents from recent clinical trials in the AHF population. METHODS The authors analyzed patients with an AHF admission within the CAN-HF (Canadian Heart Failure) registry between January 2017 and April 2020. Heart failure with reduced ejection fraction (HFrEF) was defined as left ventricular ejection fraction (LVEF) ≤40% and heart failure with preserved ejection fraction (HFpEF) as LVEF >40%. Eligibility was assessed according to the major society guidelines or enrollment criteria from recent landmark clinical trials. RESULTS A total of 809 patients with documented LVEF were discharged alive from hospital: 455 with HFrEF and 354 with HFpEF; of these patients, 284 had a de novo presentation and 525 had chronic HF. In HFrEF patients, eligibility for therapies was 73.6% for angiotensin receptor-neprilysin inhibitors (ARNIs), 94.9% for beta-blockers, 84.4% for mineralocorticoid receptor antagonists (MRAs), 81.1% for sodium/glucose cotransporter 2 (SGLT2) inhibitors, and 15.6% for ivabradine. Additionally, 25.9% and 30.1% met trial criteria for vericiguat and omecamtiv mecarbil, respectively. Overall, 71.6% of patients with HFrEF (75.5% de novo, 69.5% chronic HF) were eligible for foundational quadruple therapy. In the HFpEF population, 37.6% and 59.9% were eligible for ARNIs and SGLT2 inhibitors based on recent trial criteria, respectively. CONCLUSIONS The majority of patients admitted with AHF are eligible for foundational quadruple therapy and additional novel medications across a spectrum of HF phenotypes.
Collapse
|
18
|
Yu Y, Guan W, Masoudi FA, Wang B, He G, Spertus JA, Lu Y, Krumholz HM, Li J. Hospital Variation of Spironolactone Use in Patients Hospitalized for Heart Failure in China-The China PEACE Retrospective Heart Failure Study. J Am Heart Assoc 2022; 11:e026300. [PMID: 36172964 PMCID: PMC9673705 DOI: 10.1161/jaha.122.026300] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Although aldosterone antagonists improve outcomes in select individuals with heart failure and reduced ejection fraction, studies in the United States have raised concerns about underuse and overuse. Variations in the prescription of aldosterone antagonist in China are unknown. Methods and Results In the multicenter, hospital-based, retrospective China PEACE (China Patient-Centered Evaluative Assessment of Cardiac Events) study, we identified a nationally representative cohort of admissions for heart failure in a nationally representative sample of Chinese hospitals in 2015. Patients were classified into 1 of 3 groups according to their eligibility for spironolactone-"ideal" (left ventricular ejection fraction <40% and without contraindications), "contraindicated" (a documented contraindication, irrespective of left ventricular ejection fraction), and "uncertain-benefit" (all others). We measured hospital variation of spironolactone prescriptions at discharge in the "ideal" and "contraindicated" group and calculated the median odds ratio (MOR), a measure of institution-level variation for 2 individuals with similar characteristics discharged at 2 randomly selected hospitals. Hospital characteristics associated with spironolactone use were identified using multivariable linear regression model. Among 1222 ideal patients from 97 hospitals, the median rate of spironolactone prescription was 78.6% (interquartile range [IQR], 42.8%-89.6% [range, 0%-100%], MOR, 3.4 [95% CI, 2.7-4.0]) at discharge. Among 900 contraindicated patients from 83 hospitals, the median rate of spironolactone prescription was 30.0% (IQR, 9.1%-50.0% [range, 0%-100%], MOR, 3.1 [95% CI, 2.4-3.9]) at discharge. Hospitals with independent departments of cardiology and located in Eastern China were associated with a 38.0% (95% CI, 18.7-57.3; P<0.001) and a 14.6% (95% CI, 2.3%-26.9%; P=0.020) higher rate of spironolactone use for ideal patients. Conclusions In this national study of hospitals in China, the use of spironolactone among ideal patients and the inappropriate use of spironolactone among patients with contraindications was substantial, with rates that varied markedly by institution. Registration URL: https://www.clinicaltrials.gov. Unique identifier: NCT02877914.
Collapse
Affiliation(s)
- Yuan Yu
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingPeople’s Republic of China
| | - Wenchi Guan
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingPeople’s Republic of China
| | - Frederick A. Masoudi
- Ascension HealthSt LouisMO
- Division of CardiologyUniversity of Colorado Anschutz Medical CampusAuroraCO
| | - Bin Wang
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingPeople’s Republic of China
| | - Guangda He
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingPeople’s Republic of China
| | - John A. Spertus
- School of MedicineUniversity of MissouriKansas CityMO
- Saint Luke’s Mid America Heart InstituteKansas CityMO
| | - Yuan Lu
- Center for Outcomes Research and Evaluation, Yale‐New Haven Hospital, and Department of Internal MedicineYale University School of MedicineNew HavenCT
| | - Harlan M. Krumholz
- Center for Outcomes Research and EvaluationYale‐New Haven HospitalNew HavenCT
- Department of Health Policy and ManagementYale School of Public HealthNew HavenCT
- Section of Cardiovascular Medicine, Department of Internal MedicineYale School of MedicineNew HavenCT
| | - Jing Li
- National Clinical Research Center of Cardiovascular Diseases, National Health Commission Key Laboratory of Clinical Research for Cardiovascular Medications, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular DiseasesChinese Academy of Medical Sciences and Peking Union Medical CollegeBeijingPeople’s Republic of China
- Fuwai HospitalChinese Academy of Medical SciencesShenzhenP. R. China
| |
Collapse
|
19
|
Mathews L, Ding N, Mok Y, Shin J, Crews DC, Rosamond WD, Newton A, Chang PP, Ndumele CE, Coresh J, Matsushita K. Impact of Socioeconomic Status on Mortality and Readmission in Patients With Heart Failure With Reduced Ejection Fraction: The ARIC Study. J Am Heart Assoc 2022; 11:e024057. [PMID: 36102228 PMCID: PMC9683665 DOI: 10.1161/jaha.121.024057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Accepted: 07/11/2022] [Indexed: 11/16/2022]
Abstract
Background Low socioeconomic status (SES) is associated with a higher risk of heart failure (HF). The contribution of individual and neighborhood SES to the prognosis and quality of care for HF with reduced ejection fraction is not clear yet has important implications. Methods and Results We examined 728 participants of the ARIC (Atherosclerosis Risk in Communities) study (mean age, 78.2 years; 34% Black participants; 46% women) hospitalized with HF with reduced ejection fraction (ejection fraction <50%) between 2005 and 2018. We assessed associations between education, income, and area deprivation index with mortality and HF readmission using multivariable Cox models. We also evaluated the use of guideline-directed medical therapy (optimal: ≥3 of ß-blockers, mineralocorticoid receptor antagonist, angiotensin-converting enzyme inhibitors, or angiotensin receptor blockers; acceptable: at least 2) at discharge. During a median follow-up of 3.2 years, 58.7% were readmitted with HF, and 74.0% died. Low income was associated with higher mortality (hazard ratio [HR], 1.52 [95% CI, 1.14-2.04]) and readmission (HR, 1.45 [95% CI, 1.04-2.03]). Similarly, low education was associated with mortality (HR, 1.27 [95% CI, 1.01-1.59]) and readmission (HR, 1.62 [95% CI, 1.24-2.12]). The highest versus lowest area deprivation index quartile was associated with readmission (HR, 1.69 [95% CI, 1.11-2.58]) but not necessarily with mortality. The prevalence of optimal guideline-directed medical therapy and acceptable guideline-directed medical therapy was 5.5% and 54.4%, respectively, but did not significantly differ by SES. Conclusions Among patients hospitalized with HF with reduced ejection fraction, low SES was independently associated with mortality and HF readmission. A targeted secondary prevention approach that focuses intensive efforts on patients with low SES will be necessary to improve outcomes of those with HF with reduced ejection fraction.
Collapse
Affiliation(s)
- Lena Mathews
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of EpidemiologyJohns Hopkins UniversityBaltimoreMD
- Cicarrone Center for the Prevention of Cardiovascular Disease, Department of Medicine, Divsion of CardiologyJohns Hopkins UniversityBaltimoreMD
- School of Medicine, Johns Hopkins UniversityBaltimoreMD
| | - Ning Ding
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of EpidemiologyJohns Hopkins UniversityBaltimoreMD
- Bloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMD
| | - Yejin Mok
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of EpidemiologyJohns Hopkins UniversityBaltimoreMD
- Bloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMD
| | - Jung‐Im Shin
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of EpidemiologyJohns Hopkins UniversityBaltimoreMD
- Bloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMD
| | - Deidra C. Crews
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of EpidemiologyJohns Hopkins UniversityBaltimoreMD
- School of Medicine, Johns Hopkins UniversityBaltimoreMD
- Bloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMD
- Center for Health EquityJohns Hopkins UniversityBaltimoreMD
| | - Wayne D. Rosamond
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNC
| | - Anna‐Kucharska Newton
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNC
- College of Public HealthUniversity of KentuckyLexingtonKY
| | - Patricia P. Chang
- Gillings School of Global Public HealthUniversity of North Carolina at Chapel HillChapel HillNC
- Division of Cardiology, Department of MedicineUniversity of North Carolina at Chapel HillChapel HillNC
| | - Chiadi E. Ndumele
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of EpidemiologyJohns Hopkins UniversityBaltimoreMD
- Cicarrone Center for the Prevention of Cardiovascular Disease, Department of Medicine, Divsion of CardiologyJohns Hopkins UniversityBaltimoreMD
- School of Medicine, Johns Hopkins UniversityBaltimoreMD
- Bloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMD
- Center for Health EquityJohns Hopkins UniversityBaltimoreMD
| | - Josef Coresh
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of EpidemiologyJohns Hopkins UniversityBaltimoreMD
- School of Medicine, Johns Hopkins UniversityBaltimoreMD
- Bloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMD
| | - Kunihiro Matsushita
- Welch Center for Prevention, Epidemiology, and Clinical Research, Department of EpidemiologyJohns Hopkins UniversityBaltimoreMD
- School of Medicine, Johns Hopkins UniversityBaltimoreMD
- Bloomberg School of Public Health, Johns Hopkins UniversityBaltimoreMD
| |
Collapse
|
20
|
Establishing a Cardiac ICU Recovery Clinic: Characterizing a Model for Continuity of Cardiac Critical Care. Crit Pathw Cardiol 2022; 21:135-140. [PMID: 35994722 DOI: 10.1097/hpc.0000000000000294] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Care in the cardiovascular intensive care unit (CICU) has become increasingly intricate due to a temporal rise in noncardiac diagnoses and overall clinical complexity with high risk for short-term rehospitalization and mortality. Survivors of critical illness are often faced with debility and limitations extending beyond the index hospitalization. Comprehensive ICU recovery programs have demonstrated some efficacy but have primarily targeted survivors of acute respiratory distress syndrome or sepsis. The efficacy of dedicated ICU recovery programs on the CICU population is not defined. METHODS We aim to describe the design and initial experience of a novel CICU-recovery clinic (CICURC). The primary outcome was death or rehospitalization in the first 30 days following hospital discharge. Self-reported outcome measures were performed to assess symptom burden and independence in activities of daily living. RESULTS Using standardized criteria, 41 patients were referred to CICURC of which 78.1% established care and were followed for a median of 88 (56-122) days. On intake, patients reported a high burden of heart failure symptoms (KCCQ overall summary score 29.8 [18.0-47.5]), and nearly half (46.4%) were dependent on caretakers for activities of daily living. Thirty days postdischarge, no deaths were observed and the rate of rehospitalization for any cause was 12.2%. CONCLUSIONS CICU survivors are faced with significant residual symptom burden, dependence upon caretakers, and impairments in mental health. Dedicated CICURCs may help prioritize treatment of ICU related illness, reduce symptom burden, and improve outcomes. Interventions delivered in ICU recovery clinic for patients surviving the CICU warrant further investigation.
Collapse
|
21
|
Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022; 145:e895-e1032. [PMID: 35363499 DOI: 10.1161/cir.0000000000001063] [Citation(s) in RCA: 612] [Impact Index Per Article: 306.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
Collapse
Affiliation(s)
| | | | | | | | | | | | - Anita Deswal
- ACC/AHA Joint Committee on Clinical Practice Guidelines Liaison
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, Deswal A, Drazner MH, Dunlay SM, Evers LR, Fang JC, Fedson SE, Fonarow GC, Hayek SS, Hernandez AF, Khazanie P, Kittleson MM, Lee CS, Link MS, Milano CA, Nnacheta LC, Sandhu AT, Stevenson LW, Vardeny O, Vest AR, Yancy CW. 2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure. J Am Coll Cardiol 2022; 79:e263-e421. [PMID: 35379503 DOI: 10.1016/j.jacc.2021.12.012] [Citation(s) in RCA: 694] [Impact Index Per Article: 347.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure. METHODS A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. STRUCTURE Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.
Collapse
|
23
|
Mathews L, Han D, Evans MK, Zonderman AB, Ndumele CE, Crews DC. Prevalence of Guideline-Directed Medical Therapy for Cardiovascular Disease Among Baltimore City Adults in the Healthy Aging in Neighborhoods of Diversity Across the Life Span (HANDLS) Study. J Racial Ethn Health Disparities 2022; 9:538-545. [PMID: 33594652 PMCID: PMC10995811 DOI: 10.1007/s40615-021-00984-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2020] [Revised: 01/27/2021] [Accepted: 01/28/2021] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Guideline-directed medical therapy (GDMT) has been shown to improve outcomes for people with cardiovascular disease (CVD). Our goal was to assess racial and socioeconomic differences in GDMT use among a diverse population. METHODS We examined the cross-sectional association of race and poverty status with GDMT among 441 participants with CVD in a longitudinal cohort of urban-dwelling Black and White adults in Baltimore City, Maryland, using multivariable logistic regression. CVD status and GDMT were self-reported. RESULTS The participants' mean age was 60.5 (SD 8.5) years, with 61.7% women, 64.4% Black, and 46.9% living below poverty. Of the 126 participants with coronary artery disease (CAD), 37.3%, 54.8%, and 62.7% were on aspirin, antiplatelets, and statins, respectively. Black participants with CAD were less likely to be on aspirin, OR 0.29 (95% CI 0.13-0.67), and on combination GDMT (antiplatelet and statin), OR 0.36 (0.16-0.78) compared to Whites. There were no differences by poverty status in GDMT for CAD. Fully, 222 participants reported atrial fibrillation (AF), but only 10.5% were on anticoagulation with no significant difference by race or poverty status. The use of GDMT for heart failure and stroke was also low overall, but there were no differences by race or poverty status. CONCLUSIONS Among an urban-dwelling population of adults, the use of secondary prevention of CVD was low, with lower aspirin and combination GDMT for Black participants with CAD. Efforts to improve GDMT use at the patient and provider levels may be needed to improve morbidity and mortality and reduce disparities in CVD.
Collapse
Affiliation(s)
- Lena Mathews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
- Division of Cardiology, Johns Hopkins School of Medicine, 600 North Wolfe Street Blalock 524D, Baltimore, MD, USA.
| | - Dingfen Han
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Michele K Evans
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, National Institutes of Health, Baltimore, MD, USA
| | - Alan B Zonderman
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging Intramural Research Program, National Institutes of Health, Baltimore, MD, USA
| | - Chiadi E Ndumele
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Division of Cardiology, Johns Hopkins School of Medicine, 600 North Wolfe Street Blalock 524D, Baltimore, MD, USA
- Johns Hopkins Center for Health Equity, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| | - Deidra C Crews
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Johns Hopkins Center for Health Equity, Johns Hopkins Bloomberg School of Public Health, Baltimore, MD, USA
| |
Collapse
|
24
|
Greene SJ, Ezekowitz JA, Anstrom KJ, Demyanenko V, Givertz MM, Piña IL, O'Connor CM, Koglin J, Roessig L, Hernandez AF, Armstrong PW, Mentz RJ. Medical Therapy During Hospitalization for Heart Failure with Reduced Ejection Fraction: The VICTORIA Registry: Medical Therapy During Hospitalization for HFrEF. J Card Fail 2022; 28:1063-1077. [PMID: 35301107 DOI: 10.1016/j.cardfail.2022.02.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND For patients hospitalized for heart failure with reduced ejection fraction (HFrEF), guidelines recommend optimization of medical therapy prior to discharge. The degree to which changes in medical therapy occur during hospitalizations for HFrEF in North American clinical practice is unclear. METHODS The VICTORIA registry enrolled patients hospitalized for worsening chronic HFrEF across 51 sites in the US and Canada from February 2018-January 2019. Among patients with complete medication data and not receiving dialysis, use and dose of angiotensin-converting enzyme inhibitor (ACEI)/ angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA), and sodium glucose cotransporter-2 inhibitors (SGLT2i) were assessed at admission and discharge. RESULTS Among 1,695 patients, median (IQR) age was 69 (59-79) years and 33% were women. Among eligible patients, 33%, 25%, and 55% were not prescribed ACEI/ARB/ARNI, beta-blocker, and MRA at discharge, respectively; 99% were not prescribed SGLT2i. For each medication, >50% of patients remained on stable sub-target doses or no medication during hospitalization. In-hospital rates of initiation/dose increase were 20% for ACEI/ARB, 4% for ARNI, 20% for beta-blocker, 22% for MRA, and <1% for SGLT2i; corresponding rates of dose decrease/discontinuation were 11%, 2%, 9%, 5%, and <1%, respectively. Overall, 17% and 28% of eligible patients were prescribed triple therapy prior to admission and at discharge, respectively. At both admission and discharge, 1% of patients were prescribed triple therapy at target doses. Across classes of medication, multiple factors were independently associated with higher likelihood of in-hospital initiation/dosing increase (e.g., Canadian enrollment, White race, intensive care admission) and discontinuation/dosing decrease (e.g., worse renal function, intensive care admission). CONCLUSIONS In this contemporary North American registry of patients hospitalized for worsening chronic HFrEF, for each recommended medical therapy, the large majority of eligible patients remained on stable sub-target doses or without medication at admission and discharge. Although most patients had no alterations in medical therapy, hospitalization in Canada and multiple patient characteristics were associated with higher likelihood of favorable in-hospital medication changes.
Collapse
Affiliation(s)
- Stephen J Greene
- From the Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Durham, North Carolina
| | | | - Michael M Givertz
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Ileana L Piña
- Department of Medicine, Jefferson University, Philadelphia, Pennsylvania
| | | | | | | | - Adrian F Hernandez
- From the Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert J Mentz
- From the Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
25
|
Armbruster AL, Mann DL, Vader JM. Four-Drug Therapy For Heart Failure with Reduced LV Ejection Fraction - Here and Now. J Card Fail 2022; 28:564-566. [PMID: 35149171 DOI: 10.1016/j.cardfail.2022.01.016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2022] [Accepted: 01/26/2022] [Indexed: 10/19/2022]
Affiliation(s)
| | - Douglas L Mann
- Washington University In St Louis: Washington University in St Louis
| | - Justin M Vader
- Washington University in St Louis School of Medicine, St Louis, Missouri UNITED STATES.
| |
Collapse
|
26
|
Salah HM, Al’Aref SJ, Khan MS, Al-Hawwas M, Vallurupalli S, Mehta JL, Mounsey JP, Greene SJ, McGuire DK, Lopes RD, Fudim M. Efficacy and safety of sodium-glucose cotransporter 2 inhibitors initiation in patients with acute heart failure, with and without type 2 diabetes: a systematic review and meta-analysis. Cardiovasc Diabetol 2022; 21:20. [PMID: 35123480 PMCID: PMC8817537 DOI: 10.1186/s12933-022-01455-2] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Accepted: 01/05/2022] [Indexed: 12/26/2022] Open
Abstract
Background There is uncertainty and limited data regarding initiation of sodium-glucose cotransporter 2 (SGLT2) inhibitors among patients hospitalized with acute heart failure (AHF). This systematic review and meta-analysis aim to establish the efficacy and safety of SGLT2 inhibitors initiated in patients hospitalized for AHF. Methods PubMed/Medline, Embase, and Cochrane library were searched using the following terms: (“sglt2" and "acute heart failure") and (“sglt2" and "worsening heart failure") from inception till November 15th, 2021 for randomized controlled trials (RCTs) comparing the efficacy and safety of initiating an SGLT2 inhibitor compared with placebo in patients with AHF. Major cardiovascular and diabetes scientific meetings in 2021 were also searched for relevant studies. Prespecified efficacy outcomes were all-cause mortality, rehospitalization for heart failure, and improvement in Kansas City Cardiomyopathy Questionnaire (KCCQ) scale score. Prespecified safety outcomes were acute kidney injury (AKI), hypotension, and hypoglycemia. Random effects odds ratio (OR) and mean difference with 95% confidence intervals (CIs) were calculated. Results Three RCTs with a total of 1831 patients were included. Initiation of SGLT2 inhibitors in patients with AHF reduced the risk of rehospitalization for heart failure (OR 0.52; 95% CI [0.42, 0.65]) and improved Kansas City Cardiomyopathy Questionnaire scores (mean difference 4.12; 95% CI [0.1.89, 6.53]). There was no statistically significant effect for initiation of SGLT2 inhibitors in patients with AHF on all-cause mortality (OR 0.70; 95% CI [0.46, 1.08]). Initiation of SGLT2 inhibitors in patients with AHF did not increase the acute kidney injury (OR 0.76; 95% CI [0.50, 1.16]), hypotension (OR 1.17; 95% CI [0.80, 1.71]), or hypoglycemia (OR 1.51; 95% CI [0.86, 2.65]). Conclusion Initiation of SGLT2 inhibitors in patients hospitalized for AHF during hospitalization or early post-discharge (within 3 days) reduces the risk of rehospitalization for heart failure and improves patient-reported outcomes with no excess risk of adverse effects. Supplementary Information The online version contains supplementary material available at 10.1186/s12933-022-01455-2.
Collapse
|
27
|
Abstract
Despite recent advances in the treatment of chronic heart failure, therapeutic options for acute heart failure (AHF) remain limited. AHF admissions are associated with significant multi-organ dysfunction, especially worsening renal failure, which results in significant morbidity and mortality. There are several aspects of AHF management: diagnosis, decongestion, vasoactive therapy, goal-directed medical therapy initiation and safe transition of care. Effective diagnosis and prognostication could be very helpful in an acute setting and rely upon biomarker evaluation with noninvasive assessment of fluid status. Decongestive strategies could be tailored to include pharmaceutical options along with consideration of utilizing ultrafiltration for refractory hypervolemia. Vasoactive agents to augment cardiac function have been evaluated in patients with AHF but have shown to only have limited efficacy. Post stabilization, initiation of quadruple goal-directed medical therapy—angiotensin receptor-neprilysin inhibitors, mineral receptor antagonists, sodium glucose type 2 (SGLT-2) inhibitors, and beta blockers—to prevent myocardial remodeling is being advocated as a standard of care. Safe transition of care is needed prior to discharge to prevent heart failure rehospitalization and mortality. Post-discharge close ambulatory monitoring (including remote hemodynamic monitoring), virtual visits, and rehabilitation are some of the strategies to consider. We hereby review the contemporary approach in AHF diagnosis and management.
Collapse
Affiliation(s)
- Hayaan Kamran
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
28
|
Dai D, Sharma A, Alvarez PJ, Woods SD. Multiple comorbid conditions and healthcare resource utilization among adult patients with hyperkalemia: A retrospective observational cohort study using association rule mining. JOURNAL OF MULTIMORBIDITY AND COMORBIDITY 2022; 12:26335565221098832. [PMID: 35586031 PMCID: PMC9112318 DOI: 10.1177/26335565221098832] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 04/19/2022] [Indexed: 12/21/2022]
Abstract
Objectives To estimate the prevalence of specific comorbid conditions (CCs) and multiple comorbid conditions (MCCs) among adult patients with hyperkalemia and examine the associations between MCCs and healthcare resource utilization (HRU) and costs. Methods This retrospective observational cohort study was conducted using a large administrative claims database. We identified patients with hyperkalemia (ICD-10-CM: E87.5; or serum potassium >5.0 mEq/L; or NDC codes for either patiromer or sodium polystyrene sulfonate) during the study period (1/1/2016–6/30/2019). The earliest service/claim date with evidence of hyperkalemia was identified as index date. Qualified patients had ≥12 months of enrolment before and after index date, ≥18 years of age. Comorbid conditions were assessed using all data within 12 months prior to the index date. Healthcare resource utilization and costs were estimated using all data within 12 months after the index date. Association rule mining was applied to identify MCCs. Generalized linear models were used to examine the associations between MCCs and HRU and costs. Results Of 22,154 patients with hyperkalemia, 94% had ≥3 CCs. The most common individual CCs were chronic kidney disease (CKD, 85%), hypertension (HTN, 83%), hyperlipidemia (HLD, 81%), and diabetes mellitus (DM, 47%). The most common dyad combination of CCs was CKD+HTN (71%). The most common triad combination was CKD+HTN+HLD (62%). The most common quartet combination was CKD+HTN+HLD+DM (36%). The increased number of CCs were significantly associated with increased ED visits, length of hospital stays, and total healthcare costs (all p-value < 0.0001). Conclusions MCCs are very prevalent among patients with hyperkalemia and are strongly associated with HRU and costs.
Collapse
Affiliation(s)
- Dingwei Dai
- CVS Health Clinical Trial Services LLC, Woonsocket, RI, USA
| | - Ajay Sharma
- CVS Health Clinical Trial Services LLC, Woonsocket, RI, USA
| | - Paula J Alvarez
- Managed Care Health Outcomes, Vifor Pharma Inc., Redwood City, CA, USA
| | - Steven D Woods
- Managed Care Health Outcomes, Vifor Pharma Inc., Redwood City, CA, USA
| |
Collapse
|
29
|
Zahir D, Bonde A, Madelaire C, Malmborg M, Butt JH, Fosbol E, Gislason G, Torp-Pedersen C, Andersson C, Rossignol P, McMurray JJV, Kober L, Schou M. Temporal trends in initiation of mineralocorticoid receptor antagonists and risk of subsequent withdrawal in patients with heart failure: A nationwide study in Denmark from 2003-2017. Eur J Heart Fail 2021; 24:539-547. [PMID: 34969178 DOI: 10.1002/ejhf.2418] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2021] [Revised: 12/16/2021] [Accepted: 12/26/2021] [Indexed: 11/10/2022] Open
Abstract
AIMS Despite landmark heart failure (HF) with reduced ejection fraction (HFrEF) trials showing effect of Mineralocorticoid Receptor Antagonists (MRA) on the risk of death and HF hospitalization, it has been suggested that MRAs are underutilized or frequently withdrawn. This study sought to identify temporal trends in the initiation of MRAs and the subsequent risk of withdrawal and adherence of MRAs in HF patients treated with a renin-angiotensin system inhibitor and a beta-blocker in Denmark from 2003-2017. METHODS AND RESULTS From nationwide registries, we identified patients receiving a diagnosis of HF. Use of MRA was identified by at least one prescription within six months after the diagnosis. The absolute risk of withdrawal with treatment was assessed with cumulative incidence, accounting for the competing risk of death. To estimate adherence, we calculated the proportion of days covered (PDC). We included 51 512 patients with incident HF. During the study period 20 779 (40.3%) patients initiated MRA therapy. The incidence of withdrawal of MRA was 49.2% throughout the study period. 48.0% of the HF patients were adherent with the treatment. Among patients withdrawing treatment with MRA, the cumulative incidence of reinitiating was 36.6%. CONCLUSIONS In a nationwide cohort of patients with HF, approximately half of the patients received MRA as third-line therapy within the first six months after diagnosis and approximately half of these withdrew MRA within 5 years. These findings warrant an increasing focus on retention to MRA treatment in a real-life setting. This article is protected by copyright. All rights reserved.
Collapse
Affiliation(s)
- Deewa Zahir
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | - Anders Bonde
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| | | | | | - Jawad H Butt
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Emil Fosbol
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark
| | - Gunnar Gislason
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark.,The National Institute of Public Health, University of Southern Denmark, Denmark
| | - Christian Torp-Pedersen
- Department of Clinical Research and Cardiology, Nordsjaellands Hospital, Hillerød, Denmark.,Department of Cardiology, Aalborg University Hospital, Aalborg, Denmark
| | - Charlotte Andersson
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark.,Department of Medicine, Section of Cardiovascular Medicine, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Patrick Rossignol
- INSERM, Centre d'Investigations Cliniques-Plurithématique 1433, UMR 1116, CHRU de Nancy, French-Clinical Research Infrastructure Network (F-CRIN) INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, Université de Lorraine, France
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Lars Kober
- Department of Cardiology, Rigshospitalet, Copenhagen University Hospital, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital, Hellerup, Denmark
| |
Collapse
|
30
|
Rao VN, Murray E, Butler J, Cooper LB, Cox ZL, Fiuzat M, Green JB, Lindenfeld J, McGuire DK, Nassif ME, O'Brien C, Pagidipati N, Sharma K, Vaduganathan M, Vardeny O, Fonarow GC, Mentz RJ, Greene SJ. In-Hospital Initiation of Sodium-Glucose Cotransporter-2 Inhibitors for Heart Failure With Reduced Ejection Fraction. J Am Coll Cardiol 2021; 78:2004-2012. [PMID: 34763778 PMCID: PMC9766421 DOI: 10.1016/j.jacc.2021.08.064] [Citation(s) in RCA: 48] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 08/09/2021] [Accepted: 08/10/2021] [Indexed: 12/11/2022]
Abstract
Sodium-glucose cotransporter-2 inhibitor therapy is well suited for initiation during the heart failure hospitalization, owing to clinical benefits that accrue rapidly within days to weeks, a strong safety and tolerability profile, minimal to no effects on blood pressure, and no excess risk of adverse kidney events. There is no evidence to suggest that deferring initiation to the outpatient setting accomplishes anything beneficial. Instead, there is compelling evidence that deferring in-hospital initiation exposes patients to excess risk of early postdischarge clinical worsening and death. Lessons from other heart failure with reduced ejection fraction therapies highlight that deferring initiation of guideline-recommended medications to the U.S. outpatient setting carries a >75% chance they will not be initiated within the next year. Recognizing that 1 in 4 patients hospitalized for worsening heart failure die or are readmitted within 30 days, clinicians should embrace the in-hospital period as an optimal time to initiate sodium-glucose cotransporter-2 inhibitor therapy and treat this population with the urgency it deserves.
Collapse
Affiliation(s)
- Vishal N Rao
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Evan Murray
- Duke University School of Medicine, Durham, North Carolina, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi, USA
| | - Lauren B Cooper
- Department of Cardiology, North Shore University Hospital, Manhasset, New York, USA
| | - Zachary L Cox
- Department of Pharmacy, Vanderbilt University Medical Center, Nashville Tennessee, USA
| | - Mona Fiuzat
- Duke Clinical Research Institute, Durham, North Carolina, USA; Duke University School of Medicine, Durham, North Carolina, USA
| | - Jennifer B Green
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Endocrinology, Duke University School of Medicine, Durham, North Carolina, USA
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Darren K McGuire
- Division of Cardiology, University of Texas Southwestern Medical Center and Parkland Health and Hospital System, Dallas, Texas, USA
| | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Cara O'Brien
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Neha Pagidipati
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Muthiah Vaduganathan
- Heart and Vascular Center, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Orly Vardeny
- Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, and University of Minnesota, Minneapolis, Minnesota, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California-Los Angeles, Los Angeles, California, USA
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| |
Collapse
|
31
|
Greene SJ, Butler J, Fonarow GC. In-hospital initiation of quadruple medical therapy for heart failure: making the post-discharge vulnerable phase far less vulnerable. Eur J Heart Fail 2021; 24:227-229. [PMID: 34779112 DOI: 10.1002/ejhf.2382] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 11/10/2021] [Indexed: 11/06/2022] Open
Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, NC, USA.,Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, CA, USA
| |
Collapse
|
32
|
Blecker S, Adhikari S, Zhang H, Dodson JA, Desai SM, Anzisi L, Pazand L, Schoenthaler AM, Mann DM. Validation of EHR medication fill data obtained through electronic linkage with pharmacies. J Manag Care Spec Pharm 2021; 27:1482-1487. [PMID: 34595945 PMCID: PMC8759289 DOI: 10.18553/jmcp.2021.27.10.1482] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND: Recent linkages between electronic health records (EHRs) and pharmacy data hold opportunity for up-to-date assessment of medication adherence at the point of care. OBJECTIVE: To validate linked EHR-pharmacy data, which can be used for point-of-care interventions for concordance with insurance claims data for patients in a large health care delivery system. METHODS: We performed a retrospective cohort study of adult patients with an active antihypertensive medication order and seen as outpatients between August 25, 2019, and August 31, 2019. Pharmacy fill information was obtained from the EHR via linkages with Surescripts pharmacy and pharmacy benefit manager data, as well as from insurance claims available at our institution. We matched antihypertensive medication fills observed in the linked EHR-pharmacy database with available fills in the insurance claims database and calculated the percentage of medication fills that were available in each database. We estimated medication adherence using proportion of days covered in the linked EHR-pharmacy database and in the insurance claims database. RESULTS: Of 26,679 patients with hypertension, 23,348 (87.5%) had at least 1 antihypertensive medication fill recorded in the linked EHR-pharmacy database. Of 1,501 patients matched with the insurance database and with a documented medication fill, a fill was present for 1,484 (98.9%) and 1,259 (83.9%) patients in the linked EHR-pharmacy and insurance databases, respectively. Of 12,109 medication fills recorded in the insurance data, we found an overlap of 11,060 (91.3%) fills with the linked EHR-pharmacy database. The linked EHR-pharmacy database also contained 18,232 of 19,281 (94.6%) medication fills present in either database. Measured medication adherence was higher for patients when based on linked EHR-pharmacy data compared with insurance claims data (42% vs 30%, P < 0.001). CONCLUSIONS: Linked EHR-pharmacy data captured medication fills for the vast majority of patients and resulted in higher estimates of adherence than insurance claims. Our results suggest that pharmacy fill data available in the EHR have sufficient reliability to be used for point-of-care assessment of medication adherence. DISCLOSURES: This study was supported by grant R01HL155149 from the National Heart, Lung, and Blood Institute. Allen Thorpe provided funding for the NYU Langone Health Learning Health System Program, which helped fund this project. The authors have nothing to disclose.
Collapse
Affiliation(s)
- Saul Blecker
- Department of Population Health and Department of Medicine, NYU School of Medicine, New York, NY
| | | | - Hanchao Zhang
- Department of Population Health, NYU School of Medicine, New York, NY
| | - John A Dodson
- Department of Population Health and Department of Medicine, NYU School of Medicine, New York, NY
| | - Sunita M Desai
- Department of Population Health, NYU School of Medicine, New York, NY
| | - Lisa Anzisi
- NYU Network Integration, NYU Langone Health, New York, NY
| | - Lily Pazand
- Department of Managed Care, NYU Langone Health, New York, NY
| | | | - Devin M Mann
- Department of Population Health and Department of Medicine, NYU School of Medicine, New York, NY
| |
Collapse
|
33
|
Carnicelli AP, Li Z, Greiner MA, Lippmann SJ, Greene SJ, Mentz RJ, Hardy NC, Blumer V, Shen X, Yancy CW, Peterson PN, Allen LA, Fonarow GC, O'Brien EC. Sacubitril/Valsartan Adherence and Postdischarge Outcomes Among Patients Hospitalized for Heart Failure With Reduced Ejection Fraction. JACC-HEART FAILURE 2021; 9:876-886. [PMID: 34509408 DOI: 10.1016/j.jchf.2021.06.018] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Revised: 06/24/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022]
Abstract
OBJECTIVES The authors sought to investigate associations between sacubitril/valsartan adherence and clinical outcomes after hospitalization for heart failure with reduced ejection fraction (HFrEF). BACKGROUND Sacubitril/valsartan improves outcomes in HFrEF, though the extent to which medication adherence is associated with outcomes in routine care is less well characterized. METHODS The authors analyzed patients aged ≥65 years hospitalized for HFrEF within the Get With the Guidelines-Heart Failure registry linked with Medicare claims between October 2015 and September 2018 who were discharged with sacubitril/valsartan. Sacubitril/valsartan adherence was assessed using medication fills to calculate proportion of days covered (PDC) through 90 days postdischarge. Associations between postdischarge adherence (PDC < or ≥80%) and risk of readmission and death within 1 year were examined by comparing cumulative incidences and adjusted event rates. RESULTS Among 897 patients prescribed sacubitril/valsartan at discharge, 295 (32.9%) had PDC ≥80% and 602 (67.1%) had PDC <80%. Baseline characteristics were balanced between groups. Compared with patients with PDC <80%, patients with PDC ≥80% had a significantly lower adjusted hazard of all-cause re-hospitalization (HR: 0.66; [95% CI: 0.48-0.89]) and death (HR: 0.42; [0.22-0.79]) at 90 days and at 1 year (HR: 0.69; [0.56-0.86] and HR: 0.53; [0.38-0.74], respectively). For every 5 percentage point increase in PDC, patients experienced a significant reduction in rehospitalization (HR: 0.98; [0.97-0.99]) and death (HR: 0.96; [0.94-0.97]) at 1 year. CONCLUSIONS In patients hospitalized for HFrEF and discharged on sacubitril/valsartan, high adherence to sacubitril/valsartan within 90 days after discharge was associated with substantially lower rates of readmission and death. Additional efforts to improve adherence with sacubitril/valsartan and other guideline-directed medical therapies in HFrEF are warranted.
Collapse
Affiliation(s)
- Anthony P Carnicelli
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Zhen Li
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Melissa A Greiner
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Steven J Lippmann
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - N Chantelle Hardy
- Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vanessa Blumer
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Xian Shen
- Health Economics and Outcomes Research, Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Clyde W Yancy
- Division of Cardiology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Pamela N Peterson
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA; Division of Cardiology, Department of Medicine, Denver Health Medical Center, Denver, Colorado, USA
| | - Larry A Allen
- University of Colorado Anschutz Medical Center, Aurora, Colorado, USA
| | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, University of California at Los Angeles, Los Angeles, California, USA
| | - Emily C O'Brien
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA.
| |
Collapse
|
34
|
Cox ZL, Collins SP, Aaron M, Hernandez GA, III ATM, Davidson BT, Fowler M, Lindsell CJ, Jr FEH, Jenkins CA, Kampe C, Miller KF, Stubblefield WB, Lindenfeld J. Efficacy and safety of dapagliflozin in acute heart failure: Rationale and design of the DICTATE-AHF trial. Am Heart J 2021; 232:116-124. [PMID: 33144086 DOI: 10.1016/j.ahj.2020.10.071] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 10/27/2020] [Indexed: 01/10/2023]
Abstract
BACKGROUND Dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, reduces cardiovascular death and worsening heart failure in patients with chronic heart failure and reduced ejection fraction. Early initiation during an acute heart failure (AHF) hospitalization may facilitate decongestion, improve natriuresis, and facilitate safe transition to a beneficial outpatient therapy for both diabetes and heart failure. OBJECTIVE The objective is to assess the efficacy and safety of initiating dapagliflozin within the first 24 hours of hospitalization in patients with AHF compared to usual care. METHODS DICTATE-AHF is a prospective, multicenter, open-label, randomized trial enrolling a planned 240 patients in the United States. Patients with type 2 diabetes hospitalized with hypervolemic AHF and an estimated glomerular filtration rate of at least 30 mL/min/1.73m2 are eligible for participation. Patients are randomly assigned 1:1 to dapagliflozin 10 mg once daily or structured usual care until day 5 or hospital discharge. Both treatment arms receive protocolized diuretic and insulin therapies. The primary endpoint is diuretic response expressed as the cumulative change in weight per cumulative loop diuretic dose in 40 mg intravenous furosemide equivalents. Secondary and exploratory endpoints include inpatient worsening AHF, 30-day hospital readmission for AHF or diabetic reasons, change in NT-proBNP, and measures of natriuresis. Safety endpoints include the incidence of hyper/hypoglycemia, ketoacidosis, worsening kidney function, hypovolemic hypotension, and inpatient mortality. CONCLUSIONS The DICTATE-AHF trial will establish the efficacy and safety of early initiation of dapagliflozin during AHF across both AHF and diabetic outcomes in patients with diabetes.
Collapse
|
35
|
Srivastava PK, DeVore AD, Hellkamp AS, Thomas L, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Duffy CI, Hernandez AF, Fonarow GC. Heart Failure Hospitalization and Guideline-Directed Prescribing Patterns Among Heart Failure With Reduced Ejection Fraction Patients. JACC-HEART FAILURE 2020; 9:28-38. [PMID: 33309579 DOI: 10.1016/j.jchf.2020.08.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVES The authors sought to evaluate the association of heart failure hospitalization (HFH) with guideline-directed medical therapy (GDMT) prescribing patterns among patients with heart failure with reduced ejection fraction (HFrEF). BACKGROUND HFH represents an important opportunity to titrate GDMT among patients with HFrEF. METHODS The CHAMP-HF (Change the Management of Patients With Heart Failure) registry is a prospective registry of adults with HFrEF (ejection fraction ≤40%). Using data from the CHAMP-HF registry (N = 4,365), adjusted time-to-event models were created to study the association of HFH with GDMT prescribing patterns. RESULTS HFH (compared with no HFH) was positively associated with initiation of angiotensin-converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), angiotensin receptor-neprilysin inhibitor, beta-blocker, and mineralocorticoid receptor antagonist (MRA). HFH positively associated with dose escalation of ACE inhibitor/ARB (probability ratio: 1.71, 95% confidence interval [CI]: 1.36 to 2.16) and MRA (probability ratio: 8.71, 95% CI: 4.19 to 18.10). In those on prior therapy, HFH was associated with discontinuation and de-escalation of all classes of GDMT. ACE inhibitor/ARB, angiotensin receptor-neprilysin inhibitor, beta-blocker, and MRA de-escalation/discontinuation after HFH was associated with increased risk of all-cause mortality with hazard ratios of 3.82 (95% CI: 2.42 to 6.03), 4.76 (95% CI: 2.06 to 11.03), 2.94 (95% CI: 2.04 to 4.25), and 4.81 (95% CI: 2.61 to 8.87), respectively. CONCLUSIONS HFH positively associated with changes in GDMT, including initiation, dose escalation, discontinuation, and dose de-escalation. De-escalation/discontinuation of GDMT after HFH associated with increased risk of all-cause mortality. Educational endeavors are needed to ensure GDMT is not inappropriately held in the setting of HFH. For those in whom GDMT must be held/decreased, improvement tools at discharge and post-discharge titration clinics may help ensure lifesaving GDMT regimens remain optimized.
Collapse
Affiliation(s)
| | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anne S Hellkamp
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Laine Thomas
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Nancy M Albert
- Office of Nursing Research and Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - J Herbert Patterson
- Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, North Carolina, USA
| | - John A Spertus
- Saint Luke's Mid America Heart Institute and the University of Missouri-Kansas City, Kansas City, Missouri, USA
| | | | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA.
| |
Collapse
|
36
|
Berg DD, Braunwald E, DeVore AD, Lala A, Pinney SP, Duffy CI, Gurmu Y, Velazquez EJ, Morrow DA. Efficacy and Safety of Sacubitril/Valsartan by Dose Level Achieved in the PIONEER-HF Trial. JACC-HEART FAILURE 2020; 8:834-843. [PMID: 32800511 DOI: 10.1016/j.jchf.2020.06.008] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 06/02/2020] [Accepted: 06/02/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES This study sought to evaluate the efficacy and safety of sacubitril/valsartan according to dose level achieved in the PIONEER-HF (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on NT-proBNP in Patients Stabilized From an Acute Heart Failure Episode) trial. BACKGROUND In patients hospitalized for acute decompensated heart failure (ADHF), in-hospital initiation and continuation of sacubitril/valsartan as compared with enalapril is well tolerated, achieves a greater reduction in N-terminal pro-B-type natriuretic peptide (NT-proBNP), and reduces the risk of cardiovascular death or rehospitalization for HF through 8 weeks. However, not all patients achieve the target dose of sacubitril/valsartan, and its efficacy and safety in such patients are of interest. METHODS PIONEER-HF was a randomized, double-blind, active-controlled trial of sacubitril/valsartan versus enalapril in 881 patients stabilized during hospitalization for ADHF. Blinded study medication was administered for 8 weeks, with initial dosing selected based on the systolic blood pressure at randomization and titrated toward a target of sacubitril/valsartan 97/103 mg twice daily, or enalapril 10 mg twice daily, with an algorithm based on systolic blood pressure and the investigator's assessment of tolerability. RESULTS At 4 weeks, 199 (55%) patients allocated to sacubitril/valsartan and 211 (60%) patients allocated to enalapril were dispensed the target dose. Baseline characteristics were similar in the 2 treatment groups within each dose level. There was no heterogeneity across dose levels in the effect of sacubitril/valsartan on the reduction in NT-proBNP (pinteraction = 0.69), the reduction in cardiovascular death or rehospitalization for heart failure (pinteraction = 0.42), or the pre-specified adverse events of special interest through 8 weeks. CONCLUSIONS In hemodynamically stabilized patients with ADHF, the efficacy and safety of sacubitril/valsartan are generally consistent across dose levels. (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect on NT-proBNP in Patients Stabilized From an Acute Heart Failure Episode [PIONEER-HF]; NCT02554890).
Collapse
Affiliation(s)
- David D Berg
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts.
| | - Eugene Braunwald
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Sean P Pinney
- Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Carol I Duffy
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey
| | - Yared Gurmu
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| | - Eric J Velazquez
- Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - David A Morrow
- TIMI Study Group, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts
| |
Collapse
|
37
|
Packer M. Obesity-Associated Heart Failure as a Theoretical Target for Treatment With Mineralocorticoid Receptor Antagonists. JAMA Cardiol 2019; 3:883-887. [PMID: 30046826 DOI: 10.1001/jamacardio.2018.2090] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Importance Despite their clinical benefits, mineralocorticoid receptor antagonists are greatly underprescribed by most practitioners who treat patients with chronic heart failure. A novel approach to encouraging the use of these drugs is to enhance awareness about the intimate link between aldosterone and obesity. Observations There is a strong association between abdominal obesity and circulating levels of aldosterone, and markers of abdominal obesity identify patients most likely to benefit from mineralocorticoid receptor antagonism. In a trial of patients with heart failure and a reduced ejection fraction, patients with an increased waist circumference exhibited an approximately 50% reduction in the risk of a primary end point. The magnitude of benefit was more than twice as great in patients with abdominal obesity than in those with a normal waist circumference, and patients with abdominal obesity tolerated treatment better than nonobese patients. Similarly, in a trial of patients with heart failure and a preserved ejection fraction, those who were most likely to have abdominal obesity (identified by their level of natriuretic peptides) were most likely to demonstrate a benefit of treatment with spironolactone, exhibiting an approximately 80% reduction in the risk of a primary end point (based on a small number of events). Conclusions and Relevance Although these analyses are post hoc, their concordance and strong biological foundation suggests that abdominal obesity may identify patients who respond most favorably to mineralocorticoid receptor antagonism. Given the easy availability of its measurement, targeting patients with an increased waist circumference could enhance the adoption of these important drugs for the treatment of chronic heart failure in clinical practice.
Collapse
Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas
| |
Collapse
|
38
|
Greene SJ, Felker GM, Giczewska A, Kalogeropoulos AP, Ambrosy AP, Chakraborty H, DeVore AD, Fudim M, McNulty SE, Mentz RJ, Vaduganathan M, Hernandez AF, Butler J. Spironolactone in Acute Heart Failure Patients With Renal Dysfunction and Risk Factors for Diuretic Resistance: From the ATHENA-HF Trial. Can J Cardiol 2019; 35:1097-1105. [PMID: 31230825 PMCID: PMC6685766 DOI: 10.1016/j.cjca.2019.01.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2018] [Revised: 01/15/2019] [Accepted: 01/28/2019] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Acute heart failure (HF) patients with renal insufficiency and risk factors for diuretic resistance may be most likely to derive incremental improvement in congestion with the addition of spironolactone. METHODS The Aldosterone Targeted Neurohormonal Combined with Natriuresis Therapy in Heart Failure (ATHENA-HF) trial randomized 360 acute HF patients with reduced or preserved ejection fraction to spironolactone 100 mg daily or usual care for 96 hours. The current analysis assessed the effects of study therapy within tertiles of baseline estimated glomerular filtration rate (eGFR) and subgroups at heightened risk for diuretic resistance. RESULTS Across eGFR tertiles, there was no incremental benefit of high-dose spironolactone on any efficacy endpoint, including changes in log N-terminal pro-B-type natriuretic peptide and signs and symptoms of congestion (all P for interaction ≥ 0.06). High-dose spironolactone had no significant effect on N-terminal pro-B-type natriuretic peptide reduction regardless of blood pressure, diabetes mellitus status, and loop diuretic dose (all P for interaction ≥ 0.38). In-hospital changes in serum potassium and creatinine were similar between treatment groups for all GFR tertiles (all P for interaction ≥ 0.18). Rates of inpatient worsening HF, 30-day worsening HF, and 60-day all-cause mortality were numerically higher among patients with lower baseline eGFR, but relative effects of study treatment did not differ with renal function (all P for interaction ≥ 0.27). CONCLUSIONS High-dose spironolactone did not improve congestion over usual care among patients with acute HF, irrespective of renal function and risk factors for diuretic resistance. In-hospital initiation or continuation of spironolactone was safe during the inpatient stay, even when administered at high doses to patients with moderate renal dysfunction.
Collapse
Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA.
| | - G Michael Felker
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Anna Giczewska
- Duke Clinical Research Institute, Durham, North Carolina, USA; Department of Biomedical Engineering, Faculty of Electronics, Telecommunications and Informatics, Gdansk University of Technology, Gdansk, Poland
| | | | - Andrew P Ambrosy
- Department of Cardiology, Kaiser Permanente San Francisco Medical Center, San Francisco, California, USA; Division of Research, Kaiser Permanente Northern California, Oakland, California, USA
| | | | - Adam D DeVore
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, North Carolina, USA; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| |
Collapse
|
39
|
Abstract
PURPOSE OF REVIEW Heart failure clinical practice guidelines are fundamental and serve as framework for providers to deliver evidence-based care that correlates with enhanced patient outcomes. However, adherence, particularly to guideline-directed medical therapy, remains suboptimal for a multitude of reasons. RECENT FINDINGS Despite robust clinical trials, updated guidelines and an expert consensus statement from American Heart Association, American College of Cardiology, and Heart Failure Society of America registry data signal that heart failure patients do not receive appropriate pharmacotherapy and may receive an intracardiac device without prior initiation or optimization of medical therapy. Strategies to improve provider adherence to heart failure guidelines include multidisciplinary models and appropriate referral and care standardization. These approaches can improve morbidity, mortality, and quality of life in HF patients.
Collapse
|
40
|
Durstenfeld MS, Katz SD, Park H, Blecker S. Mineralocorticoid receptor antagonist use after hospitalization of patients with heart failure and post-discharge outcomes: a single-center retrospective cohort study. BMC Cardiovasc Disord 2019; 19:194. [PMID: 31399059 PMCID: PMC6688376 DOI: 10.1186/s12872-019-1175-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2019] [Accepted: 07/31/2019] [Indexed: 01/06/2023] Open
Abstract
Background Mineralocorticoid receptor antagonists (MRA) are an underutilized therapy for heart failure with a reduced ejection fraction (HFrEF), but the current impact of hospitalization on MRA use is not well characterized. The objective of this study was to describe contemporary MRA prescription for heart failure patients before and after the full scope of hospitalizations and the association between MRA discharge prescription and post-hospitalization outcomes. Methods We conducted a retrospective cohort study at an academic hospital system in 2013–2016. Among 1500 included hospitalizations of 1009 unique patients with HFrEF and without MRA contraindication, the mean age was 71.9 ± 13.6 years and 443 (29.5%) were female. We compared MRA prescription before and after hospitalizations with McNemar’s test and between patients with principal and secondary diagnoses of HFrEF with the chi-square test, and association of MRA discharge prescription with 30-day and 180-day mortality and readmissions using generalized estimating equations. Results MRA prescriptions increased from 303 (20.2%) to 375 (25.0%) at discharge (+4.8%, p < 0.0001). More patients with principal diagnosis of HFrEF compared to those hospitalized for other reasons received MRA (34.9% versus 21.3%, p < 0.0001) and had them initiated (21.8% versus 9.7%, p < 0.0001). MRA prescription at discharge was not associated with mortality or readmission at 30 and 180 days, and there was no interaction with principal/secondary diagnosis. Conclusions Among hospitalized HFrEF patients, 75% did not receive MRA before or after hospitalization, and nearly 90% of eligible patients did not have MRA initiated. As we found no signal for short-term harm after discharge, hospitalization may represent an opportunity to initiate guideline-directed heart failure therapy.
Collapse
Affiliation(s)
- Matthew S Durstenfeld
- Department of Medicine, Division of Cardiology, University of California, San Francisco, Box 0124, C/O Salina Gu, San Francisco, CA, 94143, USA
| | - Stuart D Katz
- Department of Medicine, New York University School of Medicine, 227 East 30th Street, New York, NY, 10016, USA
| | - Hannah Park
- Department of Population Health, New York University School of Medicine, 227 East 30th Street, New York, NY, 10016, USA
| | - Saul Blecker
- Department of Medicine, New York University School of Medicine, 227 East 30th Street, New York, NY, 10016, USA. .,Department of Population Health, New York University School of Medicine, 227 East 30th Street, New York, NY, 10016, USA.
| |
Collapse
|
41
|
Iacovoni A, D'Elia E, Gori M, Oliva F, Lorini FL, Senni M. Treating Patients Following Hospitalisation for Acute Decompensated Heart Failure: An Insight into Reducing Early Rehospitalisations. Card Fail Rev 2019; 5:78-82. [PMID: 31179016 PMCID: PMC6545980 DOI: 10.15420/cfr.2018.46.2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Accepted: 04/19/2019] [Indexed: 12/11/2022] Open
Abstract
Heart failure (HF) is a pandemic syndrome characterised by raised morbidity and mortality. An acute HF event requiring hospitalisation is associated with a poor prognosis, in both the short and the long term. Moreover, early rehospitalisation after discharge negatively affects HF management and survival rates. Cardiovascular and non-cardiovascular conditions combine to increase rates of HF hospital readmission at 30 days. A tailored approach for HF pharmacotherapy while the patient is in hospital and immediately after discharge could be useful in reducing early adverse events that cause rehospitalisation and, consequently, prevent worsening HF and readmission during the vulnerable phase after discharge.
Collapse
Affiliation(s)
- Attilio Iacovoni
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| | - Emilia D'Elia
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| | - Mauro Gori
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| | - Fabrizio Oliva
- Cardiovascular Department, ASST Grande Ospedale Metropolitano Niguarda Milan, Italy
| | | | - Michele Senni
- Cardiovascular Department, ASST Papa Giovanni XXIII Bergamo, Italy
| |
Collapse
|
42
|
Sparks ER, Beavers JC. Evaluation of a Pharmacist-Driven Aldosterone Antagonist Stewardship Program in Patients With Heart Failure. J Pharm Pract 2019; 32:158-162. [DOI: 10.1177/0897190017747083] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective: To evaluate the impact of a pharmacist-driven initiative to optimize aldosterone antagonist use in patients with heart failure with reduced ejection fraction (HFrEF) at a large community hospital. Methods: This single-center, retrospective cohort study compared patients with heart failure before and after the implementation of the initiative. Data for pre- and postinitiative patients were retrospectively collected to assess patient characteristics and aldosterone antagonist use. The primary outcome was a composite of eligible patients with heart failure discharged on aldosterone antagonist therapy or with a documented reason for ineligibility before and after commencement of pharmacist-driven aldosterone antagonist initiative. Results: The preinitiative cohort included 96 patients and the postinitiative cohort contained 92 patients. When the 3 month pre- and postinitiative groups were assessed, the primary outcome was noted in 60 (63%) of 96 patients in the preinitiative group and 87 (95%) of 92 patients in the postinitiative group ( P < .0001). Conclusion: In patients with HFrEF, a pharmacist-driven aldosterone antagonist optimization initiative significantly increased appropriate prescribing and documentation for aldosterone antagonist therapy.
Collapse
Affiliation(s)
- Eric R. Sparks
- New Hanover Regional Medical Center, Wilmington, NC, USA
| | | |
Collapse
|
43
|
|
44
|
Spironolactone and Outcomes in Older Patients with Heart Failure and Reduced Ejection Fraction. Am J Med 2019; 132:71-80.e1. [PMID: 30240686 PMCID: PMC6511886 DOI: 10.1016/j.amjmed.2018.09.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 08/31/2018] [Accepted: 09/04/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND The efficacy of mineralocorticoid receptor antagonists or aldosterone antagonists in heart failure with reduced ejection fraction (HFrEF) is well known. Less is known about their effectiveness in real-world older patients with HFrEF. METHODS Of the 8206 patients with heart failure and ejection fraction ≤35% without prior spironolactone use in the Medicare-linked OPTIMIZE-HF registry, 6986 were eligible for spironolactone therapy based on serum creatinine criteria (men ≤2.5 mg/dL, women ≤2.0 mg/dL) and 865 received a discharge prescription for spironolactone. Using propensity scores for spironolactone use, we assembled a matched cohort of 1724 (862 pairs) patients receiving and not receiving spironolactone, balanced on 58 baseline characteristics (Creatinine Cohort: mean age, 75 years, 42% women, 17% African American). We repeated the above process to assemble a secondary matched cohort of 1638 (819 pairs) patients with estimated glomerular filtration rate (eGFR) ≥30 mL/min/1.73 m2 (eGFR Cohort: mean age, 75 years, 42% women, 17% African American). RESULTS In the matched Creatinine Cohort, spironolactone-associated hazard ratios (95% confidence intervals) for all-cause mortality, heart failure readmission, and combined endpoint of heart failure readmission or all-cause mortality were 0.92 (0.81-1.03), 0.87 (0.77-0.99), and 0.87 (0.79-0.97), respectively. Respective hazard ratios (95% confidence intervals) in the matched eGFR Cohort were 0.87 (0.77-0.98), 0.92 (0.80-1.05), and 0.91 (0.82-1.02). CONCLUSIONS These findings provide evidence of consistent, albeit modest, clinical effectiveness of spironolactone in older patients with HFrEF regardless of renal eligibility criteria used. Additional strategies are needed to improve the effectiveness of aldosterone antagonists in clinical practice.
Collapse
|
45
|
Bhagat AA, Greene SJ, Vaduganathan M, Fonarow GC, Butler J. Initiation, Continuation, Switching, and Withdrawal of Heart Failure Medical Therapies During Hospitalization. JACC. HEART FAILURE 2019; 7:1-12. [PMID: 30414818 PMCID: PMC8053043 DOI: 10.1016/j.jchf.2018.06.011] [Citation(s) in RCA: 98] [Impact Index Per Article: 19.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/17/2018] [Revised: 04/28/2018] [Accepted: 04/30/2018] [Indexed: 12/11/2022]
Abstract
Patients with worsening heart failure with reduced ejection fraction (HFrEF) spend a large proportion of time in the hospital and other health care facilities. The benefits of guideline-directed medical therapy (GDMT) in the outpatient setting have been shown in large randomized controlled trials. However, the decision to initiate, continue, switch, or withdraw HFrEF medications in the inpatient setting is often based on multiple factors and subject to significant variability across providers. Based on available data, in well-selected, treatment-naïve patients who are hemodynamically stable and clinically euvolemic after stabilization during hospitalization for HF, elements of GDMT can be safely initiated. Inpatient continuation of GDMT for HFrEF appears safe and well-tolerated in most hemodynamically stable patients. Hospitalization is also a potential time for switching from an angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker to sacubitril/valsartan therapy in eligible patients, and is the subject of ongoing study. Therapy withdrawal or need for dose reduction is rarely required, but if needed identifies a particularly at-risk group of patients with progressive HF. If recurrent intolerance to neurohormonal blockers is observed, these patients should be evaluated for advanced HF therapies. There is an enduring need for using the teachable moment of HFrEF hospitalization for optimal initiation, continuation, and switching of GDMT to improve post-discharge patient outcomes and the quality of chronic HFrEF care.
Collapse
Affiliation(s)
- Aditi A Bhagat
- Division of Cardiology, Stony Brook University, Stony Brook, New York
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, California
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi.
| |
Collapse
|
46
|
Inohara T, Manandhar P, Kosinski AS, Matsouaka RA, Kohsaka S, Mentz RJ, Thourani VH, Carroll JD, Kirtane AJ, Bavaria JE, Cohen DJ, Kiefer TL, Gaca JG, Kapadia SR, Peterson ED, Vemulapalli S. Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement. JAMA 2018; 320:2231-2241. [PMID: 30512100 PMCID: PMC6583475 DOI: 10.1001/jama.2018.18077] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
IMPORTANCE Data are lacking on the effect of a renin-angiotensin system (RAS) inhibitor prescribed after transcatheter aortic valve replacement (TAVR). Treatment with a RAS inhibitor may reverse left ventricular remodeling and improve function. OBJECTIVE To investigate the association of prescription of a RAS inhibitor and outcomes after TAVR. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of TAVR procedures performed in the United States (using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry) between July 2014 and January 2016 that were linked to Medicare claims data (final date of follow-up: March 31, 2017). To account for differences in demographics, echocardiographic findings, and in-hospital complications, 1:1 propensity matching was performed. EXPOSURES Initial hospital discharge prescription of a RAS inhibitor after TAVR. MAIN OUTCOMES AND MEASURES Primary outcomes were all-cause death and readmission due to heart failure at 1 year after discharge, which were considered separately. The secondary outcome was health status assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ; score range: 0-100, with a higher score indicating less symptom burden and better quality of life; a small effect size was defined as 5 points) at 1 year. RESULTS Among 21 312 patients who underwent TAVR at 417 US sites, 8468 patients (39.7%) were prescribed a RAS inhibitor at hospital discharge. After propensity matching, 15 896 patients were included (mean [SD] age, 82.4 [6.8] years; 48.1% were women; mean [SD] left ventricular ejection fraction [LVEF], 51.9% [11.5%]). Patients with a prescription for a RAS inhibitor vs those with no prescription had lower mortality rates at 1 year (12.5% vs 14.9%, respectively; absolute risk difference [ARD], -2.4% [95% CI, -3.5% to -1.4%]; hazard ratio [HR], 0.82 [95% CI, 0.76 to 0.90]) and lower heart failure readmission rates at 1 year (12.0% vs 13.8%; ARD, -1.8% [95% CI, -2.8% to -0.7%]; HR, 0.86 [95% CI, 0.79 to 0.95]). When stratified by LVEF, having a prescription for a RAS inhibitor vs no prescription was associated with lower 1-year mortality among patients with preserved LVEF (11.1% vs 13.9%, respectively; ARD, -2.81% [95% CI, -3.95% to -1.67%]; HR, 0.78 [95% CI, 0.71 to 0.86]), but not among those with reduced LVEF (18.8% vs 19.5%; ARD, -0.68% [95% CI, -3.52% to 2.20%]; HR, 0.95 [95% CI, 0.81 to 1.12]) (P = .04 for interaction). Of 15 896 matched patients, 4837 (30.4%) were included in the KCCQ score analysis and improvements at 1 year were greater in patients with a prescription for a RAS inhibitor vs those with no prescription (median, 33.3 [interquartile range, 14.2 to 51.0] vs 31.3 [interquartile range, 13.5 to 51.1], respectively; difference in improvement, 2.10 [95% CI, 0.10 to 4.06]; P < .001), but the effect size was not clinically meaningful. CONCLUSIONS AND RELEVANCE Among patients who underwent TAVR, receiving a prescription for a RAS inhibitor at hospital discharge compared with no prescription was significantly associated with a lower risk of mortality and heart failure readmission. However, due to potential selection bias, this finding requires further investigation in randomized trials.
Collapse
Affiliation(s)
- Taku Inohara
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Pratik Manandhar
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Andrzej S. Kosinski
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Roland A. Matsouaka
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Robert J. Mentz
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Vinod H. Thourani
- Department of Cardiac Surgery, MedStar Heart and Vascular Institute and Georgetown University School of Medicine, Washington, DC
| | - John D. Carroll
- Division of Cardiology, Department of Medicine, University of Colorado, Aurora
| | - Ajay J. Kirtane
- Department of Medicine, Columbia University Medical Center, New York Presbyterian Hospital, New York, New York
| | - Joseph E. Bavaria
- Division of Cardiovascular Surgery, University of Pennsylvania, Philadelphia
| | - David J. Cohen
- Department of Medicine, Saint Luke’s Mid America Heart Institute, Kansas City, Missouri
- Department of Medicine, University of Missouri–Kansas City School of Medicine, Kansas City
| | - Todd L. Kiefer
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Jeffrey G. Gaca
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Eric D. Peterson
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| | - Sreekanth Vemulapalli
- Duke Clinical Research Institute, Duke University Medical Center, Durham, North Carolina
| |
Collapse
|
47
|
Albert NM, Kozinn MJ. In-Hospital Initiation of Guideline-Directed Heart Failure Pharmacotherapy to Improve Long-Term Patient Adherence and Outcomes. Crit Care Nurse 2018; 38:16-24. [DOI: 10.4037/ccn2018669] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Heart failure is a burdensome cardiovascular condition associated with high rates of morbidity and mortality. The 3-month period after hospitalization is a vulnerable phase in which patients are at high risk for mortality and rehospitalization. To reduce risk during this period, patients with heart failure and reduced ejection fraction should receive guideline-directed pharmacological therapies—the right drugs at the right doses—before hospital discharge. Optimal pharmacotherapies for these patients include agents that suppress the renin-angiotensin-aldosterone system, suppress the sympathetic nervous system, enhance vasodilation, slow heart rate when needed, and reduce excess volume. Because optimal prescription and adherence are both necessary to ensure the best clinical outcomes, nurses need to participate in interventions that optimize prescription and drug use over time. Collaboration with pharmacists and advanced practice acute care nurses may help ensure that medication selection and dosing are consistent with national guidelines. Use of a predischarge order set and electronic medical records checklist can enhance collaborative care.
Collapse
Affiliation(s)
- Nancy M. Albert
- Nancy M. Albert is associate chief nursing officer, Office of Nursing Research and Innovation, and a clinical nurse specialist, Kaufman Center for Heart Failure, Heart and Vascular Institute, Cleveland Clinic, Cleveland, Ohio
| | - Marc J. Kozinn
- Marc J. Kozinn is US cardiovascular medical director, heart failure, Amgen, Inc, Thousand Oaks, California
| |
Collapse
|
48
|
Kloner RA, Gross C, Yuan J, Conrad A, Pergola PE. Effect of Patiromer in Hyperkalemic Patients Taking and Not Taking RAAS Inhibitors. J Cardiovasc Pharmacol Ther 2018; 23:524-531. [PMID: 30103622 PMCID: PMC6193203 DOI: 10.1177/1074248418788334] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
Introduction: Hyperkalemia (potassium >5.0 mEq/L) affects heart failure patients with renal disease regardless of the use of renin–angiotensin–aldosterone system inhibitors (RAASi). The open-label TOURMALINE study showed that patiromer, a sodium-free, nonabsorbed potassium binder, lowers serum potassium of hyperkalemic patients similarly when given with or without food; unlike prior studies, patients were not required to be taking RAASi. We conducted post hoc analyses to provide the first report of patiromer in patients not taking RAASi. Methods: Hyperkalemic patients received patiromer, 8.4 g/d to start, adjusted to achieve and maintain serum potassium of 3.8 to 5.0 mEq/L. If taking RAASi, stable doses were required. The primary end point was the proportion of patients with serum potassium 3.8 to 5.0 mEq/L at week 3 or 4. This analysis presents data by patients taking or not taking RAASi. Results: Demographics and baseline characteristics were similar in patients taking (n = 67) and not taking RAASi (n = 45). Baseline mean (SD) serum potassium was 5.37 (0.37) mEq/L and 5.42 (0.43) mEq/L in patients taking and not taking RAASi, respectively. Mean (SD) daily patiromer doses were similar (10.7 [3.2] and 11.5 [4.0] g, respectively). The primary end point was achieved in 85% (95% confidence interval [CI]: 74-93) of patients taking RAASi and in 84% (95% CI: 71-94) of patients not taking RAASi. From baseline to week 4, the mean (SE) change in serum potassium was −0.67 (0.08) mEq/L in patients taking RAASi and −0.56 (0.10) mEq/L in patients not taking RAASi (both P < .0001 vs baseline, P = nonsignificant between groups). Adverse events were reported in 26 (39%) patients taking RAASi and 25 (54%) not taking RAASi; the most common adverse event was diarrhea (2% and 11%, respectively; no cases were severe). Five patients (2 taking RAASi) reported 6 serious adverse events; none considered related to patiromer. Conclusions: Patiromer was effective and generally well-tolerated for hyperkalemia treatment, whether or not patients were taking RAAS inhibitors.
Collapse
Affiliation(s)
- Robert A Kloner
- 1 Huntington Medical Research Institutes, Pasadena, CA, USA.,2 Division of Cardiovascular Medicine, Department of Medicine, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Coleman Gross
- 3 Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, CA, USA
| | - Jinwei Yuan
- 3 Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, CA, USA
| | - Ansgar Conrad
- 3 Relypsa, Inc., a Vifor Pharma Group Company, Redwood City, CA, USA
| | | |
Collapse
|
49
|
AlShamiri MQ, AlHabib KF, AlHabeeb W, Raslan IR, Ullah A, Elasfar AA, Alshaer F, Albackr H, Mimish L, Almasood A, AlGhamdi S, Ghabashi A. Clinical Presentation, Predictors, and Outcomes Among Mineralocorticoid Receptor Antagonist (MRA)-Eligible Acute Heart Failure Patients in the Heart Function Assessment Registry Trial in Saudi Arabia (HEARTS). Angiology 2018; 69:323-332. [DOI: 10.1177/0003319717720051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Mineralocorticoid receptor antagonist (MRA) therapy is indicated after myocardial infarction in patients with acute heart failure (AHF) with an ejection fraction ≤40% and lacking contraindications. We analyzed clinical presentations, predictors, and outcomes of MRA-eligible patients within a prospective registry of patients with AHF from 18 hospitals in Saudi Arabia, from 2009 to 2010. For this subgroup, mortality rates were followed until 2013, and the clinical characteristics, management, predictors, and outcomes were compared between MRA-treated and non-MRA-treated patients. Of 2609 patients with AHF, 387 (14.8%) were MRA eligible, of which 146 (37.7%) were prescribed MRAs. Compared with non-MRA-treated patients, those prescribed MRAs more commonly exhibited non-ST-segment elevation myocardial infarction, acute on chronic heart failure, past history of ischemic heart disease, and severe left ventricular systolic dysfunction; were more commonly administered oral furosemide and digoxin; and had higher in-hospital recurrent congestive HF rates. Mortality did not significantly differ ( P > .05) between groups. In Saudi Arabia, 37.7% of eligible patients received MRA treatment, which is higher than that in developed countries. The lack of long-term survival benefit raises concerns about systematic problems, for example, proper follow-up and management after hospital discharge, warranting further investigation.
Collapse
Affiliation(s)
- Mostafa Q. AlShamiri
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Khalid F. AlHabib
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Waleed AlHabeeb
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Ismail R. Raslan
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Anhar Ullah
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Abdelfatah A. Elasfar
- King Salman Cardiac Center, King Fahad Medical City, Riyadh, Saudi Arabia
- Cardiology Department, Tanta University, Tanta, Egypt
| | - Fayez Alshaer
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Hanan Albackr
- Department of Cardiac Sciences, King Fahad Cardiac Center, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Layth Mimish
- Department of Medicine, King Abdulaziz University Hospital, Jeddah, Saudi Arabia
| | - Ali Almasood
- Prince Sultan Cardiac Center, Riyadh, Saudi Arabia
| | - Saleh AlGhamdi
- Madina Cardiac Center, Al Madina Al Monaoarah, Saudi Arabia
| | | |
Collapse
|
50
|
A population health perspective on a claims and electronic health record-based tool to screen for suboptimal medication adherence. Am Heart J 2018; 197:150-152. [PMID: 29447775 DOI: 10.1016/j.ahj.2017.10.012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2017] [Accepted: 10/19/2017] [Indexed: 12/20/2022]
|