Heart failure and respiratory hospitalizations are reduced in patients with heart failure and chronic obstructive pulmonary disease with the use of an implantable pulmonary artery pressure monitoring device

Diuretic Treatment in Patients with Heart Failure: Current Evidence and Future Directions-Part II: Combination Therapy

PURPOSE OF REVIEW

Fluid retention or congestion is a major cause of symptoms, poor quality of life, and adverse outcome in patients with heart failure (HF). Despite advances in disease-modifying therapy, the mainstay of treatment for congestion-loop diuretics-has remained largely unchanged for 50 years. In these two articles (part I: loop diuretics and part II: combination therapy), we will review the history of diuretic treatment and current trial evidence for different diuretic strategies and explore potential future directions of research.

RECENT FINDINGS

We will assess recent trials, including DOSE, TRANSFORM, ADVOR, CLOROTIC, OSPREY-AHF, and PUSH-AHF, and assess how these may influence current practice and future research. There are few data on which to base diuretic therapy in clinical practice. The most robust evidence is for high-dose loop diuretic treatment over low-dose treatment for patients admitted to hospital with HF, yet this is not reflected in guidelines. There is an urgent need for more and better research on different diuretic strategies in patients with HF.

Benefits of remote hemodynamic monitoring in heart failure

Despite treatment advancements, HF mortality remains high, prompting interest in reducing HF-related hospitalizations through remote monitoring. These advances are necessary considering the rapidly rising prevalence and incidence of HF worldwide, presenting a burden on hospital resources. While traditional approaches have failed in predicting impending HF-related hospitalizations, remote hemodynamic monitoring can detect changes in intracardiac filling pressure weeks prior to HF-related hospitalizations which makes timely pharmacological interventions possible. To ensure successful implementation, structural integration, optimal patient selection, and efficient data management are essential. This review aims to provide an overview of the rationale, the available devices, current evidence, and the implementation of remote hemodynamic monitoring.

Meta-Analysis Comparing Outcomes of Remote Hemodynamic Assessment Versus Standard Care in Patients With Heart Failure

In patients with congestive heart failure (CHF), remote hemodynamic monitoring can reduce heart failure exacerbation and mortality. In this study, we compared the effectiveness of remote hemodynamic monitoring with that of standard care in the management of patients with CHF. The remote monitoring group included 7,733 patients, and the control group included 7,567 patients. Chi-square test and I-square statistics were used to assess heterogeneity. Risk ratios (RRs) were calculated using fixed-effects and random-effects methods to determine the risk of all-cause hospitalization and CHF-related hospitalization (primary outcomes) and all-cause mortality and device outcomes (secondary outcomes). Pooled findings indicated a 7% lower risk of all-cause hospitalization in the remote monitoring group than that in the control group (RR 0.93, 95% confidence interval [CI] 0.89 to 0.98, p = 0.004). The results also revealed a 32% lower risk of CHF-related hospitalization in the remote monitoring group than that in the control group (RR 0.68, 95% CI 0.65 to 0.71, p <0.001). No statistically significant differences were noted between the groups in terms of all-cause mortality (RR 0.97, 95% CI 0.87 to 1.07, p = 0.53) and device outcomes (RR 1.23 95% CI 0.92 to 1.65, p = 0.16). These results provided evidence regarding the comparable effectiveness of remote CHF monitoring and routine care. The current evidence is insufficient to introduce remote hemodynamic CHF monitoring; however, our results suggest that the integration of telemonitoring systems with routine medical management may improve heart failure care.

Remote Monitoring of Cardiac Implantable Electronic Devices: What is the Evidence?

PURPOSE OF REVIEW

This review offers an overview of the evidence in diagnostic and therapeutic applications of remote monitoring implantable devices.

RECENT FINDINGS

Remote monitoring of cardiac implantable devices has become more and more popular in recent years as healthcare is moving towards a more patient centralized system. For heart failure patients with an ICD or pacemaker, there is controversial evidence regarding improvements in the clinical outcome, e.g., reduction of hospitalization rates or overall mortality. New developments as hemodynamic remote monitoring via measurement of the pulmonary artery pressure are promising technical achievements showing encouraging results. In cardiac remote monitoring of syncope and arrhythmias, implantable loop recorder plays an important role in diagnostic algorithms. Although there is controversial evidence according to remote monitoring of implantable devices, its use is rapidly expanding, giving healthcare providers the opportunity to react promptly to worsening of their patients. Adequate evaluation of the data created by remote monitoring systems remains an unsolved challenge of contemporary healthcare services.

Optimal Management of Heart Failure and Chronic Obstructive Pulmonary Disease: Clinical Challenges

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are common causes of breathlessness which frequently co-exist; one potentially exacerbating the other. Distinguishing between the two can be challenging due to their similar symptomatology and overlapping risk factors, but a timely and correct diagnosis is potentially lifesaving. Modern treatment for HF can substantially improve symptoms and prognosis for many patients and may have beneficial effects for patients with COPD. Conversely, while many inhaled treatments for COPD can improve symptoms and reduce exacerbations, there is conflicting evidence regarding the safety of some inhaled treatments for COPD in patients with HF. Here we explore the overlap between HF and COPD, examine the effect of one condition on the other, and address the challenges of managing patients with both conditions.

Emerging phenotypes of pulmonary hypertension associated with COPD: a field guide

PURPOSE OF REVIEW

Pulmonary hypertension (PH) is a common complication of chronic obstructive lung disease (COPD), but clinical presentation is variable and not always 'proportional' to the severity of the obstructive disease. This review aims to analyze heterogeneity in clinical features of PH-COPD, providing a guide for diagnosis and management according to phenotypes.

RECENT FINDINGS

Recent works have focused on severe PH in COPD, providing insights into the characteristics of patients with predominantly vascular disease. The recently recognized 'pulmonary vascular phenotype', characterized by severe PH and mild airflow obstruction with severe hypoxemia, has markedly worse prognosis and may be a candidate for large trials with pulmonary vasodilators. In severe PH, which might be best described by a pulmonary vascular resistance threshold, there may also be a need to distinguish patients with mild COPD (pulmonary vascular phenotype) from those with severe COPD ('Severe COPD-Severe PH' phenotype).

SUMMARY

Correct phenotyping is key to appropriate management of PH associated with COPD. The lack of evidence regarding the use of pulmonary vasodilators in PH-COPD may be due to the existence of previously unrecognized phenotypes with different responses to therapy. This review offers the clinician caring for patients with COPD and PH a phenotype-focused approach to diagnosis and management, aimed at personalized care.

Cardiovascular disease in chronic obstructive pulmonary disease: a narrative review

Patients with chronic obstructive pulmonary disease (COPD) are at increased risk of cardiovascular disease (CVD) and concomitant disease leads to reduced quality of life, increased hospitalisations and worse survival. Acute pulmonary exacerbations are an important contributor to COPD burden and are associated with increased cardiovascular (CV) events. Both COPD and CVD represent a significant global disease impact and understanding the relationship between the two could potentially reduce this burden. The association between CVD and COPD could be a consequence of (1) shared risk factors (environmental and/or genetic) (2) shared pathophysiological pathways (3) coassociation from a high prevalence of both diseases (4) adverse effects (including pulmonary exacerbations) of COPD contributing to CVD and (5) CVD medications potentially worsening COPD and vice versa. CV risk in COPD has traditionally been associated with increasing disease severity, but there are other relevant COPD subtype associations including radiological subtypes, those with frequent pulmonary exacerbations and novel disease clusters. While the prevalence of CVD is high in COPD populations, it may be underdiagnosed, and improved risk prediction, diagnosis and treatment optimisation could lead to improved outcomes. This state-of-the-art review will explore the incidence/prevalence, COPD subtype associations, shared pathophysiology and genetics, risk prediction, and treatment of CVD in COPD.

Tailored or adapted interventions for adults with chronic obstructive pulmonary disease and at least one other long-term condition: a mixed methods review

BACKGROUND

Chronic obstructive pulmonary disease (COPD) is a chronic respiratory condition characterised by shortness of breath, cough and recurrent exacerbations. People with COPD often live with one or more co-existing long-term health conditions (comorbidities). People with more severe COPD often have a higher number of comorbidities, putting them at greater risk of morbidity and mortality.

OBJECTIVES

To assess the effectiveness of any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention for people with COPD and one or more common comorbidities (quantitative data, RCTs) in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To assess the effectiveness of an adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more common comorbidities (quantitative data, RCTs) compared to usual care in terms of the following outcomes: Quality of life, exacerbations, functional status, all-cause and respiratory-related hospital admissions, mortality, pain, and depression and anxiety. To identify emerging themes that describe the views and experiences of patients, carers and healthcare professionals when receiving or providing care to manage multimorbidities (qualitative data).

SEARCH METHODS

We searched multiple databases including the Cochrane Airways Trials Register, CENTRAL, MEDLINE, Embase, and CINAHL, to identify relevant randomised and qualitative studies. We also searched trial registries and conducted citation searches. The latest search was conducted in January 2021.

SELECTION CRITERIA

Eligible randomised controlled trials (RCTs) compared a) any single intervention for COPD adapted or tailored to their comorbidity(s) compared to any other intervention, or b) any adapted or tailored single COPD intervention (simple or complex) that is aimed at changing the management of people with COPD and one or more comorbidities, compared to usual care. We included qualitative studies or mixed-methods studies to identify themes.

DATA COLLECTION AND ANALYSIS

We used standard Cochrane methods for analysis of the RCTs. We used Cochrane's risk of bias tool for the RCTs and the CASP checklist for the qualitative studies. We planned to use the Mixed Methods Appraisal tool (MMAT) to assess the risk of bias in mixed-methods studies, but we found none. We used GRADE and CERQual to assess the quality of the quantitative and qualitative evidence respectively. The primary outcome measures for this review were quality of life and exacerbations.

MAIN RESULTS

Quantitative studies We included seven studies (1197 participants) in the quantitative analyses, with interventions including telemonitoring, pulmonary rehabilitation, treatment optimisation, water-based exercise training and case management. Interventions were either compared with usual care or with an active comparator (such as land-based exercise training). Duration of trials ranged from 4 to 52 weeks. Mean age of participants ranged from 64 to 72 years and COPD severity ranged from mild to very severe. Trials included either people with COPD and a specific comorbidity (including cardiovascular disease, metabolic syndrome, lung cancer, head or neck cancer, and musculoskeletal conditions), or with one or more comorbidities of any type. Overall, we judged the evidence presented to be of moderate to very low certainty (GRADE), mainly due to the methodological quality of included trials and imprecision of effect estimates. Intervention versus usual care Quality of life as measured by the St George's Respiratory Questionnaire (SGRQ) total score may improve with tailored pulmonary rehabilitation compared to usual care at 52 weeks (mean difference (MD) -10.85, 95% confidence interval (CI) -12.66 to -9.04; 1 study, 70 participants; low-certainty evidence). Tailored pulmonary rehabilitation is likely to improve COPD assessment test (CAT) scores compared with usual care at 52 weeks (MD -8.02, 95% CI -9.44 to -6.60; 1 study, 70 participants, moderate-certainty evidence) and with a multicomponent telehealth intervention at 52 weeks (MD -6.90, 95% CI -9.56 to -4.24; moderate-certainty evidence). Evidence is uncertain about effects of pharmacotherapy optimisation or telemonitoring interventions on CAT improvement compared with usual care. There may be little to no difference in the number of people experiencing exacerbations, or mean exacerbations with case management compared with usual care (OR 1.09, 95% CI 0.75 to 1.57; 1 study, 470 participants; very low-certainty evidence). For secondary outcomes, six-minute walk distance (6MWD) may improve with pulmonary rehabilitation, water-based exercise or multicomponent interventions at 38 to 52 weeks (low-certainty evidence). A multicomponent intervention may result in fewer people being admitted to hospital at 17 weeks, although there may be little to no difference in a telemonitoring intervention. There may be little to no difference between intervention and usual care for mortality. Intervention versus active comparator We included one study comparing water-based and land-based exercise (30 participants). We found no evidence for quality of life or exacerbations. There may be little to no difference between water- and land-based exercise for 6MWD (MD 5 metres, 95% CI -22 to 32; 38 participants; very low-certainty evidence). Qualitative studies One nested qualitative study (21 participants) explored perceptions and experiences of people with COPD and long-term conditions, and of researchers and health professionals who were involved in an RCT of telemonitoring equipment. Several themes were identified, including health status, beliefs and concerns, reliability of equipment, self-efficacy, perceived ease of use, factors affecting usefulness and perceived usefulness, attitudes and intention, self-management and changes in healthcare use. We judged the qualitative evidence presented as of very low certainty overall.

AUTHORS' CONCLUSIONS

Owing to a paucity of eligible trials, as well as diversity in the intervention type, comorbidities and the outcome measures reported, we were unable to provide a robust synthesis of data. Pulmonary rehabilitation or multicomponent interventions may improve quality of life and functional status (6MWD), but the evidence is too limited to draw a robust conclusion. The key take-home message from this review is the lack of data from RCTs on treatments for people living with COPD and comorbidities. Given the variation in number and type of comorbidity(s) an individual may have, and severity of COPD, larger studies reporting individual patient data are required to determine these effects.

The Challenge to Decide between Pulmonary Hypertension Due to Chronic Lung Disease and PAH with Chronic Lung Disease

Chronic lung diseases are strongly associated with pulmonary hypertension (PH), and even mildly elevated pulmonary arterial pressures are associated with increased mortality. Chronic obstructive pulmonary disease (COPD) is the most common chronic lung disease, but few of these patients develop severe PH. Not all these pulmonary pressure elevations are due to COPD, although patients with severe PH due to COPD may represent the largest subgroup within patients with COPD and severe PH. There are also patients with left heart disease (group 2), chronic thromboembolic disease (group 4, CTEPH) and pulmonary arterial hypertension (group 1, PAH) who suffer from COPD or another chronic lung disease as co-morbidity. Because therapeutic consequences very much depend on the cause of pulmonary hypertension, it is important to complete the diagnostic procedures and to decide on the main cause of PH before any decision on PAH drugs is made. The World Symposia on Pulmonary Hypertension (WSPH) have provided guidance for these important decisions. Group 2 PH or complex developmental diseases with elevated postcapillary pressures are relatively easy to identify by means of elevated pulmonary arterial wedge pressures. Group 4 PH can be identified or excluded by perfusion lung scans in combination with chest CT. Group 1 PAH and Group 3 PH, although having quite different disease profiles, may be difficult to discern sometimes. The sixth WSPH suggests that severe pulmonary hypertension in combination with mild impairment in the pulmonary function test (FEV1 > 60 and FVC > 60%), mild parenchymal abnormalities in the high-resolution CT of the chest, and circulatory limitation in the cardiopulmonary exercise test speak in favor of Group 1 PAH. These patients are candidates for PAH therapy. If the patient suffers from group 3 PH, the only possible indication for PAH therapy is severe pulmonary hypertension (mPAP ≥ 35 mmHg or mPAP between 25 and 35 mmHg together with very low cardiac index (CI) < 2.0 L/min/m²), which can only be derived invasively. Right heart catheter investigation has been established nearly 100 years ago, but there are many important details to consider when reading pulmonary pressures in spontaneously breathing patients with severe lung disease. It is important that such diagnostic procedures and the therapeutic decisions are made in expert centers for both pulmonary hypertension and chronic lung disease.

Wireless Hemodynamic Monitoring in Patients with Heart Failure

Purpose of Review

Wireless hemodynamic monitoring in heart failure patients allows for volume assessment without the need for physical exam. Data obtained from these devices is used to assist patient management and avoid heart failure hospitalizations. In this review, we outline the various devices, mechanisms they utilize, and effects on heart failure patients.

Recent Findings

New applications of these devices to specific populations may expand the pool of patients that may benefit. In the COVID-19 pandemic with a growing emphasis on virtual visits, remote monitoring can add vital ancillary data.

Summary

Wireless hemodynamic monitoring with a pulmonary artery pressure sensor is a highly effective and safe method to assess for worsening intracardiac pressures that may predict heart failure events, giving lead time that is valuable to keep patients optimized. Implantation of this device has been found to improve outcomes in heart failure patients regardless of preserved or reduced ejection fraction.

The impact of chronic obstructive pulmonary disease on hospitalization and mortality in patients with heart failure

BACKGROUND

Several studies have suggested that chronic obstructive pulmonary disease (COPD) could be predictive of the prognosis in patients with heart failure (HF), but yield conflicting findings. Therefore, we conducted a meta-analysis to examine the impact of COPD on adverse outcomes in patients with HF.

METHODS

We systematically searched the databases of PubMed, EMBASE, Google Scholar, Cochrane library from inception to August 2020 for the relevant studies. Adjusted risk ratios (RRs) and confidence intervals (CIs) were collected and then pooled by the Review Manager version 5.30 software with a random-effects model.

RESULTS

A total of 18 studies (6 post hoc analyses of trials and 12 observational studies) were included in this meta-analysis. COPD was associated with an increased risk of all-cause mortality (hospitalized HF: RR 1.43, 95% CI: 1.20-1.70; chronic HF: RR 1.24, 95% CI: 1.16-1.33), but not cardiovascular mortality, in patients with hospitalized HF or chronic HF. In addition, COPD was associated with increased risks of all-cause hospitalization (RR 1.31, 95% CI: 1.21-1.42) and HF hospitalization (RR 1.31, 95% CI: 1.21-1.42) in the chronic HF patients.

CONCLUSIONS

COPD comorbidity could increase the risk of all-cause mortality of HF patients. Future research should confirm the findings on hospitalization because of the limited studies included for this outcome.

Lower Rates of Heart Failure and All-Cause Hospitalizations During Pulmonary Artery Pressure-Guided Therapy for Ambulatory Heart Failure: One-Year Outcomes From the CardioMEMS Post-Approval Study

Supplemental Digital Content is available in the text.

Ambulatory hemodynamic monitoring with an implantable pulmonary artery (PA) sensor is approved for patients with New York Heart Association Class III heart failure (HF) and a prior HF hospitalization (HFH) within 12 months. The objective of this study was to assess the efficacy and safety of PA pressure-guided therapy in routine clinical practice with special focus on subgroups defined by sex, race, and ejection fraction.

Acute heart failure

Acute heart failure (AHF) is a syndrome defined as the new onset (de novo heart failure (HF)) or worsening (acutely decompensated heart failure (ADHF)) of symptoms and signs of HF, mostly related to systemic congestion. In the presence of an underlying structural or functional cardiac dysfunction (whether chronic in ADHF or undiagnosed in de novo HF), one or more precipitating factors can induce AHF, although sometimes de novo HF can result directly from the onset of a new cardiac dysfunction, most frequently an acute coronary syndrome. Despite leading to similar clinical presentations, the underlying cardiac disease and precipitating factors may vary greatly and, therefore, the pathophysiology of AHF is highly heterogeneous. Left ventricular diastolic or systolic dysfunction results in increased preload and afterload, which in turn lead to pulmonary congestion. Fluid retention and redistribution result in systemic congestion, eventually causing organ dysfunction due to hypoperfusion. Current treatment of AHF is mostly symptomatic, centred on decongestive drugs, at best tailored according to the initial haemodynamic status with little regard to the underlying pathophysiological particularities. As a consequence, AHF is still associated with high mortality and hospital readmission rates. There is an unmet need for increased individualization of in-hospital management, including treatments targeting the causative factors, and continuation of treatment after hospital discharge to improve long-term outcomes.

Pulmonary hypertension in chronic obstructive pulmonary disease

Even mild pulmonary hypertension (PH) is associated with increased mortality and morbidity in patients with chronic obstructive pulmonary disease (COPD). However, the underlying mechanisms remain elusive; therefore, specific and efficient treatment options are not available. Therapeutic approaches tested in the clinical setting, including long-term oxygen administration and systemic vasodilators, gave disappointing results and might be only beneficial for specific subgroups of patients. Preclinical studies identified several therapeutic approaches for the treatment of PH in COPD. Further research should provide deeper insight into the complex pathophysiological mechanisms driving vascular alterations in COPD, especially as such vascular (molecular) alterations have been previously suggested to affect COPD development. This review summarizes the current understanding of the pathophysiology of PH in COPD and gives an overview of the available treatment options and recent advances in preclinical studies. LINKED ARTICLES: This article is part of a themed issue on Risk factors, comorbidities, and comedications in cardioprotection. To view the other articles in this section visit http://onlinelibrary.wiley.com/doi/10.1111/bph.v178.1/issuetoc.

Chronic Obstructive Pulmonary Disease and Heart Failure: A Breathless Conspiracy

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are both common causes of breathlessness and often conspire to confound accurate diagnosis and optimal therapy. Risk factors (such as aging, smoking, and obesity) and clinical presentation (eg, cough and breathlessness on exertion) can be very similar, but the treatment and prognostic implications are very different. This review discusses the diagnostic challenges in individuals with exertional dyspnea. Also highlighted are the prevalence, clinical relevance, and therapeutic implications of a concurrent diagnosis of COPD and HF.

Pulmonary and cardiac drugs: clinically relevant interactions

Chronic heart and lung diseases are very common in the elderly population. The combination of chronic heart failure and chronic obstructive pulmonary disease (COPD) is also common and, according to current guidelines, these patients should be treated for both diseases. In patients with heart failure, beta-blockers are very important drugs because their use is associated with significantly improved morbidity and mortality. These beneficial effects were documented in patients with and without COPD, although theoretically there is a risk for bronchoconstriction, particularly with non-beta1 selective blockers. In COPD patients, long-acting sympathomimetics (LABA) improve lung function, dyspnea, and quality of life and their combination with a beta-blocker makes sense from a pharmacological and a clinical point of view, because any potential arrhythmogenic effects of the LABA will be ameliorated by the beta-blocker. Inhaled tiotropium, a long-acting muscarinic antagonist (LAMA), has been extensively investigated and no safety concerns were reported in terms of cardiac adverse effects. The same applies for the other approved LAMA preparations and LAMA-LABA combinations. Severe COPD causes air-trapping with increasing pressures in the thorax, leading to limitations in blood return into the thorax from the periphery of the body. This causes a decrease in stroke volume and cardiac index and is associated with dyspnea. All these adverse effects can be ameliorated by potent anti-obstructive therapy as recently shown by means of a LABA-LAMA combination.

Chronic heart failure management and remote haemodynamic monitoring

Heart failure (HF) has a large societal and economic burden and is expected to increase in magnitude and complexity over the ensuing years. A number of telemonitoring strategies exploring remote monitoring and management of clinical signs and symptoms of congestion in HF have had equivocal results. Early studies of remote haemodynamic monitoring showed promise, but issues with device integrity and implantation-associated adverse events hindered progress. Nonetheless, these early studies established that haemodynamic congestion precedes clinical congestion by several weeks and that remote monitoring of intracardiac pressures may be a viable and practical management strategy. Recently, the safety and efficacy of remote pulmonary artery pressure-guided HF management was established in a prospective, single-blind trial where randomisation to active pressure-guided HF management reduced future HF hospitalisations. Subsequent commercial use studies reinforced the utility of this technology and post hoc analyses suggest that tight haemodynamic management of patients with HF may be an additional pillar of therapy alongside established guideline-directed medical and device therapy. Currently, there is active exploration into utilisation of this technology and management paradigm for the timing of implantation of durable left ventricular assist devices (LVAD) and even optimisation of LVAD therapy. Several ongoing clinical trials will help clarify the extent and utility of this strategy along the spectrum of patient with HF from individuals with chronic, stable HF to those with more advanced disease requiring heart replacement therapy.

The impact of heart failure and chronic obstructive pulmonary disease on mortality in patients presenting with breathlessness

BACKGROUND

Differentiating heart failure from chronic obstructive pulmonary disease (COPD) in a patient presenting with breathlessness is difficult but may have implications for outcome. We investigated the prognostic impact of diagnoses of COPD and/or heart failure in consecutive patients presenting to a secondary care clinic with breathlessness.

METHODS

In patients with left ventricular systolic dysfunction (LVSD) by visual estimation, N-terminal pro B-type natriuretic peptide (NTproBNP) levels and spirometry were evaluated (N = 4986). Heart failure was defined as either LVSD worse than mild (heart failure with reduced ejection fraction) or LVSD mild or better and raised NTproBNP levels (> 400 ng/L) (heart failure with normal ejection fraction). COPD was defined as forced expiratory volume in 1 s (FEV₁) to forced vital capacity (FVC) ratio < 0.7. The primary outcome was all-cause mortality.

RESULTS

1764 (35%) patients had heart failure alone, 585 (12%) had COPD alone, 1751 (35%) had heart failure and COPD, and 886 (18%) had neither. Compared to patients with neither diagnosis, those with COPD alone [hazard ratio (HR) = 1.84 95% confidence interval (CI) 1.40-2.43], heart failure alone [HR = 4.40 (95% CI 3.54-5.46)] or heart failure and COPD [HR = 5.44 (95% CI 4.39-6.75)] had a greater risk of death. COPD was not associated with increased risk of death in patients with heart failure on a multivariable analysis.

CONCLUSION

While COPD is associated with increased risk of death compared to patients with neither heart failure nor COPD, it has a negligible impact on prognosis amongst patients with heart failure.

The importance of left heart disease as a cause of pulmonary hypertension in COPD

Chronic obstructive pulmonary disease (COPD) is a common respiratory condition that presents with varying degrees of severity and can be complicated by further comorbidities. Up to a third can also have pulmonary hypertension, which is an important risk factor associated with an increase in morbidity and mortality. The etiology of pulmonary hypertension contributes to diagnosis. Considering and identifying the type of pulmonary hypertension at the right time will influence management and outcome in patients with COPD.

Reducing Readmissions in Patients With Both Heart Failure and COPD

Patients with both COPD and heart failure (HF) pose particularly high costs to the health-care system. These diseases arise from similar root causes, have overlapping symptoms, and share similar clinical courses. Because of these strong parallels, strategies to reduce readmissions in patients with both conditions share synergies. Here we present 10 practical tips to reduce readmissions in this challenging population: (1) diagnose the population accurately, (2) detect admissions for exacerbations early and consider risk stratification, (3) use specialist management in hospital, (4) modify the underlying disease substrate, (5) apply and intensify evidence-based therapies, (6) activate the patient and develop critical health behaviors, (7) setup feedback loops, (8) arrange an early follow-up appointment prior to discharge, (9) consider and address other comorbidities, and (10) consider ancillary support services at home. The multidisciplinary care teams needed to support these care models pose expense to the health-care system. Although these costs may more easily be recouped under financial models such as accountable care organizations and bundled payments, the opportunity cost of an admission for COPD or HF may represent an underrecognized financial lever.

The prognostic significance of lung function in stable heart failure outpatients

BACKGROUND

This study investigated the impact on all-cause mortality of airflow limitation indicative of chronic obstructive pulmonary disease or restrictive spirometry pattern (RSP) in a stable systolic heart failure population.

HYPOTHESIS

Decreased lung function indicates poor survival in heart failure.

METHODS

Inclusion criteria: NYHA class II-IV and left ventricular ejection fraction (LVEF) < 45%. Prognosis was assessed with multivariate Cox proportional hazards models. Two criteria of obstructive airflow limitation were applied: FEV₁ /FVC < 0.7 (GOLD), and FEV₁ /FVC < lower limit of normality (LLN). RSP was defined as FEV₁ /FVC > 0.7 and FVC<80% or FEV₁ /FVC > LLN and FVC <LLN.

RESULTS

There where 573 patients in the cohort (85% of eligible patients in study period). Median follow-up was 4.7 years and 176 patients died (31%). Age, NYHA class, smoking, body mass index and LVEF were independent prognostic factors (p<0.01). Obstructive airflow limitation increased mortality using both criteria (HR_GOLD 2.07 [95% CI 1.45-2.95] p<0.01 and HR_LLN 2.00 [1.40-2.84] p<0.01) and was an independent marker when using LLN criteria (HR 1.74 [1.17-2.59] p=0.006). RSP was independently associated with mortality when defined as FVC < LLN (HR 1.54 [1.01-2.35] p=0.04) but not as FVC < 80%. Multivariate hazard ratios for a 10% decrease in predicted value of FEV1 or FVC were 1.42 (p<0.001) and 1.33 (p<0.001) in patients exhibiting airflow obstruction, and 1.36 (p=0.031) and 1.38 (p=0.041) in RSP.

CONCLUSIONS

Presence of obstructive airflow limitation indicative of COPD or RSP were associated with increased all-cause mortality, however only independently when using the LLN definition.

Implantable Hemodynamic Monitoring for Heart Failure Patients

Rates of heart failure hospitalization remain unacceptably high. Such hospitalizations are associated with substantial patient, caregiver, and economic costs. Randomized controlled trials of noninvasive telemedical systems have failed to demonstrate reduced rates of hospitalization. The failure of these technologies may be due to the limitations of the signals measured. Intracardiac and pulmonary artery pressure-guided management has become a focus of hospitalization reduction in heart failure. Early studies using implantable hemodynamic monitors demonstrated the potential of pressure-based heart failure management, whereas subsequent studies confirmed the clinical utility of this approach. One large pivotal trial proved the safety and efficacy of pulmonary artery pressure-guided heart failure management, showing a marked reduction in heart failure hospitalizations in patients randomized to active pressure-guided management. "Next-generation" implantable hemodynamic monitors are in development, and novel approaches for the use of this data promise to expand the use of pressure-guided heart failure management.

Pulmonary artery pressure-guided heart failure management: US cost-effectiveness analyses using the results of the CHAMPION clinical trial

AIMS

Haemodynamic-guided heart failure (HF) management effectively reduces decompensation events and need for hospitalizations. The economic benefit of clinical improvement requires further study.

METHODS AND RESULTS

An estimate of the cost-effectiveness of haemodynamic-guided HF management was made based on observations published in the randomized, prospective single-blinded CHAMPION trial. A comprehensive analysis was performed including healthcare utilization event rates, survival, and quality of life demonstrated in the randomized portion of the trial (18 months). Markov modelling with Monte Carlo simulation was used to approximate comprehensive costs and quality-adjusted life years (QALYs) from a payer perspective. Unit costs were estimated using the Truven Health MarketScan database from April 2008 to March 2013. Over a 5-year horizon, patients in the Treatment group had average QALYs of 2.56 with a total cost of US$56 974; patients in the Control group had QALYs of 2.16 with a total cost of US$52 149. The incremental cost-effectiveness ratio (ICER) was US$12 262 per QALY. Using comprehensive cost modelling, including all anticipated costs of HF and non-HF hospitalizations, physician visits, prescription drugs, long-term care, and outpatient hospital visits over 5 years, the Treatment group had a total cost of US$212 004 and the Control group had a total cost of US$200 360. The ICER was US$29 593 per QALY.

CONCLUSIONS

Standard economic modelling suggests that pulmonary artery pressure-guided management of HF using the CardioMEMS™ HF System is cost-effective from the US-payer perspective. This analysis provides the background for further modelling in specific country healthcare systems and cost structures.

Impact of Practice-Based Management of Pulmonary Artery Pressures in 2000 Patients Implanted With the CardioMEMS Sensor

Background:

Elevated pulmonary artery (PA) pressures in patients with heart failure are associated with a high risk for hospitalization and mortality. Recent clinical trial evidence demonstrated a direct relationship between lowering remotely monitored PA pressures and heart failure hospitalization risk reduction with a novel implantable PA pressure monitoring system (CardioMEMS HF System, St. Jude Medical). This study examines PA pressure changes in the first 2000 US patients implanted in general practice use.

Methods:

Deidentified data from the remote monitoring Merlin.net (St. Jude Medical) database were used to examine PA pressure trends from the first consecutive 2000 patients with at least 6 months of follow-up. Changes in PA pressures were evaluated with an area under the curve methodology to estimate the total sum increase or decrease in pressures (mm Hg-day) during the follow-up period relative to the baseline pressure. As a reference, the PA pressure trends were compared with the historic CHAMPION clinical trial (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in New York Heart Association [NYHA] Functional Class III Heart Failure Patients). The area under the curve results are presented as mean±2 SE, and P values comparing the area under the curve of the general-use cohort with outcomes in the CHAMPION trial were computed by the t test with equal variance.

Results:

Patients were on average 70±12 years old; 60% were male; 34% had preserved ejection fraction; and patients were followed up for an average of 333±125 days. At implantation, the mean PA pressure for the general-use patients was 34.9±10.2 mm Hg compared with 31.3±10.9 mm Hg for CHAMPION treatment and 32.0±10.5 mm Hg for CHAMPION control groups. The general-use patients had an area under the curve of −32.8 mm Hg-day at the 1-month time mark, −156.2 mm Hg-day at the 3-month time mark, and −434.0 mm Hg-day after 6 months of hemodynamic guided care, which was significantly lower than the treatment group in the CHAMPION trial. Patients consistently transmitted pressure information with a median of 1.27 days between transmissions after 6 months.

Conclusions:

The first 2000 general-use patients managed with hemodynamic-guided heart failure care had higher PA pressures at baseline and experienced greater reduction in PA pressure over time compared with the pivotal CHAMPION clinical trial. These data demonstrate that general use of implantable hemodynamic technology in a nontrial setting leads to significant lowering of PA pressures.

Challenges of Treating Acute Heart Failure in Patients with Chronic Obstructive Pulmonary Disease

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) comorbidity poses substantial diagnostic and therapeutic challenges in acute care settings. The specific role of pulmonary comorbidity in the treatment and outcomes of cardiovascular disease patients was not addressed in any short- or long-term prospective study. Both HF and COPD can be interpreted as systemic disorders associated with low-grade inflammation, endothelial dysfunction, vascular remodelling and skeletal muscle atrophy. HF is regularly treated as a broader cardiopulmonary syndrome utilising acute respiratory therapy. Based on observational data and clinical expertise, a management strategy of concurrent HF and COPD in acute settings is suggested. Concomitant use of beta2-agonists and beta-blockers in a comorbid cardiopulmonary condition seems to be safe and effective.

Remote heart function monitoring: role of the CardioMEMS HF System

Heart failure is a pandemic condition that is challenging cardiology today. The primary economical and social burden of this syndrome is hospitalization rate whose costs represent the highest ones within the entire healthcare management. Remote monitoring of physiological data, obtained through self-reporting via telephone calls or, automatically, using external devices is a potential novel approach to implement management of patients with heart failure and reduce hospitalization rates. Relatively large but, sometimes, contradicting information exists about the efficacy of remote monitoring via different noninvasive approaches to reduce the economical and social burden of heart failure management. This leaves still partly unaddressed this critical issue and generates the need for new approaches. In this context, the CardioMEMS device that can chronically monitor pulmonary pressures from a small microchip inserted transvenously in the pulmonary artery seems to represent an innovative tool to challenge hospitalization rates. Consecutive analyses from the CHAMPION study had indeed documented the efficacy of the CardioMEMS in the remote monitoring of the pulmonary circulation status of patients with heart failure and in providing adequate information to optimally manage such patients with the final result of a significant hospitalization rate reduction. The striking information here is that this appears to be true in patients with preserved left ventricular ejection fraction also. Overall, the reports from the CHAMPION study encourage the use of CardioMEMS but larger populations are needed to definitively prove its value.

The Rise of Digital Health and Potential Implications for Pharmacy Practice

The rise of technology in healthcare has led to dramatic changes in approaches to patient care by healthcare professionals. The realm of digital health has created new opportunities for pharmacists to engage patients in clinical practice. Pharmacies and industry are increasingly integrating these innovations into their businesses and practice. This article highlights areas of digital health for pharmacists to be aware of, in particular regarding areas of medication adherence and disease management. Technology plays a massive role in our individual lives; it has morphed the human experience in ways that were simply unimaginable 50 years ago. We use technology in nearly every facet of our lives. From detecting an appropriate intensity with which to brush our teeth to counting calories lost through the course of a day, technology has made a major impact on individual health. The integration of technology into our everyday lives has changed the way we communicate, how we capture and share our lives with others, how we seek answers, and how we experience life overall. Given this change in the way people operate, it is important that pharmacists adapt to these trends and incorporate technology into daily practice. The incorporation of mobile devices and technology into healthcare has been coined as mobile health (mHealth), which falls under the broader spectrum of digital health.1 –4 Digital health focuses on the integration of mobile tools (e.g., smartphones), wearable devices, and telehealth to help personalize the treatment of patients through the widespread adoption of wireless technology. The idea of involving pharmacists in mHealth has been a topic of recent interest, due in large part to the potential ramifications for the profession.4 Today, patients are using the Internet to research their health questions and help guide their personal health choices, and some of the information they find can be misleading and unreliable. It is of the utmost importance that healthcare professionals ensure there are credible sources for patients to research their questions. As pharmacists, we can research and recommend tools to patients to help solve problems related to drug information, medication adherence, and access, which includes the recent rise of novel technological devices. All of our patients will have different comfort levels with technology; despite this spectrum, there is a place for everyone to feel comfortable using digital health tools. However, there are recent technological advances coming to the field, which are already providing a benefit to patients, ranging from mobile applications to wearable technologies to ingestible medications that notify providers of patient medication adherence. We seek to help pharmacists understand the different areas of digital health, which may have substantial influence on the realm of pharmacy practice in the years to come by addressing current and upcoming digital health developments.

Telemedical Care and Monitoring for Patients with Chronic Heart Failure Has a Positive Effect on Survival

BACKGROUND

Telemedical care and monitoring programs for patients with chronic heart failure have shown beneficial effects on survival in several small studies. The utility in routine care remains unclear.

METHODS

We evaluated a large-sized telemedicine program in a routine care setting, enrolling in total 2,622 patients (54.7 percent male, mean age: 73.7 years) with chronic heart failure. We used reimbursement data from a large statutory health insurance and approached a matched control analysis. In a complex propensity score matching procedure, 3,719 suitable controls (54.2 percent male, mean age: 74.5 years) were matched to 1,943 intervention patients (54.1 percent male, mean age: 74.4 years). The primary endpoint of our analysis was survival after 1 year.

RESULTS

Analyses revealed a higher survival probability among subjects of the intervention group compared to controls group after 1 year (adjusted OR: 1.47, CI 95 percent: 1.21-1.80, p < .001) and 2 years (adjusted OR: 1.51, CI 95 percent: 1.28-1.77, p < .001), respectively.

CONCLUSIONS

The probabilities to survive after 1 and 2 years were significantly increased in the intervention group. Our findings confirm previous results of controlled trials and importantly indicate that patients with chronic heart failure may benefit from telemonitoring programs in routine care.

Hemodynamic-guided heart-failure management using a wireless implantable sensor: Infrastructure, methods, and results in a community heart failure disease-management program

BACKGROUND

The real-world impact of remote pulmonary artery pressure (PAP) monitoring on New York Heart Association (NYHA) class improvement and heart failure (HF) hospitalization rate is presented here from a single center.

HYPOTHESIS

METHODS: Seventy-seven previously hospitalized outpatients with NYHA class III HF were offered PAP monitoring via device implantation in a multidisciplinary HF-management program. Prospective effectiveness analyses compared outcomes in 34 hemodynamically monitored patients to a group of similar patients (n = 32) who did not undergo device implantation but received usual care. NYHA class and 6-minute walk testing were assessed at baseline and 90 days. All hospitalizations were collected after 6 months of the implantation date (average follow-up, 15 months) and compared with the number of hospitalizations experienced prior to hemodynamic monitoring.

RESULTS

Patients in both groups had similar distributions of age, sex, and ejection fraction. After 90 days, 61.8% of the monitored patients had NYHA class improvement of ≥1, compared with 12.5% in the controls (P < 0.001). Distance walked in 6 minutes increased by 54.5 meters in the monitored group (253.0 ± 25.6 meters to 307.4 ± 26.3 meters; P < 0.005), whereas no change was seen in the usual-care group. After implantation, 19.4% of the monitored group had ≥1 HF hospitalization, compared with 100% who had been hospitalized in the year prior to implantation. The monitored group had a significantly lower HF hospitalization rate (0.16; 95% confidence interval: 0.06-0.35 hospitalizations/patient-year) compared with the year prior (1.0 hospitalizations/patient-year; P < 0.001).

CONCLUSIONS

Hemodynamic-guided HF management leads to significant improvements in NYHA class and HF hospitalization rate in a real-world setting compared with usual care delivered in a comprehensive disease-management program.

The use of micro-electro mechanical systems in vascular monitoring: implications for clinical use

INTRODUCTION

BioMEMS relates to the implementation of Micro-Electro-Mechanical Systems (MEMS), in the biological and medical sphere. BioMEMS sensors are being utilized for many clinical applications, including a wireless urinary pressure system, right heart pressure sensor, and measurements on shearing force on the vascular system An important application of BioMEMS is on Heart failure (HF), a common disease, with a prevalence of 10% or more in persons 70 years of age or older, associated with high morbidity and mortality. HF affects over 5 million people and contributes to over 200,000 deaths a year in the United States alone.

AREAS COVERED

The purpose of this paper is to provide a short overview on the successful implementation of BioMEMS sensors in heart failure and vascular medicine. Expert commentary: BioMEMS devices have overcome current limitations in pharmacotherapies for resistant hypertension by electrical modulation of the baroreceeptors. This represents a step towards the development of biomedical micro-devices for those conditions in which pharmacotherapies result poorly effective or elicit unacceptable toxicity.

Acute decompensated heart failure (ADHF): A comprehensive contemporary review on preventing early readmissions and postdischarge death

Heart failure (HF) is an increasingly prevalent syndrome and a leading cause of both first hospitalization and readmissions. Strikingly, up to 25% of the patients are readmitted within 30 to 60-days, accounting for HF as the primary cause for readmission in the adult population. Given its poor prognosis, one could describe it as a "malignant condition". Acute decompensation is intrinsically related to increased right heart tele-diastolic pressures and often related to congestive symptoms. In-hospital strategies to adequately compensate and timely discharge patients are limited. Conversely, the fragile early postdischarge phase is a vulnerable period when one could potentially intervene cost-effectively to improve survival and to reduce morbidity. Promising transitional hospital-to-home programs may have a broader role in the near future, namely for selected higher risk patients. However, identifying patients at risk for hospital readmission has been challenging. Novel approaches, such as ferric carboxymaltose and valsartan/sacubitril, and reemerging drugs, particularly digoxin, may reduce hospitalizations. Despite this, optimizing the use of "older" therapies is still warranted. Right heart pressures monitoring may provide novel insights into promptly outpatient management. Unfortunately, randomized trials in the specific ADHF population are scarce. A novel paradigmatic approach is needed in order to suitably improve the currently poor prognosis of ADHF. Both improving survival and reducing hospitalizations are, therefore, primordial therapy goals. Lastly, no single drug has consistently proved to improve survival in HF with preserved ejection fraction (HFpEF); yet, some approaches may efficiently reduce hospitalizations. Awareness on HFpEF management beyond the failing heart is imperative.

Role of Monitoring Devices in Preventing Heart Failure Admissions

This review aims to discuss and summarize the evidence base for devices that have a role in monitoring patients with heart failure for the purpose of attempting to prevent heart failure-related admissions. Despite contemporary heart failure service provision, many patients continue to need acute admission for decompensation. There is a clinical need for a better strategy for predicting decompensation earlier so that appropriate therapeutic interventions can be commenced sooner in order to prevent the need for acute hospital admission. Between clinical assessment visits, the contemporary approach to management is based primarily on daily home monitoring of weight by patients; while this has proved useful, it falls short. For example, substantial weight gain was seen in only 20% of ADHF admission patients according to data collected in the TEN-HMS home telemonitoring study. Monitoring devices offer the possibility of tracking additional physiological or haemodynamic parameters that may allow for earlier detection and more accurate identification of patients at risk of acute decompensation.

Interventions Linked to Decreased Heart Failure Hospitalizations During Ambulatory Pulmonary Artery Pressure Monitoring

OBJECTIVES

This study sought to analyze medical therapy data from the CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in Class III Heart Failure) trial to determine which interventions were linked to decreases in heart failure (HF) hospitalizations during ambulatory pulmonary artery (PA) pressure-guided management.

BACKGROUND

Elevated cardiac filling pressures, which increase the risk of hospitalizations and mortality, can be detected using an ambulatory PA pressure monitoring system before onset of symptomatic congestion allowing earlier intervention to prevent HF hospitalizations.

METHODS

The CHAMPION trial was a randomized, controlled, single-blind study of 550 patients with New York Heart Association functional class III HF with a HF hospitalization in the prior year. All patients undergoing implantation of the ambulatory PA pressure monitoring system were randomized to the active monitoring group (PA pressure-guided HF management plus standard of care) or to the blind therapy group (HF management by standard clinical assessment), and followed for a minimum of 6 months. Medical therapy data were compared between groups to understand what interventions produced the significant reduction in HF hospitalizations in the active monitoring group.

RESULTS

Both groups had similar baseline medical therapy. After 6 months, the active monitoring group experienced a higher frequency of medications adjustments; significant increases in the doses of diuretics, vasodilators, and neurohormonal antagonists; targeted intensification of diuretics and vasodilators in patients with higher PA pressures; and preservation of renal function despite diuretic intensification.

CONCLUSIONS

Incorporation of a PA pressure-guided treatment algorithm to decrease filling pressures led to targeted changes, particularly in diuretics and vasodilators, and was more effective in reducing HF hospitalizations than management of patient clinical signs or symptoms alone.

Sustained efficacy of pulmonary artery pressure to guide adjustment of chronic heart failure therapy: complete follow-up results from the CHAMPION randomised trial

BACKGROUND

In the CHAMPION trial, significant reductions in admissions to hospital for heart failure were seen after 6 months of pulmonary artery pressure guided management compared with usual care. We examine the extended efficacy of this strategy over 18 months of randomised follow-up and the clinical effect of open access to pressure information for an additional 13 months in patients formerly in the control group.

METHODS

The CHAMPION trial was a prospective, parallel, single-blinded, multicentre study that enrolled participants with New York Heart Association (NYHA) Class III heart failure symptoms and a previous admission to hospital. Patients were randomly assigned (1:1) by centre in block sizes of four by a secure validated computerised randomisation system to either the treatment group, in which daily uploaded pulmonary artery pressures were used to guide medical therapy, or to the control group, in which daily uploaded pressures were not made available to investigators. Patients in the control group received all standard medical, device, and disease management strategies available. Patients then remained masked in their randomised study group until the last patient enrolled completed at least 6 months of study follow-up (randomised access period) for an average of 18 months. During the randomised access period, patients in the treatment group were managed with pulmonary artery pressure and patients in the control group had usual care only. At the conclusion of randomised access, investigators had access to pulmonary artery pressure for all patients (open access period) averaging 13 months of follow-up. The primary outcome was the rate of hospital admissions between the treatment group and control group in both the randomised access and open access periods. Analyses were by intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00531661.

FINDINGS

Between Sept 6, 2007, and Oct 7, 2009, 550 patients were randomly assigned to either the treatment group (n=270) or to the control group (n=280). 347 patients (177 in the former treatment group and 170 in the former control group) completed the randomised access period in August, 2010, and transitioned to the open access period which ended April 30, 2012. Over the randomised access period, rates of admissions to hospital for heart failure were reduced in the treatment group by 33% (hazard ratio [HR] 0·67 [95% CI 0·55-0·80]; p<0·0001) compared with the control group. After pulmonary artery pressure information became available to guide therapy during open access (mean 13 months), rates of admissions to hospital for heart failure in the former control group were reduced by 48% (HR 0·52 [95% CI 0·40-0·69]; p<0·0001) compared with rates of admissions in the control group during randomised access. Eight (1%) device-related or system related complications and seven (1%) procedure-related adverse events were reported.

INTERPRETATION

Management of NYHA Class III heart failure based on home transmission of pulmonary artery pressure with an implanted pressure sensor has significant long-term benefit in lowering hospital admission rates for heart failure.

FUNDING

St Jude Medical Inc.