In-Hospital Management and Long-term Clinical Outcomes and Adherence in Patients With Acute Decompensated Heart Failure: Primary Results of the First Brazilian Registry of Heart Failure (BREATHE)

Cost-Effectiveness of Mineralocorticoid Receptor Antagonists in Ischemic and Nonischemic Heart Failure With Reduced Ejection Fraction: Perspective From a Universal Healthcare System

OBJECTIVES

Mineralocorticoid receptor antagonists (MRAs) are cornerstones in the management of heart failure (HF) with reduced ejection fraction (HFrEF). New MRAs with improved safety profile, such as finerenone and eplerenone, were recently introduced. However, because of typical budget restrictions in middle-income countries, evaluating their cost-effectiveness is essential for optimizing treatment strategies.

METHODS

We used a Bayesian network and Markov influence diagrams to estimate the incremental cost-effectiveness ratios (ICERs) in international dollars (Int$) per quality-adjusted life-year (QALY). Our model was fed by a systematic review and a network meta-analysis to compare MRAs effectiveness and used data from a cohort of 1066 Brazilian individuals with HFrEF (36% with ischemic and 64% with nonischemic disease).

RESULTS

Over a 10-year time horizon, the treatment with spironolactone, eplerenone, and finerenone compared with no MRA utilization yielded discounted QALY per person of 0.072, 0.111, and 0.034, respectively. The ICERs were Int$7955, Int$6460, and Int$109 840 per QALY gained, respectively. Compared with spironolactone, eplerenone showed an ICER of Int$6178 per QALY gained. Assuming a willingness-to-pay threshold of 1 Brazilian per capita gross domestic product (Int$17 589) per QALY gained, the probabilistic sensitivity analyses suggest that spironolactone and eplerenone were cost-effective, respectively, in 87% and 92% of iterations. The 95% CIs were Int$2282 to Int$13 149 for spironolactone and Int$1795 to Int$12 351 for eplerenone per QALY gained. These findings were consistent across several scenarios including ischemic/nonischemic HF.

CONCLUSIONS

Eplerenone is likely the most cost-effective MRA in Brazil considering individuals with both ischemic and nonischemic HFrEF.

Telehealth Support From Cardiologists to Primary Care Physicians in Heart Failure Treatment: Mixed Methods Feasibility Study of the Brazilian Heart Insufficiency With Telemedicine Trial

BACKGROUND

Heart failure is a prevalent condition ideally managed through collaboration between health care sectors. Telehealth between cardiologists and primary care physicians is a strategy to improve the quality of care for patients with heart failure. Still, the effectiveness of this approach on patient-relevant outcomes needs to be determined.

OBJECTIVE

This study aimed to assess the feasibility of telehealth support provided by cardiologists for treating patients with heart failure to primary care physicians from public primary care practices in Rio de Janeiro, Brazil.

METHODS

We used mixed methods to assess the feasibility of telehealth support. From 2020 to 2022, we tested 2 telehealth approaches: synchronous videoconferences (phase A) and interaction through an asynchronous web platform (phase B). The primary outcome was feasibility. Exploratory outcomes were telehealth acceptability of patients, primary care physicians, and cardiologists; the patients' clinical status; and prescription practices. Qualitative methods comprised content analysis of 3 focus groups and 15 individual interviews with patients, primary care physicians, and cardiologists. Quantitative methods included the baseline assessment of 83 patients; a single-arm, before-and-after assessment of clinical status in 58 patients; and an assessment of guideline-directed medical therapy in 28 patients with reduced ejection fraction measured within 1 year of follow-up. We integrated qualitative and quantitative data using a joint display table and used the A Process for Decision-Making After Pilot and Feasibility Trials framework for feasibility assessment.

RESULTS

Telehealth support from cardiologists to primary care physicians was generally well accepted. As barriers, patients expressed concern about reduced direct access to cardiologists, primary care physicians reported work overload and a lack of relative advantage, and cardiologists expressed concern about the sustainability of the intervention. Quantitative analysis revealed an overall poor baseline clinical status of patients with heart failure, with 53% (44/83) decompensated, as expected. Compliance with guideline-directed medical therapy for the treatment of heart failure with reduced ejection fraction after telehealth showed a modest improvement for β-blockers (17/20, 85% to 18/19, 95%) and renin-angiotensin-aldosterone system inhibitors (14/20, 70% to 15/19, 79%) but a drop in the prescription of spironolactone (16/20, 80% to 15/20, 75%). Neprilysin and sodium-glucose cotransporter 2 inhibitors were introduced in 4 and 1 patient, respectively. Missing record data precluded a more precise analysis. The feasibility assessment was positive, favoring the asynchronous modality. Potential modifications include more effective patient and professional recruitment strategies and educational activities to raise awareness of collaborative support in primary care.

CONCLUSIONS

Telehealth was feasible to implement. Considering the stakeholders' views and insights on the process is paramount to attaining engagement. Missing data must be anticipated for future research in this setting. Considering the recommended adaptations, the intervention can be studied in a cluster-randomized trial.

Effect of Telemedicine Interventions on Heart Failure Hospitalizations: A Randomized Trial

BACKGROUND

Telemedicine interventions (TMIs) for heart failure (HF) can reduce hospitalizations and deaths. It is unclear if low literacy and limited access to technology in low- and middle-income countries affect these benefits. We evaluated whether TMIs added to usual care could reduce HF-related rehospitalizations in patients discharged from hospitals in Brazil.

METHODS

A randomized clinical trial was conducted in 6 public hospitals from September 2021 to June 2022. Patients hospitalized because of HF were randomized to usual care or a multicomponent TMIs. The TMI included weekly nurse-led structured telephone support to monitor weight, blood pressure, heart rate, decompensation signs, and treatment adherence, while promoting self-care education, including diuretic dose adjustments. The nurse was linked to a cardiologist for teleconsultations, according to predefined decision trees. An educational program via text messages was also provided. The primary outcome was HF-related rehospitalizations at 180 days, analyzed by intention-to-treat analysis.

RESULTS

Of 127 randomized patients (TMI, n=70; usual care, n=57), mean±SD age was 64±11 years, 48% were women, 71% were Black race, 33% had <4 years of education, 65% were New York Heart Association class III/IV, and 68% had reduced ejection fraction (≤50%). At 180 days, 26% of the TMI group had HF-related rehospitalizations versus 46% in usual care (relative risk [RR]=0.56, P<0.02). All-cause death or rehospitalizations occurred in 30% of the TMI group versus 47% in usual care (RR=0.63, P=0.04). Results were consistent in "per-protocol" and subgroup analyses. Enrollment was lower than expected because of COVID-19 disruptions.

CONCLUSIONS

TMI reduced HF-related rehospitalizations, demonstrating its potential to improve clinical outcomes in this population.

REGISTRATION

URL: https://www.ensaiosclinicos.gov.br/rg/RBR-10znr9xn; Unique Identifier: UTN U1111-1263-9802.

A systematic review and meta-analysis of mortality in chronic Chagas cardiomyopathy versus other cardiomyopathies: higher risk or fiction?

INTRODUCTION AND OBJECTIVES

Although multiple studies suggest that chronic Chagas cardiomyopathy (CCC) has higher mortality than other cardiomyopathies, the absence of meta-analyses supporting this perspective limits the possibility of generating robust conclusions. The aim of this study was to systematically evaluate the current evidence on mortality risk in CCC compared with that of other cardiomyopathies.

METHODS

PubMed/Medline and EMBASE were searched for studies comparing mortality risk between patients with CCC and those with other cardiomyopathies, including in the latter nonischemic cardiomyopathy (NICM), ischemic cardiomyopathy, and non-Chagas cardiomyopathy (nonCC). A random-effects meta-analysis was performed to combine the effects of the evaluated studies.

RESULTS

A total of 37 studies evaluating 17 949 patients were included. Patients with CCC had a significantly higher mortality risk compared with patients with NICM (HR, 2.04; 95%CI, 1.60-2.60; I2, 47%; 8 studies) and non-CC (HR, 2.26; 95%CI, 1.65-3.10; I2, 71%; 11 studies), while no significant association was observed compared with patients with ischemic cardiomyopathy (HR, 1.72; 95%CI, 0.80-3.66; I2, 69%; 4 studies) in the adjusted-measures meta-analysis.

CONCLUSIONS

Patients with CCC have an almost 2-fold increased mortality risk compared with individuals with heart failure secondary to other etiologies. This finding highlights the need for effective public policies and targeted research initiatives to optimally address the challenges of CCC.

Sacubitril/Valsartan Versus Enalapril in Chronic Chagas Cardiomyopathy: Rationale and Design of the PARACHUTE-HF Trial

Chronic Chagas cardiomyopathy (CCC) has unique pathogenic and clinical features with worse prognosis than other causes of heart failure (HF), despite the fact that patients with CCC are often younger and have fewer comorbidities. Patients with CCC were not adequately represented in any of the landmark HF studies that support current treatment guidelines. PARACHUTE-HF (Prevention And Reduction of Adverse outcomes in Chagasic Heart failUre Trial Evaluation) is an active-controlled, randomized, phase IV trial designed to evaluate the effect of sacubitril/valsartan 200 mg twice daily vs enalapril 10 mg twice daily added to standard of care treatment for HF. The study aims to enroll approximately 900 patients with CCC and reduced ejection fraction at around 100 sites in Latin America. The primary outcome is a hierarchical composite of time from randomization to cardiovascular death, first HF hospitalization, or relative change from baseline to week 12 in NT-proBNP levels. PARACHUTE-HF will provide new data on the treatment of this high-risk population. (Efficacy and Safety of Sacubitril/Valsartan Compared With Enalapril on Morbidity, Mortality, and NT-proBNP Change in Patients With CCC [PARACHUTE-HF]; NCT04023227).