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Kittipibul V, Mentz RJ, Clare RM, Wojdyla DM, Anstrom KJ, Eisenstein EL, Ambrosy AP, Goyal P, Skopicki HA, Ketema F, Kim DY, Desvigne-Nickens P, Pitt B, Velazquez EJ, Greene SJ. On-treatment analysis of torsemide versus furosemide for patients hospitalized for heart failure: A post-hoc analysis of TRANSFORM-HF. Eur J Heart Fail 2024. [PMID: 38745502 DOI: 10.1002/ejhf.3293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 04/04/2024] [Accepted: 05/01/2024] [Indexed: 05/16/2024] Open
Abstract
AIM The TRANSFORM-HF trial demonstrated no significant outcome differences between torsemide and furosemide following hospitalization for heart failure (HF), but may have been impacted by non-adherence to the randomized diuretic. The current study sought to determine the treatment effect of torsemide versus furosemide using an on-treatment analysis inclusive of all randomized patients except those confirmed non-adherent to study diuretic. METHODS AND RESULTS TRANSFORM-HF was an open-label, pragmatic randomized trial of 2859 patients hospitalized for HF from June 2018 through March 2022. Patients were randomized to a loop diuretic strategy of torsemide versus furosemide with investigator-selected dosage. This post-hoc on-treatment analysis included all patients alive with either known or unknown diuretic status, and excluded patients confirmed to be non-adherent to study diuretic. This modified on-treatment definition was applied separately at time of hospital discharge and 30-day follow-up. All-cause mortality and hospitalization outcomes were assessed over 12 months. Overall, 2570 (89.9%) and 2374 (83.0%) patients were included in on-treatment analyses at discharge and 30-day follow-up, respectively. There was no significant difference in all-cause mortality between torsemide and furosemide in patients on-treatment at discharge (17.5% vs. 17.8%; hazard ratio [HR] 1.01 [95% confidence interval [CI] 0.83-1.22], p = 0.96) and at 30-day follow-up (14.5% vs. 15.0%; HR 1.02 [95% CI 0.81-1.27], p = 0.90). All-cause mortality or all-cause hospitalization was similar between torsemide and furosemide in patients who were on-treatment at discharge (58.3% vs. 61.3%; HR 0.92 [95% CI 0.82-1.03]) and 30-day follow-up (60.9% vs. 64.4%; HR 0.93 [95% CI 0.82-1.05]). In patients who were on-treatment at 30-day follow-up, there were 677 total hospitalizations in the torsemide group and 686 total hospitalizations in the furosemide group (rate ratio 0.99 [95% CI 0.86-1.14], p = 0.87). CONCLUSIONS In TRANSFORM-HF, a post-hoc on-treatment analysis did not meaningfully differ from the original trial results. Among those deemed compliant with the assigned diuretic, there remained no significant difference in mortality or hospitalization after HF hospitalization with a strategy of torsemide versus furosemide. CLINICAL TRAIL REGISTRATION ClinicalTrials.gov Identifier: NCT03296813.
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Affiliation(s)
- Veraprapas Kittipibul
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Kevin J Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | | | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Hal A Skopicki
- Division of Cardiology, Stony Brook University, Stony Brook, NY, USA
| | - Fassil Ketema
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Dong-Yun Kim
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Bertram Pitt
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
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Schuermans A, Verbrugge FH. Decongestion (instead of ultrafiltration?). Curr Opin Cardiol 2024; 39:188-195. [PMID: 38362936 DOI: 10.1097/hco.0000000000001124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
PURPOSE OF REVIEW To summarize the contemporary evidence on decongestion strategies in patients with acute heart failure (AHF). RECENT FINDINGS While loop diuretic therapy has remained the backbone of decongestive treatment in AHF, multiple randomized clinical trials suggest that early combination with other diuretic classes or molecules with diuretic properties should be considered. Mineralocorticoid receptor antagonists and sodium-glucose co-transporter-2 inhibitors are disease-modifying drugs in heart failure that favourably influence prognosis early on, advocating their start as soon as possible in the absence of any compelling contraindications. Short-term upfront use of acetazolamide in adjunction to intravenous loop diuretic therapy relieves congestion faster, avoids diuretic resistance, and may shorten hospitalization length. Thiazide-like diuretics remain a good option to break diuretic resistance. Currently, ultrafiltration in AHF remains mainly reserved for patient with an inadequate response to pharmacological treatment. SUMMARY In most patients with AHF, decongestion can be achieved effectively and safely through combination diuretic therapies. Appropriate diuretic therapy may shorten hospitalization length and improve quality of life, but has not yet proven to reduce death or heart failure readmissions. Ultrafiltration currently has a limited role in AHF, mainly as bail-out strategy, but evidence for a more upfront use remains inconclusive.
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Affiliation(s)
| | - Frederik H Verbrugge
- Centre for Cardiovascular Diseases, University Hospital Brussels
- Faculty of Medicine and Pharmacy, Vrije Universiteit Brussel, Jette, Belgium
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3
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Shoji S, Kaltenbach LA, Granger BB, Fonarow GC, Al-Khalidi HR, Albert NM, Butler J, Allen LA, Felker GM, Harrison RW, Fudim M, Nelson AJ, Granger CB, Hernandez AF, Devore AD. Remote Follow-up in a Heart Failure Pragmatic Trial: Insights From the CONNECT-HF. J Card Fail 2024:S1071-9164(24)00109-X. [PMID: 38599459 DOI: 10.1016/j.cardfail.2024.03.006] [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: 11/11/2023] [Revised: 03/26/2024] [Accepted: 03/28/2024] [Indexed: 04/12/2024]
Abstract
BACKGROUND Randomized controlled trials typically require study-specific visits, which can burden participants and sites. Remote follow-up, such as centralized call centers for participant-reported or site-reported, holds promise for reducing costs and enhancing the pragmatism of trials. In this secondary analysis of the CONNECT-HF (Care Optimization Through Patient and Hospital Engagement For HF) trial, we aimed to evaluate the completeness and validity of the remote follow-up process. METHODS AND RESULTS The CONNECT-HF trial evaluated the effect of a post-discharge quality-improvement intervention for heart failure compared to usual care for up to 1 year. Suspected events were reported either by participants or by health care proxies through a centralized call center or by sites through medical-record queries. When potential hospitalization events were suspected, additional medical records were collected and adjudicated. Among 5942 potential hospitalizations, 18% were only participant-reported, 28% were reported by both participants and sites, and 50% were only site-reported. Concordance rates between the participant/site reports and adjudication for hospitalization were high: 87% participant-reported, 86% both, and 86% site-reported. Rates of adjudicated heart failure hospitalization events among adjudicated all-cause hospitalization were lower but also consistent: 45% participant-reported, 50% both, and 50% site-reported. CONCLUSIONS Participant-only and site-only reports missed a substantial number of hospitalization events. We observed similar concordance between participant/site reports and adjudication for hospitalizations. Combining participant-reported and site-reported outcomes data is important to capture and validate hospitalizations effectively in pragmatic heart failure trials.
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Affiliation(s)
- Satoshi Shoji
- Duke Clinical Research Institute, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | | | | | - Gregg C Fonarow
- Division of Cardiology, Department of Medicine, Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | | | - Nancy M Albert
- Associate Chief of Nursing, Research and Innovation- Nursing Institute and Clinical Nurse Specialist- Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland OH, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX and University of Mississippi, Jackson MS
| | - Larry A Allen
- Division of Cardiology, Department of Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - G Michael Felker
- Duke Clinical Research Institute, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Robert W Harrison
- Duke Clinical Research Institute, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA; Department of Cardiology, University of Wroclaw, Wroclaw, Poland
| | - Adam J Nelson
- Duke Clinical Research Institute, Durham, NC, USA; Victorian Heart Institute, Monash University, Melbourne, Victoria, Australia
| | - Christopher B Granger
- Duke Clinical Research Institute, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Adam D Devore
- Duke Clinical Research Institute, Durham, NC, USA; Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
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Lund JL, Cacciatore J, Tylock R, Su IH, Sharma S, Hinton SP, Smith S, Nowels MA, Chen X, Duberstein PR, Hanson LC, Mohile SG. Development and Evaluation of a Multisource Approach to Extend Mortality Follow-Up for Older Adults With Advanced Cancer Enrolled in Randomized Trials. JCO Clin Cancer Inform 2024; 8:e2300183. [PMID: 38564692 DOI: 10.1200/cci.23.00183] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Revised: 12/08/2023] [Accepted: 02/13/2024] [Indexed: 04/04/2024] Open
Abstract
PURPOSE Mortality data can complement primary end points from cancer clinical trials. Yet, identifying deaths after trial completion is challenging, as timely and comprehensive vital status data are unavailable in the United States. We developed and evaluated a multisource approach to capture death data after clinical trial completion. METHODS Individuals age 70 years and older with incurable solid tumors or lymphoma and ≥1 aging-related condition were enrolled from October 2014 to March 2019 (ClinicalTrials.gov identifier: NCT02107443 and NCT02054741). Participants provided consent to link trial information to external sources. We developed a stepped approach for extended death capture using (1) active trial follow-up up to 1 year, (2) linkage to the National Death Index (NDI), and (3) obituary searches, thus generating a 5-year survival curve. In a random sample of 50 participants who died during trial follow-up, we estimated sensitivity of death data using NDI and obituary sources and computed survival times by data source. RESULTS The two trials enrolled 1,169 participants; mean age was 76 years; 46% were female; and gastrointestinal cancer (30%) and lung cancer (26%) were the most common cancer types. Across data sources, maximum follow-up was >7 years; 5-year survival was 18%. In total, there were 841 deaths: 603 identified during trial follow-up; 199 from the NDI; and 39 from obituary searches. The sensitivity for death capture was 92% for the NDI and 94% for the obituary searches compared with the trial data, and computed survival times were similar across data sources. CONCLUSION Extending clinical trial mortality follow-up through linkage with external data sources was feasible and accurate. Future cancer clinical trials should collect necessary consent and patient identifiers for vital status linkages that can enhance understanding of longer-term outcomes.
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Affiliation(s)
- Jennifer L Lund
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
| | - Jenna Cacciatore
- Geriatric Oncology Research Group, James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Rachael Tylock
- Geriatric Oncology Research Group, James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - I-Hsuan Su
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Saloni Sharma
- Geriatric Oncology Research Group, James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Sharon Peacock Hinton
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Sabirah Smith
- Geriatric Oncology Research Group, James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY
| | - Molly A Nowels
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Rutgers, The State University of New Jersey, New Brunswick, NJ
| | - Xiaomeng Chen
- Department of Epidemiology, Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Paul R Duberstein
- Department of Health Behavior, Society, and Policy, Rutgers School of Public Health, Rutgers, The State University of New Jersey, New Brunswick, NJ
| | - Laura C Hanson
- University of North Carolina Lineberger Comprehensive Cancer Center, Chapel Hill, NC
- Division of Geriatric Medicine, Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
| | - Supriya G Mohile
- Geriatric Oncology Research Group, James P. Wilmot Cancer Institute, University of Rochester School of Medicine and Dentistry, Rochester, NY
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Fang Y, Fang D. Mendelian randomization analysis reveals causal relationship between obstetric-related diseases and COVID-19. Virol J 2024; 21:73. [PMID: 38528518 PMCID: PMC10964700 DOI: 10.1186/s12985-024-02348-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2023] [Accepted: 03/19/2024] [Indexed: 03/27/2024] Open
Abstract
BACKGROUND Several observational studies demonstrated that pregnant individuals with COVID-19 had a higher risk of preeclampsia and preterm birth. We aimed to determine whether women with COVID-19 diagnosis had adverse pregnancy outcomes. METHODS A two-sample Mendelian randomization (MR) analysis in this study was used to evaluate the casual relationships between COVID-19 infection and obstetric-related diseases based on genome-wide association studies (GWAS) dataset. Inverse-variance weighted (IVW), MR-Egger and MR-PRESSO were used to infer the connection and estimate the pleiotropy respectively. RESULTS The significant connection was observed between COVID-19 and placental disorders with betaIVW of 1.57 and odds ratio (OR) of 4.81 (95% confidence interval [CI]: 1.05-22.05, p = 0.04). However, there were no associations between COVID-19 infection and gestational diabetes mellitus (GDM) (OR = 1.12; 95% CI: 0.85-1.45, p = 0.41), other disorders of amniotic fluid and membranes (OR = 0.90; 95% CI: 0.61-1.32, p = 0.59), Intrahepatic Cholestasis of Pregnancy (ICP) (OR = 1.42; 95% CI: 0.85-2.36, p = 0.18), birth weight (OR = 1.02; 95% CI: 0.99-1.05, p = 0.19), gestational hypertension (OR = 1.00; 95% CI: 1.00-1.00, p = 0.85), spontaneous miscarriages (OR = 1.00; 95% CI: 0.96-1.04, p = 0.90) and stillbirth (OR = 1.00; 95% CI: 0.98-1.01, p = 0.62). CONCLUSION There was no direct causal relationship between COVID-19 infection and maternal and neonatal poor outcomes. Our study could alleviate the anxiety of pregnant women under the COVID-19 pandemic conditions partly.
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Affiliation(s)
- Yan Fang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No 9 Jinsui Road, Tianhe District, Guangzhou, Guangdong Province, 510623, People's Republic of China
| | - Dajun Fang
- Department of Obstetrics and Gynecology, Guangzhou Women and Children's Medical Center, Guangzhou Medical University, No 9 Jinsui Road, Tianhe District, Guangzhou, Guangdong Province, 510623, People's Republic of China.
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Kapelios CJ, Greene SJ, Mentz RJ, Ikeaba U, Wojdyla D, Anstrom KJ, Eisenstein EL, Pitt B, Velazquez EJ, Fang JC. Torsemide Versus Furosemide After Discharge in Patients Hospitalized With Heart Failure Across the Spectrum of Ejection Fraction: Findings From TRANSFORM-HF. Circ Heart Fail 2024; 17:e011246. [PMID: 38436075 PMCID: PMC10950535 DOI: 10.1161/circheartfailure.123.011246] [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: 09/20/2023] [Accepted: 01/04/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND The TRANSFORM-HF trial (Torsemide Comparison With Furosemide for Management of Heart Failure) found no significant difference in all-cause mortality or hospitalization among patients randomized to a strategy of torsemide versus furosemide following a heart failure (HF) hospitalization. However, outcomes and responses to some therapies differ by left ventricular ejection fraction (LVEF). Thus, we sought to explore the effect of torsemide versus furosemide by baseline LVEF and to assess outcomes across LVEF groups. METHODS We compared baseline patient characteristics and randomized treatment effects for various end points in TRANSFORM-HF stratified by LVEF: HF with reduced LVEF, ≤40% versus HF with mildly reduced LVEF, 41% to 49% versus HF with preserved LVEF, ≥50%. We also evaluated associations between LVEF and clinical outcomes. Study end points were all-cause mortality or hospitalization at 30 days and 12 months, total hospitalizations at 12 months, and change from baseline in Kansas City Cardiomyopathy Questionnaire clinical summary score. RESULTS Overall, 2635 patients (median 64 years, 36% female, 34% Black) had LVEF data. Compared with HF with reduced LVEF, patients with HF with mildly reduced LVEF and HF with preserved LVEF had a higher prevalence of comorbidities. After adjusting for covariates, there was no significant difference in risk of clinical outcomes across the LVEF groups (adjusted hazard ratio for 12-month all-cause mortality, 0.91 [95% CI, 0.59-1.39] for HF with mildly reduced LVEF versus HF with reduced LVEF and 0.91 [95% CI, 0.70-1.17] for HF with preserved LVEF versus HF with reduced LVEF; P=0.73). In addition, there was no significant difference between torsemide and furosemide (1) for mortality and hospitalization outcomes, irrespective of LVEF group and (2) in changes in Kansas City Cardiomyopathy Questionnaire clinical summary score in any LVEF subgroup. CONCLUSIONS Despite baseline demographic and clinical differences between LVEF cohorts in TRANSFORM-HF, there were no significant differences in the clinical end points with torsemide versus furosemide across the LVEF spectrum. There was a substantial risk for all-cause mortality and subsequent hospitalization independent of baseline LVEF. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03296813.
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Affiliation(s)
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Robert J. Mentz
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Kevin J. Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | | | - Bertram Pitt
- Department of Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Eric J. Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - James C. Fang
- University of Utah Medical Center, Salt Lake City, UT, USA
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Krim SR, Anand S, Greene SJ, Chen A, Wojdyla D, Vilaro J, Haught H, Herre JM, Eisenstein EL, Anstrom KJ, Pitt B, Velazquez EJ, Mentz RJ. Torsemide vs Furosemide Among Patients With New-Onset vs Worsening Chronic Heart Failure: A Substudy of the TRANSFORM-HF Randomized Clinical Trial. JAMA Cardiol 2024; 9:182-188. [PMID: 37955908 PMCID: PMC10644243 DOI: 10.1001/jamacardio.2023.4776] [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: 09/23/2023] [Accepted: 10/23/2023] [Indexed: 11/14/2023]
Abstract
Importance Differences in clinical profiles, outcomes, and diuretic treatment effects may exist between patients with de novo heart failure (HF) and worsening chronic HF (WHF). Objectives To compare clinical characteristics and treatment outcomes of torsemide vs furosemide in patients hospitalized with de novo HF vs WHF. Design, Setting, and Participants All patients with a documented ejection fraction who were randomized in the Torsemide Comparison With Furosemide for Management of Heart Failure (TRANSFORM-HF) trial, conducted from June 18 through March 2022, were included in this post hoc analysis. Study data were analyzed March to May 2023. Exposure Patients were categorized by HF type and further divided by loop diuretic strategy. Main Outcomes and Measures End points included all-cause mortality and hospitalization outcomes over 12 months, as well as change from baseline in the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CSS). Results Among 2858 patients (mean [SD] age, 64.5 [14.0] years; 1803 male [63.1%]), 838 patients (29.3%) had de novo HF, and 2020 patients (70.7%) had WHF. Patients with de novo HF were younger (mean [SD] age, 60.6 [14.5] years vs 66.1 [13.5] years), had a higher glomerular filtration rate (mean [SD], 68.6 [24.9] vs 57.0 [24.0]), lower levels of natriuretic peptides (median [IQR], brain-type natriuretic peptide, 855.0 [423.0-1555.0] pg/mL vs 1022.0 [500.0-1927.0] pg/mL), and tended to be discharged on lower doses of loop diuretic (mean [SD], 50.3 [46.2] mg vs 63.8 [52.4] mg). De novo HF was associated with lower all-cause mortality at 12 months (de novo, 65 of 838 [9.1%] vs WHF, 408 of 2020 [25.4%]; adjusted hazard ratio [aHR], 0.50; 95% CI, 0.38-0.66; P < .001). Similarly, lower all-cause first rehospitalization at 12 months and greater improvement from baseline in KCCQ-CSS at 12 months were noted among patients with de novo HF (median [IQR]: de novo, 29.94 [27.35-32.54] vs WHF, 23.68 [21.62-25.74]; adjusted estimated difference in means: 6.26; 95% CI, 3.72-8.81; P < .001). There was no significant difference in mortality with torsemide vs furosemide in either de novo (No. of events [rate per 100 patient-years]: torsemide, 27 [7.4%] vs furosemide, 38 [10.9%]; aHR, 0.70; 95% CI, 0.40-1.14; P = .15) or WHF (torsemide 212 [26.8%] vs furosemide, 196 [24.0%]; aHR, 1.08; 95% CI, 0.89-1.32; P = .42; P for interaction = .10), In addition, no significant differences in hospitalizations, first all-cause hospitalization, or total hospitalizations at 12 months were noted with a strategy of torsemide vs furosemide in either de novo HF or WHF. Conclusions and Relevance Among patients discharged after hospitalization for HF, de novo HF was associated with better clinical and patient-reported outcomes when compared with WHF. Regardless of HF type, there was no significant difference between torsemide and furosemide with respect to 12-month clinical or patient-reported outcomes.
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Affiliation(s)
- Selim R. Krim
- Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Senthil Anand
- Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Anqi Chen
- Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | | | - Kevin J. Anstrom
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Bertram Pitt
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Eric J. Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert J. Mentz
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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Canepa M, De Marzo V, Ameri P, Ferrari R, Tavazzi L, Rapezzi C, Porto I, Maggioni AP. Temporal trends in evidence supporting therapeutic interventions in heart failure and other European Society of Cardiology guidelines. ESC Heart Fail 2023; 10:3019-3027. [PMID: 37550897 PMCID: PMC10567640 DOI: 10.1002/ehf2.14459] [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: 12/07/2022] [Revised: 05/20/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023] Open
Abstract
AIMS This study aimed to determine whether any change occurred over time in level of evidence (LoE) of therapeutic interventions supporting heart failure (HF) and other European Society of Cardiology guideline recommendations. METHODS AND RESULTS We selected topics with at least three documents released between 2008 and April 2022. Classes of recommendations (CoR) and supporting LoE related to therapeutic interventions within each document were collected and compared over time. A total of 1822 recommendations from 18 documents on 6 topics [median number per document = 112, 867 (48%) CoR I] were included in the analysis. There was a trend towards a reduction over time in the percentage of CoR I in HF (46-36-34%), non-ST elevation myocardial infarction (NSTEMI; 78-58-54%), and pulmonary embolism (PE; 65-50-39%) guidelines, with a decrease in the total number of recommendations for HF only. Percentage of CoR I was stable over time around 40% for valvular heart disease (VHD) and atrial fibrillation (AF), and around 60% for cardiovascular prevention (CVP), with an increase in the total number of recommendations for VHD and CVP and a decrease for AF. Among CoR I, 319 (37%) were supported by LoE A, with a decrease over time for HF (56-46-42%), an increase for NSTEMI (29-38-48%) and AF (28-31-36%), a bimodal distribution for PE and CVP, and a lack for VHD. CONCLUSIONS LoE supporting therapeutic recommendations in contemporary European guidelines is generally low. Physicians should be aware of these limitations, and scientific societies promote a greater understanding of their significance and drive future research directions.
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Affiliation(s)
- Marco Canepa
- Cardiology UnitOspedale Policlinico San Martino IRCCSGenoaItaly
- Department of Internal MedicineUniversity of GenovaGenoaItaly
| | | | - Pietro Ameri
- Cardiology UnitOspedale Policlinico San Martino IRCCSGenoaItaly
- Department of Internal MedicineUniversity of GenovaGenoaItaly
| | - Roberto Ferrari
- Scientific DepartmentMTA GroupLuganoSwitzerland
- Azienda Ospedaliero‐Universitaria di Ferrara ‘Arcispedale S. Anna’FerraraItaly
| | - Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & ResearchCotignolaItaly
| | - Claudio Rapezzi
- Azienda Ospedaliero‐Universitaria di Ferrara ‘Arcispedale S. Anna’FerraraItaly
- Maria Cecilia Hospital, GVM Care & ResearchCotignolaItaly
| | - Italo Porto
- Cardiology UnitOspedale Policlinico San Martino IRCCSGenoaItaly
- Department of Internal MedicineUniversity of GenovaGenoaItaly
| | - Aldo Pietro Maggioni
- Maria Cecilia Hospital, GVM Care & ResearchCotignolaItaly
- Centro Studi ANMCO, Heart Care FoundationFlorenceItaly
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Ren Z, Zhang Z, Ling L, Liu X, Wang X. Drugs for treating myocardial fibrosis. Front Pharmacol 2023; 14:1221881. [PMID: 37771726 PMCID: PMC10523299 DOI: 10.3389/fphar.2023.1221881] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 08/29/2023] [Indexed: 09/30/2023] Open
Abstract
Myocardial fibrosis, which is a common pathological manifestation of many cardiovascular diseases, is characterized by excessive proliferation, collagen deposition and abnormal distribution of extracellular matrix fibroblasts. In clinical practice, modern medicines, such as diuretic and β receptor blockers, and traditional Chinese medicines, such as salvia miltiorrhiza and safflower extract, have certain therapeutic effects on myocardial fibrosis. We reviewed some representative modern medicines and traditional Chinese medicines (TCMs) and their related molecular mechanisms for the treatment of myocardial fibrosis. These drugs alleviate myocardial fibrosis by affecting related signaling pathways and inhibiting myocardial fibrosis-related protein synthesis. This review will provide more references and help for the research and treatment of myocardial fibrosis.
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Affiliation(s)
- Zhanhong Ren
- Hubei Key Laboratory of Diabetes and Angiopathy, Medicine Research Institute, Xianning Medical College, Hubei University of Science and Technology, Xianning, China
| | - Zixuan Zhang
- Hubei Key Laboratory of Diabetes and Angiopathy, Medicine Research Institute, Xianning Medical College, Hubei University of Science and Technology, Xianning, China
- School of Basic Medical Sciences, Xianning Medical College, Hubei University of Science and Technology, Xianning, China
| | - Li Ling
- Hubei Key Laboratory of Diabetes and Angiopathy, Medicine Research Institute, Xianning Medical College, Hubei University of Science and Technology, Xianning, China
| | - Xiufen Liu
- Hubei Key Laboratory of Diabetes and Angiopathy, Medicine Research Institute, Xianning Medical College, Hubei University of Science and Technology, Xianning, China
| | - Xin Wang
- School of Mathematics and Statistics, Hubei University of Science and Technology, Xianning, China
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10
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Greene SJ, Velazquez EJ, Anstrom KJ, Clare RM, DeWald TA, Psotka MA, Ambrosy AP, Stevens GR, Rommel JJ, Alexy T, Ketema F, Kim DY, Desvigne-Nickens P, Pitt B, Eisenstein EL, Mentz RJ. Effect of Torsemide Versus Furosemide on Symptoms and Quality of Life Among Patients Hospitalized for Heart Failure: The TRANSFORM-HF Randomized Clinical Trial. Circulation 2023; 148:124-134. [PMID: 37212600 PMCID: PMC10524905 DOI: 10.1161/circulationaha.123.064842] [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: 03/20/2023] [Accepted: 05/09/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Loop diuretics are a primary therapy for the symptomatic treatment of heart failure (HF), but whether torsemide improves patient symptoms and quality of life better than furosemide remains unknown. As prespecified secondary end points, the TRANSFORM-HF trial (Torsemide Comparison With Furosemide for Management of Heart Failure) compared the effect of torsemide versus furosemide on patient-reported outcomes among patients with HF. METHODS TRANSFORM-HF was an open-label, pragmatic, randomized trial of 2859 patients hospitalized for HF (regardless of ejection fraction) across 60 hospitals in the United States. Patients were randomly assigned in a 1:1 ratio to a loop diuretic strategy of torsemide or furosemide with investigator-selected dosage. This report examined effects on prespecified secondary end points, which included Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CSS; assessed as adjusted mean difference in change from baseline; range, 0-100 with 100 indicating best health status; clinically important difference, ≥5 points) and Patient Health Questionnaire-2 (range, 0-6; score ≥3 supporting evaluation for depression) over 12 months. RESULTS Baseline data were available for 2787 (97.5%) patients for KCCQ-CSS and 2624 (91.8%) patients for Patient Health Questionnaire-2. Median (interquartile range) baseline KCCQ-CSS was 42 (27-60) in the torsemide group and 40 (24-59) in the furosemide group. At 12 months, there was no significant difference between torsemide and furosemide in change from baseline in KCCQ-CSS (adjusted mean difference, 0.06 [95% CI, -2.26 to 2.37]; P=0.96) or the proportion of patients with Patient Health Questionnaire-2 score ≥3 (15.1% versus 13.2%: P=0.34). Results for KCCQ-CSS were similar at 1 month (adjusted mean difference, 1.36 [95% CI, -0.64 to 3.36]; P=0.18) and 6-month follow-up (adjusted mean difference, -0.37 [95% CI, -2.52 to 1.78]; P=0.73), and across subgroups by ejection fraction phenotype, New York Heart Association class at randomization, and loop diuretic agent before hospitalization. Irrespective of baseline KCCQ-CSS tertile, there was no significant difference between torsemide and furosemide on change in KCCQ-CSS, all-cause mortality, or all-cause hospitalization. CONCLUSIONS Among patients discharged after hospitalization for HF, a strategy of torsemide compared with furosemide did not improve symptoms or quality of life over 12 months. The effects of torsemide and furosemide on patient-reported outcomes were similar regardless of ejection fraction, previous loop diuretic use, and baseline health status. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03296813.
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Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.M.C., E.L.E., R.J.M.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., T.A.D., R.J.M.)
| | - Eric J Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.J.V.)
| | - Kevin J Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill (K.J.A.)
| | - Robert M Clare
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.M.C., E.L.E., R.J.M.)
| | - Tracy A DeWald
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., T.A.D., R.J.M.)
| | | | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, Oakland (A.P.A.)
| | - Gerin R Stevens
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY (G.R.S.)
| | - John J Rommel
- Novant Health Heart and Vascular Institute, Wilmington, NC (J.J.R.)
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis (T.A.)
| | - Fassil Ketema
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (F.K., D.-Y.K., P.D.-N.)
| | - Dong-Yun Kim
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (F.K., D.-Y.K., P.D.-N.)
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (F.K., D.-Y.K., P.D.-N.)
| | - Bertram Pitt
- Department of Medicine, Division of Cardiology, University of Michigan, Ann Arbor (B.P.)
| | - Eric L Eisenstein
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.M.C., E.L.E., R.J.M.)
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.M.C., E.L.E., R.J.M.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., T.A.D., R.J.M.)
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11
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Nassif M, Birmingham MC, Lanfear DE, Golbus JR, Gupta B, Fawcett C, Harrison MC, Spertus JA. Recruitment Strategies of a Decentralized Randomized Placebo Controlled Clinical Trial: The Canagliflozin Impact on Health Status, Quality of Life and Functional Status in Heart Failure (CHIEF-HF) Trial. J Card Fail 2023; 29:863-869. [PMID: 37040839 DOI: 10.1016/j.cardfail.2023.04.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 04/05/2023] [Accepted: 04/05/2023] [Indexed: 04/13/2023]
Abstract
BACKGROUND There has been growing Interest in patient-centered clinical trials using mobile technologies to reduce the need for in-person visits. The CHIEF-HF (Canagliflozin Impact on Health Status, Quality of Life and Functional Status in Heart Failure) trial was designed as a double-blind, randomized, fully decentralized clinical trial (DCT) that identified, consented, treated, and followed participants without any in-person visits. Patient-reported questionnaires were the primary outcome, which were collected by a mobile application. To inform future DCTs, we sought to describe the strategies used in successful trial recruitment. METHODS This article describes the operational structure and novel strategies employed in a completely DCT by summarizing the recruitment, enrollment, engagement, retention, and follow-up processes used in the execution of the trial at 18 centers. RESULTS A total of 18 sites contacted 130,832 potential participants, of which 2572 (2.0%) opened a hyperlink to the study website, completed a brief survey, and agreed to be contacted for potential inclusion. Of these, 1333 were eligible, and 658 consented; there were 182 screen failures, due primarily to baseline Kansas City Cardiomyopathy Questionnaire scores' not meeting inclusion criteria, resulting in 476 participants' being enrolled (18.5%). There was significant site-level variation in the number of patients invited (median = 2976; range 73-46,920) and in those agreeing to be contacted (median = 2.4%; range 0.05%-16.4%). At the site with the highest enrollment, patients contacted by electronic medical record portal messaging were more likely to opt into the study successfully than those contacted by e-mail alone (7.8% vs 4.4%). CONCLUSIONS CHIEF-HF used a novel design and operational structure to test the efficacy of a therapeutic treatment, but marked variability across sites and strategies for recruiting participants was observed. This approach may be advantageous for clinical research across a broader range of therapeutic areas, but further optimization of recruitment efforts is warranted. REGISTRATION NCT04252287 https://clinicaltrials.gov/ct2/show/NCT04252287.
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Affiliation(s)
- Michael Nassif
- University of Missouri - Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, MO
| | | | - David E Lanfear
- Heart and Vascular Institute, Henry Ford Health System, Detroit, MI
| | | | - Bhanu Gupta
- University of Kansas Medical Center, Kansas City, KS
| | | | | | - John A Spertus
- University of Missouri - Kansas City's Healthcare Institute for Innovations in Quality and Saint Luke's Mid America Heart Institute, Kansas City, MO.
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12
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Mentz RJ, DeWald TA, Velazquez EJ. Torsemide vs Furosemide After Discharge and All-Cause Mortality in Patients With Heart Failure-Reply. JAMA 2023; 329:1704. [PMID: 37191705 DOI: 10.1001/jama.2023.5291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
| | - Tracy A DeWald
- Division of Clinical Pharmacology, Duke University, Durham, North Carolina
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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13
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Mentz RJ, Anstrom KJ, Eisenstein EL, Sapp S, Greene SJ, Morgan S, Testani JM, Harrington AH, Sachdev V, Ketema F, Kim DY, Desvigne-Nickens P, Pitt B, Velazquez EJ. Effect of Torsemide vs Furosemide After Discharge on All-Cause Mortality in Patients Hospitalized With Heart Failure: The TRANSFORM-HF Randomized Clinical Trial. JAMA 2023; 329:214-223. [PMID: 36648467 PMCID: PMC9857435 DOI: 10.1001/jama.2022.23924] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
IMPORTANCE Although furosemide is the most commonly used loop diuretic in patients with heart failure, some studies suggest a potential benefit for torsemide. OBJECTIVE To determine whether torsemide results in decreased mortality compared with furosemide among patients hospitalized for heart failure. DESIGN, SETTING, AND PARTICIPANTS TRANSFORM-HF was an open-label, pragmatic randomized trial that recruited 2859 participants hospitalized with heart failure (regardless of ejection fraction) at 60 hospitals in the United States. Recruitment occurred from June 2018 through March 2022, with follow-up through 30 months for death and 12 months for hospitalizations. The final date for follow-up data collection was July 2022. INTERVENTIONS Loop diuretic strategy of torsemide (n = 1431) or furosemide (n = 1428) with investigator-selected dosage. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality in a time-to-event analysis. There were 5 secondary outcomes with all-cause mortality or all-cause hospitalization and total hospitalizations assessed over 12 months being highest in the hierarchy. The prespecified primary hypothesis was that torsemide would reduce all-cause mortality by 20% compared with furosemide. RESULTS TRANSFORM-HF randomized 2859 participants with a median age of 65 years (IQR, 56-75), 36.9% were women, and 33.9% were Black. Over a median follow-up of 17.4 months, a total of 113 patients (53 [3.7%] in the torsemide group and 60 [4.2%] in the furosemide group) withdrew consent from the trial prior to completion. Death occurred in 373 of 1431 patients (26.1%) in the torsemide group and 374 of 1428 patients (26.2%) in the furosemide group (hazard ratio, 1.02 [95% CI, 0.89-1.18]). Over 12 months following randomization, all-cause mortality or all-cause hospitalization occurred in 677 patients (47.3%) in the torsemide group and 704 patients (49.3%) in the furosemide group (hazard ratio, 0.92 [95% CI, 0.83-1.02]). There were 940 total hospitalizations among 536 participants in the torsemide group and 987 total hospitalizations among 577 participants in the furosemide group (rate ratio, 0.94 [95% CI, 0.84-1.07]). Results were similar across prespecified subgroups, including among patients with reduced, mildly reduced, or preserved ejection fraction. CONCLUSIONS AND RELEVANCE Among patients discharged after hospitalization for heart failure, torsemide compared with furosemide did not result in a significant difference in all-cause mortality over 12 months. However, interpretation of these findings is limited by loss to follow-up and participant crossover and nonadherence. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03296813.
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Affiliation(s)
- Robert J. Mentz
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Kevin J. Anstrom
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | | | - Shelly Sapp
- Duke Clinical Research Institute, Durham, North Carolina
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Shelby Morgan
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jeffrey M. Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Vandana Sachdev
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Fassil Ketema
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Dong-Yun Kim
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Bertram Pitt
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Eric J. Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
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14
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Riccardi M, Sammartino AM, Piepoli M, Adamo M, Pagnesi M, Rosano G, Metra M, von Haehling S, Tomasoni D. Heart failure: an update from the last years and a look at the near future. ESC Heart Fail 2022; 9:3667-3693. [PMID: 36546712 PMCID: PMC9773737 DOI: 10.1002/ehf2.14257] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Accepted: 11/21/2022] [Indexed: 12/24/2022] Open
Abstract
In the last years, major progress occurred in heart failure (HF) management. Quadruple therapy is now mandatory for all the patients with HF with reduced ejection fraction. Whilst verciguat is becoming available across several countries, omecamtiv mecarbil is waiting to be released for clinical use. Concurrent use of potassium-lowering agents may counteract hyperkalaemia and facilitate renin-angiotensin-aldosterone system inhibitor implementations. The results of the EMPagliflozin outcomE tRial in Patients With chrOnic heaRt Failure With Preserved Ejection Fraction (EMPEROR-Preserved) trial were confirmed by the Dapagliflozin in Heart Failure with Mildly Reduced or Preserved Ejection Fraction (DELIVER) trial, and we now have, for the first time, evidence for treatment of also patients with HF with preserved ejection fraction. In a pre-specified meta-analysis of major randomized controlled trials, sodium-glucose co-transporter-2 inhibitors reduced all-cause mortality, cardiovascular (CV) mortality, and HF hospitalization in the patients with HF regardless of left ventricular ejection fraction. Other steps forward have occurred in the treatment of decompensated HF. Acetazolamide in Acute Decompensated Heart Failure with Volume Overload (ADVOR) trial showed that the addition of intravenous acetazolamide to loop diuretics leads to greater decongestion vs. placebo. The addition of hydrochlorothiazide to loop diuretics was evaluated in the CLOROTIC trial. Torasemide did not change outcomes, compared with furosemide, in TRANSFORM-HF. Ferric derisomaltose had an effect on the primary outcome of CV mortality or HF rehospitalizations in IRONMAN (rate ratio 0.82; 95% confidence interval 0.66-1.02; P = 0.070). Further options for the treatment of HF, including device therapies, cardiac contractility modulation, and percutaneous treatment of valvulopathies, are summarized in this article.
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Affiliation(s)
- Mauro Riccardi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Antonio Maria Sammartino
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Massimo Piepoli
- Clinical Cardiology, IRCCS Policlinico San DonatoUniversity of MilanMilanItaly
- Department of Preventive CardiologyUniversity of WrocławWrocławPoland
| | - Marianna Adamo
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Matteo Pagnesi
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | | | - Marco Metra
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Stephan von Haehling
- Department of Cardiology and PneumologyUniversity of Goettingen Medical CenterGottingenGermany
- German Center for Cardiovascular Research (DZHK), Partner Site GöttingenGottingenGermany
| | - Daniela Tomasoni
- Institute of Cardiology, ASST Spedali Civili di Brescia, Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
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15
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Tavazzi L. Clinical research methodology process: what has changed with COVID-19? Eur Heart J Suppl 2022; 24:I175-I180. [DOI: 10.1093/eurheartjsupp/suac090] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
Abstract
The immediate repercussions of the pandemic on clinical research were the systematic interruption of ongoing studies and the explosion of tens of thousands of anti-COVID-19 research protocols reported in fragmented, uncoordinated, often technically insufficient international registers, from which almost nothing of significance was produced. In the first two years of intensive research, anti-inflammatory and anticoagulant benefits were identified, while the systemic nature of the viral disease was clearly manifested, but no specific antiviral drugs emerged. Subsequently, monoclonal antibodies and antiviral drugs such as Ritonavir-Boosted Nirmatrelvir (Paxlovid) have given way to more specific therapies, even if surprisingly little used. Finally, the new national Electronic Health Record (EHR-FSE2 Fascicolo Sanitario Elettronico 2 in Italian) was approved as a law, which will integrate the previous one, which is in fact not functional. The systematic, orderly and complete collection of the health data of each citizen constitutes a radical modification of the current National Health System, epidemiology and clinical research.
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Affiliation(s)
- Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care & Research , Cotignola
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16
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Eisenstein EL, Sapp S, Harding T, Harrington A, Velazquez EJ, Mentz RJ, Greene SJ, Sachdev V, Kim DY, Anstrom KJ. Ascertaining Death Events in a Pragmatic Clinical Trial: Insights From the TRANSFORM-HF Trial. J Card Fail 2022; 28:1563-1567. [PMID: 35181553 PMCID: PMC9378754 DOI: 10.1016/j.cardfail.2022.01.020] [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: 11/29/2021] [Revised: 01/17/2022] [Accepted: 01/30/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Death ascertainment can be challenging for pragmatic clinical trials that limit site follow-up activities to usual clinical care. METHODS AND RESULTS We used blinded aggregate data from the ongoing ToRsemide comparison with furoSemide FOR Management of Heart Failure (TRANSFORM-HF) pragmatic clinical trial in patients with heart failure to evaluate the agreement between centralized call center death event identification and the United States National Death Index (NDI). Of 2284 total patients randomized through April 12, 2021, 1480 were randomized in 2018-2019 and 804 in 2020-2021. The call center identified 416 total death events (177 in 2018-2019 and 239 in 2020-2021). The NDI 2018-2019 final file identified 178 death events, 165 of which were also identified by the call center. The study's inter-rater reliability metric (Cohen's kappa coefficient, 0.920; 95% confidence interval, 0.889-0.951) demonstrates a high level of agreement. The time between a death event and its identification was less for the call center (median, 47 days; interquartile range, 11-103 days) than for the NDI (median, 270 days; interquartile range, 186-391 days). CONCLUSIONS There is substantial agreement between deaths identified by a centralized call center and the NDI. However, the time between a death event and its identification is significantly less for the call center.
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Affiliation(s)
| | - Shelly Sapp
- Duke Clinical Research Institute, Durham, North Carolina
| | - Tina Harding
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Eric J Velazquez
- Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Vandana Sachdev
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Dong-Yun Kim
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, Maryland
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17
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Abassi Z, Khoury EE, Karram T, Aronson D. Edema formation in congestive heart failure and the underlying mechanisms. Front Cardiovasc Med 2022; 9:933215. [PMID: 36237903 PMCID: PMC9553007 DOI: 10.3389/fcvm.2022.933215] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 09/05/2022] [Indexed: 11/13/2022] Open
Abstract
Congestive heart failure (HF) is a complex disease state characterized by impaired ventricular function and insufficient peripheral blood supply. The resultant reduced blood flow characterizing HF promotes activation of neurohormonal systems which leads to fluid retention, often exhibited as pulmonary congestion, peripheral edema, dyspnea, and fatigue. Despite intensive research, the exact mechanisms underlying edema formation in HF are poorly characterized. However, the unique relationship between the heart and the kidneys plays a central role in this phenomenon. Specifically, the interplay between the heart and the kidneys in HF involves multiple interdependent mechanisms, including hemodynamic alterations resulting in insufficient peripheral and renal perfusion which can lead to renal tubule hypoxia. Furthermore, HF is characterized by activation of neurohormonal factors including renin-angiotensin-aldosterone system (RAAS), sympathetic nervous system (SNS), endothelin-1 (ET-1), and anti-diuretic hormone (ADH) due to reduced cardiac output (CO) and renal perfusion. Persistent activation of these systems results in deleterious effects on both the kidneys and the heart, including sodium and water retention, vasoconstriction, increased central venous pressure (CVP), which is associated with renal venous hypertension/congestion along with increased intra-abdominal pressure (IAP). The latter was shown to reduce renal blood flow (RBF), leading to a decline in the glomerular filtration rate (GFR). Besides the activation of the above-mentioned vasoconstrictor/anti-natriuretic neurohormonal systems, HF is associated with exceptionally elevated levels of atrial natriuretic peptide (ANP) and brain natriuretic peptide (BNP). However, the supremacy of the deleterious neurohormonal systems over the beneficial natriuretic peptides (NP) in HF is evident by persistent sodium and water retention and cardiac remodeling. Many mechanisms have been suggested to explain this phenomenon which seems to be multifactorial and play a major role in the development of renal hyporesponsiveness to NPs and cardiac remodeling. This review focuses on the mechanisms underlying the development of edema in HF with reduced ejection fraction and refers to the therapeutic maneuvers applied today to overcome abnormal salt/water balance characterizing HF.
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Affiliation(s)
- Zaid Abassi
- Department of Physiology, Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
- Department of Laboratory Medicine, Rambam Health Care Campus, Haifa, Israel
- *Correspondence: Zaid Abassi,
| | - Emad E. Khoury
- Department of Physiology, Bruce Rappaport Faculty of Medicine, Technion–Israel Institute of Technology, Haifa, Israel
| | - Tony Karram
- Department of Vascular Surgery and Kidney Transplantation, Rambam Health Care Campus, Haifa, Israel
| | - Doron Aronson
- Department of Cardiology, Rambam Health Care Campus, Haifa, Israel
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18
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Peters AE, DeVore AD. Pharmacologic Therapy for Heart Failure with Preserved Ejection Fraction. Cardiol Clin 2022; 40:473-489. [DOI: 10.1016/j.ccl.2022.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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19
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Pharmacological Targets in Chronic Heart Failure with Reduced Ejection Fraction. LIFE (BASEL, SWITZERLAND) 2022; 12:life12081112. [PMID: 35892914 PMCID: PMC9394280 DOI: 10.3390/life12081112] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 07/20/2022] [Accepted: 07/21/2022] [Indexed: 11/17/2022]
Abstract
Heart failure management has been repeatedly reviewed over time. This strategy has resulted in improved quality of life, especially in patients with heart failure with reduced ejection fraction (HFrEF). It is for this reason that new mechanisms involved in the development and progression of heart failure, along with specific therapies, have been identified. This review focuses on the most recent guidelines of therapeutic interventions, trials that explore novel therapies, and also new molecules that could improve prognosis of different HFrEF phenotypes.
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Imaeda S, Shiraishi Y, Kohsaka S, Niimi N, Goda A, Nagatomo Y, Takei M, Saji M, Nakano S, Kohno T, Fukuda K, Yoshikawa T. Use of short-acting vs. long-acting loop diuretics after heart failure hospitalization. ESC Heart Fail 2022; 9:2967-2977. [PMID: 35730147 DOI: 10.1002/ehf2.14030] [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: 01/07/2022] [Revised: 05/05/2022] [Accepted: 06/03/2022] [Indexed: 11/10/2022] Open
Abstract
AIMS Furosemide, a short-acting loop diuretic (SD), is the dominant agent prescribed for heart failure (HF) in clinical practice. However, accumulating data suggests that long-acting loop diuretics (LD), such as torsemide or azosemide, might have more favourable pharmacological profiles. This study aimed to investigate the relationship between the type of loop diuretics and long-term outcomes among patients hospitalized for acute HF enrolled in a contemporary multicentre registry. METHODS AND RESULTS Within the West Tokyo Heart Failure Registry from 2006 to 2017, a total of 2680 patients (60.1% men with a median age of 77 years) were analysed. The patients were characterized by the type of diuretics used at the time of discharge; 2073 (77.4%) used SD, and 607 (22.6%) used LD. The primary endpoint was composite of all-cause death or HF re-admission after discharge, and the secondary endpoints were all-cause death and HF re-admission, respectively. During the median follow-up period of 2.1 years, 639 patients died [n = 519 (25.0%) in the SD group; n = 120 (19.8%) in the LD group], and 868 patients were readmitted for HF [n = 697 (33.6%) in the SD group; n = 171 (28.2%) in the LD group]. After multivariable adjustment, the LD group had lower risk for the composite outcome [hazard ratio (HR), 0.80; 95% confidence interval (CI), 0.66-0.96; P = 0.017], including all-cause death (HR; 0.73; 95% CI; 0.54-0.99; P = 0.044) and HF re-admission (HR, 0.81; 95% CI, 0.66-0.99; P = 0.038), than the SD group. Propensity score matching yielded estimates that were consistent with those of the multivariable analyses, with sub-group analyses demonstrating that use of LD was associated with favourable outcomes predominantly in younger patients with reduced ejection fraction. CONCLUSIONS LD was associated with lower risk of long-term outcomes in patients with HF and a recent episode of acute decompensation.
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Affiliation(s)
- Shohei Imaeda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Yasuyuki Shiraishi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Shun Kohsaka
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Nozomi Niimi
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
| | - Ayumi Goda
- Department of Cardiovascular Medicine, Kyorin University Fuculty of Medicine, Tokyo, Japan
| | - Yuji Nagatomo
- Department of Cardiology, National Defense Medical College Hospital, Tokorozawa, Japan
| | - Makoto Takei
- Department of Cardiology, Saiseikai Central Hospital, Tokyo, Japan
| | - Mike Saji
- Department of Cardiology, Sakakibara Heart Institute, Tokyo, Japan
| | - Shintaro Nakano
- Department of Cardiology, Saitama Medical University International Medical Center, Saitama, Japan
| | - Takashi Kohno
- Department of Cardiovascular Medicine, Kyorin University Fuculty of Medicine, Tokyo, Japan
| | - Keiichi Fukuda
- Department of Cardiology, Keio University School of Medicine, Tokyo, Japan
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21
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Abstract
The majority of cardiovascular randomized controlled trials (RCTs) test interventions in selected patient populations under explicitly protocol-defined settings. Although these ‘explanatory’ trial designs optimize conditions to test the efficacy and safety of an intervention, they limit the generalizability of trial findings in broader clinical settings. The concept of ‘pragmatism’ in RCTs addresses this concern by providing counterbalance to the more idealized situation underpinning explanatory RCTs and optimizing effectiveness over efficacy. The central tenets of pragmatism in RCTs are to test interventions in routine clinical settings, with patients who are representative of broad clinical practice, and to reduce the burden on investigators and participants by minimizing the number of trial visits and the intensity of trial-based testing. Pragmatic evaluation of interventions is particularly important in cardiovascular diseases, where the risk of death among patients has remained fairly stable over the past few decades despite the development of new therapeutic interventions. Pragmatic RCTs can help to reveal the ‘real-world’ effectiveness of therapeutic interventions and elucidate barriers to their implementation. In this Review, we discuss the attributes of pragmatism in RCT design, conduct and interpretation as well as the general need for increased pragmatism in cardiovascular RCTs. We also summarize current challenges and potential solutions to the implementation of pragmatism in RCTs and highlight selected ongoing and completed cardiovascular RCTs with pragmatic trial designs. In this Review, Khan and colleagues discuss the benefits and challenges of including pragmatism in the design, conduct and interpretation of randomized controlled trials (RCTs) for cardiovascular disease and highlight selected ongoing and completed cardiovascular RCTs that incorporate a pragmatic design. Most cardiovascular randomized controlled trials (RCTs) conducted to date have been ‘explanatory’, that is, designed to study the intervention in optimized conditions with selected patient populations and frequent protocolized assessments. Although explanatory RCT designs increase validity, they limit the generalizability of trial findings, whereas a ‘pragmatic’ approach to RCTs yields findings more relevant to real-world practice. In pragmatic RCTs, interventions are tested in patients who are broadly representative of the condition being studied, and the study is aligned with routine clinical care to reduce costs and organizational burden. Although pragmatic RCTs tend to attenuate estimates of treatment effects, they do provide a more realistic understanding of population-level effectiveness and costs than explanatory trials. Pragmatic trials can highlight barriers to the implementation of therapies and are better suited than explanatory RCTs to assessing the effects of implementation strategies and health-care policies at the population level. Widespread implementation of pragmatic trials would require the development of technological infrastructure to collect and share data as well as regulatory guidelines amenable to findings derived from routinely collected data.
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22
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Tavazzi L, Maggioni AP, Rapezzi C, Ferrari R. Clinical trial: conventional or pragmatic? Eur J Heart Fail 2022; 24:596-599. [PMID: 35261125 DOI: 10.1002/ejhf.2480] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 12/07/2022] [Accepted: 03/08/2022] [Indexed: 11/11/2022] Open
Affiliation(s)
- Luigi Tavazzi
- Maria Cecilia Hospital, GVM Care&Research, Cotignola, Italy
| | - Aldo P Maggioni
- Maria Cecilia Hospital, GVM Care&Research, Cotignola, Italy.,Centro Studi ANMCO, Firenze, Italy
| | - Claudio Rapezzi
- Maria Cecilia Hospital, GVM Care&Research, Cotignola, Italy.,Azienda Ospedaliero-Universitaria di Ferrara "Arcispedale S. Anna", Cona, Ferrara, Italy
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23
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Peters AE, Mentz RJ, DeWald TA, Greene SJ. An evaluation of torsemide in patients with heart failure and renal disease. Expert Rev Cardiovasc Ther 2022; 20:5-11. [PMID: 34936522 PMCID: PMC8887994 DOI: 10.1080/14779072.2022.2022474] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
INTRODUCTION Torsemide is a loop diuretic that inhibits the Na+/K+/2Cl- cotransporter type 2 in the thick ascending loop of Henle, leading to increased excretion of urinary sodium and chloride and associated diuresis. While furosemide remains the dominant diuretic utilized in current practice, increasing evidence supports potential advantages of torsemide in heart failure (HF) and/or renal disease. AREAS COVERED This narrative review covers the evidence for use of torsemide in HF and renal disease. Comparative effectiveness with regards to clinical outcomes is reviewed, as well as the ongoing multicenter trial, TRANSFORM-HF, comparing the effect of torsemide versus furosemide among patients with HF. EXPERT OPINION Compared with furosemide, torsemide has favorable pharmacodynamics/pharmacokinetics including higher bioavailability, longer duration of effect, minor renal excretion, decreased kaliuresis, and enhanced natriuresis/diuresis. These properties may be further supported by differential effects on RAAS regulation and fibrosis modulation as compared with other diuretics. The limited current body of evidence indicates that torsemide may be superior to furosemide with respect to improving HF functional status and reducing HF hospitalization, and there are mixed data regarding effect on reducing overall cardiovascular hospitalizations/mortality. Further, randomized data are necessary to definitively determine if torsemide can reduce risk of mortality and hospitalization among patients with HF.
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Affiliation(s)
- Anthony E. Peters
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Robert J. Mentz
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Tracy A. DeWald
- Division of Clinical Pharmacology, Department of Medicine, Duke University School of Medicine, Durham, North Carolina
| | - Stephen J. Greene
- Duke Clinical Research Institute and Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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24
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Harrington J, Gouda P, Ezekowitz J, Mentz RJ. Exploring the pragmatic-explanatory spectrum across cardiovascular clinical trials. Contemp Clin Trials 2021; 113:106646. [PMID: 34863929 DOI: 10.1016/j.cct.2021.106646] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2021] [Revised: 11/01/2021] [Accepted: 11/27/2021] [Indexed: 11/20/2022]
Abstract
Clinical trials are a cornerstone of modern medicine and form the backbone of evidence that is used to create evidence-based guidelines. Contemporary clinical trials have tended to be quite explanatory, assessing an intervention in ideal conditions with highlyprotocolized interventions, strict inclusion/exclusion criteria, high resource utilization and with frequent (and often specialized) follow-up. In conjunction with decreased event-rates due to the improvement of cardiovascular care, this has resulted in increasingly complex, large, clinical trials that are associated with exponentially increasing costs. This has led to a strong push for streamlined trials that more truly represent "real world" settings and conduct. Such pragmatic trials emphasize "real world" conduct, including broader inclusion criteria that lead to more typical and less carefully selected patient populations, and more realistic trial setting and execution elements. We explore the spectrum of pragmatism across cardiovascular clinical trials, highlighting novel innovations and trends over the past decade.
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Affiliation(s)
- Josephine Harrington
- Duke Clinic Research Institute, Durham, NC, United States; VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Pishoy Gouda
- Duke Clinic Research Institute, Durham, NC, United States; VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Justin Ezekowitz
- Duke Clinic Research Institute, Durham, NC, United States; VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert J Mentz
- Duke Clinic Research Institute, Durham, NC, United States; VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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25
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Ter Maaten JM, Beldhuis IE, van der Meer P, Krikken JA, Coster JE, Nieuwland W, van Veldhuisen DJ, Voors AA, Damman K. Natriuresis guided therapy in acute heart failure: rationale and design of the Pragmatic Urinary Sodium-based Treatment algoritHm in Acute Heart Failure (PUSH-AHF) trial. Eur J Heart Fail 2021; 24:385-392. [PMID: 34791756 PMCID: PMC9306663 DOI: 10.1002/ejhf.2385] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Revised: 10/26/2021] [Accepted: 11/11/2021] [Indexed: 11/06/2022] Open
Abstract
Aims Insufficient diuretic response frequently occurs in patients admitted for acute heart failure (HF) and is associated with worse clinical outcomes. Recent studies have shown that measuring natriuresis early after hospital admission could reliably identify patients with a poor diuretic response during hospitalization who might require enhanced diuretic treatment. This study will test the hypothesis that natriuresis‐guided therapy in patients with acute HF improves natriuresis and clinical outcomes. Methods The Pragmatic Urinary Sodium‐based treatment algoritHm in Acute Heart Failure (PUSH‐AHF) is a pragmatic, single‐centre, randomized, controlled, open‐label study, aiming to recruit 310 acute HF patients requiring treatment with intravenous loop diuretics. Patients will be randomized to natriuresis‐guided therapy or standard of care. Natriuresis will be determined at set time points after initiation of intravenous loop diuretics, and treatment will be adjusted based on the urinary sodium levels in the natriuresis‐guided group using a pre‐specified stepwise approach of increasing doses of loop diuretics and the initiation of combination diuretic therapy. The co‐primary endpoint is 24‐h urinary sodium excretion after start of loop diuretic therapy and a combined endpoint of all‐cause mortality or first HF rehospitalization at 6 months. Secondary endpoints include 48‐ and 72‐h sodium excretion, length of hospital stay, and percentage change in N‐terminal pro brain natriuretic peptide at 48 and 72 h. Conclusion The PUSH‐AHF study will investigate whether natriuresis‐guided therapy, using a pre‐specified stepwise diuretic treatment approach, improves natriuresis and clinical outcomes in patients with acute HF.
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Affiliation(s)
- Jozine M Ter Maaten
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Iris E Beldhuis
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Peter van der Meer
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Jan A Krikken
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Jenifer E Coster
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Wybe Nieuwland
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Dirk J van Veldhuisen
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
| | - Kevin Damman
- University of Groningen, Department of Cardiology, University Medical Centre Groningen, Groningen, the Netherlands
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