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Javed N, El-Far M, Vittorio TJ. Clinical markers in heart failure: a narrative review. J Int Med Res 2024; 52:3000605241254330. [PMID: 38779976 PMCID: PMC11119339 DOI: 10.1177/03000605241254330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2023] [Accepted: 04/24/2024] [Indexed: 05/25/2024] Open
Abstract
Heart failure is a complex clinical syndrome that is one of the causes of high mortality worldwide. Additionally, healthcare systems around the world are also being burdened by the aging population and subsequently, increasing estimates of patients with heart failure. As a result, it is crucial to determine novel ways to reduce the healthcare costs, rate of hospitalizations and mortality. In this regard, clinical biomarkers play a very important role in stratifying risk, determining prognosis or diagnosis and monitoring patient responses to therapy. This narrative review discusses the wide spectrum of clinical biomarkers, novel inventions of new techniques, their advantages and limitations as well as applications. As heart failure rates increase, cost-effective diagnostic tools such as B-type natriuretic peptide and N-terminal pro b-type natriuretic peptide are crucial, with emerging markers like neprilysin and cardiac imaging showing promise, though larger studies are needed to confirm their effectiveness compared with traditional markers.
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Affiliation(s)
- Nismat Javed
- Department of Medicine, BronxCare Health System/BronxCare Hospital Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Markos El-Far
- American University of the Caribbean, Department of Medicine, Sint Maarten, West Indies
| | - Timothy J. Vittorio
- Department of Medicine, BronxCare Health System/BronxCare Hospital Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
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2
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Haywood HB, Graham AJ, Chermak D, Achanta A, Butler J, Fonarow GC, Greene SJ. Estimating the Proportion of Heart Failure Admissions Potentially Eligible for Hospital at Home. J Card Fail 2024:S1071-9164(24)00108-8. [PMID: 38588859 DOI: 10.1016/j.cardfail.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2024] [Revised: 02/27/2024] [Accepted: 03/12/2024] [Indexed: 04/10/2024]
Affiliation(s)
- Hubert B Haywood
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | - Aubrey Jolly Graham
- Department of Internal Medicine, Duke University School of Medicine, Durham, NC
| | | | - Aditya Achanta
- Department of Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX; Department of Medicine, University of Mississippi, Jackson, MI
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles, Los Angeles, CA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC; Division of Cardiology, Duke University School of Medicine, Durham, NC..
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3
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Yao Y, Zhou Z, Geng T, Cai A, Li T, Yang J, Chen J, Li L. Long-term cost-effectiveness of transcatheter mitral valve repair in HF patients with secondary mitral regurgitation. ESC Heart Fail 2024. [PMID: 38515335 DOI: 10.1002/ehf2.14729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/09/2024] [Accepted: 01/29/2024] [Indexed: 03/23/2024] Open
Abstract
AIMS The long-term cost-effectiveness of MitraClip in heart failure patients with secondary mitral regurgitation is still unclear. This study aimed to evaluate the long-term cost-effectiveness of MitraClip added to guideline-directed medical therapy vs. guideline-directed medical therapy alone in heart failure patients with secondary mitral regurgitation from the perspective of the healthcare systems of mainland China, the United Kingdom, Germany, and the United States. METHODS AND RESULTS A two-stage (decision + Markov) model was built. Health utilities were defined by the New York Heart Association class, heart failure re-hospitalization, and death and were calculated based on the 5 year follow-up results of the Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients With Functional Mitral Regurgitation trial. Direct healthcare costs were derived from the nationally representative data. Future utilities and costs were discounted at country-specific rates. The primary outcome was the lifetime incremental cost-effectiveness ratio. The mean age of the base case in our model was 72.2 years. Over a lifetime horizon, treatment with MitraClip was associated with 829 fewer heart failure re-hospitalizations per 1000 treated patients. The MitraClip treatment was associated with incremental quality-adjusted life-year gains of 0.71, 0.76, 0.78, and 0.78, as well as incremental cost-effectiveness ratios of ¥468 462, £28 910, €26 045, and $71 199 per quality-adjusted life-year for a lifetime horizon in mainland China, the United Kingdom, Germany, and the United States, respectively. In probabilistic sensitivity analysis, 0.2%, 59.4%, 99.6%, and 84.7% of patients were cost-effective in mainland China, the United Kingdom, Germany, and the United States at the country-specific willingness-to-pay thresholds. CONCLUSIONS MitraClip + guideline-directed medical therapy was cost-effective in heart failure patients with secondary mitral regurgitation in the United Kingdom, Germany, and the United States, but not in mainland China from the perspective of the national healthcare system.
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Affiliation(s)
- Younan Yao
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, 510080, China
| | - Ziyou Zhou
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, 510080, China
- Department of Cardiology, School of Medicine, South China University of Technology, Guangzhou, China
| | - Tian Geng
- Department of Emergency, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou, China
| | - Anping Cai
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, 510080, China
| | - Tian Li
- Department of Cardiology and Angiology, Medical Center, University of Freiburg, Freiburg im Breisgau, Germany
| | - Junqing Yang
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, 510080, China
| | - Jiyan Chen
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, 510080, China
- Department of Cardiology, School of Medicine, South China University of Technology, Guangzhou, China
| | - Liwen Li
- Department of Cardiology, Guangdong Cardiovascular Institute, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, No. 106, Zhongshan 2nd Road, Yuexiu District, Guangzhou, 510080, China
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4
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Lyle MA, Belkin MN. The Veterans Affairs' Dashboard Confessional: Vindication of the VA HF Dashboard. J Card Fail 2024; 30:460-461. [PMID: 38218347 DOI: 10.1016/j.cardfail.2023.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2023] [Accepted: 12/21/2023] [Indexed: 01/15/2024]
Affiliation(s)
- Melissa A Lyle
- Division of Advanced Heart Failure and Transplant Cardiology, Mayo Clinic, Jacksonville, Florida.
| | - Mark N Belkin
- Section of Cardiology, The University of Chicago Medicine, Chicago, Illinois
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5
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Gunn AH, Warraich HJ, Mentz RJ. Costs of care and financial hardship among patients with heart failure. Am Heart J 2024; 269:94-107. [PMID: 38065330 DOI: 10.1016/j.ahj.2023.12.001] [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] [Received: 08/01/2023] [Revised: 11/17/2023] [Accepted: 12/02/2023] [Indexed: 01/09/2024]
Abstract
With the implementation of new therapies, more patients are living with heart failure (HF) as a chronic condition. Alongside these advances, out-of-pocket (OOP) medical costs have increased, and patients experience significant financial burden. Despite increasing interest in understanding and mitigating financial burdens, there is a relative paucity of data specific to HF. Here, we explore financial hardship in HF from the patient perspective, including estimated OOP costs for guideline-directed medical therapy for HF with reduced ejection fraction, hospitalizations, and total direct medical costs, as well as the consequences of high OOP costs. Studies estimate that high OOP costs are common in HF, and a large proportion are related to prescription drugs. Subsequently, the effects on patients can lead to worsening adherence, delayed care, and poor outcomes, leading to a financial toxicity spiral. Further, we summarize patients' cost preferences and outline future research that is needed to develop evidence-based solutions to reduce costs in HF.
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Affiliation(s)
- Alexander H Gunn
- Department of Medicine, Duke University School of Medicine, Durham, NC.
| | - Haider J Warraich
- Department of Medicine, Brigham and Women's Hospital, Boston, MA; Harvard Medical School, Boston, MA; Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
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6
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Dixit NM, Parikh NU, Ziaeian B, Fonarow GC. Economic Modeling Analysis of an Intensive GDMT Optimization Program in Hospitalized Heart Failure Patients. Circ Heart Fail 2023; 16:e011218. [PMID: 37929591 PMCID: PMC10872946 DOI: 10.1161/circheartfailure.123.011218] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/23/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND The STRONG-HF trial (Safety, Tolerability and Efficacy of Up-Titration of Guideline-Directed Medical Therapies for Acute Heart Failure) demonstrated substantial reductions in the composite of mortality and morbidity over 6 months among hospitalized patients with heart failure (HF) who were randomized to intensive guideline-directed medical therapy (GDMT) optimization compared with usual care. Whether an intensive GDMT optimization program would be cost-effective for patients with HF with reduced ejection fraction is unknown. METHODS Using a 2-state Markov model, we evaluated the effect of an intensive GDMT optimization program on hospitalized patients with HF with reduced ejection fraction. Two population models were created to simulate this intervention, a clinical trial model, based on the participants in the STRONG-HF trial, and a real-world model, based on the Get With The Guidelines-HF registry of patients admitted with worsening HF. We then modeled the effect of a 6-month intensive triple therapy GDMT optimization program comprised of cardiologists, clinical pharmacists, and registered nurses. Hazard ratios from the intervention arm of the STRONG-HF trial were applied to both population models to simulate clinical and financial outcomes of an intensive GDMT optimization program from a US health care sector perspective with a lifetime time horizon. Optimal quadruple GDMT use was also modeled. RESULTS An intensive GDMT optimization program was extremely cost-effective with incremental cost-effectiveness ratios <$10 000 per quality-adjusted life-year in both models. Optimal quadruple GDMT implementation resulted in the most gains in life-years with incremental cost-effectiveness ratios of $60 000 and $54 000 in the clinical trial and real-world models, respectively. CONCLUSIONS An intensive GDMT optimization program for patients hospitalized with HF with reduced ejection fraction would be cost-effective and result in substantial gains in clinical outcomes, especially with the use of optimal quadruple GDMT. Clinicians, payers, and policymakers should prioritize the creation of such programs.
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Affiliation(s)
- Neal M. Dixit
- Division of Cardiovascular Medicine, Department of Medicine, University of California, Davis, Sacramento, California
| | - Neil U. Parikh
- School of Medicine, Keck School of Medicine of USC, Los Angeles, CA
| | - Boback Ziaeian
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
- Division of Cardiology, Veteran Affairs Greater Los Angeles Healthcare System, Los Angeles, CA
| | - Gregg C. Fonarow
- Division of Cardiology, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, CA
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7
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Bozkurt B, Ahmad T, Alexander KM, Baker WL, Bosak K, Breathett K, Fonarow GC, Heidenreich P, Ho JE, Hsich E, Ibrahim NE, Jones LM, Khan SS, Khazanie P, Koelling T, Krumholz HM, Khush KK, Lee C, Morris AA, Page RL, Pandey A, Piano MR, Stehlik J, Stevenson LW, Teerlink JR, Vaduganathan M, Ziaeian B. Heart Failure Epidemiology and Outcomes Statistics: A Report of the Heart Failure Society of America. J Card Fail 2023; 29:1412-1451. [PMID: 37797885 PMCID: PMC10864030 DOI: 10.1016/j.cardfail.2023.07.006] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/07/2023]
Affiliation(s)
- Biykem Bozkurt
- Winters Center for Heart Failure, Cardiology, Baylor College of Medicine, Houston, Texas.
| | - Tariq Ahmad
- Heart Failure Program Yale School of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kevin M Alexander
- Cardiovascular Medicine, Stanford University, Stanford University School of Medicine, Stanford, California
| | | | - Kelly Bosak
- KU Medical Center, School Of Nursing, Kansas City, Kansas
| | - Khadijah Breathett
- Division of Cardiology, Indiana University School of Medicine, Indianapolis, Indiana
| | - Gregg C Fonarow
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
| | - Paul Heidenreich
- Cardiovascular Medicine, Stanford University, Stanford University School of Medicine, Stanford, California
| | - Jennifer E Ho
- Advanced Heart Failure and Transplant Cardiology, Beth Israel Deaconess, Boston, Massachusetts
| | - Eileen Hsich
- Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Nasrien E Ibrahim
- Advanced Heart Failure and Transplant, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA
| | - Lenette M Jones
- Department of Health Behavior and Biological Sciences, University of Michigan, School of Nursing, Ann Arbor, Michigan
| | - Sadiya S Khan
- Northwestern University, Cardiology Feinberg School of Medicine, Chicago, Illinois
| | - Prateeti Khazanie
- Advanced Heart Failure and Transplant Cardiology, UC Health, Aurora, Colorado
| | - Todd Koelling
- Frankel Cardiovascular Center. University of Michigan, Ann Arbor, Michigan
| | - Harlan M Krumholz
- Heart Failure Program Yale School of Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Kiran K Khush
- Cardiovascular Medicine, Stanford University, Stanford University School of Medicine, Stanford, California
| | - Christopher Lee
- Boston College William F. Connell School of Nursing, Boston, Massachusetts
| | - Alanna A Morris
- Division of Cardiology, Emory School of Medicine, Atlanta, Georgia
| | - Robert L Page
- Departments of Clinical Pharmacy and Physical Medicine, University of Colorado, Aurora, Colorado
| | - Ambarish Pandey
- Cardiology, Department of Medicine, UT Southwestern Medical Center, Dallas, Texas
| | | | - Josef Stehlik
- Advanced Heart Failure Section, Cardiology, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - John R Teerlink
- Cardiology University of California San Francisco (UCSF), San Francisco, California
| | - Muthiah Vaduganathan
- Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Boback Ziaeian
- Division of Cardiology, University of California Los Angeles, Los Angeles, California
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8
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Haywood HB, Fonarow GC, Khan MS, Van Spall HGC, Morris AA, Nassif ME, Kittleson MM, Butler J, Greene SJ. Hospital at Home as a Treatment Strategy for Worsening Heart Failure. Circ Heart Fail 2023; 16:e010456. [PMID: 37646170 DOI: 10.1161/circheartfailure.122.010456] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 07/17/2023] [Indexed: 09/01/2023]
Abstract
Hospital at home (HaH) is an innovative care model that may be particularly suited for heart failure (HF). Outpatient visits and inpatient care have been the 2 traditional settings for HF care, yet may not match the social and medical needs of patients at all times. Alternative models such as HaH may represent an effective and patient-centered option for select patients with worsening HF. To date, limited research in HF and other disease states has supported HaH as being safe and lower cost than traditional inpatient admission. Supporting HaH are new payment structures, such as Medicare's Acute Hospital Care at Home waiver program. In combination with outpatient visits, outpatient intravenous diuretic clinics, inpatient care, and cardiac intensive care, HaH could be a core component of a comprehensive care model with the potential to match resource utilization with the needs of patients across the spectrum of HF severity, and improve patient outcomes.
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Affiliation(s)
- Hubert B Haywood
- Department of Medicine, Duke University Medical Center, Durham, NC (H.B.H.)
| | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center, University of California Los Angeles Medical Center (G.C.F.)
| | | | - Harriette G C Van Spall
- Department of Medicine (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
- Population Health Research Institute (H.G.C.V.S.), McMaster University, Hamilton, ON, Canada
| | | | - Michael E Nassif
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City (M.E.N.)
| | - Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA (M.M.K.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
- Department of Medicine, University of Mississippi, Jackson (J.B.)
| | - Stephen J Greene
- Division of Cardiology, Duke University Medical Center, Durham, NC (M.S.K., S.J.G.)
- Duke Clinical Research Institute, Durham, NC (S.J.G.)
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9
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Samson R, Le Jemtel TH. Sacubitril-Valsartan in Heart Failure: The Hard Sell of Spending More to Save Later. Am J Cardiol 2023; 202:237-238. [PMID: 37495439 DOI: 10.1016/j.amjcard.2023.06.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 06/29/2023] [Indexed: 07/28/2023]
Affiliation(s)
- Rohan Samson
- Advanced Heart Failure Therapies Program, University of Louisville Health-Jewish Hospital, Louisville, Kentucky.
| | - Thierry H Le Jemtel
- Section of Cardiology, John W. Deming Department of Medicine, Tulane University School of Medicine, New Orleans, Louisiana
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10
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Sukumar S, Wasfy JH, Januzzi JL, Peppercorn J, Chino F, Warraich HJ. Financial Toxicity of Medical Management of Heart Failure: JACC Review Topic of the Week. J Am Coll Cardiol 2023; 81:2043-2055. [PMID: 37197848 DOI: 10.1016/j.jacc.2023.03.402] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 03/01/2023] [Accepted: 03/06/2023] [Indexed: 05/19/2023]
Abstract
Optimal medical management of heart failure (HF) improves quality of life, decreases mortality, and decreases hospitalizations. Cost may contribute to suboptimal adherence to HF medications, especially angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors. Patients' experiences with HF medication cost include financial burden, financial strain, and financial toxicity. Although there has been research studying financial toxicity in patients with some chronic diseases, there are no validated tools for measuring financial toxicity of HF, and very few data on the subjective experiences of patients with HF and financial toxicity. Strategies to decrease HF-associated financial toxicity include making systemic changes to minimize cost sharing, optimizing shared decision-making, implementing policies to lower drug costs, broadening insurance coverage, and using financial navigation services and discount programs. Clinicians may also improve patient financial wellness through various strategies in routine clinical care. Future research is needed to study financial toxicity and associated patient experiences for HF.
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Affiliation(s)
- Smrithi Sukumar
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA. https://twitter.com/SmrithiSukumar
| | - Jason H Wasfy
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - James L Januzzi
- Department of Medicine, Cardiology Division, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jeffrey Peppercorn
- Department of Medicine, Division of Hematology/Oncology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Fumiko Chino
- Memorial Sloan Kettering, New York, New York, USA
| | - Haider J Warraich
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA; Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, Massachusetts, USA.
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11
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Harrington J, Sun JL, Fonarow GC, Heitner SB, Divanji PH, Binder G, Allen LA, Alhanti B, Yancy CW, Albert NM, DeVore AD, Felker GM, Greene SJ. Clinical Profile, Health Care Costs, and Outcomes of Patients Hospitalized for Heart Failure With Severely Reduced Ejection Fraction. J Am Heart Assoc 2023; 12:e028820. [PMID: 37158118 DOI: 10.1161/jaha.122.028820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/10/2023]
Abstract
Background Many patients with heart failure (HF) have severely reduced ejection fraction but do not meet threshold for consideration of advanced therapies (ie, stage D HF). The clinical profile and health care costs associated with these patients in US practice is not well described. Methods and Results We examined patients hospitalized for worsening chronic heart failure with reduced ejection fraction ≤40% from 2014 to 2019 in the GWTG-HF (Get With The Guidelines-Heart Failure) registry, who did not receive advanced HF therapies or have end-stage kidney disease. Patients with severely reduced EF defined as EF ≤30% were compared with those with EF 31% to 40% in terms of clinical profile and guideline-directed medical therapy. Among Medicare beneficiaries, postdischarge outcomes and health care expenditure were compared. Among 113 348 patients with EF ≤40%, 69% (78 589) had an EF ≤30%. Patients with severely reduced EF ≤30% tended to be younger and were more likely to be Black. Patients with EF ≤30% also tended to have fewer comorbidities and were more likely to be prescribed guideline-directed medical therapy ("triple therapy" 28.3% versus 18.2%, P<0.001). At 12-months postdischarge, patients with EF ≤30% had significantly higher risk of death (HR, 1.13 [95% CI, 1.08-1.18]) and HF hospitalization (HR, 1.14 [95% CI, 1.09-1.19]), with similar risk of all-cause hospitalizations. Health care expenditures were numerically higher for patients with EF ≤30% (median US$22 648 versus $21 392, P=0.11). Conclusions Among patients hospitalized for worsening chronic heart failure with reduced ejection fraction in US clinical practice, most patients have severely reduced EF ≤30%. Despite younger age and modestly higher use of guideline-directed medical therapy at discharge, patients with severely reduced EF face heightened postdischarge risk of death and HF hospitalization.
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Affiliation(s)
- Josephine Harrington
- Division of Cardiology Duke University School of Medicine Durham NC
- Duke Clinical Research Institute Durham NC USA
| | | | - Gregg C Fonarow
- Division of Cardiology, Ahmanson-UCLA Cardiomyopathy Center University of California Los Angeles Medical Center Los Angeles CA
| | | | | | | | - Larry A Allen
- Division of Cardiology & Colorado Cardiovascular Outcomes Research Consortium University of Colorado School of Medicine Aurora CO
| | | | - Clyde W Yancy
- Division of Cardiology Northwestern University Feinberg School of Medicine Chicago IL
| | - Nancy M Albert
- Nursing Institute and Kaufman Center for Heart Failure Cleveland Clinic Cleveland OH
| | - Adam D DeVore
- Division of Cardiology Duke University School of Medicine Durham NC
- Duke Clinical Research Institute Durham NC USA
| | - G Michael Felker
- Division of Cardiology Duke University School of Medicine Durham NC
- Duke Clinical Research Institute Durham NC USA
| | - Stephen J Greene
- Division of Cardiology Duke University School of Medicine Durham NC
- Duke Clinical Research Institute Durham NC USA
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12
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Ostrominski JW, Vaduganathan M, Claggett BL, de Boer RA, Desai AS, Dobreanu D, Hernandez AF, Inzucchi SE, Jhund PS, Kosiborod M, Lam CSP, Langkilde AM, Lindholm D, Martinez FA, O'Meara E, Petersson M, Shah SJ, Thierer J, McMurray JJV, Solomon SD. Dapagliflozin and New York Heart Association functional class in heart failure with mildly reduced or preserved ejection fraction: the DELIVER trial. Eur J Heart Fail 2022; 24:1892-1901. [PMID: 36054231 DOI: 10.1002/ejhf.2652] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/23/2022] [Revised: 08/01/2022] [Accepted: 08/06/2022] [Indexed: 01/07/2023] Open
Abstract
AIMS This pre-specified analysis of the DELIVER trial examined whether clinical benefits of dapagliflozin in heart failure (HF) with left ventricular ejection fraction (LVEF) >40% varied by baseline New York Heart Association (NYHA) class and examined the treatment effects on NYHA class over time. METHODS AND RESULTS Treatment effects of dapagliflozin by baseline NYHA class II (n = 4713) versus III/IV (n = 1549) were examined on the primary endpoint (cardiovascular death or worsening HF event) and key secondary endpoints. Effects of dapagliflozin on change in NYHA class at 4, 16, and 32 weeks were also evaluated. Higher baseline NYHA class was associated with older age, female sex, greater comorbidity burden, lower LVEF, and higher natriuretic peptide levels. Participants with baseline NYHA class III/IV, as compared with II, were independently more likely to experience the primary endpoint (adjusted hazard ratio [HR] 1.16 [95% confidence interval, 1.02-1.33]) and all-cause death (adjusted HR 1.22 [1.06-1.40]). Dapagliflozin consistently reduced the risk of the primary endpoint compared with placebo, irrespective of baseline NYHA class (HR 0.81 [0.70-0.94] for NYHA class II vs. HR 0.80 [0.65-0.98] for NYHA class III/IV; pinteraction = 0.921). Participants with NYHA class III/IV had greater improvement in Kansas City Cardiomyopathy Questionnaire total symptom scores between baseline and 32 weeks (+4.8 [2.5-7.1]) versus NYHA class II (+1.8 [0.7-2.9]; pinteraction = 0.011). Dapagliflozin was associated with higher odds of any improvement in NYHA class (odds ratio [OR] 1.32 [1.16-1.51]), as well as improvement to NYHA class I (OR 1.43 [1.17-1.75]), versus placebo at 32 weeks, with benefits seen as early as 4 weeks. CONCLUSIONS Among symptomatic patients with HF and LVEF >40%, treatment with dapagliflozin provided clinical benefit irrespective of baseline NYHA class and was associated with early and sustained improvements in NYHA class over time.
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Affiliation(s)
- John W Ostrominski
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Rudolf A de Boer
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Dan Dobreanu
- University of Medicine, Pharmacy, Science and Technology "G.E. Palade", Târgu Mures, Romania
| | - Adrian F Hernandez
- Department of Medicine, Duke University, Durham, NC, USA
- Duke Clinical Research Institute, Duke University, Durham, NC, USA
| | - Silvio E Inzucchi
- Section of Endocrinology, Yale University School of Medicine, New Haven, CT, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Mikhail Kosiborod
- St Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MI, USA
| | - Carolyn S P Lam
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Anna M Langkilde
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Daniel Lindholm
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, Gothenburg, Sweden
| | | | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Magnus Petersson
- Late Stage Development, Cardiovascular, Renal and Metabolism, BioPharmaceuticals R&D, Gothenburg, Sweden
| | - Sanjiv J Shah
- Feinberg Cardiovascular Research Institute, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Jorge Thierer
- Jefe de Unidad de Insuficiencia Cardíaca, Centro de Educatión Médica e Investigaciones Clínicas Norberto Quirno (CEMIC), Buenos Aires, Argentina
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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13
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Khan MS, Butler J, Vaduganathan M, Greene SJ. Heart Failure Specific Versus All-Cause Endpoints in Heart Failure Clinical Trials. J Card Fail 2022; 28:1398-1400. [PMID: 35843491 DOI: 10.1016/j.cardfail.2022.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 07/08/2022] [Indexed: 11/19/2022]
Affiliation(s)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas; Department of Medicine, University of Mississippi, Jackson, Mississippi
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina; Duke Clinical Research Institute, Durham, North Carolina.
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