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Weidenhammer A, Prausmüller S, Stadler M, Panagiotides N, Spinka G, Heitzinger G, Arfsten H, Strunk G, Barkhudaryan A, Partsch C, Bartko P, Goliasch G, Hengstenberg C, Hülsmann M, Pavo N. Eligibility and GDMT up-titration success in heart failure: A real-world assessment. PLoS One 2025; 20:e0323952. [PMID: 40424377 PMCID: PMC12112052 DOI: 10.1371/journal.pone.0323952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2025] [Accepted: 04/17/2025] [Indexed: 05/29/2025] Open
Abstract
BACKGROUND Implementation of GDMT in HFrEF remains incomplete. Prescription manners may vary based on the development of adverse effects. An HFA position paper proposed patient profiling and individualized prescription manners. This study aims to assess the eligibility for GDMT up-titration and its success in the context of clinical profiles in chronic severe HFrEF outpatients. METHODS Clinical characteristics of 900 HFrEF patients at first presentation were assessed, and GDMT up-titration limiting factors were identified by applying thresholds of mutual consent. GDMT prescription was analyzed at 6 months and 1 year. RESULTS 75% of patients had no GDMT up-titration limiting factor at baseline. Significant up-titration could be achieved in all four HF drug classes, especially within the first 6 months, irrespective of GDMT up-titration limiting factors (p ≤ 0.035 for administration and dosage, all drug classes). During up-titration, there was a balanced transition between up-titration limiting factors. 35% of patients received triple therapy on target dosages with a 2.6% one-year mortality rate. Regarding the HFA profiles, 62% of patients could not be classified into a specific HFA phenotype, including most severe patients. 98% of classifiable patients belonged to only four phenotypes, while GDMT up-titration could be achieved in all of these HFA profiles (p ≤ 0.007). CONCLUSION In this real-world study, 75% of patients with chronic severe HFrEF are eligible for GDMT up-titration towards target dosages. The clinical profile concept of the HFA might be adapted, as most classifiable patients can be up-titrated, and most severe patients are missed by the classification.
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Affiliation(s)
- Annika Weidenhammer
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Suriya Prausmüller
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Marc Stadler
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Noel Panagiotides
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Georg Spinka
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Gregor Heitzinger
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Henrike Arfsten
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Guido Strunk
- Complexity Research, Schönbrunner Straße 32, Vienna, Austria
| | - Anush Barkhudaryan
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
- Department of Cardiology, Clinic of General and Invasive Cardiology, University Clinical Hospital № 1, Yerevan State Medical University,
- “Yerevan„ Scientific Medical Center, Yerevan, Armenia
| | - Clemens Partsch
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Philipp Bartko
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Georg Goliasch
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Christian Hengstenberg
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Martin Hülsmann
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
| | - Noemi Pavo
- Department of Internal Medicine II, Clinical Division of Cardiology, Medical University of Vienna, Vienna, Austria
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2
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Basile P, Falagario A, Carella MC, Dicorato MM, Monitillo F, Santoro D, Naccarati ML, Pontone G, Ciccone MM, Santobuono VE, Guaricci AI. Eligibility of Outpatients with Chronic Heart Failure for Vericiguat and Omecamtiv Mecarbil: From Clinical Trials to the Real-World Practice. J Clin Med 2025; 14:1951. [PMID: 40142759 PMCID: PMC11942821 DOI: 10.3390/jcm14061951] [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: 01/31/2025] [Revised: 03/03/2025] [Accepted: 03/12/2025] [Indexed: 03/28/2025] Open
Abstract
Background: Several drugs are emerging as potential therapeutic resources in the context of chronic heart failure (CHF), although their impact on daily clinical practice remains unknown. The objective of this study was to investigate the theoretical eligibility for vericiguat and omecamtiv mecarbil (OM) in a real-world outpatient setting. Methods: A cross-sectional observational study was conducted, enrolling all patients with CHF who had at least one visit between January 2023 and January 2024 in a dedicated outpatient clinic of a tertiary referral center. Theoretical eligibility for vericiguat and OM in our population was assessed by adopting the criteria of the respective phase III clinical trials (VICTORIA trial for vericiguat and GALACTIC-HF trial for OM). Results: In 350 patients with CHF, the rate of individuals eligible was 2% for vericiguat and 4% for OM. A value for left ventricular ejection fraction (LVEF) over the clinical trials' cutoffs was observed in 41% of cases for vericiguat and 69% for OM. The absence of a recent heart failure (HF) worsening was found in 78% of cases for vericiguat and 72% for OM. Conclusions: Only a small proportion of CHF patients would be eligible for vericiguat and OM in a real-world outpatient setting. The absence of a recent HF worsening and an LVEF over the established trials' cutoffs are the main causes of non-eligibility. Further studies are required to assess the efficacy of these drugs in a wider population in order to increase the candidates for these beneficial treatments.
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Affiliation(s)
- Paolo Basile
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
| | - Alessio Falagario
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
| | - Maria Cristina Carella
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
| | - Marco Maria Dicorato
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
| | - Francesco Monitillo
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
| | - Daniela Santoro
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
| | - Maria Ludovica Naccarati
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
| | - Gianluca Pontone
- Department of Perioperative Cardiology and Cardiovascular Imaging, IRCCS Centro Cardiologico Monzino, 20138 Milan, Italy;
- Department of Biomedical, Surgical and Dental Sciences, University of Milan, 20122 Milan, Italy
| | - Marco Matteo Ciccone
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
| | - Vincenzo Ezio Santobuono
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
| | - Andrea Igoren Guaricci
- Cardiology Unit, Interdisciplinary Department of Medicine, University of Bari “Aldo Moro”, Polyclinic University Hospital, 70121 Bari, Italy; (P.B.); (A.F.); (M.C.C.); (M.M.D.); (F.M.); (D.S.); (M.L.N.); (M.M.C.); (V.E.S.)
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3
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Chen S, Ou W, Gan S, Chen L, Liu B, Zhang Z. Effect of sodium-glucose Co-transporter 2 inhibitors on coronary microcirculation. Front Pharmacol 2025; 16:1523727. [PMID: 40093320 PMCID: PMC11906428 DOI: 10.3389/fphar.2025.1523727] [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: 11/06/2024] [Accepted: 02/10/2025] [Indexed: 03/19/2025] Open
Abstract
Coronary microvascular disease (CMVD) has emerged as a new target for the occurrence and development of heart failure treatment. Various indicators such as Index of Microvascular Resistance, Coronary Flow Reserve, Microvascular Resistance Reserve, Hyperemic Microvascular Resistance and Coronary Flow Velocity Reserve can be used to assess CMVD. Coronary microcirculation dysfunction is one of the important pathogenic mechanisms of heart failure. Sodium-Glucose Co-Transporter 2 (SGLT2) Inhibitors have been widely used in the treatment of various types of heart failure, but their specific pharmacological mechanisms are not yet fully understood. Studies have shown that SGLT2 inhibitors may be involved in the pathophysiology of CMVD by regulating cellular pathophysiological processes such as oxidative stress, mitochondrial function, energy metabolism, vascular genesis, and signalling pathways. Therefore, coronary microvascular dysfunction may be one of the treatment targets of using SGLT2 inhibitors in heart failure. Several animal experiments have found that SGLT2 inhibitors can improve microcirculatory dysfunction. However, the results of several clinical trials on the effects of SGLT2 inhibitors on coronary microcirculation have been different. Therefore, it is still lack of conclusive evidence on the effects of SGLT2 inhibitors on microcirculatory dysfunction. This review aims to summarize the completed and ongoing experiments regarding the effects of SGLT2 inhibitors on coronary microcirculation, in order to better elucidate the impact of SGLT2 inhibitors on microcirculation. It seeks to provide valuable information for the pharmacological mechanisms of SGLT2 inhibitors, the study of diseases related to coronary microcirculation disorders, and the treatment of heart failure.
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Affiliation(s)
- Shaoxin Chen
- *Correspondence: Shaoxin Chen, ; Zhenhong Zhang,
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Dimond MG, Rosner CM, Lee SB, Shakoor U, Samadani T, Batchelor WB, Damluji AA, Desai SS, Epps KC, Flanagan MC, Moukhachen H, Raja A, Sherwood MW, Singh R, Shah P, Tang D, Tehrani BN, Truesdell AG, Young KD, Fiuzat M, O'Connor CM, Sinha SS, Psotka MA. Guideline-directed medical therapy implementation during hospitalization for cardiogenic shock. ESC Heart Fail 2025; 12:60-70. [PMID: 39327768 PMCID: PMC11769606 DOI: 10.1002/ehf2.14863] [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: 03/22/2024] [Revised: 04/24/2024] [Accepted: 05/07/2024] [Indexed: 09/28/2024] Open
Abstract
AIMS Despite significant morbidity and mortality, recent advances in cardiogenic shock (CS) management have been associated with increased survival. However, little is known regarding the management of patients who survive CS with heart failure (HF) with reduced left ventricular ejection fraction (LVEF, HFrEF), and the utilization of guideline-directed medical therapy (GDMT) in these patients has not been well described. To fill this gap, we investigated the use of GDMT during an admission for CS and short-term outcomes using the Inova single-centre shock registry. METHODS We investigated the implementation of GDMT for patients who survived an admission for CS with HFrEF using data from our single-centre shock registry from January 2017 to December 2019. Baseline characteristics, discharge clinical status, data on GDMT utilization and 30 day, 6 month and 12 month patient outcomes were collected by retrospective chart review. RESULTS Among 520 patients hospitalized for CS during the study period, 185 (35.6%) had HFrEF upon survival to discharge. The median age was 64 years [interquartile range (IQR) 56, 70], 72% (n = 133) were male, 22% (n = 40) were Black and 7% (n = 12) were Hispanic. Forty-one per cent of patients (n = 76) presented with shock related to acute myocardial infarction (AMI), while 59% (n = 109) had HF-related CS (HF-CS). The median length of hospital stay was 12 days (IQR 7, 18). At discharge, the proportions of patients on beta-blockers, angiotensin-converting enzyme inhibitors (ACEis)/angiotensin receptor blockers (ARBs)/angiotensin receptor/neprilysin inhibitors (ARNIs) and mineralocorticoid receptor antagonists (MRAs) were 78% (n = 144), 58% (n = 107) and 55% (n = 101), respectively. Utilization of three-drug GDMT was 33.0% (n = 61). Ten per cent of CS survivors with HFrEF (n = 19) were not prescribed any component of GDMT at discharge. Multivariable logistic regression adjusted for baseline GDMT use revealed that patients with lower LVEF and those who transferred to our centre from an outside hospital were more likely to experience GDMT addition (P < 0.05). Patients prescribed at least one additional class of GDMT during admission had higher odds of 6 month and 1 year survival (P < 0.01): On average, 6 month survival odds were 7.1 times greater [confidence interval (CI) 1.9, 28.5] and 1 year survival odds were 6.0 times greater than those who did not have at least one GDMT added (CI 1.9, 20.5). CONCLUSIONS Most patients who survived CS admission with HFrEF in this single-centre CS registry were not prescribed all classes or goal doses of GDMT at hospital discharge. These findings highlight an urgent need to augment multidisciplinary efforts to enhance the post-discharge medical management and outcomes of patients who survive CS with HFrEF.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Kelly C. Epps
- Inova Schar Heart and VascularFalls ChurchVirginiaUSA
| | | | | | - Anika Raja
- Inova Schar Heart and VascularFalls ChurchVirginiaUSA
| | | | - Ramesh Singh
- Inova Schar Heart and VascularFalls ChurchVirginiaUSA
| | - Palak Shah
- Inova Schar Heart and VascularFalls ChurchVirginiaUSA
| | - Daniel Tang
- Inova Schar Heart and VascularFalls ChurchVirginiaUSA
| | | | | | - Karl D. Young
- Inova Schar Heart and VascularFalls ChurchVirginiaUSA
| | - Mona Fiuzat
- Duke University Medical CenterDurhamNorth CarolinaUSA
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5
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Saveski D, Kok M, Poon S, Rojas-Fernandez C, Virani SA, Honos G, McKelvie R. The Canadian Heart Failure (CAN-HF) Registry: A Canadian Multicentre, Retrospective Study of Outpatients with Heart Failure. CJC Open 2025; 7:1-9. [PMID: 39872639 PMCID: PMC11763239 DOI: 10.1016/j.cjco.2024.09.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 09/17/2024] [Indexed: 01/30/2025] Open
Abstract
Background Guideline-directed medical therapy (GDMT) reduces events in patients with heart failure (HF) with reduced ejection fraction (HFrEF). Despite this impact, underutilization of GDMT persists. This report sought to describe HF management in Canadian outpatients treated at specialized HF clinics (HFCs). Methods The Canadian Heart Failure (CAN-HF) study was retrospective and observational, and it included 1775 patients from 6 Canadian outpatient HFCs, from the period January 2017-April 2020. Results We observed improvement in prescription rates in patients with HFrEF, between their first visit and their most-recent clinic visit, across all GDMT classes, in those who were followed at the HFC for ≥ 6 months. The largest prescription rate increases were observed for angiotensin receptor-neprilysin inhibitors and mineralocorticoid-receptor antagonists. However, more than half of the patients remained on angiotensin-converting enzyme inhibitors and/or angiotensin-receptor blockers, despite being symptomatic, according to their New York Heart Association class. Most patients (50%) were on triple therapy, as of their most-recent visit, with fewer (36%) on dual therapy, monotherapy (13%), or no GDMT (2%). Our data also suggest that patients who had been managed at the HFC for > 6 months had higher prescription rates of GDMT and were on higher doses of GDMT, compared to those who were new to the clinic. For patients with HF with preserved ejection fraction, few patients were on candesartan and less than half were on a mineralocorticoid-receptor antagonist. Conclusions Our data from HFCs that in most cases were affiliated with academic centres compare favourably with data from other analyses of ambulatory patients with HFrEF, evidence that supports the use of a specialized patient-care model.
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Affiliation(s)
- Dimitar Saveski
- St Joseph’s Health Care, Western University, London, Ontario, Canada
| | - Melanie Kok
- Novartis Pharmaceuticals Canada Inc., Montreal, Quebec, Canada
| | - Stephanie Poon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | - Sean A. Virani
- University of British Columbia, Vancouver, British Columbia, Canada
| | - George Honos
- Center Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Robert McKelvie
- St Joseph’s Health Care, Western University, London, Ontario, Canada
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6
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Johnston ED, Smith CB, Van Tuyl JS. Effects of Implementing a Heart Failure Order Set to Optimize Guideline-Directed Medical Therapy and Diuresis in Patients with Acute Heart Failure. Hosp Pharm 2024:00185787241295983. [PMID: 39544837 PMCID: PMC11559925 DOI: 10.1177/00185787241295983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2024]
Abstract
Background: Utilization of guideline-directed medical therapy in patients hospitalized for acute heart failure is suboptimal during the hospitalization and after discharge. An inpatient heart failure order set may be a convenient and useful intervention to improve heart failure therapy in the inpatient setting. Methods: This is a retrospective study that assessed the use of an inpatient heart failure order set on pharmacologic therapy in patients hospitalized for acute heart failure from May to August 2022. Patients with heart failure with an ejection fraction less than 50% were included in the analysis. The co-primary endpoints were maintenance or optimization of guideline-directed medical therapy during the hospitalization. Results: Maintenance of guideline-directed medical therapy was significantly greater when providers used the heart failure order set (OR 2.35, 95% CI 1.03-5.33, P = .041). Optimization of guideline-directed medical therapy was also statistically greater with use of the order set (OR 11.31, 95% CI 4.37-29.31, P < .001). Conclusions: An inpatient heart failure order set may be an effective strategy to improve heart failure pharmacotherapy in patients hospitalized with acute heart failure.
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Affiliation(s)
| | - Carmen B. Smith
- SSM Health Saint Louis University Hospital, Saint Louis, MO, USA
- St. Louis College of Pharmacy at UHSP, Saint Louis, MO, USA
| | - Joseph S. Van Tuyl
- SSM Health Saint Louis University Hospital, Saint Louis, MO, USA
- St. Louis College of Pharmacy at UHSP, Saint Louis, MO, USA
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7
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Licskai C, Hussey A, Ferrone M, Faulds C, Fisk M, Narayan S, O’Callahan T, Scarffe A, Sibbald S, Singh D, To T, Tuomi J, McKelvie R. An Innovative Patient-Centred Approach to Heart Failure Management: The Best Care Heart Failure Integrated Disease-Management Program. CJC Open 2024; 6:989-1000. [PMID: 39211747 PMCID: PMC11357758 DOI: 10.1016/j.cjco.2024.03.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2024] [Accepted: 03/31/2024] [Indexed: 09/04/2024] Open
Abstract
Background The management of heart failure (HF) is challenging because of the complexities in recommended therapies. Integrated disease management (IDM) is an effective model, promoting guideline-directed care, but the impact of IDM in the community setting requires further evaluation. Methods A retrospective evaluation of community-based IDM. Patient characteristics were described, and outcomes using a pre- and post-intervention design were HF-related health-service use, quality of life, and concordance with guideline-directed medical therapy (GDMT). Results 715 patients were treated in the program (2016 to 2023), 219 in a community specialist-care clinic, and 496 in 25 primary-care clinics. The overall cohort was predominantly male (60%), with a mean age of 73.5 years (± 10.7), and 60% with HF with reduced ejection fraction. In patients with ≥ 6 months of follow-up (n = 267), pre vs post annualized rates of HF-related acute health-service use decreased from 36.3 to 8.5 hospitalizations per 100 patients per year, P < 0.0001, from 31.8 to 13.1 emergency department visits per 100 patients per year, P < 0.0001, and from 152.8 to 110.0 urgent physician visits per 100 patients per year, P = 0.0001. The level of concordance with GDMT improved; the number of patients receiving triple therapy and quadruple therapy increased by 10.1% (95% confidence interval [CI], 2.4%,17.8%) and 19.6% (95% CI, 12.0%, 27.3%), respectively. Within these groups, optimal dosing was achieved in 42.5% (95% CI, 32.0%, 53.6%) and 35.0% (95% CI, 23.1%, 48.4%), respectively. In patients with at least one follow-up visit (n = 286), > 50% experienced a clinically relevant improvement in their quality of life. Conclusions A community-based IDM program for HF, may reduce HF-related acute health-service use, improve quality of life and level of concordance with GDMT. These encouraging preliminary outcomes from a real-world program evaluation require confirmation in a randomized controlled trial.
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Affiliation(s)
- Christopher Licskai
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Asthma Research Group Windsor-Essex County Inc., Windsor, Ontario, Canada
- London Health Sciences Centre, London, Ontario, Canada
| | - Anna Hussey
- Asthma Research Group Windsor-Essex County Inc., Windsor, Ontario, Canada
| | - Madonna Ferrone
- Asthma Research Group Windsor-Essex County Inc., Windsor, Ontario, Canada
- Hotel-Dieu Grace Healthcare, Windsor, Ontario, Canada
| | - Cathy Faulds
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Asthma Research Group Windsor-Essex County Inc., Windsor, Ontario, Canada
| | - Melissa Fisk
- Asthma Research Group Windsor-Essex County Inc., Windsor, Ontario, Canada
| | - Shanil Narayan
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- Huron Perth Health Care Alliance, Stratford, Ontario, Canada
- Huron Perth & Area Ontario Health Team, Stratford, Ontario, Canada
| | - Tim O’Callahan
- Asthma Research Group Windsor-Essex County Inc., Windsor, Ontario, Canada
| | - Andrew Scarffe
- Telfer School of Management, University of Ottawa, Ottawa, Ontario, Canada
| | - Shannon Sibbald
- Faculty of Health Sciences, Western University, London, Ontario, Canada
| | | | - Teresa To
- The Hospital for Sick Children, Toronto, Ontario, Canada
- ICES, Toronto, Ontario, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
| | - Jari Tuomi
- North Bay Regional Health Centre, North Bay, Ontario, Canada
| | - Robert McKelvie
- Schulich School of Medicine and Dentistry, Western University, London, Ontario, Canada
- St. Joseph’s Health Care, London, Ontario, Canada
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8
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Savarese G, Lindberg F, Cannata A, Chioncel O, Stolfo D, Musella F, Tomasoni D, Abdelhamid M, Banerjee D, Bayes-Genis A, Berthelot E, Braunschweig F, Coats AJS, Girerd N, Jankowska EA, Hill L, Lainscak M, Lopatin Y, Lund LH, Maggioni AP, Moura B, Rakisheva A, Ray R, Seferovic PM, Skouri H, Vitale C, Volterrani M, Metra M, Rosano GMC. How to tackle therapeutic inertia in heart failure with reduced ejection fraction. A scientific statement of the Heart Failure Association of the ESC. Eur J Heart Fail 2024; 26:1278-1297. [PMID: 38778738 DOI: 10.1002/ejhf.3295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 05/25/2024] Open
Abstract
Guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF) reduces morbidity and mortality, but its implementation is often poor in daily clinical practice. Barriers to implementation include clinical and organizational factors that might contribute to clinical inertia, i.e. avoidance/delay of recommended treatment initiation/optimization. The spectrum of strategies that might be applied to foster GDMT implementation is wide, and involves the organizational set-up of heart failure care pathways, tailored drug initiation/optimization strategies increasing the chance of successful implementation, digital tools/telehealth interventions, educational activities and strategies targeting patient/physician awareness, and use of quality registries. This scientific statement by the Heart Failure Association of the ESC provides an overview of the current state of GDMT implementation in HFrEF, clinical and organizational barriers to implementation, and aims at suggesting a comprehensive framework on how to overcome clinical inertia and ultimately improve implementation of GDMT in HFrEF based on up-to-date evidence.
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Affiliation(s)
- Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Felix Lindberg
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Antonio Cannata
- School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
- Department of Cardiology, King's College Hospital NHS Foundation Trust, London, UK
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', and University of Medicine Carol Davila, Bucharest, Romania
| | - Davide Stolfo
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Division of Cardiology, Cardiothoracovascular Department, Azienda Sanitaria Universitaria Integrata di Trieste, Trieste, Italy
| | - Francesca Musella
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Cardiology Department, Santa Maria delle Grazie Hospital, Naples, Italy
| | - Daniela Tomasoni
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Magdy Abdelhamid
- Faculty of Medicine, Kasr Al Ainy, Department of Cardiology, Cairo University, Cairo, Egypt
| | - Debasish Banerjee
- Renal and Transplantation Unit, St George's University Hospitals NHS Foundation Trust, Cardiovascular and Genetics Research Institute, St George's University, London, UK
| | - Antoni Bayes-Genis
- Heart Institute, Hospital Universitari Germans Trias I Pujol, CIBERCV, Badalona, Spain
| | | | - Frieder Braunschweig
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | | | - Nicolas Girerd
- Centre d'Investigation Clinique Plurithémathique Pierre Drouin & Département de Cardiologie Institut Lorrain du Cœur et des Vaisseaux, Université de Lorraine, CHRU-Nancy, Vandœuvre-lès-Nancy, France
| | - Ewa A Jankowska
- Institute of Heart Diseases, Wroclaw Medical University and Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Loreena Hill
- School of Nursing and Midwifery, Queen's University, Belfast, UK
| | - Mitja Lainscak
- Faculty of Medicine, University of Ljubljana, Ljubljana, Slovenia
| | - Yury Lopatin
- Volgograd State Medical University, Regional Cardiology Centre, Volgograd, Russia
| | - Lars H Lund
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
- Heart and Vascular Center, Karolinska University Hospital, Stockholm, Sweden
| | - Aldo P Maggioni
- ANMCO Research Center, Heart Care Foundation, Florence, Italy
| | - Brenda Moura
- Armed Forces Hospital, Faculty of Medicine of University of Porto, Porto, Portugal
| | - Amina Rakisheva
- City Cardiology Center, Konaev City Hospital, Almaty Region, Kazakhstan
| | - Robin Ray
- Department of Cardiology, St George's University Hospital, London, UK
| | - Petar M Seferovic
- University Medical Center, Medical Faculty University of Belgrade, Serbian Academy of Sciences and Arts, Belgrade, Serbia
| | - Hadi Skouri
- Cardiology Division, Internal Medicine Department, Balamand University School of Medicine, Beirut, Lebanon
| | - Cristiana Vitale
- Department of Cardiology, St George's University Hospital, London, UK
| | - Maurizio Volterrani
- Department of Exercise Science and Medicine, San Raffaele Open University of Rome, Rome, Italy
- Cardiopulmonary Department, IRCCS San Raffaele Roma, Rome, Italy
| | - Marco Metra
- ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Giuseppe M C Rosano
- Department of Cardiology, St George's University Hospital, London, UK
- Cardiology, San Raffaele Hospital, Cassino, Italy
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9
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Jarjour M, Ducharme A. Optimization of GDMT for patients with heart failure and reduced ejection fraction: can physiological and biological barriers explain the gaps in adherence to heart failure guidelines? Drugs Context 2023; 12:2023-5-6. [PMID: 38021409 PMCID: PMC10664772 DOI: 10.7573/dic.2023-5-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 10/10/2023] [Indexed: 12/01/2023] Open
Abstract
Heart failure is a growing epidemic with high mortality rates and recurrent hospital admissions that creates a burden on affected individuals, their caregivers and the whole healthcare system. Throughout the years, many randomized trials have established the effectiveness of several pharmacological therapies and electrophysiological devices to reduce hospitalizations and improve quality of life and survival, mostly for patients with heart failure with reduced ejection fraction (HFrEF). These studies led to the publication of national societies' recommendations to guide clinicians in the management of HFrEF. Yet, many reports have shown significant care gaps in adherence to these recommendations in clinical practice, highlighting suboptimal use and/or dosing of evidence-based therapies. Adherence to guidelines has been shown to be associated with the best prognosis in HFrEF, with patients presenting with intolerances or contraindications having the highest risk of events; however, it remains unclear whether this association is causal or merely a marker of more advanced disease. Furthermore, individual characteristics may limit the possibility of reaching the targeted dosage of specific agents. Herein, we provide a comprehensive overview of clinicians' adherence to heart failure guidelines in a specialized real-life setting, particularly regarding use and optimization of guideline-derived medical therapies, as well as the implementation of more recent agents such as sacubitril/valsartan and SGLT2 inhibitors. We seek potential explanations for suboptimal treatment and its impact on patient outcomes.
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Affiliation(s)
- Marilyne Jarjour
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
| | - Anique Ducharme
- Department of Medicine, Montreal Heart Institute and University of Montreal, Montreal, Canada
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10
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Ghazi L, Yamamoto Y, Fuery M, O'Connor K, Sen S, Samsky M, Riello RJ, Dhar R, Huang J, Olufade T, McDermott J, Inzucchi SE, Velazquez EJ, Wilson FP, Desai NR, Ahmad T. Electronic health record alerts for management of heart failure with reduced ejection fraction in hospitalized patients: the PROMPT-AHF trial. Eur Heart J 2023; 44:4233-4242. [PMID: 37650264 DOI: 10.1093/eurheartj/ehad512] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND AND AIMS Patients hospitalized for acute heart failure (AHF) continue to be discharged on an inadequate number of guideline-directed medical therapies (GDMT) despite evidence that inpatient initiation is beneficial. This study aimed to examine whether a tailored electronic health record (EHR) alert increased rates of GDMT prescription at discharge in eligible patients hospitalized for AHF. METHODS Pragmatic trial of messaging to providers about treatment of acute heart failure (PROMPT-AHF) was a pragmatic, multicenter, EHR-based, and randomized clinical trial. Patients were automatically enrolled 48 h after admission if they met pre-specified criteria for an AHF hospitalization. Providers of patients in the intervention arm received an alert during order entry with relevant patient characteristics along with individualized GDMT recommendations with links to an order set. The primary outcome was an increase in the number of GDMT prescriptions at discharge. RESULTS Thousand and twelve patients were enrolled between May 2021 and November 2022. The median age was 74 years; 26% were female, and 24% were Black. At the time of the alert, 85% of patients were on β-blockers, 55% on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, 20% on mineralocorticoid receptor antagonist (MRA) and 17% on sodium-glucose cotransporter 2 inhibitor. The primary outcome occurred in 34% of both the alert and no alert groups [adjusted risk ratio (RR): 0.95 (0.81, 1.12), P = .99]. Patients randomized to the alert arm were more likely to have an increase in MRA [adjusted RR: 1.54 (1.10, 2.16), P = .01]. At the time of discharge, 11.2% of patients were on all four pillars of GDMT. CONCLUSIONS A real-time, targeted, and tailored EHR-based alert system for AHF did not lead to a higher number of overall GDMT prescriptions at discharge. Further refinement and improvement of such alerts and changes to clinician incentives are needed to overcome barriers to the implementation of GDMT during hospitalizations for AHF. GDMT remains suboptimal in this setting, with only one in nine patients being discharged on a comprehensive evidence-based regimen for heart failure.
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Affiliation(s)
- Lama Ghazi
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Michael Fuery
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Kyle O'Connor
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Marc Samsky
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Ravi Dhar
- Center for Customer Insights, Yale School of Management, New Haven, CT, USA
| | | | | | | | - Silvio E Inzucchi
- Section of Endocrine & Metabolism, Yale School of Medicine, New Haven, CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Francis Perry Wilson
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Nihar R Desai
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Tariq Ahmad
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
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11
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Moghaddam N, Lindsay MP, Hawkins NM, Anderson K, Ducharme A, Lee DS, McKelvie R, Poon S, Desmarais O, Desbiens M, Virani S. Access to Heart Failure Services in Canada: Findings of the Heart and Stroke National Heart Failure Resources and Services Inventory. Can J Cardiol 2023; 39:1469-1479. [PMID: 37422257 DOI: 10.1016/j.cjca.2023.06.430] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2023] [Revised: 06/28/2023] [Accepted: 06/30/2023] [Indexed: 07/10/2023] Open
Abstract
BACKGROUND The rising incidence of heart failure (HF) in Canada necessitates commensurate resources dedicated to its management. Several health system partners launched an HF Action Plan to understand the current state of HF care in Canada and address inequities in access and resources. METHODS A national Heart Failure Resources and Services Inventory (HF-RaSI) was conducted from 2020 to 2021 of all 629 acute care hospitals and 20 urgent care centres in Canada. The HF-RaSI consisted of 44 questions on available resources, service,s and processes across acute care hospitals and related ambulatory settings. RESULTS HF-RaSIs were completed by 501 acute care hospitals and urgent care centres, representing 94.7% of all HF hospitalisations across Canada. Only 12.2% of HF care was provided by hospitals with HF expertise and resources, and 50.9% of HF admissions were in centres with minimal outpatient or inpatient HF capabilities. Across all Canadian hospitals, 28.7% did not have access to B-type natriuretic peptide testing, and only 48.1% had access to on-site echocardiography. Designated HF medical directors were present at 21.6% of sites (108), and 16.2% sites (81) had dedicated inpatient interdisciplinary HF teams. Among all of the sites, 28.1% (141) were HF clinics, and of those, 40.4% (57) had average wait times from referral to first appointment of more than 2 weeks. CONCLUSIONS Significant gaps and geographic variation in delivery and access to HF services exist in Canada. This study highlights the need for provincial and national health systems changes and quality improvement initiatives to ensure equitable access to the appropriate evidence-based HF care.
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Affiliation(s)
- Nima Moghaddam
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Nathaniel M Hawkins
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kim Anderson
- Dalhousie, University QEII Health Sciences Centre, Halifax, Nova Scotia, Canada
| | - Anique Ducharme
- Institut de Cardiologie, de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Douglas S Lee
- Peter Munk Cardiac Centre, University Health Network, Toronto, Ontario, Canada
| | - Robert McKelvie
- St Joseph's Health Care, Western University, London, Ontario, Canada
| | - Stephanie Poon
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | | | | | - Sean Virani
- Division of Cardiology, University of British Columbia, Vancouver, British Columbia, Canada
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12
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D'Amario D, Rodolico D, Delvinioti A, Laborante R, Iacomini C, Masciocchi C, Restivo A, Ciliberti G, Galli M, Paglianiti AD, Iaconelli A, Zito A, Lenkowicz J, Patarnello S, Cesario A, Valentini V, Crea F. Eligibility for the 4 Pharmacological Pillars in Heart Failure With Reduced Ejection Fraction at Discharge. J Am Heart Assoc 2023; 12:e029071. [PMID: 37382176 PMCID: PMC10356099 DOI: 10.1161/jaha.122.029071] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 05/05/2023] [Indexed: 06/30/2023]
Abstract
Background Guidelines recommend using multiple drugs in patients with heart failure (HF) with reduced ejection fraction, but there is a paucity of real-world data on the simultaneous initiation of the 4 pharmacological pillars at discharge after a decompensation event. Methods and Results A retrospective data mart, including patients diagnosed with HF, was implemented. Consecutively admitted patients with HF with reduced ejection fraction were selected through an automated approach and categorized according to the number/type of treatments prescribed at discharge. The prevalence of contraindications and cautions for HF with reduced ejection fraction treatments was systematically assessed. Logistic regression models were fitted to assess predictors of the number of treatments (≥2 versus <2 drugs) prescribed and the risk of rehospitalization. A population of 305 patients with a first episode of HF hospitalization and a diagnosis of HF with reduced ejection fraction (ejection fraction, <40%) was selected. At discharge, 49.2% received 2 current recommended drugs, β-blockers were prescribed in 93.4%, while a renin-angiotensin system inhibitor or an angiotensin receptor-neprilysin inhibitor was prescribed in 68.2%. A mineralocorticoid receptor antagonist was prescribed in 32.5%, although none of the patients showed contraindications to mineralocorticoid receptor antagonist prescription. A sodium-glucose cotransporter 2 inhibitor could be prescribed in 71.1% of patients. On the basis of current recommendations, 46.2% could receive the 4 foundational drugs at discharge. Renal dysfunction was associated with <2 foundational drugs prescribed. After adjusting for age and renal function, use of ≥2 drugs was associated with lower risk of rehospitalization during the 30 days after discharge. Conclusions A quadruple therapy could be directly implementable at discharge, potentially providing prognostic advantages. Renal dysfunction was the main prevalent condition limiting this approach.
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Affiliation(s)
- Domenico D'Amario
- Department of Translational MedicineUniversità del Piemonte OrientaleNovaraItaly
| | - Daniele Rodolico
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Agni Delvinioti
- Fondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Renzo Laborante
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Chiara Iacomini
- Fondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | | | - Attilio Restivo
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Giuseppe Ciliberti
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Mattia Galli
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
- Maria Cecilia HospitalGVM Care and ResearchCotignolaItaly
| | | | - Antonio Iaconelli
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | - Andrea Zito
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
| | | | | | - Alfredo Cesario
- Open Innovation Unit, Scientific DirectionFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
| | - Vincenzo Valentini
- Department of Bioimaging, Radiation Oncology and HematologyFondazione Policlinico Universitario "A. Gemelli" IRCCS, Università Cattolica S. CuoreRomeItaly
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary SciencesCatholic University of the Sacred HeartRomeItaly
- Department of Cardiovascular SciencesFondazione Policlinico Universitario A. Gemelli IRCCSRomeItaly
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13
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Zieroth S, Rizi SS. Time Is of the Essence. JACC. HEART FAILURE 2023:S2213-1779(23)00183-X. [PMID: 37178084 DOI: 10.1016/j.jchf.2023.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 03/24/2023] [Indexed: 05/15/2023]
Affiliation(s)
- Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.
| | - Shekoofeh Saboktakin Rizi
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
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