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Urban S, Szymański O, Grzesiak M, Tokarczyk W, Błaziak M, Jura M, Fułek M, Fułek K, Iwanek G, Gajewski P, Ponikowski P, Biegus J, Zymliński R. Effectiveness of remote pulmonary artery pressure estimating in heart failure: systematic review and meta-analysis. Sci Rep 2024; 14:12929. [PMID: 38839890 PMCID: PMC11153505 DOI: 10.1038/s41598-024-63742-0] [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: 01/15/2024] [Accepted: 05/31/2024] [Indexed: 06/07/2024] Open
Abstract
Heart failure (HF) poses a significant challenge, often leading to frequent hospitalizations and compromised quality of life. Continuous pulmonary artery pressure (PAP) monitoring offers a surrogate for congestion status in ambulatory HF care. This meta-analysis examines the efficacy of PAP monitoring devices (CardioMEMS and Chronicle) in preventing adverse outcomes in HF patients, addressing gaps in prior randomized controlled trials (RCTs). Five RCTs (2572 participants) were systematically reviewed. PAP monitoring significantly reduced HF-related hospitalizations (RR 0.72 [95% CI 0.6-0.87], p = 0.0006) and HF events (RR 0.86 [95% CI 0.75-0.99], p = 0.03), with no impact on all-cause or cardiovascular mortality. Subgroup analyses highlighted the significance of CardioMEMS and blinded studies. Meta-regression indicated a correlation between prolonged follow-up and increased reduction in HF hospitalizations. The risk of bias was generally high, with evidence certainty ranging from low to moderate. PAP monitoring devices exhibit promise in diminishing HF hospitalizations and events, especially in CardioMEMS and blinded studies. However, their influence on mortality remains inconclusive. Further research, considering diverse patient populations and intervention strategies with extended follow-up, is crucial for elucidating the optimal role of PAP monitoring in HF management.
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Affiliation(s)
- Szymon Urban
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wroclaw Medical University, Wrocław, Poland
| | - Oskar Szymański
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wrocław, Poland
| | - Magdalena Grzesiak
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wrocław, Poland.
| | - Wojciech Tokarczyk
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wrocław, Poland
| | - Mikołaj Błaziak
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wroclaw Medical University, Wrocław, Poland
| | - Maksym Jura
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wrocław, Poland
- Department of Physiology and Pathophysiology, Wroclaw Medical University, Wrocław, Poland
| | - Michał Fułek
- Department and Clinic of Internal Medicine, Occupational Diseases, Hypertension and Clinical Oncology, University Clinical Hospital in Wroclaw, Wroclaw Medical University, Wrocław, Poland
| | - Katarzyna Fułek
- Department and Clinic of Otolaryngology, Head and Neck Surgery, University Clinical Hospital in Wroclaw, Wroclaw Medical University, Wrocław, Poland
| | - Gracjan Iwanek
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wroclaw Medical University, Wrocław, Poland
| | - Piotr Gajewski
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wroclaw Medical University, Wrocław, Poland
| | - Piotr Ponikowski
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wroclaw Medical University, Wrocław, Poland
| | - Jan Biegus
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wroclaw Medical University, Wrocław, Poland
| | - Robert Zymliński
- Institute of Heart Diseases, University Clinical Hospital in Wroclaw, Wroclaw Medical University, Wrocław, Poland
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2
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Bressman E, Burke RE, Ryan Greysen S. Connected transitions: Opportunities and challenges for improving postdischarge care with technology. J Hosp Med 2024; 19:530-534. [PMID: 38180274 DOI: 10.1002/jhm.13264] [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: 09/20/2023] [Revised: 12/05/2023] [Accepted: 12/10/2023] [Indexed: 01/06/2024]
Affiliation(s)
- Eric Bressman
- Division of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Robert E Burke
- Division of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S Ryan Greysen
- Division of Hospital Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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3
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Walther CP. Cardiac Devices and Kidney Disease. Semin Nephrol 2024:151513. [PMID: 38760291 DOI: 10.1016/j.semnephrol.2024.151513] [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: 05/19/2024]
Abstract
A growing variety of cardiac devices are available to monitor or support cardiovascular function. The entwined nature of cardiovascular disease and kidney disease makes the relationship of these devices with kidney disease a multifaceted question relating to the use of these devices in individuals with kidney disease and to the effects of the devices and device placement on kidney health. Cardiac devices can be categorized broadly into cardiac implantable electronic devices, structural devices, and circulatory assist devices. Cardiac implantable electronic devices include devices for monitoring and managing cardiac electrical activity and devices for monitoring hemodynamics. Structural devices modify cardiac structure and include valve prostheses, valve repair clips, devices for treating atrial septal abnormalities, left atrial appendage closure devices, and interatrial shunt devices. Circulatory assist devices support the failing heart or support cardiac function during high-risk cardiac procedures. Evidence for the use of these devices in individuals with kidney disease, effects of the devices on kidney health and function, specific considerations with devices in kidney disease, and important knowledge gaps are surveyed in this article. With the growing prevalence of combined cardiorenal disease and the increasing variety of cardiac devices, kidney disease considerations are an important aspect of device therapy.
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Affiliation(s)
- Carl P Walther
- Selzman Institute for Kidney Health, Section of Nephrology, Department of Medicine, Baylor College of Medicine, Houston, TX.
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Marshall V WH, Wright LK, Lampert BC, Salavitabar A, Daniels CJ, Rajpal S. Invasive Implanted Hemodynamic Monitoring in Patients With Complex Congenital Heart Disease: State-of-the-Art Review. Am J Cardiol 2024; 223:123-131. [PMID: 38761965 DOI: 10.1016/j.amjcard.2024.05.010] [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] [Received: 04/01/2024] [Revised: 05/07/2024] [Accepted: 05/12/2024] [Indexed: 05/20/2024]
Abstract
As the number of patients with congenital heart disease (CHD) continues to increase, the burden of heart failure (HF) in this population requires innovative strategies to individualize management. Given the success of implanted invasive hemodynamic monitoring (IHM) with the CardioMEMSTM HF system in adults with acquired HF, this is often suggested for use in patients with CHD, though published data are limited to case reports and case series. Therefore, this review summarizes the available published reports on the use of IHM in patients with complex CHD, describes novel applications, and highlights future directions for study. In patients with CHD, IHM has been used across the lifespan, from age 3 years to adulthood, with minimal device-related complications reported. IHM uses include (1) prevention of HF hospitalizations; (2) reassessment of hemodynamics after titration of medical therapy without repeated cardiac catheterization; (3) serial monitoring of at-risk patients for pulmonary hypertension to optimize timing of heart transplant referral; (4) and hemodynamic assessment with exercise (5) or after ventricular assist device placement. IHM has the potential to reduce the number of cardiac catheterizations in anatomically complex patients and, in patients with Fontan circulation, IHM pressures may have prognostic implications. In conclusion, though further studies are needed, as patients with CHD age and HF is more prevalent, this tool may assist CHD physicians in caring for this complex patient population.
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Affiliation(s)
- William H Marshall V
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio; Heart Center, Nationwide Children's Hospital, Columbus, Ohio.
| | - Lydia K Wright
- Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Brent C Lampert
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio
| | | | - Curt J Daniels
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio; Heart Center, Nationwide Children's Hospital, Columbus, Ohio
| | - Saurabh Rajpal
- Department of Internal Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio; Heart Center, Nationwide Children's Hospital, Columbus, Ohio
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Ciotola F, Pyxaras S, Rittger H, Buia V. MEMS Technology in Cardiology: Advancements and Applications in Heart Failure Management Focusing on the CardioMEMS Device. SENSORS (BASEL, SWITZERLAND) 2024; 24:2922. [PMID: 38733027 PMCID: PMC11086351 DOI: 10.3390/s24092922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Revised: 04/28/2024] [Accepted: 04/30/2024] [Indexed: 05/13/2024]
Abstract
Heart failure (HF) is a complex clinical syndrome associated with significant morbidity, mortality, and healthcare costs. It is characterized by various structural and/or functional abnormalities of the heart, resulting in elevated intracardiac pressure and/or inadequate cardiac output at rest and/or during exercise. These dysfunctions can originate from a variety of conditions, including coronary artery disease, hypertension, cardiomyopathies, heart valve disorders, arrhythmias, and other lifestyle or systemic factors. Identifying the underlying cause is crucial for detecting reversible or treatable forms of HF. Recent epidemiological studies indicate that there has not been an increase in the incidence of the disease. Instead, patients seem to experience a chronic trajectory marked by frequent hospitalizations and stagnant mortality rates. Managing these patients requires a multidisciplinary approach that focuses on preventing disease progression, controlling symptoms, and preventing acute decompensations. In the outpatient setting, patient self-care plays a vital role in achieving these goals. This involves implementing necessary lifestyle changes and promptly recognizing symptoms/signs such as dyspnea, lower limb edema, or unexpected weight gain over a few days, to alert the healthcare team for evaluation of medication adjustments. Traditional methods of HF monitoring, such as symptom assessment and periodic clinic visits, may not capture subtle changes in hemodynamics. Sensor-based technologies offer a promising solution for remote monitoring of HF patients, enabling early detection of fluid overload and optimization of medical therapy. In this review, we provide an overview of the CardioMEMS device, a novel sensor-based system for pulmonary artery pressure monitoring in HF patients. We discuss the technical aspects, clinical evidence, and future directions of CardioMEMS in HF management.
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Affiliation(s)
| | | | | | - Veronica Buia
- Medizinische Klinik I, Klinikum Fürth, Academic Teaching Hospital of the Friedrich-Alexander-University Erlangen-Nürnberg, Jakob-Henle Str. 1, 90766 Fürth, Germany; (F.C.); (S.P.); (H.R.)
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Kagiyama N, Kasai T, Murata N, Yamakawa N, Tanaka Y, Hiki M, Inoue K, Sato A, Ishiwata S, Murata A, Shitara J, Kato T, Suda S, Matsue Y, Naito R, Minamino T, Yanagisawa N, Daida H. Feasibility of self-measurement telemonitoring using a handheld heart sound recorder in patients with heart failure - SELPH multicenter pilot study. J Cardiol 2024:S0914-5087(24)00082-0. [PMID: 38701945 DOI: 10.1016/j.jjcc.2024.04.009] [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] [Received: 12/03/2023] [Revised: 04/24/2024] [Accepted: 04/26/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND Multi-parametric assessment, including heart sounds in addition to conventional parameters, may enhance the efficacy of noninvasive telemonitoring for heart failure (HF). We sought to assess the feasibility of self-telemonitoring with multiple devices including a handheld heart sound recorder and its association with clinical events in patients with HF. METHODS Ambulatory HF patients recorded their own heart sounds, mono‑lead electrocardiograms, oxygen saturation, body weight, and vital signs using multiple devices every morning for six months. RESULTS In the 77 patients enrolled (63 ± 13 years old, 84 % male), daily measurements were feasible with a self-measurement rate of >70 % of days in 75 % of patients. Younger age and higher Minnesota Living with Heart Failure Questionnaire scores were independently associated with lower adherence (p = 0.002 and 0.027, respectively). A usability questionnaire showed that 87 % of patients felt self-telemonitoring was helpful, and 96 % could use the devices without routine cohabitant support. Six patients experienced ten HF events of re-hospitalization and/or unplanned hospital visits due to HF. In patients who experienced HF events, a significant increase in heart rate and diastolic blood pressure and a decrease in the time interval from Q wave onset to the second heart sound were observed 7 days before the events compared with those without HF events. CONCLUSIONS Self-telemonitoring with multiple devices including a handheld heart sound recorder was feasible even in elderly patients with HF. This intervention may confer a sense of relief to patients and enable monitoring of physiological parameters that could be valuable in detecting the deterioration of HF.
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Affiliation(s)
- Nobuyuki Kagiyama
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan; Department of Digital Health and Telemedicine R&D, Juntendo University, Tokyo, Japan
| | - Takatoshi Kasai
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan; Department of Digital Health and Telemedicine R&D, Juntendo University, Tokyo, Japan.
| | | | | | - Yuki Tanaka
- Solution Business Development, Philips Japan, Ltd., Tokyo, Japan
| | - Masaru Hiki
- Department of Cardiovascular Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Kenji Inoue
- Department of Cardiovascular Medicine, Juntendo University Nerima Hospital, Tokyo, Japan
| | - Akihiro Sato
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Sayaki Ishiwata
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Azusa Murata
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Jun Shitara
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Takao Kato
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Shoko Suda
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Yuya Matsue
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Ryo Naito
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | - Tohru Minamino
- Department of Cardiovascular Biology and Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
| | | | - Hiroyuki Daida
- Department of Digital Health and Telemedicine R&D, Juntendo University, Tokyo, Japan
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7
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Chau VQ, Imamura T, Narang N. Implementation of remote monitoring strategies to improve chronic heart failure management. Curr Opin Cardiol 2024; 39:210-217. [PMID: 38567948 DOI: 10.1097/hco.0000000000001119] [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: 04/05/2024]
Abstract
PURPOSE OF REVIEW The goal of this review is to describe the current evidence available for remote monitoring devices available for patients with chronic heart failure, and also detail practical clinical recommendations for implementing these tools in daily clinical practice. RECENT FINDINGS Several devices ranging from sophisticated multiparametric algorithms in defibrillators, implantable pulmonary artery pressure sensors, and wearable devices to measure thoracic impedance can be utilized as important adjunctive tools to reduce the risk of heart failure hospitalization in patients with chronic heart failure. Pulmonary artery pressure sensors provide the most granular data regarding hemodynamic status, while alerts from wearable devices for thoracic impedance and defibrillator-based algorithms increase the likelihood of worsening clinical status while also having high negative predictive value when values are within normal range. SUMMARY Multiple device-based monitoring strategies are available to reduce longitudinal risk in patients with chronic heart failure. Further studies are needed to best understand a practical pathway to integrate multiple signals of data for early clinical decompensation risk predictionVideo abstract: http://links.lww.com/HCO/A95.
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Affiliation(s)
- Vinh Q Chau
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois
| | - Teruhiko Imamura
- Second Department of Internal Medicine, University of Toyama, Toyama, Japan
| | - Nikhil Narang
- Advocate Heart Institute, Advocate Christ Medical Center, Oak Lawn, Illinois
- Division of Cardiology, Department of Medicine, University of Illinois-Chicago, Chicago, Illinois, USA
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Alfieri M, Bruscoli F, Di Vito L, Di Giusto F, Scalone G, Marchese P, Delfino D, Silenzi S, Martoni M, Guerra F, Grossi P. Novel Medical Treatments and Devices for the Management of Heart Failure with Reduced Ejection Fraction. J Cardiovasc Dev Dis 2024; 11:125. [PMID: 38667743 PMCID: PMC11050600 DOI: 10.3390/jcdd11040125] [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: 03/25/2024] [Revised: 04/13/2024] [Accepted: 04/18/2024] [Indexed: 04/28/2024] Open
Abstract
Heart failure (HF) is a growing issue in developed countries; it is often the result of underlying processes such as ischemia, hypertension, infiltrative diseases or even genetic abnormalities. The great majority of the affected patients present a reduced ejection fraction (≤40%), thereby falling under the name of "heart failure with reduced ejection fraction" (HFrEF). This condition represents a major threat for patients: it significantly affects life quality and carries an enormous burden on the whole healthcare system due to its high management costs. In the last decade, new medical treatments and devices have been developed in order to reduce HF hospitalizations and improve prognosis while reducing the overall mortality rate. Pharmacological therapy has significantly changed our perspective of this disease thanks to its ability of restoring ventricular function and reducing symptom severity, even in some dramatic contexts with an extensively diseased myocardium. Notably, medical therapy can sometimes be ineffective, and a tailored integration with device technologies is of pivotal importance. Not by chance, in recent years, cardiac implantable devices witnessed a significant improvement, thereby providing an irreplaceable resource for the management of HF. Some devices have the ability of assessing (CardioMEMS) or treating (ultrafiltration) fluid retention, while others recognize and treat life-threatening arrhythmias, even for a limited time frame (wearable cardioverter defibrillator). The present review article gives a comprehensive overview of the most recent and important findings that need to be considered in patients affected by HFrEF. Both novel medical treatments and devices are presented and discussed.
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Affiliation(s)
- Michele Alfieri
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I-Lancisi-Salesi”, 60121 Ancona, Italy; (M.A.); (F.G.)
| | - Filippo Bruscoli
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Luca Di Vito
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Federico Di Giusto
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Giancarla Scalone
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Procolo Marchese
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Domenico Delfino
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Simona Silenzi
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
| | - Milena Martoni
- Medical School, Università degli Studi “G. d’Annunzio”, 66100 Chieti, Italy;
| | - Federico Guerra
- Cardiology and Arrhythmology Clinic, Marche Polytechnic University, University Hospital “Umberto I-Lancisi-Salesi”, 60121 Ancona, Italy; (M.A.); (F.G.)
| | - Pierfrancesco Grossi
- Cardiology Unit, C. and G. Mazzoni Hospital, AST Ascoli Piceno, 63100 Ascoli Piceno, Italy; (F.B.); (F.D.G.); (G.S.); (P.M.); (D.D.); (S.S.); (P.G.)
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Manavi T, Zafar H, Sharif F. An Era of Digital Healthcare-A Comprehensive Review of Sensor Technologies and Telehealth Advancements in Chronic Heart Failure Management. SENSORS (BASEL, SWITZERLAND) 2024; 24:2546. [PMID: 38676163 PMCID: PMC11053658 DOI: 10.3390/s24082546] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Revised: 03/21/2024] [Accepted: 04/11/2024] [Indexed: 04/28/2024]
Abstract
Heart failure (HF) is a multi-faceted, complex clinical syndrome characterized by significant morbidity, high mortality rate, reduced quality of life, and rapidly increasing healthcare costs. A larger proportion of these costs comprise both ambulatory and emergency department visits, as well as hospital admissions. Despite the methods used by telehealth (TH) to improve self-care and quality of life, patient outcomes remain poor. HF management is associated with numerous challenges, such as conflicting evidence from clinical trials, heterogeneity of TH devices, variability in patient inclusion and exclusion criteria, and discrepancies between healthcare systems. A growing body of evidence suggests there is an unmet need for increased individualization of in-hospital management, continuous remote monitoring of patients pre and post-hospital admission, and continuation of treatment post-discharge in order to reduce re-hospitalizations and improve long-term outcomes. This review summarizes the current state-of-the-art for HF and associated novel technologies and advancements in the most frequently used types of TH (implantable sensors), categorizing devices in their preclinical and clinical stage, bench-to-bedside implementation challenges, and future perspectives on remote HF management to improve long-term outcomes of HF patients. The Review also highlights recent advancements in non-invasive remote monitoring technologies demonstrated by a few pilot observational prospective cohort studies.
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Affiliation(s)
- Tejaswini Manavi
- Cardiovascular Translational Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland; (T.M.); (F.S.)
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
| | - Haroon Zafar
- Cardiovascular Translational Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland; (T.M.); (F.S.)
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
- College of Science and Engineering, University of Galway, H91 TK33 Galway, Ireland
| | - Faisal Sharif
- Cardiovascular Translational Research & Innovation Centre, University of Galway, H91 TK33 Galway, Ireland; (T.M.); (F.S.)
- Lambe Institute for Translational Research, School of Medicine, University of Galway, H91 TK33 Galway, Ireland
- Department of Cardiology, University Hospital Galway, H91 YR71 Galway, Ireland
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10
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Maddox TM, Januzzi JL, Allen LA, Breathett K, Brouse S, Butler J, Davis LL, Fonarow GC, Ibrahim NE, Lindenfeld J, Masoudi FA, Motiwala SR, Oliveros E, Walsh MN, Wasserman A, Yancy CW, Youmans QR. 2024 ACC Expert Consensus Decision Pathway for Treatment of Heart Failure With Reduced Ejection Fraction: A Report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol 2024; 83:1444-1488. [PMID: 38466244 DOI: 10.1016/j.jacc.2023.12.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2024]
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11
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Sandquist K, Nawarskas J, Garcia ME. A Novel Subcutaneous Furosemide Formulation for Outpatient Management of Heart Failure. Cardiol Rev 2024:00045415-990000000-00116. [PMID: 38587384 DOI: 10.1097/crd.0000000000000576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
In patients with fluid overload and congestion, parenteral diuretic therapy is frequently utilized. However, administration of parenteral diuretic therapy commonly requires hospital admission or outpatient clinic visits. Furoscix (scPharmaceuticals, Burlington, MA), a subcutaneous formulation of furosemide designed for home use, offers new treatment possibilities with the potential for profound cost savings for patients and health systems. Currently, subcutaneous furosemide formulations have been studied in palliative care populations and outpatient clinics, however, new literature has evaluated utility in prescribing on discharge from the emergency department. This review aims to describe the pharmacokinetic profile and utilization of subcutaneous furosemide for treatment of congestion in patients with heart failure.
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Affiliation(s)
| | - James Nawarskas
- University of New Mexico College of Pharmacy, Albuquerque, NM
| | - Mark E Garcia
- From the University of New Mexico Hospital, Albuquerque, NM
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12
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Sarkar S, Koehler J, Vasudevan N. Ambulatory Risk Stratification for Worsening Heart Failure in Patients with Reduced and Preserved Ejection Fraction Using Diagnostic Parameters Available in Implantable Cardiac Monitors. Diagnostics (Basel) 2024; 14:771. [PMID: 38611683 PMCID: PMC11012110 DOI: 10.3390/diagnostics14070771] [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: 03/13/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 04/14/2024] Open
Abstract
BACKGROUND Ambulatory risk stratification for worsening heart failure (HF) using diagnostics measured by insertable cardiac monitors (ICM) may depend on the left ventricular ejection fraction (LVEF). We evaluated risk stratification performance in patients with reduced versus preserved LVEF. METHODS ICM patients with a history of HF events (HFEs) were included from the Optum® de-identified Electronic Health Record dataset merged with ICM device-collected data during 2007-2021. ICM measures nighttime heart rate (NHR), heart rate variability (HRV), atrial fibrillation (AF) burden, rate during AF, and activity duration (ACT) daily. Each diagnostic was categorized into high, medium, or low risk using previously defined features. HFEs were HF-related inpatient, observation unit, or emergency department stays with IV diuresis administration. Patients were divided into two cohorts: LVEF ≤ 40% and LVEF > 40%. A marginal Cox proportional hazards model compared HFEs for different risk groups. RESULTS A total of 1020 ICM patients with 18,383 follow-up months and 301 months with HFEs (1.6%) were included. Monthly evaluations with a high risk were 2.3, 4.2, 5.0, and 4.5 times (p < 0.001 for all) more likely to have HFEs in the next 30 days compared to those with a low risk for AF, ACT, NHR, and HRV, respectively. HFE rates were higher for patients with LVEF > 40% compared to LVEF ≤ 40% (2.0% vs. 1.3%), and the relative risk between high-risk and low-risk for each diagnostic parameter was higher for patients with LVEF ≤ 40%. CONCLUSIONS Diagnostics measured by ICM identified patients at risk for impending HFEs. Patients with preserved LVEF showed a higher absolute risk, and the relative risk between risk groups was higher in patients with reduced LVEF.
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Adamson PB, Echols M, DeFilippis EM, Morris AA, Bennett M, Abraham WT, Lindenfeld J, Teerlink JR, O'Connor CM, Connolly AT, Li H, Fiuzat M, Vaduganathan M, Vardeny O, Batchelor W, McCants KC. Clinical Trial Inclusion and Impact on Early Adoption of Medical Innovation in Diverse Populations. JACC. HEART FAILURE 2024:S2213-1779(24)00179-3. [PMID: 38530702 DOI: 10.1016/j.jchf.2024.02.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/31/2024] [Accepted: 02/26/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Inadequate inclusion in clinical trial enrollment may contribute to health inequities by evaluating interventions in cohorts that do not fully represent target populations. OBJECTIVES The aim of this study was to determine if characteristics of patients with heart failure (HF) enrolled in a pivotal trial are associated with who receives an intervention after approval. METHODS Demographics from 2,017,107 Medicare patients hospitalized for HF were compared with those of the first 10,631 Medicare beneficiaries who received implantable pulmonary artery pressure sensors. Characteristics of the population studied in the pivotal CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) clinical trial (n = 550) were compared with those of both groups. All demographic data were analyzed nationally and in 4 U.S. regions. RESULTS The Medicare HF cohort included 80.9% White, 13.3% African American, 1.9% Hispanic, 1.3% Asian, and 51.5% female patients. Medicare patients <65 years of age were more likely to be African American (33%) and male (58%), whereas older patients were mostly White (84%) and female (53%). Forty-one percent of U.S. HF hospitalizations occurred in the South; demographic characteristics varied significantly across all U.S. regions. The CHAMPION trial adequately represented African Americans (23% overall, 35% <65 years of age), Hispanic Americans (2%), and Asian Americans (1%) but underrepresented women (27%). The trial's population characteristics were similar to those of the first patients who received pulmonary artery sensors (82% White, 13% African American, 1% Asian, 1% Hispanic, and 29% female). CONCLUSIONS Demographics of Centers for Medicare and Medicaid Services beneficiaries hospitalized with HF vary regionally and by age, which should be considered when defining "adequate" representation in clinical studies. Enrollment diversity in clinical trials may affect who receives early application of recently approved innovations.
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Affiliation(s)
- Philip B Adamson
- Heart Failure Division, Abbott Laboratories, Austin, Texas, USA.
| | - Melvin Echols
- Division of Cardiology, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | | | - Mosi Bennett
- Allina Health Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | | | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christopher M O'Connor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Allison T Connolly
- Global Data Science and Analytics, Abbott Laboratories, Santa Clara, California, USA
| | - Huanan Li
- Global Data Science and Analytics, Abbott Laboratories, Santa Clara, California, USA
| | - Mona Fiuzat
- Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Orly Vardeny
- Department of Medicine, University of Minnesota, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Kelly C McCants
- Norton Heart & Vascular Institute, Norton Healthcare, Louisville, Kentucky, USA
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14
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Marshall V WH, Mah ML, DeSalvo J, Rajpal S, Lastinger LT, Salavitabar A, Armstrong AK, Berman D, Lampert B, Wright LK, Hickey J, Metzger R, Nandi D, Gajarski R, Daniels CJ. Novel uses for implanted haemodynamic monitoring in adults with subaortic right ventricles. Heart 2024; 110:491-499. [PMID: 37935570 DOI: 10.1136/heartjnl-2023-323206] [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] [Received: 07/11/2023] [Accepted: 10/10/2023] [Indexed: 11/09/2023] Open
Abstract
BACKGROUND Pulmonary hypertension (PH) is a common complication in patients with complete dextro-transposition of the great arteries (TGA) after atrial switch (D-TGA/AS) and congenitally corrected TGA (ccTGA). In this population with subaortic right ventricles (sRVs), echocardiography is a poor screening tool for PH; implantable invasive haemodynamic monitoring (IHM) could be used for this purpose, but data are limited. The aim of this study is to report on novel uses of IHM in patients with sRV. METHODS This retrospective study describes the uses of IHM, impact of IHM on heart failure hospitalisation (HFH) and device-related complications in adults with sRV from a single centre (2015-2022). RESULTS IHM was placed in 18 patients with sRV (median age 43 (range 30-54) years, 8 female, 16 with D-TGA/AS, 2 with ccTGA); 16 had moderate or severe sRV systolic dysfunction, 13 had PH on catheterisation. IHM was used for (1) Medical therapy titration, (2) Medical management after ventricular assist device in patients with transplant-limiting PH and (3) Serial monitoring of pulmonary artery pressures without repeat catheterisations to help identify the optimal time for heart transplant referral. In follow-up (median 23 months), HFHs/year were similar to the year prior to IHM (median 0 (IQR 0-1.0) before vs 0 (0-0.8) after, p=0.984). Device migration occurred in one, without long-term sequelae. CONCLUSIONS Uses of IHM in patients with sRV are described which may minimise the need for serial catheterisations in a population where PH is prevalent. HFHs were low overall but not impacted by IHM. One device-related complication occurred without long-term consequence.
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Affiliation(s)
- William H Marshall V
- Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - May Ling Mah
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jennifer DeSalvo
- Internal Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Saurabh Rajpal
- Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Lauren T Lastinger
- Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Arash Salavitabar
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Aimee K Armstrong
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Darren Berman
- Heart Institute, Children's Hospital Los Angeles, Los Angeles, California, USA
| | - Brent Lampert
- Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Lydia K Wright
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Jenne Hickey
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Rachel Metzger
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Deipanjan Nandi
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Robert Gajarski
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
| | - Curt J Daniels
- Internal Medicine, Division of Cardiovascular Medicine, The Ohio State University Wexner Medical Center, Columbus, Ohio, USA
- The Heart Center, Nationwide Children's Hospital, Columbus, Ohio, USA
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15
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Brugts JJ, Aydin D, Clephas PRD, de Boer RA. Remote haemodynamic monitoring in patients with heart failure - Authors' reply. Lancet 2024; 403:808-809. [PMID: 38431345 DOI: 10.1016/s0140-6736(23)02677-6] [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: 09/09/2023] [Accepted: 11/24/2023] [Indexed: 03/05/2024]
Affiliation(s)
- Jasper J Brugts
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam 3015GD, Netherlands
| | - Dilan Aydin
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam 3015GD, Netherlands
| | - Pascal R D Clephas
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam 3015GD, Netherlands
| | - Rudolf A de Boer
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam 3015GD, Netherlands.
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16
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Komamura K, Iwase M. Remote haemodynamic monitoring in patients with heart failure. Lancet 2024; 403:807-808. [PMID: 38431344 DOI: 10.1016/s0140-6736(23)02678-8] [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: 07/05/2023] [Accepted: 11/24/2023] [Indexed: 03/05/2024]
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17
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Dini FL, Carluccio E, Ghio S, Pugliese NR, Galeotti G, Correale M, Beltrami M, Tocchetti CG, Mercurio V, Paolillo S, Palazzuoli A. Patient phenotype profiling using echocardiography and natriuretic peptides to personalise heart failure therapy. Heart Fail Rev 2024; 29:367-378. [PMID: 37728750 DOI: 10.1007/s10741-023-10340-3] [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] [Accepted: 08/07/2023] [Indexed: 09/21/2023]
Abstract
Heart failure (HF) is a progressive condition with a clinical picture resulting from reduced cardiac output (CO) and/or elevated left ventricular (LV) filling pressures (LVFP). The original Diamond-Forrester classification, based on haemodynamic data reflecting CO and pulmonary congestion, was introduced to grade severity, manage, and risk stratify advanced HF patients, providing evidence that survival progressively worsened for those classified as warm/dry, cold/dry, warm/wet, and cold/wet. Invasive haemodynamic evaluation in critically ill patients has been replaced by non-invasive haemodynamic phenotype profiling using echocardiography. Decreased CO is not infrequent among ambulatory HF patients with reduced ejection fraction, ranging from 23 to 45%. The Diamond-Forrester classification may be used in combination with the evaluation of natriuretic peptides (NPs) in ambulatory HF patients to pursue the goal of early identification of those at high risk of adverse events and personalise therapy to antagonise neurohormonal systems, reduce congestion, and preserve tissue/renal perfusion. The most benefit of the Guideline-directed medical treatment is to be expected in stable patients with the warm/dry profile, who more often respond with LV reverse remodelling, while more selective individualised treatments guided by echocardiography and NPs are necessary for patients with persisting congestion and/or tissue/renal hypoperfusion (cold/dry, warm/wet, and cold/wet phenotypes) to achieve stabilization and to avoid further neurohormonal activation, as a result of inappropriate use of vasodilating or negative chronotropic drugs, thus pursuing the therapeutic objectives. Therefore, tracking the haemodynamic status over time by clinical, imaging, and laboratory indicators helps implement therapy by individualising drug regimens and interventions according to patients' phenotypes even in an ambulatory setting.
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Affiliation(s)
- Frank L Dini
- Istituto Auxologico IRCCS, Centro Medico Sant'Agostino, Via Temperanza, 6, 20127, Milan, Italy.
- Department of Public Health and Clinical Medicine, Umeå University, Umeå, Sweden.
| | - Erberto Carluccio
- Cardiology and Cardiovascular Pathophysiology, Santa Maria della Misericordia, University of Perugia, Perugia, Italy
| | - Stefano Ghio
- Cardiology Division, Fondazione IRCCS, Policlinico San Matteo, Pavia, Italy
| | | | | | - Michele Correale
- Department of Cardiology, University Hospital Policlinico, Riuniti, Foggia, Italy
| | - Matteo Beltrami
- Cardiology Unit, San Giovanni di Dio Hospital, Azienda USL Toscana Centro, Florence, Italy
| | - Carlo Gabriele Tocchetti
- Department of Translational Medical Sciences (DISMET), Center for Basic and Clinical Immunology Research (CISI), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Valentina Mercurio
- Department of Translational Medical Sciences (DISMET), Interdepartmental Center of Clinical and Translational Sciences (CIRCET), Interdepartmental Hypertension Research Center (CIRIAPA), Federico II University, Naples, Italy
| | - Stefania Paolillo
- Department of Advanced Biomedical Sciences, Section of Cardiology, Federico II University, Naples, Italy
| | - Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio-thoracic and vascular Department, S. Maria alle Scotte Hospital, University of Siena, Siena, Italy
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18
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Badrish N, Sheifer S, Rosner CM. Systems of care for ambulatory management of decompensated heart failure. Front Cardiovasc Med 2024; 11:1350846. [PMID: 38455722 PMCID: PMC10918851 DOI: 10.3389/fcvm.2024.1350846] [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: 12/06/2023] [Accepted: 01/25/2024] [Indexed: 03/09/2024] Open
Abstract
Heart failure (HF) represents a worldwide health burden and the annual per patient cost to treat HF in the US is estimated at $24,383, with most of this expense driven by HF related hospitalizations. Decompensated HF is a leading cause for hospital admissions and is associated with an increased risk of subsequent morbidity and mortality. Many hospital admissions for decompensated HF are considered preventable with timely recognition and effective intervention.Systems of care that include interventions to facilitate early recognition, timely and appropriate intervention, intensification of care, and optimization to prevent recurrence can help successfully manage decompensated HF in the ambulatory setting and avoid hospitalization.
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Affiliation(s)
- Narotham Badrish
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
| | - Stuart Sheifer
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
- Department of Cardiology, Virginia Heart, Falls Church, VA, United States
| | - Carolyn M. Rosner
- Department of Cardiology, Inova Schar Heart and Vascular, Falls Church, VA, United States
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19
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Bianco F, Bucciarelli V, Santolla F. Heart failure home monitoring: Are we monitoring the patient or the disease? Trends Cardiovasc Med 2024:S1050-1738(24)00016-1. [PMID: 38387746 DOI: 10.1016/j.tcm.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 02/15/2024] [Indexed: 02/24/2024]
Affiliation(s)
- Francesco Bianco
- Department of Pediatric and Congenital Cardiology and Cardiac Surgery, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy.
| | - Valentina Bucciarelli
- Department of Pediatric and Congenital Cardiology and Cardiac Surgery, Azienda Ospedaliero Universitaria "Ospedali Riuniti", Ancona, Italy
| | - Francesca Santolla
- Libera Università Mediterranea (LUM) "Giuseppe Degennaro", Casamassima, Bari, Italy
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20
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Fudim M, Butler J, Kittipibul V. Implantable Hemodynamic-GUIDE Monitors: A CHAMPION Among Devices for Heart Failure. J Am Coll Cardiol 2024; 83:695-698. [PMID: 38325995 DOI: 10.1016/j.jacc.2023.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 12/18/2023] [Indexed: 02/09/2024]
Affiliation(s)
- Marat Fudim
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland.
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA; Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Veraprapas Kittipibul
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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21
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Lindenfeld J, Costanzo MR, Zile MR, Ducharme A, Troughton R, Maisel A, Mehra MR, Paul S, Sears SF, Smart F, Johnson N, Henderson J, Adamson PB, Desai AS, Abraham WT. Implantable Hemodynamic Monitors Improve Survival in Patients With Heart Failure and Reduced Ejection Fraction. J Am Coll Cardiol 2024; 83:682-694. [PMID: 38325994 DOI: 10.1016/j.jacc.2023.11.030] [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: 09/28/2023] [Revised: 11/17/2023] [Accepted: 11/20/2023] [Indexed: 02/09/2024]
Abstract
BACKGROUND Trials evaluating implantable hemodynamic monitors to manage patients with heart failure (HF) have shown reductions in HF hospitalizations but not mortality. Prior meta-analyses assessing mortality have been limited in construct because of an absence of patient-level data, short-term follow-up duration, and evaluation across the combined spectrum of ejection fractions. OBJECTIVES The purpose of this meta-analysis was to determine whether management with implantable hemodynamic monitors reduces mortality in patients with heart failure and reduced ejection fraction (HFrEF) and to confirm the effect of hemodynamic-monitoring guided management on HF hospitalization reduction reported in previous studies. METHODS The patient-level pooled meta-analysis used 3 randomized studies (GUIDE-HF [Hemodynamic-Guided Management of Heart Failure], CHAMPION [CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients], and LAPTOP-HF [Left Atrial Pressure Monitoring to Optimize Heart Failure Therapy]) of implantable hemodynamic monitors (2 measuring pulmonary artery pressures and 1 measuring left atrial pressure) to assess the effect on all-cause mortality and HF hospitalizations. RESULTS A total of 1,350 patients with HFrEF were included. Hemodynamic-monitoring guided management significantly reduced overall mortality with an HR of 0.75 (95% CI: 0.57-0.99); P = 0.043. HF hospitalizations were significantly reduced with an HR of 0.64 (95% CI: 0.55-0.76); P < 0.0001. CONCLUSIONS Management of patients with HFrEF using an implantable hemodynamic monitor significantly reduces both mortality and HF hospitalizations. The reduction in HF hospitalizations is seen early in the first year of monitoring and mortality benefits occur after the first year.
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Affiliation(s)
- JoAnn Lindenfeld
- Vanderbilt Heart and Vascular Institute, Vanderbilt University Medical Center, Nashville, Tennessee, USA.
| | | | - Michael R Zile
- Medical University of South Carolina, Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Caroline, USA
| | - Anique Ducharme
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - Richard Troughton
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand
| | - Alan Maisel
- University of California San Diego, La Jolla, California, USA
| | - Mandeep R Mehra
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Sara Paul
- Catawba Valley Health System, Conover, North Carolina, USA
| | - Samuel F Sears
- East Carolina University, Greenville, North Carolina, USA
| | - Frank Smart
- Louisiana State University School of Medicine, New Orleans, Louisiana, USA
| | | | | | | | - Akshay S Desai
- Center for Advanced Heart Disease, Brigham and Women's Hospital, Boston, Massachusetts, USA
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22
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Parent M, Leclerc J, O'Meara E, Barrette R, Lévesque S, Parent MC, Brouillette D, Garceau P, Liszkowski M, Rouleau J, Ducharme A. Clinical Heart fAilure Management Program: Changing the practice by partnering primary care and specialists (CHAMP-HF). IJC HEART & VASCULATURE 2024; 50:101330. [PMID: 38298468 PMCID: PMC10827585 DOI: 10.1016/j.ijcha.2023.101330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 12/11/2023] [Accepted: 12/14/2023] [Indexed: 02/02/2024]
Abstract
Background While significant gains were made in the management of heart failure (HF), most patients are still diagnosed when they are acutely ill in hospital, often with advanced disease. Earlier diagnosis in the community could lead to improved outcomes. Whether a partnership and an educational program for primary care providers (PCP) increase HF awareness and management is unknown. Methods We conducted an observational study between March 2019 and June 2020 during which HF specialists gave monthly HF conferences to PCP. Using a pre-post design, medical charts and administrative databases were reviewed and a questionnaire was completed by participating PCP. Primary and secondary endpoints included: 1) the number of patients diagnosed with HF, 2) implementation of GDMT for patients with HFrEF; 3) PCPs' experience and confidence. Results Six PCP agreed to participate. Amongst the 11,909 patients of the clinic, 70 (0.59 %) patients met the criteria for HF. This number increased by 28.6 % (n = 90) after intervention. Increased use of GDMT for HFrEF patients at baseline (n = 35) was observed for all class of agents, with doubling of patients on triple therapies, from 8 (22.9 %) to 16 (45.7 %), p = 0.0047. Self-confidence on HF management was low (1, 16.7 %) but increased after the educational intervention of physicians (3, 50 %). Conclusion An educational and collaborative approach between HF specialists and community PCP increased the number of new HF cases diagnosed, enhanced implementation of GDMT in patients with HFrEF and increase PCPs' confidence in treating HF, despite being conducted during the COVID-19 pandemic.
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Affiliation(s)
- Marianne Parent
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Department of Medicine, Montreal Heart Institute, Montreal, Canada
| | - Jacinthe Leclerc
- Faculty of Pharmacy, Université Laval, Quebec, Canada
- Research Center, Quebec Heart and Lung Institute, Université Laval, Quebec, Canada
| | - Eileen O'Meara
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Department of Medicine, Montreal Heart Institute, Montreal, Canada
| | | | - Sylvie Lévesque
- Montreal Health Innovation Coordinating Center, Biostatistics, Montreal, Canada
| | - Marie-Claude Parent
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Department of Medicine, Montreal Heart Institute, Montreal, Canada
| | | | - Patrick Garceau
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Department of Medicine, Montreal Heart Institute, Montreal, Canada
| | - Mark Liszkowski
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Department of Medicine, Montreal Heart Institute, Montreal, Canada
| | - Jean Rouleau
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Department of Medicine, Montreal Heart Institute, Montreal, Canada
| | - Anique Ducharme
- Faculty of Medicine, University of Montreal, Montreal, Canada
- Department of Medicine, Montreal Heart Institute, Montreal, Canada
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23
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Wu Y, Song M, Wu M, Lin L. Advances in device-based treatment of heart failure with preserved ejection fraction: evidence from clinical trials. ESC Heart Fail 2024; 11:13-27. [PMID: 37986663 PMCID: PMC10804156 DOI: 10.1002/ehf2.14562] [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: 06/28/2023] [Revised: 09/10/2023] [Accepted: 10/02/2023] [Indexed: 11/22/2023] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a group of clinical syndromes that exhibit a remarkably heterogeneous phenotype, characterized by symptoms and signs of heart failure, left ventricular diastolic dysfunction, elevated levels of natriuretic peptides, and an ejection fraction greater than or equal to 50%. With the aging of the population and the escalating prevalence of hypertension, obesity, and diabetes, the incidence of HFpEF is progressively rising. Drug therapy options for HFpEF are currently limited, and the associated high risk of cardiovascular mortality and heart failure rehospitalization significantly impact patients' quality of life and longevity while imposing a substantial economic burden on society. Recent research indicates that certain device-based therapies may serve as valuable adjuncts to drug therapy in patients with specific phenotypes of HFpEF, effectively improving symptoms and quality of life while reducing the risk of readmission for heart failure. These include inter-atrial shunt and greater splanchnic nerve ablation to reduce left ventricular filling pressure, implantable heart failure monitor to guide diuresis, left atrial pacing to correct interatrial dyssynchrony, cardiac contractility modulation to enhance cardiac calcium handling, as well as renal denervation, baroreflex activation therapy, and vagus nerve stimulation to restore the autonomic imbalance. In this review, we provide a comprehensive overview of the mechanisms and clinical evidence pertaining to these devices, with the aim of enhancing therapeutic strategies for HFpEF.
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Affiliation(s)
- Ying Wu
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Meiyan Song
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Meifang Wu
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
| | - Liming Lin
- Department of CardiologyAffiliated Hospital of Putian University, School of Clinical Medicine, Fujian Medical UniversityPutianChina
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24
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Heidenreich P. Heart failure management guidelines: New recommendations and implementation. J Cardiol 2024; 83:67-73. [PMID: 37949313 DOI: 10.1016/j.jjcc.2023.10.009] [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: 05/30/2023] [Revised: 10/07/2023] [Accepted: 10/31/2023] [Indexed: 11/12/2023]
Abstract
The prevalence of heart failure has increased in many developed countries including Japan and the USA, due in large part to the aging of their populations. The lifetime risk of heart failure is now 20-30 % in the USA. Fortunately, there have been important advances in therapy that increase quality and length of life for those with heart failure. This review discusses the important advances in care including treatment and diagnosis and the new recommendations for this care from the recent American College of Cardiology (ACC)/American Heart Association (AHA)/Heart Failure Society of America (HFSA) Guideline. Relevant studies that have been published since the guideline was released are also included. Of the many recommendations in the ACC/AHA/HFSA Guideline, this review focuses on the definition of heart failure, the medical treatments specific to left ventricular ejection fraction, use of devices for treatment and diagnosis, diagnosis and treatment of amyloidosis, treatment of iron deficiency, screening for asymptomatic left ventricular dysfunction, use of patient reported outcomes, and tools for implementation.
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Affiliation(s)
- Paul Heidenreich
- Department of Medicine, Stanford University School of Medicine, Palo Alto, CA, USA.
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25
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Gupta K, Mastoris I, Sauer AJ. Remote Monitoring Devices and Heart Failure. Heart Fail Clin 2024; 20:1-13. [PMID: 37953016 DOI: 10.1016/j.hfc.2023.05.002] [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] [Indexed: 11/14/2023]
Abstract
Remote patient monitoring (RPM) in patients with heart failure (HF) involves transmitting physiological data from devices to a health-care provider via a wireless connection with targeted interventions when values exceed the preset threshold. Devices used in telemonitoring range from weighing scales, blood pressure cuffs, and pulse oximeters to devices used to measure cardiac filling pressure and intrathoracic impedance using cardiac implantable electronic devices and wearables. Accordingly, RPM devices can potentially engage patients in their cardiovascular care and reduce the burden of HF in society.
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Affiliation(s)
- Kashvi Gupta
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA
| | - Ioannis Mastoris
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute, University of Missouri-Kansas City, Kansas City, MO, USA.
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26
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Chouairi F, Levin A, Biegus J, Fudim M. Emerging devices for heart failure management. Prog Cardiovasc Dis 2024; 82:125-134. [PMID: 38242194 DOI: 10.1016/j.pcad.2024.01.011] [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: 01/14/2024] [Accepted: 01/14/2024] [Indexed: 01/21/2024]
Abstract
There have been significant advances in the treatment of heart failure (HF) in recent years, driven by significant strides in guideline-directed medical therapy (GDMT). Despite this, HF is still associated with high levels of morbidity and mortality, and most patients do not receive optimal medical therapy. In conjunction with the improvement of GDMT, novel device therapies have been developed to better treat HF. These devices include technology capable of remotely monitoring HF physiology, devices that modulate the autonomic nervous system, and those that structurally change the heart with the ultimate aim of addressing the root causes of HF physiology As these device therapies gradually integrate into the fabric of HF patient care, it becomes increasingly important for modern cardiologists to become familiar with them. Hence, the objective of this review is to shed light on currently emerging devices for the treatment of HF.
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Affiliation(s)
- Fouad Chouairi
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Allison Levin
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
| | - Marat Fudim
- Division of Cardiology, Department of Internal Medicine, Duke University School of Medicine, Durham, NC, USA; Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Duke Clinical Research Institute, Durham, NC, USA.
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27
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Benza RL, Adamson PB, Bhatt DL, Frick F, Olsson G, Bergh N, Dahlöf B. CS1, a controlled-release formulation of valproic acid, for the treatment of patients with pulmonary arterial hypertension: Rationale and design of a Phase 2 clinical trial. Pulm Circ 2024; 14:e12323. [PMID: 38174159 PMCID: PMC10763516 DOI: 10.1002/pul2.12323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Revised: 09/13/2023] [Accepted: 12/13/2023] [Indexed: 01/05/2024] Open
Abstract
Although rare, pulmonary arterial hypertension (PAH) is associated with substantial morbidity and a median survival of approximately 7 years, even with treatment. Current medical therapies have a primarily vasodilatory effect and do not modify the underlying pathology of the disease. CS1 is a novel oral, controlled-release formulation of valproic acid, which exhibits a multi-targeted mode of action (pulmonary pressure reduction, reversal of vascular remodeling, anti-inflammatory, anti-fibrotic, and anti-thrombotic) and therefore potential for disease modification and right ventricular modeling in patients with PAH. A Phase 1 study conducted in healthy volunteers indicated favorable safety and tolerability, with no increased risk of bleeding and significant reduction of plasminogen activator inhibitor 1. In an ongoing randomized Phase 2 clinical trial, three doses of open-label CS1 administered for 12 weeks is evaluating the use of multiple outcome measures. The primary endpoint is safety and tolerability, as measured by the occurrence of adverse events. Secondary outcome measures include the use of the CardioMEMS™ HF System, which provides a noninvasive method of monitoring pulmonary artery pressure, as well as cardiac magnetic resonance imaging and echocardiography. Other outcomes include changes in risk stratification (using the REVEAL 2.0 and REVEAL Lite 2 tools), patient reported outcomes, functional capacity, 6-min walk distance, actigraphy, and biomarkers. The pharmacokinetic profile of CS1 will also be evaluated. Overall, the novel design and unique, extensive clinical phenotyping of participants in this trial will provide ample evidence to inform the design of any future Phase 3 studies with CS1.
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Affiliation(s)
- Raymond L. Benza
- Ohio State Wexner Medical CenterThe Ohio State UniversityColumbusOhioUSA
| | | | - Deepak L. Bhatt
- Mount Sinai HeartIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | | | - Gunnar Olsson
- Institute of MedicineUniversity of GothenburgGothenburgSweden
| | - Niklas Bergh
- Institute of MedicineUniversity of GothenburgGothenburgSweden
- Early Clinical Development, Biopharmaceuticals Research and Development—CardiovascularRenal and Metabolism, AstraZenecaMölndalSweden
| | - Björn Dahlöf
- Cereno ScientificGothenburgSweden
- Institute of MedicineUniversity of GothenburgGothenburgSweden
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28
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Lala A, Hamo CE, Bozkurt B, Fiuzat M, Blumer V, Bukhoff D, Butler J, Costanzo MR, Felker GM, Filippatos G, Konstam MA, McMurray JJV, Mentz RJ, Metra M, Psotka MA, Solomon SD, Teerlink J, Abraham WT, O'Connor CM. Standardized Definitions for Evaluation of Acute Decompensated Heart Failure Therapies: HF-ARC Expert Panel Paper. JACC. HEART FAILURE 2024; 12:1-15. [PMID: 38069997 DOI: 10.1016/j.jchf.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 01/06/2024]
Abstract
Acute decompensated heart failure (ADHF) is one of the most common reasons for hospitalizations or urgent care and is associated with poor outcomes. Therapies shown to improve outcomes are limited, however, and innovation in pharmacologic and device-based therapeutics are therefore actively being sought. Standardizing definitions for ADHF and its trajectory is complex, limiting the generalizability and translation of clinical trials to effect clinical care and policy change. The Heart Failure Collaboratory is a multistakeholder organization comprising clinical investigators, clinicians, patients, government representatives (including U.S. Food and Drug Administration and National Institutes of Health participants), payors, and industry collaborators. The following expert consensus document is the product of the Heart Failure Collaboratory convening with the Academic Research Consortium, including members from academia, the U.S. Food and Drug Administration, and industry, for the purposes of proposing standardized definitions for ADHF and highlighting important endpoint considerations to inform the design and conduct of clinical trials for drugs and devices in this clinical arena.
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Affiliation(s)
- Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute and Department of Population Health Science and Policy, Mount Sinai, New York, New York, USA.
| | - Carine E Hamo
- New York University School of Medicine, Leon H. Charney Division of Cardiology, New York University Langone Health, New York, New York, USA
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiology, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vanessa Blumer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel Bukhoff
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Javed Butler
- Baylor Scott & White Research Institute, Dallas, Texas, USA; University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gerasimos Filippatos
- University of Cyprus Medical School, Shakolas Educational Center for Clinical Medicine, Nicosia, Cyprus
| | - Marvin A Konstam
- The CardioVascular Center of Tufts Medical Center, Boston, Massachusetts, USA
| | - John J V McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Marco Metra
- Cardiology, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Christopher M O'Connor
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Inova Heart and Vascular Institute, Falls Church, Virginia, USA
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29
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Kong MG, Moon I, Seo HS, Suh J, Choi JY, Na JO, Kim EJ. Home Bioelectrical Impedance Analysis Management System in Patients With Heart Failure: Rationale and Study Design. INTERNATIONAL JOURNAL OF HEART FAILURE 2024; 6:22-27. [PMID: 38303915 PMCID: PMC10827698 DOI: 10.36628/ijhf.2023.0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Revised: 07/25/2023] [Accepted: 08/11/2023] [Indexed: 02/03/2024]
Abstract
Body fluid monitoring and management are essential to control dyspnea and prevent re-hospitalization in patients with chronic heart failure (HF). There are several methods to estimate and monitor patient's volume status, such as symptoms, signs, body weight, and implantable devices. However, these methods might be difficult to use for reasons that are slow to reflect body water change, inaccurate in specific patients' condition, or invasive. Bioelectrical impedance analysis (BIA) is a novel method for body water monitoring in patients with HF, and the value in prognosis has been proven in previous studies. We aim to determine the efficacy and safety of home BIA body water monitoring-guided HF treatment in patients with chronic HF. This multi-center, open-label, randomized control trial will enroll patients with HF who are taking loop diuretics. The home BIA group patients will be monitored for body water using a home BIA device and receive messages regarding their edema status and direction of additional diuretics usage or behavioral changes through the linked application system once weekly. The control group patients will receive the usual HF management. The primary endpoint is the change in N-terminal prohormone of brain natriuretic peptide levels from baseline after 12 weeks. This trial will provide crucial evidence for patient management with a novel home BIA body water monitoring system in patients with HF.
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Affiliation(s)
- Min Gyu Kong
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Inki Moon
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Hye-Sun Seo
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jon Suh
- Division of Cardiology, Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Soonchunhyang University College of Medicine, Bucheon, Korea
| | - Jah Yeon Choi
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Jin Oh Na
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
| | - Eung Ju Kim
- Division of Cardiology, Department of Internal Medicine, Korea University Guro Hospital, Korea University College of Medicine, Seoul, Korea
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30
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Fácila Rubio L, Lozano-Granero C, Vidal-Pérez R, Barrios V, Freixa-Pamias R. New technologies for the diagnosis, treatment, and monitoring of cardiovascular diseases. REVISTA ESPANOLA DE CARDIOLOGIA (ENGLISH ED.) 2024; 77:88-96. [PMID: 37838182 DOI: 10.1016/j.rec.2023.07.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 07/20/2023] [Indexed: 10/16/2023]
Abstract
Telemedicine enables the remote provision of medical care through information and communication technologies, facilitating data transmission, patient participation, promotion of heart-healthy habits, diagnosis, early detection of acute decompensation, and monitoring and follow-up of cardiovascular diseases. Wearable devices have multiple clinical applications, ranging from arrhythmia detection to remote monitoring of chronic diseases and risk factors. Integrating these technologies safely and effectively into routine clinical practice will require a multidisciplinary approach. Technological advances and data management will increase telemonitoring strategies, which will allow greater accessibility and equity, as well as more efficient and accurate patient care. However, there are still unresolved issues, such as identifying the most appropriate technological infrastructure, integrating these data into medical records, and addressing the digital divide, which can hamper patients' adoption of remote care. This article provides an updated overview of digital tools for a more comprehensive approach to atrial fibrillation, heart failure, risk factors, and treatment adherence.
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Affiliation(s)
- Lorenzo Fácila Rubio
- Servicio de Cardiología, Consorcio Hospital General Universitario de Valencia, Universitat de València, Valencia, Spain.
| | - Cristina Lozano-Granero
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal y Centro de Investigación en Red de Enfermedades Cardiovasculares (CIBERCV), Madrid, Spain
| | - Rafael Vidal-Pérez
- Servicio de Cardiología, Complejo Hospitalario Universitario de A Coruña, A Coruña, Spain
| | - Vivencio Barrios
- Servicio de Cardiología, Hospital Universitario Ramón y Cajal, Universidad de Alcalá (UAH), Madrid, Spain
| | - Román Freixa-Pamias
- Servicio de Cardiología, Complex Hospitalari Moisès Broggi, Sant Joan Despí, Barcelona, Spain
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31
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Xia J, Brownell NK, Fonarow GC, Ziaeian B. New models for heart failure care delivery. Prog Cardiovasc Dis 2024; 82:70-89. [PMID: 38311306 DOI: 10.1016/j.pcad.2024.01.009] [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: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 02/10/2024]
Abstract
Heart failure (HF) is a common disease with increasing prevalence around the world. There is high morbidity and mortality associated with poorly controlled HF along with increasing costs and strain on healthcare systems due to a high rate of rehospitalization and resource utilization. Despite the establishment of clear evidence-based guideline directed medical therapies (GDMT) proven to improve HF morbidity and mortality, there remains significant clinical inertia to optimizing HF patients on GDMT. Only a minority of HF patients are prescribed on all four classes of GDMT. To bridge the gap between the vulnerable population of HF patients and lifesaving GDMT, HF implementation is of increasing importance. HF implementation involves strategies and techniques to improve GDMT optimization along with other modalities to improve HF management. HF implementation meets patients where they are, including at the time of acute decompensation in the inpatient setting, at the vulnerable discharge stage, and at the chronic management stage in the outpatient setting. Inpatient HF implementation strategies include protocolized rapid titration of GDMT, site-level audit-and-feedback, virtual GDMT optimization teams, and electronic health record notifications and alerts. Discharge HF implementation strategies include education at patient and provider levels, discharge summaries, and HF transitional programs. Outpatient HF implementation strategies include digital innovations such as electronic health record utilization and mobile applications, population level strategies such as registries and clinical dashboards), changes in HF team structure and member roles, remote monitoring with implanted devices and telemonitoring, and hospital at home care model. With a growing population of HF patients, there is an increasing need for novel and creative HF implementation and monitoring methods.
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Affiliation(s)
- Jeffrey Xia
- Department of Medicine David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Nicholas K Brownell
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
| | - Boback Ziaeian
- Division of Cardiology, David Geffen School of Medicine at UCLA, Los Angeles, United States of America.
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32
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Varian F, Dick J, Battersby C, Roman S, Ablott J, Watson L, Binmahfooz S, Zafar H, Colgan G, Cannon J, Suntharalingam J, Lordan J, Howard L, McCabe C, Wort J, Price L, Church C, Hamilton N, Armstrong I, Hameed A, Hurdman J, Elliot C, Condliffe R, Wilkins M, Webb A, Adlam D, Benza RL, Rahimi K, Shojaei‐Shahrokhabadi M, Lin NX, Wason JMS, McIntosh A, McConnachie A, Middleton JT, Thompson R, Kiely DG, Toshner M, Rothman A. Pulmonary Hypertension: Intensification and Personalization of Combination Rx (PHoenix): A phase IV randomized trial for the evaluation of dose-response and clinical efficacy of riociguat and selexipag using implanted technologies. Pulm Circ 2024; 14:e12337. [PMID: 38500737 PMCID: PMC10945040 DOI: 10.1002/pul2.12337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 12/19/2023] [Accepted: 01/02/2024] [Indexed: 03/20/2024] Open
Abstract
Approved therapies for the treatment of patients with pulmonary arterial hypertension (PAH) mediate pulmonary vascular vasodilatation by targeting distinct biological pathways. International guidelines recommend that patients with an inadequate response to dual therapy with a phosphodiesterase type-5 inhibitor (PDE5i) and endothelin receptor antagonist (ERA), are recommended to either intensify oral therapy by adding a selective prostacyclin receptor (IP) agonist (selexipag), or switching from PDE5i to a soluble guanylate-cyclase stimulator (sGCS; riociguat). The clinical equipoise between these therapeutic choices provides the opportunity for evaluation of individualized therapeutic effects. Traditionally, invasive/hospital-based investigations are required to comprehensively assess disease severity and demonstrate treatment benefits. Regulatory-approved, minimally invasive monitors enable equivalent measurements to be obtained while patients are at home. In this 2 × 2 randomized crossover trial, patients with PAH established on guideline-recommended dual therapy and implanted with CardioMEMS™ (a wireless pulmonary artery sensor) and ConfirmRx™ (an insertable cardiac rhythm monitor), will receive ERA + sGCS, or PDEi + ERA + IP agonist. The study will evaluate clinical efficacy via established clinical investigations and remote monitoring technologies, with remote data relayed through regulatory-approved online clinical portals. The primary aim will be the change in right ventricular systolic volume measured by magnetic resonance imaging (MRI) from baseline to maximal tolerated dose with each therapy. Using data from MRI and other outcomes, including hemodynamics, physical activity, physiological measurements, quality of life, and side effect reporting, we will determine whether remote technology facilitates early evaluation of clinical efficacy, and investigate intra-patient efficacy of the two treatment approaches.
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Affiliation(s)
- Frances Varian
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Jennifer Dick
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
| | | | - Stefan Roman
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Jenna Ablott
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Lisa Watson
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | | | - Hamza Zafar
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | | | - John Cannon
- Royal Papworth Hospital NHS Foundation TrustCambridgeUK
| | | | - Jim Lordan
- Newcastle Hospitals NHS Foundation TrustNewcastleUK
| | - Luke Howard
- Imperial College Healthcare NHS TrustLondonUK
| | - Colm McCabe
- Royal Brompton and HarefieldGuy's and St Thomas' NHS Foundation TrustLondonUK
| | - John Wort
- NHS Greater Glasgow and ClydeGlasgowUK
| | | | - Colin Church
- National Heart and Lung Institute, Faculty of Medicine, Imperial College LondonLondonUK
| | - Neil Hamilton
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Iain Armstrong
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Abdul Hameed
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Judith Hurdman
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Charlie Elliot
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Robin Condliffe
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Martin Wilkins
- National Heart and Lung Institute, Faculty of Medicine, Imperial College LondonLondonUK
| | - Alastair Webb
- Wolfson Centre for Prevention of Stroke and DementiaUniversity of OxfordOxfordUK
| | - David Adlam
- Cardiovascular Research Unit of LeicesterLeicesterUK
| | - Ray L. Benza
- Mount Sinai HeartIcahn School of Medicine at Mount SinaiNew YorkNew YorkUSA
| | - Kazem Rahimi
- Deep Medicine, Nuffield Department of Women's and Reproductive HealthUniversity of OxfordOxfordUK
| | | | - Nan X. Lin
- Biostatistics Research Group, Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - James M. S. Wason
- Biostatistics Research Group, Population Health Sciences InstituteNewcastle UniversityNewcastle upon TyneUK
| | - Alasdair McIntosh
- Robertson Centre for Biostatistics, School of Health and WellbeingUniversity of GlasgowGlasgowUK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, School of Health and WellbeingUniversity of GlasgowGlasgowUK
| | - Jennifer T. Middleton
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Roger Thompson
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - David G. Kiely
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
| | - Mark Toshner
- Department of Medicine, Heart and Lung Research InstituteUniversity of CambridgeCambridgeUK
| | - Alexander Rothman
- Division of Clinical MedicineUniversity of SheffieldSheffieldUK
- Sheffield Pulmonary Vascular Disease UnitSheffield Teaching Hospitals NHS Foundation TrustSheffieldUK
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33
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Wei C, Heidenreich PA, Sandhu AT. The economics of heart failure care. Prog Cardiovasc Dis 2024; 82:90-101. [PMID: 38244828 PMCID: PMC11009372 DOI: 10.1016/j.pcad.2024.01.010] [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: 01/13/2024] [Accepted: 01/13/2024] [Indexed: 01/22/2024]
Abstract
Heart failure (HF) poses a significant economic burden in the US, with costs projected to reach $70 billion by 2030. Cost-effectiveness analyses play a pivotal role in assessing the economic value of HF therapies. In this review, we overview the cost-effectiveness of HF therapies and discuss ways to improve patient access. Based on current costs, guideline directed medical therapies for HF with reduced ejection fraction provide high economic value except for sodium-glucose cotransporter-2 inhibitors, which provide intermediate economic value. Combining therapy with the four pillars of medical therapy also has intermediate economic value, with incremental cost-effectiveness ratios ranging from $73,000 to $98,500/ quality adjusted life-years. High economic value procedures include cardiac resynchronization devices, implantable cardioverter-defibrillators, and coronary artery bypass surgery. In contrast, advanced HF therapies have previously demonstrated intermediate to low economic value, but newer data appear more favorable. Given the affordability challenges of HF therapies, additional efforts are needed to ensure optimal care for patients. The recent Inflation Reduction Act contains provisions to reform policy pertaining to drug price negotiation and out-of-pocket spending, as well as measures to increase access to existing programs, including the Medicare low-income subsidy. On a patient level, it is also important to encourage patient and physician awareness and discussions surrounding medical costs. Overall, a broad approach to improving available therapies and access to care is needed to reduce the growing clinical and economic morbidity of HF.
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Affiliation(s)
- Chen Wei
- Department of Medicine, Stanford University School of Medicine, United States of America
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, United States of America; Palo Alto Veterans Affairs Healthcare System, Palo Alto, CA, United States of America
| | - Alexander T Sandhu
- Division of Cardiovascular Medicine, Department of Medicine, Stanford University, Stanford, CA, United States of America; Palo Alto Veterans Affairs Healthcare System, Palo Alto, CA, United States of America.
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34
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Marshall WH, Rajpal S, Mah ML, Armstrong AK, Salavitabar A, Hickey J, Metzger R, Sisk T, Daniels CJ. Early Experience and Lessons Learned Using Implanted Hemodynamic Monitoring in Patients With Fontan Circulation. J Am Heart Assoc 2023; 12:e031836. [PMID: 38063189 PMCID: PMC10863767 DOI: 10.1161/jaha.123.031836] [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: 07/18/2023] [Accepted: 11/14/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Data on the use of implanted hemodynamic monitoring (IHM) in patients with Fontan circulation are limited. This study reports our experience using the CardioMEMS HF system in adults with Fontan circulation. METHODS AND RESULTS This single-center, retrospective study evaluated heart failure hospitalizations, procedural complications, and device-related complications in patients with Fontan circulation referred for IHM placement (2015-2022). The association of pulmonary artery pressure (by most recent catheterization and median IHM pressure within 30 days of placement) with both death and follow-up Model for End-Stage Liver Disease Excluding International Normalized Ratio score were evaluated. Of 18 patients referred for IHM placement, 17 were successful (median age, 30 [range 21-48] years, 6 women). Procedural complications (access site hematomas, pulmonary artery staining) occurred in 3 patients, without device-related procedural complications. In follow-up (median, 35 [range, 6-83] months), 1 patient developed a pulmonary embolism (possibly device-related). Heart failure hospitalizations/year were similar before and after IHM (median, 1 [interquartile range, 0-1.0] versus 0.6 [0-2.3]; P=0.268), though only 46% of heart failure hospitalizations had associated IHM transmissions. IHM pressures were associated with Model for End-Stage Liver Disease Excluding International Normalized Ratio scores (R2=0.588, P<0.001), though catheterization pressures were not (R2=0.140, P=0.139). The long-term mortality rate was 53% in this cohort. On unadjusted survival analysis, IHM pressures ≥18 mm Hg were associated with mortality (log rank P=0.041), which was not reproduced with catheterization pressures (log rank P=0.764). CONCLUSIONS In patients with Fontan circulation, IHM did not reduce heart failure hospitalizations, though patient adherence to transmission was low. Device-related complications were low. IHM pressures may better represent real-life conditions compared with catheterization given associations with mortality and Model for End-Stage Liver Disease Excluding International Normalized Ratio score.
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Affiliation(s)
- William H. Marshall
- Division of Cardiovascular Medicine, Department of Internal MedicineThe Ohio State University Wexner Medical CenterColumbusOH
- Nationwide Children’s Hospital, The Heart CenterColumbusOH
| | - Saurabh Rajpal
- Division of Cardiovascular Medicine, Department of Internal MedicineThe Ohio State University Wexner Medical CenterColumbusOH
- Nationwide Children’s Hospital, The Heart CenterColumbusOH
| | - May Ling Mah
- Nationwide Children’s Hospital, The Heart CenterColumbusOH
| | | | | | - Jenne Hickey
- Nationwide Children’s Hospital, The Heart CenterColumbusOH
| | - Rachel Metzger
- Nationwide Children’s Hospital, The Heart CenterColumbusOH
| | - Tracey Sisk
- Nationwide Children’s Hospital, The Heart CenterColumbusOH
| | - Curt J. Daniels
- Division of Cardiovascular Medicine, Department of Internal MedicineThe Ohio State University Wexner Medical CenterColumbusOH
- Nationwide Children’s Hospital, The Heart CenterColumbusOH
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35
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Clephas PRD, de Boer RA, Brugts JJ. Benefits of remote hemodynamic monitoring in heart failure. Trends Cardiovasc Med 2023:S1050-1738(23)00111-1. [PMID: 38109949 DOI: 10.1016/j.tcm.2023.12.003] [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] [Received: 08/30/2023] [Revised: 11/28/2023] [Accepted: 12/13/2023] [Indexed: 12/20/2023]
Abstract
Despite treatment advancements, HF mortality remains high, prompting interest in reducing HF-related hospitalizations through remote monitoring. These advances are necessary considering the rapidly rising prevalence and incidence of HF worldwide, presenting a burden on hospital resources. While traditional approaches have failed in predicting impending HF-related hospitalizations, remote hemodynamic monitoring can detect changes in intracardiac filling pressure weeks prior to HF-related hospitalizations which makes timely pharmacological interventions possible. To ensure successful implementation, structural integration, optimal patient selection, and efficient data management are essential. This review aims to provide an overview of the rationale, the available devices, current evidence, and the implementation of remote hemodynamic monitoring.
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Affiliation(s)
- P R D Clephas
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - R A de Boer
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands
| | - J J Brugts
- Department of Cardiology, Erasmus MC University Medical Centre, Rotterdam, the Netherlands.
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36
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Markson F, Abe TA, Adedinsewo D, Olanipekun T, Shamaki GR, Kesiena O, Mentz RJ, Michos ED. Sex Differences in CardioMEMS Utilization and Impact on Readmissions and Mortality in Heart Failure Patients. JACC. HEART FAILURE 2023; 11:1760-1762. [PMID: 37855756 DOI: 10.1016/j.jchf.2023.08.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Revised: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 10/20/2023]
Affiliation(s)
- Favour Markson
- Division of General Internal Medicine, Department of Medicine, Lincoln Medical Center, Bronx, New York, USA
| | - Temidayo A Abe
- Division of Cardiology, Department of Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee, USA.
| | - Demilade Adedinsewo
- Division of Cardiology, Department of Medicine, Mayo Clinic, Jacksonville, Florida, USA
| | - Titilope Olanipekun
- Division of Critical Care, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Garba Rimamskep Shamaki
- Division of General Internal Medicine, Department of Medicine, Rochester General Hospital, Rochester, New York, USA
| | - Onoriode Kesiena
- Division of General Internal Medicine, Department of Medicine, Piedmont Athens Hospital, Athens, Georgia, USA
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Erin D Michos
- Division of Cardiology, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
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37
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Kittleson MM. Management of Heart Failure in Hospitalized Patients. Ann Intern Med 2023; 176:ITC177-ITC192. [PMID: 38079639 DOI: 10.7326/aitc202312190] [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: 12/20/2023] Open
Abstract
Heart failure affects more than 6 million people in the United States, and hospitalizations for decompensated heart failure confer a heavy toll in morbidity, mortality, and health care costs. Clinical trials have demonstrated effective interventions; however, hospitalization and mortality rates remain high. Key components of effective hospital care include appropriate diagnostic evaluation, triage and risk stratification, early implementation of guideline-directed medical therapy, adequate diuresis, and appropriate discharge planning.
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Affiliation(s)
- Michelle M Kittleson
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California (M.M.K.)
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38
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Chaikijurajai T, Rincon-Choles H, Tang WHW. Natriuretic peptide testing strategies in heart failure: A 2023 update. Adv Clin Chem 2023; 118:155-203. [PMID: 38280805 DOI: 10.1016/bs.acc.2023.11.005] [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] [Indexed: 01/29/2024]
Abstract
Natriuretic peptides (NPs), including B-type natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP), have been recommended as standard biomarkers for diagnosing heart failure (HF), and one of the strongest risk predictors for mortality and HF hospitalization regardless of ejection fraction (EF) and etiology of HF. BNP is an active neurohormone opposing renin-angiotensin-aldosterone and sympathetic nervous system overactivated in HF, whereas NT-proBNP is an inactive prohormone released from cardiomyocytes in response to wall stress. Despite substantial advances in the development of guideline-directed medical therapy (GDMT) for HF with reduced EF, studies demonstrating direct benefits of NP-guided chronic HF therapy on mortality, HF hospitalization, and GDMT optimization have yielded conflicting results. However, accumulating evidence shows that achieving prespecified BNP or NT-proBNP target over time is significantly associated with favorable outcomes, suggesting that benefits of serially measured NPs may be limited to particular groups of HF patients, such as those with extreme levels of baseline BNP or NT-proBNP, which could represent severe phenotypes of HF associated with natriuretic peptide resistance or cardiorenal syndrome. Over the past decade, clinical utilization of BNP and NT-proBNP has been expanded, especially using serial NP measurements for guiding HF therapy, optimizing GDMT and identifying at-risk patients with HF phenotypes who may be minimally symptomatic or asymptomatic.
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Affiliation(s)
- Thanat Chaikijurajai
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States; Department of Medicine, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Hernan Rincon-Choles
- Department of Nephrology, Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, United States
| | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, United States.
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39
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Joy PS, Kumar G, Jermyn R, Van Zyl J, Joseph S, Hsi B, Afzal A, Sauer A, Alam A. Heart Failure Admissions Outcomes in Patients With CardioMEMS. Am J Cardiol 2023; 207:7-9. [PMID: 37717286 DOI: 10.1016/j.amjcard.2023.08.157] [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: 06/30/2023] [Revised: 08/18/2023] [Accepted: 08/23/2023] [Indexed: 09/19/2023]
Affiliation(s)
| | - Gagan Kumar
- Northeast Georgia Medical Center, Gainesville, Georgia
| | - Rita Jermyn
- St. Francis Hospital & Heart Center, Roslyn, New York
| | | | - Susan Joseph
- The University of Maryland Medical System, Baltimore, Maryland
| | - Brian Hsi
- Baylor University Medical Center, Dallas, Texas
| | - Aasim Afzal
- Baylor University Medical Center, Dallas, Texas
| | - Andrew Sauer
- Saint Luke's Mid America Heart Institute, Kansas City, Missouri
| | - Amit Alam
- New York University, New York City, New York.
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40
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Mastoris I, Gupta K, Sauer AJ. The War Against Heart Failure Hospitalizations: Remote Monitoring and the Case for Expanding Criteria. Cardiol Clin 2023; 41:557-573. [PMID: 37743078 DOI: 10.1016/j.ccl.2023.06.001] [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] [Indexed: 09/26/2023]
Abstract
Successful remote patient monitoring depends on bidirectional interaction between patients and multidisciplinary clinical teams. Invasive pulmonary artery pressure monitoring has been shown to reduce heart failure (HF) hospitalizations, facilitate guideline-directed medical therapy optimization, and improve quality of life. Cardiac implantable electronic device-based multiparameter monitoring has shown encouraging results in predicting future HF-related events. Potential expanded indications for remote monitoring include guideline-directed medical therapy optimization, application to specific populations, and subclinical detection of HF. Voice analysis, inferior vena cava diameter monitoring, and artificial intelligence-based remote electrocardiogram show potential to gain some merit in remote patient monitoring in HF.
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Affiliation(s)
- Ioannis Mastoris
- Cardiology Division, Department of Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | - Kashvi Gupta
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO 64111, USA
| | - Andrew J Sauer
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, 4401 Wornall Road, Kansas City, MO 64111, USA.
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41
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Kelly R, Bae JY, Mansour AY, Nagpal S, Hahn S, Murugiah K. Wireless pulmonary artery sensor implantation in a unilateral lung transplant recipient. J Cardiol Cases 2023; 28:216-220. [PMID: 38024115 PMCID: PMC10658300 DOI: 10.1016/j.jccase.2023.08.004] [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: 04/09/2023] [Revised: 07/05/2023] [Accepted: 07/18/2023] [Indexed: 12/01/2023] Open
Abstract
Patients with lung transplantation can have concomitant left ventricular failure which can either precede the lung transplantation or develop after. Implantable wireless pulmonary artery (PA) pressure monitors to guide hemodynamic management in heart failure such as the CardioMEMS device (Abbott, Sylmar, CA, USA) have been shown to improve outcomes. However, in a lung transplant recipient there are unique physiological and practical considerations when contemplating to implant a PA pressure sensor such as safety of implanting the device, choice of site of implantation, accuracy of wedge tracings to calibrate, and exclusion of vascular stenoses post transplantation. We discuss these considerations in the context of a man in his early 60s with a known left lung transplant two years previously who developed worsening heart failure needing invasive monitoring. Right lung PA sensor placement was considered, but on selective pulmonary angiography the right PA was found to be of small caliber and with significant tortuosity. After careful hemodynamic assessment, the PA sensor was implanted in the PA of the transplanted lung which is the first such case to our knowledge. Learning objective We report the first documented case of an implantable wireless pulmonary artery pressure monitor (CardioMEMs) into a transplanted lung. Device-related complications, such as pulmonary artery injury, infection, and hemoptysis, must be assessed after placement. Given the changes in pulmonary artery pressures after lung transplantation, recalibration of the CardioMEMs device may need to be considered if placed within first year of transplant.
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Affiliation(s)
- Ryan Kelly
- Department of Medicine, Yale-New Haven Health Greenwich Hospital, Greenwich, CT, USA
| | - Ju Young Bae
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale New Haven Health Bridgeport Hospital, Bridgeport, CT, USA
| | - Ali Y. Mansour
- Section of Pulmonary Medicine, Department of Medicine, Montefiore Medical Center, Bronx, NY, USA
| | - Sameer Nagpal
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Samuel Hahn
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Karthik Murugiah
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
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42
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Bhimaraj A, Benjamin TA, Guglin M, Volz E, Shah H, Guha A, Bhatt K, Bennett M, Sauer A, Fudim M, Robinson M, Muse ED, Heywood TJ, Jonsson O, Abraham J. Translating Pressure Into Practice: Operational Characteristics of Ambulatory Hemodynamic Monitoring Program in the United States. J Card Fail 2023; 29:1571-1575. [PMID: 37328050 DOI: 10.1016/j.cardfail.2023.05.021] [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: 03/29/2023] [Revised: 05/17/2023] [Accepted: 05/29/2023] [Indexed: 06/18/2023]
Abstract
BACKGROUND Ambulatory hemodynamic monitoring (AHM) using an implantable pulmonary artery pressure sensor (CardioMEMS) is effective in improving outcomes for patients with heart failure. The operations of AHM programs are crucial to clinical efficacy of AHM yet have not been described. METHODS AND RESULTS An anonymous, voluntary, web-based survey was developed and emailed to clinicians at AHM centers in the United States. Survey questions were related to program volume, staffing, monitoring practices, and patient selection criteria. Fifty-four respondents (40%) completed the survey. Respondents were 44% (n = 24) advanced HF cardiologists and 30% (n = 16) advanced nurse practitioners. Most respondents practice at a center that implants left ventricular assist devices (70%) or performs heart transplantation (54%). Advanced practice providers provide day-to-day monitoring and management in most programs (78%), and use of protocol-driven care is limited (28%). Perceived patient nonadherence and inadequate insurance coverage are cited as the primary barriers to AHM. CONCLUSIONS Despite broad US Food and Drug Administration approval for patients with symptoms and at increased risk for worsening heart failure, the adoption of pulmonary artery pressure monitoring is concentrated at advanced heart failure centers, and modest numbers of patients are implanted at most centers. Understanding and addressing the barriers to referral of eligible patients and to broader adoption in community heart failure programs is needed to maximize the clinical benefits of AHM.
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Affiliation(s)
- Arvind Bhimaraj
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Terrie-Ann Benjamin
- Heart Failure Division, M Health Fairview, East Region, University of Minnesota, Minneapolis, Minnesota
| | - Maya Guglin
- Department of Internal Medicine, Division of Cardiovascular Disease, Indiana University School of Medicine, Indianapolis, Indiana
| | - Elizabeth Volz
- Department of Cardiology, University of North Carolina, Chapel Hill, North Carolina
| | - Hirak Shah
- Department of Cardiovascular Medicine, University of Kansas Medical Center, Kansas City, Kansas
| | - Ashrith Guha
- Houston Methodist DeBakey Heart and Vascular Center, Houston Methodist Hospital, Houston, Texas
| | - Kunjan Bhatt
- Department of Heart Failure, Austin Heart, Austin, Texas
| | - Mosi Bennett
- Allina Health Minneapolis Heart Institute, Minneapolis, Minnesota
| | - Andrew Sauer
- Saint Luke's Mid America Heart Institute, University of Missouri, Kansas City, Missouri
| | - Marat Fudim
- Duke Clinical Research Institute, Durham, North Carolina
| | - Monique Robinson
- Division of Advanced Heart Failure and Transplantation, Harrington Heart and Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio
| | - Evan D Muse
- Division of Cardiovascular Diseases, Scripps Research Translational Institute, La Jolla, California; Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, La Jolla, California
| | - Thomas J Heywood
- Division of Cardiovascular Medicine, Scripps Clinic, Prebys Cardiovascular Institute, La Jolla, California
| | - Orvar Jonsson
- University of South Dakota Sanford Health, Sioux Falls, South Dakota
| | - Jacob Abraham
- Center for Cardiovascular Analytics, Research and Data Science, Providence Heart Institute, Providence Research Network, Portland, Oregon.
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43
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Wissmüller M, Tichelbäcker T, Finke K, Dohr J, Adler J, Ochs L, Hohmann C, Baldus S, Rosenkranz S. [Pulmonary hypertension associated with left heart disease (group 2)]. Dtsch Med Wochenschr 2023; 148:1498-1506. [PMID: 37949078 DOI: 10.1055/a-2012-0803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2023]
Abstract
Patients with left heart disease (LHD) often display pulmonary hypertension (PH), which impacts morbidity and mortality. The pathophysiology of PH is complex and entails pulmonary congestion due to elevated left-sided filling pressures, pulmonary vasoconstriction as well as vascular remodeling. The recent ESC/ERS Guidelines on pulmonary hypertension updated the hemodynamic definitions of pulmonary hypertension in general, and the subclassification of post-capillary PH. This review summarizes recent advances in the diagnostic work-up and management strategies of PH associated with LHD. Specifically, we summarize revisited hemodynamic definitions and the characteristics of isolated post-capillary PH (IpcPH) and combined post- and pre-capillary PH (CpcPH). Furthermore, we review the current knowledge on the pathogenesis of PH-LHD, the prognostic relevance of hemodynamic parameters, and the management strategies, differentiating between treatment of the underlying left heart disease and therapies targeting the pulmonary circulation. The article emphasises the need for precise diagnostic work-up and individualized treatment strategies in patients with PH-LHD.
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44
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Schmidt KH, Bikou O, Blindt R, Bruch L, Felgendreher R, Hohenforst-Schmidt W, Holt S, Ladage D, Pfeuffer-Jovic E, Rieth A, Schmeisser A, Schnitzler K, Stadler S, Steringer-Mascherbauer R, Yogeswaran A, Kuebler WM. [Pulmonary hypertension associated with left heart disease (group 2)]. Pneumologie 2023; 77:926-936. [PMID: 37963482 DOI: 10.1055/a-2145-4792] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
Pulmonary hypertension associated with left heart disease (PH-LHD) corresponds to group two of pulmonary hypertension according to clinical classification. Haemodynamically, this group includes isolated post-capillary pulmonary hypertension (IpcPH) and combined post- and pre-capillary pulmonary hypertension (CpcPH). PH-LHD is defined by an mPAP > 20 mmHg and a PAWP > 15 mmHg, pulmonary vascular resistance (PVR) with a cut-off value of 2 Wood Units (WU) is used to differentiate between IpcPH and CpcPH. A PVR greater than 5 WU indicates a dominant precapillary component. PH-LHD is the most common form of pulmonary hypertension, the leading cause being left heart failure with preserved (HFpEF) or reduced ejection fraction (HFmrEF, HFrEF), valvular heart disease and, less commonly, congenital heart disease. The presence of pulmonary hypertension is associated with increased symptom burden and poorer outcome across the spectrum of left heart disease. Differentiating between group 1 pulmonary hypertension with cardiac comorbidities and PH-LHD, especially due to HFpEF, is a particular challenge. Therapeutically, no general recommendation for the use of PDE5 inhibitors in HFpEF-associated CpcPH can be made at this time. There is currently no reliable rationale for the use of PAH drugs in IpcPH, nor is therapy with endothelin receptor antagonists or prostacyclin analogues recommended for all forms of PH-LHD.
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Affiliation(s)
- Kai Helge Schmidt
- Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland
- Centrum für Thrombose und Hämostase (CTH), Universitätsmedizin Mainz, Mainz, Deutschland
| | - Olympia Bikou
- Medizinische Klinik und Poliklinik I, Klinikum der Universität München, München, Deutschland
| | - Rüdiger Blindt
- Kardio Bremen, Rotes Kreuz Krankenhaus Bremen, Bremen, Deutschland
| | - Leonhard Bruch
- Klinik für Innere Medizin und Kardiologie, BG Klinikum Unfallkrankenhaus Berlin, Berlin, Deutschland
| | | | | | - Stephan Holt
- Praxis am Steintor, Recklinghausen, Recklinghausen, Deutschland
| | - Dennis Ladage
- Klinik für Pneumologie, Kliniken Maria Hilf Mönchengladbach, Mönchengladbach, Deutschland
| | | | - Andreas Rieth
- Abteilung für Kardiologie, Kerckhoff-Klinik Bad Nauheim, Bad Nauheim, Deutschland
| | - Alexander Schmeisser
- Zentrum für Innere Medizin, Universitätsklinik für Kardiologie und Angiologie Magdeburg, Magdeburg, Deutschland
| | - Katharina Schnitzler
- Zentrum für Kardiologie, Kardiologie I, Universitätsmedizin Mainz, Mainz, Deutschland
| | - Stefan Stadler
- Klinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg, Deutschland
| | | | - Athiththan Yogeswaran
- Department of Internal Medicine, Member of the German Center for Lung Research, Universities of Giessen and Marburg Lung Center, Justus-Liebig-University Giessen, Giessen, Deutschland
| | - Wolfgang M Kuebler
- Institute of Physiology, Charité - Universitätsmedizin Berlin, Berlin, Deutschland
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Filippini FB, Ribeiro HB, Bocchi E, Bacal F, Marcondes-Braga FG, Avila MS, Sturmer JD, Marchi MFDS, Kanhouche G, Freire AF, Cassar R, Abizaid AA, de Brito FS. Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure. Arq Bras Cardiol 2023; 120:e20220496. [PMID: 38126512 PMCID: PMC10773459 DOI: 10.36660/abc.20220496] [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: 07/11/2023] [Revised: 04/05/2023] [Accepted: 05/17/2023] [Indexed: 12/23/2023] Open
Abstract
BACKGROUND Central Illustration : Percutaneous Strategies in Structural Heart Diseases: Focus on Chronic Heart Failure Transcatheter devices for monitoring and treating advanced chronic heart failure patients. PA: pulmonary artery; LA: left atrium; AFR: atrial flow regulator; TASS: Transcatheter Atrial Shunt System; VNS: vagus nerve stimulation; BAT: baroreceptor activation therapy; RDN: renal sympathetic denervation; F: approval by the American regulatory agency (FDA); E: approval by the European regulatory agency (CE Mark). BACKGROUND Innovations in devices during the last decade contributed to enhanced diagnosis and treatment of patients with cardiac insufficiency. These tools progressively adapted to minimally invasive strategies with rapid, widespread use. The present article focuses on actual and future directions of device-related diagnosis and treatment of chronic heart failure.
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Affiliation(s)
- Filippe Barcellos Filippini
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Alemão Oswaldo CruzSão PauloSPBrasil Hospital Alemão Oswaldo Cruz , São Paulo , SP – Brasil
| | - Henrique Barbosa Ribeiro
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Edimar Bocchi
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Fernando Bacal
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Fabiana G. Marcondes-Braga
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Monica S. Avila
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Janine Daiana Sturmer
- Hospital Alemão Oswaldo CruzSão PauloSPBrasil Hospital Alemão Oswaldo Cruz , São Paulo , SP – Brasil
| | - Mauricio Felippi de Sá Marchi
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Gabriel Kanhouche
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
| | - Antônio Fernando Freire
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Renata Cassar
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Alexandre A. Abizaid
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
| | - Fábio Sândoli de Brito
- Hospital das ClínicasFaculdade de MedicinaUniversidade de São PauloSão PauloSPBrasil Instituto do Coração do Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo , São Paulo , SP – Brasil
- Hospital Sírio-LibanêsSão PauloSPBrasil Hospital Sírio-Libanês , São Paulo , SP – Brasil
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46
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Gregson J, Stone GW, Bhatt DL, Packer M, Anker SD, Zeller C, Redfors B, Pocock SJ. Recurrent Events in Cardiovascular Trials: JACC State-of-the-Art Review. J Am Coll Cardiol 2023; 82:1445-1463. [PMID: 37758440 DOI: 10.1016/j.jacc.2023.07.024] [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: 06/20/2023] [Revised: 06/28/2023] [Accepted: 07/06/2023] [Indexed: 10/03/2023]
Abstract
Many randomized trials in cardiovascular disease have repeat nonfatal events (such as hospitalizations) occurring during patient follow-up; yet, it remains common practice to have time-to-first event as the primary outcome. We explore the value of analyses that include repeat events. Do they help us understand the effect of treatment and total disease burden? Do they enhance statistical power? Should they become a trial's primary analysis? It may also be difficult to choose which of the various statistical methods for analyzing repeat events to use, and we provide a nontechnical guide to what each method is doing. We compare several methods for repeat events: Lin Wei Yang Ying, negative binomial, joint frailty, win ratio, and area under the curve. We illustrate their performance in 5 large cardiovascular trials and compare them with time-to-first-event analyses. We review their use in recently published heart failure trials and make recommendations for their use in future trials.
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Affiliation(s)
- John Gregson
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom.
| | - Gregg W Stone
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, Texas, USA; Imperial College, London, United Kingdom
| | - Stefan D Anker
- Department of Cardiology (CVK) of German Heart Center Charité; Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | | | - Bjorn Redfors
- Department of Cardiology, Sahlgrenska University Hospital, Gothenburg, Sweden; Cardiovascular Research Foundation, New York, New York, USA
| | - Stuart J Pocock
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, United Kingdom
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47
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Zito A, Restivo A, Ciliberti G, Laborante R, Princi G, Romiti GF, Galli M, Rodolico D, Bianchini E, Cappannoli L, D'Oria M, Trani C, Burzotta F, Cesario A, Savarese G, Crea F, D'Amario D. Heart failure management guided by remote multiparameter monitoring: A meta-analysis. Int J Cardiol 2023; 388:131163. [PMID: 37429443 DOI: 10.1016/j.ijcard.2023.131163] [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: 04/06/2023] [Revised: 07/01/2023] [Accepted: 07/05/2023] [Indexed: 07/12/2023]
Abstract
BACKGROUND Several implant-based remote monitoring strategies are currently tested to optimize heart failure (HF) management by anticipating clinical decompensation and preventing hospitalization. Among these solutions, the modern implantable cardioverter-defibrillator and cardiac resynchronization therapy devices have been equipped with sensors allowing continuous monitoring of multiple preclinical markers of worsening HF, including factors of autonomic adaptation, patient activity, and intrathoracic impedance. OBJECTIVES We aimed to assess whether implant-based multiparameter remote monitoring strategy for guided HF management improves clinical outcomes when compared to standard clinical care. METHODS A systematic literature research for randomized controlled trials (RCTs) comparing multiparameter-guided HF management versus standard of care was performed on PubMed, Embase, and CENTRAL databases. Incidence rate ratios (IRRs) and associated 95% confidence intervals (CIs) were calculated using the Poisson regression model with random study effects. The primary outcome was a composite of all-cause death and HF hospitalization events, whereas secondary endpoints included the individual components of the primary outcome. RESULTS Our meta-analysis included 6 RCTs, amounting to a total of 4869 patients with an average follow-up time of 18 months. Compared with standard clinical management, the multiparameter-guided strategy reduced the risk of the primary composite outcome (IRR 0.83, 95%CI 0.71-0.99), driven by statistically significant effect on both HF hospitalization events (IRR 0.75, 95%CI 0.61-0.93) and all-cause death (IRR 0.80, 95%CI 0.66-0.96). CONCLUSION Implant-based multiparameter remote monitoring strategy for guided HF management is associated with significant benefit on clinical outcomes compared to standard clinical care, providing a benefit on both hospitalization events and all-cause death.
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Affiliation(s)
- Andrea Zito
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Attilio Restivo
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Ciliberti
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Renzo Laborante
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giuseppe Princi
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Giulio Francesco Romiti
- Department of Translational and Precision Medicine, Sapienza - University of Rome, Rome, Italy
| | - Mattia Galli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Maria Cecilia Hospital, GVM Care & Research, Cotignola, Italy
| | - Daniele Rodolico
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Emiliano Bianchini
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Luigi Cappannoli
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy
| | - Marika D'Oria
- Open Innovation Unit, Scientific Directorate, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Carlo Trani
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesco Burzotta
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alfredo Cesario
- Open Innovation Unit, Scientific Directorate, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; CEO, Gemelli Digital Medicine & Health Srl, Rome, Italy
| | - Gianluigi Savarese
- Division of Cardiology, Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Filippo Crea
- Department of Cardiovascular and Pulmonary Sciences, Catholic University of the Sacred Heart, Rome, Italy; Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Domenico D'Amario
- Department of Cardiovascular Medicine, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Translational Medicine, University of Eastern Piedmont, Maggiore della Carità Hospital, Novara, Italy.
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48
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Clephas PRD, Radhoe SP, Boersma E, Gregson J, Jhund PS, Abraham WT, McMurray JJV, de Boer RA, Brugts JJ. Efficacy of pulmonary artery pressure monitoring in patients with chronic heart failure: a meta-analysis of three randomized controlled trials. Eur Heart J 2023; 44:3658-3668. [PMID: 37210750 PMCID: PMC10542655 DOI: 10.1093/eurheartj/ehad346] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 05/17/2023] [Accepted: 05/18/2023] [Indexed: 05/23/2023] Open
Abstract
AIMS Adjustment of treatment based on remote monitoring of pulmonary artery (PA) pressure may reduce the risk of hospital admission for heart failure (HF). We have conducted a meta-analysis of large randomized trials investigating this question. METHODS AND RESULTS A systematic literature search was performed for randomized clinical trials with PA pressure monitoring devices in patients with HF. The primary outcome of interest was the total number of HF hospitalizations. Other outcomes assessed were urgent visits leading to treatment with intravenous diuretics, all-cause mortality, and composites. Treatment effects are expressed as hazard ratios, and pooled effect estimates were obtained applying random effects meta-analyses. Three eligible randomized clinical trials were identified that included 1898 outpatients in New York Heart Association functional classes II-IV, either hospitalized for HF in the prior 12 months or with elevated plasma NT-proBNP concentrations. The mean follow-up was 14.7 months, 67.8% of the patients were men, and 65.8% had an ejection fraction ≤40%. Compared to patients in the control group, the hazard ratio (95% confidence interval) for total HF hospitalizations in those randomized to PA pressure monitoring was 0.70 (0.58-0.86) (P = .0005). The corresponding hazard ratio for the composite of total HF hospitalizations, urgent visits and all-cause mortality was 0.75 (0.61-0.91; P = .0037) and for all-cause mortality 0.92 (0.73-1.16). Subgroup analyses, including ejection fraction phenotype, revealed no evidence of heterogeneity in the treatment effect. CONCLUSION The use of remote PA pressure monitoring to guide treatment of patients with HF reduces episodes of worsening HF and subsequent hospitalizations.
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Affiliation(s)
- Pascal R D Clephas
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Sumant P Radhoe
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Eric Boersma
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - John Gregson
- Department of Medical Statistics, London School of Hygiene & Tropical Medicine, Keppel Street, London WC1E 7HT, UK
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, 410 W 10th Ave, Columbus, OH 43210, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Rudolf A de Boer
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
| | - Jasper J Brugts
- Department of Cardiology, Erasmus MC University Medical Centre, Dr. Molewaterplein 40, 3015 GD Rotterdam, the Netherlands
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Wintrich J, Pavlicek V, Brachmann J, Bosch R, Butter C, Oswald H, Rybak K, Mahfoud F, Böhm M, Ukena C. Impedance-based remote monitoring in patients with heart failure and concomitant chronic kidney disease. ESC Heart Fail 2023; 10:3011-3018. [PMID: 37537796 PMCID: PMC10567629 DOI: 10.1002/ehf2.14387] [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: 03/17/2023] [Accepted: 04/03/2023] [Indexed: 08/05/2023] Open
Abstract
AIMS Remote monitoring (RM) of thoracic impedance represents an early marker of pulmonary congestion in heart failure (HF). Chronic kidney disease (CKD) may promote fluid overload in HF patients. We investigated whether concomitant CKD affected the efficacy of impedance-based RM in the OptiLink HF trial. METHODS AND RESULTS Among HF patients included in the OptiLink HF trial, time to the first cardiovascular hospitalization and all-cause death according to the presence of concomitant CKD was analysed. CKD was defined as GFR < 60 mL/min/1.73 m2 at enrolment. Of the 1002 patients included in OptiLink HF, 326 patients (33%) had HF with concomitant CKD. The presence of CKD increased transmission of telemedical alerts (median of 2 (1-5) vs. 1 (0-3); P = 0.012). Appropriate contacting after alert transmission was equally low in patients with and without CKD (57% vs. 59%, P = 0.593). The risk of the primary endpoint was higher in patients with CKD compared with patients without CKD (hazard ratio (HR), 1.62 [95% confidence interval (CI), 1.16-2.28]; P = 0.005). Impedance-based RM independently reduced primary events in HF patients with preserved renal function, but not in those with CKD (HR 0.68 [95% CI, 0.52-0.89]; P = 0.006). CONCLUSIONS The presence of CKD in HF patients led to a higher number of telemedical alert transmissions and increased the risk of the primary endpoint. Inappropriate handling of alert transmission was commonly observed in patients with chronic HF and CKD. Guidance of HF management by impedance-based RM significantly decreased primary event rates in patients without CKD, but not in patients with CKD.
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Affiliation(s)
- Jan Wintrich
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care MedicineSaarland UniversityHomburg/SaarGermany
| | - Valerie Pavlicek
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care MedicineSaarland UniversityHomburg/SaarGermany
| | - Johannes Brachmann
- Department of Internal Medicine II, Cardiology, Angiology and PneumologyKlinikum Coburg GmbHCoburgGermany
| | - Ralph Bosch
- Cardio Centrum Ludwigsburg‐BietigheimLudwigsburgGermany
| | - Christian Butter
- Immanuel Herzzentrum BrandenburgBernauGermany
- Medizinische Hochschule BrandenburgBrandenburgGermany
| | - Hanno Oswald
- Department of Cardiology, Angiology, Pneumology and Intensive Care MedicineKlinikum PeinePeineGermany
| | | | - Felix Mahfoud
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care MedicineSaarland UniversityHomburg/SaarGermany
| | - Michael Böhm
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care MedicineSaarland UniversityHomburg/SaarGermany
| | - Christian Ukena
- Department of Internal Medicine III, Cardiology, Angiology and Intensive Care MedicineSaarland UniversityHomburg/SaarGermany
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50
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Severino P, Prosperi S, D'Amato A, Cestiè C, Myftari V, Maestrini V, Birtolo LI, Filomena D, Mariani MV, Lavalle C, Badagliacca R, Mancone M, Fedele F, Vizza CD. Telemedicine: an Effective and Low-Cost Lesson From the COVID-19 Pandemic for the Management of Heart Failure Patients. Curr Heart Fail Rep 2023; 20:382-389. [PMID: 37665424 PMCID: PMC10589137 DOI: 10.1007/s11897-023-00624-y] [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] [Accepted: 08/09/2023] [Indexed: 09/05/2023]
Abstract
PURPOSE The purpose of this review is to explore the benefits and controversies that telemedicine (TM), applied to patients with heart failure (HF), can provide in terms of diagnosis, therapeutic management, and prognosis improvement. During the coronavirus disease 19 (COVID-19) outbreak, TM emerged as the most effective and feasible method available to ensure continuous care for chronic diseases. Among these, HF, characterized by high mortality, morbidity, and the need for frequent visits, may benefit of the TM role. HF patients are affected by frequent exacerbations undergoing a progressive prognosis impoverishment, strongly depending on the disease's management. A precise clinical handling is always required, with a constant optimization of the therapy, a continuous control of risk factors, and a sensitive attention to any change in symptoms, clinical signs, and laboratory tests. In this context, TM has shown to improve therapy adherence and HF: patients' self-care, impacting the prognosis even if specific results are controversial. Major evidence shows that TM may allow an adequate primary prevention, reducing the impact of the main cardiovascular risk factors. TM can also be useful for the secondary prevention, early detecting a likely HF exacerbation before it becomes clinically manifest, thereby lowering the need for hospitalization. Moreover, an optimal up-titration of the therapy and an increase in treatment adherence are feasible by using TM. However, some studies did not show unambiguous results, and uncertainties still remain.
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Affiliation(s)
- Paolo Severino
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy.
| | - Silvia Prosperi
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Andrea D'Amato
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Claudia Cestiè
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Vincenzo Myftari
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Viviana Maestrini
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Lucia Ilaria Birtolo
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Domenico Filomena
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Marco Valerio Mariani
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Carlo Lavalle
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Roberto Badagliacca
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Massimo Mancone
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Francesco Fedele
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
| | - Carmine Dario Vizza
- Department of Clinical, Internal, Anesthesiology and Cardiovascular Sciences, Sapienza University of Rome, Viale del Policlinico, 155, 00161, Rome, Italy
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