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Betka S, Kannape OA, Fasola J, Lance F, Cardin S, Schmit A, Similowski T, Soccal PM, Herbelin B, Adler D, Blanke O. Virtual reality intervention alleviates dyspnoea in patients recovering from COVID-19 pneumonia. ERJ Open Res 2023; 9:00570-2022. [PMID: 38020572 PMCID: PMC10658613 DOI: 10.1183/23120541.00570-2022] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 08/08/2023] [Indexed: 12/01/2023] Open
Abstract
Background Immersive virtual reality (iVR)-based digital therapeutics are gaining clinical attention in the field of pain management. Based on known analogies between pain and dyspnoea, we investigated the effects of visual respiratory feedback on persistent dyspnoea in patients recovering from coronavirus disease 2019 (COVID-19) pneumonia. Methods We performed a controlled, randomised, single-blind, crossover proof-of-concept study (feasibility and initial clinical efficacy) to evaluate an iVR-based intervention to alleviate dyspnoea in patients recovering from COVID-19 pneumonia. Included patients reported persistent dyspnoea (≥5 on a 10-point scale) and preserved cognitive function (Montreal Cognitive Assessment score >24). Assignment was random and concealed. Patients received synchronous (intervention) or asynchronous (control) feedback of their breathing, embodied via a gender-matched virtual body. The virtual body flashed in a waxing and waning visual effect that could be synchronous or asynchronous to the patient's respiratory movements. Outcomes were assessed using questionnaires and breathing recordings. Results Study enrolment was open between November 2020 and April 2021. 26 patients were enrolled (27% women; median age 55 years, interquartile range (IQR) 18 years). Data were available for 24 of 26 patients. The median rating on a 7-point Likert scale of breathing comfort improved from 1 (IQR 2) at baseline to 2 (IQR 1) for synchronous feedback, but remained unchanged at 1 (IQR 1.5) for asynchronous feedback (p<0.05 between iVR conditions). Moreover, 91.2% of all patients were satisfied with the intervention (p<0.0001) and 66.7% perceived it as beneficial for their breathing (p<0.05). Conclusion Our iVR-based digital therapy presents a feasible and safe respiratory rehabilitation tool that improves breathing comfort in patients recovering from COVID-19 infection presenting with persistent dyspnoea. Future research should investigate the intervention's generalisability to persistent dyspnoea with other aetiologies and its potential for preventing chronification.
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Affiliation(s)
- Sophie Betka
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Ecole Polytechnique Federale de Lausanne, Geneva, Switzerland
- Joint first authors
| | - Oliver Alan Kannape
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Ecole Polytechnique Federale de Lausanne, Geneva, Switzerland
- MindMaze SA, Lausanne, Switzerland
- Virtual Medicine Center, University Hospital Geneva, Geneva, Switzerland
- Joint first authors
| | - Jemina Fasola
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Ecole Polytechnique Federale de Lausanne, Geneva, Switzerland
| | - Florian Lance
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Ecole Polytechnique Federale de Lausanne, Geneva, Switzerland
| | | | - Aline Schmit
- Division of Lung Diseases, University Hospital and Geneva Medical School, University of Geneva, Geneva, Switzerland
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
| | - Paola Marina Soccal
- Division of Lung Diseases, University Hospital and Geneva Medical School, University of Geneva, Geneva, Switzerland
| | - Bruno Herbelin
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Ecole Polytechnique Federale de Lausanne, Geneva, Switzerland
- Joint senior authors
| | - Dan Adler
- Division of Lung Diseases, University Hospital and Geneva Medical School, University of Geneva, Geneva, Switzerland
- Joint senior authors
| | - Olaf Blanke
- Laboratory of Cognitive Neuroscience, Brain Mind Institute and Center for Neuroprosthetics, Faculty of Life Sciences, Ecole Polytechnique Federale de Lausanne, Geneva, Switzerland
- Joint senior authors
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2
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Mebazaa A, Solal AC, Colombo PC. Assessing and treating congestion in acute decompensated heart failure: are we seeing the light at the end of the tunnel? Eur Heart J 2023; 44:51-53. [PMID: 36426405 DOI: 10.1093/eurheartj/ehac680] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Affiliation(s)
- Alexandre Mebazaa
- Université Paris Cité, Inserm MASCOT, AP-HP Department of Anesthesia and Critical Care, Hôpital Lariboisière, 2 Rue Ambroise Paré, 75010, Paris, France
| | - Alain Cohen Solal
- Université Paris Cité, Inserm MASCOT, AP-HP Department of Cardiology, Hôpital Lariboisière, Paris, France
| | - Paolo C Colombo
- Department of Medicine, Division of Cardiology, Columbia University Irving Medical Center, New York, NY, USA
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3
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Ha DM, Deng LR, Lange AV, Swigris JJ, Bekelman DB. Reliability, Validity, and Responsiveness of the DEG, a Three-Item Dyspnea Measure. J Gen Intern Med 2022; 37:2541-2547. [PMID: 34981344 PMCID: PMC9360273 DOI: 10.1007/s11606-021-07307-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/23/2021] [Indexed: 02/02/2023]
Abstract
BACKGROUND Dyspnea is a common and debilitating symptom that affects many different patient populations. Dyspnea measures should assess multiple domains. OBJECTIVE To evaluate the reliability, validity, and responsiveness of an ultra-brief, multi-dimensional dyspnea measure. DESIGN We adapted the DEG from the PEG, a valid 3-item pain measure, to assess average dyspnea intensity (D), interference with enjoyment of life (E), and dyspnea burden with general activity (G). PARTICIPANTS We used data from a multi-site randomized clinical trial among outpatients with heart failure. MAIN MEASURES We evaluated reliability (Cronbach's alpha), concurrent validity with the Memorial-Symptom-Assessment-Scale (MSAS) shortness-of-breath distress-orbothersome item and 7-item Generalized-Anxiety-Disorder (GAD-7) scale, knowngroups validity with New-York-Heart-Association-Functional-Classification (NYHA) 1-2 or 3-4 and presence or absence of comorbid chronic obstructive pulmonary disease (COPD), responsiveness with the MSAS item as an anchor, and calculated a minimal clinically important difference (MCID) using distribution methods. KEY RESULTS Among 312 participants, the DEG was reliable (Cronbach's alpha 0.92). The mean (standard deviation) DEG score was 5.26 (2.36) (range 0-10) points. DEG scores correlated strongly with the MSAS shortness of breath distress-or-bothersome item (r=0.66) and moderately with GAD-7 categories (ρ=0.36). DEG scores were statistically significantly lower among patients with NYHA 1-2 compared to 3-4 [mean difference (standard error): 1.22 (0.27) points, p<0.01], and those without compared to with comorbid COPD [0.87 (0.27) points, p<0.01]. The DEG was highly sensitive to change, with MCID of 0.59-1.34 points, or 11-25% change. CONCLUSIONS The novel, ultra-brief DEG measure is reliable, valid, and highly responsive. Future studies should evaluate the DEG's sensitivity to interventions, use anchor-based methods to triangulate MCID estimates, and determine its prognostic usefulness among patients with chronic cardiopulmonary and other diseases.
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Affiliation(s)
- Duc M Ha
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling Street, Aurora, CO, 80045, USA. .,Institute for Health Research, Kaiser Permanente Colorado, Aurora, CO, USA. .,Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA.
| | - Lubin R Deng
- Denver-Seattle Center of Innovation, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA
| | - Allison V Lange
- Division of Pulmonary Sciences and Critical Care Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
| | - Jeffrey J Swigris
- Interstitial Lung Disease Program, National Jewish Health, Denver, CO, USA
| | - David B Bekelman
- Medical Service, Rocky Mountain Regional Veterans Affairs Medical Center, 1700 N Wheeling Street, Aurora, CO, 80045, USA.,Denver-Seattle Center of Innovation, Rocky Mountain Regional Veterans Affairs Medical Center, Aurora, CO, USA.,Division of General Internal Medicine, Department of Medicine, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
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4
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Hernandez M, Sullivan RD, McCune ME, Reed GL, Gladysheva IP. Sodium-Glucose Cotransporter-2 Inhibitors Improve Heart Failure with Reduced Ejection Fraction Outcomes by Reducing Edema and Congestion. Diagnostics (Basel) 2022; 12:diagnostics12040989. [PMID: 35454037 PMCID: PMC9024630 DOI: 10.3390/diagnostics12040989] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2022] [Revised: 03/30/2022] [Accepted: 04/12/2022] [Indexed: 02/07/2023] Open
Abstract
Pathological sodium-water retention or edema/congestion is a primary cause of heart failure (HF) decompensation, clinical symptoms, hospitalization, reduced quality of life, and premature mortality. Sodium-glucose cotransporter-2 inhibitors (SGLT-2i) based therapies reduce hospitalization due to HF, improve functional status, quality, and duration of life in patients with HF with reduced ejection fraction (HFrEF) independently of their glycemic status. The pathophysiologic mechanisms and molecular pathways responsible for the benefits of SGLT-2i in HFrEF remain inconclusive, but SGLT-2i may help HFrEF by normalizing salt-water homeostasis to prevent clinical edema/congestion. In HFrEF, edema and congestion are related to compromised cardiac function. Edema and congestion are further aggravated by renal and pulmonary abnormalities. Treatment of HFrEF patients with SGLT-2i enhances natriuresis/diuresis, improves cardiac function, and reduces natriuretic peptide plasma levels. In this review, we summarize current clinical research studies related to outcomes of SGLT-2i treatment in HFrEF with a specific focus on their contribution to relieving or preventing edema and congestion, slowing HF progression, and decreasing the rate of rehospitalization and cardiovascular mortality.
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Affiliation(s)
- Michelle Hernandez
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
- School of Medicine, Universidad Autónoma de Guadalajara, Zapopan 45129, Mexico
| | - Ryan D. Sullivan
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
| | - Mariana E. McCune
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
| | - Guy L. Reed
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
| | - Inna P. Gladysheva
- Department of Medicine, College of Medicine-Phoenix, University of Arizona, Phoenix, AZ 85004, USA; (M.H.); (R.D.S.); (M.E.M.); (G.L.R.)
- Correspondence: ; Tel.: +1-(602)-827-2919
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5
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Scicchitano P, Ciccone MM, Iacoviello M, Guida P, De Palo M, Potenza A, Basile M, Sasanelli P, Trotta F, Sanasi M, Caldarola P, Massari F. Respiratory failure and bioelectrical phase angle are independent predictors for long-term survival in acute heart failure. SCAND CARDIOVASC J 2022; 56:28-34. [PMID: 35389300 DOI: 10.1080/14017431.2022.2060527] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Background. The assessment of long-term mortality in acute decompensated heart failure (ADHF) is challenging. Respiratory failure and congestion play a fundamental role in risk stratification of ADHF patients. The aim of this study was to investigate the impact of arterial blood gases (ABG) and congestion on long-term mortality in patients with ADHF. Methods and results. We enrolled 252 patients with ADHF. Brain natriuretic peptide (BNP), blood urea nitrogen (BUN), phase angle as assessed by means of bioimpedance vector analysis, and ABG analysis were collected at admission. The endpoint was all-cause mortality. At a median follow-up of 447 d (interquartile range [IQR]: 248-667), 72 patients died 1-840 d (median 106, IQR: 29-233) after discharge. Respiratory failure types I and II were observed in 78 (19%) and 53 (20%) patients, respectively. The ROC analyses revealed that the cut-off points for predicting death were: BNP > 441 pg/mL, BUN > 1.67 mmol/L, partial pressure in oxygen (PaO2) ≤69.7 mmHg, and phase angle ≤4.9°. Taken together, these four variables proved to be good predictors for long-term mortality in ADHF (area under the curve [AUC] 0.78, 95% CI 0.72-0.78), thus explaining 60% of all deaths. A multiparametric score based on these variables was determined: each single-unit increase promoted a 2.2-fold augmentation of the risk for death (hazard ratio [HR] 2.2, 95% CI 1.8-2.8, p< .0001). Conclusions. A multiparametric approach based on measurements of BNP, BUN, PaO2, and phase angle is a reliable approach for long-term prediction of mortality risk in patients with ADHF.
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Affiliation(s)
- Pietro Scicchitano
- Cardiology Section, F. Perinei Hospital, Bari, Italy.,Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, University of Bari, Bari, Italy
| | - Marco Matteo Ciccone
- Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, University of Bari, Bari, Italy
| | - Massimo Iacoviello
- Department of Medical and Surgical Sciences, Cardiology Unit, University of Foggia, Foggia, Italy
| | - Piero Guida
- Ospedale Generale Regionale "F. Miulli", Acquaviva delle Fonti, Bari, Italy
| | - Micaela De Palo
- Department of Emergency and Organ Transplantation, Cardiac Surgery Section, University of Bari, Bari, Italy
| | | | - Marco Basile
- Cardiology Section, F. Perinei Hospital, Bari, Italy
| | | | | | - Mariella Sanasi
- Department of Emergency and Organ Transplantation, Section of Cardiovascular Diseases, University of Bari, Bari, Italy
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6
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Zhang X, Zhao C, Zhang H, Liu W, Zhang J, Chen Z, You L, Wu Y, Zhou K, Zhang L, Liu Y, Chen J, Shang H. Dyspnea Measurement in Acute Heart Failure: A Systematic Review and Evidence Map of Randomized Controlled Trials. Front Med (Lausanne) 2021; 8:728772. [PMID: 34692723 PMCID: PMC8526558 DOI: 10.3389/fmed.2021.728772] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/31/2021] [Indexed: 01/08/2023] Open
Abstract
Background: Dyspnea is the most common presenting symptom among patients hospitalized for acute heart failure (AHF). Dyspnea relief constitutes a clinically relevant therapeutic target and endpoint for clinical trials and regulatory approval. However, there have been no widely accepted dyspnea measurement standards in AHF. By systematic review and mapping the current evidence of the applied scales, timing, and results of measurement, we hope to provide some new insights and recommendations for dyspnea measurement. Methods: PubMed, Embase, Cochrane Library, and Web of Science were searched from inception until August 27, 2020. Randomized controlled trials (RCTs) with dyspnea severity measured as the endpoint in patients with AHF were included. Results: Out of a total of 63 studies, 28 had dyspnea as the primary endpoint. The Likert scale (34, 54%) and visual analog scale (VAS) (22, 35%) were most widely used for dyspnea assessment. Among the 43 studies with detailed results, dyspnea was assessed most frequently on days 1, 2, 3, and 6 h after randomization or drug administration. Compared with control groups, better dyspnea relief was observed in the experimental groups in 21 studies. Only four studies that assessed tolvaptan compared with control on the proportion of dyspnea improvement met the criteria for meta-analyses, which did not indicate beneficial effect of dyspnea improvement on day 1 (RR: 1.16; 95% CI: 0.99-1.37; p = 0.07; I 2 = 61%). Conclusion: The applied scales, analytical approaches, and timing of measurement are in diversity, which has impeded the comprehensive evaluation of clinical efficacy of potential therapies managing dyspnea in patients with AHF. Developing a more general measurement tool established on the unified unidimensional scales, standardized operation protocol to record the continuation, and clinically significant difference of dyspnea variation may be a promising approach. In addition, to evaluate the effect of experimental therapies on dyspnea more precisely, the screening time and blinded assessment are factors that need to be considered.
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Affiliation(s)
- Xiaoyu Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China.,School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Chen Zhao
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, Beijing, China
| | - Houjun Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Wenjing Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jingjing Zhang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Zhao Chen
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Liangzhen You
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yuzhuo Wu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Kehua Zhou
- Department of Hospital Medicine, ThedaCare Regional Medical Center-Appleton, Appleton, WI, United States
| | - Lijing Zhang
- Department of Cardiology, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Yan Liu
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China
| | - Jianxin Chen
- School of Traditional Chinese Medicine, Beijing University of Chinese Medicine, Beijing, China
| | - Hongcai Shang
- Key Laboratory of Chinese Internal Medicine of Ministry of Education, Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, China.,College of Integrated Traditional Chinese and Western Medicine, Hunan University of Chinese Medicine, Changsha, China
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7
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Palazzuoli A, Ruocco G, Severino P, Gennari L, Pirrotta F, Stefanini A, Tramonte F, Feola M, Mancone M, Fedele F. Effects of Metolazone Administration on Congestion, Diuretic Response and Renal Function in Patients with Advanced Heart Failure. J Clin Med 2021; 10:jcm10184207. [PMID: 34575318 PMCID: PMC8465476 DOI: 10.3390/jcm10184207] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 09/08/2021] [Accepted: 09/10/2021] [Indexed: 12/19/2022] Open
Abstract
Background: Advanced heart failure (HF) is a condition often requiring elevated doses of loop diuretics. Therefore, these patients often experience poor diuretic response. Both conditions have a detrimental impact on prognosis and hospitalization. Aims: This retrospective, multicenter study evaluates the effect of the addition of oral metolazone on diuretic response (DR), clinical congestion, NTproBNP values, and renal function over hospitalization phase. Follow-up analysis for a 6-month follow-up period was performed. Methods: We enrolled 132 patients with acute decompensated heart failure (ADHF) in advanced NYHA class with reduced ejection fraction (EF < 40%) taking a mean furosemide amount of 250 ± 120 mg/day. Sixty-five patients received traditional loop diuretic treatment plus metolazone (Group M). The mean dose ranged from 7.5 to 15 mg for one week. Sixty-seven patients continued the furosemide (Group F). Congestion score was evaluated according to the ESC recommendations. DR was assessed by the formula diuresis/40 mg of furosemide. Results: Patients in Group M and patients in Group F showed a similar prevalence of baseline clinical congestion (3.1 ± 0.7 in Group F vs. 3 ± 0.8 in Group M) and chronic kidney disease (CKD) (51% in Group M vs. 57% in Group F; p = 0.38). Patients in Group M experienced a better congestion score at discharge compared to patients in Group F (C score: 1 ± 1 in Group M vs. 3 ± 1 in Group F p > 0.05). Clinical congestion resolution was also associated with weight reduction (−6 ± 2 in Group M vs. −3 ± 1 kg in Group F, p < 0.05). Better DR response was observed in Group M compared to F (940 ± 149 mL/40 mgFUROSEMIDE/die vs. 541 ± 314 mL/40 mgFUROSEMIDE/die; p < 0.01), whereas median ΔNTproBNP remained similar between the two groups (−4819 ± 8718 in Group M vs. −3954 ± 5560 pg/mL in Group F NS). These data were associated with better daily diuresis during hospitalization in Group M (2820 ± 900 vs. 2050 ± 1120 mL p < 0.05). No differences were found in terms of WRF development and electrolyte unbalance at discharge, although Group M had a significant saline solution administration during hospitalization. Follow-up analysis did not differ between the group but a reduced trend for recurrent hospitalization was observed in the M group (26% vs. 38%). Conclusions: Metolazone administration could be helpful in patients taking an elevated loop diuretics dose. Use of thiazide therapy is associated with better decongestion and DR. Current findings could suggest positive insights due to the reduced amount of loop diuretics in patients with advanced HF.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
- Correspondence: ; Tel.: +39-577585363 or +39-577585461; Fax: +39-577233480
| | - Gaetano Ruocco
- Cardiology Unit, Riuniti of Valdichiana Hospital, USL SUD-EST Toscana, Montepulciano, 53045 Siena, Italy;
| | - Paolo Severino
- Department of Clinical, Internal Anesthesiology and Cardiovascular Sciences, University La Sapienza, 00185 Rome, Italy; (P.S.); (M.M.); (F.F.)
| | - Luigi Gennari
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
| | - Filippo Pirrotta
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
| | - Andrea Stefanini
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
| | - Francesco Tramonte
- Cardiovascular Diseases Unit, Department of Medical Sciences, Le Scotte Hospital, 53100 Siena, Italy; (L.G.); (F.P.); (A.S.); (F.T.)
| | - Mauro Feola
- Cardiology Unit, Regina Montis Regalis Hospital, 12084 Mondovì, Italy;
| | - Massimo Mancone
- Department of Clinical, Internal Anesthesiology and Cardiovascular Sciences, University La Sapienza, 00185 Rome, Italy; (P.S.); (M.M.); (F.F.)
| | - Francesco Fedele
- Department of Clinical, Internal Anesthesiology and Cardiovascular Sciences, University La Sapienza, 00185 Rome, Italy; (P.S.); (M.M.); (F.F.)
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8
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Xiangli S, Lan L, Libiya Z, Jun M, Shubin J. Effect of levosimendan combined with recombinant human brain natriuretic peptide on diuretic resistance. Libyan J Med 2021; 16:1973762. [PMID: 34493175 PMCID: PMC8439246 DOI: 10.1080/19932820.2021.1973762] [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] [Indexed: 10/27/2022] Open
Abstract
Levosimendan is a calcium sensitizer used for managing heart failure (HF) because of its inotropic and vasodilatory effects. As many patients do not respond to levosimendan as a monotherapy, it may be necessary to combine it with other diuretic agents such as recombinant human brain natriuretic peptide (rhBNc P). The aim of this study was to investigate efficacy of levosimendan when combined with rhBNP in patients with diuretic resistance and low ejection fraction (EF) rate.The study included HF patients with diuretic resistance and low EF. Before grouping, patients with a 24-hour urine volume of <0.5 mL/kg/h were administered with furosemide injection. Treatment group was administered levosimendan injection based on the original diuretic and rhBNP.One hundred twenty-eight patients were included, with 64 patients each in the control and treatment arms. 24-hour urine volume of the treatment group was significantly higher than that of the control group. Moreover, dyspnea score of the treatment group significantly improved compared with control group. In the treatment group, 12.5% of patients had no significant changes in the urine volume, weight, and dyspnea score before and after the treatment, indicating poor curative effect of the treatment, whereas in the control group, 23.4% of patients had poor curative effect (P < .05). No significant change was observed in the systolic blood pressure, heart rate, and serum creatinine level before and after treatment in both groups.Levosimendan in combination with rhBNP can effectively relieve diuretic resistance, reduce body weight, improve dyspnea, and ensure safety in the treatment process.
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Affiliation(s)
- Shen Xiangli
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
| | - Li Lan
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
| | - Zu Libiya
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
| | - Ma Jun
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
| | - Jiang Shubin
- Heart Center, Traditional Chinese Medicine Affiliated to Xinjiang Medical University, Urumqi, China
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9
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Chiem AT, Lim GW, Tabibnia AP, Takemoto AS, Weingrow DM, Shibata JE. Feasibility of patient-performed lung ultrasound self-exams (Patient-PLUS) as a potential approach to telemedicine in heart failure. ESC Heart Fail 2021; 8:3997-4006. [PMID: 34288549 PMCID: PMC8497224 DOI: 10.1002/ehf2.13493] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 04/23/2021] [Accepted: 06/12/2021] [Indexed: 01/14/2023] Open
Abstract
Aims Patient‐performed lung ultrasound (LUS) in a heart failure (HF) telemedicine model may be used to monitor worsening pulmonary oedema and to titrate therapy, potentially reducing HF admission. The aim of the study was to assess the feasibility of training HF patients to perform a LUS self‐exam in a telemedicine model. Methods and results A pilot study was conducted at a public hospital involving subjects with a history of HF. After a 15 min training session involving a tutorial video, subjects performed a four‐zone LUS using a handheld ultrasound. Exams were saved on a remote server and independently reviewed by two LUS experts. Studies were determined interpretable according to a strict definition: the presence of an intercostal space, and the presence of A‐lines, B‐lines, or both. Subjects also answered a questionnaire to gather feedback and assess self‐efficacy. The median age of 44 subjects was 53 years (range, 36–64). Thirty (68%) were male. Last educational level attained was high school or below for 31 subjects (70%), and one‐third used Spanish as their preferred language. One hundred fifty of 175 lung zones (85%) were interpretable, with expert agreement of 87% and a kappa of 0.49. 98% of subjects reported that they could perform this LUS self‐exam at home. Conclusions This pilot study reports that training HF patients to perform a LUS self‐exam is feasible, with reported high self‐efficacy. This supports further investigation into a telemedicine model using LUS to reduce emergency department visits and hospitalizations associated with HF.
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Affiliation(s)
- Alan T Chiem
- Emergency Medicine, Olive View-UCLA Medical Center, 14445 Olive View Drive North Annex, Sylmar, Los Angeles, California, 91342, USA
| | - George W Lim
- Emergency Medicine and Anesthesiology, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | - Amir P Tabibnia
- Emergency Medicine, Olive View-UCLA Medical Center, 14445 Olive View Drive North Annex, Sylmar, Los Angeles, California, 91342, USA
| | - Andrea S Takemoto
- Emergency Medicine, Olive View-UCLA Medical Center, 14445 Olive View Drive North Annex, Sylmar, Los Angeles, California, 91342, USA
| | - Daniel M Weingrow
- Emergency Medicine, Ronald Reagan-UCLA Medical Center, Los Angeles, California, USA
| | - Jacqueline E Shibata
- Emergency Medicine, Olive View-UCLA Medical Center, 14445 Olive View Drive North Annex, Sylmar, Los Angeles, California, 91342, USA
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10
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Evaluation of the effect of patient position in the management of chronic heart failure patients presenting with dyspnea. JOURNAL OF SURGERY AND MEDICINE 2021. [DOI: 10.28982/josam.900938] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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11
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Ibrahim A, Ghaleb R, Mansour H, Hanafy A, Mahmoud NM, Abdelfatah Elsharef M, Kamal Salama M, Elsaughier SM, Abdel-Wahid L, Embarek Mohamed M, Ibrahim AK, Abdel-Galeel A. Safety and Efficacy of Adding Dapagliflozin to Furosemide in Type 2 Diabetic Patients With Decompensated Heart Failure and Reduced Ejection Fraction. Front Cardiovasc Med 2020; 7:602251. [PMID: 33426003 PMCID: PMC7793915 DOI: 10.3389/fcvm.2020.602251] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2020] [Accepted: 11/02/2020] [Indexed: 01/10/2023] Open
Abstract
Background: Heart failure is the most common cause of hospitalization in elderly patients. It is likely that many of the mechanisms that contribute to reductions in systolic and diastolic function, seen in diabetic patients, place them at an increased risk of heart failure. Diuretic therapy, especially loop diuretics, is the usual way of managing congestion, particularly in volume-overloaded patients. Little is known about the beneficial effect of dapagliflozin when added to loop diuretics in managing patients with decompensated heart failure. Aim: To assess the effect of the addition of dapagliflozin to furosemide in managing decompensated patient with heart failure and reduced left ventricular ejection fraction in terms of weight loss and dyspnea improvement. Patients and Methods: The study included 100 type 2 diabetic patients who were admitted with decompensated heart failure. The study population was randomly divided into two arms. Serum electrolytes and kidney functions were followed up during their hospital stay. Results: With dapagliflozin, there was a statistically significant difference between the two groups regarding the change in body weight and body mass index. The diuresis parameters including urine output, total fluid loss, and fluid balance also showed a statistically significant difference in favor of the use of dapagliflozin, with no significant change in serum potassium or kidney functions. There was significant improvement in patient-reported dyspnea scores with the use of dapagliflozin. Conclusions: Dapagliflozin may provide a new drug option in the treatment of heart failure especially among vulnerable group of diabetics. It had no remarkable effects on serum potassium level and kidney functions. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04385589.
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Affiliation(s)
- Ayman Ibrahim
- Cardiology Department, Aswan University, Aswan, Egypt
| | | | | | - Amr Hanafy
- Cardiology Department, Aswan University, Aswan, Egypt
| | | | | | | | | | | | - Mona Embarek Mohamed
- Microbiology and Immunology Department, Faculty of Medicine, Assiut University, Assiut, Egypt
| | | | - Ahmed Abdel-Galeel
- Cardiovascular Medicine Department, Assiut University Heart Hospital, Assiut University, Assiut, Egypt
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12
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Palazzuoli A, Evangelista I, Nuti R. Congestion occurrence and evaluation in acute heart failure scenario: time to reconsider different pathways of volume overload. Heart Fail Rev 2020; 25:119-131. [PMID: 31628648 DOI: 10.1007/s10741-019-09868-0] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Although congestion is considered to be the main reason for hospital admission in patients with acute heart failure, a simplistic view considering idro saline retention and total body volume accumulation did not provide convincing data. Clinical congestion occurrence is often the tip of the iceberg of several different mechanisms ranging from increased filling pressure to extravascular fluid accumulation and blood flow redistribution. Therefore, the clinical evaluation is often restricted to a simple physical examination including few and inaccurate signs and symptoms. This superficial approach has led to contradictory data and patients have not been evaluated according to a more realistic clinical scenario. The integration with new diagnostic ultrasonographic and laboratory tools would substantially improve these weaknesses. Indeed, congestion could be assessed by following the most recognized HF subtypes including primitive cardiac defect, presence of right ventricular dysfunction, and organ perfusion. Moreover, there is a tremendous gap regarding the interchangeable concept of fluid retention and redistribution used with a univocal meaning. Overall, congestion assessment should be revised, considering it as either central, peripheral, or both. In this review, we aim to provide different evidence regarding the concept of congestion starting from the most recognized pathophysiological mechanisms of AHF decompensation. We highlight the fact that a better knowledge of congestion is a challenge for future investigation and it could lead to significant advances in HF treatment.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Viale Bracci, Siena, 53100, Italy.
| | - Isabella Evangelista
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Viale Bracci, Siena, 53100, Italy
| | - Ranuccio Nuti
- Cardiovascular Diseases Unit, Department of Internal Medicine, S. Maria alle Scotte Hospital, University of Siena, Viale Bracci, Siena, 53100, Italy
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13
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Greene SJ, Mentz RJ, Limkakeng AT, Irons T, Truong T, Green CL, Nowak C, Blumer V, Pang PS. Comparison of Dyspnea Measurement Instruments in Acute Heart Failure: The DYSPNEA-AHF Pilot Study. J Card Fail 2020; 27:607-609. [PMID: 33091609 DOI: 10.1016/j.cardfail.2020.10.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/05/2020] [Accepted: 10/07/2020] [Indexed: 11/28/2022]
Affiliation(s)
- Stephen J Greene
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Alexander T Limkakeng
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Thomas Irons
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Tracy Truong
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Carrie Nowak
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vanessa Blumer
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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14
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Hu J, Wan Q, Zhang Y, Zhou J, Li M, Jiang L, Yuan F. Efficacy and safety of early ultrafiltration in patients with acute decompensated heart failure with volume overload: a prospective, randomized, controlled clinical trial. BMC Cardiovasc Disord 2020; 20:447. [PMID: 33054727 PMCID: PMC7556949 DOI: 10.1186/s12872-020-01733-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/07/2020] [Indexed: 12/20/2022] Open
Abstract
Background Ultrafiltration decreases total body water and improves the alveolar to arterial oxygen gradient. The aims of the study were to investigate the efficacy and safety of early ultrafiltration in acute decompensated heart failure (ADHF) patients. Methods 100 patients with ADHF within 24 h of admission were randomly assigned into early ultrafiltration (n = 40) or torasemide plus tolvaptan (n = 60) groups. The primary outcomes were weight loss and an increase in urine output on days 4 and 8 of treatment. Results Patients who received early ultrafiltration for 3 days achieved a greater weight loss (kg) (− 2.94 ± 3.76 vs − 0.64 ± 0.91, P < 0.001) and urine increase (mL) (198.00 ± 170.70 vs 61.77 ± 4.67, P < 0.001) than the torasemide plus tolvaptan group on day 4. From days 4 to 7, patients in the early ultrafiltration group received sequential therapy of torasemide and tolvaptan. Better control of volume was reflected in a greater weight loss (− 3.72 ± 3.81 vs − 1.34 ± 1.32, P < 0.001) and urine increase (373.80 ± 120.90 vs 79.5 ± 52.35, P < 0.001), greater reduction of B-type natriuretic peptide (BNP) (pg/mL) (− 1144 ± 1435 vs − 654.02 ± 889.65, P = 0.037), NYHA (New York Heart Association) functional class (− 1.45 ± 0.50 vs − 1.17 ± 0.62, P = 0.018), jugular venous pulse (JVP) score (points) (− 1.9 ± 1.13 vs − 0.78 ± 0.69, P < 0.001), inferior vena cava (IVC) diameter (mm) (− 15.35 ± 11.03 vs − 4.98 ± 6.00, P < 0.001) and an increase in the dyspnea score (points) (4.08 ± 3.44 vs 2.77 ± 2.03, P = 0.035) in the early ultrafiltration group on day 8. No significant differences were found in the readmission and mortality rates in the 2 patient groups at the 1-month and 3-month follow-ups. Both groups had a similar stable renal profile. Conclusion Early ultrafiltration is superior to diuretics for volume overload treatment initiation of ADHF patients. Trial registration Chinese Clinical Trial Registry, ChiCTR2000030696, Registered 10 March 2020—Retrospectively registered, https://www.chictr.org.cn/showproj.aspx?proj=29099.
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Affiliation(s)
- Jingyi Hu
- Department of Critical Care Medicine (Specialty of Heart Failure), Tongren Hospital, Shanghai Jiaotong University School of Medicine, No. 1111 Xianxia Road, Shanghai, 200336, China
| | - Qianli Wan
- Department of Critical Care Medicine (Specialty of Heart Failure), Tongren Hospital, Shanghai Jiaotong University School of Medicine, No. 1111 Xianxia Road, Shanghai, 200336, China
| | - Yue Zhang
- Department of Critical Care Medicine (Specialty of Heart Failure), Tongren Hospital, Shanghai Jiaotong University School of Medicine, No. 1111 Xianxia Road, Shanghai, 200336, China
| | - Jun Zhou
- Department of Cardiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, No. 1111 Xianxia Road, Shanghai, 200336, China
| | - Miaomiao Li
- Department of Critical Care Medicine (Specialty of Heart Failure), Tongren Hospital, Shanghai Jiaotong University School of Medicine, No. 1111 Xianxia Road, Shanghai, 200336, China
| | - Li Jiang
- Department of Cardiology, Tongren Hospital, Shanghai Jiaotong University School of Medicine, No. 1111 Xianxia Road, Shanghai, 200336, China.
| | - Fang Yuan
- Department of Critical Care Medicine (Specialty of Heart Failure), Tongren Hospital, Shanghai Jiaotong University School of Medicine, No. 1111 Xianxia Road, Shanghai, 200336, China.
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15
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von Leupoldt A, Farre N. The load of dyspnoea on brain and legs. Eur Respir J 2020; 56:56/2/2001096. [DOI: 10.1183/13993003.01096-2020] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 01/05/2023]
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16
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Sung JH, Brown MC, Perez-Cosio A, Pratt L, Houad J, Liang M, Gill G, Moradian S, Liu G, Howell D. Acceptability and accuracy of patient-reported outcome measures (PROMs) for surveillance of breathlessness in routine lung cancer care: A mixed-method study. Lung Cancer 2020; 147:1-11. [PMID: 32634651 DOI: 10.1016/j.lungcan.2020.06.028] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2020] [Revised: 06/17/2020] [Accepted: 06/23/2020] [Indexed: 01/17/2023]
Abstract
BACKGROUND Breathlessness in lung cancer negatively impacts on quality of life but often goes undetected and undertreated in clinical practice. There is a need for routine surveillance for early identification and proactive management of breathlessness using patient reported outcome measures (PROMs) in clinical care but it is unclear what PROMs should be used or are accurate for use in routine care. METHODS We used mixed-methods (quantitative surveys and qualitative interviews) to examine the predictors of breathlessness in 339 lung cancer participants and acceptability of PROMs. In addition to multivariate analysis to examine predictors of dyspnea, participants completed an acceptability survey and themes were derived for the qualitative data (n = 26) to explore patient experience of PROMs. We also tested the accuracy of PROMs using a Receiver Operating Characteristic and Area Under the Curve analysis. RESULTS A total of 339 patients completed the breathlessness PROMs and acceptability survey and 26 patients participated in an in-depth interview to investigate their experiences of breathlessness and its PROMs. Prevalence of breathlessness was 51.9 % (n = 176) and 70.5 % of patients preferred the Medical Research Council (MRC) scale followed by the Breathlessness Intensity (BI) scale (63.7 %) among the five measures for breathlessness- Modified Borg Scale (MBS), Cancer Dyspnea Scale (CDS), MRC, BI, and Breathlessness Distress (BD). The finding showed wide variation in the MRC grades across the BI rating even among patients with the same BI score. AUC scores for the Borg scale was 0.71 (using MRC cut-off score of < 2), for CDS, 0.72, for BD, 0.70, and for BI 0.79. For an MRC score of 2, the Borg score cut-off was 0.8 (optimal sensitivity, 50 %; specificity, 93.3 %); the cut-off score of CDS, BD, BI score was 1.4 (optimal sensitivity, 67.1 %; specificity, 70 %), 1.5 (optimal sensitivity, 57.5 %; specificity, 73.3 %), and 1.5 (optimal sensitivity, 72.6 %; specificity, 83.3 %) respectively. AUC by ROC analysis for breathlessness and modest concordance among five PROMs showed important gaps between the individuals' experience and PROMs data. Three main themes from qualitative data included 1) Making sense of symptom reporting, 2) Valuing the reported data, 3) Managing the symptom of breathlessness. CONCLUSION This study examined measurement of breathlessness using PROMs for routine clinical care and showed that severity measures alone do not accurately detect this symptomnor the experiential dimensions of breathlessness that are critical to guide appropriate intervention.
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Affiliation(s)
- Ji Hyun Sung
- College of Nursing, Kosin University, Busan, South Korea
| | - M Catherine Brown
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Departments of Medicine and Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Andrea Perez-Cosio
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Departments of Medicine and Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Laura Pratt
- Lawrence Bloomberg School of Nursing previously, University of Toronto, Toronto, Canada
| | - Jacy Houad
- Lawrence Bloomberg School of Nursing previously, University of Toronto, Toronto, Canada
| | - Mindy Liang
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Departments of Medicine and Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Gursharan Gill
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Departments of Medicine and Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Saeed Moradian
- School of Nursing, Faculty of Health, York University, Toronto, Canada
| | - Geoffrey Liu
- Division of Medical Oncology and Hematology, Princess Margaret Cancer Centre and Departments of Medicine and Epidemiology, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada; Department of Epidemiology, Dalla Lana School of Public Health, Departments of Medicine and Biophysics, University of Toronto, Toronto, Canada
| | - Doris Howell
- Supportive Care, Princess Margaret Cancer Centre, 610 University Ave., 15-617, Toronto, Ontario, M5G 2M9, Canada.
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17
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Oguri M, Ishii H, Takahara K, Yasuda K, Takikawa T, Sumi T, Takahashi H, Murohara T. Efficacy of Rapid Decongestion Strategy in Patients Hospitalized for Acute Heart Failure. Circ J 2020; 84:958-964. [PMID: 32321902 DOI: 10.1253/circj.cj-19-1128] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Clinical congestion is the most dominant feature in patients with acute decompensated heart failure (HF). However, uncertainty exists due to the permutations and combinations of congestion status and decongestion strategies. This study investigated the effect of congestion status and its improvement on 1-year mortality.Methods and Results:In all, 453 consecutive patients hospitalized for acute decompensated HF between July 2015 and March 2017 were prospectively included in the study. Congestion was evaluated using the congestion score. The 1-year mortality rate was 22.7%. The mean (±SD) congestion scores at admission, on Day 3, and at discharge were 10.7±3.9, 3.4±3.5, and 0.3±0.8, respectively. The improvement rate in congestion scores during the first 3 days was 78%; 46.6% of patients had residual congestion. The Day 3 congestion score and the improvement rate during the first 3 days were related to 1-year all-cause mortality and cardiovascular mortality. Combined predictive values were examined by calculating multivariable-adjusted hazard ratios for associations of residual congestion and improvement rate during the first 3 days, and prognostic variables identified by the Cox regression model. Residual congestion and lesser improvement (<64%) were associated with higher relative risk of 1-year all-cause mortality and cardiovascular mortality than residual congestion and higher improvement (≥64%) or resolved congestion. CONCLUSIONS Rapid decongestion could be a prerequisite regardless of residual congestion in hospitalized acute decompensated HF patients.
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Affiliation(s)
| | - Hideki Ishii
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | | | | | - Tomonobu Takikawa
- Department of Cardiology, Nagoya University Graduate School of Medicine
| | - Takuya Sumi
- Department of Cardiology, Ichinomiya Municipal Hospital
| | | | - Toyoaki Murohara
- Department of Cardiology, Nagoya University Graduate School of Medicine
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18
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Surface respiratory electromyography and dyspnea in acute heart failure patients. PLoS One 2020; 15:e0232225. [PMID: 32348374 PMCID: PMC7190138 DOI: 10.1371/journal.pone.0232225] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 04/09/2020] [Indexed: 12/28/2022] Open
Abstract
Introduction and Objectives: Dyspnea is the most common symptom among hospitalized patients with heart failure (HF) but besides dyspnea questionnaires (which reflect the subjective patient sensation and are not fully validated in HF) there are no measurable physiological variables providing objective assessment of dyspnea in a setting of acute HF patients. Studies performed in respiratory patients suggest that the measurement of electromyographic (EMG) activity of the respiratory muscles with surface electrodes correlates well with dyspnea. Our aim was to test the hypothesis that respiratory muscles EMG activity is a potential marker of dyspnea severity in acute HF patients. Methods: Prospective and descriptive pilot study carried out in 25 adult patients admitted for acute HF. Measurements were carried out with a cardio-respiratory portable polygraph including EMG surface electrodes for measuring the activity of main (diaphragm) and accessory (scalene and pectoralis minor) respiratory muscles. Dyspnea sensation was assessed by means of the Likert 5 questionnaire. Data were recorded during 3 min of spontaneous breathing and after breathing at maximum effort for several cycles for normalizing data. An index to quantify the activity of each respiratory muscle was computed. This assessment was carried out within the first 24 h of admission, and at day 2 and 5. Results: Dyspnea score decreased along the three measured days. Diaphragm and scalene EMG index showed a positive and significant direct relationship with dyspnea score (p<0.001 and p = 0.003 respectively) whereas pectoralis minor muscle did not. Conclusion: In our pilot study, diaphragm and scalene EMG activity was associated with increasing severity of dyspnea. Surface respiratory EMG could be a useful objective tool to improve assessment of dyspnea in acute HF patients.
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19
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Fiuzat M, Lowy N, Stockbridge N, Sbolli M, Latta F, Lindenfeld J, Lewis EF, Abraham WT, Teerlink J, Walsh M, Heidenreich P, Bozkurt B, Starling RC, Solomon S, Felker GM, Butler J, Yancy C, Stevenson LW, O'Connor C, Unger E, Temple R, McMurray J. Endpoints in Heart Failure Drug Development: History and Future. JACC-HEART FAILURE 2020; 8:429-440. [PMID: 32278679 DOI: 10.1016/j.jchf.2019.12.011] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2019] [Revised: 12/12/2019] [Accepted: 12/19/2019] [Indexed: 10/24/2022]
Abstract
Heart failure (HF) patients experience a high burden of symptoms and functional limitations, and morbidity and mortality remain high despite successful therapies. The majority of HF drugs in the United States are approved for reducing hospitalization and mortality, while only a few have indications for improving quality of life, physical function, or symptoms. Patient-reported outcomes that directly measure patient's perception of health status (symptoms, physical function, or quality of life) are potentially approvable endpoints in drug development. This paper summarizes the history of endpoints used for HF drug approvals in the United States and reviews endpoints that measure symptoms, physical function, or quality of life in HF patients.
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Affiliation(s)
- Mona Fiuzat
- Duke University and Duke Clinical Research Institute, Durham, North Carolina; U.S. Food and Drug Administration, Silver Spring, Maryland.
| | - Naomi Lowy
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | | | - Marco Sbolli
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - Federica Latta
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | - JoAnn Lindenfeld
- Heart Failure and Transplantation Section, Vanderbilt University, Nashville, Tennessee
| | - Eldrin F Lewis
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - William T Abraham
- Department of Medicine, Division of Cardiovascular Medicine, Ohio State University, Columbus, Ohio
| | - John Teerlink
- Division of Cardiology, San Francisco VA Medical Center, and University of California San Francisco, San Francisco, California
| | - Mary Walsh
- St. Vincent Heart Center, Indianapolis, Indiana
| | | | - Biykem Bozkurt
- Winters Center for Heart Failure, DeBakey VA Medical Center, Cardiovascular Research Institute, Baylor College of Medicine, Houston, Texas
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio
| | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - G Michael Felker
- Duke University and Duke Clinical Research Institute, Durham, North Carolina
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson, Mississippi
| | - Clyde Yancy
- Division of Cardiology, Northwestern University, Chicago, Illinois
| | - Lynne W Stevenson
- Heart Failure and Transplantation Section, Vanderbilt University, Nashville, Tennessee
| | | | - Ellis Unger
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - Robert Temple
- U.S. Food and Drug Administration, Silver Spring, Maryland
| | - John McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
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20
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Kozhuharov N, Goudev A, Flores D, Maeder MT, Walter J, Shrestha S, Gualandro DM, de Oliveira Junior MT, Sabti Z, Müller B, Noveanu M, Socrates T, Ziller R, Bayés-Genís A, Sionis A, Simon P, Michou E, Gujer S, Gori T, Wenzel P, Pfister O, Conen D, Kapos I, Kobza R, Rickli H, Breidthardt T, Münzel T, Erne P, Mueller C. Effect of a Strategy of Comprehensive Vasodilation vs Usual Care on Mortality and Heart Failure Rehospitalization Among Patients With Acute Heart Failure: The GALACTIC Randomized Clinical Trial. JAMA 2019; 322:2292-2302. [PMID: 31846016 PMCID: PMC6990838 DOI: 10.1001/jama.2019.18598] [Citation(s) in RCA: 76] [Impact Index Per Article: 15.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Short-term infusions of single vasodilators, usually given in a fixed dose, have not improved outcomes in patients with acute heart failure (AHF). OBJECTIVE To evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation using individualized up-titrated doses of established vasodilators in patients with AHF. DESIGN, SETTING, AND PARTICIPANTS Randomized, open-label blinded-end-point trial enrolling 788 patients hospitalized for AHF with dyspnea, increased plasma concentrations of natriuretic peptides, systolic blood pressure of at least 100 mm Hg, and plan for treatment in a general ward in 10 tertiary and secondary hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Enrollment began in December 2007 and follow-up was completed in February 2019. INTERVENTIONS Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization (n = 386) or usual care (n = 402). Early intensive and sustained vasodilation was a comprehensive pragmatic approach of maximal and sustained vasodilation combining individualized doses of sublingual and transdermal nitrates, low-dose oral hydralazine for 48 hours, and rapid up-titration of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, or sacubitril-valsartan. MAIN OUTCOMES AND MEASURES The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. RESULTS Among 788 patients randomized, 781 (99.1%; median age, 78 years; 36.9% women) completed the trial and were eligible for primary end point analysis. Follow-up at 180 days was completed for 779 patients (99.7%). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 117 patients (30.6%) in the intervention group (including 55 deaths [14.4%]) and in 111 patients (27.8%) in the usual care group (including 61 deaths [15.3%]) (absolute difference for the primary end point, 2.8% [95% CI, -3.7% to 9.3%]; adjusted hazard ratio, 1.07 [95% CI, 0.83-1.39]; P = .59). The most common clinically significant adverse events with early intensive and sustained vasodilation vs usual care were hypokalemia (23% vs 25%), worsening renal function (21% vs 20%), headache (26% vs 10%), dizziness (15% vs 10%), and hypotension (8% vs 2%). CONCLUSIONS AND RELEVANCE Among patients with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, did not significantly improve a composite outcome of all-cause mortality and AHF rehospitalization at 180 days. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT00512759.
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Affiliation(s)
- Nikola Kozhuharov
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Assen Goudev
- Queen Ioanna University Hospital Sofia, Department of Cardiology, Medical University of Sofia, Sofia, Bulgaria
| | - Dayana Flores
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Micha T. Maeder
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Joan Walter
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Samyut Shrestha
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Danielle Menosi Gualandro
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Heart Institute (INCOR), University of Sao Paulo Medical School, Sao Paulo, Brazil
| | | | - Zaid Sabti
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Beat Müller
- Department of General Internal and Emergency Medicine, Medical University Clinic of the University of Basel, Kantonsspital Aarau, Aarau, Switzerland
| | - Markus Noveanu
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Thenral Socrates
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Medical Outpatient Department, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Ronny Ziller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Antoni Bayés-Genís
- Heart Institute, Hospital Universitari Germans Trias i Pujol, CIBERCV, Department of Medicine, Autonomous University of Barcelona, Barcelona, Spain
| | - Alessandro Sionis
- Intensive Cardiac Care Unit, Cardiology Department, Hospital de la Santa Creu i Sant Pau, Biomedical Research Institute IIB-Sant Pau, Autonomous University of Barcelona, Barcelona, Spain
| | - Patrick Simon
- Clinical Trial Unit, University Hospital Basel, Basel, Switzerland
| | - Eleni Michou
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - Samuel Gujer
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Internal Medicine, Kantonsspital Obwalden, Sarnen, Switzerland
| | - Tommaso Gori
- University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Philip Wenzel
- University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Otmar Pfister
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
| | - David Conen
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Population Health Research Institute, McMaster University, Hamilton, Ontario, Canada
| | - Ioannis Kapos
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
- Department of Cardiology, University Hospital Zurich, Zurich, Switzerland
| | - Richard Kobza
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Hans Rickli
- Department of Cardiology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Tobias Breidthardt
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
- Department of Internal Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thomas Münzel
- University Medical Center, Johannes Gutenberg University Mainz, Mainz, Germany
| | - Paul Erne
- Department of Cardiology, Luzerner Kantonsspital, Luzern, Switzerland
| | - Christian Mueller
- Department of Cardiology and Cardiovascular Research Institute Basel (CRIB), University Hospital Basel, University of Basel, Basel, Switzerland
- GREAT Research Network, Rome, Italy
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Yang Y, Shen C, Lu J, Xu F, Tong J, Jiang J, Fu G. Early continuous ultrafiltration in Chinese patients with congestive heart failure (EUC-CHF): study protocol for an open-label registry-based prospective clinical trial. BMC Cardiovasc Disord 2019; 19:249. [PMID: 31699029 PMCID: PMC6836341 DOI: 10.1186/s12872-019-1208-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 09/26/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND Conventional pharmacologic therapies aim to reduce fluid overload in advanced heart failure (HF) represented by intravenous (IV) loop diuretics (LDs) have sometimes not so efficacious and been reported to have side effects such as unpredictable removal of water and sodium and electrolyte disturbance. It is not certain whether early ultrafiltration (UF) is effective than LDs in relieving edema. Given the weakness of evidence for early UF in patients with fluid overload, recommendations of UF in guidelines is considered as second-line therapy only for patients with refractory congestion, who failed to respond to LD-based strategies. METHODS The early continuous ultrafiltration in Chinese patients with congestive heart failure (EUC-CHF) trial is an open-label, registry-based, prospective study, recruiting patients with severe acute decompensated HF who are hospitalized for HF worsening due to overt fluid overload 24 h from hospital admission. Forty patients will be enrolled to two treatment groups (n = 20 for each group). The primary outcomes are the changes of weight loss and dyspnea severity score after treatment, as well as the occurrence of clinically overt major bleeding. DISCUSSION EUC-CHF trial was primarily designed to evaluate the efficacy and safety of early UF in patients with acute decompensated HF to reduce volume overload and improve clinical outcome. The trial aims to determine if early UF in acute HF is superior to IV LDs in clinical parameter improvement without adverse events and prevents rehospitalization up to 30 days. Also the trial is expected to establish a scoring system based on Chinese population to guide early UF treatment in appropriate patients. EUC-CHF is one of the first controlled trials tailored to determine the benefit of UF with 24 h from hospital admission. TRIAL REGISTRATION www.chictr.org.cn, ChiCTR1800019556. Registered on 18 November 2018.
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Affiliation(s)
- Ying Yang
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Zhejiang, Hangzhou, China.
| | - Chao Shen
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Zhejiang, Hangzhou, China
| | - Jiangting Lu
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Zhejiang, Hangzhou, China
| | - Fen Xu
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Zhejiang, Hangzhou, China
| | - Jinshan Tong
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Zhejiang, Hangzhou, China
| | - Jiangfen Jiang
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Zhejiang, Hangzhou, China
| | - Guosheng Fu
- Department of Cardiology, Sir Run Run Shaw Hospital, College of Medicine, Zhejiang University, Zhejiang, Hangzhou, China.
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Dyspnea During In-Hospital Rehabilitation as a Predictor of Rehospitalization and Mortality in Patients With Acute Heart Failure. J Cardiopulm Rehabil Prev 2019; 39:E24-E27. [PMID: 31464887 DOI: 10.1097/hcr.0000000000000463] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE Consensus articles that explore rehabilitation exercise for heart failure (HF) mainly focus on stable patients with chronic HF. Results from investigations that focus on the relationship between clinical outcomes and exercise during rehabilitation of patients with acute heart failure (AHF) have produced insufficient data. The aim of this study was to evaluate the correlation between clinical outcomes and dyspnea during in-hospital early rehabilitation in patients with AHF. METHODS Dyspnea was measured using a 5-point Likert scale (5PLS) during rest and at the initiation of upright sitting and standing. Dyspnea was defined as 5PLS ≥2. The primary endpoint was combined all-cause death or rehospitalization for HF. RESULTS A total of 221 patients were included in this study; 81 patients (37%) died or were hospitalized during the follow-up period. In patients with dyspnea during upright sitting and standing, the event-free ratio was significantly lower compared with patients without dyspnea (P = .008 and P < .001, respectively). Body mass index (hazard ratio [HR] = 0.91, P = .011), noninvasive positive pressure ventilation usage (HR = 1.96, P = .042), and 5PLS ≥2 at the initiation of standing (HR = 2.63, P = .008) were detected as predictors of primary endpoint. New York Heart Association class IV at admission (OR = 3.17, P = .0114) and pre-admission Katz ADL index <6 (OR = 3.76, P = .0007) were isolated as risk factors for dyspnea when standing. CONCLUSIONS Dyspnea during standing was associated with unfavorable events in patients with AHF as a comprehensive indicator.
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23
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Smithline HA, Donnino M, Blank FSJ, Barus R, Coute RA, Knee AB, Visintainer P. Supplemental thiamine for the treatment of acute heart failure syndrome: a randomized controlled trial. BMC COMPLEMENTARY AND ALTERNATIVE MEDICINE 2019; 19:96. [PMID: 31060559 PMCID: PMC6501378 DOI: 10.1186/s12906-019-2506-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2018] [Accepted: 04/16/2019] [Indexed: 11/10/2022]
Abstract
Background The purpose of this pilot study was to determine if a definitive clinical trial of thiamine supplementation was warranted in patients with acute heart failure. We hypothesized that thiamine, when added to standard of care, would improve dyspnea (primary outcome) in hospitalized patients with acute heart failure. Peak expiratory flow rate, type B natriuretic peptide, free fatty acids, glucose, hospital length of stay, as well as 30-day rehospitalization and mortality were pre-planned secondary outcome measures. Methods This was a blinded experimental study at two urban academic hospitals. Consecutive patients admitted from the Emergency Department with a primary diagnosis of acute heart failure were recruited over 2 years. Patients on a daily dietary supplement were excluded. Randomization was stratified by type B natriuretic peptide and diabetes medication categories. Subjects received study drug (100 mg thiamine or placebo) in the evening of their first and second day. Outcome measures were obtained 8 h after study drug infusion. Dyspnea was measured on a 100-mm visual analog scale sitting up on oxygen, sitting up off oxygen, and lying supine off oxygen with 0 indicating no dyspnea. Data were analyzed using mixed-models as well as linear, negative binomial and logistic regression models to assess the impact of group on outcome measures. Results Of 130 subjects randomized, 118 had evaluable data (55 in the control and 63 in the treatment groups), 89% in both groups were adjudicated to have primarily AHF. Thiamine values increased significantly in the treatment group and were unchanged in the control group. One patient had thiamine deficiency. Only dyspnea measured sitting upright on oxygen differed significantly by group over time. No change was found for the other measures of dyspnea and all of the secondary measures. Conclusions In mild-moderate acute heart failure patients without thiamine deficiency, a standard dosing regimen of thiamine did not improve dyspnea, biomarkers, or other clinical parameters. Trial registration ClinicalTrials.gov: NCT00680706, May 20, 2008 (retrospectively registered). Electronic supplementary material The online version of this article (10.1186/s12906-019-2506-8) contains supplementary material, which is available to authorized users.
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Chapman B, DeVore AD, Mentz RJ, Metra M. Clinical profiles in acute heart failure: an urgent need for a new approach. ESC Heart Fail 2019; 6:464-474. [PMID: 31021532 PMCID: PMC6487835 DOI: 10.1002/ehf2.12439] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2018] [Accepted: 03/04/2019] [Indexed: 12/11/2022] Open
Abstract
Acute heart failure (HF) is a major public health concern, responsible for >26 million hospitalizations per year worldwide. Many trials have investigated new therapeutic options for acute HF, with most revealing equivocal results. Successful innovations in therapy for acute HF have remained limited, and standard of care has remained largely unchanged over the past decade, suggesting the need for a new approach for therapeutic decision making and clinical trial design in acute HF. This manuscript focuses on one approach that could prove useful in the development and application of novel therapies: classification of patients based on clinical profiles. While previous attempts at developing clinical profiles were successful in stratifying patients based on clinical and laboratory variables, they have not been utilized for personalized treatment strategies that improve patient outcomes. We suggest a new approach to the creation of clinical profiles that could stratify patients based on their underlying aetiology and their response to novel interventions. We also investigate novel analytic approaches to the creation of new clinical profiles that both investigators and clinicians alike could utilize to inform clinical trial design and the application of new therapies. Despite a large number of clinical trials for new therapeutic options, the treatment of acute HF has seen few advances over the past decades. Innovative approaches to patient selection through the use of clinical profiles could help to identify patients most likely to benefit from novel interventions and lead to the discovery of new therapeutic options.
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Affiliation(s)
| | - Adam D DeVore
- Duke Clinical Research Institute, 2400 Pratt Street, NP-8064, Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Robert J Mentz
- Duke Clinical Research Institute, 2400 Pratt Street, NP-8064, Durham, NC, 27705, USA.,Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Marco Metra
- Institute of Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
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Unlocking the potential of value-based health care by defining global standard sets of outcome measures that matter to patients with cardiovascular diseases. EUROPEAN HEART JOURNAL. QUALITY OF CARE & CLINICAL OUTCOMES 2018; 5:92-95. [DOI: 10.1093/ehjqcco/qcy056] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2018] [Revised: 11/29/2018] [Accepted: 12/01/2018] [Indexed: 11/15/2022]
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26
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Teneggi V, Sivakumar N, Chen D, Matter A. Drugs’ development in acute heart failure: what went wrong? Heart Fail Rev 2018; 23:667-691. [DOI: 10.1007/s10741-018-9707-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
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Is Time of the Essence? The Impact of Time of Hospital Presentation in Acute Heart Failure: Insights From ASCEND-HF Trial. JACC-HEART FAILURE 2018. [PMID: 29525328 DOI: 10.1016/j.jchf.2018.01.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
OBJECTIVES As the largest acute heart failure (AHF) trial conducted to date, the global ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure) trial database presented an opportunity to systematically describe the relationship among time of hospital presentation, clinical profile, inpatient management, and outcomes among patients admitted with AHF. BACKGROUND Time of hospital presentation has been shown to impact outcomes among patients hospitalized with many conditions. However, the association among time of presentation and patient characteristics, management, and clinical outcomes among patients hospitalized with AHF has not been well characterized. METHODS A post hoc analysis of the ASCEND-HF trial was performed, which enrolled 7,141 patients hospitalized for AHF. Patients were divided based on when they presented to the hospital; regular hours were defined as 9 am to 5 pm, Monday through Friday, and off hours were defined as 5 pm to 9 am, Monday through Friday and weekends. Clinical characteristics and outcomes were compared by time of presentation. RESULTS Overall, 3,298 patients (46%) presented during off hours. Off-hour patients were more likely to have orthopnea (80% vs. 74%, respectively) and rales (56% vs. 49%, respectively) than regular-hour patients. Off-hour patients were more likely to receive intravenous (IV) nitroglycerin (18% vs. 11%, respectively) and IV loop diuretics (92% vs. 86%, respectively) as initial therapy and reported greater relief from dyspnea at 24 h (odds ratio [OR]: 1.14; 95% confidence interval [CI]: 1.04 to 1.24; p = 0.01) than regular-hour patients. After adjustment, off-hour presentation was associated with significantly lower 30-day mortality (OR: 0.74; 95% CI: 0.57 to 0.96; p = 0.03) and 180-day mortality (hazard ratio [HR]: 0.82; 95% CI: 0.72 to 0.94; p = 0.01) but similar 30-day rehospitalization rates (p = 0.40). CONCLUSIONS In this AHF trial, patients admitted during off hours exhibited a distinct clinical profile, experienced greater dyspnea relief, and had lower post-discharge mortality than regular-hour patients. These findings have implications for future AHF trials.
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Alpert CM, Smith MA, Hummel SL, Hummel EK. Symptom burden in heart failure: assessment, impact on outcomes, and management. Heart Fail Rev 2018; 22:25-39. [PMID: 27592330 DOI: 10.1007/s10741-016-9581-4] [Citation(s) in RCA: 158] [Impact Index Per Article: 26.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Evidence-based management has improved long-term survival in patients with heart failure (HF). However, an unintended consequence of increased longevity is that patients with HF are exposed to a greater symptom burden over time. In addition to classic symptoms such as dyspnea and edema, patients with HF frequently suffer additional symptoms such as pain, depression, gastrointestinal distress, and fatigue. In addition to obvious effects on quality of life, untreated symptoms increase clinical events including emergency department visits, hospitalizations, and long-term mortality in a dose-dependent fashion. Symptom management in patients with HF consists of two key components: comprehensive symptom assessment and sufficient knowledge of available approaches to alleviate the symptoms. Successful treatment addresses not just the physical but also the emotional, social, and spiritual aspects of suffering. Despite a lack of formal experience during cardiovascular training, symptom management in HF can be learned and implemented effectively by cardiology providers. Co-management with palliative medicine specialists can add significant value across the spectrum and throughout the course of HF.
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Affiliation(s)
- Craig M Alpert
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Michael A Smith
- Department of Clinical Pharmacy, University of Michigan College of Pharmacy, Ann Arbor, MI, USA.,Department of Pharmacy Services, University of Michigan Health System, Ann Arbor, MI, USA
| | - Scott L Hummel
- Department of Internal Medicine, Division of Cardiovascular Medicine, University of Michigan, Ann Arbor, MI, USA.,VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
| | - Ellen K Hummel
- VA Ann Arbor Healthcare System, Ann Arbor, MI, USA. .,Department of Internal Medicine, Division of Geriatric and Palliative Medicine, University of Michigan, Ann Arbor, MI, USA. .,University of Michigan Frankel Cardiovascular Center, 1500 East Medical Center Dr., SPC 5233, Ann Arbor, MI, 48109-5233, USA.
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Ambrosy AP, Cerbin LP, Armstrong PW, Butler J, Coles A, DeVore AD, Dunlap ME, Ezekowitz JA, Felker GM, Fudim M, Greene SJ, Hernandez AF, O'Connor CM, Schulte P, Starling RC, Teerlink JR, Voors AA, Mentz RJ. Body Weight Change During and After Hospitalization for Acute Heart Failure: Patient Characteristics, Markers of Congestion, and Outcomes: Findings From the ASCEND-HF Trial. JACC-HEART FAILURE 2018; 5:1-13. [PMID: 28034373 DOI: 10.1016/j.jchf.2016.09.012] [Citation(s) in RCA: 74] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Revised: 08/15/2016] [Accepted: 09/22/2016] [Indexed: 12/21/2022]
Abstract
OBJECTIVES This study sought to examine the relationships between in-hospital and post-discharge body weight changes and outcomes among patients hospitalized for acute heart failure (AHF). BACKGROUND Body weight changes during and after hospitalization for AHF and the relationships with outcomes have not been well characterized. METHODS A post hoc analysis was performed of the ASCEND-HF (Acute Study of Clinical Effectiveness of Nesiritide and Decompensated Heart Failure) trial, which enrolled patients admitted for AHF regardless of ejection fraction. In-hospital body weight change was defined as the difference between baseline and discharge/day 10, whereas post-discharge body weight change was defined as the difference between discharge/day 10 and day 30. Spearman rank correlations of weight change, urine output (UOP), and dyspnea relief as assessed by a 7-point Likert scale are described. Logistic and Cox proportional hazards regression was used to evaluate the relationship between weight change and outcomes. RESULTS Study participants with complete body weight data (n = 4,172) had a mean age of 65 ± 14 years, and 66% were male. Ischemic heart disease was reported in 60% of patients and the average ejection fraction was 30 ± 13%. The median change in body weight was -1.0 kg (interquartile range: -2.1 to 0.0 kg) at 24 h and -2.3 kg (interquartile range: -5.0 to -0.7 kg) by discharge/day 10. At hour 24, there was a weak correlation between change in body weight and UOP (r = -0.381), and minimal correlation between body weight change and dyspnea relief (r = -0.096). After risk adjustment, increasing body weight during hospitalization was associated with a 16% increase per kg in the likelihood of 30-day mortality or HF readmission for patients showing weight loss ≤1 kg or weight gain during hospitalization (odds ratio per kg increase 1.16, 95% confidence interval [CI]: 1.09 to 1.27; p < 0.001). Among the subset of patients experiencing >1-kg increase in body weight post-discharge, increasing body weight was associated with higher risk of 180-day mortality (hazard ratio per kg increase 1.16; 95% CI: 1.09 to 1.23; p < 0.001). CONCLUSIONS A substantial number of patients experienced minimal weight loss or frank weight gain in the context of an AHF trial, and increasing body weight in this subset of patients was independently associated with a worse post-discharge prognosis.
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Affiliation(s)
- Andrew P Ambrosy
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | - Lukasz P Cerbin
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Javed Butler
- Division of Cardiology, Stony Brook Heart Institute, Stony Brook, New York
| | - Adrian Coles
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | - Adam D DeVore
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | - Mark E Dunlap
- Division of Cardiology, MetroHealth Campus of Case Western Reserve University, Cleveland, Ohio
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - G Michael Felker
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | - Marat Fudim
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Stephen J Greene
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina
| | - Adrian F Hernandez
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | | | - Philip Schulte
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina
| | | | - John R Teerlink
- Division of Cardiology, University of San Francisco, San Francisco, California
| | - Adriaan A Voors
- Division of Cardiology, University of Groningen, Groningen, the Netherlands
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, North Carolina; Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina.
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31
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Metra M, Ravera A, Filippatos G. Understanding worsening heart failure as a therapeutic target: another step forward? Eur J Heart Fail 2017; 19:996-1000. [DOI: 10.1002/ejhf.866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2017] [Accepted: 03/31/2017] [Indexed: 11/06/2022] Open
Affiliation(s)
- Marco Metra
- Cardiology Department of Medical and Surgical Specialties, Radiological Sciences and Public Health; University of Brescia; Brescia Italy
| | - Alice Ravera
- Cardiology Department of Medical and Surgical Specialties, Radiological Sciences and Public Health; University of Brescia; Brescia Italy
| | - Gerasimos Filippatos
- Department of Cardiology, School of Medicine; National and Kapodistrian University of Athens, Athens University Hospital Attikon; Athens Greece
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Gondos T, Szabó V, Sárkány Á, Sárkány A, Halász G. Estimation of the severity of breathlessness in the emergency department: a dyspnea score. BMC Emerg Med 2017; 17:13. [PMID: 28441939 PMCID: PMC5405485 DOI: 10.1186/s12873-017-0125-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2017] [Accepted: 04/18/2017] [Indexed: 12/11/2022] Open
Abstract
Background Dyspnea is a frequent complaint in emergency departments (ED). It has a significant amount of subjective and affective components, therefore the dyspnea scores, based on the patients’ rating, can be ambiguous. Our purpose was to develop and validate a simple scoring system to evaluate the severity of dyspnea in emergency care, based on objectively measured parameters. Methods We performed a double center, prospective, observational study including 350 patients who were admitted in EDs with dyspnea. We evaluated the patients’ subjective feeling about dyspnea and applied our Dyspnea Severity Score (DSS), rating the dyspnea in 7 Dimensions from 0 to 3 points. The DSS was validated using the deterioration of pH, base-excess and lactate levels in the blood gas samples (Objective Classification Scale (OCS) 9 points and 13 points groups). Results All of the Dimensions correlated closely with the OCS values and with the subjective feeling of the dyspnea. Using multiple linear regression analysis we were able to decrease the numbers of Dimensions from seven to four without causing a significant change in the determination coefficient in any OCS groups. This reduced DSS values (exercise tolerance, cooperation, cyanosis, SpO2 value) showed high sensitivity and specificity to predict the values of OCS groups (the ranges: AUC 0.77–0.99, sensitivity 65–100%, specificity 64–99%). There was a close correlation between the subjective dyspnea scores and the OCS point values (p < 0.001), though the scatter was very large. Conclusions A new DSS was validated which score is suitable to compare the severity of dyspnea among different patients and different illnesses. The simplified version of the score (its value ≥7 points without correction factors) can be useful at the triage or in pre-hospital care.
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Affiliation(s)
- Tibor Gondos
- Faculty of Health Sciences, Semmelweis University, Budapest, Hungary. .,Emergency Department, Jávorszky Ödön Hospital, Vác, Hungary.
| | - Viktor Szabó
- Department of Hydrodynamic Systems, Budapest University of Technology and Economics, Budapest, Hungary
| | - Ágnes Sárkány
- Emergency Department, "Szent György" University Teaching Hospital, Székesfehérvár, Hungary
| | - Adrienn Sárkány
- Emergency Department, "Kaposi Mór" University Teaching Hospital, Kaposvár, Hungary
| | - Gábor Halász
- Department of Hydrodynamic Systems, Budapest University of Technology and Economics, Budapest, Hungary
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Pang PS, Lane KA, Tavares M, Storrow AB, Shen C, Peacock WF, Nowak R, Mebazaa A, Laribi S, Hollander JE, Gheorghiade M, Collins SP. Is there a clinically meaningful difference in patient reported dyspnea in acute heart failure? An analysis from URGENT Dyspnea. Heart Lung 2017; 46:300-307. [PMID: 28433323 DOI: 10.1016/j.hrtlng.2017.03.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 03/10/2017] [Accepted: 03/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Dyspnea is the most common presenting symptom in patients with acute heart failure (AHF), but is difficult to quantify as a research measure. The URGENT Dyspnea study compared 3 scales: (1) 10 cm VAS, (2) 5-point Likert, and (3) a 7-point Likert (both VAS and 5-point Likert were recorded in the upright and supine positions). However, the minimal clinically important difference (MCID) to patients has not been well established. METHODS We performed a secondary analysis from URGENT Dyspnea, an observational, multi-center study of AHF patients enrolled within 1 h of first physician assessment in the ED. Using the anchor-based method to determine the MCID, a one-category change in the 7-point Likert was used as the criterion standard ('minimally improved or worse'). The main outcome measures were the change in visual analog scale (VAS) and 5-point Likert scale from baseline to 6-h assessment relative to a 1-category change response in the 7-point Likert scale ('minimally worse', 'no change', or 'minimally better'). RESULTS Of the 776 patients enrolled, 491 had a final diagnosis of AHF with responses at both time points. A 10.5 mm (SD 1.6 mm) change in VAS was the MCID for improvement in the upright position, and 14.5 mm (SD 2.0 mm) in the supine position. However, there was no MCID for worsening, as few patients reported worse dyspnea. There was also no significant MCID for the 5-point Likert scale. CONCLUSION A 10.5 mm change is the MCID for improvement in dyspnea over 6 h in ED patients with AHF.
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Affiliation(s)
- Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, USA; Indianapolis EMS, USA.
| | - Kathleen A Lane
- Department of Biostatistics, Indiana University School of Medicine, USA
| | - Miguel Tavares
- Department of Anesthesiology and Critical Care, Hospital Geral de Santo António, Porto, Portugal
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University, Nashville, VA, USA
| | - Changyu Shen
- Department of Biostatistics, Indiana University School of Medicine, USA
| | - W Frank Peacock
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Richard Nowak
- Department of Emergency Medicine, Henry Ford Health System, Wayne State University, USA
| | - Alexandre Mebazaa
- Department of Anesthesia and Critical Care, Hôpitaux Universitaires Saint Louis Lariboisière, France
| | - Said Laribi
- Tours University Hospital, Emergency Department, 37044, France; INSERM, U942, BIOmarkers in CArdioNeuroVAScular diseases, France
| | - Judd E Hollander
- Sidney Kimmel Medical College of Thomas Jefferson University, USA
| | - Mihai Gheorghiade
- Division of Cardiology, Northwestern University Feinberg School of Medicine, USA
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, VA, USA
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Felker GM, Mentz RJ, Cole RT, Adams KF, Egnaczyk GF, Fiuzat M, Patel CB, Echols M, Khouri MG, Tauras JM, Gupta D, Monds P, Roberts R, O’Connor CM. Efficacy and Safety of Tolvaptan in Patients Hospitalized With Acute Heart Failure. J Am Coll Cardiol 2017; 69:1399-1406. [DOI: 10.1016/j.jacc.2016.09.004] [Citation(s) in RCA: 134] [Impact Index Per Article: 19.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2016] [Revised: 09/12/2016] [Accepted: 09/12/2016] [Indexed: 01/11/2023]
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Turcato G, Cervellin G, Luca Salvagno G, Zaccaria E, Bartucci G, David M, Bonora A, Zannoni M, Ricci G, Lippi G. The Role of Red Blood Cell Distribution Width for Predicting 1-year Mortality in Patients Admitted to the Emergency Department with Severe Dyspnoea. J Med Biochem 2017; 36:32-38. [PMID: 28680347 PMCID: PMC5471657 DOI: 10.1515/jomb-2016-0026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2016] [Accepted: 09/20/2016] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Universally accepted and validated instruments for predicting the outcome of patients presenting to the emergency department (ED) with severe dyspnoea do not exist so far, nor are they regularly used by the emergency physicians. This study hence aimed to establish whether red blood cell distribution width (RDW) may be a predictive parameter of 1-year mortality in a population of patients admitted to the ED with severe dyspnoea attributable to different underlying disorders. METHODS We retrospectively evaluated all the patients undergoing arterial blood gas analysis for severe dyspnoea (irrespective of the cause) during admission to ED of University Hospital of Verona from September 1, 2014 to November 31, 2014. RESULTS The final study population consisted of 287 patients for whom complete clinical and laboratory information was available. Overall, 36 patients (12.5%) died after a 1-year follow-up. The RDW value was found to be considerably increased in patients who deceased during the follow-up compared to those who survived (17.2% versus 14.8%; p<0.001). In both univariate and multivariate analyses, the RDW value was found to be a significant predictor of 1-year mortality. In particular, patients with RDW ≥ 15.0% displayed a 72% increased risk of 1-year mortality after multiple adjustments. CONCLUSIONS The measurement of RDW, a very simple and inexpensive laboratory parameter, may represent an important factor for predicting medium-term mortality in patients presenting to the ED with severe dyspnoea.
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Affiliation(s)
- Gianni Turcato
- Emergency Department, University Hospital of Verona, Verona, Italy
| | | | - Gian Luca Salvagno
- Section of Clinical Biochemistry, University of Verona, Verona, Piazzale LA Scuro, 37100 - Verona, Italy
| | | | | | - Marco David
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Antonio Bonora
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Massimo Zannoni
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Giorgio Ricci
- Emergency Department, University Hospital of Verona, Verona, Italy
| | - Giuseppe Lippi
- Section of Clinical Biochemistry, University of Verona, Verona, Piazzale LA Scuro, 37100 - Verona, Italy
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Lund N, Gränsbo K, Wernersson C, Melander O. Cardiometabolic biomarkers are predictors of readmission and death in patients hospitalized for acute dyspnea. Am J Emerg Med 2016; 35:610-614. [PMID: 28062207 PMCID: PMC5754318 DOI: 10.1016/j.ajem.2016.12.048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Revised: 12/12/2016] [Accepted: 12/16/2016] [Indexed: 12/20/2022] Open
Abstract
Background Acute dyspnea affects a large heterogeneous patient group with high mortality and readmission rates. Purpose To investigate if cardiometabolic biomarkers and clinical characteristics predict readmission and death in patients hospitalized for acute dyspnea. Methods 65 dyspnea patients at a general internal medicine ward were followed for six months. The combined endpoint was readmission or death. Measurements and results Cardiometabolic biomarkers at admission were related to the endpoint in Cox proportional hazard models (adjusted for sex, age, oxygen saturation, respiratory rate and C-reactive protein (CRP)). The biomarkers tissue-type plasminogen activator (tPA), prolactin (PRL), tumor necrosis factor receptor superfamily member 6 (FAS) and C-C motif chemokine 3 (CCL3) were independently and significantly related to the endpoint and combined into a biomarker risk score (BRS). Each SD increment of the BRS conferred a hazard ratio (HR) of 2.13 (1.39–3.27) P = 0.001. The top vs bottom tertile of the BRS conferred a HR of 4.75 (1.93–11.68) P = 0.001. Dyspnea severity was also associated with worse outcome, HR = 3.43 (1.28–9.20) P = 0.014. However, when mutually adjusted the BRS remained significant (P = 0.004) whereas dyspnea severity was not. The BRS was related to the endpoint among patients with mild to moderate dyspnea (P = 0.016) but not among those with severe dyspnea. Conclusion A score of tPA, PRL, FAS and CCL3 predicts 6-month death and readmission in patients hospitalized for acute dyspnea and may prove useful to optimize length of stay and follow-up. Although the BRS outweighs dyspnea severity in prediction of the endpoint, its prognostic role is strongest in mild-moderate dyspnea.
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Affiliation(s)
- Nathalie Lund
- Skåne University Hospital Malmö, Clinical Research Centre, Malmoe, Sweden.
| | - Klas Gränsbo
- Skåne University Hospital Malmö, Clinical Research Centre CRC, Malmoe, Sweden
| | - Camilla Wernersson
- Skåne University Hospital Malmö, Clinical Research Centre CRC, Malmoe, Sweden
| | - Olle Melander
- Skåne University Hospital Malmö, Clinical Research Centre CRC, Malmoe, Sweden
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Greene SJ, Hernandez AF, Sun JL, Metra M, Butler J, Ambrosy AP, Ezekowitz JA, Starling RC, Teerlink JR, Schulte PJ, Voors AA, Armstrong PW, O’Connor CM, Mentz RJ. Influence of Clinical Trial Site Enrollment on Patient Characteristics, Protocol Completion, and End Points. Circ Heart Fail 2016; 9:CIRCHEARTFAILURE.116.002986. [DOI: 10.1161/circheartfailure.116.002986] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2016] [Accepted: 08/08/2016] [Indexed: 12/12/2022]
Abstract
Background—
Most international acute heart failure trials have failed to show benefit with respect to key end points. The impact of site enrollment and protocol execution on trial performance is unclear.
Methods and Results—
We assessed the impact of varying site enrollment volume among all 7141 acute heart failure patients from the ASCEND-HF trial (Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure). Overall, 398 sites enrolled ≥1 patient, and median enrollment was 12 patients (interquartile range, 5–23). Patients from high enrolling sites (>60 patients/site) tended to have lower ejection fraction, worse New York Heart Association functional class, and lower utilization of guideline-directed medical therapy but fewer comorbidities and lower B-type natriuretic peptide level. Every 10 patient increase (up to 100 patients) in site enrollment correlated with lower likelihood of protocol noncompletion (odds ratio, 0.93; 95% confidence interval [CI], 0.89–0.98). After adjustment, increasing site enrollment predicted higher risk of persistent dyspnea at 6 hours (per 10 patient increase: odds ratio 1.02; 95% CI, 1.01–1.03) but not at 24 hours (odds ratio, 0.99; 95% CI, 0.98–1.00). Higher site enrollment was independently associated with lower risk of 30-day death or rehospitalization (per 10 patient increase: odds ratio, 0.98, 95% CI, 0.96–0.99) but not 180-day mortality (hazard ratio, 0.99; 95% CI, 0.98–1.01). The influence of increasing site enrollment on clinical end points varied across geographic regions with strongest associations in Latin America and Asia-Pacific (all interaction
P
<0.01).
Conclusions—
In this large, acute heart failure trial, site enrollment correlated with protocol completion and was independently associated with trial end points. Individual and regional site performance present challenges to be considered in design of future acute heart failure trials.
Clinical Trial Registration—
URL:
http://www.clinicaltrials.gov
. Unique identifier: NCT00475852.
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Affiliation(s)
- Stephen J. Greene
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Adrian F. Hernandez
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Jie-Lena Sun
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Marco Metra
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Javed Butler
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Andrew P. Ambrosy
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Justin A. Ezekowitz
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Randall C. Starling
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - John R. Teerlink
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Phillip J. Schulte
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Adriaan A. Voors
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Paul W. Armstrong
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Christopher M. O’Connor
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
| | - Robert J. Mentz
- From the Division of Cardiology, Duke University Medical Center, Durham, NC (S.J.G., A.F.H., A.P.A., C.M.O., R.J.M.); Duke Clinical Research Institute, Durham, NC (A.F.H., J.-L.S., A.P.A., P.J.S., C.M.O., R.J.M.); Cardiology, University of Brescia, Italy (M.M.); Division of Cardiology, Stony Brook University, NY (J.B.); Canadian VIGOUR Center, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.); Cleveland Clinic, OH (R.C.S.); Section of Cardiology, San Francisco Veterans Affairs Medical Center,
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Ambrosy AP, Khan H, Udelson JE, Mentz RJ, Chioncel O, Greene SJ, Vaduganathan M, Subacuis HP, Konstam MA, Swedberg K, Zannad F, Maggioni AP, Gheorghiade M, Butler J. Changes in Dyspnea Status During Hospitalization and Postdischarge Health-Related Quality of Life in Patients Hospitalized for Heart Failure: Findings From the EVEREST Trial. Circ Heart Fail 2016; 9:CIRCHEARTFAILURE.115.002458. [DOI: 10.1161/circheartfailure.115.002458] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 03/21/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew P. Ambrosy
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Hassan Khan
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - James E. Udelson
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Robert J. Mentz
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Ovidiu Chioncel
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Stephen J. Greene
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Muthiah Vaduganathan
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Haris P. Subacuis
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Marvin A. Konstam
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Karl Swedberg
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Faiez Zannad
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Aldo P. Maggioni
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Mihai Gheorghiade
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
| | - Javed Butler
- From the Duke University Medical Center, Durham, NC (A.P.A., R.J.M., S.J.G.); Department of Medicine, Emory University School of Medicine, Atlanta, GA (H.K.); Division of Cardiology, Tufts Medical Center and Tufts University School of Medicine, Boston, MA (J.E.U., M.A.K.); Duke Clinical Research Institute, Durham, NC (R.J.M.); Institute of Emergency for Cardiovascular Diseases ‘Prof. C.C. Iliescu’, University of Medicine and Pharmacy Carol Davila, Bucuresti, Romania (O.C.); Division of Cardiology,
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Wang G, Wang P, Li Y, Liu W, Bai S, Zhen Y, Li D, Yang P, Chen Y, Hong L, Sun J, Chen J, Wang X, Zhu J, Hu D, Li H, Wu T, Huang J, Tan H, Zhang J, Liao Z, Yu L, Mao Y, Ye S, Feng L, Hua Y, Ni X, Zhang Y, Wang Y, Li W, Luan X, Sun X, Wang S. Efficacy and Safety of 1-Hour Infusion of Recombinant Human Atrial Natriuretic Peptide in Patients With Acute Decompensated Heart Failure: A Phase III, Randomized, Double-Blind, Placebo-Controlled, Multicenter Trial. Medicine (Baltimore) 2016; 95:e2947. [PMID: 26945407 PMCID: PMC4782891 DOI: 10.1097/md.0000000000002947] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2015] [Revised: 01/11/2016] [Accepted: 02/08/2016] [Indexed: 11/29/2022] Open
Abstract
The aim of the study was to evaluate the efficacy and safety of 1-h infusion of recombinant human atrial natriuretic peptide (rhANP) in combination with standard therapy in patients with acute decompensated heart failure (ADHF). This was a phase III, randomized, double-blind, placebo-controlled, multicenter trial. Eligible patients with ADHF were randomized to receive a 1-h infusion of either rhANP or placebo at a ratio of 3:1 in combination with standard therapy. The primary endpoint was dyspnea improvement (a decrease of at least 2 grades of dyspnea severity at 12 h from baseline). Reduction in pulmonary capillary wedge pressure (PCWP) 1 h after infusion was the co-primary endpoint for catheterized patients. Overall, 477 patients were randomized: 358 (93 catheterized) patients received rhANP and 118 (28 catheterized) received placebo. The percentage of patients with dyspnea improvement at 12 h was higher, although not statistically significant, in the rhANP group than in the placebo group (32.0% vs 25.4%, odds ratio=1.382, 95% confidence interval [CI]: 0.863-2.212, P = 0.17). Reduction in PCWP at 1 h was significantly greater in patients treated with rhANP than in patients treated with placebo (-7.74 ± 5.95 vs -1.82 ± 4.47 mm Hg, P < 0.001). The frequencies of adverse events and renal impairment within 3 days of treatment were similar between the 2 groups. Mortality at 1 month was 3.1% in the rhANP group vs 2.5% in the placebo group (hazard ratio = 1.21, 95% CI: 0.34-4.26; P > 0.99). 1-h rhANP infusion appears to result in prompt, transient hemodynamic improvement with a small, nonsignificant, effect on dyspnea in ADHF patients receiving standard therapy. The safety of 1-h infusion of rhANP seems to be acceptable. (WHO International Clinical Trials Registry Platform [ICTRP] number, ChiCTR-IPR-14005719.).
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Affiliation(s)
- Guogan Wang
- From the Department of Cardiology (G. Wang, P. Wang, J. Huang, H. Tan, J. Zhang, Z. Liao, L. Yu, Y. Mao, S. Ye, L. Feng, Y. Hua, X. Ni, Y. Zhang, X. Luan, X. Sun, S. Wang), Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Heart Center (P. Wang), First Hospital of Tsinghua University; Key Laboratory of Cardiovascular Drugs of Ministry of Health (Y. Li), Cardiovascular Institute and Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College; Department of Cardiology (W. Liu, S. Bai), Beijing Anzhen Hospital, The Capital University Medical Sciences, Beijing; Department of Cardiology (Y. Zhen), The First Hospital of Jilin University, Changchun; Department of Cardiology (D. Li), The Affiliated Hospital of Xuzhou Medical College, Xuzhou; Department of Cardiology (P. Yang, Y. Chen), China-Japan Friendship Hospital, Jilin University, Changchun; Department of Cardiology (LH), Jiangxi Provincial People's Hospital, Nanchang; Department of Cardiology (J. Sun), The First People's Hospital of Changzhou, Changzhou; Department of Cardiology (J. Chen), First Affiliated Hospital, College of Medicine, Zhejiang University, Hangzhou; Department of Cardiology (X. Wang), Beijing Military General Hospital; Department of Cardiology (J. Zhu, D. Hu), Peking University People's Hospital, Beijing; Department of Cardiology (H. Li), The 254 Hospital of People's Liberation Army, Tianjin; Department of Cardiology (T. Wu), Guangzhou Red Cross Hospital, Guangzhou; and Medical Research & Biometrics Center (Y. Wang, W. Li), National Center for Cardiovascular Diseases, Beijing, China
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Abstract
The field of quality-of-life (QOL) measurement grew out of attempts in the 1960s and 1970s to connect the ever-increasing levels of public expenditure on technology-based health care for chronic diseases with evidence of the benefits and harms to patients. Most of the concepts, methods, and standards for measuring QOL were derived from psychometrics, but the degree to which current tools adhere to these methods varies greatly. Despite the importance of QOL, patient-reported outcomes are not measured in most cardiovascular clinical trials. Lack of familiarity with QOL measures and their interpretation, and unrealistic expectations about the information these measures can provide, are obstacles to their use. Large clinical trials of revascularization therapy for coronary artery disease and medical treatments for heart failure show small-to-moderate QOL effects, primarily detected with disease-specific instruments. Larger treatment effects, seen in trials of device therapy for heart failure and ablation therapy for atrial fibrillation, have been detected with both generic and disease-specific instruments. A large gap remains between the parameters currently being measured in clinical research and the data needed to incorporate the 'patient's voice' into therapeutic decision-making.
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Affiliation(s)
- Daniel B Mark
- Duke Clinical Research Institute, 2400 Pratt Avenue, Room 0311, PO Box 17969, Durham, North Carolina 27715, USA
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AbouEzzeddine OF, Lala A, Khazanie PP, Shah R, Ho JE, Chen HH, Pang PS, McNulty SE, Anstrom KJ, Hernandez AF, Redfield MM. Evaluation of a provocative dyspnea severity score in acute heart failure. Am Heart J 2016; 172:34-41. [PMID: 26856213 PMCID: PMC4748181 DOI: 10.1016/j.ahj.2015.10.009] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 10/16/2015] [Indexed: 01/08/2023]
Abstract
BACKGROUND The acute heart failure (AHF) Syndromes International Working Group proposed that dyspnea be assessed under standardized, incrementally provocative maneuvers and called for studies to assess the feasibility of this approach. We sought to assess the feasibility and statistical characteristics of a novel provocative dyspnea severity score (pDS) versus the traditional dyspnea visual analog scale (DVAS) in an AHF trial. METHODS At enrollment, 24, 48 and 72hours, 230 ROSE-AHF patients completed a DVAS. Dyspnea was then assessed with 5-point Likert dyspnea scales administered during 4 stages (A: upright-with O2, B: upright-without O2, C: supine-without O2 and D: exercise-without O2). Patients with moderate or less dyspnea were eligible for the next stage. RESULTS At enrollment, oxygen withdrawal and supine provocation were highly feasible (≥97%), provoking more severe dyspnea (≥1 Likert point) in 24% and 42% of eligible patients, respectively. Exercise provocation had low feasibility with 38% of eligible patients unable to exercise due to factors other than dyspnea. A pDS was constructed from Likert scales during the 3 feasible assessment conditions (A-C). Relative to DVAS, the distribution of the pDS was more skewed with a high "ceiling effect" at enrollment (23%) limiting sensitivity to change. Change in pDS was not related to decongestion or 60-day outcomes. CONCLUSIONS Although oxygen withdrawal and supine provocation are feasible and elicit more severe dyspnea, exercise provocation had unacceptable feasibility in this AHF cohort. The statistical characteristics of a pDS based on feasible provocation measures do not support its potential as a robust dyspnea assessment tool in AHF.
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Affiliation(s)
| | - Anuradha Lala
- Brigham and Women's Hospital, Boston, MA; Mount Sinai Hospital, Icahn School of Medicine, New York, NY
| | | | - Ravi Shah
- Massachusetts General Hospital, Boston, MA
| | | | | | - Peter S Pang
- Indiana University School of Medicine, Indianapolis, IN
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Champion S, Deye N, Solal AC. Y a-t-il une place pour le dinitrate d’isosorbide dans l’œdème aigu pulmonaire? Therapie 2015; 70:265-71. [DOI: 10.2515/therapie/2014226] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 10/25/2014] [Indexed: 11/20/2022]
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Sato N, Takahashi W, Hirayama A, Ajioka M, Takahashi N, Okishige K, Wang X, Maki A, Maruyama H, Ebinger U, Yamaguchi M, Pang Y, Matsumoto H, Kawana M. Multicenter, Randomized, Double-Blinded, Placebo-Controlled Phase II Study of Serelaxin in Japanese Patients With Acute Heart Failure. Circ J 2015; 79:1237-47. [PMID: 25912697 DOI: 10.1253/circj.cj-15-0227] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Serelaxin, a recombinant form of human relaxin-2, is in development for treating acute heart failure (AHF) and a Phase II study in Japanese AHF patients was conducted. METHODS AND RESULTS A randomized, double-blind, placebo-controlled study of serelaxin at 10 and 30 µg·kg(-1)·day(-1)continuous intravenous infusion for up to 48 h, added to standard care for Japanese AHF patients. Primary endpoints were adverse events (AEs) through Day 5, serious AEs (SAEs) through Day 14, and serelaxin pharmacokinetics. Secondary endpoints included changes in systolic blood pressure (SBP) and cardiorenal biomarkers. A total of 46 patients received the study drug and were followed for 60 days. The observed AE profile was comparable between the groups, with no AEs of concern. Dose-dependent increase in the serum concentration of serelaxin was observed across the 2 dose rates of serelaxin. A greater reduction in SBP was observed with serelaxin 30 µg·kg(-1)·day(-1)vs. placebo (-7.7 [-16.4, 1.0] mmHg). A greater reduction in NT-proBNP was noted with serelaxin (-50.8% and -54.9% for 10 and 30 µg·kg(-1)·day(-1), respectively at Day 2). CONCLUSIONS Serelaxin was well tolerated in this study with Japanese AHF patients, with no AEs of concern and favorable beneficial trends on efficacy. These findings support further evaluation of serelaxin 30 µg·kg(-1)·day(-1)in this patient population.
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Affiliation(s)
- Naoki Sato
- Cardiology and Intensive Care Unit, Nippon Medical School Musashi-Kosugi Hospital
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Alexander P, Alkhawam L, Curry J, Levy P, Pang PS, Storrow AB, Collins SP. Lack of evidence for intravenous vasodilators in ED patients with acute heart failure: a systematic review. Am J Emerg Med 2015; 33:133-41. [PMID: 25530194 PMCID: PMC4344879 DOI: 10.1016/j.ajem.2014.09.009] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2014] [Revised: 09/02/2014] [Accepted: 09/02/2014] [Indexed: 01/01/2023] Open
Abstract
There are nearly 700,000 annual US emergency department (ED) visits for acute heart failure (AHF). Although blood pressure is elevated on most of these visits, acute therapy remains focused on preload and not afterload reduction. Data from recent prospective studies suggest that patients with AHF with concomitant acute hypertension benefit from intravenous (IV) vasodilators. To better understand the use of vasodilators for such patients, we conducted a systematic review of (1) currently available intravenous vasodilators for ED patients with AHF, or (2) intravenous vasodilators that are not yet available, but have completed phase III clinical trials in AHF, and may be available for ED use in the future. We used multiterm search queries to retrieve research involving nitroglycerin, nitroprusside, enalaprilat, hydralazine, relaxin, and nesiritide. A total of 2001 unique citations were identified from 3 databases: PubMed, EMBASE, and CINAHL. Of these, 1966 were excluded on the basis of established review criteria, leaving 35 published articles for inclusion. Our primary finding was that intravenous nitrovasodilators, when used in the treatment of AHF in ED and ED-like settings, do improve short-term symptoms and appear safe to administer. There are no data suggesting that they impact mortality. Other commonly used vasodilators such as hydralazine and enalaprilat have very little published data about their safety and efficacy. Of note, few studies enrolled patients early in their course of treatment. Thus, to assess the specific impact of vasodilator therapy on both short- and long-term outcomes, future research efforts should focus on patient recruitment in the ED setting.
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Affiliation(s)
- Pauline Alexander
- Department of Emergency Medicine, Vanderbilt University, 1313 21st Ave S, Nashville, TN 37232, United States.
| | - Lora Alkhawam
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 303 E Chicago Ave, Chicago, IL 60611, United States
| | - Jason Curry
- Department of Emergency Medicine, Vanderbilt University, 1313 21st Ave S, Nashville, TN 37232, United States
| | - Phillip Levy
- Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State University, 540 E Canfield St, Detroit, MI 48201, United States
| | - Peter S Pang
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 303 E Chicago Ave, Chicago, IL 60611, United States
| | - Alan B Storrow
- Department of Emergency Medicine, Vanderbilt University, 1313 21st Ave S, Nashville, TN 37232, United States
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, 1313 21st Ave S, Nashville, TN 37232, United States
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Felker GM, Butler J, Collins SP, Cotter G, Davison BA, Ezekowitz JA, Filippatos G, Levy PD, Metra M, Ponikowski P, Soergel DG, Teerlink JR, Violin JD, Voors AA, Pang PS. Heart failure therapeutics on the basis of a biased ligand of the angiotensin-2 type 1 receptor. Rationale and design of the BLAST-AHF study (Biased Ligand of the Angiotensin Receptor Study in Acute Heart Failure). JACC-HEART FAILURE 2015; 3:193-201. [PMID: 25650371 DOI: 10.1016/j.jchf.2014.09.008] [Citation(s) in RCA: 62] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/04/2014] [Revised: 09/15/2014] [Accepted: 09/18/2014] [Indexed: 01/14/2023]
Abstract
The BLAST-AHF (Biased Ligand of the Angiotensin Receptor Study in Acute Heart Failure) study is designed to test the efficacy and safety of TRV027, a novel biased ligand of the angiotensin-2 type 1 receptor, in patients with acute heart failure (AHF). AHF remains a major public health problem, and no currently-available therapies have been shown to favorably affect outcomes. TRV027 is a novel biased ligand of the angiotensin-2 type 1 receptor that antagonizes angiotensin-stimulated G-protein activation while stimulating β-arrestin. In animal models, these effects reduce afterload while increasing cardiac performance and maintaining stroke volume. In initial human studies, TRV027 appears to be hemodynamically active primarily in patients with activation of the renin-angiotensin-aldosterone system, a potentially attractive profile for an AHF therapeutic. BLAST-AHF is an international prospective, randomized, phase IIb, dose-ranging study that will randomize up to 500 AHF patients with systolic blood pressure ≥120 mm Hg and ≤200 mm Hg within 24 h of initial presentation to 1 of 3 doses of intravenous TRV027 (1, 5, or 25 mg/h) or matching placebo (1:1:1:1) for at least 48 h and up to 96 h. The primary endpoint is a composite of 5 clinical endpoints (dyspnea, worsening heart failure, length of hospital stay, 30-day rehospitalization, and 30-day mortality) combined using an average z-score. Secondary endpoints will include the assessment of dyspnea and change in amino-terminal pro-B-type natriuretic peptide. The BLAST-AHF study will assess the efficacy and safety of a novel biased ligand of the angiotensin-2 type 1 receptor in AHF.
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Affiliation(s)
- G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
| | - Javed Butler
- Division of Cardiology, Stony Brook University, Stony Brook, New York
| | - Sean P Collins
- Department of Emergency Medicine, Vanderbilt University, Nashville, Tennessee
| | - Gad Cotter
- Momentum Research, Inc, Durham, North Carolina
| | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre at the University of Alberta, Edmonton, Alberta, Canada
| | | | - Phillip D Levy
- Department of Emergency Medicine and Cardiovascular Research Institute, Wayne State School of Medicine, Detroit, Michigan
| | - Marco Metra
- Cardiology, Department of Medical and Surgical Specialties, Radiological Sciences and Public Health; University of Brescia, Brescia, Italy
| | - Piotr Ponikowski
- Department of Cardiology, Medical University, Clinical Military Hospital, Wroclaw, Poland
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California-San Francisco, San Francisco, California
| | | | - Adriaan A Voors
- Department of Cardiology, University of Groningen, Groningen, the Netherlands
| | - Peter S Pang
- Department of Emergency Medicine, Indiana University School of Medicine, Indianapolis, Indiana
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Collins S, Storrow AB, Albert NM, Butler J, Ezekowitz J, Felker GM, Fermann GJ, Fonarow GC, Givertz MM, Hiestand B, Hollander JE, Lanfear DE, Levy PD, Pang PS, Peacock WF, Sawyer DB, Teerlink JR, Lenihan DJ. Early management of patients with acute heart failure: state of the art and future directions. A consensus document from the society for academic emergency medicine/heart failure society of America acute heart failure working group. J Card Fail 2015; 21:27-43. [PMID: 25042620 PMCID: PMC4276508 DOI: 10.1016/j.cardfail.2014.07.003] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2014] [Revised: 06/28/2014] [Accepted: 07/10/2014] [Indexed: 12/18/2022]
Abstract
Heart failure (HF) afflicts nearly 6 million Americans, resulting in one million emergency department (ED) visits and over one million annual hospital discharges. An aging population and improved survival from cardiovascular diseases is expected to further increase HF prevalence. Emergency providers play a significant role in the management of patients with acute heart failure (AHF). It is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics and alternatives to hospitalization. Further, clinical trials must be conducted in the ED in order to improve the evidence base and drive optimal initial therapy for AHF. Should ongoing and future studies suggest early phenotype-driven therapy improves in-hospital and post-discharge outcomes, ED treatment decisions will need to evolve accordingly. The potential impact of future studies which incorporate risk-stratification into ED disposition decisions cannot be underestimated. Predictive instruments that identify a cohort of patients safe for ED discharge, while simultaneously addressing barriers to successful outpatient management, have the potential to significantly impact quality of life and resource expenditures.
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Affiliation(s)
- Sean Collins
- Nashville Veterans Affairs Medical Center and Vanderbilt University, Nashville, Tennessee.
| | | | | | | | | | | | | | | | | | | | | | | | | | - Peter S Pang
- Indiana University School of Medicine, Indianapolis, Indiana
| | | | | | - John R Teerlink
- San Francisco Veterans Affairs Medical Center, University of California, San Francisco, California
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Collins SP, Storrow AB, Levy PD, Albert N, Butler J, Ezekowitz JA, Michael Felker G, Fermann GJ, Fonarow GC, Givertz MM, Hiestand B, Hollander JE, Lanfear DE, Pang PS, Frank Peacock W, Sawyer DB, Teerlink JR, Lenihan DJ. Early management of patients with acute heart failure: state of the art and future directions--a consensus document from the SAEM/HFSA acute heart failure working group. Acad Emerg Med 2015; 22:94-112. [PMID: 25423908 DOI: 10.1111/acem.12538] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2014] [Accepted: 08/24/2014] [Indexed: 12/20/2022]
Abstract
Heart failure (HF) afflicts nearly 6 million Americans, resulting in 1 million emergency department (ED) visits and over 1 million annual hospital discharges. The majority of inpatient admissions originate in the ED; thus, it is crucial that emergency physicians and other providers involved in early management understand the latest developments in diagnostic testing, therapeutics, and alternatives to hospitalization. This article discusses contemporary ED management as well as the necessary next steps for ED-based acute HF research.
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Affiliation(s)
- Sean P. Collins
- The Department of Emergency Medicine; Vanderbilt University; Nashville Veterans Affairs Medical Center; Nashville TN
| | - Alan B. Storrow
- The Department of Emergency Medicine; Vanderbilt University; Nashville Veterans Affairs Medical Center; Nashville TN
| | - Phillip D. Levy
- The Department of Emergency Medicine; Wayne State University; Detroit MI
| | - Nancy Albert
- The Division of Cardiology; Cleveland Clinic; Cleveland OH
| | - Javed Butler
- The Division of Cardiology; Emory University; Atlanta GA
| | | | | | - Gregory J. Fermann
- The Department of Emergency Medicine; University of Cincinnati; Cincinnati OH
| | - Gregg C. Fonarow
- The Division of Cardiology; Ronald Reagan-UCLA Medical Center; Los Angeles CA
| | | | - Brian Hiestand
- The Department of Emergency Medicine; Wake Forest University; Winston-Salem NC
| | - Judd E. Hollander
- The Department of Emergency Medicine; Thomas Jefferson University; Philadelphia PA
| | | | - Peter S. Pang
- The Department of Emergency Medicine; Northwestern University; Chicago IL
| | - W. Frank Peacock
- The Department of Emergency Medicine; Baylor University; Houston TX
| | - Douglas B. Sawyer
- The Department of Emergency Medicine; Vanderbilt University; Nashville Veterans Affairs Medical Center; Nashville TN
| | - John R. Teerlink
- The Division of Cardiology; San Francisco Veterans Affairs Medical Center; University of California at San Francisco; San Francisco CA
| | - Daniel J. Lenihan
- The Division of Cardiology; Vanderbilt University; Nashville Veterans Affairs Medical Center; Nashville TN
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Gadler F, Valzania C, Linde C. Current use of implantable electrical devices in Sweden: data from the Swedish pacemaker and implantable cardioverter-defibrillator registry. Europace 2014; 17:69-77. [PMID: 25336667 DOI: 10.1093/europace/euu233] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
AIMS The National Swedish Pacemaker and Implantable Cardioverter-Defibrillator (ICD) Registry collects prospective data on all pacemaker and ICD implants in Sweden. We aimed to report the 2012 findings of the Registry concerning electrical devices implantation rates and changes over time, 1 year complications, long-term device longevity and patient survival. METHODS AND RESULTS Forty-four Swedish implanting centres continuously contribute implantation of pacemakers and ICDs to the Registry by direct data entry on a specific website. Clinical and technical information on 2012 first implants and postoperative complications were analysed and compared with previous years. Patient survival data were obtained from the Swedish population register database. In 2012, the mean pacemaker and ICD first implantation rates were 697 and 136 per million inhabitants, respectively. The number of cardiac resynchronization therapy (CRT) first implantations/million capita was 41 (CRT pacemakers) and 55 (CRT defibrillators), with only a slight increase in CRT-ICD rate compared with 2011. Most device implantations were performed in men. Complication rates for pacemaker and ICD procedures were 5.3 and 10.1% at 1 year, respectively. Device and lead longevity differed among manufacturers. Pacemaker patients were older at the time of first implant and had generally worse survival rate than ICD patients (63 vs. 82% after 5 years). CONCLUSION Pacemaker and ICD implantation rates seem to have reached a level phase in Sweden. Implantable cardioverter-defibrillator and CRT implantation rates are very low and do not reflect guideline indications. Gender differences in CRT and ICD implantations are pronounced. Device and patient survival rates are variable, and should be considered when deciding device type.
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Affiliation(s)
- Fredrik Gadler
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Department of Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Cinzia Valzania
- Cardiovascular Department, S. Orsola Malpighi Hospital, University of Bologna, Bologna, Italy
| | - Cecilia Linde
- Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden Department of Medicine, Karolinska Institutet, Stockholm, Sweden
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Pang PS, Collins SP, Sauser K, Andrei AC, Storrow AB, Hollander JE, Tavares M, Spinar J, Macarie C, Raev D, Nowak R, Gheorghiade M, Mebazaa A. Assessment of dyspnea early in acute heart failure: patient characteristics and response differences between likert and visual analog scales. Acad Emerg Med 2014; 21:659-66. [PMID: 25039550 DOI: 10.1111/acem.12390] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Revised: 12/26/2013] [Accepted: 01/23/2014] [Indexed: 01/14/2023]
Abstract
BACKGROUND Dyspnea is the most common symptom in acute heart failure (AHF), yet how to best measure it has not been well defined. Prior studies demonstrate differences in dyspnea improvement across various measurement scales, yet these studies typically enroll patients well after the emergency department (ED) phase of management. OBJECTIVES The aim of this study was to determine predictors of early dyspnea improvement for three different, commonly used dyspnea scales (i.e., five-point absolute Likert scale, 10-cm visual analog scale [VAS], or seven-point relative Likert scale). METHODS This was a post hoc analysis of URGENT Dyspnea, an observational study of 776 patients in 17 countries enrolled within 1 hour of first physician encounter. Inclusion criteria were broad to reflect real-world clinical practice. Prior literature informed the a priori definition of clinically significant dyspnea improvement. Resampling-based multivariable models were created to determine patient characteristics significantly associated with dyspnea improvement. RESULTS Of the 524 AHF patients, approximately 40% of patients did not report substantial dyspnea improvement within the first 6 hours. Baseline characteristics were similar between those who did or did not improve, although there were differences in history of heart failure, coronary artery disease, and initial systolic blood pressure. For those who did improve, patient characteristics differed across all three scales, with the exception of baseline dyspnea severity for the VAS and five-point Likert scale (c-index ranged from 0.708 to 0.831 for each scale). CONCLUSIONS Predictors of early dyspnea improvement differ from scale to scale, with the exception of baseline dyspnea. Attempts to use one scale to capture the entirety of the dyspnea symptom may be insufficient.
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Affiliation(s)
- Peter S. Pang
- The Department of Emergency Medicine; the Center for Cardiovascular Innovation; Northwestern University Feinberg School of Medicine; Chicago IL
- Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL
- The Institute for Public Health and Medicine; Northwestern University Feinberg School of Medicine; Chicago IL
| | - Sean P. Collins
- The Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
- The Robert Wood Johnson Clinical Scholars Program; University of Michigan; Ann Arbor MI
| | - Kori Sauser
- The Robert Wood Johnson Clinical Scholars Program; University of Michigan; Ann Arbor MI
- The Department of Emergency Medicine; University of Michigan; Ann Arbor MI
- The Department of Veterans Affairs; VA Center for Clinical Management and Research; Ann Arbor VA Healthcare System; Ann Arbor MI
| | | | - Alan B. Storrow
- The Department of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
- The Robert Wood Johnson Clinical Scholars Program; University of Michigan; Ann Arbor MI
| | - Judd E. Hollander
- The Department of Emergency Medicine; University of Pennsylvania; Philadelphia PA
| | - Miguel Tavares
- The Department of Anesthesiology and Critical Care; Hospital Geral de Santo António; Porto Portugal
| | - Jindrich Spinar
- The University Hospital Brno; Internal Cardiology Department; Brno Czech Republic
| | - Cezar Macarie
- The Prof. Dr. C.C. Iliescu National Institute of Cardiovascular Diseases; Bucharest Romania
| | - Dimitar Raev
- The Departments of Medicine and Cardiology; University Hospital “St. Anna” (DR); Sofia Bulgaria
| | - Richard Nowak
- The Department of Emergency Medicine; Henry Ford Health System; Wayne State University; Detroit MI
| | - Mihai Gheorghiade
- Department of Medicine; Northwestern University Feinberg School of Medicine; Chicago IL
| | - Alexandre Mebazaa
- The Department of Anesthesiology and Critical Care Medicine; Hopital Lariboisiere; Paris France
- The University Paris Diderot; U942 INSERM; Paris France
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Abstract
Millions of patients are hospitalized for acute heart failure (AHF) every year throughout the world. Despite tremendous advances in cardiovascular care, morbidity and mortality for AHF remain high, consuming billions of health care dollars. With the aging of the population, the incidence and prevalence of HF is projected to increase. Yet, initial treatment of AHF today is similar to 40 years ago. Multiple studies have yielded new insights regarding initial management, with regards to both treatment and strategies of care. These advances will be reviewed in the context of initial or early AHF management. There remains, however, an unmet need to improve outcomes for AHF patients.
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Affiliation(s)
- Peter S Pang
- Department of Emergency Medicine, Northwestern University Feinberg School of Medicine, 211 E Ontario St, Suite 300, Chicago, IL 60611, USA
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