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Drak D, Fulcher J, Kilian J, Chong JJH, Grover R, Sindone AP, Adams M, Lattimore JD, Keech AC. Guideline-based audit of the hospital management of heart failure with reduced ejection fraction. Intern Med J 2023; 53:1595-1601. [PMID: 35666643 DOI: 10.1111/imj.15830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 05/26/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND Heart failure is a major burden in Australia in terms of morbidity, mortality and healthcare expenditure. Multiple evidence-based therapies are recommended for heart failure with reduced ejection fraction (HFrEF), but data on physician adherence to therapy guidelines are limited. AIM To compare use of HFrEF therapies against current evidence-based guidelines in an Australian hospital inpatient population. METHODS A retrospective review of patients admitted with a principal diagnosis of HFrEF across six metropolitan hospitals in Sydney, Australia, between January 2015 and June 2016. Use of medical and device therapies was compared with guideline recommendations using individual patient indications/contraindications. Readmission and mortality data were collected for a 1-year period following the admission. RESULTS Of the 1028 HFrEF patients identified, 39 were being managed with palliative intent, leaving 989 patients for the primary analysis. Use of beta-blockers (87.7% actual use/93.6% recommended use) and diuretics (88.4%/99.3%) was high among eligible patients. There were large evidence-practice gaps for angiotensin-converting enzyme inhibitors/angiotensin II receptor blockers (ACEI/ARB; 66.4%/89.0%) and aldosterone antagonists (41.0%/77.1%). In absolute terms, use of these therapies each increased by over 11% from admission. Ivabradine (11.5%/21.2%), automated internal cardiac defibrillators (29.5%/66.1%) and cardiac resynchronisation therapy (13.1%/28.7%) were used in a minority of eligible patients. Over the 1-year follow-up period, the mortality rate was 14.8%, and 44.2% of patients were readmitted to hospital at least once. CONCLUSION Hospitalisation is a key mechanism for initiation of HFrEF therapies. The large evidence-practice gaps for ACEI/ARB and aldosterone antagonists represent potential avenues for improved HFrEF management.
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Affiliation(s)
- Douglas Drak
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Jordan Fulcher
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, NHMRC Clinical Trials Centre, Sydney, New South Wales, Australia
| | - Jens Kilian
- Department of Cardiology, Bankstown-Lidcombe Hospital, Sydney, New South Wales, Australia
| | - James J H Chong
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Westmead Hospital, Sydney, New South Wales, Australia
- Centre for Heart Research, Westmead Institute for Medical Research, Sydney, New South Wales, Australia
| | - Rominder Grover
- Sydney Local Health District, Canterbury Hospital, Sydney, New South Wales, Australia
| | - Andrew P Sindone
- Heart Failure Unit, Department of Cardiac Rehabilitation, Concord Hospital, Sydney, New South Wales, Australia
| | - Mark Adams
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Jo-Dee Lattimore
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Anthony C Keech
- Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
- Department of Cardiology, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
- Faculty of Medicine and Health, University of Sydney, NHMRC Clinical Trials Centre, Sydney, New South Wales, Australia
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Sun LY, Zghebi SS, Eddeen AB, Liu PP, Lee DS, Tu K, Tobe SW, Kontopantelis E, Mamas MA. Derivation and External Validation of a Clinical Model to Predict Heart Failure Onset in Patients With Incident Diabetes. Diabetes Care 2022; 45:2737-2745. [PMID: 36107673 PMCID: PMC9862443 DOI: 10.2337/dc22-0894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 08/20/2022] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Heart failure (HF) often develops in patients with diabetes and is recognized for its role in increased cardiovascular morbidity and mortality in this population. Most existing models predict risk in patients with prevalent rather than incident diabetes and fail to account for sex differences in HF risk factors. We derived sex-specific models in Ontario, Canada to predict HF at diabetes onset and externally validated these models in the U.K. RESEARCH DESIGN AND METHODS Retrospective cohort study using international population-based data. Our derivation cohort comprised all Ontario residents aged ≥18 years who were diagnosed with diabetes between 2009 and 2018. Our validation cohort comprised U.K. patients aged ≥35 years who were diagnosed with diabetes between 2007 and 2017. Primary outcome was incident HF. Sex-stratified multivariable Fine and Gray subdistribution hazard models were constructed, with death as a competing event. RESULTS A total of 348,027 Ontarians (45% women) and 54,483 U.K. residents (45% women) were included. At 1, 5, and 9 years, respectively, in the external validation cohort, the C-statistics were 0.81 (95% CI 0.79-0.84), 0.79 (0.77-0.80), and 0.78 (0.76-0.79) for the female-specific model; and 0.78 (0.75-0.80), 0.77 (0.76-0.79), and 0.77 (0.75-0.79) for the male-specific model. The models were well-calibrated. Age, rurality, hypertension duration, hemoglobin, HbA1c, and cardiovascular diseases were common predictors in both sexes. Additionally, mood disorder and alcoholism (heavy drinker) were female-specific predictors, while income and liver disease were male-specific predictors. CONCLUSIONS Our findings highlight the importance of developing sex-specific models and represent an important step toward personalized lifestyle and pharmacologic prevention of future HF development.
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Affiliation(s)
- Louise Y. Sun
- Division of Cardiac Anesthesiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
- Department of Anesthesiology, Perioperative and Pain Medicine, Stanford University School of Medicine, Palo Alto, CA
| | - Salwa S. Zghebi
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester, U.K
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, U.K
| | - Anan Bader Eddeen
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
| | - Peter P. Liu
- Division of Cardiology, University of Ottawa Heart Institute, Ottawa, Ontario, Canada
| | - Douglas S. Lee
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
- Ted Rodgers Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Karen Tu
- Institute for Clinical Evaluation Sciences, Toronto, Ontario, Canada
- Ted Rodgers Cardiac Centre, University Health Network, Toronto, Ontario, Canada
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- North York General Hospital, Toronto, Ontario, Canada
| | - Sheldon W. Tobe
- Temerty Faculty of Medicine, University of Toronto, Toronto, Ontario, Canada
- Division of Nephrology, Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
- Northern Ontario School of Medicine, Sudbury, Ontario, Canada
| | - Evangelos Kontopantelis
- NIHR School for Primary Care Research, Centre for Primary Care and Health Services Research, Manchester Academic Health Science Centre (MAHSC), University of Manchester, Manchester, U.K
- Division of Population Health, Health Services Research and Primary Care, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, U.K
- Division of Informatics, Imaging and Data Sciences, School of Health Sciences, Faculty of Biology, Medicine and Health, Manchester Academic Health Science Centre, University of Manchester, Manchester, U.K
| | - Mamas A. Mamas
- Keele Cardiovascular Research Group, Centre for Prognosis Research, Institutes of Applied Clinical Science and Primary Care and Health Sciences, Keele University, Staffordshire, U.K
- Department of Cardiology, Royal Stoke University Hospital, Stoke-on-Trent, U.K
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García R, Muñoz MA, Navas E, Vinyoles E, Verdú-Rotellar JM, Del Val JL. Variability in Cardiovascular Risk Factor Control in Patients with Heart Failure According to Gender and Socioeconomic Status. J Womens Health (Larchmt) 2022; 31:690-697. [PMID: 35041531 DOI: 10.1089/jwh.2021.0404] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Background: Despite considerable evidence concerning heart failure (HF) risk factors, there is scarce information about the effect and degree of control regarding socioeconomic and gender inequalities. Methods: Cohort study including HF patients >40 years of age attended in 53 primary health care centers in Barcelona (Spain). Socioeconomic status (SES) was determined by an aggregated deprivation index (MEDEA) according to the neighborhood of residence. Logistic multivariable regression was performed to analyze differences in cardiovascular risk factor control, stratifying by SES and sex. Results: A total of 8235 HF patients were included. Mean age was 78.1 (standard deviation 10.2) years, and 56.0% were women. The most prevalent cardiovascular risk factors were hypertension, diabetes, and dyslipidemia. Blood pressure was the worst controlled factor in both genders with the lowest SES (odds ratio [OR] 0.56 95% confidence interval [CI] 0.56-0.71) and (OR 0.52, 0.46-0.71), respectively. In women, a social gradient was observed for glycemic and body mass index control, which were worse in the most unfavorable socioeconomic position (OR 0.54, 95% CI 0.38-0.77), and (OR 0.45, 95% CI 0.32-0.64), respectively. Men presented worse control of blood pressure (OR 0.55, 95% CI 0.42-0.71) and smoking habit (OR 0.67, 95% CI 0.47-0.90) in the most deprived socioeconomic bracket. Conclusions: Patients with HF in the most disadvantaged socioeconomic levels presented the worst degree of control for cardiovascular risk factors, and this negative effect was stronger in women.
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Affiliation(s)
- Raquel García
- Institut Català de la Salut, Barcelona, Spain.,Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Department of Pediatrics, Obstetrics and Ginecology and Preventive Medicine, School of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Miguel-Angel Muñoz
- Institut Català de la Salut, Barcelona, Spain.,Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain.,Department of Pediatrics, Obstetrics and Ginecology and Preventive Medicine, School of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - Elena Navas
- Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Ernest Vinyoles
- Institut Català de la Salut, Barcelona, Spain.,Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - Jose-Maria Verdú-Rotellar
- Institut Català de la Salut, Barcelona, Spain.,Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
| | - José-Luis Del Val
- Institut Català de la Salut, Barcelona, Spain.,Institut Universitari d'Investigació en Atenció Primària Jordi Gol (IDIAP Jordi Gol), Barcelona, Spain
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