Early Initiation of Sacubitril/Valsartan in Patients With Acute Heart Failure and Renal Dysfunction: An Analysis of the TRANSITION Study

BACKGROUND

Treatment of patients with heart failure with reduced ejection fraction (HFrEF) and renal dysfunction (RD) is challenging owing to the risk of further deterioration in renal function, especially after acute decompensated HF (ADHF).

METHODS AND RESULTS

We assessed the effect of RD (estimated glomerular filtration rate of ≥30 to <60 mL/min/1.73 m2) on initiation, up-titration, and tolerability of sacubitril/valsartan in hemodynamically stabilized patients with HFrEF admitted for ADHF (RD, n = 476; non-RD, n = 483). At week 10, the target dose of sacubitril/valsartan (97/103 mg twice daily) was achieved by 42% patients in RD subgroup vs 54% in non-RD patients (P < .001). Sacubitril/valsartan was associated with greater estimated glomerular filtration rate improvements in RD subgroup than non-RD (change from baseline least squares mean 4.1 mL/min/1.73 m2, 95% confidence interval 2.2-6.1, P < .001). Cardiac biomarkers improved significantly in both subgroups; however, compared with the RD subgroup, the improvement was greater in those without RD (N-terminal pro-brain natriuretic peptide, -28.6% vs -44.8%, high-sensitivity troponin T -20.3% vs -33.9%) (P < .001). Patients in the RD subgroup compared with those without RD experienced higher rates of hyperkalemia (16.3% vs 6.5%, P < .001), investigator-reported cardiac failure (9.7% vs 5.6%, P = .029), and renal impairment (6.4% vs 2.1%, P = .002).

CONCLUSIONS

Most patients with HFrEF and concomitant RD hospitalized for ADHF tolerated early initiation of sacubitril/valsartan and showed significant improvements in estimated glomerular filtration rate and cardiac biomarkers.

CLINICAL TRIAL REGISTRATION

NCT02661217.

Heart and lung aquaporins play a major role in severity of heart failure with preserved ejection fraction in mice and differs between comorbidities

Introduction

Heart failure (HF) is a major public health problem worldwide. To date, HF with preserved ejection fraction (EF, HFpEF) represents half of all HF patients and its prevalence is increasing. HFpEF is associated with multiple comorbidities, including diabetes mellitus, pulmonary and systemic hypertension and obesity, mainly in elderly population. Accurately phenotyping HFpEF is crucial for the development of new therapies, appropriate patient stratification and the implementation of a personalised medicine. Cardiac and pulmonary remodelling play a major role in HFpEF severity but the specific mechanisms underlying cardiac failure and lung congestion, the last stage in HFpEF, in each comorbidity are incompletely understood, precluding the development of effective therapies. Aquaporins (AQP) are membrane proteins serving as water channels across the plasma membrane and control intra- and extracellular fluid volume and prompt to tissue oedema in many organs. However, its specific contribution in HFpEF has not been explored.

Purpose

We aimed to identify cardiac and pulmonary molecular changes associated to dysfunction and oedema in HFpEF, specific for each comorbidity.

Methods

A total of 48 C57BL/6 mice 10 weeks old were randomised to the following groups: control (Ctl; n=9), type I diabetes (Db; n=9), chronic hypoxia (PAH; n=10), obesity (Ob; n=10) and systemic arterial hypertension (SAH; n=10). Mice were followed for up to 2.5 years by echocardiography and lung ultrasound until they developed pulmonary oedema (HF) or died naturally. Lungs and heart were extracted and changes were determined by proteomic, immunohistochemistry and qRT-PCR.

Results

Diastolic dysfunction was observed in all comorbidities and above 50% of those mice developed HF. Db presented the highest ratio in developing HF. Db also showed the earliest mortality (47 weeks), whereas PAH, Ob and SAH mice survived for 82, 92 and 99 weeks, respectively (p&lt;0.001 vs Ctl). A common finding in all groups was the development of different degrees o perivascular fibrosis. Db mice, the HFpEF severest group, showed an increase in pulmonary AQP1 and 5 (p&lt;0.05 and p&lt;0.001, respectively, vs Ctl). Upregulation of AQPs correlated with increased ventricular filling pressures (E/E', r2=07). Cardiac AQP4 was also markedly elevated in Db mice in left and right ventricle (p&lt;0.001 and p=0.01, respectively, vs Ctl).

Conclusion

Increased AQPs in the lung is associated with a more aggressive development of congestion and HFpEF. In addition, increased AQP4 in the heart in the most aggressive form of HFpEF suggests a relevant role in cardiac oedema. Targeting AQPs in HFpEF may prevent oedema and decompensation.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): This study was supported from the Spanish Ministerio de Economía y Competitividad (RTI2018-096961-B-I00, SAF2015-65722-R and SAF2012-31451 to E.L-P. and Juan de la Cierva Incorporaciόn to M,V-O). The CNIC is supported by the Ministerio de Ciencia, Innovaciόn y Universidades (MCNU) and the Pro CNIC Foundation, and is a Severo Ochoa Center of Excellence (SEV-2015-0505).

1410Clinical predictors of NT-proBNP response to early initiation of sacubitril/valsartan after hospitalisation for decompensated heart failure: An analysis of the TRANSITION study

Background

NT-proBNP has diagnostic and prognostic value in patients with heart failure (HF). Compared with enalapril, sacubitril/valsartan (S/V) significantly reduced NT-proBNP within 1 week (wk) of administration and reduced HF re-hospitalisation in patients with acute decompensated HF (ADHF) in PIONEER-HF. Identification of predictors of NT-proBNP reduction with S/V could aid prognostication following hospitalisation.

Methods

TRANSITION (NCT02661217) is an open label study in stabilised ADHF patients with HFrEF that compared S/V initiation pre- versus post-discharge (within 2 wk of discharge). Baseline NT-proBNP was measured at randomisation in both S/V groups (n=950). Clinical predictors of favourable response of NT-proBNP to S/V therapy (defined as reduction to <1000 pg/ml or >30% reduction vs. baseline) were studied at discharge, 4 wk and 10 wk post-randomisation.

Results

Median NT-proBNP at randomisation was similar in patients with S/V started pre- and post-discharge (1919 vs 1659 pg/ml). In patients receiving S/V in-hospital, NT-proBNP was reduced by 28% at discharge, compared to a 3% reduction in patients receiving optimised standard of care (between group p<0.001). A favorable response was reached in 46% vs 18% patients at discharge, 46% vs 42% at 4 weeks and 51% vs 48% at 10 weeks in pre- vs post-discharge groups. (Figure 1). Predictors of favourable NT-proBNP response to S/V at discharge were hypertension and shorter time from admission to first S/V dose. At 4 wk after randomisation, NT-proBNP was reduced similarly in patients started on S/V pre- and post-discharge. When the two S/V initiation groups were combined, predictors of favorable NT-proBNP response at 4 wk were higher initial dose of S/V (≥49/51 mg b.i.d.), higher baseline levels of NT-proBNP, de novo HF hospitalisation, ACEI/ARB naïve, lower baseline creatinine, no atrial fibrillation (AFib), no prior myocardial infarction (MI). A further reduction in NT-proBNP was seen at 10 wk post-randomisation in patients started on S/V pre- and post-discharge (38% vs 34%, between group p=0.250). Predictors of favourable NT-proBNP response to S/V were similar at 4 wk and 10 wk post-randomisation.

Conclusion

In-hospital initiation of sacubitril/valsartan shortly after stabilisation was associated with a prompt improvement of NT-proBNP already at discharge, whereas higher baseline levels of NT-proBNP, higher starting dose, absence of AFib and MI history, de novo HF and ACEI/ARB naïve status were associated with favourable NT-proBNP response in the vulnerable phase after discharge.

Acknowledgement/Funding

The TRANSITION study was funded by Novartis

P2620PIONEER-HF criteria ready for the prime time? Data from REDINSCOR II registry

Background

New treatment strategies are needed to improve the prognosis in acute heart failure (AHF), recently PIONEER-HF results have been published showing in a selected group of patients a potential use of sacubitril/valsartan with safety in this scenario

Purpose

To evaluate the impact of PIONEER-HF potential indication in daily practice after AHF hospitalization at discharge

Methods

We included a subgroup of 909 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentre, prospective registry with the complete data for this analysis. In the trial left ventricular ejection fraction (LVEF) ≤40% and natriuretic peptides at admission with values of NT-ProBNP≥1600 pg/ml were needed to be included. The clinical and analytic stability at discharge to safely start sacubitril/valsartan was considered as MDRD estimated Glomerular Filtration Rate≥30 mL/min/1.73 m2, Systolic Blood Pressure ≥100 mmHg and Potassium ≤5.2 mmol/L.

Results

The mean age was 72.1±12.01 years. Of these, 373 (38.8%) were female, 734 (76,6%) were hypertensive, 462 (48.2%) had diabetes and 282 (29.9%) coronary artery disease. At admission atrial fibrillation was found in 403 patients (40.1%) and 409 (45%) had reduced LVEF. The mean levels of NT-ProBNP 7259.4±9437.1 pg/ml. In this group of patients, the in-hospital mortality was 28 (2.9%) and the 1 year follow up mortality was 197 (20.5%) and the heart failure rehospitalizations in 1 year were 303 (31,5%). In table 1 the percentage of patients that fulfil the needed criteria for the application of PIONEER HF is shown. In our registry 235 patients (25.9%) could be potential users of sacubitril/valsartan after the acute phase of hospitalization

Table 1 Elements to stablish indication Number of patients (%) NT-ProBNP ≥1600 pg/ml at admission 730 (80.3%) MDRD estimated GFR ≥30 mL/min/1.73 m2 at discharge 798 (87.8%) Systolic Blood Pressure ≥100 mmHg at discharge 755 (83.1%) Serum Potassium ≤5.2 mmol/L at discharge 856 (94.2%) Clinical and analytic stability at discharge 636 (70%) Left ventricular ejection fraction ≤40% 409 (45%) PIONEER HF Criteria 235 (25.9%) GFR: Glomerular Filtration Rate.

Conclusions

In our cohort of AHF patients around 1 out 4 could be treated with sacubitril/valsartan at discharge if we apply the PIONEER HF criteria in a contemporary setting, this finding could have potential implications in the prognosis and current costs of care in a population with high morbidity and mortality.

Acknowledgement/Funding

Heart Failure Program of the Red de Investigaciόn Cardiovascular del Instituto de Salud Carlos III, Madrid, Spain (RD12/0042) and FEDER

P4535Discharge treatment with ACE inhibitor/ARB after a heart failure hospitalization is associated with a better prognosis irrespectively of left ventricular ejection fraction

Background

Medical therapy could improve the prognosis of real-life patients discharged after a heart failure (HF) hospitalization.

Purpose

We aimed to determine the impact of discharge HF treatment on mortality and readmissions in different left ventricular ejection fraction (LVEF) groups.

Methods

Multicentre prospective registry in 20 Spanish hospitals. Patients were enrolled after a HF hospitalization.

Results

A total of 1831 patients were included (583 [31.8%] HF with reduced ejection fraction [HFrEF]; 227 [12.4%] HF with midrange ejection fraction [HFmrEF]; 610 [33.3%] HF with preserved ejection fraction [HFpEF], and 411 [22.4%] with unknown LVEF. Angiotensin-converting enzyme (ACE) inhibitors/Angiotensin II receptor blockers (ARB) at discharge were independently associated with a reduction in: i) all-cause mortality: hazard ratio (HR) 0.55, 95% confidence interval (CI) 0.41–0.74, P<0.001, with a similar effect in the four groups; ii) mortality due to refractory HF HR 0.45, 95% CI 0.29–0.64, P<0.001, with a similar effect in the three groups with known LVEF; iii) mortality/HF admissions (HR 0.61; 95% CI: 0.50–0.74), more evident in HFrEF (HR 0.54; 95% CI: 0.38–0.78) compared to HRmEF (HR 0.64; 95% CI 0.40–1.02), orHFpEF (HR 0.70; 95% CI 0.53–0.92).Inpatients with HFrEFtriple therapy (ACE inhibitor/ARB+ betablocker+ mineralocorticoid receptor antagonist) was associated with the lowest mortality risk (HR 0.21; 95% CI: 0.08–0.57, P=0.002) compared to patients that received none of these drugs.

Events according to the number of drugs – HFrEF (n=583) 0 (n=14) 1 (n=98) 2 (n=160) 3 (n=294) P Death or heart failure readmissions 10 (71.4) 58 (59.2) 66 (41.3) 106 (36.1) <0.001 All-cause mortality 9 (64.3) 28 (28.6) 31 (19.4) 36 (12.2) <0.001 Mortality due to refractory heart failure 7 (50.0) 14 (14.3) 17 (10.6) 17 (5.8) <0.001 – HFmrEF (n=227) 0 (n=18) 1 (n=57) 2 (n=81) 3 (n=65) P Death or heart failure readmissions 9 (50.0) 35 (61.4) 34 (42.0) 25 (38.5) 0.057 All-cause mortality 5 (27.8) 18 (31.6) 15 (18.5) 11 (16.9) 0.191 Mortality due to refractory heart failure 3 (16.7) 7 (12.3) 7 (8.6) 4 (6.2) 0.475 – HFpEF (n=610) 0 (n=61) 1 (n=242) 2 (n=219) 3 (n=69) P Death or heart failure readmissions 32 (52.5) 97 (40.1) 89 (40.6) 20 (29.0) 0.057 All-cause mortality 20 (32.8) 41 (16.9) 32 (14.6) 10 (14.5) 0.017 Mortality due to refractory heart failure 11 (18.0) 18 (7.4) 13 (5.9) 4 (5.8) 0.041 Outcomes according to the number of medications at discharge.

Kaplan-Meier Curves for study outcomes

Conclusions

Discharge treatment with ACE inhibitor/ARB after a HF hospitalization is associated with a reduction in all-cause and refractory HF mortality, irrespectively of LVEF.

P773Initiation of sacubitril/valsartan and optimisation of evidence-based heart failure therapies after hospitalisation for acute decompensated heart failure: An analysis of the TRANSITION study

Background

Optimisation of chronic heart failure (HF) therapy remains the key strategy to improve outcomes after hospitalisation for acute decompensated HF (ADHF) with reduced ejection fraction (HFrEF). Initiation and uptitration of disease-modifying therapies is challenging in this vulnerable patient population. We aimed to describe the patterns of treatment optimisation including sacubitril/valsartan (S/V) in the TRANSITION study.

Methods

TRANSITION (NCT02661217) was a randomised, open-label study comparing S/V initiation pre- vs. post-discharge (1–14 days) in patients admitted for ADHF after haemodynamic stabilisation. The primary endpoint was the proportion of patients achieving 97/103 mg S/V twice daily (bid) at 10 weeks post-randomisation. Up-titration of S/V was as per label. Information on dose of S/V and on the use of concomitant HF medication was collected at each study visit up to week 26.

Results

A total of 493 patients received at least one dose of S/V in the pre-discharge arm and 489 patients in the post-discharge arm. One month after randomisation, 45% of patients in the pre-d/c arm vs. 44% in the post-discharge arm used 24/26 mg bid starting dose and 42% vs. 40% were on 49/51 mg S/V bid, respectively. At week 10, 47% of patients had achieved the target dose in the pre-discharge arm vs. 51% in the post-discharge arm. At the end of the follow-up at 26 weeks, the proportion of patients on S/V target dose further increased to 53% in the pre-discharge and 61% in the post-discharge arm (Figure 1). At week 10, the mean dose of S/V was 132 mg in the pre-discharge arm and 136 mg in the post-discharge arm, and at week 26, it was 140 mg and 147 mg, respectively.

Before hospital admission, 52% and 54% of the patients received a beta-blocker (BB) in the pre-discharge and post-discharge group, respectively, and 42% in both arms received a mineralcorticoid receptor antagonist (MRA). At time of discharge, 68% and 71%% of the patients received a BB and 68% and 65% an MRA, in the pre-discharge and post-discharge groups, respectively. These proportions remained stable to week 10 and week 26.

Uptitration of sacubitril/valsartan

Conclusions

In the vulnerable post-ADHF population, initiation of S/V and up-titration to target dose was feasible within 10 weeks in half of the patients alongside with a 20% increase in the use of other disease-modifying medications that remained stable through the end of the 6-month follow-up.

Acknowledgement/Funding

The TRANSITION study was funded by Novartis

P1637Rehospitalisations during 26 weeks of follow up from initiation of sacubitril/valsartan after acute decompensated heart failure: An analysis of the TRANSITION study

Background

Patients with acute decompensated heart failure (ADHF) are at high risk of recurrent hospitalisations and death. In-hospital initiation of sacubitril/valsartan (S/V) reduced the risk for HF re-hospitalisation by 44% compared to enalapril in the PIONEER-HF study during the 8-week follow-up period. We aimed to describe the pattern of readmissions and their causes in the TRANSITION study, which randomised participants to pre-discharge or post-discharge initation of S/V.

Methods

TRANSITION (NCT02661217) was a randomised, open-label study comparing S/V initiation pre- vs. post-discharge (1–14 days) in haemodynamically stabilised patients with HF with reduced ejection fraction, admitted for ADHF. The primary endpoint was the proportion of patients achieving 97/103 mg S/V twice daily at 10 weeks post-randomisation. Information on rehospitalisation was collected throughout the study up to 26 weeks.

Results

A total of 493 patients received S/V in the pre-discharge arm and 489 patients in the post-discharge arm. Readmissions due to any cause were reported in 9.7% and 18.1% in the pre-discharge arm vs. 10.6% and 21.3% in the post-discharge arm within 30 days, and 10 weeks respectively. During the 26-weeks follow-up, all-cause readmission was reported in 34.5% of patients in the pre-discharge arm vs. 34.6% in the post-discharge arm. Median time to first rehospitalisation was 67 days in the pre-discharge arm (IQR: 26–110 days) and 50 days (IQR: 23–108 days) in the post-discharge arm. At least one HF hospitalisation was reported in 7.5% of patients in the pre-discharge arm and 7.4% in the post-discharge arm during 10 weeks and in 11.8% and 12.3% of patients, respectively, during 26 weeks of follow-up. Median duration of HF readmission was 7 days (IQR: 4–11 days) in the pre-discharge group and 6.5 days (IQR: 6.5–10 days) in the post-discharge arm. In total 2.6% and 5.5% patients in pre-discharge arm and 3.9% and 7% in the post-discharge arm visited an emergency room during 10 weeks and 26 weeks, respectively.

Conclusions

Initiation of S/V in patients hospitalised for ADHF either before or shortly after discharge, results in comparable rates of all cause and HF rehospitalisations, as well as emergency room visits without hospital admission over the 26 week follow-up period. HF re-hospitalisations rates at 10 weeks in TRANSITION are in line with the 8% in S/V arm reported in PIONEER-HF during the 8-weeks follow-up.

Acknowledgement/Funding

The TRANSITION study was funded by Novartis

P6361Prognostic value of discharge heart rate in acute heart failure patients: more relevant in atrial fibrillation?

Background

The prognostic impact of heart rate (HR) in acute heart failure (AHF) patients is not well known especially in atrial fibrillation (AF) patients.

Purpose

The aim of the study was to evaluate the impact of admission HR, discharge HR, HR difference (HRD) (admission- discharge) in AHF patients with sinus rhythm (SR) or AF on long- term outcomes.

Methods

We included 1398 patients consecutively admitted with AHF between October 2013 and December 2014 from a national multicentric, prospective registry. Logistic regression models were used to estimate the association between admission HR, discharge HR and HR difference and one- year all-cause mortality and HF readmission.

Results

The mean age of the study population was 72±12 years. Of these, 594 (42.4%) were female, 655 (77.8%) were hypertensive and 655 (46.8%) had diabetes. Among all included patients, 745 (53.2%) had sinus rhythm and 653 (46.7%) had atrial fibrillation. Only discharge HR was associated with one-year all-cause mortality (Relative risk (RR)= 1.182, confidence interval (CI) 95% 1.024–1.366, p=0.022) in SR. In AF patients discharge HR was associated with one-year all-cause mortality (RR= 1.276, CI 95% 1.115–1.459, p≤0.001). We did not observe a prognostic effect of admission HR or HRD on long-term outcomes in both groups. This relationship is not dependent on left ventricular ejection fraction (Figure 1)

Effect of post-discharge heart rate

Conclusions

In AHF patients lower discharge HR, neither the admission nor the difference, is associated with better long-term outcomes especially in AF patients

Acknowledgement/Funding

Heart Failure Program of the Red de Investigaciόn Cardiovascular del Instituto de Salud Carlos III, Madrid, Spain (RD12/0042) and the Fondo Europeo de

Lung cancer after heart transplantation: results from a large multicenter registry

In this study we analyzed Spanish Post-Heart-Transplant Tumour Registry data for adult heart transplantation (HT) patients since 1984. Median post-HT follow-up of 4357 patients was 6.7 years. Lung cancer (mainly squamous cell or adenocarcinoma) was diagnosed in 102 (14.0% of patients developing cancers) a mean 6.4 years post-HT. Incidence increased with age at HT from 149 per 100 000 person-years among under-45s to 542 among over-64s; was 4.6 times greater among men than women; and was four times greater among pre-HT smokers (2169 patients) than nonsmokers (2188). The incidence rates in age-at-diagnosis groups with more than one case were significantly greater than GLOBOCAN 2002 estimates for the general Spanish population, and comparison with published data on smoking and lung cancer in the general population suggests that this increase was not due to a greater prevalence of smokers or former smokers among HT patients. Curative surgery, performed in 21 of the 28 operable cases, increased Kaplan-Meier 2-year survival to 70% versus 16% among inoperable patients.