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Cunningham JW, Claggett BL, Lopes RD, McMurray JJV, Perkovic V, Carroll K, Hiemstra T, Khavandi K, Lukas MA, Ranganathan P, Shannon J, van Adelsberg J, Singh AK, Solomon SD. Daprodustat and Heart Failure in CKD. J Am Soc Nephrol 2024:00001751-990000000-00263. [PMID: 38383961 DOI: 10.1681/asn.0000000000000321] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2023] [Accepted: 02/19/2024] [Indexed: 02/23/2024] Open
Abstract
Key Points
Patients with CKD face meaningful risk of heart failure hospitalization.Daprodustat compared with darbepoetin was associated with a nonsignificantly greater number of heart failure hospitalizations in non-dialysis patients.
Background
Patients with CKD are at higher risk of heart failure. The hypoxia-inducible factor prolyl hydroxylase inhibitor daprodustat is an orally acting alternative to conventional injectable erythropoietin-stimulating agents (ESAs) for the treatment of anemia in patients with CKD. Whether daprodustat affects the risk of heart failure hospitalization is unknown.
Methods
The Anemia Studies in Chronic Kidney Disease: Erythropoiesis via a Novel Prolyl Hydroxylase Inhibitor Daprodustat–Dialysis (ASCEND-D; n=2964) and Anemia Studies in Chronic Kidney Disease: Erythropoiesis via a Novel Prolyl Hydroxylase Inhibitor Daprodustat–Non-Dialysis (ASCEND-ND; n=3872) trials compared daprodustat with conventional ESA in patients with anemia of CKD who did or did not require dialysis, respectively. We identified risk factors of heart failure hospitalization and assessed the effect of daprodustat compared with conventional ESA on heart failure hospitalizations.
Results
History of heart failure, diabetes, and higher systolic BP were independently associated with heart failure hospitalization in both trials, irrespective of treatment assignment. The number of first heart failure hospitalizations was greater in the daprodustat arm in patients not receiving dialysis (hazard ratio [HR], 1.22 [95% confidence interval (CI), 0.95 to 1.56], P = 0.12) and in patients receiving dialysis (HR, 1.10 [95% CI, 0.84 to 1.45], P = 0.47), although these differences were not statistically significant. HRs in patients with and without history of heart failure were 1.37 (95% CI, 0.89 to 2.11) versus 1.08 (95% CI, 0.79 to 1.46) (P-interaction=0.36) in the ASCEND-ND trial and 1.52 (95% CI, 0.97 to 2.38) versus 0.93 (95% CI, 0.66 to 1.30) (P-interaction=0.09) in the ASCEND-D trial, respectively. In post hoc analyses, daprodustat increased total (first and recurrent) heart failure hospitalizations in participants not receiving dialysis (rate ratio, 1.46 [95% CI, 1.11 to 1.92], P = 0.007) but not in participants receiving dialysis (rate ratio, 1.01 [95% CI, 0.74 to 1.39], P = 0.93). Daprodustat did not significantly affect the risk of a composite outcome of first heart failure hospitalization or death.
Conclusions
A greater number of first heart failure hospitalization events occurred in patients treated with daprodustat compared with conventional ESA, but this difference did not reach statistical significance. Differences in the number of heart failure hospitalization events were most apparent in patients not receiving dialysis and in patients with history of heart failure.
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Affiliation(s)
| | - Brian L Claggett
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Renato D Lopes
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Vlado Perkovic
- University of New South Wales, Sydney, New South Wales, Australia
| | | | | | | | | | | | | | | | - Ajay K Singh
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - Scott D Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
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Cunningham JW, Singh P, Reeder C, Claggett B, Marti-Castellote PM, Lau ES, Khurshid S, Batra P, Lubitz SA, Maddah M, Philippakis A, Desai AS, Ellinor PT, Vardeny O, Solomon SD, Ho JE. Natural Language Processing for Adjudication of Heart Failure in a Multicenter Clinical Trial: A Secondary Analysis of a Randomized Clinical Trial. JAMA Cardiol 2024; 9:174-181. [PMID: 37950744 PMCID: PMC10640703 DOI: 10.1001/jamacardio.2023.4859] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 10/29/2023] [Indexed: 11/13/2023]
Abstract
Importance The gold standard for outcome adjudication in clinical trials is medical record review by a physician clinical events committee (CEC), which requires substantial time and expertise. Automated adjudication of medical records by natural language processing (NLP) may offer a more resource-efficient alternative but this approach has not been validated in a multicenter setting. Objective To externally validate the Community Care Cohort Project (C3PO) NLP model for heart failure (HF) hospitalization adjudication, which was previously developed and tested within one health care system, compared to gold-standard CEC adjudication in a multicenter clinical trial. Design, Setting, and Participants This was a retrospective analysis of the Influenza Vaccine to Effectively Stop Cardio Thoracic Events and Decompensated Heart Failure (INVESTED) trial, which compared 2 influenza vaccines in 5260 participants with cardiovascular disease at 157 sites in the US and Canada between September 2016 and January 2019. Analysis was performed from November 2022 to October 2023. Exposures Individual sites submitted medical records for each hospitalization. The central INVESTED CEC and the C3PO NLP model independently adjudicated whether the cause of hospitalization was HF using the prepared hospitalization dossier. The C3PO NLP model was fine-tuned (C3PO + INVESTED) and a de novo NLP model was trained using half the INVESTED hospitalizations. Main Outcomes and Measures Concordance between the C3PO NLP model HF adjudication and the gold-standard INVESTED CEC adjudication was measured by raw agreement, κ, sensitivity, and specificity. The fine-tuned and de novo INVESTED NLP models were evaluated in an internal validation cohort not used for training. Results Among 4060 hospitalizations in 1973 patients (mean [SD] age, 66.4 [13.2] years; 514 [27.4%] female and 1432 [72.6%] male]), 1074 hospitalizations (26%) were adjudicated as HF by the CEC. There was good agreement between the C3PO NLP and CEC HF adjudications (raw agreement, 87% [95% CI, 86-88]; κ, 0.69 [95% CI, 0.66-0.72]). C3PO NLP model sensitivity was 94% (95% CI, 92-95) and specificity was 84% (95% CI, 83-85). The fine-tuned C3PO and de novo NLP models demonstrated agreement of 93% (95% CI, 92-94) and κ of 0.82 (95% CI, 0.77-0.86) and 0.83 (95% CI, 0.79-0.87), respectively, vs the CEC. CEC reviewer interrater reproducibility was 94% (95% CI, 93-95; κ, 0.85 [95% CI, 0.80-0.89]). Conclusions and Relevance The C3PO NLP model developed within 1 health care system identified HF events with good agreement relative to the gold-standard CEC in an external multicenter clinical trial. Fine-tuning the model improved agreement and approximated human reproducibility. Further study is needed to determine whether NLP will improve the efficiency of future multicenter clinical trials by identifying clinical events at scale.
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Affiliation(s)
- Jonathan W. Cunningham
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge
| | - Pulkit Singh
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge
| | - Christopher Reeder
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Emily S. Lau
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge
- Division of Cardiology, Massachusetts General Hospital, Boston
| | - Shaan Khurshid
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - Puneet Batra
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge
| | - Steven A. Lubitz
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - Mahnaz Maddah
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge
| | - Anthony Philippakis
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge
| | - Akshay S. Desai
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Patrick T. Ellinor
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston
| | - Orly Vardeny
- Minneapolis VA Hospital, University of Minnesota, Minneapolis
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer E. Ho
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Chatur S, Vaduganathan M, Claggett BL, Cunningham JW, Docherty KF, Desai AS, Jhund PS, de Boer RA, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CS, Martinez FA, Shah SJ, Petersson M, Langkilde AM, McMurray JJ, Solomon SD. Outpatient Worsening Among Patients With Mildly Reduced and Preserved Ejection Fraction Heart Failure in the DELIVER Trial. Circulation 2023; 148:1735-1745. [PMID: 37632455 PMCID: PMC10664793 DOI: 10.1161/circulationaha.123.066506] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Accepted: 08/21/2023] [Indexed: 08/28/2023]
Abstract
BACKGROUND Hospitalization is recognized as a sentinel event in the disease trajectory of patients with heart failure (HF), but not all patients experiencing clinical decompensation are ultimately hospitalized. Outpatient intensification of diuretics is common in response to symptoms of worsening HF, yet its prognostic and clinical relevance, specifically for patients with HF with mildly reduced or preserved ejection fraction, is uncertain. METHODS In this prespecified analysis of the DELIVER trial (Dapagliflozin Evaluation to Improve the Lives of Patients With Preserved Ejection Fraction Heart Failure), we assessed the association between various nonfatal worsening HF events (those requiring hospitalization, urgent outpatient visits requiring intravenous HF therapies, and outpatient oral diuretic intensification) and rates of subsequent mortality. We further examined the treatment effect of dapagliflozin on an expanded composite end point of cardiovascular death, HF hospitalization, urgent HF visit, or outpatient oral diuretic intensification. RESULTS In DELIVER, 4532 (72%) patients experienced no worsening HF event, whereas 789 (13%) had outpatient oral diuretic intensification, 86 (1%) required an urgent HF visit, 585 (9%) had an HF hospitalization, and 271 (4%) died of cardiovascular causes as a first presentation. Patients with a first presentation manifesting as outpatient oral diuretic intensification experienced rates of subsequent mortality that were higher (10 [8-12] per 100 patient-years) than those without a worsening HF event (4 [3-4] per 100 patient-years) but similar to rates of subsequent death after an urgent HF visit (10 [6-18] per 100 patient-years). Patients with an HF hospitalization as a first presentation of worsening HF had the highest rates of subsequent death (35 [31-40] per 100 patient-years). The addition of outpatient diuretic intensification to the adjudicated DELIVER primary end point (cardiovascular death, HF hospitalization, or urgent HF visit) increased the overall number of patients experiencing an event from 1122 to 1731 (a 54% increase). Dapagliflozin reduced the need for outpatient diuretic intensification alone (hazard ratio, 0.72 [95% CI, 0.64-0.82]) and when analyzed as a part of an expanded composite end point of worsening HF or cardiovascular death (hazard ratio, 0.76 [95% CI, 0.69-0.84]). CONCLUSIONS In patients with HF with mildly reduced or preserved ejection fraction, worsening HF requiring oral diuretic intensification in ambulatory care was frequent, adversely prognostic, and significantly reduced by dapagliflozin. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03619213.
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Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Brian L. Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Jonathan W. Cunningham
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Kieran F. Docherty
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
| | - Akshay S. Desai
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
| | - Pardeep S. Jhund
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
| | - Rudolf A. de Boer
- Erasmus Medical Center, Department of Cardiology, Rotterdam, the Netherlands (R.A.d.B.)
| | | | | | - Mikhail N. Kosiborod
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City (M.N.K.)
| | - Carolyn S.P. Lam
- National Heart Centre Singapore & Duke-National University of Singapore (C.S.P.L.)
| | | | - Sanjiv J. Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (M.P., A.M.K.)
| | - Anna Maria Langkilde
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
- Erasmus Medical Center, Department of Cardiology, Rotterdam, the Netherlands (R.A.d.B.)
- Duke University Medical Center, Durham, NC (A.F.H.)
- Yale School of Medicine, New Haven, CT (S.E.I.)
- Saint Luke’s Mid America Heart Institute and University of Missouri-Kansas City (M.N.K.)
- National Heart Centre Singapore & Duke-National University of Singapore (C.S.P.L.)
- Universidad Nacional de Córdoba, Argentina (F.A.M.)
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden (M.P., A.M.K.)
| | - John J.V. McMurray
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Scotland (K.F.D., P.S.J., J.J.V.M.)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA (S.C., M.V., B.L.C., J.W.C., A.S.D., S.D.S.)
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Cunningham JW, Singh P, Reeder C, Claggett B, Marti-Castellote PM, Lau ES, Khurshid S, Batra P, Lubitz SA, Maddah M, Philippakis A, Desai AS, Ellinor PT, Vardeny O, Solomon SD, Ho JE. Natural Language Processing for Adjudication of Heart Failure Hospitalizations in a Multi-Center Clinical Trial. medRxiv 2023:2023.08.17.23294234. [PMID: 37662283 PMCID: PMC10473787 DOI: 10.1101/2023.08.17.23294234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/05/2023]
Abstract
Background The gold standard for outcome adjudication in clinical trials is chart review by a physician clinical events committee (CEC), which requires substantial time and expertise. Automated adjudication by natural language processing (NLP) may offer a more resource-efficient alternative. We previously showed that the Community Care Cohort Project (C3PO) NLP model adjudicates heart failure (HF) hospitalizations accurately within one healthcare system. Methods This study externally validated the C3PO NLP model against CEC adjudication in the INVESTED trial. INVESTED compared influenza vaccination formulations in 5260 patients with cardiovascular disease at 157 North American sites. A central CEC adjudicated the cause of hospitalizations from medical records. We applied the C3PO NLP model to medical records from 4060 INVESTED hospitalizations and evaluated agreement between the NLP and final consensus CEC HF adjudications. We then fine-tuned the C3PO NLP model (C3PO+INVESTED) and trained a de novo model using half the INVESTED hospitalizations, and evaluated these models in the other half. NLP performance was benchmarked to CEC reviewer inter-rater reproducibility. Results 1074 hospitalizations (26%) were adjudicated as HF by the CEC. There was high agreement between the C3PO NLP and CEC HF adjudications (agreement 87%, kappa statistic 0.69). C3PO NLP model sensitivity was 94% and specificity was 84%. The fine-tuned C3PO and de novo NLP models demonstrated agreement of 93% and kappa of 0.82 and 0.83, respectively. CEC reviewer inter-rater reproducibility was 94% (kappa 0.85). Conclusion Our NLP model developed within a single healthcare system accurately identified HF events relative to the gold-standard CEC in an external multi-center clinical trial. Fine-tuning the model improved agreement and approximated human reproducibility. NLP may improve the efficiency of future multi-center clinical trials by accurately identifying clinical events at scale.
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Affiliation(s)
- Jonathan W. Cunningham
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Pulkit Singh
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Christopher Reeder
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Brian Claggett
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | | | - Emily S. Lau
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge, Massachusetts
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Shaan Khurshid
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, Massachusetts
| | - Puneet Batra
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Steven A. Lubitz
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, Massachusetts
| | - Mahnaz Maddah
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Anthony Philippakis
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, Massachusetts
| | - Akshay S. Desai
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Patrick T. Ellinor
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge, Massachusetts
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, Massachusetts
| | - Orly Vardeny
- Minneapolis VA Hospital, University of Minnesota, Minneapolis, Minnesota
| | - Scott D. Solomon
- Division of Cardiovascular Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jennifer E. Ho
- Cardiovascular Disease Initiative, Broad Institute of Harvard University and the Massachusetts Institute of Technology, Cambridge, Massachusetts
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
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Giro P, Cunningham JW, Rasmussen-Torvik L, Bielinski SJ, Larson NB, Colangelo LA, Jacobs DR, Gross M, Reiner AP, Lloyd-Jones DM, Guo X, Taylor K, Vaduganathan M, Post WS, Bertoni A, Ballantyne C, Shah A, Claggett B, Boerwinkle E, Yu B, Solomon SD, Shah SJ, Patel RB. Missense Genetic Variation of ICAM1 and Incident Heart Failure. J Card Fail 2023; 29:1163-1172. [PMID: 36882149 PMCID: PMC10477308 DOI: 10.1016/j.cardfail.2023.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [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: 02/02/2023] [Revised: 02/09/2023] [Accepted: 02/10/2023] [Indexed: 03/07/2023]
Abstract
BACKGROUND Intercellular adhesion molecule-1 (ICAM-1) is a cell surface protein that participates in endothelial activation and is hypothesized to play a central role in heart failure (HF). We evaluated associations of ICAM1 missense genetic variants with circulating ICAM-1 levels and with incident HF. METHODS AND RESULTS We identified 3 missense variants within ICAM1 (rs5491, rs5498 and rs1799969) and evaluated their associations with ICAM-1 levels in the Coronary Artery Risk Development in Young Adults Study and the Multi-Ethnic Study of Atherosclerosis (MESA). We determined the association among these 3 variants and incident HF in MESA. We separately evaluated significant associations in the Atherosclerosis Risk in Communities (ARIC) study. Of the 3 missense variants, rs5491 was common in Black participants (minor allele frequency [MAF] > 20%) and rare in other race/ethnic groups (MAF < 5%). In Black participants, the presence of rs5491 was associated with higher levels of circulating ICAM-1 at 2 timepoints separated by 8 years. Among Black participants in MESA (n = 1600), the presence of rs5491 was associated with an increased risk of incident HF with preserved ejection fraction (HFpEF; HR = 2.30; [95% CI 1.25-4.21; P = 0.007]). The other ICAM1 missense variants (rs5498 and rs1799969) were associated with ICAM-1 levels, but there were no associations with HF. In ARIC, rs5491 was significantly associated with incident HF (HR = 1.24 [95% CI 1.02 - 1.51]; P = 0.03), with a similar direction of effect for HFpEF that was not statistically significant. CONCLUSIONS A common ICAM1 missense variant among Black individuals may be associated with increased risk of HF, which may be HFpEF-specific.
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Affiliation(s)
- Pedro Giro
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Jonathan W Cunningham
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Laura Rasmussen-Torvik
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Nicholas B Larson
- Department of Quantitative Health Sciences, Mayo Clinic, Rochester, MN
| | - Laura A Colangelo
- Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - David R Jacobs
- Division of Epidemiology and Community Health, University of Minnesota School of Public Health, Minneapolis, MN
| | - Myron Gross
- Department of Laboratory Medicine and Pathology, University of Minnesota School of Medicine, Minneapolis, MN
| | - Alex P Reiner
- Department of Epidemiology, University of Washington, Seattle, WA
| | - Donald M Lloyd-Jones
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Xiuqing Guo
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Kent Taylor
- The Institute for Translational Genomics and Population Sciences, Department of Pediatrics, The Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA
| | - Muthiah Vaduganathan
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Wendy S Post
- Division of Cardiology, Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Alain Bertoni
- Department of Epidemiology and Prevention, Wake Forest School of Medicine, Winston-Salem, NC
| | | | - Amil Shah
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Brian Claggett
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Eric Boerwinkle
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Bing Yu
- Department of Epidemiology, Human Genetics and Environmental Sciences, School of Public Health, University of Texas Health Science Center, Houston, TX
| | - Scott D Solomon
- Division of Cardiology, Department of Medicine, Brigham and Woman's Hospital, Boston, MA
| | - Sanjiv J Shah
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Ravi B Patel
- From the Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL.
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6
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McDowell K, Campbell R, Simpson J, Cunningham JW, Desai AS, Jhund PS, Lefkowitz MP, Rouleau JL, Swedberg K, Zile MR, Solomon SD, Packer M, McMurray JJV. Incremental prognostic value of biomarkers in PARADIGM-HF. Eur J Heart Fail 2023; 25:1406-1414. [PMID: 37191207 DOI: 10.1002/ejhf.2887] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2023] [Revised: 04/23/2023] [Accepted: 05/10/2023] [Indexed: 05/17/2023] Open
Abstract
AIMS It is uncertain how much candidate biomarkers improve risk prediction when added to comprehensive models including routinely collected clinical and laboratory variables in heart failure. METHODS AND RESULTS Aldosterone, cystatin C, high-sensitivity troponin T (hs-TnT), galectin-3, growth differentiation factor-15 (GDF-15), kidney injury molecule-1, matrix metalloproteinase-2 and -9, soluble suppression of tumourigenicity-2, tissue inhibitor of metalloproteinase-1 (TIMP-1) and urinary albumin to creatinine ratio were measured in 1559 of PARADIGM-HF participants. We tested whether these biomarkers, individually or collectively, improved the performance of the PREDICT-HF prognostic model, which includes clinical, routine laboratory, and natriuretic peptide data, for the primary endpoint and cardiovascular and all-cause mortality. The mean age of participants was 67.3 ± 9.9 years, 1254 (80.4%) were men and 1103 (71%) were in New York Heart Association class II. During a mean follow-up of 30.7 months, 300 patients experienced the primary outcome and 197 died. Added individually, only four biomarkers were independently associated with all outcomes: hs-TnT, GDF-15, cystatin C and TIMP-1. When all biomarkers were added simultaneously to the PREDICT-HF models, only hs-TnT remained an independent predictor of all three endpoints. GDF-15 also remained predictive of the primary endpoint; TIMP-1 was the only other predictor of both cardiovascular and all-cause mortality. Individually or in combination, these biomarkers did not lead to significant improvements in discrimination or reclassification. CONCLUSIONS None of the biomarkers studied individually or collectively led to a meaningful improvement in the prediction of outcomes over what is provided by clinical, routine laboratory, and natriuretic peptide variables.
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Affiliation(s)
- Kirsty McDowell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Ross Campbell
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Joanne Simpson
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | | | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Canada
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
- National Heart and Lung Institute, Imperial College London, London, UK
| | - Michael R Zile
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, MA, USA
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
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7
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Chatur S, Cunningham JW, Vaduganathan M, Mc Causland FR, Claggett BL, Desai AS, Miao ZM, Jhund PS, de Boer RA, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez FA, Shah SJ, Petersson M, Langkilde AM, McMurray JJV, Solomon SD. Renal and blood pressure effects of dapagliflozin in recently hospitalized patients with heart failure with mildly reduced or preserved ejection fraction: Insights from the DELIVER trial. Eur J Heart Fail 2023; 25:1170-1175. [PMID: 37212168 DOI: 10.1002/ejhf.2915] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 05/16/2023] [Accepted: 05/18/2023] [Indexed: 05/23/2023] Open
Abstract
AIMS Patients recently hospitalized for heart failure (HF) often have unstable haemodynamics and experience worsening renal failure, and are at elevated risk for recurrent HF events. In DELIVER, dapagliflozin reduced HF events or cardiovascular death including among patients who were hospitalized or recently hospitalized. METHODS AND RESULTS We examined the effects of dapagliflozin versus placebo on estimated glomerular filtration rate (eGFR) slope (acute and chronic), 1-month change in systolic blood pressure, and the occurrence of serious hypovolaemic or renal adverse events in patients with and without HF hospitalization within 30 days of randomization. The 654 (90 randomized during hospitalization, 147 1-7 days post-discharge and 417 8-30 days post-discharge) recently hospitalized patients had lower baseline eGFR compared with those without recent HF hospitalization (median [interquartile range] 55 [43, 71] vs. 60 [47, 75] ml/min/1.73 m2 ). Dapagliflozin consistently reduced the risk of all-cause (pinteraction = 0.20), cardiac-related (pinteraction = 0.75), and HF-specific (pinteraction = 0.90) hospitalizations, irrespective of recent HF hospitalization. In those recently hospitalized, acute placebo-corrected eGFR reductions with dapagliflozin were modest and similar to patients without recent hospitalization (-2.0 [-4.1, +0.1] vs. -3.4 [-3.9, -2.9] ml/min/1.73 m2 , pinteraction = 0.12). Dapagliflozin's effect to slow chronic eGFR decline was similar regardless of recent hospitalization (pinteraction = 0.57). Dapagliflozin had a minimal effect on 1-month systolic blood pressure and to a similar degree in patients with and without recent hospitalization (-1.3 vs.-1.8 mmHg, pinteraction = 0.64). There was no treatment-related excess in renal or hypovolaemic serious adverse events, irrespective of recent HF hospitalization. CONCLUSION In patients recently hospitalized with HF, initiation of dapagliflozin had minimal effects on blood pressure and did not increase renal or hypovolaemic serious adverse events, yet afforded long-term cardiovascular and kidney protective effects. These data suggest that the benefit to risk ratio favours initiation of dapagliflozin among stabilized patients hospitalized or recently hospitalized for HF. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov NCT03619213.
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Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Finnian R Mc Causland
- Renal Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Zi Michael Miao
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Glasgow, UK
| | - Rudolf A de Boer
- Erasmus Medical Center, Department of Cardiology, Rotterdam, The Netherlands
| | | | | | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas, MO, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore, Singapore
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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8
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Cunningham JW, Singh P, Reeder C, Lau ES, Khurshid S, Wang X, Ellinor PT, Lubitz SA, Batra P, Ho JE. Natural Language Processing for Adjudication of Heart Failure in the Electronic Health Record. JACC Heart Fail 2023; 11:852-854. [PMID: 36939660 PMCID: PMC10694785 DOI: 10.1016/j.jchf.2023.02.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/08/2023] [Revised: 02/24/2023] [Accepted: 02/27/2023] [Indexed: 03/07/2023]
Affiliation(s)
| | | | - Christopher Reeder
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CLS 945, Boston, Massachusetts 02215, USA
| | - Emily S. Lau
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CLS 945, Boston, Massachusetts 02215, USA
| | - Shaan Khurshid
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CLS 945, Boston, Massachusetts 02215, USA
| | - Xin Wang
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CLS 945, Boston, Massachusetts 02215, USA
| | - Patrick T. Ellinor
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CLS 945, Boston, Massachusetts 02215, USA
| | - Steven A. Lubitz
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CLS 945, Boston, Massachusetts 02215, USA
| | - Puneet Batra
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CLS 945, Boston, Massachusetts 02215, USA
| | - Jennifer E. Ho
- Beth Israel Deaconess Medical Center, 330 Brookline Avenue, CLS 945, Boston, Massachusetts 02215, USA
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9
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Bhatt AS, Varshney AS, Moscone A, Claggett BL, Miao ZM, Chatur S, Lopes MS, Ostrominski JW, Pabon MA, Unlu O, Wang X, Bernier TD, Buckley LF, Cook B, Eaton R, Fiene J, Kanaan D, Kelly J, Knowles DM, Lupi K, Matta LS, Pimentel LY, Rhoten MN, Malloy R, Ting C, Chhor R, Guerin JR, Schissel SL, Hoa B, Lio CH, Milewski K, Espinosa ME, Liu Z, McHatton R, Cunningham JW, Jering KS, Bertot JH, Kaur G, Ahmad A, Akash M, Davoudi F, Hinrichsen MZ, Rabin DL, Gordan PL, Roberts DJ, Urma D, McElrath EE, Hinchey ED, Choudhry NK, Nekoui M, Solomon SD, Adler DS, Vaduganathan M. Virtual Care Team Guided Management of Patients With Heart Failure During Hospitalization. J Am Coll Cardiol 2023; 81:1680-1693. [PMID: 36889612 PMCID: PMC10947307 DOI: 10.1016/j.jacc.2023.02.029] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/17/2023] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND Scalable and safe approaches for heart failure guideline-directed medical therapy (GDMT) optimization are needed. OBJECTIVES The authors assessed the safety and effectiveness of a virtual care team guided strategy on GDMT optimization in hospitalized patients with heart failure with reduced ejection fraction (HFrEF). METHODS In a multicenter implementation trial, we allocated 252 hospital encounters in patients with left ventricular ejection fraction ≤40% to a virtual care team guided strategy (107 encounters among 83 patients) or usual care (145 encounters among 115 patients) across 3 centers in an integrated health system. In the virtual care team group, clinicians received up to 1 daily GDMT optimization suggestion from a physician-pharmacist team. The primary effectiveness outcome was in-hospital change in GDMT optimization score (+2 initiations, +1 dose up-titrations, -1 dose down-titrations, -2 discontinuations summed across classes). In-hospital safety outcomes were adjudicated by an independent clinical events committee. RESULTS Among 252 encounters, the mean age was 69 ± 14 years, 85 (34%) were women, 35 (14%) were Black, and 43 (17%) were Hispanic. The virtual care team strategy significantly improved GDMT optimization scores vs usual care (adjusted difference: +1.2; 95% CI: 0.7-1.8; P < 0.001). New initiations (44% vs 23%; absolute difference: +21%; P = 0.001) and net intensifications (44% vs 24%; absolute difference: +20%; P = 0.002) during hospitalization were higher in the virtual care team group, translating to a number needed to intervene of 5 encounters. Overall, 23 (21%) in the virtual care team group and 40 (28%) in usual care experienced 1 or more adverse events (P = 0.30). Acute kidney injury, bradycardia, hypotension, hyperkalemia, and hospital length of stay were similar between groups. CONCLUSIONS Among patients hospitalized with HFrEF, a virtual care team guided strategy for GDMT optimization was safe and improved GDMT across multiple hospitals in an integrated health system. Virtual teams represent a centralized and scalable approach to optimize GDMT.
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Affiliation(s)
- Ankeet S Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA; Kaiser Permanente San Francisco Medical Center and Division of Research, San Francisco, California, USA
| | - Anubodh S Varshney
- Division of Cardiovascular Medicine, Stanford University, Palo Alto, California, USA
| | - Alea Moscone
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Zi Michael Miao
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Safia Chatur
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Mathew S Lopes
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - John W Ostrominski
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Maria A Pabon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Ozan Unlu
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Xiaowen Wang
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Leo F Buckley
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Bryan Cook
- Mass General Brigham Center for Drug Policy, Boston, Massachusetts, USA
| | - Rachael Eaton
- Department of Pharmacy, Ohio State University Wexner Medical Center, Columbus, Ohio, USA
| | - Jillian Fiene
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Dareen Kanaan
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Julie Kelly
- Department of Pharmacy, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Danielle M Knowles
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Kenneth Lupi
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Lina S Matta
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Liriany Y Pimentel
- Department of Pharmacy Services, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Megan N Rhoten
- Department of Pharmacy Services, Carilion Roanoke Memorial Hospital, Roanoke, Virginia, USA
| | - Rhynn Malloy
- Department of Pharmacy, Children's Hospital Colorado, Denver, Colorado, USA
| | - Clara Ting
- University of Chicago Medical Center, Chicago, Illinois, USA
| | - Rosette Chhor
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Joshua R Guerin
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Scott L Schissel
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Brenda Hoa
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Connie H Lio
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Kristina Milewski
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Michelle E Espinosa
- Brigham and Women's Faulkner Hospital, Mass General Brigham, Jamaica Plain, Massachusetts, USA
| | - Zhenzhen Liu
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Ralph McHatton
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Jonathan W Cunningham
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Karola S Jering
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - John H Bertot
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Gurleen Kaur
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Adeel Ahmad
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Muhammad Akash
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Farideh Davoudi
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | | | - David L Rabin
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | | | - David J Roberts
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Daniela Urma
- Salem Hospital, Mass General Brigham, Salem, Massachusetts, USA
| | - Erin E McElrath
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Emily D Hinchey
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Niteesh K Choudhry
- Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Mahan Nekoui
- Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA
| | - Dale S Adler
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA; Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Mass General Brigham, Harvard Medical School, Boston, Massachusetts, USA.
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10
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Nauffal V, Di Achille P, Klarqvist MDR, Cunningham JW, Hill MC, Pirruccello JP, Weng LC, Morrill VN, Choi SH, Khurshid S, Friedman SF, Nekoui M, Roselli C, Ng K, Philippakis AA, Batra P, Ellinor PT, Lubitz SA. Genetics of myocardial interstitial fibrosis in the human heart and association with disease. Nat Genet 2023; 55:777-786. [PMID: 37081215 DOI: 10.1038/s41588-023-01371-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2021] [Accepted: 03/13/2023] [Indexed: 04/22/2023]
Abstract
Myocardial interstitial fibrosis is associated with cardiovascular disease and adverse prognosis. Here, to investigate the biological pathways that underlie fibrosis in the human heart, we developed a machine learning model to measure native myocardial T1 time, a marker of myocardial fibrosis, in 41,505 UK Biobank participants who underwent cardiac magnetic resonance imaging. Greater T1 time was associated with diabetes mellitus, renal disease, aortic stenosis, cardiomyopathy, heart failure, atrial fibrillation, conduction disease and rheumatoid arthritis. Genome-wide association analysis identified 11 independent loci associated with T1 time. The identified loci implicated genes involved in glucose transport (SLC2A12), iron homeostasis (HFE, TMPRSS6), tissue repair (ADAMTSL1, VEGFC), oxidative stress (SOD2), cardiac hypertrophy (MYH7B) and calcium signaling (CAMK2D). Using a transforming growth factor β1-mediated cardiac fibroblast activation assay, we found that 9 of the 11 loci consisted of genes that exhibited temporal changes in expression or open chromatin conformation supporting their biological relevance to myofibroblast cell state acquisition. By harnessing machine learning to perform large-scale quantification of myocardial interstitial fibrosis using cardiac imaging, we validate associations between cardiac fibrosis and disease, and identify new biologically relevant pathways underlying fibrosis.
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Grants
- 1R01HL139731 Foundation for the National Institutes of Health (Foundation for the National Institutes of Health, Inc.)
- T32HL007604 Foundation for the National Institutes of Health (Foundation for the National Institutes of Health, Inc.)
- K08HL159346 Foundation for the National Institutes of Health (Foundation for the National Institutes of Health, Inc.)
- 1R01HL139731 Foundation for the National Institutes of Health (Foundation for the National Institutes of Health, Inc.)
- K24HL105780 Foundation for the National Institutes of Health (Foundation for the National Institutes of Health, Inc.)
- 1R01HL092577 Foundation for the National Institutes of Health (Foundation for the National Institutes of Health, Inc.)
- 5T32HL007208-42 Foundation for the National Institutes of Health (Foundation for the National Institutes of Health, Inc.)
- 18SFRN34250007 American Heart Association (American Heart Association, Inc.)
- 18SFRN34110082 American Heart Association (American Heart Association, Inc.)
- 18SFRN34110082 American Heart Association (American Heart Association, Inc.)
- 14CVD01 Fondation Leducq
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Affiliation(s)
- Victor Nauffal
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Paolo Di Achille
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | | | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Matthew C Hill
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - James P Pirruccello
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
- Division of Cardiology, University of California San Francisco, San Francisco, CA, USA
| | - Lu-Chen Weng
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Valerie N Morrill
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Seung Hoan Choi
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Shaan Khurshid
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA
| | - Samuel F Friedman
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Mahan Nekoui
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Carolina Roselli
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Kenney Ng
- Center for Computational Health, IBM Research, Cambridge, MA, USA
| | - Anthony A Philippakis
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Eric and Wendy Schmidt Center, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Puneet Batra
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Patrick T Ellinor
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA.
| | - Steven A Lubitz
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA.
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11
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Cunningham JW, Claggett BL, Solomon SD, Vaduganathan M. Natriuretic Peptide-Based Screening for Pre-Heart Failure in Patients With Type 2 Diabetes Across the United States. JACC Heart Fail 2023:S2213-1779(23)00042-2. [PMID: 36868917 DOI: 10.1016/j.jchf.2023.01.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 01/06/2023] [Accepted: 01/09/2023] [Indexed: 03/05/2023]
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12
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Cunningham JW, Di Achille P, Morrill VN, Weng LC, Hoan Choi S, Khurshid S, Nauffal V, Pirruccello JP, Solomon SD, Batra P, Ho JE, Philippakis AA, Ellinor PT, Lubitz SA. Machine Learning to Understand Genetic and Clinical Factors Associated With the Pulse Waveform Dicrotic Notch. Circ Genom Precis Med 2023; 16:e003676. [PMID: 36580284 PMCID: PMC9975074 DOI: 10.1161/circgen.121.003676] [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] [Subscribe] [Scholar Register] [Received: 12/12/2021] [Accepted: 09/30/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Absence of a dicrotic notch on finger photoplethysmography is an easily ascertainable and inexpensive trait that has been associated with age and prevalent cardiovascular disease. However, the trait exists along a continuum, and little is known about its genetic underpinnings or prognostic value for incident cardiovascular disease. METHODS In 169 787 participants in the UK Biobank, we identified absent dicrotic notch on photoplethysmography and created a novel continuous trait reflecting notch smoothness using machine learning. Next, we determined the heritability, genetic basis, polygenic risk, and clinical relations for the binary absent notch trait and the newly derived continuous notch smoothness trait. RESULTS Heritability of the continuous notch smoothness trait was 7.5%, compared with 5.6% for the binary absent notch trait. A genome-wide association study of notch smoothness identified 15 significant loci, implicating genes including NT5C2 (P=1.2×10-26), IGFBP3 (P=4.8×10-18), and PHACTR1 (P=1.4×10-13), compared with 6 loci for the binary absent notch trait. Notch smoothness stratified risk of incident myocardial infarction or coronary artery disease, stroke, heart failure, and aortic stenosis. A polygenic risk score for notch smoothness was associated with incident cardiovascular disease and all-cause death in UK Biobank participants without available photoplethysmography data. CONCLUSIONS We found that a machine learning derived continuous trait reflecting dicrotic notch smoothness on photoplethysmography was heritable and associated with genes involved in vascular stiffness. Greater notch smoothness was associated with greater risk of incident cardiovascular disease. Raw digital phenotyping may identify individuals at risk for disease via specific genetic pathways.
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Affiliation(s)
- Jonathan W. Cunningham
- Cardiovascular Division, Brigham & Women’s Hospital, Boston
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
| | - Paolo Di Achille
- Data Sciences Platform, The Broad Institute of MIT & Harvard, Cambridge
| | - Valerie N. Morrill
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
| | - Lu-Chen Weng
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
- Cardiovascular Research Center, Massachusetts General Hospital
| | - Seung Hoan Choi
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
| | - Shaan Khurshid
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital
| | - Victor Nauffal
- Cardiovascular Division, Brigham & Women’s Hospital, Boston
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
| | - James P Pirruccello
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
- Division of Cardiology, Massachusetts General Hospital
| | | | - Puneet Batra
- Data Sciences Platform, The Broad Institute of MIT & Harvard, Cambridge
| | - Jennifer E. Ho
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA
| | | | - Patrick T. Ellinor
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
- Cardiovascular Research Center, Massachusetts General Hospital
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital
| | - Steven A. Lubitz
- Cardiovascular Disease Initiative, The Broad Institute of MIT & Harvard, Cambridge
- Cardiovascular Research Center, Massachusetts General Hospital
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital
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13
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Peikert A, Cunningham JW. Amyloid-β and the Risk of Heart Failure: Cause or Only Association? JACC Heart Fail 2023; 11:103-105. [PMID: 36599537 DOI: 10.1016/j.jchf.2022.09.010] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/26/2022] [Accepted: 09/27/2022] [Indexed: 11/11/2022]
Affiliation(s)
- Alexander Peikert
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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14
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Zhang L, Cunningham JW, Claggett BL, Jacob J, Mendelson MM, Serrano-Fernandez P, Kaiser S, Yates DP, Healey M, Chen CW, Turner GM, Patel-Murray NL, Zhao F, Beste MT, Laramie JM, Abraham WT, Jhund PS, Kober L, Packer M, Rouleau J, Zile MR, Prescott MF, Lefkowitz M, McMurray JJV, Solomon SD, Chutkow W. Aptamer Proteomics for Biomarker Discovery in Heart Failure With Reduced Ejection Fraction. Circulation 2022; 146:1411-1414. [PMID: 36029463 DOI: 10.1161/circulationaha.122.061481] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Affiliation(s)
- Luqing Zhang
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | | | - Brian L Claggett
- Brigham and Women's Hospital, Boston, MA (J.W.C., B.L.C., S.D.S.)
| | - Jaison Jacob
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | - Michael M Mendelson
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | | | - Sergio Kaiser
- Novartis Institutes for Biomedical Research, Basel, Switzerland (P.S.-F., S.K.)
| | - Denise P Yates
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | - Margaret Healey
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | - Chien-Wei Chen
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | - Gordon M Turner
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | - Natasha L Patel-Murray
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | - Faye Zhao
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | - Michael T Beste
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | - Jason M Laramie
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
| | | | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (P.S.J., J.J.V.M.)
| | - Lars Kober
- Rigshospitalet Copenhagen University Hospital, Denmark (L.K.)
| | | | - Jean Rouleau
- Montreal Heart Institute and Université de Montréal, Canada (J.R.)
| | - Michael R Zile
- Ralph H. Johnson Department of Veterans Affairs Medical Center and Medical University of South Carolina, Charleston (M.R.Z.)
| | | | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, United Kingdom (P.S.J., J.J.V.M.)
| | - Scott D Solomon
- Brigham and Women's Hospital, Boston, MA (J.W.C., B.L.C., S.D.S.)
| | - William Chutkow
- Novartis Institutes for Biomedical Research, Cambridge, MA (L.Z., J.J., M.M.M., D.P.Y., M.H., C.-W.C., G.M.T., N.L.P.-M., F.Z., M.T.B., J.M.L., W.C.)
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15
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Cunningham JW, Pfeffer MA. Clinical Translation of Cardiovascular Biomarkers - A Long and Uncertain Road. NEJM Evid 2022; 1:EVIDe2200222. [PMID: 38319843 DOI: 10.1056/evide2200222] [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] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Abstract
Biomarkers in cardiovascular medicine serve to probe disease mechanisms for research, assist in risk stratification, and - in the best cases - guide precise therapies to appropriate patients. In a classic 2007 article, Morrow and de Lemos1 proposed three criteria by which to evaluate novel cardiovascular biomarkers for clinical use. First, can the biomarker be measured reproducibly in clinical laboratories? Second, does the biomarker add incremental new information to existing tests? And third, will the measurement of the biomarker assist in the care of patients? The answer to the third question often distinguishes a research tool from a clinical instrument.
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Affiliation(s)
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston
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16
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Dubé M, Chazara O, Lemaçon A, Asselin G, Provost S, Barhdadi A, Lemieux Perreault L, Mongrain I, Wang Q, Carss K, Paul DS, Cunningham JW, Rouleau J, Solomon SD, McMurray JJ, Yusuf S, Granger CB, Haefliger C, de Denus S, Tardif J. Pharmacogenomic study of heart failure and candesartan response from the CHARM programme. ESC Heart Fail 2022; 9:2997-3008. [PMID: 35736394 PMCID: PMC9715825 DOI: 10.1002/ehf2.14026] [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: 09/23/2021] [Revised: 03/21/2022] [Accepted: 06/03/2022] [Indexed: 11/07/2022] Open
Abstract
AIMS The Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity (CHARM) programme consisted of three parallel, randomized, double-blind clinical trials comparing candesartan with placebo in patients with heart failure (HF) categorized according to left ventricular ejection fraction and tolerability to an angiotensin-converting enzyme inhibitor. We conducted a pharmacogenomic study of the CHARM trials with the objective of identifying genetic predictors of HF progression and of the efficacy and safety of treatment with candesartan. METHODS We performed genome-wide association studies in 2727 patients of European ancestry from CHARM-Overall and stratified by CHARM study according to preserved and reduced ejection fraction and according to assignment to the interventional treatment with candesartan. We tested genetic association with the composite endpoint of cardiovascular death or hospitalization for heart failure for drug efficacy in candesartan-treated patients and for HF progression using patients from both candesartan and placebo arms. The safety endpoints for response to candesartan were hyperkalaemia, renal dysfunction, hypotension, and change in systolic blood pressure between baseline and 6 weeks of treatment. To support our observations, we conducted a genome-wide gene-level collapsing analysis from whole-exome sequencing data with the composite cardiovascular endpoint. RESULTS We found that the A allele (14% allele frequency) of the genetic variant rs66886237 at 8p21.3 near the gene GFRA2 was associated with the composite cardiovascular endpoint in 1029 HF patients with preserved ejection fraction from the CHARM-Preserved study (hazard ratio: 1.91, 95% confidence interval: 1.55-2.35; P = 1.7 × 10-9 ). The association was independent of candesartan treatment, and the genetic variant was not associated with the cardiovascular endpoint in patients with reduced ejection fraction. None of the genome-wide association studies for candesartan safety or efficacy conducted in patients treated with candesartan passed the significance threshold. We found no significant association from the gene-level collapsing analysis. CONCLUSIONS We have identified a candidate genetic variant potentially predictive of the progression of heart failure in patients with preserved ejection fraction. The findings require further replication, and we cannot exclude the possibility that the results may be chance findings.
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Affiliation(s)
- Marie‐Pierre Dubé
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
- Université de Montréal, Faculty of Medicine, Department of medicineUniversité de MontréalMontrealCanada
| | - Olympe Chazara
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | - Audrey Lemaçon
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
- Université de Montréal, Faculty of Medicine, Department of medicineUniversité de MontréalMontrealCanada
| | - Géraldine Asselin
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
| | - Sylvie Provost
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
| | - Amina Barhdadi
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
| | | | - Ian Mongrain
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
| | - Quanli Wang
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | - Keren Carss
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | - Dirk S. Paul
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | | | - Jean Rouleau
- Montreal Heart InstituteMontrealCanada
- Université de Montréal, Faculty of Medicine, Department of medicineUniversité de MontréalMontrealCanada
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women's HospitalHarvard Medical SchoolBostonMAUSA
| | | | - Salim Yusuf
- The Population Health Research Institute, Hamilton Health Sciences and the School of Rehabilitation ScienceMcMaster UniversityHamiltonONCanada
| | - Chris B. Granger
- Duke Clinical Research InstituteDuke University School of MedicineDurhamNCUSA
| | - Carolina Haefliger
- Centre for Genomics Research (CGR), Discovery Sciences, BioPharmaceuticals R&D, AstraZenecaCambridgeUK
| | - Simon de Denus
- Montreal Heart InstituteMontrealCanada
- Université de Montréal Beaulieu‐Saucier Pharmacogenomics CentreMontrealCanada
- Faculty of PharmacyUniversité de MontréalMontrealCanada
| | - Jean‐Claude Tardif
- Montreal Heart InstituteMontrealCanada
- Université de Montréal, Faculty of Medicine, Department of medicineUniversité de MontréalMontrealCanada
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17
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Bonaca MP, Antman EM, Cunningham JW, Wiviott SD, Murphy SA, Halperin JL, Weitz JI, Grosso MA, Lanz HJ, Braunwald E, Giugliano RP, Ruff CT. Ischaemic and bleeding risk in atrial fibrillation with and without peripheral artery disease and efficacy and safety of full- and half-dose edoxaban vs. warfarin: insights from ENGAGE AF-TIMI 48. Eur Heart J Cardiovasc Pharmacother 2022; 8:695-706. [PMID: 34962979 DOI: 10.1093/ehjcvp/pvab089] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 10/29/2021] [Accepted: 12/26/2021] [Indexed: 06/14/2023]
Abstract
AIMS In patients with atrial fibrillation (AF), peripheral artery disease (PAD) is associated with higher rates of stroke and bleeding. Both higher dose edoxaban (60/30 mg) and lower dose edoxaban (30/15 mg) were non-inferior to warfarin for stroke and systemic embolism (SSE) and significantly reduced major bleeding in AF patients in the global study to assess the safety and effectiveness of edoxaban vs standard practice of dosing with warfarin in patients with atrial fibrillation (ENGAGE AF-TIMI 48) trial. Whether the efficacy and safety of these dosing strategies vs. warfarin are consistent in patients with AF and PAD has not been described. METHODS AND RESULTS Of 21 105 patients with AF randomized to warfarin, edoxaban 60/30 mg, or edoxaban 30/15 mg, 841 were identified with PAD. Endpoints included major adverse cardiovascular events (MACEs), SSE, and major bleeding. Patients with PAD had higher risk of MACEs [adjusted hazard ratio (HRadj) 1.33, 95% confidence interval (CI) 1.12-1.57, P = 0.001] and cardiovascular (CV) death (HRadj 1.49, 95% CI 1.21-1.83, P < 0.001) than those without PAD, but not major bleeding. The efficacy of edoxaban 60/30 mg vs. warfarin was consistent regardless of PAD (SSE HR; PAD 1.16, 95% CI 0.42-3.20; no-PAD 0.86, 95% CI 0.74-1.02, P-interaction 0.57) as was major bleeding (PAD 0.96, 95% CI 0.54-1.70; no-PAD 0.80, 95% CI 0.70-0.91, P-interaction 0.54). Edoxaban 30/15 mg was inferior for SSE, with significant heterogeneity when stratified by PAD status (P-interaction 0.039). CONCLUSION Patients with AF and PAD are at heightened risk of MACEs and CV death vs. those without PAD. The efficacy and safety of edoxaban 60/30 mg vs. warfarin in AF are consistent regardless of PAD; however, edoxaban 30/15 mg is inferior for stroke prevention in AF patients with PAD. Clinical Trial Registration: ClinicalTrials.gov identifier: NCT00781391.
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Affiliation(s)
- Marc P Bonaca
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
- CPC Clinical Research, University of Colorado School of Medicine, 13199 E. Montview Blvd., Suite 200, Aurora, CO 80045, USA
| | - Elliott M Antman
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Stephen D Wiviott
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Sabina A Murphy
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan L Halperin
- Cardiovascular Division, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Jeffrey I Weitz
- Department of Medicine, McMaster University and Thrombosis and Atherosclerosis Research Institute, Hamilton, ON, Canada
| | | | | | - Eugene Braunwald
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Robert P Giugliano
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Christian T Ruff
- TIMI Study Group, Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
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18
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Chatur S, Lakdawala NK, Cunningham JW. Random Admission Urinary Sodium for Diuretic Response: Promise in Pragmatism? Eur J Heart Fail 2022; 24:1988-1989. [PMID: 36164941 DOI: 10.1002/ejhf.2704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/24/2022] [Indexed: 11/12/2022] Open
Affiliation(s)
- Safia Chatur
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Neal K Lakdawala
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
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19
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Singh P, Haimovich J, Reeder C, Khurshid S, Lau ES, Cunningham JW, Philippakis A, Anderson CD, Ho JE, Lubitz SA, Batra P. One Clinician Is All You Need-Cardiac Magnetic Resonance Imaging Measurement Extraction: Deep Learning Algorithm Development. JMIR Med Inform 2022; 10:e38178. [PMID: 35960155 PMCID: PMC9526125 DOI: 10.2196/38178] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 07/22/2022] [Accepted: 08/11/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Cardiac magnetic resonance imaging (CMR) is a powerful diagnostic modality that provides detailed quantitative assessment of cardiac anatomy and function. Automated extraction of CMR measurements from clinical reports that are typically stored as unstructured text in electronic health record systems would facilitate their use in research. Existing machine learning approaches either rely on large quantities of expert annotation or require the development of engineered rules that are time-consuming and are specific to the setting in which they were developed. OBJECTIVE We hypothesize that the use of pretrained transformer-based language models may enable label-efficient numerical extraction from clinical text without the need for heuristics or large quantities of expert annotations. Here, we fine-tuned pretrained transformer-based language models on a small quantity of CMR annotations to extract 21 CMR measurements. We assessed the effect of clinical pretraining to reduce labeling needs and explored alternative representations of numerical inputs to improve performance. METHODS Our study sample comprised 99,252 patients that received longitudinal cardiology care in a multi-institutional health care system. There were 12,720 available CMR reports from 9280 patients. We adapted PRAnCER (Platform Enabling Rapid Annotation for Clinical Entity Recognition), an annotation tool for clinical text, to collect annotations from a study clinician on 370 reports. We experimented with 5 different representations of numerical quantities and several model weight initializations. We evaluated extraction performance using macroaveraged F1-scores across the measurements of interest. We applied the best-performing model to extract measurements from the remaining CMR reports in the study sample and evaluated established associations between selected extracted measures with clinical outcomes to demonstrate validity. RESULTS All combinations of weight initializations and numerical representations obtained excellent performance on the gold-standard test set, suggesting that transformer models fine-tuned on a small set of annotations can effectively extract numerical quantities. Our results further indicate that custom numerical representations did not appear to have a significant impact on extraction performance. The best-performing model achieved a macroaveraged F1-score of 0.957 across the evaluated CMR measurements (range 0.92 for the lowest-performing measure of left atrial anterior-posterior dimension to 1.0 for the highest-performing measures of left ventricular end systolic volume index and left ventricular end systolic diameter). Application of the best-performing model to the study cohort yielded 136,407 measurements from all available reports in the study sample. We observed expected associations between extracted left ventricular mass index, left ventricular ejection fraction, and right ventricular ejection fraction with clinical outcomes like atrial fibrillation, heart failure, and mortality. CONCLUSIONS This study demonstrated that a domain-agnostic pretrained transformer model is able to effectively extract quantitative clinical measurements from diagnostic reports with a relatively small number of gold-standard annotations. The proposed workflow may serve as a roadmap for other quantitative entity extraction.
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Affiliation(s)
- Pulkit Singh
- Data Sciences Platform, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
| | - Julian Haimovich
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
- Cardiovascular Disease Initiative, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
| | - Christopher Reeder
- Data Sciences Platform, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
| | - Shaan Khurshid
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, United States
| | - Emily S Lau
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
- Cardiovascular Disease Initiative, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
| | - Jonathan W Cunningham
- Cardiovascular Disease Initiative, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, United States
| | - Anthony Philippakis
- Data Sciences Platform, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
- Eric and Wendy Schmidt Center, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
| | - Christopher D Anderson
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, United States
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, United States
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Jennifer E Ho
- Cardiovascular Disease Initiative, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States
| | - Steven A Lubitz
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, United States
- Cardiovascular Disease Initiative, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, United States
| | - Puneet Batra
- Data Sciences Platform, The Broad Institute of Harvard and MIT, Cambridge, MA, United States
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20
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John JE, Claggett B, Skali H, Solomon SD, Cunningham JW, Matsushita K, Konety SH, Kitzman DW, Mosley TH, Clark D, Chang PP, Shah AM. Coronary Artery Disease and Heart Failure With Preserved Ejection Fraction: The ARIC Study. J Am Heart Assoc 2022; 11:e021660. [PMID: 36000416 PMCID: PMC9496411 DOI: 10.1161/jaha.121.021660] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2021] [Accepted: 12/10/2021] [Indexed: 11/30/2022]
Abstract
Background Whether coronary artery disease (CAD) is a significant risk factor for heart failure (HF) with preserved ejection fraction (HFpEF) is unclear. Methods and Results Among 9902 participants in the ARIC (Atherosclerosis Risk in Communities) study, we assessed the association of incident CAD with subsequent incident HFpEF (left ventricular ejection fraction [≥50%]) and HF with reduced ejection fraction (HFrEF; left ventricular ejection fraction <50%) using survival models with time-updated variables. We also assessed the extent to which echocardiographic correlates of prevalent CAD account for the relationship between CAD and incident HFpEF. Over 13-year follow-up, incident CAD developed in 892 participants and 178 subsequently developed HF (86 HFrEF, 71 HFpEF). Incident HFrEF and HFpEF risk were both greatest early after the CAD event. At >1 year post-CAD event, adjusted incidence of HFrEF and HFpEF were similar (7.2 [95% CI, 5.2-10.0] and 6.7 [4.8-9.2] per 1000 person-years, respectively) and CAD remained predictive of both (HFrEF: hazard ratio, 2.76 [95% CI, 1.99-3.84]; HFpEF: 1.85 [1.35-2.54]) after adjusting for demographics and common comorbidities. Among 4779 HF-free participants at Visit 5 (2011-2013), the 490 with prevalent CAD had lower left ventricular ejection fraction and higher left ventricular mass index, E/e', and left atrial volume index (all P<0.01). The association of prevalent CAD with incident HFpEF post-Visit 5 was not significant after adjusting for echocardiographic measures, with the greatest attenuation observed for left ventricular diastolic function. Conclusions CAD is a significant risk factor for incident HFpEF after adjustment for demographics and common comorbidities. This relationship is partially accounted for by echocardiographic alterations, particularly left ventricular diastolic function.
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Affiliation(s)
- Jenine E. John
- Noninvasive Cardiovascular Imaging ProgramDepartments of Medicine and RadiologyBrigham and Women’s HospitalBostonMA
- Cardiovascular DivisionBrigham and Women’s HospitalBostonMA
| | - Brian Claggett
- Cardiovascular DivisionBrigham and Women’s HospitalBostonMA
| | - Hicham Skali
- Noninvasive Cardiovascular Imaging ProgramDepartments of Medicine and RadiologyBrigham and Women’s HospitalBostonMA
- Cardiovascular DivisionBrigham and Women’s HospitalBostonMA
| | | | - Jonathan W. Cunningham
- Noninvasive Cardiovascular Imaging ProgramDepartments of Medicine and RadiologyBrigham and Women’s HospitalBostonMA
- Cardiovascular DivisionBrigham and Women’s HospitalBostonMA
| | | | - Suma H. Konety
- Division of Cardiovascular MedicineUniversity of MinnesotaMinneapolisMN
| | - Dalane W. Kitzman
- Cardiovascular Medicine SectionWake Forest School of MedicineWinston‐SalemNC
| | - Thomas H. Mosley
- Department of MedicineUniversity of Mississippi Medical CenterJacksonMS
| | - Donald Clark
- Division of CardiologyUniversity of Mississippi Medical CenterJacksonMS
| | - Patricia P. Chang
- Division of CardiologyUniversity of North Carolina at Chapel HillChapel HillNC
| | - Amil M. Shah
- Cardiovascular DivisionBrigham and Women’s HospitalBostonMA
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21
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Cunningham JW, Vaduganathan M, Claggett BL, Kulac IJ, Desai AS, Jhund PS, de Boer RA, DeMets D, Hernandez AF, Inzucchi SE, Kosiborod MN, Lam CSP, Martinez F, Shah SJ, McGrath MM, O'Meara E, Wilderäng U, Lindholm D, Petersson M, Langkilde AM, McMurray JJV, Solomon SD. Dapagliflozin in Patients Recently Hospitalized With Heart Failure and Mildly Reduced or Preserved Ejection Fraction. J Am Coll Cardiol 2022; 80:1302-1310. [PMID: 36041912 DOI: 10.1016/j.jacc.2022.07.021] [Citation(s) in RCA: 39] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Revised: 07/25/2022] [Accepted: 07/27/2022] [Indexed: 01/10/2023]
Abstract
BACKGROUND Patients recently hospitalized for heart failure (HF) are at high risk for rehospitalization and death. OBJECTIVES The purpose of this study was to investigate clinical outcomes and response to dapagliflozin in patients with HF with mildly reduced or preserved left ventricular ejection fraction (LVEF) who were enrolled during or following hospitalization. METHODS The DELIVER (Dapagliflozin Evaluation to Improve the LIVES of Patients With PReserved Ejection Fraction Heart Failure) trial randomized patients with HF and LVEF >40% to dapagliflozin or placebo. DELIVER permitted randomization during or shortly after hospitalization for HF in clinically stable patients off intravenous HF therapies. This prespecified analysis investigated whether recent HF hospitalization modified risk of clinical events or response to dapagliflozin. The primary outcome was worsening HF event or cardiovascular death. RESULTS Of 6,263 patients in DELIVER, 654 (10.4%) were randomized during HF hospitalization or within 30 days of discharge. Recent HF hospitalization was associated with greater risk of the primary outcome after multivariable adjustment (HR: 1.88; 95% CI: 1.60-2.21; P < 0.001). Dapagliflozin reduced the primary outcome by 22% in recently hospitalized patients (HR: 0.78; 95% CI: 0.60-1.03) and 18% in patients without recent hospitalization (HR: 0.82; 95% CI: 0.72-0.94; Pinteraction = 0.71). Rates of adverse events, including volume depletion, diabetic ketoacidosis, or renal events, were similar with dapagliflozin and placebo in recently hospitalized patients. CONCLUSIONS Dapagliflozin safely reduced risk of worsening HF or cardiovascular death similarly in patients with and without history of recent HF hospitalization. Starting dapagliflozin during or shortly after HF hospitalization in patients with mildly reduced or preserved LVEF appears safe and effective. (Dapagliflozin Evaluation to Improve the LIVEs of Patients With PReserved Ejection Fraction Heart Failure [DELIVER]; NCT03619213).
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Affiliation(s)
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ian J Kulac
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | | | - David DeMets
- University of Wisconsin, Madison, Wisconsin, USA
| | | | | | - Mikhail N Kosiborod
- Saint Luke's Mid America Heart Institute and University of Missouri-Kansas City, Kansas City, Missouri, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Martina M McGrath
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Eileen O'Meara
- Institut de Cardiologie de Montréal, Université de Montréal, Montréal, Québec, Canada
| | - Ulrica Wilderäng
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Daniel Lindholm
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Magnus Petersson
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - Anna Maria Langkilde
- Late-Stage Development, Cardiovascular, Renal, and Metabolism, BioPharmaceuticals R&D, AstraZeneca, Gothenburg, Sweden
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Scott D Solomon
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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22
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Wang X, Cunningham JW. Restoring balance in heart failure with preserved ejection fraction. Eur J Heart Fail 2022; 24:1415-1417. [PMID: 35789069 DOI: 10.1002/ejhf.2599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 06/26/2022] [Indexed: 11/10/2022] Open
Affiliation(s)
- Xiaowen Wang
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA, USA
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23
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Selvaraj S, Claggett B, Johansen MC, Cunningham JW, Gottesman RF, Yu B, Boerwinkle E, Mosley TH, Shah AM, Solomon SD. Apolipoprotein E Polymorphism, Cardiac Remodeling, and Heart Failure in the ARIC Study. J Card Fail 2022; 28:1128-1136. [PMID: 34965472 DOI: 10.1016/j.cardfail.2021.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [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: 07/12/2021] [Revised: 12/15/2021] [Accepted: 12/16/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND β-Amyloid has recently been discovered in the myocardium of patients with Alzheimer's disease (AD). Whether genetic variation in apolipoprotein E (APOE) ɛ4, a common variant associated with Alzheimer's disease, is associated with incident heart failure (HF), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and cardiac structure and function is unknown. METHODS AND RESULTS We studied 15,064 White and Black participants in the Atherosclerosis Risk in Communities, relating genotype status at visit 1 (1987-1989) to incident HF hospitalization using Cox regression. At visits 2, 4, and 5, we assessed NT-proBNP levels by genotype. At visits 3 and 5, we related Aβ peptides to incident HF. At visit 5 (2011-2013, n = 6251), we assessed the relationship of genotype with prevalent HF and echocardiographic parameters. The mean participant age was 54.7 ± 5.8 years, 45% were men, and 73% were White. At visit 5, there was no difference in prevalent HF by genotype. The APOE ε4 carriers did not have increased risk for HF hospitalization. The APOE ε4 genotype was not associated with cardiac structure and function or NT-proBNP levels. The Aβ peptides were not associated with incident HF after multivariable adjustment. CONCLUSIONS A genetic predisposition to Alzheimer's disease through APOE ε4 is not associated with an increased prevalence of HF, HF hospitalization, myocardial remodeling, or biochemical evidence of HF.
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Affiliation(s)
- Senthil Selvaraj
- Division of Cardiology, Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Brian Claggett
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Michelle C Johansen
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jonathan W Cunningham
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Rebecca F Gottesman
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bing Yu
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas Health Science Center at Houston, Houston, Texas
| | - Eric Boerwinkle
- Human Genetics Center, Department of Epidemiology, Human Genetics, and Environmental Sciences, The University of Texas Health Science Center at Houston, Houston, Texas; Baylor College of Medicine, Human Genome Sequencing Center, Houston, Texas
| | - Thomas H Mosley
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - Amil M Shah
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Scott D Solomon
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts.
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24
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Wijkman MO, Claggett B, Vaduganathan M, Cunningham JW, Rørth R, Jackson A, Packer M, Zile M, Rouleau J, Swedberg K, Lefkowitz M, Shah SJ, Pfeffer MA, McMurray JJV, Solomon SD. Effects of sacubitril/valsartan on glycemia in patients with diabetes and heart failure: the PARAGON-HF and PARADIGM-HF trials. Cardiovasc Diabetol 2022; 21:110. [PMID: 35717169 PMCID: PMC9206286 DOI: 10.1186/s12933-022-01545-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2022] [Accepted: 06/05/2022] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND Compared with enalapril, sacubitril/valsartan lowered HbA1c and reduced new insulin therapy in patients with heart failure with reduced ejection fraction (HFrEF) and diabetes in the PARADIGM-HF trial. We sought to assess the glycemic effects of sacubitril/valsartan in heart failure with preserved ejection fraction (HFpEF) and diabetes, and across the spectrum of left ventricular ejection fraction (LVEF) in heart failure and diabetes. METHODS We compared the effect of sacubitril/valsartan, relative to valsartan, on HbA1c, new insulin therapy and hypoglycemia in the randomized controlled trial PARAGON-HF, and performed pooled analyses of PARAGON-HF and PARADIGM-HF. RESULTS Among 2395 patients with HFpEF and diabetes in PARAGON-HF, sacubitril/valsartan compared with valsartan reduced HbA1c (baseline-adjusted between-group difference in HbA1c change at 48 weeks: - 0.24%, 95% CI - 0.33 to - 0.16%, P < 0.001). Numerically, new insulin treatment was initiated less often in the sacubitril/valsartan group than in the valsartan group, but the difference was not statistically significant (12.8% vs. 16.1%; HR: 0.80, 95% CI 0.62-1.02, P = 0.07). Hypoglycemia adverse event reports were low, but more frequent in those receiving sacubitril/valsartan than in the valsartan group (4.2% vs. 2.6%; HR: 1.64, 95% CI 1.05-2.56, P = 0.030). In a pooled analysis of PARAGON-HF and PARADIGM-HF, the effect of sacubitril/valsartan on change in HbA1c was not significantly modified by LVEF (Pinteraction = 0.56). Across the spectrum of LVEF, sacubitril/valsartan reduced new insulin therapy (HR: 0.75, 95% CI 0.63-0.89, P = 0.001), compared with enalapril or valsartan. CONCLUSIONS Sacubitril/valsartan reduced HbA1c and new insulin therapy in patients with heart failure and diabetes across the spectrum of LVEF but may be associated with a slightly higher risk for hypoglycemia. Trial registration ClinicalTrials.gov NCT01920711.
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Affiliation(s)
- Magnus O Wijkman
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
- Department of Internal Medicine, Department of Health, Medicine and Caring Sciences, Linköping University, Norrköping, Sweden
| | - Brian Claggett
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - Rasmus Rørth
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Alice Jackson
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA
- Imperial College, London, UK
| | - Michael Zile
- Medical University of South Carolina and Ralph H. Johnson Veterans Affairs Medical Center, Charleston, SC, USA
| | - Jean Rouleau
- Montreal Heart Institute, University of Montreal, Montreal, Canada
| | - Karl Swedberg
- Department of Molecular and Clinical Medicine, University of Gothenburg, Gothenburg, Sweden
| | | | - Sanjiv J Shah
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham & Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
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25
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Pirruccello JP, Di Achille P, Nauffal V, Nekoui M, Friedman SF, Klarqvist MDR, Chaffin MD, Weng LC, Cunningham JW, Khurshid S, Roselli C, Lin H, Koyama S, Ito K, Kamatani Y, Komuro I, Jurgens SJ, Benjamin EJ, Batra P, Natarajan P, Ng K, Hoffmann U, Lubitz SA, Ho JE, Lindsay ME, Philippakis AA, Ellinor PT. Genetic analysis of right heart structure and function in 40,000 people. Nat Genet 2022; 54:792-803. [PMID: 35697867 PMCID: PMC10313645 DOI: 10.1038/s41588-022-01090-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2021] [Accepted: 04/26/2022] [Indexed: 01/29/2023]
Abstract
Congenital heart diseases often involve maldevelopment of the evolutionarily recent right heart chamber. To gain insight into right heart structure and function, we fine-tuned deep learning models to recognize the right atrium, right ventricle and pulmonary artery, measuring right heart structures in 40,000 individuals from the UK Biobank with magnetic resonance imaging. Genome-wide association studies identified 130 distinct loci associated with at least one right heart measurement, of which 72 were not associated with left heart structures. Loci were found near genes previously linked with congenital heart disease, including NKX2-5, TBX5/TBX3, WNT9B and GATA4. A genome-wide polygenic predictor of right ventricular ejection fraction was associated with incident dilated cardiomyopathy (hazard ratio, 1.33 per standard deviation; P = 7.1 × 10-13) and remained significant after accounting for a left ventricular polygenic score. Harnessing deep learning to perform large-scale cardiac phenotyping, our results yield insights into the genetic determinants of right heart structure and function.
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Affiliation(s)
- James P Pirruccello
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Paolo Di Achille
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Victor Nauffal
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mahan Nekoui
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Samuel F Friedman
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Marcus D R Klarqvist
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Mark D Chaffin
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Lu-Chen Weng
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Jonathan W Cunningham
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Shaan Khurshid
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Carolina Roselli
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Honghuang Lin
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, MA, USA
- Division of Clinical Informatics, Department of Medicine, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Satoshi Koyama
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Laboratory for Cardiovascular Genomics and Informatics, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Kaoru Ito
- Laboratory for Cardiovascular Genomics and Informatics, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Yoichiro Kamatani
- Laboratory of Complex Trait Genomics, Department of Computational Biology and Medical Sciences, Graduate School of Frontier Sciences, The University of Tokyo, Tokyo, Japan
- Laboratory for Statistical and Translational Genetics, RIKEN Center for Integrative Medical Sciences, Kanagawa, Japan
| | - Issei Komuro
- Department of Cardiovascular Medicine, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Sean J Jurgens
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Department of Experimental Cardiology, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Emelia J Benjamin
- Framingham Heart Study, Boston University and National Heart, Lung, and Blood Institute, Framingham, MA, USA
- Department of Medicine, Cardiology and Preventive Medicine Sections, Boston University School of Medicine, Boston, MA, USA
- Epidemiology Department, Boston University School of Public Health, Boston, MA, USA
| | - Puneet Batra
- Data Sciences Platform, Broad Institute of MIT and Harvard, Cambridge, MA, USA
| | - Pradeep Natarajan
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | - Udo Hoffmann
- Department of Radiology, Harvard Medical School, Boston, MA, USA
- Cardiovascular Imaging Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Steven A Lubitz
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA
| | - Jennifer E Ho
- Harvard Medical School, Boston, MA, USA
- CardioVascular Institute and Division of Cardiology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Mark E Lindsay
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA
- Harvard Medical School, Boston, MA, USA
- Thoracic Aortic Center, Massachusetts General Hospital, Boston, MA, USA
| | | | - Patrick T Ellinor
- Cardiology Division, Massachusetts General Hospital, Boston, MA, USA.
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA.
- Cardiovascular Disease Initiative, Broad Institute of MIT and Harvard, Cambridge, MA, USA.
- Harvard Medical School, Boston, MA, USA.
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA.
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27
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Ravi KS, Espersen C, Curtis KA, Cunningham JW, Jering KS, Prasad NG, Platz E, Mc Causland FR. Temporal Changes in Electrolytes, Acid-Base, QTc Duration, and Point-of-Care Ultrasound during Inpatient Hemodialysis Sessions. Kidney360 2022; 3:1217-1227. [PMID: 35919528 PMCID: PMC9337888 DOI: 10.34067/kid.0001652022] [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] [Subscribe] [Scholar Register] [Received: 03/02/2022] [Accepted: 05/09/2022] [Indexed: 02/02/2023]
Abstract
Background Of the more than 550,000 patients receiving maintenance hemodialysis (HD) in the United States, each has an average of 1.6 admissions annually (>880,000 inpatient HD sessions). Little is known about the temporal changes in laboratory values, ECGs, and intravascular and extravascular volume during inpatient HD sessions. Methods In this prospective cohort study of hospitalized HD patients, we assessed intradialytic laboratory values (metabolic panels, blood gases, ionized calcium levels), ECGs, and sonographic measures of volume status. Results Among 30 participants undergoing HD (mean age 62 years; 53% men, 43% Black) laboratory values had the largest changes in the first hour of HD. There was no significant change in ionized calcium levels pre- to post-HD (change: -0.01±0.07, P=0.24); 12 of 30 and 17 of 30 patients had levels below the lower reference limit at the beginning and end of HD, respectively. The mean pH increased pre- to post-HD (change: 0.06±0.04, P<0.001); 21 of 30 had a pH above the upper reference limit post-HD. There was a trend toward longer median QTc duration from pre- to post-HD (change: 7.5 msec [-5 msec, 19 msec], P=0.07). The sum of B lines on lung ultrasound decreased from pre- to post-HD (median decrease: 3 [1, 7], P<0.01). The collapsibility index of the inferior vena cava increased pre- to post-HD (median increase: 4.8% [1.5%, 13.4%], P=0.01), whereas internal jugular vein diameter did not change (P=0.24). Conclusions Among hospitalized patients undergoing HD, we found dynamic changes in laboratory values, QTc duration, and volume status. Further research is required to assess whether HD prescriptions can be tailored to alter these variations to potentially improve patient outcomes.
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Affiliation(s)
- Katherine Scovner Ravi
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Caroline Espersen
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Cardiovascular Noninvasive Imaging Research Laboratory, Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Katherine A. Curtis
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
| | - Jonathan W. Cunningham
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Karola S. Jering
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Narayana G. Prasad
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Elke Platz
- Harvard Medical School, Boston, Massachusetts,Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Finnian R. Mc Causland
- Renal Division, Department of Medicine, Brigham and Women’s Hospital, Boston, Massachusetts,Harvard Medical School, Boston, Massachusetts
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28
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Khurshid S, Reeder C, Harrington LX, Singh P, Sarma G, Friedman SF, Di Achille P, Diamant N, Cunningham JW, Turner AC, Lau ES, Haimovich JS, Al-Alusi MA, Wang X, Klarqvist MDR, Ashburner JM, Diedrich C, Ghadessi M, Mielke J, Eilken HM, McElhinney A, Derix A, Atlas SJ, Ellinor PT, Philippakis AA, Anderson CD, Ho JE, Batra P, Lubitz SA. Cohort design and natural language processing to reduce bias in electronic health records research. NPJ Digit Med 2022; 5:47. [PMID: 35396454 PMCID: PMC8993873 DOI: 10.1038/s41746-022-00590-0] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 03/09/2022] [Indexed: 01/04/2023] Open
Abstract
Electronic health record (EHR) datasets are statistically powerful but are subject to ascertainment bias and missingness. Using the Mass General Brigham multi-institutional EHR, we approximated a community-based cohort by sampling patients receiving longitudinal primary care between 2001-2018 (Community Care Cohort Project [C3PO], n = 520,868). We utilized natural language processing (NLP) to recover vital signs from unstructured notes. We assessed the validity of C3PO by deploying established risk models for myocardial infarction/stroke and atrial fibrillation. We then compared C3PO to Convenience Samples including all individuals from the same EHR with complete data, but without a longitudinal primary care requirement. NLP reduced the missingness of vital signs by 31%. NLP-recovered vital signs were highly correlated with values derived from structured fields (Pearson r range 0.95-0.99). Atrial fibrillation and myocardial infarction/stroke incidence were lower and risk models were better calibrated in C3PO as opposed to the Convenience Samples (calibration error range for myocardial infarction/stroke: 0.012-0.030 in C3PO vs. 0.028-0.046 in Convenience Samples; calibration error for atrial fibrillation 0.028 in C3PO vs. 0.036 in Convenience Samples). Sampling patients receiving regular primary care and using NLP to recover missing data may reduce bias and maximize generalizability of EHR research.
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Affiliation(s)
- Shaan Khurshid
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Christopher Reeder
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Lia X Harrington
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Pulkit Singh
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Gopal Sarma
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Samuel F Friedman
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Paolo Di Achille
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Nathaniel Diamant
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jonathan W Cunningham
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
- Division of Cardiology, Brigham and Women's Hospital, Boston, MA, USA
| | - Ashby C Turner
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
| | - Emily S Lau
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Julian S Haimovich
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Mostafa A Al-Alusi
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
| | - Xin Wang
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Marcus D R Klarqvist
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Jeffrey M Ashburner
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Christian Diedrich
- Bayer AG, Research and Development, Pharmaceuticals, Leverkusen, Germany
| | - Mercedeh Ghadessi
- Bayer AG, Research and Development, Pharmaceuticals, Leverkusen, Germany
| | - Johanna Mielke
- Bayer AG, Research and Development, Pharmaceuticals, Leverkusen, Germany
| | - Hanna M Eilken
- Bayer AG, Research and Development, Pharmaceuticals, Leverkusen, Germany
| | - Alice McElhinney
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Andrea Derix
- Bayer AG, Research and Development, Pharmaceuticals, Leverkusen, Germany
| | - Steven J Atlas
- Harvard Medical School, Boston, MA, USA
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Patrick T Ellinor
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA
| | - Anthony A Philippakis
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
- Eric and Wendy Schmidt Center, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Christopher D Anderson
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
- Henry and Allison McCance Center for Brain Health, Massachusetts General Hospital, Boston, MA, USA
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
- Department of Neurology, Brigham and Women's Hospital, Boston, MA, USA
| | - Jennifer E Ho
- Division of Cardiology, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Puneet Batra
- Data Sciences Platform, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Steven A Lubitz
- Cardiovascular Research Center, Massachusetts General Hospital, Boston, MA, USA.
- Cardiovascular Disease Initiative, Broad Institute of Harvard and the Massachusetts Institute of Technology, Cambridge, MA, USA.
- Demoulas Center for Cardiac Arrhythmias, Massachusetts General Hospital, Boston, MA, USA.
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Pabón MA, Cunningham JW, Claggett BL, Packer M, Zile M, Pfeffer MA, Lefkowitz M, Shi V, Rizkala A, McMurray JJV, Solomon SD, Vaduganathan M. Natriuretic Peptide-Based Inclusion Criteria in Heart Failure with Preserved Ejection Fraction Clinical Trials: Insights from PARAGON-HF. Eur J Heart Fail 2022; 24:672-677. [PMID: 35080787 DOI: 10.1002/ejhf.2439] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2021] [Revised: 01/14/2022] [Accepted: 01/21/2022] [Indexed: 11/09/2022] Open
Abstract
AIM Natriuretic peptides (NPs) are now routinely incorporated as key inclusion criteria in clinical trials of heart failure with preserved ejection fraction (HFpEF) as objective measures of risk. An early amendment in PARAGON-HF required all participants to have elevated NP concentrations, but some were enrolled pre-amendment, providing a unique opportunity to understand the influence of enrollment pathway in HFpEF clinical trials. METHODS AND RESULTS Among 4,796 participants in PARAGON-HF, 193 (4.0%) did not meet the final NP-based enrollment criteria (NT-proBNP >300 pg/ml for patients in sinus rhythm or >900 pg/ml for patients in atrial fibrillation/flutter). These patients had lower rates of the primary endpoint of total HF hospitalizations and cardiovascular death as compared with patients meeting final enrollment criteria (8.6 [6.7-11.2] events per 100py vs. 14.0 [13.4-14.7] events per 100py P=0.01). The rate ratio for the treatment effect comparing sacubitril/valsartan with valsartan was 0.85 [95% CI 0.74-0.99]; P=0.035 in those who met final criteria. CONCLUSIONS NPs are an important tool in HFpEF clinical trials to objectively affirm diagnoses and enrich clinical event rates.
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Affiliation(s)
- Maria A Pabón
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Jonathan W Cunningham
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | - Michael Zile
- RHJ Department of Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, South Carolina
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | | | | | | | - John J V McMurray
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA
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Jering KS, McGrath MM, Mc Causland FR, Claggett B, Cunningham JW, Solomon SD. Excess mortality in solid organ transplant recipients hospitalized with COVID-19: A large-scale comparison of SOT recipients hospitalized with or without COVID-19. Clin Transplant 2022; 36:e14492. [PMID: 34558116 PMCID: PMC8646895 DOI: 10.1111/ctr.14492] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Revised: 09/13/2021] [Accepted: 09/17/2021] [Indexed: 12/24/2022]
Abstract
BACKGROUND Solid-organ transplant (SOT) recipients with coronavirus disease 2019 (COVID-19) have higher risk of adverse outcomes compared to the general population. Whether hospitalized SOT recipients with COVID-19 are at higher risk of mortality than SOT recipients hospitalized for other causes, including non-COVID-19 pneumonia, remains unclear. METHODS We used logistic regression to compare outcomes of SOT recipients hospitalized with COVID-19 to non-COVID-19 related admissions and with non-COVID-19 pneumonia. RESULTS Of 17,012 hospitalized SOT recipients, 1682 had COVID-19. Those with COVID-19 had higher odds of ICU admission (adjusted odds ratio [aOR] 2.12 [95%CI: 1.88-2.39]) and mechanical ventilation (aOR 3.75 [95%CI: 3.24-4.33]). COVID-19 was associated with higher odds of in-hospital death, which was more pronounced earlier in the pandemic (aOR 9.74 [95%CI: 7.08-13.39] for April/May vs. aOR 7.08 [95%CI: 5.62-8.93] for June through November 2020; P-interaction = .03). Compared to SOT recipients hospitalized with non-COVID-19 pneumonia, odds of in-hospital death were higher in SOT recipients with COVID-19 (aOR 2.44 [95% CI: 1.90-3.13]), regardless of time of hospitalization (P-interaction > .40). CONCLUSIONS In this large cohort of SOT recipients, hospitalization with COVID-19 was associated with higher odds of complications and in-hospital mortality than non-COVID-19 related admissions, and 2.5-fold higher odds of in-hospital mortality, compared to SOT recipients with non-COVID-19 pneumonia.
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Affiliation(s)
- Karola S. Jering
- Cardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Martina M. McGrath
- Harvard Medical SchoolBostonMassachusettsUSA
- Renal DivisionDepartment of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Finnian R. Mc Causland
- Harvard Medical SchoolBostonMassachusettsUSA
- Renal DivisionDepartment of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
| | - Brian Claggett
- Cardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Jonathan W. Cunningham
- Cardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
| | - Scott D. Solomon
- Cardiovascular DivisionDepartment of MedicineBrigham and Women's HospitalBostonMassachusettsUSA
- Harvard Medical SchoolBostonMassachusettsUSA
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Latifi AN, Ortiz J, Cunningham JW, McGregor PC, Aragam J. Early Identification of Decompensated Aortic Regurgitation With Stress Echocardiography. CASE (Phila) 2021; 5:403-407. [PMID: 34993372 PMCID: PMC8712953 DOI: 10.1016/j.case.2021.07.012] [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] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
•Chronic severe AR progresses slowly with a long asymptomatic compensated phase.•Stress echocardiography (SE) has the ability to uncover subclinical LV dysfunction.•SE can identify patients with severe AR who may benefit from earlier intervention.
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Affiliation(s)
- Ahmad N. Latifi
- Cardiovascular Division, Boston Medical Center, Boston, Massachusetts
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Jake Ortiz
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
| | - Jonathan W. Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Pei-Chun McGregor
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
- Harvard Medical School, Boston, Massachusetts
| | - Jayashri Aragam
- Department of Cardiology, Boston Veterans Affairs Healthcare System, West Roxbury, Massachusetts
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
- Harvard Medical School, Boston, Massachusetts
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Affiliation(s)
| | - Peder L Myhre
- Division of Medicine, Akershus University Hospital and University of Oslo, Oslo, Norway. https://twitter.com/pmyhre
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Affiliation(s)
- Jonathan W. Cunningham
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (J.W.C., B.L.C., K.S.J., M.V., A.S.B., S.D.S.)
| | - Brian L. Claggett
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (J.W.C., B.L.C., K.S.J., M.V., A.S.B., S.D.S.)
| | - Karola S. Jering
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (J.W.C., B.L.C., K.S.J., M.V., A.S.B., S.D.S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (J.W.C., B.L.C., K.S.J., M.V., A.S.B., S.D.S.)
| | - Ankeet S. Bhatt
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (J.W.C., B.L.C., K.S.J., M.V., A.S.B., S.D.S.)
| | - Ning Rosenthal
- Premier Research Services, Premier Inc., Charlotte, NC (N.R.)
| | - Scott D. Solomon
- Cardiovascular Division, Brigham and Women’s Hospital, Boston, MA (J.W.C., B.L.C., K.S.J., M.V., A.S.B., S.D.S.)
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Jering KS, Claggett BL, Cunningham JW, Rosenthal N, Vardeny O, Greene MF, Solomon SD. Clinical Characteristics and Outcomes of Hospitalized Women Giving Birth With and Without COVID-19. JAMA Intern Med 2021; 181:714-717. [PMID: 33449067 PMCID: PMC7811188 DOI: 10.1001/jamainternmed.2020.9241] [Citation(s) in RCA: 144] [Impact Index Per Article: 48.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
This cohort study compares the clinical characteristics and outcomes of hospitalized women who gave birth with and without coronavirus disease 2019.
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Affiliation(s)
- Karola S Jering
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jonathan W Cunningham
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Ning Rosenthal
- Premier Applied Sciences, Premier Inc, Charlotte, North Carolina
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota
| | - Michael F Greene
- Department of Obstetrics and Gynecology, Massachusetts General Hospital, Boston
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts
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Hussain A, Tang O, Sun C, Jia X, Selvin E, Nambi V, Folsom A, Heiss G, Zannad F, Mosley T, Virani SS, Coresh J, Boerwinkle E, Yu B, Cunningham JW, Shah AM, Solomon SD, de Lemos JA, Hoogeveen RC, Ballantyne CM. Soluble Angiotensin-Converting Enzyme 2, Cardiac Biomarkers, Structure, and Function, and Cardiovascular Events (from the Atherosclerosis Risk in Communities Study). Am J Cardiol 2021; 146:15-21. [PMID: 33539861 PMCID: PMC8038970 DOI: 10.1016/j.amjcard.2021.01.017] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Revised: 01/13/2021] [Accepted: 01/19/2021] [Indexed: 12/13/2022]
Abstract
Membrane-bound angiotensin-converting enzyme 2 is important in regulation of the renin-angiotensin-aldosterone system, but the association of cleaved soluble ACE2 (sACE2) with cardiovascular disease (CVD) is unclear. We evaluated the association of sACE2 with cardiac biomarkers, structure, and function and cardiovascular events in the Atherosclerosis Risk in Communities Study. sACE2 was measured in a subset of 497 participants (mean age 78±5.4 years, 53% men, 27% black); Cox regression analyses assessed prospective associations of sACE2 with time to first CVD event at median 6.1-year follow-up. sACE2 was higher in men, blacks, and participants with prevalent CVD, diabetes, or hypertension. Higher sACE2 levels were associated with significantly higher biomarkers of cardiac injury (high-sensitivity cardiac troponin I and T, N-terminal pro-B-type natriuretic peptide), greater left ventricular mass index, and impaired diastolic function in linear regression analyses, and with increased risk for heart failure hospitalization (adjusted hazard ratio per natural log unit increase [HR] 1.32, 95% confidence interval [CI] 1.10 to 1.58), CVD events (HR 1.34, 95% CI 1.13 to 1.60), and all-cause death (HR 1.26, 95% CI 1.01 to 1.57). In an elderly biracial cohort, sACE2 was positively associated with biomarkers reflecting myocardial injury and neurohormonal activation, left ventricular mass index, impaired diastolic function, CVD, events and all-cause death.
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Affiliation(s)
- Aliza Hussain
- Department of Medicine, Baylor College of Medicine, Houston, Texax; Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Texas
| | - Olive Tang
- Department of Epidemiology and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Caroline Sun
- Department of Medicine, Baylor College of Medicine, Houston, Texax
| | - Xiaoming Jia
- Department of Medicine, Baylor College of Medicine, Houston, Texax
| | - Elizabeth Selvin
- Department of Epidemiology and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Vijay Nambi
- Department of Medicine, Baylor College of Medicine, Houston, Texax; Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Texas; Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Aaron Folsom
- Division of Epidemiology and Community Health, University of Minnesota, Minneapolis, Minnesota
| | - Gerardo Heiss
- Department of Epidemiology, University of North Carolina, Chapel Hill, North Carolina
| | - Faiez Zannad
- French Clinical Research Infrastructure Network Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Université de Lorraine, Nancy, France
| | - Thomas Mosley
- Memory Impairment and Neurodegenerative Dementia Center, University of Mississippi Medical Center, Jackson, Mississippi
| | - Salim S Virani
- Department of Medicine, Baylor College of Medicine, Houston, Texax; Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Texas; Department of Medicine, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
| | - Josef Coresh
- Department of Epidemiology and Welch Center for Prevention, Epidemiology and Clinical Research, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Eric Boerwinkle
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Bing Yu
- School of Public Health, University of Texas Health Science Center at Houston, Houston, Texas
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Amil M Shah
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, and Harvard Medical School, Boston, Massachusetts
| | - James A de Lemos
- Division of Cardiology, University of Texas-Southwestern Medical Center, Dallas, Texas
| | - Ron C Hoogeveen
- Department of Medicine, Baylor College of Medicine, Houston, Texax; Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Texas
| | - Christie M Ballantyne
- Department of Medicine, Baylor College of Medicine, Houston, Texax; Center for Cardiometabolic Disease Prevention, Baylor College of Medicine, Houston, Texas.
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Vaduganathan M, Cunningham JW, Claggett BL, Causland FM, Barkoudah E, Finn P, Zannad F, Pfeffer MA, Rizkala AR, Sabarwal S, McMurray JJV, Solomon S, Desai AS. Worsening Heart Failure Episodes Outside a Hospital Setting in Heart Failure With Preserved Ejection Fraction: The PARAGON-HF Trial. JACC Heart Fail 2021; 9:374-382. [PMID: 33839075 DOI: 10.1016/j.jchf.2021.01.014] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Revised: 01/06/2021] [Accepted: 01/07/2021] [Indexed: 11/21/2022]
Abstract
OBJECTIVES This study sought to evaluate the frequency and prognostic implications of urgent heart failure (HF) visits in a large global clinical trial of HF with preserved ejection fraction (HFpEF). BACKGROUND Episodes of worsening HF managed without hospitalization are common and prognostically important in HF with reduced ejection fraction (EF). The significance of these ambulatory worsening HF events in HFpEF is uncertain. METHODS PARAGON-HF (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction) randomly assigned 4,796 patients with HFpEF (≥45%) to treatment with sacubitril/valsartan vs. valsartan with a primary composite endpoint of total HF hospitalizations and cardiovascular death. Urgent ambulatory HF visits requiring intravenous diuretic treatment were prospectively collected and adjudicated by a blinded committee. We examined the effect of study treatment on a prespecified expanded composite of cardiovascular death and worsening HF events (including HF hospitalizations and urgent HF visits) and the effect of each type of HF event on subsequent mortality. RESULTS Of 884 first worsening HF events, 66 (7.5%) were urgent HF visits. Patients whose first episode of worsening HF event was an urgent visit had similar age, comorbidities, baseline N-terminal prohormone of B-type natriuretic peptide, and Meta-Analysis Global Group in Chronic Heart Failure risk scores to those in whom the first HF event was a hospitalization (all comparisons p > 0.05). Regardless of the treatment setting, patients with a first episode of worsening HF had higher rates of subsequent death (19.2 per 100 patient-years; 95% confidence interval [CI]: 16.9 to 21.8 for HF hospitalization and 10.1 per 100 patients-years; 95% CI: 5.4 to 18.7 for urgent HF visit) compared with those who did not experience worsening HF (death rate 4.0 per 100 patient-years; 95% CI: 3.6 to 4.4). Including total urgent HF visits in the composite study endpoint added 95 total events and would have shortened the trial duration needed for event accrual. The addition of urgent HF visits in a prespecified composite endpoint reinforced the treatment efficacy of sacubitril/valsartan compared with valsartan (rate ratio 0.86; 95% CI: 0.75 to 0.99; p = 0.040). CONCLUSIONS Like HF hospitalizations, worsening HF events treated in the ambulatory setting are prognostically important in HFpEF. Inclusion of these events in the composite primary endpoint underscores the benefit of sacubitril/valsartan compared with valsartan in PARAGON-HF. (Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
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Affiliation(s)
- Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Finnian Mc Causland
- Division of Nephrology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ebrahim Barkoudah
- Hospital Medicine Unit and Division of General Internal Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Peter Finn
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Faiez Zannad
- Université de Lorraine INSERM, Centre, d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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37
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Affiliation(s)
| | - Mandeep R Mehra
- Brigham and Women’s Hospital and Harvard Medical School, USA
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38
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Bhatt AS, Varshney AS, Nekoui M, Moscone A, Cunningham JW, Jering KS, Patel PN, Sinnenberg LE, Bernier TD, Buckley LF, Cook BM, Dempsey J, Kelly J, Knowles DM, Lupi K, Malloy R, Matta LS, Rhoten MN, Sharma K, Snyder CA, Ting C, McElrath EE, Amato MG, Alobaidly M, Ulbricht CE, Choudhry NK, Adler DS, Vaduganathan M. Virtual optimization of guideline-directed medical therapy in hospitalized patients with heart failure with reduced ejection fraction: the IMPLEMENT-HF pilot study. Eur J Heart Fail 2021; 23:1191-1201. [PMID: 33768599 DOI: 10.1002/ejhf.2163] [Citation(s) in RCA: 42] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/10/2021] [Revised: 03/18/2021] [Accepted: 03/21/2021] [Indexed: 11/10/2022] Open
Abstract
AIMS Implementation of guideline-directed medical therapy (GDMT) for heart failure with reduced ejection fraction (HFrEF) remains incomplete. Non-cardiovascular hospitalization may present opportunities for GDMT optimization. We assessed the efficacy and durability of a virtual, multidisciplinary 'GDMT Team' on medical therapy prescription for HFrEF. METHODS AND RESULTS Consecutive hospitalizations in patients with HFrEF (ejection fraction ≤40%) were prospectively identified from 3 February to 1 March 2020 (usual care group) and 2 March to 28 August 2020 (intervention group). Patients with critical illness, de novo heart failure, and systolic blood pressure <90 mmHg in the preceeding 24 hs prior to enrollment were excluded. In the intervention group, a pharmacist-physician GDMT Team provided optimization suggestions to treating teams based on an evidence-based algorithm. The primary outcome was a GDMT optimization score, the sum of positive (+1 for new initiations or up-titrations) and negative therapeutic changes (-1 for discontinuations or down-titrations) at hospital discharge. Serious in-hospital safety events were assessed. Among 278 consecutive encounters with HFrEF, 118 met eligibility criteria; 29 (25%) received usual care and 89 (75%) received the GDMT Team intervention. Among usual care encounters, there were no changes in GDMT prescription during hospitalization. In the intervention group, β-blocker (72% to 88%; P = 0.01), angiotensin receptor-neprilysin inhibitor (6% to 17%; P = 0.03), mineralocorticoid receptor antagonist (16% to 29%; P = 0.05), and triple therapy (9% to 26%; P < 0.01) prescriptions increased during hospitalization. After adjustment for clinically relevant covariates, the GDMT Team was associated with an increase in GDMT optimization score (+0.58; 95% confidence interval +0.09 to +1.07; P = 0.02). There were no serious in-hospital adverse events. CONCLUSIONS Non-cardiovascular hospitalizations are a potentially safe and effective setting for GDMT optimization. A virtual GDMT Team was associated with improved heart failure therapeutic optimization. This implementation strategy warrants testing in a prospective randomized controlled trial.
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Affiliation(s)
- Ankeet S Bhatt
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Anubodh S Varshney
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | | | - Alea Moscone
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Jonathan W Cunningham
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Karola S Jering
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Parth N Patel
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Thomas D Bernier
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Leo F Buckley
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Bryan M Cook
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Jillian Dempsey
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Julie Kelly
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | | | - Kenneth Lupi
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Rhynn Malloy
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Lina S Matta
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Megan N Rhoten
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Krishan Sharma
- Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - Clara Ting
- Department of Pharmacy, Brigham and Women's Hospital, Boston, MA, USA
| | - Erin E McElrath
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Mary G Amato
- Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA
| | - Maryam Alobaidly
- Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA
| | - Catherine E Ulbricht
- Massachusetts College of Pharmacy and Health Sciences, Boston, MA, USA.,Department of Quality and Safety, Brigham and Women's Hospital, Boston, MA, USA
| | - Niteesh K Choudhry
- Center for Healthcare Delivery Sciences, Division of Pharmacoepidemiology and Pharmacoeconomics, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
| | - Dale S Adler
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA.,Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Muthiah Vaduganathan
- Division of Cardiology, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA, USA
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Bhatt AS, Jering KS, Vaduganathan M, Claggett BL, Cunningham JW, Rosenthal N, Signorovitch J, Thune JJ, Vardeny O, Solomon SD. Clinical Outcomes in Patients With Heart Failure Hospitalized With COVID-19. JACC Heart Fail 2021; 9:65-73. [PMID: 33384064 PMCID: PMC7833294 DOI: 10.1016/j.jchf.2020.11.003] [Citation(s) in RCA: 85] [Impact Index Per Article: 28.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Revised: 11/06/2020] [Accepted: 11/12/2020] [Indexed: 01/25/2023]
Abstract
OBJECTIVES The purpose of this study was to evaluate in-hospital outcomes among patients with a history of heart failure (HF) hospitalized with coronavirus disease-2019 (COVID-19). BACKGROUND Cardiometabolic comorbidities are common in patients with severe COVID-19. Patients with HF may be particularly susceptible to COVID-19 complications. METHODS The Premier Healthcare Database was used to identify patients with at least 1 HF hospitalization or 2 HF outpatient visits between January 1, 2019, and March 31, 2020, who were subsequently hospitalized between April and September 2020. Baseline characteristics, health care resource utilization, and mortality rates were compared between those hospitalized with COVID-19 and those hospitalized with other causes. Predictors of in-hospital mortality were identified in HF patients hospitalized with COVID-19 by using multivariate logistic regression. RESULTS Among 1,212,153 patients with history of HF, 132,312 patients were hospitalized from April 1, 2020, to September 30, 2020. A total of 23,843 patients (18.0%) were hospitalized with acute HF, 8,383 patients (6.4%) were hospitalized with COVID-19, and 100,068 patients (75.6%) were hospitalized with alternative reasons. Hospitalization with COVID-19 was associated with greater odds of in-hospital mortality as compared with hospitalization with acute HF; 24.2% of patients hospitalized with COVID-19 died in-hospital compared to 2.6% of those hospitalized with acute HF. This association was strongest in April (adjusted odds ratio [OR]: 14.48; 95% confidence interval [CI]:12.25 to 17.12) than in subsequent months (adjusted OR: 10.11; 95% CI: 8.95 to 11.42; pinteraction <0.001). Among patients with HF hospitalized with COVID-19, male sex (adjusted OR: 1.26; 95% CI: 1.13 to 1.40) and morbid obesity (adjusted OR: 1.25; 95% CI: 1.07 to 1.46) were associated with greater odds of in-hospital mortality, along with age (adjusted OR: 1.35; 95% CI: 1.29 to 1.42 per 10 years) and admission earlier in the pandemic. CONCLUSIONS Patients with HF hospitalized with COVID-19 are at high risk for complications, with nearly 1 in 4 dying during hospitalization.
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Affiliation(s)
- Ankeet S Bhatt
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Karola S Jering
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Muthiah Vaduganathan
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Brian L Claggett
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Jonathan W Cunningham
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Ning Rosenthal
- Premier Applied Sciences, Premier Inc., Charlotte, North Carolina, USA
| | | | - Jens J Thune
- Department of Cardiology, Bispebjerg University Hospital, Copenhagen, Denmark
| | - Orly Vardeny
- Center for Care Delivery and Outcomes Research, Minneapolis Veterans' Affairs Health Care System, Minneapolis, Minnesota, USA
| | - Scott D Solomon
- Department of Medicine, Division of Cardiovascular Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
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Cunningham JW, Claggett BL, Solomon SD, Zile MR. Reply: Circulating Biomarkers Specific to Myocardial Extracellular Matrix Are Required to Embrace the Heterogeneity of HFpEF. J Am Coll Cardiol 2020; 76:2417-2418. [PMID: 33183516 DOI: 10.1016/j.jacc.2020.09.551] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Accepted: 09/20/2020] [Indexed: 10/23/2022]
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Cunningham JW, Jhund PS. Vericiguat in Heart Failure With Reduced Ejection Fraction With High Natriuretic Peptides: A Case of Too Little, Too Late? JACC Heart Fail 2020; 8:940-942. [PMID: 33039450 DOI: 10.1016/j.jchf.2020.09.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Accepted: 09/01/2020] [Indexed: 11/29/2022]
Affiliation(s)
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, Scotland, United Kingdom. https://twitter.com/PSJhund
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Cunningham JW, Vaduganathan M, Claggett BL, Jering KS, Bhatt AS, Rosenthal N, Solomon SD. Clinical Outcomes in Young US Adults Hospitalized With COVID-19. JAMA Intern Med 2020; 181:2770542. [PMID: 32902580 PMCID: PMC7489373 DOI: 10.1001/jamainternmed.2020.5313] [Citation(s) in RCA: 133] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Accepted: 08/14/2020] [Indexed: 12/28/2022]
Affiliation(s)
| | | | | | | | | | - Ning Rosenthal
- Premier Applied Sciences, Premier Inc, Charlotte, North Carolina
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Cunningham JW, Ferreira JP, Zannad F. Reply: Natriuretic Peptide Measurement Is Key to a Solution in the Clinical Trial and Clinical Practice. JACC Heart Fail 2020; 8:783-784. [PMID: 32883442 DOI: 10.1016/j.jchf.2020.07.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/10/2020] [Accepted: 07/11/2020] [Indexed: 10/23/2022]
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Cunningham JW, Claggett BL, O'Meara E, Prescott MF, Pfeffer MA, Shah SJ, Redfield MM, Zannad F, Chiang LM, Rizkala AR, Shi VC, Lefkowitz MP, Rouleau J, McMurray JJV, Solomon SD, Zile MR. Effect of Sacubitril/Valsartan on Biomarkers of Extracellular Matrix Regulation in Patients With HFpEF. J Am Coll Cardiol 2020; 76:503-514. [PMID: 32731928 DOI: 10.1016/j.jacc.2020.05.072] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2020] [Revised: 05/28/2020] [Accepted: 05/28/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND Myocardial fibrosis may contribute to the pathophysiology of heart failure with preserved ejection fraction. Given the biochemical targets of sacubitril/valsartan, this study hypothesized that circulating biomarkers reflecting the mechanisms that determine extracellular matrix homeostasis are altered by sacubitril/valsartan compared with valsartan alone. OBJECTIVES This study investigated the effects of sacubitril/valsartan on biomarkers of extracellular matrix homeostasis and the association between biomarkers and the primary endpoint (total heart failure hospitalizations and cardiovascular death). METHODS N-terminal propeptide of collagen I and III, tissue inhibitor of matrix metalloproteinase 1, carboxyl-terminal telopeptide of collagen type I, and soluble ST2 were measured at baseline (n = 1,135) and 16 (n = 1,113) and 48 weeks (n = 1,016) after randomization. The effects of sacubitril/valsartan on these biomarkers were compared with those of valsartan alone. Baseline biomarker values and changes from baseline to 16 weeks were related to primary endpoint. RESULTS At baseline, all 5 biomarkers were higher than published referent control values. Sixteen weeks after randomization, sacubitril/valsartan decreased tissue inhibitor of matrix metalloproteinase 1 by 8% (95% confidence interval [CI]: 6% to 10%; p < 0.001), soluble ST2 by 4% (95% CI: 1% to 7%; p = 0.002), and N-terminal propeptide of collagen III by 3% (95% CI: 0% to 6%; p = 0.04) and increased carboxyl-terminal telopeptide of collagen type I by 4% (95% CI: 1% to 8%; p = 0.02) compared with valsartan alone, consistently in men and women and patients with left ventricular ejection fraction above or below the median of 57%. Higher levels of tissue inhibitor of matrix metalloproteinase 1 and soluble ST2 at baseline and increases in these markers at 16 weeks were associated with higher primary endpoint event rates. CONCLUSIONS Biomarkers reflecting extracellular matrix homeostasis are elevated in heart failure with preserved ejection fraction, favorably altered by sacubitril/valsartan, and have important prognostic value. (Prospective Comparison of ARNI With ARB Global Outcomes in HF With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
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Affiliation(s)
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Eileen O'Meara
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Faiez Zannad
- Centre d'Investigations Cliniques-Plurithématique 1433, and Institut National de la Santé et de la Recherche Médicale U1116, Centre Hospitalier Regional Universitaire, French Clinical Research Infrastructure Network, Investigation Network Initiative Cardiovascular and Renal Clinical Trialists, Nancy, France
| | | | | | | | | | - Jean Rouleau
- Montreal Heart Institute, Université de Montréal, Montreal, Quebec, Canada
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, Massachusetts.
| | - Michael R Zile
- Ralph H. Johnson Department of Veterans Affairs Medical Center, Charleston, South Carolina; Division of Cardiology, Medical University of South Carolina, Charleston, South Carolina.
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Cunningham JW, Vaduganathan M, Claggett BL, McMurray JJV, Solomon SD. Reply: The PARAGON-HF Trial: Toward Extension to Patients With HF Middle Range Ejection Fraction. JACC Heart Fail 2020; 8:698-699. [PMID: 32731952 DOI: 10.1016/j.jchf.2020.06.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Accepted: 06/10/2020] [Indexed: 11/25/2022]
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Cunningham JW, Vaduganathan M, Claggett BL, John JE, Desai AS, Lewis EF, Zile MR, Carson P, Jhund PS, Kober L, Pitt B, Shah SJ, Swedberg K, Anand IS, Yusuf S, McMurray JJV, Pfeffer MA, Solomon SD. Myocardial Infarction in Heart Failure With Preserved Ejection Fraction: Pooled Analysis of 3 Clinical Trials. JACC Heart Fail 2020; 8:618-626. [PMID: 32387067 DOI: 10.1016/j.jchf.2020.02.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/06/2020] [Accepted: 02/11/2020] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The authors investigated the relationship between past or incident myocardial infarction (MI) and cardiovascular (CV) events in heart failure with preserved ejection fraction (HFpEF). BACKGROUND MI and HFpEF share some common risk factors. The prognostic significance of MI in patients with HFpEF is uncertain. METHODS The authors pooled data from 3 trials-CHARM Preserved (Candesartan Cilexietil in Heart Failure Assessment of Reduction in Mortality and Morbidity), I-Preserve (Irbesartan in Heart Failure With Preserved Systolic Function), and the Americas region of TOPCAT (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist) (N = 8,916)-and examined whether MI before or following enrollment independently predicted CV death and heart failure (HF) hospitalization. RESULTS At baseline, 2,668 patients (30%) had history of MI. Prior MI was independently associated with greater risk of CV death (4.7 vs. 3.5 events/100 patient-years [py], adjusted hazard ratio [HR]: 1.42 [95% confidence interval (CI): 1.23 to 1.64]; p < 0.001). Excess sudden death drove this difference (1.9 vs. 1.2 events/100 py, adjusted HR: 1.55 [95% CI: 1.23 to 1.97]; p < 0.001). There was no difference in HF hospitalization (5.9 vs. 5.5 events/100 py, adjusted HR: 1.05, 95% CI: 0.92 to 1.19) or HF death by prior MI. During follow-up, MI occurred in 336 patients (3.8%). Risk of CV death increased 31-fold in the first 30 days after first post-enrollment MI, and remained 58% higher beyond 1 year after MI. Risk of first or recurrent HF hospitalization increased 2.4-fold after MI. CONCLUSIONS Prior MI in HFpEF is associated with greater CV and sudden death but similar risk of HF outcomes. Patients with HFpEF who experience MI are at high risk of subsequent CV death and HF hospitalization. These data highlight the importance of primary and secondary prevention of MI in patients with HFpEF. (Candesartan Cilexietil in Heart Failure Assessment of Reduction in Mortality and Morbidity [CHARM Preserved]; NCT00634712; Irbesartan in Heart Failure With Preserved Systolic Function [I-Preserve]; NCT00095238; and Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist [TOPCAT]; NCT00094302).
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Affiliation(s)
| | | | | | | | | | | | - Michael R Zile
- RHJ Department of Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, South Carolina
| | | | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Lars Kober
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor, Michigan
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | - Inder S Anand
- VA Medical Center and University of Minnesota, Minneapolis, Minnesota
| | - Salim Yusuf
- Hamilton Health Sciences and McMaster University, Hamilton, Ontario, Canada
| | - John J V McMurray
- BHF Cardiovascular Research Centre, University of Glasgow, Glasgow, Scotland, United Kingdom
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Vaduganathan M, Claggett BL, Jhund PS, Cunningham JW, Pedro Ferreira J, Zannad F, Packer M, Fonarow GC, McMurray JJV, Solomon SD. Estimating lifetime benefits of comprehensive disease-modifying pharmacological therapies in patients with heart failure with reduced ejection fraction: a comparative analysis of three randomised controlled trials. Lancet 2020; 396:121-128. [PMID: 32446323 DOI: 10.1016/s0140-6736(20)30748-0] [Citation(s) in RCA: 321] [Impact Index Per Article: 80.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 03/02/2020] [Accepted: 03/18/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND Three drug classes (mineralocorticoid receptor antagonists [MRAs], angiotensin receptor-neprilysin inhibitors [ARNIs], and sodium/glucose cotransporter 2 [SGLT2] inhibitors) reduce mortality in patients with heart failure with reduced ejection fraction (HFrEF) beyond conventional therapy consisting of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and β blockers. Each class was previously studied with different background therapies and the expected treatment benefits with their combined use are not known. Here, we used data from three previously reported randomised controlled trials to estimate lifetime gains in event-free survival and overall survival with comprehensive therapy versus conventional therapy in patients with chronic HFrEF. METHODS In this cross-trial analysis, we estimated treatment effects of comprehensive disease-modifying pharmacological therapy (ARNI, β blocker, MRA, and SGLT2 inhibitor) versus conventional therapy (ACE inhibitor or ARB and β blocker) in patients with chronic HFrEF by making indirect comparisons of three pivotal trials, EMPHASIS-HF (n=2737), PARADIGM-HF (n=8399), and DAPA-HF (n=4744). Our primary endpoint was a composite of cardiovascular death or first hospital admission for heart failure; we also assessed these endpoints individually and assessed all-cause mortality. Assuming these relative treatment effects are consistent over time, we then projected incremental long-term gains in event-free survival and overall survival with comprehensive disease-modifying therapy in the control group of the EMPHASIS-HF trial (ACE inhibitor or ARB and β blocker). FINDINGS The hazard ratio (HR) for the imputed aggregate treatment effects of comprehensive disease-modifying therapy versus conventional therapy on the primary endpoint of cardiovascular death or hospital admission for heart failure was 0·38 (95% CI 0·30-0·47). HRs were also favourable for cardiovascular death alone (HR 0·50 [95% CI 0·37-0·67]), hospital admission for heart failure alone (0·32 [0·24-0·43]), and all-cause mortality (0·53 [0·40-0·70]). Treatment with comprehensive disease-modifying pharmacological therapy was estimated to afford 2·7 additional years (for an 80-year-old) to 8·3 additional years (for a 55-year-old) free from cardiovascular death or first hospital admission for heart failure and 1·4 additional years (for an 80-year-old) to 6·3 additional years (for a 55-year-old) of survival compared with conventional therapy. INTERPRETATION Among patients with HFrEF, the anticipated aggregate treatment effects of early comprehensive disease-modifying pharmacological therapy are substantial and support the combination use of an ARNI, β blocker, MRA, and SGLT2 inhibitor as a new therapeutic standard. FUNDING None.
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Affiliation(s)
- Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Pardeep S Jhund
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Jonathan W Cunningham
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - João Pedro Ferreira
- Université de Lorraine INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France; Department of Physiology and Cardiothoracic Surgery, University of Porto, Porto, Portugal
| | - Faiez Zannad
- Université de Lorraine INSERM, Centre d'Investigations Cliniques Plurithématique 1433, INSERM U1116, CHRU de Nancy, F-CRIN INI-CRCT, Nancy, France
| | - Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, Dallas, TX, USA; Imperial College, London, UK
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles Medical Center, Los Angeles, CA, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
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Cunningham JW, Vaduganathan M, Claggett BL, McMurray JJV, Solomon SD. Reply: NT-proBNP in Heart Failure With Preserved Ejection Fraction: Quest for a Marker Reflecting the Truth. JACC Heart Fail 2020; 8:597-598. [PMID: 32616172 DOI: 10.1016/j.jchf.2020.05.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 05/11/2020] [Indexed: 10/24/2022]
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Cunningham JW, Ferreira JP, Deng H, Anker SD, Byra WM, Cleland JGF, Gheorghiade M, Lam CSP, La Police D, Mehra MR, Neaton JD, Spiro TE, van Veldhuisen DJ, Greenberg B, Zannad F. Natriuretic Peptide-Based Inclusion Criteria in a Heart Failure Clinical Trial: Insights From COMMANDER HF. JACC Heart Fail 2020; 8:359-368. [PMID: 32171760 DOI: 10.1016/j.jchf.2019.12.009] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/19/2019] [Accepted: 12/20/2019] [Indexed: 02/06/2023]
Abstract
OBJECTIVES This study investigated the effects of a mid-trial protocol amendment requiring elevated natriuretic peptides for inclusion in the COMMANDER-HF (A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction, or Stroke in Participants with Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure) trial. BACKGROUND Heart failure (HF) trials that select patients based on history of HF hospitalization alone are susceptible to regional variations in event rates. Elevated plasma concentrations of natriuretic peptides (NPs) as selection criteria may help HF ascertainment and risk enrichment. In the COMMANDER-HF trial, B-type natriuretic peptide ≥200 ng/l or N-terminal pro-B-type natriuretic peptide ≥800 ng/l were added to inclusion criteria as a mid-trial protocol amendment, providing a unique case-study of NP-based inclusion criteria. METHODS We compared the baseline characteristics, event rates, and treatment effects for patients enrolled before and after the NP protocol amendment. The primary endpoint was all-cause death, myocardial infarction, or stroke. Secondary endpoints included HF rehospitalization and cardiovascular death. RESULTS A total of 5,022 patients with left ventricular ejection fraction ≤40% and coronary artery disease were included. Compared to patients enrolled before the NP protocol amendment, those enrolled post-amendment (n = 3,867, 77%) were older, more often had diabetes, and had lower values for body mass index, left ventricular ejection fraction, and estimated glomerular filtration rate, higher heart rate, and higher event rates: primary endpoint (hazard ratio [HR]: 1.32; 95% confidence interval [CI]: 1.16 to 1.50), cardiovascular death (HR: 1.29; 95% CI: 1.11 to 1.50), HF rehospitalization (HR: 1.31; 95% CI: 1.15 to 1.49), and major bleeding (HR: 1.71; 95% CI: 1.11 to 2.65). Differences between pre- and post-amendment rates were confined to and driven by Eastern Europe. This protocol amendment did not modify the neutral effect of rivaroxaban on the primary endpoint (p interaction = 0.36) or secondary endpoints. CONCLUSIONS In a global event-driven trial of rivaroxaban in HF, requiring elevated NPs for inclusion increased event rates allowing earlier completion of the trial but did not modify treatment effect. These data inform future HF trials regarding the expected impact of NP-based inclusion criteria on patient characteristics and event rates. (COMMANDER HF [A Study to Assess the Effectiveness and Safety of Rivaroxaban in Reducing the Risk of Death, Myocardial Infarction, or Stroke in Participants With Heart Failure and Coronary Artery Disease Following an Episode of Decompensated Heart Failure] NCT01877915).
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Affiliation(s)
| | - João Pedro Ferreira
- Centre d'Investigations Cliniques-Plurithématique 1433, and INSERM U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | | | - Stefan D Anker
- Department of Cardiology (CVK); and Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | | | - John G F Cleland
- Robertson Centre for Biostatistics & Clinical Trials, University of Glasgow, Glasgow, United Kingdom; National Heart & Lung Institute, Imperial College, London, United Kingdom; National Heart & Lung Institute, Imperial College London, United Kingdom
| | | | - Carolyn S P Lam
- National Heart Centre Singapore, Singapore; Duke-National University of Singapore, Singapore; Department of Cardiology, University Medical Center, Groningen, Groningen, the Netherlands; The George Institute for Global Health, Newtown, New South Wales, Australia
| | | | - Mandeep R Mehra
- Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts
| | - James D Neaton
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, Minnesota
| | | | - Dirk J van Veldhuisen
- Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Barry Greenberg
- Department of Medicine, Cardiology Division, University of California, San Diego, California
| | - Faiez Zannad
- Centre d'Investigations Cliniques-Plurithématique 1433, and INSERM U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France.
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Cunningham JW, Vaduganathan M, Claggett BL, Zile MR, Anand IS, Packer M, Zannad F, Lam CSP, Janssens S, Jhund PS, Kober L, Rouleau J, Shah SJ, Chopra VK, Shi VC, Lefkowitz MP, Prescott MF, Pfeffer MA, McMurray JJV, Solomon SD. Effects of Sacubitril/Valsartan on N-Terminal Pro-B-Type Natriuretic Peptide in Heart Failure With Preserved Ejection Fraction. JACC Heart Fail 2020; 8:372-381. [PMID: 32241619 DOI: 10.1016/j.jchf.2020.03.002] [Citation(s) in RCA: 45] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Revised: 02/25/2020] [Accepted: 03/05/2020] [Indexed: 11/21/2022]
Abstract
OBJECTIVES The authors sought to evaluate the prognostic significance of baseline N-terminal pro-B-type natriuretic peptide (NT-proBNP), whether NT-proBNP modified the treatment response to sacubitril/valsartan, and the treatment effect of sacubitril/valsartan on NT-proBNP overall and in key subgroups. BACKGROUND Sacubitril/valsartan reduces NT-proBNP in heart failure (HF) with both reduced and preserved ejection fraction (EF), but did not significantly reduce total HF hospitalizations and cardiovascular death compared with valsartan in patients with HF with preserved EF (HFpEF). METHODS In the PARAGON-HF (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction) trial, 4,796 patients with HFpEF and elevated NT-proBNP were randomized to sacubitril/valsartan or valsartan. NT-proBNP was measured at screening in all patients and at 5 subsequent times in >2,700 patients: before, between, and after sequential valsartan and sacubitril/valsartan run-in periods, and 16 and 48 weeks post-randomization. RESULTS Median NT-proBNP was 911 pg/ml (interquartile range: 464 to 1,613 pg/ml) at screening. Screening NT-proBNP was strongly associated with the primary endpoint, total HF hospitalizations and cardiovascular death (rate ratio [RR]: 1.68 per log increase in NT-proBNP, 95% confidence interval [CI]: 1.53 to 1.85; p < 0.001). This relationship was stronger in patients with atrial fibrillation (adjusted RR: 2.33 [95% CI: 1.89 to 2.87] vs. 1.58 [95% CI: 1.42 to 1.75] in patients without atrial fibrillation; p interaction <0.001) and weaker in obese patients (adjusted RR: 1.50 [95% CI: 1.31 to 1.71] vs. 1.92 [95% CI: 1.70 to 2.17] in nonobese patients; p interaction <0.001). Screening NT-proBNP did not modify the treatment effect of sacubitril/valsartan compared with valsartan (p interaction = 0.96). Sacubitril/valsartan reduced NT-proBNP by 19% (95% CI: 14% to 23%; p < 0.001) compared with valsartan 16 weeks post-randomization, with similar reductions in men (20%) and women (18%), and in patients with left ventricular EF ≤57% (20%) and >57% (18%). Decreases in NT-proBNP predicted lower subsequent risk of the primary endpoint. CONCLUSIONS Baseline NT-proBNP predicted HF events but did not modify the sacubitril/valsartan treatment effect in patients with HFpEF. Sacubitril/valsartan reduced NT-proBNP consistently in men and women, and in patients with lower or higher EF. (Efficacy and Safety of LCZ696 Compared to Valsartan, on Morbidity and Mortality in Heart Failure Patients With Preserved Ejection Fraction [PARAGON-HF]; NCT01920711).
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Affiliation(s)
- Jonathan W Cunningham
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts. https://twitter.com/JonWCunningham
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts. https://twitter.com/mvaduganathan
| | - Brian L Claggett
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts
| | - Michael R Zile
- RHJ Department of Veterans Affairs Medical Center and Medical University of South Carolina, Charleston, South Carolina
| | - Inder S Anand
- VA Medical Center and University of Minnesota, Minneapolis, Minnesota
| | | | - Faiez Zannad
- Centre d'Investigations Cliniques-Plurithématique 1433, and INSERM U1116, CHRU, F-CRIN INI-CRCT (Cardiovascular and Renal Clinical Trialists), Nancy, France
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore; Department of Cardiology, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands; The George Institute for Global Health, Australia
| | - Stefan Janssens
- Department of Cardiology, University Hospitals, Leuven, Belgium
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Lars Kober
- Rigshospitalet Copenhagen University Hospital, Copenhagen, Denmark
| | - Jean Rouleau
- Montreal Heart Institute and Université de Montréal, Montreal, Canada
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Vijay K Chopra
- Heart Failure Unit, Medanta Medicity, Gurugram, Haryana, India
| | | | | | | | - Marc A Pfeffer
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts
| | - John J V McMurray
- BHF Cardiovascular Research Centre, Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, United Kingdom
| | - Scott D Solomon
- Brigham and Women's Hospital, Division of Cardiovascular, Boston, Massachusetts.
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