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Chioncel O, Davison B, Adamo M, Antohi LE, Arrigo M, Barros M, Biegus J, Čerlinskaitė-Bajorė K, Celutkiene J, Cohen-Solal A, Damasceno A, Diaz R, Edwards C, Filippatos G, Kimmoun A, Lam CSP, Metra M, Novosadova M, Pagnesi M, Pang PS, Ponikowski P, Radu RI, Saidu H, Sliwa K, Voors AA, Takagi K, Ter Maaten JM, Tomasoni D, Cotter G, Mebazaa A. Non-cardiac comorbidities and intensive up-titration of oral treatment in patients recently hospitalized for heart failure: Insights from the STRONG-HF trial. Eur J Heart Fail 2023; 25:1994-2006. [PMID: 37728038 DOI: 10.1002/ejhf.3039] [Citation(s) in RCA: 3] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/14/2023] [Accepted: 09/17/2023] [Indexed: 09/21/2023] Open
Abstract
AIMS To assess the potential interaction between non-cardiac comorbidities (NCCs) and the efficacy and safety of high-intensity care (HIC) versus usual care (UC) in the STRONG-HF trial, including stable patients with improved but still elevated natriuretic peptides. METHODS AND RESULTS In the trial, eight NCCs were reported: anaemia, diabetes, renal dysfunction, severe liver disease, chronic obstructive pulmonary disease/asthma, stroke/transient ischaemic attack, psychiatric/neurological disorders, and malignancies. Patients were classified by NCC number (0, 1, 2 and ≥3). The treatment effect of HIC versus UC on the primary endpoint, 180-day death or heart failure (HF) rehospitalization, was compared by NCC number and by each individual comorbidity. Among the 1078 patients, the prevalence of 0, 1, 2 and ≥3 NCCs was 24.3%, 39.8%, 24.5% and 11.4%, respectively. Achievement of full doses of HF therapies at 90 and 180 days in the HIC was similar irrespective of NCC number. In HIC, the primary endpoint occurred in 10.0%, 16.6%, 13.6% and 26.2%, in those with 0, 1, 2 and ≥3 NCCs, respectively, as compared to 19.1%, 25.4%, 23.3% and 26.2% in UC (interaction-p = 0.80). The treatment benefit of HIC versus UC on the primary endpoint did not differ significantly by each individual comorbidity. There was no significant treatment interaction by NCC number in quality-of-life improvement (p = 0.98) or the incidence of serious adverse events (p = 0.11). CONCLUSIONS In the STRONG-HF trial, NCCs neither limited the rapid up-titration of HF therapies, nor attenuated the benefit of HIC on the primary endpoint. In the context of a clinical trial, the benefit-risk ratio favours the rapid up-titration of HF therapies even in patients with multiple NCCs.
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Affiliation(s)
- Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine "Carol Davila", Bucharest, Romania
| | - Beth Davison
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
| | - Marianna Adamo
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Laura E Antohi
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine "Carol Davila", Bucharest, Romania
| | - Mattia Arrigo
- Department of Internal Medicine, Stadtspital Zurich, Zurich, Switzerland
| | | | - Jan Biegus
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Kamilė Čerlinskaitė-Bajorė
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Jelena Celutkiene
- Clinic of Cardiac and Vascular Diseases, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Alain Cohen-Solal
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Department of Cardiology, APHP Nord, Lariboisière University Hospital, Paris, France
| | | | - Rafael Diaz
- Estudios Clínicos Latinoamérica, Instituto Cardiovascular de Rosario, Rosario, Argentina
| | | | - Gerasimos Filippatos
- National and Kapodistrian University of Athens, School of Medicine, Attikon University Hospital, Athens, Greece
| | - Antoine Kimmoun
- Université de Lorraine, Nancy; INSERM, Défaillance Circulatoire Aigue et Chronique, Service de Médecine Intensive et Réanimation Brabois, CHRU de Nancy, Vandœuvre-lès-Nancy, France
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Marco Metra
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Matteo Pagnesi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Peter S Pang
- Department of Emergency Medicine, Department of Medicine, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wrocław, Poland
| | - Razvan I Radu
- Emergency Institute for Cardiovascular Diseases 'Prof. C.C. Iliescu', University of Medicine "Carol Davila", Bucharest, Romania
| | - Hadiza Saidu
- Department of Medicine, Murtala Muhammed Specialist Hospital/Bayero University Kano, Kano, Nigeria
| | - Karen Sliwa
- Division of Cardiology, Department of Medicine, Cape Heart Institute, Groote Schuur Hospital and University of Cape Town, Cape Town, South Africa
| | - Adriaan A Voors
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Koji Takagi
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Jozine M Ter Maaten
- Department of Cardiology, University Medical Centre Groningen, University of Groningen, Groningen, Netherlands
| | - Daniela Tomasoni
- Cardiology, ASST Spedali Civili and Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | - Gad Cotter
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Momentum Research Inc, Durham, NC, USA
- Heart Initiative, Durham, NC, USA
| | - Alexandre Mebazaa
- Université Paris Cité, INSERM UMR-S 942(MASCOT), Paris, France
- Department of Anesthesiology and Critical Care and Burn Unit, Saint-Louis and Lariboisière Hospitals, FHU PROMICE, DMU Parabol, APHP Nord, Paris, France
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Palazzuoli A, Metra M, Collins SP, Adamo M, Ambrosy AP, Antohi LE, Ben Gal T, Farmakis D, Gustafsson F, Hill L, Lopatin Y, Tramonte F, Lyon A, Masip J, Miro O, Moura B, Mullens W, Radu RI, Abdelhamid M, Anker S, Chioncel O. Heart failure during the COVID-19 pandemic: clinical, diagnostic, management, and organizational dilemmas. ESC Heart Fail 2022; 9:3713-3736. [PMID: 36111511 PMCID: PMC9773739 DOI: 10.1002/ehf2.14118] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Revised: 07/13/2022] [Accepted: 08/04/2022] [Indexed: 01/19/2023] Open
Abstract
The coronavirus 2019 (COVID-19) infection pandemic has affected the care of patients with heart failure (HF). Several consensus documents describe the appropriate diagnostic algorithm and treatment approach for patients with HF and associated COVID-19 infection. However, few questions about the mechanisms by which COVID can exacerbate HF in patients with high-risk (Stage B) or symptomatic HF (Stage C) remain unanswered. Therefore, the type of HF occurring during infection is poorly investigated. The diagnostic differentiation and management should be focused on the identification of the HF phenotype, underlying causes, and subsequent tailored therapy. In this framework, the relationship existing between COVID and onset of acute decompensated HF, isolated right HF, and cardiogenic shock is questioned, and the specific management is mainly based on local hospital organization rather than a standardized model. Similarly, some specific populations such as advanced HF, heart transplant, patients with left ventricular assist device (LVAD), or valve disease remain under investigated. In this systematic review, we examine recent advances regarding the relationships between HF and COVID-19 pandemic with respect to epidemiology, pathogenetic mechanisms, and differential diagnosis. Also, according to the recent HF guidelines definition, we highlight different clinical profile identification, pointing out the main concerns in understudied HF populations.
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Affiliation(s)
- Alberto Palazzuoli
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria alle Scotte HospitalUniversity of Siena53100SienaItaly
| | - Marco Metra
- Cardiology, Cardio‐Thoracic Department, Civil Hospitals, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Sean P. Collins
- Department of Emergency MedicineVanderbilt University Medical CentreNashvilleTNUSA
| | - Marianna Adamo
- Cardiology, Cardio‐Thoracic Department, Civil Hospitals, Brescia, Italy; Department of Medical and Surgical Specialties, Radiological Sciences, and Public HealthUniversity of BresciaBresciaItaly
| | - Andrew P. Ambrosy
- Department of CardiologyKaiser Permanente San Francisco Medical CenterSan FranciscoCAUSA,Division of ResearchKaiser Permanente Northern CaliforniaOaklandCAUSA
| | - Laura E. Antohi
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C.Iliescu” BucharestBucharestRomania
| | - Tuvia Ben Gal
- Department of Cardiology, Rabin Medical Center (Beilinson Campus), Sackler Faculty of MedicineTel Aviv UniversityTel AvivIsrael
| | - Dimitrios Farmakis
- Cardio‐Oncology Clinic, Heart Failure Unit, “Attikon” University HospitalNational and Kapodistrian University of Athens Medical SchoolAthensGreece,University of Cyprus Medical SchoolNicosiaCyprus
| | | | - Loreena Hill
- School of Nursing and MidwiferyQueen's UniversityBelfastUK
| | - Yuri Lopatin
- Volgograd Medical UniversityCardiology CentreVolgogradRussia
| | - Francesco Tramonte
- Cardiovascular Diseases Unit, Cardio Thoracic and Vascular Department, S. Maria alle Scotte HospitalUniversity of Siena53100SienaItaly
| | - Alexander Lyon
- Cardio‐Oncology ServiceRoyal Brompton Hospital and Imperial College LondonLondonUK
| | - Josep Masip
- Intensive Care Department, Consorci Sanitari IntegralUniversity of BarcelonaBarcelonaSpain,Department of CardiologyHospital Sanitas CIMABarcelonaSpain
| | - Oscar Miro
- Emergency Department, Hospital Clínic de BarcelonaUniversity of BarcelonaBarcelonaSpain
| | - Brenda Moura
- Armed Forces Hospital, Porto, & Faculty of MedicineUniversity of PortoPortoPortugal
| | - Wilfried Mullens
- Cardiovascular PhysiologyHasselt University, Belgium, & Heart Failure and Cardiac Rehabilitation Specialist, Ziekenhuis Oost‐LimburgGenkBelgium
| | - Razvan I. Radu
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C.Iliescu” BucharestBucharestRomania
| | - Magdy Abdelhamid
- Cardiology Department, Kasr Alainy School of MedicineCairo UniversityNew Cairo, 5th settlementCairo11865Egypt
| | - Stefan Anker
- Department of Cardiology (CVK), Berlin Institute of Health Center for Regenerative Therapies (BCRT), German Centre for Cardiovascular Research (DZHK) partner site Berlin, Charité Universitätsmedizin BerlinBerlinGermany
| | - Ovidiu Chioncel
- Emergency Institute for Cardiovascular Diseases “Prof. Dr. C.C. Iliescu” Bucharest; University for Medicine and Pharmacy “Carol Davila” BucharestBucharestRomania
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Penes D, Anton M, Maresiu CO, Boeangiu S, Margineanu C, Andrei G, Predescu L, Stavaru R, Antohi LE, Chioncel O. P264 Alcohol septal ablation in hypertrophic obstructive cardiomyopathy with mitral insufficiency of mixed mechanism. Eur Heart J Cardiovasc Imaging 2020. [DOI: 10.1093/ehjci/jez319.124] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 11/13/2022] Open
Abstract
Abstract
Alcohol septal ablation is a percutaneous intervention for hypertrophic obstructive cardiomyopathy, aiming to relieve symptoms, as an alternative to surgical myomectomy, in optimally treated but still symptomatic patients, with high surgical risk.
We present the case of 65-year-old female, with persistently elevated blood pressure, presenting with severe dyspnea and angina on exertion and frequent episodes of paroxysmal nocturnal dyspnea. Clinical examination revealed an intense left parasternal systolic murmur. Electrocardiographic findings were sinus rhythm and negative T waves in V2-V6. Transthoracic echocardiography showed a small LV cavity with severe asymmetric left ventricular hypertrophy (maximum basal interventricular septum thickness of 26 mm), with important obstruction in the left ventricular outflow tract - resting gradient 77mmHg, provoked gradient 100mmHg. TOE evaluation of the mitral valve revealed significant mitral regurgitation, with intermitent telesystolic anterior motion of the anterior mitral leaflet and also P2 scallop prolapse.
Further evaluation revealed a 60% stenosis of left anterior descending (LAD) artery of second segment, 60% stenosis of the left internal carotid artery, chronic renal disease (creatinine clearance 80ml/min), and moderate pulmonary hypertension.
Although surgery was initially proposed to the patient, given the high operative risk (EUROSCORE II 8.45%) for a complete surgical procedure (myomectomy, mitral valve repair and coronary bypass), we attempted a stepwise approach to alleviate her symptoms. Intensive medical treatment improved blood pressure control while angioplasty of the LAD alleviated her angina.
Echo-guided alcohol ablation of the interventricular septal wall was performed. Catheter-based contrast injection of a secondary septal branch of the LAD produced a subendocardial contrast in the contact area of anterior mitral valve leaflet; subsequently, embolizing the artery, producing an isolated necrosis at this level, with equalizing the pressure curves between LV and aorta.
Postintervention, initial gradients were 50mmHg at rest, 100mmHg on postextrasystolic measurement. Systolic movement of the anterior leaflet maintained a mezotelesystolic pattern. At 3-months follow-up, LVOT gradients were 27/100mmHg, without any increase in pulmonary artery pressure, but with significant improvement of dyspnea. Further risk assessment by Holter ECG monitoring identified non-sustained ventricular tachycardia, so an ICD was implanted.
The modest reduction in gradient was associated with significant clinical improvement in the patient’s symptomatology. This procedure has been refined in the last years, especially with the introduction of myocardial contrast echocardiography for better localizing the area at risk of infarction and to reduce the amount of alcohol used. Alcohol septal ablation may be part of a stepwise plan to improve symptoms, with lower procedural risks as compared to classic surgery.
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Affiliation(s)
- D Penes
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
| | - M Anton
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
| | - C O Maresiu
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
| | - S Boeangiu
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
| | - C Margineanu
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
| | - G Andrei
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
| | - L Predescu
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
| | - R Stavaru
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
| | - L E Antohi
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
| | - O Chioncel
- Institute of Cardiovascular Diseases Prof. C.C. Iliescu, Bucharest, Romania
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