1
|
Mentz RJ, Stebbins A, Butler J, Chiang CE, Ezekowitz JA, Hernandez AF, Hilkert R, Lam CSP, McDonald K, O'Connor CM, Pieske B, Ponikowski P, Roessig L, Sweitzer NK, Voors AA, Anstrom KJ, Armstrong PW. Recurrent Hospitalizations and Response to Vericiguat in Heart Failure and Reduced Ejection Fraction. JACC Heart Fail 2024:S2213-1779(23)00840-5. [PMID: 38363272 DOI: 10.1016/j.jchf.2023.12.005] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Revised: 11/06/2023] [Accepted: 12/07/2023] [Indexed: 02/17/2024]
Abstract
BACKGROUND In VICTORIA (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction), vericiguat compared with placebo reduced cardiovascular death or heart failure (HF) hospitalization in patients with HF with reduced ejection fraction. OBJECTIVES This study explored the association between vericiguat and recurrent hospitalizations and subsequent mortality after HF hospitalization. METHODS The treatment effect of vericiguat on the burden of HF hospitalizations was evaluated by assessing total HF hospitalization and cardiovascular death in the overall trial and based on baseline N-terminal pro-B-type natriuretic peptide levels with and without adjustment for VICTORIA model covariates (ie, baseline variables associated with the primary endpoint) assessed via the Andersen-Gill method. Associations between vericiguat and recurrent hospitalization and mortality adjusted for VICTORIA model covariates are reported. RESULTS There were 1,222 total HF hospitalizations and cardiovascular deaths among 2,526 patients in the vericiguat group and 1,336 total events among 2,524 patients in the placebo group (unadjusted HR: 0.89 [95% CI: 0.81-0.97] and adjusted HR: 0.92 [95% CI: 0.84-1.01]). In the subgroup with N-terminal pro-B-type natriuretic peptide levels ≤2,816 pg/mL (ie, Q1 and Q2; median or below), there was a suggestion of a benefit with vericiguat (adjusted HRs of 0.80 [95% CI: 0.64-1.01] and 0.77 [95% CI: 0.62-0.94], respectively) compared with those above this value (adjusted HRs of 1.12 [95% CI: 0.93-1.34] and 0.87 [95% CI: 0.74-1.04] for Q3 and Q4). There was no significant difference in treatment effect between patients with vs without an HF hospitalization. After HF hospitalization, the all-cause mortality rate (events per 100 patient-years) was 48.6 for vericiguat and 44.1 for placebo. CONCLUSIONS Additional investigation of the association between vericiguat and cardiovascular death and total HF hospitalizations by recurrent event analysis did not show a statistically significant reduction in events. Mortality was high after HF hospitalization, emphasizing the need for further therapies to reduce morbidity and mortality. (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction [VICTORIA]; NCT02861534).
Collapse
Affiliation(s)
- Robert J Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Amanda Stebbins
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | - Javed Butler
- Baylor University Medical Center, Dallas, Texas, USA
| | - Chern-En Chiang
- Taipei Veterans General Hospital and National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Kenneth McDonald
- St. Vincent's University Hospital and University College, Dublin, Ireland
| | | | - Burkert Pieske
- Charité University Medicine, German Heart Center, Berlin, Germany
| | | | | | - Nancy K Sweitzer
- Washington University School of Medicine in St. Louis, St. Louis, Missouri, USA
| | - Adriaan A Voors
- University of Groningen, University Medical Center of Groningen, Groningen, the Netherlands
| | - Kevin J Anstrom
- UNC Gillings School of Global Public Health, Chapel Hill, North Carolina, USA
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
| |
Collapse
|
2
|
Lerman JB, Guidot DM, Green CL, Patel CB, Agarwal R, Sweitzer NK, Keenan JE, Milano CA, Schroder JN, DeVore AD. Longitudinal Trends in Donor and Recipient Risk Profile, and Clinical Outcomes, for Donation After Circulatory Death Heart Transplantation. Circ Heart Fail 2023; 16:e011213. [PMID: 37929577 PMCID: PMC10844982 DOI: 10.1161/circheartfailure.123.011213] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Accepted: 10/16/2023] [Indexed: 11/07/2023]
Affiliation(s)
- Joseph B Lerman
- Division of Cardiology (J.B.L., C.B.P., R.A., A.D.D.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC (J.B.L., D.M.G., C.L.G., A.D.D.)
| | - Daniel M Guidot
- Duke Clinical Research Institute, Durham, NC (J.B.L., D.M.G., C.L.G., A.D.D.)
| | - Cynthia L Green
- Department of Biostatistics and Bioinformatics (C.L.G.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC (J.B.L., D.M.G., C.L.G., A.D.D.)
| | - Chetan B Patel
- Division of Cardiology (J.B.L., C.B.P., R.A., A.D.D.), Duke University School of Medicine, Durham, NC
| | - Richa Agarwal
- Division of Cardiology (J.B.L., C.B.P., R.A., A.D.D.), Duke University School of Medicine, Durham, NC
| | - Nancy K Sweitzer
- Department of Medicine, Washington University School of Medicine, St. Louis, MO (N.K.S.)
| | - Jeffrey E Keenan
- Department of Surgery (J.E.K., C.A.M., J.N.S.), Duke University School of Medicine, Durham, NC
| | - Carmelo A Milano
- Department of Surgery (J.E.K., C.A.M., J.N.S.), Duke University School of Medicine, Durham, NC
| | - Jacob N Schroder
- Department of Surgery (J.E.K., C.A.M., J.N.S.), Duke University School of Medicine, Durham, NC
| | - Adam D DeVore
- Division of Cardiology (J.B.L., C.B.P., R.A., A.D.D.), Duke University School of Medicine, Durham, NC
- Duke Clinical Research Institute, Durham, NC (J.B.L., D.M.G., C.L.G., A.D.D.)
| |
Collapse
|
3
|
Hofmeyer M, Haas GJ, Jordan E, Cao J, Kransdorf E, Ewald GA, Morris AA, Owens A, Lowes B, Stoller D, Tang WHW, Garg S, Trachtenberg BH, Shah P, Pamboukian SV, Sweitzer NK, Wheeler MT, Wilcox JE, Katz S, Pan S, Jimenez J, Smart F, Wang J, Gottlieb SS, Judge DP, Moore CK, Huggins GS, Kinnamon DD, Ni H, Hershberger RE. Rare Variant Genetics and Dilated Cardiomyopathy Severity: The DCM Precision Medicine Study. Circulation 2023; 148:872-881. [PMID: 37641966 PMCID: PMC10530109 DOI: 10.1161/circulationaha.123.064847] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 07/14/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Dilated cardiomyopathy (DCM) can lead to advanced disease, defined herein as necessitating a durable left ventricular assist device or a heart transplant (LVAD/HT). DCM is known to have a genetic basis, but the association of rare variant genetics with advanced DCM has not been studied. METHODS We analyzed clinical and genetic sequence data from patients enrolled between 2016 and 2021 in the US multisite DCM Precision Medicine Study, which was a geographically diverse, multiracial, multiethnic cohort. Clinical evaluation included standardized patient interview and medical record query forms. DCM severity was classified into 3 groups: patients with advanced disease with LVAD/HT; patients with an implantable cardioverter defibrillator (ICD) only; or patients with no ICD or LVAD/HT. Rare variants in 36 DCM genes were classified as pathogenic or likely pathogenic or variants of uncertain significance. Confounding factors we considered included demographic characteristics, lifestyle factors, access to care, DCM duration, and comorbidities. Crude and adjusted associations between DCM severity and rare variant genetic findings were assessed using multinomial models with generalized logit link. RESULTS Patients' mean (SD) age was 51.9 (13.6) years; 42% were of African ancestry, 56% were of European ancestry, and 44% were female. Of 1198 patients, 347 had LVAD/HT, 511 had an ICD, and 340 had no LVAD/HT or ICD. The percentage of patients with pathogenic or likely pathogenic variants was 26.2%, 15.9%, and 15.0% for those with LVAD/HT, ICD only, or neither, respectively. After controlling for sociodemographic characteristics and comorbidities, patients with DCM with LVAD/HT were more likely than those without LVAD/HT or ICD to have DCM-related pathogenic or likely pathogenic rare variants (odds ratio, 2.3 [95% CI, 1.5-3.6]). The association did not differ by ancestry. Rare variant genetic findings were similar between patients with DCM with an ICD and those without LVAD/HT or ICD. CONCLUSIONS Advanced DCM was associated with higher odds of rare variants in DCM genes adjudicated as pathogenic or likely pathogenic, compared with individuals with less severe DCM. This finding may help assess the risk of outcomes in management of patients with DCM and their at-risk family members. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03037632.
Collapse
Affiliation(s)
- Mark Hofmeyer
- MedStar Health Research Institute, Medstar Washington Hospital Center, Washington, DC
| | - Garrie J. Haas
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Elizabeth Jordan
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Jinwen Cao
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - Anjali Owens
- Center for Inherited Cardiovascular Disease, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brian Lowes
- University of Nebraska Medical Center, Omaha, NE
| | | | - W. H. Wilson Tang
- Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sonia Garg
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Barry H. Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, J.C. Walter Jr. Transplant Center, Houston TX
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, VA
| | - Salpy V. Pamboukian
- University of Alabama, Birmingham, AL during study conduct, current affiliation, University of Washington, Seattle, WA
| | - Nancy K. Sweitzer
- Sarver Heart Center, University of Arizona, Tucson, AZ during study conduct, current affiliation, Washington University, St. Louis, MO
| | - Matthew T. Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jane E. Wilcox
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Stuart Katz
- New York University Langone Medical Center, New York, NY
| | - Stephen Pan
- New York University Langone Medical Center, New York, NY
- current affiliation, Department of Cardiology, Westchester Medical Center & New York Medical College, Valhalla, NY
| | - Javier Jimenez
- Miami Cardiac & Vascular Institute, Baptist Health South, Miami, FL
| | - Frank Smart
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - Jessica Wang
- University of California Los Angeles Medical Center, Los Angeles, CA
| | | | | | | | - Gordon S. Huggins
- Cardiology Division, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Daniel D. Kinnamon
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Hanyu Ni
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Ray E. Hershberger
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | | |
Collapse
|
4
|
Affiliation(s)
- Sarah Chuzi
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.C., J.W.)
| | - Monica Colvin
- Department of Cardiology, University of Michigan, Ann Arbor (M.C.)
| | - Selma F Mohammed
- Division of Cardiology, Creighton University School of Medicine, Omaha, NE (S.F.M.)
| | - Jane Wilcox
- Division of Cardiology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL (S.C., J.W.)
| | - Nancy K Sweitzer
- Department of Medicine, Washington University School of Medicine, St. Louis, MO (N.K.S.)
| |
Collapse
|
5
|
Jordan E, Kinnamon DD, Haas GJ, Hofmeyer M, Kransdorf E, Ewald GA, Morris AA, Owens A, Lowes B, Stoller D, Tang WHW, Garg S, Trachtenberg BH, Shah P, Pamboukian SV, Sweitzer NK, Wheeler MT, Wilcox JE, Katz S, Pan S, Jimenez J, Fishbein DP, Smart F, Wang J, Gottlieb SS, Judge DP, Moore CK, Mead JO, Hurst N, Cao J, Huggins GS, Cowan J, Ni H, Rehm HL, Jarvik GP, Vatta M, Burke W, Hershberger RE. Genetic Architecture of Dilated Cardiomyopathy in Individuals of African and European Ancestry. JAMA 2023; 330:432-441. [PMID: 37526719 PMCID: PMC10394581 DOI: 10.1001/jama.2023.11970] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Accepted: 06/13/2023] [Indexed: 08/02/2023]
Abstract
Importance Black patients with dilated cardiomyopathy (DCM) have increased familial risk and worse outcomes than White patients, but most DCM genetic data are from White patients. Objective To compare the rare variant genetic architecture of DCM by genomic ancestry within a diverse population of patients with DCM. Design Cross-sectional study enrolling patients with DCM who self-identified as non-Hispanic Black, Hispanic, or non-Hispanic White from June 7, 2016, to March 15, 2020, at 25 US advanced heart failure programs. Variants in 36 DCM genes were adjudicated as pathogenic, likely pathogenic, or of uncertain significance. Exposure Presence of DCM. Main Outcomes and Measures Variants in DCM genes classified as pathogenic/likely pathogenic/uncertain significance and clinically actionable (pathogenic/likely pathogenic). Results A total of 505, 667, and 26 patients with DCM of predominantly African, European, or Native American genomic ancestry, respectively, were included. Compared with patients of European ancestry, a lower percentage of patients of African ancestry had clinically actionable variants (8.2% [95% CI, 5.2%-11.1%] vs 25.5% [95% CI, 21.3%-29.6%]), reflecting the lower odds of a clinically actionable variant for those with any pathogenic variant/likely pathogenic variant/variant of uncertain significance (odds ratio, 0.25 [95% CI, 0.17-0.37]). On average, patients of African ancestry had fewer clinically actionable variants in TTN (difference, -0.09 [95% CI, -0.14 to -0.05]) and other genes with predicted loss of function as a disease-causing mechanism (difference, -0.06 [95% CI, -0.11 to -0.02]). However, the number of pathogenic variants/likely pathogenic variants/variants of uncertain significance was more comparable between ancestry groups (difference, -0.07 [95% CI, -0.22 to 0.09]) due to a larger number of non-TTN non-predicted loss of function variants of uncertain significance, mostly missense, in patients of African ancestry (difference, 0.15 [95% CI, 0.00-0.30]). Published clinical case-based evidence supporting pathogenicity was less available for variants found only in patients of African ancestry (P < .001). Conclusion and Relevance Patients of African ancestry with DCM were less likely to have clinically actionable variants in DCM genes than those of European ancestry due to differences in genetic architecture and a lack of representation of African ancestry in clinical data sets.
Collapse
Affiliation(s)
- Elizabeth Jordan
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Daniel D. Kinnamon
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Garrie J. Haas
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus
| | - Mark Hofmeyer
- MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, DC
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Anjali Owens
- Center for Inherited Cardiovascular Disease, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian Lowes
- University of Nebraska Medical Center, Omaha
| | | | | | - Sonia Garg
- University of Texas Southwestern Medical Center, Dallas
| | - Barry H. Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, J. C. Walter Jr Transplant Center, Houston, Texas
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Nancy K. Sweitzer
- Sarver Heart Center, University of Arizona, Tucson
- Now with Washington University, St Louis, Missouri
| | - Matthew T. Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Jane E. Wilcox
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stuart Katz
- New York University Langone Medical Center, New York, New York
| | - Stephen Pan
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - Javier Jimenez
- Miami Cardiac and Vascular Institute, Baptist Health South, Miami, Florida
| | | | - Frank Smart
- Louisiana State University Health Sciences Center, New Orleans
| | - Jessica Wang
- University of California Los Angeles Medical Center, Los Angeles
| | | | | | | | - Jonathan O. Mead
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Natalie Hurst
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Jinwen Cao
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Gordon S. Huggins
- Cardiology Division, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Jason Cowan
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Hanyu Ni
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Heidi L. Rehm
- Center for Genomic Medicine, Massachusetts General Hospital, Boston
| | - Gail P. Jarvik
- Division of Medical Genetics, Department of Medicine, University of Washington, Seattle
- Department of Genome Sciences, University of Washington, Seattle
| | - Matteo Vatta
- Departments of Medical and Molecular Genetics, Indiana University School of Medicine, Indianapolis
| | - Wylie Burke
- Department of Bioethics and Humanities, University of Washington, Seattle
| | - Ray E. Hershberger
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- Davis Heart and Lung Research Institute, The Ohio State University, Columbus
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus
| |
Collapse
|
6
|
|
7
|
Ni H, Jordan E, Kinnamon DD, Cao J, Haas GJ, Hofmeyer M, Kransdorf E, Ewald GA, Morris AA, Owens A, Lowes B, Stoller D, Tang WHW, Garg S, Trachtenberg BH, Shah P, Pamboukian SV, Sweitzer NK, Wheeler MT, Wilcox JE, Katz S, Pan S, Jimenez J, Fishbein DP, Smart F, Wang J, Gottlieb SS, Judge DP, Moore CK, Huggins GS, Hershberger RE. Screening for Dilated Cardiomyopathy in At-Risk First-Degree Relatives. J Am Coll Cardiol 2023; 81:2059-2071. [PMID: 37225358 PMCID: PMC10563038 DOI: 10.1016/j.jacc.2023.03.419] [Citation(s) in RCA: 1] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 03/20/2023] [Indexed: 05/26/2023]
Abstract
BACKGROUND Cardiovascular screening is recommended for first-degree relatives (FDRs) of patients with dilated cardiomyopathy (DCM), but the yield of FDR screening is uncertain for DCM patients without known familial DCM, for non-White FDRs, or for DCM partial phenotypes of left ventricular enlargement (LVE) or left ventricular systolic dysfunction (LVSD). OBJECTIVES This study examined the yield of clinical screening among reportedly unaffected FDRs of DCM patients. METHODS Adult FDRs of DCM patients at 25 sites completed screening echocardiograms and ECGs. Mixed models accounting for site heterogeneity and intrafamilial correlation were used to compare screen-based percentages of DCM, LVSD, or LVE by FDR demographics, cardiovascular risk factors, and proband genetics results. RESULTS A total of 1,365 FDRs were included, with a mean age of 44.8 ± 16.9 years, 27.5% non-Hispanic Black, 9.8% Hispanic, and 61.7% women. Among screened FDRs, 14.1% had new diagnoses of DCM (2.1%), LVSD (3.6%), or LVE (8.4%). The percentage of FDRs with new diagnoses was higher for those aged 45 to 64 years than 18 to 44 years. The age-adjusted percentage of any finding was higher among FDRs with hypertension and obesity but did not differ statistically by race and ethnicity (16.2% for Hispanic, 15.2% for non-Hispanic Black, and 13.1% for non-Hispanic White) or sex (14.6% for women and 12.8% for men). FDRs whose probands carried clinically reportable variants were more likely to be identified with DCM. CONCLUSIONS Cardiovascular screening identified new DCM-related findings among 1 in 7 reportedly unaffected FDRs regardless of race and ethnicity, underscoring the value of clinical screening in all FDRs.
Collapse
Affiliation(s)
- Hanyu Ni
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA; The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Elizabeth Jordan
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA; The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Daniel D Kinnamon
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA; The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Jinwen Cao
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA; The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA
| | - Garrie J Haas
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA; Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Mark Hofmeyer
- Medstar Research Institute, Washington Hospital Center, Washington, DC, USA
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | | | | | - Anjali Owens
- Center for Inherited Cardiovascular Disease, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian Lowes
- University of Nebraska Medical Center, Omaha, Nebraska, USA
| | | | - W H Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, Ohio, USA
| | - Sonia Garg
- University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Barry H Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, J.C. Walter Jr Transplant Center, Houston Texas, USA
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Nancy K Sweitzer
- Sarver Heart Center, University of Arizona, Tucson, Arizona, USA (current address Division of Cardiology, Washington University, St Louis, Missouri, USA)
| | - Matthew T Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California, USA
| | - Jane E Wilcox
- Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Stuart Katz
- New York University Langone Medical Center, New York, New York, USA
| | - Stephen Pan
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla, New York, USA
| | - Javier Jimenez
- Miami Cardiac and Vascular Institute, Baptist Health South, Miami, Florida, USA
| | | | - Frank Smart
- Louisiana State University Health Sciences Center, New Orleans, Louisiana, USA
| | - Jessica Wang
- University of California Los Angeles Medical Center, Los Angeles, California, USA
| | | | - Daniel P Judge
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Charles K Moore
- University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Gordon S Huggins
- Cardiology Division, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts, USA
| | - Ray E Hershberger
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA; The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, Ohio, USA; Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA.
| |
Collapse
|
8
|
Pool N, Hebdon M, de Groot E, Yee R, Herrera-Theut K, Yee E, Allen LA, Hasan A, Lindenfeld J, Calhoun E, Carnes M, Sweitzer NK, Breathett K. A novel approach for assessing bias during team-based clinical decision-making. Front Public Health 2023; 11:1014773. [PMID: 37228737 PMCID: PMC10203455 DOI: 10.3389/fpubh.2023.1014773] [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: 08/08/2022] [Accepted: 03/20/2023] [Indexed: 05/27/2023] Open
Abstract
Many clinical processes include multidisciplinary group decision-making, yet few methods exist to evaluate the presence of implicit bias during this collective process. Implicit bias negatively impacts the equitable delivery of evidence-based interventions and ultimately patient outcomes. Since implicit bias can be difficult to assess, novel approaches are required to detect and analyze this elusive phenomenon. In this paper, we describe how the de Groot Critically Reflective Diagnoses Protocol (DCRDP) can be used as a data analysis tool to evaluate group dynamics as an essential foundation for exploring how interactions can bias collective clinical decision-making. The DCRDP includes 6 distinct criteria: challenging groupthink, critical opinion sharing, research utilization, openness to mistakes, asking and giving feedback, and experimentation. Based on the strength and frequency of codes in the form of exemplar quotes, each criterion was given a numerical score of 1-4 with 1 representing teams that are interactive, reflective, higher functioning, and more equitable. When applied as a coding scheme to transcripts of recorded decision-making meetings, the DCRDP was revealed as a practical tool for examining group decision-making bias. It can be adapted to a variety of clinical, educational, and other professional settings as an impetus for recognizing the presence of team-based bias, engaging in reflexivity, informing the design and testing of implementation strategies, and monitoring long-term outcomes to promote more equitable decision-making processes in healthcare.
Collapse
Affiliation(s)
- Natalie Pool
- School of Nursing, University of Northern Colorado, Greeley, CO, United States
| | - Megan Hebdon
- School of Nursing, University of Texas-Austin, Austin, TX, United States
| | - Esther de Groot
- Department of General Practice, University of Utrecht, Utrecht, Netherlands
| | - Ryan Yee
- Division of Cardiovascular Medicine Research Department, Indiana University, Indianapolis, IN, United States
| | - Kathryn Herrera-Theut
- College of Medicine, Department of Medicine and Pediatrics, University of Michigan, Ann Arbor, MI, United States
| | - Erika Yee
- College of Medicine, University of Arizona, Tucson, AZ, United States
| | - Larry A. Allen
- Division of Cardiovascular Medicine, University of Colorado, Denver, CO, United States
| | - Ayesha Hasan
- Division of Cardiovascular Medicine, Ohio State University, Columbus, OH, United States
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine, Vanderbilt University, Nashville, TN, United States
| | - Elizabeth Calhoun
- Department of Population Health, University of Kansas, Kansas City, KS, United States
| | - Molly Carnes
- Department of Medicine, University of Wisconsin, Madison, WI, United States
| | - Nancy K. Sweitzer
- Division of Cardiovascular Medicine, Washington University in St. Louis, St. Louis, MO, United States
| | - Khadijah Breathett
- Division of Cardiovascular Medicine, Indiana University, Indianapolis, IN, United States
| |
Collapse
|
9
|
Kinnamon DD, Jordan E, Haas GJ, Hofmeyer M, Kransdorf E, Ewald GA, Morris AA, Owens A, Lowes B, Stoller D, Tang WHW, Garg S, Trachtenberg BH, Shah P, Pamboukian SV, Sweitzer NK, Wheeler MT, Wilcox JE, Katz S, Pan S, Jimenez J, Aaronson KD, Fishbein DP, Smart F, Wang J, Gottlieb SS, Judge DP, Moore CK, Mead JO, Huggins GS, Ni H, Burke W, Hershberger RE. Effectiveness of the Family Heart Talk Communication Tool in Improving Family Member Screening for Dilated Cardiomyopathy: Results of a Randomized Trial. Circulation 2023; 147:1281-1290. [PMID: 36938756 PMCID: PMC10133091 DOI: 10.1161/circulationaha.122.062507] [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: 09/15/2022] [Accepted: 02/15/2023] [Indexed: 03/21/2023]
Abstract
BACKGROUND Managing disease risk among first-degree relatives of probands diagnosed with a heritable disease is central to precision medicine. A critical component is often clinical screening, which is particularly important for conditions like dilated cardiomyopathy (DCM) that remain asymptomatic until severe disease develops. Nonetheless, probands are frequently ill-equipped to disseminate genetic risk information that motivates at-risk relatives to complete recommended clinical screening. An easily implemented remedy for this key issue has been elusive. METHODS The DCM Precision Medicine Study developed Family Heart Talk, a booklet designed to help probands with DCM communicate genetic risk and the need for cardiovascular screening to their relatives. The effectiveness of the Family Heart Talk booklet in increasing cardiovascular clinical screening uptake among first-degree relatives was assessed in a multicenter, open-label, cluster-randomized, controlled trial. The primary outcome measured in eligible first-degree relatives was completion of screening initiated within 12 months after proband enrollment. Because probands randomized to the intervention received the booklet at the enrollment visit, eligible first-degree relatives were limited to those who were alive the day after proband enrollment and not enrolled on the same day as the proband. RESULTS Between June 2016 and March 2020, 1241 probands were randomized (1:1) to receive Family Heart Talk (n=621) or not (n=620) within strata defined by site and self-identified race/ethnicity (non-Hispanic Black, non-Hispanic White, or Hispanic). Final analyses included 550 families (n=2230 eligible first-degree relatives) in the Family Heart Talk arm and 561 (n=2416) in the control arm. A higher percentage of eligible first-degree relatives completed screening in the Family Heart Talk arm (19.5% versus 16.0%), and the odds of screening completion among these first-degree relatives were higher in the Family Heart Talk arm after adjustment for proband randomization stratum, sex, and age quartile (odds ratio, 1.30 [1-sided 95% CI, 1.08-∞]). A prespecified subgroup analysis did not find evidence of heterogeneity in the adjusted intervention odds ratio across race/ethnicity strata (P=0.90). CONCLUSIONS Family Heart Talk, a booklet that can be provided to patients with DCM by clinicians with minimal additional time investment, was effective in increasing cardiovascular clinical screening among first-degree relatives of these patients. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03037632.
Collapse
Affiliation(s)
- Daniel D. Kinnamon
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
| | - Elizabeth Jordan
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
| | - Garrie J. Haas
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | - Mark Hofmeyer
- Medstar Research Institute, Washington Hospital Center, Washington, DC
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA
| | | | | | - Anjali Owens
- Center for Inherited Cardiovascular Disease, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Brian Lowes
- University of Nebraska Medical Center, Omaha, NE
| | | | - W. H. Wilson Tang
- Department of Cardiovascular Medicine, Heart, Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH
| | - Sonia Garg
- University of Texas Southwestern Medical Center, Dallas, TX
| | - Barry H. Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, J.C. Walter Jr. Transplant Center, Houston TX
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, VA
| | - Salpy V. Pamboukian
- University of Alabama, Birmingham, AL; current address, University of Washington, Seattle, WA
| | - Nancy K. Sweitzer
- Sarver Heart Center, University of Arizona, Tucson, AZ; current address, Division of Cardiology, Washington University, St. Louis, MO
| | - Matthew T. Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, CA
| | - Jane E. Wilcox
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Stuart Katz
- New York University Langone Medical Center, New York, NY
| | - Stephen Pan
- Department of Cardiology, Westchester Medical Center & New York Medical College, Valhalla, NY
| | - Javier Jimenez
- Miami Cardiac & Vascular Institute, Baptist Health South, Miami, FL
| | | | | | - Frank Smart
- Louisiana State University Health Sciences Center, New Orleans, LA
| | - Jessica Wang
- University of California Los Angeles Medical Center, Los Angeles, CA
| | | | | | | | - Jonathan O. Mead
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
| | - Gordon S. Huggins
- Cardiology Division, Tufts Medical Center and Tufts University School of Medicine, Boston, MA
| | - Hanyu Ni
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
| | - Wylie Burke
- Department of Bioethics and Humanities, University of Washington, Seattle, WA
| | - Ray E. Hershberger
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus, OH
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus, OH
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, OH
| | | |
Collapse
|
10
|
Breathett K, Yee RH, Pool N, Hebdon MC, Knapp SM, Calhoun E, Sweitzer NK, Carnes M. Pilot test of a Multi-Component Implementation Strategy for Equity in Advanced Heart Failure Allocation. Am J Transplant 2023:S1600-6135(23)00348-9. [PMID: 36931436 DOI: 10.1016/j.ajt.2023.03.005] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 03/07/2023] [Accepted: 03/08/2023] [Indexed: 03/17/2023]
Abstract
Advanced heart failure (AHF) therapy allocation is vulnerable to bias related to subjective assessments and poor group dynamics. Our objective was to determine whether an implementation strategy for AHF team members could feasibly contribute to organizational and culture change supporting equity in AHF allocation. Using pretest-posttest design, the strategy included an 8-week multi-component training on bias reduction, standardized numerical social assessments, and enhanced group dynamics at an AHF center. Evaluations of organizational and cultural change included pretest-posttest AHF team member surveys, transcripts of AHF meetings to assess group dynamics using a standardized scoring system, and posttest interviews guided by framework for implementing a complex strategy. Results were analyzed with qualitative descriptive methods and Brunner-Munzel tests for relative effect (RE, RE >0.5 signals posttest improvement). The majority of survey metrics revealed potential benefit with RE >0.5. RE were >0.5 for 5 of 6 group dynamics metrics. Themes for implementation included: 1) promotes equitable distribution of scarce resources; 2) requires change in team members' time investment to correct bias and change meeting structure; 3) slows then accelerates the allocation process; 4) adaptable beyond AHF and reinforceable with semi-annual trainings. An implementation strategy for AHF equity demonstrated feasibility for organizational and culture change.
Collapse
Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine, Department of Medicine, Indiana University, Indianapolis, IN (Breathett).
| | - Ryan H Yee
- Division of Cardiovascular Medicine, Clinical Research Office, Indiana University, Indianapolis, IN (Yee)
| | - Natalie Pool
- School of Nursing, University of Northern Colorado, Greeley (Pool)
| | - Megan C Hebdon
- School of Nursing, University of Texas, San Antonio (Hebdon)
| | - Shannon M Knapp
- Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson (Knapp)
| | | | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Department of Medicine, Sarver Heart Center, University of Arizona, Tucson (Sweitzer)
| | - Molly Carnes
- Department of Medicine, University of Wisconsin (Carnes)
| |
Collapse
|
11
|
Breathett K, Yee R, Pool N, Thomas Hebdon MC, Knapp SM, Herrera-Theut K, de Groot E, Yee E, Allen LA, Hasan A, Lindenfeld J, Calhoun E, Carnes M, Sweitzer NK. Group Dynamics and Allocation of Advanced Heart Failure Therapies-Heart Transplants and Ventricular Assist Devices-By Gender, Racial, and Ethnic Group. J Am Heart Assoc 2023; 12:e027701. [PMID: 36846988 PMCID: PMC10111441 DOI: 10.1161/jaha.122.027701] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
Background US regulatory framework for advanced heart failure therapies (AHFT), ventricular assist devices, and heart transplants, delegate eligibility decisions to multidisciplinary groups at the center level. The subjective nature of decision-making is at risk for racial, ethnic, and gender bias. We sought to determine how group dynamics impact allocation decision-making by patient gender, racial, and ethnic group. Methods and Results We performed a mixed-methods study among 4 AHFT centers. For ≈ 1 month, AHFT meetings were audio recorded. Meeting transcripts were evaluated for group function scores using de Groot Critically Reflective Diagnoses protocol (metrics: challenging groupthink, critical opinion sharing, openness to mistakes, asking/giving feedback, and experimentation; scoring: 1 to 4 [high to low quality]). The relationship between summed group function scores and AHFT allocation was assessed via hierarchical logistic regression with patients nested within meetings nested within centers, and interaction effects of group function score with gender and race, adjusting for patient age and comorbidities. Among 87 patients (24% women, 66% White race) evaluated for AHFT, 57% of women, 38% of men, 44% of White race, and 40% of patients of color were allocated to AHFT. The interaction between group function score and allocation by patient gender was statistically significant (P=0.035); as group function scores improved, the probability of AHFT allocation increased for women and decreased for men, a pattern that was similar irrespective of racial and ethnic groups. Conclusions Women evaluated for AHFT were more likely to receive AHFT when group decision-making processes were of higher quality. Further investigation is needed to promote routine high-quality group decision-making and reduce known disparities in AHFT allocation.
Collapse
Affiliation(s)
| | - Ryan Yee
- Division of Cardiovascular Medicine, Research Team Indiana University Indianapolis IN
| | - Natalie Pool
- School of Nursing University of Northern Colorado Greeley CO
| | | | - Shannon M Knapp
- Division of Cardiovascular Medicine Indiana University Indianapolis IN
| | | | - Esther de Groot
- Department of General Practice University Medical Center Utrecht Utrecht Netherlands
| | - Erika Yee
- School of Medicine University of Arizona Tucson AZ
| | - Larry A Allen
- Division of Cardiovascular Medicine University of Colorado Denver CO
| | - Ayesha Hasan
- Division of Cardiovascular Medicine The Ohio State University Columbus OH
| | - JoAnn Lindenfeld
- Division of Cardiovascular Medicine Vanderbilt University Nashville TN
| | | | - Molly Carnes
- Department of Medicine University of Wisconsin Madison WI
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine University of Washington at St Louis St Louis MO
| |
Collapse
|
12
|
Peters AE, Tromp J, Shah SJ, Lam CSP, Lewis GD, Borlaug BA, Sharma K, Pandey A, Sweitzer NK, Kitzman DW, Mentz RJ. Phenomapping in heart failure with preserved ejection fraction: insights, limitations, and future directions. Cardiovasc Res 2023; 118:3403-3415. [PMID: 36448685 PMCID: PMC10144733 DOI: 10.1093/cvr/cvac179] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [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: 04/30/2022] [Revised: 09/29/2022] [Accepted: 10/10/2022] [Indexed: 12/05/2022] Open
Abstract
Heart failure with preserved ejection fraction (HFpEF) is a heterogeneous entity with complex pathophysiology and manifestations. Phenomapping is the process of applying statistical learning techniques to patient data to identify distinct subgroups based on patterns in the data. Phenomapping has emerged as a technique with potential to improve the understanding of different HFpEF phenotypes. Phenomapping efforts have been increasing in HFpEF over the past several years using a variety of data sources, clinical variables, and statistical techniques. This review summarizes methodologies and key takeaways from these studies, including consistent discriminating factors and conserved HFpEF phenotypes. We argue that phenomapping results to date have had limited implications for clinical care and clinical trials, given that the phenotypes, as currently described, are not reliably identified in each study population and may have significant overlap. We review the inherent limitations of aggregating and utilizing phenomapping results. Lastly, we discuss potential future directions, including using phenomapping to optimize the likelihood of clinical trial success or to drive discovery in mechanisms of the disease process of HFpEF.
Collapse
Affiliation(s)
- Anthony E Peters
- Division of Cardiology, Duke University School of Medicine,
Durham, North Carolina 27708, USA
- Duke Clinical Research Institute, Durham, North
Carolina 27701, USA
| | - Jasper Tromp
- Saw Swee Hock School of Public Health, National University of Singapore
& the National University Health System, Singapore
- Department of Cardiology, University Medical Center
Groningen, Groningen, The
Netherlands
- Duke-National University of Singapore Medical School,
Singapore
| | - Sanjiv J Shah
- Division of Cardiology, Northwestern University Feinberg School of
Medicine, Chicago, IL, USA
| | - Carolyn S P Lam
- Department of Cardiology, University Medical Center
Groningen, Groningen, The
Netherlands
- Duke-National University of Singapore Medical School,
Singapore
- National Heart Centre Singapore, Singapore
| | - Gregory D Lewis
- Division of Cardiology, Massachusetts General Hospital,
Boston, Massachusetts, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic,
Rochester, Minnesota, USA
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins University School of
Medicine, Baltimore, Maryland, USA
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical
Center, Dallas, Texas, USA
| | - Nancy K Sweitzer
- Cardiovascular Medicine, Sarver Heart Center, University of
Arizona, Tucson, Arizona, USA
| | - Dalane W Kitzman
- Section on Cardiovascular Medicine, Department of Internal Medicine, Wake
Forest School of Medicine, Winston-Salem, North
Carolina, USA
- Sections on Geriatrics, Department of Internal Medicine, Wake Forest School
of Medicine, Winston-Salem, North Carolina,
USA
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine,
Durham, North Carolina 27708, USA
- Duke Clinical Research Institute, Durham, North
Carolina 27701, USA
| |
Collapse
|
13
|
Chirinos JA, Lopez-Jaramillo P, Giamarellos-Bourboulis EJ, Dávila-Del-Carpio GH, Bizri AR, Andrade-Villanueva JF, Salman O, Cure-Cure C, Rosado-Santander NR, Cornejo Giraldo MP, González-Hernández LA, Moghnieh R, Angeliki R, Cruz Saldarriaga ME, Pariona M, Medina C, Dimitroulis I, Vlachopoulos C, Gutierrez C, Rodriguez-Mori JE, Gomez-Laiton E, Cotrina Pereyra R, Ravelo Hernández JL, Arbañil H, Accini-Mendoza J, Pérez-Mayorga M, Milionis C, Poulakou G, Sánchez G, Valdivia-Vega R, Villavicencio-Carranza M, Ayala-García RJ, Castro-Callirgos CA, Alfaro Carrasco RM, Garrido Lecca Danos W, Sharkoski T, Greene K, Pourmussa B, Greczylo C, Ortega-Legaspi J, Jacoby D, Chittams J, Katsaounou P, Alexiou Z, Sympardi S, Sweitzer NK, Putt M, Cohen JB. A randomized clinical trial of lipid metabolism modulation with fenofibrate for acute coronavirus disease 2019. Nat Metab 2022; 4:1847-1857. [PMID: 36344766 PMCID: PMC9640855 DOI: 10.1038/s42255-022-00698-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/05/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022]
Abstract
Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) cytotoxicity may involve inhibition of peroxisome proliferator-activated receptor alpha. Fenofibrate activates peroxisome proliferator-activated receptor alpha and inhibits SARS-CoV-2 replication in vitro. Whether fenofibrate can be used to treat coronavirus disease 2019 (COVID-19) infection in humans remains unknown. Here, we randomly assigned inpatients and outpatients with COVID-19 within 14 d of symptom onset to 145 mg of oral fenofibrate nanocrystal formulation versus placebo for 10 d, in a double-blinded fashion. The primary endpoint was a severity score whereby participants were ranked across hierarchical tiers incorporating time to death, mechanical ventilation duration, oxygenation, hospitalization and symptom severity and duration. In total, 701 participants were randomized to fenofibrate (n = 351) or placebo (n = 350). The mean age of participants was 49 ± 16 years, 330 (47%) were female, mean body mass index was 28 ± 6 kg/m2 and 102 (15%) had diabetes. Death occurred in 41 participants. Compared with placebo, fenofibrate had no effect on the primary endpoint. The median (interquartile range) rank in the placebo arm was 347 (172, 453) versus 345 (175, 453) in the fenofibrate arm (P = 0.819). There was no difference in secondary and exploratory endpoints, including all-cause death, across arms. There were 61 (17%) adverse events in the placebo arm compared with 46 (13%) in the fenofibrate arm, with slightly higher incidence of gastrointestinal side effects in the fenofibrate group. Overall, among patients with COVID-19, fenofibrate has no significant effect on various clinically relevant outcomes ( NCT04517396 ).
Collapse
Affiliation(s)
- Julio A Chirinos
- Division of Cardiovascular Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Patricio Lopez-Jaramillo
- Instituto de Investigación MASIRA, Facultad de Ciencias de la Salud, Universidad de Santander, Bucaramanga, Colombia
| | - Evangelos J Giamarellos-Bourboulis
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School and Hellenic Institute for the Study of Sepsis, Athens, Greece
| | | | | | | | - Oday Salman
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School and Hellenic Institute for the Study of Sepsis, Athens, Greece
- Department of Medicine, American University of Beirut, Beirut, Lebanon
| | | | | | | | - Luz A González-Hernández
- Unidad de VIH, Hospital Civil de Guadalajara and Universidad de Guadalajara, Guadalajara, Mexico
| | - Rima Moghnieh
- Department of Medicine, Makassed General Hospital, Beirut, Lebanon
| | - Rapti Angeliki
- 6th Department of Pulmonary Medicine, SOTIRIA Athens General Hospital of Chest Disease, Athens, Greece
| | - María E Cruz Saldarriaga
- Centro de Investigación de Enfermedades Infecciosas y Tropicales, Hospital Nacional Adolfo Guevara Velasco, Cuzco, Peru
| | - Marcos Pariona
- Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Peru
| | - Carola Medina
- Hospital Nacional Edgardo Rebagliati Martins, EsSalud, Lima, Peru
| | - Ioannis Dimitroulis
- 6th Department of Pulmonary Medicine, SOTIRIA Athens General Hospital of Chest Disease, Athens, Greece
| | - Charalambos Vlachopoulos
- 1st Department of Cardiology, National and Kapodistrian University of Athens, Medical School,, Athens, Greece
| | | | - Juan E Rodriguez-Mori
- Department of Nephrology, Hospital Nacional Alberto Sabogal Sologuren, EsSalud, Lima, Peru
| | | | | | | | | | | | | | - Charalampos Milionis
- Department of Internal Medicine, Ioannina University General Hospital, Ioannina, Greece
| | - Garyfallia Poulakou
- 3rd Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | | | | | | | | | | | | | | | - Tiffany Sharkoski
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School and Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Katherine Greene
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School and Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Bianca Pourmussa
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School and Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Candy Greczylo
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School and Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Juan Ortega-Legaspi
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School and Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Douglas Jacoby
- 4th Department of Internal Medicine, National and Kapodistrian University of Athens, Medical School and Hellenic Institute for the Study of Sepsis, Athens, Greece
| | - Jesse Chittams
- Biostatistics Analysis Core, Office of Nursing Research, University of Pennsylvania School of Nursing, Philadelphia, PA, USA
| | - Paraskevi Katsaounou
- Section of Pneumonology and Respiratory Failure, 1st Department of Critical Care Medicine, National and Kapodistrian University of Athens, Medical School, Athens, Greece
| | - Zoi Alexiou
- 2nd Department of Internal Medicine, THRIASIO Eleusis General Hospital, Eleusis, Greece
| | - Styliani Sympardi
- 1st Department of Internal Medicine, THRIASIO Eleusis General Hospital, Eleusis, Greece
| | - Nancy K Sweitzer
- Department of Medicine, Washington University School of Medicine, St. Louis, MO, USA
- Division of Cardiology, University of Arizona, Tucson, AZ, USA
| | - Mary Putt
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jordana B Cohen
- Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Renal-Electrolyte and Hypertension Division, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| |
Collapse
|
14
|
Tran JS, Loveland MG, Alamer A, Piña IL, Sweitzer NK. Clinical and Socioeconomic Determinants of Angiotensin Receptor-Neprilysin Inhibitor Prescription at Hospital Discharge in Patients With Heart Failure With Reduced Ejection Fraction. Circ Heart Fail 2022; 15:e009395. [PMID: 36378759 PMCID: PMC9673159 DOI: 10.1161/circheartfailure.121.009395] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 07/11/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Angiotensin receptor-neprilysin inhibitor (ARNI) prescription in the United States remains suboptimal despite strong evidence for efficacy and value in heart failure with reduced ejection fraction. Factors responsible for under prescription are not completely understood. Economic limitations may play a disproportionate role in reduced access for some patients. METHODS This is an analysis of the Get With The Guidelines-Heart Failure registry, supplemented with data from the Distressed Community Index. Data were fit to a mixed-effects regression model to investigate clinical and socioeconomic factors associated with ARNI prescription at hospital discharge. Missing data were handled by multilevel multiple imputation. RESULTS Of the 136 144 patients included in analysis, 12.6% were prescribed an ARNI at discharge. The dominant determinants of ARNI prescription were ARNI use while inpatient (odds ratio [OR], 72 [95% CI, 58-89]; P<0.001) and taking an ARNI before hospitalization (OR 9 [95% CI, 7-13]; P<0.001). Having an ACE (angiotensin-converting enzyme) inhibitor/angiotensin receptor blocker (ARB)/ARNI contraindication was associated with lower likelihood of ARNI prescription at discharge (OR, 0.11 [95% CI, 0.10-0.12]; P<0.001). Socioeconomic factors associated with lower likelihood of ARNI prescription included having no insurance (OR, 0.60 [95% CI, 0.50-0.72]; P<0.001) and living in a ZIP Code identified as distressed (OR, 0.81 [95% CI, 0.70-0.93]; P=0.010). The rate of ARNI prescription is increasing with time (OR, 2 [95% CI, 1.8-2.3]; P<0.001 for patients discharged in 2020 as opposed to 2017), but the disparity in prescription rates between distressed and prosperous communities appears to be increasing. CONCLUSIONS Multiple medical and socioeconomic factors contribute to low rates of ARNI prescription at hospital discharge. Potential targets for improving ARNI prescription rates include initiating ARNIs during hospitalization and aggressively addressing patients' access barriers with the support of inpatient social services and pharmacists.
Collapse
Affiliation(s)
| | | | - Ahmad Alamer
- Department of Clinical Pharmacy, Prince Sattam Bin Abdulaziz University, Alkharj, Saudi Arabia
| | - Ileana L Piña
- Dept of Medicine, Detroit Medical Center, Detroit, MI
| | | |
Collapse
|
15
|
Mwansa H, Barry I, Knapp SM, Mazimba S, Calhoun E, Sweitzer NK, Breathett K. Association Between the Affordable Care Act Medicaid Expansion and Receipt of Cardiac Resynchronization Therapy by Race and Ethnicity. J Am Heart Assoc 2022; 11:e026766. [PMID: 36129039 DOI: 10.1161/jaha.122.026766] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Black and Hispanic patients are less likely to receive cardiac resynchronization therapy (CRT) than White patients. Medicaid expansion has been associated with increased access to cardiovascular care among racial and ethnic groups with higher prevalence of underinsurance. It is unknown whether the Medicaid expansion was associated with increased receipt of CRT by race and ethnicity. Methods and Results Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington, DC, we analyzed 1061 patients from early-adopter states (Medicaid expansion by January 2014) and 745 patients from nonadopter states (no implementation 2013-2014). Estimates of change in census-adjusted rates of CRT with or without defibrillator by race and ethnicity and Medicaid adopter status 1 year before and after January 2014 were conducted using a quasi-Poisson regression model. Following the Medicaid expansion, the rate of CRT did not significantly change among Black individuals from early-adopter states (1.07 [95% CI, 0.78-1.48]) or nonadopter states (0.79 [95% CI, 0.57-1.09]). There were no significant changes in rates of CRT among Hispanic individuals from early-adopter states (0.99 [95% CI, 0.70-1.38]) or nonadopter states (1.01 [95% CI, 0.65-1.57]). There was a 34% increase in CRT rates among White individuals from early-adopter states (1.34 [95% CI, 1.05-1.70]), and no significant change among White individuals from nonadopter states (0.77 [95% CI, 0.59-1.02]). The change in CRT rates among White individuals was associated with the timing of the Medicaid implementation (P=0.003). Conclusions Among states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, implementation of Medicaid expansion was associated with increase in CRT rates among White individuals residing in states that adopted the Medicaid expansion policy. Further work is needed to address disparities in CRT among Black and Hispanic patients.
Collapse
Affiliation(s)
- Hunter Mwansa
- Frankel Cardiovascular Center University of Michigan Ann Arbor MI
| | - Ibrahim Barry
- Division of Cardiovascular Medicine, Sarver Heart Center University of Arizona Tucson AZ
| | - Shannon M Knapp
- Statistics Consulting Lab Bio5 Institute, University of Arizona Tucson AZ.,Division of Cardiovascular Medicine Indiana University Indianapolis IN
| | - Sula Mazimba
- Division of Cardiovascular Medicine University of Virginia Health System Charlottesville VA
| | | | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center University of Arizona Tucson AZ.,Division of Cardiovascular Medicine Washington University St. Louis MO
| | | |
Collapse
|
16
|
Breathett K, Knapp SM, Addison D, Johnson A, Shah RU, Flint K, Van Spall HGC, Sweitzer NK, Mazimba S. Relationships between 2018 UNOS heart policy and transplant outcomes in metropolitan, micropolitan, and rural settings. J Heart Lung Transplant 2022; 41:1228-1236. [PMID: 35882595 PMCID: PMC9489641 DOI: 10.1016/j.healun.2022.06.015] [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: 06/07/2021] [Revised: 06/10/2022] [Accepted: 06/17/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND In 2018, United Network for Organ Sharing (UNOS) extended the radius for which a heart transplant candidate can match with a donor, and outcomes across population densities are unknown. We sought to determine whether the policy change was associated with differences in heart transplant waitlist time or death post-transplant for patients from rural, micropolitan, and metropolitan settings. METHODS Using the Scientific Registry of Transplant Recipients, we evaluated U.S. adult patients listed for heart transplant from Janurary 2017 to September 2019 with follow-up through March 2020. Patients were stratified by home zip-codes to either metropolitan, micropolitan, or rural settings. Fine and Gray and Cox models were respectively used to estimate Sub-distribution hazard ratios (SHR) of heart transplant with death or removal from transplant list as a competing event, and HR of death post-transplant within population densities after versus before the UNOS policy change date, October 18, 2018. Analyses were adjusted for demographics, comorbidities, and labs. RESULTS Among 8,747 patients listed for heart transplant, 84.7% were from metropolitan, 8.6% micropolitan, and 6.6% rural settings. The 2018 UNOS policy was associated with earlier receipt of heart transplant for metropolitan [SHR 1.56 (95% CI: 1.46-1.66)] and micropolitan [SHR 1.48 (95% CI: 1.21-1.82)] populations, but not significantly for rural [SHR 1.20 (95% CI: 0.93-1.54)]; however, the interaction between policy and densities was not significant (p = .14). Policy changes were not associated with risk of death post-transplant [metropolitan: HR 1.04 (95% CI: 0.80-1.34); micropolitan: HR 1.10 (95% CI: 0.55-2.23); rural: HR 1.04 (95% CI: 0.52-2.08); interaction p = .99]. CONCLUSIONS The 2018 UNOS heart transplant policy was associated with earlier receipt of heart transplant and no difference in post-transplant survival within population densities. Additional follow-up is needed to determine whether improvements are sustained.
Collapse
Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine, Krannert Cardiovascular Institute, Indiana University, Indianapolis.
| | - Shannon M Knapp
- Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson
| | - Daniel Addison
- Division of Cardiovascular Medicine, Ohio State University
| | - Amber Johnson
- Division of Cardiovascular Medicine, University of Pittsburgh
| | | | - Kelsey Flint
- Rocky Mountain Regional Veterans Affairs Medical Center, Cardiology Section and Division of Cardiovascular Medicine, University of Colorado
| | - Harriette G C Van Spall
- Department of Medicine and Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia
| |
Collapse
|
17
|
Butler J, Stebbins A, Melenovský V, Sweitzer NK, Cowie MR, Stehlik J, Khan MS, Blaustein RO, Ezekowitz JA, Hernandez AF, Lam CSP, Nkulikiyinka R, O'Connor CM, Pieske BM, Ponikowski P, Spertus JA, Voors AA, Anstrom KJ, Armstrong PW. Vericiguat and Health-Related Quality of Life in Patients With Heart Failure With Reduced Ejection Fraction: Insights From the VICTORIA Trial. Circ Heart Fail 2022; 15:e009337. [PMID: 35656822 DOI: 10.1161/circheartfailure.121.009337] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND We examined the effects of vericiguat compared with placebo in patients with heart failure with reduced ejection fraction enrolled in VICTORIA (Vericiguat Global Study in Patients With Heart Failure With Reduced Ejection Fraction) on health status outcomes measured by the Kansas City Cardiomyopathy Questionnaire (KCCQ) and evaluated whether clinical outcomes varied by baseline KCCQ score. METHODS KCCQ was completed at baseline and 4, 16, and 32 weeks. We assessed treatment effect on KCCQ using a mixed-effects model adjusting for baseline KCCQ and stratification variables. Cox proportional-hazards modeling was performed to evaluate the effect of vericiguat on clinical outcomes by tertiles of baseline KCCQ clinical summary score (CSS), total symptom score (TSS), and overall summary score (OSS). RESULTS Of 5050 patients, 4664, 4741, and 4470 had KCCQ CSS (median [25th to 75th], 65.6 [45.8-81.8]), TSS (68.8 [47.9-85.4]), and OSS (59.9 [42.0-77.1]) at baseline; 94%, 88%, and 82% had data at 4, 16, and 32 weeks. At 16 weeks, CSS improved by a median of 6.3 in both arms; no significant differences in improvement were seen for TSS and OSS between the 2 groups (P=0.69, 0.97, and 0.13 for CSS, TSS, and OSS). Trends were similar at 4 and 32 weeks. Vericiguat versus placebo reduced cardiovascular death or heart failure hospitalization risk similarly across tertiles of baseline KCCQ CSS, TSS, and OSS (interaction P=0.13, 0.21, and 0.65). CONCLUSIONS Vericiguat did not significantly improve KCCQ scores compared with placebo. Vericiguat reduced the risk of cardiovascular death or heart failure hospitalization across the range of baseline health status. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02861534.
Collapse
Affiliation(s)
- Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson (J.B.)
| | - Amanda Stebbins
- Duke Clinical Research Institute (A.S., A.F.H., K.J.A.), Duke University School of Medicine, Durham, NC
| | - Vojtěch Melenovský
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (V.M.)
| | | | - Martin R Cowie
- Royal Brompton Hospital, London, United Kingdom (M.R.C.)
| | - Josef Stehlik
- University of Utah School of Medicine, Salt Lake City (J.S.)
| | | | | | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute (A.S., A.F.H., K.J.A.), Duke University School of Medicine, Durham, NC
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore (C.S.P.L.)
| | | | | | - Burkert M Pieske
- Charité University Medicine, German Heart Center, Berlin, Germany (B.M.P.)
| | | | - John A Spertus
- University of Missouri-Kansas City School of Medicine (J.A.S.)
| | | | - Kevin J Anstrom
- Duke Clinical Research Institute (A.S., A.F.H., K.J.A.), Duke University School of Medicine, Durham, NC
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., P.W.A.)
| | | |
Collapse
|
18
|
Heidenreich PA, Fonarow GC, Opsha Y, Sandhu AT, Sweitzer NK, Warraich HJ. Economic Issues in Heart Failure in the United States. J Card Fail 2022; 28:453-466. [PMID: 35085762 PMCID: PMC9031347 DOI: 10.1016/j.cardfail.2021.12.017] [Citation(s) in RCA: 36] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 11/16/2021] [Accepted: 12/20/2021] [Indexed: 12/27/2022]
Abstract
The cost of heart failure care is high owing to the cost of hospitalization and chronic treatments. Heart failure treatments vary in their benefit and cost. The cost effectiveness of therapies can be determined by comparing the cost of treatment required to obtain a certain benefit, often defined as an increase in 1 year of life. This review was sponsored by the Heart Failure Society of America and describes the growing economic burden of heart failure for patients and the health care system in the United States. It also provides a summary of the cost effectiveness of drugs, devices, diagnostic tests, hospital care, and transitions of care for patients with heart failure. Many medications that are no longer under patent are inexpensive and highly cost-effective. These include angiotensin-converting enzyme inhibitors, beta-blockers and mineralocorticoid receptor antagonists. In contrast, more recently developed medications and devices, vary in cost effectiveness, and often have high out-of-pocket costs for patients.
Collapse
Affiliation(s)
- Paul A. Heidenreich
- Department of Medicine, Stanford University School of Medicine, Stanford, CA,VA Palo Alto Health Care System, Palo Alto, CA
| | - Gregg C. Fonarow
- Division of Cardiology, David Geffen School of Medicine at the University of California Los Angeles, Los Angeles, CA
| | - Yekaterina Opsha
- Ernest Mario School of Pharmacy, Rutgers University, Piscataway, NJ,Saint Barnabas Medical Center, Livingston, NJ
| | - Alexander T. Sandhu
- Department of Medicine, Stanford University School of Medicine, Stanford, CA
| | - Nancy K. Sweitzer
- Division of Cardiology, University of Arizona College of Medicine, Tucson, AZ
| | - Haider J. Warraich
- Brigham and Women’s Hospital, Harvard Medical School, Boston, MA,Department of Medicine, Cardiology Section, VA Boston Healthcare System, Boston, MA
| |
Collapse
|
19
|
Ruberto K, Ehsani H, Parvaneh S, Mohler J, Fain M, Sweitzer NK, Toosizadeh N. The association between heart rate behavior and gait performance: The moderating effect of frailty. PLoS One 2022; 17:e0264013. [PMID: 35171947 PMCID: PMC8849485 DOI: 10.1371/journal.pone.0264013] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/01/2022] [Indexed: 12/17/2022] Open
Abstract
Introduction Research suggests that frailty not only influence individual systems, but also it affects the interconnection between them. However, no study exists to show how the interplay between cardiovascular and motor performance is compromised with frailty. Aim To investigate the effect of frailty on the association between heart rate (HR) dynamics and gait performance. Methods Eighty-five older adults (≥65 years and able to walk 9.14 meters) were recruited (October 2016—March 2018) and categorized into 26 non-frail (age = 78.65±7.46 years) and 59 pre-frail/frail individuals (age = 81.01±8.17) based on the Fried frailty phenotype. Participants performed gait tasks while equipped with a wearable electrocardiogram (ECG) sensor attached to the chest, as well as wearable gyroscopes for gait assessment. HR dynamic parameters were extracted, including time to peak HR and percentage increase in HR in response to walking. Using the gyroscope sensors gait parameters were recorded including stride length, stride velocity, mean swing velocity, and double support. Results Among the pre-frail/frail group, time to peak HR was significantly correlated with all gait parameters (p<0.0001, r = 0.51–0.59); however, for the non-frail group, none of the correlations between HR dynamics and gait performance parameters were significant (p>0.45, r = 0.03–0.15). The moderation analysis of time to peak HR, demonstrated a significant interaction effect of HR dynamics and frailty status on walking velocity (p<0.01), and the interaction effect was marginally non-significant for other gait parameters (p>0.10). Conclusions Current findings, for the first time, suggest that a compromised motor and cardiac autonomic interaction exist among pre-frail/frail older adults; an impaired HR performance (i.e., slower increase of HR in response to stressors) may lead to a slower walking performance. Assessing physical performance and its corresponding HR behavior should be studied as a tool for frailty screening and providing insights about the underlying cardiovascular-related mechanism leading to physical frailty.
Collapse
Affiliation(s)
- Kayleigh Ruberto
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona, United States of America
| | - Hossein Ehsani
- Kinesiology Department, University of Maryland, College Park, MD, United States of America
| | - Saman Parvaneh
- Edwards Life Sciences, Irvine, CA, United States of America
| | - Jane Mohler
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona, United States of America
| | - Mindy Fain
- Division of Geriatrics, General Internal Medicine and Palliative Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
- Arizona Center on Aging, Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Nancy K. Sweitzer
- Arizona Sarver Heart Center, Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
| | - Nima Toosizadeh
- Department of Biomedical Engineering, University of Arizona, Tucson, Arizona, United States of America
- Division of Geriatrics, General Internal Medicine and Palliative Medicine, Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
- Arizona Center on Aging, Department of Medicine, University of Arizona, Tucson, Arizona, United States of America
- * E-mail:
| |
Collapse
|
20
|
Sweitzer NK, Burkhoff D, Airhart S, Fang JC. Grace Under Pressure. Circ Heart Fail 2022; 15:e009513. [PMID: 35135327 DOI: 10.1161/circheartfailure.122.009513] [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] [Indexed: 11/16/2022]
Affiliation(s)
- Nancy K Sweitzer
- Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson (N.K.S.)
| | - Daniel Burkhoff
- Division of Cardiology, Department of Medicine, Columbia University Irving Medical Center, New York, NY (D.B.)
| | - Sophia Airhart
- Providence Heart and Vascular Institute, Portland, OR (S.A.)
| | - James C Fang
- Division of Cardiovascular Medicine, University of Utah, Salt Lake City (J.C.F.)
| |
Collapse
|
21
|
Huggins GS, Kinnamon DD, Haas GJ, Jordan E, Hofmeyer M, Kransdorf E, Ewald GA, Morris AA, Owens A, Lowes B, Stoller D, Tang WHW, Garg S, Trachtenberg BH, Shah P, Pamboukian SV, Sweitzer NK, Wheeler MT, Wilcox JE, Katz S, Pan S, Jimenez J, Aaronson KD, Fishbein DP, Smart F, Wang J, Gottlieb SS, Judge DP, Moore CK, Mead JO, Ni H, Burke W, Hershberger RE. Prevalence and Cumulative Risk of Familial Idiopathic Dilated Cardiomyopathy. JAMA 2022; 327:454-463. [PMID: 35103767 PMCID: PMC8808323 DOI: 10.1001/jama.2021.24674] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/22/2021] [Indexed: 12/19/2022]
Abstract
Importance Idiopathic dilated cardiomyopathy (DCM) aggregates in families, and early detection in at-risk family members can provide opportunity to initiate treatment prior to late-phase disease. Most studies have included only White patients, yet Black patients with DCM have higher risk of heart failure-related hospitalization and death. Objective To estimate the prevalence of familial DCM among DCM probands and the age-specific cumulative risk of DCM in first-degree relatives across race and ethnicity groups. Design, Setting, and Participants A family-based, cross-sectional study conducted by a multisite consortium of 25 US heart failure programs. Participants included patients with DCM (probands), defined as left ventricular systolic dysfunction and left ventricular enlargement after excluding usual clinical causes, and their first-degree relatives. Enrollment commenced June 7, 2016; proband and family member enrollment concluded March 15, 2020, and April 1, 2021, respectively. Exposures The presence of DCM in a proband. Main Outcomes and Measures Familial DCM defined by DCM in at least 1 first-degree relative; expanded familial DCM defined by the presence of DCM or either left ventricular enlargement or left ventricular systolic dysfunction without known cause in at least 1 first-degree relative. Results The study enrolled 1220 probands (median age, 52.8 years [IQR, 42.4-61.8]; 43.8% female; 43.1% Black and 8.3% Hispanic) and screened 1693 first-degree relatives for DCM. A median of 28% (IQR, 0%-60%) of living first-degree relatives were screened per family. The crude prevalence of familial DCM among probands was 11.6% overall. The model-based estimate of the prevalence of familial DCM among probands at a typical US advanced heart failure program if all living first-degree relatives were screened was 29.7% (95% CI, 23.5% to 36.0%) overall. The estimated prevalence of familial DCM was higher in Black probands than in White probands (difference, 11.3% [95% CI, 1.9% to 20.8%]) but did not differ significantly between Hispanic probands and non-Hispanic probands (difference, -1.4% [95% CI, -15.9% to 13.1%]). The estimated prevalence of expanded familial DCM was 56.9% (95% CI, 50.8% to 63.0%) overall. Based on age-specific disease status at enrollment, estimated cumulative risks in first-degree relatives at a typical US advanced heart failure program reached 19% (95% CI, 13% to 24%) by age 80 years for DCM and 33% (95% CI, 27% to 40%) for expanded DCM inclusive of partial phenotypes. The DCM hazard was higher in first-degree relatives of non-Hispanic Black probands than non-Hispanic White probands (hazard ratio, 1.89 [95% CI, 1.26 to 2.83]). Conclusions and Relevance In a US cross-sectional study, there was substantial estimated prevalence of familial DCM among probands and modeled cumulative risk of DCM among their first-degree relatives. Trial Registration ClinicalTrials.gov Identifier: NCT03037632.
Collapse
Affiliation(s)
- Gordon S. Huggins
- Cardiology Division, Tufts Medical Center and Tufts University School of Medicine, Boston, Massachusetts
| | - Daniel D. Kinnamon
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Garrie J. Haas
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus
| | - Elizabeth Jordan
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Mark Hofmeyer
- Medstar Research Institute, Washington Hospital Center, Washington, DC
| | - Evan Kransdorf
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | | | | | - Anjali Owens
- Center for Inherited Cardiovascular Disease, Division of Cardiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Brian Lowes
- University of Nebraska Medical Center, Omaha
| | | | | | - Sonia Garg
- University of Texas Southwestern Medical Center, Dallas
| | - Barry H. Trachtenberg
- Houston Methodist DeBakey Heart and Vascular Center, J.C. Walter Jr. Transplant Center, Houston, Texas
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | | | - Matthew T. Wheeler
- Division of Cardiovascular Medicine, Stanford University School of Medicine, Stanford, California
| | - Jane E. Wilcox
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Stuart Katz
- New York University Langone Medical Center, New York
| | - Stephen Pan
- Department of Cardiology, Westchester Medical Center and New York Medical College, Valhalla
| | - Javier Jimenez
- Miami Cardiac & Vascular Institute, Baptist Health South, Miami, Florida
| | | | | | - Frank Smart
- Louisiana State University Health Sciences Center, New Orleans
| | - Jessica Wang
- University of California Los Angeles Medical Center, Los Angeles
| | | | | | | | - Jonathan O. Mead
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Hanyu Ni
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
| | - Wylie Burke
- Department of Bioethics and Humanities, University of Washington, Seattle
| | - Ray E. Hershberger
- Division of Human Genetics, Department of Internal Medicine, The Ohio State University, Columbus
- The Davis Heart and Lung Research Institute, The Ohio State University, Columbus
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus
| |
Collapse
|
22
|
Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka RA, Yancy CW, Fonarow GC, DeVore AD, Bhatt DL, Peterson PN. Is the affordable care act medicaid expansion associated with receipt of heart failure guideline-directed medical therapy by race and ethnicity? Am Heart J 2022; 244:135-148. [PMID: 34813771 PMCID: PMC8727506 DOI: 10.1016/j.ahj.2021.11.011] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Revised: 09/17/2021] [Accepted: 11/16/2021] [Indexed: 02/03/2023]
Abstract
BACKGROUND Uninsurance is a known contributor to racial/ethnic health inequities. Insurance is often needed for prescriptions and follow-up appointments. Therefore, we determined whether the Affordable Care Act(ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment(GDMT) at discharge among patients hospitalized with heart failure(HF) by race/ethnicity. METHODS Using Get With The Guidelines-HF registry, logistic regression was used to assess odds of receiving GDMT(HF medications; education; follow-up appointment) in early vs non-adopter states before(2012 - 2013) and after ACA Medicaid Expansion(2014 - 2019) within each race/ethnicity, accounting for patient-level covariates and within-hospital clustering. We tested for an interaction(p-int) between GDMT and pre/post Medicaid Expansion time periods. RESULTS Among 271,606 patients(57.5% early adopter, 42.5% non-adopter), 65.5% were White, 22.8% African American, 8.9% Hispanic, and 2.9% Asian race/ethnicity. Independent of ACA timing, Hispanic patients were more likely to receive all GDMT for residing in early adopter states compared to non-adopter states (P <.0001). In fully-adjusted analyses, ACA Medicaid Expansion was associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients [before ACA:OR 0.40(95%CI:0.13,1.23); after ACA:OR 2.46(1.10,5.51); P-int = .0002], but this occurred in the setting of an immediate decline in prescribing patterns, particularly among non-adopter states, followed by an increase that remained lowest in non-adopter states. The ACA was not associated with receipt of GDMT for other racial/ethnic groups. CONCLUSIONS Among GWTG-HF hospitals, Hispanic patients were more likely to receive all GDMT if they resided in early adopter states rather than non-adopter states, independent of ACA Medicaid Expansion timing. ACA implementation was only associated with higher odds of receipt of ACEI/ARB/ARNI in Hispanic patients. Additional steps are needed for improved GDMT delivery for all.
Collapse
Affiliation(s)
- Khadijah K. Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Haolin Xu
- Department of Biostatistics and Bioinformatics, Duke University,
Durham, NC
| | - Nancy K. Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center,
University of Arizona, Tucson, AZ
| | - Elizabeth Calhoun
- Center for Population Science and Discovery, University of Arizona,
Tucson, AZ
| | | | - Clyde W. Yancy
- Division of Cardiology, Northwestern University Feinberg School of
Medicine, Chicago, IL
| | - Gregg C. Fonarow
- Division of Cardiology, University of California Los Angeles,
CA
| | | | - Deepak L. Bhatt
- Division of Cardiovascular Medicine, Brigham and Women’s
Hospital Heart & Vascular Center, Harvard Medical School, Boston,
MA
| | - Pamela N. Peterson
- Division of Cardiology, University of Colorado, Anschutz Medical
Campus, Aurora, CO and Division of Cardiology, Denver Health Medical Center,
Denver, CO
| |
Collapse
|
23
|
Piening BD, Dowdell AK, Zhang M, Loza BL, Walls D, Gao H, Mohebnasab M, Li YR, Elftmann E, Wei E, Gandla D, Lad H, Chaib H, Sweitzer NK, Deng M, Pereira AC, Cadeiras M, Shaked A, Snyder MP, Keating BJ. Whole Transcriptome Profiling of Prospective Endomyocardial Biopsies Reveals Prognostic and Diagnostic Signatures of Cardiac Allograft Rejection. J Heart Lung Transplant 2022; 41:840-848. [DOI: 10.1016/j.healun.2022.01.1377] [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] [Subscribe] [Scholar Register] [Received: 08/07/2021] [Revised: 01/22/2022] [Accepted: 01/25/2022] [Indexed: 11/26/2022] Open
|
24
|
Affiliation(s)
- Nancy K. Sweitzer
- Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson
| |
Collapse
|
25
|
Affiliation(s)
- Nancy K Sweitzer
- Cardiovascular Medicine, Sarver Heart Center, University of Arizona, Tucson
| |
Collapse
|
26
|
Minamisawa M, Claggett B, Suzuki K, Hegde SM, Shah AM, Desai AS, Lewis EF, Shah SJ, Sweitzer NK, Fang JC, Anand IS, O'Meara E, Rouleau JL, Pitt B, Pfeffer MA, Solomon SD, Vardeny O. Association of Hyper-Polypharmacy With Clinical Outcomes in Heart Failure With Preserved Ejection Fraction. Circ Heart Fail 2021; 14:e008293. [PMID: 34674539 DOI: 10.1161/circheartfailure.120.008293] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [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] [Indexed: 12/11/2022]
Abstract
BACKGROUND Polypharmacy is associated with a poor prognosis in the elderly, however, information on the association of polypharmacy with cardiovascular outcomes in heart failure with preserved ejection fraction is sparse. This study sought to investigate the relationship between polypharmacy and adverse cardiovascular events in patients with heart failure with preserved ejection fraction. METHODS Baseline total number of medications was determined in 1758 patients with heart failure with preserved ejection fraction enrolled in the Americas regions of the TOPCAT trial (Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist), by 3 categories: nonpolypharmacy (<5 medications), polypharmacy (5-9), and hyper-polypharmacy (≥10). We examined the relationship of polypharmacy status with the primary outcome (cardiovascular death, HF hospitalization, or aborted cardiac arrest), hospitalizations for any reason, and serious adverse events. RESULTS The proportion of patients taking 5 or more medications was 92.5% (inclusive of polypharmacy [38.7%] and hyper-polypharmacy [53.8%]). Over a 2.9-year median follow-up, compared with patients with polypharmacy, hyper-polypharmacy was associated with an increased risk for the primary outcome, hospitalization for any reason and any serious adverse events in the univariable analysis, but not significantly associated with mortality. After multivariable adjustment for demographic and comorbidities, hyper-polypharmacy remained significantly associated with an increased risk for hospitalization for any reason (hazard ratio, 1.22 [95% CI, 1.05-1.41]; P=0.009) and any serious adverse events (hazard ratio, 1.23 [95% CI, 1.07-1.42]; P=0.005), whereas the primary outcome was no longer statistically significant. CONCLUSIONS Hyper-polypharmacy was common and associated with an elevated risk of hospitalization for any reason and any serious adverse events in patients with heart failure with preserved ejection fraction. There were no significant associations between polypharmacy status and mortality.
Collapse
Affiliation(s)
- Masatoshi Minamisawa
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.M., B.C., K.S., S.M.H., A.M.S., A.S.D., M.A.P., S.D.S.).,Department of Cardiovascular Medicine, Shinshu University Hospital, Matsumoto, Nagano, Japan (M.M.)
| | - Brian Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.M., B.C., K.S., S.M.H., A.M.S., A.S.D., M.A.P., S.D.S.)
| | - Kota Suzuki
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.M., B.C., K.S., S.M.H., A.M.S., A.S.D., M.A.P., S.D.S.)
| | - Sheila M Hegde
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.M., B.C., K.S., S.M.H., A.M.S., A.S.D., M.A.P., S.D.S.)
| | - Amil M Shah
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.M., B.C., K.S., S.M.H., A.M.S., A.S.D., M.A.P., S.D.S.)
| | - Akshay S Desai
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.M., B.C., K.S., S.M.H., A.M.S., A.S.D., M.A.P., S.D.S.)
| | | | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, IL (S.J.S.)
| | | | - James C Fang
- University of Utah School of Medicine, Salt Lake City (J.C.F.)
| | | | | | | | | | - Marc A Pfeffer
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.M., B.C., K.S., S.M.H., A.M.S., A.S.D., M.A.P., S.D.S.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Boston, MA (M.M., B.C., K.S., S.M.H., A.M.S., A.S.D., M.A.P., S.D.S.)
| | - Orly Vardeny
- Minneapolis VA Center for Care Delivery and Outcomes Research and University of Minnesota Medical School (O.V.)
| |
Collapse
|
27
|
Abstract
Background The majority of living organ donors are women, but few are deceased organ donors, which increases risks associated with sex mismatched organs. We sought to identify reasons for sex disparities in organ donation and strategies for equity. Methods and Results Using Amazon's Mechanical Turk, we examined US adults' perceptions regarding donation in a mixed‐methods survey study. Results were compared by sex with Fisher's exact test and T‐tests for quantitative results and qualitative descriptive analyses for write‐in responses. Among 667 participants (55% women), the majority of men (64.8%) and women (63.4%) self‐identified as registered donors. Women's willingness to donate their own organs to family members (P=0.03) or strangers (P=0.03) was significantly higher than men. Donors from both sexes were guided by: desire to help, personal experience, and believing organs would be useless to deceased donors. Non‐donors from both sexes were guided by: no reason, medical mistrust, contemplating donation. When considering whether to donate organs of a deceased family member, women were equally guided by a family member's wishes and believing the family member had no further use for organs. Men had similar themes but valued the family member's wishes more. Among non‐donors, both sexes would consider donation if more information was provided. Conclusions In a national survey, both sexes had similar reasons for becoming and not becoming an organ donor. However, compared with men, women were more willing to donate their organs to family members and strangers. Improving education and communicating wishes regarding organ donation with direct relatives may increase sex equity in deceased organ donation.
Collapse
Affiliation(s)
- Erika Yee
- School of Medicine and Sarver Heart Center Clinical Research Office University of Arizona Tucson AZ
| | | | | | - Shannon M Knapp
- Statistics Consulting Lab Bio5 InstituteUniversity of Arizona Tucson AZ
| | - Molly Carnes
- Department of Medicine University of Wisconsin Madison WI
| | - Bessie Young
- Division of Nephrology Department of Medicine University of Washington Seattle WA
| | - Nancy K Sweitzer
- Division of Cardiology Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
| | - Khadijah Breathett
- Division of Cardiology Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
| |
Collapse
|
28
|
Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine Sarver Heart Center University of Arizona Tucson AZ
| | - Shannon M Knapp
- Statistics Consulting Lab Bio5 InstituteUniversity of Arizona Tucson AZ
| | - Molly Carnes
- Department of Medicine University of Wisconsin Madison WI
| | - Elizabeth Calhoun
- Center for Population Health Sciences University of Arizona Tucson AZ
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine Sarver Heart Center University of Arizona Tucson AZ
| |
Collapse
|
29
|
Ezekowitz J, Mentz RJ, Westerhout CM, Sweitzer NK, Givertz MM, Piña IL, O'Connor CM, Greene SJ, McMullan C, Roessig L, Hernandez AF, Armstrong PW. Participation in a Heart Failure Clinical Trial: Perspectives and Opportunities From the VICTORIA Trial and VICTORIA Simultaneous Registry. Circ Heart Fail 2021; 14:e008242. [PMID: 34407626 DOI: 10.1161/circheartfailure.120.008242] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Randomized controlled trials (RCTs) often target enrollment of patients with demographics and outcomes less representative of the broader population of interest. To provide context for the VICTORIA trial (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction), we designed a registry of hospitalized patients with worsening heart failure to characterize their clinical profile, outcomes, and reasons for their nonparticipation in a RCT. METHODS Fifty-one RCT sites in Canada and the United States participated. Eligible patients included those with chronic heart failure, hospitalized for heart failure, and an ejection fraction <45%; no other exclusions were applied. Sites identified patients between 2017 and 2019 during the RCT enrollment period. RCT eligibility criteria were applied, and non-mutually exclusive reasons for nonenrollment were captured. Mortality at 1 year was estimated via the Meta-Analysis Global Group in Chronic Heart Failure risk score or as observed in the RCT. RESULTS Overall, 2056 patients were enrolled in the registry; 61% (n=1256) were ineligible for the RCT, 37% (n=766) were eligible but not enrolled, and 2% (n=34) were also enrolled in the RCT. Registry participants had a median age of 70, 33% were women, and 63% were White. The median risk score predicted a 20.9% 1-year mortality, higher than in the RCT (predicted 14.7% and observed 11.5%). Major reasons for ineligibility in the RCT included the use of nitrates (23%), systolic blood pressure <100 mm Hg (12%), and substance use (11%) with other exclusion criteria <10%. For eligible patients, reasons for nonparticipation in the RCT included lack of interest in participating (28%), poor compliance (25%), inability to complete follow-up (23%), too sick (20%), unable to provide consent (17%), and distance from site (15%). CONCLUSIONS Patients with worsening heart failure in routine clinical practice exhibit high-risk features, and approximately one-third were eligible for an RCT but excluded. The majority of these nonparticipating patients had modifiable reasons. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02861534.
Collapse
Affiliation(s)
- Justin Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.E., C.M.W., P.W.A.)
| | - Robert J Mentz
- Duke Clinical Research Institute (R.J.M., C.M.O., S.J.G., A.F.H.), Duke University School of Medicine, Durham, NC
| | - Cynthia M Westerhout
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.E., C.M.W., P.W.A.).,Duke Clinical Research Institute (R.J.M., C.M.O., S.J.G., A.F.H.), Duke University School of Medicine, Durham, NC
| | | | - Michael M Givertz
- Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.M.G.)
| | | | | | - Stephen J Greene
- Duke Clinical Research Institute (R.J.M., C.M.O., S.J.G., A.F.H.), Duke University School of Medicine, Durham, NC.,Division of Cardiology (S.J.G.), Duke University School of Medicine, Durham, NC
| | | | | | - Adrian F Hernandez
- Duke Clinical Research Institute (R.J.M., C.M.O., S.J.G., A.F.H.), Duke University School of Medicine, Durham, NC
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.E., C.M.W., P.W.A.)
| |
Collapse
|
30
|
Mentz RJ, Mulder H, Mosterd A, Sweitzer NK, Senni M, Butler J, Ezekowitz JA, Lam CSP, Pieske B, Ponikowski P, Voors AA, Anstrom KJ, Armstrong PW, O'connor CM, Hernandez AF. Clinical Outcome Predictions for the VerICiguaT Global Study in Subjects With Heart Failure With Reduced Ejection Fraction (VICTORIA) Trial. J Card Fail 2021; 27:S1071-9164(21)00206-2. [PMID: 34217593 DOI: 10.1016/j.cardfail.2021.05.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Revised: 05/03/2021] [Accepted: 05/04/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND The prediction of outcomes in patients with heart failure (HF) may inform prognosis, clinical decisions regarding treatment selection, and new trial planning. The VerICiguaT Global Study in Subjects With Heart Failure With Reduced Ejection Fraction included high-risk patients with HF with reduced ejection fraction and a recent worsening HF event. The study participants had a high event rate despite the use of contemporary guideline-based therapies. To provide generalizable predictive data for a broad population with a recent worsening HF event, we focused on risk prognostication in the placebo group. METHODS AND RESULTS Data from 2524 participants randomized to placebo with chronic HF (New York Heart Association functional class II-IV) and an ejection fraction of less than 45% were studied and backward variable selection was used to create Cox proportional hazards models for clinical end points, selecting from 66 candidate predictors. Final model results were produced, accounting for missing data, and nonlinearities. Optimism-corrected c-indices were calculated using 200 bootstrap samples. Over a median follow-up of 10.4 months, the primary outcome of HF hospitalization or cardiovascular death occurred in 972 patients (38.5%). Independent predictors of increased risk for the primary end point included HF characteristics (longer HF duration and worse New York Heart Association functional class), medical history (prior myocardial infarction), and laboratory values (higher N-terminal pro-hormone B-type natriuretic peptide, bilirubin, urate; lower chloride and albumin). Optimism-corrected c-indices were 0.68 for the HF hospitalization/cardiovascular death model, 0.68 for HF hospitalization/all-cause death, 0.72 for cardiovascular death, and 0.73 for all-cause death. CONCLUSIONS Predictive models developed in a large diverse clinical trial with comprehensive clinical and laboratory baseline data-including novel measures-performed well in high-risk patients with HF who were receiving excellent guideline-based clinical care. CLINICAL TRIAL REGISTRATION Clinicaltrials.gov identifier, NCT02861534.Lay Summary: Patients with heart failure may benefit from tools that help clinicians to better understand a patient's risk for future events like hospitalization. Relatively few risk models have been created after the worsening of heart failure in a contemporary cohort. We provide insights on the risk factors for clinical events from a recent, large, global trial of patients with worsening heart failure to help clinicians better understand and communicate prognosis and select treatment options.
Collapse
Affiliation(s)
- Robert J Mentz
- Duke Clinical Research Institute, Duke University, Durham, North Carolina.
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | | | | | - Javed Butler
- The University of Mississippi Medical Center, Jackson, Mississippi
| | - Justin A Ezekowitz
- University of Alberta, Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore
| | - Burkert Pieske
- Charite - Campus Virchow-Klinikum (CVK), German Heart Center, Berlin, Germany
| | - Piotr Ponikowski
- The Cardiology Department, Wroclaw Medical University, Wroclaw, Poland
| | | | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | - Paul W Armstrong
- University of Alberta, Canadian VIGOUR Centre, Edmonton, Alberta, Canada
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| |
Collapse
|
31
|
Breathett K, Knapp SM, Carnes M, Calhoun E, Sweitzer NK. Imbalance in Heart Transplant to Heart Failure Mortality Ratio Among African American, Hispanic, and White Patients. Circulation 2021; 143:2412-2414. [PMID: 34125563 DOI: 10.1161/circulationaha.120.052254] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [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: 11/16/2022]
Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center (K.B., N.K.S.), University of Arizona, Tucson
| | - Shannon M Knapp
- Statistics Consulting Laboratory, Bio5 Institute (S.M.K.), University of Arizona, Tucson
| | - Molly Carnes
- Department of Medicine, University of Wisconsin, Madison (M.C.)
| | - Elizabeth Calhoun
- Center for Population Health Sciences (E.C.), University of Arizona, Tucson
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center (K.B., N.K.S.), University of Arizona, Tucson
| |
Collapse
|
32
|
Alkhatib N, Sweitzer NK, Lee CS, Erstad B, Slack M, Gharaibeh M, Karnes J, Klimecki W, Ramos K, Abraham I. Ex Ante Economic Evaluation of Arg389 Genetically Targeted Treatment with Bucindolol versus Empirical Treatment with Carvedilol in NYHA III/IV Heart Failure. Am J Cardiovasc Drugs 2021; 21:205-217. [PMID: 32710439 DOI: 10.1007/s40256-020-00425-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE The Beta-Blocker Evaluation Survival Trial showed no survival benefit for bucindolol in New York Heart Association (NYHA) class III/IV heart failure (HF) with reduced ejection fraction, but subanalyses suggested survival benefits for non-Black subjects and Arg389 homozygotes. We conducted an ex ante economic evaluation of Arg389 targeted treatment with bucindolol versus carvidolol, complementing a previous ex ante economic evaluation of bucindolol preceded by genetic testing for the Arg389 polymorphism, in which genetic testing prevailed economically over no testing. METHODS A decision tree analysis with an 18-month time horizon was performed to estimate the cost effectiveness/cost utility of trajectories of 100%, 50%, and 0% of patients genetically tested for Arg389 and comparing bucindolol with empirical carvedilol treatment as per prior BEST subanalyses. Incremental cost-effectiveness/cost-utility ratios (ICERs/ICURs) were estimated. RESULTS Race-based analyses for non-White subjects at 100% testing showed a loss of (0.04) life-years and (0.03) quality-adjusted life-years (QALYs) at an incremental cost of $2185, yielding a negative ICER of ($54,625)/life-year and ICUR of ($72,833)/QALY lost; at 50%, the analyses showed a loss of (0.27) life-years and (0.16) QALYs at an incremental cost of $1843, yielding a negative ICER of ($6826)/life-year and ICUR of ($11,519)/QALY lost; at 0%, the analyses showed a loss of (0.33) life-years and (0.30) QALYs at an incremental cost of $1459, yielding a negative ICER of ($4421)/life-year and ICUR of ($4863)/QALY lost. Arg389 homozygote analyses at 100% testing showed incremental gains of 0.02 life-years and 0.02 QALYs at an incremental cost of $378, yielding an ICER of 18,900/life-year and ICUR of $18,900/QALY gained; at 50%, the analyses showed a loss of (0.24) life-years and (0.09) QALYs at an incremental cost of $1039, yielding a negative ICER of ($4329)/life-year and ICUR of ($9336)/QALY lost; at 0%, the analyses showed a loss of (0.33) life-years and (0.30) QALYs at an incremental cost of $1459, yielding a negative ICER of ($4421)/life-year and ICUR of ($4863)/QALY lost. CONCLUSION This independent ex ante economic evaluation suggests that genetically targeted treatment with bucindolol is unlikely to yield clinicoeconomic benefits over empirical treatment with carvedilol in NYHA III/IV HF.
Collapse
|
33
|
Sweitzer NK. Showcasing Heart Failure Science at the American Heart Association Scientific Sessions. Circ Heart Fail 2020; 13:e008157. [PMID: 33320691 DOI: 10.1161/circheartfailure.120.008157] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Nancy K Sweitzer
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson
| |
Collapse
|
34
|
Ezekowitz J, Mentz RJ, Westerhout CM, Sweitzer NK, Givertz MM, Piña IL, O'Connor CM, Greene SJ, Koglin J, Roessig L, Hernandez AF, Armstrong PW. Non-participation in a Heart Failure Clinical Trial: Perspectives and Opportunities from the VICTORIA Trial and Simultaneous Registry. J Card Fail 2020. [DOI: 10.1016/j.cardfail.2020.09.192] [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] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
|
35
|
Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Yee RH, Knapp SM, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E, Sweitzer NK. Association of Gender and Race With Allocation of Advanced Heart Failure Therapies. JAMA Netw Open 2020; 3:e2011044. [PMID: 32692370 PMCID: PMC7412827 DOI: 10.1001/jamanetworkopen.2020.11044] [Citation(s) in RCA: 81] [Impact Index Per Article: 20.3] [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] [Indexed: 02/06/2023] Open
Abstract
Importance Racial bias is associated with the allocation of advanced heart failure therapies, heart transplants, and ventricular assist devices. It is unknown whether gender and racial biases are associated with the allocation of advanced therapies among women. Objective To determine whether the intersection of patient gender and race is associated with the decision-making of clinicians during the allocation of advanced heart failure therapies. Design, Setting, and Participants In this qualitative study, 46 US clinicians attending a conference for an international heart transplant organization in April 2019 were interviewed on the allocation of advanced heart failure therapies. Participants were randomized to examine clinical vignettes that varied 1:1 by patient race (African American to white) and 20:3 by gender (women to men) to purposefully target vignettes of women patients to compare with a prior study of vignettes of men patients. Participants were interviewed about their decision-making process using the think-aloud technique and provided supplemental surveys. Interviews were analyzed using grounded theory methodology, and surveys were analyzed with Wilcoxon tests. Exposure Randomization to clinical vignettes. Main Outcomes and Measures Thematic differences in allocation of advanced therapies by patient race and gender. Results Among 46 participants (24 [52%] women, 20 [43%] racial minority), participants were randomized to the vignette of a white woman (20 participants [43%]), an African American woman (20 participants [43%]), a white man (3 participants [7%]), and an African American man (3 participants [7%]). Allocation differences centered on 5 themes. First, clinicians critiqued the appearance of the women more harshly than the men as part of their overall impressions. Second, the African American man was perceived as experiencing more severe illness than individuals from other racial and gender groups. Third, there was more concern regarding appropriateness of prior care of the African American woman compared with the white woman. Fourth, there were greater concerns about adequacy of social support for the women than for the men. Children were perceived as liabilities for women, particularly the African American woman. Family dynamics and finances were perceived to be greater concerns for the African American woman than for individuals in the other vignettes; spouses were deemed inadequate support for women. Last, participants recommended ventricular assist devices over transplantation for all racial and gender groups. Surveys revealed no statistically significant differences in allocation recommendations for African American and white women patients. Conclusions and Relevance This national study of health care professionals randomized to clinical vignettes that varied only by gender and race found evidence of gender and race bias in the decision-making process for offering advanced therapies for heart failure, particularly for African American women patients, who were judged more harshly by appearance and adequacy of social support. There was no associated between patient gender and race and final recommendations for allocation of advanced therapies. However, it is possible that bias may contribute to delayed allocation and ultimately inequity in the allocation of advanced therapies in a clinical setting.
Collapse
Affiliation(s)
- Khadijah Breathett
- Sarver Heart Center, Division of Cardiology, Department of Medicine, University of Arizona, Tucson
| | - Erika Yee
- Sarver Heart Center, Clinical Research Office, University of Arizona, Tucson
| | - Natalie Pool
- College of Nursing, University of Arizona, Tucson
| | - Megan Hebdon
- College of Nursing, University of Utah, Salt Lake City
| | | | - Ryan H Yee
- Sarver Heart Center, Clinical Research Office, University of Arizona, Tucson
| | - Shannon M Knapp
- Statistics Consulting Lab, Bio5 Institute, University of Arizona, Tucson
| | - Sade Solola
- Department of Medicine, University of Arizona, Tucson
| | - Luis Luy
- University of Rochester, New York
| | | | - Leanne Zabala
- Department of Medicine, University of California, Los Angeles
| | - Jeff Stone
- Department of Psychology, University of Arizona, Tucson
| | | | - Elizabeth Calhoun
- Center for Population Health Sciences, University of Arizona, Tucson
| | - Nancy K Sweitzer
- Sarver Heart Center, Division of Cardiology, Department of Medicine, University of Arizona, Tucson
| |
Collapse
|
36
|
Dhakal BP, Sweitzer NK, Indik JH, Acharya D, William P. SARS-CoV-2 Infection and Cardiovascular Disease: COVID-19 Heart. Heart Lung Circ 2020; 29:973-987. [PMID: 32601020 PMCID: PMC7274628 DOI: 10.1016/j.hlc.2020.05.101] [Citation(s) in RCA: 110] [Impact Index Per Article: 27.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Revised: 05/02/2020] [Accepted: 05/07/2020] [Indexed: 02/06/2023]
Abstract
Coronavirus disease (COVID-19) is a serious illness caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). The symptoms of the disease range from asymptomatic to mild respiratory symptoms and even potentially life-threatening cardiovascular and pulmonary complications. Cardiac complications include acute myocardial injury, arrhythmias, cardiogenic shock and even sudden death. Furthermore, drug interactions with COVID-19 therapies may place the patient at risk for arrhythmias, cardiomyopathy and sudden death. In this review, we summarise the cardiac manifestations of COVID-19 infection and propose a simplified algorithm for patient management during the COVID-19 pandemic.
Collapse
Affiliation(s)
| | | | - Julia H Indik
- Sarver Heart Center, University of Arizona, Tucson, AZ, USA
| | - Deepak Acharya
- Sarver Heart Center, University of Arizona, Tucson, AZ, USA
| | - Preethi William
- Sarver Heart Center, University of Arizona, Tucson, AZ, USA.
| |
Collapse
|
37
|
Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka R, Yancy CW, Fonarow GC, Devore AD, Bhatt DL, Peterson P. Abstract 22: Affordable Care Act Medicaid Expansion Then and Now: Racial/Ethnic Differences in Receipt of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [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: 11/16/2022]
Abstract
Introduction:
Uninsurance is a known contributor to racial/ethnic minority health inequities. Insurance is needed for prescription medications and follow-up visits with specialists. Among racial/ethnic minority patients hospitalized with heart failure (HF), it is not well studied whether the Affordable Care Act (ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment (GDMT) on discharge from HF hospitalization.
Methods:
Using Get With The Guidelines-HF registry, logistic regression models were used to assess the odds of receiving GDMT [angiotensin converting enzyme inhibitor(ACE)/ angiotensin receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor(ARNI); beta blocker; aldosterone antagonist; hydralazine/nitrate; HF education; HF follow-up appointment] in early adopter versus non-adopter states in the periods before (2012-2013) and after ACA Medicaid Expansion (2014-2019) within each race/ethnicity. Models were adjusted for patient-level covariates and generalized estimating equations addressed within-hospital clustering. The interaction (p-int) between adopter state status and timing of ACA Medicaid Expansion (2014) was evaluated.
Results:
Among 271,606 patients (57.5% early adopter, 42.5% non-adopter states), 65.5% were White, 22.8% were African-American, 8.9% were Hispanic, and 2.9% were Asian. In fully adjusted analyses, ACA Medicaid Expansion was associated with significant likelihood of receipt of ACE/ARB/ARNI at discharge in Hispanics [before ACA: OR 0.40 (95% CI: 0.13, 1.23); after ACA: OR 2.46 (95% CI 1.10, 5.51); p-int <0.01]. Asians were more likely to receive a HF follow-up appointment [before ACA: OR 0.64 (0.20, 2.06); after ACA: OR 1.44 (0.50, 4.15); p-int 0.03]. No significant differences were found in receipt of GDMT at the time of ACA Medicaid Expansion for other racial/ethnic groups. Independent of timing of ACA, Hispanics were more likely to receive all GDMT if they resided in an early adopter state compared to non-adopter state (p<0.01). Individual evidence-based treatments varied by state group independent of ACA timing for other racial/ethnic groups. With the exception of ACE/ARB/ARNI, beta blockers, and HF follow-up, <60% of patients in both state groups received other forms of GDMT despite eligibility.
Conclusions:
Among patients hospitalized with HF at centers voluntarily participating in a national quality improvement program, the ACA Medicaid Expansion was associated with increased receipt of ACE/ARB/ARNI in Hispanics, and increased receipt of follow-up appointments in Asians. Independent of the ACA, Hispanics residing in early adopter states were more likely to receive GDMT than Hispanics in non-adopter states. Futher expansion of ACA may reduce racial/ethnic disparities in HF; however, additional steps must be taken to overcome barriers to prescribing GDMT to all.
Collapse
Affiliation(s)
| | - Haolin Xu
- Duke Clinical Rsch Institute, Durham, NC
| | | | | | | | | | | | | | | | | |
Collapse
|
38
|
Yee E, Hosseini SM, Duarte B, Knapp S, Sweitzer NK, Breathett K. Abstract 16: Sex Disparities in Organ Donation: Finding an Equal Donor Pool. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.16] [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: 11/16/2022]
Abstract
Introduction:
The majority of living organ donors are women, and the majority of deceased organ donors are men. This poses a problem for transplant candidates who have worsened survival with sex mismatched organs. The objective of this study was to identify reasons for disparities in organ donation between sexes and identify strategies to increase organ donors.
Methods:
We conducted a fifteen question survey using a crowdsourcing marketplace, Amazon’s Mechanical Turk, in September 2019. The survey assessed how participants make decisions about becoming an organ donor. The survey was distributed to U.S. adult participants, including eight write-in questions and two Likert scale questions. Qualitative descriptive analyses were used to understand reasons for and against becoming an organ donor. Quantitative results were compared with t test.
Results:
Among the 667 eligible participants representing 49 states, 54.9% were women and 63.1% were in the 18-40 age group. The majority of men (64.8%) and women (63.4%) were registered organ donors. Among men and women donors, three themes guided their willingness to donate: desire to help others, personal experience with organ donors/recipients, and believing organs would have no use to the donor once dead. Among men and women non-donors, decisions were guided by three themes: no reason, medical mistrust, considering becoming a donor. Themes varied by sex when considering whether to donate organs of a deceased family member. Women were guided equally by two themes: family member’s wishes and believing the deceased family member had no further use for organs. Men had similar themes but valued the family member’s wishes more. Women’s willingness to donate their own organs to family members (p=0.03) and strangers (p=0.02) was significantly higher than men. Among non-donors, both sexes would consider becoming organ donors if more information was provided.
Conclusion:
In a national survey of adults, women and men had similar reasons for becoming and not becoming an organ donor. However compared to men, women were more willing to donate their organs and more altruistic in the donation of family members’ organs. Women’s deceased organ donation may increase with further communication of women’s wishes before death and by improved public education about organ donation.
Collapse
|
39
|
Breathett KK, Xu H, Sweitzer NK, Calhoun E, Matsouaka R, Yancy CW, Fonarow GC, Devore AD, Bhatt DL, Peterson P. Abstract 384: Affordable Care Act Medicaid Expansion Then and Now: Racial/Ethnic Differences in Receipt of Guideline-Directed Medical Therapy During Heart Failure Hospitalizations. Circ Cardiovasc Qual Outcomes 2020. [DOI: 10.1161/hcq.13.suppl_1.384] [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: 11/16/2022]
Abstract
Introduction:
Uninsurance is a known contributor to racial/ethnic minority health inequities. Insurance is needed for prescription medications and follow-up visits with specialists. Among racial/ethnic minority patients hospitalized with heart failure (HF), it is not well studied whether the Affordable Care Act (ACA) Medicaid Expansion was associated with increased receipt of guideline-directed medical treatment (GDMT) on discharge from HF hospitalization.
Methods:
Using Get With The Guidelines-HF registry, logistic regression models were used to assess the odds of receiving GDMT [angiotensin converting enzyme inhibitor(ACE)/ angiotensin receptor blocker (ARB)/ angiotensin receptor-neprilysin inhibitor(ARNI); beta blocker; aldosterone antagonist; hydralazine/nitrate; HF education; HF follow-up appointment] in early adopter versus non-adopter states in the periods before (2012-2013) and after ACA Medicaid Expansion (2014-2019) within each race/ethnicity. Models were adjusted for patient-level covariates and generalized estimating equations addressed within-hospital clustering. The interaction (p-int) between adopter state status and timing of ACA Medicaid Expansion (2014) was evaluated.
Results:
Among 271,606 patients (57.5% early adopter, 42.5% non-adopter states), 65.5% were White, 22.8% were African-American, 8.9% were Hispanic, and 2.9% were Asian. In fully adjusted analyses, ACA Medicaid Expansion was associated with significant likelihood of receipt of ACE/ARB/ARNI at discharge in Hispanics [before ACA: OR 0.40 (95% CI: 0.13, 1.23); after ACA: OR 2.46 (95% CI 1.10, 5.51); p-int <0.01]. Asians were more likely to receive a HF follow-up appointment [before ACA: OR 0.64 (0.20, 2.06); after ACA: OR 1.44 (0.50, 4.15); p-int 0.03]. No significant differences were found in receipt of GDMT at the time of ACA Medicaid Expansion for other racial/ethnic groups. Independent of timing of ACA, Hispanics were more likely to receive all GDMT if they resided in an early adopter state compared to non-adopter state (p<0.01). Individual evidence-based treatments varied by state group independent of ACA timing for other racial/ethnic groups. With the exception of ACE/ARB/ARNI, beta blockers, and HF follow-up, <60% of patients in both state groups received other forms of GDMT despite eligibility.
Conclusions:
Among patients hospitalized with HF at centers voluntarily participating in a national quality improvement program, the ACA Medicaid Expansion was associated with increased receipt of ACE/ARB/ARNI in Hispanics, and increased receipt of follow-up appointments in Asians. Independent of the ACA, Hispanics residing in early adopter states were more likely to receive GDMT than Hispanics in non-adopter states. Futher expansion of ACA may reduce racial/ethnic disparities in HF; however, additional steps must be taken to overcome barriers to prescribing GDMT to all.
Collapse
Affiliation(s)
| | - Haolin Xu
- Duke Clinical Rsch Institute, Durham, NC
| | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Affiliation(s)
- Nancy K Sweitzer
- Department of Medicine, University of Arizona Sarver Heart Center, Tucson
| |
Collapse
|
41
|
Breathett KK, Knapp SM, Wightman P, Desai A, Mazimba S, Calhoun E, Sweitzer NK. Is the Affordable Care Act Medicaid Expansion Linked to Change in Rate of Ventricular Assist Device Implantation for Blacks and Whites? Circ Heart Fail 2020; 13:e006544. [PMID: 32233662 DOI: 10.1161/circheartfailure.119.006544] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [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] [Indexed: 12/21/2022]
Abstract
BACKGROUND The Affordable Care Act (ACA) has been associated with increased heart transplant listings among blacks, who are disproportionately uninsured. It is unclear whether the ACA is also associated with increased ventricular assist device implantation in blacks. METHODS Using Healthcare Cost and Utilization Project Data State Inpatient Databases from 19 states and Washington DC, we analyzed 1157 patients from early-adopter states (ACA Medicaid expansion by January 2014) and 785 patients from nonadopter states (no implementation from 2013 to 2014). Piecewise Poisson regression with a discontinuity was used to estimate change in census-adjusted rates of ventricular assist device implants by race and ACA adopter status 1 year before and after January 2014. RESULTS Following the ACA Medicaid expansion, the proportional change in rate increased significantly among blacks from early adopter (1.40 [95% CI, 1.12-1.75], pre 0.57/100 000 to post-ACA 0.80/100 000) but not nonadopter states (1.25 [95% CI, 0.98-1.58], pre 0.40/100 000 to post-ACA 0.50/100 000). However, the early and nonadopter changes in implantation rates were not statistically different from each other (P=0.50). There were no immediate changes in whites in either state group following the ACA Medicaid expansion (early adopter, 1.12 [95% CI, 0.98-1.29], pre 0.27/100 000 to post-ACA 0.30/100 000; nonadopter, 0.98 [95% CI, 0.82-1.16], pre 0.27/100 000 to post-ACA 0.26/100 000). CONCLUSIONS Among eligible states participating in Healthcare Cost and Utilization Project Data State Inpatient Databases, the ACA was not associated with immediate changes in ventricular assist device implantation rates by race. Although a significant increase in implantation rate was observed among blacks from early-adopter states, the change was not statistically different from the change seen in nonadopter states.
Collapse
Affiliation(s)
- Khadijah K Breathett
- Division of Cardiovascular Medicine, Sarver Heart Center (K.K.B., N.K.S), University of Arizona, Tucson
| | - Shannon M Knapp
- Statistics Consulting Lab, Bio5 Institute (S.M.K.), University of Arizona, Tucson
| | - Patrick Wightman
- Center for Population Sciences (P.W., E.C.), University of Arizona, Tucson
| | - Archita Desai
- Division of Gastroenterology, Indiana University, Indianapolis (A.D.)
| | - Sula Mazimba
- Division of Cardiovascular Medicine, University of Virginia, Charlottesville (S.M.)
| | - Elizabeth Calhoun
- Center for Population Sciences (P.W., E.C.), University of Arizona, Tucson
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine, Sarver Heart Center (K.K.B., N.K.S), University of Arizona, Tucson
| |
Collapse
|
42
|
Sweitzer NK. Under Pressure
: A New Section of
Circulation: Heart Failure
Highlighting Invasive Hemodynamics. Circ Heart Fail 2020; 13:e006927. [DOI: 10.1161/circheartfailure.120.006927] [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] [Indexed: 11/16/2022]
|
43
|
Pieske B, Patel MJ, Westerhout CM, Anstrom KJ, Butler J, Ezekowitz J, Hernandez AF, Koglin J, Lam CS, Ponikowski P, Roessig L, Voors AA, O'Connor CM, Armstrong PW, Abidin IZ, Atar D, Bahit MC, Benecke JLA, Bocchi EA, Bonderman D, Cho M, Chiang C, Cohen‐Solal A, Cowie M, Edelmann F, Emdin M, Escobedo J, Ezekowitz JA, Givertz MM, Kaye DM, Lanas F, Lassus J, Lewis BS, Lopatin Y, López‐Sendón J, Lund LH, McDonald K, Melenovský V, Mosterd A, Noori E, Oto MA, Palomino ALG, Piña IL, Ponikowski P, Pouleur A, Refsgaard J, Reyes E, Saldarriaga C, Senni M, Sim D, Siu D, Sliwa‐Hähnle K, Sweitzer NK, Troughton RW, Tsutsui H, Tziakas DN, Vazquez‐Tanus JB, Zhang J. Baseline features of the VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction) trial. Eur J Heart Fail 2019; 21:1596-1604. [DOI: 10.1002/ejhf.1664] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [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: 07/31/2019] [Accepted: 10/07/2019] [Indexed: 01/22/2023] Open
Affiliation(s)
- Burkert Pieske
- Charité University Medicine, German Heart Center Berlin Germany
| | | | | | | | - Javed Butler
- Department of MedicineUniversity of Mississippi Medical Center Jackson MS USA
| | | | | | | | - Carolyn S.P. Lam
- National Heart Centre Singapore & Duke‐National University of Singapore Singapore
| | | | | | - Adriaan A. Voors
- Groningen Heart Failure Research Institute Groningen The Netherlands
| | - Christopher M. O'Connor
- Duke Clinical Research InstituteDuke University Durham NC USA
- Inova Heart and Vascular Institute Falls Church VA USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
44
|
Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical misinformation: vet the message! Cardiovasc Res 2019; 115:e187-e188. [PMID: 30689762 PMCID: PMC10155815 DOI: 10.1093/cvr/cvz007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
|
45
|
Vardeny O, Claggett B, Vaduganathan M, Beldhuis I, Rouleau J, O'Meara E, Anand IS, Shah SJ, Sweitzer NK, Fang JC, Desai AS, Lewis EF, Pitt B, Pfeffer MA, Solomon SD. Influence of Age on Efficacy and Safety of Spironolactone in Heart Failure. JACC Heart Fail 2019; 7:1022-1028. [PMID: 31779923 DOI: 10.1016/j.jchf.2019.08.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 08/26/2019] [Accepted: 08/26/2019] [Indexed: 01/14/2023]
Abstract
OBJECTIVES The authors examined efficacy and safety of spironolactone by age in the Americas region (N = 1,767) of the TOPCAT (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist) trial. BACKGROUND Heart failure with preserved ejection fraction disproportionately affects older adults who may exhibit changes in physiology and variable pharmacokinetics. METHODS TOPCAT enrolled patients with heart failure and a left ventricular ejection fraction ≥45% who were age 50 or older with an estimated glomerular filtration rate ≥30 mL/min/1.73 m2 and prior heart failure hospitalization or elevated natriuretic peptide levels. Participants were randomized to spironolactone or placebo with a mean follow-up duration of 3.3 years. We assessed treatment effect and safety by protocol-defined age categories (<65, 65 to 74, and ≥75 years). RESULTS The mean age was 72 ± 10 years (range 50 to 97 years) with 41% over the age of 75 years. Participants ≥75 years were more commonly women and white and had a lower body mass index and estimated glomerular filtration rate compared with the younger age categories. Spironolactone reduced the primary composite outcome compared with placebo across all age categories (p interaction = 0.42). However, spironolactone was associated with an increased risk of the safety endpoint (hazard ratio: 2.54; 95% confidence interval: 1.91 to 3.37; p < 0.001), particularly in older age groups (p interaction = 0.02). Findings in the whole TOPCAT cohort were consistent with results from the Americas region. CONCLUSIONS In this post hoc, exploratory analysis of the TOPCAT trial data from the Americas region, although there was no effect of age on efficacy, there were considerable effects of age on increased rates of adverse safety outcomes. These results should be weighed when considering spironolactone for older heart failure with preserved ejection fraction patients. (Treatment of Preserved Cardiac Function Heart Failure with an Aldosterone Antagonist [TOPCAT]; NCT00094302).
Collapse
Affiliation(s)
- Orly Vardeny
- Minneapolis VA Medical Center, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota.
| | | | | | | | - Jean Rouleau
- Institut de Cardiologie de Montreal, Montreal, Quebec, Canada; Université de Montreal, Montreal, Quebec
| | - Eileen O'Meara
- Institut de Cardiologie de Montreal, Montreal, Quebec, Canada; Université de Montreal, Montreal, Quebec
| | - Inder S Anand
- Minneapolis VA Medical Center, Minneapolis, Minnesota; University of Minnesota, Minneapolis, Minnesota
| | - Sanjiv J Shah
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | | | | | | | | | | | | | | | | |
Collapse
|
46
|
Hill JA, Agewall S, Baranchuk A, Booz GW, Borer JS, Camici PG, Chen PS, Dominiczak AF, Erol Ç, Grines CL, Gropler R, Guzik TJ, Heinemann MK, Iskandrian AE, Knight BP, London B, Lüscher TF, Metra M, Musunuru K, Nallamothu BK, Natale A, Saksena S, Picard MH, Rao SV, Remme WJ, Rosenson RS, Sweitzer NK, Timmis A, Vrints C. Medical Misinformation. Circulation 2019; 139:571-572. [PMID: 30689419 DOI: 10.1161/circulationaha.118.039193] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [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: 11/16/2022]
Affiliation(s)
| | - Stefan Agewall
- Editor-in-Chief, European Heart Journal Cardiovascular Pharmacotherapy
| | | | - George W Booz
- Editor-in-Chief, Journal of Cardiovascular Pharmacology
| | | | | | | | | | - Çetin Erol
- Editor-in-Chief, Anatolian Journal of Cardiology
| | | | | | | | | | | | | | - Barry London
- Editor-in-Chief, Journal of the American Heart Association
| | | | - Marco Metra
- Editor-in-Chief, European Journal of Heart Failure
| | - Kiran Musunuru
- Editor-in-Chief, Circulation: Genomic and Precision Medicine
| | | | - Andrea Natale
- Editors-in-Chief, Journal of Interventional Cardiac Electrophysiology
| | - Sanjeev Saksena
- Editors-in-Chief, Journal of Interventional Cardiac Electrophysiology
| | - Michael H Picard
- Editor-in-Chief, Journal of the American Society of Echocardiography
| | - Sunil V Rao
- Editor-in-Chief, Circulation: Cardiovascular Interventions
| | | | | | | | - Adam Timmis
- Editor-in-Chief, European Heart Journal: Quality of Care and Clinical Outcomes
| | | |
Collapse
|
47
|
Breathett K, Yee E, Pool N, Hebdon M, Crist JD, Knapp S, Larsen A, Solola S, Luy L, Herrera-Theut K, Zabala L, Stone J, McEwen MM, Calhoun E, Sweitzer NK. Does Race Influence Decision Making for Advanced Heart Failure Therapies? J Am Heart Assoc 2019; 8:e013592. [PMID: 31707940 PMCID: PMC6915287 DOI: 10.1161/jaha.119.013592] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Race influences medical decision making, but its impact on advanced heart failure therapy allocation is unknown. We sought to determine whether patient race influences allocation of advanced heart failure therapies. Methods and Results Members of a national heart failure organization were randomized to clinical vignettes that varied by patient race (black or white man) and were blinded to study objectives. Participants (N=422) completed Likert scale surveys rating factors for advanced therapy allocation and think‐aloud interviews (n=44). Survey results were analyzed by least absolute shrinkage and selection operator and multivariable regression to identify factors influencing advanced therapy allocation, including interactions with vignette race and participant demographics. Interviews were analyzed using grounded theory. Surveys revealed no differences in overall racial ratings for advanced therapies. Least absolute shrinkage and selection operator regression selected no interactions between vignette race and clinical factors as important in allocation. However, interactions between participants aged ≥40 years and black vignette negatively influenced heart transplant allocation modestly (−0.58; 95% CI, −1.15 to −0.0002), with adherence and social history the most influential factors. Interviews revealed sequential decision making: forming overall impression, identifying urgency, evaluating prior care appropriateness, anticipating challenges, and evaluating trust while making recommendations. Race influenced each step: avoiding discussing race, believing photographs may contribute to racial bias, believing the black man was sicker compared with the white man, developing greater concern for trust and adherence with the black man, and ultimately offering the white man transplantation and the black man ventricular assist device implantation. Conclusions Black race modestly influenced decision making for heart transplant, particularly during conversations. Because advanced therapy selection meetings are conversations rather than surveys, allocation may be vulnerable to racial bias.
Collapse
Affiliation(s)
- Khadijah Breathett
- Division of Cardiovascular Medicine Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
| | - Erika Yee
- Sarver Heart Center, Clinical Research Office University of Arizona Tucson AZ
| | - Natalie Pool
- College of Nursing University of Arizona Tucson AZ
| | - Megan Hebdon
- College of Nursing University of Arizona Tucson AZ
| | | | - Shannon Knapp
- Statistics Consulting Lab Bio5 Institute University of Arizona Tucson AZ
| | - Ashley Larsen
- Sarver Heart Center, Clinical Research Office University of Arizona Tucson AZ
| | - Sade Solola
- Department of Medicine University of Arizona Tucson AZ
| | - Luis Luy
- University of Rochester Rochester New York U.S
| | | | | | - Jeff Stone
- Department of Psychology University of Arizona Tucson AZ
| | | | - Elizabeth Calhoun
- Center for Population Health Sciences University of Arizona Tucson AZ
| | - Nancy K Sweitzer
- Division of Cardiovascular Medicine Department of Medicine Sarver Heart Center University of Arizona Tucson AZ
| |
Collapse
|
48
|
Ramalho SHR, Claggett BL, Sweitzer NK, Fang JC, Shah SJ, Anand IS, Pitt B, Lewis EF, Pfeffer MA, Solomon SD, Shah AM. Impact of pulmonary disease on the prognosis in heart failure with preserved ejection fraction: the TOPCAT trial. Eur J Heart Fail 2019; 22:557-559. [PMID: 31667977 DOI: 10.1002/ejhf.1593] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 07/24/2019] [Accepted: 07/26/2019] [Indexed: 11/12/2022] Open
Affiliation(s)
- Sergio H R Ramalho
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA.,Health Sciences and Technologies Program, University of Brasilia, Brasilia, Brazil
| | - Brian L Claggett
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | | | | | | | | | | | - Eldrin F Lewis
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marc A Pfeffer
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Scott D Solomon
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Amil M Shah
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, MA, USA
| |
Collapse
|
49
|
Myhre PL, Vaduganathan M, Claggett BL, Anand IS, Sweitzer NK, Fang JC, O'Meara E, Shah SJ, Desai AS, Lewis EF, Rouleau J, Pitt B, Pfeffer MA, Solomon SD. Association of Natriuretic Peptides With Cardiovascular Prognosis in Heart Failure With Preserved Ejection Fraction: Secondary Analysis of the TOPCAT Randomized Clinical Trial. JAMA Cardiol 2019; 3:1000-1005. [PMID: 30140899 DOI: 10.1001/jamacardio.2018.2568] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [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
Importance Contemporary clinical trials of heart failure with preserved ejection fraction (HFpEF) apply natriuretic peptide (NP) thresholds to identify patients who are more likely to have the disease of interest and to enrich the baseline risk of the enrolled cohort. Objective To determine whether age, race/ethnicity, obesity, renal function, and atrial fibrillation (AF) affect the levels of NPs in HFpEF and whether the prognostic significance of NPs varies in these clinically important subgroups. Design, Setting, and Participants This secondary analysis of the Treatment of Preserved Cardiac Function Heart Failure With an Aldosterone Antagonist Trial (TOPCAT) evaluated the distribution and prognostic significance of NPs across 6 subgroups comprising 1057 adult patients (60%) in the Americas region of TOPCAT with symptomatic heart failure (HF) and a left ventricular ejection fraction of 45% or more with available NPs at baseline. Exposures Natriuretic peptides were log-transformed and standardized (expressed per 1 SD, z score) and assessed in 6 subgroups: age (cutoff, 70 years), black race, body mass index (BMI; calculated as weight in kilograms divided by height in meters squared; cutoff, 30 kg/m2), waist circumference (cutoff, 102 cm for men, 88 cm for women), estimated glomerular filtration rate (cutoff, 60 mL/min/1.73 m2), and a history of AF. Main Outcomes and Measures Time to composite cardiovascular death, hospitalization for HF, or aborted cardiac arrest at mean (SD) 2.4-year (1.5) follow-up. Results Of 1057 participants, the mean (SD) age was 72 (10) years, 183 (17.3%) were black, the mean (SD) BMI was 33.4 (8.6) kg/m2, the mean (SD) estimated glomerular filtration rate was 64.6 (21.8) mL/min/1.73 m2, and 472 (45%) had a history of AF. Median B-type NP (n = 698) and N-terminal pro-B-type NP concentrations (n = 359) were 257 (interquartile range, 149-443) ng/L and 959 (interquartile range, 554-2015) ng/L, respectively. Natriuretic peptide concentrations varied by up to 0.5 SD within the 6 subgroups, being higher in older patients with nonblack race, a lower BMI, a lower waist circumference, a lower estimated glomerular filtration rate, and a history of AF. Elevated NP levels (per 1-SD increase) were independently associated with an increased risk of the primary outcome (adjusted hazard ratio, 1.36; 95% CI, 1.22-1.54; P < .001) consistently across all investigated subgroups (interaction P > .05). In TOPCAT Americas (n = 1767), 791 (45%) were enrolled based on elevated NP levels as the qualifying criterion (as opposed to a history of HF hospitalization). This proportion was 31% (93 of 302), 34% (258 of 760), and 39% (443 of 1144) for black race, younger than 70 years, and a BMI of 30 kg/m2 or greater, respectively. Conclusions and Relevance Natriuretic peptides remain important biomarkers of prognosis in HFpEF, even in subgroups who tend to have lower NP levels. A single, absolute NP threshold for inclusion in contemporary HFpEF trials may lead to an underrepresentation of certain demographic and clinical subgroups. Trial Registration ClinicalTrials.gov Identifier: NCT00094302.
Collapse
Affiliation(s)
- Peder Langeland Myhre
- Brigham and Women's Hospital, Boston, Massachusetts.,Akershus University Hospital, Lørenskog, Norway
| | | | | | - Inder S Anand
- Veterans Affairs Medical Center, Minneapolis, Minnesota.,University of Minnesota, Minneapolis
| | | | | | - Eileen O'Meara
- Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | | | | | | | - Jean Rouleau
- Montreal Heart Institute and University of Montreal, Montreal, Quebec, Canada
| | - Bertram Pitt
- University of Michigan School of Medicine, Ann Arbor
| | | | | |
Collapse
|
50
|
Barac YD, Jawitz OK, Klapper J, Schroder J, Daneshmand MA, Patel C, Hartwig MG, Sweitzer NK, Milano CA. Heart Transplantation Survival and the Use of Traumatically Brain-Injured Donors: UNOS Registry Propensity-Matched Analysis. J Am Heart Assoc 2019; 8:e012894. [PMID: 31466496 PMCID: PMC6755844 DOI: 10.1161/jaha.119.012894] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Background The transplantation of hearts from traumatically brain‐injured (TBI) donors has been associated with inferior long‐term survival in single‐center analyses. However, in a more recent analysis, death caused by cerebrovascular accident was associated with worse posttransplant survival in recipients. The purpose of this study was to explore the outcomes of heart transplantation in recipients receiving donor hearts from TBI and non‐TBI donors in a large national registry. Methods and Results We performed a retrospective cohort analysis of the UNOS (United Network of Organ Sharing) Registry Organ Procurement and Transplantation Network between 2006 and 2018 for adult candidates wait‐listed for isolated heart transplantation. Recipients were stratified into 2 groups, TBI and non‐TBI donors. Propensity score matching was performed. Kaplan‐Meier analysis was used to estimate survival posttransplant. A total of 24 894 candidates met inclusion criteria. TBI was the leading cause of death in the donor population. Recipients of TBI donor hearts (N=13 07) were younger (median age, 55 versus 57 years; P<0.001) and less likely women (21.6% versus 29.8%; P<0.001). At 10 years, the TBI group had better long‐term survival compared with the non‐TBI group (62.8% versus 59.9%; P<0.001). After propensity group matching, the 10‐year survival was similar between groups. Conclusions In the largest analysis of heart transplants and their survival, according to the type of donor injury (TBI versus non‐TBI), we found similar survival in heart transplant recipients. Future studies should address specific subpopulations (eg, hemorrhagic stroke) in the non‐TBI group to address concerns about reduced posttransplant survival.
Collapse
Affiliation(s)
- Yaron D Barac
- Division of Cardiovascular and Thoracic Surgery Duke University Medical Center Durham NC
| | - Oliver K Jawitz
- Division of Cardiovascular and Thoracic Surgery Duke University Medical Center Durham NC
| | - Jacob Klapper
- Division of Cardiovascular and Thoracic Surgery Duke University Medical Center Durham NC
| | - Jacob Schroder
- Division of Cardiovascular and Thoracic Surgery Duke University Medical Center Durham NC
| | - Mani A Daneshmand
- Division of Cardiovascular and Thoracic Surgery Duke University Medical Center Durham NC
| | - Chet Patel
- Department of Cardiology Duke University Medical Center Durham NC
| | - Matt G Hartwig
- Division of Cardiovascular and Thoracic Surgery Duke University Medical Center Durham NC
| | - Nancy K Sweitzer
- Division of Cardiology Sarver Heart Center University of Arizona Tucson AZ
| | - Carmelo A Milano
- Division of Cardiovascular and Thoracic Surgery Duke University Medical Center Durham NC
| |
Collapse
|