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Troendle JF, Leifer ES, Yang S, Jeffries N, Kim DY, Joo J, O'Connor CM. Use of win time for ordered composite endpoints in clinical trials. Stat Med 2024; 43:1920-1932. [PMID: 38417455 DOI: 10.1002/sim.10045] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Revised: 11/29/2023] [Accepted: 02/10/2024] [Indexed: 03/01/2024]
Abstract
Consider the choice of outcome for overall treatment benefit in a clinical trial which measures the first time to each of several clinical events. We describe several new variants of the win ratio that incorporate the time spent in each clinical state over the common follow-up, where clinical state means the worst clinical event that has occurred by that time. One version allows restriction so that death during follow-up is most important, while time spent in other clinical states is still accounted for. Three other variants are described; one is based on the average pairwise win time, one creates a continuous outcome for each participant based on expected win times against a reference distribution and another that uses the estimated distributions of clinical state to compare the treatment arms. Finally, a combination testing approach is described to give robust power for detecting treatment benefit across a broad range of alternatives. These new methods are designed to be closer to the overall treatment benefit/harm from a patient's perspective, compared to the ordinary win ratio. The new methods are compared to the composite event approach and the ordinary win ratio. Simulations show that when overall treatment benefit on death is substantial, the variants based on either the participants' expected win times (EWTs) against a reference distribution or estimated clinical state distributions have substantially higher power than either the pairwise comparison or composite event methods. The methods are illustrated by re-analysis of the trial heart failure: a controlled trial investigating outcomes of exercise training.
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Affiliation(s)
- James F Troendle
- Office of Biostatistics Research, Division of Intramural Research of the National Heart, Lung, and Blood Institute, NIH/DHHS, Bethesda, Maryland, USA
| | - Eric S Leifer
- Office of Biostatistics Research, Division of Intramural Research of the National Heart, Lung, and Blood Institute, NIH/DHHS, Bethesda, Maryland, USA
| | - Song Yang
- Office of Biostatistics Research, Division of Intramural Research of the National Heart, Lung, and Blood Institute, NIH/DHHS, Bethesda, Maryland, USA
| | - Neal Jeffries
- Office of Biostatistics Research, Division of Intramural Research of the National Heart, Lung, and Blood Institute, NIH/DHHS, Bethesda, Maryland, USA
| | - Dong-Yun Kim
- Office of Biostatistics Research, Division of Intramural Research of the National Heart, Lung, and Blood Institute, NIH/DHHS, Bethesda, Maryland, USA
| | - Jungnam Joo
- Office of Biostatistics Research, Division of Intramural Research of the National Heart, Lung, and Blood Institute, NIH/DHHS, Bethesda, Maryland, USA
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Levy WS, O'Connor CM. Five-Year Experience From a Cardiovascular Physician and Advanced Practice Providers Leadership-Development Program. J Card Fail 2024:S1071-9164(24)00144-1. [PMID: 38643853 DOI: 10.1016/j.cardfail.2024.03.013] [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] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Revised: 03/15/2024] [Accepted: 03/22/2024] [Indexed: 04/23/2024]
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Gouda P, Rathwell S, Colin-Ramirez E, Felker GM, Ross H, Escobedo J, Macdonald P, Troughton RW, O'Connor CM, Ezekowitz JA. Utilizing Quality of Life Adjusted Days Alive and Out of Hospital in Heart Failure Clinical Trials. Circ Cardiovasc Qual Outcomes 2024:e010560. [PMID: 38567506 DOI: 10.1161/circoutcomes.123.010560] [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] [Received: 09/19/2023] [Accepted: 02/15/2024] [Indexed: 04/04/2024]
Abstract
BACKGROUND In heart failure (HF) trials, there has been an emphasis on utilizing more patient-centered outcomes, including quality of life (QoL) and days alive and out of hospital. We aimed to explore the impact of QoL adjusted days alive and out of hospital as an outcome in 2 HF clinical trials. METHODS Using data from 2 trials in HF (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure [GUIDE-IT] and Study of Dietary Intervention under 100 mmol in Heart Failure [SODIUM-HF]), we determined treatment differences using percentage days alive and out of hospital (%DAOH) adjusted for QoL at 18 months as the primary outcome. For each participant, %DAOH was calculated as a ratio between days alive and out of hospital/total follow-up. Using a regression model, %DAOH was subsequently adjusted for QoL measured by the Kansas City Cardiomyopathy Questionnaire Overall Summary Score. RESULTS In the GUIDE-IT trial, 847 participants had a median baseline Kansas City Cardiomyopathy Questionnaire Overall Summary Score of 59.0 (interquartile range, 40.8-74.3), which did not change over 18 months. %DAOH was 90.76%±22.09% in the biomarker-guided arm and 88.56%±25.27% in the usual care arm. No significant difference in QoL adjusted %DAOH was observed (1.09% [95% CI, -1.57% to 3.97%]). In the SODIUM-HF trial, 796 participants had a median baseline Kansas City Cardiomyopathy Questionnaire Overall Summary Score of 69.8 (interquartile range, 49.3-84.3), which did not change over 18 months. %DAOH was 95.69%±16.31% in the low-sodium arm and 95.95%±14.76% in the usual care arm. No significant difference was observed (1.91% [95% CI, -0.85% to 4.77%]). CONCLUSIONS In 2 large HF clinical trials, adjusting %DAOH for QoL was feasible and may provide complementary information on treatment effects in clinical trials.
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Affiliation(s)
- Pishoy Gouda
- University of Alberta, Edmonton, Canada (P.G., J.A.E.)
| | - Sarah Rathwell
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.R., J.A.E.)
| | - Eloisa Colin-Ramirez
- Universidad Anáhuac México, Huixquilucan, Estado de México, Naucalpan, Mexico (E.C.-R.)
| | | | | | - Jorge Escobedo
- Instituto Mexicano del Seguro Social, Mexico City, Mexico (J.E.)
| | - Peter Macdonald
- St Vincent's Hospital Sydney, Darlinghurst, NSW, Australia (P.M.)
| | - Richard W Troughton
- Christchurch Heart Institute, University of Otago, Christchurch, New Zealand (R.W.T.)
| | - Christopher M O'Connor
- Duke Clinical Research Institute, Durham, NC (G.M.F., C.M.O.)
- Inova Heart and Vascular Center, Falls Church, VA (C.M.O.)
| | - Justin A Ezekowitz
- University of Alberta, Edmonton, Canada (P.G., J.A.E.)
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (S.R., J.A.E.)
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4
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Adamson PB, Echols M, DeFilippis EM, Morris AA, Bennett M, Abraham WT, Lindenfeld J, Teerlink JR, O'Connor CM, Connolly AT, Li H, Fiuzat M, Vaduganathan M, Vardeny O, Batchelor W, McCants KC. Clinical Trial Inclusion and Impact on Early Adoption of Medical Innovation in Diverse Populations. JACC Heart Fail 2024:S2213-1779(24)00179-3. [PMID: 38530702 DOI: 10.1016/j.jchf.2024.02.015] [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] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Revised: 01/31/2024] [Accepted: 02/26/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Inadequate inclusion in clinical trial enrollment may contribute to health inequities by evaluating interventions in cohorts that do not fully represent target populations. OBJECTIVES The aim of this study was to determine if characteristics of patients with heart failure (HF) enrolled in a pivotal trial are associated with who receives an intervention after approval. METHODS Demographics from 2,017,107 Medicare patients hospitalized for HF were compared with those of the first 10,631 Medicare beneficiaries who received implantable pulmonary artery pressure sensors. Characteristics of the population studied in the pivotal CHAMPION (CardioMEMS Heart Sensor Allows Monitoring of Pressure to Improve Outcomes in NYHA Class III Heart Failure Patients) clinical trial (n = 550) were compared with those of both groups. All demographic data were analyzed nationally and in 4 U.S. regions. RESULTS The Medicare HF cohort included 80.9% White, 13.3% African American, 1.9% Hispanic, 1.3% Asian, and 51.5% female patients. Medicare patients <65 years of age were more likely to be African American (33%) and male (58%), whereas older patients were mostly White (84%) and female (53%). Forty-one percent of U.S. HF hospitalizations occurred in the South; demographic characteristics varied significantly across all U.S. regions. The CHAMPION trial adequately represented African Americans (23% overall, 35% <65 years of age), Hispanic Americans (2%), and Asian Americans (1%) but underrepresented women (27%). The trial's population characteristics were similar to those of the first patients who received pulmonary artery sensors (82% White, 13% African American, 1% Asian, 1% Hispanic, and 29% female). CONCLUSIONS Demographics of Centers for Medicare and Medicaid Services beneficiaries hospitalized with HF vary regionally and by age, which should be considered when defining "adequate" representation in clinical studies. Enrollment diversity in clinical trials may affect who receives early application of recently approved innovations.
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Affiliation(s)
- Philip B Adamson
- Heart Failure Division, Abbott Laboratories, Austin, Texas, USA.
| | - Melvin Echols
- Division of Cardiology, Morehouse School of Medicine, Atlanta, Georgia, USA
| | - Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | | | - Mosi Bennett
- Allina Health Minneapolis Heart Institute, Minneapolis, Minnesota, USA
| | | | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California, San Francisco, San Francisco, California, USA
| | - Christopher M O'Connor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Allison T Connolly
- Global Data Science and Analytics, Abbott Laboratories, Santa Clara, California, USA
| | - Huanan Li
- Global Data Science and Analytics, Abbott Laboratories, Santa Clara, California, USA
| | - Mona Fiuzat
- Duke University Medical Center and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Orly Vardeny
- Department of Medicine, University of Minnesota, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA
| | - Wayne Batchelor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Kelly C McCants
- Norton Heart & Vascular Institute, Norton Healthcare, Louisville, Kentucky, USA
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Ezekowitz J, Alemayehu W, Edelmann F, Ponikowski P, Lam CSP, O'Connor CM, Butler J, Corda S, McMullan CJ, Westerhout CM, Voors AA, Mentz RJ, Armstrong PW. Diuretic use and outcomes in patients with heart failure with reduced ejection fraction: Insights from the VICTORIA trial. Eur J Heart Fail 2024. [PMID: 38450878 DOI: 10.1002/ejhf.3179] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2023] [Revised: 01/08/2024] [Accepted: 02/11/2024] [Indexed: 03/08/2024] Open
Abstract
AIMS In VICTORIA, vericiguat compared with placebo reduced the risk of cardiovascular death (CVD) and heart failure hospitalization (HFH) in patients enrolled after a worsening heart failure (WHF) event. We examined clinical outcomes and efficacy of vericiguat as it relates to background use of loop diuretics in patients with WHF. METHODS AND RESULTS We calculated the total daily loop diuretic dose equivalent to furosemide dosing at randomization and categorized these as: no loop diuretic, 1-39, 41-80, 40, and >80 mg total daily dose (TDD). The primary composite outcome of CVD/HFH and its components were evaluated based on TDD loop diuretic and expressed as adjusted hazard ratios with 95% confidence intervals. Post-randomization rates of change in TDD were also examined. Of 4974 patients (98% of the trial) with diuretic dose information available at randomization, 540 (10.8%) were on no loop diuretic, 647 (13.0%) were on 1-39, 1633 (32.8%) were on 40, 1185 (23.8%) were on 41-80, and 969 (19.4%) were on >80 mg TDD. Patients with higher TDD had a higher rate of primary and secondary clinical outcomes. There were no significant interactions with TDD at randomization and efficacy of vericiguat versus placebo for any outcome (all pinteraction > 0.5). Post-randomization diuretic dose changes for vericiguat and placebo showed similar rates of up-titration (19.6 and 20.2/100 person-years), down-titration (16.8 and 18.1/100 person-years), and stopping diuretics (22.9 and 24.2/100 person-years). CONCLUSIONS Loop diuretic TDD at randomization was independently associated with worse outcomes in this high-risk population. The efficacy of vericiguat was consistent across the range of diuretic doses.
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Affiliation(s)
- Justin Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | | | - Frank Edelmann
- Charité University Medicine, German Heart Center, Berlin, Germany
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University Poland and Institute of Heart Diseases, University Hospital, Wroclaw, Poland
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | | | - Javed Butler
- Baylor University Medical Center, Dallas, TX, USA
- Department of Medicine, University of Mississippi Medical Center, Jackson, MS, USA
| | | | | | | | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center of Groningen, Groningen, The Netherlands
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
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Dimond MG, Ibrahim NE, Fiuzat M, McMurray JJV, Lindenfeld J, Ahmad T, Bozkurt B, Bristow MR, Butler J, Carson PE, Felker GM, Jessup M, Murillo J, Kondo T, Solomon SD, Abraham WT, O'Connor CM, Psotka MA. Left Ventricular Ejection Fraction and the Future of Heart Failure Phenotyping. JACC Heart Fail 2024; 12:451-460. [PMID: 38099892 DOI: 10.1016/j.jchf.2023.11.005] [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] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 10/19/2023] [Accepted: 11/04/2023] [Indexed: 02/04/2024]
Abstract
Heart failure (HF) is a complex syndrome traditionally classified by left ventricular ejection fraction (LVEF) cutpoints. Although LVEF is prognostic for risk of events and predictive of response to some HF therapies, LVEF is a continuous variable and cutpoints are arbitrary, often based on historical clinical trial enrichment decisions rather than physiology. Holistic evaluation of the treatment effects for therapies throughout the LVEF range suggests the standard categorization paradigm for HF merits modification. The multidisciplinary Heart Failure Collaboratory reviewed data from large-scale HF clinical trials and found that many HF therapies have demonstrated therapeutic benefit across a large range of LVEF, but specific treatment effects vary across that range. Therefore, HF should practically be classified by association with an LVEF that is reduced or not reduced, while acknowledging uncertainty around the precise LVEF cutpoint, and future research should evaluate new therapies across the continuum of LVEF.
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Affiliation(s)
| | | | - Mona Fiuzat
- Duke University Medical Center, Durham, North Carolina, USA
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom
| | - JoAnn Lindenfeld
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Tariq Ahmad
- Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Michael R Bristow
- University of Colorado Anschutz School of Medicine, Aurora, Colorado, USA
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, Texas, USA
| | | | | | | | | | - Toru Kondo
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, United Kingdom; Department of Cardiology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | | | | | - Christopher M O'Connor
- Inova Schar Heart and Vascular, Falls Church, Virginia, USA; Duke University Medical Center, Durham, North Carolina, USA
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Fuery MA, Leifer ES, Samsky MD, Sen S, O'Connor CM, Fiuzat M, Ezekowitz J, Piña I, Whellan D, Mark D, Felker GM, Desai NR, Januzzi JL, Ahmad T. Prognostic Impact of Repeated NT-proBNP Measurements in Patients With Heart Failure With Reduced Ejection Fraction. JACC Heart Fail 2024; 12:479-487. [PMID: 38127049 DOI: 10.1016/j.jchf.2023.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 10/10/2023] [Accepted: 11/04/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Although clinical studies have demonstrated the association between a single N-terminal pro-B-type natriuretic peptide (NT-proBNP) measurement and clinical outcomes in chronic heart failure, the biomarker is frequently measured serially in clinical practice. OBJECTIVES The aim of this study was to determine the added prognostic value of repeated NT-proBNP measurements compared with single measurements alone for chronic heart failure patients. METHODS In the GUIDE-IT (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure) study, 894 study participants with chronic heart failure with reduced ejection fraction were enrolled at 45 outpatient sites in the United States and Canada. Repeated NT-proBNP levels were measured over a 2-year study period. Associations between repeated NT-proBNP measurements and trial endpoints were assessed using a joint longitudinal and survival model. RESULTS After adjustment for baseline covariates, each doubling of the baseline NT-proBNP level was associated with a HR of 1.17 (95% CI: 1.08-1.28; P = 0.0003) for the primary trial endpoint of cardiovascular death or heart failure hospitalization. Serial measurements increased the adjusted HR for the primary trial endpoint to 1.66 (95% CI: 1.50-1.84; P < 0.0001), and a similar increased risk was observed across secondary trial endpoints. In joint modeling, an increase in NT-proBNP occurred weeks before the onset of adjudicated events. CONCLUSIONS Repeated NT-proBNP measurements are a strong predictor of outcomes in heart failure with reduced ejection fraction with an increase in concentration occurring well before event onset. These results may support routine NT-proBNP monitoring to assist in clinical decision making. (Guiding Evidence Based Therapy Using Biomarker Intensified Treatment in Heart Failure [GUIDE-IT]; NCT01685840).
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Affiliation(s)
- Michael A Fuery
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Eric S Leifer
- Office of Biostatistics Research, National Heart, Lung, and Blood Institute, Bethesda, Maryland, USA
| | - Marc D Samsky
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | | | - Mona Fiuzat
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA
| | | | - Ileana Piña
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - David Whellan
- Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Daniel Mark
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - G Michael Felker
- Duke University School of Medicine and Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, Connecticut, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston, Massachusetts, USA; Harvard Medical School, Boston, Massachusetts, USA; Heart Failure and Biomarker Trials, Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Center for Outcomes Research and Evaluation, Yale University School of Medicine, New Haven, Connecticut, USA.
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8
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Snyderman R, Dai KZ, O'Connor CM. Bridging the Gap Between Effective Therapies and Optimal Clinical Outcomes. Am J Med 2024; 137:192-194. [PMID: 38043884 DOI: 10.1016/j.amjmed.2023.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/13/2023] [Accepted: 11/14/2023] [Indexed: 12/05/2023]
Affiliation(s)
- Ralph Snyderman
- Duke Center for Personalized Health Care, Durham, NC; Duke University School of Medicine, Durham, NC.
| | - Kathy Z Dai
- Duke Center for Personalized Health Care, Durham, NC; Duke University School of Medicine, Durham, NC
| | - Christopher M O'Connor
- Duke University School of Medicine, Durham, NC; Inova Heart and Vascular Institute, Falls Church, VA
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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).
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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.
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10
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Lala A, Hamo CE, Bozkurt B, Fiuzat M, Blumer V, Bukhoff D, Butler J, Costanzo MR, Felker GM, Filippatos G, Konstam MA, McMurray JJV, Mentz RJ, Metra M, Psotka MA, Solomon SD, Teerlink J, Abraham WT, O'Connor CM. Standardized Definitions for Evaluation of Acute Decompensated Heart Failure Therapies: HF-ARC Expert Panel Paper. JACC Heart Fail 2024; 12:1-15. [PMID: 38069997 DOI: 10.1016/j.jchf.2023.09.030] [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] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Accepted: 09/27/2023] [Indexed: 01/06/2024]
Abstract
Acute decompensated heart failure (ADHF) is one of the most common reasons for hospitalizations or urgent care and is associated with poor outcomes. Therapies shown to improve outcomes are limited, however, and innovation in pharmacologic and device-based therapeutics are therefore actively being sought. Standardizing definitions for ADHF and its trajectory is complex, limiting the generalizability and translation of clinical trials to effect clinical care and policy change. The Heart Failure Collaboratory is a multistakeholder organization comprising clinical investigators, clinicians, patients, government representatives (including U.S. Food and Drug Administration and National Institutes of Health participants), payors, and industry collaborators. The following expert consensus document is the product of the Heart Failure Collaboratory convening with the Academic Research Consortium, including members from academia, the U.S. Food and Drug Administration, and industry, for the purposes of proposing standardized definitions for ADHF and highlighting important endpoint considerations to inform the design and conduct of clinical trials for drugs and devices in this clinical arena.
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Affiliation(s)
- Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute and Department of Population Health Science and Policy, Mount Sinai, New York, New York, USA.
| | - Carine E Hamo
- New York University School of Medicine, Leon H. Charney Division of Cardiology, New York University Langone Health, New York, New York, USA
| | - Biykem Bozkurt
- Winters Center for Heart Failure, Cardiology, Baylor College of Medicine and Michael E. DeBakey VA Medical Center, Houston, Texas, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Vanessa Blumer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart Failure, Cleveland Clinic, Cleveland, Ohio, USA
| | - Daniel Bukhoff
- Division of Cardiology, Tufts Medical Center, Boston, Massachusetts, USA; Cardiovascular Research Foundation, New York, New York, USA
| | - Javed Butler
- Baylor Scott & White Research Institute, Dallas, Texas, USA; University of Mississippi Medical Center, Jackson, Mississippi, USA
| | | | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Gerasimos Filippatos
- University of Cyprus Medical School, Shakolas Educational Center for Clinical Medicine, Nicosia, Cyprus
| | - Marvin A Konstam
- The CardioVascular Center of Tufts Medical Center, Boston, Massachusetts, USA
| | - John J V McMurray
- British Heart Foundation Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, Scotland
| | - Robert J Mentz
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA
| | - Marco Metra
- Cardiology, Cardio-Thoracic Department, Civil Hospitals; Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia, Brescia, Italy
| | | | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - John Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California-San Francisco, San Francisco, California, USA
| | - William T Abraham
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Christopher M O'Connor
- Division of Cardiology, Duke University School of Medicine, Durham, North Carolina, USA; Inova Heart and Vascular Institute, Falls Church, Virginia, USA
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Dimond MG, Fiuzat M, Mentz RJ, Lala-Trindade A, Whellan DJ, Walsh MN, Costanzo MR, Yehya A, Desvigne-Nickens P, Malik F, O'Connor CM, Bristow MR. Rewarding Site-Based Research: A Step Toward Improving the Ecosystem of Heart Failure Clinical Trials. JACC Heart Fail 2024; 12:226-228. [PMID: 37804314 DOI: 10.1016/j.jchf.2023.07.032] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/02/2023] [Revised: 07/10/2023] [Accepted: 07/13/2023] [Indexed: 10/09/2023]
Affiliation(s)
- Matthew G Dimond
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
| | - Mona Fiuzat
- Duke University Medical Center, Durham, North Carolina, USA
| | - Robert J Mentz
- Duke University Medical Center, Durham, North Carolina, USA
| | - Anu Lala-Trindade
- Icahn School of Medicine at Mount Sinai Hospital, New York, New York, USA
| | - David J Whellan
- Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | | | - Amin Yehya
- Sentara Advanced Heart Failure Center, Norfolk, Virgina, USA
| | | | - Fady Malik
- Cytokinetics, Inc, San Francisco, California, USA
| | - Christopher M O'Connor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Duke University Medical Center, Durham, North Carolina, USA
| | - Michael R Bristow
- University of Colorado Anschutz Medical Campus, Aurora, Colorado, USA
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12
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Pellicori P, Cleland JGF, Borentain M, Taubel J, Graham FJ, Khan J, Bruzzese D, Kessler P, McMurray JJV, Voors AA, O'Connor CM, Teerlink JR, Felker GM. Impact of vasodilators on diuretic response in patients with congestive heart failure: A mechanistic trial of cimlanod (BMS-986231). Eur J Heart Fail 2024; 26:142-151. [PMID: 37990754 DOI: 10.1002/ejhf.3077] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2023] [Revised: 10/04/2023] [Accepted: 10/24/2023] [Indexed: 11/23/2023] Open
Abstract
AIM To investigate the effects of Cimlanod, a nitroxyl donor with vasodilator properties, on water and salt excretion after an administration of an intravenos bolus of furosemide. METHODS AND RESULTS In this randomized, double-blind, mechanistic, crossover trial, 21 patients with left ventricular ejection fraction <45%, increased plasma concentrations of N-terminal pro-B-type natriuretic peptide (NT-proBNP) and receiving loop diuretics were given, on separate study days, either an 8 h intravenous (IV) infusion of cimlanod (12 μg/kg/min) or placebo. Furosemide was given as a 40 mg IV bolus four hours after the start of infusion. The primary endpoint was urine volume in the 4 h after the bolus of furosemide during infusion of cimlanod compared with placebo. Median NT-proBNP at baseline was 1487 (interquartile range: 847-2665) ng/L. Infusion of cimlanod increased cardiac output and reduced blood pressure without affecting cardiac power index consistent with its vasodilator effects. Urine volume in the 4 h post-furosemide was lower with cimlanod (1032 ± 393 ml) versus placebo (1481 ± 560 ml) (p = 0.002), as were total sodium excretion (p = 0.004), fractional sodium excretion (p = 0.016), systolic blood pressure (p < 0.001), estimated glomerular filtration rate (p = 0.012), and haemoglobin (p = 0.010), an index of plasma volume expansion. CONCLUSIONS For patients with heart failure and congestion, vasodilatation with agents such as cimlanod reduces the response to diuretic agents, which may offset any benefit from acute reductions in cardiac preload and afterload.
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Affiliation(s)
- Pierpaolo Pellicori
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - John G F Cleland
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | | | - Jorg Taubel
- Richmond Pharmacology Ltd, St. George's University of London, London, UK
| | - Fraser J Graham
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Javed Khan
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Dario Bruzzese
- Department of Public Health, University of Naples 'Federico II', Naples, Italy
| | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, School of Cardiovascular & Metabolic Health, University of Glasgow, Glasgow, UK
| | - Adriaan A Voors
- University of Groningen, Department of Cardiology, University Medical Center Groningen, Groningen, The Netherlands
| | | | - John R Teerlink
- Section of Cardiology, San Francisco Veterans Affairs Medical Center and School of Medicine, University of California San Francisco, San Francisco, CA, USA
| | - G Michael Felker
- Duke University School of Medicine and the Duke Clinical Research Institute, Durham, NC, USA
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Dimond M, Looby M, Shah B, Sinha SS, Isseh I, Rollins AT, Abdul-Aziz AA, Kennedy J, Tang DG, Klein KM, Casselman S, Vermeulen C, Sheaffer W, Snipes M, O'Connor CM, Shah P. Design and Rationale for the Direct Oral Anti-Coagulant Apixaban in Left Ventricular Assist Devices (DOAC LVAD) Study. J Card Fail 2023:S1071-9164(23)00863-1. [PMID: 37956897 DOI: 10.1016/j.cardfail.2023.10.473] [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: 08/02/2023] [Revised: 09/28/2023] [Accepted: 10/17/2023] [Indexed: 11/21/2023]
Abstract
Implantable left ventricular assist devices (LVAD) therapy is used to improve quality of life, alleviate symptoms, and extend survival in patients with advanced heart failure (HF). LVAD patients require chronic anticoagulation to reduce the risk of thromboembolic complications and frequently experience bleeding events. Apixaban is a direct oral anticoagulant which has become first-line therapy for patients with non-valvular atrial fibrillation and venous thromboembolism; however, its safety in LVAD patients has not been well-characterized. The evaluation of the hemocompatibility of the Direct Oral Anti-Coagulant apixaban in Left Ventricular Assist Devices (DOAC LVAD) trial is a Phase 2, open label trial of LVAD patients randomized to either apixaban or warfarin therapy. Patients randomized to apixaban will be started on a dose of 5 mg twice daily, while those randomized to warfarin will be managed to an INR goal of 2.0-2.5. All patients will be treated with aspirin 81mg daily. We plan to randomize and follow up to 40 patients for 24 weeks to evaluate the primary outcome of freedom from death or hemocompatibility related adverse events (HRAEs) (stroke, device thrombosis, bleeding, aortic root thrombus, and arterial non-CNS thromboembolism). DOAC LVAD will establish the feasibility of apixaban anticoagulant therapy in LVAD patients. Clinicaltrials.gov: NCT04865978.
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Affiliation(s)
- Matthew Dimond
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Mary Looby
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Bhruga Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Shashank S Sinha
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Iyad Isseh
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Allman T Rollins
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Ahmad A Abdul-Aziz
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Jamie Kennedy
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Daniel G Tang
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Katherine M Klein
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Samantha Casselman
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Christen Vermeulen
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Wendy Sheaffer
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | - Meredith Snipes
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA
| | | | - Palak Shah
- Advanced Heart Failure, Inova Schar Heart and Vascular, Falls Church, VA.
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14
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Gilbert ON, Mentz RJ, Bertoni AG, Kitzman DW, Whellan DJ, Reeves GR, Duncan PW, Nelson MB, Blumer V, Chen H, Reed SD, Upadhya B, O'Connor CM, Pastva AM. Relationship of Race With Functional and Clinical Outcomes With the REHAB-HF Multidomain Physical Rehabilitation Intervention for Older Patients With Acute Heart Failure. J Am Heart Assoc 2023; 12:e030588. [PMID: 37889196 PMCID: PMC10727385 DOI: 10.1161/jaha.123.030588] [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: 04/13/2023] [Accepted: 09/19/2023] [Indexed: 10/28/2023]
Abstract
Background The REHAB-HF (Rehabilitation Therapy in Older Acute Heart Failure Patients) randomized trial demonstrated that a 3-month transitional, tailored, progressive, multidomain physical rehabilitation intervention improves physical function, frailty, depression, and health-related quality of life among older adults with acute decompensated heart failure. Whether there is differential intervention efficacy by race is unknown. Methods and Results In this prespecified analysis, differential intervention effects by race were explored at 3 months for physical function (Short Physical Performance Battery [primary outcome], 6-Minute Walk Distance), cognition, depression, frailty, health-related quality of life (Kansas City Cardiomyopathy Questionnaire, EuroQoL 5-Dimension-5-Level Questionnaire) and at 6 months for hospitalizations and death. Significance level for interactions was P≤0.1. Participants (N=337, 97% of trial population) self-identified in near equal proportions as either Black (48%) or White (52%). The Short Physical Performance Battery intervention effect size was large, with values of 1.3 (95% CI, 0.4-2.1; P=0.003]) and 1.6 (95% CI, 0.8-2.4; P<0.001) in Black and White participants, respectively, and without significant interaction by race (P=0.56). Beneficial effects were also demonstrated in 6-Minute Walk Distance, gait speed, and health-related quality of life scores without significant interactions by race. There was an association between intervention and reduced all-cause rehospitalizations in White participants (rate ratio, 0.73 [95% CI, 0.55-0.98]; P=0.034) that appears attenuated in Black participants (rate ratio, 1.06 [95% CI, 0.81-1.41]; P=0.66; interaction P=0.067). Conclusions The intervention produced similarly large improvements in physical function and health-related quality of life in both older Black and White patients with acute decompensated heart failure. A future study powered to determine how the intervention impacts clinical events is required. REGISTRATION URL: https://www.clinicaltrials.gov. Identifier: NCT02196038.
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Affiliation(s)
- Olivia N. Gilbert
- Section of Cardiovascular MedicineWake Forest University School of MedicineWinston‐SalemNC
| | - Robert J. Mentz
- Department of Medicine, Cardiology DivisionDuke University School of MedicineDurhamNC
| | - Alain G. Bertoni
- Division of Public Health SciencesWake Forest University School of MedicineWinston‐SalemNC
| | - Dalane W. Kitzman
- Section of Cardiovascular MedicineWake Forest University School of MedicineWinston‐SalemNC
| | | | | | - Pamela W. Duncan
- Department of Neurology, Sticht Center on Aging, Gerontology, and Geriatric Medicine (P.W.D), Wake Forest School of MedicineWinston‐SalemNC
| | | | - Vanessa Blumer
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Kaufman Center for Heart FailureClevelandOH
| | - Haiying Chen
- Department of Biostatistics and Data ScienceWake Forest University School of MedicineWinston‐SalemNC
| | - Shelby D. Reed
- Department of Population Health SciencesDuke University School of MedicineDurhamNC
| | - Bharathi Upadhya
- Department of Medicine, Cardiology DivisionDuke University School of MedicineDurhamNC
| | | | - Amy M. Pastva
- Department of Orthopedic Surgery, Physical Therapy DivisionDuke University School of MedicineDurhamNC
- Claude D. Pepper Older Americans Independence CenterDuke University School of MedicineDurhamNC
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15
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Chew DS, Li Y, Bigelow R, Cowper PA, Anstrom KJ, Daniels MR, Davidson-Ray L, Hernandez AF, O'Connor CM, Armstrong PW, Mark DB. Cost-Effectiveness of Vericiguat in Patients With Heart Failure With Reduced Ejection Fraction: The VICTORIA Randomized Clinical Trial. Circulation 2023; 148:1087-1098. [PMID: 37671551 DOI: 10.1161/circulationaha.122.063602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2022] [Accepted: 08/10/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND The VICTORIA trial (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction) demonstrated that, in patients with high-risk heart failure, vericiguat reduced the primary composite outcome of cardiovascular death or heart failure hospitalization relative to placebo. The hazard ratio for all-cause mortality was 0.95 (95% CI, 0.84-1.07). In a prespecified analysis, treatment effects varied substantially as a function of baseline NT-proBNP (N-terminal pro-B-type natriuretic peptide) levels, with survival benefit for vericiguat in the lower NT-proBNP quartiles (hazard ratio, 0.82 [95% CI, 0.69-0.97]) and no benefit in the highest NT-proBNP quartile (hazard ratio, 1.14 [95% CI, 0.95-1.38]). An economic analysis was a major secondary objective of the VICTORIA research program. METHODS Medical resource use data were collected for all VICTORIA patients (N=5050). Costs were estimated by applying externally derived US cost weights to resource use counts. Life expectancy was projected from patient-level empirical trial survival results with the use of age-based survival modeling methods. Quality-of-life adjustments were based on prospectively collected EQ-5D-based utilities. The primary outcome was the incremental cost-effectiveness ratio, comparing vericiguat with placebo, assessed from the US health care sector perspective over a lifetime horizon. Cost-effectiveness was estimated using the total VICTORIA cohort, both with and without interaction between treatment and baseline NT-proBNP. RESULTS Life expectancy modeling results varied according to whether the observed heterogeneity of treatment effect by baseline NT-proBNP values was incorporated into the modeling. Including the interaction term, the vericiguat arm had an estimated quality-adjusted life expectancy of 4.56 quality-adjusted life-years (QALYs) compared with 4.13 QALYs for placebo (incremental discounted QALY, 0.43). Without the treatment heterogeneity/interaction term, vericiguat had 4.50 QALYs compared with 4.33 QALYs for placebo (incremental discounted QALY, 0.17). Incremental discounted costs (vericiguat minus placebo) were $28 546 with the treatment interaction and $20 948 without it. Corresponding incremental cost-effectiveness ratios were $66 509 per QALY allowing for treatment heterogeneity and $124 512 without heterogeneity. CONCLUSIONS Vericiguat use in the VICTORIA trial met criteria for intermediate value, but the incremental cost-effectiveness ratio estimates were sensitive to whether the analysis accounted for observed NT-proBNP treatment effect heterogeneity. The cost-effectiveness of vericiguat was driven by the projected incremental life expectancy among patients in the lowest 3 quartiles of NT-proBNP. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02861534.
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Affiliation(s)
- Derek S Chew
- Libin Cardiovascular Institute and O'Brien Institute for Public Health, University of Calgary, AB, Canada (D.S.C.)
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Yanhong Li
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Robert Bigelow
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Patricia A Cowper
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Kevin J Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill (K.J.A.)
| | - Melanie R Daniels
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Linda Davidson-Ray
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
- Division of Cardiology, Duke University Medical Center, Durham, NC (A.F.H., C.M.O., D.B.M.)
| | - Christopher M O'Connor
- Division of Cardiology, Duke University Medical Center, Durham, NC (A.F.H., C.M.O., D.B.M.)
- Inova Heart and Vascular Institute, Falls Church, VA (C.M.O.)
| | - Paul W Armstrong
- University of Alberta, Canadian VIGOUR Centre, Edmonton, Canada (P.W.A.)
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC (D.S.C., Y.L., R.B., P.A.C., M.R.D., L.D.-R., A.F.H., D.B.M.)
- Division of Cardiology, Duke University Medical Center, Durham, NC (A.F.H., C.M.O., D.B.M.)
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16
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Armstrong PW, Zheng Y, Lund LH, Butler J, Troughton RW, Emdin M, Lam CSP, Ponikowski P, Blaustein RO, O'Connor CM, Roessig L, Voors AA, Ezekowitz JA, Westerhout CM. Evolution of NT-proBNP During Prerandomization Screening in VICTORIA: Implications for Clinical Outcomes and Efficacy of Vericiguat. Circ Heart Fail 2023; 16:e010661. [PMID: 37503602 DOI: 10.1161/circheartfailure.123.010661] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Accepted: 06/29/2023] [Indexed: 07/29/2023]
Abstract
BACKGROUND Selecting high-risk patients with heart failure with potentially modifiable cardiovascular events is a priority. Our objective was to evaluate NT-proBNP (N-terminal pro-B-type natriuretic peptide) changes during a 30-day screening to establish (1) the frequency and direction of changes; (2) whether a relationship exists between changes in NT-proBNP and the primary composite outcome of cardiovascular death and heart failure hospitalization; and (3) whether changes in NT-proBNP relate to vericiguat's clinical benefit. METHODS VICTORIA (A Study of Vericiguat in Participants With Heart Failure With Reduced Ejection Fraction) randomized 5050 patients with heart failure with reduced ejection fraction and a recent worsening heart failure event. We studied 3821 patients who had NT-proBNP measured during screening and at randomization. RESULTS Sixteen hundred exhibited a >20% reduction, 1412 had ≤20% change, and 809 showed a >20% rise in NT-proBNP levels. As compared with the primary composite outcome of 28.4/100 patient-years (497 events; 31.1%) in patients with a >20% decline in NT-proBNP, those with >20% during screening had worse outcomes; 48.8/100 patient-years (359 events; 44.4%); adjusted hazard ratio, 1.61 (95% CI, 1.39-1.85). Those patients with a ≤20% change in NT-proBNP had intermediate outcomes; 39.2/100 patient-years (564 events; 39.9%); adjusted hazard ratio, 1.33 (95% CI, 1.17-1.51). No relationship existed between NT-proBNP changes during screening and vericiguat's effect on cardiovascular death and heart failure hospitalization. CONCLUSIONS Substantial differences occurred in the rates of cardiovascular death and heart failure hospitalization, especially in patients with a >20% change in NT-proBNP levels during screening interval. Sequential NT-proBNP levels add important prognostic information meriting consideration in future heart failure trials. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02861534.
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Affiliation(s)
- Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (P.W.A., Y.Z., J.A.E., C.M.W.)
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (P.W.A., Y.Z., J.A.E., C.M.W.)
| | - Lars H Lund
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden (L.H.L.)
| | - Javed Butler
- Baylor Scott and White Research Institute, Dallas, TX (J.B.)
| | | | - Michele Emdin
- Health Science Interdisciplinary Center, Scuola Superiore Sant'Anna, Pisa, Italy (M.E.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | | | | | | | | | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center of Groningen, the Netherlands (A.A.V.)
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (P.W.A., Y.Z., J.A.E., C.M.W.)
| | - Cynthia M Westerhout
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (P.W.A., Y.Z., J.A.E., C.M.W.)
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17
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Ezekowitz JA, McMullan CJ, Westerhout CM, Piña IL, Lopez-Sendon J, Anstrom KJ, Hernandez AF, Lam CSP, O'Connor CM, Pieske B, Ponikowski P, Roessig L, Voors AA, Koglin J, Armstrong PW, Butler J. Background Medical Therapy and Clinical Outcomes From the VICTORIA Trial. Circ Heart Fail 2023; 16:e010599. [PMID: 37417824 DOI: 10.1161/circheartfailure.123.010599] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/18/2023] [Indexed: 07/08/2023]
Abstract
BACKGROUND We examined whether the primary composite outcome (cardiovascular death or heart failure hospitalization) was related to differences in background use and dosing of guideline-directed medical therapy in patients with heart failure with reduced ejection fraction enrolled in VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction), a randomized trial of vericiguat versus placebo. METHODS We evaluated the adherence to guideline use of angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, angiotensin receptor-neprilysin inhibitors, beta-blockers, and mineralocorticoid receptor antagonists. We assessed basic adherence; indication-corrected adherence accounting for guideline indications and contraindications; and dose-corrected adherence (indication-corrected adherence+≥50% of drug dose target). Associations between study treatment and the primary composite outcome according to the adherence to guidelines were assessed using multivariable adjustment; adjusted hazard ratios with 95% CIs and Pinteraction are reported. RESULTS Of 5050 patients, 5040 (99.8%) had medication data at baseline. For angiotensin-converting enzyme inhibitor, angiotensin-receptor blockers, and angiotensin receptor-neprilysin inhibitors, basic adherence to guidelines was 87.4%, indication-corrected was 95.7%, and dose-corrected was 50.9%. For beta-blockers, basic adherence was 93.1%, indication-corrected was 96.2%, and dose-corrected was 45.4%. For mineralocorticoid receptor antagonists, basic adherence was 70.3%, indication-corrected was 87.1%, and dose-corrected was 82.2%. For triple therapy (angiotensin-converting enzyme inhibitors, angiotensin-receptor blockers, or angiotensin receptor-neprilysin inhibitors+beta-blocker+mineralocorticoid receptor antagonist), basic adherence was 59.7%, indication-corrected was 83.3%, and dose-corrected was 25.5%. Using basic or dose-corrected adherence, the treatment effect of vericiguat was consistent across adherence to guidelines groups, with or without multivariable adjustment with no treatment heterogeneity. CONCLUSIONS Patients in VICTORIA were well treated with heart failure with reduced ejection fraction medications. The efficacy of vericiguat was consistent across background therapy with very high adherence to guidelines accounting for patient-level indications, contraindications, and tolerance. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT02861534.
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Affiliation(s)
- Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (J.A.E., C.M.W., P.W.A.)
| | | | - Cynthia M Westerhout
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (J.A.E., C.M.W., P.W.A.)
| | - Ileana L Piña
- Central Michigan University, Mount Pleasant (I.L.P.)
| | - Jose Lopez-Sendon
- IdiPaz Research Institute, Hospital Universitario La Paz, Universidad Autonoma de Madrid, Spain (J.L.-S.)
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University, Durham, NC (K.J.A., A.F.H.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, NC (K.J.A., A.F.H.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | | | - Burkert Pieske
- Charité University Medicine German Heart Center, Berlin, Germany (B.P.)
| | - Piotr Ponikowski
- Department of Heart Disease, Wroclaw Medical University, Poland (P.P.)
| | | | - Adriaan A Voors
- University Medical Center Groningen, University of Groningen, the Netherlands (A.A.V.)
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada (J.A.E., C.M.W., P.W.A.)
| | - Javed Butler
- Baylor University Medical Center, Dallas, TX (J.B.)
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Felker GM, North R, Mulder H, Jones WS, Anstrom KJ, Patel MJ, Butler J, Ezekowitz JA, Lam CSP, O'Connor CM, Roessig L, Hernandez AF, Armstrong PW. Classification of Heart Failure Events by Severity: Insights From the VICTORIA Trial. J Card Fail 2023; 29:1113-1120. [PMID: 37331690 PMCID: PMC10697691 DOI: 10.1016/j.cardfail.2023.04.015] [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: 02/24/2023] [Revised: 04/19/2023] [Accepted: 04/26/2023] [Indexed: 06/20/2023]
Abstract
BACKGROUND Hospitalization due to heart failure (HFH) is a major source of morbidity, consumes significant economic resources and is a key endpoint in HF clinical trials. HFH events vary in severity and implications, but they are typically considered equivalent when analyzing clinical trial outcomes. OBJECTIVES We aimed to evaluate the frequency and severity of HF events, assess treatment effects and describe differences in outcomes by type of HF event in VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction). METHODS VICTORIA compared vericiguat with placebo in patients with HF with reduced ejection fraction (< 45%) and a recent worsening HF event. All HFHs were prospectively adjudicated by an independent clinical events committee (CEC) whose members were blinded to treatment assignment. We evaluated the frequency and clinical impact of HF events by severity, categorized by highest intensity of HF treatment (urgent outpatient visit or hospitalization treated with oral diuretics, intravenous diuretics, intravenous vasodilators, intravenous inotropes, or mechanical support) and treatment effect by event categories. RESULTS In VICTORIA, 2948 HF events occurred in 5050 enrolled patients. Overall total CEC HF events for vericiguat vs placebo were 43.9 vs 49.1 events/100 patient-years (P = 0.01). Hospitalization for intravenous diuretics was the most common type of HFH event (54%). HF event types differed markedly in their clinical implications for both in-hospital and post-discharge events. We observed no difference in the distribution of HF events between randomized treatment groups (P = 0.78). CONCLUSION HF events in large global trials vary significantly in severity and clinical implications, which may have implications for more nuanced trial design and interpretation. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT02861534).
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Affiliation(s)
- G Michael Felker
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA.
| | - Rebecca North
- Duke Aging Center, Duke University School of Medicine, Durham, NC, USA
| | - Hillary Mulder
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - W Schuyler Jones
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
| | | | - Javed Butler
- Baylor University Medical Center, Dallas, TX, USA
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | | | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC, USA
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Pieske B, Pieske-Kraigher E, Lam CSP, Melenovský V, Sliwa K, Lopatin Y, Arango JL, Bahit MC, O'Connor CM, Patel MJ, Roessig L, Morris DA, Kropf M, Westerhout CM, Zheng Y, Armstrong PW. Effect of vericiguat on left ventricular structure and function in patients with heart failure with reduced ejection fraction: The VICTORIA echocardiographic substudy. Eur J Heart Fail 2023; 25:1012-1021. [PMID: 36994634 DOI: 10.1002/ejhf.2836] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2022] [Revised: 03/24/2023] [Accepted: 03/27/2023] [Indexed: 03/31/2023] Open
Abstract
AIM Vericiguat significantly reduced the primary composite outcome of heart failure (HF) hospitalization or cardiovascular death in the VICTORIA trial. It is unknown if these outcome benefits are related to reverse left ventricular (LV) remodelling with vericiguat in patients with HF with reduced ejection fraction (HFrEF). The aim of this study was to compare the effects of vericiguat versus placebo on LV structure and function after 8 months of therapy in patients with HFrEF. METHODS AND RESULTS Standardized transthoracic echocardiography (TTE) was performed at baseline and after 8 months of therapy in a subset of HFrEF patients in VICTORIA. The co-primary endpoints were changes in LV end-systolic volume index (LVESVI) and LV ejection fraction (LVEF). Quality assurance and central reading were performed by an echocardiographic core laboratory blinded to treatment assignment. A total of 419 patients (208 vericiguat, 211 placebo) with high-quality paired TTE at baseline and 8 months were included. Baseline clinical characteristics were well balanced between treatment groups and echocardiographic characteristics were representative of patients with HFrEF. LVESVI significantly declined (60.7 ± 26.8 to 56.8 ± 30.4 ml/m2 ; p < 0.01) and LVEF significantly increased (33.0 ± 9.4% to 36.1 ± 10.2%; p < 0.01) in the vericiguat group, but similarly in the placebo group (absolute changes for vericiguat vs. placebo: LVESVI -3.8 ± 15.4 vs. -7.1 ± 20.5 ml/m2 ; p = 0.07 and LVEF +3.2 ± 8.0% vs. +2.4 ± 7.6%; p = 0.31). The absolute rate per 100 patient-years of the primary composite endpoint at 8 months tended to be lower in the vericiguat group (19.8) than the placebo group (29.6) (p = 0.07). CONCLUSIONS In this pre-specified echocardiographic study, significant improvements in LV structure and function occurred over 8 months in both vericiguat and placebo in a high-risk HFrEF population with recent worsening HF. Further studies are warranted to define the mechanisms of vericiguat's benefit in HFrEF.
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Affiliation(s)
- Burkert Pieske
- Charité University Medicine, German Heart Center, Berlin, Germany
| | | | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore, Singapore
| | - Vojtěch Melenovský
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Karen Sliwa
- Cape Heart Institute, University of Cape Town, Cape Town, South Africa
| | - Yuri Lopatin
- Volgograd State Medical University, Volgograd Regional Cardiology Center, Volgograd, Russian Federation
| | - Juan Luis Arango
- Unidad de Cirugía Cardiovascular de Guatemala, Guatemala City, Guatemala
| | - M Cecilia Bahit
- INECO Neurociencias Oroño, Fundación INECO, Rosario, Argentina
| | | | | | | | - Daniel A Morris
- Charité University Medicine, German Heart Center, Berlin, Germany
| | - Martin Kropf
- Charité University Medicine, German Heart Center, Berlin, Germany
| | | | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, AB, Canada
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Harrington J, Nixon AB, Daubert MA, Yow E, Januzzi J, Fiuzat M, Whellan DJ, O'Connor CM, Ezekowitz J, Piña IL, Adams KF, Felker GM, Karra R. Circulating Angiokines Are Associated With Reverse Remodeling and Outcomes in Chronic Heart Failure. J Card Fail 2023; 29:896-906. [PMID: 36632934 PMCID: PMC10272021 DOI: 10.1016/j.cardfail.2022.12.011] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 12/08/2022] [Accepted: 12/12/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND We sought to determine whether circulating modifiers of endothelial function are associated with cardiac structure and clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). METHODS We measured 25 proteins related to endothelial function in 99 patients from the GUIDE-IT study. Protein levels were evaluated for association with echocardiographic parameters and the incidence of all-cause death and hospitalization for heart failure (HHF). RESULTS Higher concentrations of angiopoietin 2 (ANGPT2), vascular endothelial growth factor receptor 1 (VEGFR1) and hepatocyte growth factor (HGF) were significantly associated with worse function and larger ventricular volumes. Over time, decreases in ANGPT2 and, to a lesser extent, VEGFR1 and HGF, were associated with improvements in cardiac size and function. Individuals with higher concentrations of ANGPT2, VEGFR1 or HGF had increased risks for a composite of death and HHF in the following year (HR 2.76 (95% CI 1.73-4.40) per 2-fold change in ANGPT2; HR 1.76 (95% CI 1.11-2.79) for VEGFR1; and HR 4.04 (95% CI 2.19-7.44) for HGF). CONCLUSIONS Proteins related to endothelial function associate with cardiac size, cardiac function and clinical outcomes in patients with HFrEF. These results support the concept that endothelial function may be an important contributor to the progression to and the recovery from HFrEF.
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Affiliation(s)
- Josephine Harrington
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Andrew B Nixon
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Cancer Institute, Duke University Medical Center, Durham, NC
| | - Melissa A Daubert
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Eric Yow
- Duke Clinical Research Institute, Durham, NC
| | - James Januzzi
- Massachusetts General Hospital; Harvard Medical School, Boston, MA; Baim Institute for Clinical Research, Boston, MA
| | - Mona Fiuzat
- Duke Clinical Research Institute, Durham, NC
| | - David J Whellan
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA
| | | | - Justin Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | - Kirkwood F Adams
- Department of Medicine, University of North Carolina, Chapel Hill, NC
| | - G Michael Felker
- Department of Medicine, Duke University Medical Center, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | - Ravi Karra
- Department of Medicine, Duke University Medical Center, Durham, NC; Department of Pathology, Duke University Medical Center, Durham, NC.
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Butler J, Zheng Y, Khan MS, Bonderman D, Lund LH, deFilippi CR, Blaustein RO, Ezekowitz JA, Freitas C, Hernandez AF, O'Connor CM, Voors AA, Westerhout CM, Lam CSP, Armstrong PW. Ejection Fraction, Biomarkers, and Outcomes and Impact of Vericiguat on Outcomes Across EF in VICTORIA. JACC Heart Fail 2023; 11:583-592. [PMID: 37137660 DOI: 10.1016/j.jchf.2022.12.014] [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: 06/21/2022] [Revised: 11/29/2022] [Accepted: 12/08/2022] [Indexed: 05/05/2023]
Abstract
BACKGROUND Vericiguat reduced the risk of cardiovascular death (CVD) or hospitalization for heart failure (HF) in patients with worsening HF and reduced left ventricular ejection fraction (LVEF). OBJECTIVES The authors assessed the association of LVEF with biomarker levels, risk of outcome, and whether the effect of vericiguat was homogeneous across LVEF in the VICTORIA (Vericiguat Global Study in Subjects with Heart Failure With Reduced Ejection Fraction) trial. METHODS Patients were grouped by LVEF tertiles (≤24%, 25%-33%, and >33%). Patient characteristics, clinical outcomes, and efficacy and safety of vericiguat were examined by tertile. Prespecified biomarkers including N-terminal pro-B-type natriuretic peptide, cardiac troponin T, growth differentiation factor 15, interleukin 6, high-sensitivity C-reactive protein, and cystatin C were examined. RESULTS The mean LVEF was 29% ± 8% (range: 5%-45%). A pattern of higher N-terminal pro-B-type natriuretic peptide, high-sensitivity C-reactive protein, and interleukin 6 was evident in patients in the lowest LVEF tertile vs the other tertiles. Patients with lower LVEF experienced higher rates of the composite outcome (41.7%, 36.3%, and 33.4% for LVEF ≤24, 25-33, and >33; P < 0.001). There was no significant treatment effect heterogeneity of vericiguat across LVEF groups (adjusted HR from lowest to highest tertiles: 0.79 [95% CI: 0.68-0.94]; 0.95 [95% CI: 0.82-1.11]; 0.94 [95% CI: 0.79-1.11]; P for interaction = 0.222), although the HR was numerically lower in the lowest tertile. There was also no heterogeneity of effect for CVD and HF hospitalization individually (P interaction for CVD = 0.964; HF hospitalization = 0.438). Discontinuation of treatment because of adverse events, symptomatic hypotension, or syncope was consistent across the range of LVEF. CONCLUSIONS Patients with lower LVEF had a distinctive biomarker profile and a higher risk for adverse clinical outcomes vs those with a higher LVEF. There was no significant interaction for the benefit of vericiguat across LVEF tertiles, although the largest signal for benefit in both the primary outcome and HF hospitalizations was noted in tertile 1 (LVEF ≤24%). (Vericiguat Global Study in Subjects with Heart Failure With Reduced Ejection Fraction [VICTORIA]; NCT02861534).
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Affiliation(s)
- Javed Butler
- Baylor University Medical Center, Dallas, Texas, USA; Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | | | - Lars H Lund
- Department of Medicine, Karolinska Institutet, Stockholm, Sweden; Department of Cardiology, Karolinska University Hospital, Stockholm, Sweden
| | | | | | - 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
| | | | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center of Groningen, Groningen, the Netherlands
| | | | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
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22
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Fuery MA, Leifer E, Samsky M, Sen S, O'Connor CM, Fiuzat M, Ezekowitz JA, Pina IL, Whellan DJ, Mark DB, Felker GM, Desai NR, Januzzi JL, Ahmad T. WHAT IS THE VALUE OF REPEATED NT-PROBNP MEASUREMENTS IN CHRONIC HEART FAILURE WITH REDUCED EJECTION FRACTION? J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01068-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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23
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Dimond M, Shakoor U, Rosner CM, Psotka M, Lee S, Batchelor WB, Damluji A, Desai SS, Epps KC, Flanagan MC, Moukhachen H, Raja A, Samadani T, Sherwood MW, Singh R, Shah P, Tang DG, Tehrani BN, Truesdell AG, Young KD, Sinha SS, O'Connor CM. UTILIZATION OF GUIDELINE DIRECTED MEDICAL THERAPY FOR HEART FAILURE IN CARDIOGENIC SHOCK SURVIVORS: AN INOVA SHOCK REGISTRY ANALYSIS. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01013-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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Dimond M, Lee SB, Fiuzat M, Francis C, Speir AM, O'Connor CM. TOP U.S. CARDIOLOGY AND HEART SURGERY HOSPITALS ARE UNDER-PERFORMING IN MEASURES OF PATIENT EXPERIENCE. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)02640-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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25
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Westerhout CM, Zheng Y, Lund L, Butler J, Troughton RW, Emdin M, Lam CS, Ponikowski P, Blaustein R, O'Connor CM, Roessig L, Voors A, Ezekowitz JA, Armstrong PW. NT-PROBNP DURING SCREENING IN THE STUDY OF VERICIGUAT IN PARTICIPANTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION (VICTORIA) TRIAL: INSIGHTS INTO OUTCOMES AND VERICIGUAT. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01174-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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26
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Bhatt AS, Dimond M, Fiuzat M, Vaduganathan M, Vardeny O, Divanji P, Komtebedde J, Lefkowitz MP, Nkulikiyinka R, Petersson M, Roessig L, Schaber D, O'Connor CM, Solomon SD. Impact of COVID-19 on Heart Failure Clinical Trials: Insights From the Heart Failure Collaboratory. JACC Heart Fail 2023; 11:254-257. [PMID: 36754534 PMCID: PMC9901495 DOI: 10.1016/j.jchf.2022.11.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 11/29/2022] [Indexed: 02/09/2023]
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27
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Johansen ND, Vaduganathan M, Zahir D, Fiuzat M, DeFilippis EM, Januzzi JL, Butler J, O'Connor CM, Abraham WT, Psotka MA, McMurray JJV, Dewan P, Claggett BL, Solomon SD, Modin D, Butt JH, Jensen JUS, Schou M, Torp-Pedersen C, Køber L, Gislason GH, Biering-Sørensen T. A Composite Score Summarizing Use and Dosing of Evidence-Based Medical Therapies in Heart Failure: A Nationwide Cohort Study. Circ Heart Fail 2023; 16:e009729. [PMID: 36809039 DOI: 10.1161/circheartfailure.122.009729] [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: 04/26/2022] [Accepted: 10/25/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND As heart failure therapeutic care becomes increasingly complex, a composite medical therapy score could be useful to conveniently summarize background medical therapy. We applied the composite medical therapy score developed by the Heart Failure Collaboratory (HFC) to the Danish heart failure with reduced ejection fraction population to evaluate its external validation including assessing the distribution of the score and its association with survival. METHODS In a retrospective nationwide cohort study, we identified all Danish heart failure with reduced ejection fraction patients alive on July 1, 2018, and assessed their treatment doses. Patients were excluded if they did not have at least 365 days for up-titration of medical therapy prior to identification. The HFC score (range 0-8) accounts for use and dosing of multiple therapies prescribed to each patient. Risk-adjusted association between the composite score and all-cause mortality was examined. RESULTS In total, 26 779 patients (mean age 71.9 years; 32% women) were identified. At baseline, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker was used in 77%, β-blocker in 81%, mineralocorticoid receptor antagonist in 30%, angiotensin receptor-neprilysin inhibitor in 2%, and ivabradine in 2%. The median HFC score was 4. After multivariable adjustment, higher HFC scores were independently associated with lower mortality (≥median versus CONCLUSIONS Nationwide assessment of therapeutic optimization in heart failure with reduced ejection fraction using the HFC score was feasible and the score was strongly and independently associated with survival.
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Affiliation(s)
- Niklas Dyrby Johansen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Denmark (N.D.J., D.Z., D.M., M.S., G.H.G., T.B.-S.)
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (N.D.J., T.B.-S.)
| | - Muthiah Vaduganathan
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.V., B.L.C., S.D.S.)
| | - Deewa Zahir
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Denmark (N.D.J., D.Z., D.M., M.S., G.H.G., T.B.-S.)
| | - Mona Fiuzat
- Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (M.F.)
| | - Ersilia M DeFilippis
- Division of Cardiology, Columbia University Irving Medical Center, New York, NY (E.M.D.)
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Boston (J.L.J.)
| | - Javed Butler
- Department of Medicine, University of Mississippi, Jackson (J.B.)
| | | | - William T Abraham
- Division of Cardiovascular Medicine, Davis Heart and Lung Research Institute, Ohio State University, Columbus (W.T.A.)
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Falls Church, VA (C.M.O., M.A.P.)
| | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M., P.D.)
| | - Pooja Dewan
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, UK (J.J.V.M., P.D.)
| | - Brian L Claggett
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.V., B.L.C., S.D.S.)
| | - Scott D Solomon
- Cardiovascular Division, Brigham and Women's Hospital, Harvard Medical School, Boston, MA (M.V., B.L.C., S.D.S.)
| | - Daniel Modin
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Denmark (N.D.J., D.Z., D.M., M.S., G.H.G., T.B.-S.)
| | - Jawad H Butt
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Denmark (J.H.B., L.K.)
| | - Jens Ulrik Stæhr Jensen
- Respiratory Medicine Section, Department of Medicine, Copenhagen University Hospital-Herlev and Gentofte, Denmark (J.U.S.J.)
| | - Morten Schou
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Denmark (N.D.J., D.Z., D.M., M.S., G.H.G., T.B.-S.)
| | | | - Lars Køber
- Department of Cardiology, Copenhagen University Hospital-Rigshospitalet, Denmark (J.H.B., L.K.)
| | - Gunnar H Gislason
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Denmark (N.D.J., D.Z., D.M., M.S., G.H.G., T.B.-S.)
| | - Tor Biering-Sørensen
- Department of Cardiology, Copenhagen University Hospital-Herlev and Gentofte, Denmark (N.D.J., D.Z., D.M., M.S., G.H.G., T.B.-S.)
- Department of Biomedical Sciences, Faculty of Health and Medical Sciences, University of Copenhagen, Denmark (N.D.J., T.B.-S.)
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Defilippi CR, Alemayehu WG, Voors AA, Kaye D, Blaustein RO, Butler J, Ezekowitz JA, Hernandez AF, Lam CSP, Roessig L, Seliger S, Shah P, Westerhout CM, Armstrong PW, O'Connor CM. Assessment of Biomarkers of Myocardial injury, Inflammation, and Renal Function in Heart Failure With Reduced Ejection Fraction: The VICTORIA Biomarker Substudy. J Card Fail 2023; 29:448-458. [PMID: 36634811 DOI: 10.1016/j.cardfail.2022.12.013] [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: 09/02/2022] [Revised: 12/12/2022] [Accepted: 12/12/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Circulating biomarkers may be useful in understanding prognosis and treatment efficacy in heart failure with reduced ejection fraction. In the VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction) trial, vericiguat, a soluble guanylate cyclase stimulator, decreased the primary outcome of cardiovascular death or heart failure hospitalization in heart failure with reduced ejection fraction. We evaluated biomarkers of cardiac injury, inflammation, and renal function for associations with outcomes and vericiguat treatment effect. METHODS AND RESULTS High-sensitivity cardiac troponin T (hs-cTnT), growth differentiation factor-15 (GDF-15), interleukin-6 (IL-6), high-sensitivity C-reactive protein (hs-CRP), and cystatin C were measured at baseline and 16 weeks. Associations of biomarkers with the primary outcome and its components were estimated. Interaction with study treatment was tested. Changes in biomarkers over time were examined by study treatment. One or more biomarkers were measured in 4652 (92%) of 5050 participants at baseline and 4063 (81%) at 16 weeks. After adjustment, higher values of hs-cTnT, growth differentiation factor-15, and interleukin-6 were associated with the primary outcome, independent of N-terminal pro-B-type natriuretic peptide. Higher hs-cTnT values were associated with a hazard ratio per log standard deviation of 1.21 (95% confidence interval 1.14-1.27). A treatment interaction with vericiguat was evident with hs-cTnT and cardiovascular death (P = .04), but not HF hospitalization (P = .38). All biomarkers except cystatin C decreased over 16 weeks and no relationship between treatment assignment and changes in biomarker levels was observed. CONCLUSIONS hs-cTnT, growth differentiation factor-15, and interleukin-6 levels were associated with risk of the primary outcome in VICTORIA (Vericiguat Global Study in Subjects with Heart Failure with Reduced Ejection Fraction). Uniquely, lower hs-cTnT was associated with a lower rate of cardiovascular death but not HF hospitalization after treatment with vericiguat.
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Affiliation(s)
| | | | - Adriaan A Voors
- University of Groningen, University Medical Center of Groningen, Groningen, the Netherlands
| | - David Kaye
- Baker Heart & Diabetes Institute, Melbourne, Australia
| | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi
| | - 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
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | | | - Stephen Seliger
- University of Maryland School of Medicine, Baltimore, Maryland
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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29
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Rosner CM, Lee SB, Badrish N, Maini AS, Young KD, Vorgang CM, Bagnola A, Desai SS, Hahndorf C, Looby M, Psotka MA, O'Connor CM, Cooper LB. Advanced Practice Provider Urgent Outpatient Clinic for Patients With Decompensated Heart Failure. J Card Fail 2022; 29:536-539. [PMID: 36526217 DOI: 10.1016/j.cardfail.2022.11.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/04/2022] [Accepted: 11/08/2022] [Indexed: 12/15/2022]
Affiliation(s)
| | - Seiyon Ben Lee
- Department of Statistics, George Mason University, Fairfax, Virginia
| | | | - Aneel S Maini
- Georgetown University Medical School, Washington, D.C
| | - Karl D Young
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | - Aaron Bagnola
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | | | - Mary Looby
- Inova Heart and Vascular Institute, Falls Church, Virginia
| | | | | | - Lauren B Cooper
- Inova Heart and Vascular Institute, Falls Church, Virginia; Department of Cardiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, New York
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Farsky PS, White J, Al-Khalidi HR, Sueta CA, Rouleau JL, Panza JA, Velazquez EJ, O'Connor CM. Optimal medical therapy with or without surgical revascularization and long-term outcomes in ischemic cardiomyopathy. J Thorac Cardiovasc Surg 2022; 164:1890-1899.e4. [PMID: 33610365 PMCID: PMC8260609 DOI: 10.1016/j.jtcvs.2020.12.094] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/26/2020] [Revised: 12/02/2020] [Accepted: 12/14/2020] [Indexed: 01/06/2023]
Abstract
OBJECTIVES Optimal medical therapy in patients with heart failure and coronary artery disease is associated with improved outcomes. However, whether this association is influenced by the performance of coronary artery bypass grafting is less well established. Thus, the aim of this study was to determine the possible relationship between coronary artery bypass grafting and optimal medical therapy and its effect on the outcomes of patients with ischemic cardiomyopathy. METHODS The Surgical Treatment for Ischemic Heart Failure trial randomized 1212 patients with coronary artery disease and left ventricular ejection fraction 35% or less to coronary artery bypass grafting with medical therapy or medical therapy alone with a median follow-up over 9.8 years. For the purpose of this study, optimal medical therapy was collected at baseline and 4 months, and defined as the combination of 4 drugs: angiotensin-converting enzyme inhibitor or angiotensin receptor blocker, beta-blocker, statin, and 1 antiplatelet drug. RESULTS At baseline and 4 months, 58.7% and 73.3% of patients were receiving optimal medical therapy, respectively. These patients had no differences in important parameters such as left ventricular ejection fraction and left ventricular volumes. In a multivariable Cox model, optimal medical therapy at baseline was associated with a lower all-cause mortality (hazard ratio, 0.78; 95% confidence interval, 0.66-0.91; P = .001). When landmarked at 4 months, optimal medical therapy was also associated with a lower all-cause mortality (hazard ratio, 0.82; 95% confidence interval, 0.62-0.99; P = .04). There was no interaction between the benefit of optimal medical therapy and treatment allocation. CONCLUSIONS Optimal medical therapy was associated with improved long-term survival and lower cardiovascular mortality in patients with ischemic cardiomyopathy and should be strongly recommended.
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Affiliation(s)
- Pedro S Farsky
- Instituto Dante Pazzanese de Cardiologia and Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
| | - Jennifer White
- Duke Clinical Research Institute and Department of Biostatics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Hussein R Al-Khalidi
- Duke Clinical Research Institute and Department of Biostatics and Bioinformatics, Duke University School of Medicine, Durham, NC
| | - Carla A Sueta
- Division of Cardiology, University of North Carolina, Chapel Hill, NC
| | - Jean L Rouleau
- Department of Medicine, Montréal Heart Institute, Université de Montréal, Montréal, Quebec, Canada
| | - Julio A Panza
- Westchester Medical Center and New York Medical College, Valhalla, NY
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Defilippi C, Shah SJ, Alemayehu W, Lam CSP, Butler J, Reimann S, O'Connor CM, Shah P, Westerhout CM, Armstrong PW. Targeted discovery proteomics to identify clinical phenotypes in heart failure with preserved ejection fraction: a proteomics substudy of VITALITY-HFpEF. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.781] [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: 11/14/2022] Open
Abstract
Abstract
Background
Heart failure with preserved ejection fraction (HFpEF) is a heterogenous syndrome that may emerge from overlapping systemic processes associated with several medical co-morbidities, often within an inflammatory milieu. Identification of unique proteins associated with distinct phenotypes may yield insight into novel therapeutics.
Purpose
Determine if unique clusters of circulating proteins are associated with specific clinical characteristics in patients with HFpEF.
Methods
A targeted discovery proteomics approach with 358 unique proteins associated with cardiovascular disease and inflammation (Olink) was used at baseline in VITALITY-HFpEF among 789 participants with documented left ventricular EF ≥45% and recent decompensation (<6 mos). Proteins were clustered applying the weighted correlation network analysis (WCNA). The associations of the clinical characteristics and frailty and clusters were estimated with linear regression adjusted for age and eGFR. Frailty was characterized as normal, pre-frail, and frail using the Fried criteria. KCCQ was the primary and 6-minute walk distance (6MWD) the secondary endpoint of VITALITY-HFpEF.
Results
Four unique clusters were identified containing 24, 66, 197, and 81 proteins, respectively. Figure 1 shows the adjusted association of the 4 protein clusters, shown with their hub proteins, with the clinical characteristics. The color (red: positive, green: negative relationship) and intensity indicate the magnitude of the standardized difference (relative to the variation [i.e., T-value]); p-value shown in boxes. Cluster 3, with tumor necrosis factor receptor 1 as a hub protein that mediates apoptosis and inflammation, was associated with greater frailty and physical limitation along with shorter 6MWD. In contrast, cluster 4, with protein C as a hub protein that regulates anticoagulation and exerts a protective function on endothelial cells, is associated with less frailty and younger age, and more frequently male sex. Cluster 2 was associated with only younger age and cluster 1 with no clinical characteristics.
Conclusions
Proteomics appear to identify specific clinical phenotypes associated with HFpEF. Further exploration of this approach may provide insight into the diverse pathophysiology characterizing this disorder and a more targeted approach to therapy.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): VITALITY-HFpEF was funded by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA and Bayer AG, Wuppertal, Germany.
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Affiliation(s)
- C Defilippi
- Inova Heart and Vascular Institute , Falls Church , United States of America
| | - S J Shah
- Northwestern University , Chicago , United States of America
| | - W Alemayehu
- University of Alberta, Canadian VIGOUR Centre , Edmonton , Canada
| | - C S P Lam
- National University Heart Centre, Duke-NUS , Singapore , Singapore
| | - J Butler
- Baylor University Medical Center , Dallas , United States of America
| | | | - C M O'Connor
- Inova Heart and Vascular Institute , Falls Church , United States of America
| | - P Shah
- Inova Heart and Vascular Institute , Falls Church , United States of America
| | - C M Westerhout
- University of Alberta, Canadian VIGOUR Centre , Edmonton , Canada
| | - P W Armstrong
- University of Alberta, Canadian VIGOUR Centre , Edmonton , Canada
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Tsutsui H, Lam CSP, Zhang J, Godoy-Palomino A, Tziakas D, Cohen-Solal A, Freitas C, Patel MJ, Ezekowitz JA, Hernandez AF, Pieske B, O'Connor CM, Westerhout CM, Alemayehu W, Armstrong PW. Geographic variation in heart failure with reduced ejection fraction: insights from the VICTORIA trial. Eur Heart J 2022. [DOI: 10.1093/eurheartj/ehac544.835] [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: 11/12/2022] Open
Abstract
Abstract
Background
Geographic differences and background therapy have not been explored in the global VICTORIA trial, which enrolled high-risk patients with recent worsening heart failure with reduced ejection fraction (HFrEF).
Methods and results
Among 5050 patients enrolled in 5 pre-specified geographic regions, 34% were from Eastern Europe, 18% Western Europe, 23% Asia Pacific, 14% Latin and South America, and 11% North America (Table 1). Patients from Western Europe were older, had more atrial fibrillation, and lower glomerular filtration rates. Patients from Eastern Europe had more coronary artery disease and exhibited more advanced symptoms (∼50% New York Heart Association [NYHA] class III), whereas those from Latin and South America were less symptomatic (∼70% NYHA class II). North American patients had the largest body mass index as well as more diabetes and hypertension. Levels of NT-proBNP at randomization and MAGGIC risk scores were highest in Western European patients. Evidence-based triple medication therapy was used most frequently in Latin and South America and less frequently in North America; conversely, cardiac resynchronization therapy and implantable cardioverter defibrillators were most frequently used in North America and least frequently in Latin and South America. The overall primary composite event rate (cardiovascular death or HF hospitalization) in the placebo arm was 36.6/100 person-years over a median of 10.8 months and after adjusting for the MAGGIC score. When examined by region, these event rates were nominally highest in North America and lowest in Western Europe.
Conclusion
Substantial regional differences exist in characteristics and treatments among patients in this global trial of patients with HFrEF and a recent worsening event. These findings demonstrate the continuing unmet needs and opportunities for enhancing care in HFrEF.
Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): VICTORIA was funded by Merck Sharp & Dohme Corp., a subsidiary of Merck & Co., Inc., Kenilworth, NJ, USA and Bayer AG, Wuppertal, Germany.
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Affiliation(s)
- H Tsutsui
- Kyushu University Graduate School of Medical Sciences , Fukuoka , Japan
| | - C S P Lam
- National Heart Centre Singapore, Duke-NUS , Singapore , Singapore
| | - J Zhang
- Fuwai Hospital Chinese Academy of Medical Sciences , Beijing , China
| | | | - D Tziakas
- Democritus University of Thrace , Alexandroupolis , Greece
| | | | | | - M J Patel
- Merck & Co., Inc. , Kenilworth , United States of America
| | - J A Ezekowitz
- University of Alberta, Canadian VIGOUR Centre , Edmonton , Canada
| | - A F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine , Durham , United States of America
| | - B Pieske
- Charité - University Medicine Berlin , Berlin , Germany
| | - C M O'Connor
- Inova Heart and Vascular Institute , Falls Church , United States of America
| | - C M Westerhout
- University of Alberta, Canadian VIGOUR Centre , Edmonton , Canada
| | - W Alemayehu
- University of Alberta, Canadian VIGOUR Centre , Edmonton , Canada
| | - P W Armstrong
- University of Alberta, Canadian VIGOUR Centre , Edmonton , Canada
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Tehrani BN, Sherwood MW, Rosner C, Truesdell AG, Ben Lee S, Damluji AA, Desai M, Desai S, Epps KC, Flanagan MC, Howard E, Ibrahim N, Kennedy J, Moukhachen H, Psotka M, Raja A, Saeed I, Shah P, Singh R, Sinha SS, Tang D, Welch T, Young K, deFilippi CR, Speir A, O'Connor CM, Batchelor WB. A Standardized and Regionalized Network of Care for Cardiogenic Shock. JACC Heart Fail 2022; 10:768-781. [PMID: 36175063 PMCID: PMC10404382 DOI: 10.1016/j.jchf.2022.04.004] [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] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Revised: 03/31/2022] [Accepted: 04/07/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND The benefits of standardized care for cardiogenic shock (CS) across regional care networks are poorly understood. OBJECTIVES The authors compared the management and outcomes of CS patients initially presenting to hub versus spoke hospitals within a regional care network. METHODS The authors stratified consecutive patients enrolled in their CS registry (January 2017 to December 2019) by presentation to a spoke versus the hub hospital. The primary endpoint was 30-day mortality. Secondary endpoints included bleeding, stroke, or major adverse cardiovascular and cerebrovascular events. RESULTS Of 520 CS patients, 286 (55%) initially presented to 34 spoke hospitals. No difference in mean age (62 years vs 61 years; P = 0.38), sex (25% vs 32% women; P = 0.10), and race (54% vs 52% white; P = 0.82) between spoke and hub patients was noted. Spoke patients more often presented with acute myocardial infarction (50% vs 32%; P < 0.01), received vasopressors (74% vs 66%; P = 0.04), and intra-aortic balloon pumps (88% vs 37%; P < 0.01). Hub patients were more often supported with percutaneous ventricular assist devices (44% vs 11%; P < 0.01) and veno-arterial extracorporeal membrane oxygenation (13% vs 0%; P < 0.01). Initial presentation to a spoke was not associated with increased risk-adjusted 30-day mortality (adjusted OR: 0.87 [95% CI: 0.49-1.55]; P = 0.64), bleeding (adjusted OR: 0.89 [95% CI: 0.49-1.62]; P = 0.70), stroke (adjusted OR: 0.74 [95% CI: 0.31-1.75]; P = 0.49), or major adverse cardiovascular and cerebrovascular events (adjusted OR 0.83 [95% CI: 0.50-1.35]; P = 0.44). CONCLUSIONS Spoke and hub patients experienced similar short-term outcomes within a regionalized CS network. The optimal strategy to promote standardized care and improved outcomes across regional CS networks merits further investigation.
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Affiliation(s)
- Behnam N Tehrani
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA.
| | | | - Carolyn Rosner
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Alexander G Truesdell
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | | | | | - Mehul Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Shashank Desai
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Kelly C Epps
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Edward Howard
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | - Nasrien Ibrahim
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Jamie Kennedy
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Hala Moukhachen
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Mitchell Psotka
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Anika Raja
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Ibrahim Saeed
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA; Virginia Heart, Falls Church, Virginia, USA
| | - Palak Shah
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Ramesh Singh
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Daniel Tang
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Timothy Welch
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Karl Young
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | | | - Alan Speir
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA
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Pierce JB, Mentz RJ, Sun JL, Alhanti B, Whellan DJ, Kraus WE, Piña IL, Fiuzat M, O'Connor CM, Greene SJ. Titration of medical therapy and clinical outcomes among patients with heart failure with reduced ejection fraction: Findings from the HF-ACTION trial. Am Heart J 2022; 251:115-126. [PMID: 35640729 DOI: 10.1016/j.ahj.2022.05.018] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 05/22/2022] [Accepted: 05/24/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND Clinical guidelines recommend titration of angiotensin converting enzyme inhibitors (ACEi) and beta-blockers among patients with heart failure with reduced ejection fraction (HFrEF) to maximally tolerated doses. Patient characteristics associated with dose titration and clinical outcomes subsequent to dose titration remain poorly characterized. METHODS Among 1999 ambulatory patients with chronic HFrEF in the HF-ACTION trial, use and dosing of ACEi and evidence-based beta-blockers were examined at baseline and 6-month follow-up. Multivariable logistic regression models were used to assess factors associated with dose escalation (medication initation or dosing increase) or dose de-escalation (medication discontinuation or dosing decrease). Cox proportional hazard regression models were used to examine associations between dose trajectory group (stable target, stable sub-target, dose escalation, and dose de-escalation) and subsequent mortality and hospitalization outcomes. RESULTS For both ACEi and beta-blockers, hospitalization for heart failure in the 6 months prior to enrollment (odds ratio [OR] 2.32 [95% confidence interval 1.58-3.42]) for ACEi; 1.42 [1.05-1.9] for beta-blockers) and higher systolic blood pressure (OR 1.01 [1.00-1.03] per 1 mmHg increase for ACEi; 1.01 [1.00-1.02] for beta-blockers) were associated with dose escalation. Hospitalization 6 months prior to enrollment for any cause (including HF or non-HF causes) was associated with dose de-escalation (OR 1.60 [1.14-2.25] for ACEi; 1.67 [1.20-2.33] for beta-blockers). After adjustment for patient characteristics, compared with stable target dosing, dose de-escalation of either medication was associated with greater all-cause mortality (adjusted hazard ratio [aHR] 1.64 [1.11-2.42] for ACEi; 1.62 [1.04-2.53] for beta-blockers). Compared with stable target dosing, both dose de-escalation (aHR 1.98 [1.36-2.87]) and stable sub-target dosing (aHR 1.49 [1.18-1.87]) of beta-blockers were associated with greater cardiovascular mortality or hospitalization for heart failure. CONCLUSIONS Among outpatients with chronic HFrEF, patient characteristics including recent hospitalization status and blood pressure were associated with odds of subsequent escalation and de-escalation of ACEi and beta-blocker therapy. Compared with patients receiving guildeline-recommended target doses, dose de-escalation of either medication and sub-target dosing of beta-blockers were associated with greater morbidity and mortality over long-term follow-up.
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Affiliation(s)
- Jacob B Pierce
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC
| | | | | | - David J Whellan
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - William E Kraus
- Duke Molecular Physiology Institute and Division of Cardiology, Department of Medicine, Duke University, Durham, NC
| | - Ileana L Piña
- Department of Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA
| | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, Durham, NC
| | | | - Stephen J Greene
- Department of Medicine, Duke University School of Medicine, Durham, NC; Duke Clinical Research Institute, Durham, NC.
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Lala A, O'Connor CM, Fiuzat M, Drazner MH, Mentz RJ. Recognizing Efforts that Support Clinical Trial Success: Site-Based Research Awards from the Heart Failure Collaboratory and Heart Failure Society of America. J Card Fail 2022; 28:1387-1389. [PMID: 36113899 DOI: 10.1016/j.cardfail.2022.08.001] [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] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Affiliation(s)
- Anuradha Lala
- Zena and Michael A. Wiener Cardiovascular Institute and Department of Population Health Science and Policy, Mount Sinai, New York, NY, USA
| | | | - Mona Fiuzat
- Duke University School of Medicine, Durham, NC, USA
| | - Mark H Drazner
- University of Texas Southwestern Medical Center, Dallas, TX, USA
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Armstrong PW, Zheng Y, Troughton RW, Lund LH, Zhang J, Lam CSP, Westerhout CM, Blaustein RO, Butler J, Hernandez AF, Roessig L, O'Connor CM, Voors AA, Ezekowitz JA. Sequential Evaluation of NT-proBNP in Heart Failure: Insights Into Clinical Outcomes and Efficacy of Vericiguat. JACC Heart Fail 2022; 10:677-688. [PMID: 36049817 DOI: 10.1016/j.jchf.2022.04.015] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Revised: 04/13/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The effect of vericiguat on sequential N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels and influence of this relationship on clinical outcomes is unknown. OBJECTIVES This study assessed the relationship between changes in NT-proBNP and the primary outcome (cardiovascular death or heart failure hospitalization); evaluated the effect of vericiguat on changes in NT-proBNP; and explored the association between the efficacy of vericiguat and changes in NT-proBNP. METHODS NT-proBNP was measured at randomization and at 16, 32, 48, and 96 weeks in 4,805 of 5,050 patients. The association between NT-proBNP change at week 16 and the primary outcome was assessed. The relationship between changes in NT-proBNP and the primary outcome according to treatment group was assessed by using joint modeling and mediation analysis. RESULTS A significant and sustained decline in NT-proBNP levels was seen in both treatment groups. After week 16, NT-proBNP levels decreased more with vericiguat vs placebo (any reduction: odds ratio [OR]: 1.45 [95% CI: 1.28-1.65]; P < 0.001; ≥50% reduction: OR: 1.27 [95% CI: 1.10-1.47]; P = 0.001) and were less likely to increase (≥20% increase: OR: 0.68 [95% CI: 0.59-0.78]; P < 0.001; ≥50% increase: OR: 0.70 [95% CI: 0.59-0.82]; P < 0.001). The treatment effect related to serial NT-proBNP on the primary composite outcome was HR: 0.96 (95% CI: 0.95-0.99) at week 16, which increased to HR: 0.90 (95% CI: 0.85-0.96) at week 48; the average extent of mediation of the composite outcome related to NT-proBNP was 45%. CONCLUSIONS In patients with worsening HFrEF, vericiguat significantly decreased NT-proBNP levels compared with placebo. This change appeared associated with a modest relative improvement in the primary outcome of cardiovascular death or heart failure hospitalization. (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction [VICTORIA]; NCT02861534).
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Affiliation(s)
- Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada.
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | | | - Lars H Lund
- Karolinska Institutet and Karolinska University Hospital, Stockholm, Sweden
| | - Jian Zhang
- State Key Laboratory of Cardiovascular Disease, Heart Failure Center, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore, Singapore
| | | | | | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, USA
| | | | | | - Adrian A Voors
- Department of Cardiology, University of Groningen, University Medical Center of Groningen, Groningen, the Netherlands
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
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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.
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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.)
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Sinha SS, Rosner CM, Tehrani BN, Maini A, Truesdell AG, Lee SB, Bagchi P, Cameron J, Damluji AA, Desai M, Desai SS, Epps KC, deFilippi C, Flanagan MC, Genovese L, Moukhachen H, Park JJ, Psotka MA, Raja A, Shah P, Sherwood MW, Singh R, Tang D, Young KD, Welch T, O'Connor CM, Batchelor WB. Cardiogenic Shock From Heart Failure Versus Acute Myocardial Infarction: Clinical Characteristics, Hospital Course, and 1-Year Outcomes. Circ Heart Fail 2022; 15:e009279. [PMID: 35510546 DOI: 10.1161/circheartfailure.121.009279] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND Little is known about clinical characteristics, hospital course, and longitudinal outcomes of patients with cardiogenic shock (CS) related to heart failure (HF-CS) compared to acute myocardial infarction (AMI; CS related to AMI [AMI-CS]). METHODS We examined in-hospital and 1-year outcomes of 520 (219 AMI-CS, 301 HF-CS) consecutive patients with CS (January 3, 2017-December 31, 2019) in a single-center registry. RESULTS Mean age was 61.5±13.5 years, 71% were male, 22% were Black patients, and 63% had chronic kidney disease. The HF-CS cohort was younger (58.5 versus 65.6 years, P<0.001), had fewer cardiac arrests (15.9% versus 35.2%, P<0.001), less vasopressor utilization (61.8% versus 82.2%, P<0.001), higher pulmonary artery pulsatility index (2.14 versus 1.51, P<0.01), lower cardiac power output (0.64 versus 0.77 W, P<0.01) and higher pulmonary capillary wedge pressure (25.4 versus 22.2 mm Hg, P<0.001) than patients with AMI-CS. Patients with HF-CS received less temporary mechanical circulatory support (34.9% versus 76.3% P<0.001) and experienced lower rates of major bleeding (17.3% versus 26.0%, P=0.02) and in-hospital mortality (23.9% versus 39.3%, P<0.001). Postdischarge, 133 AMI-CS and 229 patients with HF-CS experienced similar rates of 30-day readmission (19.5% versus 24.5%, P=0.30) and major adverse cardiac and cerebrovascular events (23.3% versus 28.8%, P=0.45). Patients with HF-CS had lower 1-year mortality (n=123, 42.6%) compared to the patients with AMI-CS (n=110, 52.9%, P=0.03). Cumulative 1-year mortality was also lower in patients with HF-CS (log-rank test, P=0.04). CONCLUSIONS Patients with HF-CS were younger, and despite lower cardiac power output and higher pulmonary capillary wedge pressure, less likely to receive vasopressors or temporary mechanical circulatory support. Although patients with HF-CS had lower in-hospital and 1-year mortality, both cohorts experienced similarly high rates of postdischarge major adverse cardiovascular and cerebrovascular events and 30-day readmission, highlighting that both cohorts warrant careful long-term follow-up. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03378739.
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Affiliation(s)
- Shashank S Sinha
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Carolyn M Rosner
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Behnam N Tehrani
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Aneel Maini
- Georgetown University Medical School' Washington' DC (A.M.)
| | - Alexander G Truesdell
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.).,Virginia Heart, Falls Church (A.G.T., T.W.)
| | - Seiyon Ben Lee
- Department of Statistics, George Mason University' Fairfax' VA (S.B.L., P.B., J.C.)
| | - Pramita Bagchi
- Department of Statistics, George Mason University' Fairfax' VA (S.B.L., P.B., J.C.)
| | - James Cameron
- Department of Statistics, George Mason University' Fairfax' VA (S.B.L., P.B., J.C.)
| | - Abdulla A Damluji
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Mehul Desai
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Shashank S Desai
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Kelly C Epps
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Christopher deFilippi
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - M Casey Flanagan
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Leonard Genovese
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Hala Moukhachen
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - James J Park
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Mitchell A Psotka
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Anika Raja
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Palak Shah
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Matthew W Sherwood
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Ramesh Singh
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Daniel Tang
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Karl D Young
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Timothy Welch
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.).,Virginia Heart, Falls Church (A.G.T., T.W.)
| | - Christopher M O'Connor
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
| | - Wayne B Batchelor
- Inova Heart and Vascular Institute, Inova Fairfax Medical Campus, Falls Church, VA (S.S.S., C.M.R., B.N.T., A.G.T., A.A.D., M.D., S.S.D., K.C.E., C.d., M.C.F., L.G., H.M., J.J.P., M.A.P., A.R., P.S., M.W.S., R.S., D.T., K.D.Y., T.W., C.M.O., W.B.B.)
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Tobin RS, Cosiano MF, O'Connor CM, Fiuzat M, Granger BB, Rogers JG, Tulsky JA, Steinhauser KE, Mentz RJ. Spirituality in Patients With Heart Failure. JACC Heart Fail 2022; 10:217-226. [PMID: 35361439 DOI: 10.1016/j.jchf.2022.01.014] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 01/03/2022] [Accepted: 01/26/2022] [Indexed: 06/14/2023]
Abstract
With advances in heart failure (HF) treatment, patients are living longer, putting further emphasis on quality of life (QOL) and the role of palliative care principles in their care. Spirituality is a core domain of palliative care, best defined as a dynamic, multidimensional aspect of oneself for which 1 dimension is that of finding meaning and purpose. There are substantial data describing the role of spirituality in patients with cancer but a relative paucity of studies in HF. In this review article, we explore the current knowledge of spirituality in patients with HF; describe associations among spirituality, QOL, and HF outcomes; and propose clinical applications and future directions regarding spiritual care in this population. Studies suggest that spirituality serves as a potential target for palliative care interventions to improve QOL, caregiver support, and patient outcomes including rehospitalization and mortality. We suggest the development of a spirituality-screening tool, similar to the Patient Health Questionnaire-2 used to screen for depression, to identify patients with HF at risk for spiritual distress. Novel tools are soon to be validated by members of our group. Given spirituality in HF remains less well studied compared with other patient populations, further controlled trials and uniform measures of spirituality are needed to understand its impact better.
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Affiliation(s)
- Rachel S Tobin
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.
| | - Michael F Cosiano
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | | | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Bradi B Granger
- Duke School of Nursing, Duke University, Durham, North Carolina, USA
| | - Joseph G Rogers
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Texas Heart Institute, Houston, Texas, USA
| | - James A Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute and Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Karen E Steinhauser
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Department of Population Health Sciences, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert J Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA; Duke Clinical Research Institute, Durham, North Carolina, USA
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O'Connor CM. Editorial Privilege. JACC Heart Fail 2022; 10:290. [PMID: 35361450 DOI: 10.1016/j.jchf.2022.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Greene SJ, Ezekowitz JA, Anstrom KJ, Demyanenko V, Givertz MM, Piña IL, O'Connor CM, Koglin J, Roessig L, Hernandez AF, Armstrong PW, Mentz RJ. Medical Therapy During Hospitalization for Heart Failure with Reduced Ejection Fraction: The VICTORIA Registry: Medical Therapy During Hospitalization for HFrEF. J Card Fail 2022; 28:1063-1077. [PMID: 35301107 DOI: 10.1016/j.cardfail.2022.02.011] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2021] [Revised: 02/15/2022] [Accepted: 02/19/2022] [Indexed: 01/06/2023]
Abstract
BACKGROUND For patients hospitalized for heart failure with reduced ejection fraction (HFrEF), guidelines recommend optimization of medical therapy prior to discharge. The degree to which changes in medical therapy occur during hospitalizations for HFrEF in North American clinical practice is unclear. METHODS The VICTORIA registry enrolled patients hospitalized for worsening chronic HFrEF across 51 sites in the US and Canada from February 2018-January 2019. Among patients with complete medication data and not receiving dialysis, use and dose of angiotensin-converting enzyme inhibitor (ACEI)/ angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA), and sodium glucose cotransporter-2 inhibitors (SGLT2i) were assessed at admission and discharge. RESULTS Among 1,695 patients, median (IQR) age was 69 (59-79) years and 33% were women. Among eligible patients, 33%, 25%, and 55% were not prescribed ACEI/ARB/ARNI, beta-blocker, and MRA at discharge, respectively; 99% were not prescribed SGLT2i. For each medication, >50% of patients remained on stable sub-target doses or no medication during hospitalization. In-hospital rates of initiation/dose increase were 20% for ACEI/ARB, 4% for ARNI, 20% for beta-blocker, 22% for MRA, and <1% for SGLT2i; corresponding rates of dose decrease/discontinuation were 11%, 2%, 9%, 5%, and <1%, respectively. Overall, 17% and 28% of eligible patients were prescribed triple therapy prior to admission and at discharge, respectively. At both admission and discharge, 1% of patients were prescribed triple therapy at target doses. Across classes of medication, multiple factors were independently associated with higher likelihood of in-hospital initiation/dosing increase (e.g., Canadian enrollment, White race, intensive care admission) and discontinuation/dosing decrease (e.g., worse renal function, intensive care admission). CONCLUSIONS In this contemporary North American registry of patients hospitalized for worsening chronic HFrEF, for each recommended medical therapy, the large majority of eligible patients remained on stable sub-target doses or without medication at admission and discharge. Although most patients had no alterations in medical therapy, hospitalization in Canada and multiple patient characteristics were associated with higher likelihood of favorable in-hospital medication changes.
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Affiliation(s)
- Stephen J Greene
- From the Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina.
| | - Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Durham, North Carolina
| | | | - Michael M Givertz
- Brigham and Women's Hospital Heart & Vascular Center and Harvard Medical School, Boston, Massachusetts
| | - Ileana L Piña
- Department of Medicine, Jefferson University, Philadelphia, Pennsylvania
| | | | | | | | - Adrian F Hernandez
- From the Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Alberta, Canada
| | - Robert J Mentz
- From the Duke Clinical Research Institute, Durham, North Carolina; Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
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Saldarriaga C, Atar D, Stebbins A, Lewis BS, Zainal Abidin I, Blaustein RO, Butler J, Ezekowitz JA, Hernandez AF, Lam CSP, O'Connor CM, Pieske B, Ponikowski P, Roessig L, Voors AA, Anstrom KJ, Armstrong PW. Vericiguat in Patients with Coronary Artery Disease and Heart Failure with Reduced Ejection Fraction. Eur J Heart Fail 2022; 24:782-790. [PMID: 35239245 DOI: 10.1002/ejhf.2468] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Accepted: 03/01/2022] [Indexed: 11/08/2022] Open
Abstract
AIMS Coronary artery disease (CAD) portends worse outcomes in heart failure (HF). We aimed to characterize patients with CAD and worsening HF with reduced ejection fraction (HFrEF) and evaluate post hoc whether vericiguat's treatment effect varied according to CAD. METHODS AND RESULTS Cox proportional hazards were generated for the primary endpoint of cardiovascular death or HF hospitalization (CVD/HFH). CAD was defined as previous myocardial infarction, percutaneous coronary intervention, or coronary artery bypass grafting. Of 5048 patients in VICTORIA with available data on CAD status, 2704 had CAD and were older, were more frequently male, diabetic, and had a lower glomerular filtration rate than those without CAD (all p <0.0001). Use of implantable cardioverter defibrillators and cardiac resynchronization therapy (CRT) was higher in patients with versus without CAD (33.5 vs. 21.1%; p <0.0001 and 16.3 vs. 12.8%; p = 0.0006). The primary endpoint of CVD/HFH was higher in those with versus without CAD (40.6 vs. 30.1/100 patient-years; adjusted hazard ratio [HR] 1.23; p <0.001) as was all-cause mortality (17.9% vs. 12.7%; adjusted HR 1.32; p <0.001). The primary outcome of CVD/HFH associated with vericiguat in patients with or without CAD was 38.8 vs. 27.6 per 100 patient-years and for placebo was 42.6 vs. 32.7 per 100 patient-years (interaction p = 0.78). CONCLUSION In this post hoc study, CAD was associated with more CVD and HFH in patients with HFrEF and worsening HF. Vericiguat was beneficial and safe regardless of concomitant CAD. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Clara Saldarriaga
- University of Antioquia, CardioVID clinic Department of Cardiology, Medellín, Colombia
| | - Dan Atar
- Oslo University Hospital Ulleval, Department of Cardiology, and Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Amanda Stebbins
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | | | | | | | - Javed Butler
- University of Mississippi Medical Center, Jackson, Mississippi, United States
| | | | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
| | - Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore, Singapore
| | | | - Burkert Pieske
- Charité University Medicine, German Heart Center, Berlin, Germany
| | | | | | | | - Kevin J Anstrom
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, North Carolina, United States
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O'Connor CM. Implementation Noise. JACC Heart Fail 2022; 10:211-212. [PMID: 35241247 DOI: 10.1016/j.jchf.2022.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
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Tobin RS, Samsky MD, Kuchibhatla M, O'Connor CM, Fiuzat M, Warraich HJ, Anstrom KJ, Granger BB, Mark DB, Tulsky JA, Rogers JG, Mentz RJ, Johnson KS. Race Differences in Quality of Life following a Palliative Care Intervention in Patients with Advanced Heart Failure: Insights from the Palliative Care in Heart Failure Trial. J Palliat Med 2022; 25:296-300. [PMID: 34851740 PMCID: PMC9022123 DOI: 10.1089/jpm.2021.0220] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Introduction: Black patients have a higher incidence of heart failure (HF) and worse outcomes than white patients. Guidelines recommend palliative care for patients with advanced HF, but no studies have examined outcomes in a black patient cohort. Methods: This is a post hoc analysis of the Palliative Care in Heart Failure trial, which randomized patients to usual care plus a palliative care intervention (UC+PAL) or usual care (UC). Quality of life (QoL) was measured using Kansas City Cardiomyopathy Questionnaire (KCCQ) and Functional Assessment of Chronic Illness Therapy-Palliative Care scale (FACIT-Pal). Results: Black patients represented 41% of the 148 patients. At six months, QoL improved more in UC+PAL than UC for both racial subgroups. The difference was greater for black than white patients (difference: KCCQ 10.8 vs. 2.5; FACIT-Pal: 14.8 vs. 3.9). However, the findings were not statistically significant. Conclusions: Larger studies are needed to assess the benefits of palliative care for black patients with HF. ClinicalTrials.gov Identifier: NCT01589601.
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Affiliation(s)
- Rachel S. Tobin
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Address correspondence to: Rachel S. Tobin, MD, Department of Medicine, Duke University School of Medicine, 8254 Duke North-DUMC, 3182 Erwin Road, Durham, NC 27710, USA
| | - Marc D. Samsky
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Maragatha Kuchibhatla
- Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | | | - Mona Fiuzat
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Haider J. Warraich
- Division of Cardiovascular Medicine, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School and Cardiology Section, Boston, Massachusetts, USA
| | - Kevin J. Anstrom
- Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina, USA.,Department of Biostatistics and Bioinformatics, Duke University Medical Center, Durham, North Carolina, USA
| | - Bradi B. Granger
- Duke School of Nursing, Duke University, Durham, North Carolina, USA
| | - Daniel B. Mark
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - James A. Tulsky
- Department of Psychosocial Oncology and Palliative Care, Dana-Farber Cancer Institute, Boston, Massachusetts, USA.,Division of Palliative Medicine, Department of Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA
| | - Joseph G. Rogers
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Robert J. Mentz
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Cardiology, Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kimberly S. Johnson
- Department of Medicine, Duke University School of Medicine, Durham, North Carolina, USA.,Division of Geriatrics, Geriatrics Research Education and Clinical Center, Durham VA Medical Center, Durham, North Carolina, USA
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Ostrominski JW, Hirji S, Bhatt AS, Butler J, Fiuzat M, Fonarow GC, Heidenreich PA, Januzzi JL, Lam CSP, Maddox TM, O'Connor CM, Vaduganathan M. Cost and Value in Contemporary Heart Failure Clinical Guidance Documents. JACC Heart Fail 2022; 10:1-11. [PMID: 34969491 DOI: 10.1016/j.jchf.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Revised: 07/26/2021] [Accepted: 08/13/2021] [Indexed: 01/01/2023]
Abstract
OBJECTIVES This study sought to evaluate the frequency and nature of cost/value statements in contemporary heart failure (HF) clinical guidance documents (CGDs). BACKGROUND In an era of rising health care costs and expanding therapeutic options, there is an increasing need for formal consideration of cost and value in the development of HF CGDs. METHODS HF CGDs published by major professional cardiovascular organizations between January 2010 and February 2021 were reviewed for the inclusion of cost/value statements. RESULTS Overall, 33 documents were identified, including 5 (15%) appropriate use criteria, 7 (21%) clinical practice guidelines, and 21 (64%) expert consensus documents. Most CGDs (27 of 33; 82%) included at least 1 cost/value statement, and 20 (61%) CGDs included at least 1 cost/value-related citation. Most of these statements were found in expert consensus documents (77.7%). Three (9%) documents reported estimated costs of recommended interventions, but only 1 estimated out-of-pocket cost. Of 179 cost/value-related statements observed, 116 (64.8%) highlighted the economic impact of HF or HF-related care, 6 (3.4%) advocated for cost/value issues, 15 (8.4%) reported gaps in cost/value evidence, and 42 (23.5%) supported clinical guidance recommendations. Over time, patterns of inclusion of statements and citations of cost/value have been largely stable. CONCLUSIONS Although most contemporary HF CGDs contain at least 1 cost/value statement, most CGDs focus on the high economic impact of HF and its related care; explicit inclusion of cost/value to support clinical guidance recommendations remains infrequent. These results highlight key opportunities for the integration of formalized cost/value considerations in future HF-focused CGDs.
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Affiliation(s)
- John W Ostrominski
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Sameer Hirji
- Division of Cardiac Surgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ankeet S Bhatt
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Javed Butler
- Department of Medicine, University of Mississippi School of Medicine, Jackson, Mississippi, USA
| | - Mona Fiuzat
- Division of Cardiology, Duke University, Durham, North Carolina, USA
| | - Gregg C Fonarow
- Ahmanson-UCLA Cardiomyopathy Center, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
| | - Paul A Heidenreich
- Division of Cardiovascular Medicine, Stanford Cardiovascular Institute, Stanford University, Stanford, California, USA
| | - James L Januzzi
- Division of Cardiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA; Baim Institute for Clinical Research, Boston, Massachusetts, USA
| | - Carolyn S P Lam
- National Heart Centre Singapore, Duke-National University of Singapore, Singapore
| | - Thomas M Maddox
- Division of Cardiology, Washington University School of Medicine in St Louis, St Louis, Missouri, USA; Healthcare Innovation Lab, BJC HealthCare/Washington University School of Medicine, St Louis, Missouri, USA
| | - Christopher M O'Connor
- Division of Cardiology, Duke University, Durham, North Carolina, USA; Inova Heart and Vascular Institute, Falls Church, Virginia, USA
| | - Muthiah Vaduganathan
- Division of Cardiovascular Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.
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46
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Luo N, O'Connor CM, Chiswell K, Anstrom KJ, Newby LK, Mentz RJ. Survival in Patients With Nonischemic Cardiomyopathy With Preserved vs Reduced Ejection Fraction. CJC Open 2021; 3:1333-1340. [PMID: 34901801 PMCID: PMC8640574 DOI: 10.1016/j.cjco.2021.06.007] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 06/14/2021] [Indexed: 01/09/2023] Open
Abstract
Background Prior studies suggest similar long-term mortality rates for patients with heart failure (HF) with preserved ejection fraction (HFpEF) vs reduced ejection fraction. However, although coronary heart disease (CHD) is associated with worse prognosis in HF, clinical outcomes are less well characterized for HF without CHD. We investigated the characteristics and 5-year mortality outcomes among patients with HF without significant CHD, stratified by EF. Methods Patients with clinical heart failure who underwent coronary angiography at Duke University Medical Center from 1996 through 2009 and had no significant CHD with EF ≤ 40% were compared with patients without significant CHD with EF > 40%. Survival was examined using Kaplan-Meier methods and multivariable Cox proportional hazards modeling. Analyses were repeated using EF ≥ 50%. Results Of 3154 patients with HF without significant CHD, 1530 (48.5%) had HFpEF (EF > 40%). These patients were older and more likely to have a Charlson Index ≥ 2 than patients with reduced EF. Patients with HFpEF had a lower risk of death than those with reduced EF (unadjusted hazard ratio [HR] 0.85; 95% confidence interval [CI] 0.74-0.99). From 1996 through 2009, the secular trend of death decreased among patients without CHD and with reduced EF (HR 0.92; 95% CI 0.88-0.97) but not among those with preserved EF (HR 0.99; 95% CI 0.93-1.05; P interaction 0.095). No finding was significant after multivariable risk adjustment. Results were consistent when defining preserved EF as EF ≥ 50%. Conclusions Among patients without significant CHD, those with HFpEF had similar risks of 5-year mortality as patients with HF with reduced ejection fraction.
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Affiliation(s)
- Nancy Luo
- Sutter Medical Center Sacramento, Sacramento, California, USA
| | - Christopher M O'Connor
- Inova Heart and Vascular Institute, Falls Church, Virginia, USA.,Duke University School of Medicine, Durham, North Carolina, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Kevin J Anstrom
- Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - L Kristin Newby
- Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
| | - Robert J Mentz
- Duke University School of Medicine, Durham, North Carolina, USA.,Duke Clinical Research Institute, Durham, North Carolina, USA
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47
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Costanzo MR, O'Connor CM, Ventura HO. Advanced Heart Failure: Progress and Disappointments. JACC Heart Fail 2021; 9:938-940. [PMID: 34857178 DOI: 10.1016/j.jchf.2021.10.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
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48
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Ezekowitz JA, Alemayehu W, Rathwell S, Grant AD, Fiuzat M, Whellan DJ, Ahmad T, Adams K, Piña IL, Cooper LS, Januzzi JL, Leifer ES, Mark D, O'Connor CM, Felker GM. The influence of comorbidities on achieving an N-terminal pro-b-type natriuretic peptide target: a secondary analysis of the GUIDE-IT trial. ESC Heart Fail 2021; 9:77-86. [PMID: 34784657 PMCID: PMC8787989 DOI: 10.1002/ehf2.13692] [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] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Revised: 08/19/2021] [Accepted: 10/28/2021] [Indexed: 01/27/2023] Open
Abstract
Aims N‐terminal pro‐b‐type natriuretic peptide (NT‐proBNP) values may be influenced by patient factors beyond the severity of illness, including atrial fibrillation (AF), renal dysfunction, or increased body mass index (BMI). We hypothesized that these factors may influence the achievement of NT‐proBNP targets and clinical outcomes. Methods A total of 894 patients with heart failure with reduced ejection fraction were enrolled in The Guiding Evidence‐Based Therapy Using Biomarker Intensified Treatment trial. NT‐proBNP was analysed every 3 months. Results Forty per cent of patients had AF, the median estimated glomerular filtration rate (eGFR) was 59 mL/min/1.73 m2 [interquartile range (IQR) 43–76], and median BMI was 29 kg/m2 (IQR 25–34). Patients with AF, eGFR < 60 mL/min/1.73 m2, or a BMI < 29 kg/m2 had a higher level of NT‐proBNP at randomization and over all study visits (all P values < 0.001). Over 18 months, the rate of change of NT‐proBNP was less for patients with AF (compared with those without AF, P = 0.037) and patients with an eGFR < 60 mL/min/1.73 m2 (compared with eGFR > 60 mL/min/1.73 m2, P < 0.001). The rate of change of NT‐proBNP was similar for patients with a BMI above or below the median value. Using the 90 day NT‐proBNP, patients with AF, lower eGFR, or lower BMI were less likely to achieve the target NT‐proBNP < 1000 pg/mL than patients without AF, higher eGFR, or higher BMI, respectively. None of these differed between the Usual Care or Guided Care arm for AF, eGFR, or BMI (Pinteractions all NS). Conclusions Patients with AF, a lower BMI, or worse renal function are less likely to achieve a lower or target NT‐proBNP. Clinicians should be aware of these factors both when interpreting NT‐proBNP levels and making therapeutic decisions about heart failure therapies.
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Affiliation(s)
| | | | - Sarah Rathwell
- Women and Children's Health Research Institute, University of Alberta, Edmonton, AB, Canada
| | - Andrew D Grant
- Department of Cardiac Sciences, Cumming School of Medicine, University of Calgary, and the Libin Institute of Cardiovascular Research, Calgary, AB, Canada
| | - Mona Fiuzat
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - David J Whellan
- Department of Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kirkwood Adams
- Division of Cardiology, University of North Carolina, Chapel Hill, NC, USA
| | - Ileana L Piña
- School of Medicine, Wayne State University, Detroit, MI, USA
| | - Lawton S Cooper
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - James L Januzzi
- Massachusetts General Hospital Harvard Medical School, and Baim Institute for Clinical Research, Boston, MA, USA
| | - Eric S Leifer
- National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, MD, USA
| | - Daniel Mark
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | | | - G Michael Felker
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
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49
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Lam CSP, Mulder H, Lopatin Y, Vazquez-Tanus JB, Siu D, Ezekowitz J, Pieske B, O'Connor CM, Roessig L, Patel MJ, Anstrom KJ, Hernandez AF, Armstrong PW. Blood Pressure and Safety Events With Vericiguat in the VICTORIA Trial. J Am Heart Assoc 2021; 10:e021094. [PMID: 34743540 PMCID: PMC8751950 DOI: 10.1161/jaha.121.021094] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [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: 12/11/2022]
Abstract
Background Although safety and tolerability of vericiguat were established in the VICTORIA (Vericiguat Global Study in Subjects With Heart Failure With Reduced Ejection Fraction) trial in patients with heart failure with reduced ejection fraction, some subgroups may be more susceptible to symptomatic hypotension, such as older patients, those with lower baseline systolic blood pressure (SBP), or those concurrently taking angiotensin receptor neprilysin inhibitors. We described the SBP trajectories over time and compared the occurrence of symptomatic hypotension or syncope by treatment arm in potentially vulnerable subgroups in VICTORIA. We also evaluated the relation between the efficacy of vericiguat and baseline SBP. Methods and Results Among patients receiving at least 1 dose of the study drug (n=5034), potentially vulnerable subgroups were those >75 years old (n=1395), those with baseline SBP 100–110 mm Hg (n=1344), and those taking angiotensin receptor neprilysin inhibitors (n=730). SBP trajectory was plotted as mean change from baseline over time. The treatment effect on time to symptomatic hypotension or syncope was evaluated overall and by subgroup, and the primary efficacy composite outcome (heart failure hospitalization or cardiovascular death) across baseline SBP was examined using Cox proportional hazards models. SBP trajectories showed a small initial decline in SBP with vericiguat in those >75 years old (versus younger patients), as well as those receiving angiotensin receptor neprilysin inhibitors (versus none), with SBP returning to baseline thereafter. Patients with SBP <110 mm Hg at baseline showed a trend to increasing SBP over time, which was similar in both treatment arms. Safety event rates were generally low and similar between treatment arms within each subgroup. In Cox proportional hazards analysis, there were similar numbers of safety events with vericiguat versus placebo (adjusted hazard ratio [HR], 1.18; 95% CI, 0.99–1.39; P=0.059). No difference existed between treatment arms in landmark analysis beginning after the titration phase (ie, post 4 weeks) (adjusted HR, 1.14; 95% CI, 0.93–1.38; P=0.20). The benefit of vericiguat compared with placebo on the primary composite efficacy outcome was similar across the spectrum of baseline SBP (P for interaction=0.32). Conclusions These data demonstrate the safety of vericiguat in a broad population of patients with worsening heart failure with reduced ejection fraction, even among those predisposed to hypotension. Vericiguat’s efficacy persisted regardless of baseline SBP. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT02861534.
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Affiliation(s)
- Carolyn S P Lam
- National Heart Centre Singapore & Duke-National University of Singapore Singapore
| | - Hillary Mulder
- Duke Clinical Research InstituteDuke University School of Medicine Durham NC
| | - Yuri Lopatin
- Volgograd State Medical UniversityRegional Cardiology Centre Volgograd Volgograd Russian Federation
| | - Jose B Vazquez-Tanus
- Ponce School of Medicine Ponce Puerto Rico.,Research & Cardiovascular Center and Cardiometabolic Research Center Ponce Puerto Rico
| | - David Siu
- Li Ka Shing Faculty of Medicine The University of Hong Kong Hong Kong
| | | | - Burkert Pieske
- Charité University MedicineGerman Heart Center Berlin Germany
| | | | | | | | - Kevin J Anstrom
- Duke Clinical Research InstituteDuke University School of Medicine Durham NC
| | - Adrian F Hernandez
- Duke Clinical Research InstituteDuke University School of Medicine Durham NC
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50
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Ezekowitz JA, Zheng Y, Cohen-Solal A, Melenovský V, Escobedo J, Butler J, Hernandez AF, Lam CSP, O'Connor CM, Pieske B, Ponikowski P, Voors AA, deFilippi C, Westerhout CM, McMullan C, Roessig L, Armstrong PW. Hemoglobin and Clinical Outcomes in the Vericiguat Global Study in Patients With Heart Failure and Reduced Ejection Fraction (VICTORIA). Circulation 2021; 144:1489-1499. [PMID: 34432985 DOI: 10.1161/circulationaha.121.056797] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [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: 01/06/2023]
Abstract
BACKGROUND In the VICTORIA trial (Vericiguat Global Study in Patients with Heart Failure with Reduced Ejection Fraction), anemia occurred more often in patients treated with vericiguat (7.6%) than with placebo (5.7%). We explored the association between vericiguat, randomization hemoglobin, development of anemia, and whether the benefit of vericiguat related to baseline hemoglobin. METHODS Anemia was defined as hemoglobin <13.0 g/dL in men and <12.0 g/dL in women (World Health Organization Anemia). Adverse events reported as anemia were also evaluated. We assessed the risk-adjusted relationship between hemoglobin and hematocrit with the primary outcome (composite of cardiovascular death or heart failure hospitalization) and the time-updated hemoglobin relationship to outcomes. RESULTS At baseline, 1719 (35.7%) patients had World Health Organization anemia; median hemoglobin was 13.4 g/L (25th, 75th percentile: 12.1, 14.7 g/dL). At 16 weeks from randomization, 1643 patients had World Health Organization anemia (284 new for vericiguat and 219 for placebo), which occurred more often with vericiguat than placebo (P<0.001). After 16 weeks, no further decline in hemoglobin occurred over 96 weeks of follow-up and the ratio of hemoglobin/hematocrit remained constant. Overall, adverse event anemia occurred in 342 patients (7.1%). A lower hemoglobin was unrelated to the treatment benefit of vericiguat (versus placebo) on the primary outcome. In addition, analysis of time-updated hemoglobin revealed no association with the treatment effect of vericiguat (versus placebo) on the primary outcome. CONCLUSIONS Anemia was common at randomization and lower hemoglobin was associated with a greater frequency of clinical events. Although vericiguat modestly lowered hemoglobin by 16 weeks, this effect did not further progress nor was it related to the treatment benefit of vericiguat. Registration: URL: https://www.clinicaltrials.gov: Unique identifier: NCT02861534.
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Affiliation(s)
- Justin A Ezekowitz
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., Y.Z., C.M.W., P.W.A.)
| | - Yinggan Zheng
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., Y.Z., C.M.W., P.W.A.)
| | | | - Vojtěch Melenovský
- Department of Cardiology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic (V.M.)
| | - Jorge Escobedo
- Medical Research Unit on Clinical Epidemiology, Mexican Social Security Institute, Mexico City (J.E.)
| | - Javed Butler
- Department of Medicine, University of Mississippi Medical Center, Jackson (J.B.)
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., C.M.O.)
| | - Carolyn S P Lam
- National Heart Centre Singapore and Duke-National University of Singapore (C.S.P.L.)
| | - Christopher M O'Connor
- Duke Clinical Research Institute, Duke University School of Medicine, Durham, NC (A.F.H., C.M.O.).,Inova Heart and Vascular Institute, Falls Church, VA (C.M.O., C.D.)
| | - Burkert Pieske
- Charité University Medicine, German Heart Center, Berlin (B.P.)
| | - Piotr Ponikowski
- Department of Heart Diseases, Wroclaw Medical University, Poland (P.P.)
| | - Adriaan A Voors
- Department of Cardiology, University of Groningen, University Medical Center of Groningen, The Netherlands (A.A.V.)
| | | | - Cynthia M Westerhout
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., Y.Z., C.M.W., P.W.A.)
| | | | | | - Paul W Armstrong
- Canadian VIGOUR Centre, University of Alberta, Edmonton, Canada (J.A.E., Y.Z., C.M.W., P.W.A.)
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