1
|
Bloomfield GS, Hill CL, Chiswell K, Cooper L, Gray S, Longenecker CT, Louzao D, Marsolo K, Meissner EG, Morse CG, Muiruri C, Thomas KL, Velazquez EJ, Vicini J, Pettit AC, Sanders G, Okeke NL. Cardiology Encounters for Underrepresented Racial and Ethnic Groups with Human Immunodeficiency Virus and Borderline Cardiovascular Disease Risk. J Racial Ethn Health Disparities 2024; 11:1509-1519. [PMID: 37160576 PMCID: PMC10632543 DOI: 10.1007/s40615-023-01627-0] [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: 02/01/2023] [Revised: 04/27/2023] [Accepted: 04/30/2023] [Indexed: 05/11/2023]
Abstract
BACKGROUND Underrepresented racial and ethnic groups (UREGs) with HIV have a higher risk of cardiovascular disease (CVD) compared with the general population. Referral to a cardiovascular specialist improves CVD risk factor management in high-risk individuals. However, patient and provider factors impacting the likelihood of UREGs with HIV to have an encounter with a cardiologist are unknown. METHODS We evaluated a cohort of UREGs with HIV and borderline CVD risk (10-year risk ≥ 5% by the pooled cohort equations or ≥ 7.5% by Framingham risk score). Participants received HIV-related care from 2014-2020 at four academic medical centers in the United States (U.S.). Adjusted Cox proportional hazards regression was used to estimate the association of patient and provider characteristics with time to first ambulatory cardiology encounter. RESULTS A total of 2,039 people with HIV (PWH) and borderline CVD risk were identified. The median age was 45 years (IQR: 36-50); 52% were female; and 94% were Black. Of these participants, 283 (14%) had an ambulatory visit with a cardiologist (17% of women vs. 11% of men, p < .001). In fully adjusted models, older age, higher body mass index (BMI), atrial fibrillation, multimorbidity, urban residence, and no recent insurance were associated with a greater likelihood of an encounter with a cardiologist. CONCLUSION In UREGs with HIV and borderline CVD risk, the strongest determinants of a cardiology encounter were diagnosed CVD, insurance type, and urban residence. Future research is needed to determine the extent to which these encounters impact CVD care practices and outcomes in this population. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04025125.
Collapse
Affiliation(s)
- Gerald S Bloomfield
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA.
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA.
| | - C Larry Hill
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Linda Cooper
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Shamea Gray
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
| | - Chris T Longenecker
- Division of Cardiology and Department of Global Health, University of Washington, Seattle, WA, USA
| | - Darcy Louzao
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Keith Marsolo
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Eric G Meissner
- Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Caryn G Morse
- Wake Forest University Health Sciences, Winston-Salem, NC, USA
| | - Charles Muiruri
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| | - Kevin L Thomas
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale University, New Haven, CT, USA
| | - Joseph Vicini
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - April C Pettit
- Department of Medicine, Vanderbilt University, Nashville, TN, USA
| | - Gretchen Sanders
- Duke Clinical Research Institute, Duke University School of Medicine, 300 W. Morgan Street, Durham, NC, 27701, USA
| | - Nwora Lance Okeke
- Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Department of Population Health Sciences, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
2
|
Kittipibul V, Mentz RJ, Clare RM, Wojdyla DM, Anstrom KJ, Eisenstein EL, Ambrosy AP, Goyal P, Skopicki HA, Ketema F, Kim DY, Desvigne-Nickens P, Pitt B, Velazquez EJ, Greene SJ. On-treatment analysis of torsemide versus furosemide for patients hospitalized for heart failure: A post-hoc analysis of TRANSFORM-HF. Eur J Heart Fail 2024. [PMID: 38745502 DOI: 10.1002/ejhf.3293] [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: 01/15/2024] [Revised: 04/04/2024] [Accepted: 05/01/2024] [Indexed: 05/16/2024] Open
Abstract
AIM The TRANSFORM-HF trial demonstrated no significant outcome differences between torsemide and furosemide following hospitalization for heart failure (HF), but may have been impacted by non-adherence to the randomized diuretic. The current study sought to determine the treatment effect of torsemide versus furosemide using an on-treatment analysis inclusive of all randomized patients except those confirmed non-adherent to study diuretic. METHODS AND RESULTS TRANSFORM-HF was an open-label, pragmatic randomized trial of 2859 patients hospitalized for HF from June 2018 through March 2022. Patients were randomized to a loop diuretic strategy of torsemide versus furosemide with investigator-selected dosage. This post-hoc on-treatment analysis included all patients alive with either known or unknown diuretic status, and excluded patients confirmed to be non-adherent to study diuretic. This modified on-treatment definition was applied separately at time of hospital discharge and 30-day follow-up. All-cause mortality and hospitalization outcomes were assessed over 12 months. Overall, 2570 (89.9%) and 2374 (83.0%) patients were included in on-treatment analyses at discharge and 30-day follow-up, respectively. There was no significant difference in all-cause mortality between torsemide and furosemide in patients on-treatment at discharge (17.5% vs. 17.8%; hazard ratio [HR] 1.01 [95% confidence interval [CI] 0.83-1.22], p = 0.96) and at 30-day follow-up (14.5% vs. 15.0%; HR 1.02 [95% CI 0.81-1.27], p = 0.90). All-cause mortality or all-cause hospitalization was similar between torsemide and furosemide in patients who were on-treatment at discharge (58.3% vs. 61.3%; HR 0.92 [95% CI 0.82-1.03]) and 30-day follow-up (60.9% vs. 64.4%; HR 0.93 [95% CI 0.82-1.05]). In patients who were on-treatment at 30-day follow-up, there were 677 total hospitalizations in the torsemide group and 686 total hospitalizations in the furosemide group (rate ratio 0.99 [95% CI 0.86-1.14], p = 0.87). CONCLUSIONS In TRANSFORM-HF, a post-hoc on-treatment analysis did not meaningfully differ from the original trial results. Among those deemed compliant with the assigned diuretic, there remained no significant difference in mortality or hospitalization after HF hospitalization with a strategy of torsemide versus furosemide. CLINICAL TRAIL REGISTRATION ClinicalTrials.gov Identifier: NCT03296813.
Collapse
Affiliation(s)
- Veraprapas Kittipibul
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Kevin J Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | | | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, Oakland, CA, USA
| | - Parag Goyal
- Department of Medicine, Weill Cornell Medical College, Cornell University, New York, NY, USA
| | - Hal A Skopicki
- Division of Cardiology, Stony Brook University, Stony Brook, NY, USA
| | - Fassil Ketema
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Dong-Yun Kim
- Division of Intramural Research, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Bertram Pitt
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Stephen J Greene
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| |
Collapse
|
3
|
Oikonomou EK, Aminorroaya A, Dhingra LS, Partridge C, Velazquez EJ, Desai NR, Krumholz HM, Miller EJ, Khera R. Real-world evaluation of an algorithmic machine-learning-guided testing approach in stable chest pain: a multinational, multicohort study. Eur Heart J Digit Health 2024; 5:303-313. [PMID: 38774380 PMCID: PMC11104476 DOI: 10.1093/ehjdh/ztae023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Revised: 02/13/2024] [Accepted: 03/20/2024] [Indexed: 05/24/2024]
Abstract
Aims An algorithmic strategy for anatomical vs. functional testing in suspected coronary artery disease (CAD) (Anatomical vs. Stress teSting decIsion Support Tool; ASSIST) is associated with better outcomes than random selection. However, in the real world, this decision is rarely random. We explored the agreement between a provider-driven vs. simulated algorithmic approach to cardiac testing and its association with outcomes across multinational cohorts. Methods and results In two cohorts of functional vs. anatomical testing in a US hospital health system [Yale; 2013-2023; n = 130 196 (97.0%) vs. n = 4020 (3.0%), respectively], and the UK Biobank [n = 3320 (85.1%) vs. n = 581 (14.9%), respectively], we examined outcomes stratified by agreement between the real-world and ASSIST-recommended strategies. Younger age, female sex, Black race, and diabetes history were independently associated with lower odds of ASSIST-aligned testing. Over a median of 4.9 (interquartile range [IQR]: 2.4-7.1) and 5.4 (IQR: 2.6-8.8) years, referral to the ASSIST-recommended strategy was associated with a lower risk of acute myocardial infarction or death (hazard ratioadjusted: 0.81, 95% confidence interval [CI] 0.77-0.85, P < 0.001 and 0.74 [95% CI 0.60-0.90], P = 0.003, respectively), an effect that remained significant across years, test types, and risk profiles. In post hoc analyses of anatomical-first testing in the Prospective Multicentre Imaging Study for Evaluation of Chest Pain (PROMISE) trial, alignment with ASSIST was independently associated with a 17% and 30% higher risk of detecting CAD in any vessel or the left main artery/proximal left anterior descending coronary artery, respectively. Conclusion In cohorts where historical practices largely favour functional testing, alignment with an algorithmic approach to cardiac testing defined by ASSIST was associated with a lower risk of adverse outcomes. This highlights the potential utility of a data-driven approach in the diagnostic management of CAD.
Collapse
Affiliation(s)
- Evangelos K Oikonomou
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Arya Aminorroaya
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Lovedeep S Dhingra
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Caitlin Partridge
- Yale Center for Clinical Investigation, 2 Church Street South, New Haven, 06519 CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church Street 5th Floor, New Haven, 06510 CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, 333 Cedar Street, PO Box 208017, New Haven, 06520-8017 CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, 195 Church Street 5th Floor, New Haven, 06510 CT, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, 100 College Street, New Haven, 06511 CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, 60 College Street, New Haven, 06510 CT, USA
| |
Collapse
|
4
|
Sarocchi M, Li J, Li X, Wu D, Montaño Figueroa E, Rodriguez MG, Hou M, Finelli C, Shi HX, Xiao Z, Oliva EN, Gercheva Kyuchukova L, Drummond M, Symeonidis A, Velazquez EJ, Rivoli G, Izquierdo M, Kolekar Y, Spallarossa P, Angelucci E. Cardiac effects of deferasirox in transfusion-dependent patients with myelodysplastic syndromes: TELESTO study. Br J Haematol 2024; 204:2049-2056. [PMID: 38343073 DOI: 10.1111/bjh.19316] [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: 08/28/2023] [Revised: 12/21/2023] [Accepted: 01/13/2024] [Indexed: 05/15/2024]
Abstract
Iron overload from repeated transfusions has a negative impact on cardiac function, and iron chelation therapy may help prevent cardiac dysfunction in transfusion-dependent patients with myelodysplastic syndromes (MDS). TELESTO (NCT00940602) was a prospective, placebo-controlled, randomised study to evaluate the iron chelator deferasirox in patients with low- or intermediate-1-risk MDS and iron overload. Echocardiographic parameters were collected at screening and during treatment. Patients receiving deferasirox experienced a significant decrease in the composite risk of hospitalisation for congestive heart failure (CHF) or worsening of cardiac function (HR = 0.23; 95% CI: 0.05, 0.99; nominal p = 0.0322) versus placebo. No significant differences between the arms were found in left ventricular ejection fraction, ventricular diameter and mass or pulmonary artery pressure. The absolute number of events was low, but the enrolled patients were younger than average for patients with MDS, with no serious cardiac comorbidities and a modest cardiovascular risk profile. These results support the effectiveness of deferasirox in preventing cardiac damage caused by iron overload in this patient population. Identification of patients developing CHF is challenging due to the lack of distinctive echocardiographic features. The treatment of iron overload may be important to prevent cardiac dysfunction in these patients, even those with moderate CHF risk.
Collapse
Affiliation(s)
- Matteo Sarocchi
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Junmin Li
- School of Medicine, Ruijin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Xiao Li
- Shanghai Sixth People's Hospital, Shanghai, China
| | - Depei Wu
- Jiangsu Institute of Hematology, First Affiliated Hospital of Suzhou University, Suzhou, China
| | - Efreen Montaño Figueroa
- Department of Hematology, Hospital General de México Dr Eduardo Liceaga, Mexico City, Mexico
| | - Maria Guadalupe Rodriguez
- Department of Hematology, Hospital de Especialidades, Centro Médico Nacional La Raza, IMSS, Mexico City, Mexico
| | - Ming Hou
- Department of Hematology, Qilu Hospital, Shandong University, Jinan, China
| | - Carlo Finelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Istituto di Ematologia "Seràgnoli", Bologna, Italy
| | - Hong-Xia Shi
- Peking University People's Hospital, Beijing, China
| | - Zhijian Xiao
- Institute of Hematology and Blood Diseases Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Tianjin, China
| | - Esther Natalie Oliva
- Hematology Unit, Grande Ospedale Metropolitano Bianchi Melacrino Morelli, Reggio Calabria, Italy
| | - Liana Gercheva Kyuchukova
- Clinical Hematology Clinic, Multiprofile Hospital for Active Treatment "Sveta Marina", Varna, Bulgaria
| | | | - Argiris Symeonidis
- Hematology Division, Department of Internal Medicine, University of Patras Medical School, Patras, Greece
| | - Eric J Velazquez
- Yale School of Medicine, Yale University, New Haven, Connecticut, USA
| | - Giulia Rivoli
- Hematology and Cellular Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | | | | | - Paolo Spallarossa
- Cardiovascular Disease Unit, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Emanuele Angelucci
- Hematology and Cellular Therapy, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| |
Collapse
|
5
|
Oikonomou EK, Holste G, Yuan N, Coppi A, McNamara RL, Haynes NA, Vora AN, Velazquez EJ, Li F, Menon V, Kapadia SR, Gill TM, Nadkarni GN, Krumholz HM, Wang Z, Ouyang D, Khera R. A Multimodal Video-Based AI Biomarker for Aortic Stenosis Development and Progression. JAMA Cardiol 2024:2817468. [PMID: 38581644 PMCID: PMC10999005 DOI: 10.1001/jamacardio.2024.0595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 02/27/2024] [Indexed: 04/08/2024]
Abstract
Importance Aortic stenosis (AS) is a major public health challenge with a growing therapeutic landscape, but current biomarkers do not inform personalized screening and follow-up. A video-based artificial intelligence (AI) biomarker (Digital AS Severity index [DASSi]) can detect severe AS using single-view long-axis echocardiography without Doppler characterization. Objective To deploy DASSi to patients with no AS or with mild or moderate AS at baseline to identify AS development and progression. Design, Setting, and Participants This is a cohort study that examined 2 cohorts of patients without severe AS undergoing echocardiography in the Yale New Haven Health System (YNHHS; 2015-2021) and Cedars-Sinai Medical Center (CSMC; 2018-2019). A novel computational pipeline for the cross-modal translation of DASSi into cardiac magnetic resonance (CMR) imaging was further developed in the UK Biobank. Analyses were performed between August 2023 and February 2024. Exposure DASSi (range, 0-1) derived from AI applied to echocardiography and CMR videos. Main Outcomes and Measures Annualized change in peak aortic valve velocity (AV-Vmax) and late (>6 months) aortic valve replacement (AVR). Results A total of 12 599 participants were included in the echocardiographic study (YNHHS: n = 8798; median [IQR] age, 71 [60-80] years; 4250 [48.3%] women; median [IQR] follow-up, 4.1 [2.4-5.4] years; and CSMC: n = 3801; median [IQR] age, 67 [54-78] years; 1685 [44.3%] women; median [IQR] follow-up, 3.4 [2.8-3.9] years). Higher baseline DASSi was associated with faster progression in AV-Vmax (per 0.1 DASSi increment: YNHHS, 0.033 m/s per year [95% CI, 0.028-0.038] among 5483 participants; CSMC, 0.082 m/s per year [95% CI, 0.053-0.111] among 1292 participants), with values of 0.2 or greater associated with a 4- to 5-fold higher AVR risk than values less than 0.2 (YNHHS: 715 events; adjusted hazard ratio [HR], 4.97 [95% CI, 2.71-5.82]; CSMC: 56 events; adjusted HR, 4.04 [95% CI, 0.92-17.70]), independent of age, sex, race, ethnicity, ejection fraction, and AV-Vmax. This was reproduced across 45 474 participants (median [IQR] age, 65 [59-71] years; 23 559 [51.8%] women; median [IQR] follow-up, 2.5 [1.6-3.9] years) undergoing CMR imaging in the UK Biobank (for participants with DASSi ≥0.2 vs those with DASSi <.02, adjusted HR, 11.38 [95% CI, 2.56-50.57]). Saliency maps and phenome-wide association studies supported associations with cardiac structure and function and traditional cardiovascular risk factors. Conclusions and Relevance In this cohort study of patients without severe AS undergoing echocardiography or CMR imaging, a new AI-based video biomarker was independently associated with AS development and progression, enabling opportunistic risk stratification across cardiovascular imaging modalities as well as potential application on handheld devices.
Collapse
Affiliation(s)
- Evangelos K. Oikonomou
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gregory Holste
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin
| | - Neal Yuan
- Department of Medicine, University of California, San Francisco
- Division of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, California
| | - Andreas Coppi
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Robert L. McNamara
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Norrisa A. Haynes
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Amit N. Vora
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Eric J. Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, Connecticut
| | - Venu Menon
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Samir R. Kapadia
- Heart and Vascular Institute, Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio
| | - Thomas M. Gill
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Girish N. Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
| | - Zhangyang Wang
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin
| | - David Ouyang
- Smidt Heart Institute, Department of Cardiology, Cedars-Sinai Medical Center, Los Angeles, California
- Division of Artificial Intelligence in Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale New Haven Hospital, New Haven, Connecticut
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, Connecticut
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
- Associate Editor, JAMA
| |
Collapse
|
6
|
Martens P, Greene SJ, Mentz RJ, Li S, Wojdyla D, Kapelios CJ, Mullens W, Hall ME, Ketema F, Kim DY, Eisenstein EL, Anstrom K, Fang JC, Pitt B, Velazquez EJ, Tang WHW. Impact of baseline kidney dysfunction on oral diuretic efficacy following hospitalization for heart failure - insights from TRANSFORM-HF. Eur J Heart Fail 2024. [PMID: 38558520 DOI: 10.1002/ejhf.3207] [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: 10/31/2023] [Revised: 03/10/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
AIM Among patients discharged after hospitalization for heart failure (HF), a strategy of torsemide versus furosemide showed no difference in all-cause mortality or hospitalization. Clinicians have traditionally favoured torsemide in the setting of kidney dysfunction due to better oral bioavailability and longer half-life, but direct supportive evidence is lacking. METHODS AND RESULTS The TRANSFORM-HF trial randomized patients hospitalized for HF to a long-term strategy of torsemide versus furosemide, and enrolled patients across the spectrum of renal function (without dialysis). In this post-hoc analysis, baseline renal function during the index hospitalization was assessed as categories of estimated glomerular filtration rate (eGFR; <30, 30-<60, ≥60 ml/min/1.73 m2). The interaction between baseline renal function and treatment effect of torsemide versus furosemide was assessed with respect to mortality and hospitalization outcomes, and the change in Kansas City Cardiomyopathy Questionnaire clinical summary score (KCCQ-CSS). Of 2859 patients randomized, 336 (11.8%) had eGFR <30 ml/min/1.73 m2, 1138 (39.8%) had eGFR 30-<60 ml/min/1.73 m2, and 1385 (48.4%) had eGFR ≥60 ml/min/1.73 m2. Baseline eGFR did not modify treatment effects of torsemide versus furosemide on all adverse clinical outcomes including individual components or composites of all-cause mortality and all-cause (re)-hospitalizations, both when assessing eGFR categorically or continuously (p-value for interaction all >0.108). Similarly, no treatment effect modification by eGFR was found for the change in KCCQ-CSS (p-value for interaction all >0.052) when assessing eGFR categorically or continuously. CONCLUSION Among patients discharged after hospitalization for HF, there was no significant difference in clinical and patient-reported outcomes between torsemide and furosemide, irrespective of renal function.
Collapse
Affiliation(s)
- Pieter Martens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium
- Kaufman Center for Heart Failure Treatment and Recovery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | | | - Shuang Li
- Duke Clinical Research Institute, Durham, NC, USA
| | | | - Chris J Kapelios
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Wilfried Mullens
- Department of Cardiology, Ziekenhuis Oost-Limburg A.V., Genk, Belgium
| | - Michael E Hall
- Department of Medicine, University of Mississippi, Jackson, MS, USA
| | - Fassil Ketema
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | - Dong-Yun Kim
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD, USA
| | | | | | - James C Fang
- Department of Medicine, University of Utah, Salt Lake City, UT, USA
| | - Bertram Pitt
- Department of Medicine, University of Michigan, Ann Arbor, MI, USA
| | | | - W H Wilson Tang
- Kaufman Center for Heart Failure Treatment and Recovery, Heart Vascular and Thoracic Institute, Cleveland Clinic, Cleveland, OH, USA
| |
Collapse
|
7
|
Shah NN, Sugeng L, Zhang Z, Wang K, McNamara RL, Agarwal V, Hur DJ, Lombo B, Bellumkonda L, Mankbadi M, Basem Dajani AR, Forrest JK, Krumholz HM, Reinhardt SW, Velazquez EJ, Faridi KF. Variation in Reader-Reported Severity of Paradoxical Low-Flow Low-Gradient Aortic Stenosis. J Am Soc Echocardiogr 2024; 37:466-467. [PMID: 37995937 DOI: 10.1016/j.echo.2023.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 11/08/2023] [Accepted: 11/11/2023] [Indexed: 11/25/2023]
Affiliation(s)
- Nimish N Shah
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Zhiyuan Zhang
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Kangxin Wang
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Robert L McNamara
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Vratika Agarwal
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - David J Hur
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Bernardo Lombo
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Lavanya Bellumkonda
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Michael Mankbadi
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Abdel Rahman Basem Dajani
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - John K Forrest
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Samuel W Reinhardt
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511
| | - Kamil F Faridi
- Section of Cardiovascular Medicine, Yale University School of Medicine and Yale New Haven Hospital, 300 George Street, Suite 759, New Haven, CT 06511.
| |
Collapse
|
8
|
Morrow DA, Velazquez EJ, Desai AS, DeVore AD, Lepage S, Park JG, Sharma K, Solomon SD, Starling RC, Ward JH, Williamson KM, Zieroth S, Hernandez AF, Mentz RJ, Braunwald E. Sacubitril/Valsartan in Patients Hospitalized With Decompensated Heart Failure. J Am Coll Cardiol 2024; 83:1123-1132. [PMID: 38508844 DOI: 10.1016/j.jacc.2024.01.027] [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: 11/02/2023] [Revised: 01/23/2024] [Accepted: 01/24/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND The efficacy and safety of sacubitril/valsartan in patients hospitalized with heart failure (HF) across the spectrum of left ventricular ejection fraction (EF) has not been described. OBJECTIVES Data from randomized trials of sacubitril/valsartan in HF patients with EF ≤40% (PIONEER-HF [Comparison of Sacubitril/Valsartan Versus Enalapril on Effect of NT-proBNP in Patients Stabilized From an Acute Heart Failure Episode] trial) and >40% (PARAGLIDE-HF [Prospective comparison of ARNI with ARB Given following stabiLization In DEcompensated HFpEF] trial) following recent worsening heart failure (WHF) were pooled to examine treatment effect across the EF spectrum. METHODS The PIONEER-HF and PARAGLIDE-HF trials were double-blind, randomized trials of sacubitril/valsartan vs control therapy (enalapril or valsartan, respectively). All participants in the PIONEER-HF trial and 69.5% in the PARAGLIDE-HF trial were enrolled during hospitalization for HF after stabilization. The remainder in the PARAGLIDE-HF trial were enrolled ≤30 days after a WHF event. The primary endpoint of both trials was time-averaged proportional change in N-terminal pro-B-type natriuretic peptide (NT-proBNP) from baseline through weeks 4 and 8. Adjudicated clinical endpoints were analyzed through the end of follow-up, adjusting for trial. RESULTS The pooled analysis included 1,347 patients (881 from PIONEER-HF, 466 from PARAGLIDE-HF). Baseline characteristics included median age 66 years, 36% women, 31% Black, 34% de novo HF, and median EF 30%. The reduction in NT-proBNP was 24% greater with sacubitril/valsartan vs control therapy (n = 1,130; ratio of change = 0.76; 95% CI: 0.69-0.83; P < 0.0001). Cardiovascular death or hospitalization for HF was reduced by 30% with sacubitril/valsartan vs control therapy (HR: 0.70; 95% CI: 0.54-0.91; P = 0.0077). This effect was consistent across the spectrum of EF ≤60%. Sacubitril/valsartan increased symptomatic hypotension (risk ratio: 1.35; 95% CI: 1.05-1.72). CONCLUSIONS In patients stabilized after WHF, sacubitril/valsartan led to a greater reduction in plasma NT-proBNP and improved clinical outcome compared with control therapy, in particular across the spectrum of EF ≤60%. (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect of NT-proBNP in Patients Stabilized From an Acute Heart Failure Episode [PIONEER-HF]; NCT02554890; Changes in NT-proBNP, Safety, and Tolerability in HFpEF Patients With a WHF Event [HFpEF Decompensation] Who Have Been Stabilized and Initiated at the Time of or Within 30 Days Post-decompensation [PARAGLIDE-HF]; NCT03988634).
Collapse
Affiliation(s)
- David A Morrow
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA.
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Akshay S Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Serge Lepage
- Department of Cardiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Jeong-Gun Park
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Jonathan H Ward
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Eugene Braunwald
- TIMI Study Group, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA; Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
9
|
Kapelios CJ, Greene SJ, Mentz RJ, Ikeaba U, Wojdyla D, Anstrom KJ, Eisenstein EL, Pitt B, Velazquez EJ, Fang JC. Torsemide Versus Furosemide After Discharge in Patients Hospitalized With Heart Failure Across the Spectrum of Ejection Fraction: Findings From TRANSFORM-HF. Circ Heart Fail 2024; 17:e011246. [PMID: 38436075 PMCID: PMC10950535 DOI: 10.1161/circheartfailure.123.011246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Accepted: 01/04/2024] [Indexed: 03/05/2024]
Abstract
BACKGROUND The TRANSFORM-HF trial (Torsemide Comparison With Furosemide for Management of Heart Failure) found no significant difference in all-cause mortality or hospitalization among patients randomized to a strategy of torsemide versus furosemide following a heart failure (HF) hospitalization. However, outcomes and responses to some therapies differ by left ventricular ejection fraction (LVEF). Thus, we sought to explore the effect of torsemide versus furosemide by baseline LVEF and to assess outcomes across LVEF groups. METHODS We compared baseline patient characteristics and randomized treatment effects for various end points in TRANSFORM-HF stratified by LVEF: HF with reduced LVEF, ≤40% versus HF with mildly reduced LVEF, 41% to 49% versus HF with preserved LVEF, ≥50%. We also evaluated associations between LVEF and clinical outcomes. Study end points were all-cause mortality or hospitalization at 30 days and 12 months, total hospitalizations at 12 months, and change from baseline in Kansas City Cardiomyopathy Questionnaire clinical summary score. RESULTS Overall, 2635 patients (median 64 years, 36% female, 34% Black) had LVEF data. Compared with HF with reduced LVEF, patients with HF with mildly reduced LVEF and HF with preserved LVEF had a higher prevalence of comorbidities. After adjusting for covariates, there was no significant difference in risk of clinical outcomes across the LVEF groups (adjusted hazard ratio for 12-month all-cause mortality, 0.91 [95% CI, 0.59-1.39] for HF with mildly reduced LVEF versus HF with reduced LVEF and 0.91 [95% CI, 0.70-1.17] for HF with preserved LVEF versus HF with reduced LVEF; P=0.73). In addition, there was no significant difference between torsemide and furosemide (1) for mortality and hospitalization outcomes, irrespective of LVEF group and (2) in changes in Kansas City Cardiomyopathy Questionnaire clinical summary score in any LVEF subgroup. CONCLUSIONS Despite baseline demographic and clinical differences between LVEF cohorts in TRANSFORM-HF, there were no significant differences in the clinical end points with torsemide versus furosemide across the LVEF spectrum. There was a substantial risk for all-cause mortality and subsequent hospitalization independent of baseline LVEF. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03296813.
Collapse
Affiliation(s)
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | - Robert J. Mentz
- Duke Clinical Research Institute, Durham, NC, USA
- Division of Cardiology, Duke University School of Medicine, Durham, NC, USA
| | | | | | - Kevin J. Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill, NC, USA
| | | | - Bertram Pitt
- Department of Medicine, Division of Cardiology, University of Michigan, Ann Arbor, MI, USA
| | - Eric J. Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - James C. Fang
- University of Utah Medical Center, Salt Lake City, UT, USA
| | | |
Collapse
|
10
|
Oikonomou EK, Holste G, Yuan N, Coppi A, McNamara RL, Haynes N, Vora AN, Velazquez EJ, Li F, Menon V, Kapadia SR, Gill TM, Nadkarni GN, Krumholz HM, Wang Z, Ouyang D, Khera R. A Multimodality Video-Based AI Biomarker For Aortic Stenosis Development And Progression. medRxiv 2024:2023.09.28.23296234. [PMID: 37808685 PMCID: PMC10557799 DOI: 10.1101/2023.09.28.23296234] [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] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Importance Aortic stenosis (AS) is a major public health challenge with a growing therapeutic landscape, but current biomarkers do not inform personalized screening and follow-up. Objective A video-based artificial intelligence (AI) biomarker (Digital AS Severity index [DASSi]) can detect severe AS using single-view long-axis echocardiography without Doppler. Here, we deploy DASSi to patients with no or mild/moderate AS at baseline to identify AS development and progression. Design Setting and Participants We defined two cohorts of patients without severe AS undergoing echocardiography in the Yale-New Haven Health System (YNHHS) (2015-2021, 4.1[IQR:2.4-5.4] follow-up years) and Cedars-Sinai Medical Center (CSMC) (2018-2019, 3.4[IQR:2.8-3.9] follow-up years). We further developed a novel computational pipeline for the cross-modality translation of DASSi into cardiac magnetic resonance (CMR) imaging in the UK Biobank (2.5[IQR:1.6-3.9] follow-up years). Analyses were performed between August 2023-February 2024. Exposure DASSi (range: 0-1) derived from AI applied to echocardiography and CMR videos. Main Outcomes and Measures Annualized change in peak aortic valve velocity (AV-Vmax) and late (>6 months) aortic valve replacement (AVR). Results A total of 12,599 participants were included in the echocardiographic study (YNHHS: n=8,798, median age of 71 [IQR (interquartile range):60-80] years, 4250 [48.3%] women, and CSMC: n=3,801, 67 [IQR:54-78] years, 1685 [44.3%] women). Higher baseline DASSi was associated with faster progression in AV-Vmax (per 0.1 DASSi increments: YNHHS: +0.033 m/s/year [95%CI:0.028-0.038], n=5,483, and CSMC: +0.082 m/s/year [0.053-0.111], n=1,292), with levels ≥ vs <0.2 linked to a 4-to-5-fold higher AVR risk (715 events in YNHHS; adj.HR 4.97 [95%CI: 2.71-5.82], 56 events in CSMC: 4.04 [0.92-17.7]), independent of age, sex, ethnicity/race, ejection fraction and AV-Vmax. This was reproduced across 45,474 participants (median age 65 [IQR:59-71] years, 23,559 [51.8%] women) undergoing CMR in the UK Biobank (adj.HR 11.4 [95%CI:2.56-50.60] for DASSi ≥vs<0.2). Saliency maps and phenome-wide association studies supported links with traditional cardiovascular risk factors and diastolic dysfunction. Conclusions and Relevance In this cohort study of patients without severe AS undergoing echocardiography or CMR imaging, a new AI-based video biomarker is independently associated with AS development and progression, enabling opportunistic risk stratification across cardiovascular imaging modalities as well as potential application on handheld devices.
Collapse
Affiliation(s)
- Evangelos K. Oikonomou
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Gregory Holste
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin, TX, USA
| | - Neal Yuan
- Department of Medicine, University of California San Francisco, San Francisco, CA, USA
- Division of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - Andreas Coppi
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Robert L. McNamara
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Norrisa Haynes
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Amit N. Vora
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eric J. Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Fan Li
- Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
- Center for Methods in Implementation and Prevention Science, Yale School of Public Health, New Haven, CT, USA
| | - Venu Menon
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Samir R. Kapadia
- Department of Cardiovascular Medicine, Heart and Vascular Institute, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Thomas M Gill
- Section of Geriatrics, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Girish N. Nadkarni
- The Charles Bronfman Institute for Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
- Division of Nephrology, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Harlan M. Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
| | - Zhangyang Wang
- Department of Electrical and Computer Engineering, The University of Texas at Austin, Austin, TX, USA
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Artificial Intelligence in Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT, USA
- Section of Biomedical Informatics and Data Science, Yale School of Medicine, New Haven, CT
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, CT
- Associate Editor, JAMA
| |
Collapse
|
11
|
Gaudino M, Castelvecchio S, Rahouma M, Robinson NB, Audisio K, Soletti GJ, Cancelli G, Tam DY, Garatti A, Benedetto U, Doenst T, Girardi LN, Michler RE, Fremes SE, Velazquez EJ, Menicanti L. Long-term results of surgical ventricular reconstruction and comparison with the Surgical Treatment for Ischemic Heart Failure trial. J Thorac Cardiovasc Surg 2024; 167:713-722.e7. [PMID: 35599207 DOI: 10.1016/j.jtcvs.2022.04.016] [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: 09/29/2021] [Revised: 03/28/2022] [Accepted: 04/06/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The role of surgical ventricular reconstruction (SVR) in patients with ischemic cardiomyopathy is controversial. Observational series and the Surgical Treatment of IsChemic Heart failure (STICH) trial reported contradictory results. SVR is highly dependent on operator experience. The aim of this study is to compare the long-term results of SVR between a high-volume SVR institution and the STICH trial using individual patient data. METHODS Patients undergoing SVR at San Donato Hospital (Milan) were compared with patients undergoing SVR in STICH (as-treated principle) by inverse probability treatment-weighted Cox regression. The primary outcome was all-cause mortality. RESULTS The San Donato cohort included 725 patients, whereas the STICH cohort included 501. Compared with the STICH-SVR cohort, San Donato patients were older (66.0, lower quartile, upper quartile [Q1, Q3: 58.0, 72.0] vs 61.9 [Q1, Q3: 55.1, 68.8], P < .001) and with lower left ventricular end-systolic volume index at baseline (LVESVI: 77.0 [Q1, Q3: 59.0, 97.0] vs 80.8 [Q1, Q3: 58.5, 106.8], P = .02). Propensity score weighting yielded 2 similar cohorts. At 4-year follow-up, mortality was significantly lower in the San Donato cohort compared with the STICH-SVR cohort (adjusted hazard ratio, 0.71; 95% confidence interval, 0.53-0.95; P = .001). Greater postoperative LVESVI was independently associated with mortality (hazard ratio, 1.02; 95% confidence interval, 1.01-1.03). At 4 to 6 months of follow-up, the mean reduction of LVESVI in the San Donato cohort was 39.6%, versus 10.7% in the STICH-SVR cohort (P < .001). CONCLUSIONS Patients with postinfarction LV remodeling undergoing SVR at a high-volume SVR institution had better long-term results than those reported in the STICH trial, suggesting that a new trial testing the SVR hypothesis may be warranted.
Collapse
Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY.
| | | | - Mohamed Rahouma
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - N Bryce Robinson
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Katia Audisio
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Giovanni J Soletti
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Gianmarco Cancelli
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Derrick Y Tam
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Andrea Garatti
- Department Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| | - Umberto Benedetto
- Bristol Heart Institute, University of Bristol, Bristol, United Kingdom
| | - Torsten Doenst
- Department of Cardiothoracic Surgery, University Hospital Jena, Friedrich-Schiller-University of Jena, Jena, Germany
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery, Weill Cornell Medicine, New York, NY
| | - Robert E Michler
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Albert Einstein College of Medicine, New York, NY
| | - Stephen E Fremes
- Schulich Heart Centre, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Eric J Velazquez
- Division of Cardiology, Duke University Medical Center, Durham, NC
| | - Lorenzo Menicanti
- Department Cardiac Surgery, IRCCS Policlinico San Donato, Milan, Italy
| |
Collapse
|
12
|
Krim SR, Anand S, Greene SJ, Chen A, Wojdyla D, Vilaro J, Haught H, Herre JM, Eisenstein EL, Anstrom KJ, Pitt B, Velazquez EJ, Mentz RJ. Torsemide vs Furosemide Among Patients With New-Onset vs Worsening Chronic Heart Failure: A Substudy of the TRANSFORM-HF Randomized Clinical Trial. JAMA Cardiol 2024; 9:182-188. [PMID: 37955908 PMCID: PMC10644243 DOI: 10.1001/jamacardio.2023.4776] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2023] [Accepted: 10/23/2023] [Indexed: 11/14/2023]
Abstract
Importance Differences in clinical profiles, outcomes, and diuretic treatment effects may exist between patients with de novo heart failure (HF) and worsening chronic HF (WHF). Objectives To compare clinical characteristics and treatment outcomes of torsemide vs furosemide in patients hospitalized with de novo HF vs WHF. Design, Setting, and Participants All patients with a documented ejection fraction who were randomized in the Torsemide Comparison With Furosemide for Management of Heart Failure (TRANSFORM-HF) trial, conducted from June 18 through March 2022, were included in this post hoc analysis. Study data were analyzed March to May 2023. Exposure Patients were categorized by HF type and further divided by loop diuretic strategy. Main Outcomes and Measures End points included all-cause mortality and hospitalization outcomes over 12 months, as well as change from baseline in the Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CSS). Results Among 2858 patients (mean [SD] age, 64.5 [14.0] years; 1803 male [63.1%]), 838 patients (29.3%) had de novo HF, and 2020 patients (70.7%) had WHF. Patients with de novo HF were younger (mean [SD] age, 60.6 [14.5] years vs 66.1 [13.5] years), had a higher glomerular filtration rate (mean [SD], 68.6 [24.9] vs 57.0 [24.0]), lower levels of natriuretic peptides (median [IQR], brain-type natriuretic peptide, 855.0 [423.0-1555.0] pg/mL vs 1022.0 [500.0-1927.0] pg/mL), and tended to be discharged on lower doses of loop diuretic (mean [SD], 50.3 [46.2] mg vs 63.8 [52.4] mg). De novo HF was associated with lower all-cause mortality at 12 months (de novo, 65 of 838 [9.1%] vs WHF, 408 of 2020 [25.4%]; adjusted hazard ratio [aHR], 0.50; 95% CI, 0.38-0.66; P < .001). Similarly, lower all-cause first rehospitalization at 12 months and greater improvement from baseline in KCCQ-CSS at 12 months were noted among patients with de novo HF (median [IQR]: de novo, 29.94 [27.35-32.54] vs WHF, 23.68 [21.62-25.74]; adjusted estimated difference in means: 6.26; 95% CI, 3.72-8.81; P < .001). There was no significant difference in mortality with torsemide vs furosemide in either de novo (No. of events [rate per 100 patient-years]: torsemide, 27 [7.4%] vs furosemide, 38 [10.9%]; aHR, 0.70; 95% CI, 0.40-1.14; P = .15) or WHF (torsemide 212 [26.8%] vs furosemide, 196 [24.0%]; aHR, 1.08; 95% CI, 0.89-1.32; P = .42; P for interaction = .10), In addition, no significant differences in hospitalizations, first all-cause hospitalization, or total hospitalizations at 12 months were noted with a strategy of torsemide vs furosemide in either de novo HF or WHF. Conclusions and Relevance Among patients discharged after hospitalization for HF, de novo HF was associated with better clinical and patient-reported outcomes when compared with WHF. Regardless of HF type, there was no significant difference between torsemide and furosemide with respect to 12-month clinical or patient-reported outcomes.
Collapse
Affiliation(s)
- Selim R. Krim
- Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana
- The University of Queensland School of Medicine, Ochsner Clinical School, New Orleans, Louisiana
| | - Senthil Anand
- Section of Cardiomyopathy & Heart Transplantation, John Ochsner Heart and Vascular Institute, Ochsner Clinic Foundation, New Orleans, Louisiana
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Anqi Chen
- Duke Clinical Research Institute, Durham, North Carolina
| | - Daniel Wojdyla
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | | | | | - Kevin J. Anstrom
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill, Chapel Hill
| | - Bertram Pitt
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Eric J. Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Robert J. Mentz
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| |
Collapse
|
13
|
Faridi KF, Zhu Z, Shah NN, Crandall I, McNamara RL, Flueckiger P, Bachand K, Lombo B, Hur DJ, Agarwal V, Reinhardt SW, Velazquez EJ, Sugeng L. Factors associated with reporting left ventricular ejection fraction with 3D echocardiography in real-world practice. Echocardiography 2024; 41:e15774. [PMID: 38329886 DOI: 10.1111/echo.15774] [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] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 01/20/2024] [Accepted: 01/22/2024] [Indexed: 02/10/2024] Open
Abstract
BACKGROUND Guidelines recommend 3D echocardiography (3DE) to assess left ventricular ejection fraction (LVEF) on transthoracic echocardiogram (TTE) when possible, but it is unclear which factors are most strongly associated with reporting 3DE LVEF in real-world practice. METHODS We evaluated 3DE LVEF reporting by age, sex, BMI, TTE location and variation in reporting by sonographer and reader. All TTEs were performed without contrast enhancement agent at a large medical center from 9/2015 to 12/2020 using ultrasound machines capable of 3DE. We used multivariable logistic regression to assess which factors were most associated with reporting 3DE LVEF. RESULTS Among 35 641 TTEs included in this study, 57.4% were performed on women. 3DE LVEF was reported on 18 391 TTEs (51.6% of cohort; 50.5% for women and 52.4% for men). Portable inpatient TTEs (n = 5569) had the lowest rates of 3DE LVEF reporting (30.9%), while general outpatient TTEs (n = 15 933) had greater reporting (56.9%). Outpatient TTEs with an indication for chemotherapy (n = 3244) had the highest rates of 3DE LVEF (87.2%). The median (IQR) percentage of TTEs reporting 3D LVEF was 52.7% (43.1%-68.1%) among sonographers and 51.6% (46.5%-59.6%) among readers. Among 20082 (56.3%) TTEs with 3DE LVEF measured by sonographers, 91.6% were included by readers in the final report. After adjustment, performing sonographer in the highest reporting quartile was most strongly associated with reporting 3DE LVEF (OR 7.04, 95% CI 6.55-7.56), while an inpatient portable study had the strongest negative association for reporting (OR .38, 95% CI .35-.40). CONCLUSIONS Use of 3DE LVEF in real-world practice varies substantially based on performing sonographer and is low for hospitalized patients, but can be frequently used for chemotherapy. Initiatives are needed to increase sonographer 3DE acquisition in most clinical settings.
Collapse
Affiliation(s)
- Kamil F Faridi
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Zhaohan Zhu
- Yale School of Public Health, New Haven, Connecticut, USA
| | - Nimish N Shah
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Ian Crandall
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Robert L McNamara
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Karen Bachand
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Bernardo Lombo
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - David J Hur
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Vratika Agarwal
- Division of Cardiology, Columbia University Irving Medical Center, New York, New York, USA
| | - Samuel W Reinhardt
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | |
Collapse
|
14
|
Jamil Y, Huttler J, Alameddine D, Wu Z, Zhuo H, Mena-Hurtado C, Velazquez EJ, Guzman RJ, Ochoa Chaar CI. The Impact of Ejection Fraction on Major Adverse Limb Events after Lower Extremity Revascularization. Ann Vasc Surg 2024; 98:210-219. [PMID: 37802138 DOI: 10.1016/j.avsg.2023.08.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2023] [Revised: 07/31/2023] [Accepted: 08/04/2023] [Indexed: 10/08/2023]
Abstract
BACKGROUND Peripheral arterial disease (PAD) is commonly associated with coronary artery disease, and echocardiography is frequently performed before lower extremity revascularization (LER). However, the incidence of various echocardiographic findings in patients with PAD and their impact on the outcomes of LER has not been well studied. Reduced ejection fraction (EF) ≤ 40% is associated with increased major adverse limb events (MALE) after LER. METHODS The electronic medical records of patients undergoing LER in a single center were reviewed. Patients were divided based on the presence or absence of reduced EF. Patient, transthoracic echocardiogram, procedural characteristics, and outcomes were compared between the 2 groups. RESULTS A total of 1,114 patients (N = 131, 11.8% with reduced EF) underwent LER between 2013 and 2019. Patients with reduced EF were more likely to be male and have a history of coronary artery disease and heart failure. Furthermore, they were more likely to have diastolic dysfunction with moderate to severe mitral and tricuspid valve regurgitation. Patients with reduced EF were more likely to undergo LER for chronic limb-threatening ischemia, and to be treated with endovascular procedures. Perioperatively, patients with reduced EF were more likely to develop myocardial infarction. Lastly, the 2 groups had no difference in overall MALE or major amputation. However, on Kaplan-Meier curves, MALE-free survival was significantly lower for patients with reduced EF. Regression analysis demonstrated that indication and not EF was associated with MALE and MALE-free survival. CONCLUSIONS Reduced EF is associated with decreased MALE-free survival for patients with PAD undergoing LER.
Collapse
Affiliation(s)
- Yasser Jamil
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT.
| | | | - Dana Alameddine
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Zhen Wu
- Yale School of Public Health, New Haven, CT
| | | | - Carlos Mena-Hurtado
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Raul J Guzman
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| | - Cassius Iyad Ochoa Chaar
- Division of Vascular Surgery and Endovascular Therapy, Department of Surgery, Yale School of Medicine, New Haven, CT
| |
Collapse
|
15
|
Ghazi L, Yamamoto Y, Fuery M, O'Connor K, Sen S, Samsky M, Riello RJ, Dhar R, Huang J, Olufade T, McDermott J, Inzucchi SE, Velazquez EJ, Wilson FP, Desai NR, Ahmad T. Electronic health record alerts for management of heart failure with reduced ejection fraction in hospitalized patients: the PROMPT-AHF trial. Eur Heart J 2023; 44:4233-4242. [PMID: 37650264 DOI: 10.1093/eurheartj/ehad512] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [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: 04/14/2023] [Revised: 07/25/2023] [Accepted: 07/25/2023] [Indexed: 09/01/2023] Open
Abstract
BACKGROUND AND AIMS Patients hospitalized for acute heart failure (AHF) continue to be discharged on an inadequate number of guideline-directed medical therapies (GDMT) despite evidence that inpatient initiation is beneficial. This study aimed to examine whether a tailored electronic health record (EHR) alert increased rates of GDMT prescription at discharge in eligible patients hospitalized for AHF. METHODS Pragmatic trial of messaging to providers about treatment of acute heart failure (PROMPT-AHF) was a pragmatic, multicenter, EHR-based, and randomized clinical trial. Patients were automatically enrolled 48 h after admission if they met pre-specified criteria for an AHF hospitalization. Providers of patients in the intervention arm received an alert during order entry with relevant patient characteristics along with individualized GDMT recommendations with links to an order set. The primary outcome was an increase in the number of GDMT prescriptions at discharge. RESULTS Thousand and twelve patients were enrolled between May 2021 and November 2022. The median age was 74 years; 26% were female, and 24% were Black. At the time of the alert, 85% of patients were on β-blockers, 55% on angiotensin-converting enzyme inhibitor/angiotensin receptor blocker/angiotensin receptor-neprilysin inhibitor, 20% on mineralocorticoid receptor antagonist (MRA) and 17% on sodium-glucose cotransporter 2 inhibitor. The primary outcome occurred in 34% of both the alert and no alert groups [adjusted risk ratio (RR): 0.95 (0.81, 1.12), P = .99]. Patients randomized to the alert arm were more likely to have an increase in MRA [adjusted RR: 1.54 (1.10, 2.16), P = .01]. At the time of discharge, 11.2% of patients were on all four pillars of GDMT. CONCLUSIONS A real-time, targeted, and tailored EHR-based alert system for AHF did not lead to a higher number of overall GDMT prescriptions at discharge. Further refinement and improvement of such alerts and changes to clinician incentives are needed to overcome barriers to the implementation of GDMT during hospitalizations for AHF. GDMT remains suboptimal in this setting, with only one in nine patients being discharged on a comprehensive evidence-based regimen for heart failure.
Collapse
Affiliation(s)
- Lama Ghazi
- School of Public Health, University of Alabama at Birmingham, Birmingham, AL, USA
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Michael Fuery
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Kyle O'Connor
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Marc Samsky
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Ralph J Riello
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Ravi Dhar
- Center for Customer Insights, Yale School of Management, New Haven, CT, USA
| | | | | | | | - Silvio E Inzucchi
- Section of Endocrine & Metabolism, Yale School of Medicine, New Haven, CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Francis Perry Wilson
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
| | - Nihar R Desai
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| | - Tariq Ahmad
- Clinical and Translational Research Accelerator, Yale University, New Haven, CT, 06510, USA
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, 06517, USA
| |
Collapse
|
16
|
Sangha V, Nargesi AA, Dhingra LS, Khunte A, Mortazavi BJ, Ribeiro AH, Banina E, Adeola O, Garg N, Brandt CA, Miller EJ, Ribeiro ALJ, Velazquez EJ, Giatti L, Barreto SM, Foppa M, Yuan N, Ouyang D, Krumholz HM, Khera R. Detection of Left Ventricular Systolic Dysfunction From Electrocardiographic Images. Circulation 2023; 148:765-777. [PMID: 37489538 PMCID: PMC10982757 DOI: 10.1161/circulationaha.122.062646] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2022] [Accepted: 06/26/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Left ventricular (LV) systolic dysfunction is associated with a >8-fold increased risk of heart failure and a 2-fold risk of premature death. The use of ECG signals in screening for LV systolic dysfunction is limited by their availability to clinicians. We developed a novel deep learning-based approach that can use ECG images for the screening of LV systolic dysfunction. METHODS Using 12-lead ECGs plotted in multiple different formats, and corresponding echocardiographic data recorded within 15 days from the Yale New Haven Hospital between 2015 and 2021, we developed a convolutional neural network algorithm to detect an LV ejection fraction <40%. The model was validated within clinical settings at Yale New Haven Hospital and externally on ECG images from Cedars Sinai Medical Center in Los Angeles, CA; Lake Regional Hospital in Osage Beach, MO; Memorial Hermann Southeast Hospital in Houston, TX; and Methodist Cardiology Clinic of San Antonio, TX. In addition, it was validated in the prospective Brazilian Longitudinal Study of Adult Health. Gradient-weighted class activation mapping was used to localize class-discriminating signals on ECG images. RESULTS Overall, 385 601 ECGs with paired echocardiograms were used for model development. The model demonstrated high discrimination across various ECG image formats and calibrations in internal validation (area under receiving operation characteristics [AUROCs], 0.91; area under precision-recall curve [AUPRC], 0.55); and external sets of ECG images from Cedars Sinai (AUROC, 0.90 and AUPRC, 0.53), outpatient Yale New Haven Hospital clinics (AUROC, 0.94 and AUPRC, 0.77), Lake Regional Hospital (AUROC, 0.90 and AUPRC, 0.88), Memorial Hermann Southeast Hospital (AUROC, 0.91 and AUPRC 0.88), Methodist Cardiology Clinic (AUROC, 0.90 and AUPRC, 0.74), and Brazilian Longitudinal Study of Adult Health cohort (AUROC, 0.95 and AUPRC, 0.45). An ECG suggestive of LV systolic dysfunction portended >27-fold higher odds of LV systolic dysfunction on transthoracic echocardiogram (odds ratio, 27.5 [95% CI, 22.3-33.9] in the held-out set). Class-discriminative patterns localized to the anterior and anteroseptal leads (V2 and V3), corresponding to the left ventricle regardless of the ECG layout. A positive ECG screen in individuals with an LV ejection fraction ≥40% at the time of initial assessment was associated with a 3.9-fold increased risk of developing incident LV systolic dysfunction in the future (hazard ratio, 3.9 [95% CI, 3.3-4.7]; median follow-up, 3.2 years). CONCLUSIONS We developed and externally validated a deep learning model that identifies LV systolic dysfunction from ECG images. This approach represents an automated and accessible screening strategy for LV systolic dysfunction, particularly in low-resource settings.
Collapse
Affiliation(s)
- Veer Sangha
- Department of Computer Science, Yale University, New Haven, CT, USA
| | - Arash A Nargesi
- Heart and Vascular Center, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Lovedeep S Dhingra
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Akshay Khunte
- Department of Computer Science, Yale University, New Haven, CT, USA
| | - Bobak J Mortazavi
- Department of Computer Science & Engineering, Texas A&M University, College Station, TX, USA
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT, USA
| | - Antônio H Ribeiro
- Department of Information Technology, Uppsala University, Uppsala, Sweden
| | - Evgeniya Banina
- Internal Medicine Department, Lake Regional Hospital Health, Osage Beach, MO, USA
| | - Oluwaseun Adeola
- Methodist Cardiology Clinic of San Antonio, San Antonio, TX, USA
| | - Nadish Garg
- Heart and Vascular Institute, Memorial Hermann Southeast Hospital, Houston, TX, USA
| | - Cynthia A Brandt
- Department of Emergency Medicine, Yale University, New Haven, CT, USA
- VA Connecticut Healthcare System, West Haven, CT, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Antonio Luiz J Ribeiro
- Telehealth Center and Cardiology Service, Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- Department of Internal Medicine, Faculdade de Medicina, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
| | - Luana Giatti
- Department of Preventive Medicine, School of Medicine and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Sandhi M Barreto
- Department of Preventive Medicine, School of Medicine, and Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Murilo Foppa
- Postgraduate Studies Program in Cardiology and Division of Cardiology, Hospital de Clinicas de Porto Alegre, Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
| | - Neal Yuan
- Department of Medicine, University of California, San Francisco, San Francisco, CA, USA
- Section of Cardiology, San Francisco Veterans Affairs Medical Center, San Francisco, CA, USA
| | - David Ouyang
- Department of Cardiology, Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, CA, USA
- Division of Artificial Intelligence in Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT, USA
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University, New Haven, CT, USA
- Center for Outcomes Research and Evaluation (CORE), Yale New Haven Hospital, New Haven, CT, USA
- Section of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, CT, USA
| |
Collapse
|
17
|
Vaduganathan M, Mentz RJ, Claggett BL, Miao ZM, Kulac IJ, Ward JH, Hernandez AF, Morrow DA, Starling RC, Velazquez EJ, Williamson KM, Desai AS, Zieroth S, Lefkowitz M, McMurray JJV, Braunwald E, Solomon SD. Sacubitril/valsartan in heart failure with mildly reduced or preserved ejection fraction: a pre-specified participant-level pooled analysis of PARAGLIDE-HF and PARAGON-HF. Eur Heart J 2023; 44:2982-2993. [PMID: 37210743 PMCID: PMC10424880 DOI: 10.1093/eurheartj/ehad344] [Citation(s) in RCA: 26] [Impact Index Per Article: 26.0] [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: 04/18/2023] [Revised: 05/16/2023] [Accepted: 05/17/2023] [Indexed: 05/23/2023] Open
Abstract
AIMS The PARAGLIDE-HF trial demonstrated reductions in natriuretic peptides with sacubitril/valsartan compared with valsartan in patients with heart failure (HF) with mildly reduced or preserved ejection fraction who had a recent worsening HF event, but was not adequately powered to examine clinical outcomes. PARAGON-HF included a subset of PARAGLIDE-HF-like patients who were recently hospitalized for HF. Participant-level data from PARAGLIDE-HF and PARAGON-HF were pooled to better estimate the efficacy and safety of sacubitril/valsartan in reducing cardiovascular and renal events in HF with mildly reduced or preserved ejection fraction. METHODS AND RESULTS Both PARAGLIDE-HF and PARAGON-HF were multicentre, double-blind, randomized, active-controlled trials of sacubitril/valsartan vs. valsartan in patients with HF with mildly reduced or preserved left ventricular ejection fraction (LVEF >40% in PARAGLIDE-HF and ≥45% in PARAGON-HF). In the pre-specified primary analysis, we pooled participants in PARAGLIDE-HF (all of whom were enrolled during or within 30 days of a worsening HF event) with a 'PARAGLIDE-like' subset of PARAGON-HF (those hospitalized for HF within 30 days). We also pooled the entire PARAGLIDE-HF and PARAGON-HF populations for a broader context. The primary endpoint for this analysis was the composite of total worsening HF events (including first and recurrent HF hospitalizations and urgent visits) and cardiovascular death. The secondary endpoint was the pre-specified renal composite endpoint for both studies (≥50% decline in estimated glomerular filtration rate from baseline, end-stage renal disease, or renal death). Compared with valsartan, sacubitril/valsartan significantly reduced total worsening HF events and cardiovascular death in both the primary pooled analysis of participants with recent worsening HF [n = 1088; rate ratio (RR) 0.78; 95% confidence interval (CI) 0.61-0.99; P = 0.042] and in the pooled analysis of all participants (n = 5262; RR 0.86; 95% CI: 0.75-0.98; P = 0.027). In the pooled analysis of all participants, first nominal statistical significance was reached by Day 9 after randomization, and treatment benefits were larger in those with LVEF ≤60% (RR 0.78; 95% CI 0.66-0.91) compared with those with LVEF >60% (RR 1.09; 95% CI 0.86-1.40; Pinteraction = 0.021). Sacubitril/valsartan was also associated with lower rates of the renal composite endpoint in the primary pooled analysis [hazard ratio (HR) 0.67; 95% CI 0.43-1.05; P = 0.080] and the pooled analysis of all participants (HR 0.60; 95% CI 0.44-0.83; P = 0.002). CONCLUSION In pooled analyses of PARAGLIDE-HF and PARAGON-HF, sacubitril/valsartan reduced cardiovascular and renal events among patients with HF with mildly reduced or preserved ejection fraction. These data provide support for use of sacubitril/valsartan in patients with HF with mildly reduced or preserved ejection fraction, particularly among those with an LVEF below normal, regardless of care setting.
Collapse
Affiliation(s)
- Muthiah Vaduganathan
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | | | - Brian L Claggett
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Zi Michael Miao
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Ian J Kulac
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | | | | | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Eric J Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Akshay S Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | | | - John J V McMurray
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Eugene Braunwald
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women’s Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| |
Collapse
|
18
|
Ahmad Y, Velazquez EJ. The Interplay of Complete Revascularization and Angina: More Is More? J Am Coll Cardiol 2023; 82:314-316. [PMID: 37468186 DOI: 10.1016/j.jacc.2023.06.002] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 06/07/2023] [Indexed: 07/21/2023]
Affiliation(s)
- Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
19
|
Greene SJ, Velazquez EJ, Anstrom KJ, Clare RM, DeWald TA, Psotka MA, Ambrosy AP, Stevens GR, Rommel JJ, Alexy T, Ketema F, Kim DY, Desvigne-Nickens P, Pitt B, Eisenstein EL, Mentz RJ. Effect of Torsemide Versus Furosemide on Symptoms and Quality of Life Among Patients Hospitalized for Heart Failure: The TRANSFORM-HF Randomized Clinical Trial. Circulation 2023; 148:124-134. [PMID: 37212600 PMCID: PMC10524905 DOI: 10.1161/circulationaha.123.064842] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2023] [Accepted: 05/09/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND Loop diuretics are a primary therapy for the symptomatic treatment of heart failure (HF), but whether torsemide improves patient symptoms and quality of life better than furosemide remains unknown. As prespecified secondary end points, the TRANSFORM-HF trial (Torsemide Comparison With Furosemide for Management of Heart Failure) compared the effect of torsemide versus furosemide on patient-reported outcomes among patients with HF. METHODS TRANSFORM-HF was an open-label, pragmatic, randomized trial of 2859 patients hospitalized for HF (regardless of ejection fraction) across 60 hospitals in the United States. Patients were randomly assigned in a 1:1 ratio to a loop diuretic strategy of torsemide or furosemide with investigator-selected dosage. This report examined effects on prespecified secondary end points, which included Kansas City Cardiomyopathy Questionnaire Clinical Summary Score (KCCQ-CSS; assessed as adjusted mean difference in change from baseline; range, 0-100 with 100 indicating best health status; clinically important difference, ≥5 points) and Patient Health Questionnaire-2 (range, 0-6; score ≥3 supporting evaluation for depression) over 12 months. RESULTS Baseline data were available for 2787 (97.5%) patients for KCCQ-CSS and 2624 (91.8%) patients for Patient Health Questionnaire-2. Median (interquartile range) baseline KCCQ-CSS was 42 (27-60) in the torsemide group and 40 (24-59) in the furosemide group. At 12 months, there was no significant difference between torsemide and furosemide in change from baseline in KCCQ-CSS (adjusted mean difference, 0.06 [95% CI, -2.26 to 2.37]; P=0.96) or the proportion of patients with Patient Health Questionnaire-2 score ≥3 (15.1% versus 13.2%: P=0.34). Results for KCCQ-CSS were similar at 1 month (adjusted mean difference, 1.36 [95% CI, -0.64 to 3.36]; P=0.18) and 6-month follow-up (adjusted mean difference, -0.37 [95% CI, -2.52 to 1.78]; P=0.73), and across subgroups by ejection fraction phenotype, New York Heart Association class at randomization, and loop diuretic agent before hospitalization. Irrespective of baseline KCCQ-CSS tertile, there was no significant difference between torsemide and furosemide on change in KCCQ-CSS, all-cause mortality, or all-cause hospitalization. CONCLUSIONS Among patients discharged after hospitalization for HF, a strategy of torsemide compared with furosemide did not improve symptoms or quality of life over 12 months. The effects of torsemide and furosemide on patient-reported outcomes were similar regardless of ejection fraction, previous loop diuretic use, and baseline health status. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03296813.
Collapse
Affiliation(s)
- Stephen J Greene
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.M.C., E.L.E., R.J.M.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., T.A.D., R.J.M.)
| | - Eric J Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.J.V.)
| | - Kevin J Anstrom
- Gillings School of Global Public Health, University of North Carolina, Chapel Hill (K.J.A.)
| | - Robert M Clare
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.M.C., E.L.E., R.J.M.)
| | - Tracy A DeWald
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., T.A.D., R.J.M.)
| | | | - Andrew P Ambrosy
- Division of Research, Kaiser Permanente Northern California, Oakland (A.P.A.)
| | - Gerin R Stevens
- Department of Cardiology, Northwell Health, Zucker School of Medicine at Hofstra/Northwell, North Shore University Hospital, Manhasset, NY (G.R.S.)
| | - John J Rommel
- Novant Health Heart and Vascular Institute, Wilmington, NC (J.J.R.)
| | - Tamas Alexy
- Division of Cardiology, University of Minnesota, Minneapolis (T.A.)
| | - Fassil Ketema
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (F.K., D.-Y.K., P.D.-N.)
| | - Dong-Yun Kim
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (F.K., D.-Y.K., P.D.-N.)
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, MD (F.K., D.-Y.K., P.D.-N.)
| | - Bertram Pitt
- Department of Medicine, Division of Cardiology, University of Michigan, Ann Arbor (B.P.)
| | - Eric L Eisenstein
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.M.C., E.L.E., R.J.M.)
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, NC (S.J.G., R.M.C., E.L.E., R.J.M.)
- Division of Cardiology, Duke University School of Medicine, Durham, NC (S.J.G., T.A.D., R.J.M.)
| |
Collapse
|
20
|
Mentz RJ, Ward JH, Hernandez AF, Lepage S, Morrow DA, Sarwat S, Sharma K, Starling RC, Velazquez EJ, Williamson KM, Desai AS, Zieroth S, Solomon SD, Braunwald E. Angiotensin-Neprilysin Inhibition in Patients With Mildly Reduced or Preserved Ejection Fraction and Worsening Heart Failure. J Am Coll Cardiol 2023; 82:1-12. [PMID: 37212758 DOI: 10.1016/j.jacc.2023.04.019] [Citation(s) in RCA: 29] [Impact Index Per Article: 29.0] [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: 03/27/2023] [Revised: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND U.S. guidelines recommend consideration of sacubitril/valsartan in chronic heart failure (HF) and mildly reduced or preserved ejection fraction (EF). Whether initiation is safe and effective in EF >40% after a worsening heart failure (WHF) event is unknown. OBJECTIVES PARAGLIDE-HF (Prospective comparison of ARNI with ARB Given following stabiLization In DEcompensated HFpEF) assessed sacubitril/valsartan vs valsartan in EF >40% following a recent WHF event. METHODS PARAGLIDE-HF is a double-blind, randomized controlled trial of sacubitril/valsartan vs valsartan in patients with EF >40% enrolled within 30 days of a WHF event. The primary endpoint was time-averaged proportional change in amino terminal pro-B-type natriuretic peptide (NT-proBNP) from baseline through Weeks 4 and 8. A secondary hierarchical outcome (win ratio) consisted of: 1) cardiovascular death; 2) HF hospitalizations; 3) urgent HF visits; and 4) change in NT-proBNP. RESULTS In 466 patients (233 sacubitril/valsartan; 233 valsartan), time-averaged reduction in the NT-proBNP was greater with sacubitril/valsartan (ratio of change: 0.85; 95% CI: 0.73-0.999; P = 0.049). The hierarchical outcome favored sacubitril/valsartan but was not significant (unmatched win ratio: 1.19; 95% CI: 0.93-1.52; P = 0.16). Sacubitril/valsartan reduced worsening renal function (OR: 0.61; 95% CI: 0.40-0.93) but increased symptomatic hypotension (OR: 1.73; 95% CI: 1.09-2.76). There was evidence of a larger treatment effect in the subgroup with EF ≤60% for NT-proBNP change (0.78; 95% CI: 0.61-0.98) and the hierarchical outcome (win ratio: 1.46; 95% CI: 1.09-1.95). CONCLUSIONS Among patients with EF >40% stabilized after WHF, sacubitril/valsartan led to greater reduction in plasma NT-proBNP levels and was associated with clinical benefit compared with valsartan alone, despite more symptomatic hypotension. (Prospective comparison of ARNI with ARB Given following stabiLization In DEcompensated HFpEF; NCT03988634).
Collapse
Affiliation(s)
- Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina, USA.
| | - Jonathan H Ward
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | | | - Serge Lepage
- Department of Cardiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Samiha Sarwat
- Novartis Pharmaceuticals Corporation, East Hanover, New Jersey, USA
| | - Kavita Sharma
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio, USA
| | - Eric J Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | | | - Akshay S Desai
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Eugene Braunwald
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| |
Collapse
|
21
|
Mentz RJ, Ward JH, Hernandez AF, Lepage S, Morrow DA, Sarwat S, Sharma K, Solomon SD, Starling RC, Velazquez EJ, Williamson K, Zieroth S, Braunwald E. Rationale, Design and Baseline Characteristics of the PARAGLIDE-HF Trial: Sacubitril/Valsartan vs Valsartan in HFmrEF and HFpEF With a Worsening Heart Failure Event. J Card Fail 2023; 29:922-930. [PMID: 36796671 DOI: 10.1016/j.cardfail.2023.02.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2023] [Revised: 02/03/2023] [Accepted: 02/08/2023] [Indexed: 02/16/2023]
Abstract
BACKGROUND The PARAGON-HF trial studied the effect of sacubitril/valsartan (Sac/Val) compared with valsartan (Val) on clinical outcomes in patients with chronic heart failure with preserved ejection fraction (HFpEF) or mildly reduced EF (HFmrEF). Further data are needed regarding the use of Sac/Val in these groups with EF and with recent worsening heart failure (WHF) events and in key populations not broadly represented in the PARAGON-HF trial, including those with de novo HF, the severely obese and Black patients. METHODS The PARAGLIDE-HF trial is a multicenter, double-blind, randomized, controlled trial of Sac/Val vs Val that enrolled patients at 100 sites. Medically stable patients ≥ 18 years old with EF > 40%, amino terminal-pro B-type natriuretic peptide (NT-proBNP) levels ≥ 500 pg/mL and within 30 days of a WHF event were eligible for participation. Patients were randomly assigned 1:1 to Sac/Val vs Val. The primary efficacy endpoint is time-averaged proportional change in NT-proBNP from baseline through Weeks 4 and 8. Secondary endpoints include clinical outcomes during follow-up and additional biomarker assessments. Safety endpoints include symptomatic hypotension, worsening renal function and hyperkalemia. RESULTS The trial enrolled 467 participants from June 2019 through October 2022 (52% women, 22% Black, age 70 ± 12 years, median (IQR) BMI 33 (27-40) kg/m2). The median (IQR) EF was 55% (50%-60%), 23% with HFmrEF (LVEF 41%-49%), 24% with EF > 60% and 33% with de novo HFpEF. Median screening NT-proBNP was 2009 (1291-3813) pg/mL, and 69% were enrolled in the hospital. CONCLUSIONS The PARAGLIDE-HF trial enrolled a broad and diverse range of patients with heart failure with mildly reduced or preserved ejection fraction and will inform clinical practice by providing evidence about the safety, tolerability and efficacy of Sac/Val vs Val in those with a recent WHF event.
Collapse
Affiliation(s)
| | | | | | - Serge Lepage
- Department of Cardiology, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - David A Morrow
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | | | - Kavita Sharma
- Division of Cardiology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Scott D Solomon
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| | - Randall C Starling
- Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, OH, USA
| | - Eric J Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | | | - Shelley Zieroth
- Section of Cardiology, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eugene Braunwald
- Cardiovascular Division, Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA
| |
Collapse
|
22
|
Mentz RJ, DeWald TA, Velazquez EJ. Torsemide vs Furosemide After Discharge and All-Cause Mortality in Patients With Heart Failure-Reply. JAMA 2023; 329:1704. [PMID: 37191705 DOI: 10.1001/jama.2023.5291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/17/2023]
Affiliation(s)
- Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
| | - Tracy A DeWald
- Division of Clinical Pharmacology, Duke University, Durham, North Carolina
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
23
|
Oikonomou EK, Suchard M, Miller EJ, Velazquez EJ, Khera R. MECHANISTIC EVALUATION OF AN AI-DRIVEN CLINICAL DECISION SUPPORT TOOL TO PERSONALIZE THE USE OF ANATOMICAL TESTING IN SUSPECTED CORONARY ARTERY DISEASE. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01804-1] [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]
|
24
|
Ghazi L, O'Connor K, Yamamoto Y, Fuery M, Sen S, Samsky M, Riello RJ, Huang J, Olufade T, McDermott J, Inzucchi SE, Velazquez EJ, Wilson FP, Desai NR, Ahmad T. Pragmatic trial of messaging to providers about treatment of acute heart failure: The PROMPT-AHF trial. Am Heart J 2023; 257:111-119. [PMID: 36493842 DOI: 10.1016/j.ahj.2022.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Revised: 11/29/2022] [Accepted: 12/01/2022] [Indexed: 05/11/2023]
Abstract
Acute Heart failure (AHF) is among the most frequent causes of hospitalization in the United States, contributing to substantial health care costs, morbidity, and mortality. Inpatient initiation of guideline-directed medical therapy (GDMT) is recommended for patients with heart failure with reduced ejection fraction (HFrEF) to reduce the risk of cardiovascular death or HF hospitalization. However, underutilization of GDMT prior to discharge is pervasive, representing a valuable missed opportunity to optimize evidence-based care. The PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failure tests the effectiveness of an electronic health record embedded clinical decision support system that informs providers during hospital management about indicated but not yet prescribed GDMT for eligible AHF patients with HFrEF. PRagmatic Trial Of Messaging to Providers about Treatment of Acute Heart Failureis an open-label, multicenter, pragmatic randomized controlled trial of 1,012 patients hospitalized with HFrEF. Eligible patients randomized to the intervention group are exposed to a tailored best practice advisory embedded within the electronic health record that alerts providers to prescribe omitted GDMT. The primary outcome is an increase in the proportion of additional GDMT medication classes prescribed at the time of discharge compared to those in the usual care arm.
Collapse
Affiliation(s)
- Lama Ghazi
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Kyle O'Connor
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Michael Fuery
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Marc Samsky
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Ralph J Riello
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | | | | | | | - Silvio E Inzucchi
- Section of Endocrine & Metabolism, Yale School of Medicine, New Haven, CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Francis Perry Wilson
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA
| | - Nihar R Desai
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tariq Ahmad
- Clinical and Translational Research Accelerator (CTRA), Yale School of Medicine, New Haven, CT, USA; Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.
| |
Collapse
|
25
|
Mentz RJ, Anstrom KJ, Eisenstein EL, Sapp S, Greene SJ, Morgan S, Testani JM, Harrington AH, Sachdev V, Ketema F, Kim DY, Desvigne-Nickens P, Pitt B, Velazquez EJ. Effect of Torsemide vs Furosemide After Discharge on All-Cause Mortality in Patients Hospitalized With Heart Failure: The TRANSFORM-HF Randomized Clinical Trial. JAMA 2023; 329:214-223. [PMID: 36648467 PMCID: PMC9857435 DOI: 10.1001/jama.2022.23924] [Citation(s) in RCA: 55] [Impact Index Per Article: 55.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
IMPORTANCE Although furosemide is the most commonly used loop diuretic in patients with heart failure, some studies suggest a potential benefit for torsemide. OBJECTIVE To determine whether torsemide results in decreased mortality compared with furosemide among patients hospitalized for heart failure. DESIGN, SETTING, AND PARTICIPANTS TRANSFORM-HF was an open-label, pragmatic randomized trial that recruited 2859 participants hospitalized with heart failure (regardless of ejection fraction) at 60 hospitals in the United States. Recruitment occurred from June 2018 through March 2022, with follow-up through 30 months for death and 12 months for hospitalizations. The final date for follow-up data collection was July 2022. INTERVENTIONS Loop diuretic strategy of torsemide (n = 1431) or furosemide (n = 1428) with investigator-selected dosage. MAIN OUTCOMES AND MEASURES The primary outcome was all-cause mortality in a time-to-event analysis. There were 5 secondary outcomes with all-cause mortality or all-cause hospitalization and total hospitalizations assessed over 12 months being highest in the hierarchy. The prespecified primary hypothesis was that torsemide would reduce all-cause mortality by 20% compared with furosemide. RESULTS TRANSFORM-HF randomized 2859 participants with a median age of 65 years (IQR, 56-75), 36.9% were women, and 33.9% were Black. Over a median follow-up of 17.4 months, a total of 113 patients (53 [3.7%] in the torsemide group and 60 [4.2%] in the furosemide group) withdrew consent from the trial prior to completion. Death occurred in 373 of 1431 patients (26.1%) in the torsemide group and 374 of 1428 patients (26.2%) in the furosemide group (hazard ratio, 1.02 [95% CI, 0.89-1.18]). Over 12 months following randomization, all-cause mortality or all-cause hospitalization occurred in 677 patients (47.3%) in the torsemide group and 704 patients (49.3%) in the furosemide group (hazard ratio, 0.92 [95% CI, 0.83-1.02]). There were 940 total hospitalizations among 536 participants in the torsemide group and 987 total hospitalizations among 577 participants in the furosemide group (rate ratio, 0.94 [95% CI, 0.84-1.07]). Results were similar across prespecified subgroups, including among patients with reduced, mildly reduced, or preserved ejection fraction. CONCLUSIONS AND RELEVANCE Among patients discharged after hospitalization for heart failure, torsemide compared with furosemide did not result in a significant difference in all-cause mortality over 12 months. However, interpretation of these findings is limited by loss to follow-up and participant crossover and nonadherence. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03296813.
Collapse
Affiliation(s)
- Robert J. Mentz
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Kevin J. Anstrom
- Gillings School of Global Public Health, University of North Carolina at Chapel Hill
| | | | - Shelly Sapp
- Duke Clinical Research Institute, Durham, North Carolina
| | - Stephen J. Greene
- Duke Clinical Research Institute, Durham, North Carolina
- Department of Medicine, Division of Cardiology, Duke University School of Medicine, Durham, North Carolina
| | - Shelby Morgan
- Duke Clinical Research Institute, Durham, North Carolina
| | - Jeffrey M. Testani
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Vandana Sachdev
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Fassil Ketema
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Dong-Yun Kim
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Patrice Desvigne-Nickens
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Bertram Pitt
- Division of Cardiology, Department of Medicine, University of Michigan, Ann Arbor
| | - Eric J. Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut
| |
Collapse
|
26
|
Mori M, Mark DB, Khera R, Lin H, Jones P, Huang C, Lu Y, Geirsson A, Velazquez EJ, Spertus JA, Krumholz HM. Identifying quality of life outcome patterns to inform treatment choices in ischemic cardiomyopathy. Am Heart J 2022; 254:12-22. [PMID: 35932911 DOI: 10.1016/j.ahj.2022.07.007] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Revised: 06/14/2022] [Accepted: 07/28/2022] [Indexed: 06/15/2023]
Abstract
BACKGROUND The Surgical Treatment for Ischemic Heart Failure (STICH) trial found that routine use of coronary artery bypass surgery (CABG) improved mean quality of life (QoL) scores relative to guideline-directed medical therapy (GDMT) in patients with ischemic cardiomyopathy. However, mean differences in QoL scores do not provide what patients want to know when facing a high-risk/high-benefit treatment choice. METHODS We analyzed Kansas City Cardiomyopathy Questionnaire (KCCQ) Overall Summary scores in CABG and GDMT patients over 36 months using a combination of statistical methods to group QoL data into clinically relevant outcome patterns (phenotype trajectories) and to then identify the main baseline predictors of each phenotype. QoL outcome phenotypes were developed using mixture models to define the dominant phenotype trajectories present in STICH QoL data. Logistic regression models were used to predict each patient's probability of achieving each outcome pattern with each treatment. RESULTS In STICH, 592 patients underwent CABG and 607 were managed with GDMT. Our analyses identified 3 phenotype trajectory patterns in both treatment groups. Two of the 3 trajectories showed improving patterns, and were classified as "good QoL trajectories," seen in 498 (84.1%) CABG and 449 (73.9%) GDMT patients. Defining a consequential CABG-GDMT treatment difference as a >10% higher absolute predicted probability of belonging to good QoL trajectories, 277 (23.5%) patients were more likely to have good outcome with CABG while 45 (3.8%) patients were more likely to have a good outcome with GDMT. For 644 (54.7%) patients, CABG and GDMT probabilities of a good outcome were within 5% of each other. CONCLUSIONS The pattern of QoL outcomes after CABG compared with GDMT in STICH followed 3 main phenotypic trajectories, which could be predicted based on individual baseline features. Patient-specific predictions about expected QoL outcomes with different treatment choices provide an intuitive framework for personalizing patient decision making.
Collapse
Affiliation(s)
- Makoto Mori
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT
| | - Daniel B Mark
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Rohan Khera
- Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Haiqun Lin
- Division of Nursing Science, School of Nursing & Department of Biostatistics and Epidemiology, School of Public Health, Rutgers University, Newark, NJ
| | - Philip Jones
- Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Biomedical and Health Informatics, University of Missouri, Kansas City, MO
| | - Chenxi Huang
- Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT
| | - Yuan Lu
- Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - Arnar Geirsson
- Division of Cardiac Surgery, Yale School of Medicine, New Haven, CT
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, CT
| | - John A Spertus
- Saint Luke's Mid America Heart Institute, Kansas City, MO; Department of Biomedical and Health Informatics, University of Missouri, Kansas City, MO
| | - Harlan M Krumholz
- Center for Outcomes Research and Evaluation, YaleNew Haven Hospital, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine and the Department of Health Policy and Management, Yale School of Public Health, New Haven, CT.
| |
Collapse
|
27
|
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.
Collapse
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
| | | | | |
Collapse
|
28
|
Ahmad Y, Lansky AJ, Velazquez EJ. Is CABG Indicated in Patients With Ischemic Cardiomyopathy?-Reply. JAMA Cardiol 2022; 7:1177. [PMID: 36223088 DOI: 10.1001/jamacardio.2022.3312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Alexandra J Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| |
Collapse
|
29
|
Eisenstein EL, Sapp S, Harding T, Harrington A, Velazquez EJ, Mentz RJ, Greene SJ, Sachdev V, Kim DY, Anstrom KJ. Ascertaining Death Events in a Pragmatic Clinical Trial: Insights From the TRANSFORM-HF Trial. J Card Fail 2022; 28:1563-1567. [PMID: 35181553 PMCID: PMC9378754 DOI: 10.1016/j.cardfail.2022.01.020] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 01/17/2022] [Accepted: 01/30/2022] [Indexed: 11/16/2022]
Abstract
BACKGROUND Death ascertainment can be challenging for pragmatic clinical trials that limit site follow-up activities to usual clinical care. METHODS AND RESULTS We used blinded aggregate data from the ongoing ToRsemide comparison with furoSemide FOR Management of Heart Failure (TRANSFORM-HF) pragmatic clinical trial in patients with heart failure to evaluate the agreement between centralized call center death event identification and the United States National Death Index (NDI). Of 2284 total patients randomized through April 12, 2021, 1480 were randomized in 2018-2019 and 804 in 2020-2021. The call center identified 416 total death events (177 in 2018-2019 and 239 in 2020-2021). The NDI 2018-2019 final file identified 178 death events, 165 of which were also identified by the call center. The study's inter-rater reliability metric (Cohen's kappa coefficient, 0.920; 95% confidence interval, 0.889-0.951) demonstrates a high level of agreement. The time between a death event and its identification was less for the call center (median, 47 days; interquartile range, 11-103 days) than for the NDI (median, 270 days; interquartile range, 186-391 days). CONCLUSIONS There is substantial agreement between deaths identified by a centralized call center and the NDI. However, the time between a death event and its identification is significantly less for the call center.
Collapse
Affiliation(s)
| | - Shelly Sapp
- Duke Clinical Research Institute, Durham, North Carolina
| | - Tina Harding
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Eric J Velazquez
- Division of Cardiology, Yale University School of Medicine, New Haven, Connecticut
| | - Robert J Mentz
- Duke Clinical Research Institute, Durham, North Carolina
| | | | - Vandana Sachdev
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | - Dong-Yun Kim
- Division of Intramural Research, National Heart, Lung and Blood Institute, Bethesda, Maryland
| | | |
Collapse
|
30
|
Ahmad T, Desai NR, Yamamoto Y, Biswas A, Ghazi L, Martin M, Simonov M, Dhar R, Hsiao A, Kashyap N, Allen L, Velazquez EJ, Wilson FP. Alerting Clinicians to 1-Year Mortality Risk in Patients Hospitalized With Heart Failure: The REVEAL-HF Randomized Clinical Trial. JAMA Cardiol 2022; 7:905-912. [PMID: 35947362 PMCID: PMC9366654 DOI: 10.1001/jamacardio.2022.2496] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Accepted: 06/21/2022] [Indexed: 01/18/2023]
Abstract
Importance Heart failure is a major cause of morbidity and mortality worldwide. The use of risk scores has the potential to improve targeted use of interventions by clinicians that improve patient outcomes, but this hypothesis has not been tested in a randomized trial. Objective To evaluate whether prognostic information in heart failure translates into improved decisions about initiation and intensity of treatment, more appropriate end-of-life care, and a subsequent reduction in rates of hospitalization or death. Design, Setting, and Participants This was a pragmatic, multicenter, electronic health record-based, randomized clinical trial across the Yale New Haven Health System, comprising small community hospitals and large tertiary care centers. Patients hospitalized for heart failure who had N-terminal pro-brain natriuretic peptide (NT-proBNP) levels of greater than 500 pg/mL and received intravenous diuretics within 24 hours of admission were automatically randomly assigned to the alert (intervention) or usual-care groups. Interventions The alert group had their risk of 1-year mortality calculated using an algorithm that was derived and validated using similar historic patients in the electronic health record. This estimate, including a categorical risk assessment, was presented to clinicians while they were interacting with a patient's electronic health record. Main Outcomes and Measures The primary outcome was a composite of 30-day hospital readmissions and all-cause mortality at 1 year. Results Between November 27, 2019, through March 7, 2021, 3124 patients were randomly assigned to the alert (1590 [50.9%]) or usual-care (1534 [49.1%]) group. The alert group had a median (IQR) age of 76.5 (65-86) years, and 796 were female patients (50.1%). Patients from the following race and ethnicity groups were included: 13 Asian (0.8%), 324 Black (20.4%), 136 Hispanic (8.6%), 1448 non-Hispanic (91.1%), 1126 White (70.8%), 6 other ethnicity (0.4%), and 127 other race (8.0%). The usual-care group had a median (IQR) age of 77 (65-86) years, and 788 were female patients (51.4%). Patients from the following race and ethnicity groups were included: 11 Asian (1.4%), 298 Black (19.4%), 162 Hispanic (10.6%), 1359 non-Hispanic (88.6%), 1077 White (70.2%), 13 other ethnicity (0.9%), and 137 other race (8.9%). Median (IQR) NT-proBNP levels were 3826 (1692-8241) pg/mL in the alert group and 3867 (1663-8917) pg/mL in the usual-care group. A total of 284 patients (17.9%) and 270 patients (17.6%) were admitted to the intensive care unit in the alert and usual-care groups, respectively. A total of 367 patients (23.1%) and 359 patients (23.4%) had a left ventricular ejection fraction of 40% or less in the alert and usual-care groups, respectively. The model achieved an area under the curve of 0.74 in the trial population. The primary outcome occurred in 619 patients (38.9%) in the alert group and 603 patients (39.3%) in the usual-care group (P = .89). There were no significant differences between study groups in the prescription of heart failure medications at discharge, the placement of an implantable cardioverter-defibrillator, or referral to palliative care. Conclusions and Relevance Provision of 1-year mortality estimates during heart failure hospitalization did not affect hospitalization or mortality, nor did it affect clinical decision-making. Trial Registration ClinicalTrials.gov Identifier NCT03845660.
Collapse
Affiliation(s)
- Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Nihar R. Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Aditya Biswas
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Lama Ghazi
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Melissa Martin
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
| | - Michael Simonov
- Joint Data Analytics Team, Yale University School of Medicine, New Haven, Connecticut
| | - Ravi Dhar
- Department of Psychology, Yale University, New Haven, Connecticut
- Department of Management and Marketing, Yale School of Management, New Haven, Connecticut
| | - Allen Hsiao
- Joint Data Analytics Team, Yale University School of Medicine, New Haven, Connecticut
| | - Nitu Kashyap
- Joint Data Analytics Team, Yale University School of Medicine, New Haven, Connecticut
| | - Larry Allen
- Division of Cardiology, University of Colorado School of Medicine, Aurora
| | - Eric J. Velazquez
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - F. Perry Wilson
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut
- Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
31
|
Ahmad T, Desai NR, Velazquez EJ. SGLT2 Inhibitors Should Be Considered for All Patients With Heart Failure. J Am Coll Cardiol 2022; 80:1311-1313. [PMID: 36041913 DOI: 10.1016/j.jacc.2022.08.005] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 08/04/2022] [Indexed: 10/15/2022]
Affiliation(s)
- Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA.
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
32
|
Loring Z, Holmqvist F, Sze E, Alenezi F, Campbell K, Koontz JI, Velazquez EJ, Atwater BD, Bahnson TD, Daubert JP. Acute echocardiographic and hemodynamic response to his-bundle pacing in patients with first-degree atrioventricular block. Ann Noninvasive Electrocardiol 2022; 27:e12954. [PMID: 35445488 PMCID: PMC9296787 DOI: 10.1111/anec.12954] [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] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 03/02/2022] [Accepted: 03/14/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Atrial pacing and right ventricular (RV) pacing are both associated with adverse outcomes among patients with first-degree atrioventricular block (1°AVB). His-bundle pacing (HBP) provides physiological activation of the ventricle and may be able to improve both atrioventricular (AV) and inter-ventricular synchrony in 1°AVB patients. This study evaluates the acute echocardiographic and hemodynamic effects of atrial, atrial-His-bundle sequential (AH), and atrial-ventricular (AV) sequential pacing in 1°AVB patients. METHODS Patients with 1°AVB undergoing atrial fibrillation ablation were included. Following left atrial (LA) catheterization, patients underwent atrial, AH- and AV-sequential pacing. LA/left ventricular (LV) pressure and echocardiographic measurements during the pacing protocols were compared. RESULTS Thirteen patients with 1°AVB (mean PR 221 ± 26 ms) were included. The PR interval was prolonged with atrial pacing compared to baseline (275 ± 73 ms, p = .005). LV ejection fraction (LVEF) was highest during atrial pacing (62 ± 11%), intermediate with AH-sequential pacing (59 ± 7%), and lowest with AV-sequential pacing (57 ± 12%) though these differences were not statistically significant. No significant differences were found in LA or LV mean pressures or LV dP/dT. LA and LV volumes, isovolumetric times, electromechanical delays, and global longitudinal strains were similar across pacing protocols. CONCLUSION Despite pronounced PR prolongation, the acute effects of atrial pacing were not significantly different than AH- or AV-sequential pacing. Normalizing atrioventricular and/or inter-ventricular dyssynchrony did not result in acute improvements in cardiac output or loading conditions.
Collapse
Affiliation(s)
- Zak Loring
- Division of CardiologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Duke Clinical Research InstituteDurhamNorth CarolinaUSA
| | - Fredrik Holmqvist
- Division of CardiologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Department of CardiologyLund UniversityLundSweden
| | - Edward Sze
- Division of CardiologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Maine Medical CenterPortlandMaineUSA
| | - Fawaz Alenezi
- Division of CardiologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Kristen Campbell
- Maine Medical CenterPortlandMaineUSA
- Department of PharmacyDuke University Medical CenterDurhamNorth CarolinaUSA
| | - Jason I. Koontz
- Division of CardiologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - Eric J. Velazquez
- Division of CardiologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Section of Cardiovascular MedicineDepartment of Internal MedicineYale UniversityNew HavenConnecticutUSA
| | - Brett D. Atwater
- Division of CardiologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
- Section of Cardiac ElectrophysiologyInova Heart and Vascular InstituteFairfaxVirginiaUSA
| | - Tristram D. Bahnson
- Division of CardiologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
| | - James P. Daubert
- Division of CardiologyDepartment of MedicineDuke UniversityDurhamNorth CarolinaUSA
| |
Collapse
|
33
|
Affiliation(s)
- Yousif Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Alexandra J Lansky
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, Yale University, New Haven, Connecticut
| |
Collapse
|
34
|
Ghazi L, Yamamoto Y, Riello RJ, Coronel-Moreno C, Martin M, O’Connor KD, Simonov M, Huang J, Olufade T, McDermott J, Dhar R, Inzucchi SE, Velazquez EJ, Wilson FP, Desai NR, Ahmad T. Electronic Alerts to Improve Heart Failure Therapy in Outpatient Practice: A Cluster Randomized Trial. J Am Coll Cardiol 2022; 79:2203-2213. [DOI: 10.1016/j.jacc.2022.03.338] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2022] [Revised: 03/16/2022] [Accepted: 03/17/2022] [Indexed: 10/18/2022]
|
35
|
Chew DS, Cowper PA, Al-Khalidi H, Anstrom KJ, Daniels MR, Davidson-Ray L, Li Y, Michler RE, Panza JA, Piña IL, Rouleau JL, Velazquez EJ, Mark DB. Cost-Effectiveness of Coronary Artery Bypass Surgery Versus Medicine in Ischemic Cardiomyopathy: The STICH Randomized Clinical Trial. Circulation 2022; 145:819-828. [PMID: 35044802 PMCID: PMC8959089 DOI: 10.1161/circulationaha.121.056276] [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] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The STICH Randomized Clinical Trial (Surgical Treatment for Ischemic Heart Failure) demonstrated that coronary artery bypass grafting (CABG) reduced all-cause mortality rates out to 10 years compared with medical therapy alone (MED) in patients with ischemic cardiomyopathy and reduced left ventricular function (ejection fraction ≤35%). We examined the economic implications of these results. METHODS We used a decision-analytic patient-level simulation model to estimate the lifetime costs and benefits of CABG and MED using patient-level resource use and clinical data collected in the STICH trial. Patient-level costs were calculated by applying externally derived US cost weights to resource use counts during trial follow-up. A 3% discount rate was applied to both future costs and benefits. The primary outcome was the incremental cost-effectiveness ratio assessed from the US health care sector perspective. RESULTS For the CABG arm, we estimated 6.53 quality-adjusted life-years (95% CI, 5.70-7.53) and a lifetime cost of $140 059 (95% CI, $106 401 to $180 992). For the MED arm, the corresponding estimates were 5.52 (95% CI, 5.06-6.09) quality-adjusted life-years and $74 894 lifetime cost (95% CI, $58 372 to $93 541). The incremental cost-effectiveness ratio for CABG compared with MED was $63 989 per quality-adjusted life-year gained. At a societal willingness-to-pay threshold of $100 000 per quality-adjusted life-year gained, CABG was found to be economically favorable compared with MED in 87% of microsimulations. CONCLUSIONS In the STICH trial, in patients with ischemic cardiomyopathy and reduced left ventricular function, CABG was economically attractive relative to MED at current benchmarks for value in the United States. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT00023595.
Collapse
Affiliation(s)
- Derek S Chew
- Duke Clinical Research Institute (D.S.C., P.A.C., H.A., K.J.A., M.R.D., L.D.-R., Y.L., D.B.M.), Duke University, Durham, NC.,Department of Cardiac Sciences, Libin Cardiovascular Institute (D.S.C.), University of Calgary, Alberta, Canada.,O'Brien Institute for Public Health (D.S.C.), University of Calgary, Alberta, Canada
| | - Patricia A Cowper
- Duke Clinical Research Institute (D.S.C., P.A.C., H.A., K.J.A., M.R.D., L.D.-R., Y.L., D.B.M.), Duke University, Durham, NC
| | - Hussein Al-Khalidi
- Duke Clinical Research Institute (D.S.C., P.A.C., H.A., K.J.A., M.R.D., L.D.-R., Y.L., D.B.M.), Duke University, Durham, NC.,Department of Biostatistics and Bioinformatics (H.A., K.J.A.), Duke University, Durham, NC
| | - Kevin J Anstrom
- Duke Clinical Research Institute (D.S.C., P.A.C., H.A., K.J.A., M.R.D., L.D.-R., Y.L., D.B.M.), Duke University, Durham, NC.,Department of Biostatistics and Bioinformatics (H.A., K.J.A.), Duke University, Durham, NC
| | - Melanie R Daniels
- Duke Clinical Research Institute (D.S.C., P.A.C., H.A., K.J.A., M.R.D., L.D.-R., Y.L., D.B.M.), Duke University, Durham, NC
| | - Linda Davidson-Ray
- Duke Clinical Research Institute (D.S.C., P.A.C., H.A., K.J.A., M.R.D., L.D.-R., Y.L., D.B.M.), Duke University, Durham, NC
| | - Yanhong Li
- Duke Clinical Research Institute (D.S.C., P.A.C., H.A., K.J.A., M.R.D., L.D.-R., Y.L., D.B.M.), Duke University, Durham, NC
| | - Robert E Michler
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, Bronx, NY (R.E.M.)
| | - Julio A Panza
- Department of Cardiology, Westchester Medical Center, Westchester Medical Center Health Network, Valhalla, NY (J.A.P.)
| | - Ileana L Piña
- Department of Medicine, Wayne State University, Detroit, MI (I.L.P.)
| | - Jean L Rouleau
- Institut de Cardiologie de Montréal, Université de Montréal, Canada (J.L.R.)
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT (E.J.V.)
| | - Daniel B Mark
- Duke Clinical Research Institute (D.S.C., P.A.C., H.A., K.J.A., M.R.D., L.D.-R., Y.L., D.B.M.), Duke University, Durham, NC.,Division of Cardiology, Department of Medicine, Duke University Medical Center, Durham, NC (D.B.M.)
| | | |
Collapse
|
36
|
Faridi K, Huang H, Parise H, Ahmad T, Mori M, Chung M, Yeh RW, Velazquez EJ. DAYS ALIVE OUT OF HOSPITAL FOR PATIENTS WITH LEFT VENTRICULAR DYSFUNCTION AND CORONARY ARTERY DISEASE TREATED WITH CORONARY ARTERY BYPASS SURGERY OR MEDICAL THERAPY: FINDINGS FROM THE STICH TRIAL. J Am Coll Cardiol 2022. [DOI: 10.1016/s0735-1097(22)02049-6] [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: 11/26/2022]
|
37
|
Ghazi L, Desai NR, Simonov M, Yamamoto Y, O'Connor KD, Riello RJ, Huang J, Olufade T, McDermott J, Inzucchi SE, Velazquez EJ, Wilson FP, Ahmad T. Rationale and design of a cluster-randomized pragmatic trial aimed at improving use of guideline directed medical therapy in outpatients with heart failure: PRagmatic trial of messaging to providers about treatment of heart failure (PROMPT-HF). Am Heart J 2022; 244:107-115. [PMID: 34808104 DOI: 10.1016/j.ahj.2021.11.010] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 11/15/2021] [Accepted: 11/16/2021] [Indexed: 11/01/2022]
Abstract
Heart failure with reduced ejection fraction (HFrEF) is one of the most common chronic illnesses in the United States and carries significant risk of morbidity and mortality. Use of guideline-directed medical therapy (GDMT) for patients with HFrEF has been shown to dramatically improve outcomes, but adoption of these treatments remains generally low. Possible explanations for poor GDMT uptake include lack of knowledge about recommended management strategies and provider reluctance due to uncertainties regarding application of said guidelines to real-world practice. One way to overcome these barriers is by harnessing the electronic health record (EHR) to create patient-centered "best practice alerts" (BPAs) that can guide clinicians to prescribe appropriate medical therapies. If found to be effective, these low-cost interventions can be rapidly applied across large integrated healthcare systems. The PRagmatic Trial Of Messaging to Providers about Treatment of Heart Failure (PROMPT-HF) trial is a pragmatic, cluster randomized controlled trial designed to test the hypothesis that tailored and timely alerting of recommended GDMT in heart failure (HF) will result in greater adherence to guidelines when compared with usual care. PROMPT-HF has completed enrollment of 1,310 ambulatory patients with HFrEF cared for by 100 providers who were randomized to receive a BPA vs usual care. The BPA alerted providers to GDMT recommended for their patients and displayed current left ventricular ejection fraction (LVEF) along with the most recent blood pressure, heart rate, serum potassium and creatinine levels, and estimated glomerular filtration rate. It also linked to an order set customized to the patient that suggests medications within each GDMT class not already prescribed. Our goal is to examine whether tailored EHR-based alerting for outpatients with HFrEF will lead to higher rates of GDMT at 30 days post randomization when compared with usual care. Additionally, we are assessing clinical outcomes such as hospital readmissions and death between the alert versus usual care group. Trial Registration: Clinicaltrials.gov NCT04514458.
Collapse
|
38
|
Doenst T, Haddad H, Stebbins A, Hill JA, Velazquez EJ, Lee KL, Rouleau JL, Sopko G, Farsky PS, Al-Khalidi HR. Renal function and coronary bypass surgery in patients with ischemic heart failure. J Thorac Cardiovasc Surg 2022; 163:663-672.e3. [PMID: 32386761 PMCID: PMC7541611 DOI: 10.1016/j.jtcvs.2020.02.136] [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] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2019] [Revised: 01/24/2020] [Accepted: 02/13/2020] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Chronic kidney disease is a known risk factor in cardiovascular disease, but its influence on treatment effect of bypass surgery remains unclear. We assessed the influence of chronic kidney disease on 10-year mortality and cardiovascular outcomes in patients with ischemic heart failure treated with medical therapy (medical treatment) with or without coronary artery bypass grafting. METHODS We calculated the baseline estimated glomerular filtration rate (Chronic Kidney Disease Epidemiology Collaboration formula, chronic kidney disease stages 1-5) from 1209 patients randomized to medical treatment or coronary artery bypass grafting in the Surgical Treatment for IsChemic Heart failure trial and assessed its effect on outcome. RESULTS In the overall Surgical Treatment for IsChemic Heart failure cohort, patients with chronic kidney disease stages 3 to 5 were older than those with stages 1 and 2 (66-71 years vs 54-59 years) and had more comorbidities. Multivariable modeling revealed an inverse association between estimated glomerular filtration rate and risk of death, cardiovascular death, or cardiovascular rehospitalization (all P < .001, but not for stroke, P = .697). Baseline characteristics of the 2 treatment arms were equal for each chronic kidney disease stage. There were significant improvements in death or cardiovascular rehospitalization with coronary artery bypass grafting (stage 1: hazard ratio, 0.71; confidence interval, 0.53-0.96, P = .02; stage 2: hazard ratio, 0.71; confidence interval, 0.59-0.84, P < .0001; stage 3: hazard ratio, 0.76; confidence interval, 0.53-0.96, P = .03). These data were inconclusive in stages 4 and 5 for insufficient patient numbers (N = 28). There was no significant interaction of estimated glomerular filtration rate with the treatment effect of coronary artery bypass grafting (P = .25 for death and P = .54 for death or cardiovascular rehospitalization). CONCLUSIONS Chronic kidney disease is an independent risk factor for mortality in patients with ischemic heart failure with or without coronary artery bypass grafting. However, mild to moderate chronic kidney disease does not appear to influence long-term treatment effects of coronary artery bypass grafting.
Collapse
Affiliation(s)
- Torsten Doenst
- Department of Cardiothoracic Surgery, Jena University Hospital, Friedrich-Schiller-University of Jena, Jena, Germany.
| | - Haissam Haddad
- Department of Medicine, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | | | - James A Hill
- Division of Cardiovascular Medicine, Department of Medicine, University of Florida, Malcom Randal VAMC, Gainesville, Fla
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Kerry L Lee
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC
| | - Jean L Rouleau
- Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - George Sopko
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Md
| | - Pedro S Farsky
- Department of Cardiology, Instituto Dante Pazzanese de Cardiologia, Sao Paulo, Brazil; Department of Cardiology, Hospital Israelita Albert Einstein, Sao Paulo, Brazil
| | - Hussein R Al-Khalidi
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Duke Clinical Research Institute, Durham, NC
| |
Collapse
|
39
|
Bloomfield GS, Alenezi F, Chiswell K, Dunning A, Okeke NL, Velazquez EJ. Progression of cardiac structure and function in people with human immunodeficiency virus. Echocardiography 2022; 39:268-277. [PMID: 35048419 DOI: 10.1111/echo.15302] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2021] [Revised: 12/13/2021] [Accepted: 01/04/2022] [Indexed: 12/15/2022] Open
Abstract
OBJECTIVE People living with HIV (PLWH) are at increased risk for cardiac dysfunction. It is unknown how their global longitudinal cardiac function, cardiac structure, and other indices of function progress over time. We aimed to characterize the longitudinal trend in cardiac structure and function in PLWH. DESIGN Retrospective study of PLWH with clinically obtained echocardiograms at an academic medical center. METHODS We reviewed archived transthoracic echocardiograms (TTEs) performed between 2001 and 2012 on PLWH. The primary outcome measures were progression of global longitudinal strain (GLS, left and right ventricles), LV mass, E/e' ratio, LV end-systolic, and -diastolic volumes using hierarchical mixed model analysis as a function of CD4+ T cell count and HIV RNA suppression. Models were adjusted for clinical and demographic characteristics. RESULTS We analyzed 469 TTEs from 150 individuals (median age 46 years, 58% male). Median CD4+ T cell counts at nadir and proximal to first echocardiogram were 85 and 222 cells/mm3 , respectively. Over a median of 5 years, LV mass index increased regardless of nadir or proximal CD4+ T cell count or viral suppression status. PLWH with viral suppression at baseline had more normal GLS throughout the follow-up period. There were no significant trends in LV end-systolic volume index or E/e'. CONCLUSIONS In PLWH, HIV viral suppression is associated with early gains in echocardiographic indices of cardiac function that persist for up to >5 years. HIV disease control impacts routine echocardiographic measures with known impacts on long-term prognosis.
Collapse
Affiliation(s)
- Gerald S Bloomfield
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
- Duke Global Health Institute, Duke University, Durham, North Carolina, USA
| | - Fawaz Alenezi
- Division of Cardiology, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Karen Chiswell
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Allison Dunning
- Duke Clinical Research Institute, Duke University, Durham, North Carolina, USA
| | - Nwora Lance Okeke
- Division of Infectious Diseases, Department of Medicine, Duke University, Durham, North Carolina, USA
| | - Eric J Velazquez
- Division of Cardiology, Yale University, New Haven, Connecticut, USA
| |
Collapse
|
40
|
Khera R, Liu Y, de Lemos JA, Das SR, Pandey A, Omar W, Kumbhani DJ, Girotra S, Yeh RW, Rutan C, Walchok J, Lin Z, Bradley SM, Velazquez EJ, Churchwell KB, Nallamothu BK, Krumholz HM, Curtis JP. Association of COVID-19 Hospitalization Volume and Case Growth at US Hospitals with Patient Outcomes. Am J Med 2021; 134:1380-1388.e3. [PMID: 34343515 PMCID: PMC8325555 DOI: 10.1016/j.amjmed.2021.06.034] [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] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 06/25/2021] [Accepted: 06/28/2021] [Indexed: 12/01/2022]
Abstract
BACKGROUND Whether the volume of coronavirus disease 2019 (COVID-19) hospitalizations is associated with outcomes has important implications for the organization of hospital care both during this pandemic and future novel and rapidly evolving high-volume conditions. METHODS We identified COVID-19 hospitalizations at US hospitals in the American Heart Association COVID-19 Cardiovascular Disease Registry with ≥10 cases between January and August 2020. We evaluated the association of COVID-19 hospitalization volume and weekly case growth indexed to hospital bed capacity, with hospital risk-standardized in-hospital case-fatality rate (rsCFR). RESULTS There were 85 hospitals with 15,329 COVID-19 hospitalizations, with a median hospital case volume was 118 (interquartile range, 57, 252) and median growth rate of 2 cases per 100 beds per week but varied widely (interquartile range: 0.9 to 4.5). There was no significant association between overall hospital COVID-19 case volume and rsCFR (rho, 0.18, P = .09). However, hospitals with more rapid COVID-19 case-growth had higher rsCFR (rho, 0.22, P = 0.047), increasing across case growth quartiles (P trend = .03). Although there were no differences in medical treatments or intensive care unit therapies (mechanical ventilation, vasopressors), the highest case growth quartile had 4-fold higher odds of above median rsCFR, compared with the lowest quartile (odds ratio, 4.00; 1.15 to 13.8, P = .03). CONCLUSIONS An accelerated case growth trajectory is a marker of hospitals at risk of poor COVID-19 outcomes, identifying sites that may be targets for influx of additional resources or triage strategies. Early identification of such hospital signatures is essential as our health system prepares for future health challenges.
Collapse
Affiliation(s)
- Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn.
| | - Yusi Liu
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - James A de Lemos
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Sandeep R Das
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Ambarish Pandey
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Wally Omar
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass
| | - Dharam J Kumbhani
- Division of Cardiology, University of Texas Southwestern Medical Center, Dallas
| | - Saket Girotra
- Division of Cardiovascular Medicine, Department of Internal Medicine, University of Iowa, Iowa City
| | - Robert W Yeh
- Division of Cardiology, Beth Israel Deaconess Medical Center, Boston, Mass; Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center, Boston, Mass
| | | | | | - Zhenqiu Lin
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| | - Steven M Bradley
- Healthcare Delivery Innovation Center, Minneapolis Heart Institute, Minn
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | - Keith B Churchwell
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn
| | | | - Harlan M Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn; Department of Health Policy and Management, Yale School of Public Health, New Haven, Conn
| | - Jeptha P Curtis
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Conn; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Conn
| |
Collapse
|
41
|
Chouairi F, Fuery M, Clark KA, Mullan CW, Stewart J, Caraballo C, Clarke JRD, Sen S, Guha A, Ibrahim NE, Cole RT, Holaday L, Anwer M, Geirsson A, Rogers JG, Velazquez EJ, Desai NR, Ahmad T, Miller PE. Evaluation of Racial and Ethnic Disparities in Cardiac Transplantation. J Am Heart Assoc 2021; 10:e021067. [PMID: 34431324 PMCID: PMC8649228 DOI: 10.1161/jaha.120.021067] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [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: 11/16/2022]
Abstract
Background Racial and ethnic disparities contribute to differences in access and outcomes for patients undergoing heart transplantation. We evaluated contemporary outcomes for heart transplantation stratified by race and ethnicity as well as the new 2018 allocation system. Methods and Results Adult heart recipients from 2011 to 2020 were identified in the United Network for Organ Sharing database and stratified into 3 groups: Black, Hispanic, and White. We analyzed recipient and donor characteristics, and outcomes. Among 32 353 patients (25% Black, 9% Hispanic, 66% White), Black and Hispanic patients were younger, more likely to be women and have diabetes mellitus or renal disease (all, P<0.05). Over the study period, the proportion of Black and Hispanic patients listed for transplant increased: 21.7% to 28.2% (P=0.003) and 7.7% to 9.0% (P=0.002), respectively. Compared with White patients, Black patients were less likely to undergo transplantation (adjusted hazard ratio [aHR], 0.87; CI, 0.84-0.90; P<0.001), but had a higher risk of post-transplant death (aHR, 1.14; CI, 1.04-1.24; P=0.004). There were no differences in transplantation likelihood or post-transplant mortality between Hispanic and White patients. Following the allocation system change, transplantation rates increased for all groups (P<0.05). However, Black patients still had a lower likelihood of transplantation than White patients (aHR, 0.90; CI, 0.79-0.99; P=0.024). Conclusions Although the proportion of Black and Hispanic patients listed for cardiac transplantation have increased, significant disparities remain. Compared with White patients, Black patients were less likely to be transplanted, even with the new allocation system, and had a higher risk of post-transplantation death.
Collapse
Affiliation(s)
- Fouad Chouairi
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | - Michael Fuery
- Department of Internal Medicine Yale School of Medicine New Haven CT
| | - Katherine A Clark
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | - Clancy W Mullan
- Division of Cardiac Surgery Yale School of Medicine New Haven CT
| | - James Stewart
- Division of Cardiac Surgery Yale School of Medicine New Haven CT
| | - Cesar Caraballo
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | | | - Sounok Sen
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | - Avirup Guha
- Case Western Reserve University Cleveland OH
| | | | | | - Louisa Holaday
- Department of Internal Medicine Yale School of Medicine New Haven CT.,Yale National Clinicians Scholar Program New Haven CT
| | - Muhammed Anwer
- Division of Cardiac Surgery Yale School of Medicine New Haven CT
| | - Arnar Geirsson
- Division of Cardiac Surgery Yale School of Medicine New Haven CT
| | - Joseph G Rogers
- Division of Cardiology Duke University Medical Center Durham NC
| | - Eric J Velazquez
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | - Nihar R Desai
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | - Tariq Ahmad
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT
| | - P Elliott Miller
- Section of Cardiovascular Medicine Yale School of Medicine New Haven CT.,Yale National Clinicians Scholar Program New Haven CT
| |
Collapse
|
42
|
Greene SJ, Velazquez EJ, Anstrom KJ, Eisenstein EL, Mentz RJ. Reply: Pragmatic Clinical Trials: The Big Picture. JACC Heart Fail 2021; 9:606-608. [PMID: 34325892 DOI: 10.1016/j.jchf.2021.05.018] [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] [Received: 05/10/2021] [Accepted: 05/10/2021] [Indexed: 11/17/2022]
|
43
|
Oikonomou EK, Van Dijk D, Parise H, Suchard MA, de Lemos J, Antoniades C, Velazquez EJ, Miller EJ, Khera R. A phenomapping-derived tool to personalize the selection of anatomical vs. functional testing in evaluating chest pain (ASSIST). Eur Heart J 2021; 42:2536-2548. [PMID: 33881513 PMCID: PMC8488385 DOI: 10.1093/eurheartj/ehab223] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 03/14/2021] [Accepted: 03/31/2021] [Indexed: 11/14/2022] Open
Abstract
AIMS Coronary artery disease is frequently diagnosed following evaluation of stable chest pain with anatomical or functional testing. A more granular understanding of patient phenotypes that benefit from either strategy may enable personalized testing. METHODS AND RESULTS Using participant-level data from 9572 patients undergoing anatomical (n = 4734) vs. functional (n = 4838) testing in the PROMISE (PROspective Multicenter Imaging Study for Evaluation of Chest Pain) trial, we created a topological representation of the study population based on 57 pre-randomization variables. Within each patient's 5% topological neighbourhood, Cox regression models provided individual patient-centred hazard ratios for major adverse cardiovascular events and revealed marked heterogeneity across the phenomap [median 1.11 (10th to 90th percentile: 0.52-2.61]), suggestive of distinct phenotypic neighbourhoods favouring anatomical or functional testing. Based on this risk phenomap, we employed an extreme gradient boosting algorithm in 80% of the PROMISE population to predict the personalized benefit of anatomical vs. functional testing using 12 model-derived, routinely collected variables and created a decision support tool named ASSIST (Anatomical vs. Stress teSting decIsion Support Tool). In both the remaining 20% of PROMISE and an external validation set consisting of patients from SCOT-HEART (Scottish COmputed Tomography of the HEART Trial) undergoing anatomical-first vs. functional-first assessment, the testing strategy recommended by ASSIST was associated with a significantly lower incidence of each study's primary endpoint (P = 0.0024 and P = 0.0321 for interaction, respectively), as well as a harmonized endpoint of all-cause mortality or non-fatal myocardial infarction (P = 0.0309 and P < 0.0001 for interaction, respectively). CONCLUSION We propose a novel phenomapping-derived decision support tool to standardize the selection of anatomical vs. functional testing in the evaluation of stable chest pain, validated in two large and geographically diverse clinical trial populations.
Collapse
Affiliation(s)
- Evangelos K Oikonomou
- Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - David Van Dijk
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Department of Computer Science, Yale University, 51 Prospect St, New Haven, CT 06520-8285, USA
| | - Helen Parise
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Marc A Suchard
- Department of Biostatistics, Fielding School of Public Health, University of California, 650 Charles E. Young Drive S, Los Angeles, CA 90095, USA
- Departments of Computational Medicine and Human Genetics, David Geffen School of Medicine at UCLA, University of California, 695 Charles E. Young Drive S, Los Angeles, CA 90095, USA
| | - James de Lemos
- Division of Cardiology, Department of Internal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390-8830, USA
| | - Charalambos Antoniades
- Division of Cardiovascular Medicine, Radcliffe Department of Medicine, University of Oxford, Level 6, West Wing, John Radcliffe Hospital, Headley Way, OX3 9DU, Oxford, UK
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Edward J Miller
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
| | - Rohan Khera
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, 333 Cedar Street, New Haven, CT 06520-8056, USA
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, MS 1 Church Street, Suite 200, New Haven, CT 06510, USA
| |
Collapse
|
44
|
Chouairi F, Fuery MA, Mullan CW, Caraballo C, Sen S, Maulion C, Wilkinson ST, Surti T, McCullough M, Miller PE, Pacor J, Leifer ES, Felker GM, Velazquez EJ, Fiuzat M, O'Connor CM, Januzzi JL, Desai NR, Ahmad T. The Impact of Depression on Outcomes in Patients With Heart Failure and Reduced Ejection Fraction Treated in the GUIDE-IT Trial. J Card Fail 2021; 27:1359-1366. [PMID: 34166799 DOI: 10.1016/j.cardfail.2021.06.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/22/2021] [Revised: 06/04/2021] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND It remains unclear why depression is associated with adverse outcomes in patients with heart failure (HF). We examine the relationship between depression and clinical outcomes among patients with HF with reduced ejection fraction managed with guideline-directed medical therapy (GDMT). METHODS AND RESULTS Using the GUIDE-IT trial, 894 patients with HF with reduced ejection fraction were stratified according to a history of depression, and Cox proportional hazards regression modeling was used to examine the association with outcomes. There were 140 patients (16%) in the overall cohort who had depression. They tended to be female (29% vs 46%, P < .001) and White (67% vs 53%, P = .002). There were no differences in GDMT rates at baseline or at 90 days; nor were there differences in target doses of these therapies achieved at 90 days (NS, all). amino-terminal pro-B-type natriuretic peptide levels at all time points were similar between the cohorts (P > .05, all). After adjustment, depression was associated with all-cause hospitalizations (hazard ratio, 1.42, 95% confidence interval 1.11-1.81, P < .01), cardiovascular death (hazard ratio, 1.69, 95% confidence interval 1.07-2.68, P = .025), and all-cause mortality (hazard ratio, 1.54, 95% confidence interval 1.03-2.32, P = .039). CONCLUSIONS Depression impacts clinical outcomes in HF regardless of GDMT intensity and amino-terminal pro-B-type natriuretic peptide levels. This finding underscores the need for a focus on mental health in parallel to achievement of optimal GDMT in these patients. TRIAL REGISTRATION NCT01685840, https://clinicaltrials.gov/ct2/show/NCT01685840.
Collapse
Affiliation(s)
- Fouad Chouairi
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Duke University University School of Medicine, Durham, North Carolina
| | - Michael A Fuery
- Yale University School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Clancy W Mullan
- Department of Cardiac Surgery, Yale University School of Medicine, New Haven, CT
| | - Cesar Caraballo
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research & Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut
| | - Sounok Sen
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Christopher Maulion
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Samuel T Wilkinson
- Center for Outcomes Research & Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut; Department of Psychiatry Yale University School of Medicine, New Haven, Connecticut
| | - Toral Surti
- Center for Outcomes Research & Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut; Department of Psychiatry Yale University School of Medicine, New Haven, Connecticut
| | | | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Justin Pacor
- Yale University School of Medicine, New Haven, Connecticut; Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Eric S Leifer
- Division of Cardiovascular Sciences, National Heart, Lung, and Blood Institute, Bethesda, Maryland
| | | | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut
| | - Mona Fiuzat
- Duke Clinical Research Institute, Durham, North Carolina
| | | | | | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut; Center for Outcomes Research & Evaluation (CORE), Yale University School of Medicine, New Haven, Connecticut
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut; Yale University School of Medicine, New Haven, Connecticut.
| |
Collapse
|
45
|
Park J, Kim Y, Pereira J, Hennessey KC, Faridi KF, McNamara RL, Velazquez EJ, Hur DJ, Sugeng L, Agarwal V. Understanding the role of left and right ventricular strain assessment in patients hospitalized with COVID-19. ACTA ACUST UNITED AC 2021; 6:100018. [PMID: 34095889 PMCID: PMC8168299 DOI: 10.1016/j.ahjo.2021.100018] [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] [Subscribe] [Scholar Register] [Received: 01/09/2021] [Revised: 05/16/2021] [Accepted: 05/17/2021] [Indexed: 01/07/2023]
Abstract
Background Coronavirus disease 2019 (COVID-19) can cause cardiac injury resulting in abnormal right or left ventricular function (RV/LV) with worse outcomes. We hypothesized that two-dimensional (2D) speckle-tracking assessment of LV global longitudinal strain (GLS) and RV free wall strain (FWS) by transthoracic echocardiography can assist as markers for subclinical cardiac injury predicting increased mortality. Methods We performed 2D strain analysis via proprietary software in 48 patients hospitalized with COVID-19. Clinical information, demographics, comorbidities, and lab values were collected via retrospective chart review. The primary outcome was in-hospital mortality based on an optimized abnormal LV GLS value via ROC analysis and RV FWS. Results The optimal LV GLS cutoff to predict death was −13.8%, with a sensitivity of 85% (95% CI 55–98%) and specificity of 54% (95% CI 36–71%). Abnormal LV GLS >-13.8% was associated with a higher risk of death [unadjusted hazard ratio 5.15 (95% CI 1.13–23.45), p = 0.034], which persisted after adjustment for clinical variables. Among patients with LV ejection fraction (LVEF) >50%, those with LV GLS > −13.8% had higher mortality compared to those with LV GLS <-13.8% (41% vs. 10%, p = 0.030). RV FWS value was higher in patients with LV GLS >-13.8% (−13.7 ± 5.9 vs. −19.6 ± 6.7, p = 0.003), but not associated with decreased survival. Conclusion Abnormal LV strain with a cutoff of >−13.8% in patients with COVID-19 is associated with significantly higher risk of death. Despite normal LVEF, abnormal LV GLS predicted worse outcomes in patients hospitalized with COVID-19. There was no mortality difference based on RV strain.
Collapse
Key Words
- 2D, Two-dimensional
- ARDS, acute respiratory distress syndrome
- COVID-19
- COVID-19, Coronavirus Disease 2019
- EF, ejection fraction
- FAC, fractional area change
- FWS, free wall strain
- GLS, global longitudinal strain
- HFrEF, heart failure reduced ejection fraction
- Hs-TNT, high sensitivity troponin T
- ICC, intra-class correlation coefficient
- LV, left ventricle
- Left ventricular strain
- NT-proBNP, NT-pro-brain natriuretic peptide
- RV, right ventricle
- Speckle-tracking echocardiography
- TTE, transthoracic echocardiography
Collapse
Affiliation(s)
- Jakob Park
- Department of Internal Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Yekaterina Kim
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Jason Pereira
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kerrilynn C Hennessey
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Kamil F Faridi
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Robert L McNamara
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - David J Hur
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Lissa Sugeng
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Vratika Agarwal
- Section of Cardiovascular Medicine, Department of Medicine, Yale School of Medicine, New Haven, CT, USA
| |
Collapse
|
46
|
Sharma A, Greene S, Vaduganathan M, Fudim M, Ambrosy AP, Sun JL, McNulty SE, Hernandez AF, Borlaug BA, Velazquez EJ, Mentz RJ, DeVore AD, Alhanti B, Margulies K, Felker GM. Growth differentiation factor-15, treatment with liraglutide, and clinical outcomes among patients with heart failure. ESC Heart Fail 2021; 8:2608-2616. [PMID: 34061470 PMCID: PMC8318489 DOI: 10.1002/ehf2.13348] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Revised: 03/08/2021] [Accepted: 03/26/2021] [Indexed: 12/21/2022] Open
Abstract
Aims Associations between growth differentiation factor‐15 (GDF‐15), cardiovascular outcomes, and exercise capacity among patients with a recent hospitalization for heart failure (HHF) and heart failure with reduced ejection fraction (HFrEF) are unknown. We utilized data from the ‘Functional Impact of GLP‐1 for Heart Failure Treatment’ (FIGHT) study to address these knowledge gaps. Methods and results FIGHT was a randomized clinical trial testing the effect of liraglutide (vs. placebo) among 300 participants with HFrEF and a recent HHF. Multivariable regression models evaluated associations between baseline GDF‐15 and change in GDF‐15 (per 1000 pg/mL increase from baseline to 30 days) with clinical outcomes (at 180 days) and declines in exercise capacity (6 min walk distance ≥ 45 m). At baseline (n = 249), median GDF‐15 value was 3221 pg/mL (interquartile range 1938–5511 pg/mL). Participants in the highest tertile of baseline GDF‐15 were more likely to be male and have more co‐morbidities. After adjustment, an increase in GDF‐15 over 30 days was associated with higher risk of death or HHF [hazard ratio 1.35, 95% confidence interval (CI) 1.11–1.64]. In addition, higher baseline GDF‐15 (per 1000 pg/mL until 6000 pg/mL) and an increase in GDF‐15 over 30 days were associated with declining 6 min walk distance (odds ratio 1.26, 95% CI 1.02–1.55 and odds ratio 1.37, 95% CI 1.12–1.69, respectively). GDF‐15 levels remained stable among participants randomized to liraglutide. Conclusions An increase in GDF‐15 over 30 days among patients in HFrEF was independently associated with an increased risk of cardiovascular events and declining exercise capacity. These results support the value of longitudinal GDF‐15 trajectory in informing risk of heart failure disease progression.
Collapse
Affiliation(s)
- Abhinav Sharma
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Stephen Greene
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA
| | - Muthiah Vaduganathan
- Brigham and Women's Hospital Heart and Vascular Center, Harvard Medical School, Boston, MA, USA
| | - Marat Fudim
- DREAM-CV Lab, McGill University Health Centre, McGill University, Montreal, Quebec, Canada
| | - Andrew P Ambrosy
- Kaiser Permanente San Francisco Medical Center, San Francisco, CA, USA
| | - Jie-Lena Sun
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA
| | - Steven E McNulty
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA
| | - Adrian F Hernandez
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA
| | - Barry A Borlaug
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN, USA
| | - Eric J Velazquez
- Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - Robert J Mentz
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA
| | - Adam D DeVore
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA
| | - Kenneth Margulies
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
| | - G Michael Felker
- Duke Clinical Research Institute, Duke University, 200 Morris Street, Durham, NC, 27701, USA
| |
Collapse
|
47
|
Ahmad T, Yamamoto Y, Biswas A, Ghazi L, Martin M, Simonov M, Hsiao A, Kashyap N, Velazquez EJ, Desai NR, Wilson FP. REVeAL-HF: Design and Rationale of a Pragmatic Randomized Controlled Trial Embedded Within Routine Clinical Practice. JACC Heart Fail 2021; 9:409-419. [PMID: 33992566 DOI: 10.1016/j.jchf.2021.03.006] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/26/2021] [Accepted: 03/02/2021] [Indexed: 01/30/2023]
Abstract
Heart failure (HF) is one of the most common causes of hospitalization in the United States and carries a significant risk of morbidity and mortality. Use of evidence-based interventions may improve outcomes, but their use is encumbered in part by limitations in accurate prognostication. The REVeAL-HF (Risk EValuation And its Impact on ClinicAL Decision Making and Outcomes in Heart Failure) trial is the first to definitively evaluate the impact of knowledge about prognosis on clinical decision making and patient outcomes. The REVeAL-HF trial is a pragmatic, completely electronic, randomized controlled trial that has completed enrollment of 3,124 adults hospitalized for HF, defined as having an N-terminal pro-B-type natriuretic peptide level of >500 pg/ml and receiving intravenous diuretic agents within 24 h of admission. Patients randomized to the intervention had their risk of 1-year mortality generated with information in the electronic health record and presented to their providers, who had the option to give feedback on their impression of this risk assessment. The authors are examining the impact of this information on clinical decision-making (use of HF pharmacotherapies, referral to electrophysiology, palliative care referral, and referral for advanced therapies like heart transplantation or mechanical circulatory support) and patient outcomes (length of stay, post-discharge 30-day rehospitalizations, and 1-year mortality). The REVeAL-HF trial will definitively examine whether knowledge about prognosis in HF has an impact on clinical decision making and patient outcomes. It will also examine the relationship between calculated, perceived, and real risk of mortality in this patient population. (Risk EValuation And Its Impact on ClinicAL Decision Making and Outcomes in Heart Failure [REVeAL-HF]; NCT03845660).
Collapse
Affiliation(s)
- Tariq Ahmad
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut, USA.
| | - Yu Yamamoto
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Aditya Biswas
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lama Ghazi
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Melissa Martin
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Michael Simonov
- Joint Data Analytics Team, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Allen Hsiao
- Joint Data Analytics Team, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nitu Kashyap
- Joint Data Analytics Team, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, Connecticut, USA; Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut, USA
| | - F Perry Wilson
- Clinical and Translational Research Accelerator, Yale University School of Medicine, New Haven, Connecticut, USA; Section of Nephrology, Yale University School of Medicine, New Haven, Connecticut, USA
| |
Collapse
|
48
|
Guha A, Caraballo C, Jain P, Miller PE, Owusu-Guha J, Clark KAA, Velazquez EJ, Ahmad T, Baldassarre LA, Addison D, Weintraub NL, Desai NR. Outcomes in patients with anthracycline-induced cardiomyopathy undergoing left ventricular assist devices implantation. ESC Heart Fail 2021; 8:2866-2875. [PMID: 33982867 PMCID: PMC8318466 DOI: 10.1002/ehf2.13362] [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] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Revised: 03/20/2021] [Accepted: 03/29/2021] [Indexed: 02/06/2023] Open
Abstract
Aims Improved cancer survivorship has led to a higher number of anthracycline‐induced cardiomyopathy patients with end‐stage heart failure. We hypothesize that outcomes following continuous‐flow LVAD (CF‐LVAD) implantation in those with anthracycline‐induced cardiomyopathy are comparable with other aetiologies of cardiomyopathy. Methods and results Using the Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) from 2008 to 2017, we identified patients with anthracycline‐induced cardiomyopathy who received a CF‐LVAD and compared them with those with idiopathic dilated (IDM) and ischaemic cardiomyopathies (ICM). Mortality was studied using the Cox proportional hazards model. Other adverse events were evaluated using competing risk models. Overall, 248 anthracycline‐induced cardiomyopathy patients underwent CF‐LVAD implantation, with a median survival of 48 months, an improvement compared with those before 2012 [adjusted hazards ratio (aHR): 0.53; confidence interval (CI): 0.33–0.86]. At 12 months, 85.1% of anthracycline‐induced cardiomyopathy, 86.0% of IDM, and 80.2% of ICM patients were alive (anthracycline‐induced cardiomyopathy vs. IDM: aHR: 1.12; CI: 0.88–1.43 and anthracycline‐induced cardiomyopathy vs. ICM: aHR: 0.98; CI: 0.76–1.28). Anthracycline‐induced cardiomyopathy patients had a higher major bleeding risk compared with IDM patients (aHR: 1.23; CI: 1.01–1.50), and a lower risk of stroke and prolonged respiratory support compared to ICM patients (aHR: 0.31 and 0.67 respectively; both P < 0.05). There was no difference in the risk of major infection, acute kidney injury, and venous thromboembolism. Conclusions After receiving a CF‐LVAD, survival in patients with anthracycline‐induced cardiomyopathy is similar to those with ICM or IDM. Further research into differential secondary endpoints‐related disparities is warranted.
Collapse
Affiliation(s)
- Avirup Guha
- Harrington Heart and Vascular Institute, Case Western Reserve University, Cleveland, OH, USA.,Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA
| | - Cesar Caraballo
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.,Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | - Prantesh Jain
- Division of Hematology and Medical Oncology, University Hospitals Cleveland Medical Center, Seidman Cancer Center at Case Comprehensive Cancer Center, Case Western Reserve University, Cleveland, OH, USA
| | - P Elliott Miller
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.,Yale National Clinician Scholars Program, New Haven, CT, USA
| | - Jocelyn Owusu-Guha
- Pharmacy Department, OhioHealth Riverside Methodist Hospital, Columbus, OH, USA
| | - Katherine A A Clark
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Eric J Velazquez
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA
| | - Tariq Ahmad
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.,Center for Outcomes Research and Evaluation, New Haven, CT, USA
| | | | - Daniel Addison
- Cardio-Oncology Program, Division of Cardiology, The Ohio State University Medical Center, Columbus, OH, USA.,Cancer Control Program, Department of Medicine, Ohio State University Comprehensive Cancer Center, Columbus, OH, USA
| | - Neal L Weintraub
- Department of Medicine, Division of Cardiology, and Vascular Biology Center, Medical College of Georgia at Augusta University, Augusta, GA, USA
| | - Nihar R Desai
- Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, CT, USA.,Center for Outcomes Research and Evaluation, New Haven, CT, USA
| |
Collapse
|
49
|
Pareek M, Singh A, Vadlamani L, Eder M, Pacor J, Park J, Ghazizadeh Z, Heard A, Cruz-Solbes AS, Nikooie R, Gier C, Ahmed ZV, Freeman JV, Meadows J, Smolderen KG, Lampert R, Velazquez EJ, Ahmad T, Desai NR. Relation of Cardiovascular Risk Factors to Mortality and Cardiovascular Events in Hospitalized Patients With Coronavirus Disease 2019 (from the Yale COVID-19 Cardiovascular Registry). Am J Cardiol 2021; 146:99-106. [PMID: 33539857 PMCID: PMC7849530 DOI: 10.1016/j.amjcard.2021.01.029] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 01/07/2021] [Accepted: 01/11/2021] [Indexed: 01/08/2023]
Abstract
Individuals with established cardiovascular disease or a high burden of cardiovascular risk factors may be particularly vulnerable to develop complications from coronavirus disease 2019 (COVID-19). We conducted a prospective cohort study at a tertiary care center to identify risk factors for in-hospital mortality and major adverse cardiovascular events (MACE; a composite of myocardial infarction, stroke, new acute decompensated heart failure, venous thromboembolism, ventricular or atrial arrhythmia, pericardial effusion, or aborted cardiac arrest) among consecutively hospitalized adults with COVID-19, using multivariable binary logistic regression analysis. The study population comprised 586 COVID-19 positive patients. Median age was 67 (IQR: 55 to 80) years, 47.4% were female, and 36.7% had cardiovascular disease. Considering risk factors, 60.2% had hypertension, 39.8% diabetes, and 38.6% hyperlipidemia. Eighty-two individuals (14.0%) died in-hospital, and 135 (23.0%) experienced MACE. In a model adjusted for demographic characteristics, clinical presentation, and laboratory findings, age (odds ratio [OR], 1.28 per 5 years; 95% confidence interval [CI], 1.13 to 1.45), previous ventricular arrhythmia (OR, 18.97; 95% CI, 3.68 to 97.88), use of P2Y12-inhibitors (OR, 7.91; 95% CI, 1.64 to 38.17), higher C-reactive protein (OR, 1.81: 95% CI, 1.18 to 2.78), lower albumin (OR, 0.64: 95% CI, 0.47 to 0.86), and higher troponin T (OR, 1.84; 95% CI, 1.39 to 2.46) were associated with mortality (p <0.05). After adjustment for demographics, presentation, and laboratory findings, predictors of MACE were higher respiratory rates, altered mental status, and laboratory abnormalities, including higher troponin T (p <0.05). In conclusion, poor prognostic markers among hospitalized patients with COVID-19 included older age, pre-existing cardiovascular disease, respiratory failure, altered mental status, and higher troponin T concentrations.
Collapse
Affiliation(s)
- Manan Pareek
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Avinainder Singh
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Lina Vadlamani
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Maxwell Eder
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Justin Pacor
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Jakob Park
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Zaniar Ghazizadeh
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Alex Heard
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Ana Sofia Cruz-Solbes
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Roozbeh Nikooie
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Chad Gier
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Zain V. Ahmed
- Department of Cardiology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - James V. Freeman
- Department of Cardiology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Judith Meadows
- Department of Internal Medicine, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Kim G.E. Smolderen
- Department of Cardiology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Rachel Lampert
- Department of Cardiology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Eric J. Velazquez
- Department of Cardiology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Tariq Ahmad
- Department of Cardiology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut
| | - Nihar R. Desai
- Department of Cardiology, Yale New Haven Hospital, Yale University School of Medicine, New Haven, Connecticut,Corresponding author: Tel.: +1 203 764 7424
| |
Collapse
|
50
|
McPadden J, Warner F, Young HP, Hurley NC, Pulk RA, Singh A, Durant TJS, Gong G, Desai N, Haimovich A, Taylor RA, Gunel M, Dela Cruz CS, Farhadian SF, Siner J, Villanueva M, Churchwell K, Hsiao A, Torre CJ, Velazquez EJ, Herbst RS, Iwasaki A, Ko AI, Mortazavi BJ, Krumholz HM, Schulz WL. Clinical characteristics and outcomes for 7,995 patients with SARS-CoV-2 infection. PLoS One 2021; 16:e0243291. [PMID: 33788846 PMCID: PMC8011821 DOI: 10.1371/journal.pone.0243291] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 02/26/2021] [Indexed: 02/03/2023] Open
Abstract
OBJECTIVE Severe acute respiratory syndrome virus (SARS-CoV-2) has infected millions of people worldwide. Our goal was to identify risk factors associated with admission and disease severity in patients with SARS-CoV-2. DESIGN This was an observational, retrospective study based on real-world data for 7,995 patients with SARS-CoV-2 from a clinical data repository. SETTING Yale New Haven Health (YNHH) is a five-hospital academic health system serving a diverse patient population with community and teaching facilities in both urban and suburban areas. POPULATIONS The study included adult patients who had SARS-CoV-2 testing at YNHH between March 1 and April 30, 2020. MAIN OUTCOME AND PERFORMANCE MEASURES Primary outcomes were admission and in-hospital mortality for patients with SARS-CoV-2 infection as determined by RT-PCR testing. We also assessed features associated with the need for respiratory support. RESULTS Of the 28605 patients tested for SARS-CoV-2, 7995 patients (27.9%) had an infection (median age 52.3 years) and 2154 (26.9%) of these had an associated admission (median age 66.2 years). Of admitted patients, 2152 (99.9%) had a discharge disposition at the end of the study period. Of these, 329 (15.3%) required invasive mechanical ventilation and 305 (14.2%) expired. Increased age and male sex were positively associated with admission and in-hospital mortality (median age 80.7 years), while comorbidities had a much weaker association with the risk of admission or mortality. Black race (OR 1.43, 95%CI 1.14-1.78) and Hispanic ethnicity (OR 1.81, 95%CI 1.50-2.18) were identified as risk factors for admission, but, among discharged patients, age-adjusted in-hospital mortality was not significantly different among racial and ethnic groups. CONCLUSIONS This observational study identified, among people testing positive for SARS-CoV-2 infection, older age and male sex as the most strongly associated risks for admission and in-hospital mortality in patients with SARS-CoV-2 infection. While minority racial and ethnic groups had increased burden of disease and risk of admission, age-adjusted in-hospital mortality for discharged patients was not significantly different among racial and ethnic groups. Ongoing studies will be needed to continue to evaluate these risks, particularly in the setting of evolving treatment guidelines.
Collapse
Affiliation(s)
- Jacob McPadden
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, United States of America
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
| | - Frederick Warner
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - H. Patrick Young
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Nathan C. Hurley
- Department of Computer Science and Engineering, Texas A&M University, College Station, Texas, United States of America
| | - Rebecca A. Pulk
- Corporate Pharmacy Services, Yale New Haven Health, New Haven, Connecticut, United States of America
| | - Avinainder Singh
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Thomas J. S. Durant
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Guannan Gong
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
- Interdepartmental Program in Computational Biology and Bioinformatics, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Nihar Desai
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
| | - Adrian Haimovich
- Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Richard Andrew Taylor
- Department of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Murat Gunel
- Department of Genetics, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Medical Scientist Training Program, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Yale Center for Genome Analysis, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, United States of America
| | - Charles S. Dela Cruz
- Department of Internal Medicine, Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Shelli F. Farhadian
- Department of Internal Medicine, Section of Infectious Diseases, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Jonathan Siner
- Department of Internal Medicine, Pulmonary, Critical Care and Sleep Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Merceditas Villanueva
- Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Center for Interdisciplinary Research on AIDS, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Keith Churchwell
- Yale New Haven Hospital, New Haven, Connecticut, United States of America
| | - Allen Hsiao
- Department of Pediatrics, Yale School of Medicine, New Haven, Connecticut, United States of America
- Information Technology Services, Yale New Haven Health, New Haven, Connecticut, United States of America
| | - Charles J. Torre
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Information Technology Services, Yale New Haven Health, New Haven, Connecticut, United States of America
| | - Eric J. Velazquez
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Roy S. Herbst
- Yale Comprehensive Cancer Center, Yale School of Medicine, New Haven, Connecticut, United States of America
| | - Akiko Iwasaki
- Department of Immunobiology, Yale University School of Medicine, New Haven, Connecticut, United States of America
- Howard Hughes Medical Institute, Chevy Chase, Maryland, United States of America
| | - Albert I. Ko
- Department of Epidemiology of Microbial Diseases, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Bobak J. Mortazavi
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Department of Computer Science and Engineering, Texas A&M University, College Station, Texas, United States of America
- Center for Remote Health Technologies and Systems, Texas A&M University, College Station, Texas, United States of America
| | - Harlan M. Krumholz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
- Department of Internal Medicine, Section of Cardiovascular Medicine, Yale School of Medicine, New Haven, Connecticut, United States of America
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut, United States of America
| | - Wade L. Schulz
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, Connecticut, United States of America
- Department of Laboratory Medicine, Yale University School of Medicine, New Haven, Connecticut, United States of America
| |
Collapse
|