The Heart Failure Optimization Study (HF-OPT): rationale and design

BACKGROUND

According to the current guidelines, implantable cardioverter-defibrillators (ICD) for primary prevention in patients with heart failure and reduced ejection fraction (HFrEF) should not be considered until optimal guideline-directed medical therapy (GDMT) has been achieved for a minimum of 3 months. Optimization of GDMT often needs time beyond 3 months after diagnosis. The aim of the Heart Failure Optimization Study (HF-OPT) is to evaluate the recovery of left ventricular function beyond 3 months after diagnosis of newly diagnosed HFrEF.

METHODS

The HF-OPT multicenter study is comprised of two non-randomized phases (registry and study). During the first 90 days a wearable cardioverter-defibrillator (WCD) is prescribed and patients are enrolled in an observational pre-study registry. Registry subjects meeting inclusion criteria for the study portion at day 90 have ongoing left ventricular ejection fraction (LVEF) reassessment at 90, 180 and 360 days after the index hospital discharge, regardless of continued WCD use. Approximately 600 subjects will be enrolled in the study portion. Of those, one-third are anticipated to start the study phase at day 90 with reduced LVEF. The primary objective of this study is to observe the rate of recovery of LVEF > 35% between 90 and 180 days, while key secondary endpoints include mortality and WCD recorded arrhythmias and shocks.

DISCUSSION

The HF-OPT study will provide important information on the rate of additional recovery of LVEF > 35%, between 90 and 180 days, in newly diagnosed HF with reduced LVEF patients being titrated with GDMT. The results of the study may impact indications for primary prophylactic ICD implantation.

Change in health-related quality of life among patients with a reduced ejection fraction initiating guideline-directed medical therapy

Background

Management of patients with heart failure (HF) should include patient reported outcomes (PROs). The Kansas City Cardiomyopathy Questionnaire is self-administered with subscales to evaluate HF symptom burden, physical limitations, social limitations (recreational participation), and quality of life (QoL). Change in PROs among newly diagnosed patients with HF and reduced ejection fraction (HFrEF) prescribed a wearable cardioverter defibrillator (WCD) and initiating guideline-directed medical therapy (GDMT) has not been assessed.

Purpose

Examine PROs over 180 days of receiving GDMT for newly diagnosed HFrEF.

Methods

Patients (n=93, 75.3% male) were enrolled ≤10 days post-hospitalization for new onset HF; all patients had an EF ≤35% and were prescribed a WCD. Health status, as measured by PRO was assessed at baseline, day 90, and day 180. Controlling for age and EF at baseline, changes in PROs over the 180-day study period were evaluated using repeated measures modeling. Pairwise comparisons with Bonferroni adjustments were used to compare adjacent timepoints. Higher scores reflect better health status.

Results

After controlling for age (mean 56±13.4) and baseline EF (mean 22±7.7) improvements in health status were observed. From baseline to day 90, physical limitation, symptom frequency, QoL, and the summary score all increased (Δ: 17.8, 23.7, 28.4, 23.7, respectively; all p's <0.05). From day 90 to day 180, only QoL continued to improve (Δ 7.5, p=0.001). Change in social limitations over time was not significant (p=0.42).

Conclusion

Patients report improved health status in the months following a new diagnosis of HFrEF when prescribed a WCD and GDMT.

Change in Quality of Life

Funding Acknowledgement

Type of funding source: None

Human Embryonic Stem Cell Therapy in Chronic Spinal Cord Injury: A Retrospective Study

Human embryonic stem cells (hESCs) have a role in treating neurological disorders. The efficacy and safety of hESC in treating spinal cord injury (SCI) was reported in our previous study. In the present study, we have evaluated the efficacy and safety of hESC therapy in 226 patients with SCI. In the first treatment phase (T1), 0.25 mL hESCs were administered intramuscularly twice daily, 1 mL every 10 days i.v., and 1-5 mL every 7 days. Of 153 patients in the American Spinal Injury Association (ASIA) scale A at the beginning of T1, a significant number of patients (n = 80; 52.3%) moved to lower scales at the end of T1 (p = 0.01). At the end of T2, of 32 patients in ASIA scale A, 12 patients (37.5%) moved to scale B (p = 0.01). Of 19 patients, 3 patients (37.5%) moved to scale B at the end of T3 (p = 0.02). No serious adverse events (AEs) were observed. hESC transplantation is safe and effective.

The clinical implications of first-pass metabolism: treatment strategies for the 1990s

The first-pass effect is real. It may pose obstacles to the treatment of disease, and strategies need to be developed to address the problem that first pass can cause. First we have to look at identifying the problem, and this symposium has helped to further emphasize that the problem exists and awareness is increasing. The first-pass effect has been a basic tenant of pharmacology but an area not receiving active research interest and one that is often overlooked in the clinical arena. Avoiding drug interactions is a consideration, and that is a major challenge to the field of clinical pharmacology. Clinicians need to be aware of the problem, aware of the danger areas with drugs, and first pass. Another alternative is to turn to chemical modification of a drug that avoids needing to take first pass into consideration.

Risk factors not addressed in antihypertensive therapy based solely on blood pressure control

There has been a considerable revolution in the field of hypertension therapy. We have gone through an era in which patients with severe hypertension and those with accelerated hypertension had a very short life expectancy. Currently blood pressure can be readily controlled with a marked improvement in longevity. We have gone from an era in which stroke was common due to hypertensive cardiovascular disease to an era in which patients are effectively treated and there has been a marked reduction in the incidence of stroke. The challenge is whether we can reduce the very high mortality due to coronary artery disease in patients with hypertension as we have done with stroke. New groups of drugs that may have a more favorable effect on metabolic and hemodynamic risk considerations have been developed over the last decade. These agents may reduce the risk for coronary heart disease to a greater extent than previously employed therapy. While there are no randomized placebo-controlled studies demonstration this, a theoretical basis does exist to give the physician reason to think about prioritizing therapies and tailoring them to the needs of the individual patient.