Ultra-fast remote up-titration of heart failure treatment: a safe, efficient and feasible protocol

Introduction

Heart failure (HF) is a common disease with a significant economic burden, mainly caused by HF hospitalisations and significant morbi-mortality. Nevertheless, HF patients are still undertreated due to a clinical inertia that needs to be reversed as soon as possible using new, safe and available methods. Remote up-titrating HF medication might be the solution to rapidly optimize HF treatment to maximal tolerated doses.

Purpose

Our objective was to describe the safety, efficacy and feasibility of an ultra-fast remote up-titration protocol of HF treatment.

Methods

Patients with a recent hospitalization due to a HF decompensation and left ventricular ejection fraction <50% were retrospectively included in our database. We collected clinical, biological and treatment data at enrollment and at the end of HF medication optimization. Our protocol consisted in remote consultation (via telephone or video-consultation) every 15 days with a 72h prior blood test. Blood pressure (BP), heart rate (HR) and weight were recorded either by tele-monitoring or self-measurement.

Results

We evaluated 96 patients, 25% female with a mean LVEF at 29%, main etiology of HF was ischemic (48%) and mean NTproBNP was 2384 pg/mL. Mean BP was 112/70 mmHg, HR was 73 bpm, glomerular filtration rate (GFR) 71 ml/min and potassium concentration was 4,4 mEq/L. Ninety four patients were initially treated with a beta blocker (BB), 29% of our cohort was treated either with an angiotensin-converting enzyme inhibitor (ACEI) or an angiotensin receptor blocker (ARB) and 59% was treated with angiotensin receptor neprilysin inhibitor (ARNI). A total of 72 patients were treated with a mineralocorticoid receptor antagonist (MRA) and 58 patients were also treated with an inhibitor of sodium-glucose transport protein 2 (SLGT2i), Figure 1. Median duration of tele-titration consultation was 42 days. We up-titrated BB in 50% of our patients, of which 10% were at maximum dose, making a total of 98% of our cohort under BB treatment. Sixty percent of patients under ACEI or ARB were switched to ARNI. Of the 82% of patients under ARNI, up to 50% achieved the maximal dose.

We introduced or up-titrated ARM in 41 patients, reaching the target dose in 37%. Dose variations and mean initial and final doses are shown in Figure 2.1 and 2.2

Minor adverse events that motivated a down-titration or a cessation of treatment were, hyperkalemia 5%, acute renal failure (ARF) 6%, hypotension 3% and bradycardia 2%. Non urgent hospitalization due to ARF with hyperkalemia or HF only occurred in 2 cases.

The limiting factors for not reaching the optimal targeted dose were low HR in 20%, hypotension in 11%, high concentration of potassium 10% and chronic renal failure in 9%.

Conclusion

Remote up-titration of HF medication is a promising tool in the fight against clinical inertia and a fast, feasible, safe (only 2% of major events) and efficient solution to our undertreated patients.

Funding Acknowledgement

Type of funding sources: None.

Benefits of interventional telemonitoring in patients with chronic heart failure

Background

The aim of this study was to assess the effect of interventional specialized Telemonitoring (ITM) compared to standard telemonitoring (STM) and standard of care (SC) on preventing all causes of death, cardiovascular mortality and unplanned hospitalization in heart failure (HF) patients.

Methods and results

414 HF-patients derived from two French cohorts (OSICAT and ETAPES) were included in this study, and subsequently randomized into three groups ITM-group (n=220), STM-group (n=99) and SC-group (n=95). The telemonitoring was performed by the specialized HF-cardiology staff at a university hospital. During the mean follow-up period of 344 days, there were significantly fewer primary endpoints like unplanned hospitalization (13.6% vs 34.3% vs 36.8%, p<0.05), all-cause of death (4.5% vs 20.2% vs 16.8%, p<0.05) and cardiovascular mortality (3.2% vs 15.2% vs 8.4%, p<0.05) in the ITM-group. The multivariate logistic regression revealed a significant negative association between the ITM and unplanned hospitalization (OR=0.293 95% CI [0.160–0.535], p<0.05) and all-cause of death (OR=0.243 95% CI [0.099–0.596], p=0.002), respectively. Kaplan Meier and log rank test showed significant difference in median event-free survival in favor of ITM-group.

Conclusions

Using ITM to follow-up HF-patients results in reducing the rate of unplanned hospitalization and all cause of death.

Funding Acknowledgement

Type of funding sources: None.

Myocardial bridging is significantly associated with myocardial infarction with non-obstructive coronary arteries

Background

Myocardial infarction with non-obstructive coronary arteries (MINOCA) is a common disorder characterized by the presence of clinical criteria for acute myocardial infarction in the absence of obstructive coronary artery disease on angiography. We aim to investigate the relationship between myocardial bridging (MB) and MINOCA.

Methods

An observational retrospective study was conducted on 15,036 patients who had been referred for coronary angiography and who fulfilled the Fourth Universal Definition of Myocardial Infarction. The study population was divided into STEMI and non-STEMI patients, from which we defined two main groups: the MINOCA group and the coronary artery disease (CAD) group. Statistical analyses were carried out by using SPSS, version 20.

Results

The prevalence of angiographic MB among the groups was significantly greater in the MINOCA group (2.9% vs. 0.8%). MINOCA accounted for 14.5% of spontaneous myocardial infarction, and the clinical presentation was frequently NSTEMI rather than STEMI (84.3% vs. 15.7%). After adjusting for confounders, multivariate analyses showed a positive association between MB and MINOCA [OR=3.28, 95% CI (2.34; 4.61) p<0.001]. Cardiovascular risk factors were less common in the MINOCA population, which was younger and more often female.

Conclusion

MB is a risk factor for MINOCA. Because MB prevalence differed significantly between the controls (CAD group) and cases (MINOCA group), which were positively associated to MB, it seems likely that MB would be a potential cause of MINOCA. Investigations for MB in MINOCA cases and especially in NSTEMI patients seem necessary.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): Rangueil Hospital

Long-term clinical outcome after percutaneous coronary interventions in the elderly: results for 512 consecutive patients

AIMS

Elderly patients are increasingly being referred for percutaneous coronary intervention (PCI), but there is a paucity of current data on the long-term outcome of elective PCI in elderly patients. We sought to define the risks facing elderly patients undergoing contemporary PCIs.

METHODS AND RESULTS

Retrospectively, in a single-centre registry, we studied the mortality and the outcome of 512 consecutive patients > 75 years old who underwent PCI, between January 1st 2000 and December 31st 2001. Clinical endpoints included in-hospital mortality; major adverse cardiovascular and cerebro-vascular events (MACCE) defined by the components of death, myocardial infarction, stroke, and repeat coronary revascularisation (target vessel revascularisation or not) by surgery or PCI, within the hospitalisation period and at long-term follow up. We compared 315 patients 75-79 years old (group I) with 197 patients > 80 years old (group II). In-hospital mortality and MACCE rates were not different between the two groups. Independent predictors of in-hospital major events found by multivariate analysis were: ST-segment elevation myocardial infarction or STEMI (Odds Ratio [OR]=2.58, 95% CI=1.15-5.78), left ventricular ejection fraction or LVEF <40% (OR=4.98, 95% CI=2.19-11.36) and prior coronary artery bypass grafting or CABG (OR=3.13, 95% CI=1.06-9.26). Mean long-term follow-up was 51.3 months. Death was significantly more frequent in the older group (42% vs 26%, p<0.0001). Independent predictors of long-term mortality found by multivariate analysis were: LVEF < 40% (Hazard Ratio=4.12, 95% CI=2.69-6.32), creatinine rate (HR=1.00, 95% CI=1.00-1.006) use cut-off see table and prior carotid surgery or stroke (HR=2.2, 95% CI=1.19-4.14).

CONCLUSIONS

Although age is not an independent predictive factor of morbidity or mortality, co-morbidities in the elderly strongly influence long-term clinical outcomes after PCI.

NMR and cDNA array analysis prior to heart failure reveals an increase of unsaturated lipids, a glutamine/glutamate ratio decrease and a specific transcriptome adaptation in obese rat heart

Obesity is a risk factor for heart failure through a set of hemodynamic and hormonal adaptations, but its contribution at the molecular level is not clearly known. Therefore, we investigated the kinetic cardiac transcriptome and metabolome in the Spontaneous Hypertensive Heart Failure (SHHF) rat. The SHHF rat is devoid of leptin signaling when homozygous for a mutation of the leptin receptor (ObR) gene. The ObR-/- SHHF rat is obese at 4 months of age and prone to heart failure after 14 months whereas its lean counterpart ObR-/+ is prone to heart failure after 16 months. We used a set of rat pangenomic high-density macroarrays to monitor left ventricle cardiac transcriptome regulation in 4- and 10-month-old, lean and obese animals. Comparative analysis of left ventricle of 4- and 10-month-old lean rat revealed 222 differentially expressed genes while 4- and 10-month-old obese rats showed 293 differentially expressed genes. (1)H NMR analysis of the metabolome of left ventricular extracts displayed a global decrease of metabolites, except for taurine, and lipid concentration. This may be attributed to gene expression regulation and likely increased extracellular mass. The glutamine to glutamate ratio was significantly lower in the obese group. The relative unsaturation of lipids increased in the obese heart; in particular, omega-3 lipid concentration was higher in the 10-month-old obese heart. Overall, several specific kinetic molecular patterns act as a prelude to heart failure in the leptin signaling deficient SHHF obese rat.

[Angiotensin receptor blockers and cardiac rhythm disorders]

Angiotension Receptor Blockers (ARB) are able to prevent the occurrence of atrial fibrillation (AF) through various mechanisms among them: neurhumoral antagonism and hemodynamic control. This occurs during arterial hypertension and chronic heart failure both diseases known to be associated with left atrial dysfunction. In the CHARM program, candesartan reduced by 20% the incidence of AF and thus also mortality and the incidence of hospitalisation for heart failure related to AF This beneficial effect is also observed with ACE inhibitors but is more important and potentated by ARB. In the Val-Heft study, valsartan on the top of standard treatment including ACE inhibitors, significantly lowered the cases of AF In hypertensive patients, ARB are more powerful than ACE inhibitors for the prevention of AF In the LIFE study, patients in the losartan arm had 33% less AF than patients from the other arm, despite treatment with atenolol and similar blood pressure reduction. Moreover ARB beside their specific effects are also able to increase efficiency of anti-arrhythmic agent; since after cardioversion patients treated with amiodarone plus irbesartan had a lower rate of recurrence of atrial fibrillation than patients treated with amiodarone alone. Finally ARB may reduce the risk of sudden death by ventricular arrhythmias in patients with diabetes mellitus.

[Cardiac asystole during acute anterior myocardial infarction: a consequence of endocardiac reflexes]

The authors report a case of paroxysmal, complete atrioventricular block during an anterior acute myocardial infarction, leading to asystolia. The different possible physiopathological mechanisms are discussed, suggesting a paroxysmal nodal conduction defect, secondary to transient parasympathetic stimulation, triggered by a Bezold-Jarish type of cardiac reflex. This reflex is frequently involved in various pathologic situations or diagnostic procedures, usual in cardiology. Although it is frequently observed in inferior myocardial infarction, it can occur during an anterior acute myocardial infarction.

[Myocardial infarction in a young female smoker taking oral contraception]

A 33 year old woman suffered a lateral myocardial infarction for the first time, and was treated by pre-hospital thrombolysis and secondary angioplasty on the diagonal artery. Fifteen days before the cardiac event she had undergone a left ovarian cyst excision and left salpingectomy for an ectopic pregnancy. She was a moderate smoker and had been taking a second-generation biphasic minidose oral contraceptive (ethinyl-estradiol 30-40mg and levonorgestrel 150-200 mg) for about ten years. Fifteen days before the myocardial infarction and due to the ectopic pregnancy she had changed to a combined monophasic minidose oral contraceptive pill containing ethinylestradiol (30 mg) and drospirenone (3 mg). The eventual outcome was favourable, with no complications. In this article we discuss the possible implications of the various factors (oral contraceptive, tobacco use, and surgical intervention) in this young woman with a myocardial infarction.

[Cardiac cellular therapy: from cells to the first clinical uses]

Despite the improvement in revascularisation techniques, coronary artery disease remains the principal aetiology of cardiac failure in developed countries. The therapeutic management of cardiac failure has been improved over recent years, yet cardiac failure is still associated with significant morbidity and mortality. As cardiac transplantation lacks donors, techniques that allow myocardial regeneration represent an attractive alternative. To date, several types of cells are under study and are suitable for implantation into infarcted myocardium (myoblasts, medullary stem cells...). Following good preclinical study results, the first human cell therapy trials, using the intramyocardial route, have begun, in the course of aorto-coronary bypass surgery in patients with chronic ischaemic cardiopathy and little altered left ventricular function, and then in those with ventricular dysfunction. Different modes of administration of these cell therapy products are under study and could be envisaged in clinical situations such as just after infarction in order to improve ventricular remodelling with an intracoronary injection technique. As for every new treatment, there are numerous problems to resolve, from understanding the relevant mechanisms of cellular transplantation, to the secondary effects that it could entail. Nevertheless, cardiac cellular transplantation is expanding rapidly and with the evolution of techniques it allows a glimpse of a new field of treatment for cardiac failure.

[Identification of viable myocardium in ischemic heart disease with severe left ventricular contractile dysfunction: comparison of myocardial scintigraphy with 99mTc-sestamabi and with 201-thallium]

The aim of this study was to compare quantitatively uptake of 99mTc-Sestamibi at rest and that of late redistribution of 201Tl in the same patients with severe ischaemic left ventricular dysfunction, and to correlate the uptake of the tracer to regional ventricular dysfunction studied by ECG grated 99Tc-Sestamini. A double isotope myocardial scintigraphy, 201 Thallium at rest/redistribution and 99Tc-Sestamibi at rest and on exercise, was performed in 28 patients with severe postinfarction ischaemic cardiomyopathy (EF= 29 +/- 4%). Quantitative analysis for each patient and each isotope were performed with respect to the number of hits expressed in percentage of the activity of a normal zone in 17 circumferential profiles distributed in 4 zones, that is to say in 476 segments. A score allowed counting of viable and non-viable segments and evaluation of contractile function of the 17 segments with respect to wall motion and systolic thickening. Total concordance of global uptake of the two isotopes was observed in 430 of the 476 segments (90.3%) (r= 0.814, p< 0.0001), but the 99mTc-Sestamibi uptake was less than 201 Th (71 +/- 23% vs 73 +/- 21%, p= 0.0001). With respect to left ventricular wall motion, uptake of 99mTc-Sestamibi was greater than that of 201Tl in normal or hypokinetic segments but less in akinetic and dyskinetic segments. The difference between the two isotopes was most marked in segments with very severe contractile dysfunction. The authors conclude that the uptake of 99mTc-Sestamibi is correlated with that of late distribution of 201Tl when left ventricular contraction is not too poor and should no longer be considered as only a marker of perfusion but can also be useful in the investigation of myocardial viability.

[Long-term follow-up after primary angioplasty: is stenting beneficial?]

BACKGROUND

Primary stenting leads to a better short-term outcome than balloon angioplasty for acute myocardial infarction in randomised trials. However few data are available about the long-term outcome of primary stenting in acute myocardial infarction (AMI).

OBJECTIVES

The aim of this study was to compare the three-year outcome after primary stenting versus balloon angioplasty in patients with acute myocardial infarction.

METHODS

We conducted a retrospective study including 157 patients with AMI in a single center. Patients underwent balloon angioplasty (N = 48) or primary stenting (N = 109) within six hours after the onset of chest pain. We looked at the outcome during three years focusing on global mortality, major adverse cardiac events (MACE), reinterventions and target vessel revascularization (TVR).

RESULTS

The two groups are similar for their baseline characteristics. No difference was noted for in-patient mortality in the balloon angioplasty group and the primary stenting group (2.1 vs 2.8%; P = ns). The three-year mortality was not significantly different in the two groups. Regarding MACE (27.8 vs 31.7; P = 0.95), reinterventions (20.4 vs 24.7%; P = 0.98) and TVR (18.6 vs 17.8%; P = 0.69), both groups were statistically not different.

CONCLUSION

In the long-term patients treated with stent placement have similar rates of MACE, reinterventions or TVR than patients undergoing balloon angioplasty. If few studies noted a benefit in short-term outcomes, primary stenting doesn't improve the prognosis of acute myocardial infarction on long-term follow-up, which is dependent on atherosclerosis.

[Therapeutic education for cardiac failure patients: the I-care programme]

Therapeutic education is becoming increasingly important in the management of chronic diseases including cardiac failure. The I-CARE programme consists of an evaluation of the role of therapeutic education in France, creating standardised tools and setting up training sessions for therapeutic education in the context of cardiac failure. Approximately two thirds of the French centres contacted perform therapeutic education with their available means. The lack of personnel, space, and training tools represent obstacles to the development of therapeutic education. The tools developed in the programme fall into 5 areas: diagnosis education, understanding the illness, diet, physical activity/daily life, and treatment. Training sessions were organised for the teams, consisting of at least one cardiologist and nurse. The I-CARE programme should allow the expansion of therapeutic education for cardiac failure and improve the multidisciplinary management of this disease which increasingly affects often elderly subjects.

[Obesity and cardiac failure]

Obesity alone is the cause of 11% of cases of cardiac failure in men and 14% of cases in women in the United States. The frequency of obesity continues to rise in our country, 41% of our compatriots being obese or overweight. It is expected that obesity will become an important cause of cardiac failure in the coming years. The Framingham study showed that, after correction for other risk factors, for every point increase in body mass index, the increase in risk of developing cardiac failure was 5% in men and 7% in women. There are three physiopathological mechanisms to explain the adverse effects of obesity on left ventricular function: an increase in ventricular preload secondary to increased plasma volume induced by the high fatty mass; an increase in left ventricular afterload due to the common association of hypertension generated by activation of the sympathetic nervous system by hyperinsulinism; and systolic and diastolic dysfunction due to changes in the myocardial genome and coronary artery disease induced by risk factors of atherosclerosis aggravated by obesity. The adipocyte also secretes a number of hormones which act directly or indirectly on the myocardium: angiotensin II, leptin, resistin, adrenomedulin, cytokines. These haemodynamic and hormonal changes profoundly modify the genetic expression of the myocardium in obesity, favourising hypertrophy of the myocyte and the development of interstitial fibrosis. Whether it be eccentric in the absence of hypertension or concentric when hypertension is associated with obesity, left ventricular hypertrophy, although normalising left ventricular wall stress, has adverse consequences causing abnormal relaxation and decreased left ventricular compliance. Therefore, in obese patients, two forms of cardiac failure may be observed. The more common is due to diastolic dysfunction, obesity being one of the principal causes of cardiac failure with preserved systolic function. Cardiac failure due to systolic dysfunction is less common and may be observed in cases with inappropriate left ventricular hypertrophy which does not normalise abnormal left ventricular wall stress leading to cardiomyopathy, and in cases with associated coronary artery disease. Whatever the underlying mechanism, the diagnosis of cardiac failure is made more difficult by obesity. From the prognostic point of view, in the global population of patients with cardiac failure, obesity improves survival because it counteracts the adverse effect of cachexia; however, obesity increases the risk of sudden death. In fact, obesity is associated with dynamic change in QT interval. In cases of cardiac failure secondary to obesity-related cardiomyopathy, loss of weight leads to an improved functional status and a reduction of left ventricular remodelling and an increase of the ejection fraction.

[Prognosis scores to help revascularization for ischemic heart failure]

AIMS

Patients suffering from coronary heart disease with ventricular systolic dysfunction present a bad prognosis and should be potentially revascularized. Up to now, surgery appeared to be the most feasible revascularization technique for such patients. Aims of this study were to assess the influence of different treatments (surgery, angioplasty or exclusively medical treatment) on clinical outcome and to establish a prognostic score practitioners to select the most appropriate therapy adapted to their patient profiles.

METHOD

From 1995 to 2000, 492 patients were included in this cohort: 365 in the angioplasty group, 96 in the surgical group and 31 in the medical group. Kaplan Meier curves were made with a multivariate analysis to determine the significant predictive factors of mortality and major adverse cardiac events.

RESULTS

After a mean follow-up of 32 +/- 19 months, there was no statistical difference in mortality rate between the groups. However, the survival rate without MACE is higher in the surgical group, intermediate in the angioplasty group and lower in the medical group. Using the significant predictive factors of MACE in multivariate analysis, a prognostic score has been established in order to discriminate three categories of severity. For each category, angioplasty was compared with surgery in terms of the event-free-survival rate. For the two extreme categories (severe and non-severe), both treatments were equal. For the intermediate category, surgery obtained greater results.

CONCLUSION

This prognostic score could help physicians in choosing the appropriate revascularization technique to treat patients with severe ischemic heart failure.

Pre-Hospital Fibrinolysis Followed by Angioplasty or Primary Angioplasty in Acute Myocardial Infarction: The Long-Term Clinical Outcome

BACKGROUND

Randomized trials comparing primary angioplasty and in-hospital fibrinolysis in acute myocardial infarction (AMI) have shown an advantage for primary angioplasty. The long-term follow-up of pre-hospital fibrinolysis followed by elective or rescue coronary angioplasty versus primary angioplasty is not well established after acute myocardial infarction. This study sought to assess the long-term clinical outcome of patients with AMI having either received pre-hospital fibrinolysis optimized by coronary angioplasty or primary angioplasty.

METHODS

We conducted a retrospective analysis involving 318 patients who either underwent primary angioplasty ( n = 157) or received pre-hospital fibrinolysis followed by an angioplasty (rescue or elective) ( n = 161) within 6 hours of the onset of chest pain.

RESULTS

The groups were similar regarding their baseline characteristics except for the ages. No difference was noted for in-hospital mortality (primary PTCA group: 2.48%, combined group: 2.54%; p = ns) with no increased risk of hemorrhage. The 3-year mortality was not significantly different in the two groups (9.7% vs. 4.9%; p = 0.15). Regarding major adverse cardiac events (29.5% vs. 37.5%; p = 0.23), reintervention (22.5% vs. 23.2%; p = 0.99) or target lesion revascularization (16.1% vs. 14.7%; p = 0.68), the groups were statistically similar.

CONCLUSION

These data from real-life practice emphasize the safety and similar benefits on the long-term clinical outcome of AMI patients having undergone either pre-hospital fibrinolysis followed by angioplasty or primary angioplasty.

[Holter EKG for the hypertensive heart disease]

During chronic mechanical overload induced by hypertension, left ventricular hypertrophy predisposes to atrial and ventricular arrhythmias. Atrial arrhythmias, mainly atrial fibrillation, decrease cardiac output and increase the risk of embolism whereas ventricular arrhythmias remain the major cause of sudden death. In hypertensive patients, Holter EKG recordings frequently detect atrial or ventricular premature beats and more rarely atrial or ventricular tachycardia. In these patients, the presence of non-sustained ventricular tachycardia is considered as an independent predictor of mortality. Moreover, this non invasive method through the assessment of heart rate variability allows the study of the autonomic control of the heart, known to modulate occurrence of arrhythmias.

[Revascularization of acute myocardial infarction. Doing better and doing more]

Effectiveness, safety, moderation, complementary, network, consensus, strategy and evaluation are the key words in the therapeutic management of acute myocardial infarction. They focus the development of pharmacological and interventional tools of recanalisation, and the decisions for those who use them. In order to cover a condition for which the patient and doctor alike choose neither time nor place, they lead to linking methods and disciplines together for a united approach. They take account of practice in order to adapt scientific data to the realities of exercise, to justify the given means, and to propose clear, realistic and useful management guidelines to first contact doctors. They deliver the best to the greatest number of patients.