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Curtain JP, Talebi A, McIntosh A, McConnachie A, O'Donnell J, Welsh P, Osmanska J, Lee MMY, Sonecki P, Akl T, Seo J, Gopinathan V, Hurwitz J, Thiagarajan S, Pettit S, Kalra PR, Patel RK, Mark PB, Lang NN, McMurray JJV, Petrie MC, Gardner RS, Jhund PS. Measuring congestion with a non-invasive monitoring device in heart failure and haemodialysis: CONGEST-HF. Eur J Heart Fail 2024. [PMID: 38741283 DOI: 10.1002/ejhf.3290] [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: 04/12/2024] [Revised: 04/26/2024] [Accepted: 04/30/2024] [Indexed: 05/16/2024] Open
Abstract
AIMS We examined the effectiveness of a novel cardiopulmonary management wearable sensor (worn for less than 5 mins) at measuring congestion and correlated the device findings with established clinical measures of congestion. METHODS AND RESULTS We enrolled three cohorts of patients: (1) patients with heart failure (HF) receiving intravenous diuretics in hospital; (2) patients established on haemodialysis, and (3) HF patients undergoing right heart catheterization (RHC). The primary outcomes in the respective cohorts were a Spearman correlation between (1) change in weight and change in thoracic impedance (TI) (from enrolment, 24 h after admission to discharge) in patients hospitalized for HF; (2) lung ultrasound B-lines and volume removed during dialysis with device measured TI, and (3) pulmonary capillary wedge pressure (PCWP) and sub-acoustic diastolic, third heart sound (S3) in the patients undergoing RHC. A total of 66 patients were enrolled. In HF patients (n = 25), change in weight was correlated with both change in device TI (Spearman correlation [rsp] = -0.64, p = 0.002) and change in device S3 (rsp = -0.53, p = 0.014). In the haemodialysis cohort (n = 21), B-lines and TI were strongly correlated before (rsp = -0.71, p < 0.001) and after (rsp = -0.77, p < 0.001) dialysis. Volume of fluid removed by dialysis was correlated with change in device TI (rsp = 0.49, p = 0.024). In the RHC cohort (n = 20), PCWP measured at one time point and device S3 were not significantly correlated (rsp = 0.230, p = 0.204). There were no device-related adverse events. CONCLUSIONS A non-invasive device was able to detect changes in congestion in patients with HF receiving decongestion therapy and patients having fluid removed at haemodialysis. The cardiopulmonary management device, which measures multiple parameters, is a potentially useful tool to monitor patients with HF to prevent hospitalizations.
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Affiliation(s)
- James P Curtain
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- St James Hospital, Dublin, Ireland
| | - Atefeh Talebi
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Alasdair McIntosh
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Joanne O'Donnell
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow, UK
| | - Paul Welsh
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Joanna Osmanska
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Matthew M Y Lee
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Piotr Sonecki
- Department of Cardiology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Tony Akl
- Analog Devices Inc, Wilmington, MA, USA
| | | | | | | | | | | | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Rajan K Patel
- Glasgow Renal and Transplant Unit, Queen Elizabeth University Hospital, Glasgow, UK
| | - Patrick B Mark
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Ninian N Lang
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - John J V McMurray
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Roy S Gardner
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Clydebank, UK
| | - Pardeep S Jhund
- BHF Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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Packer M, Anker SD, Butler J, Cleland JGF, Kalra PR, Mentz RJ, Ponikowski P, Talha KM. Redefining Iron Deficiency in Patients With Chronic Heart Failure. Circulation 2024. [PMID: 38733252 DOI: 10.1161/circulationaha.124.068883] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024]
Affiliation(s)
- Milton Packer
- Baylor University Medical Center, Dallas, TX; Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor University Medical Center, Dallas, TX; University of Mississippi Medical Center, Jackson, MS
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK; Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, North Caroline and Duke Clinical Research Institute, Durham, NC
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland; Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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Packer M, Anker SD, Butler J, Cleland JGF, Kalra PR, Mentz RJ, Ponikowski P. Identification of three mechanistic pathways for iron-deficient heart failure. Eur Heart J 2024:ehae284. [PMID: 38733250 DOI: 10.1093/eurheartj/ehae284] [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: 11/13/2023] [Revised: 02/29/2024] [Accepted: 04/23/2024] [Indexed: 05/13/2024] Open
Abstract
Current understanding of iron-deficient heart failure is based on blood tests that are thought to reflect systemic iron stores, but the available evidence suggests greater complexity. The entry and egress of circulating iron is controlled by erythroblasts, which (in severe iron deficiency) will sacrifice erythropoiesis to supply iron to other organs, e.g. the heart. Marked hypoferraemia (typically with anaemia) can drive the depletion of cardiomyocyte iron, impairing contractile performance and explaining why a transferrin saturation < ≈15%-16% predicts the ability of intravenous iron to reduce the risk of major heart failure events in long-term trials (Type 1 iron-deficient heart failure). However, heart failure may be accompanied by intracellular iron depletion within skeletal muscle and cardiomyocytes, which is disproportionate to the findings of systemic iron biomarkers. Inflammation- and deconditioning-mediated skeletal muscle dysfunction-a primary cause of dyspnoea and exercise intolerance in patients with heart failure-is accompanied by intracellular skeletal myocyte iron depletion, which can be exacerbated by even mild hypoferraemia, explaining why symptoms and functional capacity improve following intravenous iron, regardless of baseline haemoglobin or changes in haemoglobin (Type 2 iron-deficient heart failure). Additionally, patients with advanced heart failure show myocardial iron depletion due to both diminished entry into and enhanced egress of iron from the myocardium; the changes in iron proteins in the cardiomyocytes of these patients are opposite to those expected from systemic iron deficiency. Nevertheless, iron supplementation can prevent ventricular remodelling and cardiomyopathy produced by experimental injury in the absence of systemic iron deficiency (Type 3 iron-deficient heart failure). These observations, taken collectively, support the possibility of three different mechanistic pathways for the development of iron-deficient heart failure: one that is driven through systemic iron depletion and impaired erythropoiesis and two that are characterized by disproportionate depletion of intracellular iron in skeletal and cardiac muscle. These mechanisms are not mutually exclusive, and all pathways may be operative at the same time or may occur sequentially in the same patients.
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Affiliation(s)
- Milton Packer
- Baylor Heart and Vascular Institute, Baylor University Medical Center, 621 North Hall Street, Dallas, TX 75226, USA
- Imperial College, London, UK
| | - Stefan D Anker
- Department of Cardiology of German Heart Center Charité, Institute of Health Center for Regenerative Therapies, German Centre for Cardiovascular Research, partner site Berlin, Charité Universitätsmedizin, Berlin, Germany
| | - Javed Butler
- Baylor Scott and White Research Institute, Baylor University Medical Center, Dallas, TX, USA
- University of Mississippi Medical Center, Jackson, MS, USA
| | - John G F Cleland
- British Heart Foundation Centre of Research Excellence, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- College of Medical, Veterinary & Life Sciences, University of Glasgow, Glasgow, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Robert J Mentz
- Division of Cardiology, Department of Medicine, Duke University School of Medicine, Durham, NC, USA
- Duke Clinical Research Institute, Durham, NC, USA
| | - Piotr Ponikowski
- Institute of Heart Diseases, Wroclaw Medical University, Wroclaw, Poland
- Institute of Heart Diseases, University Hospital, Wroclaw, Poland
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Ray R, Ford I, Cleland JGF, Graham F, Ahmed FZ, Al-Mohammad A, Cowburn PJ, Critoph C, Kalra PA, Lane RE, Ludman A, Pellicori P, Petrie MC, Robertson M, Seed A, Squire I, Kalra PR. The Impact of Ferric Derisomaltose on Cardiovascular and Noncardiovascular Events in Patients With Anemia, Iron Deficiency, and Heart Failure With Reduced Ejection Fraction. J Card Fail 2024; 30:682-690. [PMID: 37926238 PMCID: PMC11096866 DOI: 10.1016/j.cardfail.2023.10.006] [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: 08/10/2023] [Revised: 10/09/2023] [Accepted: 10/11/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND In some countries, intravenous ferric derisomaltose (FDI) is only licensed for treating iron deficiency with anemia. Accordingly, we investigated the effects of intravenous FDI in a subgroup of patients with anemia in the IRONMAN (Effectiveness of Intravenous (IV) Iron Treatment Versus Standard Care in Patients With Heart Failure and Iron Deficiency) trial. METHOD AND RESULTS IRONMAN enrolled patients with heart failure, a left ventricular ejection fraction of ≤45%, and iron deficiency (ferritin <100 µg/L or transferrin saturation of <20%), 771 (68%) of whom had anemia (hemoglobin <12 g/dL for women and <13 g/dL for men). Patients were randomized, open label, to FDI (n = 397) or usual care (n = 374) and followed for a median of 2.6 years. The primary end point, recurrent hospitalization for heart failure and cardiovascular death, occurred less frequently for those assigned to FDI (rate ratio 0.78, 95% confidence interval 0.61-1.01; P = .063). First event analysis for cardiovascular death or hospitalization for heart failure, less affected by the coronavirus disease 2019 pandemic, gave similar results (hazard ratio 0.77, 95% confidence interval 0.62-0.96; P = .022). Patients randomized to FDI reported a better Minnesota Living with Heart Failure quality of life, for overall (P = .013) and physical domain (P = .00093) scores at 4 months. CONCLUSIONS In patients with iron deficiency anemia and heart failure with reduced left ventricular ejection fraction, intravenous FDI improves quality of life and may decrease cardiovascular events.
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Affiliation(s)
- Robin Ray
- Department of Cardiology, St George's University Hospitals NHS Foundation Trust, London, UK; Molecular and Clinical Sciences Institute, St. George's University of London, United
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Fraser Graham
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Fozia Z Ahmed
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Abdallah Al-Mohammad
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Peter J Cowburn
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Chris Critoph
- Department of Cardiology, University Hospitals Dorset NHS Foundation Trust, Bournemouth, UK
| | - Philip A Kalra
- Department of Renal Medicine, Northern Care Alliance NHS Foundation Trust Salford Care Organisation, Salford, UK
| | - Rebecca E Lane
- Department of Cardiology, Royal Brompton and Harefield Hospitals, London, UK
| | - Andrew Ludman
- Department of Cardiology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | | | - Alison Seed
- Department of Cardiology, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Iain Squire
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK; Faculty of Science and Health, University of Portsmouth, Portsmouth, UK.
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Cleland JGF, Kalra PA, Pellicori P, Graham FJ, Foley PWX, Squire IB, Cowburn PJ, Seed A, Clark AL, Szwejkowski B, Banerjee P, Cooke J, Francis M, Clifford P, Wong A, Petrie C, McMurray JJV, Thomson EA, Wetherall K, Robertson M, Ford I, Kalra PR. Intravenous iron for heart failure, iron deficiency definitions, and clinical response: the IRONMAN trial. Eur Heart J 2024; 45:1410-1426. [PMID: 38446126 PMCID: PMC11032711 DOI: 10.1093/eurheartj/ehae086] [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: 08/18/2023] [Revised: 11/26/2023] [Accepted: 01/30/2024] [Indexed: 03/07/2024] Open
Abstract
BACKGROUND AND AIMS What is the relationship between blood tests for iron deficiency, including anaemia, and the response to intravenous iron in patients with heart failure? METHODS In the IRONMAN trial, 1137 patients with heart failure, ejection fraction ≤ 45%, and either serum ferritin < 100 µg/L or transferrin saturation (TSAT) < 20% were randomized to intravenous ferric derisomaltose (FDI) or usual care. Relationships were investigated between baseline anaemia severity, ferritin and TSAT, to changes in haemoglobin from baseline to 4 months, Minnesota Living with Heart Failure (MLwHF) score and 6-minute walk distance achieved at 4 months, and clinical events, including heart failure hospitalization (recurrent) or cardiovascular death. RESULTS The rise in haemoglobin after administering FDI, adjusted for usual care, was greater for lower baseline TSAT (Pinteraction < .0001) and ferritin (Pinteraction = .028) and more severe anaemia (Pinteraction = .014). MLwHF scores at 4 months were somewhat lower (better) with FDI for more anaemic patients (overall Pinteraction = .14; physical Pinteraction = .085; emotional Pinteraction = .043) but were not related to baseline TSAT or ferritin. Blood tests did not predict difference in achieved walking distance for those randomized to FDI compared to control. The absence of anaemia or a TSAT ≥ 20% was associated with lower event rates and little evidence of benefit from FDI. More severe anaemia or TSAT < 20%, especially when ferritin was ≥100 µg/L, was associated with higher event rates and greater absolute reductions in events with FDI, albeit not statistically significant. CONCLUSIONS This hypothesis-generating analysis suggests that anaemia or TSAT < 20% with ferritin > 100 µg/L might identify patients with heart failure who obtain greater benefit from intravenous iron. This interpretation requires confirmation.
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Affiliation(s)
- John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow, Lanarkshire, G12 8TA, UK
| | - Philip A Kalra
- Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
- The University of Manchester, Manchester, UK
| | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow, Lanarkshire, G12 8TA, UK
| | - Fraser J Graham
- School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow, Lanarkshire, G12 8TA, UK
| | - Paul W X Foley
- Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Peter J Cowburn
- University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Alison Seed
- Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | | | | | | | - Justin Cooke
- Chesterfield Royal Hospital NHS Foundation Trust, Chesterfield, UK
| | | | | | - Aaron Wong
- Princess of Wales Hospital, Bridgend, UK
| | - Colin Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow, Lanarkshire, G12 8TA, UK
- University Hospital Monklands, Airdrie, UK
| | - John J V McMurray
- School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow, Lanarkshire, G12 8TA, UK
| | | | - Kirsty Wetherall
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Michele Robertson
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
- College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK
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6
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Osmanska J, Brooksbank K, Docherty KF, Robertson S, Wetherall K, McConnachie A, Hu J, Gardner RS, Clark AL, Squire IB, Kalra PR, Jhund PS, Muntendam P, McMurray JJV, Petrie MC, Campbell RT. A novel, small-volume subcutaneous furosemide formulation delivered by an abdominal patch infusor device in patients with heart failure: results of two phase I studies. Eur Heart J Cardiovasc Pharmacother 2024; 10:35-44. [PMID: 37804170 PMCID: PMC10766906 DOI: 10.1093/ehjcvp/pvad073] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/22/2023] [Revised: 09/01/2023] [Accepted: 10/04/2023] [Indexed: 10/09/2023]
Abstract
AIMS Subcutaneous (SC) furosemide has potential advantages over intravenous (IV) furosemide by enabling self-administration or administration by a lay caregiver, such as facilitating early discharge, preventing hospitalizations, and in palliative care. A high-concentration, pH-neutral furosemide formulation has been developed for SC administration via a small patch infusor pump. We aimed to compare the bioavailability, pharmacokinetic (PK), and pharmacodynamic (PD) profiles of a new SC furosemide formulation with conventional IV furosemide and describe the first use of a bespoke mini-pump to administer this formulation. METHODS AND RESULTS A novel pH-neutral formulation of SC furosemide containing 80 mg furosemide in ∼2.7 mL (infused over 5 h) was investigated. The first study was a PK/PD study of SC furosemide compared with 80 mg IV furosemide administered as a bolus in ambulatory patients with heart failure (HF). The primary outcome was absolute bioavailability of SC compared with IV furosemide. The second study investigated the same SC furosemide preparation delivered by a patch infusor in patients hospitalized with HF. Primary outcome measures were treatment-emergent adverse events, infusion site pain, device performance, and PK measurements.The absolute bioavailability of SC furosemide in comparison to IV furosemide was 112%, resulting in equivalent diuresis and natriuresis. When SC furosemide was administered via the patch pump, there were no treatment-emergent adverse events and 95% of participants reported no/minor discomfort at the infusion site. CONCLUSION The novel preparation of SC furosemide had similar bioavailability to IV furosemide. Administration via a patch pump was feasible and well tolerated.
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Affiliation(s)
- Joanna Osmanska
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
- Department of Cardiology, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - Katriona Brooksbank
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - Kieran F Docherty
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
- Department of Cardiology, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
| | - Stacy Robertson
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - Kirsty Wetherall
- Robertson Centre for Biostatistics, University of Glasgow G12 8TB, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, University of Glasgow G12 8TB, UK
| | | | - Roy S Gardner
- Scottish National Advanced Heart Failure Service, Golden Jubilee National Hospital, Glasgow G81 4DY, UK
| | - Andrew L Clark
- Department of Academic Cardiology, Hull University Teaching Hospital NHS Trust, Hull GU16 5JQ, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, and NIHR Cardiovascular Biomedical Research Centre, Glenfield Hospital, Leicester LE3 9QP, UK
| | - Paul R Kalra
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3LY, UK
| | - Pardeep S Jhund
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | | | - John J V McMurray
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
- Department of Cardiology, Glasgow Royal Infirmary, Glasgow G40SF, UK
| | - Ross T Campbell
- School of Cardiovascular and Metabolic Health, British Heart Foundation Glasgow Cardiovascular Research Centre, University of Glasgow, Glasgow G12 8TA, UK
- Department of Cardiology, Queen Elizabeth University Hospital, Glasgow G51 4TF, UK
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7
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Wong KYK, Hughes DA, Debski M, Latt N, Assaf O, Abdelrahman A, Taylor R, Allgar V, McNeill L, Howard S, Wong SYS, Jones R, Cassidy CJ, Seed A, Galasko G, Clark A, Wilson D, Davis GK, Montasem A, Lang CC, Kalra PR, Campbell R, Lip GYH, Cleland JGF. Effectiveness of out-patient based acute heart failure care: a pilot randomised controlled trial. Acta Cardiol 2023; 78:828-837. [PMID: 37694719 DOI: 10.1080/00015385.2023.2197834] [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: 05/08/2021] [Revised: 03/21/2023] [Accepted: 03/25/2023] [Indexed: 09/12/2023]
Abstract
OBJECTIVES Acute heart failure (AHF) hospitalisation is associated with 10% mortality. Outpatient based management (OPM) of AHF appeared effective in observational studies. We conducted a pilot randomised controlled trial (RCT) comparing OPM with standard inpatient care (IPM). METHODS We randomised patients with AHF, considered to need IV diuretic treatment for ≥2 days, to IPM or OPM. We recorded all-cause mortality, and the number of days alive and out-of-hospital (DAOH). Quality of life, mental well-being and Hope scores were assessed. Mean NHS cost savings and 95% central range (CR) were calculated from bootstrap analysis. Follow-up: 60 days. RESULTS Eleven patients were randomised to IPM and 13 to OPM. There was no statistically significant difference in all-cause mortality during the index episode (1/11 vs 0/13) and up to 60 days follow-up (2/11 vs 2/13) [p = .86]. The OPM group accrued more DAOH {47 [36,51] vs 59 [41,60], p = .13}. Two patients randomised to IPM (vs 6 OPM) were readmitted [p = .31]. Hope scores increased more with OPM within 30 days but dropped to lower levels than IPM by 60 days. More out-patients had increased total well-being scores by 60 days (p = .04). OPM was associated with mean cost savings of £2658 (95% CR 460-4857) per patient. CONCLUSIONS Patients with acute HF randomised to OPM accrued more days alive out of hospital (albeit not statistically significantly in this small pilot study). OPM is favoured by patients and carers and is associated with improved mental well-being and cost savings.
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Affiliation(s)
- K Y K Wong
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
- Liverpool Centre for Cardiovascular Science, Liverpool, UK
| | - D A Hughes
- Centre for Health Economics and Medicines Evaluation, Bangor University, Bangor, UK
| | - M Debski
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - N Latt
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - O Assaf
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - A Abdelrahman
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - R Taylor
- Research and Development Department, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - V Allgar
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - L McNeill
- Accountant, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - S Howard
- Financial Information And Costing Manager, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - S Y S Wong
- Department of Care of the Older Person, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - R Jones
- Public Involvement Group, Research and Development Department, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - C J Cassidy
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - A Seed
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - G Galasko
- Department of Cardiology, Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - A Clark
- Peninsula Clinical Trials Unit, University of Plymouth, Plymouth, UK
| | - D Wilson
- Department of Cardiology, Worcestershire Royal Hospital (Worcestershire Acute Hospital NHS Trust), Worcester, UK
| | - G K Davis
- Cardiorespiratory Research Centre, Edge Hill University Medical School, Ormskirk, UK
| | - A Montasem
- Institute of Life Course and Medical Sciences, School of Dental Sciences, Liverpool University Dental Hospital, University of Liverpool, Liverpool, UK
| | - C C Lang
- Department of Cardiology, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - P R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - R Campbell
- Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - G Y H Lip
- Liverpool Centre for Cardiovascular Science at University of Liverpool, Liverpool John Moores University and Liverpool Heart & Chest Hospital, Liverpool, UK
- Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - J G F Cleland
- Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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8
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Yeoh SE, Osmanska J, Petrie MC, Brooksbank KJM, Clark AL, Docherty KF, Foley PWX, Guha K, Halliday CA, Jhund PS, Kalra PR, McKinley G, Lang NN, Lee MMY, McConnachie A, McDermott JJ, Platz E, Sartipy P, Seed A, Stanley B, Weir RAP, Welsh P, McMurray JJV, Campbell RT. Dapagliflozin vs. metolazone in heart failure resistant to loop diuretics. Eur Heart J 2023; 44:2966-2977. [PMID: 37210742 PMCID: PMC10424881 DOI: 10.1093/eurheartj/ehad341] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [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: 04/14/2023] [Revised: 05/11/2023] [Accepted: 05/16/2023] [Indexed: 05/23/2023] Open
Abstract
BACKGROUND AND AIMS To examine the decongestive effect of the sodium-glucose cotransporter 2 inhibitor dapagliflozin compared to the thiazide-like diuretic metolazone in patients hospitalized for heart failure and resistant to treatment with intravenous furosemide. METHODS AND RESULTS A multi-centre, open-label, randomized, and active-comparator trial. Patients were randomized to dapagliflozin 10 mg once daily or metolazone 5-10 mg once daily for a 3-day treatment period, with follow-up for primary and secondary endpoints until day 5 (96 h). The primary endpoint was a diuretic effect, assessed by change in weight (kg). Secondary endpoints included a change in pulmonary congestion (lung ultrasound), loop diuretic efficiency (weight change per 40 mg of furosemide), and a volume assessment score. 61 patients were randomized. The mean (±standard deviation) cumulative dose of furosemide at 96 h was 977 (±492) mg in the dapagliflozin group and 704 (±428) mg in patients assigned to metolazone. The mean (±standard deviation) decrease in weight at 96 h was 3.0 (2.5) kg with dapagliflozin compared to 3.6 (2.0) kg with metolazone [mean difference 0.65, 95% confidence interval (CI) -0.12,1.41 kg; P = 0.11]. Loop diuretic efficiency was less with dapagliflozin than with metolazone [mean 0.15 (0.12) vs. 0.25 (0.19); difference -0.08, 95% CI -0.17,0.01 kg; P = 0.10]. Changes in pulmonary congestion and volume assessment score were similar between treatments. Decreases in plasma sodium and potassium and increases in urea and creatinine were smaller with dapagliflozin than with metolazone. Serious adverse events were similar between treatments. CONCLUSION In patients with heart failure and loop diuretic resistance, dapagliflozin was not more effective at relieving congestion than metolazone. Patients assigned to dapagliflozin received a larger cumulative dose of furosemide but experienced less biochemical upset than those assigned to metolazone. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT04860011.
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Affiliation(s)
- Su Ern Yeoh
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Joanna Osmanska
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Mark C Petrie
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Katriona J M Brooksbank
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Andrew L Clark
- Department of Cardiology, Hull University Teaching Hospitals NHS Trust, Castle Hill Hospital, Cottingham HU3 2JZ, UK
| | - Kieran F Docherty
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Paul W X Foley
- Department of Cardiology, The Great Western Hospital, Swindon SN3 6BB, UK
| | - Kaushik Guha
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3LY, UK
| | - Crawford A Halliday
- Department of Cardiology, Royal Alexandria Hospital, NHS Greater Glasgow and Clyde, Paisley, UK
| | - Pardeep S Jhund
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth PO6 3LY, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth PO1 2DT, UK
| | - Gemma McKinley
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow G12 8TB, UK
| | - Ninian N Lang
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Matthew M Y Lee
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Alex McConnachie
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow G12 8TB, UK
| | - James J McDermott
- Biopharmaceuticals, Medical Affairs, AstraZeneca, Wilmington, DE 19803, USA
| | - Elke Platz
- Cardiovascular Division, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Peter Sartipy
- Cardiovascular, Renal and Metabolism, AstraZeneca, BioPharmaceuticals R&D, Gothenburg 431 83, Sweden
| | - Alison Seed
- Lancashire Cardiac Centre, Blackpool Teaching Hospitals NHS Trust, Blackpool FY3 8NP, UK
| | - Bethany Stanley
- Robertson Centre for Biostatistics, School of Health and Wellbeing, University of Glasgow, Glasgow G12 8TB, UK
| | - Robin A P Weir
- Cardiology Department, University Hospital Hairmyres, Lanarkshire G75 8RG, UK
| | - Paul Welsh
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - John J V McMurray
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
| | - Ross T Campbell
- BHF Glasgow Cardiovascular Research Centre, School of Cardiovascular and Metabolic Health, University of Glasgow, 126 University Place, Glasgow G12 8TA, UK
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9
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Ford I, Kalra PR. Unanswered questions from the IRONMAN trial - Authors' reply. Lancet 2023; 401:1495-1496. [PMID: 37149301 DOI: 10.1016/s0140-6736(23)00448-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 02/27/2023] [Indexed: 05/08/2023]
Affiliation(s)
- Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ, UK.
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow G12 8QQ, UK; Faculty of Science and Health, University of Portsmouth, Portsmouth, UK; Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK; Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
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10
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Graham FJ, Pellicori P, Kalra PR, Ford I, Bruzzese D, Cleland JG. Intravenous iron in patients with heart failure and iron deficiency: an updated meta-analysis. Eur J Heart Fail 2023; 25:528-537. [PMID: 36823953 PMCID: PMC10946839 DOI: 10.1002/ejhf.2810] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [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: 11/19/2022] [Revised: 02/04/2023] [Accepted: 02/22/2023] [Indexed: 02/25/2023] Open
Abstract
AIMS For patients with heart failure (HF) and iron deficiency (ID), randomized trials suggest that intravenous (IV) iron reduces hospitalizations for heart failure (HHF), but uncertainty exists about the effects in subgroups and the impact on mortality. We conducted a meta-analysis of randomized trials investigating the effect of IV iron on clinical outcomes in patients with HF. METHODS AND RESULTS We identified randomized trials published between 1 January 2000 and 5 November 2022 investigating the effect of IV iron versus standard care/placebo in patients with HF and ID in any clinical setting, regardless of HF phenotype. Trials of oral iron or not in English were not included. The main outcomes of interest were a composite of HHF and cardiovascular death (CVD), on HHF alone and on cardiovascular and all-cause mortality. Ten trials were identified with 3373 participants, of whom 1759 were assigned to IV iron. IV iron reduced the composite of recurrent HHF and CVD (rate ratio 0.75, 95% confidence interval [CI] 0.61-0.93; p < 0.01) and first HHF or CVD (odds ratio [OR] 0.72, 95% CI 0.53-0.99; p = 0.04). Effects on cardiovascular (OR 0.86, 95% CI 0.70-1.05; p = 0.14) and all-cause mortality (OR 0.93, 95% CI 0.78-1.12; p = 0.47) were inconclusive. Results were similar in analyses confined to the first year of follow-up, which was less disrupted by the COVID-19 pandemic. Subgroup analyses found little evidence of heterogeneity for the effect on the primary endpoint, although patients with transferrin saturation <20% (OR 0.67, 95% CI 0.49-0.92) may have benefited more than those with values ≥20% (OR 0.99, 95% CI 0.74-1.30) (heterogeneity p = 0.07). CONCLUSION In patients with HF and ID, this meta-analysis suggests that IV iron reduces the risk of HHF but whether this is associated with a reduction in cardiovascular or all-cause mortality remains inconclusive.
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Affiliation(s)
- Fraser J. Graham
- Robertson Centre for BiostatisticsUniversity of GlasgowGlasgowUK
| | | | - Paul R. Kalra
- Department of CardiologyPortsmouth Hospitals University NHS TrustPortsmouthUK
- College of Medical, Veterinary & Life SciencesUniversity of GlasgowGlasgowUK
- Faculty of Science and HealthUniversity of PortsmouthPortsmouthUK
| | - Ian Ford
- Robertson Centre for BiostatisticsUniversity of GlasgowGlasgowUK
| | - Dario Bruzzese
- Department of Public HealthUniversity of Naples Federico IINaplesItaly
| | - John G.F. Cleland
- School of Cardiovascular and Metabolic HealthUniversity of GlasgowGlasgowUK
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11
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Kalra PR, Cleland JGF, Petrie MC, Thomson EA, Kalra PA, Squire IB, Ahmed FZ, Al-Mohammad A, Cowburn PJ, Foley PWX, Graham FJ, Japp AG, Lane RE, Lang NN, Ludman AJ, Macdougall IC, Pellicori P, Ray R, Robertson M, Seed A, Ford I. Intravenous ferric derisomaltose in patients with heart failure and iron deficiency in the UK (IRONMAN): an investigator-initiated, prospective, randomised, open-label, blinded-endpoint trial. Lancet 2022; 400:2199-2209. [PMID: 36347265 DOI: 10.1016/s0140-6736(22)02083-9] [Citation(s) in RCA: 88] [Impact Index Per Article: 44.0] [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: 10/09/2022] [Revised: 10/16/2022] [Accepted: 10/17/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND For patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric carboxymaltose administration improves quality of life and exercise capacity in the short-term and reduces hospital admissions for heart failure up to 1 year. We aimed to evaluate the longer-term effects of intravenous ferric derisomaltose on cardiovascular events in patients with heart failure. METHODS IRONMAN was a prospective, randomised, open-label, blinded-endpoint trial done at 70 hospitals in the UK. Patients aged 18 years or older with heart failure (left ventricular ejection fraction ≤45%) and transferrin saturation less than 20% or serum ferritin less than 100 μg/L were eligible. Participants were randomly assigned (1:1) using a web-based system to intravenous ferric derisomaltose or usual care, stratified by recruitment context and trial site. The trial was open label, with masked adjudication of the outcomes. Intravenous ferric derisomaltose dose was determined by patient bodyweight and haemoglobin concentration. The primary outcome was recurrent hospital admissions for heart failure and cardiovascular death, assessed in all validly randomly assigned patients. Safety was assessed in all patients assigned to ferric derisomaltose who received at least one infusion and all patients assigned to usual care. A COVID-19 sensitivity analysis censoring follow-up on Sept 30, 2020, was prespecified. IRONMAN is registered with ClinicalTrials.gov, NCT02642562. FINDINGS Between Aug 25, 2016, and Oct 15, 2021, 1869 patients were screened for eligibility, of whom 1137 were randomly assigned to receive intravenous ferric derisomaltose (n=569) or usual care (n=568). Median follow-up was 2·7 years (IQR 1·8-3·6). 336 primary endpoints (22·4 per 100 patient-years) occurred in the ferric derisomaltose group and 411 (27·5 per 100 patient-years) occurred in the usual care group (rate ratio [RR] 0·82 [95% CI 0·66 to 1·02]; p=0·070). In the COVID-19 analysis, 210 primary endpoints (22·3 per 100 patient-years) occurred in the ferric derisomaltose group compared with 280 (29·3 per 100 patient-years) in the usual care group (RR 0·76 [95% CI 0·58 to 1·00]; p=0·047). No between-group differences in deaths or hospitalisations due to infections were observed. Fewer patients in the ferric derisomaltose group had cardiac serious adverse events (200 [36%]) than in the usual care group (243 [43%]; difference -7·00% [95% CI -12·69 to -1·32]; p=0·016). INTERPRETATION For a broad range of patients with heart failure, reduced left ventricular ejection fraction and iron deficiency, intravenous ferric derisomaltose administration was associated with a lower risk of hospital admissions for heart failure and cardiovascular death, further supporting the benefit of iron repletion in this population. FUNDING British Heart Foundation and Pharmacosmos.
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Affiliation(s)
- Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK; College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK; Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | | | - Philip A Kalra
- Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK; Faculty of Biology, Medicine and Health, The University of Manchester, Manchester, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Fozia Z Ahmed
- Department of Cardiology, Manchester University NHS Foundation Trust, Manchester, UK
| | - Abdallah Al-Mohammad
- Department of Cardiology, Sheffield Teaching Hospitals NHS Foundation Trust, Sheffield, UK; Department of Infection, Immunity and Cardiovascular Disease, The University of Sheffield, Sheffield, UK
| | - Peter J Cowburn
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul W X Foley
- Wiltshire Cardiac Centre, Great Western Hospitals NHS Foundation Trust, Swindon, UK
| | - Fraser J Graham
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Alan G Japp
- Edinburgh Heart Centre, Royal Infirmary of Edinburgh, Edinburgh, UK
| | - Rebecca E Lane
- Department of Cardiology, Royal Brompton and Harefield Hospitals, London, UK
| | - Ninian N Lang
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Andrew J Ludman
- Department of Cardiology, Royal Devon University Healthcare NHS Foundation Trust, Exeter, UK
| | | | - Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Robin Ray
- Cardiology Department, St George's University Hospitals NHS Foundation Trust, London, UK
| | - Michele Robertson
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Alison Seed
- Department of Cardiology, Blackpool Teaching Hospitals NHS Foundation Trust, Blackpool, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK.
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12
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Pellicori P, Kalra PR, Clark AL, Friday JM, Cleland JGF. Chronic kidney disease (CKD) and CKD-ism in heart failure - what a mess! Eur J Heart Fail 2022; 24:2196-2198. [PMID: 36130835 DOI: 10.1002/ejhf.2696] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 09/18/2022] [Indexed: 01/18/2023] Open
Affiliation(s)
- Pierpaolo Pellicori
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Andrew L Clark
- Department of Cardiology, Hull University Hospitals Trust, Castle Hill Hospital, Kingston-Upon-Hull, UK
| | - Jocelyn M Friday
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - John G F Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
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13
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Kalra PR, Cleland JG, Petrie MC, Ahmed FZ, Foley PW, Kalra PA, Lang NN, Lane RE, Macdougall IC, Pellicori P, Pope MTB, Robertson M, Squire IB, Thomson EA, Ford I. Rationale and design of a randomised trial of intravenous iron in patients with heart failure. Heart 2022; 108:1979-1985. [PMID: 35948408 DOI: 10.1136/heartjnl-2022-321304] [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: 04/25/2022] [Accepted: 07/12/2022] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES For patients with a reduced left ventricular ejection fraction (LVEF) heart failure with reduced ejection fraction (HFrEF) and iron deficiency, administration of intravenous iron improves symptoms, exercise capacity and may in the following 12 months, reduce hospitalisations for heart failure. The Effectiveness of Intravenous iron treatment versus standard care in patients with heart failure and iron deficiency (IRONMAN) trial evaluated whether the benefits of intravenous iron persist in the longer term and impact on morbidity and mortality. METHODS IRONMAN is a prospective, randomised, open-label, blinded endpoint (PROBE) event-driven trial. Patients aged ≥18 years with HFrEF (LVEF ≤45%) and evidence of iron deficiency (ferritin <100 µg/L and/or TSAT <20%) were enrolled if they had either a current or recent hospitalisation for heart failure or elevated plasma concentrations of a natriuretic peptide. Participants were randomised to receive, or not to receive, intravenous ferric derisomaltose in addition to guideline-recommended therapy for HFrEF. Every 4 months, intravenous iron was administered if either ferritin was <100 µg/L or, provided ferritin was ≤400 µg/L, TSAT was <25%. The primary endpoint is a composite of total hospitalisations for heart failure and cardiovascular death. Hospitalisation and deaths due to infection are safety endpoints. RESULTS Trial recruitment was completed across 70 UK hospital sites in October 2021. Participants were followed until the end of March 2022. We plan to report the results by November 2022. CONCLUSIONS IRONMAN will determine whether repeated doses of intravenous ferric derisomaltose are beneficial and safe for the long-term treatment of a broad range of patients with HFrEF and iron deficiency. TRIAL REGISTRATION NUMBER NCT02642562.
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Affiliation(s)
- Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.,School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - John Gf Cleland
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Mark C Petrie
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK.,Golden Jubilee National Hospital, Clydebank, UK
| | - Fozia Z Ahmed
- Division of Cardiovascular Sciences, The University of Manchester Faculty of Biology Medicine and Health, Manchester, UK
| | | | - Philip A Kalra
- Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Ninian N Lang
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Rebecca E Lane
- Part of Guy's and St Thomas' NHS Foundation Trust, Royal Brompton and Harefield Hospitals, London, UK
| | | | | | - Michael T B Pope
- Department of Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Michele Robertson
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Iain B Squire
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre Cardiovascular Diseases, Leicester, UK
| | - Elizabeth A Thomson
- School of Cardiovascular and Metabolic Health, University of Glasgow, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
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14
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Austin RC, Schoonhoven L, Richardson A, Kalra PR, May CR. Qualitative interviews results from heart failure survey respondents on the interaction between symptoms and burden of self-care work. J Clin Nurs 2022. [PMID: 35945903 DOI: 10.1111/jocn.16484] [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: 04/20/2022] [Revised: 07/23/2022] [Accepted: 07/28/2022] [Indexed: 11/28/2022]
Abstract
AIMS AND OBJECTIVES Following a cross-sectional survey, a sub-sample of participants was interviewed to explore the interaction between symptoms and burden of treatment. BACKGROUND Burden of treatment considers both the work associated with illness and treatment, including self-care work, as well as the individuals' capabilities and resources to engage in that work. The recent survey revealed the existence of a complex interaction. DESIGN Qualitative abductive analysis of semi-structured interviews. METHODS Adults with heart failure who participated in the survey were purposely sampled and invited to participate in semi-structured interviews. Location and mode of interview varied by participant choice. Excerpts from the verbatim transcripts were assessed for interactions between symptoms and burden of treatment, and when identified these were characterised and explained. We followed COREQ checklist for reporting. The patient research ambassador group was involved from research design to dissemination. RESULTS Participants (n = 32) consistently discussed how symptoms altered their capability to engage in self-care work. As symptom intensity increased the difficultly of their self-care work increased. A number of intervening factors appeared to influence the relationship between symptoms and burden of treatment. Intervening factors included illness pathology, illness identity, the value of the tasks attempted and available support structures. These factors may change how symptoms and burden of treatment are perceived; a model was constructed to explain and summarise these interactions. CONCLUSIONS The interaction between symptoms and burden of treatment is complex. Intervening factors-illness identity and pathology, task value and performance, and available support structures-appear to exert a strong influence on the interaction between symptoms and burden of treatment. RELEVANCE TO CLINICAL PRACTICE These intervening factors present clinicians and researchers with opportunities to develop interventions that might reduce burden of treatment and improve symptoms and quality of life. CLINICAL TRIAL REGISTRATION SYMPACT was registered with ISRCTN registry: ISRCTN11011943.
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Affiliation(s)
- Rosalynn C Austin
- Department of Cardiology, Portsmouth Hospitals University NHS Trust (PHU), Portsmouth, UK.,School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) Wessex, Southampton, UK
| | - Lisette Schoonhoven
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Alison Richardson
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) Wessex, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust (PHU), Portsmouth, UK.,College of Medical, Veterinary and Life Sciences, Institute of Health and Wellbeing, University of Glasgow, Glasgow, UK.,Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Carl R May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,National Institute for Health Research (NIHR), Applied Research Collaboration (ARC) North Thames, London, UK
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15
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Austin RC, Schoonhoven L, Koutra V, Richardson A, Kalra PR, May CR. SYMptoms in chronic heart failure imPACT on burden of treatment (SYMPACT): a cross-sectional survey. ESC Heart Fail 2022; 9:2279-2290. [PMID: 35451208 PMCID: PMC9288776 DOI: 10.1002/ehf2.13904] [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] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 01/19/2022] [Accepted: 03/11/2022] [Indexed: 12/11/2022] Open
Abstract
Aims This study aimed to describe patient‐reported symptoms and burden of treatment (BoT) experienced by patients with chronic heart failure (CHF). BoT describes the illness workload, individual capacity to perform that work, and resultant impact on the individual. Overwhelming BoT is related to poor quality of life and worse clinical outcomes. This research is the first to explore symptoms and BoT in people with CHF, in the UK. Methods and results This is a cross‐sectional questionnaire survey of CHF patients. Participants completed the Heart Failure Symptom Survey (HFSS; max score 10) and the Minnesota Living with Heart Failure Questionnaire (MLHFQ; max scores: physical 40, emotional 25, and total 105), which measured symptoms. BoT was measured with the Patient Experience with Treatment and Self‐management (PETS; max score 100) questionnaires. Participant characteristics and questionnaire results were summarized using descriptive statistics. Relationships between symptoms and BoT, summarized by the workload and impact indices, were explored using Spearman's and Pearson's correlation coefficients together with scatter plots. The survey was completed by 333 participants, mean age of 71 (±13) years old. The majority (89%) were recruited from secondary care NHS trusts, and 25% were female. All types of heart failure were represented. Mean symptom scores were as follows: HFSS burden score: 2.4 (±2.1), and MLHFQ scores: physical score 20 (±12.4), emotional score 9.9 (±8.1), and total score 41.3 (±26.3). The highest mean PETS domain scores were exercise [51.3 (±24.7)], diet [40.3 (±22.7)], difficulty with healthcare services [39.9 (±21.3)], and physical and mental fatigue [36.0 (±25.7)]. Pairwise correlations were observed between HFSS scores and MLHFQ physical and emotional sub‐scores with PETS workload and impact indices. Positive correlations were weak to moderate (0.326–0.487) between workload index and symptoms, and moderate to strong between impact index and symptoms (0.553–0.725). The P value was 0.006, adjusted by Bonferroni's correction. Conclusions Symptoms are associated with BoT in CHF patients. Although symptom burden was low, CHF patients reported higher levels of burden around self‐care activities of exercise, diet, healthcare interaction, as well as physical and mental fatigue due to engagement with self‐care regimens. Observed higher levels of burden were in key self‐care areas for CHF and suggest areas where service delivery and support of CHF patients may be improved to reduce BoT. Clinicians could individualize their consultations by focusing on troublesome symptoms, as well as alleviating illness workload, which may better enable patients to live well with CHF.
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Affiliation(s)
- Rosalynn C Austin
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,Department of Cardiology, Portsmouth Hospitals University NHS Trust (PHU), Queen Alexandra Hospital, Cardiology Research Nurses, C-Level, Southwick Hill, Cosham, Portsmouth, PO6 3LY, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) Wessex, Southampton, UK
| | - Lisette Schoonhoven
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Vasiliki Koutra
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,Centre for Sport, Exercise and Osteoarthritis Research Versus Arthritis, Southampton, UK
| | - Alison Richardson
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, UK.,National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) Wessex, Southampton, UK.,University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust (PHU), Queen Alexandra Hospital, Cardiology Research Nurses, C-Level, Southwick Hill, Cosham, Portsmouth, PO6 3LY, UK.,Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, UK.,Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Carl R May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK.,Applied Research Collaboration (ARC) North Thames, National Institute for Health Research (NIHR), London, UK
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16
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Pollock RF, Kalra PA, Kalra PR, Ahmed FZ. A Systematic Review, Meta-Analysis, and Indirect Comparison of Blindly Adjudicated Cardiovascular Event Incidence with Ferric Derisomaltose, Ferric Carboxymaltose, and Iron Sucrose. Adv Ther 2022; 39:4678-4691. [PMID: 35947351 PMCID: PMC9464736 DOI: 10.1007/s12325-022-02242-x] [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] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Accepted: 06/22/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION Intravenous (IV) iron is the preferred treatment for patients with iron deficiency anemia (IDA) who require rapid replenishment of iron stores or in whom oral iron is not tolerated or effective. Data from two large-scale randomized controlled trials (RCTs) have recently been published reporting the incidence of adjudicated cardiovascular events after ferric derisomaltose (FDI) and iron sucrose (IS). The objective was to calculate the relative incidence of cardiovascular events with FDI and IS, and to conduct an indirect comparison with ferric carboxymaltose (FCM) based on previously published studies of cardiovascular risk. METHODS RCTs reporting the incidence of blindly adjudicated cardiovascular events in IDA patients treated with IV iron were identified by systematic literature review (SLR). Pairwise random effects meta-analyses of FDI versus IS, and FCM versus IS were conducted for the pre-specified adjudicated composite cardiovascular endpoint of: death due to any cause, nonfatal myocardial infarction, nonfatal stroke, unstable angina requiring hospitalization, congestive heart failure, arrhythmia, and protocol-defined hypertensive and hypotensive events. Analyses were also conducted for the composite endpoint excluding blood pressure events. Meta-analysis results were combined in an adjusted indirect comparison to provide an indirect estimate of cardiovascular risk with FDI versus FCM. RESULTS The SLR retrieved 694 unique articles, of which four were RCTs reporting the incidence of the composite cardiovascular endpoint; two studies comparing FCM (N = 1529) with IS (N = 1505), and two studies comparing FDI (N = 2008) with IS (N = 1000). The odds ratios of the composite CV endpoint were 0.59 (95% confidence interval: 0.39-0.90) for FDI versus IS, 1.12 (95% CI 0.90-1.40) for FCM versus IS, and the indirect OR for FDI versus FCM was 0.53 (95% CI 0.33-0.85). CONCLUSIONS Pooling data from four large-scale RCTs suggested that FDI was associated with significantly lower incidence of cardiovascular adverse events compared to both FCM and IS.
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Affiliation(s)
- Richard F Pollock
- Covalence Research Ltd, Rivers Lodge, West Common, Harpenden, AL5 2JD, UK.
| | - Philip A Kalra
- Department of Renal Medicine, Salford Royal Hospital, Northern Care Alliance NHS Foundation Trust, Salford, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
- Faculty of Science and Health, University of Portsmouth, Portsmouth, UK
| | - Fozia Z Ahmed
- Department of Cardiology, Manchester Academic Health Science Centre, Manchester University NHS Foundation Trust, Manchester, UK
- Manchester University NHS Foundation Trust, Manchester, UK
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17
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Morton G, Bolam H, Hirmiz Z, Chahal R, Guha K, Kalra PR. NICE diagnostic heart failure pathway: screening referrals identifies patients better served by community-based management. ESC Heart Fail 2021; 8:5600-5605. [PMID: 34569187 PMCID: PMC8712913 DOI: 10.1002/ehf2.13608] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 08/16/2021] [Accepted: 09/01/2021] [Indexed: 11/10/2022] Open
Abstract
AIMS Evaluate whether UK National Institute for Health & Care Excellence (NICE) chronic heart failure (HF) guidelines can be safely and effectively refined through specialist referral management. METHODS AND RESULTS All referrals to a UK centre 1/3/2019-30/5/2019 and 1/6/2020-31/7/2020 were reviewed by HF specialists. Patients were triaged to specialist assessment in HF clinic, according to the NICE HF diagnostic pathway [urgency based on N-terminal pro brain natriuretic peptide (NTproBNP) levels], or the referrer given remote Advice & Guidance (A&G), to aid primary care management. Standardized triage criteria for recommending primary care management were (i) presentation inconsistent with HF, (ii) competing comorbidity/frailty meant specialist assessment in clinic not in patient's best interests, (iii) recent assessment for same condition, or (iv) patient had known HF. Following triage patients managed in the primary care were categorized as low or high risk of adverse outcomes. Outcome measures were 90 day all-cause and HF hospital admission and mortality rates. Four hundred and eighty-six patients had the median age of 80 (74-86) years, and 253 (52%) were male. Two hundred and six (42%) had NTproBNP > 2000 pg/mL. Primary care management was recommended for 128 patients (26%): 105 (22%) A&G alone and 23 input from community HF nurse specialists. Primary care management was recommended due to the following: presentation inconsistent with HF 53 (42%), more important competing comorbidity/frailty 35 (27%), recent assessment 17 (13%), and known HF 23 (18%). Patients managed in primary care had higher rates of all-cause hospitalization (30% vs. 19%; P = 0.018) and death (7% vs. 2%; P = 0.0054) than those seen in HF clinic. Of those managed in primary care, 50 (39%) were determined to be at low risk and 78 (61%) at high risk. High-risk patients were older (87 vs. 80 years; P = 0.0026), had much higher NTproBNP (2666 vs. 697 pg/mL; P < 0.0001), and were managed in the primary care due to severe comorbidity (45%) or known HF (31%). They had extremely high rates of adverse outcomes: 35 all-cause hospitalization (45%), 12 HF hospitalization (15%), and 9 deaths (12%). Low-risk patients were usually felt not to have HF (86%) and confirmed to have low rates of adverse outcomes: three all-cause hospitalizations (6%; P < 0.0001 compared with high risk) and zero HF hospitalization (P = 0.0033) or death (P = <0.012). CONCLUSIONS Incorporating specialist referral management into NICE HF diagnostic pathway reduces the demand on HF clinics and may improve the patient experience by facilitating community care. However, many of the patients identified for primary care management are at very high risk of adverse outcomes in the short term and are frequently hospitalized. Urgent implementation of alternative pathways and community-based care packages in parallel for these high-risk patients is extremely important.
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Affiliation(s)
- Geraint Morton
- Department of CardiologyQueen Alexandra Hospital, Portsmouth Hospitals University NHS TrustPortsmouthUK
| | - Helena Bolam
- Department of CardiologyQueen Alexandra Hospital, Portsmouth Hospitals University NHS TrustPortsmouthUK
| | - Zaid Hirmiz
- Hampshire, Southampton and Isle of Wight CCGHampshireUK
| | - Raj Chahal
- Department of CardiologyUniversity Hospitals Dorset NHS Foundation TrustPooleUK
| | - Kaushik Guha
- Department of CardiologyQueen Alexandra Hospital, Portsmouth Hospitals University NHS TrustPortsmouthUK
| | - Paul R. Kalra
- Department of CardiologyQueen Alexandra Hospital, Portsmouth Hospitals University NHS TrustPortsmouthUK
- Faculty of Science and HealthUniversity of PortsmouthPortsmouthUK
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18
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Graham FJ, Pellicori P, Ford I, Petrie MC, Kalra PR, Cleland JGF. Intravenous iron for heart failure with evidence of iron deficiency: a meta-analysis of randomised trials. Clin Res Cardiol 2021; 110:1299-1307. [PMID: 33755777 DOI: 10.1007/s00392-021-018] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2021] [Accepted: 03/03/2021] [Indexed: 05/20/2023]
Abstract
BACKGROUND The recent AFFIRM-AHF trial assessing the effect of intravenous (IV) iron on outcomes in patients hospitalised with worsening heart failure who had iron deficiency (ID) narrowly missed its primary efficacy endpoint of recurrent hospitalisations for heart failure (HHF) or cardiovascular (CV) death. We conducted a meta-analysis to determine whether these results were consistent with previous trials. METHODS We searched for randomised trials of patients with heart failure investigating the effect of IV iron vs placebo/control groups that reported HHF and CV mortality from 1st January 2000 to 5th December 2020. Seven trials were identified and included in this analysis. A fixed effect model was applied to assess the effects of IV iron on the composite of first HHF or CV mortality and individual components of these. RESULTS Altogether, 2,166 patients were included (n = 1168 assigned to IV iron; n = 998 assigned to control). IV iron reduced the composite of HHF or CV mortality substantially [OR 0.73; (95% confidence interval 0.59-0.90); p = 0.003]. Outcomes were consistent for the pooled trials prior to AFFIRM-AHF. Whereas first HHF were reduced substantially [OR 0.67; (0.54-0.85); p = 0.0007], the effect on CV mortality was uncertain but appeared smaller [OR 0.89; (0.66-1.21); p = 0.47]. CONCLUSION Administration of IV iron to patients with heart failure and ID reduces the risk of the composite outcome of first heart failure hospitalisation or cardiovascular mortality, but this outcome may be driven predominantly by an effect on HHF. At least three more substantial trials of intravenous iron are underway.
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Affiliation(s)
- Fraser J Graham
- Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, University Avenue, Glasgow, UK.
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, University Avenue, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, University Avenue, Glasgow, UK
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - John G F Cleland
- Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, University Avenue, Glasgow, UK
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Abstract
OBJECTIVE Explore the interaction between patient experienced symptoms and burden of treatment (BoT) theory in chronic heart failure (CHF). BoT explains how dynamic patient workload (self-care) and their capacity (elements influencing capability), impacts on patients' experience of illness. DESIGN Review of qualitative research studies. DATA SOURCES CINAHL, EMBASE, MEDLINE, PsycINFO, Scopus and Web of Science were searched between January 2007 and 2020. ELIGIBILITY CRITERIA Journal articles in English, reporting qualitative studies on lived experience of CHF. RESULTS 35 articles identified related to the lived experience of 720 patients with CHF. Symptoms with physical and emotional characteristics were identified with breathlessness, weakness, despair and anxiety most prevalent. Identifying symptoms' interaction with BoT framework identified three themes: (1) Symptoms appear to infrequently drive patients to engage in self-care (9.2% of codes), (2) symptoms appear to impede (70.5% of codes) and (3) symptoms form barriers to self-care engagement (20.3% of codes). Symptoms increase illness workload, making completing tasks more difficult; simultaneously, symptoms alter a patient's capacity, through a reduction in their individual capabilities and willingness to access external resources (ie, hospitals) often with devasting impact on patients' lives. CONCLUSIONS Symptoms appear to be integral in the patient experience of CHF and BoT, predominately acting to impede patients' efforts to engage in self-care. Symptoms alter illness workload, increasing complexity and hardship. Patients' capacity is reduced by symptoms, in what they can do and their willingness to ask for help. Symptoms can lower their perceived self-value and roles within society. Symptoms appear to erode a patient's agency, decreasing self-value and generalised physical deconditioning leading to affective paralysis towards self-care regimens. Together describing a state of overwhelming BoT which is thought to be a contributor to poor engagement in self-care and may provide new insights into the perceived poor adherence to self-care in the CHF population. PROSPERO REGISTRATION NUMBER CRD42017077487.
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Affiliation(s)
- Rosalynn C Austin
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, Hampshire, UK
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, Hampshire, UK
- National Institite for Health Research (NIHR) Applied Research Collaboration (ARC) Wessex, Southampton, UK
| | - Lisette Schoonhoven
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, Hampshire, UK
- National Institite for Health Research (NIHR) Applied Research Collaboration (ARC) Wessex, Southampton, UK
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Mike Clancy
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, Hampshire, UK
- University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK
| | - Alison Richardson
- School of Health Sciences, Faculty of Environmental and Life Sciences, University of Southampton, Southampton, Hampshire, UK
- National Institite for Health Research (NIHR) Applied Research Collaboration (ARC) Wessex, Southampton, UK
- University Hospital Southampton NHS Foundation Trust, Southampton General Hospital, Southampton, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, Hampshire, UK
- Faculty of Health and Science, University of Portsmouth, Portsmouth, Hampshire, UK
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life Sciences, University of Glasgow, Glasgow, Scotland
| | - Carl R May
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, UK
- National Institute for Health Research (NIHR), Applied Research Collaboration (ARC) North Thames, London, UK
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20
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Mahadevan K, Cowan E, Kalsi N, Bolam H, Arnett R, Hobson A, Guha K, Morton G, Brennan PA, Kalra PR. Distractions in the cardiac catheterisation laboratory: impact for cardiologists and patient safety. Open Heart 2021; 7:openhrt-2020-001260. [PMID: 33268470 PMCID: PMC7713203 DOI: 10.1136/openhrt-2020-001260] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Revised: 09/03/2020] [Accepted: 09/03/2020] [Indexed: 11/23/2022] Open
Abstract
Objective To understand human factors (HF) contributing to disturbances during invasive cardiac procedures, including frequency and nature of distractions, and assessment of operator workload. Methods Single centre prospective observational evaluation of 194 cardiac procedures in three adult cardiac catheterisation laboratories over 6 weeks. A proforma including frequency, nature, magnitude and level of procedural risk at the time of each distraction/interruption was completed for each case. The primary operator completed a National Aeronautical and Space Administration (NASA) task load questionnaire rating mental/physical effort, level of frustration, time-urgency, and overall effort and performance. Results 264 distractions occurred in 106 (55%) out of 194 procedures observed; 80% were not relevant to the case being undertaken; 14% were urgent including discussions of potential ST-elevation myocardial infarction requiring emergency angioplasty. In procedures where distractions were observed, frequency per case ranged from 1 to 16 (mean 2.5, SD ±2.2); 43 were documented during high-risk stages of the procedure. Operator rating of NASA task load parameters demonstrated higher levels of mental and physical workload and effort during cases in which distractions occurred. Conclusions In this first description of HF in adult cardiac catheter laboratories, we found that fewer than half of all procedures were completed without interruption/distraction. The majority were unnecessary and without relation to the case or list. We propose the introduction of a ‘sterile cockpit’ environment within catheter laboratories, as adapted from aviation and used in surgical operating theatres, to minimise non-emergent interruptions and disturbances, to improve operator conditions and overall patient safety.
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Affiliation(s)
- Kalaivani Mahadevan
- Cardiology Department, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Elena Cowan
- Cardiology Department, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Navneet Kalsi
- Royal Hampshire County Hospital, Winchester, Hampshire, UK
| | - Helena Bolam
- Cardiology Department, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Richard Arnett
- Quality Enhancement Office, Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Alex Hobson
- Cardiology Department, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Kaushik Guha
- Cardiology Department, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Geraint Morton
- Cardiology Department, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - Peter A Brennan
- Maxillofacial Surgery Department, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.,University of Portsmouth, Portsmouth, Hampshire, UK
| | - Paul R Kalra
- Cardiology Department, Queen Alexandra Hospital, Portsmouth Hospitals University NHS Trust, Portsmouth, UK.,University of Portsmouth, Portsmouth, Hampshire, UK
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21
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Graham FJ, Pellicori P, Ford I, Petrie MC, Kalra PR, Cleland JGF. Intravenous iron for heart failure with evidence of iron deficiency: a meta-analysis of randomised trials. Clin Res Cardiol 2021; 110:1299-1307. [PMID: 33755777 PMCID: PMC8318946 DOI: 10.1007/s00392-021-01837-8] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [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] [Received: 01/27/2021] [Accepted: 03/03/2021] [Indexed: 12/20/2022]
Abstract
Background The recent AFFIRM-AHF trial assessing the effect of intravenous (IV) iron on outcomes in patients hospitalised with worsening heart failure who had iron deficiency (ID) narrowly missed its primary efficacy endpoint of recurrent hospitalisations for heart failure (HHF) or cardiovascular (CV) death. We conducted a meta-analysis to determine whether these results were consistent with previous trials. Methods We searched for randomised trials of patients with heart failure investigating the effect of IV iron vs placebo/control groups that reported HHF and CV mortality from 1st January 2000 to 5th December 2020. Seven trials were identified and included in this analysis. A fixed effect model was applied to assess the effects of IV iron on the composite of first HHF or CV mortality and individual components of these. Results Altogether, 2,166 patients were included (n = 1168 assigned to IV iron; n = 998 assigned to control). IV iron reduced the composite of HHF or CV mortality substantially [OR 0.73; (95% confidence interval 0.59–0.90); p = 0.003]. Outcomes were consistent for the pooled trials prior to AFFIRM-AHF. Whereas first HHF were reduced substantially [OR 0.67; (0.54–0.85); p = 0.0007], the effect on CV mortality was uncertain but appeared smaller [OR 0.89; (0.66–1.21); p = 0.47]. Conclusion Administration of IV iron to patients with heart failure and ID reduces the risk of the composite outcome of first heart failure hospitalisation or cardiovascular mortality, but this outcome may be driven predominantly by an effect on HHF. At least three more substantial trials of intravenous iron are underway. Graphic abstract ![]()
Supplementary Information The online version contains supplementary material available at 10.1007/s00392-021-01837-8.
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Affiliation(s)
- Fraser J Graham
- Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, University Avenue, Glasgow, UK.
| | - Pierpaolo Pellicori
- Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, University Avenue, Glasgow, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, University Avenue, Glasgow, UK
| | - Mark C Petrie
- British Heart Foundation Cardiovascular Research Centre, University of Glasgow, Glasgow, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals University NHS Trust, Portsmouth, UK
| | - John G F Cleland
- Robertson Centre for Biostatistics, University of Glasgow, Boyd Orr Building, University Avenue, Glasgow, UK
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22
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Sorbets E, Fox KM, Elbez Y, Danchin N, Dorian P, Ferrari R, Ford I, Greenlaw N, Kalra PR, Parma Z, Shalnova S, Tardif JC, Tendera M, Zamorano JL, Vidal-Petiot E, Steg PG. Long-term outcomes of chronic coronary syndrome worldwide: insights from the international CLARIFY registry. Eur Heart J 2021; 41:347-356. [PMID: 31504434 PMCID: PMC6964227 DOI: 10.1093/eurheartj/ehz660] [Citation(s) in RCA: 47] [Impact Index Per Article: 15.7] [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] [Received: 08/06/2019] [Revised: 08/19/2019] [Accepted: 08/28/2019] [Indexed: 01/08/2023] Open
Abstract
Aims Over the last decades, the profile of chronic coronary syndrome has changed substantially. We aimed to determine characteristics and management of patients with chronic coronary syndrome in the contemporary era, as well as outcomes and their determinants. Methods and results Data from 32 703 patients (45 countries) with chronic coronary syndrome enrolled in the prospective observational CLARIFY registry (November 2009 to June 2010) with a 5-year follow-up, were analysed. The primary outcome [cardiovascular death or non-fatal myocardial infarction (MI)] 5-year rate was 8.0% [95% confidence interval (CI) 7.7–8.3] overall [male 8.1% (7.8–8.5); female 7.6% (7.0–8.3)]. A cox proportional hazards model showed that the main independent predictors of the primary outcome were prior hospitalization for heart failure, current smoking, atrial fibrillation, living in Central/South America, prior MI, prior stroke, diabetes, current angina, and peripheral artery disease. There was an interaction between angina and prior MI (P = 0.0016); among patients with prior MI, angina was associated with a higher primary event rate [11.8% (95% CI 10.9–12.9) vs. 8.2% (95% CI 7.8–8.7) in patients with no angina, P < 0.001], whereas among patients without prior MI, event rates were similar for patients with [6.3% (95% CI 5.4–7.3)] or without angina [6.4% (95% CI 5.9–7.0)], P > 0.99. Prescription rates of evidence-based secondary prevention therapies were high. Conclusion This description of the spectrum of chronic coronary syndrome patients shows that, despite high rates of prescription of evidence-based therapies, patients with both angina and prior MI are an easily identifiable high-risk group who may deserve intensive treatment. Clinical registry ISRCTN43070564 ![]()
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Affiliation(s)
- Emmanuel Sorbets
- Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Avicenne, 125 rue de Stalingrad, 93000 Bobigny, France.,Paris 13 University, 74 rue Marcel Cachin, 93000 Bobigny, France.,NHLI Imperial College, Dovehouse Street, London SW3 6LP, UK.,ICMS, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.,Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, French Alliance for Cardiovascular Trials, INSERM U1148, Laboratory for Vascular Translational Science, 46 rue Henri Huchard, 75018 Paris, France
| | - Kim M Fox
- NHLI Imperial College, Dovehouse Street, London SW3 6LP, UK.,ICMS, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK
| | - Yedid Elbez
- Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, French Alliance for Cardiovascular Trials, INSERM U1148, Laboratory for Vascular Translational Science, 46 rue Henri Huchard, 75018 Paris, France
| | - Nicolas Danchin
- Université de Paris, 15 rue de l'école de médecine, 75005 Paris, France.,Hôpital Européen Georges Pompidou, Assistance Publique-Hôpitaux de Paris, 20 rue Leblanc, 75015 Paris, France
| | - Paul Dorian
- University of Toronto, Department of Medicine, Suite RFE 3-805, 190 Elizabeth Street, Toronto, ON, M5G 2C4, Canada
| | - Roberto Ferrari
- University of Ferrara Via Aldo Moro 8, 44124 Cona (FE) Italy and Maria Cecilia Hospital, GVM Care & Research, Via Corriera, 1 - 48033 Cotignola (RA), Italy
| | - Ian Ford
- Robertson Centre for Biostatistics, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow G12 8QQ, UK
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, Boyd Orr Building, University Avenue, University of Glasgow, Glasgow G12 8QQ, UK
| | - Paul R Kalra
- Cardiology department, Queen Alexandra Hospital, Southwick Hill Rd, Portsmouth, UK
| | - Zofia Parma
- Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Ziolowa Street 45/47, 40-635 Katowice, Poland
| | - Svetlana Shalnova
- National Research Center for Preventive Medicine, Moscow, Bldg. 3, 10, Petroverigskiy Pereulok, 101990, Moscow, Russian Federation
| | - Jean-Claude Tardif
- Montreal Heart Institute, Université de Montreal, 5000 rue Belanger, Montreal, QC H1T 1C8, Canada
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, Ziolowa Street 45/47, 40-635 Katowice, Poland
| | - José Luis Zamorano
- University Hospital Ramon y Cajal, Carretera Colmenar Km 9,100, 28034 Madrid, Spain
| | - Emmanuelle Vidal-Petiot
- Université de Paris, 15 rue de l'école de médecine, 75005 Paris, France.,Physiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat and INSERM U1149, Centre de Recherche sur l'Inflammation, 46, rue Henri Huchard, 75018 Paris, France
| | - Philippe Gabriel Steg
- NHLI Imperial College, Dovehouse Street, London SW3 6LP, UK.,ICMS, Royal Brompton Hospital, Sydney Street, London SW3 6NP, UK.,Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, French Alliance for Cardiovascular Trials, INSERM U1148, Laboratory for Vascular Translational Science, 46 rue Henri Huchard, 75018 Paris, France.,Université de Paris, 15 rue de l'école de médecine, 75005 Paris, France
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23
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McCambridge J, Keane C, Walshe M, Campbell P, Heyes J, Kalra PR, Cowie MR, Riley JP, O'Hanlon R, Ledwidge M, Gallagher J, McDonald K. The prehospital patient pathway and experience of care with acute heart failure: a comparison of two health care systems. ESC Heart Fail 2020; 8:1076-1084. [PMID: 33369196 PMCID: PMC8006706 DOI: 10.1002/ehf2.13089] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 10/12/2020] [Accepted: 10/19/2020] [Indexed: 01/12/2023] Open
Abstract
Aims This study aimed to analyse community management of patients during the symptomatic period prior to admission with acute decompensated heart failure (ADHF). Methods and results We conducted a prospective, two‐centre, two‐country observational study evaluating care pathways and patient experience in patients admitted to hospital with ADHF. Quantitative and qualitative data were gathered from patients, carers, and general practitioners (GPs). From the Irish centre, 114 patients enrolled, and from the English centre, 50 patients. Symptom duration longer than 72 h prior to hospitalization was noted among 70.4% (76) Irish and 80% (40) English patients, with no significant difference between those with a new diagnosis of HF [de novo HF (dnHF)] and those with known HF [established HF (eHF)] in either cohort. For the majority, dyspnoea was the dominant symptom; however, 63.3% (31) of these Irish patients and 47.2% (17) of these English patients did not recognize this as an HF symptom, with no significant difference between dnHF and eHF patients. Of the 46.5% (53) of Irish and 38% (19) of English patients reviewed exclusively by GPs before hospitalization, numbers prescribed diuretics were low (11.3%, six; and 15.8%, three, respectively); eHF patients were no more likely to receive diuretics than dnHF patients. Barriers to care highlighted by GPs included inadequate access to basic diagnostics, specialist support and up‐to‐date patient information, and lack of GP comfort in managing HF. Conclusion The aforementioned findings, consistent across both health care jurisdictions, show a clear potential to intervene earlier and more effectively in ADHF or to prevent the need for hospitalization.
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Affiliation(s)
- Joseph McCambridge
- Cardiology Department, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Ciara Keane
- Cardiology Department, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Myra Walshe
- Cardiology Department, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Patricia Campbell
- Cardiology Department, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - James Heyes
- Portsmouth Hospital NHS Trust, Portsmouth, UK
| | | | - Martin R Cowie
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Jillian P Riley
- Imperial College London (Royal Brompton Hospital), London, UK
| | - Rory O'Hanlon
- Cardiology Department, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Mark Ledwidge
- Cardiology Department, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Joseph Gallagher
- Cardiology Department, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland.,Irish College of General Practitioners, Lincoln Place, Dublin 2, Ireland
| | - Kenneth McDonald
- Cardiology Department, St. Vincent's University Hospital, Elm Park, Dublin 4, Ireland
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Austin RC, Schoonhoven L, Richardson A, Kalra PR, May CR. How do SYMPtoms and management tasks in chronic heart failure imPACT a person's life (SYMPACT)? Protocol for a mixed-methods study. ESC Heart Fail 2020; 7:4472-4477. [PMID: 32940966 PMCID: PMC7754908 DOI: 10.1002/ehf2.13010] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2020] [Revised: 05/16/2020] [Accepted: 08/27/2020] [Indexed: 12/17/2022] Open
Abstract
Aims Patients with chronic heart failure (CHF) struggle to follow self‐care plans, which may lead to worsening illness and poor quality of life. Burden of treatment (BoT) describes this workload and its impact on patients' lives. Suggesting the balance between a patient's treatment workload and their capability to manage it is crucial. If BoT is reduced, self‐care engagement and quality of life may improve. This article describes the SYMPACT study design and methods used to explore how symptoms and management tasks impact CHF patients' lives. Methods and results We used a sequential exploratory mixed‐methods design to investigate the interaction between symptoms and BoT in CHF patients. Conclusions If symptoms and BoT are intrinsically linked, then the high level of symptoms experienced by CHF patients may lead to increased treatment burden, which likely decreases patients' engagement with self‐care plans. SYMPACT may identify modifiable factors to improve CHF patients' experience.
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Affiliation(s)
- Rosalynn C. Austin
- School of Health Sciences, Faculty of Environmental and Life SciencesUniversity of SouthamptonSouthamptonUK
- Department of CardiologyPortsmouth Hospitals University NHS TrustHampshireUK
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) WessexSouthamptonUK
| | - Lisette Schoonhoven
- School of Health Sciences, Faculty of Environmental and Life SciencesUniversity of SouthamptonSouthamptonUK
- Julius Center for Health Sciences and Primary CareUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Alison Richardson
- School of Health Sciences, Faculty of Environmental and Life SciencesUniversity of SouthamptonSouthamptonUK
- National Institute for Health Research (NIHR) Applied Research Collaboration (ARC) WessexSouthamptonUK
- Clinical Academic FacilityUniversity Hospital Southampton NHS Foundation TrustTremona RoadSouthamptonUK
| | - Paul R. Kalra
- Department of CardiologyPortsmouth Hospitals University NHS TrustHampshireUK
- Institute of Health and Wellbeing, College of Medical, Veterinary and Life SciencesUniversity of Glasgow and the University of PortsmouthGlasgowUK
| | - Carl R. May
- Faculty of Public Health and PolicyLondon School of Hygiene and Tropical MedicineLondonUK
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Zheng A, Cowan E, Mach L, Adam RD, Guha K, Cowburn PJ, Haydock P, Kalra PR, Flett A, Morton G. Characteristics and outcomes of patients with suspected heart failure referred in line with National Institute for Health and Care Excellence guidance. Heart 2020; 106:1579-1585. [PMID: 32690621 PMCID: PMC7525790 DOI: 10.1136/heartjnl-2019-316511] [Citation(s) in RCA: 8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2020] [Revised: 05/29/2020] [Accepted: 06/02/2020] [Indexed: 12/17/2022] Open
Abstract
OBJECTIVE To describe the population, heart failure (HF) diagnosis rate, and 1-year hospitalisation and mortality of patients with suspected HF and elevated N-terminal pro B-type natriuretic peptide (NTproBNP) investigated according to UK National Institute for Health and Care Excellence (NICE) guidelines. METHODS NICE recommends patients with suspected HF, based on clinical presentation and elevated NTproBNP, are referred for specialist assessment and echocardiography. Patients should be seen within 2 weeks when NTproBNP is >2000 pg/mL (2-week pathway: 2WP) or within 6 weeks when NTproBNP is 400-2000 pg/mL (6-week pathway: 6WP). This is a retrospective, multicentre, observational study of consecutive patients with suspected HF referred from primary care between 2014 and 2016 to dedicated secondary care HF clinics based on the NICE 2WP and 6WP. Data were obtained from hospital records and episode statistics. Mortality and hospitalisation rates were calculated 1 year from NTproBNP measurement. RESULTS 1271 patients (median age 80; IQR 73-85) were assessed, 680 (53%) of whom were female. 667 (53%) were referred on the 2WP and 604 (47%) on the 6WP. 698 (55%) were diagnosed with HF (369 HF with reduced ejection fraction) and 566 (45%) as not HF (NHF). 1-year mortality was 10% (n=129) and hospitalisation was 33% (n=413). Patients on the 2WP had higher mortality and hospitalisation rates than those on the 6WP, 14% vs 6% (p<0.001) and 38% vs 27% (p<0.001), respectively. All-cause mortality (11% vs 9%; p=0.306) and hospitalisation rates (35% vs 29%; p=0.128) did not differ between HF and NHF patients, respectively. CONCLUSIONS Outcomes using the NICE approach of short waiting time targets for specialist assessment of patients with suspected HF and raised NTproBNP are not known. The model identifies an elderly population a high proportion of whom have HF. Irrespective of diagnosis, patients have high rates of adverse outcomes. These contemporary real-world data provide a platform for discussions with patients and shaping HF services.
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Affiliation(s)
- Alice Zheng
- Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK .,Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Elena Cowan
- Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Lukas Mach
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Robert D Adam
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Kaushik Guha
- Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Peter James Cowburn
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul Haydock
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Paul R Kalra
- Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Andrew Flett
- Cardiology, University Hospital Southampton NHS Foundation Trust, Southampton, UK
| | - Geraint Morton
- Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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Clark AL, Kalra PR, Petrie MC, Mark PB, Tomlinson LA, Tomson CR. Change in renal function associated with drug treatment in heart failure: national guidance. Heart 2020; 105:904-910. [PMID: 31118203 PMCID: PMC6582720 DOI: 10.1136/heartjnl-2018-314158] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Revised: 01/22/2019] [Indexed: 12/11/2022]
Abstract
Inhibitors of the renin–angiotensin–aldosterone (RAAS) system are cornerstones of the management of patients with heart failure with reduced left ventricular ejection fraction (HFrEF). However, RAAS inhibitors may cause decline in renal function and/or hyperkalaemia, particularly during initiation and titration, intercurrent illness and during worsening of heart failure. There is very little evidence from clinical trials to guide the management of renal dysfunction. The Renal Association and British Society for Heart Failure have collaborated to describe the interactions between heart failure, RAAS inhibitors and renal dysfunction and give clear guidance on the use of RAAS inhibitors in patients with HFrEF. During initiation and titration of RAAS inhibitors, testing renal function is mandatory; a decline in renal function of 30% or more can be acceptable. During intercurrent illness, there is no evidence that stopping RAAS inhibitor is beneficial, but if potassium rises above 6.0 mmol/L, or creatinine rises more than 30%, RAAS inhibitors should be temporarily withheld. In patients with fluid retention, high doses of diuretic are needed and a decline in renal function is not an indication to reduce diuretic dose: if the patient remains congested, more diuretics are required. If a patient is hypovolaemic, diuretics should be stopped or withheld temporarily. Towards end of life, consider stopping RAAS inhibitors. RAAS inhibition has no known prognostic benefit in heart failure with preserved ejection fraction. Efforts should be made to initiate, titrate and maintain patients with HFrEF on RAAS inhibitor treatment, whether during intercurrent illness or worsening heart failure.
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Affiliation(s)
- Andrew L Clark
- Academic Cardiology, Hull York Medical School in the University of Hull, Hull, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Mark C Petrie
- University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, UK.,Golden Jubilee National Hospital, Golden Jubilee National Hospital, Clydebank, UK
| | - Patrick B Mark
- University of Glasgow Institute of Cardiovascular and Medical Sciences, Glasgow, UK
| | - Laurie A Tomlinson
- Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
| | - Charles Rv Tomson
- Department of Renal Medicine, Freeman Hospital, Newcastle upon Tyne, UK
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27
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Abstract
Just under 1 million people in the UK have symptomatic heart failure. Decompensated heart failure is associated with a particularly poor prognosis with in-hospital mortality at around 10%. Over the last 30 years renin-angiotensin-aldosterone system antagonists have been shown to have incremental benefit on improved quality of life, reduced hospitalisation and mortality rates in those with heart failure with reduced ejection fraction. Concomitant chronic kidney disease and 'acute kidney injury' are common and associated with adverse outcomes.In patients with decompensated heart failure, congestion is a key driver of deterioration in renal function. Decongestion is fundamental to successful management. Yet it is not uncommon to see prognostically important medication (such as angiotensin converting enzyme inhibitors and mineralocorticoid antagonists) inappropriately stopped, along with under-diuresis of the patient. This leaves the patient still in a state of congestion without the prognostic medication at discharge, with resultant adverse outcome. The British Society for Heart Failure and the Renal Association have produced consensus guidance to help guide management in a more consistent fashion based on heart failure classification, whether the patient is congested and the degree of renal impairment. Early heart failure specialist review is associated with improved patient outcomes.
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Affiliation(s)
| | | | - Paul R Kalra
- Portsmouth Hospitals NHS Trust, Portsmouth, UK and honorary professor, University of Portsmouth, Portsmouth, UK
| | - Philip A Kalra
- Salford Royal NHS Foundation Trust, Salford, UK and University of Manchester, Manchester, UK
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28
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Vidal-Petiot E, Greenlaw N, Kalra PR, Garcia-Moll X, Tardif JC, Ford I, Zamorano J, Ferrari R, Tendera M, Fox KM, Steg PG. Chronic Kidney Disease Has a Graded Association with Death and Cardiovascular Outcomes in Stable Coronary Artery Disease: An Analysis of 21,911 Patients from the CLARIFY Registry. J Clin Med 2019; 9:E4. [PMID: 31861379 PMCID: PMC7019870 DOI: 10.3390/jcm9010004] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [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: 12/11/2019] [Revised: 12/11/2019] [Accepted: 12/13/2019] [Indexed: 12/01/2022] Open
Abstract
: Chronic kidney disease (CKD) is associated with an increased cardiovascular risk in a broad spectrum of populations. However, the risk associated with a reduced estimated glomerular filtration rate (eGFR) in patients with stable coronary artery disease receiving standard care in the modern era, independently of baseline cardiovascular disease, risk factors, and comorbidities, remains unclear. We analyzed data from 21,911 patients with stable coronary artery disease, enrolled in 45 countries between November 2009 and July 2010 in the CLARIFY registry. Patients with abnormal renal function were older, with more comorbidities, and received slightly lower-although overall high-rates of evidence-based secondary prevention therapies than patients with normal renal function. The event rate of patients with CKD stage 3b or more (eGFR <45 mL/min/1.73 m2) was much higher than that associated with any comorbid condition. In a multivariable adjusted Cox proportional hazards model, lower eGFR was independently associated with a graded increased risk of cardiovascular mortality, with adjusted HRs (95% CI) of 0.98 (0.81-1.18), 1.31 (1.05-1.63), 1.77 (1.38-2.27), and 3.12 (2.25-4.33) for eGFR 60-89, 45-59, 30-44, and <30 mL/min/1.73 m2, compared with eGFR ≥90 mL/min/1.73 m2. A strong graded independent relationship exists between the degree of CKD and cardiovascular mortality in this large cohort of patients with chronic coronary artery disease, despite high rates of secondary prevention therapies. Among clinical risk factors and comorbid conditions, CKD stage 3b or more is associated with the highest cardiovascular mortality.
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Affiliation(s)
- Emmanuelle Vidal-Petiot
- Université de Paris, Paris, France;
- Physiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, 75018 Paris, France
- Institut nationale de la santé et de la recherché médicale (INSERM) U1149, Centre de Recherche sur l’Inflammation, 75018 Paris, France
| | - Nicola Greenlaw
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ, UK; (N.G.); (I.F.)
| | - Paul R. Kalra
- Portsmouth Hospitals NHS Trust, Portsmouth PO6 3LY, UK;
| | | | - Jean-Claude Tardif
- Montreal Heart Institute, Université de Montreal, Montreal, QC H1T1C8, Canada;
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow G12 8QQ, UK; (N.G.); (I.F.)
| | - Jose Zamorano
- University Hospital Ramon y Cajal, 28040 Madrid, Spain;
| | - Roberto Ferrari
- Centro Cardiologico Universitario di Ferrara, University of Ferrara, 44124 Cona, FE, Italy;
- Maria Cecilia Hospital, GVM Care & Research, 48033 Cotignola, RA, Italy
| | - Michal Tendera
- Department of Cardiology and Structural Heart Disease, School of Medicine in Katowice, Medical University of Silesia, 40-055 Katowice, Poland;
| | - Kim M. Fox
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London SW3 6NP, UK;
| | - Philippe Gabriel Steg
- Université de Paris, Paris, France;
- National Heart and Lung Institute, Imperial College, Royal Brompton Hospital, London SW3 6NP, UK;
- Cardiology Department, Assistance Publique-Hôpitaux de Paris, Hôpital Bichat, French Alliance for Cardiovascular Trials, INSERM U1148, 75018 Paris, France
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29
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Gulati A, Japp AG, Raza S, Halliday BP, Jones DA, Newsome S, Ismail NA, Morarji K, Khwaja J, Spath N, Shakespeare C, Kalra PR, Lloyd G, Mathur A, Cleland JG, Cowie MR, Assomull RG, Pennell DJ, Ismail TF, Prasad SK. Absence of Myocardial Fibrosis Predicts Favorable Long-Term Survival in New-Onset Heart Failure. Circ Cardiovasc Imaging 2018; 11:e007722. [DOI: 10.1161/circimaging.118.007722] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [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: 01/19/2023]
Affiliation(s)
- Ankur Gulati
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Alan G. Japp
- Edinburgh Heart Centre, United Kingdom (A.G.J., N.S.)
| | - Sadaf Raza
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Brian P. Halliday
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Daniel A. Jones
- Department of Cardiology, Barts and London NHS Trust, London, United Kingdom (D.A.J., A.M.)
| | - Simon Newsome
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, United Kingdom (S.N.)
| | - Nizar A. Ismail
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Kishen Morarji
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Jahanzaib Khwaja
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Nick Spath
- Edinburgh Heart Centre, United Kingdom (A.G.J., N.S.)
| | - Carl Shakespeare
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Paul R. Kalra
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Guy Lloyd
- Barts Heart Centre, St. Bartholomew’s Hospital University College Hospitals London Institute of Cardiovascular Science UCL and The William Harvey Research Institute, Queen Mary University of London (G.L.)
| | - Anthony Mathur
- Department of Cardiology, Barts and London NHS Trust, London, United Kingdom (D.A.J., A.M.)
| | - John G.F. Cleland
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Martin R. Cowie
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
- National Heart and Lung Institute, Imperial College, London, United Kingdom (M.R.C., D.J.P., S.K.P.)
| | - Ravi G. Assomull
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
| | - Dudley J. Pennell
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
- National Heart and Lung Institute, Imperial College, London, United Kingdom (M.R.C., D.J.P., S.K.P.)
| | - Tevfik F. Ismail
- School of Biomedical Engineering and Imaging Sciences, King’s College London, United Kingdom (T.F.I.)
| | - Sanjay K. Prasad
- Royal Brompton Hospital, London, United Kingdom (A.G., S.R., B.P.H., N.A.I., K.M., J.K., C.S., P.R.K., J.G.F.C., M.R.C., R.G.A., D.J.P., S.K.P.)
- National Heart and Lung Institute, Imperial College, London, United Kingdom (M.R.C., D.J.P., S.K.P.)
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30
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Morton G, Philip L, Gilpin T, Chan PE, Guha K, Kalra PR. Does specialist review for patients with suspected heart failure predict better outcomes? An observational study on the utility of compliance with NICE guidelines. BMJ Open 2018; 8:e021856. [PMID: 30139902 PMCID: PMC6112396 DOI: 10.1136/bmjopen-2018-021856] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
OBJECTIVES Compare outcomes in patients with suspected heart failure (HF) and raised natriuretic peptides who are reviewed in a specialist HF clinic in line with National Institute for Health and Care Excellence (NICE) guidelines (compliant group) versus patients who are not reviewed in the clinic (non-compliant group). DESIGN Retrospective observational study. SETTING Single large UK district general hospital. PARTICIPANTS 567 consecutive patients in primary care with raised N-terminal pro-brain natriuretic peptide (NT-pro-BNP) levels (>400 pg/mL) from February to September 2014. INTERVENTIONS 161 (28%) patients were referred to the specialist HF clinic and 406 (72%) were not. Outcomes were compared between the two groups. OUTCOME MEASURES All-cause and cardiovascular (CV) hospitalisations and all-cause mortality. RESULTS The compliant group were slightly younger than the non-compliant group (78±9 vs 80±9; p=0.019) but had much higher NT-pro-BNP (3108±4526 vs 2271±3637 pg/mL; p<0.0001). Despite this, over a mean follow-up period of 9±2 months, rates of all-cause hospitalisation (24% vs 44%; p<0.0001) and CV hospitalisation (3% vs 15%, p<0.0001) were significantly lower in the compliant group versus the non-compliant group, respectively. There was no significant difference in mortality rates (6% compliant group vs 8% non-compliant group; p=0.487). CONCLUSIONS Hospitalisation rates in patients with suspected HF and raised NT-pro-BNP were extremely high over a relatively short follow-up period. Patients reviewed in a specialist HF clinic had much higher NT-pro-BNP levels, suggesting they were at higher risk of adverse outcomes, yet also had significantly lower rates of all-cause and CV hospitalisation. Our findings support implementation of the relevant NICE guidelines for patients with suspected HF.
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Affiliation(s)
- Geraint Morton
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, Wessex, UK
| | - Legate Philip
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, Wessex, UK
| | - Thomas Gilpin
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, Wessex, UK
| | - Pik Ee Chan
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, Wessex, UK
| | - Kaushik Guha
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, Wessex, UK
| | - Paul R Kalra
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, Wessex, UK
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Affiliation(s)
| | - Iain Squire
- British Society for Heart Failure, Professor of Cardiovascular Medicine, University of Leicester, University Road Leicester, LE1 7RH, UK, Tel: +44 (0)116 256 3021, Fax: +44 (0)116 250 2405
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Kernan R, Lennon E, Gallagher J, Walshe M, Riley JP, Keane C, Kalra PR, Cowie MR, McDonald K. P5692Evaluating the patient and carers perspective of the heart failure pathway following an admission with an acute decompensation of heart failure. Eur Heart J 2018. [DOI: 10.1093/eurheartj/ehy566.p5692] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- R Kernan
- University College Dublin, Dublin, Ireland
| | - E Lennon
- University College Dublin, Dublin, Ireland
| | | | - M Walshe
- Heart Failure Unit, Dublin, Ireland
| | - J P Riley
- Imperial College London, London, United Kingdom
| | - C Keane
- Heart Failure Unit, Dublin, Ireland
| | - P R Kalra
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - M R Cowie
- Imperial College London, London, United Kingdom
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33
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Neville DM, Rupani H, Kalra PR, Adeniji K, Quint M, De Vos R, Begum S, Mottershaw M, Fogg C, Jones TL, Lanning E, Bassett P, Chauhan AJ. Exploring the Waveform Characteristics of Tidal Breathing Carbon Dioxide, Measured Using the N-Tidal C Device in Different Breathing Conditions (The General Breathing Record Study): Protocol for an Observational, Longitudinal Study. JMIR Res Protoc 2018; 7:e140. [PMID: 29798833 PMCID: PMC5992452 DOI: 10.2196/resprot.9767] [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] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 02/22/2018] [Accepted: 02/23/2018] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND In an increasingly comorbid population, there are significant challenges to diagnosing the cause of breathlessness, and once diagnosed, considerable difficulty in detecting deterioration early enough to provide effective intervention. The burden of the breathless patient on the health care economy is substantial, with asthma, chronic heart failure, and pneumonia affecting over 6 million people in the United Kingdom alone. Furthermore, these patients often have more than one contributory factor to their breathlessness symptoms, with conditions such as dysfunctional breathing pattern disorders-an under-recognized component. Current methods of diagnosing and monitoring breathless conditions can be extensive and difficult to perform. As a consequence, home monitoring is poorly complied with. In contrast, capnography (the measurement of tidal breath carbon dioxide) is performed during normal breathing. There is a need for a simple, easy-to-use, personal device that can aid in the diagnosis and monitoring of respiratory and cardiac causes of breathlessness. OBJECTIVE The aim of this study was to explore the use of a new, handheld capnometer (called the N-Tidal C) in different conditions that cause breathlessness. We will study whether the tidal breath carbon dioxide (TBCO2) waveform, as measured by the N-Tidal C, has different characteristics in a range of respiratory and cardiac conditions. METHODS We will perform a longitudinal, observational study of the TBCO2 waveform (capnogram) as measured by the N-Tidal C capnometer. Participants with a confirmed diagnosis of asthma, breathing pattern disorders, chronic heart failure, motor neurone disease, pneumonia, as well as volunteers with no history of lung disease will be asked to provide twice daily, 75-second TBCO2 collection via the N-Tidal C device for 6 months duration. The collated capnograms will be correlated with the underlying diagnosis and disease state (stable or exacerbation) to determine if there are different TBCO2 characteristics that can distinguish different respiratory and cardiac causes of breathlessness. RESULTS This study's recruitment is ongoing. It is anticipated that the results will be available in late 2018. CONCLUSIONS The General Breathing Record Study will provide an evaluation of the use of capnography as a diagnostic and home-monitoring tool for various diseases. REGISTERED REPORT IDENTIFIER RR1-10.2196/9767.
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Affiliation(s)
| | - Hitasha Rupani
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Paul R Kalra
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Kayode Adeniji
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Matthew Quint
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Ruth De Vos
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Selina Begum
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | | | - Carole Fogg
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
| | - Thomas L Jones
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom
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Kalra PR, Greenlaw N, Ford I, Steg PG, Fox KM. The Reply. Am J Med 2018; 131:e129. [PMID: 29454433 DOI: 10.1016/j.amjmed.2017.09.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Accepted: 09/18/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Paul R Kalra
- Portsmouth Hospital NHS Trust, Portsmouth and NHLI Imperial College, London, UK
| | | | - Ian Ford
- Robertson Centre, University of Glasgow, Glasgow, Scotland
| | - Ph Gabriel Steg
- Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Assistance Publique-Hôpitaux de Paris, Paris, France; NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK
| | - Kim M Fox
- NHLI Imperial College, ICMS, Royal Brompton Hospital, London, UK
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Abstract
There are multiple evidence-based drug treatments for chronic heart failure (HF), both disease-modifying agents and those for symptom control. The majority of the evidence base supports drugs used in HF with reduced left ventricular ejection fraction. The mainstay of disease modification involves manipulation of neurohormonal activation that occurs in HF. In addition to established angiotensin-converting enzyme inhibitors, beta blockers and mineralocorticoid receptor antagonists (MRAs), newer agents are now available such as the angiotensin receptor neprilysin inhibitors. Achieving the optimal drug regimen is complex and best performed by a specialist heart failure team. We aim to provide a comprehensive overview of contemporary drug therapies in chronic heart failure, as well as practical guidance for their use. There is a focus on treating patients with challenging comorbidities such as hypotension and chronic kidney disease (CKD), where a thorough understanding of drug therapy is essential. Multiple trials assessing the benefits of new therapies in HF, such as intravenous iron, are also ongoing.
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Affiliation(s)
- Helena Bolam
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Geraint Morton
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Paul R Kalra
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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Kang CK, Pope M, Lang CC, Kalra PR. Iron deficiency in heart failure: Efficacy and safety of intravenous iron therapy. Cardiovasc Ther 2017; 35. [PMID: 28836730 DOI: 10.1111/1755-5922.12301] [Citation(s) in RCA: 12] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2017] [Revised: 08/07/2017] [Accepted: 08/20/2017] [Indexed: 12/21/2022] Open
Abstract
AIM To discuss the pathophysiology of iron metabolism in chronic heart failure (CHF) and the current knowledge of the efficacy of intravenous (IV) iron therapy in patients with CHF and identify points of controversy as well as highlight areas for future research. DISCUSSION Iron deficiency is a recognized complication of many chronic conditions. Numerous studies have reported that iron deficiency is highly prevalent in patients with CHF and is associated with exercise intolerance, reduced quality of life, and increased risk of hospitalization and mortality. Several small studies have demonstrated IV iron to be associated with improvements in symptoms, exercise capacity, quality of life, renal function, New York Heart Association (NYHA) functional class and left ventricular ejection fraction (LVEF), and reduction in NT-pro-brain natriuretic peptide (NT-proBNP) in patients with CHF and iron deficiency. Two larger-scale trials confirming these results (FAIR-HF and CONFIRM-HF) have led to guideline recommendations that IV iron therapy should be considered in patients with CHF with reduced ejection fraction and iron deficiency (serum ferritin <100 μg/L, or ferritin between 100 and 299 μg/L with transferrin saturation <20%) to provide symptomatic relief and improve exercise capacity and quality of life. CONCLUSION Intravenous iron therapy improves symptoms, exercise capacity, and quality of life, at least in the short-to-intermediate time. However, there are still currently no standardized criteria used to define iron deficiency and the underlying mechanism of iron deficiency in CHF remains incompletely understood. Further work is required to improve the ability to identify iron deficiency in patients with CHF and evaluate the effect of iron repletion on hard endpoints including hospitalization and mortality.
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Affiliation(s)
- Chan-Keat Kang
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Michael Pope
- Department of Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
| | - Chim C Lang
- Division of Molecular and Clinical Medicine, Ninewells Hospital and Medical School, University of Dundee, Dundee, UK
| | - Paul R Kalra
- Department of Cardiology, Portsmouth Hospitals NHS Trust, Portsmouth, UK
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Kalra PR, Greenlaw N, Ferrari R, Ford I, Tardif JC, Tendera M, Reid CM, Danchin N, Stepinska J, Steg PG, Fox KM. Hemoglobin and Change in Hemoglobin Status Predict Mortality, Cardiovascular Events, and Bleeding in Stable Coronary Artery Disease. Am J Med 2017; 130:720-730. [PMID: 28109968 DOI: 10.1016/j.amjmed.2017.01.002] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.0] [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: 10/13/2016] [Revised: 12/31/2016] [Accepted: 01/03/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Anemia is a predictor of adverse outcomes in acute myocardial infarction. We studied the relationship of hemoglobin, or its change over time, and outcomes in patients with stable coronary artery disease. METHODS The ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease is a prospective, cohort study of outpatients with stable coronary artery disease (32,901 in 45 countries 2009-2010): 21,829 with baseline hemoglobin levels. They were divided into hemoglobin quintiles and anemia status (anemic or normal at baseline/follow-up: normal/normal; anemic/normal; normal/anemic; anemic/anemic. All-cause mortality, cardiovascular events, and major bleeding at 4-year follow-up were assessed. RESULTS Low baseline hemoglobin was an independent predictor of all-cause, cardiovascular, and noncardiovascular mortality, the composite of cardiovascular death/myocardial infarction or stroke and major bleeds (all P <.001; unadjusted models). Anemia at follow-up was independently associated with all-cause mortality (hazard ratio [HR], 1.90; 95% confidence interval [CI], 1.55-2.33 for anemic/anemic; 1.87; 1.54-2.28 for normal/anemic; both P <.001), noncardiovascular mortality (P <.001), and cardiovascular mortality (P = .001). Patients whose baseline anemia normalized (anemic/normal) were not at increased risk of death (HR, 1.02; 95% CI, 0.77-1.35), although the risk of major bleeding was greater (HR, 2.06; 95% CI, 1.23-3.44; P = .013) than in those with normal hemoglobin throughout. Sensitivity analyses excluding patients with heart failure and chronic kidney disease at baseline yielded qualitatively similar results. CONCLUSIONS In this large population with stable coronary artery disease, low hemoglobin was an independent predictor of mortality, cardiovascular events, and major bleeds. Persisting or new-onset anemia is a powerful predictor of cardiovascular and noncardiovascular mortality.
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Affiliation(s)
- Paul R Kalra
- Portsmouth Hospital NHS Trust, Portsmouth and NHLI Imperial College, London, United Kingdom.
| | | | - Roberto Ferrari
- Department of Cardiology and LTTA Centre, University Hospital of Ferrara and Maria Cecilia Hospital, GVM Care&Research, E.S: Health Science Foundation, Cotignola, Italy
| | - Ian Ford
- Robertson Centre, University of Glasgow, Scotland
| | | | | | - Christopher M Reid
- Curtin University, Western Australia & Monash University, Victoria, Australia
| | - Nicolas Danchin
- Cardiology, European Hospital Georges-Pompidou, Paris, France
| | | | - Ph Gabriel Steg
- Département Hospitalo-Universitaire FIRE, Hôpital Bichat, Assistance Publique - Hôpitaux de Paris, France; NHLI Imperial College, ICMS, Royal Brompton Hospital, London, United Kingdom
| | - Kim M Fox
- NHLI Imperial College, ICMS, Royal Brompton Hospital, London, United Kingdom
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38
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Kalra PR, García-Moll X, Zamorano J, Kalra PA, Fox KM, Ford I, Ferrari R, Tardif JC, Tendera M, Greenlaw N, Steg PG. Impact of chronic kidney disease on use of evidence-based therapy in stable coronary artery disease: a prospective analysis of 22,272 patients. PLoS One 2014; 9:e102335. [PMID: 25051258 PMCID: PMC4106833 DOI: 10.1371/journal.pone.0102335] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2014] [Accepted: 06/17/2014] [Indexed: 11/23/2022] Open
Abstract
Purpose To assess the frequency of chronic kidney disease (CKD), define the associated demographics, and evaluate its association with use of evidence-based drug therapy in a contemporary global study of patients with stable coronary artery disease. Methods 22,272 patients from the ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease (CLARIFY) were included. Baseline estimated glomerular filtration rate (eGFR) was calculated (CKD-Epidemiology Collaboration formula) and patients categorised according to CKD stage: >89, 60–89, 45–59 and <45 mL/min/1.73 m2. Results Mean (SD) age was 63.9±10.4 years, 77.3% were male, 61.8% had a history of myocardial infarction, 71.9% hypertension, 30.4% diabetes and 75.4% dyslipidaemia. Chronic kidney disease (eGFR<60 mL/min/1.73 m2) was seen in 22.1% of the cohort (6.9% with eGFR<45 mL/min/1.73 m2); lower eGFR was associated with increasing age, female sex, cardiovascular risk factors, overt vascular disease, other comorbidities and higher systolic but lower diastolic blood pressure. High use of secondary prevention was seen across all CKD stages (overall 93.4% lipid-lowering drugs, 95.3% antiplatelets, 75.9% beta-blockers). The proportion of patients taking statins was lower in patients with CKD. Antiplatelet use was significantly lower in patients with CKD whereas oral anticoagulant use was higher. Angiotensin-converting enzyme inhibitor use was lower (52.0% overall) and inversely related to declining eGFR, whereas angiotensin-receptor blockers were more frequently prescribed in patients with reduced eGFR. Conclusions Chronic kidney disease is common in patients with stable coronary artery disease and is associated with comorbidities. Whilst use of individual evidence-based medications for secondary prevention was high across all CKD categories, there remains an opportunity to improve the proportion who take all three classes of preventive therapies. Angiotensin-converting enzyme inhibitors were used less frequently in lower eGRF categories. Surprisingly the reverse was seen for angiotensin-receptor blockers. Further evaluation is required to fully understand these associations. The CLARIFY (ProspeCtive observational LongitudinAl RegIstry oF patients with stable coronary arterY disease) Registry is registered in the ISRCTN registry of clinical trials with the number ISRCTN43070564. http://www.controlled-trials.com/ISRCTN43070564.
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Affiliation(s)
- Paul R Kalra
- Portsmouth Hospitals NHS Trust, Portsmouth, United Kingdom; NHLI Imperial College, ICMS, London, United Kingdom
| | - Xavier García-Moll
- Unitat Hospitalització, Servei de Cardiologia, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain
| | | | - Philip A Kalra
- Salford Royal NHS Foundation Trust, Salford, United Kingdom
| | - Kim M Fox
- NHLI Imperial College, ICMS, London, United Kingdom; Royal Brompton Hospital, London, United Kingdom
| | - Ian Ford
- University of Glasgow, Glasgow, United Kingdom
| | - Roberto Ferrari
- Department of Cardiology, Azienda Ospedaliero-Universitaria di Ferrara, Ospedale di Cona, Cona, Italy
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Zachariah D, Brown R, Kanagala P, Bashir A, Mohan M, Callan P, Rajendra R, Clark AL, Squire I, Gunning M, Lang CC, Kalra PR. The impact of age and chronic kidney disease on secondary prevention post-primary percutaneous coronary intervention. QJM 2014; 107:185-92. [PMID: 24194563 DOI: 10.1093/qjmed/hct222] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [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] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVE Historical data suggest elderly patients and those with chronic kidney disease (CKD) receive suboptimal secondary prevention following myocardial infarction (MI). We evaluated the impact of age and CKD on secondary prevention following primary percutaneous coronary intervention (PPCI) in a contemporary unselected cohort. DESIGN We studied 1169 consecutive patients from five UK centres receiving PPCI for ST elevation MI, with use of evidence-based secondary prevention at discharge assessed by age (<60, 60-75 and >75 years) and estimated glomerular filtration rate (eGFR). Follow-up prescribing practice was assessed in 567 patients. RESULTS One-fifth of patients receiving PPCI were >75 years. This group received fewer secondary prevention drugs at discharge compared to younger patients (P < 0.01 for β-blockers, angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARB) and statins). By 6 weeks post-PPCI, there was a small drop-off in evidence-based therapy; β-blocker and statin use in those >75 years fell from 90% to 86% and 96% to 93%, respectively. CKD (eGFR<60 ml/min/1.73 m(2)) was seen in 17.6%. Declining renal function was associated with age, female sex and lower use of ACE inhibitor/ARB. At discharge 83.5% of patients with eGFR<60 ml/min/1.73 m(2) were receiving ACE inhibitors/ARB, dropping to 77.5% at 6 weeks (compared with 95% and 92%, respectively, in patients with eGFR >60 ml/min/1.73 m(2)). CONCLUSION The uptake of secondary prevention medication is high following PPCI in the UK, even in the elderly and in those with renal dysfunction. A focus on strategies to improve up-titration and continuation of drugs following discharge is required.
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Affiliation(s)
- D Zachariah
- Cardiology Department, Queen Alexandra hospital, Southwick Hill Rd, Cosham, Portsmouth, PO6 3LY, UK.
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Watson K, Zachariah D, Kalra PR. Challenges to advancing the evidence base for nephrology: the time is right for collaboration. J Ren Care 2013; 39:191-3. [PMID: 24245970 DOI: 10.1111/j.1755-6686.2013.12044.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Kathryn Watson
- Wessex Renal Transplant Unit, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, Hampshire, UK
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41
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Abstract
Biomarkers have an increasingly important clinical role in managing patients with heart failure as well as those with kidney disease, both common conditions with generally poor prognostic outcomes and huge impacts on healthcare economics. For patients with chronic heart failure, biomarkers have become centre place in streamlining diagnostic pathways as well as identifying those with worse prognosis. There is much interest in the role for biomarkers in identifying patients at risk of acute kidney injury, although a number of these currently remain as research tools or are in the early stages of evaluation in clinical practice. Patients with cardiorenal syndrome represent a particular challenge to the clinician, and recent studies have suggested a valuable clinical role for certain biomarkers in this setting, either on their own or in combination. This paper will focus on biomarkers with a current clinical role in patients with cardiorenal disease (natriuretic peptides and neutrophil gelatinase-associated lipocalin), although brief reference will be made to other biomarkers with potential future application.
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Affiliation(s)
- Donah Zachariah
- Department of Cardiology, Queen Alexandra Hospital, Portsmouth Hospitals NHS Trust, Portsmouth, Hampshire, UK.
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42
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Menown IBA, Davies S, Gupta S, Kalra PR, Lang CC, Morley C, Padmanabhan S. Resting heart rate and outcomes in patients with cardiovascular disease: where do we currently stand? Cardiovasc Ther 2013; 31:215-23. [PMID: 22954325 PMCID: PMC3798132 DOI: 10.1111/j.1755-5922.2012.00321.x] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/20/2012] [Indexed: 12/20/2022] Open
Abstract
BACKGROUND Data from large epidemiological studies suggest that elevated heart rate is independently associated with cardiovascular and all-cause mortality in patients with hypertension and in those with established cardiovascular disease. Clinical trial findings also suggest that the favorable effects of beta-blockers and other heart rate-lowering agents in patients with acute myocardial infarction and congestive heart failure may be, at least in part, due to their heart rate-lowering effects. Contemporary clinical outcome prediction models such as the Global Registry of Acute Coronary Events (GRACE) score include admission heart rate as an independent risk factor. AIMS This article critically reviews the key epidemiology concerning heart rate and cardiovascular risk, potential mechanisms through which an elevated resting heart rate may be disadvantageous and evaluates clinical trial outcomes associated with pharmacological reduction in resting heart rate. CONCLUSIONS Prospective randomised data from patients with significant coronary heart disease or heart failure suggest that intervention to reduce heart rate in those with a resting heart rate >70 bpm may reduce cardiovascular risk. Given the established observational data and randomised trial evidence, it now appears appropriate to include reduction of elevated resting heart rate by lifestyle +/- pharmacological therapy as part of a secondary prevention strategy in patients with cardiovascular disease.
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Kalra PR, Zachariah D, Greenlaw N, Ford I, Fox K. 127 CHARACTERISTICS AND TREATMENT OF 2346 PATIENTS WITH STABLE CORONARY ARTERY DISEASE IN UK PRIMARY CARE. Heart 2013. [DOI: 10.1136/heartjnl-2013-304019.127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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Sands R, Zachariah D, Kalra PR. 7th annual scientific meeting of the uk cardiorenal forum. J Ren Care 2013; 39:62-4. [PMID: 23432743 DOI: 10.1111/j.1755-6686.2013.12002.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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45
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Green D, Kalra PR, Kalra PA. Echocardiographic abnormalities in dialysis patients with normal ejection fraction. Nephrol Dial Transplant 2012; 27:4256-9. [PMID: 22892125 DOI: 10.1093/ndt/gfs357] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Darren Green
- Vascular Research Group, Department of Renal Medicine, Salford Royal Hospital, Manchester Academic Health Sciences Centre, UK.
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Sandek A, Bjarnason I, Volk HD, Crane R, Meddings JB, Niebauer J, Kalra PR, Buhner S, Herrmann R, Springer J, Doehner W, von Haehling S, Anker SD, Rauchhaus M. Studies on bacterial endotoxin and intestinal absorption function in patients with chronic heart failure. Int J Cardiol 2012; 157:80-5. [DOI: 10.1016/j.ijcard.2010.12.016] [Citation(s) in RCA: 142] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 12/04/2010] [Indexed: 12/19/2022]
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Banner NR, Bonser RS, Clark AL, Clark S, Cowburn PJ, Gardner RS, Kalra PR, McDonagh T, Rogers CA, Swan L, Parameshwar J, Thomas HL, Williams SG. UK guidelines for referral and assessment of adults for heart transplantation. Heart 2011; 97:1520-7. [PMID: 21856726 DOI: 10.1136/heartjnl-2011-300048] [Citation(s) in RCA: 85] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Patients with advanced heart failure have a dismal prognosis and poor quality of life. Heart transplantation provides an effective treatment for a subset of these patients. This article provides cardiologists with up-to-date information about referral for transplantation, the role of left ventricular assist devices prior to transplant, patient selection, waiting-list management and donor heart availability. Timing is of central importance; patients should be referred before complications (eg, cardiorenal syndrome or secondary pulmonary hypertension) have developed that will increase the risk of, or potentially contraindicate, transplantation. Issues related to heart failure aetiology, comorbidity and adherence to medical treatment are reviewed. Finally, the positive role that cardiologists can play in promoting and facilitating organ donation is discussed.
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Affiliation(s)
- Nicholas R Banner
- Consultant in Cardiology, Transplant Medicine and Circulatory Support, The Royal Brompton and Harefield NHS Trust, Harefield Hospital, Hill End Road, Harefield, Middlesex UB9 6JH, UK.
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Assomull RG, Shakespeare C, Kalra PR, Lloyd G, Gulati A, Strange J, Bradlow WM, Lyne J, Keegan J, Poole-Wilson P, Cowie MR, Pennell DJ, Prasad SK. Role of cardiovascular magnetic resonance as a gatekeeper to invasive coronary angiography in patients presenting with heart failure of unknown etiology. Circulation 2011; 124:1351-60. [PMID: 21900085 DOI: 10.1161/circulationaha.110.011346] [Citation(s) in RCA: 93] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND In patients presenting with new-onset heart failure of uncertain etiology, the role of coronary angiography (CA) is unclear. Although conventionally performed to differentiate underlying coronary artery disease from dilated cardiomyopathy, CA is associated with a risk of complications and may not detect an ischemic cause resulting from arterial recanalization or an embolic episode. In this study, we assessed the diagnostic accuracy of a cardiovascular magnetic resonance (CMR) protocol incorporating late gadolinium enhancement (LGE) and magnetic resonance CA as a noninvasive gatekeeper to CA in determining the etiology of heart failure in this subset of patients. METHODS AND RESULTS One hundred twenty consecutive patients underwent CMR and CA. The etiology was ascribed by a consensus panel that used the results of the CMR scans. Similarly, a separate consensus group ascribed an underlying cause by using the results of CA. The diagnostic accuracy of both strategies was compared against a gold-standard panel that made a definitive judgment by reviewing all clinical data. The study was powered to show noninferiority between the 2 techniques. The sensitivity of 100%, specificity of 96%, and diagnostic accuracy of 97% for LGE-CMR were equivalent to CA (sensitivity, 93%; specificity, 96%; and diagnostic accuracy, 95%). As a gatekeeper to CA, LGE-CMR was also found to be a cheaper diagnostic strategy in a decision tree model when United Kingdom-based costs were assumed. The economic merits of this model would change, depending on the relative costs of LGE-CMR and CA in any specific healthcare system. CONCLUSION This study showed that LGE-CMR is a safe, clinically effective, and potentially economical gatekeeper to CA in patients presenting with heart failure of uncertain etiology.
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Affiliation(s)
- Ravi G Assomull
- Cardiovascular Magnetic Resonance Unit, Royal Brompton Hospital, London, UK
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Chrysochou C, Sharma R, Kalra PA, Kalra PR. Improved left ventricular filling following bilateral renal artery stenting. Int J Cardiol 2011; 150:e40-1. [PMID: 19897262 DOI: 10.1016/j.ijcard.2009.09.477] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2009] [Accepted: 09/09/2009] [Indexed: 11/19/2022]
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