Abstract Background The contribution of diabetes to the burden of heart failure (HF) remains largely undescribed. Assessing diabetes temporal trends among US patients hospitalized with HF, and their ...relation with quality measures, in real-world practice can help to define this burden. Methods Using data from the Get With the Guidelines–Heart Failure registry, we assessed temporal trends in diabetes prevalence among patients with HF, and in subgroups with reduced ejection fraction (HFrEF - EF <40%), borderline EF (HFbEF - 40% ≤ EF< 50%), or preserved EF (HFpEF - EF ≥50%), hospitalized between 2005 and 2015. Logistic regression was used to assess whether in-hospital outcomes and HF quality of care were related to trends. Results Among 364,480 HF hospitalizations, 160,171 had diabetes (44.0% overall, 41.8% in HFrEF, 46.7% in HFbEF, 45.5% in HFpEF). There was a temporal increase in diabetes frequency in HF patients (43.2% to 45.8%; Ptrend < 0.0001), including among those with HFrEF (42.0% to 43.6%; Ptrend < 0.0001), HFbEF (46.0% to 49.2%; Ptrend < 0.0001), or HFpEF (43.6% to 46.8%, Ptrend < 0.0001). Diabetic patients had a longer hospital stay (adjusted odds ratio aOR: 1.14, 95%CI: 1.12–1.16), but lower in-hospital mortality (aOR: 0.93 0.89–0.97) compared to those without diabetes, with limited differences in quality measures. Temporal trends in diabetes were not associated with in-hospital mortality or length of stay. There were no temporal interactions of most HF quality measures with diabetes status. Conclusions Approximately 44% of hospitalized HF patients have diabetes, and this proportion has been increasing over the past 10 years, particularly among those patients with new onset HFpEF.
The efficacy, safety, and clinical importance of extended-duration thromboprophylaxis (EDT) for prevention of venous thromboembolism (VTE) in medical patients remain unclear. We compared the efficacy ...and safety of EDT in patients hospitalized for medical illness.
Electronic databases of PubMed/MEDLINE, EMBASE, Cochrane Central, and ClinicalTrials.gov were searched from inception to March 21, 2019. We included randomized clinical trials (RCTs) reporting use of EDT for prevention of VTE. We performed trial sequential and cumulative meta-analyses to evaluate EDT effects on the primary efficacy endpoint of symptomatic VTE or VTE-related death, International Society on Thrombosis and Haemostasis (ISTH) major or fatal bleeding, and all-cause mortality. The pooled number needed to treat (NNT) to prevent one symptomatic or fatal VTE event and the number needed to harm (NNH) to cause one major or fatal bleeding event were calculated. Across 5 RCTs with 40,247 patients (mean age: 67-77 years, proportion of women: 48%-54%, most common reason for admission: heart failure), the duration of EDT ranged from 24-47 days. EDT reduced symptomatic VTE or VTE-related death compared with standard of care (0.8% versus 1.2%; risk ratio RR: 0.61, 95% confidence interval CI: 0.44-0.83; p = 0.002). EDT increased risk of ISTH major or fatal bleeding (0.6% versus 0.3%; RR: 2.04, 95% CI: 1.42-2.91; p < 0.001) in both meta-analyses and trial sequential analyses. Pooled NNT to prevent one symptomatic VTE or VTE-related death was 250 (95% CI: 167-500), whereas NNH to cause one major or fatal bleeding event was 333 (95% CI: 200-1,000). Limitations of the study include variation in enrollment criteria, individual therapies, duration of EDT, and VTE detection protocols across included trials.
In this systematic review and meta-analysis of 5 randomized trials, we observed that use of a post-hospital discharge EDT strategy for a 4-to-6-week period reduced symptomatic or fatal VTE events at the expense of increased risk of major or fatal bleeding. Further investigations are still required to define the risks and benefits in discrete medically ill cohorts, evaluate cost-effectiveness, and develop pathways for targeted implementation of this postdischarge EDT strategy.
PROSPERO CRD42018109151.
Celotno besedilo
Dostopno za:
DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Abstract The prevalence of patients with concomitant heart failure (HF) and diabetes mellitus (DM) continues to increase with the general aging of the population. In patients with chronic HF, ...prevalence of DM is 24% compared with 40% in those hospitalized with worsening HF. Patients with concomitant HF and DM have diverse pathophysiologic, metabolic, and neurohormonal abnormalities that potentially contribute to worse outcomes than those without comorbid DM. In addition, although stable HF outpatients with DM show responses that are similar to those of patients without DM undergoing evidence-based therapies, it is unclear whether hospitalized HF patients with DM will respond similarly to novel investigational therapies. These data support the need to re-evaluate the epidemiology, pathophysiology, and therapy of HF patients with concomitant DM. This paper discusses the role of DM in HF patients and underscores the potential need for the development of targeted therapies.
Abstract Objectives This study assessed the comparative frequency of precipitating clinical factors leading to hospitalization among heart failure (HF) patients with reduced, borderline, and ...preserved ejection fraction (EF) Background There are few data assessing the comparative frequency of clinical factors leading to HF among hospitalized among patients with reduced, borderline, and preserved EF. Methods We analyzed the factors potentially contributing to HF hospitalization among 99,825 HF admissions from 305 hospitals in the Get With The Guidelines-HF (GWTG-HF) database between January 2005 and September 2013 and assessed their association with length of stay and in-hospital mortality. Results Mean patient age was 72.6 ± 14.2 years, 49% were female, and mean EF was 39.3 ± 17.2%. Common factors included pneumonia/respiratory process (28.2%), arrhythmia (21.7%), medication noncompliance (15.8%), worsening renal failure (14.7%), and uncontrolled hypertension (14.5%). In patients with borderline EF (EF 40% to 49%), pneumonia was associated with longer hospital stay, whereas dietary and medication noncompliance were associated with reduced length of stay. In patients with preserved EF (EF ≥50% or qualitative assessment of normal or mild dysfunction), pneumonia, weight gain, and worsening renal function were independently associated with longer lengths of stay. Worsening renal function and pneumonia were independently associated with higher in-hospital mortality in all HF groups, and acute pulmonary edema was associated with higher mortality in reduced EF. Dietary noncompliance (14.7%) was associated with reduced mortality for all groups but reached statistical significance in the subgroups of reduced (odds ratio OR: 0.65; 95% confidence interval CI: 0.46 to 0.91) and preserved systolic function (OR: 0.52; 95% CI: 0.33 to 0.83). Patients presenting with ischemia had a higher mortality rate (OR: 1.31; 95% CI: 1.02 to 1.69; and 1.72; 95% CI: 1.27 to 2.33, respectively, in the 2 groups). Conclusions Potential precipitating factors among patients hospitalized with HF vary by EF group and are independently associated with clinical outcomes.
Aims
The clinical outcomes for patients with worsening chronic heart failure (WCHF) remain exceedingly poor despite contemporary evidence‐based therapies, and effective therapies are urgently needed. ...Accumulating evidence supports augmentation of cyclic guanosine monophosphate (cGMP) signalling as a potential therapeutic strategy for HF with reduced or preserved ejection fraction (HFrEF and HFpEF, respectively). Direct soluble guanylate cyclase (sGC) stimulators target reduced cGMP generation due to insufficient sGC stimulation and represent a promising method for cGMP enhancement.
Methods
The phase II SOluble guanylate Cyclase stimulatoR in heArT failurE Study (SOCRATES) programme consists of two randomized, parallel‐group, placebo‐controlled, double‐blind, multicentre studies, SOCRATES‐REDUCED (in patients with LVEF <45%) and SOCRATES‐PRESERVED (in those with LVEF ≥45%), that will explore the pharmacodynamic effects, safety and tolerability, and pharmacokinetics of four dose regimens of the once‐daily oral sGC stimulator vericiguat (BAY 1021189) over 12 weeks compared with placebo. These studies will enrol patients stabilized during hospitalization for HF at the time of discharge or within 4 weeks thereafter. The primary endpoint in SOCRATES‐REDUCED is change in NT‐proBNP at 12 weeks. The primary endpoints in SOCRATES‐PRESERVED are change in NT‐proBNP and left atrial volume at 12 weeks.
Perspectives
SOCRATES will be the first programme to enrol specifically both inpatients and outpatients with WCHF and patients with reduced or preserved ejection fraction. Results will inform the benefits of pursuing subsequent event‐driven clinical outcome trials with sGC stimulators in this patient population.
Trial registration
NCT01951625 (SOCRATES‐REDUCED) and NCT01951638 (SOCRATES‐PRESERVED)
Aims
We sought to conduct a meta‐analysis regarding the safety and efficacy of sodium‐glucose co‐transporter 2 (SGLT2) inhibitors in patients with heart failure (HF).
Methods and results
MEDLINE, ...Scopus, Cochrane CENTRAL, and ClinicalTrials.gov were searched from their inception to November 2020 for placebo‐controlled randomized controlled trials of SGLT2 inhibitors. Randomized controlled trials were selected if they reported at least one of the prespecified outcomes in patients with HF. Hazard ratios (HRs) or risk ratios and their corresponding 95% confidence intervals were pooled using a random‐effects model. A total of seven trials including 16 820 HF patients (N = 8884 in the SGLT2 inhibitor arms; N = 7936 in the placebo arms) were included. In the overall HF cohort, SGLT2 inhibitors compared with placebo significantly reduced the risk of the composite endpoint of first HF hospitalization or cardiovascular death HR: 0.77 (0.72–0.83); P < 0.001; I2 = 0%, time to first HF hospitalization HR: 0.71 (0.64–0.78); P < 0.001; I2 = 0, cardiovascular mortality HR: 0.87 (0.79–0.96); P = 0.005; I2 = 0%, and all‐cause mortality HR: 0.89 (0.82–0.96); P = 0.004; I2 = 0%. Results remained consistent across HF‐specific trials and according to diabetes mellitus status. A trend towards benefit was observed in patients with HF with preserved ejection fraction for the composite of HF hospitalization and cardiovascular death HR: 0.80 (0.63–1.00); P = 0.05; I2 = 29%. No increased risk of hypovolaemia, hyperkalaemia, and hypotension was seen with SGLT2 inhibitors compared with placebo.
Conclusions
SGLT2 inhibitors significantly improve cardiovascular outcomes including cardiovascular and all‐cause mortality in patients with HF without an increased risk of serious adverse events. A trend towards benefit was observed in patients with HF with preserved ejection fraction.
We present the hypothesis that advanced stage cancer is also a heart failure syndrome. It can develop independently of or in addition to cardiotoxic effects of anti‐cancer therapies. This includes an ...increased risk of ventricular arrhythmias. We suggest the pathophysiologic link for these developments includes generalized muscle wasting (i.e. sarcopenia) due to tissue homeostasis changes leading to cardiac wasting associated cardiomyopathy. Cardiac wasting with thinning of the ventricular wall increases ventricular wall stress, even in the absence of ventricular dilatation. In addition, arrhythmias may be facilitated by cellular wasting processes affecting structure and function of electrical cells and conduction pathways.
We submit that in some patients with advanced cancer (but not terminal cancer), heart failure therapy or defibrillators may be relevant treatment options. The key points in selecting patients for such therapies may be the predicted life expectancy, quality of life at intervention time, symptomatic burden, and consequences for further anti‐cancer therapies.
The cause of death in advanced cancer is difficult to ascertain and consensus on event definitions in cancer is not established yet. Clinical investigations on this are called for. Broader ethical considerations must be taken into account when aiming to target cardiovascular problems in cancer patients.
We suggest that focused attention to evaluating cardiac wasting and arrhythmias in cancer will herald a further evolution in the rapidly expanding field of cardio‐oncology.
Highlights • Enrollment criteria used in advanced heart failure clinical trials vary widely. • New York Heart Association class and left ventricular ejection fraction are the most frequent criteria. ...• Cutoff points for quantitative criteria vary considerably. • Average left ventricular ejection fraction among participants increased over time.
Abstract Recent clinical trials in patients with heart failure with preserved ejection fraction (HFpEF) have provided important insights into participant selection strategies. Historically, HFpEF ...trials have included patients with relatively preserved left ventricular ejection fraction ranging from 40% to 55% and a clinical history of heart failure. Contemporary HFpEF trials have also incorporated inclusion criteria such as hospitalization for HFpEF, altered functional capacity, cardiac structural and functional abnormalities, and abnormalities in neurohormonal status (e.g., elevated natriuretic peptide levels). Careful analyses of the effect of these patient selection criteria on outcomes in prior trials provide valuable lessons for future trial design. We review recent and ongoing HFpEF clinical trials from a patient selection perspective and appraise trial patient selection methodologies in relation to outcomes. This review reflects discussions between clinicians, scientists, trialists, regulators, and regulatory representatives at the 10th Global CardioVascular Clinical Trialists Forum in Paris, France, on December 6, 2013.
Depression in heart failure: Can PHQ-9 help? Bhatt, Kunal N; Kalogeropoulos, Andreas P; Dunbar, Sandra B ...
International journal of cardiology,
10/2016, Letnik:
221
Journal Article
Recenzirano
Abstract Background The Patient Health Questionnaire 9 (PHQ-9) is an effective tool for identification and grading of depression symptoms. Data on PHQ-9 utility for patients with heart failure (HF) ...are limited. Methods We evaluated the severity of depression by PHQ-9 at baseline and its association with health care resource utilization (HCRU) rates and quality of life (QoL) in 308 outpatients enrolled in a prospective HF cohort study. Depression symptoms were stratified according to PHQ-9 score as minimal (0–4), mild (5–9), or moderate-to-severe (10–27). Results Mean age of patients was 57 ± 11 years; 65% were men; 50% were white and 47% black; ejection fraction was 30 ± 15%. Over 24 ± 12 months (total: 625 person-years), there were 41 (13.3%) major clinical events (34 deaths, 5 transplants, 2 ventricular assist device implantations), 633 all-cause admissions (249 39.3% for HF), and 362 emergency department (ED) visits. Moderate-to-severe depressive symptoms were associated with 70% more all-cause admissions compared to patients without depressive symptoms and 2.5 times more HF-related admissions. However, less than 50% of patients with moderate-to-severe symptoms were on antidepressants. In adjusted analyses, even mild depressive symptoms were associated with 57% more all-cause admissions compared to patients without depressive symptoms and more than 2-fold higher rate of HF-related admissions. Depressive symptoms were not associated with ED visits. Increasing PHQ-9 score was associated with progressively worse QoL. PHQ-9 was not associated with major clinical events. Conclusions PHQ-9 effectively identifies HF patients at risk for increased HCRU and lower QoL. Interventions to reduce depression symptoms may help improve HF outcomes.
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