Abstract
Background
Two–dimensional speckle tracking (2D–ST) analysis allows to evaluate both atrial and ventricular function. Recently, it has been demonstrated that the ratio between left atrial ...reservoir (LAr) assessed by 2D–ST and the E/e’ ratio could allow a more accurate estimation of left ventricular filling pressure. Aim of the study. To evaluate if the ratio between LAr and E/e’ is also associated with heart failure progression among chronic heart failure (CHF) outpatients.
Methods
All patients enrolled underwent a medical visit, an ECG and an echocardiographic examination. LAr was assessed by 2D–ST. The early diastolic peak at pulsed Doppler (E) and at the level of septal (e’s) and lateral (e’l) mitral annulus by Tissue Doppler Imaging (TDI) were also evaluated. Then the ratio between E and e’s (E/es) and between E and the mean of e’s and e’l (E/em) were also calculated. Finally, the ratio between LAr and E/es (LAr/Ees) and E/em (LAr/Eem) were computed. During follow–up the progression of heart failure, defined as heart failure hospitalization or death, were evaluated.
Results
Among 256 patients, LAr/Eem and LA/Ees were available in 191 patients (age 64±13 years,80 % males, mean LVEF 39±11%, NYHA class 2.3±0.5). All patients were in conventional medical therapy (sacubitril/valsartan or ACE–inhibitors or Angiotensin II receptor blockers in 85%, beta–blockers in 94%, mineralcorticoid receptor antagonists in 73%, diuretics in 81%, SGLT2 inhibitors in 21%). During a mean follow–up of 13±7 months, 25 patients experienced death (9) and/or hospitalization (21) for heart failure worsening. At univariate Cox univariate regression analysis, both LAr/Eem (HR 0.61; 95%CI: 0.43–0.87; p:0.006) and LAr/Ees (HR 0.43; 95%CI: 0.25–0.71; p:0.001) were associated with the events. However, LAr/Ees showed a greater accuracy than LAr/Eem (C–index 0.76 vs. 0.73) and remained significantly associated with the events at multivariate analysis after correction for age, LVEF, NYHA class and estimated glomerular filtration rate (HR: 0.55; 95%CI: 0.33–0.92; p:0.22). Figure shows Kaplan–Meier curves according with the median value of LAr/Eem (panel A) and LAr/Ees (panel B).
Conclusions
The ratio between LAr and E/es is a new echocardiographic parameter able to reflect both left ventricular filling pressure and worse prognosis among patients affected by CHF. Further studies should evaluate its incremental value in stratifying patients’ prognosis.
Many patients with chronic opioid dependence are referred to drug-free outpatient treatment following inpatient detoxification even though successful outpatient treatment engagement and abstinence ...from opioids occur only in a minority of cases. This retrospective cohort analysis of medical records documents the post-discharge outcome in a treatment setting that maximizes the support during transition to abstinence-oriented outpatient care, with comprehensive social, medical and mental health services, including the availability of naltrexone. Participants were male veterans (N = 112) admitted at an urban VAmedical center. Most patients (78%) successfully completed acute detoxification, 49% initiated naltrexone, and 76% accepted a VA aftercare plan. At 90-day follow-up, only 22% remained in aftercare, and < 3% had toxicology-verified abstinence from opioids. At one-year follow-up, 1 out of 5 had been readmitted for detoxification and 4.5% had died. Most patients successfully detoxified from opioids, but very few remained engaged and stabilized in abstinence-oriented outpatient treatment.
Abstract
Background
Myocardial deformation evaluated by two–dimensional speckle tracking echocardiography (STE) is a useful tool to evaluate both left and right ventricular function. However, there ...are no conclusive data about the relationship between strain measures and heart rate (HR).
Aim of the Study
To analyse changes in left (LV) and right ventricular (RV) longitudinal strain associated with variations of HR in patients with and without chronic heart failure (CHF). Methods. We enrolled 45 patients. Of the 38 patients diagnosed with CHF, 21 were carrying an ICD (Group 1), and 17 an ICD with CRT (Group 2). Group 3 included 7 participants without CHF with sinus node dysfunction that were carrying a pacemaker. The frequency of atrial stimulation was increased to 90 beats/min and an echocardiogram was performed at each increase of 10 beats/min. Global LV and RV longitudinal strain (LVGLS and RVGLS, respectively) and RV free wall longitudinal strain (RVfwLS) were calculated at each HR, together with other echocardiographic parameters. Worsening or improvement of strain measures was defined as a relative change from baseline of 10%.
Results
The reproducibility of strain measurements was assessed in all the images obtained at the different HRs for 19 of the study participants. A high degree of reproducibility was observed for LVGLS (ICC = 0.96; 95% CI, 0.93 – 0.97) as well as for RVGLS (ICC = 0.91; 95%CI, 0.86 – 0.94) and RVfwLS (ICC = 0.91; 95%CI, 0.85 – 0.94). When analysed as continuous variables, significant reductions in LVGLS were detected at higher HRs, whereas improvements in both RVGLS and RVfwLS were observed (left panels of the figure). Patients with worsening of LVGLS (76% overall) were more likely to present lower baseline LV function and maximum relative changes of LVGLS correlated significantly with the E/e’ ratios (r = –0.56; p < 0.001). Only few patients (18% for RVGLS and 16% for RVfwLS) exhibited HR–related worsening of RV strain measures, which was associated with lower levels of baseline RV function and higher pulmonary systolic pressures. Finally, 21 (47%) and 25 (56%) of the participants responded with improvements in RVGLS and RVfwLS, respectively. Right panels of the figure show the trend of left and right measures in the different groups.
Conclusions
Our findings revealed heterogeneous RV and LV responses to increases in HR. These findings might ultimately be used to optimize cardiac functionality at rest in patients diagnosed with CHF.
Abstract
Aims
The current European Society of Cardiology guidelines provide clear indication for the treatment of acute and chronic heart failure (HF).Nevertheless,there is the constant need of ...real–world evidence concerning the effectiveness,adherence and persistence to drug therapy.We investigated the use of sacubitril/valsartan for the treatment of HF with reduced ejection fraction in real–world clinical practice in Italy.
Methods
An observational, retrospective,non–interventional cohort study based on electronic medical records from nine specialized hospital heart failure Centers in Italy was carried out on patients prescribed with sacubitril/valsartan.
Results
Overall,948 patients had a prescription of sacubitril/valsartan, 924 (mean age 64.5 years, 84.6% male) had 6 months of characterization and 12 months of follow–up. The initial dose was 24/26 mg for 548 (59.3%),49/51 mg for 333 (36.0%),97/103 mg for 43 (4.7).The final dose was available for 881 patients and it was:24/26 mg for 254 (28.8%),49/51 mg for 229 (26.0%),97/103 mgfor 398 (45.2).The time to maximal dose prescribed (weeks) was:for 97/103 mg 6.9 ± 6.2 weeks;for 49/51 mg 6.2 ± 6.7 weeks.Blood pressure and hypotension in 65% of the patients, and worsening of chronic kidney disease in 10.6% were the main reasons for not reaching target dose; fifty percent had a change in sacubitril/valsartan dose during follow–up and 70.2% patients were persistent with treatment during the last three months of follow–up, with a sensitivity analysis (persistence during the last four months of follow–up) showing 72.0% persistence. Adherence data, available for 387 patients, showed fully adherence for 53%.Discontinuation (102/387 patients) was mainly due to hypotension and occurred after a mean time of 34.3 ± 28.7 weeks. During follow–up, of the 606 patients with available data, 434 patients (71.6%) had an HF add–on drug or drugs concomitant to sacubitril/valsartan. Although not significantly (p=0.405), HF–related hospitalization during follow–up was higher in not persistent patients (23.9%) versus persistent (19%) to sacubitril/valsartan treatment.Pharmacoutilization data at 1–year expressed as medication possession ratio (MPR) are shown in the Figure.
Conclusions
Real–world data of sacubitril/valsartan use in clinical practice in Italy show a rapid titration of to target dose, high therapeutic adherence allowing a good level of therapeutic management in line with ESC guidelines in patients with reduced ejection fraction.
Abstract
Background
Sacubitril/valsartan reduced heart failure (HF)–related hospitalizations and cardiovascular mortality in PARADIGM–HF and has become a foundational treatment for HF with reduced ...ejection fraction (HFrEF). However, data of its routine real–world use is limited, and evidence from Italian settings is lacking. Aim of the study. The REAL.IT study aimed to characterize the demographics, pharmacotherapy, clinical characteristics, and outcomes of sacubitril/valsartan–treated Italian patients with HFrEF.
Methods
Electronic medical records of patients initiating sacubitril/valsartan from October 2016 to June 2019 at nine specialized hospital outpatient HF Centers across Italy were reviewed.
Results
Overall, 924 adults (mean age 64.5 years, 84.6% male) were included. Clinical characteristics are shown in Table 1. At baseline, 38.7% had an ischemic HF etiology, 45.9% hypertension, 23.2% atrial fibrillation, 25.4% diabetes mellitus, 26.1% an implantable cardioverter–defibrillator, 31.9% coronary artery bypass grafting. There were no clear patterns of patient selection over time. As shown in Table 1, during follow–up NYHA class improved in 37.5% after a mean of 5.3 ± 3.8 months; 36.1% and 16.7% of patients were in NYHA class III during characterization and after one year of follow–up, respectively. Left ventricular ejection fraction (LVEF) improved ≥5% in 56.3% of patients at one year; 39.7% had ≥30% reduction of N–terminal pro–B–type natriuretic peptide; 2.2% had hyperkalemia during characterization and 2.6% during follow–up; 3.8% had hypotension during characterization and 12% during follow–up. A total of 50 (5.8%) of patients had device implantation (ICD/CRT) during follow–up. HF–related hospitalization was recorded in 19.6% of patients during follow–up; 3.8% of patients died, approximately 1.3% from cardiovascular causes.
Conclusions
Our real–world data confirm the favorable effectiveness and tolerability of sacubitril/valsartan observed in pivotal randomized controlled trials.
Abstract Background Over the last few years, treatment with sodium glucose cotransporter 2 inhibitors (SGLT2i) dapaglifozin and empaglifozin was shown to reduce the combined risk of cardiovascular ...death and/or hospitalization for heart failure (HF) among patients with heart failure with reduced ejection fraction. Subsequent RCTs have demonstrated similar reduction in the combined endpoint also in patients with left ventricular ejection fraction (LVEF) >40%. Nevertheless, real world data on the current state of implementation of SGLT2i therapy in HF clinical practice are scarce. The aim of the study was therefore to evaluate the impact of SGLT2i treatment in a real world population of HF patients. Methods 527 consecutive patients with HF, treated with SGLT2i and with 6 months of follow-up already enrolled in the PONTE (PDTA FOR THE INTEGRATED FOLLOW-UP IN THE HOSPITAL TERRITORY OF THE PATIENT WITH HEART FAILURE) HF project, a care model implemented in Puglia region (Italy) based on hospital-territory integration aimed at the optimized management of patient with HF after hospitalization, were considered for the study. Demographic, clinical, laboratory and instrumental characteristics, changes in NYHA class, creatinine, NT-proBNP, medications, LVEF after initiation of therapy with SGLT2i were evaluated. Results The 527 enrolled patients (mean age of 67,40 years, 75% hypertensive, 39% diabetic, 51% ischemic heart disease, 52% with ICD, 35% with atrial fibrillation) were in NYHA class I in 3,2% of cases, class II in 56,6%, class III in 38,5%, class IV in 1,7%. Mean LVEF was 34,20% (63% of patients had LVEF <35%), NT-proBNP 2606,86 pg/ml, creatinine 1,19 mg/dl. 95,1% of patients was on treatment with beta-blockers, 52,7% with ACE inhibitors, 55,1% with ARNI. After a follow-up of 6 months, a reduction of patients in NYHA classes III+IV from 40,2 to 19,0% as well as an increase in patients in classes I+II from 59,8 to 81,0% (NYHA I increasing from 3,2 to 14,6%) were observed. Furthermore, mean LVEF increased from 34,20 to 37,68% and patients taking loop diuretics reduced from 83,9 to 77,4%. Creatinine remained stable (1,19 vs 1,21 mg/dl), while NT-proBNP lowered from 2606,86 to 1603,32 pg/ml. Conclusions Our real world data on SGLT2i in HF patients seem to confirm the efficacy of this class of drugs in a short term follow-up, with a positive effect on symptoms (improvement in NYHA class and fewer patients taking loop diuretics), NT-proBNP and LVEF.
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