Angiotensin-converting Enzyme Inhibitors/angiotensin Receptor Blockers Research Articles

Association between critical care admission and chronic medication discontinuation post-hospital discharge: A retrospective cohort study

Background: Discontinuation of important chronic medication after hospitalisation is common. This study aimed to investigate the association between critical care (vs non-critical care) admission and discontinuation of chronic medications post-hospital discharge, along with factors associated with discontinuation among critical care survivors. Methods: This was a retrospective cohort study in Lothian, Scotland of adults who were admitted to hospital between 01/01/2012 and 31/12/2019 and survived to hospital discharge. Medication classes investigated were statins, angiotensin converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARBs), beta-blockers, oral anticoagulants, and thyroid hormones. The risk of medication discontinuation for each class was estimated by odds ratios (OR), with 95% confidence intervals (95%CI), using multivariable logistic regression adjusted for patient demographics, main clinical condition, and index comorbidity. A secondary analysis assessed factors associated with discontinuation in critical care survivors. Results: There were 22,340 critical care and 367,185 non-critical care survivors included. Critical care admission had the highest association with ACEi/ARBs discontinuation (adjusted OR 2.41, 95%CI: 2.26–2.58), followed by oral anticoagulants (adjusted OR 1.33, 95%CI: 1.15–1.53), and beta blockers (adjusted OR 1.18, 95%CI: 1.07–1.29). There was no significant association with thyroid hormones or statin discontinuation. Among critical care survivors, hospital length of stay of 14 days or more was associated with increased discontinuation across all medication classes. Conclusion: Critical care admission was associated with discontinuation of three out of five medication classes studied (ACEi/ARBs, beta-blockers, and oral anticoagulants). Further research is needed to understand the reason for increased medication discontinuation in critical care survivors and how these risks can be mitigated to improve patient outcomes.

Variability in guideline-directed medical therapy across sites and operators and long-term mortality and amputation outcomes risk in patients undergoing peripheral vascular interventions

The use of guideline-directed medical therapy (GDMT) in patients undergoing peripheral vascular interventions (PVIs) decreases the risk of death and amputation and may decrease hospital readmissions. The variability of GDMT prescription across sites and operators and the proportionality of risk is not well understood. We aimed to study the association between variability of GDMT prescription at the site and operator level and outcomes (including 90-day readmissions and 24-month all-cause mortality and major amputation). We examined GDMT discharge rates in PVIs performed between 2017 and 2018 using Medicare-linked Vascular Quality Initiative registry. GDMT included a statin, antiplatelet therapy, and angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE-i/ARB) if hypertensive. Quartiles (Q1-4) of GDMT rates were documented by operators and sites and variability was quantified using median odds ratios (MOR) and intraclass correlation (ICC). The association between lower GDMT rates (per 10%) by sites and operators with 90-day readmission were calculated using logistic regression, and with 24-month mortality and major amputation using parametric survival model. Models were adjusted for patient-level factors and included sites and operators nested within sites as 2 random effects. GDMT rates for 17,147 patients across 223 sites and 1,263 operators ranged from 0% to 38% (Q1, MOR 1.43, 95%CI 1.39-1.47, P ≤ .001) to 57%-100% (Q4, MOR 1.48, 95%CI 1.44-1.51, P ≤ .001). Four percent of variance in GDMT use was explained by sites (ICC 3.9, 95%CI 2.9-5.3) and operators (ICC 4.1, 95%CI 3.1-5.4). A dose-response relationship was noted between lower GDMT rates and increased risk of 90-day readmission risk by sites (P = .021) and operators (P < .001). Lower GDMT prescription by site was associated with higher risk of 24-month mortality (HR = 1.07, 95%CI 1.02-1.13) and major amputation (HR = 1.08, 95%CI 1.01-1.15). Similar associations were found for GDMT use by provider (mortality HR = 1.05, 95%CI 1.02-1.08 and amputation HR = 1.04, 95%CI 1.00-1.08). Both at the operator and health system level, there was significant variability in GDMT prescription following PVI, proportionally translating into risk for readmission, mortality, and major amputation. Targeted quality efforts should prioritize both operator and site levels to improve GDMT use and outcomes for patients undergoing PVI.

Add-on Sacubitril/Valsartan Therapy Induces Left Ventricular Remodeling in Non-responders to Cardiac Resynchronization Therapy to a Similar Extent as in Heart Failure Patients Without Resynchronization.

Non-responders to cardiac resynchronization therapy (CRT-NR) have poor prognosis. Sacubitril/valsartan (SV) treatment improved the outcome of patients with heart failure with reduced left ventricular (LV) ejection fraction (HFrEF) in randomized trials with no data on the specific cohort of CRT-NRs. The aim of this study was to compare the echocardiographic and biomarker changes in CRT-NR patients treated with versus without SV, and in patients with HFrEF on SV therapy. CRT-NR patients initiated on SV (groupI), CRT-NR patients on angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) (groupII), and patients with HFrEF (without CRT) initiated on SV (groupIII) were identified in our heart failure (HF) registry. CRT-NR was defined as < 10% improvement in left ventricular ejection fraction (LV EF) 6months after the implantation. Echocardiographic parameters and N-terminal pro-B-type natriuretic peptide (NT-proBNP) levels at baseline and at the end of follow-up were compared. A total of 275 patients (groupI, 70; groupII, 70; and groupIII, 135) were included. After a follow-up of 7.54 ± 1.8months (mean ± standard deviation [SD]), LV EF (%) increased in groupI (25.2 ± 5.7 versus 29.4% ± 6.7; p < 0.001) and in groupIII (26.6 ± 6.4 versus 29.9 ± 6.7; p < 0.001). LV end-systolic diameters (mm) decreased in groupI (56.6 ± 9.0 versus 54.3 ± 8.7; p = 0.004) and in groupIII (55.9 ± 9.9 versus 54.3 ± 11.2; p = 0.021). The levels of NT-proBNP (pg/mL) decreased in groupI (2058.86 [1041.07-4502.51] versus 1121.55 [545-2541]; p < 0.001) and in groupIII (2223.35 [1233.03-4795.96] versus 1123.09 [500.38-2651.27]; p < 0.001). The extent of improvement was similar in groupsI and III (p > 0.05). No significant changes were detected in groupII. SV therapy induced similar improvements in echocardiographic parameters and in NT-proBNP levels in CRT-NR patients and in patients with HFrEF without resynchronization.

Efficacy and safety of mineralocorticoid receptor antagonists for the treatment of low-renin hypertension: a systematic review and meta-analysis.

Hypertension is the leading risk factor for premature death. The optimal treatment of low-renin hypertension (LRH), present in 30% of hypertensive individuals, is not known. LRH likely reflects a state of excess salt, expanded volume and/or mineralocorticoid receptor (MR) activation. Therefore, targeted treatment with MR antagonists (MRA) may be beneficial. The objective of this systematic review was to assess the efficacy of MRA therapy in LRH. MEDLINE, Embase and Cochrane databases were searched for randomised controlled trials of adults with LRH that compared the efficacy of MRA to placebo or other antihypertensive treatments. Risk of bias was assessed using the Cochrane risk of bias tool. A meta-analysis was performed using a random-effects model to estimate the difference in blood pressure and the certainty of evidence was assessed using the GRADE approach. The protocol is registered on PROSPERO (CRD42022318763). From the 1612 records identified, 17 studies met the inclusion criteria with a total sample size of 1043 participants. Seven studies (n = 345) were assessed as having a high risk of bias. Meta-analysis indicated that MRA reduced systolic blood pressure by -6.8 mmHg (95% confidence interval -9.6 to -4.1) and -4.8 mmHg (95% confidence interval -11.9 to 2.4) compared to angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) and diuretics. The certainty of the evidence was assessed as moderate and very low, respectively. The findings of this systematic review suggest that MRA is effective in lowering blood pressure in LRH and may be better than ACEi/ARB. Translation to clinical practice is limited by the uncertainty of evidence.

Prevalence, Risk Factors, and Mortality of Patients Presenting with Moderate and Severe Hyponatremia in Emergency Departments.

Hyponatremia is among the most common electrolyte disturbances encountered in clinical practice and is associated with a high rate of morbidity and mortality. However, there are very limited data on adult cases presenting to emergency departments with hyponatremia. This study aimed to evaluate the frequency, clinical characteristics, and outcomes in hyponatremic patients presenting to emergency departments. This retrospective study analyzed all patients older than 18 years who visited our institution's emergency department between October 2018 and October 2019 and has a serum sodium (Na) level <130 mmol/L. Among 24,982 patients who visited the emergency department and had a documented serum sodium level, 284 were included. Patients' median age was 67.13 ± 14.8 years. Younger patients are less likely to develop severe hyponatremia compared to older patients (adjusted odds ratio (AOR): 0.415; 95% confidence interval (CI): 0.231-0.743; p=0.003). Asymptomatic hyponatremia and gastrointestinal manifestations were the most common presenting hyponatremia symptoms (33.7% and 24.2%, respectively). Proton pump inhibitor (PPI) use, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACE/ARB) use, and spironolactone use (OR = 2.6 and 3.9, 2.3 with a p=0.02, 0.03, and 0.05, respectively) were associated with increased odds of severe hyponatremia. There is no difference in the overall mortality rate within 6 months of presentation between severe and moderate hyponatremia groups (11.1% versus 16.2%, p=0.163). Moderate and severe hyponatremia are not uncommon among patients presenting to emergency departments. Moderate hyponatremia can be asymptomatic with clinical significance. Older patients, use of PPI, use of ACEi/ARBs, and spironolactone use were associated with an increased risk of severe hyponatremia compared to moderate. Further prospective analysis of a larger population is needed to confirm our findings.

Trajectories of adherence to ACEI/ARB medications following a motivational interviewing intervention among Medicare Advantage beneficiaries in Texas

ObjectivesTo assess the impact of student telephone motivational interviewing intervention on angiotensin-converting enzyme inhibitors/angiotensin-receptor blockers (ACEI/ARBs) adherence trajectories and identify predictors of each trajectory. MethodsThe intervention group included continuously enrolled Medicare Advantage Plan patients non-adherent to ACEI/ARBs vs the control group (1:2 ratio). The intervention was tailored by pre-intervention trajectories and included an initial and five follow-up calls. Adherence was measured 6 months after initial calls using the proportion of days covered (PDC). Monthly PDCs were integrated into a group-based trajectory model and categorized patients into 4-groups. A multinomial logistic regression model was used to evaluate trajectory predictors. ResultsThe study comprised 240 intervention patients and 480 controls with four trajectories: adherent trajectory 44.2%, gradual improvement in adherence 13.4%, slow decline in adherence 24.1%, and discontinuation 18.3%. Patients with the intervention were less likely to experience a slow decline in adherence than controls (OR: 0.627 [0.401–0.981]). Patients with specialty prescribers’ visits, ≥ 1 previous hospitalization, rapid decline in adherence as pre-intervention trajectory, and higher CMS risk score were associated with discontinuation trajectory. ConclusionIntervention patients vs controls had a lower likelihood of following a slow decline in adherence pattern. Practice implicationsThis study underscores the importance of individualized interventions and the association between past adherence patterns and post-intervention trajectories.

Timing of angiotensin receptor-neprilysin inhibitor initiation in patients with heart failure and reduced ejection fraction: data from the Swedish heart failure registry

Abstract Background International guidelines recommend early and fast optimization of the treatments for heart failure with reduced ejection fraction (HFrEF). Angiotensin receptor-neprilyisin inhibitor (ARNI) reduced mortality/morbidity in HFrEF. However, despite early initiation of ARNI appeared safe and of potential benefit in randomized clinical trials, their early implementation is underutilized in real world. Purpose To explore the timing, modalities and predictors of ARNI initiation in a large, nationwide cohort of patients with HFrEF. Methods ARNI-naïve patients with HFrEF (EF&amp;lt;40%) registered in the SwedeHF Registry from January 2017 to December-2021 were included. Separate analyses were performed to investigate ARNI initiation in terms of 1) course of the disease (duration of HF &amp;lt;6 vs ≥6 months), 2) location (in hospital vs out-patient), 3) time from a previous HF hospitalization (in-hospital or ≤14 days from discharge vs 15-90 days vs &amp;gt;90 days or no initiation). Results Analysis 1) Among 16,086 HFrEF patients registered in SwedeHF during the study period, 63% had an HF duration &amp;lt;6 months. 5% vs. 9% of patients with HF duration &amp;lt;6 vs. ≥6 initiated ARNI, respectively. Younger age and referral to specialty care were more strongly associated with ARNI initiation whether HF duration was ≥6 or &amp;lt;6 months. In-patient status, lower EF, and hypertension were independently associated with initiation only if HF duration was &amp;lt;6 months, and HF nurse-led clinic and higher income only if HF duration was ≥6 months. Previous ACEi/ARB use was associated with more likely ARNI initiation in HF duration ≥6 months and less likely initiation in HF duration &amp;lt;6 months (Figure). Analysis 2) Of 1,065 HFrEF patients who initiated ARNI, 30% started as in-patients. Analysis 3) Among 3,892 patients registered as in-patients in SwedeHF, 8% initiated ARNI ≤14 days from the hospital discharge, 4% between 15-90 days, and 88% &amp;gt;90 days or did not initiate. Important independent predictors of earlier initiation (≤14 days) were a more recent registration in SwedeHF, follow-up in specialty care and HF nurse-led clinic, lower EF, worse New York Heart Association class, previous use of angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARB), use of mineralocorticoid receptor antagonist, ICD/CRT, and higher income, whereas older age, higher mean arterial pressure, atrial fibrillation (AF), chronic obstructive pulmonary disease (COPD), and living alone where associated with lower likelihood. Conclusions In this nationwide HFrEF cohort ARNI were rarely initiated early at/after an HF hospitalization discharge, initiation was more likely in the out-patient setting and in the later course of the HF disease. Key patient characteristics associated with early initiation were linked with more severe HF and follow-up in dedicated HF care. Overall our data highlight a delayed initiation of ARNI therapy and claim for better implementation in the early stage of HF.Predictors of ARNI initiation

Home hospital heart failure admissions are an opportunity to initiate goal directed medical therapy - a retrospective analysis

Abstract Background There is growing recognition of the importance of goal directed medical therapy (GDMT) initiation for heart failure (HF) during hospitalization. Home hospital provides traditional inpatient hospital care in the patient’s home. Data describing GDMT initiation in home hospital is lacking. Purpose We described the rate of GDMT prescription on admission to and on discharge from home hospital for HF exacerbations, and compared the rate of sodium/glucose cotransporter-2 inhibitors (SGLT2i) prescription before and after home hospitalization. Methods This retrospective cohort is derived from all HF hospitalizations in two home hospital programs in the US between February 2020 and October 2022. Patients with heart failure with reduced ejection fraction (HFrEF; EF &amp;lt;50%) and patients with heart failure with preserved ejection fraction (HFpEF) who were hospitalized after February 2022 (when the FDA approved SGLT2i for HFpEF) were included. Exclusion criteria were if care was escalated to the traditional hospital setting, if patient goals of care were comfort care only, or if patients were receiving palliative inotropes. We report the rate of GDMT prescription immediately prior to home hospital admission and at discharge. GDMT for HFrEF was defined as beta-blocker, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), angiotensin receptor-neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists (MRA), and SGLT2i; for HFpEF, only SGLT2i were considered. For the entire cohort, McNemar’s chi-squared test was performed to compare the rate of SGLT2i prescription before and after admission. Other GDMT therapies were not compared due to insufficient power. Reasons for not initiating GDMT are reported. Data were collected through manual chart review. Results We studied 173 hospitalizations; 95 patients had HFrEF and 78 had HFpEF. Mean age was 77.3 years; 65% had atrial fibrillation, 57% had diabetes mellitus, and 51% had chronic kidney disease. For patients with HFrEF, rates of beta-blocker, ACEi/ARB, ARNI, MRA, and SGLT2i prescription on admission were 88%, 56%, 16%, 34%, and 14% and on discharge were 85%, 49%, 17%, 35%, and 23% respectively; Figure 1. For the entire cohort – patients with HFrEF or HFpEF, the difference between the rate of SGLT2i prescription before and after the admission was statistically significant (12.1% vs 20.8%, p-value &amp;lt; 0.001); Figure 2. In 89% of hospitalizations GDMT was not initiated; the three most common reasons were no reason cited (68%), deferral to outpatient follow-up (14%), and kidney dysfunction (10%). Conclusion Home hospital admission for HF represents a feasible opportunity to initiate GDMT. Patients admitted to home hospital for HF had a statistically significant increase in the rate of SGLT2i prescription, although the overall rate remained low. Future study will investigate if GDMT prescription rates are improved with cardiology e-consultation in home hospitalizations.GDMT Prescription Rate - Reduced EFSGLT2i Prescription Rate

Impact of controlled blood pressure and pulse rate at discharge on clinical outcomes in patients with ST-segment elevation myocardial infarction

BackgroundAlthough major guidelines recommend the routine introduction of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) and beta-blockers for patients with ST-segment elevation myocardial infarction (STEMI), evidence regarding the target blood pressure (BP) or pulse rate (PR) at hospital discharge is sparse. This retrospective study aimed to compare the clinical outcomes in patients with STEMI between those with good BP and PR control and those with poor BP or PR control. MethodsWe included 748 patients with STEMI who received both ACE inhibitors/ARBs and beta-blockers at hospital discharge, and divided them into a good control group (systolic BP ≤140 mmHg and PR ≤80 bpm, n = 564) and a poor control group (systolic BP >140 mmHg or PR >80 bpm, n = 184). The primary endpoint was major cardiovascular events (MACE) defined as the composite of all-cause death, non-fatal myocardial infarction, and re-admission for heart failure. ResultsDuring the median follow-up duration of 568 days, a total of 119 MACE were observed. The Kaplan-Meier curves showed that MACE were more frequently observed in the poor control group (p = 0.009). In the multivariate Cox hazard analysis, the good control group was inversely associated with MACE (HR 0.656, 95 % CI: 0.444–0.968, p = 0.034) after controlling for multiple confounding factors. ConclusionsThe good control of systolic BP and PR at discharge was inversely associated with long-term adverse events in STEMI patients treated with both ACE inhibitors/ARBs and beta blockers. This study suggests the importance of titration of ACE inhibitors/ARBs and beta-blockers for better clinical outcomes in patients with STEMI.

Impact of Ramadan fasting on eGFR in patients with late stage chronic kidney disease

Aims: Ramadan fasting is a significant religious practice observed annually by approximately 1.9 billion adult Muslims worldwide. However, its potential impact on kidney health in individuals with chronic kidney disease (CKD) remains a subject of concern. This study aimed to investigate the effects of Ramadan fasting on renal function in patients with stage 3-5 CKD and to identify any associated risk factors.&#x0D; Methods: A single-center, self-controlled longitudinal observational study was conducted on 192 stable patients with stage 3-5 CKD who observed Ramadan fasting. The fasting period was about 14-15 hours per day for one month Various clinical parameters, including eGFR, blood urea nitrogen (BUN), sodium (Na+), potassium (K+), calcium (Ca++), phosphorus, parathyroid hormone (PTH), albumin, uric acid, fasting glucose, total cholesterol, triglyceride, high-density lipoprotein (HDL) cholesterol, low-density lipoprotein (LDL) cholesterol, and hemoglobin (Hgb), were measured before and after Ramadan fasting. P0.05). Furthermore, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB) did not impact eGFR (0.084). Notably, Ramadan fasting led to improvements in metabolic parameters, such as fasting glucose and lipid profile, except for triglyceride levels (p

Effects of renin-angiotensin system blockers on outcomes from COVID-19: a systematic review and meta-analysis of randomized controlled trials.

Randomized controlled trials (RCTs) have assessed the effects of renin-angiotensin system (RAS) blockers in adults with coronavirus disease 2019 (COVID-19). This meta-analysis provides estimates of the safety and efficacy of treatment with (vs. without) RAS blockers from these trials. PubMed, Web of Science, and ClinicalTrials.gov were searched (1 March-12 April 2023). Event/patient numbers were extracted, comparing angiotensin-converting enzyme (ACE) inhibitor/angiotensin-receptor blocker (ARB) treatment with no treatment, for the outcomes: intensive care unit (ICU) admission, mechanical ventilation, vasopressor use, acute kidney injury (AKI), renal replacement therapy (RRT), acute myocardial infarction, stroke/transient ischaemic attack, heart failure, thromboembolic events, and all-cause death. Fixed-effects meta-analysis estimates were pooled. Sixteen RCTs including 3492 patients were analysed. Compared with discontinuation of RAS blockers, continuation was not associated with increased risk of ICU [risk ratio (RR) 0.96, 0.66-1.41], ventilation (RR 0.77, 0.55-1.09), vasopressors (RR 0.92, 0.58-1.44), AKI (RR 1.01, 0.40-2.56), RRT (RR 1.01, 0.46-2.21), or thromboembolic events (RR 1.07, 0.36-3.19). RAS blocker initiation was not associated with increased risk of ICU (RR 0.71, 0.47-1.08), ventilation (RR 1.12, 0.91-1.38), AKI (RR 1.28, 0.89-1.86), RRT (RR 1.66, 0.89-3.12), or thromboembolic events (RR 1.20, 0.06-23.70), although vasopressor use increased (RR 1.27, 1.02-1.57). The RR for all-cause death in the continuation/discontinuation trials was 1.24 (0.80-1.92), and 1.22 (0.96-1.55) in the initiation trials. In patients with severe/critical COVID-19, RAS blocker initiation increased the risk of all-cause death (RR 1.31, 1.01-1.72). ACE inhibitors and ARBs may be continued in non-severe COVID-19 infection, where indicated. Conversely, initiation of RAS blockers may be harmful in critically ill patients.PROSPERO registration number: CRD42023408926.

A Cross sectional descriptive study to investigate the different effects of using approved therapeutic regimens options on the quality of life for chronic heart disease patients with reduced ejection fraction

Abstract Aim Investigate the different effects on the quality of life (QOL) between the approved regimens used for Heart failure patients with reduced ejection fraction (HFrEF) treatment in clinical practice. Methods Cross Sectional descriptive study on (HFrEF) patients was conducted from December 2021 to Mars 2023 at governmental and private hospitals in Egypt and Saudi Arabia, the 118 patients were receiving different treatment regimens divided into 4 groups, all groups have B-blockers and mineralocorticoid receptor antagonist (MRA); 1.Conventional therapy group of 33 patients: angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEi/ARBs), 2. Group of 22 patients: Sacubitril/Valsartan as an angiotensin receptor-neprilysin inhibitor (ARNI), 3. Group of 33 patients (ACEi/ARBs) + Sodium−glucose co-transporter 2 inhibitors (SGLT2i), 4. Group of 30 patients (ARNI) with SGLT2i. Their quality of life assessment was done using validated questionnaire MLHFQ (Minnesota Living with Heart Failure Questionnaire) as face to face interviews and data were collected from hospital records. Statistical software IBM SPSS package version 27.0, a one-way ANOVA test was conducted to compare the difference between 4 groups normally distributed quantitative variables. Post hoc pairwise multiple comparisons were executed using the Tukey HSD test. A multiple linear regression analysis was conducted to assess the ability of the independent variables (Platelets count, Ejection Fraction EF%, Hemoglobin, S.Cr, Gender, WBCs and Urea) to predict the value of MLHFQ score. Significance was judged at the 5% level. Results There was a statistically significant difference In MLHFQ Score for the four groups: F (3, 114) = 8.135, P = 0.000. The actual difference in mean scores was relatively high and this was approved by a large effect size, calculated using eta squared (0.176). Post hoc comparisons indicated that the mean score for Conventional regimen group (M = 68.06, SD = 19.77, CI95% 11.92–38.67, P &amp;lt; 0.05) and SGLT2i containing regimen group (M = 56.88, SD = 22.21, CI95% 0.74–27.48, P = 0.034) both were significantly different from that of ARNI + SGLT2i combination containing regimen group (M = 42.77, SD = 19.04). By comparing the EF% between the 4 groups, There was a statistically significant difference: F (3, 114) = 2.725, P = 0.047. Post hoc comparisons indicated that the mean score for Conventional containing regimen (M = 33, SD = 8.746, CI95% 0.1–10.43, P = 0.044) was significantly different from that of ARNI + SGLT2i combination regimen (M = 27.73, SD = 7.497). The linear regression analysis for variables showed statistical significance (F Change (7,110) = 5.234, P = .000).The statistically significant affected predicted variables are (S.Cr, P = 0.01), (B.urea, P = 0.003), (Hb, P = 0.011), while R2 = 0.25 explained only 25% of the variance in the dependent variable (MLHFQ score). Conclusions The early beginning of ARNI + SGLT2i with B-blocker + MRA may improve the QOL beside the approved reduction in heart failure hospitalizations. Additional Content An author video to accompany this abstract is available on https://academic.oup.com/eurheartjsupp. Please click on the arrow next to ‘More Content’ and then click on ‘Author videos’.

Beta-blockers and renin-angiotensin system inhibitors for Takotsubo syndrome recurrence: a network meta-analysis

IntroductionTakotsubo syndrome (TTS) is an acute heart failure syndrome, featured by transient left ventricular systolic dysfunction. Recurrences of TTS are not infrequent and there is no standard preventive therapy. The...

Effects of sodium-glucose co-transporter-2 inhibitors by background cardiovascular medications: A systematic review and meta-analysis.

To explore whether the beneficial cardiovascular (CV) effect of sodium-glucose co-transporter-2 (SGLT-2) inhibitors is consistent with or without concurrent use of CV medications in patients with type 2 diabetes, heart failure (HF) or chronic kidney disease. We searched Medline and Embase up to September 2022 for CV outcomes trials. The primary endpoint was the composite of cardiovascular (CV) death or hospitalization for HF. Secondary outcomes included the individual components of CV death, hospitalization for HF, death from any cause, major adverse CV events or renal events, volume depletion and hyperkalaemia. We pooled hazard ratios (HRs) and risk ratios alongside 95% confidence intervals (CIs). We included 12 trials comprising 83 804 patients. SGLT-2 inhibitors reduced the risk of CV death or hospitalization for HF regardless of background use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEIs/ARBs), angiotensin receptor-neprilysin inhibitors (ARNIs), b-blockers, diuretics, mineralocorticoid receptor antagonists (MRAs), or triple combination therapy of either an ACEI/ARB plus b-blocker plus MRA, or an ARNI plus b-blocker plus MRA (HRs ranged from 0.61 to 0.83; P > .1 for each subgroup interaction). Similarly, no subgroup differences were evident for most analyses for the secondary outcomes of CV death, hospitalization for HF, all-cause mortality, major adverse CV or renal events, hyperkalaemia and volume depletion rate. The benefit of SGLT-2 inhibitors seems to be additive to background use of CV medications in a broad population of patients. These findings should be interpreted as hypothesis generating because most of the subgroups analysed were not prespecified.

Trends of antihypertensive use among patients with cancer and hypertension in the United States 2002–2019

BackgroundHypertension (HTN) is the most frequently reported comorbidity in patients with malignancy. This study was conducted to assess the trend of different antihypertensive (AHT) medications used in cancer patients. MethodsWe used the Medical Expenditure Panel Survey (MEPS) database from 2002 to 2019 to identify adult (age >18 years) cancer patients with HTN using appropriate International Classification of Disease (ICD)-9 and ICD-10 codes. Benign and uncertain neoplasms were excluded. P-trend values were calculated using weighted logistic regression with “year” as the predictor variable. ResultsWe identified ∼46 million adult hypertensive cancer patients with an increasing trend from 2002 to 2019 (3.3 m–6.7 m). Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEI/ARB) use in hypertensive cancer patients increased steadily, while diuretics and combined drugs decreased. Calcium channel blocker (CCB) use increased since 2014–15. In cancer patients with heart failure (HF), beta-blocker (BB) use increased; however, diuretic use peaked in 2014–15 and declined. The use of ACEi/ARB in cancer patients with Diabetes (DM) has increased, whereas BB, CCB, and diuretic use remained stable. Hypertensive cancer patients with Atherosclerotic Cardiovascular Disease (ASCVD) had increased ACEI/ARB use. Combination AHT use has decreased broadly. ConclusionThe ACEI/ARB and CCB use trends increased over the past two decades, whereas diuretics have declined. In cancer patients with DM or ASCVD, the use of ACEI/ARB is trending up. BB use showed an increasing trend in patients with HF. Combined AHT and diuretics use decreased. Total expenditure and out-of-pocket expenditure have a decreasing trend for all AHT medications.

Prescription of guideline-directed medical therapies in patients with diabetes and chronic kidney disease from the CURE-CKD Registry, 2019-2020.

Guideline-directed medical therapy (GDMT) is designed to improve clinical outcomes. The study aim was to assess GDMT prescribing rates and prescribing-persistence predictors in patients with diabetes and chronic kidney disease (CKD) from the Center for Kidney Disease Research, Education, and Hope Registry. Data were obtained from adults ≥18 years old with diabetes and CKD between 1 January 2019 and 31 December 2020 (N = 39 158). Baseline and persistent (≥90 days) prescriptions for GDMT, including angiotensin converting enzyme (ACE) inhibitor/angiotensin receptor blocker (ARB), sodium-glucose cotransporter-2 (SGLT2) inhibitor and glucagon-like peptide 1 (GLP-1) receptor agonist were assessed. The population age (mean ± SD) was 70 ± 14 years, and 49.6% (n = 19 415) were women. Baseline estimated glomerular filtration rate (2021 CKD-Epidemiology Collaboration creatinine equation) was 57.5 ± 23.0 ml/min/1.73 m2 and urine albumin/creatinine 57.5 mg/g (31.7-158.2; median, interquartile range). Baseline and ≥90-day persistent prescribing rates, respectively, were 70.7% and 40.4% for ACE inhibitor/ARB, 6.0% and 5.0% for SGLT2 inhibitors, and 6.8% and 6.3% for GLP-1 receptor agonist (all p < .001). Patients lacking primary commercial health insurance coverage were less likely to be prescribed an ACE inhibitor/ARB [odds ratio (OR) = 0.89; 95% confidence interval (CI) 0.84-0.95; p < .001], SGLT2 inhibitor (OR 0.72; 95% CI 0.64-0.81; p < .001) or GLP-1 receptor agonist (OR 0.89; 95% CI 0.80-0.98; p = .02). GDMT prescribing rates were lower at Providence than UCLA Health. Prescribing for GDMT was suboptimal and waned quickly in patients with diabetes and CKD. Type of primary health insurance coverage and health system were associated with GDMT prescribing.

A machine learning evaluation of patient characteristics associated with prescribing of guideline-directed medical therapy for heart failure.

Patients with heart failure and reduced ejection fraction (HFrEF) are consistently underprescribed guideline-directed medications. Although many barriers to prescribing are known, identification of these barriers has relied on traditional a priori hypotheses or qualitative methods. Machine learning can overcome many limitations of traditional methods to capture complex relationships in data and lead to a more comprehensive understanding of the underpinnings driving underprescribing. Here, we used machine learning methods and routinely available electronic health record data to identify predictors of prescribing. We evaluated the predictive performance of machine learning algorithms to predict prescription of four types of medications for adults with HFrEF: angiotensin converting enzyme inhibitor/angiotensin receptor blocker (ACE/ARB), angiotensin receptor-neprilysin inhibitor (ARNI), evidence-based beta blocker (BB), or mineralocorticoid receptor antagonist (MRA). The models with the best predictive performance were used to identify the top 20 characteristics associated with prescribing each medication type. Shapley values were used to provide insight into the importance and direction of the predictor relationships with medication prescribing. For 3,832 patients meeting the inclusion criteria, 70% were prescribed an ACE/ARB, 8% an ARNI, 75% a BB, and 40% an MRA. The best-predicting model for each medication type was a random forest (area under the curve: 0.788-0.821; Brier score: 0.063-0.185). Across all medications, top predictors of prescribing included prescription of other evidence-based medications and younger age. Unique to prescribing an ARNI, the top predictors included lack of diagnoses of chronic kidney disease, chronic obstructive pulmonary disease, or hypotension, as well as being in a relationship, nontobacco use, and alcohol use. We identified multiple predictors of prescribing for HFrEF medications that are being used to strategically design interventions to address barriers to prescribing and to inform further investigations. The machine learning approach used in this study to identify predictors of suboptimal prescribing can also be used by other health systems to identify and address locally relevant gaps and solutions to prescribing.

Is Use of Evidence-Based Medications One Year After an Acute Coronary Syndrome Related to the Severity of Left Ventricular Systolic Dysfunction?

Beta blockers (BB), angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACEi/ARB), and mineralocorticoid receptor antagonists (MRA) improve outcomes following an acute coronary syndrome (ACS) in patients with a reduced left ventricular ejection fraction (LVEF). Treatment benefits are greater with lower LVEF and higher dose. Dispensing of BB, ACEi/ARB, and MRA, and the number (%) taking ≥50% of the recommended dose at one year were audited in 1,444 ACS patients admitted to three New Zealand hospitals between 2015 and 2019, who had a predischarge LVEF <50%, and were alive at 12 months. Results are summarised in the Table.TableMedication dispensedLVEF <30% n=159LVEF 30%–40% n=606LVEF 41%–<50% n=679Beta blockerDischarge143 (90%)503 (83%)563 (83%)One year119 (75%)478 (79%)533 (78%)Dose ≥50% recommended48 (30%)131 (22%)119 (18%)ACEi or ARBDischarge137 (86%)483 (80%)561 (83%)One year108 (68%)471 (77%)535 (79%)Dose ≥50% recommended27 (17%)127 (21%)131 (19%)MRADischarge52 (33%)87 (14%)26 (4%)One year49 (31%)97 (16%)34 (5%)Dose ≥50% recommended27 (17%)60 (10%)21 (3%) Open table in a new tab In ACS patients with a reduced LVEF, evidence-based medications were poorly targeted to those with the lowest LVEF, often stopped after discharge, and the dose seldom increased. Strategies are needed to improve long-term use of evidence-based medications, especially in high-risk patients. This study is consistent with other large registries.

The clinical efficacy of fluticasone propionate combined with ACEI/ARB in the treatment of immunoglobulin A nephropathy

BackgroundImmunoglobulin A nephropathy (IgAN) is the most common primary glomerulopathy worldwide, and lacks the effective treatment. The study was aimed to investigate the clinical efficacy of fluticasone propionate aerosol combined with angiotensin converting enzyme inhibitor / angiotensin receptor blocker (ACEI/ARB) in the treatment of IgAN.Methods142 patients with biopsy-proven IgAN at Shenzhen People?s hospital from June 2018 to June 2020 were enrolled. The patients were randomly divided into the supportive care plus fluticasone group and the supportive care group. The patients of the supportive care plus fluticasone group were treated with fluticasone propionate aerosol (250 ?g Bid) combined with ACEI/ARB, while the supportive care group was merely treated with ACEI/ARB. The patients were followed up at 3, 6 and 9 months after enrollment. Primary outcomes include changes in proteinuria and estimated glomerular filtration rate (eGFR).ResultsThe level of proteinuria in the supportive care plus fluticasone group was significantly lower compared with the supportive care group at 0, 3, 6 and 9 months. Meanwhile, during the follow-up period, no serious adverse events were recorded during the study in either group. However, fluticasone treatment did not alleviate the decline in eGFR.ConclusionFluticasone propionate aerosol combined with ACEI/ARB can reduce the level of proteinuria in thetreatment of IgAN, and has no significant effects on renal function.

Influence of chronic obstructive pulmonary disease on long-term hospitalization and mortality in patients with heart failure with reduced ejection fraction

BackgroundHeart failure with reduced ejection fraction (HFrEF) can coexist with chronic obstructive pulmonary disease (COPD), which complicates the clinical situation and worsens quality of life. The study used standard diagnostic criteria for detecting COPD in hospitalized HFrEF patients and to survey the influence of other comorbidities and medications on the long-term outcomes of HFrEF + COPD patients.MethodsWe retrospectively recruited patients hospitalized due to HFrEF in a tertiary medical center and examined and followed up clinical outcomes, including length of hospital stay, mortality, and readmission episodes, for a 5-year period. Risk factors for mortality were analyzed using multivariate analysis.ResultsOf the 118 hospitalized HFrEF study participants, 68 had concurrent COPD whereas 50 did not. There was a significant increase in the male predominance, smoking history, higher hemoglobin level and increased length of hospital stay in the HF + COPD group than in the HF-only group. Lower left ventricular ejection fraction was found in the HF and COPD comorbidity group. In multivariate analysis, angiotensin-converting enzyme inhibitor/angiotensin receptor blocker (ACEI/ARB) use independently associated with a beneficial effect on survival in HF patients with COPD. Oral corticosteroid uses and stroke as a comorbidity were independently associated with a shorter time to the first readmission episode.ConclusionIn HFrEF patients, COPD was associated with a prolonged length of hospital stay. ACEI/ARB use might relate to a beneficial effect on survival in HF patients with COPD. The use of maintenance oral corticosteroid in patients with both HF and COPD should be crucially evaluated to determine the clinical benefit and disadvantages.