Guideline-directed Medical Treatment Research Articles

Unveiling the future of cardiac care: advances in mechanical circulatory support

Congestive heart failure (CHF) is a multifaceted clinical syndrome characterized by the inability of the heart to pump blood effectively, leading to inadequate oxygen and nutrient delivery to the body tissues. Despite advancements in treatment strategies, including guideline-directed medical treatment (GDMT), end-stage CHF remains a significant cause of morbidity and mortality worldwide. Heart transplantation is considered to be the gold standard treatment of end stage CHF but constrained by the lack of organ donors, lengthening waitlists, and the negative side effects of lifelong immunosuppressive medications. Mechanical circulatory support (MCS) has emerged as a pivotal intervention for patients with end-stage CHF, serving as a bridge to recovery, transplantation, or destination therapy. The aim of this narrative review is to highlight the historical development of MCS, to assess the recent status of MCS device technology and discuss current challenges associated with complications of MCS that need to be solved in the future by device development. The history of MCS dates back to pioneering efforts in the 1960s, with significant progress in device development and utilization over decades. MCS devices, including left ventricular assist devices (LVADs), extracorporeal membrane oxygenation (ECMO), and artificial hearts, play a crucial role in providing circulatory support to patients with end-stage CHF. Recent advancements in MCS technology aim to decrease the device size, enhance blood compatibility, reduce thrombo-embolic complications, and prolong device durability and battery life and improve physiological performance of MCS. Continued research and innovation are essential to address these challenges and improve outcomes in patients with end-stage CHF. Artificial intelligence (AI) has emerged as a valuable tool in cardiovascular medicine to facilitate risk prediction, patient selection, and treatment optimization for MCS and heart transplantation. Despite these advancements, challenges persist in MCS device selection, resource allocation, and integration of AI into clinical practice. Continued research and innovation are essential to address these challenges and improve outcomes in patients with advanced heart failure.

Assessing and Improving the Care of Patients With Heart Failure in Ghana: Protocol for a Prospective Observational Study and the Ghana Heart Initiative-Heart Failure Registry.

Heart failure (HF) is a leading cause of morbidity and mortality globally, with a high disease burden. The prevalence of HF in Ghana is increasing rapidly, but epidemiological profiles, treatment patterns, and survival data are scarce. The national capacity to diagnose and manage HF appropriately is also limited. To address the growing epidemic of HF, it is crucial to recognize the epidemiological characteristics and medium-term outcomes of HF in Ghana and improve the capability to identify and manage HF promptly and effectively at all levels of care. This study aims to determine the epidemiological characteristics and medium-term HF outcomes in Ghana. We conducted a prospective, multicenter, multilevel cross-sectional observational study of patients with HF from January to December 2023. Approximately 5000 patients presenting with HF to 9 hospitals, including teaching, regional, and municipal hospitals, will be recruited and evaluated according to a standardized protocol, including the use of an echocardiogram and an N-terminal pro-brain natriuretic peptide (NT-proBNP) test. Guideline-directed medical treatment of HF will be initiated for 6 months, and the medium-term outcomes of interventions, including rehospitalization and mortality, will be assessed. Patient data will be collated into a HF registry for continuous assessment and monitoring. This intervention will generate the necessary information on the etiology of HF, clinical presentations, the diagnostic yield of various tools, and management outcomes. In addition, it will build the necessary capacity and support for HF management in Ghana. As of July 30, 2023, the training and onboarding of all 9 centers had been completed. Preliminary analyses will be conducted by the end of the second quarter of 2024, and results are expected to be publicly available by the middle of 2024. This study will provide the necessary data on HF, which will inform decisions on the prevention and management of HF and form the basis for future research. ISRCTN Registry (United Kingdom) ISRCTN18216214; https:www.isrctn.com/ISRCTN18216214. DERR1-10.2196/52616.

Cardiac contractility modulation in patients with heart failure - A review of the literature.

Experimental in vivo and in vitro studies showed that electric currents applied during the absolute refractory period can modulate cardiac contractility. In preclinical studies, cardiac contractility modulation (CCM) was found to improve calcium handling, reverse the foetal myocyte gene programming associated with heart failure (HF), and facilitate reverse remodeling. Randomized control trials and observational studies have provided evidence about the safety and efficacy of CCM in patients with HF. Clinically, CCM therapy is indicated to improve the 6-min hall walk, quality of life, and functional status of HF patients who remain symptomatic despite guideline-directed medical treatment without an indication for cardiac resynchronization therapy (CRT) and have a left ventricular ejection fraction (LVEF) ranging from 25 to 45%. Although there are promising results about the role of CCM in HF patients with preserved LVEF (HFpEF), further studies are needed to elucidate the role of CCM therapy in this population. Late gadolinium enhancement (LGE) assessment before CCM implantation has been proposed for guiding the lead placement. Furthermore, the optimal duration of CCM application needs further investigation. This review aims to present the existing evidence regarding the role of CCM therapy in HF patients and identify gaps and challenges that require further studies.

Kiosk 2R-TB-05 - The Dynamic Increment of Epicardial Adipose Tissue Is Associated with Reverse Remodeling After Guideline-directed Medical Treatment in Dilated Cardiomyopathy Patients

Kiosk 2R-TB-05 - The Dynamic Increment of Epicardial Adipose Tissue Is Associated with Reverse Remodeling After Guideline-directed Medical Treatment in Dilated Cardiomyopathy Patients

Heart failure early post-discharge appointment: a 1.5-year single-centre experience

Abstract Background According to Heart Failure (HF) guidelines, a follow-up visit should be conducted within 1 to 2 weeks after hospital discharge to monitor signs and symptoms of HF, optimize therapy, and evaluate treatment side effects. Retrospective studies have shown that this approach is associated with lower 30-day readmission rates. Purpose Our aim is to describe the role of early post-discharge appointment in the management of HF patients and to evaluate prognostic factors after HF hospitalization. Methods We conducted a single-centre prospective registry of consecutive patients evaluated in the early post-discharge appointment at our centre, from March 2021 to September 2022. HF symptoms, vital signs, blood test results, treatment decision, and 90-day HF events were recorded. Results Overall, 153 patients were included (mean age 65.7 ± 13.0 years, 63.4% male). The mean time from hospital discharge to post-discharge appointment was 13.4 ± 5.7 days. Left ventricle ejection fraction was reduced in 83.6% (n = 127) of patients. Guideline-directed medical treatment prescribed at discharge, as well as up-titration and withdrawal patterns at the post-discharge appointment, are presented in Table 1. At the post-discharge appointment, 34.3% of patients (n = 35) presented with drug adverse effects, most often including hyperkalemia (17.5%, n = 22), acute kidney injury (9.9%, n = 12), and hypotension (3.9%, n = 6). Of those evaluated at the post-discharge appointment, 11.2% (n = 17) were scheduled to another appointment one week later, for early re-evaluation, 90.1% (n = 137) were followed-up in the standard HF ambulatory program, and 2.6% (n = 4) were hospitalized. The serum creatinine (1.10 [0.87 – 1.36] mg/dL vs 1.40 [1.09 – 1.95] mg/dL, p<0.001), the serum C cystatin (1.50 [1.25 – 1.98] mg/dL vs 1.97 [1.54 – 2.46] mg/dL, p = 0.007) and the NT-proBNP levels (1859 [977 – 4877] mg/dL vs 5928 [2817 – 11957] mg/dL, p = 0.013), measured at the time of the post-discharge appointment, were found to be associated with HF events within 90 days (urgent HF visit or HF hospitalization). An NT-proBNP level above 2400 pg/mL adjusted to C cystatin was found to be a strong predictor of 90-day HF events (OR 9.855, 95% CI 2.657 – 36.550, p = 0.001). This model yielded a good prognostic performance (AUC 0.790, CI 95% 0.689-0.890, p<0.001). Conclusions Early evaluation of HF patients after hospital discharge allows for guideline-directed medical therapy up-titration and early detection of drug adverse effects. The NTproBNP level and kidney function, assessed early after discharge, have been found to be strong predictors of 90-day HF events, indicating which patients would benefit most from a stricter follow-up program. Table 1 – Guideline-directed medical therapy patterns of prescription both at hospital discharge and during the early post-discharge appointment. ACE, angiotensin converting enzyme; ARA, aldosterone receptor antagonist, MRA, mineralocorticoid receptor antagonist.

Abstract 18811: Heart Failure in a Carrier of Danon Disease

Background: Danon Disease is a rare X-linked dominant genetic condition characterized by hypertrophic cardiomyopathy, skeletal muscle myopathy, and intellectual disability, among other serious complications. The disease is a lysosomal storage disorder in which a mutation in the LAMP-2 gene causes a defect in the lysosome membrane and an accumulation of glycogen in vital tissue including cardiac muscle cells. It occurs more commonly in males, who are also more severely affected than females with this condition. There are no specific treatments available, although studies involving gene therapy have been ongoing. Patients with Danon Disease often require heart transplantation as treatment for end-stage heart failure. Description of Case: A 37-year-old female with a known family history of Danon Disease was discovered to be a carrier of the LAMP-2 mutation after presenting to the hospital with dizziness and palpitations. An echocardiogram obtained at the time of diagnosis revealed left ventricular hypertrophy and left ventricular apical thrombus with normal ejection fraction. She was started on anticoagulation and began following closely with a heart failure clinic. Since diagnosis, she has had multiple echocardiograms which have shown a steady decline in her ejection fraction to 25% and biventricular failure. An ICD was placed, with no shocks ever administered. She has had multiple hospital admissions for exacerbations of heart failure since diagnosis. Telemetry monitoring during these admissions revealed frequent premature ventricular contractions attributed to the patient’s severe cardiomyopathy. Despite continuation of guideline-directed medical treatment, this patient’s systolic heart failure is anticipated to continue worsening. She will likely require heart transplant, for which evaluation has already been initiated. Discussion: Danon Disease is a rare lysosomal storage disorder that often involves progressively worsening cardiomyopathy. Individuals with a known family history of this condition should be referred early for genetic testing. If found to have the condition or be a carrier, they should begin following with a heart failure specialist and consideration for advanced therapies, like transplant, should be initiated.

Investigating the impact of suboptimal prescription of preoperative antiplatelets and statins on race and ethnicity-related disparities in major limb amputation.

Non-Hispanic Black and Hispanic patients with symptomatic PAD may receive different treatments than White patients with symptomatic PAD. The delivery of guideline-directed medical treatment may be a modifiable upstream driver of race and ethnicity-related disparities in outcomes such as limb amputation. The purpose of our study was to investigate the prescription of preoperative antiplatelets and statins in producing disparities in the risk of amputation following revascularization for symptomatic peripheral artery disease (PAD). We used data from the Vascular Quality Initiative, a vascular procedure-based registry in the United States (2011-2018). We estimated the probability of preoperative antiplatelet and statin prescriptions and 1-year incidence of amputation. We then estimated the amputation risk difference between race/ethnicity groups that could be eliminated under a hypothetical intervention. Across 100,579 revascularizations, the 1-year amputation risk was 2.5% (2.4%, 2.6%) in White patients, 5.3% (4.9%, 5.6%) in Black patients, and 5.3% (4.7%, 5.9%) in Hispanic patients. Black (57.5%) and Hispanic patients (58.7%) were only slightly less likely than White patients (60.9%) to receive antiplatelet and statin therapy. However, the effect of antiplatelets and statins was greater in Black and Hispanic patients such that, had all patients received these medications, the estimated risk difference comparing Black to White patients would have reduced by 8.9% (-2.9%, 21.9%) and the risk difference comparing Hispanic to White patients would have been reduced by 17.6% (-0.7%, 38.6%). Even though guideline-directed care appeared evenly distributed by race/ethnicity, increasing access to such care may decrease health care disparities in major limb amputation.

Patient phenotype profiling using echocardiography and natriuretic peptides to personalise heart failure therapy.

Heart failure (HF) is a progressive condition with a clinical picture resulting from reduced cardiac output (CO) and/or elevated left ventricular (LV) filling pressures (LVFP). The original Diamond-Forrester classification, based on haemodynamic data reflecting CO and pulmonary congestion, was introduced to grade severity, manage, and risk stratify advanced HF patients, providing evidence that survival progressively worsened for those classified as warm/dry, cold/dry, warm/wet, and cold/wet. Invasive haemodynamic evaluation in critically ill patients has been replaced by non-invasive haemodynamicphenotype profiling using echocardiography. Decreased CO is not infrequent among ambulatory HF patients with reduced ejection fraction, ranging from 23 to 45%. The Diamond-Forrester classification may be used in combination with the evaluation of natriuretic peptides (NPs) in ambulatory HF patients to pursue the goal of early identification of those at high risk of adverse events and personalise therapy to antagonise neurohormonal systems, reduce congestion, and preserve tissue/renal perfusion. The most benefit of the Guideline-directed medical treatment is to be expected in stable patients with the warm/dry profile, who more often respond with LV reverse remodelling, while more selective individualised treatments guided by echocardiography and NPs are necessary for patients with persisting congestion and/or tissue/renal hypoperfusion(cold/dry, warm/wet, and cold/wet phenotypes) to achieve stabilizationandto avoid further neurohormonal activation, as a result of inappropriate use of vasodilating or negative chronotropic drugs, thuspursuing the therapeutic objectives. Therefore, tracking the haemodynamic status over time by clinical, imaging, and laboratory indicators helps implement therapy by individualising drug regimens and interventionsaccording to patients'phenotypes even in an ambulatory setting.

Contemporary secondary prevention in survivors of ST-elevation myocardial infarction with and without chronic kidney disease: a retrospective analysis.

Survivors of myocardial infarction have an elevated risk of long-term mortality. We sought to evaluate guideline-directed medical treatment and its impact on long-term mortality in survivors of ST-elevation myocardial infarction (STEMI) according to their chronic kidney disease (CKD) stage. Using German health insurance claims data, 157663 hospitalized survivors of STEMI were identified. Regarding different CKD stages, we retrospectively analysed the filled prescriptions of platelet inhibitors (PAI)/oral anticoagulation, statins, beta-blocker and angiotensin-converting enzyme inhibitors/angiotensin II type 1 receptor antagonists (ACE-I/AT1-A) and their association with long-term mortality. Prescription rates for all four guideline-directed drugs were highest in patients without or with mild CKD and lowest in patients on dialysis. They dropped from 73.4% to 39.2% in patients without CKD and from 47.1% to 29% in patients on dialysis within the 5-year follow-up period. Mortality rates were dramatically increased in patients with CKD compared with patients without CKD (5-year mortality: no CKD, 16.7%; CKD stage 3, 47.1%; CKD stage 5d, 69.7%). Filled prescriptions of at least one drug class [one drug: hazard ratio (HR) 0.70, 95% confidence interval (95% CI) 0.66-0.74; four drugs: HR 0.28, 95% CI 0.27-0.30; P<.001 for both] as well as the distinct drug classes (statins: HR 0.55, 95% CI 0.54-0.56; ACE-I/AT1-A: HR 0.68, 95% CI 0.67-0.70; beta-blocker: HR 0.87, 95% CI 0.85-0.90; PAI/oral anticoagulation: HR 0.97, 95% CI 0.95-1.00; all P<.05) improved long-term mortality. An improved long-term guideline-recommended drug therapy after STEMI regardless of renal impairment might lead to beneficial effects on long-term mortality.

Optimization of guideline-directed medical treatment for heart failure patients with reduced ejection fraction.

With the increasing number of medications demonstrating mortality benefits in heart failure with reduced ejection fraction (HFrEF), the pharmacological treatment of HFrEF is entering a new phase. To enhance outcomes in heart failure patients through medical treatment, the choice of appropriate medications and simultaneous and rapid uptitration are critical. However, there are several challenges encountered during this medication uptitration, including issues like hypotension, fatigue, worsening renal function, and hyperkalemia. This paper addresses strategies for effectively managing these challenges to successfully reach the maximum tolerated dose in patients. Additionally, it will discuss the management of comorbidities often associated with heart failure, the importance of exercise and rehabilitation, and the significance of proper nutrition intake, in addition to guideline-directed medical therapy.

Effects of empagliflozin on cardiac structure, function and biomarkers in patients with heart failure with preserved ejection fraction: study protocol for a randomised, placebo-controlled prospective trial

IntroductionHeart failure (HF) with preserved ejection fraction (HFpEF) has become the main type of HF worldwide. Although large randomised controlled studies have demonstrated the beneficial effects of sodium–glucose cotransporter 2...

Impact of mineralocorticoid receptor gene NRC2 on the prediction of arrhythmia after acute myocardial infarction

Abstract Funding Acknowledgements Type of funding sources: None. Introduction Patients with acute myocardial infarction (AMI) suffer from distress that causes a rise in cortisol (stress hormone) which acts through glucocorticoid receptors (GR) and mineralocorticoid receptors (MR). Both receptors are present in cardiomyocyte nuclei (1-4). The animal model study in 2017 showed that activated MR increases cardiomyocyte oxidative stress leading to adverse electrophysiological remodelling that causes arrhythmias. 1.4% of tachyarrhythmias which is the main cause of cardiac death occur within the first month in AMI patients. MR are encoded by the human gene NR3C2 (nuclear receptor subfamily 3 group C member (5-6). Thus, we hypothesized that NR3C2 rs2070950, rs4635799 and rs5522 gene polymorphisms might have an extensive impact on rhythm disorders that occur in a cohort of AMI patients. Aim The aim is to evaluate the impact of the NR3C2 rs2070950, rs4635799 and rs5522 genes polymorphism in patients that developed rhythm and conduction disorders after suffering AMI. Methods The study included 301 patients treated at our hospital after suffering from AMI; all study subjects underwent primary percutaneous coronary intervention (PCI) and guideline-directed medical treatment (1). Patients' blood samples that were collected upon arrival had cortisol and troponin I levels checked and SNPs of the NR3C2 gene (rs2070950, rs4635799 and rs5522) assessed. To avoid inaccuracies all patients with a previous history of coronary syndrome or PCI were excluded. Rhythm conduction disorders and NR3C2 gene polymorphism were analyzed using the exact Fisher’s test. All the statistical analyses were performed with SPSS 27.0 software. The value of p &amp;lt; 0.05 was considered statistically significant. Results Patients with ventricular and atrial events in the early phase of AMI had higher levels of serum cortisol than the patients that did not have rhythm disorders (p=0.001) (Table 1). Rhythm disorders such as ventricular tachycardia (VT), ventricular flutter (VF) and atrial flutter or atrial fibrillation (AF/AFL) that occurred during hospitalization for AMI were notably associated with rs5522 gene polymorphism. During a hospital stay for AMI higher rs5522 TT genotype frequency was noticed in patients with AF/AFL than in patients without. C allele recurrence was 19.6%. Moreover, the protective effect was detected for AF/AFL there is also a protective effect in VA. (Table 2). Despite this, the gene polymorphism and high-grade atrioventricular block (HAVB) were unrelated. Genes rs2070950 and rs4635799 were not found significant to rhythm and conduction disorders. Conclusions Patients with the rs5522 TT allele are more prone to experience a higher frequency of arrhythmias. However, if at least one rs5522 C is found it associates with a smaller risk of arrhythmias post-AMI, meaning that this gene possibly limits damaging effects on cardiomyocytes that are caused by cortisol.

How German vascular surgeons and angiologists judge walking exercise for patients with PAD.

Background: To determine the physician's perspective and perception on walking exercise as well as barriers in guideline-directed best medical treatment of patients with lower extremity peripheral arterial disease (PAD). Patients and methods: All members of the German Society for Vascular Surgery and Vascular Medicine and of the German Society for Angiology - Society for Vascular Medicine with valid email address were invited to participate in an electronic survey on walking exercise for treatment of intermittent claudication that was developed by the authors. Results: Amongst 3910 invited participants, 743 (19%) provided valid responses (33% females, 84% vascular surgery, 15% angiology). Thereof, 65% were employed by non-university hospitals, 16% by university institutions, and 18% by outpatient facilities. A mean of 14 minutes were spent per patient to counsel and educate, while only 53% responded they had enough time in everyday clinical practice. While 98% were aware of the beneficial impact of structured exercise training (SET) on pain free walking distance and 90% advise their patients to adhere to SET, only 44% provided useful guidance to patients to find local SET programmes and merely 42% knew how to prescribe SET as service that can be reimbursed by medical insurances. Approximately 35% knew a local SET programme and appropriate contact person. Health-related quality of life was assessed in a structured way by only 11%. Forty-seven percent responded that medical insurances should be responsible to implement and maintain SET programmes, while only 4% held hospital physicians responsible to achieve this task. Conclusions: This nationwide survey study amongst vascular specialists illustrates the current insufficient utilisation of SET as an evidence-based therapeutic cornerstone in patients with lower extremity PAD in Germany. The study also identified several barriers and flaws from the physician's perspectives which should be addressed collectively by all health care providers aiming to increase the SET use and eventually its' impact on patients with PAD.

Impact of updated trial data on the cost-effectiveness of percutaneous mitral repair.

When updated clinical trial data becomes available reassessing the cost-effectiveness of technologies may modify estimates and influence decision-making. We investigated the impact of updated trial outcomes on the cost-effectiveness of percutaneous mitral repair (PR) for secondary mitral regurgitation. We updated our previous three-state time-varying Markov model to assess the cost-effectiveness of PR + guideline directed medical treatment (GDMT) versus GDMT alone. Key clinical inputs (overall survival (OS) and heart failure hospitalisations (HFH)) were obtained using the 3-year trial findings from the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy) RCT. We calculated incremental cost-effectiveness ratios (ICER) and report how these differ between analyses based on early (2-year) and updated (3-year) evidence. Updated trial data showed an increase in mortality in the intervention arm between two and three years follow-up that was not seen in the control arm. Deterministic and multivariate cost-effectiveness modelling yielded incremental cost effectiveness ratios ICERs of €38,123 and €31,227 /QALY. Compared to our 2-year based estimate (€21,918 / QALY) these results imply an approximate 1.5-fold increase in ICER. The availability of updated survival analyses from the COAPT pivotal trial suggests previous estimates based on 2-year trial findings were over optimistic for the intervention.

Effectiveness and Safety of Sacubitril/Valsartan for Heart Failure with Reduced Ejection Fraction Secondary to Duchenne Muscular Dystrophy-Associated Cardiomyopathy

In individuals with an ejection fraction of 40% or less, the use of sacubitril/valsartan significantly lowers mortality or hospitalization. There has been no research related to the effectiveness and safety of sacubitril/valsartan in patients with Duchenne muscular dystrophy (DMD)-associated cardiomyopathy. We hereby report a case of DMD-associated cardiomyopathy and heart failure with reduced ejection fraction who had been on routine guideline-directed medical treatment with no change in clinical or echocardiographic markers. When guideline-directed medical therapy was unsuccessful, sacubitril/valsartan was started which resulted in a significant change in functional class and significant ventricular remodeling, including an improvement in left ventricular (LV) ejection fraction, reduction in LV diastolic diameter, and a reduction in mitral regurgitation.

Efficacy of guideline-directed medical treatment in heart failure with mildly reduced ejection fraction.

Heart failure with mildly reduced ejection fraction (HFmrEF) has received increasing attention following the publication of the latest ESC guidelines in 2021. However, it remains unclear whether patients with HFmrEF could benefit from guideline-directed medical treatment (GDMT), referring the combination of ACEI/ARB/ARNI, β-blockers, and MRAs, which are recommended for those with reduced ejection fraction. This study explored the efficacy of GDMT in HFmrEF patients. This was a retrospective cohort study of HFmrEF patients admitted to The First Affiliated Hospital of Dalian Medical University between 1 September 2015 and 30 November 2019. Propensity score matching (1:2) between patients receiving triple-drug therapy (TT) and non-triple therapy (NTT) based on age and sex was performed. The primary outcome was all cause death, cardiac death, rehospitalization from any cause, and rehospitalization due to worsening heart failure. Of the 906 patients enrolled in the matched cohort (TT group, n=302; NTT group, N=604), 653 (72.08%) were male, and mean age was 61.1±11.92. Survival analysis suggested that TT group experienced a significantly lower incidence of prespecified primary endpoints than NTT group. Multivariable Cox regression showed that TT group had a lower risk of all-cause mortality (HR 0.656, 95% CI 0.447-0.961, P=0.030), cardiac death (HR 0.599, 95% CI 0.380-0.946, P=0.028), any-cause rehospitalization (HR 0.687, 95% CI 0.541-0.872, P=0.002), and heart failure rehospitalization (HR 0.732, 95% CI 0.565-0.948, P=0.018). In patients with HFmrEF, combined use of neurohormonal antagonists produces remarkable effects in reducing the occurrence of the primary outcome of rehospitalization and death. Thus, the treatment of HFmrEF should be categorized as HFrEF due to the similar benefit of neurohormonal blocking therapy in HFrEF and HFmrEF.

Assessment of Depression and Adherence to Guideline-Directed Medical Therapies Following Percutaneous Coronary Intervention

Depression is associated with increased risk of primary and secondary cardiovascular events. Medication adherence may play an essential role. To evaluate the association of depression and 12-month adherence to guideline-directed medical therapies (eg, antiplatelet agents, β-blockers, renin-angiotensin-aldosterone system inhibitors [ie, angiotensin-converting enzyme inhibitors and angiotensin receptor blockers], and statins) following percutaneous coronary intervention. This retrospective cohort study included individuals who underwent percutaneous coronary intervention from January 1, 2014, to December 31, 2019. Data were collected from a large US health claims database and analyzed between February and August 2022. Proportion of days covered (PDC) for classes of guideline-directed medical therapies, with 12-month adherence categorized as adequate (PDC ≥80% to <90%) or optimal (PDC ≥90%). Multivariable-adjusted regression models were used to evaluate the association of depression with adherence; models incorporated demographic characteristics, comorbid medical and psychiatric conditions, depression treatment, and guideline-directed medical therapy treatment adjustment. The hypothesis was that those with depression would have lower odds of either adequate or optimal adherence to agents essential for guideline-directed medical therapy. Of 124 443 individuals (mean [SD] age, 69.3 [10.6] years; 41 430 [33.3%] female sex; 3694 [3.0%] Asian, 12 611 [10.1%] Black, and 12 337 [9.9%] Hispanic individuals) who received percutaneous coronary interventions, 20 711 (16.6%) had a diagnosis of depression. Those with depression were significantly less likely to obtain adequate 12-month adherence to antiplatelets (odds ratio [OR], 0.80; 95% CI, 0.77-0.85), β-blockers (OR, 0.84; 95% CI, 0.80-0.88), and statins (OR, 0.88; 95% CI, 0.85-0.93) than those without depression; there was no association between depression and adherence to renin-angiotensin-aldosterone system inhibitors (OR, 0.93; 95% CI, 0.85-1.00). Those with depression had similarly decreased likelihood of optimal 12-month adherence to antiplatelets, β-blockers, and statins as well as renin-angiotensin-aldosterone system inhibitors (OR, 0.87; 95% CI, 0.82-0.94). In this cohort study, patients with depression were less likely to achieve adequate or optimal adherence to medications essential to guideline-directed medical therapies following percutaneous coronary intervention compared with those without depression. Recognition of depression may facilitate targeted interventions to address medication adherence and thereby improve secondary cardiovascular disease prevention.

Prescription Rates and Prognostic Implications of Optimally Targeted Guideline-Directed Medical Treatment in Heart Failure and Atrial Fibrillation: Insights From The MISOAC-AF Trial.

Heart failure (HF) and atrial fibrillation (AF) commonly coexist in real-life clinical practice. Among patients with HF with reduced ejection fraction (HFrEF) or HF with mildly reduced ejection fraction (HFmrEF), guidelines call for evidence-based target doses of renin-angiotensin-aldosterone system inhibitors and beta-blockers. However, target doses of guideline-directed medical treatment (GDMT) are often underused in real-world conditions, including HF-AF comorbidity. This retrospective cohort study of a randomized trial (Motivational Interviewing to Support Oral AntiCoagulation adherence in patients with nonvalvular AF) included hospitalized patients with AF and HFrEF or HFmrEF. Optimally targeted GDMT was defined as intake of evidence-based target doses of renin-angiotensin-aldosterone system and beta-blockers at 3 months after discharge. Rates of optimally targeted GDMT achievement across the baseline estimated glomerular filtration rate (eGFR) were assessed. Independent predictors of nontargeted GDMT and its association with all-cause mortality and the composite of cardiovascular death or HF hospitalization were assessed by regression analyses. In total, 374 patients with AF and HFrEF or HFmrEF were studied. At 3 months after discharge, 30.7% received target doses of GDMT medications. The rate of optimally targeted GDMT was reduced by 11% for every 10 mg/min/1.73 m 2 decrease in baseline eGFR [adjusted β = 0.99; 95% confidence interval (CI), 0.98-0.99] levels. After a median 31-month follow-up period, 37.8% patients in the optimally targeted GDMT group died, as compared with 67.8% (adjusted hazard ratio: 1.49; 95% CI, 1.05-2.13) in the nontargeted GDMT group. The risk of cardiovascular death or HF hospitalization was also higher in these patients (adjusted hazard ratio: 1.60; 95% CI, 1.17-2.20). Target doses of all HF drugs were reached in roughly one-third of patients with AF and HFrEF or HFmrEF 3 months after hospital discharge. Nontargeted GDMT was more frequent across lower eGFR levels and was associated with worse outcomes.

Treatment response in recent-onset heart failure with reduced ejection fraction: non-ischaemic vs. ischaemic aetiology.

In heart failure (HF) with reduced left ventricular ejection fraction (HFrEF), the prognosis appears better in non-ischaemic than in ischaemic aetiology. Infrequent diagnostic work-up for ischaemic heart disease (IHD) in HF is reported. In this study, we compared short-term response to initiated guideline-directed medical treatment (GDMT) in recent-onset HFrEF of non-ischaemic (non-IHF) vs. ischaemic (IHF) aetiology and evaluated the frequency of coronary investigation. Patients hospitalized with recent-onset HFrEF [left ventricular ejection fraction (LVEF)<40%] between 1 January 2016 and 31 December 2019 were included. Treatment response was determined by use of a hierarchical clinical composite outcome classifying each patient as worsened, improved, or unchanged based on hard outcomes (mortality, heart transplantation, and HF hospitalization) and soft outcomes (±≥10 unit change in LVEF, ±≥30% change in N-terminal pro-B-type natriuretic peptide, and ±≥1 point change in New York Heart Association functional class) during 28weeks of follow-up. The associations between baseline characteristics and composite changes were analysed with multiple logistic regression. Among the 364 patients analysed, 47 were not investigated for IHD. Comparing non-IHF (n=203) vs. IHF (n=114), patients were younger (mean age 61.0 vs. 69.4years, P<0.001) with lower mean LVEF (26% vs. 31%, P<0.001), but with similar male predominance (70.4% vs. 75.4%, P=0.363). For non-IHF vs. IHF, the composite outcomes were worsened (19.1% vs. 43.9%, P<0.001) and improved (74.2% vs. 43.9%, P<0.001). After multivariable adjustments, IHF was associated with increased odds for worsening [odds ratio (OR) 2.94; 95% confidence interval (CI) 1.51-5.74; P=0.002] and decreased odds for improvement (OR 0.35; 95% CI 0.18-0.65; P<0.001). In cases without previous IHD or new-onset myocardial infarction (n=261), a decision for coronary investigation was made in 69.0%. In recent-onset HFrEF, patients with non-IHF responded better to GDMT than patients with IHF. Almost one-third of patients selected for follow-up at HF clinics were never investigated for IHD.

Impact of Inpatient Initiation of Sodium-Glucose Cotransporter-2 Inhibitors on Prescription Rates in Patients With Heart Failure With Reduced Ejection Fraction

Despite large, randomized controlled trials and guideline recommendations, patients with heart failure with reduced ejection fraction (HFrEF) continue to receive suboptimal guideline-directed medical treatment (GDMT). This study aimed to evaluate the potential effect of inpatient initiation of sodium-glucose cotransport-2 (SGLT2) inhibitors on postdischarge prescribing rates and the downstream impact on clinical outcomes. The INitiation of SGlt2i in Hospital for HFrEF (INSIGHT-HF) study was a retrospective analysis of hospitalized patients older than 18 years with a left ventricular ejection fraction (LVEF) ≤40% conducted from July 2020 and July 2021. Our primary outcome was SGLT2i prescription rates at 30days. Among 2,663 eligible patients with documented HFrEF, 177 (6.6%) had SGLT2i initiated during their index hospitalization. The rate of SGLT2i prescriptions at 30days was significantly higher in those with inpatient initiation of SGLT2i compared with those who did not start while inpatient (96% vs 14.7%, p <0.0001). The heart failure readmission rate in the first 30days was significantly lower in those with inpatient initiation of SGLT2i compared with those who did not start during hospitalization. (9.3% vs 22.7%, p=0.04). Cardiovascular mortality was numerically, but not significantly, different between groups (4% vs 10.7%, p=0.21). Inpatient initiation of an SGLT2i was associated with a significantly higher postdischarge rate of SGLT2i prescriptions and significantly lower heart failure readmission rates at 30days. In conclusion, these findings highlight the importance of initiating SGLT2i during inpatient hospitalization to improve the quality of care in patients with HFrEF.