Medical Therapy For Heart Failure Research Articles

Initiation of Medical Therapy for Heart Failure Patients According to Kidney Function: A Danish Nationwide Study.

Use of medical therapies for heart failure (HF) patients with moderate kidney dysfunction is low. We hypothesized that lack of initiation of HF therapy reflects the clinicians' reluctance in very elderly and frail patients more than kidney dysfunction itself. HF patients were identified from nationwide registers between 2014 and 2021. Information was obtained on eGFR, frailty status, and prescription of HF therapy. Patients were divided into three groups: normal kidney function (eGFR ≥ 60); moderate kidney dysfunction (GFR between 30 and 59); and severe kidney dysfunction (GFR < 30). Multivariate Cox models were used to study the association of eGFR, age, and frailty with use of HF therapy. Of the 42,320 HF patients included those with lower eGFR were significantly older and frailer (median age 74.3 years and 37.8% frail). The crude initiation rate of all three drug classes decreased with decreasing eGFR in a stepwise fashion. After adjusting for age and frailty status, initiation of MRA decreased with decreasing kidney function (moderate kidney function HR 0.80(95% CI 0.77-0.84) and severe kidney function HR 0.24(0.21-0.27)). After adjusting for age and frailty status, initiation of RAS inhibitor and BB was not significantly lower for moderate kidney dysfunction (HR 0.97(0.93-1.02), and HR 1.06(0.97-1.16, respectively)). Initiation of RAS inhibitor was significantly lower for patients with severe kidney dysfunction, HR 0.45(0.41-0.50), but not for BB initiation HR 1.09(1.05-1.14). In a real-world HF cohort, patients with moderate and severe kidney dysfunction were associated with reduced use of MRA irrespective of age and frailty. Reduced use of RASi was associated with severe kidney dysfunction, whereas for patients with moderate kidney dysfunction, reduced use was mainly driven by aging and frailty. Reduced use of BB seemed to be primarily explained by aging and frailty.

A profile on the CardioMEMS HF system in the management of patients with early stages of heart failure: an update

ABSTRACT Introduction Over the past decade, there have been noteworthy advances in the evaluation and treatment of heart failure (HF). Despite an improved understanding of this chronic disease, HF is still one of the leading causes of morbidity and mortality in the United States and worldwide. Decompensation and rehospitalization of HF patients remain an integral problem in disease management, with significant economic implications. Remote monitoring systems have been developed to detect HF decompensation early and address it before hospitalization. The CardioMEMS HF system is a wireless pulmonary artery (PA) monitoring system that detects changes in PA pressure and transmits data to the healthcare provider. As changes in PA pressures occur early during HF decompensation, the CardioMEMS HF system allows providers to institute timely changes in HF medical therapies to alter the course of the decompensation. The use of the CardioMEMS HF system has been shown to reduce HF hospitalization and improve quality of life. Areas Covered This review will focus on the available data supporting the expanded utilization of the CardioMEMS system in patients with HF. Expert Opinion The CardioMEMS HF system is a relatively safe and cost-effective device that reduces the incidence of HF hospitalization and qualifies as intermediate-to-high value medical care.

Association between a hospitalization for heart failure and the initiation/discontinuation of guideline-recommended treatments: An analysis from the Swedish Heart Failure Registry.

To investigate whether a heart failure (HF) hospitalization is associated with initiation/discontinuation of guideline-directed medical HF therapy (GDMT) and consequent outcomes. Among patients in the Swedish HF registry with an ejection fraction <50% enrolled in 2009-2018, initiation/discontinuation of GDMT was investigated by assessing dispensations of GDMT in those with versus without a HF hospitalization. Of 14 737 patients, 6893 (47%) were enrolled when hospitalized for HF. Initiation of GDMT was more likely than discontinuation following a HF hospitalization compared to a control group of patients without a HF hospitalization (odds ratio range 2.1-4.0 vs. 1.4-1.6 for the individual medications), although the proportion of patients not on GDMT was still high (8.1-44.0%). Key patient characteristics triggering less use of GDMT (i.e. less initiation or more discontinuation) were older age and worse renal function. Following a HF hospitalization, initiation of renin-angiotensin system inhibitors/angiotensin receptor-neprilysin inhibitors or beta-blockers was associated with lower and their discontinuation with higher mortality risk, but no association with mortality was observed for initiation/discontinuation of mineralocorticoid receptor antagonists. Following a HF hospitalization, initiation of GDMT was more likely than discontinuation, although still limited. Perceived or actual low tolerance were barriers to GDMT implementation. Early re-/initiation of GDMT was associated with better survival. Our findings represent a call for further implementing the current guideline recommendation for an early re-/initiation of GDMT following a HF hospitalization.

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.

Heart Failure Therapies following Acute Coronary Syndromes with Reduced Ejection Fraction: Data from the ACSIS Survey.

Guideline-directed medical therapies for heart failure (HF) may benefit patients with reduced left ventricular ejection fraction (LVEF) following acute coronary syndromes (ACS). Few real-world data are available regarding the early implementation of HF therapies in patients with ACS and reduced LVEF. Data collected from the 2021 nationwide, prospective ACS Israeli Survey (ACSIS). Drug classes included: (a) angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARB) or angiotensin receptor-neprilysin inhibitors (ARNI); (b) beta-blockers; (c) mineralocorticoid receptor antagonist (MRA) and (d) sodium-glucose cotransporter-2 inhibitors (SGLT2I). The utilization of HF therapies at discharge or 90 days following ACS was analyzed in relation to LVEF [reduced ≤40% (n = 406) or mildly-reduced 41-49% (n = 255)] and short-term adverse outcomes. History of HF, anterior wall myocardial infarction and Killip class II-IV (32% vs. 14% p < 0.001) were more prevalent in those with reduced compared to mildly-reduced LVEF. ACEI/ARB/ARNI and beta-blockers were used by the majority of patients in both LVEF groups, though ARNI was prescribed to only 3.9% (LVEF ≤ 40%). MRA was used by 42.9% and 12.2% of patients with LVEF ≤40% and 41-49%, respectively, and SGLT2I in about a quarter of both LVEF groups. Overall, ≥3 HF drug classes were documented in 44% of the patients. A trend towards higher rates of 90-day HF rehospitalizations, recurrent ACS or all-cause death was noted in those with reduced (7.6%) vs. mildly-reduced (3.7%) LVEF, p = 0.084. No association was observed between the number of HF drug classes or the use of ARNI and/or SGLT2I with adverse clinical outcomes. In current clinical practice, the majority of patients with reduced and mildly-reduced LVEF are treated by ACEI/ARB and beta-blockers early following ACS, whereas MRA is underutilized and the adoption of SGLT2I and ARNI is low. A greater number of therapeutic classes was not associated with reduced short-term rehospitalizations or mortality.

Baseline native T1 values are associated with adverse outcome in a newly diagnosed, hospitalised heart failure patient population

Abstract Funding Acknowledgements Type of funding sources: None. Background Tissue characterisation by T1 mapping on Cardiac Magnetic Resonance (CMR) imaging is a non-invasive assessment of diffuse cardiac fibrosis and has been shown to predict outcome in Heart Failure (HF). Purpose There is a need for improved risk stratification that delivers more personalised care for HF patients. We conducted the first prospective study to investigate novel CMR tissue characterisation biomarkers and correlate to adverse outcome, in a cohort of patients hospitalised with a new HF diagnosis. Methods This was single centre observational study. Inclusion criteria were admission with signs and symptoms of HF, and LVEF ≤50% or elevated plasma NTproBNP and being treated with intravenous furosemide. 43 consecutive eligible participants were included and underwent comprehensive CMR to establish anatomy, function and myocardial tissue characteristics during their presentation admission. Participants were managed according to best practice HF guidelines and underwent reviews at 6, 12–18 and 24–30 months. All clinically relevant event data e.g. death and rehospitalisation were recorded. Baseline CMR volumes, function, presence of Late Gadolinium Enhancement (LGE) and T1 mapping values were compared between the adverse event group and no adverse event group. ‘Adverse event’ was defined as all-cause mortality or HF hospitalisation. Results The median follow-up of 43 participants was 24.4 months. 41 (95%) were diagnosed with HF with reduced EF and 2 (5%) with HF with preserved Ejection Fraction. Baseline clinical, biochemical characteristics and NYHA class were similar between the adverse event and no adverse event groups. There was no significant difference between baseline LVEF (37% vs. 23%; p = 0.339) or NTproBNP levels (4948 vs.5456; p = 0.929) between groups. There was high uptake of HF medical therapy in both groups. (Table 1) 9 participants (21%) experienced adverse events. There was a significantly higher proportion of Ischaemic Cardiomyopathy in the adverse event group (67% vs. 18%; p = 0.008) with lower indexed LV volumes and mass. Native septal T1 (ms) was significantly higher in the adverse event group compared with the no adverse event group (1035 vs.996 p = 0.045). (Table 1) Receiver Operating Characteristic (ROC) analysis indicated a Native T1 cut-off value of 1022ms as most sensitive and specific. Kaplan-Meier survival analysis comparing those with Native T1 &amp;lt;1022ms and those with Native T1 &amp;gt;1022ms on their baseline CMR showed an adverse event-free survival benefit favouring the lower T1 value group (HR 11.4, p = 0.003 - Figure 1). Conclusions In a cohort of all-comer hospitalised patients with a new diagnosis of HF, followed up over a 24-month period, there was a high rate of adverse events. A higher native T1 value on baseline CMR was associated with worse outcome in terms of all-cause mortality or HF hospitalisation.

POINT: Should New Drug Development in Heart Failure Focus on Patients Discharged From an Acute Heart Failure Admission? Lessons From Recent Studies

POINT: Should New Drug Development in Heart Failure Focus on Patients Discharged From an Acute Heart Failure Admission? Lessons From Recent Studies

Pulmonary Hypertension in Left Heart Diseases: Pathophysiology, Hemodynamic Assessment and Therapeutic Management.

Pulmonary hypertension (PH) associated with left heart diseases (PH-LHD), also termed group 2 PH, represents the most common form of PH. It develops through the passive backward transmission of elevated left heart pressures in the setting of heart failure, either with preserved (HFpEF) or reduced (HFrEF) ejection fraction, which increases the pulsatile afterload of the right ventricle (RV) by reducing pulmonary artery (PA) compliance. In a subset of patients, progressive remodeling of the pulmonary circulation resulted in a pre-capillary phenotype of PH, with elevated pulmonary vascular resistance (PVR) further increasing the RV afterload, eventually leading to RV-PA uncoupling and RV failure. The primary therapeutic objective in PH-LHD is to reduce left-sided pressures through the appropriate use of diuretics and guideline-directed medical therapies for heart failure. When pulmonary vascular remodeling is established, targeted therapies aiming to reduce PVR are theoretically appealing. So far, such targeted therapies have mostly failed to show significant positive effects in patients with PH-LHD, in contrast to their proven efficacy in other forms of pre-capillary PH. Whether such therapies may benefit some specific subgroups of patients (HFrEF, HFpEF) with specific hemodynamic phenotypes (post- or pre-capillary PH) and various degrees of RV dysfunction still needs to be addressed.

Management of Ventricular Arrhythmias in Heart Failure.

Despite substantial progress in medical and device-based heart failure (HF) therapy, ventricular arrhythmias (VA) and sudden cardiac death (SCD) remain a major challenge. Here we review contemporary management of VA in the context of HF with one particular focus on recent advances in imaging and catheter ablation. Besides limited efficacy of antiarrhythmic drugs (AADs), their potentially life-threatening side effects are increasingly acknowledged. On the other hand, with tremendous advances in catheter technology, electroanatomical mapping, imaging, and understanding of arrhythmia mechanisms, catheter ablation has evolved into a safe, efficacious therapy. In fact, recent randomized trials support early catheter ablation, demonstrating superiority over AAD. Importantly, CMR imaging with gadolinium contrast has emerged as a central tool for the management of VA complicating HF: CMR is not only essential for an accurate diagnosis of the underlying entity and subsequent treatment decisions, but also improves risk stratification for SCD prevention and patient selection for ICD therapy. Finally, 3-dimensional characterization of arrhythmogenic substrate by CMR and imaging-guided ablation approaches substantially enhance procedural safety and efficacy. VA management in HF patients is highly complex and should be addressed in a multidisciplinary approach, preferably at specialized centers. While recent evidence supports early catheter ablation of VA, an impact on mortality remains to be demonstrated. Moreover, risk stratification for ICD therapy may have to be reconsidered, taking into account imaging, genetic testing, and other parameters beyond left ventricular function.

P1 NEW TREATMENT STRATEGIES IN PATIENTS WITH SENILE CARDIAC AMYLOIDOSIS

Abstract We present the case of a 75 year–old man, diabetic, dyslipidemic, hypertensive, previous ischemic heart disease, AF, previous hospitalizations for heart failure, who underwent cardiology evaluation for worsening dyspnea (NYHA class II–III), swallen ankles and elevated BNP levels (900 pg/ml). The patient suffered from sensory–motor polyneuropathy diagnosed with EMG and ENG. Echocardiographic evaluation: severe concentric hypertrophy of the left ventricle (SIV 18 mm, PP 17 mm), granular sparkling and EF 50%, left atrium dilatation, light–moderate mitral regurgitation, moderate tricuspid regurgitation with PAPS 40–45 mmHg. Circumferential pericardial effusion (12 mm). Moreover, we noticed a decreased longitudinal contractive function of the left ventricle (TDI e‘, a’, e s’ &amp;lt;5 cm/s e absolute GLS &amp;lt; 15%), speckle–tracking ‘cherry on the top‘ and restrictive diastolic pattern. •ECG: low QRS voltage and increased wall thickness (&amp;gt;12 mm). •Laboratory: (SPIE and UPIE) no monoclonal protein present. •Bone scintigraphy: grade 3 cardiac uptake. •Cardiac MRI: asymmetric hypertrophy of the left ventricle with moderate biventricular systolic dysfunction. Subendocardial late gadolinium enhancement. •Genetic testing: no sarcomeric or TTS gene mutations. All findings were suggestive for senile cardiac amyloidosis (ATTR wt), the patient was discharged from the hospital with optimized medical therapy for heart failure and follow up was prescribed. After 3 months from the first diagnosis we added Tafamidis to the therapy (ESC indications class IB). ATTR–ACT, published on ‘New England Journal of Medicine’ showed that Tafamis is superior to placebo in reducing the combination of all–cause mortality and cardiovascular–related hospitalizations. Tafamidis was also associated with a significant reduction in the decline in functional capacity (as measured by the 6–minute walk test) and the decline in quality of life (as measured by the KCCQ–OS) at month 30, with differences first observed at 6 months. Tafamidis was well–tolerated, with a safety profile comparable to placebo. Follow–up: 6 months later the introduction of Tafamidis, the patient has not needed other hospitalizations for heart failure, well tolerates the drug with a subjective symptom reduction and remarkable improvement in quality of life.

P70 UNEXPLAINED TRANSIENT BIVENTRICULAR DYSFUNCTION IN A PATIENT WITH DISSEMINATED TUBERCULOSIS AND SEVERE EOSINOPHILIA

Abstract Introduction Tuberculosis (TB) is an infectious disease with significant global burden. Pericardial injury is relatively common, while myocardial involvement has only rarely been described. Case presentation A 29-years-old man from Gambia with disseminated TB, treated with isoniazid, rifampin, pyrazinamide and ethambutol, was admitted to our hospital. He denied history of heart disease, cardiovascular risk factors and voluptuary habits. Laboratory exams revealed severe eosinophilia without microbiological evidence of parasitic infection; a lymphocyte proliferation test ruled out allergic reaction to anti-TB therapy. Baseline echocardiographic evaluation showed normal cardiac function with negative troponin. The patient, subsequently, developed worsening dyspnoea and asthenia with progressive biventricular dysfunction. Therefore, he was admitted to our department for further investigations. Cardiac magnetic resonance (CMR) showed a 20% left ventricular ejection fraction and absence of myocardial oedema or fibrosis [Fig.1]. Coronary CT angiography (CCTA) was unremarkable. Endomyocardial biopsy (EMB) showed absence of TB lesions or eosinophilic infiltration. Cardiac troponin and electrocardiogram remained negative throughout. Optimal medical therapy (OMT) for heart failure was promptly initiated. After several months an almost complete recovery of cardiac function was documented [Fig.2]. Discussion In cases of ventricular dysfunction, establishing an etiological diagnosis is imperative, though sometimes challenging. When pre-test probability is low, CAD can be ruled out by CCTA. Myocarditis is a common cause of reversible cardiac dysfunction. In this case, the absence of Lake Louise criteria, negative bioptic findings, persistently negative cardiac troponin and microbiological tests argue against this diagnosis. However, the timing of investigations can affect diagnostic accuracy; furthermore, focal lesions can be missed by EMB, leading to false negative results. Alcoholic cardiomyopathy (CMP) could be an option, but it was not considered due to absence of alcohol consumption. The clinical picture was not compatible with a typical CMP phenotype. Immune-mediated reaction to anti-TB drugs was ruled out by immunological testing. Although not previously described, ethambutol and pyrazinamide direct cardiotoxicity may explain transient impairment of cardiac function. Recovery may be related to withdrawal of these drugs and introduction of guideline-directed OMT.

MP-453089-9 OUTCOMES WITH GUIDELINE-DIRECTED MEDICAL THERAPY AND CARDIAC IMPLANTABLE ELECTRONIC DEVICE THERAPIES FOR PATIENTS WITH HEART FAILURE WITH REDUCED EJECTION FRACTION

Foundational guideline-directed medical therapy (GDMT) for heart failure (HF) with reduced ejection fraction (HFrEF) now consists of 4 classes. There is limited real-world evidence for outcomes associated with GDMT or GDMT with cardiac implantable electronic device therapies (here, implantable cardiac defibrillators [ICDs]/cardiac resynchronization therapy defibrillators [CRT-Ds]). The present study assessed outcomes associated with GDMT or GDMT with ICD/CRT-D for patients with HFrEF and left ventricular ejection fraction (LVEF) ≤35%. We analyzed patients (age ≥18 years) with HFrEF (LVEF ≤35%) in a deidentified real-world dataset including 5,218,134 patients from 20 US institutions with appropriate permissions (egnite Database; egnite, Aliso Viejo, CA, US). Treatment rates, LVEF improvement, and all-cause mortality were examined using unadjusted Kaplan–Meier analysis with first documented echocardiogram with LVEF ≤35% as index event. Mortality analysis used prescribed GDMT class count and device placement as time-varying covariates and censored patients at last clinical encounter. Treatment rate and LVEF improvement analysis censored patients at last clinical encounter/death. Of 362,693 patients with documented HF, 22,061 were included with LVEF ≤35%, prescription history through ≥1 year pre-index, and no device therapy pre-index. Median (IQR) time from index to censor/death was 13.5 (4.2–27.1) months. At index, 95.7%, 73.5%, 29.4%, and 3.5% of patients had ≥1, 2, 3, or all 4 GDMT classes prescribed, respectively. At 18 months, an estimated (95% CI) 98.7% (98.5–98.9%), 84.8% (84.5–85.1%), 43.2% (42.7–43.7%), and 8.1% (7.7–8.4%) had ≥1, 2, 3, or all 4 GDMT classes prescribed, respectively; an estimated 15.3% (14.7–15.9%) had device placement. Of those without a device, by 18 months, an estimated 39.1% (38.2–40.0%) had a documented LVEF >35%. Cohorts with a device and 2, 3, or 4 GDMT classes prescribed had estimated 18-month survival of 83.1% (79.2–87.2%), 85.4% (82.0–89.0%), or 88.9% (83.5–94.8%), respectively (Figure). There were insufficient data for analysis of those with a device and 0/1 GDMT classes. Cohorts without a device and 0, 1, 2, 3, or 4 GDMT classes prescribed had estimated 18-month survival of 70.8% (66.3–75.6%), 73.4% (71.7–75.2%), 77.8% (76.8–78.8%), 81.8% (80.7–82.9%), and 87.6% (85.4–89.9%), respectively (Figure). Higher counts of GDMT classes prescribed and device therapy with GDMT were associated with greater survival in this population.

Echocardiographic Features Beyond Ejection Fraction and Associated Outcomes in Patients With Heart Failure With Mildly Reduced or Preserved Ejection Fraction.

Heart failure (HF) guidelines recommend assessment of left ventricular ejection fraction (LVEF) to classify patients and guide therapy implementation. However, LVEF alone may be insufficient to adequately characterize patients with HF, especially those with mildly reduced or preserved LVEF. Recommendations on additional testing are lacking, and there are limited data on use of echocardiographic features beyond LVEF in patients with heart failure with mildly reduced or preserved LVEF. In patients with HF with mildly reduced or preserved LVEF identified in a large US health care system, the association of the following metrics with mortality was evaluated: LV global longitudinal strain (LV GLS>-16), left atrial volume index (>28 mL/m2), left ventricular hypertrophy (LVH), and E/e´>13 and e´<9. A multivariable model for mortality was constructed including age, sex, and key comorbidities followed by stepwise selection of echocardiographic features. Characteristics and outcomes of subgroups with normal versus abnormal LV GLS and LVEF were evaluated. Among 2337 patients with complete echocardiographic data assessed between 2017 and 2020, the following features were associated with all-cause mortality on univariate analysis over 3 years of follow-up: E/e´+e´, LV GLS, left atrial volume index (all P<0.01). In the multivariable model (C-index=0.65), only abnormal LV GLS was independently associated with all-cause mortality (HR, 1.35 [95% CI, 1.11-1.63]; P=0.002). Among patients with LVEF>55%, 498/1255 (40%) demonstrated abnormal LV GLS. Regardless of specific LVEF, patients with abnormal LV GLS demonstrated a higher burden of multiple comorbidities and higher event rates compared with patients with normal LV GLS. In a large, real-world HF with mildly reduced or preserved LVEF population, echocardiographic features, led by LV GLS, were associated with adverse outcomes irrespective of LVEF. A large proportion of patients demonstrate adverse myocardial function by LV GLS despite preserved LVEF and may represent a key cohort of interest for HF medical therapies and future clinical studies.

Polypharmacy and Optimization of Guideline-Directed Medical Therapy in Heart Failure: The GUIDE-IT Trial

BackgroundPolypharmacy is common among patients with heart failure with reduced ejection fraction (HFrEF). However, its impact on the use of optimal guideline-directed medical therapy (GDMT) is not well established. ObjectivesThis study sought to evaluate the association between polypharmacy and odds of receiving optimal GDMT over time among patients with HFrEF. MethodsThe authors conducted a post hoc analysis of the GUIDE-IT (Guiding Evidence-Based Therapy Using Biomarker Intensified Treatment) trial. Polypharmacy was defined as receiving ≥5 medications (excluding HFrEF GDMT) at baseline. The outcome of interest was optimal triple therapy GDMT (concurrent administration of a renin-angiotensin-aldosterone blocker and beta-blocker at 50% of the target dose and a mineralocorticoid receptor antagonist at any dose) achieved over the 12-month follow-up. Multivariable adjusted mixed-effect logistic regression models with multiplicative interaction terms (time × polypharmacy) were constructed to evaluate how polypharmacy at baseline modified the odds of achieving optimal GDMT on follow-up. ResultsThe study included 891 participants with HFrEF. The median number of non-GDMT medications at baseline was 4 (IQR: 3-6), with 414 (46.5%) prescribed ≥5 and identified as being on polypharmacy. The proportion of participants who achieved optimal GDMT at the end of the 12-month follow-up was lower with vs without polypharmacy at baseline (15% vs 19%, respectively). In adjusted mixed models, the odds of achieving optimal GDMT over time were modified by baseline polypharmacy status (P for interaction < 0.001). Patients without polypharmacy at baseline had increased odds of achieving GDMT (OR: 1.16 [95% CI: 1.12-1.21] per 1-month increase; P < 0.001) but not patients with polypharmacy (OR: 1.01 [95% CI: 0.96-1.06)] per 1-month increase). ConclusionsPatients with HFrEF who are on non-GDMT polypharmacy have lower odds of achieving optimal GDMT on follow-up.

Patient Selection for Mineralocorticoid Receptor Antagonists in Heart Failure with Mildly Reduced or Preserved Ejection Fraction.

The mineralocorticoid receptor is a steroid hormone receptor that contributes to cardiac tissue inflammation, fibrosis, and cardiac dysfunction and plays an important role in the pathophysiology of heart failure. Mineralocorticoid receptor antagonists (MRA) are an important component of guideline-directed medical therapy for heart failure to improve clinical outcomes. Clinical trial evidence in heart failure with reduced ejection fraction (HFrEF) informed a strong guideline recommendation for use of MRA in symptomatic patients, barring contraindications. In heart failure with mildly reduced ejection fraction (HFmrEF) and in heart failure with preserved ejection fraction (HFpEF), data are less robust, and this drug class received a weaker recommendation in the heart failure treatment guidelines. Thus, careful selection of patients with HFmrEF/HFpEF who are most likely to benefit from MRA is paramount to better optimize use of these medications. The purpose of this narrative review is to outline the rationale for the use of MRA in heart failure, summarize the clinical trial evidence for MRA in HFmrEF/HFpEF, discuss clinical considerations for their use, and describe investigations of nonsteroidal MRA in HFmrEF/HFpEF.

Pregabalin Does Not Increase Risk of Heart Failure Exacerbation in Patients With Pre-existing Heart Failure.

Through actions of calcium channel trafficking inhibition and sodium/water retention, pregabalin may increase the risk of acute heart failure (AHF). The objective of this study was to determine the prevalence of heart failure (HF) acute exacerbations, measured by a composite of emergency department (ED) visits, per-patient per-year (PPPY) hospitalizations, time-to first ED admission, and time-to hospitalizations in pre-existing HF patients taking pregabalin compared with those who were pregabalin-naive. A retrospective cohort study of pregabalin users with HF were propensity score-matched to pregabalin-naïve patients with HF to evaluate the composite of ED admissions or PPPY hospitalizations, time-to first ED admission, and time-to hospitalizations during the 365 days post-index. Doubly robust generalized linear regression and Cox-proportional hazard regression modeling were undertaken for analysis of differences between groups. The matched cohort of 385 pregabalin users and 3460 pregabalin nonusers were principally middle-aged, equally gender distributed, and primary Caucasian. Most patients were on guideline-directed HF medical therapy. The estimated cumulative incidence of the primary outcome was a hazard ratio of 1.099 (95% CI: 0.789-1.530; P = 0.58). This large, single-center, cohort study shows pregabalin is not associated with an increased risk of AHF events in patients with pre-existing HF.

Novel Strategies to Improve Prescription of Guideline-Directed Medical Therapy in Heart Failure.

To examine the emerging data for novel strategies being studied to improve use and dose titration of guideline-directed medical therapy (GDMT) for patients with heart failure (HF). There is mounting evidence to employ novel multi-pronged strategies to address HF implementation gaps. Despite high-level randomized evidence and clear national society recommendations, a large gap persists in use and dose titration of guideline-directed medical therapy (GDMT) in patients with heart failure (HF). Accelerating the safe implementation of GDMT has proven to reduce the morbidity and mortality associated with HF but remains an ongoing challenge for patients, clinicians, and health systems. In this review, we examine the emerging data for novel strategies to improve the use of GDMT including the use of multidisciplinary team-based approaches, nontraditional patient encounters, patient messaging/engagement, remote patient monitoring, and electronic health record (EHR)-based clinical alerts. While societal guidelines and implementation studies have focused on heart failure with reduced ejection fraction (HFrEF), expanding indications and evidence for the use of sodium glucose cotransporter2 (SGLT2i) will necessitate implementation efforts across the LVEF spectrum.

Angiotensin Receptor-Neprilysin Inhibitor Therapy and Cardiac Remodeling in Heart Failure: Consensus Statement from India

Adverse cardiac remodeling refers to progressive structural and functional modifications in the heart because of increased wall stress in the myocardium, loss of viable myocardium, and neurohormonal stimulation. The guideline-directed medical therapy for Heart failure (HF) includes Angiotensin receptor-neprilysin inhibitor (ARNI) (sacubitril/valsartan), β-blockers, sodium-glucose co-transporter 2 (SGLT2) inhibitors, and mineralocorticoid receptor antagonists (MRA). ARNI is under-prescribed in India despite its attractive safety and efficacy profile. Therefore, the consensus discusses objectives and topics related to ARNI in the management of cardiac remodeling, and experts shared their views on the early timely intervention of effective dosage of ARNI to improve the diagnosis and enhance mortality and morbidity benefits in cardiac reverse remodeling (CRR).

Deciding Whether to Take Sacubitril/Valsartan: How Cardiologists and Patients Discuss Out-of-Pocket Costs.

Background Out-of-pocket costs have significant implications for patients with heart failure and should ideally be incorporated into shared decision-making for clinical care. High out-of-pocket cost is one potential reason for the slow uptake of newer guideline-directed medical therapies for heart failure with reduced ejection fraction. This study aims to characterize patient-cardiologist discussions involving out-of-pocket costs associated with sacubitril/valsartan during the early postapproval period. Methods and Results We conducted content analysis on 222 deidentified transcripts of audio-recorded outpatient encounters taking place between 2015 and 2018 in which cardiologists (n=16) and their patients discussed whether to initiate, continue, or discontinue sacubitril/valsartan. In the 222 included encounters, 100 (45%) contained discussions about cost. Cost was discussed in a variety of contexts: when sacubitril/valsartan was initiated, not initiated, continued, and discontinued. Of the 97 cost conversations analyzed, the majority involved isolated discussions about insurance coverage (64/97 encounters; 66%) and few addressed specific out-of-pocket costs or affordability (28/97 encounters; 29%). Discussion of free samples of sacubitril/valsartan was common (52/97 encounters; 54%), often with no discussion of a longer-term plan for addressing cost. Conclusions Although cost conversations were somewhat common in patient-cardiologist encounters in which sacubitril/valsartan was discussed, these conversations were generally superficial, rarely addressing affordability or cost-value judgments. Cardiologists frequently provided patients with a course of free sacubitril/valsartan samples without a plan to address the cost after the samples ran out.

Giant asymptomatic pulmonary herniation following minimally invasive mitral valve replacement

Minimally invasive valve procedures have become the standard procedure for valvular surgery. Right thoracotomy is the preferred incision for mitral or tricuspid interventions. Complications regarding thoracotomy are almost always either overlooked or ignored. Pulmonary herniation is not that infrequent, but mostly asymptomatic or masked. Pulmonary herniation through thoracotomy incision is the most common presentation and is usually in a limited area. Herein, we present a 62-year-old female patient with giant pulmonary herniation that did not cause any respiratory issues following minimally invasive mitral valve surgery. No treatment was required for pulmonary herniation. She was only given full medical therapy for heart failure.