Optimization Of Heart Failure Treatment Research Articles

Optimization of Patient Pathway in Heart Failure with Reduced Ejection Fraction and Worsening Heart Failure. Role of Vericiguat.

Heart failure (HF) is a progressive condition with periods of apparent stability and repeated worsening HF events. Over time, unless optimization of HF treatment, worsening HF events become more frequent and patients enter into a cycle of recurrent events with high morbidity and mortality. In patients with HF there is an activation of deleterious neurohormonal pathways, such as the renin angiotensin aldosterone system and the sympathetic system, and an inhibition of protective pathways, including natriuretic peptides and guanylate cyclase. Therefore, HF burden can be reduced only through a holistic approach that targets all neurohormonal systems. In this context, vericiguat may play a key role, as it is the only HF drug that activates the nitric oxide-soluble guanylate cyclase-cyclic guanosine monophosphate system. On the other hand, it has been described relevant disparities in the management of HF population. Consequently, it is necessary to homogenize the management of these patients, through an integrated patient-care pathway that should be adapted at the local level. In this context, the development of new technologies (ie, video call, specific platforms, remote control devices, etc.) may be very helpful. In this manuscript, a multidisciplinary group of experts analyzed the current evidence and shared their own experience to provide some recommendations about the therapeutic optimization of patients with recent worsening HF, with a particular focus on vericiguat, and also about how the integrated patient-care pathway should be performed.

Mechanical support for the failing single ventricle after Fontan

Mechanical support for the failing single ventricle after Fontan

2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction

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Implementing Nonphysician Provider Guideline-Directed Medical Therapy Heart Failure Clinics: A Multi-National Imperative

Heart failure (HF) is a global epidemic, with more than 60 million patients living with HF worldwide. 1 Lippi G Sanchis-Gomar F. Global epidemiology and future trends of heart failure. AME Med J. 2020; 5 Crossref Google Scholar With an ageing population, this number is projected to continue to increase and will result in significant economic and resource strain on health care systems. Despite recent advances in pharmacotherapy, morbidity and mortality related to HF remains high. This, in part, may be related to a significant portion of patients receiving sub-optimal, guideline-directed medical pharmacotherapy (GDMT). Greene et al 2 Greene SJ Butler J Albert NM et al. Medical therapy for heart failure with reduced ejection fraction: the champ-hf registry. J Am Coll Cardiol. 2018; 72: 351-366 Crossref PubMed Scopus (270) Google Scholar highlighted this trend in the United States through the Change the Management of Patients with Heart Failure (CHAMP-HF) registry. Among patients with HF with reduced ejection fraction (HFrEF) eligible for angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers, angiotensin receptor neprilysin inhibitors (ARNi), beta blockers (BB), and mineralocorticoid receptor antagonists, these therapies were, concerningly, only prescribed in 27%, 33%, and 67% of eligible patients. Only a small portion of patients started on these foundational therapies were receiving target doses. Most notably, only 1% of the 3518 patients (approximately 35 patients) were simultaneously receiving target doses of all 3 therapies. The picture is similar internationally, with British registry data showing that failure to prescribe all 3 disease-modifying therapies is negatively associated with mortality in patients discharged after a recent HF hospitalization. It should also be mentioned that current registry data was collected before the release of recent sodium-glucose transport protein 2 inhibitor data, which has now led to an additional class of medications being recommended as part of the therapeutic backbone for HFrEF. 3 Maddox TM Januzzi JL et al. 2021 update to the 2017 acc expert consensus decision pathway for optimization of heart failure treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology solution set oversight committee. J Am Coll Cardiol. 2021; 77: 772-810 Crossref PubMed Scopus (83) Google Scholar Furthermore, recent data from CONNECT-HF continues to reveal suboptimal dosing for patients with HFrEF, between 25% and 40% for ACEI, angiotensin receptor blocker, ARNI, BB, and mineralocorticoid receptor antagonist therapy. 4 CONNECT-HF: Can Additional HospitalPost-Discharge QI Interventions Improve HF Outcomes, Care?. American College of Cardiology, 2021https://www.acc.org/Latest-in-Cardiology/Articles/2021/05/12/19/40/Mon-8am-CONNECT-HF-acc-2021 Google Scholar

Medical Treatment of Heart Failure: Ignore the Ejection Fraction and Treat All?

The left ventricular ejection fraction (LVEF), the most widely used index of LV function, has an essential role in defining heart failure (HF) phenotypes and guiding treatment of chronic HF. 1 Maddox TM Januzzi JL Allen LA Breathett K Butler J Davis LL et al. 2021 Update to the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: answers to 10 pivotal issues about heart failure with reduced ejection fraction: a report of the American College of Cardiology Solution Set Oversight Committee. J Am Coll Cardiol. 2021; 77: 772-810 Crossref PubMed Scopus (83) Google Scholar

28561 Optimization of Heart Failure Treatment Using a Novel Application Programming Interface (API)

ABSTRACT IMPACT: This project will aid in the optimization of treatment for those with heart failure with a reduced ejection fraction in order to both maximize health benefits and minimize financial burdens. OBJECTIVES/GOALS: To evaluate the accuracy and clinical applicability of a novel web-based application programming interface in the optimization of care for patients being treated for heart failure with reduced ejection fraction (HFrEF). The purpose of this validation is to ensure the translatability of this algorithm to a clinical setting using real-world data. METHODS/STUDY POPULATION: This study is a retrospective analysis of a previously created algorithm designed to optimize therapy for patients currently diagnosed with HFrEF. Patients that are seen for HFrEF treatment at Michigan Medicine are enrolled in a heart failure registry and were included in this study. Exceptions include those with heart transplants, LVAD, and those undergoing treatment with chronic inotropes (milrinone/dobutamine). Clinically relevant information (demographics, vital statistics, labs, and medications including dose and frequency) was taken from their respective electronic health record (EHR) and this data was used as the input for the algorithm. The therapy recommendations were collected and manually compared to the 2017 ACC/AHA/HFSA guidelines to verify the accuracy of the algorithm outputs. RESULTS/ANTICIPATED RESULTS: Data is currently being collected and analyzed. At first glance, our algorithm has been successful at detecting patients that are good candidates for therapy optimization. Based on inputs given, the treatment recommendations have been appropriate when compared to the most up-to-date HF treatment guidelines. The algorithm has also correctly identified levels of urgency for therapeutic recommendations. Finally, we have also shown the algorithm to have effectiveness for identifying areas of inappropriately adjusted therapy. Preliminary results have led to changes to the functionality of the algorithm, including how medications are retrieved from the EHR’s and how medication doses are identified. Previous iterations created discrepancies in dosing and the algorithm has since been adjusted. DISCUSSION/SIGNIFICANCE OF FINDINGS: By verifying its validity, our algorithm can accurately flag patients with HFrEF that are eligible for therapy optimization and give providers the opportunity to make appropriate changes. Given the high health and financial burdens of HFrEF, our algorithm has the ability to provide significant morbidity, mortality, and financial benefits.

Abstract 393: Addressing The Gap In Outpatient Guideline Directed Medical Therapy Dosing In Heart Failure With Reduced Ejection Fraction: Preliminary Findings

Background: The benefit of guideline directed medical therapy (GDMT) in heart failure with reduced ejection fraction (HFrEF) is well established in the medical literature and clinical practice guidelines. The low prevalence of optimal dosing of these medications remains an obstacle in providing quality care for this patient population. Methods: An electronic medical record (EMR) triggered alert was attached to all patient charts with ICD-10 codes associated with HFrEF at a single internal medicine residency-associated outpatient primary care office. This alert urged use of a GDMT initiation and titration reference sheet based on the 2017 ACC Expert Consensus Decision Pathway for Optimization of Heart Failure Treatment: Answers to 10 Pivotal Issues About Heart Failure With Reduced Ejection Fraction . A retrospective review of patients with corresponding ICD-10 codes and documented ejection fractions less than or equal to 40% was conducted and the intensity of GDMT dosing in these patients was recorded. A group of patients treated 3 years prior to the intervention were then compared to those treated after the intervention Results: 38 patients with a documented diagnosis of HFrEF that were evaluated between January 9, 2017 and January 9, 2020 were identified. 32 (84.2%) of these patients were on GDMT beta blockers and only 1 (3.1%) of these patients were receiving the target dose. Of the 31 (81.5%) of patients receiving ACE/ARB/ARNi therapy, 9 (41.9%) patients received target dosing. Mineralocorticoid receptor antagonist therapy (MRA) was prescribed to 11 (28.9%) patients; all of these patients received the target dose. Uptitration of medication was observed in the management of 9 (23.7%) of patients. Following the intervention, 8 patients with a documented diagnosis of HFrEF were evaluated between January 9, 2020 and March 5, 2020.GDMT beta blockers were prescribed to 7 (87.5%) of these patients; 1 (12.5%) patient received a target dose. ACE/ARB/ARNi therapy was given to all 8 patients and half of the patients were prescribed a target dose. MRA treatment was given to 2 (25%) of the8 patients; both patients were given the target dose. Uptitration of GDMT was observed in 1 (12.5%) patient following the intervention. There was no statistically significant difference between pre-intervention and post-intervention groups (P= 0.7187) regarding initiation and uptitration of GDMT. Conclusion: An EMR triggered effort to improve GDMT dosing in HFrEF patients did not show significant improvement in a small patient population over a short time period.

Optimization of Heart Failure Treatment by Heart Rate Reduction.

Heart failure (HF) treatment should be optimized in addition to guideline-directed and recommended drugs to achieve an appropriate heart rate (i.e. 50−60 bpm) by ivabradine in patients with a heart rate >70 bpm in sinus rhythm and with an ejection fraction ≤35%. Heart rate reduction was to reduce cardiovascular death and HF hospitalization dependent on baseline resting heart rate. In particular in patients at a heart rate >75 bpm, a reduction in cardiovascular death, all-cause death, HF death, HF hospitalization and all-cause hospitalization has been observed. The optimal heart rate achieved appears to be between 50−60 bpm, if well tolerated as in these patients the lowest event rate is observed on treatment. Heart rate reduction is, therefore, a treatable risk factor in chronic HF. Observational studies support the concept that it is a risk indicator in other cardiovascular and non-cardiovascular conditions. Whether heart rate reduction is also modifying risk in other conditions than chronic HF should be explored in prospective clinical trials.

Evolution of mitral regurgitation in patients with heart failure referred to a tertiary heart failure clinic.

AbstractAimsSignificant mitral regurgitation (MR) is an important predictor for all‐cause mortality and heart failure (HF) hospitalizations independent of left ventricular ejection fraction (LVEF). The aims of this study were to investigate (i) in how many patients referred to a tertiary outpatient HF clinic HF therapy could be optimized, (ii) the effect of optimized treatment on MR severity, and (iii) whether a reduction in MR resulted in improvement of symptoms.Methods and resultsForty‐seven referred patients with therapy‐resistant symptomatic chronic HF with an LVEF <40% and at least moderate MR were analysed on admission and after optimization of HF treatment after 6–18 months. The patients were classified as a volume responder when LV end‐systolic volume (LVESV) decreased ≥15%, as LVEF responder when LVEF increased by ≥5% points, as clinical responder when New York Heart Association (NYHA) class improved at least one category, and as MR responder when MR severity improved at least one category to maximally moderate. After 14 ± 4 months of treatment optimization, optimal doses of angiotensin‐converting enzyme inhibitors/angiotensin receptor blocker were seen in 18 (38%) patients compared with three (6%) at baseline (P < 0.001), and optimal doses of beta‐blockers were seen in 14 (30%) patients compared with four (9%) at baseline (P < 0.001). In total, 68% of the patients were clinical responders, 57% MR responders, 34% volumetric responders, and 49% LVEF responders. NYHA class improved from 2.9 ± 0.6 to 2.0 ± 0.9 (P < 0.001), MR class from 5.2 ± 0.8 to 3.6 ± 1.5 (P < 0.001), LVEF from 24% ± 9% to 31% ± 12% (P < 0.01), and LVESV non‐significantly improved. The positive predictive value of MR response to NYHA response was 88%; the negative predictive value was 53%, agreement 69%, and kappa 0.39. The positive predictive value of LVEF response to NYHA response was 76%; the negative predictive value was 44%, agreement 60%, and kappa 0.21. The positive predictive value of LVESV volume response to NYHA response was 75%; the negative predictive value was 39%, agreement 51%, and kappa 0.12.ConclusionsAlthough this study was limited by a small number of patients, initiation and up‐titration of recommended HF therapy in patients referred to our tertiary HF outpatient clinic resulted in significant MR reduction in over half of the patients, emphasizing the importance of optimal medical treatment in these very sick cardiac patients with otherwise grave prognosis. MR reduction was best correlated to NYHA improvement.

Medical Inertia in the Optimization of Heart Failure Treatment after Discharge and its Relationship to Outcome

Background: After discharge, patients with Acute Heart Failure (AHF) have a high risk of early re-admission and death. Many patients are discharged early before treatment has been optimized. By using a multicenter cohort of AHF patients, we analyzed changes in evidence-based HF medication between admission, discharge and early follow-up as well as their links to mortality. Methods: Clinical data and medications were collected during hospitalization. Changes in medication during the 3 months following discharge as well as the rate of all-cause mortality at one year were analyzed. Results: Among survivors at 3 months, 275 patients with LVEF ≤ 40% were included (age 72 ± 14 y). Between admission and discharge, usage of angiotensin converting enzyme inhibitor (ACE-I) or angiotensin receptor blocker (ARB) and beta blocker (BB) increased by 19 to 20% and MRA by 8%. At discharge, ACE-I or ARB were prescribed in 80% of cases with the mean dose reaching 36 ± 31% of target dose, BB in 70% with the mean dose of 27 ± 51% of the target dose, mineraloreceptor antagonists (MRA) were prescribed in 23% and diuretics in 88% cases. Three months after discharge, there were few changes in medications. Start in ACE-I or ARB, beta-blockers and MRA was performed in 3 to 7% while cessation was performed in 5 to 6% cases. Changes in doses were observed in about 25% cases. usage of BB and Ace ORARB >/ % of target dose at 3 months shows a tendency to deusage montality [ HR=5,2999;95%ic1,7369-16-1722; p=0,0635]. Conclusion: Our data points out inertia in optimization of evidence-based HF medications after discharge and focus on potential explanations of such inertia. Medical ineatia have a potential impaction on outcomein heart failure.

PM098 Optimization of Heart Failure Treatment at Hospital Discharge: a 30-day Follow-up Study “On behalf of the Roci Pilot Project”

PM098 Optimization of Heart Failure Treatment at Hospital Discharge: a 30-day Follow-up Study “On behalf of the Roci Pilot Project”

Urine measurement indicates the plasma brain natriuretic peptide concentration during optimization of heart failure treatment

Aim: To assess the correlation between the amino-terminal pro-hormone brain natriuretic peptide (NT-proBNP) concentration in blood and urine during a period when actively adjusting the treatment of heart failure (HF). Methods: Plasma and urine analyses of NT-proBNP were compared in 51 patients on admission to and discharge from a nurse-led outpatient clinic where HF treatment was optimized. The median time between the two measurements was 42 days. Correlations were analyzed using linear regression, where R2 is the degree of variability in the plasma NT-proBNP concentration that can be accounted for by the urinary NT-proBNP. Results: There was a statistically significant linear relationship between the urine and plasma concentrations of NT-proBNP on both occasions, but R2 varied greatly depending on how the data were presented. The correlation between the raw data showed an R2 of only 30%, and it almost doubled upon logarithm transformation, which shows that the variability (error) was concentration-dependent. Correction of the urinary NT-proBNP for urinary creatinine further increased R2 for the logarithm-transformed correlation to 68% on admission and 76% on discharge. The highest R2 (77%) was obtained when the relative changes in urinary NT-proBNP/creatinine between admission and discharge were compared with the corresponding relative changes in the plasma concentration. The sensitivity and specificity of the urine in indicating plasma concentration changes > 10% were 82% and 86%, respectively. Conclusion: Relative changes in plasma NT-proBNP could be reliably estimated from urine samples during a period of optimization of HF treatment.

Optimization of heart failure medication after cardiac resynchronization therapy and the impact on long-term survival.

Treatment with evidence-based heart failure (HF) medication reduces morbidity and mortality, yet they remain underused and underdosed. Cardiac resynchronization therapy (CRT) improves haemodynamics, and might allow for optimization of HF medication. We analysed treatment with HF medication after CRT implantation, long-term adherence to this treatment, and its association with patient survival. This observational study included 826 consecutive patients who received a CRT device at a tertiary centre. Data were obtained from patient files and prescription data from the Danish National Prescription Registry. Doses are expressed as percentages of target doses. We used Cox proportional hazard model to compute adjusted hazard ratios (aHRs) for survival with 95% confidence intervals (CIs), adjusted for potential confounders. During the median (quartiles) follow-up of 4.4 (3.0-6.7) years, 324 patients died. Daily doses of beta-blocker (BB) (53 (27-90) vs. 43 (22-75)%; P < 0.001) and angiotensin-converting enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB) (78 (45-100) vs. 74 (44-97)%; P = 0.02) had increased after 6-month follow-up compared with pre-implantation doses. After 4 years, adherence was 95% to BB and 94% to ACEi/ARB. Treatments with low (≤50%) and high (>50%) doses were associated with prolonged survival for BB (low: aHR 0.65 (0.47-0.90); P = 0.009, and high: aHR 0.50 (0.35-0.70); P < 0.001) and for ACEi/ARB (low: aHR 0.68 (0.46-1.00); P = 0.05, and high: aHR 0.55 (0.38-0.80); P = 0.002). After CRT implantation, optimization of HF treatment is possible, and long-term adherence to HF medication remains high. Higher doses of BB and ACEi/ARB were associated with prolonged survival.

Abstract 17912: Importance of Acute Hemodynamic Effects of Inhaled Nitric Oxide in Optimization of Heart Failure Treatment in Patients with Pulmonary Hypertension due to Left Heart Disease

Background: Pulmonary hypertension (PH) due to left heart disease (LHD) is a major category of the disorder. We have recently reported that elevated pulmonary vascular resistance (PVR) in patients with post-capillary PH (pc-PH: defined as mean pulmonary arterial pressure (mPAP)≥25mmHg and pulmonary capillary wedge pressure (PCWP)&gt;15mmHg) is associated with poor prognosis compared with those with no PH or pc-PH without elevated PVR. Although new treatment is required for targeting pulmonary vascular disease (PVD), thereis a concern about raising PCWP. In this study, we thus examined acute hemodynamic effects of inhaled nitric oxide (iNO) in patients with PH due to LHD and whether optimal heart failure (HF) treatment ameliorates pc-PH. Methods: We examined 60 consecutive pc-PH patients with chronic heart failure (63±14[SD] years, M/F 38/22, NYHA≥2) who underwent acute vasoreactivity test by iNO (40 ppm for 10 min) under right heart catheterization at our hospital from June 2011 to May 2014. Among them, 25 had valvular heart disease (VHD) and 35 had non-VHD. PVD (defined as PVR&gt; 240dynes/s/cm -5 ) was noted in 18. We also evaluated right ventricular systolic pressure (RVSP) by echocardiography after optimization of HF treatment such as medications and valvular surgery. Results: iNO significantly decreased mPAP (-1.7±0.5 mmHg; P&lt;0.01) and PVR (-66 ±14dyne/s/cm -5 , P&lt;0.01) without altering cardiac output. iNO significantly increased PCWP (1.3±0.5 mmHg, P=0.01) only in non-VHD patients, while it significantly increased mean arterial pressure and systemic vascular resistance in VHD patients than in non-VHD patients (both P&lt;0.05). Pc-PH patients with PVD were re-classified as having pc-PH without PVD in 9 and no PH in 1. Eight patients remained pc-PH with PVD. After the optimal medical treatment for 7.6 months, RVSP was significantly decreased in both non-VHD and VHD patient (-8±3mmHg, P=0.04, -19±8mmHg, P=0.01, respectively). However, in non-VHD group, significant reduction in RVSP was noted only in pc-PH patients without PVD (-8±3mmHg, P=0.03). Conclusions: These results indicate that elevated PVR in patients with pc-PH and non-VHD could be a novel therapeutic indication for NO-related pulmonary vasodilators in the current practice of HF.

Reduction of ICD indications after optimization of heart failure treatment in patients with severe left ventricular systolic dysfunction

Background: Patients with LVEF≤35% and NYHA class II or III heart failure under optimal medical treatment have an indication of an ICD in primary prevention. Data regarding the magnitude of improvement of LVEF after intensive optimization of heart failure medical treatment are scarce. Purpose: To assess the clinical, echocardiographic and biological impact of intensive optimization of heart failure medical treatment in patients with severe left ventricular systolic dysfunction. Methods: This is an observational prospective study in which patients visited in a heart failure unit with LVEF≤35%, without an ICD, with heart failure and non-optimal heart failure medical treatment are included. Up-titration of beta blockers, ACE inhibitors/ARB and aldosterone antagonist are gradually performed in the day hospital of the heart failure unit up to 100% of the target dose or the maximum tolerated dose. At 6 month after completion of drug up-titration the echocardiography is repeated and clinical follow-up assessed again. Results: 85 patients have been already included. 34/85 are still being up-titraded. 3/85 died during follow-up. The 6 month follow-up has been accomplished in 48/85 patients, age 65±14 years, 9 (19%) female, 20 (42%) with ischemic heart disease. Patients on 100% of target dose of beta blockers, ACE inhibitors/ARB and aldosterone antagonists increased from 8%, 23% and 17% to 81%, 77% and 72%, respectively, with up-titration. NYHA class diminished at 6 month: 2,1±0,6 vs 1,5±0,6, p 35% in 25/48 (52%) patients at 6 month after up-titration. Consequently, patients with an ICD indication were reduced: 44 (92%) vs 12 (25%) when comparing before and after 6 month of completion of optimization of heart failure medical therapy. Moreover, pro-BNP levels were also reduced: 2676±227 vs 1754±1804 pg/ml before and after 6 month of up-titration completion. Conclusions: Intensive optimization of heart failure medical therapy in patients with severe systolic left ventricular impairment improves symptoms and quality of life and reduces hospital admissions. Furthermore LVEF increases in the majority of patients and ICD indications are accordingly reduced.

The benefits of using a heart failure management programme in Swedish primary healthcare

Heart failure (HF) is a common condition with which high mortality, morbidity, and poor quality of life are associated. It has previously been shown that use of HF management programmes (HFMPs) in HF clinics can be beneficial. The purpose of this study was to evaluate if the use of HFMPs also has beneficial effects on HF patients in primary healthcare (PHC). This is a randomized, prospective, open-label study including 160 patients from five PHC centres with systolic HF and a mean age of 75 years (standard deviation 7.8). In the intervention group, an intensive follow-up was performed by HF nurses and physicians providing information and education about HF and the optimization of HF treatment according to recognized guidelines. There was a significant improvement of composite endpoints in the intervention group. Significantly more patients with reduced N-terminal pro brain natriuretic peptide (P = 0.012), improved cardiac function (P = 0.03), fewer healthcare contacts (P = 0.04), and fewer emergency room visits and admittances (P = 0.0002 and P = 0.03, respectively) could be seen in the intervention group when compared with the control group. The use of a HFMP in a PHC setting was found to have beneficial effects in terms of reducing the number of healthcare contacts and hospital admissions, and improving cardiac function in patients with systolic HF, even if the result should be interpreted with caution. It can therefore be recommended that HFMPs should be used in PHC.