Secondary Prevention Of Heart Failure Research Articles

Physical activity and cardiac rehabilitation for the primary and secondary prevention of heart failure

Heart failure (HF) is a mounting global health and financial concern. With the introduction of angiotensin receptor-neprilysin inhibitors and sodium-glucose cotransporter-2 inhibitors, outcomes for HF have improved dramatically in recent years, however, the increase in HF cases remains uncontrolled, and reliance on current medical treatment alone is no longer sufficient. Therefore, primary prevention through exercise habits and secondary prevention through cardiac rehabilitation (CR) are becoming increasingly important to reduce the number of HF cases. We have previously highlighted the benefits of adopting a healthy lifestyle in preventing cardiovascular disease (CVD), even in individuals with cancer. Our findings underscore the importance of incorporating regular exercise into lifestyle modification and highlight the critical role of exercise habits in primary prevention, especially in terms of CVD prevention. The importance of CR is emphasized in the many guidelines such as European, American, and Japanese guidelines. CR is given a Class I recommendation due to its association with improved prognosis for patients with HF. Furthermore, early initiation of CR is recommended, especially for older patients with HF, because CR has been reported to reduce the length of stay and prevent rehospitalization. In addition to the existing evidence, the Nationwide Population-Based Database in Japan has indicated the importance of CR in patients with acute HF and of enhancing gait speed in preventing HF. Although the importance of CR is recognized worldwide, actual utilization of CR by patients remains low. The challenge for the future is to raise awareness among attending physicians and patients about the importance of exercise habits and CR by actively promoting individualized rehabilitation.

Cardiac Structure and Function in Patients With Obesity and Non-alcoholic Fatty Liver Disease.

Introduction Non-alcoholic fatty liver disease (NAFLD) has emerged as a leading cause of chronic liver disease worldwide. The global prevalence of NAFLD is expected to increase dramatically with the increasing prevalence of obesity and type 2 diabetes mellitus (T2DM). The role of NAFLD as a cardiometabolic risk factor or component of metabolic syndrome on the heart remains unclear. Thus, the independent effect of NAFLD on structural and functional heart parameters warrants validation. Our goal was to study cardiac structure and function in subjects with obesity and NAFLD. Methods A total of 164 patients were examined in this cross-sectional study. Participants were grouped based on BMIand the presence or absence of abdominal obesity (AO) and/or NAFLD. The subjects were divided into four groups:group 1: normal BMI without AO and NAFLD; group 2: BMI ≥ 25 kg/m2or AO without NAFLD; group 3: BMI ≥ 25 kg/m2and AO without NAFLD;group 4: patients with BMI ≥ 25 kg/m2,AO, and NAFLD. We performed a thorough clinical examination, a biochemical blood analysis, and echocardiography. Indices of liver steatosis and fibrosis were calculated. A study of liver assessment of the controlled attenuation parameter (CAP) and liver stiffness measurement (LSM) was conducted. Statistical analysis was performed using IBM SPSS Statistics version 26 (IBM Corp., Armonk, NY). Results The mean age of the participants was 35.0 (31.0-38.5) years. We found a higher frequency of multiple cardiometabolic risk factors in the general cohort. However, on comparing groups 3 and 4, we found a higher frequency of hyperinsulinemia, homeostatic model assessment of insulin resistance (HOMA-IR), and obesity (p < 0.05). To assess the role of NAFLD independent of obesity, we conducted further analyses after adjusting for BMI. Among patients with NAFLD, we observed a similar trend for parameters of carbohydrate metabolism (p < 0.005).In individuals with NAFLD, an increase in left atrial (LA) volume, interventricular septal (IVS) thickness, and left ventricular (LV) myocardial mass, and a decrease in LV ejection fraction and LV stroke volume index were found (p < 0.005). The hepatic steatosis index (HSI) correlated with LA volume, LV end-systolic volume (ESV) and LV end-diastolic volume (EDV), stroke volume, and LV myocardial mass. An association between an increase in CAP score and an increase in the LA volume, stroke volume index, IVS thickness, LV myocardial mass, and the values of LSM with an increase in the LA volume was established. Conclusion The presence of NAFLD without cardiovascular disease and diabetes mellitus revealed an association with the structural and functional parameters of the heart.The results of this study can also be used to improve the effectiveness of a comprehensive assessment of patients and to develop strategies for the primary and secondary prevention of heart failure with preserved ejection fraction in NAFLD.

Sodium-Glucose Cotransporter-2 (SGLT2) Inhibitor Therapy for the Primary and Secondary Prevention of Heart Failure in Patients With and Without Type 2 Diabetes Mellitus: A Systematic Review.

The global prevalence of heart failure (HF) is rising and carries a heavy social and economic burden. Type 2 diabetes mellitus (T2DM) patients are at an increased risk of incident HF even in the absence of cardiovascular risk factors. Patients with established HF are at an increased risk of death following a worsening HF event. Various trials on sodium-glucose cotransporter-2 (SGLT2) inhibitors have shown that these novel drugs prevent incident HF and reduce the risk of worsening HF in both patients with T2DM and those without diabetes. This literature review analyzed the data from 13 randomized controlled trials that met the pre-specified inclusion criteria. The aim was to compare the clinical outcomes of SGLT2 inhibitors for primary and secondary prevention of HF in patients with T2DM and those without diabetes. In addition, this study collated and summarized the patients' clinical characteristics with respect to the clinical outcome, and finally, it evaluated the safety considerations when using SGLT2 inhibitors. The data showed that SGLT2 inhibitors are effective and safe in the primary and secondary prevention of HF across a broad spectrum of patient populations and care settings. Therefore, wider eligibility for their use should be considered.

A Hybrid Model of Prognostic Medication Up-Titration for Left Ventricular Systolic Dysfunction (LVSD) Post Myocardial Infarction Within a Cardiac Rehabilitation Program

Readmission and death from heart failure following Left Ventricular Systolic Dysfunction (LVSD) post Myocardial Infarction (MI) is high due to adverse cardiac remodelling. Early optimisation of prognostic medications for secondary prevention can help with cardiac remodelling but is often suboptimal in clinical practice despite international guidelines. Outpatient cardiac nurse clinics require capacity, and this means multiple visits for patients who are already expected to attend cardiac rehabilitation (CR). This often leads to inequity due to accessibility, affordability, and availability. An innovative sustainable model to address unmet need and reduce clinic burden was implemented at cardiac rehabilitation to up-titrate pharmacotherapy by nurse prescribers working at the top of their scope of practice. Retrospective six =-month audit from April to October 2019. Entry criteria was LV impairment ± regional wall motion abnormalities post MI; patients had to be euvolaemic and have regular CR attendance. An up-titration policy used the European Society Cardiology Guidelines 2017/19 to increase medications fortnightly. 129 patients attended CR and 39 had LVSD but only 19 patients completed optimisation. 30% had a repeat echocardiogram and 100% had improved LV function. Average up-titration was 3 per person saving 119 cardiac nurse clinics. Medication optimisation by Cardiac nurse prescribers for LVSD post MI at CR is an effective and efficient model for secondary prevention of heart failure, readmission and death. Furthermore, this innovative model provides accessible, affordable, and equitable care to cardiac patients by maximising current resources and reducing the burden of outpatient clinics.

Cardiovascular Effects of Hypoglycemic Agents in Diabetes Mellitus

Despite substantial improvements over the years, diabetes mellitus is still associated with cardiovascular disease, heart failure, and excess mortality. The objective of this article is to examine existing data on the reduction of cardiovascular morbidity and mortality in diabetes. Control of glycemia, lipid levels, and blood pressure are described in brief. The main scope of this article is, however, to review the glucose-independent cardiovascular effect of antidiabetic pharmacological agents (mainly other than insulin). The article is a narrative review based on recently published reviews and meta-analyses complemented with data from individual trials, when relevant. Older data suggest a cardioprotective role of metformin (an inexpensive and safe drug); a role to date not convincingly challenged. The cardiovascular effects of thiazolidinediones, sulphonylurea, and glinides are debatable. Recent large-scale cardiovascular outcome trials suggest a neutral profile of dipeptidyl peptidase 4 inhibitors, yet provide compelling evidence of cardioprotective effects of glucagon-like 1 receptor antagonists and sodium-glucose transporter 2 inhibitors. Metformin may have a role in primary and secondary prevention of cardiovascular disease; glucagon-like 1 receptor antagonists and sodium-glucose co-transporter 2 inhibitors play a role in secondary prevention of atherosclerotic cardiovascular disease. Sodium-glucose transporter 2 inhibitors have a role to play in both primary and secondary prevention of heart failure; yet, they carry a small risk of the potentially dangerous adverse effect, euglycemic diabetic ketoacidosis.

Marine-Derived Omega-3 Polyunsaturated Fatty Acids and Heart Failure: Current Understanding for Basic to Clinical Relevance.

Heart failure (HF) is a rapidly growing global public health problem. Since HF results in high mortality and re-hospitalization, new effective treatments are desired. Although it remains controversial, omega 3 polyunsaturated fatty acids (n-3 PUFAs), such as the eicosapentaenoic acid and docosahexaenoic acid, have been widely recognized to have benefits for HF. In a large-scale clinical trial regarding secondary prevention of HF by n-3 PUFA (GISSI-HF trial), the supplementation of n-3 PUFA significantly reduced cardiovascular mortality and hospitalization. Other small clinical studies proposed that n-3 PUFA potentially suppresses the ventricular remodeling and myocardial fibrosis, which thereby improves the ventricular systolic and diastolic function both in ischemic and non-ischemic HF. Basic investigations have further supported our understanding regarding the cardioprotective mechanisms of n-3 PUFA against HF. In these reports, n-3 PUFA has protected hearts through (1) anti-inflammatory effects, (2) intervention of cardiac energy metabolism, (3) modification of cardiac ion channels, (4) improvement of vascular endothelial response, and (5) modulation of autonomic nervous system activity. To clarify the pros and cons of n-3 PUFA on HF, we summarized recent evidence regarding the beneficial effects of n-3 PUFA on HF both from the clinical and basic studies.

Type 2 Diabetes Mellitus and Heart Failure: Innovative Possibilities for Management of Prognosis

Type 2 diabetes mellitus (T2DM) has gone beyond the professional interests of one specialty. T2DM, cardiovascular (CV) diseasesand chronic kidney disease, considered from the standpoint of a single cardio-reno-metabolic continuum, place a heavy economicburden on society. At the same time, the improvement of diagnostic methods and medical technologies led to distinct decreasein the frequency and mortality from a number of complications of T2DM, including myocardial infarction and stroke, but other statestook their place. Thus, heart failure (HF) has taken the position of one of the most frequent complications with average prevalenceof 24-40 % and significant predominance of HF with preserved ejection fraction (HFpEF). According to this paradigm, HFpEF is nota disease of diastolic dysfunction, but a systemic disease, the central element of which is impaired renal function. All this togetherhas a potential value for choosing the optimal therapy. In recent years the results of specially designed studies assessing the CV-safetyof antidiabetic drugs from the groups of dipeptidyl peptidase-4 (DPP4) inhibitors, glucagon-like preptide-1 (GLP-1) receptor agonists and sodium - glucose co-transporter-2 (SGLT2) inhibitors have become known. These drugs, except for SGLT2 inhibitors, by their mechanism of action affecting insulin resistance and hyperglycemia, demonstrated neutral or negative result on the frequency of hospitalizations due to HF. The EMPA-REG OUTCOME study with SGLT2, which has a special insulin-independent mechanism of action, demonstrated not only the efficacy and CV-safety of the drug in the form of a decrease in CV mortality by 38 %, but also a decrease in hospitalizations for HF by 35 %. Further studies with SGLT2 inhibitors confirmed positive effect on HF, indicating a class effect of the drugs. The recently completed study DECLARE-TIMI 58 proved the advantages of using dapagliflozin for the primary and secondary prevention of HF. This review highlights the prevalence of HF in diabetes mellitus, a new concept of the pathophysiology of HF, the main groups of sugar-lowering drugs and their effect on CV outcomes, in particular on HF.

Dietary Patterns in Secondary Prevention of Heart Failure: A Systematic Review.

Background: Diet is an important factor in secondary prevention of heart failure (HF) but there is still no consensus as to which dietary model should be adopted by this population. This systematic review aims to clarify the relationship between dietary patterns and secondary prevention in HF. Methods: We searched the Medline, Embase and Cochrane databases for studies with different dietary patterns and outcomes of secondary prevention in HF. No limitation was used in the search. Results: 1119 articles were identified, 12 met the inclusion criteria. Studies with Dietary Approaches to Stop Hypertension (DASH), Mediterranean, Hyperproteic and Low-carb diets were found. The DASH pattern showed improvement in cardiac function, functional capacity, blood pressure, oxidative stress and mortality. The Mediterranean diet had a correlation with inflammation, quality of life and cardiac function but just on cross-sectional studies. Regarding the Hyperproteic and Low-carb diets only one study was found with each pattern and both were able to improve functional capacity in patients with HF. Conclusions: DASH pattern may have benefits in the secondary prevention of HF. The Mediterranean diet demonstrated positive correlation with factors of secondary prevention of HF but need more RCTs and cohort studies to confirm these effects. In addition, the Hyperproteic and Low-carb diets, despite the lack of studies, also demonstrated positive effects on the functional capacity in patients with HF.

Can we go beyond surrogates?

Two years ago, data presented at the annual American Diabetes Association (ADA) meeting in New Orleans showed a marked decrease in deaths, especially those due to cardiovascular disease, with the use of empagliflozin. Two major questions have been asked: (i) was the result a fluke; and (ii) was it a class effect, or was it specific to the agent used? The hope that both questions would be answered by a second study has been answered: the conclusions of EMPA-REG were not an anomaly and it is a class effect, not one caused by a specific drug. Importantly, do these studies require us to alter our algorithms for the treatment of type 2 diabetes? The CANagliflozin cardioVascular Assessment Study (CANVAS) was designed similarly to EMPA-REG, enrolling individuals who either had known cardiac disease or were at high risk for cardiac disease. In fact, CANVAS involved two stages, CANVAS and CANVAS R, which can be analyzed together. There were 10 142 patients in the combined trial followed for a mean of 3.6 years. The average age was 63.3 years, 35.8% were women, the mean duration of diabetes was 13.5 years, and 65.6% had known cardiovascular disease. In EMPA-REG, 7020 patients were followed for 3.1 years, 28.5% were women, and all had established cardiovascular disease. The primary endpoint of both studies was the composite of cardiovascular death, non-fatal myocardial infarction, and non-fatal stroke. In both studies, the components of the composite endpoint were studied along with other endpoints, including hospitalization for heart failure, all-cause mortality, and progression of renal disease. The primary endpoint was identically positive for superiority with hazard ratio of 0.86 for empagliflozin versus placebo and for canagliflozin versus placebo. Some differences were observed: both death from cardiovascular disease and all-cause mortality occurred significantly less frequently with empagliflozin in EMPA-REG, but the 13% lower total and cardiovascular mortality seen with canagliflozin in CANVAS was not statistically significant. Both studies showed a lower likelihood of hospitalization for heart failure with the intervention, even in patients without known heart failure at baseline, suggesting either that that diagnosis is often missed or that de novo heart failure may be prevented by these agents. Perhaps the strongest answer to the initial two questions comes from the CVD-REAL Study. Rather than being a randomized controlled clinical trial, that study analyzed medical claims, primary care or hospital records, and national registries from the US, Norway, Denmark, Sweden, Germany, and the UK, including 309 056 patients started on a sodium-glucose cotransporter 2 (SGLT2) inhibitor or on other glucose-lowering drugs using a propensity score matching algorithm. Canagliflozin was used by 53% of those receiving SGLT2 inhibitors, dapagliflozin was used by 42% and empagliflozin was used by 5%; those using these agents had hazard ratios for hospitalization for heart failure and for mortality of 0.61 and 0.49, respectively, with no differences either by country or by drug. The interesting hypothesis that this and the two controlled trials show the harm of alternative treatments of diabetes rather than the benefit of SGLT2 inhibitors has not been confirmed by subset analyses of drug use in the control groups. There are several potentially important differences between the studies. Strokes increased with empagliflozin in EMPA-REG (not statistically significant). There was a significantly increased likelihood of lower extremity amputation in CANVAS, although these events may not have been fully studied in EMPA-REG. Finally, the benefit of SGLT2 inhibitor therapy were seen within 3 months in EMPA-REG, while not appearing as rapidly in CANVAS. Furthermore, in neither study was there a reduction in non-fatal myocardial infarction. These considerations suggest that the benefit of SGLT2 inhibitors is not due to improvement in the underlying atherosclerotic process. It is likely that all SGLT2 inhibitors will receive an indication for secondary prevention of heart failure; whether the agents should be used in primary prevention is a much more difficult question, because it would require a very large study of patients without heart disease. The introduction of HbA1c measurements in the late 1970s radically and significantly improved our treatment of diabetes. However, our treatment of diabetes is ultimately not to lower HbA1c, but to prevent the complications of diabetes. Values of HbA1c are only a surrogate measure of diabetes. Currently, there is little agreement on the treatment algorithm for diabetes after metformin therapy. One may now argue that an SGLT2 inhibitor should be the preferred second-line therapy.

Incidence of first heart failure hospitalisation and mortality in Aboriginal and non-Aboriginal patients in Western Australia, 2000–2009

ObjectivesTo compare the incidence of first heart failure (HF) hospitalisation, antecedent risk factors and 1-year mortality between Aboriginal and non-Aboriginal populations in Western Australia (2000–2009). MethodsA population-based cohort aged 20–84years comprising Aboriginal (n=1013; mean 54±14years) and non-Aboriginal patients (n=16,366; mean 71±11years) with first HF hospitalisation was evaluated. Age and sex-specific incidence rates and HF antecedents were compared between subpopulations. Regression models were used to examine 30-day and 1-year (in 30-day survivors) mortality. ResultsAboriginal patients were younger, more likely to reside in rural/remote areas (76% vs 23%) and to be women (50.6% vs 41.7%, all p<0.001). Aboriginal (versus non-Aboriginal) HF incidence rates were 11-fold higher in men and 23-fold in women aged 20–39years, declining to about 2-fold in patients aged 70–84years.Ischaemic and rheumatic heart diseases were more common antecedents of HF in younger (<55years) Aboriginal versus non-Aboriginal patients (p<0.001). Hypertension, diabetes, chronic kidney disease, renal failure, chronic obstructive pulmonary disease, and a high Charlson comorbidity index (>=3) were also more prevalent in younger and older Aboriginal patients (p<0.001). Although 30-day mortality was similar in both subpopulations, Aboriginal patients aged <55years had a 1.9 risk-adjusted hazard ratio (HR) for 1-year mortality (p=0.015). ConclusionsAboriginal people had substantially higher age and sex-specific HF incidence rate and prevalence of HF antecedents than their non-Aboriginal counterparts. HR for 1-year mortality was also significantly worse at younger ages, highlighting the urgent need for enhanced primary and secondary prevention of HF in this population.

Secondary Prevention of Heart Failure: Prevention with Cardiac Rehabilitation as a Disease Management Program

Secondary Prevention of Heart Failure: Prevention with Cardiac Rehabilitation as a Disease Management Program

The Application of Vascular Function Tests for the Primary and Secondary Preventions of Heart Failure

Arterial stiffness and central hemodynamics are known to be independent risk markers for cardiovascular disease. Then, we examined the applicability of these markers for the management of heart failure (HF). Brachial-ankle pulse wave velocity (baPWV), the radial augmentation index (rAI), the first and second peaks of the radial systolic pressure (SBP1 and SBP2) and PP2 (SBP2 minus diastolic pressure) were measured in 60 patients hospitalized with left ventricle ejection fraction (LVEF) !40%. Up to five year follow-up, none of these markers could predict the re-admission for exacerbation of HF. On the other hand, in 2654 men without cardiovascular disease, PP2, a marker of central pulse pressure, showed a significant odds ratio for new elevation of serum N-terminal fragment B-type natriuretic peptide (NT-proBNP) levels. Thus, central pulse pressure seems to be a useful marker for the primary prevention of subclinical HF, although arterial stiffness and pressure wave analysis are limited to be markers for the secondary prevention of HF.

WHF1-2 Primary and Secondary Prevention of Heart Failure

WHF1-2 Primary and Secondary Prevention of Heart Failure

Primary and secondary prevention of heart failure with statins

Statins are effective in the prevention of coronary heart disease (CHD), a leading cause of heart failure (HF). Secondary analyses from 11 randomized clinical trials of patients with high-risk acute or stable coronary heart disease, but without HF, suggest that statins may prevent new-onset HF or HF-related hospitalization. In persons with established HF, several cohort studies found an approximate 35% relative risk reduction in all-cause mortality. While ongoing randomized clinical trials will help to determine the efficacy of statins in persons with established HF, it is reasonable to consider this class of medications in patients with a history of cardiovascular disease, dyslipidemia or diabetes mellitus, and who have either developed, or who remain at risk of, HF.

Prävention des plötzlichen Herztodes

The problem of sudden cardiac death (SCD) is complex and many questions concerning the pathophysiologic mechanism are still unanswered. At present the only reliable way of recognizing high risk patients is by means of left ventricular dysfunction, measured as LV-EF<or=35%. The positive predictive accuracy for other non-invasive risk markers is too low. So far, antiarrhythmic drugs have failed to successfully prevent SCD. More than 25 years of clinical experience with the implantable defibrillator (ICD) with its continuous technical improvement has made the ICD the most effective weapon against SCD. Its effectiveness has been demonstrated in many prospective trials and the use of the ICD is fully enclosed within the current guidelines for the prevention of SCD. Guidelines do not, however, replace the physician's judgement and experience to correctly evaluate the patient's status. ICD therapy in the primary and secondary prevention of heart failure, which is often accompanied by a high risk of SCD is, however, not justified without guideline-adjusted therapy.