Guidelines For Treatment Of Heart Failure Research Articles

Assessing red blood cell distribution width in Vietnamese heart failure patients: A cross-sectional study.

Heart failure (HF) is becoming a growing public health concern. Diagnostic tests for determining the severity of HF often come with high costs and require specialized expertise, which makes it difficult to assess HF severity, especially in low-income countries or at primary healthcare facilities. Recently, red blood cell distribution width (RDW) has emerged as a promising, easily accessible marker associated with HF severity. The study aimed to assess changes in RDW levels in HF patients and the diagnostic value of RDW in detecting acute heart failure (AHF) among HF patients. We conducted a cross-sectional examination involving 351 participants divided into HF and non-HF cohorts. HF was defined and categorized according to the diagnostic and treatment guidelines for AHF and chronic heart failure (CHF) set forth by the European Society of Cardiology (2021). Univariate and multivariate analysis of factors associated with AHF was performed. The study revealed that HF patients displayed higher median RDW levels (14.90% [13.70-17.00]) compared to non-HF individuals (13.00% [12.23-13.78]). RDW was notably elevated in HF patients with left ventricular ejection fraction < 50% compared to those with left ventricular ejection fraction ≥ 50%. ROC curve analysis of RDW for AHF detection identified a cutoff value of 13.85%, with a sensitivity of 86.05% and specificity of 47.18%, statistically significant at p < 0.001. RDW > 13.85% was identified as an independent risk factor for AHF in patients with HF, with odds ratios of 2.644 (95% CI, 1.190-5.875; p = 0.017). The study revealed significant RDW variations in patients with CHF and AHF compared to the control group. These findings suggest that RDW could be a biomarker for detecting HF severity.

SGLT2 inhibitors attenuate endothelial to mesenchymal transition and cardiac fibroblast activation

Beneficial effects of sodium glucose co-transporter 2 inhibitors (SGLT2is) in cardiovascular diseases have been extensively reported leading to the inclusion of these drugs in the treatment guidelines for heart failure. However, molecular actions especially on non-myocyte cells remain uncertain. We observed dose-dependent inhibitory effects of two SGLT2is, dapagliflozin (DAPA) and empagliflozin (EMPA), on inflammatory signaling in human umbilical vein endothelial cells. Proteomic analyses and subsequent enrichment analyses discovered profound effects of these SGLT2is on proteins involved in mitochondrial respiration and actin cytoskeleton. Validation in functional oxygen consumption measurements as well as tube formation and migration assays revealed strong impacts of DAPA. Considering that most influenced parameters played central roles in endothelial to mesenchymal transition (EndMT), we performed in vitro EndMT assays and identified substantial reduction of mesenchymal and fibrosis marker expression as well as changes in cellular morphology upon treatment with SGLT2is. In line, human cardiac fibroblasts exposed to DAPA showed less proliferation, reduced ATP production, and decelerated migration capacity while less extensive impacts were observed upon EMPA. Mechanistically, sodium proton exchanger 1 (NHE1) as well as sodium-myoinositol cotransporter (SMIT) and sodium-multivitamin cotransporter (SMVT) could be identified as relevant targets of SGLT2is in non-myocyte cardiovascular cells as validated by individual siRNA-knockdown experiments. In summary, we found comprehensive beneficial effects of SGLT2is on human endothelial cells and cardiac fibroblasts. The results of this study therefore support a distinct effect of selected SGLT2i on non-myocyte cardiovascular cells and grant further insights into potential molecular mode of action of these drugs.

Analysis of factors influencing doctors' awareness of clinical guidelines for heart failure treatment

Aim. To find out the relationship between the awareness level of clinical guidelines on heart failure (HF) with reduced ejection fraction and a number of professional characteristics (specialty, work experience, self-assessment of awareness level, attitude towards the use of guidelines, the main way of document study). To improve the efficiency and development of the postgraduate education system, the factors that influence doctors' awareness of guidelines should be determined.Material and methods. The study included the results of an anonymous survey of 207 doctors (155 cardiologists, 44 therapists, 8 doctors of other specialties). To assess the significance of differences, Student's t-test, c2-test and Fisher's exact test were used.Results. The mean number of correct answers to the questionnaire among cardiologists was significantly higher than among general practitioners (p&lt;0,001). In the group of physicians with less than 5 years of work experience, there was a large variability in the mean number of correct answers — 6,2±4,0. Physicians with 6-10 years and 11-20 years of experience in their specialty were more likely to choose the correct answers than doctors with more than 20 years of experience. Professionals who considered themselves "fully informed" on clinical guidelines gave fewer correct answers than doctors who had less high self-rating (p&lt;0,001). The proportion of correct answers in the subgroup of doctors who consider guidelines to be mandatory was greater than in the subgroups of doctors who hold a different opinion (p&lt;0,05). The best results were shown by physicians who indicated direct text-oriented way as preferred for studying guidelines (p&lt;0,001).Conclusion. The awareness level of clinical guidelines on the treatment of HF by cardiologists should be considered insufficient, and by therapists — extremely low. Doctors are not sufficiently informed about the need to comply with clinical guidelines. When planning training, the specialty and work experience of the doctor should be taken into account. Unjustifiably high self-rating of knowledge interferes with professional development. The best way of self-education should be considered direct study of the text of clinical guidelines.

Estimating the clinical and budgetary impact of using angiotensin receptor neprilysin inhibitor as first line therapy in patients with HFrEF.

Recent updates of international treatment guidelines for heart failure with reduced ejection fraction (HFrEF) differ regarding the use of angiotensin receptor neprilysin inhibitor (ARNI) as first-line treatment. The American Heart Association/American College of Cardiology/Heart Failure Society of America (AHA/ACC/HFSA) 2022 guidelines gives ARNI a Class IA recommendation for HFrEF patients while the European Society of Cardiology's guidelines are less clear when ARNI could be considered as first line treatment option in de novo patients. This study aimed to model the clinical and budgetary outcomes of implementing these guidelines, comparing conservative ARNI prescription patterns with less conservative in Sweden and in the United Kingdom. A health economic model was developed to compare different treatment patterns for HFrEF. Incident cohorts were included on an annual basis and followed over 10years. The model included treatment specific all-cause mortality and hospitalization rates, as well as drug acquisition, monitoring, and hospitalization costs. Increasing the use of ARNI could lead to about 7000-12300 life years gained and 2600-4600 hospitalizations prevented in Sweden. These health benefits come with an additional cost of 112-195 million euros. Similar results were estimated for the United Kingdom, albeit on a larger population. Increasing the proportion of patients receiving ARNI instead of angiotensin converting enzyme inhibitors as first-line treatment of HFrEF will lead to a considerable number of additional life years gained and prevented hospitalizations but with additional cost in terms of health care expenditure in Sweden and in the United Kingdom.

Achieving optimal doses in treatment of heart failure with reduced ejection fraction at Gia Dinh People's Hospital

Heart failure (HF) with reduced ejection fraction (HFrEF) is a complex clinical syndrome associated with high mortality, long hospital length of stay, high readmission rates, reduced exercise tolerance, and decreased quality of life, as well as requiring significant resources to support treatment and care 1. Currently, it is reported that approximately 50% of all heart failure cases are HFrEF. However, due to recent advancements in cardiovascular diagnostic imaging, earlier, and possibly more precise, detection of HFrEF is greatly enabled. Not only does this seemingly increase the incidence rate of HfrEF in the general population, but it also gives treatment facilities an advantage in improving the prognosis and average life expectancy for these newly rising cases of HFrEF 2. According to heart failure treatment guidelines by Heart Associations around the world, an effective, interdisciplinary, and coordinated care system needs to be applied to all heart failure patients, including the reduced ejection fraction heart failure group, in order to achieve optimal guidelinesrecommended therapy, reduce mortality and readmission. In addition, each patient needs to be provided with a detailed treatment plan, which comprises treatment goals, effective management of comorbidities, follow-up time, diet, and physical activity 6. Therefore, the critical role of HF management programs in improving symptoms and quality of life in both inpatient and outpatient settings has been well recognized and paid continuous attention for the last two decades, with regular updates on team-based healthcare systems and home-based patient care 8,9,10. Recent updates in treatment guidelines have highlighted the role of the treating physician in customizing and adjusting the therapeutic drugs’ doses, to match those recommended as target or optimal, which must also be well-tolerated by the patients, with the aim of improving clinical outcomes 12. Therefore, it could be deduced that not only the sheer application of the four evidence-based foundational treatment but also dose adjustment over time of each one, should be collectively recognized as the basis of treating patients with HFrEF. The operation of a highlyspecialized unit, solely dedicated to the management of HF, known as ‘Heart Failure Unit’, has proven its effectiveness, by means of optimization of medical therapy, irrespective of baseline EF, but most notably reduced EF. Therefore, patients’ symptoms and readmission rate in facilities with “Heart Failure Unit” has witnessed a noticeable reduction. In today’s Vietnam, many tertiary medical facilities have implemented such centralized heart failure care models, and the Cardiology Department of Nhan dan Gia Dinh Hospital is definitely not an exception. The Heart Failure Unit in our department has been established and operating with a soulful dedication to providing HF patients with utmost comprehensive care and guideline-recommended therapy.

Quality improvement collaborative to optimize heart failure care inpatients from a network ofclinics inArgentina during the COVID-19 pandemic.

Heart failure (HF) is a major clinical and public health problem associated with significant mortality, morbidity, and health-care costs. Despite the existence of evidence-based guidelines for the optimal treatment of HF, the quality of care remains suboptimal. Our aim was to increase the use a care bundle in 50% of enrolled subjects during their hospitalization and discharge and to reduce their readmission for HF causes by 10%. We conducted an uncontrolled before-after study in eight hospitals in Argentina to evaluate the effect of a quality improvement intervention on the use of an HF care bundle in patients with HF New York Heart Association (NYHA) Class II-III. The HF bundle of care included medication, continuum of care, lifestyle habits, and predischarge examinations. Training and follow-up of multidisciplinary teams in each center were performed through learning sessions and plan-do-study-act improvement cycles. Data collectors reviewed bundle compliance in the health records of recruited patients after their hospital discharge and verified readmissions through phone calls to patients within 30-40 days after discharge. We recruited 200 patients (83 before and 127 during the intervention phase), and bundle compliance increased from 9.6% to 28.3% [odds ratio 3.71, 95% confidence interval (8.46; 1.63); P = .002]. Despite a slow improvement during the first months, bundle compliance gained momentum near the end of the intervention surpassing 80%. We observed a non-significant decreased readmission rate within 30 days of discharge due to HF in the postintervention period [8.4% vs. 5.5%, odds ratio 0.63, 95% CI (1.88; 0.21); P = .410]. Qualitative analysis showed that members of the intervention teams acknowledged the improvement of work organization and standardization of care, teamwork, shared mental model, and health record completeness as well as the utility of training fellows. Despite the challenges related to the pandemic, better care of patients with HF NYHA Class II-III was possible through simple interventions and collaborative work. Graphical abstract.

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.

EE671 Budgetary Impact and Health Outcomes of Implementing New Treatment Guidelines for Heart Failure in Norway

EE671 Budgetary Impact and Health Outcomes of Implementing New Treatment Guidelines for Heart Failure in Norway

Compliance to guideline-recommended pharmacotherapy in patients with heart failure, 2014 to 2020

Abstract Background Poor drug adherence in heart failure (HF) is associated with increased morbidity and mortality. Aims We aimed to investigate compliance to European guidelines for treatment of HF in Norway by measuring initiation and persistence of inhibitors of the renin-angiotensin system (RASi), β-blockers (BB) and mineralocorticoid receptor antagonists (MRA). Methods We included all patients ≥18 years with a first hospital contact for HF registered in the Norwegian Patient Registry (NPR) between 2014–2020. Patients &amp;gt;80 years of age and patients that deceased within the first 30 days were excluded. The study population was linked to the Norwegian Prescription Database for longitudinal data on drug prescriptions. Dual HF therapy was defined as taking at least two recommended HF drug classes, triple HF therapy was defined as taking all three drug classes. To estimate initiation, we counted the days from index HF to the first HF prescription, dual HF therapy and triple HF therapy within the first 365 days. We repeated the analysis for drug-naive patients, as some patients receive HF drugs for other indications or based on a tentative HF diagnosis. Patients were considered persistent if they did not experience any treatment break of more than 30 days. We allowed for stockpiling up to a maximum of 60 days, except for when the dose changed or if patients switched medication within the same drug class. Initiation and persistence were calculated by the Kaplan-Meier method, followed to death or December 2020. Results Out of 54,899 patients, 75%, 69% and 21% initiated BB, RASi and MRA, respectively (Figure 1). 13% of the population did not receive any of the three drug groups. Dual HF therapy was prescribed to 61% of the patients and triple HF therapy to 16%. In drug-naive patients, a lower proportion received any HF-drug within the first year (BB, 61%; RASi, 55%; and MRA, 19%), however, a higher proportion was collected within the first 30 days (BB, 48%; RASi, 46%; and MRA, 11%). Among the patients initiating therapy, 72% were persistent on BB, 71% on RASi and 48% on MRA throughout the first year with prominent declines in persistence around 3 and 6 months after initiation (Figure 2). Two years after initiation, the proportions of patients on BB, RASi and MRA decreased to 58%, 57% and 31%, respectively. The 5-year persistence was 38%, 37% and 15%, respectively. Conclusion This study found poor treatment compliance to HF medications in a real-world population of HF patients with only 61% of patients initiating dual pharmacotherapy and only 16% received all three dug classes. Nearly half of the patients discontinued RASi and BB within 2 years. The results suggest that systematic efforts should be done to increase the proportion of patients on guideline recommended therapies. These efforts should be focused on early initiation of multiple drug therapies as well as to maintain patients on treatment over time. Funding Acknowledgement Type of funding sources: Other. Main funding source(s): Novartis Norway AS and The Norwegian Research Council

심부전 환자에서 엠파글리플로진의 유효성 및 안전성 검토

The United States (US) Food and Drug Administration (FDA) approved empagliflozin, which is a sodiumglucose cotransporter 2 (SGLT2) inhibitor used for type 2 diabetes, for the treatment of heart failure (HF) with reduced ejection fraction (HFrEF) in 2021. Earlier this year, empagliflozin became the only SGLT2 inhibitor approved for the treatment of HF with preserved ejection fraction (HFpEF) as well. These approvals were based on the studies that showed empagliflozin reducing hospitalization for HF and cardiovascular mortality. Based on these new findings, SGLT2 inhibitors, including empagliflozin, have been recently added to the heart failure treatment guidelines in the US and Europe. Although empagliflozin is approved for adults with HFrEF in South Korea, treatment guidelines for chronic heart failure have not been updated to include this drug and other SGLT2 inhibitors, yet. Therefore, the purpose of this review is to examine the studies on the efficacy and safety of empagliflozin in heart failure and its current place in clinical practice.

Clinical, paraclinical characteristics and real –world treatment of acute heart failure at Hanoi Heart Hospital

Background: At Hanoi Heart Hospital, in recent years, along with the development of science and technology, the development of modern treatment measures such as percutaneous coronary intervention, coronary artery bypass surgery, heart valve replacement ... helped save the lives of many patients. However, these patients still require continued treatment for heart failure as a complication of the primary illness and thus also increase the number of patients with heart failure, both acute and decompensated. Objective: “Describe the clinical and subclinical characteristics of hospitalized patients with acute heart failure and the status of heart failure treatment according to current heart failure treatment guidelines at Hanoi Heart Hospital”. Method: Cross-sectional, prospective, descriptive analysis with convenient sample size. Results: From January 2018 to december 2018, 475 patients were hospitalized due to acute heart failure or decompensation ,63,8% male and 36, 2% female. Mean age 69,1 ± 13,8; 63,6% newly discovered heart failure; 41,4% EF 40 – 50% and 58,6% EF &lt; 40%; number of Hopital days 8.3 ± 6.2 days(( 1- 46 days); there are five (1.1%) patients died in hospital; among them a patient who was treated for one day due to severe illness died; we have used interventions, assisted circulation and respiration such as CRT, CRT-D, CVVH, IABP, atrial septal defect and ECMO. Conclusion: Results of treatment of acute heart failure at Hanoi Heart Hospital is feasible with rate of discharge is 87,7%.

Treating heart failure in patients with diabetes: The view of the cardiologist

Diabetes is a very important comorbidity in patients with heart failure. When both diseases coexist cardiovascular morbidity and mortality is greatly increased. Therefore, it is of clinical importance to treat both diseases as early as possible with an optimal therapy.Hitherto, heart failure therapy did not differ if a patient had concomitant diabetes. However, with SGLT-2 inhibitors having demonstrated to reduce hospitalization of heart failure independent of diabetes state and expected to be included into the ESC heart failure treatment guidelines in 2021 coexisting diabetes potentially will make a difference when to start therapy.In this article we provide an overview of current recommendations and also provide clinical considerations for the therapy of heart failure with concomitant diabetes.

Effects of neurohormonal antagonists on blood pressure in patients with heart failure with reduced ejection fraction (HFrEF): a systematic review protocol

BackgroundSeveral cardiovascular pathologies cause heart failure. Heart failure with reduced ejection fraction (HFrEF) is deteriorated by neurohormonal activation, so neurohormonal antagonists are recommended in HFrEF patients. They improve morbidity, mortality, and quality of life and reduce hospital admissions. Heart failure treatment guidelines recommend achieving target doses of those drugs. However, many clinicians prescribe suboptimal doses for the fear of inducing hypotension. The aim of this systematic review and meta-analysis is to understand whether it is still beneficial to uptitrate the doses of those drugs even if the patient is at the risk of developing hypotension.MethodsThe primary outcome is symptomatic or asymptomatic hypotension in patients on neurohormonal antagonist drugs for HFrEF. Secondary outcomes are blood pressure reduction, New Yok Heart Association functional class deterioration, non-fatal cardiovascular events, cardiovascular mortality, all-cause mortality, heart failure hospitalizations, and adverse events. Randomized controlled trials involving adults with HFrEF will be included. Comprehensive literature search will be done in MEDLINE, Scopus, Web of Science, WHO Global Index Medicus, and the Cochrane Central Register of Controlled Trials. MEDLINE will be searched first using controlled vocabulary and free text terms and then adapted to other databases. Linear and nonlinear dose-response meta-analyses will be conducted. Publication bias and statistical heterogeneity will be tested by Egger’s regression and Cochran’s Q tests, respectively. Sensitivity, subgroup, and meta-regression analyses will be performed. Grading of Recommendations Assessment, Development and Evaluation approach will be used to judge the quality of evidence.DiscussionThis systematic review and meta-analysis will provide information about the risk of hypotension in patients on neurohormonal antagonist drugs for HFrEF. The results will be published in a peer-reviewed journal. The implications for further research will be discussed.Systematic review registrationPROSPERO CRD42019140307

Selected intriguing forms of treatment for chronic heart failure – data from international observational registries

The presented paper gathers the results of three publications based on prospective, international, observation registries of patients with heart failure (HF) – HF Pilot, HF Long-Term and QUALIFY (The quality of adherence to guideline recommendations for life-saving treatment in heart failure). The aim of the analysis was to assess the effect of beta-blockers on prognosis in HF with associated atrial fibrillation; to compare the effectiveness of furosemide and torasemide in HF; and to assess the adherence of physicians in Poland to European recommendations. 797 patients were included in the analysis assessing the effects of beta-blockers. Patients with a beta blocker compared to those without were less likely to achieve primary (all-cause death; 10.9% vs 25.6%, p = 0.001) and secondary (all-cause death or HF hospitalization; 30.6% vs 44.2%, p = 0.02) endpoints. Beta-blocker was an independent predictor of only the primary endpoint (HR 0.52; 95% CI, 0.31–0.89; p = 0.02). Both endpoints were least frequently observed in the group with a heart rate of 80–109/min. In the group of 1440 patients with HF, it was shown that patients treated with torasemide compared to furosemide were less likely to experience secondary (death from any cause or HF hospitalization; 26.4% vs 34.7%; p = 0.04), but not primary (death from any cause; 9.8% vs 14.1%; p = 0.13) endpoint. Patients treated with furosemide also had a greater severity of HF symptoms in NYHA class (p = 0.04). Adherence of physicians in Poland to HF treatment guidelines was also analyzed. An analysis of 209 HF outpatients with reduced left ventricular ejection fraction showed a satisfactory adherence to the recommended HF therapy in 72% of cases.

Good Physician Adherence to Guideline-Directed Medical Therapy Associated with Lower Patient Mortality and Hospitalisation Rates Across The World

While the guidelines for the managements of heart diseases have been well-developed and updated periodically, they do not guarantee to reduce the number of heart disease morbidity and mortality. Since the holistic approach is not carefully applied, this morbidity rate may not be significantly reduced. The holistic approach to managing heart disease has broad aspects, but the most important aspect is regarding physician adherence to Guideline-Directed Medical Therapy (GDMT). This paper aimed to discuss the physician adherence to GDMT, and its role in reducing morbidity and in-hospitalization in heart disease patients. Several large scale studies have revealed that good adherence to heart failure treatment guidelines among physicians improved not only quality of life but also resulted in a better prognosis. On other hands, because the main target of physicians adherence to GDMT is to achieve maximally tolerated dose, it is also important that the understanding when and how to add, switch, and titrate all therapies to maximally tolerated doses and ideally target doses is important to reduce the morbidity and mortality of heart disease patients. However, in some points, this principle might not be applied properly due to several limitations. In this case, physicians may have to consider the balance between patients preferences, healthcare resources, and the risk of adverse outcomes. In conclusion, it should be noted that physician adherence to GDMT has an important role to reduce morbidity and mortality of heart disease patients.

Adherence to European Society of Cardiology Heart Failure Treatment Guideline in Haji Adam Malik General Hospital Medan

Background. Heart failure is a public health problem and the main cause of morbidity and mortality in the world. The goal of the therapy is to reduce symptoms, prevents rehospitalization and increases survivability. Objective. To evaluate the adherence to the European Society of Cardiology for heart failure treatment at H. Adam Malik Medan hospital. Methods. The study was descriptive observational cross sectional design with medical record data of heart failure at H. Adam Malik Hospital, using consecutive sampling method. The adherence of guidelines was assessed by: (1) drug prescribing (“yes” or “no”), and (2) guideline adherence indicator (GAI), both GAI-3 or GAI-5, by calculating the proportion as the number of drugs prescribed by number of drugs indicated to the ESC guidelines. Results. From research, the predominant GAI-3 and GAI-5 were High, which were 54.9% and 59.5%, respectively. The recommended drug used based on indications were ACE-i / ARB (89.1%), beta-blockers (83.4%), MRA (73.6%), diuretics (93.7%), and digitalis (20,8%). Conclusion. The predominant category in adherence to the ESC heart failure treatment guidelines based on GAI-3 and GAI-5 is High.

Fear of Physical Activity, Anxiety, and Depression

Abstract. Background: Physical activity (PA) is recommended by heart failure treatment guidelines. Adherence to exercise prescriptions is low and not much is known about everyday PA in this patient group. Aims: This study describes objectively assessed everyday PA/sedentary behavior in men and women with chronic heart failure and examines associations of potential barriers for engaging in PA, namely fear of physical activity (FoPA), general anxiety, and depression, with indicators of PA and sedentary behavior. Method: In 61 outpatients with heart failure (67.5 ± 10.7 years of age) the impact of FoPA, trait anxiety, and depression on 6-day accelerometer measures was evaluated using linear regression models. Results: Sedentary behavior was prevalent in men and women alike, with lying down and sitting/standing as predominant activity classes during daytime. Men had higher PA energy expenditure (726 vs. 585 kcal/d, Cohen’s effect size d = 0.74) and walked up/down more often (0.21% vs. 0.12% of total PA, d = 0.56) than women. FoPA did not differ between sexes. FoPA, but not anxiety and depression, significantly and consistently predicted less walking up/down independent of covariates (β-values between −0.26 and −0.44, p-values &lt; 0.024). Limitations: The self-selected sample included few women. Medical data were assessed via self-reports. Conclusion: FoPA, but not anxiety and depression, significantly and consistently predicted less walking up/down independent of covariates. These preliminary findings highlight FoPA as a barrier to everyday PA in patients with heart failure.

Elucidation of the Strongest Predictors of Cardiovascular Events in Patients with Heart Failure

BackgroundIn previous retrospective studies, we identified the 50 most influential clinical predictors of cardiovascular outcomes in patients with heart failure (HF). The present study aimed to use the novel limitless-arity multiple-testing procedure to filter these 50 clinical factors and thus yield combinations of no more than four factors that could potentially predict the onset of cardiovascular events. A Kaplan–Meier analysis was used to investigate the importance of the combinations. MethodsIn a multi-centre observational trial, we prospectively enrolled 213 patients with HF who were hospitalized because of exacerbation, discharged according to HF treatment guidelines and observed to monitor cardiovascular events. After the observation period, we stratified patients according to whether they experienced cardiovascular events (rehospitalisation or cardiovascular death). FindingsAmong 77,562 combinations of fewer than five clinical parameters, we identified 151 combinations that could potentially explain the occurrence of cardiovascular events. Of these, 145 combinations included the use of inotropic agents, whereas the remaining 6 included the use of diuretics without bradycardia or tachycardia, suggesting that the high probability of cardiovascular events is exclusively determined by these two clinical factors. Importantly, Kaplan–Meier curves demonstrated that the use of inotropes or of diuretics without bradycardia or tachycardia were independent predictors of a markedly worse cardiovascular prognosis. InterpretationPatients treated with either inotropic agents or diuretics without bradycardia or tachycardia were at a higher risk of cardiovascular events. The uses of these drugs, regardless of heart rate, are the strongest clinical predictors of cardiovascular events in patients with HF.

Genetic Variation of Hepatic Enzymes Influence on β-Blocker Dose in Patients With Reduced Ejection Fraction Heart Failure

Beta-blockers such as metoprolol, carvedilol, and bisoprolol are indicated for the treatment of patients with reduced ejection fraction heart failure. Heart failure treatment guidelines call for titration of these medications to specific target doses for morbidity and mortality benefit. Hepatic enzymes are responsible for metabolizing these medications; however, these enzymes are subject to genetic variations (polymorphisms) that can increase or decrease enzyme activity. Metoprolol relies almost exclusively on this enzyme for degradation to inactive metabolites, whereas carvedilol relies on this enzyme only partially for metabolism, and the portion of drug that is metabolized by CYP2D6 becomes active metabolites. The clinical significance of genetic variations in CYP2D6 in heart failure patients requiring treatment with carvedilol and metoprolol remains unclear, and further research is needed before any strong recommendations on treatment approach can be made. However, based on what is known regarding the incidence of genetic variations of this enzyme, it is reasonable to conclude that heart failure patients of European and Asian ancestry may be at a greater risk of intolerance to guideline-directed doses of metoprolol. Patients of North African ancestry may be at a lower risk of intolerance to metoprolol, although limited data are available to conclude. Additionally, due to the significant prevalence of CYP2D6 enzyme variations among all ethnicities, it may be reasonable to consider switching to carvedilol for patients who are unable to fully titrate metoprolol.

Need to revisit heart failure treatment guidelines for hyperkalaemia management during the use of mineralocorticoid receptor antagonists.

Need to revisit heart failure treatment guidelines for hyperkalaemia management during the use of mineralocorticoid receptor antagonists.