Search

The PIONEER-HF (comParIson Of sacubitril/valsartaN versus Enalapril on Effect on nt-pRo-bnp in patients stabilized from an acute Heart Failure episode) trial demonstrated the efficacy and safety of sacubitril/valsartan (S/V) in stabilized patients with acute decompensated heart failure (HF) and reduced ejection fraction.The study sought to determine whether and how prior HF history and treatment with an angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) affected the results.The PIONEER-HF trial was a prospective, multicenter, double-blind, randomized clinical trial enrolling 881 patients with an ejection fraction ≤40%. Patients were randomly assigned 1:1 to in-hospital initiation of S/V (n = 440) versus enalapril (n = 441). Pre-specified subgroup analyses were performed based on prior HF history (i.e., de novo HF vs. worsening chronic HF) and treatment with an ACE inhibitor or ARB (i.e., ACE inhibitor or ARB-yes vs. ACE inhibitor or ARB-no) at admission.At enrollment, 303 (34%) patients presented with de novo HF and 576 (66%) patients with worsening chronic HF. A total of 421 (48%) patients had been treated with an ACE inhibitor or ARB, while 458 (52%) had not been treated with an ACE inhibitor or ARB. N-terminal pro-B-type natriuretic peptide declined significantly in all 4 subgroups (p 0.001), with greater decreases in the S/V versus the enalapril arm (p 0.001). There was no interaction between prior HF history (p = 0.350) or ACE inhibitor or ARB treatment (p = 0.880) and the effect of S/V versus enalapril on cardiovascular death or rehospitalization for HF. The incidences of adverse events were comparable between S/V and enalapril across all 4 subgroups.Among patients admitted for acute decompensated HF, S/V was safe and well tolerated, led to a significantly greater reduction in N-terminal pro-B-type natriuretic peptide, and improved clinical outcomes compared with enalapril irrespective of previous HF history or ACE inhibitor or ARB treatment. (Comparison of Sacubitril/Valsartan Versus Enalapril on Effect of NT-proBNP in Patients Stabilized From an Acute Heart Failure Episode [PIONEER-HF]; NCT02554890).

BackgroundGuidelines recommend that patients with heart failure with reduced ejection fraction (HFrEF) have medical therapy titrated to target doses derived from clinical trials, as tolerated. The degree to which titration occurs in contemporary U.S. practice is unknown.ObjectivesThis study sought to characterize longitudinal titration of HFrEF medical therapy in clinical practice and to identify associated factors and reasons for medication changes.MethodsAmong 2,588 U.S. outpatients with chronic HFrEF in the CHAMP-HF (Change the Management of Patients with Heart Failure) registry with complete medication data and no contraindications to medical therapy, use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA) were examined at baseline and at 12-month follow-up.ResultsAt baseline, 658 (25%), 525 (20%), 287 (11%), and 45 (2%) patients were receiving target doses of MRA, beta-blocker, ACEI/ARB, and ARNI therapy, respectively. At 12months, proportions of patients with medication initiation or dose increase were 6% for MRA, 10% for beta-blocker, 7% for ACEI/ARB, and 10% for ARNI; corresponding proportions with discontinuation or dose decrease were 4%, 7%, 11%, and 3%, respectively. Over 12months,&nbsp

Heart failure with preserved ejection fraction (HFpEF) is now the most common form of HF, affecting over 3 million adults in the United States alone. HFpEF is a heterogenous syndrome. One important phenotype may be related to comorbid conditions, including diabetes mellitus (DM). DM has a prevalence of approximately 45% in HFpEF, but characteristics and outcomes of this population are poorly understood. In this review, the authors summarize data from several clinical trials of HFpEF therapeutics and provide original data from a large cohort using the Get With The Guidelines-HF registry, which together suggest that DM is associated with increased morbidity and long-term mortality in HFpEF. The authors then discuss several common pathological mechanisms in HFpEF and DM, including sodium retention, metabolic derangements, impaired skeletal muscle function, and potential therapeutic targets. As the understanding of comorbid HFpEF and DM improves, it is hoped clinicians will be better equipped to offer effective, patient-centered treatments.

Background Few contemporary data exist evaluating care patterns and outcomes in heart failure (HF) across the spectrum of kidney function. Objectives This study sought to characterize differences in quality of care and outcomes in patients hospitalized for HF by degree of kidney dysfunction. Methods Guideline-directed medical therapies were evaluated among patients hospitalized with HF at 418 sites in the GWTG-HF (Get With The Guidelines–Heart Failure) registry from 2014 to 2019 by discharge CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration)-derived estimated glomerular filtration rate (eGFR). We additionally evaluated the risk-adjusted association of admission eGFR with in-hospital mortality. Results Among 365,494 hospitalizations (age 72 ± 15 years, left ventricular ejection fraction [EF]: 43 ± 17%), median discharge eGFR was 51 ml/min/1.73 m2 (interquartile range: 34 to 72 ml/min/1.73 m2), 234,332 (64%) had eGFR Conclusions Despite facing elevated risks of mortality, patients with comorbid HF with reduced EF and kidney disease are not optimally treated with evidence-based medical therapies, even at levels of eGFR where such therapies would not be contraindicated by kidney dysfunction. Further efforts are required to mitigate risk in comorbid HF and kidney disease.

Background Guidelines strongly recommend patients with heart failure with reduced ejection fraction (HFrEF) be treated with multiple medications proven to improve clinical outcomes, as tolerated. The degree to which gaps in medication use and dosing persist in contemporary outpatient practice is unclear. Objectives This study sought to characterize patterns and factors associated with use and dose of HFrEF medications in current practice. Methods The CHAMP-HF (Change the Management of Patients with Heart Failure) registry included outpatients in the United States with chronic HFrEF receiving at least 1 oral medication for management of HF. Patients were characterized by baseline use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA). Patient-level factors associated with medication use were examined. Results Overall, 3,518 patients from 150 primary care and cardiology practices were included. Mean age was 66 ± 13 years, 29% were female, and mean EF was 29 ± 8%. Among eligible patients, 27%, 33%, and 67% were not prescribed ACEI/ARB/ARNI, beta-blocker, and MRA therapy, respectively. When medications were prescribed, few patients were receiving target doses of ACEI/ARB (17%), ARNI (14%), and beta-blocker (28%), whereas most patients were receiving target doses of MRA therapy (77%). Among patients eligible for all classes of medication, 1% were simultaneously receiving target doses of ACE/ARB/ARNI, beta-blocker, and MRA. In adjusted models, older age, lower blood pressure, more severe functional class, renal insufficiency, and recent HF hospitalization generally favored lower medication utilization or dose. Social and economic characteristics were not independently associated with medication use or dose. Conclusions In this contemporary outpatient HFrEF registry, significant gaps in use and dose of guideline-directed medical therapy remain. Multiple clinical factors were associated with medication use and dose prescribed. Strategies to improve guideline-directed use of HFrEF medications remain urgently needed, and these findings may inform targeted approaches to optimize outpatient medical therapy.

Patients with heart failure with reduced ejection fraction (HFrEF) face high risks of deterioration in health status, hospitalization, or death. Diabetes mellitus (DM) is a frequent comorbidity that adds therapeutic complexity and further contributes to adverse health outlook. The U.S. Food and Drug

Background: Patients with heart failure (HF) have a poor prognosis and are categorized by ejection fraction (EF).Objectives: This study sought to characterize differences in outcomes in pat...

Heart failure (HF) is associated with significant morbidity and mortality. Although initially thought to be harmful in HF, beta-adrenergic blockers (β-blockers) have consistently been shown to reduce mortality and HF hospitalization in chronic HF with reduced ejection fraction. Proposed mechanisms include neurohormonal blockade and heart rate reduction. A new therapeutic agent now exists to target further heart rate lowering in patients who have been stable on a “maximally tolerated β-blocker dose,” but this definition and how to achieve it are incompletely understood. In this review, the authors summarize published reports on the mechanisms by which β-blockers improve clinical outcomes. The authors describe differences in doses achieved in landmark clinical trials and those observed in routine clinical practice. They further discuss reasons for intolerance and the evidence behind using β-blocker dose and heart rate as therapeutic targets. Finally, the authors offer recommendations for clinicians actively initiating and up-titrating β-blockers that may aid in achieving maximally tolerated doses.

BACKGROUND: The Hospital Readmissions Reduction Program (HRRP) has been associated with reduced 30-day readmissions for acute myocardial infarction (AMI) and heart failure (HF). OBJECTIVE: To test whether this 30-day readmission reduction is a manifestation of practices that defer or avoid hospitalizations beyond the 30-day period. METHODS: At all U.S. hospitals under HRRP, we calculated daily readmission rates for elderly Medicare fee-for-service beneficiaries through day-60 post-discharge following a hospitalization for AMI and HF—the 2 target cardiovascular conditions - as well as pneumonia in July 2008-June 2016. We applied a robust bias-corrected non-parametric regression approach to evaluate for discontinuities in rates around day 30. RESULTS: We identified 3256 eligible hospitals, with median readmission rates in the days 1-30 and 31-60 post-discharge of 19.6% (IQR: 16.7%, 22.9%) and 7.8% (IQR: 6.5%, 9.4%) for AMI, 23.0% (IQR: 20.6%, 25.3%) and 11.4% (IQR: 10.2%, 12.6%) for HF, and 17.5% (IQR: 15.4%, 19.8%) and 8.3% (IQR: 7.3%, 9.3%) for pneumonia, respectively. Daily readmission rates decreased across most of the 60 post-discharge days, with no discontinuities in the local polynomial regression for readmission at the 30-day mark, with a >95% power to detect 0.1% difference for each outcome across 30 days. Similarly, there was no discontinuity in mortality at 30 days post-discharge, or for either outcome at hospitals that incurred readmission penalties. CONCLUSION: There was no evidence that clinicians adopted strategies that specifically deferred admissions or affected mortality in the 30-day period after discharge. The findings are consistent with the institution of strategies that generally affected readmission risk after discharge.

Background In 2009, the Centers for Medicare & Medicaid Services (CMS) began publicly reporting 30-day hospital readmission rates for patients discharged with acute myocardial infarction (MI), heart failure (HF), or pneumonia. Objectives This study assessed trends of 30-day readmission rates and post-discharge care since the implementation of CMS public reporting. Methods We analyzed Medicare claims data from 2006 to 2012 for patients discharged after a hospitalization for MI, HF, or pneumonia. For each diagnosis, we estimated trends in 30-day all-cause readmissions and post-discharge care (emergency department visits and observation stays) by using hospitalization-level regression models. We modeled adjusted trends before and after the implementation of public reporting. To assess for a change in trend, we tested the difference between the slope before implementation and the slope after implementation. Results We analyzed 37,829 hospitalizations for MI, 100,189 for HF, and 79,076 for pneumonia from >4,100 hospitals. When considering only recent trends (i.e., since 2009), we found improvements in adjusted readmission rates for MI (−2.3%), HF (−1.8%), and pneumonia (−2.0%), but when comparing the trend before public reporting with the trend after reporting, there was no difference for MI (p = 0.72), HF (p = 0.19), or pneumonia (p = 0.21). There were no changes in trends for 30-day post-discharge care for MI or pneumonia; however, the trend decreased for HF emergency department visits from 2.3% to −0.8% (p = 0.007) and for observation stays from 15.1% to 4.1% (p = 0.04). Conclusions The release of the CMS public reporting of hospital readmission rates was not associated with any measurable change in 30-day readmission trends for MI, HF, or pneumonia, but it was associated with less hospital-based acute care for HF.

The impact of heart failure hospitalization (HFH) on guideline-directed medical therapy (GDMT) prescribing patterns among patients with chronic heart failure with reduced ejection fraction is unknown. Using data from the Change the Management of Patients with Heart Failure registry (n=4365), we

Despite advancements in heart failure (HF) management, HF outcomes post-discharge have started to worsen since 2010. We explored whether these observed patterns were related to longitudinal increases in HF severity among those hospitalized over time. Among patients hospitalized for HF in the GWTG

Current guidelines recommend an evaluation for underlying heart disease and reversible conditions for patients with new-onset heart failure (HF). There are limited data on contemporary testing for coronary artery disease (CAD) in HF patients. We performed an analysis of the GWTG-HF registry linked

There is a paucity of data on the patients [pts] with heart failure (HF) who leave against medical advice (AMA). We sought to identify pts and hospital characteristics and outcomes of hospitalized pts with HF who left AMA compared to pts discharged home. Data from Get With The Guidelines-HF from

Angiotensin receptor-neprilysin inhibitors (ARNIs) reduce mortality and heart failure (HF) hospitalization in acute and chronic HF with reduced ejection fraction. The uptake and utilization of this medication in routine clinical practice is evolving. Among 3875 patients enrolled in the CONNECT-HF

Heart failure with preserved ejection fraction (HFpEF) is now the most common form of HF, affecting over 3 million adults in the United States alone. HFpEF is a heterogenous syndrome. One important phenotype may be related to comorbid conditions, including diabetes mellitus (DM). DM has a prevalence of approximately 45% in HFpEF, but characteristics and outcomes of this population are poorly understood. In this review, the authors summarize data from several clinical trials of HFpEF therapeutics and provide original data from a large cohort using the Get With The Guidelines-HF registry, which together suggest that DM is associated with increased morbidity and long-term mortality in HFpEF. The authors then discuss several common pathological mechanisms in HFpEF and DM, including sodium retention, metabolic derangements, impaired skeletal muscle function, and potential therapeutic targets. As the understanding of comorbid HFpEF and DM improves, it is hoped clinicians will be better equipped to offer effective, patient-centered treatments.

Guidelines strongly recommend patients with heart failure with reduced ejection fraction (HFrEF) be treated with multiple medications proven to improve clinical outcomes, as tolerated. The degree to which gaps in medication use and dosing persist in contemporary outpatient practice is unclear.This study sought to characterize patterns and factors associated with use and dose of HFrEF medications in current practice.The CHAMP-HF (Change the Management of Patients with Heart Failure) registry included outpatients in the United States with chronic HFrEF receiving at least 1 oral medication for management of HF. Patients were characterized by baseline use and dose of angiotensin-converting enzyme inhibitor (ACEI)/angiotensin II receptor blocker (ARB), angiotensin receptor neprilysin inhibitor (ARNI), beta-blocker, and mineralocorticoid receptor antagonist (MRA). Patient-level factors associated with medication use were examined.Overall, 3,518 patients from 150 primary care and cardiology practices were included. Mean age was 66 ± 13 years, 29% were female, and mean EF was 29 ± 8%. Among eligible patients, 27%, 33%, and 67% were not prescribed ACEI/ARB/ARNI, beta-blocker, and MRA therapy, respectively. When medications were prescribed, few patients were receiving target doses of ACEI/ARB (17%), ARNI (14%), and beta-blocker (28%), whereas most patients were receiving target doses of MRA therapy (77%). Among patients eligible for all classes of medication, 1% were simultaneously receiving target doses of ACE/ARB/ARNI, beta-blocker, and MRA. In adjusted models, older age, lower blood pressure, more severe functional class, renal insufficiency, and recent HF hospitalization generally favored lower medication utilization or dose. Social and economic characteristics were not independently associated with medication use or dose.In this contemporary outpatient HFrEF registry, significant gaps in use and dose of guideline-directed medical therapy remain. Multiple clinical factors were associated with medication use and dose prescribed. Strategies to improve guideline-directed use of HFrEF medications remain urgently needed, and these findings may inform targeted approaches to optimize outpatient medical therapy.

Patients with heart failure (HF) have a poor prognosis and are categorized by ejection fraction (EF).This study sought to characterize differences in outcomes in patients hospitalized with heart failure with preserved ejection fraction (HFpEF) (EF ≥50%), heart failure with borderline ejection fraction (HFbEF) (EF 41% to 49%), and heart failure with reduced ejection fraction (HFrEF) (EF ≤40%).Data from GWTG-HF (Get With The Guidelines-Heart Failure) were linked to Medicare data for longitudinal follow-up. Multivariable models were constructed to examine 5-year outcomes and to compare survival to median survival of the U.S.A total of 39,982 patients from 254 hospitals who were admitted for HF between 2005 and 2009 were included: 18,299 (46%) had HFpEF, 3,285 (8.2%) had HFbEF, and 18,398 (46%) had HFrEF. Overall, median survival was 2.1 years. In risk-adjusted survival analysis, all 3 groups had similar 5-year mortality (HFrEF 75.3% vs. HFpEF 75.7%; hazard ratio: 0.99 [95% confidence interval: 0.958 to 1.022]; HFbEF 75.7% vs. HFpEF 75.7%; hazard ratio: 0.99 [95% confidence interval: 0.947 to 1.046]). In risk-adjusted analyses, the composite of mortality and rehospitalization was similar for all subgroups. Cardiovascular and HF readmission rates were higher in those with HFrEF and HFbEF compared with those with HFpEF. When compared with the U.S. population, HF patients across all age and EF groups had markedly lower median survival.Among patients hospitalized with HF, patients across the EF spectrum have a similarly poor 5-year survival with an elevated risk for cardiovascular and HF admission. These findings underscore the need to improve treatment of patients with HF.

Cardiac transplantation (HTX) is the gold standard and is an increasingly utilized therapy for patients with end-stage heart failure [(1)][1]. Strategies to reduce the risk of waitlist mortality remain urgently needed. The Public Health Service defines increased risk donors (IRDs) as donors who

Circulating high-sensitivity cardiac troponin (hsTn) and soluble ST2 (sST2) reflect myocardial stress in pts w/ heart failure (HF). In contrast, production of cGMP in response to activation of natriuretic peptide receptors has favorable effects on cardiac afterload and preload. The effects of

There are limited data on the efficacy, safety, and tolerability of sacubitril/valsartan (S/V) in heart failure with a reduced ejection fraction (HFrEF) patients not previously treated with an angiotensin converting-enzyme inhibitor (ACEi)/angiotensin receptor blocker (ARB). The PIONEER-HF trial

Reducing readmissions after a hospitalization for acute decompensated heart failure (ADHF) is an important goal for patients, clinicians, and policy makers. Despite this, 30-day readmission rates remain high, in part because there are limited evidence-based, in-hospital interventions that improve HF

Patient reported outcomes (PROs) objectively measure health-related quality of life and provide prognostic information. Despite apparent advantages, the use of PROs in routine clinical care are rare. To better understand the barriers and facilitators of routine PRO use, we conducted a multi-center

Heart failure (HF) is associated with significant morbidity and mortality. Although initially thought to be harmful in HF, beta-adrenergic blockers (β-blockers) have consistently been shown to reduce mortality and HF hospitalization in chronic HF with reduced ejection fraction. Proposed mechanisms include neurohormonal blockade and heart rate reduction. A new therapeutic agent now exists to target further heart rate lowering in patients who have been stable on a "maximally tolerated β-blocker dose," but this definition and how to achieve it are incompletely understood. In this review, the authors summarize published reports on the mechanisms by which β-blockers improve clinical outcomes. The authors describe differences in doses achieved in landmark clinical trials and those observed in routine clinical practice. They further discuss reasons for intolerance and the evidence behind using β-blocker dose and heart rate as therapeutic targets. Finally, the authors offer recommendations for clinicians actively initiating and up-titrating β-blockers that may aid in achieving maximally tolerated doses.

Aortix (Procyrion, Houston, Texas) is a percutaneous mechanical circulatory support (pMCS) device deployed in the descending aorta via the femoral artery to provide cardiac unloading and augment renal and systemic perfusion. This first-in-human, single-center study (Sanatorio Italiano, Asuncion

In 2009, the Centers for MedicareMedicaid Services (CMS) began publicly reporting 30-day hospital readmission rates for patients discharged with acute myocardial infarction (MI), heart failure (HF), or pneumonia.This study assessed trends of 30-day readmission rates and post-discharge care since the implementation of CMS public reporting.We analyzed Medicare claims data from 2006 to 2012 for patients discharged after a hospitalization for MI, HF, or pneumonia. For each diagnosis, we estimated trends in 30-day all-cause readmissions and post-discharge care (emergency department visits and observation stays) by using hospitalization-level regression models. We modeled adjusted trends before and after the implementation of public reporting. To assess for a change in trend, we tested the difference between the slope before implementation and the slope after implementation.We analyzed 37,829 hospitalizations for MI, 100,189 for HF, and 79,076 for pneumonia from4,100 hospitals. When considering only recent trends (i.e., since 2009), we found improvements in adjusted readmission rates for MI (-2.3%), HF (-1.8%), and pneumonia (-2.0%), but when comparing the trend before public reporting with the trend after reporting, there was no difference for MI (p = 0.72), HF (p = 0.19), or pneumonia (p = 0.21). There were no changes in trends for 30-day post-discharge care for MI or pneumonia; however, the trend decreased for HF emergency department visits from 2.3% to -0.8% (p = 0.007) and for observation stays from 15.1% to 4.1% (p = 0.04).The release of the CMS public reporting of hospital readmission rates was not associated with any measurable change in 30-day readmission trends for MI, HF, or pneumonia, but it was associated with less hospital-based acute care for HF.

Background: Hemoconcentration correlates with superior decongestion and improved outcomes among acute heart failure (AHF) patients, but data are limited to those with preserved renal function receiving intravenous diuretics. The role of hemoconcentration in AHF complicated by cardiorenal syndrome (

Background: Hyper- and hypokalemia are common in heart failure (HF) and associated with worse outcomes. Normal values are established in the general population (3.5-5.0mmol/L), but the optimal potassium (K+) range in patients with HF is unknown. Methods: Using the Swedish HF Registry, we studied HF

Background: Few data exist regarding contemporary care patterns for heart failure with reduced ejection fraction (HFrEF) in the outpatient setting. Change the Management of Patients with Heart Failure (CHAMP-HF) is a prospective cohort study designed to characterize current management of patients

Background: More than 50% of patients with heart failure (HF) and a reduced ejection fraction (EF) are overweight. Although liraglutide is FDA-approved for weight loss, prior clinical trials excluded patients with HF. Methods: Patients with a recent hospitalization for HF and an EF

Decongestion strategies in acute heart failure (AHF) have been posited to result in varying degrees of renin-angiotensin-aldosterone system (RAAS) activation. The association between the degree of RAAS activation and outcomes after AHF is unknown. We analyzed 427 AHF patients enrolled in DOSE and

Increased resting heart rate (HR) is associated with worse outcomes in mostly white populations, but its significance is not well established in African Americans whose cardiac comorbidities and structural abnormalities differ. We studied the prognostic utility of HR in a community-based African

Elevated jugular venous pressure (JVP) and peripheral edema predict worse outcomes in chronic heart failure (HF) patients. We studied these findings in acute HF in the ASCEND-HF trial of nesiritide vs. placebo. Of 7,141 ASCEND-HF patients, 7,135 patients had complete data on baseline JVP and

Although aerobic exercise improves quality of life as assessed by a disease-specific instrument in ambulatory HF patients with a reduced EF, the impact of an exercise intervention on general health status has not been reported. HF-ACTION enrolled 2331 outpatients with HF and an EF

The clinical course of body weight change during hospitalization for acute heart failure (HF) and its relationship with outcomes have not been well-characterized. A post-hoc analysis was performed of the ASCEND-HF trial, which enrolled patients admitted for acute HF. Spearman rank correlations of

While abnormal resting left ventricular (LV) global longitudinal strain (GLS) has been described in patients with heart failure with preserved ejection fraction (HFpEF), its prevalence and clinical significance are poorly understood. Patients enrolled in the RELAX trial of sildenafil in HFpEF (EF

In July 2009 the Centers for Medicare and Medicaid Services began publicly reporting risk-standardized 30-day hospital readmission rates for heart failure (HF) and other conditions. The impact of this policy change on different measures of acute care utilization has not been previously evaluated.

Previous studies suggest that left ventricular (LV) global longitudinal strain (GLS) analysis by 2-dimensional speckle tracking echocardiography is useful to detect subclinical LV dysfunction. However, no prior study has used GLS to assess cardiac allograft function prior to transplantation or to