scholarly journals Prescription bias in the treatment of chronic systolic heart failure impacts outcome

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
H Arfsten ◽  
G Goliasch ◽  
N Pavo ◽  
P.E Bartko ◽  
G Spinka ◽  
...  
Keyword(s):  
Beta Blockers ◽  
Systolic Heart Failure ◽  
Renin Angiotensin System ◽  
Angiotensin System ◽  
Number Of Patients ◽  
Study Population ◽  
Chronic Systolic Heart Failure ◽  
One Year ◽  
The Individual ◽  
Target Dosage

Abstract Background There is evidence that medical therapy with beta-blockers (BB) and renin-angiotensin-system-inhibitors, uptitrated to target dosage (TD) decreases mortality and hospitalizations in HFrEF. However, physicians seemingly do not sufficiently follow the guidelines and a great number of patients do not receive recommended dosages. As humans are visually deceivable, it might be that absolute numerical values of equipotent recommended TD and the “milligram-based” subjective weighting of tolerability by the individual physician influences the maximal prescribed dosage. Purpose We sought to assess whether different numerical TD of equipotent medications affect prescription patterns, potentially biases uptitration and impacts outcome. Methods 3737 HFrEF outpatients were identified from a prospective registry. Maximal achieved dosages of BB, ACEi and ARB after one year of repeated visits for uptitration were assessed. BB, ACEi and ARB with largest numerical differences in TD (10mg/d bisoprolol/nebivolol vs 200mg/d metoprolol; 10mg/d ramipril vs 40mg/d lisinopril/enalapril/fosinopril; and 32mg/d candesartan vs 320mg/d valsartan) were compared using the individually achieved dose as percentage of the defined TD at one year of FUP. The association of maximal achieved TD with HF hospitalization and overall survival were determined. Results Median age was 65 years (IQR: 55–74), 2720 patients (73%) were male. Within the whole study population, 1434 patients (38%) received bisoprolol/nebivolol, 280 (8%) metoprolol. Ramipril was prescribed in 599 (16%) patients, lisinopril/enalapril/fosinopril in 1138 (30%). 409 patients (11%) were on candesartan, 173 (5%) on valsartan. Significant differences at baseline were not clinically meaningful and there were no contraindications for uptitration in all subgroups. After one year aiming for up-titration dosages increased significantly in all medication-groups (p<0.001 for all). However, significantly less patients were treated with the TD when TD was numerically higher (BB: metoprolol (57 (20%)) vs bisoprolol/nebivolol (446 (31%), p<0.001); ACEi: lisinopril/enalapril/fosinopril (231 (20%) vs ramipril (313 (52%), p<0.001); ARB: valsartan (45 (26%) vs candesartan (166 (41%), p<0.001)). At 45 (IQR: 32–68) months of FUP, 859 (23%) of the patients were hospitalized for HF or died. Achievement of TD significantly improved outcome (Fig. 1A-C) and showed association with mortality and HF-hospitalization (BB: adj.HR=0.87, 95% CI: 0.79–0.95, p<0.001; ACEi: adj.HR=0.89, 95% CI: 0.81–0.97, p=0.023; ARB: adj.HR=0.74, 95% CI: 0.69–0.91, p=0.009). Conclusion The present analysis described the influence of the numerical values of recommended TD of equipotent drugs on the prescription behavior of the treating physician and on outcome. This psychological phenomenon was identified a substantial confounder at least partly responsible for the underuse of BB, ACEi and ARB in HF. Moreover, it was never shown that this cognitive illusion based on risk aversion is linked to outcome. Figure 1 Funding Acknowledgement Type of funding source: None

scholarly journals Impact of air pollution and smoking on COVID-19: a review

2021 ◽  
Vol 15 (1) ◽  
Author(s):  
Vijaytha Vijayakumar ◽  
A. Sabu ◽  
M. Haridas
Keyword(s):  
Air Pollution ◽  
Renin Angiotensin System ◽  
Main Body ◽  
Angiotensin System ◽  
Forested Areas ◽  
Clean Air ◽  
Severity Of The Disease ◽  
Earth Day ◽  
The Individual ◽  
Tract Infections

Abstract Background The 21st century already witnessed many deadly epidemics and pandemics. The major ones were respiratory tract infections like SARS (2003), H1N1 (2009), MERS (2012) and the most recent pandemic COVID-19 (2019). The COVID-19 story begins when pneumonia of unknown cause was reported in the WHO country office of China at the end of 2019. SARS-CoV-2 is the causative agent that enters the host through the receptor ACE2, a component of the renin–angiotensin system. Main body of the abstract Symptoms of COVID-19 varies from patient to patient. It is all about the immunity and health status of the individual that decides the severity of the disease. The review focuses on the significant and often prevailing factors, those that influence the lung function. The factors that compromise the lung functions which may prepare the ground for severe COVID-19 infection are interestingly looked into. Focus was more on air pollution and cigarette smoke. Short conclusion The fact that the forested areas across the world show very low COVID-19 infection rate suggests that we are in need of the “Clean Air” on the fiftieth anniversary of World Earth Day. As many policies are implemented worldwide to protect from SARS-CoV-2, one simple remedy that we forgot was clean air can save lives. SARS-CoV-2 infects our lungs, and air pollution makes us more susceptible. In this crucial situation, the focus is only on the main threat; all other conditions are only in words to console the situation.

Abstract 13174: Sex Differences in Clinical Characteristics, Management and Prognosis in Patients With Heart Failure With Preserved Ejection Faction: Insights From the CHART-2 Study

Circulation ◽  
2015 ◽  
Vol 132 (suppl_3) ◽  
Author(s):  
Kanako Tsuji ◽  
Yasuhiko Sakata ◽  
Masanobu Miura ◽  
Soichiro Tadaki ◽  
Ryoichi Ushigome ◽  
...  
Keyword(s):  
Heart Failure ◽  
Sex Differences ◽  
Beta Blockers ◽  
Renin Angiotensin System ◽  
Class Iii ◽  
Angiotensin System ◽  
Renin Angiotensin ◽  
Female Patients ◽  
Increased Risk ◽  
Patients With Heart Failure

Background: The number of the patients with heart failure with preserved ejection fraction (HFpEF) has been rapidly increasing worldwide. However, sex differences in patients with HFpEF remain to be elucidated. Methods and Results: We examined sex differences in 3,124 consecutive patients with HFpEF (EF≥50%, mean 69.4years, 34.7% female) registered in our Chronic Heart Failure Analysis and Registry in the Tohoku District-2 (CHART-2) Study (N=10,219). Female patients, as compared with male patients, were characterized by higher age (72 vs. 68 years, P<0.01), higher LVEF (67 vs. 64%, P<0.01), higher heart rate (74 vs. 70bpm, PNYHA class III (14.1 vs. 7.0%, P<0.01), higher BNP levels (106 vs. 73pg/mL, P<0.01), lower prevalence of coronary artery disease (30 vs. 53%, P<0.01) and lower prescription rates of renin angiotensin system inhibitors (64.7 vs. 71.8%, P<0.01) and beta-blockers (37.8 vs. 43.9%, P<0.01). During the median 3.2-year follow-up, 147 female patients and 245 males died. Although there was no sex difference in all-cause mortality (13.6 vs. 12.0%, P=0.11), female patients more frequently died due to cardiovascular causes (53.7 vs. 39.2%, hazard ratio (HR): 1.62, 95% CI 1.20-2.18, P<0.01), and experienced more HF admissions (12.6 vs. 9.8%, HR: 1.35, 95% CI 1.08-1.68, P<0.01). Use of beta-blockers or renin-angiotensin system inhibitors was not associated with decreased incidence of death or HF admission in both sexes. In contrast, use of statins was associated with reduced incidence of all-cause death in both sexes (males and females; adjusted HR, 0.59 and 0.57; 95% CI 0.46-0.77 and 0.47-0.70, respectively, both P<0.01) and was also associated with reduced incidence of HF admission in males (adjusted HR: 0.67, 95%CI 0.53-0.85, P<0.01) but not in females (adjusted HR: 0.83, 95% CI 0.63-1.10, P=0.19). Conclusions: As compared with males, female patients with HFpEF were characterized by severer condition of HF and increased risk of cardiovascular death and HF admission. Although statin use was equally associated with improved mortality in both sexes, female patients with HFpEF may benefit from statins less than males in terms of reduction of HF admission.

scholarly journals The Renin Angiotensin System — Its Physiology and Role in Disease States

1983 ◽  
Vol 11 (4) ◽  
pp. 369-376 ◽  
Author(s):  
G. S. Stokes
Keyword(s):  
Renin Angiotensin System ◽  
Plasma Renin ◽  
Angiotensin System ◽  
Renin Angiotensin ◽  
Disease States ◽  
Electrolyte Depletion ◽  
Predominant Factor ◽  
The Individual ◽  
Effective Use ◽  
Selection Of

The renin-angiotensin system is one of a number of interlinked mechanisms regulating vascular resistance and blood volume. Under certain conditions it may become a predominant factor in maintaining vascular tone. Knowledge about these conditions (sodium depletion, mineralocorticoid deficiency, renovascular hypertension and iatrogenic hyperreninaemic states) is important for the safe and effective use of drugs which inhibit the renin-angiotensin system. Measurements of plasma renin activity are useful in the diagnostic assessment of hypertensive patients with hypokalaemia or evidence of renal artery stenosis. They may also have a place in the management of refractory or dialysis-resistant hypertension. Their use in the selection of antihypertensive therapy for the individual patient is controversial. Sequential measurements of plasma renin are helpful in analysing states of electrolyte depletion, and in titrating therapy for Addison's disease.

scholarly journals The complex interaction between atrial fibrillation and heart failure in elderly patients

2019 ◽  
Vol 89 (2) ◽  
Author(s):  
Stefano Fumagalli ◽  
Giulia Pelagalli ◽  
Marta Migliorini ◽  
Serena Boni ◽  
Francesca Nigro ◽  
...  
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Elderly Patients ◽  
Beta Blockers ◽  
Geriatric Medicine ◽  
Renin Angiotensin System ◽  
Cardiac Resynchronization ◽  
Angiotensin System ◽  
Complex Patients ◽  
Important Challenge

Heart failure (HF) and atrial fibrillation (AF) often coexist. Subjects with permanent AF show the highest prevalence of HF. Patients with incident AF have HF in a great number of cases and, reciprocally, in patients with incident HF, an AF can be frequently found. The simultaneous presence of the two conditions is associated with mortality rates higher than those observed in individuals with only one or none of them. Interestingly, HF and AF could synergistically promote in elderly patients the development of disability and dementia. Inflammatory mechanisms coupled with changes of renin-angiotensin system, hormonal pathways and neuro-mediators could simultaneously promote left atrium remodeling and sustain both HF and AF. Beta-blockers and digoxin seem to have small therapeutic effect and limited influence on prognosis in these very complex patients. Sinus rhythm restoration could slow down the progression of disability in symptomatic subjects. Recent evidence seem to suggest that upstream therapy coupled with rehabilitation, and that AV node ablation associated with cardiac resynchronization therapy could benefit subjects with HF and AF. In conclusion, elderly patients simultaneously presenting problems of cardiac function and arrhythmia are an important challenge for geriatric medicine, and request important efforts to improve their functional profile and prognosis.

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