Abstract MP71: Socioeconomic Status, Guideline Directed Medical Therapy, and Prognosis in Heart Failure With Reduced Ejection Fraction: The Atherosclerosis Risk in Community (ARIC) Study

Circulation ◽  
2020 ◽  
Vol 141 (Suppl_1) ◽  
Author(s):  
Lena Mathews ◽  
Ning Ding ◽  
Amira Collison ◽  
Yejin Mok ◽  
Jung-Im Shin ◽  
...  
Keyword(s):  
Heart Failure ◽  
Socioeconomic Status ◽  
Ejection Fraction ◽  
Racial Differences ◽  
Medical Therapy ◽  
Angiotensin Receptor Blockers ◽  
Area Deprivation ◽  
Aldosterone Antagonists ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Introduction: Current research suggests racial differences exist in the utilization of guideline directed medical therapy (GDMT) and prognosis in heart failure with reduced ejection fraction (HFrEF). Whether individual and community level socioeconomic status (SES) impacts prescription patterns of GDMT and prognosis in HFrEF has not been studied. Methods: We studied 669 ARIC participants with incident HFrEF (EF<50%) (mean age 77.6 (SD 6.5) years; 39% black; 46% women) during 2005-2017 (median 1.8 years of follow-up). We assessed the proportion of patients on optimal GDMT (defined as ß-blockers [BB] and ACE inhibitors [ACEI] or angiotensin receptor blockers [ARB]) or adequate GDMT (one of either BB, ACEI/ARB, aldosterone antagonists [AA], or hydralazine and nitrates [H-ISDN]) at hospital discharge by individual SES (education and income), neighborhood SES (area deprivation index: ADI) and their combination (Table). We also examined the contribution of GDMT prescription to prognosis overall, and by SES. Subsequently, we quantified the association of SES with mortality and re-hospitalization for HFrEF. Results: The proportion of patients prescribed optimal and adequate GDMT was 54% and 81%, respectively. BB were most frequently prescribed (83%), followed by ACEI/ARB (61%), AA (11%), and H-ISDN (9%). Overall, BB were associated with lower mortality, while H-ISDN were associated with higher mortality, compared to their non-use counterparts. ACEI/ARB were associated with lower re-hospitalization, compared to non-users of ACEI/ARB. The prescription of GDMT and the effect of GDMT on prognosis did not significantly differ by SES. Despite that, lower SES was independently associated with higher risk of mortality and re-hospitalization (Table). Conclusions: Overall, optimal GDMT was low at discharge, but did not differ by SES. Despite that, there were significant differences in death and re-hospitalization by SES, suggesting a potential need for tailored approaches to HFrEF management for low SES individuals.

scholarly journals Safety and Tolerability of Initiating Maximum-Dose Sacubitril-Valsartan in Patients on Target Dose Renin-Angiotensin System Inhibitors

2019 ◽  
Vol 2019 ◽  
pp. 1-6 ◽  
Author(s):  
Helena Norberg ◽  
Ellinor Bergdahl ◽  
Krister Lindmark
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Ace Inhibitors ◽  
Maximum Dose ◽  
Angiotensin Receptor Blockers ◽  
Renin Angiotensin System ◽  
Target Dose ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Aim. Sacubitril-valsartan has proven beneficial in heart failure with reduced ejection fraction. Guidelines recommend initiating half-dose sacubitril-valsartan before up-titration even to patients already on target dose angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARB). To reduce the number of titration steps needed in order to simplify for the patient as well as the clinic, we aimed to investigate the safety and tolerability of switching patients on target dose ACE inhibitors or ARBs directly to maximum-dose sacubitril-valsartan. Methods. This prospective cohort study was conducted between April 2016 and November 2017. A total of 66 patients with heart failure and reduced ejection fraction already on guideline-recommended target dose ACE inhibitors or ARBs (equivalent to enalapril 10 mg twice daily) were switched to maximum-dose sacubitril-valsartan (200 mg twice daily). The patients were followed for twelve months. Results. Patients had a mean age of 72 ± 10 years, mean systolic blood pressure of 121 ± 17 mmHg, and 92% were male. At 12-month follow-up, nine patients (14%) had discontinued sacubitril-valsartan, four patients (6%) had a dose reduction, and 17 patients (26%) had developed symptomatic hypotension. No angioedema occurred within the 12-month follow-up and there were no hospitalizations or emergency room visits within the first 14 days. Conclusions. Switching directly from target dose ACE inhibitors or ARBs to maximum-dose sacubitril-valsartan was safe and generally well tolerated.

scholarly journals The Management of Heart Failure with Preserved Ejection Fraction

2015 ◽  
Vol 1 (1) ◽  
pp. 11 ◽  
Author(s):  
Andrew JS Coats ◽  
Louise G Shewan ◽  
◽  
◽  
◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Beta Blockers ◽  
Angiotensin Receptor Blockers ◽  
Left Ventricular ◽  
Clinical Syndrome ◽  
Aldosterone Antagonists ◽  
Sharp Separation ◽  
Clinical Trial Evidence ◽  
Receptor Blockers

Heart failure is defined as a clinical syndrome and is known to present with a number of different pathophysiological patterns. There is a remarkable degree of variation in measures of left ventricular systolic emptying and this has been used to categorise heart failure into two separate types: low ejection fraction (EF) heart failure or HF-REF and high EF heart failure or HF-PEF. Here we review the pathophysiology, epidemiology and management of HF-PEF and argue that sharp separation of heart failure into two forms is misguided and illogical, and the present scarcity of clinical trial evidence for effective treatment for HF-PEF is a problem of our own making; we should never have excluded patients from major trials on the basis of EF in the first place. Whilst as many heart failure patients have preserved EFs as reduced we have dramatically under-represented HF-PEF patients in trials. Only four trials have been performed in HF-PEF specifically, and another two trials that recruited both HF-PEF and HF-REF can be considered. When we consider the similarity in outcomes and neurohormonal activation between HF-REF and HF-REF, the vast corpus of trial data that we have to attest to the efficacy of various treatment (angiotensinconverting-enzyme [ACE] inhibitors, angiotensin receptor blockers [ARBs], beta-blockers and aldosterone antagonists) in HF-REF, and the much more limited number of trials of similar agents showing near statistically significant benefits in HF-PEF the time has come rethink our management of HF-PEF, and in particular our selection of patients for trials.

Outcomes of a Pharmacist-Managed Heart Failure Medication Titration Assistance Clinic

2018 ◽  
Vol 52 (8) ◽  
pp. 724-732 ◽  
Author(s):  
Shubha Bhat ◽  
Mayank Kansal ◽  
George T. Kondos ◽  
Vicki Groo
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Ace Inhibitors ◽  
Chart Review ◽  
Ace Inhibitor ◽  
Angiotensin Receptor Blockers ◽  
Retrospective Chart Review ◽  
National Guidelines ◽  
Reduced Ejection Fraction ◽  
Receptor Blockers

Background: National guidelines recommend angiotensin-converting enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs) and β-blockers (BBs) at target doses for morbidity and mortality benefits in heart failure with reduced ejection fraction (HFrEF); regardless, titration of these therapies in practice remains suboptimal. We implemented an outpatient pharmacist-managed HFrEF medication titration assistance clinic (MTAC) at one institution to improve titration for general cardiology (GC) patients. Objective: To evaluate MTAC impact by determining the proportion of patients on target or maximum tolerated ACE inhibitor/ARB and BB doses. Methods: A retrospective chart review of adult patients with documented ejection fraction ≤40% managed in the MTAC or GC from 2011 to 2013 was conducted. HFrEF medication regimens were collected at initial visit and months 1, 2, 3, 6, 9, and 12 to assess titration. Target doses were defined per guideline or dose at which ejection fraction recovered during the study. Maximum tolerated doses were defined as the highest dose patients tolerated without physiological limitations. Results: Of 148 patients, the MTAC managed 51 and GC managed 97. At baseline, 90% of MTAC versus 82% of GC patients were prescribed ACE inhibitors/ARBs and BBs. In the MTAC, 4% were at target or maximum tolerated doses compared with 32% of GC patients ( P < 0.001). At 12 months, 95% of patients in the MTAC and 87% in GC were prescribed ACE inhibitors/ARBs and BBs. Of those prescribed ACE inhibitors/ARBs and BBs, 64% in the MTAC versus 40% in GC reached target or maximum tolerated doses ( P = 0.01). Conclusions: The pharmacist-managed MTAC increased the proportion of patients on optimal HFrEF therapies and are a resource for GC patients.

SGLT-2-Inhibitors in Heart Failure

2020 ◽  
pp. 1-4
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Enzyme Inhibitors ◽  
Therapeutic Option ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Converting Enzyme Inhibitors ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction ◽  
Effective Therapeutic Option ◽  
Receptor Blockers

Heart failure is a frequent and highly debilitating pathology. Angiotensin‐converting enzyme inhibitors and angiotensin receptor blockers, β‐ blockers, mineralocorticoid receptor antagonists, and valsartan/sacubitril have been shown to reduce mortality in chronic heart failure with reduced ejection fraction. Recently, glifozines (SGLT‐2 inhibitors) have become another effective therapeutic option for heart failure with reduced ejection fraction, in patients with and without diabetes mellitus. The review presents the effects of SGLT‐2 inhibitors on the cardiovascular system and heart failure.

Impact of Clinical Audit on Adherence to the Guidelines Directed Medical Therapy in Patients Admitted with Heart Failure

2020 ◽  
Vol 15 (2) ◽  
pp. 117-123
Author(s):  
Aashiq A. Shukkoor ◽  
Nimmy E. George ◽  
Shanmugasundaram Radhakrishnan ◽  
Sivakumar Velusamy ◽  
Tamilarasu kaliappan ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Acute Heart Failure ◽  
Medical Therapy ◽  
Clinical Audit ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Receptor ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction ◽  
The Impact

Background: The adoption of guideline recommendations of pharmacotherapy to improve the clinical course of Heart Failure (HF) remains below par. Our objective is to evaluate the impact of clinical audit on adherence to the Guideline-Directed Medical Therapy (GDMT) in patients admitted with acute heart failure with reduced ejection fraction (EF). Methods: A prospective interventional study was conducted over a period of 12 months from June 2018 to May 2019 in all patients admitted with acute heart failure with reduced ejection fraction. The discharge prescriptions of patients who met the inclusion criteria were audited for appropriateness in the usage of neurohormonal blockers and Ivabradine, by a clinical pharmacist on a monthly basis. Audit results were presented to the practicing physicians every month and feedback was given. Results: Discharge prescriptions of 716 patients who presented with HF were audited for the reasonable or unreasonable omission of neurohormonal blocking drugs. The first-month audit revealed that the unreasonable omission of Angiotensin-Converting Enzyme Inhibitors/ Angiotensin Receptor Blockers/ Angiotensin Receptor Neprilisin Inhibitors ( ACEI/ARB/ARNI), Betablockers and Mineralocorticoid Receptor Antagonists (MRA) were 24.5%, 13.1%, and 9.09% respectively, which reduced to nil at the end of the study period (p=0.00). Initiation of Ivabradine before prescribing or achieving the target dose of Betablocker was noted in 38.18% of patients in the first month, which was also reduced to nil (p=0.00) at the end of the study. Conclusion: This study reveals that periodic clinical audit improves adherence to GDMT in patients admitted with heart failure with reduced ejection fraction.

scholarly journals Rationale for and Practical Use of Sacubitril/Valsartan in the Patient’s Journey with Heart Failure and Reduced Ejection Fraction

2021 ◽  
Vol 7 ◽  
Author(s):  
Mauro Gori ◽  
James L Januzzi ◽  
Emilia D’Elia ◽  
Ferdinando L Lorini ◽  
Michele Senni
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Enzyme Inhibitors ◽  
Angiotensin Receptor Blockers ◽  
Angiotensin Converting Enzyme Inhibitors ◽  
Electrolyte Imbalance ◽  
Converting Enzyme Inhibitors ◽  
Reduced Ejection Fraction ◽  
Reverse Remodelling ◽  
Receptor Blockers

Sacubitril with valsartan (sacubitril/valsartan) is a relatively novel compound that has become a milestone in the treatment of patients with chronic heart failure (HF) with reduced ejection fraction (HFrEF) in the last decade. Contemporary data suggest that sacubitril/valsartan is associated with improved outcomes compared with angiotensin-converting enzyme inhibitors and angiotensin receptor blockers, and has a greater beneficial effect on myocardial reverse remodelling. Additionally, two recent trials have shown that sacubitril/valsartan is well-tolerated even in the acute HF setting, thus enabling a continuum of use in the patient’s journey with HFrEF. This article summarises available data on the effectiveness and tolerability of sacubitril/valsartan in patients with HFrEF, and provides the clinician with practical insights to facilitate the use of this drug in every setting, with an emphasis on acute HF, hypotension, electrolyte imbalance and renal insufficiency.

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