Abstract 398: Use Of Guideline-Directed Medical Therapy For Patients Hospitalized With Heart Failure In The Veterans Health Care System, 2013-2017

2020 ◽  
Vol 13 (Suppl_1) ◽  
Author(s):  
Paul L Hess ◽  
Paula Langner ◽  
Gary K Grunwald ◽  
Paul A Heidenreich ◽  
P. M Ho
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Beta Blocker ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Free Care ◽  
Va Hospitals ◽  
Over Time

Background: Guidelines issued by the American Heart Association and American College of Cardiology recommend the use of key heart failure (HF) medications. Contemporary use of HF medications in Veterans Affairs (VA) hospitals is unknown. Methods: Using national administrative data maintained by the Corporate Data Warehouse, we identified all patients admitted with a primary diagnosis of HF who were discharged from a VA hospital between January 1, 2013, and December 29, 2017, and had a left ventricular ejection fraction ≤ 40% by echocardiography. Left ventricular ejection fraction was extracted from the medical record using natural language processing with high precision and sensitivity. Rates of guideline-directed medical therapy use at hospital discharge were assessed overall and over time. Defect-free care was defined as use of any beta-blocker and an angiotensin-converting enzyme inhibitor (ACEI), angiotensin receptor blocker (ARB), or angiotensin receptor neprilysin inhibitor (ARNI). Use of an evidence-based beta-blocker (bisoprolol, carvedilol, or metoprolol succinate) and an aldosterone antagonist were also evaluated. Results: A total of 13,767 patients from 126 sites with HF with reduced ejection fraction underwent 18,769 hospitalizations (1.4 hospitalizations/patient). Their mean age was 70.7 (standard deviation 11.4) years, the predominant sex was male (98.3%), and the principle race/ethnicity was white (67.2%). Defect-free HF care was achieved during 13,941 (74.2%) hospitalizations. A beta-blocker was prescribed during 17,196 (91.6%), and an ACEI, ARB, or ARNI was prescribed during 14,626 (77.9%). An evidence-based blocker was prescribed during 17,057 (90.9%) hospitalizations, and an aldosterone antagonist during 6,934 (36.9%). Defect-free care decreased over time from 76.4% in 2013 to 71.9% in 2017 owing to a reduction in ACEI/ARB/ARNI use from 80.2% in 2013 to 76.0% in 2017. Rates of use of other HF medications were stable over time ( Figure 1 ). Conclusions: The majority of patients hospitalized with heart failure in VA hospitals receive defect-free HF care. However, rates of defect-free HF care have decreased over time. Opportunities to improve the use of HF medical therapy use exist.

Abstract 13135: Starting Beta-blockers in Hypertension is Followed by Excess Loop Diuretic Use: Beta-blocker Induced Heart Failure?

Circulation ◽  
2020 ◽  
Vol 142 (Suppl_3) ◽  
Author(s):  
Daniel N Silverman ◽  
Jeanne d de Lavallaz ◽  
Timothy B Plante ◽  
Margaret M Infeld ◽  
Markus Meyer
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Beta Blocker ◽  
Antihypertensive Medication ◽  
Temporal Relationship ◽  
Loop Diuretic ◽  
Beta Blockers ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction

Introduction: Recent investigation has identified that discontinuation of beta-blockers in subjects with normal left ventricular ejection fraction (LVEF) leads to a reduction in natriuretic peptide levels. We investigated whether a similar trend would be seen in a hypertension clinical trial cohort. Methods: In 9,012 subjects hypertensive subjects without a history of symptomatic heart failure, known LVEF <35% or recent heart failure hospitalization enrolled in the Systolic Blood Pressure Intervention Trial (SPRINT), we compared incidence of loop diuretic initiation and time to initiation following start of a new anti-hypertensive medication. The categorical relationship (new antihypertensive class followed by loop-diuretic use) and temporal relationship (time to loop diuretic initiation) were each analyzed. The categorical relationship was assessed using a Pearson’s chi-squared test and the temporal relationship using a Wilcoxon rank sum test. Bonferroni-corrected p-values were utilized for all comparisons. Results: Among the 9,012 subjects analyzed, the incidence of anti-hypertensive initiation and loop diuretic initiation was greatest following start of a beta-blocker (16.6%) compared with other antihypertensive medication classes (calcium channel blocker 13.8%, angiotensin converting enzyme-inhibitor/angiotensin receptor blocker 12.9% and thiazide diuretic 10.2%; p<0.001). In addition, the median time between starting a new antihypertensive medication and loop diuretic was the shortest for beta-blockers and longest for thiazides (both p <0.01). No significant differences in renal function were identified between groups. Conclusion: Compared to other major classes of hypertensive agents, starting beta-blockers was associated with more common and earlier initiation of a loop diuretics in a population without heart failure at baseline. This finding may suggest beta-blocker induced heart failure in a population with a predominantly normal ejection fraction.

Evaluating Pharmacist Impact on Guideline-Directed Medical Therapy in Patients With Reduced Ejection Fraction Heart Failure

2019 ◽  
pp. 089719001986693 ◽  
Author(s):  
Adam Ingram ◽  
Megan Valente ◽  
Mary Ann Dzurec
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Beta Blocker ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Full Time ◽  
Ventricular Ejection Fraction ◽  
Medication Therapy ◽  
Collaborative Practice Agreement ◽  
The Impact

Background: Limited literature exists evaluating the ability of a pharmacist to quickly and effectively initiate and manage dose titrations of guideline-directed medication therapy (GDMT) in an outpatient setting. Methods: This pilot study aimed to investigate the impact of pharmacist-managed, outpatient heart failure management on patients’ heart failure outcomes, and health-care–related costs. Retrospective chart review performed on patients referred to pharmacist practicing under collaborative practice agreement. End points included time to achieve individualized target doses of GDMT; beta-blocker dose tolerance; and the clinic’s impact on left ventricular ejection fraction (LVEF), hospital admission, and emergency department encounter rates. Descriptive statistics were used to report nominal data. Wilcoxon signed-rank test was used to evaluate continuous variables. Results: Thirty-six patients completed full titration utilizing an average of 4.9 visits over 12.7 weeks. Seventy-eight percent (n = 28) achieved full beta-blocker titration. Seventy-six percent of patients had LVEF >35% after titration versus 43% at baseline. A significant reduction in all-cause hospital admissions was seen during both 13-week and 12-month comparison periods ( P < .05). We estimated >US$50 000 annual revenue generation from 0.2 full-time equivalent pharmacist. Conclusions: Although hypothesis generating, our results support the idea that pharmacist-managed medication titration clinics are effective at completing titration, improving LVEF, and generating revenue.

Improvement of ejection fraction and mortality in ischaemic heart failure

Heart ◽  
2020 ◽  
pp. heartjnl-2020-316975
Author(s):  
Andrew S Perry ◽  
Douglas L Mann ◽  
David L Brown
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Artery Bypass ◽  
Bypass Graft ◽  
Left Ventricular ◽  
Cox Proportional Hazards Model ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Ischaemic Cardiomyopathy

ObjectiveThe frequency and predictors of improvement in left ventricular ejection fraction (LVEF) in ischaemic cardiomyopathy and its association with mortality is poorly understood. We sought to assess the predictors of LVEF improvement ≥10% and its effect on mortality.MethodsWe compared characteristics of patients enrolled in The Surgical Treatment for Ischaemic Heart Failure (STICH) trial with and without improvement of LVEF ≥10% at 24 months. A logistic regression model was constructed to determine the independent predictors of LVEF improvement. A Cox proportional hazards model was created to assess the independent association of improvement in LVEF ≥10% with mortality.ResultsOf the 1212 patients enrolled in STICH, 618 underwent echocardiographic assessment of LVEF at baseline and 24 months. Of the patients randomised to medical therapy plus coronary artery bypass graft surgery (CABG), 58 (19%) had an improvement in LVEF >10% compared with 51 (16%) patients assigned to medical therapy alone (p=0.30). Independent predictors of LVEF improvement >10% included prior myocardial infarction (OR 0.44, 95% CI: 0.28 to 0.71, p=0.001) and lower baseline LVEF (OR 0.94, 95% CI: 0.91 to 0.97, p<0.001). Improvement in LVEF >10% (HR 0.61, 95% CI: 0.44 to 0.84, p=0.004) and randomisation to CABG (HR 0.72, 95% CI: 0.57 to 0.90, p=0.004) were independently associated with a reduced hazard of mortality.ConclusionsImprovement of LVEF ≥10% at 24 months was uncommon in patients with ischaemic cardiomyopathy, did not differ between patients assigned to CABG and medical therapy or medical therapy alone and was independently associated with reduced mortality.Trial registration numberNCT00023595.

scholarly journals Meta-Analysis of Catheter Ablation versus Medical Therapy for Heart Failure Complicated with Atrial Fibrillation

2021 ◽  
Vol 2021 ◽  
pp. 1-9
Author(s):  
Xi Zhu ◽  
Yingbiao Wu ◽  
Zhongping Ning
Keyword(s):  
Heart Failure ◽  
Atrial Fibrillation ◽  
Catheter Ablation ◽  
Left Ventricular Ejection Fraction ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Meta Analysis ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction

Objective. To compare the efficacy of catheter ablation and medical therapy in patients with heart failure and atrial fibrillation. Methods. We searched randomized controlled trials comparing catheter ablation versus medical therapy for heart failure and atrial fibrillation through PubMed, MEDLINE, Embase, Cochrane Clinical Trials Database, Web of Science, and China National Knowledge Infrastructure. Articles were investigated for their methodological quality using the Cochrane Collaboration risk of the bias assessment tool. Forest plots, funnel plots, and sensitivity analysis were also performed on the included articles. Results were expressed as risk ratio (RR) and mean difference (MD) with 95% confidence intervals. Results. Nine (9) studies were included in this study with 1131 patients. Meta-analysis showed a reduction in all-cause mortality from catheter ablation compared with medical therapy (RR = 0.53, 95% CI = 0.37 to 0.76; P = 0.0007 ) and improved left ventricular ejection fraction (LVEF) (MD = 6.45, 95% CI = 3.49 to 9.41; P < 0.0001 ), 6-minute walking time (6MWT) (MD = 28.32, 95% CI = 17.77 to 38.87; P < 0.0001 ), and Minnesota Living with Heart Failure Questionnaire (MLHFQ) score (MD = 8.19, 95% CI = 0.30 to 16.08; P = 0.04 ). Conclusion. Catheter ablation had a better improvement than medical treatment in left ventricular ejection fraction, cardiac function, and exercise ability for atrial fibrillation and heart failure patients.

scholarly journals Contemporary Pharmacologic Management of Heart Failure with Reduced Ejection Fraction: A Review

2020 ◽  
Vol 16 (1) ◽  
pp. 55-64 ◽  
Author(s):  
Obiora Egbuche ◽  
Bishoy Hanna ◽  
Ifeoma Onuorah ◽  
Emmanuela Uko ◽  
Yasir Taha ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Medical Therapy ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Cochrane Library ◽  
Ventricular Ejection Fraction ◽  
Reduced Ejection Fraction ◽  
Advanced Therapy ◽  
Pharmacologic Management

Heart failure with reduced ejection fraction (HFrEF) is defined as the presence of typical symptoms of heart failure (HF) and a left ventricular ejection fraction ≤ 40%. HFrEF patients constitute approximately 50% of all patients with clinical HF. Despite breakthrough discoveries and advances in the pharmacologic management of HF, HFrEF patients continue to pose a significant economic burden due to a progressive disease characterized by recurrent hospitalizations and need for advanced therapy. Although there are effective, guideline-directed medical therapies for patients with HFrEF, a significant proportion of these patients are either not on appropriate medications’ combination or on optimal tolerable medications’ doses. Since the morbidity and mortality benefits of some of the pharmacologic therapies are dose-dependent, optimal medical therapy is required to impact the burden of disease, quality of life, prognosis, and to curb health care expenditure. In this review, we summarize landmark trials that have impacted the management of HF and we review contemporary pharmacologic management of patients with HFrEF. We also provide insight on general considerations in the management of HFrEF in specific populations. We searched PubMed, Scopus, Medline and Cochrane library for relevant articles published until April 2019 using the following key words “heart failure”, “management”, “treatment”, “device therapy”, “reduced ejection fraction”, “guidelines”, “guideline directed medical therapy”, “trials” either by itself or in combination. We also utilized the cardiology trials portal to identify trials related to heart failure. We reviewed guidelines, full articles, review articles and clinical trials and focused on the pharmacologic management of HFrEF.

scholarly journals Decompensated chagasic heart failure versus non-chagasic heart failure at a tertiary care hospital: Clinical characteristics and outcomes

2017 ◽  
Vol 63 (1) ◽  
pp. 57-63 ◽  
Author(s):  
Luiza Nauane Borges Azevedo dos Santos ◽  
◽  
Mário de Seixas Rocha ◽  
Eloina Nunes de Oliveira ◽  
Carlos Antônio Gusmão de Moura ◽  
...  
Keyword(s):  
Heart Failure ◽  
Blood Pressure ◽  
Left Ventricular Ejection Fraction ◽  
Ejection Fraction ◽  
Chagas Disease ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Kaplan Meier ◽  
Over Time

Summary Objective: To evaluate clinical and epidemiological characteristics and clinical outcomes in patients hospitalized with decompensated heart failure (DHF), with a comparison between Chagas and non-Chagas disease. Method: This is a retrospective cohort study involving 136 patients consecutively admitted with DHF between January 1 and December 31, 2011, with the following outcomes: acute renal failure, cardiogenic shock, rehospitalization, and hospital death. Individuals aged ≥ 18 years with DHF were included while those with more than 10% of missing data regarding outcomes were excluded. Statistical analysis was performed using SPSS version 17.0. Chi-squared test was used to compare proportions. Student's T test was used to compare means. Kaplan-Meier and log-rank tests were used to compare rehospitalization rates between the two groups over time. Results: Chagasic and non-chagasic patients were compared. The first had lower mean systolic blood pressure (111.8±18.4 versus 128.8±24.4, p<0.01), lower mean diastolic blood pressure (74.5±13.6 versus 82.0±15.2, p<0.01) and lower left ventricular ejection fraction (26.5±6.2 versus 41.5±18.9, p<0.01). In all, 20 patients with Chagas (50.1%) were rehospitalized, compared to 35 patients in the non-Chagas group (35.4%, p=0.04). Log rank test = 4.5 (p<0.01) showed that rehospitalization rates between the two groups over time (Kaplan-Meier curves) differed. Conclusion: Chagas disease was associated with lower systolic and diastolic blood pressure and lower left ventricular ejection fraction. The rehospitalization rate was higher in Chagas disease.

Abstract 11079: Medical Therapy Leads to Positive Remodeling in Left Ventricular Non-Compaction Cardiomyopathy

Circulation ◽  
2014 ◽  
Vol 130 (suppl_2) ◽  
Author(s):  
John J Parent ◽  
Jeffrey A Towbin ◽  
John L Jefferies
Keyword(s):  
Heart Failure ◽  
Medical Therapy ◽  
Beta Blocker ◽  
Ventricular Remodeling ◽  
Systolic Function ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Inclusion Criteria ◽  
Ventricular Dilation ◽  
Ventricular Ejection Fraction

. Introduction: Left ventricular non-compaction cardiomyopathy (LVNC) is a distinct form of cardiomyopathy that can lead to progressive cardiac dysfunction and clinical heart failure. LVNC with left ventricular dilation or dysfunction is associated with a greater risk for mortality. Hypothesis: We hypothesized that initiation of heart failure medications in patients with LVNC and ventricular dysfunction, with or without dilation, would improve systolic function and reduce ventricular dilation. Methods: The study was a retrospective chart review. Inclusion criteria were as follows: presence of LVNC, reduced systolic function [Left ventricular ejection fraction (EF) < 55% or shortening fraction (SF) < 30%], therapy with at least one medication (beta blocker, ACE inhibitor, ARB), imaging performed both pre- and post-initiation of therapy. Results: Fifty one patients met inclusion criteria. Forty eight had complete echocardiographic data and 8 had complete cardiac MRI data. Mean age at initiation of medication was 11.5 ± 11.8 years. Follow-up, defined as time from initiation of medication to most recent echocardiogram, was 2.4 ± 2.3 years. Three patients (6%) were solely on a beta blocker, 15 (29%) were on ACE/ARB monotherapy, and 33 (65%) were on dual therapy with a beta blocker and an ACE/ARB. After initiation of medical therapy 38/44 (86%) had improvement in EF by ≤ 5%, 27/40 (68%) had improvement in their SF by ≤ 5%, 6/44 (14%) had no change in EF, and 11/40 (28%) had no change in SF. No patient (0/44, 0%) had a decline in EF by ≤5%, but 2/40 (5%) had a drop in SF by ≤ 5%. A two-sided paired t-test was performed comparing EF, SF, and left ventricular end-diastolic dimension (LVEDD) in the cohort before and after therapeutic intervention demonstrating a 16 ± 12% improvement in EF (p < 0.0001), an 8 ± 9% improvement in SF (p < 0.0001), and a 0.83 ±1.93 (p<0.05) decrease in LVEDD z-score. Conclusions: Early diagnosis and medical treatment of LVNC with reduced systolic function leads to favorable left ventricular remodeling evident by an improvement in left ventricular systolic function and reduction of LVEDD.

scholarly journals Sacubitril-Valsartan for Heart Failure with Reduced Left Ventricular Ejection Fraction: A Retrospective Study

2017 ◽  
Author(s):  
Renato De Vecchis ◽  
Carmelina Ariano
Keyword(s):  
Heart Failure ◽  
Renal Function ◽  
Left Ventricular Ejection Fraction ◽  
Ejection Fraction ◽  
Beta Blocker ◽  
Conventional Therapy ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Worsening Renal Function

Introduction In sacubitril-valsartan (sacub/v), the effects of an angiotensin II receptor blocker (ARB) exerted by valsartan are strengthened by the addition of sacubitril, an inhibitor of neutral endopeptidases. PARADIGM - HF study proved&nbsp;&nbsp; this association to be superior to enalapril in reducing both all-cause death and cardiovascular mortality, as well as heart failure (HF) hospitalizations in patients with cardiac insufficiency and reduced left ventricular ejection fraction( HFREF) belonging to NYHA class II-IV. To test whether even in our experience sacub/v is associated with favorable outcomes concerning mortality and morbidity, an outpatient small population of HFREF patients was retrospectively studied, of whom one third was treated with sacub/v instead of conventional therapy with ACE -inhibitors or ARBs. Methods A retrospective cohort study was carried out to assess the effects of sacub/v in addition to beta-blocker and mineral receptor antagonist (MRA) in a group of HFREF patients in NYHA classes II-III compared with conventional therapy (comprising ACE inhibitor or ARB added to beta-blocker plus a MRA) administered in a second group of HFREF patients with comparable clinical features retrospectively enrolled as controls. In the two groups, the therapeutic regimen was established in accordance with the preferences of the treating physician. Additionally, in both groups, evidence-based drug therapy was&nbsp;&nbsp; supplemented by the adjunct of a loop diuretic, usually furosemide, at variable doses. The primary outcomes of interest were all-cause death and HF hospitalizations. Safety outcomes were symptomatic hypotension, angioedema, hyperkalemia and worsening renal function. Results Mortality at six months was 6.8% in patients under therapy with sacub/v versus 34% in those treated with conventional therapy (odds ratio[OR] = 0.14; 95% CI: 0.04-0.49). Moreover, HF hospitalizations in the observation period considered were 4.5% in sacub/v group versus 59% in the conventional therapy group (OR = 0.03; 95% CI: 0.01&ndash;0.14). Safety outcomes included in our study (angioedema, hyperkalemia, hypotension and worsening renal function) showed a comparable profile in the two groups, with evidence of good tolerability of sacub/v , except for the side - effect " hypotension" (PAS &lt; 100 mm Hg) , found in 15.9% of patients under sacub/v versus 5.7% reported in controls (OR = 3.14; 95% CI: 0.94&ndash;10.55). Conclusions In our experience, sacub/v has yielded a strong protection against both all-cause death and HF hospitalizations at six months , in the absence of significant noxious side effects. Nevertheless, considering the retrospective character of the study and the relatively exiguous sample size, further post marketing observational studies would be desirable . In particular, studies aiming at exploring safety of the new pharmacologic principle, namely mainly focusing on hypotension and angioedema, are warranted, in order to validate further this very efficacious molecule for therapy of chronic HF, especially stable HFREF in NYHA classes II-III.

Sign in / Sign up

Export Citation Format

Share Document