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.

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.

scholarly journals Clinical Outcomes in Patients with Ischemic versus Non-Ischemic Cardiomyopathy after Angiotensin-Neprilysin Inhibition Therapy

2021 ◽  
Vol 10 (21) ◽  
pp. 4989
Author(s):  
Mohammad Abumayyaleh ◽  
Christina Pilsinger ◽  
Ibrahim El-Battrawy ◽  
Marvin Kummer ◽  
Jürgen Kuschyk ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Ischemic Cardiomyopathy ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Tachyarrhythmias ◽  
Ventricular Ejection Fraction ◽  
One Year ◽  
The Impact

Background: The angiotensin receptor-neprilysin inhibitor (ARNI) decreases cardiovascular mortality in patients with chronic heart failure with a reduced ejection fraction (HFrEF). Data regarding the impact of ARNI on the outcome in HFrEF patients according to heart failure etiology are limited. Methods and results: One hundred twenty-one consecutive patients with HFrEF from the years 2016 to 2017 were included at the Medical Centre Mannheim Heidelberg University and treated with ARNI according to the current guidelines. Left ventricular ejection fraction (LVEF) was numerically improved during the treatment with ARNI in both patient groups, that with ischemic cardiomyopathy (n = 61) (ICMP), and that with non-ischemic cardiomyopathy (n = 60) (NICMP); p = 0.25. Consistent with this data, the NT-proBNP decreased in both groups, more commonly in the NICMP patient group. In addition, the glomerular filtration rate (GFR) and creatinine changed before and after the treatment with ARNI in both groups. In a one-year follow-up, the rate of ventricular tachyarrhythmias (ventricular tachycardia and ventricular fibrillation) tended to be higher in the ICMP group compared with the NICMP group (ICMP 38.71% vs. NICMP 17.24%; p = 0.07). The rate of one-year all-cause mortality was similar in both groups (ICMP 6.5% vs. NICMP 6.6%; log-rank = 0.9947). Conclusions: This study shows that, although the treatment with ARNI improves the LVEF in ICMP and NICMP patients, the risk of ventricular tachyarrhythmias remains higher in ICMP patients in comparison with NICMP patients. Renal function is improved in the NICMP group after the treatment. Long-term mortality is similar over a one-year follow-up.

scholarly journals Profile of Hospitalized Hypertensives with Preserved and Reduced Left Ventricular Ejection Fraction in Nigeria

2019 ◽  
Vol 14 ◽  
Author(s):  
Akinsanya Daniel Olusegun-Joseph ◽  
Kamilu M Karaye ◽  
Adeseye A Akintunde ◽  
Bolanle O Okunowo ◽  
Oladimeji G Opadijo ◽  
...  
Keyword(s):  
Heart Failure ◽  
Left Ventricular Ejection Fraction ◽  
Ejection Fraction ◽  
Left Ventricular ◽  
Ventricular Ejection ◽  
Teaching Hospitals ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Hypertensive Patients ◽  
The Impact

Introduction The impact of preserved and reduced left ventricular ejection fraction (LVEF) has been well studied in heart failure, but not in hypertension. We aimed to highlight the prevalence, clinical characteristics, comorbidities and outcomes of hospitalized hypertensives with preserved and reduced LVEF from three teaching hospitals in Nigeria. Methods: This is a retrospective study of hypertensives admitted in 2013 in three teaching hospitals in Lagos, Kano and Ogbomosho, who had echocardiography done while on admission. Medical records and echocardiography parameters of the patients were retrieved and analyzed. Results: 54 admitted hypertensive patients who had echocardiography were recruited, of which 30 (55.6%) had reduced left ventricular ejection fraction (RLVEF), defined as ejection fraction <50%; while 24 (44.4%) had preserved left ventricular ejection fraction (PLVEF). There were 37(61.5%) females and 17 (31.5%) males. Of the male patients 64.7% had RLVEF, while 35.3% had PLVEF. 19(51.4%) of females had RLVEF, while 48.6% had PLVEF. Mean age of patients with PLVEF was 58.83±12.09 vs 54.83± 18.78 of RLVEF; p-0.19. Commonest comorbidity was Heart failure (HF) followed by stroke (found among 59.3% and 27.8% of patients respectively). RLVEF was significantly commoner than PLVEF in HF patients (68.8% vs 31.3%; p- 0.019); no significant difference in stroke patients (46.7% vs 53.3%; p-0.44). Mortality occurred in 1 (1.85%) patient who had RLVEF.         Conclusion: RLVEF was more common than PLVEF among admitted hypertensive patients; they also have more comorbidities. In-hospital mortality is, however, very low in both groups.

Comparison of the prognosis and outcome of heart failure with reduced ejection fraction patients treated with sacubitril/valsartan according to age

2021 ◽  
Author(s):  
Mohammad Abumayyaleh ◽  
Ibrahim El-Battrawy ◽  
Marvin Kummer ◽  
Christina Pilsinger ◽  
Katherine Sattler ◽  
...  
Keyword(s):  
Heart Failure ◽  
Chronic Heart Failure ◽  
Ejection Fraction ◽  
Older Patients ◽  
Left Ventricular ◽  
Adult Patients ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
Reduced Ejection Fraction ◽  
The Impact

The treatment with sacubitril/valsartan in patients suffering from chronic heart failure with reduced ejection fraction increases left ventricular ejection fraction and decreases the risk of sudden cardiac death. We conducted a retrospective analysis regarding the impact of age differences on the treatment outcome of sacubitril/valsartan in patients with chronic heart failure with reduced ejection fraction. Patients were defined as adults if ≤65 years (n = 51) and older if >65 years of age (n = 76). The incidence of ventricular arrhythmias at 1-year follow-up was comparable in both groups (30.8 vs 26.5%; p = 0.71). The mortality rate in adult patients is significantly lower as compared with older patients (2 vs 14.5%; log-rank = 0.04). Older patients may suffer remarkably more side effects than adult patients (21.1 vs 11.8%; p = 0.03).

scholarly journals Are we aiming for different metabolic targets in heart failure patients?

2020 ◽  
Vol 41 (Supplement_2) ◽  
Author(s):  
J Brito ◽  
J.R Agostinho ◽  
C Duarte ◽  
B Silva ◽  
S Pereira ◽  
...  
Keyword(s):  
Heart Failure ◽  
High Risk ◽  
Ejection Fraction ◽  
Cardiovascular Events ◽  
Cox Regression ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Ventricular Ejection Fraction ◽  
The Impact ◽  
Very High

Abstract Introduction Metabolic control plays an important role on major cardiovascular events (MACE) prevention. The 2019 ESC guidelines on dyslipidaemia management recommend tighter LDL-cholesterol (LDL-C) control in order to prevent cardiovascular events. However, it is not yet proven that thigh control of dyslipidaemia, glycaemic levels and body mass index (BMI) in Heart Failure (HF) patients (pts) have an impact on prognosis. Objective To evaluate the impact of LDL-C, HbA1c and BMI values on HF pts mortality and MACE rates. Methods Single centre study that included consecutive pts hospitalized for acute / decompensated chronic HF in a tertiary Hospital between January 2016 to December 2018 and followed for 12 months. The impact of LDL-C, HbA1c and BMI on mortality and MACE was assessed using Cox regression and Kaplan-Meier curve, after adjustment for age, sex, functional class and ejection fraction. A safety cut-off was established when any of these variables was deemed protective using ROC curve analysis. Results Two hundred twenty-four patients (71.68±13.45 years, 63.8% males) were included. Eighty-four (37.5%) pts had type 2 diabetes, 39.7% had ischemic heart disease and the median left ventricular ejection fraction was 34% (IQR 25–49.5; 60.3% HFrEF; 13.8% HFmrEF; 22.3% HFpEF). The median BMI was 25.4 kg/m2 (IQR 23.1–30.5), HbA1c, 6.4% (IQR 5.6–6.8) and LDL-C, 89.5 mg/dL (IQR 64–106); 145 (64.7%) pts were medicated with statins. The overall mortality and MACE rates during follow-up were 16.1% and 21.0%, respectively. According to the CV risk classification 39.7% pts were at very high risk and 19.6% pts at high risk. On multivariate analysis HbA1c (HR 1.5 IQR 1.1–1.9; p=0.007) and female sex (HR 9.453 IQR 2.4–37.2; p=0.001) were independent predictors of mortality, whereas LDL-C (OR 1.05 IQR 1.022–1.075; p&lt;0.001) and BMI (OR 1.23 IQR 1.075–1.404; p=0.002) were independent protective factors. LDL-C and BMI had no effect on MACE rates, although HbA1c was an independent predictor of MACE (HR 1.27 IQR 1.03–1.57; p=0.026). For high and very high-risk pts there was still a protective trend on mortality, although non-significant, for higher levels of LDL-C (OR 1.04 IQR 0.99–1.075; P=NS). Protective LDL-C cut-off were estimated for the whole population (LDL-C 88mg/dL; AUC 0.819; sn 56.6%, sp 100%) and for the high and very-high CV risk pts (LDL-C 84mg/dL; AUC 0.815; sn 59.3%; sp 100%). A BMI safety cut-off for mortality of 25.75 kg/m2 was found (AUC 0.627; sn 61.2%; sp 58.3%). Conclusion This study supports the theory of the obesity and LDL-C paradox in HF. Lower LDL-C and BMI increased mortality and there is no trade-off effect on MACE rates, supporting the idea that LDL-C and BMI should not be aggressively addressed in HF pts. In our cohort a cut-off level of LDL-C below 88mg/dL is associated with higher mortality. On the other hand, diabetes should be actively treated as HbA1c predicts death and MACE in HF pts. Funding Acknowledgement Type of funding source: None

scholarly journals Prevalence and outcome of cardiac amyloidosis in an all-comer population of patients with non-ischaemic heart failure

2021 ◽  
Vol 42 (Supplement_1) ◽  
Author(s):  
S Goebel ◽  
S Schwuchow-Thonke ◽  
O Hahad ◽  
M Brandt ◽  
U Von Henning ◽  
...  
Keyword(s):  
Heart Failure ◽  
Ejection Fraction ◽  
Cardiac Amyloidosis ◽  
Troponin I ◽  
Left Ventricular ◽  
Left Ventricular Ejection ◽  
Unknown Etiology ◽  
Ventricular Ejection Fraction ◽  
All Cause Mortality ◽  
The Impact

Abstract Background Cardiac amyloidosis (CA) is increasingly recognized as an underlying cause of heart failure with preserved ejection fraction (HFpEF), associated with high morbidity and mortality. However, most studies, solely investigated the prevalence of CA in special subgroups including HFpEF and severe aortic valve disease. Purpose With the present study we sought to investigate prevalence of different phenotypes of CA in an all comer-population of patients with non-ischaemic heart failure (HF) and to analyze the impact of CA on all-cause mortality. Methods The My Biopsy HF-Study (German clinical trials register number: 22178) is a retrospective monocentric study investigating the underlying etiology of HF in an all-comer population of patients with HF of unknown etiology. Patients presenting with symptoms of HF at the University Medical Centre between 14/10/2012 and 01/03/2021, who underwent endomyocardial biopsy (EMB) were enrolled in the present study. Ischaemic HF and valvular HF were ruled out prior to EMB. Specimens were sent for further examination to a specialized laboratory approved by the Food and Drug Administration Results Between October 2012 and March 2021, 767 patients (71.6% men) with HF of unknown etiology were included. Mean age at the time of presentation was 55.4 years (±14.4). Altogether, 72.5% of the patients presented with HF with reduced ejection fraction (HFrEF), 7.1% were diagnosed with HF with mid-range ejection fraction (HFmrEF) and 20.4% with HFpEF. Based on histological examination and genotyping, CA was diagnosed in 44 (5.7%) patients (immunglobulin light chain [AL] CA: 15 patients; variant transthyretin [ATTRv] CA: 6 patients; wild type transthyretin [ATTRwt] CA: 21 patients; de novo CA: 2 patients). Patients with CA were older compared with patients without CA (69.4±11.4 vs. 54.1±14.5; p&lt;0.0001), had a higher prevalence of arterial hypertension (68.2% vs. 50.9%; p=0.045) and showed a better left ventricular ejection fraction based on echocardiographic examination (47.5% vs. 32.6%; p&lt;0.0001). With respect to biomarker expression, levels of both brain natriuretic peptide and high-sensitive troponin I were significantly higher in patients without CA (BNP: 914.1 vs 612; p=0.01; troponin I: 812.8 vs. 171.7; p=0.006). In univariate logistic regression analysis CA was associated with a significant all-cause mortality (hazard ratio [HR] per unit increase [ui], 5.17, 95% CI, 2.93–9.08; p&lt;0.0001), even after adjustment for classical cardiovascular risk factors (HRperui 3.12, 95% CI, 1.11–8.76; p=0.03) and comorbidities like chronic obstructive pulmonary disease, chronic kidney disease and stroke (HRperui 2.93, 95% CI, 1.2–7.15; p=0.018). Conclusions Among patients presenting with HF of unknown etiology, including patients with HFpEF, HFmrEF and HFrEF, cardiac amyloidosis is the underlying cause of HF in 5.7% of patients and is independently associated with all-cause mortality. FUNDunding Acknowledgement Type of funding sources: None.

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.

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