Association of Guideline-Based Medical Therapy with Malignant Arrhythmias and Mortality among Heart Failure Patients Implanted with Cardioverter Defibrillator (ICD) or Cardiac Resynchronization-Defibrillator Device (CRTD)

Aim: Evaluate prevalence of heart failure (HF) medications and their association with ventricular arrhythmia (VA) and survival among patients implanted with primary prevention implantable cardiac defibrillator (ICD)/cardiac resynchronization therapy + defibrillator (CRTD) devices. Methods: Association of treatment and dose (% guideline recommended target) of beta-adrenergic receptor antagonist (BB), angiotensin-antagonists (AngA), and mineralocorticoid-antagonists (MRA), after ICD/CRTD implant with VA and mortality was retrospectively analyzed. Results: Study included 186 HF patients; 42.5% and 57.5% implanted with ICD and CRTD, respectively. During 3.8 (2.1;6.7) years; 52 (28%) had VA and 77 (41.4%) died. Treatment (% of patients) included: BB (83%), AngA (87%), and MRA (59%). Median doses were 25(12.5;50)% of target for all medications. BB treatment >25% target dose was associated with reduced VA incidence. In the multivariable model including age, gender, diabetes, heart rate, and medication doses, increased BB dose was associated with reduced VA (hazard ratio (HR) 0.443 95% CI 0.222–0.885; p = 0.021). In the multivariable model for overall mortality including age, gender, renal disease, VA, and medical treatment, VA was associated with increased mortality (HR 2.672; 95% CI 1.429–4.999; p = 0.002) and AngA treatment was associated with reduced mortality (HR 0.515; 95% CI 0.285–0.929; p = 0.028). Conclusions: In this cohort of real-life HF patients discharged after ICD/CRTD implant, prevalence of guideline-based HF medications was high, albeit with low doses. Higher BB dose was associated with reduced VA, while AngA was associated with improved survival.

Abstract 15483: A Clinic-based Intervention Achieves Target Doses of Guideline-directed Medical Therapy in Heart Failure

Introduction: Target doses of guideline-directed medical therapy (GDMT) reduce morbidity and mortality, and yet, are challenging to achieve in patients with heart failure and reduced ejection fraction (HFrEF). Long-term, relationship-based approaches are not well described. Methods: We implemented a person-centered approach in a nurse-managed multidisciplinary heart failure clinic. We used repeated measures analysis to prospectively evaluate patient satisfaction, appointment attendance, dose optimization of GDMT for renin-angiotensin inhibitors, beta-blockers (BB), mineralocorticoid antagonists (MRA), and anticoagulation, and ICD placement and cardiac rehab participation at 12 months. GDMT was scored 0-6, with one point for each guideline-indicated therapy. Composite scores were compared using ANOVA at baseline, 6-months, and 12-months. Results: Participants (n=102) were age 68 (± 14.95) years on average, predominantly white (95.1%), male (62.75%), and high school graduates (88.24%). At 12-months, the proportion of patients on ≥50% of target doses improved: renin-antiotensin inhibitors from 27% to 41%, beta-blockers from 46% to 64%, and MRA from 35% to 65%. Cardiac rehab attendance improved from 25% to 84%. Patient satisfaction with care improved; four (3.9%) patients did not attend scheduled follow-up in the 12-month period. Though overall composite scores of GDMT improved (F=51.74, p <0.001), only 12% of patients achieved target doses for all 3 medication classes concomitantly. No participants were readmitted within 30 days of HF-hospitalization; all-cause 30-day readmission was 10.5%. Conclusion: A persistent patient-provider relationship and person-centered approach to HF management may improve GDMT.

COVID-19, ACE2, and the cardiovascular consequences

The novel SARS coronavirus SARS-CoV-2 pandemic may be particularly deleterious to patients with underlying cardiovascular disease (CVD). The mechanism for SARS-CoV-2 infection is the requisite binding of the virus to the membrane-bound form of angiotensin-converting enzyme 2 (ACE2) and internalization of the complex by the host cell. Recognition that ACE2 is the coreceptor for the coronavirus has prompted new therapeutic approaches to block the enzyme or reduce its expression to prevent the cellular entry and SARS-CoV-2 infection in tissues that express ACE2 including lung, heart, kidney, brain, and gut. ACE2, however, is a key enzymatic component of the renin-angiotensin-aldosterone system (RAAS); ACE2 degrades ANG II, a peptide with multiple actions that promote CVD, and generates Ang-(1–7), which antagonizes the effects of ANG II. Moreover, experimental evidence suggests that RAAS blockade by ACE inhibitors, ANG II type 1 receptor antagonists, and mineralocorticoid antagonists, as well as statins, enhance ACE2 which, in part, contributes to the benefit of these regimens. In lieu of the fact that many older patients with hypertension or other CVDs are routinely treated with RAAS blockers and statins, new clinical concerns have developed regarding whether these patients are at greater risk for SARS-CoV-2 infection, whether RAAS and statin therapy should be discontinued, and the potential consequences of RAAS blockade to COVID-19-related pathologies such as acute and chronic respiratory disease. The current perspective critically examines the evidence for ACE2 regulation by RAAS blockade and statins, the cardiovascular benefits of ACE2, and whether ACE2 blockade is a viable approach to attenuate COVID-19. Listen to this article’s corresponding podcast at: https://ajpheart.podbean.com/e/covid-19-ace2-and-the-cardiovascular-consequences/ .