Heartfailure risks associated with several DPP4 inhibi- tors have been assessed in randomized clinical trials, meta-analyses, and observational studies, producing con- flicting results ranging from reduced risk [3, 17, 18], to no risk [7, 9, 11, 12, 30–32], to high risk [8, 16, 30, 33– 35] of heartfailure. Such discrepant findings may have stemmed primarily from different comparator groups across these studies as well as differences in study design and population selection. For this very reason, it was dif- ficult to make a head-to-head comparison of our results with those previous studies. However, it is noteworthy that no prior studies directly compared DPP4 inhibitors with SGLT2 inhibitors, and our finding that at a class level DPP4 inhibitors are associated with higher risk of heartfailurehospitalization than SGLT2 inhibitors will be an important addition to the literature.
Cardiac resynchronization therapy (CRT) is an estab- lished treatment for patients with symptomatic HF and reduced left ventricular ejection fraction (LVEF). 5–7 Randomized, controlled clinical trials have consistently demonstrated a bene ﬁ t in mortality, reduction in heartfailurehospitalization (HFH), and symptomatic improvement. 8–10 Although CRT has proven to be bene- ﬁ cial, not all patients respond to CRT, with nearly one- third of patients being classi ﬁ ed as non-responders due to failure to respond symptomatically and/or lack of ventri- cular reverse remodeling. 11,12 Failure to respond results in progression of HF, worsening of symptoms, increased hospitalization for HF, and increased mortality. 13 Reasons for suboptimal response include both patient factors, such as arrhythmia, scar burden, lead location, and QRS mor- phology and duration as well as device factors, such as suboptimal atrioventricular (AV) timing and <90% biven- tricular (BiV) pacing. 14 Maintaining delivery of CRT pacing is essential to these bene ﬁ ts, as even <10% reduc- tions in pacing percentage have been shown to reduce survival bene ﬁ t. 15–17 In addition, ventricular pacing per- centage as recorded by the device may not be an accurate index of consistent capture of the myocardium, which is required for effective pacing. The hOLter for Ef ﬁ cacy analysis (OLE) CRT study showed that the average percent ventricular (%V) pacing as reported by the device signi ﬁ - cantly overestimated the percent effective CRT (%e-CRT) pacing that captured the myocardium (94.8% vs 87.5%, P<0.001). 18 A signi ﬁ cant minority of subjects (18%) had a discrepancy of at least 3% points between the device recorded %V pacing and the %e-CRT pacing (mean 39% ±41%). When patients receive suboptimal CRT, more adverse events would be expected to increase the cost of care, primarily through increased hospitalizations. We sought to determine the impact of maximizing effective pacing delivery on HF hospitalizations and associated health-care expenditures from the US payer perspective.
This study evaluated the risk of heartfailurehospitalization in a 1:1 matched pair sample of sitagliptin ever and never users derived from the Taiwan’s National Health Insurance. A total of 85,859 ever users and 85,859 never users matched on 8 digits of propensity score were followed for the first event of heartfailurehospitalization until December 31, 2011. The treatment effect (forever versus never users, and for tertiles of cumulative duration of therapy) was estimated by Cox regression incorporated with the inverse probability of treatment weighting using propensity score. Additionally, adjusted hazard ratios for heartfailure were estimated for the baseline characteristics in sitagliptin ever users. Results showed that the incidence of heartfailurehospitalization was 1,020.16 and 832.54 per 100,000 person- years, respectively, for ever and never users, with an overall hazard ratio (95% confidence intervals) of 1.262 (1.167-1.364). While compared to never users, the respective hazard ratio for the first, second, and third tertile of cumulative duration < 3.7, 3.7-10.3 and >10.3 months was 2.721 (2.449-3.023), 1.472 (1.318-1.645) and 0.515 (0.447-0.594). Older age, longer diabetes duration, male sex, and use of insulin, sulfonylurea, calcium channel blockers, aspirin, ticlopidine, clopidogrel and dipyridamole were significantly associated with a higher risk in sitagliptin users, but dyslipidemia and use of metformin and statin were protective. In conclusion, sitagliptin increases the risk of heartfailurehospitalization within one year of its use, but reduces the risk thereafter. Some factors predisposing to sitagliptin-related heartfailure are worthy of attention in clinical practice.
Cardiac resynchronization therapy (CRT) has been shown to improve symptoms, increase exercise capacity, de- crease heartfailurehospitalization and decrease mortality in patients with New York Heart Association (NYHA) class 3/4 with depressed systolic function and a pro- longed QRS [1-3]. However, 20% - 30% of patients who receive CRT therapy do not show significant clinical im- provement [4-6]. As a result there has been intense in- vestigation to develop non invasive parameters to predict CRT response [7-9]. While mechanical dyssynchrony assessed in the longitudinal axis of myocardial motion was shown to be predictive in single center trials [7-10]. The multi-center PROSPECT trial failed to identify any echocardiographic dyssynchrony criteria to predict re- sponders better than clinical criteria . Speckle track- ing radial strain from routine gray scale 2D echocardio- graphic images has been proposed to quantify dyssyn- chrony and to predict immediate and long term response to CRT .
Methods and Results- — FS was assessed using a modi ﬁ ed Rosow-Breslau questionnaire administered during routine annual telephone interviews conducted from 1993 through 2007 among 15 277 ARIC study participants. An FS score was constructed as a summary measure of responses to questions about participants ’ ability to perform selected tasks of daily living (eg, walking half a mile, climbing stairs). Incidence of CVD was assessed through ARIC surveillance of hospitalized events. Rate of change in FS over time prior to and following a CVD event was examined using generalized estimating equations. A decline in FS was observed on average 2 years prior to a myocardial infarction hospitalization and on average 3 years prior to a stroke or heartfailurehospitalization. FS post – myocardial infarction declined relative to pre-event levels but improved to close to pre – myocardial infarction levels within 3 years. Decline in FS following incident heartfailure and stroke remained over time. Observed patterns of change in FS did not differ appreciably by race or sex.
The results of cardiovascular death, non-fatal myocardial infarction, non-fatal stroke and hospitalization of con- gestive heartfailure, and the composite event---MACE were presented in Table 3 and Additional file 1: Table S1-S4. Only hospitalization of congestive heartfailure was demonstrated a statistically significant with regard to different levels of ACR, especially in high and low levels of ACR, since patients who had the medium level of ACR (10 to 30 mg/g) were scarce. In unadjusted models, the HR of higher levels of ACR (> 30 mg/g) was nearly 3-fold of the reference ACR (HR 2.95, 95%CI 1.46–5.96, p = 0.003). After being adjusted, the strength of the association was exaggerated (HR 4.58, 95%CI 1.78–11.76, p = 0.007). In patients below the age of 65, compared with lower level of ACR (< 10 mg/g), ACR levels of > 30 mg/g were associated with around 11-fold independent risk of heartfailurehospitalization (HR 11.22, p = 0.033). While the risk reduced to nearly 6-fold in patients above the age of 65 (HR 5.85, p = 0.002).
pulmonary hypertension(2) (Tables 1 and 2). The favorable effects of phosphodiesterase - 5 ( PDE5) inhibitors, in particular sildenafil, in the treatment of pulmonary hypertension are mainly attributed to the action exerted on the pulmonary arteriolar -precapillary district ( so-called “precapillary pulmonary selectivity” of PDE5 inhibitors)(3-4). In other words, the benefit of PDE5i in treating heartfailure may originate from its hemodynamic effect for the combined post- and pre-capillary PH (Cpc-PH), but not for the isolated postcapillary PH (Ipc-PH)(5).
not require hospitalization has not been fully evaluated. Furthermore, due to the unavailability of data, HF sub- type according to ejection fraction was not differentiated while a recent study suggests that obesity and related cardiometabolic traits including insulin resistance are more strongly associated with risk of incident HF with preserved versus reduced ejection fraction (HFpEF ver- sus HFrEF) . Despite these limitations, our study has major strengths. We used a validated nationwide cohort database representing the Korean population provided by the Korean government. The KNHIS database, which was used in the current study, includes the lifestyle and laboratory data of a large sample, enabling adjustment for diverse confounding factors.
Hjalmarson et al., 2000; Jamali, Tang, Khot, & Fowler, 2001; Packer et al., 1996; Packer et al., 2001; Pitt et al., 1999), diagnostic and invasive (Guru et al., 2007; Udell et al., 2007) procedures, likely extend to patients in the early stages of HF by treating risk factors and preventing or slowing progressive changes in heart structure and function. The prescription of HF therapies such as angiotensin converting enzyme (ACE) inhibitors, beta (β)-blockers, diuretics and digoxin are supported by the AHA/ACC and European Society of Cardiology guidelines, as are certain diagnostic and invasive procedures (Hunt et al., 2001; Remme & Swedberg, 2002). However, in the Initiation Management Predischarge process for Assessment of Carvedilol Therapy for HeartFailure (IMPACT-HF) registry, in 30 US hospitals, 60-day death or rehospitalization exceeded 30%, despite the use of evidence-based therapies, such as ACE inhibitors, digoxin and β-blockers (O'Connor, Stough, Gallup, Hasselblad, & Gheorghiade, 2005). Thus, there exists a need to exploe other factors which may influence the progression of HF, such as sociodemographic and SES variables.
Methods: Hospice utilization (mean days on hospice per decedent) for 2012 from the Dartmouth Atlas (a project of the Dartmouth Institute that reports a variety of public health and policy-related statistics) was merged with hospital- level 30-day mortality and readmission rates for pneumonia and heartfailure from CMS. The association between hospice use and outcomes was analyzed with multivariate quantile regression controlling for quality of care metrics, acute care bed availability, regional variability and other measures.
Chronic heartfailure is a dynamic situation rather than a steady-state condition and, as heart function changes, many patients develop exacerbations. Many clinical features have been shown to have prognostic significance in patients. For example, severity of symptoms, exercise capacity, haemodynamics, plasma hormone concentrations such as noradrenaline, renin activity and B-type natriuretic peptide (BNP) are all indicative in terms of prognosis.
Heartfailure (HF) has been recognized as a pandemic and is a serious clinical and health problem associated with significant mortality, morbidity and expenditure on healthcare, especially among older people. Progress in medicine has made it possible for an increasing number of people with HF to live longer than ever before. Therefore, a new and serious clinical problem has appeared – advanced heartfailure (AHF). A better under- standing of this issue is very important, because there are many more patients waiting for transplantations than there are available hearts. The role of the medical team is to keep the patient in the best condition until the heart transplant/implantation of left ventricular assist devices or at least to ensure the best possible quality of life. This article reviews the available data on AHF. The authors have succinctly presented different definitions and methods of the AHF diagnosis established by medical societies, as well as epidemiological data, methods of assessment, and possible treatment strategies.
measures with illness and demographics, which subse- quently alter prescribing practices and outcomes. 11 12 44 KPI for depression were expanded, as a high burden was noted in CASPA, this also being a signi ﬁ cant factor in many dimensions of self-care and compliance. In hos- pital, discharge and outpatient indicators were designed to re ﬂ ect the potential blocks to maximising proven pharmacological prescription and access to cardiac rehabilitation; at the core of these were reasons for non- prescription or subtherapeutic prescription. The actual speciﬁcs on medication titration across all domains were rested. It is noted that care and resources are needed to titrate many variables in CHF care, for example, ββ and ACE-I (see online supplementary appendix E, F). This information can be extrapolated from frequency of contact with medical practitioner and central pharmacy prescription slips. Appropriate early therapeutics—to prevent further heart muscle damage, good symptom relief and minimising iatrogenic adverse effects such as renal dysfunction and electrolyte derangements are within the control of the health systems and builds client con ﬁ dence, and are considered vital. Domain 6: overall, we felt, in the community, that the greatest value in the Figure 4 Performance measures within each treatment dimensions divided into mild and moderate or greater acute
Days alive and free from mechanical ventilation, renal replacement therapy, or vasopressors (i.e., organ failure free days) has also been proposed. These endpoints are clinically meaningful, and widespread use of the Surviv- ing Sepsis Campaign guidelines has led to more consist- ent timing and application of life support interventions. Nonetheless, the decision to institute supportive therap- ies is often subjective and can be influenced by external factors (e.g., reimbursement incentives, interactions of various medical specialists (e.g., intensivists and nephrol- ogists)), which introduces increased variability (i.e., ran- dom noise) in the study and possibly bias if the study is not blinded. Other complex issues also warrant consid- eration, including whether patients value more event- free days equally regardless of when they occur (e.g., moving from 0 to 1 day is the same/better/worse than moving from 29 to 30 days), handling inclusion of mul- tiple organs (i.e., are all organs of equal value or should failure in some organs be weighted more heavily than others), and methodology to account for pre-existing organ dysfunction. Interventions can be effective in preventing organ dysfunction (in patients who do not have organ dysfunction) and/or preventing progression of organ dysfunction (in patients who already have some degree of organ dysfunction). An adequate organ dys- function scoring system must capture both of these possibilities.
Coenzyme Q10 (CoQ10) is present naturally in the body. It works as an electron carrier in the mitochondria to produce energy and is also a powerful antioxidant . In the heart muscle of patients with HF, CoQ10 levels are decreased and the deficiency becomes more pronounced when the severity of HF get worsen . Cholesterol lowering drugs statins used in patients with HF also block the synthesis of CoQ10, which further decreases its levels in the body . In several double blind controlled trials CoQ10 was able to improve symptoms, quality of life (QOL) and functional capacity in patients with heartfailure without any side effects . CoQ10 blocks the vicious metabolic cycle in chronic heartfailure. CoQ10 is present in food, including plants and fish, but levels are not enough to make an impact on HF. It is the first drug to improve heartfailure related deaths in over a decade .
Agreement between the FCU and reference method was estimated, with a cut-off at LVEF < 50%. Heartfailure cri- teria and classification were based on the results from the reference examinations and NT-proBNP levels. HF in study patients was classified according to the 2016 ESC Guidelines : “Heartfailure with reduced ejection frac- tion (HFrEF): Patients with LVEF <40%. Heartfailure with mid-range ejection fraction (HFmrEF): Patients with LVEF 40% to 49%, NT-proBNP > 125 ng/L, and at least one additional criterion: Signs of relevant structural heart dis- ease (LVH and/or LAE), or diastolic dysfunction. Heartfailure with preserved ejection fraction (HFpEF): Patients with LVEF ≥50%, NT-proBNP > 125 ng/L, and at least one additional criterion: Signs of relevant structural heart disease (LVH and/or LAE), or diastolic dysfunction, (LVH= left ventricular hypertrophy; LAE= left atrial en- largement; diastolic dysfunction = assessment through conventional ultrasound examination incorporating rele- vant two-dimensional and Doppler data)”.
Background and Aim: The absence of data in our context motivates this study aiming to determine the frequency of AHF at the ICU, assess the in-hospital evolution of the disease and to find out poor prognosis. Material and Methods: It was an observational and descriptive study covering the time from January 1, 2014 to March 30, 2017 involving all inpatient records in ICU. From January 2014 to December 2017, collected data included those on socio-demographic, history of diseases and physical examination, and some labor data including Pro BNP, serum creatinine, blood ionogram, cardiac enzymes and blood count. Also data electrocardiography, echocardiography and in-hospital evolution were collected. Statistical Analysis: Statistical analysis was performed using SPSS (IBM Inc) version 18. Results: AHF occured in 47.36% with a mean age of 58.74 ± 18.407 and extremes of 17 and 90 years, women representing 53.1% (sex ratio Male:Female = 0.88). Hypertension and diabetes were the predominant cardiovascular risk factors with respectively 67.4% and 18.4%. At admission 44%, 37.7% and 17.9% of patients were respectively hypertensive, normotensive and hypotensive. The clinical expression was mainly global heartfailure with 42.6% followed by left heartfailure and right heartfailure with respectively 37% and 20.4%. The coronary syndromes (all forms) was the first cause of ICA with 34% of cases followed by pulmonary embolism and hypertension with respectively 25.3% and 24.1%. Mean hospital stay was How to cite this paper: Youssouf, C.,
failure. In diastolic heartfailure, however, β-blockers are used to decrease heart rate, increase the duration of diastole, and modify the hemodynamic response to exercise. In systolic heartfailure, β-blockers are used chronically to increase inotropic state and modify LV remodeling. In systolic heartfailure, β-blockers must be titrated slowly and carefully over an extended time period. This is generally not necessary in diastolic heartfailure. Diuretics are used in the treatment of both systolic and diastolic heartfailure. However, the doses of diuretics used to treat diastolic heartfailure are generally smaller than the doses used in systolic heartfailure. Some drugs are used only to treat either systolic or diastolic heartfailure but not both. For example, calcium channel blockers such as diltiazem, nifedipine, and verapamil have no place in the treatment of systolic heartfailure. By contrast, each of these has been proposed as being useful in the treatment of diastolic heartfailure.
The study population was identified among patients with a first ever HF hospitalization in the period from 2008 to 2014. Patients were required to have a primary or a second- ary discharge diagnosis of HF and to be alive at discharge. Patients with a HF hospitalization before 2008 were excluded, as were patients and comparison subjects who had received domiciliary care or were living in a nursing home prior to study inclusion. Each patient entered the study on their date of discharge and was individually matched with five com- parison subjects from the general population based on age and sex. All comparison subjects had to be born in the same year and were included from the same date as their matched patient. Five comparison subjects were used to minimize the bias introduced with the matching. Both groups were followed until an outcome of interest occurred, death, for a maximum of 5 years or until end of study (December 31, 2015). Comorbidities were identified by hospital discharge codes in a 10-year period prior to first HF hospitalization. Diabetes mellitus was additionally identified by at least one filled prescription for a glucose lowering drug in the 6 months prior to the first HF hospitalization. Ongoing use of medica- tion was defined by at least one filled prescription of the drug in the preceding 6 months or 7 days after being discharged but was not included in the adjusted Cox regression analyses. To assess whether it was merely the hospitalization in itself and not necessarily the diagnosis of HF which explained the associations with the outcomes of interest, we conducted two sensitivity analyses in an attempt to identify potential detec- tion bias associated with hospitalizations in general: first, we included patients diagnosed with HF in an outpatient clinic, with no previous hospitalization for HF, rather than at time of first hospitalization and compared them to comparison subjects from the general population and, secondly, we used an active comparison group of patients undergoing knee replacement, as these patients are hospitalized and there is a focus on their ability to manage at home after discharge.