Objective
Recent studies have reported suboptimal up-titration of heart failure (HF) therapies in patients with heart failure and a reduced ejection fraction (HFrEF). Here, we report on the achieved doses after nurse-led up-titration, reasons for not achieving the target dose, subsequent changes in left ventricular ejection fraction (LVEF), and mortality.
Methods
From 2012 to 2018, 378 HFrEF patients with a recent (< 3 months) diagnosis of HF were referred to a specialised HF-nurse led clinic for protocolised up-titration of guideline-directed medical therapy (GDMT). The achieved doses of GDMT at 9 months were recorded, as well as reasons for not achieving the optimal dose in all patients. Echocardiography was performed at baseline and after up-titration in 278 patients.
Results
Of 345 HFrEF patients with a follow-up visit after 9 months, 69% reached ≥ 50% of the recommended dose of renin-angiotensin-system (RAS) inhibitors, 73% reached ≥ 50% of the recommended dose of beta-blockers and 77% reached ≥ 50% of the recommended dose of mineralocorticoid receptor antagonists. The main reasons for not reaching the target dose were hypotension (RAS inhibitors and beta-blockers), bradycardia (beta-blockers) and renal dysfunction (RAS inhibitors). During a median follow-up of 9 months, mean LVEF increased from 27.6% at baseline to 38.8% at follow-up. Each 5% increase in LVEF was associated with an adjusted hazard ratio of 0.84 (0.75–0.94, p = 0.002) for mortality and 0.85 (0.78–0.94, p = 0.001) for the combined endpoint of mortality and/or HF hospitalisation after a mean follow-up of 3.3 years.
Conclusions
This study shows that protocolised up-titration in a nurse-led HF clinic leads to high doses of GDMT and improvement of LVEF in patients with new-onset HFrEF.
Patients with atherosclerotic CGI have an increased estimated CVD risk, and severe excess mortality. Secondary cardiovascular prevention therapy should be advocated in patients with CGI.
Chimpanzees (Pan troglodytes) build nests at night for sleeping and occasionally during daytime for resting. Over the course of seven years, forest fragments in Bulindi, Uganda, were reduced in size by about 80% when landowners converted forest to agricultural land. However, unlike other studies on nesting behavior in response to habitat disturbance, chimpanzees at Bulindi had no opportunity to retreat into nearby undisturbed forest. To understand behavioral adaptations to forest clearance, we compared Bulindi chimpanzees' nesting characteristics before and after this period of major deforestation. After deforestation, chimpanzees built nests at lower heights in shorter trees, and reused a larger proportion of their nests. Additionally, average nest group size increased after deforestation, even though community size declined by approximately 20% over the same period. The substantial decrease in available forest habitat may have caused the chimpanzees to aggregate for nesting. However, more cohesive nesting may also have been influenced by dietary shifts (increased reliance on agricultural crops) and a need for enhanced safety with increased human encroachment. Conversely, the chimpanzees selected similar tree species for nesting after deforestation, apparently reflecting a strong preference for particular species, nested less often in exotic species, and built integrated nests (constructed using multiple trees) at a similar frequency as before fragment clearance. Chimpanzees living in unprotected habitat in Uganda, as at Bulindi, face mounting anthropogenic pressures that threaten their survival. Nevertheless, our study shows that chimpanzees can adjust their nesting behavior flexibly in response to rapid, extensive habitat change. While behavioral flexibility may enable them to cope with deforestation, at least to a certain point, the long‐term survival of chimpanzees in fast‐changing human‐modified landscapes requires intensive conservation efforts.
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