Clinical Course of Patients With Worsening Heart Failure With Reduced Ejection Fraction

Butler, Javed; Yang, Mei; Manzi, Massimiliano Alfonzo; Hess, Gregory P.; Patel, Mahesh J.; Rhodes, Thomas; Givertz, Michael M.

doi:10.1016/j.jacc.2018.11.049

Cited by 187 publications

(196 citation statements)

References 21 publications

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“…For example, in contrast to the CAT, DEFINITE and DANISH trials, we did not exclude patients with valvular disease, those on anti-arrhythmics, or permanent atrial fibrillation patients, respectively (23, 25,26). Increased mortality in our patient cohort may also be related to heart failure progression in our cohort or the type and severity of comorbidities (27). Cardiovascular disease, for example, is responsible for 30% more hospitalizations in outer regional and rural centers than urban centers.…”

Section: Mortality Was Higher In Regional North Queenslandmentioning

confidence: 99%

Primary Prevention Implantable Cardiac Defibrillators: A Townsville District Perspective

Engstrom

Dobson

et al. 2020

Front. Cardiovasc. Med.

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Background: Despite major advances in treating patients with severe heart failure, deciding who should receive an implantable cardiac defibrillator (ICD) remains challenging. Objective: To study the risk factors and mortality in patients after receiving an ICD (January 2008-December 2015) in a regional hospital in Australia. Methods: Eighty-two primary prevention patients received an ICD for ischemic cardiomyopathy (ICM, n = 41) and non-ischemic cardiomyopathy (NICM, n = 40) with 4.8-yrs follow-up. One patient had mixed ICM/NICM indications. Ventricular arrhythmias were assessed using intracardiac electrograms. Statistical analysis compared the total population and ICM and NICM groups using Kaplan-Meier for survival, Cox regression for mortality predictors, and binary logistic regression for predictors of ventricular arrhythmias (p < 0.05). Results: Major risk factors were hypercholesterolemia (70.7%), hypertension (47.6%), and obesity (41.5%). Severe obstructive sleep apnea (OSA) was found exclusively in NICM patients (23.7%, p = 0.001). Mortality was 30.5% after 4.8-yrs. The majority of patients (n=67) had no sustained ventricular arrhythmias yet 28% received therapy (n = 23), 18.51% were appropriate (n = 15), and 13.9% inappropriate (n = 11). Patients receiving ≥2 incidences of inappropriate shocks were 18-times more likely to die (p = 0.013). Three sudden cardiac deaths (SCD) (3.7%) were prevented by the ICD. Conclusion: Patients implanted with an ICD in Townsville had 30.5% all-cause mortality after 4.8-yrs. Only 28% of patients received ICD therapy and 13.9% were inappropriate. OSA may have contributed to the fourfold increase in inappropriate therapy in NICM patients. Our study raises important efficacy, ethical and healthcare cost questions about who should receive an ICD, and possible regional and urban center disparities.

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Section: Mortality Was Higher In Regional North Queenslandmentioning

confidence: 99%

Primary Prevention Implantable Cardiac Defibrillators: A Townsville District Perspective

Engstrom

Dobson

et al. 2020

Front. Cardiovasc. Med.

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“…8 In the PINNACLE HF study, one out of six patients with 'chronic stable' HFrEF developed clinical worsening within 18 months of HF diagnosis and had a higher risk for 2 year mortality and recurrent HF hospitalizations. 10 The use of standard-of-care therapies both before and after the onset of worsening HF was low, with a great proportion of patients receiving monotherapy. 10 Clinical trial data suggest that the elevated mortality risk persists for at least 90 days after an admission for HF in patients with HFrEF.…”

Section: Challenges In the Definition Of Clinical Stability And Symptmentioning

confidence: 99%

“…10 The use of standard-of-care therapies both before and after the onset of worsening HF was low, with a great proportion of patients receiving monotherapy. 10 Clinical trial data suggest that the elevated mortality risk persists for at least 90 days after an admission for HF in patients with HFrEF. 11 However, neither the absence of a prior HF hospitalization nor a mildly symptomatic status can ensure clinical stability.…”

Section: Challenges In the Definition Of Clinical Stability And Symptmentioning

confidence: 99%

“…symptomatic patient with HFrEF continues to experience considerable hospitalizations and mortality burden, 10,12,13 with sudden cardiac death being the most prevalent mode of death, while death from worsening HF rises as symptoms worsen. 28 Whether sudden cardiac death represents the main mode of death for both ischaemic and non-ischaemic mildly symptomatic systolic HF patients remains unclear.…”

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confidence: 99%

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Mildly symptomatic heart failure with reduced ejection fraction: diagnostic and therapeutic considerations

et al. 2020

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Aims Whereas up to about half of patients with heart failure with reduced ejection fraction (HFrEF) report no or only mild symptoms and are considered as clinically stable, the progressive nature of HFrEF, often silent, renders clinical stability a misleading situation, especially if disease progression is unrecognized. We highlight the challenges in the definition of clinical stability and mild symptomatic status in HFrEF, outline clinical characteristics and available diagnostic tools, and discuss evidence and gaps in the current guidelines for the management of these patients. Methods and Results This is a state-of-the-art review that focuses on clinical, diagnostic, and therapeutic aspects in mildly symptomatic HFrEF patients; summarizes the challenges; and proposes directions for future research in this group of patients. The New York Heart Association classification has been widely used as a measure of prognosis in HFrEF, but it lacks objectivity and reproducibility in terms of symptoms assessment. The definition of clinical stability as described in current guidelines is vague and may often lead to underdiagnosis of disease progression in patients who appear to be 'stable' but in fact are at an increased risk of clinical worsening, hospitalization, or death. Although an increasing number of clinical trials proved that the efficacy of HFrEF therapies was unrelated to the symptomatic status of patients and led to their implementation early in the course of the disease, clinical inertia in terms of under-prescription or underdosing of guideline-recommended medications in mildly symptomatic HFrEF patients is still a challenging issue to deal with. Conclusions Mildly symptomatic status in a patient with HFrEF is very frequent; it should not be ignored and should not be regarded as an index of disease stability. The application of risk scores designed to predict mortality and mode of death should be engaged among mildly symptomatic patients, not only to identify the most suitable HF candidates for cardioverter defibrillator implantation, but also to identify patients who might benefit from early intensification of medical treatment before the implementation of more interventional approaches.

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“…Large claims datasets suggest that administrative codes for HF appear in medical records well before hospitalization events. 4 Patients with HF may be initially diagnosed and cared for outside the hospital with escalation of HF therapies in ambulatory care or administration of intravenous diuretics in emergency or urgent care settings. Furthermore, more than half of new diagnoses have HF with preserved ejection fraction (HFpEF), which has less-distinguished biomarker and imaging signatures.…”

mentioning

confidence: 99%

De novo heart failure: where the journey begins

Myhre

Januzzi

Butler

et al. 2019

European J of Heart Fail

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Clinical Course of Patients With Worsening Heart Failure With Reduced Ejection Fraction

Cited by 187 publications

References 21 publications

Primary Prevention Implantable Cardiac Defibrillators: A Townsville District Perspective

Primary Prevention Implantable Cardiac Defibrillators: A Townsville District Perspective

Mildly symptomatic heart failure with reduced ejection fraction: diagnostic and therapeutic considerations

De novo heart failure: where the journey begins

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