heart failure

Cardiac resynchronization can be a great benefit to selected patients with CHF. Primary care clinicians need to be involved in identifying these patients and making sure they are treated. James W. Mold, MD, MPH

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Importance: Heart failure (HF) affects more than 64 million individuals worldwide, and acute HF is associated with 1-year mortality rates of 23.6% in North America and Europe. Cardiac dyssynchrony from conduction system disease may cause HF progression, particularly in patients with left ventricular (LV) systolic dysfunction.

Observations: Electrical dyssynchrony in HF most commonly presents as left bundle-branch block and affects 20% to 30% of patients with reduced LV ejection fraction (LVEF). Cardiac resynchronization therapy, which includes biventricular pacing and conduction system pacing, restores synchronous ventricular contraction and is recommended for patients with symptomatic HF despite optimal medical therapy, LVEF of 35% or less, and left bundle-branch block. Delayed referral for device therapy in this population is associated with worse clinical outcomes. Resynchronization should also be considered for patients requiring chronic ventricular pacing, typically due to symptomatic bradycardia because right ventricular pacing for atrioventricular block may result in ventricular dyssynchrony and increased risk of LV systolic dysfunction. Biventricular pacing uses 2 leads to stimulate the right ventricle and LV simultaneously; conduction system pacing uses a single lead to stimulate the His bundle or left bundle branch. An individual patient-level meta-analysis of 5 randomized clinical trials (N = 3872) reported biventricular pacing was associated with lower all-cause mortality compared with medical therapy or implantable cardioverter-defibrillator over a median follow-up of 23.7 months (13.7% vs 20.8%; hazard ratio, 0.66 [95% CI, 0.57-0.77]). A meta-analysis of 7 small randomized clinical trials, including 408 patients with HF and LVEF of 40% or less, reported that compared with biventricular pacing, conduction system pacing was associated with improvement in LVEF (mean difference, 2.06%; P = .03). An observational study of 1778 patients with LVEF of 35% or less undergoing cardiac resynchronization therapy reported conduction system pacing was associated with lower rates of HF hospitalization (12% vs 19%; hazard ratio, 0.67 [95% CI, 0.52-0.86]). A trial of 249 patients without HF undergoing permanent pacing for atrioventricular block-related bradycardia reported lower rates of pacing-induced cardiomyopathy, defined as a decrease in LVEF of at least 10% to less than 50% after conduction system pacing vs right ventricular pacing (6% vs 15%; P = .01).

Conclusions and relevance: Cardiac dyssynchrony due to conduction system disease occurs in 20% to 30% of patients with HF and systolic dysfunction. Cardiac resynchronization therapy restores synchronous ventricular activation in patients with HF, reduced LVEF, and left bundle-branch block, or in those requiring chronic ventricular pacing, and may improve LV function, decrease HF hospitalizations, and reduce mortality.

Author/s:

Caique M. Ternes, Jitae A. Kim, Anirban Basu

Early Invasive or Conservative Strategies for Older Patients With Acute Coronary Syndromes: A Meta-Analysis

Hope Smashey — Tue, 01 Jul 2025 19:20:08 +0000

Date Added:

July 1, 2025

Journal/Publication:

JAMA Intern Medicine

Publication Date:

June 23, 2025

URL:

Early Invasive or Conservative Strategies for Older Patients With Acute Coronary Syndromes: A Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jamainternmed.2025.2058

Keywords

PMID (1):

40549394

MeSH

acute coronary syndrome

conservative treatment

myocardial infarction

heart failure

stroke

aged

In patients over the age of 70 who experience a heart attack, it appears that non-intervention is as good as early intervention considering the increased risk of bleeding. James W. Mold, MD, MPH

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Importance: The optimal management strategy for older patients who present with acute coronary syndrome (ACS) remains unclear due to a paucity of randomized evidence. New large and longer-term randomized data are available.

Objective: To test the association of an early invasive strategy vs a conservative strategy with clinical outcomes for patients 70 years or older who present with ACS.

Data sources: A literature search strategy was designed in collaboration with a medical librarian. MEDLINE, Embase, and the Cochrane Central Register of Controlled Trials were systematically searched ,with no language restrictions from inception through October 2024. Bibliographies of previous reviews and conference abstracts from major cardiovascular scientific meetings were handsearched.

Study selection: Studies were deemed eligible following review by 2 independent, masked investigators if they randomly allocated patients 70 years or older who presented with ACS to early invasive or conservative management and reported clinical end points. Observational analyses were excluded. No trials were excluded based on sample size or follow-up duration.

Data extraction and synthesis: Data were extracted independently and in triplicate. Clinical end points were pooled in meta-analyses that applied fixed-effects and random-effects modeling to calculate summary estimates for relative risks (RRs) and hazard ratios, along with their corresponding 95% CIs.

Main outcomes and measures: The prespecified primary end point was all-cause death. Secondary end points included recurrent myocardial infarction (MI), repeated coronary revascularization, major bleeding, cardiovascular death, death or MI, stroke, heart failure hospitalization, major adverse cardiac events, major adverse cardiovascular or cerebrovascular events, and length of hospital stay.

Results: The sample size-weighted mean age of participants across included trials was 82.6 years, and 46% were female. In the pooled analysis, there was no significant difference in all-cause death between the invasive and conservative strategies (RR, 1.05; 95% CI, 0.98-1.11; P = .15; I2 = 0%). An early invasive strategy was associated with a reduced risk of recurrent MI of 22% (RR, 0.78; 95% CI, 0.67-0.91; P = .001; I2 = 0%) and repeated coronary revascularization during follow-up of 57% (RR, 0.43; 95% CI, 0.30-0.60; P < .001; I2 = 33.3%). However, an invasive strategy was associated with an increased risk of major bleeding (RR, 1.60; 95% CI, 1.01-2.53; P = .05; I2 = 16.7). No differences were observed in secondary end points. Results in the non-ST-elevation ACS population were consistent with the overall findings.

Conclusions and relevance: The results of this systematic review and meta-analysis suggest that, in older patients with ACS, an early invasive strategy was not associated with reduced all-cause death compared with conservative management. An early invasive strategy was associated with reduced recurrent MI and repeated coronary revascularization during follow-up but increased risk of major bleeding. Competing risks associated with an early invasive strategy should be weighed in shared therapeutic decision-making for older patients with ACS.

Author/s:

Rohin K Reddy, David Koeckerling, Christian Eichhorn, Yasser Jamil, Maddalena Ardissino, Volker Braun, Haitham Abu Sharar, Norbert Frey, James P Howard, Yousif Ahmad

Atrial Fibrillation: A Review

Alex Haga — Sun, 05 Jan 2025 21:39:50 +0000

Date Added:

January 5, 2025

Journal/Publication:

JAMA

Publication Date:

December 16, 2024

URL:

Atrial Fibrillation: A Review

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.22451

Keywords

atrial fibrillation

heart failure

stroke

PMID (1):

39680399

MeSH

atrial fibrillation

A review of current knowledge and opinion regarding the causes and management of atrial fibrillation. James W. Mold, MD, MPH

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Importance: In the US, approximately 10.55 million adults have atrial fibrillation (AF). AF is associated with significantly increased risk of stroke, heart failure, myocardial infarction, dementia, chronic kidney disease, and mortality.

Observations: Symptoms of AF include palpitations, dyspnea, chest pain, presyncope, exertional intolerance, and fatigue, although approximately 10% to 40% of people with AF are asymptomatic. AF can be detected incidentally during clinical encounters, with wearable devices, or through interrogation of cardiac implanted electronic devices. In patients presenting with ischemic stroke without diagnosed AF, an implantable loop recorder (ie, subcutaneous telemetry device) can evaluate patients for intermittent AF. The 2023 American College of Cardiology (ACC)/American Heart Association (AHA)/American College of Clinical Pharmacy (ACCP)/Heart Rhythm Society (HRS) Guideline writing group proposed 4 stages of AF evolution: stage 1, at risk, defined as patients with AF-associated risk factors (eg, obesity, hypertension); stage 2, pre-AF, signs of atrial pathology on electrocardiogram or imaging without AF; stage 3, the presence of paroxysmal (recurrent AF episodes lasting ≤7 days) or persistent (continuous AF episode lasting >7 days) AF subtypes; and stage 4, permanent AF. Lifestyle and risk factor modification, including weight loss and exercise, to prevent AF onset, recurrence, and complications are recommended for all stages. In patients with estimated risk of stroke and thromboembolic events of 2% or greater per year, anticoagulation with a vitamin K antagonist or direct oral anticoagulant reduces stroke risk by 60% to 80% compared with placebo. In most patients, a direct oral anticoagulant, such as apixaban, rivaroxaban, or edoxaban, is recommended over warfarin because of lower bleeding risks. Compared with anticoagulation, aspirin is associated with poorer efficacy and is not recommended for stroke prevention. Early rhythm control with antiarrhythmic drugs or catheter ablation to restore and maintain sinus rhythm is recommended by the 2023 ACC/AHA/ACCP/HRS Guideline for some patients with AF. Catheter ablation is first-line therapy in patients with symptomatic paroxysmal AF to improve symptoms and slow progression to persistent AF. Catheter ablation is also recommended for patients with AF who have heart failure with reduced ejection fraction (HFrEF) to improve quality of life, left ventricular systolic function, and cardiovascular outcomes, such as rates of mortality and heart failure hospitalization.

Conclusions and relevance: AF is associated with increased rates of stroke, heart failure, and mortality. Lifestyle and risk factor modification are recommended to prevent AF onset, recurrence, and complications, and oral anticoagulants are recommended for those with an estimated risk of stroke or thromboembolic events of 2% or greater per year. Early rhythm control using antiarrhythmic drugs or catheter ablation is recommended in select patients with AF experiencing symptomatic paroxysmal AF or HFrEF.

Author/s:

Darae Ko, Mina K Chung, Peter T Evans, Emelia J Benjamin, Robert H Helm

Management of Atrial Fibrillation

Erin Blanchette — Mon, 18 Nov 2024 14:34:46 +0000

Date Added:

November 18, 2024

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

November 14, 2024

URL:

Management of Atrial Fibrillation

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.19565

Keywords

atrial fibrillation

coronary artery disease

PMID (1):

39541112

MeSH

atrial fibrillation

Atrial Fibrillation* / diagnosis

Platelet Aggregation Inhibitors

Mitral Valve Stenosis

Atrial Appendage

coronary artery disease

heart failure

stroke

2023 guidelines from the ACC/AHA/ACCP/HRS on treatment of patients with atrial fibrillation. James W. Mold, MD, MPH

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Atrial fibrillation has a lifetime prevalence of 15% to 40% and predisposes patients to stroke and cardiac dysfunction. This JAMA Clinical Guidelines Synopsis focuses on recommendations for long-term management of AF, including new paradigms for rhythm control and stroke risk reduction.

Author/s:

Francis J Alenghat, Jason T Alexander, Gaurav A Upadhyay

Mineralocorticoid receptor antagonists in heart failure: an individual patient level meta-analysis

Alex Haga — Wed, 25 Sep 2024 13:12:34 +0000

Date Added:

September 25, 2024

Journal/Publication:

Lancet

Publication Date:

September 1, 2024

Issue:

10458

Volume:

404

Pages:

1119-1131

URL:

Mineralocorticoid receptor antagonists in heart failure: an individual patient level meta-analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/S0140-6736(24)01733-1

Keywords

mineralocorticoid

mineralocorticoid receptor antagonist

heart failure

PMID (1):

39232490

MeSH

Eplerenone* / therapeutic use

Heart Failure* / drug therapy

Mineralocorticoid Receptor Antagonists* / therapeutic use

Naphthyridines* / therapeutic use

Spironolactone* / therapeutic use

Stroke Volume* / drug effects

Mineralocorticoid Receptor Antagonists

Spironolactone

Eplerenone

Naphthyridines

A meta-analysis of the effects of mineralocorticoid receptor antagonists in patients with heart failure with various degrees of LV function. James W. Mold, MD, MPH

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Background: Mineralocorticoid receptor antagonists (MRAs) reduce hospitalisations and death in patients with heart failure and reduced ejection fraction (HFrEF), but the benefit in patients with heart failure and mildly reduced ejection fraction (HFmrEF) or heart failure and preserved ejection fraction (HFpEF) is unclear. We evaluated the effect of MRAs in four trials that enrolled patients with heart failure across the range of ejection fraction.

Methods: This is a prespecified, individual patient level meta-analysis of the RALES (spironolactone) and EMPHASIS-HF (eplerenone) trials, which enrolled patients with HFrEF, and of the TOPCAT (spironolactone) and FINEARTS-HF (finerenone) trials, which enrolled patients with HFmrEF or HFpEF. The primary outcome of this meta-analysis was a composite of time to first hospitalisation for heart failure or cardiovascular death. We also estimated the effect of MRAs on components of this composite, total (first or repeat) heart failure hospitalisations (with and without cardiovascular deaths), and all-cause death. Safety outcomes were also assessed, including serum creatinine, estimated glomerular filtration rate, serum potassium, and systolic blood pressure. An interaction between trials and treatment was tested to examine the heterogeneity of effect in these populations. This study is registered with PROSPERO, CRD42024541487.

Findings: 13 846 patients were included in the four trials. MRAs reduced the risk of cardiovascular death or heart failure hospitalisation (hazard ratio 0·77 [95% CI 0·72-0·83]). There was a statistically significant interaction by trials and treatment (p for interaction=0·0012) due to the greater efficacy in HFrEF (0·66 [0·59-0·73]) compared with HFmrEF or HFpEF (0·87 [0·79-0·95]). We observed significant reductions in heart failure hospitalisation in the HFrEF trials (0·63 [0·55-0·72]) and the HFmrEF or HFpEF trials (0·82 [0·74-0·91]). The same pattern was observed for total heart failure hospitalisations with or without cardiovascular death. Cardiovascular death was reduced in the HFrEF trials (0·72 [0·63-0·82]) but not in the HFmrEF or HFpEF trials (0·92 [0·80-1·05]). All-cause death was also reduced in the HFrEF trials (0·73 [0·65-0·83]) but not in the HFmrEF or HFpEF trials (0·94 [0·85-1·03]). With an MRA, the risk of hyperkalaemia was doubled compared with placebo (odds ratio 2·27 [95% CI 2·02-2·56]), but the incidence of serious hyperkalaemia (serum potassium >6·0 mmol/L) was low (2·9% vs 1·4%); the risk of hypokalaemia (potassium <3·5 mmol/L) was halved (0·51 [0·45-0·57]; 7% vs 14%).

Interpretation: Steroidal MRAs reduce the risk of cardiovascular death or heart failure hospitalisation in patients with HFrEF and non-steroidal MRAs reduce this risk in patients with HFmrEF or HFpEF.

Funding: None.

Author/s:

Pardeep S Jhund, Atefeh Talebi, Alasdair D Henderson, Brian L Claggett, Muthiah Vaduganathan

Management of Chronic Heart Failure with Reduced Ejection Fraction

Alex Haga — Tue, 20 Aug 2024 20:11:08 +0000

Date Added:

August 20, 2024

Journal/Publication:

The Journal of the American Board of Family Medicine

Publication Date:

May 1, 2024

Issue:

Volume:

Pages:

364-371

URL:

Management of Chronic Heart Failure with Reduced Ejection Fraction

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.3122/jabfm.2023.230436R1

Keywords

heart failure

Reduced Ejection Fraction

CHF

pharmacotherapy

HFrEF

PMID (1):

39142870

MeSH

Heart Failure* / drug therapy

Heart Failure* / diagnosis

Mineralocorticoid Receptor Antagonists* / therapeutic use

Sodium-Glucose Transporter 2 Inhibitors / therapeutic use

Aminobutyrates / therapeutic use

Angiotensin Receptor Antagonists* / therapeutic use

Valsartan

A review of the management of CHF with reduced ejection fraction. James W. Mold, MD, MPH

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Heart failure with reduced ejection fraction (HFrEF) is a commonly seen clinical entity in the family physician's practice. This clinical review focuses on the pharmacologic management of chronic HFrEF. Special attention is paid to the classification of heart failure and the newest recommendations from the American Heart Association concerning the use of guideline-directed medical therapy. β blockers, ACE inhibitors, ARBs, mineralocorticoid receptor antagonists are discussed in detail. The new emphasis on sacubitril-valsartan and SGLT2i's as therapies for HFrEF are reviewed, followed by a brief discussion of more advanced therapies and comorbidity management.

Author/s:

Brandon Williamson, Carl Tong

Revisiting Race and the Benefit of RAS Blockade in Heart Failure: A Meta-Analysis of Randomized Clinical Trials

Alex Haga — Thu, 27 Jun 2024 23:40:01 +0000

Date Added:

June 27, 2024

Journal/Publication:

JAMA

Publication Date:

June 25, 2024

URL:

Revisiting Race and the Benefit of RAS Blockade in Heart Failure: A Meta-Analysis of Randomized Clinical Trials

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2024.6774

Keywords

RAS blocker

heart failure

renin-angiotensin system

PMID (1):

38809561

MeSH

Angiotensin Receptor Antagonists* / therapeutic use

Angiotensin-Converting Enzyme Inhibitors* / therapeutic use

Black or African American

Renin-Angiotensin System* / drug effects

Heart Failure* / drug therapy

RAS blockers work as well for CHF in Black people as in White people. James W. Mold, MPH

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Importance: Concerns have arisen that renin-angiotensin system (RAS) blockers are less effective in Black patients than non-Black patients with heart failure and reduced ejection fraction (HFrEF).

Objective: To determine whether the effects of RAS blockers on cardiovascular outcomes differ between Black patients and non-Black patients with HFrEF.

Data sources: MEDLINE and Embase databases through December 31, 2023.

Study selection: Randomized trials investigating the effect of RAS blockers on cardiovascular outcomes in adults with HFrEF that enrolled Black and non-Black patients.

Data extraction and synthesis: Individual-participant data were extracted following Preferred Reporting Items for Systematic Reviews and Meta-analyses Independent Personal Data (PRISMA-IPD) reporting guidelines. Effects were estimated using a mixed-effects model using a 1-stage approach.

Main outcome and measure: The primary outcome was first hospitalization for HF or cardiovascular death.

Results: The primary analysis, based on the 3 placebo-controlled RAS inhibitor monotherapy trials, included 8825 patients (9.9% Black). Rates of death and hospitalization for HF were substantially higher in Black than non-Black patients. The hazard ratio (HR) for RAS blockade vs placebo for the primary composite was 0.84 (95% CI, 0.69-1.03) in Black patients and 0.73 (95% CI, 0.67-0.79) in non-Black patients (P for interaction = .14). The HR for first HF hospitalization was 0.89 (95% CI, 0.70-1.13) in Black patients and 0.62 (95% CI, 0.56-0.69) in non-Black patients (P for interaction = .006). Conversely, the corresponding HRs for cardiovascular death were 0.83 (95% CI, 0.65-1.07) and 0.84 (95% CI, 0.77-0.93), respectively (P for interaction = .99). For total hospitalizations for HF and cardiovascular deaths, the corresponding rate ratios were 0.82 (95% CI, 0.66-1.02) and 0.72 (95% CI, 0.66-0.80), respectively (P for interaction = .27). The supportive analyses including the 2 trials adding an angiotensin receptor blocker to background angiotensin-converting enzyme inhibitor treatment (n = 16 383) gave consistent findings.

Conclusions and relevance: The mortality benefit from RAS blockade was similar in Black and non-Black patients. Despite the smaller relative risk reduction in hospitalization for HF with RAS blockade in Black patients, the absolute benefit in Black patients was comparable with non-Black patients because of the greater incidence of this outcome in Black patients.

Author/s:

Li Shen, Matthew M Y Lee, Pardeep S Jhund, Christopher B Granger, Inder S Anand

Sodium-Glucose Cotransporter-2 Inhibitors and Major Adverse Cardiovascular Outcomes: A SMART-C Collaborative Meta-Analysis

Alex Haga — Sun, 16 Jun 2024 19:07:38 +0000

Date Added:

June 16, 2024

Journal/Publication:

Circulation

Publication Date:

June 4, 2024

Issue:

Volume:

149

Pages:

1789–1801

URL:

Sodium-Glucose Cotransporter-2 Inhibitors and Major Adverse Cardiovascular Outcomes: A SMART-C Collaborative Meta-Analysis

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1161/CIRCULATIONAHA.124.069568

Keywords

heart failure

metabolic syndrome

Renal Insufficiency

sodium-glucose cotransporter-2 inhibitors

PMID (1):

PMC11149938

MeSH

Cardiovascular Diseases* / mortality

diabetes mellitus

Type 2 / complications

diabetes mellitus, type 2

Type 2 / mortality

renal insufficiency

Chronic / drug therapy

Chronic / mortality

Sodium-Glucose Transporter 2 Inhibitors* / adverse effects

Sodium-Glucose Transporter 2 Inhibitors* / therapeutic use

SGLT2 inhibitors reduce the risk of death and hospitalization from CHF probably because of their osmotic diuretic effect. They have not been compared to other less expensive diuretics to my knowledge. James W. Mold, MD, MPH

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Background: Sodium-glucose cotransporter-2 inhibitors (SGLT2i) consistently improve heart failure and kidney-related outcomes; however, effects on major adverse cardiovascular events (MACE) across different patient populations are less clear.

Methods: This was a collaborative trial-level meta-analysis from the SGLT2i Meta-analysis Cardio-Renal Trialists Consortium, which includes all phase 3, placebo-controlled, outcomes trials of SGLT2i across 3 patient populations (patients with diabetes at high risk for atherosclerotic cardiovascular disease, heart failure [HF], or chronic kidney disease). The outcomes of interest were MACE (composite of cardiovascular death, myocardial infarction , or stroke), individual components of MACE (inclusive of fatal and nonfatal events), all-cause mortality, and death subtypes. Effect estimates for SGLT2i versus placebo were meta-analyzed across trials and examined across key subgroups (established atherosclerotic cardiovascular disease, previous myocardial infarction, diabetes, previous HF, albuminuria, chronic kidney disease stages, and risk groups).

Results: A total of 78 607 patients across 11 trials were included: 42 568 (54.2%), 20 725 (26.4%), and 15 314 (19.5%) were included from trials of patients with diabetes at high risk for atherosclerotic cardiovascular disease, HF, or chronic kidney disease, respectively. SGLT2i reduced the rate of MACE by 9% (hazard ration [HR], 0.91 [95% CI, 0.87-0.96], P<0.0001) with a consistent effect across all 3 patient populations (I2=0%) and across all key subgroups. This effect was primarily driven by a reduction in cardiovascular death (HR, 0.86 [95% CI, 0.81-0.92], P<0.0001), with no significant effect for myocardial infarction in the overall population (HR, 0.95 [95% CI, 0.87-1.04], P=0.29), and no effect on stroke (HR, 0.99 [95% CI, 0.91-1.07], P=0.77). The benefit for cardiovascular death was driven primarily by reductions in HF death and sudden cardiac death (HR, 0.68 [95% CI, 0.46-1.02] and HR, 0.86 [95% CI, 0.78-0.95], respectively) and was generally consistent across subgroups, with the possible exception of being more apparent in those with albuminuria (Pinteraction=0.02).

Conclusions: SGLT2i reduce the risk of MACE across a broad range of patients irrespective of atherosclerotic cardiovascular disease, diabetes, kidney function, or other major clinical characteristics at baseline. This effect is driven primarily by a reduction of cardiovascular death, particularly HF death and sudden cardiac death, without a significant effect on myocardial infarction in the overall population, and no effect on stroke. These data may help inform selection for SGLT2i therapies across the spectrum of cardiovascular-kidney-metabolic disease.

Keywords: diabetes mellitus; heart failure; meta-analysis; metabolic syndrome; renal insufficiency, chronic; sodium-glucose cotransporter-2 inhibitors.

Author/s:

Siddharth M Patel, Yu Mi Kang, KyungAh Im, Brendon L Neuen, Stefan D Anker, Deepak L Bhatt, Javed Butler, David Z I Cherney

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, I

Rowan Hutchins — Sun, 03 Dec 2023 06:00:00 +0000

Date Added:

December 3, 2023

Journal/Publication:

Circulation

Publisher:

AHA

Publication Date:

November 9, 2023

URL:

2023 International Consensus on Cardiopulmonary Resuscitation and Emergency Cardiovascular Care Science With Treatment Recommendations: Summary From the Basic Life Support; Advanced Life Support; Pediatric Life Support; Neonatal Life Support; Education, I

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1161/CIR.0000000000001179

Keywords

first aid

heart failure

neonates

PMID (1):

37942682

MeSH

Cardiopulmonary Resuscitation

Heart Arrest

Heart Rate

Premature Birth

2023 updates to the International Liaison Committee on Resuscitation guidelines for resuscitation. James W. Mold, MD, MPH

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The International Liaison Committee on Resuscitation engages in a continuous review of new, peer-reviewed, published cardiopulmonary resuscitation and first aid science. Draft Consensus on Science With Treatment Recommendations are posted online throughout the year, and this annual summary provides more concise versions of the final Consensus on Science With Treatment Recommendations from all task forces for the year. Topics addressed by systematic reviews this year include resuscitation of cardiac arrest from drowning, extracorporeal cardiopulmonary resuscitation for adults and children, calcium during cardiac arrest, double sequential defibrillation, neuroprognostication after cardiac arrest for adults and children, maintaining normal temperature after preterm birth, heart rate monitoring methods for diagnostics in neonates, detection of exhaled carbon dioxide in neonates, family presence during resuscitation of adults, and a stepwise approach to resuscitation skills training. Members from 6 International Liaison Committee on Resuscitation task forces have assessed, discussed, and debated the quality of the evidence, using Grading of Recommendations Assessment, Development, and Evaluation criteria, and their statements include consensus treatment recommendations. Insights into the deliberations of the task forces are provided in the Justification and Evidence-to-Decision Framework Highlights sections. In addition, the task forces list priority knowledge gaps for further research. Additional topics are addressed with scoping reviews and evidence updates.

Author/s:

Janet E. Bray, Kee-Chong Ng, Helen G. Liley, Robert Greif, Jestin N. Carlson, Peter T. Morley, an R. Drennan, Michael Smyth, Barnaby R. Scholefield, Gary M. Weiner, Adam Cheng, Therese Djärv, Cristian Abelairas-Gómez, Jason Acworth, Lars W. Andersen, Dianne L. Atkins, David C. Berry, Farhan Bhanji, Joost Bierens, Thomaz Bittencourt Couto, Vere Borra, Bernd W. Böttiger, Richard N. Bradley, Jan Breckwoldt, Pascal Cassan, Wei-Tien Chang, Nathan P. Charlton, Sung Phil Chung, Julie Considine, Daniela T. Costa-Nobre, Keith Couper, Katie N. Dainty, Vihara Dassanayake, Peter G. Davis, Jennifer A. Dawson, Maria Fernanda de Almeida, Allan R. De Caen, Charles D. Deakin, Bridget Dicker, Matthew J. Douma, Kathryn Eastwood, Walid El-Naggar, Jorge G. Fabres, Joe Fawke, ino Fijacko, Judith C. Finn, Gustavo E. Flores, Elizabeth E. Foglia, Fredrik Folke, Elaine Gilfoyle, Craig A. Goolsby, Asger Granfeldt, Anne-Marie Guerguerian, Ruth Guinsburg, Tetsuo Hatanaka, Karen G. Hirsch, Mathias J. Holmberg, et al.

Heart Failure With Preserved Ejection Fraction

Rowan Hutchins — Sun, 19 Mar 2023 05:00:00 +0000

Date Added:

March 19, 2023

Journal/Publication:

JAMA

Publisher:

American Medical Association

Publication Date:

March 14, 2023

Issue:

Volume:

329

Pages:

827-838

URL:

Heart Failure With Preserved Ejection Fraction

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2023.2020

Keywords

PMID (1):

36917048

MeSH

furosemide

Sodium Potassium Chloride Symporter Inhibitors

empagliflozin

quality of life

diabetes mellitus

diabetes mellitus, type 2

A review of the possible causes, diagnosis, and management of heart failure with preserved ejection fraction. Notice that SGLT2 inhibitors reduced hospitalizations and cardiovascular deaths by <2% (absolute risk reduction) per year and have not been compared head-to-head against less expensive meds like HCTZ or ramipril. James W. Mold, MD, MPH

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Importance Heart failure with preserved ejection fraction (HFpEF), defined as HF with an EF of 50% or higher at diagnosis, affects approximately 3 million people in the US and up to 32 million people worldwide. Patients with HFpEF are hospitalized approximately 1.4 times per year and have an annual mortality rate of approximately 15%.

Observations Risk factors for HFpEF include older age, hypertension, diabetes, dyslipidemia, and obesity. Approximately 65% of patients with HFpEF present with dyspnea and physical examination, chest radiographic, echocardiographic, or invasive hemodynamic evidence of HF with overt congestion (volume overload) at rest. Approximately 35% of patients with HFpEF present with “unexplained” dyspnea on exertion, meaning they do not have clear physical, radiographic, or echocardiographic signs of HF. These patients have elevated atrial pressures with exercise as measured with invasive hemodynamic stress testing or estimated with Doppler echocardiography stress testing. In unselected patients presenting with unexplained dyspnea, the H2FPEF score incorporating clinical (age, hypertension, obesity, atrial fibrillation status) and resting Doppler echocardiographic (estimated pulmonary artery systolic pressure or left atrial pressure) variables can assist with diagnosis (H2FPEF score range, 0-9; score >5 indicates more than 95% probability of HFpEF). Specific causes of the clinical syndrome of HF with normal EF other than HFpEF should be identified and treated, such as valvular, infiltrative, or pericardial disease. First-line pharmacologic therapy consists of sodium-glucose cotransporter type 2 inhibitors, such as dapagliflozin or empagliflozin, which reduced HF hospitalization or cardiovascular death by approximately 20% compared with placebo in randomized clinical trials. Compared with usual care, exercise training and diet-induced weight loss produced clinically meaningful increases in functional capacity and quality of life in randomized clinical trials. Diuretics (typically loop diuretics, such as furosemide or torsemide) should be prescribed to patients with overt congestion to improve symptoms. Education in HF self-care (eg, adherence to medications and dietary restrictions, monitoring of symptoms and vital signs) can help avoid HF decompensation.

Conclusions and Relevance Approximately 3 million people in the US have HFpEF. First-line therapy consists of sodium-glucose cotransporter type 2 inhibitors, exercise, HF self-care, loop diuretics as needed to maintain euvolemia, and weight loss for patients with obesity and HFpEF.

Author/s:

Redfield, Margaret, Borlaug, Barry

Chlorthalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events

Aubrey Delammermore — Mon, 19 Dec 2022 06:00:00 +0000

Date Added:

December 19, 2022

Journal/Publication:

New England Journal of Medicine

Publisher:

Massachusetts Medical Society

Publication Date:

December 14, 2022

URL:

Chlorthalidone vs. Hydrochlorothiazide for Hypertension–Cardiovascular Events

Type:

Clinical Research Results

Format:

Article

DOI (1):

10.1056/NEJMoa2212270

Keywords

hypertension

cardiovascular events

heart failure

veterans

infarction

PMID (1):

36516076

MeSH

Hydrochlorothiazide

Sodium Chloride Symporter Inhibitors

Hypokalemia

Angina, Unstable

Chlorthalidone

HCYZ seems to be as effective as chlorthalidone for reducing the risk of major CV events. James W. Mold, MD, MPH

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Background: Whether chlorthalidone is superior to hydrochlorothiazide for preventing major adverse cardiovascular events in patients with hypertension is unclear.

Methods: In a pragmatic trial, we randomly assigned adults 65 years of age or older who were patients in the Department of Veterans Affairs health system and had been receiving hydrochlorothiazide at a daily dose of 25 or 50 mg to continue therapy with hydrochlorothiazide or to switch to chlorthalidone at a daily dose of 12.5 or 25 mg. The primary outcome was a composite of nonfatal myocardial infarction, stroke, heart failure resulting in hospitalization, urgent coronary revascularization for unstable angina, and non-cancer-related death. Safety was also assessed.

Results: A total of 13,523 patients underwent randomization. The mean age was 72 years. At baseline, hydrochlorothiazide at a dose of 25 mg per day had been prescribed in 12,781 patients (94.5%). The mean baseline systolic blood pressure in each group was 139 mm Hg. At a median follow-up of 2.4 years, there was little difference in the occurrence of primary-outcome events between the chlorthalidone group (702 patients [10.4%]) and the hydrochlorothiazide group (675 patients [10.0%]) (hazard ratio, 1.04; 95% confidence interval, 0.94 to 1.16; P = 0.45). There were no between-group differences in the occurrence of any of the components of the primary outcome. The incidence of hypokalemia was higher in the chlorthalidone group than in the hydrochlorothiazide group (6.0% vs. 4.4%, P<0.001).

Conclusions: In this large pragmatic trial of thiazide diuretics at doses commonly used in clinical practice, patients who received chlorthalidone did not have a lower occurrence of major cardiovascular outcome events or non-cancer-related deaths than patients who received hydrochlorothiazide. (Funded by the Veterans Affairs Cooperative Studies Program; ClinicalTrials.gov number, NCT02185417.).

Author/s:

Ishani, A., Cushman, W. C., Leatherman, S. M., R. A., Woods, P., Glassman, P. A., Taylor, A. A., Hau, C., Klint, A., Huang, G. D., Brophy, M. T., Fiore, L. D., Ferguson, R. E., Diuretic Comparison Project Writing Group

Management of Heart Failure

Aubrey Delammermore — Sat, 24 Sep 2022 05:00:00 +0000

Date Added:

September 24, 2022

Journal/Publication:

JAMA Clinical Guidelines Synopsis

Publisher:

American Medical Association

Publication Date:

September 15, 2022

Pages:

E1-E2

URL:

Management of Heart Failure

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1001/jama.2022.16667

Keywords

Stroke Volume

American Heart Association

Cardiology

heart failure

Sodium

PMID (1):

36107415

MeSH

Mineralocorticoid Receptor Antagonists

Angiotensin Receptor Antagonists

Sodium-Glucose Transporter 2 Inhibitors

Angiotensin-Converting Enzyme Inhibitors

Angioedema

Updated guidelines for management of congestive heart failure rom the American College of Cardiology and the American Heart Association. James W. Mold, MD, MPH

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GUIDELINE TITLE 2022 American College of Cardiology
(ACC)/American Heart Association AHA)/Heart Failure
Society of America (HFSA) Guidelines for the Management
of Heart Failure
RELEASE DATE April 1, 2022
PRIOR VERSIONS 2017 ACC/AHA/HFSA Focused Update
of the 2013 ACCF/AHA Guideline for the Management of
Heart Failure and 2013 ACCF/AHA Guideline for the
Management of Heart Failure
DEVELOPER AND FUNDING SOURCE ACC/AHA Joint
Committee on Clinical Practice Guidelines
TARGET POPULATION Adult patients with a diagnosis of
or at risk for heart failure (HF)
MAJOR RECOMMENDATIONS
• Classifications for HF are separated into 4 categories based
on ejection fraction (EF) and disease history: HF with
reduced EF (EF 40%), HF with mildly reduced EF
(EF 41%-49%), HF with preserved EF (EF 50%), and HF
with improved EF (EF previously 40% with improvement
to >40%).
• In patients with chronic HF with reduced EF, angiotensin
receptor–neprilysin inhibitors (ARNIs) are preferred over
angiotensin-converting enzyme inhibitors (ACEIs) and
angiotensin II receptor blockers (ARBs). If ARNI use is not
feasible, ACEIs are preferred over ARBs, unless there is
significant cough or angioedema (class 1, level of
evidence [LOE] A).
• Sodium-glucose cotransporter 2 (SGLT2) inhibitors should
be included across all HF categories (symptomatic HF with
reduced EF [class 1, LOE A]; HF with mildly reduced EF and
HF with preserved EF [class 2a, LOE B-R]).
• Patients with HF with improved EF should continue to
receive medical therapy originally indicated for HF with
reduced EF (class 1, LOE B-R).
• Evidence-based treatment of HF with preserved EF
includes blood pressure control (class 1, LOE C-LD),
SGLT2 inhibitors (class 2a, LOE B-R), mineralocorticoid
antagonists, ARBs, and ARNIs (class 2b, LOE B-R).

Author/s:

Belkin, M. N., Cifu, A. S., Pinney, S.

Milestones in Heart Failure: How Far We Have Come and How Far We Have Left to Go

Saige Blanchard — Mon, 03 Jan 2022 06:00:00 +0000

Date Added:

January 3, 2022

Journal/Publication:

Cureus Journal of Medical Science

Publication Date:

December 12, 2021

URL:

Milestones in Heart Failure: How Far We Have Come and How Far We Have Left to Go

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.7759/cureus.20359

Keywords

MeSH

Angiotensin Receptor Antagonists

heart failure

Disease Progression

A nice summary of what we currently know about the pharmacologic treatment of congestive heart failure. James W. Mold, MD, MPH

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Heart failure is a clinically complex syndrome that results due to the failure of the ventricles to function as pump and oxygenate end organs. The repercussions of inadequate perfusion are seen in the form of sympathetic overactivation and third spacing, leading to clinical signs of increased blood pressure, dyspnea, fatigue, palpitations, etc. This article provided a brief overview of the clinical syndrome of heart failure; its epidemiology, risk factors, symptoms, and staging; and the mechanisms involved in disease progression. This article also described several landmark trials in heart failure that tested the efficacy of first-line drugs such as beta-blockers, angiotensin receptor blockers, angiotensin-converting enzyme inhibitors, and the latest drugs in the field of heart failure: angiotensin receptor neprilysin inhibitors. Most studies described in this article were guideline-setting trials that revolutionized the practice of medicine and cardiology.

Author/s:

H., Kela, I., Kakarlala, C., Hassan, M., Belavadi, R., Gudigopuram, S. V. R., Raguthu, C., Modi, S., Sange, I.

Screening for Hypertension in Adults

Saige Blanchard — Wed, 05 May 2021 05:00:00 +0000

Date Added:

May 5, 2021

Journal/Publication:

Journal of the American Medical Association

Publisher:

U.S. Preventative Services Task Force

Publication Date:

April 27, 2021

Issue:

Volume:

325

Pages:

1650-1656

URL:

Screening for Hypertension in Adults

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Web Page

DOI (1):

10.1001/jama.2021.4987

Keywords

hypertension

heart failure

myocardial infarction

chronic kidney disease

MeSH

blood pressure

Mass Screening

hypertension

myocardial infarction

No surprise that the USPSTF recommends in-office screening for hypertension. What seems interesting is that they suggest getting confirmatory readings from outside the office before making the diagnosis. James W. Mold, MD, MPH

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IMPORTANCE Hypertension is a prevalent condition that affects approximately 45% of the adult US population and is the most commonly diagnosed condition at outpatient office visits. Hypertension is a major contributing risk factor for heart failure, myocardial infarction, stroke, and chronic kidney disease. OBJECTIVE To reaffirm its 2015 recommendation, the US Preventive Services Task Force (USPSTF) commissioned a systematic review to evaluate the benefits and harms of screening for hypertension in adults, the accuracy of office blood pressure measurement for initial screening, and the accuracy of various confirmatory blood pressure measurement methods. POPULATION Adults 18 years or older without known hypertension. EVIDENCE ASSESSMENT Using a reaffirmation deliberation process, the USPSTF concludes with high certainty that screening for hypertension in adults has substantial net benefit. RECOMMENDATION The USPSTF recommends screening for hypertension in adults 18 years or older with office blood pressure measurement. The USPSTF recommends obtaining blood pressure measurements outside of the clinical setting for diagnostic confirmation before starting treatment. (A recommendation)

Author/s:

U.S. Preventative Services Task Force

Estimating Lifetime Benefits of Comprehensive Disease-Modifying Pharmacological Therapies in Patients With Heart Failure With Reduced Ejection Fraction: A Comparative Analysis of Three Randomised Controlled Trials

John Bayhi — Tue, 26 May 2020 20:29:33 +0000

Date Added:

May 26, 2020

Journal/Publication:

Lancet

Publisher:

Elsevier Ltd

Publication Date:

May 21, 2020

Volume:

Online ahead of print

URL:

Estimating Lifetime Benefits of Comprehensive Disease-Modifying Pharmacological Therapies in Patients With Heart Failure With Reduced Ejection Fraction: A Comparative Analysis of Three Randomised Controlled Trials

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.1016/S0140-6736(20)30748-0

Keywords

CHF patients

heart failure

pharmacologic management

PMID (1):

32446323

MeSH

Humans

Angiotensin Receptor Antagonists

Mineralocorticoid Receptor Antagonists

Angiotensin-Converting Enzyme Inhibitors

Sodium-Glucose Transporter 2 Inhibitors

Peptidyl-Dipeptidase A

Neprilysin

heart failure

SLC5A2 protein, human

sodium-glucose transporter 2

Stroke Volume

Control Groups

Receptors, Drug

Progression-Free Survival

Receptors, Angiotensin

NR3C2 protein, human

For those of you who still initiate and manage CHF with reduced LV ejection fraction, this meta-analysis appears to support using combinations of the following five agents: 1) an ACEI or ARB, 2) a beta-blocker, 3) a mineralocorticoid receptor antagonist [MRA], 4) an angiotensin receptor–neprilysin inhibitor [ARNI], and 5) a sodium/glucose cotransporter 2 [SGLT2] inhibitor. They estimate that combined therapy could increase life expectancy for an 80-year-old 1.4 years and for a 55-year-old 6.3 years. If we are going to continue to manage these patients, it looks like we are going to have to develop specific CHF visits and protocols like those used in CHF clinics run by cardiology teams. James W. Mold, MD, MPH

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Background: Three drug classes (mineralocorticoid receptor antagonists [MRAs], angiotensin receptor-neprilysin inhibitors [ARNIs], and sodium/glucose cotransporter 2 [SGLT2] inhibitors) reduce mortality in patients with heart failure with reduced ejection fraction (HFrEF) beyond conventional therapy consisting of angiotensin-converting enzyme (ACE) inhibitors or angiotensin receptor blockers (ARBs) and β blockers. Each class was previously studied with different background therapies and the expected treatment benefits with their combined use are not known. Here, we used data from three previously reported randomised controlled trials to estimate lifetime gains in event-free survival and overall survival with comprehensive therapy versus conventional therapy in patients with chronic HFrEF.

Methods: In this cross-trial analysis, we estimated treatment effects of comprehensive disease-modifying pharmacological therapy (ARNI, β blocker, MRA, and SGLT2 inhibitor) versus conventional therapy (ACE inhibitor or ARB and β blocker) in patients with chronic HFrEF by making indirect comparisons of three pivotal trials, EMPHASIS-HF (n=2737), PARADIGM-HF (n=8399), and DAPA-HF (n=4744). Our primary endpoint was a composite of cardiovascular death or first hospital admission for heart failure; we also assessed these endpoints individually and assessed all-cause mortality. Assuming these relative treatment effects are consistent over time, we then projected incremental long-term gains in event-free survival and overall survival with comprehensive disease-modifying therapy in the control group of the EMPHASIS-HF trial (ACE inhibitor or ARB and β blocker).

Findings: The hazard ratio (HR) for the imputed aggregate treatment effects of comprehensive disease-modifying therapy versus conventional therapy on the primary endpoint of cardiovascular death or hospital admission for heart failure was 0·38 (95% CI 0·30-0·47). HRs were also favourable for cardiovascular death alone (HR 0·50 [95% CI 0·37-0·67]), hospital admission for heart failure alone (0·32 [0·24-0·43]), and all-cause mortality (0·53 [0·40-0·70]). Treatment with comprehensive disease-modifying pharmacological therapy was estimated to afford 2·7 additional years (for an 80-year-old) to 8·3 additional years (for a 55-year-old) free from cardiovascular death or first hospital admission for heart failure and 1·4 additional years (for an 80-year-old) to 6·3 additional years (for a 55-year-old) of survival compared with conventional therapy.

Interpretation: Among patients with HFrEF, the anticipated aggregate treatment effects of early comprehensive disease-modifying pharmacological therapy are substantial and support the combination use of an ARNI, β blocker, MRA, and SGLT2 inhibitor as a new therapeutic standard.

Funding: None.

Author/s:

Vaduganathan, M., Claggett, BL, Jhund, PS, Cunningham, JW, Ferreira, JP, Zannad, F, Packer, M, Fonarow, GC, McMurray, JJV, Solomon, S.D.