bluuebunny/crossref_metadata_2025_split huggingface dataset:
Evaluation of a prescribing pharmacist-led heart failure (HF) up-titration clinic
Authors: Williams R , Donald R , James A , Schiavone E , Hughes D , Wong A 
Published: October 2022

Abstract

Background/Introduction
Pharmacotherapy is considered the cornerstone of treatment for patients with heart failure with reduced ejection fraction (HFrEF). Modulation of the renin-angiotensin-aldosterone (RAAS) and sympathetic nervous system have been shown to improve survival, reduce the risk of heart failure (HF) hospitalisations and improve quality of life. Unless contraindicated or not tolerated, these patients should be prescribed angiotensin-converting enzyme inhibitor (ACEi)/angiotensin-receptor blocker (ARB)/angiotensin receptor-neprilysin inhibitor (ARNI), beta-blocker, mineralocorticoid receptor antagonist (MRA) and sodium-glucose co-transporter 2 (SGLT2) inhibitor and up-titrated to guideline directed dosages.1 Despite the availability of effective treatments, patients are often sub-optimally dosed and experience a prolonged optimisation process. Pharmacist-led clinics can complement existing services and increase uptake of guideline directed medical therapies (GDMT).

Purpose
To evaluate the effectiveness of pharmacist-led heart failure clinics in the Princess of Wales Hospital, supported by the Heart Failure team, in optimisation of patients with HFrEF.

Methods
Patients who attended HF pharmacist led clinic between November 2020 and November 2021 were included in the analysis. Baseline demographics, left ventricular ejection fraction (LVEF), biomarkers, vital signs and medications were documented at baseline and after optimisation of GDMT. Number of clinics appointments and rate of hospitalisation and mortality were captured during the study period.

Results
76 patients were reviewed over a total of 318 consultations (34% virtual), averaging 4 consultations per patient. The mean age was 71 years, 36% of patients were female, mean LVEF was 32% and NT-proBNP 3078ng/L with 15% of patients on “quadruple therapy” at baseline. 93% of patients were referred by cardiologists and the average time from referral to first appointment was 42 days. Post-optimisation, 67% of patients were receiving “quadruple therapy”, with increased uptake of ACEi/ARB/ARNI, beta-blocker, MRA and SGLT2i from baseline (100%, 77%, 93% and 90% respectively). Mean LVEF increased to 42% and mean NT-proBNP reduced to 1695ng/L. No significant changes in creatinine clearance, blood pressure, heart rate or serum potassium (sK+) were recorded. The hospitalisation rate was 11% for heart failure, 6% for other cardiovascular causes and the mortality rate was 7%.

Conclusions
The pharmacist-led HF clinic demonstrated a high uptake of optimally dosed GDMT and improvements in NT-proBNP and LVEF. Pharmacist-led clinics can enhance the provision of existing heart failure services to improve patient outcomes and heart failure care.

Funding Acknowledgement
Type of funding sources: None.
Efficacy and safety of sacubitril/valsartan according to frailty in heart failure with preserved ejection fraction: a post hoc analysis of the PARAGON-HF trial
Authors: Butt J H , Dewan P , Kober L , Jhund P S , Solomon S D , McMurray J J V 
Published: October 2022

Abstract

Introduction
Frailty is an increasingly common problem and frail patients are less likely to receive pharmacological therapy because the benefit/risk profile is perceived to be less favorable than in non-frail patients.

Purpose
We investigated the prevalence of frailty, the relationship between frailty status and outcomes, and the efficacy of sacubitril/valsartan, compared with valsartan, according to frailty status in patients with heart failure (HF) with preserved fraction (HFpEF) randomized in PARAGON-HF.

Methods
Patients aged ≥50 years with a left ventricular ejection fraction ≥45%, structural heart disease, and elevated natriuretic peptide were enrolled in PARAGON-HF. Using the Rockwood cumulative deficit approach, a 41-item Frailty Index (FI) was constructed, and a FI score was calculated, with higher scores indicating greater frailty. The primary endpoint was a composite of total HF hospitalizations and cardiovascular death.

Results
Of the 4,796 patients randomized in PARAGON-HF, a FI was calculable in 4,795. Mean FI was 0.227 (standard deviation, 0.091; range, 0.061–0.537). In total, 2,165 (45.2%) patients had class 1 frailty (FI &lt;0.210, i.e., not frail), 2.084 (43.5%) had class 2 (FI 0.211–0.310, i.e. more frail), and 546 (11.4%) were in class 3 frailty (FI &gt;0.311, i.e. most frail). There was a graded relationship between FI class and the primary endpoint, with a significantly higher risk associated with greater frailty (class 1, reference; class 2, rate ratio 2.19 [95% CI, 1.85–2.60]; class 3, 3.29 [95% CI, 2.65–4.09]). The effect of sacubitril/valsartan versus valsartan on the primary endpoint from lowest to highest FI class (as a rate ratio) was: 0.98 [95% CI, 0.76–1.27], 0.92 [95% CI, 0.76–1.12], and 0.69 [95% CI, 0.51–0.95]), respectively (P for interaction=0.23) (Table). When FI was examined as a continuous variable, the interaction with treatment was significant for the primary outcome (P for interaction 0.002) and total HF hospitalizations (P for interaction &lt;0.001) with those most frail deriving greater benefit (Figure). Adverse reactions and discontinuation of trial treatment were not more frequent with sacubitril/valsartan than valsartan, in frailer patients.

Conclusions
Frailty was common in patients with HFpEF in PARAGON-HF and associated with worse outcomes. There was a greater reduction in total HF hospitalizations with sacubitril/valsartan, compared with valsartan, in the frailest patients.

Funding Acknowledgement
Type of funding sources: Other. Main funding source(s): The PARAGON trial was sponsored by Novartis
The clinical relevance of quality of life in patients with acute decompensated heart failure with preserved ejection fraction: insights from the PURSUIT-HFpEF Registry
Authors: Seo M , Watanabe T , Yamada T , Yano M , Hayashi T , Yasumura Y , Hikoso S , Sotomi Y , Sakata Y 
Published: October 2022

Abstract

Background
Improvement of quality of life (QOL) is one of the most important therapeutic goals for patients with heart failure with preserved ejection fraction (HFpEF). It is, therefore, clinically relevant to comprehensively identify aggravating factors among cardiac factors, non-cardiac comorbidities, and social factors. The aim of this study was to elucidate determinant factors of impaired QOL and clarify the association between QOL and prognosis in patients with HFpEF.

Methods and results
Patient data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. EuroQol 5 dimensions 5-level (EQ-5D-5L) data were obtained at discharge to evaluate patients' health-related QOL. A total of 864 patients were enrolled in this study. Multivariable logistic regression analysis revealed that only non-cardiac factors such as age, female sex, frailty, malnutrition and inflammation were significantly associated with low EQ-5D-5L score, whereas cardiac factors showed no significant association after multivariable adjustment. A total of 206 patients died over a mean follow-up period of 2.0±1.2 years. Kaplan–Meier survival curve analysis demonstrated a significant increase in risk of mortality stratified by tertiles of EQ-5D-5L score (p&lt;0.0001). Cox multivariable analysis revealed that patients with low EQ-5D-5L score had a significantly greater risk of mortality than those with high EQ-5D-5L score (adjusted hazard ratio: 2.20 (1.40–3.45), p=0.001).

Conclusion
Among patients with HFpEF, non-cardiac factors such as age, female sex, frailty, malnutrition and inflammation are significantly associated with impaired QOL. The QOL score itself also offers useful prognostic information in patients with HFpEF.

Funding Acknowledgement
Type of funding sources: None.
Efficacy of empagliflozin in patients with heart failure according to baseline KDIGO risk categories – findings from the EMPEROR-Pooled
Authors: Butler J 
Published: October 2022

Abstract

Background and objective
Chronic kidney disease (CKD) is common in patients with heart failure (HF) and is associated with an incrementally higher risk for mortality and morbidity. EMPEROR-Pooled studied 9,718 HF patients across two trials and showed that empagliflozin reduces the risk for HF hospitalization or cardiovascular (CV) death, slows the progression of estimated glomerular filtration rate (eGFR) decline, and improves health status in patients with HF and reduced ejection fraction (HFrEF) as well as preserved ejection fraction (HFpEF).

Purpose
We explored the effect of empagliflozin on CV and kidney endpoints in patients across KDIGO (Kidney Disease Improving Global Outcomes) risk categories in EMPEROR-Pooled.

Methods
3,730 participants with left ventricular EF ≤40% (EMPEROR-Reduced) and 5,988 with left ventricular EF &gt;40% (EMPEROR-Preserved) were categorized using baseline eGFR and UACR values into 4 categories according to KDIGO classification. The key outcomes were (1) a composite of CV death or hospitalization for HF, (2) first hospitalization for HF, (3) CV death and (4) eGFR slope change/year.

Results
The proportion of participants in low-, moderate-, high-, and very high-risk KDIGO categories was 31.4%, 29.6%, 22.0%, 16.9% for empagliflozin and 32.5%, 28.4%, 21.8%, 17.2% for placebo, respectively. Patients on placebo in higher baseline KDIGO risk categories had a higher risk of CV death or hospitalization for HF (6.78, 11.30, 15.15, and 20.70 events per 100 patient-years for low-, moderate-, high-, and very high-risk patients, respectively) (Figure 1). Similar trends were seen for first HF hospitalization (4.46, 7.68, 11.14, and 15.98 per 100 patients-years at risk) and CV death (2.98, 5.31, 5.69, and 7.60 per 100 patients-years at risk). eGFR slope decreased less in higher baseline KDIGO risk categories (−3.13 in low-, −2.81 in moderate-, −2.17 in high- and −1.61 ml/min/1.73 m2 per year in very high-risk category) (Figure 2).
Empagliflozin reduced the risk of CV death or hospitalizations for HF similarly across KDIGO risk categories (hazard ratio [HR] 0.81; 95% confidence interval [CI] 0.66, 1.01 for low-, HR 0.63; 95% CI 0.52, 0.76 for moderate-, HR 0.82; 95% CI 0.68, 0.98 for high- and HR 0.84; 95% CI 0.71, 1.01 for very high-risk group; P trend=0.299). Similarly, empagliflozin reduced the risk of first HF hospitalization (P trend=0.186), CV death (P trend=0.663) or eGFR slope change (P trend=0.069) across the four groups.

Conclusions
Treatment with empagliflozin reduced the risk for CV death or HF hospitalization and slowed the rate of kidney function decline similarly in all KDIGO CKD risk categories.

Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Boehringer Ingelheim & Eli Lilly and Company Diabetes Alliance
Heterogeneous and overlapping mechanisms of myocardial ischemia in patients with ischemia and non-obstructive coronary arteries. Preliminary results from the MOSAIC-COR Registry
Authors: Szolc P S , Niewiara L , Legutko J , Kleczynski P , Rzeznik D , Tekieli L , Podolec J , Diachyshyn M , Stapor M , Zmudka K , Guzik B 
Published: October 2022

Abstract

Background
Patients with ischemia and non-obstructive coronary arteries (INOCA) account for 30–70% of all patients undergoing elective coronary angiography for angina. In these group of patients various mechanisms may be responsible for myocardial ischemia, including increased microvascular resistance, epicardial spasm or microvascular spasm. There are limited data on the prevalence and coexistence of different mechanisms in patients with INOCA.

Purpose
The primary objective was to assess the occurrence of coronary microcirculatory disease (CMD), epicardial vasospastic angina (EVSA), microvascular vasospastic angina (MVSA) and their coexistance in patients with INOCA. The secondary objective was the analysis of subgroups' clinical characteristics.

Methods
This was a single-center, prospective, observational study. In the absence of significant coronary artery stenosis, a complex functional coronary assessment was performed. Values of fractional flow reserve (FFR), RFR, coronary flow reserve (CFR) and index of microcirculatory resistance (IMR) were determined. Coronary artery and microvascular vasoreactivity was tested using the provocative acetylcholine test.

Results
We enrolled 90 consecutive patients with INOCA. Overlapping of CMD and CMD/EVSA phenomenon was observed. Accordingly, we distinguished 6 subgroups of INOCA patients in comparison to the CorMicA trial. Mixed pathophysiology (CMD+EVSA and CMD+MVSA) was diagnosed in 33% of patients. In the CMD+EVSA subgroup, 73% of subjects were male, while in the CMD+MVSA only 7.1% were male (p=0.005). Typical cardiovascular risk factors were common in the whole INOCA group.

Conclusions
The INOCA population is a heterogeneous group with various pathophysiology of myocardial ischemia. Overlapping of different pathomechanisms is a frequent phenomenon, which has to be consider for treatment optimization and future research.

Funding Acknowledgement
Type of funding sources: None.
Ethnic disparities in ST-segment myocardial infarction outcomes and processes of care in patients with and without standard modifiable cardiovascular risk factors: a nationwide cohort study
Authors: Weight N , Moledina S , Dafaalla M , Mamas M A 
Published: October 2022

Abstract

Background
There is growing interest in patients presenting with ST-elevation myocardial infarction (STEMI) in the absence of `standard modifiable cardiovascular risk factors' (SMuRFs), which include current smoking, hypertension, diabetes and hypercholesterolaemia. Recent trials have demonstrated how these “SMuRFless” patients can have poorer outcomes after STEMI then those patients with SMuRFs, but these trials have not looked at the role of ethnicity in outcomes (1).

Methods
We analysed 118,177 STEMI patients using the Myocardial Infarction National Audit Project (MINAP) registry. Clinical characteristics and outcomes were analysed using hierarchical logistic regression models according to the presence of ≥1 SMuRF (88,055) and compared to the “SMuRFless” cohort (30,122), with a subgroup analysis comparing the outcomes of white and ethnic minority patients (comprising Black, Asian, Mixed and other) depending on SMuRF status. Our primary outcomes were in-hospital mortality and major adverse cardiovascular events (MACE), and secondary outcomes were in-hospital cardiac mortality and major bleeding.

Results
SMuRFless patients had a higher incidence of MACE (OR 1.09, CI 1.02–1.16), in-hospital mortality (OR 1.09, CI 1.01–1.18), and cardiac-mortality (OR 1.08, CI 1.00–1.17) than those with SMuRFs after adjusting for baseline demographics, haemodynamic status, killip classification, cardiac arrest, and common comorbidities. There were no statistically significant differences in our outcome measures between white and ethnic minority patients. Ethnic minority patients were more likely to undergo revascularisation by PCI or CABG (ethnic minority with SMuRFs 88%, ethnic minority SMuRFless 87%, white with SMuRFs 80%, white SMuRFless 77%).

Conclusion
SMuRFless patients have a higher incidence of MACE, in-hospital mortality, and cardiac-mortality than those with SMuRFs, which persists after adjusting for baseline demographics, haemodynamic status, killip classification, cardiac arrest, and common comorbidities. Ethnic minority patients were more likely undergo ICA and revascularisation regardless of SMuRF status but did not have poorer outcomes when compared to white patients.

Funding Acknowledgement
Type of funding sources: None.
The association between cardiovascular risk factors and coronary CT angiography findings for predicting obstructive coronary artery disease in Korean patients with stable chest pain
Authors: Kim D , Choi H , Ko D G , Park K T 
Published: October 2022

Abstract

Background/Introduction
The 2019 European Society of Cardiology (ESC) guidelines currently recommend the use of coronary computed tomography angiography (CCTA) as the initial test for diagnosing coronary artery disease (CAD) in symptomatic patients in whom obstructive CAD cannot be excluded by clinical assessment alone.

Purpose
The purpose of this study is to identify the prevalence of obstructive CAD in patients with stable chest pain, and the correlation between several clinical cardiovascular disease (CVD) risk factors and CCTA findings presented by Coronary Artery Disease Reporting and Data System (CAD-RADS).

Methods
The present study is a single-center retrospective cross-sectional study. A total of 1,892 patients with stable chest pain who underwent CCTA were enrolled in this study. Diamond-Forrester classification, Framingham risk score (FRS), atherosclerotic CVD (ASCVD) 10-year risk score, coronary artery calcium score (CACS) and CAD-RADS category were obtained from every patient.

Results
Among 1,892 patients (mean age, 60.5±8.6 years; men, 59.3%), 356 (18.8%) had obstructive CAD according to CCTA. Patients with high and intermediate ASCVD 10-year risk score had 2.59 times (aOR 2.59, 95% CI; 1.58 to 4.23) and 1.66 times (aOR 1.66, 95% CI; 1.04 to 2.65) higher odds of having obstructive CAD than patients with low ASCVD 10-year risk score, respectively (adjusted for Diamond-Forrester classification and CACS group). Higher ASCVD risk scores were significantly associated with higher CAD-RADS category (p&lt;0.001), and patients with CAD-RADS category 3 had ASCVD 10-year risk score of 20.1±12.7. CACS showed the highest discrimination in presence of obstructive CAD, followed by ASCVD 10-year risk score, FRS, and Diamond-Forrester classification (AUC: 0.821 [95% CI; 0.797–0.845]; 0.711 [95% CI; 0.683–0.740]; 0.675 [95% CI; 0.646–0.704]; 0.600 [95% CI; 0.569–0.632], respectively).

Conclusion
This is the first study of CCTA findings in stable chest pain patients in Korea. The prevalence of obstructive CAD in patients with stable chest pain was 18.8%. Higher ASCVD score is significantly associated with presence of obstructive CAD and higher CAD-RADS category. As coronary stenosis of 50%-69% had a mean ASCVD score of 20.1, we should consider CCTA for identifying obstructive CAD in patients with ASCVD score over 20 with stable chest pain.

Funding Acknowledgement
Type of funding sources: None.
Absolute flow and resistance have a lower variability in repeated testing as compared to CFR and IMR: an EDIT-CMD substudy
Authors: Jansen T P J , De Vos A , Damman P , Paradies V , Konst R E , Teerenstra S , Van Den Oord S C H , Dimitriu-Leen A , Maas A H E M , Smits P C , Elias-Smale S E , Van Royen N 
Published: October 2022

Abstract

Background
Invasive coronary function testing (CFT), including both acetylcholine (ACH) spasm provocation testing and assessment of coronary flow and resistance, is recommended to assess coronary vasomotor dysfunction (CVDys) in patients with angina and non-obstructive coronary artery disease (ANOCA).

Objectives
To determine repeat testing reliability of invasive measurements of CVDys.

Methods
In the EDIT-CMD trial, 73 patients underwent both baseline and follow-up CFT after six weeks. Repeat testing reliability for CVDys assessment, including coronary flow reserve (CFR), index of microvascular resistance (IMR), absolute flow (Q) and microvascular resistance (R) was assessed by 1.) comparing continuous values between baseline and follow-up measurement, including difference and correlation between the two measurements 2.) classification agreement (CCA) for the presence of CMD according to cut-offs, which was also assessed for ACH spasm provocation test and 3.) Bland-Altman plots. Fisher-Z scores were used to compare correlations.

Results
Mean CFR was 3.1±1.5 at baseline and 4.1±1.5 at follow-up (P=0.03), with no significant correlation (ρ=0.285, P=0.10). Mean IMR was 27±12 at baseline and 27±19 at follow-up (P=0.94), with a trend to a significant correlation (ρ=0.312, P=0.07). The CCA between the baseline and follow-up was 74% for CFR and 57% for IMR.
Mean Q was 183±72 at baseline and 192±78 at follow-up (P=0.49), with a significant correlation (ρ=0.579, P&lt;0.001). Mean R was 527±233 at baseline and 506±228 at follow-up (P=0.67), with a significant correlation (ρ=0.51, p=0.03). The CCA between R at baseline and 6 weeks follow-up was 72% and for Q this was 82%.
The correlation coefficient (ρ) of Q was significantly better than the ρ of CFR (P=0.006). The ρ of R and IMR did not differ.
For the ACH spasm provocation test we found a CCA of 79% between both measurements.

Conclusion
This is the first study to assess re-test reliability of the invasive CFT. Measurements of Q and R show higher agreement and correlation than their surrogates CFR and IMR in assessing microvascular function. ACH provocation spasm test also demonstrated good re-test reliability.

Funding Acknowledgement
Type of funding sources: Private company. Main funding source(s): Abbott
Effect of rivaroxaban monotherapy vs. combination with anti-platelet therapy in patients with atrial fibrillation and stable coronary artery disease across different body mass index categories
Authors: Ishii M , Kaikita K , Yasuda S , Akao M , Ako J , Matoba T , Nakamura M , Miyauchi K , Hagiwara N , Kimura K , Hirayama A , Matsui K , Ogawa H , Tsujita K 
Published: October 2022

Abstract

Background
The AFIRE (Atrial Fibrillation and Ischemic Events With Rivaroxaban in Patients With Stable Coronary Artery Disease) trial showed both noninferiority for efficacy and superiority for safety endpoints of rivaroxaban monotherapy compared to rivaroxaban plus antiplatelet therapy (combination therapy) in patients with atrial fibrillation (AF) and stable coronary artery disease (CAD). However, no accumulating evidence regarding efficacy and safety of these fixed-dose direct oral anticoagulant therapy was available in underweight and obese patients.

Purpose
The aim of this post-hoc analysis of the AFIRE trial was to evaluate outcomes of rivaroxaban monotherapy (vs. combination therapy) in patients with AF and stable CAD across body mass index (BMI) categories.

Methods
Patients were categorized into groups 1 (underweight: BMI of &lt;18.5 kg/m2), 2 (normal: BMI of 18.5 to &lt;25 kg/m2), 3 (overweight: BMI of 25 to &lt;30 kg/m2), and 4 (obesity: BMI of ≥30 kg/m2). Efficacy (a composite of all-cause death, myocardial infarction, unstable angina requiring revascularization, stroke, or systemic embolism) and safety (major bleeding defined according to International Society on Thrombosis and Haemostasis criteria) were compared between rivaroxaban monotherapy and combination therapy across BMI categories.

Results
We analyzed 2,054 patients with a median age of 75.0 (interquartile range [IQR], 69 to 80)) years old and CHA2DS2-VASc of 4 (IQR, 3 to 5). Group 1 through 4 included 72 (3.5%), 1,158 (56.4%), 680 (33.1%), 144 (7.0%) patients and 62.3%, 52.3%, 36.2%, and 30.3% were received reduced dose of rivaroxaban, respectively. Although the sample sizes for group 1 and 4 were limited, monotherapy was superior to combination therapy for efficacy in group 2 (hazard ratio [HR], 0.64; 95% CI, 0.44 to 0.95) and safety in group 3 (HR, 0.25; 95% CI, 0.10 to 0.62), whereas a significant difference in the endpoints was not observed in the other BMI categories. Impact of monotherapy on endpoints did not have a significant interaction in BMI.

Conclusions
Rivaroxaban monotherapy had similar effect on prognosis across all BMI categories in patients with AF and stable CAD.

Funding Acknowledgement
Type of funding sources: Foundation. Main funding source(s): The Japan Cardiovascular Research Foundation based on a contract with Bayer Yakuhin, Ltd