145 research outputs found
Impact of the COVID-19 pandemic on implementation of novel guideline-directed medical therapies for heart failure in Germany: a nationwide retrospective analysis
Background
Guideline-directed medical therapy (GDMT) is the cornerstone in the treatment of patients with heart failure and reduced ejection fraction (HFrEF) and novel substances such as sacubitril/valsartan (S/V) and sodium-glucose co-transporter-2 inhibitors (SGLT2i) have demonstrated marked clinical benefits. We investigated their implementation into real-world HF care in Germany before, during, and after the COVID-19 pandemic period.
Methods
The IQVIA LRx data set is based on âŒ80% of 73 million people covered by the German statutory health insurance. Prescriptions of S/V were used as a proxy for HFrEF. Time trends were analysed between Q1/2016 and Q2/2023 for prescriptions for S/V alone and in combination therapy with SGLT2i.
Findings
The number of patients treated with S/V increased from 5260 in Q1/2016 to 351,262 in Q2/2023. The share of patients with combination therapy grew from 0.6% (29 of 5260) to 14.2% (31,128 of 219,762) in Q2/2021, and then showed a steep surge up to 54.8% (192,429 of 351,262) in Q2/2023, coinciding with the release of the European Society of Cardiology (ESC) guidelines for HF in Q3/2021. Women and patients aged >80 years were treated less often with combined therapy than men and younger patients. With the start of the COVID-19 pandemic, the number of patients with new S/V prescriptions dropped by 17.5% within one quarter, i.e., from 26,855 in Q1/2020 to 22,145 in Q2/2020, and returned to pre-pandemic levels only in Q1/2021.
Interpretation
The COVID-19 pandemic was associated with a 12-month deceleration of S/V uptake in Germany. Following the release of the ESC HF guidelines, the combined prescription of S/V and SGLT2i was readily adopted. Further efforts are needed to fully implement GDMT and strengthen the resilience of healthcare systems during public health crises
Profiles of cognitive impairment in chronic heart failureâA cluster analytic approach
BackgroundCognitive impairment is a major comorbidity in patients with chronic heart failure (HF) with a wide range of phenotypes. In this study, we aimed to identify and compare different clusters of cognitive deficits.MethodsThe prospective cohort study âCognition.Matters-HFâ recruited 147 chronic HF patients (aged 64.5 ± 10.8 years; 16.2% female) of any etiology. All patients underwent extensive neuropsychological testing. We performed a hierarchical cluster analysis of the cognitive domains, such as intensity of attention, visual/verbal memory, and executive function. Generated clusters were compared exploratively with respect to the results of cardiological, neurological, and neuroradiological examinations without correction for multiple testing.ResultsDendrogram and the scree plot suggested three distinct cognitive profiles: In the first cluster, 42 patients (28.6%) performed without any deficits in all domains. Exclusively, the intensity of attention deficits was seen in the second cluster, including 55 patients (37.4%). A third cluster with 50 patients (34.0%) was characterized by deficits in all cognitive domains. Age (p = 0.163) and typical clinical markers of chronic HF, such as ejection fraction (p = 0.222), 6-min walking test distance (p = 0.138), NT-proBNP (p = 0.364), and New York Heart Association class (p = 0.868) did not differ between clusters. However, we observed that women (p = 0.012) and patients with previous cardiac valve surgery (p = 0.005) prevailed in the âglobal deficitsâ cluster and the âno deficitsâ group had a lower prevalence of underlying arterial hypertension (p = 0.029). Total brain volume (p = 0.017) was smaller in the global deficit cluster, and serum levels of glial fibrillary acidic protein were increased (p = 0.048).ConclusionApart from cognitively healthy and globally impaired HF patients, we identified a group with deficits only in the intensity of attention. Women and patients with previous cardiac valve surgery are at risk for global cognitive impairment when suffering HF and could benefit from special multimodal treatment addressing the psychosocial condition
"GOLD or lower limit of normal definition? a comparison with expert-based diagnosis of chronic obstructive pulmonary disease in a prospective cohort-study"
<p>Abstract</p> <p>Background</p> <p>The Global initiative for chronic Obstructive Lung Disease (GOLD) defines COPD as a fixed post-bronchodilator ratio of forced expiratory volume in 1 second and forced vital capacity (FEV1/FVC) below 0.7. Age-dependent cut-off values below the lower fifth percentile (LLN) of this ratio derived from the general population have been proposed as an alternative. We wanted to assess the diagnostic accuracy and prognostic capability of the GOLD and LLN definition when compared to an expert-based diagnosis.</p> <p>Methods</p> <p>In a prospective cohort study, 405 patients aged â„ 65 years with a general practitioner's diagnosis of COPD were recruited and followed up for 4.5 (median; quartiles 3.9; 5.1) years. Prevalence rates of COPD according to GOLD and three LLN definitions and diagnostic performance measurements were calculated. The reference standard was the diagnosis of COPD of an expert panel that used all available diagnostic information, including spirometry and bodyplethysmography.</p> <p>Results</p> <p>Compared to the expert panel diagnosis, 'GOLD-COPD' misclassified 69 (28%) patients, and the three LLNs misclassified 114 (46%), 96 (39%), and 98 (40%) patients, respectively. The GOLD classification led to more false positives, the LLNs to more false negative diagnoses. The main predictors beyond the FEV1/FVC ratio for an expert diagnosis of COPD were the FEV1 % predicted, and the residual volume/total lung capacity ratio (RV/TLC). Adding FEV1 and RV/TLC to GOLD or LLN improved the diagnostic accuracy, resulting in a significant reduction of up to 50% of the number of misdiagnoses. The expert diagnosis of COPD better predicts exacerbations, hospitalizations and mortality than GOLD or LLN.</p> <p>Conclusions</p> <p>GOLD criteria over-diagnose COPD, while LLN definitions under-diagnose COPD in elderly patients as compared to an expert panel diagnosis. Incorporating FEV1 and RV/TLC into the GOLD-COPD or LLN-based definition brings both definitions closer to expert panel diagnosis of COPD, and to daily clinical practice.</p
Left Ventricular Remodeling and Myocardial Work: Results From the Population-Based STAAB Cohort Study
Introduction: Left ventricular (LV) dilatation and LV hypertrophy are acknowledged precursors of myocardial dysfunction and ultimately of heart failure, but the implications of abnormal LV geometry on myocardial function are not well-understood. Non-invasive LV myocardial work (MyW) assessment based on echocardiography-derived pressure-strain loops offers the opportunity to study detailed myocardial function in larger cohorts. We aimed to assess the relationship of LV geometry with MyW indices in general population free from heart failure.Methods and Results: We report cross-sectional baseline data from the Characteristics and Course of Heart Failure Stages A-B and Determinants of Progression (STAAB) cohort study investigating a representative sample of the general population of WĂŒrzburg, Germany, aged 30â79 years. MyW analysis was performed in 1,926 individuals who were in sinus rhythm and free from valvular disease (49.3% female, 54 ± 12 years). In multivariable regression, higher LV volume was associated with higher global wasted work (GWW) (+0.5 mmHg% per mL/m2, p < 0.001) and lower global work efficiency (GWE) (â0.02% per mL/m2, p < 0.01), while higher LV mass was associated with higher GWW (+0.45 mmHg% per g/m2, p < 0.001) and global constructive work (GCW) (+2.05 mmHg% per g/m2, p < 0.01) and lower GWE (â0.015% per g/m2, p < 0.001). This was dominated by the blood pressure level and also observed in participants with normal LV geometry and concomitant hypertension.Conclusion: Abnormal LV geometric profiles were associated with a higher amount of wasted work, which translated into reduced work efficiency. The pattern of a disproportionate increase in GWW with higher LV mass might be an early sign of hypertensive heart disease
Anålise de timol em cera de abelha por micro-extracção em fase sólida (SPME)
A aplicação contĂnua de acaricĂdas lipofĂlicos sintĂ©ticos no tratamento das
abelhas conduz a uma acumulação que depende da frequĂȘncia, lipofilicidade e
quantidade de princĂpio activo utilizada. Este efeito Ă© mais acentuado na cera
de abelha que no mel, no entanto, e porque a persistĂȘncia destes resĂduos Ă©
elevada, provoca o aparecimento de resistĂȘncias e a perda do seu efeito
acaricida.[1] Esta razĂŁo levou Ă pesquisa de outros compostos alternativos nĂŁo
tĂłxicos e nĂŁo persistentes, com efeito sobre o ĂĄcaro das abelhas, Varroa
Jacobsoni. Entre estes compostos encontra-se o timol, um composto fenĂłlico,
volĂĄtil, presente no tomilho. Dos diversos componentes dos Ăłleos essenciais
este Ă© sem dĂșvida o que demonstrou maior efeito acaricida, utilizando-se no
tratamento das abelhas directamente ou como componente de diversas
formulaçÔes.[2] Em Portugal, foi introduzido muito recentemente sob a forma
comercial de APIGUARD: um gel, Ă base de timol, que controla termicamente a
libertação do princĂpio activo.
O controlo dos resĂduos de timol na cera de abelha e no mel Ă© assim um
desafio actual quer do ponto de vista sanitĂĄrio quer de qualidade alimentar.
A micro-extracção em fase sólida (SPME) é uma técnica de preparação de
amostras que se baseia na sorção de analĂtos no revestimento de uma fibra de
sĂlica fundida e posterior desorção tĂ©rmica no injector de um cromatĂłgrafo em
fase gasosa (GC). Para alĂ©m de combinar num Ășnico processo etapas de
extracção, purificação e concentração dos analitos, a técnica de SPME
apresenta uma série de vantagens relativamente às técnicas de extracção
convencionais, como a extracção lĂquido-lĂquido e extracção em fase sĂłlida,
nomeadamente a sua relativa simplicidade e rapidez, reduzido custo e nĂŁo
utilização de solventes para a extracção de analitos, para além de permitir a
extracção por imersĂŁo directa na amostra gasosa ou lĂquida e extracção por
amostragem do espaço-de-cabeça da amostra lĂquida ou sĂłlida.[3] Ao contrĂĄrio
das técnicas tradicionais, que permitem uma extracção quantitativa dos
analitos, a tĂ©cnica de SPME baseia-se num equilĂbrio de partição do analito.
Esta particularidade torna a tĂ©cnica de SPME bastante sensĂvel a parĂąmetros
experimentais que possam afectar os coeficientes de partição dos analitos e,
consequentemente, a sensibilidade e reprodutibilidade dos resultados.[4]
O objectivo deste trabalho Ă© o desenvolvimento de uma metodologia para a
anĂĄlise de timol em ceras contaminadas, utilizando como padrĂŁo interno a
benzofenona. Em primeiro lugar, procedeu-se à optimização da técnica através
da determinação da quantidade de cera, temperatura de anĂĄlise e perĂodo de
contacto da fibra com o espaço-de-cabeça da amostra mais adequados para o
caso em estudo. Numa segunda fase, procedeu-se Ă anĂĄlise de diversas
lĂąminas de cera contaminadas propositadamente com timol e sujeitas a
diferentes condiçÔes de armazenamento: em frio, ao ar e em estufa.
Finalmente, procedeu-se à construção da curva de calibração e quantificação
do timol presente nas diversas amostras de cera analisadas.
Considerando-se os resultados, para os nĂveis de contaminação avaliados, as
condiçÔes analĂticas mais adequadas ocorrem com a utilização de 1 g de cera,
mantendo-se a fibra em contacto com o espaço-de-cabeça durante 40 minutos
a uma temperatura de 60 ÂșC. Nestas condiçÔes experimentais foi possĂvel obter
uma boa correlação linear (r2=0,990) no intervalo de concentraçÔes [3,5-14
mg/g]. A quantidade de timol encontrada nas amostras Ă© significativamente
inferior Ă colocada durante o processo de fabrico das lĂąminas, pelo que o
processo de conservação não é o mais adequado, sendo evidente uma menor
quantidade de timol quando a lĂąmina de cera Ă© colocada na estufa
Incremental prognostic value of a novel metaboliteâbased biomarker score in congestive heart failure patients
Aims: The Cardiac Lipid Panel (CLP) is a newly discovered panel of metabolite-based biomarkers that has shown to improve the diagnostic value of N terminal pro B type natriuretic peptide (NT-proBNP). However, little is known about its usefulness in predicting outcomes. In this study, we developed a risk score for 4-year cardiovascular death in elderly chronic heart failure (CHF) patients using the CLP.
Methods and results: From the Cardiac Insufficiency Bisoprolol Study in Elderly trial, we included 280 patients with CHF aged >65 years. A targeted metabolomic analysis of the CLP biomarkers was performed on baseline serum samples. Cox regression was used to determine the association of the biomarkers with the outcome after accounting for established risk factors. A risk score ranging from 0 to 4 was calculated by counting the number of biomarkers above the cut-offs, using Youden index. During the mean (standard deviation) follow-up period of 50 (8) months, 35 (18%) subjects met the primary endpoint of cardiovascular death. The area under the receiver operating curve for the model based on clinical variables was 0.84, the second model with NT-proBNP was 0.86, and the final model with the CLP was 0.90. The categorical net reclassification index was 0.25 using three risk categories: 0-60% (low), 60-85% (intermediate), and >85% (high). The continuous net reclassification index was 0.772, and the integrated discrimination index was 0.104.
Conclusions: In patients with CHF, incorporating a panel of three metabolite-based biomarkers into a risk score improved the prognostic utility of NT-proBNP by predicting long-term cardiovascular death more precisely. This novel approach holds promise to improve clinical risk assessment in CHF patients
PREVALENCE AND PROGNOSTIC IMPACT OF ANEMIA AND RENAL INSUFFICIENCY: RELATION TO HEART FAILURE SEVERITY
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