A Multi-Specialty Delphi Consensus on Assessing and Managing Cardiopulmonary Risk in Patients with COPD

Mohit Bhutani,1 Jean Bourbeau,2 Shaun G Goodman,3 Nathaniel Mark Hawkins,4 Alan G Kaplan,5 Peter James Lin,6 Erika Dianne Penz,7 Subodh Verma,8 Shelley Zieroth9 1Department of Medicine, Division of Pulmonary Medicine, University of Alberta, Edmonton, Alberta, Canada; 2Department of Medicine, Division of Pulmonary Medicine, McGill University Health Centre, McGill University, Montreal, Quebec, Canada; 3Department of Medicine, Division of Cardiology, University of Toronto, Toronto, Ontario, Canada; 4Department of Medicine, Division of Cardiology, University of British Columbia, Vancouver, British Columbia; 5Department of Family and Community Medicine, University of Toronto, Toronto, Ontario, Canada; 6The Canadian Heart Research Centre, Primary Care Initiatives, Toronto, Ontario, Canada; 7College of Medicine, Division of Respirology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; 8Department of Surgery, Department of Pharmacology and Toxicology, University of Toronto, Toronto, Ontario, Canada; 9College of Medicine, Section of Cardiology, University of Manitoba, Winnipeg, Manitoba, CanadaCorrespondence: Mohit Bhutani, Department of Medicine, Division of Pulmonary Medicine, University of Alberta, 3-133 Clinical Sciences Building, 11304-83 Avenue NW, Edmonton, Alberta, T6G 2G3, Canada, Tel +1-780-492-3739, Email [email protected]: In Canada, COPD represents a significant burden to the patient and health system, as it is often under or misdiagnosed and sub-optimally treated. Cardiovascular disease (CVD) is a common co-morbidity in COPD and there is significant interplay between these two chronic conditions. Across all stages of COPD disease severity, deaths can be attributed not only to respiratory causes but also to cardiovascular-related factors. The established links between COPD and CVD suggest the need for a greater degree of collaboration between respirologists and cardiologists. This modified Delphi consensus was initiated to consider how optimal COPD care can be delivered within Canada, with specific consideration of reducing cardiopulmonary risk and outcomes in COPD patients.Methods: A steering group with interest in the management of COPD and CVD from primary care, cardiology, and respirology identified 40 statements formed from four key themes. A 4-point Likert scale questionnaire was sent to healthcare professionals working in COPD across Canada by an independent third party to assess agreement (consensus) with these statements. Consensus was defined as high if ≥ 75% and very high if ≥ 90% of respondents agreed with a statement.Results: A total of 100 responses were received from respirologists (n=30), cardiologists (n=30), and primary care physicians (n=40). Consensus was very strong (≥ 90%) in 28 (70%) statements, strong (≥ 75 and < 90%) in 7 (17.5%) statements and was not achieved (< 75%) in 5 (12.5%) of statements.Conclusion: Based on the consensus scores, 9 key recommendations were proposed by the steering group. These focus on the need to comprehensively risk stratify and manage COPD patients to help prevent exacerbations. Consensus within this study provides a call to action for the expeditious implementation of the latest COPD guidelines from the Canadian Thoracic Society.Keywords: chronic obstructive pulmonary disease, consensus development, consultation and referral, primary care, health care, Canad

An international Delphi consensus regarding best practice recommendations for hyperkalaemia across the cardiorenal spectrum.

AIMS: Renin-angiotensin-aldosterone system inhibitors (RAASi) are guideline-recommended therapy for individuals with cardiorenal disease. They are associated with increased risk of hyperkalaemia, a common and life-threatening disorder for this population. RAASi-induced hyperkalaemia often leads to dose reduction or discontinuation, reducing cardiorenal protection. Guideline recommendations differ between specialties for the clinical management of hyperkalaemia. Using a modified Delphi method, we developed consensus recommendations for optimal management of hyperkalaemia in adults with cardiorenal disease. METHODS AND RESULTS: An international steering group of cardiologists and nephrologists developed 39 statements regarding hyperkalaemia care, including risk factors and risk stratification, prevention, correction, and cross-specialty coordination. Consensus was determined by agreement on an online questionnaire administered to cardiorenal specialists across Europe and North America. The threshold for consensus agreement was established a priori by the steering group at 67%. Across November 2021, 520 responses were received from Canada (n = 50), France (n = 50), Germany (n = 54), Italy (n = 58), Spain (n = 57), the UK (n = 49), and the US (n = 202); 268 from cardiologists and 252 from nephrologists. Twenty-nine statements attained very high agreement (≥90%) and 10 attained high agreement (≥67%-<90%), with strong alignment between cardiologists and nephrologists. CONCLUSION: A high degree of consensus regarding hyperkalaemia evaluation and management exists among healthcare professionals. Based on high levels of agreement, the steering group derived six key recommendations for hyperkalaemia prevention and management in people with cardiorenal disease. Future studies examining the quality of hyperkalaemia care delivery are required

Pseudo cardiac tamponade in the setting of excess pericardial fat

Cardiac tamponade is the phenomenon of hemodynamic compromise caused by a pericardial effusion. Following a myocardial infarction, the most common causes of pericardial fluid include early pericarditis, Dressler's syndrome, and hemopericardium secondary to a free wall rupture. On transthoracic echocardiography, pericardial fluid appears as an echo-free space in between the visceral and parietal layers of the pericardium. Pericardial fat has a similar appearance on echocardiography and it may be difficult to discern the two entities. We present a case of a post-MI patient demonstrating pseudo tamponade physiology in the setting of excessive pericardial fat

Empagliflozin in acute myocardial infarction in patients with and without type 2 diabetes : A pre-specified analysis of the EMPACT-MI trial

Aims: In the EMPACT-MI trial, empagliflozin reduced heart failure (HF) hospitalizations but not mortality in acute myocardial infarction (MI). Contemporary reports of clinical event rates with and without type 2 diabetes mellitus (T2DM) in acute MI trials are sparse. The treatment effect of empagliflozin in those with and without T2DM in acute MI is unknown. Methods and results: A total of 6522 patients with acute MI with newly reduced left ventricular ejection fraction (LVEF) to <45%, congestion, or both, were randomized to empagliflozin 10 mg or placebo. The primary endpoint was time to first HF hospitalization or all-cause death. Rates of endpoints with and without T2DM and the efficacy and safety of empagliflozin according to T2DM status were assessed. Overall, 32% had T2DM; 14% had pre-diabetes; 16% were normoglycaemic; 38% had unknown glycaemic status. Patients with T2DM, compared to those without T2DM, were at higher risk of time to first HF hospitalization or all-cause death (hazard ratio [HR] 1.44; 95% confidence interval [CI] 1.06-1.95) and all-cause death (HR 1.70; 95% CI 1.13-2.56). T2DM did not confer a higher risk of first HF hospitalization (HR 1.22, 95% CI 0.82-1.83). Empagliflozin reduced first and total HF hospitalizations, but not all-cause mortality, regardless of presence or absence of T2DM. The safety profile of empagliflozin was the same with and without T2DM. Conclusion: Patients with acute MI, LVEF <45% and/or congestion who had T2DM were at a higher risk of mortality than those without T2DM. Empagliflozin reduced first and total HF hospitalizations regardless of the presence or absence of T2DM

Left Ventricular Function, Congestion, and Effect of Empagliflozin on Heart Failure Risk After Myocardial Infarction

Background: Empagliflozin reduces the risk of heart failure (HF) hospitalizations but not all-cause mortality when started within 14 days of acute myocardial infarction (AMI). Objectives: This study sought to evaluate the association of left ventricular ejection fraction (LVEF), congestion, or both, with outcomes and the impact of empagliflozin in reducing HF risk post-AMI. Methods: In the EMPACT-MI (Trial to Evaluate the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction) trial, patients were randomized within 14 days of an AMI complicated by either newly reduced LVEF<45%, congestion, or both, to empagliflozin (10 mg daily) or placebo and were followed up for a median of 17.9 months. Results: Among 6,522 patients, the mean baseline LVEF was 41 ± 9%; 2,648 patients (40.6%) presented with LVEF <45% alone, 1,483 (22.7%) presented with congestion alone, and 2,181 (33.4%) presented with both. Among patients in the placebo arm of the trial, multivariable adjusted risk for each 10-point reduction in LVEF included all-cause death or HF hospitalization (HR: 1.49; 95% CI: 1.31-1.69; P < 0.0001), first HF hospitalization (HR: 1.64; 95% CI: 1.37-1.96; P < 0.0001), and total HF hospitalizations (rate ratio [RR]: 1.89; 95% CI: 1.51-2.36; P < 0.0001). The presence of congestion was also associated with a significantly higher risk for each of these outcomes (HR: 1.52, 1.94, and RR: 2.03, respectively). Empagliflozin reduced the risk for first (HR: 0.77; 95% CI: 0.60-0.98) and total (RR: 0.67; 95% CI: 0.50-0.89) HF hospitalizations, irrespective of LVEF or congestion, or both. The safety profile of empagliflozin was consistent across baseline LVEF and irrespective of congestion status. Conclusions: In patients with AMI, the severity of left ventricular dysfunction and the presence of congestion was associated with worse outcomes. Empagliflozin reduced first and total HF hospitalizations across the range of LVEF with and without congestion. (Trial to Evaluate the Effect of Empagliflozin on Hospitalization for Heart Failure and Mortality in Patients with Acute Myocardial Infarction [EMPACT-MI]; NCT04509674

iCARDIO Alliance Global Implementation Guidelines on Heart Failure 2025

Inconsistencies in healthcare access, varying infrastructure, resource constraints and diverse local practices as well as practical and political issues restrict the global applicability of currently available guidelines. There is a need for universal recommen dations that address the unique challenges faced by patients and healthcare providers worldwide. Our iCARDIO Alliance Global Implementation Guidelines emphasize the incorporation of novel therapies, while integrating standard of care with the most uptodate evidence to enable clinicians to optimize patient care. This document is about heart failure (HF), including acute and chronic heart failure, heart failure with reduced ejection fraction and heart failure with preserved ejection fraction as well as cardiomyopathies. Contextspecific recommendations tailored to individual patient needs are highlighted providing a thorough evaluation of the risks, benefits, and overall value of each therapy, aiming to establish a standard of care that im proves patient outcomes and reduces the burden of hospitalization in this susceptible population. These guidelines provide evidencebased recommendations that represent a group consensus considering the many other published guidelines that have reviewed many of the issues discussed here, but they also make new recommendations where new evidence has recently emerged. Most importantly these guidelines also provide recommendations on a number of issues where resource limitations may put constraints on the care provided to HF patients. Such “economic adjustment” recommendations aim to provide guid ance for situations when “Resources are somewhat limited” or when “Resources are severely limited”. Hence, this document presents not only a comprehensive but also concise update to HF management guidelines thereby aiming to provide a unified strategy for the pharmacological, nonpharmacological, invasive and interventional management of this significant global health challenge that is applicable to the needs of healthcare around the globe.Versión publicada - versión final del edito

Sacubitril/valsartan in heart failure with mildly reduced or preserved ejection fraction: a pre-specified participant-level pooled analysis of PARAGLIDE-HF and PARAGON-HF

Background and aims: The PARAGLIDE-HF trial demonstrated reductions in natriuretic peptides with sacubitril/valsartan compared with valsartan in patients with heart failure (HF) with mildly reduced or preserved ejection fraction who had a recent worsening HF event, but was not adequately powered to examine clinical outcomes. PARAGON-HF included a subset of PARAGLIDE-HF-like patients who were recently hospitalized for HF. Participant-level data from PARAGLIDE-HF and PARAGON-HF were pooled to better estimate the efficacy and safety of sacubitril/valsartan in reducing cardiovascular and renal events in HF with mildly reduced or preserved ejection fraction. Methods: Both PARAGLIDE-HF and PARAGON-HF were multicenter, double-blind, randomized, active-controlled trials of sacubitril/valsartan vs. valsartan in patients with HF with mildly reduced or preserved left ventricular ejection fraction (LVEF &gt;40% in PARAGLIDE-HF and ≥45% in PARAGON-HF). In the pre-specified primary analysis, we pooled participants in PARAGLIDE-HF (all of whom were enrolled during or within 30 days of a worsening HF event) with a ‘PARAGLIDE-like’ subset of PARAGON-HF (those hospitalized for HF within 30 days). We also pooled the entire PARAGLIDE-HF and PARAGON-HF populations for a broader context. The primary endpoint for this analysis was the composite of total worsening HF events (including first and recurrent HF hospitalizations and urgent visits) and cardiovascular death. The secondary endpoint was the pre-specified renal composite endpoint for both studies (≥50% decline in estimated glomerular filtration rate from baseline, end-stage renal disease, or renal death). Results: Compared with valsartan, sacubitril/valsartan significantly reduced total worsening HF events and cardiovascular death in both the primary pooled analysis of participants with recent worsening HF (n=1,088; rate ratio [RR] 0.78; 95% confidence interval [CI] 0.61-0.99; P=0.042) and in the pooled analysis of all participants (n=5,262; RR 0.86; 95% CI: 0.75-0.98; P=0.027). In the pooled analysis of all participants, first nominal statistical significance was reached by day 9 after randomization and treatment benefits were larger in those with LVEF ≤60% (RR 0.78; 95% CI 0.66-0.91) compared with those with LVEF &gt;60% (RR 1.09; 95% CI 0.86-1.40; Pinteraction=0.021). Sacubitril/valsartan was also associated with lower rates of the renal composite endpoint in the primary pooled analysis (hazard ratio [HR] 0.67; 95% CI 0.43-1.05; P=0.080) and the pooled analysis of all participants (HR 0.60; 95% CI 0.44-0.83; P=0.002). Conclusions: In pooled analyses of PARAGLIDE-HF and PARAGON-HF, sacubitril/valsartan reduced cardiovascular and renal events among patients with HF with mildly reduced or preserved ejection fraction. These data provide support for use of sacubitril/valsartan in patients with HF with mildly reduced or preserved ejection fraction, particularly among those with an LVEF below normal, regardless of care setting