Browsing by Author "Devore, Adam D"
Now showing 1 - 3 of 3
- Results Per Page
- Sort Options
Item Open Access Blood Pressure Response during Cardiopulmonary Exercise Testing in Heart Failure.(Medicine and science in sports and exercise, 2018-07) Il'giovine, Zachary J; Solomon, Nicole; Devore, Adam D; Wojdyla, Daniel; Patel, Chetan B; Rogers, Joseph GIntroduction
The prognostic value of peak V˙O2 and V˙E/V˙CO2 slope measured during cardiopulmonary exercise (CPX) testing has been well established in patients with advanced heart failure, but blood pressure response to exercise is less well characterized.Methods
We retrospectively studied 151 outpatients who underwent CPX testing as part of an advanced heart failure evaluation. The outcome of interest was failure of medical management, defined by death, cardiac transplantation, or left ventricular assist device placement. Patients were stratified into tertiles by change in systolic blood pressure (SBP) (<13, 13-26, and ≥27 mm Hg) during exercise.Results
Patients in the lowest tertile had the lowest peak V˙O2 (10.2 vs 10.6 vs 13.6 mL·kg·min, P = <0.001), the highest V˙E/V˙CO2 slope (42.8 vs 42.1 vs 36.3, P = 0.030), the shortest mean exercise time (5.1 vs 6.0 vs 7.0 min, P = <0.001), and the highest probability of failure of medical management at 1.5 yr (0.69 vs 0.41 vs 0.34, P = 0.011). After multivariate adjustment, increased SBP <20 mm Hg during exercise was associated with a lower hazard of medical management failure (hazard ratio = 0.96, 95% confidence interval [CI] = 0.934-0.987), whereas SBP increases >20 mm Hg were associated with an increased hazard (hazard ratio = 1.046, 95% CI = 1.018-1.075).Conclusion
In conclusion, changes in SBP during CPX testing provide additional prognostic information above standard clinical variables. The peculiar increase in risk noted in those with a rise in SBP >20 mm Hg is less clear and needs to be investigated further.Item Open Access Projected Clinical Benefits of Implementation of SGLT-2 Inhibitors Among Medicare Beneficiaries Hospitalized for Heart Failure.(Journal of cardiac failure, 2022-04) Vaduganathan, Muthiah; Greene, Stephen J; Zhang, Shuaiqi; Solomon, Nicole; Chiswell, Karen; Devore, Adam D; Butler, Javed; Heidenreich, Paul A; Huang, Joanna C; Kittleson, Michelle M; Joynt Maddox, Karen E; Mcdermott, James J; Owens, Anjali Tiku; Peterson, Pamela N; Solomon, Scott D; Vardeny, Orly; Yancy, Clyde W; Fonarow, Gregg CBackground
The sodium-glucose cotransporter-2 (SGLT-2) inhibitors form the latest pillar in the management of heart failure with reduced ejection fraction (HFrEF) and appear to be effective across a range of patient profiles. There is increasing interest in initiating SGLT-2 inhibitors during hospitalization, yet little is known about the putative benefits of this implementation strategy.Methods
We evaluated Medicare beneficiaries with HFrEF (≤ 40%) hospitalized at 228 sites in the Get With The Guidelines-Heart Failure (GWTG-HF) registry in 2016 who had linked claims data for ≥ 1 year postdischarge. We identified those eligible for dapagliflozin under the latest U.S. Food and Drug Administration label (excluding estimated glomerular filtration rates < 25 mL/min per 1.73 m2, dialysis and type 1 diabetes). We evaluated 1-year outcomes overall and among key subgroups (age ≥ 75 years, gender, race, hospital region, kidney function, diabetes status, triple therapy). We then projected the potential benefits of implementation of dapagliflozin based on the risk reductions observed in the Dapagliflozin and Prevention of Adverse Outcomes in Heart Failure (DAPA-HF) trial.Results
Among 7523 patients hospitalized for HFrEF, 6576 (87%) would be candidates for dapagliflozin (mean age 79 ± 8 years, 39% women, 11% Black). Among eligible candidates, discharge use of β-blockers, ACEi/ARB, MRA, ARNI, and triple therapy (ACEi/ARB/ARNI+β-blocker+MRA) was recorded in 88%, 64%, 29%, 3%, and 20%, respectively. Among treatment-eligible patients, the 1-year incidence (95% CI) of mortality was 37% (36-38%) and of HF readmission was 33% (32-34%), and each exceeded 25% across all key subgroups. Among 1333 beneficiaries eligible for dapagliflozin who were already on triple therapy, the 1-year incidence of mortality was 26% (24%-29%) and the 1-year readmission due to HF was 30% (27%-32%). Applying the relative risk reductions observed in DAPA-HF, absolute risk reductions with complete implementation of dapagliflozin among treatment-eligible Medicare beneficiaries are projected to be 5% (1%-9%) for mortality and 9% (5%-12%) for HF readmission by 1 year. The projected number of Medicare beneficiaries who would need to be treated for 1 year to prevent 1 death is 19 (11-114), and 12 (8-21) would need to be treated to prevent 1 readmission due to HF.Conclusions
Medicare beneficiaries with HFrEF who are eligible for dapagliflozin after hospitalization due to HF, including those well-treated with other disease-modifying therapies, face high risks of mortality and HF readmission by 1 year. If the benefits of reductions in death and hospitalizations due to HF observed in clinical trials can be fully realized, the absolute benefits of implementation of SGLT-2 inhibitors among treatment-eligible candidates are anticipated to be substantial in this high-risk postdischarge setting.Item Open Access The Association Between Beta-blocker and Renin-Angiotensin System Inhibitor Use After Heart Failure With Reduced Ejection Fraction Hospitalization and Outcomes in Older Patients.(Journal of cardiac failure, 2023-04) Gilstrap, Lauren; Solomon, Nicole; Chiswell, Karen; James O'Malley, A; Skinner, Jonathan S; Fonarow, Gregg C; Bhatt, Deepak L; Yancy, Clyde W; Devore, Adam DIntroduction
Beta-blockers (BB) and renin-angiotensin system inhibitors (RASi) are foundational for the treatment of heart failure with reduced ejection fraction (HFrEF). However, given the increased risk of side effects in older patients, uncertainty remains as to whether, on net, older patients benefit as much as the younger patients studied in trials.Methods and results
Using the Get With The Guidelines-Heart Failure registry linked with Medicare data, overlap propensity weighted Cox proportional hazard models were used to examine the association between BB and RASi use at hospital discharge and 30-day and 1-year outcomes among patients with HFrEF. Among the 48,711 patients (aged ≥65 years) hospitalized with HFrEF, there were significant associations between BB and/or RASi use at discharge and lower rates of 30-day and 1-year mortality, including those over age 85 (30-day hazard ratio 0.56, 95% confidence interval 0.45-0.70; 1-year hazard ratio 0.69, 95% confidence interval 0.61-0.78). In addition, the magnitude of benefit associated with BB and/or RASi use after discharge did not decrease with advancing age. Even among the oldest patients, those over age 85, with hypotension, renal insufficiency or frailty, BB and/or RASi use at discharge was still associated with lower 1-year mortality or readmission.Conclusions
Among older patients hospitalized with HFrEF, BB and/or RASi use at discharge is associated with lower rates of 30-day and 1-year mortality across all age groups and the magnitude of this benefit does not seem to decrease with advancing age. These data suggest that, absent a clinical contraindication, BB and RASi should be considered in all patients hospitalized with HFrEF before or at hospital discharge, regardless of age.