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21st April 2023
Hospital Healthcare Europe is delighted to welcome cardiologist Dr Andrew Coats as an advisory board member and speaker at the upcoming Clinical Excellence in Cardiovascular Care event on 10 May 2023.
Dr Coats, Scientific Director and CEO at Sydney’s Heart Research Institute, will chair a panel discussion on the use and misuse of modern technology in the treatment of the heart. He will be joined by consultant cardiologists Matthew Kahn and Jennifer Peal from Liverpool Heart and Chest Hospital and Newcastle’s Freeman Hospital, respectively.
This inaugural event in HHE’s Clinical Excellence series brings together renowned experts from recognised Centres of Excellence to share best practice and explore the latest advances in cardiovascular care from heart failure to interventional cardiology.
Providing the opportunity to gain CPD hours, the day-long event will also focus on how to best use multidisciplinary teams and improve patient care in this area. The agenda has been created by HHE with the support of four advisory board members to offer cardiologists and members of the multidisciplinary team a comprehensive overview of this broad clinical area.
To coincide with the event, a new Clinical Excellence section has been added to the HHE website with a whole host of additional content and interviews with prominent cardiologists from Centres of Excellence and beyond. This includes a fascinating interview with Dr Coats, who is also editor-in-chief of the Cardiac Failure Review journal. HHE spoke to him about his career in cardiology, and heart failure in particular, as well as his pioneering approach to optimising and achieving excellence in patient care.
Find out more about Clinical Excellence in Cardiovascular Care, including the timings and agenda, and register for free, here.
Further events in HHE’s Clinical Excellence series will be announced soon, with respiratory coming first in the summer of 2023.
17th April 2023
Dr Andrew Coats describes himself as a career cardiologist specialising in heart failure. He is CEO and scientific director of the Heart Research Institute in Sydney, Australia.
Spending around two-thirds of his time in Australia and the remainder in the UK, Dr Coats has had three separate careers. He left medicine to pursue several management and fund-raising roles, took up an academic position and finally moved into commercialisation – currently holding many patents and three start-up companies focusing on devices related to heart failure.
He spoke to Hospital Healthcare Europe about his career and work in cardiology.
The Institute is dedicated to heart disease and is a basic science research institute looking at novel treatments. In addition to running the Institute, I still find time to see patients, where my focus is on heart failure. The centre is involved with the delivery of a wide range of cardiovascular treatments and interventions, including transplantations.
The challenge in healthcare is getting funding for ever more that you can do. Running a clinical service in the NHS, as I did in the early 2000s, brings its own challenges, especially managing performance, but having an MBA management qualification helps a lot. While most managers look for ways to increase staff performance, in the NHS setting I had to manage performance differently. Given a fixed annual budget for the services we could provide, my role was to prevent surgeons and cardiologists from undertaking too much work and spending the fixed annual budget too quickly. But managing a service is difficult with the overarching challenge being to make it all work under cost pressures, disease pressures, surviving the Covid-19 era, dealing with political diktats and doing it all affordably, despite the demand from an ageing population and expectations increasing.
While there are many clinical and scientific achievements within the organisation, the people are both our best weapon and our worst enemy. Consequently, it is fundamental to achieve a sense of team spirit, effective leadership and communication – you can do 10 times more if you align people and if they’re working together. You can have people who are working furiously for what they perceive as the important pressures and what they’re trying to achieve, but a lot of that effort is wasted if they’re not co-ordinated. The biggest challenges and the greatest successes are achieving a joined-up sense of working together.
It’s not so much the written strategy for an organisation that is ultimately important but the process of writing one because you get people to talk to each other and understand each other’s perspective. This creates a shared understanding of what they are trying to achieve together and not just their piece of the puzzle. This shared understanding is crucial to the success of a service, largely because it allows clinicians, whose primary focus is patient care, to appreciate the wider perspective of the service as a whole.
The Institute has formalised and written curricula, which are accredited, for young doctors wishing to specialise in cardiology. These doctors are allocated to hospitals with dedicated trainers and educators to allow them the necessary time to gain experience and become independent consultants a few years later. Over the last 10 to 15 years, there has been a greater and separate accreditation for their ability to perform certain complex or high-risk procedures. This requires the clinician to demonstrate capability, audit their practice and do a minimum number of procedures every year to maintain their accreditation.
Today, I’m a clinical researcher who evaluates patients rather than undertaking laboratory-based work. In other words, assessing patients’ responses to treatment or the impact of novel devices and involvement with clinical trials. I’ve been involved in many studies over the years and some have led to changes in clinical practice. For instance, I was the first to demonstrate the huge benefits of exercise among those with end-stage heart failure awaiting a transplant, dispelling the perceived wisdom at the time that such patients should not exercise. While not the only group, my team and I were able to show that beta-blockers – which were thought to worsen heart failure and should therefore be avoided – could in fact improve survival if started slowly. More recently, I’ve worked with others to discover that the SGLT-2 inhibitors designed for use in type 2 diabetes are effective in heart failure.
While there have been many benefits associated with medical treatments, devices are very much a growth area. This includes several device therapies that, for instance, can cause electrical stimulation and blockade of the reflex control system, as well as those pacing the heart in a more sophisticated way. Or even devices to control blood flow across the chambers of the heart. Such devices, together with stem cell and gene therapy and monoclonal antibodies, mean the developments in heart failure occur from a variety of different sources.
Perhaps one of the biggest challenges in cardiovascular disease is the need for a paradigm shift in the treatment approach. There are currently two diametrically opposed approaches: splitters and lumpers. The splitters’ philosophy is predicated on the belief that because every patient is unique, treatment should be personalised. In contrast, lumpers believe it is more productive to focus on a particular disease and perform trials to see what works. However, while the lumper approach identifies benefits for patients with a particular condition, these interventions are not always 100% effective.
In heart failure, for example, there are actually two types: a low and a high ejection fraction. Drug treatments mainly work in low ejection fraction. In fact, when drug therapy was used in those with a high ejection fraction, the treatment was ineffective simply because there are several possible causes of this type of heart failure. In trying to better understand which patients are likely to respond to a treatment intervention, cardiologists have borrowed the strategy of precision medicine used by oncologists.
It therefore becomes possible to define patients into much smaller subtypes of disease and then optimise the treatments for this subgroup. While patient identification may initially be more expensive, the overall cost to the health service is lower as there are a smaller number of patients within each subtype. In short, the challenge is therefore to move cardiology from lumpers to splitters and develop more precision medicine.
I’m also involved in multiple research projects developing a raft of innovations, and these will hopefully deliver improvements to the care of patients with heart failure in the coming years.
Dr Coats is an advisory board member for HHE Clinical Excellence in Cardiovascular Care. He will be chairing a panel discussion at the event on 10 May 2023. Find out more and register for free here.
6th April 2023
In a study using deep learning-enabled image segmentation of cardiac magnetic resonance imaging data, US researchers identified how variation in the left ventricle (LV) sphericity index in otherwise normal hearts, predicts the risk for cardiomyopathy and related outcomes such as atrial fibrillation.
Dilation of cardiac chambers and or a decline in systolic function are key indicators of disease and which can be assessed using conventional imaging modalities to quantify such changes. Moreover, deep neural networks have shown a great potential in image pattern recognition and automated methods achieve a performance on par with human experts in analysing cardiovascular magnetic resonance images and deriving clinically relevant measures. Cardiomyopathies of different aetiologies can often result in a similar end-stage phenotype of a more round, spherical ventricle. In fact, in patients with cardiac diseases, a greater sphericity of the left ventricle, has, for example, been shown to be an independent predictor of 10-year survival following an acute myocardial infarction. In the current study, researchers thought that even among those with normal heart function, there was likely to be variation in cardiac sphericity, in particular, sphericity of the left ventricle and that this may serve as marker of cardiac risk, especially among those with an underlying genetic risk.
Using automated deep-learning segmentation of cardiac magnetic resonance imaging (MRI) data, the researchers estimated and analysed the sphericity index in patients who were part of the UK Biobank database but excluded those with either abnormal left ventricular size or systolic function.
Cardiac sphericity and risk of cardiomyopathy
In a total of 38,897 participants, the researchers calculated that for one standard deviation increase in the sphericity index, or roundness of the heart, there was an associated 47% increased incidence of cardiomyopathy (hazard ratio, HR = 1.47, 95% CI 1.10 – 1.98, p = 0.01). In addition, the same increase in the sphericity index, was associated with a 20% increased incidence of atrial fibrillation (HR = 1.20, 95% CI 1.11 – 1.28, p < 0.001) and which was independent of clinical factors and traditional magnetic resonance imaging (MRI) measurements. In contrast, similar increases in the sphericity index were non-significantly associated with the risk of both heart failure (p = 0.3) and cardiac arrest (p = 0.70).
The team also identified four loci associated with sphericity at genome-wide significance and concluded that the variation in left ventricular sphericity in otherwise normal hearts, predicts the risk for cardiomyopathy and related outcomes and is caused by non-ischaemic cardiomyopathy.
Citation
Vukadinovic M et al. Deep learning-enabled analysis of medical images identifies cardiac sphericity as an early marker of cardiomyopathy and related outcomes. Med 2023
1st March 2023
Increases in the level of N-terminal B-type natriuretic peptide (NT-proBNP) over time are associated with a higher risk of incident heart failure and death among those initially without the disease according to the findings of a study by US researchers.
NT-proBNP levels serve as an important biomarker for patients with chronic heart failure. In fact, higher levels of the protein upon admission to hospital with COVID-19, have also been associated with an increased mortality risk and other complications in patients with and without heart failure. However, in many studies, NT-proBNP has been assessed at a single time-point and in the current work, researchers looked at changes in the biomarker over time and whether this might be prognostic for the development of heart failure among those who were initially free of the disease.
The team used data from the Atherosclerosis in the Communities (ARIC) study and included participants who had measurements of the biomarker at year 2 and 6 (i.e., 4 years apart) but had not been diagnosed with heart failure. The primary exposure variable was the change in NT-proBNP between visits 2 and 4, categorised as either <125 pg/mL or ≥125 pg/mL and the primary outcome measures were set as incident heart failure (HF) hospitalisation and all-cause mortality.
NT-proBNP and risk of heart failure
Data were available for 9,776 individuals (mean age = 57.1 years, 56.5% female) and who were included in the analysis.
Individuals with NT-proBNP levels of 125 pg/mL or higher at both visits had a significantly higher risk of incident HF compared to those with levels below this threshold (adjusted Hazard Ratio, aHR = 2.40, 95% CI 2.00 – 2.88). Similarly, there was an elevated risk of mortality (aHR = 1.68, 95% CI 1.47 – 1.91). Interestingly, those with NT-proBNP levels of 125 pg/mL or higher at visit 2 but which was lower at visit 4, still had a higher risk of HF although the result was not significant (HR = 1.01, 95% 0.71 – 1.43) when compared to those who levels were below the threshold at both visits. There was also a significant increase in HF and mortality risk based on the percent change in the biomarker per 1 standard deviation increase. There were also significant associations with cardiovascular risk factors such as systolic blood pressure, body mass index, triglyceride and low-density lipoprotein cholesterol and the change in NT-proBNP.
The authors concluded that the changes in NT-proBNP over time, reflected a dynamic change in the risk of HF events and death among those without prevalent clinical HF. They added that serial measurements of NT-proBNP could be use to improve risk stratification of patients pre-heart failure.
Citation
Jia X et al. Association of Long-term Change in N-Terminal Pro-B-Type Natriuretic Peptide With Incident Heart Failure and Death. JAMA Cardiol 2023
24th January 2023
Treatment with the loop diuretic torsemide (TM) leads to a similar level of all-cause mortality and all-cause hospitalisations as furosemide (FM) following hospital discharge in patients with heart failure according to the findings of a randomised trial by US researchers.
Heart failure is growing public health concern with an estimated global prevalence exceeding 37.7 million people. Both fluid retention and congestion are key features of the condition which are treated with loop diuretics and this approach is recommended in therapy guidelines. Although furosemide is an established loop diuretic, another agent, torsemide, has both a longer half-life and greater oral bioavailability than furosemide. Moreover, some evidence points to a lower mortality in patients with congestive heart failure treated with torsemide compared to furosemide. However, studies have not been sufficiently powered to address mortality differences between the two agents.
In the present study, researchers undertook an open-label, randomised trial to examine the comparative effectiveness of TM and FM in patients discharged from hospital following an admission for heart failure, irrespective of their ejection fraction. The researchers hypothesised that torsemide would lower all-cause mortality by 20% compared to furosemide. Patients were eligible if they were hospitalised for either de novo heart failure or a worsening of chronic heart failure and randomised 1:1 to either furosemide or torsemide. The researchers set the primary effectiveness outcome as all cause mortality whereas one of the main secondary outcomes was all-cause hospitalisations.
Torsemide and all-cause mortality
A total of 2,859 patients with a mean age of 64.5 years (36.9% female) were randomised to either diuretic and followed for a median of 17.4 months.
During follow-up, death occurred in 26.1% of the TM group and 26.2% of the FM group and this difference was not significant (hazard ratio, HR = 1.02, 95% CI 0.89 – 1.18, p = 0.76). In addition, all-cause mortality or all-cause hospitalisations occurred in 47.3% of those assigned to TM and 49.3% of patients in the FM group (HR = 0.92, 95% CI 0.83 – 1.02). There were also no significant differences in any of the subgroups analysed, including patients with differing levels of ejection fractions.
Although there were no significant differences between the two loop diuretics, the researchers did acknowledge at least two potentially important study limitations including treatment discontinuation (9.5% of any agent at 6 months) and cross-over (7% for TM to FM) between the two agents could have had an effect.
They concluded that while torsemide did not lower all-cause mortality compared to furosemide, these findings should be interpreted with caution given the rates of discontinuation and cross-over.
Citation
Mentz RJ et al. Effect of torsemide vs furosemide after discharge on all-cause mortality in patients hospitalized with heart failure: The TRANSFORM-HF randomized clinical trial. JAMA 2023
4th November 2022
A higher level of plant omega-3 levels in ambulatory heart failure patients significantly reduced all-cause mortality and first heart failure hospitalisation risk compared to levels of marine-based omega-3 according to the findings of a study by Spanish researchers.
The supplementation with marine-based omega-3 fatty acids can provide a small beneficial advantage in terms of mortality and cardiovascular-related hospital admission in patients with heart failure. Other work has suggested that omega-3 fatty acid supplements also offer benefits on recurrent heart failure hospitalisation although further work is required to confirm these findings. However, not everyone eats fish or wants to take supplements and for such individuals, omega-3 fatty acids can be obtained through the diet via other sources. For example, plant omega-3 sources include alpha-linolenic acid (ALA) which is present in flaxseed and walnut oil. But whether this plant-based source of fatty acids provides the same benefits to heart failure patients as marine-based acids is unclear.
In the present study, the Spanish team speculated that regular consumption of ALA foods would provide a beneficial effect in terms of morbidity and mortality for patients with heart failure. To provide a more accurate measure of intake, rather than relying on self-reporting, the Spanish team assessed ALA levels in serum phospholipids which provides a more objective measure of ALA intake. For comparative purposes, they also measured serum levels of marine-based omega-3 fatty acids, eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA). The team recruited patients who attended a heart failure unit with a tertiary hospital in Barcelona. The primary outcome was a composite of all-cause mortality or first heart failure hospitalisation although the researchers also separately examined the components of the composite as secondary outcomes. The levels of ALA were split into quartiles and multivariable regression analysis was used and focused on a comparison of the lowest (Q1) versus the highest (Q2 – Q4) levels.
Plant omega 3 levels and heart failure outcomes
A total of 905 patients with a mean age of 67 years (31.7% female) were included and followed up for a median of 2.4 years.
The primary endpoint occurred in 184 patients during follow-up including141 heart failure hospitalisations. When comparing ALA levels between Q1 and Qs 2-Q4, there was a 39% lower risk of the primary endpoint (Hazard ratio, HR = 0.61, 95% CI 0.46 – 0.81, p = 0.001). There were similarly significant reductions for the components of the composite, i.e., all-cause mortality (HR = 0.58, 95% CI 0.41 – 0.82, p = 0.002) and first heart failure hospitalisation (HR = 0.58, 95% CI 0.40 – 0.84).
Interestingly, when looking at the combined levels of EPA and DHA there was no significant effect on the primary endpoint when comparing Q1 with Q2 – Q4 (HR = 1.11, 95% CI 0.82 – 1.51, p = 0.502). The effect on both all-cause mortality and heart failure hospitalisation were also non-significant.
The authors concluded that elevated levels of plant omega-3 fatty acids in serum were related to a lower risk of incident adverse clinical outcomes in patients with heart failure.
Citation
Lazaro I et al. Relationship of Circulating Vegetable Omega-3 to Prognosis in Patients With heart failure J Am Coll Cardiol 2022
13th October 2022
Heart failure patients who receive remote disease monitoring and consultations may experience short-term cardiovascular and mortality benefits.
Digital health interventions (DHIs) have contributed to the transformation of healthcare delivery in the past decade and especially since the COVID-19 pandemic when interventions such as telemedicine for remote consultations became the ‘norm’ in many specialities.
Nevertheless, while imposed in many therapy areas during the pandemic, there are actually potential benefits for patients cardiovascular disease. For example, connected health technologies, such as mobile phones, smartphones, tablets, wearable devices, smartwatches and personal health sensors, all provide an opportunity to revolutionise cardiovascular disease prevention through personalised, convenient, and easily accessible patient education and behaviour change support.
The value of DHIs for the prevention of cardiovascular disease was explored in a systematic review and meta-analysis in 2015, in which the authors concluded that the available data provide evidence that DHIs can reduce cardiovascular disease (CVD) outcomes and have a positive impact on risk factors for CVD.
However, given that the data used in the aforementioned meta-analysis was collected more than 8 years ago and the COVID-19 pandemic lead to enforced telemedicine and remote monitoring, for the present study, a Malaysian team of researchers sought to update the effectiveness of DHIs for patients with cardiovascular disease.
The researchers included randomised trials, observational and cohort studies that specifically addressed the effect of a telemedicine intervention on cardiovascular outcomes for those either at risk (i.e. for primary prevention) or those with established CVD (secondary prevention).
The primary outcome was cardiovascular-related mortality, whereas secondary outcomes included hospitalisation, all-cause mortality and all-cause hospitalisation. Interventions were categorised as remote consultations; remote monitoring of health or diagnostic measures; transmission of medical data and finally remote case management.
A total of 72 studies with 127,869 participants (65% male) were included in the analysis. The duration of studies ranged from 1 to 79 months and 49 were short-term (< 12 months) and 22 long-term (> 12 months). Overall, 39 studies included patients with heart failure, 19 addressed secondary prevention and 12 primary prevention.
For heart failure patients, combined remote monitoring and consultation were associated with a 17% reduced risk of cardiovascular mortality (risk ratio, RR = 0.83, 95% CI 0.70 – 0.99, p = 0.036). In addition, this combination significantly reduced hospitalisation for a cardiovascular cause (RR = 0.71, 95% CI 0.58 – 0.87, p = 0.0002) though this was largely in short-term (i.e. < 12 month) studies.
However, telemedicine had no effect on all-cause hospitalisation among those with heart failure (RR = 1.02, 95% CI 0.94 – 1.10, p = 0.71).
In secondary prevention studies, the combination of remote monitoring and consultation was associated with a small reduction in systolic blood pressure (mean difference = -3.59, p < 0.0001) but not on diastolic pressure. There was also a small but significant effect of remote consultations on body-mass index (p < 0.0064) in primary prevention.
The authors concluded that a combination of remote disease monitoring and consultation appeared to reduce cardiovascular-related hospitalisation and mortality risk among patients with heart failure in the short-term.
They called for future research to evaluate the sustained effect of telemedicine interventions.
Citation
Kuan PX et al. Efficacy of telemedicine for the management of cardiovascular disease: a systematic review and meta-analysis Lancet Digit Health 2022.
17th June 2022
The different exercise-based cardiac rehabilitation programs available for those with heart failure all appear to provide broadly similar benefits to patients. This was the main conclusion of a network meta-analysis by Australian researchers.
Heart failure patients have a reduced exercise capacity and one important aspect of a cardiac rehabilitation program is physical activity and exercise. In fact, exercise-based cardiac rehabilitation programs have demonstrated numerous benefits for people with heart failure including improvements in exercise capacity, quality of life and better clinical outcomes.
There are several different types of exercise-based cardiac rehabilitation programs including home-based (HB), centre-based (CB), hybrid-based (HB), where more two delivery modes were included in the program and finally, technology-enabled (TE) where > 50% of the program was delivered via text messaging or video calls.
While there is clear evidence that exercise-based cardiac rehabilitation programs are effective, what is not so clear is the the relative merits of the different programs, since in most analyses, pairwise comparisons have be used.
For the present study, the Australian team turned to the use of a network meta-analysis, which enables the simultaneous comparison of the different interventions to overcome the limitations imposed by using a pairwise approach.
They searched for randomised trials (with usual care as a comparator) in which there was a comparison of exercise-based cardiac rehabilitation programs in adult, heart failure patients with either a preserved or reduced ejection fraction and where the program lasted for a minimum of 4 weeks.
In addition, studies were included if these reported on several different outcomes such as exercise capacity (peak oxygen uptake, Vo2 peak), the 6 minute walk distance, the Kansas City Cardiomyopathy questionnaire (KCCQ) and the physical component summary score of the short form survey 36 (SF-36). The researchers also considered the impact of programs on clinical outcomes such as heart failure-related hospitalisation and mortality.
Exercise-based cardiac rehabilitation an heart failure outcomes
A total 139 randomised controlled trials including 18,670 participants with a median age of 61.1 years (71.4% male) were analysed. The median duration of the exercise program was 12 weeks and median length of follow-up in studies was 16 weeks.
Only CB, HB and TE programs were associated with an increase in Vo2 peak compared to usual care and there were no statistically significant differences between these three modes of delivery.
The six minute walk distance was improved only by hybrid, CB and HB programs and again, there were no significant differences between the programs. Only HB programs improved the KCCQ and none of the delivery modes improved the SF-36 physical component summary score compared to usual care.
Heart failure-related hospitalisation (odds ratio, OR = 0.41, 95% CI 0.17 – 0.76) and mortality (OR = 0.42, 95% CI 0.16 – 0.90) were only reduced after CB programs.
The authors concluded that exercise-based cardiac rehabilitation programs appeared to improve functional capacity and clinical outcomes in those with heart failure. They added that since the different programs were comparably beneficial, the selection of a program should be tailored to the needs of the individual patient.
Citation
Tegegne TK et al. Effects of exercise-based cardiac rehabilitation delivery modes on exercise capacity and health-related quality of life in heart failure: a systematic review and network meta-analysis Open Heart 2022
12th April 2022
A randomised trial by researchers from the Canadian VIGOUR Centre, University of Alberta, Canada showed that reduced sodium intake had no effect on clinical events including cardiovascular-related hospitalisations or mortality in ambulatory heart failure patients compared with usual care, but did have a small, but significant, positive effect on quality of life and improved disease functional class.
In patients with congestive heart failure, the reduced low cardiac output decreases the fullness of the arterial circulation initiates several internal mechanisms to increase vascular resistance and enhance sodium and water renal retention.
In fact, in a study that examined factors associated with a worsening of heart failure, noncompliance with salt restriction, was a factor in over a fifth (22%) of cases.
As a result, dietary advice advocating a reduced sodium intake is arguably the most frequent self-care behaviour recommendation to patients with heart failure and is endorsed by all heart failure guidelines.
Nevertheless, the beneficial effect of lowering sodium intake is not clear cut and some evidence suggests that a reduced sodium intake to less than 2g/day is unwarranted in mild heart failure. In contrast, other data shows that sodium restriction (< 2.5 g/day) was associated with a significantly higher risk of death or heart failure hospitalisation.
With some uncertainties over whether a reduced sodium intake was beneficial to those with heart failure, for the present study, the Canadian team examined the effect of a dietary intervention of less than 1.5 g/day (1500 mg) of sodium compared to usual care, i.e., where no such recommendation was in place. Included patients had chronic heart failure (New York Heart Association functional class, 2 – 3) and had optimal medical therapy. Individuals were then randomised 1:1 to the low sodium diet or usual care.
The low sodium intervention was supported by behavioural counselling and meal plans and menus for a period of 12 months. Dietary sodium intake was assessed using a 3-day food record at baseline and again after 6 and 12 months for both groups.
The primary outcome of interest was a composite of cardiovascular-related hospitalisation, cardiovascular-related emergency department visits and all-cause mortality within 12 months of randomisation. In addition, to the clinical outcomes, quality of life was assessed using the Kansas City Cardiomyopathy Questionnaire (KCCQ) overall summary score, as well any changes in the New York Heart Association functional class.
Reduced sodium intake and cardiovascular outcomes
A total of 806 patients with median age of 67 years (66% male) were randomised to the low sodium arm (397) or usual care. At baseline the median sodium intake was 2286 mg/day for the low sodium group and 2119 mg/day for control arm. After 12 months, the sodium intake reduced by 4% in the control arm but by 28% in the low sodium group.
Within 12 months, the primary outcome occurred in 15% of those in the low sodium arm and 17% in the usual care group (adjusted hazard ratio, HR = 0.99, 95% CI 0.66 – 1.47, p = 0.95). All-cause mortality rates were also similar (6% vs 4%, low sodium vs usual care), giving a hazard ratio of 1.35 (95% CI 0.64 – 2.82, p = 0.43).
Whilst there were no significant differences in clinical outcomes, participants assigned to the low sodium group did see a small, but significant increase in the overall KCCQ summary score of 3.38 points (p = 0.011) and those in the low sodium group had a greater odds of improving by one NYHA functional class compared to the usual care group (odds ratio, OR = 0.59, 95% CI 0.40 – 0.86, p = 0.006).
The authors concluded that while a low sodium diet did not impact significantly on clinical outcomes, it did produce small but significant improvements in quality of life and NYHA functional class.
Citation
Ezekowitz JA et al. Reduction of dietary sodium to less than 100 mmol in heart failure (SODIUM-HF): an international, open-label, randomised, controlled trial Lancet 2022
28th January 2022
Heart failure (HF) patients have a higher risk of cancer and cancer-related mortality compared to matched-controls according to research by a team from the Cardiovascular Disease Unit, Genoa, Italy.
There is emerging evidence that the incidence of cancer is higher among those with cardiovascular disease and heart failure and this latter group frequently die from cancer. In fact, research has uncovered the increased risk of cancer among HF patients, persists beyond the first year after their HF diagnosis and that their prognosis is worse compared to non-heart failure patients with cancer.
Despite this purported association, other work among 28,341 Physicians’ Health Study participants, has shown that HF is not associated with an increased risk of cancer among male physicians. It has also been suggested that while heart failure patients did have a slightly increased risk of various cancer subtypes, these increased risks were largely drive by comorbidities.
Given this potential uncertainty over the HF-cancer association, the Italian team attempted to provide greater clarity by undertaking a retrospective cohort study of healthcare records in Puglia, a region of southern Italy. They included patients aged 50 years and older, diagnosed with heart failure but without a history of cancer in the three years prior to their inclusion in the analysis.
The team included a control group without HF who were matched on age and sex. The primary outcomes of the study were cancer incidence as well as mortality. In an effort to examine whether HF severity influenced the study outcomes, the researchers also explored patients use of doses in excess of 80 mg/day of furosemide and equivalents for longer than 30 days in the year before the index date.
Heart failure patients and cancer
A total of 104,020 HF patients with a mean age of 76 years were matched to an equal number of control patients. The researchers identified a total of 12,036 new diagnoses of cancer in HF patients and 7,045 in controls after a median follow-up period of 5 years. This gave an incidence cancer rate of 21.36 per 1000 person-years among those with HF and 12.42 in the control arm (Hazard ratio, HR = 1.76, 95% CI 1.71 – 1.81).
The cancer mortality rate was also higher among HF patients compared with controls (HR = 4.11, 95% CI 3.86 – 4.38). This difference was also seen among HF patients aged less than 70 years (HR = 1.66, 95% CI 1.58 – 1.75) and in those over 80 years of age (HR = 2.07).
High dose loop diuretics also showed an important effect with a higher cancer incidence (HR = 1.11, 95% CI 1.03 – 1.21) and cancer-related mortality (HR = 1.35).
The authors concluded that HF patients had both a higher incidence of cancer and cancer mortality than matched controls and speculated that given that the risk was elevated among those with high dose loop diuretics, it was possible that the overall cancer risks were potentially higher in those with decompensated, i.e., more severe HF.
Citation
Bertero E et al. Cancer Incidence and Mortality According to Pre-Existing Heart Failure in a Community-Based Cohort JACC CardioOncology 2022
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