2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Yancy, Clyde W.; Jessup, Mariell; Bozkurt, Biykem; Butler, Javed; Casey, Donald E.; Colvin, Monica; Drazner, Mark H.; Filippatos, Gerasimos; Fonarow, Gregg C.; Givertz, Michael M.; Hollenberg, Steven M.; Lindenfeld, Jo Ann; Masoudi, Frederick A.; McBride, Patrick E.; Peterson, Pamela N.; Stevenson, Lynne Warner; Westlake, Cheryl

doi:10.1016/j.jacc.2017.04.025

Cited by 2,361 publications

(506 citation statements)

References 190 publications

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“…The inclusion of only six patients with an eGFR <30 mL/min/1.73 m 2 in the present study was likely related to the current guidelines, which recommend initiating spironolactone in HF patients with eGFR >30 mL/min/1.73 m 2 4, 6. Nonetheless, results of this study provide useful information for the development of future trials to evaluate patiromer in a broad group of patients who might be at risk for the development of hyperkalaemia if administered an ACEi or ARB and an MRA.…”

Section: Discussionmentioning

confidence: 99%

“…The study population had characteristics that may make spironolactone initiation clinically desirable but challenging: HFrEF or HF with preserved EF (HFpEF) patients with CKD and high rates of other cardiovascular risk factors, such as diabetes (43%) and hypertension (94%), all but one of whom were on one or more RAASi at baseline. Spironolactone was initiated at 25 mg/day, uptitrated to 50 mg/day to meet the target doses used in HF trials1, 4, 5; in the present trial, all participants achieved the 50 mg/day dose. At the end of the treatment period, 90.5% of patients had serum K + in the range of 3.5–5.5 mEq/L, and 84.1% had serum K + in the range of 4.0–5.1 mEq/L.…”

Section: Discussionmentioning

confidence: 99%

“…The role of spironolactone in HFpEF patients remains uncertain,29, 30, 31 although MRAs received a Class IIb recommendation in the recently updated American Heart Association/American College of Cardiology HF guidelines to reduce hospitalization in appropriately selected patients with HFpEF 4. Nonetheless, the results of this study suggest that, in HF patients who, in the opinion of their treating physician, may benefit from spironolactone initiation and uptitration to 50 mg, patiromer was able to maintain serum K + in the target range in the majority of patients; this was achieved with improved control of hyperkalaemia and a low incidence of hypokalaemia and hypomagnesaemia, as well as acceptable tolerability.…”

Section: Discussionmentioning

confidence: 99%

“…Renin–angiotensin–aldosterone system inhibitors (RAASi) are guideline recommended with a Class 1 indication to reduce cardiovascular and total mortality in patients with heart failure (HF) and reduced left ventricular ejection fraction (EF) 1, 2, 3, 4, 5, 6. In patients with HF with reduced EF (HFrEF) at highest risk of cardiovascular death, such as those with diabetes mellitus and/or chronic kidney disease (CKD), the risk of worsening renal function and hyperkalaemia often precludes or limits the use of optimal doses of RAASi, especially mineralocorticoid receptor antagonists (MRAs) 7, 8, 9.…”

Section: Introductionmentioning

confidence: 99%

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Evaluation of an individualized dose titration regimen of patiromer to prevent hyperkalaemia in patients with heart failure and chronic kidney disease

et al. 2018

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AimsHyperkalaemia risk precludes optimal renin–angiotensin–aldosterone system inhibitor use in patients with heart failure (HF), particularly those with chronic kidney disease (CKD). Patiromer is a sodium‐free, non‐absorbed potassium (K+)‐binding polymer approved for the treatment of hyperkalaemia. In PEARL‐HF, patiromer 25.2 g (fixed dose) prevented hyperkalaemia in HF patients with or without CKD initiating spironolactone. The current study evaluated the effectiveness of a lower starting dose of patiromer (16.4 g/day) followed by individualized titration in preventing hyperkalaemia and hypokalaemia when initiating spironolactone.Methods and resultsThis open‐label 8‐week study enrolled 63 patients with CKD, serum K+ 4.3–5.1 mEq/L, and chronic HF, who, based on investigator opinion, should receive spironolactone. Eligible patients started spironolactone 25 mg/day and patiromer 16.8 g/day (divided into two doses), with patiromer titrated to maintain serum K+ 4.0–5.1 mEq/L. Mean (standard deviation) serum K+ was 4.78 (0.51) mEq/L at baseline; weekly values were 4.48–4.70 mEq/L during treatment. Serum K+ of 3.5–5.5 mEq/L at the end of study treatment (primary endpoint) was achieved by 57 (90.5%) patients; 53 (84.1%) had serum K+ 4.0–5.1 mEq/L. One patient (1.6%) developed hypokalaemia, and two patients (3.2%) developed hypomagnesaemia. Spironolactone was increased to 50 mg/day in all patients; 43 (68%) patients required one or more patiromer dose titration. Adverse events (AEs) occurred in 36 (57.1%) patients, with a low rate of discontinuations [four (6.3%) patients]. The most common AE was mild to moderate abdominal discomfort [four (6.3%) patients].ConclusionsIn this open‐label study, patiromer 16.8 g/day followed by individualized titration maintained serum K+ within the target range in the majority of patients with HF and CKD, all of whom were uptitrated to spironolactone 50 mg/day, patiromer was well tolerated, with a low incidence of hyperkalaemia, hypokalaemia, and hypomagnesaemia.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Evaluation of an individualized dose titration regimen of patiromer to prevent hyperkalaemia in patients with heart failure and chronic kidney disease

et al. 2018

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“…The lifetime risk of developing heart failure is high, and it is among the most common discharge diagnoses in the United States, with frequent costly readmissions for decompensation once disease has been established 1. While invasively measured biomarkers have improved prognostication, prediction of new‐onset heart failure remains challenging 2. Increased knowledge of risk factors for incident heart failure in the general population could enable earlier diagnosis, preemptive treatment, and risk factor control, to possibly mitigate disease development and improve outcomes.…”

Section: Introductionmentioning

confidence: 99%

Bioimpedance and New‐Onset Heart Failure: A Longitudinal Study of >500 000 Individuals From the General Population

Lindholm

Fukaya

Leeper

et al. 2018

JAHA

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BackgroundHeart failure constitutes a high burden on patients and society, but although lifetime risk is high, it is difficult to predict without costly or invasive testing. We aimed to establish new risk factors of heart failure, which potentially could enable early diagnosis and preemptive treatment.Methods and ResultsWe applied machine learning in the UK Biobank in an agnostic search of risk factors for heart failure in 500 451 individuals, excluding individuals with prior heart failure. Novel factors were then subjected to several in‐depth analyses, including multivariable Cox models of incident heart failure, and assessment of discrimination and calibration. Machine learning confirmed many known and putative risk factors for heart failure and identified several novel candidates. Mean reticulocyte volume appeared as one novel factor and leg bioimpedance another, the latter appearing as the most important new marker. Leg bioimpedance was lower in those who developed heart failure during an up to 9.8‐year follow‐up. When adjusting for known heart failure risk factors, leg bioimpedance was inversely related to heart failure (hazard ratio [95% confidence interval], 0.60 [0.48–0.73] and 0.75 [0.59–0.94], in age‐ and sex‐adjusted and fully adjusted models, respectively, comparing the upper versus lower quartile). A model including leg bioimpedance, age, sex, and self‐reported history of myocardial infarction showed good discrimination for future heart failure hospitalization (Concordance index [C‐index]=0.82) and good calibration.ConclusionsLeg bioimpedance is inversely associated with heart failure incidence in the general population. A simple model of exclusively noninvasive measures, combining leg bioimpedance with history of myocardial infarction, age, and sex provides accurate predictive capacity.

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Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement

Inohara

Manandhar

Kosinski

et al. 2018

JAMA

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IMPORTANCE Data are lacking on the effect of a renin-angiotensin system (RAS) inhibitor prescribed after transcatheter aortic valve replacement (TAVR). Treatment with a RAS inhibitor may reverse left ventricular remodeling and improve function. OBJECTIVE To investigate the association of prescription of a RAS inhibitor and outcomes after TAVR. DESIGN, SETTING, AND PARTICIPANTS Retrospective cohort study of TAVR procedures performed in the United States (using the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapies Registry) between July 2014 and January 2016 that were linked to Medicare claims data (final date of follow-up: March 31, 2017). To account for differences in demographics, echocardiographic findings, and in-hospital complications, 1:1 propensity matching was performed. EXPOSURES Initial hospital discharge prescription of a RAS inhibitor after TAVR. MAIN OUTCOMES AND MEASURES Primary outcomes were all-cause death and readmission due to heart failure at 1 year after discharge, which were considered separately. The secondary outcome was health status assessed by the Kansas City Cardiomyopathy Questionnaire (KCCQ; score range: 0-100, with a higher score indicating less symptom burden and better quality of life; a small effect size was defined as 5 points) at 1 year. RESULTS Among 21 312 patients who underwent TAVR at 417 US sites, 8468 patients (39.7%) were prescribed a RAS inhibitor at hospital discharge. After propensity matching, 15 896 patients were included (mean [SD] age, 82.4 [6.8] years; 48.1% were women; mean [SD] left ventricular ejection fraction [LVEF], 51.9% [11.5%]). Patients with a prescription for a RAS inhibitor vs those with no prescription had lower mortality rates at 1 year (12.5% vs 14.9%, respectively; absolute risk difference [ARD], −2.4% [95% CI, −3.5% to −1.4%]; hazard ratio [HR], 0.82 [95% CI, 0.76 to 0.90]) and lower heart failure readmission rates at 1 year (12.0% vs 13.8%; ARD, −1.8% [95% CI, −2.8% to −0.7%]; HR, 0.86 [95% CI, 0.79 to 0.95]). When stratified by LVEF, having a prescription for a RAS inhibitor vs no prescription was associated with lower 1-year mortality among patients with preserved LVEF (11.1% vs 13.9%, respectively; ARD, −2.81% [95% CI, −3.95% to −1.67%]; HR, 0.78 [95% CI, 0.71 to 0.86]), but not among those with reduced LVEF (18.8% vs 19.5%; ARD, −0.68% [95% CI, −3.52% to 2.20%]; HR, 0.95 [95% CI, 0.81 to 1.12]) (P = .04 for interaction). Of 15 896 matched patients, 4837 (30.4%) were included in the KCCQ score analysis and improvements at 1 year were greater in patients with a prescription for a RAS inhibitor vs those with no prescription (median, 33.3 [interquartile range, 14.2 to 51.0] vs 31.3 [interquartile range, 13.5 to 51.1], respectively; difference in improvement, 2.10 [95% CI, 0.10 to 4.06]; P < .001), but the effect size was not clinically meaningful. CONCLUSIONS AND RELEVANCE Among patients who underwent TAVR, receiving a prescription for a RAS inhibitor at hospital discharge compared with no prescription was s...

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2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure

Cited by 2,361 publications

References 190 publications

Evaluation of an individualized dose titration regimen of patiromer to prevent hyperkalaemia in patients with heart failure and chronic kidney disease

Evaluation of an individualized dose titration regimen of patiromer to prevent hyperkalaemia in patients with heart failure and chronic kidney disease

Bioimpedance and New‐Onset Heart Failure: A Longitudinal Study of >500 000 Individuals From the General Population

Association of Renin-Angiotensin Inhibitor Treatment With Mortality and Heart Failure Readmission in Patients With Transcatheter Aortic Valve Replacement

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