Francisco Gomez

Incidence and mortality of heart failure: A community-based study

BACKGROUND Data on the incidence and mortality of heart failure (HF) in community-based populations of developed countries are limited. We estimated the trends of the incidence and, the mortality of HF. METHODS Prospective population-based study in a white, low-middle class Mediterranean community of 267,231 inhabitants in Spain. Participants were all the patients (=>14 years), newly diagnosed with HF (4793), according to the Framingham criteria, from January 1, 2000 through December 31, 2007. Main outcome were incidence and mortality following an HF diagnosis. RESULTS Incidence of HF increased among both men and women, and among persons with systolic and non-systolic HF. Incidence of HF increased from 296 per 100,000 person-years in 2000 to 390 per 100,000 person-years in 2007 (RR 1.32, CI 95% 1.27-13.7, P<.01). Although, risk-adjusted mortality declined from 2000 to 2007, the prognosis for patients with newly diagnosed HF remains poor. In 2007, risk-adjusted 30-day, 1-year, and 4-years mortality was 12.1%, 28.8%, and 61.4%, respectively. Incidence and mortality of systolic HF were higher than those of non-systolic HF (P<0.05). CONCLUSIONS During the last 8 years, in a white, middle class population of the south of Europe, the increased incidence and the decreased mortality of heart failure have resulted in an increased prevalence of heart failure. Incidence and mortality of systolic heart failure were higher than those of non-systolic heart failure.

Metformin therapy and prognosis of patients with heart failure and new-onset diabetes mellitus. A propensity-matched study in the community

OBJECTIVE To assess the effect of the commencement of metformin therapy (CMet) on the prognosis of patients with newly diagnosed heart failure (HF) and new-onset diabetes mellitus (DM) treated with a contemporary medical regimen. METHODS Prospective study of 1519 HF patients with DM during 9 years. Mean age was 71.7+/-7.8 years, 817 (53.8%) were women, and 780 (51.3%) had preserved systolic function. During a median follow-up of 56.9+/-18.2 months, 1045 patients (68.8%) died, 1344 (88.5%) were hospitalized for worsening HF, 593 (39.0%) did not CMet, and 391 of the patients CMet (42.2%) had a mean HbA1c=<7.0%. No case of lactic acidosis due to metformin was observed. We propensity-score matched 592 patients who CMet with another 592 patients non-CMet. RESULTS CMet was associated with a decreased mortality (HR [CI 95%]: .85 [.82-.88]), mainly due to a reduced cardiovascular mortality (HR: .78 [.74-.82]), and with a lower hospitalization rate (HR: .81 [.79-.84]). Nevertheless, CMet was not associated with an improved prognosis of HF patients with a mean HbA1c=<7.0%. These relationships of CMet with prognosis were maintained, independently of the gender, the type of HF (systolic or, non-systolic), the comorbidities, and the medication used (P<.01). CONCLUSION Metformin therapy is associated with a reduced mortality of heart failure patients with new-onset diabetes mellitus, mainly due to a decreased cardiovascular mortality, and with a lower hospitalization rate. Nevertheless, CMet was not associated with an improved prognosis of HF patients with a mean HbA1c=<7.0%.

Impact of new-onset diabetes mellitus and glycemic control on the prognosis of heart failure patients: A propensity-matched study in the community ☆

OBJECTIVES To assess the incidence of type 2 diabetes mellitus (DM) in patients with heart failure (HF), and to evaluate the effect of new-onset DM and glycemic control on the prognosis of HF patients treated with a contemporary medical regimen. METHODS Prospective study of 5314 HF patients and previously unknown DM during 9 years. Their mean age was 71.8 ± 7.9 years, 53.0% were women, and 50.2% had non-systolic HF. During a median follow-up of 56.9 ± 18.2 months, 68.9% of the patients died, 88.6% were hospitalized for HF, and 1519 (27.3%) developed new-onset DM. We propensity-matched those 1519 HF patients with DM, with 1519 HF patients non-diagnosed with DM. RESULTS The age- and sex-adjusted incidence (per 100 HF patients/years) of DM in HF patients was 3.20, higher in women and in patients with non-systolic HF (p<0.01). Patients with HF and DM and those with a mean HbA1c>7.0% presented an increased mortality (HR of death [CI 95%]: 2.44 [1.68-3.19] and, HR: 2.56 [1.77-3.35], respectively), mainly due to an increased cardiovascular mortality (HR ≥ 2.40 [1.46-3.34]) (P<0.001). The rate of hospitalization, of 30-day readmissions, and the number of visits were higher among HF patients with DM or with HbA1c>7.0% (p<0.001). These relationships of DM and its poor metabolic control with prognosis were maintained, independently of the gender, the type of HF (systolic or, non-systolic), the comorbidities, and the medication used (P<0.01). CONCLUSION New-onset diabetes mellitus and its poor metabolic control (HbA1c>7.0%) are associated with a increased mortality and morbidity of patients with heart failure.

Results of genotype-guided antiplatelet therapy in patients who undergone percutaneous coronary intervention with stent

BACKGROUND Clopidogrel has provided beneficial effects in acute coronary syndrome and percutaneous coronary intervention. Different polymorphisms have been associated with differences in clopidogrel response. The aim of this study was to check if CYP2C19/ABCB1-genotype-guided strategy reduces the rates of cardiovascular events and bleeding. METHODS This experimental study included patients undergoing percutaneous coronary intervention with stent. The prospective genotype-guided strategy (intervention group) was compared against a retrospective non-tailored strategy (control group). Primary efficacy endpoint was the composite of cardiovascular death, acute coronary syndrome or stroke during 12months after intervention. Secondary endpoint was to compare the efficacy of the different antiplatelet therapies used in genotyping conditions. RESULTS The study included 719 patients undergone stent, more than 86% with acute coronary syndrome. The primary endpoint occurred in 32 patients (10.1%) in the genotyping group and in 59 patients (14.1%) in the control group (HR 0.63, 95% CI (0.41-0.97), p =0.037). There was no difference in The Thrombolysis in Myocardial Infarction major and minor bleeding criteria between the two groups (4.1% vs. 4.7%, HR=0.80, 95% CI (0.39-1.63), p=0.55). In intervention group, there was no difference in the rate of events in patients treated with clopidogrel versus patients treated with other antiplatelet treatments (9.1% vs 11.5% p=0.44), or bleeding (3.7% vs 4.6%, p=0.69). CONCLUSIONS The genotype-guided strategy could reduce the rates of composite of cardiovascular events and bleeding during 12months after percutaneous coronary intervention compared to a non-genotype-guide strategy.

Mortality and morbidity of newly diagnosed heart failure treated with statins: a propensity-adjusted cohort study.

BACKGROUND The effect of treatment with statins on the prognosis of newly diagnosed heart failure (ndHF) is not established. We evaluate the relationship of commencing treatment with statins (CTS) with the mortality and the morbidity of ndHF, systolic (HF-DSF) and non-systolic (HF-PSF). METHODS Prospective propensity-adjusted cohort study over 5 years on 2573 patients with ndHF. The main outcomes were all-cause and cardiovascular mortality, hospitalizations and visits. We analyze the independent relationship of CTS with the mortality and the morbidity, stratifying patients for cardiovascular co-morbidity, after adjusting for potential confounders. RESULTS 1343 patients (52.2%) CTS, 1071 (39.5%) died, and 1729 (67.2%) were hospitalized. CTS was associated not only with a lower mortality: RR for HF-overall (CI 95%) 0.23 (0.10 to 0.36), RR for HF-PSF 0.34 (0.21 to 0.47), and RR for HF-DSF 0.20 (0.09 to 0.31), but with dose-dependency (statin>20 mg/day vs. statin<=20 mg/day): RR for HF-overall 0.49 (0.33 to 0.67), RR for HF-PSF 0.53 (0.39 to 0.70), and RR for HF-DSF 0.37 (0.26 to 0.52), and with a lower rate of hospitalization (per 100 persons-year): HF-overall (13.3 vs. 18.2), HF-PSF (13.9 vs. 19.7), and HF-DSF (12.7 vs. 16.6), (P<0.001 in all cases), even after adjustment for the propensity to take statins, or other medications, and other potential confounders. CONCLUSION The commencement of treatment with statins is associated with a dose-dependent reduction of the mortality and of the morbidity of patients with ndHF (systolic or non-systolic).

Prognosis of heart failure with preserved ejection fraction treated with β-blockers: A propensity matched study in the community

BACKGROUND The effect of treatment with β-blockers on the prognosis of patients newly diagnosed with heart failure with preserved ejection fraction (HFpEF) is unknown. OBJECTIVE To analyze the relationship of commencing treatment with the β-blockers bisoprolol or carvedilol (CT-βB) with the prognosis of newly diagnosed HFpEF. METHODS Prospective study over 10years on 2704 patients with HFpEF. Main outcomes were mortality (all-cause and cardiovascular), hospitalizations for HF worsening, and visits. The independent relationship between CT-βB and the prognosis, stratifying patients for cardiovascular co-morbidity after propensity score-matching (985 patients CT-βB vs. another 985 patients non-CT-βB), was analyzed. RESULTS During a median follow-up of 1877.4days (interquartile range, 1-3651.2) 1600 died (81.2%), and 1702 were hospitalized (86.4%). CT-βB was associated with a lower risk of mortality (all-cause: HR [CI 95%] 0.78 [0.71 to 0.85], and cardiovascular: 0.75 [0.69 to 0.82]), a lower hospitalization rate (per 100 persons-year), 15.8 vs. 19.2, and a lower 30-day readmission rate (per 100 persons-year), 4.0 vs. 5.8, (P<0.001 in all cases), even after adjustment for the propensity to take β-blockers or other medications, comorbidities, and other potential confounders. These effects of CT-βB were independent of gender, and were observed in both patients taking high dose βB (over the median dose) and lower dose βB (under or equal to the median dose). CONCLUSIONS In this propensity matched study, commencing treatment with bisoprolol or carvedilol, both at high and at lower doses, is associated with an improved prognosis of patients newly diagnosed with HFpEF.

Mortality and morbidity of newly diagnosed heart failure with preserved systolic function treated with β-blockers: A propensity-adjusted case–control populational study

BACKGROUND The effect of treatment with β-blockers on the prognosis of patients newly diagnosed with heart failure with preserved systolic function (HF-PSF) is unknown. OBJECTIVES To analyze the relationship of commencing treatment with the β-blockers bisoprolol or carvedilol (CT-βB) with the mortality and the morbidity of newly diagnosed HF-PSF. METHODS Prospective propensity-adjusted cohort study over 5 years on 1085 adults diagnosed with HF-PSF for the first time, in an integrated university-based health organization in Spain. The independent relationship between CT-βB and mortality and morbidity was analyzed, stratifying patients for comorbidity, after a multivariable adjustment for potential confounders. RESULTS The 378 patients (34.8%) who CT-βB were more frequently older women, with more cardiovascular comorbidity. Of the total patients 554 (51.0%) died, and 711 (65.5%) were hospitalized. Using an intent-to-treat approach, CT-βB was associated with a lower risk of mortality (all-cause: RR [CI 95%] 0.37 [0.21 to 0.50], and cardiovascular: 0.31 [0.18 to 0.45]), and a lower age- and sex-adjusted hospitalization rate (per 100 persons/year), 13.6 vs. 19.2, (P<0.001 in all cases), even after adjustment for the propensity to take β-blockers, or other medications, comorbidities, and other potential confounders. CONCLUSIONS In this observational study, commencing treatment with the β-blockers bisoprolol or carvedilol is associated with a reduced mortality and morbidity of patients with newly diagnosed heart failure with preserved systolic function.

Mortality of newly diagnosed heart failure treated with amiodarone A propensity-matched study

BACKGROUND Studies on the safety of amiodarone therapy in heart failure (HF) presented conflicting results. We evaluated the relationship of commencing treatment with amiodarone (CTA) with the mortality and the morbidity of patients newly diagnosed with HF. METHODS Prospective cohort study over 7 years on 3734 patients with HF. Main outcomes were all-cause and cardiovascular mortality, hospitalizations and visits. 739 patients who commenced treatment with amiodarone were propensity-matched with another 739 patients. Non-commencing treatment with amiodarone. We analyze the independent relationship of commencing treatment with amiodarone, with the mortality and the morbidity, stratifying patients for cardiovascular co-morbidity, after propensity score-matching. RESULTS During a median follow-up of 46.1 months, 644 (43.6%) died, and 1086 (73.5%) were hospitalized. Commencing treatment with amiodarone was associated with a higher all-cause mortality (HR 1.70 [CI 95%, 1.50 to 1.91]), particularly among women (HR: 1.77 [1.55 to 2.00]), and among patients with non-systolic HF (HR: 1.87 [1.66 to 2.09], P<0.001 in all the cases), even after adjustment for the propensity to take amiodarone, or other medications, and other potential confounders. Commencing treatment with amiodarone was not associated with cardiovascular mortality, hospitalizations, or visits. CONCLUSION The commencement of treatment with amiodarone is associated with an increased mortality of patients with heart failure, mainly in women and in patients with non-systolic heart failure.

Mortality and morbidity of non-systolic heart failure treated with angiotensin-converting enzyme inhibitors: a propensity-adjusted case-control study.

BACKGROUND The effect of treatment with angiotensin-converting enzyme inhibitors (ACEIs) on the prognosis of patients newly diagnosed with heart failure with preserved systolic function (HF-PSF) is unclear. We evaluate the relationship of commencing ACEI therapy (C-ACEI-T) with the morbidity and mortality of patients with HF-PSF. METHODS Prospective propensity-adjusted cohort study over 5 years on 1120 adults diagnosed with HF-PSF for the first time, within an integrated health organization in Spain. We analyzed the independent relationship between C-ACEI-T and mortality, and morbidity, stratifying patients according to comorbidity, after a multivariable adjustment for potential confounders. RESULTS The 865 patients (77.2%) who C-ACEI-T were younger, with more cardiovascular comorbidity. During the median follow-up of 908.3 days (interquartile range 558.6-1302.0) 580 patients (51.8%) died, and 727 (64.9%) were hospitalized. Using an intention-to-treat analysis, C-ACEI-T was associated with a lower risk of all-cause (RR [CI 95%] 0.34 [0.23 to 0.46]), and cardiovascular (RR 0.28 [0.20 to 0.36]) mortality, and a lower age- and sex-adjusted rate of hospitalization (per 100 persons-year), 12.3 vs. 19.4, (P<0.001 in all cases), even after adjustment for the propensity to take ACEIs, or other medications, comorbidities, and other potential confounders. CONCLUSION In this prospective observational study the establishment of ACEI therapy is associated with a reduced mortality and morbidity of patients with newly diagnosed non-systolic heart failure.

Prognosis of heart failure treated with digoxin or with ivabradine: A cohort study in the community

Resting heart rate (HR) reduction with ivabradine (IVA) improves outcomes of patients with heart failure and reduced ejection fraction (HFrEF). Nevertheless, the best option to slow HR in patients with HFrEF treated with beta‐blockers and a HR >70 bpm is unsettled.