Simultaneous initiation of quadruple therapy for heart failure with reduced ejection fraction: initial experience in Afro Caribbean Jamaican population
Main Article Content
Abstract
Background: Among Afro Caribbean Jamaican patients with heart failure with reduced ejection fraction (HFrEF), improvements in cardiac function associated with simultaneous initiation of quadruple therapy, have not been previously reported and we aimed to assess this special population.
Methods: Combined quadruple therapy (angiotensin-receptor neprilysin inhibitor, beta-blocker, mineralocorticoid receptor antagonist, and Sodium-glucose cotransporter-2 inhibitors) was simultaneously initiated in 120 Afro Jamaican patients with HFrEF from the Heart Institute of the Caribbean. Patient data was consecutively recorded in our electronic medical records. Changes in Ejection fraction (EF) and N-terminal pro b-type natriuretic peptide (NT-ProBNP) levels, were evaluated after 90 days and statistically analysed during this two-year study.
Results: Patient mean age was 63 ± 12.7 years old, 68% male, with mean Body Mass index (BMI) 32.2±6.7 Kg/m2. Hypertension was observed in 62.5 %, T2Diabetes Mellitus in 31.7%, and history of old myocardial infarction in 15.7 %. Atrial fibrillation was present in 7.8% and left bundle branch block in 16.5 %. Other cardiomyopathies (idiopathic, peripartum and non-compaction) were noted in 16.6 %. After the quadruple therapy for a median follow-up period of 90 days, significant improvements of cardiac function were achieved. The mean NT pro-BNP level was significantly decreased from a Baseline of 3111.21 pg/mL ± 4535 to 1806.6 ± 2265.3 pg/ml. A mean change in NT Pro BNP of 1305 pg/mL ± 5069 (p < 0.001). The mean left ventricle ejection fraction (LVEF) improved from a baseline of 33.4 % ± 7.8 to 44.4 % ± 10.9. A mean change in LVEF of 11.3% ± 9.1 (p <0.001). Notably, an improvement of >10% in the LVEF was observed in 41.5% of the total population. In a separate analysis, the subgroup with T2 Diabetes mellitus showed more pronounced (mean change in EF 9.1% ± 11.0) improvement in LVEF than the non-diabetic (mean change in EF 7.7% ± 11.7) but no significant differences in the change of the NT pro-BNP levels were noted between both subgroups. The most frequent therapy adverse effect was hypotension (13.63%) followed by cough (6.81%) and kidney dysfunction (2.27%) but none of the patients presented Angioedema.
Conclusion: Among Afro Caribbean Jamaican patients with heart failure and reduced ejection fraction, simultaneous initiation of the quadruple therapy was demonstrated to be feasible, well tolerated and associated with significant functional improvement.
Keywords:
Heart Failure, Therapy, Afro Jamaican
Article Details
How to Cite
FELIX, Nunura; DELANI, Campbell.
Simultaneous initiation of quadruple therapy for heart failure with reduced ejection fraction: initial experience in Afro Caribbean Jamaican population.
Medical Research Archives, [S.l.], v. 12, n. 4, apr. 2024.
ISSN 2375-1924.
Available at: <https://esmed.org/MRA/mra/article/view/5221>. Date accessed: 03 july 2024.
doi: https://doi.org/10.18103/mra.v12i4.5221.
Section
Research Articles
The Medical Research Archives grants authors the right to publish and reproduce the unrevised contribution in whole or in part at any time and in any form for any scholarly non-commercial purpose with the condition that all publications of the contribution include a full citation to the journal as published by the Medical Research Archives.
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2. Zannad F., Ferreira J.P., Pocock S.J., et al. SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR-Reduced and DAPA-HF trials. Lancet 2020;396:819-829.
3. Bassi N.S., Ziaeian B., Yancy C.W., Fonarow G.C. Association of optimal implementation of sodium-glucose cotransporter 2 inhibitor therapy with outcome for patients with heart failure". JAMA Cardiol 2020May6.
4. Lewsey SC, Breathett K. Racial and ethnic disparities in heart failure: current state and future directions. Curr Opin Cardiol. 2021 May 1;36(3):320-328. doi: 10.1097/HCO.0000 000000000855.
5. J.J.V. McMurray, M. Packer, A.S. Desai, et al. Angiotensin–neprilysin inhibition versus enalapril in heart failure N Engl J Med, 371 (2014), pp. 993-1004
6. McMurray JJV, Solomon SD, Inzucchi SE et al. DAPA-HF Trial Committees and Investigators. Dapagliflozin in Patients with Heart Failure and Reduced Ejection Fraction. N Engl J Med. 2019 Nov 21;381(21):1995-2008. doi: 10.1056 /NEJMoa1911303. Epub 2019 Sep 19.
7. Reza N, Nayak A, Lewsey SC, DeFilippis EM. Representation matters: a call for inclusivity and equity in heart failure clinical trials. Eur Heart J Suppl. 2022 Dec 19;24(Suppl L):L45-L48. doi: 10.1093/eurheart jsupp/suac115.
8. Chaturvedi N, McKeigue PM, Marmot MG. Resting and ambulatory blood pressure differences in Afro-Caribbeans and Europeans .Hypertension. 1993; 22:90–96
9. Dungu JN, Papadopoulou SA, Wykes K, Mahmood I, Marshall J, Valencia O, Fontana M, Whelan CJ, Gillmore JD, Hawkins PN, Anderson LJ. Afro-Caribbean Heart Failure in the United Kingdom: Cause, Outcomes, and ATTR V122I Cardiac Amyloidosis. Circ Heart Fail. 2016 Sep;9(9):e003352. doi: 10.1161/CIR CHEARTFAILURE.116.003352.
10. Atlas of humanity: Jamaica https://www.atlasofhumanity.com/jamaica
11. Nunura F., Tulloch-Reid E., Baugh D. and Madu E. Heart Failure Demographic and Clinical Features: The Caribbean Perspective. A Single-Center 100-Case Series Discussion and Review of the Literature Biomed J Sci & Tech Res Sep 4, 2017
12. Nunura F., Tulloch-Reid E., Baugh D. and Madu E Normal Coronary Arteries in Afro-Caribbean Patients with Heart Failure and Reduced Ejection Fraction: An Unresolved Equation Therapeutic Advances in Cardiology Nov 21, 2017
13. Solomon SD, Jhund PS, Claggett BL, Dewan P, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Inzucchi SE, Desai AS, Bengtsson O, Lindholm D, Sjostrand M, Langkilde AM, McMurray JJV. Effect of Dapagliflozin in Patients With HFrEF Treated With Sacubitril/Valsartan: The DAPA-HF Trial. JACC Heart Fail. 2020 Oct;8(10):811-818. doi: 10.1016/j.jchf.2020.04.008.
14. Jiang J, Gao J, Zhang X, Li Y, Dang H, Liu Y, Chen W. Combined treatment with sacubitril/valsartan plus dapagliflozin in patients affected by heart failure with reduced ejection fraction. Front Cardiovasc Med. 2023 Mar 22;10: 1097066. doi: 10.3389/fcvm.2023. 1097066.
15. Mustapic I, Bakovic D, Susilovic-Grabovac Z, Borovac JA. Left Ventricular Systolic Function After 3 Months of SGLT2 Inhibitor Therapy in Heart Failure Patients with Reduced Ejection Fraction. J Cardiovasc Transl Res. 2023 Oct; 16(5):987-998. doi: 10.1 007/s12265-023-10389-3. Epub 2023 May 8.
16. Nunura F., Tulloch-Reid E. , Nepaul D., Baugh D. and Madu E Real-World Evidence for the Tolerance and Effectiveness of the First Drug (Sacubitril/Valsartan) in a New Class-ARN in Afro-Caribbean Patients with Heart Failure with Reduced Ejection Fraction Journal of Clinical and Experimental Cardiology Jun 10, 2019
17. DeVore AD, Hellkamp AS, Thomas L, Albert NM, Butler J, Patterson JH, Spertus JA, Williams FB, Duffy CI, Hernandez AF, Fonarow GC. Improvement in Left Ventricular Ejection Fraction in Outpatients With Heart Failure With Reduced Ejection Fraction: Data From CHAMP-HF. Circ Heart Fail. 2020 Jul;13(7):e006833. doi: 10.1161/CIRCHEART FAILURE.119.006833.
18. Nayak A, Hicks AJ, Morris AA. Understanding the Complexity of Heart Failure Risk and Treatment in Black Patients. Circ Heart Fail. 2020 Aug;13(8):e007264. doi: 10.1161/CIRCHEARTFAILURE.120.007264. Epub 2020 Aug 13.
19. McDonagh TA, Metra M, Adamo M, Gardner RS, Baumbach A, Böhm M, Burri H, Butler J, Čelutkienė J, Chioncel O, Cleland JGF, Coats AJS, Crespo-Leiro MG, Farmakis D, Gilard M, Heymans S, Hoes AW, Jaarsma T, Jankowska EA, Lainscak M, Lam CSP, Lyon AR, McMurray JJV, Mebazaa A, Mindham R, Muneretto C, Francesco Piepoli M, Price S, Rosano GMC, Ruschitzka F, Kathrine Skibelund A; ESC Scientific Document Group. 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. Eur Heart J. 2021 Sep 21;42(36):3599-3726. doi: 10.1093/eurheartj/ehab368.
20. McMurray JJV, Solomon SD, Inzucchi SE, Køber L, Kosiborod MN, Martinez FA,Ponikowski P, Sabatine MS, Anand IS, Belohla´vek J, Bo¨hm M, Chiang CE, Chopra VK, de Boer RA, Desai AS, Diez M, Drozdz J, Duka´t A, Ge J, Howlett JG, Katova T, Kitakaze M, Ljungman CEA, Merkely B, Nicolau JC, O’Meara E, Petrie MC, Vinh PN, Schou M, Tereshchenko S, Verma S, Held C, DeMets DL, Docherty KF, Jhund PS, Bengtsson O, Sjo¨strand M, Langkilde AM; DAPA-HF Trial Committees and Investigators. Dapagliflozin in patients with heart failure and reduced ejection fraction. N Engl J Med 2019;381: 1995–2008
21. Solomon SD, Jhund PS, Claggett BL, Dewan P, Køber L, Kosiborod MN, Martinez FA, Ponikowski P, Sabatine MS, Inzucchi SE, Desai AS, Bengtsson O, Lindholm D, Sjostrand M, Langkilde AM, McMurray JJV. Effect of dapagliflozin in patients with HFrEF treated with sacubitril/valsartan: the DAPA-HF trial. JACC Heart Fail 2020;8:811–818.
22. Zannad F, Ferreira JP, Pocock SJ, Anker SD, Butler J, Filippatos G, Brueckmann M, Ofstad AP, Pfarr E, Jamal W, Packer M. SGLT2 inhibitors in patients with heart failure with reduced ejection fraction: a meta-analysis of the EMPEROR Reduced and DAPA-HF trials. Lancet 2020;396:819–829.
23. Bauersachs J. Heart failure drug treatment: the fantastic four. Eur Heart J. 2021 Feb 11;42(6):681-683. doi: 10.1093/eurheartj/ ehaa1012.
24. Bassi NS, Ziaeian B, Yancy CW, Fonarow GC. Association of Optimal Implementation of Sodium-Glucose Cotransporter 2 Inhibitor Therapy With Outcome for Patients With Heart Failure. JAMA Cardiol. 2020 Aug 1;5(8): 948-951. doi: 10.1001/jamacardio.2020.0898.
25. Heidenreich PA, Bozkurt B, Aguilar D, Allen LA, Byun JJ, Colvin MM, et al. 2022 AHA/ACC/HFSA guideline for the management of heart failure: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. Circulation 2022;145(18): e876–e894.
26. McMurray JJV, Packer M. How should we sequence the treatments for heart failure and a reduced ejection fraction?: a redefinition of evidence-based medicine. Circulation 2021; 143:875–877.
27. Greene SJ, Butler J, Fonarow GC. Simultaneous or rapid sequence initiation of quadruple medical therapy for heart failure-optimizing therapy with the need for speed. JAMA Cardiol 2021;6:743–744
28. Straw S, McGinlay M, Witte KK. Four pillars of heart failure: contemporary pharmacological therapy for heart failure with reduced ejection fraction. Open Heart 2021 ;8:e001585.
29. Shelley Hall, Four pillars of heart failure therapy should be rapidly and simultaneously introduced. Baylor University Medical Center, part of Baylor Scott & White Health [https://blog.bswhealth.med/four-pillars-of-heart-failure-therapy-should-be-rapidly-and-simultaneously-introduced/], June 2023.
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