Iron Deficiency, Anemia, and Iron Supplementation in Patients With Heart Failure: A Population-Level Study.

BACKGROUND: Studies have shown an association between iron deficiency (ID) and clinical outcomes in patients with heart failure (HF), irrespective of the presence of ID anemia (IDA). The current study used population-level data from a large, single-payer health care system in Canada to investigate the epidemiology of ID and IDA in patients with acute HF and those with chronic HF, and the iron supplementation practices in these settings. METHODS: All adult patients with HF in Alberta between 2012 and 2019 were identified and categorized as acute or chronic HF. HF subtypes were determined through echocardiography data, and ID (serum ferritin concentration <100 µg/L, or ferritin concentration between 100 and 300 µg/L along with transferrin saturation <20%), and IDA through laboratory data. Broad eligibility for 3 clinical trials (AFFIRM-AHF [Study to Compare Ferric Carboxymaltose With Placebo in Patients With Acute HF and ID], IRONMAN [Intravenous Iron Treatment in Patients With Heart Failure and Iron Deficiency], and HEART-FID [Randomized Placebocontrolled Trial of Ferric Carboxymaltose as Treatment for HF With ID]) was determined. RESULTS: Among the 17 463 patients with acute HF, 38.5% had iron studies tested within 30 days post-index-HF episode (and 34.2% of the 11 320 patients with chronic HF). Among tested patients, 72.6% of the acute HF and 73.9% of the chronic HF were iron-deficient, and 51.4% and 49.0% had IDA, respectively. Iron therapy was provided to 41.8% and 40.5% of patients with IDA and acute or chronic HF, respectively. Of ID patients without anemia, 19.9% and 21.7% were prescribed iron therapy. The most common type of iron therapy was oral (28.1% of patients). Approximately half of the cohort was eligible for each of the AFFIRM-AHF, intravenous iron treatment in patients with HF and ID, and HEART-FID trials. CONCLUSIONS: Current practices for investigating and treating ID in patients with HF do not align with existing guideline recommendations. Considering the gap in care, innovative strategies to optimize iron therapy in patients with HF are required.

Use of Guideline-Directed Medical Therapy in Patients Aged ≥ 65 Years After the Diagnosis of Heart Failure: A Canadian Population-Based Study.

Background: Guideline-directed medical therapy (GDMT) improves clinical outcomes in patients with heart failure with reduced ejection fraction (HFrEF). Despite its proven efficacy, GDMT is underutilized in clinical practice. The current study examines GDMT utilization after incident hospitalization for HF to promote medication initiation, and titration to target dosing within a reasonable time period. Methods: This observational study identified 66,372 patients with HFrEF who were aged ≥ 65 years and had an incident HF hospitalization, using administrative health data (2013-2018). GDMT (angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, angiotensin receptor-neprilysin inhibitors, ß-blockers (BB), and mineralocorticoid receptor antagonists ) received within the 6 months after hospitalization was evaluated by monitoring therapy combinations, optimal dosing (proportion receiving ≥ 50% of the target dose for these inhibitors and blockers, and any dose of MRA), and maximal and last dose assessed, and by use of a GDMT intensity score. Results: Among patients with HFrEF, 4768 (7.2%) were on no therapy, 17,184 (25.9%), were on monotherapy, 30,912 (46.6%) were on dual therapy, and 13,508 (20.4%) were on triple therapy. Only 8747 (13.2%) and 5484 (8.3%) achieved optimal GDMT based on the maximum dose and the last dispensed dose, respectively, within 6 months postdischarge. Finally, 38,869 (58.6%) achieved < 50% of the maximum intensity score, 23,006 (34.7%) achieved between 50% and 74% of the maximum intensity score, and 4497 (6.8%) achieved a score that was ≥ 75% of the maximum intensity score. Conclusions: Current pharmacologic management for patients with HFrEF does not align with the Canadian guidelines. Given this gap in care, innovative strategies to optimize care in patients with HFrEF are needed.

Introduction: Les traitements médicamenteux préconisés dans les lignes directrices (TMPLD) permettent d'améliorer les résultats cliniques des patients atteints d'insuffisance cardiaque à fraction d'éjection réduite (ICFER). En dépit des preuves de leur efficacité, les TMPLD sont sous-utilisés dans la pratique clinique. La présente étude porte sur l'utilisation des TMPLD après une hospitalisation incidente en raison d'une IC afin de favoriser l'amorce de la médication, et l'ajustement de la posologie en vue d'atteindre la dose cible dans un délai raisonnable. Méthodes: Cette étude observationnelle portait sur 66 372 patients atteints d'ICFER qui avaient ≥ 65 ans et une hospitalisation incidente en raison d'une IC, et reposait sur les données administratives sur la santé (2013-2018). Nous avons évalué les TMPLD (inhibiteurs de l'enzyme de conversion de l'angiotensine, bloqueurs des récepteurs de l'angiotensine, ß-bloquants [BB] et antagonistes des récepteurs des minéralocorticoïdes [ARM]) reçus dans les six mois après l'hospitalisation par la surveillance des combinaisons de traitement, la posologie optimale (proportion recevant ≥ 50 % de la dose cible pour ces inhibiteurs et ces bloquants, et toute dose d'ARM), la dose maximale et la dernière dose évaluées, et par l'utilisation d'un score d'intensité des TMPLD. Résultats: Parmi les patients atteints d'ICFER, 4 768 (7,2 %) n'avaient reçu aucun traitement, 17 184 (25,9 %), avaient reçu une monothérapie, 30 912 (46,6 %) avaient reçu une bithérapie et 13 508 (20,4 %) avaient reçu une trithérapie. Seuls 8 747 (13,2 %) et 5 484 (8,3 %) avaient obtenu les TMPLD optimaux en fonction de la dose maximale et de la dernière dose administrée, et ce, respectivement, dans les six mois après la sortie de l'hôpital. Enfin, 38 869 (58,6 %) avaient obtenu < 50 % du score d'intensité maximale, 23 006 (34,7 %) avaient obtenu entre 50 % et 74 % du score d'intensité maximale, et 4 497 (6,8 %) avaient obtenu un score qui était ≥ 75 % du score d'intensité maximale. Conclusions: La prise en charge pharmacologique actuelle des patients atteints d'ICFER va à l'encontre des lignes directrices canadiennes. Compte tenu de cette lacune dans les soins, des stratégies novatrices pour optimiser les soins aux patients atteints d'ICFER sont nécessaires.

Clinical electrophysiology of the aging heart.

INTRODUCTION: Advancements in medical and consumer-grade technologies have made it easier than ever to monitor a patient's heart rhythm and to diagnose arrhythmias. Octogenarians with symptomatic arrhythmias have unique management challenges due to their frailty, complex drug interactions, cognitive impairment, and competing comorbidities. The management decisions are further complicated by the lack of randomized evidence to guide treatment. AREAS COVERED: A comprehensive literature review was undertaken to outline various tachyarrhythmias and bradyarrhythmias and their management, the role of cardiac implantable electronic devices, cardiac ablations, and specific geriatric arrhythmia considerations as recommended in international guidelines. EXPERT OPINION: Atrial fibrillation (AF) is arguably the most important arrhythmia in the elderly and is associated with significant morbidity and mortality. Early diagnosis of AF, potentially with smart devices (wearables), has the potential to reduce the incidence of stroke, systemic emboli, and the risk of dementia. Bradyarrhythmias have a high incidence in the elderly as well, often requiring implantation of a permanent pacemaker. Leadless pacemakers implanted directly into the right ventricle are great options for gaining traction in elderly patients.

Dosimetry analysis of panoramic-imaging devices in different-sized phantoms.

The aim of this study is to measure the radiographic dose in adult, adolescent, and child head-sized PMMA phantoms for three panoramic-imaging devices: the panoramic mode on two CBCT machines (Carestream 9300 and i-CAT NG) and the Planmeca ProMax 2D. A SEDENTEXCT dose index adult phantom and custom-built adolescent and pediatric PMMA dosimetry phantoms were used. Panoramic radiographs were performed using a Planmeca ProMax 2D and the panoramic mode on a Carestream 9300 CBCT and an i-CAT NG using the protocols used clinically. Point dose measurements were performed at the center, around the periphery and on the surface of each phantom using a thimble ionization chamber. Five repeat measurements were taken at each location. For each machine, single-factor ANOVA was conducted to determine dose differences between protocols in each phantom, as well as determine the differences in absorbed dose when the same protocol was used for different-sized phantoms. For any individual phantom, using protocols with lower kVp, mA, or acquisition times resulted in statistically significant dose savings, as expected. When the same protocol was used for different-sized phantoms, the smaller phantom had a higher radiation dose due to less attenuation of x-rays by the smaller phantom and differences in the positioning of the ion chamber relative to the focal trough. The panoramic-mode on the CBCT machines produce images suitable for clinical use with similar dose levels to the stand-alone panoramic device. Significant dose savings may result by selecting age- and size- appropriate protocols for pediatric patients, but a wider range of protocols for children and adolescents may be beneficial.