Remote monitoring titration clinic to implement guideline-directed therapy for heart failure patients with reduced ejection fraction: a pilot quality-improvement intervention.

Introduction: Guideline-directed medical therapy (GDMT) is the recommended treatment for heart failure with reduced ejection fraction (HFrEF). However, the implementation remains limited, with suboptimal use and dosing. The study aimed to assess the feasibility and effect of a remote monitoring titration program on GDMT implementation. Methods: HFrEF patients were randomly assigned to receive either usual care or a quality-improvement remote titration with remote monitoring intervention. The intervention group used wireless devices to transmit heart rate, blood pressure, and weight data daily, which were reviewed by physicians and nurses every 2-4 weeks. Medication tolerance was assessed via phone, and dosage instructions were given. This workflow was repeated until target doses were reached or further adjustments were not tolerated. A 4-GDMT score measured use and target dosage, with the primary endpoint being the score at 6 months follow-up. Results: Baseline characteristics were similar (n = 55). A median of 85% of patients complied with transmitting device data every week. At the 6-month follow-up, the intervention group had a 4-GDMT score of 64.6% compared to 56.5% in the usual care group (p = 0.01), with a difference of 8.1% (95% CI: 1.7%-14.5%). Similar results were seen at the 12-month follow-up [difference 12.8% (CI: 5.0%-20.6%)]. The intervention group showed a positive trend in ejection fraction and natriuretic peptides, with no significant difference between groups. Conclusions: The study suggests that a full-scale trial is feasible and that utilizing a remote titration clinic with remote monitoring has the potential to enhance the implementation of guideline-directed therapy for HFrEF.

Crystal structures of four dimeric manganese(II) bromide coordination complexes with various derivatives of pyridine N-oxide.

Four manganese(II) bromide coordination complexes have been prepared with four pyridine N-oxides, viz. pyridine N-oxide (PNO), 2-methyl-pyridine N-oxide (2MePNO), 3-methyl-pyridine N-oxide (3MePNO), and 4-methyl-pyridine N-oxide (4MePNO). The compounds are bis-(µ-pyridine N-oxide)bis-[aqua-dibromido-(pyridine N-oxide)manganese(II)], [Mn2Br4(C5H5NO)4(H2O)2] (I), bis-(µ-2-methyl-pyridine N-oxide)bis-[di-aqua-dibromido-manganese(II)]-2-methyl-pyridine N-oxide (1/2), [Mn2Br4(C6H7NO)2(H2O)4]·2C6H7NO (II), bis-(µ-3-methyl-pyridine N-oxide)bis-[aqua-dibromido-(3-methyl-pyridine N-oxide)manganese(II)], [Mn2Br4(C6H7NO)4(H2O)2] (III), and bis-(µ-4-methyl-pyridine N-oxide)bis-[di-bromido-methanol(4-methyl-pyridine N-oxide)manganese(II)], [Mn2Br4(C6H7NO)4(CH3OH)2] (IV). All the compounds have one unique MnII atom and form a dimeric complex that contains two MnII atoms related by a crystallographic inversion center. Pseudo-octa-hedral six-coordinate manganese(II) centers are found in all four compounds. All four compounds form dimers of Mn atoms bridged by the oxygen atom of the PNO ligand. Compounds I, II and III exhibit a bound water of solvation, whereas compound IV contains a bound methanol mol-ecule of solvation. Compounds I, III and IV exhibit the same arrangement of mol-ecules around each manganese atom, ligated by two bromide ions, oxygen atoms of two PNO ligands and one solvent mol-ecule, whereas in compound II each manganese atom is ligated by two bromide ions, one O atom of a PNO ligand and two water mol-ecules with a second PNO mol-ecule inter-acting with the complex via hydrogen bonding through the bound water mol-ecules. All of the compounds form extended hydrogen-bonding networks, and compounds I, II, and IV exhibit offset π-stacking between PNO ligands of neighboring dimers.

Structures of substituted pyridine N-oxide with manganese(II) acetate.

Manganese(II) acetate coordination polymers have been prepared with three derivatives of pyridine N-oxide. The compounds are catena-poly[manganese(II)-µ3-acetato-di-µ2-acetato-[aqua-manganese(II)]-µ2-acetato-µ-(pyridine N-oxide)-manganese(II)-µ3-acetato-µ2-acetato-µ-(pyridine N-oxide)-[aqua-manganese(II)]-di-µ2-acetato], [Mn4(CH3COO)8(C5H5NO)2(H2O)2] n , (I), catena-poly[[manganese(II)]-µ3-acetato-µ2-acetato-µ-(2-methyl-pyridine N-oxide)-[aqua-manganese(II)]-di-µ2-acetato-manganese(II)-di-µ2-acetato-µ3-acetato-[aqua-manganese(II)]-µ2-acetato-µ-(2-methyl-pyridine N-oxide)], [Mn4(CH3COO)8(C6H7NO)2(H2O)2] n , (II), and catena-poly[[manganese(II)-di-µ2-acetato-µ-(4-methyl-pyridine N-oxide)] monohydrate], {[Mn(CH3COO)2(C6H7NO)]·H2O} n , (III). Compounds (I) and (II) both have three unique Mn atoms; in both compounds two of them sit on a crystallographic inversion center while the third is on a general position. In compound (III), the single unique Mn atom sits on a general position. Pseudo-octa-hedral six-coordinate mangan-ese(II) centers are found in all compounds. All of the compounds form chains of Mn atoms bridged by acetate ions and the oxygen atom of the N-oxide in pyridine N-oxide (PNO), 2-methyl-pyridine N-oxide (2MePNO), or 4-methyl-pyridine N-oxide (4MePNO). Compound (I) and (II) both exhibit a bound water of solvation. In (I), the water hydrogen bonds to a nearby acetate whereas in (II) the water mol-ecule forms bridging hydrogen bonds between two neighboring acetates. In compound (III) a water mol-ecule of solvation is found in the lattice, not bound to the metal ion but hydrogen bonding to a bridging acetate.

Manganese(II) chloride complexes with pyridine N-oxide (PNO) derivatives and their solid-state structures.

Three manganese(II) N-oxide complexes have been synthesized from the reaction of manganese(II) chloride with either pyridine N-oxide (PNO), 2-methyl-pyridine N-oxide (2MePNO) or 3-methyl-pyridine N-oxide (3MePNO). The compounds were synthesized from methano-lic solutions of MnCl2·4H2O and the respective N-oxide, and subsequently characterized structurally by single-crystal X-ray diffraction. The compounds are catena-poly[[aqua-chlorido-manganese(II)]-di-µ-chlorido-[aqua-chlorido-manganese(II)]-bis-(µ-pyridine N-oxide)], [MnCl2(C5H5NO)(H2O)] n or [MnCl2(PNO)(H2O)] n (I), catena-poly[[aqua-chlorido-man-gan-ese(II)]-di-µ-chlorido-[aqua-chlorido-manganese(II)]-bis-(µ-2-methyl-pyridine N-oxide)], [MnCl2(C6H7NO)(H2O)] n or [MnCl2(2MePNO)(H2O)] n (II), and bis-(µ-3-methyl-pyridine N-oxide)bis-[di-aqua-dichlorido-manganese(II)], [Mn2Cl4(C6H7NO)2(H2O)4] or [MnCl2(3MePNO)(H2O)2]2 (III). The MnII atoms are found in pseudo-octa-hedral environments for each of the three complexes. Compound I forms a coordination polymer with alternating pairs of bridging N-oxide and chloride ligands. The coordination environment is defined by two PNO bridging O atoms, two chloride bridging atoms, a terminal chloride, and a terminal water. Compound II also forms a coordination polymer with a similar metal cation; however, the coordination polymer is bridged between MnII atoms by both a single chloride and 2MePNO. The distorted octahedrally coordinated metal cation is defined by two bridging 2MePNO trans to each other, two chlorides, also trans to one another in the equatorial (polymeric) plane, and a terminal chloride and terminal water. Finally, complex III forms a dimer with two bridging 3MePNOs, two terminal chlorides and two terminal waters forming the six-coordinate metal environment. All three compounds exhibit hydrogen bonding between the coordinating water(s) and terminal chlorides.