v-heft and the road to a-heft · left ventricular internal diameter in diastole >2.7 cm per...
Post on 18-Sep-2018
212 Views
Preview:
TRANSCRIPT
Measuring Quality and Performance in Treatment of Heart Failure in African-American Patients:
V-HeFT and the Road to A-HeFT Peter Carson M.D.
Chronology of ISDN/Hydralazine
ISDN/HYD V-HeFT I
FDA
(Paper NDA)
BIDIL
Sub-group
Analyses A-HeFT
1980 1985 1995 2000
FDA
(BIDIL) FDA
(Sub-group)
1990
Heart Failure Therapy – the beginning
Vasodilator Therapy
5 NITRO0010 — AHeFT Slides — v11
Chest. 1978;73:8-13.
V-HeFT Inclusions/Exclusions
• Men between the ages of 18 and 75. Veterans Hospitals
• Cardiac dilatation (cardiothoracic ratio >0.55 on chest x-ray film or a left ventricular internal diameter in diastole >2.7 cm per square meter on echocardiography) or radionuclide LVEF <45 percent
• reduced exercise tolerance (peak <25 ml per kg of body weight per minute) -excluded if exercise tolerance was limited by chest pain rather than by breathlessness and fatigue.
• Exclusions - a myocardial infarction within the previous 3 months, obstructive valvular disease or considerable CAD, COPD, or other disease likely to limit five-year survival.
• No concomitant CV meds- BB, RAS inhibitors, vasodilators
Survival in All Patients V-HeFT I
9
ISDN/HYD n = 186 148 109 71 37 16
Placebo n = 276 202 135 84 41 10
Prazosin n = 183 135 94 58 27 7
25
50
75
100
0 365 730 1095 1460 1825
Su
rviv
al, %
P = 0.093
ISDN/HYD vs placebo
Days since randomization date
Cohn JN et al. N Engl J Med. 1986;314:1547-1552.
ISDN/HYD
Placebo
Prazosin
ISDN/HYD = isosorbide dinitrate plus hydralazine
2
6
Survival in All Patients V-HeFT II
ISDN/HYD n = 401 332 242 157 86 3
Enalapril n = 403 346 265 169 89 1
Enalapril
lSDN/HYD
40
50
60
70
80
90
100
0 365 730 1095 1460 1825
Su
rviv
al,
%
Time, days since randomization
HR = 1.23 (0.97, 1.55)
Log-rank P = 0.083
Cohn JN et al. N Engl J Med. 1991;325:303-310.
Effect of Captopril on BP
100
80
60
40
20
0 Placebo Captopril
12.5 mg Captopril 25.0 mg
Captopril 37.5 mg
Captopril 50.0 mg
43 33 36 42 38 40 50 34 46 35
Whites
Blacks
Perc
en
t P
ati
en
ts A
ch
ievin
g B
loo
d
Pre
ssu
re G
oal
(< 9
1 m
mH
g)
V-HeFT II: Baseline Variables
Black (n = 215)
White (n = 574)
Ejection fraction (%)
MVO (ml / Kg / min)
SBP sitting (mmHg)
PNE (pg / ml)
PRA (ng / mL / hr)
Cardiothoracic ratio
CAD (%)
Hx HTN (%)
29.2 ± 11.5
13.4 ± 3.4
126.0 ± 16.6
449 (330 - 602)
6.55 ( 3.4 - 12.7 )
54.3 ± 6
28.4
64.9
29.0 ± 11.1
13.9 ± 3.5 *
126.4 ± 17.3
504 (368 - 693) **
7.3 ( 3.9 - 17.7 )
52.2 ± 6 *
61.6 **
41.5 **
PNE = plasma norepinephrine; PRA = plasma renin activity
* = p < 0.05; ** = p < 0.01
2
Survival in Black Patients and White Patients V-HeFT II
Carson P et al. J Card Fail. 1999;5:178-187.
Black patients White patients
ISDN/HYD
Enalapril
Time, days since randomization Patients, n
ISDN/HYD 109 92 67 49 29 1 282 231 171 105 55 1
Enalapril 106 93 69 47 24 2 292 251 194 123 66 1
40
50
60
70
80
90
100
0 365 730 1095 1460 1825
Su
rviv
al, %
40
50
60
70
80
90
100
0 365 730 1095 1460 1825
Su
rviv
al, %
HR = 1.01 (0.65, 1.58)
P = 0.96
HR = 1.39 (1.05, 1.83)
P = 0.02
V - HeFT II: Mortality by Race and Hypertensive
History
Months 0 6 12 18 24 30 36 42 48 54 60 66
p < 0.47
Hyd - Iso Enalapril
0 0.1
0.2
0.3 0.4
0.5
0.6
0.7
0.8
Cu
mu
lative
Mo
rta
lity
Black Patients w / o Hypertensive History (n = 72)
p < 0.24
0 0.1
0.2
0.3 0.4
0.5
0.6
0.7
0.8
Cum
ula
tive M
ort
alit
y
Months 0 6 12 18 24 30 36 42 48 54 60 66
White Patients w / o Hypertensive History (n = 318)
Black Patients with Hypertensive History (n = 132)
p < 0.65
0 0.1
0.2
0.3 0.4
0.5
0.6
0.7
0.8 C
um
ula
tive
Mo
rta
lity
Months 0 6 12 18 24 30 36 42 48 54 60 66
p < 0.026
0 0.1
0.2
0.3 0.4
0.5
0.6
0.7
0.8
Cu
mu
lative
Mo
rta
lity
Months 0 6 12 18 24 30 36 42 48 54 60 66
White Patients with Hypertensive History (n = 218)
V-HeFT ll Remodeling
V-HeFT ll Data
Survival in All Patients V-HeFT I
9
ISDN/HYD n = 186 148 109 71 37 16
Placebo n = 276 202 135 84 41 10
Prazosin n = 183 135 94 58 27 7
25
50
75
100
0 365 730 1095 1460 1825
Su
rviv
al, %
P = 0.093
ISDN/HYD vs placebo
Days since randomization date
Cohn JN et al. N Engl J Med. 1986;314:1547-1552.
ISDN/HYD
Placebo
Prazosin
ISDN/HYD = isosorbide dinitrate plus hydralazine
V-HeFT I: Baseline Variables
Black (n = 180)
White (n = 480)
Ejection fraction (%)
SBP sitting (mmHg)
Age (years)
Cardiothoracic ratio
CAD (%)
Hx HTN (%)
31.3 ± 14.1
118.0 ± 16.4
56.3 ± 9.0
55.0 ± 6.3
20.8
46.6
29.3 ± 12.4
119.7 ±19.6
59.2 ± 6.9 **
52.7 ± 6.3 **
50.2 **
37.3 *
* = p < 0.05; ** = p < 0.01 Black vs White CAD = coronary artery disease
hx HTN = history of hypertension
Survival in Black Patients and White Patients V-HeFT I
Patients, n
ISDN/HYD 49 43 36 28 16 8 132 102 71 42 22 9
Placebo 79 61 44 29 14 3 192 140 91 55 27 8
Time, days since randomization
ISDN/HYD
Placebo
Black patients
HR = 0.53 (0.29, 0.98)
P = 0.04
White patients
HR = 0.88 (0.63, 1.24)
P = 0.47
30
40
50
60
70
80
90
100
0 365 730 1095 1460 1825 S
urv
ival
, %
30
40
50
60
70
80
90
100
0 365 730 1095 1460 1825
Su
rviv
al, %
Carson P et al. J Card Fail. 1999;5:178-187
CHF Hospitalization
V - HeFT I
Race Subgroup
Total
Hospitalized
CHF
V - HeFT II
White Black
Total
Hospitalized
CHF
HYD - ISO Enalapril Total HYD - ISO Total Enalapril
Placebo HYD - ISO Prazosin Total Placebo HYD - ISO Prazosin Total
49 (25.5 %)
40 (31.5 %)
32 (24.2 %)
121 16 (25.5 %)
12 (25.5 %)
12 (25.5 %)
39
51 (18.1 %)
51 (17.5 %)
102 24 (22.6 %)
23 (21.1 %)
47
V-HeFT and the Road to A-HeFT
• The V-HeFT retrospective analysis
indicated mortality benefit in African-
American patients.
• There was a physiologic rationale
developing related to NO
• Like all post-hoc analyses, this needed to
be prospectively tested for validity.
• IT WAS!
Taylor AL et al. N Engl J Med. 2004;351:2049-2057.
A-HeFT: All-Cause Mortality 43% Decrease
Fixed-dose H/I 518 463 407 359 313 251 13
Placebo 532 466 401 340 285 232 24
Days Since Baseline Visit Date
0 100 200 300 400 500 600 85
90
95
100
Sur
viva
l (%
)
P=0.01
ISDN/HYD FDC
Placebo Hazard ratio=0.57
Racial Differences in the Outcome of Left Ventricular Dysfunction Dries et al, NEJM 1999; 340:609-616
Exner DV et al. N Engl J Med 2001;344:1351-1357.
Outcomes among Black Patients as Compared with Matched White Patients.
Exner DV et al. N Engl J Med 2001;344:1351-1357.
Outcomes among Black and Matched White Patients Assigned to Enalapril Therapy as Compared with
Placebo.
Exner DV et al. N Engl J Med 2001;344:1351-1357.
Rates of Death from Any Cause (Top Panel) and of Hospitalization for Heart Failure (Bottom Panel) among Black Patients and Matched
White Patients Randomly Assigned to Enalapril or Placebo.
top related