How to Live Longer With Congestive Heart Failure
More Than A Fifth Of Older Adults With RSV Have Acute Cardiac Events, Data Reveal
A study yesterday in JAMA Internal Medicine demonstrates that 22% of hospitalized adults aged 50 years or older with respiratory syncytial virus (RSV) infection experienced an acute cardiac event—most frequently acute heart failure (16%). Moreover, 1 in 12 of infected patients (8.5%) had no documented underlying cardiovascular disease.
RSV is associated with annual totals of up to 160,000 US hospitalizations, 10,000 deaths, and $4 billion in direct healthcare costs among adults age 65 years or older.
"Despite evidence of considerable RSV-associated morbidity, mortality, and health care expenditure, the potential severity of RSV infection in adults has historically been underappreciated by public health professionals and clinicians," the authors write. RSV is rarely tested for in the clinical settings, and symptoms usually mirror other respiratory diseases, they add.
Despite evidence of considerable RSV-associated morbidity, mortality, and health care expenditure, the potential severity of RSV infection in adults has historically been underappreciated.
The study consisted of outcomes among 6,248 adults aged 50 years and older hospitalized for RSV during 2014 to 2018, and then in 2022 and 2023, in 12 US states. Almost 60% of the adults were women, and 65.9% were White.
Upon hospital admission, 93.1% of those included in the study had a fever, and 80.6% had a cough.
Heart failure most common eventA total of 56.4% of patients had underlying cardiovascular disease, including 31.9% with heart failure, 30.2% with coronary artery disease, and 25.2% with atrial fibrillation. After cardiovascular disease, diabetes (35%) and chronic obstructive pulmonary disease (34.8%) were the most common underlying conditions.
According to the authors, the weighted estimated prevalence of experiencing an acute cardiac event among adults aged 50 years or older hospitalized with laboratory-confirmed RSV infection was 22.4% (95% confidence interval [CI], 21.0% to 23.7%.) Among those events, acute heart failure was the most common, with a prevalence of 15.8% (95% CI, 14.6% to 17.0%) in all RSV-infected patients.
Patients with underlying cardiovascular disease had a greater weighted risk of experiencing an acute cardiac event of any category compared to those without underlying cardiovascular disease (33.0% vs 8.5%). A history of heart failure, age 85 years or older, and atrial fibrillation were also associated with a higher risk of having an acute cardiac event.
Experiencing an acute cardiac event during hospitalization was also associated with more severe RSV outcomes, including intensive care unit admission, invasive mechanical ventilation, and in-hospital death.
"Acute cardiac events occurred frequently among adults with a history of underlying cardiovascular disease, particularly chronic heart failure," the authors concluded. "However, acute cardiac events also occurred in 1 in 12 adults who had no previous documentation of cardiovascular disease, suggesting that severe RSV infection may precipitate or reveal previously undiagnosed cardiovascular disease."
RSV vaccine uptake lowAwareness of RSV's costly impact in the United States is growing, however, and in 2023, the first vaccine for adults ages 65 and older was approved for use in older Americans.
In an editor's note published on the study, Tracy Wang, MD, MHS, a JAMA Internal Medicine associate editor, warns that RSV vaccine uptake among older Americans has been very low, much lower than flu vaccination.
"Prior RSV-related efforts have focused on infants and young children, with many clinicians and patients still unaware of RSV burden of disease and prognosis in older adults," Wang writes. Moreover, RSV vaccines are inconsistently covered by insurance carriers.
"This coverage difference means that many clinic offices need to refer patients to pharmacies for vaccination, and out-of-pocket costs may be necessary for vaccination," she adds. "Vaccine fatigue and access barriers among currently eligible persons need to be addressed to enhance uptake by those who stand to benefit."
Study Furthers Understanding Of Lung Regeneration
We anticipate this protocol will be used to further understand how AT1 cells react to toxins, bacteria, and viral exposures, and will be used in basic developmental studies, disease modeling, and potential engineering of future regenerative therapies
Claire BurgessThe results of this study provide an in vitro model of human AT1 cells, which line the vast majority of the gas exchange barrier of the distal lung, and are a potential source of human AT1s to develop regenerative therapies. The new model will help researchers of pulmonary diseases deepen their understanding of lung regeneration, specifically after an infection or exposure to toxins, as well as diseases of the alveolar epithelium such as acute respiratory distress syndrome (ARDS) and pulmonary fibrosis.
"Uncovering the ability to generate human alveolar epithelial type I cells and similar cell types from pluripotent stem cells has expanded our knowledge of biological processes and can significantly improve disease understanding and management," said Darrell Kotton, MD, Director, Center for Regenerative Medicine (CReM) of Boston University and Boston Medical Center.
This new study also furthers the CReM's goal of generating every human lung cell type from iPSCs as a pathway to improving disease management and provides a source of cells for future transplantation to regenerate damaged lung tissues in vivo. "We know that the respiratory system can respond to injury and regenerate lost or damaged cells, but the depth of that knowledge is currently limited," said Claire Burgess, PhD, Boston University Chobanian and Avedisian School of Medicine, who is the study's first author. "We anticipate this protocol will be used to further understand how AT1 cells react to toxins, bacteria, and viral exposures, and will be used in basic developmental studies, disease modeling, and potential engineering of future regenerative therapies."
Source: Boston Medical Center
Advance In The Treatment Of Acute Heart Failure Identified
A multicenter study led by Vanderbilt University Medical Center (VUMC) and Lipscomb University College of Pharmacy in Nashville has identified a potential new treatment for acute heart failure, a leading cause of hospitalization and death.
The drug, dapagliflozin, was initially approved for the treatment of Type 2 diabetes, but it since has been shown to reduce the risk of hospitalization for heart failure and death in patients with serious health problems that include heart and chronic kidney disease and heightened cardiovascular risk.
Reporting this month in the Journal of the American College of Cardiology, the researchers found that dapagliflozin also benefits patients after admission to the hospital for acute heart failure. The drug improves diuresis, the elimination of excess fluid from the lungs, thereby relieving congestion, and it can reduce hospital stays.
"We demonstrated safety and efficacy of initiating dapagliflozin within the first day of hospitalization for acute heart failure," said the paper's first author, Zachary Cox, PharmD, professor of Pharmacy Practice at Lipscomb University. This "will have international impact on the treatment of acute heart failure."
Each year 800,000 patients with acute heart failure are admitted to U.S. Hospitals from emergency rooms. These patients are at high risk for prolonged hospital stays and death. The annual cost of treating acute heart failure in the United States is estimated to exceed $34 billion.
Diuretics are administered to most patients with acute heart failure to improve symptoms and lung congestion caused by fluid buildup. However, the optimal approach to diuretic therapy in patients hospitalized for acute heart failure remains poorly defined and contributes to prolonged inpatient stays and high death and readmission rates.
Furthermore, many patients do not respond to diuretics, and about half of patients are discharged with persistent congestion. This can result in patients returning to the hospital soon after discharge and being readmitted for further heart failure therapy.
Dapagliflozin is a sodium-glucose cotransporter 2 (SGLT2) inhibitor that acts on the kidneys to increase the removal of sodium and glucose from the body. In April 2020, VUMC began a randomized, clinical trial of the drug in patients hospitalized with acute heart failure.
The study was designed by VUMC's JoAnn Lindenfeld, MD, and Sean Collins, MD, MSc, and by Cox, a member of VUMC's heart failure research team.
Lindenfeld, professor of Medicine in the Division of Cardiology, is nationally known for her innovative contributions to the field of heart failure.
Collins, professor of Emergency Medicine, directs the Center for Emergency Care Research and Innovation (CERI), a national leader in emergency care research, co-directs the Vanderbilt Coordinating Center, which supports VUMC-led clinical research, and is associate director for clinical trials research in the Vanderbilt Institute for Medicine and Public Health.
Cox is a fellow of the Heart Failure Society of America who has published extensively in the field.
Despite the COVID-19 pandemic, which reached its crescendo in the middle of the study, the researchers were able to enroll 240 patients and complete the trial, "thanks to the diligent effort and collaboration between the CERI research team, and … the departments of emergency medicine and cardiology," Cox said.
"This unique partnership allows VUMC to conduct trials in acute heart failure that are only possible in a small number of medical centers across the world," he said.
The trial "really highlights the novelty of our Emergency Medicine infrastructure, and why we are a leader in designing and conducting highly impactful clinical trials such as this one," Collins added.
Patients were enrolled at five sites in addition to VUMC: TriStar Centennial Medical Center and Ascension St. Thomas Hospital West in Nashville, the University of North Carolina at Chapel Hill, the University of Mississippi Medical Center in Jackson, and INTEGRIS Health Baptist Medical Center in Oklahoma City.
Within 24 hours of admission for acute heart failure, patients were randomized to receive either dapagliflozin or conventional diuretic treatment.
While early administration of dapagliflozin did not improve weight-based diuretic efficiency compared to conventional treatment, patients who received the drug experienced no increase in adverse events, required shorter periods of IV diuresis, and were discharged faster during the five-day study period.
The trial demonstrated the safety and efficacy of starting a drug during early hospitalization that will continue to be prescribed upon discharge to help achieve optimal outpatient therapy and reduce the likelihood of readmission.
"It is a way to both improve diuresis AND get a head start on implementing Guideline Directed Medical Therapy in patients with acute heart failure," Lindenfeld said.
Other VUMC co-authors are Cathy Jenkins, MS, and Frank Harrell Jr., PhD, Department of Biostatistics, and Christina Kampe, MAcc, Karen Miller, RN, MPA, and William Stubblefield, MD, MPH, Department of Emergency Medicine.
The study was an investigator-initiated trial funded by AstraZeneca but independently conducted by VUMC investigators. Dapagliflozin is marketed under the brand name FARXIGA. Acute heart failure research at VUMC is supported in part by the National Heart, Lung and Blood Institute of the National Institutes of Health.
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