October 2016 Br J Cardiol 2016;23:(4) doi: 10.5837/bjc.2016.032 Online First
Thomas Green, Kaushiki Singh, Hugh F McIntyre
National Institute for Health and Care Excellence (NICE) guidance supports the introduction of sacubitril/valsartan under the supervision of a heart failure specialist with access to a multi-disciplinary heart failure team. Clinical information was obtained retrospectively on all patients with a primary coded diagnosis of heart failure discharged from the Conquest Hospital, Hastings, UK during the calendar year 2015. We recorded the proportion of patients meeting the NICE recommendation and those patients meeting the additional PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) study inclusion criteria.
In a total of 205 assessable patients discharged with a primary diagnosis of heart failure during the calendar year 2015, inpatient mortality was 11%, with a crude readmission rate during the year of 17%. The number of patients meeting the NICE criteria was 26 (13%). In hierarchical analysis taking the major PARADIGM-HF inclusion criteria, 20 patients (10%) patients met the inclusion criteria.
In conclusion, the findings from this audit suggest that the number of patients potentially suitable for sacubitril/valsartan therapy is low. Given the PARADIGM-HF study run-in design, the optimal dose and stability of angiotensin-converting enzyme (ACE) inhibitor and angiotensin-receptor blocker medication may need to be clarified if sacubitril/valsartan is to be commenced during or shortly after hospitalisation.
October 2016 Br J Cardiol 2016;23:(4) doi: 10.5837/bjc.2016.033 Online First
Freya M Lodge, Julie Phillips, Tristan Groves, Zaheer R Yousef
The first-in-class drug sacubitril/valsartan (EntrestoTM) has been recommended for use in the UK by the National Institute for Health and Care Excellence (NICE) following evidence from the PARADIGM-HF (Prospective comparison of ARNI with ACEI to Determine Impact on Global Mortality and morbidity in Heart Failure) trial. To qualify, patients should have severe left ventricular dysfunction (ejection fraction ≤35%), New York Heart Association (NYHA) grade II–IV symptomatic heart failure, and be on a stable dose of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin-receptor blocker (ARB). We evaluated all patients seen in our nurse-led heart failure clinics over a six-month period to assess suitability for sacubitril/valsartan and the resulting cost implication.
Of 553 patients seen, more than two thirds (69%) were unsuitable, of whom most had an ejection fraction greater than 35%. Other reasons included hypotension, NYHA class I, renal dysfunction, intolerance of ACEi/ARB and compliance concerns. There were 49 patients who died within nine months of the study period end. Of these, most (84%) were unsuitable for sacubitril/valsartan. Compared with current local use of ACEi and ARB, switching the 174 suitable patients to sacubitril/valsartan would cost £171,816 per year.
In our real-world experience, 31–37% of patients attending a specialist nurse-led heart failure clinic may be suitable for sacubitril/valsartan therapy. While the clinical benefits of this treatment are well proven and a recent NICE technology assessment has demonstrated cost-effectiveness, the medication has significant upfront cost implications for healthcare commissioners.
October 2016 Br J Cardiol 2016;23:(4) doi: 10.5837/bjc.2016.034 Online First
Usha Rao, Timothy J Gilbert, Simon C Eccleshall
Drug-eluting stents (DES) have revolutionised the treatment of acute coronary syndrome, resulting in improvement in mortality and morbidity. However, there have been safety concerns, mainly involving a small, but long-term, risk of stent thrombosis (ST) and in-stent restenosis (ISR). Stent fracture (SF) is a lesser-known complication that can predispose to both ST and ISR and for which there is no general consensus for treatment. We present an interesting case and a new approach to treating this complex problem.
MEETING REPORT Online First
MEETING REPORT Online First