bluuebunny/crossref_metadata_2025 huggingface dataset:
The impact of COVID 19 on heart failure hospitalization and management from an Asian perspective
Authors: Ruan X , Tan V.H , Huang W.L , Oh Y.Z , Teo Z.W , Ang T.B , Cao Y , Foong M.M , Huang Y.H , Yusoff N.A.B , Loh D.H.F , Lee S.S.G
Published: October 2021

Introduction

COVID 19 is a global pandemic that has stretched healthcare resources. We explored the shift in patient demographics and clinical management of systolic heart failure (HF) patients during the COVID 19 outbreak.

Purpose

To examine the impact of COVID 19 on the hospitalization rates of decompensated systolic HF patients in a tertiary hospital in Asia and delineate differences in the clinical characteristics and management of these patients.

Methods

Data was extracted from the admission registry for systolic HF patients admitted to the tertiary hospital from January to June 2019 (pre-COVID) and the corresponding time period in 2020 during the COVID outbreak. We compared the demographics, clinical management and outcomes of these patients.

Results

There was a significant reduction in patients admitted for systolic HF during the COVID period, 174 (6.3%) compared to 240 (8.5%) pre-COVID (p=0.001). The baseline demographics were similar except for the age of patients admitted during the COVID 19 period, which were younger at 66.1±13.5 compared to 69.9±13.9 pre-COVID (p=0.007). The mean left ventricular ejection fraction (LVEF) was lower during the COVID period (22.9±10.1% vs 24.9±10.1%; p=0.032). More patients during the COVID period were placed on mineralocorticoid receptor antagonists (p=0.001) and SGLT2 inhibitors (p<0.001). For those with recurrent admission for systolic HF, the number for HF admissions in the preceding one year was lower during COVID period compared to pre-COVID (0.2±0.5 vs 0.5±1.0 readmissions, p<0.001). There was no COVID 19 infection among those admitted for systolic HF. The 30-day all-cause mortality and readmission rates were comparable between both groups. Cardiac related mortalities were higher during the COVID 19 period compared to the pre-COVID period (77.8% vs 100.0%, p=1.000). No difference was observed in the length of stay nor proportion of patients who required a higher level of care in high dependency or intensive care unit during the COVID outbreak. Those who were admitted during the COVID period were more likely first presentation of decompensated systolic HF, 119 (68.4%) compared to 135 (56.3%) pre-COVID (p=0.014).

Conclusion

Similar to the existing publications, there was a reduction in patients admitted for HF during the COVID period. However, for those who were admitted, these patients were younger and had lower LVEF. Most of them were first diagnosed with systolic HF during the hospitalizations. For those who had previous history of systolic HF, they had a lower number of HF admissions in the preceding one year compared to those who were admitted during the pre-COVID period. There was no difference in the 30-day mortality and utilization of high dependency or intensive care unit during the COVID outbreak.

Funding Acknowledgement

Type of funding sources: None.
Chronic heart failure in intensive care unit: can we accurately predict the risk?
Authors: Maltes S , Maltes S , Rocha B.M.L , Cunha G.J.L , Lopes P , Moura A , Aguiar C.M.T , Coelho F , Torres J , Santos P , Monteiro F , Lamas T , Carmo E , Ferreira J , Mendes M
Published: October 2021

Background

Severity of disease scoring systems, namely the Simplified Acute Physiology Score (SAPS) and Acute Physiology and Chronic Health Evaluation (APACHE), are widely used to predict mortality in Intensive Care Units (ICU). Yet, neither score includes chronic HF in their model. We aimed to evaluate whether these scores perform well in risk prediction of death of patients previously diagnosed with heart failure (HF).

Methodology

This is a single-center retrospective cohort of patients admitted to an ICU in 2019. Those whose admission lasted <24 hours were excluded from analysis. The SAPS II and APACHE II scores were calculated using data from the first 24 hours of ICU admission, imputing the worst variable obtained within this timeframe. HF was defined according to the ESC recommendations. In order to assess the performance of the scores, Receiver Operating Characteristic (ROC) Curves were used to predict the risk of death in ICU in HF compared to the non-HF population.

Results

A total of 267 patients were hospitalized in ICU for a period over 24 hours in 2019 (mean age 67±16 years; 58.8% males; 21.7% with chronic HF; 33.7% admitted for sepsis). Compared to patients without HF, those with chronic HF were older (74±13 vs. 65±16 years; p<0.001) and had higher risk scores (mean SAPS II: 43.2±21.7 vs. 56.5±20.7; p<0.001; mean APACHE II: 19.8±10.0 vs. 25.1±10.0; p<0.001). Moreover, these patients were at higher risk of meaningful events during hospitalization (e.g. acute kidney injury: 38.0 vs. 66.1%; p<0.001; shock at any time: 52.4 vs. 67.8%; p=0.036). Furthermore, patients with HF had a trend towards higher mortality rates in ICU (17.3 vs. 28.8%; p=0.051) and a significantly higher death in overall hospitalization (30.8 vs. 45.8%; p=0.032). ROC curves performed well in predicting the risk of ICU death regardless of HF (SAPS II – AUC 0.78 vs. 0.81; p=0.36; APACHE II – AUC 0.75 vs. 0.78; p=0.37).

Conclusion

Approximately 1 in every 4 patients admitted to the ICU had chronic HF. Traditional risk scoring systems (SAPS II and APACHE II) performed well regardless of HF. While these results are reassuring as far as risk stratification accuracy is concerned, HF patients remained at a higher risk for worse outcomes. Therefore, prognostic tools with a therapeutic clinical applicability are urgently needed to improve the outcome of this population.

Funding Acknowledgement

Type of funding sources: None.
Impact of gastrointestinal hemorrhage on hospital outcomes of patients with hypertrophic cardiomyopathy
Authors: Shah K , Thyagaturu H , Mughal M , Gandhi H , Harmouch F , Modi V , Kothari J , Shirani J
Published: October 2021

Background

Patients with hypertrophic cardiomyopathy (HCM) may be at relatively high risk of gastrointestinal hemorrhage (GIH) due to acquired von Willebrand disease (aVWD) and anticoagulation for atrial fibrillation among others factors.

Purpose

We aimed to evaluate impact of GIH on in-hospital outcomes of patients with HCM.

Methods

The National Inpatient Sample reported 45,305 admissions for adults with HCM during a two-year period (2016–2017). Among them, 1,490 patients (3.3%) also had GIH. Baseline characteristics and in-hospital outcomes of the two groups were compared. Multivariable logistic regression analysis was used to assess the independent impact of GIH on in-hospital outcomes of HCM patients.

Results

Out of 45,305 HCM patients, 1490 (3.2%) also had concomitant diagnosis of GIH. HCM patients with GIH were older (70±9 vs 66±23 years), were more often male (64% vs 61%), and had higher prevalence of prior myocardial infarction (12% vs 7%, p<0.001) and cirrhosis (7.1% vs 2.6%, p<0.001) while being less often obese (15% vs 22%, p=0.01) or having a history of congestive heart failure (30% vs 36%, p=0.03) [Table 1]. Hospital mortality was significantly higher among those with GIH (6.4% vs 3.5%, p<0.001). Multivariable logistic regression analysis identified GIH as an independent predictor of higher in-hospital mortality [adjusted odds ratio (aOR)=1.60, 95% confidence interval (CI)=1.02–2.63, p=0.001], hypovolemic shock (aOR=5.17, 95% CI=2.5–10.6, p<0.001), mean length of stay (Δ +2.4 days, p<0.001) and mean hospital cost (Δ +$21,162, p=0.004).

Conclusion

Adults with HCM and GIH are older, less often obese with higher prevalence of cirrhosis and prior myocardial infarction. Presence of GIH is an independent predictor of higher mortality, hypovolemic shock, length of stay and hospital cost in HCM adults admitted to hospital.

Funding Acknowledgement

Type of funding sources: None. Table 1
Prevalence of left bundle branch block and CRT treatment in a large regional unselected ECG database
Authors: Lind S , Gatti P , Kristjansdottir I , Gadler F
Published: October 2021

Introduction

Heart failure is a clinical syndrome in which signs and symptoms are due to functional and/or structural abnormalities of the heart which prevent the necessary supply of oxygenated blood or do so at the expense of high filling pressures. It has a prevalence of 1–2% in the western world and increasing prevalence with increasing age. While the prognosis for coronary heart disease has improved significantly, the same does not apply for heart failure, perhaps because some effective treatment methods have not been sufficiently implemented in health care. One effective but underutilized heart failure treatment is the cardiac resynchronisation therapy (CRT), that coordinates the contraction of the left and right ventricles via a pacemaker (PM). CRT treatment is an evidence based treatment recommended by among other the ESC guidelines for heart failure. Clinical studies have suggested decreases in mortality, hospitalization, morbidity and improvements in quality of life for heart failure patients receiving a CRT.

Purpose

To find a new clinical pathway to improve CRT implementation and to evaluate if it might be optimized through ECG-based surveillance and thus improving prognosis.

Methods

In a population of approximately 2.5 million people in our region we investigated the University Hospital's ECG database between 2000 and 2018. During which time 432 108 adult patients with 1 482 489 ECG's presented to the hospital. We searched and found 5 511 unique patients with the following ECG criteria: QRS ≥150 ms at any time, LBBB and Non pace. According to the Pacemaker Registry we excluded 771 patients that had previously received a PM/CRT. We also identified patients with diagnosis of heart failure by using the ICD-10 codes (I42.0 and I50).

Results

Our final cohort consists of 4 740 patients. The median age was 75 (19–112) years, 34.5% were female and 14.9% were subsequently implanted with a CRT (60% with CRT-D). The median time to CRT implantation from the first ECG with LBBB was 244 (IQR 994) days. Of the 4 740 patients 20.6% had a previous hospitalistion for heart failure with a median delay from the hospitalisation to CRT implantation of 5 (IQR 5.4) years.

Conclusions

Our observational data from a large real-life regional ECG database show there is a considerable number of heart failure patients that could benefit from CRT treatment. Using an existing ECG database could be useful in finding patients with indication for CRT implantation. This could possibly influence morbidity and mortality in a regional heart failure population by minimizing the delay of CRT treatment.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): Karolinska University Hospital Research Fund
Estimating pVO2 and prognosis through cardiac exercise stress test in a heart failure population
Authors: De Almeida J.P.L , Milner J , Rosa J , Coutinho R , Ferreira M , Goncalves L
Published: October 2021

Background

Compared with the cardiac exercise stress test, more commonly used to assess the presence of ischemia, the cardiopulmonary exercise test has the advantage of providing expired gas analysis. According to current guidelines, cardiopulmonary exercise testing should be considered to stratify the risk of adverse events and to provide measures of survival improvement in heart failure populations. However, cardiac exercise stress test is more readily available and widespread than cardiopulmonary exercise testing. We aimed to compare prognostic information given by estimated pVO2 – which can be obtained from cardiac exercise stress test – and real measured pVO2 – which requires cardiopulmonary exercise test – in a heart failure population.

Methods

We conducted a retrospective analysis of 214 patients with HF underwent cardiac exercise stress test and accessed their 5 year survival. Non-urgent transplanted (UNOS Status 2) patients were censored alive on the date of the transplant. Duringthe cardiopulmonary exercise test, cardiac exercise stress test data simultaneously collected. Based on protocol stage achieved, estimated METs were used to calculate estimated pVO2 (pVO2 = estimated METs x 3.5). Estimated and real pVO2 were correlated using Pearson correlation and the age-adjusted prognostic power of each was determined using Cox proportional hazardsanalysis.

Results

164 patients were male (77%) and the mean age of the population was 56±10 years. 78 (36%) patients had an ischemic etiology. Within 5 years from testing, 46 patients died (21.5%) and 55 patients (26%) were transplanted. Naughton modified (n=165) was the most commonly used protocol, followed by Naughton (n=39) and Bruce (n=10). Estimated pVO2 and measured pVO2 correlated significantly (R=0.66, p<0.01) (Figure 1). Both estimated (HR=0.91, 95% CI 0.86–0.95, p<0.01) and measured pVO2 (HR=0.86, 95% CI 0.80–0.91, p<0.01) strongly predicted prognosis in this population.

Conclusions

Estimated pVO2 correlated with measured pVO2 and strongly predicted prognosis in this heart failure population. Because it can be obtained from conventional cardiac exercise testing, it may become an alternative prognostic tool to cardiopulmonary testing.

Funding Acknowledgement

Type of funding sources: None. Figure 1. Measured vs estimated pVO2
Global longitudinal strain predicts clinical disease progression in stable asymptomatic heart failure patients better than left ventricular ejection fraction
Authors: Marschall A , Del Castillo Carnevali H , Fernandez Pascual C , Lorente Rubio A , Morales Gallardo M.J , Dejuan Bitria C , Delgado Calva F.A , Duarte Torres J , Biscotti Rodil B , Rodriguez Torres D , Rueda Linares A , Gomez Sanchez I , Basabe Velasco E , Alvarez Anton S , Marti Sanchez D
Published: October 2021

Background

Previous studies have shown that left ventricular (LV) global longitudinal strain (GLS) is a feasible and reliable predictor for outcomes in heart failure (HF) patients with greater accuracy than LV ejection fraction (LVEF). However, these studies rarely included stable or asymptomatic patients.

Purpose

To assess the predictive value of GLS, as compared to LVEF, in asymptomatic stable HF patients.

Methods

This is a retrospective study, including patients with HF with reduced and mid-range ejection fraction (HFrEF: LVEF<40%; HFmrEF: LVEF 40–49%) in NYHA I with no history of decompensation within the previous 6 months. All patients underwent comprehensive baseline echocardiographic assessment. The primary endpoint was the composite of cardiovascular death, hospitalization and need for intensification of HF treatment within a 12 month follow-up period.

Results

Out of 837 patients with LVEF <50% that underwent follow-up in our HF unit between January 2016 and December 2017, 153 patients were included in the study. The mean age was 74 (±10.2) years and 82% were male. The cumulative incidence of HF progression was 17.8%, with a median time to event of 193 days. Death and hospitalization due to HF accounted for three-quarters of the events. The mean LVEF was 40.9% (± 6.96),without significant differences between patients with and without clinical progression (39.5% vs 43%, p=0.093). We did not find significant differences between the two groups, concerning LV and atrial dimensions, as well as mitral inflow, PSAP and tricuspid annular systolic plane excursion (TAPSE). LV GLS was significantly lower (i.e. less negative) in patients that presented clinical progression, that in patients without disease progression (−7.7 vs −12.2, p<0.001). Receiver operating characteristic curve and univariate Cox regression analysis identified GLS as the most accurate predictor for clinical progression among all continuous variables (AUC: 0.809, cut-off: −8.5%, sensitivity: 74.1%, specificity: 89%, HR: 14.78 (95% CI: 6.2–35.1), p<0.001). LVEF predicted HF progression less precisely (AUC: 0.654, cut-off: 42%, sensitivity: 70.4%, specificity: 54%, HR: 2.38 (95% CI: 1.1–5.2), p=0.03).

Conclusion

In asymptomatic stable HF patients (in NYHA I), LV GLS showed to be a more accurate predictor of clinical disease progression than LVEF.

Funding Acknowledgement

Type of funding sources: None. Global longitudinal strain (GLS)Receiver operating characteristic (ROC)
Sodium-glucose co-transporter-2 inhibitors improve cardiovascular outcomes in heart failure with reduced ejection fraction regardless of ischemic etiology
Authors: Patoulias D , Boulmpou A , Tsavousoglou C , Toumpourleka M , Siskos F , Nikolaidis A , Papadopoulos C.E , Vassilikos V , Doumas M
Published: October 2021

Background

Coronary artery disease remains the main underlying cause of heart failure (HF), despite the progress in prevention, diagnosis and treatment. Sodium-glucose co-transporter-2 inhibitors have been shown to improve surrogate cardiovascular outcomes in patients with HF with reduced ejection fraction (HFrEF), regardless of diabetes status.

Purpose

We sought to determine the effect of SGLT-2 inhibitors on the primary composite endpoint (cardiovascular death or hospitalization for HF) across the two hallmark trials in the HFrEF population (EMPEROR Reduced and DAPA-HF), according to ischemic or non-ischemic etiology of HF.

Methods

We pooled data from EMPEROR reduced and DAPA-HF trials in a total of 8,474 patients with HFrEF, performing a sub-analysis according to the presence of ischemic cardiomyopathy as the underlying cause of HFrEF.

Results

Treatment with SGLT-2 inhibitors resulted in a significant decrease in the risk for the primary composite outcome in patients with HFrEF of ischemic etiology, equal to 18% (RR=0.82, 95% CI: 0.73–0.92, I2=0%). In patients with HFrEF of non-ischemic etiology, SGLT-2 inhibitors produced a significant decrease in the risk for the primary composite outcome equal to 18% (RR=0.72, 95% CI: 0.63–0.82, I2=0%). Despite the greater effect in patients with non-ischemic HFrEF, no subgroup difference was detected (p=0.16). Generated results are summarized in Figure 1.

Conclusions

SGLT-2 inhibitors improve surrogate cardiovascular outcomes both in patients with ischemic and non-ischemic HFrEF.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Value of echocardiography using knowledge-based reconstruction in determining right ventricular volumes in pulmonary sarcoidosis: comparison with cardiac magnetic resonance imaging
Authors: Mathijssen H , Huitema M.P , Bakker A.L.M , Akdim F , Van Es H.W , Grutters J.C , Post M.C
Published: October 2021

Background

Right ventricular (RV) dysfunction in sarcoidosis is associated with adverse outcomes. Assessment of RV function by conventional transthoracic echocardiography (TTE) is challenging due to the complex RV geometry. Knowledge-based reconstruction (KBR) combines TTE measurements with three-dimensional coordinates to determine RV volumes.

Purpose

The aim of this study was to investigate the accuracy of TTE-KBR compared to the gold standard cardiac magnetic resonance imaging (CMR) in determining RV dimensions in pulmonary sarcoidosis.

Methods

Pulmonary sarcoidosis patients prospectively received same-day TTE and TTE-KBR. If performed, CMR within three months after TTE-KBR was used as reference standard. Outcome parameters included RV end-diastolic volume (RVEDV), end-systolic volume (RVESV), stroke volume (RVSV) and ejection fraction (RVEF).

Results

282 patients underwent same day TTE and TTE-KBR. In total, 122 patients received a CMR within 90 days of TTE and were included. TTE-KBR measured RVEDV and RVESV showed strong correlation with CMR measurements (R=0.73, R=0.76), while RVSV and RVEF correlated weakly (R=0.46, R=0.46). Bland-Altman analyses (mean bias ±95% limits of agreement), showed good agreement for RVEDV (ΔRVEDVKBR-CMR, 5.67±55.4mL), while RVESV, RVSV and RVEF showed poor agreement (ΔRVESVKBR-CMR, 21.6±34.1mL; ΔRVSVKBR-CMR, −16.1±42.9mL; ΔRVEFKBR-CMR, −12.9±16.4%). Image quality, time to CMR and learning curve showed no impact.

Conclusions

TTE-KBR is convenient and shows good agreement with CMR for RVEDV. However, there is poor agreement for RVESV, RVSV and RVEF. The use of TTE-KBR does not seem to provide additional value in the determination of RV dimensions in pulmonary sarcoidosis patients.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): ZonMW (The Netherlands Organisation for Health Research and Development) Figure 1. Correlation plotsFigure 2. Bland-Altman plots
Non-vitamin K oral anticoagulants versus warfarin for treating left ventricular thrombus
Authors: Kam K.K.H , Chan J.S.K , Lee A.P.W
Published: October 2021

Background

Left ventricular thrombus (LVT) is associated with significant morbidity and mortality. Traditionally treated with anticoagulation by Warfarin, it is unclear if non-vitamin K oral anticoagulants (NOAC) are comparably efficacious and safe. Such data is also scarce in Asian patients.

Purpose

To compare the clinical efficacy and safety of NOAC with warfarin for managing LVT.

Methods

Clinical and echocardiographic records of all adult patients with echocardiography-confirmed LVT during January 2011 to January 2020 were retrieved. Any discontinuation of anticoagulation at one year was recorded. Outcomes of patients on NOAC were compared to those on warfarin. The primary outcomes were cumulative mortality and net adverse clinical events (NACE; any of cerebrovascular accident, systemic thromboembolism, intracranial haemorrhage, fatal bleeding, and overt bleeding). Secondary outcomes were complete LVT resolution and percentage reduction in LVT size at three-month follow-up, and the components of NACE.

Results

In total, 43 patients were included; 28 were treated by warfarin and 15 by NOAC, with mean follow-up periods of 20±12 months and 22±9 months respectively (p=0.522). Significantly fewer NACE were observed in the NOAC cohort (p=0.046; Figure 1), with a trend for lower cumulative mortality (p=0.058; Figure 2). There were no significant differences in the secondary outcomes. Additionally, given resolution of LVT, discontinuation of anticoagulation by one year was not associated with significantly different outcomes.

Conclusion

NOAC may be an efficacious and safe alternative to warfarin for treating LVT. Further studies are required to confirm our findings and delineate the optimal duration of anticoagulation.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): Hong Kong Special Administrative Region Government Health and Medical Research Fund Figure 1Figure 2
Therapeutic role of Prostaglandin E2 receptor 4 stimulation in inflammatory cardiomyopathy
Authors: Takakuma A.T , Nishii M.N , Saji R.S , Sakai K.S , Matsumura R.M , Ogawa F.O , Takeuchi I.T
Published: October 2021

Background

Prostaglandin E2 receptor 4 (EP4) plays a crucial role in inflammatory diseases. Inflammatory cardiomyopathy often leads to refractory heart failure.

Purpose

We aimed to evaluate the role of EP4 in the development of inflammatory cardiomyopathy.

Methods

Experimental autoimmune myocarditis (EAM) was induced by immunization with cardiac myosin in balb/c mice. EP4 selective antagonist (CJ-42794, Cayman Chemical: 30 mg/kg/day), EP4 selective agonist (20 mg/kg/day), both, or vehicle alone was daily administrated after the immunization. Cardiac function and dimensions were assessed by echocardiography. Blood pressure and heart rate were assessed with tail-cuff method. Cardiac inflammation and fibrosis were immunohistologically examined. Molecular examination was performed by RT-PCR and immunoblotting.

Results

Cardiac dysfunction and dilatation were worsened on day 21 in EP4 antagonist-treated group compared with in the vehicle-treated group, accompanied by an increase in cellular infiltration area (21.7±1.9 vs. 11.0±2.7%, P=0.0367, respectively). Conversely, cardiac dysfunction and dilatation were improved in EP4 agonist-treated group compared with in the vehicle-treated group (Left ventricular fractional shortening: 69±3% vs. 40±4%, P<0.0001; Left ventricular systolic dimension: 0.7±0.1mm vs. 1.9±0.3mm, P=0.0007; respectively). These parameters did not show significant differences between both-treated group and the vehicle-treated group. The protective effect of EP4 stimulation in EAM was also kept on day 56. Moreover, cardiac fibrosis area as well as mRNA expressions of Type III collagen and brain natriuretic peptide in the bulk hearts was significantly reduced on day 56 in EP4 agonist-treated group compared with in the vehicle-treated group (12.3±2.4% vs. 24.7±3.0%, P=0.0278, respectively). Cardiac expression of phosphorylated smad 2/3 protein as well as TGF-β1 mRNA did not show significant differences between the 2 groups, while cardiac expression of RORgammat protein, the master regulator of Th17 immunity was increased in the EP4 antagonist-treated group.

Conclusions

EP4 activation negatively regulated the induction of cardiac autoimmunity, which alleviated cardiac dysfunction, dilatation, and fibrosis. EP4 may be a therapeutic target for preventing the development of inflammatory cardiomyopathy.

Funding Acknowledgement

Type of funding sources: None.
Mortality and long-term outcomes of palliative inotropes in ischemic and non-ischemic cardiomyopathy
Authors: Tolia S , Khan M , Khan S , Alexander D , Soltys M , Kamba K , Brennan S , Adhikari S , Hussain S , Joshi A , Sciamanna C , Narang N , Pillarella J , Cotts W , Andrade A
Published: October 2021

Background

Palliative inotropes are frequently utilized for symptom management in patients with end stage heart failure who are unable to undergo durable advanced heart failure therapies. With the advent of improved medical management and early intervention, palliative inotropes may allow for improved patient outcomes than seen previously. In this study, we aim to investigate the survival and outcomes of palliative inotrope therapy and its impacts on ischemic versus non-ischemic cardiomyopathy.

Methods

We retrospectively analyzed 220 patients with American Heart Association Stage D heart failure who were discharged with palliative inotrope therapy after January 1, 2010. Patients who underwent mechanical circulatory support (MCS) or those who underwent heart transplant were excluded. Those with a history of coronary artery disease, myocardial infarction, history of percutaneous intervention, or coronary artery bypass grafting were assigned to ischemic cardiomyopathy (ICM), while patients without these findings were assigned to non-ischemic cardiomyopathy (NICM). Statistical analysis was completed using Chi-Square and Student's t-tests, wherein p<0.05 was considered statistically significant.

Results

Of the 220 patients, 87 had NICM as opposed to 133 with ICM. Mean age was found to be higher among patients with ICM (70 [62–79]) compared to NICM (65 [55–72], p-value <0.01). No significant difference was seen in total days on inotrope therapy (p=0.6). While more patients in both groups were placed on milrinone as opposed to dobutamine, there was no difference between patients with ischemic and NICM (p=0.66 and 0.51 respectively). Although a greater number of patients with NICM had been lost to follow up, admitted to hospice, or expired at 2 years (p<0.01), survival at 3 months, 1 year, and 2 years showed no difference between both groups. No difference was seen in number of hospitalizations or clinic visits in one year. Both groups had similar complication rates with intravenous-access related PICC line infections and new arrhythmias. (See Table).

Conclusion

Despite more frequent use of durable mechanical support devices, many patients who are deemed unsuitable for invasive measures are treated with palliative inotrope therapy. We have found that there is no significant difference in survival, complications, and outcomes of patients on palliative inotropes among ischemic and NICM. These findings show the versatility of palliative inotrope therapy in end stage heart failure. Further studies with larger populations need to be evaluated.

Funding Acknowledgement

Type of funding sources: None.
Low serum chloride level gives renin-angiotensin system inhibitor a prognostic impact in heart failure patients with preserved ejection fraction
Authors: Shirotani S , Jujo K , Kishihara M , Watanabe S , Endo N , Takada T , Abe T , Minami Y , Hagiwara N
Published: October 2021

Background

Hypochloremia is associated with a poor prognosis of heart failure (HF) patients. This phenomenon is sustained even in HF with preserved ejection fraction (HFpEF). Serum chloride level is known to be affected by serum renin secretion; however, this relationship is one of the least investigated field in HF patients. Renin-angiotensin system (RAS) inhibitor is recommended as a first-line medication for HF patients with reduced left ventricular ejection fraction, but no prior studies of RAS inhibitors have achieved to improve the prognosis of HFpEF patients.

Purpose

We investigated the relationship between baseline serum chloride level and the prognostic impact of RAS inhibitor in HFpEF patients.

Methods

This is an observational study including 1,913 consecutive patients who admitted to hospital due to worsening of HF and discharged alive in a single university hospital. After excluding patients who received regular hemodialysis and whose left ventricular ejection fraction were under 50%, 506 HFpEF patients were ultimately analyzed. They were categorized into tertiles by serum chloride levels at discharge (T1: −100 mEq/L, T2: 101–104 mEq/L, T3: 105- mEq/L), and patients in each category were further divided into subgroups depending on the prescription of RAS inhibitor at discharge (RAS inhibitor group and Non-RAS inhibitor group). The primary endpoint of this study was death from any cause.

Results

During the observation period with 479 days of median follow-up, 77 (15.2%) died. Patients in the RAS inhibitor group had significantly better prognosis than those in the Non-RAS inhibitor group in T1 category (Log-rank: p=0.003, Figure). In contrast, there was no statistical difference in the mortality between the RAS inhibitor group and Non-RAS inhibitor group in T2 and T3 categories (Log-rank: p=0.15, p=0.81, respectively, Figure). Multivariate Cox regression analysis in T1 category revealed that taking RAS inhibitor at discharge was independently associated with a lower mortality rate, even after the adjustment of diverse covariates (hazard ratio: 0.40, 95% confidence interval: 0.20–0.80).

Conclusion

In this observational study, the administration of RAS inhibitor was associated with an improved prognosis of HFpEF patients only in low serum chloride level at discharge. Therapeutic strategy focusing on the chloride level may be one of the promising options to find the light on a unintervenable prognosis of HFpEF.

Funding Acknowledgement

Type of funding sources: None.
Changing demographics, temporal trend in waitlist and post-transplant outcomes after heart transplantation in the United States: analysis of unos database 1991–2019
Authors: Akintoye E , Alvarez P , Shin D , Egbe A , Panos A , Briasoulis A
Published: October 2021

Background

The landscape of heart transplantation (HT) has changed significantly with respect to patient selection, surgical techniques, and patient outcomes. We sought to investigate temporal trends in patient characteristics, waitlist and post-transplant outcomes after HT in the U.S.

Methods

We queried the national database of the United Network of Organ Sharing (UNOS) to identify adults listed for HT in the U.S. between 1991 and 2019. Patients were divided into four eras based on the three time points in which changes were made to the patient selection/allocation policy (1999, 2006, and 2018), and patient characteristics as well as waitlist and post-transplant outcomes were evaluated for each era.

Results

Between 1991 and 2019, a total of 95,179 patients were added to the waitlist for HT in the U.S. Compared to era 1, patients listed in era 4 were older (mean age: 52.4 years), more female (27.6%) and ethnic minorities (40%), and with higher-risk comorbidities (28.8% diabetes, 35.6% obese). Over the study period, there were 22,070 waitlist deaths and 61,687 transplants.

Compared to the preceding era, there was significant decrease in waitlist mortality in the last 2 eras (e.g., sub-hazard ratio for era 4 vs era 3 =0.37, 95% CI=0.32–0.44). For each year, only 27.1% to 40.5% of those on the waitlist were transplanted. Among those who were transplanted, there was increase in the rates of in-hospital stroke (2.8% in era 1 to 3.7% in era 4), renal failure requiring dialysis (7.2% to 17.1%), and hospital length of stay (14 to 17 days), p-values<0.001 for all. However, this has not negatively impacted short-term survival when compared to the preceding era (1-year graft survival = 89.7% in era 4). Based on a projection model, we predict a 47% increase in living adult heart transplant recipients to to 44,366 in 2040.

Conclusion

There have been significant changes in the characteristics of patients listed for HT in the U.S., including an increasing proportion of high-risk co-morbidities. Although the transplant volume has increased, the wide supply-demand gap persisted. The last 2 changes in the allocation policy in 2006 and 2018 achieved their primary objective of reducing waitlist mortality.

Funding Acknowledgement

Type of funding sources: None.
B-lines by lung ultrasound is associated with pulmonary symptoms and cardiac function in acute malaria: a prospective cohort study
Authors: Wegener A , Holm A , Gomes L , Lima K , Matos L , Vieira I , Kaagaard M , Souza R , Marinho C , Sorensen T , Silvestre O , Brainin P
Published: October 2021

Background

Malaria patients are at risk of cardiopulmonary complications, but diagnosis and management are difficult in resource limited environments. B-lines by lung ultrasonography (LUS) can identify pulmonary alterations, however, little is known about the usefulness in malaria.

Purpose

We aimed to investigate the occurrence of B-lines in acute malaria patients at baseline and at follow-up, and whether they are associated with shortness of breath and impaired left ventricular ejection fraction (LVEF).

Methods

Adult patients with non-severe acute malaria were prospectively enrolled from June to December 2020 in community healthcare clinics in a remote area. Patients were age- and sex-matched to controls without a prior history of malaria. We examined patients prior to anti-malaria treatment and at follow-up. Malaria treatment was administered according to national guidelines. Patients were excluded if they were pregnant, had concomitant infections or recent chest trauma. Patients underwent LUS (8-zones), echocardiography and peripheral blood smear. Measurements were blinded to clinical variables and outcomes.

Results

We included a total of 99 patients (median age 40±15 years, 55% men). Patients suffered from Plasmodium vivax (n=75), P. falciparum (n=22), and a mix of the two (n=2) and median parasite density was 1,595 parasites/mL (interquartile range [IQR] 528–6,585/mL). Follow-up was completed in 71 patients and the median follow-up time was 31 days (IQR 27–40 days).

Patients with acute malaria had significantly more B-lines at baseline than matched controls (P-value<0.001) and fewer B-lines at follow-up (P-value<0.001) (Figure 1). In acute malaria patients, number of B-lines at baseline correlated significantly with shortness of breath (OR 1.20, [1.04 to 1.39], P-value=0.01) and with LVEF (adjusted for age and sex: +8% [+1% to +15%], P-value=0.016 per 1% decrease in LVEF). There was no correlation between number of B-lines and parasite density (+2% [−5% to +11%], P-value=0.53 per 1000 increase in parasite density).

Conclusion

B-lines detected by LUS are more frequent in patients with acute malaria than in age- and sex-matched controls and decrease in response to treatment. B-lines also correlate with shortness of breath and lower LVEF at baseline. Because LUS is a quick and accessible examination, it may potentially facilitate risk stratification and therapeutic decisions regarding cardiopulmonary complications in patients with acute malaria.

Funding Acknowledgement

Type of funding sources: Foundation. Main funding source(s): Danish Heart Association
Cardiac allograft vasculopathy and acute rejection surveillance in the same procedure through a single vascular access. High volume center experience
Authors: Arellano Serrano C , Oteo Dominguez J.F , Garcia Touchard A , Fernandez Diaz J.A , Del Trigo Espinosa M , Mitroi C , Hernandez Perez F.J , Gomez Bueno M , Goicolea Ruigomez J , Segovia Cubero J
Published: October 2021

Introduction

Cardiac Allograft Vasculopathy (CAV) and Acute Rejection (AR) surveillance after a Heart Transplant (HT) is based on the performance of Coronary Angiography (CAG) that requires arterial access and Endomyocardial Biopsy, normally Ventricular Right (RV-EMB), which requires venous access. Depending on the clinical indication, HT patients are referred to the cath lab to perform both procedures in the same day. We evaluated the effectiveness and safety of performing a Left Ventricular Endomyocardial Biopsy (LV-EMB) and a CAG with a single artery access.

Methods

We retrospectively analyzed HT patients referred to cath lab for surveillance of AR and CAV on the same day between January 2018 and March 2021. We compared the procedures performed with two accesses (Group 1; CAG + RV-EMB) versus procedures made with a single artery access (Group 2; CAG + LV-EMB).

Results

121 Procedures were performed within the indicated period, 96 (79.3%) belong to the double access group and 25 (20.7%) to the single access group. All procedures were successful and without major complications. There were only 2 cases of insufficient sample, one for each group. Baseline characteristics in both groups and AR or CAV presence were similar (table). Total procedure time (52.00±15.30 vs 33.36±18.69min) and fluoroscopic time (10.70±4.89 vs 6.84±1.82 min) were significantly shorter in the single access group (p<0.001 in both). The most used arterial access in group 2 was the right radial artery (15; 60%) followed by the right femoral artery (5; 20%).

Conclusions

Performing an endomyocardial biopsy and coronary angiography through a single arterial access is as effective and safe as with double access, arterial and additional venous. Procedure time and fluoroscopic time is significantly less when it is performed through the same access.

Funding Acknowledgement

Type of funding sources: None.
Right ventricular dysfunction but not left ventricular ejection fraction is associated with length of stay in acute heart failure
Authors: Berrill M , Ashcroft E , Baltabaeva A
Published: October 2021

Background

Acute heart failure (AHF) remains a substantial healthcare burden worldwide. It is therefore important to identify triaging markers which are associated with length of stay (LOS). Attention from an echocardiographic perspective often centres on the left-ventricular ejection fraction (LVEF). The role of right ventricular (RV) function and pulmonary hypertension (PHT) remains less certain.

Methods

We investigated LOS in 440 consecutive patients presenting in AHF. We also identified those admitted ≥5 days – the cut-off date when reimbursement for AHF-related hospital care is reduced significantly in England. All patients underwent bedside echocardiography within 24 hours of recruitment, prior to intensive diuresis. Patients were followed up for 2 years. We analysed the association between echo parameters with LOS in 414 patients who survived to discharge. We also compared those admitted ≥5 and <5 days.

Results

The average LOS for survivors was 7.7±5.7 days; 216 (52.2%) stayed ≥5 days, with 198 (47.8%) discharged <5 days. LVEF was not correlated with LOS; Spearman's ρ −0.062 (p=0.207). RV fractional area change (ρ −0.108 [p<0.03]), tricuspid annulus plane systolic plane excursion (ρ −0.166 [p<0.001]) and systolic pulmonary artery pressure (ρ −0.161 [p<0.001]) were all correlated with LOS. In patients with longer LOS, greater BNP, diabetes and chronic kidney disease were more prevalent. 2-year all-cause mortality was 41.0% in those admitted ≥5 days and 27.1% for <5 days (Hazard ratio 1.57; 95% CI 1.13–2.19 [p=0.007]).

Discussion

RV dysfunction and severe PHT, not LVEF, were correlated with increased LOS in 414 consecutive patients discharged from an admission with AHF. These patients will place a disproportionate cost on health care resources. These hypothesis generating results suggest early echo assessment to quantify RV dysfunction may help to risk stratify patients with AHF and re-design hospital tariffs.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott Laboratories Table and KM curve
Use of echocardiography and heart failure mortality from registry data in Japan
Authors: Okushi Y O , Kusunose K K , Ise T I , Yamaguchi K Y , Yagi S Y , Fukuda D F , Yamada H Y , Soeki T S , Wakatsuki T W , Sata M S
Published: October 2021

Background

There are several recommendations for the use of echocardiography in acute hospitalized HF. Echocardiography requires a high degree of skill on the part of the examiner, and the skill may be more improved in larger volume centers.

Purpose

In this study, we investigated whether the use and volume of echocardiography is associated with in-hospital mortality from the real world registry database of heart failure (HF) hospitalizations.

Methods

This study was based on the Diagnosis Procedure Combination database in the Japanese Registry of All Cardiac and Vascular Datasets (JROAD-DPC). We categorized the 739 hospitals into 3 groups according to the number of echocardiographic studies performed annually (first tertile: <2500 cases, second tertile: 2500–4500 cases, third tertile: >4500 cases) and compared the groups of patients who were first admitted to the categorized hospitals with heart failure between April 2015 and March 2016. We estimated the odds ratios and their 95% confidence interval for in-hospital mortality using multivariable models. The variables of multivariable analysis were selected by stepwise method.

Results

A total of 80,496 HF patients were hospitalized, and 73.2% were examined for echocardiography. We found that the use and volume of echocardiography exams were associated with significantly lower odds of all-cause hospital mortality in heart failure (adjusted OR: 0.48 for use of echocardiography and 0.78 for the third tertile; both P<0.001).

Conclusions

The use of echocardiography was associated with decreased odds of hospital mortality in HF. The volumes of echocardiographic examinations were also associated with hospital mortality; thus, this study suggests that the skill of echocardiography may be improved in the large volume center and provide good outcomes in HF.

Funding Acknowledgement

Type of funding sources: Public Institution(s). Main funding source(s): Japan Society for the Promotion of Science (JSPS) Flowchart of this studyOdds ratio of in-hospital mortality
Prognostic value of a new systemic inflammation-nutrition index in patients admitted with acute decompensated heart failure; a comparison with malnutrition
Authors: Yamada T , Watanabe T , Morita T , Kawasaki M , Kikuchi A , Kawai T , Seo M , Nakamura J , Kayama K , Fukunami M
Published: October 2021

Background

Systemic inflammation plays a critical role in the outcomes of heart failure. Malnutrition is also associated with poor outcome in heart failure patients. It has been recently reported that advanced lung cancer inflammation index (ALI), which is calculated as body mass index × serum albumin / neutrophil to lymphocyte ratio (NLR), is an independent prognostic marker in several types of cancer. However, there is no information available on the prognostic impact of ALI in patients admitted with acute decompensated heart failure (ADHF), especially in comparison with malnutrition.

Methods and results

We studied 263 ADHF patients discharged with survival. At the discharge, we measured ALI. Malnutrition was assessed by prognostic nutritional index (PNI) and controlling nutritional status score (CONUT). During a follow up period of 5.1±4.3 yrs, 67 patients had cardiovascular death (CVD). ALI was significantly smaller in patients with than without CVD (32.5±18.2 vs 52.2±30.2, p<0.0001). At multivariate Cox regression analysis, ALI was significantly associated with CVD, independently of prior heart failure hospitalization, systolic blood pressure and eGFR, although PNI and CONUT showed the association with CVD at unvariate analysis. By receiver-operator curve analysis, AUC of ALI was 0.733 (0.664–0.803), which was significantly greater than that of PNI (0.664 [0.590–0.739]) and CONUT (0.591 [0.509–0.672]). Patients with lowest tertile of ALI (<32.0) had a increased risk of mortality than middle tertile (NLR=32.0–53.6; HR 2.06 [1.15–3.71]) and highest tertile (ALI>53.6: HR 5.80 [2.60–12.94]) (48% vs 21% vs 9%, p<0.0001, respectively).

Conclusion

ALI, a systemic inflammation-nutrition index, is more useful prognostic marker than malnutrition in patients admitted with ADHF.

Funding Acknowledgement

Type of funding sources: None.
Predictors of Acute Heart Failure Decompensation at 30 days After Discharge. Results from a Multidisciplinary Heart Failure unit
Authors: Gorriz Magana J , Abad Romero R , Nieto Ibanez D , Olsen Rodriguez R , Perela Alvarez C , Espinosa Pascual M J , Fraile Sanz A , Perea Egido J , Alonso Martin J ,   PROAMTIC
Published: October 2021

Background

Unexpected readmissions are frequent among heart failure (HF) patients (pts). These are associated with high economic cost and have great clinical relevance. HF Units are cornerstones to build early intervention to prevent readmissions.

Due to their natural history HF implies multiple readmissions, with high costs and clinical relevance. HF Units are cornerstones to avoid early readmission.

Purpose

We aimed to identify predictors of early HF decompensation (at 30 days) that could recognize high risk patients during the systematic follow-up in our Multidisciplinary Heart Failure Program (MHFP) that was launched in February 2019.

Methods

We carried out an analytical and observational study including all patients admitted to our University Hospital, which covers 220,000 individuals. We built a predictive multivariate model with Logistic Regression using relevant predictors (clinical and statistical) that were identified.

Results

A total of 235 acute HF decompensations were referred to our MHFP. The 69.8% of them were men with median age of 75 years (interquartile range, IR 71–81). Mean left ventricular ejection fraction was 41% (IR 29–54%. A total of 55% with reduced and 30% with preserved ejection fraction). The 26% of the patients had right ventricle dilatation and 35% disfunction. Left bundle branch block was present in 27% of them. Median glomerular filter was 54ml/min (IR 37–73ml/min) and median pulmonary artery systolic pressure 50mmhg (IR 42–66mmg). Mean time to readmission was 19.6 months.

Among decompensations that we detected in MHFP during 30 days after discharge, just 39% (5 pts) could be detected and managed in day hospital and 61% (8 pts) as an admission.

In Table 01 we show the predictors that were included in the multivariate model. We finally found that it was just the NTproBNP level in a blood test within 7–10 days after discharge (R2N 0.59) which remains significative. Risk increased 1.20 times (1.0001851000) for each 1000 units rise in blood test (Table 1. Graph 1).

Conclusion

According to our results, detecting high NTproBNP levels in blood test within 7–10 days after discharge might predict a higher HF decompensation risk. The final multivariate model would explain 59% of those events at one month after discharge.

Funding Acknowledgement

Type of funding sources: None. Graph 1