bluuebunny/crossref_metadata_2025 huggingface dataset:
Determinants and differences of delay in cardiac resynchronization therapy
Authors: Gatti P , Lind S , Kristiandottir I , Azari A , Savarese G , Anselmino M , Linde C , Gadler F
Published: November 2023

Background

Cardiac resynchronization therapy (CRT) is recommended for the treatment of heart failure (HF) patients with reduced ejection fraction and left bundle branch block (LBBB) but is still largely underused which may further deteriorate the HF condition. Studying the impact and factors related to delays in CRT with or without an Implantable cardioverter defibrillator (ICD) is fundamental to enhance CRT implementation in clinical practice.

Methods

We used a central ECG database together with National patient registries to identify LBBB patients with a QRS duration of more than 150 ms and estimated a class I indication for CRT based on a registered diagnosis of HF and ejection fraction < 35% (baseline date). We compared patient characteristics in those with CRT-D, CRT without defibrillator (CRT-P) and patients with an indication but without CRT. Factors associated with CRT-P or CRT-D were analyzed as well as factors related to delay in CRT utilization. Outcome parameters were HF hospitalization and combined total and CV mortality and the impact of the delay in CRT utilization on outcome was analysed.

Results

Of 5359 patients with LBBB and QRS > 150ms, 1268 (24%) developed a class I indication for CRT. Of these 31% received a CRT-P, 36% CRT-D and 33% were not implanted. Independent predictors for CRT-P were age > 75 years and for CRT-D ischemic heart failure aetiology, hypertension and male sex. Patients with CRT-D had similar HF hospitalization rate (hazard ratio (HR): 0.95, 95% (CI) 0.80-1.14) as patients with CRT-P. In contrast, patients indicated but not implanted with CRT had a significantly higher prevalence of HF hospitalization (HR: 1.65, CI 1.39-1.96). A delay in CRT use > 365 days (161 patients) from indication (baseline) was associated with increased risk of overall mortality and cardiovascular mortality compared to CRT implantation < 30 days from the indication (HR: 1.64, CI 1.05-2.55 and HR: 1.87, CI 1.10-3.18). Age > 75 years, male sex, paroxysmal atrial fibrillation, diabetes and ischemic heart disease were associated with significant delay in CRT use (>365 days).

Conclusion

In a large real-world setting, delay in CRT implantation was common and associated with increased mortality. The findings suggest a need for new methods to find and treat HF patients with an indication for CRT.
Bridging therapy and risk of major bleeding and thrombosis in continuous-flow left ventricular assist device patients: a quasi-experimental study
Authors: Roovers R P W , Camilleri E , Janssen E , Jukema J W , Palmen M , Van Rein N , Tops L F
Published: November 2023

Background

Bridging with low molecular weight heparin (LMWH) on top of vitamin K antagonist treatment is recommended in continuous-flow left ventricular assist device (CF-LVAD) patients during subtherapeutic anticoagulation. However, the consequence of bridging on the risk of bleeding and thrombosis are unknown.

Aim

To assess the risk of major bleeding and thrombosis associated with bridging in CF-LVAD patients, through a regression discontinuity (RD) design, a quasi-experimental design.

Methods

We included CF-LVAD patients implanted at our university medical center between 2010-2021. Outcomes were major bleeding (INTERMACS type 3, 4, 5) and thromboembolic events (pump thrombosis, arterial non-central nervous system and venous thromboembolism). We estimated incidence rates and hazard ratios (HR) with 95% confidence intervals (95%CI) by time-dependent Cox regression. Using an RD design, a quasi-experimental design, we compared patients using LMWH due to a subtherapeutic international normalized ratio (INR) to patients with no LMWH and an INR just in target range. As LMWH treatment is initiated based on an INR threshold (i.e., when INR is below the lower target range) and INR is subject to random variability, patients just below and in the INR target range are comparable, mimicking a randomized trial. Analyses were performed five times including INRs±0.1, ±0.2, ±0.3, ±0.4 and ±0.5 around the INR threshold.

Results

77 patients were included, with a median age at implantation of 69 years, 60 (78%) were male, 45 (58%) had ischemic heart failure and 35 (45%) had INTERMACS classification 3. We included 35,466 INRs during 91 patient-years of follow-up. Bridging was associated with increased major bleeding rates compared to no-bridging in all analyses (Figure 1). In particular, the risk of major bleeding was 6.9-fold increased (95%CI 1.2-38.9) during bridging compared to no-bridging considering INR+0.1, and 3.4-fold (95%CI 1.4-8.2) considering INR±0.5 (Figure 2A). While thrombotic events were infrequent, the risk of thrombosis was around unity during bridging compared to no-bridging considering INR±0.5 (HR 1.1, 95%CI 0.1-9.9, Figure 2B).

Conclusions

During bridging with LMWH, CF-LVAD patients had a 6.9-fold increased risk of major bleeding, while the risk of thrombosis was around unity compared to no-bridging.Incidence ratesHazard ratios
Outcomes of pediatric ventricular assist device in the United States: an analysis of the national inpatient sample database
Authors: Hamzah M , Hejazi Y , Mostafa G , Macrae D
Published: November 2023

Background

Infants and children with advanced heart failure, refractory to medications, are frequently supported with ventricular assist devices (VAD).

Purpose

To describe the patient characteristics of those who were supported with VADs and describe the factors associated with mortality with use of VAD in the USA.

Methods

We conducted a retrospective analysis of a large administrative database, the National Inpatient Sample (NIS) dataset for the years 2010 to 2018. We identified pediatric patients (0–18 years of age) who had implantation of VAD during the hospitalization. Patient characteristics and outcomes were compared between survivors and those who died during the hospitalization.

Results

We identified 1620 patients with VAD procedure in the years we studied. Of them, 324 patients (20%) died during the hospitalization. The trend of utilizing VAD was increasing during the years of the study (Fig. 1). Mortality trend over the study years is presented in figure 2. In multivariable regression analysis, patients with VAD who died were more likely to be less than 1 year of age (OR=4.14, 95% CI:2.29–7.50, p < 0.001), on mechanical ventilation for more than 96 hours (OR=10.71, 95% CI: 6.69–17.14=5, p < 0.001), had liver failure (OR 19.88, 95% CI:10.15-38.95, p<0.001). Those who survived to hospital discharge were more likely to have orthotopic heart transplantation (OR=19.08, 95% CI: 8.12-44.81, p<0.001) and were diagnosed with dilated cardiomyopathy (OR=5.08, 95% CI: 3.38-7.63, p<0.001).

Conclusion

VAD in pediatric population is increasingly being used in the United States as a bridge to recovery or transplantation. During study period, in hospital mortality trended down significantly. Younger patient's age; less than one year, liver failure and >96 hours mechanical ventilation are considerable risk factors for mortality. Prospective studies are needed to account for confounders, and further classify risk factors based on underlying structural heart disease and clinical status at time of hospital admission.
Dissociation of LA volume and deformation is a hallmark of ATTR-CA
Authors: Satyavolu B , Ozbay B , Rearick C , Soman P , Sade L E
Published: November 2023

Background

Transthyretin Cardiac amyloidosis (ATTR-CA) is associated with an infiltrative left atrial (LA) cardiomyopathy.

Purpose

We sought to identify unique characteristics of LA cardiomyopathy in CA compared to non-amyloid states of left ventricular hypertrophy (LVH).

Methods

In suspected patients, a diagnosis of ATTR-CA was made by a positive Tc-99m PYP in conjunction with negative serum/urine studies for a clonal plasma cell dyscrasia. Endomyocardial biopsy was performed when clinically indicated. All patients underwent complete transthoracic echocardiography (TTE) with speckle tracking strain imaging. Left ventricular (LV) strain, LA reservoir strain (LASr) and LA volume index (LAVI) were measured. LA stiffness index was estimated by the ratio (E/e’)/LASr. ATTR-CA patients were compared to patient with non- CA LVH (interventricular septal thickness > 1.2 cm). Atrial fibrillation (AF) during the TTE was noted. Logistic regression and Cox-regression analyses were performed to find the independent determinant of ATTR-CA and outcome predictors, respectively.

Results

We studied 98 patients with ATTR-CA (44 with AF) and 62 patients with non-CA LVH (35 with AF). ATTR-CA patients had a higher prevalence of relative apical sparing (RAS) (79% vs 20%, p<0.0001), reduced LASr (9.8±4.8% vs 14.0±7.2%; p<0.001) and high LA stiffness (2.5±0.2 vs 1.4±0.9; p<0.001) irrespective of AF. Surprisingly, LAVI of ATTR-CA patients was significantly lower than non- CA LVH patients (44±15 ml/m2 vs 51±24 ml/m2; p=0.046). Consequently, LAVI correlated strongly with LASr in non-amyloid LVH group (r= -0.52, p<0.001) whereas no correlation was observed in ATTR-CA (p<0.05) (Figure 1). Patients with ATTR-CA had the lowest LASr and highest LA stiffness regardless of AF (Figure 2). Importantly, LASr determined ATTR-CA among all study subjects independently of RAS (p<0.001) and emerged as a predictor of composite endpoint including all-cause mortality, hospitalization from heart failure and stroke in ATTR-CA patients (p=0.037).

Conclusion

ATTR-CA is characterized by severely reduced LASr and increased LA stiffness, yet LA dilatation is relatively less severe when compared to other causes of LVH. LASr seems promising to make the differential diagnosis of ATTR-CA and is of prognostic importance.Figure 1Figure 2
Role of NTproBNP and donor-derived cell-free DNA in the diagnosis of acute rejection in heart transplant recipients: a prospective study
Authors: Jimenez-Blanco Bravo M , Crespo Leiro M , Marco Clement I , Lozano Jimenez S , Donoso V , Ortiz Bautista C , Farrero M , De Antonio M , Diaz Molina B , Diez Lopez C , Rangel Sousa D , Salterain N , Garrido Bravo I , Segovia Cubero J
Published: November 2023

Background

Donor-derived cell-free DNA (dd-cfDNA) has shown a good ability to rule out rejection in heart transplant (HT) recipients, but there is scarce information on the utility of NTproBNP (and the combination of both biomarkers) in this setting.

Methods

We prospectively obtained levels of both biomarkers in all patients included in the FreeDNA-CAR study (NCT 04973943), just before performing surveillance endomyocardial biopsies (EMB) at 0.5, 1, 2, 3, 4, 6 and 12 months post-HT. Primary end-point was the correlation between dd-cfDNA and NTproBNP levels.

Results

A total of 206 HT patients from 12 different centers were included (mean age 54±12 years, 74% male), with a median of 5.6 EBM per patient. After excluding visits with missing data, 883 pairs of EBM-both biomarkers were available for analysis.

ACR, defined as grade ≥2R, was present in 37 EMB (4.2%), and AMR ≥1 in 16 EMB (1.8%). Median (IQR) NTproBNP values for each ACR group were: 0R 1067 pg/ml (454-2563), 1R 1300 pg/ml (562-3298) and 2R-3R 1780 pg/ml (943-4880) and median dd-cfDNA values: 0R 0.08% (0.038-0.178), 1R 0.105% (0.04-0.34), 2R-3R 0.22% (0.058-0.7). Regarding AMR, median NTproBNP in pAMR0 was 1200 pg/ml (504-2840) and in pAMR≥1 2230 pg/ml (806-4256) (Figures 1A and 1B).

Using a GEE (generalized estimating equation) approach to account for repeated measures in each individual, a statistically significant correlation between both biomarkers was found, with a coefficient of 0.001 (CI95% 0.0006-0.002), meaning that for every increase of 100 units of NTproBNP, %dd-cfDNA increased in 0.001, p <0.001 (Figure 2).

Moreover, in a multivariable analysis, both biomarkers were associated with the risk of acute rejection, with an OR 1.48 (CI95% 1.04-2.11), p=0.03 for dd-cfDNA, and OR 1.007 (IC95% 1.001-1-013) p=0.017 for each additional 100 pg/ml of NTproBNP.

Conclusion

In a cohort of HT patients in their first post-transplant year, dd-cfDNA and NT-proBNP levels were associated with acute rejection and showed a good correlation between them. Further studies are needed in order to determine if the combination of both biomarkers could improve individual performance and increase the number of EMB that could be safely eliminated.Median (IQR) NTproBNP levels (pg/ml)Linear prediction of dd-cfDNA
Donor-derived cell-free DNA as a new biomarker for acute rejection in heart transplant recipients: results from the freedna car study
Authors: Jimenez-Blanco Bravo M , Crespo Leiro M , Garcia Cosio M D , Hernandez Perez F J , Lopez Villela R , Ortiz Bautista C , Farrero M , Zegri Reiriz I , Diaz Molina B , Diez Lopez C , Rangel Sousa D , Salterain N , Garrido Bravo I , Segovia Cubero J
Published: November 2023

Background

There is an increasing body of evidence supporting the potential utility of donor-derived cell-free DNA as a non-invasive biomarker that could allow surveillance of rejection without the need of repeated endomyocardial biopsies (EMB) in heart transplant (HT) recipients.

Methods

Free-DNA CAR was a multicenter, observational, prospective study, performed between 2019 and 2022 (NCT 04973943). All patients underwent per-protocol surveillance EMB at 0.5, 1, 2, 3, 4, 6 and 12 months post-HT. Dd-cfDNA levels were determined prior to each EMB, using Next Generation Sequencing technology. Primary end-point was the association between dd-cfDNA levels and the presence of clinically relevant rejection defined as ACR grade ≥2R and/or pAMR≥1.

Results

The cohort included 206 patients from 12 HT centers (mean age 54 ± 12 years, 74% male), with a total of 1006 pairs of EMB-dd-cfDNA determinations. ACR ≥2 was present in 44 EMB (4.4%) and AMR ≥1 in 17 EMB (1.7%). Two samples had simultaneous ACR≥2 and pAMR≥1.

Patients with clinically relevant rejection had dd-cfDNA levels significantly higher than those without, 0.189% (0.058-0.6) vs 0.097% (0.04-0.24), p=0.0049 (Figure 1A, with %dd-cfDNA logtransformed as log2(x+0.01) in order to reduce the skewness). Median (IQR) dd-cfDNA values for each group are shown in figure 1B.

Using GEE (generalized estimating equation) models in order to account for repeated individual measures, a trend to significant association between %dd-cfDNA and rejection was found (OR 1.25, IC95% 0.95-1.64) (Figure 2), even though it did not reach statistical significance (p = 0.109).

In the subgroup of samples evaluated for ACR (n =991, after excluding 15 samples that did not have ACR but had AMR ≥1), there was also a significant difference between those with and without rejection: 0.205% (0.06-0.65) in ACR≥2 vs 0.097 (0.04-0.24) in ACR 0-1, p = 0.0097.

Area under the ROC curve for the composite endpoint was 0,61. A 0.15% dd-cfDNA threshold showed a negative predictive value of 96%, which could allow to safely eliminate 61% of EMB.

Conclusions

Dd-cfDNA appears to be an excellent biomarker to rule out ACR and AMR. Its high negative predictive value could allow to eliminate a significant percentage of surveillance EMB currently performed in HT recipients.Median (IQR) dd-cfDNA values
Cardiac rejection diagnosis using serum mRNA encoding proteins related to fibrotic process
Authors: Rosello-Lleti E , Perez Carrillo L , Benitez Ramos M , Gimenez Escamilla I , Delgado Arija M , Gonzalez I , Portoles M , Tarazon E
Published: November 2023

Background

Finding a standardized, non-invasive method of diagnosis of rejection is still a challenge in the field of heart transplantation. A novel alternative for allograft rejection diagnosis is the detection of biomarkers present in serum. Cardiac fibrosis appears to be present in patients who are experiencing cardiac allograft rejection. Thus, the process of fibrosis could offer a wide range of candidate molecules to explore as possible biomarkers.

Purpose

This study aimed to determine the expression of fibrosis-related coding mRNAs in serum of patient with cardiac rejection and evaluate the diagnostic capacity as potential biomarkers for the non-invasive detection of mild (grade 1R) and moderate/severe (grade ≥2R) cellular rejection.

Methods

We included consecutive serum samples from transplant recipients undergoing routine endomyocardial biopsies. Non-coding RNA sequencing analysis (Illumina HiSeq 2500) was performed on 40 samples, 28 diagnosed with acute cellular rejection (Grade 1R, n=16; and Grade ≥2R, n=12) and 12 samples without cardiac rejection.

Results

We detected 228 mRNA related to fibrosis in serum, which 38 presented differential expression in patients with cardiac rejection of Grade ≥2R. We obtained 16 molecules that showed excellent diagnostic ability in moderate-severe rejection (AUC > 0.800). We highlight RELB that was able to detect mild rejection (AUC=0.734, p<0.05). We stand out TNS1 (AUC=0.972), COL4A2 (AUC=0.958) and JAK1 (AUC=0.944), p<0.0001, for its relevant diagnostic capacity of acute cellular rejection.

Conclusions

We propose serum mRNA levels of genes encoding fibrosis related proteins as potential biomarkers of cardiac rejection. We highlight the role of RELB due to its excellent diagnostic capacity for acute cellular rejection correlating with the severity of the episode.
Clinical relevance and outcome of routine endomyocardial biopsy to detect rejection after heart transplantation
Authors: Kieviet L , Szymanski M K , Van Der Meer M G , Van Der Kaaij N P , De Jonge N , Van Laake L W , Oerlemans M I F
Published: November 2023

Background

After heart transplantation (HTx), endomyocardial biopsies (EMBs) are the gold standard to monitor cardiac allograft rejection. However, a clear consensus on the optimal frequency and duration of EMB monitoring is lacking.

Purpose

Since the first HTx in 1985 in our center, EMB protocols have gradually changed to a low-frequency schedule. We assessed the diagnostic yield and complication rate of the three different EMB protocols used during the past 37 years.

Methods

In this retrospective, single centre, observational study, all biopsy data of routine EMBs after HTx between 1985 and 2022 were collected for analysis. Patients with symptom-driven biopsies or follow up in another hospital were excluded. The total number of biopsies, type of rejection and complications were evaluated.

Results

In a total of 431 patients (69.6% male, mean age at transplant 48±13 years), 6692 routine surveillance EMB procedures were performed. The average number of biopsy procedures per patient was 25.1±8.1 for protocol 1 (n=44, 1985-1994), 17.0 ±3.6 for protocol 2 (n= 213, 1994-2009) and 11.3±2.6 for protocol 3 (n=174, 2009-2022). Cellular rejection was detected in 8.93%, of which grade I, II and III cellular rejections were seen in 7.32%, 1.58% and 0.03%, respectively. The frequency of ≥ ISHLT grade 2R requiring additional treatment was 1.61% and decreased over time with each EMB protocol (2.80%, 1.72%, and 0.76%). Complication rate was 1.63%, mainly consisting of puncture of the carotid artery (57.9%). Independent of the EMB protocol used, the majority of rejections occurred within the first six months after HTx (68.7%).

Conclusion

Complications of EMB after HTx are rare. Cellular rejection mostly occurs within the first 6 months after HTx. The incidence of clinically relevant cellular rejection (≥ISHLT grade 2) has declined over time, partly due to improved immunosuppressive therapy. A conservative approach using a low-frequency EMB schedule seems feasible and safe.Cellular rejection per protocol
Left atrial stiffness evaluation in beta-thalassemia major patients
Authors: Patsourakos D , Aggeli C , Gatzoulis K , Dimitroglou Y , Koukos M , Gialleli F , Tsioufis K
Published: November 2023

Introduction

Diastolic dysfunction is the earliest cardiac abnormality in β-thalassemia major (β-TM) patients and HFpEF is the predominant cardiac phenotype in symptomatic β-TM patients. Left atrial stiffness index (LASI) has been proved to have prognostic value in HFpEF patients.

Purpose

In our study we aimed to evaluate LASI in β-TM patients and assess its relation with conventional indices of diastolic function.

Methods

Sixty β-TM patients and twenty-nine controls were included in this cross-sectional study. Left ventricular ejection fraction (LVEF), early mitral inflow velocity to basal septal early diastolic velocity ratio (E/e'), left atrial volume index (LAVI), tricuspid valve regurgitation velocity (TVR) and left atrial deformation at reservoir phase (LASr) were calculated. T2* was used for myocardial iron load estimation. LASI was calculated as the [E/e’]/[LASr] ratio. Patients with LVEF <50% were excluded. LAVI, E/e’ and TVR were used as criteria of diastolic dysfunction.

Results

LASI was greater in patients compared to controls (0.30 ± 0.22 vs 0.18 ± 0.06, p = 0.003). Patients with diastolic dysfunction (n = 16) had greater LASI than patients without (n = 20) (0.49 ± 0.35 vs 0.21 ± 0.05, p = 0.001) as well as lower LASr (34.0 ± 15.6% vs 42.1 ± 6.7%, p = 0.043). Patients with indeterminate diastolic status (n = 24) had LASI = 0.26 ± 0.08 and LASr = 45.5 ± 13.6%. No correlation was found between LASI and T2* (p = 0.221).

Conclusions

β-TM patients with echocardiographic evidence of diastolic dysfunction have increased LASI. Myocardial iron load did not correlate with left atrial stiffness. A significant portion of β-TM patients have indeterminate diastolic function based on conventional criteria and novel indices, such as LASI or LASr, could be useful for reclassification of these particular patients.
Cost-effectiveness of HerzMobil Tirol, a multidimensional post-discharge disease management program for heart failure patients Economic evaluation along a one-year observation period
Authors: Poelzl G , Egelseer-Bruendl T , Jahn B , Arvandi M , Puntscher S , Santamaria-Navarro J , Pfeifer B , Rissbacher C , Modre-Osprian R , Siebert U
Published: November 2023

Methods

We conducted a cost-effectiveness analysis along a retrospective cohort study of the routine DMP in the province of Tyrol, Austria (HerzMobil Tirol, DMP-HMT) with a propensity score matched cohort of 257 individuals in the usual care (UC) and 251 in the DMP group and a one-year follow up (2016-2019). We determined the effectiveness (hospital-free life expectancy, event-free life years and life years gained, and number of avoided rehospitalizations), costs (DMP, rehospitalizations) and the incremental cost-effectiveness ratio (ICER) of DMP-HMT vs. UC. Data preparation included two steps, missing value imputation and adjustment for remaining confounding due to imperfect matching. We performed a nonparametric sensitivity analysis with bootstrap sampling (n=5,000 replications), sensitivity analyses on costs of HF-rehospitalizations after events that are highly irrelevant for the stated research question and on costs per disease-related diagnosis (DRG) score for rehospitalizations.

Results

The base-case analysis showed that, on average, DMP-HMT results in 42 additional hospital-free life days, 0.54 event-free days to the next cardiovascular event, 40 additional life days, and 0.12 avoided hospitalizations per person compared to UC. The average DPM costs are EUR 1,916 per person. Mean rehospitalization costs are EUR 5,551 in HMT and EUR 6,943 in UC. The ICER of DMP-HMT compared to UC is EUR 4,773 per life-year gained outside the hospital. In a sensitivity analysis, DMP-HMT was also cost saving when "high irrelevant costs" related to the DMP were replaced with average costs. The ICER decreases with increasing costs per DRG score.

Conclusions

Our economic evaluation along the cohort study showed that the DMP HerzMobil Tirol is cost-effective compared to UC based on the one-year time follow up horizon. The DMP was cost-saving in a sensitivity analysis correcting for "high irrelevant costs". Our findings promote widespread adoption of telemedicine assisted DMP for HF. Further research is needed on the long-term assessment of benefits and costs beyond the study period using a decision-analytic model and considering upcoming real-world evidence.
Effectiveness of transitional-care programmes according to the sex of patients with heart failure managed in integrated care systems: a study with longitudinal real-world data in 77,554 patients
Authors: Alcober Morte L , Torres B , Vela E , Cleries M , Corbella M , Jose N , Ramos R , Ras M , Enjuanes C , Comin-Colet J
Published: November 2023

Background

Integrated heart failure (HF) programs are the recommended setting for management of patients with HF. In this setting, several sex differences in outcomes and medical resource use have been described. However, the whether the effectiveness of such HF programs may differ according to sex has not been evaluated.

Purpose

To analyze the effect of sex on health outcomes before and after a pragmatic implementation of an intensive transitional care nurse-based HF management program integrating hospital and primary care and resources for patients with HF at a high risk of events in a health-care area of 209,255 inhabitants.

Methods

We included all individuals consecutively admitted to hospital with at least one ICD-9-CM code for HF as primary diagnosis and discharged alive in Catalonia (7,794,749 inhabitants) during 2015-2019. We considered 3 periods: pre-implementation (2015-2016), transition (2017) and consolidation (2018-2019). We compared outcomes between patients of the implementation area and the rest of Catalonia stratified by sex.

Results

We included 77,554 patients in the study: 3,396 in the implementation area and 74, 158 in the rest of Catalonia. 35,895 (46.3%) were male and 41,659 (53.7%) female. Death occurred in 37,469 (48.3%), clinically related readmission in 41,709 (53.8%) and HF readmission in 29,755 (38.4%). In the population in which the HF program was implemented (HUB-Delta area), multivariate adjusted Cox proportional hazards analyses (Table 1) showed reduction in all-cause death, clinically related readmission and HF readmission both in the transition period (2017) and in the consolidation period (2018-2019) in both men and women. As shown in Figure 1 (left column), compared to the rest of Catalonia, the implementation of the programme in the HUB-Delta area significantly improved outcomes in patients with HF during the consolidation period and these benefits (central and right column) were equally observed in both sexes. The reduction of mortality was more prominent among females (26% of relative change) compared to males (9.3% of relative change). Whereas, clinically related readmission and HF readmission improved more in males (15.7% and 20.7% relative change respectively in males and 7% and 12.6% in females.

Conclusions

Implementation of a transitional intensive care nurse-based HF management program improves clinical outcomes in both males and females. The benefits in prevention of readmission seemed to be more prominent among men while women experienced a higher benefit in terms of mortality. These differences should be considered in the planning of future programs and their causes should be further analysed.Table 1Figure 2
Impact of a structured educational intervention on attitudes and clinical practices in heart failure among physicians in argentina
Authors: Burgos L , Duczynski M P , Coronel M L , Folino C , Thierer J
Published: November 2023

Introduction

It is necessary to identify areas for improvement in the care of patients with heart failure (HF), and thus implement educational interventions to optimize the quality of care and their clinical outcomes.

Objective

The aim of this study was to evaluate the attitudes, knowledge, confidence and care pathways of patients with HF among physicians in Argentina and their subsequent changes after an educational intervention.

Methods

We conducted a cross-sectional study using a self-administered survey to evaluate clinical practice patterns and attitudes/perceptions regarding the diagnosis, treatment and follow-up of HF patients in the outpatient and inpatient settings. Survey respondents were physicians from 22 centers in Argentina who participated in a comprehensive educational programme for the care of HF patients conducted between March and July 2021. The educational intervention was based on a 30-hour training programme in heart failure clinics and a final examination. Simple road maps were created to address the knowledge gaps identified in the pre-intervention phase.

Results

A total of 50 physicians were surveyed; the mean age was 41±8 years and 86% were cardiologists. The educational intervention significantly increased physicians' confidence in diagnosing HFpEF, with 52% feeling "confident" or "very confident" before and 84% after the intervention (p<0.001). In outpatients with HFrEF, more physicians reported prioritizing quadruple therapy with SLGT-2i, mineralocorticoid receptor antagonists (MRA), beta-blockers and angiotensin receptor neprilysin inhibitors (ARNI) in the post-intervention period (p<0.05, figure 2). No differences were found in the reported time to optimal medical treatment (p=0.7). After the intervention, the proportion of physicians who felt "confident" or "very confident" in identifying patients who could benefit from an implantable cardioverter-defibrillator increased from 70% to 96% (p=0.01). After the intervention, more doctors considered "relevant" and "very relevant" the administration of hypertonic saline (22% to 52%; p=0.01), and intravenous iron (56% to 80%; p=0.041). Compared to the pre-intervention period, more physicians prioritized quadruple therapy with beta-blockers, MRA, ARNI and SGLT2i (p<0.05, figure 2) at hospital discharge. There was a significant increase in the use of the discharge checklist from 26% to 48% (p=0.05).

Conclusions

A multifaceted structured educational intervention was effective in improving knowledge and attitudes about the diagnosis and management of patients with HF among physicians in Argentina. The results of the present study demonstrate that an educational intervention can increase knowledge and improve clinical attitudes in the diagnosis of HFpEF and management of outpatients and hospitalized patients with HFrEF. Further studies are needed to determine the impact of such programmes in other countries.
Palliative care assessment and outcomes in patients admitted for heart failure in an Australian quaternary healthcare service
Authors: Ye S , Corbett C , Dennis A , Jape D , Hopper I
Published: November 2023

Background/Introduction

Heart failure (HF) has high mortality and healthcare utilisation, and despite patients having similar palliative care needs to cancer patients(1), they are much less likely to have their PC needs assessed and managed (2-3). Expert consensus guidelines from cardiology and palliative care groups recommend early integration of a palliative approach in addition to usual care, but the complex and unpredictable trajectory of HF, lack of referral criteria and misunderstandings about PC are potential barriers that affect specialist PC referrals. Given the issues surrounding integration of PC in HF patients, we sought to understand the use of PC by patients with HF at our institution.

Purpose

To characterise the pattern and predictors of referrals of HF patients to the inpatient PC service in an Australian quaternary health service.

Methods

A single-centre retrospective cohort study was performed using electronic medical record data in consecutive patients admitted for HF at a quaternary health service in Australia, over a 12 month period from July 2019 to June 2020. All adults ≥ 18 years of age and admitted for HF were identified using the Diagnostic Related Group (DRG) admission code for ‘Heart Failure and Shock’.

Results

The 502 patients admitted for HF were elderly (median age 82 years, IQR 15) and 50% were male. Functional status was poor, with 29% unable to care for themselves and 56% requiring some level of assistance. General medicine was the major admitting unit with 67% (n=338 of 502) of patients, and the cardiology and advanced heart failure units admitted 12% (n=59) and 5% (n=26) of patients, respectively. Conversely, the main treating team in the ambulatory setting was cardiology in 51% (n=253). HF patients had high mortality rate at 32% during the median follow up time of 27 months (interquartile range 8 months).

Seven percent (n=37 of 502) were referred to inpatient specialist PC, and often in the terminal phase. High dependency (defined as Australian-modified Karnofsky Performance Status 10-40) (62% vs 28%, p<0.01) and New York Heart Association class III-IV symptoms (86% vs 42%, p<0.01) were associated with referral, but one or more previous admission for HF in the last 12 months was not (35% vs. 28%, p=0.35). In all HF patients, symptoms were poorly assessed and discussion about prognosis occurred in 10% despite the high mortality. Referral to inpatient PC resulted in more prescribing of symptom medications on discharge (41% vs 2%, p<0.01) and referral to community PC (46% vs 1%, p<0.01).

Conclusion

Referral to inpatient specialist PC in hospitalised HF patients is low relative to the morbidity and mortality in these patients. In addition, treating teams do not routinely assess symptoms or discuss disease trajectory. More work is needed to ensure that HF patients’ PC needs are integrated into care as recommended by expert consensus.Table 1
Atrial cardiomyopathy by strain predicts atrial fibrillation in young Lamin A/C patients
Authors: Katarina Vlaisavljevic K V , Christine Rootwelt-Norberg C R N , Eystein Skjolsvik E S , Kaspar Broch K B , Mette E. Estensen M E , Kristina H. Haugaa K H , Nina E. Hasselberg N H
Published: November 2023

Introduction

Cardiac laminopathy is a malignant and highly arrhythmogenic form of dilated cardiomyopathy caused by variants in the lamin A/C (LMNA) gene. Atrial fibrillation (AF) is common during disease progression and often occurs at a young age, before evident structural cardiac changes and therefore, decision making on anticoagulation for AF is challenging. Whether atrial cardiomyopathy is present at this early stage of LMNA disease has not yet been explored.

Purpose

We aimed to evaluate for atrial cardiomyopathy in LMNA genotype positive subjects without prior atrial arrhythmias and assess whether atrial cardiomyopathy would be associated with the occurrence of AF during follow-up.

Methods

We prospectively recruited LMNA genotype-positive patients in a cohort study. Patients without prior documented atrial arrhythmias were evaluated for atrial cardiomyopathy by echocardiography. Atrial cardiomyopathy was evaluated by left atrial (LA) volume index (LAVI) and LA strain (peak reservoir strain and peak conduit strain). LA strain was assessed by 2D speckle-tracking echocardiography, averaged from apical four- and two-chamber views using a LA strain dedicated software with R-wave at end diastole as zero-reference point.

Results

We evaluated 129 LMNA genotype positive patients (51% women, age 40±15 years), of whom 57 patients (44%) had previous AF. Hence, we included 72 patients (32±14 years old, 49% female, left ventricular ejection fraction 53±11%) for assessment of atrial cardiomyopathy. The mean LA reservoir strain was 35±14%, conduit strain 25±13% and LAVI 38±23 ml/m2. During 7.7±5.0 years of follow-up, 28 (39%) patients developed AF after a median of 2.2 years. Patients with AF during follow-up had larger LAVI (47±30 vs. 32±10ml/m2, p=0.01) and worse LA reservoir strain (29±12% vs. 38±14%, p=0.02) at baseline than those who did not develop AF. LA reservoir strain and LAVI at baseline were both predictors of AF during short-term follow-up (HR 0.95 [CI 0.90-0.99], p=0.025 and HR 1.02 [CI 1.01-1.03], p=0.009, respectively), whereas LA conduit strain was not (HR 0.98 [CI 0.94-1.03], p=0.45). ROC analysis identified LA reservoir strain better than 32.5% as the best discriminating value for survival free of AF (log rank p=0.05) (Figure).

Conclusion

Atrial cardiomyopathy was common in LMNA genotype positive patients without previous atrial arrhythmias. LA volume and and LA reservoir strain predicted new onset AF during follow-up and may be used as markers for detecting short term risk of AF and potentially guide anticoagulation treatment in LMNA disease.LA reservoir strain and AF in LaminA/C
The PRELIEVE trial:Final 1-year outcomes of the prospective atrial flow regulator study
Authors: Paitazoglou C , Bergmann M , Kilicaslan B , Kilic T , Bartunek J , Pfister R , Iliadis C , Kaya E , Ozdemir R
Published: November 2023

Background

Implantation of the Atrial Flow Regulator (AFR) with an 8 or 10mm interatrial fenestration reduces left sided filling pressures in symptomatic heart failure (HF). Here, we report the final one-year results on safety and efficacy of the AFR in HF patients.

Methods

PRELIEVE is a prospective, non-randomized, multi-center, single-arm study in HF patients with reduced (HFrEF) or preserved (HFpEF) ejection fraction. Patients with elevated fillings pressure at rest received an 8mm shunt device while those with exercise-induced rise in filling pressure received a 10mm AFR shunt device.

Results

Out of 109 enrolled patients 106 patients (n=62 HFrEF and n=44 HFpEF) received a successful device implantation (n=86 8mm AFR and n=20 10mm AFR). All-cause and cardiovascular mortality were 21% and 14% respectively in HFrEF and 7% and 0% respectively in HFpEF. HF hospitalization rate was 19% in HFrE and 9% in HFpEF. In 85 patients (n=44 HFrEF and n=41 HFpEF) with completed follow-up, device patency was documented in all patients having adequate image quality at 1-year follow-up (n=78). NYHA class >1 increase was noted in 67.5% HFrEF and 63.7% HFpEF patients.

Quality of life assessed from the KCCQ score (overall summary score) increased from 49 + 23 to 72+24 in HFrEF and from 41+20 to 55+26 in HFpEF patients. Improved KCCQ>5 points was noted in 67.4% HFrEF and 44.7% in HFpEF patients. Six minute walking distance increased from 203+101m to 269+108m in HFrEF and from 228+121 m to 253+109m in HFpEF. Improved walking distance by either 50 m or by 50% was noted in 59.5% in HFrEF and 41.2% in HFpEF patients.

Among echocardiography parameters, right ventricular diameter tended to increase in patients receiving 10 mm shunt device (Delta 1year vs. baseline 3.1 +11.2 mm), no changes were observed in patients treated with 8 mm shunt device. Note, pacemaker presence or resting pulmonary vascular resistance were similar.

Conclusions

Implantation of AFR device with either 8 or 10 mm shunt size in HF patients was safe and feasible irrespective of baseline ejection fraction. Signals of clinical efficacy were observed in the majority of patients. This study warrants further clinical evaluation of the AFR device in HF.Clinical efficacy parameters
Tricuspid regurgitation and heart failure: the faith of treated vs untreated cohort in the percutaneous era
Authors: Zancanaro E , Berti S , Nardone A , Romeo M R , Maisano F
Published: November 2023

Background/Introduction

Tricuspid regurgitation (TR) is associated with heart failure and reduced survival.Within a short-time period, transcatheter tricuspid valve repair or replacement (TTVR)(TTVr) for TR has evolved from innovation to clinical reality. Still, most patients arrive in an advanced state of heart failure (HF), as well as most cohorts remained untreated for various reasons. The faith of these two therapeutic approaches gives differences in results among survival and clinical status at distance.

Purpose

The present study’s aim is to provide 1 year results between TR patients treated with TTVR and TTVr compared to untreated patients, in terms of cardiac survival, rehospitalization, right-side heart failure symptoms development, and NYHA improvement.

The secondary endpoint is to analyze gender disparities as well as echocardiographic and medical therapy changes between groups.

Methods

78 patients (pts) have been prospectively inserted into a dedicated database from January 2020 till January 2023. 26 pts (36%) have been treated with TTVR/r (Treated Group-TG) and 51 pts (65%) have been left untreated with medical therapy (MT) optimization (UN-Treated Group-UNTG).

In TG, 9 (34%) underwent TEER (Transcatheter Edge-To-Edge Repair), 13 (50%) annuloplasty and 4(15%) TTVr. Tri-Score was used to define right-side pathology in both groups; the Tri-Score mean of 3.9 (8-1 +/- SD 1.68) was in TG, while 6,17 (10-2+/- SD 1.9) in UNTG. In UNTG 52% were female gender while 76%in TG. Most of the patients in UNTG were in TR stage 5 (47%) while in stage 4 in TG (42%).

For 1 year follow-up (FUP), Kaplan-Meier weighted survival curves related to cardiac death and HF rehospitalization have been computed as well as Chi-squared test to evaluate right-side HF symptoms progression, echocardiographic changes in right ventricular function, NYHA progression and medical therapy changes, between the 2 groups.

Results

Analyzing the cardiac death between the 2 groups, there was a significant statistical difference since TG has a less incidence of exitus in the general population (p-value =0,05), Figure 1. Concerning gender, in female gender, the treated pts have lower cardiac death incidence (p-value =0,03).Concerning HF hospitalization, TG has a lower incidence with p-value =0,005, Figure 2. No difference according to gender.

In TG there was a significant improvement in NYHA class at FUP (p-value =0,001) as well as an improvement of right-side HF symptoms (p-value =0,001). In UNTG there was a significant increase in the dosage of HF drugs compared to TG, (p-value =0,001) as well as an increase in right ventricular function and dimension at echocardiogram (p-value =0,001).

Conclusion(s)

this study shows that treatment in case of TR with right side HF has a positive impact upon cardiac death,HF hospitalisation at 1 year. As well as there is a significant improvement in clinical and ecocardiographic status at FUP in treated group.figure 1figure 2
Virtual Multi-disciplinary Team (vMDT) platform improves workflows and productivity within the heart failure pathway for patients in the UK National Health Service (NHS)
Authors: Akram M , Roebuck A , Howarth J
Published: November 2023

Background

We implemented a virtual MDT platform as a technical solution to assist a heart failure MDT. vMDT would enable the team to document discussions and create actions for individual team members that were visible and transparent and thus ensuring rapid completion relating to patient care plans. Patients cases processed via this pathway in comparison to traditional approaches were able to access treatment optimisation and newer heart failure therapies more rapidly. Data from the vMDT platform helped plan for wider transformation.

Purpose

Integrating care between general practice (GP), community and hospital specialists is the current focus for the National Health Service (NHS) in the UK. An integrated approach necessitated better communication and sharing of information between MDTs. We decided that it was necessary to have the digital infrastructure to deliver this approach.

Method

The vMDT system harnessed information relevant to the patients heart failure and presented it to MDT members to view and contribute to the patients treatment plan, before, during and after a scheduled MDT meeting. Following the meeting the platform would instantly communicate actions to members of the professional team, ensuring transparency and rapid completion of actions. Processes were simplified, meaning that patients could be referred onwards at the click of a button. The patients could be referred into this pathway by a GP when patients continued to have symptoms. Pathway was made available to GP clinics covering a 200,000 patient population. Led by the commissioning transformation team, who managed the project alongside the GP cardiovascular lead, community heart failure nurse lead, and Hospital heart failure specialist nurse leads. Clinical pharmacists linked to the GP clinics were included and were the ones who would prepare, upload and present the heart failure cases.

Results

98% (150 processed over 10 months) of patients referred along this pathway could be managed effectively. 5% would otherwise have been lost to follow up. 100% of actions created through this pathway were completed. 62% had their treatment optimised. Clinician satisfaction improved.

Conclusion

Virtual MDTs are the rave but there needs to be digital infrastructure to support this novel way of working, especially if we are to scale this up. A digital platform needs to have the safeguards for information security but also needs to align to an improved workflow for the health professionals working within the service. In future we would like to look at whether addition of decision support can further improve productivity and outcomes relating to optimisation of therapy for heart failure patients.
Hand-held echocardiography-based heart failure screening in hypertensive or diabetic patients in community: a pilot study
Authors: Yang Z , Kang Y , Zhong X , Chen Q , Chen X , Wang H , Zhang Q
Published: November 2023

Background

There is lack of solid data on screening methods for preclinical heart failure (HF) in primary care settings. Standard echocardiography is not regarded as a routine test due to high cost and need of operation by specialists. Hand-held echocardiography (HHE) has been used in various clinical settings with easier access and lower price but has never been integrated into HF screening programme.

Purpose

This study aimed to explore the feasibility and cost-effectiveness of hand HHE-based HF screening strategies in patients with risk factors in community.

Methods

The registered patients with hypertension or diabetes at two Chinese community health service centres (CHSCs) who had not been diagnosed previously as HF were recruited. Every patient received symptom assessment (dyspnea and/or lower limb edema), blood test for N-terminal-probrain natriuretic peptide (NT-proBNP ≥ 125 pg/ml regarded as positive), and HHE for any indexed abnormality in the dedicated protocol with focused and semiquantitative scanning [i.e. left ventricular (LV) dilation, left atrial (LA) dilation, interventricular septum (IVS) thickening, LV systolic dysfunction by calipers, as well as region wall motion abnormality, valvular stenosis, ≥moderate valvular regurgitation, significant pericardial effusion by eyeballing). By using the results of all the three modalities for screening compared to the concurrent guidelines, the patients were categorized into HF stages A, B, or C as the "gold standard". Three screening strategies were proposed (Figure 1), of which Strategy I was designed as a single test, Strategy II as a combined test, and Strategy III as a stratified stepwise test. Diagnostic accuracy and cost-effectiveness of each strategy was calculated in comparison with the "gold standard".

Results

A total of 423 patients (70 ± 9 years; 46.6% males) were enrolled. There were 166 (39.2%) symptomatic patients, while 106 (25.1%) patients had elevated NT-proBNP. HHE abnormalities were found in 286 (67.0%) patients, of which IVS thickening was the most common finding (47.0%), followed by LA enlargement (30.0%). LV systolic dysfunction was identified in 18 (4.3%) patients. 232 (54.8%) and 59 (13.9%) patients were reclassified as HF stage B and C, respectively. As shown in Figure 2, the stepwise Strategy III of using symptoms for the first stratification, followed by choosing HHE or NT-proBNP test led to a 100% accuracy and a 35.6% reduction in cost.

Conclusions

HHE-based focused screening detects HF earlier in high-risk populations. The screening strategy combined with symptoms, NT-proBNP, and HHE is feasible for identifying underdiagnosed HF stage B or C that may be considered in primary care.Scheme of HF stage screening strategiesHF Screening and cost-effectiveness