bluuebunny/crossref_metadata_2025 huggingface dataset:
Development of a risk stratification score based on social predictors in patients undergoing implantable cardioverter defibrillator
Authors: Viana T , Vieira De Melo R.M , Figueiredo C.S , Azevedo D.F.C , Carvalho W.N , Grimaldi A.C , Da Silva D.N.V , Passos L.C.S
Published: October 2021

Introduction

The implantable cardioverter defibrillator (ICD) has been shown to be effective in reducing cardiovascular mortality in selected patients with cardiomyopathy in primary and secondary prevention. However, as it is an invasive and costly procedure, it is necessary to identify the patients who most benefit from this therapy. The evaluation of a multidisciplinary team for CRT candidates can contribute to the improvement of results.

Objective

Development of a risk score based on social predictors in patients undergoing ICD implantation.

Methods

Prospective cohort conducted between January 2017 and September 2019 with patients who underwent ICD implantation in primary and secondary prevention. Patients were evaluated before implantation of the device by a multidisciplinary team that analyzed four social predictors for an unfavorable outcome (low medication adherence, presence of psychosocial risks, low family income and low level of education). The social score was calculated by the simple arithmetic sum of the number of predictors present in each patient. Variables with a possible association (p<0.1) with mortality in 1 year of follow-up were used in the multivariate model by Cox regression.

Results

205 patients were evaluated with a mean follow-up of 416.5 (± 271.6) days. 140 (68.3%) were male, with an mean age of 54.6 years (± 14.6) and an mean LVEF of 43.8% (± 18.5). Most patients 160 (78.0%) were referred for secondary prevention, with Chagas disease being the most prevalent cause of cardiomyopathy 113 (55.1%). Mortality at 1 year was 32 (15.6%). In the multivariate analysis, with the inclusion of the variables: age, secondary prevention, Chagas' disease, LVEF <40% and social score; only the highest score on the social score and LVEF <40% were independently associated with 1-year mortality, RR: 1.5, IC 1.2–2.0; p=0.003 and RR: 4.1, CI 1.2–14.2; p=0.02, respectively. Mortality increased significantly as the score on the social score increased: 6.0% for a score of 0, 7.5% for 1 point; 21.7% for 2 points; 25.0% for 3 points and 29.0% for 4 points; p=0.006, Log-Rank (Figure 1).

Conclusion

The social score can represent a simple prognostic tool that can be usefully used in candidates for ICD. The use of a multidisciplinary team to evaluate patients who are candidates for ICD can help to correctly identify patients who can benefit most from therapy.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Timing of ejection fraction reassessment after sacubitril-valsartan initiation for indication to defibrillator implantation. A single center experience
Authors: Carinci V , Leci E , Bugani G , Greco C , D'Angelo C , Pecoraro A , Casella G
Published: October 2021

Background

Sacubitril/Valsartan (SV) has recently been validated in the therapy of heart failure (HF) with reduced ejection fraction (EF). SV is effective on symptoms and heart remodeling. At the moment the best timing to EF assessment after SV initiation in order to proceed with defibrillator (ICD) implantation, it's unknown.

Purpose

Evaluate the timing of improvement of EF after SV initiation in patients (pts) with systolic HF, candidates to primary prevention ICD implantation.

Methods

We enrolled all consecutive pts candidates to primary prevention ICD implantation that underwent SV initiation from February 2018. We evaluated clinical and echo follow up (Fup). Results have been analyzed with paired T-test).

Results

The study involved 61 pts (mean age 67±10 years, 71% male, ischemic cardiopathy 44%, mean time from diagnosis 31 months) with mean EF at enrollment 30±5% (ED vol 94 ml/m2, ES vol 64 ml/m2, severe MR 21%) and mean NYHA 3±0.6. After a mean Fup of 6 months mean EF increased to 37±7% (ED vol 80 ml/m2, ES vol 51 ml/m2, severe MR 8%, p<0.004), NYHA decreased to 2±0.6 (p<0.04). In 69% pts SV dosage reached 97/103 mg bid. 28 pts (45%) had first Fup at 3 months and showed already mean EF 34±6% and mean NYHA 1.6±0.6 (p<0.04). 26 pts (43%) had last Fup echo after 1 year (mean 17±10 months) and showed further EF little improvement (38.3±8%, p 0.05).

Conclusions

After SV initiation in systolic HF, heart remodeling is already evident at 3 months Fup and better appreciable at 6 months Fup. Little non significant further EF improvement could be seen later. In our study best timing to decide for primary prevention ICD is likely between 3 and 6 months after SV initiation.

Funding Acknowledgement

Type of funding sources: None. Figure 1
Detailed analysis of left ventricular deformation in athletes doing high dynamic sports – a three-dimensional speckle-tracking echocardiographic study
Authors: Nemes A , Gyenes N , Kormanyos A , Vagvolgyi A , Balogh L , Pucsok J , Lengyel C
Published: October 2021

Background

Physiologic remodeling due to repetitive overload induced by exercise training is a known feature in the athletes' heart including significant changes in left ventricular (LV) deformation mechanics. The aim of the present study was to investigate three-dimensional speckle-tracking echocardiography- (3DSTE-)derived LV strains in elite athletes doing high dynamic sports with different grades of static components of their training.

Methods

The athlete group comprised 67 subjects (mean age: 23.6±6.4 years, 50 men). The following groups were created regarding their physical activity: Group C. I. (high dynamic/low static) (n=12, mean age: 23.1±4.0 years, Group C. II. (high dynamic/moderate static) (n=22, mean age: 24.8±7.8 years) and Group C. III. (high dynamic/high static) (n=33, mean age: 23.0±6.1 years). Their results were compared to 83 age- and gender-matched non-athletic healthy controls (mean age: 23.6±3.2 years, 50 men). All athletes and non-athletes underwent a complete two-dimensional Doppler echocardiography examination with 3DSTE.

Results

None of the healthy subjects or athletes had any known cardiovascular risk factors or received drugs and ECG showed no significant alterations. Athletes spent 10.8±3.3 years, 10.1±5.9 years and 6.9±4.2 years in elite sport in Groups C. I., C. II. and C. III., respectively. No significant differences could be seen in the ratio of athletes being in an actual race period between Groups C. I., C. II. and C. III. [n=3 (25%), n=11 (50%) and n=11 (32%), respectively]. Enlarged LV dimensions and thickened posterior wall and interventricular septum were found in all athletes compared to the non-athlete healthy control group by 2-dimensional echocardiography. Increased 3DSTE-derived LV end-diastolic and end-systolic volumes could be seen in all athletes, the largest values were seen in the C. III. group. Global LV-LS (−18.5±3.0% vs. −16.3±2.3%, p<0.05), LV-CS (−29.9±5.2% vs. −28.1±4.8%, p<0.05) and LV-AS (−43.7±5.4% vs. −40.9±4.8%, p<0.05) were increased as compared to those of non-athlete controls. All apical regional LV strains proved to be increased in all athletes with enhanced basal LS and midventricular LS, AS and 3DS. Global LV strains did not differ between the athlete groups based on static component of their training. No significant regional differences in LV strains could be detected between C. I., C. II. and C. III. groups (except in midventricular LV-LS).

Conclusions

Enhanced LV contractility represented by LV strains in longitudinal and circumferential directions could be demonstrated in elite athletes doing high dynamic sports, which does not depend on the grade of the static component of their training.

Funding Acknowledgement

Type of funding sources: None.
Pacemaker upgrade to CRT-D or CRT-P without prior ventricular arrhythmias: a long-term single-centre retrospective analysis
Authors: Schwertner W.R , Veres B , Kuthi L , Behon A , Eperke M , Tokodi M , Kosztin A , Kovacs A , Osztheimer I , Zima E , Geller L , Merkely B
Published: October 2021

Background

Cardiac Resynchronization Therapy (CRT) can reverse the harmful effects of right ventricular pacing (RVP). Data are sparse on comparing all-cause mortality among patients undergone CRT-defibrillator (CRT-D) or CRT-pacemaker (CRT-P) upgrade from pacemakers without prior ventricular arrhythmias (VAs).

Purpose

We compared the differences in long-term all-cause mortality, postprocedural complications and the occurrence of VAs among patients receiving CRT-D or CRT-P upgrade.

Methods

Patients with a previously implanted conventional pacemaker (PM) developing heart failure (HF) despite optimal medical treatment and high rates of RVP, were included. Altogether 270 patients were investigated, 83 (30.7%) upgraded to CRT-D, 187 (69.3%) to CRT-P in our retrospective registry. The primary endpoint was all-cause mortality, secondary endpoints were malignant VAs and implantation-related complications.

Results

CRT-D upgrade patients were more likely to be males, have a favourable renal function and lower left ventricular ejection fraction (LVEF). During the median follow-up time of 3.7 years, 25 (30.1%) of CRT-D and 131 (70.1%) of CRT-P upgrade patients reached the primary endpoint. The CRT-D upgrade group showed a lower risk of all-cause mortality in the total cohort (HR: 0.55; 95% CI: 0.38–0.78; p=0.004) and in the ischaemic subgroups compared to CRT-P. After adjustment, CRT-D, ischaemic HF aetiology and LVEF have been confirmed as independent predictors of all-cause mortality. Malignant VA occurrence was higher among CRT-D patients (10.8% vs 1.1%; p=0.001), while no difference was observed in the rate of complications between the two patient groups. However, lead removal was performed more frequently (13.3% vs 1.1%; p<0.001) during CRT-D upgrade procedures compared to CRT-P.

Conclusions

Patients among the total and ischaemic HF aetiology subgroup benefited more from the CRT-D upgrade, although VAs and lead removal were more common than in the CRT-P group.

Funding Acknowledgement

Type of funding sources: Public grant(s) – National budget only. Main funding source(s): This work was supported by the ÚNKP-20-3-I-SE-43 New National Excellence Program if the Ministry for Innovation and Technology in Hungary. Project no. NVKP_16-1–2016-0017 (“National Heart Program”) has been implemented with the support provided by the National Research, Development and Innovation Fund of Hungary, financed under the NVKP_16 funding scheme. The research was financed by the Thematic Excellence Programme (2020-4.1.1.-TKP2020) of the Ministry for Innovation and Technology in Hungary, within the framework of the Therapeutic Development and Bioimaging thematic programmes of the Semmelweis University. All-cause mort of pts after UPG
QRS narrowing predicts left ventricular reverse remodelling after resynchronization therapy in patients with end-stage heart failure
Authors: Neves Pereira M , Leite P.V.H , Dias G , Cardoso A.F , Tinoco M , Azevedo O , Cordeiro F , Ribeiro S , Ferreira F , Sanfins V , Lourenco A
Published: October 2021

Introduction

Cardiac resynchronization therapy (CRT) is an established treatment for heart failure (HF) patients, however one-third of the patients fail to benefit from CRT. The relationship between the QRS duration, severity of mechanical dyssynchrony and efficacy of CRT is not completely understood. We determined if QRS duration shortening after CRT implantation was predictive of left ventricular reverse remodelling.

Methods

We retrospectively enrolled 227 patients undergoing CRT implantation between 2013 and 2020 according to the guidelines. 88 patients were included in our analysis, from whom all data were available, and these represent our sample. Clinical, electrocardiographic and echocardiographic parameters were evaluated at baseline and after 6 months of CRT implantation. Response to CRT was defined as a reduction in left ventricular end-diastolic volume (LVEDV) >15%. Linear regression models were used.

Results

88 patients were included (mean age 69±10 years, 62.5% males, 36.4% ischemic etiology). Baseline left ventricular ejection fraction (LVEF) was 27,5±5,8% and LVEDV was 181±69 ml. After 6 months of CRT, 52 patients (59.1%) were considered responders. Baseline LVEDV was superior in responders when compared with non responders (199±85 ml vs 168±53 ml, p=0.038). No significant differences were noted in male gender (p=0.823), ischemic cardiomyopathy (p=0.065), LVEF (p=0.853), atrial fibrillation (p=0.390), left bundle branch block (p=0.950) or biventricular pacing (p=0.154) between them.

QRS duration at baseline was similar between responders and non-responders (165±17 ms vs 163±17 ms, p=0.620). After 6 months of CRT, the reduction of QRS duration in responders was significantly higher than non-responders (p<0.001).

QRS duration was reduced from 165±17 ms to 136±15 ms in responders vs 163±17 ms to 160±17 ms in non-responders, (p<0.001). The change in QRS duration positively correlated with the change in LVEDV (0. 654; p<0.001). Multi-linear regression analysis suggested that QRS duration shortening had a significant effect on LVEDV (y = 14,375 + 1.354 X, R2 0.337, p<0.001)

Conclusion

QRS duration shortening after CRT implantation was predictive of LV reverse remodelling in end-stage heart failure patients. Further prospective studies should be conducted to assess the prognostic value of QRS narrowing in response to CRT.

Funding Acknowledgement

Type of funding sources: None.
Adherence to guidelines of diagnostic and therapeutic practices for suspected infections of cardiac implantable electronic devices
Authors: De Ciancio G , Filippetti L , Blangy H , Huttin O , Goehringer F , Juilliere Y , Sadoul N , Selton-Suty C
Published: October 2021

Background

Despite guidelines describing the optimal diagnostic and therapeutic procedures of patients with suspected infection of cardiac implantable electronic device (CIED), the management of such patients is often challenging.

Purpose

The aim of this study was to describe our diagnostic and therapeutic practices for suspected CIED infection and to compare them to European Heart Rhythm Association (EHRA) guidelines.

Methods

Patients hospitalized in our tertiary care hospital for suspected CIED infection from 2014 to 2019 were retrospectively included. We applied the EHRA classification and compared diagnostic and therapeutic management to EHRA guidelines.

Results

Among 184 patients (mean age 72.3±12.4 years), 137 had a proven infection of the lead (either by TTE/TEE, by [18F]FDG PET/CT, or by positive culture of the lead) or an isolated pocket infection without proof of lead infection and 47 had no proof of infection of CIED.

According to EHRA classification, CIED infection was considered as definite in 145 patients, possible in 31 and excluded in 8.

Regarding recommended diagnostic procedures, blood cultures were performed in 90.8%, TTE in 97.8%, TEE in 85.9%, [18F]FDG PET/CT in 50.5% and imaging for embolisms in 78.3% of the patients.

Compared to therapeutic recommendations for the 145 cases of definite CIED infection, device removal was performed in 96 patients (66.2%), antibiotic therapy was prescribed in 130 (89.7%), with a duration equal or superior to the one recommended in 105 (72.4%) of the patients.

One-year survival rate was 66.3% and was better in patients with device removal than in patients without, both in the whole population (respectively 77.7% and 48.6%) and in the patients with definite CIED infection (80.0% vs 49.0%). After adjustement on age and Charlson's score, patients without device removal had a significantly higher risk of 1-year mortality (HR=3.40 [1.84–6.26], p=0.0001).

Conclusion

Suspicion of CIED infection are difficult situations. The use of theoretical classification helps to define the different types of cases and the resultant therapeutic approach.

In daily practice, our study shows that the strict adherence to these guidelines is not always possible. This study shows a relatively good use of diagnostic procedures. However, theoretical advice for medical therapy and removal procedures are not always properly followed. To improve patients' prognosis, infected device removal must be systematically discussed in multidisciplinary endocarditis team, weighing the benefit-risk ratio of the strict appliance of the guidelines.

Funding Acknowledgement

Type of funding sources: None. Diagnostic comparisonTherapeutic comparison
Subclavian versus axillary vein puncture for implantation of cardiac electronic devices. A meta-analysis
Authors: Anagnostopoulos I , Kousta M , Kossyvakis C , Lakka E , Paraskevaidis N.T , Giannopoulos G
Published: October 2021

Background

Implantation of CIED has become a daily practice for patients with rhythm disturbances, those with an indication for primary or secondary sudden cardiac death prevention as well as for patients with heart failure and marked ventricular dyssynchrony. Most of the complications observed following implantation seem to be procedure-related. The latter has led many physicians to replace the classic subclavian approach with alternative techniques such as cephalic vein cut-down and axillary vein puncture (AVP). Recent data support that these techniques may be associated with similar success rates and lower adverse events.

Purpose

This meta-analysis was performed to compare axillary to subclavian vein puncture (SVP) for implantation of cardiac implantable electronic devices (CIED), in terms of safety and efficacy.

Methods

We searched MedLine, via PubMed, for studies comparing subclavian to axillary vein approach in terms of safety and efficacy. Safety endpoints were considered the incidence of pneumothorax, device related infections and major bleeding events. Efficacy and feasibility were assessed by the incidence of lead failure (lead dislodgement, lead fracture or insulation defects) and the number of successfully cannulated veins, respectively. Studies were judged as eligible if they reported at least one of the predefined outcomes. Effect size was calculated using the risk difference along with the corresponding 95% confidence interval (CI). A random- effects DerSimonian-Laird model was adopted.

Results

Seven studies fulfilled the inclusion criteria and were included in the final analysis, resulting in 3642 patients (59.1% males) with a pooled mean (SD) age of 66.1 (12.7) years. Axillary vein puncture (AVP) was performed in 45.8% of them. All, but one study, used fluoroscopic guidance (with or without venography) for axillary vein cannulation. The CIED most commonly implanted was a permanent pacemaker (73%). Both techniques resulted in similar percentages of successful cannulations (1066/1099 for AVP and 906/931 for SVP, RD: 0; 95% CI: −0.01–0.01, I2: 0%, Figure 1A). There was a significantly higher risk for pneumothorax with the subclavian approach (RD: 0.02; 95% CI: 0.01–0.03, I2: 49.31%, Figure 2A). No significant differences were observed regarding the incidence of bleeding and infections (Figure 2B, 2C). SVP was also associated with a significantly increased risk for lead failure (RD: 0.01; 95% CI: 0.00–0.03, I2: 48.47%, Figure 1B).

Conclusions

AVP seems to be a feasible approach for implantation of CIED. Moreover, it seems to be both a more safe and effective choice compared to SVP, as it is associated with reduced risk for pneumothorax and lead failure. More data especially comparing AVP to cephalic cut-down are needed to safely guide the daily practice.

Funding Acknowledgement

Type of funding sources: None. Figure 1Figure 2
Prediction of functional capacity by the HFA-PEFF score in patients with acute decompensated heart failure with preserved ejection fraction: a post-hoc analysis from the PURSUIT-HFpEF registry
Authors: Iwakura K , Onishi T , Sotomi Y , Okada M , Koyama Y , Okamura A , Tamaki S , Yano M , Hayashi T , Yamada T , Yasumura Y , Fujii K , Hikoso S , Sakata Y
Published: October 2021

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) is still challenging, and the H2FPEF- and the HFA-PEFF score were proposed as simple and reliable diagnostic tools. We recently reported that the HFA-PEFF score was significantly associated with the composite endpoint of all-cause death and heart failure readmission in patients with acute decompensated HFpEF (Sotomi. Eur J Heart Fail, in press).

Purpose

To investigate the relation whether the HFA-PEFF or H2FPEF score can evaluate functional capacity in patients with HFpEF

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for acute decompensated HFpEF. We performed 6 minute walk (6MW) test and measured NT-proBNP before discharge. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients (age 81±9 years, male gender 45%) hospitalized for acute decompensated HFpEF for the present study. The H2FPEF score was obtained in 588 (77.7%) patients and all patients had ≥2 points. The HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. We divided these patients into 3 groups based on the HFA-PEFF score (score 2 to 4, 5, and 6) or on the H2FPEF score (score 0 to 3, 4 to 5 and 6 to 8). There were a significant difference in NT-pro BNP between 3 groups based on HFA-PEFF score (p=0.01, Table 1), and patients with score 6 had significantly higher NT-proBNP than those with score 2 to 4 (p=0.02). A significant difference was observed in 6MW distance among these groups (p=0.04, Table), and those with score 6 had significantly shorter distance than those with score 2 to 4 (p=0.04). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE, and Kaplan-Meier survival analysis demonstrated that classification of HFA-PEFF score significantly stratified the patients' risk for MACE. On the other hand, there was no significant difference in 6MW distance among 3 groups based on H2FPEF score (p=0.53), and H2FPEF score was not an independent predictor for MCE by the Cox model analysis. Moreover, the lowest H2PEF score group had higher NT-proBNP than other 2 groups (p=0.02)

Conclusions

The HFA-PEFF score predicted functional capacity as well as prognosis in patients hospitalized for HFpEF, while the H2PEF score did not.

Funding Acknowledgement

Type of funding sources: None. Table 1
Recurrent heart failure hospitalizations in patients with preserved ejection fraction: predictors and outcome
Authors: Schrutka L , Seirer B , Frommlet F , Binder C , Duca F , Rettl R , Dachs T.M , Dalos D , Badr-Eslam R , Kastner J , Hengstenberg C , Bonderman D
Published: October 2021

Background

Heart failure with preserved ejection fraction (HFpEF) is the most common form of HF and its prevalence is approaching epidemic proportions. Current treatment strategies aim to improve clinical status and reduce mortality rates. Episodes of acute HF are one of the main reasons for hospitalization in people over 65 years; however, they have not been well studied in HFpEF patients yet.

Objectives

The aim of this study was to investigate the impact of recurrent HF hospitalizations on long-term outcomes and to find predictors for subsequent events.

Methods

Between December 2010 and December 2019, 422 patients with confirmed HFpEF were enrolled in this study and prospectively followed.

Results

During follow-up, 190 HFpEF patients (45%) experienced HF hospitalizations with a median frequency of 2 (IQR: 1–4). Those presenting with acute HF had higher body mass indices (p=0.018), worse performance in 6-minute walking tests (p<0.001), higher levels of N-terminal prohormone of brain natriuretic peptide (NT-proBNP, p<0.001) and, compared to stable patients, a larger proportion suffered from New York Heart Association functional class ≥ III (p<0.001). Furthermore, baseline left ventricular diastolic dysfunction (early mitral inflow velocity/early diastolic mitral annular velocity; p=0.002) as well as right ventricular afterload (pulmonary artery wedge pressure; p<0.001) were more pronounced in patients with acute deteriorations. Over the observation period 107 patients (25%) died. Kaplan-Meier curves revealed increasingly worse survival in patients with recurrent HF events (5-years survival: 1 HF event 66% vs ≥3 HF events 53%, p<0.001; Figure). Time to last hospitalization was a strong predictor of survival with an adjusted HR of 2.5 (95% CI 1.63–3.98; p<0.001) in multivariate Cox regression analysis. Predictors of recurrent HF hospitalization were 6-minute walking distance (OR: 0.07, CI 0.02–0.22; p=0.001), systolic pulmonary artery pressure (OR: 1.05, CI 1.03–1.07, p=0.001) and NT-pro BNP (OR: 4.92, CI: 2.68–9.04, p=0.001)

Conclusions

HFpEF patients experiencing recurrent HF hospitalizations have worse long-term outcome. Intensive efforts should be made to maintain HFpEF patients compensated over time.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis
Peak atrial longitudinal strain predicts exercise tolerance in heart failure with preserved ejection fraction
Authors: Sengupta S , Mohan J.C , MacGowan G.A , Jakovljevic D.J
Published: October 2021

Purpose

The present study i) determined left atrial (LA) and left ventricular (LV) strains at rest and in response to exercise in patients with heart failure with preserved ejection fraction (HFpEF) and heart failure with reduced ejection fraction (HFrEF), and ii) assessed the relationship between LA and LV strains and exercise tolerance.

Methods

Forty HFpEF patients (age 59±7 yrs; 25 females), 40 stable HFrEF patients (age 57+6 yrs, 15 females) and 20 controls (age 56+6 yrs, 13 females) underwent baseline clinical and biochemical assessment, resting and exercise stress transthoracic echocardiography using modified Bruce protocol. Speckle-tracking echocardiography was performed to define peak atrial longitudinal strain (PALS) and left ventricular global longitudinal strain (LVGLS). LA stiffness index and LV stiffness index were also derived.

Results

Compared to healthy controls, HFpEF and HFrEF showed significantly lower PALS at rest (34.03±1.85 vs. 23.06±4.69 vs. 11.51±1.44%, p<0.01) and after exercise (34.41±1.24 vs. 18.48±3.51 vs 10.47±1.49, p<0.01 for both). In response to exercise, the PALS significantly reduced in HFpEF by 26%, but only 8% in HFrEF and remained unchanged in controls. LA stiffness index was higher in HFpEF and HFrEF compared to healthy controls at rest (0.57±0.22 vs. 1.19±0.63 vs. 0.27±0.06, p<0.01) and in response to exercise (0.83±0.46 vs. 1.37±0.63 vs. 0.33±0.04, p<0.01). Compared to healthy controls, HFpEF and HFrEF demonstrated significantly lower LVGLS at rest (−20.27±0.98 vs. −15.89±2.72 vs.-11.14±3.40%, p<0.01) and after exercise (−19.9±0.8 vs.-15.5±3.18 vs.-11.01±2.6%, p<0.01). LV stiffness index was significantly higher in HFpEF and HFrEF compared to healthy controls at rest (0.16±0.05 vs. 0.14±0.07 vs. 0.11±0.02, p<0.01) and in response to exercise (0.18±0.07 vs. 0.15±0.06 vs. 0.13±0.02, p<0.01). Exercise tolerance i.e. exercise duration was significantly lower by 28% and 30% in HFpEF and HFrEF compared with controls (363±152 vs. 352±91 vs. 505±42, p<0.01). There was a significant relationship between peak atrial longitudinal strain and exercise tolerance in HFpEF (r=0.32, p=0.04).There was no significant relationship between exercise tolerance and LVGLS (r=0.058, p=0.72), LA stiffness (r=−0.17, p=0.3), LV stiffness (r=0.88, p=.59). There was no significant relationship between exercise tolerance and PALS (r=0.021, p=0.89) or LVGLS (r=0.12, p=0.48) in HFrEF.

Conclusion

HFpEF and HFrEF are associated with reduced left atrial and left ventricular strains and increased arial and ventricular stiffness.Peak atrial longitudinal strain is a significant determinant of exercise tolerance in HFpEF but not in HFrEF.

Funding Acknowledgement

Type of funding sources: None.
Heart failure re-hospitalization differently affects the following mortality in patients with reduced, mid-range and preserved LVEF
Authors: Abe T , Jujo K , Watanabe S , Kishihara M , Shirotani S , Takada T , Yoshida A , Saito K , Hagiwara N
Published: October 2021

Introduction

The recent advances in the treatment for heart failure with reduced ejection fraction (HFrEF) have been remarkable, while no therapy has convincingly improved the prognosis in HF patients with preserved (HFpEF) and mid-range (HFmrEF) ejection fraction. Frequent decompensations of HF lead to progressive deterioration of cardiac and renal function, and quality of life. Hence, prior studies have reported that the mortality of HFrEF patients increases as hospitalization for HF repeats. However, it is still unclear whether this trend applies for HFpEF and HFmrEF patients.

Purpose

We aimed to compare the prognostic impact of re-hospitalization due to HF on cardiovascular death (CVD) among HFrEF, HFmrEF and HFpEF patients.

Methods

This observational study included 1,930 consecutive patients who were hospitalized for worsening of HF and discharged alive. Of them, patients who have never or have not been hospitalized for HF at least last 2 years, were finally analyzed. Patients were consisted of the population with HFrEF (EF<40%, n=421), HFmrEF (EF 40–49%, n=202) and HFpEF (EF>50%, n=291). Patients in each EF-classified population were divide into 2 subgroups based on whether patients were re-hospitalized for HF during the observational period, respectively. The primary endpoint of this study was CVD.

Results

During the observation period, Kaplan-Meier analysis showed that patients who were re-hospitalized for HF had higher event rate of CVD in HFrEF group (Log-rank p=0.008, Figure). Even after adjusting with multivariate covariates including age, sex, EF, brain natriuretic peptide and estimated glomerular filtration rate, re-hospitalization for HF was an independent predictor for CVD in HFrEF group (HR: 1.95, 95% CI: 1.11–2.86, p=0.029). However, in HFmrEF group and HFpEF group, there was no significant difference in the rates of CVD between 2 subgroups divided whether patients were re-hospitalized for HF or not (p=0.91, p=0.34, respectively).

Conclusion

Re-hospitalization for HF affected the CVD rate in HFrEF group, but not in HFmrEF and HFpEF groups. The prevention of re-hospitalization for HF is important particularly in HFrEF patients in order to improve cardiovascular mortality.

Funding Acknowledgement

Type of funding sources: None.
Predictors and prognosis of RV function in pulmonary hypertension due to heart failure with reduced ejection fraction
Authors: Schmeisser A , Rauwolf T.H , Groscheck T , Fischbach K , Luani B , Kropf S , Tanev I , Hansen M , Meissler S , Schaefer K , Steendijk P , Braun-Dullaeus R
Published: October 2021

Background and aims

Failure of right ventricular (RV) function worsens outcome in pulmonary hypertension (PH). The adaptation of RV contractility to afterload, the RV-pulmonary artery (PA) coupling, is defined by the ratio of RV end-systolic to PA elastances (Ees/Ea). Using pressure volume loop (PV-L) technique we aimed to identify an Ees/Ea cutoff predictive for overall survival and to assess hemodynamic and morphologic conditions for adapted RV function in secondary PH due to Heart Failure with Reduced Ejection Fraction (HFREF).

Methods

This post hoc analysis is based on 112 patients of the prospective Magdeburger Resynchronization Responder Trial. All patients underwent right and left heart echocardiography, and a baseline PV-L and RV catheter measurement. A subgroup of patients (n=50) without a pre-implanted cardiac device underwent MRI at baseline.

Results

The analysis revealed that 0.68 is an optimal Ees/Ea cutoff (area under the curve: 0.697, p<0.001) predictive for overall survival (median follow up = 4.7 years, Ees/Ea ≥0.68 vs. <0.68, log-rank 8.9, p=0.003. In patients with PH (n=76, 68%) Multivariate Cox-regression demonstrated the independent prognostic value of RV-Ees/Ea in PH patients (HR 0.2, p<0.038). Patients without PH (n=36, 32%) and those with PH but RV-Ees/Ea ≥0.68 showed comparable RV-Ees/Ea ratios (0.88 vs. 0.9, p=0.39), RV size/function, and survival. In contrast, secondary PH with RV-PA coupling ratio Ees/Ea <0.68 corresponded extremely close to cut-off values that define RV dilatation/remodeling (RVEDV >160ml, RV-mass/volume-ratio <0.37 g/ml) and dysfunction (RVEF <38%, TAPSE <16mm, FAC <42%, and stroke-volume/end-systolic volume ratio <0.59) and is associated with a dramatically increased short and medium-term all-cause mortality. Independent predictors of prognostically unfavorable RV-PA coupling (Ees/Ea <0.68) in secondary PH were a preexistent dilated RV (end-diastolic volume >171ml, odds ratio, OR 0.96, p=0.021), high pulsatile load (PA compliance <2.3 ml/mmHg, OR 8.6, p=0.003), and advanced systolic left heart failure (left ventricular (LV) ejection fraction <30%, OR 1.23, p=0.028).

Conclusions

The RV-PA coupling ratio Ees/Ea predicts overall survival in PH due to HFREF and is mainly affected by pulsatile load, RV remodeling and LV dysfunction. Prognostically favorable coupling (RV-Ees/Ea ≥0.68) in PH was associated with preserved RV size/function and mid-term survival, comparable to HFREF without PH.

Funding Acknowledgement

Type of funding sources: Private grant(s) and/or Sponsorship. Main funding source(s): Boston Scientific
Reverse remodelling criteria to predict cardiovascular death in heart failure with reduced or mid-range ejection fraction
Authors: Aimo A , Fabiani I , Vergaro G , Arzilli C , Chubuchny V , Pasanisi E.M , Petersen C , Poggianti E , Taddei C , Bayes-Genis A , Lupon J , Giannoni A , Georgiopoulos G , Passino C , Emdin M
Published: October 2021

Aims

Reverse remodelling (RR) is the recovery from left ventricle (LV) dilatation and dysfunction. There are no established definitions of RR. We sought to identify RR criteria that better predicted cardiovascular death.

Methods and results

Forty-two studies used 25 criteria to define RR, most commonly (n=12) as LV end-systolic volume (LVESV) reduction ≥15%. We evaluated 927 patients with LV ejection fraction (LVEF) <50% undergoing 2 echocardiograms within 12±2 months. Over a median 2.8-year follow-up after the second echocardiogram (1.3–4.9), 123 cardiovascular deaths occurred (13%). Model 1 included age, LVEF, N-terminal pro-B-type natriuretic peptide (NT-proBNP), ischaemic aetiology, cardiac resynchronization therapy (CRT), estimated glomerular filtration rate (eGFR), New York Heart Association (NYHA), and LVESV index (LVESVi), and Model 2 the validated 3C-HF score. Two RR criteria proved particularly effective in risk reclassification over Model 1 and Model 2: LVEF increase ≥1 category (severe [LVEF ≤30%], moderate [LVEF 31–40%], mild LV dysfunction [LVEF 41–55%] and normal LV function [LVEF ≥56%]), and LVEF increase >10 U. The same 2 criteria yielded independent prognostic significance and improved reclassification also in patients with LVEF <40% or LVEF ≤35%. LVEF increase ≥1 category and LVEF increase >10 U displayed a stronger prognostic value than LVESV reduction ≥15%, both in the whole population and the subsets with LVEF <40% or ≤35%.

Funding Acknowledgement

Type of funding sources: None.
The representativeness of VICTORIA and GALACTIC-HF trials in a contemporary cohort of patients with heart failure with reduced ejection fraction
Authors: Oliveira Campinas A , Campos S.C , Costa R.C , Dias De Frias A.D.F , Alexandre A.A , Gomes C.G , Santos M.S , Torres S.T
Published: October 2021

Introduction

New therapies for heart failure with reduced ejection fraction (HFrEF) have been recently developed. It is still unclear the proportion of patients of clinical practice that will benefit from them. We aimed to examine the representativeness of the VICTORIA and GALACTIC-HF trials among a contemporary cohort of HFrEF patients followed at an HF outpatient clinic.

Methods

We performed a retrospective, cross-sectional, single-center study of 100 consecutive HFrEF patients from our HF outpatient clinic (January-June 2020). VICTORIA eligibility criteria were an LVEF <45%; NT-proBNP ≥1000 pg/mL if sinus rhythm (SR) or ≥1600 pg/mL if atrial fibrillation (Afib); and prior hospitalization in the last 6 months or IV diuretic therapy in the last 3 months. GALACTIC-HF eligibility criteria were an LVEF <35%, hospitalization or emergency room visit in the last 12 months; NT-proBNP >400 ng/mL if SR or ≥1200 pg/mL if Afib or atrial flutter.

Results

The mean age of our patients was 62±12 years and only 24% were female. The etiology of HF was ischemic in 42% of the patients, 86% of patients were in NYHA II class and 5% in NYHA III-IV. The mean LVEF was 34±5% and the median NT-proBNP was 482 pg/mL [172–1120]. Regarding treatment, 92% of patients were on betablockers (BB), 67% on ACEI/ARBs, 25% on ARNI, 81% on MRA and 30% on iSGLT2. The use of implantable cardioverter-defibrillators was 38% and 20% of patients were resynchronized. The proportion of patients meeting VICTORIA and GALACTIC-HF eligibility criteria was 11% and 21%, respectively. But excluding the criteria of recent hospitalization the representativeness of the VICTORIA trial increased to 28% and the GALACTIC-HF to 44%. The patients that met VICTORIA eligibility criteria were older (60±11 y vs 10±12 y; p=0.006), had worse functional class (NYHA III-IV: 18% vs 3%; p=0.03), were less likely to be treated with an MRA (55% vs 85%; p=0.013) and an iSGLT2 (0% vs 34%; p=0.02). Those that met GALACTIC-HF eligibility criteria had a lower LVEF (31±3% vs 35±6%; p=0.01), were less likely to be treated with an iSGLT2 (35% vs 10%; p=0.02) and more likely to be treated with a loop diuretic (86% vs 65%; p=0.06).

Conclusions

In a contemporary optimally treated HFrEF cohort only a small proportion of patients met the eligibility criteria used in VICTORIA and GALACTIC-HF trials, which identified older patients with more advanced disease.

Funding Acknowledgement

Type of funding sources: None.
Evaluation of right ventricular function in acute pulmonary embolism by 3D ejection fraction and longitudinal strain echocardiography in acute phase and follow-up
Authors: Ramos Lopez N , Mahia Casado P.M.C , Islas Ramirez F.I.R , Ferrera C.F.D , Enriquez Vazquez D.E.V , Luque Diaz T.L.D , Noriega Sanz F.N.S , Abelaira Freire J.A.F , Perez Serrano M.P.S , Higueras Nafria J.H.N , Galvan Herraez L.G.H , Pedrajas J.M.P , Fernandez Ortiz A.F.O , Salinas Sanguino P.S.S , Macaya C.M.M
Published: October 2021

Background

Assessment of right ventricular (RV) function by transthoracic echocardiography (TTE) in acute pulmonary embolism (PE) has an essential role to severity stratification. However, there is no reliable information on RV function about the clinical utility of advanced TTE parameters in follow-up.

Purpose

We aimed to assess the clinical utility of 3D RV ejection fraction (3DEF) and free wall longitudinal strain (FWLS) compared to conventional parameters in evaluating RV function in patients with acute PE at time of diagnosis and after follow-up and the relation with adverse outcomes.

Methods

We prospectively recruited 86 patients with intermediate-high and high-risk bilateral PE from 2018 to 2020 in our centre. Patients underwent TTE during admission and at 6 to 12 months follow-up that included conventional RV parameters (pulsed Doppler S wave (S'), TAPSE, and fractional area change (FAC)). 3DEF and FWLS were obtained as well. Normal values were stablished according to European guidelines.

Results

Mean age was 63.7±16.5 years, 58% males. Reperfusion treatment was performed in a 26,8%. In-hospital mortality was 4,7% (3 patients in the acute phase of PE and 1 due to rePE. The median follow-up was 1.3 years (IQR 1–2.5). 9 patients died (2 due to PE, 3 due to respiratory failure and 5 due to cancer). Patients with adverse events had a greater severity in PESI scale and worse RV function assessed by 3DEF and 3D volumes. There were no significant differences between groups in FAC, S' and TAPSE (Table 1).

Baseline echocardiographic parameters were analyzed in the acute phase during admission and at 6–12 month follow-up (Table 2). There was a significant improvement in conventional parameters (TAPSE and FAC) and a reversal of FWLS values (P=0,01) at follow-up. 3DEF improved, but was not statistically significant (p=0,06). There was a greater reversal in end-systolic volume compared to end-diastolic volume.

Conclusion

Advanced RV function assessment by 3DEF and FWLS is useful in the acute phase and follow-up. FWLS showed and early normalization after PE resolution, whereas 3DEF improved but remained pathological at 6–12 months follow-up.

Funding Acknowledgement

Type of funding sources: None. Table 1Table 2
Prediction of major adverse cardiovascular events in heart failure patients using face recognition: rationale and study design of the CARDIOMIRROR trial
Authors: Jimenez-Blanco Bravo M , Alvarez Garcia J , Del Prado Diaz S , Esteban Fernandez A , Cordero Pereda D , Zamorano Gomez J.L
Published: October 2021

Background

Heart failure (HF) is a growing epidemic, currently affecting more than 26 million people around the globe. Although numerous prognostic markers of death and HF hospitalization have been identified, their clinical applicability is limited and precise risk stratification in HF remains challenging.

Aim

The aim of this project is to develop a software (“intelligent mirror” or CARDIOMIRROR) with the ability to detect significant facial changes in patients with heart failure with reduced ejection fraction (HFrEF). Our main hypothesis is that facial changes will correlate with major adverse cardiovascular events (MACE) in these patients.

Methods

For this purpose, we have designed an observational, prospective, multicenter pilot study, which will include 100 adult ambulatory patients with HFrEF, in NYHA class ≥ II and, at least, one hospitalization due to decompensated HF in the past 12 months or BNP ≥500 pg/ml.

The primary end-point is to analyze the morphological and colorimetric facial changes that occur in patients with HFrEF, and to determine the association between these changes and the presence of MACE at 1 year, including episodes of acute decompensated HF, myocardial infarction, stroke or death.

Secondary end-points include the correlation between facial changes and natriuretic peptides, LVEF, quality of life, NYHA class and daily physical activity.

All patients will be given a Smartphone, and they will be required to take a daily 7-seconds video of their face during 12 months of follow-up. This daily video will be sent to an automatic server for its morphologic and colorimetric analysis by experienced engineers (Figure 1), employing Deep Learning, virtual and augmented Reality, Internet of Things and Data Analytics.

Conclusion

The CARDIOMIRROR study represents a revolutionary strategy, as it involves shifting from a traditional “reactive” model to an innovative “predictive” model, in which medical care anticipates the event in question. Its results could potentially change the conventional approach to HF patients.

Funding Acknowledgement

Type of funding sources: None. Morphologic (left), colorimetric (right)
Linking extracellular inhibitors of Wnt/beta-catenin signaling to carotid intima-media thickness in heart failure with reduced ejection fraction
Authors: Szabo T.M , Fehervari L , Nagy E.E , Frigy A
Published: October 2021

Background

The Wnt/β-catenin signaling pathway plays an important role in endothelial inflammation, vascular calcification, contributing to atherosclerosis development and progression. Sclerostin and Dickkopf-1 (DKK-1) are soluble extracellular canonical Wnt signaling inhibitors frequently associated with atherosclerotic disease.

Purpose

We investigated the possible association between carotid intima-media thickness (cIMT) and circulating levels of sclerostin and DKK-1 in patients with heart failure with reduced ejection fraction (HFrEF).

Methods

65 patients with HFrEF were assigned to one of two groups based on cIMT measurements: 30 patients had normal cIMT, whereas 35 patients showed pathological cIMT. CIMT was assessed by vascular ultrasonography, and values above 0.9 mm were considered abnormal. Serum sclerostin and DKK-1 levels were measured using commercially available ELISA kits. Unpaired t-test and Mann-Whitney test were used for statistical analysis (p<0.05 was considered statistically significant).

Results

Patients belonging to the group with abnormal cIMT were older (70±9 years vs. 57±12 years, p<0.0001), had higher systolic blood pressure (123±16 mm Hg vs. 112±15 mm Hg, p=0.005), and had more often type 2 diabetes mellitus (40.00% vs. 13.33%, p=0.017). Sclerostin levels were significantly higher in the abnormal cIMT population (537.91±816.69 pg/mL vs. 276.37±173.21 pg/mL, p=0.017), whereas serum DKK-1 concentrations did not differ significantly (398.34±218.73 pg/mL vs. 352.35±188.08 pg/mL, p=0.498). The two groups had similar C-reactive protein levels (1.78±2.77 mg/dL vs. 1.88±2.77 mg/dL, p=0.200), estimated glomerular filtration rates (73.60±22.32 mL/min/1.73m2 vs. 66.25±23.69 mL/min/1.73m2, p=0.254) and body mass index (27.58±4.95 kg/m2 vs. 26.65±5.75 kg/m2, p=0.490).

Conclusion

Patients with HFrEF and increased cIMT had elevated levels of serum sclerostin. DKK-1 levels did not increase with the progression of cIMT. Further studies with large sample size are needed to establish the involvement of these proteins in vascular calcification and atherosclerosis in the setting of HFrEF.

Funding Acknowledgement

Type of funding sources: None.
The value of GRACE risk score for predicting mortality in heart failure patients admitted with non-ST elevation acute coronary syndrome
Authors: Bouzas Cruz N , Cordero A , Alvarez-Alvarez B , Bertomeu-Gonzalez V , Gonzalez-Ferrero T , Zuazola P , Garcia-Rodeja F , Martinon-Martinez J , Jimenez-Ramos V , Gomez-Otero I , Diaz-Louzao C , Gude-Sampedro F , Gonzalez-Juanatey J.R
Published: October 2021

Background

Acute coronary syndrome (ACS) in heart failure (HF) patients has not been well studied yet.

Purpose

The main aims of this study were to compare the characteristics and outcomes of Non-ST elevation ACS (NSTACS) in patients with and without prior HF, and to assess the GRACE risk score performance for risk stratification in both groups.

Methods

All consecutive patients (n=5661) admitted due to a NSTACS from November'2003 to November'2017 in two Spanish hospitals were retrospectively analysed. Patients were divided according to prior HF. As GRACE score predicts mortality in 6 months, logistic regression models were used to predict mortality in both groups. The different aspects of model performance were studied, including calibration and discrimination.

Results

Killip class, GRACE and CRUSADE scores were higher in HF-patients compared to patients without prior HF. Also, HF-patients had more complications (major bleeding, worsening HF, acute kidney injury) and higher mortality. Discrimination capacity of GRACE score to predict mortality at 6 months was slightly higher in non-HF patients (AUC 83.9% [81.6–86.2]) than in HF-patients [AUC 77.0% [70.1–83.8]) (Figure 1). The risk score calibration was acceptable for both groups [Brier scores were 0.139 (c-AUC 0,77) for HF-patients, and 0.046 (c-AUC 0.839) for non-HF patients]. Finally, HF-patients with lower GRACE scores had a higher predicted mortality than non-HF patients (Table 1).

Conclusions

We showed the potential utility of GRACE risk score in HF-patients admitted with NSTACS, expanding the indication of GRACE risk score for HF-patients as well. In fact, GRACE risk score not only keeps its accuracy, but it is even more robust in HF-patients than in non-HF patients.

Funding Acknowledgement

Type of funding sources: None. Figure 1Table 1