bluuebunny/crossref_metadata_2025 huggingface dataset:
Myocardial work – new insights from deformation imaging in patients with advanced heart failure
Authors: Spinka G , Bartko P.E , Heitzinger G , Prausmueller S , Pavo N , Arfsten H , Kastl S , Hengstenberg C , Huelsmann M , Goliasch G
Published: November 2020

Background

The evaluation of myocardial contractility appears to be a major determinant for the prognosis and allocation of treatment strategies in advanced systolic heart failure (HFrEF). Non-invasive measurement of myocardial work is currently emerging as a new promising method for the assessment of myocardial contractility, as it additionally accounts for hemodynamic loading conditions of the ventricle.

Objectives

This study sought to assess the prognostic impact of myocardial work in patients with advanced heart failure and to compare it with routinely used deformation imaging parameters.

Methods

We included 234 patients with HFrEF under guideline directed therapy and comprehensively assessed myocardial work, as well as global longitudinal strain (GLS) by speckle tracking echocardiography. The primary endpoint was all-cause mortality.

Results

Median age of the patients was 68 years (IQR 60–75) and 78% were male. Over a 5-year follow-up period, 107 patients died. Median GWI was 526 mmHg% (IQR 366–779) and median GCW was 730 mmHg% (IQR 523–988). Parameters of myocardial work displayed a strong and independent association with long-term mortality, even after careful adjustment for clinical and echocardiographic confounders (Table 1). Additionally, we observed a significantly better calibration towards long-term mortality for GCW compared to GLS as the current golden standard for myocardial deformation imaging (AUC 0.63 vs. 0.60; P=0.007).

Conclusion

This is the first study to comprehensively assess global myocardial work in patients with advanced heart failure. Important treatment decisions rely on the assessment of myocardial contractility and risk stratification, specifically in late stages of the disease where exact guiding of treatment success and timely allocation of more aggressive treatment strategies are warranted. By incorporating loading conditions, myocardial work seems to be able to sensitively detect changes in myocardial contractility thath predict a dismal course of the disease. Furthermore, our data suggests that global constructive work is a more sensitive parameter to predict long-term outcome compared to the currently used echocardiographic deformation imaging parameters (i.e. GLS).

Funding Acknowledgement

Type of funding source: None
Limitations of sexual activity in patients with chronic heart failure
Authors: Barquinha S , Alves J.A , Franco C.F , Trindade M.T , Silva T.P.S , Goncalves A.P.G , Ferreira V.F , Moreira R.M , Timoteo A.T.T , Soares R.S , Ferreira R.F
Published: November 2020

Background

Limitation of sexual activity may potentially have a great impact in the quality of life of patients with chronic heart failure (HF), although the burden of sexual limitation and its clinical drivers are not completely understood. We aimed to characterize the impact of sexual limitation and how it relates to different measures of HF severity, in patients with HF.

Methods

We prospectively selected a cohort of patients followed in our ambulatory HF Clinics, with HF and currently or previously documented left ventricular ejection fraction (LVEF) ≤40%, aged between 18 and 80 years, with NYHA class I-IV. Clinical, laboratorial, imaging and ergometric data was collected. A questionnaire characterizing sexual activity of the patient was filled by her/himself before consultation with the physician, while alone in a private room.

Results

A total of 65 patients were selected, 75% of which were male, with mean age 61±11 years, 32% were in NYHA I or II, and 21% had a resynchronization system. Mean BNP was 520±850 pg/mL, LVEF was 39±12% and peak oxygen consumption (pVO2) was 17.2±5.3 mL/min/m2. Limitations of sexual activity were reported in 40 (62%) patients, including erectile dysfunction (25%), fatigue (11%), reduction of libidum (8%), fear of HF symptoms during sexual activity (5%), absence of sexual partner (5%), and other reasons (8%). Of these 40 patients, 22 (55%) reported severe or very severe sexual limitation. Only 2 (3%) patients actively searched for clinical aid. Patients with sexual limitations were older (63±12 vs 56±11 years), were in higher NYHA classes (One-Way ANNOVA), had higher levels of BNP (775±1051 vs 181±212 pg/mL) and lower glomerular filtration rates (66±19 vs 86±23 mL/min) (all p<0.05). Other major variables such as ischemic etiology, diabetes, resynchronization therapy, LVEF and pVO2 were not associated with the presence or severity of sexual limitations, although there was a numerical trend for lower pVO2 (16.5±5.8 vs 19.0±4.0 mL/l/min/m2, p=0.20). NYHA class ≥II (β 6.5, 95% CI 0.4–10.5) and BNP levels (β 1.03, 95% CI 1.01–1.06) were independent predictors of sexual dysfunction.

Conclusions

Sexual limitation was highly prevalent among patients with HF, was often severe and the most frequent reason was erectile dysfunction. Simple and highly accessible parameters, such as age, NYHA class, BNP levels and renal function, are related to the presence of sexual limitation. More attention should be payed to sexual limitation in patients with HF considering the high burden and the large room for improvement.

Funding Acknowledgement

Type of funding source: None
Association between use of beta-blockers and mortality/morbidity in patients with heart failure with reduced, midrange or preserved ejection fraction and advanced chronic kidney disease
Authors: Fu E , Uijl A , Dekker F.W , Lund L.H , Savarese G , Carrero J.J
Published: November 2020

Background

Beta-blockers reduce mortality and morbidity in patients with heart failure (HF) with reduced ejection fraction (HFrEF). However, patients with advanced chronic kidney disease (CKD) were underrepresented in landmark trials.

Purpose

We evaluated if beta-blockers are associated with improved survival and cardiovascular outcomes in patients with HFrEF and advanced CKD, and if potential benefits of beta-blockers would extend also to HFpEF and HFmrEF with advanced CKD.

Methods

We identified 3906 persons with an ejection fraction <40% and advanced CKD (eGFR <30 mL/min/1.73m2) enrolled in the Swedish Heart Failure Registry during 2001–2016. We did not exclude patients with atrial fibrillation. The associations between beta-blocker use, 5-year all-cause mortality, and the composite of time to cardiovascular (CV) mortality/first HF hospitalization were assessed by multivariable Cox regression. Analyses were adjusted for 36 variables, including demographics, laboratory measures, comorbidities, medication use, medical procedures, and socioeconomic status. To assess consistency, the same analyses were performed in a positive control cohort of 12,673 patients with moderate CKD (eGFR <60–30 mL/min/1.73m2). Analyses were repeated in individuals with HF with preserved ejection fraction (HFpEF; EF ≥50%) or midrange ejection fraction (HFmrEF; EF 40–49%).

Results

In HFrEF and advanced CKD, 89% received beta-blockers. Overall, median (IQR) age was 81 (74–86) years, 36% were women and median eGFR was 26 (20–28) ml/min/1.73m2. During a median of 1.3 years follow-up, 2086 (53.4%) individuals had a subsequent HF hospitalization, and 2954 (75.6%) individuals died, of which 2089 (70.1%) due to cardiovascular causes. Beta-blocker use was associated with a significant reduction in 5-year all-cause mortality [adjusted hazard ratio (HR) 0.86; 95% confidence interval (CI) 0.76–0.96)] and CV mortality/HF hospitalization (HR 0.87; 95% CI 0.77–0.98). The magnitude of the associations between beta-blocker use and outcomes was similar to that observed for HFrEF patients with mild/moderate CKD [all-cause mortality: 0.85 (95% CI 0.78–0.91); CV mortality/HF hospitalization: 0.88 (95% CI 0.82–0.96)]. Adjusted HRs were 0.88 (95% CI 0.77–1.02) and 1.07 (95% CI 0.92–1.24) for individuals with HFpEF and advanced CKD and 0.95 (95% CI 0.80–1.13) and 1.13 (95% CI 0.94–1.36) for individuals with HFmrEF and advanced CKD, for all-cause mortality and CV mortality/HF hospitalization, respectively.

Conclusion

Despite lack of trial evidence, the use of beta-blockers in patients with HFrEF and advanced CKD was high in routine Swedish care, and was independently associated with reduced mortality to the same degree as HFrEF with moderate CKD. However, these benefits were not observed in patients with HFpEF or HFmrEF with severe CKD.

Funding Acknowledgement

Type of funding source: None
Donepezil markedly prevents the progression of chronic heart failure and renal dysfunction in renal artery stenosis-induced hypertensive rats
Authors: Li M , Zheng C , Kawada T , Uemura K , Inagaki M , Nishikawa T , Sugimachi M
Published: November 2020

Introduction

Parasympathetic activation by donepezil has been shown to improve prognosis in chronic heart failure (CHF) rats following myocardial infarction. We examined whether donepezil is effective in the treatment of another CHF model complicated with renal artery stenosis (RAS)-induced hypertension.

Methods

RAS was created by ligating the left renal artery up to 50% in SD rats, at the same time, we implanted a blood pressure (BP) transmitter for confirming RAS-induced hypertension (7-week post-RAS: systolic BP = 154±7 mmHg; diastolic BP = 115±8 mmHg). In the 11th week after induction of RAS, surviving animals were randomly assigned to untreated (UT, n=10) or donepezil treated [DT, n=10, dissolved in drinking water (3mg/kg/day)] group. After a 6-week treatment, the effects of donepezil were evaluated by hemodynamics, blood levels of neurohumoral markers, and morphology.

Results

Compared with UT, DT significantly prevented the progression of the left kidney atrophy (2.38±0.13 vs. 1.51±0.34 g/kg, P<0.05) and kidney fibrosis (left: −64%, P<0.001; right: −55%, P<0.01). DT also significantly prevented the progression of CHF, through suppressing cardiac hypertrophy (2.30±0.06 vs. 2.57±0.08 g/kg, P<0.01), cardiac fibrosis (−70%, P<0.01), and cardiac dysfunction [cardiac index: 102±3 vs. 86±3 ml/min/kg, P<0.05; left ventricular (LV) end-diastolic pressure: 12±2 vs. 20±2 mmHg, P<0.05; LV dp/dtmin: 5856±259 vs. 4924±227 mmHg/sec, P<0.05]. DT not only decreased serum levels of creatinine (0.54±0.02 vs. 0.63±0.03 mg/dl, P<0.05) and uric acid (1.4±0.2 vs. 1.9±0.2 mg/dl, P<0.05); but also decreased plasma levels of norepinephrine (273±38 vs. 846±242, P<0.01), AVP (2729±347 vs. 4783±695 pg/ml, P<0.05), BNP (360±13 vs. 460±39 pg/ml, P<0.05), angiotensin II and aldosteron, and suppressed the systemic inflammation.

Conclusions

Donepezil treatment markedly prevented the progression of CHF and renal dysfunction, and improved the neurohumoral markers in the CHF rat model complicated with RAS-induced hypertension, suggesting that donepezil may be used as a new pharmacotherapy for CHF patients complicated with RAS-induced hypertension.

Funding Acknowledgement

Type of funding source: None
Serum uric acid, influence of sacubitril/valsartan, and cardiovascular outcomes in heart failure with preserved ejection fraction: PARAGON-HF
Authors: Selvaraj S , Claggett B.L , Veldhuisen D.V , Anand I.S , Pieske B , Rouleau J.L , Zile M.R , Shi V.C , Lefkowitz M.P , McMurray J.J.V , Solomon S.D
Published: November 2020

Background

Serum uric acid (SUA) is a biomarker of several pathobiologies relevant to the pathogenesis of heart failure with preserved ejection fraction (HFpEF), though by itself may also worsen outcomes. In HF with reduced EF, SUA is independently associated with adverse outcomes and sacubitril/valsartan reduces SUA compared to enalapril. These effects in HFpEF have not been delineated.

Purpose

To determine the prognostic value of SUA, relationship of change in SUA to quality of life and outcomes, and influence of sacubitril/valsartan on SUA in HFpEF.

Methods

We analyzed 4,795 participants from the Prospective Comparison of ARNI with ARB Global Outcomes in HF with Preserved Ejection Fraction (PARAGON-HF) trial. We related baseline hyperuricemia to the primary outcome (CV death and total HF hospitalization), its components, myocardial infarction or stroke, and a renal composite outcome. At the 4-month visit, the relationship between SUA change and Kansas City Cardiomyopathy Questionnaire overall summary score (KCCQ-OSS) and several biomarkers including N-terminal pro-B-type natriuretic peptide (NT-proBNP) were also assessed. We simultaneously adjusted for baseline and time-updated SUA to determine whether lowering SUA was associated with clinical benefit.

Results

Average age was 73±8 years and 52% were women. After multivariable adjustment, hyperuricemia was associated with increased risk for most outcomes (primary outcome HR 1.61, 95% CI 1.37, 1.90, Fig 1A). The treatment effect of sacubitril/valsartan for the primary outcome was not modified by baseline SUA (interaction p=0.11). Sacubitril/valsartan reduced SUA −0.38 mg/dL (95% CI: −0.45, −0.31) compared with valsartan (Fig 1B), with greater effect in those with baseline hyperuricemia (−0.50 mg/dL) (interaction p=0.013). Change in SUA was independently and inversely associated with change in KCCQ-OSS (p=0.019) and eGFR (p<0.001), but not NT-proBNP (p=0.52). Time-updated SUA was a stronger predictor of adverse outcomes over baseline SUA.

Conclusions

SUA independently predicts adverse outcomes in HFpEF. Sacubitril/valsartan significantly reduces SUA compared to valsartan, an effect that was stronger in those with higher baseline SUA, and reducing SUA was associated with improved outcomes.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis
Right ventricular free wall strain and effect of implantable defibrillator in non-ischemic heart failure
Authors: Jensen D.H , Elming M.B , Risum R , Haarbo J , Philbert B , Svendsen J.H , Pehrson S , Kober L , Thune J.J
Published: November 2020

Background

Patients with left ventricular systolic heart failure have a significantly increased risk of all-cause mortality and sudden cardiac death. A cardiac magnetic resonance (CMR) sub-study of the Danish Study to Assess the Efficacy of Implantable Cardioverter Defibrillators (ICDs) in Patients with Nonischemic Systolic Heart Failure on Mortality (DANISH) trial found that in patients who also had reduced right ventricular ejection fraction, ICD implantation significantly increased survival. Recent studies have found that right ventricular free wall strain (RV-FWS) assessed by echocardiography has a similar prognostic power as right ventricular ejection fraction assessed by CMR and RV-FWS determined by echocardiographic may be a more accessible imaging modality to identify patients more likely to benefit from ICD implantation.

Purpose

To investigate if echocardiographic RV-FWS is related to risk of all-cause death in patients with heart failure and left ventricular systolic dysfunction and whether RV-FWS can identify a sub-group of patients more likely to benefit from ICD implantation.

Methods

RV-FWS was measured in 343 patients with left ventricular systolic heart failure included in the DANISH trial at our hospital, who underwent an echocardiographic examination before randomization. Cox regression was used to assess the effects of RV-FWS and ICD implantation on all-cause mortality. Impaired RV-FWS was defined as RV-FWS >−20% according to guidelines.

Results

Median RV-FWS was −19% (quartiles: −24% to −14%). Impaired RV-FWS was present in 186 (54%) patients, and 70 (20.4%) patients died. RV-FWS was related to all-cause mortality both univariably, hazard ratio (HR) 1.07 (95% confidence interval [CI], 1.03–1.11), P=0.001, and adjusted for age, gender, tricuspid annular plane systolic excursion and left ventricular ejection fraction, HR 1.06 (95% CI 1.01–1.10), P=0.009. There was a significant interaction between impaired RV-FWS and effect of ICD, P for interaction=0.045 and ICD implantation significantly reduced mortality in patients with impaired RV-FWS, HR 0.52 (95% CI 0.28–0.96), P=0.04, but not in patients with normal RV-FWS, HR 1.34 (95% CI 0.64–2.82), P=0.44.

Conclusion

RV-FWS was independently related to all-cause mortality and associated with effect of ICD implantation. With validation in larger studies, impaired RV-FWS may potentially become a candidate for selecting patients for ICD implantation.

Impaired RVFWS and effect of ICD

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Danish Heart Foundation
First-phase ejection fraction predicts response to cardiac resynchronization therapy and adverse outcomes
Authors: Gu H , Baldeep S , Fang L , Webb J , Jackson T , Claridge S , Razavi R , Chowienczyk P , Rinaldi C
Published: November 2020

Background

Cardiac Resynchronization Therapy (CRT) is an important therapeutic treatment for chronic heart failure. However, even in carefully selected cases up to 40% of patient fail to respond. First-phase ejection fraction (EF1), the ejection fraction up to the time of maximal ventricular contraction, is a novel and more sensitive echocardiographic measure of early systolic function.

Purpose

We examined the value of EF1, to predict response to CRT and clinical outcomes after CRT.

Methods

We analysed echocardiograms from 197 patients who underwent CRT between 2009 and 2018 and were followed to determine clinical outcomes.

Results

Volumetric response rate (reduction in end-systolic volume ≥15%) was 92.3% vs. 12.1%, for those with EF1 in the highest vs. lowest tertiles (p<0.001). A cut-off value of 11.9% for EF1 had >85% sensitivity and specificity for prediction of response to CRT; on multivariate logistic regression analysis incorporating previously defined predictors, EF1 was the strongest predictor of response (OR: 1.563, 95% CI: 1.371–1.782, p<0.001) (table 1). EF1 was also the strongest predictor of a clinical composite score (OR: 1.115, 95% CI: 1.044–1.191, p=0.001). Improvement in EF1 at 6 months after CRT implantation (6.5±5.8% vs 1.8±4.3% in responders vs. non-responders, p<0.001) was the best predictor of heart failure re-hospitalization and death after median follow-up of 29.2 months (HR: 0.819, 95% CI:0.765–0.876, p<0.001).

Conclusion

EF1 is a promising marker to identify patients likely to respond to CRT and most likely provides a measure of myocardial viability that determines response.

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): British Heart Foundation, Wellcome/EPSRC Centre for Medical Engineering
Validation of the EUROMACS right-sided heart failure risk score in left ventricular assist device patients: a single center experience
Authors: Valente F , Vachiery J.L , Dewachter C , Stefanidis C , Vanden Eyden F , De Maertelaer V , Roussoulieres A
Published: November 2020

Background

Right Heart failure (RHF) is a severe complication after left ventricular assist device (LVAD) implantation, increasing early and late mortality. A simple 5-item score, the EUROMACS-RHF risk score, was developed to predict early RHF and mortality after implantation.

Purpose

The aim of the study was to investigate whether EUROMACS-RHF risk score was applicable in a single center to predict early (<30 days) post-operative RHF.

Methods

From February 2011 to October 2019 all LVAD implanted patients in our institution were retrospectively reviewed. Only patients with complete data for risk score calculation and RHF analysis were included. Baseline characteristics and hospitalization data, including preoperative clinical, biological, echocardiographic and hemodynamic data were obtained. Based on these informations, EUROMACS-RHF risk score was calculated and classified in low, intermediate and high.

The link between the EUROMACS-RHF risk score and early severe RHF was investigated using Pearson's exact chi-square tests.

Results

The analysis included 88 patients (67 males; 49±2 years). Etiology of HF was ischemic in 36 patients (41%), dilated cardiomyopathy in 21 (24%) and others causes in 31 (35%). A Heart Ware LVAD (94%) was implanted as bridge to transplantation in 96% of the patients; 81 patients (90%) had severe INTERMACS (1–3) profile.

RHF was identified in 21 patients (24.1%), of which 15 (18%) were treated with inotropes for ≥14 days, 8 (9%) had an RVAD, and 11 (13%) were treated with inhaled NO for ≥48 hours. Patients with severe RHF had a significantly longer length of ICU stay compared to patients without (median 20 days versus 6,5 days). The early (<30 days) post-operatory mortality was of 43% (n=9/21) in the RHF group and 6% (n=4/69) in patients without RHF (p<0.001). Three of the twelve patients alive in the RHF group had an emergency transplant.

The prediction of RHF from the EUROMACS-RHF risk score and the observed severe RHF are presented in the table. A high preoperative EUROMACS-RHF score was able to predict the presence of RHF in 52% of patients (p=0.005), while a low score predicted the absence of RHF in 52% of patients (p<0.001). In contrast, an intermediate EUROMACS risk score was not found to predict early RHF (p=0.283).

Conclusion

In our cohort, the EUROMACS-RHF risk score was effective in predicting early severe RHF, in particular for patients with preoperatory low (no RHF) and high (RHF) scores. This external validation confirms the clinical usefulness in risk prediction before LVAD implantation.

Figure 1

Funding Acknowledgement

Type of funding source: None
Three-year outcomes of selective incomplete versus complete revascularization in heart failure patients receiving multivessel percutaneous coronary intervention
Authors: Chang C , Hsieh M , Chen D , Chen C , Hsieh I
Published: November 2020

Background

Heart failure (HF) patients with multi-vessel disease (MVD) are often associated with comorbidities to limit the possibility to achieve complete revascularization (CR) in percutaneous coronary intervention (PCI). The planned selective incomplete revascularization (SIR) may be an alternative opinion for these patients.

Purpose

To investigate 3-year clinical outcomes of SIR versus CR in HF patients with MVD in a real-word registry.

Methods

A total of 566 HF patients with MVD receiving either SIR or CR were enrolled. SIR was planned pre-PCI based on clinical exams to avoid non-viable tissue revascularization. Major adverse cardiac events (MACEs) was a composite of in-hospital death, recurrent myocardial infarction, any revascularization, and all-cause death at 3-year follow-up.

Results

There was no significant differences between SIR and CR groups in in-hospital death, any revascularization, all-cause death and MACEs (24.3% vs. 24.9%, p=0.922). However, SIR had a significant lower incidence of recurrent myocardial infarction than CR (3.2% vs. 7.2%, p=0.032).

Conclusion

The 3-year outcomes of PCI with planned SIR were completely comparable to with CR in HF patients with MVD. Planned SIR can be an opinion for HF patients with MVD who are not suitable to achieve CR.

Kaplan-Meier curve of 3-year MACEs

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Chang Gung Medical Research Program
Social frailty provides additive prognostic impact on one-year outcome in aged patients with congestive heart failure
Authors: Jujo K , Kagiyama N , Kamiya K , Saito H , Saito K , Ogasahara Y , Maekawa E , Konishi M , Kitai T , Iwata K , Wada H , Kasai T , Nagamatsu H , Ozawa T , Matsue Y
Published: November 2020

Background

Frailty is associated with multisystem declines in physiologic reserve and increased vulnerability to stressors, resulting in increased risks of adverse clinical outcomes in patients with heart failure (HF). Although frailty is conceptualized as an accumulation of deficits in multiple areas, most of the studies have focused mainly on physical frailty, and the social domains is one of the least investigated area.

Objectives

We prospectively evaluated the incidence and prognostic implication of social frailty (SF) in older patients with HF.

Methods

The FRAGILE-HF is a multicenter, prospective cohort study including patients hospitalized for HF and aged ≥65 years old. We defined SF by Makizako's 5 items, which are 5 questions proposed and validated to be associated with future disability. The primary endpoint of this study was a composite of death from any cause and rehospitalization due to HF. The impact of SF on all-cause mortality alone was also evaluated.

Results

Among 1,240 hospitalized HF patients, 5 simple questions revealed that 825 (66.5%) were in SF. During 1-year observation period after the discharge, the combined endpoint was observed in 399 (32.2%) patients, and 145 (11.7%) patients died. Kaplan-Meier analysis showed that SF patients had significantly higher rates of both the combined endpoint and all-cause mortality than those without SF (Log-rank test: p<0.05 for both, Figures). Moreover, SF remained independently associated with higher event rate of the combined endpoint (hazard ratio: 1.30; 95% confidence interval: 1.02 to 1.66; p=0.038) and all-cause mortality (hazard ratio: 1.53; 95% confidence interval: 1.01 to 2.30; p=0.044), even after adjusting for other covariates. Significant incremental prognostic value was shown when information on social frailty was added to known risk factors for combined endpoint (NRI: 0.189, 95% confidence interval: 0.063–0.316, p=0.003) and all-cause mortality (NRI: 0.234, 95% confidence interval: 0.073–0.395, p=0.004).

Conclusions

Among older hospitalized patients with heart failure, two-thirds of the population was with SF. Evaluating SF provides additive prognostic information in elderly patients with heart failure.

Funding Acknowledgement

Type of funding source: Private grant(s) and/or Sponsorship. Main funding source(s): Novartis Pharma Research Grants, Japan Heart Foundation Research Grant
The integrated role of NT-pro BNP and STE-GLS for the early detection of chemotherapy-induced cardiotoxicity
Authors: Youssef G , Sulaiman L , Hisham D , Abdel Hamid M
Published: November 2020

Background

Chemotherapeutic agents, used for the treatment of breast cancer, have many side effects, among them is cardiomyopathy. Ejection fraction (EF) is fails to detect the subtle alterations of left ventricular (LV) function. There comes the need for a more sensitive tool for the detection of preclinical chemotherapy-induced cardiomyopathy.

Aim

Detection of subclinical LV systolic dysfunction in breast cancer patients after 6 weeks of the initiation of their chemotherapeutic treatment, using N-terminal pro brain natriuretic peptide (NT-proBNP) plasma level as well as Speckle tracking echo-global longitudinal strain (STE-GLS).

Methods

Seventy-four asymptomatic, non-metastasizing breast cancer female patients were included. They were assessed before taking their first chemotherapeutic session and 6 weeks thereafter. Assessment included baseline clinical characteristics, conventional two-dimensional (2D) as well as three-dimensional (3D) echocardiography. Loops of different apical views were recorded for later offline STE-GLS analysis. Blood samples for NT-BNP plasma level were collected before and 6 weeks after the initiation of chemotherapy. Samples were later analyzed using a Sandwich ELISA technique.

Results

The median NT-proBNP almost doubled after 6 weeks of chemotherapy (73.50 vs 34.4 pg/L, p value <0.001). One patient died before her scheduled follow up visit, and the cause of death is unknown. Fifty patients showed NT-proBNP elevation at their follow up, compared to the baseline visit, 22 (44%) of them had worse (less negative) LV-GLS in their follow up visit. Five patients had an abnormally elevated NT-proBNP plasma level, all of them had a worse follow up LV-GLS. Only two patients showed significant reduction of LVEF >10% to less <53% (chemotherapy-induced cardiotoxicity) but their NT-proBNP did not exceed the cutoff limit.

Conclusion

The integration of LV-GLS and NT-proBNP is useful in the diagnosis of subclinical, subtle chemotherapy-induced cardiotoxicity. Early detection will prompt early cardioprotective measures and thus helps improving the clinical outcomes.

Funding Acknowledgement

Type of funding source: None
Natural history and prognostic significance of anaemia and iron deficiency in ambulatory patients with heart failure
Authors: Graham F.J , Masini G , Pellicori P , Cleland J.G.F , Kazmi S , Clark A.L
Published: November 2020

Background

Anaemia and iron deficiency (ID) are both common and associated with adverse outcomes in patients with heart failure (HF). However, the incidence of and recovery from anaemia and ID and their impact on prognosis are not well described.

Methods

Between 2001 and 2018, patients with suspected HF referred to a clinic serving a local population of ∼500,000 were invited to be enrolled in a long-term registry. HF was defined as relevant symptoms or signs with either at least moderate systolic dysfunction on echocardiography or raised plasma concentration of amino-terminal pro-B type natriuretic peptide (NT-proBNP ≥125pg/ml). ID was defined as a transferrin saturation (TSAT) of <20%, anaemia was defined as a haemoglobin (Hb) of <13.0 g/dL in men and <12.0 g/dL in women. At 1-year follow-up, 872 patients had repeat assessments for ID. Patients were grouped into four phenotypes according to the presence or absence of anaemia and/or ID. Those who developed or recovered from ID and anaemia were assessed separately. Survival analysis was conducted at 5 years after the one-year visit.

Results

The prevalence of ID and anaemia at baseline was 40% and 29% respectively. At baseline and at one-year, 53% of patients had either ID, anaemia or both. Compared to other groups, those with both anaemia and ID were older, had worse renal function and higher median NT-proBNP. In patients with TSAT >20% without anaemia at baseline, 23% had ID at 1 year, 14% were anaemic and 6% developed both. At one year, 11% of patients with anaemia and ID at baseline had normal values for both compared to 16% of those with anaemia but not ID. In patients with ID without anaemia at baseline, 51% remained iron deficient at one year, irrespective of initial Hb.

At 5-years, survival was markedly worse for those with anaemia at baseline compared to those without anaemia, irrespective of iron status. Compared to those who had normal TSATs and Hb, those with both anaemia and ID had the worst survival (HR=2.35; 1.77–3.11; p<0.001), followed by those with anaemia without ID (HR=1.93; 1.40–2.67; p<0.001) and those with isolated ID (HR=1.34; 1.01–1.78; p=0.046).

Compared to patients who never had anaemia or ID, patients who developed (HR 2.01; 1.41–2.88; p<0.001) or recovered from (HR 2.21; 1.45–3.39; p<0.001) anaemia or ID (HR 1.61; 1.14–2.28; 0.007 and HR 1.63; 1.16–2.28; 0.005 respectively) had a worse prognosis.

Conclusions

About 30% of patients with HF who have neither anaemia nor ID will develop such problems within a year and this associated with a worse prognosis. Recovery from ID and anaemia is also common, but this is not associated with a better prognosis. Factors leading to the development of anaemia and ID may be driving prognosis rather than anaemia and ID themselves

Funding Acknowledgement

Type of funding source: None
Comparative prognostic impact of ACCI and AHEAD risk score in heart failure with reduced, mid-range and preserved left ventricular ejection fraction admitted for acute decompensated heart failure
Authors: Kayama K , Yamada T , Watanabe T , Morita T , Furukawa Y , Tamaki S , Kawasaki M , Kikuchi A , Kawai T , Seo M , Nakamura J , Kawahira M , Fukunami M
Published: November 2020

Background

Comorbidities are strongly associated with poor clinical outcome in heart failure patients (pts). The Age-adjusted Charlson comorbidity index (ACCI), which is well-known widely used comorbidity index, recently has been used as a robust prognostic model in heart failure pts. On the other hand, AHEAD risk score has been recently reported as a useful long-term risk stratification score in acute decompensated heart failure (ADHF) pts. Recently, a new group of heart failure pts with mid-range ejection fraction (HFmrEF) has been defined, separated from reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF). We sought to compare the prognostic value of ACCI and AHEAD score in ADHF pts, relating to HFrEF, HFmrEF and HFpEF.

Methods

We prospectively studied 410 consecutive ADHF pts (HFrEF [n=143], HFmrEF [n=99] and HFpEF [n=168]) with survival discharge. ACCI contains 19 issues which was weighted according to their potential influence on mortality. AHEAD risk score is a simple index, which is range 0–5; atrial fibrillation, hemoglobin <13 mg/dL for men and 12 mg/dL for women, age >70 years, creatinine >130 μmol/L, and diabetes mellitus. The endpoint of this study was all cause death (ACD).

Results

During a follow-up period of 2.4±1.4 years, 119 pts had ACD (42, 29 and 48 pts in HFrEF, HFmrEF and HFpEF, respectively). At univariate Cox analysis, ACCI and AHEAD risk score were significantly associated with ACD in each subgroup. At multivariate Cox analysis, in HFrEF pts, ACCI, but not AHEAD risk score, showed the significant and independent association with ACD. In HFmrEF, both ACCI and AHEAD risk score was significantly and independently associated with ACD and ROC analysis showed AUC of ACCI was greater than that of AHEAD risk score (0.778 [0.683–0.855] vs 0.637 [0.572–0.764], p=0.07). On the other hand, in HFpEF pts, AHEAD risk score, but not ACCI, showed the significant and independent association ACD.

Conclusion

ACCI provides more prognostic value in HFrEF pts, and AHEAD risk score has more prognostic value in HFpEF pts. In HFmrEF pts, both ACCI and AHEAD score might have prognostic values, although ACCI tends to be more associated with ACD than AHEAD score.

Funding Acknowledgement

Type of funding source: None
Is hypocapnia a risk factor for non-invasive ventilation failure in acute heart failure?
Authors: Carrillo-Aleman L , Montenegto Moure A , Lopez Gomez L , Bayoumi Delis P.S , Agamez Luengas A.A , Higon Canigral A , Casado Mansilla D , Carrasco Gonzalez E , Tornero Yepez P , Martinez Perez V , Carrillo Alcaraz A
Published: November 2020

Introduction

Non-invasive ventilation (NIV) has become a standard treatment for acute respiratory failure. Multiple factors associated with failure of this ventilatory technique have been described. Some authors postulate that the presence of hypocapnia at the onset of NIV increases the mortality of patients with acute heart failure (AHF).

Purpose

To analyse whether the presence of hypocapnia is a risk factor for failure of NIV in the patient with AHF.

Methods

Observational, retrospective study on a prospective database. All patients with AHF admitted to Intensitive Care Unit (ICU) between January 1997 and December 2017 for respiratory failure and requiring NIV are included. The inclusion criteria were the presence of dyspnea, respiratory rate ≥30 and PaO2/FiO2 <250 mmHg. The exclusion criteria were the presence of cardiogenic shock and AHF due to involvement of the right ventricle. Hypocapnia is defined as the presence of PaCO2 <35 mmHg) in basal gasometry prior to NIV, normocapnia as PaCO2 between 35 and 45 mmHg and PaCO2 hypercapnia greater than 45 mmHg. NIV failure is defined as the need for endotracheal intubation or death in ICU. Quantitative variables are expressed as means ± standard deviation, and qualitative variables as percentages. Comparison between variables has been made using the Ji2 linear trend test and single factor ANOVA. Multivariate analysis was performed using logistic regression with the calculation of odds ratios (OR) and their 95% confidence intervals (CI-95%).

Results

A total of 1009 patients with AHF, 158 (15.7%) normocapnic, 361 (35.8%) hypocapnic and 490 (48.5%) hypercapnic were analyzed. The age in the 3 groups was 73.3±10.4, 73.3±11.2 and 75.6±8.9 years (p=0.001), respectively. In the normocapnic group the respiratory rate was 36±4, PaCO2 40±3 and PaO2/FiO2 125±31. In the hypocapnic group 37±3, 28±3 and 134±30; and in the hypercapnic group 37±6, 65±16 and 126±36, respectively. NIV failure was observed in 15 (9.5%) of normocapnic patients, 56 (15.5%) of hypocapnic patients and 54 (11%) of hypercapnic patients (p=0.070). Independent risk factors for NIV failure were SAPS II (OR=1.07, CI-95%=1.04–1.09), order of non-intubation (OR=2.88, CI-95%=1.45–1.81), baseline SOFA (OR=1.76, CI-95%=1.48–2.08), HACOR index at 1 hour NIV (OR=1,62, CI-95%=1.45–1.08), the presence of acute coronary syndrome (OR=2.18, CI-95%=1.18–4.01), the presence of NIV-related complication (OR=6.42, CI-95%=3.47–11.89) and hypocapnia at the onset of NIV (OR=3.842, CI-95%=2.02–7.27).

Conclusions

Hypocapnia at the beginning of NIV in the patient with AHF is a frequent finding. Among the risk factors for poor prognosis, the presence of hypocapnia is a strong predictor of NIV failure.

Funding Acknowledgement

Type of funding source: None
Ischemic heart disease is more prevalent in low-income-countries and more often undertreated: data from report-hf
Authors: Tromp J , Bamadhaj S , Cleland J.G.F , Angermann C.E , Dahlstrom U , Ertl G , Hassanein M , Perrone S.V , Ghadanfar M , Schweizer A , Obergfell A , Collins S.P , Filipatos G.F , Lam C.S.P , Dickstein K
Published: November 2020

Background

The pathogenic role of ischemic heart disease (IHD) in heart failure is well known. However, little is known about the global differences in the prognostic significance and treatment patterns of IHD in acute heart failure (AHF).

Methods

We prospectively enrolled 18,553 patients with AHF from 44 countries and 365 centers in the REPORT-HF registry. Patients with a history of coronary artery disease, an ischemic etiology of the AHF event or coronary revascularization were classified as IHD. Differences in clinical characteristics, treatment and outcome were analyzed.

Results

Compared to 9,344 (50%) patients without IHD, the 9,189 (50%) patients with IHD were older, more often had a left ventricular ejection fraction [LVEF] <40%, (HFrEF) and decompensated chronic HF (DCHF) and had a greater comorbidity burden. Despite patients from lower-income countries having a higher prevalence of IHD (55% vs. 45% in high-income countries), only 27% of patients with IHD from low-income countries were treated with medicines commonly prescribed for HF (Figure A) compared to 16% of patients with IHD from high income countries. After correction for clinical confounders and medication use, patients with IHD had a shorter “door-to-nitrates and -diuretics time” and worse 1-year mortality (hazard ratio: 1.18, 95% CI: 1.09, 1.27, Figure B) irrespective of geographic region (Pinteraction >0.1). We found a significant interaction for prognosis (Pinteraction <0.001) between IHD and HF diagnosis (DCHF vs. new-onset HF) as well as HF subtype (HFrEF vs. HF with preserved ejection fraction) respectively, such that IHD conveyed worse outcomes in patients with new-onset HF and HFrEF respectively in all world regions.

Conclusion

In this large global contemporary cohort of patients with AHF, IHD was more common in patients from low income countries, conveyed worse 1-year mortality, particularly in patients with new onset HF and patients with HFrEF. Despite worse outcomes, patients in regions with the greatest burden of IHD were more often undertreated.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Novartis
Change in high-sensitivity troponin t levels and 1-year outcomes in patients with acute heart failure: China PEACE prospective heart failure study
Authors: Li J , Zhang L , Wu C
Published: November 2020

Background

High-sensitivity cardiac troponin T (hs-cTnT) is an important prognostic marker in heart failure (HF). However, it is unclear whether the change of hs-cTnT levels can predict long-term clinical outcomes in patients with acute HF.

Purpose

To examine the association between change in hs-cTnT from hospital admission to 1-month after discharge and subsequent 1-year cardiovascular death or HF hospitalization in patients with acute HF.

Methods

We included patients hospitalized primarily for HF from 52 hospitals in China, who had central analysis of hs-cTnT at both admission and 1-month after discharge. Change in hs-cTnT was calculated as hs-cTnT level at 1-month minors that at admission. The composite outcome measure was cardiovascular death or HF hospitalization within 1 year after discharge. We tested the linearity assumption between change in hs-cTnT level and the composite events using restricted cubic splines. To further explore the quantitative association between change in hs-cTNT and the events, we also applied a Cox proportional hazards model using change in hs-cTNT as a continuous variable, adjusting for hs-cTnT level at admission (log transformed) and known prognostic variables.

Results

We included 2355 patients hospitalized primarily for HF. Median change in hs-cTnT from baseline was −2.7ng/L (IQR −9 to 0.7). 614 (26.1%) patients experienced the events of cardiovascular death or HF hospitalization within 1 year. Among patients with hs-cTnT <14ng/L (the upper limit of the reference value) at admission, patients had low risk of the events regardless whether hs-cTNT ≥14ng/L at 1-month or not (20.2% vs. 14.1%, p=0.11). Among patients with hs-cTnT ≥14ng/L at admission, patients with hs-cTNT ≥14ng/L at 1-month had higher risk of the events than those with hs-cTnT <14ng/L (36.4% vs. 18.6%, p<0.0001). The association between change in hs-cTnT and the events was non-linear. When change in hs-cTnT was <4ng/L and >−4ng/L, per 1 ng/L decrease was associated with a 7% reduction in risk of the events [hazard ratio (HR) 0.93, 95% CI 0.88–0.99]. When change in hs-cTnT was <−4ng/L, there was a levelling off in the reduced risk (HR: 0.99, 95% CI 0.99–1.00). While change in hs-cTnT was >4ng/L, it was not significantly associated with the events any longer (Figure 1).

Conclusion

Among patients hospitalized for HF, changes in hs-cTnT from admission to 1 month can predict the risk of cardiovascular death and HF hospitalization.

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): The National Key Research and Development Program from the Ministry of Science and Technology of China; the CAMS Innovation Fund for Medical Science; the 111 Project from the Ministry of Education of China
Serial echocardiographical assessment for urgent control of rapid atrial fibrillation in acute heart failure
Authors: Iwahashi N , Kirigaya J , Horii M , Hanajima Y , Abe T , Akiyama E , Okada K , Matsuzawa Y , Maejima N , Hibi K , Kosuge M , Ebina T , Tamura K , Kimura K
Published: November 2020

Objectives

Doppler echocardiography is a well-recognized technique for noninvasive evaluation; however, little is known about its efficacy in patients with rapid atrial fibrillation (AF) accompanied by acute decompensated heart failure (ADHF). The aim of this study was to explore the usefulness of serial echocardiographical assessment for rapid AF patients with ADHF.

Patients

A total of 110 ADHF patients with reduced ejection fraction (HFrEF) and rapid AF who were admitted to the CCU unit and received landiolol treatmentto decrease the heart rate (HR) to <110 bpm and change HR (ΔHR) of >20% within 24 hours were enrolled.

Interventions

Immediately after admission, the patients (n=110) received landiolol, and its dose was increased to the maximum; then, we repeatedly performed echocardiography. Among them, 39 patients were monitored using invasive right heart catheterization (RHC) simultaneously with echocardiography.

Measurements and main results

There were significant relationships between Doppler and RHC parameters through the landiolol treatment (Figure, baseline–max HR treatment). We observed for the major adverse events (MAE) during initial hospitalization, which included cardiac death, HF prolongation (required intravenous treatment at 30 days), and worsening renal function (WRF). MAE occurred in 44 patients, and logistic regression analyses showed that the mean left atrial pressure (mLAP)-Doppler (odds ratio = 1.132, 95% confidence interval [CI]: 1.05–1.23, p=0.0004) and stroke volume (SV)-Doppler (odds ratio = 0.93, 95% confidence interval [CI]: 0.89–0.97, p=0.001) at 24 hours were the significant predictors for MAE, and multivariate analysis showed that mLAP-Doppler was the strongest predictor (odds ratio = 1.16, 95% CI: 0.107–1.27, p=0.0005) (Table).

Conclusions

During the control of the rapid AF in HFrEF patients withADHF, echocardiography was useful to assess their hemodynamic condition, even at bedside.

Doppler for rapid AF of ADHF

Funding Acknowledgement

Type of funding source: None
Monitoring stroke volume changes in acute heart failure patients
Authors: Barki M , Losito M , Caracciolo M.M , Bandera F , Rovida M , Alfonzetti E , Guazzi M
Published: November 2020

Background

Stroke volume (SV) is the net result of cardiac dynamics and functional capacity. Notably, acute decompensated heart failure (ADHF) patients admitted highly congested and with a reduced SV (primarily wet and cold phenotype) exhibit a poorer prognosis. However, how SV may change in wet and warm phenotype during acute hospital setting remains undefined.

Purpose

To evaluate, in a cohort of ADHF patients, the pattern of SV changes during hospitalization.

Methods

Eighty-one ADHF patients (mean age 75.75±10.6 years, 59% males) warm and wet phenotype were prospectively enrolled within 24–48 hours from admission to the emergency department. In either the acute phase and at pre-discharge all patients underwent M-Mode, 2-Dimensions, Doppler and Speckle Tracking echocardiography (STE). SV and SV indexed (SVi) were estimated using the non-invasive doppler method multiplying the left ventricular outflow tract (LVOT) cross-sectional area (CSA) and the velocity time-integral (VTI) of the LVOT.

Results

From admission to discharge, despite a targeted decongestion we observed only minimal and non-significant changes in the average SV and SVi (SV: from 46.9±14.7 ml at admission to 47.2±15.12 at discharge, p=0.9; SVi: from 26.6±8.5 ml/m2 at admission to 27.1±8.4 ml/m2 at discharge, p=0.73). When we looked at those patients improving (Group I) vs non improving SV (Group II) we observed that subjects in Group I exhibited a significantly lower prevalence of mitral regurgitation (MR) both at admission (Group I: MR adm. 23% vs Group II: MR adm: 53% p<0.05) and at the pre-discharge (Group I: MR disch. 13.4% vs Group II: MR disch. 45% p<0.05), a significantly higher global peak atrial longitudinal strain (GPALS) at pre-discharge (Group I: GPALS disch. 17.25±6.5% vs Group II disch. 11±7.1%; p=0.04), along with a significantly greater improvement in terms of GPALS (ΔGPLAS) during hospitalization (Group I: from 13±6.9% to 17.25±6.5%, p=0.04; Group II: from 13.85±8.4% to 11±7.1%, p=0.6) (Figure 1). Interestingly, when evaluated with Pearson's coefficient, in the whole population a significant direct correlation was observed between ΔSV and ΔGPALS (r=0.67 95% CI 0.4–0.7, p<0.001) (Figure 2).

Conclusions

In ADHF patients, the wet and warm phenotype displays a decreased forward SV which does not improve after decongestion therapy on average variations. In this context, the coexistence of LA impairment and hemodynamically significant MR seems to play a key role whereas, LA functional properties recover at least in part in patients who are able to show a SV improvement. Further analysis are necessary to test whether a lack of SV improvement in the short term may impact the long-term outcome.

Funding Acknowledgement

Type of funding source: None