bluuebunny/crossref_metadata_2025 huggingface dataset:
Left and right ventricular function alterations in obstructive sleep apnea patients assessed by 2D speckle tracking echocardiography
Authors: Tamulenaite E , Kondrataviciene L , Miliauskas S , Ereminiene E
Published: October 2022

Introduction

Obstructive sleep apnea (OSA) is related to increased left ventricular (LV) transmural pressure, blood pressure instability and increased pulmonary artery pressure (PAP) leading to left and right ventricular (RV) dysfunction and heart failure. 2D speckle tracking echocardiography (STE) is useful method for subclinical biventricular dysfunction diagnosis, thus might help to earlier treatment for OSA patients.

Purpose

The aim of the study was to evaluate changes of biventricular function and mechanics in patients with OSA.

Methods

We obtained 2D STE from 47 obese patients. 13 patients either did not have OSA, or it was mild (apnea/hypopnea index (AHI) 5–14/hour). OSA group (N=34) consisted of subjects with moderate or severe OSA (AHI ≥15/hour). New indexing for LV myocardial mass and LA volume by height was applied according new guidelines for obese patients. Statistical analyses were performed using the SPSS 27.0 software. The value of p<0.05 was considered as statistically significant.

Results

BMI did not differ between groups (p=0.108). Control group patients were younger, had higher female ratio, meanwhile arterial hypertension was more prevalent in OSA group (26 (76.5%) vs. 5 (38.5%), p=0.014). New indexing by height for left ventricular myocardial mass revealed higher LV MMi in OSA patients (p=0.007), and higher prevalence of LV diastolic dysfunction (p=0.023) was found in this group of patients. Moreover, LA reservoir function was significantly lower in OSA group compared to controls p<0.001. LV ejection fraction and conventional RV function parameters (s', fractional area change (FAC)) did not differ between groups, however LV and RV global longitudinal strain was reduced in OSA patients (p=0.035 and p=0.026, respectively). OSA patients had significantly higher RA diameter, and mean PAP (p=0.043 and p=0.037, respectively) (Table 1).

Conclusions

Moderate or severe obstructive sleep apnea is related to reduced biventricular longitudinal strain, more prevalent LV diastolic dysfunction and lower LA reservoir function. New indexing for LV myocardial mass by height helps to identify myocardial structural changes in obese patients with OSA.

Funding Acknowledgement

Type of funding sources: None.
Predicting the long-termoutcome of patients admitted with acute heart failure to the emergency department using renal markers
Authors: De Almeida J P L , Martinho S , Campos G , Alves P , Rosa J , Ferreira M , Goncalves L
Published: October 2022

Introduction

Renal dysfunction is one of the most important comorbidities in patients with chronic heart failure (HF) and frequently accentuated in the setting of acute HF (AHF). Serum creatinine and blood urea nitrogen (BUN) have been classically used as markers of renal dysfunction, despite having several limitations. High (BUN)/creatinine ratio has been associated with higher mortality in patients with HF. We aimed to predict the long-term outcome of patients admitted with acute heart failure to the emergency department using renal markers.

Methods

900 patients admitted to our emergency department diagnosed with AHF were retrospectively analysed. Patients were divided into 4 groups according to BUN and SCr on admission:

– BUN ≤33 mg/dL and SCr ≤1.56 mg/dL (group LowBUN/LowCr), n=544;

– BUN ≤33 mg/dL and SCr >1.56 mg/dl (group LowBUN/HighCr), n=25;

– BUN >33 mg/dL and SCr ≤1.56 mg/dL (group HighBUN/LowCr), n=131;

– BUN >33 mg/dL and SCr >1.56 mg/dL (group HighBUN/HighCr), n=200;

The primary end-point of this study was the occurrence of all-cause mortality during follow-up.

Results

The median (IQR) BUN level on admission was 28.0 (20) mg/dL, median (IQR) SCr level on admission was 1.15 (0.73) mg/d, mean age was 81±7 years, 50.8% (n=457) were women and median follow up was 7 months. A total of 41.2% patients were diabetic, 21.7% had at least mild COPD, CAD was present in 28.9% of cases, 44.0% had valvular heart disease and 68.4% patients had atrial fibrillation.

Creatinine, BUN and Cr/BUN ratio predicted survival at 6 months (p<0.05).

Survival was the lowest in the group HighBUN/HighCr and the highest in the group LowBUN/LowCr. As expected, BUN/Cr ratio was the highest in group HighBUN/LowCr and the lowest in group LowBUN/HighCr.

Conclusions

Despite not having the highest BUN/Cr ratio, patients with BUN >33 mg/dL and SCr >1.56 mg/dL showed the worst prognosis.

Funding Acknowledgement

Type of funding sources: None.
Living with heart failure: quality of life, particularly sexual life, is impaired by emotional burden as reported by patients
Authors: Wehrmann L , Hausmann L , Pohlink C
Published: October 2022

Background

Symptoms of heart failure (HF) include shortness of breath and limited exercise capacity as a result of fluid retention and circulatory disorders. Life expectancy of HF patients has improved, mainly driven by current treatment modalities. The burden of HF in terms of quality of life (QoL) and emotional well-being is frequently neglected and is less well described than typical HF symptoms.

Purpose

The aim of this study is to better understand the impact of HF on patients' QoL and emotional well-being from the patients' perspective.

Methods

Data on disease perception and physical as well as emotional burden was collected using an online survey from Nov to Dec 21 from patients with HF diagnosis (Nfemale=830; Nmale=927).

Results

Overall, the majority of HF patients considered being capable of fulfilling everyday routines as highly important. In detail, 87% of HF patients rated taking care of themselves, 82% running the household independently, 83% mobility outside the house and 74% social life with highest importance*. Impairments in the same QoL determining aspects from above showed a bimodal distribution of HF patients meaning that they were either highly affected or not affected at all.

Male and female HF patients rated QoL aspects in terms of importance and impairment equally, except sexual life importance and sexual impairments, which were ranked higher by men (56% vs. 42%*, 39% vs. 32%§, respectively).

Being asked about their biggest concern regarding HF via an open-ended question, death was the most commonly reported term. However, 20% indicated social and emotional worries as their first concern. Indeed, HF patients were frequently emotionally affected and almost every second HF patient stated considerable restrictions of their daily obligations and every third of their social life due to emotional problems. Patient-reported emotions were being worried (53%#), listless/without energy (47%#), fatigue (45%#) and/or afraid (42%#).

Interestingly, the fraction of HF patients being unsatisfied with their sexual life was larger when patients indicated feeling emotionally affected (worried, listless, fatigue, afraid). On the other hand, HF patients indicating no negative emotions were more satisfied with their sexual life highlighting the importance of sexual health contributing to QoL.

Conclusion(s)

The emotional burden experienced by HF patients is as high as their physical impairments culminating in considerable restrictions of their daily routines due to emotional problems. Additionally, emotional well-being is strongly linked with sexual satisfaction.

*On a scale from 1 = “not important” to 10 = “very important” rated ≥7.

§On a scale from 1 = “not affected” to 10 = “no activity possible” rated ≥7.

#On a scale of 1 = “never” to 10 = “very often” rated ≥7.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Novartis Pharma GmbH
The burden and pattern of comorbidities and its relation to mortality in frail vs non-frail patients with chronic heart failure
Authors: Sze S , Pellicori P , Zhang J , Weston J , Squire I B , Clark A
Published: October 2022

Background

Frailty is common in patients with chronic heart failure (CHF). Frail patients are at high risk of poor clinical outcomes which might be attributable to the presence of multiple comorbidities. The impact of comorbidities on mortality in frail patients with CHF is not well described.

Aim

To compare the burden and patterns of comorbidities in frail vs non-frail patients with CHF and their impact on mortality.

Methods

We studied consecutive patients attending a routine follow-up visit to a HF clinic. Frailty was assessed using the Clinical Frailty Scale (CFS); those with CFS>4 were classified as frail. Patients were classified into 6 comorbidity groups including: metabolic (obesity, diabetes); respiratory; renal; cancer; neuropsychiatric (depression, dementia); and degenerative (falls, arthritis, fragility fractures). We investigated the relation between frailty, comorbidity groups and all-cause mortality in patients with CHF.

Results

Amongst 467 patients with CHF [67% male, median (IQR) age 76 (69–82) years, NTproBNP 1156 (469–2463) ng/L], 291 patients had HF with reduced ejection fraction (HFrEF, LVEF <40%), and 176 had HF with preserved ejection fraction (HFpEF, LVEF ≥40%). Frailty was more common in HFpEF vs HFrEF (51 vs 40%). 64% of patients had >4 comorbidities (36% 5–6, 21% 7–9 and 7% >9 comorbidities).

Frail patients were more likely to have multiple comorbidities than non-frail patients (85% vs 48% with >4 comorbidities, p<0.001). The number of comorbidities increased with worsening frailty severity (Figure 1). Those with HFrEF were more like to suffer from cancer, whereas those with HFpEF were more likely to have neuropsychiatric, metabolic and degenerative comorbidities.

During a median follow up of 554 days, 82 (18%) patients died. Increasing number of comorbidities was associated with increasing mortality. (Figure 2) Patients who were frail with >4 comorbidities had a 6-fold increased risk of mortality compared to those who were neither frail nor had multiple comorbidities [HR (95% CI) 6.6 (3.2–13.9), p<0.001]. In a model adjusted for age, sex, logNTproBNP and NYHA class, amongst comorbidity groups, the presence of renal and neuropsychiatric comorbidities were independent predictors of higher mortality.

Conclusion

Frail patients with CHF have a high comorbidity burden. The co-existence of frailty and multiple comorbidities predisposes to higher risk of mortality. Future studies should investigate whether treatment focusing on comorbidities improve outcomes.

Funding Acknowledgement

Type of funding sources: None.
Hyponatremia and in-hospital outcomes of patients admitted for heart failure: analysis of the national inpatient sample
Authors: Kang C , Asemota I , Reyes Pinzon V , Khamooshi P , Atluri R , Soon-Shiong R
Published: October 2022

Background

Hyponatremia serves as a well established predictor of mortality for advanced heart failure (1). The aim of this study is to reassess the association between hyponatremia and in-hospital outcomes in patients with acute decompensated heart failure (ADHF) by using a nationally representative sample.

Methods

We queried the National Inpatient Sample (NIS) database collected between 2016 and 2018 to identify patients with a primary diagnosis of HF and stratified the cohort on the basis of presence or absence of hyponatremia. The outcomes of interest included in-hospital mortality, common associated complications and usage of circulatory support.

Results

Among 727,629 hospital admissions for HF, 72,824 (10%) of them had an additional diagnosis of hyponatremia. The hyponatremia cohort appeared similar in age and had similar rates of Charlson comorbidity index greater than 4 (71 years vs 72 years and 33% vs 35%, respectively) compared to the non-hyponatremia cohort. The comorbidities more prevalent in patients with hyponatremia included: hypothyroidism (17% vs 21%, p<0.001), liver disease (4% vs 11%, p<0.001) and anemia (31% vs 42, p<0.001). By contrast, dyslipidemia, chronic obstructive pulmonary disease, chronic kidney disease, hypertension, diabetes mellitus, obesity, smoking status and supplemental oxygen use were comparable in both groups. ADHF patients with hyponatremia did not have higher odds of in-hospital mortality (aOR: 1.08, 95% CI: 0.98–1.19, p=0.138) when adjusted for comorbidities. Nevertheless, patients with hyponatremia had an adjusted increase in mean hospital charges of 14,731 US$ (95% CI: 11065–18397, p<0.001), length of stay by 2.6 days (95% CI: 2.5–2.8, p<0.001), usage of intra-aortic balloon pump (aOR: 1.97, 95% CI: 1.50–2.59, p<0.001) and left ventricular assist device (aOR: 2.21, 95% CI: 1.639–2.98, p<0.001), and higher incidence of acute renal failure (aOR: 1.13, 95% CI: 1.08–1.189, p<0.001) and cardiogenic shock (aOR: 1.58, 95% CI: 1.42–1.76, p<0.001) in comparison to patients without hyponatremia.

Conclusion

Multiple clinical variables excluded in the NIS dataset could have impacted the primary outcome. Clinicians who observe hyponatremia in ADHF patients should stay wary of potential side effects and maintain a low threshold to escalate care.

Funding Acknowledgement

Type of funding sources: None.
COVID-19 vaccination decrease the risk of Intensive Care Unit hospitalisation in heart failure patients even in the time of Omicron variant: population based study
Authors: Parenica J , Jarkovsky J , Benesova K , Hlasensky J , Miklikova M , Kala P , Ondrus T , Lokaj P , Dusek L
Published: October 2022

Background

Heart failure (HF) patients, especially those in higher age, are at high risk of severe course of COVID-19.

Purpose

The aim of this work was to compare the risk of the necessity of intensive care being provided in the Intensive care units in HF patients with and without COVID-19 vaccination in the time of Omicron variant.

Methods

The analysis was done on data from the National Health Information System, which was supplemented with data from the Information System of Infectious Diseases.

Results

At the beginning of 2022, we estimate a total of 128,848 HF patients. Of these, 52.5% were men, mean of age (±SD) was 71.8 (±11.6) years, mean of age of women was 78.2 (±10.7). In January 2022, 560,886 cases of COVID-19 were diagnosed in the Czech Republic (5,241.1 cases per 100,000 population), the mean of the age was 32.5 (±18.3) years. At this time, the Omicron variant prevailed in the Czech Republic. Total 1,667 COVID-19 cases were HF patients, 56.3% were men. Not vaccinated were 420 patients, vaccinated without booster were 556 patients and vaccinated with booster were 691 patients. The risk of hospitalisation within 14 days from COVID-19 diagnosis was 46.7% (95% CI 41.5%; 51.8%) in not vaccinated group, 37.0% (32.9%; 41.2%) in vaccinated group and 22.6% (19.8; 26.0%) in vaccinated with booster group. The risk of the necessity of intensive care being provided in the Intensive care units was 11.1% (7.7%; 14.5%) in not vaccinated group, 4.7% (2.8%; 6.6%) in vaccinated group and 3.7% (2.0%; 5.4%) in vaccinated with booster group (Figure 1).

Conclusion

COVID-19 vaccination decrease the risk of Intensive Care Unit hospitalisation in heart failure patients even in the time of Omicron variant.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): The Ministry of Health of the Czech Republic – conceptual development of research organisation (FNBr, 65269705; funding was given to University Hospital Brno)
Left ventricular ejection fraction is not a determinant of outcome in acute heart failure
Authors: Berrill M , Ashcroft E , Baltabaeva A
Published: October 2022

Aims

Attention to left ventricular performance in acute heart failure (AHF) has historically focussed on deteriorating systolic function in the left ventricle (LV) as assessed by impaired LV ejection fraction (LVEF).

Methods

418 consecutive AHF patients presenting over 12 months were prospectively recruited and underwent bed-side echocardiography within 24 hours of recruitment. LV systolic function was assessed by LVEF >50% (HFpEF), 41–49% (HFmrEF) and <40% (HFrEF). Contractile function was assessed by LV MR dp/dt with ROC analysis identifying the cut-off of 570mmHg/s with the maximum Younden Index. Diastolic function was assessed by the ratio of mitral inflow E wave velocity to lateral e' velocity (E/e'), with a cut-off of 10.9 associated with the maximum Younden Index.

Results

The average age of patients was 78.7±11.7 years and 47.1% of patients were female. Mean BNP was 1331 pg/ml. 55.5% of patients had hypertension, 36.4% had coronary artery disease, 31.1% diabetes and 45.2% chronic kidney disease. Overall 2-year mortality was 38%. A 3-way comparison of 2-year mortality by LVEF (HFpEF vs. HFmrEF vs. HFmrEF) from ESC guideline criteria was not prognostic (38.6% vs. 30.9% vs. 43.9% [p=0.10). An LV MR dp/dt cut-off of 570mmHg was associated with worse outcome (HR 1.55 95% CI (1.05–2.29 [p=0.026]). Cut-offs for diastolic dysfunction identified from this AHF cohort (E/e' >10.9) and from ESC guidelines (E/e' >14) [p=0.09 & p=0.20]) could not identify those at risk of poor outcome.

Conclusion

In this study of acute heart failure LV ejection fraction is not associated with prognosis. LV systolic function assessed by the MR dp/dt, a measure of global contractile function, identified a cut-off of 570mmHg which could predict 2-year outcome. This suggests decline the ability of LV to generate contractile force predicts outcome in AHF. Diastolic function remains challenging to assess and a crude evaluation using E/e' could not identify those at risk of poor outcome in AHF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Abbott
Pre-discharge B-lines at bedside predicts 30-day and multiple 90-day hospital re-admission in patients admitted for acute decompensated heart failure
Authors: Zisis G , Huynh Q , Whitmore K , Lay M , Yang Y , Carrington M , Marwick T
Published: October 2022

Background

Inadequate decongestion at index admission for Acute Decompensation of Heart Failure (ADHF) is a common cause of adverse outcomes. A bedside 9-zone Lung and IVC ultrasound assessment (LUICA) may help to guide decongestion and reduce hospital readmission or mortality.

Purpose

To identify predictors of multiple 90-day hospital representations or mortality based on a bedside handheld 9-zone LUICA volume assessment obtained by HF nurses.

Methods

Patients admitted for ADHF, enrolled in the RISK-HF registry and undergoing pre-discharge LUICA, were assessed for 90-day readmission and/or mortality. The primary outcome of this observational report was prediction of multiple hospital representations based on pre-discharge volume status. The LUICA was performed with a hand-held ultrasound (HHU) device (Lumify, Philips) by trained HF-nurses. Functional capacity was measured with Duke Activity Status Index (DASI). Paired t-tests were used to compare mean differences. Logistic and linear regression were used to study relationships of outcomes with clinical characteristics. Cox regression was used to analyse time to repeated readmission or death. Analysis conducted with SPSS statistics V27 and STATA SE16.

Results

Of 302 ADHF patients, 67 readmitted within 30-days (age 76±8.5; men, 60%; HFrEF; 44%) and 235 did not readmit within 30-days (age 72±14; 57% men; 52% HFrEF). Readmission occurred in older patients (p=0.05), with pre-discharge signs of residual congestion that was based on the number of b-lines (p<0.01) (Table 1). Pre-discharge B-lines were predictive of DAOOH (β −0.41, −0.6, −0.22, p<0.01) and of multiple 90-day hospital readmissions (β 0.03, 0.018, 0.05, p<0.01), independently of 30-day event risk score, number of readmissions the preceding 12 months and age at index admission (Table 2). Number of B-lines at discharge was also associated with repeated readmission or death (HR=1.02 [1.01, 1.04]) in time-to-event analysis, independent of any other factors.

Conclusion

Pre-discharge residual congestion defined by the number B-lines increases the likelihood of multiple 90-day adverse outcomes.

Funding Acknowledgement

Type of funding sources: Other. Main funding source(s): The University of MelbourneBaker Heart & Diabetes Institute
Should we continue trusting bodyweight for HF volume telemonitoring?
Authors: Casquete D , Numan L , Codina P , Domingo M , Santiago-Vacas E , Cediel G , Zamora E , Crespo E , Santesmases J , Ruiz-Cueto M , Bares D , Altabella M , Barcelo E , Lupon J , Bayes-Genis A
Published: October 2022

Background

Telemonitoring of body weight, blood pressure and heart rate has extensively been used to facilitate early recognition of heart failure (HF) decompensations in order to prevent hospital admissions. Mixed results have been shown by different clinical trials regarding the effectiveness of telemonitoring in HF management. It is recognized that HF decompensation starts with an increase in intra cardiac filling pressure. The relationship between daily pulmonary artery pressure (PAP) values measurements and body weight is not completely established.

Purpose

To study the relationship between daily changes in body weight and invasive daily measurements such as diastolic PAP assessed by a pulmonary artery pressure sensor (CardioMEMS).

Methods

Eleven patients with left sided chronic HF implanted with a CardioMEMS device were included in the study (age 75±9 years, ejection fraction 52±10%). Daily measured body weight and pulmonary artery pressures were recorded during 6 months. The primary endpoint was to assess the correlation between the “PAP deviation” – defined as the difference between daily diastolic PAP and mean diastolic PAP over the study period – and the “weight deviation” – defined as the difference between daily body weight determinations and mean body weight.

Results

During the 6-months study period, 1766 body weight and diastolic PAP measurements were recorded (158±47 daily measurements per patient). We found a weak although significant correlation between changes in body weight and changes in diastolic PAP (Figure 1). When analyzing data individually, no patient presented a strong correlation between the two variables.

Conclusions

Our results suggest that repeated measurements of body weight have limited utility in detecting left sided heart failure decompensations. More complex and patient-specific thresholds for the biometric measurements are needed to improve early detection of decompensation in HF patients. For the development of early detection algorithms, we may learn from invasive methods, such as the CardioMEMS device.

Funding Acknowledgement

Type of funding sources: None.
Non-invasive assessment of right ventricular function and pulmonary pressures in cardiogenic shock remains challenging: don't pack away the PAC just yet
Authors: Szekely Y , Brahmbhatt D H , Scolari F L , Doumouras B S , Billia F
Published: October 2022

Background

Cardiogenic shock (CS) is associated with high levels of morbidity and mortality despite advances in treatment. Patients with right ventricle (RV) dysfunction have been shown to have poorer outcomes. It is suggested that invasive monitoring through pulmonary artery catheter (PAC) placement can assist in guiding management to improve survival, though they are associated with adverse events.

Purpose

This study assessed the utility of non-invasive, echocardiographic assessment of RV performance and pulmonary artery pressures (PAP) in patients with CS.

Methods

Consecutive patients admitted to a North American quaternary cardiac intensive care unit who had PAC placement were recruited into this study. Invasive haemodynamic assessment was followed by transthoracic echocardiography (TTE) performed by a critical care cardiologist, blinded to the invasive measurements. TTE images were later reported by a second cardiologist, blinded to the invasive measurements and the patient. Correlations between RV and pulmonary invasive and non-invasive parameters were evaluated using Pearson's correlation.

Results

Overall, 96 assessments of 60 patients were compared. Patients were predominantly male (73%), aged 58±14 years and SCAI stage C (55%) and D (22%) at the time of assessment. Invasive measurements of right heart and pulmonary function was possible in all patients. Mean RAP was 8.5±4.7 mmHg, systolic PAP 37.5±9.9 mmHg, diastolic PAP 18.1±6.5 mmHg, mean PAP 25.1±7.2 mmHg, pulmonary capillary wedge pressure (PCWP) 16.0±16.4 mmHg, pulmonary vascular resistance (PVR) 157±99dyn s cm–5, RV stroke work index (RVSWI) 7.0±3.9 g min/m2 and PAP index (PAPi) 2.9±4.2. When compared to non-invasive echocardiographic parameters, there was little correlation with invasive values (Table). RVSWI moderately correlated with peak tricuspid regurgitation (TR) velocity, tricuspid annular plane systolic excursion (TAPSE) and estimated systolic PAP; while peak TR velocity was mild-moderately correlated with PAP and PCWP. No single non-invasive parameter demonstrated strong prediction of invasive values.

Conclusion

Non-invasive assessment of right heart and pulmonary haemodynamic parameters is of limited validity when compared with invasive monitoring through PAC in patients with CS. PAC remains the most reliable method of assessing the RV haemodynamic profile in CS. Future studies should evaluate the clinical benefit of invasive haemodynamic monitoring in this population.

Funding Acknowledgement

Type of funding sources: None.
Detrimental effects of intense vasodilation in women with acute heart failure: novel insights from a prospective randomized controlled trial
Authors: Wussler D , Belkin M , Walter J , Kozhuharov N , Goudev A , Flores D , Maeder M , Shrestha S , Gualandro D , De Oliveira M , Rickli H , Breidthardt T , Muenzel T , Erne P , Mueller C
Published: October 2022

Background

Guidelines recommend evaluating the risk/benefit ratio of novel therapies individually in women and men, as the pathophysiology and the response to treatment may differ according to sex. Among patients with acute heart failure (AHF), a strategy of intensive vasodilation, compared with usual care, overall did provide comparable outcomes. However, sex-specific differences in heart failure pathophysiology and the effect of the strategy in women with AHF remained unclear.

Purpose

To characterize sex-specific differences in heart failure pathophysiology and to evaluate the effect of a strategy that emphasized early intensive and sustained vasodilation in women with AHF.

Methods

In a randomized, open-label blinded-end-point trial patients hospitalized for AHF were enrolled in 10 hospitals in Switzerland, Bulgaria, Germany, Brazil, and Spain. Inclusion criteria were AHF expressed by acute dyspnea and increased plasma concentrations of natriuretic peptides, systolic blood pressure ≥100 mmHg, and a plan for treatment in a general ward. Patients were randomized 1:1 to a strategy of early intensive and sustained vasodilation throughout the hospitalization or usual care. The primary end point was a composite of all-cause mortality or rehospitalization for AHF at 180 days. The subgroup analysis according to sex was predefined.

Results

Among 781 patients who completed the trial, 288 (36.9%) were women. Women were significantly older, had a higher systolic blood pressure at presentation and a more common history of diastolic dysfunction (all ps<0.05), whereas men had a significantly higher body surface area, a more common history of ischemic heart disease and a significant lower left ventricular ejection fraction (all ps<0.05). The primary end point, a composite of all-cause mortality or rehospitalization for AHF at 180 days, occurred in 53 female patients (37.9%) in the intervention group (including 28 deaths [20.0%]) and in 35 female patients (23.6%) in the usual care group (including 22 deaths [14.9%]) (absolute difference for the primary end point, 14.3%; adjusted hazard ratio, 1.62 [95% CI, 1.05–2.50]; P=0.03).

Conclusion

Among women with AHF, a strategy of early intensive and sustained vasodilation, compared with usual care, had a detrimental effect on a composite outcome of all-cause mortality and AHF rehospitalization at 180 days.

Funding Acknowledgement

Type of funding sources: Public hospital(s). Main funding source(s): University Hospital Basel
Impact of metformin on the all-cause mortality in diabetic patients hospitalized with acute heart failure
Authors: Chun K H , Oh J , Lee C J , Kang S M
Published: October 2022

Introduction

Although the hypothesis that metformin is beneficial for diabetic patients with heart failure (HF) has been steadily raised, there have been no solid data on the efficacy of metformin in acute HF patients.

Purpose

We investigated the impact of metformin on all-cause mortality in hospitalized acute HF patients with type 2 diabetes.

Methods

The Korean Acute Heart Failure registry enrolled patients hospitalized for acute HF from 2011 to 2014. Among this cohort, we analyzed patients with diabetes. We investigated all-cause mortality at 1 year after discharge. Propensity score matching (1:1 matching) and Cox proportional hazard models were used to assess difference in all-cause mortality.

Results

The study analyzed 1,976 diabetic patients (median age 72 years, mean left ventricular ejection fraction (LVEF) 34%, 54.5% male). Among them, 712 (36%) patients were on metformin. After 1:1 propensity score matching, 1,424 patients (712 metformin users vs. 712 non-users) were analyzed. During the median follow-up period of 11 months, 146 (21%) metformin non-users died and 108 (15%) metformin users died. Kaplan-Meier curves showed a higher all-cause mortality rate in non-users than in metformin users (Log-rank P=0.0025). After adjustment for clinically relevant variables, metformin was associated with lower risk for all-cause mortality (HR 0.713, 95% CI 0.551–0.922, P=0.01). In subgroup analyses, metformin use was significantly associated with a lower all-cause mortality in higher eGFR group (≥60 ml/min/1.73 m2, HR 0.531, 95% CI 0.357–0.790, P=0.002), but not in lower eGFR group (<60 ml/min/1.73 m2, HR 0.905, 95% CI 0.643–1.275, P=0.569, P-for-interaction=0.033). There was no significant interaction of metformin use for all-cause mortality between the subgroups with LVEF ≤40% and LVEF >40% (P-for-interaction=0.906).

Conclusion

Metformin use was associated with a lower risk for 1-year all-cause mortality in diabetic acute HF patients, especially in high eGFR group.

Funding Acknowledgement

Type of funding sources: None.
Early follow-up in a cardiological day hospital after heart surgery. Impact on hospital readmissions
Authors: Vaqueriza Cubillo D , Gomez Mariscal E , Dominguez Munoa M , Beltran Herrera C , Suberviola Sanchez-Caballero V , Briongos Figuero S , Estevez Paniagua A , Sanchez Hernandez A , Mora Yague L , Jimenez Loeches S , Giganto Arroyo M L , Cano Moracho J M , Cuerpo Caballero G , Gonzalez Pinto A , Munoz Aguilera R
Published: October 2022

Introduction

In the first few months after a heart surgery, hospital readmissions and are common. To reduce these events, we developed an early follow-up protocol after discharge based on attention in our cardiological day hospital (CDH), which allows clinical and analytical assessment, monitoring and intravenous treatment if needed, at successive visits. The objective of the study is to assess the protocol impact on the rate of early readmissions, after its implementation in January of 2016.

Methods

Patients in our area discharged after heart surgery between 2013 and 2019 were included. They were divided into two groups, one with conventional follow-up and one with initial follow-up in CDH. Baseline clinical characteristics, type of surgery and surgical risk were compared. The primary endpoint was the time to the first any-cause readmission. The follow-up time was 200 days from discharge. Quantitative variables were compared using Student's t test and categorical variables using chi-square test. Cox proportional hazards model was used for multivariate analysis.

Results

436 patients, 166 with conventional and 270 with CDH follow-up, were included. Baseline characteristics are shown in the table. We found a trend of decreasing readmissions in the CDH group (23,5% in conventional group, 16,3% in CDH group, HR 0,74; CI 95%: 0,48–1,14, p 0,19) although statistical significance was not achieved. In multivariate analysis, the variables independently associated (p<0.05) with an increased risk of readmission at 200 days were: active encocarditis, prior atrial fibrillation, hypertension, Euroscore II surgical risk index >1.13, hospital length of stay >14 days and age>73 years. The time to a first cardiological assessment after discharge decreased significantly in the CDH group (64 vs 18 days, p<0.001).

Conclusions

In patients followed in CDH after heart surgery, there is a trend towards less readmissions in the first months after discharge. Some baseline characteristics have been shown to be independently associated with the risk of readmission, which will help us to identify the most at-risk patients, on which an intervention could have a greater benefit.

Funding Acknowledgement

Type of funding sources: None.
Absolute coronary flow and microvascular resistances in severe aortic stenosis: invasively quantification
Authors: Abellas Sequeiros R A , Gutierrez Barrios A , Santas Alvarez M , Izaga Torralba E , Bayon Lorenzo J , Canadas Pruano D , Gonzalez Juanatey C , Ocaranza Sanchez R
Published: October 2022

Background

Chest pain in aortic stenosis (AS) has been attributed to the loss of coronary flow reserve however; this has not been directly quantified to date.

Purpose

To determine whether there is a decrease in coronary flow as a cause of chest pain or dyspnea in patients with severe AS

Methods

Patients with AS and normal left ventricular ejection fraction (LVEF) underwent coronariography previous to valve replacement. In those patients without obstructive coronary disease, an invasive physiological evaluation was performed to measure absolute coronary flow (Q) and microvascular resistances (R). Left anterior descending artery (LAD) was explored in all cases and, in a subgroup of patients, we also studied the circumflex (CX).

Results

51 patients were included. 86% presenting with dyspnea, 26% also reported chest pain, and 11.8% syncope. No patient was admitted due to heart failure. Mean pressure gradient for AS was 52.44±15.41 mmHg with a mean aortic valve area of 0.76±0.17 cm2. Mean LVEF was 63±8.35%. The physiological study of LAD was successfully completed in all patients. 68.6% presented a normal / increased LAD-Q with a mean quantified flow of 262.118±161.99 mL/min. LAD-R proved normal in 56.9% of the cases and low in 13.7%. The quantified mean LAD-R was 400.78±195.89 UW.

The physiological study of the CX was carried out in 34 patients. 82.3% presented normal / increased CX-Q, with a mean value of 201.82±117.91 mL/min. CX-R proved normal in 76.5% of the cases and low in 17.6%, with a mean value of 604.147±367.23 UW.

Conclusion

Invasive intracoronary measurements demonstrated most of patients with severe AS maintain normal values of Q and R

Funding Acknowledgement

Type of funding sources: None.
Association of serum MMP9 with adverse features of plaque progression in patients with chronic coronary syndrome (CCS)
Authors: Caselli C , Ragusa R , Di Giorgi N , Lorenzoni V , Buechel R R , Teresinska A , Pizzi M N , Roque A , Poddighe R , Knuuti J , Parodi O , Pelosi G , Scholte A , Rocchiccioli S , Neglia D
Published: October 2022

Background

Previous studies have demonstrated that MMP-9 may be a predictor of atherosclerotic plaque instability and future adverse cardiovascular events, but longitudinal data on the association between MMP9 and coronary disease progression are lacking.

Purpose

This study is aimed at investigating whether MMP9 is associated with atherosclerotic plaque progression.

Methods

MMP9 serum levels were measured in stable patients with chronic coronary syndrome (CCS) undergoing coronary computed tomography angiography at baseline and after a period of 6.5±1.1 years of follow up to assess progression of Total, Fibrous, Fibro-fatty, Necrotic Core, and Dense Calcium plaque volume (PV). The relationship of serum MMP9 with plaque progression was assessed using linear regression analysis, adjusting for clinical variables including, age, sex, risk factors, medical therapy, LDL-C, TG/HDL-C ratio, hs-CRP, and the presence of obstructive CAD (>50% coronary stenosis in at least one major coronary vessels).

Results

A total of 157 patients (58±8 years of age; 66% males) were included in the analysis, with median MMP9 values of 135±186 mg/dL (mean ± SD). Annual changes of Total, Fibrous-Fatty and Necrotic Core PV were significantly different across MMP9 tertiles (Figure 1). Multivariable linear regression analysis demonstrated a positive association between serum levels of MMP9 and annual change of Total and Necrotic Core PV (Figure 1).

Conclusion

Among patients with CCS, MMP9 serum levels were an independent predictor of progression of coronary plaque burden and, in particular, of adverse plaque features, such as Necrotic Core PV. This association was robust and independent from baseline traditional cardiovascular risk factors and medications, supporting for MMP9 a role as a novel marker of residual coronary risk.

Funding Acknowledgement

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): Horizon 2020 - Project “Simulation Modeling of coronary ARTery disease: a tool for clinical decision support–SMARTool”
Left ventricular ejection fraction – human vs artificial intelligence: quo vadis?
Authors: Botan R , Winkler A , Dindane Z , Nowack T , Heitmann C , Mierke J , Linke A , Sveric K
Published: October 2022

Background/Introduction

Two-dimensional echocardiography (Echo) is a feasible method for assessing left ventricular (LV) ejection fraction (EF) in daily practice. However, the interpretation of Echo exams depends on the user's expertise and may vary between different operators. A novel, vendor-neutral artificial intelligence (AI) performs both, automated evaluation of Echo exams and calculations of biplane LV EF in one workflow.

Purpose

We sought to assess the ability of the AI to automatically identify appropriate LV 4- and 2-chamber views (4CV) (2CV) from routine Echo examinations and compare the resulting biplane EF with conventional hand-tracing biplane Simpson method (Human).

Methods

We prospectively enrolled 311 patients who underwent clinically indicated Echo exams. Biplane LV EF was manually traced online on 4CV and 2CV by cardiologists (Human). After completion of the exam, the AI-based solution recognized the optimal LV 4CV and 2CV according to quality and depth criteria and automatically performed the calculation of biplane EF by endocardial borderline detection without Human's interaction. Spearman's correlation (R) and Bland-Altman analysis with limits of agreement (LOA) were assessed for bias between the two methods. In a subgroup of 20 patients, Echo exams were automatically reanalyzed by the AI, and conventional biplane Simpson of LV EF was performed by two cardiologists blinded to the previous results to determine intraclass correlation (ICC). Significance was defined as a 2-tailed p value <0.05.

Results

311 patients (median age 72 years [19–97]; 40% female) received an Echo for valvular heart disease, ischemic and non-ischemic heart failure or other indications (39, 31, 19 and 11%). 16 cases (5%) did not pass AI's criteria due to poor Echo imaging or impaired acoustic window of patients. In 53 patients (17%) either 4CV or 2CV were recognized, but the AI system successfully identified both 4CV and 2CV in 242 patients (overall feasibility 78%). For these 242 patients, correlation between AI and Human biplane LV EF was r=0.83 (p<0.001) (Figure 1 left). The absolute mean bias between methods was 5.2% (p<0.001) and absolute LOA ranged from −9.0 to +19.4% (Figure 1 right). ICC of LV EF by Human was 0.77 (p<0.001). The AI's ability to correctly re-/classify 4CV and 2CV was 100% with an ICC of 1 for fully automated LV EF measurements.

Conclusion

The results provided by the AI-based software showed very good capability to identify 4CV and 2CV and good LV EF result compared to Human manual tracings, especially since patients were not pre-selected. However, differences between AI and Human measurements are not negligible and warrant further investigations.

Funding Acknowledgement

Type of funding sources: None.
The Impact of Living with INOCA
Authors: Gulati M , Khan N , George M , Berry C , Chieffo A , Camici P G , Crea F , Kaski J C , Marzilli M , Merz C N B
Published: October 2022

Background

There is limited literature available on the impact of myocardial ischemia but no obstructive coronary arteries (INOCA) on patients' lives.

Purpose

We sought to determine how INOCA impacts the physical, social, and mental health of persons with this diagnosis.

Methods

A survey was made available to all members of the patient support group from INOCA International over a 3-month time period. Fitness was estimated using the Duke Activity Status Index (DASI), assessing levels of activities performed prior to the onset of INOCA symptoms, and after the diagnosis of INOCA. The formula to estimate fitness in metabolic equivalents (METs) = 0.43 × DASI + 9.6 / 3.5

Results

A total of 297 patients with INOCA responded to the survey; 91.2% were women. The most common diagnosis was coronary microvascular dysfunction (64.3%) and coronary artery spasm (50.5%) (Table 1). 34.4% reported living with symptoms for ≥3 years before their diagnosis of INOCA was made. 77.8% who had been told their symptoms were not cardiac. The symptoms the respondents experienced were numerous, but 92.9% reported symptoms of chest pain, pressure, or discomfort. Fitness levels prior to the onset of INOCA symptoms were significantly higher compared to after diagnosed with INOCA (8.6±1.8 METs vs 5.6±1.8 METs; P<0.0001). Most respondents reported an adverse impact on their home life (80.5%), social life (80.1%), mental health (70.4%), outlook on life (69.7%), sex life (55.9%), and their partner/spouse relationship (53.9%). Work life was also affected once living with INOCA: approximately three-quarters had reduced their work hours or stopping work completely, 47.5% retired early, and 38.4% applied for disability. While living with INOCA, for each 1-MET decrease in fitness, there was a loss of 3.0±0.6 days/months of physical health, 1.8±0.6 days/month of mental health, and 2.9±0.7 days/months of inability to perform recreational activities (p<0.0001) (Figure 1).

Conclusions

Living with INOCA has significant impact on physical, mental and social health. Significant physical fitness declines are seen in those living with INOCA and are lower in those experiencing any adverse impact of living with INOCA. Additionally, the impact of INOCA on the ability to work has important economic consequences to both the patient and society. Increased recognition of the impact of INOCA on these aspects of health need to be recognized and further work is needed to better diagnosis and treat the symptoms of INOCA to improve the quality of life, cardiovascular outcomes, and overall health of this frequently encountered cardiovascular disorder.

Funding Acknowledgement

Type of funding sources: None.
Relationship between sclerostin and coronary tortuosity in postmenopausal females with non-obstructive coronary artery disease
Authors: Mohamady M A S , Mohamed Farag E , Mohamed Ibrahim I , Abdelaziz M
Published: October 2022

Background

Coronary tortuosity (CT) is commonly encountered in postmenopausal females and is usually present without obstructive lesions. Circulating sclerostin levels are elevated in postmenopausal females. In view of sclerostin's vasculoprotective effect, we aimed to find possible association between circulating sclerostin and CT.

Method

We prospectively enrolled 273 consecutive postmenopausal females with non-obstructive coronary artery disease diagnosed by coronary angiography. Presence and severity (by tortuosity score) of CT as well as serum sclerostin levels were assessed for each patient.

Results

Patients with CT (128, 47% of study group)were significantly older (P<0.001),with higher prevalence of hypertension (P=0.001) and had significantly higher levels of both sclerostin (P<0.001) and hs-CRP (P=0.001).Multivariate binary logistic regression revealed that the presence of CT (dependent variable) was associated with high sclerostin level (OR 8.9, 95% CI: 4.9–16.2, P<0.001). Using ROC curve analysis, Sclerostin at a cutoff value of >650 pg/ml was found to be associated with presence of CT (AUC 0.69, 95% CI: 0.61–0.75, P<0.001) with sensitivity and specificity of 75% and 72.4%, respectively. Using Pearson's correlation analysis, significant positive correlation between sclerostin and severity of CT was found (r=0.29, P=0.001).

Conclusion

High circulating sclerostin is associated with the presence and severity of CT in postmenopausal females. This may add to the literature on the incompletely understood pathogenesis of CT.

Funding Acknowledgement

Type of funding sources: None.
Comorbidity and medication use in patients with angina due to a coronary vasomotion disorder
Authors: Blundell H , Ambery P , Arnold M , Brookes-Smith I , Kiddle S , Greasley P J , Berry C
Published: October 2022

Background

Microvascular angina and vasospastic angina are disorders of coronary vasomotion. The associations between these conditions, comorbidity and medication use in relatively unselected populations is not well described.

Aim

To describe the proportions of patients with concomitant morbidity and related medication use in an international, contemporary, clinical database.

Methods

TriNetX, a global federated health research network with access to anonymized electronical medical records (EMRs) from participating healthcare organizations including academic medical centres, specialty physician practices, and community hospitals, predominantly in the USA was used. The ICD10 code (I20.1) representing “Angina pectoris with documented spasm” was used as a primary search term. ICD10 codes were also used for cardiorenal and metabolic conditions. Medication use was classified as occurring prior to or on the date of the angina episode. The time-period for defining the analysis population was 01.01.2017–31.12.2019. The population age was ≥18 years.

Results

Data were available on 12,200 individuals (mean (SD) age 63 (13) years; 63% female). The % of individuals with a concomitant diagnosis is described in Table 1. Hypertension occurred in almost two thirds of individuals, an anxiety disorder affected more than one quarter and type 2 diabetes and/or obesity occurred in one fifth. Medication use is described in Table 2. Half of patients received a calcium channel blocker therapy. Nitroglycerin, beta-blockers, and isosorbide mononitrate were less commonly used (45%, 45% and 23%, respectively). Most (58%) patients were prescribed an antacid. Half of patients received statin treatment (50% overall; 36% atorvastatin) and insulin (12%) and metformin (9%) were the most commonly prescribed antidiabetic medications.

Conclusions

Angina associated with coronary spasm associates with female sex and cardio-metabolic risk factors. Contemporary pharmacotherapy for diabetes and statins appear to be under-used.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): AstraZeneca