bluuebunny/crossref_metadata_2025 huggingface dataset:
Outcomes of implantable cardioverter-defibrillators in patients with a left ventricular assist device: a systematic review and meta-analysis
Authors: Rahhal A , Alasad F , Aljundi A , Mohammad H , Aburamadan A , Chapra A , Mahfouz A , Alyafei S , Carr C , Alkhulaifi A , Omar A
Published: October 2024

Introduction

Implantable Cardioverter-Defibrillators (ICDs) improve survival in advanced heart failure with reduced ejection fraction (HFrEF) and prevent sudden cardiac death. However, the prognostic benefits of ICDs among patients with a Left Ventricular Assist Device (LVAD) remain uncertain and controversial. Therefore, we conducted a systematic review and meta-analysis to assess the effectiveness and safety of ICD implantation among LVAD recipients.

Methods

We performed a systematic review and meta-analysis following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. We searched PubMed and EMBASE for the peer-reviewed articles published in English assessing the impact of ICD implantation among LVAD recipients, till 10/01/2024. ICD implantation was defined as implantation before LVAD, simultaneous implantation with LVAD, or within 30 days of LVAD insertion. Two independent review authors assessed the quality and risk of bias of the included studies. A random-effect model was used to combine data in forest plots. The primary outcome was all-cause mortality associated with ICD implantation compared to no ICD implantation, and the secondary outcomes included ventricular arrhythmia (VT), and hemorrhagic stroke. Heterogeneity was assessed using Q test and I2, with I2 > 50% indicating marked heterogeneity.

Results

A total of 13 observational studies comprising 54571 recipients of LVAD were included in the analysis of the primary outcome. All-cause mortality was similar among patients with ICD versus no ICD (Odds Ratio [OR]= 0.77; 95% CI, 0.57-1.04, I2= 89%, P=0.09), as shown in Figure 1. Likewise, ICD implantation was associated with similar rates of VT and hemorrhagic stroke (VT: OR= 1.81, 95% Cl, 0.82-4.01, I2= 90%, P=0.14; hemorrhagic stroke: OR= 1.01, 95% Cl, 0.81-1.25, I2= 0%, P= 0.95).

Conclusion

Among patients with HFrEF and LVAD as advanced heart failure therapy, ICD implantation didn’t provide additional prognostic survival benefit, suggesting possible use of LVAD without ICD implantation.Figure 1.Forest plot of mortality
Extending the window in clinical decision making: the role for Impella 5.5 in cardiogenic shock
Authors: Desai A , Sharma S , Luce C , Goswami R
Published: October 2024

Background

Acute decompensated heart failure (HF) refractory to medical management deteriorates quickly to cardiogenic shock, ultimately requiring mechanical circulatory support (MCS). These devices aim to provide circulatory support as a bridge to advanced therapies. We report patient outcomes with the latest minimally invasive temporary MCS device: Impella 5.5 with SmartAssist.

Methods

All patients who underwent Impella 5.5 implantation between January 2020 and December 2023 were analyzed. Duration of Impella support and peri-implant parameters were collected from electronic medical records. ANOVA was performed and utilized a p-value of <0.05 as significant for statistical analysis.

Results

During our review period, a total of 99 patients were supported with Impella 5.5 in the setting of cardiogenic shock. 92 were bridged to heart transplant (BTT), of which 17 also received combined kidney transplantation. Two underwent durable VAD implantation (BTVAD), and 3 had native heart recovery (BTR) and explant. Two patients died, yielding a survival rate of 98%. For BTT group, the median age was 60 years (52-65) at implant and a median BMI of 27 kg/m² (24-31) with a mean support duration of 29 days (SD ±24). Baseline GFR was 49 mL/min/1.73m² (35-65). In the BTVAD group, the median BMI was 43 kg/m² (39-46) with an average duration of support of 22 days (SD ±8) with a GFR of 55 mL/min/1.73m² (38-73). The BTR group had a median BMI of 29 kg/m² (27-30) with an average duration of support of 15 days (SD ±7) and a lower baseline GFR of 36 mL/min/1.73m² (26 – 37) compared to BTT or BTVAD. The two patients that died were supported for an average of 42 days (SD ±9.2) and expired due to non-candidacy in the setting of newly detected prostate cancer in one patient and multi-organ failure in another. All BTVAD and BTT patients did not have a stroke or major vascular complications before terminal therapy.

Conclusion

Our center highlights the role of early Impella 5.5 placement in the stabilization of patients in cardiogenic shock, thereby providing both patients and providers time for decision-making while optimizing end-organ perfusion beyond the accepted duration of 14 days.Impella Data - Entire CohortImpella Data - Stratified by Outcome
Nationwide analysis of in-hospital mortality and renal infarction trends following cardiac output assist device placement from 2017 to 2020
Authors: Perry J , Akinti O A , Mcnamara A , Sinclair S , Adarsh Balaji A B , Kibwey Peterkin K P , Khan A
Published: October 2024

Background

Cardiac output assist devices (COAD) have become a crucial therapeutic option for advanced heart failure patients. However, the clinical outcomes and complications associated with cardiac output device placement, especially in relation to renal health, remain a subject of concern.

Purpose

We aimed to examine temporal trends of in-hospital mortality and renal infarct (RI) among heart failure in patients who underwent placement of cardiac output assist devices, including intra-aortic balloon pumps and impeller-based devices, between 2017 and 2020.

Methods

The National Inpatient Sample was queried from 2017 to 2020 to identify all adults who underwent COAD using the International Classification of Diseases 10th Revision codes. The Cochran-Armitage test was used to assess the linear trend of in-hospital RI among patients with COAD. Multivariate and univariate regression analysis was conducted to assess the yearly association of COAD with in-hospital mortality and RI with COAD. The Elixhauser comorbidity index was used to adjust for confounders. Linear logistic results are represented as adjusted odds ratios (ORs) with their respective 95% Confidence Intervals (CI).

Results

Of the 176,225 patients who underwent COAD, 385 (0.2%) experienced RI, predominantly male (72%) with a mean age of 58. Trend analysis showed an upward trend in RI (trend: 0.21%, p < 0.001) associated with COAD from 2017 to 2020. In 2018, 0.19% of patients had RI (OR = 3, 95% CI 2.1-6.1, p < 0.001), 0.23% in 2019 (OR = 4.6, 95% CI 2.5-7, p < 0.001), and 0.29% in 2020 (OR = 3.6, 95% CI 2.3-5.9, p < 0.001), compared to 0.17% in 2017 (OR = 2.3, 95% CI 1.1-4.7) demonstrated in Figure 1. Mortality among RI and COAD patients was 40% in 2017 (OR 3, 95% CI 1.2-8.9, p = 0.04), decreased to 24% in 2018 (OR 1.2, p = 0.69), but increased to 43% in 2019 (OR 3.2, 95% CI 1.2-7.9, p = 0.01) and remained high at 42% in 2020 (OR 2.9, 95% CI 1.3-6.9, p = 0.019) as illustrated in Table 1. Overall, in-hospital mortality was 38% (OR 2.5, 95% CI 1.5-4, p < 0.001).

Conclusions

Our study identified a rising trend in in-hospital RI rates among patients with cardiac output assist devices from 2017 to 2020, accompanied by a significant risk of in-hospital mortality. Despite these complications occurring in a small percentage of individuals, they highlight the critical need for vigilant monitoring and proactive management in this patient population.Figure 1
Reversibility of precapillary pulmonary hypertension and outcomes after heart transplantation bridged with left ventricular assist devices: insight from the UNOS
Authors: Alnsasra H , Kanneganti Perue R , Khalil F , Regev O , Kushwaha S , Briasoulis A , Asleh R
Published: October 2024

Background

In light of the updated lowered threshold for diagnosing pulmonary hypertension (PH), the reversibility of precapillary PH with left ventricular assist device (LVAD) and the associated post heart transplantation (HT) outcomes remain unclear.

Purpose and methods

Using data from the United Network for Organ Sharing database, we aimed to investigate predictors of persistent precapillary PH in HT recipients bridged with LVAD, and examine the interrelated post-HT survival, using the updated pulmonary vascular resistance (PVR) cutoff of >2 WU for precapillary PH.

Results

Among 2169 HT recipients bridged with LVAD, 1299 had PVR>2 at baseline; 551 (42.4%) of whom normalized their PVR≤2 and 748 (57.6%) remained with elevated PVR>2 after LVAD implantation. Female sex (adjusted odds ratio [aOR] 2.22, 95% confidence interval [CI]:1.61-3.07, p<0.001) and inotropes-treatment at-listing (aOR 1.31, 95% CI: 1.03-1.66, p=0.028) were associated with persistently elevated PVR post LVAD. Conversely, longer duration of LVAD support (aOR 0.74, 95% CI: 0.65-.84, p<0.001) and use of HeartMate 2 (aOR 0.74, CI: 0.59-0. 93, p=0.011) were protective against persistently elevated PVR post-LVAD. Persistently elevated PVR >2 post-LVAD was associated with increased risk of death compared to those who normalized their PVR (adjusted hazard ratio [aHR] 1.26, 95% CI: 1.01-1.57, p=0.037). However, normalized PVR post-LVAD group had comparable survival to those with PVR≤2 at baseline (aHR 0.76, 95% CI: 0.57-1.02, p=0.07).

Conclusions

Many HT recipients bridged with LVAD remain with PVR>2 post-LVAD implantation, which is associated with increased risk of death post-HT compared to patients with normalized PVR post-LVAD.
Afterload mismatch is associated with gender mismatch and negatively affect long-term outcome after heart transplant
Authors: Coriano' M , Pradegan N , Golfetto A , Tarzia V , Angelini A , Gambino A , Tessari C , Fedrigo M , Toscano G , Iliceto S , Gerosa G , Tona F
Published: October 2024

Background

Cardiac physiology changes after heart transplant (HT), resulting in a restrictive physiology with an increase in both arterial elastance (Ea) and ventricular elastance (Ees). This leads to a higher susceptibility to develop afterload mismatch, although the early identification of this phenomenon has not yet been explored. The aim of this study is to identify the presence of afterload mismatch after HT, its determinants, and its impact on cardiac mortality.

Methods

We conducted an observational, single-centre study based on the historical cohort of patients who underwent HT from 1985 to 2015 at our institution. We included patients who had survived the first year after HT with left ventricular ejection fraction (LVEF) ≥ 50%, International Society of Heart and Lung Transplantation (ISHLT) cardiac allograft vasculopathy of grade 0-1, and ISHLT acute cellular rejection of grade 0-1R at 1 year after HT. Ea and Ees were calculated using a non-invasive method based on blood pressure and end-systolic volume and end-diastolic volume measured at transthoracic echocardiography. Patients were grouped in 3 categories according to the presence of increased afterload and afterload mismatch as follows: low afterload (LA - Ea lower the median), matched high afterload (MHA - Ea higher of equal than the median, Ees higher or equal than the median), afterload mismatch (AM - Ea higher or equal than the median, Ees lower than the median). The impact of AM on long-term outcome, defined as cardiac mortality, was investigated, as well as predictors of AM.

Results

The study cohort consisted of 345 HT patients. The median of Ea and Ees were 4.0mmHg/mL and 6.75mmHg/mL, respectively. 49 patients (13%) developed AM, while LA and MHA groups accounted for 49% and 36% of the cohort, respectively. Patients with AM were mostly male (91%), with ischemic heart disease (45%) and a higher percentage of left ventricular assisted device prior to HT (8%). LVEF was lower in AM (57% vs 63% and 64% for LA and MHA respectively, p < 0.0001), while stroke volume was lower than LA and similar to MHA (27ml vs 35mL and 26mL for LA and MHA respectively, p = 0.0001). Predictors of AM were male recipient from male donor (Mr/Md) (β 015, p = 0.0067) and Mr from female donor (Mr/Fd) (β 0.6, p = 0.0078). After a median of 11.3-year follow-up, 59 (17%) HT recipients died. Cardiac mortality was higher in AM than in the other groups (AM median survival 17.2y vs 27.8y and 24.1y for LA and MHA respectively, log-rank p = 0.005). After adjusting for confounding variables, AM was a predictor of cardiac mortality (HR: 2.26; 95%CI 1.18 – 4.35), such as Mr/Fd (HR 2.94; 95%CI 1.18 – 4.35, p = 0.0358).

Conclusion

AM, in the context of a normal LVEF, is associated with male donor and sex mismatch, and negatively affects long-term outcome after HT.KM curvesCox proportional hazard model
Novel clinical method: left ventricular diastolic pressure curve by echocardiography
Authors: Fernandes J F , Smiseth O A , Ohte N , Wakami K , Donal E , Remme E , Lamata P
Published: October 2024

Background

A non-invasive clinical method for construction of the systolic part of the left ventricular (LV) pressure curve was recently introduced. There is, however, no clinical method available to construct the LV diastolic pressure curve.

Purpose

The aim of this study was construction of patient-specific LV diastolic pressure curves from echocardiographic data and have initial validation against simultaneously acquired pressure curves by high-fidelity LV pressure catheters (micromanometers).

Methods

The study included 108 patients referred for diagnostic left heart catheterization due to suspected coronary artery disease. 81 patients were used as a training cohort. The construction of a diastolic pressure curve is based on a reference unitless pressure trace and seven key pressure-time diastolic events estimated in each patient. The reference diastolic pressure trace was generated from a group of 8 patients with LV pressures recorded by micromanometer. Each individual pressure trace from the reference cohort was first annotated with the occurrence of the key diastolic events: mitral valve (MV) opening, minimum LV pressure, peak of early-diastolic mitral flow velocity (E) and start and peak of atrial contraction-induced velocity (A), and MV closure. Then the temporal intervals between these events were normalized before calculating an averaged pressure curve (Figure 1, panels A-C).

A patient-specific LV diastolic pressure curve was constructed by adjusting the standard curve according to estimated LV pressure at the key diastolic events (shown in Figure 1D). The estimation of the pressure-time instants is based on the LV volume temporal transient, used to estimate filling flow rate (Q=dV/dt) and flow acceleration and deceleration (dQ/dt=d2V/dt2), as well as a set of biomarkers including left atrial reservoir strain, peak systolic LV pressure, and body mass index. LV volume temporal traces were generated by combining global 2D volumes with global longitudinal strain.

The ability to generate patient-specific diastolic LV pressure curves was validated in a second cohort of 7 patients studied with micromanometer-tipped catheters. Echocardiography and LV pressure were recorded from the same series of beats and recordings were done during breath-hold at end-expiration. The agreement was accessed qualitatively and considering the mean diastolic LV pressure.

Results

There was good agreement between measured and estimated LV diastolic pressure curves, qualitatively and quantitatively, via mean diastolic PLV: Bias 0.2 mmHg, limits of agreement <3.2 mmHg (Figure 1D-F).

Conclusions

The results suggest that the LV diastolic pressure curve can be estimated by echocardiography. The method needs validation in larger populations.Non-invasive diastolic LV pressure curve
The impact of a dedicated heart failure clinic on patients with heart failure with reduced ejection fraction
Authors: Almaghraby A , Alsaid M S I , Younes R , Farag M , Ahmed S
Published: October 2024

Introduction

Heart failure (HF) is not a diagnosis but rather a syndrome with a variety of potential causes and once a patient has been diagnosed as having HF, the underlying etiology should be sought and treated.

Thus, patients with HF should be engaged in a disease management program that includes a dedicated wider healthcare team which is critical for delivering the best care for patients. A dedicated HF clinic is one of the cornerstones of this ultimate management program. This clinic is specifically made to make sure of the proper management and follow-up of those patients.

There is a scarce evidence of weather a dedicated HF clinic can alter the long-term outcomes of HF patients or not. Thus, the aim of this study is to search for the impact of a dedicated HF clinic on patients with HF with reduced ejection fraction (HFrEF) regarding the symptoms, management received according to latest guidelines, the patients’ quality of life and impact on health care resources.

Patients and Methods

This is a single center retrospective study that included patients presented to a dedicated heart failure clinic at a secondary care hospital through a one-year period.

The study group included patients with diagnosis of HFrEF only who had one or more visit to the HF clinic.

These patients served as their own control. Hospital admissions and emergency room visits in the 12-month period preceding enrollment was compared to the number in the following year after enrollment.

Patients with incomplete data and those with ejection fraction >40% were excluded.

Results

The study included 48 patients with a mean age of 65 years, 70.8% of them were males. Most of the patients were hypertensive (77.1%), diabetic (75%) and with history of coronary artery disease (60.4%).

Symptoms improved significantly in all patients, left ventricular volumes and ejection fraction improved (31±8.1% vs 40.7±10.5%) (P<0.0001).

NT-ProBNP level improved significantly (5927 ng/L vs 3135 ng/L) (P = 0.03).

The guideline directed medical therapy was used properly before and after the clinic.

There was a significant improvement in the quality of life where the KCCQ-12 score improved from 71.25±13.2 to 83.3±13.3 (P<0.0001), six-minute walk test also improved significantly from 362±184 meters to 479±211 meters (P = 0.005).

Regarding the economic impact, there was no significant difference in the number of unplanned visits (20.8% vs 10.4%) (P = 0.16) but there was a significant reduction in the number of HF hospitalizations within one year (20.8% vs 6.25%) (P = 0.038)

Conclusion

Dedicated HF clinics are very important now for the proper management of HF patients where it is proved that it can improve HF symptoms, improve the quality of life measurements, maintain the proper guideline directed therapy and reduce the economic burden of HF through reducing the number of HF hospitalizations.Clinical dataOutcomes
The impact of heart failure caregiver burden and patient heart failure severity: analysis of the needs assessment tool: advanced heart failure (NAT: PD-HF)
Authors: Sato T , Nagai T , Tatsuta D , Koya J , Nishino K , Naito S , Mizuguchi Y , Temma T , Kamiya K , Narita H , Tsuruga K , Anzai T
Published: October 2024

Background

Not only patients with heart failure (HF), but also their caregivers have reported experiencing distress, depression, anxiety, social isolation, and health problems related to caring for a patient. Needs assessment tools have been used in clinical practice to identify patients' problems and needs from an early stage, however, their relationship with caregiver burden and the severity of the HF patients they care for has not been well investigated.

Purpose

The purpose of this study is to examine the relationship between distress and HF severity in patients and their caregivers using the Needs Assessment Tool: Progressive Disease-Heart Failure (NAT: PD- HF).

Methods

We enrolled consecutive 106 chronic HF patients who were admitted to a university hospital and assessed needs by the NAT: PD-HF between February 2023 and July 2023. We also enrolled 95 of their caregivers. The NAT: PD-HF is administered by the health care provider in the form of an interview with the patient and their caregiver. The questionnaire consists of an assessment of the patient's well-being and an assessment of the caregiver's ability to care for the patient. The healthcare provider completes the tool by indicating the level of distress (none, mild, significant) for each section. The severity of the New York Heart Association (NYHA) functional classification is examined in each patient.

Results

The median age was 72 years (interquartile range 59-81), and 41% were in NYHA class III or IV. The most common relationship between patients and their primary caregivers was partners (53%), followed by children (26%), parents (8%), and siblings (5%). There were 100 patients (94%) with more than mild distress, 57 with NYHA I or II and 43 with NYHA III or IV (P = 0.037). There were also 84 (88%) caregivers with more than mild distress, 47 with NYHA I or II, and 37 with NYHA III or IV of the patients they cared for (P = 0.026). Twenty-four patients (22.6%) were in severe distress, of which 10 were NYHA I or II and 14 were NYHA III or IV (P = 0.044). Among caregivers, 18 (18.9%) were in severe distress, of whom 6 with NYHA I or II and 12 with NYHA III or IV for whom they are caring (P = 0.010).

Conclusions

Regardless of the severity of HF, caregivers were found to experience distress as similar rate as that in the HF patients they cared for. The proportion of patients and caregivers experiencing distress was found to increase with the severity of HF. It is important to introduce palliative care for HF from the early stage of the disease and to support not only the patient but also the caregivers by using screening tools to identify distress.
Delivering remote monitoring, through primary care, to patients with chronic heart failure
Authors: Coughlan A , Mathews C , Levis O , Mooney C , English K , Fox S , Schitter E , Chaffard M , Marshall L , Glynn J , Hurlebaus J , Bailey D
Published: October 2024

It is estimated that over 90,000 patients in Ireland have a diagnosis of Heart Failure. The HeartCare at Home study was commenced in 2021 as a collaboration between Centric Health and Roche Diagnostic. The study aimed to examine the feasibility of implementing a remote monitoring programme for patients with heart failure, through primary care, and the impact on hospitalisations, A&E attendances, and GP visits.

Patients were referred to the study by their GP. Patients were provided with a blood pressure monitor, weighing scales and smart device in line with the study protocol. The remote monitoring app, a CE-certified Medical Device Class IIa, was provided by Luscii Healthtech. Patients were requested to input their weight, blood pressure, heart rate and symptoms for two weeks after a undergoing a clinical onboard to establish a baseline. Thereafter, readings were entered by patients twice weekly. Patients participated for a minimum of 12 months. If measurements fell outside pre-determined parameters or a deterioration was noted, the team was alerted through the Luscii app dashboard. Where clinically appropriate and in line with cardiologist approved protocols, the team supported the patient to titrate their diuretic medication at home for a maximum of 3 days, with continuous daily monitoring. The patient’s GP was informed of all deteriorations and changes in the patient’s condition and of all recommendations made by the HeartCare at Home team.

One hundred and sixty-two patients were onboarded to the programme while 120 patients completed one year follow up (42% female; median age 76 years, range 31-100 years). Thirty five percent of patients had a diagnosis of HFrEF, 13% HFpEF, and 6% HFmrEF while 43% were undifferentiated. Seventy five percent of patients had a NYHA I or II classification. Over 95,000 clinical measurements were recorded through the Luscii app over the course of the study. Of the decompensations managed directly by the HeartCare at Home team with medication titration and daily monitoring, 70% were clinically resolved following the HeartCare at Home protocol. Adherence to inputting monitoring data remained strong throughout the intervention period with over 89% of participating patients continuing to upload readings as scheduled at 12 months. Using established and secure communication pathways, such as HealthLink and Healthmail, the clinical team were able to interact with each patients GP to ensure continuity of care and optimised patient treatment.

The HeartCare at Home study demonstrates the feasibility of implementing a remote monitoring programme through primary care. Remote monitoring with direct access to clinical support has potential benefits for patients, clinicians, and the health service at large. Further research, in a larger cohort, and examination of the cost of implementation of remote monitoring in primary care, is warranted.
Beneficial effects of the SGLT2 inhibition on oxidative skeletal muscle in infarcted rats
Authors: Souza L M , Damatto F C , Rodrigues E A , Santos A C C , Silva R C F , Meirelles A L B , Mota G A F , Pagan L U , Gatto M , Murata G M , Ojopi E B , Zornoff L A M , Okoshi K , Okoshi M P
Published: October 2024

Introduction

Metabolic, morphological, and biochemical changes in skeletal muscle are common in chronic heart failure patients. Despite the cardioprotective effects of sodium-glucose co-transporter 2 (SGLT2) inhibition in heart failure, the impact of this drug on skeletal muscle remains poorly understood. This study investigated the effects of SGLT2 inhibitor empagliflozin (EMPA) on the soleus muscle of rats with myocardial infarction (MI)-induced heart failure.

Methods

One week after MI induction, male Wistar rats were divided into Sham (n=10), Sham+EMPA (n=12), MI (n=10) and MI+EMPA (n=09) groups. EMPA was added to rat chow (5 mg/kg/day) for 12 weeks. Cardiac remodeling was evaluated by echocardiogram. Enzymatic activity and oxidative stress marker concentrations were assessed by spectrophotometry; protein expression was evaluated by Western blotting. After histological analysis of the left ventricle (LV), only rats with MI greater than 35% of total LV area were included in the study. Statistical analysis: ANOVA and Tukey or Kruskal–Wallis and Dunn and t test; p<0.05.

Results

Infarction size did not differ between groups. Infarcted groups had larger LV systolic and diastolic diameters, LV diastolic area (Sham 47±7.1; Sham+EMPA 48±4.5; MI 100±16.1*; MI+EMPA 85±10.1#† mm2; p<0.05: * vs Sham; # vs Sham+EMPA; † vs MI), and left atrial diameter (Sham 5.62±0.2; Sham+EMPA 5.65±0.3; MI 7.69±1.3*; MI+EMPA 6.85±0.9#† mm; p<0.05: * vs Sham; # vs Sham+EMPA; † vs MI); and lower LV posterior wall shortening velocity and ejection fraction than control groups. Echocardiographic changes were attenuated in MI+EMPA compared to MI. Other results are shown in Picture 1.

Conclusion

SGLT2 inhibitor empagliflozin attenuates infarction-induced cardiac remodeling in rats. Empagliflozin prevents increase in oxidative stress, modulates protein turnover by IGF-1 pathway, and attenuates morphological and biochemical changes in the soleus muscle of infarcted rats.
Quality of muscle in the thigh predicts the prognosis in patients with non-ischemic cardiomyopathy
Authors: Yoshida T , Shibata A , Onoda M , Hayashi O , Tanihata A , Kitada R , Yamazaki T , Izumiya Y , Fukuda D
Published: October 2024

Background

Skeletal muscle atrophy is an independent prognostic predictor for patients with chronic heart failure, and the concept of sarcopenia has garnered scientific attention. Furthermore, the importance of not only muscle mass but also quality of muscle has been pointed out. And a sarcopenia diagnosis is confirmed by the presence of low quality of muscle. However, there is a lack of consensus on the implications of ectopic fat as a quality of muscle for the prognosis in patients with non-ischemic cardiomyopathy.

Purpose

We investigated whether intramuscular fat (IMF) in the thigh affects the prognosis in patients with non-ischemic cardiomyopathy.

Methods

We recruited 250 patients who were diagnosed with non-ischemic cardiomyopathy by cardiac catheterization and echocardiographic date between September 2017 and November 2022. Finally, 223 patients enrolled in this prospective study conducted at a single center. Functional status was evaluated by using cardiopulmonary exercise test at baseline. All patients were measured quantity of the percentage of IMF (%IMF) in the thigh using computed tomography scan. Demographic, laboratory and echocardiographic date were collected from the patients’ medical records. Patients were followed up for up to 3 years. Clinical endpoints were cardiovascular death or unexpected rehospitalization because of cardiac events.

Results

During the follow-up 58 patients had cardiac events. The %IMF was significantly higher in the group with adverse events than without (4.49 ± 4.21 and 3.06 ± 2.39%, respectively; p = 0.001). Spearman correlation coefficient analysis showed a modest correlation between %IMF and exercise tolerance such as anaerobic threshold (Spearman r = -0.367; p < 0.001) and peak oxygen uptake (Spearman r = -0.382; p < 0.001). Patients were divided into 2 groups according to the median values of %IMF. Kaplan-Meier analysis demonstrated that events were significantly higher in the high %IMF group (log-rank p = 0.008). Furthermore, subgroup with left ventricular ejection fraction ≦ 40% or BMI ≧ 22 had a significantly greater frequency of adverse events in the high %IMF group. However, there was no significant difference in %IMF between the groups when divided into two groups at the mean age of this study. Multivariate Cox regression analysis adjusted for left ventricular ejection fraction, estimated glomerular filtration rate, hemoglobin and body mass index found %IMF as an independent factor of adverse events (hazard ratio 1.088; 95% confidential interval 1.024-1.156; p = 0.007).

Conclusions

In patients with non-ischemic cardiomyopathy, quality of muscle represented by %IMF in the thigh is an independent factor for predicting adverse cardiac events.
Validation of existing risk scores for worsening renal function in patients with newly diagnosed heart failure: a longitudinal population cohort study
Authors: Wang H , Tao Y W , Hussain M , Oswald A S , Win M L , Liew Y J , Gao C , Guignard-Duff M , Cole C , Hall C , Das S , Baruah R , Mordi I R , Lang C C
Published: October 2024

Background

Worsening renal function (WRF) is one of the strongest predictors of outcome in patients with heart failure (HF). The presence of WRF often influences the decision to start, up-titrate, or discontinue disease-modifying HF therapies and is one of the key determinants of suboptimal guideline-directed medical therapy. However, there are now potential cardiovascular pharmacotherapies that have favourable cardiorenal outcomes and reduce the risk of renal decline. It is therefore important to identify patients with HF early in their disease trajectory who are at risk of developing WRF.

Purpose

The aim of this study was to evaluate two existing WRF risk scores (the Forman risk score and the Basel risk score) in a population-based longitudinal cohort diagnosed with incident HF.

Methods

Data for individuals with incident HF between 2016 to 2021 were extracted and analysed from the NELSON study conducted in Tayside, Scotland. WRF was defined as a composite event of (i) having two consecutive eGFRs declined by 40% or greater; (ii) having an eGFR < 15mL/min/1.73m2; (iii) initiation of sustained dialysis; (iv) development of end-stage kidney disease; or (v) receiving kidney transplantation. The primary outcome was the occurrence of WRF within 180 days of diagnosis of HF. Among patients hospitalised with HF, in-hospital WRF was also assessed. The area under the curve (AUC) was used to assess the discrimination performance of the two risk scores in individuals with incident HF diagnosed as either in-patients or out-patients.

Results

4076 individuals (mean age 72.8 ± 13.2; 58% male; 1081 HFrEF, 646 HFmrEF, 1348 HFpEF, and 1001 HF with unknown ejection fraction (EF)) who were WRF-free at incident HF diagnosis were identified. Of these, 2095 (51.4%) were diagnosed as in-patients, and 1981 (48.6%) were diagnosed as out-patients. 285 (7%) patients developed WRF within 180 days post HF diagnosis. Among the 2,095 HF in-patients, 75 (3.6%) developed WRF before discharge. The Forman risk score had an AUC of 0.618 (95% CI: 0.585 – 0.651) in predicting 180-day WRF, and an AUC of 0.650 (0.587 – 0.713) for in-hospital WRF. The Basel risk score showed similar discriminating performance with an AUC of 0.618 (0.585 – 0.651) for 180-day WRF, and 0.656 (0.593 – 0.719) for in hospital WRF.

Conclusions

In a contemporary population, conventional risk scores such as the Forman or Basel risk scores have limited discrimination in predicting WRF in incident HF. New models with better discrimination for WRF prediction are therefore needed.
Accelerometer-measured physical activity pattern in older patients with frailty and heart failure
Authors: Sze S , Krishnan S , Squire I B
Published: October 2024

Background

Physical activity (PA) assessed by accelerometers represents a novel method to understand the PA profile of older patients with heart failure (HF). We hypothesized that PA level and pattern vary in HF patients across the spectrum of frailty status.

Aim

To report the duration, intensity and volume of PA in older patients with HF according to frailty status.

Methods

We recruited 150 HF patients≥65 years from a hospital-based HF clinic between March and October 2023. Frailty was assessed using the Short Physical Performance Battery (SPPB); patients with SPPB 10-12, 7-9, 4-6 and ≤3 was classified as robust, mildly, moderately and severely frail respectively. To evaluate PA profile, all patients wore a wrist accelerometer on their non-dominant hand for 7 days (24 hours/ day). PA parameters including average acceleration over 24 hours (proxy of volume of activity); time spent in inactive, light, moderate and vigorous intensity activities; intensity gradient (more negative gradient equates to poorer intensity profile) and time of most active continuous bouts of PA, were compared amongst frailty groups.

Results

146 participants with good quality accelerometer data were included in the analysis; median age 80 (range 65-94 years), 65% male. Thirty-eight percent had heart failure with reduced ejection fraction (HFrEF); 21% had NYHA class III/IV symptoms; median NT-proBNP was 2040 ng/L (IQR = 1110 - 4930). Frail patients were more likely to be older with more comorbidities; they also had more severe HF symptoms and higher NT-proBNP.

Frail patients had lower volume of PA compared to robust patients, evidenced by lower average acceleration (milligravity-mg) over 24 hours [20.4 (robust); 16.0 (mildly frail); 13.5 (moderately frail); 13.2 (severely frail), p<0.001]. PA intensity profile was poorer in frail patients compared to robust patients [median intensity gradient: -2.72 (robust); -2.92 (mildly frail); -3.00 (moderately frail); -3.07 (severely frail), p<0.001]. (Table 1)

Frail patients spent more time inactive compared to robust patients [median time spent inactive (minutes): 654 (robust); 689 (mildly frail); 780 (moderately frail); 720 (severely frail), p<0.001]. The median time (minutes) spent in light [225 (robust); 190 (mildly frail); 164 (moderately frail); 159 (severely frail)] and moderate to vigorous activity [62 (robust), 23 (mildly frail), 15 (moderately frail) and 13 (severely frail), p<0.001] were significantly shorter in frail compared to robust patients. (Figure 1) The most active continuous bout of PA of patients across the frailty spectrum appeared to between 10 AM to 2 PM.

Conclusion

The duration, volume and intensity of PA was generally low in older patients with HF. Worse frailty status was associated with longer duration of physical inactivity, shorter duration of light, moderate or vigorous activity, poorer PA intensity profile and lower volume of PA.
Effectiveness of empagliflozin in patients with heart failure and COPD: Results from EMPEROR-Preserved and EMPEROR-Reduced
Authors: Von Haehling S , Butler J , Anker S D
Published: October 2024

Background

Heart failure (HF) and chronic obstructive pulmonary disease (COPD) are chronic, progressive syndromes that share numerous risk factors and clinical symptoms. We sought to analyse the relationship between COPD status and outcomes in patients receiving empagliflozin or placebo in the EMPEROR-Preserved and EMPEROR-Reduced trials.

Methods and results

We analyzed data of 9,718 patients, including 1,238 (12.7%) with COPD. Compared to patients without COPD, patients with COPD were more likely to be in NYHA class III (19.4 vs. 28.4%), to be male (62.4 vs. 69.0%), to have higher body mass index (29.0±5.7 vs. 29.5±6.1 kg/m2), to be white, to be smoker or ex-smoker (47.1 vs. 71.9%), to be older (69.6±10.5 vs. 72.1±8.7y, all p<0.0001), to have a longer duration of HF (5.0 vs. 5.4y, p=0.04), to have higher haemoglobin and high-sensitivity troponin T values (both p<0.01), and a trend towards more advanced kidney dysfunction. Patients with COPD exhibited a higher adjusted risk of reaching the primary endpoint of first HF hospitalization or CV death compared to those without COPD (adjusted hazard ratio [HR] 1.52, 95% confidence interval [95% CI] 1.28-1.80, p<0.0001). The favorable impact of empagliflozin on the primary outcome remained consistent regardless of COPD status at baseline (no COPD: HR 0.76, 95% CI 0.68-0.84, COPD: HR 0.82, 95% CI 0.66-1.03, p for interaction 0.50, Figure). The effects on HF hospitalizations, cardiovascular and all-cause mortality were not affected by COPD status. The Kansas City Cardiomyopathy Questionnaire showed similar improvement in patients with or without COPD treated with empagliflozin. The distribution of adverse events was comparable between patients receiving empagliflozin and those on placebo, irrespective of COPD status at baseline.

Conclusions

COPD is frequently encountered in patients with HF and associated with worse outcomes. Among patients with COPD, treatment with empagliflozin is associated with consistent efficacy on outcomes and improvement in quality of life as in patients without COPD.
The underestimated risk of prediabetes on cardiovascular outcomes in heart failure with reduced left ventricular function
Authors: Hammer A , Kazem N , Baumer U , Steinacher E , Koller L , Sulzgruber P , Hengstenberg C , Niessner A , Hofer F
Published: October 2024

Background

The global prevalence of prediabetes and diabetes is increasing, highlighting an urgent public health challenge. While the cardiovascular (CV) risk of diabetes is well studied, profound data on the CV risk of prediabetes in patients with heart failure (HF) remain scarce in current literature. Therefore, we aimed to investigate the relationship of prediabetes and diabetes with common HF associated events such as all-cause, CV death and hospitalization for HF (HHF) in patients with HF with reduced ejection fraction (HFrEF).

Methods

Patients with HFrEF who were admitted to a tertiary academic center between 01/2005 and 07/2019 were included in the present analysis and then stratified according to their glycemic state. Prediabetes was defined as an HbA1c value between 5.7% and 6.4% and the absence of diabetes mellitus. The primary outcome was a composite of CV death and HHF. Secondary outcomes were the individual components of the primary outcome and all-cause death. We used cox regression models adjusted for age, sex, chronic kidney disease, body mass index, prior myocardial infarction, hypertension, CRP, and LDL-C.

Results

In total, 1,777 patients (median age 69 years, 24.3% female) were included in the present analysis and followed over a median of 4 years. Among them, 35.2% were diabetic, 18.7% prediabetic, and 46.1% showed non-impaired glucose metabolism. NT-proBNP levels were comparable between all glycemic groups. Both prediabetes and diabetes were found to significantly increase the risk of CV-death or HHF compared to those with normal glucose metabolism, with adjusted hazard ratios (HR) of 1.41 (95% Confidence Interval [CI]: 1.05-1.89) and 1.52 (95% CI: 1.17-1.97), respectively. This elevated risk applied to both components of the primary outcome, as illustrated in Figure 1. Notably, the increased risk of all-cause mortality was statistically significant only among diabetic patients (adj. HR 1.75; 95%CI: 1.30-2.36), with prediabetic patients showing a trend towards increased risk but not reaching statistical significance (adj. HR 1.40; 95%CI: 0.99-1.97).

Conclusion

The findings of this study underscores the independent associations between both prediabetes and diabetes with increased risks of cv-death and HHF in patients diagnosed with HFrEF. This emphasizes the critical role of glycemic status in the prognostication and management of HFrEF. The associations suggest that prediabetes is not merely a transient or benign state but has significant implications for cardiovascular health, particularly in the context of HF. In light of these findings, screening of prediabetes in patients with HFrEF might help to identify patients at risk who are susceptible for the development of HF related adverse events.Forest plot for all study endpointsKaplan-Meier curves for CV-death/HHF
Single center experience of internal jugular vein as alternative access for implantation of a wireless pulmonary artery pressure sensor
Authors: Albulushi A , Youssef A
Published: October 2024

This single-center study delves into the novel use of the internal jugular vein (IJ) as an alternative access pathway for the implantation of the CardioMEMS device, a wireless pulmonary artery pressure sensor. This approach is compared to the conventional femoral vein access in terms of procedural times, contrast volume, and patient outcomes. The study spans five years, from 2018 to 2023, evaluating the efficacy and safety of IJ access for CardioMEMS implantation.

The analysis revealed a tendency towards shorter procedural times and reduced contrast volume with IJ access, although statistical significance was not reached due to the small sample size. Notably, IJ access provided a quicker needle-to-door time, suggesting benefits such as improved patient throughput and potentially shorter hospital stays, which are pivotal in a healthcare landscape that prioritizes efficiency and cost-effectiveness.

In conclusion, this investigation offers initial evidence that IJ vein access is a feasible and potentially superior alternative for CardioMEMS device implantation. While the findings are preliminary due to the study's limited scale, they pave the way for future larger-scale, multicenter studies. Such research could confirm the benefits of IJ access and possibly influence clinical practices, enhancing the management of heart failure patients.
REDUCE-HF: a stronger heart go a long way
Authors: Kam K , Chan C P , Wong L N , Lai L , Mak H L , Fung K Y , Chan W C , So K , Cheung L L , Tan G M , Lee P W , Yan B
Published: October 2024

Introduction/Purpose

Heart failure (HF) is a serious cardiovascular condition with a significant global health concern. The risk of heart failure rehospitalisation is high globally and locally, the 30-day HF readmission was about 32% from a local study (1). The study aims to adopt an intensive treatment strategy similar to Strong-HF trial (2) and evaluate rapid up-titration of guideline directed medical therapy (GDMT) and close follow-up will improve patients' outcomes after acute heart failure (AHF).

Objectives

The Reduction of Decompensation and Unnecessary Cardiac failure Emergency admissions: ambulatory Heart Failure service model (REDUCE-HF) is a non-randomised prospective study evaluating clinical outcome of patients discharged from AHF. Exclusion criteria included primary valvular disorders, end-stage renal failure and metastatic cancer. After HF discharge, eligible patients were recruited into our REDUCE-HF program irrespective of LVEF. They were subsequently managed in our ambulatory HF centre within two weeks, where intensive up-titration of GDMT and close follow-up would be proceeded. The data of our service model will be compared with our 5-year historical cohort. Primary outcome comprised of all-cause mortality and heart failure hospitalisation. Secondary outcome will be comparison of clinical and functional status at baseline and 3-month on follow up.

Results

Between October 2022, and December 2023, 245 patients were successfully recruited into our REDUCE-HF service model. Historical cohort of 6867 patients with primary diagnosis of acute heart failure were served as control (usual care pathway), data extracted from 2018 to 2022. Their mean age was 67.8+/-12.2 and 72.2%were male. 60% of them were HFrEF (EF<=40%) and 28% were ischaemic cardiomyopathy. The mean follow up period was 3 months. At 90 days, REDUCE-HF cohort group has shown much lower all-cause mortality than usual care group (2.5% vs 9.3%, HR 0.26, 95% CI 0.18-0.41, p<0.001). There was a much lower incidence of heart failure hospitalisation in REDUCE-HF group as compared to control (8.6% vs 13.1%, HR 0.65; 95% CI 0.55 to 0.74, p<0.01). In secondary outcome, there was significant reduction of NT-ProBNP of 45.2% (from 4229 to 2319pg/m, p<0.001), tremendous increment of 6-minute walk test (from 211 to 250m, p<0.001) and remarkable improvement of KCCQ score from 55.1 to 86.7, p<0.001. The overall LVEF was significantly increased from 39% to 44%, p<0.05. The positive outcome were attributed to good adherence to GDMT: ACEi/ARB/ARNI 91%, Betablocker 90.3%, MRA 72.4% and SGLT2i 95.5%.

Conclusion

The REDUCE-HF ambulatory service model has been proven effective in reducing mortality, decompensation and preventing unnecessary heart failure hospitalisation in this prospective study. By intervening proactively, this model not only enhances the quality of life but also hold promise in alleviating the burden of in-patient services on heart failure.