bluuebunny/crossref_metadata_2025 huggingface dataset:
Left atrial functional assessment a prime clue in solving the puzzle of stable angina symptoms in suspected coronary artery disease patients
Authors: Tewari S , Khare H , Sahu A , Khanna R , Kumar S , Garg N , Kapoor A
Published: November 2023

Background

Assessing clinically for significant coronary artery disease (CAD) in stable angina patients presents a formidable task. Routinely performed echocardiography is limited in diagnosing CAD with provision for the regional wall motion abnormality (RWMA) for left ventricle (LV) systolic dysfunction and altered mitral inflow velocities for LV diastolic dysfunction. However, the advent of two-dimensional (2D) speckle-tracking technique has established the era of strain imaging, opening new possibilities in echocardiography. It is now possible to have a detailed functional assessment of left atrium (LA). We utilised speckle tracking imaging to obtain strain parameters for LA function. Combining these strain parameters with the doppler myocardial velocities and mitral inflow velocities, may prove useful mode of imaging to diagnose significant CAD in stable angina patients.

Purpose

To study the parameters of left atrial functions utilising echocardiographic strain imaging and evaluate their correlation with the syntax score-II in patients with symptoms of stable angina.

Methods

103 patients with symptoms of stable angina undergoing coronary angiography for suspected coronary artery disease(CAD), were considered for LA function assessment and compared with their syntax-II score.

Results

The LA reservoir function parameters, peak atrial longitudinal strain (PALS) and peak global systolic strain rate (LAsSR), decreased with increasing syntax-II score (p values 0.011 and 0.001 respectively) and the parameter of LA conduit function, peak global early diastolic strain rate (LAeSR) increased (p value <0.001). The LA filling pressures reflected by E/e`, also increased with more severe syntax-II score (p value <0.001). We, further, configured cut off values of < 23.56 for PALS, < 1.15 for LAsSR, > -1.09 for LAeSR, and E/e` ratio > 10.39 as predictors of significant CAD, with good sensitivity and specificity. Therefore, stable angina patients who had significant CAD on coronary angiogram represented by severe syntax score-II, had higher LA filling pressures and deranged LA function with transition from more of reservoir chamber to merely a conduit.

Conclusion

Our study shows a significant association between LA strain parameters (PALS, LAsSR, and LAeSR) and LA filling pressures (E/e`), with the presence of significant CAD in these patients. The stable angina patients with more severe CAD as quantified by their severe syntax score-II, have an impaired LA reservoir and LA functions more as a conduit, with elevated filling pressures. This study establishes a significant association between LA deformation strain variables and severity of CAD and hence LA strain imaging can be a useful tool to diagnose significant CAD in stable angina patients.
The prognostic value of echocardiographic right ventricular global longitudinal strain in heart failure: A systematic review and meta-analysis
Authors: Anastasiou V , Papazoglou A S P , Moysidis D V M , Daios S D , Peteinidou E P , Zegkos T Z , Giannakoulas G G , Karamitsos T K , Ziakas A Z , Kamperidis V K
Published: November 2023

Background

Right ventricular (RV) dysfunction is a well-recognized adverse prognostic feature in patients with heart failure (HF). However, accurate RV functional assessment remains challenging in clinical practice. Recently, many studies have demonstrated that RV global longitudinal strain (RV GLS) assessed using speckle tracking echocardiography might be a powerful prognosticator in HF.

Aim

To systematically appraise and quantitatively synthesize the prognostic evidence of RV GLS derived by echocardiography, across the entire spectrum of left ventricular ejection function (LVEF) in HF.

Methods

A systemic literature review was conducted in MEDLINE, Scopus and Cochrane databases to identify every study reporting the predictive role of RV GLS in HF subjects irrespective of LVEF. A random-effects meta-analysis was conducted to quantify the adjusted and unadjusted hazard ratios [(a)HRs] for all-cause-mortality and the composite outcome of all-cause mortality or any HF-related hospitalization per each unit of increase in RV GLS. Subgroup analysis was feasible for patients with LVEF<45%.

Results

Thirteen studies were deemed eligible for inclusion in the systematic review. Of them, 8 provided appropriate quantitative data for the meta-analysis, encompassing a total of 3,736 patients. When adjusted for pre-specified clinically-relevant parameters, it was shown that each unit of increase in RV GLS conferred increased risk of all-cause mortality (pooled aHR=1.08 [1.03-1.13]; p<0.01; I²=76%) and the composite outcome (pooled aHR= 1.10 [1.06-1.15]; p<0.01; I²=0%) for patients with HF (Abstract Picture 1 and 2). Subgroup analysis for HF patients with LVEF<45% yielded similar results, with each increase of 1% in RV GLS being independently associated with increased risk of all-cause mortality (pooled aHR=1.10 [1.06-1.13]; p<0.01; I²=0) and the composite end-point (pooled aHR= 1.13 [1.07-1.20]; p<0.01; I²=0%) (Abstract Picture 1 and 2).

Conclusion

RV GLS assessed by speckle-tracking echocardiography is a novel echocardiographic biomarker that can further add in patient prognostication across a wide range of HF populations regardless of LVEF.RV GLS and all-cause mortalityRV GLS and the composite outcome
Association between implanted cardioverter-defibrillator and mortality for patients with left ventricular ejection fraction near 35%
Authors: Wasfy J , Achanta A , Hidrue M K , Urbut S , Axtell A L , Berman A B , Chen C , Gustus S , Picard M H
Published: November 2023

Background

Consensus guidelines support the use of implanted cardioverter-defibrillators (ICD) for primary prevention of sudden cardiac death in patients with either non-ischemic or ischemic cardiomyopathy with left ventricular ejection fraction ≤ 35%. Despite that class 1 recommendation, evidence from trials for efficacy specifically for patients with left ventricular ejection fraction (LVEF) near 35% is weak. Past trials are underpowered for this population and future trials are unlikely to be performed. As such, we aimed to use a large longitudinal echocardiography database linked to mortality to assess the comparative effectiveness of ICD therapy near the conventional primary prevention LVEF threshold.

Methods

Patients with lowest LVEF between 33-38% without an ICD prior to the lowest-LVEF echo (defined as "time zero") were identified by querying echocardiography data from November 28, 2001 until July 9, 2020 at large general hospital-based echocardiography registry linked to ICD treatment status. These data were then linked to mortality and comorbidity data. After inclusion and exclusion criteria were applied, 6,144 patients remained for the analytic cohort.

Given evidence of covariate imbalance around the LVEF = 35% threshold, fuzzy regression discontinuity methods were considered but not used. Instead, to assess the association between ICD and mortality, multiple propensity score methods including matching and inverse probability of treatment weighting (IPTW) were used to create synthetic reference groups. Survival was then assessed with Cox proportional hazards models considering treatment status as a time-dependent covariate.

Results

In bivariate unadjusted comparisons, patients who received ICDs were substantially more often male (85.6% vs. 64.9%, p < 0.0001), more often white (87.3% vs. 82.9%, p < 0.048), and more often had a history of ventricular tachycardia (41.1% vs. 12.1%, p < 0.0001) and myocardial infarction (42.1% vs. 34.7%, p = 0.008). In the propensity matched sample, after accounting for time-dependence, there was no association between ICD and mortality (HR 1.09, 95% CI 0.86-1.39, p = 0.474). In the IPTW analysis, there also was no association between ICD and mortality (HR 1.09, 95% CI 0.91-1.30, p = 0.3672).

Conclusions

ICD therapy was not associated with reduced mortality near the conventional LVEF threshold of 35%. Although this treatment design cannot definitively demonstrate lack of efficacy, our results are concordant with available prior trial data. A definitive, well-powered trial is needed to answer the common and important clinical question of primary prevention ICD efficacy near the threshold of LVEF = 35%.
Efficacy of implantable cardioverter-defibrillator in non-ischemic systolic heart failure in patients with and without chronic kidney disease: an extended follow-up analysis of the DANISH trial
Authors: Doi S N , Butt J H , Thune J J , Nielsen J C , Haarbo J , Yafasova A , Bruun N E , Gustafsson F , Eiskjaer H , Hassager C , Svendsen J H , Hofsten D E , Torp-Pedersen C , Pehrson S , Kober L
Published: November 2023

Background

Patients with heart failure (HF) and chronic kidney disease (CKD) may have an increased risk of death from causes competing with arrhythmic death, which could have implications for the efficacy of implantable cardioverter defibrillators (ICDs).

Purpose

In this extended follow-up study of the Danish Study to Assess the Efficacy of primary prevention of Implantable Cardioverter Defibrillators in Patients with Non-ischemic Systolic Heart failure on Mortality (DANISH), adding four years of additional follow-up, we examined the long-term effects of primary-prevention ICD implantation, compared with usual medical care, according to baseline CKD status.

Methods

In the DANISH trial, 1,116 patients with non-ischemic systolic HF were randomized to receive an ICD (N=556) or usual care (N=550). Outcomes were analyzed according to CKD status (eGFR ≥/< 60 mL/min/1.73 m2) at baseline. The primary outcome was death from any cause. Secondary outcomes were cardiovascular death and sudden cardiovascular death.

Results

In total, 1,113 patients had an available eGFR measurement at baseline (median eGFR 73 ml/min/1.73 m2), and 316 (28%) had CKD. During a median follow-up of 9.5 years, ICD implantation, compared with usual medical care, did not reduce the rate of death from any cause (no CKD, HR 0.81 [95% CI, 0.64-1.03]; CKD, HR 0.92 [0.68-1.26]; P for interaction=0.31) or cardiovascular death (no CKD, HR 0.76 [0.57-1.02]; CKD, HR 0.95 [0.66-1.36]; P for interaction=0.21), irrespective of baseline CKD status. Similarly, baseline CKD status did not modify the beneficial effects of ICD implantation on sudden cardiovascular death (no CKD, HR 0.57 [0.32-1.00]; CKD, HR 0.60 [0.31-1.14]; P for interaction=0.70).

Conclusions

Primary-prevention ICD implantation did not provide an overall survival benefit regardless of baseline kidney function in patients with non-ischemic systolic heart failure.Figure
QRS width variation as a marker of prognosis after CRT implantation: getting slimmer is getting better
Authors: Ferreira D , Brito J , Silva P A , Antonio P S , Pereira S C , Silva B V , Oliveira C , Garcia B , Martins A M , Raposo P M , Gregorio C , Fonseca J , Abrantes A , Vilela M , Cravo J
Published: November 2023

Introduction

Cardiac resynchronization therapy (CRT) is a major therapeutic tool in the management of patients with systolic heart failure. However, controversy remains regarding who will most benefit from this device. The aim of the present study was to evaluate the impact of QRS duration on echocardiographic response and clinical outcomes.

Methods

We conducted a retrospective, observational, single-center study of patients submitted to CRT implantation. Only patients with electro and echocardiographic data on baseline and follow-up were included. CRT response was defined as an improvement of LVEF >10% or LVESV>5%. CRT superresponse was defined as an improvement of LVEF above the population 4th quartile (18%). Impact of QRS variables on CRT response was evaluated with ROC curve analysis. Clinical outcomes were defined as hospitalizations due to heart failure and all-cause mortality. Impact of QRS on clinical endpoints, response and superresponse was evaluated with survival analysis.

Results

From a total of 654 pts a total of 245 fulfilled the inclusion criteria. (57,3%% female, mean age). Most of the pts had a non-ischemic etiology (61,5%) and atrial fibrillation was present in 29.4%. The QRS characteristics were the following, baseline: 162+21ms, follow-up 159+28ms, mean QRS variation: 3+29ms. CRT response occurred in 69% of the pts and superresponse in 26%.

QRS variation is the best predictor of CRT response (AUC =0,66, 95%CI 0,58-0,74, p<0,001). Interestingly, a QRS reduction above 8ms presented the best accuracy (S:70%;E:57%) for response to CRT. On multivariate analysis, after adjustment for gender, atrial fibrillation and cardiopathy etiology, only a QRS reduction above 8ms (p 0.028, HR 1.974 CI (1.075-3.623) and lower baseline LVEF (p = 0.02, 95% CI 0.943 (0.909-0.979) were significant independent predictors of CRT superresponse.

Additionally, a QRS reduction higher than 8ms was a protective factor for long-term clinical outcomes during follow-up (p<0.001 HR (2,445) 1,553 a 3,849) – fig.1.

Conclusion

In pts with implanted CRT a reduction in QRS width, as small as 8ms, its a marker of improved LV function and a better clinical prognosis.
Transition from temporary microaxial left ventricular assist devices to durable mechanical circulatory support systems
Authors: Lewin D , Szymanski M K , Meyer A L , Saeed D , Scandroglio A M , Akhyari P , Meyns B , Loforte A , Oezkur M , Zimpfer D , Gustafsson F , Billion M , Belohlavek J , Bernhardt A M , Potapov E
Published: November 2023

Background

Circulatory support with a catheter-based microaxial temporary left ventricular assist device (tLVAD) plays a major role in the treatment of severe cardiogenic shock. In most patients who fail to recover while on temporary mechanical circulatory support (tMCS), durable left ventricular assist device (dLVAD) therapy is usually considered a reliable option. The aim of this study was to identify outcome predictors after the transition from a catheter-based microaxial tLVAD to dLVAD.

Methods

This is a retrospective analysis of data from a multicentre registry on patients who were transitioned from a catheter-based microaxial tLVAD to a dLVAD between 01/2017 and 10/2022 (n=341) from 19 European high-volume centres with regard to survival and outcome up to one year after dLVAD implantation.

Results

Patients were supported with an Impella 5.5 (92), 5.0 (155), CP (92), or 2.5 (2) and transitioned to Heartmate 3 (205), a HeartWare HVAD (129) or EXCOR VAD (7) during the same period. The Impella was implanted via the axillary artery in 245 (71.8%), the femoral artery in 93 (27.3%), and via direct access to the aorta in three (0.9%) patients. One hundred and thirty-three (40.5%) patients additionally required extracorporeal life support before and/or during Impella therapy. The aetiology of cardiogenic shock necessitating tMCS was most commonly acute myocardial infarction (31.7%), followed by acute decompensation of ischaemic (28.4%) or dilated cardiomyopathy (27.0%). The 30-day and 1-year survival were 87% and 70%, respectively. The uni- and multivariable analysis included 312 patients with an at least 1-year follow-up or death within the first year after dLVAD implantation. The following risk factors for 1-year mortality were identified: age (OR 1.02), specifically age over 55 years (OR 1.09), BMI >30 kg/m² (OR 2.2), female sex (OR for male sex 0.4), as well as elevated total bilirubin (OR 1.13) and low platelet counts (OR 0.996).

Conclusions

During preoperative conditioning, efforts should be undertaken towards normalising platelet counts and liver function. Using the identified risk factors as a basis, we created a risk score to estimate 1-year mortality to optimise patient selection for dLVAD implantation, with the aim of improving the outcome in this critical patient population.Normogram 1y-mortality prediction scoreCIF death grouped by quartiles of score
Necropsy findings in heart transplant recipients with and without primary graft dysfunction: a retrospective study
Authors: Belfort D S P , Mangini S , Avila M S , Marcondes-Braga F G , Campos I W , Seguro L F B C , Bacal F , Gutierrez P S
Published: November 2023

Background

Primary graft dysfunction (PGD) is the leading cause of death in the first year after heart transplant (HT). Physiopathology of PGD is not clear, and histological findings are not defined in literature.

Purpose

The objective of this study is to describe the morphological findings in the hearts of patients who died within the first 14 days after HT and to compare findings between 2 groups: a group with the diagnosis of PGD and a group without PGD.

Methods

We included all adult patients submitted to HT in one center who died within the first 14 days after the procedure and were submitted to necropsy between January 1st, 2013 and March 31st, 2020. Demographic, perioperative, histological and immunohistochemical data on heart slides obtained on necropsy were recorded retrospectively. We retrospectively analyzed if the patients met the ISHLT criteria for PGD, and then we categorized them in two groups: PGD group or non-PGD group. All heart slides were reviewed by an experienced pathologist considering the presence of histological features of acute cellular rejection, antibody-mediated rejection, necrosis and its morphological characteristics if present. Pathologist was blind for each patient group. We considered the necrosis significant if it took more than 10% of the examined area. All findings were compared between groups.

Results

Among 322 HTs performed, 31 patients died within 14 days after the procedure. Five patients were not subjected to autopsy, and the remaining 26 patients were included. Twelve patients presented PGD, while 14 patients did not. Comparison between groups shows longer ischemia time, higher incidence of pre-transplant mechanical circulatory support, lower post-transplant left ventricular ejection fraction and higher incidence of post-transplant right ventricular dysfunction in PGD group (Table 1). Necropsy findings were similar between groups and four patterns of necrosis were found, namely microcalcified, contraction-band, coagulative and liquefactive necrosis (Table 2). Necrosis was detected in the 80.7% of all cases, taking more than 10% of the myocardial area in 46.1% of them. Seven patients (26.9%) presented signs of mild cellular rejection (1R). One of them had also antibody-mediated rejection. One patient presented hyperacute graft rejection. The cause of death was defined by necropsy in 21 cases. The most common cause of death in PDG group was cardiogenic shock (66.7%), while in non-PGD group septic shock (28.5%) and bleeding (21.4%) were the most common causes.

Conclusion

While left ventricular ejection fraction was significantly lower in PGD group, necrosis was a frequent finding both groups, raising the hypothesis maybe necrosis is not directly the cause of cardiac dysfunction in PGD. More studies are needed to fully understand PGD pathology.Table 1Table 2
Elevated lipoprotein a level in heart transplant patients is associated with cardiac allograft vasculopathy
Authors: Enriquez Vazquez D , Barge-Caballero E , Domenech-Garcia N , Rodriguez-Vazquez P , Formoso-Lavandeira M D , Barge-Caballero G , Couto-Mallon D , Paniagua-Martin M J , Blanco-Canosa P , Grille-Cancela Z , Lopez-Canoa J N , Lopez-Vazquez P , Vazquez-Rodriguez J M , Crespo-Leiro M G
Published: November 2023

Introduction

Lipoprotein A (LpA) is considered a cardiovascular disease (CVD) risk factor and its interest has grown in recent years. High LpA levels (above 50 mg/dL) are associated with an increase in the occurrence of CVD and degenerative aortic valve disease despite treatment with statins and low LDL levels. The prevalence of elevated LpA levels after heart transplantation (HT) and the implication on the development of cardiac allograft vasculopathy (CAV) is not well known.

Objective

To assess the prevalence of elevated LpA levels in patients with HT and the relationship between higher LpA levels and CAV at 1 year.

Methods

Retrospective, unicentric and observational study based on the historical cohort of HT patients. We selected those patients in whom a pre-transplant serum sample was available in the biobank for LpA analysis. CAV was diagnosed with coronary angiography.

Results

We studied 80 HT patients. Baseline characteristics are in table 1. Median LpA levels were 14.5 (5.0-35.3), and from the 80 HT patients, 16 (20,0%) had LpA≥50 mg/dl (figure 1A). Out of the 80 patients, 68 had a coronary angiography at 1 year follow up (3 died before 1 year and 9 patients did not have angiography at 1 year for diverse reasons).

Twenty patients (29.4%) presented CAV in the first year. Patients with elevated LpA levels had more frequency of CAV at 1 year [11/16 (68.8%) vs 9/43 (17.3%); p<0,001]. LpA levels in patients with CAV was higher (62.5+-58.8 vs 23.9+29.8; p<0,001) (figure 1B).

LDLc and Total cholesterol were significantly lower in patients with CAV at 1 year in this population. In univariate analysis, smoker donors were associated with CAV development (60.0% vs 33.3%; p 0.042). We did not find differences in other recipient or donor cardiovascular risk factors, rejection episodes or CMV infection in the first year.

Conclusion

Elevated LpA levels (≥50 mg/dl) are frequent in HT patients (20%) and in our cohort, were associated with CAV at 1-year post-HT. Further studies are needed to verify these results and study the relationship with the development of other cardiovascular events in HT patients.Table 1Figure 1
The "Triage" clinic: close communication between hospital and community heart failure unit reduces readmissions
Authors: Weinstein J M , Kiselnik D S , Sidi A , Hemo Z , Guterman E , Refaelovich E
Published: November 2023

Background

Heart Failure (HF) causes an immense medical and financial burden on health systems. Recurrent hospitalizations lead to a severe reduction in quality of life and worsen prognosis. The chance of readmission is 24% within a month after discharge and over 50% within 6 months, despite great improvements in treatment. A large proportion of readmissions are for noncardiac reasons.

Aim

To reduce readmissions in patients recently discharged from a hospitalization for HF worsening, by improving and promoting close communication between hospital and community.

Methods

We initiated a pilot study at our community HF unit (HFU), whereby details of patients hospitalized for HF on two general medical wards were sent directly by the ward nursing staff to the HFU head nurse, and the patients were invited to the HFU as soon as possible after discharge (the Triage clinic). The treatment protocol included IV therapy where indicated (furosemide, iron) and titration of oral medications, with close medical and laboratory follow-up. Readmissions rates over 1, 3, 6 & 12 months (for HF or all causes, including HF) were compared to the equivalent period prior to the index admission. A further comparison was made with a control group of HF patients invited to the HFU but who chose not to attend.

Results

Between 2/2020 and 3/2021, 108 patients were seen in the Triage clinic, within an average time of 11 days from discharge. After the first visit, 10 patients were discharged and 1 died. 97, 75 & 46 patients completed follow-up of 3, 6 & 12 months, respectively. Readmissions for HF were 50% lower over 1,3, & 6 months compared to the equivalent period before treatment in the Triage clinic, and 15% lower after 12 months. Readmissions for all causes were 45% lower over 1, 3 & 6 months compared to the equivalent period before treatment in the Triage clinic, and 35% lower after 12 months. In the control group, 55, 33 and 15 patients completed follow-up of 3, 6 & 12 months, respectively. On comparing the Triage group to the control group, there was a reduction of 75% in recurrent admissions for HF or all causes after 1 month, and 60% reduction after 3, 6 and 12 months. In the Triage group, there were an average 2.5 changes in therapy per patient per month. On average, there was an average 1.6 IV furosemide and 2.6 IV iron treatments per patient per year. The functional capacity improved by a factor of 2.5.

Conclusions

Promoting close communication between hospital and community can lead to a significant improvement in HF care, as seen by better quality and efficacy of therapy and speed of access. This in turn reduces rehospitalizations and improves quality of life.
The effect of SGLT2 inhibitor on clinical outcomes in patients with type 2 diabetes and atrial fibrillation
Authors: Shin S H , Cho Y , Park M A , Jang J H , Kim D Y , Kim S H
Published: November 2023

Background

Atrial fibrillation (AF) is the most common arrhythmia and represents a significant public health burden with an increased risk of stroke, heart failure (HF) and mortality. Sodium glucose cotransporter 2 (SGLT2) inhibitors improve clinical outcomes in several populations including type 2 diabetes, chronic renal insufficiency, and HF. However, limited data exist on their effects on AF.

Purpose

We investigated impact of SGLT2 inhibitor on clinical outcomes compared to dipeptidyl peptidase 4 (DPP4) inhibitor among patients with type 2 diabetes and AF.

Methods

We conducted a retrospective cohort study using the National Health Insurance Service database. A total of 4,771 patients with type 2 diabetes and AF who were newly prescribed SGLT2 inhibitors or DPP4 inhibitors from Jan 2014 to Dec 2019 were selected and matched in a 1:2 ratio by propensity score with 38 confounding variables. We assessed the relationship of SGLT2 inhibitor with clinical outcomes including mortality, stroke, myocardial infarction (MI) and hospitalization for HF compared with DPP4 inhibitor using Cox regression model.

Results

Over the follow-up, 181 patients (3.7%) died, 121 patients (2.5%) were hospitalized for HF, 95 patients (2.0%) experienced MI, and 293 patients (6.1%) had stroke. Compared to DPP4 inhibitor, SGLT2 inhibitor was associated with lower risk of mortality (HR 0.61; 95% CI 0.39-0.94; P=0.025), but not of MI (HR 1.22 [95% CI 0.71-2.08]; P=0.46) or stroke (HR 1.0 [95% CI 0.75-1.33]; P=0.98). While the incidence of hospitalizations for HF tended to be lower in the SGLT2 inhibitor group, it did not reach a statistical significant level (HR 0.63 [95% CI 0.39-1.02]; P=0.06).

Conclusion

In a nationwide cohort of patients with type 2 diabetes and AF, SGLT2 inhibitor was associated with a lower risk of mortality compared to DPP4 inhibitor.
Soluble transferrin receptor as a marker of tissue iron deficiency: impact on health-related quality of life in patients with heart failure without systemic iron deficiency or anaemia
Authors: Ras Jimenez M , Ramos Polo R , Jimenez Marrero S , Jose Bazan N , Corbella M , Calero Molina E , Alcoberro L , Quiros Hidalgo E , Enjuanes Grau C , Yun Viladomat S , Ruiz Munoz M , Garay A , Moliner P , Comin Colet J
Published: November 2023

Background

Soluble receptor of transferrin (sTfR) is a marker of tissue iron status and may help to inform on subtle iron depletion and increased iron demand of functional proteins at tissular level even in the absence of systemic iron deficiency or anaemia. Raised sTfR levels have been associated with of all-cause mortality and impaired exercise capacity in patients with heart failure (HF). However, the impact quality of life (QoL) has not been evaluated.

Purpose

The aim of our study was to describe the association between sTfR as a marker of increased iron demand and tissue iron deficiency and QoL in non-anaemic patients with HF and normal systemic iron status.

Methods

We conducted an observational, prospective, cohort study of 1120 consecutive patients with chronic HF (DAMOCLES study). For the current sub-study, we selected all patients form the DAMOCLES cohort that had normal haemoglobin levels and normal systemic iron and available QoL data. Tissue ID was defined as levels of sTfR> 75th percentile (1.63mg/L). To assess QoL, we used the Minnesota Living with Heart Failure Questionnaire (MLHFQ). The primary endpoint was the overall summary score (OSS) of the MLHFQ instrument self-administered at inclusion in the study.

The unadjusted parametric and non-parametric associations between sTfR and the MLHFQ OSS scores were explored using General Additive Models (GAM). Univariate and multivariate linear regression models were constructed to explore the associations between sTfR levels and tissue ID and the QoL scores. All models were adjusted by age, sex, and prognostic factors such as LVEF, NYHA, NT-proBNP levels and iron status parameters among other well-known determinants of HF severity.

Results

The final study cohort consisted in 206 patients. Mean age was 70±12 years, mean LVEF was 43±15% and 61 (30%) were women. Mean sTfR values were 1.42±0.66 mg/L. Tissue ID was present in 54 patients (26%). Mean MLHFQ OSS were 42±26. Global QoL was significantly worse in patients with tissue ID compared to patients without tissue ID (51±27 vs. 39±20, p-value=0.006, respectively). In unadjusted GAM models (Figure 1) showed a direct and significant association between increased iron demand and worse global QoL with a linear p-value<0.0001.

As shown in Table 1, higher sTfR were associated with higher MLHFQ OSS scores in unadjusted models. These findings were confirmed in forward stepwise multivariate linear regression models (Table 1).

Conclusions

In a cohort of HF patients without iron deficiency or anaemia, higher levels of sTfR indicating increased iron demand and tissue ID were associated with worse QoL.
Hemodynamic forces analysis using transthoracic echocardiogram in acute heart failure
Authors: Vassia V , Pantaleoni S , Ferrando F , Airale L , Milan A , Norbiato C , Iannaccone A
Published: November 2023

Introduction

Heart failure (HF) represents a major health problem, being one of the leading causes of hospitalization.

At present, echocardiography plays a key role in HF diagnosis and many innovations have been made. Particularly, in the last decades attention was directed towards fluid dynamic study, as it seems to better predict ventricular dysfunction. Therefore, the concept of hemodynamic forces (HDF) was introduced.

Purpose

The aim of our study was to evaluate HDF in patients with acute HF in the setting of the Emergency Room and at the time of recovery, furthermore, comparing them with healthy volunteers. Patients were also contacted 30 days after discharge in order to evaluate whether there had been new hospital admissions.

Methods

We enrolled 132 patients, of whom only 14 were effectively recruited given the need for the presence of sinus rhythm and the absence of severe valvulopathies. These patients were compared with 8 healthy volunteers. All individuals underwent trans-thoracic echocardiography, in order to assess cardiac morphology and function. HDF analysis was performed using QStrain software.

Results

The graphical presentation of HDF analysis differed in a statistically significant manner between patients with acute HF and healthy volunteers, with the first group showing a lower systolic peak (7.66% [6.32;14.3] vs 21.6 % [18.4;26.7]; p 0.003) and a shorter diastolic time (372 msec [342;472] vs 631 msec [468;679]; p = 0.012). Moreover, in patients with HF we identified a statistically significant reduction of the Inward Displacement (ID), a recently introduced parameter of systolic function, (12667 [10404;22647] vs 27289 [25131;29001]; p 0.003) and an increased systolic ratio, consisting of the ratio between transverse and apical-basal HDF (23.6±10.9 in HF patients vs 17.5±5.60 in healthy subjects; p = 0.102).

Comparing patients with HF in the acute phase and at the time of recovery, we couldn’t obtain statistically significant results due to the small sample size. However, considering case by case, we pointed out a difference in ID and in systolic ratio which seemed to better identify effective hemodynamic stability compared with Ejection Fraction (EF) and Global Longitudinal Strain (GLS).

Conclusion

Our study appears to be the first one to evaluate HDF in the setting of acute HF. Our results suggest how HDF analysis could be a useful tool improving HF management, particularly leading to a better identification of effective hemodynamic compensation.

However, we also emphasized the limitations of this tool, which currently restrict its use to the outpatient setting, particularly in the field of research.
Speckle-tracking global longitudinal strain as a predictor of clinical outcomes in patients with idiopathic inflammatory myopathies
Authors: Stronati G , Paolini F , Brugiatelli L , Alfieri M , Bastianoni G , Palmieri D , Paladini A , Dello Russo A , Moroncini G , Danieli M , Guerra F
Published: November 2023

Background

Idiopathic inflammatory myopathies (IIM) are systemic immune-mediated diseases that involve the skeletal muscle and several other organ systems, including the heart. Nonetheless, cardiac involvement in IIM is frequent and initially subclinical. Previous studies have demonstrated how speckle-tracking-derived global longitudinal strain (GLS), as a measurement of the subclinical systolic ventricular dysfunction, is significantly lower in IIM compared to healthy controls.

Purpose

To assess the progression of myocardial deformation in patients with IIM and test GLS as a prognostic marker of death and cardiovascular events.

Methods

We enrolled all consecutive patients with a diagnosis of IIM sent to our Cardiology Clinic. The diagnosis of definite idiopathic polymyositis or idiopathic dermatomyositis as made according to the Bohan and Peter criteria and confirmed by muscle biopsy. Patients with inclusion body myositis, necrotizing autoimmune myositis, overlap myositis, and juvenile myositis were excluded from our study. All patients underwent full evaluation, including clinical, ecg and echocardiographic assessment as well as GLS calculation both at baseline and follow up appointments. Primary endpoint was a composite of death and cardiovascular events.

Results

41 consecutive patients (28 females, 58±15 years) with IIM were consecutively enrolled and followed up for a median of 8 years (4-11 years). During follow-up, a progressive worsening of LVEF (-4%; p=.03) and left GLS (LGLS: +3%; p=.04) was shown, along with an increase in atrial volumes (iLAV: +8 cm2/m2; p=.02; iRAV: +10 cm2/m2; p=0.01) and estimated filling pressures (E/e': +2; p=.01).

A left GLS (LGLS) > -16% predicted the composite endpoint with a sensitivity of 80% and a specificity of 67% (AUC 0.74). Estimated survival from the composite endpoint was 85% for the normal LGLS group and 35% for the impaired LGLS group (Figure 1). Right GLS was not significantly associated with the primary endpoint.

Conclusions

Heart involvement is becoming a major cause of death in patients with myositis. Data reported that subclinical heart involvement, characterized by biochemical and instrumental modifications, is estimated to affect around 70% of patients with myositis. Cardiac involvement in IIM is often subclinical in the early stages of the disease. GLS has been proven to be an effective tool to predict heart disease. Our results show that GLS worsens over time and can be used as a possible predictor of death and cardiovascular events in this population.Figure 1
Organ perfusion pressure at admission and clinical outcomes in patients hospitalized for acute heart failure
Authors: Bocchino P P , Cingolani M , Frea S , Angelini F , Gallone G , Garatti L , Sacco A , Raineri C , Pidello S , Morici N , De Ferrari G M
Published: November 2023

Background

Hypoperfusion portends adverse outcomes in acute heart failure (AHF). The gradient between end-organ inflow and outflow pressures may more closely reflect hypoperfusion than mean arterial pressure (MAP) alone.

Purpose

To investigate organ perfusion pressure (OPP), calculated as MAP minus central venous pressure (CVP), as a prognostic marker in AHF.

Methods

The SNIP-AHF study was a multicenter retrospective cohort study of 200 consecutive patients hospitalized for AHF treated with sodium nitroprusside. Only patients with both MAP and invasive CVP data available from the SNIP-AHF cohort were included. The primary endpoint was to assess OPP as a predictor of worsening heart failure (WHF) at 48 hours.

Results

146 patients were included (mean age: 61.1±13.5 years, 32 [21.9%] females; mean left ventricular ejection fraction: 23.8%±11.4%, mean MAP: 80.2±13.2 mmHg, mean CVP: 14.0±6.1 mmHg). WHF occurred in 14 (9.6%) patients. At multivariable models including hemodynamic variables (OPP, shock index, MAP and CVP), OPP at admission was the best predictor of WHF at 48 hours (OR 0.91 [95%CI 0.86-0.96], p-value = 0.001) with an optimal cut-off value of 67.5 mmHg (specificity 47.3%, sensitivity 100%, AUC 0.784±0.054 [p-value<0.001]). In a multivariable model including univariable significant parameters available at first beside assessment, namely New York Heart Association functional class, OPP, shock index, MAP and left ventricular end-diastolic diameter, OPP significantly predicted WHF at 48 hours (OR 0.82 [95%CI 0.68-0.98], p-value=0.027).

Conclusion

In this retrospective analysis on patients hospitalized for AHF treated with sodium nitroprusside, on-admission OPP significantly predicted WHF at 48 hours with high sensitivity.OPP in acute heart failureMultivariable analysis on WHF
The effect of intra-aortic balloon pumping on hemodynamics and left ventricular load in Impella-supported condition: A simulation study
Authors: Matsushita H , Yokota S Y , Kakuuchi M K , Yokoi A Y , Nishiura A N , Yoshida Y Y , Uemura K U , Kawada T K , Unoki T U , Nishikawa T N , Saku K S
Published: November 2023

Introduction

Intra-aortic balloon pumping (IABP) is a commonly used percutaneous mechanical circulatory support device. Although IABP combined with Impella, a percutaneous left ventricular assist device, has shown positive outcomes in a few case reports of acute heart failure, its hemodynamic and left ventricular (LV) unloading effects remain unclear.

Purpose

We conducted a simulation study to clarify the clinical benefits of adding IABP to Impella-supported conditions.

Methods

We used SimulinkⓇ for cardiovascular simulation. The systemic and pulmonary circulation were modelled by using a 5-element resistance-capacitance network with four ventricles represented by time-varying elastance and unidirectional valves (Figure 1A). We compared total systemic flow, coronary perfusion pressure (CPP), and pressure-volume relationships (PV loop) in severe LV dysfunction (LV end-systolic elastance: 0.2 mmHg/mL) under three scenarios: IABP with a 40 mL balloon volume added to baseline, IABP added to Impella CP support at P2 (partial support) and P8 (total support) (Figure 1B).

Results

As shown in Figure 2A, IABP increased total systemic flow and CPP, and shifted the PV loop to the left. In P2-Impella condition, the addition of IABP increased native cardiac output (0.3 to 0.7 L/min) and total systemic flow (2.7 to 2.9 L/min), while decreased Impella pump flow due to increased afterload of Impella during diastole. IABP further moved PV loop leftward and reduced LV pressure-volume area (PVA) by -3.8% from Impella only and -7.8% from baseline (Figure 2B). In P8-Impella condition, IABP did not change total systemic flow, CPP, or PV loop (Figure 2C).

Conclusions

The addition of IABP to Impella could increase CPP while increasing Impella pump afterload and decreasing Impella flow. Overall, IABP slightly increased total systemic flow and decreased LV workload in Impella partial support condition. In specific clinical situations, IABP has the potential to be used as adjuvant therapy alongside Impella partial support.Figure 1
Association between sex and efficacy of intravenous ferric carboxymaltose in patients with acute heart failure and iron deficiency: an AFFIRM-AHF subgroup analysis
Authors: Rosano G , Roubert B
Published: November 2023

Background/Introduction

Heart failure (HF) pathophysiology, clinical presentation and treatment response is known to differ between males and females (1). In the AFFIRM-AHF trial, intravenous (IV) ferric carboxymaltose (FCM) reduced the risk of HF hospitalisations and improved quality of life vs placebo in patients with iron deficiency who had stabilised following an acute HF (AHF) episode (2,3); the effect of sex on outcomes with iron-repletion therapy in these high-risk patients has not been fully explored.

Purpose

To investigate the interaction between sex and the effects of FCM vs placebo on clinical outcomes in the AFFIRM-AHF population.

Methods

In AFFIRM-AHF, patients with left ventricular ejection fraction <50% and iron deficiency (defined as serum ferritin <100 ng/mL, or 100–299 ng/mL if transferrin saturation is <20%) who had stabilised following recent hospitalisation for AHF were randomised 1:1 to receive IV FCM or placebo for up to 24 weeks.2 The primary endpoint was a composite of total HF hospitalisations and cardiovascular (CV) death up to Week 52; secondary endpoints are listed in the Figure.2 In this prespecified analysis, AFFIRM-AHF patients were stratified into male and female subgroups and the interaction between sex and clinical outcomes with FCM vs placebo was explored.

Results

Of the 1108 patients included in the AFFIRM-AHF full analysis set, 614 (FCM: 314; placebo: 300) were male and 494 (FCM: 244; placebo: 250) were female. At baseline, a New York Heart Association functional class of III and above was more common in females (59.0%) than in males (48.4%). For the primary endpoint, the adjusted annualised event rate per 100 patient-years with FCM vs placebo was 53.3 vs 83.3 in males (rate ratio [RR] 0.64; 95% confidence interval [CI] 0.46–0.89) and 63.1 vs 60.3 in females (RR 1.05; 95% CI 0.72–1.53) (Figure). For all secondary endpoints except time to CV death, effect sizes in male and female subgroups were similar to those for the primary endpoint. The interaction between sex and treatment effect was non-significant for the primary endpoint (P-interaction=0.054) but reached significance for the secondary endpoints of total CV hospitalisations and CV death (P-interaction=0.024) and time to first HF hospitalisation or CV death (P-interaction=0.043).

Conclusion(s)

The results of this exploratory subgroup analysis suggest that iron deficiency treatment with IV FCM following an AHF episode may be more effective in males than in females; this may be related to baseline differences between sex subgroups, beyond the factors adjusted for in this analysis.Figure
Deep night: critical periods for the onset of acute myocardial infarction in obstructive sleep apnea patients
Authors: Zhang R U I Y A N , Quan W E I W E I , Wang Y
Published: November 2023

Introduction

Obstructive sleep apnea (OSA) is associated with acute nocturnal hemodynamic and neurohormonal abnormalities that may increase the risk of coronary events, especially during deep sleeping time. This study sought to investigate the circadian variation of onset of acute myocardial infarction (AMI) in OSA patients and its long-term prognosis.

Purpose

In this study, we tested the hypothesis that people with OSA are more likely to have AMI during deep sleeping time than the other six-hour intervals of the day. Additionally, we assess the impact of circadian symptom-onset patterns of AMI on prognosis in OSA patients.

Methods

We prospectively enrolled 397 patients with AMI, for which the time of onset of chest pain was clearly identified. All subjects were categorized into non-OSA (n = 280) and OSA (n = 117) groups. The association between AMI onset time and major adverse cardiovascular and cerebrovascular events (MACCEs) was estimated by Cox proportional hazards regression.

Results

AMI onset occurred from midnight to 6 a.m. in 33% of OSA patients, as compared with 15% in non-OSA patients (P < 0.01). For OSA people, the relative risk of AMI from midnight to 6 a.m. was 1.990 (95% CI 1.329-2.929) compared with non-OSA patients (Figure 1). After a median of 2.89 ± 0.78 years follow-up, symptom onset time was significantly associated with risks of MACCEs in OSA patients, but not in non-OSA patients. The hazard ratios (HRs) for OSA patients were 4.683 (95% CI 2.024 to 21.409) for midnight to 6 a.m., and 6.964 (95% CI 1.379 to 35.169) for 6 p.m. to midnight as compared with AMI presenting during noon to 6 p.m (Figure 2).

Conclusion

Patients with OSA showed a peak incidence of AMI during the deep night, which was independently associated with adverse events.Figure 1Figure 2
One-year outcomes in cardiogenic shock triggered by supraventricular tachycardia: an analysis of the FRENSHOCK multicenter prospective registry
Authors: Cherbi M , Bonnefoy E , Lamblin N , Gerbaud E , Bonello L , Roubille F , Levy B , Labbe V , Marchandot B , Lattuca B , Biendel-Picquet C , Leurent G , Puymirat E , Maury P , Delmas C
Published: November 2023

Background

Cardiogenic shock (CS) is the most severe form of heart failure (HF), resulting in high early and long-term mortality. Characteristics of CS secondary to supraventricular tachycardia (SVT) are poorly reported. Based on a large registry of unselected CS, our aim was to compare one-year outcomes between SVT-triggered and non-SVT-triggered CS.

Methods

FRENSHOCK is a prospective registry including 772 CS from 49 centers. One to three triggers could be identified (ischemic, mechanical complications, ventricular/supraventricular arrhythmia, bradycardia, iatrogenesis, infection, non-compliance, others). One-year outcomes (rehospitalizations, mortality, heart transplantation (HTx), ventricular assist devices (VAD)) were analyzed, adjusted on independent predictive factors.

Results

Within 769 CS included, 100 were SVT-triggered (13%) with 65 with SVT as exclusive trigger (8.5%). SVT triggered CS patients were more male with more frequent history of cardiomyopathy or chronic kidney disease, and more profound CS (biventricular failure and multiorgan failure). At 1-year, there was no difference in all-cause mortality (HR 0.91 [0.66 – 1.26], p = 0.58), need for HTx or VAD (OR 0.88 [0.41 – 1.88], p = 0.74) or rehospitalizations (OR 1.24 [0.78 – 1.98], p = 0.36). Patients with SVT as exclusive trigger presented more 1-year rehospitalizations (OR 3.74 [1.05 – 10.5], p = 0.01).

Conclusion

SVT is a frequent trigger of CS alone or in association in more than 10% of miscellaneous CS. Although SVT-triggered CS patients were more comorbid with more pre-existing cardiomyopathies and HF, they presented similar rates of mortality, HTx and VAD at 1-year arguing for a better overall prognosis.Graphical abstract