bluuebunny/crossref_metadata_2025 huggingface dataset:
Prevalence and incidence of diastolic dysfunction in new-onset atrial fibrillation: implications for clinical and preclinical HFpEF
Authors: Naser J , Lee E , Scott C G , Kennedy A M , Pellikkka P A , Lin G , Pislaru S V , Borlaug B A
Published: November 2023

Background

Atrial fibrillation (AF) and heart failure with preserved ejection fraction (HFpEF) are closely associated diseases that frequently coexist. However, due to the overlapping symptoms, the diagnosis of HFpEF can be overlooked with symptoms being attributed to AF.

Purpose

We aimed to investigate the prevalence of diastolic dysfunction (DD) in patients with new-onset AF compared to sinus rhythm (SR), study changes in diastolic function parameters over time in the two groups and compare the incidence of DD at follow-up.

Methods

Adults with new diagnosis of AF and adults in SR were identified. Patients with previous cardiac surgeries, congenital heart disease, hypertrophic or infiltrative cardiomyopathy, primary mitral disease, left-sided valve disease, low ejection fraction, enlarged left ventricle, or with no 6-month follow-up echocardiogram were excluded. Diastolic function was assessed through 4 components: mitral medial e’ <0.07 m/sec, mitral medial E/e’ >15 in SR and >11 in AF, TR velocity >2.80 m/sec, and left atrial volume index >34 ml/m2, with severe DD (SDD) defined by ≥3/4 findings and moderate DD (MDD) by ≥2/4 abnormal diastolic function parameters. Annualized changes were calculated as the difference between follow-up and baseline values divided by years in between. In a secondary analysis, patients with new-onset AF were propensity score-matched to patients with SR in a 3:1 ratio based on age, sex, body mass index, and comorbidities.

Results

Overall, 1,747 patients with incident AF (median age 67 years; 34% females) and 29,623 in SR (median age 59 years; 51% females) were included. New-onset AF was independently associated with the presence of SDD vs SR (8% vs 2%) and MDD (25% vs 11%, p<.001 for both in adjusted analysis). Over median follow-up of 3.2 (IQR 1.6-5.8) years, annualized severity progression in each of the 4 diastolic function parameters was greater in the AF group (p<.001 for all), Table. The incidence rates of SDD and MDD were 3.7 and 8.8 per 100-person year, respectively, in AF versus 1.1 and 3.6 per 100-person years, respectively, in SR (p<.001 for both at univariate and multivariable analysis), Figure. Results were similar in the propensity-score matched analysis.

Conclusions

Patients with new-onset AF more commonly have moderate or severe diastolic dysfunction that indicates the presence of potentially overlooked clinical HFpEF (when symptoms exist) or preclinical HFpEF (when symptoms are absent) compared to patients in SR. In long-term follow-up, patients with AF display accelerated progression in DD; suggesting that therapies to prevent progression to symptomatic HFpEF may be highest value in this patient population.
Impact of Clostridioides difficile infection in heart failure hospitalizations: analysis from the national inpatient sample database
Authors: Badu I , Taha A , Duhan S , Blagoie J , Tarff A , Hussein S , Hussein M H , Khir F , Keisham B , Sandhyavenu H
Published: November 2023

Background

Congestive heart failure (CHF) patients are at greater risk of nosocomial infections such as Clostridioides difficile infection (CDI) due to higher comorbidities, readmission rates, and prolonged hospital stays. Further, hypovolemia and sympathetic drive may aggravate myocardial dysfunction due to demand mismatch and worsen clinical outcomes.

Purpose

To assess the impact of CDI in congestive heart failure (CHF) hospitalizations nationally in the US.

Methods

The National Inpatient Sample database from 2016 to 2019 was queried to identify patients with a primary diagnosis of CHF. Subsequently, the sample was stratified based on the presence of CDI as a secondary diagnosis. The adjusted odds ratios (aOR) of in-hospital outcomes were calculated using chi-square statistics in software STAT v.17.

Results

Of 1,270,414 weighted hospitalizations with CHF, 8275 were diagnosed with CDI (0.65%). On adjusted analysis, patients with CHF and CDI had significantly higher in-hospital mortality (aOR 3.58, 95% CI 3.28-4.51, p<0.001), cardiac arrest (aOR 3.89, 95% CI 2.79-5.41, p<0.001), AMI (aOR 1.37, 95% CI 1.08-, p=0.007), MCS (aOR 5.16, 95% CI 3.91-6.8, p<0.001), stroke (aOR 1.85, 95% CI 1.09-3.14, p=0.022) and MACE (aOR 2.54, 95% CI 2.21-2.91, p<0.001), (Figure 1). Additionally, HF patients with CDI are associated with longer lengths of stay (12±16 vs. 5±6 ) and adjusted total charge ($133,045±291,290 vs. $51,919±133,303) compared to HF patients without CDI (Table 1).

Conclusions

CDI in CHF hospitalizations have adverse in-hospital outcomes with higher rates of in-hospital mortality, AMI, stroke, and MACE. This highlights the importance of early detection and aggressive infection prevention strategies in this high-risk population.Figure 1Table 1
Prognostic implications of angiopoietin-2 in heart failure and the influence of empagliflozin: the EMPEROR program
Authors: Butler J
Published: November 2023

Background

Heart failure (HF) development and progression is associated with endothelial dysfunction, oxidative stress, and inflammation. The mechanisms involved in endothelial repair in HF are not fully understood. Emerging evidence suggests that angiopoietin-2 (Angpt2), a vascular destabilizing factor, may be related to outcome in HF.

Aim

To assess the association between Angpt2 and clinical outcomes in a pooled analysis of the EMPEROR-Reduced and EMPEROR-Preserved trials, and to evaluate if the response to empagliflozin therapy in HF is modulated by Angpt2 levels.

Methods and results

Angpt2 levels (ng/ml) were measured in serum samples from 1131 EMPEROR study participants by using Roche Cobas Elecsys assay, within biomarker research agreement between Boehringer Ingelheim and Roche Diagnostics International Ltd, at baseline, week 12 and week 52. Patients were divided into tertiles of baseline Angpt2 levels (<2.58 ng/mL; ≥2.58 ng/mL <4.71 ng/mL and ≥4.71 ng/mL). Patients in the highest tertile were more frequently white people, had a higher prevalence of New York Heart Association class III-IV symptoms, HF hospitalization within 12 months, obesity, diabetes, atrial fibrillation, elevated natriuretic peptides, worse renal function, and lower prevalence of coronary disease, compared to the lowest tertile (p<0.05 for all). Higher tertile at baseline was associated with increased risk for adverse HF and kidney events (Table 1). Empagliflozin treatment was associated with reduction of the serum Angpt2 versus placebo at week 12 (adjusted gMean 0.872 [0.828-0.917], p<0.0001) but not at week 52 (adjusted gMean ratio 0.946, [0.879-1.019], p=0.145). Empagliflozin significantly reduced the risk of hospitalization for HF and cardiovascular death particularly for patients with highest baseline Angpt2 levels (lowest tertile HR 1.21 [0.63-2.31]; middle tertile HR 0.65 [0.37-1.16]; highest tertile HR 0.64 [0.42-0.97], P-trend=0.139).

Conclusion

Higher Angpt2 levels at baseline were associated with more advanced HF and worse prognosis. Treatment with empagliflozin was associated with reduction of Angpt2 level at week 12. The benefit of empagliflozin on major HF events was consistent across baseline Angpt2 levels.Table 1
Low muscle strength as a predictor of incident pneumonia in older patients with heart failure: sub-analysis of fragile-hf
Authors: Yamaguchi K , Konishi M , Kagiyama N , Kasai T , Kamiya K , Saito H , Saito K , Maekawa E , Kitai T , Iwata K , Jujo K , Wada H , Momomura S , Hibi K , Matsue Y
Published: November 2023

Background

Patients with heart failure often develop pneumonia during the course of their illness, which leads to high mortality. A decrease in swallowing muscle strength due to aging or concomitant disease may be involved in the development of pneumonia in the elderly. We sought to investigate the association between low muscle strength and the incidence of pneumonia in older patients hospitalized for worsening HF.

Methods

We carried out a sub-analysis of FRAGILE-HF, a prospective multicenter study, including 1228 consecutive older (>=65 years) hospitalized patients with HF (median age 81; 57.6% male; left ventricular ejection fraction (LVEF) 46±17%). The patients were followed-up for two years after discharge from the index hospitalization.

Results

A total of 87 patients (7.1%) developed pneumonia after discharge, with an incidence of 43 per 1,000 patient-years. The patients with incident pneumonia were more likely to be male and had lower body mass index than those without pneumonia. A total of 895 patients (72.9%) with low muscle strength, defined as handgrip strength <28 kg for men and <18 kg for women according to the international criteria, were more likely to develop pneumonia than those with normal muscle strength (p<0.001 for log-rank: figure). Low muscle strength was a significant predictor of incident pneumonia after adjustment with age, sex, body mass index, LVEF, and history of chronic lung disease and cerebral infarction (adjusted hazard ratio with 95% confidence interval: 3.31 [1.68-6.53], p<0.001). Furthermore, 43.7% and 19.1% died in patients with and without pneumonia during the follow-up period, respectively, with the subsequent risk of all-cause mortality after the occurrence of pneumonia (adjusted hazard ratio: 4.09 [2.85-5.87], p<0.001).

Conclusions

Low muscle strength was associated with incident pneumonia in older patients hospitalized for worsening HF. This finding may support the need for an interventional study targeting muscle wasting to prevent pneumonia in HF.
Atrial fibrillation as a trigger for acute heart failure
Authors: Halhal B , Bar O , Aronson D
Published: November 2023

Background

Both atrial fibrillation (AF) and heart failure (HF) facilitate the occurrence and aggravate the prognosis of each other, and often coexist (1). Rapid AF is considered to be a trigger for HF decompensation. However, rapid AF can also be secondary to the increase sympathetic drive associated with HF decompensation. Few data are available regarding the hemodynamic and metabolic consequences of rapid AF in acute HF.

Purpose

To study the clinical impact of rapid AF in acute HF.

Methods

We studied 8,997 patients admitted with acutely decompensated heart failure (ADHF). Propensity-score matching was generated using 21 clinical variables. The primary endpoint was in-hospital mortality.

Results

Rapid AF (defined as ventricular rate ≥110) at admission was present in 339 patients (3.8%). Patient with rapid AF had higher prevalence of diabetes, ischemic heart disease chronic lung disease, and higher levels of BUN and white blood cells (All P<0.001). Systolic blood pressure was lower and diastolic blood pressure was higher with rapid AF (Table). Blood lactate levels were slightly higher with rapid AF but the O2 saturation, pH, bicarbonate and pCO2 levels were similar (Table). In a multivariable logistic regression model, adjusting for all available clinical variables, the odds ration (OR) for in hospital mortality was 1.07 (95% CI 0.77 to 1.49; P=0.69). Propensity score matching yielded 338 patient pairs. In-hospital mortality occurred in 16.3% of patients with rapid AF and in 12.7% of patients without rapid AF ( OR 1.34; 95% CI 0.87 to 2.08, P= 0.19).

Conclusion

Rapid AF at admission was not associated with a significant hemodynamic or metabolic compromise and carried a similar risk for in-hospital mortality as in patients without rapid AF.Hemodynamic and metabolic parameters
Predicting heart failure readmission and all-cause mortality in patients with acute heart failure: a simple predischarge risk score
Authors: Espersen C , Campbell R , Claggett B , Lewis E , Docherty K , Lee M , Lindner M , Brainin P , Biering-Soerensen T , Solomon S , McMurray J , Platz E
Published: November 2023

Introduction

Predischarge risk stratification of patients hospitalized for acute heart failure (AHF) could facilitate tailored treatment and follow-up, however, simple scores to predict short-term risk for HF readmission or death are lacking.

Purpose

We sought to develop a congestion-focused risk score to predict HF readmission and all-cause mortality after discharge in patients hospitalized for AHF.

Methods

We used data from a prospective, two-center observational study in adults hospitalized for AHF. Laboratory data were collected on admission. Patients underwent a physical examination, 4-zone, and in a subset 8-zone, lung ultrasound (LUS), and conventional echocardiography at baseline (within a median of 1 day after admission). A second LUS was performed before discharge in a subset of patients. The primary endpoint was the composite of HF rehospitalization or all-cause death. HF hospitalizations were adjudicated blinded to LUS findings.

Results

Among 297 patients with complete data (median age 74 years, 43% women, mean left ventricular ejection fraction 39%), 76 patients (26%) were hospitalized for HF or died within 90 days after discharge. A stepwise Cox regression model selected four significant independent predictors of the composite outcome and each was assigned points proportional to its regression coefficient: NT-proBNP ≥2000 pg/mL (admission) (3 points), systolic blood pressure <120 mmHg (baseline) (2 points), left atrial volume index ≥60 mL/m² (baseline) (1 point) and ≥9 B-lines on predischarge 4-zone LUS (3 points). The weighted risk score provided adequate risk discrimination for the composite outcome (HR 1.48 per 1 point increase, 95% confidence interval: 1.32-1.67, p<0.001, C-statistic: 0.70; Figure 1). In a subset of patients with 8-zone LUS data (n=176), results were similar (C-statistic: 0.72).

Conclusion

A four-variable, weighted risk score integrating clinical, laboratory and ultrasound imaging data provided adequate risk discrimination for 90-day adverse outcomes in patients hospitalized for AHF. If validated in a larger dataset, this score could be used to identify patients needing the closest monitoring, more intensive follow-up and early treatment adjustment.Figure 1.
The prognostic impact of follow-up cardiac Metaiodobenzylguanidine imaging: relation to differential trajectories in left ventricular ejection fraction after acute decompensation
Authors: Kayama K , Yamada T , Watanabe T , Morita T , Kawasaki M , Kikuchi A , Kondo T , Kawai T , Nishimoto Y , Seo M , Nakamura J , Fukunami M
Published: November 2023

Background

Cardiac metaiodobenzylguanidine (MIBG) imaging provides prognostic information in patients with heart failure (HF). Recently, the trajectory of left ventricular ejection fraction (LVEF) has been focused in patients with reduced LVEF admitted for acute decompensated heart failure (ADHF). We sought to prospectively investigate the prognostic value of the follow-up cardiac MIBG imaging in ADHF patients with reduced LVEF, in relation to LVEF trajectory.

Methods

We prospectively studied 145 ADHF patients with reduced LVEF<40%. The cardiac MIBG heart-to-mediastinum ratio (late HMR) was measured on the delayed image at the discharge and 6 months’ follow-up (6FUP). HF recovered LVEF (HFrecEF) was defined as those with a second measurement of LVEF at 6FUP of ≥ 40% with a 10-point increase from baseline LVEF, according to the previous report. Furthermore, in the present study, HFrecEF was classified into the two groups; patients with partial recovery of LVEF (≥40%, <50%) (HFparEF) and complete recovery of LVEF (≥50%) (HFcorEF). The endpoint was a cardiac event (CE) defined as a composite of cardiac death and unplanned hospitalization for worsening HF.

Results

At 6 months after the discharge, HFrecEF was observed in 97 (67%) of 145 study patients and the remaining 48 (33%) patients did not have HFrecEF (HFnorEF). In the subgroup of HFrecEF, 43 (30%) patients had HFparEF and 54 (37%) patients had HFcorEF. Late HMR at 6FUP in HFcorEF patients was significantly greater than those in HFparEF and HFnorEF patients, which was also observed at the discharge with non-significant difference. The change of late HMR significantly correlated with the improvement in LVEF (r=0.33, p<0.001). During a follow-up period of 4.3 ± 2.6 years, 28 patients in HFnorEF, 11 patients in HFparEF and 4 patients in HFcorEF had CEs, respectively. Kaplan-Meier analysis revealed that HFnorEF patients had a significantly higher risk of cardiac events than those with HFparEF and HFcorEF. (58.3% vs 25.6% vs 7.4% P < 0.0001). Patients with lower late HMR at 6FUP had a greater risk of CEs than those with higher late HR at 6FUP in HFrecEF, especially in HFparEF, which was not observed in HFnorEF subgroup.

Conclusion

The follow-up MIBG imaging after the discharge could provide the additional prognostic information in ADHF patients with recovered LV function.
The prognostic impact of cardiac Metaiodobenzylguanidine imaging related to left ventricular geometry in patients with acute decompensated heart failure: a prospective study
Authors: Kayama K , Yamada T , Watanabe T , Morita T , Kawasaki M , Kikuchi A , Kondo T , Kawai T , Nishimoto Y , Seo M , Nakamura J , Fukunami M
Published: November 2023

Background

It is known that changes in the geometry of the left ventricle (LV), such as dilation or hypertrophy, are associated with cardiovascular events. The sympathetic nervous system also plays a crucial role in exacerbating these changes. Cardiac iodine-123 metaiodobenzylguanidine (MIBG) imaging can evaluate cardiac sympathetic neuronal activity and has been strongly associated with poor clinical outcomes in heart failure (HF). However, the prognostic significance of cardiac MIBG imaging related to LV geometry is still unclear, particularly in patients admitted for acute decompensated HF (ADHF).

Methods

We studied consecutive 575 patients admitted for ADHF and echocardiography were performed just before discharge. In cardiac MIBG imaging, the heart-to-mediastinum ratio (HMR) was measured on the delayed image. We divided the patients into four groups according to the relative wall thickness (RWT) and LV mass index (LVMI) based on the ASE/EACVI classification as follows: normal (n=75), normal RWT and LVMI; concentric remodeling (n=56), high RWT and normal LVMI; eccentric hypertrophy (n=298), normal RWT and high LVMI; and concentric hypertrophy (n=146), high RWT and LVMI. The endpoint of this study was all cause death (ACD).

Results

During a follow-up period of 4.2 ± 2.5 years, 272 patients had ACDs (normal [n=32], concentric remodeling [n=28], eccentric hypertrophy [n=137] and concentric hypertrophy [n=75]). There was no significant association between LV geometry and ACDs. At univariate Cox analysis, late HMR was significantly and independently associated with ACDs in the subgroup of patients with eccentric hypertrophy (p=0.0004). However, there was no significant association between late HMR and ACDs in those with other subgroups of LV geometry. At multivariate Cox analysis, late HMR was also significantly associated with ACDs even after adjusting for major HF confounders in the subgroup of patients with eccentric hypertrophy (p=0.0042). Furthermore, Kaplan-Meier analysis revealed that patients with lower late HMR (<1.524: determined by ROC curve analysis) had a significantly higher risk of ACDs in the subgroup with eccentric hypertrophy (61% vs 37%, p<0.0001).

Conclusions

LV geometry has an impact on the prognostic value of cardiac MIBG imaging in patients admitted for ADHF.
The classification shifting and outcomes of DELIVER-type patients with acute heart failure and preserved ejection fraction
Authors: Ling L , Huang W M , Sung S H
Published: November 2023

Background

The DELIVER trial enrolled subjects with acute heart failure (AHF) and preserved ejection fraction (HFpEF) who had elevated biomarkers and cardiac structural abnormalities. Given the benefits of sodium-glucose cotransporter 2 inhibitors (SGLT2i) in AHF, it is important to understand the differences between DELIVER-type and non-DELIVER-type patients and how their classification may shift over time.

Method

This study enrolled patients hospitalized for AHF with LVEF ≥ 50%. Patients with elevated N-terminal pro B-type natriuretic peptide (NT-proBNP ≥ 300 or 600 pg/mL, depending on cardiac rhythm) and cardiac structural abnormalities (enlarged left atrial volume or index, or left ventricular hypertrophy) were classified as DELIVER-type. Patients who did not meet these criteria were classified as non-DELIVER-type. Patients with estimated glomerular filtration rate ≤ 25 mL/min/1.73m2 and those receiving SGLT2i treatment were excluded. Echocardiographic variables were obtained pre-discharge and one year after the index day. All-cause mortality and heart failure hospitalization up to one year were determined by web-based electronic record.

Result

The study included 385 subjects with an average age of 83.7 ± 13.9 years, of whom 53.2% were men. The DELIVER-type group had a higher proportion of atrial fibrillation, larger left atrial volume, thicker left ventricular wall, higher levels of the ratio of early diastolic mitral inflow velocity to early diastolic medial mitral annulus velocity (medial mitral E/e'), and higher pulmonary artery systolic pressure (PASP), as well as more evident haemoconcentration and body weight reduction during hospitalization. Kaplan-Meier curve analysis revealed higher rates of all-cause mortality and hospitalization for heart failure at one year in patients with DELIVER-type (Figure 1). In Cox regression analysis, the DELIVER-type subjects had comparable clinical outcomes after accounting for factors such as age, gender, atrial fibrillation, haemoglobin levels, and estimated glomerular filtration rate, compared to non-DELIVER subjects (hazard ratio and 95% confidence interval of mortality [1.62 (0.81-3.25)]). In one-year follow-up, 41.7% of patients shifted from non-DELIVER type to DELIVER-type, but only 14.6% of DELIVER-type subjects had classification shifting.

Conclusion

Non-DELIVER-type subjects had modestly lower event rates compared to those with DELIVER-type. The high proportion of classification shifting from non-DELIVER-type to DELIVER-type suggested that eligibility could vary during follow-up and that these patients could benefit from SGLT2i therapy.Baseline characteristicsClass shifting in DELIVER type
Regional left ventricular longitudinal strain and heart failure in a low-risk community
Authors: Sengelov M , Kristoffer Grundtvig Skaarup K G S , Mats Christian Hoejbjerg Lassen M C H L , Niklas Dyrby Johansen N D J , Frederikke Vyff F V , Kirstine Ravnkilde K R , Maria Flarup Dons M F D , Adam Femerling Langhoff A F L , Gorm Boje Jensen G B J , Peter Schnohr P S , Rasmus Moegelvang R M , Tor Biering-Soerensen T B S
Published: November 2023

Background

Global longitudinal strain is a well-established prognosticator of heart failure (HF) in the general population. The prognostic values of regional left ventricular (LV) longitudinal strain of the basal, mid and apical regions remain unexplored in the general population.

Purpose

The purpose of this study was to investigate the relationship between regional LV strain and incident HF in the general population.

Methods

This prospective cohort study included randomly selected citizens from a major metropolitan area. All participants were examined with echocardiography. The outcome was incident HF. Participants were excluded if regional LV strain was not assessable in all 3 LV regions or if they had atrial fibrillation or HF at baseline. A multivariable Cox regression model adjusted for sex, age, smoking status, heart rate, systolic blood pressure, history of ischemic heart disease, hypertension, diabetes, LV mass index, LV ejection fraction and E/e’ was used.

Results

A total of 3,952 individuals were included. Mean age was 56±18 years and 43% were male. Mean basal, mid, and apical LV strain was 16.4±2.6%, 19.5±2.6 and 22.8±3.6% respectively. Median follow-up was 5.4 years (IQR: 4.4; 6.3) and 99 developed HF. In multivariable Cox regressions models, only decreasing LV basal strain was associated with future HF (HR = 1.18, 95%CI (1.06; 1.32), P = 0.003, per 1% decrease) (Figure 1). Additionally, LV basal strain provided incremental prognostic information regarding future HF to the Atherosclerosis Risk in Communities HF risk score (continuous net reclassification index = 0.468, 95% CI (0.155; 0.687)).

Conclusion

In individuals from the general population, basal LV strain entailed incremental prognostic information regarding the risk of incident HF.Basal strain and incident HF
ACUTE HF score predicts in-hospital mortality in patients with acute heart failure
Authors: Pastore M C , Mandoli G E , Campora A , Renzelli A , Olivoni G , Toscano M , Pavoncelli S , Delcuratolo E , Lambardi M , Morrone F , Cavigli L , Focardi M , D'ascenzi F , Valente S , Cameli M
Published: November 2023

Background

ACUTE HF is a multiparametric score combining clinical, biochemical and echocardiographic indexes, which was developed and validated in different studies as prognostic tool in acute heart failure (HF) patients for the prediction of 30-days, 6-months and 5-years mortality after discharge. However, in these critical patients the prediction of in-hospital mortality may be fundamental to guide therapeutic management during hospital stay.

Objective

The aim of our study was to assess the prognostic value of ACUTE HF score for in-hospital mortality in an external cohort of patients hospitalized for acute HF.

Methods

Consecutive patients hospitalized for acute HF between 2020 and 2021 in our University Hospital were retrospectively enrolled. Patients with unclear diagnosis of de-novo, decompensated HF or HF reacutization were excluded. Clinical, biohumoral and echocardiographic data were collected. ACUTE HF score was calculated as : 1.4*[serum creatinine>2mg/dl]+0.8*[ejection fraction<30]+ 0.7*[age>76]+0.7*[prior hospitalization for AHF]+0.9*[prior stroke/transient ischemic attack]+0.5*[more than moderate mitral regurgitation]+0.8*[use of non-invasive ventilation]. Then, it was used to divide the population into three risk groups (low risk: ACUTE HF ≤1.5; intermediate risk: 1.5

Results

Overall, 1291 patients were included in the present study (age=77±13 years, mean ejection fraction = 41 ± 13%). Median in-hospital follow up was 9 [6;15] days, during which 115 patients died. Patients who died during hospitalization were older, had worse renal function and higher mitral regurgitation severity, and more frequently had arterial hypertension, diabetes mellitus, chronic obstructive pulmonary disease and history of stroke. With ROC curves, it showed to be a good predictor of in-hospital mortality, with an AUC=0.66, which was even higher in patients with preserved ejection fraction (AUC=0.76, Fig.1). With multivariate analysis, ACUTE HF score showed to be a predictor of in-hospital mortality independent from arterial hypertension, diabetes mellitus, chronic kidney disease (OR = 1.5 [C.I. 1.22 – 1.81 each point increase]. Kaplan Meier analysis showed a good risk stratification of study cohort divided into 3 risk groups according to ACUTE HF (Fig.2)

Conclusions

ACUTE HF score is an independent and reliable predictor of in-hospital mortality in patients hospitalized for acute HF. After multiple external validation, considering its rapid and easy calculation, we suggest its use in the management algorithms of acute HF patients in daily clinical practice.Fig.1Fig.2
Larger change in intra-thoracic impedance before and during heart failure hospitalization is associated with longer length of stay in patients with cardiovascular implanted electronic devices
Authors: Sarkar S , Koehler J
Published: November 2023

Background

Intra-thoracic impedance measured in implantable cardioverter defibrillators (ICD) and cardiac resynchronization therapy defibrillators (CRTD) is a measure of intravascular blood volume and have been shown to correlate with intracardiac pressures in previous studies.

Purpose

We investigated whether amount of change of intrathoracic impedance before admission is associated with length of stay (LOS) during heart failure (HF) hospitalizations in a large real-world cohort of patients with ICD/CRTD devices.

Methods

We linked a deidentified database of aggregated electronic health record during the period from 2007-2017 to a manufacturer’s device data warehouse with device based continuous diagnostic monitoring data. Patients with ICD/CRTD implants with intra-thoracic impedance measurements were included for this study. HF event was defined as an inpatient, emergency department, or observation unit stay in a hospital with primary diagnosis of HF and intravenous diuretics administration. Relative change of daily intra-thoracic impedance measurement from 60 days prior to admission and date of admission as well as from admission to discharge were compared in HF events with LOS < 5 days and LOS ≥ 5 days using a Wilcoxon rank sum test.

Results

A total of 17,886 patients with 1.8±1.2 years of follow-up met inclusion criteria. The average age of patients was 66.6 ±12.3 years, with 72% being males, and 51% with ICD devices. The relative change in intra-thoracic impedance from 60 days prior till date of admission and from admission to discharge for HF events with LOS < 5 days and LOS ≥ 5 days are shown in Table. A total of 1456 patients had 1720 HF events of which 874 events had LOS< 5 days and 846 had LOS≥ 5 days. HF events with a longer length of stay (LOS ≥ 5 days) had a higher relative decrease in intra-thoracic impedance prior to admission compared to HF events with a shorter length of stay. HF events with a longer length of stay (LOS≥ 5 days) had a higher relative increase in intra-thoracic impedance during hospital stay.

Conclusions

In a large real-world population of patients with ICD/CRTD devices, longer length of stay is more likely in patients with a larger relative decrease in intra-thoracic impedance prior to admission, indicating more accumulated fluid. Further, larger relative increase in intra-thoracic impedance during hospital stay was observed in patients with longer length of stay, indicating more fluid removal.
Disproportionate MR and 5-year mortality following acute heart failure hospitalisation
Authors: Berrill M , Beeton I , Fluck D , John I , Baltabaeva A
Published: November 2023

Background

The clinical implications of disproportionate mitral regurgitation (DispMR) is contentious and uncertainty remains if this cohort of patients benefit from intervention. Its prognostic significance in acute heart failure remains incompletely investigated.

Purpose

To examine whether DispMR, defined by the ratio of the effective regurgitant orifice area (ERO)/LVEDV >0.14mm2/ml, is an independent predictor of long-term mortality following hospitalisation for AHF.

Methods

418 consecutive AHF patients were recruited and followed up for the primary outcome of all-cause, 5-year mortality. A key secondary outcome was cardiovascular (CV) death. Patients were recruited if they displayed signs and symptoms of AHF, had point-of-care brain-natriuretic peptide >100pg/ml and had evidence of AHF on comprehensive bedside transthoracic echocardiography. 30 variables encompassing age, gender, BMI, a history of COPD, CKD, hypertension, diabetes, previous CVA, CAD, AF on admission ECG, admission systolic BP, NYHA classification, heart rate, Na, BNP, urea, anaemia, LA size, RA size, TR severity, lateral E/e’ >14, RV diastolic area, TAPSE, SPAP, LVEF phenotype, a loop diuretic, MRA, beta-blocker, ARB/ACE-I, CCB or statin prescribed on discharge were included. Multivariate Cox-proportional hazard models were constructed to test for an independent prognostic role of DispMR. Missing outcome data was right-censored.

Results

313/418 (74.8%) displayed secondary MR and had quantifiable ERO and LVEDV (median age 81, 53.4% male) and were included in analysis. 217/313 (66.5%) displayed DispMR. Kaplan-Meier curve analysis revealed worse all-cause mortality in DispMR vs. proportionate MR (HR 1.72 95% CI 1.31-2.27 [p<0.001]). On multivariable analysis DispMR was independently associated with all-cause mortality (HR 1.77 (95% CI 1.26-2.51 [p=0.0012]). 284/313 (90.7%) had CV mortality data available. DispMR was associated with increased risk of 5-year, unadjusted, CV mortality compared to proportionate MR (HR 1.72 95% CI 1.31-2.27 [p<0.001]). These effects were present across all ejection fraction phenotypes.

Conclusions

Among patients with quantifiable MR in AHF, the presence of DispMR was independently associated with long-term outcome. These results suggest assessment of MR within the context of LV volumes can identify patients at increased risk and should have implications for future guidelines.
The HFA PEFF diagnostic algorithm poorly correlates with invasive LV filling pressure in HF PEF
Authors: Bauer F , Berthelot E , Gueffet J P , Damy T , Eicher J C , Logeart D , Fauvel C , Trochu J N , Habib G , Isnard R , Degroote P , Lamblin N
Published: November 2023

Background

Heart failure with preserved ejection fraction (HFPEF) patients typically have elevated LV filling pressures, whether at rest and/or on exercise. In 2020, the HFA-ESC proposed a process to detect HFPEF called HFA–PEFF diagnostic algorithm, which has not been validated against invasive right heart catheterization (RHC).

Purpose

The purpose of this work was to compare this algorithm against LV filling pressures invasively calculated.

Methods

PH-HF registry enrolled 663 patients with HF from which 276 had preserved ejection fraction with and without pulmonary hypertension explored at 11 French centres between 2011 and 2021. Patients meeting the 2021 ESC definition of heart failure underwent both RHC at steady state under optimal medical therapy and a complete ultrasound study within 24 hours. From 4 domains, the HFA–PEFF score was calculated with the use of major and minor criteria. A score ≥5 points is considered to be diagnostic, while between 2-4, further investigations are requested. The score was compared to pulmonary wedge pressure.

Results

Mean age age was 69,5±12.4 years, 35,1% male, mean left ventricular ejection fraction was 62,5±7,2%. Wedge pressure was 20,5±7,5 mm Hg and HFA-PEFF score averaged 4,9±1,2 with 181 patients (66%) above 5. Sensitivity and specificity were 68% and 46%, respectively. The figure 1 demonstrates the misclassification of patients, particularly those with high HFA-PEFF score but normal left ventricular filling pressure (lower right), that are badly categorized.

Conclusions

The HFA-PEFF score poorly correlates with invasive measurement of LV filling pressure. Patients with high score may require more careful attention as they are often misclassified.Figure 1
Reduced systolic flow efficacy in left ventricular dyssynchrony evident by blood speckle imaging
Authors: Witso M , Hammersboen L E , Frostlid V C , Fadnes S , Sletten O J , Lovstakken L , Odland H H , Remme E W , Stugaard M , Skulstad H
Published: November 2023

Introduction

Intraventricular vortices facilitate efficient blood flow in a healthy heart. Changes in the blood flow pattern can cause energy loss and inefficient filling or ejection. Thus changes, or reduction in vorticity may therefore be of importance for cardiac function. Blood speckle imaging (BSI) is a novel blood flow visualization tool based on echocardiography, partially overcoming the angel dependency of conventional colour Doppler. BSI tracks speckles generated by the moving blood cells, similar to myocardial speckle tracking, but requires a very high frame rate limiting penetration. Dyssynchrony in left bundle branch block (LBBB) affects the systolic functions but there is limited insight into how LBBB alters the blood flow vorticity.

Purpose

We investigated the effect of dyssynchrony on blood flow hemodynamics using blood speckle imaging.

Methods

In eight anesthetized canine mongrels, left ventricular flow was visualized using BSI. A qualitative visual assessment of vortices during the cardiac cycle, together with a quantitative assessment based on kinetic energy loss and vorticity were made. Regional myocardial function parameters were measured by sonomicrometry. Peak septal flash strain in isovolumetric contraction (IVC) was measured by sonomicrometry (figure) as an indicator of dyssynchrony. Assessments were made at baseline, under right ventricular free wall pacing (RV pacing) mimicking LBBB, after induced LBBB by ablation and under cardiac resynchronization therapy (CRT).

Results

During IVC at baseline all animals had a central ventricular vortex. However during RV pacing and LBBB it was distorted in various patterns. RV pacing significantly reduced the number of vortices in systole and disrupted the central vortex in IVC (1.0±0.0 vs 0.4±0.5, p=0.01). Energy loss (EL) in systole increased (40.2±12.5 vs 55.3±23.3 mW/m, p<.05). Septal end systolic strain was significantly reduced (-8.8±5.1 vs -1.9±7.3 %, p<0.01) and septal flash strain was significantly increased (1.0±1.4 vs 7.7±3.6 and 6.6±3.8 [ER1] [ER2] %, p<0.01) in RV pacing and LBBB. CRT caused a realignment of the central vortex (0.8±0.5 vs0.3±0.5, p=0.03). The change in energy loss was not significant, but numerically reduced (55.4±38.8 vs 76.4±48.9 mW/m, p=0.06). See table and figure 1.

Conclusions

The main systolic vortex in IVC was disrupted during septal flash by RV pacing and LBBB, altering the flow pattern compared to baseline. The resultant unstructured flow pattern had increased energy loss in systole, indicating a less efficient flow pattern and less preservation of energy. It should be further explored if this is of importance to understand the reduced LV function and LV remodelling during dyssynchrony.Figure 1Table 1
Prognostic implications of right ventricular systolic and diastolic strain in heart failure
Authors: Matshela M R
Published: November 2023

Background

2D- speckle-tracking echocardiography (2D-STE) has recently be used to assess subclinical myocardial dysfunction, however its utility in heart failure with reduced ejection fraction (HFrEF) has been specifically focusing on the longitudinal systolic function of the left ventricle (LV).

Aim

To assess the prognostic relation between right ventricular (RV) systolic and diastolic strain parameters with clinical outcome in patients with advanced heart failure (HFrEF).

Methods and results

Of the initial 2217 HFrEF patients screened for this study only 562 consecutive patients with HFrEF were eligible and retrospectively enrolled, and 2D-STE strain parameters assessed on the 2D-TTE images. All patients were prospectively followed for development of new outcome/cardiac events which included hospitalization for acute HF, CVS-related death, heart transplantation, or need for ventricular assist device implantation.

Conventional TTE was performed in all subjects and reviewed. RV longitudinal strain parameters (RVLS, RVLD) by 2D-STE were assessed and averaged in all segments (apical 4CV, global RVLS and RVLD) and also averaged free-wall.

Of the 562 patients at baseline, 263 had 117 new events during a mean follow-up of 1.4 ± 0.7 years. RV free wall and global RV systolic and diastolic strain parameters, elevated NT Pro-BNP, RV fractional area change, low TAPSE, LV end-diastolic volume and the presence of at least moderate TR, and PASP > 40mmHg were independently predictive of combined outcomes ( p <.001).

Overall, the best performance parameters predictive of cardiovascular events were for RV Free Wall systolic and diastolic strain (AUC: 0.84 and 74), global RV systolic and diastolic strain (AUC: 0.77 and 70) and RV fractional area change (AUC: 0.67). The strongest association between the degree of RV dysfunction and the risk of cardiovascular events was only evident for RV strain (free wall > global strain).

Conclusion

Patients with HFrEF, RV strain parameters are stronger predictors of outcome than other conventional parameters and should be included for regular clinical screening as these parameters provide a stronger prognostic stratification.
Prognostically optimal heart rate at discharge in hospitalized patients with heart failure and atrial fibrillation
Authors: Kishihara M , Jujo K , Kawakami R , Fukushima N , Takada T , Abe T , Shirotani S , Yoshida A , Hata T , Watanabe S , Kawamoto T , Hasegawa S , Yamaguchi J
Published: November 2023

Background

The management of heart rate (HR) is crucial for improving the clinical prognosis of patients with heart failure (HF) and atrial fibrillation (AF). Tachycardia induced by AF can cause decompensation of HF and subsequent hospitalization, but guidelines do not mention a specific target HR for patients with HF and persistent AF. Indeed, the prognostic impact of HR at discharge for hospitalized patients with HF and AF is still unclear.

Purpose

The purpose of this study was to determine the optimal HR at discharge for improving the prognosis of hospitalized patients with HF and AF.

Methods

In this observational study, 334 patients with persistent AF were analyzed from a database of 1,930 consecutive patients hospitalized for HF. Patients with sinus rhythm or paroxysmal AF, those with cardiac pacemakers or other antiarrhythmic devices, and those whose HR was not recorded at discharge were excluded. Participants were divided into 4 groups based on HR at discharge, with every 10 beats per minute (bpm) increment: HR <60 bpm (N=79), 61 bpm < HR <70 bpm (N=89), 71 bpm < HR <80 bpm (N=101), and 81 bpm < HR (N=65). The association between HR at discharge and the incidence of composite death from any cause and rehospitalization due to HF was analyzed as the primary endpoint.

Results

The average age of participants was 78 years, and 60% were men. At discharge, the clinical profiles of patients in the 4 groups were comparable. During the median follow-up period of 356 days, the primary endpoint occurred in 133 patients (39.8%). Kaplan-Meier analysis showed a significantly higher incidence of the primary endpoint in patients with HR >81 bpm at discharge than in those with HR <60 bpm at discharge (log-rank test for trend: p=0.039, Figure A). After adjusting for diverse covariates, including the use of beta-blockers, multivariable Cox regression analysis revealed that HR >81 bpm at discharge was associated with the primary endpoint, with a hazard ratio of 1.75 (95% confidence interval: 1.03–2.98) compared to HR <60 bpm. Restricted cubic spline confirmed that HR >81 bpm at discharge was an independent predictor for the primary endpoint by a referred HR of 61 bpm (Figure B).

Conclusions

This observational study suggests that for better clinical outcomes, the HR at discharge for patients with HF and persistent AF should be controlled to less than 80 bpm.Figure AFigure B
Outcome of transcatheter mitral valve repair in heart failure patients with reduced ejection fraction and severe left ventricular dilatation
Authors: Sone M , Suzuki A , Kikuchi N , Yoshikawa M , Minami Y , Inagaki Y , Nakao M , Domoto S , Arashi H , Arai K , Shiga T , Ashihara K , Niinami H , Yamaguchi J
Published: November 2023

Introduction

The COAPT trial demonstrated the benefit of transcatheter edge­to­edge mitral valve repair (TEER) for heart failure patients who had reduced ejection fraction (HFrEF) with symptomatic secondary mitral regurgitation (MR). However, patients with severe left ventricular (LV) dilatation were not included in the COAPT trial. Furthermore, disproportionate LV dilatation was suggested as a possible explanation for the lack of benefit in the MITRA­FR trial.

Purpose

The purpose of this study was to assess the safety and efficacy of TEER in HFrEF patients with severe LV dilatation.

Methods

We studied 75 HFrEF patients who underwent mitral valve repair between 2018-2021. Reduced LV ejection fraction (LVEF) was defined as LVEF of 40% or less. These patients were categorized with and without severe LV dilatation based on left ventricular end-diastolic volume index (LVEDVI) using a median cut­off value of >139ml/m2 in men and >128cm/m2 in women.

Results

There were 37 patients with severe LV dilatation (D) and 38 without (ND). Median LVEDVI was 172 [149-190] ml/m2 in the D group vs 120 [105-127] ml/m2 in the ND group. Compared to the ND patients, patients with severe LV dilatation were more treated with SGLT2-inhibitor (rate 24% vs 3%), had lower LVEF (30 [25-31] % vs 32 [30-36] %), and higher BNP (1160 [683-2586] vs 619 [396-1253] pg/ml). There was no significant difference in MR grade (4 [3-4] vs 4 [3-4]), EROA (0.32 [0.22-0.66] vs 0.34 [0.24-0.48] cm2), NYHA class (3 [2-4] vs 3 [2-3]) and mean systolic pulmonary pressure (31 [20-43] vs 34 [25-41] mmHg). Peri­procedural adverse events were rare in both groups. 1 patient had pseudoaneurysm in the ND group, and 1 patient had cardiogenic shock and 1 patient had stroke after the procedure in the D group. At discharge, there was marked improvement in MR grade (1 [1-2] vs 1 [1-2] for both). D group had a tendency of higher reduction in LVEDVI (-12 [-24--1] vs -5[-13-4] ml/m2) than ND group. BNP level of the D group had a significantly higher degree of decline before discharge (-458 [-141--1566] to -102 [+51--306] pg/ml) than that of ND group. No differences were noted in mortality between two groups (Figure).

Conclusion

TEER in HFrEF patients with severe LV dilatation seems to provide similar outcomes compared to patients with less severe dilatation. Further studies are needed to clarify the indication and establish the effectiveness of TEER in these patients.
Cardiac resynchronosation and left ventricular ejection fraction improvement with single ventricular conduction pacing system lead
Authors: Ayala Valani F G , Ayala Valani L M , Ayala Paredes F
Published: November 2023

Background

Conduction system pacing is a new modality to obtain physiologic pacing (PP) and normal to near normal cardiac synchrony; they often obtain shorter QRS durations and they could replace the need of Bi-V (CRT) implants if LVEF improves as much with less leads implanted.

Methods

From our cohort of 340 physiologic pacing attempts (2019-2023), we extracted all patients (pts) with available ultrasounds before and after implants, aiming to describe the variation of Left Ventricular Ejection Fraction (LVEF) over time; all attempts, including failures were analyzed.

Results

A total of 146 pts completed follow-up LVEF evaluation. Pts were 36,8% females; median age was 79 +/- 8.5 years. Indications were: SSS 25%, AV block 41% (including 11 post TAVR), Pacemaker induced cardiomyopathy (PIMC) 27% and AV node ablation in 7%. Success to achieve cardiac resynchronisation (defined as a QRS shorter than 140ms and a LVAT shorter than 90ms, or 20% reduction in QRS width) was obtained in 82,6% of pts (higher success rate achieved with LBB-P: 88,4% vs 55,5% for His-P). Procedural time (pts in-out) was 88min (+/- 37min). Pts with a QRS larger than 150ms (CRT indication) were 49% of the cohort. Patients with a LVEF less than 50% accounted for 54,8% of the cohort. Mean QRS duration was 141,9ms (+/-36) pre-implant and 129,3ms (+/- 19) post implant. Mean LVEF was 43,6% (+/- 14) before implant and increased to 50,2% (+/-12) post implant for the entire cohort, in pts with CRT indication, variation persisted: mean LVEF improved from 33,2 to 43,8% and QRS duration from 172,9 to 136,8ms. Pts with less than 50% LVEF had a response rate of 75,5% (increase in LVEF from 4-41%), and 33% of patients increase their LEVF between 10-30% (deemed super responders), only one pt decrease 10% her LVEF (a His failure implant).

Conclusion

Cardiac resynchronisation is feasible with only one ventricular lead, potentially with longer duration of batteries and lesser costs. Response rate is similar to CRT historical controls but super responders are twice to three times higher than historical controls.