bluuebunny/crossref_metadata_2025 huggingface dataset:
Effects of a multidisciplinary heart failure program in short term readmissions of heart failure patients, preliminary results
Authors: Gorriz Magana J , Espinosa Pascual M.J , Abad Romero R , Olsen Rodriguez R , Nieto Ibanez D , Perela Alvarez C , Fraile Sanz A , Saavedra Falero J , Perea Egido J
Published: November 2020

Background

Unexpected readmissions are frequent among heart failure patients, due to their natural history that implies multiple readmissions, with high costs and clinical relevance.

Purpose

We aimed to assess the impact of a Multidisciplinary Heart Failure Program (MHFP) on the readmission-free period after an episode of acute decompensated heart failure (ADHF).

Methods

We carried out an analytical and observational study including all patients admitted to our Universitary Hospital, which covers 220,000 individuals, with an episode of heart failure when there was not a Multidisciplinary Heart Failure Program (January 2013 to December 2013). Once the MHFP was established, we compared non-MHFP patients with every patient admitted during February 2019 and February 2020 in terms of clinical data, imaging technique findings and short-term readmissions.

Results

The rate of readmission during this period was a 24.8% in non-MHFP and 17.2% in MHFP (p=0.15). However, we could find differences in median time to readmission due to ADHF, that was 1.74 months (CI 95%, 0.12–3.35) in non-MHFP, compared to 5.125 months (CI 95%, 4.15–6.09) in MHFP (p=0.002) (see Graph 1). There were also no significant differences in terms of basic characteristics between the MHFP and the non-MHFP patients (age, gender, left ventricular ejection fraction, left bundle branch block, hypertension). It is remarkable that establishing a MHFP has lengthened the readmission-free period. The rate of decompensation in the first and sixth month was respectively in the non–MHFP 9% and 21%; and in the MHFP 2% and 10%.

Conclusion

According to our results, the implantation of this Multidisciplinary Heart Failure Program has shown a reduction in the time to ADHF readmission compared with a cohort of similar pts some years before, which is clinically relevant.

Graph 1

Funding Acknowledgement

Type of funding source: None
Heart failure with improved ejection fraction in advanced heart failure clinic
Authors: Kittipibul V.K , Sinphurmsukskul S.S , Chattranukulchai P.C , Krailak L.K , Boonbumrung N.B , Nakviroj P.N , Ariyachaipanich A.A , Siwamogsatham S.S , Boonyaratavej S.B , Puwanant S
Published: November 2020

Objectives

The aims of the study were: (1) to determine the pattern of myocardial fibrosis assessed by delayed gadolinium enhancement cardiac MRI (DGE-CMRI) in patients with heart failure improved ejection fraction (HF-iEF) in an advanced heat failure clinic; and (2) to examine the dosage of beta-blocker and angiotensin converting enzyme inhibitor/ angiotensin receptor blockage/angiotensin neprilysin inhibitor (ACE-I/ARB/ARNI) in those patients.

Methods

HF-iEF was defined as patients with LVEF >40% with previously documented LVEF <35% at baseline.

Results

Among 312 consecutive patients with HF-rEF who were referred for an advanced HF clinic, 18% (56 patients) had HF-iEF within 12 months after referral. Of these, 84% (47 patients) had non-ischemic cardiomyopathy (CM); complete data on MRI for analysis were available for 25 of these patients (62%). Myocardial scar was found in 52% of patients with nonischemic CM (13 of 25). All patients with nonischemic CM had the myocardial scar of less than 10% of the total LV volume. Mid-wall DGE of the interventricular septum was the most common scar pattern. Among patients with HF-iEF, 36% (20 patients) were referred for heart transplant. Two patients with peripartum related and nonischemic etiologies were listed for heart transplant, and delisted 12 months after. No patient died during 1-year follow up. At 12 months, the mean LVEF change was +27±12%. Improvement of the LVEF to ≥50% occurred in 31 patients (55%). The percentage use of ACE-I/ARB/ARNI and beta-blocker was significantly increased, at 1-year-follow-up. Fourteen percent and 48% of patients achieved target dose of ACE-I/ARB/ARNI and beta-blocker, respectively. There was no significant association between myocardial scar pattern or extent and dosage of medical titration.

Conclusions

HF-iEF was present in 18% of patients with HF-rEF after 1-year follow-up in advanced heart failure clinic. Mid-wall DGE of the interventricular septum was the most common scar pattern in nonischemic HF-iEF. None of patients with nonischemic HF-iEF had myocardial scar >10% of the total LV volume. Improvement of LVEF to ≥50% occurred in approximately half of the study patients, and led to delisting patients from heart transplant waiting list. The majority of patients had recovery of the LVEF when the target dose of beta-blocker or ACE-I/ARB/ARNI had not been achieved during medical up-titration.

Funding Acknowledgement

Type of funding source: None
Impella versus intra-aortic balloon pump in cardiogenic shock: a meta-analysis assessing 30-days mortality
Authors: Shariff M , Doshi R , Pedreira Vaz I , Adalja D , Krishnan A , Hegde S , Kumar A
Published: November 2020

Introduction

Cardiogenic shock is linked with eminent morbidity and mortality despite advances in treatment modality. Adjuvant treatment modalities to provide mechanical haemodynamic support in the form of intra-aortic balloon pump (IABP) or Impella are being used among patients with cardiogenic shock. The Impella prunes left ventricular preload, whereas, IABP persuades after load reduction and both contribute to improved cardiac output. A few underpowered randomised control trials (RCTs) and observational studies compared short term mortality benefit of Impella juxtaposed to IABP among patients with cardiogenic shock.

Purpose

A meta-analysis of RCTs and observational studies researching the short-term mortality in cardiogenic shock comparing Impella to IABP was executed.

Methods

The databases PubMed, EMBASE and Cochrane were searched systematically to identify relevant RCTs and observational studies contrasting Impella to IABP and reporting 30-days mortality as outcomes. The search terms used were “Impella”, “IAPB”, “intra-aortic balloon pump” and all word variations were utilised. The search was conducted from the debut of the databases up to January 2020. Two reviewers independently and in tandem performed data screening and extraction from identified articles. Inverse variance method with Paule-Mandel estimator for tau2 and Hartung-Knapp adjustment was used to calculate Risk Ratio with 95% confidence interval. Heterogeneity was assessed using I2 statistics. Furthermore, we calculated the 95% predictive interval for the pooled estimate. All statistical analysis for this meta-analysis was carried out using R statistical software version 3.6.2 using the package meta ( ). Additionally, Grading of Recommendations, Assessment, Development and Evaluations (GRADE) criteria were used to assess the certainty of evidence.

Results

Five studies constituting 728 patients were included in the final analysis. Two were RCTs (ISAR-SHOCK trial and IMPRESS in Severe Shock trial), one study was a propensity score matched observational study and two were unmatched observational studies. There was no difference in the risk of 30-days mortality in patients treated with Impella as compared to IABP [Risk Ratio: 0.97, 95% confidence interval: 0.66–1.41, I2: 32%]. To account for the heterogeneity, we calculated 95% predictive interval: 0.46–2.02. Thus, very low certainty of evidence concluded no difference in the risk of 30-days mortality among cardiogenic shock patients treated with Impella in opposition to IABP.

Conclusion

This meta-analysis comparing Impella juxtaposed with IABP demonstrated no difference in the risk of 30-days mortality among patients with cardiogenic shock.

30-days Mortality

Funding Acknowledgement

Type of funding source: None
Impact of influenza and pneumococcal vaccines upon in-hospital mortality in patients with heart failure: a retrospective cohort study in the United States
Authors: Gonuguntla K , Patil S.P , Rojulpote C
Published: November 2020

Introduction

Heart failure has been increasing in prevalence over the past decade. Respiratory infections have been associated with exacerbations of underlying heart failure. Hence, vaccinations against these infections may serve to be an effective intervention to improve overall outcomes.

Purpose

We sought to compare the in-hospital mortality in patients with heart failure who received influenza and pneumococcal vaccine.

Methods

We analysed the United States National Inpatient Sample Database from 2010–2014 to identify patients with primary discharge diagnosis of heart failure. We identified pneumococcal vaccine with ICD 9 code V03.82 and influenza vaccine with ICD-9 code V04. 81. We excluded patients who were transferred out to prevent duplication of data. Chi-Square test was used for statistical analysis.

Results

The sample consisted of 587,018 patients with heart failure from 2010 to 2014 (Mage= 70.53±14.6 years), the majority of whom were male (60.1%) and Caucasian (53.2%). Upon comparing the group that received the influenza vaccine to the group that did not receive the influenza vaccine, rates of in-hospital mortality in patients with heart failure were 1.3% vs 3.6%; p<0.001. Furthermore, comparison of the group that received pneumococcal vaccine to the group that did not receive the pneumococcal vaccine, rates of in-hospital mortality were 1.2% vs 3.6%; p<0.001.

Conclusions

Despite the growing awareness regarding vaccinations in patients with heart failure the rates of vaccination in heart failure patients remain low. Our study findings indicate that patients who received influenza and pneumococcal vaccine had lower in-hospital mortality. The results of our study indicate that these vaccines have a significant impact in improving outcomes in heart failure patients.

Funding Acknowledgement

Type of funding source: None
High prevalence of alcohol- and substance abuse among young heart failure patients in Sweden
Authors: Lindgren M , Habtemichael L , Rosengren A , Schaufelberger M
Published: November 2020

Background

Heart failure in the young is increasing. Increasing prevalence of overweight and obesity may be of importance. While alcohol and drugs are known to have cardiotoxic effects, few studies have investigated the prevalence of alcohol- or substance abuse among young patients with HF.

Aim

To investigate the prevalence of alcohol- and substance abuse in a cohort of young patients with heart failure.

Methods

All patients that received a diagnosis of heart failure at Sahlgrenska University Hosital (Sweden) between 1997 and 2016, ages 18–54, with a previously documented transthoracic echocardiogram were included. A systematic evaluation of participants electronic health records was performed, where predefined details about the use of alcohol, narcotic drugs and anabolic steroids, as well as echocardiographic findings were recorded.

Result

A total of 1363 patients were included (1001 men and 366 women, mean age 45 years), 190 (14%) of which were <34 years, 304 (22%) 35–44, and 869 (64%) 45–54 years. In total, a record of either alcohol- or substance abuse was found in 28% of men and 9% of women, respectively. The prevalence of Anabolic steroids was found to be 2% among men. For substance abuse, the prevalence was found to be 12% in men and 5% in women. Alcohol abuse was found in 24% of men and 5% of women. Both alcohol- and drug abuse was most common in the highest age group.

Conclusion

There was a high prevalence of alcohol- and/or drug-abuse among young adults with heart failure, especially in male patients.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): The Swedish state under the agreement concerning research and education of doctors [grant number ALFGBG-427301]; The Swedish Society for Physicians, the Health & Medical Care Committee of the Regional Executive Board, Region Västra Götaland, Sweden, and the Swedish Heart and Lung Foundation [grant number 2015-0438]
Effects of canagliflozin in patients with type 2 diabetes and chronic heart failure: a randomized trial (CANDLE)
Authors: Tanaka A , Hisauchi I , Taguchi I , Sezai A , Toyoda S , Tomiyama H , Sata M , Ueda S , Oyama J , Kitakaze M , Murohara T , Node K
Published: November 2020

Background

Little is known about the impacts of sodium glucose co-transporter 2 inhibitors on cardiac functional parameters, such as natriuretic peptides, in type 2 diabetes (T2D) patients with concomitant chronic heart failure (CHF).

Purpose

To compare the effect of canagliflozin with glimepiride, based on changes in N-terminal pro-brain natriuretic peptide (NT-proBNP), in that patient population.

Methods

This trial was an investigator-initiated, multicenter, prospective, randomized, open-label, blinded-endpoint trial at 34 centers in Japan. Patients with T2D and clinically stable CHF excluding NYHA class IV, randomized to receive canagliflozin 100 mg or glimepiride (starting dose: 0.5 mg), were examined using the primary endpoint of non-inferiority of canagliflozin versus glimepiride, defined as a margin of 1.1 in the upper-limit of the 2-sided 95% confidence interval (95% CI) for the group ratio of percentage change in NT-proBNP at 24 weeks.

Results

Data analysis of 233 patients (mean age 68.6±10.1 yrs; 75% male) showed mean left ventricular ejection fraction (LVEF) at randomization was 57.6±14.6%, with 71% of patients having a preserved LVEF (≥50%). The ratio of NT-proBNP percentage change was 0.48 (95% CI, −0.13 to 1.59, P=0.226), and therefore did not meet the prespecified non-inferiority margin. However, data stratified according to baseline NT-proBNP levels showed a trend that canagliflozin treatment reduced NT-proBNP levels to a greater extent than in subgroups with elevated levels of NT-proBNP (Figure A). Furthermore, NT-proBNP levels in the canagliflozin group did show a nonsignificant trend lower in the subgroup with preserved LVEF (Figure B), but not in the subgroup with reduced LVEF (Figure C). Additionally, the changes in the NYHA class were comparable between groups (P=0.061) in the overall cohort, whereas in the subgroup with a preserved LVEF canagliflozin caused a significant improvement in NYHA classes compared to that found for glimepiride treatment (P=0.027).

Conclusions

This trial did not meet the predefined primary endpoint of changes in NT-proBNP levels, with 24 weeks of treatment with canagliflozin relative to glimepiride which together with other recent studies would question the value of continuing to monitor NT-proBNP levels after the initial diagnosis of heart failure. Nevertheless, in a subgroup with preserved LVEF, there was a non-significant trend for canagliflozin treatment to reduce NT-proBNP levels and improve symptoms even in stable HF patients. Further research is therefore warranted to determine whether patients with preserved LVEF, regardless of diabetes status, could potentially benefit from treatment with SGLT2 inhibitors.

Changes in NT-proBNP

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Mitsubishi Tanabe Pharma Corporation
Discharge heart rate and clinical outcomes in hospitalized heart failure patients with coexisted atrial fibrillation
Authors: Xing F , Bai X , Li J
Published: November 2020

Background

Whether discharge heart rate for hospitalized heart failure (HF) patients with coexisted atrial fibrillation (AF) is associated with long-term clinical outcomes and whether this association differs between patients with and without beta-blockers have not been well studied.

Purpose

We investigated the associations between discharge heart rate and clinical outcomes in hospitalized HF patients with coexisted AF, while stratified to beta-blockers at discharge.

Methods

The study cohort included 1631 HF patients hospitalized primarily with AF, which was from the China PEACE Prospective Heart Failure Study. Clinical outcome was 1-year combined all-cause mortality and HF hospitalization after discharge. We analyzed association between outcome and heart rate at discharge with restricted cubic spline and Cox proportional hazard ratios (HR).

Results

The median age was 68 (IQR: 60- 77) years, 41.9% were women, discharge heart rate was (median (IQR)) 75 (69- 84) beats per minute (bpm), and 60.2% received beta-blockers at discharge. According to the result of restricted cubic spline plot, the relationship between discharge heart rate and clinical outcome may be nonlinear (P<0.01). Based on above result, these patients were divided into 3 groups: lowest <65 bpm, middle 65–86 bpm and highest ≥87 bpm, clinical outcomes occurred in 128 (64.32%), 624 (53.42%) and 156 (59.32%) patients in the lowest, middle, and highest groups respectively. In the Cox proportional hazard analysis, the lowest and highest groups were associated with increased risks of clinical outcome compared with the middle group (HR: 1.289, 95% confidence interval (CI): 1.056 - 1.573, p=0.013; HR: 1.276, 95% CI: 1.06 - 1.537, p=0.01, respectively). And a significant interaction between discharge heart rate and beta-blocker use was observed (P<0.001 for interaction). Stratified analysis showed the lowest group was associated with increased risks of clinical outcomes in patients with beta-blockers (HR: 1.584, 95% confidence interval (CI): 1.215–2.066, p=0.001).

Conclusion

There may be a U-curve relationship between discharge heart rate and clinical outcomes in hospitalized HF patients with coexisted AF. They may have the best clinical outcomes with heart rates of 65 - 86 bpm. And strict heart rate control (<65 bpm) may be avoided for patients who discharge with beta-blockers.

Figure 1

Funding Acknowledgement

Type of funding source: Other. Main funding source(s): This work was supported by the National Key Research and Development Program (2017YFC1310803) from the Ministry of Science and Technology of China; the CAMS Innovation Fund for Medical Science (2017-I2M-B&R-02); the 111 Project from the Ministry of Education of China (B16005).
Cause-specific mortality and heart failure readmissions according to the HFA-PEFF algorithm in patients hospitalised for heart failure with preserved ejection fraction
Authors: Verbrugge F.H , Reddy Y.N.V , Carter R.E , Borlaug B.A
Published: November 2020

Background

The HFA-PEFF algorithm has been recently developed and is recommended by the European Society of Cardiology to make a diagnosis of heart failure with preserved ejection fraction (HFpEF). Based on functional echocardiography criteria, morphological criteria, and natriuretic peptide levels, a score from 1 to 6 is obtained with higher scores indicating a higher probability of HFpEF.

Purpose

This study investigates the prognostic value of the HFA-PEFF score in HFpEF patients hospitalised for decompensation.

Methods

This retrospective cohort study includes consecutive patients with HFpEF, admitted to Mayo Clinic Rochester between 2010–2015 and requiring treatment with intravenous loop diuretics for congestion. The HFA-PEFF score was calculated for all patients with echocardiography data available within 1 year and natriuretic peptide levels obtained upon admission. The study population was subsequently stratified according to HFA-PEFF score ≤4 (n=79), =5 (n=93), or =6 (n=271). Incidence rates of recurrent heart failure admissions per 100 patient-years of follow-up, time to all-cause mortality, and mortality causes were compared among strata.

Results

In 443 patients with HFpEF (78±12 years; 60% women), higher HFA-PEFF score was associated with older age, female gender, higher systolic blood pressure, and worse renal function. Heart failure readmission rates were higher in patients with HFA-PEFF score =5 [46.0 (38.5–53.5)] or HFA-PEFF score =6 [45.0 (40.1–49.8)] versus HFA-PEFF score ≤4 [28.9 (22.7–35.0); P-value<0.001 for differences; see upper panel figure]. Increasing HFA-PEFF score was associated with a shorter median survival (P-value<0.001), which was 65 months (36–89 months) in HFA-PEFF score ≤4, 45 months (26–59 months) in HFA-PEFF score =5, and 28 months (22–42 months) in HFA-PEFF score =6 (see lower panel figure). The proportions of deaths directly related to heart failure were comparable among HFA-PEFF strata (49% versus 49% versus 52%, respectively; P-value=0.903), as was the contribution of cardiovascular death (60% versus 57% versus 63%, respectively; P-value=0.662). Overall, few differences in patterns of mortality causes were observed among strata. There was a lower contribution of primary respiratory disease (mainly chronic obstructive pulmonary disease) to mortality in patients with a higher HFA-PEFF score (26% versus 19% versus 6%, respectively; P-value<0.001).

Conclusions

Higher HFA-PEFF score in hospitalized patients with HFpEF is associated with increased risk of subsequent heart failure readmissions and all-cause mortality, which includes both heart failure specific and non-heart failure mortality.

Heart failure readmissions & mortality

Funding Acknowledgement

Type of funding source: Foundation. Main funding source(s): Belgian American Educational Foundation (B.A.E.F.); Special Research Fund (BOF) of Hasselt University (Hasselt, Belgium)
Validation and comparison of BIOSTAT risk score and AHEAD score for patients with acute heart failure
Authors: Ishiwata S , Matsue Y , Kasai T , Yatsu S , Matsumoto H , Shitara J , Shimizu M , Kurita A , Kato T , Suda S , Hiki M , Takagi A , Daida H
Published: November 2020

Background/Introduction

Acute heart failure (AHF) is one of the major causes of mortality, and identifying the patients at high risk of mortality at the time of admission is crucial to improve clinical outcomes. Although some risk prediction models for patients with AHF have been proposed mainly from randomized clinical trials, the patients in such studies tend not to be similar to those in the real world. Recently, BIOSTAT risk score and AHEAD score derived from two large-scale registry dataset are proposed as useful risk stratification tools for patients with AHF. However, these scores have not been well externally validated and their prognostic prediction performance has not been directly compared.

Purpose

To validate and compare prognostication of BIOSTAT risk score and AHEAD score in AHF patients.

Methods

Patients who consecutively admitted to the cardiac intensive-care unit in our institution with a diagnosis of AHF from 2007 to 2011 were analyzed. Among them, patients with acute coronary syndrome, dialysis, malignancy were excluded. BIOSTAT risk score was calculated using 5 factors (age, blood urea nitrogen, BNP, hemoglobin, prescription of beta blockers), and AHEAD score was also calculated with 5 factors (atrial fibrillation, hemoglobin, age, creatinine, and diabetes mellitus). We also developed AHEAD + BNP model incorporating BNP into AHEAD score. Endpoint was 1-year all-cause death.

Results

Overall, 591 eligible patients were enrolled (mean age was 70±14 years old, 64.8% were male) and 96 patients (16.2%) died during the follow-up of 1-year. The median [interquartile range] of AHEAD score and BIOSTAT risk score were 2 [1–3] and 3 [2–4], respectively. The areas under the curves of receiver operating characteristic curve (AUC) were 0.66 for AHEAD, 0.68 for AHEAD + BNP, and 0.72 for BIOSTAT, respectively. The calibration plots for AHEAD, AHEAD + BNP, and BIOSTAT models showed good calibration (Hosmer-Lemeshow test: p=0.89, 0.74, and 0.74, respectively). The BIOSTAT model's AUC was significantly higher compared to AHEAD (p=0.018) and marginally statistically higher compared to AHEAD + BNP (p=0.054). However, BIOSTAT model showed statistically significant net reclassification improvement compared to both AHEAD (NRI: 0.43, p<0.001) and AHEAD + BNP (NRI: 0.43, p<0.001).

Conclusion

The BIOSTAT score comprised of five readily available clinical variables predict 1-year mortality of patients with AHF with good discrimination and calibration.

ROC curves

Funding Acknowledgement

Type of funding source: None
Early coronary angiography in acute ischemic heart failure is associated with improved survival and lower rates of heart failure hospitalization
Authors: Kosyakovsky L , Wang X , Austin P.C , Abdel-Qadir H , Lawler P.R , Croxford R , Farkouh M.E , Goodman S.G , Spertus J.A , Ross H.J , Lee D.S
Published: November 2020

Background

While coronary ischemia plays a major role in the pathogenesis and prognosis of heart failure (HF), the indications for coronary angiography in acute HF have not been established.

Purpose

To identify the clinical predictors of performing early coronary angiography in acute ischemic HF and determine the association of angiography with all-cause mortality, cardiovascular death, and HF readmissions.

Methods

We identified all acute HF patients who presented to any of 70 emergency departments in Ontario, Canada and determined whether they underwent early coronary angiography (defined as angiography performed within 14 days of hospital presentation) using procedural data contained in the Canadian Institute for Health Information (CIHI) database (April 2010 to March 2013). We selected patients for detailed chart review using stratified random sampling, including only those with acute ischemic HF, which we defined inclusively as those who had at least ONE of the following: previous myocardial infarction (MI), troponin elevation, or active angina on presentation. We excluded patients for whom angiography on the index admission might reasonably have been withheld, including those with recent pre-admission angiography or revascularization procedures, palliative patients, and those with contraindications to invasive angiography such as anaphylaxis to contrast, severe renal impairment, and high-risk bleeding. Predictors of 14-day coronary angiography were determined using multivariable logistic regression. We compared mortality and readmissions up to two-year follow-up. Inverse probability of treatment weighting (IPTW) using the propensity score was used to adjust for differences in baseline characteristics between the two cohorts.

Results

Of 6,172 initially screened patients, 4,118 met criteria for acute ischemic HF. After exclusions, 2,994 were included in the study. Of these, 1,567 (52.3%) underwent early angiography and 1,427 (47.7%) did not (median age 75 [IQR 65–83] years and 40.9% women). Clinical factors associated with greater odds of early angiography included previous MI, anginal symptoms at presentation, New York Heart Association (NYHA) III-IV symptoms, and family history of coronary artery disease. After IPTW, early angiography was associated with lower all-cause mortality (HR 0.74, 95% CI; 0.61–0.90, p=0.002) and cardiovascular death (HR 0.72, 95% CI; 0.56–0.93, p=0.012) at two years. HF readmissions were also lower with early angiography (HR 0.84, 95% CI; 0.71–0.99, p=0.042).

Conclusion

Early coronary angiography in acute ischemic heart failure was associated with lower all-cause mortality, cardiovascular death, and HF readmissions.

Funding Acknowledgement

Type of funding source: Public grant(s) – National budget only. Main funding source(s): Canadian Institute of Health Research Grant
Prognostic role of sonographic decongestion in patients with acute heart failure with reduced and preserved ejection fraction: a multicentre study
Authors: Pugliese N.R , Mazzola M , Bandini G , Barbieri G , Spinelli S , De Biase N , Masi S , Moggi-Pignone A , Ghiadoni L , Taddei S , Sicari R , Pang P.S , Gargani L
Published: November 2020

Aims

Our aim was to assess the dynamic changes of pulmonary congestion (PC) through variations of sonographic B-lines, in addition to conventional clinical, biohumoral and echocardiographic findings, to improve prognostic stratification of patients admitted for acute heart failure with reduced and preserved ejection fraction (HFrEF, HFpEF).

Methods

In this multicenter, prospective, observational study, lung ultrasound was performed in all patients at admission and before discharge by trained investigators, blinded to clinical findings and outcomes.

Results

We enrolled 208 consecutive patients admitted for acute heart failure (125 HFrEF, 83 HFpEF, mean age 75.9±11.7 years, 36% females, mean ejection fraction 38%). After 180-day follow-up, 38 composite endpoint events occurred (cardiovascular deaths or HF re-hospitalisations). In a multivariate model, B-lines at discharge had independent prognostic value in the overall population together with NT-proBNP, moderate-to-severe mitral regurgitation (MR) and inferior vena cava diameter at admission. When dividing the population in HFrEF and HFpEF, B-lines at discharge was the only independent parameter to predict events in all subgroups. At ROC analysis, a cut-off of B-lines>15 at discharge displayed the highest accuracy in predicting adverse events (AUC=0.80, p<0.0001). The identification of patients unable to halve B-lines during hospitalization (ΔB-lines%), in addition to B-lines >15 at discharge, improved event classification (integrated discrimination improvement=4%, p=0.01; continuous net reclassification improvement=22.8%, p=0.04).

Conclusions

The presence of residual subclinical sonographic PC at discharge predicts adverse events in the whole spectrum of acute HF patients, independently of conventional biohumoral and echocardiographic parameters. The dynamic evaluation of pulmonary decongestion during hospital stay can further improve patient risk stratification.

Funding Acknowledgement

Type of funding source: None
Intramyocardial fast-SENC is less impacted by compensatory mechanisms while monitoring cardiotoxic effects of chemotherapy than echocardiography and conventional CMR: the PREFECT study
Authors: Steen H , Montenbruck M , Gersak B , Schwarz A.K , Esch S , Kelle S , Giusca S , Korosoglou G , Wuelfing P , Dent S , Lenihan D
Published: November 2020

Background

Cancer treatments (CT) have been shown to occasionally elicit a toxic reaction on the heart. Echocardiography (ECHO) and cardiac magnetic resonance imaging (CMR) have been used to monitor cardiotoxicity through left ventricular ejection fraction (LVEF) and global longitudinal strain (GLS). Fast-SENC (fSENC) CMR testing directly measures intramyocardial contraction to quantify subtle changes in function capable of detecting cardiotoxicity missed by conventional imaging modalities. The PREFECT study compares fast-SENC vs ECHO in terms of sensitivity of predicting and detecting subclinical (sCTX) or clinical cardiotoxicity (cCTX) irrespective of loading conditions or changes in cardiac output.

Methods

A single center, prospective clinical trial of patients receiving anthracycline-based CT had fSENC acquired during CMR exams with a 1.5T scanner. Intramyocardial LV & RV strain was quantified with MyoStrain software. Three short axis scans (basal, midventricular, & apical) were used to calculate peak strain in 16 LV & 6 RV longitudinal segments while three long axis scans (2-, 3-, & 4-chamber) were used to calculate 21 LV & 5 RV circumferential segments.

Results

63 patients had 323 scans; 41% experienced sCTX and 15% cCTX. Figure 1 shows a Box and Whisker's plot for the % of fSENC ≤−17 by cardiotoxicity status. Both fSENC and CMR LVEF detected sCTX and cCTX based on ANOVA analysis (p<0.001) although fSENC had better delineation of both sCTX and cCTX. However, ECHO LVEF and GLS did not detect sCTX or cCTX (p=NS). CMR stroke volume index decreased while blood pressure and heart rate increased for both sCTX and cCTX (p<0.001). Meanwhile, mass index and end-systolic volume index increased for cCTX (p<0.001).

Conclusion

Segmental fSENC detected early CT-induced sCTX regardless of loading conditions. ECHO did not detect sCTX potentially due to compensatory mechanisms or acoustic window limitations in breast cancer and lymphoma patients that had less effect on CMR.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Myocardial solution (MSI)
Donepezil as a novel therapy for suppressing the progression of cardiovascular remodeling in obesity-induced hypertensive rats with reperfused myocardial infarction
Authors: Li M , Zheng C , Kawada T , Inagaki M , Uemura K , Sugimachi M
Published: November 2020

Introduction

Acetylcholinesterase inhibition by donepezil has been shown to improve long-term survival in permanent myocardial infarction (MI)-induced chronic heart failure rats. This study examined whether donepezil is applicable to the treatment of obesity-induced hypertension with reperfused MI (RMI).

Methods

Four-week-old SD rats were fed a high-fat diet (57% kcal as fat) for 15 weeks. We implanted a blood pressure (BP) telemetry into the animals (8-week-old) for monitoring artery pressure. After a 1-week recovery, RMI was created by occluding the left coronary artery (30min) followed by reperfusion. Surviving animals were randomly assigned to untreated (UT, n=16) or donepezil treated (DT, n=16, 3 mg/kg/day) group. After a 10-week treatment, the effects of donepezil were evaluated by hemodynamics, blood biomarkers, immunohistochemistry, and morphology.

Results

The high-fat diet caused obesity and hypertension (9-week-old: systolic BP = 134±4 mmHg; diastolic BP = 92±2 mmHg) in the normal rats. Compared with UT, DT significantly decreased the heart rate (296±5 vs. 318±8 bpm, P<0.05). DT significantly prevented the progression of cardiac remodeling and dysfunction [cardiac index: 91±4 vs. 73±9 ml/min/kg, P<0.01; left ventricular (LV) end-diastolic pressure: 11±1 vs. 20±2 mmHg, P<0.01; LV dp/dt max: 5347±206 vs. 3637±433 mmHg/sec, P<0.01], through increasing capillary density (+120%/field, P<0.001), reducing cardiac fibrosis (−50%, P<0.01) and myocardial infarcted area (17±2 vs. 24±2%, P<0.05), suppressing cardiac hypertrophy (2.35±0.04 vs. 2.70±0.14 g/kg, P<0.01) and coronary artery remodeling (wall thickness: 30±1 vs. 37±2 mm, P<0.01; media-to-lumen ratio: 2.3±0.2 vs. 6.2±1.6, P<0.001). Additionally, DT not only decreased plasma levels of insulin, norepinephrine, BNP, angiotensin II, but also improved the systemic inflammation.

Conclusions

Donepezil treatment significantly suppressed the progression of cardiovascular remodeling and dysfunction following RMI in obesity-induced hypertensive rats, suggesting that donepezil may be used as a potential candidate for post-RMI therapy in obesity-induced hypertensive patients.

Funding Acknowledgement

Type of funding source: None
Predictors of mortality in patients with VA-extracorporeal membrane oxygenation
Authors: Kang J , Lee H.S , Han S.M , Cho H.J
Published: November 2020

Background

Venoarterial extracorporeal membrane oxygenation (VA-ECMO) support is a lifesaving tool used in the treatment of cardiogenic shock, acute heart failure, or extracorporeal cardiopulmonary resuscitation (CPR). We report on a single center experience with ECMO and aim to identify the prognostic markers for in-hospital mortality and death at 72 hours after ECMO.

Methods

Between 2011 and 2019 we evaluated 131 patients, who received ECMO. Collected data was analyzed to identify baseline characteristic, outcomes including clinical variables predictive of poor outcome.

Results

The mean age was 62.5 years, 67.2% were male patients, with prior CPR in 61.8%. The annual number of VA-ECMO procedures steadily increased, whereas in-hospital mortality is decreasing. Within the total cohort, the indication for VA-ECMO was cardiac arrest in 19.1%, acute coronary syndrome in 41.2%, acute heart failure in 23.7%, and myocarditis in 10.7%.

Overall in-hospital mortality was 58.8%. Multivariate logistic regression model revealed presence of malignancy, history of revascularization, duration of cardiac arrest, and low BMI as independent predictors for mortality in 72 hours after ECMO (table). On the other hand, predictors of in-hospital mortality were prior congestive heart failure, male, and history of malignancy. The C-statistic for discriminating mortality in 72 hours after ECMO with the duration of cardiac arrest was 0.67 (figure).

Conclusions

Although the use of ECMO as a last line in the treatment of critical patients measures constitutes an important improvement in their care; with 41.2% overall survival; patient selection and timing of ECMO initiation remains challenging. The importance of consideration for ECMO use earlier in course of illness rather than later.

Funding Acknowledgement

Type of funding source: None
Long-term prognostic value of the combination of malnutrition and pulmonary-systemic pressure ratio in patients admitted with acute decompensated heart failure
Authors: Yamada T , Watanabe T , Morita T , Furukawa Y , Tamaki S , Kawasaki M , Kikuchi A , Kawai T , Seo M , Nakamura J , Kayama K , Fukunami M
Published: November 2020

Background

Malnutrition is associated with increased mortality risk in patients (pts) with acute decompensated heart failure (ADHF). On the other hand, concomitant presence of pulmonary hypertension in heart failure is associated with increased adverse events and may be related to interventricular uncoupling and impaired cardiac efficiency. It has recently been shown that an increased mean pulmonary artery pressure to mean systemic arterial pressure ratio (MPS ratio), a marker of interventricular coupling and efficiency, is associated with worse clinical outcomes in patients with advanced heart failure. However, there is no information available on the long-term prognostic value of the combination of malnutrition and MPS ratio in pts admitted for ADHF.

Methods and results

We studied 248 pts admitted for ADHF, who underwent right heart catheterization at the admission and were discharged with survival. Malnutrition was assessed by geriatric nutritional risk index (GNRI), prognostic nutritional index (PNI) and controlling nutritional status score (CONUT). During a mean follow-up period of 5.2±4.4 yrs, 62 pts had cardiovascular death (CVD). MPS ratio was significantly greater in pts with than without CVD (0.408±0.114 vs 0.347±0.102, p=0.0001). GNRI and PNI were significantly lower, CONUT was significantly greater in pts with than without CVD. At multivariate Cox regression analysis, GNRI and MPS ratio were significantly associated with CVD, independently of prior heart failure hospitalization, eGFR, and serum sodium level and anemia, although PNI and CONUT showed the association with CVD at unvariate analysis. Pts with malnutrition (GNRI≤median value=96.5) and greater MPS ratio (≥median value=0.346) had a significantly higher CVD risk than those with either and none of them (51% vs 20% vs 12%, p<0.0001, respectively).

Conclusions

The combination of malnutrition and MPS ratio might be useful for stratifying pts at risk for CVD in patients with ADHF.

Funding Acknowledgement

Type of funding source: None
Chronic coronary syndromes lead to reduced strain parameters compared to patients without myocardial ischemia in a propensity score-matched cohort assessed by cardiac magnetic resonance imaging
Authors: Vietheer J , Unbehaun C.U , Weferling M , Fischer-Rasokat U , Wolter J.S , Von Jeinsen B , Zipse L , Keller T , Hamm C.W , Rolf A
Published: November 2020

Background

Vasodilator perfusion cardiac magnetic resonance (CMR) has evolved as gold standard in detecting myocardial perfusion deficits (MPD). Even reversible chronic MPD in chronic coronary syndromes can lead to impaired myocardial contractility similar to hibernating myocardium. Feature tracking strain analysis (FTS) provides the opportunity to detect these subclinical alterations of myocardial function before ejection fraction (EF) is impaired. It was therefore the aim of this study to investigate, if subtle changes in myocardial mechanics can be detected by FT strain analysis in patients with MPD.

Methods

Between April 2017 and October 2019 we identified 226 patients with MPD by vasodilator stress CMR out of 1500 patients included in our tertiary care center registry. Propensity score matching was used to identify patients without MPD with similar myocardial characteristics defined by EF, enddiastolic volume indexed by body surface area (EDVi) and native T1-mapping. Steady state free precession cine CMR sequences were analyzed by FTS retrospectively generating three global strain parameters: global longitudinal, circumferential and radial strain (GLS, GCS, GRS).

Results

Propensity score matching yielded 104 patients in each group (MPD mean age 63.6±12.8 years, 25 females; no MPD mean age 67.7±10.6 years, 26 females; LV-EF 51.3±16.0% vs. 52.6±15.2%, p=0.2307; EDVi 88.3±32.7 ml/m2 vs. 82.6±29.3 ml/m2, p=0.1533; native T1 values 1139±60 ms vs. 1125±63 ms, p=0.118). All global strain parameters were significantly reduced in MPD patients compared to patients with no MPD (global longitudinal strain −15.5±4.9 vs. −17.1±4.9, p=0.0046, global circumferential strain −18.0±5.4 vs. −19.4±5.6, p=0.0298; global radial strain 35.4±14.8 vs. 39.4±15.6, p=0.0127).

Conclusion

Chronic Coronary Syndromes cause subtle changes of myocardial mechanics, which are not reflected by EF but can be detected with FTS.

Funding Acknowledgement

Type of funding source: None
Effect of myocardial ischemia in diabetic and non-diabetic patients: long-term follow-up of MASS registry
Authors: Camara De Carvalho F , Hueb W , Lima E.G , Linhares Filho J.P.P , Ribeiro M.O.L , Martins E.B , Batista D.V , Garzillo C.L , Ribas F.F , Boros G.A.B , Rezende P.C , Serrano Junior C.V , Ramires J.A.F , Kalil Filho R
Published: November 2020

Background

Prognostic role of ischemia has been debated. The association with diabetes mellitus (DM) seems to add risks of cardiovascular events. We aimed to assess whether ischemia confers additional risks in diabetic population.

Methods

A single-center, prospective study including subjects with multivessel coronary artery disease who underwent surgery, percutaneous intervention or medical therapy. They were stratified according to presence of ischemia and DM. Primary endpoint was defined as death or myocardial infarction (MI). Secondary endpoint was death.

Results

We enrolled 1001 patients with conclusive stress tests: 790 (79%) with ischemia and 211 (21%) without ischemia. Mean follow-up was 8.7 years (IQR 4.04–10.07). The primary outcome occurred in 228 (28.9%) patients with ischemia and 64 (30.3%) without ischemia (p=0.60). Event rate among those with negative stress test, with or without DM, was similar (p=0.96 and p=0.60 respectively). Among those with ischemia, 145 (35.6%) with DM presented the combined event compared to 83 (21.7%) without DM (HR: 1.39; 95% CI 1.06–1.83, p=0.01). Death occurred in 117 diabetic and 65 (17%) in non-diabetic subjects (HR: 1.49, 95% CI: 2.03, p=0.01).

Conclusion

Overall, the presence or absence of ischemia was not related to death or MI. However, subset of patients with DM and ischemia revealed increased risk of death and cardiovascular events irrespective of treatment strategy.

Funding Acknowledgement

Type of funding source: Public Institution(s). Main funding source(s): Zerbini Foundation
Diagnostic accuracy of two-dimensional coronary angiographic derived fractional flow reserve
Authors: Sadeghipour P , Babakhani H , Abdi S , Ghasemi M , Moosavi J , Sadeghian M , Shafe O , Mohebbi B
Published: November 2020

Background

Non-invasive fractional flow reserve (NiFFR) is an emerging method for evaluating the functional significance of a coronary lesion during diagnostic coronary angiography (CAG). The method relies on the computational flow dynamics and the 3D reconstruction of the vessel extracted from CAG. In the present study, we sought to evaluate the diagnostic performance and applicability of 2D-based NiFFR.

Methods

In this prospective observational study, we evaluated 2D-based NiFFR in 279 candidates for invasive CAG and invasive FFR. NiFFR was calculated via 2 methods: variable NiFFR, in which the contrast transport time was extracted from the angiographic view, and fixed NiFFR, in which a prespecified frame count was applied.

Results

The final analysis was performed on 245 patients (250 lesions). Variable NiFFR had an area under the receiver operating characteristic curve of 81.5%, an accuracy of 80.0%, a sensitivity of 82.2%, a specificity of 82.2%, a negative predictive value of 91.4%, and a positive predictive value of 63.6%. The mean difference between FFR and NiFFR was −0.0244 ±0.0616 (P≤0.0001). A pressure wire-free hybrid strategy was possible in 68.8% of our population with variable NiFFR.

Conclusions

Our 2D-based NiFFR yielded results comparable to those derived from 3D-based software. Our findings should, however, be confirmed in larger trials.

Pressure wire-free hybrid strategy

Funding Acknowledgement

Type of funding source: None
Prognostic value of pre-revascularization fractional flow reserve mediated by the post-revascularization level: a causal mediation analysis
Authors: Hamaya R , Mittleman M , Hoshino M , Kanaji Y , Lee J , Hwang D , Zhang J , Chen S , Koo B , Kakuta T
Published: November 2020

Background

The prognostic value of pre-percutaneous coronary intervention (PCI) fractional flow reserve (FFR) can depend on that of the post-PCI FFR and their interaction. To correctly interpret the prognostic value of pre-PCI FFR, it is essential to understand to what extent the relationship between pre-PCI FFR and clinical outcome is explained by pre-PCI FFR-related post-PCI FFR.

Purpose

The aim of this study is to investigate the extent to which post-PCI FFR mediates the relationship between pre-PCI FFR and vessel-related outcomes using a global, multicenter collaboration registry.

Methods

Patient data from 4 global FFR registries were pooled and 1488 patients with pre-PCI FFR ≤0.80 were analyzed. The primary outcome was target vessel failure (TVF) during 2-years of follow-up. We evaluated the extent to which post-PCI FFR <0.90 mediated the association between pre-PCI FFR <0.75 and TVF employing a causal mediation analysis in a counterfactual framework.

Results

Among 1488 patients, the mean (standard deviation) age was 63.5 (9.9) years and 78% (1161 patients) were male. The median (IQR) pre-PCI and post-PCI FFR were 0.71 (0.62–0.76) and 0.88 (0.83–0.92), respectively. The direct effect of low pre-PCI FFR (<0.75) on TVF was significantly elevated (OR: 1.81, 95% CI: 1.03–3.18, p=0.038), and was not mediated by post-PCI FFR<0.90 (indirect effect, OR: 1.01, 95% CI: 0.98–1.05, p=0.39). In the model, post-PCI FFR explained only 2.2% of the association between pre-PCI FFR and TVF. The subgroup analysis implicated that the prognostic information of pre-PCI FFR was mainly for diffuse lesions.

Conclusions

The prognostic information of pre-PCI FFR did not greatly depend on the results of PCI assessed by post-PCI FFR. Pre-PCI FFR, as a prognostic marker, may mainly reflect the global atherosclerotic burden of the artery, not the extent of the modifiable epicardial stenosis, thus providing independent information from post-PCI FFR.

Interpretation

Funding Acknowledgement

Type of funding source: None