bluuebunny/crossref_metadata_2025 huggingface dataset:
Prevalence of pulmonary hypertension in mitral regurgitation and its influence on outcomes
Authors: Ratwatte S , Strange G , Stewart S , Playford D , Celermajer D
Published: November 2023

Background

Pulmonary hypertension (PHT) commonly co-exists with significant mitral regurgitation (MR), but its prevalence and prognostic importance has not been well documented.

Purpose

In a large cohort of adults with ≥moderate MR, we aimed to describe the prevalence and severity of PHT and assess its influence on outcomes.

Methods

We analysed the National Echocardiography Database of Australia (data from 2000-2019). Adults with an estimated right ventricular systolic pressure (eRVSP), left ventricular ejection fraction (LVEF) >50% and with moderate or greater MR were included (n= 9683). These subjects were then categorised according to their eRVSP. The relationship between PHT severity and mortality outcomes were evaluated (median follow-up of 3.2 years, interquartile range 1.3-6.2years).

Results

Subjects were aged 76±12years and 62.6% (6038) were female. Overall, 959 (9.9%) had no PHT; and 2952 (30.5%), 3167 (32.7%), 1588(16.4%) and 1017 (10.5%) patients had borderline, mild, moderate and severe PHT respectively. A "typical left heart disease" phenotype was identified with worsening PHT, showing rising E:e’, right and left atrial sizes increasing progressively, from no PHT to severe PHT (p<0.0001, for all). With increasing PHT severity, 1- and 5-year actuarial mortality increased from 8.5% and 39.7%, and from to 33.0% and 79.8% respectively (p<0.0001). Similarly, adjusted survival analysis showed the risk of long-term mortality progressively increased with higher eRVSP levels (adjusted hazard ratio (aHR) 1.20, 95% confidence interval 1.04-1.38 in borderline PHT, to aHR2.86, 95%CI 2.48-3.31 in severe PHT, p<0.0001) (Figure 1). A mortality inflection was apparent at an eRVSP level >34.00mmHg (HR1.27, CI1.00-1.36) (Figure 2).

Conclusions

In this large study we characterise the close but incompletely understood relationship between significant MR and complicating PHT. Mortality increases as PHT becomes more severe from an eRVSP of approximately 34mmHg onwards.Adjusted Risk for All-Cause MortalityThreshold for Mortality
Long-term outcomes of patients with tachycardia-induced cardiomyopathy
Authors: Serban T , Weidlich S , Pfister O , Kuehne M , Sticherling C , Badertscher P
Published: November 2023

Introduction

Tachycardia-induced cardiomyopathy (TCM) is a reversible type of heart failure that occurs after sustained tachyarrhythmia. TCM can occur on its own (pure TCM) or superimposed on another type of CM (impure TCM). Survival data for such patients are lacking.

Purpose

We aimed to compare the 5-year survival rates of pure and impure TCM patients compared to other types of CM.

Methods

We retrospectively identified patients with reduced ejection fraction (≤50%) and/or atrial fibrillation or flutter with a left ventricular ejection fraction (LVEF) that improved from baseline (≥ 15% in LVEF at follow-up (FU)) through retrospective chart review. Patients were then divided into four groups (pure TCM, impure TCM, ischemic CM and nonischemic CM). The primary outcome was defined as a composite of death, life-threatening arrhythmia or cardiogenic shock. Secondary outcome was cardiovascular re-admission during FU.

Results

238 patients were included (mean age 68 ± 12 years, 31% women). Patients were classified as pure TCM in 35%, impure TCM in 18%, ischemic CM in 24% and non-ischemic CM in 23%. Median FU was 5 (IQR 4-6) years. 13 (5.5%) patients reached the composite outcome at FU. While patients with pure TCM showed similar survival rates as patients with ischemic or nonischemic CM (Figure), a significant difference in survival was observed between impure CM and ischemic and non-ischemic CM with respect to the composite outcome (11% vs 2.7%, p = 0.024). Patients with impure CM showed comparable rates of cardiovascular re-admission during FU compared to patients with ischemic and non-ischemic CM (45% vs. 49%, p = 0.91).

Conclusions

TCM patients have survival rates similar to patients with another type of CM. Patients with TCM on top of a non-ischemic or ischemic CM (impure TCM) demonstrated the lowest 5-year survival rates. Early detection and treatment of cardiac arrhythmias in patients with impure TCM seem to be warranted.Figure
Incorporating hypochloremia provides additive prognostic information in hospitalized patients with heart failure
Authors: Misumi K , Matsue Y , Nogi K , Kitai T , Oishi S , Suzuki S , Yamamoto M , Kida K , Okumura T , Nogi M , Ishihara S , Ueda T , Kawakami R , Saito Y , Minamino T
Published: November 2023

Background

Although hypochloremia has been suggested as a strong marker of mortality in hospitalized patients with heart failure (HF), it has not been clarified whether incorporating hypochloremia into pre-existing prognostic model improves the model performance to predict long-term mortality in patients with chronic heart failure.

Purpose

The aim of this study is to develop a novel risk model which adds hypochloremia as a component into the pre-existing risk model and identify whether the model performance has improved its performance or not.

Methods

We calculated the pre-existing modified Get-With-the-Guideline®risk score(GWTG-RS) which is composed of GWTG risk score + anemia + NYHA + log-BNP, and also developed a new risk score adding hypochloremia into the modified GWTG-RS in patients enrolled in REALITY-AHF or NARA-HF. Hypochloremia was defined as < 97 mmol/L. The validation and comparison of the model performance were performed in two large scale heart failure cohorts. All models were tested for one-year mortality.

Results

We tested the prognostic value of hypochloremia measured at the time of discharge in 2,496 hospitalized patients with HF registered to REALITY-AHF or NARA-HF. Patients with hypochloremia were strongly associated with one-year mortality compared to those without (Log-rank: p<0.001), and this association was retained even after adjustment for GWTG-RS variables, anemia, NYHA and log-BNP (HR 1.64; p<0.001). Next, we tested whether adding hypochloremia to the prediction model comprised of the modified GWTG-RS improves its performance, and it yields numerically larger area under the curve (0.740 vs. 0.749; p = 0.059) and significant improvement in net-reclassification (0.159; p = 0.010).

Conclusions

Presence or absence of hypochloremia at discharge provides incremental prognostic information on top of pre-existing risk prediction model in hospitalized patients with HF.Kaplan-Meier curves for 1-year survival
Symptoms vs. pathology and outcomes in patients with reduced ejection fraction
Authors: Kanonidis E , Deedwania P , Bhyan P , Lam P H , Raman V K , Faselis C , Aronow W S , Fonarow G C , Ahmed A , Kanonidis I
Published: November 2023

Background

After acute myocardial infarction (AMI), patients have similar mortality regardless of whether AMI is silent or not. Less is known about whether outcomes after left ventricular systolic dysfunction (LVSD) varies by absence or presence of heart failure (HF) symptoms (Stage B and C HF, respectively).

Methods

In Studies of Left Ventricular Dysfunction (SOLVD), patients with EF ≤35% were randomized to enalapril or placebo. We compared 4-year mortality in 2569 patients with HF symptoms (Stage C HF) enrolled in SOLVD-Treatment trial with that in 4228 patients without symptoms (Stage B) in SOLVD-Prevention trial, adjusting for 24 baseline characteristics including age, sex, race, EF, symptoms (as indexed by NYHA class).

Results

Patients in SOVLD-Treatment had a higher risk of death (HR, 2.63; 95% CI, 2.37–2.90; p<0.001), which remained significant after adjustment for 23 covariates except NYHA (HR, 1.35; 95% CI, 1.16–1.60; p<0.001; Figure, left panel). However, when NYHA was added to the model, the significant was lost (adjusted HR, 1.15; 95% CI, 0.97–1.36; p = 0.117; Figure, right panel).

Conclusion

These findings suggest that unlike in patients with AMI, in patients with reduced EF, those with HF symptoms have higher mortality, even after adjustment for other covariates.
Food insecurity is associated with a higher body mass index and lower albumin levels in patients with congestive heart failure in the All of Us research program
Authors: Rtabi H , Driggin E , Kurian D C , Maurer M A , Raiszadeh F
Published: November 2023

Introduction

Congestive Heart Failure (CHF) is an extremely prevalent disorder worldwide with high morbidity and mortality rates. Estimates suggest that approximately 80% of cardiovascular diseases (CVD), including CHF, can be prevented by controlling risk factors and adopting a healthy lifestyle. However, there are substantial barriers to implementing this guidance for many patients, including food insecurity, which is a household-level economic and social condition of limited or uncertain access to adequate food. Food insecurity is also associated with a greater prevalence of overweight and obesity, which plays a role in the pathogenesis of CHF.

Purpose

Our goal is to examine the difference in body mass index (BMI), nutritional and cardiac-specific markers—specifically albumin, B-type natriuretic peptides (BNP), N-terminal pro-B-type natriuretic peptides (NT-proBNP), and troponin I (TnI)—between patients with CHF who are food secure and patients with CHF who are food insecure. To our knowledge, no prior studies have examined this important relationship in a large population-based sample.

Methods

We use the All of Us Research Program (AoURP) to analyze a large cohort of 372,380 participants representing the diversity of the US population in terms of ancestry, demographics, socioeconomic status, and other characteristics. Of the 372,380 participants, 12,529 had CHF, of which 1472 answered the two validated screening questions for food insecurity, also known as the "hunger vital sign". We split the CHF participants between a food-secure group (1297 participants) and a food-insecure group (175 participants), where food security is defined as responding "never" to both questions of the "hunger vital sign".

Results

Our findings indicate that the food insecure participants are younger (p<0.0001), less likely to drink alcohol (p<0.0001), less educated (p<0.0001), and more likely to be black (p<0.0001), female (p<0.0001), and Hispanic (p<0.001). The mean (+-SD) BMI for the food insecure group is 35.0 (+-8.8) kg m-2 compared to 31.3 (+-7.2) kg m-2 for the food secure group (p<0.00001) and the mean (+-SD) albumin level for the food insecure group is 34.2 (+- 2.9) g/L compared to 38.4 (+-4.2) g/L for the food secure group (p<0.0001). The differences in BNP, NT-proBNP, and TnI are not statistically significant.

Conclusion

Our findings–demographic differences, higher mean BMI, lower albumin levels in CHF patients who are food insecure–indicate the necessity to reevaluate our approach to care for historically underserved patients.
Predictive utility of health-related quality of life and the 6-minute walking test in transthyretin amyloid cardiomyopathy - a comparison
Authors: Poledniczek M , Duca F , Willixhofer R , Kronberger C , Camuz Ligios L , Kastner J , Bergler-Klein J , Kammerlander A , Badr Eslam R
Published: November 2023

Introduction

Both health-related quality of life (HR-QoL) as well as submaximal physical performance as assessed using the 6-minute walking test (6-MWT) have been shown to predict outcome in heart failure. However, it is currently unclear how the predictive utility of different HR-QoL measurement tools compares to the 6-MWT in transthyretin amyloid cardiomyopathy (ATTR-CM).

Aims

To evaluate predictive utility of the Kansas City Cardiomyopathy Questionnaire (KCCQ), the Minnesota Living with Heart Failure Questionnaire (MLHFQ) and the EuroQol Five Dimensions Questionnaire (EQ-5D) in comparison to the 6-MWT in patients with ATTR-CM.

Methods and results

186 patients diagnosed with ATTR-CM were included and data from 474 visits (2.55 per patient) was analysed. All scores and distance walked in the 6-MWT were transformed into Z-values by subtracting the mean and dividing by the standard deviation.

In a cox regression analysis for all-cause mortality adjusted for age and sex, the KCCQ [Hazard Ratio (HR): 0.560, p = < 0.001], the EQ-5D visual analogue scale (HR: 0.712, p = 0.005) and the MLHFQ (HR: 0.613, p = < 0.001) proved predictive of outcome. For heart failure hospitalisation, the KCCQ (HR: 0.455, p = < 0.001), the EQ-5D overall score (HR: 0.753, p = 0.007), the EQ-5D visual analogue scale (HR: 0.631, p = < 0.001) and the MLHFQ score (HR: 0.466, p = < 0.001) were shown to be of high predictive utility. In comparison, the 6-MWT HRs were 0.434 and 0.544 for mortality and heart failure hospitalisation, respectively (p = < 0.001).

Conclusion

Prognostic utility of the KCCQ and MLHFQ scores is non-inferior to the 6-MWT in ATTR-CM. While much more simplistic, the EQ-5D is lacking behind the other tested questionnaires with regard to predictive utility.
Epidemiology of acute heart failure admissions in Iceland: phenotype distribution and prognostic implications
Authors: Agnarsson H R , Hansen J S , Gunnarsson D A , Einarsson H , Gunnthorsdottir I , Ingimarsdottir I
Published: November 2023

Background/Introduction

Contemporary data that describe underlying causes of acute heart failure (AHF) epidemiology in a nation-wide unselected real-life cohort is lacking. Advances in diagnostics, including imaging and genetics, have facilitated the identification of the underlying cause of heart failure (HF). This is the first Icelandic nation-wide study on HF epidemiology of patients hospitalised for AHF.

Purpose

Investigate the underlying causes of AHF in Iceland and the patients‘ prognosis according to phenotypes.

Methods

This study used data from the Icelandic Heart Failure Registry (IHFR) and included all hospital admissions for AHF at Landspitali University Hospital from January 2020 to June 2022 (n = 1723). Differences in survival between HF phenotypes were analysed using a multivariate log-rank test, both after diagnosis and after the first discharge.

Results

The study found that 39.8% of the cases had heart failure with reduced ejection fraction (HFrEF), 17.4% had HF with mildly reduced ejection fraction (HFmrEF), 40.3% had HF with preserved ejection fraction (HFpEF), 0.9% had HF with improved ejection fraction (HFimpEF), and 1.5% had unknown ejection fraction (EF). The average length of hospital admission varied by phenotype, ranging from 8.1 to 15.9 days. Women accounted for 41.15% of all admissions, with the most common phenotype amongst women being HFpEF (57.8%) and the least common being HFrEF (25.1%). The mean age at admission was 75.8 years. Roughly 79% of the whole cohort had NYHA class III-IV at admission; 33% of HFrEF, 13% of HFmrEF and 32% of HFpEF admissions. The most common underlying cause of AHF was coronary artery disease (CAD, 30.9%) followed by atrial fibrillation (15.0%), hypertension (9.8%), diastolic dysfunction (9.4%) and valvular heart disease (9.2%). Other more rare causes were dilated cardiomyopathy (4.4%), amyloidosis (3.2%), broken heart disease (1.5%), myocarditis (0.4%), postpartum cardiomyopathy (0.2%) and Fabry disease (0.1%). During the study period, 422 mortalities were recorded, with 106 in-hospital deaths. After excluding in-hospital mortalities, no significant difference in survival between phenotypes was observed after the first discharge. However, a significant difference in survival was observed with respect to the date of diagnosis (p = 0.0191).

Conclusion

This study provides new insights into the underlying causes of AHF and patients' prognosis according to phenotypes in Iceland. Our results demonstrate that the most common underlying cause of AHF was CAD, followed by atrial fibrillation and hypertension and that the cohort was highly symptomatic, with a large proportion of patients having NYHA class III-IV at admission. Our findings also highlight significant differences in the prevalence of HF phenotypes between genders, with women more commonly presenting with HFpEF and less commonly with HFrEF.
Impact of hypochloremia on mortality in heart failure patients: systematic review and metanalysis
Authors: Stankowski K , Villaschi A , Cannata F , Figliozzi S , Tartaglia F , Pini D , Stefanini G , Condorelli G
Published: November 2023

Background

Electrolyte imbalances are common in patients with heart failure (HF). Several studies have shown that low serum chloride level is associated with adverse outcomes in patients who are hospitalised with acute HF as well as in outpatients with chronic HF, however the exact prognostic value of hypochloremia has not been quantified.

Objectives

We performed a systematic review and meta-analysis to assess the impact of hypochloremia on all-cause mortality in HF patients.

Methods

Data search was conducted from inception through February 1, 2023, using the following MeSH terms: ("chloride" OR "hypochloremia") AND "heart failure". Studies reporting serum chloride measurement and cardiovascular outcomes in HF patients were included. The pre-defined primary outcome was all-cause mortality. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were used as effect estimates and calculated with a random-effect model; fixed-effect model and leave-one-out sensitivity analysis were also performed.

Results

A total of fifteen studies, involving 25,848 patients, were included for quantitative analysis. Prevalence of hypochloremia ranged from 7.4% to 26.1%. Median follow-up time ranged from 6 to 67 months. Hypochloremia as a categorical variable was associated with an increased risk of all-cause mortality (HR 1.56; 95% CI: 1.38 to 1.75; p < 0.001; figure 1). As a continuous variable, serum chloride was associated with all-cause mortality (HR per mmol/l decrease in serum chloride: 1.06; 95% CI 1.05 to 1.07; p < 0.001; figure 2). Fixed-effect model and leave-one-out sensitivity analyses confirmed such findings.

Conclusions

Hypochloremia exhibits a substantial prognostic value in HF patients. Serum chloride can be used as an effective tool for risk stratifying patients with HF.Hypochloremia and all-cause mortalitySerum chloride and all-cause mortality
Relationship between change in Kansas City Cardiomyopathy Questionnaire scores and outcomes in patients with HFrEF
Authors: Yang M , Kondo T , Mcdowell K , Campbell R T , Desai A S , Vaduganathan M , Solomon S D , Jhund P S , Mcmurray J J V
Published: November 2023

Background

Although a 5-point change in Kansas City Cardiomyopathy Questionnaire (KCCQ) scores is widely recognized as representing a clinically meaningful change in symptoms and quality of life, it is not known how changes KCCQ scores relate to risk of hospitalization and death.

Purpose

To evaluate how changes in KCCQ summary scores relate to subsequent risk of hospitalization and death in a large cohort of patients with heart failure and reduced ejection fraction (HFrEF).

Methods

We used individual patient data from 3 HFrEF trials (ATMOSPHERE, PARADIGM-HF, and DAPA-HF) to examine the association between changes in KCCQ summary scores between baseline and 8-months and the subsequent risk of cardiovascular death or HF hospitalization, using Cox-proportional hazard models. Change in score was categorized as very small (>0 <5), small (> = 5 <10), moderate (> = 10 <20), and large (> = 20) points. We examined the KCCQ total symptom score (KCCQ-TSS), KCCQ clinical summary score (KCCQ-CSS), and KCCQ overall summary score (KCCQ-OSS).

Results

Among 15,892 participants with HFrEF, 1403 patients (8.8%) had a large deterioration in KCCQ score, 1688 (10.6%) a moderate deterioration, 1442 (9.1%) a small deterioration, 1527 (9.6%) a very small deterioration, and 2326 (14.6%) no deterioration. Conversely, 1836 patients (11.6%) had a very small improvement, 1732 (10.9%) a small improvement, 2202 (13.9%) a moderate improvement, and 1736 (10.9%) a large improvement. Patients with larger changes in KCCQ scores were older and more often female and had lower baseline summary scores and worse heart failure characteristics. Worsening heath status i.e., decrease in the KCCQ-TSS, was associated with a higher risk of the composite outcome (and each of its components), as well as all-cause mortality (Figure 1). On the contrary, improvements in KCCQ-TSS were not associated with better clinical outcomes (Figure 1). The findings were similar for 4-month changes of KCCQ-TSS, and changes in other KCCQ scores (KCCQ-CSS and KCCQ-OSS) at both 4 and 8-months.

Conclusion

Decreases (deterioration) in KCCQ summary scores during follow-up were associated with worse outcomes in patients with HFrEF but no association was seen between improvement in KCCQ scores and outcomes. These findings have potential implications for the interpretation of the effect of treatment on KCCQ scores.
Trends in heart failure mortality in the USA 1999 to 2020
Authors: Gonuguntla K , Chobufo M D C , Sama C S , Shaik A S , Sattar Y S , Thyagaturu H T , Raina S R
Published: November 2023

Background

Heart failure (HF) is a complex clinical syndrome which is a public health challenge in the US. Despite advancements in HF treatment strategies the mortality reduction has been far from ideal. We aimed to study the trends of HF mortality stratified by race and gender from 1999 to 2020.

Methods

The CDC WONDER multiple cause of death dataset was used to analyze trends in mean age at death (MAD) and age adjusted mortality rate (AAMR, expressed per 100,000 persons) for patients dying from HF (underlying cause of death) and dying with HF (co-morbid HF) in the USA.

Results

From 1999 to 2020, the AAMR and MAD for patients dying from HF were 19.3 (Men, Women; 21.3, 17.7) and 83.2 (Men, Women; 85.3, 80.4; p <0.01). The AAMR and MAD for patients dying with HF were 72.4 (Men, Women; 85.8, 63.0) and 81.1 years (Men, Women; 83.2, 78.6; p <0.01). The AAMR and MAD remained stable in both genders between the years 1999 and 2020. The AAMR and MAD among White, Black and other race patients dying with HF were (73.3, 75.1, and 37.7; p<0.01) and (81.4, 74.0 and 79.8; p<0.01). The AAMR and MAD among White, Black and other race patients dying from HF were (20.2, 22.5, and 8; p<0.01) and (84, 76.1 and 85.1; p<0.01). While there was no statistically significant change in AAMR and MAD among persons dying from HF, there was a significant decline in AAMR among persons dying with HF with an AAPC of -0.5(-0.8 to -0.1). Black patients witnessed a statistically significant decline in MAD from 77.8 in 1999 to 74.3 in 2020, MAD remained stable in Whites and Other Races.

Conclusion

Despite advances in guideline directed medical therapy with proven mortality benefit for management of heart failure, the nationwide HF mortality trend has plateaued. Racial disparities with higher HF related mortality in Black patients continue to exist. Therefore, systemic efforts are needed to optimize the HF outcomes by optimizing the preventive and treatment strategies of HF.
Efficacy of intravenous iron therapy in iron-deficient patients with heart failure: an updated systematic review and meta-analysis
Authors: Freitas M , Lucena L , Goncalves T A T , Dantas J M C
Published: November 2023

Background/Introduction

Iron deficiency is a common finding in chronic diseases such as heart failure (HF), as well as being a predictor of worse functional class and a higher risk of death in patients with a reduced/moderated reduced left ventricular ejection fraction (HFrEF/HFmrEF). Despite numerous trials evaluating iron supplementation in patients with HF and iron deficiency, the impact on mortality and hospitalisations is not well-established.

Purpose

The aim of our study was to assess the efficacy of IV iron supplementation on clinical and blood biochemical outcomes in iron-deficient patients with heart failure (HFmrEF and HFrEF).

Methods

We systematically searched PubMed, EMBASE, and the Cochrane Central Register of Controlled Trials for randomised controlled trials (RCTs) studying the effects of iron therapy in patients with HF. Statistical analysis was performed using RevMan 5.1.7. Heterogeneity was assessed with I² statistics; p-values inferior to 0.10 and I²>25% were classified with significant heterogeneity.

Results

Ten RCTs were included comprising a total of 3447 participants, of whom 1810 (52.5%) have received iron infusion. The 6-minute walk distance after 12 weeks of treatment was significantly higher in those who received iron supplementation (MD 54.23; 95% CI 25.41-83.05; p = 0.0002; I² = 64%; Fig. number 1A). Hospital admissions for heart failure were significantly lower in patients randomised to iron therapy when compared with the control group (OR 0.57; 95% CI 0.46-0.70; p <0.001; I² = 17%; Fig. number 1B). There was no statistically significant difference among groups regarding cardiovascular death (OR 0.87; 95% CI 0.71-1.07; p = 0.19; I² = 0%; Fig. number 2A ), all-cause hospitalisations (OR 1.00; 95% CI 0.37-2.73; p = 1.00; I² = 81%; Fig. number 2B), and hospital admissions for cardiovascular causes (OR 0.72; 95% CI 0.4-1.33; p = 0.3; I² = 77%). Ferritin levels have shown a significant increase (MD 212.34; 95% CI 127.05-297.62; I² = 98%).

Conclusion(s)

This meta-analysis suggests that intravenous iron supplementation in patients with heart failure and iron deficiency was associated with a lower risk of hospital admissions for heart failure and improved exercise capacity, albeit with inconclusive data about the reduction in cardiovascular mortality.Relevant clinical outcomesSecondary relevant clinical outcomes
Impact of left atrial dysfunction on mortality in patients with atrial fibrillation and heart failure
Authors: Yamamoto J , Hayama H , Yamamoto M , Hara H , Hiroi Y
Published: November 2023

Background

Patients with atrial fibrillation and heart failure have elevated left ventricular end-diastolic pressure in addition to decreased left atrial function, and there are few reports of useful prognostic indices on echocardiography.

Purpose

We investigated the association between left atrial reservoir strains (LArs) and all cause mortality in patients with atrial fibrillation and heart failure.

Methods

We retrospectively enrolled patients aged 18 years or older with acute heart failure complicated by atrial fibrillation who were consecutively admitted to our hospital from January 2014 to December 2018. Exclusion criteria were acute coronary syndromes, no transthoracic echocardiogram performed within 30 days before or after admission, and missing data. All patients had follow-up from admission until death or last contact or March 2022.

Results

320 patients (mean age 79 ± 12 years, 163 women) were included in the analysis. During a median follow-up of 473 days, 113 patients were observed with all cause death. Multivariate analysis adjusted for age, gender, body mass index, brain natriuretic peptide, estimated glomerular filtration rate, hemoglobin, oral anticoagulants, antiplatelet agents, and beta-blockers showed that LArs was an independent predictor of all cause death (hazard ratio [HR] 0.94, 95% confidence interval [CI] 0.90-0.99, p = 0.016). Furthermore, multivariate adjustment of all cause mortality in the LArs tertile showed that the low LArs group (LArs < 7.16%; HR 1.83, 95% CI 1.15-2.92; p = 0.011) had a significantly increased risk of all cause death compared to the high LArs group (LArs > 10.52%). The results were consistent with no interaction in sub analyses grouped by oral anticoagulant status or left ventricular ejection fraction of 50%.

Conclusions

We found a significant association between LArs and all cause mortality in patients with atrial fibrillation and heart failure. Those with reduced LArs in such patient groups had a poor prognosis, suggesting the need for aggressive treatments and careful follow-up.
The prognostic impact of cardio-renal anaemia syndrome in Japanese acute decompensated heart failure patients stratified by left ventricular ejection fraction
Authors: Moriki T , Hamada T , Kubo T , Takabayashi K , Kawai K , Furuno T , Yabe T , Yamada E , Yamasaki N , Kitaoka H
Published: November 2023

Background

Cardio-renal anaemia syndrome (CRAS) has been reported to be an important prognostic factor for events in heart failure (HF) patients. Previous reports have shown that it has relatively little prognostic impact in patients with preserved left ventricular ejection fraction (LVEF), which remains controversial. We therefore investigated the prognostic impact of CRAS in Japanese acute decompensated heart failure (ADHF) patients according to LVEF.

Methods

We combined two registry studies of ADHF patients in Japan and examined HF events and their associated factors over a 2-year observation period. The prognostic impact of CRAS was also analysed by LVEF. The primary endpoint was defined as all-cause mortality or HF hospitalisation. Renal dysfunction was defined as eGFR <60 mL/min/1.73 m2 and anaemia as haemoglobin <13 g/dl in men and <12g/dl in women. CRAS was defined as the presence of both renal dysfunction and anaemia. Three groups were also created by LVEF (>50%, 40-49% and <40%) and analysed separately.

Results

A total of 2142 patients were enrolled. Mean age was 78.7 years and 49% of the patients was male. Previous coronary artery disease and atrial fibrillation were present in 31% and 44% of the patients, respectively. Medications included beta-blockers in 61% and renin-angiotensin system inhibitors in 53% of the patients. Renal dysfunction was present in 1676 (74%) and anaemia was seen in 1523 (67%) patients. CRAS was present in 1190 (53%) patients. During the mean follow-up period of 623±244 days, the primary endpoint was observed in 1015 patients, with 563 deaths and 737 HF hospitalisations. Multivariate analysis in a Cox proportional hazards model showed that CRAS was an independent prognostic factor in all patients (hazard ratio [HR]1.488;95% confidence interval [CI] 1.292-1.715, p<0.001). Multivariate analysis was also performed in three groups of patients with LVEF >50%, 40-49% and <40%. As with all patients, CRAS was an independent predictor of the primary endpoint in the three groups. (LVEF >50% [1273 patients]: HR1.313[95%CI 1.089-1.583], p = 0.004; LVEF 40-49% [381 patients]:HR,1.907[95%CI 1.323-2.750], p<0.001; LVEF <40% [651 patients]:HR: 1.446[95%CI 1.117-1.872]; p = 0.005)

Conclusion

In the present registry study of Japanese patients with ADHF, CRAS was a important prognostic factor. The results also confirmed a similar trend in patients with any LVEF.
Contrasting patterns of symptoms compared to mortality in women and men with Congestive Heart Failure (the G-CHF registry)
Authors: Walli-Attaei M , Joseph P , Mccready T , Yusuf S
Published: November 2023

Background

There is a paucity of data on the clinical characteristics, management, and outcomes of women compared with men with heart failure, especially in low-and middle-income countries.

Purpose

In this study from the Global Congestive Heart Failure registry, we examined sex differences in risk factors, clinical characteristics, treatments, and the risk of heart failure hospitalization and mortality by country economic status and by left ventricular ejection fraction (LVEF) category.

Methods

In the prospective Global-Congestive Heart Failure (G-CHF) study, participants with established heart failure were considered for inclusion from 40 high-, middle-, and low-income countries. We recorded information on the demographic characteristics, medical history, and treatments of participants. We report data on heart failure hospitalization and mortality by sex overall, by country economic status, and by LVEF category.

Results

From December 2016 to July 2022, 23,000 participants were recruited and followed up. The average age of women in the study was 62 years compared to 64 years in men. Fewer women than men had a LVEF ≤40 (51.7% women vs 66.3% men). By contrast, more women than men had an LVEF≥ 50 (33.2% women vs 18.6% men). Hypertensive heart failure was the most common etiology in women (25.5% women vs 16.8% men), and ischemic heart failure was the most common etiology in men (45.6% men vs 26.6% women). Signs and symptoms of heart failure were more common in women than men: 42.6% of women were NYHA functional class III/IV compared to 37.9% of men. Among participants with a LVEF <35, use of implantable cardiac defibrillator (ICD) was lower in women than men in the overall study (8.7% women vs 17.2% men), and within countries categorized by economic status. However, the use of heart failure medicines and cardiac tests did not differ systematically by sex. Differences by sex were not observed in the adjusted risk of heart failure hospitalization overall (women-to-men adjusted hazard ratio 1.0 (95% CI 0.94 to 1.07)). This pattern was consistent within countries categorized by economic status, geographic region, and by LVEF category. Women had a lower adjusted risk of mortality overall (women-to-men adjusted hazard ratio 0.82 (95% CI 0.77 to 0.87), which was consistently observed within countries categories by economic status, geographic region, and LVEF levels.

Conclusions

There are differences between women and men in heart failure symptoms, underlying causes, ejection fraction categories, and use of an ICD. However, use heart failure medications, cardiac tests, and hospitalization were similar in women and men; but women had a lower risk of death.
Characteristics, clinical presentation and treatment in older patients with cardiac sarcoidosis
Authors: Yoshii T , Kitai T , Sakamoto T , Nakagawa S , Irie Y , Moriuchi K , Amano M , Amaki M , Kanzaki H , Izumi C
Published: November 2023

Background

Patients with cardiac sarcoidosis have high risks of heart failure and lethal arrhythmic events, and often require comprehensive therapies including medications for heart failure, anti-arrhythmic drugs, and immunosuppressive therapy in addition to implantable device therapies. However, controversy exist whether these treatments should be applied to the elderly patients.

Purpose

The aim of this study was to investigate whether older age affects treatment strategy in patients with cardiac sarcoidosis.

Methods

A total of 4,566 patients with hospitalized cardiac sarcoidosis were identified from the Japanese diagnosis procedure combination database from 2012 to 2020. Among them, we analyzed 1,946 patients who were initiated corticosteroid therapy during the hospitalization. Patients’ characteristics and treatment including starting dose of corticosteroid therapy were compared between patients aged ≧ 70 years and those with < 70 years.

Results

A mean age was 63±11 years, and 1,256 patients (64.5 %) were female. Older patients (age ≧ 70 years , n = 599 [30.8%]) had lower BMIs (22.4±3.7 vs 23.1±4.1 kg/m2, p = 0.001), and higher prescription rates of diuretics (268 [44.7 %] vs 488 [36.2%], p<0.001) , calcium channel broker (162 [27.1%] vs 195 [14.5%], p<0.001), anti-diabetes drugs (204 [34.1%] vs 344 [25.5%], p<0.001), statin (252 [42.1%] vs 461 [34.2%], p = 0.001), anti-coagulant therapy (322 [53.8%] vs 658 [48.9%], p = 0.050), and anti-platelet therapy (119 [19.9%] vs 106 [7.9%], p<0.001). There were no significant differences regarding beta-blockers, angiotensin converting enzyme inhibitors or angiotensin receptor blockers, mineralocorticoid receptor antagonists, SGLT-2 inhibitors, amiodarone, and immunosuppressive therapies except for corticosteroids. The starting dose of corticosteroids were significantly lower in the older group (37 vs 46 mg/day, p<0.001). In addition, older patients were associated with a higher risk of hospitalization due to acute decompensated heart failure (53 [8.9%] vs 78 [5.8%], p = 0.014), while patients with age <70 years had a higher risk of fatal ventricular arrhythmia (11 [1.8%] vs 49 [3.6 %], p = 0.033). Thirty days mortality and the prevalence of cardiac resynchronization therapy were similar between both groups (5 vs 3, p = 0.064; 2 [2.4%] vs 71 [3.8%], p = 0.768, respectively).

Conclusion

Older patients with cardiac sarcoidosis tended to be treated with lower doses of corticosteroids, and were more likely to admit due to heart failure exacerbation, while the risks of arrhythmic events were higher in the younger group.
Change in incidence of ischemic stroke and mortality among patients with atrial fibrillation over a period of 30 years, a nationwide, register-based cohort study
Authors: Basic C , Spanos E , Mandelenakis Z , Zverkova-Sanstrom T , Rosengren A
Published: November 2023

Background

During the last decades we have faced large changes in lifestyle and cardiovascular risk factor patterns, as well as screening and treatment advances of patients with atrial fibrillation (AF).

Aim

To investigate trends in ischemic stroke (IS) and mortality in Sweden over a period of 30 years among patients with AF and compare it to matched controls without AF.

Methods

This is a Swedish nationwide registry-based retrospective case-control study of patients diagnosed with AF combining data from National Patient Register (NPR) and Cause of Death Register between 1987 and 2018. Controls were defined as Swedish inhabitants without AF and matched by age, sex and county. With the use of international classification of diseases (ICD) 9- and 10- codes we identified all patients diagnosed with AF, and comorbidities at baseline from NPR.

Results

In total, we identified 739,388 patients with AF and 1,386,448 matched controls. The mean age of the study population was 78.8 (12.6); and (46.2%) were female. Cochran-Armitage test showed a significant increase of all comorbidities over time, except for myocardial infarction for patients and PAH för controls. The Incidence rate for IS per 1000 person-year within one year declined from 40.9 (95% C.I.: 30.1-55.6) in 1987 to 16.2 (95% C.I.: 9.9-26.4) in 2017 (p <.0001) for patients with AF and from 12.2 (95% CI: 7.0-21.4) in 1987 to 6.2 (95% CI: 2.8-13.7) in 2017 (p <.0001) in controls. The prescription of oral anticoagulant therapy (OAK) increased from 40% in 2006 to almost 80% in 2018. The total 1-year mortality rate of IS was at 175.4 (151.3-203.4) for AF cases and 58.3 (45.1-75.4) for controls (p<0001). Compared to controls and adjusted for age, sex and comorbidities patients had HR for IS at 3.01 (95% CI: 2.89-3.13) between 1987 and 1999 that decreased to HR 2.75 (95% CI: 2.63-2.88) between 2010 and 2017 in patients with AF. After adjustment for baseline comorbidities and OAK the one-year risk for IS decreased from HR 1.01 (95% CI: 0.95-1.08) in 2012 to 0.41 (95% CI: 0.36-0.47) in patients and HR 0.50 (95% CI: 0.43-0.58) in 2012 to 0.37 (95% CI: 0.31-0.43) in controls, respectively (both p<0.0001).

Conclusions

This study revealed significant prognostic improvement of patients with AF showing decrease in the incidence rate and relative risk for IS, as well as all-cause mortality within one year of AF diagnose. The prescription of OACs almost doubled between 2006 and 2018 in patients with AF and was associated with a significant decrease of the relative risk for IS to almost same level as in controls without AF.
Non-invasive pressure-volume loops from cardiovascular magnetic resonance predict cardiovascular mortality in heart failure with reduced ejection fraction
Authors: Arvidsson P M , Berg J , Jablonowski R , Carlsson M , Arheden H
Published: November 2023

Background

Heart failure with reduced ejection fraction (HFrEF) is characterized by impaired ventricular energetics secondary to ventricular remodeling. Left ventricular pressure-volume (PV) loop analysis (Figure 1) can now be performed noninvasively using cardiovascular magnetic resonance (CMR) imaging, enabling study of cardiac thermodynamic efficiency without the risk and cost associated with invasive measurements (1–3). Here we investigated whether noninvasive PV loops from CMR can predict cardiovascular death in HFrEF patients.

Methods

We analyzed 135 datasets (age 60±12 years, 79% male) from HFrEF patients (LVEF≤40%) who underwent clinical CMR examination at our center between 2004-2013. Pressure-volume loop parameters were computed from manually segmented CMR data and same-day brachial blood pressure (Segment 4.0 R11026, Medviso, Lund, Sweden). The primary endpoint was cardiovascular mortality extracted from national registries with a 5-year follow-up. Parameters of interest were selected from univariate Cox regression, and associations with clinical outcome evaluated using multivariate Cox regression. Survival was visualized using Kaplan-Meier analysis. Statistical analysis was performed in R 4.0.3 (R Core Team).

Results

A total of 19 deaths from cardiovascular causes occurred during follow-up. Univariate Cox regression found stroke work (SW, joule), ventricular efficiency (VE, %), external power (J/s), contractility (mmHg/ml), and energy per ejected volume (mJ/ml) computed from PV loops associated with the primary endpoint alongside age, LVEF, and NT-proBNP level. In multivariate Cox regression adjusted for age, ventricular efficiency remained significant (HR 0.86, p<0.001), while EF did not (p = 0.077). Event-free survival is shown in Figure 2.

Conclusion

Ventricular efficiency derived from non-invasive pressure-volume loop analysis from standard CMR scans, may outperform LV EF as a predictor of cardiovascular mortality in HFrEF.

Figures:

Figure 1. Example of left ventricular pressure-volume (PV) loop. The area enclosed by the loop is the stroke work (SW). The area bounded by the PV loop and the end-systolic pressure-volume relationship (ESPVR) is the potential energy (PE). Ventricular efficiency (VE) is calculated as SW/(PE+SW).

Figure 2. Kaplan-Meier plots of survival by tertiles of stroke work and ventricular efficiency.Figure 1Figure 2
Prognostic evaluation of heart failure in women: insight from the MECKI score database
Authors: Salvioni E , Moscucci F , Bonomi A , Mapelli M , Paolillo S , Corra U , Vignati C , Mattavelli I , Magri D , Sciomer S , Piepoli M , Agostoni P
Published: November 2023

Background

Heart failure (HF) in women often assumes extremely peculiar characteristics. The risk stratification and prognostic evaluation of HF in women is a challenge for clinicians. The actual prognostic scores are, in fact, lacking a specific sex-oriented assessment. In HF women show better survival despite a comparatively low peak oxygen consumption (VO2) at cardiopulmonary exercise testing: this raises doubt about the accuracy of risk assessment in women. Previous studies on MECKI score database have demonstrated that female prognostic advantage is lost when sex-specific differences are correctly considered.

Purpose

The present analysis has the aim to identify parameters which could be differently associated to prognosis in men and women and to re-calibrate the MECKI score according to these differences.

Methods

The new weights of the MECKI score variables according to gender, were calculated using the means of the 200 repetitions obtained to cross-validation procedure. The primary outcome of the study was the composite of all-cause mortality, urgent heart transplant and LVAD implant. The difference in predictive ability between the native and gender re-calibrated MECKI was calculated with the ROC curve at 2 years follow-up and calibration plot.

Results

We retrospectively analyzed 7900 HF patients with reduced ejection fraction included in the MECKI score registry (61±13 years, 6456 M/ 1444 F, LVEF 33±10%, VO2 /kg 14.9±4.9 mL/min Kg). Patients follow up was: 4.05 years [1.72-7.47]. Table 1 presents the weights of the individual MECKI variables for males and females. The main differences have been detected for the intercept value, hemoglobin and Na+. We used these variables to recalibrate the algorithm of MECKI score. We obtained higher AUC for MECKI re-calibrated by gender than for Native MECKI (0.7893 vs. 0.7799, p = 0.0194, Fig. 1 left panel). Moreover, the gender MECKI was better calibrated (Fig. 1, right panels).

Conclusions

The calibration of MECKI Score according to gender specific differences improves the prognostic power and accuracy of mortality prediction at two years follow up.Fig 1Table 1
Role of renal function in patients with advanced heart failure: insights from the help-hf registry
Authors: Villaschi A , Chiarito M , Pagnesi M , Stolfo D , Baldetti L , Lombardi C M , Adamo M , Loiacono F , Merlo M , Cappelletti A M , Sinagra G , Metra M , Pini D
Published: November 2023

Background

Chronic kidney disease (CKD) and heart failure (HF) strongly interact in determining patients prognosis. However, the prevalence and impact of CKD in advanced HF is still poorly characterized.

Objective

To determine the prevalence and prognostic impact of CKD and how estimated glomerular filtration rate (eGFR) might limit the use of guideline directed medical therapy in a large cohort of HF patients with at least one high-risk I NEED HELP marker.

Methods

1120 patients enrolled in the HELP-HF registry were included in the analysis; eGFR was calculated according to the Chronic Kidney Disease Epidemiology Collaboration formula. Patients were stratified according to eGFR into three categories (> 60 ml/min, 30-60 ml/min, <30 ml/min). The primary endpoint was a composite of all-cause death and HF-hospitalization. Secondary endpoints were all-cause death, HF-hospitalization and cardiovascular death.

Results

291 patients (25.98%) had an eGFR>60 ml/min, whereas 497 (44.37%) had eGFR between 30 and 60 ml/min and 332 (29.64%) had <30 ml/min. The risk of the primary endpoint was increased in patients with worse renal function (eGFR 30-60, HR 1.34, 95%CI 1.05-1.71, p = 0.017; eGFR<30, HR 1.88, 95%CI 1.47-2.42, p<0.001), whereas only patients with eGFR<30 ml/min demonstrated higher risk of all-cause death (HR = 2.36, 95%CI 1.68-3.31, p<0.001) and CV death (HR = 3.08, 95%CI 2.00-4.75, p<0.001). No difference in HF hospitalizations was seen with respect to patients with eGFR>60 ml/min. Once analyzed as a continuous variable, eGFR was significantly associated with each outcome. The impact of CKD was also confirmed in patients fulfilling the 2018 ESC-HFA definition of advanced HF. Logistic regression showed that patients with lower eGFR and with HF with reduced (HFrEF) and mildly reduced ejection fraction (HFmrEF) were less frequently discharged on maximal tolerated dose of mineral corticoid receptor antagonists (p= 0.001 for HrEF, p= 0.013 for HFmrEF), while lower eGFR was associated with less frequent use of maximal tolerated dose of a renin-angiotensin inhibitors (including angiotensin receptor-neprilysin inhibitors) only among patients with HFmrEF (p = 0.018).

Conclusions

Chronic kidney disease is highly prevalent among patients with advanced HF and impacts on patients’ prognosis and survival. The use of GDMT was significantly limited in patients with lower eGFR only in patients with HFrEF and HFmrEF.