bluuebunny/crossref_metadata_2025 huggingface dataset:
Clinical characteristics and long-term outcomes of patients with heart failure with supra-normal ejection fraction: data from LECRA-HF registry
Authors: Stepien K , Eliasz K , Nowak K , Kachnic N , Karcinska A , Del Carmen Yika A , Furczynski J , Platschek M , Matrejek A , Zalewski J , Nessler J
Published: October 2024

Background

Heart failure with preserved ejection fraction (HFpEF) remains insufficiently characterized subgroup of HF with increasing prevalence and limited treatment options. Relationship between clinically assessed left ventricular ejection fraction (LVEF) and survival showed that LVEF ≥65% is associated with higher mortality. Therefore, a novel category of heart failure with supra-normal left ventricular ejection fraction (HFsnEF) was introduced in 2019. However, clinical characteristics and long-term outcomes of HFsnEF patients remain insufficiently elucidated.

Purpose

We sought to characterize Polish HFsnEF patients and to provide their long-term mortality in comparison to HFpEF.

Methods

Of 1186 patients enrolled in the single-center Lesser Poland Cracovian Heart Failure (LECRA-HF) Registry between 2009 and 2019 and hospitalized due to HF decompensation 261 (22%) of them were those with LVEF ≥50%. 40 (15.3%) of them were classified as HFsnEF (LVEF ≥65%) and the remaining 221 (84.7%) as HFpEF. The data including patients’ demography, anthropometric measurements, cardiovascular risk factors, prior cardiological treatment and other comorbidities were collected. The long-term follow-up of all-cause mortality was obtained from the Polish National Death Registry.

Results

HFsnEF patients were less frequently hypertensive (75 vs 88.2%, P=0.026) and had higher baseline LVEF (65 [65-70] vs 55 [50-60] %, P<0.001) than HFpEF subjects. Furthermore, HFsnEF patients presented lower INR (1.1 [1-1.6] vs 1.3 [1.1-1.9], P=0.027) and total protein level (57 [25-63] vs (65.2 [60.2-69.9] g/L, P=0.008) on admission. HFsnEF patients were less frequently treated on discharge with mineralocorticoid receptor antagonists (25 vs 46.2%, P=0.013) as well as loop diuretics (60 vs 76%, P=0.017). The Kaplan-Meier analysis showed that all-cause mortality is higher in HFsnEF than in HFpEF (65.0 vs 55.2%, P=0.044, Figure 1). The independent predictors of long-term mortality were age and diagnosis of HFsnEF (HR 1.037, 95% CI 1.018-1.056 and HR 1.665, 95% CI 1.063-2.608, respectively).

Conclusions

Our findings indicate that every seventh Polish patient admitted with HFpEF could be classified as HFsnEF. Baseline characteristics of HFsnEF patients are different than HFpEF. Simultaneously, the HFsnEF diagnosis is associated with lower long-term survival.
Temporal trends in sudden cardiac death after acute decompensation in HFrEF patients: a 13-year Japanese multicentre registry study
Authors: Fukuoka R , Kohsaka S , Nakamaru R , Shiraishi Y , Nagatomo Y , Mizuno A , Kohno T , Kitamura M , Nomoto M , Ieda M , Kawamura A , Yoshikawa T
Published: October 2024

Background

The implementation of guideline-based medical therapy (GBMT) for heart failure with reduced ejection fraction (HFrEF) has significantly contributed to reducing mortality risks. Yet, detailed analyses on temporal trends of sudden cardiac death (SCD) among these patients, especially post-discharge following acute decompensation, remain scarce.

Purpose

This study aimed to explore changes in the incidence of SCD over the last 13 years in patients with HFrEF discharged after acute decompensation treatment, and to identify clinical factors associated with SCD risk.

Methods

We analyzed 2,604 consecutive HFrEF (left ventricular ejection fraction [LVEF] ≤40%) patients enrolled in a Japanese multicentre acute heart failure (HF) registry from 2009 to 2021. SCD was defined as an unexpected and otherwise unexplained death in a previously stable patient or death due to documented or presumed cardiac arrhythmia without a clear non-cardiovascular cause. The determination of death cause (SCD, pump failure death, or other) was made by a central adjudicating committee. The Fine and Gray method was employed to analyze factors associated with SCD. The variables submitted to the model included age (≥70 years), gender, LVEF (<30%), ischaemic aetiology and prescription of GBMT (use of renin-angiotensin system inhibitors, β-blockers and mineralocorticoid receptor antagonist) at discharge.

Results

The mean age of studied patients was 70.9±14.2 years, and 70.0% were male. During the 1-year follow-up period, 262 deaths (10.1%) occurred, including 51 SCDs (2.0%). Older age was associated with an increased risk of SCD (adjusted hazard ratio [HR] 2.81, 95% confidence interval [CI] 1.40-5.64, P=0.004). Further, patients with an ischaemic aetiology had a higher risk of SCD (HR 1.84, 95% CI 1.06-3.22, P=0.032). During the study period, mean age remained constant (71.0 years to 70.7 years, P for trend =0.884). The proportion of ischaemic aetiology also remained constant (from 37.2% to 38.2%, P for trend =0.972). Overall, there were significant decreases in the incidence of all cause death and SCD (from 13.7% to 8.4%, P for trend =0.002; and from 3.5% to 1.0%, P for trend <0.001; Figure A). Notably, there was an increase in the prescription rate of three classes of GBMT at discharge (from 30.9% to 45.6%, P for trend <0.001; Figure B), and the rate of implantable cardioverter-defibrillator (ICD) use in eligible patients (New York Heart Association functional class II-III with LVEF ≤35%) remained constant (from 9.6% to 11.6%, P for trend =0.157; Figure B).

Conclusions

With the increasing use of GBMT, the incidence of SCD decreased in real-world patients with HFrEF registered in a Japanese acute HF registry over the past decade.
Prognostic significance of right ventricle to pulmonary artery coupling acute improvement after mitral transcatheter edge-to-edge repair
Authors: Diano A , Caretta A , Viani G M , Pavon A G , Milzi A , Pedrazzini G , Faletra F F , Leo L A
Published: October 2024

Background

Transcatheter Edge-to-Edge Repair (TEER) of mitral valve is a valid treatment option for severe mitral regurgitation. The right ventricle is acutely affected by early hemodynamic changes following the correction of significant mitral regurgitation. Echocardiographic parameters of the right chambers could have a prognostic impact even in a periprocedural setting. In particular, right ventricle to pulmonary artery coupling improvement may be of pivotal importance, as this parameter is a validated marker of right ventricle function.

Purpose

To evaluate the prognostic impact of early improvement of right ventricle to pulmonary artery coupling assessed by means of the Tricuspid Annular Plane Systolic Excursion/Pulmonary Artery Systolic Pressure (TAPSE/PASP) ratio after TEER.

Methods

This retrospective single centre study included patients treated with TEER in our hospital from 2015 to 2023. Transthoracic echocardiography was performed before and shortly after device positioning. Acute effects of TEER on echocardiographic parameters were assessed by paired samples t-test. Diagnostic accuracy of the percent variation in the TAPSE/PASP ratio was assessed by means of receiver-operating characteristics analysis. Prognosis was evaluated by Kaplan-Meier analysis.

Results

The study included 95 patients (age 78 ± 10 years; 63% men; BMI 25 ± 5 kg/m2) with severe or moderate-to-severe mitral regurgitation. Mean baseline Left Ventricle (LV) ejection fraction was 45 ± 16%, LV end-diastolic volume was 157 ± 62 ml and effective regurgitant orifice area was 41 ± 25 mm2. Post-procedural echocardiographic assessment showed early improvement of LV end-diastolic diameter (p < 0.001), LV end-diastolic volume (p = 0.025), LV stroke volume (p < 0.001), LV global longitudinal strain (p < 0.001), right ventricle free wall longitudinal strain (p < 0.001) and PASP (p = 0.002). Percent improvement of TAPSE/PASP ratio showed a sufficient diagnostic accuracy in predicting a composite outcome of hospitalisation for heart failure and all cause mortality at 1 year (area under the curve 0.66, p = 0.047), with an optimal cut-off of 5.5%. An improvement of the TAPSE/PASP ratio over this threshold was associated with a reduction in the composite outcome (hazard ratio 0.38, p = 0.045).

Conclusion

TEER improves both left and right ventricular dynamics, which can be detected with echocardiography. In particular, an acute improvement of the TAPSE/PASP ratio is associated with an improvement in short-term prognosis. A comprehensive assessment of right ventricular function, including TAPSE/PASP ratio, should be routinely performed before and after TEER.
Impact of household income on acute decompensated heart failure outcomes: national representative sample
Authors: Sequeira Gross J , Francis Morel G
Published: October 2024

Background

The clinical outcomes of ADHF have been extensively studied; however, the impact of household income still needs to be better understood. This study aimed to elucidate the relationship between household income and outcomes in patients with ADHF.

Methods

This national retrospective cohort study used data from the 2016-2020 National Inpatient Database, focusing on patients admitted with ADHF. We stratified the cohort into two groups based on the median household income: below $50k and above $86k. The selection criteria included patients aged ≥ 18 years diagnosed with ADHF, excluding those with incomplete income data. The primary outcome was all-cause inpatient mortality, with a length of stay (LOS) and total hospital charges as secondary outcomes. Statistical analysis employed logistic and linear regressions adjusted for confounders, with the significance level set at p<0.05. We accounted for missing data using multiple imputation analyses.

Results

1,123,024 patients admitted with ADHF met the inclusion criteria. We divided the groups into two cohorts: low-income (64%, N=718,735) and high-income (36%, N=404,289). No increase in mortality was identified (adjusted aOR: 1.05; p = 0.212). The study revealed that high-income patients had marginally longer average LOS (5.62 days vs. 5.35 days, p < 0.0001) and higher hospital charges ($62,512.46 vs. $49,440.14, p < 0.0001) compared to their low-income counterparts. Low-income patients exhibited a higher prevalence of hypertension and obesity, whereas high-income individuals were more affected by atrial fibrillation and hyperlipidemia (hypertension and obesity, p < 0.0001; atrial fibrillation, p < 0.0001).

Conclusion

In this national retrospective cohort of patients admitted for ADHF over five years, income did not affect mortality. However, LOS and total charges were affected by the median household income.
Effects of prognostic nutritional index and obesity on 1-year mortality in patients with acute heart failure
Authors: El-Sheikh M , Grand J , Olsen N , Taraldsen I , Kandiah A , Wisborg F , Hove J
Published: October 2024

Background

Increased body mass index (BMI) has paradoxically been linked to improved survival rates among patients with acute heart failure (AHF). However, the impact of different nutritional statuses on this obesity paradox on 1-year mortality remains unclear. The prognostic nutritional index (PNI) is a simple tool to assess nutrition status. Recently, landmark findings such as the STEP-HFpEF (Semaglutide Treatment Effect in People With Obesity and HFpEF) trial showed at 1-year, semaglutide not only reduced weight considerably, but also significantly improved health-related quality of life, functional status, and CRP levels. Also, the semaglutide effects on heart disease and stroke in patients with overweight or obesity (SELECT) trial demonstrated a 20% reduction in cardiovascular outcomes.

Purpose

To investigate the association between obesity and AHF on all-cause mortality according to nutritional status.

Methods

The cohort study comprised 7258 patients with a cardiopulmonary condition, all of whom were admitted and included on-site at the Emergency Department (ED) in a large University Hospital in Denmark, between March 2020 and March 2022. The follow-up time was at least 365 days. 408 patients with AHF were identified by chart review by trained cardiologists for analysis. PNI was calculated according to the formula: 10×serum albumin (g/ dL) + 5×total lymphocyte count×109/L. A value ≥ 38 is considered well-nourished, and a value < 38 is considered malnourished. Patients were divided into High-PNI (≥38) and Low-PNI (<38) according to cut-off value of PNI. The Kaplan-Meier (KM) curves were used to analyze cumulative survival in each subgroup, and the log-rank test was used to compare differences between groups. Cox regression models were used to analyze associa­tions between BMI, nutritional status and outcomes, expressed as hazard ratios (HR) and relative 95% confi­dence intervals (CI).

Results

Amongst 408 hospitalized AHF patients, 384 (mean age 75.6 ±11.7) with available PNI scores were enrolled into this study. 55.7% (n=214) were male, 56.4% (n=93) died in the Low-PNI group and 34.2% (n=75) died in the High-PNI group within 1 year. After adjusting for potential confounders in the High-PNI population, compared with the under/normal and overweight BMI group, obesity was negatively associated with 1-year mortality, with adjusted HR of 0.47, 95% CI (0.24–0.94), P = 0.033. However, this correlation disappeared in the Low-PNI group (obese BMI: HR 1.2, 95% CI 0.71–2.1, P = 0.457). In addition, those who were overweight in the Low-PNI group had an 80% increase in 1-year risk of death.

Conclusion

Obesity (BMI>30) was associated with reduced 1-year mortality only in AHF-patients with good nutritional status. However, this association disappeared in malnourished patients. Consequently, additional research is essential to formulate weight loss recommendations for malnourished obese patients with AHF.
National early warning score predicts 90 days all-cause mortality among patients with acute heart failure
Authors: Caidi N O E , Wisborg F W , Taraldsen I T , Kandiah A K , El-Sheikh M S , Hove J H , Grand J G
Published: October 2024

Background

Acute heart failure (AHF) is defined as new-onset or worsening of symptoms and signs of heart failure including symptoms or signs related to congestion and volume overload. Patients presenting with AHF are a heterogeneous group as AHF is not a specific disease but a shared clinical presentation of different cardiac abnormalities. Due to the heterogeneity of the patient population, a prognostic tool is needed to identify AHF patients with a high risk of death.

The National Early Warning Score (NEWS) is a system for scoring the vital signs that are measured at the patient's bedside and is developed to predict acute mortality within 24 hours. The NEWS has previously been used to evaluate all cost mortality for patients admitted to the Emergency Department (ED). There is limited data regarding the role of the NEWS in predicting adverse outcomes in patients with acute heart failure.

Purpose

To evaluate NEWS measured at the ED and clinical outcomes in patients with AHF.

Methods

This prospective, observational cohort study included consecutive patients with AHF admitted through the emergency department (ED) at a large public hospital from 10 March 2020 to 31 March 2022 and had a follow-up period of 365 days. Trained cardiologists assessed all patients for the presence of AHF. According to the cut-off value for the NEWS, high-risk groups are defined by a NEWS score > 7. The patients were categorized into two groups, high-risk and low-risk, depending on the scores they received from the NEWS assessment. The primary outcome was all-cause mortality at 90 days. We used multivariable Cox regression (hazard ratios [HRs]) to compare survival, adjusting for age, sex, smoking, known heart failure (HF), and lactate levels at admission.

Results

In the study period from March 10, 2020, to March 31, 2022, 408 patients were identified with AHF. Upon arrival to the ED, the median first NEWS was 4 (IQR 2-6). 323 patients were categorized in the low-risk group and 69 patients in the high-risk group. 16 patients had missing values upon arrival at the ED. The high-risk group exhibited significantly faster heart rate, lower saturation, and higher oxygen demand compared. A Kaplan-Meier plot revealed a statistically significant difference in all-cause mortality over 90 days between low-risk and high-risk groups among AHF patients (log rank, p-value < 0.001).

After multivariable adjustment, NEWS>7 (HR, 1.69; CI, 1.18 to 2.45) (p-value= 0.004) and higher age (HR, 1.04; CI 1.03 to 1.07) were statistically associated with higher all-cause mortality (p <0.001).

Conclusion

In this prospective, observational cohort study of AHF patients presenting at the ED an initial NEWS >7 was associated with a significant all-cause mortality after 90 days.GRAPHIC ABSTRACT
Basal natriuresis as a predictor of diuretic resistance and clinical evolution in acute heart failure
Authors: Scatularo E , Battioni L , Guazzone A , Esperon G , Corsico L , Grancelli H O
Published: October 2024

Introduction

Current clinical guidelines recommend serial measurement of natriuresis to detect diuretic resistance (DR) and to adjust the dose of furosemide in patients with acute heart failure (AHF) (1-5). However, multiple natriuretic dosages could make more complex the AHF management. Our objective was to correlate a single measurement of basal natriuresis (BN) on admission with the development of DR and cardiovascular (CV) events in patients hospitalized for AHF and during early outpatient follow-up (6-11).

Methodology

Prospective, multicenter study that included patients admitted to the coronary care unit (CCU) for AHF. Patients in shock or with creatinine >2.5 mg% at admission were excluded. Patients included received 40 mg of intravenous furosemide on admission, BN was measured in the first urination (the result was blinded to the treating physician), and subsequent diuretic treatment was guided by a pre-established protocol. The BN was considered low if it was <70 meq/L. The DR was defined as a combined endpoint composed of the requirement for intravenous furosemide ≥240 mg/day, tubular diuretic blockade (TB), hypertonic saline solution (HSS) or renal replacement therapy (RRT). In-hospital CV mortality was evaluated, as well as CV mortality and AHF readmissions at 60-day post-discharge follow-up.

Results

157 patients were included, 56% men, with a median age of 74 years. The median BN was 103 meq/L (IQR 74-122), and BN was low in 22% of the cohort (N=34). DR was presented in 19% (N=30), 12.7% (N=20) required furosemide ≥240 mg/day, 8% (N=13) TB, 1 patient HSS and 4% (N=6) RRT. In-hospital CV mortality was 5.7%, CV mortality at 60-day follow-up 6.8%, and AHF readmissions at 60-day follow-up 12.2%.

The group with low BN presented more DR (44% vs 12%; p 0.0001; RR 0.27; 95% CI 0.15-0.5), persistence of congestion at 48 hs (26.5% vs 11.4%; p 0.05; RR 0.48; IC 95% 0.22-1), administration of furosemide ≥240 mg/day (29% vs 8%; RR 0.27; 95% CI 0.12-0.61; p 0.003), more cumulative dose of furosemide at 72 hours (220mg [IQR 180-440] vs 160mg [IQR 100-180]; p 0.0001), use of TB (20.6 vs 4.9%; p 0.008; RR 0.23; 95%CI 0.08-0.65) and RRT (11.8 vs 1.6%; p 0.02; RR 0.14; 95%CI 0.02-0.72). Low BN was associated with in-hospital worsening of AHF (26.5% vs 9%; p 0.016; RR 0.34; 95%CI 0.15-0.74), inotropics use (21% vs 7%; p 0.048; RR 0.36; 95%CI 0.14 -0.88) or mechanical respiratory assistance (12% vs 2%; p 0.02; RR 0.14; 95%CI 0.02-0.72). Low BN presented higher in-hospital CV mortality (12% vs 4%; p 0.1), without association with endpoints in outpatient 60-day follow-up.

Conclusions

In patients hospitalized for AHF, low BN was associated with DR, persistence of congestion, need for more aggressive decongestion strategies, and a worse in-hospital clinical outcome
Machine learning to improve the performance of natriuretic peptides across age groups for the diagnosis of acute heart failure
Authors: Perez Vicencio D , Doudesis D , Thurston A J F , Lee K K , Mills N L
Published: October 2024

Background

Guidelines recommend N-terminal pro-B-type natriuretic peptide (NT-proBNP) thresholds for the diagnosis of acute heart failure but performance of these thresholds in different age groups is uncertain and could be improved using machine learning methods that incorporate age as a continuous measure.

Purpose

To evaluate the diagnostic performance of guideline-recommended NT-proBNP thresholds for different age groups and a validated decision-support tool using machine learning for the diagnosis of acute heart failure.

Methods

NT-proBNP concentrations and the output from the CoDE-HF decision-support tool that uses machine learning to combine NT-proBNP and age as continuous variables with other patient variables were determined in 10,369 patients (median age 73 [interquartile range 59-82]) with suspected acute heart failure pooled from fourteen studies. The diagnostic performance of guideline-recommended NT-proBNP uniform rule-out thresholds (300 pg/mL), and age-stratified rule-in thresholds (450 pg/mL, 900 pg/mL and 1,800 pg/mL for <50, 50-75 and ≥75 years, respectively) and CoDE-HF were evaluated using random effects meta-analysis across patient age groups.

Results

Overall, 43.9% (4549/10 369) of patients had an adjudicated diagnosis of acute heart failure. The negative predictive value (NPV) of the rule-out threshold of 300 pg/mL was lower in patients with increasing age (NPV 88.2% [confidence interval (CI) 83.5-91.8%] ≥75 years versus 98.9% [97.6-99.5%] <50 years) (Figure 1). Conversely, the positive predictive value (PPV) of age stratified rule-in thresholds was lower in younger patients (PPV 61.8% [55.9-67.4%] <50 years versus 80.5 % [71.1-87.4%] ≥75 years) (Figure 2). CoDE-HF had improved diagnostic performance compared to NT-ProBNP thresholds for all age groups, with the lowest NPV and PPV being 96.4% (93.8-97.9%) and 78.6% (59.8-90.0%), respectively.

Conclusion

The diagnostic performance of guideline recommended thresholds of NT-proBNP to rule-in and rule-out acute heart failure varies significantly with age. A decision-support tool that incorporates NT-proBNP with age as continuous variables provides a more consistent and accurate approach.Figure 1.Negative predictive valueFigure 2.Positive predictive value
Impact of global longitudinal strain and anemia for predicting cardiovascular mortality in patients hospitalized for acute heart failure with atrial fibrillation
Authors: Yamamoto J , Hayama H , Enomoto Y , Yamamoto M , Hara H , Hiroi Y
Published: October 2024

Background

Iron deficiency is a prognostic factor in heart failure (HF) with reduced ejection fraction (EF). In patients with atrial fibrillation (AF) and HF, left ventricular EF (LVEF) measurements are imprecise due to irregular tachycardia, but it is unclear whether global longitudinal strain (GLS) and anemia assessment are prognostic.

Purpose

We examined whether GLS and anemia predict cardiovascular death (CD) in patients with acute HF complicated by AF.

Methods

We retrospectively enrolled patients aged 18 years or older with acute HF complicated by AF 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 were followed up from admission to CD (due to myocardial infarction, HF, stroke or sudden death), or were censored at the date of last contact or 3 years. Anemia was defined as hemoglobin < 12 g/dL in females and hemoglobin < 13 g/dL in males. Patients were divided into four groups according to median GLS and anemia status.

Results

A total of 320 patients (mean age 79 ± 12 years, 163 females) were included in the analysis. The median duration of AF was 1.2 years; 11% (36/320) had paroxysmal AF. The median brain natriuretic peptide value was 623 pg/ml, and 52% of the patients (165/320) were in New York Heart Association functional class 4. During a median follow-up of 528 days, 24% (77/320) patients were observed with CDs: 2 myocardial infarctions, 51 HF-related deaths, 6 strokes, and 18 sudden cardiac deaths. At the 3-year follow-up, the survival rate by the Kaplan-Meier curve was 89% (95% confidence interval (CI) 76%-95%) in the no anemia group with high GLS (< -10%) and 40% (95% CI 25%-54%) in the anemia group with low GLS (≥ -10%) (p < 0.001, log-rank test). In multivariate Cox regression analysis, GLS (adjusted hazard ratio (aHR) 1.06, 95% CI 1.01-1.14, p = 0.017) and hemoglobin (aHR 0.85, 95% CI 0.76-0.96, p = 0.009) were independent factors for CD, with a significantly increased risk in the anemia group with low GLS compared to the no anemia group with high GLS (aHR 4.11, 95% CI 1.59-10.6, p = 0.004). The results were consistent with no interaction by gender or LVEF 50%.

Conclusions

Anemic patients with low GLS with AF and HF may have poor prognosis. Prospective studies are needed to determine whether iron supplementation improves prognosis in such patients.
Enhancing the selection of heart failure patients for invasive procedures: how machine learning can predict the diagnostic yield of endomyocardial biopsy
Authors: Basile C , Bollano E , Rawshani A , Ljungman C , Polte C , Karason K , Bobbio E
Published: October 2024

Background

Determining the etiology of heart failure (HF) is crucial for appropriate treatment. Endomyocardial biopsy (EMB) is an invasive procedure that complements clinical assessment and imaging in diagnosing various cardiac disorders. The diagnostic value of EBM depends upon the anticipated yield of the procedure. Whether results from non-invasive examinations may predict the diagnostic yield from EMB is unclear.

Purpose

We aimed to investigate the relative importance of clinical and instrumental features in predicting a diagnostic EMB result, using a machine learning (ML) approach.

Methods

We retrospectively examined 665 consecutive adult patients with HF symptoms who underwent right EBM as part of their diagnostic work-up. The primary outcome was a positive biopsy result with a clear diagnosis. The ML algorithm consisted of Gradient Boosting Machines (GBM), with computation of relative variable importance using conditional importance. We calculated the conditional variable importance for 53 clinical or instrumental variables. Model performance was evaluated using a receiver operating characteristic curve, which was compared to a logistic regression model using the same variables. Validation was performed using a 10-fold cross-validation model.

Results

Among the 665 patients (50±14 years, 67% male), the EMB provided a diagnosis in 138 cases (20.8%). Patients attaining diagnosis were more often older, had a shorter disease duration, presented with ventricular arrhythmia or cardiac arrest, had a pacemaker or defibrillator, displayed higher creatinine, NT-proBNP and high-sensitive troponin T levels, and had smaller ventricular volumes with higher ejection fraction at CMR. All patients with a diagnostic EMB showed late gadolinium enhancement (LGE) on cardiac magnetic resonance (CMR) in the right ventricle, the right atrium or in the left atrium. The relative importance of different variables predicting outcomes is presented in Figure 1. The top six included four distinct CMR features and two circulating biomarkers (NT-proBNP and high-sensitive troponin T). LGE in the right ventricle and the presence of left ventricular hypertrophy were stronger predictors compared to the remaining variables. The GBM model performed significantly better than the logistic regression model (AUC GBM 0.98, AUC logistic regression 0.93, DeLong’s test p<0.001) (Figure 2).

Conclusion

Using a ML algorithm, CMR LGE, left ventricular hypertrophy, and elevated cardiac biomarkers, stand out as strong overall predictors of an endomyocardial biopsy with a high diagnostic yield.Figure 1Figure 2
Disparity in receiving destination treatment for heart failure patients according to HIV status
Authors: Shoar S , Kumar V , Demelash S , Cascoperez A , Mujahid Z , Hassen G , Patarroyo-Aponte G , Sharma S K , Asadi S
Published: October 2024

Background

Patients living with HIV (PLWH) are well known to be at higher risk of developing cardiovascular diseases. However, PLWH with end-stage HF (ESHF) might not be considered for definitive treatments equally as their HIV-negative counterparts.

Methods

National Inpatient Sample (NIS) database was queried to identify ESHF patients hospitalized to receive left ventricular assist device (LVAD) or undergo heart transplantation (HTX). In-hospital outcomes of this population were stratified based on HIV status.

Results

Weighted data of a total of 16,700 ESHF patients was retrieved, out of which 65 patients (0.2%) had a positive HIV status. Out of 65 PLWH with ESHF, 35 patients (53.8%) received LVAD, and 30 patients (46.1%) received HTX, which were comparable to their HIV-negative counterparts (58.4% and 43.1%, respectively). Although PLWH had a longer length of stay (39.7±35.6 days vs. 49.5±, 42.3 days, p=0.3) and higher hospital charges ($1,458,527±$ 1,509,873 vs. $1,113,344±$953,830) than HIV negative counterparts, the difference was not statistically significant. Mortality rate did not differ between HF patients based on HIV positive status or the bridge/destination treatment they had received.

Conclusions

Although the proportion of PLWH with HF who received HTX has decreased over the last few years, the proportion of those who received LVAD has been on a compensatory rise. HIV positive status is not associated with a higher mortality rate but increases the length of stay and hospital charges.
Acute hemodynamic effect of oral ketones in patients with acutely decompensated heart failure and low cardiac output syndrome: a prospective randomized study.
Authors: Sramko M , Benak A , Holek M , Kleissner M , Pazdernik M , Kissimon F , Svirlochova V , Franekova J , Kautzner J , Melenovsky V
Published: October 2024

Background

Preliminary studies showed positive inotropic effect of mild ketosis in patients with heart failure with reduced ejection fraction (HFrEF).

Purpose

To evaluate the acute hemodynamic effect of oral administration of beta-hydroxybutyrate (OHB) in patients with HFrEF and low cardiac output syndrome.

Methods

Patients with acutely decompensated HFrEF treated with inotropic therapy were randomized (1:1) to enteral bolus of OHB (25g of OHB monoester in 65 ml of solution; H.V.M.N Ketone Ester, H.V.M.N, USA) administered three times with 3-hour intervals or to euvolemic placebo. The serum concentration of OHB, biochemical markers, and invasive hemodynamics (Swan-Ganz catheter with continuous thermodilution) were repeatedly measured before and during 24 hours after administration of OHB. The primary endpoint was the maximum change in cardiac index (CI).

Results

The study included 20 patients with decompensated HFrEF (age: 57 ± 8 years; left ventricular ejection fraction: 21 ± 4%; non-ischemic cardiomyopathy: 16 [80%], median INTERMACS class: 3 [IQR 2 - 4]), who were treated with milrinone (0.5 ± 0.1 ug/kg/min, n=18) or levosimendan (0.1 ug/kg/min up to 25 mg, n=2). Patients in the OHB group (n = 10) did not differ from the placebo group (n = 10) in baseline clinical, biochemical, hemodynamic or echocardiographic characteristics. Baseline OHB concentration was normal (<0.6 mmol/L) in all patients. Administration of OHB increased serum concentration from 0.3 ± 0.2 mmol/L to a maximum of 2.4 ± 0.7 mmol/L (<0.001). Concentrations of OHB peaked at 1.5 ± 0.5 hours after administration of each OHB drink, and the maximum concentration was achieved at 4.1 ± 2.5 hours (Figure 1). No changes in OHB concentration were observed in the placebo group. In both study groups, there was a significant increase of CI at 3 hours compared to baseline, but the increase was significantly greater in the OHB group (OHB: 3.2 ± 0.6 vs. 2.1 ± 0.4 L/min/m2; placebo: 2.3 ± 0.4 vs. 2.0 ± 0.3 L/min/m2; both p<0.001 compared to baseline; p < 0.001 for OHB vs. placebo at 3 hours). The maximum relative increase of CI was 60 ± 24% in the OHB group (p <0.001) and 18 ± 8% in the placebo group (p< 0.01). The change of CI correlated with the change of OHB concentration in the OHB group (r = 0.58, p<0.001) but not in the placebo group (r = 0.1, p = 0.3). The changes in CI were not related to heart rate or concentration of norepinephrine, which did not change significantly throughout the study in both groups.

Conclusion

Oral administration of OHB leads to a significant temporary increase in myocardial contractility. This novel therapeutic concept might be a promising adjunction to inotropic support in patients with decompensated HFrEF.
Comparing treatment strategies for heart failure: a real-world analysis of adding ARNI or SGLT2i to older GDMT
Authors: Amornritvanich P , Numthavaj P , Anothaisintawee T , Tansawet A , Thakkinstian A
Published: October 2024

Background

Heart failure (HF) is a global burden with limited treatment options beyond established guideline-directed medical therapy (GDMT). Newer medications, like angiotensin receptor-neprilysin inhibitors (ARNIs) and sodium-glucose cotransporter-2 inhibitors (SGLT2i), show promise, but real-world evidence on their effectiveness compared to traditional GDMT is lacking.

Objective

This study assessed the real-world effectiveness of adding ARNIs and SGLT2i to existing GDMT regimens for various HF types using network meta-analysis (NMA).

Methods

We analyzed data from observational studies, evaluating the impact of different treatment combinations on all-cause mortality (ACM) and heart failure hospitalization (HFH).

Results

Adding ARNIs to GDMT significantly reduced ACM compared to older regimens (hazard ratio [HR] 0.59, 95% confidence interval [CI] 0.42-0.84), representing a 41% decrease in mortality risk. SGLT2i+2GDMT demonstrated the most significant HFH reduction (HR 0.16, 95% CI 0.06-0.47), translating to an 84% reduction in hospitalization risk.

Conclusion

Incorporating ARNIs or SGLT2i into existing GDMT regimens improves real-world outcomes for HF patients, supporting current guideline recommendations. Personalized treatment plans considering individual needs and preferences are crucial for optimal patient care.Network map of All-cause mortalityRelative treatment effects for ACM
Effect of renin-angiotensin system inhibitors in elderly patients with heart failure and reduced ejection fraction
Authors: Tamaki Y , Yaku H , Yamamoto E , Ozasa N , Inuzuka Y , Enomoto S , Miyake M , Kondo H , Tamura T , Morimoto T , Nakagawa Y , Kato T , Kimura T
Published: October 2024

Background

More than half of the patients admitted for acute decompensated heart failure (ADHF) in Japan are over 80 years of age. Both Japanese and European heart failure guidelines recommend the use of renin-angiotensin system inhibitors (RASIs) in patients with heart failure with reduced ejection fraction (HFrEF). However, there is a paucity of data on the effect of RASIs in elderly patients with HFrEF, because elderly patients have been excluded from large clinical trials.

Purpose

The purpose of the current study was to clarify the effect of RASIs in elderly patients with HFrEF.

Methods

This was a post-hoc analysis of a prospective, observational, multicentre cohort study that enrolled consecutive patients admitted with ADHF to 19 secondary and tertiary hospitals in Japan between October 2014 and March 2016. Patients who were ≥ 80 years old, with left ventricular ejection fraction (LVEF) < 40% and discharged alive were included in the present study. RASIs were defined as either ACE inhibitors or angiotensin II receptor blockers. The primary endpoint was a composite of all-cause death and heart failure (HF) hospitalisation.

Results

Among 518 patients enrolled, 288 patients received RASIs at discharge and 230 patients did not. The median follow-up period was 335 days (interquartile range; 124 – 499 days). Patients receiving RASIs were younger (85.7 ± 4.4 vs. 86.5 ± 4.4 years of age, p=0.03), had a higher body mass index (BMI; 21.4 ± 3.3 vs. 20.6 ± 3.7 kg/m², p=0.01) and better renal function (eGFR; 45.4 ± 21.5 vs. 38.2 ± 19.2 ml/min/1.73m², p<0.001). Patients receiving RASIs had a higher LVEF (30.9 ± 6.3 vs. 28.5 ± 7.1%, p<0.001). The use of beta-blockers at discharge was more prevalent in patients receiving RASIs (77.8% vs. 60.4%, p<0.001), but the use of mineralocorticoid receptor antagonists was not (50.0% vs. 42.2%, p=0.08). The cumulative incidence of all-cause death or HF hospitalisation one year after discharge was significantly lower in patients receiving RASIs (40.1% vs. 59.5%, p<0.001). Even after adjusting for confounders, the risk of a composite of all-cause death and HF hospitalisation was significantly lower in patients receiving RASIs (adjusted hazard ratio 0.59, 95% confidence interval 0.45-0.77, p<0.001). There was no interaction between the effect of RASIs and subgroup factors such as age, BMI, dementia, malignancy, frailty, and renal function.

Conclusion

Use of RASIs at discharge was associated with lower incidence of all-cause death or HF hospitalisation in elderly patients with HFrEF.
Paracetamol and adverse cardiovascular outcomes in patients with heart failure
Authors: Ren Q W , Zhang J N , Guo R A N , Gu W L , Yiu K H
Published: October 2024

Background

Paracetamol is the most widely used pain killer worldwide, yet its potential influence on cardiovascular events among patients with heart failure (HF) remains unclear. Thus, this study aims to investigate both the short-term and long-term effects of paracetamol use on all-cause mortality and cardiovascular events in HF patients.

Methods

Using the previously validated territory-wide clinical information registry, paracetamol use was identified among all eligible patients with HF (N = 211,409) from 2000 to 2020. A case-crossover design was used to investigate the associations between short-term use of paracetamols and all-cause mortality and cardiovascular outcomes. Defined daily dose (DDD) was used to evaluate the dose-response relationship. Additionally, the marginal structural design was applied to model paracetamol use as a time-varying exposure and evaluate its long-term effects during the follow-up period.

Results

Of all eligible subjects, the mean age was 73.2±12.3 years, and 43.6% was male. Over a median follow-up of 10.5 years (interquartile range: 5.7-15.8), 113,258 (53.6%) patients were re-hospitalised for HF, HF-related death occurred in 11,892 (5.6%) patients, incident myocardial infarction (MI) in 28223 (13.3%) patients, incident stroke in 26458 (12.5%) patients, cardiovascular death (CVD) in 72,175 (34.1%) patients and all-cause death in 123,505 (58.4%) patients. Associating HF rehospitalisation to previous paracetamol exposure using the case-crossover design displayed an elevated risk (OR 3.62, 95% CI 3.53-3.71). Associations were similar for MI (OR 5.77, 95% CI 5.50-6.05), stroke (OR 2.37, 95% CI 2.25-2.49), HF-related death (OR 1.86, 95% CI 1.75-1.98), CVD (OR 3.64, 95% CI 3.55-3.73), and all-cause mortality (OR 3.32, 95% CI 3.26-3.39). Moreover, compared with paracetamol users taking the reference dose, users of low, medium and high doses of paracetamol had 16%, 17% and 52% higher risk of HF rehospitalisation. During the long-term follow-up, the average weighted hazard ratio (HR) for HF rehospitalisation in paracetamol users was 2.48 (95% CI 2.46–2.50) as compared with paracetamol non-users after accounting for all-cause mortality as a competing risk. Similarly, the average weighted HR for incident MI or stroke was 2.71 (2.62-2.81) and 3.45 (3.34-3.57), respectively. However, neutral results were shown for HF-related death, CVD and all-cause mortality.

Conclusion

The use of paracetamol among patients with HF is common. Paracetamol was associated with adverse cardiovascular outcomes both in short-term and long-term follow-up with a dose-response relationship, while its impact on long-term mortality remained neutral. Future randomized controlled trials or experimental studies are warranted to gain a comprehensive understanding of the underlying mechanisms driving such associations between paracetamol and adverse cardiovascular outcomes.
The impact of a cardio-geriatric integrated care on mortality and readmissions in older patients with Heart Failure. Results of a quasi-experimental study
Authors: Mazzarone T , Mazzarone T , Okoye C , Pescatore G , Maccioni L , Bianco M G , Guarino D , Giusti A , Guerrini C , Cargiolli C , Virdis A
Published: October 2024

Background

Despite advancements in heart failure (HF) management, older adults still experience adverse outcomes. Post-discharge care for frail elders is often complicated by non-cardiac events and Hospital-Acquired Deconditioning Syndrome. While an integrated multidisciplinary approach combining cardiological and geriatric expertise appears highly beneficial, it remains underutilized.

Purpose

To evaluate the effectiveness of an integrated Cardio-Geriatric approach in improving one-year mortality, reducing HF readmissions and increasing days-alive-out-of-hospital (DAOH) among older patients discharged from acute care hospitals.

Methods

The study utilized a before-and-after design. The study enrolled two groups of patients: the first consisted of individuals aged ≥ 65 years hospitalized for acute HF between January 2018 and December 2019, receiving usual care (UC) post-discharge follow-up (referral to a cardiologist and general practitioner); the second group evaluated outpatients in the Cardio-Geriatric ambulatory clinic (CG) within three weeks after discharge for acute HF between January 2020 and December 2022. Primary outcomes included one-year all-cause mortality, HF readmissions and DOAH. Cox Regression analysis adjusted for age, sex, frailty status, and main comorbidities assessed CG effectiveness.

Results

Among 606 patients (mean age 86 years, 56% females), 477 received US, the remaining 175 were referred to the CG. At 1-year follow-up we observed a significant reduction in re-hospitalizations between CG and UC (36.5% vs. 53.6%; respectively, p < 0.001) and mortality (20% vs. 44.8%; respectively, p < 0.001). CG patients had more than double DAOH (300 ± 100 vs 156 ± 145 days, p <0.001). Cox regression analysis confirmed CG integrated approach as a protective factor for mortality or re-hospitalization even after adjustment for confounders [aHR 0.50; 95% CI (0.28-0.89)]. Respiratory diseases, neurological conditions, and infections were common causes of readmission, emphasizing the need for comprehensive post-discharge care.

Conclusion

The Cardio-Geriatric integrated approach significantly improved outcomes, highlighting the potential of integrated care in addressing the multifaceted needs of older adults with heart failure
Left atrial reservoir strain as a prognostic indicator for cardiovascular events after mitral valvuloplasty
Authors: Torii Y , Taiji O , Madoka S , Toshiaki T , Tomohiko T , Shoji M , Junko O , Misaki K , Atsuyo O , Aoi H , Hisachi K , Kyoko M , Junichi K , Tomoko T , Yutaka F
Published: October 2024

Background

In patients after mitral valvuloplasty (MVP), assessing valve function and heart failure (HF) is crucial for prognostic predictions. Left ventricular diastolic function assessed by transthoracic echocardiography (TTE) plays an important role in the evaluation of HF in general practice. However, post-mitral valve surgery patients are excluded from the left ventricular diastolic function assessment guidelines proposed by the American Society of Echocardiography in 2016 due to their low correlation with left ventricular diastolic function indices. On the contrary, the left atrial reservoir strain (LARS) before MVP is considered as a prognostic factor, reflecting left atrial dysfunction caused by mitral regurgitation. Nevertheless, there are limited reports on the relationship between LARS and cardiovascular (CV) events after MVP.

Purpose

The study aims to investigate the utility of LARS in predicting CV events after MVP.

Methods

The study included 249 patients who underwent TTE between January 2011 and January 2023 after MVP at our hospital. Patient background data, including NYHA classification, medical history, medications, blood tests, and TTE data, were collected at the time of follow-up TTE. LARS, left ventricular global longitudinal strain (LV-GLS), and right ventricular free wall strain (RV-FWSL) analysis were performed using a vender-independent external strain analysis software for all patients in the cohort. The primary endpoints were cardiovascular death and HF rehospitalization. The predictor of cardiovascular events was assessed using the Cox proportional hazards model and Kaplan-Meier curve (KMC).

Results

The mean age was 61±14 years, and 159 patients (64%) were male. The median time from surgery to TTE was 4.8 (1.0-6.8) years, 32 patients (13%) had events within 8.5 (3.7-10.8) years after TTE. The event groups had higher age, NYHA classification, and NT-pro BNP compared to the non-event group. TTE parameters such as left ventricular mass index, left ventricular end-diastolic volume and end-systolic volume were larger, and LV-GLS and LARS were significantly lower in the event group. In multivariate Cox proportional hazards models showed that LARS was also a prognostic indicator even after adjustment for several variables (Table 1). The KMC showed that LARS was associated with events regardless of left atrial volume index (Log-rank p <0.001, chi-square:31.03) (Figure 1).

Conclusion

LARS was strongly associated with CV events after MVP. We consider LARS to be a useful prognostic indicator after MVP.
Left ventricular dysfunction, pulmonary congestion, or both and cardiovascular risk after acute myocardial infarction
Authors: Nunes J T , Chen Y , Odugbemi T , Chu A , Fang J , Basque S , Odutayo A , Adbel-Qadir H , Ko D T , Godoy L C , Goodman S , Lee D S , Udell J A
Published: October 2024

Background

Patients with acute myocardial infarction (AMI) complicated by left ventricular systolic dysfunction (LVSD), pulmonary congestion, or both are at increased risk for adverse cardiovascular events, including long-term heart failure. The EMPACT-MI trial studied the efficacy and safety of early initiation of a sodium-glucose cotransporter-2 inhibitor (SGLT2i) in this population. We set out to evaluate the contemporary real-world risk associated with AMI presenting with LVSD and/or congestion and the projected impact of implementing early SGLT2i post-MI across the spectrum of risk.

Purpose

To evaluate the independent risk of presenting with LVSD, congestion, or both in patients with AMI. We will further explore the potential impact of the implementation of early initiation of SGLT2i in real-world clinical practice.

Methods

We conducted a retrospective population-based cohort study in Ontario, Canada, analyzing AMI hospitalizations from April 2009 to March 2022, emulating the EMPACT-MI trial cohort. Patients that survived to hospital discharge were stratified by baseline presentation with LVSD (defined as LVEF<50%), signs or symptoms of congestion or both and compared with a referent group without either risk factor (none). Exclusion criteria were previously established heart failure, prior SGLT2i use, eGFR < 20 ml/min/1.73m2 or chronic dialysis. The primary outcome was a composite of HF hospitalization or all-cause mortality at 30 days and 1 year. We used a multivariable logistic regression model to report an odds ratio (OR) and 95% confidence intervals (CI) adjusted for clinical risk factors.

Results

Among 36,837 AMI patients, 3% presented with congestion, 55% with LVSD, 10% with both, and 32% with none. Age/sex-adjusted 30-day event rates for the primary endpoint were 30%, 22%, 57%, and 7%, respectively. The corresponding adjusted ORs were 3.34 (95% CI: 2.05-5.46) for congestion, 3.58 (95% CI: 2.72-4.71) for LVSD, and 7.01 (95% CI: 5.09-9.65) for both, versus the reference group (none) (Figure 1). At year 1, a similar pattern of risk was observed (Figure 2). Based on the results of the EMPACT-MI trial being reported at the ACC conference in April 2024, relative and absolute risk differences in outcomes with implementation of early initiation of SGLT2i post-MI in real-world clinical practice across the spectrum of presentation will be reported.

Conclusion

Patients presenting with pulmonary congestion and/or LVSD remain at high risk of adverse cardiovascular events following AMI. This high-risk group represents an unmet need with a potential impact for improvement with novel interventions such as SGLT2i.