bluuebunny/crossref_metadata_2025_split huggingface dataset:
P759Electrocardiographic predictors of adverse in-hospital outcomes in the Takotsubo syndrome
Authors: Jha S 
Published: October 2019

Abstract

Background
The takotsubo syndrome is a life-threatening acute cardiac condition. However, little is known about risk factors associated with worse outcomes in TS, and no high-risk electrocardiographic criteria have been defined for patients with TS. We sought to identify high-risk admission ECG findings among patients with TS.

Methods
Using the Swedish Angiography and Angioplasty Registry (SCAAR) we identified all cases of TS who were treated at our university hospital between 2008 and 2017. We reviewed all cases and included patients who met the revised Gothenburg diagnostic criteria. We conducted an in-depth review of all presenting electrocardiograms, using a pre-defined case report form (CRF), including the following variables: heart rate; rhythm; PR-interval; QRS axis; QTc-interval; T-wave inversion.; presence of Q-wave; T-wave axis; and the magnitude of ST-segment deviation in each individual lead. The primary endpoint was the occurrence of in-hospital major adverse cardiac event (MACE), defined as the composite of death, ventricular tachycardia or fibrillation (VT/VF), atrioventricular block ≥2 or asystole >10 seconds.

Results
We identified 161 patients with TS, of whom 151 (93.8%) were women. The mean age was 69±13 years. MACE occurred in 19 patients (11.8%), and VT/VF occurred in 14 patients (8.7%). No clinical variables were significantly different between patients with and without MACE. Patients with MACE were less likely than those without MACE to have sinus rhythm (79.0% versus 95.8%, p=0.02) or T-wave inversion (15.8% versus 52.8%, p=0.02). T-wave inversion was less common among patients with than without VT/VF (14.3% versus 51.7%, p=0.01). After adjustment for age and sex T-wave inversion was independently associated with lower risk of MACE (Odds ratio 0.13, 95% confidence interval 0.04 to 0.48, p>0.001).

Conclusions
T-wave inversion is common in TS and is associated with lower risk of adverse events, driven by a lower risk of VT/VF.
P763Home Monitoring is associated with fewer gastrointestinal bleeding events following ventricular assist device implantation
Authors: Gkouziouta A , Aravanis N , Zarkalis D , Bonios M , Fragkoulis S , Adamopoulos S , Kogerakis N 
Published: October 2019

Abstract

Introduction
Patients (pts) treated with a continuous flow left ventricular assist device (LVAD) are at increased risk for both bleeding and thromboembolic events. Maintenance of oral anticoagulation (AC) in the therapeutic range is difficult to achieve.

Hypothesis
Increased frequency of international normalized ratio (INR) home monitoring (HM) decreases the incidence of gastrointestinal bleeding and thromboembolic events (stroke, pump thrombosis) compared to standard of care (SOC).

Methods
We analyzed the efficacy of outpatient AC monitoring in consecutive pts who underwent VAD implantation at our institution between 2008–2018. Time in therapeutic range (TTR) was defined as percent of time with INR 2.5–2.8. HM pts had biweekly INR measurements using the Coagucheck XS ROCHE, while SOC pts had INR measured every 1–3 weeks. Gastrointestinal bleeding (GIB) and thromboembolic events were assessed by retrospective blinded chart review. Logistic regression was used to model the impact of TTR on the risk of GIB and THROMB.

Results
There were 85 pts: 44 in HM and 40 in SC arm with similar characteristics. SOC patients were more likely to have ischemic cardiomyopathy (63% vs 30%, p=0.006) and an LVAD (60% vs 25%, p=0.002). The use of HM was associated with a 19.7% reduction in the risk of GIB (8.8% vs 28.5%, p=0.043) and a trend towards lower risk of THROMB (6.8% vs 14.9%, p=0.19). HM pts had significantly longer TTR (52±20% vs 39±22%, p=0.007). Each percentage increase in TTR was associated with a 5.2% decrease in the risk of GIB [Odds Ratio (OR) 0.95, 95% Confidence Interval (CI) 0.91–0.99, p=0.009] even after adjustment for aspirin use and monitoring duration (OR 0.95, 95% CI 0.91–0.99, p=0.020). There was a similar decrease in the risk of overall bleeding (OR 0.94, 95% CI 0.90–0.98, p=0.008).

Conclusions
Increased frequency of home INR monitoring achieved a higher TTR and was associated with a 20% reduction in risk of gastrointestinal bleeding.
P764A quality improvement program for heart failure involving structured patient data, diagnosis and organization of care - results from the 4D heart failure project
Authors: Matan D , Lofstrom U , Cabrera-Corovic C , Eriksson B L , Ekstrom M , Hage C , Ljunggren G , Lynga P , Persson B , Eriksson M J , Wallen H , Janerot Sjoberg B , Malmqvist K , Linde C , Persson H 
Published: October 2019

Abstract

Background
Heart failure (HF) management is suboptimal in Sweden despite available evidence-based treatments.

Purpose
We hypothesized that a comprehensive organizational improvement programme could improve HF management, treatment and outcome.

Methods
Between 2012 and 2017 a HF improvement programme (the 4D Heart Failure project) was conducted in an urban region in Sweden (>2.2 million inhabitants). The steering committee led working groups 2012–17 including all health care providers with 250 primary care centers to build a standardized care process. HF outpatient care was centralized at five hospital-based HF clinics and included multidisciplinary health care teams.
The outcomes were: 1) prescription withdrawals of HF medication (RAS-inhibitors and beta-blockers, MRA) per year, expressed as percentage (%), 2) one-year all-cause mortality or heart failure readmission by multivariable Cox regression, 3) total number of admitted HF patients, subdivided by new-onset and previously known HF, per million inhabitants and year.

Results
Between 2012 and 2017, yearly visits to the five HF clinics increased 3.5 times from 3200 to 11700, to a total of 47400 visits or 15800 patients (average 3 visits/patient). Prescription withdrawals of MRAs for readmitted HF patients increased from 37% to 60%, of beta-blockers and RAS-inhibitors from 80 to 90%. Similar increases were noted for all admitted patients. One-year mortality or HF readmission was 48% (n=17124/35880) over the period and decreased significantly (adjusted HR 0.98 per year, 95% CI 0.97–0.99, p<0.001). Number of admitted HF patients, new-onset or readmitted HF patients decreased by 16%, 13% and 20%, respectively (p<0.0001, Figure).
Numbers of admitted patients 2012-2017

Conclusion
A comprehensive standardized care HF management programme in an urban region substantially increased access to multidisciplinary hospital-based HF clinics, and increased use of evidence-based medications. HF admissions and readmissions were reduced, as was the risk of one-year mortality or HF rehospitalization.

Acknowledgement/Funding
County of Stockholm and the Karolinska Institute
P769Quality of life in outpatients with heart failure in relation to mortality and admissions for heart failure
Authors: Grundtvig M , Vollnes-Eriksen T , Hole T 
Published: October 2019

Abstract

Studies report relation between quality of life and outcome. However, less is known about how various aspects of quality of life relates to mortality and admissions for heart failure.

Method
Mortality was examined in 7001 patients with completed Minnesota Living with Heart Failure Questionnaire (MLWHFQ) at the first visit to specialised hospital outpatient clinics included in our registry. A subset of 4264 patients with a second MLWHFQ at a late follow-up visit was assessed for the number of admissions and days in hospital for reason of heart failure during a six months period prior to the late visit.

Results
In multivariate Cox proportional hazard regression model for time to death after the first visit with a median 19 months follow-up and 1001 deaths, the MLWHFQ score for the subset of the “physical domain” (question 2 to 9) was a significant independent predictor for mortality (P=0.002) adjusted for gender, NYHA-class, blood pressure, s-sodium, stroke, obstructive lung disease, eGFR, anemia, age, daily dose diuretic, and ischemic cause for heart failure. The total MLWHFQ score and the Minnesota “emotional domain” (question 17–21) were not significant variables when the MLWHFQ “physical domain” was entered in the analysis.
The number of admissions for heart failure and the number of days in hospital for these admissions in a six months period prior to the late visit were analysed by linear regression for related variables. The total MLWHFQ score at the late visit was highly significant for the number of admissions in the six months period (p<0.001) adjusted for the daily dose diuretic, NYHA functional class and proBNP. The MLWHFQ “physical domain” and the MLWHFQ “emotional domain” were not significant variables when the total score was entered. The number of days in hospital was related to the daily dose diuretic, NYHA functional class, proBNP, and in addition anaemia at the late visit again with the MLWHFQ total score being a significant predictor (=0.001)

Conclusions
Disease specific quality of life measured with MLWHFQ “physical domain” was a highly significant predictor for mortality after the first visit. The late total MLWHFQ score was a better predictor for heart failure related admissions and days in hospital than the subset domains in multivariate analysis.

Acknowledgement/Funding
None
P770New disease-specific adherence questionnaire can predict 2-year survival in chronic heart failure
Authors: Voronkov L G , Solonovych A S 
Published: October 2019

Abstract

Background
Several studies demonstrated that adherence to treatment is a predictor of clinical prognosis in cardiovascular patients (pts). It may be assumed that disease-specific questionnaires may better separate pts by their clinical risk than non-specific ones.

Objective
To compare the prognostic value of conventional Morisky-Green non-specific adherence questionnaire (MGQ) and proposed new disease-specific questionnaire in chronic heart failure (CHF).

Methods
124 stable CHF pts NYHA II-III with reduced left ventricular ejection fraction (rLVEF) on standard treatment were examined. To evaluate pts adherence to treatment we used MGQ and proposed by our HF clinic new score which include 10 questions: 1) Can you name cardiologic medications which have been taken by you during last month? (yes – 1 point, no – 0); 2) Have you taken regular all cardiologic drugs recommended for you during last month? (yes – 1, no - 0); 3) Did you sometimes miss your medications intake during last month? (yes – 0, no – 1); 4) Did you withdraw recommended cardiologic drugs by yourself when your feeling is good? (yes – 0, no – 1); 5) Do you know you should take recommended drugs all time? (yes – 1, no – 0); 6) Is the time of all your drugs intake written down by you? (yes – 1, no – 0); 7) Are there any days when you forget to take your medicines? (yes – 0, no – 1); 8) I assess my weight not less than 3 times a week (yes – 1, no – 0); 9) I monitor my fluid intake regularly (yes – 1, no – 0); 10) I keep low-salt diet (yes – 1, no – 0). Adherence if 8–10 point – good, 5–7 – moderate, ≤4 – poor.

Results
By the final score of each questionnaire, pts were divided for 2 groups: 1) with poor-to-moderate adherence (for MGQ ≤3; for new questionnaire ≤7) and 2) with good adherence (for MGQ 4; for new questionnaire 8–10). MGQ failed to predict long-term (24 month) survival (fig. 1) while poor-to-moderate adherence detected by new score was associated with significantly lower survival rate (fig. 2).
Survival curves

Conclusion
In contrast to non-specific MGQ, proposed disease-specific questionnaire is valid to predict 2-year survival in CHF with rLVEF. More data are needed to introduce it in practice.
P772Angiotensin-converting enzyme inhibitors and angiotensin receptor blockers for heart failure patients with different left ventricular ejection fraction categories: from the KCHF Registry
Authors: Yoshikawa Y , Tamaki Y , Yaku H , Yamamoto E , Ozasa N , Inuzuka Y , Morimoto T , Kato T , Kimura T 
Published: October 2019

Abstract

Background
The current guidelines recommend different medical treatment strategies for heart failure (HF) patients according to category of left ventricular ejection fraction (LVEF). Angiotensin-converting enzyme inhibitors/angiotensin receptor blockers (ACE-I/ARB) is an established medical treatment for heart failure with reduced ejection fraction (HFrEF), whereas its usefulness remains to be elucidated for non-HFrEF, especially for heart failure with mid-range ejection fraction (HFmrEF).

Purpose
This study aimed to assess the difference in association between ACE-I/ARB and clinical outcomes depending on LVEF category.

Methods
The Kyoto Congestive Heart Failure (KCHF) Registry is a multicentre registry without any exclusion criteria which included consecutive patients hospitalized for congestive HF in Japan. In each LVEF group (HFrEF, HFmrEF and heart failure with preserved ejection fraction [HFpEF]), we compared those who were prescribed ACE-I/ARB as discharge medication and those not, and assessed their 1-year clinical outcomes. We defined the primary outcome measure as a composite of all-cause death and HF hospitalization. We constructed a multivariable Cox regression model incorporating 24 clinically relevant factors. We assessed adjusted hazard ratios (HRs) of those with ACE-I/ARB relative to those not, and also interaction between ACE-I/ARB prescription at discharge and LVEF category.

Results
A total of 3717 patients were included in this study, where the number of patients in each LVEF group were as follows; 1383 patients with HFrEF, 703 with HFmrEF and 1631 with HFpEF, respectively (Figure). As shown in the table, the HRs for the primary outcome measure were significant in the HFrEF and HFmrEF groups, whereas the HR in the HFpEF group was insignificant. The interaction between ACE-I/ARB prescription and LVEF category for the primary outcome measure was statistically significant.
Hazard ratios by LVEF category Outcome measures HFrEF HFmrEF HFpEF P interaction HR (95% CI) P value HR (95% CI) P value HR (95% CI) P value All-cause death + HF hospitalization 0.66 (0.54–0.79) <0.001 0.61 (0.45–0.82) 0.001 0.95 (0.80–1.14) 0.61 0.01 All-cause death 0.62 (0.48–0.81) <0.001 0.52 (0.35–0.77) 0.001 0.73 (0.58–0.93) 0.01 0.10 HF hospitalization 0.73 (0.57–0.92) 0.009 0.59 (0.40–0.87) 0.007 1.14 (0.90–1.44) 0.28 0.07 Hazard ratios of ACE-I/ARB relative to non-ACE-I/ARB for primary outcome measures in each LVEF category.
Study flowchart

Conclusions
The risk ratios of those who were prescribed ACE-I/ARB relative to those not were significantly low in HFmrEF as well as HFrEF, whereas the risk ratios were insignificant in HFpEF. ACE-I/ARB could be a potential choice of treatment for HFmrEF patients.
P779Eligible patients for the PARADIGM-HF trial in a real-world outpatient clinic and its cardiovascular risk
Authors: Chen X , Schaufelberger M , Fu M 
Published: October 2019

Abstract

Background
In the PARADIGM-HF trial sacubitril-valsartan, an angiotensin receptor-neprilysin inhibitor (ARNI), was more effective than enalapril for some patients with heart failure (HF). However, the eligibility of the PARADIGM-HF study to a real-world heart failure population was not well established.

Purpose
To investigate the eligibility of PARADIGM-HF Trial in a real-world clinical setting and its cardiovascular risk.

Methods
We made secondary analysis of patients (n=4872) with heart failure prospectively enrolled in the Swedish Heart Failure Registry from the Outpatient Clinic, during 2005–2016. The eligibility for PARADIGM-HF in real world was studied based on patients whether they were either fully or partially compatible with the PARADIGM-HF study population. Mortality data during follow-up were obtained from the Death Registry of the National Board of Health and Welfare in Sweden.

Results
Heart failure with reduced LVEF (≤40%) (HFrEF) were found in 2165 patients, 653 patients (30%) were fully and 958 (44%) were partially compatible with PARADIGM-HF criteria respectively (figure). In both the fully and partially eligible groups there were more male. Despite that the fully eligible patients were younger than non-eligible patients (77.6±12.7 vs. 84.0±13.7 years), they were clearly older than in PARADIGM-HF trial. Moreover, those fully-eligible patients had lower all-cause mortality compared with both partially-and non-eligible patients (45.6% vs. 68.5, HR 1.43 (1.18–1.75) p<0.001) after adjusted for sex, age, BMI, smoking, hypertension and diabetes. However, both fully- and partially eligible patients had higher all-cause mortality than that in PARADIGM-HF.
figure

Conclusion
In a real world outpatient clinical setting, around 35% to 50% of HFrEF were eligible for treatment with ARNI except that they are older, sicker and carried higher risk for all-cause mortality than the PARADIGM-HF trial population.
P782The evaluation of a nurse-led Sacubitril/Valsartan initiation and titration clinic
Authors: Brown A , Westley K , Amiruddin Z , Driver W , Runnett C , Matthews I , Ripley D , Thomas H 
Published: October 2019

Abstract

Background
Sacubitril/Valsartan is a new NICE-approved treatment for heart failure patients with NYHA 2–4 symptoms, LVEF<35% and on a stable dose of ACEi/ARB medication. The PARADIGM-HF trial was stopped early after showing an absolute risk reduction of cardiovascular death/hospitalisation of 5%. NICE specify that it should be initiated by a heart failure specialist with access to a multidisciplinary team. We set up a secondary care specialist nurse-led clinic in our trust in North England for Sacubitril/Valsartan initiation and monitoring.

Purpose
To assess compliance to NICE guidelines and establish the number of clinic visits required for dose titration. To compare demographics and treatment outcomes of our patients with the trial population.

Methods
A retrospective analysis of all patients prescribed Sacubitril/Valsartan over two years with a minimum follow up of 6 months. Data was collected from patient records and compared with NICE guidelines and the PARADIGM-HF trial (total population and Western European subset).

Results
159 patients commenced Sacubitril/Valsartan. Table 1 shows demographic and therapy data and demonstrates our cohort is largely similar to the Western Europe cohort of Paradigm-HF. However, our patients had higher rates of MRA and complex device treatments. Prescribing was compliant with NICE guidelines in 97%. Failure to exceed the target 50% ACEi/ARB dose was the main reason for non-compliance in 60% (3/5). These 3 patients all discontinued. Overall 16% discontinued the drug (42% for hypotension) compared to 18% in the trial. No serious adverse reactions occurred. Mean number of clinic visits was 3.7±1.4.
Table 1. Demographic and therapy data Cohort size Age Female % Ischaemic Aetiology % LVEF B-Blocker % MRA % CRT % ICD % North England 159 69.3±11.1 20 59 27 90 73 23 47 PARADIGM-HF full trial 8442 63.8±11.5 21 60 30 93 54 7 15 Western European Subset 1680 68.3±9.9 18 30 95 44 12 33

Conclusion
Our cohort closely reflects the trial and the resultant NICE guidelines. More of our patients are treated with MRA and complex devices compared to PARADIGM-HF. This may be due to the quality of our service or may reflect our patient selection. Similar tolerability in our patients is reassuring as study patients are highly selected. Those receiving suboptimal ACE/ARB doses (therefore not NICE compliant) prior to initiation all failed to tolerate the new drug which cautions against straying from guidance. Our data shows a specialist nurse-led service can be delivered safely and effectively achieving therapeutic doses with a small number of patient visits. This data supports its deliverability in a non-trial setting.
P783Guideline-directed therapy at discharge is important in patients with heart failure and atrial fibrillation
Authors: Yoo B S , Ahn M S , Lee S J , Son J W , Kim J Y , Park S W 
Published: October 2019

Abstract

Background
There are limited and conflicting data regarding the prognostic implication of guideline-directed therapy, especially in heart failure (HF) patients with atrial fibrillation (AF). Thus, this study evaluated the relationship between guideline adherence to recommended therapy at discharge and relevant 60-day clinical outcomes in acute HF patients with AF having reduced ejection fraction (HFrEF) or preserved ejection fraction (HFpEF).

Methods and results
Of 5,625 acute HF patients in the Korean Acute Heart Failure Registry, 2,071 with documented AF (HFrEF, n=986; HFpEF, n=1,085) were separately analysed. A guideline adherence score was calculated for the prescription of angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, β-blockers, mineralocorticoid receptor antagonists, and anticoagulants. In HFrEF patients with AF, there was significant trend of increase in mortality (p for trend <0.001) and composite endpoint (p for trend = 0.002) according to guideline adherence. Poor adherence was associated with a significantly high risk of mortality (hazard ratio [HR], 4.75; 95% confidence interval [95% CI], 1.77–12.74) and composite endpoint (HR, 2.36; 95% CI, 1.33–4.18). In HFpEF patients with AF, there was a significant increasing trend for rehospitalization (p for trend = 0.04) and composite endpoint (p for trend = 0.03). However, the beneficial effect of good guideline adherence was statistically non-significant for all clinical outcomes

Conclusion
Better adherence to guidelines was associated with a better 60-day prognosis in both HFrEF and HFpEF patients with AF. However, the beneficial effect of guideline adherence was more pronounced in HFrEF patients with AF.
P789TLR-4 expression predicts mortality in patients with acute heart failure
Authors: Krychtiuk K A , Lenz M , Huber K , Hengstenberg C , Wojta J , Heinz G , Speidl W S 
Published: October 2019

Abstract

Background
Inflammation is regarded as an important trigger for disease progression in heart failure (HF) and activation of the inflammatory system was implicated in the pathophysiology of acute heart failure (AHF).
Toll-like receptors (TLRs) play an important role in acute inflammatory processes in critically ill patients by binding to pathogen associated molecular patterns (PAMP) and danger associated molecular patterns (DAMP). However, it is not known whether the expression patterns of TLRs on neutrophils and monocytes are associated with outcome in patients with severe AHF requiring intensive care unit (ICU) admission.
The aim of this prospective, observational study was to analyze whether TLR-expression on monocytes or neutrophils is associated with 30-day survival in patients with severe AHF.

Methods
We included 84 patients with severe AHF admitted to a cardiac ICU. Blood was taken at admission and mean fluorescence activity (MFI) of TLR-2, TLR-4 and TLR-9 on monocytes and neutrophils was analyzed by flow cytometry.

Results
Median age was 64 (IQR 48–74) years and 76.2% of patients were male. Median NT-proBNP was 4941 (IQR 1298–12273) pg/mL and 30-day mortality was 33.3%. TLR-4 expression on monocytes in survivors (740 IQR 694–854) was significantly lower than in non-survivors (871 IQR 723–979; p<0.05). TLR-2 and TLR-9 expression on monocytes and TLR expression on neutrophils was not associated with survival. TLR-4 expression on monocytes was significantly associated with survival independent of age, sex, creatinine and NT-proBNP levels.

Conclusion
Monocyte TLR-4 expression predicts mortality in patients admitted to a cardiac ICU for severe acute heart failure. This suggests that activation of the innate immune system by TLR-binding of DAMPS may play a significant role in critically ill acute heart failure patients.