P1511 Comparison between echocardiographic right ventricular-pulmonary arterial coupling and right ventricular longitudinal strain to identify pulmonary hypertension in heart failure

Background

Both the ratio between tricuspid annular plane systolic excursion (TAPSE) and doppler estimated systolic pulmonary artery pressure (SPAP) and right ventricular longitudinal strain (RVSL) have been proposed as sensitive measures of RV contractile function and demonstrate important prognostic implications in heart failure (HF). However, a comparison between measurements to discern pulmonary hypertension (PH) in heart failure has not been adequately explored.

Methods

Consecutive subjects undergoing right heart catheterization (RHC) and simultaneous echocardiography to evaluate HF were enrolled. Subjects with atrial fibrillation, recent acute coronary syndrome and poor diagnostic images were excluded. RV-PA coupling was assessed based on the ratio between invasively derived RV elastance and arterial elastance (Ees/Ea) and correlated with TAPSE/RVSP and speckle-tracking derived RVSL. ROC analysis was performed to identify PH, defined as invasive PA mean pressure ≥25mmHg.

Results

99 subjects were analysed (age: 59 ± 14; 49% female). Both TAPSE/RVSP (r = 0.47; p < 0.001) and RVSL (r = 0.48; p < 0.001) demonstrated significant associations with invasive Ees/Ea. TAPSE/RVSP was significantly lower in PH when compared with non-PH subjects (0.42 ± 0.27 vs 0.65 ± 0.34mm/mmHg; p < 0.001) and demonstrated strong differentiating ability (AUC = 0.80) for PH. RVSL, however, did not significantly differ between groups (p > 0.05).

Conclusions

Both TAPSE/RVSP and RVSL demonstrate significant association with invasive measures of RV-PA coupling. The stronger ability of TAPSE/RVSP to distinguish PH as compared with RVSL may be attributed to the lower load-dependency of this measure.

Sex- and age-related differences in the management and outcomes of chronic heart failure: an analysis of patients from the ESC HFA EORP Heart Failure Long-Term Registry

AIMS

This study aimed to assess age- and sex-related differences in management and 1-year risk for all-cause mortality and hospitalization in chronic heart failure (HF) patients.

METHODS AND RESULTS

Of 16 354 patients included in the European Society of Cardiology Heart Failure Long-Term Registry, 9428 chronic HF patients were analysed [median age: 66 years; 28.5% women; mean left ventricular ejection fraction (LVEF) 37%]. Rates of use of guideline-directed medical therapy (GDMT) were high (angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers and mineralocorticoid receptor antagonists: 85.7%, 88.7% and 58.8%, respectively). Crude GDMT utilization rates were lower in women than in men (all differences: P ≤ 0.001), and GDMT use became lower with ageing in both sexes, at baseline and at 1-year follow-up. Sex was not an independent predictor of GDMT prescription; however, age >75 years was a significant predictor of GDMT underutilization. Rates of all-cause mortality were lower in women than in men (7.1% vs. 8.7%; P = 0.015), as were rates of all-cause hospitalization (21.9% vs. 27.3%; P < 0.001) and there were no differences in causes of death. All-cause mortality and all-cause hospitalization increased with greater age in both sexes. Sex was not an independent predictor of 1-year all-cause mortality (restricted to patients with LVEF ≤45%). Mortality risk was significantly lower in patients of younger age, compared to patients aged >75 years.

CONCLUSIONS

There was a decline in GDMT use with advanced age in both sexes. Sex was not an independent predictor of GDMT or adverse outcomes. However, age >75 years independently predicted lower GDMT use and higher all-cause mortality in patients with LVEF ≤45%.

Type 2 diabetes increases the long-term risk of heart failure and mortality in patients with atrial fibrillation

AIMS

Impact of type 2 diabetes mellitus (T2DM) on non-thromboembolic outcomes in atrial fibrillation (AF) is insufficiently explored. This prospective cohort study of AF patients aimed (i) to analyse the association between T2DM and heart failure (HF) events (including new-onset HF), and all-cause and cardiovascular mortality, (ii) to assess the impact of baseline T2DM treatment on outcomes, and (iii) to explore characteristics of new-onset HF phenotypes in relation to T2DM status.

METHODS AND RESULTS

Of 1803 AF patients (515/1288, with/without prior HF), 389 (22%) had T2DM at baseline. After 5 years of median follow-up, T2DM patients had an 85% greater risk of HF events [adjusted hazard ratio (aHR) 1.85; 95% confidence interval (CI) 1.51-2.28; P < 0.001], including a 45% increased risk for new-onset HF (1.45; 1.17-2.28; P = 0.015). T2DM conferred a 56% higher all-cause (1.56, 1.22-2.01; P = 0.003) and a 48% higher cardiovascular mortality (1.48; 1.34-1.93; P = 0.007). Fine-Gray analysis, with mortality as a competing risk, confirmed greater HF risk among T2DM patients. All risks were highest among insulin-treated patients. The prevalence of new-onset HF phenotypes was as follows: 67% preserved ejection fraction (HFpEF), 20% mid-range ejection fraction (HFmrEF) and 13% reduced ejection fraction (HFrEF). On time-dependent Cox regression, adjusted for baseline characteristics and an interim acute coronary event, T2DM increased aHRs for new-onset HFpEF (2.38; 1.30-4.58; P <0.001) and the combined HFmrEF/HFrEF (1.77; 1.11-3.62; P = 0.017).

CONCLUSIONS

Atrial fibrillation patients with T2DM have independently increased risk of new-onset/recurrent HF events, cardiovascular and all-cause mortality, particularly when insulin-treated. The prevailing phenotype of new-onset HF was HFpEF; T2DM conferred higher risk of both HFpEF and HFmrEF/HFrEF.

European Society of Cardiology/Heart Failure Association position paper on the role and safety of new glucose-lowering drugs in patients with heart failure

Type 2 diabetes mellitus (T2DM) is common in patients with heart failure (HF) and associated with considerable morbidity and mortality. Significant advances have recently occurred in the treatment of T2DM, with evidence of several new glucose-lowering medications showing either neutral or beneficial cardiovascular effects. However, some of these agents have safety characteristics with strong practical implications in HF [i.e. dipeptidyl peptidase-4 (DPP-4) inhibitors, glucagon-like peptide-1 receptor agonists (GLP-1 RA), and sodium-glucose co-transporter type 2 (SGLT-2) inhibitors]. Regarding safety of DPP-4 inhibitors, saxagliptin is not recommended in HF because of a greater risk of HF hospitalisation. There is no compelling evidence of excess HF risk with the other DPP-4 inhibitors. GLP-1 RAs have an overall neutral effect on HF outcomes. However, a signal of harm suggested in two small trials of liraglutide in patients with reduced ejection fraction indicates that their role remains to be defined in established HF. SGLT-2 inhibitors (empagliflozin, canagliflozin and dapagliflozin) have shown a consistent reduction in the risk of HF hospitalisation regardless of baseline cardiovascular risk or history of HF. Accordingly, SGLT-2 inhibitors could be recommended to prevent HF hospitalisation in patients with T2DM and established cardiovascular disease or with multiple risk factors. The recently completed trial with dapagliflozin has shown a significant reduction in cardiovascular mortality and HF events in patients with HF and reduced ejection fraction, with or without T2DM. Several ongoing trials will assess whether the results observed with dapagliflozin could be extended to other SGLT-2 inhibitors in the treatment of HF, with either preserved or reduced ejection fraction, regardless of the presence of T2DM. This position paper aims to summarise relevant clinical trial evidence concerning the role and safety of new glucose-lowering therapies in patients with HF.

Subtypes of atrial fibrillation with concomitant valvular heart disease derived from electronic health records: phenotypes, population prevalence, trends and prognosis

AIMS

To evaluate population-based electronic health record (EHR) definitions of atrial fibrillation (AF) and valvular heart disease (VHD) subtypes, time trends in prevalence and prognosis.

METHODS AND RESULTS

A total of 76 019 individuals with AF were identified in England in 1998-2010 in the CALIBER resource, linking primary and secondary care EHR. An algorithm was created, implemented, and refined to identify 18 VHD subtypes using 406 diagnosis, procedure, and prescription codes. Cox models were used to investigate associations with a composite endpoint of incident stroke (ischaemic, haemorrhagic, and unspecified), systemic embolism (SSE), and all-cause mortality. Among individuals with AF, the prevalence of AF with concomitant VHD increased from 11.4% (527/4613) in 1998 to 17.6% (7014/39 868) in 2010 and also in individuals aged over 65 years. Those with mechanical valves, mitral stenosis (MS), or aortic stenosis had highest risk of clinical events compared to AF patients with no VHD, in relative [hazard ratio (95% confidence interval): 1.13 (1.02-1.24), 1.20 (1.05-1.36), and 1.27 (1.19-1.37), respectively] and absolute (excess risk: 2.04, 4.20, and 6.37 per 100 person-years, respectively) terms. Of the 95.2% of individuals with indication for warfarin (men and women with CHA2DS2-VASc ≥1 and ≥2, respectively), only 21.8% had a prescription 90 days prior to the study.

CONCLUSION

Prevalence of VHD among individuals with AF increased from 1998 to 2010. Atrial fibrillation associated with aortic stenosis, MS, or mechanical valves (compared to AF without VHD) was associated with an excess absolute risk of stroke, SSE, and mortality, but anticoagulation was underused in the pre-direct oral anticoagulant (DOAC) era, highlighting need for urgent clarity regarding DOACs in AF and concomitant VHD.

Limited value of NT-proBNP as a prognostic marker of all-cause mortality in patients with heart failure with preserved and mid-range ejection fraction in primary care: A report from the swedish heart failure register

Aim: The prognostic value of natriuretic peptides in the management of heart failure (HF) patients with ejection fraction (EF) <40% is well established, but is less known for those with EF ≥40% managed in primary care (PC). Therefore, the aim of this study is to describe the prognostic significance of plasma NT-proBNP in such patients managed in PC.Subjects: We included 924 HF patients (48% women) with EF ≥40% and NT-proBNP registered in the Swedish Heart Failure Registry. Follow-up was 1100 ± 687 days.Results: One-, three- and five-year mortality rates were 8.1%, 23.9% and 44.7% in patients with EF 40-50% (HFmrEF) and 7.3%, 23.6% and 37.2% in patients with EF ≥50% (HFpEF) (p = 0.26). Patients with the highest mean values of NT-proBNP had the highest all-cause mortality but wide standard deviations (SDs). In univariate regression analysis, there was an association only between NT-proBNP quartiles and all-cause mortality. In HFmrEF patients, hazard ratio (HR) was 1.96 (95% CI 1.60-2.39) p < 0.0001) and in HFpEF patients, HR was 1.72 (95% CI 1.49-1.98) p < 0.0001). In a multivariate Cox proportional hazard regression analysis, adjusted for age, NYHA class, atrial fibrillation and GFR class, this association remained regarding NT-proBNP quartiles [HR 1.83 (95% CI 1.38-2.44), p < 0.0001] and [HR 1.48 (95% CI 1.16-1.90), p = 0.0001], HFmrEF and HFpEF, respectively.Conclusion: NT-proBNP has a prognostic value in patients with HF and EF ≥40% managed in PC. However, its clinical utility is limited due to high SDs and the fact that it is not independent in this population which is characterized by high age and much comorbidity.Key pointsIt is uncertain whether NT-proBNP predicts risk in heart failure with preserved ejection fraction (EF > 40%, HFpEF) managed in primary care.We show that high NT-proBNP predicts increased all-cause mortality in HFpEF-patients managed in primary care.The clinical use is however limited due to large standard deviations, many co-morbidities and high age.Many of these co-morbidities contribute to all-cause mortality and management of these patients should also focus on these co-morbidities.

Prevalence and correlates of coronary microvascular dysfunction in heart failure with preserved ejection fraction: PROMIS-HFpEF

Aims

To date, clinical evidence of microvascular dysfunction in patients with heart failure (HF) with preserved ejection fraction (HFpEF) has been limited. We aimed to investigate the prevalence of coronary microvascular dysfunction (CMD) and its association with systemic endothelial dysfunction, HF severity, and myocardial dysfunction in a well defined, multi-centre HFpEF population.

Methods and results

This prospective multinational multi-centre observational study enrolled patients fulfilling strict criteria for HFpEF according to current guidelines. Those with known unrevascularized macrovascular coronary artery disease (CAD) were excluded. Coronary flow reserve (CFR) was measured with adenosine stress transthoracic Doppler echocardiography. Systemic endothelial function [reactive hyperaemia index (RHI)] was measured by peripheral arterial tonometry. Among 202 patients with HFpEF, 151 [75% (95% confidence interval 69-81%)] had CMD (defined as CFR <2.5). Patients with CMD had a higher prevalence of current or prior smoking (70% vs. 43%; P = 0.0006) and atrial fibrillation (58% vs. 25%; P = 0.004) compared with those without CMD. Worse CFR was associated with higher urinary albumin-to-creatinine ratio (UACR) and NTproBNP, and lower RHI, tricuspid annular plane systolic excursion, and right ventricular (RV) free wall strain after adjustment for age, sex, body mass index, atrial fibrillation, diabetes, revascularized CAD, smoking, left ventricular mass, and study site (P < 0.05 for all associations).

Conclusions

PROMIS-HFpEF is the first prospective multi-centre, multinational study to demonstrate a high prevalence of CMD in HFpEF in the absence of unrevascularized macrovascular CAD, and to show its association with systemic endothelial dysfunction (RHI, UACR) as well as markers of HF severity (NTproBNP and RV dysfunction). Microvascular dysfunction may be a promising therapeutic target in HFpEF.

Continuous-flow mechanical circulatory support is not associated with early graft failure: An analysis of the International Society for Heart and Lung Transplantation registry

BACKGROUND

Continuous-flow mechanical circulatory support (CF-MCS) is associated with impaired vascular function and increased risk of vasoplegia. One contributing factor to early graft failure (EGF) is severe vasoplegia. We tested the hypothesis that CF-MCS is associated with increased risk of EGF.

METHODS

Adult primary heart transplant recipients in the ISHLT Registry from 2005 to 2013 were stratified into three groups based on pre-transplant MCS: No MCS (n = 11 748), pulsatile (P)-MCS (n = 718), and CF-MCS (n = 3818). EGF was defined as death/retransplantation due to graft failure within 30 days after HT. Comparisons were made using descriptive statistics and associations. EGF was assessed with multivariable Cox proportional hazard regression.

RESULTS

The incidence of EGF within 30 days was similar between groups (No MCS 2.2%, P-MCS 3.3%, CF-MCS 2.1%, P = .10). Following multivariable adjustment, the risk of EGF was not statistically different for those with CF-MCS compared with P-MCS (HR 0.75, 95% CI 0.46-1.21, P = .24). The risk of EGF was numerically, but not statistically significantly higher for CF-MCS compared with No MCS (HR 1.24, 95% CI 0.92-1.67, P = .16).

CONCLUSION

CF-MCS use was not associated with a statistically significant increased risk of EGF resulting in death or retransplantation in the first 30 days after transplant.

Incidence of, Associations With and Prognostic Impact of Worsening Renal Function in Heart Failure With Different Ejection Fraction Categories

There are no studies of long-term worsening renal function (WRF) in heart failure (HF) with different ejection fraction (EF) groups. The aim was to compare incidence of, associations with and prognostic impact of WRF in HF with preserved (HFpEF), mid-range (HFmrEF), and reduced EF (HFrEF). The Swedish Heart Failure Registry (SwedeHF) was merged with the Stockholm Creatinine Measurement (SCREAM) registry 2006 to 2010. The associations between EF and WRF (≥25% decrease in eGFR) and the associations between WRF25-49% and WRF≥50% within year one and subsequent all-cause mortality were all assessed with multiadjusted Cox regression. Of 7,154 patients, 41.6% of HFpEF versus 34.5% and 35.4% of HFmrEF and HFrEF patients developed WRF≥25% during year one. The WRF risk was higher in HFpEF (reference) than in HFmrEF, hazard ratio (95% confidence interval) 0.890 (0.794 to 0.997) and HFrEF 0.870 (0.784 to 0.965). WRF within year one was strongly associated with subsequent long-term mortality in all EF groups, yielding adjusted HRs with WRF25-49% and WRF≥50%: HFpEF, 1.101 (0.913 to 1.328) and 2.096 (1.652 to 2.659), in HFmrEF 1.654 (1.353 to 2.022) and 2.375 (1.807 to 3.122) and in HFrEF 1.212 (1.060 to 1.386) and 1.694 (1.412 to 2.033). In conclusion, the long-term WRF risk was high in HF and highest in HFpEF. WRF was strongly associated with mortality in all EF groups, although in HFpEF only with the most severe WRF.

P3544Role of cardiovascular comorbidities in heart failure across the ejection fraction spectrum

Background

Comorbidities are associated with heart failure (HF) development, severity and outcomes, but may play different roles in HF with preserved (HFpEF) vs. mid-range (HFmrEF) vs. reduced ejection fraction (HFrEF). A detailed characterization of HF patients according to EF and comorbidities may improve prognostication and facilitate trial design.

Purpose

To investigate characteristics and outcomes in a large and unselected cohort of HF patients according to EF strata and presence/absence of concomitant type 2 diabetes (T2DM), atrial fibrillation (AF) and chronic kidney disease (CKD).

Methods

Patients enrolled in the Swedish HF registry between 2000–2012 were considered. Kaplan Meier curves and multivariable Cox regression models were fitted to assess risk and predictors of outcomes (HF and all-cause hospitalization; composite of cardiovascular (CV) death and HF hospitalization).

Results

Of 42,583 patients (23% HFpEF, 21% HFmrEF, 56% HFrEF), 24% had T2DM, 49% CKD defined as eGFR&lt;60 ml/min/1.73m2, and 56% AF. T2DM, AF and CKD coexisted in 8% of the population with similar distribution across all EF strata. AF and CKD were the most likely to coexist. Prevalence of AF and/or CKD was highest in HFpEF and lowest in HFrEF, whereas prevalence of T2DM was similar across the EF spectrum (Figure). Compared to patients without T2DM and/or AF and/or CKD, those with any of them were more likely to suffer from other comorbidities (i.e. hypertension, anemia, COPD), to be inpatients, have more severe HF (higher NYHA class, NT-proBNP levels and use of diuretics, longer HF duration) but less likely to be followed-up in specialty vs. primary care. Concomitant history of ischemic heart disease was more likely in patients with vs. without CKD and/or T2DM but less likely in those with vs without AF.

Patients with vs. without T2DM and/or CKD and/or AF had worse prognosis. In particular, risk of HF hospitalization and composite of HF hospitalization/CV death was highest in patients with HFrEF and concomitant comorbidities, whereas the risk of all-cause hospitalization was highest in those with HFpEF or HFmrEF and concomitant comorbidities. Prognostic predictors of CV death/HF hospitalization were consistent in patients with T2DM, CKD or AF, regardless of EF (e.g. male sex, older age, lower EF category, more severe HF, ischemic heart disease, anemia, COPD).

Comorbidities burden

Conclusion

HF patients show a high burden of concomitant diseases, specifically T2DM, CKD and AF. CKD and AF are more prevalent in HFpEF vs. HFmrEF vs. HFrEF, whereas T2DM prevalence is consistent across the EF spectrum. Presence of comorbidities identifies patients with more severe HF regardless of EF category. Presence of comorbidities may identify patients at higher risk of CV outcomes in HFrEF and those at higher risk of non-CV events in HFpEF.

Acknowledgement/Funding

This study has been supported by funding from Boehringer Ingelheim

The additive value of echocardiographic pulmonary to left atrial global strain ratio in the diagnosis of pulmonary hypertension

BACKGROUND

The distinction between pre-capillary and post-capillary pulmonary hypertension (PH) is central to accurate diagnosis and appropriate therapy. We aimed to investigate the ability of the novel echocardiographic pulmonary to left atrial global strain ratio (ePLAGS) to distinguish pre-capillary from post-capillary PH and compare its discriminatory strength with the echocardiographic pulmonary to left atrial ratio (ePLAR).

METHODS

Consecutive subjects with unexplained dyspnea or heart failure underwent echocardiography immediately followed by right heart catheterization. Subjects who did not satisfy the ESC/ERS criteria for PH, in atrial fibrillation or under pacemaker therapy, or with significant concomitant valvular disease were excluded. ePLAGS was calculated as peak tricuspid regurgitation velocity divided by left atrial global reservoir strain.

RESULTS

One hundred and thirty PH subjects, as defined by right heart catheterization, were included in the analysis (pre-capillary: n = 64, post-capillary: n = 66). ePLAGS was lower in pre-capillary compared with post-capillary PH (0.19 ± 0.14 vs. 0.45 ± 0.58 m/s/%; p = 0.02) and significantly different between combined post- and pre-capillary PH (Cpc-PH) and isolated post-capillary PH (Ipc-PH) (0.62 ± 0.85 vs. 0.32 ± 0.19 m/s/%; p = 0.04). ePLAR was higher in pre-capillary as compared with post-capillary PH (0.37 ± 0.16 vs. 0.20 ± 0.08; p < 0.001) but did not differ between Ipc-PH and Cpc-PH. ePLAGS demonstrated stronger discriminating power than ePLAR to distinguish pre-capillary from post-capillary PH (AUC = 0.80 vs. 0.70). In the setting of post capillary PH, ePLAGS showed reasonable ability to distinguish Ipc-PH from Cpc-PH (AUC = 0.65). ePLAR, however, did not differentiate these two groups (AUC = 0.49; p > 0.05).

CONCLUSIONS

ePLAGS accurately differentiates pre-capillary from post-capillary PH and demonstrates higher diagnostic ability than ePLAR.

Cardiac implantable electronic devices with a defibrillator component and all-cause mortality in left ventricular assist device carriers: results from the PCHF-VAD registry

AIMS

To compare characteristics of left ventricular assist device (LVAD) recipients receiving a cardiac implantable electronic device (CIED) with a defibrillator component (implantable cardioverter-defibrillator and cardiac resynchronization therapy with defibrillation, CIED-D) vs. those without one, and to assess whether carrying such a device contiguously with an LVAD is associated with outcomes.

METHODS AND RESULTS

Overall, 448 patients were analysed (mean age 52 ± 13 years, 82% male) in the multicentre European PCHF-VAD registry. To account for all active CIED-Ds during ongoing LVAD treatment, outcome analyses were performed by a time-varying analysis with active CIED-D status post-LVAD as the time-varying covariate. At the time of LVAD implantation, 235 patients (52%) had an active CIED-D. Median time on LVAD support was 1.1 years (interquartile range 0.5-2.0 years). A reduction of 36% in the risk of all-cause mortality was observed in patients with an active CIED-D [hazard ratio (HR) 0.64, 95% confidence interval (CI) 0.46-0.91; P = 0.012), increasing to 41% after adjustment for baseline covariates (HR 0.59, 95% CI 0.40-0.87; P = 0.008) and 39% after propensity score adjustment (HR 0.61, 95% CI 0.39-0.94; P = 0.027). Other than CIED-D, age, LVAD implant as redo surgery, number of ventricular arrhythmia episodes and use of vasopressors pre-LVAD were remaining significant risk factors of all-cause mortality. Incident ventricular arrhythmias post-LVAD portended a 2.4-fold and 2.6-fold increased risk of all-cause and cardiovascular death, respectively; carrying an active CIED-D remained associated with a 47% and 43% reduction in these events, respectively.

CONCLUSIONS

In an analysis accounting for all active CIED-Ds, including those implanted during LVAD support, carrying such a device was associated with significantly better survival during LVAD support.

Antithrombotic therapy and major adverse limb events in patients with chronic lower extremity arterial disease: systematic review and meta-analysis from the European Society of Cardiology Working Group on Cardiovascular Pharmacotherapy in Collaboration with the European Society of Cardiology Working Group on Aorta and Peripheral Vascular Diseases

Aims

The role and selection of antithrombotic therapy to improve limb outcomes in chronic lower extremity artery disease (LEAD) is still debated. We conducted a meta-analysis to examine the efficacy and safety of antithrombotic and more intense antithrombotic therapy on limb outcomes and limb salvage in patients with chronic LEAD.

Methods and results

Study inclusion criteria were: enrolment of patients with LEAD, randomized allocation to more vs. less intense antithrombotic therapy [more vs. less intense single-antiplatelet therapy (SAPT); dual-antiplatelet therapy vs. SAPT; dual antithrombotic therapy vs. SAPT or oral anticoagulant]; enrolment of ≥200 patients; reporting of at least one of following outcomes: limb amputation or revascularization. Seven randomized studies enrolling 30 447 patients were included. Over a median follow-up of 24 months, more vs. less intense antithrombotic therapy or placebo significantly reduced the risk of limb revascularization [relative risk (RR) 0.89, 95% confidence interval (CI) 0.83–0.94] and limb amputation (RR 0.63, 95% CI 0.46–0.86), as well as stroke (RR 0.82, 95% CI 0.70–0.97). There was no statistically significant effect on the risk of myocardial infarction (RR 0.98, 95% CI 0.87–1.11), all-cause (RR 0.93, 95% CI 0.86–1.01), and cardiovascular death (RR 0.97, 95% CI 0.86–1.08). Risk of major bleeding increased (RR 1.23, 95% CI 1.04–1.44).

Conclusion

In patients with LEAD, more intense antithrombotic therapy reduces the risk of limb amputation and revascularization as well as stroke with an increase in the risk of bleeding events.

2019 EACTS Expert Consensus on long-term mechanical circulatory support

Long-term mechanical circulatory support (LT-MCS) is an important treatment modality for patients with severe heart failure. Different devices are available, and many-sometimes contradictory-observations regarding patient selection, surgical techniques, perioperative management and follow-up have been published. With the growing expertise in this field, the European Association for Cardio-Thoracic Surgery (EACTS) recognized a need for a structured multidisciplinary consensus about the approach to patients with LT-MCS. However, the evidence published so far is insufficient to allow for generation of meaningful guidelines complying with EACTS requirements. Instead, the EACTS presents an expert opinion in the LT-MCS field. This expert opinion addresses patient evaluation and preoperative optimization as well as management of cardiac and non-cardiac comorbidities. Further, extensive operative implantation techniques are summarized and evaluated by leading experts, depending on both patient characteristics and device selection. The faculty recognized that postoperative management is multidisciplinary and includes aspects of intensive care unit stay, rehabilitation, ambulatory care, myocardial recovery and end-of-life care and mirrored this fact in this paper. Additionally, the opinions of experts on diagnosis and management of adverse events including bleeding, cerebrovascular accidents and device malfunction are presented. In this expert consensus, the evidence for the complete management from patient selection to end-of-life care is carefully reviewed with the aim of guiding clinicians in optimizing management of patients considered for or supported by an LT-MCS device.

Temporal Trends of De Novo Malignancy Development After Heart Transplantation

BACKGROUND

Malignancy is a concern in cardiac transplant recipients, but the temporal trends of de novo malignancy development are unknown.

OBJECTIVES

The goal of this study was to describe the temporal trends of the incidence, types, and predictors of de novo malignancy in cardiac transplant recipients.

METHODS

The authors analyzed the temporal trends of post-transplant incidence, types, and predictors of malignancy using 17,587 primary adult heart-only transplant recipients from the International Society for Heart and Lung Transplantation registry. The main study outcomes included the incidence of, types of, and time to de novo malignancy.

RESULTS

The risk of any de novo solid malignancy between years 1 and 5 after transplantation was 10.7%. The cumulative incidence by malignancy type was: skin cancer (7.0%), non-skin solid cancer (4.0%), and lymphoproliferative disorders (0.9%). There was no temporal difference in the time to development according to malignancy type. However, the cumulative incidence of de novo solid malignancy increased from 2000 to 2005 vs. 2006 to 2011 (10.0% vs. 12.4%; p < 0.0001). Survival in patients after de novo malignancy was markedly lower than in patients without malignancy (p < 0.0001). Older recipients and patients who underwent transplantation in the recent era had a higher risk of de novo malignancy.

CONCLUSIONS

More than 10% of adult heart transplant recipients developed de novo malignancy between years 1 and 5 after transplantation, and this outcome was associated with increased mortality. The incidence of post-transplant de novo solid malignancy increased temporally, with the largest increase in skin cancer. Individualized immunosuppression strategies and enhanced cancer screening should be studied to determine whether they can reduce the adverse outcomes of post-transplantation malignancy.

Sacubitril/valsartan eligibility and outcomes in the ESC-EORP-HFA Heart Failure Long-Term Registry: bridging between European Medicines Agency/Food and Drug Administration label, the PARADIGM-HF trial, ESC guidelines, and real world

AIMS

To assess the proportion of patients with heart failure and reduced ejection fraction (HFrEF) who are eligible for sacubitril/valsartan (LCZ696) based on the European Medicines Agency/Food and Drug Administration (EMA/FDA) label, the PARADIGM-HF trial and the 2016 ESC guidelines, and the association between eligibility and outcomes.

METHODS AND RESULTS

Outpatients with HFrEF in the ESC-EORP-HFA Long-Term Heart Failure (HF-LT) Registry between March 2011 and November 2013 were considered. Criteria for LCZ696 based on EMA/FDA label, PARADIGM-HF and ESC guidelines were applied. Of 5443 patients, 2197 and 2373 had complete information for trial and guideline eligibility assessment, and 84%, 12% and 12% met EMA/FDA label, PARADIGM-HF and guideline criteria, respectively. Absent PARADIGM-HF criteria were low natriuretic peptides (21%), hyperkalemia (4%), hypotension (7%) and sub-optimal pharmacotherapy (74%); absent Guidelines criteria were LVEF>35% (23%), insufficient NP levels (30%) and sub-optimal pharmacotherapy (82%); absent label criteria were absence of symptoms (New York Heart Association class I). When a daily requirement of ACEi/ARB ≥ 10 mg enalapril (instead of ≥ 20 mg) was used, eligibility rose from 12% to 28% based on both PARADIGM-HF and guidelines. One-year heart failure hospitalization was higher (12% and 17% vs. 12%) and all-cause mortality lower (5.3% and 6.5% vs. 7.7%) in registry eligible patients compared to the enalapril arm of PARADIGM-HF.

CONCLUSIONS

Among outpatients with HFrEF in the ESC-EORP-HFA HF-LT Registry, 84% met label criteria, while only 12% and 28% met PARADIGM-HF and guideline criteria for LCZ696 if requiring ≥ 20 mg and ≥ 10 mg enalapril, respectively. Registry patients eligible for LCZ696 had greater heart failure hospitalization but lower mortality rates than the PARADIGM-HF enalapril group.

Prognostic impact of Framingham heart failure criteria in heart failure with preserved ejection fraction

AIMS

This study aims to assess prognostic impact of Framingham criteria for heart failure (FC-HF) in patients with stable heart failure (HF) with preserved ejection fraction (HFpEF).

METHODS AND RESULTS

In the prospective Karolinska-Rennes (KaRen) study, we assessed stable HFpEF patients after an acute HF episode. We evaluated associations between the four descriptive models of HFpEF and the composite endpoint of all-cause mortality and HF hospitalization. The descriptive models were FC-HF alone, FC-HF + natriuretic peptides (NPs) according to the PARAGON trial, FC-HF + NPs + echocardiographic HFpEF criteria according to European Society of Cardiology HF guidelines, and FC-HF + NPs + echocardiographic criteria according to the PARAGON trial. Out of the 539 patients enrolled in KaRen, 438 returned for the stable state revisit after 4-8 weeks, 13 (2.4%) patients died before the planned follow-up, and 88 patients (16%) declined or were unable to return. Three hundred ninety-nine patients have FC registered at follow-up, and among these, the four descriptive models were met in 107 (27%), 82 (22%), 61 (21%), and 69 (22%) patients, and not met in 292 (73%). The 107 patients that had FC-HF at stable state (descriptive model 1) could also be part of the other models because all patients in models 1-4 had to fulfil the FC-HF. The patients in model 0 did not fulfil the criteria for FC-HF but could have single FC. Of single FC, only pleural effusion predicted the endpoint [hazard ratio (HR) 3.38, 95% confidence interval (CI) 1.47-7.76, P = 0.004]. Patients without FC-HF had better prognosis than patients meeting FC-HF. The unadjusted associations between the four HFpEF descriptive models and the endpoint were HR 1.54, 95% CI 1.14-2.09, P = 0.005; HR 1.71, 95% CI 1.24-2.36, P = 0.002; HR 1.95, 95% CI 1.36-2.81, P = 0.001; and HR 2.05, 95% CI 1.45-2.91, P < 0.001, for descriptive models 1-4, respectively. No descriptive model independently predicted the endpoint.

CONCLUSIONS

In ambulatory HFpEF patients, a quarter met FC-HF, while most met NP and echocardiography criteria for HF. Residual FC-HF tended to be associated with increased risk for mortality and HF hospitalization, further strengthened by NPs and echocardiographic criteria, highlighting its role in clinical risk assessment.