Prediction of functional capacity by the HFA-PEFF score in patients with acute decompensated heart failure with preserved ejection fraction: a post-hoc analysis from the PURSUIT-HFpEF registry

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) is still challenging, and the H2FPEF- and the HFA-PEFF score were proposed as simple and reliable diagnostic tools. We recently reported that the HFA-PEFF score was significantly associated with the composite endpoint of all-cause death and heart failure readmission in patients with acute decompensated HFpEF (Sotomi. Eur J Heart Fail, in press).

Purpose

To investigate the relation whether the HFA-PEFF or H2FPEF score can evaluate functional capacity in patients with HFpEF

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for acute decompensated HFpEF. We performed 6 minute walk (6MW) test and measured NT-proBNP before discharge. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients (age 81±9 years, male gender 45%) hospitalized for acute decompensated HFpEF for the present study. The H2FPEF score was obtained in 588 (77.7%) patients and all patients had ≥2 points. The HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. We divided these patients into 3 groups based on the HFA-PEFF score (score 2 to 4, 5, and 6) or on the H2FPEF score (score 0 to 3, 4 to 5 and 6 to 8). There were a significant difference in NT-pro BNP between 3 groups based on HFA-PEFF score (p=0.01, Table 1), and patients with score 6 had significantly higher NT-proBNP than those with score 2 to 4 (p=0.02). A significant difference was observed in 6MW distance among these groups (p=0.04, Table), and those with score 6 had significantly shorter distance than those with score 2 to 4 (p=0.04). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE, and Kaplan-Meier survival analysis demonstrated that classification of HFA-PEFF score significantly stratified the patients' risk for MACE. On the other hand, there was no significant difference in 6MW distance among 3 groups based on H2FPEF score (p=0.53), and H2FPEF score was not an independent predictor for MCE by the Cox model analysis. Moreover, the lowest H2PEF score group had higher NT-proBNP than other 2 groups (p=0.02)

Conclusions

The HFA-PEFF score predicted functional capacity as well as prognosis in patients hospitalized for HFpEF, while the H2PEF score did not.

Funding Acknowledgement

Type of funding sources: None. Table 1

Reappraising the role of baseline plasma C-reactive protein levels on recurrence after catheter ablation of persistent atrial fibrillation: insight from EARNEST-PVI trial

Background

Subclinical inflammation is an important pathogenesis of developing and sustaining atrial fibrillation (AF). Because AF itself contribute to the inflammatory response, the role of baseline subclinical inflammation on AF recurrence after catheter ablation (CA) remains controversial in patients with persistent AF.

Purpose

To evaluate whether baseline plasma C-reactive protein (CRP) levels, a sensitive marker of inflammation, are associated with AF recurrence following CA.

Methods

The analysis was performed from the EARNEST-PVI trial, a randomized controlled trial designed to assess a CA strategy for persistent AF, which was conducted in the Osaka region of Japan. A total of 441 patients (median age, 67 years; 26% female; 25% long-standing persistent AF) whose plasma CRP levels were measured at baseline were included in this study.

Results

At baseline, a median (interquartile range) of plasma CRP level was 0.10 [0.06–0.19] mg/dl. Plasma CRP levels significantly increased at discharge (0.83 [0.21–1.84] mg/dl, p<0.001) and decreased 1 year after CA (0.10 [0.05–0.20] mg/dl, p=0.040) compared to the baseline value. During the follow-up of 1 year, 115 patients (26%) experienced AF recurrence, and the incidence was significantly higher in 124 patients with low CRP levels at baseline (cut-off ≤0.06 mg/dl) than the other 317 patients (33.9% vs. 23.0%, p=0.017). After adjustment of age, gender, body mass index, long-standing persistent AF, CA strategy, and plasma brain natriuretic peptide levels, low plasma CRP levels was a significant predictor of AF recurrence (hazard ratio, 1.51; 95% confidence interval, 1.02–2.24; p=0.042).

Conclusions

Low plasma CRP levels at baseline predicted AF recurrence in the EARNEST-PVI trial. Reappraising the role of CRP on AF recurrence may be needed in patients with persistent AF.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): Johnson & Johnson KK

Renal function and arrhythmia outcomes in persistent atrial fibrillation patients after catheter ablation: subanalysis of the EARNEST-PVI trial

Background

Atrial fibrillation (AF) reduces the renal function. Renal dysfunction and AF often coexist. Catheter ablation (CA) of persistent AF can maintain a sinus rhythm and may improve the renal function.

Purpose

We sought to elucidate whether the estimated glomerular filtration rate (eGFR) in patients with persistent AF was increased after CA, especially with the presence of an AF recurrence.

Methods

We enrolled 487 persistent AF patients whose eGFR data were available both before and 1-year after the CA out of 512 patients in the EARNEST-PVI trial.

Results

The mean age was 65±9 year and 113 patients (24.8%) had long-standing persistent AF. We compared the eGFR at baseline with that 1-year after the CA. AF recurrences were recognized in 118 patients (25.8%). The eGFR was similar between the group without recurrence and that with recurrence at baseline (without AF recurrence vs. with AF recurrence; 63.8±14.3 vs. 62.7±13.6 mL/min/1.73m2, p=0.46). In patients without AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 13 (3.8%), 198 (58.4%), 98 (28.9%), 26 (7.7%), 3 (0.9%), and 1 (0.3%), respectively at baseline. In the patients with AF recurrence, the G1, G2, G3a, G3b, G4, and G5 were 3 (2.5%), 68 (57.8%), 38 (32.2%), 6 (5.1%), 3 (2.5%), and 0 (0%), respectively at baseline. The ΔeGFR was significantly higher in the patients without AF recurrence than in those with AF recurrence (without AF recurrence vs. with AF recurrence; 5.1 [−0.3, 10.8] vs. 3.0 [−3.0, 7.6], p=0.0033). In the patients without AF recurrence, a better eGFR class at 1-year after the CA than in those before the CA was recognized in 75 patients (22.1%), while it was recognized in 19 patients (16.1%) with AF recurrences.

Conclusion

Successful catheter ablation in patients with persistent AF led to a better renal outcome.

Funding Acknowledgement

Type of funding sources: Private company. Main funding source(s): This study was funded by Medtronic, Johnson & Johnson, and Abbott.

The impact of substrate and trigger ablation for reduction of functional mitral regurgitation in patients with persistent atrial fibrillation

Background

Functional mitral regurgitation (FMR) is not uncommon in atrial fibrillation (AF) patients. Left atrial (LA) substrate remodeling and corresponding mitral valve annulus dilation has been reported as the most possible cause of FMR. Percutaneous catheter ablation (CA) is an effective treatment for AF. Although significant FMR could be improved by sinus restoration, patients with mitral regurgitation were more likely to experience recurrent AF post ablation, especially those with significant mitral regurgitation. There is no information available on the efficacy of CA for persistent AF in patients with FMR.

Purpose

The purpose of this study is to investigate the predictors of FMR improvement by CA and to determine the efficacy of substrate and trigger CA for persistent AF in patients with FMR.

Methods

We prospectively studied 512 consecutive patients admitted for persistent AF ablation from the EARNEST-PVI (Prospective Multicenter Randomized Study of Effect of Extensive Ablation on Recurrence in Patients with Persistent Atrial Fibrillation Treated with Pulmonary Vein Isolation) trial.

On admission, enrolled patients were randomly assigned in a 1:1 ratio to pulmonary vein isolation (PVI) or PVI-plus additional ablation (linear ablation or/and CFAE ablation). Of the 512 patients, we studied 94 patients with preoperative echocardiography showing moderate or greater baseline FMR. FMR grades were classified into 5 grades (0/1/2/3/4). The FMR improvement group (FMRI(+)) was defined as a case in which the FMR was improved by two or more grades compared the preoperative echocardiography and the one year follow-up examination.

Results

Of the 94 patients, 42 were in the PVI group and 52 were in the PVI-plus additional ablation group. There were 30 cases in the FMRI(+) group and 64 cases in the FMRI(−) group. There were no significant baseline differences in age, sinus rhythm maintenance, plasma B-type natriuretic peptide (BNP) level, left ventricular diastolic dimension, or left atrium dimension between the FMRI(+) and FMRI(−) groups. AF duration was significantly shorter in the FMRI(+) group than FMRI(−) groups (5.8±9.4 months vs 12.4±15.4 months, p<0.0001). In addition, significantly more additional ablation cases were observed in the FMRI(+) group than in the FMRI(−) group (73.3% vs 46.8%, p=0.016). In multivariate analyses, only additional ablation was an independent predictor of FMRI (odds ratio 0.226 95% CI 0.081–0.626; p=0.004).

Conclusions

Catheter ablation is a valid option for the treatment of AF in patients with functional MR and additional substrate and trigger ablation were the only independent predictor of FMR improvement.

Funding Acknowledgement

Type of funding sources: None.

Differences in quality of life improvement with pulmonary vein isolation alone vs. more extensive ablation of persistent atrial fibrillation: insights from the EARNEST-PVI trial

Background

Improving the quality of life (QoL) is one of the main purposes of catheter ablation (CA) of persistent atrial fibrillation (AF). QoL improvement in persistent AF patients has not been fully clarified. The EARNEST-PVI trial was a multi-center randomized trial comparing clinical outcomes of pulmonary vein isolation (PVI) alone and more intensive ablation in addition to PVI including complex fractionated atrial electrogram (CFAE) and linear ablation (PVI plus).

Purpose

To investigate the QoL change after persistent AF ablation and the differences between the PVI-alone strategy and the PVI plus strategy.

Methods

In the EARNEST-PVI trial, patients with persistent AF who underwent an initial catheter ablation (n=512) were randomly assigned in a 1:1 ratio to either PVI alone or PVI plus. Quality of life was assessed at baseline and at 12 months after ablation for AF using the 36-Item Short Form Health Survey. Scores were also converted to a physical health component summary (PCS), a mental health component summary (MCS) and a role/social component summary (RCS).

Results

In the EARNEST-PVI trial, the PVI alone strategy was associated with higher recurrence rate compared with the PVI plus additional ablation strategy. After excluding 68 patients for whom preoperative or postoperative QoL assessment was not available, 222 patients were evaluated respectively. Overall, significant improvements in PCS (46.2±11.4 to 48.7±11.4]), MCS (50.1±8.8 to 54.3±8.6) and RCS (44.6±13.3 to 48.6±11.3) occurred 12 months after ablation (P<0.001, respectively). Although significant QoL improvement occurred in both PVI alone and PLI plus strategies, the changes in PCS was greater in the PVI-plus than that in PVI-alone (3.5±10.3 vs 1.5±10.6, P=0.04).

Conclusions

Ablation for persistent atrial fibrillation improved both physical and mental quality of life. The PVI-plus strategy showed greater improvement in physical QoL.

Funding Acknowledgement

Type of funding sources: None. QoL improvement

Diverse diaryl sulfide synthesis through consecutive aryne reactions

An efficient method to synthesize diaryl sulfides with structural diversity is disclosed. Demethylative hydrothiolation of aryne intermediates generated from o-iodoaryl triflates with methylthio-substituted o-silylaryl triflates and further aryne reactions afford diverse diaryl sulfides.

Assembly of four modules onto a tetraazide platform by consecutive 1,2,3-triazole formations

Efficient consecutive 1,2,3-triazole formations using multiazide platforms are disclosed. On the basis of unique clickability of the 1-adamantyl azido group, a four-step synthesis of tetrakis(triazole)s was achieved from a tetraazide platform molecule. This method was applied to a convergent synthesis of tetrafunctionalized probes in a modular synthetic manner.

Validation of the HFA-PEFF- and H2FPEF score in Japanese patients with heart failure with preserved ejection fraction

Background

Diagnosing heart failure with preserved ejection fraction (HFpEF) still remains challenging, and simple and reliable diagnostic tools have been required. Recently, novel and evidence-based diagnostic algorithms for HFpEF were proposed, such as H2FPEF score (Circulation. 2018) and HFA-PEFF score (Eur Heart J 2019), and their accuracy was validated in the outside patient group. However, there are regional and ethnic variations in patient characteristics of HFpEF, particularly between Western and Asian countries, and it is not elucidated whether these diagnostic scores are useful in Asian population.

Purpose

To investigate the validity of the HFA-PEFF- and H2FPEF score in Japanese patients with HFpEF.

Methods

We calculated H2FPEF score and the second step of HFA-PEFF score among the registered patients in the PURSUIT-HFpEF (Prospective, Multicenter, Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) study, which is a multicenter registration of patients hospitalized for HFpEF. The obtained scores were compared with the scores of the HFpEF cohort in the previous validation studies. We followed the study patients for median of 360 days (IQR 237–630 days) to observe the major adverse cardiovascular events (MACE; composite of death, heart failure hospitalization and stroke).

Results

We enrolled 757 patients hospitalized for HFpEF between June 2016 and August 2019 for the present study. H2FPEF score was obtained in 588 (77.7%) patients among them. Compared with the HFpEF cohorts in the previously reported sub-analysis of TOPCAT trial, the PURSUIT-HFpEF cohort had lower mean value of HFpEF score (4.0±1.8 points vs. 6.0±2.0 points in Americans or 5.3±1.9 points in Russians). It had significantly higher proportion (40.3%, p<0.001) of patients in the low likelihood of HFpEF category (0–3 points) than the TOPCAT cohorts (8.0% in Americans and 19.6% in Russians).

HFA-PEFF score was obtained in 615 (81.2%) patients, though global longitudinal strain was not available. The mean value of HFA-PEFF score was 5.0±0.8, and all patients had ≥2 points. The proportion of patients in the high likelihood of HFpEF category (5–6 points) was 88.3%, which was significantly higher (p<0.001) than those of the HFpEF cohort from Europe and USA in the previous validation study (Eur J Heart Fail 2019). There was no correlation between H2FPEF score and HFA-PEFF score (R=0.06, p=0.14). Cox proportional hazard model selected HFA-PEFF score as a significant predictor for MACE during follow-up period, whereas H2PEF score was not selected. Kaplan-Meier survival analysis demonstrated that patients with 6 points of HFA-PEFF score had higher incidence rate of MACE than those with ≤5 points (p=0.002).

Conclusion

The HFA-PEFF score could be more useful for the diagnosis and risk stratification for HFpEF than the H2PEF score in the Japanese cohort.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

Triazole formation of phosphinyl alkynes with azides through transient protection of phosphine by copper

An efficient preparation method of functionalized phosphines by copper-catalyzed azide-alkyne cycloaddition (CuAAC) through the transient protection of phosphine from the Staudinger reaction is disclosed. Diverse phosphines were prepared from phosphinyl alkynes and azides by the click reaction at the ethynyl group without damaging the phosphinyl group. Double- and triple-click assemblies of azides were accomplished by triazole formations and robust azaylide formation.

Impact of simple nutrition index on the long-term mortality of acute decompensated heart failure patients with preserved left ventricular ejection fraction: insight from PURSUIT-HFpEF registry

Background

The novel nutrition index; triglyceride (TG) × total cholesterol (TG) × body weight (BW) index (TCBI) has been reported to be an easy and useful predictor for patients with coronary artery disease. However, there is no information available on the prognostic value of TCBI in patients with heart failure with preserved LVEF (HFpEF) who admitted with acute decompensated heart failure (ADHF).

Methods and results

Data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study. PURSUIT-HFpEF study is a prospective multicenter observational study in which collaborating hospitals recorded clinical, echocardiographic, and outcome data of ADHF pts with HFpEF. We enrolled consecutive 757 HFpEF patients who admitted with ADHF from June 2016 to June 2019. TCBI was calculated by the formula; TG × TC × BW / 1000 at the discharge. After we excluded patients with in-hospital death or without sufficient data, we analyzed 419 patients. The primary endpoint was all-cause mortality. During a median follow up period of 1.1 (0.9–1.9) years, 59 patients died. ROC analysis revealed that TCBI at discharge was a fair discriminator for predicting all-cause mortality (AUC 0.676, sensitivity 53%, specificity 78%). Multivariate Cox proportional analysis showed that TCBI (p=0.002) was an independent predictor for all cause death after adjustment with major confounders such as age, gender, NT-proBNP, hemoglobin and serum creatinine level. We divided patients into 4 groups according to quartiles of TCBI. Kaplan-Meier analysis showed a significantly higher risk of all-cause death in relation to the decrease in TCBI.

Conclusion

TCBI, a simple and novel nutrition index, is a useful and strong long-term prognostic indicator in ADHF patients with HFpEF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnositics K.K.; Fuji Film Toyoma Chemical Co. Ltd.

Clinical characteristics and prognostic impact of pulmonary hypertension in heart failure with preserved ejection fraction: the PURSUIT HFpEF study

Background

Heart failure (HF) with preserved ejection fraction (HFpEF) can develop pulmonary hypertension (PH), which can result from pre-capillary PH as well as post-capillary PH. However, the prevalence and clinical significance of pre-capillary component of PH in HFpEF remain unknown.

Purpose

We aimed to investigate prevalence, clinical features, and prognostic impact of pre-capillary and/or post capillary PH associated with HFpEF.

Methods

From the PURSUIT-HFpEF (Prospective Multicenter Observational Study of Patients with Heart Failure with Preserved Ejection Fraction) registry, 204 patients (men: 46%, age: 79±9 years) who were hospitalized with HF and underwent right heart catheterization were divided into 4 groups according to the PH guidelines: non-PH, isolated post-capillary PH (Ipc-PH), pre-capillary PH, and combined pre- and post-capillary PH (Cpc-PH). Patients who had been diagnosed with idiopathic pulmonary arterial hypertension were excluded from the analysis.

Results

The prevalence of PH was 31% (Ipc-PH: 22%, pre-capillary PH: 3%, Cpc-PH: 6%). The prevalence of subcategories of PH was significantly different depending on mean right atrial pressure (RAP) (figure). Echocardiography at discharge showed no significant differences in RV diameter or TAPSE, but smaller LV diameter and higher E/e' in pre-capillary PH and Cpc-PH, which resulted in a higher operant diastolic elastance (Ed). Composite endpoint of all-cause mortality and HF hospitalization at 1 year occurred 13% in non-PH, 25% in Ipc-PH, 49% in pre-capillary PH, and 63% in Cpc-PH, respectively (p=0.001 by log-rank test).

Conclusions

Distinct prevalence of PH was observed in the groups with different RAP levels. Pre-capillary component of PH was associated with impaired LV diastolic function and worse outcomes in HFpEF.

Figure 1

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd

Role of diuretics on long-term mortality may differ in volume status in patients with acute myocardial infarction

Background

Diuretics has been reported to have a potential for an activation of the renin-angiotensin-aldosterone system and the sympathetic nervous system, leading to a possibility of poor clinical outcome in patients with cardiovascular disease. However, few data are available on clinical impact of diuretics on long-term outcome in patients with acute myocardial infarction (AMI) based on plasma volume status.

Methods

To address the issue, a total of 3,416 survived patients with AMI who were registered to a large database of the Osaka Acute Coronary Insufficiency Study (OACIS) were studied. Plasma volume status was assessed with the estimated plasma volume status (ePVS) that was calculated at discharge as follows: actual PV = (1 − hematocrit) × [a + (b × body weight)] (a=1530 in males and a=864 in females, b=41.0 in males and b=47.9 in females); ideal PV = c × body weight (c=39 in males and c=40 in females), and ePVS = [(actual PV − ideal PV)/ideal PV] × 100 (%). Multivariable Cox regression analysis and propensity score matching were performed to account for imbalances in covariates. The endpoint was all-cause of death (ACD) within 5 years.

Results

During a median follow-up period of 855±656 days, 193 patients had ACD. In whole population, there was no significant difference in long-term mortality risk between patients with and without diuretics in both multivariate cox regression model and propensity score matching population. When patients were divided into 2 groups according to ePVS with a median value of 4.2%, 46 and 147 patients had ACD in groups with low ePVS and high ePVS, respectively. Multivariate Cox analysis showed that use of diuretics was independently associated with an increased risk of ACD in low ePVS group, (HR: 2.63, 95% confidence interval [CI]: 1.22–5.63, p=0.01), but not in high ePVS group (HR: 0.70, 95% CI: 0.44–1.10, p=0.12). These observations were consistent in the propensity-score matched cohorts; the 5-year mortality rate was significantly higher in patients with diuretics than those without among low ePVS group (4.7% vs 1.7%, p=0.041), but not among high ePVS group (8.0% vs 10.3%, p=0.247).

Conclusion

Prescription of diuretics at discharge was associated with increased risk of 5-year mortality in patients with AMI without PV expansion, but not with PV expansion. The role of diuretics on long-term mortality may differ in plasma volume status. Therefore, prescription of diuretics after AMI may be considered based on plasma volume status.

Funding Acknowledgement

Type of funding source: None

Prognostic value of nutritional status in patients with heart failure with preserved ejection fraction, with and without atrial fibrillation: insights From PURSUIT-HFpEF Registry

Background

Malnutrition is one of the most important comorbidities among heart failure (HF) patients, and serum cholinesterase (CHE) has been reported to be a prognostic factor in HF patients. On the other hand, atrial fibrillation (AF) is frequently observed in patients with HF with preserved ejection fraction (HFpEF). However, there is little information available on the prognostic value of nutritional status in HFpEF patients, with and without AF. We sought to clarify the prognostic value of CHE in HFpEF with and without AF and compare it with that of other nutrition indices such as gastric nutritional risk index (GNRI), controlling nutritional status (CONUT), and the prognostic nutritional index (PNI).

Methods and results

Patients data were extracted from The Prospective mUlticenteR obServational stUdy of patIenTs with Heart Failure with Preserved Ejection Fraction (PURSUIT HFpEF) study, which is a prospective multicenter observational registry for acute decompensated heart failure patients with left ventricular ejection fraction ≥50% in Osaka. We analyzed 380 patients (median age: 80 [75–87] years, male: 46%) after exclusion of patients with in-hospital death, missing follow-up data, or missing data to calculate nutritional indices. On admission, 155 patients had AF. Laboratory data were obtained at discharge. During a mean follow up period of 1.1±0.6 years, 131 patients had a composite endpoint (CE) of all-cause death and hospitalization for worsening heart failure or cerebrovascular disorder. In multivariate Cox analysis, in patients with AF, CHE was significantly associated with CE independently of age, gender and body mass index after the adjustment with serum albumin, total cholesterol levels and total lymphocyte count, while it was not significantly associated with CE in patients without AF. C-index of CHE (0.708) was higher than that of GNRI (0.555, p=0.0028), CONUT (0.651, p=0.208) and PNI (0.635, p=0.208) in AF patients, while there were no significant differences in those nutritional indices in patients without AF. Kaplan-Meier curve analysis revealed that AF patients with lower CHE (<208 U/L = median value) had higher risk of CE than those with higher CHE (44% vs 18%, adjusted HR 3.26 95% CI [1.66–6.67], p=0.0005), while there was no significant difference in the occurrence rate of CE between patients with and without higher CHE in non-AF group (42% vs 31%, adjusted HR 1.28 95% CI [0.78–2.13], p=0.33).

Conclusions

Prognostic value of CHE would be stronger than other nutritional indices in HFpEF patients with AF, while it would be weak in HFpEF patients without AF.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K.; Fuji Film Toyama Chemical Co. Ltd.

The impact of frailty and aging on prognosis in patients with heart failure with preserved ejection fraction – insights from PURSUIT-HFpEF registry

Introduction

Frailty and aging are two common conditions both associated with increased vulnerability to stressful events with high risk of adverse outcomes.

Purpose

To evaluate the association between frailty and aging and their impacts on clinical outcome in patients with heart failure with preserved ejection fraction (HFpEF).

Methods

Analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 757 patients hospitalized for acute heart failure (diagnosed by using Framingham criteria) met the inclusion criteria: a left ventricular ejection fraction ≥50% and brain natriuretic peptide ≥100pg/ml. We included 483 patients (age, 80±9 years; men, 45%; atrial fibrillation, 35%) whose follow-up data after survival discharge were available. Patients' frailty and aging were evaluated using the clinical frailty scale (CFS) and age quartiles (Q1: <76 years (n=122), Q2: 76–82 years (n=111), Q3: 82–87 years (n=127), Q4: >87 years (n=123)), respectively. The primary clinical endpoint was defined as the composite of death, re-hospitalization for heart failure, and cerebrovascular accident.

Results

The median (interquartile range) CFS rating was 3 (2–5), and there was a little correlation between CFS rating and age (r2=0.16, p<0.001). The prevalence of frailty, defined as a CFS rating >4 (n=132), was positively correlated with age quartiles (Q1: 9.0%, Q2: 21.4%, Q3: 29.9%, Q4: 48.0%, p<0.001). During the median follow-up period 396 days (interquartile range, 344–698) after discharge, the clinical endpoint was observed in 172 patients. The incidence was higher in patients with frailty than those without it (49.6% vs. 30.4%, log-rank p<0.001). It was also correlated with age quartiles (Q1: 23.0%, Q2: 34.2%, Q3: 36.2%, Q4: 48.8%, log-rank p=0.001). Multivariate Cox regression analysis revealed that frailty (hazard ratio, 1.52; 95% confidence interval, 1.09–2.10; p=0.013) and age (hazard ratio per quartile increase, 1.24; 95% confidence interval, 1.07–1.43; p=0.004) were both associated with the clinical endpoint. Subgroup analysis in 352 patients without frailty also revealed the significant impact of age on the endpoint (1.26; 1.06–1.51; p=0.008). However, in 131 patients with frailty, there was no significant impact of age on the endpoint (1.16; 0.90–1.51; p=0.25).

Conclusions

Frailty was common and was associated with aging in HFpEF patients. Although they were both associated with unfavorable events, aging was no longer a significant predictor of adverse outcomes under the frailty conditions.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K. and Fuji Film Toyama Chemical Co. Ltd.

The comparison of clinical significance between atrial and ventricular structural remodeling in patients with heart failure with preserved ejection fraction – insights from PURSUIT-HFpEF registry

Introduction

Structural remodeling is an important aspect of pathophysiology of heart failure (HF). The compensatory mechanism against diastolic dysfunction would be more obvious on the left atrium rather than left ventricle in HF with preserved ejection fraction (HFpEF).

Purpose

To investigate the impact of left atrial (LA) and left ventricular (LV) remodeling on clinical outcomes in HFpEF patients.

Methods

Analysis was performed from a prospective multicenter observational registry for HFpEF (PURSUIT-HFpEF Registry) conducted in the Osaka region of Japan. A total of 757 patients hospitalized for acute HF (diagnosed by using Framingham criteria) met the inclusion criteria: a LV ejection fraction ≥50% and brain natriuretic peptide ≥100pg/ml. We included 381 patients (age, 82±9 years; men, 45%; atrial fibrillation (AF), 34%) whose follow-up data after survival discharge were available and whose LA volume index (LAVI) and left ventricular end-diastolic volume index (LVEDVI) at discharge were measured by the biplane Simpson's method using echocardiography. The primary endpoint was defined as the composite of death, re-hospitalization for HF, and cerebrovascular accident.

Results

The LAVI and LVEDVI at discharge was 54±25 ml/m2 and 55±21 ml/m2, respectively (r2=0.014, p=0.021). When patients were classified into the LAVI tertiles groups (T1: <40ml/m2 (n=124), T2: 41–59ml/m2 (n=127), T3: >60ml/m2 (n=130)), there was a positive correlation between the prevalence of diastolic dysfunction and the LAVI tertiles (T1, 21.0%; T2, 48.8%; T3, 51.5%; p<0.001). On the other hand, significant association was not observed between the prevalence of diastolic dysfunction and the LVEDVI tertile groups (p=0.42). During the median follow-up period of 396 days (IQR, 345–698), the composite endpoint was observed in 131 patients and there was a positive correlation between the endpoint and the LAVI tertiles (T1, 24.2%; T2, 38.6%; T3, 40.3%; p=0.011). On the other hand, no correlation was found between the endpoint and the LVEDVI tertiles (p=0.13). After adjustment for age, gender, and presence of diastolic dysfunction, Cox regression analysis revealed that not LVEDVI but LAVI at discharge was a significant predictor of the composite endpoint in the entire cohort (hazard ratio per 10 ml/m2 increase; 1.09; 95% confidence interval, 1.02–1.16; p=0.009) and in the sinus rhythm subgroup (1.10; 1.01–1.20; p=0.034). However, not LAVI but LVEDVI was a significant predictor for the adverse outcomes in the AF subgroup (1.23; 1.04–1.46; p=0.016).

Conclusions

Increased LAVI at discharge, which was associated with diastolic dysfunction, related to unfavorable prognosis in patients with HFpEF. However, LAVI was no more a predictor for the adverse outcomes but LVEDVI was in the AF subgroup. The clinical significance of atrial and ventricular remodeling may differ between sinus rhythm and AF rhythm in HFpEF population.

Funding Acknowledgement

Type of funding source: Private company. Main funding source(s): Roche Diagnostics K.K. and Fuji Film Toyama Chemical Co. Ltd.

Sex differences in door-to-balloon time and long-term adverse events after percutaneous coronary intervention for acute coronary syndrome: a sub-study from the Prospective JAMIR study

Background

Shortening of onset to admission time (OAT) and door-to-balloon time (DBT) is associated with lower adverse cardiac event after primary percutaneous coronary intervention (PCI) in patients with acute myocardial infarction (AMI). Bleeding event also results in poor outcome in patients with AMI after primary PCI. Little is known about sex differences in DBT and ischemic, bleeding events after AMI.

Purpose

This study aimed to assess the sex differences of OAT, DTB and adverse cardiac event, incident of bleeding event after primary PCI in patients with AMI.

Methods

The Japan AMI Registry (JAMIR) is a multicenter, nationwide, prospective registry enrolling patients with AMI from 50 institutes between December 2015 and May 2017. Primary endpoints of this study were ischemic event (composite of cardiovascular death, myocardial infarction and ischemic stroke) and bleeding event (BARC type 3 or 5,).Median follow-up period was 12 months.

Results

A total of 3,411 patients were enrolled at first. Among them, 329 patients without treated with PCI and 199 patients missing OAT time were excluded from this study. A total 2883 patients of men (n=2240, 77.7%) and women (n=643, 22.3%) were enrolled. OAT and DBT of women were significantly longer than that of men (OAT: 130min, interquartile range 62–300 min vs. 155 min, interquartile range 69–350 min, p=0.040, DBT: 67 min, interquartile range 50–95 min vs. 75 min, interquartile range 53–120 min, p<0.001). There was no significant difference in ischemic events between men and women (7.1% vs. 7.5%, log-rank p=0.741, Figure 1). Multivariate Cox regression analysis showed female sex was significantly associated with lower ischemic event (hazard ratio 0.57; 95% confidence interval 0.38–0.85; p=0.007). Bleeding event of women was significantly higher than that of men (BARC type 3 or 5: 3.8% vs. 7.8%, p<0.001, Figure 2).

Conclusion

The real-world database of the JAMIR showed that the female sex was significant factor for the delay in primary percutaneous coronary intervention and high incident of bleeding, however, ischemic event was lower than that of male sex. Sex difference appears to be associated with ischemic and bleeding event after acute myocardial infarction.

Funding Acknowledgement

Type of funding source: None