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Pandhi P, Streng KW, Anker SD, Cleland JG, Damman K, Dickstein K, Pellicori P, Lang CC, Ng L, Samani NJ, Zannad F, Metra M, Rossignol P, Filippatos G, van Veldhuisen DJ, Voors AA, Ter Maaten JM. The value of spot urinary creatinine as a marker of muscle wasting in patients with new-onset or worsening heart failure. J Cachexia Sarcopenia Muscle 2021; 12:555-567. [PMID: 33742549 PMCID: PMC8200450 DOI: 10.1002/jcsm.12690] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 12/07/2020] [Accepted: 02/01/2021] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Muscle wasting and unintentional weight loss (cachexia) have been associated with worse outcomes in heart failure (HF), but timely identification of these adverse phenomena is difficult. Spot urinary creatinine may be an easily accessible marker to assess muscle loss and cachexia. This study investigated the association of urinary creatinine with body composition changes and outcomes in patients with new-onset or worsening HF (WHF). METHODS In BIOSTAT-CHF, baseline spot urinary creatinine measurements were available in 2315 patients with new-onset or WHF in an international cohort (index cohort) and a validation cohort of 1431 similar patients from Scotland. RESULTS Median spot urinary creatinine concentrations were 5.2 [2.7-9.6] mmol/L in the index cohort. Median age was 69 ± 12 years and 73% were men. Lower spot urinary creatinine was associated with older age, lower height and weight, worse renal function, more severe HF, and a higher risk of >5% weight loss from baseline to 9 months (odds ratio = 1.23, 95% CI = 1.09-1.39 per log decrease; P = 0.001). Spot urinary creatinine was associated with Evans criteria of cachexia (OR = 1.26 per log decrease, 95% CI = 1.04-1.49; P = 0.016) and clustered with markers of heart failure severity in hierarchical cluster analyses. Lower urinary creatinine was associated with poorer exercise capacity and quality of life (both P < 0.001) and predicted a higher rate for all-cause mortality [hazard ratio (HR) = 1.27, 95% CI = 1.17-1.38 per log decrease; P < 0.001] and the combined endpoints HF hospitalization or all-cause mortality (HR = 1.23, 95% CI = 1.15-1.31 per log decrease; P < 0.001). Significance was lost after addition of the BIOSTAT risk model. Analyses of the validation cohort yielded similar findings. CONCLUSIONS Lower spot urinary creatinine is associated with smaller body dimensions, renal dysfunction, and more severe HF in patients with new-onset/WHF. Additionally, lower spot urinary creatinine is associated with an increased risk of weight loss and a poorer exercise capacity/quality of life. Urinary creatinine could therefore be a novel, easily obtainable marker to assess (risk of) muscle wasting in HF patients.
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund LH, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Cosedis Nielsen J, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Optimized implementation of cardiac resynchronization therapy: a call for action for referral and optimization of care: A joint position statement from the Heart Failure Association (HFA), European Heart Rhythm Association (EHRA), and European Association of Cardiovascular Imaging (EACVI) of the European Society of Cardiology. Eur J Heart Fail 2021; 22:2349-2369. [PMID: 33136300 DOI: 10.1002/ejhf.2046] [Citation(s) in RCA: 100] [Impact Index Per Article: 33.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/29/2020] [Revised: 10/28/2020] [Accepted: 10/29/2020] [Indexed: 12/28/2022] Open
Abstract
Cardiac resynchronization therapy (CRT) is one of the most effective therapies for heart failure with reduced ejection fraction and leads to improved quality of life, reductions in heart failure hospitalization rates and all-cause mortality. Nevertheless, up to two-thirds of eligible patients are not referred for CRT. Furthermore, post-implantation follow-up is often fragmented and suboptimal, hampering the potential maximal treatment effect. This joint position statement from three European Society of Cardiology Associations, Heart Failure Association (HFA), European Heart Rhythm Association (EHRA) and European Association of Cardiovascular Imaging (EACVI), focuses on optimized implementation of CRT. We offer theoretical and practical strategies to achieve more comprehensive CRT referral and post-procedural care by focusing on four actionable domains: (i) overcoming CRT under-utilization, (ii) better understanding of pre-implant characteristics, (iii) abandoning the term 'non-response' and replacing this by the concept of disease modification, and (iv) implementing a dedicated post-implant CRT care pathway.
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Kobayashi M, Voors AA, Ouwerkerk W, Duarte K, Girerd N, Rossignol P, Metra M, Lang CC, Ng LL, Filippatos G, Dickstein K, van Veldhuisen DJ, Zannad F, Ferreira JP. Perceived risk profile and treatment optimization in heart failure: an analysis from BIOlogy Study to TAilored Treatment in chronic heart failure. Clin Cardiol 2021; 44:780-788. [PMID: 33960439 PMCID: PMC8207977 DOI: 10.1002/clc.23576] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2020] [Revised: 01/07/2021] [Accepted: 02/08/2021] [Indexed: 12/21/2022] Open
Abstract
Background Achieving target doses of angiotensin‐converting‐enzyme inhibitor/angiotensin‐receptor blockers (ACEi/ARB) and beta‐blockers in heart failure with reduced ejection fraction (HFrEF) is often underperformed. In BIOlogy Study to TAilored Treatment in chronic heart failure (BIOSTAT‐CHF) study, many patients were not up‐titrated for which no clear reason was reported. Therefore, we hypothesized that perceived‐risk profile might influence treatment optimization. Methods We studied 2100 patients with HFrEF (LVEF≤40%) to compare the clinical characteristics and adverse events associated with treatment up‐titration (after a 3‐month titration protocol) between; a) patients not reaching target doses for unclear reason; b) patients not reaching target doses due to symptoms and/or side effects; c) patients reaching target doses. Results For ACEi/ARB, (a), (b) and (c) was observed in 51.3%, 25.9% and 22.7% of patients, respectively. For beta‐blockers, (a), (b) and (c) was observed in 67.5%, 20.2% and 12.3% of patients, respectively. By multinomial logistic regression analysis for ACEi/ARB, patients in group (a) and (b) had lower blood pressure and poorer renal function, and patients in group (a) were older and had lower ejection fraction. For beta‐blockers, patients in group (a) and (b) had more severe congestion and lower heart rate. At 9 months, adverse events (i.e., hypotension, bradycardia, renal impairment, and hyperkalemia) occurred similarly among the three groups. Conclusions Patients in whom clinicians did not give a reason why up‐titration was missed were older and had more co‐morbidities. Patients in whom up‐titration was achieved did not have excess adverse events. However, from these observational findings, the pattern of subsequent adverse events among patients in whom up‐titration was missed cannot be determined.
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Ravera A, Santema BT, Sama IE, Meyer S, Lombardi CM, Carubelli V, Ferreira JP, Lang CC, Dickstein K, Anker SD, Samani NJ, Zannad F, van Veldhuisen DJ, Teerlink JR, Metra M, Voors AA. Quality of life in men and women with heart failure: association with outcome, and comparison between the Kansas City Cardiomyopathy Questionnaire and the EuroQol 5 dimensions questionnaire. Eur J Heart Fail 2021; 23:567-577. [PMID: 33728762 PMCID: PMC8252457 DOI: 10.1002/ejhf.2154] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Revised: 03/04/2021] [Accepted: 03/10/2021] [Indexed: 11/21/2022] Open
Abstract
Aims We sought to analyse quality of life (QoL) measures derived from two questionnaires widely used in clinical trials, the Kansas City Cardiomyopathy Questionnaire (KCCQ) and the EuroQoL 5 dimensions (EQ‐5D), and to compare their prognostic value in men and women with heart failure and reduced ejection fraction (HFrEF). Methods and results From the BIOlogy Study to TAilored Treatment in Chronic Heart Failure (BIOSTAT‐CHF) we compared KCCQ and EQ‐5D at baseline and after 9 months in 1276 men and 373 women with new‐onset or worsening symptoms of HFrEF, who were sub‐optimally treated and in whom there was an anticipated up‐titration of guideline‐derived medical therapies. Women had significantly worse baseline QoL (median) as compared with men, both when assessed with KCCQ overall score (KCCQ‐OS, 44 vs. 53, P < 0.001) and EQ‐5D utility score (0.62 vs. 0.73, P < 0.001). QoL improved equally in women and men at follow‐up. All summary measures of QoL were independently associated with all‐cause mortality, with KCCQ‐OS showing the most remarkable association with mortality up to 1 year compared to the EQ‐5D scores (C‐statistic 0.650 for KCCQ‐OS vs. 0.633 and 0.599 for EQ‐5D utility score and EQ‐5D visual analogue scale, respectively). QoL was associated with all outcomes analysed, both in men and women (all P for interaction with sex >0.2). Conclusion Amongst patients with HFrEF, women reported significantly worse QoL than men. QoL was independently associated with subsequent outcome, similarly in men and women. The KCCQ in general, and the KCCQ‐OS in particular, showed the strongest independent association with outcome.
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Gupta P, Voors AA, Patel P, Lane D, Anker SD, Cleland JGF, Dickstein K, Filippatos G, Lang CC, van Veldhuisen DJ, Metra M, Zannad F, Samani NJ, Jones DJL, Squire IB, Ng LL. Non-adherence to heart failure medications predicts clinical outcomes: assessment in a single spot urine sample by liquid chromatography-tandem mass spectrometry (results of a prospective multicentre study). Eur J Heart Fail 2021; 23:1182-1190. [PMID: 33759308 DOI: 10.1002/ejhf.2160] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Revised: 02/13/2021] [Accepted: 03/19/2021] [Indexed: 12/28/2022] Open
Abstract
AIMS Liquid chromatography-mass spectrometry (LC-MS/MS) is an objective new technique to assess non-adherence to medications. We used this method to study the prevalence, predictors and outcomes of non-adherence in patients with heart failure with reduced left ventricular ejection fraction (HFrEF). METHODS AND RESULTS This study included 1296 patients with HFrEF from BIOSTAT-CHF, a study that aimed to optimise guideline-recommended therapies. Angiotensin-converting enzyme inhibitors (ACEi), angiotensin receptor blockers (ARBs), mineralocorticoid receptor antagonists, β-blockers and loop diuretics were measured in a single spot urine sample at 9 months using LC-MS/MS. The relationship between medication non-adherence and the composite endpoint of all-cause death or heart failure hospitalisation, over a median follow-up of 21 months, was evaluated. Non-adherence to at least one prescribed medication was observed in 45.9% of patients. The strongest predictor of non-adherence was non-adherence to any of the other medication classes (P < 0.0005). Regional differences within Europe were observed. On multivariable analyses, non-adherence to ACEi/ARBs and β-blockers was associated with an increased risk of the composite endpoint [hazard ratio (HR) 1.38, 95% confidence interval (CI) 1.09-1.95, P = 0.008 and HR 1.48, 95% CI 1.12-1.96, P = 0.006, respectively). Non-adherence to β-blockers was also associated with an increased risk of death (HR 2.48, 95% CI 1.67-3.68, P < 0.0005). Patients who were non-adherent to loop diuretics were healthier and had a decreased risk of the composite endpoint (HR 0.69, 95% CI 0.51-0.93, P = 0.014). Non-adherence to mineralocorticoid receptor antagonists was not related to any clinical outcome. CONCLUSION Non-adherence to medications, assessed by a single urine test, is common and predicts clinical outcomes in patients with HFrEF.
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Emmens JE, Jia C, Ng LL, van Veldhuisen DJ, Dickstein K, Anker SD, Lang CC, Filippatos G, Cleland JGF, Metra M, Voors AA, de Boer RA, Tietge UJF. Impaired High-Density Lipoprotein Function in Patients With Heart Failure. J Am Heart Assoc 2021; 10:e019123. [PMID: 33870728 PMCID: PMC8200730 DOI: 10.1161/jaha.120.019123] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Background We recently showed that, in patients with heart failure, lower high‐density lipoprotein (HDL) cholesterol concentration was a strong predictor of death or hospitalization for heart failure. In a follow‐up study, we suggested that this association could be partly explained by HDL proteome composition. However, whether the emerging concept of HDL function contributes to the prognosis of patients with heart failure has not been addressed. Methods and Results We measured 3 key protective HDL function metrics, namely, cholesterol efflux, antioxidative capacity, and anti‐inflammatory capacity, at baseline and after 9 months in 446 randomly selected patients with heart failure from BIOSTAT‐CHF (A Systems Biology Study to Tailored Treatment in Chronic Heart Failure). Additionally, the relationship between HDL functionality and HDL proteome composition was determined in 86 patients with heart failure. From baseline to 9 months, HDL cholesterol concentrations were unchanged, but HDL cholesterol efflux and anti‐inflammatory capacity declined (both P<0.001). In contrast, antioxidative capacity increased (P<0.001). Higher HDL cholesterol efflux was associated with lower mortality after adjusting for BIOSTAT‐CHF risk models and log HDL cholesterol (hazard ratio, 0.81; 95% CI, 0.71–0.92; P=0.001). Other functionality measures were not associated with outcome. Several HDL proteins correlated with HDL functionality, mainly with cholesterol efflux. Apolipoprotein A1 emerged as the main protein associated with all 3 HDL functionality measures. Conclusions Better HDL cholesterol efflux at baseline was associated with lower mortality during follow‐up, independent of HDL cholesterol. HDL cholesterol efflux and anti‐inflammatory capacity declined during follow‐up in patients with heart failure. Measures of HDL function may provide clinical information in addition to HDL cholesterol concentration in patients with heart failure.
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Boorsma EM, Ter Maaten JM, Damman K, van Veldhuisen DJ, Dickstein K, Anker SD, Filippatos G, Lang CC, Metra M, Santos K, Voors AA. Dipeptidyl peptidase 3, a marker of the antagonist pathway of the renin-angiotensin-aldosterone system in patients with heart failure. Eur J Heart Fail 2021; 23:947-953. [PMID: 33742751 PMCID: PMC8359955 DOI: 10.1002/ejhf.2158] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 03/12/2021] [Accepted: 03/16/2021] [Indexed: 01/21/2023] Open
Abstract
Aims Recently, dipeptidyl peptidase 3 (DPP3) has been discovered as the peptidase responsible for cleavage of angiotensin (1–7) [Ang (1–7)]. Ang (1–7) is part of the angiotensin‐converting enzyme–Ang (1–7)–Mas pathway which is considered to antagonize the renin–angiotensin–aldosterone system (RAAS). Since DPP3 inhibits the counteracting pathway of the RAAS, we hypothesize that DPP3 might be deleterious in the setting of heart failure. However, no data are available on DPP3 in chronic heart failure. We therefore investigated the clinical characteristics and outcome related to elevated DPP3 concentrations in patients with worsening heart failure. Methods and results Dipeptidyl peptidase 3 was measured in 2156 serum samples of patients with worsening heart failure using luminometric immunoassay (DPP3‐LIA) by 4TEEN4 Pharmaceuticals GmbH, Hennigsdorf, Germany. Predictors of DPP3 levels were selected using multiple linear regression with stepwise backward selection. Median DPP3 concentration was 11.45 ng/mL with a range from 2.8 to 84.9 ng/mL. Patients with higher DPP3 concentrations had higher renin [78.3 (interquartile range, IQR 26.3–227.7) vs. 120.7 IU/mL (IQR 34.74–338.9), P < 0.001, for Q1–3 vs. Q4] and aldosterone [88 (IQR 44–179) vs. 116 IU/mL (IQR 46–241), P < 0.001, for Q1–3 vs. Q4] concentrations. The strongest independent predictors for higher concentration of DPP3 were log‐alanine aminotransferase, log‐total bilirubin, the absence of diabetes, higher osteopontin, fibroblast growth factor‐23 and N‐terminal pro‐B‐type natriuretic peptide concentrations (all P < 0.001). In univariable survival analysis, DPP3 was associated with mortality and the combined endpoint of death or heart failure hospitalization (P < 0.001 for both). After adjustment for confounders, this association was no longer significant. Conclusions In patients with worsening heart failure, DPP3 is a marker of more severe disease with higher RAAS activity. It may be deleterious in heart failure by counteracting the Mas receptor pathway. Procizumab, a specific antibody against DPP3, might be a potential future treatment option for patients with heart failure.
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Woolley RJ, Ceelen D, Ouwerkerk W, Tromp J, Figarska SM, Anker SD, Dickstein K, Filippatos G, Zannad F, Marco M, Ng L, Samani N, van Veldhuisen DJ, Lang C, Lam CS, Voors AA. Machine learning based on biomarker profiles identifies distinct subgroups of heart failure with preserved ejection fraction. Eur J Heart Fail 2021; 23:983-991. [PMID: 33651430 PMCID: PMC8360080 DOI: 10.1002/ejhf.2144] [Citation(s) in RCA: 61] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 11/02/2021] [Accepted: 02/26/2021] [Indexed: 12/17/2022] Open
Abstract
Aims The lack of effective therapies for patients with heart failure with preserved ejection fraction (HFpEF) is often ascribed to the heterogeneity of patients with HFpEF. We aimed to identify distinct pathophysiologic clusters of HFpEF based on circulating biomarkers. Methods and results We performed an unsupervised cluster analysis using 363 biomarkers from 429 patients with HFpEF. Relative differences in expression profiles of the biomarkers between clusters were assessed and used for pathway over‐representation analyses. We identified four distinct patient subgroups based on their biomarker profiles: cluster 1 with the highest prevalence of diabetes mellitus and renal disease; cluster 2 with oldest age and frequent age‐related comorbidities; cluster 3 with youngest age, largest body size, least symptoms and lowest N‐terminal pro‐B‐type natriuretic peptide (NT‐proBNP) levels; and cluster 4 with highest prevalence of ischaemic aetiology, smoking and chronic lung disease, most symptoms, as well as highest NT‐proBNP and troponin levels. Over a median follow‐up of 21 months, the occurrence of death or heart failure hospitalization was highest in clusters 1 and 4 (62.1% and 62.8%, respectively) and lowest in cluster 3 (25.6%). Pathway over‐representation analyses revealed that the biomarker profile of patients in cluster 1 was associated with activation of inflammatory pathways while the biomarker profile of patients in cluster 4 was specifically associated with pathways implicated in cell proliferation regulation and cell survival. Conclusion Unsupervised cluster analysis based on biomarker profiles identified mutually exclusive subgroups of patients with HFpEF with distinct biomarker profiles, clinical characteristics and outcomes, suggesting different underlying pathophysiological pathways.
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Mullens W, Auricchio A, Martens P, Witte K, Cowie MR, Delgado V, Dickstein K, Linde C, Vernooy K, Leyva F, Bauersachs J, Israel CW, Lund L, Donal E, Boriani G, Jaarsma T, Berruezo A, Traykov V, Yousef Z, Kalarus Z, Cosedis Nielsen J, Steffel J, Vardas P, Coats A, Seferovic P, Edvardsen T, Heidbuchel H, Ruschitzka F, Leclercq C. Withdrawn as duplicate: Optimized Implementation of cardiac resynchronization therapy - a call for action for referral and optimization of care. Europace 2021; 25:euab035. [PMID: 33544835 PMCID: PMC11026865 DOI: 10.1093/europace/euab035] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/28/2021] [Indexed: 11/14/2022] Open
Abstract
Ahead of Print article withdrawn by publisher. This article has been withdrawn due to a publisher error that caused the article to be duplicated. The definitive version of this article is published under https://doi.org/10.1093/europace/euaa411.
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Davison BA, Senger S, Sama IE, Koch GG, Mebazaa A, Dickstein K, Samani NJ, Metra M, Anker SD, Cleland JG, Ng LL, Mordi IR, Zannad F, Filippatos GS, Hillege HL, Ponikowski P, van Veldhuisen DJ, Lang CC, van der Meer P, Núñez J, Bayés-Genís A, Edwards C, Voors AA, Cotter G. Is acute heart failure a distinctive disorder? An analysis from BIOSTAT-CHF. Eur J Heart Fail 2021; 23:43-57. [PMID: 33340221 DOI: 10.1002/ejhf.2077] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 11/13/2020] [Accepted: 12/04/2020] [Indexed: 12/13/2022] Open
Abstract
AIMS This retrospective analysis sought to identify markers that might distinguish between acute heart failure (HF) and worsening HF in chronic outpatients. METHODS AND RESULTS The BIOSTAT-CHF index cohort included 2516 patients with new or worsening HF symptoms: 1694 enrolled as inpatients (acute HF) and 822 as outpatients (worsening HF in chronic outpatients). A validation cohort included 935 inpatients and 803 outpatients. Multivariable models were developed in the index cohort using clinical characteristics, routine laboratory values, and proteomics data to examine which factors predict adverse outcomes in both conditions and to determine which factors differ between acute HF and worsening HF in chronic outpatients, validated in the validation cohort. Patients with acute HF had substantially higher morbidity and mortality (6-month mortality was 12.3% for acute HF and 4.7% for worsening HF in chronic outpatients). Multivariable models predicting 180-day mortality and 180-day HF readmission differed substantially between acute HF and worsening HF in chronic outpatients. Carbohydrate antigen 125 was the strongest single biomarker to distinguish acute HF from worsening HF in chronic outpatients, but only yielded a C-index of 0.71. A model including multiple biomarkers and clinical variables achieved a high degree of discrimination with a C-index of 0.913 in the index cohort and 0.901 in the validation cohort. CONCLUSIONS This study identifies different characteristics and predictors of outcome in acute HF patients as compared to outpatients with chronic HF developing worsening HF. The markers identified may be useful in better diagnosing acute HF and may become targets for treatment development.
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Filippatos G, Angermann CE, Cleland JGF, Lam CSP, Dahlström U, Dickstein K, Ertl G, Hassanein M, Hart KW, Lindsell CJ, Perrone SV, Guerin T, Ghadanfar M, Schweizer A, Obergfell A, Collins SP. Global Differences in Characteristics, Precipitants, and Initial Management of Patients Presenting With Acute Heart Failure. JAMA Cardiol 2021; 5:401-410. [PMID: 31913404 DOI: 10.1001/jamacardio.2019.5108] [Citation(s) in RCA: 43] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Importance Acute heart failure (AHF) precipitates millions of hospital admissions worldwide, but previous registries have been country or region specific. Objective To conduct a prospective contemporaneous comparison of AHF presentations, etiologic factors and precipitants, treatments, and in-hospital outcomes among global regions through the International Registry to Assess Medical Practice with Longitudinal Observation for Treatment of Heart Failure (REPORT-HF). Design, Setting, and Participants A total of 18 553 adults were enrolled during a hospitalization for AHF. Patients were recruited from the acute setting in Western Europe (WE), Eastern Europe (EE), Eastern Mediterranean and Africa (EMA), Southeast Asia (SEA), Western Pacific (WP), North America (NA), and Central and South America (CSA). Patients with AHF were approached for consent and excluded only if there was recent participation in a clinical trial. Patients were enrolled from July 23, 2014, to March 24, 2017. Statistical analysis was conducted from April 18 to June 29, 2018; revised analyses occurred between August 6 and 29, 2019. Main Outcomes and Measures Heart failure etiologic factors and precipitants, treatments, and in-hospital outcomes among global regions. Results A total of 18 553 patients were enrolled at 358 sites in 44 countries. The median age was 67.0 years (interquartile range [IQR], 57-77), 11 372 were men (61.3%), 9656 were white (52.0%), 5738 were Asian (30.9%), and 867 were black (4.7%). A history of HF was present in more than 50% of the patients and 40% were known to have a prior left-ventricular ejection fraction lower than 40%. Ischemia was a common AHF precipitant in SEA (596 of 2329 [25.6%]), WP (572 of 3354 [17.1%]), and EMA (364 of 2241 [16.2%]), whereas nonadherence to diet and medications was most common in NA (306 of 1592 [19.2%]). Median time to the first intravenous therapy was 3.0 (IQR, 1.4-5.6) hours in NA; no other region had a median time above 1.2 hours (P < .001). This treatment delay remained after adjusting for severity of illness (P < .001). Intravenous loop diuretics were the most common medication administered in the first 6 hours of AHF management across all regions (65.4%-89.9%). Despite similar initial blood pressure across all regions, inotropic agents were used approximately 3 times more often in SEA, WP, and EE (11.3%-13.5%) compared with NA and WE (3.1%-4.3%) (P < .001). Older age (odds ratio [OR], 1.0; 95% CI, 1.00-1.02), HF etiology (ischemia: OR, 1.65; 95% CI, 1.11-2.44; valvular: OR, 2.10; 95% CI, 1.36-3.25), creatinine level greater than 2.75 mg/dL (OR, 1.85; 95% CI, 0.71-2.40), and chest radiograph signs of congestion (OR, 2.03; 95% CI, 1.39-2.97) were all associated with increased in-hospital mortality. Similarly, younger age (OR, -0.04; 95% CI, -0.05 to -0.02), HF etiology (ischemia: OR, 0.77; 95% CI, 0.26-1.29; valvular: OR, 2.01; 95% CI, 1.38-2.65), creatinine level greater than 2.75 mg/dL (OR, 1.16; 95% CI, 0.31-2.00), and chest radiograph signs of congestion (OR, 1.02; 95% CI, 0.57-1.47) were all associated with increased in-hospital LOS. Conclusions and Relevance Data from REPORT-HF suggest that patients are similar across regions in many respects, but important differences in timing and type of treatment exist, identifying region-specific gaps in medical management that may be associated with patient outcomes.
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Simpson J, Jhund PS, Lund LH, Padmanabhan S, Claggett BL, Shen L, Petrie MC, Abraham WT, Desai AS, Dickstein K, Køber L, Packer M, Rouleau JL, Mueller-Velten G, Solomon SD, Swedberg K, Zile MR, McMurray JJV. Prognostic Models Derived in PARADIGM-HF and Validated in ATMOSPHERE and the Swedish Heart Failure Registry to Predict Mortality and Morbidity in Chronic Heart Failure. JAMA Cardiol 2021; 5:432-441. [PMID: 31995119 DOI: 10.1001/jamacardio.2019.5850] [Citation(s) in RCA: 52] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Importance Accurate prediction of risk of death or hospitalizations in patients with heart failure (HF) may allow physicians to explore how more accurate decisions regarding appropriateness and timing of disease-modifying treatments, advanced therapies, or the need for end-of-life care can be made. Objective To develop and validate a prognostic model for patients with HF. Design, Setting, and Participants Multivariable analyses were performed in a stepwise fashion. Harrell C statistic was used to assess the discriminative ability. The derivation cohort was Prospective Comparison of ARNI With ACEI to Determine Impact on Global Mortality and Morbidity in Heart Failure trial (PARADIGM-HF) participants. The models were validated using the Aliskiren Trial to Minimize Outcomes in Patients with Heart Failure Trial (ATMOSPHERE) study and in the Swedish Heart Failure Registry (SwedeHF). A total of 8399 participants enrolled in PARADIGM-HF. Data were analyzed between June 2016 and June 2018. Main Outcomes and Measures Cardiovascular death, all-cause mortality, and the composite of cardiovascular death or HF hospitalization at both 1 and 2 years. Results Complete baseline clinical data were available for 8011 patients in PARADIGM-HF. The mean (SD) age of participants was 64 (11.4) years, 78.2% were men (n = 6567 of 8399), and 70.6% were New York Heart Association class II (n = 5919 of 8399). During a mean follow-up of 27 months, 1546 patients died, and 2031 had a cardiovascular death or HF hospitalization. The common variables were: male sex, race/ethnicity (black or Asian), region (Central Europe or Latin America), HF duration of more than 5 years, New York Heart Association class III/ IV, left ventricular ejection fraction, diabetes mellitus, β-blocker use at baseline, and allocation to sacubitril/valsartan. Ranked by χ2, N-terminal pro brain natriuretic peptide was the single most powerful independent predictor of each outcome. The C statistic at 1 and 2 years was 0.74 (95% CI, 0.71-0.76) and 0.71 (95% CI, 0.70-0.73) for the primary composite end point, 0.73 (95% CI, 0.71-0.75) and 0.71 (95% CI, 0.69-0.73) for cardiovascular death, and 0.71 (95% CI, 0.69-0.74) and 0.70 (95% CI, 0.67-0.74) for all-cause death, respectively. When validated in ATMOSPHERE, the C statistic at 1 and 2 years was 0.71 (95% CI, 0.69-0.72) and 0.70 (95% CI, 0.68-0.71) for the primary composite end point, 0.71 (95% CI, 0.69-0.74) and 0.70 (95% CI, 0.69-0.72) for cardiovascular death, and 0.71 (95% CI, 0.69-0.74) and 0.70 (95% CI, 0.68-0.72) for all-cause death, respectively. An online calculator was created to allow calculation of an individual's risk (http://www.predict-hf.com). Conclusions and Relevance Predictive models performed well and were developed and externally validated in large cohorts of geographically representative patients, comprehensively characterized with clinical and laboratory data including natriuretic peptides, who were receiving contemporary evidence-based treatment.
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Santema BT, Chan MMY, Tromp J, Dokter M, van der Wal HH, Emmens JE, Takens J, Samani NJ, Ng LL, Lang CC, van der Meer P, Ter Maaten JM, Damman K, Dickstein K, Cleland JG, Zannad F, Anker SD, Metra M, van der Harst P, de Boer RA, van Veldhuisen DJ, Rienstra M, Lam CSP, Voors AA. Correction to: The influence of atrial fibrillation on the levels of NT-proBNP versus GDF-15 in patients with heart failure. Clin Res Cardiol 2020; 110:1351. [PMID: 33141252 PMCID: PMC8318930 DOI: 10.1007/s00392-020-01762-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/02/2022]
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Hall T, Orn S, Zannad F, Rossignol P, Duarte K, Solomon S, Atar D, Agewall S, Dickstein K, Girerd N. The association of smoking to cardiovascular death differs according to age and sex following myocardial infarction complicated by heart failure or left ventricular dysfunction. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1640] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
Smoking is associated with higher morbidity and mortality following myocardial infarction (MI), but reports of the impact on cardiovascular (CV) death in aged and female patients experiencing MI complicated with left ventricular dysfunction or overt heart failure are limited.
Methods
In an individual patient data meta-analysis of high-risk MI patients, the association of smoking to CV death was investigated. Cox proportional hazard models exploring smoking status and risk according to age and sex were performed to study the relationship of smoking to independently adjudicated CV death endpoints.
Results
28,771 patients from the CAPRICORN, EPHESUS, OPTIMAAL and VALIANT trials were assessed. 18,325 (64%) reported smoking (9185 (32%) current and 9051 (32%) past), 2662 (9%) were above ≥80 years and 8607 (30%) were women. Overall, using non-smokers as referent, the association of smoking to CV mortality was neutral (HR=1.07, 0.98 to 1.16, p=0.12 for active smoking and HR=1.10, 1.02 to 1.18, p=0.01 for past smoking). The associations for active and past smokers with outcome, adjusted for age and sex in the overall study sample and according to different age and sex categories, are presented in figure 1. In analyses that included interaction terms, the association for active smokers depended on age and sex; the risk of CV mortality was weakened in women (interaction HR=0.81, 0.69 to 0.96, p=0.01) and older age (interaction HR per 10 years increase=0.88, 0,82 to 0.95, p=0.001). In contrast, the association to CV death for past smokers was not modified by sex or age (p=0.86 and p=0.17 respectively).
Conclusions
The association of smoking to CV death differed according to age and sex in MI complicated with left ventricular dysfunction or overt heart failure. Significant association of active and/or past smoking with increased risk of CV death was mainly observed in the 60–69 years category. The underlying reasons of the lack of association of smoking with outcome in older patients in this specific context should be explored further in future studies.
Figure 1
Funding Acknowledgement
Type of funding source: None
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Normand C, Linde C, Bogale N, Dickstein K. National healthcare expenditure influences CRT implantations- results from CRT Survey II with 11088 patients. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1089] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Abstract
Background
Cardiac Resynchronization Therapy (CRT) reduces morbidity and mortality in selected patients with heart failure (HF) and electrical dyssynchrony. This treatment receives level I recommendations in ESC guidelines from both HFA and EHRA. However, despite these strong recommendations, CRT implantation practice varies greatly in ESC member states.
Purpose
To describe how countries' healthcare expenditure affects CRT implantation practice.
Methods
Between 2015 and 2017, two ESC associations, EHRA and HFA, conducted the CRT Survey II, a survey of CRT implantations in 11,088 patients in 42 ESC member states. We divided these countries into three groups according to their current health expenditure per capita.
Results
The countries with the lowest health care expenditure were more likely to implant CRT in patients who had strong guideline recommendations for implantation such as symptomatic heart failure, LVEF≤35%, sinus rhythm, QRS duration ≥150 ms and LBBB. These countries were also less likely to implant patients with weaker recommendation level such as those with atrial fibrillation, and were more likely to implant CRT in patients hospitalized for HF in the past year or with NYHA functional class III or IV HF.
Conclusions
CRT Survey II has demonstrated a non-uniform delivery of healthcare. Countries with low health care expenditure appear to be reserving CRT therapy for younger patients, those with guideline recommendation level I indications and patients with more severe symptoms of heart failure.
Funding Acknowledgement
Type of funding source: Other. Main funding source(s): The work was supported by the European Heart Rhythm Association; the Heart Failure Association; Biotronik; Boston Scientific; Medtronic; Sorin; St. Jude; Abbott; Bayer; Bristol-Myers Squibb and Servier.
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Hui S, Sharma A, Docherty K, McMurray J, Pitt B, Dickstein K, Pfeffer M, Girerd N, Rossignol P, Ferreira J, Zannad F. Non-fatal cardiovascular events preceding sudden cardiac death in patients with an acute myocardial infarction complicated by heart failure: insights from the High-Risk-Myocardial-Infarction database. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.0927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Sudden cardiac death (SCD) is responsible for 20–40% of mortality following acute myocardial infarction (AMI). The risk of SCD is even higher among patients with AMI complicated by heart failure (HF) (either clinically apparent HF or left ventricular dysfunction). The temporal relationship between an AMI complicated by HF and subsequent SCD and the association of non-fatal cardiovascular (CV) events following AMI with SCD has yet to be described.
Purpose
Among patients with AMI complicated by HF, we evaluated the probability and temporal association of subsequent non-fatal cardiovascular (CV) events (HF hospitalization, recurrent MI, or stroke) and SCD.
Methods
The High-Risk Myocardial Infarction (HRMI) database contains 28,771 patients with signs of HF or reduced LV ejection fraction (<40%) after AMI. Among patients with an AMI complicated by HF, we used adjudicated cause of death from the HRMI Database to identify: 1) the temporal distribution of SCD among patients following an index AMI; 2) the probability of having SCD following a non-fatal CV event following the index AMI.
Results
Median follow-up was 1.9 years. Mean age was 65.0±11.5 years and 70% were male. The incidence of CV death was 7.9 per 100 patient-year [py] and for SCD was 3.1 per 100py (40% of CV deaths). SCD rates were highest in the early period (<90 days) after AMI and decreased over time. Recurrent MI preceded 9.6% of SCD after a median time of 145 days; HF hospitalization preceded 17.0% of SCD after a median 144 days; and stroke preceded 2.7% of SCD after a median of 138 days (vs. non-sudden CV death: MI 46.6% at 1 days, HF hospitalization: 30.9% at 67 days, stroke 12.9% at 9 days). The incidence of SCD preceded by HF hospitalization was significantly higher than SCD without preceding HF hospitalization.
Conclusion
Among patients with AMI complicated by HF, SCD predominantly occurred in the early “high-risk” period after AMI; SCD rates decreased afterwards. Patients with non-fatal HF hospitalizations during follow-up may have a higher subsequent SCD risk. Preventing HF onset after MI may help decreasing SCD.
Proportion of sudden cardiac death
Funding Acknowledgement
Type of funding source: Public Institution(s). Main funding source(s): Lucien Award, McGill University
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Tromp J, Bamadhaj S, Cleland J, Angermann C, Dahlstrom U, Ertl G, Hassanein M, Perrone S, Ghadanfar M, Schweizer A, Obergfell A, Collins S, Filipatos G, Lam C, Dickstein K. Ischemic heart disease is more prevalent in low-income-countries and more often undertreated: data from report-hf. Eur Heart J 2020. [DOI: 10.1093/ehjci/ehaa946.1192] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Abstract
Background
The pathogenic role of ischemic heart disease (IHD) in heart failure is well known. However, little is known about the global differences in the prognostic significance and treatment patterns of IHD in acute heart failure (AHF).
Methods
We prospectively enrolled 18,553 patients with AHF from 44 countries and 365 centers in the REPORT-HF registry. Patients with a history of coronary artery disease, an ischemic etiology of the AHF event or coronary revascularization were classified as IHD. Differences in clinical characteristics, treatment and outcome were analyzed.
Results
Compared to 9,344 (50%) patients without IHD, the 9,189 (50%) patients with IHD were older, more often had a left ventricular ejection fraction [LVEF] <40%, (HFrEF) and decompensated chronic HF (DCHF) and had a greater comorbidity burden. Despite patients from lower-income countries having a higher prevalence of IHD (55% vs. 45% in high-income countries), only 27% of patients with IHD from low-income countries were treated with medicines commonly prescribed for HF (Figure A) compared to 16% of patients with IHD from high income countries. After correction for clinical confounders and medication use, patients with IHD had a shorter “door-to-nitrates and -diuretics time” and worse 1-year mortality (hazard ratio: 1.18, 95% CI: 1.09, 1.27, Figure B) irrespective of geographic region (Pinteraction >0.1). We found a significant interaction for prognosis (Pinteraction <0.001) between IHD and HF diagnosis (DCHF vs. new-onset HF) as well as HF subtype (HFrEF vs. HF with preserved ejection fraction) respectively, such that IHD conveyed worse outcomes in patients with new-onset HF and HFrEF respectively in all world regions.
Conclusion
In this large global contemporary cohort of patients with AHF, IHD was more common in patients from low income countries, conveyed worse 1-year mortality, particularly in patients with new onset HF and patients with HFrEF. Despite worse outcomes, patients in regions with the greatest burden of IHD were more often undertreated.
Funding Acknowledgement
Type of funding source: Private company. Main funding source(s): Novartis
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van der Wal HH, Grote Beverborg N, Dickstein K, Anker SD, Lang CC, Ng LL, van Veldhuisen DJ, Voors AA, van der Meer P. Iron deficiency in worsening heart failure is associated with reduced estimated protein intake, fluid retention, inflammation, and antiplatelet use. Eur Heart J 2020; 40:3616-3625. [PMID: 31556953 PMCID: PMC6868426 DOI: 10.1093/eurheartj/ehz680] [Citation(s) in RCA: 69] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2019] [Revised: 07/04/2019] [Accepted: 09/10/2019] [Indexed: 12/29/2022] Open
Abstract
Aims Iron deficiency (ID) is common in heart failure (HF) patients and negatively impacts symptoms and prognosis. The aetiology of ID in HF is largely unknown. We studied determinants and the biomarker profile of ID in a large international HF cohort. Methods and results We studied 2357 worsening HF patients from the BIOSTAT-CHF cohort. ID was defined as transferrin saturation <20%. Univariable and multivariable logistic regression models were constructed to identify determinants for ID. We measured 92 cardiovascular markers (Olink Cardiovascular III) to establish a biomarker profile of ID. The primary endpoint was the composite of all-cause mortality and first HF rehospitalization. Mean age (±standard deviation) of all patients was 69 ± 12.0 years, 26.1% were female and median N-terminal pro B-type natriuretic peptide levels (+interquartile range) were 4305 (2360–8329) ng/L. Iron deficiency was present in 1453 patients (61.6%), with highest prevalence in females (71.1% vs. 58.3%; P < 0.001). Independent determinants of ID were female sex, lower estimated protein intake, higher heart rate, presence of peripheral oedema and orthopnoea, chronic kidney disease, lower haemoglobin, higher C-reactive protein levels, lower serum albumin levels, and P2Y12 inhibitor use (all P < 0.05). None of these determinants were sex-specific. The biomarker profile of ID largely consisted of pro-inflammatory markers, including paraoxonase 3 (PON3) and tartrate-resistant acid phosphatase type 5. In multivariable Cox proportional hazard regression analyses, ID was associated to worse outcome, independently of predictors of ID (hazard ratio 1.25, 95% confidence interval 1.06–1.46; P = 0.007). Conclusion Our data suggest that the aetiology of ID in worsening HF is complex, multifactorial and seems to consist of a combination of reduced iron uptake (malnutrition, fluid overload), impaired iron storage (inflammation, chronic kidney disease), and iron loss (antiplatelets). ![]()
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Normand C, Linde C, Bogale N, Blomström-Lundqvist C, Auricchio A, Stellbrink C, Witte KK, Mullens W, Sticherling C, Marinskis G, Sciaraffia E, Papiashvili G, Iovev S, Dickstein K. Cardiac resynchronization therapy pacemaker or cardiac resynchronization therapy defibrillator: what determines the choice?-findings from the ESC CRT Survey II. Europace 2020; 21:918-927. [PMID: 31157387 DOI: 10.1093/europace/euz002] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 01/21/2019] [Indexed: 01/18/2023] Open
Abstract
AIMS The decision to implant a cardiac resynchronization therapy pacemaker (CRT-P) or a cardiac resynchronization therapy defibrillator (CRT-D) may be challenging. There are no clear guideline recommendations as no randomized study of cardiac resynchronization therapy (CRT) has been designed to compare the effects of CRT-P with those of CRT-D on patients' outcomes. In the CRT Survey II, we studied patient and implantation centre characteristics associated with the choice of CRT-P vs. CRT-D. METHODS AND RESULTS Clinical practice data from 10 692 patients undergoing CRT implantation of whom 7467 (70%) patients received a CRT-D and 3225 (30%) received a CRT-P across 42 ESC countries were collected and analysed between October 2015 and January 2017. Factors favouring the selection of CRT-P implantation included age >75 years, female gender, non-ischaemic heart failure (HF) aetiology, New York Heart Association functional Class III/IV symptoms, left ventricular ejection fraction >25%, atrial fibrillation, atrioventricular (AV) block II/III, and implantation in a university hospital. CONCLUSION In a large cohort from the CRT Survey II, we found that patients allocated to receive CRT-P exhibited particular phenotypes with more symptomatic HF, more frequent comorbidities, advanced age, female gender, non-ischaemic HF aetiology, atrial fibrillation, and evidence of AV block. There were substantial differences in the proportion of patients allocated to receive CRT-P vs. CRT-D between countries.
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Ferreira JP, Ouwerkerk W, Santema BT, van Veldhuisen DJ, Lang CC, Ng LL, Anker SD, Dickstein K, Metra M, Cleland JGF, Nilesh SJ, Filippatos G, Aboumsallem JP, de Boer RA, Figarska S, Sama IE, Voors AA, Zannad F. Differences in biomarkers and molecular pathways according to age for patients with HFrEF. Cardiovasc Res 2020; 117:2228-2236. [DOI: 10.1093/cvr/cvaa279] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Revised: 08/21/2020] [Accepted: 09/17/2020] [Indexed: 12/14/2022] Open
Abstract
Abstract
Aims
Elderly patients with heart failure with reduced ejection fraction (HFrEF) have worse prognosis and less often receive guideline-recommended therapies. We aim to better understand the underlying pathophysiological processes associated with ageing in HFrEF potentially leading to targeted therapies in this vulnerable population.
Methods and results
From a panel of 363 cardiovascular biomarkers available in 1611 patients with HFrEF in the BIOSTAT-CHF index cohort and cross-validated in 823 patients in the BIOSTAT-CHF validation cohort, we tested which biomarkers were dysregulated in patients aged >75 vs. <65 years. Second, pathway overrepresentation analyses were performed to identify biological pathways linked to higher plasma concentrations of biomarkers in elderly vs. younger patients. After adjustment, multiple test correction [false discovery rate (FDR) 1%], and cross-validation, 27/363 biomarkers were associated with older age, 22 positively and 5 negatively. The biomarkers that were positively associated with older age were associated with tumour cell regulation, extra-cellular matrix organization, and inflammatory processes, whereas biomarkers negatively associated with older age were associated with pathways that may point to cell proliferation and tumourigenesis. Among the 27 biomarkers, WFDC2 (WAP four-disulphide core domain protein 2)—that broadly functions as a protease inhibitor—was associated with older age and had the strongest association with all outcomes. No protein-by-sex interaction was observed.
Conclusions
In elderly HFrEF patients, pathways associated with extra-cellular matrix organization, inflammatory processes, and tumour cell regulation were activated, while pathways associated with tumour proliferation functions were down-regulated. These findings may help in a better understanding of the ageing processes in HFrEF and identify potential therapeutic targets.
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Gauthey A, Willems R, Vandekerckhove Y, Mullens W, Stefan L, Carryn X, Blommaert D, Mairesse G, Dickstein K, Normand C, Linde C, Le Polain de Waroux JB. Benchmarking Belgian CRT practice against the rest of Europe: insights from the ESC-CRT survey II. Acta Cardiol 2020; 75:492-496. [PMID: 31190617 DOI: 10.1080/00015385.2019.1621455] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This subanalysis of the Euro-CRT survey II specifically focus on Belgian practice for CRT implantation. It explores Belgian adherence with the guidelines but also benchmark CRT practice in Belgium against the other European countries. Overall, Belgian management of CRT implantation is performed with great agreement with guidelines. This report could be used to provide guidance for both practical and economical approaches.
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Kristensen SL, Castagno D, Shen L, Jhund PS, Docherty KF, Rørth R, Abraham WT, Desai AS, Dickstein K, Rouleau JL, Zile MR, Swedberg K, Packer M, Solomon SD, Køber L, McMurray JJV. Prevalence and incidence of intra-ventricular conduction delays and outcomes in patients with heart failure and reduced ejection fraction: insights from PARADIGM-HF and ATMOSPHERE. Eur J Heart Fail 2020; 22:2370-2379. [PMID: 32720404 DOI: 10.1002/ejhf.1972] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Revised: 07/16/2020] [Accepted: 07/17/2020] [Indexed: 11/08/2022] Open
Abstract
AIMS The importance of intra-ventricular conduction delay (IVCD), the incidence of new IVCD and its relationship to outcomes in heart failure and reduced ejection fraction (HFrEF) are not well studied. We addressed these questions in the PARADIGM-HF and ATMOSPHERE trials. METHODS AND RESULTS The risk of the primary composite outcome of cardiovascular death or heart failure hospitalization and all-cause mortality were estimated by use of Cox regression according to baseline QRS duration and morphology in 11 861 patients without an intracardiac device. At baseline, 1789 (15.1%) patients had left bundle branch block (LBBB), 524 (4.4%) right bundle branch block (RBBB), 454 (3.8%) non-specific IVCD, 2588 (21.8%) 'mildly abnormal' QRS (110-129 ms) and 6506 (54.9%) QRS <110 ms. During a median follow-up of 2.5 years, the risk of the primary composite endpoint was higher among those with a wide QRS, irrespective of morphology: hazard ratios (95% confidence interval) LBBB 1.36 (1.23-1.50), RBBB 1.54 (1.31-1.79), non-specific IVCD 1.65 (1.40-1.94) and QRS 110-129 ms 1.35 (1.23-1.47), compared with QRS duration <110 ms. A total of 1234 (15.6%) patients developed new-onset QRS widening ≥130 ms (6.1 per 100 patient-years). Incident LBBB occurred in 495 (6.3%) patients (2.4 per 100 patient-years) and was associated with a higher risk of the primary composite outcome [hazard ratio 1.42 (1.12-1.82)]. CONCLUSION In patients with HFrEF, a wide QRS was associated with worse clinical outcomes irrespective of morphology. The annual incidence of new-onset LBBB was around 2.5%, and associated with a higher risk of adverse outcomes, highlighting the importance of repeat electrocardiogram review. TRIAL REGISTRATION ClinicalTrials.gov Identifier NCT0083658 (ATMOSPHERE) and NCT01035255 (PARADIGM-HF).
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Botto GL, Gasparini M, Brasca FMA, Casale MC, Occhetta E, Racheli M, Bertaglia M, Zanon F, Zardini M, Rapacciuolo A, Mascioli G, Curnis A, Metra M, Normand C, Dickstein K, Linde C. Second European Society of Cardiology Cardiac Resynchronization Therapy Survey: the Italian cohort. J Cardiovasc Med (Hagerstown) 2020; 21:634-640. [PMID: 32740496 DOI: 10.2459/jcm.0000000000001035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
AIM Adherence to guidelines was not homogeneous in Europe, according to the survey on cardiac resynchronization therapy conducted in 2008-2009. The aim of our study was to compare the results in the Italian and European cohorts of the Second European Cardiac Resynchronization Therapy Survey. METHODS Patients' characteristics, procedural data and follow-up were collected. Italian records were compared with European countries. RESULTS Italian hospitals enrolled 526 patients. The italian cohort was older (71.6 ± 9.5 vs. 68.4 ± 10.8; P < 0.00001), had less severe NYHA class (>II 47.2 vs. 59.6%; P < 0.00001), higher ejection fraction (30.3 ± 7.4 vs. 28.4 ± 8.2%; P < 0.00001), and less atrial fibrillation prevalence (34.4 vs. 41.2%; P = 0.00197) than the European cohort. Italian patients were more frequently hospitalized for heart failure in the previous year (51.9 vs. 46.2%; P = 0.01118) and had lower mean QRS duration (151 ± 26 vs. 157 ± 27 ms; P < 0.0001). CRT-D were more often implanted in Italian patients (79.3 vs. 69.3%; P < 0.00001). The complication rate was similar (4.6% vs. 5.6%; ns). The rate of use of ACEi/ARBs in Italy was lower than in Europe (77.2 vs. 86.9%; P < 0.00001). Patients were followed up in the implantation centre (92.1 vs. 86%; P = 0.00014), but rarely with remote monitoring (25.9 vs. 30%; P = 0.04792). CONCLUSION The survey demonstrates important similarities as well as substantial differences regarding most of the aspects evaluated. Efforts to implement adherence to guidelines will be endorsed in Italy.
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Hui SK, Sharma A, Docherty K, McMurray JJV, Pitt B, Dickstein K, Pfeffer MA, Girerd N, Rossignol P, Ferreira JP, Zannad F. Non-fatal cardiovascular events preceding sudden cardiac death in patients with an acute myocardial infarction complicated by heart failure: insights from the high-risk myocardial infarction database. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2020; 10:127-131. [PMID: 33620418 DOI: 10.1093/ehjacc/zuaa012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 08/09/2020] [Accepted: 08/16/2020] [Indexed: 11/13/2022]
Abstract
AIMS Among patients with acute myocardial infarction (AMI) complicated by heart failure [HF; clinical HF or left ventricular (LV) systolic dysfunction], we explored the probability of subsequent non-fatal cardiovascular (CV) events and sudden cardiac death (SCD). METHODS AND RESULTS The high-risk myocardial infarction (HRMI) database contains 28 771 patients with signs of HF or reduced LV ejection fraction (<40%) after AMI. We evaluated the temporal association between SCD with preceding non-fatal CV event [HF hospitalization, recurrent myocardial infarction (MI), or stroke]. Median follow-up was 1.9 years. Mean age was 65.0 ± 11.5 years and 70% were male. The incidence of CV death was 7.9 per 100 patient-years and for SCD was 3.1 per patient-years (40% of CV deaths). The incidence of SCD preceded by HF hospitalization was greater than SCD without preceding HF hospitalization (P < 0.05). However, overall, SCD was less likely to be preceded by a non-fatal CV event compared to other causes of death: 9.6% of SCD events were preceded by an MI (vs. 46.6% for non-sudden CV death); 17.0% of SCD events were preceded with an HF hospitalization (vs. 25.4% for non-sudden CV death); and 2.7% of SCD events were preceded by stroke (vs.12.9% for non-sudden CV death). CONCLUSION Among patients with AMI complicated by HF, SCD, compared with other causes of death, was less likely to be preceded by a non-fatal CV event. As patients are less likely to have preceding non-fatal CV events to alert the healthcare team of a possible impending SCD event, additional strategies for risk stratification for SCD are needed.
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Shi C, van der Wal HH, Silljé HHW, Dokter MM, van den Berg F, Huizinga L, Vriesema M, Post J, Anker SD, Cleland JG, Ng LL, Samani NJ, Dickstein K, Zannad F, Lang CC, van Haelst PL, Gietema JA, Metra M, Ameri P, Canepa M, van Veldhuisen DJ, Voors AA, de Boer RA. Tumour biomarkers: association with heart failure outcomes. J Intern Med 2020; 288:207-218. [PMID: 32372544 PMCID: PMC7496322 DOI: 10.1111/joim.13053] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2020] [Revised: 02/18/2020] [Accepted: 02/25/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND There is increasing recognition that heart failure (HF) and cancer are conditions with a number of shared characteristics. OBJECTIVES To explore the association between tumour biomarkers and HF outcomes. METHODS In 2,079 patients of BIOSTAT-CHF cohort, we measured six established tumour biomarkers: CA125, CA15-3, CA19-9, CEA, CYFRA 21-1 and AFP. RESULTS During a median follow-up of 21 months, 555 (27%) patients reached the primary end-point of all-cause mortality. CA125, CYFRA 21-1, CEA and CA19-9 levels were positively correlated with NT-proBNP quartiles (all P < 0.001, P for trend < 0.001) and were, respectively, associated with a hazard ratio of 1.17 (95% CI 1.12-1.23; P < 0.0001), 1.45 (95% CI 1.30-1.61; P < 0.0001), 1.19 (95% CI 1.09-1.30; P = 0.006) and 1.10 (95% CI 1.05-1.16; P < 0.001) for all-cause mortality after correction for BIOSTAT risk model (age, BUN, NT-proBNP, haemoglobin and beta blocker). All tumour biomarkers (except AFP) had significant associations with secondary end-points (composite of all-cause mortality and HF hospitalization, HF hospitalization, cardiovascular (CV) mortality and non-CV mortality). ROC curves showed the AUC of CYFRA 21-1 (0.64) had a noninferior AUC compared with NT-proBNP (0.68) for all-cause mortality (P = 0.08). A combination of CYFRA 21-1 and NT-proBNP (AUC = 0.71) improved the predictive value of the model for all-cause mortality (P = 0.0002 compared with NT-proBNP). CONCLUSIONS Several established tumour biomarkers showed independent associations with indices of severity of HF and independent prognostic value for HF outcomes. This demonstrates that pathophysiological pathways sensed by these tumour biomarkers are also dysregulated in HF.
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