Lifestyle Modifications for Preventing and Treating Heart Failure

The Lunch Conference Diet: Fostering Resident Engagement in Culinary Medicine Through a Curriculum Centered on Changes to Provided Conference Food

BACKGROUND

Despite the burden of chronic disease attributable to lifestyle, most internal medicine residents do not receive adequate training in nutrition and nutrition counseling.

METHODS

We held a culinary medicine workshop in September 2018, followed by didactic sessions throughout the academic year. Changes were made to lunch conference food to more closely follow the Mediterranean diet and to encourage healthy eating. With a modified NUTCOMP (Nutrition Competence Questionnaire) instrument, we assesses residents' perceived competence with nutrition counseling before and after the curriculum.

RESULTS

Twenty-six of 30 residents completed the pre-curriculum and post-curriculum surveys (not the same 26). The mean NUTCOMP score increased from 3.5 to 4.0 (P < .0001), indicating an increased perceived competence with nutritional counseling. Residents felt that nutritional counseling was important before and after the curriculum (4.2 to 4.3, P = .48). Conference food was more nutritious at the end of the intervention (Mediterranean diet score range 1-4 to 4-7) and residents enjoyed the food more.

CONCLUSIONS

An innovative, multimodal nutrition curriculum centered on changes to catered lunch conference food improved resident's confidence with nutritional counseling. This could feasibly be integrated into other residency programs with supportive leadership and adequate training.

The Association between Nutritional Status and In-Hospital Mortality among Patients with Heart Failure-A Result of the Retrospective Nutritional Status Heart Study 2 (NSHS2)

BACKGROUND

A nutritional status is related to the prognosis and length of hospitalisation of patients with heart failure (HF). This study aims to assess the effect of nutritional status on in-hospital mortality in patients with heart failure.

METHODS

We conducted a retrospective study and analysis of medical records of 1056 patients admitted to the cardiology department of the University Clinical Hospital in Wroclaw (Poland).

RESULTS

A total of 1056 individuals were included in the analysis. A total of 5.5% of patients died during an in-hospital stay. It was found that in the sample group, 25% of patients who died had a BMI (body mass index) within the normal range, 6% were underweight, 47% were overweight, and 22% were obese. Our results show that non-survivors have a significantly higher nutrition risk screening (NRS) ≥3 (21% vs. 3%; p < 0.001); NYHA (New York Heart Association) grade 4 (70% vs. 24%; p < 0.001). The risk of death was lower in obese patients (HR = 0.51; p = 0.028) and those with LDL (low-density lipoprotein) levels from 116 to <190 mg/dL (HR = 0.10; p = 0.009, compared to those with LDL <55 mg/dL). The risk of death was higher in those with NRS (nutritional risk score) score ≥3 (HR = 2.31; p = 0.014), HFmrEF fraction (HR = 4.69; p < 0.001), and LDL levels > 190 mg/dL (HR = 3.20; p = 0.038).

CONCLUSION

The malnutrition status correlates with an increased risk of death during hospitalisation. Higher TC (total cholesterol) level were related to a lower risk of death, which may indicate the "lipid paradox". Higher BMI results were related to a lower risk of death, which may indicate the "obesity paradox".

Cardiovascular Biomarkers and Heart Failure Risk in Stable Patients With Atherothrombotic Disease: A Nested Biomarker Study From TRA 2°P-TIMI 50

Background

Patients with stable atherothrombotic disease vary in their risk of developing heart failure (HF). Circulating cardiovascular biomarkers may improve HF risk assessment and identify patients who may benefit from emerging HF preventive therapies.

Methods and Results

We measured high‐sensitivity cardiac troponin I and BNP (B‐type natriuretic peptide) in 15 833 patients with prior myocardial infarction, ischemic stroke, or peripheral artery disease from the TRA 2°P‐TIMI 50 (Thrombin Receptor Antagonist in Secondary Prevention of Atherothrombotic Ischemic Events‐Thrombolysis in Myocardial Infarction 50) trial, excluding patients with recent myocardial infarction (<30 days). Biomarkers were categorized using a priori cut points. Hospitalization for HF (HHF) end points were adjudicated with blinded structured review of serious adverse events. Associations between biomarkers and HHF outcomes were adjusted for sex and independent clinical risk predictors of HHF in our cohort (age ≥75, prior HF, type 2 diabetes mellitus, polyvascular disease, body mass index, anemia, chronic kidney disease, hypertension). Baseline high‐sensitivity cardiac troponin I and BNP each identified a significant graded risk of HHF independent of clinical risk predictors, including in the subgroups of patients with and without type 2 diabetes mellitus and with and without prior HF. Patients with both high‐sensitivity cardiac troponin I ≥5 ng/L and BNP ≥100 pg/mL had the highest HHF event rates. When added to a multivariable Cox regression model with clinical risk predictors (C‐index 0.88; 95% CI, 0.85–0.90), BNP (C ‐index 0.92; 95% CI, 0.90–0.93), and high‐sensitivity cardiac troponin I (C‐index 0.90; 95% CI, 0.88–0.92) each significantly improved the prognostic performance of the model (both P_LRT<0.001).

Conclusions

Biomarkers of myocardial injury and hemodynamic stress are independent predictors of HHF risk in patients with stable atherothrombotic disease, with and without prior HF and/or type 2 diabetes mellitus.

Registration

URL: https://www.clinicaltrials.gov; Unique identifier: NCT00526474.

Re-evaluating the causes and consequences of non-resolving inflammation in chronic cardiovascular disease

Cardiac injuries, like heart attacks, drive the secondary pathology with advanced heart failure. In this process, non-resolving inflammation is a prime component of accelerated cardiovascular disease and subsequent fatal events associated with imbalanced diet, physical inactivity, disrupted circadian rhythms, neuro-hormonal stress, and poly- or co-medication. Laboratory rodents have established that splenic leukocyte-directed resolution mechanisms are essential for cardiac repair after injury. Here, we discuss the impact of three lifestyle-related factors that are prime causes of derailed cardiac healing, putative non-resolving inflammation-resolution mechanisms in cardiovascular diseases, and progressive heart failure after cardiac injury. The presented review resurfaces the lifestyle-related risks and future research directions required to understand the molecular and cellular mechanisms between the causes of cardiovascular disease and their related consequences of non-resolving inflammation.

Refocusing on the Primary Prevention of Heart Failure

Purpose of review

The burden of heart failure (HF) is a significant national and global public health problem, with prevalence rates on the rise. Given the significant morbidity, mortality, and healthcare costs attributable to HF, it is of utmost importance to utilize preventive strategies to prevent the development of HF. Therefore, we sought to address how a multi-modal risk assessment approach can be used to stratify patients for HF risk and guide implementation of therapeutic strategies to prevent HF.

Recent findings

New externally validated, multivariate prediction models for incident HF can be applied in the general population and may be used to aide clinicians in assessing individualized HF risk and screening for HF. Recent clinical trial data suggest a natriuretic peptide biomarker-based screening approach coupled with team-based cardiovascular care to focus on optimization of guideline-directed medical therapy may help prevent new-onset HF. However, widespread implementation of clinical risk scores and/or biomarkers is needed.

Summary

In addition to promoting a heart healthy lifestyle, prevention and management of modifiable risk factors, including intensive blood pressure lowering and use of sodium-glucose cotransporter-2 inhibitors, can prevent incident HF.

Associations of the Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay diet with cardiac remodelling in the community: the Framingham Heart Study

Normal cardiac function is directly associated with the maintenance of cerebrovascular health. Whether the Mediterranean-Dietary Approaches to Stop Hypertension Intervention for Neurodegenerative Delay (MIND) diet, designed for the maintenance of neurocognitive health, is associated with cardiac remodelling is unknown. We evaluated 2512 Framingham Offspring Cohort participants who attended the eighth examination cycle and had available dietary and echocardiographic data (mean age 66 years; 55 % women). Using multivariable regression, we related the cumulative MIND diet score (independent variable) to left ventricular (LV) ejection fraction, left atrial emptying fraction, LV mass (LVM), E/e' ratio (dependent variables; primary), global longitudinal strain, global circumferential strain (GCS), mitral annular plane systolic excursion, longitudinal segmental synchrony, LV hypertrophy and aortic root diameter (secondary). Adjusting for age, sex and energy intake, higher cumulative MIND diet scores were associated with lower values of indices of LV diastolic (E/e' ratio: logβ = -0·03) and systolic function (GCS: β = -0·04) and with higher values of LVM (logβ = 0·02), all P ≤ 0·01. We observed effect modification by age in the association between the cumulative MIND diet score and GCS. When we further adjusted for clinical risk factors, the associations of the cumulative MIND diet score with GCS in participants ≥66 years (β = -0·06, P = 0·005) and LVM remained significant. In our community-based sample, relations between the cumulative MIND diet score and cardiac remodelling differ among indices of LV structure and function. Our results suggest that favourable associations between a higher cumulative MIND diet score and indices of LV function may be influenced by cardiometabolic and lifestyle risk factors.

Remote monitoring for heart failure management during COVID-19 pandemic

Background

COVID-19 pandemic impacted on heart failure patients’ lifestyle and quality of life, affecting both physical activity levels and state of health.

Methods

Demographic data and device records were extracted for patients with heart failure in the 16 weeks at the turn of lockdown during pandemic. To explore the variability across the lockdown period, a week-to-week analysis was performed. Patients were interviewed to investigate physical activity and psychological insights. The primary endpoint was the variation in physical activity at the turn of lockdown.

Results

At our facility, 2225 patients implanted with a cardiac device were screened and data were collected for 211 patients fulfilling the inclusion criteria. Patients’ physical activity significantly decreased in the lockdown period compared with the control period (active time per day 8.0% vs. 10.8%; relative reduction [RRR] 25.9%; p < 0.0001). A small decrease was noted for mean heart rate (70.1 vs. 71.7 beats per minute [bpm]; RRR 2.2%; p < 0.0001), while thoracic impedance slightly increased (82.2 vs. 82.7 ohm; RRR 0.6%; p = 0.001). Patients’ physical activity decreased from week 7 to week 11 (10.9% vs. 6.9%; RRR 36.7%; P < 0.0001) with an increase between week 11 and week 16 (6.9% vs. 8.5%; RRR 18.8%; P < 0.0001). Patients’ perceptions about physical activity showed a very low correlation with remote monitoring-assessed physical activity levels (r² = 0.035, p = 0.039).

Conclusions

Telemedicine and remote monitoring can explore the impact of COVID-19 pandemic on vital signs and physical activity levels of heart failure patients, playing a crucial role in the prediction of heart failure worsening during circumstances discouraging outpatient visits.

The Longitudinal Assessment of Neuropsychiatric Symptoms in Mild Cognitive Impairment and Alzheimer's Disease and Their Association With White Matter Hyperintensities in the National Alzheimer's Coordinating Center's Uniform Data Set

BACKGROUND

Neuropsychiatric symptoms (NPSs) are common in Alzheimer's disease (AD). NPSs contribute to patients' distress, caregiver burden, and institutionalization. White matter hyperintensities (WMHs) appear on magnetic resonance imaging, usually indicative of cerebrovascular disease. WMHs have been associated with certain NPSs. We aimed to assess the relationship between WMH and NPS severity in mild cognitive impairment (MCI) due to AD (MCI-AD) and in AD and to assess the ability of WMHs to predict NPS progression. Data were obtained from the National Alzheimer's Coordinating Center.

METHODS

A total of 252 participants (114 with MCI-AD and 138 with AD) were used in this study. Baseline WMHs were quantified using an automated segmentation technique. NPSs were measured using the Neuropsychiatric Inventory. Mixed-effect models and correlations were used to determine the relationship between WMHs and NPSs.

RESULTS

Longitudinal mixed-effect models revealed a significant relationship between increase in Neuropsychiatric Inventory total scores and baseline WMHs (p = .014). There was a significant relationship between baseline WMHs and an increase in delusions (p = .023), hallucinations (p = .040), agitation (p = .093), depression (p = .017), and irritability (p = .002). Correlation plot analysis showed that baseline whole-brain WMHs predicted change in future Neuropsychiatric Inventory total scores (r = .169, p = .008) and predicted change in future agitation severity scores (r = .165, p = .009). WMHs in the temporal lobes (r = .169, p = .008) and frontal lobes (r = .153, p = .016) contributed most to this change.

CONCLUSIONS

Depression, irritability, and agitation are common NPSs and very distressful to patients and caregivers. Our findings of increased NPS severity over time in MCI-AD and AD with increased WMHs have important implications for treatment, arguing for aggressive treatment of vascular risk factors in patients with MCI-AD or AD.

Psychological stress in heart failure: a potentially actionable disease modifier

Psychological stress is common in patients with heart failure, due in part to the complexities of effective disease self-management and progressively worsening functional limitations, including frequent symptom exacerbations and hospitalizations. Emerging evidence suggests that heart failure patients who experience higher levels of stress may have a more burdensome disease course, with diminished quality of life and increased risk for adverse events, and that multiple behavioral and pathophysiological pathways are involved. Furthermore, the reduced quality of life associated with heart failure can serve as a life stressor for many patients. The purpose of this review is to summarize the current state of the science concerning psychological stress in patients with heart failure and to discuss potential pathways responsible for the observed effects. Key knowledge gaps are also outlined, including the need to understand patterns of exposure to various heart failure-related and daily life stressors and their associated effects on heart failure symptoms and pathophysiology, to identify patient subgroups at increased risk for stress exposure and disease-related consequences, and the effect of stress specifically for patients who have heart failure with preserved ejection fraction. Stress is a potentially modifiable factor, and addressing these gaps and advancing the science of stress in heart failure is likely to yield important insights about actionable pathways for improving patient quality of life and outcomes.

COVID-19 and the Case for Medical Management and Primary Care

Hospitals and health systems suffer an over-reliance on elective surgeries to remain profitable. As a result, systems report record losses, while demand for emergency room, hospital, and intensive care beds have surged. Studies have admitted that many surgeries are unnecessary, and physician leaders admit that profit plays a role in driving such needless cost and risk. Most diseases are better managed with medications and lifestyle changes. But it pays more to replace a knee than to prevent that replacement. We must bring surgical and medical value closer in-line. Communities of color are suffering disproportionately from coronavirus. The social determinants of health that lead to higher concentrations of hypertension and diabetes can be mitigated by investment in primary care. Such investment has been proven to decrease cost and increase quality of life. However, the United States spends 50% less on primary care, than other developed countries. While showing promise, telehealth is not a panacea. It relies on continued reimbursement parity, and there remains a digital divide. Any meaningful fix will draw the ire from those who profit from such a profligate system. If we want to improve quality, access and equity, while avoiding unnecessary hospitalizations, risky surgeries, and runaway costs, we must invest in primary care.

A Mediterranean Dietary Pattern Predicts Better Sleep Quality in US Women from the American Heart Association Go Red for Women Strategically Focused Research Network

Consumption of a Mediterranean diet has been linked to better sleep health in older, European populations. However, whether this dietary pattern is predictive of sleep quality in US women, a group prone to poor sleep, is unknown. This prospective cohort study of 432 US women (20–76 y; 60% racial/ethnic minority) evaluated whether compliance with a Mediterranean diet at baseline predicted sleep quality at 1-y follow-up. Alternate Mediterranean (aMed) diet scores and habitual sleep quality were computed from the validated Block Brief Food Frequency Questionnaire and Pittsburgh Sleep Quality Index (PSQI), respectively. Linear regression models evaluated prospective associations of the aMed diet pattern and its components with measures of sleep quality, after adjustment for age, BMI, race/ethnicity, education, and health insurance status. Higher baseline aMed scores were associated with lower PSQI scores (β = −0.30 ± 0.10, p < 0.01), indicative of better sleep quality, higher sleep efficiency (β = 1.20 ± 0.35, p < 0.001), and fewer sleep disturbances (β = −0.30 ± 0.12, p = 0.01) at 1-y. Fruit and vegetable consumption also predicted lower PSQI scores, higher sleep efficiency and fewer sleep disturbances (all p < 0.05). Higher legume intake predicted better sleep efficiency (β = 1.36 ± 0.55, p = 0.01). These findings suggest that adherence to a Mediterranean diet pattern should be evaluated as a strategy to promote sleep quality in US women.

Mechanistic Insights into the Oxidized Low-Density Lipoprotein-Induced Atherosclerosis

Dyslipidaemia has a prominent role in the onset of notorious atherosclerosis, a disease of medium to large arteries. Atherosclerosis is the prime root of cardiovascular events contributing to the most considerable number of morbidity and mortality worldwide. Factors like cellular senescence, genetics, clonal haematopoiesis, sedentary lifestyle-induced obesity, or diabetes mellitus upsurge the tendency of atherosclerosis and are foremost pioneers to definitive transience. Accumulation of oxidized low-density lipoproteins (Ox-LDLs) in the tunica intima triggers the onset of this disease. In the later period of progression, the build-up plaques rupture ensuing thrombosis (completely blocking the blood flow), causing myocardial infarction, stroke, and heart attack, all of which are common atherosclerotic cardiovascular events today. The underlying mechanism is very well elucidated in literature but the therapeutic measures remains to be unleashed. Researchers tussle to demonstrate a clear understanding of treating mechanisms. A century of research suggests that lowering LDL, statin-mediated treatment, HDL, and lipid-profile management should be of prime interest to retard atherosclerosis-induced deaths. We shall brief the Ox-LDL-induced atherogenic mechanism and the treating measures in line to impede the development and progression of atherosclerosis.

Lower socioeconomic status predicts higher mortality and morbidity in patients with heart failure

OBJECTIVE

It is not fully understood whether and how socioeconomic status (SES) has a prognostic impact in patients with heart failure (HF). We assessed SES and its association with patient characteristics and outcomes in a contemporary and well-characterised HF cohort.

METHODS

Socioeconomic risk factors (SERF) were defined in the Swedish HF Registry based on income (low vs high according to the annual median value), education level (no degree/compulsory school vs university/secondary school) and living arrangement (living alone vs cohabitating).

RESULTS

Of 44 631 patients, 21% had no, 33% one, 30% two and 16% three SERF. Patient characteristics strongly and independently associated with lower SES were female sex and no specialist referral. Additional independent associations were older age, more severe HF, heavier comorbidity burden, use of diuretics and less use of HF devices. Lower SES was associated with higher risk of HF hospitalisation/mortality, and overall cardiovascular and non-cardiovascular events. These associations persisted after extensive adjustment for patient characteristics, treatments and care. The magnitude of the association increased linearly with the increasing number of coexistent SERF: HR (95% CI) 1.09 (1.05 to 1.13) for one, 1.16 (1.12 to 1.20) for two and 1.22 (1.18 to 1.28) for three SERF (p<0.01).

CONCLUSIONS

In a contemporary and well-characterised HF cohort and after comprehensive adjustment for confounders, lower SES was linked with multiple factors such as less use of HF devices and age, but most strongly with female sex and lack of specialist referral; and associated with greater risk of morbidity/mortality.

Addressing Comorbidities in Heart Failure: Hypertension, Atrial Fibrillation, and Diabetes

Heart failure (HF) is a growing global epidemic and an increasingly cumbersome burden on health care systems worldwide. As such, optimal management of existing comorbidities in the setting of HF is particularly important to prevent disease progression, reduce HF hospitalizations, and improve quality of life. In this review, the authors address 3 key comorbidities commonly associated with HF: hypertension, atrial fibrillation, and diabetes mellitus. They comprehensively describe the epidemiology, management, and emerging therapies in these 3 disease states as they relate to the overall HF syndrome.

Heart Failure With Preserved Ejection Fraction: A Comprehensive Review and Update of Diagnosis, Pathophysiology, Treatment, and Perioperative Implications

Almost three-quarters of all heart failure patients who are older than 65 have heart failure with preserved ejection fraction (HFpEF). The proportion and hospitalization rate of patients with HFpEF are increasing steadily relative to patients in whom heart failure occurs as result of reduced ejection fraction. The predominance of the HFpEF phenotype most likely is explained by the prevalence of medical conditions associated with an aging population. A multitude of age-related, medical, and lifestyle risk factors for HFpEF have been identified as potential causes for the sustained low-grade proinflammatory state that accelerates disease progression. Profound left ventricular (LV) systolic and diastolic stiffening, elevated LV filling pressures, reduced arterial compliance, left atrial hypertension, pulmonary venous congestion, and microvascular dysfunction characterize HFpEF, but pulmonary arterial hypertension, right ventricular dilation and dysfunction, and atrial fibrillation also frequently occur. These cardiovascular features make patients with HFpEF exquisitely sensitive to the development of hypotension in response to acute declines in LV preload or afterload that may occur during or after surgery. With the exception of symptom mitigation, lifestyle modifications, and rigorous control of comorbid conditions, few long-term treatment options exist for these unfortunate individuals. Patients with HFpEF present for surgery on a regular basis, and anesthesiologists need to be familiar with this heterogeneous and complex clinical syndrome to provide successful care. In this article, the authors review the diagnosis, pathophysiology, and treatment of HFpEF and also discuss its perioperative implications.

Temporal trends and predictors of inhospital death in patients hospitalised for heart failure in Germany

AIMS

We investigated trends in incidence, case fatality rate, patient characteristics and adverse inhospital events of patients hospitalised for heart failure in Germany.

METHODS AND RESULTS

The German nationwide inpatient sample (2005-2016) was used for this analysis. Patients hospitalised due to heart failure were selected for analysis. Temporal trends in the incidence of hospitalisations, case fatality rate and treatments were analysed and predictors of inhospital death were identified. The analysis comprised a total number of 4,539,140 hospitalisations (52.0% women, 81.0% aged ≥70 years) due to heart failure. Although hospitalisations increased from 381 (2005) to 539 per 100,000 population (2016) (β estimate 0.06, 95% confidence interval (CI) 0.06 to 0.07, P < 0.001) in parallel with median age and prevalence of comorbidities, the inhospital case fatality rate decreased from 11.1% to 8.1% (β estimate -0.36, 95% CI -0.37 to -0.35, P < 0.001) and the rate of major adverse cardiovascular and cerebrovascular events (β estimate -0.24, 95% CI -0.25 to -0.23, P < 0.001) decreased from 12.7% to 10.3%. Age 70 years and older (odds ratio (OR) 2.60, 95% CI 2.57 to 2.63, P < 0.001) and cancer (OR 1.93, 95% CI 1.91 to 1.96, P < 0.001) were independent predictors of inhospital death.

CONCLUSION

Hospitalisations for heart failure increased in Germany from 2005 to 2016, whereas the major adverse cardiovascular and cerebrovascular event rate and inhospital case fatality rate decreased during this period despite higher patient age and increasing prevalence of comorbidities.

Diabetes and Heart Failure: A Marriage of Inconvenience

Type 2 diabetes and congestive heart failure are growing public health problems and are expected to worsen in the next decade. There is an inarguable link between diabetes and heart failure but only recently has there been an effort to elucidate the underlying pathophysiologic connection resulting in diabetic cardiomyopathy. Traditionally, diabetes and heart failure have been treated as 2 distinct disease entities, but recent advances in individual therapies have shown remarkable concomitant improvements in both diabetes and cardiovascular outcomes. This article aims to review the key connections in the epidemiology and etiopathophysiology of type 2 diabetes and heart failure.

Artificial Intelligence and Big Data in Diabetes Care: A Position Statement of the Italian Association of Medical Diabetologists

Since the last decade, most of our daily activities have become digital. Digital health takes into account the ever-increasing synergy between advanced medical technologies, innovation, and digital communication. Thanks to machine learning, we are not limited anymore to a descriptive analysis of the data, as we can obtain greater value by identifying and predicting patterns resulting from inductive reasoning. Machine learning software programs that disclose the reasoning behind a prediction allow for “what-if” models by which it is possible to understand if and how, by changing certain factors, one may improve the outcomes, thereby identifying the optimal behavior. Currently, diabetes care is facing several challenges: the decreasing number of diabetologists, the increasing number of patients, the reduced time allowed for medical visits, the growing complexity of the disease both from the standpoints of clinical and patient care, the difficulty of achieving the relevant clinical targets, the growing burden of disease management for both the health care professional and the patient, and the health care accessibility and sustainability. In this context, new digital technologies and the use of artificial intelligence are certainly a great opportunity. Herein, we report the results of a careful analysis of the current literature and represent the vision of the Italian Association of Medical Diabetologists (AMD) on this controversial topic that, if well used, may be the key for a great scientific innovation. AMD believes that the use of artificial intelligence will enable the conversion of data (descriptive) into knowledge of the factors that “affect” the behavior and correlations (predictive), thereby identifying the key aspects that may establish an improvement of the expected results (prescriptive). Artificial intelligence can therefore become a tool of great technical support to help diabetologists become fully responsible of the individual patient, thereby assuring customized and precise medicine. This, in turn, will allow for comprehensive therapies to be built in accordance with the evidence criteria that should always be the ground for any therapeutic choice.

The burden of non-cardiac comorbidities and association with clinical outcomes in an acute heart failure trial - insights from ASCEND-HF

AIMS

Non-cardiac comorbidities are highly prevalent in patients with heart failure (HF). Our objective was to define the association between non-cardiac comorbidity burden and clinical outcomes, costs of care, and length of stay within a large randomized trial of acute HF patients.

METHODS AND RESULTS

Patients with complete medical history for the following comorbidities were included: diabetes mellitus, chronic obstructive pulmonary disease, chronic liver disease, history of cancer within the last 5 years, chronic renal disease (baseline serum creatinine >3.0 mg/mL), current smoking, alcohol abuse, depression, anaemia, peripheral arterial disease, and cerebrovascular disease. Patients were classified by overall burden of non-cardiac comorbidities (0, 1, 2, 3, and 4+). Hierarchical generalized linear models were used to assess associations between comorbidity burden and 30-day all-cause death or HF hospitalization and 180-day all-cause death in addition to costs of care and length of stay. A total of 6945 patients were included in the final analysis. Mean comorbidity number was 2.2 (± 1.34). Patients with 4+ comorbidities had higher rates of 30-day all-cause death/HF hospitalization as compared with patients with no comorbidities [odds ratio (OR) 3.32, 95% confidence interval (CI) 1.61-6.84; P < 0.01]. Similar results were seen with respect to 180-day death (OR 2.13, 95% CI 1.33-3.43; P < 0.01). Higher comorbidity burden was associated with higher 180-day costs of care and length of stay.

CONCLUSIONS

Higher comorbidity burden is associated with poor clinical outcomes, higher costs of care, and extended length of stay. Further studies are needed to define the impact of comorbidity management programmes on outcomes for HF patients.

Traditional Brazilian Diet and Olive Oil Reduce Cardiometabolic Risk Factors in Severely Obese Individuals: A Randomized Trial

Cardioprotective effects associated with extra virgin olive oil (EVOO) have been studied within the Mediterranean diet. However, little is known about its consumption in the traditional Brazilian diet (DieTBra) or without any dietary prescription, particularly in severely obese individuals. This study aimed to assess the effectiveness of DieTBra and EVOO in cardiometabolic risk factor (CMRF) reduction in severely obese individuals. We conducted a parallel randomized clinical trial with 149 severely obese individuals (body mass index ≥ 35.0 kg/m²) aged 18–65 years, assigned to three groups: 52 mL/day of EVOO (n = 50), DieTBra (n = 49), and DieTBra + 52 mL/day of EVOO (n = 50). Participants were followed up for 12 weeks. Low-density lipoprotein cholesterol (LDL-c) was the primary endpoint and several cardiometabolic parameters were secondary endpoints. Endpoints were compared at baseline and at the end of the study using analysis of variance, the Kruskal–Wallis test, and Student’s t-test. The TC/High-density lipoprotein (HDL) ratio (−0.33 ± 0.68, p = 0.002) and LDL/HDL ratio (−0.26 ± 0.59, p = 0.005) decreased in the EVOO group. Delta values for all variables showed no significant statistical difference between groups. However, we highlight the clinical significance of LDL-c reduction in the EVOO group by 5.11 ± 21.79 mg/dL and in the DieTBra group by 4.27 ± 23.84 mg/dL. We also found a mean reduction of around 10% for Castelli II (LDL/HDL) and homocysteine in the EVOO group and TG and the TG/HDL ratio in the DieTBra group. EVOO or DieTBra when administered alone lead to reduction in some cardiometabolic risk parameters in severely obese individuals.

Utility of single-item questions to assess physical inactivity in patients with chronic heart failure

Aim

The purpose of this study was to explore the utility of two single‐item self‐report (SR) questions to assess physical inactivity in patients with heart failure (HF).

Methods and results

This is a cross‐sectional study using data from 106 patients with HF equipped with accelerometers for 1 week each. Two SR items relating to physical activity were also collected. Correlations between accelerometer activity counts and the SR items were analysed. Patients were classified as physically active or inactive on the basis of accelerometer counts, and the SR items were used to try to predict that classification. Finally, patients were classified as having high self‐reported physical activity or low self‐reported physical activity, on the basis of the SR items, and the resulting groups were analysed for differences in actual physical activity. There were significant but weak correlations between the SR items and accelerometer counts: ρ = 0.24, P = 0.016 for SR1 and ρ = 0.21, P = 0.033 for SR2. Using SR items to predict whether a patient was physically active or inactive produced an area under the curve of 0.62 for SR1, with a specificity of 92% and a sensitivity of 30%. When dividing patients into groups on the basis of SR1, there was a significant difference of 1583 steps per day, or 49% more steps in the high self‐reported physical activity group (P < 0.001).

Conclusions

There might be utility in the single SR question for high‐specificity screening of large populations to identify physically inactive patients in order to assign therapeutic interventions efficiently where resources are limited.

Heart failure with preserved ejection fraction: insights from recent clinical researches

Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for nearly half of the cases of HF and its incidence might be increasing with the aging society. Patients with HFpEF present with significant symptoms, including exercise intolerance, impaired quality of life, and have a poor prognosis as well as frequent hospitalization and increased mortality compared with HF with reduced ejection fraction. The concept of HFpEF is still evolving and may be a virtual complex rather than a real systemic disorder. Thus, beyond solely targeting cardiac abnormalities management strategies need to be extended, such as left ventricular diastolic dysfunction. In this review, we examine new diagnostic algorithms, pathophysiology, current management status, and ongoing trials based on heterogeneous pathophysiology and etiology in HFpEF.

Sodium Intake and Target Organ Damage in Hypertension-An Update about the Role of a Real Villain

Salt intake is too high for safety nowadays. The main active ion in salt is sodium. The vast majority of scientific evidence points out the importance of sodium restriction for decreasing cardiovascular risk. International Guidelines recommend a large reduction in sodium consumption to help reduce blood pressure, organ damage, and cardiovascular risk. Regulatory authorities across the globe suggest a general restriction of sodium intake to prevent cardiovascular diseases. In spite of this seemingly unanimous consensus, some researchers claim to have evidence of the unhealthy effects of a reduction of sodium intake, and have data to support their claims. Evidence is against dissenting scientists, because prospective, observational, and basic research studies indicate that sodium is the real villain: actual sodium consumption around the globe is far higher than the safe range. Sodium intake is directly related to increased blood pressure, and independently to the enlargement of cardiac mass, with a possible independent role in inducing left ventricular hypertrophy. This may represent the basis of myocardial ischemia, congestive heart failure, and cardiac mortality. Although debated, a high sodium intake may induce initial renal damage and progression in both hypertensive and normotensive subjects. Conversely, there is general agreement about the adverse role of sodium in cerebrovascular disease. These factors point to the possible main role of sodium intake in target organ damage and cardiovascular events including mortality. This review will endeavor to outline the existing evidence.

Cardiac changes associated with vascular aging

Cardiovascular aging is a complex process of adaptive structural and functional changes over time. With advancing age, the arterial tree thickens and decreases in compliance, resulting in increased pulse wave velocity, systolic blood pressure, and left ventricular afterload. In response to these arterial changes, the myocardium remodels to maintain systolic function and diastolic filling. These adaptive mechanisms are not necessarily pathologic but increase the susceptibility for myocardial ischemia and heart failure in the presence of common age-associated comorbidities. This article reviews the pathophysiology of cardiovascular aging and discusses therapeutic interventions that may ameliorate these processes.

Improvement in women's cardiovascular functioning during cognitive-behavioral therapy for alcohol use disorder

The cardiovascular system is disrupted by chronic excessive alcohol use and often impaired in individuals with an alcohol use disorder (AUD). Less is known about cardiovascular recovery when an individual receives treatment for AUD. This observational study aimed to extend the growing body of evidence for cardiovascular biomarkers and intervention targets in the treatment of AUD. We examined cardiovascular function in 92 women before and after 12 weeks of cognitive-behavioral therapy (CBT) for AUD. Participants were recruited exclusively from a randomized clinical trial comparing group versus individual CBT treatment strategies (parent study); no control group of untreated, but treatment-seeking women was available. Demographic and drinking data were obtained from the parent study. Cardiovascular data were collected as part of this separate study, prior to and following the clinical trial. Mixed-model analyses revealed multiple within-person cardiovascular changes indicative of improving health from pre- to posttreatment, including reduced heart rate and vessel stiffness as well as increased heart rate variability and baroreflex sensitivity. These significant improvements remained when extent of drinking during treatment was included in the models, suggesting that active ingredients of AUD treatment may serve to benefit physical health over and above drinking reductions. Future studies should assess the time course of cardiovascular recovery during addiction treatment and the mechanisms by which evidence-based AUD treatments may benefit physical as well as mental health. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Effects of mindfulness-based interventions on health-related outcomes for patients with heart failure: a systematic review

BACKGROUND

Mindfulness-based interventions may offer a promising approach for promoting psychological and physical health and wellbeing for patients with heart failure. However, the effects of mindfulness-based interventions for this population have not been systematically reviewed.

AIMS

This review aimed to synthesise available evidence to assess the effects of mindfulness-based interventions on psychological and physical outcomes and health-related quality of life in patients with heart failure.

METHODS

Seven English and two Chinese electronic databases were searched with keywords from inception to May 2019. Experimental studies that examined mindfulness-based interventions in adults with heart failure were eligible for inclusion. Two reviewers independently performed study selection, data extraction and study quality assessment. The results were then narratively synthesised.

RESULTS

This review identified five studies involving 467 patients with heart failure. The reviewed studies had weak to moderate quality. There were consistent findings that mindfulness-based interventions could significantly reduce depression (three studies) and anxiety (two studies) and improve health-related quality of life (two studies) after intervention. However, the effects on physical symptoms were inconsistent in three studies. The effects on physical function were only measured in one study, with non-significant changes being reported.

CONCLUSIONS

This review provides preliminary evidence that mindfulness-based interventions are beneficial for patients with heart failure in reducing depression and anxiety and enhancing health-related quality of life in the short term. These findings should be carefully generalised considering the methodological limitations across studies. More rigorous studies are required to examine further the effects of mindfulness-based interventions in patients with heart failure.

Heart Failure With Preserved Ejection Fraction In Perspective

Approximately half of the patients with signs and symptoms of heart failure have a left ventricular ejection fraction that is not markedly abnormal. Despite the historically initial surprise, heightened risks for heart failure specific major adverse events occur across the broad range of ejection fraction, including normal. The recognition of the magnitude of the problem of heart failure with preserved ejection fraction in the past 20 years has spurred an explosion of clinical investigation and growing intensity of informative outcome trials. This article addresses the historic development of this component of the heart failure syndrome, including the epidemiology, pathophysiology, and existing and planned therapeutic studies. Looking forward, more specific phenotyping and even genotyping of subpopulations should lead to improvements in outcomes from future trials.