ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure 2012

Elevated plasma endothelin-1 is related to low natriuresis, clinical signs of congestion, and poor outcome in acute heart failure

AIMS

Endothelin-1 (ET-1) is a potent vasoconstrictor, which regulates renal and vascular function. We aimed to relate plasma levels of ET-1 with the clinical picture and outcomes in acute heart failure (AHF).

METHODS AND RESULTS

We studied 113 patients with AHF [mean age 65 ± 13 (years), median (upper and lower quartiles) N-terminal pro-B-type natriuretic peptide, 5422 (2689; 8582) (pg/mL)], in whom plasma levels of ET-1 were serially measured at admission (10.8 ± 5.2), Day 1 (9.5 ± 3.4), and Day 2 (8.9 ± 3.8) (pg/mL). The population was divided into tertiles across baseline ET-1 levels. Patients in the highest ET-1 tertile had predominant clinical signs of peripheral congestion; however, no difference was observed in pulmonary congestion and severity of dyspnoea. They also presented lower spot urine sodium at admission (75 ± 35 vs. 99 ± 43 vs. 108 ± 30), 6 h (84 ± 34 vs. 106 ± 43 vs. 106 ± 35), and Day 1 (75 ± 38 vs. 96 ± 36 vs. 100 ± 35) (mmol/L), when compared with the second and first tertile, respectively (all P < 0.05); furthermore, they received higher doses of intravenous furosemide from Day 2 and had longer intravenous diuretics, as median switch to oral furosemide was 4 (3; 4) vs. 3 (2; 4) vs. 2 (2; 3) (days), respectively, P < 0.05. There was no difference in serum creatinine, urea, and renal injury biomarkers (kidney injury molecule-1, serum cystatin C, and urine neutrophil gelatinase-associated lipocalin) between the ET-1 tertiles. Higher values of ET-1 measured at each time point were related with a higher risk of 1 year mortality.

CONCLUSIONS

Elevation of ET-1 is related to clinical signs of peripheral congestion, low urine sodium excretion, and poor outcome in AHF.

Renal profiling based on estimated glomerular filtration rate and spot urine sodium identifies high-risk acute heart failure patients

AIMS

In acute heart failure (AHF), assessment of renal function comprises estimation of glomerular filtration rate (eGFR), which does not provide any information about renal sodium/water handling. We describe the interactions between urinary sodium concentration and eGFR to better characterize AHF patients.

METHODS AND RESULTS

In 219 patients with AHF, spot urine sodium (UNa⁺ ) and eGFR were assessed on admission, day 1 and day 2 of hospitalization. We found no correlation between UNa⁺ and eGFR (calculated on each consecutive day, as an average of all three values, and as changes from baseline; all P > 0.05). The population was subsequently divided into four profiles based on eGFR (preserved vs. impaired; cutoff of 60 mL/min/1.73 m² ) and UNa⁺ (sodium excreter vs. non-excreter; cutoff of 60 mmol/L). At day 1, there were 70 (31.9%) patients classified as preserved eGFR/sodium excreter, 37 (16.8%) as impaired eGFR/sodium non-excreter, 72 (32.9%) as impaired eGFR/sodium excreter, and 40 (18%) as preserved eGFR/sodium non-excreter. Both sodium non-excreter profiles were associated with an increased risk of in-hospital heart failure worsening [odds ratio (OR) 2.8, 95% confidence interval (CI) 1.3-6.4], inotrope use (OR 2.6, 95% CI 1.1-6.7) and rehospitalization due to AHF (OR 3.2, 95% CI 1.6-6.2; all P < 0.05). The preserved eGFR/sodium non-excreter profile was associated with highest 1-year mortality (52.5%) and remained an independent prognosticator after adjustment for other prognosticators (hazard ratio 2.9, 95% CI 1.7-5.2; P < 0.0005).

CONCLUSIONS

In AHF, values of spot UNa⁺ and eGFR are not interrelated. Concomitant assessment of eGFR and spot UNa⁺ may be useful for better clinical and therapeutic profiling of patients.

Comparison of Outcomes After Ablation of Atrial Fibrillation in Patients With Heart Failure With Preserved Versus Reduced Ejection Fraction

Catheter ablation improves outcomes in atrial fibrillation (AF) patients with heart failure (HF) with reduced ejection fraction (HFrEF). We sought to evaluate the efficacy and safety of catheter ablation of AF in HF patients with a preserved ejection fraction (HFpEF). We performed a retrospective study of all patients who underwent de novo radiofrequency catheter ablation enrolled in the UC San Diego AF Ablation Registry. The primary outcome was recurrence of all atrial arrhythmias on or off antiarrhythmic drugs (AAD). Of 547 total patients, 51 (9.3%) had HFpEF, 40 (7.3%) had HFrEF, and 456 (83.4%) were without HF. There was no difference in recurrence of atrial arrhythmias on or off AAD (Adjusted Hazard Ratio [AHR] 1.92 [95% CI 0.97 to 3.83] for HFpEF vs HFrEF and AHR 0.90 [95% CI 0.59 to 1.39] for HFpEF vs no HF) or off AAD (AHR 1.96 [95% CI 0.99 to 3.90] for HFpEF vs HFrEF and AHR 1.14 [95% CI 0.74 to 1.77] for HFpEF vs no HF). There was also no difference in rates of all-cause hospitalizations (AHR 1.80 [95% CI 0.97 to 3.33] for HFpEF vs HFrEF and AHR 2.05 [95% CI 1.30 to 3.23] for HFpEF vs no HF) or rates of all-cause mortality (AHR 0.53 [95% CI 0.05 to 6.11] for HFpEF vs HFrEF and AHR 2.46 [95% CI 0.34 to 17.92] for HFpEF vs no HF). There were no significant differences in AAD use (p = 0.176) or procedural complications between groups (p = 0.980). In conclusion, there were no significant differences in arrhythmia-free survival between patients with HFpEF and HFrEF that underwent catheter ablation of AF.

Predictive Factors on the Incidence of Heart Failure in Patients with Ischemic Heart Disease: Using a 10-Year Population-Based Korea National Health Insurance Cohort Data

Early risk stratification and preventative strategies are required in patients with ischemic heart disease (IHD) to prevent heart failure (HF). We aimed to investigate the rate of progression to HF and to investigate the factors predicting the development of HF in a population with IHD for 10 years. A descriptive study was conducted using Korea National Health Insurance Service-National Sample Cohort (NHI-NSC) data (2005-2015). Among the patients diagnosed with IHD for the first time in 2005-2006, 2271 men and 2037 women who responded to the health check-up survey were finally selected. Cox Proportional Hazard regression analyses and the Kaplan-Meier survival analysis were used. HF incidence rates were 5.1% in men and 8.0% in women. The mean duration of transition to HF was 4.85 ± 2.73 years in men and 4.73 ± 2.73 years in women. The non-incidence rate of HF was higher in men than in women (Log-rank test, p = 0.0003). Bivariate analyses showed that older age, prevalence of hypertension and diabetes, less alcohol, and lower physical exercise were associated with the incidence of HF in both men and women. Multivariate analyses found that HF incidence in aged subjects ≥70 years was 1.46 times higher in men and 1.44 times higher in women compared to those in their 30 s (p < 0.001). Prevalence of hypertension reduced the incidence of HF by 0.78 and 0.87 for men and women, respectively. The prevalence of diabetes increased 1.23 times only in men. These findings suggest that special attention such as periodic counseling and education is needed to prevent progression to HF in elderly and diabetic patients during follow-up after IHD.

Efficacy and safety of early initiation of eplerenone treatment in patients with acute heart failure (EARLIER trial): a multicenter, randomized, double-blind, placebo-controlled trial

AIMS

A mineralocorticoid receptor antagonist (MRA) is effective in patients with chronic heart failure; however, the effects of the early initiation of an MRA in patients with acute heart failure (AHF) have not been elucidated.

METHODS AND RESULTS

In this multicenter, randomized, double-blind, placebo-controlled, parallel-group study, we focused on the safety and effectiveness of the treatment with eplerenone, a selective MRA in 300 patients with AHF, that is, 149 in the eplerenone group and 151 in the placebo group in 27 Japanese institutions. The key inclusion criteria were (1) patients aged 20 years or older and (2) those with left ventricular ejection fraction of ≤ 40%. The primary outcome was a composite of cardiac death or first re-hospitalization due to cardiovascular disease within 6 months. The mean age of the participants was 66.8 years, 27.3% were women, and the median levels of brain natriuretic peptide were 376.0 pg/mL. The incidences of the primary outcome were 19.5% in the eplerenone group and 17.2% in the placebo group (hazard ratio (HR): 1.09, 95% confidence interval (CI): 0.642-1.855). In prespecified secondary outcomes, HR for the composite endpoint, cardiovascular death, or first re-hospitalization due to heart failure (HF) within 6 months was 0.55 (95% CI: 0.213 to 1.434). The safety profile for eplerenone was as expected.

CONCLUSION

The early initiation of eplerenone in patients with AHF could safely be utilized. The reduction of the incidence of a composite of cardiovascular death or first re-hospitalization for cardiovascular diseases by eplerenone is inconclusive because of inadequate power.

Comparison of the Outcome of Patients Protected by the Wearable Cardioverter Defibrillator (WCD) for <90 Wear Days versus ≥90 Wear Days

BACKGROUND/AIM

The wearable cardioverter/defibrillator (WCD) is recommended to prevent sudden cardiac death (SCD). Guidelines suggest a 90 days' period, but prolongation of WCD wear time until increasing the ejection fraction (≥35%) might be suggested.

PATIENTS AND METHODS

A cohort of 153 patients with prescribed WCD were divided into two groups: A <90 wear days' group (n=112) vs. ≥90 wear days' group (n=41) and followed.

RESULTS

In the first group, WCD shock occurred in 3.6% of patients, 47.3% improved in left ventricular ejection fraction (LVEF) after 3 months, and 37.5% had a cardiac implantable electronic device (CIED) implantation with appropriate implantable cardioverter defibrillator (ICD) shock events occurring in 6 patients. Two of these patients already received WCD shock therapy due to ventricular fibrillation. A 20.5% improved in LVEF after 6-12 months, but 73% were already implanted with ICD. In the second group, 4.9% received WCD shock, 34.1% improved in LVEF after 3 months, 48.8% were implanted with ICD, and 2 had ICD shocks during follow up time. LVEF improvement after 6-12 months occurred in 26.8%. ICD implantation was prevented in 7.3% of patients due to LVEF recovery.

CONCLUSION

Prolonging wearing days of WCD may reduce the number of inappropriate ICD implantation.

Summed rest score in gated myocardial perfusion imaging is a good predicator for treatment-related cardiotoxicity after anthracycline chemotherapy in patients with diffuse large B-cell lymphoma

Anthracycline chemotherapy is commonly used in the treatment of diffuse large B-cell lymphoma (DLBCL). Treatment-related cardiotoxicity (TRC) is defined as when the patient is identified to have one of the following clinical manifestations: Symptomatic heart failure, cardiac death, arrhythmia, infarction, a decrease in left ventricular ejection fraction (LVEF) of >15% from baseline or a decrease in LVEF of >10 to <50%. TRC may induce severe cardiac failure or cardiac arrhythmia as the main cause of death. The present study aimed to investigate the prognostic value of the summed rest score (SRS) in gated myocardial perfusion imaging (G-MPI) for the early detection of TRC caused by anthracycline chemotherapy in patients with DLBCL. A total of 36 DLBCL patients were enrolled in the present study, and a series of parameters were compared at baseline and after chemotherapy. According to the occurrence of TRC during the observation period, the patients were divided into two groups, and parameters associated with cardiac function were compared. The SRS in G-MPI and the corrected QT interval in the electrocardiogram were significantly different before and after chemotherapy (P=0.012 and P=0.015, respectively). By comparing parameters associated with cardiac function between the TRC group (n=22) and the no-TRC group (n=14), it was found that only SRS was significantly different (P=0.012). Multivariate logistic regression analysis showed that the SRS level was the only independent predicator for TRC (P=0.018; HR, 6.053; 95% CI, 1.364-26.869). Receiver operating characteristic curve analysis identified an optimal SRS cutoff of >1 for predicting TRC after anthracycline chemotherapy (P<0.001). Overall, the G-MPI SRS level was an early indicator for TRC surveillance in patients with DLBCL after anthracycline chemotherapy. The application of G-MPI SRS in clinical practice may contribute to early treatment and a subsequent decrease in mortality caused by such cardiovascular complications.

Diagnostic performance of congestion score index evaluated from chest radiography for acute heart failure in the emergency department: A retrospective analysis from the PARADISE cohort

BACKGROUND

Congestion score index (CSI), a semiquantitative evaluation of congestion on chest radiography (CXR), is associated with outcome in patients with heart failure (HF). However, its diagnostic value in patients admitted for acute dyspnea has yet to be evaluated.

METHODS AND FINDINGS

The diagnostic value of CSI for acute HF (AHF; adjudicated from patients' discharge files) was studied in the Pathway of dyspneic patients in Emergency (PARADISE) cohort, including patients aged 18 years or older admitted for acute dyspnea in the emergency department (ED) of the Nancy University Hospital (France) between January 1, 2015 and December 31, 2015. CSI (ranging from 0 to 3) was evaluated using a semiquantitative method on CXR in consecutive patients admitted for acute dyspnea in the ED. Results were validated in independent cohorts (N = 224). Of 1,333 patients, mean (standard deviation [SD]) age was 72.0 (18.5) years, 686 (51.5%) were men, and mean (SD) CSI was 1.42 (0.79). Patients with higher CSI had more cardiovascular comorbidities, more severe congestion, higher b-type natriuretic peptide (BNP), poorer renal function, and more respiratory acidosis. AHF was diagnosed in 289 (21.7%) patients. CSI was significantly associated with AHF diagnosis (adjusted odds ratio [OR] for 0.1 unit CSI increase 1.19, 95% CI 1.16-1.22, p < 0.001) after adjustment for clinical-based diagnostic score including age, comorbidity burden, dyspnea, and clinical congestion. The diagnostic accuracy of CSI for AHF was >0.80, whether alone (area under the receiver operating characteristic curve [AUROC] 0.84, 95% CI 0.82-0.86) or in addition to the clinical model (AUROC 0.87, 95% CI 0.85-0.90). CSI improved diagnostic accuracy on top of clinical variables (net reclassification improvement [NRI] = 94.9%) and clinical variables plus BNP (NRI = 55.0%). Similar diagnostic accuracy was observed in the validation cohorts (AUROC 0.75, 95% CI 0.68-0.82). The key limitation of our derivation cohort was its single-center and retrospective nature, which was counterbalanced by the validation in the independent cohorts.

CONCLUSIONS

In this study, we observed that a systematic semiquantified assessment of radiographic pulmonary congestion showed high diagnostic value for AHF in dyspneic patients. Better use of CXR may provide an inexpensive, widely, and readily available method for AHF triage in the ED.

Natriuretic peptides for the detection of diastolic dysfunction and heart failure with preserved ejection fraction-a systematic review and meta-analysis

BACKGROUND

An overview of the diagnostic performance of natriuretic peptides (NPs) for the detection of diastolic dysfunction (DD) and heart failure with preserved ejection fraction (HFpEF), in a non-acute setting, is currently lacking.

METHODS

We performed a systematic literature search in PubMed and Embase.com (May 13, 2019). Studies were included when they (1) reported diagnostic performance measures, (2) are for the detection of DD or HFpEF in a non-acute setting, (3) are compared with a control group without DD or HFpEF or with patients with heart failure with reduced ejection fraction, (4) are in a cross-sectional design. Two investigators independently assessed risk of bias of the included studies according to the QUADAS-2 checklist. Results were meta-analysed when three or more studies reported a similar diagnostic measure.

RESULTS

From 11,728 titles/abstracts, we included 51 studies. The meta-analysis indicated a reasonable diagnostic performance for both NPs for the detection of DD and HFpEF based on AUC values of approximately 0.80 (0.73-0.87; I² = 86%). For both NPs, sensitivity was lower than specificity for the detection of DD and HFpEF: approximately 65% (51-85%; I² = 95%) versus 80% (70-90%; I² = 97%), respectively. Both NPs have adequate ability to rule out DD: negative predictive value of approximately 85% (78-93%; I² = 95%). The ability of both NPs to prove DD is lower: positive predictive value of approximately 60% (30-90%; I² = 99%).

CONCLUSION

The diagnostic performance of NPs for the detection of DD and HFpEF is reasonable. However, they may be used to rule out DD or HFpEF, and not for the diagnosis of DD or HFpEF.

Safety and efficacy of soluble guanylate cyclase stimulators in patients with heart failure: A systematic review and meta-analysis

BACKGROUND

The utility of novel oral soluble guanylate cyclase (sGC) stimulators (vericiguat and riociguat), in patients with reduced or preserved ejection fraction heart failure (HFrEF/HFpEF) is currently unclear.

AIM

To determine the efficacy and safety of sGC stimulators in HF patients.

METHODS

Multiple databases were searched to identify relevant randomized controlled trials (RCTs). Data on the safety and efficacy of sGC stimulators were compared using relative risk ratio (RR) on a random effect model.

RESULTS

Six RCTs, comprising 5604 patients (2801 in sGC stimulator group and 2803 placebo group) were included. The primary endpoint (a composite of cardiovascular mortality and first HF-related hospitalization) was significantly reduced in patients receiving sGC stimulators compared to placebo [RR 0.92, 95% confidence interval (CI): 0.85-0.99, P = 0.02]. The incidence of total HF-related hospitalizations were also lower in sGC group (RR 0.91, 95%CI: 0.86-0.96, P = 0.0009), however, sGC stimulators had no impact on all-cause mortality (RR 0.96, 95%CI: 0.86-1.07, P = 0.45) or cardiovascular mortality (RR 0.94, 95%CI: 0.83-1.06, P = 0.29). The overall safety endpoint (a composite of hypotension and syncope) was also similar between the two groups (RR 1.50, 95%CI: 0.93-2.42, P = 0.10). By contrast, a stratified subgroup analysis adjusted by type of sGC stimulator and HF (vericiguat vs riociguat and HFrEF vs HFpEF) showed near identical rates for all safety and efficacy endpoints between the two groups at a mean follow-up of 19 wk. For the primary composite endpoint, the number needed to treat was 35, the number needed to harm was 44.

CONCLUSION

The use of vericiguat and riociguat in conjunction with standard HF therapy, shows no benefit in terms of decreasing HF-related hospitalizations or mortality.

The impact of psychoeducational interventions on the outcomes of caregivers of patients with heart failure: A systematic review and meta-analysis

BACKGROUND

Heart failure is a global health care problem that causes a significant economic burden. Despite medical advancements, it's prognosis remains poor as many patients with heart failure experience symptoms that negatively impact Quality of Life. Caregivers are often responsible for helping and supporting family members manage their heart failure symptoms at home. In addition to managing their own medical problems and maintaining social and personal lives, significant burden and stress can occur. At present, caregivers receive little guidance or information to support them in their caregiving role.

OBJECTIVES

This review aims to determine the impact of psychoeducational interventions on the outcomes of caregivers of patients with heart failure.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

Five electronic databases: PsycINFO, Medline, CINAHL Plus, EMBASE and SCOPUS were searched from June 2007 to August 2019.

REVIEW METHODS

The conduct and reporting of this review was based on the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. The Cochrane Risk of Bias Tool was used to assess the risk of bias amongst randomised controlled trials, and the Newcastle Ottawa Scale was used to assess risk of bias in one quasi-experimental study.

RESULTS

Ten articles met the inclusion criteria, consisting of seven studies, with a total sample size of 953 participants. The pooled result from two studies, conducted in America and China, reported that psychoeducational interventions significantly reduced depression at six months' follow-up (SMD -0.82; 95% CI -1.17 to -0.47; p = 0.73, I² =0%). The pooled result from two studies conducted in Sweden and Taiwan showed a significant improvement in heart failure knowledge at six months' follow-up (SMD 0.97; 95% CI 0.70 to 1,25; p < 0.00001, I² =0%). Finally, pooled results from three studies conducted in Sweden, China and Taiwan found a significant improvement in Quality of Life at 3 months' follow- up (SMD 0.25; 95% CI 0.25 to 0.48; p = 0.03). The three most common intervention components included: group based educational sessions, telemonitoring and telephone support, and written resources.

CONCLUSIONS

There was no specific type of psychoeducational intervention found to have a significant impact on caregiver outcomes, as interventions were heterogeneous consisting of multiple components. Further research is needed to determine the effectiveness of individual and combined components to identify the ideal intervention format and design for caregivers of patients with heart failure.

Ionomic profiling of pericardial fluid in ischemic heart disease

Metals are essential cofactors that play a crucial role in heart function at the cell and tissue level. Information regarding the role of metals in the pericardial fluid and its ionome in ischemic heart disease (IHD) is limited. We aimed to determine the association of elements in pericardial fluid and serum samples of IHD patients and their correlation with systolic and diastolic function. IHD patients have been studied with systolic and diastolic dysfunction categorized on the basis of echocardiographic parameters. We measured concentrations of sixteen elements in the pericardial fluid and serum of 46 patients obtained during open heart surgery with IHD by ICP-MS. The levels of chromium and nickel in pericardial fluid were significantly higher as compared with serum samples of IHD patients (p < 0.05). The chromium, nickel and manganese levels in pericardial fluid were lower in patients with ejection fraction (EF) < 45% as compared to EF > 45% (p < 0.05). There was no significant difference in pericardial concentrations of elements in diastolic dysfunction grade 0-1 with 2 in IHD patients. We also found that decreased concentration of these elements in pericardial fluid is associated with decreased systolic function. These results suggest that pericardial fluid concentrations of these metals may reflect the extent of ischemic heart disease. These findings are hypothesis generating with regards to a role in the pathogenesis of the disorder.

Differences in biomarkers and molecular pathways according to age for patients with HFrEF

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 &gt;75 vs. &lt;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.

Muscle and cardiac therapeutic strategies for Duchenne muscular dystrophy: past, present, and future

BACKGROUND

Duchenne muscular dystrophy (DMD) is a severe X-linked neuromuscular childhood disorder that causes progressive muscle weakness and degeneration and results in functional decline, loss of ambulation and early death of young men due to cardiac or respiratory failure. Although the major cause of the disease has been known for many years-namely mutation in the DMD gene encoding dystrophin, one of the largest human genes-DMD is still incurable, and its treatment is challenging.

METHODS

A comprehensive and systematic review of literature on the gene, cell, and pharmacological experimental therapies aimed at restoring functional dystrophin or to counteract the associated processes contributing to disease progression like inflammation, fibrosis, calcium signaling or angiogenesis was carried out.

RESULTS

Although some therapies lead to satisfying effects in skeletal muscle, they are highly ineffective in the heart; therefore, targeting defective cardiac and respiratory systems is vital in DMD patients. Unfortunately, most of the pharmacological compounds treat only the symptoms of the disease. Some drugs addressing the underlying cause, like eteplirsen, golodirsen, and ataluren, have recently been conditionally approved; however, they can correct only specific mutations in the DMD gene and are therefore suitable for small sub-populations of affected individuals.

CONCLUSION

In this review, we summarize the possible therapeutic options and describe the current status of various, still imperfect, strategies used for attenuating the disease progression.

The clinical implication of new-onset in-hospital atrial fibrillation in patients with acute decompensated heart failure

BACKGROUND

To investigate the clinical implication of the temporal difference in atrial fibrillation (AF)-onset in acute decompensated heart failure (ADHF) and its impact on post-discharge prognosis.

METHODS

336 new-onset ADHF patients without any history of AF before admission were enrolled (201 males, 63 ± 16 year-old) and classified into two groups based on their history of AF: the Control group (No AF was detected during hospitalization, n = 278), and the In-hos-AF group (AF occurred during hospitalization, n = 58). Post discharge prognosis including rehospitalization due to worsening HF, cardiac death, all-cause death and cerebrovascular event were compared.

RESULTS

Kaplan-Meier analysis demonstrated that the incidence of rehospitalization due to HF, cardiac death, all-cause death and cerebrovascular event in the In-hos-AF group was not significantly different from that in the Control group (P > 0.05 respectively). However, when AF recurred in the In-hos-AF group patients (n = 24, 41%) after discharge, the incidence of rehospitalization due to HF and cardiac deaths were higher than those without AF recurrence (P = 0.018 and P = 0.027 respectively). Cox proportional analysis revealed that AF developing after discharge was proven to be an independent risk factor for rehospitalization due to HF (HR 1.845, P = 0.043), cardiac death (HR 3.562, P = 0.013) and all-cause deaths (HR 2.138, P = 0.020).

CONCLUSION

Clinical outcomes of new-onset in-hospital AF patients were as good as those without AF history until AF recurrence. However, AF recurrence led to worse prognosis. Therefore, treatment for new-onset in-hospital AF in ADHF patients might be postponed until AF recurrence.

Time trends in the use and appropriateness of natriuretic peptide testing in primary care: an observational study

BACKGROUND

Diagnosing heart failure (HF) is difficult, relying on medical history, symptoms, and signs only. Clinical guidelines recommend natriuretic peptides (NPs) as an additional diagnostic test, notably to exclude HF in suspected patients. NP testing has been available since 2003 for primary care in the Netherlands, but little is known about its uptake.

AIM

To evaluate the trend in ordering and appropriateness of NP testing in primary care.

DESIGN & SETTING

An observational study was performed between January 2005 and December 2013. Nine Dutch general practices participated, with 21 000 registered people (approximately 4300 aged ≥65 years).

METHOD

The total number of patients undergoing NP testing each year was calculated per 1000 patient years (PY) based on the total practice population. NP levels were used to assess whether NP testing was applied to exclude or confirm HF.

RESULTS

The number of NP testing increased from 2.5 per 1000 PY in 2005 to 14.0 per 1000 PY in 2013, with a peak in 2009 of 15.6 per 1000 PY. The proportion of participants with N-terminal B-type natriuretic peptide (NTproBNP) below 125 pg/ml (the exclusionary threshold recommended by the European Society of Cardiology [ESC] guidelines on HF) was on average 30%, and highest in the first year (47%).

CONCLUSION

After a rapid uptake of NP testing in primary care from 2005 onwards, the use of it seemed to stabilise after 2009, thus leaving patients who are prone to HF without an optimal diagnostic work-up.

Training general practitioners to improve evidence-based drug treatment of patients with heart failure: a cluster randomised controlled trial

Aims

To assess whether a single training session for general practitioners (GPs) improves the evidence-based drug treatment of heart failure (HF) patients, especially of those with HF with reduced ejection fraction (HFrEF).

Methods and results

A cluster randomised controlled trial was performed for which patients with established HF were eligible. Primary care practices (PCPs) were randomised to care-as-usual or to the intervention group in which GPs received a half-day training session on HF management. Changes in HF medication, health status, hospitalisation and survival were compared between the two groups. Fifteen PCPs with 200 HF patients were randomised to the intervention group and 15 PCPs with 198 HF patients to the control group. Mean age was 76.9 (SD 10.8) years; 52.5% were female. On average, the patients had been diagnosed with HF 3.0 (SD 3.0) years previously. In total, 204 had HFrEF and 194 HF with preserved ejection fraction (HFpEF). In participants with HFrEF, the use of angiotensin-converting enzyme inhibitors/angiotensin receptor blockers decreased in 6 months in both groups [5.2%; (95% confidence interval (CI) 2.0–10.0)] and 5.6% (95% CI 2.8–13.4)], respectively [baseline-corrected odds ratio (OR) 1.07 (95% CI 0.55–2.08)], while beta-blocker use increased in both groups by 5.2% (95% CI 2.0–10.0) and 1.1% (95% CI 0.2–6.3), respectively [baseline-corrected OR 0.82 (95% CI 0.42–1.61)]. For health status, hospitalisations or survival after 12–28 months there were no significant differences between the two groups, also not when separately analysed for HFrEF and HFpEF.

Conclusion

A half-day training session for GPs does not improve drug treatment of HF in patients with established HF.

Electronic supplementary material

The online version of this article (10.1007/s12471-020-01487-x) contains supplementary material, which is available to authorized users.

Non-invasive ventilation improves exercise tolerance and peripheral vascular function after high-intensity exercise in COPD-HF patients

AIM

Evaluate the acute effects of non-invasive positive pressure ventilation (NiPPV) during high-intensity exercise on endothelial function in patients with coexisting chronic obstructive pulmonary disease (COPD) and heart failure (HF).

METHODS

This is a randomized, double blinded, sham-controlled study involving 14 COPD-HF patients, who underwent a lung function test and Doppler echocardiography. On two different days, patients performed incremental cardiopulmonary exercise testing (CPET) and two constant-work rate tests (80% of CPET peak) receiving Sham or NiPPV (bilevel mode - Astral 150) in a random order until the limit of tolerance (Tlim). Endothelial function was evaluated by flow mediated vasodilation (FMD) at three time points: 1) Baseline; 2) immediately post-exercise with NiPPV; and 3) immediately post-exercise with Sham.

RESULTS

Our patients had a mean age of 70 ± 7 years, FEV₁ 1.9 ± 0.7 L and LVEF 41 ± 9%. NIPPV resulted in an increased Tlim (NiPPV: 130 ± 29s vs Sham: 98 ± 29s p = 0.015) and SpO₂ (NiPPV: 94.7 ± 3.5% vs Sham: 92.7 ± 5.2% p = 0.03). Also, NiPPV was able to produce a significant increase in FMD (%) (NiPPV: 9.2 ± 3.1 vs Sham: 3.6 ± 0.7, p < 0.05), FMD (mm) (NiPPV: 0.41 ± 0.18 vs Sham: 0.20 ± 0.11, p < 0.05), Blood flow velocity (NiPPV: 33 ± 18 vs Baseline: 20 ± 14, p < 0.05) and Shear Stress (SS) (NiPPV: 72 ± 38 vs Baseline: 43 ± 25, p < 0.05). We found correlation between Tlim vs. ΔSS (p = 0.03; r = 0.57). Univariate-regression analysis revealed that increased SS influenced 32% of Tlim during exercise with NiPPV.

CONCLUSION

NiPPV applied during high-intensity exercise can acutely modulate endothelial function and improve exercise tolerance in COPD-HF patients. In addition, the increase of SS positively influences exercise tolerance.

Atrial fibrillation in patients with heart failure with preserved ejection fraction

PURPOSE OF REVIEW

To review the shared pathology of atrial fibrillation and heart failure with preserved ejection fraction (HFpEF) and the prognostic, diagnostic, and treatment challenges incurred by the co-occurrence of these increasingly prevalent diseases.

RECENT FINDINGS

Multiple risk factors and mechanisms have been proposed as potentially linking atrial fibrillation and HFpEF, with systemic inflammation more recently being invoked. Nonvitamin K oral anticoagulants, left atrial appendage occlusion devices, and catheter ablation have emerged as alternative treatment options. Other novel pharmacological agents, such as neprilysin inhibitors, need to be studied further in this patient population.

SUMMARY

Atrial fibrillation and HFpEF commonly co-occur because of their shared risk factors and pathophysiology and incur increased morbidity and mortality relative to either condition alone. Although the presence of both diseases can often make each diagnosis difficult, it is important to do so early in the disease course as there are now a variety of treatment options aimed at improving symptoms and quality of life, slowing disease progression, and improving prognosis. However, more research needs to be performed on the role of catheter ablation in this population. Novel pharmacologic and procedural treatment options appear promising and may further improve the treatment options available to this growing population.

Are there gender differences in the association between body mass index and left ventricular diastolic function? A clinical observational study in the Japanese general population

BACKGROUND

Increased body mass index (BMI) is a major risk factor for heart failure with preserved ejection fraction (HFpEF), and HFpEF is more prevalent in elderly females than males. We hypothesized that there may be gender differences in the association between BMI and echocardiographic left ventricular (LV) diastolic parameters.

METHODS

We enrolled 456 subjects (243 males) without overt cardiac diseases, all of whom underwent a health checkup. Early (E) and late (A) diastolic transmitral flow velocity, early diastolic mitral annular velocity (e'), and left atrial (LA) volume index were measured by echocardiography to assess LV diastolic function. To examine gender differences in the association between BMI and LV diastolic function, we analyzed the interaction effects of gender on the association between BMI and echocardiographic LV diastolic parameters.

RESULTS

Although there were significant gender differences in the association between BMI and E/A and e' in the crude model (interaction effect 0.037 and 0.173, respectively; P = .006 and .022, respectively), these differences were not statistically significant after adjustment for factors related to LV diastolic function. On the other hand, there were significant associations between BMI and LV diastolic parameters in each gender, even after adjustment.

CONCLUSIONS

Our findings suggest there is no gender difference in the association between BMI and echocardiographic LV diastolic parameters. However, the association between BMI and LV diastolic parameters was significant in both genders. Controlling body weight might be beneficial for both women and men to prevent progression of LV diastolic dysfunction and development of HFpEF.

Clofibrate improves myocardial ischemia-induced damage through regulation of renin-angiotensin system and favours a pro-vasodilator profile in left ventricle

Myocardial ischemia initiates a chain of pathological conditions leading to cardiomyocyte death. Therefore, pharmacological treatment to stop ischemia-induced damage is necessary. Fibrates, have been reported to decrease inflammatory markers and to modulate the renin-angiotensin system (RAS). Our aim was to explore if clofibrate treatment, administered one week after myocardial event, decreases MI-induced cardiac damage. Wistar rats were assigned to: 1. Sham or 2. Coronary artery ligation (MI). Seven days after, rats were subdivided to receive vehicle (V) or clofibrate [100 mg/kg (C)] daily for 7 days. Blood samples and left ventricle were analyzed. RAS components [angiotensin II, angiotensin converting enzyme (ACE), and AT₁-receptor] decreased in MI-C compared to MI-V, while [Ang-(1-7), bradykinin, ACE-2, and AT₂-receptor] raised in response to clofibrate treatment. Oxidative stress markers increased in MI-V rats, a profile reverted in MI-C rats. Nitric oxide (NO) pathway (Akt, eNOS, and NO) exhibits a lower participation in MI-V, but clofibrate raised NO-pathway components and its production. MI-induced fibrosis and structural damage was also improved by clofibrate-treatment. In conclusion, clofibrate administration to 7 days MI-rats exerts an antioxidant, pro-vasodilator expression profile, and anti-fibrotic effect suggesting that PPARα activation can be considered a therapeutic target to improve cardiac condition posterior to ischemia.

Distinct clinical phenotypes of congestion in acute heart failure: characteristics, treatment response, and outcomes

Aims

Patients with acute heart failure (AHF) are included into clinical trials regardless of differences in baseline clinical characteristics. The aim of this study was to assess patients with AHF according to the presence of central and/or peripheral congestion at hospital admission and evaluate treatment response and outcomes in studied phenotypes.

Methods and results

We investigated retrospectively 352 patients (mean age: 68 ± 13 years, 77% men) hospitalized due to AHF with the signs of congestion on admission. Patients were divided according to the type of signs of congestion into three groups: A, isolated pulmonary congestion (n = 52, 15%); B, isolated peripheral congestion (n = 31, 9%); and C, signs of mixed (peripheral and central) congestion (n = 269, 76%). Patients from Group A had lower concentration of urea, bilirubin, and gamma‐glutamyl transferase whereas higher level of haematocrit, albumin, and leukocytes on admission. The highest baseline N‐terminal pro‐B‐type natriuretic peptide level (median: 4113 vs. 3634 vs. 6093 pg/mL) and percentage of patients with chronic heart failure (56 vs. 58 vs. 74%; A vs. B. vs. C, respectively, all P < 0.01) were observed in Group C. There were no differences in terms of demographics, co‐morbidities, left ventricular ejection fraction, and applied treatment between studied groups. Patients from Group A had the highest systolic blood pressure on admission (145 ± 37 vs. 122 ± 20 vs. 130 ± 29 mmHg) and the biggest decrease in systolic blood pressure [−22 (−45 to −4) vs. −2 (−13 to 2) vs. −10 (−25 to 0) mmHg] and heart rate [−16 (−35 to −1.5) vs. −1 (−10 to 5) vs. −7 (−20 to 0) b.p.m.] with the lowest weight change [−1.0 (−1.0 to 0) vs. −2.9 (−3.8 to −0.9) vs. −2.0 (−3.0 to −1.0) kg; all P < 0.01] after 48 h of hospitalization. There were differences in short‐term and long‐term outcomes with favourable results in Group A. Group A experienced less frequent in‐hospital heart failure worsening during the first 48 h (4 vs. 23 vs. 7%), had shorter length of hospital stay [6 (5–8) vs. 7 (5–11) vs. 7 (6–11) days], and had lower 1 year all‐cause mortality (12 vs. 28 vs. 29%; all P < 0.05). Presence of peripheral congestion on admission was independent predictor for all‐cause mortality within 1 year [hazard ratio (95% confidence interval): 2.68 (1.06–6.79); P = 0.04].

Conclusions

Patterns of congestion in AHF are associated with differences in clinical characteristics, treatment response, and outcomes. It needs to be considered once planning clinical trials in AHF.

Effectiveness of Nurse-Led Heart Failure Self-Care Education on Health Outcomes of Heart Failure Patients: A Systematic Review and Meta-Analysis

Poor self-care behaviors can lead to an increase in the risk of adverse health outcomes among patients with heart failure. Although a number of studies have investigated the effectiveness of nurse-led self-care education, the evidence regarding the effects of nurse-led intervention in heart failure remains uncertain. This study aimed to evaluate evidence on the effectiveness of nurse-led heart failure self-care education on health outcomes in patients with heart failure. To identify studies testing nurse-led education designed to improve self-care among heart failure patients, comprehensive search methods were used between January 2000 and October 2019 to systematically search six electronic databases: PubMed, CINAHL, Embase, Cochrane library, Web of Science, and SCOPUS. All the eligible study data elements were independently assessed and analyzed using random-effects meta-analysis methods. Of 612 studies, eight articles were eligible for this study. Nurse-led heart failure self-care education significantly reduced the risk of all-cause readmission (risk ratio (RR) = 0.75, 95% confidence interval (CI) = 0.66–0.85), heart failure specific readmission (RR = 0.60, 95% CI = 0.42–0.85), and all-cause mortality or readmission (RR = 0.71, 95% CI = 0.61–0.82). However, nurse-led heart failure self-care education was not associated with improvements in the quality of life and heart failure knowledge. Studies on the effectiveness of nurse-led heart failure self-care education mostly report only the positive effects on patients’ health outcomes, whereas evidence of the effectiveness of the nurse-led approach is still limited. Therefore, high quality randomized controlled trials with detailed and explicit descriptions on the components of the interventions are needed.

A Three-Part, Randomised Study to Investigate the Safety, Tolerability, Pharmacokinetics and Mode of Action of BC 007, Neutraliser of Pathogenic Autoantibodies Against G-Protein Coupled Receptors in Healthy, Young and Elderly Subjects

Background and Objective

BC 007 is a substance with a novel and innovative mode of action for the first-time causal treatment of chronic heart failure, associated with the occurrence of autoantibodies against the β1-adrenoceptor, and other diseases of mostly the heart and vascular system, being accompanied by the occurrence of functionally active agonistic autoantibodies against G-protein-coupled receptors (_fGPCR-AAb). The proposed mechanism of action of BC 007 is the neutralisation of these pathogenic autoantibodies which stimulate the respective receptor. To evaluate the safety, tolerability, pharmacokinetics and mode of action of BC 007, single intravenous infusions of increasing concentration were given to healthy young males and healthy elderly autoantibody-negative and autoantibody-positive participants of both sexes.

Methods

This study was subdivided into three parts. Part A was a single-centre, randomised, double-blind, placebo-controlled safety and tolerability study including healthy young male autoantibody-negative Whites (N = 23) and Asians (N = 1), testing doses of 15, 50 and 150 mg BC 007 (Cohorts 1–3) and elderly male and female Whites (N = 8), testing a dose of 150 mg BC 007 (Cohort 4), randomly assigned in a 3:1 ratio to BC 007 or placebo. Open-label Part B included _fGPCR-AAb-positive subjects (50 and 150 mg BC 007, Cohorts 1 and 2, respectively). Open-label Part C included _fGPCR-AAb-positive subjects for testing doses of 300, 450, 750, 1350 mg and 1900 mg BC 007. Lower doses were either given as an infusion or divided into a bolus plus infusion up to a dose of 300 mg followed by a constant bolus of 150 mg up to a dose of 750 mg, while at doses of 1350 mg and 1900 mg it was a slow infusion with a constant infusion rate. Infusion times increased with increasing dose from 20 min (15, 50 or 150 mg) to 40 min (300, 450 or 750 mg), 75 min (1350 mg) and 105 min (1900 mg).

Results

The mean observed BC 007 area under the concentration–time curve (AUC_0–24) increased with increasing dose in a dose proportional manner (slope estimate of 1.039). No serious adverse events were observed. Drug-related adverse events were predominantly the expected mild-to-moderate increase in bleeding time (aPTT), beginning with a dose of 50 mg, which paralleled the infusion and returned to normal shortly after infusion. _fGPCR-AAb neutralisation efficiency increased with increasing dose and was achieved for all subjects in the last cohort.

Conclusion

BC 007 is demonstrated to be safe and well tolerated. BC 007 neutralised _fGPCR-AAb, showing a trend for a dose-response relationship in elderly healthy but _fGPCR-AAb-positive subjects.

ClinicalTrials.gov Registration Number

NCT02955420.

Oxidative Stress, Kinase Activity and Inflammatory Implications in Right Ventricular Hypertrophy and Heart Failure under Hypobaric Hypoxia

High altitude (hypobaric hypoxia) triggers several mechanisms to compensate for the decrease in oxygen bioavailability. One of them is pulmonary artery vasoconstriction and its subsequent pulmonary arterial remodeling. These changes can lead to pulmonary hypertension and the development of right ventricular hypertrophy (RVH), right heart failure (RHF) and, ultimately to death. The aim of this review is to describe the most recent molecular pathways involved in the above conditions under this type of hypobaric hypoxia, including oxidative stress, inflammation, protein kinases activation and fibrosis, and the current therapeutic approaches for these conditions. This review also includes the current knowledge of long-term chronic intermittent hypobaric hypoxia. Furthermore, this review highlights the signaling pathways related to oxidative stress (Nox-derived O₂^.- and H₂O₂), protein kinase (ERK5, p38α and PKCα) activation, inflammatory molecules (IL-1β, IL-6, TNF-α and NF-kB) and hypoxia condition (HIF-1α). On the other hand, recent therapeutic approaches have focused on abolishing hypoxia-induced RVH and RHF via attenuation of oxidative stress and inflammatory (IL-1β, MCP-1, SDF-1 and CXCR-4) pathways through phytotherapy and pharmacological trials. Nevertheless, further studies are necessary.

Regional adiposity and heart failure with preserved ejection fraction

The role of obesity in the pathogenesis of heart failure (HF), and in particular HF with preserved ejection fraction (HFpEF), has drawn significant attention in recent years. The prevalence of both obesity and HFpEF has increased worldwide over the past decades and when present concomitantly suggests an obese-HFpEF phenotype. Anthropometrics, including body mass index, waist circumference, and waist-to-hip ratio, are associated with incident HFpEF. However, the cardiovascular effects of obesity may actually be driven by the distribution of fat, which can accumulate in the epicardial, visceral, and subcutaneous compartments. Regional fat can be quantified using non-invasive imaging techniques, including computed tomography, magnetic resonance imaging, and dual-energy X-ray absorptiometry. Regional variations in fat accumulation are associated with different HFpEF risk profiles, whereby higher epicardial and visceral fat have a much stronger association with HFpEF risk compared with elevated subcutaneous fat. Thus, regional adiposity may serve a pivotal role in the pathophysiology of HFpEF contributing to decreased cardiopulmonary fitness, impaired left ventricular compliance, upregulation of local and systemic inflammation, promotion of neurohormonal dysregulation, and increased intra-abdominal pressure and vascular congestion. Strategies to reduce total and regional adiposity have shown promise, including intensive exercise, dieting, and bariatric surgery programmes, but few studies have focused on HFpEF-related outcomes among obese. Further understanding the role these variable fat depots play in the progression of HFpEF and HFpEF-related hospitalizations may provide therapeutic targets in treating the obese-HFpEF phenotype.

Second European Society of Cardiology Cardiac Resynchronization Therapy Survey: the Italian cohort

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.

Reversible Cancer Therapeutics-related Cardiac Dysfunction Complicating Intra-cardiac Thrombi

Epirubicin-based chemotherapy carries a risk of inducing heart failure, although the frequency is rare. Bevacizumab, an anti-vascular endothelial growth factor monoclonal antibody, has recently been widely used in patients with recurrent breast cancer as a first-line chemotherapeutic agent. Heart failure or arterial thromboembolism has been reported as a rare cardiovascular complication of bevacizumab. We herein report a breast cancer patient with reversible cancer therapeutics-related cardiac dysfunction associated with bevacizumab and epirubicin complicating intracardiac thrombi in the left atrium and left ventricle. This case underscores the importance of tailored medical planning according to the individual status in patients receiving anti-cancer therapies.

Nurses as educators in the comprehensive heart failure care programme-Are we ready for it?

Aim

To assess education frequency and nurses' comfort when educating patients hospitalized in different hospital units to prepare them for self-care.

Design

A cross-sectional survey. The study included nurses working in units where HF patients were hospitalized.

Results

The average score for comfort of education was 5.43 (between "slightly comfortable" and "very comfortable"). The most comfortable topics were "Daily weight monitoring" (5.81 ± 1.25), "Signs/symptoms of worsening condition" (5.77 ± 1.19) and "Fluid restriction" (5.76 ± 1.23). The respondents felt least comfortable when teaching about "Medications" (5.06 ± 1.35) and "Low-sodium diet" (5.31 ± 1.42). The mean score obtained for education frequency was 5.21 (SD 2.51). The nurses most frequently educated their patients on such topics as "Daily weight monitoring" (5.82), "Signs/symptoms of worsening condition" (5.9) and "Fluid restriction" (5.92).

Conclusions

Polish nurses are not ready to perform comprehensive HF care tasks without preparation.

Circulating microRNA in Heart Failure - Practical Guidebook to Clinical Application

Heart failure (HF) remains a major cause of death and disability worldwide. Currently, B-type natriuretic peptide and N-terminal pro-brain natriuretic peptide are diagnostic biomarkers used in HF. Although very sensitive, they are not specific enough and do not allow the prediction or early diagnosis of HF. Many ongoing studies focus on determining the underlying cause and understanding the mechanisms of HF on the cellular level. MicroRNAs (miRNAs) are non-coding RNAs which control the majority of cellular processes and therefore are considered to have a potential clinical application in HF. In this review, we aim to provide synthesized information about miRNAs associated with ejection fraction, HF etiology, diagnosis, and prognosis, as well as outline therapeutic application of miRNAs in HF. Further, we discuss methodological challenges associated with the analysis of miRNAs and provide recommendations for defining a study population, collecting blood samples, and selecting detection methods to study miRNAs in a reliable and reproducible way. This review is intended to be an accessible tool for clinicians interested in the field of miRNAs and HF.

Dynamic monitoring of the effects of adherence to medication on survival in heart failure patients: A joint modeling approach exploiting time-varying covariates

Adherence to medication is the process by which patients take their drugs as prescribed, and represents an issue in pharmacoepidemiological studies. Poor adherence is often associated with adverse health conditions and outcomes, especially in case of chronic diseases such as heart failure (HF). This turns out in an increased request for health care services, and in a greater burden for the health care system. In recent years, there has been a substantial growth in pharmacotherapy research, aimed at studying effects and consequences of proper/improper adherence to medication both for the increasing awareness of the problem and for the pervasiveness of poor adherence among patients. However, the way adherence is computed and accounted for into predictive models is far from being informative as it may be. In fact, it is usually analyzed as a fixed baseline covariate, without considering its time-varying behavior. The purpose and novelty of this study is to define a new personalized monitoring tool exploiting time-varying definition of adherence to medication, within a joint modeling approach. In doing so, we are able to capture and quantify the association between the longitudinal process of dynamic adherence to medication with the long-term survival outcome. Another novelty of this approach consists of exploiting the potential of health care administrative databases in order to reconstruct the dynamics of drugs consumption through pharmaceutical administrative registries. In particular, we analyzed administrative data provided by Regione Lombardia - Healthcare Division related to patients hospitalized for HF between 2000 and 2012.

Recent updates on novel therapeutic targets of cardiovascular diseases

In recent times cardiovascular diseases (CVDs) are the leading cause of mortality universally, caused more or less 17.7 million casualties with 45% of all illnesses (except communicable ones) in 2015 as per World Health Organization (WHO). According to American National Center for Health Statistics, cardiac disorders are costliest. Moreover, health care expenditures related to cardiac disorders are anticipated to exceed than diabetes and Alzheimer's. Straining of reactive oxygen species with diminished neutralization & inflammation critically adds to atherosclerosis and also proceed to other cardiovascular diseases such as cardiac remodeling and myocardial infarction (MI). In the past few years, researchers revealed multiple drug targets from animal studies and evaluated them in the therapeutics of cardiac disorders, which offered exciting clues for novel therapeutic strategies. Although, only few newer agents approved clinically and actual approaches for treatment are lagging behind. Several novel drugs found effective for the treatment of hypertension, congestive heart failure, cardiac arrhythmia and angina pectoris. Detailed mechanism of action, basic and clinical pharmacology of all novel drugs has been discussed in this review.

Digoxin, mortality, and cardiac hospitalizations in patients with atrial fibrillation and heart failure with reduced ejection fraction and atrial fibrillation: An AF-CHF analysis

BACKGROUND

Recent publications have raised serious concerns regarding the safety of digoxin for atrial fibrillation (AF). However, the subgroup of patients with reduced ejection fraction and AF have been speculated to derive clinical benefit from digoxin. We aimed to assess the impact of digoxin on mortality and cardiovascular hospitalizations in the Atrial Fibrillation and Congestive Heart Failure (AF-CHF) trial since all AF-CHF patients had an ejection fraction ≤35% and AF.

METHODS AND RESULTS

Using marginal structural modeling, a contemporary statistical method that overcomes limitations of traditional modeling techniques and reduces bias, we assessed the impact of digoxin on the pre-specified primary and secondary outcomes of the AF-CHF trial, i.e., all-cause, cardiac and arrhythmic death as well as cardiovascular hospitalization. Among 1376 patients, 869 (65%) were on digoxin at one-year follow-up. Over a mean (SD) follow-up of 37 (19) months (maximum 74 months), 445 (32%) patients died, 357 (26%) from cardiovascular causes and 159 (12%) from arrhythmic death. Digoxin was significantly associated with all-cause, cardiac, and arrhythmic death, with estimated hazard ratios (HR) of 1.39 (95% confidence interval [CI] 1.11-1.73, P = 0.004), 1.44 (95% CI 1.13-1.82, P = 0.003), and 2.03 (95% CI 1.63-2.54, P < 0.0001), respectively. Digoxin was not associated with cardiovascular hospitalizations [HR 1.12 (95% CI 0.91-1.37), P = 0.29].

CONCLUSION

Digoxin is associated with increased all-cause mortality among patients with combined heart failure with reduced ejection fraction and AF, which is predominantly driven by arrhythmic deaths. In contrast, cardiovascular hospitalizations were not impacted by digoxin.

Inequalities in heart failure care in a tax-financed universal healthcare system: a nationwide population-based cohort study

Aims

Data on socioeconomic‐related differences in heart failure (HF) care are sparse. Inequality in care may potentially contribute to a poor clinical outcome. We examined socioeconomic‐related differences in quality of HF care among patients with incident HF with reduced ejection fraction (EF) (HFrEF).

Methods and results

We conducted a nationwide population‐based cohort study among patients with HFrEF (EF ≤40%) registered from January 2008 to October 2015 in the Danish Heart Failure Registry, a nationwide registry of patients with a first‐time primary HF diagnosis. Associations between individual‐level socioeconomic factors (cohabitation status, education, and family income) and the quality of HF care defined by six guideline‐recommended process performance measures [New York Heart Association (NYHA) classification, treatment with angiotensin‐converting‐enzyme inhibitors (ACEI)/angiotensin receptor blockers (ARB), beta‐blockers and mineralocorticoid receptor antagonists, exercise training, and patient education] were assessed using multiple imputation and multivariable logistic regression controlling for potential confounders. Among 17 122 HFrEF patients included, 15 290 patients had data on all six process performance measures. Living alone was associated with lower odds of NYHA classification [adjusted OR (aOR) 0.81; 95% confidence interval (CI): 0.72–0.90], prescription of ACEI/ARB (aOR 0.76; 95% CI: 0.68–0.88) and beta‐blockers (aOR 0.84; 95% CI: 0.76–0.93), referral to exercise training (aOR 0.75; 95% CI: 0.69–0.81), and patient education (aOR 0.73; 95% CI: 0.67–0.80). Compared with high‐level education, low‐level education was associated with lower odds of NYHA classification (aOR 0.93; 95% CI: 0.79–1.11), treatment with ACEI/ARB (aOR 0.99; 95% CI: 0.81–1.20) and beta‐blockers (aOR 0.93; 95% CI: 0.79–1.09), referral to exercise training (aOR 0.73; 95% CI: 0.65–0.82), and patient education (aOR 0.86, 95% CI: 0.75–0.98). An income in the lowest tertile was associated with lower odds of NYHA classification (aOR 0.67; 95% CI: 0.58–0.79), prescription of ACEI/ARB (aOR 0.80, 95% CI: 0.67–0.95) and beta‐blockers (aOR 0.88, 95% CI: 0.86–1.01), referral to exercise training (aOR 0.59, 95% CI: 0.53–0.64), and patient education (aOR 0.66; 95% CI: 0.59–0.74) compared with an income in the highest tertile. Overall, no systematic differences were seen when the analyses were stratified by sex and age groups.

Conclusions

Living alone, low‐level education, and income in the lowest tertile were associated with reduced use of recommended processes of HF care among Danish HFrEF patients with a first‐time primary HF diagnosis. Efforts are warranted to ensure guideline‐recommended HF care to all HFrEF patients, irrespective of socioeconomic background.

Effectiveness of high intensity interval training supplemented with peripheral and inspiratory resistance training in chronic heart failure: a pilot study

Background: Cardiac rehabilitation (CR) is an evidence-based therapy in chronic heart failure (CHF). There is still debate about the optimal training protocol in CHF. The use of high intensity interval training (HIIT) supplemented with peripheral (PRT) and inspiratory resistance training (IRT) might be more beneficial because of the higher impact on the peripheral and inspiratory muscles, with less symptoms of dyspnoea and lower amount of dropouts as a result. We compared our standard exercise-based CR programme, mainly consisting of moderate intensity interval training to a programme combining HIIT, PRT and IRT (resistance training supplemented HIIT (RHIIT) programme).Design: Randomised controlled pilot study.Methods: Twenty patients with CHF were randomised on a 1:1 basis to the standard or RHIIT programme. At baseline and after 3 months, peak exercise capacity (VO₂peak), peripheral (QF) and inspiratory respiratory muscle strength (MIP), quality of life (QOL) and physical activity were measured.Results: The RHIIT programme resulted in a significantly larger improvement in QF (ΔQF RHIIT programme: 19.3 ± 11.8 vs standard programme: -6.89 ± 19.0 Nm (p < .01)) and MIP (ΔMIP RHIIT programme: -44.9 ± 29.9 vs standard programme: 0.56 ± 19.4 cmH₂O (p < .01)). Both programmes equally improved in VO₂peak (p = .91), whereas ventilatory efficiency and physical activity remained stable.Conclusion: HIIT supplemented with PRT and IRT might be applicable as standard protocol in CHF. Larger studies are warranted to confirm our findings. The RHIIT programme resulted in similar training effects in VO₂peak in a shorter training period. This might be beneficial in a chronic patient population such as CHF, where adherence is difficult.

Left Ventricular Assist Device Implantation and Concomitant Dor Procedure: a Single Center Experience

OBJECTIVE

Left ventricular assist device (LVAD) implantation with concomitant Dor plasty is only reported anecdotally. We herein aimed to describe our experience with LVAD and concomitant Dor procedures and describe long-term outcomes of this special subset of heart failure patients.

METHODS

Between January/2010 and December/2018, 144 patients received LVAD therapy at our institution. Of those, five patients (80% male, 60.4±7.2 years) presented with an apical aneurysm and received concomitant Dor plasty. Apical aneurysms presented diameter between 75 and 98 mm, with one impending rupture.

RESULTS

Procedural success was achieved in all patients. No unplanned right ventricular assist device implantation occurred. Furthermore, no acute 30-day mortality was seen. In follow-up, one patient was lost due to intentional disconnection of the driveline. One patient underwent heart transplantation on postoperative day 630. The remaining three patients are still on device with sufficient flow; pump thromboses were successfully managed by lysis therapy in one patient.

CONCLUSION

LVAD implantation with concomitant Dor procedure is feasible, safe, and occasionally performed in patients with ischemic cardiomyopathy. Major advantages are prevention of thromboembolism and facilitation of LVAD placement by improving pump stability and warranting midventricular, coaxial alignment of the inflow cannula. In long-term follow-up, no adverse event associated with Dor plasty was observed.

Family History of Atrial Fibrillation and Risk of Cardiovascular Events: A Multicenter Prospective Cohort Study

BACKGROUND

To investigate the association between family history of atrial fibrillation (AF) with cardiovascular events (CVEs), major adverse cardiac events (MACE), and cardiovascular mortality.

METHODS

Multicenter prospective observational cohort study including 1722 nonvalvular AF patients from February 2008 to August 2019 in Italy. Family history of AF was defined as the presence of AF in a first-degree relative: mother, father, sibling, or children. Primary outcome was a composite of CVEs including fatal/nonfatal ischemic stroke and myocardial infarction, and cardiovascular death. Second, we analyzed the association with major adverse cardiac event.

RESULTS

Mean age was 74.6±9.4 years; 44% of women. Family history of AF was detected in 368 (21.4%) patients, and 3.5% had ≥2 relatives affected by AF. Age of AF onset progressively decreased from patients without family history of AF, compared with those with single and multiple first-degree affected relatives (P<0.001). During a mean follow-up of 23.7 months (4606 patients/y) 145 CVEs (3.15%/y), 98 major adverse cardiac event (2.13%/y), and 57 cardiovascular deaths (0.97%/y) occurred. After adjustment for cardiovascular risk factors, family history of AF was associated with a higher risk of CVEs (hazard ratio, 1.524 [95% CI, 1.021-2.274], P=0.039), major adverse cardiac event (hazard ratio, 1.917 [95% CI, 1.207-3.045], P=0.006), and cardiovascular mortality (hazard ratio, 2.008 [95% CI, 1.047-3.851], P=0.036). Subgroup analysis showed that this association was modified by age, sex, and prior ischemic heart disease.

CONCLUSIONS

In a cohort of elderly patients with a high atherosclerotic burden, family history of AF is evident in >20% of patients and was associated with an increased risk for CVEs and mortality. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01882114.

Lung Ultrasound Eight-Point Method in Diagnosing Acute Heart Failure in Emergency Patients with Acute Dyspnea: Diagnostic Accuracy and 72 h Monitoring

Background and Objectives: Acute dyspnea is a common chief complaint in the emergency department (ED), with acute heart failure (AHF) as a frequent underlying disease. Early diagnosis and rapid therapy are highly recommended by international guidelines. This study evaluates the accuracy of point-of-care B-line lung ultrasound in diagnosing AHF and monitoring the therapeutic success of heart failure patients. Materials and Methods: This is a prospective mono-center study in adult patients presenting with undifferentiated acute dyspnea to a German ED. An eight-zone pulmonary ultrasound was performed by experienced sonographers in the ED and 24 and 72 h after. Along with the lung ultrasound evaluation patients were asked to assess the severity of shortness of breath on a numeric rating scale. The treating ED physicians were asked to assess the probability of AHF as the underlying cause. Final diagnosis was adjudicated by two independent experts. Follow-up was done after 30 and 180 days. Results: In total, 102 patients were enrolled. Of them, 89 patients received lung ultrasound evaluation in the ED. The sensitivity of lung ultrasound evaluation in ED in diagnosing AHF was 54.2%, specificity 97.6%. As much as 96.3% of patients with a positive LUS test result for AHF in ED actually suffered from AHF. Excluding diuretically pretreated patients, sensitivity of LUS increased to 75% in ED. Differences in the sum of B-lines between admission time point, 24 and 72 h were not statistically significant. There were no statistically significant differences in the subjectively assessed severity of dyspnea between AHF patients and those with other causes of dyspnea. Of the 89 patients, 48 patients received the final adjudicated diagnosis of AHF. ED physicians assessed the probability of AHF in patients with a final diagnosis of AHF as 70%. Roughly a quarter (23.9%) of the overall cohort patients were rehospitalized within 30 days after admission, 38.6% within 180 days of follow-up. Conclusion: In conclusion, point-of-care lung ultrasound is a helpful tool for the early rule-in of acute heart failure in ED but only partially suitable for exclusion. Of note, the present study shows no significant changes in the number of B-lines after 24 and 72 h.

Clinical value of detecting autoantibodies against β1-, β2,- and α1-adrenergic receptors in carvedilol treatment of patients with heart failure

Objective

To determine the possible association of anti-β₁-adrenergic receptors (anti-β₁-AR), anti-β₂-AR and anti-α₁-AR with carvedilol treatment in patients with heart failure (HF).

Methods

A total of 267 HF patients were prospectively enrolled. Blood samples were measured by an enzyme-linked immunosorbent assay. All of the patients received carvedilol for their HF. Each patient was followed up for six months and their cardiac function was measured.

Results

The final analysis encompassed 137 patients comprising 65 patients with three autoantibodies (positive group) and 72 patients without all three autoantibodies but with one or two autoantibodies (negative group). The frequency and geometric mean titer of anti-β₁-AR, anti-β₂-AR, and anti-α₁-AR were significantly lower in the group without all three autoantibodies after six months of carvedilol treatment (all P < 0.01; from 100% to 57%, 50%, and 49%, respectively; and from 1: 118, 1: 138, and 1: 130 to 1: 72, 1: 61, and 1: 67, respectively). Furthermore, 28 patients in the positive group demonstrated complete ablation of autoantibodies. In addition, left ventricular remodelling and function was significantly improved by the use of carvedilol combined with the standard treatment regime for six months in the positive group (P < 0.01) when compared to the negative group (P < 0.05).

Conclusions

Carvedilol treatment significantly decreases frequency and geometric mean titer in patients with all three autoantibodies, even up to complete ablation, and significantly improved cardiac function and remodelling. The effect of carvedilol is probably correlated to the presence of all three autoantibodies.

Relationship between the place of living and mortality in patients with advanced heart failure

Background

Social and environmental factors in advanced heart failure (HF) patients may be crucial to cope with the end stages of the disease. This study analyzes health inequalities and mortality according to place of residence (rural vs urban) in HF patients at advanced stages of the disease.

Methods

Population-based cohort study including 1148 adult patients with HF attended in 279 primary care centers. Patients were followed for at least 1 year after reaching New York Heart Association IV functional class, between 2010 and 2014.

Data came from primary care electronic medical records. Cox regression models were applied to determine the hazard ratios (HR) of mortality.

Results

Mean age was 81.6 (SD 8.9) years, and 62% were women. Patients in rural areas were older, particularly women aged > 74 years (p = 0.036), and presented lower comorbidity. Mortality percentages were 59 and 51% among rural and urban patients, respectively (p = 0.030). Urban patients living in the most socio-economically deprived neighborhoods presented the highest rate of health service utilization, particularly with primary care nurses (p-trend < 0.001). Multivariate analyses confirmed that men (HR 1.60, 95% confidence interval (CI) 1.34–1.90), older patients (HR 1.05, 95% CI 1.04–1.06), Charlson comorbidity index (HR 1.16, 95% CI 1.11–1.22), and residing in rural areas (HR 1.35, 95% CI 1.09 to 1.67) was associated with higher mortality risk.

Conclusions

Living in rural areas determines an increased risk of mortality in patients at final stages of heart failure.

Extracellular vesicle Cystatin C and CD14 are associated with both renal dysfunction and heart failure

AIMS

Extracellular vesicles (EVs) are small double-membrane plasma vesicles that play key roles in cellular crosstalk and mechanisms such as inflammation. The role of EVs in combined organ failure such as cardiorenal syndrome has not been investigated. The aim of this study is to identify EV proteins that are associated with renal dysfunction, heart failure, and their combination in dyspnoeic patients.

METHODS AND RESULTS

Blood samples were prospectively collected in 404 patients presenting with breathlessness at the emergency department at National University Hospital, Singapore. Renal dysfunction was defined as estimated glomerular filtration rate < 60 mL/min/1.73 m² . The presence of heart failure was independently adjudicated by two clinicians on the basis of the criteria of the European Society of Cardiology guidelines. Protein levels of SerpinG1, SerpinF2, Cystatin C, and CD14 were measured with a quantitative immune assay within three EV sub-fractions and in plasma and were tested for their associations with renal dysfunction, heart failure, and the concurrence of both conditions using multinomial regression analysis, thereby correcting for confounders such as age, gender, ethnicity, and co-morbidities. Renal dysfunction was found in 92 patients (23%), while heart failure was present in 141 (35%). In total, 58 patients (14%) were diagnosed with both renal dysfunction and heart failure. Regression analysis showed that Cystatin C was associated with renal dysfunction, heart failure, and their combination in all three EV sub-fractions and in plasma. CD14 was associated with both renal dysfunction and the combined renal dysfunction and heart failure in all EV sub-fractions, and with presence of heart failure in the high density lipoprotein sub-fraction. SerpinG1 and SerpinF2 were associated with heart failure in, respectively, two and one out of three EV sub-fractions and in plasma, but not with renal dysfunction.

CONCLUSIONS

We provide the first data showing that Cystatin C and CD14 in circulating EVs are associated with both renal dysfunction and heart failure in patients presenting with acute dyspnoea. This suggests that EV proteins may be involved in the combined organ failure of the cardiorenal syndrome and may represent possible targets for prevention or treatment.

The effect of milrinone on mortality in adult patients who underwent CABG surgery: a systematic review of randomized clinical trials with a meta-analysis and trial sequential analysis

Background

As an inodilator, milrinone is commonly used for patients who undergo coronary artery bypass graft (CABG) surgery because of its effectiveness in decreasing the cardiac index and mitral regurgitation. The aim of this study was to perform a systematic review and meta-analysis of existing studies from the past 20 years to evaluate the impact of milrinone on mortality in patients who undergo CABG surgery.

Methods

We performed a systematic literature search on the application of milrinone in patients who underwent CABG surgery in studies published between 1997 and 2017 in BioMed Central, PubMed, EMBASE, and the Cochrane Central Register. The included studies evaluated milrinone groups compared to groups receiving either placebo or standard treatment and further compared the systemic administration.

Results

The network meta-analysis included 723 patients from 16 randomized clinical trials. Overall, there was no significant difference in mortality between the milrinone group and the placebo/standard care group when patients underwent CABG surgery. In addition, 9 trials (with 440 randomized patients), 4 trials (with 212 randomized patients), and 10 trials (with 470 randomized patients) reported that the occurrence of myocardial infarction (MI), myocardial ischemia, and arrhythmia was lower in the milrinone group than in the placebo/standard care group. Between the milrinone treatment and placebo/standard care groups, the occurrence of myocardial infarction, myocardial ischemia, and arrhythmia was significantly different. However, the occurrence of stroke and renal failure, the duration of inotropic support (h), the need for an intra-aortic balloon pump (IABP), and mechanical ventilation (h) between these two groups showed no differences.

Conclusions

Based on the current results, compared with placebo, milrinone might be unable to decrease mortality in adult CABG surgical patients but can significantly ameliorate the occurrence of MI, myocardial ischemia, and arrhythmia. These results provide evidence for the further clinical application of milrinone and of therapeutic strategies for CABG surgery. However, along with milrinone application in clinical use, sufficient data from randomized clinical trials need to be collected, and the potential benefits and adverse effects should be analyzed and reevaluated.

Characterization of dendritic cells in human and experimental myocarditis

Aims

Dendritic cells (DCs) are central mediators of adaptive immunity, and there is growing evidence of their role in myocardial inflammatory disease. We hypothesized that plasmacytoid and myeloid DCs are involved in the mechanisms of myocarditis and analysed these two main subtypes in human myocarditis subjects, as well as in a murine model of experimental autoimmune myocarditis (EAM).

Methods and results

Circulating DCs were analysed by flow cytometry in patients with acute myocarditis, dilated cardiomyopathy, and controls. Myocardial biopsies were immunostained for the presence of DCs and compared with non‐diseased controls. In a mouse model of acute myocarditis induced through synthetic cardiac myosine peptide injection, effects of immunomodulation including DC inhibition through MCS‐18 versus placebo treatment were tested at the peak of inflammation (Day 21), as well as 1 week later (partial recovery). Circulatory pDCs and mDCs were significantly reduced in myocarditis patients compared with controls (P < 0.01 for both) and remained so even after 6 months of follow‐up. Human myocarditis biopsies showed accumulation of pDCs (two‐fold CD304+/three‐fold CD123+, all P < 0.05) compared with controls. Myocardial pDCs and mDCs accumulated in EAM (P for both <0.0001). MCS‐18 treatment reduced pDC levels (P = 0.009), reduced myocardial inflammation (myocarditis score reduction from 2.6 to 1.8, P = 0.026), and improved ejection fraction (P = 0.03) in EAM at Day 21 (peak of inflammation). This effect was not observed during the partial recovery of inflammation on Day 28.

Conclusions

Circulating DCs are reduced in human myocarditis and accumulate in the inflamed myocardium. MCS‐18 treatment reduces DCs in EAM, leading to amelioration of inflammation and left ventricular remodelling during the acute phase of myocarditis. Our data further elucidate the role of DCs and their specific subsets in acute inflammatory cardiomyopathies.

Autonomic dysfunction in cardiac amyloidosis assessed by heart rate variability and heart rate turbulence

BACKGROUND

Cardiac amyloidosis (CA) is characterized by left ventricular hypertrophy (LVH) and autonomic nervous imbalance due to amyloid infiltration. However, autonomic dysfunction is often seen in heart failure (HF) with LVH from other etiologies. We aimed to characterize autonomic dysfunction in CA from other etiologies of LVH.

METHODS

Fifty-five HF patients with LVH (35 males, mean age 65 ± 16 years) were enrolled. LVH was defined as left ventricular mass index measured by echocardiography >95 g/m2 in women and 115 g/m2 in men. The etiology was as follows: amyloid light chain (AL)-CA, n = 14; hypertrophic cardiomyopathy, n = 21; and aortic stenosis (AS), n = 20. With the patient in a clinically stable condition, heart rate variability (HRV) and heart rate turbulence (HRT), which reflect autonomic dysfunction, were measured using Holter monitoring and compared among the three groups.

RESULTS

Brain natriuretic peptide levels, LVH severity, left ventricular ejection fraction, and tissue Doppler index E/e' did not differ among the three groups. However, severe abnormalities of HRV and HRT were obtained in AL-CA. In the ROC analysis to identify AL-CA in HF with LVH, the best cutoff value for standard deviation of all R-R intervals, standard deviation of the 5-min mean R-R intervals, turbulence onset, and turbulence slope were 68.5 ms (AUC: 0.865), 58.5 ms (AUC: 0.834), 0.25% (AUC: 0.813), and 1.00 ms/RR (AUC 0.736), respectively.

CONCLUSION

Autonomic dysfunction is a hallmark of AL-CA, and its noninvasive assessment by Holter monitoring may be a useful tool for differential diagnosis of HF with LVH.

Adherence to prescribed medications in patients with heart failure: insights from liquid chromatography-tandem mass spectrometry-based urine analysis

AIMS

None of the existing studies on adherence have directly measured levels of all medications (or their metabolites) in patients with heart failure (HF).

METHODS AND RESULTS

We used liquid chromatography-tandem mass spectrometry to measure the presence of prescribed drugs (diuretics, angiotensin-converting enzyme inhibitors, angiotensin receptor blockers, beta-blockers, and mineralocorticoid receptor antagonists) in the urine of patients reviewed 4-6 weeks after hospitalization with HF. Patients were unaware that adherence was being assessed. Of the 341 patients studied, 281 (82.4%) were adherent, i.e. had all prescribed drugs of interest detectable in their urine. Conversely, 60 patients (17.6%) were partially or completely non-adherent. Notably, 24 of the 60 were non-adherent to only diuretic therapy and only seven out of all 341 patients studied (2.1%) were completely non-adherent to all prescribed HF drugs. There were no major differences in baseline characteristics between adherent and non-adherent patients.

CONCLUSION

Non-adherence, assessed using a single spot urine measurement of drug levels, was confirmed in one of five patients evaluated 4-6 weeks after hospitalization with HF.

Growth differentiation factor 15 as mortality predictor in heart failure patients with non-reduced ejection fraction

Aims

The prognostic value of biomarkers in patients with heart failure (HF) and mid‐range (HFmrEF) or preserved ejection fraction (HFpEF) has not been widely addressed. The aim of this study was to assess whether the prognostic value of growth differentiation factor 15 (GDF‐15) is superior to that of N‐terminal pro‐brain natriuretic peptide (NT‐proBNP) in patients with HFmrEF or HFpEF.

Methods and results

Heart failure patients with either HFpEF or HFmrEF were included in the study. During their first visit to the HF unit, serum samples were obtained and stored for later assessment of GDF‐15 and NT‐proBNP concentrations. Patients were followed up by the HF unit. The main endpoint was all‐cause mortality. A total of 311 patients, 90 (29%) HFmrEF and 221 (71%) HFpEF, were included. Mean age was 72 ± 13 years, and 136 (44%) were women. No differences were found in GDF‐15 or NT‐proBNP concentrations between both HF groups. During a median follow‐up of 15 months (Q1–Q3: 9–30 months), 98 patients (32%) died, most (71%) of cardiovascular causes. Patients who died had higher median concentrations of GDF‐15 (4085 vs. 2270 ng/L, P < 0.0001) and NT‐proBNP (1984 vs. 1095 ng/L, P < 0.0001). A Cox multivariable model identified New York Heart Association Functional Class III (P = 0.04), systolic blood pressure (P = 0.01), left atrial diameter (P = 0.03), age >65 years (P < 0.0001), and GDF‐15 concentrations (P = 0.01) but not NT‐proBNP as independent predictors of all‐cause mortality. The area under the curve was 0.797 for the basic model including NT‐proBNP, and the area under the curve comparing the overall model was 0.819, P = 0.016 (DeLong's test). Integrated discrimination improvement index after the inclusion of GDF‐15 in the model with the mortality risk factors was 0.033; that is, the ability to predict death increased by 3.3% (P = 0.004). Net reclassification improvement was 0.548 (P < 0.001); that is, the capacity to improve the classification of the event (mortality) was 54.8%. GDF‐15 concentrations were divided in tertiles (<1625, 1625–4330, and >4330 ng/L), and survival curves were evaluated using the Kaplan–Meier technique. Patients in the highest tertile had the poorest 5 year survival, at 16%, whereas the lowest tertile had the best survival, of 78% (P < 0.001).

Conclusions

Growth differentiation factor 15 was superior to NT‐proBNP for assessing prognosis in patients with HFpEF and HFmrEF. GDF‐15 emerges as a strong, independent biomarker for identifying HFmrEF and HFpEF patients with worse prognosis.

Sarcopenia, sarcopenic overweight/obesity and risk of cardiovascular disease and cardiac arrhythmia: A cross-sectional study

BACKGROUND

Sarcopenia is an age-dependent skeletal muscle disorder that is common in patients with heart failure. The current study aimed to investigate the associations of sarcopenia with carotid atherosclerosis, cardiovascular disease and cardiac arrhythmia in a middle-aged and elderly population without clinical heart failure.

METHODS

A total of 2432 participants (992 men and 1440 women) from Shanghai Changfeng Study were included for analysis. The degree of sarcopenia was measured using height-adjusted appendicular skeletal muscle mass (ASM/height²). Carotid plaques were detected by carotid artery ultrasonography, and myocardial ischemia, infarction and cardiac arrhythmia were diagnosed based on electrocardiogram, past history and clinical manifestations.

RESULTS

Sarcopenia was associated with higher prevalence of carotid atherosclerosis (26.4% vs 20.4%, P = 0.027), myocardial infarction (4.0% vs 1.1%, P = 0.001), and premature ventricular contraction (4.0% vs 2.0%, P = 0.034) in the participants with normal body weight, and higher prevalence of carotid atherosclerosis (45.0% vs 31.2%, P = 0.016), myocardial infarction (10.0% vs 4.3%, P = 0.020) and atrial fibrillation (7.5% vs 1.3%, P < 0.001) in those with overweight/obese status. After adjustment for age, gender, cigarette smoking, alcohol drinking, menopausal status in women and other metabolic and inflammatory confounding factors, sarcopenia was independently associated with the risk of myocardial infarction in the whole population, and the risk of atrial fibrillation in the overweight/obese participants (all P < 0.05). Compared with nonsarcopenic lean participants, the risk of myocardial infarction was gradually increased in sarcopenic lean (OR 3.08 [1.28-7.45], P = 0.012) and sarcopenic overweight/obese participants (OR 4.07 [1.31-12.62], P = 0.015). For the atrial fibrillation, the participants with either sarcopenia or overweight/obesity alone showed no higher risk. However, concomitant sarcopenia and overweight/obesity was associated with approximately 5-fold risk of atrial fibrillation (OR 5.68 [1.34-24.12], P = 0.019) after multiple adjustment.

CONCLUSION

Sarcopenia is associated with myocardial infarction and atrial fibrillation in middle-aged and elderly adults without clinical heart failure.

Identifying the most important ECG predictors of reduced ejection fraction in patients with suspected acute coronary syndrome

BACKGROUND

Non-invasive screening tools of cardiac function can play a significant role in the initial triage of patients with suspected acute coronary syndrome. Numerous ECG features have been previously linked with cardiac contractility in the general population. We sought to identify ECG features that are most predictive for real-time screening of reduced left ventricular ejection fraction (LVEF) in the acute care setting.

METHODS

We performed a secondary analysis of a prospective, observational cohort study of patients evaluated for suspected acute coronary syndrome. We included consecutive patients in whom an echocardiogram was performed during indexed encounter. We evaluated 554 automated 12-lead ECG features in multivariate linear regression for predicting LVEF. We then used regression trees to identify the most important predictive ECG features.

RESULTS

Our final sample included 297 patients (aged 63 ± 15, 45% females). The mean LVEF was 57% ± 13 (IQR 50%-65%). In multivariate analysis, depolarization dispersion in the horizontal plane; global repolarization dispersion; and abnormal temporal indices in inferolateral leads were all independent predictors of LVEF (R² = 0.452, F = 6.679, p < 0.001). Horizontal QRS axis deviation and prolonged ventricular activation time in left ventricular apex were the most important determinants of reduced LVEF, while global QRS duration was of less importance.

CONCLUSIONS

Poor R wave progression in precordial leads with dominant QS pattern in V3 is the most predictive feature of reduced LVEF in suspected ACS. This feature constitutes a simple visual marker to aid clinicians in identifying those with impaired cardiac function.