Temporal trends in characteristics and outcome of heart failure patients with and without significant coronary artery disease

Effect of anaemia and iron deficiency in heart failure with mildly reduced ejection fraction

OBJECTIVE

The present study aims to clarify the prevalence and prognostic impact of anaemia and iron deficiency in patients with heart failure with mildly reduced ejection fraction (HFmrEF).

BACKGROUND

The prognostic impact of anaemia and iron deficiency in HFmrEF has not yet been clarified.

METHODS

Consecutive patients with HFmrEF were retrospectively included at one institution from 2016 to 2022. Patients with anaemia (i.e. haemoglobin <13 g/dL in males and < 12 g/dL in females) were compared to patients without, respectively patients with or without iron deficiency. The primary endpoint was all-cause mortality at 30 months (median follow-up), secondary endpoints comprised HF-related rehospitalisation.

RESULTS

Two thousand one hundred and fifty four patients with HFmrEF with a median haemoglobin level of 12.2 g/dL were included. Anaemia was present in 52% of patients with HFmrEF and associated with a higher risk of all-cause mortality (44% vs. 18%; HR = 3.021; 95% CI 2.552-3.576; p =.001) and HF-related rehospitalisation (18% vs. 8%; HR = 2.351; 95% CI 1.819-3.040; p =.001) at 30 months, which was confirmed after multivariable adjustment. Although iron status was infrequently assessed in anaemics with HFmrEF (27%), the presence of iron deficiency was associated with higher risk of rehospitalisation for worsening HF (25% vs. 15%; HR = 1.746; 95% CI 1.024-2.976; p =.038), but not all-cause mortality (p =.279) at 30 months.

CONCLUSION

Anaemia and iron deficiency are very common in atleast half of patients with HFmrEF and independently associated with adverse long-term prognosis.

Effect of severity and etiology of chronic kidney disease in patients with heart failure with mildly reduced ejection fraction

OBJECTIVE

The study investigates the prognostic impact of the severity and etiology of chronic kidney disease (CKD) in patients with heart failure with mildly reduced ejection fraction (HFmrEF).

BACKGROUND

Data regarding the outcomes in patients with CKD in HFmrEF is scarce.

METHODS

Consecutive patients with HFmrEF were retrospectively included at one institution from 2016 to 2022. Prognosis of patients with different stages and etiologies of CKD was investigated with regard to the primary endpoint of all-cause mortality at 30 months.

RESULTS

A total of 2155 consecutive patients with HFmrEF were included with an overall prevalence of CKD of 31%. Even milder stages of CKD (i.e., KDIGO stage 3a) were associated with an increased risk of 30-months all-cause mortality (HR = 1.242; 95% CI 1.147-1.346; p = 0.001). However, long-term prognosis did not differ in patients with KDIGO stage 5 compared to patients with stage 4 (HR = 0.886; 95% CI 0.616-1.275; p = 0.515). Furthermore, the highest risk of HF-related rehospitalization was observed in patients with KDIGO stages 3b and 4 (log rank p ≤ 0.015), whereas patients with KDIGO stage 5 had a lower risk of HF-related rehospitalization compared to patients with KDIGO stage 4 (HR = 0.440; 95% CI 0.228-0.849; p = 0.014). In contrast, the etiology of CKD was not associated with the risk of 30-month all-cause mortality (log rank p ≥ 0.347) and HF-related rehospitalization (log rank p ≥ 0.149).

CONCLUSION

In patients with HFmrEF, even milder stages of CKD were independently associated with increased risk of 30-months all-cause mortality.

Prognostic Implications of Type 2 Diabetes Mellitus in Heart Failure with Mildly Reduced Ejection Fraction

BACKGROUND

Data regarding the characterization and outcomes of diabetics with heart failure with a mildly reduced ejection fraction (HFmrEF) is scarce. This study investigates the prevalence and prognostic impact of type 2 diabetes in patients with HFmrEF.

METHODS

Consecutive patients with HFmrEF (i.e., left ventricular ejection fraction 41-49% and signs and/or symptoms of HF) were retrospectively included at one institution from 2016 to 2022. Patients with type 2 diabetes (dia-betics) were compared to patients without (i.e., non-diabetics). The primary endpoint was all-cause mortality at 30 months. Statistical analyses included Kaplan-Meier, multivariable Cox regression analyses and propensity score matching.

RESULTS

A total of 2169 patients with HFmrEF were included. The overall prevalence of type 2 diabetes was 36%. Diabetics had an increased risk of 30-months all-cause mortality (35.8% vs. 28.6%; HR = 1.273; 95% CI 1.092-1.483; p = 0.002), which was confirmed after multivariable adjustment (HR = 1.234; 95% CI 1.030-1.479; p = 0.022) and propensity score matching (HR = 1.265; 95% CI 1.018-1.572; p = 0.034). Diabetics had a higher risk of HF-related rehospitalization (17.8% vs. 10.7%; HR = 1.714; 95% CI 1.355-2.169; p = 0.001). Finally, the risk of all-cause mortality was increased in diabetics treated with insulin (40.7% vs. 33.1%; log-rank p = 0.029), whereas other anti-diabetic pharmacotherapies had no prognostic impact in HFmrEF.

CONCLUSIONS

Type 2 diabetes is common and independently associated with adverse long-term prognosis in patients with HFmrEF.

Diagnostic and Prognostic Value of Aminoterminal Prohormone of Brain Natriuretic Peptide in Heart Failure with Mildly Reduced Ejection Fraction Stratified by the Degree of Renal Dysfunction

Limited data concerning the diagnostic and prognostic value of blood-derived biomarkers in heart failure with mildly reduced ejection fraction (HFmrEF) is available. This study investigates the diagnostic and prognostic value of aminoterminal prohormone of brain natriuretic peptide (NT-proBNP) in patients with HFmrEF, stratified by the estimated glomerular filtration rate (eGFR). Consecutive patients with HFmrEF were retrospectively included at one institution from 2016 to 2022. First, the diagnostic value of NT-proBNP for acute decompensated heart failure (ADHF) was tested. Thereafter, the prognostic value of NT-proBNP levels was tested for 30-months all-cause mortality in patients with ADHF. From a total of 755 patients hospitalized with HFmrEF, the rate of ADHF was 42%. Patients with ADHF revealed higher NT-proBNP levels compared to patients without (median 5394 pg/mL vs. 1655 pg/mL; p = 0.001). NT-proBNP was able to discriminate ADHF with an area under the curve (AUC) of 0.777 (p = 0.001), with the highest AUC in patients with eGFR ≥ 60 mL/min (AUC = 0.800; p = 0.001), and no diagnostic value was seen in eGFR < 30 mL/min (AUC = 0.576; p = 0.210). Patients with NT-proBNP levels > 3946 pg/mL were associated with higher rates of all-cause mortality at 30 months (57.7% vs. 34.4%; HR = 2.036; 95% CI 1.423-2.912; p = 0.001), even after multivariable adjustment (HR = 1.712; 95% CI 1.166-2.512; p = 0.006). In conclusion, increasing NT-proBNP levels predicted the risk of ADHF and all-cause mortality in patients with HFmrEF and preserved renal function; however, NT-proBNP levels were not predictive in patients with HFmrEF and eGFR < 30 mL/min.

The Efficacy of Self-care Behaviors, Educational Interventions, and Follow-up Strategies on Hospital Readmission and Mortality Rates in Patients with Heart Failure

Heart failure (HF), a worldwide epidemic with significant morbidity and mortality risks, is frequently secondary to cardiovascular disorders and probably is the common final way to survive patients. Almost 25% of hospitalized patients with acute HF are expected to be readmitted within 30 days post-discharge, and the rates of rehospitalization increase to almost one-third at 60 days and 60 percent within one year of discharge. Although care planning for patients with heart failure is complex, multidisciplinary, and resource-dependent, optimal self-care management along with appropriate educational intervention and follow-up strategy could be able to reduce readmissions, decline the duration of hospitalization, increase life expectancy, decrease the rates of mortality, and reduce costs of healthcare services for patients with HF. However, there are contradictions in previous reports about the efficacy of self-care, mainly due to patients' non-adherence to self-care behaviors. Therefore, the current study aimed to review the investigations on the effectiveness of self-care of HF patients in reducing hospital readmissions and increasing quality of life, and discuss novel approaches for predischarge educational interventions and postdischarge follow-up strategies.

Outcomes of Emergent Isolated Coronary Bypass Grafting in Heart Failure Patients

Patients with previously diagnosed HF are at greater risk for subsequent morbidity and mortality when hospitalized for an Acute Myocardial Infarction (AMI). The purpose of our study was to describe the time trend of the incidence of emergent CABG in patients with and without HF, the clinical characteristics, outcomes, and the risk factors for mortality of surgical revascularization in the short and medium term. This was a single-center retrospective observational study of patients who underwent isolated emergency CABG from January 2009 to January 2020. A propensity-score matching analysis yielded two comparable groups (n = 430) of patients without (n = 215) and with (n = 215) heart failure. In-hospital mortality did not differ in the two groups (2.8%; p > 0.9); the patients with heart failure presented more frequently with cardiogenic shock, and there was an association with mortality and mechanical circulatory support (OR 16.7−95% CI 3.31−140; p = 0.002) and postoperative acute renal failure (OR 15.9−95% CI 0.66−203; p = 0.036). In the early- and mid-term, heart failure and NSTEMI were associated with mortality (HR 3.47−95% CI 1.15−10.5; p = 0.028), along with age (HR 1.28−95% CI 1.21−1.36; p < 0.001). Surgical revascularization offers an excellent solution for patients with acute coronary syndrome, leading to a good immediate prognosis even in those with chronic heart failure.

Treatment response in recent-onset heart failure with reduced ejection fraction: non-ischaemic vs. ischaemic aetiology

AIMS

In heart failure (HF) with reduced left ventricular ejection fraction (HFrEF), the prognosis appears better in non-ischaemic than in ischaemic aetiology. Infrequent diagnostic work-up for ischaemic heart disease (IHD) in HF is reported. In this study, we compared short-term response to initiated guideline-directed medical treatment (GDMT) in recent-onset HFrEF of non-ischaemic (non-IHF) vs. ischaemic (IHF) aetiology and evaluated the frequency of coronary investigation.

METHODS AND RESULTS

Patients hospitalized with recent-onset HFrEF [left ventricular ejection fraction (LVEF) < 40%] between 1 January 2016 and 31 December 2019 were included. Treatment response was determined by use of a hierarchical clinical composite outcome classifying each patient as worsened, improved, or unchanged based on hard outcomes (mortality, heart transplantation, and HF hospitalization) and soft outcomes (± ≥10 unit change in LVEF, ± ≥30% change in N-terminal pro-B-type natriuretic peptide, and ± ≥1 point change in New York Heart Association functional class) during 28 weeks of follow-up. The associations between baseline characteristics and composite changes were analysed with multiple logistic regression. Among the 364 patients analysed, 47 were not investigated for IHD. Comparing non-IHF (n = 203) vs. IHF (n = 114), patients were younger (mean age 61.0 vs. 69.4 years, P < 0.001) with lower mean LVEF (26% vs. 31%, P < 0.001), but with similar male predominance (70.4% vs. 75.4%, P = 0.363). For non-IHF vs. IHF, the composite outcomes were worsened (19.1% vs. 43.9%, P < 0.001) and improved (74.2% vs. 43.9%, P < 0.001). After multivariable adjustments, IHF was associated with increased odds for worsening [odds ratio (OR) 2.94; 95% confidence interval (CI) 1.51-5.74; P = 0.002] and decreased odds for improvement (OR 0.35; 95% CI 0.18-0.65; P < 0.001). In cases without previous IHD or new-onset myocardial infarction (n = 261), a decision for coronary investigation was made in 69.0%.

CONCLUSIONS

In recent-onset HFrEF, patients with non-IHF responded better to GDMT than patients with IHF. Almost one-third of patients selected for follow-up at HF clinics were never investigated for IHD.

Trends in Ischemic Evaluation in New-Onset Heart Failure Without Known Coronary Artery Disease

BACKGROUND

Guidelines recommend consideration of an ischemic evaluation (Class IIa-IIb) in new-onset heart failure (HF), but it is not well-known how often this is performed and leads to revascularization.

OBJECTIVES

The authors investigated temporal trends in ischemic evaluation and revascularization within 90 days of HF onset in Denmark 2008-2018.

METHODS

From the Danish nationwide administrative registries, diagnostic tests and revascularizations within 90 days were identified among patients with new-onset HF between 2008 and 2018, alive 90 days after diagnosis.

RESULTS

Of 61,475 patients (mean age: 72.6 ± 13.8 years, 46% women), 12,503 (20%) underwent an ischemic evaluation, of whom 10,547 (84%) underwent invasive coronary angiography, and 1,956 (16%) underwent an initial noninvasive test, most frequently coronary computed tomographic angiography (n = 1,813, 93%). Of those who were initially referred for coronary computed tomographic angiography, 374 (21%) had a subsequent invasive coronary angiogram undertaken. Among individuals undergoing ischemic testing, percutaneous coronary intervention and coronary artery bypass graft surgery were performed in 1,354 (11%) and 619 (5%), respectively, corresponding to 2.2% and 1.0% of the entire sample. Between 2008 and 2018, the number of patients referred for ischemic evaluations increased, adjusted OR for 1.07 (95% CI: 1.06-1.07) per year high, and was greater among older versus younger individuals (OR: 1.01 [95% CI: 0.99-1.03], OR: 1.04 [95% CI: 1.03-1.06], OR: 1.06 [95% CI: 1.05-1.07], OR: 1.11 [95% CI: 1.09-1.12], and OR: 1.14 [95% CI: 1.10-1.18] per year increase for age group <50, 51-60, 61-75, 76-85, and >85 years, respectively, P for interaction <0.0001).

CONCLUSIONS

In clinical practice, few patients with new-onset HF are referred for an ischemic evaluation and a minority undergo revascularization. Studies are needed to establish the appropriateness of this practice.

Left Main Coronary Artery Disease-Current Management and Future Perspectives

Due to its anatomical features, patients with an obstruction of the left main coronary artery (LMCA) have an increased risk of death. For years, coronary artery bypass grafting (CABG) has been considered as a gold standard for revascularization. However, notable advancements in the field of percutaneous coronary intervention (PCI) led to its acknowledgement as an important treatment alternative, especially in patients with low and intermediate anatomical complexity. Although recent years brought several random clinical trials that investigated the safety and efficacy of the percutaneous approach in LMCA, there are still uncertainties regarding optimal revascularization strategies. In this paper, we provide a comprehensive review of state-of-the-art diagnostic and treatment methods of LMCA disease, focusing on percutaneous methods.