Clinical practice update on heart failure 2019: pharmacotherapy, procedures, devices and patient management. An expert consensus meeting report of the Heart Failure Association of the European Society of Cardiology

[Self-care education during Cardiac Rehabilitation programs for patients with Heart Failure with preserved Ejection Fraction: a Delphi Study]

OBJECTIVES

To develop a decalogue of self-care competencies to manage educational intervention during Cardiac Rehabilitation (CR) programs in Heart Failure with preserved Ejection Fraction (HFpEF) patients through multidisciplinary consensus.

DESIGN

3-round e-Delphi study using an initial questionnaire of 23 competencies based on the main recommendations of the CR and self-care guidelines. SITE: It was framed under the ethics of a randomised clinical trial developed at the Regional Hospital of Malaga. The survey was designed and disseminated as an online questionnaire.

PARTICIPANTS

The expert panel comprised two patients with HFpEF and 13 healthcare professionals from Internal Medicine (n=3), Cardiology (n=2), Physiotherapy (n=3), Nursing (n=3) and Occupational Therapy (n=2).

METHOD

The analysis of results included the content validity index, the percentage of agreement, and the concordance using Fleiss Kappa and Krippendorff's alpha.

RESULTS

After the third round, 20 self-care competencies were identified, grouped into 12 domains, with sufficient consensus for their inclusion in the decalogue.

CONCLUSIONS

The decalogue of self-care competencies generated from the multidisciplinary consensus guides education in patients with HFpEF, systematically addressing educational content tailored to patients for clinical practice in CR programs.

Overview of Panax ginseng and its active ingredients protective mechanism on cardiovascular diseases

ETHNIC PHARMACOLOGICAL RELEVANCE

Panax ginseng is a traditional Chinese herbal medicine used to treat cardiovascular diseases (CVDs), and it is still widely used to improve the clinical symptoms of various CVDs. However, there is currently a lack of summary and analysis on the mechanism of Panax ginseng exerts its cardiovascular protective effects. This article provides a review of in vivo and in vitro pharmacological studies on Panax ginseng and its active ingredients in reducing CVDs damage.

AIM OF THIS REVIEW

This review summarized the latest literature on Panax ginseng and its active ingredients in CVDs research, aiming to have a comprehensive and in-depth understanding of the cardiovascular protection mechanism of Panax ginseng, and to provide new ideas for the treatment of CVDs, as well as to optimize the clinical application of Panax ginseng.

METHODS

Enrichment of pathways and biological terms using the traditional Chinese medicine molecular mechanism bioinformatics analysis tool (BATMAN-TCM). The literature search is based on electronic databases such as PubMed, ScienceDirect, Scopus, CNKI, with a search period of 2002-2023. The search terms include Panax ginseng, Panax ginseng ingredients, ginsenosides, ginseng polysaccharides, ginseng glycoproteins, ginseng volatile oil, CVDs, heart, and cardiac.

RESULTS

132 articles were ultimately included in the review. The ingredients in Panax ginseng that manifested cardiovascular protective effects are mainly ginsenosides (especially ginsenoside Rb1). Ginsenosides protected against CVDs such as ischemic reperfusion injury, atherosclerosis and heart failure mainly through improving energy metabolism, inhibiting hyper-autophagy, antioxidant, anti-inflammatory and promoting secretion of exosomes.

CONCLUSION

Panax ginseng and its active ingredients have a particularly prominent effect on improving myocardial energy metabolism remodeling in protecting against CVDs. The AMPK and PPAR signaling pathways are the key targets through which Panax ginseng produces multiple mechanisms of cardiovascular protection. Extracellular vesicles and nanoparticles as carriers are potential delivery ways for optimizing the bioavailability of Panax ginseng and its active ingredients.

Association Between Adherence to a 3-Month Cardiac Rehabilitation Program and Long-Term Clinical Outcomes in Japanese Patients With Cardiac Implantable Electronic Devices

PURPOSE

The objective of this study was to evaluate the association between comprehensive cardiac rehabilitation (CCR) completion and long-term clinical outcomes in patients with cardiac implantable electronic devices (CIED).

METHODS

This retrospective cohort study included 834 patients with CIED who participated in CCR, which included a cardiopulmonary exercise test or 6-min walk test. Patients with a left ventricular ejection fraction ≤40%, predicted peak oxygen uptake ≤80%, or B-type natriuretic peptide level ≥80 pg/mL were eligible. The primary outcome was all-cause mortality.

RESULTS

After excluding 241 patients with duplicate records and 69 who underwent CCR in the outpatient department, the data of 524 patients were analyzed. Mean age was 64 ± 15 yr, 389 (74%) patients were men, left ventricular ejection fraction was 31 ± 15%, and 282 (54%) patients had a history of hospitalization for worsening heart failure. Of the patients referred for CCR, 294 (56%) completed the program, and an additional 230 patients started but did not complete CCR. Over a 3.7-yr median follow-up period, all-cause mortality occurred in 156 (30%) patients. Completers had lower all-cause mortality rates than non-completers (log-rank 15.77, P < .001). After adjusting for prognostic baseline characteristics, completers had 58% lower all-cause mortality risks than non-completers (HR = 0.42; 95% CI, 0.27-0.64, P < .001).

CONCLUSIONS

Three-mo CCR program completion was associated with lower mortality risks in patients with CIED. New programs or management methods are needed to decrease mortality risks, especially for those who cannot complete CCR programs.

Salt versus no salt restriction in heart failure a review

BACKGROUND

For decades standard teaching recommended salt intake (sodium) reduction in patients suffering from heart failure. Neurohumoral activation with subsequent fluid retention provided a solid rationale for this long-standing recommendation. Until recently no large randomized clinical trial of sodium restriction was available, while some observational studies and metanalyses even suggested a worse outcome with strict sodium restriction in patients with heart failure.

METHODS

In this narrative review we aimed to extricate from the literature whether strict sodium restriction is beneficial in patients with heart failure. We searched PubMed indexed articles between 2000 and 2023 for these terms: heart failure, salt, sodium, fluid intake.

RESULTS

Most randomized trials were small and showed a wide heterogeneity of interventions. A single large, randomized clinical trial was stopped early due to futility. Overall, there is no evidence that severe sodium restriction reduces the incidence of mortality and hospitalization in patients with heart failure. Quality of life and functional class may improve slightly with sodium restriction.

CONCLUSION

Morbidity and mortality are not reduced with sodium restriction in patients with heart failure, although some symptomatic improvement may be expected.

Two-Year Outcomes of Primary Prophylactic Use of Defibrillators for Ischemic and Non-Ischemic Cardiomyopathy - Propensity Score-Matched Analysis From the Nippon Storm Study

BACKGROUND

In 2016, the DANISH study reported negative results regarding the efficacy of implantable cardioverter-defibrillators (ICDs) in patients with non-ischemic cardiomyopathy (NICM) and reduced left ventricular ejection fraction (LVEF). In this study we determined the efficacy of using ICDs for primary prophylaxis in patients with NICM.Methods and Results: We selected 1,274 patients with underlying cardiac disease who were enrolled in the Nippon Storm Study. We analyzed the data of 451 patients with LVEF ≤35% due to NICM or ischemic cardiomyopathy (ICM) who underwent ICD implantation for primary prophylaxis (men, 78%; age, 65±12 years; LVEF, 25±6.4%; cardiac resynchronization therapy, 73%; ICM, 33%). After propensity score matching, we compared the baseline covariates between groups: NICM (132 patients) and ICM (132 patients). The 2-year appropriate ICD therapy risks were 27.7% and 12.2% in the NICM and ICM groups, respectively (hazard ratio, 0.390 [95% confidence interval, 0.218-0.701]; P=0.002).

CONCLUSIONS

This subanalysis of propensity score-matched patients from the Nippon Storm Study revealed that the risk of appropriate ICD therapy was significantly higher in patients with NICM than in those with ICM.

Empagliflozin in the treatment of heart failure

Heart failure (HF) affects more than 60 million individuals globally. Empagliflozin is currently approved for type 2 diabetes and chronic HF. Clinical trials have demonstrated that empagliflozin reduces the composite end point of hospitalizations for HF and mortality and improves the quality of life irrespective of left ventricular ejection fraction. Empagliflozin is a once-daily medication with minimal drug-drug interactions and does not require titration. Empagliflozin causes mild weight loss and does not significantly reduce blood pressure. Empagliflozin acts as an enabler for other HF drugs by reducing the risk of hyperkalemia. Empagliflozin is also beneficial for chronic kidney disease which exists commonly with HF. This review outlines the pharmacokinetics, pharmacodynamics, safety, and efficacy of empagliflozin in HF across various sub-groups and settings.

The Influence of Hybrid Comprehensive Telerehabilitation on Anxiety in Heart Failure Patients: The TELEREH-HF Randomized Clinical Trial

Telerehabilitation for heart failure (HF) patients is beneficial for physical functioning, prognosis, and psychological status. The study aimed at evaluating the influence of hybrid comprehensive telerehabilitation (HCTR) on the level of anxiety in comparison to usual care (UC). The TELEREH-HF study was a multicenter prospective RCT in 850 clinically stable HF participants. Patients underwent clinical examinations, including the assessment of anxiety, at entry and after the 9-week training program (HCTR) or observation (UC). The State-Trait Anxiety Inventory (STAI) was used. 20.3% HCTR and 20.1% UC patients reported high level of anxiety as a state at baseline, with higher STAI results in younger participants (< 63 y.o.) (p = .048 for HCTR; p = .026 for UC). At both stages of the study, patients with lower level of physical capacity (measured by a peak VO2) had shown significantly higher level of anxiety. There were no significant changes in anxiety levels during the 9-week observation for the entire study population, although there were different patterns of change in anxiety (both trait and state) in younger and older groups,with the decrease in younger patients, and the increase-in the older group.Trial registry number NCT02523560 (Clinical Trials.gov), date of registration: August 14, 2015.

Diagnostic accuracy of prehospital lung ultrasound for acute decompensated heart failure: A systematic review and Meta-analysis

BACKGROUND

Lung ultrasound (LUS) reduces time to diagnosis and treatment of acute decompensated heart failure (ADHF) in emergency department (ED) patients with undifferentiated dyspnea. We conducted a systematic review to evaluate the diagnostic accuracy and clinical impact of LUS for ADHF in the prehospital setting.

METHODS

We performed a keyword search of multiple databases from inception through June 1, 2023. Included studies were those enrolling prehospital patients with undifferentiated dyspnea or suspected ADHF, and specifically diagnostic studies comparing prehospital LUS to a gold standard and intervention studies with a non-US comparator group. Title and abstract screening, full text review, risk of bias (ROB) assessments, and data extraction were performed by multiple authors. and adjudicated. The primary outcome was pooled sensitivity, specificity, and diagnostic likelihood ratios (LR) for prehospital LUS. A test-treatment threshold of 0.7 was applied based on prior ADHF literature in the ED. Intervention outcomes included mortality, mechanical ventilation, and time to HF specific treatment.

RESULTS

Eight diagnostic studies (n = 691) and two intervention studies (n = 70) met inclusion criteria. No diagnostic studies were low-ROB. Both intervention studies were critical-ROB, and not pooled. Pooled sensitivity and specificity of prehospital LUS for ADHF were 86.7% (95%CI:70.8%-94.6%) and 87.5% (78.2%-93.2%), respectively, with similar performance by physician vs. paramedic LUS and number of lung zones evaluated. Pooled LR+ and LR- were 7.27 (95% CI: 3.69-13.10) and 0.17 (95% CI: 0.06-0.34), respectively. Area under the summary receiver operating characteristic curve was 0.922. At the observed 42.4% ADHF prevalence (pre-test probability), positive pre-hospital LUS exceeded the 70% threshold to initiate treatment (post-test probability 84%, 80-88%).

CONCLUSIONS

LUS had similar diagnostic test characteristics for ADHF diagnosis in the prehospital setting as in the ED. A positive prehospital LUS may be sufficient to initiate early ADHF treatment based on published test-treatment thresholds. More studies are needed to determine the clinical impact of prehospital LUS.

Gut Permeability and Immune-Mediated Inflammation in Heart Failure

Heart failure (HF) is characterized by low-grade immune-mediated inflammation due to increased Toll-like receptor (TLR) expression as response to endotoxin increase and dysregulated gut barrier permeability. We investigated TLR expression and possible gut dysbiosis in HF patients compared to a control group. We enrolled 80 Caucasian HF patients and 20 controls. Low-grade immune-mediated inflammation was evaluated by TLR expression, while gut dysbiosis by the detection of zonulin and bacterial endotoxin activity in a semi-quantitative (endotoxin activity assay [EAA]) and quantitative (limulus amebocyte lysate [LAL] test) way. Compared to controls, patients with HF showed significantly higher age and blood pressure values, worse metabolic profile and kidney function, higher inflammatory biomarkers levels, and lower levels of zonulin and endotoxin activity. When dividing failing patients in those with reduced ejection fraction (HF-rEF) and those with preserved ejection fraction (HF-pEF), HF-rEF patients showed significantly higher values of inflammatory biomarkers and TLR expression than HF-pEF patients. Gut permeability biomarkers inversely correlated with the severity of HF and positively with renal function. eGFR was retained as an independent predictor of zonulin variation in all the three groups of failing patients. Present data work to extend current knowledge about the role of gut microbiota in immune-mediated inflammation in HF.

Sacubitril/valsartan improves the prognosis of acute myocardial infarction: a meta-analysis

OBJECTIVE

To systematically evaluate the effect of sacubitril/valsartan (SV) on the prognosis of patients with acute myocardial infarction (AMI), and to provide evidence for expanding the clinical application of SV.

METHODS

PubMed, EMbase, Web of Science, and Cochrane Library were searched from inception to October 2023 for randomized controlled trials (RCTs) of SV in patients with AMI. The article was screened and evaluated by the Cochrane 5.1.0 bias risk assessment tool. RevMan5.3 was used for meta-analysis of the outcome indicators.

RESULTS

Ten RCTs involving 7230 patients were included. The results showed that SV increased left ventricular eject fraction ( MD  = 2.86, 95% CI [1.81-3.90], P  < 0.00001) and reduced readmission rate ( RR  = 0.46, 95% CI [0.32-0.68], P  < 0.0001), decreased N-terminal pro-brain natriuretic peptide ( MD = -477.46, 95% CI [-914.96 to -39.96], P  = 0.03), and reduced major adverse cardiovascular and cerebrovascular event (MACCE) ( RR  = 0.48, 95% CI [0.27-0.85], P  = 0.01). There was no significant difference in the rate of adverse reaction (AR) between the trial group and the control group ( RR  = 0.88, 95% CI [0.60-1.30], P  = 0.52).

CONCLUSION

SV can effectively improve the prognosis of AMI, prevent complications, and there is no significant difference in safety compared with angiotensin-converting enzyme inhibitor/angiotensin receptor blocker.

Weight telemonitoring of heart failure versus standard of care in a real-world setting: Results on mortality and hospitalizations in a 6-month nationwide matched cohort study

AIMS

Evaluating the benefit of telemonitoring in heart failure (HF) management in real-world settings is crucial for optimizing the healthcare pathway. The aim of this study was to assess the association between a 6-month application of the telemonitoring solution Chronic Care Connect™ (CCC) and mortality, HF hospitalizations, and associated costs compared with standard of care (SOC) in patients with a diagnosis of HF.

METHODS AND RESULTS

From February 2018 to March 2020, a retrospective cohort study was conducted using the largest healthcare insurance system claims database in France (Système National des Données de Santé) linked to the CCC telemonitoring database of adult patients with an ICD-10-coded diagnosis of HF. Patients from the telemonitoring group were matched with up to two patients from the SOC group based on their high-dimensional propensity score, without replacement, using the nearest-neighbour method. A total of 1358 telemonitored patients were matched to 2456 SOC patients. The cohorts consisted of high-risk patients with median times from last HF hospitalization to index date of 17.0 (interquartile range: 7.0-66.0) days for the telemonitoring group and 27.0 (15.0-70.0) days for the SOC group. After 6 months, telemonitoring was associated with mortality risk reduction (hazard ratio [HR] 0.71, 95% confidence interval [CI] 0.56-0.89), a higher risk of first HF hospitalization (HR 1.81, 95% CI 1.55-2.13), and higher HF healthcare costs (relative cost 1.38, 95% CI 1.26-1.51). Compared with the SOC group, the telemonitoring group experienced a shorter average length of overnight HF hospitalization and fewer emergency visits preceding HF hospitalizations.

CONCLUSION

The results of this nationwide cohort study highlight a valuable role for telemonitoring solutions such as CCC in the management of high-risk HF patients. However, for telemonitoring solutions based on weight and symptoms, consideration should be given to implement additional methods of assessment to recognize imminent worsening of HF, such as impedance changes, as a way to reduce mortality risk and the need for HF hospitalizations. Further studies are warranted to refine selection of patients who could benefit from a telemonitoring system and to confirm long-term benefits in high-risk and stable HF patients.

Sex differences in achieving guideline-recommended heart rate control among a large sample of patients at risk for sudden cardiac arrest

Background

Despite known clinical benefits, guideline-recommended heart rate (HR) control is not achieved for a significant proportion of patients with HF with reduced ejection fraction. The wearable cardioverter-defibrillator (WCD) provides continuous HR monitoring and alerts that could aid medication titration.

Objective

This study sought to evaluate sex differences in achieving guideline-recommended HR control during a period of WCD use.

Methods

Data from patients fitted with a WCD from 2015 to 2018 were obtained from the manufacturer's database (ZOLL). The proportion of patients with adequate nighttime resting HR control at the beginning of use (BOU) and at the end of use (EOU) were compared by sex. Adequate HR control was defined as having a nighttime median HR <70 beats/min.

Results

A total of 21,440 women and a comparative sample of 17,328 men (median 90 [IQR 59-116] days of WCD wear) were included in the final dataset. Among patients who did not receive a shock, over half had insufficient HR control at BOU (59% of women, 53% of men). Although the proportion of patients with resting HR ≥70 beats/min improved by EOU, 43% of women and 36% of men did not achieve guideline-recommended HR control.

Conclusion

A significant proportion of women and men did not achieve adequate HR control during a period of medical therapy optimization. Compared with men, a greater proportion of women receiving WCD shocks had insufficiently controlled HR in the week preceding ventricular tachyarrhythmia/ventricular fibrillation and 43% of nonshocked women, compared with 36% of men, did not reach adequate HR control during the study period. The WCD can be utilized as a remote monitoring tool to record HR and inform adequate uptitration of beta-blockers, with particular focus on reducing the treatment gap in women.

Correlation of ventricle epicardial fat volume and triglyceride-glucose index in patients with chronic heart failure

To explore the association of ventricle epicardial fat volume (EFV) calculated by cardiac magnetic resonance (CMR) and the insulin resistance indicator of triglyceride-glucose (TyG) index in patients with chronic HF (CHF), this retrospective cohort study included adult CHF patients with confirmed diagnosis of heart failure from January 2018 to December 2020. All patients underwent 3.0T CMR, and EFV were measured under short-axis cine. Spearman correlation, multivariate linear regression, and restricted cubic spline (RCS) regression were used to analyze their association. There were 516 patients with CHF, of whom 69.8% were male. Median EFV was 57.14mL and mean TyG index was 8.48. Spearman correlation analysis showed that TyG index was significantly correlated with the EFV in CHF patients (r = 0.247, P < 0.001). Further analysis showed that TyG index levels were significantly associated with EFV as both continuous variables (Unstandardized β = 6.556, P < 0.001) and across the increasing quartiles (β = 7.50, 95% CI [1.41, 13.59], P < 0.05). RCS demonstrated there were a positive trend and linear association between EFV and TyG index in CHF patients (P for nonliearity = 0.941). In patients with CHF, the TyG index was positively and linearly associated with the EFV, which supports the metabolic roles of epicardial adipose tissue regarding insulin resistance.

Effect of different intensity exercises on cardiopulmonary function and quality of life of patients with chronic heart failure : A systematic review and meta-analysis

BACKGROUND

Exercise-based cardiac rehabilitation has positive benefits for patients with chronic heart failure (CHF), but the choice of exercise intensity has been controversial. The aim of this systematic review and meta-analysis was to investigate the effects of different exercise intensities on cardiopulmonary function and quality of life (QoL) of patients with CHF.

METHODS

Randomized controlled trials (RCTs) of different exercise intensities applied to patients with CHF were searched in PubMed, Web of Science, the Cochrane Library, and Embase databases from inception to December 2021. Study selection and data extraction were performed simultaneously by two independent reviewers, using the Physiotherapy Evidence Database Scale (PEDro) for quality assessment of the included literature. The weighted mean differences (WMD) or standardized mean difference (SMD) were calculated by employing a fixed or random effects model. Other statistical analyses included subgroup analysis and sensitivity analysis. Quality of evidence was evaluated by the Grade of Recommendation, Assessment, Development, and Evaluation (GRADE) method.

RESULTS

Eight RCTs were included. Analyses reported no significant improvement in left ventricular ejection fractions (LVEF; WMD = 0.47, 95% CI [-4.10, 5.03], p = 0.841), peak oxygen uptake (peak VO2) (SMD = 0.38, 95% CI [-0.03, 0.80], p = 0.069) and 6‑min walking distance (6MWD) (WMD = 14.10, 95% CI [-9.51, 37.72], p = 0.242). Exercise interventions of varying intensity produced small-to-moderate beneficial effects on QoL (WMD = -4.99, 95% CI [-8.29, -1.68], p = 0.003), which appeared to be attenuated at long-term follow-up (WMD = 2.12, 95% CI [-2.91, 7.16], p = 0.409).

CONCLUSION

High-intensity exercise does not have a significant advantage over moderate-intensity exercise in improving cardiopulmonary function and aerobic capacity in patients with CHF. Beneficial changes in QoL from high-intensity exercise also appeared to decrease during long-term follow-up, indicating a cumulative effect of the efficacy of high-intensity exercise.

Cardio-renal-metabolic disease in primary care setting

In the primary care setting providers have more tools available than ever before to impact positively obesity, diabetes, and their complications, such as renal and cardiac diseases. It is important to recognise what is available for treatment taking into account diabetes heterogeneity. For those who develop type 2 diabetes (T2DM), effective treatments are available that for the first time have shown a benefit in reducing mortality and macrovascular complications, in addition to the well-established benefits of glucose control in reducing microvascular complications. Some of the newer medications for treating hyperglycaemia have also a positive impact in reducing heart failure (HF). Technological advances have also contributed to improving the quality of care in patients with diabetes. The use of technology, such as continuous glucose monitoring systems (CGM), has improved significantly glucose and glycated haemoglobin A1c (HbA1c) values, while limiting the frequency of hypoglycaemia. Other technological support derives from the use of predictive algorithms that need to be refined to help predict those subjects who are at great risk of developing the disease and/or its complications, or who may require care by other specialists. In this review we also provide recommendations for the optimal use of the new medications; sodium-glucose co-transporter-2 inhibitors (SGLT2i) and Glucagon-like peptide-receptor agonists 1 (GLP1RA) in the primary care setting considering the relevance of these drugs for the management of T2DM also in its early stage.

Measurement of peripheral arterial tone to detect sleep-disordered breathing in patients with heart failure

PURPOSE

Sleep-disordered breathing is highly prevalent in patients with heart failure and is related to increased mortality and morbidity. The gold standard for sleep diagnostic is polysomnography in a sleep laboratory. Measurement of peripheral arterial tone with a wrist-worn diagnostic device is a promising method to detect sleep-disordered breathing without major technical effort.

METHODS

We prospectively enrolled patients with heart failure with reduced ejection fraction for measurement of the peripheral arterial tone and polysomnography simultaneously during one night in the sleep laboratory. Raw data of polysomnography was analyzed blindly by sleep core lab personnel and compared with automatic algorithm-based sleep results of measurement of the peripheral arterial tone.

RESULTS

A total of 25 patients provided comparable sleep results. All patients had sleep-disordered breathing and were identified by measurement of the peripheral arterial tone. The comparison of apnea-hypopnea index between peripheral arterial tone 38.8 ± 17.4/h and polysomnography 44.5 ± 17.9/h revealed a bias of - 5.7 ± 9.8/h with limits of agreement of ± 19.2/h in Bland-Altman analysis but showed high and significant Pearson correlation (r = 0.848, p < 0.001).

CONCLUSION

The findings suggest that measurement of the peripheral arterial tone may be useful to identify sleep-disordered breathing in patients with heart failure with reduced ejection fraction.

Advances in device-based treatment of heart failure with preserved ejection fraction: evidence from clinical trials

Heart failure with preserved ejection fraction (HFpEF) is a group of clinical syndromes that exhibit a remarkably heterogeneous phenotype, characterized by symptoms and signs of heart failure, left ventricular diastolic dysfunction, elevated levels of natriuretic peptides, and an ejection fraction greater than or equal to 50%. With the aging of the population and the escalating prevalence of hypertension, obesity, and diabetes, the incidence of HFpEF is progressively rising. Drug therapy options for HFpEF are currently limited, and the associated high risk of cardiovascular mortality and heart failure rehospitalization significantly impact patients' quality of life and longevity while imposing a substantial economic burden on society. Recent research indicates that certain device-based therapies may serve as valuable adjuncts to drug therapy in patients with specific phenotypes of HFpEF, effectively improving symptoms and quality of life while reducing the risk of readmission for heart failure. These include inter-atrial shunt and greater splanchnic nerve ablation to reduce left ventricular filling pressure, implantable heart failure monitor to guide diuresis, left atrial pacing to correct interatrial dyssynchrony, cardiac contractility modulation to enhance cardiac calcium handling, as well as renal denervation, baroreflex activation therapy, and vagus nerve stimulation to restore the autonomic imbalance. In this review, we provide a comprehensive overview of the mechanisms and clinical evidence pertaining to these devices, with the aim of enhancing therapeutic strategies for HFpEF.

The Clinical Impact and Good Practices of Remote Patient Monitoring for Chronic Heart Failure: A French Case Report

Purpose

Remote patient monitoring (RPM) can improve the management of chronic diseases. Since 2019, RPM in chronic heart failure (CHF) management has been internationally supported. However, evidence on the clinical impact and good practices of RPM is scarce. We present a case of a patient with CHF that used RPM in France.

Patients and Methods

A 74-year-old male was diagnosed with CHF (NYHA I) at the AP-HP Cochin Hospital in January 2020. He faced repetitive hospitalizations for acute heart failure and acute kidney injury. The causes of these acute episodes were unknown. Three therapeutic interventions were implemented (diuretic treatment, RPM and therapeutic education sessions). The patient answered questionnaires regularly and directly through the RPM web application named Satelia®Cardio. Therapeutic education was provided to instruct the patient about his symptoms and treatment management.

Results

Since November 11, 2020, the patient had seven hospitalizations representing a total length of stay of 76 days over a period of 15 months and 2 weeks. Pericarditis was diagnosed as a potential cause and a pre-operative checkup was performed. No tangible benefits were found with diuretic treatment and therapeutic education since they had no effect on stopping the acute episodes leading to hospitalization. RPM did not trigger any clinical alerts until his last hospitalization. During this stay, a clinical telehealth nurse reviewed the patient's clinical setup and found that his initial baseline weight was incorrectly inputted. Since amending this, there were no new episodes. A high-risk, complex and costly heart surgery for pericardial decortication was avoided, and patient satisfaction has increased.

Conclusion

To respect good practices, inclusion not only involves adding or registering a patient to a telehealth activity and database but involves redesigning the management and pathway of patients in order to conduct periodic and personalized clinical care via integrated technology into routine care.

Assessment of Knowledge and Perception of Sodium-Glucose Co-transporter 2 (SGLT-2) Inhibitors Prescription among Physicians in Saudi Arabia

BACKGROUND

Sodium-glucose cotransporter 2 inhibitors are a new class of medications that have been proven to improve both glycemic control and cardio-renal outcomes. The knowledge, attitude, and perception toward their prescriptions in Jazan, Saudi Arabia, are still unknown.

OBJECTIVE

The study aimed to measure the level of knowledge and attitude toward sodium-glucose cotransporter 2 inhibitors prescription among physicians in the Jazan region, Saudi Arabia.

METHODS

Data analysis was performed using Statistical Package for the Social Sciences, SPSS 23rd version. Frequency and percentages were used to display categorical variables. Minimum, maximum, mean, and standard deviation were used to test numerical variables. Independent t-test and ANOVA test were both utilized to test the factors associated with knowledge and attitude toward the use of SGLT-2 inhibitors.

RESULTS

A total of 65 participants were included in the study. 26.2% had a low knowledge level, 30.8% had a moderate knowledge level, and 43.1% had a high knowledge level of sodium-glucose cotransporter 2 inhibitors. 9.2% had a low attitude level, 43.1% had a moderate attitude level, and 47.7% had a high attitude level toward sodium-glucose cotransporter 2 inhibitors. Age, professional status, years of experience, and specialty were significantly associated with attitude but not with the knowledge of sodium-glucose cotransporter 2 inhibitors prescription.

CONCLUSION

While the study cohort scored high in the knowledge and attitude domains of the survey, a large proportion failed to answer very essential questions in type 2 diabetes management. An educational awareness program needs to be carried out to strengthen the physicians' knowledge of SGLT2 inhibitors prescription.

Health care resource use, diagnostic delay and disease burden in transthyretin amyloid cardiomyopathy in Sweden

AIMS

To estimate healthcare resource use and direct healthcare costs of Transthyretin Amyloid Cardiomyopathy (ATTR-CM) in Sweden over 12 months across severity stages as defined by the New York Heart Association (NYHA). Secondary to investigate the current diagnostic trajectory for patients with ATTR-CM in Sweden.

METHODS

A stratified inclusion of patients with a confirmed diagnosis of ATTR-CM in different NYHA classes. Data was extracted from medical records in two cardiology clinics in Sweden. Healthcare resource use data were retrospectively collected for 12 months.

RESULTS

38 patients were included, of whom 7 were in NYHA class II, 20 in class III and 4 in class IV. The total cost of health care per patient increased from SEK 69,000 (€6800) in NYHA stage II, SEK 219,000 (€21,500) in NYHA stage III, to SEK 638,000 (€62,900) in stage IV, mainly due to an increase in inpatient stays. Mean time (standard deviation, SD) from any cardiac related diagnosis prior to ATTR-CM diagnosis was 3.5 (3.1) years.

CONCLUSIONS

Advanced ATTR-CM stages are associated with significant healthcare costs, as patients more often require resource-intensive inpatient care. The current diagnostic trajectory of ATTR-CM in this study was characterized by a diagnostic delay of several years.

Missed opportunities in the diagnosis of heart failure: a real-world assessment

AIMS

Heart failure (HF) is a leading cause of hospitalization worldwide. An early HF diagnosis is key to reducing hospitalizations. We used electronic health records (EHRs) to characterize HF pathways at the primary care physician (PCP) level prior to a first HF hospitalization (hHF). This study aimed to identify missed opportunities for HF diagnosis and management at the PCP level before a first hHF.

METHODS AND RESULTS

This cohort study used EHRs of a large health care organization in Portugal. Patients with incident hHF between 2017 and 2020 were identified. Missed opportunities were defined by the absence of any of the following work-up in the 6 months after signs or symptoms had been recorded: lab results and electrocardiogram, natriuretic peptides, echocardiogram, referral to HF specialist, or HF medication initiation. A total of 2436 patients with a first hHF were identified. The median (interquartile range) age at the time of hospitalization was 81 (14) years, and 1361 (56%) were women. Most patients were treated with cardiovascular drugs prior or at index event. A total of 720 (30%) patients had records of HF signs or symptoms, 94% (n = 674) within 6 months prior to hHF. Among patients with recorded HF signs or symptoms, 410 (57%) had clinical management considered adequate before signs and symptoms were recorded. Of the 310 remaining patients, 155 (50%) had a follow-up that was considered inadequate.

CONCLUSIONS

Relatively few patients with a first hHF had primary care records of signs or symptoms prior to admission. Of these, nearly half had inadequate management considering diagnosis and treatment. These data suggest the need to improve PCP HF awareness.

Evolution of economic burden of heart failure by ejection fraction in newly diagnosed patients in Spain

OBJECTIVE

To describe healthcare resource utilization (HCRU) and costs, in patients with newly diagnosed heart failure (HF) according to ejection fraction (EF) in Spain.

METHODS

Retrospective cohort study that analyzed anonymized, integrated and computerised medical records in Spain. Patients with ≥ 1 new HF diagnosis between January 2013 and September 2019 were included and followed-up during a 4-year period. Rates per 100 person-years of HCRU and costs were estimated.

RESULTS

Nineteen thousand nine hundred sixty-one patients were included, of whom 43.5%, 26.3%, 5.1% and 25.1% had HF with reduced, preserved, mildly reduced and unknown EF, respectively. From year 1 to 4, HF rates of outpatient visits decreased from 1149.5 (95% CI 1140.8-1159.3) to 765.5 (95% CI 745.9-784.5) and hospitalizations from 61.7 (95% CI 60.9-62.7) to 15.7(14.7-16.7) per 100 person-years. The majority of HF-related healthcare resource costs per patient were due to hospitalizations (year 1-4: 63.3-38.2%), followed by indirect costs (year 1-4: 12.2-29.0%), pharmacy (year 1-4: 11.9-19.9%), and outpatient care (year 1-4: 12.6-12.9%). Mean (SD) per patient HF-related costs decreased from 2509.6 (3518.5) to 1234.6 (1534.1) Euros (50% cost reduction). At baseline, 70.1% were taking beta-blockers, 56.3% renin-angiotensin system inhibitors, 11.8% mineralocorticoid receptor antagonists and 8.9% SGLT2 inhibitors. At 12 months, these numbers were 72.3%, 65.4%, 18.9% and 9.8%, respectively.

CONCLUSIONS

Although the economic burden of HF decreased over time since diagnosis, it is still substantial. This reduction could be partially related to a survival bias (sick patients died early), but also to a better HF management. Despite that, there is still much room for improvement.

Predictors of self-care behaviors in individuals with heart failure in Brazil

OBJECTIVE

To identify the predictors of self-care behaviors in individuals with heart failure.

METHOD

A cross-sectional study including 405 patients with heart failure. Self-care behaviors were assessed by the Self-Care of Heart Failure Index. Sociodemographic and clinical characteristics were investigated as predictors of self-care maintenance, management and confidence through logistic regressions.

RESULTS

The predictors of self-care maintenance were number of children (p<0.01), left ventricular ejection fraction (p<0.01), positive feeling about disease (p=0.03), obesity (p=0.02) and dialytic chronic kidney disease (p<0.01). The predictors of self-care management were having married children (p<0.01) and sleep apnea (p<0.01). The predictors of self-care confidence were family income (p<0.01), number of hospitalizations in the previous 12 months (p=0.01), number of daily medication doses (p<0.01) and sedentarism (p<0.01).

CONCLUSION

Some predictors related to the self-care behaviors were found, so some intensified education and social aid should be aimed at patients with these specific characteristics.

Benefits of Cardiac Rehabilitation in Cardio-Renal Patients With Heart Failure With Reduced Ejection Fraction

PURPOSE

Chronic kidney disease (CKD) is common in heart failure (HF). Chronic kidney disease often worsens the prognosis and impairs the management of patients with HF. Chronic kidney disease is frequently accompanied by sarcopenia, which limits the benefits of cardiac rehabilitation (CR). The aim of this study was to evaluate the impact of CR on cardiorespiratory fitness in HF patients with reduced ejection fraction (HFrEF) according to the CKD stage.

METHODS

We conducted a retrospective study including 567 consecutive patients with HFrEF, who underwent a 4-wk CR program, and who were evaluated by cardiorespiratory exercise test before and after the program. Patients were stratified according to their estimated glomerular filtration rate (eGFR). We performed multivariate analysis looking for factors associated with an improvement of 10% in peak oxygen uptake (V˙ o2peak ).

RESULTS

Thirty-eight percent of patients had eGFR <60 mL/min/1.73m². With decreasing eGFR, we observed deterioration in V˙ o2peak , first ventilatory threshold (VT1) and workload and an increase in brain natriuretic peptide levels at baseline. After CR, there was an improvement in V˙ O2peak (15.3 vs 17.8 mL/kg/min, P < .001), VT1 (10.5 vs 12.4 mL/kg/min, P < .001), workload (77 vs 94 W, P < .001), and brain natriuretic peptide (688 vs 488 pg/mL, P < .001). These improvements were statistically significant for all stages of CKD. In a multivariate analysis predicting factors associated with V˙ o2peak improvement, renal function did not interfere with results.

CONCLUSIONS

Cardiac rehabilitation is beneficial in patients with HFrEF with CKD regardless of CKD stage. The presence of CKD should not prevent the prescription of CR in patients with HFrEF.

Vericiguat

Each month, subscribers to The Formulary Monograph Service receive 5 to 6 well-documented monographs on drugs that are newly released or are in late phase 3 trials. The monographs are targeted to Pharmacy & Therapeutics Committees. Subscribers also receive monthly 1-page summary monographs on agents that are useful for agendas and pharmacy/nursing in-services. A comprehensive target drug utilization evaluation/medication use evaluation (DUE/MUE) is also provided each month. With a subscription, the monographs are available online to subscribers. Monographs can be customized to meet the needs of a facility. Through the cooperation of The Formulary, Hospital Pharmacy publishes selected reviews in this column. For more information about The Formulary Monograph Service, contact Wolters Kluwer customer service at 866-397-3433.

Clinical Pathway for Coronary Atherosclerosis in Patients Without Conventional Modifiable Risk Factors: JACC State-of-the-Art Review

Reducing the incidence and prevalence of standard modifiable cardiovascular risk factors (SMuRFs) is critical to tackling the global burden of coronary artery disease (CAD). However, a substantial number of individuals develop coronary atherosclerosis despite no SMuRFs. SMuRFless patients presenting with myocardial infarction have been observed to have an unexpected higher early mortality compared to their counterparts with at least 1 SMuRF. Evidence for optimal management of these patients is lacking. We assembled an international, multidisciplinary team to develop an evidence-based clinical pathway for SMuRFless CAD patients. A modified Delphi method was applied. The resulting pathway confirms underlying atherosclerosis and true SMuRFless status, ensures evidence-based secondary prevention, and considers additional tests and interventions for less typical contributors. This dedicated pathway for a previously overlooked CAD population, with an accompanying registry, aims to improve outcomes through enhanced adherence to evidence-based secondary prevention and additional diagnosis of modifiable risk factors observed.

The impact of informal caregivers' preparedness on short-term outcomes of heart failure patients with insufficient self-care

AIMS

Even though self-care is essential in the long-term management of heart failure (HF), it is often not performed adequately in HF populations. Mobilizing informal caregivers may be one way to help patients perform self-care, support individual needs, and maintain health. However, informal caregivers often face insufficient preparation for providing long-term care. This insufficient caregiver preparedness may lead to a decline in caregiver contributions and affect the outcomes of care in patients with HF. This study aimed to explore whether informal caregivers' preparedness is a predictor that influences short-term outcomes of HF patients; to analyse whether caregiver contribution to self-care of HF (CC-SCHF) plays a mediating role between informal caregivers' preparedness and HF short-term outcomes.

METHODS AND RESULTS

A prospective observational study was conducted in China. After controlling for covariates, higher levels of informal caregivers' preparedness were significantly associated with lower 3-month mortality [odds ratio (OR) = 0.919, 95% confidence interval (CI) = (0.855-0.988), P = 0.022] and 3-month readmission rate [OR = 0.883, 95% CI = (0.811-0.961), P = 0.004] and shorter length of hospital stay (β = -0.071, P < 0.001). The informal caregiver's preparedness was positively associated with CC-SCHF maintenance (r = 0.708, P < 0.01), CC-SCHF management (r = 0.431, P < 0.01), and CC-SCHF confidence (r = 0.671, P < 0.01). The CC-SCHF management was a mediator in the relationship between informal caregivers' preparedness and 3-month readmission rate [effect 95% CI = (-0.054 to -0.001)] and length of hospital stay [effect 95% CI = (-0.235 to -0.042)].

CONCLUSION

A higher level of informal caregivers' preparedness is associated with better short-term outcomes of HF patients with insufficient self-care.

Impact of Mineralocorticoid Receptor Antagonists in the Treatment of Heart Failure: Targeting the Heart Failure Cascade

Epidemiological data from the Indian subcontinent on the burden of Heart failure (HF) is scarce. Mineralocorticoid receptor antagonists (MRAs) are usually used in the management of HF and hypertension. A consortium of experts reviewed and opined on the pathophysiological role of aldosterone in HF and its cascading effects on the heart in terms of cardiac fibrosis, cardiac hypertrophy, and remodeling, increased propensity to cause arrhythmias in addition to its effect on sodium and water retention. This expert opinion document highlights the various mechanisms of action of MRAs. It provides clinical experience and practice-based expert opinion on the use of spironolactone and eplerenone in patients with HF. The role of MRAs in diabetic patients with HF has also been profiled.

Mutual Effect Modification between Insulin Resistance and Endothelial Dysfunction in Predicting Incident Heart Failure in Hypertensives

Insulin resistance and endothelial dysfunction are associated with heart failure (HF). Our objective was to investigate whether endothelial dysfunction and insulin resistance are independent predictors of incident HF and if a possible interaction exists between them. We enrolled 705 white never-treated hypertensives. Endothelium-dependent vasodilation was investigated by intra-arterial infusion of acetylcholine. During the follow-up [median: 117 months (range: 31-211)], we documented 223 new cases of HF (3.3 events/100 patient-years). We stratified the study population into progressors and non-progressors; progressors showed an older age and a higher prevalence of females, as well as higher mean values of baseline glucose, insulin, homeostasis model assessment (HOMA), creatinine, and high-sensitivity C-reactive protein (hs-CRP), whereas the estimated glomerular filtration rate (e-GFR) and endothelium-dependent vasodilation were lower. In the multiple Cox regression analysis, serum hs-CRP (HR = 1.362, (95% CI = 1.208-1.536), HOMA (HR = 1.293, 95% CI = 1.142-1.465), maximal acetylcholine (Ach)-stimulated forearm blood flow (FBF) (100% increment, HR = 0.807, 95% CI = 0.697-0.934), and e-GFR (10 mL/min/1.73 m2 increment, HR = 0.552, 95% CI = 0.483-0.603) maintained an independent association with incident HF. HOMA and endothelial dysfunction interact between them in a competitive manner (HR = 6.548, 95% CI = 4.034-10.629), also showing a mutual effect modification. Our findings demonstrate that both endothelial dysfunction and HOMA are independent and strong predictors of incident HF in hypertensives, these two risk factors interact between them with a competitive mechanism.

Effectiveness of a 12-week tele-exercise training program on cardiorespiratory fitness and heart rate recovery in patients with cardiometabolic multimorbidity

BACKGROUND

Exercise has positive impacts on cardiometabolic health. However, evidence regarding the effectiveness of tele-exercise training on cardiorespiratory fitness and heart rate recovery in patients with cardiometabolic multimorbidity remains limited.

AIMS

The aim of this study was to assess whether an assumed increase in physical activity (PA) after a 12-week tele-exercise training program improved cardiorespiratory fitness and heart rate recovery of patients with cardiometabolic multimorbidity.

METHODS

A parallel-group randomized controlled trial was conducted. Eligible patients with cardiometabolic multimorbidity (n = 83) were randomized 1:1 to either an experimental group (EG, received a 12-week tele-exercise training program with 3 sessions/week and 30 min/session and weekly remote monitoring for maintenance of exercise) or a control group (CG, usual care only). PA, cardiorespiratory fitness, and heart rate recovery were assessed at baseline and 12 weeks. Generalized estimating equations were used to examine the intervention effects via the interaction of time and group.

RESULTS

Sixty-eight participants (81.9%) completed the study, and 83 were included in the intention-to-treat analysis. The EG with higher vigorous-intensity PA (β = 714, p = .037), walking behavior (β = 750, p = .0007), and total amount of PA (β = 1748, p = .001) after the intervention had significantly elevated cardiorespiratory fitness, including VO2peak (β = 3.9, p = .042), workload (β = 17.9, p = .034), and anaerobic threshold (β = 2.1, p = .041), and increased one-min heart rate recovery (β = 5.3, p = .025), compared with the CG.

LINKING EVIDENCE TO ACTION

A 12-week tele-exercise training program was effective for increased PA, elevated cardiorespiratory fitness, and improved heart rate recovery for patients with cardiometabolic multimorbidity. These findings highlight the feasibility of better delivering lifestyle interventions for cardiometabolic health management.

Proportion of right ventricular failure and echocardiographic predictors in continuous-flow left ventricular assist device: a systematic review and meta-analysis

Background

Right ventricular failure (RVF) in patients with a continuous-flow left ventricle assist device (CF-LVAD) is associated with higher incidence of mortality. This systematic review aims to assess the overall proportion of RVF and the pre-operative echocardiographic parameters which are best correlating to RVF.

Methods

A systematic research was conducted between 2008 and 2019 on MEDLINE, EMBASE, PUBMED, UPTODATE, OVID, COCHRANE LIBRARY, and Google Scholar electronic databases by performing a PRISMA flowchart. All observational studies regarding echocardiographic predictors of RVF in patients undergoing CF-LVAD implantation were included.

Results

A total number of 19 observational human studies published between 2008 and 2019 were included. We identified 524 RVF patients out of a pooled final population of 1741 patients. The RVF overall proportion was 28.25% with 95% confidence interval (CI) 0.24-0.34. The highest variability of perioperative echocardiographic parameters between the RVF and no right ventricular failure (NO-RVF) groups has been found with tricuspid annular plane systolic excursion (TAPSE), fractional area change (FAC), and right ventricular global longitudinal strain (RVGLS). Their standardized mean deviation (SMD) was - 0.33 (95% CI - 0.54 to - 0.11; p value 0.003), - 0.34 (95% CI - 0.53 to - 0.15; p value 0.0001), and 0.52 (95% CI 0.79 to 0.25; p value 0.0001), respectively.

Conclusions

The echocardiographic predictors of RVF after CF-LVAD placement are still uncertain. However, there seems to be a trend of statistical correlation between TAPSE, FAC, and RVGLS with RVF event after CF-LVAD placement.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-022-01447-7.

Policy-Driven Post-Acute Care Program Lowers Mortality Rate and Medical Expenditures After Hospitalization for Acute Heart Failure: A Nationwide Propensity Score-Matched Study

OBJECTIVE

The beneficial effects of multidisciplinary disease management programs have been demonstrated. The present study investigated the effects of a policy-driven, health insurance-reimbursed, heart failure (HF) post-acute care (PAC) program on mortality, health care service utilization, and readmission expenses for patients following hospitalization for HF.

DESIGN

This was a retrospective propensity score-matched cohort study using the Taiwan National Health Insurance Research Database.

SETTING AND PARTICIPANTS

In total, 4346 patients (2173 receiving HF-PAC and 2173 controls) with left ventricular ejection fraction of ≤40% who were discharged following hospitalization for HF were included for analysis.

METHODS

All patients were followed up after discharge for all-cause mortality, emergency visits within 30 days, and length of stay and medical expenses for readmission within 180 days after discharge.

RESULTS

After propensity score matching, baseline characteristics of the HF-PAC and control groups were similar. During a mean follow-up period of 1.59 ± 0.92 years, according to the Cox multivariable analysis, HF-PAC reduced mortality by 48% compared with the control group, independent of traditional risk factors (hazard ratio = 0.520, 95% CI = 0.452-0.597, P < .001). Kaplan-Meier curves revealed that HF-PAC was associated with a higher cumulative survival rate (log-rank = 96.43, P < .001). HF-PAC also decreased the frequency of emergency visits after discharge by 23% in the 30 days post discharge and decreased length of stay and medical expenses related to readmission by 61% and 63%, respectively, in the 180 days post discharge (all P < .001).

CONCLUSIONS AND IMPLICATIONS

HF-PAC reduces short-term all-cause emergency visits, length of stay, and medical expenses for all-cause readmission and all-cause mortality in patients discharged following hospitalization for HF. Our findings suggest that PAC should include care continuity, optimal adaptation of transitional care components, and HF cardiologist engagement with multidisciplinary coordination.

The Efficacy and Safety of Patiromer for Heart Failure Patients: A Systematic Review and Meta-Analysis

PURPOSE

To evaluate the efficacy and safety of patiromer, a novel potassium binder, in reducing the risk of hyperkalemia in patients with heart failure and optimizing their RAASi therapy.

DESIGN

Systematic review and meta-analyses.

METHOD

The authors conducted a systematic search in Pubmed, Embase, Web of Science, and Cochrane Library for randomized controlled trials investigating the efficacy and safety of patiromer in heart failure patients from inception to 31 January 2023 and updated on 25 March 2023. The primary outcome was the association between the reduction of hyperkalemia and patiromer compared with placebo, and the secondary outcome was the association between optimization of RAASi therapy and patiromer.

RESULTS

A total of four randomized controlled trials (n = 1163) were included in the study. Patiromer was able to reduce the risk of hyperkalemia in heart failure patients by 44% (RR 0.56, 95% CI 0.36 to 0.87; I² = 61.9%), improve tolerance to target doses of MRA in patients with heart failure (RR 1.15, 95% CI 1.02 to 1.30; I² = 49.4%), and decrease the proportion of all-cause discontinuation of RAASi (RR 0.49, 95% CI 0.25 to 0.98; I² = 48.4%). However, patiromer therapy was associated with an increased risk of hypokalemia (RR 1.51, 95% CI 1.07 to 2.12; I² = 0%), while no other statistically significant adverse events were observed.

CONCLUSION

Patiromer appears to have a considerable effect on reducing the incidence of hyperkalemia in heart failure patients and on optimizing the therapy of RAASi in those patients.

Feasibility of the Omaha system for the care of children with dilated cardiomyopathy

Aim

To explore the feasibility of Omaha system theory in the care of children with dilated cardiomyopathy (DCM), which may provide a practical basis for the continuous nursing of DCM children.

Methods

A total of 1,392 records describing symptoms, signs, and nursing interventions were extracted from the medical records of 76 children suffered from DCM. Content analysis method was used to find out existent nursing problems, make precise nursing plans, and take corresponding nursing measurements according to the medical records of DCM children. Cross-mapping method was utilized to compare the conceptual consistency of the medical records and Omaha system (problem classification and intervention subsystems).

Results

Of the total 1,392 records, 1,094 (78.59%) were complete consistency, while 245 (17.60%) were partial consistency, and 53 (3.81%) were inconsistency with the Omaha system concepts. The concept matching degree of medical records and Omaha system was approximately 96.19%.

Conclusions

The Omaha system may be an effective nursing language for Chinese DCM children, which may be useful to guide nurses in the care of DCM. Further well-design studies need to fully evaluate the feasibility and effectiveness of the Omaha system in nursing children with DCM.

Telemedicine Support for Primary Care Providers versus Usual Care in Patients with Heart Failure: Protocol of a Pragmatic Cluster Randomised Trial within the Brazilian Heart Insufficiency with Telemedicine (BRAHIT) Study

Heart failure is a prevalent condition and a frequent cause of hospital readmissions and poor quality of life. Teleconsultation support from cardiologists to primary care physicians managing patients with heart failure may improve care, but the effect on patient-relevant outcomes is unclear. We aim to evaluate whether collaboration through a novel teleconsultation platform in the Brazilian Heart Insufficiency with Telemedicine (BRAHIT) project, tested on a previous feasibility study, can improve patient-relevant outcomes. We will conduct a parallel-group, two-arm, cluster-randomised superiority trial with a 1:1 allocation ratio, with primary care practices from Rio de Janeiro as clusters. Physicians from the intervention group practices will receive teleconsultation support from a cardiologist to assist patients discharged from hospitals after admission for heart failure. In contrast, physicians from the control group practices will perform usual care. We will include 10 patients per each of the 80 enrolled practices (n = 800). The primary outcome will be a composite of mortality and hospital admissions after six months. Secondary outcomes will be adverse events, symptoms frequency, quality of life, and primary care physicians' compliance with treatment guidelines. We hypothesise that teleconsulting support will improve patient outcomes.

An update on utilising brain natriuretic peptide for risk stratification, monitoring and guiding therapy in heart failure

INTRODUCTION

Heart failure (HF) is a dominant health problem with an overall poor prognosis. Natriuretic peptides (NPs) are upregulated in HF as a compensatory mechanism. They have extensively been used for diagnosis and risk stratification.

AREAS COVERED

This review addresses the history and physiology of NPs in order to understand their current role in clinical practice. It further provides a detailed and updated narrative review on the utility of those biomarkers for risk stratification, monitoring, and guiding therapy in HF.

EXPERT OPINION

NPs show excellent predictive ability in heart failure patients, both in acute and chronic settings. Understanding their pathophysiology and their modifications in specific situations is key for an adequate interpretation in specific clinical scenarios in which their prognostic value may be weaker or less well evaluated. To better promote risk stratification in HF, NPs should be integrated with other predictive tools to develop multiparametric risk models. Both inequalities of access to NPs and evidence caveats and limitations will need to be addressed by future research in the coming years.

Sodium-glucose cotransporter 2 inhibitors and heart failure: the best timing for the right patient

Sodium-glucose cotransporter 2 inhibitors (SGLT2i), initially born as anti-diabetic drugs, have shown many beneficial effects on the cardiovascular system, in particular against heart failure (HF). HF is a complex and multifaceted disease that requires a comprehensive approach. It should not be considered as a simplistic cardiac disease, but a systemic disease that leads to multisystemic organ failure and death. Exploiting their pleiotropic effects, SGLT2i are a very valid tool for HF treatment. Beyond the indication to reduce HF hospitalization and death risk, in patients with diabetes mellitus at high cardiovascular risk or with established cardiovascular event, SGLT2i administration reported beneficial effects regarding the wide spectrum of HF manifestations and stages, independently by diabetes mellitus presence. Recent evidence focuses on HF rehospitalization, cardiac and all-cause death reduction, as well as symptoms and quality of life improvement, in patients with chronic HF or with a recent HF decompensation episode. Given the recent finding about the SGLT2i usefulness in HF patients, further studies are needed to define the best administration timing to maximize the SGLT2i-derived beneficial effects.

EHRA expert consensus document on the management of arrhythmias in frailty syndrome, endorsed by the Heart Rhythm Society (HRS), Asia Pacific Heart Rhythm Society (APHRS), Latin America Heart Rhythm Society (LAHRS), and Cardiac Arrhythmia Society of Southern Africa (CASSA)

There is an increasing proportion of the general population surviving to old age with significant chronic disease, multi-morbidity, and disability. The prevalence of pre-frail state and frailty syndrome increases exponentially with advancing age and is associated with greater morbidity, disability, hospitalization, institutionalization, mortality, and health care resource use. Frailty represents a global problem, making early identification, evaluation, and treatment to prevent the cascade of events leading from functional decline to disability and death, one of the challenges of geriatric and general medicine. Cardiac arrhythmias are common in advancing age, chronic illness, and frailty and include a broad spectrum of rhythm and conduction abnormalities. However, no systematic studies or recommendations on the management of arrhythmias are available specifically for the elderly and frail population, and the uptake of many effective antiarrhythmic therapies in these patients remains the slowest. This European Heart Rhythm Association (EHRA) consensus document focuses on the biology of frailty, common comorbidities, and methods of assessing frailty, in respect to a specific issue of arrhythmias and conduction disease, provide evidence base advice on the management of arrhythmias in patients with frailty syndrome, and identifies knowledge gaps and directions for future research.

The Usefulness of Bioelectrical Impedance as a Marker of Fluid Status in Patients With Congestive Heart Failure: A Systematic Review and Meta-Analysis

Bioelectrical impedance analysis (BIA) is a method that measures electrical currents conducted through water, which assesses fluid status by measuring extracellular water (ECW), total body water (TBW), and resistance (R). Limited studies are done to evaluate the utility of BIA in patients with congestive heart failure (CHF), and therefore, we performed a systematic review and meta-analysis to evaluate this. A comprehensive literature search was performed at Medline and Embase until March 2022. Our primary outcome was a comparison of TBW and ECW between patients with CHF and controls. Our secondary outcome was to compare R between the groups. All analysis was conducted using RevMan 5.4 software. Six studies with 1,046 patients met our inclusion criteria. Out of 1,046 patients, 526 had CHF and 538 had no CHF. Among patients with CHF, all 526 had decompensated CHF. There was no significant difference in TBW between patients with heart failure and the control group (mean deviation (MD) = 1.42 (-0.44-3.27), percent of variation (I2) = 0%, p = 0.13). ECW was significantly higher with an assessment of BIA in heart failure patients compared to patients in the control group (MD = 1.62 (0.82-2.42), I2 = 0%, p < 0.0001). Resistance of extracellular fluid was significantly lower in the heart failure group (MD = -45.64 (-72.88--18.41), I2 = 83%, p = 0.001). Publication bias was deferred as the number of included studies was less than 10. BIA can be helpful in ambulatory and inpatient setting to identify patients' fluid status, which can improve outcomes. However, larger prospective studies are needed to further evaluate the usefulness of BIA in the CHF population.

Numerical analysis of different cardiac functions and support modes on blood damage potential in an axial pump

BACKGROUND

Cardiac functions and support modes of left ventricular assist device (LVAD) will influence the pump inner flow field and blood damage potential.

METHODS

Computational fluid dynamics (CFD) method and lumped-parameter-model (LPM) were applied to investigate the impacts of cardiac functions under full (9000 rpm) and partial (8000 rpm) support modes in an axial pump.

RESULTS

The constitution of hemolysis index (HI) in different components of the pump was investigated. HI was found to be more sensitive to positive incidence angles (i) compared with negative incidence angles in rotors. Negative incidence angles had little impact on HI both in rotors and the outlet guide vanes. The improved cardiac function made only a minor difference in HIave (estimated average HI in one cardiac cycle) by 9.88%, as the flow rate expanded mainly to higher flow range. Switching to partial support mode, however, would induce a periodic experience of severe flow separation and recirculation at low flow range. This irregular flow field increased HIave by 47.97%, remarkably increasing the blood damage potential.

CONCLUSION

This study revealed the relationship between the blade incidence angle i and HI, and recommended negative-incidence-angle blade designs as it yielded lower HI. Moreover, to avoid flow range below 50% of the design point, careful evaluations should be made before switching support modes as weaning procedures in clinical applications.

Performance of the heart failure risk scores in predicting 1 year mortality and short-term readmission of patients

AIMS

The aim of this study was to assess the performance of these main scores in predicting prognosis in patients with heart failure (HF).

METHODS AND RESULTS

A total of 2008 patients who were admitted to the Fourth People's Hospital of Zigong, Sichuan, from December 2016 to June 2019 and diagnosed with HF were included in the study. We compared the prognostic predictive performance of Seattle Heart Failure Model (SHFM), Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC-HF) risk score, Get With the Guidelines-Heart Failure programme (GWTG-HF), Acute Study of Clinical Effectiveness of Nesiritide in Decompensated Heart Failure (ASCEND) risk scores, the Acute Decompensated Heart Failure National Registry (ADHERE) model, Barcelona Bio-Heart Failure (BCN-Bio-HF) risk calculator, and Gruppo Italiano per lo Studio della Streptochinasi nell'Infarto Miocardico-Heart Failure (GISSI-HF) for the endpoints. The primary endpoint was 1 year all-cause mortality and the secondary endpoint was the incidence of 28 day readmission post-discharge. At 1 year follow-up, 44 (2.21%) patients with HF died. Discrimination analyses showed that all risk scores performed reasonably well in predicting 1 year mortality, with areas under the receiver operating characteristic curve (AUCs) fluctuating between 0.757 and 0.822. GISSI-HF showed the best discrimination with the AUC of 0.822 (0.768-0.876), followed by MAGGIC-HF, BCN-Bio-HF, ASCEND, SHFM, GWTG-HF, and ADHERE with AUCs of 0.819 (0.756-0.883), 0.812 (0.758-0.865), 0.802 (0.742-0.862), 0.787 (0.725-0.849), 0.762 (0.684-0.840), and 0.757 (0.681-0.833), respectively. All risk scores were similarly predictive of 28 day emergency readmissions, with AUCs fluctuating between 0.609 and 0.680. Overestimation of mortality occurred in all scores except the ASCEND. The risk scores remained with good prognostic discrimination in patients with biventricular HF and in the subgroup of patients taking angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker.

CONCLUSIONS

Currently assessed risk scores have limited clinical utility, with fair accuracy and calibration in assessing patients' 1 year risk of death and poor accuracy in assessing patients' risk of readmission. There is a need to incorporate more patient-level information, use more advanced technologies, and develop models for different subgroups of patients to achieve more practical, innovative, and accurate risk assessment tools.

Effects of traditional Chinese eight brocade exercise with same frequency and different durations on the quality of life, 6-min walk and brain natriuretic peptide in patients with chronic heart failure

BACKGROUND

Traditional Chinese eight brocade exercise (TCEBE) with same cycle and frequency and different durations has an effect on patients with chronic heart failure (CHF). However, relevant reports on the topic are lacking.

OBJECTIVE

This study aims to explore the differences of rehabilitation effect by conducting TCEBE with the same cycle and frequency and different single exercise time for patients with CHF.

METHODS

A total of 103 patients with CHF were randomly divided into long-time group (LTG), short-time group (STG) and control group (CG). The subjects in the three groups were given corresponding routine treatment. In addition, under the guidance of professional TCEBE coaches and nurses, TCEBE was conducted for 12 weeks (3 times/week) for LTG (60 min/time) and STG (30 min/time). Minnesota living with heart failure questionnaire (MLHFQ) was used, and 6-min walk (6MWK) and brain nautical peptide (BNP) were tested.

RESULTS

1) At 12 weeks, the comparison between groups obtained the following results: For the LTG, MLHFQ was less than that of the CG (P < 0.01), 6MWT was greater than that of the CG (P < 0.05), and 6MWT was greater than that of the STG (P < 0.05); for the STG, MLHFQ was less than that of the CG (P < 0.05); no significant difference in BNP was found among the three groups; 2) At 12 weeks and 0 weeks, the comparison obtained the following results: For the LTG, MLHFQ decreased by 37.7 %, and 6MWT increased by 46.7 % (P < 0.01); for the STG, MLHFQ decreased by 31.7 %, and 6MWT increased by 31.5 % (P < 0.01); for the CG, MLHFQ decreased by 14.6 %, and 6MWT increased by 19.7 % (P < 0.05); no significant change in BNP was found in each group.

CONCLUSION

TCEBE of two kinds of duration improves the quality of life and 6MWT of patients with CHF but has no positive effect on BNP. Compared with 30-min/time, 60-min/time further improves 6MWT in patients with CHF but has no additional benefit on quality of life.

Heart Failure Pharmacological Management: Gaps and Current Perspectives

Proper therapeutic management of patients with heart failure (HF) is a major challenge for cardiologists. Current guidelines indicate to start therapy with angiotensin converting enzyme inhibitors/angiotensin receptor neprilysin inhibitors (ACEi/ARNI), beta blockers (BB), mineralocorticoid receptor antagonists (MRAs) and sodium glucose cotransporter 2 inhibitors (SGLT2i) to reduce the risk of death and hospitalization due to HF. However, certain aspects still need to be defined. Current guidelines propose therapeutic algorithms based on left ventricular ejection fraction values and clinical presentations. However, these last do not always reflect the precise hemodynamic status of patients and pathophysiological mechanisms involved, particularly in the acute setting. Even in the field of chronic management there are still some critical points to discuss. The guidelines do not specify which of the four pillar drugs to start first, nor at what dosage. Some authors suggest starting with SGLT2i and BB, others with ACEi or ARNI, while one of the most recent approach proposes to start with all four drugs together at low doses. The aim of this review is to revise current gaps and perspectives regarding pharmacological therapy management in HF patients, in both the acute and chronic phase.

Comparison of Hemodynamic Response between Patients with Systolic Heart Failure Differing in Serum Aldosterone Concentrations during and after a 6-Minute Walk Test

Aldosterone regulates hemodynamics, including blood pressure (BP), and is involved in the development and progression of cardiovascular diseases, including systolic heart failure (HF). While exercise intolerance is typical for HF, neither BP nor heart rate (HR) have specific characteristics in HF patients. This study compares BP and HR profiles during and after standardized exercise between patients with systolic HF with either lower or higher aldosterone concentrations. We measured BP and HR in 306 ambulatory adults with systolic HF (left ventricular ejection fraction (LVEF) <50%) during and after a 6 min walk test (6MWT). All patients underwent a resting transthoracic echocardiography, and venous blood samples were collected for biochemical analyses. The patients were also divided into tertiles of serum aldosterone concentration: T1 (<106 pg/mL), T2 (106 and 263 pg/mL) and T3 (>263 pg/mL), respectively. Individuals from T1 and T2 were combined into T1-T2 as the reference group for comparisons with patients from T3. The individuals from T3 had significantly lower systolic, mean and diastolic BPs at rest, at the end and at 1 and 3 min post-6MWT recovery, as well as a more dilated left atrium and right ventricle alongside a higher concentration of N-terminal pro-B-type natriuretic peptide (NT-proBNP). Higher serum aldosterone concentration in HF patients with an LVEF < 50% is associated with a lower 6MWT BP but not an HR profile.

Patient-reported outcome is associated with health care costs in patients with ischaemic heart disease and arrhythmia

AIMS

Systematic use of patient-reported outcomes (PROs) have the potential to improve quality of care and reduce costs of health care services. We aimed to describe whether PROs in patients diagnosed with heart disease are directly associated with health care costs.

METHODS AND RESULTS

A national cross-sectional survey including PROs at discharge from a heart centre with 1-year follow-up using data from national registers. We included patients with either ischaemic heart disease (IHD), arrhythmia, heart failure (HF), or valvular heart disease (VHD). The Hospital Anxiety and Depression Scale, the heart-specific quality of life, the EuroQol five-dimensional questionnaire, and the Edmonton Symptom Assessment Scale were used. The economic analysis was based on direct costs including primary, secondary health care, and medical treatment. Patient-reported outcomes were available from 13 463 eligible patients out of 25.241 [IHD (n = 7179), arrhythmia (n = 4322), HF (n = 987), or VHD (n = 975)]. Mean annual total direct costs in all patients were €23 228 (patients with IHD: €19 479, patients with arrhythmia: €21 076, patients with HF: €34 747, patients with VDH: €48 677). Hospitalizations contributed overall to the highest part of direct costs. For patients discharged with IHD or arrhythmia, symptoms of anxiety or depression, worst heart-specific quality of life or health status, and the highest symptom burden were associated with increased economic expenditure. We found no associations in patients with HF or VHD.

CONCLUSION

Patient-reported outcomes at discharge from a heart centre were associated with direct health care costs in patients with IHD and arrhythmia.

REGISTRATION

ClinicalTrials.gov: NCT01926145.

An inevitable or modifiable trajectory towards heart failure in high-risk individuals: insights from the nurse-led intervention for less chronic heart failure (NIL-CHF) study

AIMS

We extended follow-up of a heart failure (HF) prevention study to determine if initially positive findings of improved cardiac recovery were translated into less de novo HF and/or all-cause mortality (primary endpoint) in the longer term.

METHODS AND RESULTS

The Nurse-led Intervention for Less Chronic HF (NIL-CHF) study was a single-centre randomized trial of nurse-led prevention involving cardiac inpatients without HF. At 3 years, 454 survivors (aged 66 ± 11 years, 71% men and 68% coronary artery disease) had the following: (i) a normal echocardiogram (128 cases/28.2%), (ii) structural heart disease (196/43.2%), or (iii) left ventricular diastolic dysfunction/left ventricular systolic dysfunction (LVDD/LVSD: 130/28.6%). Outcomes were examined during median 8.3 (interquartile range 7.8-8.8) years according to these hierarchal groups and change in cardiac status from baseline to 3 years. Overall, 109 (24.0%) participants had a de novo HF admission or died while accumulating 551 cardiovascular-related admissions/3643 days of hospital stay. Progressively worse cardiac status correlated with increased hospitalizations (P < 0.001). The mean rate (95% confidence interval) of cardiovascular admissions/days of hospital stay being 0.09 (0.05-0.12) admissions/0.33 (0.13-0.54) days vs. 0.27 (0.20-0.34) admissions/2.20 (1.36-3.04) days per annum for those with a normal echocardiogram vs. LVDD/LVSD at 3 years. With progressively higher event rates, the adjusted hazard ratio for a de novo HF admission and/or death associated with a structural abnormality (24.5% of cases) and LVDD/LVSD (36.2%) at 3 years was 1.57 (0.82-3.01; P = 0.173) and 2.07 (1.05-4.05; P = 0.035) compared with a normal echocardiogram (10.9%). Mortality also mirrored the direction/extent of cardiac status/trajectory.

CONCLUSIONS

These data suggest the positive initial effects of NIL-CHF intervention on cardiac recovery contributed to better long-term outcomes among patients at high risk of HF. However, prevention of HF remains challenging.

Impact of Diet on Gut Microbiota Composition and Microbiota-Associated Functions in Heart Failure: A Systematic Review of In Vivo Animal Studies

Heart failure (HF) represents a cardiovascular disease with high mortality and morbidity. The latest evidence shows that changes in the composition of the gut microbiota might play a pivotal role in the prevention and management of HF. This systematic review aims at assessing the potential associations between the diet, gut microbiota, and derived metabolites with the outcomes of HF. A systematic literature search was performed up to July 2022 on the PubMed, Web of Science, and Scopus databases. The PRISMA guidelines were followed when possible. The risk of bias was assessed with the SYRCLE and ARRIVE tools. A total of nine pre-clinical studies on animal models, with considerable heterogeneity in dietary interventions, were included. High-fiber/prebiotic diets (n = 4) and a diet rich in polyphenols (n = 1) modified the gut microbiota composition and increased microbial metabolites' activities, linked with an improvement in HF outcomes, such as a reduction in systolic blood pressure, cardiac hypertrophy, and left ventricular thickness. A high-fat diet (n = 2) or a diet rich in choline (n = 2) induced an increase in TMAO and indole derivative production associated with a decrease in cardiac function, systemic endotoxemia, and inflammation and an increase in cardiac fibrosis and cardiac remodeling. Although results are retrieved from animal studies, this systematic review shows the key role of the diet-especially a high-fiber and prebiotic diet-on gut microbial metabolites in improving HF outcomes. Further studies on human cohorts are needed to identify personalized therapeutic dietary interventions to improve cardiometabolic health.