Non-cardiac comorbidities and mortality in patients with heart failure with reduced vs. preserved ejection fraction: a study using the Swedish Heart Failure Registry

Reassessing heart failure therapy in Thailand: Patient insights and treatment outcomes from the Thai heart failure registry

BACKGROUND

This research analyzed the demographics, management, and outcomes of patients with heart failure (HF) in Thailand.

METHODS

The Thai Heart Failure Registry prospectively enrolled patients diagnosed with HF from 36 hospitals in Thailand. Follow-up data were recorded at 6, 12, 18, and 24 months. This study primarily focused on two outcomes: mortality and HF-related hospitalizations.

RESULTS

The study included 2639 patients aged at least 18. Their mean age was 59.2 ± 14.5 years, and most were male (68.4%). Patients were classified as having HF with reduced ejection fraction (HFrEF, 80.7%), HF with preserved ejection fraction (HFpEF, 9.0%), or HF with mildly reduced ejection fraction (HFmrEF, 10.3%). Guideline-directed medical therapy utilization varied. Beta-blockers had the highest usage (93.2%), followed by mineralocorticoid receptor antagonists (65.7%), angiotensin-converting enzyme inhibitors (39.3%), angiotensin receptor blockers (28.2%), angiotensin receptor-neprilysin inhibitors (16.1%), and sodium-glucose cotransporter-2 inhibitors (8.0%). The study monitored a composite of mortality and HF incidents, revealing incidence rates of 11.74, 12.50, and 8.93 per 100 person-years for the overall, HFrEF, and HFmrEF/HFpEF populations, respectively.

CONCLUSIONS

Despite high guideline-directed medical therapy adherence, the Thai Heart Failure Registry data revealed high mortality and recurrent HF rates. These findings underscore limitations in current HF treatment efficacy. The results indicate the need for further investigation and improvements of HF management to enhance patient outcomes.

Heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) accounts for nearly half of all heart failure cases and has a prevalence that is expected to rise with the growing ageing population. HFpEF is associated with significant morbidity and mortality. Specific HFpEF risk factors include age, diabetes, hypertension, obesity and atrial fibrillation. Haemodynamic contributions to HFpEF include changes in left ventricular structure, diastolic and systolic dysfunction, left atrial myopathy, pulmonary hypertension, right ventricular dysfunction, chronotropic incompetence, and vascular dysfunction. Inflammation, fibrosis, impaired nitric oxide signalling, sarcomere dysfunction, and mitochondrial and metabolic defects contribute to the cellular and molecular changes observed in HFpEF. HFpEF impacts multiple organ systems beyond the heart, including the skeletal muscle, peripheral vasculature, lungs, kidneys and brain. The diagnosis of HFpEF can be made in individuals with signs and symptoms of heart failure with abnormality in natriuretic peptide levels or evidence of cardiopulmonary congestion, facilitated by the use of HFpEF risk scores and additional imaging and testing with the exclusion of HFpEF mimics. Management includes initiation of guideline-directed medical therapy and management of comorbidities. Given the significant impact of HFpEF on quality of life, future research efforts should include a particular focus on how patients can live better with this disease.

Exploring the Association Between Heart Rate Control and Rehospitalization: A Real-World Analysis of Patients Hospitalized with Heart Failure with Reduced Ejection Fraction

BACKGROUND

In patients with heart failure with reduced ejection fraction (HFrEF), lower discharge heart rate (HR) is known to be associated with better outcomes. However, the effect of HR control on patient outcomes, and the demographic and clinical determinants of this association, are not well documented.

OBJECTIVES

The purpose of this work was to evaluate the association between the HR control and the risk of post-discharge rehospitalization in patients hospitalized with HFrEF.

METHODS

Data were collected using a retrospective medical record review in the USA. Reduction in HR between admission and discharge ("HR control") defined the primary exposure, categorized as no reduction, > 0 to < 20% reduction, and ≥ 20% reduction. Time to first rehospitalization in the post-discharge follow-up defined the study outcome and was analyzed using multivariable Cox regression modeling.

RESULTS

A total of 1002 patients were analyzed (median age, 63 years; median follow-up duration, 24.2 months). At admission, 59.1% received beta-blockers, 57.4% received diuretics, and 47.5% received angiotensin-converting enzyme (ACE) inhibitors. Most patients (90.5%) achieved some HR control (38.4% achieved > 0 to < 20% reduction, and 52% achieved ≥ 20% reduction). Approximately 39% were rehospitalized during the follow-up (14% within 30 days). In multivariable analysis, patients with > 0 to < 20% reduction in HR had a 39% lower risk of rehospitalization [hazard ratio 0.61; 95% confidence interval (CI) 0.43-0.85]; patients with ≥ 20% reduction in HR had a 38% lower rehospitalization risk (hazard ratio 0.62; 95% CI 0.45-0.87) than those with no HR reduction.

CONCLUSIONS

Reduction in HR between admission and discharge was associated with reduced risk for rehospitalization. Findings indicate HR control as an important goal in the management of patients hospitalized for HFrEF.

Diabetes and Heart Failure: A Literature Review, Reflection and Outlook

Heart failure (HF) is a complex clinical syndrome caused by structural or functional dysfunction of the ventricular filling or blood supply. Diabetes mellitus (DM) is an independent predictor of mortality for HF. The increase in prevalence, co-morbidity and hospitalization rates of both DM and HF has further fueled the possibility of overlapping disease pathology between the two. For decades, antidiabetic drugs that are known to definitively increase the risk of HF are the thiazolidinediones (TZDs) and saxagliptin in the dipeptidyl peptidase-4 (DPP-4) inhibitor, and insulin, which causes sodium and water retention, and whether metformin is effective or safe for HF is not clear. Notably, sodium-glucose transporter 2 (SGLT2) inhibitors and partial glucagon-like peptide-1 receptor agonists (GLP-1 RA) all achieved positive results for HF endpoints, with SGLT2 inhibitors in particular significantly reducing the composite endpoint of cardiovascular mortality and hospitalization for heart failure (HHF). Further understanding of the mutual pathophysiological mechanisms between HF and DM may facilitate the detection of novel therapeutic targets to improve the clinical outcome. This review focuses on the association between HF and DM, emphasizing the efficacy and safety of antidiabetic drugs and HF treatment. In addition, recent therapeutic advances in HF and the important mechanisms by which SGLT2 inhibitors/mineralocorticoid receptor antagonist (MRA)/vericiguat contribute to the benefits of HF are summarized.

Heart Failure With Preserved Ejection Fraction: Will Cardiac Magnetic Imaging Impact on Diagnosis, Treatment, and Outcomes?: Explaining the Need for Advanced Imaging to Clinical Stakeholders

Clinicians frequently equate symptoms of volume overload to heart failure (HF) but such generalization may preclude diagnostic or etiologic precision essential to optimizing outcomes. HF itself must be specified as the disparate types of cardiac pathology have been traditionally surmised by examination of left ventricular (LV) ejection fraction (EF) as either HF with preserved LVEF (HFpEF-LVEF >50%) or reduced LVEF of (HFrEF-LVEF <40%). More recent data support a third, potentially transitional HF subtype, but therapy, assessment, and prognosis have been historically dictated within the corresponding LV metrics determined by echocardiography. The present effort asks whether this historically dominant role of echocardiography is now shifting slightly, becoming instead a shared if not complimentary test. Will there be a gradual increasing profile for cardiac magnetic resonance as the attempt to further refine our understanding, diagnostic accuracy, and outcomes for HFpEF is attempted?

Effect of dapagliflozin on uric acid in patients with chronic heart failure and hyperuricemia

BACKGROUND

Patients with chronic heart failure (CHF) frequently develop hyperuricemia, an elevated serum uric acid level, associated with adverse outcomes. Dapagliflozin, a sodium-glucose cotransporter-2 inhibitor, demonstrates reduction in cardiovascular mortality and hospitalization in patients with CHF and ejection fraction (HFrEF), irrespective of diabetes. However, dapagliflozin's effect on the uric acid levels in patients with CHF and hyperuricemia remain unclear.

AIM

To investigate the effects of dapagliflozin on uric acid levels in CHF patients with hyperuricemia.

METHODS

We conducted a randomized, double-blind, placebo-controlled trial in 200 patients with CHF and hyperuricemia, with HFrEF and serum uric acid levels ≥ 7 mg/dL (≥ 416 μmol/L). The participants were randomly assigned to receive a daily dose of 10 mg dapagliflozin or placebo for 24 months. The primary endpoint was the change in serum uric acid level from baseline to 24 months. Secondary endpoints included changes in left ventricular ejection fraction (LVEF), N-terminal pro-B-type natriuretic peptide (NT-proBNP), and quality of life (QoL) scores, as well as the incidence of cardiovascular death and hospitalization for heart failure.

RESULTS

At 24 months, dapagliflozin significantly reduced serum uric acid levels by 1.2 mg/dL (71 μmol/L) compared with placebo (95%CI: -1.5 to -0.9; P < 0.001). Dapagliflozin also significantly improved LVEF by 3.5% (95%CI: 2.1-4.9; P < 0.001), NT-proBNP by 25% (95%CI: 18-32; P < 0.001), and QoL scores by 10 points (95%CI: 7-13; P < 0.001) and reduced the risk of cardiovascular death and hospitalization for heart failure by 35% (95%CI: 15-50; P = 0.002) compared with the placebo. Adverse events were similar between the two groups, except for a higher rate of genital infections in the dapagliflozin group (10% vs 2%, P = 0.01).

CONCLUSION

Dapagliflozin significantly lowered serum uric acid levels and improved the clinical outcomes in patients with CHF and hyperuricemia. Therefore, dapagliflozin may be a useful therapeutic option for this high-risk population.

Use of Statins in Heart Failure with Preserved Ejection Fraction: Current Evidence and Perspectives

Systemic inflammation and coronary microvascular endothelial dysfunction are essential pathophysiological factors in heart failure (HF) with preserved ejection fraction (HFpEF) that support the use of statins. The pleiotropic properties of statins, such as anti-inflammatory, antihypertrophic, antifibrotic, and antioxidant effects, are generally accepted and may be beneficial in HF, especially in HFpEF. Numerous observational clinical trials have consistently shown a beneficial prognostic effect of statins in patients with HFpEF, while the results of two larger trials in patients with HFrEF have been controversial. Such differences may be related to a more pronounced impact of the pleiotropic properties of statins on the pathophysiology of HFpEF and pro-inflammatory comorbidities (arterial hypertension, diabetes mellitus, obesity, chronic kidney disease) that are more common in HFpEF. This review discusses the potential mechanisms of statin action that may be beneficial for patients with HFpEF, as well as clinical trials that have evaluated the statin effects on left ventricular diastolic function and clinical outcomes in patients with HFpEF.

Non-coding RNAs in the pathophysiology of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is the largest unmet clinical need in cardiovascular medicine. Despite decades of research, the treatment option for HFpEF is still limited, indicating our ongoing incomplete understanding on the underlying molecular mechanisms. Non-coding RNAs, comprising of microRNAs (miRNAs), long non-coding RNAs (lncRNAs) and circular RNAs (circRNAs), are non-protein coding RNA transcripts, which are implicated in various cardiovascular diseases. However, their role in the pathogenesis of HFpEF is unknown. Here, we discuss the role of miRNAs, lncRNAs and circRNAs that are involved in the pathophysiology of HFpEF, namely microvascular dysfunction, inflammation, diastolic dysfunction and cardiac fibrosis. We interrogated clinical evidence and dissected the molecular mechanisms of the ncRNAs by looking at the relevant in vivo and in vitro models that mimic the co-morbidities in patients with HFpEF. Finally, we discuss the potential of ncRNAs as biomarkers and potential novel therapeutic targets for future HFpEF treatment.

Multimorbidity in patients with acute heart failure across world regions and country income levels (REPORT-HF): a prospective, multicentre, global cohort study

BACKGROUND

Multimorbidity (two or more comorbidities) is common among patients with acute heart failure, but comprehensive global information on its prevalence and clinical consequences across different world regions and income levels is scarce. This study aimed to investigate the prevalence of multimorbidity and its effect on pharmacotherapy and prognosis in participants of the REPORT-HF study.

METHODS

REPORT-HF was a prospective, multicentre, global cohort study that enrolled adults (aged ≥18 years) admitted to hospital with a primary diagnosis of acute heart failure from 358 hospitals in 44 countries on six continents. Patients who currently or recently participated in a clinical treatment trial were excluded. Follow-up data were collected at 1-year post-discharge. The primary outcome was 1-year post-discharge mortality. All patients in the REPORT-HF cohort with full data on comorbidities were eligible for the present study. We stratified patients according to the number of comorbidities, and countries by world region and country income level. We used one-way ANOVA, χ2 test, or Mann-Whitney U test for comparisons between groups, as applicable, and Cox regression to analyse the association between multimorbidity and 1-year mortality.

FINDINGS

Between July 23, 2014, and March 24, 2017, 18 553 patients were included in the REPORT-HF study. Of these, 18 528 patients had full data on comorbidities, of whom 11 360 (61%) were men and 7168 (39%) were women. Prevalence rates of multimorbidity were lowest in southeast Asia (72%) and highest in North America (92%). Fewer patients from lower-middle-income countries had multimorbidity than patients from high-income countries (73% vs 85%, p<0·0001). With increasing comorbidity burden, patients received fewer guideline-directed heart failure medications, yet more drugs potentially causing or worsening heart failure. Having more comorbidities was associated with worse outcomes: 1-year mortality increased from 13% (no comorbidities) to 26% (five or more comorbidities). This finding was independent of common baseline risk factors, including age and sex. The population-attributable fraction of multimorbidity for mortality was higher in high-income countries than in upper-middle-income or lower-middle-income countries (for patients with five or more comorbidities: 61% vs 27% and 31%, respectively).

INTERPRETATION

Multimorbidity is highly prevalent among patients with acute heart failure across world regions, especially in high-income countries, and is associated with higher mortality, less prescription of guideline-directed heart failure pharmacotherapy, and increased use of potentially harmful medications.

FUNDING

Novartis Pharma.

TRANSLATIONS

For the Arabic, French, German, Hindi, Mandarin, Russian and Spanish translations of the abstract see Supplementary Materials section.

Exploring the Mechanistic Link Between Obesity and Heart Failure

PURPOSE OF REVIEW

Among subtypes of cardiovascular disease, obesity has a potent and unique association with heart failure (HF) that is unexplained by traditional cardiovascular risk mediators. The concomitant rise in the prevalence of obesity and HF necessitates better understanding of their relationship to develop effective prevention and treatment strategies. The purpose of this review is to provide mechanistic insight regarding the link between obesity and HF by elucidating the direct and indirect pathways linking the two conditions.

RECENT FINDINGS

Several direct pathophysiologic mechanisms contribute to HF risk in individuals with excess weight, including hemodynamic alterations, neurohormonal activation, hormonal effects of dysfunctional adipose tissue, ectopic fat deposition with resulting lipotoxicity and microvascular dysfunction. Obesity further predisposes to HF indirectly through causal associations with hypertension, dyslipidemia, and most importantly, diabetes via insulin resistance. Low levels of physical activity and fitness further influence HF risk in the context of obesity. These various processes lead to myocardial injury and cardiac remodeling that are reflected by abnormalities in cardiac biomarkers and cardiac function on myocardial imaging. Understanding and addressing obesity-associated HF is a pressing clinical and public health challenge which can be informed by a deeper understanding of the complex pathways linking these two conditions together.

Non-eligibility for pivotal HFpEF/HFmrEF outcome trials and mortality in a contemporary heart failure cohort

Pivotal outcome trials targeting heart failure with preserved (HFpEF) and mildly-reduced ejection fraction (HFmrEF) may have excluded patients at highest risk of poor outcomes. We aimed to assess eligibility for HFpEF/HFmrEF outcome trials in an unselected heart failure cohort and its association with all-cause mortality. Among 32.028 patients presenting to a tertiary care center emergency unit for any reason between August 2018 and July 2019, we identified 407 admissions with evident HFpEF and HFmrEF. Eligibility criteria for pivotal trials CHARM-Preserved, I-PRESERVE, TOPCAT, PARAGON-HF, EMPEROR-Preserved and DELIVER were assessed by chart review. The proportions of admissions fulfilling HFpEF/HFmrEF trial eligibility criteria were 88% for CHARM-Preserved, 40% for I-PRESERVE, 35% for TOPCAT, 28% for PARAGON-HF, 51% for EMPEROR-Preserved, and 49% for DELIVER. During a median follow-up of 1.9 years, death-from-any-cause occurred in 121 cases (30%). Twenty-four-month overall survival estimates for non-eligible and eligible admissions were 53% vs. 76% for CHARM-Preserved (HR=2.32, 95% CI: 1.47-3.67, p<0.001), 62% vs. 87% for I-PRESERVE (HR=2.97, 1.85-4.77, p<0.001), 67% vs. 84% for TOPCAT (HR=2.04, 1.29-3.24, p = 0.002), 68% vs. 85% for PARAGONHF (HR=2.28, 1.33-3.90, p = 0.003), 64% vs. 81% for EMPEROR-Preserved (HR=1.90, 1.27-2.84, p = 0.002), and 65% vs. 80% for DELIVER (HR=1.71, 1.14-2.57, p = 0.010). Exclusion criteria independently predicting death were eGFR <20 ml/min/1.73 m2, COPD with home oxygen therapy, and severe valvular heart disease. Conclusively, in a contemporary HFpEF/HFmrEF cohort, non-eligibility for outcome trials predicted for strongly increased mortality. HFpEF/HFmrEF patients at highest mortality risk were likely underrepresented in previous outcome trials and their treatment remains an unmet medical need.

Palliative Care for Patients With Heart Failure With Preserved Ejection Fraction

Heart failure with preserved ejection fraction (HFpEF) has become the leading form of heart failure worldwide, particularly among elderly patient populations. HFpEF is associated with significant morbidity and mortality that may benefit from incorporation of palliative care (PC). Patients with HFpEF have similarly high mortality rates to patients with heart failure with reduced ejection fraction. PC trials for heart failure have shown improvement in quality of life, quality of death, and health care utilization, although most trials defined heart failure clinically without differentiating between HFpEF and heart failure with reduced ejection fraction. As such, the timing and role of PC for HFpEF care remains uncertain, and PC referral rates for HFpEF are very low despite potential improvements in important patient-centered outcomes. Specific barriers to referral include limited data, prognostic uncertainty, provider misconceptions about PC, inadequate specialty PC workforce, complexities of treating multimorbidity, and limited home care options for patients with heart failure. While there are many barriers to integration of PC into HFpEF care, there are multiple potential benefits to patients with HFpEF throughout their disease course. As this population continues to grow, targeted efforts to study and implement PC interventions are needed to improve patient quality of life and death.

Development of a tool to predict the risk of incident heart failure in a general population: the HUNT for HF risk score

AIMS

Currently, no incident heart failure (HF) risk score that is in regular use in a general population is available. We aimed to develop this and compare with existing HF risk scores.

METHODS AND RESULTS

Participants in the third wave (2006-08) of the population-based Trøndelag Health Study 3 (HUNT3) were included if they reported no previous HF. Any hospital diagnoses captured during follow-up (until the end of 2018) of HF, cardiomyopathy, or hypertensive heart disease were assessed by an experienced cardiologist. Valid HF events were defined as symptoms/signs of HF and objective evidence of structural/functional abnormality of the heart at rest. The model was compared with slightly modified HF risk scores (the Health Aging and Body Composition HF risk score, the Framingham HF risk score, the Pooled Cohort equations to Prevent HF risk score, and NORRISK 2). Among 36 511 participants (mean ± SD age of 57.9 ± 13.3 years, 55.4% female), with a mean follow-up of 10.2 ± 1.3 years, 1366 developed HF (incidence rate of 3.66 per 1000 participant years). Out of the 38 relevant clinical variables assessed, we identified 12 (atrial fibrillation being the strongest) that independently predicted an HF event. The final model demonstrated good discrimination (C statistics = 0.904) and calibration, was stable in internal validation, and performed well compared with existing risk scores. The model identified that, at enrolment, 31 391 (86%), 2386 (7%), 1246 (3%), and 1488 (4%) had low, low-intermediate, high-intermediate, and high 10-year HF risk, respectively.

CONCLUSIONS

Twelve clinical variables independently predicted 10-year HF risk. The model may serve well as the foundation of a practical, online risk score for HF in general practice.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04648852.

Comprehensive characterization of non-cardiac comorbidities in acute heart failure: an analysis of ESC-HFA EURObservational Research Programme Heart Failure Long-Term Registry

AIMS

To evaluate the prevalence and associations of non-cardiac comorbidities (NCCs) with in-hospital and post-discharge outcomes in acute heart failure (AHF) across the ejection fraction (EF) spectrum.

METHODS AND RESULTS

The 9326 AHF patients from European Society of Cardiology (ESC)-Heart Failure Association (HFA)-EURObservational Research Programme Heart Failure Long-Term Registry had complete information for the following 12 NCCs: anaemia, chronic obstructive pulmonary disease (COPD), diabetes, depression, hepatic dysfunction, renal dysfunction, malignancy, Parkinson's disease, peripheral vascular disease (PVD), rheumatoid arthritis, sleep apnoea, and stroke/transient ischaemic attack (TIA). Patients were classified by number of NCCs (0, 1, 2, 3, and ≥4). Of the AHF patients, 20.5% had no NCC, 28.5% had 1 NCC, 23.1% had 2 NCC, 15.4% had 3 NCC, and 12.5% had ≥4 NCC. In-hospital and post-discharge mortality increased with number of NCCs from 3.0% and 18.5% for 1 NCC to 12.5% and 36% for ≥4 NCCs.Anaemia, COPD, PVD, sleep apnoea, rheumatoid arthritis, stroke/TIA, Parkinson, and depression were more prevalent in HF with preserved EF (HFpEF). The hazard ratio (95% confidence interval) for post-discharge death for each NCC was for anaemia 1.6 (1.4-1.8), diabetes 1.2 (1.1-1.4), kidney dysfunction 1.7 (1.5-1.9), COPD 1.4 (1.2-1.5), PVD 1.2 (1.1-1.4), stroke/TIA 1.3 (1.1-1.5), depression 1.2 (1.0-1.5), hepatic dysfunction 2.1 (1.8-2.5), malignancy 1.5 (1.2-1.8), sleep apnoea 1.2 (0.9-1.7), rheumatoid arthritis 1.5 (1.1-2.1), and Parkinson 1.4 (0.9-2.1). Anaemia, kidney dysfunction, COPD, and diabetes were associated with post-discharge mortality in all EF categories, PVD, stroke/TIA, and depression only in HF with reduced EF, and sleep apnoea and malignancy only in HFpEF.

CONCLUSION

Multiple NCCs conferred poor in-hospital and post-discharge outcomes. Ejection fraction categories had different prevalence and risk profile associated with individual NCCs.

Therapies for patients with coexisting heart failure with reduced ejection fraction and non-alcoholic fatty liver disease

Heart failure with reduced ejection fraction (HFrEF) and nonalcoholic fatty liver disease (NAFLD) are two common comorbidities that share similar pathophysiological mechanisms. There is a growing interest in the potential of targeted therapies to improve outcomes in patients with coexisting HFrEF and NAFLD. This manuscript reviews current and potential therapies for patients with coexisting HFrEF and NAFLD. Pharmacological therapies, including angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, mineralocorticoids receptor antagonist, and sodium-glucose cotransporter-2 inhibitors, have been shown to reduce fibrosis and fat deposits in the liver. However, there are currently no data showing the beneficial effects of sacubitril/valsartan, ivabradine, hydralazine, isosorbide nitrates, digoxin, or beta blockers on NAFLD in patients with HFrEF. This study highlights the importance of considering HFrEF and NAFLD when developing treatment plans for patients with these comorbidities. Further research is needed in patients with coexisting HFrEF and NAFLD, with an emphasis on novel therapies and the importance of a multidisciplinary approach for managing these complex comorbidities.

A network medicine approach to study comorbidities in heart failure with preserved ejection fraction

BACKGROUND

Comorbidities are expected to impact the pathophysiology of heart failure (HF) with preserved ejection fraction (HFpEF). However, comorbidity profiles are usually reduced to a few comorbid disorders. Systems medicine approaches can model phenome-wide comorbidity profiles to improve our understanding of HFpEF and infer associated genetic profiles.

METHODS

We retrospectively explored 569 comorbidities in 29,047 HF patients, including 8062 HFpEF and 6585 HF with reduced ejection fraction (HFrEF) patients from a German university hospital. We assessed differences in comorbidity profiles between HF subtypes via multiple correspondence analysis. Then, we used machine learning classifiers to identify distinctive comorbidity profiles of HFpEF and HFrEF patients. Moreover, we built a comorbidity network (HFnet) to identify the main disease clusters that summarized the phenome-wide comorbidity. Lastly, we predicted novel gene candidates for HFpEF by linking the HFnet to a multilayer gene network, integrating multiple databases. To corroborate HFpEF candidate genes, we collected transcriptomic data in a murine HFpEF model. We compared predicted genes with the murine disease signature as well as with the literature.

RESULTS

We found a high degree of variance between the comorbidity profiles of HFpEF and HFrEF, while each was more similar to HFmrEF. The comorbidities present in HFpEF patients were more diverse than those in HFrEF and included neoplastic, osteologic and rheumatoid disorders. Disease communities in the HFnet captured important comorbidity concepts of HF patients which could be assigned to HF subtypes, age groups, and sex. Based on the HFpEF comorbidity profile, we predicted and recovered gene candidates, including genes involved in fibrosis (COL3A1, LOX, SMAD9, PTHL), hypertrophy (GATA5, MYH7), oxidative stress (NOS1, GSST1, XDH), and endoplasmic reticulum stress (ATF6). Finally, predicted genes were significantly overrepresented in the murine transcriptomic disease signature providing additional plausibility for their relevance.

CONCLUSIONS

We applied systems medicine concepts to analyze comorbidity profiles in a HF patient cohort. We were able to identify disease clusters that helped to characterize HF patients. We derived a distinct comorbidity profile for HFpEF, which was leveraged to suggest novel candidate genes via network propagation. The identification of distinctive comorbidity profiles and candidate genes from routine clinical data provides insights that may be leveraged to improve diagnosis and identify treatment targets for HFpEF patients.

Comorbidity profile and outcomes in patients with chronic heart failure in a Latin American country: Insights from the Colombian heart failure registry (RECOLFACA)

BACKGROUND

Heart failure (HF) is usually accompanied by cardiovascular and non-cardiovascular comorbidities, which may significantly impact its prognosis. In this study we aimed to characterize the comorbidity profile and its impact in mortality in patients with HF diagnosis from the Colombian Heart Failure Registry (RECOLFACA).

METHODS

RECOLFACA enrolled adult patients with HF diagnosis from 60 centers in Colombia during the period 2017-2019. The primary outcome was all-cause mortality. A Cox proportional hazards regression model was used to assess the impact of the comorbidities in mortality. A p-value of <0.05 was considered significant.

RESULTS

From the total 2528 patients included in the registry, 2514 patients (58% males, mean age 68 years) had information regarding comorbidity diagnoses. 2321 patients (92.3%) reported at least one comorbidity. Arterial hypertension was the most frequent individual diagnosis (72%; n = 1811), followed by anemia (30.1%, n = 726). The most frequently observed coexisting comorbidities were coronary disease (CHD) with dyslipidemia, and chronic kidney disease (CKD) with type 2 Diabetes Mellitus (T2DM). Different patterns of comorbidity coexistence were observed when comparing HF patients by sex and left-ventricular ejection fraction (LVEF) classification. The only comorbidities that were significantly associated with mortality after multivariate adjustment were T2DM (HR 1.45. 95% CI 1.01-2.12), anemia (HR 1.48. 95% CI 1.02-2.16), and CHD (HR 1.59. 95% CI 1.09-2.33).

CONCLUSION

Multiple comorbidities were frequently observed in the patients from the RECOLFACA. T2DM, anemia and CHD were significantly associated with a higher risk of mortality, highlighting the importance of promoting an optimal follow-up and control of these conditions.

Diet-Induced Microbiome's Impact on Heart Failure: A Double-Edged Sword

Heart failure (HF) is a debilitating disease with a significant clinical and economic impact worldwide. Multiple factors seem to increase the risk of developing HF, such as hypertension, obesity and diabetes. Since chronic inflammation plays a significant role in HF pathophysiology and gut dysbiosis is associated with low-grade chronic inflammation, the risk of cardiovascular diseases is likely modulated by the gut microbiome (GM). Considerable progress has been made in HF management. However, there is a need to find new strategies to reduce mortality and increase the quality of life, mainly of HFpEF patients, since its prevalence continues to rise. Recent studies validate that lifestyle changes, such as diet modulation, represent a potential therapeutic approach to improve several cardiometabolic diseases, although their effects on the GM and its indirect cardiac impact still warrant further research. Hence, in this paper, we aim to clarify the link between HF and the human microbiome.

Association of Dapagliflozin Use With Clinical Outcomes and the Introduction of Uric Acid-Lowering Therapy and Colchicine in Patients With Heart Failure With and Without Gout: A Patient-Level Pooled Meta-analysis of DAPA-HF and DELIVER

Importance

Gout is common in patients with heart failure (HF), and sodium-glucose cotransporter 2 inhibitors, a foundational treatment for HF, reduce uric acid levels.

Objective

To examine the reported prevalence of gout at baseline, the association between gout and clinical outcomes, and the effect of dapagliflozin in patients with and without gout and the introduction of new uric acid-lowering therapy and colchicine.

Design, Setting, and Participants

This post hoc analysis used data from 2 phase 3 randomized clinical trials conducted in 26 countries, DAPA-HF (left ventricular ejection fraction [LVEF] ≤40%) and DELIVER (LVEF >40%). Patients with New York Heart Association functional class II through IV and elevated levels of N-terminal pro-B-type natriuretic peptide were eligible. Data were analyzed between September 2022 and December 2022.

Intervention

Addition of once-daily 10 mg of dapagliflozin or placebo to guideline-recommended therapy.

Main Outcomes and Measures

The primary outcome was the composite of worsening HF or cardiovascular death.

Results

Among 11 005 patients for whom gout history was available, 1117 patients (10.1%) had a history of gout. The prevalence of gout was 10.3% (488 of 4747 patients) and 10.1% (629 of 6258 patients) in those with an LVEF up to 40% and greater than 40%, respectively. Patients with gout were more often men (897 of 1117 [80.3%]) than those without (6252 of 9888 [63.2%]). The mean (SD) age was similar between groups, 69.6 (9.8) years for patients with gout and 69.3 (10.6) years for those without. Patients with a history of gout had a higher body mass index, more comorbidity, and lower estimated glomerular filtration rate and were more often treated with a loop diuretic. The primary outcome occurred at a rate of 14.7 per 100 person-years (95% CI, 13.0-16.5) in participants with gout compared with 10.5 per 100 person-years (95% CI, 10.1-11.0) in those without (adjusted hazard ratio [HR], 1.15; 95% CI, 1.01-1.31). A history of gout was also associated with a higher risk of the other outcomes examined. Compared with placebo, dapagliflozin reduced the risk of the primary end point to the same extent in patients with (HR, 0.84; 95% CI, 0.66-1.06) and without a history of gout (HR, 0.79; 95% CI, 0.71-0.87; P = .66 for interaction). The effect of dapagliflozin use with other outcomes was consistent in participants with and without gout. Initiation of uric acid-lowering therapy (HR, 0.43; 95% CI, 0.34-0.53) and colchicine (HR, 0.54; 95% CI, 0.37-0.80) was reduced by dapagliflozin compared with placebo.

Conclusions and Relevance

This post hoc analysis of 2 trials found that gout was common in HF and associated with worse outcomes. The benefit of dapagliflozin was consistent in patients with and without gout. Dapagliflozin reduced the initiation of new treatments for hyperuricemia and gout.

Trial Registration

ClinicalTrials.gov Identifiers: NCT03036124 and NCT03619213.

The NO-cGMP-PKG Axis in HFpEF: From Pathological Mechanisms to Potential Therapies

Heart failure with preserved ejection fraction (HFpEF) accounts for almost half of all heart failure (HF) cases worldwide. Unfortunately, its incidence is expected to continue to rise, and effective therapy to improve clinical outcomes is lacking. Numerous efforts currently directed towards the pathophysiology of human HFpEF are uncovering signal transduction pathways and novel therapeutic targets. The nitric oxide-cyclic guanosine phosphate-protein kinase G (NO-cGMP-PKG) axis has been described as an important regulator of cardiac function. Suppression of the NO-cGMP-PKG signalling pathway is involved in the progression of HFpEF. Therefore, the NO-cGMP-PKG signalling pathway is a potential therapeutic target for HFpEF. In this review, we aim to explore the mechanism of NO-cGMP-PKG in the progression of HFpEF and to summarize potential therapeutic drugs that target this signalling pathway.

Comorbidities complicating heart failure: changes over the last 15 years

AIMS

Management of comorbidities represents a critical step in optimal treatment of heart failure (HF) patients. However, minimal attention has been paid whether comorbidity burden and their prognostic value changes over time. Therefore, we examined the association between comorbidities and clinical outcomes in HF patients between 2002 and 2017.

METHODS AND RESULTS

The 2002-HF cohort consisted of patients from The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) trial (n = 1,032). The 2017-HF cohort were outpatient HF patients enrolled after hospitalization for HF in a tertiary referral academic hospital (n = 382). Kaplan meier and cox regression analyses were used to assess the association of comorbidities with HF hospitalization and all-cause mortality. Patients from the 2017-cohort were more likely to be classified as HF with preserved ejection fraction (24 vs 15%, p < 0.001), compared to patients from the 2002-cohort. Comorbidity burden was comparable between both cohorts (mean of 3.9 comorbidities per patient) and substantially increased with age. Higher comorbidity burden was significantly associated with a comparable increased risk for HF hospitalization and all-cause mortality (HR 1.12 [1.02-1.22] and HR 1.18 [1.05-1.32]), in the 2002- and 2017-cohort respectively. When assessing individual comorbidities, obesity yielded a statistically higher prognostic effect on outcome in the 2017-cohort compared to the 2002-HF cohort (p for interaction 0.026).

CONCLUSION

Despite major advances in HF treatment over the past decades, comorbidity burden remains high in HF and influences outcome to a large extent. Obesity emerges as a prominent comorbidity, and efforts should be made for prevention and treatment. Created with BioRender.com.

Comprehensive Review of Cardiovascular Disease Risk in Nonalcoholic Fatty Liver Disease

Nonalcoholic Fatty Liver Disease (NAFLD) is a growing global phenomenon, and its damaging effects in terms of cardiovascular disease (CVD) risk are becoming more apparent. NAFLD is estimated to affect around one quarter of the world population and is often comorbid with other metabolic disorders including diabetes mellitus, hypertension, coronary artery disease, and metabolic syndrome. In this review, we examine the current evidence describing the many ways that NAFLD itself increases CVD risk. We also discuss the emerging and complex biochemical relationship between NAFLD and its common comorbid conditions, and how they coalesce to increase CVD risk. With NAFLD's rising prevalence and deleterious effects on the cardiovascular system, a complete understanding of the disease must be undertaken, as well as effective strategies to prevent and treat its common comorbid conditions.

Breaking the Cycle of Heart Failure With Preserved Ejection Fraction and Atrial Fibrillation

Heart failure with preserved ejection fraction (HFpEF) and AF are two common cardiovascular conditions that are inextricably linked to each other's development and progression, often in multimorbid patients. Current management is often directed to specific components of each disease without considering their joint impact on diagnosis, treatment and prognosis. The result for patients is suboptimal on all three levels, restricting clinicians from preventing major adverse events, including death, which occurs in 20% of patients at 2 years and in 45% at 4 years. New trial evidence and reanalysis of prior trials are providing a glimmer of hope that adverse outcomes can be reduced in those with concurrent HFpEF and AF. This will require a restructuring of care to integrate heart failure and AF teams, alongside those that manage comorbidities. Parallel commencement and non-sequential uptitration of therapeutics across different domains will be vital to ensure that all patients benefit at a personal level, based on their own needs and priorities.

Association between periodontitis and heart failure in the general population

AIMS

Data on the association between periodontitis and preclinical cardiac alterations remain scarce. The aim of the current study is to determine if periodontitis is associated with morphological and functional cardiac changes measured by transthoracic echocardiography as well as different heart failure (HF) phenotypes.

METHODS

Participants from the population-based Hamburg City Health Study [ClinicalTrial.gov (NCT03934957)], who underwent transthoracic echocardiography and periodontal screening were included. Periodontitis was classified according to Eke and Page (none/mild, moderate, severe). The 2021 ESC HF guidelines were applied and HF was classified into HF with preserved ejection fraction (HFpEF, ejection fraction ≥50%), HF with mid-range and reduced ejection fraction [HF(m)rEF, ejection fraction <50%], and HF in general [HFpEF and HF(m)rEF]. Due to limited size, all subjects with LVEF <50% and symptoms or signs of HF were classified as HF with reduced and mildly reduced ejection fraction [HF(m)rEF].

RESULTS

Within 6209 participants with full periodontal examination, we identified an overlap of n = 167 participants with periodontitis and HF. Participants with severe periodontitis showed a higher burden of cardiovascular risk factors (men at advanced age, diabetes mellitus, hypertension) when compared with participants with none/mild periodontitis. After adjustment for age, sex, body mass index, smoking, diabetes, hypertension, atrial fibrillation, and coronary artery disease, severe periodontitis was significantly associated with HF(m)rEF (odds ratio: 3.16; 95% CI: 1.21, 8.22; P = 0.019), although no association was found for HFpEF and HF in general.

CONCLUSIONS

The current study demonstrated that severe periodontitis was significantly associated with HF(m)rEF, although no relevant associations were found with HFpEF and HF in general as well as echocardiographic variables. The results implicate a potential target group, who need special attention from cooperating physicians and dentists. Future studies are warranted to verify whether systemic inflammation could be the link between the two diseases.

Subclinical Risk Factors for Heart Failure With Preserved and Reduced Ejection Fraction Among Black Adults

Importance

Sparse data exist regarding the contributions of subclinical impairments in cardiovascular and noncardiovascular function to incident heart failure (HF) with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF) among Black US residents, limiting understanding of the etiology of HF subtypes.

Objectives

To identify subclinical cardiovascular and noncardiovascular risk factors associated with HFrEF and HFpEF in Black US residents.

Design, Setting, and Participants

This cohort study used cross-sectional and time-to-event analysis with data from the community-based Jackson Heart Study (JHS), a longitudinal cohort study with baseline data collected from 2000 to 2004 (visit 1) and 10-year follow-up for incident HF. Black US residents from the Jackson, Mississippi, metropolitan area enrolled in JHS; those with prevalent HF, with moderate or greater aortic or mitral valve diseases on visit 1, who died before 2005, and who had missing HF status on follow-up were excluded. The analysis included 4361 participants and was performed between June 2020 to August 2021.

Exposures

Quantitative measures of cardiovascular (left ventricular mass index [LVMI], left ventricular ejection fraction [LVEF], left atrial [LA] diameter, and pulse pressure) and noncardiovascular (percent predicted forced expiration volume in 1 second [FEV1 (percent predicted)], estimated glomerular filtration rate (eGFR), waist circumference, and hemoglobin A1c [HbA1c] level) organ function.

Main Outcomes and Measures

Incident HF, HFrEF, and HFpEF over 10-year follow-up.

Results

The 4361 participants had a mean (SD) age of 54 (13); 2776 (64%) were women; and there were 163 HFpEF and 146 HFrEF events. In multivariable models incorporating measures reflecting each organ system, factors associated with incident HFpEF included greater LA diameter (hazard ratio [HR], 1.23; 95% CI, 1.03-1.47; P = .02), higher pulse pressure (HR, 1.23; 95% CI, 1.05-1.44; P = .009), lower FEV1 (percent predicted) (HR, 1.22; 95% CI, 1.04-1.43; P = .02), lower eGFR (HR, 1.43; 95% CI, 1.19-1.72; P < .001), higher HbA1c level (HR, 1.25; 95% CI, 1.07-1.45; P = .005), and higher waist circumference (HR, 1.41; 95% CI, 1.18-1.69; P < .001). Factors associated with incident HFrEF included greater LVMI (HR, 1.25; 1.07-1.46; P = .005), lower LVEF (HR, 1.65; 95% CI, 1.42-1.91; P < .001), lower FEV1 (percent predicted) (HR, 1.19; 95% CI, 1.00-1.42; P = .047), and lower eGFR (HR, 1.27; 95% CI, 1.04-1.55; P = .02).

Conclusions and Relevance

In this community-based cohort study of Black US residents, subclinical impairments in cardiovascular and noncardiovascular organ function were differentially associated with risk of incident HFpEF and HFrEF.

The Association between Marital Status and Outcomes of Patients Hospitalized with Heart Failure

BACKGROUND

Little is known about the association between marital status and long-term outcomes of patients hospitalized with heart failure (HF). We aimed to examine the association between marital status and early as well as long-term outcomes of patients hospitalized with HF.

METHOD

We analyzed data of 4089 patients hospitalized with HF and were enrolled in the multicenter national survey in Israel between March and April 2003 and were followed until December 2014. Patients were classified into married (N = 2462, 60%) and unmarried (N = 1627, 40%).

RESULTS

Married patients were more likely to be males, younger, and more likely to have past myocardial infarction and previous revascularization. Also, they tended to have higher rates of diabetes mellitus (DM) and dyslipidemia, as well as smokers. Survival analysis showed that unmarried patients had higher mortality rates at 1 and 10 years (33% vs. 25%, at 1 year, 89% vs. 80% at 10 years, all p < 0.001). Consistently, multivariable analysis showed that unmarried patients had independently 44% and 35% higher risk of mortality at 1- and 10-year follow-up respectively (1-year HR = 1.44; 95%CI 1.14-1.81; p = 0.002, 10-year HR = 1.35; 95%CI 1.19-1.53; p ≤ 0.001). Other consistent predictors of mortality at both 1- and 10-year follow-up include age, renal failure, and advanced HF.

CONCLUSIONS

Being unmarried is independently associated with worse short- and long-term outcomes, particularly among women. Thus, attempts to intensify secondary preventive measures should focus mainly on unmarried patients and mainly women.

Prognostic importance of improving hepatorenal function during hospitalization in acute decompensated heart failure

AIMS

The Model for End-stage Liver Disease eXcluding International normalized ratio (MELD-XI) is an established scoring system that reflects hepatorenal function. However, little is known about the prognostic value of changes in MELD-XI score during hospitalization in acute decompensated heart failure (ADHF).

METHODS AND RESULTS

We prospectively analysed 536 patients admitted for ADHF between January 2018 and December 2019. In the MELD-XI, 9.44 is the lowest possible score and considered to be normal, and values above 9.44 are classified as high. We calculated MELD-XI scores at admission and discharge and used them to divide patients into four groups depending on whether the score was high (>9.44) or normal (9.44) at each time point as follows: normal score at both measurements (persistently normal group, n = 99), high score at admission and normal score at discharge (high-to-normal group, n = 108), normal score at admission and high score at discharge (normal-to-high group, n = 24), and high score at both measurements (persistently high group, n = 305). The persistently high group had higher blood urea nitrogen, creatinine, and N-terminal pro-brain natriuretic peptide levels at both admission and discharge and significantly higher left ventricular end-diastolic, left atrial, right ventricular end-diastolic, and maximal inferior vena cava diameters at discharge. During the median follow-up period of 369 days (Q1, Q3: 97, 576), 231 (43.1%) patients reached the primary endpoint (a composite of all-cause death or re-hospitalization for heart failure). The Kaplan-Meier analysis revealed a significantly higher composite event rate in the persistently high group than in the persistently normal and high-to-normal groups (log-rank test, P < 0.001). Compared with the persistently high group, the high-to-normal group remained significantly associated with lower composite event risk after multivariate adjustment (hazard ratio, 0.30; 95% CI, 0.12-0.69; P = 0.004).

CONCLUSIONS

Our study suggests that changes in hepatorenal function during hospitalization are associated with the severity of heart failure and systemic congestion and that they provide useful information for predicting clinical outcomes in patients with ADHF.

Heart failure with preserved ejection fraction: Squaring the circle between comorbidities and cardiovascular abnormalities

Heart Failure with preserved Ejection Fraction (HFpEF) is nowadays considered a major healthcare issue. According to forecasts two third of all Heart Failure patients will belong to this phenotype by year 2050, overwhelming those affected by Heart Failure with reduced Ejection Fraction (HFrEF). Both epidemiological and mechanistic studies support the concept that HFpEF represents true HF although aggravated by a collection of comorbidities. There is urgent need of improving its phenotyping due to the high degree of disease heterogeneity within HFpEF that lead to the failure of randomized clinical trials in demonstrating a remarkable impact of drugs in improving its morbidity and mortality.

Gout Arthritis During Admission for Decompensated Heart Failure—A Descriptive Analysis of Risk Factors, Treatment and Prognosis

Background

Chronic heart failure and hospital admissions are well-known risk factors for acute gouty arthritis. However, in-depth analyses of patients admitted for decompensated heart failure (DHF) who subsequently developed a gout attack are sparse. This study aims to characterize DHF patients who developed a gout attack during their inpatient treatment and describe potential risk factors, its consequences, and its management in the setting of heart failure exacerbation.

Methods

Retrospective chart review of 50 patients with an admission diagnosis of DHF who subsequently experienced a gout attack during admission at a Swiss tertiary care hospital between 2018 and 2020. Patients with a refusal of the general research consent were excluded (n = 10).

Results

A gout attack developed in 66/1,832 (3.6%) DHF admissions of whom 50 individual patients were analyzed. Patients were predominately male (76%), of advanced age (median 80.5 years), with several comorbidities including chronic kidney disease (74%), comorbid gout (70%, only 43% on urate lowering therapy) and hyperuricemia (median 547 μmol/l, IQR 434–667 μmol/l). Diuretics were intensified in all patients. Acute gout presented as polyarticular arthritis (62%) and was often accompanied by fever (30%). Joint aspiration was performed in 32%, and intra-articular steroid injections administered in 20% of patients. Median length of stay and 6-month mortality were 16 days (IQR 12–25) and 32%, respectively, compared to 9 days (IQR 6–14) and 16% for DHF patients without a gout attack.

Conclusion

Our study highlights features of gout attacks in the context of DHF including the absence of comorbid gout in a significant proportion of patients, the presence of polyarticular disease during the flare, and a poor prognosis. The present study identifies the necessity to better address gout as a comorbidity in DHF patients and may assist clinicians in identifying DHF patients at risk for a gout attack.

Multimodality imaging in patients with heart failure and preserved ejection fraction: an expert consensus document of the European Association of Cardiovascular Imaging

Nearly half of all patients with heart failure (HF) have a normal left ventricular (LV) ejection fraction (EF) and the condition is termed heart failure with preserved ejection fraction (HFpEF). It is assumed that in these patients HF is due primarily to LV diastolic dysfunction. The prognosis in HFpEF is almost as severe as in HF with reduced EF (HFrEF). In contrast to HFrEF where drugs and devices are proven to reduce mortality, in HFpEF there has been limited therapy available with documented effects on prognosis. This may reflect that HFpEF encompasses a wide range of different pathological processes, which multimodality imaging is well placed to differentiate. Progress in developing therapies for HFpEF has been hampered by a lack of uniform diagnostic criteria. The present expert consensus document from the European Association of Cardiovascular Imaging (EACVI) provides recommendations regarding how to determine elevated LV filling pressure in the setting of suspected HFpEF and how to use multimodality imaging to determine specific aetiologies in patients with HFpEF.

Clinical risk factors for mortality in an analysis of 1375 patients admitted for COVID treatment

The goal of the present work was to examine clinical risk factors for mortality in 1375 COVID + patients admitted to a hospital in Suffolk County, NY. Data were collated by the hospital epidemiological service for patients admitted from 3/7/2020 to 9/1/2020. Time until final discharge or death was the outcome. Cox proportional hazards models were used to estimate time until death among admitted patients. In total, all cases had resolved leading to 207 deaths. Length of stay was significantly longer in those who died as compared to those who did not (p = 0.007). Of patients who had been discharged, 54 were readmitted and nine subsequently died. Multivariable-adjusted Cox proportional hazards regression revealed that in addition to older age, male sex, and a history of chronic heart failure, chronic obstructive pulmonary disease, and diabetes, that a history of premorbid depression was a risk factors for COVID-19 mortality (aHR = 2.42 [1.38-4.23] P = 0.002), and that this association remained after adjusting for age and for neuropsychiatric conditions as well as medical comorbidities including cardiovascular disease and pulmonary conditions. Sex-stratified analyses revealed that associations between mortality and depression was strongest in males (aHR = 4.45 [2.04-9.72], P < 0.001), and that the association between heart failure and mortality was strongest in participants aged < 65 years old (aHR = 30.50 [9.17-101.48], P < 0.001). While an increasing number of studies have identified several comorbid medical conditions including chronic heart failure and age of patient as risk factors for mortality in COVID + patients, this study confirmed several prior reports and also noted that a history of depression is an independent risk factor for COVID-19 mortality.

Mode of Death in Patients With Heart Failure and Preserved Ejection Fraction: Insights From PARAGON-HF Trial

BACKGROUND

Patients with heart failure (HF) and preserved left ventricular ejection fraction comprise a heterogeneous group including some with mildly reduced EF. We hypothesized that mode of death differs by EF in ambulatory patients with HF and preserved left ventricular ejection fraction.

METHODS

PARAGON-HF trial (Prospective Comparison of Angiotensin Receptor-Neprilysin Inhibitor With Angiotensin-Receptor Blocker Global Outcomes in Heart Failure With Preserved Ejection Fraction) compared clinical outcomes in 4796 patients with chronic HF and EF ≥45% randomly assigned to sacubitril/valsartan or valsartan. We examined the mode of death in relation to baseline EF in logistic regression models and the effect of randomized treatment on cause-specific death in Cox regression models. Nonlinear relationships with continuous EF were modelled using quadratic and cubic terms.

RESULTS

Of 691 deaths during the trial, 416 (60%) were ascribed to cardiovascular, 220 (32%) to noncardiovascular, and 55 (8%) to unknown causes. Of cardiovascular deaths, 154 (37%) were due to sudden death, 118 (28%) were due to HF, 35 (8%) to stroke, 27 (6%) to myocardial infarction, and 82 (20%) to other cardiovascular causes. Rates of all-cause, cardiovascular, and sudden death were higher in those with lower left ventricular ejection fraction (all P<0.001), while rates of non-cardiovascular death were greater in patients with higher EF. Sacubitril/valsartan did not reduce overall death, cardiovascular death, or sudden death compared with valsartan, irrespective of baseline EF (all P for interaction >0.30).

CONCLUSIONS

Among patients with HF and preserved left ventricular ejection fraction enrolled in PARAGON-HF, the proportion of cardiovascular and sudden death were higher in those with lower left ventricular EF, and the proportion of noncardiovascular death rose with EF. Regardless of EF, sacubitril/valsartan did not reduce death from any cause compared with valsartan. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.

Redefining β-blocker response in heart failure patients with sinus rhythm and atrial fibrillation: a machine learning cluster analysis

BACKGROUND

Mortality remains unacceptably high in patients with heart failure and reduced left ventricular ejection fraction (LVEF) despite advances in therapeutics. We hypothesised that a novel artificial intelligence approach could better assess multiple and higher-dimension interactions of comorbidities, and define clusters of β-blocker efficacy in patients with sinus rhythm and atrial fibrillation.

METHODS

Neural network-based variational autoencoders and hierarchical clustering were applied to pooled individual patient data from nine double-blind, randomised, placebo-controlled trials of β blockers. All-cause mortality during median 1·3 years of follow-up was assessed by intention to treat, stratified by electrocardiographic heart rhythm. The number of clusters and dimensions was determined objectively, with results validated using a leave-one-trial-out approach. This study was prospectively registered with ClinicalTrials.gov (NCT00832442) and the PROSPERO database of systematic reviews (CRD42014010012).

FINDINGS

15 659 patients with heart failure and LVEF of less than 50% were included, with median age 65 years (IQR 56-72) and LVEF 27% (IQR 21-33). 3708 (24%) patients were women. In sinus rhythm (n=12 822), most clusters demonstrated a consistent overall mortality benefit from β blockers, with odds ratios (ORs) ranging from 0·54 to 0·74. One cluster in sinus rhythm of older patients with less severe symptoms showed no significant efficacy (OR 0·86, 95% CI 0·67-1·10; p=0·22). In atrial fibrillation (n=2837), four of five clusters were consistent with the overall neutral effect of β blockers versus placebo (OR 0·92, 0·77-1·10; p=0·37). One cluster of younger atrial fibrillation patients at lower mortality risk but similar LVEF to average had a statistically significant reduction in mortality with β blockers (OR 0·57, 0·35-0·93; p=0·023). The robustness and consistency of clustering was confirmed for all models (p<0·0001 vs random), and cluster membership was externally validated across the nine independent trials.

INTERPRETATION

An artificial intelligence-based clustering approach was able to distinguish prognostic response from β blockers in patients with heart failure and reduced LVEF. This included patients in sinus rhythm with suboptimal efficacy, as well as a cluster of patients with atrial fibrillation where β blockers did reduce mortality.

FUNDING

Medical Research Council, UK, and EU/EFPIA Innovative Medicines Initiative BigData@Heart.

Effect of ivabradine in heart failure: a meta-analysis of heart failure patients with reduced versus preserved ejection fraction

In clinical trials of heart failure reduced ejection fraction (HFrEF), ivabradine seemed to be an effective heart rate lowering agent associated with lower risk of cardiovascular death. In contrast, ivabradine failed to improve cardiovascular outcomes in heart failure preserved ejection fraction (HFpEF) despite the significant effect on heart rate. This meta-analysis is the first to compare the effects of ivabradine on heart rate and mortality parameters in HFpEF versus HFrEF. We screened three databases: PubMed, Embase, and Cochrane Library. The outcomes of these studies were mortality, reduction in heart rate, and left ventricular function improvement. We compared the efficacy of ivabradine treatment in HFpEF versus HFrEF. Heart rate analysis of pooled data showed decrease in both HFrEF (-17.646 beats/min) and HFpEF (-11.434 beats/min), and a tendency to have stronger bradycardic effect in HFrEF (p = 0.094) in randomized clinical trials. Left ventricular ejection fraction analysis revealed significant improvement in HFrEF (5.936, 95% CI: [4.199-7.672], p < 0.001) when compared with placebo (p < 0.001). We found that ivabradine significantly improves left ventricular performance in HFrEF, at the same time it exerts a tendency to have improved bradycardic effect in HFrEF. These disparate effects of ivabradine and the higher prevalence of non-cardiac comorbidities in HFpEF may explain the observed beneficial effects in HFrEF and the unchanged outcomes in HFpEF patients after ivabradine treatment.

Positionspapier „Schlafmedizin in der Kardiologie“, Update 2021

Es hat sich viel getan in der Welt der Schlafmedizin in der Kardiologie, weshalb eine vollwertige Überarbeitung des Positionspapiers „Schlafmedizin in der Kardiologie“ erforderlich wurde. In der aktuellen neuartigen Version finden sich nicht nur alle verfügbaren Studien, Literaturstellen und Updates zu Pathophysiologie, Diagnostik- und Therapieempfehlungen, sondern auch Ausblicke auf neue Entwicklungen und zukünftige Forschungserkenntnisse. Dieses überarbeitete Positionspapier gibt Empfehlungen für Diagnostik und Therapie von Patienten mit kardiovaskulären Erkrankungen mit schlafassoziierten Atmungsstörungen und erteilt darüber hinaus einen fundierten Überblick über verfügbare Therapien und Evidenzen, gibt aber ebenso Ratschläge wie mit Komorbiditäten umzugehen ist. Insbesondere enthält dieses überarbeitete Positionspapier aktualisierte Stellungnahmen zu schlafassoziierten Atmungsstörungen bei Patienten mit koronarer Herzerkrankung, Herzinsuffizienz, arterieller Hypertonie, aber auch für Patienten mit Vorhofflimmern. Darüber hinaus finden sich erstmals Empfehlungen zur Telemedizin als eigenes, neues Kapitel. Dieses Positionspapier bietet Kardiologen sowie Ärzten in der Behandlung von kardiovaskulären Patienten die Möglichkeit einer evidenzbasierten Behandlung der wachsend bedeutsamen und mit zunehmender Aufmerksamkeit behafteten Komorbidität schlafassoziierter Atmungsstörungen. Und nicht zuletzt besteht mit diesem neuen Positionspapier eine enge Verknüpfung mit dem neuen Curriculum Schlafmedizin der Deutschen Gesellschaft für Kardiologie, weshalb dieses Positionspapier eine Orientierung für die erworbenen Fähigkeiten des Curriculums im Umgang von kardiovaskulären Patienten mit schlafassoziierten Atmungsstörungen darstellt.

Heart failure with preserved ejection fraction in Belgium: characteristics and outcome of a real-life cohort

BACKGROUND

Due to aging of the population and the increase of cardiovascular risk factors, heart failure and preserved ejection fraction (HFpEF) is a rising health issue. Few data exist on the phenotype of HFpEF patients in Belgium and on their prognosis.

OBJECTIVES

We describe clinical characteristics and outcomes of Belgian HFpEF patients.

METHODS

We prospectively enrolled 183 HFpEF patients. They underwent clinical examination, comprehensive biological analysis and echocardiography, and were followed for a combined outcome of all-cause mortality and first HF hospitalisation.

RESULTS

Belgian patients with HFpEF were old (78 ± 8 years), predominantly females (62%) with multiple comorbidities. Ninety-five per cent were hypertensive, 38% diabetic and 69% overweight. History of atrial fibrillation was present in 63% of population, chronic kidney disease in 60% and anaemia in 58%. Over 30 ± 9 months, 55 (31%) patients died, 87 (49%) were hospitalised and 111 (63%) reached the combined outcome. In multivariate Cox analysis, low body mass index (BMI), NYHA class III and IV, diabetes, poor renal function and loop diuretic intake were independent predictors of the combined outcome (p < .05). BMI and renal function were also independent predictors of mortality, as were low haemoglobin, high E/e' and poor right ventricular function.

CONCLUSION

Belgian patients with HFpEF are elderly patients with a high burden of comorbidities. Their prognosis is poor with high rates of hospitalisation and mortality. Although obesity is a risk factor for developing HFpEF, low BMI is the strongest independent predictor of mortality in those patients.

Prevalence and Prognostic Significance of Pulmonary Function Test Abnormalities in Hospitalized Patients With Acute Decompensated Heart Failure With Preserved and Reduced Ejection Fraction

BACKGROUND

This study evaluated the prevalence and prognostic impact of lung function abnormalities in patients with acute decompensated heart failure (ADHF) with reduced ejection fraction (HFrEF) and preserved ejection fraction (HFpEF).Methods and Results:Of the 1,012 consecutive patients who were admitted to Nara Medical University with ADHF between 2011 and 2018, 657 routinely underwent spirometry (pulmonary function test [PFT]) before discharge. Lung function was classified as normal or abnormal (restrictive, obstructive, or mixed). Abnormal PFTs were seen in 63.0% of patients with ADHF (36.7%, 13.1%, and 13.2% for restrictive, obstructive, and mixed, respectively). The prevalence of abnormal PFT increased with age (P<0.001). Overall, abnormal PFT was an independent predictor of the composite endpoint of cardiovascular mortality or hospitalization for HF (adjusted hazard ratio [HR] 1.402; 95% confidence interval [CI] 1.039-1.914; P=0.027). Abnormal PFT (adjusted HR 2.294; 95% CI 1.368-4.064; P=0.001), as well as the restrictive (HR 2.299; 95% CI 1.322-4.175; P=0.003) and mixed (HR 2.784; 95% CI 1.399-5.581; P=0.004) patterns, were predictive of the composite endpoint in HFpEF, but not in HFrEF.

CONCLUSIONS

Abnormal PFT was prevalent and associated with poor outcomes in ADHF. Spirometry may be a useful tool in patients with ADHF, especially in those with HFpEF, to identify those at higher risk of a poorer outcome.

[Air pollution and heart rhythm disturbance: A retrospective study]

INTRODUCTION

According to many studies, exposure to air pollution increases cardiovascular morbidity and mortality. It has also been shown that the frequency of heart rhythm disorders in Region wallonne is very high.

OBJECTIVES

The objective of this study is to test the hypothesis of a link between rhythm disorders measured by cardiac holters and data from devices measuring the concentration of air pollutants present in ambient air.

METHODOLOGY

The health data were obtained via the Erasme hospital's cardiology center. This is a retrospective data collection over the last 2 to 5 years. The environmental data are: PM2.5, PM10, NO2, O3 and temperature. The statistical models were based on "cross-case" analyses.

RESULTS

An association between PM10 and the number of ESAs was observed. An increase of 10μg/m³ of PM10 increases the number of ESAs by 20% (P=0.040). The number of ESAs increases with age (63% more ESAs when age increases by 10 years). A history of intervention also decreases the number of ESAs (-35%), the same phenomenon is observed for pacemaker wearers (-66%). The strongest association observed between NO2 and ESA with an OR of 1.37 (P=0.027) in the final model. No significant association was observed between the effects of air pollution and VPCs.

CONCLUSION

Our analyses resume the effects of the different pollutants on rhythm disorders, the effects adjusted for treatment and co-morbidities. They open the door to other more refined studies based on individual measurements.

Signs of diastolic dysfunction are graded by serum testosterone levels in aging C57BL/6 male mice

We investigated whether maladaptive, age-associated changes in heart structure and function were linked to circulating testosterone levels. Male C57BL/6 mice had a gonadectomy (GDX) or sham surgery at 4 weeks and effects of GDX on the heart were examined with echocardiography. Serum testosterone was measured with ELISA. Left ventricular (LV) mass increased with age but was smaller in GDX mice than sham at 18 months (144.0 ± 8.7 vs 118.2 ± 11.9 mg; p = 0.009). The isovolumic relaxation time (IVRT) declined with age but was prolonged in GDX mice at 18 months (10.5 ± 0.8 vs 12.5 ± 0.5 msec, p = 0.008). Ejection fraction did not change with age or GDX, but E/A ratios were lower in GDX mice than controls at 18 months (1.6 ± 0.2 vs 1.3 ± 0.1, p = 0.021). When links between serum testosterone and cardiac parameters were examined longitudinally in 18-24-month-old mice, LV mass declined with decreasing testosterone (β = 37.70, p = 0.016), however IVRT increased as testosterone decreased (β=-2.69, p = 0.036). Since longer IVRT and lower E/A ratios are signs of diastolic dysfunction, low circulating testosterone may promote or exacerbate diastolic dysfunction in older males. These findings suggest that lower testosterone directly modifies heart structure and function to promote maladaptive remodeling and diastolic dysfunction in the aging heart.

Epidemiological and clinical boundaries of heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is highly prevalent and is associated with relevant morbidity and mortality. However, an evidence-based treatment is still absent. The heterogeneous definitions, differences in aetiology/pathophysiology, and diagnostic challenges of HFpEF made it difficult to define its epidemiological landmarks so far. Several large registries and observational studies have recently disclosed an increasing incidence/prevalence, as well as its prognostic significance. An accurate definition of HFpEF epidemiological boundaries and phenotypes is mandatory to develop novel effective and rational therapeutic approaches.

Variation in use and dosing escalation of renin angiotensin system, mineralocorticoid receptor antagonist, angiotensin receptor neprilysin inhibitor and beta-blocker therapies in heart failure and reduced ejection fraction: Association of comorbidities

BACKGROUND

In patients with heart failure and reduced ejection fraction (HFrEF), angiotensin converting enzyme inhibitors (ACEi), angiotensin II receptor blockers (ARB), or angiotensin receptor neprilysin inhibitor (ARNI), mineralocorticoid receptor antagonists (MRA), and beta-blockers (βB) are underutilized. It is unknown if patients with and without comorbidities have similar ACEi/ARB/ARNI, MRA, and βB prescription patterns.

METHODS

Baseline data from the CHAMP-HF (Change the Management of Patients with Heart Failure) registry were categorized by history of atrial fibrillation, asthma/chronic lung disease, obstructive sleep apnea, and depression. Using multivariate hierarchical logistic models, associations of ACEi/ARB/ARNI, MRA and βB medication use and dose by comorbidities were assessed after adjusting for patient characteristics.

RESULTS

Of 4,815 HFrEF patients from 152 CHAMP-HF sites, ACEi/ARB/ARNI use was lower in patients with more comorbidities, and generally, MRA use was low and βB use was high. In adjusted analyses, patients with HFrEF and comorbid obstructive sleep apnea, vs. without, were more likely to be prescribed ARNI (OR [95% CI]: 1.25 [1.00, 1.55]); P = .047 and MRA (1.31 [1.11, 1.55]); P = .002 and less likely to be prescribed ACEi (0.74 [0.63, 0.88]); P < .001. Patients with atrial fibrillation, vs. without, were less likely to receive ACEi/ARB (0.82 [0.71, 0.95]); P = .006 and any study medication (0.81 [0.67, 0.97]); P = .020. Comorbid lung disease and history of depression were not associated with HFrEF prescriptions.

CONCLUSIONS

Renin-angiotensin-aldosterone blockade therapy prescription and dose varied by comorbidity status, but βB therapy did not. In quality efforts, leaders need to consider use and dosing of prescriptions in light of prevalent comorbidities.

Global Differences in Heart Failure With Preserved Ejection Fraction: The PARAGON-HF Trial

BACKGROUND

Heart failure with preserved ejection fraction (HFpEF) is a global public health problem with important regional differences. We investigated these differences in the PARAGON-HF trial (Prospective Comparison of Angiotensin Receptor Neprilysin Inhibitor With Angiotensin Receptor Blocker Global Outcomes in HFpEF), the largest and most inclusive global HFpEF trial.

METHODS

We studied differences in clinical characteristics, outcomes, and treatment effects of sacubitril/valsartan in 4796 patients with HFpEF from the PARAGON-HF trial, grouped according to geographic region.

RESULTS

Regional differences in patient characteristics and comorbidities were observed: patients from Western Europe were oldest (mean 75±7 years) with the highest prevalence of atrial fibrillation/flutter (36%); Central/Eastern European patients were youngest (mean 71±8 years) with the highest prevalence of coronary artery disease (50%); North American patients had the highest prevalence of obesity (65%) and diabetes (49%); Latin American patients were younger (73±9 years) and had a high prevalence of obesity (53%); and Asia-Pacific patients had a high prevalence of diabetes (44%), despite a low prevalence of obesity (26%). Rates of the primary composite end point of total hospitalizations for HF and death from cardiovascular causes were lower in patients from Central Europe (9 per 100 patient-years) and highest in patients from North America (28 per 100 patient-years), which was primarily driven by a greater number of total hospitalizations for HF. The effect of treatment with sacubitril-valsartan was not modified by region (interaction P>0.05).

CONCLUSIONS

Among patients with HFpEF recruited worldwide in PARAGON-HF, there were important regional differences in clinical characteristics and outcomes, which may have implications for the design of future clinical trials. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT01920711.

Clinical profile and contemporary management of patients with heart failure with preserved ejection fraction: results from the CHECK-HF registry

Background

Clinical management of heart failure with preserved ejection fraction (HFpEF) centres on treating comorbidities and is likely to vary between countries. Thus, to provide insight into the current management of HFpEF, studies from multiple countries are required. We evaluated the clinical profiles and current management of patients with HFpEF in the Netherlands.

Methods

We included 2153 patients with HFpEF (defined as a left ventricular ejection fraction ≥ 50%) from the CHECK-HF registry, which included patients from 2013 to 2016.

Results

Median age was 77 (IQR 15) years, 55% were women and the most frequent comorbidities were hypertension (51%), renal insufficiency (45%) and atrial fibrillation (AF, 38%). Patients between 65 and 80 years and those over 80 years had on average more comorbidities (up to 64% and 74%, respectively, with two or more comorbidities) than patients younger than 65 years (38% with two or more comorbidities, p-value < 0.001). Although no specific drugs are available for HFpEF, treating comorbidities is advised. Beta-blockers were most frequently prescribed (78%), followed by loop diuretics (74%), renin-angiotensin system (RAS) inhibitors (67%) and mineralocorticoid receptor antagonists (MRAs, 39%). Strongest predictors for loop-diuretic use were older age, higher New York Heart Association class and AF.

Conclusion

The medical HFpEF profile is determined by the underlying comorbidities, sex and age. Comorbidities are highly prevalent in HFpEF patients, especially in elderly HFpEF patients. Despite the lack of evidence, many HFpEF patients receive regular beta-blockers, RAS inhibitors and MRAs, often for the treatment of comorbidities.

Supplementary Information

The online version of this article (10.1007/s12471-020-01534-7) contains supplementary material, which is available to authorized users.

Estimated plasma volume status in heart failure: clinical implications and future directions

Congestion is one of the main predictors of poor outcome in patients with heart failure (HF). Assessing and monitoring congestion is essential for optimizing HF therapy. Among the various available methods, serial measurements of estimated plasma volume (ePVS) using routine blood count and/or body weight (e.g., the Strauss, Duarte, Hakim formulas) may be useful in HF management. Further prospective study is warranted to determine whether ePVS can help optimize decongestion therapy (loop diuretics, mineralocorticoid receptor antagonists, SGLT2i) in various HF settings. This narrative review summarizes the recent evidence supporting the association of ePVS with clinical congestion and outcome(s) and discusses future directions for monitoring ePVS in HF.

Predictive value of H2 FPEF score in patients with heart failure with preserved ejection fraction

Aims

The H₂FPEF score is a convenient risk stratification tool for diagnosing heart failure with preserved ejection fraction (HFpEF). This study examined the value of the H₂FPEF score for predicting all‐cause mortality and rehospitalization in HFpEF patients.

Methods and results

This was a retrospective cohort study of patients diagnosed with HFpEF by echocardiography at a single tertiary centre between 1 January 2015 and 30 April 2018. According to the H₂FPEF score, the subjects were divided into low (0–1 points), intermediate (2–5 points), and high (6–9 points) score groups. The primary outcomes were all‐cause mortality and rehospitalization. A total of 476 patients (mean age: 70.5 ± 8.4 years, 60.7% female) were included. Of these, 47 (9.9%), 262 (55.0%), and 167 (35.1%) were classified into the low, intermediate, and high score groups, respectively. Over a mean follow‐up of 27.5 months, 63 patients (13.2%) died, and 311 patients (65.3%) were rehospitalized. The mortality rates were 3 (6.4%), 29 (11.1%), and 31 (18.6%), and the number of patients with rehospitalization was 28 (59.6%), 159 (60.7%), and 124 (74.3%) for the low, intermediate, and high score groups, respectively. Multivariate Cox regression identified H₂FPEF score as an independent predictor of all‐cause mortality (hazard ratio [HR]: 1.46, 95% CI: 1.23–1.73, P < 0.0001) and rehospitalization (HR: 1.15, 95% CI: 1.08–1.22, P < 0.0001). Receiver operating characteristic (ROC) analysis demonstrated the H₂FPEF score can effectively predict all‐cause mortality (AUC 0.67, 95% CI: 0.60–0.73, P < 0.0001) and rehospitalization (AUC 0.59, 95% CI: 0.54–0.65, P = 0.001) after adjusting for age and NYHA class. With a cut‐off value of 5.5, the sensitivity and specificity were 68.3% and 55.4% for all‐cause mortality and 50.5% and 66.7% for rehospitalization.

Conclusions

The H₂FPEF score can be used to predict prognosis in HFpEF patients. Higher scores are associated with higher all‐cause mortality and rehospitalization.