Ischemic Etiology in Advanced Heart Failure: Insight from the HELP-HF Registry

Distribution and Prognostic Impact of Different Heart Failure Etiologies in Patients with Heart Failure with Mildly Reduced Ejection Fraction

OBJECTIVE

The study investigates the characteristics and prognostic impact of different heart failure (HF) etiologies in patients with heart failure with mildly reduced ejection fraction (HFmrEF).

BACKGROUND

Data regarding the characterization of patients with HFmrEF and their outcomes is scarce.

METHODS

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

RESULTS

From a total of 1,832 patients hospitalized with HFmrEF, ICM was the most common HF etiology in 68.7 %, followed by hypertensive (9.7 %) and primary non-ischemic cardiomyopathies (NICM) (8.1 %). Within the entire study cohort, the presence of ICM was not associated with the risk of all-cause mortality (HR = 0.864; 95 % CI 0.723 - 1.031), however after multivariable adjustment (HR = 0.792; 95 % CI 0.646 - 0.972; p = 0.026) and propensity score matching (25.7% vs. 31.4 %; log rank p = 0.050), the presence of ICM was associated with lower risk of all-cause mortality at 30 months compared to patients without ICM.

CONCLUSION

ICM is the most common etiology of HF in HFmrEF and may be associated with favorable outcomes. This may be related to better adherence to pharmacological treatment and improved revascularization strategies for HFmrEF patients with ICM.

Frailty according to the 2019 HFA-ESC definition in patients at risk for advanced heart failure: Insights from the HELP-HF registry

AIMS

Frailty is highly prevalent in patients with heart failure (HF), but a concordant definition of this condition is lacking. The Heart Failure Association of the European Society of Cardiology (HFA-ESC) proposed in 2019 a new multi-domain definition of frailty, but it has never been validated.

METHODS AND RESULTS

Patients from the HELP-HF registry were stratified according to the number of HFA-ESC frailty domains fulfilled and to the cumulative deficits frailty index (FI) quintiles. Prevalence of frailty and of each domain was reported, as well as the rate of the composite of all-cause death and HF hospitalization, its single components, and cardiovascular death in each group and quintile. Among 854 included patients, 37 (4.3%), 206 (24.1%), 365 (42.8%), 217 (25.4%), and 29 (3.4%) patients fulfilled zero, one, two, three, or four domains, respectively, while 179 patients had a FI < 0.21 and were considered not frail. The 1-year risk of adverse events increased proportionally to the number of domains fulfilled (for each criterion increase, all-cause death or HF hospitalization: hazard ratio [HR] 1.43, 95% confidence interval [CI] 1.27-1.62; all-cause death: HR 1.72, 95% CI 1.46-2.02, HF hospitalizations: subHR 1.21, 95% CI 1.04-1.31; cardiovascular death: HR 1.77, 95% CI 1.45-2.15). Consistent results were found stratifying the cohort for FI quintiles. The FI as a continuous variable demonstrated higher discriminative ability than the number of domains fulfilled (area under the curve = 0.68 vs. 0.64, p = 0.004).

CONCLUSION

Frailty in patients at risk for advanced HF, assessed via a multi-domain approach and the FI, is highly prevalent and identifies those at increased risk of adverse events. The FI was found to be slightly more effective in identifying patients at increased risk of mortality.

Characteristics and outcomes of patients with tricuspid regurgitation and advanced heart failure

AIMS

To evaluate the role of tricuspid regurgitation in advanced heart failure.

METHODS

The multicenter observational HELP-HF registry enrolled consecutive patients with heart failure and at least one 'I NEED HELP' criterion evaluated at four Italian centers between January 2020 and November 2021. Patients with no data on tricuspid regurgitation and/or receiving tricuspid valve intervention during follow-up were excluded. The population was stratified by no/mild tricuspid regurgitation vs. moderate tricuspid regurgitation vs. severe tricuspid regurgitation. Variables independently associated with tricuspid regurgitation, as well as the association between tricuspid regurgitation and clinical outcomes were investigated. The primary outcome was all-cause mortality.

RESULTS

Among the 1085 patients included in this study, 508 (46.8%) had no/mild tricuspid regurgitation, 373 (34.4%) had moderate tricuspid regurgitation and 204 (18.8%) had severe tricuspid regurgitation. History of atrial fibrillation, any prior valve surgery, high dose of furosemide, preserved left ventricular ejection fraction, moderate/severe mitral regurgitation and pulmonary hypertension were found to be independently associated with an increased likelihood of severe tricuspid regurgitation. Estimated rates of 1-year all-cause death were of 21.4, 24.5 and 37.1% in no/mild tricuspid regurgitation, moderate tricuspid regurgitation and severe tricuspid regurgitation, respectively (log-rank P  < 0.001). As compared with nonsevere tricuspid regurgitation, severe tricuspid regurgitation was independently associated with a higher risk of all-cause mortality (adjusted hazard ratio 1.38, 95% confidence interval 1.01-1.88, P  = 0.042), whereas moderate tricuspid regurgitation did not.

CONCLUSION

In a contemporary, real-world cohort of patients with advanced heart failure, several clinical and echocardiographic characteristics are associated with an increased likelihood of severe tricuspid regurgitation. Patients with severe tricuspid regurgitation have an increased risk of mortality.