Sex Differences in Left Ventricular Cavity Dilation and Outcomes in Acute Heart Failure Patients With Left Ventricular Systolic Dysfunction

Sex Differences in Prognosis of Heart Failure Due to Ischemic and Nonischemic Cardiomyopathy

BACKGROUND

Limited research has explored sex-specific differences in death predictors of HF patients with ischemic (iCMP) and nonischemic (niCMP) cardiomyopathy. This study assessed sex differences in niCMP and iCMP prognosis.

METHODS

We studied 7487 patients with HF between February 2017 and September 2020. Clinical features and echocardiographic findings were collected. We used Kaplan-Meier, Cox proportional hazard models, and chi-square scores of Cox regression to determine death predictors in women and men.

RESULTS

The mean age was 64.3 ± 14.2 years, with 4417 (59%) males. Women with iCMP and niCMP exhibited a significantly higher mean age, higher mean left ventricular ejection fraction, and smaller left ventricular diastolic diameter than men. Over 2.26 years of follow-up, 325 (14.7%) women and 420 (15.7%) men, and 211 women (24.5%) and 519 men (29.8%) with niCMP (p = NS) and iCMP (p = 0.004), respectively, died. The cumulative incidence of death was higher in men with iCMP (log-rank p < 0.0001) but similar with niCMP. Cox regression showed chronic kidney disease, diabetes, stroke, atrial fibrillation, age, and myocardial infarction as the main predictors of death for iCMP in women and men.

CONCLUSIONS

Women exhibited a better prognosis than men with iCMP, but similar for niCMP. Nevertheless, sex was not an independent predictor of death for both CMP.

Increasing efficiency of SVMp+ for handling missing values in healthcare prediction

Missing data presents a challenge for machine learning applications specifically when utilizing electronic health records to develop clinical decision support systems. The lack of these values is due in part to the complex nature of clinical data in which the content is personalized to each patient. Several methods have been developed to handle this issue, such as imputation or complete case analysis, but their limitations restrict the solidity of findings. However, recent studies have explored how using some features as fully available privileged information can increase model performance including in SVM. Building on this insight, we propose a computationally efficient kernel SVM-based framework (l2-SVMp+) that leverages partially available privileged information to guide model construction. Our experiments validated the superiority of l2-SVMp+ over common approaches for handling missingness and previous implementations of SVMp+ in both digit recognition, disease classification and patient readmission prediction tasks. The performance improves as the percentage of available privileged information increases. Our results showcase the capability of l2-SVMp+ to handle incomplete but important features in real-world medical applications, surpassing traditional SVMs that lack privileged information. Additionally, l2-SVMp+ achieves comparable or superior model performance compared to imputed privileged features.

Cardiothoracic ratio values and trajectories are associated with risk of requiring dialysis and mortality in chronic kidney disease

BACKGROUND

The prognostic role of the cardiothoracic ratio (CTR) in chronic kidney disease (CKD) remains undetermined.

METHODS

We conducted a retrospective cohort study of 3117 patients with CKD aged 18-89 years who participated in an Advanced CKD Care Program in Taiwan between 2003 and 2017 with a median follow up of 1.3(0.7-2.5) and 3.3(1.8-5.3) (IQR) years for outcome of end-stage renal disease (ESRD) and overall death, respectively. We developed a machine learning (ML)-based algorithm to calculate the baseline and serial CTRs, which were then used to classify patients into trajectory groups based on latent class mixed modelling. Association and discrimination were evaluated using multivariable Cox proportional hazards regression analyses and C-statistics, respectively.

RESULTS

The median (interquartile range) age of 3117 patients is 69.5 (59.2-77.4) years. We create 3 CTR trajectory groups (low [30.1%], medium [48.1%], and high [21.8%]) for the 2474 patients with at least 2 CTR measurements. The adjusted hazard ratios for ESRD, cardiovascular mortality, and all-cause mortality in patients with baseline CTRs ≥0.57 (vs CTRs <0.47) are 1.35 (95% confidence interval, 1.06-1.72), 2.89 (1.78-4.71), and 1.50 (1.22-1.83), respectively. Similarly, greater effect sizes, particularly for cardiovascular mortality, are observed for high (vs low) CTR trajectories. Compared with a reference model, one with CTR as a continuous variable yields significantly higher C-statistics of 0.719 (vs 0.698, P = 0.04) for cardiovascular mortality and 0.697 (vs 0.693, P < 0.001) for all-cause mortality.

CONCLUSIONS

Our findings support the real-world prognostic value of the CTR, as calculated by a ML annotation tool, in CKD. Our research presents a methodological foundation for using machine learning to improve cardioprotection among patients with CKD.

The Efficacy and Safety of a Qiliqiangxin Capsule Combined with Sacubitril/Valsartan in the Treatment of Chronic Heart Failure: A Systematic Review and Meta-Analysis

Background

Qiliqiangxin (QLQX) capsules are a commonly used proprietary Chinese medicine for the adjuvant treatment of chronic heart failure (CHF) in China. In recent years, several randomized controlled trials (RCTs) have reported on the efficacy and safety of QLQX combined with sacubitril/valsartan for CHF.

Objective

The purpose of this study was to systematically analyze the clinical efficacy and safety of QLQX combined with sacubitril/valsartan in the management of CHF and to provide clinicians as well as scientists with optimal evidence-based medical evidence.

Methods

We searched RCTs to evaluate the efficacy and safety of QLQX combined with sacubitril/valsartan in the treatment of CHF in the Wanfang Database, China National Knowledge Infrastructure, China Science and Technology Journal Database, PubMed, Embase, and Cochrane Library databases from their inception until January 8, 2022. RCTs on QLQX in combination with sacubitril/valsartan for CHF were included. The outcome measures considered were total effective rate, left ventricular ejection fraction (LVEF), left ventricular end-diastolic dimension (LVEDD), 6-minute walking distance (6-MWD), and adverse events. The quality of the included RCTs was assessed thereafter using the Cochrane risk of bias tool. RevMan 5.3 software was used to conduct the meta-analysis.

Results

The meta-analysis included 17 trials involving 1427 CHF patients. The results indicated that with sacubitril/valsartan administration combined with QLQX treatment, the total effective rate (relative risk (RR) = 1.24; 95% confidence interval (CI) (1.17, 1.31); p < 0.01), LVEF (mean difference (MD) = 6.20; 95% CI (5.36, 7.05; p < 0.01)), and 6-MWD (MD = 55.87; 95% CI (40.66, 71.09); p < 0.01) of CHF patients were significantly increased, and the LVEDD value of CHF patients was noted to be significantly reduced (MD = -3.98; 95% CI (-4.47, -3.48); p < 0.01). Moreover, there was no increase in the number of adverse events during treatment (RR = 0.67; 95% CI (0.33, 1.34); p < 0.01).

Conclusions

This study indicated that in CHF patients, on the basis of sacubitril/valsartan treatment, combination with QLQX can potentially enhance the total effective rate, improve LVEF and 6-MWD, and reduce LVEDD values, with good safety. However, considering the poor quality of the included studies, a multicenter, randomized, double-blind controlled study is needed for further confirmation.

The efficacy of ginseng-containing traditional Chinese medicine in patients with acute decompensated heart failure: A systematic review and meta-analysis

Objective: To evaluate the efficacy of ginseng-containing traditional Chinese medicine (TCM) for acute decompensated heart failure (ADHF). Methods: Seven databases were included from establishment until 10 July 2022. Pooled data were analyzed with random-effects model. The risk of bias was measured by the risk of bias tool for randomized trials (RoB 2). Modified Jadad scale score was used to assess the quality of including studies. The meta-analysis was performed with RevMan 5.3. Trial sequential analysis was assessed to avoid type I errors. We have registered our protocol in PROSPERO (CRD42021267742). Results: Twenty-eight articles were included. The results demonstrated that compared with conventional western therapy (WT), ginseng-containing TCM combined with WT further improved clinical efficacy (RR: 1.25, 95% CI: 1.20-1.29, p < 0.00001, I2 = 8%), left ventricular ejection fraction (LVEF) (MD: 5.80, 95% CI: 4.86-6.74, p < 0.00001, I2 = 89%), stroke volume (MD: 13.80, 95% CI: 12.66-14.95, p < 0.00001, I2 = 93%), 6-min walk test (MD: 53.03, 95% CI: 20.76-85.29, p = 0.001, I2 = 97%), decreased 6-month rehospitalization (RR: 0.44, 95% CI: 0.18-1.11, p = 0.08, I2 = 0%), brain natriuretic peptide (MD: 188.12, 95% CI: 248.13 to -128.11, p < 0.00001, I2 = 94%), N-terminal pro-B-type natriuretic peptide (MD = -503.29; 95% CI: 753.18 to -253.40, p < 0.0001, I2 = 89%) and Minnesota living heart failure questionnaire scores (MD: 9.68, 95% CI: 13.67 to -5.70, p < 0.00001, I2 = 83%). The ROB2 assessment and modified Jaded scores showed most studies included were with some concerns. Conclusion: Compared with WT alone, ginseng-containing TCM is a possible way to benefit ADHF patients. However, limited by the quality of including trials, more high-quality studies are needed to provide reliable evidence.

Prognostic Implications of Left Ventricular Ejection Fraction and Left Ventricular End-Diastolic Diameter on Clinical Outcomes in Patients with ICD

Background: Left ventricular ejection fraction (LVEF) is a suboptimal indicator of risk stratification for patients with an implantable cardioverter defibrillator (ICD). Studies have shown that left ventricular end-diastolic diameter (LVEDD) was associated with all-cause mortality and ventricular arrhythmias. We examined the quantified prognostic value of LVEF and LVEDD for clinical outcomes, respectively. Method: This study retrospectively enrolled patients with ICD implantation in a single center. The associations between LVEF or LVEDD and all-cause mortality and appropriate shocks were analyzed using Cox regression and Fine-gray competing risk regression, respectively. Result: During a median follow up of 59.6 months, 168/630 (26.7%) patients died. LVEF and LVEDD were strongly associated with all-cause mortality (LVEF per 10%: HR 0.77, 95%CI 0.64−0.93, p = 0.006; LVEDD per 10 mm: HR 1.54, 95%CI 1.27−1.85, p < 0.001). After a median interrogation time of 37.1 months, 156 (24.8%) patients received at least one shock. LVEF was not associated with appropriate shock, whereas larger LVEDD (per 10 mm) was significantly associated with a higher risk of shock (HR: 1.27, 95%CI 1.06−1.52, p = 0.008). The addition of LVEF or LVEDD to clinical factors provided incremental prognostic value and discrimination improvement for all-cause mortality, while only the addition of LVEDD to clinical factors improved prognostic value for shock intervention. Conclusions: Baseline LVEF and LVEDD show a linear relationship with all-cause mortality in patients with ICD. However, whereas LVEF is not associated with shock, a linear relationship exists between LVEDD and appropriate shock. LVEDD adds more predictive value in relation to all-cause mortality and appropriate shocks than LVEF.

Dilated Left Ventricular End-Diastolic Diameter Is a New Risk Factor of Acute Kidney Injury Following Coronary Angiography

Purpose

Left ventricular end-diastolic diameter (LVEDD) is a common indicator in echocardiogram, and dilated LVEDD was correlated with left ventricular insufficiency. However, it is uncertain whether dilated LVEDD is associated with increasing the risk of contrast-associated acute kidney injury (CA-AKI) in patients with coronary artery disease (CAD).

Patients and Methods

We enrolled 8,189 patients with CAD undergoing coronary angiography (CAG) between January 2007 and December 2018. Patients were divided into two groups according to the LVEDD length (normal LVEDD: men: LVEDD ≤56 mm, women: LVEDD ≤51 mm; dilated LVEDD: men: LVEDD >56 mm, women: LVEDD >51 mm). The endpoints were CA-AKI⁰³⁵⁰ and CA-AKI⁰⁵²⁵ (CA-AKI⁰³⁵⁰: an increase in the serum creatinine (Scr) level by >0.3 mg/dl or >50% within the first 48 h after CAG; CA-AKI⁰⁵²⁵: an absolute Scr increase ≥ 0.5 mg/dl or a relative increase ≥ 25% within 72 h after contrast medium exposure). In-hospital dialysis, 30-day mortality, and 1-year mortality were contained as well. Univariate and multivariable logistic regressions were used to assess the association between LVEDD and CA-AKI.

Results

Among 8,189 participants (men: 76.6%, mean age: 64.4 ± 10.7 years), 1,603 (19.6%) presented with dilated LVEDD. In addition, the dilated LVEDD group indicated an elevation of CA-AKI⁰³⁵⁰ (12.4 vs. 6.2%, p < 0.001) and CA-AKI⁰⁵²⁵ (15.0 vs. 8.8%; p < 0.001) when compared with the normal group. According to multivariable logistic analysis, dilated LVEDD was an independent predictor of CA-AKI⁰³⁵⁰ [adjusted odds ratio (aOR): 1.31; 95% confidence interval (CI): 1.06–1.61, p = 0.010) and CA-AKI⁰⁵²⁵ (aOR: 1.32; 95% CI: 1.04–1.67; p = 0.020).

Conclusion

In conclusion, these results demonstrated that the dilated LVEDD was a significant and independent predictor of CA-AKI following CAG in patients with CAD. Further verifications are needed to verify the association between LVEDD and CA-AKI.

Performance of Prognostic Risk Scores in Elderly Chinese Patients with Heart Failure

Purpose

Elderly heart failure (HF) patients have different clinical characteristics and poorer prognosis compared with younger patients. Prognostic risk scores for HF have not been validated well in elderly patients. We aimed to validate the Seattle Heart Failure Model (SHFM) and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score in an elderly Chinese HF cohort.

Patients and Methods

This retrospective study enrolled 675 elderly HF patients (age≥70 years) discharged from our hospital between 2012 and 2017. The performance of the two risk scores was evaluated in terms of discrimination, using receiver-operating characteristic analysis, and calibration using a calibration plot and Hosmer–Lemeshow (H-L) test. Absolute risk reclassification was used to compare the two scores.

Results

During the mean follow-up time of 32.6 months, 193 patients (28.6%) died, and 1-year mortality was 10.5%. The predicted median 1-year mortality was 8% for the SHFM and 18% for the MAGGIC score. A Kaplan–Meier survival curve demonstrated that event rates of all-cause mortality significantly increased with increasing SHFM and MAGGIC scores. The discriminatory capacity of the SHFM was greater than that of the MAGGIC score (c-statistics were 0.72 and 0.67, respectively; P = 0.05). The calibration plot for the SHFM was better than that for MAGGIC score for 1-year mortality (SHFM: H-L χ² =8.2, P = 0.41; MAGGIC: H-L χ² =18.8, P =0.02). Compared with the MAGGIC score, the net reclassification index (NRI) of the SHFM was 2.96% (Z=5.88, P< 0.0001).

Conclusion

The SHFM performs better than MAGGIC score, having good discrimination, calibration and risk classification for the prediction of 1-year mortality in elderly Chinese HF patients.

Sex-Specific Prognostic Implications in Dilated Cardiomyopathy After Left Ventricular Reverse Remodeling

BACKGROUND

Women affected by Dilated Cardiomyopathy (DCM) experience better outcomes compared to men. Whether a more pronounced Left Ventricular Reverse Remodelling (LVRR) might explain this is still unknown.

AIM

We investigated the relationship between LVRR and sex and its long-term outcomes.

METHODS

A cohort of 605 DCM patients with available follow-up data was consecutively enrolled. LVRR was defined, at 24-month follow-up evaluation, as an increase in left ventricular ejection fraction (LVEF) ≥ 10% or a LVEF > 50% and a decrease ≥ 10% in indexed left ventricular end-diastolic diameter (LVEDDi) or an LVEDDi ≤ 33 mm/m². Outcome measures were a composite of all-cause mortality/heart transplantation (HTx) or ventricular assist device (VAD) and a composite of Sudden Cardiac Death (SCD) or Major Ventricular Arrhythmias (MVA).

RESULTS

181 patients (30%) experienced LVRR. The cumulative incidence of LVRR at 24-months evaluation was comparable between sexes (33% vs. 29%; p = 0.26). During a median follow-up of 149 months, women experiencing LVRR had the lowest rate of main outcome measure (global p = 0.03) with a 71% relative risk reduction compared to men with LVRR, without significant difference between women without LVRR and males. A trend towards the same results was found regarding SCD/MVA (global p = 0.06). Applying a multi-state model, male sex emerged as an independent adverse prognostic factor even after LVRR completion.

CONCLUSIONS

Although the rate of LVRR was comparable between sexes, females experiencing LVRR showed the best outcomes in the long term follow up compared to males and females without LVRR. Further studies are advocated to explain this difference in outcomes between sexes.

Clinical presentation and outcomes in women and men with advanced heart failure

OBJECTIVE

To examine clinical characteristics and outcomes in women and men referred for advanced heart failure (HF) therapies such as left ventricular assist device (LVAD) or heart transplantation (HTx). Design: A retrospective study of 429 (23% women) consecutive adult HF patients not on inotropic or mechanical circulatory support with left ventricular ejection fraction ≤45% referred for assessment of advanced HF therapies at a single tertiary institution between 2002 and 2016. Clinical characteristics and outcomes were compared in women and men, and all patients underwent right heart catheterization (RHC). Results: At evaluation, women were younger than men (48 ± 13 vs. 51 ± 12 years, p = .02), and less likely to have ischemic cardiomyopathy. There were no significant differences in NYHA class, contemporary HF therapy use, or physical examination findings, except for lower jugular vein distension and body surface area in women. On RHC, women had lower cardiac filling pressures, but similar pulmonary vascular resistance and cardiac index. Peak oxygen uptake from cardiopulmonary exercise testing was similar in both sexes. At total follow-up time, there were 164 deaths (21% vs. 44%, p < .0001), 46 LVADs (3% vs. 13%, p = .005), 110 HTxs (32% vs. 25%, p = .15), and 82 HTxs without requiring LVAD (29% vs. 16%, p = .03) in women and men. The time from RHC to HTx (±LVAD) was significantly shorter in women compared to men. Female sex was significantly associated with higher survival independent of time-trend, age, and comorbidities. Conclusion: At evaluation, hemodynamics were less deranged in women. A higher proportion of women received HTx, their waitlist time was shorter, and survival greater.

D-dimer level and long-term outcome in patients with end-stage heart failure secondary to idiopathic dilated cardiomyopathy

Background

Previous studies had demonstrated hemostatic abnormalities in patients with heart failure (HF) and several studies have shown that abnormal coagulation indices, represented by elevated D-dimer, had prognostic significance in patients with compatible or acute decompensated HF. However, the impact of D-dimer on the outcome in patients with end-stage HF remains unclear.

Methods

A total of 244 consecutive patients with end-stage HF due to idiopathic dilated cardiomyopathy (DCM) were prospectively enrolled from February 2011 to September 2014. D-dimer levels were measured and its prognostic value was assessed. Primary endpoint was all-cause mortality during the follow-up period. Secondary endpoints were stroke, bleeding, occurrence of sustained ventricular tachycardia or ventricular fibrillation, and major adverse cardiovascular events (MACE).

Results

D-dimer was significantly elevated in the non-survivors (median: 0.8 vs. 1.1 mg/L, P < 0.001). Traditional markers including B-type natriuretic peptide, troponin I, left ventricular ejection fraction, and left ventricular end-diastolic dimension provided limited prognostic value; but the addition of D-dimer refined the risk stratification. The optimal cut-off value of D-dimer to predict all-cause mortality was 0.84 mg/L by receiver operator characteristic analysis. Elevated D-dimer level was independently associated with increased risk of long-term all-cause mortality (HR = 2.315, 95% CI: 1.570–3.414, P < 0.001) and MACE (HR = 1.256, 95% CI: 1.058–1.490, P = 0.009), and the predictive value was independent of age, sex, atrial fibrillation and anticoagulation status.

Conclusions

Elevated D-dimer level was independently associated with poor long-term outcome in patients with end-stage HF secondary to idiopathic DCM, and the predictive value was superior to that of traditional prognostic markers.

Performance of Prognostic Risk Scores in Heart Failure Patients: Do Sex Differences Exist?

BACKGROUND

Sex differences in the performance of prognostic risk scores in heart failure (HF) patients have not previously been investigated. We examined the performance of 2 commonly used scores in predicting mortality and a composite end point consisting of ventricular assist device, heart transplantation, or mortality in women vs men with HF.

METHODS

This was a retrospective study of 1,136 (25% women) consecutive ambulatory adult HF patients with reduced left ventricular ejection fraction (≤ 40%) followed at a single institution from 2000 to 2012. Discrimination, calibration, and absolute risk reclassification of the Seattle Heart Failure Model (SHFM) and the Meta-Analysis Global Group in Chronic Heart Failure (MAGGIC) score to predict 1- and 3-year outcomes were compared between women and men.

RESULTS

At 1- and 3-year follow-ups, 116 (22% women) and 231 (21% women) patients died, respectively. Survival was equal between sexes (P = 0.41). The SHFM and the MAGGIC score showed similar discriminatory capacity in women (c-statistics 0.84, 95% CI 0.77-0.92, and 0.74, 95% CI 0.64-0.83) and men (c-statistics 0.74, 95% CI 0.69-0.79, and 0.70, 95% CI 0.64-0.75). There was no difference in the predicted and observed 1-year mortality by the scores in both sexes. Compared with the SHFM, the MAGGIC score better reclassified 10% (95% CI 7%-14%) of women and 18% (95% CI 15%-20%) of men. At 3-year follow-up, similar results were seen for discrimination, whereas both scores overestimated mortality with more marked overestimation in women. The results were reproducible for the composite end point, with improved calibration at 3-year follow-up in both scores.

CONCLUSIONS

Our findings support the use of the MAGGIC score in both women and men owing to better risk classification.

Sex Differences in New York Heart Association Functional Classification and Survival in Acute Heart Failure Patients With Preserved or Reduced Ejection Fraction

BACKGROUND

The aim of this study was to evaluate the influence of sex on the relationship between the New York Heart Association (NYHA) functional classification and survival in acute decompensated heart failure (HF) patients with preserved or reduced ejection fraction (EF).

METHODS

Of 4842 patients enrolled in the Acute Decompensated Heart Failure Syndromes (ATTEND) registry, 4717 (2730 men and 1987 women) were investigated to assess the association of sex, NYHA functional class, and preserved or reduced EF with all-cause death. Men and women were divided into 6 groups based on left ventricular EF (preserved or reduced) and NYHA functional class (II, III, or IV) at admission.

RESULTS

Among both sexes with preserved EF, multivariable analysis confirmed that NYHA functional class IV was associated with a significantly higher risk of all-cause death than NYHA functional class II. Similarly, in women with reduced EF, NYHA functional class IV was a significant predictor of all-cause death compared with class II. However, in men with reduced EF, the adjusted risk of all-cause death was similar for those in NYHA functional classes II, III, and IV. Furthermore, the interaction between sex and NYHA functional classes II to IV was statistically significant for all-cause death in reduced EF patients (P for interaction = 0.037), but not in preserved EF patients (P for interaction = 0.711).

CONCLUSIONS

NYHA functional class IV was a significant predictor of all-cause death in both sexes with preserved EF, whereas NYHA functional class IV was a significant predictor of all-cause death in women, but not in men, with reduced EF.

Sex-Specific Considerations in Guidelines Generation and Application

New knowledge about male-female differences in pathophysiology, diagnosis, and treatment is shifting the practice of medicine from a one-size-fits all approach to a more individualized process that considers sex-specific interventions at the point of care. In this article, we review how clinical practice guideline committees can incorporate a structured framework to determine whether sex-specific assessments of the quality of the evidence or the particular recommendations should be made. The process can be operationalized by societies who author clinical practice guidelines by developing formal policies to approach biological sex in a systematic way, and by ensuring that writing committees include an individual who will champion the formal appraisal of the literature for associations between sex and the outcomes of interest. Ongoing challenges are discussed, and solutions are provided for how to disaggregate the evidence, how to assess bias, how to improve search strategies, and what to do when the data are insufficient to make sex-specific recommendations. Application of sex-specific recommendations will involve routinely asking whether the presentation, diagnostic workup, or management might change for each patient if they were the opposite sex.