Lifestyle Modifications for Preventing and Treating Heart Failure

Transforming personalized weight forecasting: From the Personalized Metabolic Avatar to the Generalized Metabolic Avatar

BACKGROUND AND OBJECTIVE

Developing predictive computational models of metabolism using mechanistic approaches is complex and resource intensive. Data-driven models offer a reliable, fast, and continuously updating solution for predictive analytics. Previously, we developed the Personalized Metabolic Avatar (PMA), a gated recurrent unit deep learning model, to forecast personalized weight variations based on macronutrient composition and daily energy balance. This model allows for diet plan simulations and tailored goal setting, empowering individuals with the knowledge to achieve long-lasting healthy lifestyle results. However, the PMA requires adaptation through the collection of individual-specific data. Our objective is to address this limitation by creating a more generalized model that maintains predictive accuracy without the need for individual data measurement.

METHODS

We propose the Generalized Metabolic Avatar (GMA) to generalize metabolic predictions for a broader user base by incorporating parameters such as age and gender, thus eliminating the need for individual data measurement and enabling application to individuals who have not been previously analyzed. The GMA's predictive accuracy was assessed in both ideal conditions and real-world scenarios. Comparative evaluations against the PMA were performed to validate the GMA's viability and efficiency.

RESULTS

The GMA demonstrated promising predictive accuracy, with an average RMSE of 0.54 ± 0.03 in ideal conditions and 0.92 ± 0.76 in real-world scenarios. Comparative evaluations showed that the GMA maintains comparable accuracy to the PMA (PMA RMSE: 0.42 ± 0.04; GMA RMSE: 0.44 ± 0.17), while significantly reducing computational time (PMA: 12.0 ± 1.22 s; GMA: 0.15 ± 0.11 s).

CONCLUSIONS

The GMA offers significant advantages over the PMA by employing a single, scalable model that captures common weight fluctuations through age and gender distinctions. It reduces overfitting and enhances generalizability, achieving comparable accuracy to complex deep learning models. The GMA significantly improves computational efficiency by eliminating the need for individual retraining and maintains robust predictive performance even with limited user-specific data.

Effectiveness of Exercise on Fatigue for Patients With Heart Failure: A Systematic Review and Meta-Analysis

Exercise is the standard treatment for fatigue in heart failure (HF) patients. However, no study has investigated the effect of exercise on improving fatigue and HR-QoL in HF patients. Our study adhered to the Cochrane Handbook for Systematic Reviews of Interventions and followed the PRISMA statement. The date of the last search was October 31, 2021. We included randomized controlled trials (RCTs) using exercise to improve fatigue and HR-QoL. The combined exercise training studies showed improvement in fatigue (SMD = -.51, 95% CI = -.89 to -.12, p = .001, I2 = 48%). The IMT studies showed significantly improved fatigue (MD = -11.36, 95%CI = -15.30 to -7.41, p < .00001, I2 = 54%). However, three studies, with moderate heterogeneity (p = .10, I2 = 56%), showed non-significant changes in HR-QoL (SMD = -0.04, 95% CI = -.45 to .37, p = .83).

A Podcast on Patient and Physician Perspectives in the Holistic Care of Heart-Related Challenges of Type 2 Diabetes

Type 2 diabetes (T2D) frequently coexists with cardiorenal complications. Therefore, a holistic approach to patient management is required, with specialists such as primary care physicians, cardiologists, endocrinologists, and nephrologists working together to provide patient care. Although glycemic control is important in the management of T2D, patients with T2D and acceptable glycemic control are still at risk from cardiovascular (CV) events such as stroke, heart attack, and heart failure (HF). Therefore, management of other risk factors, such as high blood pressure, high cholesterol, smoking cessation, and excess bodyweight, are imperative for reducing the risk of CV disease and HF in patients with T2D. In addition to pharmacological interventions, patient self-care, including beneficial dietary changes, regular exercise, and smoking cessation are critical for improving heart health and reducing the risk of CV events and progression of HF. In this podcast, a patient with lived experience of the heart-related challenges of T2D and a cardiologist discuss the link between T2D and heart-related complications, the pharmacological interventions and lifestyle modifications that can be used to reduce the risk of CV events and prevent HF, and the complexities of engaging with the healthcare system when managing multiple comorbidities. The discussion highlights the importance of patient education and empowerment for the management of heart-related challenges of T2D, and the central role of collaborative care between physicians of multiple specialties to reduce CV risk for patients with T2D.

Psychological distress in heart failure patients: Implications for healthcare utilization and expenditure

AIMS

Psychological distress is prevalent among heart failure (HF) patients, yet its impact on healthcare expenditure and utilization remains understudied. The aim of this study was to investigate the prevalence of psychological distress in HF patients and its impact on healthcare expenditure and utilization.

METHODS AND RESULTS

We analysed data from the Medical Expenditure Panel Survey from January 2016 to December 2021, focusing on adults diagnosed with HF. We assessed the prevalence of psychological distress using the Kessler 6 (K6) questionnaire and examined its association with healthcare utilization and expenditures through multivariate regression models, adjusting for relevant covariates. Among 10 681 886 HF patients, 6.8% experienced psychological distress. The mean age was 69.9 years, and 50% were female. Multivariable analysis revealed significant associations between psychological distress and smoking (adjusted odds ratio [aOR] 2.87), Charlson comorbidity index ≥3 (aOR 3.05), and sleep disorders (aOR 2.82). Protective factors included exercise (aOR 0.40), higher education (aOR 0.89) and higher income levels (middle-income: aOR 0.19, high-income: aOR 0.20). HF patients with psychological distress incurred significantly higher annual total expenses ($14 709, p < 0.01), with inpatient costs ($6014, p = 0.02) and office-based expenses ($3993, p = 0.04) being notably elevated. Additionally, these patients exhibited more frequent annual emergency room visits (0.07 visits, p < 0.01), hospital discharges (0.2 discharges, p = 0.01), and nights spent in the hospital (1.4 nights, p < 0.01).

CONCLUSION

Psychological distress in HF patients is associated with significantly higher medical expenditure and healthcare utilization. These findings underscore the need for integrated care approaches and present possible areas for intervention to address this significant healthcare burden.

Dietary Inflammatory Score and Incident Heart Failure in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) Study

BACKGROUND

Inflammation plays a key role in the development of heart failure (HF), and diet is a known modifiable factor that modulates systemic inflammation. The dietary inflammatory score (DIS) is a tool that quantifies the inflammatory components of diet. We sought to determine whether the DIS is associated with incident HF events.

METHODS

We examined a total of 17,975 participants without HF at baseline who were in the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The main exposure variable was the DIS quartile, which was derived from the Food Frequency Questionnaire obtained at baseline study enrollment. The main outcome was an incident HF event, defined as hospitalization due to HF or death. To examine the association between the DIS and incident HF events, we conducted Cox proportional hazard regression modeling, adjusting for total energy intake, sociodemographic factors and pro-inflammatory lifestyle behaviors.

RESULTS

The sample mean age was 64 + 9.2 years, 55.8% were female, and 32.3% were Black. Over a median follow-up of 11.1 years, we observed 900 incident HF events, including 752 hospitalizations and 148 deaths due to HF. In an adjusted model, the highest DIS quartile (Q4) was associated with incident HF (HR 1.26 95% CI 1.03-1.54). Of note, these findings remained, even after adjusting for comorbid conditions and physiological parameters. In an age-stratified analysis, the association was present only in those aged < 65 years (Q4: HR 1.65 95% CI 1.08-2.51). Moreover, the association was present for heart failure with reserved ejection fraction (Q4: HR 1.44 95% CI 1.07-1.94) but not for heart failure with preserved ejection fraction.

CONCLUSION

The highest DIS quartile was associated with incident HF events. These findings indicate the potential value of specific dietary patterns to prevent HF.

Association between the healthy eating index 2020 and heart failure among the U.S. middle-aged and older adults from NHANES 2005-2020: a cross-sectional study

Objective

This study aims to shed light on the correlation between Healthy Eating Index-2020 (HEI-2020) and heart failure (HF) in American adults aged 50 or above.

Methods

Data were from the National Health and Nutrition Examination Survey 2005-2020, encompassing 13,105 participants with an age of 50 or above. HEI-2020 score was utilized for rating the dietary quality. The link of HEI-2020 to HF was assessed via logistic regression, restricted cubic splines (RCS), generalized additive models (GAM), weighted quantile sum (WQS) regression, as well as quantile g-computation (Qgcomp) models.

Results

A negative association between HEI-2020 and HF risk was uncovered in middle-aged and older Americans (OR = 0.99, 95% CI: 0.98-1.00, p = 0.006). The highest quartile (Q4) exhibited a markedly lower HF risk than the lowest quartile (Q1) (OR = 0.70, 95% CI: 0.55-0.89, p = 0.004). RCS and GAM analyses demonstrated a linear dose-response relationship between HEI-2020 and HF. Finally, WQS regression and Qgcomp models revealed a beneficial combined influence of 13 dietary components on HF risk, with dairy and whole fruits emerging as the most influential.

Conclusion

Elevated HEI-2020 scores are linked to decreased HF risks among Americans aged 50 or above, suggesting that adherence to the Dietary Guidelines for Americans can mitigate HF risk.

Influence of Insertion/Deletion Polymorphism of the Angiotensin Converting Enzyme Gene on Adiposity and Cardiac Function in Patients with Heart Failure

BACKGROUND

The angiotensin-converting enzyme (ACE) insertion/deletion (I/D) polymorphism (rs4340) is associated with the pathogenesis of heart failure (HF). This polymorphism may contribute to a greater propensity for severe HF and excess weight.

OBJECTIVE

To evaluate adiposity, cardiac function, and their association with ACE I/D polymorphism in HF patients.

METHODS

Cross-sectional study with ambulatory individuals ≥18 years diagnosed with HF. Genetic analysis was performed using polymerase chain reaction followed by agarose gel electrophoresis. Left ventricular ejection fraction (LVEF) was determined by echocardiography. Nutritional status was assessed using body mass index, while adiposity was analyzed using bioelectrical impedance analysis (BIA), waist circumference, waist-to-hip ratio, and waist-to-height ratio. The adopted significance level was 5% (p < 0.05).

RESULTS

Seventy-one individuals were included, with a mean age of 55.8 ± 13.0 years, predominantly male (66.2%), with functional class I and II (90.9%), and a median LVEF of 30% (24-40). The prevalence of overweight was 38%, class I obesity was 23.9%, and class II and III obesity was 12.7%, with 50.7% exhibiting excess adiposity as assessed by BIA. A total of 88 D alleles and 54 I alleles of the ACE gene were identified. Regarding ACE genotypes, 38.1% were DD, 47.8% were ID, and 14.1% were II. In the multivariate analysis, the D allele (DD + ID genotypes versus II) was associated with LVEF (PR 0.995; 95% CI 0.991-1.000; p = 0.048) and with the etiology of HF (dilated cardiomyopathy: PR 1.283; 95% CI 1.039-1.583; p = 0.021). No independent association was found with adiposity.

CONCLUSION

The presence of the D allele of the ACE polymorphism is associated with LVEF and HF etiology. Despite overweight being prevalent in the sample, no independent associations were found.

Western Diet and Inflammatory Mechanisms in African American Adults With Heart Failure

BACKGROUND

Black adults have a higher risk for heart failure (HF) than others, which may be related to higher cardiovascular risk factors and also inflammatory dietary patterns. The Western diet is associated with inflammation and contributes to HF. Trimethylamine N-oxide is a diet-linked metabolite that contributes to inflammation and is associated with higher tumor necrosis factor-alpha (TNF-α) levels, especially in HF populations. The dietary inflammatory index score measures a diet's inflammatory potential and food's inflammatory effects.

OBJECTIVE

The purpose of this pilot study was to explore associations between the Western diet, dietary inflammatory index, trimethylamine N-oxide, relevant covariates and variables, and TNF-α in Black persons with HF.

METHODS

Thirty-one Black participants (mean age = 55 years, 68% women) with HF were enrolled. Trimethylamine N-oxide and TNF-α levels were analyzed using immunoassays. A food frequency questionnaire was completed, and dietary inflammatory index scores and food groups were calculated. Analyses included correlations and I-test statistics.

RESULTS

Mean dietary inflammatory index score was -0.38, noting an anti-inflammatory diet with slightly higher inflammatory diet scores in men compared to women. The dietary inflammatory index score showed a negative association with dietary choline but not with trimethylamine N-oxide or TNF-α. Trimethylamine N-oxide and age were positively correlated, along with the correlation for TNF-α with a moderate effect size. No relationship was found among dietary inflammatory index, TNF-α, and trimethylamine N-oxide variables.

DISCUSSION

A greater understanding of intake of inflammatory foods and relationships with immune factors is warranted to inform intervention development. In Black adults with HF, it is important to consider the intake of inflammatory foods as increased age may affect the retention of dietary metabolites. Metabolites may also increase the levels of inflammation. Knowledge about these relationships could lead to tailored dietary interventions based on diet, age, and culture patterns.

Ultrasound-measured Quadriceps Muscle Thickness and Mortality in Older Patients With Heart Failure

BACKGROUND

Ultrasound might be helpful for muscle mass assessment in patients with heart failure (HF). We aimed to determine the feasibility and prognostic implications of ultrasound-measured quadriceps muscle thickness (QMT) in older patients with HF.

METHODS

This was a post hoc analysis of a multicentre prospective cohort study including patients hospitalized for HF aged 65 years and older. QMT at rest and during isometric contractions using ultrasound was measured with the patient in the supine position before discharge.

RESULTS

The interobserver agreement for measuring QMT was excellent, with intraclass correlation coefficients of 0.979 (95% confidence interval [CI], 0.963-0.988) at rest and 0.997 (95% CI, 0.994-0.998) during isometric contraction. The intraobserver reproducibility was also excellent (intraclass correlation coefficient > 0.92). Of the 595 patients (median age, 81 years; 56% male), median QMT at rest and during contraction were 18.9 mm and 24.9 mm, respectively. The patients were grouped according to sex-specific tertiles of height-adjusted QMT. During the median follow-up of 735 days, 157 deaths occurred, and Kaplan-Meier curve analysis showed that the lowest tertile of the height-adjusted QMT was associated with a higher mortality. Cox proportional hazard analysis revealed that thinner height-adjusted QMT was independently associated with higher mortality, even after adjusting for conventional risk factors (per 1 mm/m increase: hazard ratio, 0.94; 95% CI, 0.89-0.99; P = 0.030 [at rest] and hazard ratio, 0.94; 95% CI, 0.90-0.99; P = 0.015 [during isometric contraction]).

CONCLUSIONS

Ultrasound-measured QMT in older patients with HF is feasible, and thinner height-adjusted QMT at rest and during isometric contraction was independently associated with higher mortality.

Identification of Pre-Heart Failure in Early Stages: The Role of Six Stages of Heart Failure

Despite increased availability of effective drug therapy for treatment of heart failure (HF), the morbidity and mortality in chronic heart failure (CHF) are unacceptably high. Therefore, there is an urgent need to ascertain new imaging techniques to identify early sub-clinical forms of cardiac dysfunctions, to guide early relevant treatment. It seems that all the behavioral risk factors-such as tobacco, alcoholism, Western-type diet, sedentary behavior and obesity, emotional disorders, and sleep disorder are associated with early cardiac dysfunction, which may be identified by speckle-tracking echocardiography (STE). Cardiac remodeling can also occur chronologically in association with biological risk factors of CHF, such as diabetes mellitus (DM), hypertension, cardiomyopathy, valvular heart disease, and coronary artery disease (CAD). In these conditions, twisting and untwisting of the heart, cardiac fibrosis, and hypertrophy can be identified early and accurately with 2-Dimentional (2D) and 3D echocardiography (2D echo and 3D echo) with tissue Doppler imaging (TDI), strain imaging via STE, and cardiac magnetic resonance imaging (CMR). Both 2D and 3D echo with STE are also useful in the identification of myocardial damage during chemotherapy and in the presence of risk factors. It is possible that global longitudinal systolic strain (GLS) obtained by STE may be an accurate marker for early identification of the severity of CAD in patients with non-ST segment elevation MI. Left ventricular ejection fraction (LVEF) is not the constant indicator of HF and it is normal in early cardiac dysfunction. In conclusion, this review suggests that GLS can be a useful early diagnostic marker of early or pre-cardiac dysfunction which may be treated by suitable drug therapy of HF along with the causes of HF and adhere to prevention strategies for recurrence. In addition, STE may be a superior clinical tool in the identification of cardiac dysfunction in its early stages compared to ejection fraction (EF) based on conventional echocardiography. Therefore, it is suggested that the chances of either stalling or reversing HF are far better for patients who are identified at an early stage of the disease.

Prevalence of complications and co-morbidities in males and females with obesity: Real-world insights from claims data analysis

AIM

To comprehensively examine the range of co-morbidities among males and females with a diagnosis of obesity.

MATERIALS AND METHODS

This cross-sectional retrospective study used US commercial and Medicare claims data from Merative MarketScan Research Databases to identify adults (age ≥ 18 years) with a diagnosis of obesity with continuous insurance coverage from 2018 to 2020. Co-morbidities were tabulated based on coded diagnoses, and prevalences were calculated in males and females across age groups. Age-adjusted odds ratios (ORs) determined differences in co-morbidities between the sexes.

RESULTS

Of an eligible sample of 6.9 million, we identified 2 028 273 individuals with at least one obesity-related International Classification of Diseases, 10th Revision, Clinical Modification code. The proportions of males and females with obesity were 43.0% versus 57.0%. The most prevalent co-morbidities among males and females were hypertension (62.8% vs. 52.2%), dyslipidaemia (63.3% vs. 50.3%) and depression and/or anxiety (D/A; 29.7% vs. 48.5%). The prevalence of D/A was high in the younger age group, but steadily decreased with age in both sexes; however, hypertension and dyslipidaemia continued to increase with age. The presence of diagnosis of hypertension and dyslipidaemia was 6-8 years earlier in males than in females. Females had higher odds than males for osteoarthritis (OR 1.33), depression (OR 2.22) or osteoporosis (OR 7.10); all P < .0001.

CONCLUSIONS

Males with obesity received a diagnosis of cardiovascular risk factors at an earlier age than females, which may have contributed to the higher prevalence of coronary heart disease. Understanding sex-specific variations in co-morbidities across ages can support early screening and diagnosis of risk clusters for optimal obesity management.

Elevated meteorin-like protein from high-intensity interval training improves heart function via AMPK/HDAC4 pathway

High-intensity interval training (HIIT) has been found to be more effective in relieving heart failure (HF) symptoms, than moderate-intensity continuous aerobic training (MICT). Additionally, higher meteorin-like protein (Metrnl) levels are seen after HIIT versus MICT. We investigated whether Metrnl contributed to post-HF cardiac functional improvements, and the signaling pathways involved. 50 HF patients underwent MICT, and another 50, HIIT, which was followed by cardiac function and serum Metrnl measurements. Metrnl was also measured in both blood and skeletal muscle samples of mice with transverse aortic constriction-induced HF after undergoing HIIT. Afterward, shRNA-containing adenovectors were injected into mice, yielding five groups: control, HF, HF + HIIT + scrambled shRNA, HF + HIIT + shMetrnl, and HF + Metrnl (HF + exogenous Metrnl). Mass spectrometry identified specific signaling pathways associated with increased Metrnl, which was confirmed with biochemical analyses. Glucose metabolism and mitochondrial functioning were evaluated in cardiomyocytes from the five groups. Both HF patients and mice had higher circulating Metrnl levels post-HIIT. Metrnl activated AMPK in cardiomyocytes, subsequently increasing histone deacetylase 4 (HDAC4) phosphorylation, leading to its cytosolic sequestration and inactivation via binding with chaperone protein 14-3-3. HDAC4 inactivation removed its repression on glucose transporter type 4, which, along with increased mitochondrial complex I-V expression, yielded improved aerobic glucose respiration and alleviation of mitochondrial dysfunction. All these changes ultimately result in improved post-HF cardiac functioning. HIIT increased skeletal muscle Metrnl production, which then operated on HF hearts to alleviate their functional defects, via increasing aerobic glucose metabolism through AMPK-HDAC4 signaling.

Alcoholic cardiomyopathy: an update

Alcohol-induced cardiomyopathy (AC) is an acquired form of dilated cardiomyopathy (DCM) caused by prolonged and heavy alcohol intake in the absence of other causes. The amount of alcohol required to produce AC is generally considered as >80 g/day over 5 years, but there is still some controversy regarding this definition. This review on AC focuses on pathogenesis, which involves different mechanisms. Firstly, the direct toxic effect of ethanol promotes oxidative stress in the myocardium and activation of the renin-angiotensin system. Moreover, acetaldehyde, the best-studied metabolite of alcohol, can contribute to myocardial damage impairing actin-myosin interaction and producing mitochondrial dysfunction. Genetic factors are also involved in the pathogenesis of AC, with DCM-causing genetic variants in patients with AC, especially titin-truncating variants. These findings support a double-hit hypothesis in AC, combining genetics and environmental factors. The synergistic effect of alcohol with concomitant conditions such as hypertension or liver cirrhosis can be another contributing factor leading to AC. There are no specific cardiac signs and symptoms in AC as compared with other forms of DCM. However, natural history of AC differs from DCM and relies directly on alcohol withdrawal, as left ventricular ejection fraction recovery in abstainers is associated with an excellent prognosis. Thus, abstinence from alcohol is the most crucial step in treating AC, and specific therapies are available for this purpose. Otherwise, AC should be treated according to current guidelines of heart failure with reduced ejection fraction. Targeted therapies based on AC pathogenesis are currently being developed and could potentially improve AC treatment in the future.

The potential preventive effect of probiotics, prebiotics, and synbiotics on cardiovascular risk factors through modulation of gut microbiota: A review

Cardiovascular diseases (CVDs) are a significant contributor to global morbidity and death, underscoring the importance of their prevention and treatment. The association between the development and progression of CVD and several risk factors has been extensively studied. Among these risk factors, the gut microbiota has garnered considerable attention of the scientific community during the last two decades. In particular, dysbiosis is directly associated with many risk factors of CVD in the host, such as diabetes. Prior research has demonstrated a robust correlation between dysbiosis and the development of CVD. Probiotics, prebiotics, and synbiotics are considered important regulators of microbiota imbalances as they increase the colonization of beneficial bacteria and thereby alter the gut microbiota. Although these beneficial effects of biotics are now widely recognized, new evidence has demonstrated that target therapy of the microbiota affects many other organs, including the heart, through a process commonly referred to as the gut-heart axis. In this review, we will discuss the potential benefits of probiotics, prebiotics, and synbiotics for the beneficial effects on cardiovascular disease by modulating gut microbiota.

Diet and risk for hernia: a Mendelian randomization analysis

Background

The relationship between dietary factors and hernias is currently unclear.

Methods

The UK Biobank was used to extract dietary factors that were used as exposures, including intake of alcohol, non-oily fish, beef, fresh fruit, oily fish, salad/raw vegetables, dried fruit, coffee, cereal, salt, tea, water, cooked vegetables, cheese, Lamb/mutton, pork, poultry, processed meat, and bread. The FinnGen biobank was used to obtain GWAS data on hernias as outcomes. The main analysis of this study was performed using the weighted median, MR-Egger, and IVW methods. Cochran's Q test was utilized to assess heterogeneity. To find potential outliers, the MR-PRESSO method was used. Leave-one-out analysis was employed to assess the IVW method's robustness.

Results

Alcoholic consumption per week (OR: 0.614; p = 0.00614) reduced the risk of inguinal hernia. Alcohol intake frequency (OR: 1.309; p = 0.0477) increased the risk of ventral hernia (mainly including incisional hernia and parastomal hernia). The intake of non-oily fish (OR: 2.945; p = 0.0214) increased the risk of inguinal hernia. Salt added to food (OR: 1.841; p = 0.00267) increased the risk of umbilical hernia. Cheese intake (OR: 0.434; p = 0.000536) and dried fruit intake (OR: 0.322; p = 0.00716) decreased the risk of ventral hernia, while cooked vegetable intake (OR: 4.475; p = 0.0380) increased the risk of ventral hernia. No causal relationships were found with hernias from other dietary factors.

Conclusion

Inguinal, umbilical, and ventral hernias are all related to dietary factors.

Has the Expansion of Health Insurance Coverage via the Implementation of the Affordable Care Act Influenced Inequities in Coronary Revascularization in New York City?

BACKGROUND/PURPOSE

In 2014, New York City implemented the Affordable Care Act (ACA) leading to insurance coverage gains intended to reduce inequities in healthcare services use. The paper documents inequalities in coronary revascularization procedures (percutaneous coronary intervention and coronary artery bypass grafting) usage by race/ethnicity, gender, insurance type, and income before and after the implementation of the ACA.

METHODS

We used data from the Healthcare Cost and Utilization Project to identify NYC patients hospitalized with the diagnosis of coronary artery disease (CAD) and/or congestive heart failure (CHF) in 2011-2013 (pre-ACA) and 2014-2017 (post-ACA). Next, we calculated age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization. Logistic regression models were used to identify the variables associated with receiving a coronary revascularization in each period.

RESULTS

Age-adjusted rates of CAD and/or CHF hospitalization and coronary revascularization in patients 45-64 years of age and 65 years of age and older declined in the post-ACA period. Disparities by gender, race/ethnicity, insurance type, and income in the use of coronary revascularization persist in the post-ACA period.

CONCLUSIONS

Although this health care reform law led to the narrowing of inequities in the use of coronary revascularization, disparities persist in NYC in the post-ACA period.

How to tackle therapeutic inertia in heart failure with reduced ejection fraction. A scientific statement of the Heart Failure Association of the ESC

Guideline-directed medical therapy (GDMT) in patients with heart failure and reduced ejection fraction (HFrEF) reduces morbidity and mortality, but its implementation is often poor in daily clinical practice. Barriers to implementation include clinical and organizational factors that might contribute to clinical inertia, i.e. avoidance/delay of recommended treatment initiation/optimization. The spectrum of strategies that might be applied to foster GDMT implementation is wide, and involves the organizational set-up of heart failure care pathways, tailored drug initiation/optimization strategies increasing the chance of successful implementation, digital tools/telehealth interventions, educational activities and strategies targeting patient/physician awareness, and use of quality registries. This scientific statement by the Heart Failure Association of the ESC provides an overview of the current state of GDMT implementation in HFrEF, clinical and organizational barriers to implementation, and aims at suggesting a comprehensive framework on how to overcome clinical inertia and ultimately improve implementation of GDMT in HFrEF based on up-to-date evidence.

Predictors of quality of life in primary caregivers of patients with heart failure: A model of health literacy and caregiving burden

BACKGROUND

Heart Failure (HF) is a chronic disease that impairs patients' ability to care for themselves. The accumulation of caregiving activities by caregivers to patients creates stress.

OBJECTIVES

This study intends to investigate the mediating role of caregiving burden in the relationship between health literacy and quality of life of caregivers.

METHODS

This study is a cross-sectional research conducted through a questionnaire survey. A convenience sampling method was employed to select 410 primary caregivers for the study.

RESULTS

The overall mean score for quality of life for caregivers of patients with HF was (49.30±9.64). The results showed that the caregiving burden mediated the relationship between health literacy and quality of life, with the mediating effect accounting for 39.04 % (P < 0.05) of the total effect.

CONCLUSION

Caregiving burden is a mediating variable in the relationship between health literacy and quality of life. Therefore, we offer some recommendations for healthcare professionals: ①We suggest that healthcare professionals provide relevant education and training to caregivers, as this can enhance their knowledge and skills in effectively managing the health condition of patients;②Healthcare professionals can also proactively assess the caregiver's burden level and design personalized support plans based on the assessment results.

Circulatory Metabolite Ratios as Indicators of Lifestyle Risk Factors Based on a Greek NAFLD Case-Control Study

An ensemble of confounding factors, such as an unhealthy diet, obesity, physical inactivity, and smoking, have been linked to a lifestyle that increases one's susceptibility to chronic diseases and early mortality. The circulatory metabolome may provide a rational means of pinpointing the advent of metabolite variations that reflect an adherence to a lifestyle and are associated with the occurrence of chronic diseases. Data related to four major modifiable lifestyle factors, including adherence to the Mediterranean diet (estimated on MedDietScore), body mass index (BMI), smoking, and physical activity level (PAL), were used to create the lifestyle risk score (LS). The LS was further categorized into four groups, where a higher score group indicates a less healthy lifestyle. Drawing on this, we analyzed 223 NMR serum spectra, 89 MASLD patients and 134 controls; these were coupled to chemometrics to identify "key" features and understand the biological processes involved in specific lifestyles. The unsupervised analysis verified that lifestyle was the factor influencing the samples' differentiation, while the supervised analysis highlighted metabolic signatures. Τhe metabolic ratios of alanine/formic acid and leucine/formic acid, with AUROC > 0.8, may constitute discriminant indexes of lifestyle. On these grounds, this research contributed to understanding the impact of lifestyle on the circulatory metabolome and highlighted "prudent lifestyle" biomarkers.

Adherence to an antioxidant diet and lifestyle is associated with reduced risk of cardiovascular disease and mortality among adults with nonalcoholic fatty liver disease: evidence from NHANES 1999-2018

Background

Nonalcoholic fatty liver disease (NAFLD) stands a prevalent chronic liver condition significantly influenced by oxidative stress. We investigated the unclear relationship between antioxidant-rich diet and lifestyle and cardiovascular disease (CVD) prevalence rate and mortality in adult patients with NAFLD.

Methods

This study utilized data from the National Health and Nutrition Examination Survey (NHAENS) spanning from 1999 to 2018 to investigate the association between adherence to an antioxidant-rich diet and lifestyle and the cardiovascular disease (CVD) prevalence rate and mortality in adult patients with NAFLD. The study employed the Oxidative Balance Score (OBS) to define antioxidant diet and lifestyle.

Results

Including 8,670 adult patients with NAFLD, the study revealed an inverse association between OBS and the prevalence of most CVD conditions. Fully adjusted models demonstrated that each unit increase in diet OBS, lifestyle OBS, and overall OBS corresponded to a 2, 7, and 2% reduction in all-cause mortality, respectively. In models 2, findings revealed that lifestyle Q2 and Q3 were linked to reduced cancer mortality, whereas diet and overall OBS did not exhibit an association. Additionally, Stratified analysis revealed that age (<45 years) and education level (> high school) significantly influenced the association between the OBS and the prevalence of CVD.

Conclusion

These results underscore the protective link between adherence to an antioxidant diet and lifestyle and a diminished prevalence of CVD and mortality in adults with NAFLD, particularly among younger and higher-educated populations.

Heart failure in children and adolescents: an update on diagnostic approaches and management

Cardiac failure is a clinical syndrome that may develop in children owing to cardiac dysfunction or underlying structural heart diseases. Considering the differences in diagnostic and therapeutic approaches for pediatric heart failure (PHF) and adult heart failure, we have reviewed the current literature on PHF. Relevant studies were extracted from MEDLINE/PubMed, Google Scholar, and Clinical Trial Registries using the terms "pediatric heart failure" or "heart failure in children" and "management" or "decongestive therapy." Recent advances in diagnostic approaches, such as cardiac magnetic resonance, speckle-tracking echocardiography, tissue Doppler imaging, and molecular diagnostic techniques, have increased our under -standing of PHF. It is imperative that clinicians evaluate the interrelated factors responsible for the develop ment of PHF, including myocardial function, pulmonary and systemic blood flow, heart rhythm, valve function, and nutritional status. Although recent advances have demon strated the efficacy of many new drugs in adult heart failure trials, it cannot be concluded that these drugs will show similar efficacy in children, considering the heterogeneous nature of the underlying mechanisms and variable pharmacody-namics and pharmacokinetics. Therefore, the underlying pathophysiology of PHF and the mechanisms of action of different drugs should be considered when selecting appropriate therapies. Further trials are needed to establi sh the efficacy and safety of these drugs, and a combined mul-ti disciplinary strategy will help enhance PHF outcomes.

Telemedicine and patients with heart failure: evidence and unresolved issues

BACKGROUND

Heart failure is the leading cause of cardiac-related hospitalizations. Limited access to reevaluations and outpatient appointments restricts the application of modern therapies. Telemedicine has become an essential resource in the healthcare system because of its countless benefits, such as higher and more frequent appointments and faster titration of medications. This narrative review aimed to demonstrate the evidence and unresolved issues related to the use of telemedicine in patients with heart failure. No studies have examined heart failure prevention; however, several studies have addressed the prevention of decompensation with positive results. Telemedicine can be used to evaluate all patients with heart failure, and many telemedicine platforms are available. Several strategies, including both noninvasive (phone calls, weight measurement, and virtual visits) and invasive (implantable pulmonary artery catheters) strategies can be implemented. Given these benefits, telemedicine is highly desirable, particularly for vulnerable groups. Although some questions remain unanswered, the development of new technologies can complement remote visits and improve patient care.

Lifestyle Medicine: An Antidote to Cardiovascular Diseases

Despite numerous advances in basic understanding of cardiovascular disease pathophysiology, pharmacology, therapeutic procedures, and systems improvement, there hasn't been much decline in heart disease related mortality in the US since 2010. Hypertension and diet induced risk continue to be the leading causes of cardiovascular morbidity. Even with the excessive mortality associated with the COVID-19 pandemic, in 2020, heart disease remained the leading cause of death. Given the degree of disease burden, morbidity, and mortality, there is an urgent need to redirect medical professionals' focus towards prevention through simple and cost effective lifestyle strategies. However, current practice paradigm and financial compensation systems are mainly centered disease management and not health promotion. For example, the financial value placed on 3-10 min smoking cessation counseling (.24RVUs) is 47-fold lower than an elective PCI (11.21 RVUs). The medical community seems to be enamored with the latest and greatest technology, new devices, and surgical procedures. What if the greatest technology of all was simply the way we live every day? Perhaps when this notion is known by enough, we will switch to this lifestyle medicine technology to prevent disease in the first place.

Ready-to-Eat Food Environments and Risk of Incident Heart Failure: A Prospective Cohort Study

BACKGROUND

Food environments have been linked to cardiovascular diseases; however, few studies have assessed the relationship between food environments and the risk of heart failure (HF). We aimed to evaluate the association between ready-to-eat food environments and incident HF at an individual level in a large prospective cohort.

METHODS

Exposure to ready-to-eat food environments, comprising pubs or bars, restaurants or cafeterias, and fast-food outlets, were individually measured as both proximity and density metrics. We also developed a composite ready-to-eat food environment density score by summing the densities of 3 types of food environments. Cox proportional analyses were applied to assess the associations of each single type and the composite food environments with HF risk.

RESULTS

Closer proximity to and greater density of ready-to-eat food environments, particularly for pubs and bars and fast-food outlets (P<0.05 for both proximity and density metric) were associated with an elevated risk of incident HF. Compared with those with no exposure to composite ready-to-eat food environments, participants in the highest density score category had a 16% (8%-25%; P<0.0001) higher risk of HF. In addition, we found significant interactions of food environments with education, urbanicity, and density of physical activity facilities on HF risk (all Pinteraction<0.05); the ready-to-eat food environments-associated risk of HF was stronger among participants who were poorly educated, living in urban areas, and without physical activity facilities.

CONCLUSIONS

Exposure to ready-to-eat food environments is associated with a higher risk of incident HF, suggesting the potential importance of minimizing unfavorable food environments in the prevention of HF.

Prioritizing the primary prevention of heart failure: Measuring, modifying and monitoring risk

With the rising incidence of heart failure (HF) and increasing burden of morbidity, mortality, and healthcare expenditures, primary prevention of HF targeting individuals in at-risk HF (Stage A) and pre-HF (Stage B) Stages has become increasingly important with the goal to decrease progression to symptomatic (Stage C) HF. Identification of risk based on traditional risk factors (e.g., cardiovascular health which can be assessed with the American Heart Association's Life's Essential 8 framework), adverse social determinants of health, inherited risk of cardiomyopathies, and identification of risk-enhancing factors, such as patients with viral disease, exposure to cardiotoxic chemotherapy, and history of adverse pregnancy outcomes should be the first step in evaluation for HF risk. Next, use of guideline-endorsed risk prediction tools such as Pooled Cohort Equations to Prevent Heart Failure provide quantification of absolute risk of HF based in traditional risk factors. Risk reduction through counseling on traditional risk factors is a core focus of implementation of prevention and may include the use of novel therapeutics that target specific pathways to reduce risk of HF, such as mineralocorticoid receptor agonists (e.g., fineronone), angiotensin-receptor/neprolysin inhibitors, and sodium glucose co-transporter-2 inhibitors. These interventions may be limited in at-risk populations who experience adverse social determinants and/or individuals who reside in rural areas. Thus, strategies like telemedicine may improve access to preventive care. Gaps in the current knowledge base for risk-based prevention of HF are highlighted to outline future research that may target approaches for risk assessment and risk-based prevention with the use of artificial intelligence, genomics-enhanced strategies, and pragmatic trials to develop a guideline-directed medical therapy approach to reduce risk among individuals with Stage A and Stage B HF.

Differences in predictors of incident heart failure according to atherosclerotic cardiovascular disease status

AIMS

Heart failure (HF) is a common cause of morbidity and mortality, related to a broad range of sociodemographic, lifestyle, cardiometabolic, and comorbidity risk factors, which may differ according to the presence of atherosclerotic cardiovascular disease (ASCVD). We assessed the association between incident HF with baseline status across these domains, overall and separated according to ASCVD status.

METHODS AND RESULTS

We included 5758 participants from the Baker Biobank cohort without HF at baseline enrolled between January 2000 and December 2011. The primary endpoint was incident HF, defined as hospital admission or HF-related death, determined through linkage with state-wide administrative databases (median follow-up 12.2 years). Regression models were fitted adjusted for sociodemographic variables, alcohol intake, smoking status, measures of adiposity, cardiometabolic profile measures, and individual comorbidities. During 65 987 person-years (median age 59 years, 38% women), incident HF occurred among 784 participants (13.6%) overall. Rates of incident HF were higher among patients with ASCVD (624/1929, 32.4%) compared with those without ASCVD (160/3829, 4.2%). Incident HF was associated with age, socio-economic status, alcohol intake, smoking status, body mass index (BMI), waist circumference, waist-hip ratio, systolic blood pressure (SBP), and low- and high-density lipoprotein cholesterol (LDL-C and HDL-C), with non-linear relationships observed for age, alcohol intake, BMI, waist circumference, waist-hip ratio, SBP, LDL-C, and HDL-C. Risk factors for incident HF were largely consistent regardless of ASCVD status, although diabetes status had a greater association with incident HF among patients without ASCVD.

CONCLUSIONS

Incident HF is associated with a broad range of baseline sociodemographic, lifestyle, cardiometabolic, and comorbidity factors, which are mostly consistent regardless of ASCVD status. These data could be useful in efforts towards developing risk prediction models that can be used in patients with ASCVD.

Summary and Comparison of the 2022 ACC/AHA/HFSA and 2021 ESC Heart Failure Guidelines

The guidelines released by the American College of Cardiology/American Heart Association/Heart Failure Society of America (ACC/AHA/HFSA) in 2022 and those released in 2021 by the European Society of Cardiology (ESC) play a crucial role in offering evidence-based recommendations for the diagnosis and management of heart failure (HF). This comprehensive review aims to provide an overview of these guidelines, incorporating insights from relevant clinical trials. While there is considerable alignment between the two sets of guidelines, certain notable differences arise due to variations in publication timelines, which we will outline. By presenting this summary, our objective is to empower clinicians to make informed decisions regarding HF management in their own practice, and facilitate the development of more harmonized guidelines in the future.

Association of Malnutrition and High Bleeding Risk with Long-Term Prognosis in Patients with Acute Coronary Syndrome following Percutaneous Coronary Intervention

BACKGROUND

Malnutrition in cardiovascular disease is associated with poor prognosis, especially in patients with heart failure and acute coronary syndrome (ACS). High bleeding risk is also linked to coronary artery disease prognosis, including ACS. However, whether the extent of malnutrition and high bleeding risk have a cumulative impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention remains unclear.

METHODS

We analyzed 275 patients with ACS treated with percutaneous coronary intervention. The Controlling Nutritional Status score and Japanese version of the Academic Research Consortium for High Bleeding Risk criteria (J-HBR) were retrospectively evaluated. The primary and secondary outcomes were adjusted using the inverse probability treatment weighting method.

RESULTS

The prevalence of moderate or severe malnutrition in this cohort was 16%. Kaplan-Meier analysis showed a significantly higher incidence of major adverse cardiovascular and cerebrovascular events in patients who were moderately or severely malnourished than in those who were not. Notably, the incidence of these major events was similar between severely malnourished patients with J-HBR and those without.

CONCLUSION

Moderate or severe malnutrition has a significant impact on the long-term prognosis of patients with ACS who undergo percutaneous coronary intervention.

What are the outcomes of dietary interventions in Heart Failure with preserved Ejection Fraction? A systematic review and meta-analysis

AIMS

To determine the efficacy of dietary interventions in Heart Failure with preserved Ejection Fraction (HFpEF).

METHOD AND RESULTS

Keyword searches were performed in five bibliographic databases to identify randomized or controlled studies of dietary interventions conducted in HFpEF or mixed heart failure (HF) samples published in the English language. Studies were appraised for bias and synthesized into seven categories based on the similarity of the intervention or targeted population. The quality of the body of evidence was assessed via the GRADE (Grading of Recommendations, Assessment, Development, and Evaluations) framework. Twenty-five unique interventions were identified; 17 were considered for meta-analysis. Most studies were judged to be at high risk of bias. There was moderate-quality evidence that caloric restriction led to clinically meaningful improvements in blood pressure and body weight. There was moderate-quality evidence that carbohydrate restriction resulted in meaningful reductions in blood pressure. There was very low-quality evidence that protein supplementation improved blood pressure and body weight and moderate-quality evidence for clinically meaningful improvements in function.

CONCLUSIONS

While some types of dietary interventions appeared to deliver clinically meaningful change in critical outcomes; the study heterogeneity and overall quality of the evidence make it difficult to make firm recommendations. Greater transparency when reporting the nutritional composition of interventions would enhance the ability to pool studies.

REGISTRATION

PROSPERO CRD42019145388.

The relationship between symptom perception and fear of progression in patients with chronic heart failure: a multiple mediation analysis

AIMS

Studies have shown that symptom perception is associated with fear of progression (FOP) in many diseases and regulated by psychological factors. Whether the association also occurs in patients with chronic heart failure (HF) remains unclear, as do the specific mechanisms involved. This study aimed to explore the multiple mediation effects of self-care confidence and mental resilience on the relationship between symptom perception and FOP in Chinese patients with chronic HF.

METHODS AND RESULTS

A cross-sectional study was conducted on 247 patients with chronic HF recruited from two hospitals in Yangzhou, China. The sociodemographic and clinical data and self-reported questionnaires including heart failure somatic perception, fear of progression, self-care confidence, and mental resilience were collected. Data analysis relating to correlations and mediating effects was carried out by SPSS 26.0 and PROCESS v3.3 macro. Fear of progression was positively correlated with symptom perception (r = 0.599, P < 0.01), but negatively correlated with self-care confidence (r = -0.663, P < 0.01), mental resilience-strength (r = -0.521, P < 0.01), and mental resilience-toughness (r = -0.596, P < 0.01). The relationship between symptom perception and FOP was mediated by self-care confidence [effect = 0.095, 95% confidence interval (CI) (0.054-0.142)] and mental resilience-toughness [effect = 0.033, 95% CI (0.006-0.074)], respectively, and together in serial [effect = 0.028, 95% CI (0.011-0.050)]. The proportion of the mediating effect accounting for the total effect was 31.0%.

CONCLUSION

Self-care confidence and mental resilience-toughness were multiple mediators of the association between symptom perception and FOP in patients with chronic HF. Interventions targeted at strengthening self-care confidence and mental resilience may be beneficial for the reduction of FOP, especially with regard to toughness.

The Promise and Risks of mHealth in Heart Failure Care

Mobile health (mHealth) is an emerging approach to health care. It involves wearable, connected technologies that facilitate patient-symptom or physiological monitoring, support clinical feedback to patients and physicians, and promote patients' education and self-care. Evolving algorithms may involve artificial intelligence and can assist in data aggregation and health care teams' interpretations. Ultimately, the goal is not merely to collect data; rather, it is to increase actionability. mHealth technology holds particular promise for patients with heart failure, especially those with frequently changing clinical status. mHealth, ideally, can identify care opportunities, anticipate clinical courses and augment providers' capacity to implement, titrate and monitor interventions safely, including evidence-based therapies. Although there have been marked advancements in the past decade, uncertainties remain for mHealth, including questions regarding optimal indications and acceptable payment models. In regard to mHealth capability, a better understanding is needed of the incremental benefit of mHealth data over usual care, the accuracy of specific mHealth data points in making clinical care decisions, and the efficiency and precision of algorithms used to dictate actions. Importantly, emerging regulations in the wake of COVID-19, and now the end of the federal public health emergency, offer both opportunity and risks to the broader adoption of mHealth-enabled services. In this review, we explore the current state of mHealth in heart failure, with particular attention to the opportunities and challenges this technology creates for patients, health care providers and other stakeholders.

Probiotics and Prebiotics in Cardiovascular Diseases

This Special Issue, titled "Probiotics and Prebiotics in Cardiovascular Diseases", encompasses two comprehensive review articles examining the potential of gut-microbiota-targeted reprogramming interventions designed to prevent the onset and progression of cardiovascular diseases [...].

Allostatic load and incident heart failure in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study

BACKGROUND

Allostatic load (AL) is the physiologic "wear and tear" on the body from stress. Yet, despite stress being implicated in the development heart failure (HF), it is unknown whether AL is associated with incident HF events.

METHODS

We examined 16,765 participants without HF at baseline from the REasons for Geographic and Racial Differences in Stroke (REGARDS) cohort. The main exposure was AL score quartile. AL was determined according to 11 physiologic parameters, whereby each parameter was assigned points (0-3) based on quartiles within the sample, and points were summed to create a total AL score ranging from 0-33. The outcome was incident HF event. We examined the association between AL quartile (Q1-Q4) and incident HF events using Cox proportional hazards models, adjusted for demographics, socioeconomic factors, and lifestyle.

RESULTS

The mean age was 64 ± 9.6 years, 61.5% were women, and 38.7% were Black participants. Over a median follow up of 11.4 years, we observed 750 incident HF events (635 HF hospitalizations and 115 HF deaths). Compared to the lowest AL quartile (Q1), the fully adjusted hazards of an incident HF event increased in a graded fashion: Q2 HR 1.49 95% CI 1.12-1.98; Q3 HR 2.47 95% CI 1.89-3.23; Q4 HR 4.28 95% CI 3.28-5.59. The HRs for incident HF event in the fully adjusted model that also adjusted for CAD were attenuated, but remained significant and increased in a similar, graded fashion by AL quartile. There was a significant age interaction (p-for-interaction < 0.001), whereby the associations were observed across each age stratum, but the HRs were highest among those aged < 65 years.

CONCLUSION

AL was associated with incident HF events, suggesting that AL could be an important risk factor and potential target for future interventions to prevent HF.

Impact of Lifestyle Modifications on Cardiovascular Health: A Narrative Review

Cardiovascular diseases (CVDs) remain a leading cause of morbidity and mortality worldwide. Lifestyle modifications have gained increasing recognition as key interventions in preventing and managing CVDs. This narrative review aims to provide a thorough assessment of the impact of lifestyle modifications on cardiovascular health. The review encompasses various aspects, including diet, physical activity, smoking cessation, stress management, and weight management. Additionally, the review explores the underlying mechanisms by which lifestyle modifications influence cardiovascular health and highlights the evidence from clinical trials, observational studies, and meta-analyses. The findings of this review emphasize the importance of lifestyle modifications in reducing the risk factors associated with CVDs and improving cardiovascular outcomes.

Insight into different phenotypic presentations of heart failure with preserved ejection fraction

Heart failure (HF) with preserved ejection fraction (HFpEF) accounts for half of all HF diagnoses, and its prevalence is increasing at an alarming rate. Lately, it has been recognized as a clinical syndrome due to diverse underlying etiology and pathophysiological mechanisms. The classic echocardiographic features of HFpEF have been well described as preserved ejection fraction (≥50%), left ventricular hypertrophy, and left atrial enlargement. However, echocardiography can play a key role in identifying the principal underlying mechanism responsible for HFpEF in the individual patient. The recognition of different phenotypic presentations of HFpEF (infiltrative, metabolic, genetic, and inflammatory) can assist the clinician in tailoring the appropriate management, and offer prognostic information. The goal of this review is to highlight several key phenotypes of HFpEF and illustrate the classic clinical scenario and echocardiographic features of each phenotype with real patient cases.

Prevalence and prognostic impact of the coexistence of cachexia and sarcopenia in older patients with heart failure

BACKGROUND

No study with an adequate patients' number has examined the relationship/overlap between sarcopenia and cachexia. We examined the prevalence of the overlap and prognostic implications of sarcopenia and cachexia in older patients with heart failure using well-accepted definitions.

METHODS

This was a post-hoc sub-analysis of the FRAGILE-HF study, a prospective, multicenter, observational study conducted at 15 hospitals in Japan. In total, 905 hospitalized older patients were classified into four groups based on the presence or absence of cachexia and/or sarcopenia, which were defined according to the Evans and Asian Working Group for Sarcopenia criteria revised in 2019, respectively. The primary endpoint was 2-year all-cause mortality.

RESULTS

Cachexia and sarcopenia prevalence rates were 32.7% and 22.7%, respectively. Patients were classified into the non-cachexia/non-sarcopenia (55.7%), cachexia/non-sarcopenia (21.7%), non-cachexia/sarcopenia (11.6%), and cachexia/sarcopenia (11.0%) groups. During the 2-year follow-up period after discharge, 158 (17.5%) all-cause deaths (124 cardiovascular deaths [CVD] and 34 non-CVD) were observed. The cachexia/sarcopenia group had the lowest body fat mass and exhibited significantly higher mortality rates (log-rank P < 0.001). Cox proportional hazard analysis revealed that cachexia/sarcopenia was an independent prognostic factor after adjusting for known prognostic factors (versus non-cachexia/non-sarcopenia: hazard ratio, 2.78; 95% confidence interval, 1.80-4.29; P < 0.001). Neither cachexia/non-sarcopenia nor non-cachexia/sarcopenia were significantly associated with all-cause mortality compared with non-cachexia/non-sarcopenia.

CONCLUSIONS

Cachexia and sarcopenia are prevalent among older hospitalized patients with heart failure; nonetheless, the overlap is not as prominent as previously expected. The presence of cachexia and sarcopenia is a risk factor for all-cause mortality.

Heart Failure with Preserved Ejection Fraction in Children

Diastolic dysfunction (DD) refers to abnormalities in the mechanical function of the left ventricle (LV) during diastole. Severe LVDD can cause symptoms and the signs of heart failure (HF) in the setting of normal or near normal LV systolic function and is referred to as diastolic HF or HF with preserved ejection fraction (HFpEF). Pediatric cardiologists have long speculated HFpEF in children with congenital heart disease and cardiomyopathy. However, understanding the risk factors, clinical course, and validated biomarkers predictive of the outcome of HFpEF in children is challenging due to heterogeneous etiologies and overlapping pathophysiological mechanisms. The natural history of HFpEF varies depending upon the patient's age, sex, race, geographic location, nutritional status, biochemical risk factors, underlying heart disease, and genetic-environmental interaction, among other factors. Pediatric onset HFpEF is often not the same disease as in adults. Advances in the noninvasive evaluation of the LV diastolic function by strain, and strain rate analysis with speckle-tracking echocardiography, tissue Doppler imaging, and cardiac magnetic resonance imaging have increased our understanding of the HFpEF in children. This review addresses HFpEF in children and identifies knowledge gaps in the underlying etiologies, pathogenesis, diagnosis, and management, especially compared to adults with HFpEF.

Revisiting skeletal myopathy and exercise training in heart failure: Emerging role of myokines

Exercise intolerance remains a major unmet medical need in patients with heart failure (HF). Skeletal myopathy is currently considered as the major limiting factor for exercise capacity in HF patients. On the other hand, emerging evidence suggest that physical exercise can decrease morbidity and mortality in HF patients. Therefore, mechanistic insights into skeletal myopathy may uncover critical aspects for therapeutic interventions to improve exercise performance in HF. Emerging data reviewed in this article suggest that the assessment of circulating myokines (molecules synthesized and secreted by skeletal muscle in response to contraction that display autocrine, paracrine and endocrine actions) may provide new insights into the pathophysiology, phenotyping and prognostic stratification of HF-related skeletal myopathy. Further studies are required to determine whether myokines may also serve as biomarkers to personalize the modality and dose of physical training prescribed for patients with HF and exercise intolerance. In addition, the production and secretion of myokines in patients with HF may interact with systemic alterations (e.g., inflammation and metabolic disturbances), frequently present in patients with HF. Furthermore, myokines may exert beneficial or detrimental effects on cardiac structure and function, which may influence adverse cardiac remodelling and clinical outcomes in HF patients. Collectively, these data suggest that a deeper knowledge on myokines regulation and actions may lead to the identification of novel physical exercise-based therapeutic approaches for HF patients.

Genetically predicted blood pressure, antihypertensive drugs and risk of heart failure: a Mendelian randomization study

BACKGROUND

Elevated blood pressure (BP) was associated with higher risk of heart failure, but the relationship between BP-lowering via antihypertensive drugs and diminution of heart failure was inconclusive. This study aimed to estimate the causal association of BP with heart failure, and explore the effects of BP-lowering through different antihypertensive drug classes on heart failure risk using Mendelian randomization analysis with genetic variants as instrument variables.

METHODS

Genetic variants associated with BP were derived from UK Biobank ( n  = 317 754) and the genome-wide association study (GWAS) meta-analysis of UK Biobank and International Consortium of Blood Pressure ( n  = 757 601). Heart failure summary association data were contributed by HERMES Consortium (47 309 heart failure cases and 930 014 controls). Inverse variance weighted (IVW) was performed to estimate causality between exposure and outcome, and weighted median was utilized as sensitivity analysis, and Mendelian randomization-Egger regression was used to identify pleiotropy of instrument variables. Multivariable Mendelian randomization (MVMR) was applied to control for the confounders.

RESULTS

Genetically predicted SBP and DBP were associated with heart failure [SBP: odds ratio (OR) = 1.355, 95% confidence interval (CI) 1.201-1.529; DBP: OR = 1.348, 95% CI 1.213-1.498] in UK Biobank. Likewise, in the GWAS meta-analysis of UK Biobank and International Consortium of Blood Pressure, the causal associations were observed between SBP, DBP and heart failure (SBP: OR = 1.237, 95% CI 1.188-1.289; DBP: OR = 1.337, 95% CI 1.245-1.437). Genetically determined β-blockers and calcium channel blockers (CCBs) were associated with lower risk of heart failure (β-blockers: OR = 0.617, 95% CI 0.453-0.839; CCBs: OR = 0.730, 95% CI 0.625-0.851). No association was found between angiotensin receptor blockers (ARBs) and heart failure (OR = 1.593, 95% CI 0.647-3.924). When adjusted for smoking, alcohol, physical activity, fruit and vegetable intake, the results were stable.

CONCLUSION

Our study indicates causal associations between SBP, DBP, and heart failure, and suggests the preventive effects of heart failure by BP-lowering using β-blockers and CCBs.

Preferences of Older Adult Veterans With Heart Failure for Engaging With Mobile Health Technology to Support Self-care: Qualitative Interview Study Among Patients With Heart Failure and Content Analysis

BACKGROUND

Heart failure (HF) affects approximately 6.5 million adults in the United States, disproportionately afflicting older adults. Mobile health (mHealth) has emerged as a promising tool to empower older adults in HF self-care. However, little is known about the use of this approach among older adult veterans.

OBJECTIVE

The goal of this study was to explore which features of an app were prioritized for older adult veterans with HF.

METHODS

Between January and July 2021, we conducted semistructured interviews with patients with heart failure aged 65 years and older at a single facility in an integrated health care system (the Veterans Health Administration). We performed content analysis and derived themes based on the middle-range theory of chronic illness, generating findings both deductively and inductively. The qualitative questions captured data on the 3 key themes of the theory: self-care maintenance, self-care monitoring, and self-care management. Qualitative responses were analyzed using a qualitative data management platform, and descriptive statistics were used to analyze demographic data.

RESULTS

Among patients interviewed (n=9), most agreed that a smartphone app for supporting HF self-care was desirable. In addition to 3 a priori themes, we identified 7 subthemes: education on daily HF care, how often to get education on HF, support of medication adherence, dietary restriction support, goal setting for exercises, stress reduction strategies, and prompts of when to call a provider. In addition, we identified 3 inductive themes related to veteran preferences for app components: simplicity, ability to share data with caregivers, and positive framing of HF language.

CONCLUSIONS

We identified educational and tracking app features that can guide the development of HF self-care for an older adult veteran population. Future research needs to be done to extend these findings and assess the feasibility of and test an app with these features.

Particle Tracing Based on 4D Flow Magnetic Resonance Imaging: A Systematic Review into Methods, Applications, and Current Developments

BACKGROUND

Particle tracing based on 4D Flow MRI has been applied as a quantitative and qualitative postprocessing technique to study temporally evolving blood flow patterns.

PURPOSE

To systematically review the various methods to perform 4D Flow MRI-based particle tracing, as well as the clinical value, clinical applications, and current developments of the technique.

STUDY TYPE

The study type is systematic review.

SUBJECTS

Patients with cardiovascular disease (such as Marfan, Fontan, Tetralogy of Fallot), healthy controls, and cardiovascular phantoms that received 4D Flow MRI with particle tracing.

FIELD STRENGTH/SEQUENCE

Three-dimensional three-directional cine phase-contrast MRI, at 1.5 T and 3 T.

ASSESSMENT

Two systematic searches were performed on the PubMed database using Boolean operators and the relevant key terms covering 4D Flow MRI and particle tracing. One systematic search was focused on particle tracing methods, whereas the other on applications. Additional articles from other sources were sought out and included after a similar inspection. Particle tracing methods, clinical applications, clinical value, and current developments were extracted.

STATISTICAL TESTS

The main results of the included studies are summarized, without additional statistical analysis.

RESULTS

Of 127 unique articles retrieved from the initial search, 56 were included (28 for methods and 54 for applications). Most articles that described particle tracing methods used an adaptive timestep, a fourth order Runge-Kutta integration method, and linear interpolation in the time dimension. Particle tracing was applied in heart chambers, aorta, venae cavae, Fontan circulation, pulmonary arteries, abdominal vasculature, peripheral arteries, carotid arteries, and cerebral vasculature. Applications were grouped as intravascular, intracardiac, flow stasis, and research.

DATA CONCLUSIONS

Particle tracing based on 4D Flow MRI gives unique insight into blood flow in several cardiovascular diseases, but the quality depends heavily on the MRI data quality. Further studies are required to evaluate the clinical value of the technique for different cardiovascular diseases.

EVIDENCE LEVEL

5.

TECHNICAL EFFICACY

Stage 1.

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.

Relationship of Circulating Vegetable Omega-3 to Prognosis in Patients With Heart Failure

BACKGROUND

There is an urgent need for cost-effective strategies to promote quality of life in patients with heart failure (HF). Several studies reported benefits in HF prognosis for marine omega-3 fatty acids and plant-based dietary patterns.

OBJECTIVES

The aim of this study was to explore whether dietary alpha-linolenic acid (ALA), the main plant omega-3, relates to a better HF prognosis.

METHODS

ALA was determined in serum phospholipids (which reflect long-term dietary ALA intake and metabolism) by gas chromatography in 905 ambulatory patients with HF caused by different etiologies.

RESULTS

After a median follow-up of 2.4 years (range: 0.02-3 years), 140 all-cause deaths, 85 cardiovascular (CV) deaths, and 141 first HF hospitalizations (composite of all-cause death and first HF hospitalization, n = 238) were documented. Using Cox regression analyses, we observed that, compared with patients at the lowest quartile of ALA in serum phospholipids (Q1), those at the 3 upper quartiles (Q2-Q4) exhibited a reduction in the risk of composite of all-cause death and first HF hospitalization (HR: 0.61; 95% CI: 0.46-0.81). Statistically significant reductions were observed for all-cause death (HR: 0.58; 95% CI: 0.41-0.82), CV death (HR: 0.51; 95% CI: 0.32-0.80), first HF hospitalization (HR: 0.58; 95% CI: 0.40-0.84), and the composite of CV death and HF hospitalization (HR: 0.58; 95% CI: 0.42-0.79).

CONCLUSIONS

HF patients with bottom 25% ALA levels in serum phospholipids had a worse prognosis during a mid-term follow-up compared with those with the highest levels. This might be a target population in whom to test dietary ALA-rich interventions to promote quality of life.

Personalized Metabolic Avatar: A Data Driven Model of Metabolism for Weight Variation Forecasting and Diet Plan Evaluation

Development of predictive computational models of metabolism through mechanistic models is complex and resource demanding, and their personalization remains challenging. Data-driven models of human metabolism would constitute a reliable, fast, and continuously updating model for predictive analytics. Wearable devices, such as smart bands and impedance balances, allow the real time and remote monitoring of physiological parameters, providing for a flux of data carrying information on user metabolism. Here, we developed a data-driven model of end-user metabolism, the Personalized Metabolic Avatar (PMA), to estimate its personalized reactions to diets. PMA consists of a gated recurrent unit (GRU) deep learning model trained to forecast personalized weight variations according to macronutrient composition and daily energy balance. The model can perform simulations and evaluation of diet plans, allowing the definition of tailored goals for achieving ideal weight. This approach can provide the correct clues to empower citizens with scientific knowledge, augmenting their self-awareness with the aim to achieve long-lasting results in pursuing a healthy lifestyle.

Determinants of improvement of left ventricular mechano-energetic efficiency in hypertensive patients

Background

Arterial hypertension, especially when coexisting with other cardiovascular risk factors, could determine an imbalance between myocardial energetic demand and altered efficiency, leading to an early left ventricular (LV) systolic dysfunction, even in terms of echo-derived mechano-energetic efficiency indexed for myocardial mass (MEEi). We aim to analyse an improvement in LV MEEi, if any, in a population of hypertensive patients with a long-term follow-up and to identify clinical, metabolic and therapeutic determinants of LV MEEi amelioration.

Materials and methods

In total, 7,052 hypertensive patients, followed-up for 5.3 ± 4.5 years, enrolled in the Campania Salute Network, underwent echocardiographic and clinical evaluation. LV MEEi was obtained as the ratio between stroke volume and heart rate and normalized per grams of LV mass and ΔMEEi was calculated as difference between follow-up and baseline MEEi. Patients in the highest ΔMEEi quartile (≥0.0454 mL/s/g) (group 1) were compared to the merged first, second and third quartiles (<0.0454 mL/s/g) (group 2). METS-IR (Metabolic Score for Insulin Resistance), an established index of insulin sensitivity, was also derived.

Results

Patients with MEEi improvement experienced a lower rate of major cardiovascular events (p = 0.02). After excluding patients experiencing cardiovascular events, patients in group 1 were younger (p < 0.0001), less often diabetic (p = 0.001) and obese (p = 0.035). Group 1 experienced more frequently LV mass index reduction, lower occurrence of LV ejection fraction reduction, and had a better metabolic control in terms of mean METS-IR during the follow-up (all p < 0.0001). Beta-blockers were more often used in group 1 (p < 0.0001) than group 2. A logistic regression analysis showed that younger age, lower mean METS-IR values, more frequent LV mass index reduction and therapy with beta-blockers were significantly associated with LV MEEi improvement, independently of presence of diabetes and obesity.

Conclusion

Metabolic control and therapy with beta-blockers could act in a synergic way, determining an improvement in LV MEEi in hypertensive patients over time, possibly confining cardiac damage and hampering progression toward heart failure.

A health and lifestyle framework: An evidence-informed basis for contemporary physical therapist clinical practice guidelines with special reference to individuals with heart failure

BACKGROUND AND PURPOSE

This study proposes contemporary physical therapist clinical practice guidelines (CPGs) with special reference to heart failure (HF) be grounded in an evidence-informed integrative health and lifestyle framework to not only better reflect the totality and weighting of the literature, but also in the interest of superior patient, clinical, and economic outcomes.

METHODS

As an illustration, a health and lifestyle framework is described to underpin, thereby complement, recently published physical therapist CPGs for individuals with HF.

RESULTS

The case for the framework, an alternative to a single-disease biomedical perspective, is consistent with 21st century professional and epidemiologic indicators. Four themes that emerged from the HF CPGs and further support such a framework, emerged that is, limitations of conventionally constructed CPGs; physical therapists' scope of practice as "health" professionals; "best" practice in an era of NCDs including HF; and superior economic benefit.

DISCUSSION

A health and lifestyle framework underpinning contemporary physical therapist CPGs will enable clinicians to better appreciate the power of lifestyle change in maximizing the health of the heart, its healing and repair, and in mitigating and reversing signs and symptoms of cardiac dysfunction. Further, a focus on health and lifestyle will augment the benefits of the core, evidence-based, key action statements related to exercise in the HF CPGs.

Importance of healthy lifestyle factors and ideal cardiovascular health metrics for risk of heart failure in Chinese adults

BACKGROUND

The relative importance of healthy lifestyle factors and cardiovascular health metrics for the risk of heart failure is uncertain in Chinese populations. We aimed to compare the strength of associations between healthy lifestyle factors and ideal cardiovascular health metrics in the risk of heart failure in middle-aged Chinese adults.

METHODS

A healthy lifestyle score (HLS) was constructed using smoking, drinking, physical activity, diet, body mass index and waist circumference, and compared with a more comprehensive set of metrics that included cardiovascular-disease risk biomarkers (blood pressure, blood glucose and blood lipids) in addition to the HLS. This broader set of factors [called 'ideal cardiovascular health metrics' (ICVHMs)] was evaluated in 487 197 participants in the China Kadoorie Biobank.

RESULTS

A total of 4208 incident cases of heart failure were recorded during a median follow-up of 10 years. Both HLS [hazard ratio (HR), 0.88; 95% confidence interval (CI), 0.85, 0.91] and ICVHMs (0.87: 0.84, 0.89) were inversely associated with risk of heart failure (P < 0.001 for linear trend). Compared with participants with 0-1 HLS, the multivariable-adjusted HR of those with 4-5 HLS was 0.68 (0.59, 0.77). Compared with participants with 0-2 ICVHMs, the adjusted HR (95% CIs) of those who had 7-8 ICVHMs was 0.47 (0.36, 0.60). ICVHMs were more strongly predictive of risk of heart failure (area under curve, 0.61 vs 0.58, P < 0.001) than healthy lifestyle factors alone.

CONCLUSIONS

Higher levels of healthy lifestyle factors and ICVHMs were each inversely associated with heart failure, and lifestyle factors combined with cardiometabolic factors improved the prediction of heart failure compared with healthy lifestyle factors alone.

2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure: A Report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines

AIM

The "2022 AHA/ACC/HFSA Guideline for the Management of Heart Failure" replaces the "2013 ACCF/AHA Guideline for the Management of Heart Failure" and the "2017 ACC/AHA/HFSA Focused Update of the 2013 ACCF/AHA Guideline for the Management of Heart Failure." The 2022 guideline is intended to provide patient-centric recommendations for clinicians to prevent, diagnose, and manage patients with heart failure.

METHODS

A comprehensive literature search was conducted from May 2020 to December 2020, encompassing studies, reviews, and other evidence conducted on human subjects that were published in English from MEDLINE (PubMed), EMBASE, the Cochrane Collaboration, the Agency for Healthcare Research and Quality, and other relevant databases. Additional relevant clinical trials and research studies, published through September 2021, were also considered. This guideline was harmonized with other American Heart Association/American College of Cardiology guidelines published through December 2021. Structure: Heart failure remains a leading cause of morbidity and mortality globally. The 2022 heart failure guideline provides recommendations based on contemporary evidence for the treatment of these patients. The recommendations present an evidence-based approach to managing patients with heart failure, with the intent to improve quality of care and align with patients' interests. Many recommendations from the earlier heart failure guidelines have been updated with new evidence, and new recommendations have been created when supported by published data. Value statements are provided for certain treatments with high-quality published economic analyses.