Clinical characteristics and outcomes of heart failure with preserved ejection fraction: Lessons from epidemiological studies

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

Purpose

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

Patients and Methods

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

Results

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

Conclusion

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

Association between the beta-blockers, calcium channel blockers, all-cause mortality and length of hospitalization in patients with heart failure with preserved ejection fraction: A meta-analysis of randomized controlled trials

PURPOSE

To establish an association between beta-blockers (BBs), calcium channel blockers (CCBs), all-cause mortality, and hospitalization in patients with Heart failure with preserved Ejection Fraction (HFpEF).

METHODS

The present meta-analysis has been performed as per the guidelines of (PRISMA). An inclusive literature search was made without any limitations on language using the electronic databases Cochrane Library, EMBASE, and PubMed up to November 2022. The outcomes evaluated in this meta-analysis involved all-cause mortality and hospitalization due to heart failure. The number of patients with HFpEF and their positive outcomes was extracted and analyzed using RevMan software.

RESULTS

In total, 10 articles were included in the present meta-analysis, with a pooled sample size of 12 940 HFpEF patients. In comparison with placebo, both BB and CCB substantially reduced the risk of all-cause mortality and hospitalization. However, BB are more effective because they provide a significant reduction in all-cause mortality (risk ratio (RR) = 0.60; 95% confidence interval [CI] = 0.43-0.83; p = .002] and hospitalization (RR = 0.54; 95% CI = 0.37-0.80; p = .002) as compared with CCB with a risk ratio of all-cause mortality (RR = 0.77; 95% CI = 0.60-0.98; p = .03) and hospitalization (RR = 0.63; 95% CI = 0.44-0.90; p < .00001). A random-effects model was used because of high heterogeneity between the studies (I2  > 70%).

CONCLUSIONS

The current meta-analysis suggests that BBs were more beneficial than CCB in reducing all-cause mortality and hospitalization duration in patients with HFpEF.

Diastolic dysfunction and mortality in 436 360 men and women: the National Echo Database Australia (NEDA)

Aims 

To examine the characteristics/prognostic impact of diastolic dysfunction (DD) according to 2016 American Society of Echocardiography (ASE) and European Society of Cardiovascular Imaging (ESCVI) guidelines, and individual parameters of DD.

Methods and results 

Data were derived from a large multicentre mortality-linked echocardiographic registry comprising 436 360 adults with ≥1 diastolic function measurement linked to 100 597 deaths during 2.2 million person-years follow-up. ASE/European Association of Cardiovascular Imaging (EACVI) algorithms could be applied in 392 009 (89.8%) cases; comprising 11.4% of cases with ‘reduced’ left ventricular ejection fraction (LVEF < 50%) and 88.6% with ‘preserved’ LVEF (≥50%). Diastolic function was indeterminate in 21.5% and 62.2% of ‘preserved’ and ‘reduced’ LVEF cases, respectively. Among preserved LVEF cases, the risk of adjusted 5-year cardiovascular-related mortality was elevated in both DD [odds ratio (OR) 1.31, 95% confidence interval (CI) 1.22–1.42; P < 0.001] and indeterminate status cases (OR 1.11, 95% CI 1.04–1.18; P < 0.001) vs. no DD. Among impaired LVEF cases, the equivalent risk of cardiovascular-related mortality was 1.51 (95% CI 1.15–1.98, P < 0.001) for increased filling pressure vs. 1.25 (95% CI 0.96–1.64, P = 0.06) for indeterminate status. Mitral E velocity, septal e’ velocity, E:e’ ratio, and LAVi all correlated with mortality. On adjusted basis, pivot-points of increased risk for cardiovascular-related mortality occurred at 90 cm/s for E wave velocity, 9 cm/s for septal e’ velocity, an E:e’ ratio of 9, and an LAVi of 32 mL/m².

Conclusion 

ASE/EACVI-classified DD is correlated with increased mortality. However, many cases remain ‘indeterminate’. Importantly, when analysed individually, mitral E velocity, septal e’ velocity, E:e’ ratio, and LAVi revealed clear pivot-points of increased risk of cardiovascular-related mortality.

Preoperative elevated E/e' (≥ 15) with preserved ejection fraction is associated with the development of postoperative heart failure in intermediate-risk non-cardiac surgical patients

PURPOSE

Left ventricular diastolic dysfunction is an independent risk factor for adverse cardiovascular morbidities and mortalities in cardiovascular and high-risk surgical patients. However, there were only a few investigations among intermediate-risk surgical patients. This study aimed to investigate postoperative heart failure (HF) in intermediate-risk surgical patients who had preoperative diastolic dysfunction with preserved ejection fraction (EF).

METHODS

Consecutive patients underwent intermediate-risk surgery between January 2016 and December 2018 were retrospectively evaluated. Patients with preserved EF were divided into three groups using one of the parameters of diastolic function: the ratio of early diastolic filling velocity to the peak diastolic velocity of mitral medial annulus (E/e') ≥ 15, E/e' between 8 and 15, and E/e' < 8. Postoperative HF was defined as clinical symptoms and radiological evidence and low SpO₂ less than 93%. The primary outcome was the incidence of postoperative HF and its relation to preoperative E/e'. Chi-squared test, unpaired t test with Welch's correction, and multivariate logistic regression were used for analysis.

RESULTS

In total, 965 patients were included in the final analysis. Postoperative HF developed in 36/965 (3.7%) patients with preserved EF. The incidence of postoperative HF was stratified according to the E/e', and the rates of HF occurrence in patients with E/e' < 8, 8-15, and ≥ 15 were 1.8%, 2.7%, and 15%, respectively (P < 0.01).

CONCLUSION

Preoperative elevated E/e' (≥ 15) was associated with the development of postoperative HF in intermediate-risk surgical patients with preserved EF.

Pharmacological treatment patterns in heart failure: a population-based cohort study

BACKGROUND

Although the efficacy and safety of existing therapies of heart failure (HF) have been demonstrated in clinical trials, little is known about the treatment patterns in clinical practice, especially in France.

OBJECTIVES

To describe the treatment initiation patterns and the subsequent treatment changes among HF patients, in the first year following an incident hospitalization for HF, in a French real-world setting.

METHODS

A cohort of patients aged ≥ 40 years, with an incident hospitalization for HF between 01/01/2008 and 31/12/2013, was identified in the 1/97th permanent random sample of the French nationwide claims database and followed 1 year. HF drug exposure-beta blockers (BB), angiotensin-converting enzyme inhibitors (ACEI), angiotensin receptor blockers (ARBs), aldosterone antagonists (AA), diuretics, digoxin, or ivabradine-was assessed quarterly using a Proportion of Days Covered ≥ 66% (≥ 60 days out of the 90 days of the quarter), by considering HF drugs individually or in combination. Drug changes were assessed between each quarter.

RESULTS

Between 2008 and 2013, 7387 patients were included. Their mean age was 77.7 years (± 12.0 years) and 51.6% were women. During the follow-up, 24.4% died, 20% were not exposed to any HF treatment, 48.3 to 43.2% had diuretics, one third had BB or ACEI, 9% had ARB or AA, 6% had digoxin, and 2% had ivabradine. The main change occurred between the first and the second quarter for 53.1% of the initially untreated patients.

CONCLUSION

This study provides valuable information on treatment patterns after an initial hospitalization for HF.

Inhibition of the renin-angiotensin system in the cardiorenal syndrome with anaemia: a double-edged sword

: The term 'cardiorenal syndrome' (CRS) was introduced to describe problems related to the simultaneous existence of heart and renal insufficiency. The prevalence of anaemia in CRS is high and increases the risk of hospitalizations and death. Renin-angiotensin system (RAS) inhibition is the cornerstone therapy in cardiovascular and renal medicine. As angiotensin II regulates both glomerular filtration rate (GFR) and erythropoiesis, RAS inhibition can further deteriorate renal function and lower hematocrit or cause anaemia in patients with heart failure. The aim of this review is to explore the relationship among CRS, anemia and administration of angiotensin-converting enzyme inhibitor (ACEi) or angiotensin receptor blocker (ARB) and summarize the evidence suggesting that RAS inhibition may be considered an iatrogenic cause of deterioration of CRS with anemia. It should be emphasized however, that RAS inhibition reduces mortality in both groups with and without worsening of renal function, and therefore, no patient with CRS should be denied an ACEi or ARB trial without careful evaluation.

The American Heart Association Heart Failure Summit, Bethesda, April 12, 2017

The American Heart Association convened a meeting to summarize the changing landscape of heart failure (HF), anticipate upcoming challenges and opportunities to achieve coordinated identification and treatment, and to recommend areas in need of focused efforts. The conference involved representatives from clinical care organizations, governmental agencies, researchers, patient advocacy groups, and public and private healthcare partners, demonstrating the breadth of stakeholders interested in improving care and outcomes for patients with HF. The main purposes of this meeting were to foster dialog and brainstorm actions to close gaps in identifying people with or at risk for HF and reduce HF-related morbidity, mortality, and hospitalizations. This report highlights the key topics covered during the meeting, including (1) identification of patients with or at risk for HF, (2) tracking patients once diagnosed, (3) application of population health approaches to HF, (4) improved strategies for reducing HF hospitalization (not just rehospitalization), and (5) promoting HF self-management.

Differences in blood pressure riser pattern in patients with acute heart failure with reduced mid-range and preserved ejection fraction

Aims

Heart failure (HF) is classified into three types according to left ventricular ejection fraction (EF). The effect of blood pressure (BP) on the pathogenesis of each type is assumed to be different. However, the association between the prognosis of each type of HF and abnormal BP variations assessed by ambulatory BP monitoring (ABPM), such as nocturnal hypertension and the riser pattern, remains unclear.

Methods and results

We studied 325 consecutive patients with decompensated HF who were acutely admitted to our hospital and underwent ABPM at discharge. During a mean follow‐up of 30.0 months, 52 cardiovascular and 112 all‐cause deaths occurred. The Cox proportional hazards model showed that the mean values of 24 h, awake, and sleep‐time systolic BP (SBP), and abnormal 24 h ABPM patterns, such as nocturnal hypertension and non‐dipper pattern, were not associated with either all‐cause or cardiovascular mortality in patients with HF with reduced EF (HFrEF), HF with mid‐range EF (HFmrEF), or HF with preserved EF (HFpEF), except for sleep‐time SBP in HFrEF. However, the riser pattern was a significant and independent predictor of all‐cause and cardiovascular deaths in patients with HFpEF (hazard ratio, 2.01; 95% confidence interval, 1.12–3.62; 0.0200; and hazard ratio, 2.48; 95% confidence interval, 1.08–5.90; 0.0332, respectively). Sleep‐time pulse rate was similarly decreased in both the riser and non‐riser groups.

Conclusions

The riser pattern of SBP was associated with an increased risk of adverse outcomes among patients with HFpEF but not HFrEF or HFmrEF.

The changing trend of cardiovascular disease and its clinical characteristics in Ethiopia: hospital-based observational study

Objective

The aim of this study was to assess the pattern of cardiovascular diseases (CVDs), their clinical characteristics, and associated factors in the outpatient department of the chronic illness clinic of Gondar University Referral Hospital.

Method

A retrospective cross-sectional study was conducted among patients on follow-up at the outpatient chronic illness clinic of the hospital from October 2010 to October 2015. The source population for the study included patients with a diagnosis of CVD whose medical records have the required socio-demographic information during the study period. The data were collected from August 2015 to December 2015. Chi-square and binary logistic regression tests were performed to test the significance of difference among predictive variables and CVDs.

Results

Of 1105 patient medical records, 862 fulfilled the inclusion criteria. The majority of the patients were females (65%) and living in urban areas (62.7%). Hypertension accounted for the majority (62.3%) of CVDs followed by heart failure (HF) (23.9%). Headache was the leading chief complaint among the patients (37.7%) upon diagnosis and was the prominent clinical feature in more than half of the patients during their course of follow-up. Higher proportions of dyslipidemia (85.7%), hypertension (72.8%), and ischemic heart disease (IHD) (73.2%) were associated with urban residency (P<0.01). Patients from rural areas (crude odds ratio [COR] =1.306 [95% confidence interval 1.026–2.166], adjusted odds ratio [AOR] =1.272 [95% confidence interval 1.017–2.030]) and those with comorbidity illnesses (COR= 1.813 [1.279–2.782], AOR =1.551 [95% confidence interval 1.177–2.705]) were more likely to have poor CVD outcome (P<0.05).

Conclusion

Hypertension was found to be the most frequent CVD followed by HF, and hypertensive heart disease was the leading cause of cardiac diseases. Most of the patients had improved assessment in the last follow-up, but patients from rural regions and those with comorbidty had higher likelihood of poor cardiovascular outcome.

Understanding the Epidemiology of Heart Failure to Improve Management Practices: An Asia-Pacific Perspective

Heart failure (HF) is a major global healthcare problem with an estimated prevalence of approximately 26 million. In Asia-Pacific regions, HF is associated with a significant socioeconomic burden and high rates of hospital admission. Epidemiological data that could help to improve management approaches to address this burden in Asia-Pacific regions are limited, but suggest patients with HF in the Asia-Pacific are younger and have more severe signs and symptoms of HF than those of Western countries. However, local guidelines are based largely on the European Society of Cardiology and American College of Cardiology Foundation/American Heart Association guidelines, which draw their evidence from studies where Western patients form the major demographic and patients from the Asia-Pacific region are underrepresented. Furthermore, regional differences in treatment practices likely affect patient outcomes. In the following review, we examine epidemiological data from existing regional registries, which indicate that these patients represent a distinct subpopulation of patients with HF. In addition, we highlight that patients with HF are under-treated in the region despite the existence of local guidelines. Finally, we provide suggestions on how data can be enriched throughout the region, which may positively affect local guidelines and improve management practices.

Relationship among multifaceted factors including blood pressure at discharge and long-term clinical outcome in patients with cardiovascular diseases

The relationship among blood pressure (BP) levels at discharge, other multifaceted factors assessed in cardiac rehabilitation programs, and prognosis for up to 2 years was examined in 154 consecutive cases (132 patients; 69 males; 79 ± 12 years, mean ± SD). A total of 72 composite events occurred (58 rehospitalizations from cardiovascular causes and 14 all-cause death events). The relationship between the systolic BP (SBP) at discharge and the long-term prognosis formed a J-shaped curve, with the event rate being lowest in patients with SBP of 115-125 mmHg. This relationship was still significant after adjustment of multifaceted factors assessed in cardiac rehabilitation programs.

Combined effect of left ventricular ejection fraction and post-cardiac depressive symptoms on major adverse cardiac events after successful primary percutaneous coronary intervention: a 12-month follow-up

BACKGROUND

Despite the technical advancement of percutaneous coronary intervention, major adverse cardiac events after percutaneous coronary intervention are still a critical issue in Korea as well as in western society. Recently, low left ventricular ejection fraction and depressive symptoms have been regarded as independent predictors of adverse outcomes after successful primary percutaneous coronary intervention. However, there are few studies on the combined effect of left ventricular ejection fraction at baseline and post-cardiac depressive symptoms on major adverse cardiac events after percutaneous coronary intervention.

AIM

The aim of the current study is to examine the combined effect of low left ventricular ejection fraction and post-cardiac depressive symptoms on major adverse cardiac events after successful primary percutaneous coronary intervention.

METHODS

A total of 221 patients who underwent successful percutaneous coronary intervention were assessed for left ventricular ejection fraction and depressive symptoms at baseline and 1 month after discharge, using the patient health questionnaire 9. Major adverse cardiac event-free survival rates during the 12-month follow-up period were analysed by Kaplan-Meier survival curves and Cox proportional hazard regression methods.

RESULTS

We found that the combined effect of baseline left ventricular ejection fraction less than 60% and depressive symptoms at 1 month after discharge were significantly correlated with increased incidence of major adverse cardiac events after successful primary percutaneous coronary intervention (hazard ratio 4.049; 95% confidence interval 1.365-12.011) after adjusting for sex, high sensitivity C-reactive protein, depressive symptoms at baseline and comorbidity.

CONCLUSIONS

Our results suggest that healthcare professionals should be aware of the necessity of early screening for post-cardiac depressive symptoms after discharge in percutaneous coronary intervention patients with a low left ventricular ejection fraction.

Scoring System Based on Electrocardiogram Features to Predict the Type of Heart Failure in Patients With Chronic Heart Failure

Background

Heart failure (HF) is divided into heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Mortality from HF is inversely related to left ventricular function. Additional studies are required to distinguish between these two types of HF. A previous study showed that HFrEF is less likely when electrocardiogram (ECG) findings are normal. This study aims to create a scoring system based on ECG findings that will predict the type of HF.

Methods

We performed a cross-sectional study analyzing ECG and echocardiographic data from 110 subjects with chronic HF. HFrEF was defined as an ejection fraction ≤ 40%.

Results

Fifty people were diagnosed with HFpEF and 60 people suffered from HFrEF. Multiple logistic regression analysis revealed certain ECG variables that were independent predictors of HFrEF, i.e., left atrial hypertrophy (LAH), QRS duration > 100 ms, right bundle branch block (RBBB), ST-T segment changes and prolongation of the QT interval. Based on receiver operating characteristic (ROC) curve analysis, we obtained a score for HFpEF of -1 to +3, while HFrEF had a score of +4 to +6 with 76% sensitivity, 96% specificity, a 95% positive predictive value, an 80% negative predictive value and an accuracy of 86%.

Conclusions

The scoring system derived from this study, including the presence or absence of LAH, QRS duration > 100 ms, RBBB, ST-T segment changes and prolongation of the QT interval can be used to predict the type of HF with satisfactory sensitivity and specificity.

Characterizing heart failure in the ventricular volume domain

Heart failure (HF) may be accompanied by considerable alterations of left ventricular (LV) volume, depending on the particular phenotype. Two major types of HF have been identified, although heterogeneity within each category may be considerable. All variants of HF show substantially elevated LV filling pressures, which tend to induce changes in LV size and shape. Yet, one type of HF is characterized by near-normal values for LV end-diastolic volume (EDV) and even a smaller end-systolic volume (ESV) than in matched groups of persons without cardiac disease. Furthermore, accumulating evidence indicates that, both in terms of shape and size, in men and women, the heart reacts differently to adaptive stimuli as well as to certain pharmacological interventions. Adjustments of ESV and EDV such as in HF patients are associated with (reverse) remodeling mechanisms. Therefore, it is logical to analyze HF subtypes in a graphical representation that relates ESV to EDV. Following this route, one may expect that the two major phenotypes of HF are identified as distinct entities localized in different areas of the LV volume domain. The precise coordinates of this position imply unique characteristics in terms of the actual operating point for LV volume regulation. Evidently, ejection fraction (EF; equal to 1 minus the ratio of ESV and EDV) carries little information within the LV volume representation. Thus far, classification of HF is based on information regarding EF combined with EDV. Our analysis shows that ESV in the two HF groups follows different patterns in dependency of EDV. This observation suggests that a superior HF classification system should primarily be founded on information embodied by ESV.

A pilot study of angiogenin in heart failure with preserved ejection fraction: a novel potential biomarker for diagnosis and prognosis?

Characteristics of heart failure with preserved ejection fraction (HFPEF) have not yet been fully understood. The objectives of this pilot study are to detect protein expression profile in the sera of HFPEF patients, and to identify potential biomarkers for the disease. Five hundred and seven proteins were detected in the sera of healthy volunteers and patients with either HFPEF or hypertension using antibody microarrays (three in each group). The results showed that the serum concentrations of 17 proteins (e.g. angiogenin, activin A and artemin) differed considerably between HFPEF and non-HFPEF patients (hypertensive patients and healthy controls), while a protein expression pattern distinct from that in non-HFPEF patients was associated with HFPEF patients. The up-regulation of angiogenin in both HFPEF patients with LVEF ≥50% (P = 0.004) and a subset of HFPEF patients with LVEF = 41–49% (P < 0.001) was further validated in 16 HFPEF patients and 16 healthy controls. Meanwhile, angiogenin distinguished HFPEF patients from controls with a mean area under the receiver operating characteristic curve of 0.88 (P < 0.001) and a diagnostic cut-off point of 426 ng/ml. Moreover, the angiogenin levels in HFPEF patients were positively correlated with Lg(N-terminal pro-B-type natriuretic peptide, NT-proBNP) (P < 0.001). In addition, high angiogenin level (≥426 ng/ml) was a predictor of all-cause death within a short-term follow-up duration, but not in the longer term of 36 months. This pilot study indicates that the aforementioned 17 potential biomarkers, such as angiogenin, may hold great promise for both diagnosis and prognosis assessment of HFPEF.

Heart failure in East Asia

Heart failure (HF) carries a major burden of disease in East Asia, with high associated risk of mortality and morbidity. In recent decades, the epidemiology of HF has changed with social and economical development in East Asia. The burden of HF is still severe in East Asia.

The prevalence of HF ranges from 1.3% to 6.7% throughout the region. As aetiological factors, ischaemic heart disease has increased and valvular disease reduced in most East Asian countries. Diuretics are the most commonly used drugs (51.0%-97%), followed by renin-angiotensin system (RAS) inhibitors (59%-77%), with angiotensin-converting enzyme inhibitors, ACEI, (32%-52%) and has angiotensin-2 receptor blockers, ARBs (31%-44%) in similar proportions. β-blocker use has also increased in recent years.

Total mortality from HF ranges from 2% to 9% in China, Taiwan, Singapore, Thailand, and Japan. Age>65 years, diabetes mellitus, anaemia, renal dysfunction and atrial fibrillation (AF) are associated with adverse outcome. More prospective, region-specific data are still required, particularly regarding new drug therapies such as eplerenone and ivabradine.

Who enrolls in the Medicare Part D prescription drug benefit program? Medication use among patients with heart failure

Background

Dispensing data from Medicare Part D standalone prescription drug plans are now available, but characteristics of enrollees with heart failure have not been well described.

Methods and Results

We identified 81 874 patients with prevalent heart failure as of January 1, 2010, in a nationally representative 5% sample of Medicare beneficiaries. We classified patients according to enrollment in a Medicare Part D plan as of January 1, 2010. Demographic characteristics, comorbid conditions, and prescriptions were compared by enrollment status. A total of 49 252 (60.2%) were enrolled in a Medicare Part D plan as of January 1. Enrollees were more often women, black, and of lower socioeconomic status. Enrollees with heart failure more often filled prescriptions for loop diuretics than angiotensin‐converting enzyme inhibitors or angiotensin receptor blockers, β‐blockers, or aldosterone antagonists. During the first 4 months of 2010, 5444 (12.3%) reached the coverage gap, and 566 (1.3%) required catastrophic coverage beyond the gap.

Conclusions

Medicare beneficiaries with heart failure differ significantly according to enrollment in Part D prescription drug plans and represent a population underrepresented in clinical efficacy trials. Many face the coverage gap, and few select Medicare Part D plans that provide coverage during the gap. Linking Medicare Part D event data with clinical registries could help to determine whether eligible enrollees are undertreated for heart failure.

Home telemonitoring study for Japanese patients with heart failure (HOMES-HF): protocol for a multicentre randomised controlled trial

INTRODUCTION

Despite the encouraging results from several randomised controlled trials (RCTs) and meta-analyses, the ability of home telemonitoring for heart failure (HF) to improve patient outcomes remains controversial as a consequence of the two recent large-scale RCTs. However, it has been suggested that there is a subgroup of patients with HF who may benefit from telemonitoring. The aim of the present study was to investigate whether an HF management programme using telemonitoring could improve outcomes in patients with HF under the Japanese healthcare system.

METHODS AND ANALYSIS

The Home Telemonitoring Study for Japanese Patients with Heart Failure (HOMES-HF) study is a prospective, multicentre RCT to investigate the effectiveness of home telemonitoring on the primary composite endpoint of all-cause death and rehospitalisation due to worsening HF in recently admitted HF patients (aged 20 and older, New York Heart Association classes II-III). The telemonitoring system is an automated physiological monitoring system including body weight, blood pressure and pulse rate by full-time nurses 7 days a week. Additionally, the system was designed to make it a high priority to support patient's self-care instead of an early detection of HF decompensation. A total sample size of 420 patients is planned according to the Schoenfeld and Richter method. Eligible patients are randomly assigned via a website to either the telemonitoring group or the usual care group by using a minimisation method with biased-coin assignment balancing on age, left ventricular ejection fraction and a history of ischaemic heart disease. Participants will be enrolled until August 2013 and followed until August 2014. Time to events will be estimated using the Kaplan-Meier method, and HRs and 95% CIs will be calculated using the Cox proportional hazards models with stratification factors.

TRIAL REGISTRATION

The study is registered at UMIN Clinical Trials Registry (UMIN000006839).

Prognostic significance of applying the European Society of Cardiology consensus algorithm for heart failure with preserved systolic function diagnosis

BACKGROUND

The diagnosis of heart failure with preserved left ventricular ejection fraction (HFpEF) is challenging. Although diagnostic criteria have been proposed, limited information exists concerning its implication on prognosis. We aimed to evaluate the prognostic significance of applying the European Society of Cardiology algorithm for HFpEF diagnosis, namely the tissue Doppler imaging information, in patients with acute heart failure (HF).

HYPOTHESIS

The application of the European Society of Cardiology algorithm for HFpEF diagnosis, identifies a group of HF patients with high morbidity and mortality.

METHODS

Consecutive patients admitted due to acute HF were recruited. The European Society of Cardiology algorithm was used in the HFpEF diagnosis. Patients were followed for a 6-month period and mortality and rehospitalization due to HF were recorded.

RESULTS

A total of 491 patients were included in this registry. Mean patient age was 78 years and 63% were women; 177 patients had HFpEF and 314 had HF with reduced ejection fraction (HFrEF). Of the HFpEF patients, 44.8% had an E/E' ratio >15 and 1.8% had an E/E' ratio <8. Patients with HFpEF and those with HFrEF had a similarly dismal prognosis when considering all-cause mortality, and morbidity and mortality, but there was a trend for better survival when HF death was the outcome in analysis (hazard ratio 1.63 [95% confidence interval: 0.95-2.80, P = 0.08]).

CONCLUSIONS

The use of objective criteria for diagnosis of HFpEF identifies patients with similar outcomes as patients with HFrEF; this observation increases the robustness of the diagnostic criteria for HFpEF. The use of objective criteria for the diagnosis of HFpEF identifies patients with a similarly ominous prognosis as patients with HFrEF; this observation increases the robustness of the diagnostic criteria for HFpEF. Identifying these patients based on objective criteria, as we did, is an important step for future investigation, namely drugs, warranted to the HFpEF approach.

Clinical picture and social characteristics of super-elderly patients with heart failure in Japan

The number of super-elderly patients older than 80 years with chronic heart failure (HF) is dramatically increased in Japan; however, therapeutic strategies for patients 80 years or older remains to be established. The present investigation was undertaken to clarify the clinical picture and socioeconomic characteristics of super-elderly HF patients. A total of 380 consecutive patients with acute HF or acutely worsening chronic HF were divided into three groups according to age: patients younger than 60 years, those 60 to 80 years, and those 80 years or older (super-elderly group). HF patients in the super-elderly group initially presented with more atypical symptoms at admission compared with those in the younger age group. The prevalence of HF with preserved ejection fraction was more pronounced compared with the patients in the younger age group. Furthermore, the social background was quite different for the 3 groups in several respects: recurrent hospitalization, the prevalence of dementia, and the number of patients living alone all increased with age. The lack of social support in patients with HF is a problem that needs to be resolved in the "super-graying" societies such as Japan.

Depressive symptoms are common and associated with adverse clinical outcomes in heart failure with reduced and preserved ejection fraction

BACKGROUND

Little is known about depressive symptoms in heart failure with preserved ejection fraction (HFpEF, EF ≥50%). We aimed to assess the prevalence of depression, to clarify the impact of depressive symptoms upon clinical outcomes, and to identify factors associated with these symptoms in HF with reduced EF (HFrEF, EF <50%) and HFpEF.

METHODS AND RESULTS

A total of 106 HF outpatients were enrolled. Of them, 61 (58%) had HFpEF. Most patients were male (HFrEF 80%, HFpEF 70%) and the mean of plasma B-type natriuretic peptide (BNP) level in the HFrEF group was similar to that in the HFpEF group (164.8 ± 232.8 vs. 98.7 ± 94.8 pg/mL). HFrEF patients were treated more frequently with beta-blockers compared with HFpEF patients (71% vs. 43%, p=0.004). Depressive symptoms were assessed using the Center for Epidemiologic Studies Depression Scale (CES-D). The prevalence of depression (CES-D score ≥16), and CES-D score did not significantly differ between HFrEF and HFpEF (24% vs. 25%, 14.1 ± 8.3 vs. 12.1 ± 8.3, respectively). During the 2-year follow-up, depressed patients had more cardiac death or HF hospitalization in HFrEF (55% vs. 12%, p=0.002) and HFpEF (35% vs. 11%, p=0.031). Cox proportional hazard analysis revealed that a higher CES-D score, indicating increased depressive symptoms, predicted cardiac events independent of BNP in HFrEF [hazard ratio (HR) 1.07, 95% confidence interval (CI) 1.01-1.13] and HFpEF (HR 1.09, 95% CI 1.04-1.15). Multiple regression analyses adjusted for BNP showed that independent predictors of depressive symptoms were non-usage of beta-blockers and being widowed or divorced in HFrEF. On the other hand, usage of warfarin was the only independent risk factor for depressive symptoms in HFpEF (all, p<0.05).

CONCLUSIONS

Depressive symptoms are common and independently predict adverse events in HFrEF/HFpEF patients. This study suggests that beta-blockers reduce depressive symptoms in HFrEF. In contrast, treatment for depression remains to be elucidated in HFpEF.

Evaluation of the impact of atrial fibrillation on rehospitalization events in heart failure patients in recent years

BACKGROUND

Although we have previously reported that the presence of paroxysmal atrial fibrillation (AF) is an independent risk factor for rehospitalization in patients with congestive heart failure (CHF) in a population from 1996 to 2002, the impact of AF configuration as a risk factor in a more recent population remains to be clarified.

METHODS AND RESULTS

319 patients with CHF admitted to our institute in 2006-2007 were retrospectively evaluated. The patients were divided into 3 groups in accordance with their basic cardiac rhythm, i.e. sinus rhythm (n=210), chronic AF (n=68), and paroxysmal AF (n=41). During the follow-up period of 19 ± 17 months, there was no significant difference in mortality or rehospitalization events among the 3 groups (p=0.542). In the multivariate analysis, no administration of β-blockers was the only independent risk factor for rehospitalization due to CHF exacerbation.

CONCLUSIONS

The clinical impact of AF configuration as a risk factor of rehospitalization due to CHF exacerbation was considered to be decreased in recent years.

Accumulation of pericardial fat correlates with left ventricular diastolic dysfunction in patients with normal ejection fraction

BACKGROUND

Left ventricular diastolic dysfunction (LVDD) plays an important role in heart failure with normal left ventricular ejection fraction (LVEF). Obesity is one of the major comorbid conditions of LVDD. Pericardial fat (PF) is an ectopic fat depot with possible paracrine or mechanical effects on the coronary circulation and myocardial function.

METHODS

We measured PF volume on 64 slice computed tomography and analyzed echocardiographic parameters to confirm LVDD in 229 consecutive patients suspected of coronary artery disease with LVEF of more than 50% and no symptomatic heart failure (59% men, 67±12 years). LVDD was defined as the ratio of transmitral Doppler early filling velocity to tissue Doppler early diastolic mitral annular velocity (E/e') >10.

RESULTS

PF volume correlated significantly with E/e' (r=0.21, p<0.01), left ventricular mass index (r=0.23, p<0.001), and left atrial diameter (r=0.32, p<0.001). The mean PF volume was significantly greater in patients with LVDD (184±61cm(3), n=141) than in those without LVDD (154±58, n=88, p<0.001). Multivariate logistic regression analysis indicated that PF volume correlated significantly with the presence of LVDD (odds ratio: 2.00 per 100cm(3) increase in PF volume, p=0.02) independent of age, gender, abdominal obesity, hypertension, and diabetes.

CONCLUSIONS

PF volumes are significantly associated with LVDD, independent of other factors such as hypertension or diabetes. PF may be implicated in the pathogenesis of LVDD in patients with normal LVEF.

Synergistic prognostic values of cardiac sympathetic innervation with left ventricular hypertrophy and left atrial size in heart failure patients without reduced left ventricular ejection fraction: a cohort study

OBJECTIVES

This study tested whether cardiac sympathetic innervation assessed by metaiodobenzylguanidine (MIBG) activity has long-term prognostic value in combination with left ventricular hypertrophy (LVH) and left atrial size in heart failure (HF) patients without reduced left ventricular ejection fraction (LVEF).

DESIGN

A single-centre prospective cohort study.

SETTING/PARTICIPANTS

With primary endpoints of cardiac death and rehospitalisation due to HF progression, 178 consecutive symptomatic HF patients with 74% men, mean age of 56 years and mean LVEF of 64.5% were followed up for 80 months. The entry criteria consisted of LVEF more than 50%, completion of predischarge clinical evaluations including cardiac MIBG and echocardiographic studies and at least more than 1-year follow-up when survived.

RESULTS

Thirty-four patients with cardiac evens had larger left atrial dimension (LAD), increased LV mass index, reduced MIBG activity quantified as heart-to-mediastinum ratio (HMR) than did the others. Multivariable Cox analysis showed that LAD and HMR were significant predictors (HR of 1.080 (95% CI 1.00 to 1.16, p=0.044) and 0.107 (95% CI 0.01 to 0.61, p=0.012, respectively). Thresholds of HMR (1.65) and LAD (37 mm) were closely related to identification of high-risk patients. In particular, HMR was a significant determinant of cardiac events in both patients with and without LV hypertrophy. Reduced HMR with enlarged LAD or LV hypertrophy identified patients at most increased risk; overall log-rank value, 11.5, p=0.0032 for LAD and 17.5, p=0.0002, respectively.

CONCLUSIONS

In HF patients without reduced LV ejection fraction, impairment of cardiac sympathetic innervation is related to cardiac outcomes independently and synergistically with LA size and LV hypertrophy. Cardiac sympathetic innervation assessment can contribute to better risk-stratification in combination with evaluation of LA size and LV mass but is needed to be evaluated for establishing aetiology-based risk assessment in HF patients at increased risk.

Prevalence of heart failure with preserved ejection fraction in Latin American, Middle Eastern, and North African Regions in the I PREFER study (Identification of Patients With Heart Failure and PREserved Systolic Function: an epidemiological regional study)

The aims of the present study were to estimate the prevalence of heart failure (HF) with preserved ejection fraction (HF-PEF) in patients with HF and to compare their clinical characteristics with those with reduced ejection fraction in non-Western countries. The left ventricular ejection fraction ≥ 45% if measured < 1 year before the visit was used to qualify the patients as having HF-PEF. Of the 2,536 consecutive outpatients with HF, 1990 (79%) had the EF values recorded. Of these patients, 1291 had HF-PEF, leading to an overall prevalence of 65% (95% confidence interval 63% to 67%). Compared to the patients with HF and a reduced ejection fraction, those with HF-PEF were more likely to be older (65 vs 62 years, p < 0.001), female (50% vs 28%, p < 0.001), and obese (39% vs 27%, p < 0.001). They more frequently had a history of hypertension (78% vs 53%, p < 0.001) and atrial fibrillation (29% vs 24%, p = 0.03) and less frequently had a history of myocardial infarction (21% vs 44%, p < 0.001). Only 29% of patients with HF-PEF and hypertension had optimal blood pressure control. Left ventricular hypertrophy was less frequent in those with HF-PEF (58% vs 69%, p < 0.001). The prevalence of HF-PEF was lower in the Middle East (41%), where coronary artery disease was more often found than in Latin America (69%) and North Africa (75%), where the rate of hypertension was greater. In conclusion, in the present diverse non-Western study, HF-PEF represented almost 2/3 of all HF cases in outpatients. HF-PEF mostly affects older patients, women, and the obese. Hypertension was the most frequently associated risk factor, highlighting the need for optimal blood pressure control.

A large Venous-Arterial PCO(2) Is Associated with Poor Outcomes in Surgical Patients

Background. This study evaluated whether large venous-arterial CO(2) gap (PCO(2) gap) preoperatively is associated to poor outcome. Method. Prospective study which included adult high-risk surgical patients. The patients were pooled into two groups: wide [P(v-a)CO(2)] versus narrow [P(v-a)CO(2)]. In order to determine the best value to discriminate hospital mortality, it was applied a ROC (receiver operating characteristic) curve for the [P(v-a)CO(2)] values collected preoperatively, and the most accurate value was chosen as cut-off to define the groups. Results. The study included 66 patients. The [P(v-a)CO(2)] value preoperatively that best discriminated hospital mortality was 5.0 mmHg, area = 0.73. Preoperative patients with [P(v-a)CO(2)] more than 5.0 mmHg presented a higher hospital mortality (36.4% versus 4.5% P = 0.004), higher prevalence of circulatory shock (56.8% versus 22.7% P = 0.01) and acute renal failure postoperatively (27.3% versus 4.5% P = 0.02), and longer hospital length of stays 20.0 (14.0-30.0) versus 13.5 (9.0-25.0) days P = 0.01. Conclusions. The PCO(2) gap values more than 5.0 mmHg preoperatively were associated with worse postoperatively outcome.

Characterization of heart failure patients with preserved ejection fraction: a comparison between ADHERE-US registry and ADHERE-International registry

AIMS

To characterize geographic differences in clinical characteristics and care of patients hospitalized with heart failure and preserved ejection fraction (HF-PEF).

METHODS AND RESULTS

Using data on 61 182 admissions in 307 US hospitals from March 2004 to March 2006 from the Acute Decompensated Heart Failure National Registry (ADHERE)-United States (US) database and 10 904 admissions in 70 hospitals from 10 countries from March 2005 to January 2009 from the ADHERE-International (I) database composed of countries in Asia-Pacific and Latin-American regions, we compared characteristics, treatments, length of stay, and in-hospital mortality between patients with PEF (left ventricular EF ≥ 40%). There were 26 258 (49.6%) admissions with HF-PEF in the ADHERE-US and 4206 (45.7%) in ADHERE-I. The USA cohort was older [median 77.2 years (25th, 75th, 66.5, and 84.4) vs. 71.0 (59.0, 79.0), P< 0.001] and more likely to be female (61.8 vs. 54.7%, P< 0.001). The international cohort had a longer length of stay [median 6.0 days (4.0, 10.0)] vs. 4.0 days [3.0, 7.0], P< 0.001) and higher use of inotropes (12.5 vs. 4.8%, P< 0.001). At discharge, angiotensin-converting enzyme inhibitors/angiotensin receptor blockers, beta-blockers, and diuretics were prescribed more in the USA (57.6 vs. 54.4%, P< 0.001; 63.0 vs. 35.5%, P< 0.001; 78.2 vs. 76.2%, P< 0.001); digoxin was prescribed more outside the USA (26.0 vs. 17.7%, P< 0.001). After adjusting for baseline characteristics, 7-day inpatient mortality was similar between the international and the USA cohorts [hazard ratio 0.80, 95% CI (0.61-1.05); P= 0.11].

CONCLUSIONS

Clinical characteristics, inpatient interventions, discharge therapies, and length of stay vary significantly for HF-PEF patients across geographic regions. This has important implications for global clinical trials and outcome studies in HF.