Interventional heart failure therapy: A new concept fighting against heart failure

A profile of the impella 5.5 for the clinical management of cardiogenic shock and a review of the current indications for use and future directions

INTRODUCTION

The Impella 5.5 device is a surgically inserted, trans-valvular, microaxial flow device capable of providing 5.5 L/min of continuous, antegrade flow from the left ventricle (LV) to the aorta. The ability of the Impella 5.5 to fully pressure and volume unload the dysfunctional LV while allowing for mobilization and rehabilitation has rapidly expanded its use. Clinical use scenarios include escalation of support for acute myocardial infarction cardiogenic shock (AMICS), transition from extracorporeal membrane oxygenation to mobile support, bridge to transplantation or durable MCS in acute decompensated heart failure, or perioperative use in post-cardiotomy cardiogenic shock (PCCS).

AREAS COVERED

This review provides a profile of the Impella 5.5 device, summarizes the current literature surrounding clinical applications, reviews active and upcoming clinical trials, and projects future applications for the device through an expert review.

EXPERT OPINION

The development of the Impella 5.5 has allowed for monitoring of left-heart recovery, optimizing right ventricular function, and rehabilitating patients to meet bridging endpoints. The 2018 heart transplant allocation system modifications have expanded the use of temporary mechanical circulatory support (tMCS) on the transplant waitlist, increasing the number of patients transplanted on support. With increased safety and durability, an expanding frontier is used in perioperative support for PCCS in high-risk cardiac surgery.

Usefulness of hypochloremia at the time of discharge to predict prognosis in patients with chronic heart failure after hospitalization

BACKGROUND

Hypochloremia has been suggested as a strong marker of mortality in hospitalized patients with heart failure (HF). This study aimed to clarify whether incorporating hypochloremia into pre-existing prognostic models improved the performance of the models.

METHODS

We tested the prognostic value of hypochloremia (<97 mEq/L) measured at discharge in hospitalized patients with HF registered in the REALITY-AHF and NARA-HF studies. The primary outcome was 1-year mortality after discharge.

RESULTS

Among 2496 patients with HF, 316 (12.6 %) had hypochloremia at the time of discharge, and 387 (15.5 %) deaths were observed within 1 year of discharge. The presence of hypochloremia was strongly associated with higher 1-year mortality compared to those without hypochloremia (log-rank: p < 0.001), and this association remained even after adjustment for the Get With the Guideline-HF risk model (GWTG-HF), anemia, New York Heart Association (NYHA) classification, and log-brain natriuretic peptide (BNP) [hazard ratio (HR) 1.64; p < 0.001]. Furthermore, adding hypochloremia to the prediction model composed of GWTG-HF + anemia + NYHA class + log-BNP yielded a numerically larger area under the curve (0.740 vs 0.749; p = 0.059) and significant improvement in net reclassification (0.159, p = 0.010).

CONCLUSIONS

Incorporating the presence of hypochloremia at discharge into pre-existing risk prediction models provides incremental prognostic information for hospitalized patients with HF.

Impact of off-hours admissions in STEMI-related cardiogenic shock managed with microaxial flow pump - insights from J-PVAD

BACKGROUND

ST-segment elevation myocardial infarction (STEMI) complicated by cardiogenic shock (STEMI-CS) is associated with high mortality rates. Patients admitted during off-hours, specifically on weekends and at night, show higher mortality rates, which is called the "off-hours effect". The off-hours effect in patients with STEMI-CS treated with mechanical circulatory support, especially Impella, has not been fully evaluated.

AIMS

We aimed to investigate whether off-hours admissions were associated with higher mortality rates in this population.

METHODS

We used large-scale Japanese registry data for consecutive patients treated with Impella between February 2020 and December 2021 and compared on- and off-hours admissions. On- and off-hours were defined as the time between 8:00 and 19:59 on weekdays and the remaining time, respectively. The Cox proportional hazards model was used to calculate the adjusted hazard ratios (aHRs) for 30-day mortality.

RESULTS

Of the 1,207 STEMI patients, 566 (46.9%) patients (mean age: 69 years; 107 females) with STEMI-CS treated with Impella were included. Of these, 300 (53.0%) were admitted during on-hours. During the follow-up period (median 22 days [interquartile range 13-38 days]), 112 (42.1%) and 91 (30.3%) deaths were observed among patients admitted during off- and on-hours, respectively. Off-hours admissions were independently associated with a higher risk of 30-day mortality than on-hours admissions (aHR 1.60, 95% confidence interval: 1.07-2.39; p=0.02).

CONCLUSIONS

Our findings indicated the persistence of the "off-hours effect" in STEMI-CS patients treated with Impella. Healthcare professionals should continue to address the disparities in cardiovascular care by improving the timely provision of evidence-based treatments and enhancing off-hours medical services.

NETs: an extracellular DNA network structure with implication for cardiovascular disease and cancer

Cardiovascular (CV) diseases and tumors are best known for its high morbidity and mortality worldwide. There is a growing recognition of the association between CV diseases and tumorigenesis. In addition to CV damage caused by anti-tumor drugs and tumor-induced organ dysfunction, CV events themselves and their treatment may also have a role in promoting tumorigenesis. Therefore, Therefore, the diagnosis and treatment of the two kinds of diseases have entered the era of clinical convergence. Emerging evidence indicates significant biologic overlap between cancer and CV diseases, with the recognition of shared biologic mechanisms. Neutrophil extracellular traps (NETs) represent an immune mechanism of neutrophils promoting the development of tumors and their metastasis. It has been recently demonstrated that NETs exist in various stages of hypertension and heart failure, exacerbating disease progression. At present, most studies focus on the biological role of NETs in CV diseases and tumor respectively, and there are relatively few studies on the specific regulatory mechanisms and effects of NETs in cardiovascular diseases associated with tumors. In this narrative review, we summarize some recent basic and clinical findings on how NETs are involved in the pathogenesis of cardiovascular diseases associated with tumors. We also highlight that the development of treatments targeting NETs may be one of the effective ways to prevent and treat cardiovascular diseases associated with tumors.

The impact of ECPELLA on haemodynamics and global oxygen delivery: a comprehensive simulation of biventricular failure

BACKGROUND

ECPELLA, a combination of veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) and Impella, a percutaneous left ventricular (LV) assist device, has emerged as a novel therapeutic option in patients with severe cardiogenic shock (CS). Since multiple cardiovascular and pump factors influence the haemodynamic effects of ECPELLA, optimising ECPELLA management remains challenging. In this study, we conducted a comprehensive simulation study of ECPELLA haemodynamics. We also simulated global oxygen delivery (DO2) under ECPELLA in severe CS and acute respiratory failure as a first step to incorporate global DO2 into our developed cardiovascular simulation.

METHODS AND RESULTS

Both the systemic and pulmonary circulations were modelled using a 5-element resistance‒capacitance network. The four ventricles were represented by time-varying elastances with unidirectional valves. In the scenarios of severe LV dysfunction, biventricular dysfunction with normal pulmonary vascular resistance (PVR, 0.8 Wood units), and biventricular dysfunction with high PVR (6.0 Wood units), we compared the changes in haemodynamics, pressure-volume relationship (PV loop), and global DO2 under different VA-ECMO flows and Impella support levels.

RESULTS

In the simulation, ECPELLA improved total systemic flow with a minimising biventricular pressure-volume loop, indicating biventricular unloading in normal PVR conditions. Meanwhile, increased Impella support level in high PVR conditions rendered the LV-PV loop smaller and induced LV suction in ECPELLA support conditions. The general trend of global DO2 was followed by the changes in total systemic flow. The addition of veno-venous ECMO (VV-ECMO) augmented the global DO2 increment under ECPELLA total support conditions.

CONCLUSIONS

The optimal ECPELLA support increased total systemic flow and achieved both biventricular unloading. The VV-ECMO effectively improves global DO2 in total ECPELLA support conditions.

The HFSA Advanced Heart Failure and Transplant Cardiology Fellowship Consensus Conference

There is waning interest among cardiology trainees in pursuing an Advanced Heart Failure/Transplant Cardiology (AHFTC) fellowship as evidenced by fewer applicants in the National Resident Matching Program match to this specialty. This trend has generated considerable attention across the heart failure community. In response, the Heart Failure Society of America convened the AHFTC Fellowship Task Force with a charge to develop strategies to increase the value proposition of an AHFTC fellowship. Subsequently, the HFSA sponsored the AHFTC Fellowship Consensus Conference April 26-27, 2023. Before the conference, interviews of 44 expert stakeholders diverse across geography, site of practice (traditional academic medical center or other centers), specialty/area of expertise, sex, and stage of career were conducted virtually. Based on these interviews, potential solutions to address the declining interest in AHFTC fellowship were categorized into five themes: (1) alternative training pathways, (2) regulatory and compensation, (3) educational improvements, (4) exposure and marketing for pipeline development, and (5) quality of life and mental health. These themes provided structure to the deliberations of the AHFTC Fellowship Consensus Conference. The recommendations from the Consensus Conference were subsequently presented to the HFSA Board of Directors to inform strategic plans and interventions. The HFSA Board of Directors later reviewed and approved submission of this document. The purpose of this communication is to provide the HF community with an update summarizing the processes used and concepts that emerged from the work of the HFSA AHFTC Fellowship Task Force and Consensus Conference.

Superhydrophilic and Antifriction Thin Hydrogel Formed under Mild Conditions for Medical Bare Metal Guide Wires

Medical guide wires play a crucial role in the process of intravascular interventional therapy. However, it is essential for bare metal guide wires to possess both hydrophilic lubricity and coating durability, avoiding tissue damage caused by friction inside the blood vessel during the interventional procedure. Additionally, it is still a huge challenge for diverse metal materials to bind with polymer coatings easily. Herein, we present a hydrogel coating scheme and its preparation method for various wires under mild conditions for environmental protection purposes. The preparation process involves surface pretreatment, including low-temperature heating and silanization, followed by a two-step dip coating and ultraviolet polymerization. The whole process leads to the formation of an interpenetrating cross-linked hydrogel network from the substrate to the surface section. This study confirms the superhydrophilicity and lubricity of three metal wires with the designed coating, especially reducing the friction significantly by ≥ 95%. The thin coating (average thickness <6.2 μm) demonstrates strong adhesion with various substrates and exhibits resistance to 25 or even 125 cycles of friction, indicating excellent stability and preventing easy detachment. The finally prepared composite nickel-titanium (NiTi) guide wire with stainless steel (SS) and platinum-tungsten (Pt-W) coils (overall diameter of ∼0.36 mm) shows satisfactory performance with a friction of 0.183 N for 25 cycles, meeting the clinical requirements (average friction ≤0.2 N) for interventional operation. These findings highlight the potential of this study in advancing the development of medical devices, particularly in the field of intravascular interventional therapy.

Predictive value of the Ishii score for sarcopenia and the prognosis of older patients hospitalized with heart failure

AIMS

Although sarcopenia is common and associated with poor outcomes in patients with heart failure, its simple screening methods remain unclear. We aimed to investigate the predictive value of the Ishii score, which includes age, grip strength, and calf circumference, for sarcopenia and its prognostic predictability in patients with heart failure.

METHODS

This was a subanalysis of the FRAGILE-HF study. Receiver operating characteristic curves were used to evaluate the predictive value for sarcopenia. Patients were stratified into the high and low Ishii score groups based on the cutoff values of the Ishii score determined by the Youden index for sarcopenia, and the 1-year mortality rates were compared.

RESULTS

Of the 1262 study participants, 936 were evaluated with sarcopenia, and 184 (55 women, 129 men) were diagnosed with sarcopenia. The areas under the receiver operating characteristic curves for sarcopenia were 0.73 and 0.87 for women and men, respectively. The optimal cutoff values for predicting sarcopenia were 165 and 141 for women and men, respectively. Using these cutoff values, the sensitivity and specificity for sarcopenia were 70.9% and 68.5% for women and 88.4% and 69.7% for men, respectively. At 1 year, 151 (low Ishii score group, 98; high Ishii score group, 53) deaths were observed. Adjusted Cox proportional hazards analysis showed that the high Ishii score group was significantly associated with 1-year mortality.

CONCLUSION

Among older patients hospitalized for heart failure, the Ishii score is useful for predicting sarcopenia and 1-year mortality. Geriatr Gerontol Int 2024; 24: 147-153.

Mechanical circulatory support in cardiogenic shock

Cardiogenic shock is a complex and diverse pathological condition characterized by reduced myocardial contractility. The goal of treatment of cardiogenic shock is to improve abnormal hemodynamics and maintain adequate tissue perfusion in organs. If hypotension and insufficient tissue perfusion persist despite initial therapy, temporary mechanical circulatory support (t-MCS) should be initiated. This decade sees the beginning of a new era of cardiogenic shock management using t-MCS through the accumulated experience with use of intra-aortic balloon pump (IABP) and venoarterial extracorporeal membrane oxygenation (VA-ECMO), as well as new revolutionary devices or systems such as transvalvular axial flow pump (Impella) and a combination of VA-ECMO and Impella (ECPELLA) based on the knowledge of circulatory physiology. In this transitional period, we outline the approach to the management of cardiogenic shock by t-MCS. The management strategy involves carefully selecting one or a combination of the t-MCS devices, taking into account the characteristics of each device and the specific pathological condition. This selection is guided by monitoring of hemodynamics, classification of shock stage, risk stratification, and coordinated management by the multidisciplinary shock team.

Changes in Kidney Function After Diagnosis of Advanced Heart Failure

BACKGROUND

Kidney function and its association with outcomes in patients with advanced heart failure (HF) has not been well-defined.

METHODS AND RESULTS

We conducted a retrospective cohort study comprising all adult residents of Olmsted County, Minnesota, with HF who developed advanced HF from 2007 to 2017. Patients were grouped by estimated glomerular filtration rate (eGFR) at advanced HF diagnosis using the 2021 Chronic Kidney Disease Epidemiology Collaboration equation. A linear mixed effects model was fitted to assess the relationship between development of advanced HF and longitudinal eGFR trajectory. A total of 936 patients with advanced HF (mean age 77 years, 55% male, 93.7% White) were included. Twenty-two percent of these patients had an eGFR of <30 at advanced HF diagnosis, 22% had an eGFR of 30-44, 23% had an eGFR of 45-59, and 32% had an eGFR of ≥60 mL/min/1.73 m2. The eGFR decreased faster after advanced HF (7.6% vs 10.9% annual decline before vs after advanced HF), with greater decreases after advanced HF in those with diabetes and preserved ejection fraction. An eGFR of <30 mL/min/1.73 m2 was associated with worse survival after advanced HF compared with an eGFR of ≥60 mL/min/1.73 m2 (adjusted hazard ratio 1.30, 95% confidence interval 1.07-1.57).

CONCLUSIONS

eGFR deteriorated faster after patients developed advanced HF. An eGFR of <30 mL/min/1.73 m2 at advanced HF diagnosis was associated with higher mortality.

Regional Variation in the Clinical Practice and Prognosis in Patients With Heart Failure With Reduced Ejection Fraction in Japan - A Report From the Japanese Registry of Acute Decompensated Heart Failure (JROADHF)

BACKGROUND

The present study aimed to clarify the regional variations in clinical practice and the prognosis of patients with heart failure with reduced ejection fraction (HFrEF) in Japan using the Japanese Registry of Acute Decompensated Heart Failure (JROADHF).

METHODS AND RESULTS

We recruited data of hospitalized patients with HFrEF (n=4,329) from the JROADHF. The patients were divided into 6 groups based on the region of Japan where they were hospitalized: Hokkaido-Tohoku (n=504), Kanto (n=958), Chubu (n=779), Kinki (n=902), Chugoku-Shikoku (n=446), and Kyushu (n=740). We compared the patients' characteristics, including etiology of HF and prognosis after discharge. The age of the patients was lowest in the Kanto and Kinki regions. In contrast, there were no differences in the prevalence of comorbidities, levels of B-type natriuretic peptide, or left ventricular EF among the 6 groups. Post-discharge cardiospecific prognosis, specifically, the composite of cardiac death or HF hospitalization, cardiac death, and HF hospitalization, was comparable among the 6 regions.

CONCLUSIONS

There were no differences in cardiospecific prognosis in patients with HFrEF among the 6 regions in Japan.

Catheter ablation of malignant atrial fibrillation as palliative therapy for end-stage heart failure: A case report

Recent randomized controlled trials have demonstrated the superiority of atrial fibrillation (AF) ablation to medical therapy in reducing mortality and morbidity in patients with heart failure (HF) with reduced ejection fraction, but patients with end-stage HF were often excluded. A 64-year-old man diagnosed with dilated cardiomyopathy was hospitalized due to worsening HF and incident AF. An echocardiographic examination revealed the left ventricular end-diastolic diameter of 90 mm and left ventricular ejection fraction of 12 %. Cardioversion was performed to restore sinus rhythm, but intermittent transitions to AF caused the patient hemodynamic instability and mental distress. We carefully performed AF ablation, and sinus rhythm was maintained thereafter. After cardiac rehabilitation, he was successfully discharged home. However, he was re-hospitalized due to worsening HF 6 months post-AF ablation, and he eventually passed away. While AF ablation cannot prevent the progression of inherent cardiomyopathy, it can improve the quality of life even for patients with end-stage HF. However, the effect was temporary and considered a palliative treatment. This case highlights the potential benefits and limitations of AF ablation in end-stage HF patients and the need for further research to establish the optimal treatment for this population.

Learning objective

Atrial fibrillation ablation can restore sinus rhythm and improve the quality of life even in some patients with end-stage heart failure (HF). However, it cannot prevent the progression of inherent cardiomyopathy. In the era of interventional HF therapy, catheter ablation may have a palliative role in reducing patient distress caused by life-threatening arrhythmias in patients with end-stage HF.

Derivation and validation of a machine learning-based risk prediction model in patients with acute heart failure

BACKGROUND

Risk stratification is important in patients with acute heart failure (AHF), and a simple risk score that accurately predicts mortality is needed. The aim of this study is to develop a user-friendly risk-prediction model using a machine-learning method.

METHODS

A machine-learning-based risk model using least absolute shrinkage and selection operator (LASSO) regression was developed by identifying predictors of in-hospital mortality in the derivation cohort (REALITY-AHF), and its performance was externally validated in the validation cohort (NARA-HF) and compared with two pre-existing risk models: the Get With The Guidelines risk score incorporating brain natriuretic peptide and hypochloremia (GWTG-BNP-Cl-RS) and the acute decompensated heart failure national registry risk (ADHERE).

RESULTS

In-hospital deaths in the derivation and validation cohorts were 76 (5.1 %) and 61 (4.9 %), respectively. The risk score comprised four variables (systolic blood pressure, blood urea nitrogen, serum chloride, and C-reactive protein) and was developed according to the results of the LASSO regression weighting the coefficient for selected variables using a logistic regression model (4 V-RS). Even though 4 V-RS comprised fewer variables, in the validation cohort, it showed a higher area under the receiver operating characteristic curve (AUC) than the ADHERE risk model (AUC, 0.783 vs. 0.740; p = 0.059) and a significant improvement in net reclassification (0.359; 95 % CI, 0.10-0.67; p = 0.006). 4 V-RS performed similarly to GWTG-BNP-Cl-RS in terms of discrimination (AUC, 0.783 vs. 0.759; p = 0.426) and net reclassification (0.176; 95 % CI, -0.08-0.43; p = 0.178).

CONCLUSIONS

The 4 V-RS model comprising only four readily available data points at the time of admission performed similarly to the more complex pre-existing risk model in patients with AHF.

The Spectrum of Heart Failure Management

Heart failure, a complex cardiovascular condition, is a huge burden on patients, caregivers, and healthcare systems and it is prevalent worldwide. Heart failure is caused by a wide variety of underlying conditions that include both cardiac and non-cardiac pathologies. Identifying the underlying cause enables us to apply etiology-based interventions. The spectrum of heart failure management ranges from classification to transplantation. In addition to its classification and monitoring, this article reviews various management strategies, including both conventional methods and the latest innovations. These include lifestyle interventions, pharmacotherapy, device therapy, transplantation, and regenerative medicine.

Larissa Heart Failure Risk Score and Mode of Death in Acute Heart Failure: Insights from REALITY-AHF

Patients with heart failure (HF) patients may die either suddenly (sudden cardiac death/SCD) or progressively from pump failure. The heightened risk of SCD in patients with HF may expedite important decisions about medications or devices. We used the Larissa Heart Failure Risk Score (LHFRS), a validated risk model for all-cause mortality and HF rehospitalization, to investigate the mode of death in 1363 patients enrolled in the Registry Focused on Very Early Presentation and Treatment in Emergency Department of Acute Heart Failure (REALITY-AHF). Cumulative incidence curves were generated using a Fine-Gray competing risk regression, with deaths that were not due to the cause of death of interest as a competing risk. Likewise, the Fine-Gray competing risk regression analysis was used to evaluate the association between each variable and the incidence of each cause of death. The AHEAD score, a well-validated HF risk score ranging from 0 to 5 (atrial fibrillation, anemia, age, renal dysfunction, and diabetes mellitus), was used for the risk adjustment. Patients with LHFRS 2-4 exhibited a significantly higher risk of SCD (HR hazard ratio adjusted for AHEAD score 3.15, 95% confidence interval (CI) (1.30-7.65), p = 0.011) and HF death (adjusted HR for AHEAD score 1.48, 95% CI (1.04-2.09), p = 0.03), compared to those with LHFRS 0,1. Regarding cardiovascular death, patients with higher LHFRS had significantly increased risk compared to those with lower LHFRS (HR 1.44 adjusted for AHEAD score, 95% CI (1.09-1.91), p = 0.01). Lastly, patients with higher LHFRS exhibited a similar risk of non-cardiovascular death compared to those with lower LHFRS (HR 1.44 adjusted for AHEAD score, 95% CI (0.95-2.19), p = 0.087). In conclusion, LHFRS was associated independently with the mode of death in a prospective cohort of hospitalized HF patients.

In-Hospital Outcomes of Heart Failure Patients with Valvular Heart Disease: Insights from Real-World Claims Data

Purpose

Heart failure (HF) is a serious public health burden that is rapidly increasing in the aging population. Valvular heart disease (VHD) is a known etiology of heart failure (HF); however, the impact of VHD on outcomes of patients with HF has not been well-studied in Japan. This study aimed to determine the rates of VHD in Japanese patients admitted for HF and explore associations of VHD with in-hospital outcomes through a claim-based analysis.

Patients and methods

We analyzed claims data from 86,763 HF hospitalizations (January 2017 through December 2019) from the Medical Data Vision database. Common etiologies of HF were examined, then hospitalizations were categorized into those with VHD and those without. Covariate-adjusted models were used to explore the association of VHD with in-hospital mortality, length of stay, and medical cost.

Results

Of 86,763 hospitalizations for HF, 13,183 had VHD and 73,580 did not. VHD was the second most frequent etiology of HF (15.2%). The most frequent type of VHD was mitral regurgitation (36.4% of all hospitalizations with VHD), followed by aortic stenosis (33.7%) and aortic regurgitation (16.4%). There was no significant difference in in-hospital mortality between hospitalizations with VHD vs those without (9.0% vs 8.9%; odds ratio [95% CI]: 1.01 [0.95-1.08]; p=0.723). Hospitalizations with VHD were associated with significantly longer length of stay (26.1 vs 24.8 days; incident rate ratio [95% CI]: 1.05 [1.03-1.07]; p<0.001) and higher medical costs (1536 vs 1195 thousand yen; rate ratio [95% CI]: 1.29 [1.25-1.32]; p<0.001).

Conclusion

VHD was a frequent etiology of HF that was associated with significant medical resource use. Future studies are needed to investigate whether timely VHD treatment could reduce HF progression and its associated healthcare resource utilization.

Persistent Hypochloremia Is Associated with Adverse Prognosis in Patients Repeatedly Hospitalized for Heart Failure

BACKGROUND

Hypochloremia reflects neuro-hormonal activation in patients with heart failure (HF). However, the prognostic impact of persistent hypochloremia in those patients remains unclear.

METHODS

We collected the data of patients who were hospitalized for HF at least twice between 2010 and 2021 (n = 348). Dialysis patients (n = 26) were excluded. The patients were divided into four groups based on the absence/presence of hypochloremia (<98 mmol/L) at discharge from their first and second hospitalizations: Group A (patients without hypochloremia at their first and second hospitalizations, n = 243); Group B (those with hypochloremia at their first hospitalization and without hypochloremia at their second hospitalization, n = 29); Group C (those without hypochloremia at their first hospitalization and with hypochloremia at their second hospitalization, n = 34); and Group D (those with hypochloremia at their first and second hospitalizations, n = 16).

RESULTS

a Kaplan-Meier analysis revealed that all-cause mortality and cardiac mortality were the highest in Group D compared to the other groups. A multivariable Cox proportional hazard analysis revealed that persistent hypochloremia was independently associated with both all-cause death (hazard ratio 3.490, p < 0.001) and cardiac death (hazard ratio 3.919, p < 0.001).

CONCLUSIONS

In patients with HF, prolonged hypochloremia over two hospitalizations is associated with an adverse prognosis.