Association of heart failure and its comorbidities with loss of life expectancy

Urate-lowering therapy in patients with hyperuricemia and heart failure: A retrospective cohort study using the UK Clinical Practice Research Datalink

BACKGROUND

Elevated serum uric acid (sUA) is associated with heart failure (HF).

HYPOTHESIS

Urate-lowering therapy (ULT) in HF is associated with lower risk of HF hospitalization (hHF) and mortality.

METHODS

Data on patients with HF and gout or hyperuricemia in the Clinical Practice Research Datalink database linked to the Hospital Episode Statistics and the Office for National Statistics in the United Kingdom were analyzed. Risks of hHF and all-cause mortality or cardiovascular-related mortality by ULT exposure (ULT initiated within ≤6 months of gout or hyperuricemia diagnosis) were analyzed in a propensity score-matched cohort using adjusted Cox proportional hazards regression models.

RESULTS

Of 2174 propensity score-matched pairs, patients were predominantly male, aged >70 years, with mean ± standard deviation sUA 9.3 ± 1.8 (ULT-exposed) and 9.4 ± 1.9 mg/dL (ULT-unexposed). At 5 years, ULT-exposed patients had a 43% lower risk of hHF or all-cause mortality (adjusted hazard ratio [HR]: 0.57; 95% confidence interval [CI]: 0.51-0.65) and a 19% lower risk of hHF or cardiovascular-related mortality (adjusted HR: 0.81; 95% CI: 0.71-0.92) versus no ULT exposure.

CONCLUSION

ULT was associated with reduced risk of adverse clinical outcomes in patients with HF and gout or hyperuricemia over 5 years.

A follow-up program in patients after hospitalization for heart failure: long-term health related quality of life and associated factors

Background

The well-being of individuals with chronic heart failure (HF) is significantly influenced by their health-related quality of life (HRQoL), which serves as a crucial measure indicating how HF affects their daily activities. Monitoring programs aimed at reducing the number of hospitalizations and improving functional conditions are currently being offered to patients with chronic HF.

The objective

To examine the long-term health-related quality of life changes in patients with heart failure enrolled in a follow-up program after hospitalization and to evaluate the factors associated with quality of life of patients with heart failure.

Methods

This prospective study was conducted between 2019 and 2020 at the Department of Cardiology of Lithuanian University of Health Sciences. Patients were divided into two groups: Group I consisted of 71 patients (60.2%) where the Minnesota Living with Heart Failure Questionnaire (MLHFQ) score decreased by more than 10 points at 4th visit if compared to the 1st one; and Group II consisted of 47 patients (39.8%) where the MLHFQ score remained unchanged or increased by less than 10 points at the 4th visit if compared to the 1st visit.

Results

Statistically significant differences were observed between groups. In Group II, a history of myocardial infarction was more frequent (p = 0.038), and there was a significantly higher occurrence of significant coronary artery disease (p = 0.006). Laboratory parameters indicating liver function exhibited statistically significant deterioration among patients in Group II. Specifically, AST (p = 0.050), ALT (p = 0.010), and GGT (p = 0.031) levels significantly increased. Upon analyzing the echocardiographic data, a statistically significant difference was found between the groups in relation to the left ventricular ejection fraction (LVEF) (p = 0.043) and TAPSE (p = 0.031). An analysis of changes in dimensions related to QoL was conducted during the long-term follow-up program, which revealed statistically significant differences between groups in overall changes based on the MLHFQ (p < 0.001). This difference was also observed across all dimensions, including the emotional, physical, and social aspects (p < 0.001).

Conclusion

Patients who had a higher LVEF at baseline, as well as those with an etiology of ischemic heart disease (IHD), better liver function, and fewer manifestations of edema, demonstrated a statistically significant improvement in their quality of life throughout the course of the patient monitoring program.

Harmony in Chaos: Deciphering the Influence of Ischemic Cardiomyopathy and Non-Cardiac Comorbidities on Holter ECG Parameters in Chronic Heart Failure Patients: A Pilot Study

Background and Objective: In the landscape of heart failure, non-cardiac comorbidities represent a formidable challenge, imparting adverse prognostic implications. Holter ECG monitoring assumes a supplementary role in delineating myocardial susceptibility and autonomic nervous system dynamics. This study aims to explore the potential correlation between Holter ECG parameters and comorbidities in individuals with ischemic cardiomyopathy experiencing heart failure (HF), with a particular focus on the primary utility of these parameters as prognostic indicators. Materials and Methods: In this prospective inquiry, a cohort of 60 individuals diagnosed with heart failure underwent stratification into subgroups based on the presence of comorbidities, including diabetes, chronic kidney disease, obesity, or hyperuricemia. Upon admission, a thorough evaluation of all participants encompassed echocardiography, laboratory panel analysis, and 24 h Holter monitoring. Results: Significant associations were uncovered between diabetes and unconventional physiological indicators, specifically the Triangular index (p = 0.035) and deceleration capacity (p = 0.002). Pertaining to creatinine clearance, notable correlations surfaced with RMSSD (p = 0.026), PNN50 (p = 0.013), and high-frequency power (p = 0.026). An examination of uric acid levels and distinctive Holter ECG patterns unveiled statistical significance, particularly regarding the deceleration capacity (p = 0.045). Nevertheless, in the evaluation of the Body Mass Index, no statistically significant findings emerged concerning Holter ECG parameters. Conclusions: The identified statistical correlations between non-cardiac comorbidities and patterns elucidated in Holter ECG recordings underscore the heightened diagnostic utility of this investigative modality in the comprehensive evaluation of individuals grappling with HF. Furthermore, we underscore the critical importance of the thorough analysis of Holter ECG recordings, particularly with regard to subtle and emerging parameters that may be overlooked or insufficiently acknowledged.

Analysis of the survival time of patients with heart failure with reduced ejection fraction: a Bayesian approach via a competing risk parametric model

PURPOSE

Heart failure (HF) is a widespread ailment and is a primary contributor to hospital admissions. The focus of this study was to identify factors affecting the extended-term survival of patients with HF, anticipate patient outcomes through cause-of-death analysis, and identify risk elements for preventive measures.

METHODS

A total of 435 HF patients were enrolled from the medical records of the Rajaie Cardiovascular Medical and Research Center, covering data collected between March and August 2018. After a five-year follow-up (July 2023), patient outcomes were assessed based on the cause of death. The survival analysis was performed with the AFT method with the Bayesian approach in the presence of competing risks.

RESULTS

Based on the results of the best model for HF-related mortality, age [time ratio = 0.98, confidence interval 95%: 0.96-0.99] and ADHF [TR = 0.11, 95% (CI): 0.01-0.44] were associated with a lower survival time. Chest pain in HF-related mortality [TR = 0.41, 95% (CI): 0.10-0.96] and in non-HF-related mortality [TR = 0.38, 95% (CI): 0.12-0.86] was associated with a lower survival time. The next significant variable in HF-related mortality was hyperlipidemia (yes): [TR = 0.34, 95% (CI): 0.13-0.64], and in non-HF-related mortality hyperlipidemia (yes): [TR = 0.60, 95% (CI): 0.37-0.90]. CAD [TR = 0.65, 95% (CI): 0.38-0.98], CKD [TR = 0.52, 95% (CI): 0.28-0.87], and AF [TR = 0.53, 95% (CI): 0.32-0.81] were other variables that were directly related to the reduction in survival time of patients with non-HF-related mortality.

CONCLUSION

The study identified distinct predictive factors for overall survival among patients with HF-related mortality or non-HF-related mortality. This differentiated approach based on the cause of death contributes to the estimation of patient survival time and provides valuable insights for clinical decision-making.

Scoping Review of Measures of Comorbidities in Heart Failure

BACKGROUND

Comorbidities are risk factors for poor clinical outcomes in patients with heart failure. However, no consensus has been reached on how to assess comorbidities related to clinical outcomes in patients with heart failure.

OBJECTIVE

The aims of this study were to review (1) how comorbidities have been assessed, (2) what chronic conditions have been identified as comorbidities and (3) the rationale for choosing the comorbidity instruments and/or specific comorbidities when exploring clinical outcomes in patients with heart failure.

METHODS

The clinical outcomes of interest were mortality, hospitalization, quality of life, and self-care. Three electronic databases and reference list searches were used in the search.

RESULTS

In this review, we included 39 articles using 3 different ways to assess comorbidities in the relationship with clinical outcomes: using an instrument (ie, Charlson Comorbidity Index), disease count, and including individual comorbidities. A total of 90 comorbidities were investigated in the 39 articles; however, definitions and labels for the diseases were inconsistent across the studies. More than half of the studies (n = 22) did not provide a rationale for selecting the comorbidity instruments and/or all of the specific comorbidities. Some of the rationale for choosing the instruments and/or specific comorbidities was inappropriate.

CONCLUSIONS

We found several issues related to measuring comorbidities when examining clinical outcomes in patients with heart failure. Researchers need to consider these methodological issues when measuring comorbidities in patients with heart failure. Further efforts are needed to develop guidelines on how to choose proper measures for comorbidities.

Self-care behaviour and associated factors among heart failure patients in Ethiopia: a systematic review and meta-analysis

OBJECTIVE

This study aimed to estimate the pooled level of self-care behaviour among heart failure patients in Ethiopia.

DESIGN

Systematic review and meta-analysis.

DATA SOURCE

PubMed/MEDLINE, HINARI, Web of Sciences, Scopus, Google Scholar, Science Direct, African journals online and University repositories were searched from 1 January 2000 to 1 November 2023.

ELIGIBILITY CRITERIA

We include studies that examined self-care behaviour among heart failure patients, studies that report factors associated with self-care behaviour and observational studies (cross-sectional, case-control and cohort) with full text available.

DATA EXTRACTION AND SYNTHESIS

The data were extracted with Microsoft Excel and analysed by using STATA V.11 software. The weighted inverse variance random-effects model at 95% CI was used to estimate the pooled level of self-care behaviour and its associated factors among heart failure patients. Tests of heterogeneity, test of publication bias and subgroup analyses were also employed.

RESULTS

Thirteen cross-sectional studies with 4321 study participants were included; and the pooled level of good self-care behaviour among heart failure patients in Ethiopia was found to be 38.3% (95% CI 31.46 to 45.13). Only 68.8% of heart failure patients were knowledgeable about heart failure. Knowledge about heart failure (Adjusted Odds Ratio (AOR)=3.39; 95% CI 2.42 to 4.74) and absence of comorbidity (AOR=2.69; 95% CI 1.35 to 5.37) were significantly associated with good self-care behaviour among heart failure patients in Ethiopia.

CONCLUSION

The majority of heart failure patients in Ethiopia did not adhere to the recommended self-care behaviours. Nearly one-third of heart failure patients were not knowledgeable about heart failure. Knowledge about heart failure and the absence of comorbidities were significantly associated with good self-care behaviour. Therefore, efforts should be devoted to increasing knowledge and preventing comorbidities among heart failure patients.

PROSPERO REGISTRATION NUMBER

CRD42023394373.

Resource utilisation and outcomes of people with heart failure in England: a descriptive analysis of linked primary and secondary care data - the PULSE study

BACKGROUND

Heart failure (HF) is associated with high levels of resource use and mortality, but prior UK studies have not compared outcomes by HF subtype (HF with reduced ejection fraction (HFrEF) and HF with preserved ejection fraction (HFpEF)) in large patient populations. This study investigated healthcare resource utilisation and mortality in patients with HF in England, overall and by HF subtype.

METHODS

This non-interventional cohort study linked data from the Clinical Practice Research Datalink database to Hospital Episode Statistics inpatient and UK Office for National Statistics mortality data. Patients with a recorded HF diagnosis (new (incident) or existing (prevalent)) based on clinical codes or measures of ejection fraction between 2015 and 2019 were included.

RESULTS

Of 383 896 patients identified with HF, 100 224 patients (26%) had a recorded subtype: 68 780 patients with HFrEF (69%) and 31 444 patients (31%) with HFpEF. In total, 918 553 person-years (PY) were included (median follow-up: 2.1 years): 625 619 PY (68%) for unknown HF subtype, 204 862 PY (22%) for HFrEF and 88 017 PY (10%) for HFpEF. Overall, 11% of patients experienced ≥1 HF hospitalisation. After age and sex adjustment, hospitalisations for HF (HHF; including recurrent hospitalisations) and HF-related general practitioner consultations occurred at rates of approximately 80/1000 and 124/1000 PY, respectively, and were highest for patients with HFrEF and unknown subtype. Overall, all-cause and cardiovascular mortality rates were 132/1000 and 49/1000 PY, respectively. Patients with unknown subtype had the highest 1-year and 5-year mortality (20% and 48%), followed by HFrEF (8% and 35%) and HFpEF (6% and 25%).

CONCLUSIONS

HF is associated with high levels of healthcare resource use, mortality, HHF and comorbidities. Ensuring that patients receive early and appropriate guideline-directed therapies to manage HF and associated comorbidities is likely to improve patient care and reduce the burden of HF on the English healthcare system.

Relationship between comorbidity and health outcomes in patients with heart failure: a systematic review and meta-analysis

BACKGROUND

The prevalence of heart failure (HF) is expected to rise due to increased survivorship and life expectancy of patients with acute heart conditions. Patients with HF and other multiple comorbid conditions are likely to have poor health outcomes. This study aimed to assimilate the current body of knowledge and to provide the pooled effect of HF patients' comorbid conditions on health outcomes.

METHODS

A systematic search was performed using MEDLINE, EMBASE and CINAHL databases. Observational studies evaluating the relationship between comorbid conditions and the health outcomes of HF were included. The pooled effect sizes of comorbidity on the identified health outcomes were calculated using a random effects model, and the heterogeneity was evaluated using I2 statistics.

RESULTS

A total of 42 studies were included in this review, and a meta-analysis was performed using the results of 39 studies. In the pooled analysis, the presence of a comorbid condition showed a significant pooled effect size in relation to the prognostic health outcomes: all-cause mortality (HR 1.31; 95% CI 1.18, 1.45), all-cause readmission (HR 1.16; 95% CI 1.09, 1.23), HF-related readmission (HR 1.13; 95% CI 1.05, 1.23), and non-HF-related readmission (HR 1.17; 95% CI 1.07, 1.27). Also, comorbidity was significantly associated with health-related quality of life and self-care confidence. Furthermore, we identified a total of 32 comorbid conditions from included studies. From these, 16 individual conditions were included in the meta-analyses, and we identified 10 comorbid conditions to have negative effects on overall prognostic outcomes: DM (HR 1.16, 95% CI 1.11, 1.22), COPD (HR 1.31, 95% CI 1.23, 1.39), CKD (HR 1.18, 95% CI 1.14, 1.23, stroke (HR 1.25, 95% CI 1.17, 1.31), IHD (HR 1.17, 95% CI 1.11, 1.23), anemia (HR 1.42, 95% CI 1.14, 1.78), cancer (HR 1.17, 95% CI 1.04, 1.32), atrial fibrillation (HR 1.25, 95% CI 1.01, 1.54), dementia (HR 1.19, 95% CI 1.03, 1.36) and depression (HR 1.17, 95% CI 1.04, 1.31).

CONCLUSIONS

Comorbid conditions have significantly negative pooled effects on HF patient health outcomes, especially in regard to the prognostic health outcomes. Clinicians should carefully identify and manage these conditions when implementing HF interventions to improve prognostic outcomes.

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.

Device Interventions for Heart Failure

Despite remarkable advances in drug therapy for heart failure (HF), the residual HF-related morbidity, mortality, and hospitalizations remain substantial across all HF phenotypes, and significant proportions of patients with HF remain symptomatic despite optimal drug therapy. Driven by these unmet clinical needs, the exponential growth of transcatheter interventions, and a recent shift in the regulatory landscape of device-based therapies, novel device-based interventions have emerged as a potential therapy for various phenotypes of HF. Device-based interventions can overcome some of the limitations of drug therapy (eg, intolerance, nonadherence, inconsistent delivery, and recurrent and long-term cost) and can target some HF-related pathophysiologic pathways more effectively than drug therapy. This paper reviews the current evolving landscape of device-based interventions in HF and highlights critical points related to implementation of these therapies in the current workflow of HF management.

Acute Cardiorenal Syndrome: An Update

The complex dynamic pathophysiological interplay between the heart and kidney causes a vicious cycle of worsening renal and/or cardiovascular function. Acute decompensated heart failure causing worsening renal function defines Type 1 cardiorenal syndrome (CRS). Altered hemodynamics coupled with a multitude of nonhemodynamic factors namely pathological activation of the renin angiotensin aldosterone system and systemic inflammatory pathways mechanistically incite CRS type 1. A multipronged diagnostic approach utilizing laboratory markers, noninvasive and/or invasive modalities must be implemented to enable timely initiation of effective treatment strategies. In this review, we discuss the pathophysiology, diagnosis, and emerging treatment options for CRS type 1.

Chronic Kidney Disease as a Comorbidity in Heart Failure

Heart failure (HF) is one of the greatest problems in healthcare and it often coexists with declining renal function. The pathophysiology between the heart and the kidneys is bidirectional. Common mechanisms leading to the dysfunction of these organs result in a vicious cycle of cardiorenal deterioration. It is also associated with difficulties in the treatment of aggravating HF and chronic kidney disease (CKD) and, as a consequence, recurrent hospitalizations and death. As the worsening of renal function has an undeniably negative impact on the outcomes in patients with HF, searching for new treatment strategies and identification of biomarkers is necessary. This review is focused on the pathomechanisms in chronic kidney disease in patients with HF and therapeutic strategies for co-existing CKD and HF.

Temporal trends in the incidence of malignancy in heart failure: a nationwide Danish study

AIMS

Cancer and heart failure (HF) share risk factors, pathophysiological mechanisms, and possibly genetics. Improved HF survival may increase the risk of cancer due to a competing risk. Whether the incidence of cancer has increased over time in patients with HF as survival has improved is unclear. Therefore, temporal trends of new onset cancer in HF patients between 1997 and 2016 were investigated.

METHODS AND RESULTS

Using Danish nationwide registers, 103 711 individuals alive, free of cancer, and aged 30-80 years 1 year after HF diagnosis (index date) were included between 1 January 1997 and 31 December 2016. A five-year incidence rate of cancer for each year after index date was calculated. The median age and proportion of women at the index date decreased with advancing calendar time [1997-2001: 70.3 interquartile range (Q1-Q3 62.5-75.7), 60.9% men; 2012-16: 67.6 (59.2-73.8), 67.5% men]. The five-year incidence rate of cancer was 20.9 and 20.2 per 1,000 person-years in 1997 and 2016, respectively. In a multivariable Cox regression model, the hazard rates between index years 1997 (reference) and 2016 were not significantly different [hazard ratio 1.09 (0.97-1.23)]. The five-year absolute risk of cancer did not change with advancing calendar year, going from 9.0% (1997-2001) to 9.0% (2012-16). Five-year cumulative incidence of survival for HF patients increased with advancing calendar year, going from 55.9% (1997-2001) to 74.3% (2012-2016).

CONCLUSION

Although cancer rates during 1997-2016 have remained stable within 1-6 years after the HF diagnosis, long-term survival following a HF diagnosis has increased significantly.

Comorbidities complicating heart failure: changes over the last 15 years

AIMS

Management of comorbidities represents a critical step in optimal treatment of heart failure (HF) patients. However, minimal attention has been paid whether comorbidity burden and their prognostic value changes over time. Therefore, we examined the association between comorbidities and clinical outcomes in HF patients between 2002 and 2017.

METHODS AND RESULTS

The 2002-HF cohort consisted of patients from The Coordinating Study Evaluating Outcomes of Advising and Counseling in Heart Failure (COACH) trial (n = 1,032). The 2017-HF cohort were outpatient HF patients enrolled after hospitalization for HF in a tertiary referral academic hospital (n = 382). Kaplan meier and cox regression analyses were used to assess the association of comorbidities with HF hospitalization and all-cause mortality. Patients from the 2017-cohort were more likely to be classified as HF with preserved ejection fraction (24 vs 15%, p < 0.001), compared to patients from the 2002-cohort. Comorbidity burden was comparable between both cohorts (mean of 3.9 comorbidities per patient) and substantially increased with age. Higher comorbidity burden was significantly associated with a comparable increased risk for HF hospitalization and all-cause mortality (HR 1.12 [1.02-1.22] and HR 1.18 [1.05-1.32]), in the 2002- and 2017-cohort respectively. When assessing individual comorbidities, obesity yielded a statistically higher prognostic effect on outcome in the 2017-cohort compared to the 2002-HF cohort (p for interaction 0.026).

CONCLUSION

Despite major advances in HF treatment over the past decades, comorbidity burden remains high in HF and influences outcome to a large extent. Obesity emerges as a prominent comorbidity, and efforts should be made for prevention and treatment. Created with BioRender.com.

Heterogeneous trends of premature mortalities in Japan: joinpoint regression analysis of years of life lost from 2011 to 2019

Purpose

To assess long-term premature mortalities in Japan for providing evidence of strategies for sustainable development in population health.

Methods

Descriptive study for observing the trends of premature mortalities due to 10 major causes and all-cause in Japan was conducted using governmental statistics taken between 2011 and 2019. Years of life lost (YLL) was calculated for each cause, and the trends of these were examined by joinpoint regression analysis.

Results

The means of YLL for all-cause through 2011 to 2019 were 8,121,565.1 in males and 6,743,198.4 in females. For each cause, the trends of age-standardized YLL were downward except for malignant neoplasm of pancreas and heart failure in males, and malignant neoplasm of pancreas, malignant neoplasm of breast, and age-related physical debility in females. One significant joinpoint for heart failure was found in males, and one significant joinpoint for each of malignant neoplasm of pancreas and age-related physical debility were found in females.

Conclusions

Premature mortalities due to malignant neoplasm of pancreas in both sexes, heart failure in males and malignant neoplasm of breast in females were issues to be prioritized for promoting population health in Japan.

Why Do so Few People with Heart Failure Receive Cardiac Rehabilitation?

Many people with heart failure do not receive cardiac rehabilitation despite a strong evidence base attesting to its effectiveness, and national and international guideline recommendations. A more holistic approach to heart failure rehabilitation is proposed as an alternative to the predominant focus on exercise, emphasising the important role of education and psychosocial support, and acknowledging that this depends on patient need, choice and preference. An individualised, needs-led approach, exploiting the latest digital technologies when appropriate, may help fill existing gaps, improve access, uptake and completion, and ensure optimal health and wellbeing for people with heart failure and their families. Exercise, education, lifestyle change and psychosocial support should, as core elements, unless contraindicated due to medical reasons, be offered routinely to people with heart failure, but tailored to individual circumstances, such as with regard to age and frailty, and possibly for recipients of cardiac implantable electronic devices or left ventricular assist devices.

Diabetes mellitus and the causes of hospitalisation in people with heart failure

INTRODUCTION

Diabetes mellitus (DM) is associated with increased risk of hospitalisation in people with heart failure and reduced ejection fraction (HFrEF). However, little is known about the causes of these events.

METHODS

Prospective cohort study of 711 people with stable HFrEF. Hospitalisations were categorised by cause as: decompensated heart failure; other cardiovascular; infection or other non-cardiovascular. Rates of hospitalisation and burden of hospitalisation (percentage of follow-up time in hospital) were compared in people with and without DM.

RESULTS

After a mean follow-up of 4.0 years, 1568 hospitalisations occurred in the entire cohort. DM (present in 32% [n=224]) was associated with a higher rate (mean 1.07 vs 0.78 per 100 patient-years; p<0.001) and burden (3.4 vs 2.2% of follow-up time; p<0.001) of hospitalisation. Cause-specific analyses revealed increased rate and burden of hospitalisation due to decompensated heart failure, other cardiovascular causes and infection in people with DM, whereas other non-cardiovascular causes were comparable. Infection made the largest contribution to the burden of hospitalisation in people with and without DM.

CONCLUSIONS

In people with HFrEF, DM is associated with a greater burden of hospitalisation due to decompensated heart failure, other cardiovascular events and infection, with infection making the largest contribution.

Iron Deficiency in Heart Failure: Mechanisms and Pathophysiology

Iron is an essential micronutrient for a myriad of physiological processes in the body beyond erythropoiesis. Iron deficiency (ID) is a common comorbidity in patients with heart failure (HF), with a prevalence reaching up to 59% even in non-anaemic patients. ID impairs exercise capacity, reduces the quality of life, increases hospitalisation rate and mortality risk regardless of anaemia. Intravenously correcting ID has emerged as a promising treatment in HF as it has been shown to alleviate symptoms, improve quality of life and exercise capacity and reduce hospitalisations. However, the pathophysiology of ID in HF remains poorly characterised. Recognition of ID in HF triggered more research with the aim to explain how correcting ID improves HF status as well as the underlying causes of ID in the first place. In the past few years, significant progress has been made in understanding iron homeostasis by characterising the role of the iron-regulating hormone hepcidin, the effects of ID on skeletal and cardiac myocytes, kidneys and the immune system. In this review, we summarise the current knowledge and recent advances in the pathophysiology of ID in heart failure, the deleterious systemic and cellular consequences of ID.

Human immunodeficiency virus infection and risks of morbidity and death in adults with incident heart failure

AIMS

Human immunodeficiency virus (HIV) increases the risk of heart failure (HF), but whether it influences subsequent morbidity and mortality remains unclear.

METHODS AND RESULTS

We investigated the risks of hospitalization for HF, HF-related emergency department (ED) visits, and all-cause death in an observational cohort of incident HF patients with and without HIV using data from three large US integrated healthcare delivery systems. We estimated incidence rates and adjusted hazard ratios (aHRs) by HIV status at the time of HF diagnosis for subsequent outcomes. We identified 448 persons living with HIV (PLWH) and 3429 without HIV who developed HF from a frequency-matched source cohort of 38 868 PLWH and 386 586 without HIV. Mean age was 59.5 ± 11.3 years with 9.8% women and 31.8% Black, 13.1% Hispanic, and 2.2% Asian/Pacific Islander. Compared with persons without HIV, PLWH had similar adjusted rates of HF hospitalization [aHR 1.01, 95% confidence interval (CI): 0.81-1.26] and of HF-related ED visits [aHR 1.22 (95% CI: 0.99-1.50)], but higher adjusted rates of all-cause death [aHR 1.31 (95% CI: 1.08-1.58)]. Adjusted rates of HF-related morbidity and all-cause death were directionally consistent across a wide range of CD4 counts but most pronounced in the subset with a baseline CD4 count <200 or 200-499 cells/μL.

CONCLUSION

In a large, diverse cohort of adults with incident HF receiving care within integrated healthcare delivery systems, PLWH were at an independently higher risk of all-cause death but not HF hospitalizations or HF-related ED visits. Future studies investigating modifiable HIV-specific risk factors may facilitate more personalized care to optimize outcomes for PLWH and HF.

Endocrine Challenges in Patients with Continuous-Flow Left Ventricular Assist Devices

Heart failure (HF) remains a leading cause of morbidity, hospitalization, and mortality worldwide. Advancement of mechanical circulatory support technology has led to the use of continuous-flow left ventricular assist devices (LVADs), reducing hospitalizations, and improving quality of life and outcomes in advanced HF. Recent studies have highlighted how metabolic and endocrine dysfunction may be a consequence of, or associated with, HF, and may represent a novel (still neglected) therapeutic target in the treatment of HF. On the other hand, it is not clear whether LVAD support, may impact the outcome by also improving organ perfusion as well as improving the neuro-hormonal state of the patients, reducing the endocrine dysfunction. Moreover, endocrine function is likely a major determinant of human homeostasis, and is a key issue in the recovery from critical illness. Care of the endocrine function may contribute to improving cardiac contractility, immune function, as well as infection control, and rehabilitation during and after a LVAD placement. In this review, data on endocrine challenges in patients carrying an LVAD are gathered to highlight pathophysiological states relevant to this setting of patients, and to summarize the current therapeutic suggestions in the treatment of thyroid dysfunction, and vitamin D, erythropoietin and testosterone administration.